Computational studiesshow that CB7 is the most suitably sized homologue dueto its strong affinity for guest molecules and its high water solubility.Complex formation has been studied by direct titrations monitoredusing UV–vis spectroscopy, finding a preferential interactionwith protonated aminophenoxazinone species with high binding affinities × 106 M–1; CB7·DiS-NH3+, Ka = (3.91 ± 0.53)× 104 M–1; and DiS-(NH3+)2, Ka= (1.27 ±0.42) × 105 M–1). NMR characterizationand stability analysis were also performed and revealed an interestingpKa modulation and stabilization by cucurbiturils(2-amino-3H-phenoxazin-3-one (APO),pKa = 2.94 ± 0.30, and CB7·APO, pKa = 4.12 ± 0.15; 2,2′-disulfanediyldianiline(DiS-NH2), pKa = 2.14 ± 0.09, and CB7·DiS-NH2, pKa = 3.26± 0.09), thus favoring applications in different kinds of cropsoils. Kinetic studies have demonstrated the stability of the CB7·APO complex at different pH media for more than 90min. An in vitro bioassay with etiolated wheat coleoptiles showedthat the bioactivity of APO and DiS-NH2 is enhanced upon complexation.Aqueous solubility and stability often limit the applicationofaminophenoxazinones and their sulfur mimics as promising agrochemicalsin a sustainable agriculture inspired by allelopathy. This paper presentsa solution to the problem using host–guest complexation withcucurbiturils ( Naturalproducts have recently arisen as potential replacements, given theirshort half-lives and new modes of action, which allow a rebrandingapproach to weed control.3 organic nanoparticles,4 and nanotubes5 have been selected ashost candidates and have afforded outstanding results in aqueous mediawhen applied to phytotoxic or antibacterial compounds.A common problem associated with the large-scaleapplication ofnatural products is their poor water solubility and soil stability,which limit effective chemical transport and result in insufficientlifetimes to affect inhibition in the target weed. One promising strategyto solve this problem is the encapsulation of those agrochemicalsin the water-soluble host via host–guest interactions. Cyclodextrins,n]uril (nCB), a well-studiedsynthetic macrocyclic host family in supramolecularchemistry, has shown relevant applications in medicinal chemistryand drug delivery, for example, CB7 has been used tocomplex with oxaliplatin, ferrocene derivatives, and curcumin to treatdifferent kinds of tumors.6 In addition, CB7 is the prototypical nCB homologueemployed in the biological field due to its high water solubilityin comparison to the other homologues of interest (n = 6 and 8). Indeed, the concentration of CB7 in neatwater can reach as high as 5 mM, while CB6 and CB8 only dissolve on a micromolar scale.Cucurbit2+: 688.2111 amo  and [CB7·DiS-(NH3+)2]2+: 706.2027 amo . Both freeanalytes were also tested for stability at pH 2.12 and pH 1.5, respectively,and showed great stabilities in acid. In contrast, the stability ofthe analytes in basic media is in general much worse, even with theaddition of CB7 or CB6. It was found thataround 35% of APO was degraded after a kinetic periodof 90 min (see the Supporting Information). The addition of 1 equiv. of CB7 only slowed downthis process to around 30%, an insignificant difference. Meanwhile,the addition of CB6 made the degradation happen evenfaster. The same phenomenon is also observed in the case of DiS-NH2 for which CB7 reduced the degradation slightly, while CB6 acceleratedit, likely due to a supramolecular catalytic effect .Thestability of the CB7 complexes were evaluatedin vitro to test theirefficacy as potential bioherbicides with enhanced physicochemicalproperties. APO and DiS-NH2 havebeen previously studied as lead compounds for agrochemical synthesiswith some success.16 In detail, we carried out experiments with etiolated wheat coleoptile,using high concentrations of undifferentiated plant cells, at differentpH values. These evaluations showed that the complexes exhibited differentbioactivities depending on the acidity, thus supporting our previousstudies . IC50 values to compare the bioactivity profiles,and it can be clearly observed that CB7 encapsulationenhances the biological activity. Thus, in the case of APO, the IC50 is reduced more than fivetimes when the bioactive compound is complexed by cucurbituril inacidic media. This is also clear from APO is encapsulated at pH 4.6, in contrast with <10% inhibition displayedby free APO. In the case of IC50, at pH 6.6, APO·CB7 exhibits a value of 343 mM at the higher concentration,whereas the free compound is essentially inactive. Acidification ofthe medium results in an increase in bioactivity. Thus, in the caseof the free compound, the water solubility is enhanced after protonation,and this explains the increase in activity at 1000 μM. In thecase of APO·CB7, complexation allows the inhibitionof elongation at lower concentrations. For example, the increase inbioactivity at 300 μM is directly dependent on pH and thereforedirectly dependent on the complexation degree due to the large numberof protonated species available in the solution.studies S10. Figustudies S10. IC50Figure S11a shows how CB7 encapsulationof APO at pH 4.6 causes an orange staining, which isnot seen in the free compound bioassay. This could be explained bythe higher solubility and transport of the compound after complexationwith CB7. The bioassay performed at pH 5.6  does not show any staining dueto the small quantities of the charged APO species presentin the solution test (according to the pKa curve in CB7, thereby enhancing their physicochemical properties.In addition to the inhibition of elongation, theappearance ofthe coleoptiles was also modified by application of the bioherbicides. DiS-NH2 are also significant,although lower than those for APO, due to the intrinsicwater solubility. This compoundis already known to be an interesting agrochemical lead, and CB7 can improve its activity further, as shown in Figure S10, CB7 presents a significant activity at 1000μM, but the bioactivity results at lower concentration can onlybe explained by a complexation process.The inhibitionvalues for APO·CB7 and DiS-NH2·CB7 to thepositive control Logran. The main component of this controlis triasulfuron, a halogenated and highly environmentally persistentherbicide. In contrast, aminophenoxazinones are natural compoundsproduced by plants as a part of their own defensive system; therefore,their assimilation and degradation by other plants and microorganismsafter application are in any case more environmentally friendly.The results obtainedat pH 4.6 and 5.6 are similar for Ka modifications of aminophenoxazinonesand their disulfide mimics by CB7 for the first time.UV–vis absorption spectral titrations showed moderate-to-highbinding affinities, with values >106 M–1 and modification of their pKa valuesby more than one unit for every compound. NMR spectroscopy confirmedthe change in the chemical microenvironment due to CB7 complexation by way of a change in the chemical shifts. The stabilityof the compounds after complexation was analyzed at different pH values,and it was found that the addition of CB7 to APO and DiS-NH2 in a 1:1 ratioprevents degradation, whereas the smaller homologue CB6 promotes it. This suggests the formation of complexes with the protonatedspecies. In vitro studies with wheat ethiolated coleoptiles demonstratethat CB7 is able to enhance the bioactivity of the guestmolecules by modifying its physicochemical properties. In addition,as a result of pKa modification, APO and DiS-NH2 couldbe applied to protect a larger range of crops as they can now be usedin a new soil acidity range. These findings provide a new strategyto apply aminophenoxazinones and their mimics to plant systems usingthe supramolecular organic-solvent-free method, thus resulting ina new family of green agrochemicals.In conclusion, we have reported the supramolecular host–guestinteraction and p


P = 0.018). More specifically, the slope was significantly altered in male adults , while there was no significant difference in the slope of female adults . Furthermore, offset was significantly lower compared with full-term controls in both male  and female adults , indicating a systematic shift of the regression line after preterm birth. Gestational age had a significant effect on the slope in very preterm and/or very low birth weight adults and more specifically in male very preterm and/or very low birth weight adults, indicating that the difference in slope is specifically related to preterm birth. The shape or tension term of the scaling law had no significant effect on cognitive performance, while the size of the cortex did. Results demonstrate altered scaling of cortical surface and cortical thickness in very premature-born adults. Data suggest altered mechanical forces acting on the cortex after preterm birth.A universal allometric scaling law has been proposed to describe cortical folding of the mammalian brain as a function of the product of cortical surface area and the square root of cortical thickness across different mammalian species, including humans. Since these cortical properties are vulnerable to developmental disturbances caused by preterm birth in humans and since these alterations are related to cognitive impairments, we tested (i) whether cortical folding in preterm-born adults follows this cortical scaling law and (ii) the functional relevance of potential scaling aberrances. We analysed the cortical scaling relationship in a large and prospectively collected cohort of 91 very premature-born adults  and 105 full-term controls at 26 years of age based on the total surface area, exposed surface area and average cortical thickness measured with structural magnetic resonance imaging and surface-based morphometry. We found that the slope of the log-transformed cortical scaling relationship was significantly altered in adults (very preterm and/or very low birth weight: 1.24, full-term: 1.14,  et al. observed aberrant allometric scaling of cortical surface and cortical thickness in preterm-born adults. Results suggest altered cortical folding in human prematurity.Using structural magnetic resonance imaging, Schmitz-Koep   Furthermore, at 8 years of age, males were particularly vulnerable to the adverse effects of preterm birth on white matter development.24 Since these measures influence cortical folding after preterm birth and because Kapellou et al.25 found a disrupted scaling relation between cortical surface area and cerebral volume in extremely preterm infants, which was particularly associated with the male sex, we also explored the interaction effect of sex and prematurity on the scaling law.Moreover, distinctive structural brain alterations after preterm birth indicate differential vulnerability of male and female individuals: for example, Benavides 19 we also tested whether potential changes in the scaling relationship among these properties are also important for cognitive functioning in preterm-born adults.In the present study, we investigated whether the allometric scaling law of cortical folding holds in the case of preterm birth using structural MRI measures of 91 very premature-born adults [i.e. < 32 weeks of gestation and/or birth weight (BW) <1500 g] and 105 FT controls at 26 years of age. Furthermore, as alterations of individual properties of cortical folding, such as T and surface area, have been shown to be relevant for cognitive deficits after preterm birth,26–28 all participants were part of the Bavarian Longitudinal Study (BLS), a geographically defined, whole-population sample of neonatal at-risk children and healthy FT controls who were followed from birth into adulthood.30 Between January 1985 and March 1986, 682 infants were born very preterm  and/or with very low birth weight . From the initial 916 FT-born infants born in the same time period at the same obstetric hospitals who were alive at 6 years, 350 were randomly selected as control participants within the stratification variables of sex and family socioeconomic status in order to be comparable with the VP/VLBW sample. Informed consent from a parent and/or legal guardian was obtained. Of these infants, 411 VP/VLBW individuals and 308 controls were eligible for the 26-year follow-up assessment. 