To analyze the relationship between the development of childhood solid tumors and 1) birth weight and 2) fetal growth, using two Brazilian population-based data sets.A case–cohort study was performed using two population-based data sets, and linkage between the Live Birth Information System  and 14 population-based cancer registries (PBCRs) was established. Four controls per case were chosen randomly from the SINASC data set. Tumors were classified as central nervous system (CNS), non-CNS embryonal, and other tumors (“miscellaneous”). Adjustments were made for potential confounders . Odds ratios (ORs) with 95% confidence intervals (CIs) were computed using unconditional logistic regression analysis.In a trend analysis, for every 500 g of additional birth weight, the crude OR was 1.12 (CI: 1.00–1.24) and the adjusted OR was 1.02 (CI: 0.90–1.16) for all tumors. For every 1 000 g of additional birth weight, the crude OR was 1.25 (CI: 1.00–1.55) and the adjusted OR was 1.04 (CI: 0.82–1.34) for all tumors. Among children diagnosed after reaching the age of 3 years, in the miscellaneous tumor category, the OR was significantly increased for every additional 500 g and 1 000 g of birth weight.The study data suggested that increased birth weight was associated with childhood solid tumor development, especially among children more than 3 years old with “miscellaneous” tumors. Causes of childhood cancer are poorly understood. Research showing transplacental exposure to carcinogenic agents as a risk factor for cancer has led to the notion that important events associated with the development of embryonic tumors can occur in utero . Birth cFetal growth can be influenced by environmental and genetic factors . CirculaSocioeconomic factors have been related to birth weight. Establishing the cutoff for high and low birth weight in different societies can be a challenge. Population-based studies are essential to describe epidemiological patterns that can provide clues for future studies.The aim of this study was to analyze the relationship between the development of childhood solid tumors and 1) birth weight and 2) fetal growth, using two Brazilian population-based data sets.n = 566). The National Cancer Institute  (Rio de Janeiro) has promoted the establishment of cancer registries in various Brazilian cities, and there are now 25 PBCRs distributed across major cities in all regions of Brazil. A total of 60% met International Agency for Research on Cancer (IARC) (Lyon) standard criteria for data quality parameters, such as percentage of cases 1) confirmed microscopically (> 75%) and 2) collected only through death certificates (< 20%) (Data were obtained from 14 population-based cancer registries (PBCRs) in Brazil. Cases among children with solid tumors born after 1999 and diagnosed between 2000 and 2010 were included  corresponding to cases obtained from PBCRs for 14 cities in Brazil’s five regions (n = 5 824 824) were obtained. Multiple pregnancies  were excluded. Although SINASC was implemented in 1990, the system went through a maturation process, becoming more reliable since 2000, and the coverage of procedures has gradually improved. The information has been extensively used to obtain health indicators, and to conduct epidemiological studies and health surveillance activities. Data for variables such as birth weight, newborn sex, hospital of birth, type of delivery, maternal age, and maternal education level are considered to have good completeness and reliability (n = 162), neuroblastoma (n = 82), retinoblastoma (n = 37), renal tumors (n = 84), liver tumors (n = 13), soft tissue sarcomas (n = 46), germ cell tumors (n = 40), bone tumors (n = 11), carcinomas (n = 31), and non-specified tumors (n = 60), based on the criteria of the International Classification of Childhood Cancer, Third Edition (ICCC-3) , which was done using R software (RecordLinkage Package) . The datn = 1 580) from the SINASC data source, ordered by birth year and sex. Increasing the ratio of controls to cases beyond four is considered unnecessary except when the effect of exposure is large . These data, along with the Human Development Index (HDI) score, childhood cancer incidence and mortality rates, and birth weight categories for Brazil’s five different regions, are shown in Unconditional logistic regression analysis was carried out using IBM SPSS Statistics for Windows version 21.0  to evaluate the association between birth weight, fetal growth, and childhood solid tumors. Odds ratios (ORs) with 95% confidence intervals (CIs) for birth weight and fetal growth were estimated in a multivariate model. Adjustments were made using variables that were potential risk factors for childhood cancer, such as maternal age at delivery, mode of delivery, maternal education level, birth order, gestational age, sex, and geographic region, and associated with birth weight. The analysis of all tumors and for each specific group always included the total control group for comparison. Cases with birth weight for gestational age (BWGA) that were missing data  were excluded. Birth weight was 1) evaluated as a continuous variable, with units of 500 g and 1 000 g; 2) evaluated as a categorical variable, with three levels, including the reference group with normal birth weight (2 500– 4 000 g); and 3) divided into five categories, with the reference group as normal birth weight (3 000–3 499 g). Sex, birth weight, and gestational age were used to classify infants by weight into the following gestational age categories: large for gestational age (LGA), defined as a birth weight above the sex- and gestational age–specific 90th percentile; small for gestational age (SGA), defined as a birth weight below the 10th percentile; and appropriate for gestational age (AGA), defined as a birth weight between the 10th and 90th percentiles. A large, published birth cohort of Brazilian population birth weight centiles was used to define these categories . SeparatAll data were kept strictly confidential to ensure anonymity. The study was approved by INCA’s Research Ethics Committee (ref# 13596513.7.0000.5274).n = 127), neuroblastoma (n = 65), retinoblastoma (n = 28), renal tumors (n = 61), liver tumors (n = 6), soft tissue sarcomas (n = 29), germ cell tumors (n = 32), bone tumors (n = 5), carcinomas (n = 8), and non-specified tumors (n = 31). Linkage identified 74%–80% of CNS tumors, neuroblastoma, retinoblastoma, renal tumors, soft tissue sarcomas, and germ cell tumors; 45% of hepatoblastomas, bone tumors, and non-specified tumors; and only 26% of carcinomas.Linkage between the two sources identified 395 cases . After excluding three cases that were missing BWGA, the cases were classified into CNS tumors (n = 1), polydactyly (n = 1), syndactyly (n = 1), other congenital anomaly of the foot (n = 2), Down syndrome (n = 3), macrocephaly (n = 1), unspecified syndrome (n = 1), spina bifida (n = 1), unspecified brain abnormality (n = 1), congenital anomaly of male genital tract (n = 1), unspecified head and neck abnormality (n = 2), and multiple malformations (n = 1). There were minor differences among the mean birth weights for each tumor type and controls (P = 0.649). The mean birth weight calculated was 3 261 g (CI: 3 176–3 346 g) for CNS tumors; 3 260 g (CI: 3 154–3 366 g) for neuroblastomas; 3 287 g (CI: 3 101– 3 472 g) for retinoblastomas; 3 211 g (CI: 3089–3 334 g) for renal tumors; 3 131 g (CI: 2 537–3 724 g) for liver tumors; 3 618 g (CI: 3 085–4 151 g) for bone tumors; 3 307 g (CI: 3 111–3 504 g) for soft tissue sarcoma; 3 275 g (CI: 3 130–3 420 g) for germ cell tumors; 3 311 g (CI: 2 987–3 634 g) for carcinomas; 3 203 g (CI:3 009–3 396 g) for non-specified tumors; and 3 204 g (CI: 3 178–3 229 g) for the control group. Mean birth weight calculated by geographic region was 3 220 g (CI: 3 158–3 282 g) for the North region; 3 252 g (CI: 3 211–3 293 g) for the North-east; 3 163 g (CI: 3 117–3 208 g) for the Southeast; 3 212 g (CI: 3 166–3 257 g) for the South; and 3 253 g (CI: 3 172–3 333 g) for the Middle West. Among the case group, 77.4% of infants with SGA had an adequate birth weight (2 500–4 000 g). Among the control group, 63.7% of infants with SGA had an adequate birth weight (2 500–4 000 g). Overall, 66.3% of infants with SGA had an adequate birth weight (2 500–4 000 g). Tests were then run to determine if birth weight per se and BWGA were related. Overall, agreement between the two measures was moderate, as shown by a weighted kappa of 0.56 (CI: 0.53–0.59). There was no association between perinatal and demographic variables, despite a slight difference in both the control and case groups for number of prenatal visits and in the control group for maternal age. In the control group, males were heavier than females (P < 0.001) (The distribution patterns of the children included in the study sample are shown in < 0.001) . Crude aTests were also run to determine if the association with birth weight was significantly different when the diagnosis was made in children before or after they had reached 3 years of age. In the miscellaneous group, there was a significant (twofold) increase in risk for every 500 g of additional birth weight  in children who were diagnosed after reaching age 3.The risk association between pediatric tumors, fetal growth, and birth weight, by age of diagnosis, is shown in