The association between intrauterine growth restriction and cardiovascular disease (CVD) later in life might be confounded by familial factors. We conducted a binational register-based cohort study to assess associations of birth weight for gestational age (GA), a proxy for intrauterine growth restriction, and GA with CVD risk in early adulthood, before and after addressing familial factors via sibling comparison. We included 3,410,334 live nonmalformed singleton births from Sweden (1973–1996) and Denmark (1978–1998). During a median follow-up period of 10 years from age 18 years onwards, 29,742 individuals developed incident CVD . Compared with individuals born with appropriate birth weight for GA  or full term , individuals born severely small for GA  or preterm (22–36 weeks) were at increased risk of CVD (hazard ratio (HR) = 1.38 : 1.32, 1.45) and HR = 1.31 , respectively). The association was attenuated when comparing individuals born SGA with their AGA siblings  but remained robust when comparing individuals born preterm with their term siblings . Our findings suggest that both SGA and preterm birth are associated with CVD risk in early adulthood, with greater familial confounding noted for SGA birth. Rapid pA long-standing hypothesis proposes that intrauterine growth restriction (IUGR) can increase the risk of CVD later in life . HoweverThe survival rate of preterm infants has dramatically increased over the past few decades . Long-teUsing nationwide population-based Swedish and Danish registers, we investigated the associations of gestational age and birth weight for gestational age with CVD risk in early adulthood in a binational cohort of approximately 3.5 million individuals. In addition to the population analysis, we compared the risks between siblings to address the potential influence of familial  factors shared by siblings.We conducted a population-based cohort study of liveborn singletons without malformations who were born in Sweden during 1973–1996 and in Denmark during 1978–1998, as recorded in the nationwide Swedish and Danish Medical Birth Registers (MBRs). The MBRs contain prospectively collected information from standardized antenatal, obstetric, and neonatal records and cover virtually all births taking place in Sweden  and Denmn = 1,018), gestational age , and birth weight . Individuals with congenital heart disease, nonspecific malformations, or chromosomal abnormalities  were further excluded  codes  are provided in Web Table 1, available at https://doi.org/10.1093/aje/kwac223). We followed all individuals from age 18 years to emigration, death, or December 31, 2014, in Sweden or to December 31, 2016, in Denmark, whichever came first. Individuals who died , emigrated , or received a diagnosis of CVD  before age 18 years were excluded. In total, 3,410,334 individuals were included in the population analysis. In sibling analyses, we included 2,371,230 individuals who had at least 1 full sibling . Inclusions/exclusions are summarized in Web Figure 1.During the study period, we identified 2,420,647 liveborn singletons in Sweden and 1,243,198 in Denmark. We excluded births with no information or erroneous information on sex  and records of hospital-based outpatient care since 2001 . The DanA range of CVD diagnoses/causes of death have been validated in the Swedish and Danish patient registers and cause-of-death registers, and the overall quality of these registers is considered high. For instance, in the Swedish National Patient Register, the positive predictive value is 98% for myocardial infarction  and 98.6We used the MBRs to obtain demographic information on cohort members, including sex and year of birth. We also extracted information on their parents, including maternal age, maternal country of birth, parity, maternal marital status, and maternal smoking in early pregnancy. Missingness in covariates was coded as “unknown,” given the relatively small rates of missing data.Using the MBRs, the patient registers, and the Danish National Diabetes Register (available since 1995), we identified maternal complications during pregnancy, including maternal hypertensive disease  and diabetes . We also obtained information on maternal and paternal CVD history at the time of the individual’s birth from the patient registers. Relevant ICD codes are listed in Web Table 1.We first calculated incidence rates of CVD according to birth and parental characteristics. We also estimated age-adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) for CVD by contrasting these characteristics, using Cox regression with attained age as the underlying time scale.In the population analysis, we employed Cox regression to compute HRs and 95% CIs for CVD among severely or moderately SGA and LGA individuals as compared with AGA individuals. We also estimated HRs for CVD among individuals born very preterm, moderately preterm, early-term, and late- to postterm as compared with individuals born full-term. Estimates were crude or adjusted for demographic characteristics, including attained age , sex, country, and year of birth; factors associated with SGA or preterm birth, including parity, maternal age at birth, maternal country of birth, and maternal marital status; and predictors of CVD risk in offspring, that is, maternal and paternal history of CVD. To illustrate the independent effect, we mutually adjusted for continuous gestational age and birth weight for gestational age in an additional model. The proportional hazards assumption was not violated according to Schoenfeld residual plots.To shed light on the impact of familial factors, we performed a sibling comparison using stratified Cox regression analysis allowing the baseline hazard to vary between families . Briefly, this analysis contrasted the rates within each set of full siblings discordant on birth weight for gestational age or gestational age and CVD, although nondiscordant siblings were also included in the analysis and contributed to the point estimates of covariates. This approach inherently controls for familial  factors that siblings share . We adjuWe then estimated the HRs for CVD for each percentile of birth weight for gestational age and week of gestational age, where we applied restricted cubic splines and used the 50th percentile and 40 weeks as the reference categories for birth weight for gestational age and gestational age, respectively. To explore different effects on CVD subtypes, we separately examined the associations for hypertensive disease, ischemic heart disease, and cerebrovascular disease.2). In addition, because of different rates of CVD in Sweden versus Denmark, as well as the known sex disparity in CVD occurrence, we performed analyses stratified by country and sex. Finally, we assessed the potential carryover effect in sibling analysis, that is, whether the exposure to SGA/preterm birth in the first sibling may influence the risk of being SGA/preterm for the second sibling. In this regard, we performed analysis by separating sibling pairs with the first sibling exposed to SGA/preterm birth from those with the second sibling exposed.We performed several additional analyses to test the robustness of our findings. Firstly, to illustrate the comparability between the entire cohort and the sibling cohort, we compared the baseline characteristics between 2 cohorts and conducted a population analysis restricted to individuals with at least 1 sibling. Secondly, to understand whether hypertensive disease dominated the observed associations, we repeated the primary analysis by limiting outcomes to CVD other than hypertensive disease. Thirdly, to address the concern that secondary diagnoses or causes of death had lower validity, we repeated the analyses using only the primary diagnosis or cause of death. Fourthly, to better control for confounding, we restricted analyses to persons whose mothers had no record of hypertensive or diabetic disease or of smoking early in pregnancy, and to individuals born during 1992–1994 in Sweden for the adjustment of maternal body mass index (weight (kg)/height (m)Data were processed using SAS 9.4  and analyzed using STATA 14.2 .During a median follow-up period of 10 years , 29,742 individuals developed incident CVD . After controlling for attained age, individuals born in Denmark and those born in more recent years had higher risks of CVD than other cohort members (Web Table 2). Slightly elevated CVD risk was observed among individuals whose mothers were young at childbirth (age ≤19 years), were from the Nordic countries, were unmarried, or smoked during pregnancy. Maternal pregestational diabetes, hypertensive disease before and during pregnancy, and maternal/paternal history of CVD were associated with an elevated risk of CVD in the offspring.In the primary population analysis, individuals born severely SGA (less than third percentile) were found to be at higher risk of CVD in early adulthood, compared with individuals born AGA  was associated with an elevated risk of CVD  was associated with elevated risks of hypertensive disease and ischemic stroke in both population and sibling analyses. Preterm birth was associated with elevated risks of ischemic heart disease and hemorrhagic stroke in the population analysis but not in the sibling analyses .Individuals with at least 1 sibling were highly comparable to the entire cohort (Web Table 4), and restricting the data to these individuals yielded very similar results in population comparisons for SGA and preterm birth (Web Table 5). Analyses of CVD risk after excluding hypertensive disease; after excluding CVD as a secondary diagnosis or a secondary cause of death; or after restricting the analyses to individuals of mothers without maternal hypertensive disease, diabetes, or smoking during pregnancy yielded comparable results, with widely overlapping 95% CIs (Web Tables 6 and 7). Adjustment for maternal body mass index also did not change the results among individuals born during 1992–1994 in Sweden (Web Table 8). In addition, we observed similar associations in men and women and in Danes and Swedes (Web Table 9). Finally, we observed similar results between sibling pairs with different orders of exposure (Web Table 10).In this binational cohort study of approximately 3.4 million individuals in Sweden and Denmark, we found that those born SGA or preterm were at elevated risk of CVD in early adulthood, compared with those born AGA or full-term, respectively. Importantly, when SGA individuals were compared with their AGA full siblings, the elevated risk of early-onset CVD was substantially reduced or even eliminated. In contrast, preterm birth was associated with a robust risk increase in the sibling analysis despite a moderate attenuation of the point estimate. Similar risk patterns were observed for the linear relationship with CVD risk and for most CVD subtypes.Most previous studies in this area have investigated the risk of CVD later in life in relation to birth weight or birth weight adjusted for gestational age , 8. HoweGenetic factors influence both fetal growth and risk of CVD . The genOn the other hand, IUGR has been suggested to lead to functional alterations in fetal development, including alterations in the cardiovascular system , 52, whiIt is also notable that we previously found that low birth weight was associated with increased risk of hemorrhagic stroke within twin pairs . In the In line with previous investigations , 20, ourTogether, these findings indicate a causal relationship between preterm birth and CVD development later in life, although a contribution of familial confounding to the association was also observed. They corroborate current knowledge about the subclinical structural and functional alterations in essential organs among individuals born preterm, increasing vulnerability to CVD in adulthood . HoweverThis large-scale binational cohort study with long and virtually complete data capture up to 41 years of age allowed us to investigate cardiovascular outcomes in early adulthood. The nationwide, prospectively collected, and high-quality register data minimized biases that are common in observational studies . The sibling comparison rigorously controlled for familial factors  shared between full siblings. Lastly, our findings are robust, because similar associations were found in 2 independent countries/populations, although a higher absolute risk of CVD was observed in Denmark than in Sweden. This may have been due to differences in registration , 36 and Our study had several limitations. First, to better capture CVD cases, we also used information from secondary diagnoses or causes of death, which may have lower validity and represent other underlying diseases leading to the health-care visit or death . ReassuOur findings suggest that SGA and preterm birth are associated with an elevated risk of CVD in early adulthood. Familial confounding might play a greater role in the association between SGA birth and CVD risk. Although familial factors would also contribute to the association between preterm birth and CVD, the robust association in sibling comparisons supports the hypothesis of a causal relationship.Web_Material_kwac223Click here for additional data file.


