Although food and nutrient consumption among the Japanese population, known to have one of the longest life expectancies in the world, has changed markedly after World War II, little is known about the influences age, time and birth cohort have had. The present study examined the effects age, time and birth cohort have had on intake of 14 food groups from 1989 to 2009, using published data from the National Health and Nutrition Survey in Japan.The survey included 575 adults (271 men and 304 women) in 1989, 8431 (3952 men and 4479 women) in 1999 and 5632 (2629 men and 3003 women) in 2009. The effects of age on energy-adjusted food intakes defined by gender and birth cohort  were estimated using the mean polish process.Intakes of meat and confectionary increased whereas those of milk and dairy products, sugar, and fats and oils decreased from 1989 to 2009. Both men and women in the 1940’s birth cohort consumed more fruit, although differences in food intake by birth cohort were less discernible. Furthermore, meat, fats and oils, and wheat intake decreased while fruits, fish, beans and vegetables consumption increased with aging in both men and women.The present analysis suggests intakes of meat and confectionary have increased in Japan over the past 20 years regardless of age and generation. Also, younger individuals are less likely to consume fruits, fish, beans and vegetables regardless of the birth cohort and time period. Differences in food group consumption by birth cohorts born between 1930 and 1979 were not obvious. The first indication of these findings would be that in order to avoid ongoing increases in meat and confectionery intake, the public health strategy should target the whole Japanese population. Secondly, intervening with the diet of younger individuals, especially today, would be reasonable as it is unknown whether today’s younger individuals will adopt a healthier diet when they age as the other generations did. The Japanese diet is often considered synonymous with a healthy diet . Food coIt has been suggested that fat intake (% energy) has increased, particularly among adults less than 60 years of age but not among older people ,8. TotalAlong with a significant change in the socio-economic environment after World War II, the nutritional status of Japanese people improved dramatically . NutritiTo accurately evaluate whether food intake has changed with age, it is necessary to separate time and birth cohort effects . A birthThe Ministry of Health, Labour and Welfare of Japan has been conducting annual cross-sectional NHNS-J since 1945. Details of NHNS-J including its survey methods, historical background, and purpose, have previously been described ,3,16. BrSince individual-level data were not publicly available, we used publically available mean intakes of selected food groups according to age group in each survey year. In this study, we used published data from adults aged 20 or older who participated in the 1989 , 1999 1 and 2009per capita. Consequently, we used gender- and age-stratified food intakes for single-person households assuming that it represented individual intake.Semi-weighed three-day (1989 NHNS-J) and one-day 1999 and 2009 NHNS-J) dietary records were used to estimate the nutrient and food intake of individual participants. The recording was done in November, excluding Sundays and national holidays. In the semi-weighed method, all subjects were asked to weigh the amount of each food before and/or after preparation. If weighing the food was difficult , estimated portion sizes were recorded . When fa09 NHNS-JIn the present study, we selected 14 food groups from the Standard Tables of Food Composition for the analyses: 11 food groups  with relatively high daily intake (>30 g/day), and three food groups  that were considered important for understanding the secular and generational transition of the Japanese diet. Since intake from five food groups  were relatively low (<30 g/day), and beverage intake included both soft drinks and alcohol, we did not analyze these food groups. In order to avoid confusion between fat (nutrient) and fats and oils (food group), we quoted “fats and oils” when we refer to the food group.We took into consideration changes in the coding system from the fourth to fifth revisions of the Standard Tables of Food Composition in the analysis. For example, rice was mainly coded as milled rice in 1989 and 1999 NHNS-J, but as steamed rice in 2009 NHNS-J . The weiTo investigate the effects of age, time and birth cohort on food intake, the data were organized according to age group and time periods over the 10-year intervals, we created age-period contingency tables for each food intake, and simulated birth cohorts were constructed by combining age groups and time periods. The cohort effect is considered as a time (year)-age interaction since each cohort is uniquely defined by the pair of variables, age and year of the survey. Subjects aged 20–29 years in 1989, 1999 and 2009 were defined as the 1960–1969, 1970–1979 and 1980–1989 birth cohorts, respectively.Rij = ai+tj+c(k) where Rij (food intake) is modeled by the sum of the effects of the ith age group  represented by ai, the effects of the jth time period (1989 or 1999 or 2009 survey) represented by tj, and the effects of the kth cohort  represented by c(k). c(k) are the residual values, defined as the lack of additivity of age and time in determining Rij. We estimated the parameter c(k) by the mean polish process [c(k) value greater than zero indicates a greater than additive influence and less than zero indicates less than additive influence from age/time effects on food intakes. If no age/time interaction exists (no cohort influence), then the residual values will be small and close to zero. C(k) is defined as the residual of age/time interaction. It does not have reference groups. Instead, c(k) value of zero indicates no interaction, i.e. no cohort effect. Mean polish process does not provide information about statistical significance, but residual values obtained with this method provide a descriptive tool to detect and interpret interactions (lack of additivity) between two categorical variables, i.e. age and time [This investigation used a statistical model  symbolic process ,24. A c were adjusted for energy , using the energy density method, and expressed as food intakes (g/day)/energy intake (kJ /day) × 4,186.The annual average food and energy intake are presented by gender age group in Table Differences in food intakes by birth cohort, often referred to as birth cohort effect are grouped according to gender and shown in Table Differences in food intake by time period according to gender are shown in Table Differences in food intake by age according to gender are shown in Table In the present study, differences in food intake by age, time, and birth cohort were examined using 1989, 1999 and 2009 NHNS-J. The main findings of the present study are three-fold. First, intake of certain foods changed in a steady pattern with aging. Second, intake of certain foods also changed in a steady pattern with time between 1989 and 2009. Third, differences by birth cohort for food intake were less discernible.Meat, fat, and oil intakes were lower in older age groups of both genders than the younger groups. This finding is consistent with previous longitudinal studies that found decreases in total fat consumption with aging among older Americans  or olderet al. reported that fat intake decreased, while intake of fruits and vegetables increased in 1253 men and women born in 1946 from the 17 year British birth cohort study [et al. reported that meat intake decreased in men and women during their 6-year follow-up of a community dwelling in adults aged 70 years or over in New Zealand. They examined the association between age, time, and cohort effects, and they also reported that older adults, particularly women, were making healthier food choices. For example, women ate brown or whole-wheat bread at the 6-year follow-up [Intake of fruits, fish, beans, and vegetables were higher in older age groups of both genders than younger groups. Since intake of these foods is encouraged in the “Dietary Guidelines for Japanese”  or “Healrt study . Fernyhoollow-up .It is also possible that food palatability changes with aging, thus increasing preference for these foods in older individuals . The maiOur finding that younger individuals consumed less fruits, fish, beans, and vegetables indicates that public health strategies likely need to pay more attention to these age groups in order to achieve the goal of the Japanese health promotion plan called “Health Japan 21” by the Ministry of Health, Labour and Welfare of Japan .Differences in food intake by birth cohort were relatively small in the present study. Only fruit intake in men tended to be higher in earlier birth cohorts than in recent ones. For example, fruit intake of men born in 1930–1939 was 5.7 g/4,186 kJ/day higher than that in men born in 1970–79. Fruit consumption would be influenced by environmental and host factors, such as household income, marital status and food availability . Indeed,Some studies reported that differences exist in body mass index  or in moIn the present analysis, we also found a tendency for increased intake of meat and confectionery in both men and women in recent surveys. In contrast, intake of milk and dairy products, sugar, and fats and oils decreased in recent surveys in both men and women. Although some of these observed changes may be due to variations in the survey methods over the years, they may indicate that the Japanese diet is shifting toward higher intakes of meat and confectionery, and lower intakes of milk and dairy products, sugar and fats and oils. Even though we found in the present study that intakes of “fats and oils” decreased in Japan in the last two decades, the percentage of energy obtained from fat increased from 6.9% to 26.5% between 1949 and 2000 NHNS-J -45. ThesEven though intake of milk and dairy products is encouraged in Japanese dietary guidelines, or “Health Japan 21”, since these products provide a good source of calcium, vitamins and protein, their consumption decreased over the past 20 years. Attention should, therefore, be paid to the time trends in milk and dairy intake in order to achieve the goals of “Health Japan 21”.Strengths of the present study include the examination of independent associations of age, time and birth cohort with certain food groups and energy intakes by separating out the other two effects with the use of publically available data on the general Japanese population born between 1930 and 1979. Also, the fact that the mean polish method does not require a special statistical package makes the present and present-like analysis easily reproducible. We believe public health programs for chronically emerging conditions should be designed after the elucidation of possible age, time and birth cohort effects.per capita in 1989 used in the analysis was derived from NHNS-J participants living in a single-person household. The representation of single-person households may be limited. However, the difference in nutritional intake per capita between single-person and full households in 1989 was not large. For example, the mean per capita energy intake in each type of household was 1,980 kcal  and 2,061 kcal  per day, respectively [One major limitation of this study is that only data from 1989, 1999 and 2009 NHNS-J were used in the analyses. Although NHNS-J has been conducted since 1945, gender- and age-stratified data were not available before 1986. Furthermore, we required 10-year intervals between three surveys in order to correspond with the 10-year age categories used in the published NHNS-J results. In addition, gender- and age-stratified nutritional intake ectively . FurtherThe time effect in this study, i.e., the time trend between the 1989 and 2009 surveys, might therefore have been influenced by changes in the coding practice that occurred with the revision. It is necessary, in future