Birth weight has been associated with childhood cancer risk in the literature. High birth weight has also been implicated as a risk factor for adult cancers  . SeveralWhile errors in birth weight have occurred in the SINASC neonatal registry, the SINASC data have an intraclass correlation coefficient of 0.57, suggesting that socioeconomic status can be used to evaluate risk . PreviouSeveral authors have suggested that BWGA is an indicator of fetal growth and a better predictor than birth weight per se for risk of several tumor types , 5. BirtHigh birth weight has been reported as a risk factor for bone tumors . Among tOverall, this study found a 4% increase in childhood solid tumors for every 1000 g of additional birth weight. No differences were seen for either CNS or non-CNS embryonal tumors. Nevertheless, because it is well known that hepatoblastoma, which was included in the non-CNS embryonal tumor group, is associated with low birth weight, the six cases of hepatoblastoma were excluded from the study. For the miscellaneous group, a risk of 1.37 (CI: 0.71–2.66) was observed for each additional 1 000 g of birth weight. When data were stratified based on age at diagnosis, birth weight was associated with the miscellaneous category, with a risk of 1.27 CI: 0.82–1.99) for each increase of 1 000 g, for children 3 or more years old. Children less than 3 years old at diagnosis who were small for their gestational age had a 45% higher risk of CNS tumors, although the difference was not significant . In a recent pooled analysis, higher birth weight was associated with non-leukemia cancer diagnosed at or after the age of 3 years 2–1.99 fo.In a nested case–control study from Brazilian hospital-based data, mean birth weight for cases was 3 320 g, slightly higher than the mean birth weight of the cases in this study (3 259 g).The main strength of this study was the use of population-based data rather than self-reported data , which prevented recall bias issues. In addition, controls and cases were chosen from the same birth certificate database, so selection and information bias are also unlikely. Finally, the study’s main data source (the SINASC database) is recognized as being of good quality, with complete and consistent information . UnfortuThis study also had several limitations. First, the SINASC data on birth characteristics have only been available since 2000. Therefore, selected cases were obtained from the cohort born after 1999 and diagnosed from 2000–2010, limiting the analysis to data from children 0 to 10 years old. Second, the small size of the data set generated a low number of different tumor types, making it impossible to analyze by tumor type. Third, information on other potential confounders, such as infectious diseases and environmental exposures , was not available. Finally, maternal education was used as proxy for socioeconomic status, which is not optimum, but no other adequate variable was available.The findings of this study suggest that increased birth weight is associated with the development of childhood solid tumors, especially among children more than 3 years old at diagnosis, with tumors classified as “miscellaneous.” Birth weight by gestational age was not associated with this outcome. In the study’s heterogeneous population, birth weight was a difficult variable to interpret. Birth weight according to ethnic, socioeconomic, and perinatal care differences is still challenging to analyze. Larger samples are necessary. However, the Brazilian Live Birth Information System (SINASC) cohort used in this study only dated back to 2000, and the country’s PBCRs only had updated information until 2010. In the near future, as the scope of both data sources grows, it will be possible to obtain larger samples.The authors are grateful to all of the coordinators of the PBCRs and regional SINASCs in Brazil who contributed the data sets that made this work possible.None.Conselho Nacional de Desenvolvimento Científico e Tecnológico, CNPq) (Brasília) (#306291/2014-2) and the Foundation for Support of Research in the State of Rio de Janeiro  (Rio de Janeiro) (#212989-2016).NPS has a scholarship from CAPES/MS  (Brasília). BDC has a scholar grant from the National Council for Scientific and Technological Development .Authors hold sole responsibility for the views expressed in the manuscript, which may not necessarily reflect the opinion or policy of the


Within-subject coefficient of variation (wsCV) and intra-class correlation coefficient (ICC) are measured to assess the reproducibility and Dice similarity index is evaluated for the spatial alignment between DTI and anatomical images. Topup-s2v pipeline provides highest reproducibility  and best correction of image distortion (Dice = 0.83). This study definitely provides a recipe for data processing, enabling for a clinical suitability of kidney DTI.Diffusion tensor imaging (DTI) is particularly suitable for kidney studies due to tubules, collector ducts and blood vessels in the medulla that produce spatially restricted diffusion of water molecules, thus reflecting the high grade of anisotropy detectable by DTI. Kidney DTI is still a challenging technique where the off-resonance susceptibility artefacts and subject motion can severely affect the reproducibility of results. The aim of this study is to design a reliable processing pipeline by assessing different image processing approaches in terms of reproducibility and image artefacts correction. The results of four different processing pipelines ( It is based on diffusion weighted imaging (DWI), a non-invasive technique that provides useful information on tissue diffusion properties as well as microstructural changes in different pathologies3. In addition to the diffusion estimation revealed by DWI, DTI allows the analysis of anisotropic properties of the tissues by returning the preferential water diffusion directions, quantitatively represented by the fractional anisotropy (FA). Due to the restricted water molecular mobility in organized tissue structures, DTI has been used to provide information on tissue organization as well as microstructural integrity5.Magnetic resonance (MR) diffusion tensor imaging (DTI) is a powerful technique that allows 6, DTI has been recently applied to different intra-abdominal organs7 including prostate10, liver12 and kidney14. DTI is particularly suitable for kidney studies due to well-defined structural organization. Indeed, tubules, collector ducts and blood vessels in the medulla produce spatially restricted diffusion of water molecules, thus reflecting the high grade of anisotropy detectable with DTI. Since the first DTI analysis of the kidney described by Ries et al.13 in which the anisotropy differences revealed by DTI in the medulla with respect to the cortex were proven, further studies demonstrated that FA values of the medulla in healthy kidneys are higher compared to that of the cortex16. Moreover, since DTI does not require any contrast agent administration, it is suitable for the imaging of subjects with kidney dysfunction, for which the use of contrast agents is highly contraindicated. In this scenario, recent studies demonstrated the ability of DTI to detect renal damage in chronic kidney diseases, glomerulonephritis and renal lesions20. DTI was also applied in subjects after renal allograft to study the differences of diffusion parameters between transplanted and healthy kidney and the correlation with clinical parameters as the estimated glomerular filtration rate22.Mainly used in neuroimaging studies for the characterization of brain white matter tracts23. Moreover, the need to obtain DTI images with adequate spatial and angular resolution results in prolonged scan time, thus producing increased subject movement both between and within DTI volumes during the acquisition. Therefore, in this context ad hoc image processing methodologies able to correct or mitigate image artefacts are recommended.DTI is typically obtained by acquiring a set of spin echo echo-planar imaging (EPI) sequences with different diffusion directions and b-values. Due to the rapid switching of diffusion encoding gradients and the low bandwidth in phase encoding direction, it is well known that DTI images obtained with EPI suffer from off-resonance induced distortions as eddy-currents and susceptibility-induced geometric distortions25. Moreover, several methods have been proposed to correct susceptibility-induced geometric distortion by using an additional DTI image acquired with reversed phase encoding direction27 or by retrospective deformable registration procedures29. More recently, a novel methodology correcting the motion occurring both between (volume-to-volume) and within (slice-to-volume) each DTI volume was proposed30. However, as the aforementioned image processing methods have mainly been developed for processing brain DTI, their use was poorly or never investigated in kidney DTI where the image mis-registration due to subject motion and the geometric distortion artefacts are extremely detrimental. In this scenario, in order to assess the clinical utility of kidney DTI, the reliability of the results derived from DTI could be demonstrated by the standardization of both acquisition protocols and image processing pipelines31.Recent advances in brain DTI processing methods demonstrated