260 individuals from the VP/VLBW group and 229 controls participated in psychological assessments.31 All participants underwent screening for MRI-related exclusion criteria, which included (self-reported): claustrophobia, inability to lie still for > 30 min, unstable medical conditions (e.g. severe asthma), epilepsy, tinnitus, pregnancy, non-removable MRI-incompatible metal implants and a history of severe central nervous system trauma or disease that would impair further analysis of the data. The most frequent reason not to perform the MRI examination, however, was that participants declined to participate. Finally, 101 VP/VLBW individuals and 111 FT controls underwent MRI at 26 years of age (see n = 145) and the Department of Radiology, University Hospital of Bonn (n = 67). The study was carried out in accordance with the Declaration of Helsinki and was approved by the local ethics committees of the Klinikum rechts der Isar, Technische Universität München and the University Hospital Bonn. All study participants gave written informed consent and received travel expenses as well as a small payment for participation.Our study sample was previously described in: age see . MRI dat32 GA in weeks was determined from maternal reports on the first day of the last menstrual period and serial ultrasounds during pregnancy. When the difference between the methods was >2 weeks, clinical assessment at birth using the Dubowitz scoring system was applied.33 BW in grams was obtained from obstetric records. The duration of mechanical ventilation in days was computed from daily records by research nurses.As previously described,31 global cognitive performance was assessed at the age of 26, prior to and independent of the MRI examination. Study participants were assessed using a short version of the ‘Wechsler Intelligenztest für Erwachsene’, the German adaptation of the Wechsler Adult Intelligence Scale, Third edition,34 which was carried out by trained psychologists who were blinded to group membership. This version included six subtests , which were used to derive full-scale intelligence quotient (IQ) estimates.31 Participants with missing data were excluded from the analysis of the functional relevance of scaling behaviour. Results were available for 88 VP/VLBW individuals and 103 FT individuals.As previously described,22 at both sites, Bonn and Munich, MRI data acquisition was performed on Philips Achieva 3T TX systems or Philips Ingenia 3T systems using an eight-channel SENSE head coil. Subject distribution among scanners: Bonn Achieva 3T: 5 VP/VLBW, 12 FT, Bonn Ingenia 3T: 33 VP/VLBW, 17 FT, Munich Achieva 3T: 60 VP/VLBW, 65 FT, Munich Ingenia 3T: 3 VP/VLBW, 17 FT. Across all scanners, sequence parameters were kept identical. Scanners were checked regularly to provide optimal scanning conditions and MRI physicists at the University Hospital Bonn and Klinikum Rechts der Isar regularly scanned imaging phantoms, to ensure within-scanner signal stability over time. The signal-to-noise ratio was not significantly different between scanners . A high-resolution T1-weighted 3D-magnetization prepared rapid acquisition gradient echo sequence  was acquired. All images were visually inspected for artefacts.MRI data acquisition has been described previously:35 MRI data were processed using Freesurfer v6.0 (http://surfer.nmr.mgh.harvard.edu/). Total surface area At , exposed surface area Ae  and average T  were extracted for each participant as described previously and global gyrification index was calculated as At/Ae.8 The Freesurfer ‘recon-all’ pipeline failed in three cases. Output quality was assessed using Freesurfer’s QA tools (https://surfer.nmr.mgh.harvard.edu/fswiki/QATools), and 13 subjects were excluded. Finally, 91 VP/VLBW subjects and 105 FT subjects were included in the analyses . To control for possible scanner effects, we applied ComBat, a technique that removes unwanted sources of scanner variability.36 ComBat-harmonized values of At, Ae and T were used for all further analyses.All statistical analyses were performed using IBM SPSS version 26 . Statistical significance was defined as 10(Ae) and y = log10(AtT1/2) with α as a slope. First, to compare the slopes of VP/VLBW individuals and FT controls, we used multiple linear regression with sex and group (VP/VLBW versus FT) as categorical variables. 95% confidence intervals (CIs) were calculated. As a control analysis, we regressed out sex from x and y separately and repeated the multiple linear regression analysis with the residuals of x and y and with the group as a categorical variable.To investigate the universal scaling law, we transformed to logarithmic coordinates, i.e. , x = loget al.8 we assumed a linear relationship with the slope of 1.25 as predicted by the theory with log(k) as the offset (K = logAt − 1.25logAe + 0.25logT2). We used multiple linear regression with sex and group as categorical variables.Second, we compared the mean offset. Following Wang P = 0.048), we repeated comparisons of slope and offset between VP/VLBW individuals and FT controls for male and female participants separately. We used multiple linear regression with the group as a categorical variable.Because there was a significant interaction effect of sex:group on the slope  from the Human Connectome Project  using multiple linear regression with GA, BW and duration of ventilation as continuous variables and sex as a covariate of no interest. Results were corrected for multiple comparisons using the Benjamini–Hochberg procedure.At − 1.25logAe + 0.25logT2), the isometric term (I = logAt + logAe + logT2) and shape term (S = At + Ae − T2) proposed by Wang et al.38 We used multiple linear regression with sex and group as categorical variables to compare offset, isometric term and shape term between VP/VLBW individuals and FT controls.To assess the functional relevance of scaling behaviour, we used the independent morphological measures offset, or tension term  or age at scanning (P = 0.274). By design of the study, VP/VLBW subjects had significantly lower GA (P < 0.001) and lower BW (P < 0.001). Furthermore, VP/VLBW individuals had significantly lower full-scale IQ (P < 0.001), verbal IQ (P = 0.001), performance IQ (P < 0.001), total surface area (P = 0.001), exposed surface area (P = 0.023) and the global gyrification index (P < 0.001). Global T was not significantly lower in the VP/VLBW group compared with the FT group (P = 0.165). Results were very similar after correcting for scanner effects using ComBat harmonization. VP/VLBW individuals had a significantly lower total surface area (P = 0.001), exposed surface area (P = 0.021) and global gyrification index (P < 0.001), while global T was not significantly lower in the VP/VLBW group compared with the FT group (P = 0.152). P = 0.805, female P = 167). Compared with male and female FT subjects, male and female VP/VLBW subjects had significantly lower GA , lower BW , lower full-scale IQ , verbal IQ , performance IQ , total surface area  and global gyrification index , respectively. The exposed surface area was significantly lower in male VP/VLBW subjects compared with male FT subjects (P = 0.024). There was no significant difference in exposed surface area in female subjects (P = 0.168). Global T was not significantly different in both male and female VP/VLBW subjects compared with male and female FT subjects, respectively . Results were very similar after correcting for scanner effects using ComBat harmonization. Male and female VP/VLBW subjects had a significantly lower total surface area  and global gyrification index  compared with male and female FT controls. Exposed surface area was significantly lower in male VP/VLBW subjects compared with male FT subjects (P = 0.029). There was no significant difference in exposed surface area in female subjects (P = 0.126). Global T was not significantly different in both male and female VP/VLBW subjects compared with male and female FT subjects, respectively . P = 0.02 and the F (1189) = 5.655, P = 0.018]. The theoretically predicted slope of 1.25 is not within the 95% CI of the slope for FT controls. However, the 95% CI of the slope for FT controls overlaps with the 95% CI of the slope for subjects in the age range 22–36 years from the HCP . Regressing out sex from x and y separately as a control analysis, there was still a significant effect of the group on the slope . F  = 15.659, P < 0.001]. F  = 0.127, P = 0.722].To compare the slopes of VP/VLBW individuals and FT controls, we used multiple linear regression and found a significant effect of group (VP/VLBW versus FT) on the slope . The theoretically predicted slope of 1.25 is not within the 95% CI of the slope for male FT controls. However, the 95% CI of the slope for male FT controls overlaps with the 95% CI of the slope for subjects in the age range 22–36 years from the HCP . Because there was a significant interaction effect of sex:group on the slope, we repeated comparisons of slope and offset between VP/VLBW individuals and FT controls for male and female participants separately. In male participants, there was a significant effect of group on the slope . F  = 5.336, P = 0.023]. In female participants, there was no significant effect of group on the slope . There was no significant effect of BW or duration of ventilation on the slope .We first assessed the effect of birth variables on the slope in the VP/VLBW group using multiple linear regression analysis. After false discovery rate correction using the Benjamini–Hochberg procedure,37 there was a significant effect of GA on the slope  in the group of male VP/VLBW subjects. There was no significant effect of BW or duration of ventilation on the slope .Because there was a sex-specific effect of preterm birth on the slope, we repeated this analysis for male and female VP/VLBW subjects separately. After false discovery rate correction using the Benjamini–Hochberg procedure,37 there was no significant effect of GA, BW or duration of ventilation on offset .Second, we investigated the effect of birth variables on the offset using multiple linear regression analysis. This analysis was restricted to VP/VLBW subjects since offset was significantly lower in VP/VLBW subjects regardless of sex. After false discovery rate correction using the Benjamini–Hochberg procedure,In summary, GA had a significant effect on the exponent of the universal scaling law in male preterm-born adults, indicating that the difference is specifically related to preterm birth.F = 12.937, P < 0.001]. There was no significant difference in the shape term between VP/VLBW adults and FT controls . There was no significant interaction effect of sex:group on offset, the isometric term  or shape term .To assess the functional relevance of scaling behaviour, we analysed the effect of the independent morphological measures offset (tension term), isometric term and shape term on cognitive performance in the VP/VLBW group. Offset was significantly lower in VP/VLBW adults compared with FT controls. Furthermore, there