The association between mode of delivery (MOD) and parent-infant-bonding has only been studied in mothers and findings have been inconclusive. The aim of this study was to prospectively investigate how MOD relates to postpartum parent-infant-bonding in both mothers and fathers and whether these associations are mediated by birth experience.N = 1,780 participants who completed quantitative questionnaires during pregnancy as well as 8 weeks and 14 months postpartum. MOD was dummy coded, contrasting spontaneous vaginal delivery against vaginal delivery induced by drugs, operative vaginal delivery, planned, and unplanned cesarean section. Parent-infant bonding and birth experience were assessed using validated scales. A moderated mediation analysis based on ordinary least square (OLS) regression and bootstrapped estimates was conducted, considering relevant confounding variables.This study is part of the prospective cohort study “Dresden Study on Parenting, Work, and Mental Health” (DREAM). Our sample comprised Compared to spontaneous vaginal delivery, all categories of MOD predicted more negative birth experiences in both parents. A more positive birth experience predicted stronger parent-infant-bonding at 8 weeks, but not at 14 months postpartum. Mothers who delivered via cesarean section (planned or unplanned) reported stronger parent-infant-bonding at 8 weeks and 14 months postpartum. In fathers, only unplanned cesarean section was associated with stronger parent-infant-bonding at 8 weeks postpartum. At 8 weeks postpartum, birth experience mediated the association between a vaginal delivery induced by drugs and a planned cesarean section and mother-infant-bonding and between a vaginal delivery induced by drugs, an operative vaginal delivery, and planned cesarean section and father-infant-bonding. At 14 months postpartum, birth experience mediated the association between a vaginal delivery induced by drugs, operative vaginal delivery, and planned cesarean section and parent-infant-bonding in both parents.The results emphasize the importance of the birth experience for parent-infant-bonding in both mothers and fathers. Further research should address the mechanisms by which parents with an unplanned cesarean section establish stronger parent-infant-bonding compared to parents whose baby was delivered via spontaneous vaginal delivery, despite their overall more negative birth experiences. Childbirth is considered as one of the most powerful life experiences, both physically and psychologically, leaving an impression for everyone involved in this process –3. With However, it remains unclear how MOD and parent-infant-bonding are linked to each other. There is limited, mixed evidence regarding this association focussing on mothers. Some studies indicate little to no difference in mother-infant-bonding, regardless of whether the mother undergoes a CS (planned or unplanned) or a vaginal delivery –29. ThenAs briefly indicated above, previous research focused mainly on mothers , 41. HowTherefore, the aim of this study is to examine the impact of MOD on parent-infant-bonding, at 8 weeks and 14 months postpartum, including both mothers and fathers. Additionally, it will be investigated whether this association is mediated by birth experience. Since we are particularly interested in comparing mothers and fathers, parental sex is included as a moderator, resulting in a moderated mediation model  for the The present study is part of the Dresden Study on Parenting, Work, and Mental Health . This prospective cohort study investigates the association between parental work participation and distribution, stress factors and their impact on various perinatal outcomes as well as the long-term mental and somatic health of the family. Participants are (expectant) parents, recruited at information evenings at hospitals and birth preparation courses in Dresden, Germany, and surroundings. At present, the longitudinal design consists of six measurement points: T1 during pregnancy, T2 at 8 weeks after the expected birth date, T3 at 14 months after the actual birth (the date the child was born), T4 at 2 years, T5 at 3 years, and T6 at 4.5 years postpartum. For this study, data of the first three measurement points (T1─T3) were used. Participants completed quantitative questionnaires at each measurement point, either in paper and pencil format or online. Study participation is voluntary and not financially compensated. However, small incentives  are provided with every follow-up questionnaire. All participants provided written informed consent. Kress et al.  provide 3rd 2020, the day of data extraction, n = 3,827 mothers and fathers were included in the cohort. Inclusion criteria for the present study were expecting one child (singleton pregnancy) and paternal presence during childbirth. Also, the questionnaires at T1, T2, and T3 had to be completed in a defined time frame for this study. Particularly, parents were excluded if T1 was completed after childbirth because the confounding variable prenatal symptoms of depression required the measurement during pregnancy. Further, parents were excluded if T2 was completed earlier than 6 weeks or later than 16 weeks postpartum, and/or if T3 was completed earlier than 12 months or later than 16 months postpartum. This is substantial, because the personal assessment of birth experience and parent-infant-bonding may be time-dependent [n = 1,780 participants.By Decemberependent , 56 and,ependent . RetentiInformation about mode of delivery (MOD) was retrieved from maternal report based on maternity records  at T2. CBirth experience was assessed using the German version of the Salmon’s Item List (SIL) in mothers and fathers at T2 . The SILParent-infant-bonding was measured by the German version of the Postpartum Bonding Questionnaire (PBQ) –61 at T2The selection of potential confounding variables was based on the existing literature , 62–73. Mothers and fathers were asked at T2 about when they held their baby for the first time, i.e., within the first minutes, within the first hour, or more than an hour after childbirth.All variables were assessed in both mothers and fathers, except for MOD and birth complications. These were based on maternal report and then assigned to both partners prior to analyses.p < 0.05 with 95% confidence intervals was applied. Unstandardized regression coefficients (b) and HC4 heteroskedasticity-consistent standard errors [Statistical analyses were conducted with IBM SPSS Statistics Version 27.0  and the d errors  are repod errors , 80, Hayd errors , and Pred errors .The hypothesised conceptual model in Fig. relative conditional effects. Therefore, whenever the investigated path concerned the predictor, we analyzed and interpreted the relative conditional effects. To depict these effects, a notation with θ is used [For a detailed discussion of the advantages of a moderated mediation analysis over, e.g., subgroup analysis or multi-group structural equation modelling, see Hayes . Each ef is used , 78: a vN = 1,780 participants . The characteristics of the sample are displayed in Table SD = 6.06), ranging from 9 to 41. Mean age at T1 was 30.13 years (SD = 3.94) for mothers and 32.23 years (SD = 4.89) for fathers. Most of the participating parents were born in Germany , living in a permanent relationship , and were expecting their first child . The CS rate in this study was 15% in mothers, which is approximately 5% lower than the number previously reported for Dresden [SD = 20.25) and 93.10 for fathers (SD = 14.83). For mothers, the mean score of the PBQ was 12.85 (SD = 9.84) at T2 and 13.80 (SD = 10.04) at T3. For fathers, the mean score of the PBQ was 12.63 (SD = 8.22) at T2 and 13.17 (SD = 8.22) at T3. The intercorrelations between all study variables are displayed in Table The final sample consisted of M = 6.69, SD = 4.72, n = 141) than completers , t(1180) = 3.13, p = 0.002, d = 0.28. Additionally, non-completers more often had no university-degree (54.9% against 40.8%), χ2(1) = 10.20, p = 0.001, ϕ = 0.09 and were more often unemployed (4.8% against 2.0%), χ2(1) = 4.23, p = 0.040, ϕ = -0.06 than completers. Also, non-completers had a spontaneous VD less often (46.9% against 59.8%) and an unplanned CS more often (13.3% against 8.2%) compared to completers, χ2(4) = 10.44, p = 0.034, V = 0.09. Finally, non-completers had 3 or more birth complications more often than completers (6.2% against 1.9%), χ2(3) = 10.02, p = 0.018, V = 0.09. Among fathers, non-completers more often had no university degree than completers (60.4% against 42.6%), χ2(1) = 12.17, p < 0.001, ϕ = 0.12.Dropout analyses were carried out to examine whether completers and non-completers differed statistically significantly from each other regarding the predictors, confounding variables, and sociodemographic characteristics (tables provided upon request). Among mothers, non-completers reported higher mean EPDS scores . As shown in Table b = -0.032, p > 0.05).A more positive birth experience predicted lower PBQ scores at T2 in mothers and fathers, indicating stronger parent-infant-bonding  of parent-infant-bonding at T3 and there was a statistically significant interaction effect between the birth experience and parental sex . When parents reported a more negative birth experience (lower SIL scores), fathers reported more bonding difficulties than mothers (higher PBQ scores). This is illustrated in Fig. However, parental sex was a statistically significant predictor . The results are presented in Table In contrast to the relative conditional direct effects, the relative conditional indirect effects consider the effect of MOD on parent-infant-bonding through the birth experience. Among mothers, the birth experience mediated the association between induced VD, as well as planned CS and parent-infant-bonding