robust results by reducing the effects of image artefacts. In particular, different strategies were developed to deal with eddy-currents distortions as well as subject movement34 of healthy subjects, thus demonstrating the repeatability of DTI parametric maps with a typical processing pipeline. However, to the best of our knowledge, this is the first study aimed to assess the effects of different processing pipelines to the reproducibility of the kidney DTI. Moreover, this is the first study where the slice-to-volume motion correction is included as preprocessing step in kidney DTI.In this study, different image processing steps are evaluated to provide an optimal image processing protocol for kidney DTI. In this setting, in order to address the aforementioned image artefacts affecting kidney DTI, different strategies, both in acquisition and processing step, which tackle the eddy-currents, susceptibility-induced distortion and motion both between and within DTI volumes, are applied. Moreover, a test-retest reproducibility analysis is conducted for each tested processing pipeline in order to assess the reproducibility of the results. In literature several studies were based on reliability and repeatability analysis in both renal DWI and DTIThe study was approved by Local Ethics Committee  with protocol number 17/17. Written informed consent was obtained for all participants and all the procedures adopted in this study were performed in accordance with the approved guidelines and regulations. Between May and September 2018, 14 healthy volunteers  with no history of kidney pathologies, vascular diseases, diabetes, hypertension and no contraindications for MR exam were enrolled in this study.35, the MR exam was performed without any specific subject preparation. Anatomical image, within a field of view comprising both left and right kidneys, was acquired in breath-hold using an oblique-coronal T2-weighted half-Fourier acquisition single-shot turbo spin echo (HASTE) with following parameters: TR/TE, 1400/91 ms; slice thickness 5 mm; field of view, 380 × 380 mm2; matrix, 320 × 320; pixel size, 1.188 × 1.188 mm2; slices, 36; parallel imaging accelerator factor, 2. DTI images were acquired with a respiratory-triggered oblique-coronal fat-saturated twice-refocused EPI sequence with the following parameters: b-values, 0 and 500 s/mm2; number of images at b = 0 s/mm2, 6; diffusion directions, 6; TR/TE, 1800/74 ms; averages, 3; slices, 23; slice thickness, 3 mm; field of view, 319 × 319 mm2; matrix, 152 × 152; pixel size, 2.1 × 2.1 mm2; parallel imaging acceleration factor, 2. Depending on the individual respiratory cycle, acquisition time varied from 5 to 6 min. Two sets of DTI data were acquired with the phase-encoding direction reversed (left to right and right to left) to enable the geometric distortion correction resulting from EPI acquisition26. In order to quantify the reproducibility of kidney DTI, the DTI sequence was repeated in the same MR session without moving the subject into the scanner, thus obtaining two sets of DTI images for each participant.MR exam was performed for all participants using a 3T scanner  with a 4-channel phased-array body coil. Since it was already demonstrated that the DTI parametric map values are not influenced by subject fasting or hydration status36 was applied to the DTI images. In particular, the mean absolute (i.e. with a reference volume) and relative (i.e. with the previous volume) motion between different volumes of each acquired DTI were calculated by means of averaging translation and rotation parameters across all voxels.The image quality for each participant was visually checked by an expert radiologist with more than 5 years of experience in abdominal imaging. Moreover, as additional quality check, an automated image quality controleddy);correction of eddy-currents and volume-to-volume movement (indicated as eddy-s2v);correction of eddy-currents, volume-to-volume and slice-to-volume movement (indicated as topup);correction of eddy-currents, volume-to-volume movement and susceptibility-induced distortion correction (indicated as topup-s2v).correction of eddy-currents, volume-to-volume and slice-to-volume movement and susceptibility-induced distortion correction  library39 (available at http://www.mrtrix.org). Moreover, a tensor-based deterministic approach40 was used to whole-kidney tractography reconstruction with the following parameter: FA threshold of 0.1 and angle threshold of 60°. Tractography reconstructions were visually inspected for both anatomical and color-coding consistency.For each processing pipelines, FA, mean diffusivity (MD), radial diffusivity (RD) and axial diffusivity (AD) parametric maps were evaluated from the eigenvalues of the diffusion tensor by means of MRtrix3 software toolboxb = 0 s/mm2 images, indicated as b0-image, was evaluated for each processing pipeline.Both parametric maps and tractography were evaluated also from DTI data without any image processing procedure, thus obtaining a total of five different sets of images for each participant. Finally, the mean between the 41. A coronal slice in the central kidney section closest to the renal hilum was selected for the segmentation procedure. Three kidney sections corresponding to upper, middle and inferior pole were selected for ROI analysis. For each section, two circular ROIs of 58 mm2 were manually drawn in the renal cortex and medulla for both kidneys thus obtaining a total of twelve ROIs. The combination of b0-image and FA map was used to accurately define cortex and medulla and to avoid renal pelvis, vessels and calyces  were annotated with the open source software ITK-SNAP v3.6.042 (wsCV) and intra-class correlation coefficient43 (ICC). The wsCV was evaluated by the ratio between the within-subject standard deviation and the mean value of the entire population. Values of wsCV < 0.1 reflected low variability between measurements, >0.1 and <0.2 represented moderate variability and >0.2 were considered for highly variable measurements44. ICC  was evaluated as:BMS and WMS respectively are the between- and within-subject mean squares and k represents the number of repeated measurements. For the ICC parameter, a value >0.7 was considered for highly reliable measurements44.A paired t-test was performed in order to assess the statistical differences between cortical and medullary ROI mean values. Moreover, a paired t-test was also used to statistically estimate the difference between values from left and right kidney. The statistical significance was assumed as p < 0.05. The test-retest reliability was quantitatively assessed both for cortical and medullary ROI mean values via within-subject coefficient of variationtopup-s2v pipeline. The binary kidney 3D masks obtained from b0-image were then resliced to the HASTE space in order to quantitatively compare the spatial overlap.Both kidneys were manually segmented on the HASTE image. The segmentation procedure consisted in generating 2D mask for each slice containing the kidney parenchima in the coronal plane thus composing a 3D binary mask. Border pixels isointense respect to the kidney parenchima were included during the segmentation process to avoid bias due to partial volume effects. In order to evaluate the results of geometric distortion correction routine, the same segmentation procedure was applied to the b0-image obtained from both DTI without processing and with 45 was used to quantitatively compare the 3D masks obtained from HASTE and b0-images. In particular, the Dice index was calculated as:A and B correspond to the mask from HASTE and b0-image, respectively.Dice similarity coefficienttopup-s2v pipeline is reported in Fig. All participants in this study completed the MR exam and no images were discarded after the preliminary visual inspection. The image quality is also confirmed with the control report  and from 0.76 and 0.87 (mean ± standard deviation: 0.83 ± 0.03) when 31 and no consensus was reached on the optimal processing protocol in kidney DTI. To the best of our knowledge, this is the first study where the comparison between different processing pipelines is achieved and a reliable processing protocol in kidney DTI is proposed. In this study, five different processing pipelines are tested in order to compare the results in terms of reproducibility of DTI parametric map values.In this work, we show that the choice of the optimal processing pipeline in kidney DTI is critical for both standardization and reproducibility of the results. To date, a high heterogeneity of processing pipelines was found in literature17. Therefore, we select a b-value of 500 s/mm2 since it can be considered as a good compromise between image quality and pure diffusion measurement46. In addition, considering that less restrictive structures require lower b-value to be revealed by diffusion imaging47, the choice of optimal b-value depends on water diffusion constrained by the underlying anatomical components that, in the case of the healthy kidneys are less restricitive structures (i.e. collector ducts and tubules). In this setting, we select the optimal b-value by considering the MD values of kidneys reported in literature34.The acquisition protocol of the presented study is designed to make the DTI data comparable with those present the literature. The coronal