was a significant difference in the isometric term between groups . There was no significant effect of offset and the shape term on full-scale IQ .After false discovery rate correction using the Benjamini–Hochberg procedure,In summary, while the size of the cortex had a significant effect on cognitive performance in preterm-born adults, its shape or tension had no significant effect.Based on structural MRI, we found a significant effect of preterm birth on the scaling of the cortical surface and T in adults. The exponent of the scaling law was significantly different in male preterm-born adults, which was associated with GA. Both male and female adults born preterm showed significantly lower offsets compared with FT controls, suggesting a systematic shift in the relationship between cortical surface and thickness. The shape or tension term of the scaling law had no significant effect on cognitive performance, while the size of the cortex did. Hence, altered neurodevelopment after preterm birth leads to differences in the allometric scaling of cortical folding.6 GA had a significant effect on the slope in preterm-born adults and more specifically in male preterm-born adults, indicating that this difference in the allometric scaling principles is specifically related to preterm birth. Both male and female preterm-born adults showed significantly lower offsets compared with FT controls, indicating a systematic shift after preterm birth, which implies that other parameters, such as changes in the mechanical forces acting on the cortex, may differ.We found a significant effect of prematurity on the exponent of the universal scaling law, specifically in male participants, implying fundamental differences in the physical model proposed by Mota and Herculano-Houzel.et al.25 found a disrupted scaling relation in extremely preterm infants indicated by a lower scaling exponent. Increasing prematurity and male sex were associated with a lower scaling exponent. In contrast, Paul et al.39 found no influence of GA on the power law scaling relationship in preterm infants. However, first, these studies investigated infants, while the present study analysed young adults; second, the scaling law tested in these two studies was based on the relationship between surface area and cerebral volume, while Mota and Herculano-Houzel6 described the degree of folding as a function of the product of surface area and the square root of T; and third, no control groups were used to analyse group differences. Using the same scaling law as Mota and Herculano-Houzel,6 Wang et al.8 investigated the effects of sex, age and the presence of Alzheimer’s disease on cortical folding. While healthy male and female brains scaled in the same way, patients with Alzheimer’s disease had a possible change in the exponent compared with controls.8 In the present study, we could not confirm the theoretically predicted exponent of 1.25 of the universal scaling law proposed by Mota and Herculano-Houzel6 in all FT controls and in male FT controls, since 1.25 was not within the 95% CI of the slope for all FT controls and for male FT controls. A potential reason might be scanner effects. However, both for all FT controls and for male FT controls, the 95% CI of the slope overlapped with the 95% CI of the slope for healthy young adults aged 22–36 years from the HCP , which can be interpreted as tension/pressure applied to the cortical tissue38 and shape term had no significant effect on cognitive performance. In general, alterations of cortical macro-architecture (beyond volume) after preterm birth are associated with impaired cognitive performance: for example, reduced surface area was associated with reduced IQ scores in VLBW young adults.19 Furthermore, reduced T in the left hemisphere was associated with lower full-scale IQ in the cohort investigated in the present study.16 Lastly, gyrification and cortical complexity were linked with reduced full-scale IQ in the same cohort.15 A possible reason might be that we investigated a scaling law of global cortical folding in the present study, while associations might be regionally specific.We found a significant effect of the isometric term, which carries information about the size of the cortex and is highly correlated with grey matter volume,One of the strengths of our study is that a relevant impact of age is excluded, as VP/VLBW subjects and FT controls were examined in a narrow age range, with the same mean age of 26 years at the time of the MRI scan.Furthermore, the study has the strength of a large sample (91 VP/VLBW and 105 FT adults).A limitation of the present study is the bias of the current sample towards VP/VLBW adults with less severe neonatal complications, less functional impairments and higher IQ since participants with more birth complications in the initial BLS sample were more likely to be excluded in initial screening for MRI due to the exclusion criteria for MRI. Thus, the reported differences are conservative estimates of true differences. However, our final sample was still representative of the full cohort in terms of GA and BW, as these values were not significantly different in VP/VLBW subjects with MRI data compared with subjects without MRI data see .In conclusion, altered neurodevelopment after preterm birth leads to differences in allometric scaling of cortical surface and T with sex-specific effects on the exponent in male preterm-born adults and a systematic shift in both sexes, indicating altered mechanical forces acting on the cortex after preterm birth. Results suggest altered cortical folding in human prematurity.fcac341_Supplementary_DataClick here for additional data file.


Moreover, they need longer PN support (p < 0.05) and invasive ventilation (p < 0.01). G1 presented a higher rate of BPD (p = 0.026). At linear regression analysis, BW and PN resulted as independent predictor of increased risk . Preventive strategies are fundamental to prevent chronic alteration in bone structures and to reduce the risk of short stature. Screening for MBD based on serum ALP could be helpful in clinical practice to identify subjects at increased risk.Metabolic bone disease of prematurity (MBD) is a condition of reduced bone mineral content (BMC) compared to that expected for gestational age (GA). Preterm birth interrupts the physiological process of calcium (Ca) and phosphorus (P) deposition that occurs mostly in the third trimester of pregnancy, leading to an inadequate bone mineralization during intrauterine life (IUL). After birth, an insufficient intake of Ca and P carries on this alteration, resulting in overt disease. If MBD is often a self-limited condition, in some cases it could hesitate the permanent alteration of bone structures with growth faltering and failure to wean off mechanical ventilation due to excessive chest wall compliance. Despite advances in neonatal intensive care, MBD is still frequent in preterm infants, with an incidence of 16–23% in very-low-birth-weight  and 40–60% in extremely low-birth-weight  infants. Several risk factors are associated with MBD , pulmonary bronchodysplasia (BPD), necrotizing enterocolitis (NEC), and some chronic medications). The aim of this study was to evaluate the rate of MBD in a cohort of VLBWI and the role of some risk factors. We enrolled 238 VLBWIs . 52 subjects were classified as increased risk (G1) and 186 as standard risk (G2) according to serum alkaline phosphatase (ALP) and phosphorus (P) levels. G1 subjects have lower GA ( Osteopenia or metabolic bone disease of prematurity (MBD) identify a condition of reduced bone mineral content compared to that expected for gestational age, associated with alterations in biochemical and radiological indices ,2. MBD iAfter preterm birth, an inadequate intake of calcium and phosphorus carries on these alterations, resulting in the development of overt disease .The diagnosis of MBD is mainly biochemical through specific indices of bone turn-over. It includes evaluation of serum levels of calcium, phosphorus, parathyroid hormone (PTH) and alkaline phosphatase (ALP) and urinary excretion of calcium and phosphorus. The main change in biochemical indices associated with MBD is the reduction of phosphoremia to concentrations below 4.5 mg/dl . HypophoThe American Academy of Pediatrics Committee on Nutrition (AAP-CON) recommends to screen all very-low-birth-weight infants through the measurement of serum levels of phosphorus and alkaline phosphatase around the fourth week of life .Despite advances in neonatal intensive care and implementation of nutritional support, MBD is still frequent in preterm infants, with an incidence of 16–23% in very-low-birth-weight  infants and in 40–60% in extremely low-birth-weight  infants ,17. MoreSeveral risk factors are associated with the development of MBD, including malabsorption syndrome, prolonged immobility, total parenteral nutrition (PN) for more than 4 weeks, pulmonary bronchodysplasia (BPD), necrotizing enterocolitis (NEC), liver disease, chronic kidney disease and medication (as chronic use of diuretics) ,6,20,21.Moreover, even if in the majority of cases MBD is a self-limiting condition, in some cases it could lead to a permanent alteration of bone structure that could cause growth faltering and alteration of respiratory patterns due to excessive chest wall compliance .Considering the increased risk of preterm infants to develop MBD and the possible consequences in later life, the present study aimed to evaluate the rate of MBD in a cohort of VLBW infants and the correlation with clinical data and known risk factors.A total of 289 VLBWIs were enrolled in the present study; 51 infants died during the first six weeks of life , so 238 subject with a mean gestational age of 29.2 ± 1.98 weeks and mean birth weight of 1131.13 ± 258.20 g were included in the final analysis . According to serum P and ALP concentration performed at 25.84 ± 3.45 days of life ,25,26, sp < 0.01) and birth weight . Moreover, they needed a longer parenteral nutrition support  and invasive ventilation .As shown in p = 0.026).To better understand the influences of the main comorbidities, we analyzed the rate of necrotizing enterocolitis, cholestasis, pulmonary bronchodysplasia, intraventricular hemorrhage, retinopathy of prematurity and sepsis into groups. A χ2-test was applied in order to evaluate differences in G1 vs. G2. Fisher’s test was applied instead of the χ2-test if the numerosity of a single cell was <5. G1 subjects presented a higher rate of BPD  presented radiological signs of osteopenia at X-ray performed at discharge. Specifically, four patients presented a reduction in bone mineral content and one patient presented an increased submetaphyseal lucency. No cases of spontaneous fractures occurred in our population. These patients were of a birth weight of less than 1000 g and had ALP > 1000 UI/L. Moreover, they experienced prolonged mechanical ventilation due to severe pulmonary bronchodysplasia. X-ray pictures relative to the five patients with radiological signs of osteopenia are shown in the Twenty-two subjects were discharged with oral therapy with fructose 1–6 bisphosphate and calcium gluconate. They needed to continue oral supplementation until normalization of serum ALP levels, which occurs at a mean age of 46.85 ± 0.95 post-conceptional weeks.Preterm infants have an increased risk of developing abnormalities in bone tissue due to reduced mineral reserves. Although in most cases it is a self-limiting phenomenon, sometimes it could lead to permanent changes in bone structure .In this study we investigated an increased risk of