analyses, to calculate food intakes according to the same standard tables. With regard to age effects, men and women consumed more fruits, fish, beans and vegetables with aging, and less wheat, meat, and fats and oils. A longer-term study, in which the same subjects are measured repeatedly, would be needed to clarify the aging-related changes. Finally, the present study using the mean polish process should be interpreted in a descriptive manner, and further studies using statistical methods such as analysis of variance are needed to test the described findings.In summary, the present analysis suggests that meat and confectionary consumption have been increasing in Japan in the past 20 years regardless of the age and generation. Also, younger individuals are less likely to consume fruits, fish, beans and vegetables regardless of the birth cohort and time period. Differences in food group intakes by birth cohorts born between 1930 and 1979 were not obvious. These findings indicate firstly that, the whole Japanese population would need to be targeted in order to avoid ongoing increases in meat and confectionery intake. Secondly, prioritizing younger individuals of today for dietary intervention would be reasonable as it is unknown whether today’s younger individuals adopt a healthier diet when they age as the generations did before.NHNS-J: National Health and Nutrition Survey in Japan.The authors declare that they have no competing interests.The work was carried out in collaboration among all the authors. RO and HY defined the research theme, HY designed the methods, and RO analyzed the data, interpreted the results and drafted the manuscript. KT supervised the analyses, interpreted the findings, and contributed to critical revision of the manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2458/14/328/prepub


Eosinophilic esophagitis (EE) is an increasingly recognized primary clinicopathologic disorder of the esophagus which lacks a specific etiology. Most reports on EE have been limited to the esophagus mucosa. We present a 56-year-old man with the mural form of EE and superficial squamous cell carcinoma in the esophagus. The eosinophils diffusely invaded the full-thickness of the esophagus, mainly infiltrating the muscularis, including the skeletal and smooth muscles. The lesions in the mucosa, submucosa, and adventitia were slight. Although the superficial squamous cell carcinoma was excited by an endoscopic biopsy, there were some changes in the architecture and size of the squamous epithelial cells. The changed cells also expressed the p53 protein. It appears that the eosinophils stimulated cell proliferation, followed by genetic mutations and cancer development. The patient survived with resection of the esophagus and inhaled corticosteroids. Eosinophilic esophagitis (EE) was first described by Furuta et al. and deemed a variant of eosinophilic gastroenteritis . Since tA 56-year-old man presented as having abdominal distention with no reason for six years. Chinese medicine helped to relieve his symptoms. He had no other complaints, although six months prior, his skin had started itching, and three weeks prior he felt unable to successfully swallow hard food but could swallow semifluid food. He also had no history of asthma or allergies. The man went to the local hospital and had a gastroscopic examination, which showed a mass of about 1.3 cm × 1.2 cm in size , locatedThe esophagus was resected, which was 20 cm in length and 3 cm in circumference. The entire esophagus was very hardened and thick. There was mucosal erosion of about 1.2 cm × 1.1 cm in size , locatedFive tissues were biopsied . Two tisAfter esophageal resection, there were mucosal coloboma and no remnants of squamous cell carcinoma . The str9). A subsequent blood smear examination showed 50% (absolute number was 3.70 × 109) eosinophils (9)  . After tEosinophilic esophagitis (EE) is defined as a primary clinicopathological disorder of the esophagus. It is characterized by esophageal and/or upper gastrointestinal tract symptoms associated with esophageal mucosal biopsy specimens containing ≥15 intraepithelial eosinophils/HPF (high-power field) in one or more biopsy specimens. It is also characterized by the absence of pathologic gastrointestinal reflux disease, as evidenced by normal pH monitoring of the distal esophagus, or lack of response to high-dose proton pump inhibitor medications . In our EE should be distinguished from gastroesophageal reflux disease (GERD). In our case, the patient had no symptoms of heartburn and regurgitation. Eosinophils diffusely invaded the middle and lower esophagus, generally exceeding 15/HPF. The blood eosinophils returned to normal when the patient was treated with inhaled corticosteroids, so GERD was excluded. Eosinophilic gastroenteritis (EGE) was also a possibility as this condition involves the esophagus. However, although the patient had peripheral blood eosinophilia, he had no complaints of abdominal pain, nausea, weight loss, or diarrhea. In addition, there were no eosinophils in the epiploon, and the surgeon found that the stomach was soft, so the diagnosis of EGE was removed as well. Eosinophilic fasciitis also involves the esophagus. However, the antinuclear antibody, anti-DNA antibody, and rheumatoid factor were normal, so a diagnosis of eosinophilic fasciitis was not made.The cause of EE is still uncertain. Fifty to eighty percent of EE patients suffer from other allergic conditions , and antEosinophils can be present in malignant tumors. As we know, malignant tumor cells can release the cytokines, eotaxin, IL-5, and eosinophil chemotactic factor of anaphylaxis (ECF-A), which stimulates the recruitment of eosinophils from circulation into the tumor site. However, there is no case report about EE-associated superficial squamous cell carcinoma of the esophagus in English literature. In our case, the patient's clinical history showed that EE existed first, and squamous cell carcinoma confined to the mucosa developed later. The relationship between EE and esophageal squamous cell carcinoma is unclear. In EE, basal cell hyperplasia correlates with the density of intraepithelial eosinophils . In the In our case, the patient could not successfully swallow hard food. This symptom may be related to injury of the muscle and nerve plexus of the muscularis. After the surgery was complete and inhaled corticosteroids were taken, there were no further complaints of abdominal distention and itching skin. The patient survived with no recurrence of his condition.


Lippia origanoides, a species of the Verbenaceae family that shows promise as a crop plant, was investigated along an altitudinal gradient in the basin of the Chicamocha River in northeastern Colombia. The economic importance of the species, quality of its essential oils, and the fact that it is restricted to some few semiarid areas in northern South America may put the species at risk in a scenario of uncontrolled harvest of natural populations. Lippia origanoides was sampled along an altitudinal gradient from 365 to 2595 m.a.s.l. throughout Chicamocha River Canyon, a semiarid area in northeastern Colombia. Genetic diversity was assessed by means of AFLP markers. The number of AFLP loci (355) and the number of individuals sampled (173) were sufficient to reliably identify four populations at contrasting altitudes , two populations in the lower basin, one population in the medium basin, and one population in the upper basin, with a low level of admixture between them. In average, genetic diversity within populations was relatively high ; nevertheless, diversity was significantly reduced at higher altitude, a pattern that may be consistent with a scenario of range expansion toward higher elevations in an environment with more extreme conditions. The differences in altitude among the basins in the Chicamocha River seem to be relevant in determining the genetic structure of this species.The genetic diversity and population structure of  Plant species that show tolerance or resistance to extreme conditions, such as those associated with arid and semiarid areas and that, additionally, are important for agricultural and/or industrial applications, are of interest for population genetics studies, not only because these species may be pre-adapted to the consequences of climate change  but also because their uncontrolled exploitation from the wild may impose a risk for their survival.Lippia origanoides H.B.K., an aromatic plant species of the Verbenaceae family that has promise for the quality and potential industrial use of its essential oils. The species occurs in northern South America , the south (departments of Cauca and Nariño), and the Atlantic coast   .Lippia origanoides has an important phytochemical variation represented in three chemotypes according to the major compounds present in their essential oils   . The bioterranea , Sclerotaseolina , Rhizocts maydis , Mycosphijiensis , Mycobacrculosis , Candidama cruzi , Escheri zeamais , antivir zeamais ,b, and D zeamais . These rspectrum , with pospectrum . NowadayL. origanoides as n = 12. Nevertheless, additional studies are needed to confirm its monoploid number and ploidy , in a topography of steep slopes (>60°) and shallow soils . At low asticity , and othasticity . In contL. origanoides along an elevation gradient (365–2595 m.a.s.l.) at the lower, medium, and upper basins of the Chicamocha River, a semiarid area in Colombia, using AFLP molecular markers. Our ultimate aim is to investigate the processes that influenced the current distribution of L. origanoides in the canyon, mainly in those populations at higher elevations. For this purpose, we analyzed a sample of 173 individuals from the lower, medium, and upper basins of the canyon, using 355 AFLP loci, and applied a variety of approaches for assessing genetic structure and diversity with dominant markers.The objective of this study was to evaluate the genetic structure of Lippia origanoides is an aromatic shrub, erect and branched, which grows to 3 m in height and belongs to the Verbenaceae family  that according to preliminary results are informative in L. origanoides . The AFLP amplifications were carried out as recommended by the manufacturer. The visualization of the products was performed following the manufacturer's instructions, although the staining of 6% PAGE was performed in silver nitrate. The gels were documented with a scanner Epson Perfection® 4490 Photo ; each image was optimized and scored using GIMP 2.6 and EasyPen i405 . This procedure of digital-scoring was performed by painting a black line on the bands indicating their presence and a white line indicating the absence of the fragment, which improved automated processing for obtaining the presence/absence or 1/0 matrix with Cross Checker 2.91  was used to amplify five selective primer combinations  using the distance matrix under the method proposed by  library  in the p library . Additio library  to calcuIn most genetic studies, the number of markers and the number of individuals sampled are defined either arbitrarily or by available resources. However, in genetic structure studies, this may have a great effect on the validity and reliability of the inferred clusters. For this reason, we used the method reported by We estimated the appropriate number of groups or partitions (populations or subpopulations), in addition to the level of admixture between the groups, and assigned each individual to each of the inferred populations using two Bayesian approaches implemented in the programs STRUCTURE 2.2  and BAPShttp://www.bioportal.uio.no). Similarity among runs was estimated according to ΔK as the mean of the absolute values of the second order rate of change of L(K) (Ln P(D) in STRUCTURE output) divided by the standard deviation according to the methodology proposed by ΔK were calculated using an R-script “Structure-sum-2011” available from http://uit.no/ansatte/organisasjon/ansatte/person?p_document_id=41186&p_dimension_id=88165  approach, in which there are K populations