Peroxisome biogenesis disorders (PBDs) are a group of metabolic diseases caused by dysfunction of peroxisomes. Different forms of PBDs are described; the most severe one is the Zellweger syndrome (ZS). We report on an unusual presentation of Zellweger syndrome manifesting in a newborn with severe and fulminant sepsis, causing death during the neonatal period.A term male Caucasian neonate presented at birth with hypotonia and poor feeding associated with dysmorphic craniofacial features and skeletal abnormalities. Blood tests showed progressive leukopenia; ultrasounds revealed cerebral and renal abnormalities. He died on the fourth day of life because of an irreversible Gram-negative sepsis. Post-mortem tests on blood and urine samples showed biochemical alterations suggestive of ZS confirmed by genetic test.ZS is an early and severe forms of PBDs. Peroxisomes are known to be involved in lipid metabolism, but recent studies suggest their fundamental role in modulating immune response and inflammation. In case of clinical suspicion of ZS it is important to focus the attention on the prevention and management of infections that can rapidly progress to death. PEX genes which code for peroxins, proteins involved in peroxisome assembly, including proteins involved in the import of peroxisomal matrix and membrane proteins [Peroxisome biogenesis disorders (PBDs – MIM#601539) are rare autosomal recessive disorders, caused by mutations in any of the 14 different PBDs are divided into two groups: Zellweger spectrum disorder (PBD-ZSD) and rhizomelic chondrodysplasia punctata type 1. PBD-ZSD includes three different syndromes: Zellweger syndrome (ZS - MIM# 214100), neonatal adrenoleukodystrophy (NALD - MIM# 202370) and infantile Refsum disease (IRD - MIM# 266510) ranging from severe, intermediate and mild phenotype, respectively [PBDs prevalence is estimated to be 1 in 50.000 births in North America with huge differences worldwide. A lower incidence of ZS was reported in Japan (1 in 500.000 newborns), whereas the highest incidence was described in the Saguenay-Lac St Jean, region of Quebec (around 1 in 12.000 births) .ZS is the most severe form of PBD-ZSD, resulting from the complete absence of functional peroxisomes. It is called ‘cerebrohepatorenal syndrome’ because of its typical clinical presentation during infancy with cerebral dysgenesis, hepatic dysfunction and evidence of renal disease. Moreover, these patients may present with typical dysmorphic features, severe hypotonia, seizures, failure to thrive and skeletal defects –7.ZS can be diagnosed biochemically, detecting elevated very long chain fatty acids (VLCFA) in a fasting plasma sample, in particular elevated levels of C26:0, C26:1, ratio C24:0/C22:0, ratio C26:0/C22:0 .Recent reviews underline the involvement of peroxisomes in immune response and inflammation resulting in an inadequate defense in case of infection, but further studies are still required to improve knowledge about the relation between peroxisomal disorders and immunity –10.We present a case of ZS in a newborn dead by a Gram-negative fulminant sepsis, whose diagnosis was confirmed only post mortem.The proband is the first child of unrelated healthy Caucasian parents. Prenatal ultrasound was uncomplicated, family history was silent.The male neonate was born at 37 weeks’ gestation after planned caesarean section (with intact membrane and no active labor) because of breech presentation. GBS antenatal screening was negative. A placental surface culture was sterile and histological analysis of the placenta did not show chorioamnionitis. Apgar score at birth was 6 and 9 at 1st and 5th minute, respectively, body weight was 2460 g  length was 47 cm (4th centile), while head circumference was within the normal range  .3), whereas total white cell count (5.810/mm3), C reactive protein (0.8 mg/dl) and blood gas analysis were within a normal range [3) and neutrophil (480/mm3) counts; E. coli was yielded from blood culture. Broad spectrum antibiotics (penicillin and gentamicin) were promptly administered. The neonate underwent mechanical ventilation and was treated with intravenous fluids, catecholamine support  and i.v. sodium bicarbonate . Despite intensive care, the baby died after 5 h.At birth the newborn presented with hypotonia, bilateral club feet and dysmorphic features . The baby was unable to suck but breast milk was given via orogastric tube. Glucose infusion was administered for transient hypoglycemia. Neutrophil count was at the lower limit for age  with elevated C24:0/C22:0 ratio .PEX6 gene was found confirming the diagnosis of Zellweger Syndrome: c.1958C > G (p.Ser653*) variant was inherited by the mother and c.2440C > T (p.Arg814*) variant was inherited by the father.A compound heterozygous mutation of PEX genes encode for several proteins called peroxins that are involved in various stages of peroxisomal protein import and/or in the biogenesis of peroxisomes. In particular, peroxins are part of the formation of peroxisomal membranes, peroxisomal growth, fission and proliferation, and import of matrix proteins [PEX6 gene, the one found mutated in our patient, encode for a 104 kDa peroxin that is a cytosolic AAA protein (ATPase associated with diverse cellular activities), part of PEX1–PEX6–PEX26 export complex [PEX6 and PEX1 form a hetero-hexameric ring, best described as a trimer of PEX1/PEX6 dimers fundamental to import peroxisomal matrix proteins and/or vesicles fusion [PEX6 gene have been identified, being the second most recurrent PEX gene involved in PBD-ZSD genesis [Peroxisomes are small cellular organelles bound by a single membrane, containing variable compositions of proteins with detoxify functions The proteins . All of  complex . The AAAs fusion , 15. So  genesis .PEX6 gene mutations, inherited from parents and combined in an compound heterozygosis previously unreported.We describe an unusual presentation of Zellweger syndrome manifesting in a newborn with an overwhelming sepsis. Zellweger syndrome was confirmed by two pathogenic Although symptoms developed close to 72 h of life  many data strongly support a horizontal transmission of E coli .Moreover, poor feeding and hypotonia (2 symptoms that could be consistent with sepsis) may be more easily explained by the underlying Zellweger disease.Zellweger disease was likely responsible for the overwhelming course of sepsis and death within a few hours. Indeed, a pivotal role of peroxisomes in regulating inflammation and antimicrobial responses has been recently hypothesized. Three main reasons support this assumption: 1) peroxisomes can contribute and modulate the cellular redox status, fundamental for the antiviral interferon-mediated cellular response, both producing and cleaning up reactive oxygen (ROS) and reactive nitrogen species (RNS) ; 2) peroThus, it is not surprising that considerable experimental evidence has recently emerged to support the concept that peroxisomes are pivotal organelles in coordinating cellular and systemic immune response strategies by serving as signaling platforms to initiate immune pathways, and by controlling the synthesis and breakdown of immune bioactive metabolites .Patients with ZS have poor prognosis (often within the first year of life) due to infectious respiratory morbidity, or to severe epilepsy .Increased susceptibility to infections has been also recently reported in one case of ZS. Cardoso et al. described a 2-month-old infant admitted for severe failure to thrive, with several recurrent opportunistic infections during the hospital stay, lymphopenia and thymic atrophy. Diagnosis of ZS was confirmed and a primary immunodeficiency was suspected, but subsequently it was not confirmed .Due to the fulminant course of sepsis, we were unable to study the immune function, although an increased susceptibility to infections is common in many metabolic diseases. Sepsis is a life threatening condition resulting from a dysregulated response to infections. Classically, the acute phase of sepsis is characterized by an initial strong pro-inflammatory and innate immune status aimed to eliminate the pathogen, while in the later phase of sepsis there is a shift toward an anti-inflammatory and immunosuppressive status, resulting in diminished inflammation and initiation of tissue repair. Sepsis has always been considered as an inflammatory disease but recent research suggests an important contribution of other mechanisms such as coagulation, complement activation, microbiome composition, thermoregulation, circadian rhythm and metabolism. The pathogenesis of sepsis is characterized by profound changes in metabolic homeostasis and energy balance,  , 22. TheIn conclusion, ZS is a severe form of PBDs with poor prognosis. Peroxisomes are organelles involved in metabolic processes, and their role in modulating immune response and inflammation is increasingly recognized. In the clinical suspicion of ZS it is important to address promptly the diagnosis and to provide supportive therapy, particularly for preventing severe and potentially fatal neonatal infections. On the other hand, we recommend to investigate for an underlying metabolic disease in every neonate with multiple dysmorphic features and rapid worsening of suspected sepsis.