developing MBD and the presence of known risk factors in a cohort of very-low-birth-weight infants.The rate of MBD found in our population reflects what is reported in the literature, i.e., 22% VLBWI with gestational age < 32 weeks are at an increased risk of developing MBD during hospital stays ,21,22,23This is probably a consequence of the fact that the highest bone mineralization occurs in the last trimester of pregnancy, and that intrauterine growth retardation may be associated with placental dysfunction, and therefore a reduction in nutrient supply from mother to fetus ,25. As pThese data confirm data reported in a retrospective study published by Viswanathan et al. in 2014. The author compares 71 premature infants who developed MBD with 159 healthy controls. The MBD group has a lower gestational age and birth weight than the healthy controls . UkarapoThe increased length of the stay in our population at risk confirms what was reported in previous study by Chen and coworkers ,27.A significant difference was also found in the incidence of bronchodysplasia and in the longer duration of mechanical and noninvasive ventilation in infants at increased risk. These data confirm the findings of the previous published studies ,10,27,28A higher incidence of bronchodysplasia and the prolonged duration of artificial ventilation were also found in a study published by Avila-Alvarez and colleagues, although the differences in this case do not reach statistical significance . ProbablThe strength of the present study is that we included a relatively large cohort of VLBWIs and all subjects were managed  in a standardized manner according to internal procedures. The limit is that we conducted a retrospective observational study.A retrospective study was conducted. Preterm infants were enrolled at birth and evaluated at 25.84 ± 3.45 days of life.p and ALP concentration were dosed between 3rd and 5th week of life. Subjects were classified as “increased risk” (G1) if P ≤ 4.5 mg/dl or ALP ≥ 900 UI/L, or “standard risk” (G2) if P ≥ 4.5 mg/dl and ALP ≤ 900 UI/L [Very-low-birth-weight infants (birth weight < 1500 gr) with gestational age ≤ 32 weeks, born between January 2017 and December 2020 and admitted to the Neonatal Intensive Care Unit at Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico in Milan, were enrolled. Subjects who died during the first six weeks of life and with genetic abnormalities were excluded from analysis. According to AAP-CON guidelines , serum pInfants’ baseline characteristics, days of PN, days on mechanical ventilation, length of hospital stay and incidence of comorbidities such as necrotizing enterocolitis (stage II-b to III-b according to Bell’s criteria ), pulmonDuring hospitalization, infants were fed according to internal procedures for nutrition in VLBW infants . ParenteRegarding enteral feeding, it was started as soon as possible during the first days of life. Fresh own mother’s milk was the first choice; if milk from the infant’s mother was not available or insufficient, pasteurized donor human milk was chosen. When an enteral volume of 80 mL/kg/day was reached and enteral nutrition was adequately tolerated, a target fortification using multicomponent bovine-based fortifiers was started in order to achieve an enteral energy intake between 110 and 160 kcal/kg/day, with a protein intake of 3.5–4.5 g/kg/day, as recommended in ESPGHAN guidelines ,36.Moreover, all subjects were supplemented with fructose 1–6 bisphosphate and calcium gluconate according to internal procedure .Weight, length and head circumference were measured by trained paramedical staff from our institution according to standard procedure.Weight was measured using the incubator integrated scale, while length was measured to the nearest 1 mm on a Harpenden infantometer, which has a fixed headboard and moveable footboard. Head circumference was measured to the nearest 1 mm using non-stretch measuring tape .Weight, length and head circumference z-score were calculated using the z-score calculator provided by Intergrowth-21st project .Chest C-rays were performed before discharge to evaluate the presence of radiological signs of metabolic bone disease. According to Koo’s criteria, a pediatric radiologist reviewed the X-ray exams in order to find the following signs of alteration in bone mineralization and/or structure: presence of loss of dense zone of provisional calcification at metaphysis, increased submetaphyseal lucency, thinning of cortex, fraying, splaying or cupping of metaphysis .Continuous variables are presented as mean and standard deviation, while categorical variables are expressed as absolute numbers or percentages. Differences between G1–G2 were evaluated using t-test for continuous variables and χ2-test for categorical variables or Fisher’s test if cell had fewer than 5 elements. All statistical analysis was performed by SPSS 20 statistical package. A multivariate linear regression analysis was applied to evaluate the influences of known risk factors . The statistical significance level was fixed at 0.05.Despite nutritional approach and early supplementation with calcium, phosphorus and vitamin D, preterm infants have an increased risk of MBD, especially if born with a weight below 1000 g. Screening for MBD based on serum ALP could be helpful in clinical practice to identify subjects at increased risk. Further studies are needed to explore the pathophysiological mechanisms underlying the development of MBD, in order to implement preventive therapies to reduce the incidence of this complication in a susceptible population that is still elevated.


Among them, 119 infants acquired the infection in utero. Infected infants, symptomatic at birth, obtained lower scores on the Cognitive and Motor Scale on Bayley-III compared to asymptomatic and uninfected infants . Many severe or moderate sequelae rose up within the first year of life. At 24 months, we observed sequelae in 24.6% (14/57) of infected children classified as asymptomatic at birth, compared to 68.6% (24/35) of symptomatic ones ; (5) Conclusions: Infected babies symptomatic at birth have a worse prognosis than asymptomatic ones. Long-term sequelae may occur in infected children asymptomatic at birth after the first year of life. Multidisciplinary follow-up until 4–6 years of age should be performed in all infected children, regardless of the presence of symptoms at birth.(1) Background: Infections in pregnancy can lead to miscarriage, premature birth, infections in newborns, and developmental disabilities in babies. Infected infants, symptomatic at birth, can have long-term sequelae, and asymptomatic babies are also at increased risk of developing long-term sensorineural outcomes. Targeted therapy of the pregnant mother can reduce fetal and neonatal harm. (2) Aim of the study: To explore the association between symptoms and time of onset of long-term sequelae in infected children born from mothers who contracted an infection during pregnancy, by a long-term multidisciplinary follow-up. (3) Methods: For up to 2–4 years, we evaluated cognitive, motor, audiological, visual, and language outcomes in infants with symptomatic and asymptomatic congenital infections and in uninfected infants. (4) Results: 186 infants born from women who acquired Cytomegalovirus infection ( Toxoplasma gondii, Treponema pallidum, Hepatitis B and C viruses, Human Immunodeficiency Virus, Parvovirus B19, and non-polio Enteroviruses [Some maternal infections contracted before or during pregnancy can be transmitted to the fetus during gestation , during labor and childbirth , and through breastfeeding . The microorganisms most frequently responsible for congenital infections are Cytomegalovirus (CMV), oviruses . Infectioviruses ,4,5,6,7.oviruses ,9,10. Tooviruses . When thoviruses ,12. Howeoviruses . These sToxoplasma gondii, and Treponema pallidum are prospectively monitored in a multidisciplinary follow-up of at least 24 months. The service aims to diagnose sensorineural deficit and development delay early and activate the rehabilitation measures quickly.At the “Bambino Gesù” Children’s Hospital in Rome, there is an active multidisciplinary follow-up service and a specific outpatient clinic for newborns and children born to mothers who have contracted infections transmissible to the fetus during pregnancy. Infants with and without congenital infection from Cytomegalovirus, Toxoplasma gondii, and Syphilis that had been referred to our clinic from other hospitals both located in the Lazio Region and other Italian Regions. Patients’ data were retrospectively obtained from medical records to assess short-term outcomes (at 12 months of life) and long-term outcomes (at 2–4 years of life)  .We collected information on infant condition at birth: gender, Apgar score at 5 min, birth weight, gestational age (GA), mode of delivery, ultrasonography, brain magnetic resonance imaging (MRI), hearing, and ophthalmologic examinations. Maternal infection-related variables were the time of the infection onset in pregnancy, laboratory values, and therapies, when available, as our institution does not have a delivery room and the women are referred to us by external service centers after giving birth. The retrospective study was reported to the Hospital Ethics Committee, which approved it.Infants were classified as symptomatic or asymptomatic if they had symptoms or not at birth for congenital CMV and Toxoplasmosis and high probable, possible, less likely, and unlikely congenital Syphilis. Clinically, the infants enrolled in the study were defined as small for gestational age (SGA) if their birthweight was less than the 10th percentile for gestational age. Head circumference was considered small for gestational age if its measurement at birth was less than the 10th percentile for gestational age. Infants were considered having a microcephaly if their head circumference was lower than the 3rd percentile.Congenital CMV infection (cCMV) was defined according to the results of the consensus recommendations for prevention, diagnosis, and therapy by Rawlison et al. . AsymptoToxoplasma congenital infections were diagnosed by clinical symptoms and serological exams during the hospitalization and, in asymptomatic neonates, by comparing and monitoring the serological maternal  and neonatal status . Moreover, we performed a polymerase chain reaction for Toxoplasma DNA in serum at the first clinical evaluation. Overall, the neonatal infection was considered symptomatic in the presence of one or more of the following: intrauterine growth retardation, prematurity, petechiae, tachypnea, hepatomegaly, splenomegaly, thrombocytopenia, coagulopathy, seizures, microcephaly, hypotonia, chorioretinitis, abnormal skeletal radiography, hyperacusis, and retinitis. Associated main laboratory findings were thrombocytopenia and elevations in transaminases, in addition to specific laboratory tests for the disease. Microcephaly was considered when head circumference (HC) was below two standard deviations.Symptomatic Treponema pallidum, and skeletal radiography, when appropriate. When the baby was hospitalized in the suspect of symptomatic syphilis and required therapy, we also performed a polymerase chain reaction for treponemal DNA in the cerebrospinal fluid.Congenital syphilis was diagnosed according to CDC criteria for confirmed, possible, less likely, and unlikely by clinical symptoms and, in asymptomatic neonates, by comparing the serological maternal status with that of the baby at birth. In neonates, we performed the polymerase chain reaction for treponemal DNA in serum and serological analysis: rapid