and the individuals are assigned to these populations probabilistically. We used a model of ancestry with no admixture and a model of allele frequencies uncorrelated or independent, suitable for dominant molecular markers . Ten runid=88165 .Similarly, we used BAPS  to infer the genetic structure in our data considering the geographic information collected in the field. Briefly, BAPS treats both K and allele frequencies as random variables, and returns one optimal partitioning and the probability of the optimal K. In order to strengthen the inferences, we used as prior the geographic coordinates of the sampled individuals. Spatial clustering and admixture of individuals based on mixture clustering were calculated using a vector of values of K from 2 to 20 and 20 replicates. Voronoi tessellation and admixture clustering graphics were obtained to indicate the optimal partitioning or potential population structure and the level of admixture within the clusters inferred from the canyon of the Chicamocha River.full model was also used for estimating genetic diversity, defined as the average panmictic heterozygosity within each population or cluster, without assuming HWE  and Shannon's information index (I)   was calcndex (I)  and theyII, a measure of the amount of genetic differentiation among contemporaneous populations and estimated by HICKORY, and (2) AMOVA, analysis of molecular variance among populations using pairwise difference as distance method and 100,000 permutations for support, implemented in ARLEQUIN 3.5 (Two approaches for determining the level of genetic differentiation among populations or clusters were used: (1) θQUIN 3.5 .Lippia origanoides is an aromatic and medicinal species promising for the quality of its essential oils and the broad activity spectrum that these have shown against pathogenic microorganisms, relevant to agriculture and human health  and Betéitiva in the upper basin . The elevation range covered during the sampling was between 365 and 2595 m.a.s.l. for the entire canyon. On average, elevations for each basin were: (1) 532 m.a.s.l. for the lower basin, (2) 1440 m.a.s.l. for the medium basin, and (3) 2350 m.a.s.l. for the upper basin.N criterion as 1−(3/N), where N is the number of samples)  on a digital image ; 244 (68.7%) and 227 (63.9%) markers were polymorphic at 0.99 and 0.95, respectively. According to samples) . Howeversamples) .A pairwise individual-by-individual genetic distance matrix was built following the method of L. origanoides , with low level of admixture between clusters or populations  was not a suitable criterion for determining the optimal K, given that L(K) increased after reaching the real value of K in our data  with a reduction of 20% compared with the other populations of the canyon. Lippia origanoides is considered to be a habitat specialist species, with high levels of plasticity and stress tolerance  as an alternative measure to quantitate diversity (see I = 0.44) and significantly higher than UB (I = 0.348), which is in accordance to the results presented above. Interestingly, the genetic diversity in L. origanoides seems to follow a pattern previously reported for species inhabiting elevation gradients, which are characterized by exhibiting a marked decrease in genetic variation in marginal populations compared with populations centrally situated , as suggested by k) was estimated as Ct = (Ht−Ht/k)/Ht .The individual contribution of each population to genetic diversity was determined using Ht/k)/Ht , where HFull loci show the values of Nei's genetic diversity and Shannon's information index estimated using the full set of markers scored in this study, 355 AFLP loci. The estimators of the diversity were reduced in approximately 30% compared with the data sets that fulfill the parameters of polymorphism, usually 0.99 level of polymorphism.The effect of monomorphic markers on estimation of diversity was evaluated. In I = 0.453 and hs = 0.484. Although the value of I reported for LBb in our study (I = 0.425) was similar to that obtained by hs presented here is significantly different (hs = 0.484 vs. hs = 0.288), probably due to the use of different molecular marker systems  was previously reported by  systems .FST = 0.17916, P-value < 0.0000). In general, 17.9% of the variation was due to differences between populations of the canyon, while the remaining variation was due to differences between individuals within populations. The Bayesian estimate of differentiation among contemporary populations θII and implemented in HICKORY showed a similar level of population subdivision (θII = 0.15592 ± 0.02311). Pairwise FST estimates (see FST = 0.306), and moderate differentiation between nearby populations .The distribution of genetic diversity within and among populations in the canyon of the Chicamocha River was determined using two-level analysis of molecular variance see . AMOVA sates see  indicateL. origanoides in the canyon and at contrasting elevations , and probably to the difference in altitude among the basins. The population that contributed the most to the genetic diversity was LBa, which corresponds to the municipalities of Juntas and Jordan, where further research and conservation activities should be focused. However, these previous results encourage further sampling and research in areas that have not been sampled yet in order to understand more of the adaptation and distribution of this important species in Colombia.In summary, with the results obtained in this study, we conclude that the genetic structure of


The ongoing rapid urbanization in China offers rural population opportunities not only for economic improvement but also for substantial health risks. Albeit some researches related to rural-urban difference of metabolic syndrome (MS), there lacks studies focusing on this point in undeveloped provinces in China.The survey, as part of China National Diabetes and Metabolic disorders Study, was conducted in Shaanxi province from June 2007 to May 2008. A total of 3,297 adults aged 20 years or older were included, of which 1,467 individuals were from urban areas, 839 from semi-urban areas, and 890 from rural areas. The MS was defined according to the 2009 Joint Interim Statement.P = 0.017), in particular among females . After adjusted for the listed risk factors, rural residents had a 27.6% increased risk of having MS than urban residents. With respect to MS components, the crude prevalence of raised fasting glucose and raised blood pressure was significantly greater in rural than in urban participants. However, no significant difference in the prevalence of MS was observed between semi-urban and urban participants.The age-standardized prevalence of MS was significant higher in rural residents than in urban counterparts (29.0% vs. 25.9%, Rural residents in Shaanxi province, northwest China, were at increased risk of MS, which could be partly explained by sociodemographic and lifestyle differences. In addition, the gap between urban and semi-urban areas seemed to be minimized in related to MS prevalence. Much more attention should be paid to and intervention strategies were needed to address the rural-urban disparities in China. Metabolic syndrome (MS) is defined as a cluster of metabolic abnormalities including abdominal obesity, hyperglycemia, hypertension, and dyslipidemia,2. The pDifferent from the developed provinces in which urbanization has been almost achieved, Shaanxi province, as an undeveloped representative of China, is at an accelerated process of urbanization nowadays, which results in rural industrialization, conversion of farmland, and in situ “urbanized rural residents”,16. The We utilized the data of the 2007-08 China National Diabetes and Metabolic Disorders Study, aiming to evaluate the rural-urban differences in prevalence of MS and its individual components in Shaanxi province, northwestern China.This cross-sectional survey, as part of China National Diabetes and Metabolic disorders Study, was conThe study was primarily designed to provide accurate estimates of the prevalence of diabetes. A sample size of 3,200 individuals was planned to provide an 80% power to detect a 3% prevalence of diabetes , which was sufficient to examine MS due to its higher prevalence compared with diabetes. A total of 3,930 individuals who had lived in their residence for 5 years or longer were randomly chosen and invited. A total of 3,297 individuals completed the survey and examination . After the exclusion of 101 individuals for whom any data of waist circumference, fasting blood glucose, blood pressure, serum triglycerides, and serum high-density lipoprotein cholesterol (HDL-c) were missing, 3,196 individuals were finally included as study participants, of which 1,467 individuals were from urban areas (street district from urban city), 839 from semi-urban areas (street district of country-seat), and 890 from rural areas . The study was approved by the Ethics Committee of Xijing Hospital, Fourth Military Medical University. All the participants signed written informed consent prior to data collection.A standardized questionnaire was designed and performed by trained nurses or physicians at local health stations or in community clinics to collect data on demographic characteristics, lifestyle risk factors, personal medical history, and family history of diseases. EducatiAfter at least 10 hours of overnight fasting, all participants were administered an oral glucose tolerance test to measure blood glucose. A standard 75-g glucose solution was given to participants with no history of diabetes, while a steamed bun that contained approximately 80 g of complex carbohydrates was given to those with a self-reported history of diabetes for safety reasons. Blood samples were collected at 0, 30, and 120 minutes after the glucose or carbohydrate load to measure blood glucose. Fasting blood samples were also collected to measure serum triglycerides and HDL-c level with the use of an enzymatic method. All laboratory measurements met a standardization and certification program.The MS was defined according to the 2009 Joint Interim Statement (2009 JIS) proposed by the International Diabetes Federation Task Force on Epidemiology and Prevention, the National Heart, Lung, and Blood Institute, the American Heart Association, the World Heart Federation, the International Atherosclerosis Society, and the International Association for the Study of Obesity, using the Asian criteria for central obesity when ≥ 3 of the following components were present[t-test for measurement data, and chi-square test for enumeration data. P < 0.05 was defined as the threshold for statistical significance.Data analysis was conducted by SPSS 18.0 or Stata 11.0 and data were expressed as mean ± standard deviation (SD), median with interquartile range, or percentage as suitable. Comparisons between groups were analyzed by svy command (direct standardization) to account for the overall population. The calculations were weighted based on the 2006 population distribution of Shaanxi province[Age-standardized prevalence estimates and 95% confidence intervals (95% CI) of MS for urban, semi-urban and rural residents stratified by sex were calculated with Stata province.Stepwise multivariate analysis was utilized to examine the association between residents’ location and MS. The reference group was urban residence. In model 0, the unadjusted odds ratio (OR) and 95% CI for MS were calculated. Model 1 was adjusted for age, sex and ethnics; Model 2 was further adjusted for sociodemographic and lifestyle variables including educational level, yearly family income, cigarette smoking, alcohol drinking and physical activities; and model 3 was added for previous factors plus family history of diabetes and hypertension.The clinical characteristics of study participants were showed in Table The age-standardized prevalence of MS in all, male and female urban participants was 25.9%, 27.6% and 24.4%, respectively. In all and female subgroups, rural participants had a significant higher prevalence compared