The PompeQoL questionnaire: Development and validation of a new measure for children and adolescents with Pompe disease.

Genetic disorders pose great challenges for affected individuals and their families, as they must cope with the irreversible nature of the disease and a life-long dependence on medical assistance and treatment. Children and adolescents dealing with Pompe disease (PD) often struggle to keep up with their peers in physical activities. To gain valuable insights into their subjective experiences and better understand their perception and coping related to daily challenges linked to their condition and treatment, the use of standardized questionnaires is crucial. This study introduces the novel PompeQoL 1.0 questionnaire for children and adolescents with PD, designed for comprehensive assessment of both disease-specific FDH and HRQoL through self- and proxy reports. Content validity was ensured through patients' and parents' involvement at the initial stages of development and in subsequent cognitive debriefing process. Participants found the questionnaire easy to understand, answerable, relevant, and comprehensive. Adjustments based on feedback from patients and their parents improved its utility as a patient- and observer-reported outcome measure. After careful item examination, 52 items were selected, demonstrating moderate to excellent test-retest reliability for most scales and initial evidence for satisfactory construct validity. The PompeQoL questionnaire stands as a valuable screening instrument for both clinical and research purposes. Future research should prioritize additional revisions and larger validation studies, focusing on testing the questionnaire in clinical practice and trials. Nevertheless, the PompeQoL 1.0 stands out as the first standardized measure providing insights into disease-specific FDH and HRQoL among children and adolescents with various forms of PD.

Room Temperature Light Emission from Superatom-like Ge-Core/Si-Shell Quantum Dots.

We have demonstrated the high-density formation of super-atom-like Si quantum dots with Ge-core on ultrathin SiO2 with control of high-selective chemical-vapor deposition and applied them to an active layer of light-emitting diodes (LEDs). Through luminescence measurements, we have reported characteristics carrier confinement and recombination properties in the Ge-core, reflecting the type II energy band discontinuity between the Si-clad and Ge-core. Additionally, under forward bias conditions over a threshold bias for LEDs, electroluminescence becomes observable at room temperature in the near-infrared region and is attributed to radiative recombination between quantized states in the Ge-core with a deep potential well for holes caused by electron/hole simultaneous injection from the gate and substrate, respectively. The results will lead to the development of Si-based light-emitting devices that are highly compatible with Si-ultra-large-scale integration processing, which has been believed to have extreme difficulty in realizing silicon photonics.

Quality of life of pediatric and adult individuals with osteogenesis imperfecta: a meta-analysis.

BACKGROUND: Osteogenesis imperfecta (OI) is a group of rare inheritable disorders of connective tissue. The cardinal manifestations of OI are low bone mass and reduced bone mineral strength, leading to increased bone fragility and deformity that may lead to significant impairment in daily life. The phenotypic manifestations show a broad range of severity, ranging from mild or moderate to severe and lethal. The here presented meta-analysis aimed to analyze existing findings on quality of life (QoL) in children and adults with OI. METHODS: Nine databases were searched with predefined key words. The selection process was executed by two independent reviewers and was based on predetermined exclusion and inclusion criteria. The quality of each study was assessed using a risk of bias tool. Effect sizes were calculated as standardized mean differences. Between-study heterogeneity was calculated with the I2 statistic. RESULTS: Among the studies included two featured children and adolescents (N = 189), and four adults (N = 760). Children with OI had significantly lower QoL on the Pediatric quality of life inventory (PedsQL) with regards to the total score, emotional, school, and social functioning compared to controls and norms. The data was not sufficient to calculate differences regarding OI-subtypes. In the adult sample assessed with Short Form Health Survey Questionnaire, 12 (SF-12) and 36 items (SF-36), all OI types showed significantly lower QoL levels across all physical component subscales compared to norms. The same pattern was found for the mental component subscales namely vitality, social functioning, and emotional role functioning. The mental health subscale was significantly lower for OI type I, but not for type III and IV. All of the included studies exhibited a low risk of bias. CONCLUSIONS: QoL was significantly lower in children and adults with OI compared to norms and controls. Studies in adults comparing OI subtypes showed that the clinical severity of the phenotype is not related to worse mental health QoL. Future research is needed to examine QoL in children and adolescents in more sophisticated ways and to better understand the association between clinical severity of an OI-phenotype/severity and mental health in adults.

Towards the Growth of Hexagonal Boron Nitride on Ge(001)/Si Substrates by Chemical Vapor Deposition.