Microdissection testicular sperm extraction (microTESE) in men with non-obstructive azoospermia (NOA) is the procedure that results in the highest number of sperm cells retrieved for in vitro fertilization (IVF). This study presents a novel assessment of predictors of sperm retrieval as well as downstream embryology and pregnancy outcomes in cases of men with NOA undergoing microTESE.p-value of < 0.05 considered significant for the parameters estimated in each model.A retrospective chart review of 72 men who underwent microTESE for predictors of fertility outcomes including sperm retrieved at microTESE, embryology progression to embryo transfer (ET), clinical pregnancy, live birth, and surplus sperm retrieved for additional IVF/intracytoplasmic injection cycles beyond one initial cycle. Statistical models for each of these outcomes were fitted, with a Seventy-two men underwent microTESE, and 51/72 (70.8%) had sperm retrieved. Of those, 29/43 (67.4%) reached ET. Of the couples who underwent ET, 21/29 (72.4%) achieved pregnancy and 18/29 (62.1%) resulted in live birth. Of the men with sperm retrieved, 38/51 (74.5%) had surplus sperm cryopreserved beyond the initial IVF cycle.Age, testicular volume, FSH, and testicular histopathology were assessed as predictors for sperm retrieved at microTESE, progression to ET, pregnancy, live birth, and surplus sperm. There were no preoperative predictors of sperm retrieval, clinical pregnancy, or live birth. Age predicted reaching ET, with older men having increased odds. FSH level had a negative relationship with surplus sperm retrieved. Men with hypospermatogenesis histology had higher rates of sperm retrieval, clinical pregnancy, live birth, and having surplus sperm.Men who underwent microTESE with a hypospermatogenesis histopathology had better outcomes, including higher rates of sperm retrieval, clinical pregnancy, live birth, and having surplus sperm retrieved. Increasing male partner age increased the odds of reaching ET. No other clinical factors were predictive for the outcomes considered. Approximately 1% of men in the United States and 5–10% of men evaluated for infertility are azoospermic . It has Although sperm retrieval is clearly a rate-limiting first step, the goal of the couple is not simply retrieved sperm but also downstream outcomes, and ultimately live birth. Surplus sperm beyond an initial IVF/ICSI cycle may be important for the couple as well depending on family planning. There has been little data on microTESE outcomes other than sperm retrieval thus far including a study by Yildirim et al. which evaluated sperm retrieval and pregnancy rates and found a negative correlation with FSH levels . Aydin en = 72) by a single reproductive urologist (PKK) to be used for IVF/ICSI after having had a minimum of two semen analyses with centrifugation revealing azoospermia, serum hormone testing, and genetic testing with karyotypes and Y chromosome microdeletions assays, the results of which are described in Table Between January 2012 and January 2019, men diagnosed with NOA at a couples fertility center, due to primary testicular dysfunction, underwent microTESE  and the predictors, and describe our analytic sample. Each outcome variable was then modeled using logistic regression analysis, with a given binary indicator  as the outcome, and the factors of interest , each of which were measured prior to the outcomes being measured, as predictors. Results were described via estimates of adjusted odds ratios and 95% confidence intervals. We could not consider more than four independent predictors given the reduced size of our sample and concerns about reliability of the estimated regression coefficients that would arise from trying to include more predictors . All anaThe characteristics of the men in our analytic sample are described in Table Of the 51 men with sperm retrieved, 29/43 (67.4%) had embryology progress to allow for ET, and the remaining eight either cryopreserved sperm for future use and have not undergone IVF/ICSI yet, or transferred retrieved sperm to another center for IVF/ICSI, where complete data was not available. Of the couples who underwent ET, 9/29 (31%) had day 3 embryo transfers and 20/29 (69%) had day 5 blastocyst transfers, which was at the discretion of the reproductive endocrinologist and embryologist. Of the couples who underwent ET, 21/29 (72.4%) achieved a clinical pregnancy and 18/29 (62.1%) resulted in live birth. Clinical pregnancy was defined as confirmation of a fetal heartbeat, via transvaginal sonogram, at 6–7 weeks of gestation. Of the men who successfully had sperm retrieved, 38/51 (74.5%) had surplus sperm cryopreserved beyond one cycle of IVF/ICSI  of the couples achieved a pregnancy with live birth with the first IVF/ICSI cycle, 10 (26%) of them did not achieve a pregnancy with the first IVF cycle, and 8 (21%) of them had sperm cryopreserved for future use and have not undergone an IVF cycle yet or transferred sperm to another center. Of the 10 couples with surplus sperm available who did not achieve a pregnancy on the first IVF/ICSI cycle, 1 achieved a pregnancy with live birth on a second cycle, 2 have not undergone a second cycle, 2 had an additional negative IVF/ICSI cycle, 3 had an additional 2 negative cycles, and 2 had an additional 3 negative cycles including one with recurrent pregnancy losses with these cycles.p = 0.845).Overall, ten of the female partners were considered to have diminished ovarian reserve (DOR) defined as day 3 FSH of > 10 mIU/mL and/or antimüllerian hormone (AMH) < 1 ng/mL. The outcomes of couples with a female partner with DOR are described in Table Although DOR status and age-related decline in female fertility are the primary obstacles from a female factor standpoint in these couples, 15 women in this cohort had other potential factors identified and managed medically or surgically prior to their IVF cycles. Six had endometrial polyps identified and hysteroscopically resected, 3 had polycystic ovarian syndrome (including 1 of the women who had a polyp as well), 1 had endometriosis, 4 had oligomenorrhea, 1 had a relevant uterine fibroid, and 1 had a history of previous unilateral oophorectomy. All of these conditions were treatable prior to, or with the IVF cycle and were not considered impactful to reproductive outcomes with IVF/ICSI with microTESE sperm.p = 0.049). FSH level had a marginally significant negative relationship with surplus sperm retrieved for more than one IVF/ICSI cycle. After adjusting for age, testicular volume, and FSH levels, men with a hypospermatogenesis histological pattern had significantly higher odds of sperm retrieval, clinical pregnancy, live birth, and having surplus sperm retrieved for more than one IVF/ICSI cycle. We note that for three of the five outcomes, only 64 cases were available for analysis due to missing values on the outcomes, further underscoring the significant relationships of the predictor variables identified in these cases.Table Since the advent of microTESE for NOA due to primary testicular dysfunction, multiple investigators have assessed predictors such as age, testicular volume and FSH levels of various outcomes –20. MostAll patients in this cohort underwent varicocele repair if a palpable varicocele was present on their physical examination with reassessment of their semen analysis at 3 to 6 months post varicocele repair prior to undergoing microTESE. Men who had return of sperm to the ejaculate following varicocele repair did not undergo microTESE and were not included in this sample. Varicocele repair was recommended for all men with palpable varicoceles prior to microTESE as a number of studies have revealed return of sperm to the ejaculate in men with NOA who underwent varicocele repair –28. TherPreviously published studies on predictors of microTESE outcomes have primarily focused on sperm retrieval as the sole endpoint for success. In 2004, Tsujimura et al. found FSH, testosterone levels, and inhibin B levels to be the most influential predictive factors for sperm retrieval in a retrospective review of 100 men who underwent microTESE for NOA . RamasamThis current study examined predictors for multiple microTESE/IVF/ICSI outcomes and revealed a hypospermatogenesis histology pattern as being significantly associated with several outcomes, including higher rates of sperm retrieval, clinical pregnancy, live birth, and having surplus sperm retrieved for future IVF/ICSI cycles when compared to maturation arrest or Sertoli cell only patterns. After adjusting for age, volume, and FSH levels, men with hypospermatogenesis patterns had 423% higher odds of having sperm retrieved. Those with maturation arrest histology also had substantially higher odds; however, this study was not powered to allow for detection of this odds ratio as significant. After adjusting for testicular volume, FSH, and histology pattern, each additional year of male age resulted in 11% higher odds of reaching ET. FSH levels trended towards significance with a negative relationship to odds of ET, but did not reach statistical significance. Adjusting for age, testicular volume, and FSH levels; those with hypospermatogenesis patterns had 413% higher odds of achieving a clinical pregnancy, 385% higher odds of live birth, and 650% higher odds of having surplus sperm retrieved for multiple IVF/ICSI cycles. FSH levels had a marginally significant negative relationship to retrieving surplus sperm. Although histopathology is not known in order to counsel couples prior to microTESE, it is useful to be able to counsel couples that the other potential predictors of outcomes should not be a deterrent to proceeding with microTESE/IVF/ICSI, even though they may be assumed to be unfavorable by patients and clinicians, they do not predict unfavorable outcomes.An unexpected finding of this study was that male partner age was a significant predictor of reaching ET with older men having increased odds. This seems counterintuitive as there are data consistent with semen parameters and sperm DNA fragmentation worsening with increased age. However, the median age of the patient cohort in the current study was 35 years of age and only 15% 11/72) of them were in their forties, 2.8% (2/72) were in their fifties, and 2.8% (2/72) were in their sixties. Most of the men were in their twenties and thirties, so although age is a significant predictor, most men were below ages considered to be advanced paternal age which are typically the age ranges associated with poorer fertility outcomes overall. A previous publication revealed that increased age of men at the time of microTESE did not adversely impact sperm retrieval rates [/72 of thA limitation of this study is the sample size, although the statistical methodology utilized was appropriate for the size of the data set. The size of the sample is unique as NOA is present in only 1 % of men in the population. It would, therefore, be quite challenging for a single practicing reproductive urologist to accrue a larger sample of men undergoing microTESE, which would allow for more statistical power. Multi-site collaborations may be important to study this problem further in the future. An additional challenge to the power of the current study is that not all couples with NOA elect to undergo this level of treatment, technology, and expense.A major strength and the novelty of this study is that all fertility diagnostic categories were included, making it the most comprehensive assessment of the predictors for multiple embryologic and clinical outcomes for these couples, including the most critical outcome, live birth, while accounting for male and female factors. It is also the only study evaluating predictors of surplus sperm cryopreserved for use beyond the initial IVF/ICSI cycle. The rate-limiting factor in the majority of these cases was NOA, based on overall female partner age, and there being no significant difference in mean female partner age between those for whom their cycles resulted in live birth versus those that did not. There was also only a small percentage of female partners in this cohort who were diagnosed with DOR, two of whom underwent donor oocyte cycles excluding oocyte quality as a variable in their outcomes.Men with NOA who underwent microTESE with a hypospermatogenesis testicular histopathology had better outcomes including rates of sperm retrieval, as well as downstream outcomes specifically clinical pregnancy, live birth, and having surplus sperm retrieved for more than one IVF/ICSI cycle, over those with histopathologic patterns of maturation arrest and Sertoli cell only. Increasing male partner age increased odds of reaching ET. No other clinical factors were significantly predictive for the outcomes considered in this study, which adds to the existing literature and aims to aid in the management and counseling of men with NOA.


