Endoscopic treatment of an esophageal perforation in eosinophilic esophagitis by insertion of a self-expanding metal stent.

We present the case of a 29-year-old patient with multiple allergies, mild asthma and rhinoconjunctivitis who reported a history of esophageal impactions after ingestion of solid foods. These episodes resolved spontaneously at home and by self-induced vomiting and never required endoscopic removal. The patient presented to the emergency department due to a sensation of food impaction lasting more than 12 hours after eating meat the night before, which did not subside with the intake of liquids or self-induced vomiting. Endoscopic evaluation was requested for foreign body extraction. A meat bolus impacted in the distal esophagus was easily removed using a Roth basket, revealing a severe esophageal stricture that prevented passage of the endoscope into the gastric cavity. Furthermore, in the same area where the foreign body was previously located, a deep esophageal tear was seen. Given the high suspicion of perforation, the patient was examined, and thoracic and cervical crepitation was observed. It was decided to immediately insert, with only endoscopic control, a partially covered Ultraflex® esophageal stent measuring 18 mm in diameter and 15 cm in length. After insertion, clinical improvement and cessation of crepitation were observed.

Comparison between multicomponent and simultaneous dual-task exercise interventions in long-term nursing home residents: the Ageing-ONDUAL-TASK randomized controlled study.

BACKGROUND: the potential benefits of dual-task interventions on older adults living in long-term nursing homes (LTNHs) from a multidimensional perspective are unknown. We sought to determine whether the addition of simultaneous cognitive training to a multicomponent exercise program offers further benefits to dual-task, physical and cognitive performance, psycho-affective status, quality of life and frailty in LTNH residents. Design: a single-blind randomized controlled trial. SETTING: nine LTNHs in Gipuzkoa, Spain. SUBJECTS: 85 men and women (ACTRN12618000536268). METHODS: participants were randomly assigned to a multicomponent or dual-task training group. The multicomponent group performed two sessions per week of individualized and progressive strength and balance exercises for 3 months. The dual-task group performed simultaneous cognitive tasks to the same tasks as in the multicomponent group. Gait speed under single- and dual-task conditions, physical and cognitive performance, psycho-affective status, quality of life and frailty were measured at baseline and after 3 months of intervention. RESULTS: both groups showed clinically significant improvements on gait performance under single- and dual-task conditions and on the short physical performance battery (P < 0.05). Both interventions were effective in maintaining cognitive function (P > 0.05). Only the multicomponent group significantly improved quality of life, and reduced anxiety and Fried frailty score (P < 0.05). No group-by-time interactions were found except for the chair-stand test in favour of the multicomponent group (P < 0.05). CONCLUSIONS: the addition of simultaneous cognitive training does not seem to offer significantly greater benefits to the evaluated multicomponent exercise program in older adults living in LTNHs.

CADORmed: a tool for internal dose assessment.

CADORmed is a free bespoke Excel® tool for committed effective dose assessment using latest dose coefficients from ICRP OIR publications. The field of application of CADORmed is special monitoring, and it is not available for the dose assessment of chronic exposure. Calculations are made according to EURADOS guidelines and principles (EURADOS report 2013-1). The Chi-squared test for the goodness of fit is made with a scattering factor for type A and type B errors according to the EURADOS report. The Intake is calculated with the maximum likelihood method. Measurements that are below the detection limit are incorporated by the use of an allocated value equal to one-half or one-quarter of the detection limit. The Identification of rogue data can easily be achieved. Advanced options may also be used: mixed ingestion and inhalation, mixture of default absorption types, correction for DTPA treatment, calculation with a new intake and adjustment when the date of intake are unknown. The validation of the tool has been included in the work plan of EURADOS WG 7. The validation plan has been defined and the validation tests completed. All changes are traced in a Quality Assurance document.

Bioassays in workers exposed to long time random intakes.