The growth of hexagonal boron nitride (hBN) on epitaxial Ge(001)/Si substrates via high-vacuum chemical vapor deposition from borazine is investigated for the first time in a systematic manner. The influences of the process pressure and growth temperature in the range of 10-7-10-3 mbar and 900-980 °C, respectively, are evaluated with respect to morphology, growth rate, and crystalline quality of the hBN films. At 900 °C, nanocrystalline hBN films with a lateral crystallite size of ~2-3 nm are obtained and confirmed by high-resolution transmission electron microscopy images. X-ray photoelectron spectroscopy confirms an atomic N:B ratio of 1 ± 0.1. A three-dimensional growth mode is observed by atomic force microscopy. Increasing the process pressure in the reactor mainly affects the growth rate, with only slight effects on crystalline quality and none on the principle growth mode. Growth of hBN at 980 °C increases the average crystallite size and leads to the formation of 3-10 well-oriented, vertically stacked layers of hBN on the Ge surface. Exploratory ab initio density functional theory simulations indicate that hBN edges are saturated by hydrogen, and it is proposed that partial de-saturation by H radicals produced on hot parts of the set-up is responsible for the growth.

Amino Acid and Phospholipid Metabolism as an Indicator of Inflammation and Subtle Cardiomyopathy in Patients with Marfan Syndrome.

Patients with Marfan syndrome (MFS) have an increased risk of aortic aneurysm formation, dissection and development of a subtle cardiomyopathy. We analyzed amino acid and lipid metabolic pathways in MFS patients, seeking biomarker patterns as potential monitoring tools of cardiovascular risk with deterioration of myocardial function. We assessed myocardial function in 24 adult MFS patients and compared traditional laboratory values and mass spectrometry-based amino acid, phospholipid and acylcarnitine metabolomes in patients with those in healthy controls. Analytes for which values differed between patients and controls were subjected to regression analysis. A high proportion of patients had signs of impaired diastolic function and elevated serum levels of NT-proBNP. Patients had lower serum levels of taurine, histidine and PCaeC42:3 than controls. The evidence of diastolic dysfunction, aortic root dimensions and history of aortic root surgery correlated with NT-proBNP and taurine levels. Alterations in serum levels of metabolism derived analytes link MFS pathophysiology with inflammation, oxidative stress and incipient cardiomyopathy.

Strong Electron-Phonon Interaction in 2D Vertical Homovalent III-V Singularities.

Highly polar materials are usually preferred over weakly polar ones to study strong electron-phonon interactions and its fascinating properties. Here, we report on the achievement of simultaneous confinement of charge carriers and phonons at the vicinity of a 2D vertical homovalent singularity (antiphase boundary, APB) in an (In,Ga)P/SiGe/Si sample. The impact of the electron-phonon interaction on the photoluminescence processes is then clarified by combining transmission electron microscopy, X-ray diffraction, ab initio calculations, Raman spectroscopy, and photoluminescence experiments. 2D localization and layer group symmetry properties of homovalent electronic states and phonons are studied by first-principles methods, leading to the prediction of a type-II band alignment between the APB and the surrounding semiconductor matrix. A Huang-Rhys factor of 8 is finally experimentally determined for the APB emission line, underlining that a large and unusually strong electron-phonon coupling can be achieved by 2D vertical quantum confinement in an undoped III-V semiconductor. This work extends the concept of an electron-phonon interaction to 2D vertically buried III-V homovalent nano-objects and therefore provides different approaches for material designs, vertical carrier transport, heterostructure design on silicon, and device applications with weakly polar semiconductors.

Targeted metabolomic analysis of serum phospholipid and acylcarnitine in the adult Fontan patient with a dominant left ventricle.