at T2. Among fathers, the birth experience mediated the association between induced VD, operative VD, as well as planned CS and parent-infant-bonding at T2.That is, an induced VD and planned CS, mediated by birth experience, seemed to be associated with weaker parent-infant-bonding at T2 in mothers (higher PBQ scores) compared to spontaneous VD. The same pattern was found among fathers, with the addition of the category operative VD. That is, an induced VD, an operative VD, and a planned CS, mediated by birth experience, seemed to be associated with weaker parent-infant-bonding at T2 in fathers (higher PBQ scores) compared to spontaneous VD.The relative conditional direct and indirect effects at T3 are reported in Table The birth experience mediated the association between induced VD, operative VD, as well as planned CS and parent-infant-bonding at T3 in both mothers and fathers. That is, an induced VD, operative VD, and planned CS, mediated by birth experience, seemed to be associated with weaker parent-infant-bonding at T3 in both parents (higher PBQ scores) compared to spontaneous VD.Lastly, the indices of a moderated mediation  in both The aim of this study was to prospectively investigate the role of MOD and birth experience for parent-infant-bonding in both mothers and fathers. All categories of the MOD predicted more negative birth experiences in mothers and fathers compared to spontaneous VD. A more positive birth experience predicted stronger parent-infant-bonding at 8 weeks postpartum, but not at 14 months postpartum. In mothers who delivered their baby via planned CS or unplanned CS parent-infant-bonding was stronger at 8 weeks and 14 months postpartum compared to spontaneous VD. In fathers whose baby was delivered via unplanned CS parent-infant-bonding was stronger at 8 weeks postpartum compared to spontaneous VD. However, in fathers no associations between MOD and parent-infant-bonding were found at 14 months postpartum.The birth experience mediated the association of induced VD, planned CS with mother-infant-bonding and of induced VD, operative VD, and planned CS with father-infant-bonding at 8 weeks postpartum. At 14 months postpartum, the birth experience mediated the association of induced VD, operative VD, and planned CS with parent-infant-bonding in both mothers and fathers.Both mothers and fathers experienced the birth of their infant via induced VD, operative VD, planned CS, and unplanned CS more negative than parents, whose baby was delivered via spontaneous VD, indicating that the MOD is a relevant factor contributing to the self-reported birth experience of parents. These findings are contributing to previous research and, especially in fathers, extending the evidence to two more MODs, i.e., induced VD and planned CS. One factor in explaining these results could be the violation of expectations , 84, as A more positive birth experience predicted stronger parent-infant-bonding in mothers and fathers at 8 weeks postpartum, but not at 14 months postpartum. One explanation for this finding might be the hormone oxytocin, which is released during labour and birth to regulate maternal stress and pain as well as stimulate positive feelings such as joy and happiness . OxytociAlso, when parents experienced a more negative birth, fathers reported weaker parent-infant-bonding at 14 months postpartum than mothers. One explanation might be that fathers might not have talked much about and in turn processed their negative birth experience, thereby giving this event more space influencing father-infant-bonding. In support of this, a recent narrative review by Masoumi  showed tcompensatory care theory, linking more parental care to parents with preterm babies, aiming to compensate for adverse consequences for the preterm infant at higher risk [Mothers who delivered their baby via planned CS or unplanned CS reported stronger parent-infant-bonding at 8 weeks and 14 months postpartum compared to mothers delivering via spontaneous VD. In fathers, only the delivery of the infant via unplanned CS was associated with stronger parent-infant-bonding at 8 weeks postpartum compared to the delivery via spontaneous VD. At 14 months postpartum, no category of the MOD had a direct effect on parent-infant-bonding among fathers. Apparently, these findings are contradictory to previous research, finding either no association between the MOD and mother-infant-bonding –29 or inher risk . This apAnother important aspect potentially accounting for the conflicting evidence might be the birth experience, which had not been considered in prior studies that investigated the direct association between MOD and parent-infant-bonding. Due to our mediation model, the relative conditional direct effects are controlled for the birth experience in this study and therefore might be more reliable for assessing the direct effect of MOD on parent-infant-bonding. As the relative conditional direct and indirect effects indicate, controlling for or mediating by birth experience may make a difference in presence or direction of the associations found between MOD and parent-infant-bonding.positive birth experience predicted stronger parent-infant-bonding, this is a logical result, contributing to the relative conditional direct effect that we found. Among those delivering via planned CS and experiencing the birth as more negative compared to spontaneous VD, the reported bonding seemed to be weaker, which explains the relative conditional indirect effect that we found. Therefore, it seems to be the more negative birth experience that accounts for the reverse effects between associations with and without the mediation effect. Although, looking at the bootstrapped 95% CI, it is important to notice that the relative conditional indirect effects of planned CS in mothers at T2 and T3 were close to being statistically insignificant, whereas the relative conditional direct effects were statistically significant at p < 0.01. Further studies should address whether the indirect effects can be replicated or whether the direct effects might be of greater importance.Among mothers, the birth experience mediated the association between induced VD as well as planned CS and weaker parent-infant-bonding at 8 weeks postpartum. Among fathers, the same associations were found at that measurement point with the addition of operative VD. At 14 months postpartum, the birth experience mediated the association between induced VD, operative VD, and planned CS and weaker parent-infant-bonding in both parents. Thus, considering the mediation effects, i.e., the effect of the MOD on parent-infant-bonding mediated by the birth experience, our results are in line with previous studies, linking especially a CS with weaker mother-infant-bonding , 31. AlsNonetheless, in at least some cases, the birth experience operated as a mediator of the association between MOD and parent-infant-bonding and even reversed the association of planned CS and parent-infant-bonding in mothers. Hence, our study’s results suggest that investigating the association between MOD and parent-infant-bonding should not be conducted without considering the birth experience.Several strengths of the present study can be highlighted. Data of the large prospective cohort study DREAM were used, thereby enabling the investigation of the longitudinal associations of the MOD, birth experience, and parent-infant-bonding, while controlling for relevant confounding variables. Besides, this was the first study to include the father in the investigation of the association between MOD and parent-infant-bonding. In addition, a novelty of this study was the examination of the birth experience as a mediator in both mothers and fathers. Hence, this study extends the existing literature in this field. Moreover, our results provide a possible clarification to the heterogeneous body of literature, as the birth experience was shown to be a mediator in explaining the association between some categories of the MOD and weaker parent-infant-bonding in our study. Another strength of our study was the large sample size and use of validated instruments of high psychometric quality. The PBQ was found to be the most studied, evidence based instrument with high psychometric qualities for measuring postpartum bonding in a recent systematic review by Wittkowski et al. . BesidesHowever, some limitations of this study should be noted. For one, self-selection bias known in epidemiologic studies –109 did Additionally, we only considered prenatal symptoms of depression as a confounding variable, although also postpartum depressive symptoms seem to be linked with weaker mother-infant-bonding , 115. Yedisorders seem very promising. In addition, studies using observational procedures to assess infant’s attachment to their parents and interaction between infants and parents would complement the parent’s perspective and provide a more comprehensive picture of the parent-infant-relationship. Generally, fathers should more often be included in these studies, as mothers and fathers might have differential needs in e.g., making a more positive birth experience possible. As we emphasized the importance of a positive birth experience, conditions in hospital care under which obstetricians and midwives work, should be improved [social stigma that delivering via CS (planned or unplanned) seems to be attached to, in terms of avoiding the strenuous process of childbirth, seemingly choosing the somewhat simpler way of delivering. This picture does not do justice to the delivery via CS, indeed it neglects the clinical and psychological indications for a planned or unplanned CS [Further research is necessary investigating the mediating role of the birth experience for the association between MOD and parent-infant-bonding in more detail and attempting to replicate