Objective: To explore the association of the methylenetetrahydrofolate reductase (MTHFR) C677T polymorphism with birth body mass and risk of autism in Chinese Han population.Methods: A total 1,505 Chinese Han autism patients were recruited, using the Diagnostic and Statistical Manual of Mental Disorders, 4th revised version (DSM-IV-R) diagnostic criteria for autism, and 1,308 sex-matched healthy controls were also enrolled for the study. All the participants' birth body masses were counted according to the medical records. The MTHFR C677T genotypes were detected using the polymerase chain reaction-restrict fragment length polymorphism (PCR-RFLP) method. The association between C677T polymorphism, birth body mass, and risk of autism were analyzed using the chi-square tests.Results: The present study found that the MTHFR 677T was significantly associated with risk of autism [P = 0.004, odds ratio (OR) = 1.18, 95% CI = 1.02–1.29). The autism children more frequently showed low birth body mass (<2.5 kg) than healthy control subjects . The interactive effects between MTHFR 677T and low birth body mass  were also significantly associated with risk of autism.Conclusions: The MTHFR C677T polymorphism and low birth body mass may be associated with risk of autism in Chinese Han population. Autism is a common neurodevelopmental disorder, which is clinically characterized by social communication and language communication disorders and repetitive and stereotyped interests and hobbies. At present, exact molecular and biochemical mechanism of autism has not been fully understood. Nevertheless, multiple genetic factors, environmental factors, and their interactions are believed to be involved in autism –4.A large number of family and twin studies show that autism is highly inheritable, with heritability ranging from 60 to 90% –8. GenetMTHFR) gene may be one of the candidate genes for neurodevelopmental disorders such as autism , Han nationality, regardless of gender, age 3–18 years old, outpatient children, and with written informed consent form signed by the children themselves or their guardians. Exclusion criteria were the following: patients with mental retardation, schizophrenia, affective disorders, and other mental disorders that meet the DSM-IV Axis I diagnostic criteria; patients with severe physical diseases; and those unwilling to sign the informed consent form.The control group consisted of 1,318 Chinese Han healthy controls, including 792 male and 526 female. Admission criteria were the following: Han nationality, regardless of gender, age 3–18 years old, database of normal subjects recruited from the community or physical examination center, with written informed consent form signed by the subjects themselves or their guardians. Exclusion criteria were the following: other mental disorders conforming to axis I diagnostic criteria such as autism, mental retardation, schizophrenia, and affective disorders in DSM-IV; patients with severe physical diseases; and those unwilling to sign the informed consent form.All the participants' birth body masses were counted according to the medical records. According to the World Health Organization (WHO) standards, the birth body mass of full-term normal delivery children is divided into three groups: low birth body mass infants (<2.5 kg), normal birth body mass infants (2.5–4.0 kg), and fetal macrosomias (≥4.0 kg) .Five milliliters of peripheral venous blood was extracted from all subjects, which was placed in ethylenediaminetetraacetic acid (EDTA) anticoagulation tube and stored at 4°C. A small amount of blood genomic DNA extraction kit from Qiagen Company was used to extract genomic DNA from samples within 1 week. After quality control, the samples were stored at −70°C for later use.Hinf I at 37°C overnight and observed by 4% agarose gel electrophoresis.The PCR amplification primer sequences were as follows: upstream, 5′ AGC CCA GCC ACT CAC TGT TTT 3′; downstream, 5′ CAG CGA ACT CAG CAC TCC A 3′. Twenty-five microliters PCR amplification reaction system consist of 0.4 μM primer, 10 mM Tris–HCl (pH 8.3), 1.5 mM magnesium chloride, 50 mM potassium chloride, 200 μM deoxyribonucleotide triphosphates (dNTPs), 30–50 ng genomic DNA, and 1 U Taq DNA polymerase. PCR amplification conditions were predenaturation at 94°C for 5 min, denaturation at 94°C for 30 s, annealing at 64°C for 30 s, extension at 72°C for 1 min, a total of 35 cycles, and finally extension at 72°C for 10 min. The PCR products were digested with restriction enzyme MTHFR C677T polymorphism site and birth body mass and risk of autism, and logistic regression analysis was used to comprehensively evaluate the contribution of genetic and environmental factors to autism risk. The statistical significance level of bilateral tests was set at P < 0.05.All data were managed and analyzed by Statistical Packages for Social Science 16.0 (SPSS 16.0) software. The Hardy–Weinberg equilibrium test was carried out on the genotype distribution of patients with fitness test. Chi-square analysis was used to test the association between the MTHFR C677T (rs1801133) polymorphism in the case group and the control group both passed the Hardy–Weinberg equilibrium test, and there was no significant difference between the observed value and the expected value (P > 0.05) (The genotype frequency of  > 0.05) . This shx2 = 8.088, df = 2, P = 0.018) and in allele frequencies , respectively (MTHFR gene was significantly associated with risk of autism .The genotype and allele distributions are all shown in ectively . The resP = 0.003) , suggesting that low birth body mass infants may increase risk of autism.The average birth body mass in autism group was (3.15 ± 0.74) kg, male (3.24 ± 0.33) kg, and female (3.06 ± 0.62) kg. The average birth body mass of the healthy control group was (3.24 ± 0.52) kg, male (3.35 ± 0.49) kg, female (3.22 ± 0.46) kg, respectively. According to the WHO standards, newborn body mass is divided into low birth weight infants <2.5 kg, normal birth weight infants 2.5–4.0 kg, and fetal macrosomia ≥4.0 kg, respectively. The frequency of autism children with low birth body mass in the autism group (8.6%) was higher than that in the healthy control group (5.3%) (= 0.003) . CompareMTHFR gene and low birth body mass on the risk of autism, the number of children with autism who both carried MTHFR 677T and low birth body mass, were counted then were compared to the other children. The results indicated that the frequency of autism children both carrying MTHFR 677T and with low birth body mass  was statistically higher than that of other subjects . Although the number of patients carrying risk factors of 677T allele and low birth body mass infants in the two groups was relatively small , there was also a strong statistical correlation effect . The logistic multifactor regression analyses were conducted to explore the effects of potential risk factors for autism. The diagnosis of autism was set as dependent variable, and the independent variables includes age, gender, MTHFR C677T polymorphism, birth body mass, and interaction between MTHFR C677T polymorphism and birth body mass, respectively. The results showed that sex, MTHFR C677T polymorphism, birth body mass, and interaction between MTHFR C677T polymorphism and birth body mass all significantly increased the risk of autism , also may play an important regulatory role in neurodevelopmental disorders such as autism , to some extent, which verifies that MTHFR may be one of the predisposing genes for autism. Paşca et al. . Guo et al.  in the analysis of 54 pairs of identical twins with inconsistent autistic characteristics, indicating that low birth body mass was related to the risk of autism. A meta-analysis reported by Wang et al. (RR) = 1.26; 95% CI: 1.20–1.34; P < 0.001].In addition, this study also found that low birth body mass (<2.5 kg) might increase risk of autism. There have been many reports that low birth body mass may be one of the risk factors for autism , 49, andg et al.  investigMTHFR 677T and with low birth body mass  was much higher than that of other subjects  . Moreover, the logistic regression analysis showed that gender, MTHFR C677T polymorphism, birth body mass, interaction between MTHFR C677T polymorphism, and birth body mass significantly increased risk of autism in children. El-Baz et al.  (P < 0.001), which was basically consistent with the conclusion of this study. A meta-analysis showed association between maternal MTHFR C677T polymorphism with low birth body mass under most of the genetic models, respectively. Specifically, the carriers of the TT genotype increased the risk of low birth body mass (MTHFR C677T causes the decrease in enzyme activity, the plasma homocysteine concentration increases, which leads to oxidative stress, arteriolar constriction, endothelial damage, and placental thrombosis (MTHFR enzyme activity is reduced due to MTHFR C677T, which may cause the deficiency of folate. Folate deficiency is a modifiable nutritional status that has been linked with adverse pregnancy outcomes including low birth body mass (In our study, we further explore the interactive effects of MTHFR 677T and low birth body mass on the risk of autism. The results indicated that the frequency of autism children both carrying z et al.  found thody mass . One exprombosis , 55. Allrombosis . Anotherody mass , 58. Thuody mass .MTHFR 677T and low birth body mass may be one of the important influencing factors of autism risk.In the present study, the mean age of healthy control subjects was much older than that of autistic patients. Although there was age mismatch, it could also ensure that there was no risk of autism in the control group, and the birth body mass statistics of normal subjects were relatively accurate. In the future, it is planned to further expand the sample size and include age-matched healthy controls. In addition, the specific neurobiological mechanism of genetic polymorphism affecting risk of autism needs to be further elaborated, and further verification of sample size expansion and long-term follow-up in different populations is needed. In conclusion, this study suggests that The original contributions presented in the study are included in the article/supplementary materials; further inquiries can be directed to the corresponding author/s.The studies involving human participants were reviewed and approved by the medical ethics committee of Peking University Sixth Hospital and Beijing Children's Hospital. Written informed consent to participate in this study was provided by the participants' legal guardian/next of kin.JZ, SS, and WY designed the study. JZ, SS, XM, and WY contributed to analysis, interpretation of data, and wrote the first draft of the manuscript. YS and LW contribute to the clinical assessment and experimental examination, as well as the statistical analyses. All authors contributed to drafting the work, revising it critically for important intellectual content, made substantial contributions to the concept, design of the study, acquisition, analysis, and interpretation of the data.