Epidemiologic studies suggest that maternal organophosphorus (OP) pesticide exposure is associated with poorer fetal growth, but findings are inconsistent. We explored whether paraoxonase (PON1), a key enzyme involved in detoxification of OPs, could be an effect modifier in this association.192PON1 and −108PON1) and enzyme activity (paraoxonase and arylesterase). Infant birth weight, head circumference, and gestational age were obtained from medical records.The study population included 470 pregnant women enrolled in the CHAMACOS Study, a longitudinal cohort study of mothers and children living in an agricultural region of California. We analyzed urine samples collected from mothers twice during pregnancy for dialkyl phosphate (DAP) metabolites of OP pesticides. We analyzed maternal and fetal (cord) blood samples for PON1 genotype : −0.9, 0.0) and smaller head circumference  than those with the −108CCPON1 genotype. Infants' arylesterase and paraoxonase activity were positively associated with gestational age. There was some evidence of effect modification with DAPs: maternal DAP concentrations were associated with shorter gestational age only among infants of the susceptible −108TTPON1 genotype . However, maternal DAP concentrations were associated with larger birth weight  and head circumference  in infants with non-susceptible genotypes.Infants' PON1 genotype and activity were associated with birth outcome, but mothers' were not. Infants with the susceptible Infants whose PON1 genotype and enzyme activity levels suggested that they might be more susceptible to the effects of OP pesticide exposure had decreased fetal growth and length of gestation. PON1 may be another factor contributing to preterm or low birth weight birth. Organophosphorus (OP) pesticides are a class of widely used, neurotoxic insecticides that include compounds such as chlorpyrifos, diazinon, and malathion. Chlorpyrifos and diazinon were used in household pest control products until 2000–2001, when they were voluntarily phased out by the manufacturers. However, use of these and other OP pesticides in agriculture continues, with approximately 73 million pounds applied in the United States each year Whyatt et al. in vitro esterase activity can be measured against several substrates including paraoxon, chlorpyrifos-oxon, diazoxon, and phenyl acetate One possible explanation for the lack of consistency in epidemiologic studies is individual and population-level differences in susceptibility to OPs PON1 gene 192PON1 SNP results in a Q/R amino acid substitution that affects the enzyme's catalytic efficiency, with the R alloform hydrolyzing chlorpyrifos-oxon more efficiently than the Q. In contrast, a T/C allelic substitution at position −108 in the promoter region impacts the amount of enzyme expressed, with the −108CCPON1 genotype displaying significantly higher levels of plasma PON1 There is a wide variability in PON1 enzyme activity in humans 192 QQPON1 genotype, and inversely associated with birth length, but only among mothers with low paraoxonase activity 192PON1 genotype and work in greenhouses among floriculture workers in Mexico; however, in this case, greenhouse work was associated with non-significantly increased odds of low birth weight among mothers with the 192 RRPON1 genotype.Few studies have examined the interaction of PON1 enzyme activity or genotype and OP pesticide exposure on birth outcome. In the same New York City population described above The present study expands upon our previous analysis of maternal DAP metabolites and birth outcome, first by examining the main effect of PON1 on fetal growth and length of gestation and then by exploring interaction of maternal DAP levels and PON1.Participants were pregnant women enrolled in the Center for the Health Assessment of Mothers and Children of Salinas (CHAMACOS), a longitudinal cohort study investigating the effects of exposure to OP pesticides and other environmental chemicals on the health of pregnant women and their children PON1 genotype information was available for 451 mothers and 436 infants, and PON1 activity data were available for 371 mothers and 324 infants.A total of 601 pregnant women were enrolled in the study and 538 were followed through delivery. We excluded stillbirths (n = 3), twins (n = 5), infants weighing <500 g at birth (n = 1), women with hypertension during pregnancy (n = 15), and women with existing or gestational diabetes (n = 26). We also excluded mother-infant pairs for whom we had no information on PON1 genotype or activity (n = 21), leaving a final sample size of 467. Of these, We obtained signed informed consent from all women at the time of enrollment in the study. All study procedures were approved by the Committee for the Protection of Human Subjects at the University of California, Berkeley.Women were interviewed at the end of the first (mean ± standard deviation (SD) = 13.6±6.5 weeks) and second (mean ± SD = 25.8±2.5 weeks) trimesters of pregnancy. All interviews were conducted in English or Spanish by bilingual, bicultural interviewers using structured questionnaires.Demographic data collected included maternal age, marital status, educational attainment, country of birth, number of years lived in the United States, language spoken in the home, family income, and the number of people supported by that income. Questionnaires also gathered information on behavioral characteristics, including tobacco, alcohol, drug, and caffeine use, and health information, including previous pregnancies and medical conditions. Body mass index (BMI) was calculated using self-reported pre-pregnancy weight and measured height. Data on pregnancy complications and birth outcomes, including infant birth weight, length, head circumference, and gestational age, were abstracted from medical records by a registered nurse.Spot urine samples were collected from mothers at the time of each interview and stored at −80°C until shipment to the Centers for Disease Control and Prevention (CDC) for analysis of OP pesticide metabolites. Dialkyl phosphate (DAP) metabolites were measured in urine samples using gas chromatography-tandem mass spectrometry (GC-MS/MS) and quantified using isotope dilution calibration Six DAP metabolites were quantified: three dimethyl phosphate (DM) metabolites  which are derived from pesticides such as malathion, oxydemeton-methyl, and dimethoate, and three diethyl phosphate (DE) metabolites  derived from pesticides such as diazinon, chlorpyrifos, and disulfoton. Although not all OP pesticides devolve to DAPs, approximately 80% of the OP pesticides used in the Salinas Valley devolve to one or more of these metabolites. DAP concentrations were converted to SI units (nanomoles per liter) and summed to generate variables for total DMs, total DEs, and total DAPs. All women had detectable levels of DAP metabolites in their urine. For a small number of women (n = 8) levels of one metabolite could not be calculated due to analytic interference. Because metabolites were highly correlated within the DE or DM groups, regression was used to impute the value of the missing metabolite based on the concentrations of the other two metabolites. Creatinine concentrations in urine were determined using a commercially available diagnostic enzyme method .−108PON1 and 192PON1 SNPs was performed using genomic DNA extracted from blood clots. For the coding SNP, 192PON1, we used the Taqman real-time PCR method with probes custom-designed by Applied Biosystems, Inc. . For the promoter SNP, −108PON1, a two-part nested PCR strategy was used: first, the region surrounding the SNP was pre-amplified using non-allelic flanking primers, then the resulting amplicon was diluted and served as the template for the subsequent Amplifluor assay. Each plate of DNA incorporated randomly distributed blank samples and duplicate DNA samples independently isolated from the same subjects. We observed a high rate of concordance (>99%) among duplicate DNA samples (4% of samples). All discrepancies were resolved with additional genotyping.Maternal and fetal  blood was collected at the time of delivery and stored at −80°C. Analysis of PON1 genotype and activity has been described previously Two substrate-specific PON1 enzyme activity assays (arylesterase and paraoxonase) were performed using spectrophotometric methods as described by Huen et al. PON1 genotypes were examined categorically; for −108PON1, the CC genotype is the reference, and for 192PON1, the RR genotype is the reference. Arylesterase and paraoxonase activity in maternal and umbilical cord blood were examined as continuous variables, normalized by dividing by the standard deviation. Potential confounders were selected a priori from the set of characteristics known to be associated with birth outcome in this population. Covariates were kept in the final models if they were also associated with PON1 genotype or activity or if their exclusion from the model changed the coefficient on the main effect by more than 10%. Models of PON1 genotype included maternal pre-pregnancy BMI and maternal weight gain during pregnancy as covariates. Models of PON1 enzyme activity also included maternal age and country of birth, as well as assay temperature, since ambient temperature has been shown to affect hydrolysis rates 192PON1 genotype by stratifying by genotype and by testing for interaction between activity and genotype using cross-product terms. As no statistically significant interaction was found, analyses of PON1 activity on birth outcome controlled for 192PON1 genotype as a covariate but not as an effect modifier. Models of birth weight, length and head circumference also controlled for gestational age and gestational age2 to examine associations independent of gestational duration.Initial analyses used linear regression to examine the main association of PON1 genotype and activity with length of gestation and infant birth weight, length, and head circumference independent of pesticide exposure. Maternal and child PON1 genotype, two cross-product terms were included in the model (e.g. QR*DAP concentrations and RR*DAP concentrations), and the overall statistical significance of both terms in the model was determined using Wald tests. Similar cross-product terms were generated using tertiles of PON1 activity. Statistical significance for interaction was set at p-value<0.1. To further investigate effect modification by PON1, we then stratified the linear regression models by genotype or by tertiles of enzyme activity.Subsequent analyses explored whether PON1 genotype or activity was an effect modifier in the association of maternal DAP metabolite concentrations and length of gestation or fetal growth. Linear regression models were created for the association of total urinary concentrations of DMs, DEs and DAPs with these birth outcomes using the same methods and covariates as described in our previously published study in utero OP pesticide exposure. The analyses were conducted using DAP concentrations unadjusted for creatinine. Subsequent sensitivity analyses included creatinine as a covariate in the models.The variables for total concentrations of DMs, DEs and DAPs were log-transformed