Workers who are occupationally exposed to radioactive aerosols are usually subjected to periodic controls of internal contamination by performing bioassays (whole body or partial body monitoring and measurement of excreta samples). The intakes are also estimated by using Static Air Samples (SAS). These measurements are used to estimate the radioactive intakes of the workers. A typical assumption is the workers are chronically (constant) exposed for long periods of time. However, the intakes are random and there are also periods without any exposure (weekends, holidays, etc.). The method presented here considers both facts. Simulations help to choose the most appropriate method of evaluation to minimize the statistical uncertainties in the intake. It has been applied to evaluate workers exposed to UO2 aerosols for a long time (30 years or more for most of them) in the same working area (sintering). Results of measurements of uranium in urine and daily intakes (from SAS) of these workers have been used. For this evaluation, the new Occupational Intakes of Radionuclides (OIR) biokinetic models of the International Commission on Radiological Protection (ICRP) for uranium have been solved. For some workers the evaluation gives a significative deviation between the intake estimated from urine samples and the intake estimated using the SAS values, supporting the idea that the physiological standard parameters of the reference worker are not always applicable. The computations have been implemented in the BIOKMOD code.

INTERNAL DOSIMETRY TOOL FOR THE IMPLEMENTATION AND USE OF NEW ICRP/OIR MODELS: A CAESIUM STUDY.

In case of accidental intake of radioactive material, the dose assessment requires information on the radionuclide distribution in the body. Measurements of retention or excretion are compared with model's predictions to estimate the intake. The reference models for internal dosimetry purposes are those proposed by ICRP and have been recently updated in the 'Occupational Intakes of Radionuclides (OIR)' series. This work focusses on the implementation of the new caesium model in a computer package, ICRP130Models (integrated in the toolbox BIOKMOD), together with new features aimed at estimating the intake and the dose from bioassay measurements. The software gives the best fitted intake and the committed effective dose, as well as the chi-squared test and the p-value as an indication of the goodness of the fit in the assessment process. The possibility to build the model as a function of a parameter allows the user to look for different options when fitting the bioassay measurements.

SLM Manufacturing Redesign of Cooling Inserts for High Production Steel Moulds and Benchmarking with Other Industrial Additive Manufacturing Strategies.

Moulding technologies are remarkably effective for parts requiring high production volumes. Yet cooling the moulds after each injection can cause a significant loss of time. A possibility for reducing the cooling times is to use cooling inserts and conformal cooling strategies. In the present case, the original inserts of a mould must be substituted because the original material cannot be utilized anymore (toxicity). Will it be technically feasible to achieve a proper cooling only by modifying the inserts? Here, the cooling inserts of high production steel moulds utilized to manufacture ribs for swimming pool sinks' plastic cages are redesigned, simulated and manufactured, taking advantage of Selective Laser Melting possibilities and without modifying the geometry of the obtained parts, nor the rest of the moulds. The results reveal a reduction in the mould cooling times of up to 8%, while maintaining the same conformation properties, thus leading to important savings of time and some global costs in the production outcomes. The study also benchmarks the production economic limits of this approach compared to other possible strategies, such as the development of full new conformal cooling moulds or the industrial production of the parts with plastic additive manufacturing (multi jet fusion) technology.

THE EURADOS WORK TOWARDS A REVIEW ON RETROSPECTIVE DOSIMETRY AFTER INCORPORATION OF RADIONUCLIDES.

Biological dosimetry methods are well established and validated for providing dose estimates following external radiation exposures. In contrast, interpreting biological dosimetry data in cases of internal exposures is still challenging. In this context, a joint collaboration between two Working Groups (WG) of European Radiation Dosimetry Group (EURADOS), WG10 on 'Retrospective Dosimetry' and WG7 on 'Internal Dosimetry', was initiated with the aim to address the main issues related to the advantages and limitations of biological and electron paramagnetic resonance (EPR) dosimetry in cases of internal and mixed internal/external exposures. The organization of the review work, the main findings of the analysis performed and the driving lines for possible future research work are briefly described in the present document.

Bioassay and alpha spectrometry in indirect monitoring of Spanish workers exposed to enriched uranium.

Workers at risk of exposure to uranium compounds should be monitored and their internal exposure quantified in terms of committed effective dose E(50) in mSv. In vitro bioassay methods can quantify uranium in urine and faeces at low activity levels. Alpha spectrometry (AS) is the most common method used for monitoring alpha-emitting radionuclides in internal dosimetry services. It provides isotopic information and low minimum detectable activity (MDA) values (≤0.50 mBq per sample). This study reports the results of a five-year monitoring of workers exposed to uranium at a Spanish Juzbado facility, which produces nuclear fuel elements enriched with up to 5 % of 235U. Monitoring included about 100 workers per year, most of whom had worked at the facility for more than 10 years before the individual monitoring programme was established. We analysed nearly 550 samples of more than 200 workers over five years. The obtained results indicate that workers were adequately protected from uranium exposure through inhalation and had an acceptably low chronic intake at the facility.