BACKGROUND: Patients with a Fontan circulation have altered cholesterol and lipoprotein values. We analysed small organic molecules in extended phopsholipid and acylcarnitine metabolic pathways ('metabolomes') in adult Fontan patients with a dominant left ventricle, seeking differences between profiles in baseline and Fontan circulations. METHODS: In an observational matched cross-sectional study, we compared phosphatidylcholine (PC), sphingomyelin (SM), and acylcarnitine metabolomes (105 analytes; AbsoluteIDQ® p180 kit (Biocrates Life Sciences AG, Innsbruck, Austria) in 20 adult Fontan patients having a dominant left ventricle with those in 20 age- and sex-matched healthy controls. RESULTS: Serum levels of total PC (q-value 0.01), total SM (q-value 0.0002) were significantly lower, and total acylcarnitines (q-value 0.02) were significantly higher in patients than in controls. After normalisation of data, serum levels of 12 PC and 1 SM Fontan patients were significantly lower (q-values <0.05), and concentrations of 3 acylcarnitines were significantly higher than those in controls (q-values <0.05). CONCLUSION: Metabolomic profiling can use small specimens to identify biomarker patterns that track derangement in multiple metabolic pathways. The striking alterations in the phospholipid and acylcarnitine metabolome that we found in Fontan patients may reflect altered cell signalling and metabolism as found in heart failure in biventricular patients, chronic low-level inflammation, and alteration of functional or structural properties of lymphatic or blood vessels. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov Identifier NCT03886935.

Structural and mechanistic insights into mechanoactivation of focal adhesion kinase.

Focal adhesion kinase (FAK) is a key signaling molecule regulating cell adhesion, migration, and survival. FAK localizes into focal adhesion complexes formed at the cytoplasmic side of cell attachment to the ECM and is activated after force generation via actomyosin fibers attached to this complex. The mechanism of translating mechanical force into a biochemical signal is not understood, and it is not clear whether FAK is activated directly by force or downstream to the force signal. We use experimental and computational single-molecule force spectroscopy to probe the mechanical properties of FAK and examine whether force can trigger activation by inducing conformational changes in FAK. By comparison with an open and active mutant of FAK, we are able to assign mechanoactivation to an initial rupture event in the low-force range. This activation event occurs before FAK unfolding at forces within the native range in focal adhesions. We are also able to assign all subsequent peaks in the force landscape to partial unfolding of FAK modules. We show that binding of ATP stabilizes the kinase domain, thereby altering the unfolding hierarchy. Using all-atom molecular dynamics simulations, we identify intermediates along the unfolding pathway, which provide buffering to allow extension of FAK in focal adhesions without compromising functionality. Our findings strongly support that forces in focal adhesions applied to FAK via known interactions can induce conformational changes, which in turn, trigger focal adhesion signaling.

Photoluminescence from GeSn nano-heterostructures.

We investigate the distribution of Sn in GeSn nano-heteroepitaxial clusters deposited at temperatures well exceeding the eutectic temperature of the GeSn system. The 600 °C molecular beam epitaxy on Si-patterned substrates results in the selective growth of GeSn nano-clusters having a 1.4 ± 0.5 at% Sn content. These nano-clusters feature Sn droplets on their faceted surfaces. The subsequent deposition of a thin Ge cap layer induced the incorporation of the Sn atoms segregated on the surface in a thin layer wetting the nano-dots surface with 8 ± 0.5 at% Sn. The presence of this wetting layer is associated with a relatively strong photoluminescence emission that we attribute to the direct recombination occurring in the GeSn nano-dots outer region.

Impact of the precursor chemistry and process conditions on the cell-to-cell variability in 1T-1R based HfO2 RRAM devices.

The Resistive RAM (RRAM) technology is currently in a level of maturity that calls for its integration into CMOS compatible memory arrays. This CMOS integration requires a perfect understanding of the cells performance and reliability in relation to the deposition processes used for their manufacturing. In this paper, the impact of the precursor chemistries and process conditions on the performance of HfO2 based memristive cells is studied. An extensive characterization of HfO2 based 1T1R cells, a comparison of the cell-to-cell variability, and reliability study is performed. The cells' behaviors during forming, set, and reset operations are monitored in order to relate their features to conductive filament properties and process-induced variability of the switching parameters. The modeling of the high resistance state (HRS) is performed by applying the Quantum-Point Contact model to assess the link between the deposition condition and the precursor chemistry with the resulting physical cells characteristics.

Selective Epitaxy of InP on Si and Rectification in Graphene/InP/Si Hybrid Structure.