with urban counterparts . However, no significant differences in the prevalence of MS were observed between semi-urban and urban participants in all, male and female subgroups  than in rural (12.7%) residents. Lao XQ This discrepancy could be partly explained by the fact that our survey was conducted in an undeveloped province within five years while most of previous studies analyzed data from surveys in developed provinces or ten years ago. Shaanxi province, different from developed provinces in which the urbanization has been almost achieved, is at an accelerated process of urbanization. The ongoing urbanization brings rural residents both higher income and an unhealthy lifestyle, as poor early life conditions increase the risk of obesity in a subsequently more socio-economically developed environment. With thDifferent from the report by Ntandou G, no signAlthough our study was a multistage, stratified randomly sampling survey, some limitations should be considered. Firstly, the cross-sectional natural decides a possible deficiency of causal inferences. Secondly, urban and women participants were oversampled, which may result in a potential selection bias contributed to the rural-urban difference. Thirdly, risk factors such as dietary intake , environmental hazards, and diabetes or hypertension knowledge were not assessed for some reasons. We were thus unable to further explore the possible cause of rural-urban difference. Lastly, the data of yearly family income in our survey could not totally reflect the real disposable income which is hard to obtain due to privacy in China.The results of the study indicated that rural residents in Shaanxi province, northwest China, were at increased risk of MS, which could be partly explained by sociodemographic and lifestyle differences. Furthermore, the gap between urban and semi-urban areas seemed to be minimized in related to MS prevalence. It’s in question whether our study was an isolated issue or would happen in another province. However, it’s most likely that China’s urbanization will continue unabated. Considering the high prevalence of MS among rural populations and the likelihood of developing medical complications, much more attention should be paid and intervention strategies were needed to address the rural-urban disparities in China.The authors declare that they have no conflict of interests.SX, JM and CY contributed equally to the study. SX, JM had full access to all the data in the study, and took responsibility for the integrity of the data and the accuracy of the analysis. QJ, SX, JM, and CY conceived the study. All authors contributed to the analysis, which was mainly done by SX and JM. SX and CY wrote the first draft, and all authors contributed to the writing of the final report. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2458/14/104/prepub


Primigravidity is one of the main risk factors for both malaria and anaemia. Since the implementation of intermittent preventive treatment (IPTp) in sub-Saharan Africa, the relationship between anaemia and gravidity and its evolution during pregnancy has been little explored. This study aimed to evaluate the impact of gravidity on the variation of haemoglobin during pregnancy according to the timing of gestation.Data from three studies carried out in nearby areas in south Benin  between 2005 and 2012 were analysed. At inclusion  women’s age, area of residence, schooling, gravidity, gestational age, weight and height were recorded. Thick blood smears were performed on ANV1, second visit (ANV2) and at delivery. In Allada, women’s serum ferritin and CRP concentrations were also assessed. The impact of gravidity on maternal haemoglobin (Hb) was analysed using a logistic or linear regression depending on the outcome. The statistical significance was set to P < 0.05.In total, data from 3,591 pregnant women were analysed. Both univariate and multivariate analyses showed a constant association between Hb concentrations and gravidity in the three periods of Hb assessment . Mean Hb concentration was significantly lower in primigravidae than in multigravidae at ANV1 . Afterwards, there was a significant increase in primigravidae only, with a tendency to reversal between primigravidae and multigravidae, which was confirmed at delivery . The prevalence of malaria infection was halved between ANV1 and delivery in primigravidae while it decreased by only 38% among multigravidae, who were less prone to malaria infection . Iron deficiency was more common in multigravidae, and it decreased slightly in this group between ANV1 and delivery.In a context of IPTp, Hb levels improved progressively throughout pregnancy in primigravidae, likely as a result of reduction in malaria infection. In multigravidae, the improvement was less perceptible and anaemia was mainly due to iron deficiency. As part of the prospective cohort study (Anaemia in Pregnancy: Etiologies and Consequences “APEC”) carried out in Benin between 2010 and 2012, primigravidae and multigravidae were followed from the first antenatal visit (ANV1) until delivery. In a preceding paper ) at ANV1 and 3294.5 (CI95%: [2208.3-4447.1]) at delivery.When considering studies separately, there was an overall suppress differences between primigravidae and multigravidae at each visit that did not reach significance. After pooling data from the three studies, both univariate and multivariate analyses showed a constant association between Hb concentrations and gravidity in the three periods of Hb assessment Table . Mean Hbvs Ouidah study, P < 0.001). At ANV2, malaria (P < 0.001), low BMI (P < 0.001), study  were associated to lower Hb levels. At delivery, gestational age higher than or equal to 37 weeks (P = 0.005) and more than four ANVs during the follow-up (P = 0.003) were associated with a higher Hb concentration, whereas malaria (P < 0.001) and low BMI (P = 0.012) were related to lower Hb levels.The following covariates were associated to lower Hb levels at ANV1: gestational age more than or equal to 16 weeks (P < 0.001), malaria (P < 0.001), low BMI (P = 0.001), study (STOPPAM and APEC studies P = 0.003) , malaria (P < 0.001) and low BMI (P < 0.001). On ANV2, only STOPPAM study (P < 0.001), malaria (P = 0.001) and low BMI (P = 0.01) were still associated with a higher risk for maternal anaemia. At delivery, a high number of ANVs (more than four) (P = 0.001) was associated with a decreased risk for maternal anaemia, whereas malaria (P < 0.001) was related to a higher risk of maternal anaemia.When maternal Hb was considered as a categorical variable (anaemia or no anaemia), primigravidity remained associated with a better Hb status at delivery . Iron deficiency was assessed only in the APEC study. At ANV1, ANV2 and delivery, iron deficiency was more common in multigravidae, but the difference was only significant at ANV1 and ANV2.The relationships between the two main aetiologies of anaemia, malaria and iron deficiency, and gravidity are presented in Table This study showed that if primigravidae were the most vulnerable group to anaemia at the beginning of pregnancy, they rapidly increased their Hb to reach higher levels than multigravidae at delivery. Protective interventions against malaria  appeared to play a major role in this process, which was demonstrated in three studies conducted in different areas at different times in southern Benin.et al[Although the women come from three different studies, they nevertheless share common factors. They all originated from the same region of Benin, with the same climatic pattern, and potentially similar malaria transmission in all sites . They weet al. STOPPAMThe analyses of data from each of the three studies separately showed that primigravidae who were initially at higher risk of anaemia at inclusion (ANV1), increased progressively Hb concentration and became, although not significantly, at lower risk of anaemia at delivery compared with multigravidae. Pooling all data from the three studies increased the sample size and thus the power of the analysis, demonstrating the importance of gravidity as a determinant of maternal anaemia, even after adjusting on the characteristics of each population. In addition, taking into account gestational age in the multivariate analyses minimized the effect of potential confounders such as the gestational plasma volume changes that might as well have played a role in the parity-related difference.et al showed in Malawian women a decrease of maternal anaemia only in primigravidae [et al showed a decrease of anaemia in only Ghanaian multigravidae [Primigravidae had a lower mean Hb and an increased risk for anaemia in early pregnancy compared to multigravidae, prior to the administration of IPTp. Furthermore, an overall decrease in the proportion of malaria infections after women were given IPTp has been shown ,15-17. Igravidae , whereasgravidae . Finallygravidae .et al showed in Spanish, well-nourished, pregnant women (including primi and multigravidae) who received an iron supplementation (40-60 mg/day) that iron deficiency increased importantly as pregnancy progressed (from 8% at inclusion to 68% at delivery) [In spite of IPTp and iron supplementation, multigravidae increased Hb levels, but not in the same proportion as primigravidae, and consequently were at higher risk of anaemia at delivery. Indeed, in the APEC study, the proportion of women presenting with iron deficiency was higher in multigravidae than in primigravidae at each blood assessment. As previously described , there ielivery) . A similelivery) .et al[vs less than 19% of primigravidae. This is in agreement with the results of APEC (36% and 24% in the two groups).The lack of longitudinal data for pregnant women with the same definition of iron deficiency makes comparisons of prevalence of iron deficiency difficult among studies from sub-Saharan Africa. Nevertheless, in Kenyan pregnant women of less than 24 weeks’ gestational age, results close to the findings of this study were found by Alusala et al. The autIn the context of IPTp, primigravidae were shown to have a progressive increase in Hb concentration throughout pregnancy. The effect of IPTp on anaemia in multigravidae women was less marked, as they are less susceptible to malaria and nutritional deficiencies seem to be the main causes of anaemia in this group. There is a need to reinforce malaria prevention strategies in both groups, and to undertake additional measures focusing on the reduction of micronutrient deficiencies in multigravidae. For instance, women should be encouraged to take iron supplements from the first pregnancy until menopause, even at lower doses during the interval between pregnancies, to reduce iron side effects and increase compliance. This strategy is relatively easy to implement as the target population may be identified at the first pregnancy.The authors declare that they have no competing interests.SO participated to conceive APEC study, participated in its design and coordination, performed statistical analyses and drafted and finalized the manuscript. FBL participated in statistical analyses and the finalization of the manuscript. VB participated to conceive Ouidah study, participated in its design and coordination, participated to the statistical analyses of the manuscript. BTH participated to implement and coordinate STOPPAM study and the finalization of the manuscript. GKK participated to implement APEC study, in the statistical analyses and the finalization of the manuscript. MMKA participated to the implementation and coordination of APEC study. NF participated to conceive, implement and coordinate STOPPAM study and the finalization of the manuscript. AM participated to conceive, implement and coordinate STOPPAM study and the finalization of the manuscript. PD participated to conceive and coordinate STOPPAM study and the finalization of the manuscript. MC participated to conceive and coordinate the three studies , in the statistical analyses and the finalization of the manuscript. All authors read and approved the final manuscript.