Measurements and Monte Carlo Simulations of 241Am Activities in Three Skull Phantoms: EURADOS-USTUR Collaboration.

An international intercomparison was organized by Working Group 7, Internal Dosimetry, of the European Radiation Dosimetry Group in collaboration with Working Group 6, Computational Dosimetry, for measurement and Monte Carlo simulation of Am in three skull phantoms. The main objectives of this combined exercise were (1) comparison of the results of counting efficiency in fixed positions over each head phantom using different germanium detector systems, (2) calculation of the activity of Am in the skulls, (3) comparison of Monte Carlo simulations with measurements (spectrum and counting efficiency), and (4) comparison of phantom performance. This initiative collected knowledge on equipment, detector arrangements, calibration procedures, and phantoms used around the world for in vivo monitoring of Am in exposed persons, as well as on the Monte Carlo skills and tools of participants. Three skull phantoms (BfS, USTUR, and CSR phantoms) were transported from Europe (10 laboratories) to North America (United States and Canada). The BfS skull was fabricated with real human bone artificially labeled with Am. The USTUR skull phantom was made from the US Transuranium and Uranium Registries whole-body donor (case 0102) who was contaminated due to an occupational intake of Am; one-half of the skull corresponds to real contaminated bone, the other half is real human bone from a noncontaminated person. Finally, the CSR phantom was fabricated as a simple hemisphere of equivalent bone and tissue material. The three phantoms differ in weight, size, and shape, which made them suitable for an efficiency study. Based on their own skull calibration, the participants calculated the activity in the three European Radiation Dosimetry Group head phantoms. The Monte Carlo intercomparison was organized in parallel with the measurement exercise using the voxel representations of the three physical phantoms; there were 16 participants. Three tasks were identified with increasing difficulty: (1) Monte Carlo simulation of the simple CSR hemisphere and the Helmholz Zentrum München high-purity germanium detector for calculating the counting efficiency for the 59.54 keV photons of Am, in established measurement geometry; (2) Monte Carlo simulation of particular measurement geometries using the BfS and USTUR voxel phantoms and the Helmholz Zentrum München high-purity germanium detector detector; and (3) application of Monte Carlo methodology to calculate the calibration factor of each participant for the detector system and counting geometry (single or multidetector arrangement) to be used for monitoring a person in each in vivo facility, using complex skull phantoms. The results of both exercises resulted in the conclusion that none of the three available head phantoms is appropriate as a reference phantom for the calibration of germanium detection systems for measuring Am in exposed adult persons. The main reasons for this are: (1) lack of homogeneous activity distribution in the bone material, or (2) inadequate shape/size for simulating an adult skull. Good agreement was found between Monte Carlo results and measurements, which supports Monte Carlo calibration of body counters as an alternative method when appropriate physical phantoms are not available and the detector and source are well known.

Monitoring and Dose Assessment for Children Following a Radiation Emergency-Part II: Calibration Factors for Thyroid Monitoring.

Past radiological and nuclear accidents have demonstrated that monitoring a large number of children following a radiological and nuclear emergency can be challenging, in accommodating their needs as well as adapting monitoring protocols and applying age-specific biokinetics to account for various ages and body sizes. This paper presents the derived calibration factors for thyroid monitoring of children of all ages recommended by the International Commission on Radiological Protection using four selected detectors at given times following a short-term (acute) intake of I by inhalation. These calibration factors were derived by Monte Carlo simulations using the models of various detectors and pediatric voxel phantoms. A collection of lookup tables is presented in this paper which may be directly used as a quick reference by emergency response personnel or technical experts performing thyroid monitoring and assessment without doing time-consuming calculations.

Experiences of Population Monitoring Using Whole-Body Counters in Response to the Fukushima Nuclear Accident.