to reduce the impact of outlier points. The measurements at two time points during pregnancy were averaged to create a summary measure of Covariates included in the models were maternal age, pregnancy weight gain, gestational age at first prenatal care visit (in weeks), and gestational age at urine collection (in weeks) as continuous variables and parity (0 or ≥1), infant sex, country of birth (US or other), household income (≤poverty or >poverty), and maternal pre-pregnancy BMI  as categorical variables. Smoking, alcohol, and drug use were not included in the final models because very few women reported use and their inclusion did not alter the results.Statistical analyses were performed using STATA/IC version 10.1 .Characteristics of the study population are shown in 192PON1 Q allele and the −108PON1 T allele were 50% and 46% in this population, respectively, and did not differ between mothers and newborns. The mean arylesterase and paraoxonase activity was 33.6 U/mL  and 256.6 U/L , respectively, for infants and 136.6 U/mL  and 989.0 U/L  for mothers.The allele frequencies of the −108TTPON1 genotype and paraoxonase activity (a combined measure of both quantity and enzyme efficiency) was lower among mothers and infants with either the −108TTPON1 or 192QQPON1 genotype, suggesting that individuals with these genotypes might be more susceptible to the adverse effects of OP pesticide exposure. The lowest arylesterase and paraoxonase levels were seen in mothers and infants who were homozygous for both −108TTPON1 and 192QQPON1.192PON1 genotype to better capture overall PON1 status. On average, infants with the susceptible −108TTPON1 genotype were born earlier  and had smaller head circumferences , after controlling for confounders, than infants with the −108CCPON1 genotype. Smaller head circumference was also seen among infants with the −108CTPON1 genotype  compared to those with −108CCPON1. No associations were seen with 192PON1; however, when the −108PON1 and 192PON1 genotypes were combined, we observed shorter gestation , birth weight , and head circumference  among infants with double homozygote −108TT/192QQPON1 genotypes compared to those with −108CC/192RRPON1, with the magnitude of effect considerably larger than for −108PON1 genotype alone.The independent association of infant PON1 genotype or enzyme activity with birth outcome, without consideration of pesticide metabolite levels, is shown in 192PON1 genotype, each standard deviation increase in arylesterase activity was associated with 0.2 week  increase in gestational duration  decrease in gestational age among −108TTPON1 infants and a 1.0 week  decrease among 192QQPON1 infants  increase in birth weight and a 0.7 cm  increase in head circumference. Each 10-fold increase in DMs was associated with a 0.8 cm  increase in head circumference among infants with high levels of arylesterase activity  and birth weight . This interaction appears to be driven by positive associations of DAPs with fetal growth among those with non-susceptible genotypes. We did find statistically significant interaction between DE metabolites and −108PON1 genotype for gestational age, supporting our finding that prenatal DE exposure was associated with shorter length of gestation only among the susceptible −108TTPON1 infants. Although we observed similar patterns with gestational age for 192PON1 and for DAPs and DMs, the interaction terms for these models were not statistically significant.Results of tests for interaction between PON1 and DAPs are shown in −108TTPON1). This suggests that low PON1 activity may be a factor contributing to preterm birth or restricted fetal growth.This study found that infant, but not maternal, PON1 genotype and activity were associated with birth outcome in a population of pregnant women living in an agricultural community. Specifically, we observed shorter gestation and smaller head circumference among infants who might be more susceptible to the effects of exposure to OP pesticides, either because they had lower PON1 enzyme activity (measured as arylesterase or paraoxonase activity) or because they were of a susceptible genotype  Results with nsistent . Only on192QQPON1 mothers 192QQPON1 and −108TTPON1 infants. The New York studies also found that, among mothers with low arylesterase levels, DM concentrations were negatively associated with birth length Our evidence for interaction between PON1 and OP exposure on birth outcome is supported by three other studies in utero DM levels. However, the only significant interaction that we observed for gestational age was with DE concentrations, not DMs. It is possible that the reason we did not observe an association of gestational age with DE metabolites previously is that it was masked by the role of PON1. Observing interaction with DE concentrations is plausible since the known biologically relevant action of PON1 is with two DE pesticides, chlorpyrifos and diazinon. PON1 does not hydrolyze DM pesticides such as malathion, oxydemeton-methyl, and dimethoate directly, but may have an indirect effect on their toxicity; by detoxifying chlorpyrifos oxon or diazoxon, PON1 prevents these OPs from inhibiting the carboxylesterases that detoxify some of the DM OPs. Thus, interaction of PON1 and DM metabolites is not unexpected.Examining interaction by PON1 expands on our earlier findings of shorter duration of gestation with increasing in utero DAP concentrations. These findings are in contrast with other studies, notably Whyatt et al., who that found OP pesticide levels in maternal blood were associated with decreased fetal growth. In fact, stratification by PON1 status served to magnify some of those positive associations, such that in the non-susceptible groups , increasing DAP concentrations were associated with increased birth weight and head circumference. We have no ready explanation for these findings, although it is possible that, among the less susceptible groups, high DAP concentrations in urine are actually an indication of high metabolizers (i.e. those who detoxify and excrete OP pesticides quickly), rather than high exposure.We previously reported borderline increases in birth weight and head circumference associated with The use of DAP metabolites to measure exposure has some limitations. DAPs measure short term exposure to OP pesticides. Although we took the average of two DAP measurements, one in early and one in late pregnancy, they may not reflect on-going exposure throughout gestation. Additionally, DAP metabolites in urine may overestimate OP pesticide exposure to the extent that they reflect exposure to preformed DAPs in the environment as well as to the parent OP compound 192PON1 and −108PON1. Although we have recently shown that other PON1 polymorphisms are also associated with arylesterase and paraoxonase activity in this cohort, most of them were in strong linkage disequilibrium with the two examined in this study Despite its large sample size, this study also lacked power to thoroughly examine interaction and conduct stratified analyses. We examined only two main polymorphisms, −108TTPON1 genotype and low arylesterase and paraoxonase activity on shorter gestation and smaller head circumference. This finding has important implications as a potential risk factor for preterm birth and fetal growth restriction and adds to the growing body of evidence that PON1 genotype may affect child development In summary, we found evidence for a main effect of infant This study also provides additional evidence that exposure to OP pesticides may impact fetal growth and length of gestation, particularly among individuals with increased susceptibility to OP pesticides. Additional studies are needed to help resolve continuing inconsistencies between the small number of existing studies.Table S1Association of maternal PON1 genotype (N = 451) and activity (N = 371) with birth outcome, CHAMACOS Study, Salinas Valley, CA.(DOC)Click here for additional data file.


Severe dehydration is generally believed to be a cause of significant hyperbilirubinemia in newborn babies. This study aimed to analyze the weight loss of healthy term newborn infants at 24, 48 and 72 hours after birth to predict significant hyperbilirubinemia at 72 hours.From January 2007 to December 2008, we conducted this retrospective chart review by measuring total bilirubin (transcutaneous and serum) in 343 healthy, term newborns with a birth body weight of more than 2500 g. We then analyzed the association between body weight loss (BWL) and significant hyperbilirubinemia  72 hours after birth. Receiver operating characteristic curves were used to evaluate the appropriate cutoff BWL percentages on the first three days after birth for the prediction of neonatal hyperbilirubinemia 72 hours after birth.p < 0.05). Breastfeeding was not statistically correlated with significant hyperbilirubinemia (p=0.86). To predict significant hyperbilirubinemia 72 hours after birth, receiver operating characteristic curve analysis showed that the optimum cutoff BWL percentages were 4.48% on the first day of life , 7.60% on day 2 , and 8.15% on day 3  .A total of 115 (33.5%) neonates presented with significant hyperbilirubinemia 72 hours after birth, and the percentages of BWL on the first three days were all higher than those in the non-significant hyperbilirubinemia group (all BWL on the first three days after birth may be a predisposing factor for neonatal hyperbilirubinemia, and may also serve as a helpful clinical factor to prevent significant hyperbilirubinemia 72 hours after birth. The optimal BWL cutoff percentages on the first three days after birth presented in this study may predict hyperbilirubinemia and indicate the need for supplementary feeding. Sixty to 80% of healthy, full-term infants are expected to present with idiopathic neonatal jaundice in the initial postnatal period . IdiopatPrevious studies have suggested that 7% to 10% BWL by day 3 in fully breastfed infants is abnormal neonatal BWL ,5. HowevWe conducted a retrospective chart review of all neonates with a gestational age of more than 37 weeks and a birth body weight (BW) of more than 2500 g from January 2007 to December 2008 at a medical hospital. The exclusion criteria were a history of birth trauma, cephalohematoma, instrumental delivery, exposure to certain medications (mother or baby), history of gestational diabetes, early onset hyperbilirubinemia (less than 48 hours), pathological neonatal jaundice , prenatal asphyxia, major organ anomalies, small for gestational age infants and infants who were exclusively formula fed.In total, 166 neonates were excluded due to pathological neonatal jaundice (n = 42), early onset hyperbilirubinemia (n = 10), neonatal infections (n = 37), cephalohematoma (n = 7), prenatal asphyxia (n = 3), major organ anomalies (n = 2), and 65 who were discharged home within 2 days after birth. Three hundred and forty-three newborns were enrolled in further analysis. Gestational age was not analyzed, as the gestational age of all infants in the study was greater than 37 weeks, and most infants were around 39 to 40 weeks.The study was approved by the institution’s Human Subjects Review Committee of Asia University