Many visitors, including military troops, who enter highland regions from low altitude areas may suffer from acute mountain sickness (AMS), which negatively impacts workable man-hours and increases healthcare costs. The aim of this study was to evaluate the population level risk factors and build a multivariate model, which might be applicable to reduce the effects of AMS on Chinese young men traveling to this region.Chinese highland military medical records were used to obtain data of young men (n = 3727) who entered the Tibet plateau between the years of 2006-2009. The relationship between AMS and travel profile, demographic characteristics, and health behaviors were evaluated by logistic regression. Univariate logistic models estimated the crude odds ratio. The variables that showed significance in the univariate model were included in a multivariate model to derive adjusted odds ratios and build the final model. Data corresponding to odd and even years (2 subsets) were analyzed separately and used in a simple cross-validation.vs. 1300-1500 m, adjusted odds ratio (AOR) = 1.32-1.44) to higher altitudes  by air or rapid land transport for emergency mission deployment  during the cold season  are at great risk for developing AMS. Non-Tibetan male soldiers , born and raised in lower provinces , and deployed without prophylaxis , also represented a population at significantly increased risk for AMS. The predicted model was built; the area under receiver operating characteristic curve was 0.703.Univariate analysis indicated that travel profile, prophylactic use, ethnicity, and province of birth were all associated with AMS in both subsets. In multivariate analysis, young men who traveled from lower altitude (600-800 m Before a group of young men first enter a high altitude area, it is important that a health service plan should be made referring to the group's travel profile and with respect to young men's ethnicity and province of birth. Low-cost Chinese traditional prophylactic drugs might have some effect on decreasing the risk of AMS, although this needs further verification. Acute mountain sickness (AMS) is an important public health problem for highland newcomers . Its sym2 values that are experienced during short-term exposure to hypoxic conditions [Many factors have been suggested as associated with AMS and may be useful for predicting risk of AMS. Some studies have assessed AMS risk by evaluating type and frequency of symptoms experienced by individuals during previous exposures ,10, othenditions ,12. Howenditions , optic nnditions ,15, werenditions , and thenditions -19. HoweSuccessful AMS control should take population level factors into account. As some researchers have emphasized , an evalThis study was approved by the Ethical Review Board of the Third Military Medical University. The requirement for informed consent was waived by the committee since we extracted data retrospectively from medical records. No intervention was performed between study researchers and individuals whose data were accessed and all data were anonymized prior to retrieval and analysis.For cross-validation the sample of data were partitioned into two complementary subsets  according to their year of entry into the high altitude region and analyzed respectively as shown in Figure p < 0.10, and was a screening criterion to find candidate independent variables for entering into the multiple analysis. Multivariate logistic regression analyses were performed to calculate the adjusted odds ratios (AORs) and build the AMS probability model for the young men population. The fulfillment of independence and collinearity were tested in the multivariate models. The fit of the multiple logistic regression models was evaluated by the Hoshmer-Lameshow goodness-of-fit test. The discriminative power of significant predictive factors was tested using receiver operating characteristic (ROC) curves, including the area under the curve, with 95%CI. The regression analyses were performed by using SPSS 13.0 software . The ROC curve analyses were performed using Med Calc 11.6 software (Belgium). In multivariate analysis, a two-tailed p < 0.05 was considered statistically significant.Logistic regression analysis was used to estimate the risk of AMS ; univariRelevant data were obtained from the Health Service Department of the Chinese highland forces. Medical records of all young men who entered the Tibet-Qinghai Plateau during the years 2006-2009 were considered. The records had been originally collected by the respective Health Service Departments  in Tibet. Because the data were from troops in different military operations, a few items in the health records differed, so we sometimes classified data according to the overall indications . The demographic characteristics, routine clinical parameters, and disease history were extracted from individual's medical record sheets. The travel profile was taken from the medical log file. Generally, personal information on the health record sheets was self-reported by the young men, while military medical officers entered the clinical information, and the leader of the health service group completed the medical log file. We excluded cases in which study data were missing.An individual's data were included in this study if the young man: 1) had entered an area of 2900-4300 m and stayed there for at least two weeks; 2) had traveled to the high altitude location by vehicle or airplane; and 3) was born and had been raised in a region < 2500 m altitude. Individuals were excluded from this study if they had: 1) other acute diseases when they entered the high altitude area; 2) any severe chronic disease; 3) served in a highland region previously; 4) slept in a place higher than their destination during their trip; 5) passed through an area higher than their destination for more than four hours during their trip; or 6) incomplete study information. Any records that met the above criteria but represented an ethnicity group that composed less than 1% of the total medical records under consideration were also excluded. A total of 3727 young men's health records were included in this study. The range of ages was 17 to 26 years old (19.58 ± 1.34). The ethnic distribution was 93.16% Han (ethnic Chinese), 4.51% Hui (Muslim), and 2.33% Tibetan (who came from areas < 2500 m in the Sichuan or Gansu provinces). The diagnosis of AMS was based on the "Diagnostic Criteria of High Altitude Disease in China", which was brought into effect in China during the 1990s and introduced to the world through translation by John B. West in 2010 , military rank, alcohol drinking, cigarette smoking, prophylaxis, start point altitude, destination altitude, deployment type, and travel season. These variables were chosen based on their status as recognized or hypothesized risk factors of AMS -25 and tFor each factor, two to four coded categories were established. Ethnicity was classified as Han, Tibetan, and Hui, as above mentioned. Because provinces in western China, except for Tibet and Qinghai, have an average altitude of 500-2500 m and those in the east are < 500 m, we divided the young men by province birthplace and residence (either east or west). We then subdivided the west province individuals into northwest and southwest groups according to the distinct climates of each region . The northwest provinces included Xinjiang, Inner Mongolia, Shanxi, Gansu, and Ningxia; the southwest provinces included Sichuan, Yunnan, and Guizhou. Since the sample size for the east provinces was relatively small (n = 917) we did not subdivide by climate. Education was divided among ≤junior high school, high school, and ≥college. According to the World Health Organization's classifications, the BMI was divided into three groups: underweight (< 18.5), normal (18.5-24.9), and overweight (25.0-29.9). MilitarThe descriptive analysis of the odd years data group, along with results of the univariate logistic regression, which was used to determine the variables status as potential risk or protective factors for the disease, are given in Table vs. Han, p < 0.10) and province of birth  were significantly associated with AMS in the odd years data set. In the even years data set, however, province of birth , ethnicity , BMI , and military rank  were significantly associated with AMS.For the demographic factors, only ethnicity . No cigarette smoking was also identified as protective, but only in the odd years data set . The consumption of alcohol was not a significant contributor.Among the health behavior factors, a protective effect was found from the administration of prophylaxis ; 2) came from a lower start point altitude ; 3) went to the highland in an emergency situation or by air ; or 4) traveled in a cold season . The analysis of even years data yielded similar results: , , , respectively.In the odd years data set, all of the travel factors examined were found to be significantly associated with AMS. Young men were significantly more likely to develop AMS if they: 1) went to a higher altitude  were included in the multivariate logistic regression model. Then BMI, cigarette smoking, and military rank lost significance (p > 0.05); thus, these three variables were excluded from subsequent multiple regression models. When the multiple regressions were re-run, start point altitude, destination altitude, deployment type, travel season, prophylaxis, ethnicity, and province of birth retained significance in both data subsets ; there was no difference in risk found between Hui (Muslim) and Han (ethnic Chinese). Birth in eastern provinces was associated with significantly higher AMS incidence than birth in northwestern provinces ; there was no significant difference in risk found between birth in southwestern and northwestern provinces. Prophylaxis use was correlated to lower AMS incidence than non-use . The start point of 600-800 m was determined to be a significantly stronger AMS risk factor than the 1300-1500 m start point ; there was no significant AMS risk difference between the start point of 900-1100 m and 1300-1500 m. The destination altitude of 4100-4300 m also represented a significantly stronger AMS risk factor and had more effect than the 2900-3100 m destination ; meanwhile, the destination altitude of 3600-3700 m was associated with significantly higher risk than that of 2900-3100 m . Emergency land deployment was associated with higher AMS incidence than was normal land deployment . Normal air deployment was associated with higher AMS incidence than was normal land deployment . Emergency air deployment was associated with higher AMS incidence than was normal land deployment . Finally, travel in the cold season contributed stronger AMS risk than travel in the warm season . Then, the regression model equations of odd years dataset (Model I) and even years dataset (Model II) were derived, wherein the expected probability of each model in its training data were recorded for ROC analysis:In the multivariate models, Tibetan ethnicity was associated with significantly lower AMS risk than Han ethnicity , X2: birth province (east), X3: prophylactic use, X4: start point (600-800 m), X5: destination (3600-3700 m), X6: destination (4100-4300 m), X7: transportation (emergency by land), X8: transportation , X9: transportation (emergency by air), X10: season. Variables' range value: 0 or 1.n both models, Xp = 0.331, Model II: p = 0.068). The VIF of independent variables indicated an acceptable absence of collinearity (VIF < 0.50). Then, a 2-fold cross-validation was performed. Model I cross-validation was performed on dataset II, followed by Model II cross-validation on dataset I. The result of expected probability of each model was recorded for ROC analysis. The ROC curves for each model's training data and testing data were drawn. In Model I's training data, the area under the ROC curve was 0.705 , while in its testing data, the area under ROC curve was 0.701 ; there was no significant difference between the two curves . In Model II's training data, the area under the curve was 0.709 , while in its testing data, the area under ROC curve was 0.707 ; again, the two curves were not significantly different . These findings indicated that both models were significant and fit well; however, Model II seemed more appropriate as it had a higher area under curve in cross-validation than Model I.The Hosmer-Lemeshow tests revealed that both models fit well , demographic characteristics , and prophylaxis.The most important risk factors for AMS are rate of ascent and altitude reached . There aType of deployment can also significantly affect the ascent rate, which in turn affects the risk of AMS. In our study, the risk of AMS was significantly higher for individuals