Whole-body counter measurements of residents of Fukushima Prefecture have been extensively performed after the Fukushima Dai-ichi Nuclear Power Plant accident in March 2011. These measurements have demonstrated that the levels of internal contamination with radioactive cesium (Cs and Cs) in the residents are very low. This article provides an overview of and lessons learned from these whole-body counter measurements with emphasis on the technical problems encountered, and it discusses the effective use of whole-body counters for assessing the internal thyroid doses of individuals when direct measurements of I in the thyroid are difficult or impossible to implement for the total affected population in a short time after a nuclear reactor accident. The application of this dose reconstruction method requires determining the intake ratio of I to cesium isotopes at appropriate times and considers the short biological half-lives of cesium isotopes, in particular for children.

Managing Internal Radiation Contamination Following an Emergency: Identification of Gaps and Priorities.

Following a radiological or nuclear emergency, first responders and the public may become internally contaminated with radioactive materials, as demonstrated during the Goiânia, Chernobyl and Fukushima accidents. Timely monitoring of the affected populations for potential internal contamination, assessment of radiation dose and the provision of necessary medical treatment are required to minimize the health risks from the contamination. This paper summarizes the guidelines and tools that have been developed, and identifies the gaps and priorities for future projects.

Summing coincidence errors using 152Eu lungs to calibrate a lung-counting system: are they significant?

The use of a lung phantom containing 152Eu/241 Am activity can provide a sufficient number of energy lines to generate an efficiency calibration for the in vivo measurements of radioactive materials in the lungs. However, due to the number of energy lines associated with 152Eu, coincidence summing occurs and can present a problem when using such a phantom for calibrating lung-counting systems. A Summing Peak Effect Study was conducted at three laboratories to determine the effect of using an efficiency calibration based on a 152Eu/241 Am lung phantom. The measurement data at all three laboratories showed the presence of sum peaks. While one of the laboratories found only small biases (< 5%) when using the 152Eu/241 Am calibration, the other facilities noted up to 30% positive bias in the 140 keV to 190 keV energy range that prevents the use of the 152Eu/241 Am lung phantom for routine calibrations. Although manufactured by different vendors, the three facilities use similar types of germanium detectors (38 cm2 by 25 mm thick or 38 cm2 by 30 mm thick) for counting. These results underscore the need to evaluate the coincidence summing effect, which appear system dependent, when using a nuclide such as 152Eu for the calibration of low-energy lung counting systems and highlight the problem of using a general calibration curve in place of specific nuclide calibration factors.

Developing a physiologically based approach for modeling plutonium decorporation therapy with DTPA.

PURPOSE: To develop a physiologically based compartmental approach for modeling plutonium decorporation therapy with the chelating agent Diethylenetriaminepentaacetic acid (Ca-DTPA/Zn-DTPA). MATERIALS AND METHODS: Model calculations were performed using the software package SAAM II (©The Epsilon Group, Charlottesville, Virginia, USA). The Luciani/Polig compartmental model with age-dependent description of the bone recycling processes was used for the biokinetics of plutonium. RESULTS: The Luciani/Polig model was slightly modified in order to account for the speciation of plutonium in blood and for the different affinities for DTPA of the present chemical species. The introduction of two separate blood compartments, describing low-molecular-weight complexes of plutonium (Pu-LW) and transferrin-bound plutonium (Pu-Tf), respectively, and one additional compartment describing plutonium in the interstitial fluids was performed successfully. CONCLUSIONS: The next step of the work is the modeling of the chelation process, coupling the physiologically modified structure with the biokinetic model for DTPA. RESULTS of animal studies performed under controlled conditions will enable to better understand the principles of the involved mechanisms.

Comparison of two leg phantoms containing (241)Am in bone.

Three facilities (CIEMAT, HMGU and HML) have used their in vivo counters to compare two leg phantoms. One was commercially produced with (241)Am activity artificially added to the bone inserts. The other, the United States Transuranium and Uranium Registries' (USTUR) leg phantom, was manufactured from (241)Am-contaminated bones resulting from an intake. The comparison of the two types of leg phantoms showed that the two phantoms are not similar in their activity distributions. An error in a bone activity estimate could be quite large if the commercial leg phantom is used to estimate what is contained in the USTUR leg phantom and, consequently, a real person. As the latter phantom was created as a result of a real contamination, it is deemed to be the more representative of what would actually happen if a person were internally contaminated with (241)Am.

[Socio-cultural and perinatal factors associated with exclusive breast feeding]. / Factores socioculturales y perinatales relacionados con la lactancia materna exclusiva.