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Our report covers two cases of severe hypoxic-ischemic encephalopathy in newborns whose birth was complicated by shoulder dystocia. In both cases, there were inconsistencies observed among cardiotocographic traces, baby's clinical conditions at birth, and umbilical cord blood gases. Namely, normal cardiotocographic monitoring and cord pH > 7, in spite of the fact that the newborns were severely depressed at birth and their blood gases evaluated within 1 h from birth showed a severe metabolic acidosis. Moreover, one of the two newborns displayed moderately low hemoglobin levels. Metabolic and infectious causes were ruled out. Both newborns developed severe hypoxic-ischemic encephalopathy and received therapeutic hypothermia for 72 h. Both survived, one with a severe dystonic cerebral palsy whereas the other developed only a mild developmental delay in language. Cardiac asystole theory could explain these two cases, reinforcing the need for specific resuscitation guidelines for infants experiencing a birth complicated by shoulder dystocia. Shoulder dystocia is a severe condition capable of posing a risk to the health of the newborn by increasing the odds of perinatal asphyxia, hypoxic-ischemic encephalopathy, perinatal mortality, and brachial plexus paralysis .Asphyxia following shoulder dystocia is sometimes very severe, and perinatal mortality has been reported in spite of a remarkably short head-body delivery interval . In thes2) 0.3. His Apgar scores were 0, 0, 5 at 1, 5, and 10 min, respectively. The cord blood gas analysis revealed an arterial pH 7.16, pCO2 58 mmHg (kPa 7.7), base excess (BE) −8.4 mmol/l, lactate 10.2 mmol/l; the pH from the venous sample was 7.26, pCO2 42 mmHg (kPa 5.6), BE −7.5 mmol/l, lactate 8.8 mmol/l.The firstborn male of a healthy G1, P0, 21-year old mom, was born at 41+1 weeks gestation, birth weight 3,700 g, by vaginal delivery after spontaneous rupture of membrane (SROM) of 15 h; two vacuum tractions were performed because of a prolonged active second stage of labor. Cardiotocographic monitoring was normal for the expulsive period. After the extraction of the fetal head, a maneuver of digital hooking (Bourgeois maneuver) was performed for the disengagement of the shoulders. The delay between the extraction of the fetal head and the disengagement of the shoulders was 2 min. There was a presence of thick meconium-stained amniotic fluid after the fetal extraction. At birth, the umbilical cord was immediately clamped. The baby was in cardiac asystole at auscultation, without spontaneous respiratory efforts, pale, and hypotonic. Cardiopulmonary resuscitation was started and continued according to the neonatal resuscitation program (NRP) . A pulse2 83 mmHg (kPa 11.0), BE −21 mmol/l, lactate 14 mmol/l, and glucose 4.7 mmol/l. A neurologic exam showed moderate hypoxic-ischemic encephalopathy. Amplitude-integrated electroencephalography (aEEG) monitoring showed a burst suppression type trace. The arterial gas at 1 h of life showed pH 7.01, pCO2 58 (kPa 7.7), BE −21 mmol/l, and lactate 18 mmol/l. Hemoglobin at 14 h of life was 12.1 g/dl. Active hypothermic treatment was started and maintained for 72 h. Because of clinical suspicion of seizures, the baby was loaded with Phenobarbital but not maintained due to a lack of electroencephalographic abnormalities and normalization of the clinical picture. At about 4 h after birth, as spontaneous respiration improved, the newborn was extubated and gradually weaned off any ventilatory support. At 13 days of life (DOL), the overall neurologic exam showed a favorable evolution. The otoacoustic emission test results were normal, bilaterally. He was discharged on 14 DOL. His first head magnetic resonance imaging (MRI), done at 1 month of life, was normal. Follow-up at 30 months of age showed only a mild developmental delay in language and he required follow-up sessions with a speech therapist.Upon arrival in the NICU, his umbilical vein was catheterized, and blood work was done. Capillary gas performed on the neonate at about 30 min of life showed a pH 6.8, pCOA female newborn was born at 41+6 weeks gestation, from a 32-year old, G1, P0 mom. The pregnancy was spontaneous and without complications. The mother had been admitted the day before to the hospital ward and labor was induced with prostaglandins for post-term pregnancy. The spontaneous rupture of the membranes occurred 13 h before delivery. The amniotic fluid was slightly stained with meconium. At 7 cm of cervical dilatation, infusion with oxytocin was started. Continuous cardiotocographic monitoring showed no abnormalities. Her birth was assisted by a midwife and a gynecologist. When the head came out with difficulty, the anterior part of the newborn's shoulder was trapped under the pubic symphysis. The doctor performed three maneuvers in succession  obtaining the disengagement of the shoulders; the head-body delivery interval was 3 min. At birth, the umbilical cord was immediately clamped. The arterial and vein cord pH were 7.09 (lactate 10.3 mmol/l) and 7.17 (lactate 9.3 mmol/l), respectively. The newborn was apneic, asystolic at auscultation, atonic, and areflexic. Resuscitation was immediately started and continued up to endotracheal intubation and chest compressions. Pulse oximetry and ECG confirmed persistent asystole, therefore, one dose of epinephrine, followed by a normal saline bolus was administered via the cannulated umbilical vein. Heart rate was detected at 13 min of life and spontaneous respiratory activity resumed 40 min after birth. Apgar score was 0, 0, 0, 3 at 1, 5, 10, and 15 min.2 29.1 mmHg (kPa 3.9) BE −19 mmol/l, HCO3 10.5 mmol/l, and lactate 9.8 mmol/l. Hemoglobin values at birth and at 2 days of life were 15.2 and 14.9 g/dl, respectively. The neurologic exam showed a severe hypoxic-ischemic encephalopathy. Since the aEEG was profoundly abnormal, systemic hypothermic treatment was started and continued for 72 h. She received Phenobarbital to treat seizures. At DOL 5, her head MRI confirmed a hypoxic-ischemic insult mainly at the level of the deep gray matter. On DOL 6 she was extubated to nasal continuous positive airways pressure, and then to humidified high flow nasal cannulae. At the 2-years follow-up, the baby showed severe dystonic cerebral palsy and neurosensorial deficits.The newborn was then transferred to NICU and mechanically ventilated. The temperature at admission, after passive cooling initiated in the delivery room, was 34°C. At 1 h from birth, the venous gas analysis showed a pH 7.10, pCOThe two cases described in the present study are similar to three other cases reported in literature , 5 whereCardiac Asystole Theory , could help to improve the understanding of these dramatic cases. Dissemination of this knowledge is also useful to improve resuscitation reaction of the asphyxiated newborn whose birth is complicated by shoulder dystocia. In these cases, the first importance is to avoid unjustified delayed volume replacement during resuscitation. Secondly, it could be useful to provide resuscitation at the mother's bedside, while the obstetrician provides cord milking.Future efforts need to be undertaken to prospectively gather data to deepen the knowledge and to refine the therapeutic approach to the potentially harmful condition of shoulder dystocia.The combined findings of normal FHR, almost normal cord pH and blood gases, elevated cord lactate, very low pH on blood gas analysis obtained within 1 h of life and severe cardiorespiratory depression in newborns with shoulder dystocia, justify the suspicion of complete cord obstruction and blood sequestration within the placenta. These newborns should be regarded as volume-depleted and resuscitated with volume expansion.This report raises awareness to clinicians resuscitating newborns with shoulder dystocia about the underlying mechanism of asphyxia in this condition. Future efforts toward resuscitation guidelines are needed to refine the therapeutic approach facing this potentially harmful condition.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. Written informed consent to participate in this study was provided by the participants' legal guardian/next of kin. Written informed consent was obtained from the individual(s), and minor(s)' legal guardian/next of kin, for the publication of any potentially identifiable images or data included in this article.GA and CM conceived the presented idea. GA, CM, SS, and FS reviewed the case reports. EF supervised the findings of this work. All authors discussed the results and contributed to the final manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Background: Preterm birth is the most frequent cause of neonatal death, but its aetiology remains unclear. It has been suggested that the imbalance of immunological mechanisms responsible for maintaining pregnancy is contributing to preterm birth pathogenesis. We aimed to investigate global gene expression and the levels of several complement system components in umbilical cord blood samples from preterm neonates and compare them to term newborns. We sought to examine how differentially expressed genes could affect various immune-related pathways that are believed to be crucial factors in preterm birth.Material and methods: We enrolled 27 preterm infants (<37 weeks GA) and 52 term infants (>37 weeks GA), from which umbilical cord blood samples were collected. From these samples, peripheral blood mononuclear cells were isolated and subsequent RNA isolation was performed. We used Affymetrix Human Gene 2.1 ST Array Strip for microarray experiment and DAVID resources for bioinformatics analysis of the obtained data. Concentrations of C2, C3a, C5/C5a, C9, FactorD, Properdin were measured in umbilical cord blood plasma samples using multiplex fluorescent bead-based immunoassays using Luminex technology.Results: The levels of C3a and C5/5a were significantly elevated in preterm neonates compared to term babies, whereas C9 concentration was evidently increased