experiencing air or emergency deployment, especially for those in emergency air deployment conditions. Gradual land transportation used in cases of normal deployment is represented by a slower ascent rate, while rapid land transportation, such as used in cases of emergency deployment, is represented by a faster ascent rate; air transportation always is represented by the fastest ascent rate. However, deployment type also is influenced by task status. Normal deployment is typical of a routine action, whereas emergency deployment is always indicative of an emergency operation, wherein soldiers deal with some task immediately upon arrival. The intensive labor itself causes hypoxia, which can cause greater severity and incidence of AMS in the early hours of exposure to high altitude .High altitude stress is primarily due to hypoxia, which is a result of experiencing low atmospheric pressure. However, dry air and cold are also significant contributors to AMS development . On the In our study, young men who were born and raised in the east provinces of mainland China were more like to develop AMS. The main reason was determined to be the difference in altitude between the east (sea level) and west provinces . The results from our study indicate that individuals born in regions in the higher altitude level have an inherent advantage over those born in lower level, particularly in regards to less risk of developing AMS when traveling to Tibet. One possible reason for this is that young men who were born and raised in west provinces lived for long periods at relatively higher altitudes. This may have primed the individuals to the lower oxygen content of higher altitudes, which manifested as a factor for reduced risk of AMS. The two subdivided western groups (northwest and southwest) had no significant difference in AMS rate, suggesting that other regional factors, such as climate or social environment of the birth province, have no relationship with AMS. Further studies are needed to verify this presumption.Ethnicity differences were found to significantly affect the development of AMS. It is well established that Tibetans are better adapted to high altitude and have a greater physical capacity in that environment than newcomers . In our Many commercially available prophylactic drugs efficiently prevent AMS; these include the long-established acetazolamide and dexamethasone . In ChinStill other factors, such as BMI, smoking, and military rank were slightly associated with AMS by univariate analysis; however, in multivariate analysis the significance was lost. Other researchers have reported that obesity is a risk factor of AMS ,36; howeThe results derived from this study can be used as a reference when planning an operation of a group of young men entering highland regions. Obviously, slowing down or limiting the ascent profile of people starting from lower regions, allowing time for acclimatization, and limiting the final altitude will be helpful for reducing AMS risk, if the operations allow. Young men whose homelands are in low altitude should be given more medical attention to detect early symptoms and given more time to acclimatize. In addition, administration of prophylaxis using Chinese traditional drugs prior to the initiation of the operation might be beneficial, although this needs further verification. If the operation or mission condition do not allow for decreased ascent rate, the AORs could be a quantitative reference when calculating the additional medical resources that should be prepared for the corresponding condition. For example, assuming all other conditions are equal, travel in the cold season should deploy 1/4 more medical resources than in warm season. The model established could be used as a tool that considers multiple factors to estimate AMS rate before a group of young men newly enters highland areas. The particular factors can be entered into the model to forecast the AMS rate before a group enters the highlands. This information could then assistant the authorities in preparing adequate medical resources, such as medicine, oxygen equipment, and accompanying physicians, to support the operation. It also could help the authorities to evaluate the work ability in the early time of the young men's group entering the highland and allow for arranging reasonable operations that may be achieved under the likely conditions. It is important to note the inherent limitations of a retrospective study (detailed below) restrict the design an absolutely accurate equation. Nevertheless, the newly developed statistical models could provide some timely information pertaining to the need for medical preparations aimed at a young men population newly entering highland areas. It also provides some valuable information applicable to designing future prospective research studies and health intervention strategies.Our study was, to our knowledge, the first analysis of the relationship between multiple population level factors and AMS in China's highland troops, and also the first study aimed to assess risk of AMS for young adult Chinese males who newly entered high altitude regions (> 3000 m) by using simple and accessible population level factors which do not require complex or costly biochemical or physiological tests. This study had sufficient sample size to assess the impact of high altitude on AMS adjusting for the factors related to travel, demographics, and health behaviors which may affect AMS. The validity of AMS data from the military medical records is likely to be high, as the data were collected by trained investigators using rigorous criteria and the individual's health records were available (in most cases) for adjudication.Several limitations existed in this study design and should be considered when generalizing our findings to other populations or conditions. First, in this study the AMS diagnosis criteria were based on the published "Diagnostic Criteria of High Altitude Disease in China". Thus, the incidence of AMS may be different according to the use of different scoring systems, such as the Lake Louise AMS Scoring System. Second, the study was carried out in a homogenous population group; all were young adult males, and most were in similar physical fitness (including BMI). Third, in this study, occupation, diet, and physical load at high altitude were negligible because everyone experienced the same conditions. Therefore, the identifiable risk factors for AMS among such a specialized population are limited. Moreover, the results were based on previously collected data that did not allow direct testing of causal effects. Precise AMS severity was not described in all the medical records, limiting the study's ability to deal with the outcome of AMS as all-or-none. Finally, AMS cases were diagnosed by different observers over a period of almost four years, so some bias is inevitable and uncontrollable; however, we presumed the sample size was large enough to, at least partially, limit this confounding effect.From a public health perspective, medical departments must deploy reasonable medical human resources, medicines, and equipment to efficiently cope with AMS. All these preparations are based on quantitative pre-evaluation of a certain population's risk of developing AMS. In this study, we estimated the AORs of AMS risk and built an AMS prediction model for a young men population newly entering highland areas. When planning a highland operation, the high risk factors of low altitude homeland, high ascent rate, and high ascent altitude, should be minimized or the traveler's give more time for acclimatization . Effective health service plans could be made according to the group's travel profile and their ethnicity and birth province structure (quantitatively estimated by the AORs and the newly developed model). The Chinese traditional hypoxia prophylaxis, rhodiola and danshen, might be beneficial, although this needs further verification. At this time, it is difficult to make an accurate equation to precisely predict AMS, due to some shortcomings of the study design; thus, further investigations including other populations will be necessary. Nevertheless, the findings from this study provide a valuable reference to guide highland health services and provide information for further study.AMS: acute mountain sickness; 95%CI: 95% confidential interval; OR: odds ratio; AOR: adjusted odds ratio; NCO: non-commissioned officer; BMI: body mass index; receiver operating characteristic curves: ROC curves.The authors declare that they have no competing interests.YG and XL designed the study. XL collected and analyzed the data and drafted the manuscript. HY provided expert statistical advice. FT and YL collected the data. TP provided technical support. All authors were involved in critical evaluation and editing of the manuscript, and read and approved the final version.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2458/11/740/prepub


Falls are the number one cause of injuries in older adults, and are particularly common in long-term care (LTC). Lack of objective evidence on the mechanisms of falls in this setting is a major barrier to prevention. Video capture of real-life falls can help to address this barrier, if valid tools are available for data analysis. To address this need, we developed a 24-item fall video analysis questionnaire (FVAQ) to probe key biomechanical, behavioural, situational, and environmental aspects of the initiation, descent, and impact stages of falls. We then tested the reliability of this tool using video footage of falls collected in LTC.Over three years, we video-captured 221 falls experienced by 130 individuals in common areas  of two LTC facilities. The FVAQ was developed through literature review and an iterative process to ensure our responses captured the most common behaviours observed in preliminary review of fall videos. Inter-rater reliability was assessed by comparing responses from two teams, each having three members, who reviewed 15 randomly-selected videos. Intra-rater reliability was measured by comparing responses from one team at baseline and 12 months later.In 17 of the 24 questions, the percentage of inter- and intra-rater agreement was over 80% and the Cohen's Kappa was greater than 0.60, reflecting good reliability. These included questions on the cause of imbalance, activity at the time of the fall, fall direction, stepping responses, and impact to specific body sites. Poorer agreement was observed for footwear, contribution of clutter, reach-to-grasp responses, and perceived site of injury risk.Our results provide strong evidence of the reliability of the FVAQ for classifying biomechanical, behavioural, situational, and environmental aspects of falls captured on video in common areas in LTC. Application of this tool should reveal new and important strategies for the prevention and treatment of falls and fall-related injuries in this setting. Falls are the cause of over 90% of hip and wrist fractures  and 65% An important barrier to fall prevention is lack of objective evidence on the mechanisms of these events - how and why they occur. Our current understanding of the circumstances of falls is based on interviews or incident reports, exploring a limited set of outcomes in community-dwelling individuals -9. HowevVideo technology provides a means for capturing footage of real-life falls in high-risk environments such as LTC -16, and Between March 2007 and June 2010, we collected video footage of 221 falls experienced by 130 different residents from networks of digital video cameras installed in common areas  in two LTC facilities in the Greater Vancouver area: Delta View Life Enrichment Centre, a 312-bed multi-level facility located in Delta, BC, and New Vista Society Care Home, a 236-bed facility located in Burnaby, BC. In both facilities, no stairs were located in the areas accessible to residents. The Delta View facility had a network of 216 digital cameras, while New Vista facility had 48 cameras. All cameras were networked to digital video recorders, which stored video data at a resolution of 640 × 480 pixels and a frame rate of 15 frames per second.At both facilities, the occurrence of a fall  triggerResidents of New Vista had an average age of 81 years (SD = 13), and 67% were female. Residents at Delta View had an average age of 82 years (SD = 10), and 61% were female. Among the 15 participants included in this study, the mean age was 82 years (SD = 12), and 47% (n = 7) were women. As described previously , among rOur fall video analysis questionnaire (FVAQ) included 24 primary questions probing biomechanical, situational, behavioural, and environmental aspects of falls observed in the video footage Figure . While fFor