slice orientation of DTI images is chosen since whole kidneys can be imaged with reduced number of slices and, consequently, reduced scan time respect to axial or sagittal image acquisition strategies. However, the coronal acquisition is mainly prone to respiratory movement artefacts and it can be considered as an increased difficulty to deal with. Moreover, the respiratory triggering is adopted during the DTI acquisition since it was demonstrated the feasibility of kidney DTI with excellent cortico–medullary differentiation50. Moreover, as pointed out in Fig. 33. The radial orientation of tubules in the renal medulla produces more restricted movement of the water molecules respect to cortex and, as a consequence, FA and AD  maps result in higher values in the medulla than the cortex. Conversely, since MD and RD parametric maps represent the mean diffusivity and the diffusivity parallel to the principal diffusion direction respectively, it is expected to observe higher values of such diffusivity parameters in the cortex respect to medulla51. According to the results found in literature50, the overall paired t-test results from right and left kidney in terms of parametric map values show no consistent difference. However, as shown in Fig. eddy-s2v considerably differ between right and left kidney. The unwanted results might be explained by the influence of an improper processing pipeline. The influence of the different processing pipelines is also visually confirmed in Fig. topup  imagingIn conclusion, the processing procedure can dramatically affect the reliability of kidney DTI. We propose a robust processing pipeline that, including off-resonance induced geometric distortion and both volume-to-volume and slice-to-volume motion correction, ensures highly reproducible results.Supplementary info


Introduction: Cystic lesions of the spleen are infrequent and usually diagnosed incidentally. These lesions are rare and their differential diagnosis is very wide. Splenic epithelial cysts are the most common type of primary splenic cyst (4%). Surgical treatment is indicated for cysts larger than 5 cm or symptomatic. Nowadays, spleen preserving surgery is the gold standard treatment considering the immunologic role of the spleen and the increased risk of post-splenectomy infections.Case presentation: A 17 year old girl presented to the outpatient clinic with moderate left upper quadrant abdominal pain of 2 weeks duration with loss of appetite and denied fever, chills, sweating and jaundice. Abdominal examination showed tender splenomegaly. The abdominal imaging  was suggestive of hydatid cyst of the spleen, for which she received Albendazole for 1 month and then operated by laparotomy with partial resection and un-roofing of the splenic cyst. The pathology report showed a splenic epithelial cyst (SEC).Conclusion: SEC is a rare pathology that could mimic splenic hydatid cyst. The clinical and radiological pictures may be commonly misleading and non-conclusive. Definitive diagnosis is made on histopathology. Spleen conserving surgery, when possible, is the preferred modality for treatment. They arDiagnostic imaging modalities such as abdominal ultrasound, scan and MRI demonstrate easily the splenic cyst but are unable to differentiate SEC from other types of primary splenic cyst such as parasitic and neoplastic ,6. The dWe herein report an interesting case of large epithelial cyst with elevated serum total IgE level misdiagnosed as Hydatid cyst. This work has been reported in line with the SCARE criteria .2A 17 year old horse-rider girl was referred to our clinic for 2 weeks history of moderate continuous, crampy abdominal pain, starting in the epigastric region and shifted to the left upper quadrant. This pain was associated with fatigue, loss of appetite. Patient denies any nausea, vomiting, diarrhea, fever, night sweats. She reported a remoteleft shoulder pain with negative MRI. Her physical exam was positive for splenomegaly 9 cm below costal margins, and left upper quadrant tenderness, with no rebound tenderness. Her laboratory examination showed a Hg:12.8 g/dL, platelet: 124,000/mmSerologic test for Hepatitis B virus (HBV), hepatitis C virus (HCV), Cytomegalovirus (CMV), HIV, Toxoplasmosis, Entamoeba histolytica, Leishmania brazilensis, donovani, and EBV IgM were all negative. EBV IgG was elevated showing prior immunization. The immune-diffusion test for Echinococus multilocularis was negative. The Indirect hemagglutination test and the Elisa test for Echinococcus granulosus were also negative.Nevertheless, due to an elevated IgE level: 317 kU/L, the patient was considered as having splenic hydatid cyst and was treated by albendazole PO with meals in a dose of 400 mg twice daily for 28 days, and received the anti-pneumococcal vaccine.Due to the severe continuous pain, the large size, the risk of spontaneous rupture and the patient’s wishes to resume her hobby as a horse-rider as soon as possible, she was consented for operative exploration via a laparotomy incision for splenic cyst un-roofing.Exploration was done, abdominal cavity was protected by hypertonic saline (3%NaCl) filled pads, cyst was punctured, 2 liters of dark green fluid was aspirated. Hypertonic saline was injected in the cyst, and then aspirated after 15 min. Un-roofing and partial resection was done afterward.The postoperative course was un-eventful and the patient was discharged home on the post-operative day 5.The pathology report showed stratified epithelium with fibro-inflammatory reaction in the pericystic zone compatible with splenic epithelial cyst.3 normalization of eosinophils (2.5%).The patient still symptom free after 5 years of follow up and her labs showed a WBC: 7700/mm3SEC are congenital true splenic cyst characterized by an epithelial lining. They are divided in 3 subgroups depend on the type of epithelial lining, Epidermoid cysts are covered with stratified squamous epithelial lining, Mesothelial cyst with cuboidal epithelial lining and Dermoid cyst with squamous epithelium with hair follicles, sebaceous glands and skin appendages . The epiThe clinical presentation of SEC is non-specific and it can be various depend on the size, location and the presence of complications. Uncomplicated cyst less than 8 cm in diameter are usually asymptomatic . The incRegarding the pre-operative diagnosis of our case, the negative Echinococcosis detection test doesn’t rule out the hydatid disease and is present only in case of microscopic rupture . AccordiNowadays, the expansion of medical screening systems increases the incidental detection of splenic lesions especially for SEC . EpithelConcerning the indication of surgical treatment, there is a limited data to determine the appropriate time to interfere. Traditionally, it has been recommended to treat symptomatic cysts, or when they are larger than 5 cm due to an increased risk of spontaneous rupture, hemoperitoneum, chemical peritonitis or abscess formation . HoweverThere are multiple surgical treatment modalities including aspiration, marsupialization, cystectomy, cyst de-roofing, cyst de-capsulation, partial splenectomy and splenectomy ,20.Historically, open total splenectomy was the ideal surgical approach in front of SEC in order to decrease the risk of bleeding and complications from the cyst. Currently, with the awareness of immunologic role of the spleen and particularly in young age and the increased risk of post splenectomy sepsis, splenic preserving surgery with laparoscopic approach is advocated ,20. LapaIn conclusion, epithelial splenic cyst is a rare entity, usually diagnosed incidentally in asymptomatic patients. Symptoms when present are related to size and location. SEC can be misdiagnosed as hydatid cyst. Imaging can be helpful in the diagnosis but cannot differentiate it from the other types of primary cyst. The definitive diagnosis is based on pathologic examination of operative specimen. SEC is best treated by parenchymal sparing surgery.We have no conflict of interest to declare.No funding source.The submitted article is a case report, ethical approval has been exempted by our institution.A Written informed consent was obtained from the patient for surgery and potential publication of this case report and any accompanying images.Youssef Sleiman and Ali Bohlok wrote the manuscript. Melody El-Khoury assisted in large part of the literature review and revised the manuscript for correction before submission. Marc Zalcman did the imaging diagnosis, and wrote the imaging part of the manuscript. Issam El Nakadi and operated the patient, wrote the part about the detailed operative technique and revised the manuscript for correction before submission. Peter Demetter and did the pathologic examination of the operative specimen and explained the pathologic diagnosis in the manuscript. All authors have read and approved the manuscript before submission to your journal.Not applicable.Dr Issam El Nakadi.The data sets supporting the conclusions of this article are included within the article.All procedures reported here were in accordance with the ethical standards of the Institut Jules-Bordet Committee and with the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. Informed consent was obtained from all the subject of the case report included in the study.Not commissioned, externally peer reviewed.