in central Taiwan.The following variables were analyzed: gender, gestational age, birth BW, BW on the first day (24 hours) after birth (day 1), BW on the second day (48 hours) after birth (day 2), BW on the third day (72 hours) after birth (day 3), BWL/percentage on day 2 and day 3, feeding style (exclusively breast fed or mixed feeding), delivery method , and total bilirubin level on day 3.Exclusive breast feeding is the optimal initial feeding style for infants according to the WHO treatment guidelines. However, when there was insufficient breast milk formula was given, and the feeding style was classified as mixed feeding.Transcutaneous total bilirubin was routinely checked in all infants using a transcutaneous device , and total serum bilirubin (TSB) was checked by heel stick for blood sampling (direct spectrophotometric method) when the infants presented with a transcutaneous bilirubin level of more than 15 mg/dL. The infants were divided into two groups: the significant hyperbilirubinemia group  ,7, and tt-test, Mann–Whitney U test, Spearman’s rank correlation, and receiver operating characteristic (ROC) curves. Because some data did not meet the normal assumption after a normal distribution test of the continuous variables, Spearman’s rank correlation was chosen. The results of the descriptive analyses of the independent variables were reported as percentages and mean ± standard deviation (SD). The differences between the groups were presented as 95% confidence intervals (CIs). Probability levels less than 0.05 were considered to be significant. Interobserver agreements in analyzing the scores of the two scoring systems were calculated by kappa statistics. We also examined the test parameters, including sensitivity, specificity, area under the ROC curve (AUC), positive likelihood ratio (LR+), and negative likelihood ratio (LR–) at the various cutoff values. The AUC, calculated using the trapezoidal rule, was considered as a global measure of the diagnostic value of that parameter. LR+ and LR– were calculated for the best cutoff values. The criterion value indicated the value corresponding to the highest accuracy . Statistical analyses were performed using SPSS software .All statistical analyses were performed using Yate’s correction of contingency, During the study period, 343 neonates with a gestational age of more than 37 weeks and a birth BW above 2500 g were analyzed. The mean birth BW was 3119 ± 352 g, and the mean BWL percentage on day 3 was 7.07 ± 2.82%. The mean TSB level 72 hours after birth was 13.39 ± 3.12 mg/dL. In addition, 115 neonates (33.5%) had levels of TSB higher than 15 mg/dL 72 hours after birth.Table The strength of correlation among the BWL percentages within the first three days was identified by Spearman’s rank correlation coefficients Table . The BWLTable Breastfeeding offers many benefits for neonates including host protection, better developmental outcomes, and decreased rates of infectious diseases, infant death syndrome, overweight and even asthma -12. HoweEven though many reports support the idea that breastfeeding induces severe hyperbilirubinemia, we found that breastfeeding was not statistically correlated with significant hyperbilirubinemia, thereby supporting the use of breast milk. A previous study reported that a BWL of more than 7% was an independent risk factor for early neonatal jaundice, and that infants with a BWL of more than 7% had a 1.4-fold increased risk of jaundice . In the We determined two cutoff points for each BWL percentage from day 1 to day 3 in order to be more easily applicable in a clinical setting, and to provide a point as to when significant hyperbilirubinemia 72 hours after birth can be ruled in or out. Based on the results of ROC analysis, the neonates with a BWL percentage on day 1 of less than 0.43% did not progress to significant hyperbilirubinemia 72 hours after birth, while a BWL percentage of more than 10.23% on day 1 led to significant hyperbilirubinemia 72 hours after birth. In addition, the neonates with BWL percentages less than 2.97% on day 2 and less than 0.60% on day 3 did not progress to significant hyperbilirubinemia 72 hours after birth, while those with BWL percentages of more than 10.93% on day 2 and 11.33% on day 3 did progress to significant hyperbilirubinemia 72 hours after birth. Primary care pediatricians should pay more attention to the patients in the indeterminate zone because it is not easy to predict significant hyperbilirubinemia 72 hours after birth in such cases. In addition, the physicians should attempt to persuade family members to increase the oral intake for these neonates to prevent further dehydration-induced significant hyperbilirubinemia 72 hours after birth. Based on our results, BWL percentage cutoff values of 4.48% on day 1, 7.60% by day 2, and 8.15% by day 3 were useful in predicting significant hyperbilirubinemia 72 hours after birth. We believe that this may be a helpful clinical tool when evaluating neonates with physical dehydration on the first three days after birth.For non-pathological hyperbilirubinemia infants, dehydration is thought to be the major factor -5. HowevThere are some limitations to the present study. First, we used two different methods of measuring total bilirubin. Although the accuracy of a transcutaneous device has been proven, there may have been some deviation between the two methods. Second, maternal and neonatal risk factors for hyperbilirubinemia were not addressed . Third, the difficulty in assessing the adequacy of intake in breastfeeding and the variable timing of shifting to mixed feeding made the line between two feeding groups more blurred. Fourth, the major limitation may have been that we didn’t enroll more patients in the study. Finally, the study was performed in Taiwan and the cutoff values may not necessarily be applicable to other regions of the world.In conclusion, BWL on the first three days after birth may be a predisposing factor for neonatal hyperbilirubinemia, and may also serve as a helpful factor to prevent significant hyperbilirubinemia 72 hours after birth. The optimal BWL cutoff percentages on the first three days after birth presented in this study may predict hyperbilirubinemia and indicate the need for supplementary feeding.BWL: Body weight loss; TSB: Total serum bilirubin; ROC: Receiver operating characteristic; BW: Bodyweight; AUC: Area under the ROC curve; LR+: Positive likelihood ratio; LR: Negative likelihood ratio.The authors declare that they have no competing interests.WCY and LLZ reviewed the medical records, analyzed and interpreted the data, and drafted the manuscript; YCL and CHC interpreted the data and drafted the manuscript. YCF analyzed and interpreted the data. HPW designed and oversaw the study, interpreted the data, and revised the manuscript. All authors read and approved the final manuscript for publication.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2431/13/145/prepub


Maternal dietary patterns were evaluated by diet scores  and by carbohydrate quality (glycemic index and glycemic load). Poisson regression with robust standard errors was used to examine the relative risk of SGA and separately LGA, with dietary patterns and other lifestyle factors. Linear regression was used to determine the association of birthweight and early infant growth with better dietary patterns. Relative risk of SGA and LGA was not associated with dietary patterns. Birthweight and infant growth were not associated with maternal diet. Smoking, however, increased the risk of delivering an SGA infant , while higher prepregnancy BMI increased the risk of delivering an LGA infant . Future studies are needed to evaluate whether deficiencies in more specific maternal dietary nutrients play a role in fetal growth.Our analysis examined the impact of maternal dietary patterns and lifestyle factors on markers of fetal growth, specifically birthweight and size for gestational age  or large-for-gestational age (LGA)). The Infant Feeding Practices Study II, a prospective cohort study, surveyed pregnant women during their 3rd trimester, of which a subgroup ( Fetal growth is an important determinant not only of infant survival but also of future chronic disease risk. Both low and high birthweight have been associated with increased infant mortality and long-term morbidity , 2. Low Maternal nutrition is the major fuel for fetal growth . While mOur objective was to determine the association of overall maternal dietary patterns, as evaluated by the Alternative Healthy Eating Index for Pregnancy (AHEI-P) and the alternate Mediterranean diet (aMED), with birthweight, birthweight-for-gestational age , and early infant growth by 4–6 months of life in the Infant Feeding Practices Study II (IFPSII). Furthermore, the association of carbohydrate quality and quantity, as measured by the average glycemic index (GI) of diet and glycemic load (GL), was investigated as well.IFPSII (2005–2007) is a longitudinal cohort study, sampling US women from a nationally distributed consumer opinion panel during their 3rd trimester of pregnancy . After d2) and smoking (yes or no) during pregnancy were reported in the prenatal questionnaire during the 3rd trimester. Maternal alcohol use (g) and gestational weight gain (kg) were reported in the prenatal FFQ and neonatal questionnaire, respectively.Maternal demographics were either available via the panel database or collected through a short demographic questionnaire . ExamineThe Diet History Questionnaire (DHQ) is a validated FFQ originally developed by the National Cancer Institute. The DHQ was modified to reflect dietary intake in the past month rather than the past year and included additional foods and nutrients relevant to pregnant women, such as specific types of fish and dietary supplements . As a retrans fat, and sodium received lower scores. For healthier components, the mother's observed intake was divided by the criterion for maximum points and multiplied by 10. To assign higher points for lower intake of less healthy components, the mother's observed intake was divided by the criterion for maximum points, subtracted from 1, and then multiplied by 10. Sodium intake was divided into eleven groups and scored on a 0–10 point scale. All of the above scores for the individual dietary components were then summed to get the total AHEI-P score for each mother with higher scores indicating better dietary patterns. AHEI-P was categorized into tertiles and also examined as a continuous variable.The original Healthy Eating Index (HEI) was developed to measure overall dietary patterns based on the 1995 Food Guide Pyramid and Dietary Guidelines for Americans . Since tThe traditional Mediterranean diet, originally derived from dietary intake observed in the Mediterranean region, distinguishes itself from the AHEI-P based on its different nutrient requirements, such as low intake of saturated fats . To measGI is a measure of the glycemic effect of a particular food relative to a standard amount of glucose. GL is a measure of both the quality and quantity of carbohydrate consumption and is calculated based on a food's GI . Both GIInfant's birthweight was reported on the birth