fall initiation, we considered the biomechanical cause of imbalance, the activity at the time of the fall, and situational and environmental factors that have been associated with falls. These include clutter or tripping hazards, poor lighting, floor transitions, poor footwear, use of assistive devices, and held objects. Collectively, these items provide insight on “why” and “how” the fall occurred. We classified the biomechanical cause of imbalance based on the most common self-reported causes of falls in community-dwelling older adults  ,22-26. TFor fall descent, we considered the initial direction of the fall and attempts to recover balance or prepare for landing Figure . Fall diFor fall impact, we considered the landing configuration  and the occurrence of contact to key body sites  Table . CollectReliability testing was conducted over the course of one year. 15 fall videos were selected randomly (using a random number generator to minimize bias) from our database. Seven (47%) videos were recorded at New Vista and 8 (53%) were from Delta View. Four (27%) of the falls occurred relatively close to the camera, 5 (33%) occurred at a far distance, and 6 (40%) occurred at a moderate distance. The time interval between fall initiation  to fall impact ranged from about 700 ms (for a rapid trip) to 3000 ms ; and the corresponding number of video frames ranged from 10 – 45. There were no major body occlusions of body segments or missing frames.Our sample size of 15 falls was based on published guidelines for observer agreement studies . We estiWe first evaluated inter-rater reliability by having two teams separately analyze the selected 15 videos. Each team consisted of three members, who were research assistants or graduate students trained by co-author SNR using the previously mentioned instruction manual. Team members were blinded to answers from the other team. Furthermore, team members were prevented from examining corresponding fall incident reports completed by LTC care providers . Intra-rater reliability was evaluated by having one team (consisting of the same three members) re-analyze the same 15 videos one year later, while blinded to their previous answers. Each team was led by a chair, who provided instructions and recorded the team’s answers to each question. The videos were played using Windows Movie Maker . During analysis, the team members first viewed the video at normal speed, and then through frame-by-frame review while discussing and reaching consensus on the most appropriate answer to each question. We did not include “can’t tell” responses. Rather, for each question, the team was instructed to select the best available answer, along with the estimated probability (between 1-100%) of the answer being correct. On average, each fall was examined for approximately 20 minutes.For each question, we report the percentage of agreement between the two teams, calculated as the number of cases with the same response divided by the total number of cases, and the corresponding Cohen’s Kappa coefficient . Landis 2 = 0.37; p = 0.001).19 of the 24 questions had good inter-rater reliability, with a percentage of agreement over 80% and Cohen's Kappa greater than 0.60 Table . Among a2 = 0.31; p = 0.005).18 of 24 questions had good intra-rater reliability Table . The aveGood inter- and intra-rater reliability was observed for biomechanical cause of imbalance, activity at the time of the fall, use of mobility aids, height of the fall, and floor conditions Table . HoweverGood inter- and intra-rater reliability was observed for initial fall direction and stepping responses Table . There w2 = 0.84; p < 0.001).Good inter- and intra-rater reliability was observed for landing configuration and impact to the head, pelvis, hand, and knee Table . Only moFalls are the number one cause of injury in older adults, and are particularly common in LTC. Lack of objective evidence on the mechanisms of falls in this setting is a major barrier to prevention. Video capture of real-life falls can address this barrier, if valid analysis tools are available. In this study, we developed and evaluated the reliability of a comprehensive questionnaire for analyzing falls captured on video in LTC. We focused the FVAQ on the initiation, descent, and impact stages of falls ,20 and tOur results provide strong evidence of the reliability of the FVAQ. We found that 17 of the 24 questions met our criteria for good inter-rater and intra-rater reliability. Teams rated their probability in selecting the correct answer between 84 - 100% (depending on the question), reflecting their strong confidence, and the adequacy of our video collection techniques, in identifying key features of the fall . A significant correlation existed between agreement and probability, although probability explained only 37% and 31% of the variance in inter-rater and intra-rater agreement, respectively.In completing the FVAQ, the team often faced challenges related to camera resolution, distance between the faller and the camera. In each case, only a single camera recorded the fall. Clearly, improvements in the number and resolution of cameras should improve the reliability of most questions in the FVAQ. However, of the six poorly scoring questions, only one - type of footwear – was clearly related to video quality . More complex challenges arose for other items, which might be addressed through refinements to the questions and/or instruction manual for improved clarity. For example, we observed poor reliability for contribution of clutter in causing the fall. This may more relate to the ambiguity in our definition of clutter, or the challenge of attributing casual links between falls and environmental features , aside fThe 24 questions on the FVAQ probe previously hidden aspects of falls and contribute new information to guide fall prevention efforts. For example, information on the biomechanical causes of imbalance and activities leading to falls (both of which exhibited strong reliability) helps to guide improved fall risk assessment and balance training protocols, along with efforts to reduce environmental hazards and create safer movement environments supports . InformaHowever, there are important limitations to our study. We focused on assessing the internal reliability (reproducibility of results) of the FVAQ. Additional studies are required to examine external validity, for example by relating FVAQ responses to data from fall incident reports, observed injuries, risk for future falls, and the nature of future falls. Furthermore, we designed the FVAQ to focus on the situational and environmental context of falls in common areas of two LTC facilities . Accordingly, it may not capture the range of mechanisms of falls in bedrooms, bathrooms, and stairways, or among healthier older adults living in the community. Furthermore, the FVAQ probes a limited set of features of the built environment, behavioural factors (such as secondary attention tasks or aggression), and disease-related behaviours . Finally, we recognize that currently, there is limited partnering between researchers and care providers in LTC for video capture of falls. We hope that our model for data collection and analysis facilitates growth in the applications of this tool to LTC and other high risk settings, such as hospitals or senior centres ,40. FurtIn summary, this study presents and establishes the reliability of a questionnaire for analyzing the mechanisms of falls captured on video in common areas of LTC. The FVAQ opens a window on key aspects of fall initiation, descent, and impact. When combined with health data, the FVAQ should provide researchers and clinicians with an improved understanding of the mechanisms and guidance in the prevention of falls and fall-related injuries in the high-risk LTC setting.LTC: Long-term care; FVAQ: Fall video analysis questionnaire.The authors declared that they have no competing interests.YY participated in the experimental design, data collection, data analysis, preparation and review of the manuscript. RS participated in the data collection, data analysis, preparation and review of the manuscript. FF participated in the experimental design, data collection, and review of the manuscript. SR participated in the experimental design, data collection, data analysis, preparation and review of the manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2318/13/40/prepubFall Video Analysis Questionnaire (FVAQ) – short form version.Click here for fileFall video analysis instruction manual (short version).Click here for file


ED visits diagnosed as migraine among females in two cities in Canada, Toronto (N = 704) and Ottawa , were analyzed. In the study case-crossover design was used. Conditional logistic regression was realized to estimate odds ratios (ORs) and their 95% confidence intervals (CIs) relative to an increase in an interquartile range  of sulphur dioxide. In the constructed conditional logistic regression models, temperature and relative humidity were adjusted in the form of natural splines. In Toronto positive and statistically significant associations of sulphur dioxide with migraine ED visits were obtained: all ages, OR = 1.04 ; age group , OR = 1.05 . In Ottawa positive correlations were observed: all ages, OR = 1.05 ; age group , OR = 1.06 . The results suggest that female migraine may be affected by ambient sulphur dioxide.Ambient sulphur dioxide (SO The aim of this paper was to investigate potential correlations between ambient sulphur dioxide and female emergency department (ED) visits for migraine in two Canadian cities, Toronto and Ottawa, two locations with different levels of the pollutant concentrations. Case-crossover (CC) design was used . ConditiThis study was inspired by a few recent publications –5, relatPopulation considered in this study were patients served by two different hospitals in Canada: in Toronto and Ottawa. In Toronto we considered the period between April 1, 1999 and March 31, 2002. In this time period we had 898 ED visits diagnosed as migraine, where 704 cases (78%) were females. In Ottawa we considered the period between April 1, 1992 and December 31, 2000, and we identified 4,568 migraine cases, 74% among them  were female patients. We considered patients of all ages. We applied the ICD-9 codes , second , and each next was created from the current one by shifting it by one year. In this sequence, the last element was defined to be the age group . The length of the age groups (here 30 years) was chosen rather arbitrarily but in relation to the number of ED visits. For the elements of this sequence, the CC analysis was performed separately. Thus the first OR corresponds to the age group , second , and so on. The calculations were executed for female patients only.Hourly air pollution data were obtained from fixed monitoring stations in the considered cities. These data were supplied by Environment Canada. For each air pollution variable, we have 24 measurements recorded at hourly intervals. The daily shared exposures of the population were expressed as mean values among stations in city In Toronto positive and statistically significant associations of sulphur dioxide with migraine were obtained: all ages, OR = 1.04 ; age group , OR = 1.05 . In Ottawa positive associations (no significant) were observed: all ages, OR = 1.05 ; age group , OR = 1.06 . Our hypothesis is that ambient sulphur dioxide is associated with ED visits for migraine. The above reported results were obtained using the time-stratified  case-crossover technique. It is possible that by increasing the number of control periods, we may improve our estimations [The main results are organized in the form of three figures .In Toronto, for many age groups the results were positive and statistically significant  short-term effects were observed for ambient sulphur dioxide exposures on daily ED visits for migraine for females. Ambient air pollutant affects patients of different age ranges. The results suggest that above a specific level of sulphur dioxide concentrations or acute air pollution events (large Q3) might result in elevated number of ED visits for this health condition. The shape of the relations by age group Figures  and 2 inA few published studies have examined the effect of air pollution on migraine. In previous publication related to ED in Ottawa , the autThe limitations of this study are typical of this type of research. They include the adequacy of the model and impact of measurement error in the exposure and outcome variables . The maiThe results support the hypothesis that ED visits for migraine condition are associated with ambient sulphur dioxide. The large majority of this air pollution arises from combustion of fossil fuels .