in term infants. The expression of 250 genes was upregulated at least 2-fold and 3781 genes were downregulated at least 2-fold in preterm neonates in comparison with term infants. Functional annotation analysis revealed that in preterm infants in comparison to term babies there was a significant downregulation of genes encoding several Toll-like receptors, interleukins and genes involved in major signalling pathways  and vital cellular processes .Conclusions: Preterm birth results in immediate and long-term complications. Our results indicate that infants born prematurely show significant differences in complement components concentration and a downregulation of over 3,000 genes, involved mainly in various immune-related pathways, including innate immune response, phagocytosis and TLR function, when compared to full-term babies. Further studies on larger cohorts are needed to elucidate the role of immunity in prematurity. Preterm birth (PTB), defined by the World Health Organization (WHO) as a delivery prior to 37 completed weeks of gestation, accounts for roughly 5-18% of all births worldwide However, PTB aetiology remains not fully understood. Despite the multitude of risk factors identified According to Gomez-Lopez et al., during late pregnancy, the pro-inflammatory nuclear factor-kB (NF-κB) signalling pathway is activated and that leads to recruitment of circulating maternal leukocytes at maternal/foetal interface by chemotaxis Neonates are forced to rely mainly on their innate immune defence, because their inexperienced adaptive immune system fully develops only later, in the early childhood In our previous studies, we have investigated umbilical cord blood (UCB) expression levels of small non-coding RNAs (miRNAs) potentially involved in angiogenesis control in preterm newborns and term neonates In total, 27 preterm infants born <37 weeks GA and 52 term infants born at >37 weeks GA all appropriate-for-gestational-age were enrolled in this study from the Department of Obstetrics and Gynaecology of the Pomeranian Medical University in Szczecin, Poland. We excluded subjects with severe congenital malformations, known chromosomal abnormalities, intracranial haemorrhage, cyanotic heart defects, inherited metabolic disorders, severe anaemia, congenital infections and severe infectious diseases, maternal history of tobacco and/or alcohol abuse; maternal infections were also excluded. For each recruited neonate we documented sex, GA, birth weight and physical measurements, Apgar score, clinical course. The study adhered to the tenets of the Declaration of Helsinki, and approval was obtained from the Local Ethics Committee. All parents provided written informed consent for their children participation in the study.We collected autologous umbilical cord blood from all patients at birth in accordance with NetCord-FACT International Standards for Cord Blood Collection Concentrations of C2, C3a, C5/C5a, C9, FactorD, Properdin were measured in UCB plasma using multiplex fluorescent bead-based immunoassays . The procedure was performed according to the manufacturer's protocol, as previously described 6). Concentration and quality of the obtained RNA was assessed using Epoch spectrophotometer .The mirVana™ miRNA Isolation Kit  was used for total RNA isolation from collected umbilical cord blood cells . The following criteria were applied to generate bubble plots: p-value < 0.5, adjusted method = Benjamini For functional annotation and enrichment analysis, we used DAVID Bioinformatics Resources  at The nonparametric Mann-Whitney test was used to compare values between study groups, because in majority of cases the quantitative variables distribution notably differed from the normal distribution. Spearman's rank correlation coefficient (Rs) was used to measure the strength of associations between gestational age and concentrations of each tested complement component. The sign of the Rs value indicates the direction of the association (positive or negative), while higher absolute value (closer to -1 or +1) indicates stronger association. We considered p<0.05 statistically significant. Statistica 13 software  was used for statistical analysis.In total, 27 preterm and 52 term neonates were enrolled in this study. The characteristics of the study groups are summarized in Table From six factors tested, we observed differences in concentration of C3a, C5/C5a and C9 between the study groups Figure . The meaThere was a significant positive correlation between GA and C5/C5a  and C9  in term infants and between GA and C2  in preterm infants.Microarray analysis showed that expression of 250 genes was upregulated at least 2-fold fold 18.73 to 2) and 3781 genes were downregulated at least 2-fold (fold -14.55 to -2) in PBMCs isolated from UCB samples from preterm neonates in comparison with term infants  Classification of biological processes and KEGG Database of pathways. Analysis of functional annotations mainly identified downregulated processes  in PBMCs from UCB of preterm neonates when compared with term infants. The results of these analyses are displayed as separate bubble graphs for biological processes and pathways  Classification of biological processes and KEGG Database of pathways. Analysis of functional annotations mainly identified downregulated processes  in PBMCs from UCB of preterm neonates when compared with term infants. The results of these analyses are displayed as separate bubble graphs for biological processes and pathways  and mapped the relationships between genes and GO terms in these processes with circos plots with visualization of FC (fold change) values and gene symbols Figure .TLR1, 2, 4, 5, 6, 8 and TLR10), and of various genes associated with interleukins  was decreased in PBMCs from UCB samples from preterm neonates. In addition, major signalling pathways  and vital cellular processes  were also significantly downregulated in preterm neonates in comparison with term infants.Overall, the obtained results indicate significant downregulation of genes involved in immune response and related signalling pathways  in preterm infants when compared to term neonates. In particular, the expression of genes encoding several Toll-like receptors (TLRs) family members  expression was significantly downregulated in our preterm neonates group (fold=-4.32), when compared to term neonates. Interestingly, several studies indicate that C3a could also have an anti-inflammatory and a neuroprotective effect in the brain tissue against neonatal hypoxia-ischemia injury It has also been indicated that increase in plasma complement components in apparently infection-free premature neonates could be either due to subclinical infection (enhanced activation of complement) and/or lower binding potential of complement receptors TLR5) and other transcripts with proven involvement in immune-related processes, which were overlapping and significant in both analyses. The expression pattern of these genes involved in immune response was opposite in UCB samples (downregulation) and maternal whole blood (upregulation) in PTB group when compared with full-term infants.Several other studies focused on gene expression changes in maternal whole blood, or in amniotic fluid supernatant TLR5, which confirms previous studies, but also TLR1, 2, 4, 6, 8 and TLR10 were downregulated in our preterm group, when compared with term babies. TLRs have been shown to trigger pro-inflammatory and pro-labour mediators release in uterine epithelial cells, foetal membranes and placenta, which could lead to preterm birth TLR5, associated with development of bronchopulmonary dysplasia in preterm neonates FFAR2, also plays a significant role in immune response to bacteria and specifically gut microbes-host crosstalk, as Ffar2 signalling modulates gut inflammatory tone and pathogen defence Toll-like receptors (TLRs) are highly conserved evolutionary receptors of the innate immunity, which constitute the first barrier against pathogens Our results implicate that not only genes involved in innate immunity are highly downregulated in preterm infants, but also expression of those related to the adaptive immunity is lower than in term neonates. Moreover, among those under-expressed genes in our preterm group are also well-known players in multiple biological processes: JAK kinases, NOD2, MAPK kinases family, TLRs, NF-κB family and other, which may suggest inefficiencies in basic cellular processes. The deficiencies in adaptive immunity are rather understandable since adaptive immunity requires acquisition of immunological memory. Previous reports indicate that when compared to adults, neonates, and those born prematurely even more prominently, have generally lower absolute numbers of circulating lymphocytes, deficient T cell function because of more naïve T cells and less memory T cells, bias towards Th2 CD4+ T cell phenotype, reduced production of cytokines such as IFN-γ, TNF-α, IL-12 and lower production IgG and IgA antibodies This study provides interesting findings, but some limitations are present. The main limitation is unequally sized groups, which occurred due to difficulties in recruiting preterm neonates to the study. This is quite understandable though, as parents of premature infants are more reluctant to agree on their neonate participation than parents of full-term babies. Additionally, in this study women were not tested for antiphosholipid antibodies (positivity is associated with preterm birth), as in Poland this testing is recommended only in recurrent miscarriages. Another possible limitation of this study is the borderline significance of difference in IL-6 levels between tested groups, which could reflect non-clinically evident infections.Prematurely born neonates are at high risk of immediate and long-term complications following preterm birth. Disturbances in immune functions have been suggested to contribute to both preterm birth and prematurity-related complications. Our results indicate differences in complement components concentration and a significant downregulation of over 3,000 genes in UCB from preterm infants when compared with term babies. These differentially expressed genes are involved mainly in various immune-related pathways, including innate immune response, phagocytosis and TLR function. Further functional studies are required to elucidate how this gene downregulation affects pathways that they are involved in. Our findings emphasize the need for further studies on large cohorts for better understanding of postnatal stages in development of immune system.