screener after delivery. Gestational age was determined based on the mother's expected date of delivery and the infant's birth date, as reported on the birth screener. Infant's birth length and gender were reported on the neonatal questionnaire. Data on gender, birthweight, and gestational age were used to identify infants as small-for-gestational age  or large-for-gestational age  . BirthweAt the 3rd-, 5th-, 7th-, and 12th-month postpartum mailed surveys, mothers reported their infant's weight and length and the date of each measurement based on their last pediatrician's visit. From these questionnaires, weight and length measurements were used to calculate WFL z-scores when the infant's age was between 4 and 6 months using the 2000 CDC growth charts. This age was chosen because change in WFL in the first 6 months of life is a marker for accelerated infant growth.n = 6), type I or type II diabetes (n = 9), or missing gender information (n = 66). Associations between tertiles of AHEI-P and maternal covariates were assessed using ANOVA for continuous variables and χ2-test for categorical variables. Poisson regression with robust standard errors [The final analytic sample included 893 participants after exclusions for gestational ages above 43.5 weeks .Multiple linear regression analysis was used to determine the association of birthweight, WFL z-score at birth, and WFL z-score at 4–6 months with AHEI-P, aMED, GI, and GL. Models for birthweight and birth WFL z-score were fully adjusted for the above-mentioned covariates with additional adjustment for gestational age. Change in infant growth as an outcome was modeled with WFL z-score at 4–6 months, adjusting for gestational age, WFL z-score at birth, and all the other covariates . All assP < 0.0001). Women with higher AHEI-P scores tended to be older, with higher education, lower poverty index ratio, and lower prepregnancy BMI (Tables The mean (±standard deviation) AHEI-P, aMED, GI, and GL values were 59.1 ± 11.8 points, 4.0 ± 1.8 points, 50.0 ± 3.6 percent, and 141.5 ± 66.0 g, respectively. Total food energy increased with higher AHEI-P tertiles (I Tables . Women eEighty-two (9.2%) infants were LGA. No significant associations between AHEI-P tertiles and LGA were observed. The relative risk of the highest versus the lowest tertile of AHEI-P was 0.92 : 0.50–1.69). LGA, however, was associated with prepregnancy BMI (Relative Risk (RR) = 1.06, 95% CI: 1.03–1.09). aMED, GI, and GL were not associated with LGA .n = 46) (data not shown).Seventy-one (8.0%) infants were SGA. Similarly, after adjusting for covariates, no significant differences were examined across the tertiles of AHEI-P in association with SGA risk. The risk estimate of the highest tertile compared to the lowest tertile of AHEI-P was 0.93 (95% CI: 0.49–1.75). SGA, however, was associated with maternal race  and smoking status . aMED, GI, and GL were not associated with SGA . StratifNeither birthweight z-scores nor birth WFL z-scores were associated with AHEI-P scores . The meaIn a nationally distributed sample of 893 US mothers of healthy singletons delivered after 35 weeks of gestation, maternal dietary patterns and carbohydrate quality during third trimester were not associated with offspring outcomes consisting of birthweight, size-for-gestational age , and infant growth in the first 4–6 months of life. On the other hand, maternal characteristics including race, smoking status, and prepregnancy BMI were associated with SGA and LGA risk.P trend = 0.009) [Two previous studies have examined dietary patterns as measured by AHEI-P in association with birthweight outcomes. In the Infancia y Medio Ambiente (INMA) cohort of 787 pregnant Spanish women, investigators found a reduced risk of fetal growth restriction (FGR) for weight  per five-point increase in AHEI-P (Odds Ratio (OR) = 0.70, 95% CI: 0.59–0.85) . Better = 0.009) . However= 0.009) . For com= 0.009) . Also, a= 0.009) . These f2) with intrauterine growth restriction compared to women with normal prepregnancy BMI (18.5 ≤ BMI < 25) [Our observation that prepregnancy weight affects birthweight suggests that diet is not completely irrelevant. As prepregnancy BMI is associated with infant size-at-birth, this association suggests prepregnancy diet may be related to fetal growth. In our study, mothers had a 6% higher risk (95% CI: 1.03–1.09) of delivering an LGA infant per unit increase in BMI. These findings are consistent with previous studies –28. DjelMI < 25) . These fin utero depends on maternal factors other than prenatal dietary patterns. Smoking is a well-known modifiable risk factor for restricting fetal growth and our findings for smoking are in agreement with previous studies [Among pregnant US women with sufficient energy intake, smoking during pregnancy increased SGA risk. This result indicates that growth  studies , 31. Ourn = 893) was comparable to the INMA cohort (n = 787). Fourth, the IFPSII population largely consisted of healthy singletons, which restricts the generalizability of our results.Our analysis should be interpreted in the context of the strengths and limitations of the study. Two key strengths include the prospective study design with the assessment of prenatal diet prior to the examined birth outcomes and the evaluation of maternal diet using validated measures of dietary patterns. There were also several limitations. First, while prenatal diet was only measured once during the third trimester, repeated measurements may have better captured dietary intake. Dietary intake in both the INMA and Project Viva cohorts reflected intake in the first trimester. However, we do not expect maternal diet to differ significantly between early and late pregnancy . As suchOur findings suggest that prenatal dietary patterns as measured by AHEI-P and aMED, and carbohydrate quality based on GI and GL, during the 3rd trimester do not affect birth outcomes defined by birthweight, SGA and LGA, as well as infant growth at 4–6 months. Our results continue to emphasize the importance of prepregnancy BMI and smoking habits as key risk factors for SGA and LGA and as such continue to be clinically useful indicators for identifying women at risk for poor birth outcomes.


We report a case of epidermal inclusion cyst in a 32-year-old male. This was a complication of circumcision that was neglected over years to form stones and urethrocutaneous fistula. Complete excision of the cyst and repair of the fistula were performed successfully. Histopathological examination confirmed our diagnosis. Epidermal inclusion cyst is a rare complication of neonatal male circumcision. A search of all databases revealed that very few reports are available in the literature –6.Thirty-two-year-old patient presented to our department complaining of hard lesion on the ventral aspect of penile skin. The lesion has increased gradually in size over last 3 years. The patient reported passage of few drops of urine after micturition from 2 small opening close to the mass. He had a history of circumcision when he was 2 years old. Examination revealed subcoronal cyst with hard object inside like stones and 2 small urethrocutaneous fistulae. X-ray revealed radioopaque shadows suggesting stones.Subcoronal circumferential incision with degloving of penile skin was performed. The cyst was incised and revealed 4 different size stones . The innEpidermal inclusion cyst results from implantation and proliferation of epidermal element in the dermis . EpidermUrethral diverticulum with stone formation is the most important differential diagnosis of this case. This was excluded after exploring the cyst and detection of penile skin as the wall of the cyst. In cases of urethral diverticulum, the wall should be urothelium not penile skin.Epidermal inclusion cyst is a rare complication of male circumcision. It is the only report of penile epidermal inclusion cyst complicated with stones and urethrocutaneous fistula. Complete excision of the cyst and repair of fistula is easy and curative.


Sequences of high voltage pulses were applied to chicken liver tissue in order to expose it to electric field which was measured by means of MREIT. MREIT was also evaluated for its use in electroporation based treatments by calculating electric field distribution for two regions, the tumor and the tumor-liver region, in a numerical model based on data obtained from clinical study on electrochemotherapy treatment of deep-seated tumors. Electric field distribution inside tissue was successfully measured ex vivo using MREIT and significant changes of tissue electrical conductivity were observed in the region of the highest electric field. A good agreement was obtained between the electric field distribution obtained by MREIT and the actual electric field distribution in evaluated regions of a numerical model, suggesting that implementation of MREIT could thus enable efficient detection of areas with insufficient electric field coverage during electroporation based treatments, thus assuring the effectiveness of the treatment.Magnetic resonance electrical impedance tomography (MREIT) was recently proposed for determining electric field distribution during electroporation in which cell membrane permeability is temporary increased by application of an external high electric field. The method was already successfully applied for reconstruction of electric field distribution in agar phantoms. Before the next step towards  Electrochemotherapy (ECT) and nonthermal irreversible electroporation ablation (NTIRE) are potent procedures used in solid tumor treatment. In addition, NTIRE is also promising ablation method for nonmalignant tissues. Both, ECT and NTIRE, rely on cell membrane electroporation, a process which increases cell membrane permeability due to externally applied electric field in situ and only for irreversible electroporation based treatments such as NTIRE in situ thus taking into account actual tissue conductivity and electrodes position. Since electric field distribution is available immediately after the delivery of electric pulses also corrective intervention would be possible.Recently, ECT and NTIRE have been also used in treatment of deep-seated tumors ex vivo liver tissue can be efficiently monitored by MREIT. In addition, feasibility of using MREIT to monitor electric field distribution during electroporation based treatments was evaluated in silico on a recently reported case The aim of this study was to investigate whether electric field distribution during electroporation of Uel of either 1000 V or 1500 V and a duration of 100 µs were delivered between electrode pairs 1–2 and 1–3 by an electric pulse generator Cliniporator Vitae  to establish electric field distribution below and above reversible electroporation threshold value in the case of Uel  = 1000 V and Uel  = 1500 V, respectively. Electroporation threshold values were already determined in previous study Chicken liver primarily intended for human consumption were obtained from a slaughterhouse  which operates in accordance to Slovenian law. Experiments were in compliance with the slaughterhouse as all of their goods are produced strictly for human consumption. The process of slaughtering is