In China, a decoction is one of the most common clinical dosage forms. Nanometre aggregates (NAs), which often consist of circular or irregular nanoparticles, have been observed in previous research on decoctions. A Bai-Hu-Tang (BHT) decoction is an ancient clinical dosage form in China. The purpose of this work was to isolate and characterize NAs from BHT and to investigate their antipyretic effect. A BHT decoction was prepared by the traditional method. The mechanism and active components of the aggregates in BHT were investigated by high-speed centrifugation, transmission electron microscopy (TEM), and HPLC (high-performance liquid chromatography). In addition to the aggregation, therapeutic activities were evaluated through temperature measurements, enzyme-linked immunosorbent assays, cellular uptake measurements and fluorescence imaging. The majority of the NAs in BHT had diameters of 100 nm, and the spherical structures contained C, O, Mg, Al, Si, Ca, Zn et al. Antipyretic bioactive compounds, such as neomangiferin, mangiferin, glycyrrhizic acid and ammonium glycyrrhizinate, existed in the aggregates. In addition, the NAs in BHT had a better antipyretic effect than the other dispersion phases of BHT. In particular, the nanometre aggregates of Bai-Hu-Tang (N-BHT) were easily taken up by cells, and the fluorescein isothiocyanate (FITC) signals of NAs were more enriched in the lungs and brain than in other organs over time. These results revealed that the antipyretic effect was associated with the NAs in BHT. The discovery of NAs might present a new perspective for understanding BHT decoctions and even lead to the development of a new nanomedicine approach in traditional Chinese medicine (TCMs). Therefore, this topic deserves further study. Some primary tests were performed to determine their biological activities3. These results provided inspiration to determine the role of nanometre aggregates in decoction. Herbal or plant material is boiled to form decoctions, in which the chemicals are soluble and form hydrogen bonds, complexes and metal salts. The reason for this solubilization is that decoctions contain a variety of natural surface-active agents, such as saponins, sterols, gums, proteins and mucus, and micelles can be formed during the preparation process so as to solubilization. The physical and chemical properties of a decoction may also be influenced and changed by secondary metabolites, biological macromolecules and inorganic elements. In what form and with what components the bioactive phytochemicals are dispersed determine their delivery, assimilation, action and metabolism.In China, a decoction is one of the most common clinical dosage forms. The phytochemicals in herbal or plant materials are dissolved by boiling them in water. It is generally believed that the efficacy of insoluble phytochemicals is improved by the decocting process. However, so far, it is unknown in what form the bioactive constituents are dispersed and with what other components their delivery is achieved. Nanoparticles or aggregates that were naturally formed have been found in herbal medicinal broth3. Zhuang Y et al. demonstrated that aggregates commonly exist in TCMs and were able to survive the GI environment1. Nanometre aggregates can provide site-specific drug delivery via either a passive or active targeting mechanism4. Nanometre aggregates have a high solubilization capacity and targeting capability for poorly soluble Chinese herbal medicinal ingredients5.Related literatures have reported that TCMs form aggregates in aqueous solutions. Aggregation was observed in Ge gen decoctions6 and acute suppurative tonsillitis7. BHT, composed of Rhizoma Anemarrhenae, Radix Glycyrrhizae, japonica rice and gypsum, is the classic prescription for high fever at the Traditional Chinese Medicine Hospital. Anemarrhenae is appointed as the principle ingredient, which is widely used for the treatment of fever and known for its anti-inflammatory and anti-diabetic effects8. The active component of Anemarrhenae is mangiferin. In addition, the main components of gypsum, japonica rice and Radix Glycyrrhizae are inorganic elements, polysaccharides, glycyrrhizins and ammonium glycyrrhizinate, respectively. A number of investigations were recently carried out internationally to identify the compounds relevant to the antipyretic effect of BHT. Wang et al. reported previously that gypsum alone can relieve fever, and its effect is rapid but brief; the effect of Anemarrhenae used alone is slow but persistent. When these two traditional Chinese medicines are combined, their pharmacological effects are better than the effects of the individual medicines9. Qiao Y et al. reported that mangiferin is one of the relatively insoluble constituents in Anemarrhenae; its effect is significant and may be related to the antipyretic mechanism of BHT10. Pharmacological studies indicate that mangiferin is related to anti-inflammatory, antipyretic, analgesic, antibacterial, immune regulation, hypoglycaemic and antioxidant effects11. As the principle ingredient of BHT, mangiferin provides pharmacological activities that are highly relevant to the therapeutic functions of the decoction. However, it was not entirely clear in what form mangiferin is distributed in BHT and how it is delivered to the target sites. Therefore, these questions are the major subject of this study. This study aims to analyse and elucidate the existing form of mangiferin in BHT and to investigate whether there are nanometre aggregates in BHT that improve the dissolution of mangiferin and increase its targeting ability.BHT is a classic traditional Chinese herbal medicinal preparation that was first described in the Eastern Han Dynasty, approximately 1700 years ago. It has a good effect on the treatment of fever caused by acute infectious diseases such as pneumonia, epidemic haemorrhagic fever (EHF), influenzaet al.  significantly increased the temperature of model group rabbits, which exhibited curling up and trembling, and their body temperature (Tb) underwent a perceptible rise at 2 h after injection accompanied by a redness of the ears, eyes, and lips and a shortness of breath and reached a maximum at 2.5 h. Most rabbits suffered from febrile reactions such as cyanotic lips, conjunctival congestion, spirit depression, anorexia and thirst. In our study, we found that the Tb of the normal group essentially remained stable at all times, and the Tb of the model group showed a biphasic thermal response similar to that observed in other studies12. The peak fever temperatures were observed at 1 h (Δ1.57 ± 0.19 °C) and 3 h (Δ1.80 ± 0.12 °C), and the difference was statistically significant (P < 0.01)  (20 μg·kg01) Fig. . PositivAfter LPS induction, the levels in the model group increased significantly compared with those in the normal group (P < 0.01) Fig. . AdminisFluorescence microscopy: The subcellular localization of free FITC in Caco-2 cells was investigated using fluorescence microscopy. The results indicated that only a small amount of FITC was observed in the nucleus of Caco-2 cells after 2 h of incubation with free FITC. The fluorescence signals of FITC-NA were observed in the Caco-2 cells, which were consistent with the results of flow cytometry Fig. .Figure 5Flow cytometry: This study found a linear relationship between the fluorescence intensity and the amount of nanoparticles endocytosed by the cells. As illustrated free FITC as a control showed only auto-fluorescence Fig. . CompareIn vivo imaging analysis: We studied the in vivo biodistribution of nanoparticles in mice, and fluorescence images were obtained at different time points post-injection. We found that FITC-nanometre aggregates were more enriched in the lung and brain than in other organs over time, with the maximum uptake at 2 h. The control group revealed that the majority of free FITC, free mangiferin and FITC with N-BHT was found in the liver and kidneys, suggesting that FITC-nanometre aggregates selectively targeted the lungs and brain. The ex vivo fluorescence images of excised tissues further confirmed a much higher accumulation of FITC-nanometre aggregates in the lung and brain compared to free FITC , which seriously restricts its development and utilization.BHT is a classic prescription, and its antipyretic effect results from synergistic interactions among all of the components in the formula. BHT not only inhibited fever in rabbits and reduced elevated TNF-α, IL-1β, IL-6, and CD8+ levels but also promoted a significant increase in the CD4+ level and CD4+/CD8+ levelsAnemarrhenae Rhizoma and Cortex Phellodendri are combined, the amount and rate of mangiferin absorption significantly decrease, but timosaponin from Anemarrhenae can obviously promote the in vivo absorption of mangiferin16. In contrast, the use of Chinese herbal medicines containing Anemarrhenae (as in BHT) increases the absorption of mangiferin, as evidenced in an everted gut sac model trial. Therefore, it is important to increase the solubility and bioavailability of these compounds in pharmaceutical processes to meet the preparation requirements and demand for clinical applications. In our paper, it is demonstrated by means of high-speed centrifugation coupled with dialysis and TEM that NAs exist in BHT. The results of the antipyretic experiment showed that N-BHT was more effective than the liquid and sediment of