The epitaxial integration of highly heterogeneous material systems with silicon (Si) is a central topic in (opto-)electronics owing to device applications. InP could open new avenues for the realization of novel devices such as high-mobility transistors in next-generation CMOS or efficient lasers in Si photonics circuitry. However, the InP/Si heteroepitaxy is highly challenging due to the lattice (∼8%), thermal expansion mismatch (∼84%), and the different lattice symmetries. Here, we demonstrate the growth of InP nanocrystals showing high structural quality and excellent optoelectronic properties on Si. Our CMOS-compatible innovative approach exploits the selective epitaxy of InP nanocrystals on Si nanometric seeds obtained by the opening of lattice-arranged Si nanotips embedded in a SiO2 matrix. A graphene/InP/Si-tip heterostructure was realized on obtained materials, revealing rectifying behavior and promising photodetection. This work presents a significant advance toward the monolithic integration of graphene/III-V based hybrid devices onto the mainstream Si technology platform.

Reduced-Pressure Chemical Vapor Deposition Growth of Isolated Ge Crystals and Suspended Layers on Micrometric Si Pillars.

In this work, we demonstrate the growth of Ge crystals and suspended continuous layers on Si(001) substrates deeply patterned in high aspect-ratio pillars. The material deposition was carried out in a commercial reduced-pressure chemical vapor deposition reactor, thus extending the "vertical-heteroepitaxy" technique developed by using the peculiar low-energy plasma-enhanced chemical vapor deposition reactor, to widely available epitaxial tools. The growth process was thoroughly analyzed, from the formation of small initial seeds to the final coalescence into a continuous suspended layer, by means of scanning and transmission electron microscopy, X-ray diffraction, and µ-Raman spectroscopy. The preoxidation of the Si pillar sidewalls and the addition of hydrochloric gas in the reactants proved to be key to achieve highly selective Ge growth on the pillars top only, which, in turn, is needed to promote the formation of a continuous Ge layer. Thanks to continuum growth models, we were able to single out the different roles played by thermodynamics and kinetics in the deposition dynamics. We believe that our findings will open the way to the low-cost realization of tens of micrometers thick heteroepitaxial layer (e.g., Ge, SiC, and GaAs) on Si having high crystal quality.

Material insights of HfO2-based integrated 1-transistor-1-resistor resistive random access memory devices processed by batch atomic layer deposition.

With the continuous scaling of resistive random access memory (RRAM) devices, in-depth understanding of the physical mechanism and the material issues, particularly by directly studying integrated cells, become more and more important to further improve the device performances. In this work, HfO2-based integrated 1-transistor-1-resistor (1T1R) RRAM devices were processed in a standard 0.25 µm complementary-metal-oxide-semiconductor (CMOS) process line, using a batch atomic layer deposition (ALD) tool, which is particularly designed for mass production. We demonstrate a systematic study on TiN/Ti/HfO2/TiN/Si RRAM devices to correlate key material factors (nano-crystallites and carbon impurities) with the filament type resistive switching (RS) behaviours. The augmentation of the nano-crystallites density in the film increases the forming voltage of devices and its variation. Carbon residues in HfO2 films turn out to be an even more significant factor strongly impacting the RS behaviour. A relatively higher deposition temperature of 300 °C dramatically reduces the residual carbon concentration, thus leading to enhanced RS performances of devices, including lower power consumption, better endurance and higher reliability. Such thorough understanding on physical mechanism of RS and the correlation between material and device performances will facilitate the realization of high density and reliable embedded RRAM devices with low power consumption.

Dislocation-free Ge Nano-crystals via Pattern Independent Selective Ge Heteroepitaxy on Si Nano-Tip Wafers.

The integration of dislocation-free Ge nano-islands was realized via selective molecular beam epitaxy on Si nano-tip patterned substrates. The Si-tip wafers feature a rectangular array of nanometer sized Si tips with (001) facet exposed among a SiO2 matrix. These wafers were fabricated by complementary metal-oxide-semiconductor (CMOS) compatible nanotechnology. Calculations based on nucleation theory predict that the selective growth occurs close to thermodynamic equilibrium, where condensation of Ge adatoms on SiO2 is disfavored due to the extremely short re-evaporation time and diffusion length. The growth selectivity is ensured by the desorption-limited growth regime leading to the observed pattern independence, i.e. the absence of loading effect commonly encountered in chemical vapor deposition. The growth condition of high temperature and low deposition rate is responsible for the observed high crystalline quality of the Ge islands which is also associated with negligible Si-Ge intermixing owing to geometric hindrance by the Si nano-tip approach. Single island as well as area-averaged characterization methods demonstrate that Ge islands are dislocation-free and heteroepitaxial strain is fully relaxed. Such well-ordered high quality Ge islands present a step towards the achievement of materials suitable for optical applications.