regulated by Rules on animal protection and welfare at slaughter  which ensures ethical standards of slaughtering procedure and is in compliance with European Union Council directive on the protection of animals at the time of slaughter or killing (93/119/EC). Temperature of the tissue was maintained at 4°C before the beginning of experiment when they were allowed to heat up to the room temperature. Tissues were sectioned in flat and cylindrical shaped samples with a diameter of 20 mm and placed in an acrylic glass container see . Four cyφ stored in acquired imagesγ is the proton gyromagnetic ratio and tc is the total duration of the applied electric pulses. Once these are known, electric current density in the sample J  =   can be calculated from the current induced magnetic field change vector Bc  =   using Ampere’s lawMREIT algorithms are in general used for reconstruction of conductivity distribution inside samples ex vivo tissue presented in this study was such that currents were flowing predominately in the plane perpendicular to the electrodes. This allowed a simpler current distribution reconstruction by disregarding two negligible in-slice magnetic field change components  and using only the nonzero component in direction parallel to the imaging slice, i.e. Bz, for calculation of the current density JCDI = MR images of current induced magnetic field changes were obtained by means of two-shot RARE CDI sequence u satisfies the following boundary conditions:After current density inside the sample was obtained, the MREIT J-substitution algorithm was applied. The algorithm is based on iteratively solving of Laplace’s equation:e is the boundary of the electrodes, n denotes normal vector to the boundary, Uel is the voltage on the electrodes measured by the generator, σ is unknown electrical conductivity of the sample and k denotes a number of current iteration. Electrical conductivity was updated after each iteration (k+1)σ falls below 0.01 electric field distribution E can be calculated using Ohm’s lawB component, we performed a simulation in the case of a 3-D numerical model designed for the purpose of an electrochemotherapy treatment of deep-seated liver tumors. The treatment was done as part of an on-going Phase I/II clinical study . The study was approved by Institutional Medical Board and Ethical Committee of the Republic of Slovenia. A report of the treatment was published by Edhemovic et al, where all details about the treatment procedure can be found In order to evaluate the proposed MREIT algorithm used to acquire the current and electric field distribution during electroporation based treatments without rotating the subject, i.e. using only one in silico MREIT evaluation we focused on two regions between two pairs of electrodes where electroporation occurs due to the highest electric field. The first region or the tumor region was situated between the electrode pair 3–4. The tumor had a homogeneous electrical conductivity σT = 0.4 S/m. The second region or the tumor-liver region was situated between the electrode pair 4–6. The region consisted of tumor and liver tissues, each with its own electrical conductivity. The liver had a homogeneous electrical conductivity σL = 0.05 S/m. On the border between tumor and liver tissue we applied gradual change of electrical conductivity using sigmoid curve.Briefly, a model of a patient with a metastasis located between the inferior vena cava (IVC) and the main hepatic veins was studied. The model included a 3-D geometry of the metastasis that was built by means of segmented MRI images of the patient B*  =  B and the electric field distribution E*  =  E were calculated for two regions – the tumor and the tumor-liver region by applying electric pulses with amplitudes of Uapp = 1700 V and Uapp = 2100 V between each pair of electrodes . The obtained electric field distribution E* can be considered as an actual electric field distribution. It was used as a reference in evaluation of MREIT results using only one B* component, i.e. Bz, established during application of pulses in one direction (either between electrodes pair 3–4 or 4–6). These calculations were done by solving the 3-D numerical model using the finite element method with the commercial finite element software package COMSOL Multiphysics 3.5a . The current density distribution JCDI =  was calculated using Eq. (3) by means of only the component zB in an xy-plane positioned across the middle of the tumor . When tissue was exposed to electric pulses with an amplitude of Uel  = 1000 V no significant alteration of electrical conductivity was measured except near boundaries and in the region of inactive electrode. On contrary, major changes of conductivity were observed in the region between the electrodes compared to the rest of the tissue when it was exposed to pulses with Uel  = 1500 V. Current density was at both applied amplitudes the highest near the active electrodes and in the region of increased conductivity in the case of Uel  = 1500 V.When a tissue sample is exposed to electroporation pulses an electric current density and electric field are established inside the tissue. The former was successfully measured by the CDI method using only the Uel  = 1000 V and Uel  = 1500 V) are presented in Measured electric current and voltage for liver tissues exposed to four 100 µs long electroporation pulses with different amplitudes (Uel  = 1000 V and Uel  = 1500 V) delivered between the electrode pairs 1–2 and 1–3 are shown in Uel  = 1500 V case than in Uel  = 1000 V, as well as higher in case when pulses were delivered between electrodes pair 1–2 than between 1–3. Results were successfully and reproducibly obtained in all treated liver tissues.Electric field distributions in the liver tissue for electric pulses with different amplitudes (Bz component is compared with the corresponding true electric field calculated by the 3-D numerical model of a deep-seated tumor in liver.Evaluation results of MREIT to monitor electric field distribution during electroporation based treatments are presented in ex vivo liver tissue experiment. Feasibility of MREIT to use in electroporation based treatments such as electrochemotherapy and nonthermal irreversible electroporation ablation was evaluated also using numerical modeling on a recently reported case.The aim of this study was to investigate feasibility of the MREIT technique to monitor electric field distribution during tissue electroporation by means of an Uel = 1500 V (Uel = 1000 V due to lower electric field. Observed tissue changes are a consequence of local tissue electroporation as electric field in the region between electrodes exceeded reversible threshold value in the case of Uel = 1500 V whereas most of this region remained under the threshold value in the case of Uel = 1000 V. Comparison of electric current (As shown in = 1500 V . The reg current  also conB component using a 3-D numerical model built for the purpose of electrochemotherapy treatment of deep-seated tumors in liver. An electric field was successfully obtained in both regions, i.e. in the tumor region and in the tumor-liver region. As shown in Implementation of MREIT during electroporation pulse delivery could significantly improve electroporation procedures in clinical applications such as ECT and NTIRE. Adequate electric field distribution and sufficiently high local electric field are two of the most important conditions for successful realization of both therapies. Even though the treatment planning for ECT already proved in clinical treatment of deep-seated tumors ex vivo was measured during electroporation by applying electrical pulses in one direction only. As expected, alteration of tissue conductivity distribution caused by applied high voltage pulses was detected. Conductivity changes that occur during the pulse In this study new potential in monitoring electric field distribution by means of MREIT were examined. Electric field distribution in tissue samples


Every cell division in budding yeast is inherently asymmetric and counts on the correct positioning of the mitotic spindle along the mother-daughter polarity axis for faithful chromosome segregation. A surveillance mechanism named the spindle position checkpoint (SPOC), monitors the orientation of the mitotic spindle and prevents cells from exiting mitosis when the spindle fails to align along the mother-daughter axis. SPOC is essential for maintenance of ploidy in budding yeast and similar mechanisms might exist in higher eukaryotes to ensure faithful asymmetric cell division. Here, we review the current model of SPOC activation and highlight the importance of protein localization and phosphorylation for SPOC function. S. cerevisiae, spindle alignment along the polarity axis is particularly crucial for fidelity of chromosome segregation. This is mainly because of the physical constrains that arise from the establishment of the site of cell division (bud neck) before entry into mitosis  [KAR9 or DYN1 pathway genes frequently misalign their spindles and rely on SPOC for survival [mitotic exit network (MEN) in response to spindle orientation defects. SPOC inhibition of MEN involves phosphorylation events and alterations in the localization of proteins.In budding yeast, a faithful mitosis requires positioning of the mitotic spindle along the mother-bud axis to ensure that the expanding anaphase spindle leaves one set of chromosomes in the mother cell while the second set is dragged through the bud neck into the daughter cell Figure . Misaligt (SPOC) -12. Mutasurvival . SPOC deThis review aims to assemble the recent advances in the SPOC field into a model. Starting from mitotic exit in budding yeast, we will focus on how SPOC inhibits MEN and how SPOC components are regulated.fourteen early anaphase release (FEAR) network which promotes Cdk dependent phosphorylation of Net1 [mitotic exit network (MEN) [Mitosis in budding yeast is driven by the activity of the sole cyclin dependent kinase (Cdk) Cdc28 in complex with mitotic cyclins (Clb1-4) -15. Cons of Net1 -27. FEAR of Net1 . Full rerk (MEN)   .MEN was first proposed as an essential pathway for mitotic exit, by the analysis of temperature sensitive mutants that arrest in late anaphase with high mitotic cyclin levels . Since tspindle pole body  [anaphase promoting complex (APC) activator Cdh1 [MEN is a signal transduction pathway driven by the Ras-like GTPase Tem1 Figure . GTP-boun yeast) ,41. Thisn yeast) -44. Actin yeast) ,46. Henctor Cdh1 ,47.GTPase activating protein (GAP) complex Bfa1-Bub2 inhibits Tem1 activity by promoting GTP hydrolysis [guanine nucleotide exchange factor (GEF), Lte1, presumably promotes Tem1 activation in the daughter cell compartment, although the molecular basis of this activation is still unclear. Lte1 has a GEF domain homologous to that of Cdc25 [lte1Δ cells fail to exit mitosis at low temperatures. This mitotic exit defect is suppressed by a high copy number of TEM1 [in vitro [Tem1 is supposedly active in the GTP bound state by similarity to its fission yeast homologue Spg1 . The twodrolysis . The putof Cdc25 . In addi of TEM1 . These o of TEM1 . Further of TEM1 . In factin vitro . Insteadin vitro ,53.How is MEN activated? Polarity factors such as Rho-like GTPase Cdc42 and its effectors Cla4, Ste20, Gic1 and Gic2 promote mitotic exit mainly through targeting of Lte1 to the bud cortex and by interfering with Bfa1-Bub2 GAP function -57. In aCdh1 which in turn promotes Cdc5 degradation [On the other hand, Cdc14 released via MEN eventually inactivates the MEN forming a negative feedback loop. Firstly, Cdc14 activates APCradation . Secondlradation . In addiradation ,57. Furtradation . This isradation .S. cerevisiae BUB2 (budding uninhibited by benomyl) gene was originally identified in a genetic screen for mitotic checkpoint related genes required to delay cell cycle progression in response to microtubule defects  [spindle assembly checkpoint  [BFA1  was discovered by homology to the fission yeast's Byr4 which together with Cdc16 (homologue of Bub2 in S. pombe) is involved in inhibition of the septation initiation network  [spindle position checkpoint (SPOC) [The odazole) . At thattubules) -67. BFA1mitosis) -70. In smitosis) ,71-74. It (SPOC) ,11 , Bub2 alone does not affect the hydrolysis and dissociation of GTP from Tem1. However, Bub2 in the presence of Bfa1 increases the GTP dissociation and hydrolysis rate of Tem1 in vitro .in vitro [Bub2 and Bfa1 physically interact with each other and with Tem1 ,75. Bfa1in vitro . Cdc5 thin vitro ,80.KIN4 was first identified as a genetic interactor of KAR9 in a large scale synthetic genetic array (SGA) analysis where the deletion of KIN4 decreased the survival of kar9Δ cells [kin4Δ is very similar to bfa1Δ or bub2Δ cells: all mutant cell types fail to arrest in response to spindle misalignment. Like Bfa1, high levels of Kin4 cause an anaphase arrest due to inactivation of the MEN that can be reverted by deletion of BUB2. However, unlike Bfa1 and Bub2, Kin4 is not required for the metaphase arrest induced upon microtubule depolymerization [Another kinase involved in Bfa1-Bub2 regulation is the Kin4 kinase. 9Δ cells . Followi9Δ cells ,83. As srization ,83.cytoplasmic microtubules (cMTs). By phosphorylating Bfa1, Kin4 inhibits Bfa1 phosphorylation by Cdc5 in vivo and hence promotes Bfa1-Bub2 GAP activity [in vitro [in vivo could only be understood by protein localization studies which will be discussed in next sections .Kin4 phosphorylates Bfa1 when the anaphase spindle is misplaced in the mother or when there are defective activity -84. InteTaken together, Bfa1-Bub2, Cdc5, and Kin4 constitute the SPOC. Activity of the GAP complex is regulated by two opposing kinases; Cdc5 and Kin4. If the spindle is correctly aligned, Cdc5 phosphorylates Bfa1 and inactivates the Bfa1-Bub2 GAP complex which leads to mitotic exit. However if the spindle is misaligned or the proper microtubule cortex interactions are interfered, Kin4 kinase activates the GAP complex by phosphorylating Bfa1 and preventing the inhibitory phosphorylation of Bfa1 by Cdc5. Eventually, GAP complex delays mitotic exit through inhibition of Tem1 until spindle re-aligns in the mother-bud direction Figure .Experiments based on fluorescence microscopy and immuno-electron microscopy have shown that most of the MEN and SPOC components associates with the cytoplasmic surface of the SPBs and many of them translocates to the bud neck in telophase to regulate cytokinesis Figure  10,37,3,61,85-96Bfa1, Bub2 and Tem1 localize to the cytoplasmic face (outer plaque) of the SPBs, preferentially to the bud-ward directed SPB  . The terSPB-bound Bfa1-Bub2 protein amounts increase in anaphase at the dSPB with a parallel decrease at the mSPB from which Bfa1-Bub2 eventually disappears . Tem1 loHow Bfa1-Bub2 and Tem1 asymmetry is established, is a question that still remains to be answered. So far, it has been shown that neither the forces generated during spindle elongation nor SPB inheritance nor passing from the bud neck affect Bfa1 asymmetry ,105. ActKin4 localization is quite different than that of Bfa1-Bub2 and Tem1. During most of an unperturbed cell cycle Kin4 associates with the cortex of the mother cell body and accumulates at the bud neck in late anaphase. However, for a short time period during mid-anaphase, Kin4 also localizes to the mSPB ,83   [How Kin4 associates with the cortex and SPBs, what restricts Kin4 to the mother cell or what excludes it from the daughter cell is still unclear. However, data about Kin4 localization have been accumulating over the years. It has been shown that Kin4 binds to the SPBs via Spc72 which is the SPB outer plaque component that binds γ-tubulin . In addiin SPOC) ,106.in vivo because Cdc5 dependent phosphorylation of Bfa1, Nud1 and Spc72 is lost in the nud1-2 temperature sensitive mutant in which Bfa1, Nud1 and Spc72 are mislocalized at 37°C [Cdc5 localizes to both SPBs in mitosis and to the bud neck during telophase ,90. C-te at 37°C ,97.Upon spindle misalignment or microtubule defects (i.e. depolymerization by nocodazole) Bfa1-Bub2 and Tem1 localization changes from asymmetric to symmetric  Figure . The terDespite the lack of mechanistic understanding for the establishment of Bfa1-Bub2 and Tem1 asymmetry, more insight has been gained into how the asymmetry is broken. The order of the events most likely starts with the change in Kin4 localization which is triggered by SPOC activating conditions, like misaligned spindles or defective microtubules (see the section: Sensory mechanisms for SPOC activation). Thereby, Kin4 gets access to Bfa1 and phosphorylates it on at least two residues (S150 and S180) .1/2 > 200 s). However, phosphorylation of Bfa1 by Kin4 loosens Bfa1-Bub2 interaction with the dSPB and promotes rapid exchange (t1/2 ≈ 20 s) of the Bfa1-Bub2 GAP complex at both SPBs [What is the functional consequence of Bfa1 phosphorylation by Kin4? Careful FRAP measurements have shown that Bfa1-Bub2 is stably associated with the dSPB during an unperturbed cell cycle  regardless of the cell cycle stage and the spindle alignment status [in vitro in the absence of SPBs further supports this notion. Rigorous biochemical analysis will be however necessary to clarify the molecular mechanism of Tem1 inhibition by Bfa1-Bub2 upon SPOC activation.On the other hand, Tem1 association with the SPBs is highly dynamic in the presence of Bfa1-Bub2  at the SPBs even when the anaphase spindle is correctly aligned [Role of Kin4 in SPOC function involves regulation of both its localization and its activity. SPB localization of Kin4 is essential for its role in activating Bfa1-Bub2, as preventing Kin4 SPB binding by targeting Kin4 constitutively to the cell cortex results in SPOC deficiency. In addition, constitutive targeting of Kin4 to the SPB outer plaque (via a Kin4-Spc72 chimera) is able to cause a 10 min delay in mitotic exit by promoting some Bfa1-Bub2 turnover  recently demonstrated the importance of Kin4's C-terminal region for Kin4 localization and SPOC activity. Overexpression of the Kin4 kinase domain, which resides at the N-terminal region of Kin4, is enough to inhibit mitotic exit but its expression at endogenous levels is not sufficient to keep the anaphase arrest upon spindle misalignment. Furthermore, Kin4 lacking the C terminal 146 amino acids cannot localize to the mother cell cortex and the SPBs and thus it is unable to engage SPOC. Finally, a single amino acid substitution (F793A) at the C terminal region prevents cortical localization of Kin4  and results in SPOC deficiency . All afoELM1, or replacement of the wild type ELM1 with a kinase dead allele rescues the toxicity of KIN4 overexpression. In addition, elm1 cells are deficient in keeping the SPOC arrest in response to spindle misalignment [ELM1 [Kin4 kinase activity is absolutely vital for SPOC function. Lately, we and others have shown that Kin4 kinase activity requires another kinase, namely Elm1 ,110. Elmlignment ,110. Thint [ELM1 . Elm1 isnt [ELM1 .in vivo. It is, therefore reasonable to hold Kin4 in an active state and change its localization as a response to spindle misalignment. Consequently, it is unlikely that Elm1 is either a sensor or a protein related with the sensor of the SPOC, but Elm1 phosphorylation of Kin4 at T209 residue is indispensable for Kin4 kinase activity and SPOC function [Several protein kinases are regulated through T-loop phosphorylation. A dephosphorylated T-loop acts as an autoinhibitor by blocking substrate access to the active site or by blocking ATP binding . Hence, function ,106,110.Kin4 T-loop phosphorylation by Elm1 persists throughout the cell cycle, with an increase in mitosis . Kin4 kiELM1 allele which cannot localize to the bud neck were reported to be SPOC deficient [Elm1 localizes to the bud neck as soon as a bud neck forms and dissociates from there prior to cytokinesis. Elm1 bud neck localization depends on the septin Cdc12 and is mutually required for proper localization of the septins Cdc12 and Cdc11 ,117. Budeficient . It is tin vitro. Mutation of these phosphorylation sites to alanine results in mild SPOC deficiency without affecting Kin4 kinase activity and localization [elm1Δ cells, Kin4 localizes to the SPBs as in wild type cells and to the mother cell cortex only with slightly reduced efficiency, whereas bud neck localization of Kin4 is significantly reduced [In addition to T209 phosphorylation, Elm1 phosphorylates other residues in the C-terminal region of Kin4 lization . At pres reduced ,110.elm1Δ cells can still localize on both sub-cellular positions [rts1Δ cells requires Elm1, which supports another notion that Rts1 can act downstream and/or parallel of Elm1 in Kin4 regulation [Kin4 kinase activity appears to be dispensable for Kin4 SPB and cortex localization because a kinase dead mutant of Kin4 and Kin4 of ositions ,106. HenFigure Phosphorylation of Bfa1 by Kin4 increases the turn-over rate of Bfa1-Bub2 at the SPBs accompanied by a decrease in the levels of SPB associated Bfa1-Bub2. Kin4 phosphorylated Bfa1 is protected from the GAP inhibition action of the polo-like kinase Cdc5, simply because Bfa1-Bub2 dissociates from the SPBs and therefore it is kept away from Cdc5 which phosphorylates Bfa1 at the SPBs ,99.BUB2 and/or BFA1 deleted cells [Together with Bfa1-Bub2; Tem1 is also released into the cytoplasm because Tem1 binds to the SPBs mainly via Bfa1-Bub2 ,99. Henced cells ,73, we cSPOC gets activated when the mitotic spindle misaligns in the mother cell. This could be due to defects in cMT nucleation or in spindle positioning pathways. Observations indicate that loss of cMT-daughter cell cortex interactions is the main activator of Bfa1 symmetry rather than loss of mitotic spindle integrity or cMT-mother cortex interactions . TreatmeIt is also worth mentioning that, cMT-bud neck contact was also reported to be important in SPOC arrest in a way that persistent loss of cMT-bud neck interaction causes SPOC failure ,121. TheMoreover, SPB itself might be a part of the SPOC sensory mechanism. Kin4 binds to the SPBs via the γ-tubulin receptor Spc72 . Neverthspindle assembly checkpoint (SAC). SAC senses the occupancy of the kinetochores by the microtubules and the lack of tension between the sister kinetochores [What is the molecular mechanism sensing cMT-cortex interaction? We could learn from the sensory machinery of