plasma reagent, quantitative Treponema pallidum hemagglutination test (TPHA), specific IgG and IgM anti All infected infants of this cohort were regularly evaluated to intercept the presence of a neurological disability early: the presence of cerebral palsy (CP) was defined according to Bax . To evalRepeated examinations of the fundus assessed visual function and retinal diseases. Normal vision was defined as the “absence of any detectable pathology of the visual system”; mild abnormal vision as “the presence of a mild impairment which allowed useful vision”; and severe visual impairment as “a child functionally blind or perceives light only” .Hearing function was explored by automatic auditory brainstem response (AABR) and brainstem auditory evoked potentials (BAEPs). The global auditory function was defined as normal in the “absence of any detectable pathology”, as mild if requiring hearing aids or as severe if functionally deaf (uncorrected even with aids) .Data are shown as numbers and percentages for categorical variables, whereas continuous variables are expressed as mean ± standard deviation (SD) if they were normally distributed or as median and interquartile range if normality could not be accepted.p-value < 0.05 was considered statistically significant. Statistical analysis was performed using software programs Microsoft Excel (2016 for Windows) and SPSS (version 20 for Windows).Clinical characteristics of the infants’ diagnosis at admission and the neurodevelopmental assessment in children with symptomatic, asymptomatic infected, and uninfected infants were compared using the Chi-squared test for categorical variables, whereas ANOVA was performed for continuous variables. A n = 103/186; 55.4%), or Toxoplasma gondii infection , or Syphilis  during pregnancy. We did not observe infants from twin pregnancies. Among those 186 babies, 119 (64%) were affected by a confirmed maternal–fetal infection and the others resulted as uninfected. Among infected babies, 92/119 (77.3%) attended visits for 2–4 years.During the study period, we observed 205 infants born to women with definite infection during pregnancy. Of those babies, 19 were lost to follow-up before 12 months of age. Therefore, we considered for inclusion in this study 186 infants. Their mothers contracted Cytomegalovirus infection (The flowchart of the study is shown in Only 37/119 (31.1%) infected neonates were symptomatic at birth. Considering brain ultrasound (US) at birth, in 23/37 (62%) symptomatic neonates the brain US showed abnormal imaging findings related to the intrauterine infection, intracranial calcification included. Among asymptomatic neonates, 19/82 (23%) also showed brain US variations that were not considered by the neuroradiologist as specific or attributable and suggestive of fetal brain infectious involvement. In 4/67 uninfected neonates (6.0%), US showed mild cerebral ventriculomegaly lower than 10 mm, stable and non-evolutionary, cystic formation of the choroid plexus of the left ventricle (2 mm), and hyper-echogenicity of the periventricular deep white matter.p = 0.001; F = 8.605, p < 0.001; F = 13.029, p < 0.001; F = 4.066, p = 0.019). No clinically significant differences were found between uninfected and asymptomatic infected babies at birth  were born preterm; 10 (58.8%), 5 (29.4%), and 2 (11.8%) of them were among symptomatic infected babies, asymptomatic infected, and uninfected, respectively. The gender of newborns and the mode of delivery did not differ between groups.p = 0.030).Clinical characteristics of children did not differ concerning the type of maternal infection, except for CMV-infected infants, who presented lower birth weight and lower head circumference compared to other infants born to mothers with toxoplasma or syphilis infection  received a specific pharmacological treatment: 31 (36.9%) neonates with CMV infection received intravenous ganciclovir and/or oral valganciclovir, 15 (83.3%) neonates with Toxoplasmosis received oral pyrimethamine and sulfadiazine and 12 (70.6%) received aqueous penicillin G intravenous treatment for congenital Syphilis.p = 0.026; F = 3.07, p = 0.049), without any major differences related to the etiologic agent of the infection  infected children, symptomatic or asymptomatic at birth, resulted free from any sequela at the multidisciplinary clinical and instrumental evaluation, while the other 29 children (24.3%) showed one or more sequelae .The short-term outcome at Time-point 1  in the cohort of 119 infected children, divided by the major development domains, visual and auditory function, is summarized in Overall, 4/119 (3.4%) children showed cognitive delay  already diagnosable before 12 months of life; 3 of them were born from mothers with Cytomegalovirus infection contracted early in pregnancy.None of the children observed had cerebral palsy, but 17/119 (14.3%) had a motor delay . Again, most of those children 11/17 (64.7%) were born from pregnancies complicated by maternal Cytomegalovirus infection contracted early in pregnancy.Additionally, 13 of 119 children (10.9%) had sensorineural hearing loss (SNHL), which was bilateral severe in only one case. There were no children with delayed-onset hearing loss, but 4 children showed a progressive SNHL, and 1/119 (0.8%) children had severe visual impairment.Furthermore, 92 infected children were regularly observed up to 2–4 years of life: 4/27 (14.8%) of patients lost to follow-up had mild or mild unilateral hearing loss. After 2 years of life, 54/92 (58.7%) of infected children were free of sequelae during the follow-up. Their long-term outcomes at time point 2 (T2) are summarized in The most relevant aspects are the increase in cases of cognitive delay (3 new cases compared to the year of life) and above all the appearance of a considerable number of cases of delay in the language area  prevalent in those babies born to mothers with infection by Cytomegalovirus.Toxoplasma gondii, and Syphilis. In total, 119/186 (64.0%) babies were infected at birth, with symptoms or not, globally considering them, beyond the specific pathogen, and separately. It is well known that up to two-thirds of cCMV-infected infants symptomatic at birth had long-term sequelae, in agreement with the literature reports (40–60%) [In this study, we assessed the incidence and type of neurodevelopmental and sensorineural adverse outcomes of infants born to mothers infected in pregnancy by Cytomegalovirus, (40–60%) ,21, wher(40–60%) , and ora(40–60%) .As among children who develop SNHL secondary to cCMV infection, hearing loss may be present at birth or may have a delayed onset, occurring during the first years of life. Many of those babies are asymptomatic at birth. This observation underlines the need for a close follow-up of all newborns with cCMV infection, regardless of the presence of symptoms at birth, as the baby can receive serial audiological monitoring during the first years of life and up to school age to promptly detect any SNHL and proceed with rehabilitation interventions, which is able to reduce the functional deterioration resulting from deafness, significantly improving the receptive and expressive language and the socio-emotional development. In addition to all potential benefits, the use of antiviral therapy with ganciclovir and valganciclovir must consider known risks, such as neutropenia, as well as potential risks, such as gonadal toxicity and carcinogenicity, which have been observed in animal models  . Given tToxoplasma gondii is not a newly discovered germ, there is currently no standardized treatment for congenital toxoplasmosis, and opinions on drugs and duration are sometimes conflicting. Furthermore, most drugs work against actively dividing tachyzoites and not encysted bradyzoites, making eradicating the disease more complicated. This applies to symptomatic infants but also to serologically positive but asymptomatic infants, who are often treated until the infection is excluded, usually in three to four months [Among our patients, half of the babies without symptoms of congenital Toxoplasmosis at birth showed long-term sequelae. Although r months . What isThe treatment of the asymptomatic infant exposed to Syphilis in pregnancy who is unlikely to have the disease is also much discussed. These are those children whose mothers received adequate therapy before 4 weeks after delivery but for whom, in the absence of prolonged follow-up, most infectious disease specialists and even CDCs recommend benzathine penicillin G 50,000 units/kg for intramuscular (IM) dose in a single dose, even if asymptomatic ,26. IndeIn neonates exposed to infections during pregnancy, a long-term multi-specialist follow-up is unquestionable, regardless of the type of germ and regardless of the presence of symptoms at birth. Currently, pharmacological and rehabilitative treatments are available that are effective in preventing both short- and long-term outcomes, but unfortunately, the indications for the treatment are often conflicting, especially when symptoms are not present at birth. This consideration further underlines the importance of long-term follow-up multicenter studies and the need for consensus conferences, which, based on the studies, issue shared and homogeneous recommendations to follow, especially when no signs and symptoms are present at birth.Most moderate or severe sequelae rose in infants within the first year of life, and more than half of infected children had no sequelae in our cohort.Toxoplasma-infected patients (14.3%). Recently, Al Malki et al. suggested that a maternal Toxoplasmosis infection could have a role in developing childhood autism linked to several points of mutation of mitochondrial and nuclear DNA [Toxoplasma infection (7.1%) was lower than those disclosed by Peyron et al. in a previous cohort of adult individuals with treated congenital toxoplasmosis (12.7%) [A new finding is the presence of a higher incidence of cognitive impairment at 24 months of follow-up in lear DNA . Convers (12.7%) .Infants with congenital CMV infection had the highest incidence of sensorineural hearing loss (14.3%); as is well-known, among hearing-impaired children, cCMV is a common cause of sensorineural hearing loss. The mechanisms by which cCMV infection induces sensorineural deafness have been partially characterized: a pro-inflammatory reaction, the apoptosis of cochlear spiral ganglion, and vascular changes are all involved .Toxoplasma (35.7%) and in the cCMV group (26.1%). The association of language delay in congenital Toxoplasmosis is poorly reported in the literature, but our incidence was similar to those detected in a Brazilian cohort (26.4%) [Language delay was observed in all three infections, with a higher rate in the  (26.4%) .Toxoplasma and Syphilis, for which less data are available compared to cCMV.Limitations of this study include the single-center site and the small sample size. However, we compared short-term and long-term neurodevelopmental outcomes in uninfected and infected infants, always using the same objective methods: our findings could be helpful to counsel parents about these congenital infections, especially in the case of This study confirms that infants with congenital infection who were symptomatic at birth have a worse prognosis than asymptomatic ones. Long-term sequelae may occur in infected children, also if asymptomatic at birth, up to 2–4 years of age. These results highlight the importance of the multidisciplinary follow-up that these children need, independently from the presence of overt symptoms of infection at birth and regardless of the type of congenital infection.