OBJECTIVE: To determine the prevalence of exclusive breastfeeding (EBF) in a Basic Health Area, and the maternal factors and socio-cultural perinatal problems related to the initiation and maintenance of the EBF. METHOD: Observational, cross-sectional study. The study was carried out in Mazarrón Health Center (Cartagena Primary Care Management, Area II, Murcia).The participants of the study were all the children born between 11/01/2004 and 11/30/2005 along with their mothers (236 children overall). The study consisted of an interview that was conducted by a nurse during the 15 months check-up. The questionnaire was made up of thirteen questions including, sex, race, place of birth, weight, birth weight, prematurity, number of siblings (Perinatal care variables), and others, such as, age, number of children, nationality, education and occupation ( maternal variables) and one question on the number of EBF months. Those children who did not attend the health center and those who were not found during the data collection period did not participate in the research. RESULTS: The number of mothers who responded to the questionnaire was 89.8% (212). The prevalence at the beginning of EBF is 75.4% (156) of all children. The average length of EBF is 2.99 months. The average maternal age is 31.26 years. The percentage of mothers who did not work was 45.9% (89). The lowest percentage of EBF is found in premature boys born by caesarean. Maternal origin positively influences EBF. The women with the greatest breastfeeding capacities are African. CONCLUSIONS: Both the prevalence at home and the average length of the EBF in the Health Area are high; the most influencing maternal factors are maternal origin and the type of childbirth.

The CONRAD approach to biokinetic modeling of DTPA decorporation therapy.

Diethylene Triamine Pentaacetic Acid (DTPA) is used for decorporation of plutonium because it is known to be able to enhance its urinary excretion for several days after treatment by forming stable Pu-DTPA complexes. The decorporation prevents accumulation in organs and results in a dosimetric benefit, which is difficult to quantify from bioassay data using existing models. The development of a biokinetic model describing the mechanisms of actinide decorporation by administration of DTPA was initiated as a task in the European COordinated Network on RAdiation Dosimetry (CONRAD). The systemic biokinetic model from Leggett et al. and the biokinetic model for DTPA compounds of International Commission on Radiological Protection Publication 53 were the starting points. A new model for biokinetics of administered DTPA based on physiological interpretation of 14C-labeled DTPA studies from literature was proposed by the group. Plutonium and DTPA biokinetics were modeled separately. The systems were connected by means of a second order kinetics process describing the chelation process of plutonium atoms and DTPA molecules to Pu-DTPA complexes. It was assumed that chelation only occurs in the blood and in systemic compartment ST0 (representing rapid turnover soft tissues), and that Pu-DTPA complexes and administered forms of DTPA share the same biokinetic behavior. First applications of the CONRAD approach showed that the enhancement of plutonium urinary excretion after administration of DTPA was strongly influenced by the chelation rate constant. Setting it to a high value resulted in a good fit to the observed data. However, the model was not yet satisfactory since the effects of repeated DTPA administration in a short time period cannot be predicted in a realistic way. In order to introduce more physiological knowledge into the model several questions still have to be answered. Further detailed studies of human contamination cases and experimental data will be needed in order to address these issues. The work is now continued within the European Radiation Dosimetry Group, EURADOS.

Aplicaciones médicas como ayuda al diagnóstico en la medicina. Experiencia SOFTEL-MINSAP / Medical application for support of diagnosis in medicine. SOFTEL-MINSAP experience

La Inteligencia Artificial (IA) en una primera aproximación, se puede definir como la rama de la computación que estudia la automatización del comportamiento inteligente. La investigación en este campo ha llevado al desarrollo de herramientas computacionales específicas, entre las cuales se cuentan una gran diversidad de formalismos de representación de conocimientos y de algoritmos que los aplican, además de los lenguajes, estructuras de datos y técnicas de programación utilizados para su implementación. Este mecanismo es el que intentan imitar los programas de inteligencia artificial llamados sistemas expertos o sistemas basados en el conocimiento. La Empresa SOFTEL, perteneciente al Ministerio de la Informática y las Comunicaciones (MIC), desde sus inicios desarrolló la informática médica, y dentro de ésta la rama de Inteligencia Artificial en aplicaciones como INFOTOXI, encargado de controlar y diagnosticar intoxicación por productos tóxicos en centros dedicados a este tema; GERISOFT, para la Atención Primaria de Salud del adulto mayor y el SEAA, Sistema de Ayuda Diagnóstica en la Asistencia Primaria. Para desarrollar estos sistemas se apoyaron en el conocimiento de médicos especialistas del Ministerio de Salud Pública (MINSAP) en calidad de expertos. Dichos sistemas fueron instalados en diferentes unidades del sistema de salud(AU)