other mitotic checkpoints like tochores . It has tochores -125. On tochores -132. Aurtochores -138.per se does not activate SPOC, indicates that tension created on SPBs by the spindle forces are not involved in SPOC activation [It would be interesting to understand if any similarity exists between SPOC and SAC sensory mechanisms. The fact that disruption of the spindle microtubules tivation . HoweverDrosophila male germ line stem cells [Spindle orientation along the polarity axis is vital in asymmetric cell divisions to assure the outcome of the division is asymmetric. Therefore it is likely that checkpoints ensuring correct spindle positioning exist in higher eukaryotes too. Interestingly, studies from Yamashita and colleagues indicate the presence of a checkpoint, monitoring centrosome orientation in em cells ,140. Cenem cells ,140. Manem cells ,141-146.Salvador-Warts-Hippo pathway  of Drosophila and human [2+-calmodulin-dependent protein kinase) upon amino acid sequence similarity [Functional higher eukaryotic equivalents of Tem1, Bfa1-Bub2 and Kin4 have not been identified so far. Nevertheless, homologues of the downstream MEN components Cdc15 and Dbf2-Mob1 exist in nd human . In addind human -150  is transmitted to the SPOC activating kinase Kin4. Elm1 and Rts1 are upstream elements controlling Kin4 activity and localization. However, Elm1 activates Kin4 regardless of the spindle direction and we lack information about how exactly Rts1 contributes to Kin4 localization. Analysis of how Kin4 is localized to the cell cortex and to the SPBs might lead us to understand Rts1's role in Kin4 regulation and might help us to find other regulators of Kin4.Another ambiguity is how the MEN gets activated, and especially how SPOC is inactivated after re-alignment of a previously misaligned spindle. Polarized localization of the SPOC activator Kin4 to the mother and MEN activator Lte1 to the daughter cell could be an explanation for this. However, what happens in reality is probably more complex than that, because Lte1 is not essential for mitotic exit at physiological temperatures and the role of Lte1 in MEN activation is so far uncertain.Is Kin4 pathway the only way of GAP activation? Analysis of protein binding dynamics shows that Kin4 is the major factor promoting Bfa1-Bub2 turnover at the SPBs. However, even in cells lacking Kin4, Bfa1-Bub2 binding to the SPBs becomes slightly dynamic upon misorientation of the anaphase spindle. This observation suggests that yet unidentified pathways might also regulate Bfa1-Bub2 in parallel to Kin4 as a response to spindle misalignment. Indeed, Bfa1-Bub2 is also required for metaphase and G2/M arrests due to spindle or DNA damage respectively. In addition, the phosphorylation status of Bfa1 and Bub2 changes as a response to SAC and DNA damage checkpoint activation ,158,159.In conclusion, more work has to be done to illuminate the SPOC field. Like in every concept, the more insight we gain, it is likely that the more unknowns we will face. We believe that elucidation of the mechanisms by which SPOC works will progress faster in this era of molecular and systems biology.The authors declare that they have no competing interests.AKC wrote the manuscript with help of BI and the critical input of GP. AKC and BI designed and prepared the figures. All authors read and approved the final manuscript.Molecular Biology of Centrosomes and Cilia (MBCC) at German Cancer Research Center (DKFZ) in Heidelberg/Germany. AKC is a PhD student and BI is a postdoctoral fellow. We are interested in understanding how spindle orientation and cytokinesis are coordinated with chromosome segregation in budding yeast and how ciliogenesis occurs in mammalian cells.GP is the group leader of the Helmholtz junior research group


Infant mortality (IM) and birth outcomes, key population health indicators, have lifelong implications for individuals, and are unequally distributed globally. Even among western industrialized nations, striking cross-country and within-country patterns are evident. We sought to better understand these variations across and within the United States of America (USA) and Western Europe (WE), by conceptualizing a social determinants of IM/birth outcomes framework, and systematically reviewing the empirical literature on hypothesized social determinants ) and intermediary determinants . To date, the evidence suggests that income inequality and social policies  may help to explain cross-country variations in IM/birth outcomes. Within countries, the evidence also supports neighbourhood SES  and income inequality (USA) as social determinants. By contrast, within-country social cohesion/social capital has been underexplored. At the individual level, mixed associations have been found between individual SES, race/ethnicity, and selected intermediary factors  with IM/birth outcomes. Meanwhile, this review identifies several methodological gaps, including the underuse of prospective designs and the presence of residual confounding in a number of studies. Ultimately, addressing such gaps including through novel approaches to strengthen causal inference and implementing both health and non-health policies may reduce inequities in IM/birth outcomes across the western developed world. Infant mortality (IM), an important health outcome during the first year of life, is unequally distributed across countries at a global level . Among OCross-national variations in birth outcomes are equally apparent in the fetal mortality rate (FMR), which includes spontaneous intrauterine deaths occurring at ≥20 weeks of gestation. Annual fetal deaths account for almost as much reproductive loss as IM in the USA, with a FMR of 6.2 fetal deaths per 1,000 live births and fetal deaths in 2005 . SlightlPreterm birth (PTB) (<37 weeks gestation) and very preterm birth (VPTB) (<32 weeks gestation) are leading causes of mortality and morbidity in infants worldwide ,9. In 20IM and birth outcomes are key population health indicators, for three primary reasons. First, IM is a widely accepted indicator of social development and economic change , and IM/Wide variations in birth outcomes are also observed within western developed nations. Racial/ethnic disparities in IM are persistent within the USA, with Blacks carrying an excessive burden of infant death that has a significant impact on overall national trends ,14. SociDisproportionate levels of IM/adverse birth outcomes are present within WE nations. The UK exhibits large variations in IM among different ethnic groups ,19. PTB across countries. Likewise, a social determinant of IM/birth outcomes framework which conceptualises the dynamic interplay between contextual and individual level social determinants with IM/birth outcomes may aid in deciphering patterns of disparities in IM/birth outcomes within countries.To better understand these striking cross-country and within-country patterns, a conceptual framework for the societal to individual level determinants of IM/birth outcomes is needed. In particular, identifying contextual social determinants at the upstream macro level may help to explain the wide variations in IM/birth outcomes social determinants of IM/birth outcomes , race/ethnicity, residential segregation, gender, social capital/cohesion, and the macroeconomic and macrosocial context, e.g., macroeconomic and social policies including labour market regulations [per capita and income inequality. The broader macroeconomic and social context generates social stratification i.e., the sorting of people into dominant and subordinate SES, racial/ethnic, and gender groups  SES influences future health behaviours at some, but not other, points in time in women over the lifecourse; these behaviours in turn shape future IM/birth outcomes.i.e., USA and WE states. To our knowledge, this represents the first comprehensive review of the social determinants of IM/birth outcomes. We searched PubMed, EmBase, and PsychInfo databases from 1966 to 31 December 2011, using combinations of keywords/subject headings to identify original articles and systematic review articles of birth outcomes and cross-country macroeconomic and macrosocial social determinants, within-country contextual social determinants, and within-country individual level social determinants: “birth outcomes”, “infant mortality”, “fetal mortality”, “neonatal mortality”, “preterm birth”, “low birth weight”, “social determinants”, “gross domestic product”, “income inequality”, “social policies”, “maternity leave”, “neighbourhood deprivation”, “neighbourhood socioeconomic status”, “maternal socioeconomic status”, “race/ethnicity”, “residential segregation”, “social cohesion/capital”, “maternal health behaviour”, “maternal smoking”, “maternal stress/distress”. For the purpose of this systematic review, we focused on non-medical social and economic determinants of birth outcomes, and did not review health care/systems as a social determinant. Recent national and international commissioned reports on the social determinants of health, including by the WHO Commission on the Social Determinants of Health [We systematically reviewed the empirical literature on each of these contextual and individual level social determinants  of IM/birth outcomes, within and across western developed nations f Health  and the f Health , have liThis study addresses a significant gap in the literature to date: that so far there has been insufficient attention paid to the social determinants of IM/birth outcomes as compared to adult health, including in wealthy/industrialized nations. Furthermore, while several systematic reviews of selected social determinants in relation to birth outcomes have been published, no work to date has yet considered them simultaneously. By doing so, we aimed to identify global patterns and gaps in the literature on the social determinants of IM/birth outcomes, and thereby to advance research in these areas. Through promoting understanding of the ways in which societal determinants may facilitate or hinder health and well-being at the very start of life, we may ultimately inform more effective interventions and policies to reduce health inequalities across the lifecourse in the western developed world.For each social determinant, per capita, appears to influence IM, at least below a certain threshold or during earlier time periods. Of 140 references returned in our search and the articles cited in relevant publications, three original articles met the inclusion criteria (per capita (reflecting average standards of living for households) is linked ecologically and cross sectionally to IMRs across developing and developed countries, with a curvilinear relationship suggesting diminishing health returns to higher GDP among rich nations. In a time series analysis of high and middle income countries  that examined changes in exposures and outcomes (“first difference models”) and thereby reduced confounding, Ensor and colleagues [per capita and IMRs between 1936 and 1965; this association was absent in more recent time periods (after 1965). Similar patterns among 18 OECD countries were seen by Wennemo [Country level economic development, commonly measured using GDP criteria . Rodgerslleagues  found a  Wennemo .Of 2,116 references yielded in our search and references cited in relevant abstracts, 14 individual studies  satisfied the inclusion criteria . Income unpaid maternity leave through the 1993 Family and Medical Leave Act [paid maternity leave policies since 1945. In WE countries, paid maternity leave ranges from a maximum of 14 weeks in Germany and Switzerland to approximately 77 weeks in Sweden [Of 1,665 references and articles cited, five original articles were included in our review . Social eave Act . By contn Sweden . Contempn Sweden . Neverthn Sweden .per capita. Two other investigations, including one that used instrumental variable analysis, also supported a greater role of non-health versus health spending [Government spending on non-health factors, and to a lesser extent on health factors, may also help to account for cross-country variations in IMRs. In a pooled cross sectional analysis adjusting for multiple country level factors, total government spending  was significantly inversely associated with post-neonatal mortality rates (for deaths 29 days to one year of age), but not NMRs . In a respending ,54.Based on 513 references and articles cited in relevant papers, 49 studies  met the inclusion criteria .USA. Neighbourhood level socioeconomic deprivation may partially account for variations in USA pregnancy outcomes through enabling women’s access to material resources and services. We identified 31 studies of neighbourhood SES and birth outcomes in the USA  and an adverse birth outcome  ( the USA . The maj/or LBW) . SignifiWE. Neighbourhood socioeconomic deprivation also appears to determine birth outcomes in Western Europe. We identified 18 studies of neighbourhood SES and IM/birth outcomes  were included .USA. Residential segregation, defined as the extent to which social groups characterized by income or race/ethnicity are spatially separated from one another, may also contribute to IM/birth outcome disparities through the effects of harmful material and psychosocial environments within segregated communities. In an ecological analysis, residential segregation by income was positively related to IMRs, independent of mean household income and metropolitan area income inequality [by race/ethnicity have found associations with higher IM/PTB risks [i.e., the benefits from residing in a neighbourhood containing same-ethnic individuals as oneself, possibly through political empowerment and social cohesion  satisfied our inclusion criteria .USA. Six [USA. Six ,127,128 USA. Six  on stateUSA. Six ,127,129 USA. Six ,127,129 USA. Six . ControlUSA. Six  found noWE. Few studies in WE have examined the associations between income inequality and IM/birth outcomes. One ecological study in Italy observed a positive relation between the provincial Gini coefficient and IMRs [and IMRs .Of 13 references and articles cited in those publications, two original articles (both from the USA) were included in the review .USA. The degrees of social support, trust, networks, and connectedness characterizing a neighbourhood or community are referred to as stocks of social capital/cohesion [cohesion , and coucohesion . In an ecohesion . In a mucohesion .WE. There is a dearth of research on social cohesion and infant health in WE nations, such that no studies were identified on this topic.Of 91 references and articles cited, 38 articles  met the inclusion criteria .USA. Recent USA data shows a more than two-fold difference between non-Hispanic Blacks and non-Hispanic Whites for the IMR , NMR (9.0 vs. 3.6), FMR (11.1 vs. 4.8), and PMR (12.3 vs. 5.6) [et al. [vs. 5.6) ,259. Thevs. 5.6) ,268,269.vs. 5.6) . Howevervs. 5.6) ,145. Rac [et al.  found thWE. Increases in migration to WE nations in recent decades have affected birth outcomes of ethnic populations. The risks of fetal, neonatal, and infant mortality are generally higher among refugees and non-refugee migrants than non migrants, although these patterns vary by country of origin and receiving country [ country . Finding country ,27,153.  country  and thos country . Migrant country . Foreign country , higher  country .Of 1,808 references and articles cited in relevant papers, 67 studies  were included in our review .USA. Parental SES may account for variations in IM/birth outcomes by shaping access to instrumental resources for adopting healthy practices and avoiding harmful risks; it also sorts individuals into different socioeconomic environments e.g., neighbourhoods of residence. We identified 44 American studies of parental SES and birth outcomes  met the inclusion criteria .USA. Preconception health behaviours  may protect against adverse birth outcomes, while other behaviours  may contribute to them [ to them . Materna to them . Of 11 U to them . Pericon to them . However to them .WE. The implications of poor maternal health behaviours likewise apply within WE countries. In the UK, maternal obesity has been associated with significantly higher risks of IM [ks of IM  and adveks of IM . Other Uks of IM . For smoks of IM .Of 930 references and the articles cited in those publications, 39 articles  were included .USA. Maternal psychosocial factors may be important determinants of birth outcomes, plausibly acting through behavioural or direct physiologic pathways [et al. [pathways ,282. Difpathways . In six pathways ,232,233.WE. Maternal distress and anxiety can independently contribute to adverse fetal and neonatal outcomes [outcomes . Of seveoutcomes ,241,242.outcomes .This paper focused on key indicators of population health at the very onset of life—IM and birth outcomes—reflecting short term and wide ranging changes in societal conditions, indicators that can signify profound social and economic sequelae over the life course for individuals and populations. To explain patterns of IM/birth outcome variations across and within western developed countries, we conceptualized a framework and conducted systematic reviews of the empirical literature on the social determinants of IM/birth outcomes, spanning determinants from the societal down to the individual level. Unlike previous systematic reviews, we considered these social determinants and intermediary factors simultaneously to identify more general patterns and gaps that characterize this literature.per capita may play a modest role in explaining current IM/birth outcome variations across the western developed world. Meanwhile, the epidemiological literature provides support for other macroeconomic/societal conditions as more important explanatory factors. For instance, nearly two-thirds of income inequality studies have found linkages with IM/birth outcomes, although these studies have been largely ecological and cross sectional in design. Likewise, in ecological cross sectional studies, paid maternal leave policies, levels of social spending, and ratios of social to health spending have all been found to predict IMRs in the hypothesized directions.Consistent with the well known curvilinear relationship between GDP and life expectancy—the Preston curve —with dimWithin both the USA and WE countries, the evidence in roughly two-thirds of studies suggests that neighbourhood SES is a determinant of adverse birth outcomes. However, most of these studies have been cross sectional rather than prospective. Furthermore, no studies have yet explored whether specific neighbourhood material goods and services may be related to IM/birth outcomes; such analyses could help to unpack the specific mechanisms for the effects of neighbourhood SES. Most studies on residential segregation by race/ethnicity in the USA show positive findings, although have been largely ecological in design; multilevel studies which account for individual level factors exhibit more mixed findings. In WE countries, the presence of lower levels of residential segregation may account for the lack of investigation of segregation in those settings; the limited evidence to date supports a health-protective ethnic density effect of segregation. Meanwhile, social cohesion/capital has been relatively underexplored as a predictor of birth outcomes. The few published studies in the USA support a relationship, while no studies have yet been conducted on social cohesion/capital and IM/birth outcomes within WE countries. Like for neighbourhood SES, studies on individual SES have found primarily inverse associations with IM/birth outcomes, but the majority of studies have likewise been cross sectional. For other individual level social determinants, associations have been relatively mixed for race/ethnicity and selected intermediary behavioural and psychosocial factors .versus spurious associations due to residual confounding. In future investigations, statistical models should attempt to specify other social determinants at multiple levels. Furthermore, this literature would benefit from the growing arsenal of novel analytical approaches to improve causal inference, such as instrumental variable analysis [Adopting a social determinants of IM/birth outcomes conceptual framework and jointly examining the empirical evidence on these social determinants further suggests several conceptual and methodological gaps in the literature. First, our framework highlights multiple levels of social determinants, the presence of multiple factors at each level, and the importance of stratification by SES, race/ethnicity, and gender ,27 to thanalysis , propensanalysis , and maranalysis .Second, because social stratification leads to differential exposures to social determinants, and thereby to material conditions and psychosocial resources, some demographic and socioeconomic population groups may exhibit stronger associations for social determinants with health outcomes than other groups . Yet apaThird, among the cross-country and within-country contextual social determinants that we reviewed, nearly two-thirds (64.2%) of investigations have focused on factors at the neighbourhood level . Critically, studies of macroeconomic and macrosocial factors at higher geographical levels than neighbourhoods comprise only about one-third (35.8%) of studies on contextual social determinants. Better understanding the social determinants of IM/birth outcome disparities and better addressing these inequities will require in depth research and attention to these most fundamental “causes of causes” of health and disease ,291.Notably, our study was limited in several respects. As indicated earlier, it excluded the literature on a wider set of countries, including developing nations which are characterized by a higher burden of IM/adverse birth outcomes. This exclusion was to reduce potential residual confounding, although at the price of reduced generalisability. In addition, we did not perform a meta-analysis or other quantitative analysis, in light of the heterogeneity of effect size measures, presence of cross sectional designs, and lack of adjustment for important confounders in many studies, as well as insufficient numbers of studies for some social determinants  that reduced our confidence in the validity of summary estimates . We instIn keeping with the recent Adelaide Statement on Health in All Policies , at a so