our findings. In particular, the association between an unplanned CS and parent-infant-bonding should be further studied, examining mechanisms like the compensatory care theory . As we fimproved , 118, thimproved , midwiveimproved , and obsimproved  underlinimproved . For fatimproved , 47, 48.improved  should bimproved  refer toanned CS –126. SocWe pioneered to show the mediating role of the birth experience in both mothers and fathers for some categories of the MOD and weaker parent-infant-bonding at both 8 weeks and 14 months postpartum. This underscores the importance of a positive birth experience for both parents, which should receive more attention in both obstetrical care and in research by examining its influence in several relevant associations for parents and their infants. Hence, our study suggests that the impact of the MOD on parent-infant-bonding should not be investigated without the consideration of the birth experience. Further studies should investigate whether our results regarding the impact of an unplanned CS on parent-infant-bonding can be replicated. What is more, our study highlights that fathers might have differential needs than mothers that should be targeted in birth preparation courses and hospital care. With e.g., improving the hospital conditions for obstetricians and midwifes and addressing the father more in birth preparation courses, enabling a more positive birth experience for both parents and stronger parent-infant-bonding might be facilitated. As especially stronger parent-infant-bonding is shown to have positive impacts on the infant’s development , 128, th


Prenatal ultrasound diagnosis of anorectal malformations (ARMs) is challenging and often missed as direct visualization of the anal sphincter is not routinely performed, plus the technique is operator-dependent and inaccurate, also in expert hands. Other indirect signs, such as rectosigmoid overdistension or intraluminal calcifications, are occasionally present in late pregnancy. The detection of a cyst of the lower abdomen in the first trimester may be an early sign of ARM. Here we reported our experience and a review of the literature of such cases.Isolated cases of lower abdomen cysts encountered in the first trimester at the Prenatal Diagnosis Unit during the last 5 years were retrieved and compared with those found in literature. Post-natal clinical data were analyzed to check the presence and type of malformations.A total of three cases of lower abdomen cysts were found in our center and 13 in literature. In our case series all the cysts spontaneously regressed and were no longer visible since the second trimester of pregnancy, while in literature this was reported in only 4 out of 13 cases. ARM was confirmed in all patients at birth or post-mortem.The finding of a lower abdomen cyst during the first trimester of pregnancy could be an early predictive sign of ARM, even if it disappears during pregnancy. In these cases, we suggest mentioning to the parents the possibility of an ARM during the counseling and to refer the couple to a Colorectal Center. Anorectal malformations (ARM) are a complex spectrum of congenital defects of the distal bowel occurring in 1:2000–5000 live births ; the absReview of the literature has shown only a few cases of isolated ARM suspected in the first trimester, described at ultrasound mainly as cystic or tubular structures of the lower abdomen. Here we reported our experience with three such cases.® Ultrasound Machine, with follow-up every 1–2 weeks after the diagnosis of a lower abdomen cyst till its complete regression.Isolated cases of lower abdomen cysts  encountered in the first trimester at the Prenatal Diagnosis Unit of the Ca’ Foncello Hospital, Treviso – Italy, during the last 5 years were retrieved. Sonographic characteristics of the fetuses and cystic lesions were retrieved, as well as mothers’ clinical data, pregnancy courses, and post-natal outcome of newborns. Ultrasound exams were performed by the same team using the G.E. Voluson E10We used the following combination of keywords to search analogous case reports and series on Pubmed: “first trimester”, “prenatal diagnosis”, “anal atresia” “anorectal malformation”, “anal sphincter”, prenatal ultrasound”, “cystic anomalies “, “pelvic cyst”, and “abdominal cyst”. Cases presenting OEIS complex  were excluded because the cyst was due to omphalocele.A total of three cases of lower abdominal cysts were found in our records. Characteristics are summarized in Table g. At birth, the definitive diagnosis of ARM with no fistula was made. Screening for associated anomalies was negative and the patient underwent colostomy at birth and anorectal reconstruction (PSARP) 5 months.A 31-years-old healthy woman underwent an ultrasound examination at 12 weeks and 4 days of gestation. On transabdominal US an anechoic cystic structure measuring 8 mm and posterior to the bladder was identified in the lower abdomen. From 14 weeks the lesion was no longer detectable. No other fetal malformations were detected during the follow-up. Karyotype analysis was normal . The woman had a normal spontaneous vaginal delivery at 38 weeks of gestation and the child weighed 3280g and the diagnosis of rectovestibular fistula was made at perineal inspection. Screening for associated anomalies was negative and the patient underwent PSARP at 2 days of life.A 30-years-old healthy woman underwent an ultrasound examination at 13 weeks of gestation. On transabdominal US an anechoic cystic structure measuring 5 mm with hyperechoic walls was identified in the lower abdomen posterior to the bladder. From 19 weeks the structure was no longer detectable. No other malformations were detected and karyotype analysis was normal . Due to preterm premature rupture of membranes (pPROM) the woman had a vaginal delivery at 36 weeks of gestation. The child was a female weighing 2410g and a diagnosis of perineal fistula with a bucket handle was performed. The newborn underwent PSARP at 2 days of life.A 39-years-old patient with medical history of anterior sacral meningocele, anal stenosis and a scimitar sacrum performed the first ultrasound examination at 12 weeks and 6 days of gestation. On transabdominal US a cystic structure measuring 8 mm  could be helpful to better characterize the nature of fetal abdominal cysts , but in Similarly to our cases, in 4 out of 13 fetuses the lesions spontaneously disappeared later in pregnancy. This phenomenon could be explained by the decompression of the distended colon through a fistula . On the Bischoff et al.  stated tIn our series, one case was part of Currarino syndrome, confirmed postnatally by genetic analysis. This emphasizes the importance of an early US sign to predict ARM and proceed with further investigations to identify other possible fetal anomalies, refer the mother to a tertiary care hospital, and provide specialist pregnancy and genetic counseling, also in terms of termination or continuation of pregnancy.In conclusion, direct signs of ARM are not detectable in the first trimester of pregnancy due to the late development and difficult evaluation of the perianal muscular complex. However, ARM should be considered in differential diagnosis when a lower abdomen cyst is found during the first trimester, even if it disappears during pregnancy. Unfortunately, the absence of prospective studies and the few cases described in literature make this premature finding an inadequate diagnostic sign; however, this justify a careful US prenatal evaluation of the anal dimple from the late second and third trimester and, in case of anomaly, proper counselling should be offered to the mother, considering the morbidity, pathologic associations and impaired outcome of ARM.


The sodium-glucose co-transporter 2 inhibitor empagliflozin improves cardiovascular outcome in patients with type 2 diabetes mellitus (T2DM) and heart failure. Experimental studies suggest a direct cardiac effect of empagliflozin associated with an improvement in left ventricular diastolic function.E/E´ ratio were enrolled and randomized 1:1 to receive empagliflozin 10 mg/day versus placebo. The primary endpoint was the change of left ventricular E/E´ ratio after 12 weeks of intervention.In the randomized, double-blind, two-armed, placebo-controlled, parallel group trial EmDia, patients with T2DM and elevated left ventricular E/e´ ratio . After 12 weeks of intervention, empagliflozin resulted in a significant higher decrease in the primary endpoint E/e´ ratio by − 1.18  − 1.72/− 0.65]; P < 0.0001) compared with placebo. The beneficial effect of empagliflozin was consistent across all subgroups and also occurred in subjects with heart failure and preserved ejection fraction (n = 30). Additional effects of empagliflozin on body weight, HbA1c, uric acid, red blood cell count, hemoglobin, mean corpuscular hemoglobin, and hematocrit were detected . Approximately one-third of the reduction in E/e´ by empagliflozin could be explained by the variables examined.A total of 144 patients with T2DM and an elevated left ventricular Empagliflozin improves diastolic function in patients with T2DM and elevated end-diastolic pressure. Since the positive effects were consistent in patients with and without heart failure with preserved ejection fraction, the data add a mechanistic insight for the beneficial cardiovascular effect of empagliflozin.Clinicaltrials.gov, unique identifier: NCT02932436.The online version contains supplementary material available at 10.1007/s00392-023-02164-w. Diabetes mellitus is an epidemic disease affecting more than 460 million people worldwide . In receThe specific mechanisms mediating the beneficial effects of empagliflozin on cardiovascular outcome remain controversial . PreviouThe EmDia trial was designed to evaluate the effect of empagliflozin compared to