A convincing body of epidemiological research has linked birth by Cesarean section (C-section) with an increased risk of infectious and chronic diseases such as autoimmune diseases, asthma, and obesity, and even some cancers –4. CompaMicrobiota restoration for infants born by C-section has been proposed, tested for safety in small proof-of-concept clinical trials, and evaluated based on the efficacy to compensate for a lack of maternal microbiota transfer during birth. Proposed therapies include “vaginal seeding”, which is based on the inoculation of newborns with a microbiome sample collected from the mother’s vagina before birth , and matMicrobiome has asked several experts in the field to present their perspectives on the biological mechanisms, clinical relevance and potential for therapeutic restoration of the neonatal microbiome [To contribute to the ongoing debate and provide a knowledge base for a broader scientific, clinical and public discussion of microbiome restoration therapies in infants born by C-section, crobiome . Here, win utero remains controversial and likely non-significant under non-pathological conditions , there s topic:  or enters topic:  in pregns topic:  and cohos topic:  in mice,s topic: , and bres topic: , 20 amoni.e., the taxonomic resolution typically achieved with 16S rRNA gene amplicon or metagenome sequencing, may obscure microbiota alterations at the strain level. Instead of receiving optimal microbial strains from their mothers, infants born by C-section could obtain alternative, suboptimal strains from other, alternative sources, including nutrition [Bifidobacterium strains [Bacteroides and Parabacteroides, which are frequently transferred from mothers during vaginal birth [Most published studies have reported major compositional microbiota differences between vaginally delivered and C-section infants during the first weeks and months of life that disappear between 2 and 5 years of age, as the infant microbiota matures towards an adult state , 21, 22,utrition . This co strains . It shoual birth , 26, 27,al birth  and persal birth , suggestal birth . These tThere have only been a few attempts to quantify the neonatal microbiome in terms of absolute intestinal microbial abundances , but with unexpected and interesting results. Quantitative fecal microbiota profiling of preterm infants identified bacterial and fungal blooms and extinctions, which would not have been detectable with standard, qualitative microbiota analysis methods such as 16S rRNA gene amplicon sequencing . For exaBacteroides strains, has been reported both for vaginal seeding [Bacteroides strains were among the most frequently engrafted members of the donor microbiota in patients with recurrent Clostridioides difficile infection that received FMT from healthy donors [Vaginal bacteria and maternal vaginal strains constitute only a small and transient fraction of the neonatal intestinal microbiota after birth, whereas intestinal microbes and maternal intestinal strains contribute a larger and more persistent portion , 27, 32. seeding , 33 and  seeding . It is c seeding . Interesy donors , 35, indIn conclusion, limitations in our mechanistic understanding of the microbiome initialization and development process and its resilience to perturbation currently prevent a comprehensive assessment of the acute and lasting functional consequences of C-section for the microbiome and the host, as well as ultimately the health effects of the proposed microbiota restoration therapies.


Ossa cordis prevalence, histology and anatomical location between differing veterinary species and in humans. In addition, it also identifies associated factors such as aging and cardiovascular disease for each species in relation to functional roles and developmental mechanisms that these bone structures may play. The potential functions of Ossa cordis are presented, ranging from aiding cardiac contraction and conduction, providing cardiac structure, and protecting components of the heart, through to counteracting high mechanical stress. Furthermore, this review discusses the evidence and rationale behind the theories regarding the formation and development of Ossa cordis in different veterinary species and in people.This systematic review highlights the similarities and variations in  A total of 31 relevant papers were collected and evaluated within this review Figure .. AnatomICVGAN., .Ossa cordis; all species included: written in English, German or French. Exclusion criteria: Review papers; written in languages other than English, French or German. No date exclusions were made.Literature review inclusion criteria: Original research documenting the presentation, formation and function of Os* cordis; Os cordis AND heart anatomy; Os* cordis AND histology; Os* cordis AND cardiac anatomy; Osteocyte AND heart; Osteocyte AND cardiac skeleton; Osteocyte AND myocardium AND cardiac skeleton; Osteoblast AND heart; Osteoblast AND heart AND cardiac skeleton; Fulcrum AND osteocyte; Fulcrum AND heart; Fulcrum AND osteocyte AND heart2.1Ossa cordis are usually associated with the atrioventricular rings and cardiac septa; however, this bone has shown a great deal of variation between species, and even individuals, in relation to its presence and number size, shape and position . The closely related Cervidae, Giraffidae and Camelidae families, within the Artiodactyla order also contain species with Ossa cordis.When present, n Tables  and 2. M2.2Bos taurus), Ossa cordis  of the hearts investigated   and 20% of native Iranian cattle (n = 8 from 40)  James, ; 80% of 0) Pour, . The os 0) Pour, . One stue James, , howevere James, .2.3Bubalus bubalis) 93% of hearts had two Ossa cordis [n = 14 from 15  an os cordis was referred to (no measurements or numbers) at the base of the aortic fibrous ring in each individual , os cordis dextrum measuring 10‐15 mm (n = 25) was present in all hearts, situated deep within the interatrial septum. Additionally, an os cordis sinistrum was found within the left atrioventricular ring in 10 of the hearts  and two antelope species. Antilope cervicapra (blackbuck) and Boselaphus tragocamelus (nilgai)  male white‐tailed deer were greater in size than both Wisconsin female deer and both male and female deer from Texas (n = 45), but adult Ossa cordis measurements remained similar  including four deer: Axis axis , Cervus nippon (sika deer), Dama dama  and Odocoileus virginianus (white tailed deer), which were generally present in mature individuals , Ossa cordis were not detected in 11 adults and 9 young  heart, a single os cordis was reported within the right trigone of the cardiac skeleton, whilst the left fibrous trigone contained a small structure composed of hyaline cartilage  a single os cordis was present in all 10 hearts investigated, in a comparable position to cattle os cordis dextrum , cardiac bone presented in 8 of 11 (73%) Doberman pinscher hearts  hearts had islands of cartilage present within the central fibrous body, and in a further 19 hearts bone was also found in this region  58 of the 63 cat , the only pinniped with confirmed Ossa cordis so far. From the two pups, 3 subadults and 6 adults investigated, one pup and three adults had Cartilago cordis and one adult had an Ossa cordis containing marrow in the right fibrous trigone  over five years of age, however, in a four‐year‐old which died following cardiac arrhythmias, multiple bone foci were observed within the left atrioventricular valve cusps . Despite these similarities with larger mammal Ossa cordis it should be noted that all three chimpanzee hearts had idiopathic myocardial fibrosis, indeed the level of fibrosis was a factor associated with the presence of os cordis ; the os cordis dextrum length increased from 36.98 to 37.61 mm, respectively, and os cordis sinistrum lengths increased from 8.20 to 13.83 mm with age , formation of bone tissue from cartilage, as opposed to intramembranous ossification, bone laid down directly onto mesenchyme  had no os cordis but did have cartilage present, whilst older hearts (up to 5 years old) had Ossa cordis present in the same anatomical location as the cartilage observed in the calf, indicating that the bone may have developed from the cartilage  or cartilage being associated with Ossa cordis is not direct evidence for EO. Indeed, many species contain a Cartilago cordis which do not appear to develop into an Ossa cordis. The lack of bone development in these species could be related to the size of the animal or heart shape. In otters, it was suggested that the reason for bone formation was related to unusually high mechanical forces on the heart for an animal of that size and its cone‐like heart shape  get lodged in the atrial wall and eventually differentiate into cartilage . The study found that in the three hearts containing Ossa cordis, two had marked IMF (level 6) and one had moderate to severe IMF (level 5)  the cardiac valves also contained metaplastic bone , as indicated in the horse  cartilaginous foci were found within the central fibrous body . In cattle and camels, it has been proposed that the cardiac muscle anchors onto Ossa cordis improving contraction  Ossa cordis from cartilage may have been triggered by mechanical stress  and bundle of His . Samples and methods used were as described previously (Keane, Paul, Sturrock, Rauch, & Rutland, Click here for additional data file.