the BHT administered to the treatment groups. In particular, N-BHT was easily ingested by cells and targeted the brain and lungs, which often leads to fatal inflammation in the form of a high fever. Thus, it is reasonable to predict that antipyretic effects are associated with these nanoparticles.For instance, when 17. However, mangiferin and neomangiferin are not amphipathic molecules as ephedrine and pseudoephedrine are, so why they are loaded in nanometre aggregates? Why the nanometre aggregates formed and what forms of mangiferin and neomangiferin existed are very interesting questions. We have a hypothesis. Their absorption may occur through cooperation of the chemical constituents in Rhizoma Anemarrhenae, Radix Glycyrrhizae, japonica rice and gypsum. Combined with the characterization results and the results of related experiments, we surmised the formation mechanism of BHT nanoparticles. It is generally acknowledged that saponins from liquorice are promising solubilizers in Chinese herbal decoctions18. Reports have also shown that glycyrrhizin and its derivatives have a significant solubilization effect on saikosaponin and saikosaponian19. The solubility of mangiferin and neomangiferin was enhanced when Rhizoma Anemarrhenae and Radix Glycyrrhizae were boiled together. At the same time, boiling japonica rice generated many small granules with a water film containing abundant polysaccharides, which can be hydrolysed to monosaccharides and oligosaccharides. The chemical constituents would be embedded or adsorbed in the granules. Therefore, only the smaller granules, which ranged from 50 to 500 nm nanoparticles, would not be coagulated by the water film and electric double layer. Moreover, inorganic ions in gypsum, Ca2+, Mg2+, and Zn2+, act as zeta potential modifiers and play a critical role in sol stability to form an electric double layer. Neomangiferin and mangiferin were loaded in these nanoparticles. This finding may be a new description of the antipyretic mechanism of BHT and even lead to the development of an approach to finding new TCMs.Nanoparticles have been detected in Ma Xing Shi Gan Tang (MXSGT), and the formation of MXSGT nanometre aggregates may rely on the action of amphiphilic molecules (ephedrine and pseudoephedrine), which could interact with other molecules via hydrophobic or ionic interactions to form nanometre aggregates20.Naturally occurring nanometre aggregates were successfully separated from a decoction of a classic Chinese herbal medicine (BHT) with dialysis and high-speed centrifugation. Neomangiferin and mangiferin have been demonstrated to be associated with the nanometre aggregates, which may have a profound influence on the assimilation, delivery and bioactivities of BHT. Our approaches and discoveries may inspire studies on the interaction of active phytochemicals in herbal decoctions and the corresponding pharmacological implications. However, if the nanometre aggregates in BHT will be used as a new preparation, many studies on the methods of separation, purification, security and stability need to be carried outA 20 cm dialysis bag  with a 3500 molecular weight cut-off and 36 mm diameter was boiled for 10 min in ethylenediaminetetraacetic acid (EDTA) with bicarbonate, accurately adjusting the pH to 8. The dialysis bag was rinsed with distilled water to remove impurities. The above operations were repeated 2 times.−1 for 30 min. Eventually, the liquid in the unit was removed by centrifugation at 10000 rpm·min−1 for 30 min (Xiang Yi H-2050R centrifuge). The dialysis and centrifugation operations were repeated four times. Through the above operations, the sediment of the Bai-Hu-Tang decoction , dialysate of the Bai-Hu-Tang decoction , and nanometre aggregates of the Bai-Hu-Tang decoction  were acquired  was centrifuged at 4000 rpm for 30 min; then, the supernatant was filtered through filter paper and a 0.45 μm membrane, sequentially. The filtrate was sealed in a 20 cm dialysis bag to constitute a unit. The unit was immersed in 200 mL of water in a beaker, which was placed on a constant-temperature vibrating water bath  and then dialyzed and separated at 120 rpm·minred Fig. .Figure 8A drop of part IV was placed on a copper grid coated with carbon film and air-dried. Transmission electron microscopy  was performed to observe the morphology and analyse constituent elements. The particle size distribution was determined by a Malvern laser particle size analyser 2000. The stability of Part IV was also observed at 8, 16, and 24 h in the study.−1, and the temperature of the column oven was set at 30 °C.The analysis of multiple components occurred on a C18 column in an HPLC system . The mobile phase consisted of 25 mM dibasic potassium phosphate (solvent A) and acetonitrile (solvent B) with the following gradient elution program: 10 → 28  at 0–18 min, 28 → 33  at 18–20 min, and 33 → 39  at 20–26 min. The appropriate concentration of the sample solution was selected, and the injection volume was 10 μL. The absorbance of the eluate was monitored at 257 nm. The flow rate was 1 mL·min−1), mangiferin (0.3 mg·mL−1), glycyrrhizic acid (0.1 mg·mL−1) and ammonium glycyrrhizinate (0.1 mg·mL−1) were prepared in methanol according to their solubility. The calibration curves were prepared with seven concentration levels, and the dilution factors were injected in different volumes of 0.2 μL, 0.5 μL, 1 μL, 2 μL, 4 μL, 8 μL, 10 μL, 12 μL, 14 μL, 16 μL and 20 μL.Primary stock solutions of neomangiferin  and UV spectra with those of standard compounds . Phases I~IV were condensed to 25 mL. Corresponding amounts (2 mL) of I~IV were suspended in methanol (8 mL) and placed in an ultrasonic bath  for 10 min. Subsequently, the different phases were centrifuged at 2000 rpm·minRabbits were purchased from the laboratory animal centre of Heilongjiang University of Traditional Chinese Medicine, Certificate No. SCXK(Hei)2008-004 . The temperature, humidity, and light conditions in the rabbits’ environment were kept constant, with food and water provided ad libitum. All rabbits were acclimated in the laboratory for at least one week prior to the experiment. Before testing, the animals were fasted overnight with free access to drinking water. All animal experiments were carried out in accordance with the Guidelines for the Care and Use of Laboratory Animals and were approved by the Animal Ethics Committee of Heilongjiang University of Chinese Medicine (No. 2016101601).The rabbits were fixed in a prone position, and the basal Tb was monitored via an MC-347 soft electronic clinical thermometer inserted approximately 4 cm into the rectum. This procedure was performed at least twice in three days prior to the experiments to avoid rectal temperature changes after handling. The Tb of each rabbit was recorded as an average of the Tb over a period of 30 min prior to administration and fever induction. Animals with a Tb below 38 °C or above 40 °C were not used in any experiments. All the animals were used only once in this experiment.−1) elicited a biphasic thermal change in body temperature beginning 0.5 h after injection. The first thermal phase of the LPS response could characterize Yang-ming-re-zheng , while the second thermal phase always resulted in weakness and spirit depression21. Forty-two rabbits were randomly divided into seven groups, each with an identical number of rabbits (n = 6). One of the groups served as the ‘normal’ group, whereas the other 6 groups were subjected to the fever induction model. A febrile response was induced and monitored over time. Briefly, the Tb was immediately measured after rabbits received an injection of LPS in sodium chloride solution (20 μg·mL−1) in a marginal ear vein. Then, every 0.5 h, the temperature was measured once, and these measurements continued for 5 h. One measurement once was taken at every time point, and the values displayed were recorded.Intravenous administration of LPS , model group , promethazine hydrochloride group , BHT group (BHT), sediment of BHT group (S-BHT), nanometre aggregates of BHT group (N-BHT), and dialysate of BHT group (D-BHT). The PH group was treated by gavage injection, and the treatment solution or normal saline was instilled into the colons of rabbits in the other experimental groups or control group, respectively, 0.5 h before LPS injection. The level of febrile response was expressed as the change in temperature from the basal temperature (°C), where the difference is expressed as ΔT (ΔT = measurement temperature-Tb).