placebo on left ventricular diastolic function in subjects with type 2 diabetes mellitus and elevated left ventricular end-diastolic pressure in a randomized, double-blind controlled clinical trial combined with comprehensive clinical and molecular phenotyping.The EmDia trial is a randomized, double-blind, two-armed, placebo-controlled, parallel group, investigator-initiated study of phase IV. The University Medical Center of the Johannes Gutenberg-University Mainz conducted the single-center trial as study sponsor. All study documents were approved by the local ethics committee and the data protection officer prior to study initiation. All study participants provided informed written consent, and study procedures have been performed in line with the principles outlined in the Declaration of Helsinki and the recommendations for Good Clinical Practice. The trial was registered at clinicaltrials.gov with the unique identifier: NCT02932436 (EudraCT number: 2016-001264-11). The rationale and design of the trial have been described in detail recently  through week 1 ]9.49 (IQR 8.14/11.18)] and week 12 (9.12 (IQR 7.51/10.80)) of intervention in individuals receiving empagliflozin 10 mg/day, while no change in E/e´ ratio was observed in individuals receiving placebo. The analysis of the primary study endpoint, i.e., the change in E/e´ ratio after 12 weeks of intervention, in a linear regression analysis with E/e´ ratio at 12 weeks as dependent variable and adjustment for the covariates age, sex, and E/e´ ratio at baseline, demonstrated that empagliflozin led to a significant decrease in E/e´ ratio by − 1.18  − 1.72 to − 0.65; P < 0.0001) after 12 weeks of intervention compared with placebo  and also in sensitivity analysis with additional adjustment for arterial hypertension . When analyzing the components of E/e´ ratio separately a trend for a beneficial effect of empagliflozin on both E  and e´  was observed. In the placebo group, there was no significant decrease of E/e´ ratio after 12 weeks of intervention (P = 0.53).The IQR 8.40/1.90] thrE/e´ ratio by empagliflozin compared with placebo (β-estimate: − 0.52 (95% CI − 1.10 to 0.06), although this result did not pass the threshold of statistical significance (P = 0.081).Analysis of the short-term effect of empagliflozin on diastolic function after 1 week of intervention indicated a decrease in P = 0.009), which was not seen after 12 weeks (β-estimate: − 0.01 95% CI − 0.195 to 0.175), P = 0.91). A similar result was registered for the effect of empagliflozin on systolic blood pressure (β-estimateafter 1 week: − 4.53 (95% CI − 8.13 to − 0.92), P = 0.015) and diastolic blood pressure (β-estimateafter 1 week: -3.05 (95% CI − 5.05 to − 1.05), P = 0.0034). With regard to measures of vascular function , no statistical effect of empagliflozin compared to placebo was detectable. The ankle–brachial index was not affected by empagliflozin after 12 weeks of intervention compared to placebo . Furthermore, no changes were observed for relative wall thickness, troponin or heart rate under treatment.To comprehensively evaluate the effects of empagliflozin 10 mg/day compared with placebo in individuals with type 2 diabetes mellitus, further endpoints were analyzed. First, the change of left ventricular ejection fraction, left ventricular mass index, and left-ventricular end-diastolic volume throughout the study was assessed in crude analysis. Subsequently, a linear regression analysis with adjustment for age, sex, and baseline value of the respective biomarker confirmed the absence of an impact of empagliflozin on left ventricular systolic function and left ventricular hypertrophy after 1 and 12 weeks of treatment, respectively (see Table P < 0.0001), HbA1c (β-estimate: − 0.43 (95% CI − 0.62 to − 0.23), P < 0.0001), and uric acid (β-estimate: − 0.66 (95% CI − 1.01 to − 2.96), P = 0.0005) after 12 weeks of intervention. No significant effect of empagliflozin was found with respect to C-reactive protein and fatty liver index levels.Due to the known impact of empagliflozin on body weight, further metabolic biomarkers were explored. Multivariable regression analysis revealed a significant effect of empagliflozin 10 mg/day versus placebo on body mass index . In addition, mean corpuscular hemoglobin concentration was reduced by empagliflozin (β-estimate: − 0.36 (95% CI − 0.61 to − 0.12), P = 0.005), whereas hematocrit  and level of hemoglobin (β-estimate: 0.82 (95% CI 0.55–1.09), P < 0.0001) were increased by 12 weeks of therapy with empagliflozin.Last, the effect of empagliflozin on hematological biomarkers was analyzed. No significant effect of empagliflozin on leukocyte and platelet count was found, whereas a highly significant increase in red blood cell count was detected (β-estimate: 0.29 (95% CI 0.20–0.38), E/e´ ratio across subgroups. For the subgroup with congestive heart failure, a mean LVEF of 54.6% ± 5.6% (placebo group) and 56.2% ± 7.0% (intervention group) was documented at baseline examination (lowest LVEF: 43.2%), indicating the predominant prevalence of heart failure with preserved ejection fraction in the cohort.In a next step, sensitivity analysis in clinically relevant subgroups has been carried out Fig. . Of clinE/E´ ratio was carried out. As illustrated in Table E/E' ratio was investigated: body mass index, systolic and diastolic blood pressure, eGFR, HbA1c, NT-proBNP, uric acid, hematocrit, and hemoglobin. The strongest effects on the change in left ventricular diastolic function were determined by the effect of empagliflozin on hemoglobin, hematocrit, and glomerular filtration rate. Overall, approximately a third of the reduction of E/e´ ratio by empagliflozin was found to be explained via the impact of empagliflozin on all variables explored in the analysis (β–estimatefully adjusted: − 0.77 (95% CI − 1.52 to − 0.02), P = 0.046).To decipher the contribution of the systemic effects of empagliflozin on the change in left ventricular diastolic function, a mediation analysis for the effect of 12-week empagliflozin on E/e´ ratio after 12 weeks of therapy with empagliflozin 10 mg/day compared to placebo as an adjunct to standard therapy, which was consistent across subgroups. The change in E/e´ ratio was accompanied by significant effects of empagliflozin on metabolic and hematologic biomarkers in this cohort with predominantly preserved left ventricular ejection fraction, which in turn explain approximately one-third of the beneficial effect of the drug on left ventricular diastolic function.The present study investigated the effects of the SGLT2 inhibitor empagliflozin in patients with diastolic dysfunction and type 2 diabetes mellitus. The results indicate a significant improvement in diastolic function as measured by left ventricular E/e´ ratio [E/e´ ratio are more consistent for individuals at risk of developing heart failure  stage A/B) [E/e´ ratio[E/e´ ratio observed in the EmDia trial is of specific interest in the context of the beneficial effect of empagliflozin in patients with heart failure and preserved ejection fraction with and without diabetes mellitus [The results of the EmDia trial add to the growing body of evidence supporting a positive effect of empagliflozin on cardiovascular health . Althouge´ ratio . Interesage A/B) –15 as coage A/B) –18. Receage A/B) , 20. In age A/B) . The impage A/B) . Given t/e´ ratio and subs/e´ ratio, the redmellitus .The transient reduction in systolic and diastolic blood pressure after one week of therapy supports the hypothesis that part, and in particular the early, cardiovascular effects of empagliflozin may be mediated via an improvement in ventricular loading through a reduction in afterload that is likely secondary to the diuretic effects of the drug . In the The improvement in diastolic function found in the EmDia trial provides new insights relevant in context of the results of the recently published EMPEROR-PRESERVED clinical trial investigating the efficacy and safety of empagliflozin in individuals with heart failure and preserved ejection fraction (defined by a left ventricular ejection fraction > 40%) independent of the presence of diabetes mellitus . Since nE/e´ ratio, which precluded consideration of other markers for cardiac function that have been reported to predict cardiovascular outcome, such as left atrial volume index or cardiac strain [E/e´ ratio is known to predict cardiovascular outcome [The major strength of the present study is the well-phenotyped cohort, which was studied in a dedicated study center by trained staff in a highly standardized setting minimizing variability of data assessment at high accuracy and reproducibility. However, several limitations should be noted when interpreting the study results. The assessment of diastolic function was limited to left ventricular c strain . Since l outcome , the dem outcome .The results of the present EmDia trial demonstrated that empagliflozin 10 mg/day improved diastolic function in patients with type 2 diabetes mellitus and elevated left ventricular end-diastolic pressure within 12 weeks of treatment. The beneficial effect of empagliflozin was consistent across all subgroups and also occurred in subjects with heart failure and preserved ejection fraction, supporting the positive effect of empagliflozin reported in the literature regarding the treatment of patients with heart failure and including patients with heart failure with preserved ejection fraction. Because the identified positive hemodynamic, metabolic, and hematological effects of empagliflozin explain only part of its effect on cardiac function, future studies will be important to identify to what extent this mechanism contributes to improved clinical outcome in subjects with heart failure.Supplementary file1 (DOCX 144 KB)Below is the link to the electronic supplementary material.