Preterm birth is a global health problem that affects 11% of all live births: it remains a significant cause of death and an important cause of long-term loss of human potential among survivors all around the world. In the last decade, many developed countries have seen an increase in the rate of infants born preterm. Various theoretical and practical concepts have been discussed that aim to optimize the perinatal care of preterm infants and their mothers. These include the definition of hospitals with different levels of care, the regionalization of care, the creation of large care units with high case numbers, and a high level of expertise. This review article focuses on the connection between health care structures and different aspects of preterm birth. Furthermore, this review article highlights the fact that preterm birth is a heterogeneous syndrome with many underlying pathologies and that the causality for a large number of cases remains unexplained. There is still a significant knowledge gap concerning the actual drivers of spontaneous preterm birth, and future research particularly in parturition immunology as well as genetics of prematurity will be essential to identify new targets for therapy. Worldwide, about 11% of all children are born preterm, resulting in a total of 15 million children born before the 37th week of gestation. In many countries, the rate of preterm births is increasing, and the survival rate of preterm babies has dramatically improved in developed countries . PretermVarious theoretical and practical concepts aim to optimize the perinatal care of preterm infants and their mothers. These include the definition of hospitals with different levels of care, the regionalization of care, the creation of large care units with high case numbers, and a high level of expertise. This review article focuses on the connection between health care structures and different aspects of preterm birth.According to the WHO definition, a child is born preterm if it is born before the completed 37th week of gestation or with fewer than 259 days since the first day of the mother’s last menstrual period. Depending on completed gestational age in weeks, preterm neonates are divided into extremely preterm (< 28), very preterm (28–31), and moderately preterm born neonates (≥ 32). From the 34th week of gestation onwards, these children are also referred to as late preterm neonates [A stillbirth is defined as a child born with a weight of more than 1000 g or with a gestational age of 28 weeks [In many countries, the rate of children born too early is increasing and varies between 10 and 15%, depending on the region and country . PretermOver three-quarters of all preterm babies are born between the 32nd and 36th week of gestation. Most of these moderate preterm babies survive with little supportive therapy. Nevertheless, these children have a higher relative risk of dying within the first year of life than term infants. Due to their sheer number, these children account for an essential proportion of infant mortality . The shoPreterm birth has various causes, but there are two major categories: spontaneous preterm birth due to spontaneous onset of labor or following prelabor preterm rupture of membranes (pPROM), and the provider-initiated preterm birth, by induction of birth or elective cesarean section before the completed 37th week of pregnancy. In the case of provider-initiated preterm birth, a distinction is made between infant, maternal, and other non-medical indications .In up to half of the cases of preterm birth, the cause remains unexplained. Social and environmental factors are known to influence the risk of preterm birth. Maternal risk factors include a low BMI, very young or advanced age, and short intervals between consecutive pregnancies. The availability of assisted conception resulted in an increased rate of multiple pregnancies, which increase the risk of preterm birth tenfold due to uterine overdistension.Boys are more frequently born prematurely , with males of similar gestation having a poorer prognosis than girls . GeneticThe chances to survive as an extremely preterm infant vary depending on medical resources available in obstetrics and neonatal care . In deveIn 2005, the Institute of Medicine (IOM) estimated that the yearly costs of preterm birth in the US, including the costs of delivery, medical care up to the age of five, but also the lifelong costs of specific neurodevelopmental impairment, and the resulting reduced productivity amounted to about $26 billion. Additional long-term conditions threaten preterm babies in their further development: asthma, hypertension, insulin resistance, learning, and behavioral problems . The heaFamilies with a preterm baby born are faced with numerous burdens, especially if the child has severe impairments. Costs are incurred for child care of siblings during hospitalization and outpatient appointments, transport costs, and additional expenses for accommodation. Family members usually care for these patients, which may affect their employment situation and often means financial losses in family income . The burFigure Numerous studies have shown that hospital structures have a considerable influence on the outcome of preterm infants. An extensive meta-analysis by Lasswell et al. summarized studies over 30 years to investigate the relationship between hospital level at birth and neonatal mortality for high-risk infants. The authors reported that the birth of a very low birth weight (VLBW) infant and VPT infant outside a level III hospital represented a significant risk factor for higher neonatal mortality—an observation that was evident over the entire observation period of 30 years . When liBased on the data of the Vermont-Oxford network on VLBW infants between 2010 and 2013 treated in 862 NICUs, Rochow et al. simulated how two different strategies for forming larger NICUs would affect neonatal mortality . Step byFrom an organizational and logistical point of view, there are many arguments in favor of centralizing the highly specialized care of preterm infants. Centralization allows the concentration of cost-intensive technologies and the development of highly specialized expertise among nursing staff and physicians in a few locations.A comprehensive assessment of risk factors for preterm birth early in pregnancy will be critically important for the prevention of preterm birth. Particular emphasis should be placed on risk factors for preterm birth that can be managed, such as smoking during pregnancy, adherence to dietary recommendations during pregnancy, and maternal stress. When taking the medical history, it is essential to consider that an interval between two pregnancies of less than 12 months is associated with a four-fold increase in risk for preterm birth. Another strong risk factor is a previous spontaneous preterm birth associated with an odds ratio for a repetition of 3.6 .It is critically important to assess cervical length by ultrasound between gestational weeks 16 and 24. Previous studies have demonstrated that singleton pregnancies with cervical shortening to less than 25 mm without a history of preterm birth have a risk of 25–30% for prematurity . The preHowever, it is crucial to note that a substantial portion of pregnant women that will be affected by preterm birth does not have any discernible risk factors . This fiNumerous studies investigated a variety of prenatal interventions to prevent preterm birth. The majority of interventional studies have focused on vaginally applied progesterone formulations to inhibit inflammation and cervical ripening and on mechanical techniques to address cervical insufficiencies such as cervical pessaries or invasive cervical cerclage.A recent meta-analysis of randomized clinical trials that investigated progesterone treatment in singleton pregnancies with cervical shortening below 25 mm has established a significant benefit of vaginally applied progesterone with a 22.5% reduction of preterm births in the progesterone group compared to 14.1% in the placebo group. The progesterone treatment group had a relative risk of 0.62  and showed improved neonatal outcomes . Vaginal progesterone is the only intervention for the prevention of preterm birth that is recommended by guidelines in most countries .Mechanical interventions to address cervical insufficiency have been widely used since the 1970s. However, while numerous trials have investigated the efficiency of these measures to prevent preterm birth, the evidence for cervical cerclage and cervical pessaries remains inconclusive. The lack of clarity is mainly because the majority of studies were performed over 10 years ago in very heterogeneous patient populations, and many of these are not meeting modern standards for follow-up and outcome reporting. Since large-scale meta-analyses of individual data from published studies on cervical pessaries and cervical cerclage have yielded contradictory results ), most aEpidemiological studies have identified several risk factors associated with preterm birth, such as genitourinary infections , nutritiSmoking constitutes a common and modifiable risk factor for preterm birth. Encouragingly, national tobacco control programs for the prevention of passive smoking were associated with a reduction of prematurity in some European countries . FurtherA summary of recommendations and strategies for the prevention of preterm birth is displayed in Fig. Prematurity represents a global health problem with an estimated 1.1 million neonatal deaths linked to complications of premature birth. Indeed, premature death is second only to pneumonia as the most common cause of mortality in children under the age of five. In many low- and middle-income countries, preterm birth is mostly a structural problem that must be addressed by socio-economic improvements, availability of prenatal care, and prevention of transmitted diseases. In contrast, in some high-income countries, the rate of preterm birth has increased in recent years due to the widening use of assisted reproduction techniques or medically induced induction of birth.However, even when accounting for these medical practices and when comparing the best performing developed countries, there is still an increased rate of preterm birth in many high-income countries in Europe and North America in the last decade . This woIt is well known that preterm birth displays significant genetic heritability, but very little is known about specific genetic factors that predispose to prematurity. Furthermore, a substantial amount of current research data indicates that many cases of preterm birth are based on a disorder of the feto-maternal immune adaptation . Both onPrevious research approaches to clarify this question were primarily the targeted elimination of individual inflammation cascades by transgenic mouse models. It became clear, however, that the mechanisms were redundant since switching off individual genes or pathways is usually not sufficient to switch off maternal immune tolerance for the fetus .In future research on the pathophysiology of preterm birth, it is, therefore, crucial to take a hypothesis-free approach. This means a departure from the analysis of individual inflammation genes or pathways towards a systems biological approach with the help of next-generation sequencing combined with proteome analyses on patient samples or controls. This approach provides an example of how basic research on preterm-birth might lead to better therapeutic approaches in the future.