−1 for 10 min to obtain serum. The serum samples were kept at −20 °C for use in biochemical assays to determine IL-6, IL-1β, and TNF-α levels by commercially available ELISA kits according to the manufacturer’s protocol.Five hours after the LPS injection, 2.0 mL blood samples were obtained from the ear artery with a disposable blood collector. The rabbits were killed immediately. The blood samples were transferred into aseptic tubes and centrifuged at 3000 rpm·min2CO3 aq.) overnight. FITC (1.0 mg) dissolved in water (0.5 mL) was added to the NAs of BHT, followed by magnetic stirring in darkness at 4 °C for 8 h to form nanometre aggregates associated with FITC. Caco-2 cells  were seeded at a density of 5.0 × 105 cells on 24-well plates and maintained until the cells were adhered. Then, 0.1 mL of FITC-NAs were added to 0.5 mL of HBSS. FITC alone was the control group. Caco-2 cells were treated with the above samples and incubated at 37 °C and 5% CO2 for 24 h. The cell monolayers were rinsed three times with pre-warmed PBS (pH 7.4) and observed using an Olympus DP-71 digital camera .Fluorescence microscopy. The NAs of BHT were dialyzed at pH 9.0 . The samples were centrifuged for 5 min at 1000 rpm. The cells were redissolved in 2 mL of PBS and analysed by flow cytometry.Flow cytometry. To evaluate the cellular uptake rate, recording images is not sufficient. In this study, we also determined the uptake rate by flow cytometry . Briefly, Caco-2 cells were seeded at a density of 5.0 × 10−1. Normal saline (0.9%) was administered as a blank control. The other groups were given free FITC, free mangiferin and FITC with BHT as negative controls. FITC fluorescence was measured at excitation/emission wavelengths of 490/520 nm. Finally, the mice were sacrificed, and the heart, liver, spleen, lung, kidneys and brain of each mouse were removed to measure the individual fluorescence intensities.Mice were purchased from the laboratory animal centre of Heilongjiang University of Traditional Chinese Medicine, Certificate No. SCXK(Hei)2013-0004 . To evaluate the affinity towards different organs and the targeting ability of the nanometre aggregates, FITC-NAs were intravenously administered into the first group at a dose of 0.1 mg·kgEach experiment was performed separately at least three times. The data were expressed as the mean ± standard deviation, and a statistical comparison between different groups was performed by a t-test. p < 0.05 indicates significance. Statistical analysis was conducted using SPSS 19.0.


Background and Objectives. The purpose of the study was to investigate the relationship between children’s birth weight/length and a risk of overweight and obesity. Materials and Methods. The study involved 747 children from kindergartens, as well as primary and middle schools from southeastern Poland. All the subjects were examined on fasting status. Each child was examined for body mass and height, in order to calculate their body mass index (BMI), and BMI centile. The parents completed a questionnaire related to basic information about the child and the family. Results. In the study group, the male infants presented greater birth body weight and birth body length. A comparison of the distribution of birth weights and lengths between the children with normal BMI and with high BMI showed statistically significant differences only in the case of birth length of 12–15-year-old children and in the group of boys aged 12–15 years. In the case of the female children and the group of 7–11-year-olds a statistically significant difference was found in the BMI centile at a later age—a higher centile was found in the girls and in the children aged 7–11 years classified as adequate for gestational age (AGA). Conclusions. Birth body weight is positively related to BMI centile; however, no significant differences were found in birth weight between children with overweight/obesity and children with normal body weight. Birth length is associated with a lower BMI centile only in boys aged 12–15 years, and lower birth length is found in boys with overweight and obesity. The normal course of pregnancy may be related to childhood overweight or obesity. Important factors determining the probability that a child will be affected by overweight or obesity include, e.g., his/her birth weight and length. A positive linear relationship between birth weight and obesity was observed by many researchers. The related findings show, e.g., that each increase in birth weight by 100 g is associated with a greater likelihood of obesity .There are sex-related differences in the relationship between birth body weight and risk of overweight and obesity in children. Excessive birth weight is linked with a greater risk of overweight or obesity both in girls and in boys. On the other hand, low birth weight is associated with a lower risk of overweight and obesity only in girls. These differences should be taken into account in the process of designing interventions aimed at reducing overweight and obesity in children . FurtherIn the mechanism of catch-up growth, children with low birth weight postnatally show compensatory growth in accordance with their genetic determinants and then rapidly increase body weight.A postnatal growth spike and risk of obesity may occur when offspring that experienced a protein deficiency are exposed to an energy-rich diet. Several auto-, para-, and endocrine hormonal factors stimulating adipose tissue growth can induce adipose tissue expansion. Among them, insulin-like growth factor 2 (IGF2), which is produced by one of the best known epigenetically imprinted genes, is associated with higher body weight and obesity. One possible mechanism for increasing IGF2 expression in adipose tissue is increased methylation of differentially methylated regions (DMR) in the H19 control region (ICR/H19) .IGF2 gene expression and CpG IGF2/H19 methylation in the tissue itself. These studies confirmed that histone methylation may result in different transcription consequences depending on the effect of the residues [Recent studies showed that prenatal low-protein intake and postnatal high-fat intake lead to an increase in adipose tissue through changes in residues . A studyresidues .Based on birth weight and/or birth length, as well as timing of delivery relative to the expected due date, it can be determined whether or not the birth weight and/or birth length are adequate for gestational age (AGA). It was established, based on available evidence, that birth weight and length appropriate for gestational age is in the range between the 10th and 90th centiles, relative to the gestational age. The related values below the 10th centile and above the 90th centile correspond to children rated as small for gestational age (SGA) and large for gestational age (LGA), respectively .Both large and small birth weight may predispose in the future, inter alia, to metabolic and cardiovascular diseases. Some authors argued that the threshold values for SGA are reflected by the fifth, third, or even second centiles ,10.It is sometimes assumed that SGA is a synonym for intrauterine growth restriction (IUGR), a condition reflected by low body weight and/or length of the fetus and/or neonate, relative to the expected values. Therefore, IUGR is always a pathology, while the population of children classified as SGA at birth also includes healthy, constitutionally small children . IUGR maIntrauterine growth restriction is associated with complications which may develop at every stage of life. For instance, a susceptibility to impaired glucose tolerance and type 2 diabetes occur in childhood, while adolescence is linked with a predisposition to early puberty, and adulthood is additionally associated with a greater risk of a metabolic syndrome .The purpose of the study was to investigate the relationship between children’s birth weight/length and a risk of overweight and obesity.The kindergartens and schools were randomly selected for the study. Invitations were sent to 1000 families with children in educational institutions in southeastern Poland. Replies were received from 858 families. The eligibility criteria included consent of the parent or legal guardian for their child’s participation in the study, the child’s consent to participate, and the child’s age in the range 3–18 years. The study group did not include children failing to meet the above eligibility criteria, or children with disabilities or lower limb injuries adversely affecting the children’s vertical position. Overall, 57 parents did not agree to participate in the study, 12 children did not agree to the study, 10 children were not fasting on the day of the study, 15 children were absent on the day of the study, and 17 mothers did not provide data on the course of pregnancy. Finally, the study involved 747 mothers and children. After obtaining consent, it turned out that the age range of respondents was within the range of 4–15 years. The subjects’ mean age was 9.36 years ± 3.52 years. The girls and the boys did not differ significantly in terms of age.Parents were informed about the objectives and course of the examinations, and about the criteria excluding children from the study. All the subjects were examined on fasting status, and consecutive measurements were performed in the morning. Each child was examined for body mass and height, in order to calculate their body mass index (BMI) and BMI centile.The parents completed a questionnaire related to basic information about the child and the family, and provided copies of the child’s health record and personal maternity record.p < 0.05. It was calculated that the minimum sample size should be 246 girls and 296 boys.According to demographic data, in the area where the research was carried out in 2017, 2,129,138 residents lived there and 51% of them were women and 49% were men. Furthermore, 14.4% of the female population were girls and 15.8% of the male population were boys of pre-school and school ages. Due to the fact that the occurrence of excessive body weight in children shows a large discrepancy with regard to sex, the sample size was calculated separately for girls and boys. The size of the required sample was calculated, taking into account a 95% confidence level and the estimated average