Prematurity is the most important cause of death among children under the age of five years. Globally, most preterm births occur in Sub-Saharan Africa. Subsequent prematurity leads to significant neonatal morbidity, mortality and long-term disabilities. This study aimed to determine the causes, survival rates and outcomes of preterm births up to six weeks of corrected age in Ghana.An observational prospective cohort study of infants born preterm was conducted in a tertiary hospital in Accra, Ghana from August 2019 to March 2020. Inclusion was performed within 48 h after birth of surviving infants; multiple pregnancies and stillbirths were excluded. Causes of preterm birth were categorized as spontaneous (including preterm pre-labour rupture of membranes) or provider-initiated . Survival rates and adverse outcomes were assessed at six weeks of corrected age. Recruitment and follow-up were suspended due to the COVID-19 outbreak. Descriptive statistics and differences between determinants were calculated using Chi-squared tests or Kruskal-Wallis test.n = 116, 65%) were provider-initiated, often due to hypertensive disorders in pregnancy . Sixty-two infants were followed-up out of which fifty-two survived, presenting a survival rate of 84% (n = 52/62) at six weeks corrected age in this group. Most infants  experienced complications, predominantly consisted of NICU admission (92%) and interval illnesses (21%) including jaundice and sepsis.Of the 758 preterm deliveries, 654 (86.3%) infants were born alive. 179 were enrolled in the cohort and were analyzed. Nine (5%) were extremely preterm [gestational age (GA) < 28 weeks], 40 (22%) very preterm (GA 28–31 weeks), and 130 (73%) moderate to late preterm (GA 32–37 weeks) births. Most deliveries (The incidence of adverse outcomes associated with preterm birth in a tertiary facility with NICU capacity is high. Larger longitudinal studies are needed for an in-depth understanding of the causes and longer-term outcomes of preterm birth, and to identify effective strategies to improve outcomes in resource constrained settings. Preterm birth is the leading cause of neonatal and perinatal morbidity and mortality globally –3. EveryPreterm birth complications are the most common cause of death in children under five, leading to approximately a million deaths per year , 10. TheAmong surviving preterm infants, the incidence of neonatal mortality and morbidity is higher compared to those born at term . AlthougGhana, a West-African middle-income country, has a prematurity rate of 14.5%  and 128,Given the need for LMIC-based studies to better understand the causes, survival, and outcomes of preterm births , this stThis study was nested in the PETITE study , an observational prospective cohort study. Recruitment was started in August 2019 and follow-up of these infants commenced in November 2019. However, due to the COVID-19 pandemic, research activities were terminated in March 2020 . ResultsThe PETITE study was conducted at Korle-Bu Teaching Hospital (KBTH) at the Departments of Obstetrics and Gynaecology, and Child Health in Ghana's capital, Accra. KBTH is a teaching hospital for the University of Ghana Medical School. The department of Obstetrics and Gynaecology is the largest department and approximately 10,000 deliveries take place annually and accommodates a neonatal intensive care unit (NICU) . The depEligibility criteria were livebirth preterm infants through any mode of delivery. Other eligibility criteria were maternal age of 18 years or older and provision of written informed consent. Exclusion criteria were multiple pregnancy, stillbirth, and early neonatal death prior to recruitment.On a daily basis, research assistants assessed women admitted to the maternity wards that were eligible for inclusion and willing to provide informed consent. Once informed consent was given, information about the woman's socio-economic, last pregnancy and delivery, and (obstetric) history, were obtained from the patient files and by questionnaire. Phone numbers were collected in order to contact participants for follow-up visits located at the Child Health department of KBTH, when their infants reached 6 weeks corrected age. During follow-up, trained research assistants and pediatricians obtained infant medical history and anthropometric information from infants' medical files and by examination. Loss to follow-up was considered when phone numbers were out of order or when participants remained unreachable after several attempts.The outbreak of the COVID-19 pandemic impacted data-collection heavily, as the recruitment of participants and follow-up visits in the hospital were halted. Due to the country's lock-down that followed shortly after , accompaThe causes of preterm birth were categorized into spontaneous onset of labour (including preterm prelabour rupture of membranes), or provider-initiated birth  and measured as an outcome in this study –30.Mortality rates were calculated among excluded and included neonates. Stillbirths were defined as death after 28 weeks of pregnancy occurring before or during birth. Early and late neonatal deaths were defined as infant death occurring within the first week of life and after the first week but before the end of the fourth week of life respectively . NeonataTo analyze infant morbidity at follow-up, a composite variable for complications was created, consisting of diagnosis of heart murmur, wheezing, and decreased muscle tone, as well as NICU admission, postpartum and/or (emergency) hospital re-admission and interval-illness after discharge. Interval-illness was any form of illness reported by the mother, including (emergency) hospital admission. Additionally, head circumference , body length (cm), weight  and umbilical herniation were assessed at follow-up.Based on the WHO's definition, preterm birth was defined as birth <37 weeks of gestation and categorized as extremely preterm (birth <28 weeks), very preterm (birth between 28 and 31 weeks), or moderate to late preterm (between 32 and 37 weeks of gestation) , 30. GenMaternal determinants included age (years), ethnicity, educational level, current occupation, marital status, current body mass index (BMI), and maternal intoxication during current pregnancy or gave up before or during current pregnancy . Medical and obstetric history were reported, including maternal chronic disease  or malaria), parity, number of antenatal care (ANC) visits, at least eight or more ANC contacts as recommended by recent WHO guidelines , , low birth weight , body length (cm), small for gestational age , Apgar scores at one and five minutes (dichotomized into <7 and ≥7), NICU admission, length of NICU admission (days), need of resuscitation , and infant mortality defined as death after hospital discharge reported during follow-up.Based on previously reported data, per month a minimum of 150 eligible preterm births were expected . In combWomen's baseline characteristics and infants' perinatal and short-term outcomes were presented by classification of preterm birth according to the WHO. DescripMaternal, obstetric, and infant (outcome) characteristics of followed-up infants and deceased infants were compared to infants that were lost to follow-up  with descriptive statistics. Missing data was not imputed due to low occurrence, and analyses were restricted to women of whom gestational age at birth was reported.p-value <0.05 was considered as significant. Data were collected by paper questionnaires, entered into REDCap and downloaded into IBM SPSS Statistics (version 21.0 for Windows) to perform statistical analyses.A Approval was obtained from the Ethical and Protocol Review Committee of College of Health Sciences, University of Ghana (CHS-Et/Ml0- 9.2/2018–2019). Written informed consent was obtained from all the mothers prior to enrolment.A total of 758 preterm deliveries occurred during the recruitment period. Of these deliveries, 181 (49.5% of the eligible births) were enrolled in the cohort study, and data of 179 (98.9%) infants were available at time of data analysis. This included 8 (4.5%) infant deaths. A total of 26 (14.5%) mothers declined further participation during follow-up . In totan = 129, 72.1%), more than half of them had secondary level education  and nearly three-quarters of women had an informal occupation . One-third of the women were nullipara  and in most women  gestational age was determined using ultrasound scan. On average women received their first ultrasound at 19 weeks of gestation  (not shown in Table) and attended 5.4 (SD ± 2.4) ANC visits of which 17% attended ANC eight times or more . HDP was reported in almost half of the women . In total over three-fourths received antenatal corticoid therapy  and among women with a gestational age below 34 weeks (n = 80), 90% received corticoid steroids antenatally  (not shown in table). The vast majority delivered by caesarean section .n = 56, 31.3%) of women had comorbidities, including sickle cell disease , hepatitis B infection , human immunodeficiency virus , malaria in pregnancy alone , and tuberculosis . Fourteen (7.8%) women reported substance exposure or use: household smoke exposure , alcohol use during pregnancy , nicotine use during pregnancy , and regularly smoking cigarettes before pregnancy . The mean gestational age at booking = 15.6 weeks ±7.0 SD).Mean (current) maternal BMI was 30.3 (SD ± 6.1) and almost a third (n = 618) of 81.5% . Of these, 104  were stillbirths, and 36  were early neonatal deaths (of which five occurred after inclusion).There were 140 perinatal deaths  and 654 live births  among the 758 preterm births that occurred during the recruitment period resulting in a perinatal survival rate (n = 5) were extremely preterm and the other half (n = 5) were very preterm born. Mortality rates for moderate to late preterm birth infants were 38 per 1,000 births , very premature 150 per 1,000 births , and extremely preterm 778 per 1,000 livebirths .Of the 179 surviving infants included in the preterm birth cohort, eight (4.5%) died before discharge, including five (2.8%) early neonatal and three (1.7%) late neonatal deaths. Of the 62 (34.6%) infants that were followed-up to six weeks corrected age, 52 survived (83.9%). Ten (16.1%) infants died between discharge and follow-up at unknown age, half of these . The proportion of female and male sex were similar . Mean birth weight was 2061.5 g (SD ± 714.4) with an average body length of 44.7 cm (SD ± 5.1). Low birth weight was reported in three-quarters  of infants and about 10% were small for gestational age . More than one-third  of births occurred spontaneously and 64.8% (n = 116) were provider-initiated. Low Apgar scores (<7) at one and five minutes were reported in 83 (48.5%) and 34 (20%) of infants. The vast majority  of the neonates included in the cohort were admitted to the NICU.n = 42, 80.8%), and nearly 20%  were very preterm. No extremely preterm born infants attended follow-up; out of the total of nine eligible infants, seven (77.8%) died and two (22.2%) infants were lost to follow-up (n = 42/52), compared to those whose infants died  or were lost to follow-up .Outcomes of infants up to six weeks of corrected age were assessed for a total of 52 surviving infants . On averollow-up . Women wn = 47, 92.2) with a mean length of stay of approximately 13 days  in which very preterm infants were admitted for significantly longer  than moderate to late preterm infants (mean = 9.8 ± 9.7 SD) (p = 0.03). On average, infants had a head circumference of 37.8 cm (SD ± 3.8), with a body length of 58.1 cm (SD ± 4.4), and mean body weight of 5091.7 g (±1333.8 SD) at six weeks follow up. A heart murmur was diagnosed once , as well as wheezing  and decreased muscle tone . Almost one-third of infants were diagnosed with umbilical herniation . In 21.2% (n = 11) of infants, post-discharge interval-illness was reported which led to re-admission in eight (72.7%) due to jaundice , sepsis  and fever with upper respiratory tract infection . On average, infants were re-admitted for eight days . In most of the infants  the composite of adverse outcomes was reported.Most neonates were admitted to the NICU  experienced adverse outcomes, predominately NICU admission and interval-illness.The perinatal survival rates reported among preterm born infants in this urban middle-income country referral setting seem better compared to some other LMIC settings mentioned in the WHO report “Born too soon”, which shows survival rates at merely 30% in infants born at 28 to 32 weeks and almost no survival in infants born at <28 weeks . To illuTo assess adverse infant outcomes in this study, physical abnormalities, interval illness and health-seeking behavior were used as proxies in a combined variable for infant morbidity. Apart from restricted growth, no other consensus criteria for morbidity are available for preterm infants . Our cohEvidence-based interventions for preterm and low birth weight infants were recently summarized in a meta-analysis study, including interventions that can be provided prior to referral and in facilities without a NICU . ImportaOur study has several strengths. These include the prospective observational design in which infants were followed-up to determine the survival rates of prematurely born infants. In addition, the gestational age was established by ultrasound early in pregnancy or at first antenatal care visit. Whereas ultrasound is considered as the golden standard for gestational age assessment, this method is less common in LMIC studies . While mYet, several limitations exist, and these relate particularly to the small sample size, low number of followed-up infants and lacking data of NICU admission. This was a direct result from the abrupt ending of the PETITE study in March 2020 due to the SARS-CoV-2 pandemic, which also withheld us from more extensive research in preterm birth morbidity, as certain adverse outcomes can only be diagnosed after a longer period of time, such as cerebral palsy or developmental disorders. Also, the six weeks follow-up visit was hampered as many mothers were difficult to contact or did not come to follow-up schedules. Therefore, we were forced to assess a composite of adverse infant outcomes at six weeks, which reduces our ability to explore the impact on specific outcomes. Also, it is plausible that the mortality estimates may be an underestimation of the true incidence, due to survivor's bias , and exclusion of multiple gestations and infants who died <48 h. Also, due to the abrupt ending of follow-up because of study suspension caused by the COVID-19 pandemic, missed cases of post-discharge  deaths may have occurred, leading to overestimated perinatal survival rates. Furthermore, the generalizability of our findings is limited to higher level facilities, as morbidity and mortality in facilities without extensive NICU and pediatric support can be expected to be higher. Similarly, as followed-up infants were moderate to late preterm born and no extremely preterm infants were represented, the morbidity and mortality estimates for infants born at lower gestational ages can be expected to be higher as well. Lastly, cranial ultrasonography was not performed in this study, as such intraventricular hemorrhage and congenital abnormalities, both resulting in long-term morbidity, could not be diagnosed.Globally, one out of every 10 infants is born preterm, of which many will not survive the neonatal period or experience severe morbidities , 14, 15.The incidence of adverse outcomes associated with preterm birth in a tertiary facility with NICU capacity is high, despite the availability of specialized neonatal care. Both observational and intervention studies based in LMICs will be necessary to reduce the research gap, gain an in-depth understanding of causes and long-term outcomes of preterm birth, and effectiveness of approaches to improve these in order to achieve Sustainable Development Goal #3—ensuring healthy lives and promoting well-being at all ages.