It has been reported that lifestyle factors may affect birth weight; however, few studies have explored the association between lifestyle factors and low birth weight in preterm and term births in China. The objective of this study was to explore the effect of lifestyle on low birth weight in preterm and term births.This case-control study was conducted in fourteen hospitals in Jiangmen, Guangdong Province. Data were collected from August 2015 to May 2016 using a standard questionnaire. Data were analysed using logistic regression.Women who delivered preterm and were physically active (1–3 times per week and ≥ 4 times per week) had reduced odds of having low birth weight babies . Pregnant women who had insufficient gestational weight gain had increased odds of having low birth weight babies . Women exposed to passive smoking had an increased risk of delivering low birth weight infants . Insufficient gestational weight gain and excessive gestational weight gain were both significantly associated with low birth weight  for term deliveries. In addition, parity, history of low birth weight, antenatal care and gestational hypertension were significantly associated with the likelihood of low birth weight.Pregnant women without exercise contraindications should remain physically active. Pregnant women should be aware of the negative effects of smoke and be aware of strategies to protect themselves from passive smoke exposure. Hospitals should inform pregnant women of the importance appropriate gestational weight gain. These recommendations should be put into practice to decrease the prevalence of low birth weight infants. Low birth weight is a serious condition in developing countries. Although lifestyle factors may affect low birth weight, few studies have explored the association between lifestyle factors and low birth weight in preterm and term births.This study was conducted in fourteen randomly selected hospitals in Jiangmen, Guangdong Province, China. Data were collected from August 2015 to May 2016 using a questionnaire and medical records. A total of 294 preterm low birth weight infants, 289 term low birth weight infants and 1381 controls were selected.In the preterm low birth weight group, physical activity and insufficient gestational weight gain were associated with low birth weight. Meanwhile, in the term low birth weight group, insufficient gestational weight gain and excessive gestational weight gain were both significantly associated with low birth weight. In addition, in the term low birth weight group, women who experienced passive smoking had an increased risk of delivering low birth weight infants.In conclusion; findings from this study may help hospitals develop proper, immediate and sustainable measures to improve maternal and child health.Low birth weight (LBW) is defined as less than 2500 g at birth, irrespective of the gestation age . Babies The average prevalence rate of LBW is 15% worldwide , 7. In mMany lifestyle factors have been associated with birth weight –13. PrevThis case-control study was conducted in fourteen hospitals in Jiangmen, Guangdong Province. A stratified sampling method was adopted according to region, and then purposive selection was performed based on number of deliveries. Hospitals were chosen to ensure that there were at least two hospitals in each region. The cases and controls in this study were recruited from the same hospitals from August 2015 to May 2016. Informed consent was obtained from each woman.α/2 = 1.96), 80% power (Zβ = 0.84), a control to case ratio of 1:2 (r = 2), an odds ratio to be detected ≥2 and an exposure of 3.5% for the control group [The sample size was determined using the proportion difference approach with the assumption of a 95% confidence level  twins or multiple births, 2) congenital anomalies and stillbirths, and 3) birth weight ≥ 4000 g. A total of 294 preterm LBW infants and 289 term LBW infants were selected.For each case, two pregnant women who delivered at the same hospital and their newborns were selected as the controls. The control group inclusion criteria were as follows: 1) singleton births, 2) delivery time close to that of the case and 3) a birth weight ≥ 2500 g. The exclusion criteria were the same as those for the cases. Finally, 1381 controls were selected.Data were collected through a questionnaire and prospective case enrolment. The questionnaire was designed by local clinical experts and research team after group consultation and review. An obstetric nurse with a public health background facilitated questionnaire completion in the postnatal ward. High-risk lifestyle factors were only assessed in the questionnaire. The questionnaire included sections focused on demographics, lifestyle factors, and other potential LBW-related factors. Maternal demographic characteristics included age, height, pre-pregnancy weight, level of education, average income per person in the family, and marital status. Lifestyle factors included cigarette smoking, passive smoking, drinking, physical activity, coffee or tea drinking and gestational weight. The interviewees were questioned about whether they smoked and how many cigarettes were smoked per day . PassiveThe prospective case enrollment included information regarding delivery , integrated information about the newborns, and information regarding antenatal care and medical conditions before, at and post-delivery . The information was collected from the obstetric records. The gestational age estimate that was recorded was assumed to represent the best available clinical estimate. Birth weight was measured using an infant electronic scale within 1 h of birth. In addition, the duplicate information about risk factors included in both the questionnaire and checklist were cross-checked to ensure data quality.p-value less than 0.1 (90% level of significance) in the bivariate analysis. Second, to control for potential confounders, a multivariate logistic regression was performed. We used the odds ratios (ORs) and 95% confidence intervals (CIs) to make comparisons between the groups. The p-values of all the statistical analyses were two sided. The level of significance for the multivariate analysis was 95% (P < 0.05).All analyses were conducted using SPSS 22.0 . All potentially relevant variables were first analyzed with a bivariate logistic regression to assess the associations between the preterm and term group: general demographic characteristics , pre-pregnancy BMI, parity, history of LBW, antenatal care, gestational hypertension and fetal sex. The criterion for selecting variables was set at a The study criteria were met in 294 preterm LBW cases, 289 term LBW cases and 1381 controls. Table The distribution of lifestyle factors in the cases and control are shown in Table The bivariate and multivariate analysis of socio-demographic characteristics in the preterm LBW and control groups revealed that the LBW status was significantly associated with age more than 35 years , parity more than one , history of LBW , gestational hypertension  and antenatal care. In the term LBW and control groups, the LBW status was significantly associated with pre-pregnancy BMI less than 18.5 , parity more than one , history of LBW , gestational hypertension  and antenatal care.In the bivariate analysis, physical activity and gestational weight gain were significantly associated with preterm LBW. However, in the bivariate analysis, passive smoking and gestational weight gain were significantly associated with term LBW. The results of multivariate analysis are summarized in Tables These findings suggest that maternal physical activity during pregnancy has a positive association with preterm LBW but not term LBW. Pregnant women who were exposed to smoking during pregnancy had increased odds of having term LBW babies. In addition, insufficient gestational weight gain had a significant association with preterm and term LBW and excessive gestational weight gain was only significantly associated with term LBW.This study showed that socio-demographic characteristics could affect the weight of newborns. Parity and antenatal care were both positively associated with LBW, in accordance with previous findings , 34. AdeIn the preterm LBW group, this study suggested that moderate intensity physical activity may decrease rates of preterm LBW. Similarly, previous studies suggested that appropriate physical activity was a protective factor for LBW , 40. TheIn the term LBW group, data in the study confirmed that passive smoking was associated with LBW. A previous study suggested that passive smoking was associated with LBW . A studyThe study by Scholl suggested that insufficient gestational weight gain was associated with inadequate nutrient intake , which wThis study has several strengths but also some limitations. Its main strength is that the case group was divided into a preterm and a term group. These groups were propitious for exploring the real association between lifestyle factors and preterm and term LBW and for providing guidance for the development of appropriate and sustainable interventions to improve maternal health. Another strength is that we considered confounders including economic status, and education level, which may influence the association with birth weight.One limitation is that participants were not matched due to logistic constraints of recruitment in 14 hospitals. However, in most previous studies subjects were not matched , 58. AnoThis study suggests that pregnant women without exercise contraindications should perform regular appropriate physical activity to improve their health status and pregnancy outcomes. Pregnant women should be aware of the dangers of passive smoking and be provided strategies to decrease exposure. As women are particularly vulnerable to the impacts of passive smoking in public places, research and health programs have focused on mothers and their LBW newborns . These fThis study was conducted to investigate the impact of lifestyle factors on LBW in preterm and term births after controlling for relevant confounders. Physical activity may be associated with a reduced risk of preterm LBW and pregnant women who experience passive smoking have an increased risk of delivering term LBW babies. Moreover, insufficient gestational weight gain had a significant association with preterm and term LBW.