The incidence of pancreatic cystic lesions (PCLs) has been rising due to improvements in imaging. Of these, intraductal papillary mucinous neoplasms (IPMNs) are the most common and are thought to contribute to almost 20% of pancreatic adenocarcinomas. All major society guidelines for the management of IPMNs use size defined by maximum diameter as the primary determinant of whether surveillance or surgical resection is recommended. However, there is no consensus on how these measurements should be obtained or whether a single imaging modality is superior. Furthermore, the largest diameter may fail to capture the complexity of PCLs, as most are not perfectly spherical. This article reviews current PCL measurement techniques in CT, MRI, and EUS and posits volume as a possible alternative to the largest diameter. Despite recent advances in cancer detection and management strategies, pancreatic cancer remains among the deadliest worldwide. In the United States, pancreatic cancer is responsible for 8.2% of all cancer deaths and has an estimated 5-year survival of 11.5 percent [Pancreatic cystic lesions (PCLs) represent a significant portion of premalignant pancreatic lesions and contribute to nearly 20% of pancreatic adenocarcinomas . PCLs arAmong neoplastic PCLs, IPMNs are the most common. The point prevalence of IPMNs in those above age 60 is ~1 in 100 subjects ,6. WhileThe early detection of high-risk BD-IPMNs is crucial, as the 5-year survival after the surgical resection of IPMNs with invasive cancers ranges from 31 to 60%, compared to 90 to 100% in noninvasive IPMNs ,14,15,16There are five sets of guidelines from major societies regarding the management of PCLs. Each set of guidelines seeks to establish high-risk features summarized in Despite the consistent use of PCL size as one of the primary determinants of surveillance and management recommendations for BD-IPMNs, there is inconsistent evidence to support this. The two major considerations in cyst measurement are baseline size and incremental growth, where a rate of growth greater than 5 mm every 2 years is regarded as a worrisome feature . HoweverAs noted in most of the PCL management guidelines, the three most common imaging modalities for detecting and diagnosing pancreatic cysts are CT, MRI, and EUS. Each modality comes with its own risks and benefits. While MRI can provide the high contrast definition of soft tissue without exposing patients to radiation, it is more time-consuming and expensive than CT . CT is mn = 68). They used cyst diameter as the definition of cyst size. While there were no major discrepancies in size, EUS was superior in identifying specific characteristics, such as intracystic nodules, wall thickness, and septations [n = 267; median 1.5 mm, range 0–9 mm). This study also determined that the larger the cyst size, the larger the absolute size discrepancy between the imaging modalities [Du et al. compared the difference in cyst size measurement and cyst characteristic appearance across CT, MRI, and EUS; . The authors measured the maximum dimension of the pancreatic cyst in two axes—cross-sectional and coronal—in all three imaging modalities. The larger of the two measurements was selected to define cyst size in the analysis. Of the three imaging modalities, EUS had the widest range of 95% limits of agreement (−17.43 to +23.87) and very good reliability with an intraclass correlation coefficient of 0.84 (95% CI 0.58–0.94) for mucinous lesions. EUS was specifically found to underestimate the size of PCLs located in the pancreatic tail when compared to CT and MRI [Lee et al. assessed the PCLs of patients who had all CT, MRI, and EUS images taken within three months prior to surgical resection  between EUS and CT, 4 mm (0–17 mm) between EUS and MRI, and 3 mm (2–20 mm) between CT and MRI. Histopathologic data from resection were then compared to 12 EUS, 13 CT, and 8 MRI measurements. The median size differences were: 9.5 mm (0–20 mm) between EUS and pathology, 5 mm 0–21 mm) between CT and pathology, and 5.5 mm (2–44 mm) between MRI and pathology [ mm betweTwo additional studies also compared PCL size data obtained from imaging to surgically resected pathology specimens. Leeds et al. compared the maximum diameters of cysts measured with CT and EUS to the measurements of surgically resected pathology specimens in 70 patients. Measurements included maximum diameter in the axial, sagittal, and coronal planes. There were no significant differences found between measurements obtained via either imaging modality when compared to pathology . Huynh e3/6; ellipsoid volume = R1 × R2 × R3 × π/6 ) ) . Whetherp = 0.43; κ = 0.70) [p = 0.822; specificity p = 0.096), while EUS showed lesser specificity compared to MRI . This study therefore posits that MRI may be a better imaging tool to guide PCL management than EUS [Multiple studies have compared the diagnostic accuracy of various imaging modalities  using the IAP/Fukuoka guidelines in predicting advanced neoplasia in IPMNs. In a study of 86 patients with IPMNs, the diagnostic performance of CT and MRI for the prediction of malignant IPMNs was comparable with good inter-modality agreement ( = 0.70) . A meta- = 0.70) . A meta-than EUS .As cited in This inconsistent evidence has prompted some investigators to question whether other criteria might better predict the malignant risk of BD-IPMNs than cyst size. The growth rate has been proposed as a possible alternative. A study of 52 patients with BD-IPMN diagnosed by ERCP or MRI/MRCP had a mean follow-up of 31.2 months to assess for changes in maximum diameter and MPD diameter. Seven of the lesions demonstrated growth on follow-up imaging, and both cyst size > 3 cm and MPD dilatation were associated with an increased likelihood of growth . El ChafRecently, some investigators have evaluated cyst volume as an alternative predictor of malignant risk, as it is proposed to be more accurate for lesions that are not perfectly spherical. For example, a recent radiology guideline paper proposed volumetry as a more objective alternative to diametric size . Studies3 [Multiple imaging modalities, including ultrasound, CT, and MRI, are already being used to assess volume and risk stratify lesions in other solid organs. There is a well-established precedent for this in solid masses. Buerke et al. demonstrated the feasibility and precision of volume assessment of peripheral, abdominal, and thoracic lymph nodes using CT imaging . Subsequ3 . Despite the precedent of solid lesion volumetry with CT and MRI, image-guided volumetry is less frequently used in cystic lesions. Autosomal dominant polycystic kidney disease (ADPKD) is an example where cystic lesion volumes are routinely measured using imaging . MultiplThe ellipsoid volume formula method  × width × depth × (π/6)) uses the measurements of longitudinal length, maximum width, and maximum depth from coronal and sagittal MRI slices to calculate volume . The midGiven the lack of evidence that PCL size by the maximum diameter is a reliable tool for determining malignant risk, recent research has focused on PCL volume as a possible alternative for risk assessment. Awe et al. reviewed 195 patients with PCLs at a single center to correlate size, as measured by maximum axial diameter (MAD), and volume. For MAD measurement, a region of interest (ROI) was drawn in the axial dimension of the CT imaging slice with the largest MAD. Then, a quantitative imaging software platform was used to generate a 3D ROI and edited to exclude vasculature, ducts, surgical hardware, and bowel gas. After a final 3D ROI was generated, the software generated values for MAD, volume, surface area, and sphericity. Results showed that MAD is a poor correlate of volume in smaller cysts (1–3 cm). When there were subsequent CT or MRI images collected over a year later for comparison, MAD changes over that time also correlated poorly with volume changes. Unsurprisingly, these estimates were even less reliable in non-spherical cysts. Therefore, the authors concluded that MAD incompletely captures the complexity of pancreatic cysts . NotablySimilarly, a single-center retrospective study by Pandey et al. evaluated 164 IPMNs on 107 MRI images and compared manual and semi-automatic largest diameter and volume measurements between three radiologists to assess for interobserver reproducibility. All three readers were taught a standard protocol to obtain these measurements. First, each reader measured the largest diameter of the IPMN manually using electronic calipers on both axial T2W and coronal three-dimensional MRCP images on the cross-section with the largest diameter. They then excluded any ductal extension and separated groups of cysts if there was a dividing septum >1 mm thick. This was followed by semi-automatic measurements, which involved the interactive segmentation of the lesion on each slice where the lesion was visible. All measurements were performed using a commonly available commercial Picture Archiving and Communication System  software. Of the six measurements collected for each IPMN, the highest interobserver reproducibility was seen for axial manual diameter measurements in cysts ≥1.5 cm, while the lowest was seen for coronal manual diameter measurements on cysts measuring <1.5 cm. This overall high interobserver reproducibility was attributed to the standardized measurement protocol taught to the three readers at the beginning of the study. Therefore, the authors concluded that a standardized cyst measurement technique would benefit IPMN follow-up since each follow-up image is often read by different radiologists. Additionally, the semi-automatic method of volume measurement in this study did not rely on the subjective selection of a cyst cross-section with the largest diameter by the reader, suggesting that cyst volume measurement may allow for more a reproducible cyst monitoring mechanism, especially in the absence of a standardized measurement protocol . Pozzi Mucelli et al. assessed 106 patients with a histopathological diagnosis of BD- and mixed-type IPMN with an available preoperative MRI to test the hypothesis that volume could serve as a better predictor of malignancy than size. All MRIs were evaluated on a PACS by two radiologists in consensus reading, with one cyst chosen per patient . Several IPMN parameters were collected, including a maximum diameter on axial and coronal T2W images, elongation value (defined as 1-(width/length)), maximum MPD diameter, the presence of contrast-enhancing mural nodules, cyst wall thickening ≥ 2 mm, growth of >5 mm per year during follow-up, solitary vs. multifocal, location, and volume. Volume was calculated on axial T2W images, on which an ROI was drawn along the edge of the BD-IPMN on multiple levels. The software then automatically calculated the volume. Interestingly, the analysis of these data showed that neither elongation value nor volume were associated with advanced neoplasia. This is despite the confirmation with elongation value data that most of these lesions were not spherical. The only variables in the study which were associated with advanced neoplasia were the presence of contrast-enhancing mural nodules, a diameter of MPD ≥ 5 mm, and serum CA 19-9 level > 37 . Studies that utilized PCL size as one of the topics of investigation often used the maximum diameter of cysts seen on a 2D imaging modality  to define the cyst size. This generalized sizing technique assumes that pancreatic cysts are roughly spherical and that the largest diameter captures the overall size of the cyst. However, this does not reflect the natural variability of PCLs, which can have a multitude of morphological appearances . TherefoThe limitations of the maximum diameter measurement on 2D imaging can be somewhat overcome by measuring the cyst’s length, height, and width to appropriately capture the three-dimensional volume the cyst occupies rather than merely its maximal length. Such measurements can more accurately evaluate a cyst that does not comply with the spherical assumption. However, the measurements are again restrained by the angle of view available in each imaging modality. The cyst may be oriented in such a way that three perpendicular views are inadequate to estimate an accurate cyst size. While three-axis measurement has the potential to offer improved accuracy by allowing for the calculation of volume, it may be more difficult and time-consuming to obtain and report. Several studies discussed above evaluated the efficacy and reliability of cyst volume measurements, not only in the pancreas but in other organs as well. While one study has suggested the reproducibility of cyst volume measurement using a semi-automatic volume measurement method, another study did not find a strong correlation between cyst volume and the risk of malignancy. Therefore, additional larger studies to evaluate the relationship between cyst volume and malignant risk would provide guidance as to whether developing a uniform system to assess cyst volume would be useful. Given that cyst volume measurement can be relatively reliably reproduced using commercially available PACS software, collecting more data on cyst volume measurement through meta-analysis may prove to be valuable. The cited references unanimously voice the lack of standardized protocol of cyst size measurement and raise it as a potential threat to accurately monitoring pancreatic cysts. A study has demonstrated that a standardized cyst size measurement method can be taught to radiographic readers with high reproducibility. Such an assessment should be taken into account by entities creating pancreatic cyst diagnosis and management guidelines. The development of a standardized cyst size measurement protocol may become useful to guarantee universal reliability in pancreatic cyst management.