occurrence of the phenomenon of excessive body weight at the level of 20% in girls and 26% in boys. The level of significance was considered as Body height was measured with a Seca 213 stadiometer . The subject was standing barefoot with his/her back to the measuring rod of the stadiometer. Body height was measured three times, and the mean value was calculated to eliminate measurement error. The appliance conforms with Annex VI to Directive 93/42/EEC concerning medical devices.Body mass was assessed using Tanita BC 420 MA, an analyzer complying with applicable requirements, in accordance with European standards and directives, i.e., NAWI (Non-Automatic Weighing Instruments) and MDD . Devices carrying the MA symbol are designed for medical applications, as they are validated and approved for such use. The analyzer was certified for compliance with 93/42 EEC (the European Union (EU) standard for medical devices).Information related to perinatal risk factors for overweight and obesity was retrieved from the child’s health record and personal maternity record. The relevant data included the child’s birth body weight and birth body length, as well as duration of pregnancy.After the above data were collected, the children’s current BMI centiles were calculated by reference to the Polish centile grids , and theBased on their body weight at birth, the children were classified as hypertrophic neonates (body weight over 4000 g—macrosomia), eutrophic neonates , neonates with low birth weight , neonates with very low birth weight , neonates with extremely low birth weight , and neonates with incredibly low birth weight , by reference to the Centers for Disease Control (CDC) classification .The children were also classified based on their body weight at birth relative to the duration of gestation: adequate for gestational age , small for gestational age , and large for gestational age  .n), percentage (%), x (mean), Me (median), and standard deviation (s).Data analysis was carried out using selected methods of descriptive statistics and statistical inference. Selected numerical characteristics of the tested parameters were determined: number  or Kruskal–Wallis tests (for comparing more than three groups) were used. The statistical significance level was For the correlation of variables that did not meet the criterion of the normality of distribution, the Spearman rank correlation coefficient was calculated.The analysis also used logistic regression using the input method to verify the effect of interfering factors on test results.Calculations were performed with Statistica 10.0 .The approval of the Bioethics Committee of the University of Rzeszów No. 18/12/2015 from 2 December 2015 was obtained for conducting the research.p < 0.001 ***) and birth body length .Analyses were conducted to examine the relationship of birth weight and birth length to abnormalities in BMI occurring at a later age. At birth, the children’s mean length was 55 ± 3.3 cm and mean weight was 3359 ± 565 g. In the study group, the male infants presented greater birth body weight  and in the group of boys aged 12–15 years (p = 0.003 **)  .Additionally, an alternative analysis was conducted to examine a BMI centile-based classification of the children in relation to their birth weight and length. This analysis also took into account the children’s age and sex, since the impact of perinatal factors may be greater in the case of younger children.p = 0.046 *), in the entire group of girls (p = 0.028 *), in the group of girls aged 7–11 years (p = 0.008 *), and in the two younger age groups (p = 0.027 * for the children aged 4–6 and p = 0.029 * for the children aged 7–11 years). Greater birth weights correspond to higher BMI centiles. Additionally, one negative correlation was found—in the group of boys aged 12–15 years. Greater birth length coincided with the subject’s lower BMI centile (p = 0.039 *)  .p = 0.035 *) and in the children aged 7–11 years (p = 0.009 **) classified as AGA . In the case of the female children and the group of 7–11-year-olds, a statistically significant difference was found in the BMI centile at a later age—a higher centile was found in the girls (d as AGA .p < 0.001 ***). The chi-square test of independence showed a sex-related difference, namely, more frequent occurrence of hypertrophic and less frequent occurrence of eutrophic type among male neonates. In further analyses, the LBW group included the children with birth weight classified as VLBW and ILBW.Subsequent classification was related to the children’s birth weights, which in a majority of the cases were in the range of 2500–4000 g (84.5%). Statistically significant differences were found between the girls and the boys . The LBW group comprised relatively more children with low body mass, and fewer children with normal BMI relative to age and sex   .Numerous studies provide evidence supporting the hypothesis that the size of the child at birth is related to a risk of diseases later in life. Such associations are well established, in particular for low birthweight and a greater risk of such conditions as coronary heart disease, diabetes, hypertension, and stroke in adulthood. These relationships are modified by growth patterns following birth . NumerouThe results suggest that people with low birth weight face decreased long-term risk of being overweight, while high birth weight predisposes for being overweight at an older age. Therefore, preventing excessive food intake, i.e., avoiding maternal overnutrition, overweight, and/or diabetes during pregnancy, may be a promising strategy for overweight prevention ,20. The The longitudinal study of Lindberg et al. presented no significant differences between children with normal or low birth weight with respect to the prevalence of overweight/obesity; however, at the age of 3.5 years, the mean body height, body weight, and BMI in the children with marginally low birth weight were lower compared to the children in the control group .An opposite trend was shown by Jornayvaz et al. , where mThe research review carried out by Ribeiro et al. suggests that both cardiometabolic events and obesity are linked to intrauterine nutritional deficiency, which, in combination with food supply exceeding the organism’s metabolic needs during early life stages, leads to endocrine changes .According to a comprehensive literature review carried out by Araújo de França et al. , birth bChildren who are born small for gestational age (SGA) are more likely to develop obesity, insulin resistance, and type 2 diabetes . FurtherIt is estimated that, worldwide, 8–26% of neonates are born with low weight (LBW). These infants face a risk of medical problems during childhood and in adulthood. Scientific evidence suggests that the postnatal period is of critical importance, because lifelong predispositions to metabolic disorders and obesity may result from nutritional style experienced at this time. In view of the fact that optimum nutrition in the case of LBW, pre-term, and SGA infants continues to be a matter of dispute, it can be assumed that many infants are not managed in an optimal manner. This may lead to a rapid increase in body weight and continuous health problems ,28.It was also shown that the children born small for gestational age (SGA) presented lower BMI centile corresponding to their current body weight. This association was found in the girls and children aged 7–11 years.p = 0.069).A difference approaching statistical significance was also shown in the case of current body weight classification (based on BMI centile) versus birth weight classification. The highest percentage of the children with overweight and obesity had a birth weight below 2500 g : 49–52) and 50 cm (IQR: 49–52), respectively .The present study shows an opposite relationship. The children with normal body weight at 12–15 years of age had greater birth length compared to the children with overweight and obesity. This relationship was confirmed by a negative correlation between birth length and current body weight centile among the oldest boys.Birth body weight is positively related to BMI centile; however, no significant differences were found in birth weight between children with overweight/obesity and children with normal body weight. Being born small for gestational age is not linked with a greater risk and prevalence of overweight and obesity.Birth length is associated with a lower BMI centile only in boys aged 12–15 years, and lower birth length is found in boys with overweight and obesity.Strengths and Limitations of the StudyIn future studies, it would be necessary to enlarge the number of examined children, especially for children aged 16–18, after puberty.A limitation of this study is also the analysis of only two factors potentially affecting the occurrence of overweight and obesity in children, as well as the fact that the perinatal data came from medical records and not from a direct examination carried out by the authors.In subsequent analyses, it would also be worth taking into account the influence of environmental or genetic factors, which would undoubtedly increase the scientific level of the paper. The study’s strength is that the sample is representative of the study population. In addition, comparable results were obtained with other researchers, which can be considered a general trend for children in the analyzed age group.