Forty-six percent of students were extremely likely and 26% moderately likely to get birth control from a pharmacist because it would be easier to adhere to birth control, could prevent unintended pregnancies, would be more convenient, and require less time. Concerns included the lack of Pap screenings and prescriptions written for the wrong birth control. Within most student characteristics or attitudes assessed, at least 70% of the students would use this service. Based on student opinions, female college students would use pharmacists prescribing birth control services.In the United States, the overall unintended pregnancy rate is about 45%. Women between 20–24 years old account for 59% of the unintended pregnancies. Continuous birth control use is related to decreasing unintended pregnancies. Therefore, we assessed female college students’ opinions about pharmacists prescribing birth control in a community pharmacy using an intersectionality framework. A survey with 49 items about provider attributes, pharmacy services use and evaluation, advantages and barriers of pharmacists prescribing birth control, sexual and reproductive history, and demographics was distributed by survey link and QR code. Recruitment was done by investigators and students  via emails, social media posts, and direct student contact. Respondents ( Unintended pregnancies are recognized as individual, family, and societal concerns. Forty-five percent of pregnancies are unintended in the United States with higher prevalence in those 20–24 years old, with low income, and/or from minority groups . The cosBoth the Healthy People 2020 initiatives  and the The American College of Obstetricians and Gynecologists (ACOG) position on this topic is that hormonal contraception should be available over the counter with no age restrictions ,12. ACOGThe pharmacist prescribing model allows pharmacists in community pharmacies to prescribe hormonal contraception for patients. Pharmacists obtain this ability through legislation or collaborative practice agreements with physicians. Eleven states and the District of Columbia have scope of practice or standing order legislative authorities allowing pharmacist to prescribe hormonal contraception ,15,16,17Data have documented adolescents ,19,20, wEmerging outcomes from pharmacist prescribing birth control are positive. Within two years of implementing pharmacist prescribed birth control for Oregon women receiving Medicaid, an estimated 51 unintended pregnancies were prevented, and about $1.6 million dollars saved .Public opinions and perceptions are important in advancing pharmacists as birth control prescribers through state legislative processes and approvals. Gaps in identifying characteristics associated with using pharmacist birth control services still exist or need confirmation. The viewpoints of women aged 20–24 are particularly important since they have the highest prevalence of unintended pregnancy in the United States .Students had positive comments about pharmacists prescribing birth control but also some concerns. Survey advantages and concerns prompted responses (survey items) are listed in The mean number of prompted and other stated concerns were 2.1 ± 1.3 with most students listing one (34.3%) or two (24.9%) concerns . AdditioIn Sexual practices of the students and likelihood of obtaining birth control from a pharmacist results are presented in p = 0.027) and times of unprotected intercourse in the last year (p = 0.044) had significant differences within the variable.For the specific sexual practice variables, 69% to 89% of the female college students stated they were extremely or moderately likely to get their birth control from a pharmacist . Only sep = 0.7413).An ordinal regression on likelihood of obtaining birth control from a pharmacist did not yield a significant model for the variables age, age at first intercourse, number of sexual partners, or number of times intercourse per week (model significance p = 0.01), having greater confidence in pharmacist prescription dispensing (p = 0.01) and counseling (p = 0.000), and believing pharmacists have more knowledge than their doctor, nurse practitioner, or physician assistant (p = 0.000) were associated with greater likelihood of getting their birth control from a pharmacist.Previous use and quality assessment of pharmacy services and their impact on opinions about obtaining birth control from a pharmacy are depicted in p = 0.000) and decreasing unintended pregnancies (p = 0.000), the greater the likelihood of receiving their birth control from a community pharmacist.Most female college students thought that receiving birth control from their pharmacist would definitely (59.5%) and probably (30.5%) increase their birth control adherence, and would definitely (63.0%) and probably (27.0%) decrease unintended pregnancies. The greater the belief of an impact of pharmacists prescribing birth control on increasing birth control adherence  range with some aspects of the pharmacy and getting birth control in that environment lower (7.4 to 8.7). The results are shown in p < 0.0001). The attributes trustworthiness , approachability  and visit expense  were statistically significant in predicting likelihood of using a pharmacist as a primary provider for contraceptives. The greater the perception of trustworthiness and approachability the students had for the pharmacist, the greater their likelihood to use the pharmacist as a primary provider for birth control. The lower the students perceived the pharmacy visit expense to be, the more likely they would use the pharmacist as a primary provider of birth control.Using the nine attributes in This study provided evidence that women are interested in pharmacists prescribing birth control. Seventy-three percent of Michigan female college students felt they were likely to obtain their birth control from a community pharmacist. They felt the community pharmacist visit for birth control would be more convenient, save time, and make obtaining birth control easier. They also felt this pharmacy service would help them continue and be more adherent to their birth control, and prevent unintended pregnancies. The predominant concerns the students had were not getting regular Pap smears and screenings and potentially being prescribed the wrong birth control. These advantages and concerns are similar to other studies ,22,23,24In terms of targeting this service to select groups of college students, we found across all our student characteristics to have high support for obtaining birth control in a community pharmacy, making the service generalizable across diverse students. Overall, at least 70% of the female college students across the various student characteristics stated they would use pharmacist birth control services, a measurement of acceptability. No statistically significant differences were seen between race and ethnic groups, religion/spirituality groups, residence while going to college, size of city living in during childhood, political party, type of college, student enrollment status, employment, and medical or medication insurance coverage. Students from a foreign country  were more likely to use this service than American born and naturalized citizen students, which might be related to lack of a primary care provider, health insurance, and or transportation, or non-prescription access to contraception in their birth country. Healthcare students were more likely than non-healthcare students to use a pharmacist for birth control, which might reflect greater understanding of pharmacist education and training and subsequent medication expertise. Variability within the healthcare students existed with pharmacy students having the highest, medical students in the middle, and nursing students the lowest likelihood. These differences could be related to territoriality and profession-centrism regarding writing prescriptions for patient management . No diffOur study is the first study with a diverse female college participant cohort to assess opinions about pharmacists prescribing birth control, a group which could use this service. We chose this cohort since college students are in the age groups with the highest unintended pregnancy rates . AnotherUnintended pregnancy rates are higher in minority women and those living in poverty . In our Past experiences with pharmacists influenced the female college students’ likelihood of having a pharmacist prescribe birth control to them in a community pharmacy. Using pharmacist birth control services in the future varied based on past pharmacy services used and confidence in pharmacists. Having received a vaccination from a pharmacist and being more confident with pharmacists filling prescriptions and providing counseling were associated with a greater likelihood of obtaining birth control from a community pharmacist. About one third of the students (37.3%) thought pharmacists knew more about birth control than primary care providers, which could be influenced by the high percentage of pharmacy students in the database. Students’ rankings of pharmacist attributes were very positive, at least 8.4 or higher on a 10-point scale. Pharmacy attributes such as privacy, time, and cost were lower but still above 7.4 on a 10-point scale. Pharmacist trustworthiness, approachability, and visit expenses significantly influenced their likelihood of using birth control pharmacists. In the opinion-based studies about pharmacist prescribing, women of all ages would use or support this service, but they do express concerns as well ,26,27,28Our study had a few limitations. The results represent one Midwest state and only college student opinions, which might not represent other states or women of different ages. Within all demographics, likelihood to use pharmacist birth control prescribing was high. The chance to win one of two $250 gift cards was most likely not an incentive for survey completion. Since the survey incentive was insignificant, respondent bias could exist with those more positive or opposed more likely to complete the survey. Recruitment was challenging with only 857 completed surveys after mass emailing, social media posts, and face to face recruiting at two major universities and two community colleges. Difficulty recruiting for another public perception of pharmacists prescribing birth control also was noted in a study using social media to recruit women of any age . Only 2.Some but not all students might have been aware of pharmacists prescribing birth control prior to the study so different degrees of previous opinion development. Many student pharmacists could have learned about this service in class or at national and state pharmacy meetings. Learning about this service might have occurred in other curriculums. Medical students might have discussed the American College of Obstetrics and Gynecology preference for over-the-counter birth control, which could have influenced their opinions on pharmacists prescribing contraception. Little is known about the coverage of this new pharmacy service in other healthcare and non-healthcare  student curriculums. At the initiation of this survey, this pharmacy service was not available in Michigan. Now one large pharmacy chain in Michigan is offering this service through a collaborative practice agreement. The pharmacy chain started its service the month after our recruitment ended, which was the month Covid-19 hit Michigan. Prior to Covid-19, minimal marketing had occurred and during Covid-19, pharmacists prescribing birth control was not the focus of pharmacy patient health care, so most likely this new pharmacy provider of birth control had little impact on students’ opinions.Many female college students in Michigan are receptive to pharmacists prescribing birth control in a community pharmacy. They feel this service will make getting and adhering to birth control easier and decrease their worries about getting pregnant. Their positive attitude results combined with reported prevention of unintended pregnancies and decreased health care costs outcomes in Oregon  support