Of 515 miRNAs, 25 were significantly associated with intrauterine smoke exposure . The IUS associated miRNAs were correlated with well-known asthma genes  and enriched in disease-relevant pathways (oxidative stress). Eleven IUS-miRNAs were also correlated with clinical measures  in children with asthma, further supporting their likely disease relevance. Lastly, we found substantial differences in IUS effects by sex, finding 95 significant IUS-miRNAs in male samples, but only four miRNAs in female samples. The miRNA–mRNA correlation networks were predictive of IUS  and suggested that IUS-miRNAs are involved in regulation of disease-relevant genes , LBH regulator of WNT signaling (LBH)) and sex hormone signaling (Coactivator associated methyltransferase 1(CARM1)). Our study demonstrated differential expression of miRNAs by IUS during early prenatal human lung development, which may be modified by sex. Based on their gene targets and correlation to clinical asthma and atopy outcomes, these IUS-miRNAs may be relevant for subsequent allergy and asthma risk. Our study provides insight into the impact of IUS in human fetal lung transcriptional networks and on the developmental origins of asthma and allergic disorders.Intrauterine smoke (IUS) exposure during early childhood has been associated with a number of negative health consequences, including reduced lung function and asthma susceptibility. The biological mechanisms underlying these associations have not been established. MicroRNAs regulate the expression of numerous genes involved in lung development. Thus, investigation of the impact of IUS on miRNA expression during human lung development may elucidate the impact of IUS on post-natal respiratory outcomes. We sought to investigate the effect of IUS exposure on miRNA expression during early lung development. We hypothesized that miRNA–mRNA networks are dysregulated by IUS during human lung development and that these miRNAs may be associated with future risk of asthma and allergy. Human fetal lung samples from a prenatal tissue retrieval program were tested for differential miRNA expression with IUS exposure . RNA was extracted and miRNA-sequencing was performed. We performed differential expression using IUS exposure, with covariate adjustment. We also considered the above model with an additional sex-by-IUS interaction term, allowing IUS effects to differ by male and female samples. Using paired gene expression profiles, we created sex-stratified miRNA–mRNA correlation networks predictive of IUS using DIABLO. We additionally evaluated whether miRNAs were associated with asthma and allergy outcomes in a cohort of childhood asthma. We profiled pseudoglandular lung miRNA in  The World Health Organization reported that there were 1.3 billion tobacco users worldwide in 2021 (WHO 2021). In spite of the epidemiological data demonstrating poor health outcomes associated with smoking during pregnancy, the Centers for Disease Control and Prevention (CDC) reports that in 2016 roughly 7% of pregnant women in the United States smoked during pregnancy CDC 2018), with some state-specific rates as high as 30%. Intrauterine smoke (IUS) exposure has been associated with myriad negative health consequences to the unborn child, including intrauterine growth restriction ,5, atopy, with soDespite minimal human data elucidating the biological mechanisms underlying the epidemiologic association of IUS exposure with respiratory and allergic outcomes, there are ample animal data that demonstrate intrauterine-smoke-induced changes during lung development, which lead to increased postnatal disease susceptibility. In animal studies, maternal smoke exposure in the later stages of pregnancy has been associated with a multitude of adverse lung effects for the offspring, including fewer alveoli identified on lung histology , increasWhile the pathophysiology of IUS on fetal lung tissue is not entirely known, genomic profiling has started to reveal its complex impact . SpecifiWe aimed to better understand the effect of IUS exposure on miRNA expression in humans during the critical lung developmental period, hypothesizing that IUS-associated miRNAs may have regulatory impacts on pathways relevant to asthma and allergy. Using paired miRNA-sequencing and gene expression assays from a unique resource of human fetal lung tissue samples from the pseudoglandular stage of lung development—the time during which branching morphogenesis and airway development occur—we demonstrated that IUS is associated with changes in miRNA profiles and that the IUS-effect may be sex-specific. Furthermore, IUS-associated miRNAs are plausibly disease-related, based on their predicted mRNA targets, which are known to impact disease susceptibility, and their associations with clinical outcomes in a cohort of children with asthma.n = 298 samples, n = 139 (47%) of which had evidence of IUS exposure, based on our validated assay measuring placental cotinine concentration (>7.5 ng/g) [n = 159 (53%) of which did not have evidence of IUS exposure. The distributions of estimated sample ages (days post-conception) and sex  were approximately equal in the two exposure groups (We profiled miRNA and mRNA levels in .5 ng/g) ; and n =e groups .After quality-control, 515 miRNAs were tested for differential expression using a dichotomized IUS-exposure group. After adjusting for age, sex, run, and RUVr factors, we detected 25 miRNAs significantly associated with IUS  and asthma and allergy .Possible empirical mRNA targets for each of these miRNAs, measured by pairwise correlation to fetal lung microarray data, are provided in These possible functional consequences were also echoed in pathway analyses based on the theoretical mRNA targets: IUS-miRNAs were enriched in lung development pathways such as Wnt signaling  and branGiven the known evidence of sexual dimorphism of miRNA expression during development ,38 and shsa-miR-331-3p, significantly decreased with IUS in males (log2FC = −0.46 based on interaction model) and negatively correlated with genes such as NLRP5 and FGD5; DIABLO correlation networks in hsa-miR-29c-3p and hsa-miR-200a-3p were selected  versus −0.10 . Only one mRNA (MAP4K2) was selected in both models. The two miRNAs decreased with IUS-exposure in female fetal lung samples were not found to be significant in the univariate model , yet the DIABLO analysis generated models with high discriminative ability between IUS-exposed and unexposed samples , suggesting that prioritization of miRNAs with strong mRNA correlations could identify additional miRNAs for further study.We applied DIABLO to our dataset, to identify miRNA and mRNA features both correlated across the ‘omes and discriminatory of IUS-exposures. The male-only DIABLO model selected one miRNA, selected B. Intereselected . For exa1/FVC) in childhood asthmatics. Repeating these analyses stratifying GARCS by gender, we found that some of these miRNAs may have sex-specific associations with asthma and allergy outcomes: for example, after stratification, associations between miR-101-3p and clinical outcomes were only detected in the male subcohort  and with serum miRNA-seq profiles. Of the 25 IUS-miRNAs significant in the all-sample analysis, 17 were detected. Eleven demonstrated differential expression with markers of asthma severity and atopy in childhood asthmatics . Notablyubcohort .Despite the preponderance of evidence demonstrating the substantial negative health consequences of smoking, maternal smoking during pregnancy remains a large public health problem. Epidemiological data have demonstrated that exposure to intrauterine smoke is associated with asthma and allergic sensitization in childhood ,12 and hThe pseudoglandular period is the histological stage of lung development during which branching morphogenesis and airway development commence . BiologiIn concordance with our findings, previous investigations also suggested that regulation of genes involved in the oxidative stress response in early lung development has critical implications for allergy and asthma susceptibility in the postnatal period. The developing fetus is highly vulnerable to oxidative stress injury, as both the immune system and lung structural cells are immature and highly susceptible to toxic exposure, even during these early developmental stages ,46. The Our results also suggest that IUS results in dysregulation of the metabotropic glutamate receptor (mGLuR) pathway, which is also relevant to the development of asthma and allergy. The mGLuRs are members of the G-protein coupled receptor family . These rAs post-natal phenotypic profiling of disease features is not possible with fetal tissue, examining IUS–miRNA correlates with clinical outcomes in relevant cohorts is one of the few options available for functional evaluation within human tissues and in vivo. While we recognize that this may limit the clinical utility of our findings, our findings demonstrate biological relevance. With the caveat that our findings are associative and not causal, and that the miRNA impacts could be context-specific , we investigated whether the miRNAs differentially expressed by IUS were associated with lung function and markers of atopy in children with asthma. Of the 17 IUS-associated miRNAs that were available for evaluation in GACRS, we found that 11 of them demonstrated an association with lung function and/or atopy in a well-characterized cohort of childhood asthmatics, offering further support for our hypothesis that IUS-associated miRNAs may be important in the biological mechanisms underlying the development of asthma and allergy.ERAP2) gene. Genetic polymorphisms in ERAP2 have been previously associated with atopic dermatitis risk, suggesting a potential role in the development of atopy [IL-33) signaling [IL-33 plays an important role in type-2 innate immunity, via activation of allergic inflammation-related eosinophils [IL-33, additional investigation will be needed to confirm this finding.For example, we found that IUS exposure was associated with increased miR-543 expression in human fetal lung tissue. Based on our empirical miRNA–mRNA correlations, miR-543 regulates the intrauterine expression of several genes implicated in atopy, including the endoplasmic reticulum aminopeptidase 2  levels, measures of pulmonary function, and increased inflammation [IFIH1), which has been shown to sense rhinoviruses. They postulate that miR-101-3p may play a regulatory role in rhinovirus-induced asthma [We additionally found evidence for sex-specificity in IUS-exposure associations with miRNA expression. By allowing for sex-by-IUS interactions in regression modeling, we found 95 miRNAs significantly associated with IUS in male samples, whereas only four miRNAs were significantly associated with IUS in female samples. For example, miR-101-3p significantly decreased with IUS-exposure in our all-sample analysis and in male samples, but not in female fetal lung samples. We additionally showed that decreased expression of miR-101-3p is associated with increased house dust mite sensitization and increased bronchodilator response in childhood asthmatics, with this finding again detected in all-sample and male subjects, but not female subjects. To our knowledge, this miRNA has not previously been examined in a sex dimorphism context, but its clinical relevance is corroborated by findings from Wang and colleagues in a mixed-gender adult asthma study. Wang et al. found that miR-101-3p was downregulated in asthmatic subjects as compared to healthy controls and that miR-101-3p expression was correlated with interleukin 13  and mRNAs such as the Wnt-signaling regulator LBH, FLRT1, RNF26, and SLFNL1. In the female-only model, hsa-miR-29c-3p and hsa-miR-200a-3p were selected and negatively correlated with genes of biological relevance, including ADAM19, AGO1, CRNN, and SLC41A1 [MAP4K2; this gene family has been extensively associated with airway inflammation in asthma and COPD, including experimental demonstrations that it can be induced by cigarette smoke exposure [Support for the sex-specific impacts of IUS on miRNA profiles was also evident in our sex-stratified miRNA–mRNA network analyses. Using DIABLO, we discovered sparse candidate regulatory networks that had strong miRNA–mRNA correlations, while being highly discriminative of IUS exposure . Strikingly, no miRNAs and only one mRNA gene were common between the male-only model and the female-only networks, and the miRNA–mRNA correlations found in one sex tended to be much lower in magnitude in the other sex. However, both networks involved genes plausibly relevant to allergy, airway remodeling, and disease. The male-only DIABLO model selected one miRNA,  SLC41A1 ,62. Furtexposure . We alsoexposure  and was Given that the IUS-miRNAs for both sexes are plausibly associated with asthma and allergy susceptibility , our work contributes a better understanding of miRNAs and gene targets, to prioritize functional investigation into the poorly understood mechanisms underlying IUS exposure and possible post-natal disease risks. Our work adds to reports of the potential sex-specific impacts of IUS . We thusOur study has several limitations. Our prenatal lung samples were obtained from a de-identified fetal tissue biorepository, so only sample age, IUS, and sex were available. We attempted to address potential unmeasured confounders such as fetal comorbidities and other environmental exposures through statistical approaches (RUV), but residual confounding may still have been present. We also note that our measure of intrauterine smoke exposure  does not preclude exposure to nicotine via other methods of consumption or it may not capture effects due to cumulative smoking habits . Similarly, our study may have underestimated the transcriptional dysregulation due to cumulative IUS exposure, and many epidemiological studies often find third-trimester IUS to be the most predictive of future disease risk; however, we found striking shifts in miRNA profiles even within very early lung development, in samples with gestational ages from the first and early second trimester of pregnancy. Lastly, validation is challenging for studies of the developmental origins of disease. Technical replication was not possible, due to the limited quantity of RNA available from these rare tissues, and functional validation was not performed. Although our results suggest that IUS-associated miRNAs are associated with asthma and allergy risk based on mRNA targets and comparison to clinical outcomes in childhood asthmatics, future studies should use animal or cell-line models, to measure the functional impact of the miRNAs and whether those impacts persist from pre-natal life to early childhood.Human fetal lung tissue samples were collected as part of a prenatal tissue retrieval program sponsored by the National Institute of National Child Health and Development (NICHD), the University of Maryland Brain and Tissue Bank for Developmental Disorders , and the Center for Birth Defects Research , as previously described . The stuDue to de-identification, only estimated post-gestational age, IUS, and sex were available for each sample. We assessed IUS with placental cotinine concentration , using an assay our group previously demonstrated had high sensitivity and specificity (AUC = 0.88), relative to self-reported maternal cigarette smoking status . The sam5 mapped reads, no missing metadata, age 7–17 weeks pseudoglandular period), and miRNAs (non-zero counts in at least 25% of samples).Our methods for fetal lung miRNA profiling and analysis are described in detail within a previous publication . Briefly2 , sex , technical batch , and four inferred covariates  for inclusion in regression models. A statistically significant difference in mean miRNA levels by IUS was defined using a Wald test at a prespecified multiple testing corrected Storey q-value of <0.10; that is, we tolerated up to 10% false positives among our reported IUS-miRNAs. The pre-specified value of 10% was chosen because it is commonly used, as it provides a reasonable margin of error for genomics studies.We regressed the count of each miRNA (outcome) in the IUS group (dichotomized at exposed at ≥ or non-exposed at <7.5 ng cotinine/g placenta) in the DESeq2 negative binomial model, adjusting for post-conceptional age and agemponents  represenWe also considered the above model with an additional sex-by-IUS interaction term, allowing IUS effects to differ between male and female samples. We tested for statistically significant interactions , indicative of miRNAs with sex-specific IUS effects, and within in each sex tested if their IUS effect significantly differed from the null .A central hypothesis of our work was that IUS-miRNAs may be associated with known asthma and allergy-related mRNA targets. Thus, as one approach to interpreting the functional impact of IUS-miRNAs, we examined the hypothesized mRNA targets of each miRNA  and performed a GSEA pathway analysis using the miEAA 2.0 webportal  applied 2, sex, batch, and RUV components). Similarly, mRNA levels were represented using log2 (probeset intensities) and regressed on age, age2, sex, batch, and RUVr components .A limitation of target predictions is that miRNA–mRNA correlations may be context-specific. The aforementioned paired microarray measurements allowed us to calculate empirical correlations between IUS-miRNAs and mRNA gene targets within the fetal lungs. We first residualized both miRNA and microarray probe intensities for covariates, then examined pairwise miRNA–mRNA Spearman correlations. The intention of residualization is to remove technical noise  and sample metadata: namely, global miRNA and mRNA profiles strongly vary with post-conceptional age in this dataset . Thus, nTo compliment these pairwise correlation tests, we used the multivariate, multi-omic  integration algorithm DIABLO  to integ1PP), dichotomized as the mean value; the ratio of FEV1 to forced vital capacity (FEV1/FVC), dichotomized as the mean value; bronchodilator response (BDR), measured as a percent change in FEV1 dichotomized at 8% [As a final assessment of the hypothesis that IUS-associated miRNAs may regulate biological pathways that are relevant to asthma and allergy, we evaluated whether IUS-miRNAs were associated with asthma and allergy outcomes in a well-characterized cohort of childhood asthma. The Genetics of Asthma in Costa Rica Study (GACRS) is a cross-sectional study of 1165 Costa Rican children with asthma aged 6 to 14 years and recruited between February 2001 and August 2008. A previous publication  describeed at 8% ; the loged at 8% .Small RNA sequencing (RNA-seq) was performed on the serum samples from 1134 GACRS children following established protocols . Small RAnalysis code  and raw/processed miRNA-sequencing and microarray data for fetal lung are publicly available .In summary, we identified differential expression of miRNAs by IUS exposure in human lung development, that these miRNAs as associated with well-known genes and biological pathways associated with asthma and atopy, and that these miRNAs correlated with clinical asthma and atopy measures in a well-characterized cohort of childhood asthma. Our work provides support for the growing body of evidence that miRNAs are critical to normal lung development and that common intrauterine exposures such as maternal smoking can impact lung development in a sex-specific manner and influence subsequent disease susceptibility. These data provide additional support for the developmental origin of asthma and allergy.