Plasmodium vivax congenital malaria case in Guatemala and the first case in Latin America with genotypical, histological and clinical characterization. The findings show that maternal P. vivax infection still occurs in areas that are in the pathway towards malaria elimination, and can be associated with detrimental health effects for the neonate. It also highlights the need in very low transmission areas of not only maintaining, but increasing awareness of the problem and developing surveillance strategies, based on population risk, to detect the infection especially in this vulnerable group of the population.This is a report of the first  Congenital malaria (CM) has been an often neglected consequence of malaria in pregnancy. It occurs when malaria parasites cross the placenta either during pregnancy or at delivery -3. TherePlasmodium falciparum and from sub-Saharan Africa [Congenital malaria has been predominantly reported for n Africa -7. The pn Africa ,6,8. Then Africa -12. Littn Africa ,14. MorePlasmodium vivax congenital mono-infection on the neonate’s health have not yet been reported. This is the first P. vivax CM case from Guatemala and the first case in Latin American in which a comprehensive clinical, histological and genotypical investigation has been carried out.In Latin America, reports on CM have been scarce ,15,16; aP. falciparum has been reported in the FBC area . Malaria transmission is sustained in the population by the temporal succession of the main vectors, Anopheles albimanus, Anopheles vestitipennis and Anopheles darlingi[On September 2010, a 21-days-old female baby with a two-day history of fever was admitted to Fray Bartolomé de las Casas (FBC) District Hospital. FBC is a rural low-transmission malaria endemic area  in Northern Guatemala. FBC was a high-risk area where malaria transmission has been greatly reduced over the last years due to a scale-up of control interventions. Long-lasting insecticide-treated nets (LLITNs) and the improvement of the case management system implemented from 2006, resulted in a dramatic reduction in malaria parasite incidence from 91/1,000 population in 2006 to 1.9/1,000 population in 2010. Since 2009, no case of  darlingi.st day of admission, 24,000 platelets/μL on the 2nd day of admission), and leucopaenia (white blood cells 3.5x103/μL) with relative lymphocytosis (66.8%). Yet, the newborn did not show any signs or symptoms of haemodynamic failure nor evidence of bleeding throughout admission or after discharge. Biochemical and microbiological examinations were not available in the hospital. Based on initial suspicion of neonatal sepsis, the baby was started on intravenous (IV) ampicillin along with IV fluids and antipyretics. The thick blood smear examination showed P. vivax infection , and then she was started on anti-malarial treatment with oral chloroquine (CQ) . The neonate was treated with CQ only, following national guidelines in Guatemala that do not recommend the administration of primaquine to infants less than six months. Clinical progress was adequate and the baby was discharged after treatment completion. National guidelines also recommend therapy with ¼ tablet of CQ 150 mg base every 21 days until the patient is six months of age, so the infant kept on with CQ prophylaxis until that age after treatment completion. Follow-up during household visits two and eight months after hospital discharge was also favourable.On admission physical examination of the baby revealed paleness, hepatosplenomegaly (1 cm), dusky skin appearance and desquamation, and a body temperature of 36.7°C which increased to 38.9°C in the next 24 hours. Neurological, respiratory and cardiac examinations were unremarkable. Main laboratory findings were anaemia (Hb 7.2 g/dL), severe thrombocytopaenia  visit, at 16 weeks of gestational age, in a multi-centre descriptive study –PregVax study- aimed to determine the burden and impact of This is a retrospective congenital malaria case report that mainly builds on the hospital clinical data available during its management. Molecular analyses, which were available due to the mother’s participation in the main study and carried out after the detection of CM infection, allowed the confirmation of the malaria case.Plasmodium infection was not detected in the mother, either actively or passively, during pregnancy, neither by microscopy nor by polymerase chain reaction (PCR) at any of the ANC at 16, 21 and 26 weeks of gestational age. Delivery was at term (40 weeks), and the birth weight was 2,839 g. At delivery, the mother reported fever within the last 24 hours. Physical examination showed an axillary temperature of 38°C, paleness, and laboratory tests showed thrombocytopaenia  and haemoglobin of 12.4 g/dL. Plasmodium vivax asexual parasites  were detected in peripheral blood . Cord blood parasitaemia determination is not routinely done at this health facility. In this case, cord blood parasitaemia determination was done later after birth at the study referral laboratory as part of the study objectives.Immediately after birth, physical examination of the newborn revealed no clinical abnormalities. No Plasmodium vivax infection was detected by conventional PCR for specific P. vivax merozoite surface protein 1 gene (Pvmsp1) in all samples except in the newborn’s blood at the time of birth . Species-specific primers and probes were used as previously described by Veron et al. [DNA extraction (Purelink TM Genomic DNA Kit – Invitrogen) was done on one whole blood-spot on filter paper from each of the following compartments: maternal peripheral blood at delivery, placental and cord blood, and neonate’s blood at the time of birth and during hospital admission. n et al. , selecteP. vivax microsatellites (MS) were amplified from P. vivax positive samples as described in Karunaweera et al. [2, 200 μM of each deoxynucleotide triphosphate, 5 picomoles of each primer and 2.5U of FastStar Taq polymerase (Roche). To determine the amplicon length variation, PCR products were analyzed by CEQ 8000 Genetic Analysis System (Beckman Coulter) using CEQ 8000 software for fragment analysis. Identical allelic profiles were obtained at the seven MS loci tested , confirming that the same genotype was present in all compartments.Seven a et al. . BrieflyP. vivax congenital malaria in Guatemala and the first one from Latin America with clinical, histological and genotypical characterization. Co-infection with P. falciparum was excluded by molecular diagnosis, and the same parasite genotype in maternal blood at delivery, in placental and cord blood and in peripheral blood of the 21-days-old neonate was detected by microsatellite genotyping.This is the first reported case of P. vivax, but only three were reported as CM cases [Plasmodium species was excluded. Most of the information on CM comes from high malaria transmission areas and indicates that CM is rarely symptomatic [Several reports have been published from Latin America on malaria infection during the neonatal period ,22,23 moCM cases ,15,16. Iptomatic .P. vivax infection, however, the possibility of a new infection, although very unlikely, it cannot be totally ruled out.In the case outlined here, the onset of symptoms occurred 21 days after birth. The possibility that the neonate’s infection was acquired in the short period after birth from an infected mosquito bite is very low given the low malaria transmission in the FBC area. The microsatellite genotyping showing identical allelic profiles at all MS loci tested does reinforce the vertical transmission of the P. vivax infection and/or by the absence of a placental binding phenotype of P. vivax parasites [The physiopathology of CM is not well known. It has been hypothesized that, although the placenta functions as an effective barrier, maternal micro-transfusions into the foetal circulation, and direct penetration of the parasite through the placental villi could lead to vertical transmission of malaria . In thisarasites .In a malaria pre-elimination context, as is the case of the FBC area, the level of acquired anti-malarial immunity in the population may decreased and waned dramatically leading to increased susceptibility and risk of more severe forms of malaria when infection occurs. This may be particularly frequent and serious in vulnerable groups of the population, such as pregnant women and neonates. In the current case, the baby presented with severe thrombocytopaenia and anaemia, both being potential life-threatening haematological complications. This report highlights the need of establishing epidemiological and clinical surveillance strategies as malaria control programmes are reducing transmission to near-elimination levels, to effectively and promptly detect infections ,27. The P. vivax malaria occurs in very low malaria endemic settings, and it may be detrimental for the infant’s health. These findings emphasize the relevance in very low transmission areas of not only maintaining, but even increasing clinical and epidemiological awareness of this preventable and treatable disease in pregnancy and in the neonate. They also highlight the need for establishing active surveillance strategies in the areas that are in the pathway towards malaria elimination.Mother-to-child transmission of The case study protocol was approved by the Universidad del Valle de Guatemala Ethics Review Committee. Written informed consent was obtained from the mother for her participation and that of her baby for the publication of this case report. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.All authors have made substantial contributions to the investigations presented in this manuscript. MEC supervised all data collection and participated in drafting the manuscript, AB drafted the manuscript, and NP conceived and designed the report. MM and CS carried out the molecular and genotyping studies. AB, NP, AM, MD and CM revised the manuscript. All authors have read and approved the final manuscript.