Photodetection in Hybrid Single-Layer Graphene/Fully Coherent Germanium Island Nanostructures Selectively Grown on Silicon Nanotip Patterns.

Dislocation networks are one of the most principle sources deteriorating the performances of devices based on lattice-mismatched heteroepitaxial systems. We demonstrate here a technique enabling fully coherent germanium (Ge) islands selectively grown on nanotip-patterned Si(001) substrates. The silicon (Si)-tip-patterned substrate, fabricated by complementary metal oxide semiconductor compatible nanotechnology, features ∼50-nm-wide Si areas emerging from a SiO2 matrix and arranged in an ordered lattice. Molecular beam epitaxy growths result in Ge nanoislands with high selectivity and having homogeneous shape and size. The ∼850 °C growth temperature required for ensuring selective growth has been shown to lead to the formation of Ge islands of high crystalline quality without extensive Si intermixing (with 91 atom % Ge). Nanotip-patterned wafers result in geometric, kinetic-diffusion-barrier intermixing hindrance, confining the major intermixing to the pedestal region of Ge islands, where kinetic diffusion barriers are, however, high. Theoretical calculations suggest that the thin Si/Ge layer at the interface plays, nevertheless, a significant role in realizing our fully coherent Ge nanoislands free from extended defects especially dislocations. Single-layer graphene/Ge/Si-tip Schottky junctions were fabricated, and thanks to the absence of extended defects in Ge islands, they demonstrate high-performance photodetection characteristics with responsivity of ∼45 mA W(-1) and an Ion/Ioff ratio of ∼10(3).

Public health impact and cost-effectiveness of intranasal live attenuated influenza vaccination of children in Germany.

In 2011, intranasally administered live attenuated influenza vaccine (LAIV) was approved in the EU for prophylaxis of seasonal influenza in 2-17-year-old children. Our objective was to estimate the potential epidemiological impact and cost-effectiveness of an LAIV-based extension of the influenza vaccination programme to healthy children in Germany. An age-structured dynamic model of influenza transmission was developed and combined with a decision-tree to evaluate different vaccination strategies in the German health care system. Model inputs were based on published literature or were derived by expert consulting using the Delphi technique. Unit costs were drawn from German sources. Under base-case assumptions, annual routine vaccination of children aged 2-17 years with LAIV assuming an uptake of 50% would prevent, across all ages, 16 million cases of symptomatic influenza, over 600,000 cases of acute otitis media, nearly 130,000 cases of community-acquired pneumonia, nearly 1.7 million prescriptions of antibiotics and over 165,000 hospitalisations over 10 years. The discounted incremental cost-effectiveness ratio was 1,228 per quality-adjusted life year gained from a broad third-party payer perspective (including reimbursed direct costs and specific transfer payments), when compared with the current strategy of vaccinating primarily risk groups with the conventional trivalent inactivated vaccine. Inclusion of patient co-payments and indirect costs in terms of productivity losses resulted in discounted 10-year cost savings of 3.4 billion. In conclusion, adopting universal influenza immunisation of healthy children and adolescents would lead to a substantial reduction in influenza-associated disease at a reasonable cost to the German statutory health insurance system. On the basis of the epidemiological and health economic simulation results, a recommendation of introducing annual routine influenza vaccination of children 2-17 years of age might be taken into consideration.

Oxygen vacancy induced room temperature ferromagnetism in Pr-doped CeO2 thin films on silicon.

Integration of functional oxides on Si substrates could open a pathway to integrate diverse devices on Si-based technology. Oxygen vacancies (Vo(··)) can strongly affect solid state properties of oxides, including the room temperature ferromagnetism (RTFM) in diluted magnetic oxides. Here, we report a systematical study on the RTFM of oxygen vacancy engineered (by Pr(3+) doping) CeO2 epitaxial thin films on Si substrates. High quality, mixed single crystalline Ce1-xPrxO2-δ (x = 0-1) solid solution films were obtained. The Ce ions in CeO2 with a fluorite structure show a Ce(4+)-dominant valence state in all films. The local crystal structures of the films were analyzed in detail. Pr doping creates both Vo(··) and PrO8-complex defects in CeO2 and their relative concentrations vary with the Pr-doping level. The RTFM properties of the films reveal a strong dependence on the relative Vo(··) concentration. The RTFM in the films initially increases with higher Pr-doping levels due to the increase of the F(+) center (Vo(··) with one occupied electron) concentration and completely disappears when x > 0.2, where the magnetic polaron concentration is considered to decline below the percolation threshold, thus long-range FM order can no longer be established. We thus demonstrate the possibility to directly grow RTFM Pr-doped CeO2 films on Si substrates, which can be an interesting candidate for potential magneto-optic or spintronic device applications.