Artificial Intelligence (AI) in a first approximation can be defined as the branch of computer science that studies the automation of intelligent behavior. This research has led to the development of specific computational tools, which include a wide range of knowledge representation formalisms and related algorithms, in addition to the language of data structures and programming techniques used for its implementation. This mechanism is attempting to imitate the programs of artificial intelligence known as expert systems or knowledge-based systems. Softel Company, owned by the Ministry of Informatics and Communications (MIC), from its inception has developed medical informatics within this branch of artificial intelligence in applications such as INFOTOXI, in charge of monitoring and diagnosing poisoning by toxic products in centers devoted to this theme; GER-ISOFT, for Primary Health Care for the elderly and SAAS System Diagnostic Support in Primary Care. The development of these systems was supported in the knowledge of specialist doctors from the Ministry of Public Health of Cuba (MINSAP), in quality of experts in their respective subjects. These systems are deployed in different units of the health system(AU)

Factores socioculturales y perinatales relacionados con la lactancia materna exclusiva / Socio-cultural and perinatal factors associated with exclusive breast feeding

Objetivo Conocer la prevalencia de la lactancia materna exclusiva (LME) en la zona básica de Mazarrón y los factores socioculturales y perinatales que pueden influir en la LME.MétodoEstudio observacional descriptivo transversal. Realizado en el Centro de Salud de Mazarrón, Gerencia de Atención Primaria de Cartagena, Área II, Murcia. Participaron todos los niños nacidos entre el 01/11/04 y el 30/11/05 y sus madres (236 niños). Se realizó una entrevista dirigida por la enfermera en la revisión de 15 meses. El cuestionario consta de trece preguntas, incluye variables perinatales (sexo, raza, nacido en España, peso al nacer, prematuridad, gemelaridad, n.o de hermanos, etc.), maternas (tipo de parto, edad, n.o de hijos, nacionalidad, nivel de estudios y ocupación) y otra acerca del n.o de meses de LME.ResultadosEl n.o de madres que respondieron al cuestionario fue del 89,8% (212). La prevalencia en el inicio de LME es del 75,4% de los niños (156). La duración media de LME es de 2,99 meses. La edad media materna es de 31,26 años y el 45,9% de las madres no trabaja (89). El menor porcentaje de LME es en niños varones, prematuros y procedentes de cesárea.ResultadosInfluyen de manera positiva para la LME la población de origen materno, donde las que más lactan son las mujeres procedentes de África.ConclusionesLa prevalencia en el inicio de LME en la zona de salud es elevada. Los factores maternos que más influyen son la población de origen materno y el tipo de parto(AU)

Objective To determine the prevalence of exclusive breastfeeding (EBF) in a Basic Health Area, and the maternal factors and socio-cultural perinatal problems related to the initiation and maintenance of the EBF.MethodObservational, cross-sectional study. The study was carried out in Mazarrón Health Center (Cartagena Primary Care Management, Area II, Murcia).The participants of the study were all the children born between 11/01/2004 and 11/30/2005 along with their mothers (236 children overall). The study consisted of an interview that was conducted by a nurse during the 15 months check-up. The questionnaire was made up of thirteen questions including, sex, race, place of birth, weight, birth weight, prematurity, number of siblings (Perinatal care variables), and others, such as, age, number of children, nationality, education and occupation ( maternal variables) and one question on the number of EBF months.MethodThose children who did not attend the health center and those who were not found during the data collection period did not participate in the research.ResultsThe number of mothers who responded to the questionnaire was 89.8% (212). The prevalence at the beginning of EBF is 75.4% (156) of all children. The average length of EBF is 2.99 months.ResultsThe average maternal age is 31.26 years. The percentage of mothers who did not work was 45.9% (89). The lowest percentage of EBF is found in premature boys born by caesarean. Maternal origin positively influences EBF. The women with the greatest breastfeeding capacities are African.ConclusionsBoth the prevalence at home and the average length of the EBF in the Health Area are high; the most influencing maternal factors are maternal origin and the type of childbirth (AU)