X-ray characterization of Ge dots epitaxially grown on nanostructured Si islands on silicon-on-insulator substrates.

On the way to integrate lattice mismatched semiconductors on Si(001), the Ge/Si heterosystem was used as a case study for the concept of compliant substrate effects that offer the vision to be able to integrate defect-free alternative semiconductor structures on Si. Ge nanoclusters were selectively grown by chemical vapour deposition on Si nano-islands on silicon-on-insulator (SOI) substrates. The strain states of Ge clusters and Si islands were measured by grazing-incidence diffraction using a laboratory-based X-ray diffraction technique. A tensile strain of up to 0.5% was detected in the Si islands after direct Ge deposition. Using a thin (∼10 nm) SiGe buffer layer between Si and Ge the tensile strain increases to 1.8%. Transmission electron microscopy studies confirm the absence of a regular grid of misfit dislocations in such structures. This clear experimental evidence for the compliance of Si nano-islands on SOI substrates opens a new integration concept that is not only limited to Ge but also extendable to semiconductors like III-V and II-VI materials.

Social familiarity reduces reaction times and enhances survival of group-living predatory mites under the risk of predation.

BACKGROUND: Social familiarity, which is based on the ability to recognise familiar conspecific individuals following prior association, may affect all major life activities of group-living animals such as foraging, reproduction and anti-predator behaviours. A scarcely experimentally tested explanation why social familiarity is beneficial for group-living animals is provided by limited attention theory. Limited attention theory postulates that focusing on a given task, such as inspection and assessment of unfamiliar group members, has cognitive and associated physiological and behavioural costs with respect to the attention paid to other tasks, such as anti-predator vigilance and response. Accordingly, we hypothesised that social familiarity enhances the anti-predator success of group-living predatory mites, Phytoseiulus persimilis, confronted with an intraguild predator, the predatory mite Amblyseius andersoni. METHODOLOGY/PRINCIPAL FINDINGS: We videotaped and analysed the response of two P. persimilis larvae, held in familiar or unfamiliar pairs, to attacks by a gravid A. andersoni female, using the behavioural analyses software EthoVision Pro®. Familiar larvae were more frequently close together, reacted more quickly to predator attacks, survived more predator encounters and survived longer than unfamiliar larvae. SIGNIFICANCE: In line with the predictions of limited attention theory, we suggest that social familiarity improves anti-predator behaviours because it allows prey to shift attention to other tasks rather than group member assessment.

Self- and parent-perceived stigmatisation in children and adolescents with congenital or acquired facial differences.

BACKGROUND: The risk of social stigmatisation is an important determinant in the decision for plastic and reconstructive surgery in children and adolescents. The purposes of this cross-sectional study were threefold: (1) to assess self- and proxy-reported stigma experiences of children and adolescents with congenital or acquired facial differences; (2) to compare patients versus controls; and (3) to identify predictors of perceived stigmatisation. METHODS: Data were obtained from a cohort of 87 children (ages 9 months to 16 years) with facial burn scars, port-wine stains, infantile haemangioma or congenital melanocytic nevi, using parent questionnaires (n = 85) and standardised interviews in children older than 7 years (n = 29). Perceived stigmatisation was assessed with the Perceived Stigmatization Questionnaire. Self-reported stigmatisation was compared versus a matched control group consisting of 29 children and adolescents without a facial difference. Medical, demographic and parental psychological variables were examined as predictors of proxy-perceived stigmatisation. RESULTS: Patients with a facial difference reported significantly higher levels of stigma experiences than control subjects. A majority of the patients reported having experienced expressions of pity, staring or startled reactions; and about one-quarter had been teased about their facial difference. Multivariate analysis indicated that proxy-perceived stigmatisation was predicted by larger size of the facial difference and greater age of the child. Gender and type of facial difference (acquired vs. congenital) had no significant impact. CONCLUSIONS: These results demonstrate that children with a facial difference are at higher risk of experiencing stigmatisation than children without a visible difference. Children with a facial difference that covers more than 25% of their face are particularly vulnerable to stigmatisation and therefore need special monitoring.