Epidermoid cyst in an intrapancreatic accessory spleen is a rare benign lesion that is difficult to diagnose preoperatively. Cyst fluid analysis for biochemistry markers has been widely used to aid the diagnosis of pancreatic cysts. A high cyst fluid carcinoembryonic antigen (CEA) level (>800 ng/mL) is said to be useful in distinguishing intraductal papillary mucinous neoplasm (IPMN) and mucinous cystic neoplasm (MCN) from other non-mucinous cysts. We herein report a case of epidermoid cyst in an intrapancreatic accessory spleen with abnormally high CEA level (3582 ng/mL) in the cyst fluid, suggesting a potential pitfall in using cyst fluid CEA level as an indicator of mucinous neoplasms. Around 5% of them are located near or in the tail of the pancreas.1We herein report a case of ECIAS with abnormally high CEA level in cyst fluid, and a preoperative radiological diagnosis of pancreatic mucinous cystic neoplasm.A 28-year-old Chinese woman with an unremarkable past medical history was presented to the hospital with dyspepsia and epigastric pain. She underwent abdominal ultrasound, which revealed a simple cyst at the pancreatic tail measuring 1.4 x1.7 x1.5cm in size, with no internal septa or solid area. A subsequent magnetic resonance imaging revealed a well-defined solitary unilocular cystic lesion in the pancreatic tail region, measuring up to 2.34 cm. There was a small mural nodule in its dependent portion and a minimal enhancement at its thin wall without significant enhancement of the mural nodule. There was no vascular invasion, definite communication with the non-dilated pancreatic duct, or lymphadenopathy. A contrast-enhanced computed tomography (CT) was also performed to further characterize the lesion, which revealed a 1.5 x 1.8 x 1.4 cm mildly lobulated, hypodense, and unilocular cyst in the tail of the pancreas. It showed no internal septation or calcification. The pancreatic duct was not dilated . The radEndoscopic ultrasound with linear echoendoscope was also performed and again revealed a 1.6x1.5cm cystic lesion at the pancreatic tail. There was a thin septum within the cyst and a suspicious 5mm mural nodule . The panBased on the radiological findings and cyst fluid biochemistry findings, a laparoscopic distal pancreatectomy with spleen preservation was performed. The surgery was uneventful.Macroscopic examination of the resected specimen showed a unilocular cyst within the pancreatic parenchyma measuring 1.5 x 1.4 x 1 cm with brownish contents. Microscopic examination showed an intrapancreatic simple unilocular cyst lined by bland -ooking, non-keratinizing squamous epithelium 3B. SurroThe patient was discharged one week after surgery, following an uneventful postoperative course.,48,49Accessory spleens are congenital and caused by incomplete fusion of multiple buds of splenic tissue in the dorsal mesogastrium during embryogenesis. The most frequent location is in the splenic hilum and is occasionally found in the pancreas.1The accurate diagnosis of ECIAS by preoperative imaging and cyst fluid biochemistry assessment is difficult. Among the reported cases of ECIAS, only five of them have been diagnosed accurately before surgery.,50,45,52,46Cyst fluid analysis for cytology and biochemistry markers have been widely used to aid the diagnosis of pancreatic cysts. Cyst fluid carcinoembryonic antigen (CEA) is useful in distinguishing intraductal papillary mucinous neoplasm (IPMN) and mucinous cystic neoplasm (MCN) from other cysts types, with relatively high diagnostic accuracy.46Currently, there are no reports regarding cyst fluid biochemistry in ECIAS to date in the English literature. In our case, the cyst fluid showed an amylase level of 879 IU/L, and CEA level of 3582 ng/mL. Although the amylase level was inconclusive, the CEA level was very high and alarming. This high level of CEA and suspicious features in radiological exams prompted the surgeons to offer distal pancreatectomy for the patient. But the final histological diagnosis was ECIAS, suggesting a potential pitfall in using cyst fluid CEA level as an indicator of mucinous neoplasms.According to a study about CEA level in the epidermoid cyst of the spleen,-57Histologically, the differential diagnoses of ECIAS include lymphoepithelial cyst, dermoid cyst, and retention cyst. Lymphoepithelial cyst is also lined by squamous epithelium, but there should be abundant lymphocytes in the wall with germinal center formation.54ECIAS is a rare benign cystic lesion of the pancreas. It is difficult to diagnose preoperatively and often misinterpreted as other cystic neoplasms of the pancreas, such as IPMN and MCN. Cyst fluid analysis for amylase and CEA have been widely used to aid the diagnosis of pancreatic cysts. A high CEA level is reported to be relatively accurate in discriminating IPMN and MCN from other non-mucinous cysts. However, due to the ability of squamous epithelium in ECIAS to produce CEA, the high CEA level in cyst fluid can be misleading. We should be cautious in interpreting cyst fluid biochemistry results and always correlate with clinical and radiological findings to have a more accurate preoperative diagnosis for pancreatic cysts. The typical histological findings of an epidermoid cyst of the spleen/accessory spleen are benign keratinizing or non- keratinizing squamous epithelial lining within normal splenic tissue. The presence of normal splenic tissue around the cyst lining allows differentiation from other cysts, which are also lined by squamous epithelium, including lymphoepithelial cyst, dermoid cyst, and retention cyst.


This study aimed to assess the correlation between Sjögren′s Syndrome (SS) and adverse pregnancy outcomes, with the aim of providing a basis for preconception and pregnancy interventions in women with SS.A search of electronic databases in English and Chinese databases from January 2005 to December 2021, was conducted to collect the literature of case-control studies or cohort studies on the association between SS and pregnancy outcome studies. Literature inclusion and data extraction were performed according to established criteria, and the Newcastle-Ottawa scale was used to evaluate the quality of the literature. Stata 15 software was used for meta-analysis.A total of nine papers were included in this study. Meta-analysis results showed that SS was associated with spontaneous abortion , preterm birth , low birth mass , and birth defects .SS can increase the incidence of adverse pregnancy outcomes. Sjögren′Syndrome (SS) is a systemic immune disease, mainly characterized by the impairment or absence of secretory gland function leading to pathological damage in the oral cavity and eyes, and also involving other tissues and organs of the body. Antibody testing revealed positive anti-Ro/SSA and anti-La/SSB antibodies.SS is an autoimmune disease with a good prognosis, and most of them can be remitted after standardized treatment, but patients with combined visceral damage can experience relapse after discontinuation of the drug. In early clinical practice, most SS patients were diagnosed at the age of 40‒50 years, so its effect on pregnancy was not taken seriously. However, in recent years, women's reproductive age has been higher, coupled with the enhanced public awareness of early diagnosis and early treatment, more than 25% of SS patients are diagnosed before the age of 35,In this study, the authors intend to investigate the effect of SS on pregnancy outcomes through a literature review and meta-analysis in order to provide a basis for the management of women with SS during pregnancy.The databases including CNKI, Wanfang Database, Cqvip Database, PubMed, Web of Science, Embase and Cochrane Library were searched. The search terms were as follows: (1) SS; (2) Pregnancy, pregnancy outcome; (3) Spontaneous abortion, preterm birth, low birth weight, congenital malformation, birth defect, congenital heart disease, congenital heart block; the combination of (1)+(2) or (1)+(3) was searched. The NoteExpress library was used for the removal of duplicate articles. This study is a literature review and has no ethical implications. The review was conducted according to PRISMA 2020 statement.(1) A case-control study or a cohort study; (2) The publication time of the literature: January 2005 to March 2022; (3) The patients in the case group were diagnosed with pSS, and the control group consisted of healthy pregnant women; (4) The literature was in Chinese or English; (5) At least one of the following outcomes was described: (a) Spontaneous abortion: miscarriage within 28-weeks of gestation without any interventions; (b) Birth defect: morphological, structural and functional abnormalities, including congenital heart disease, Down's syndrome, harelip, thalassemia, malformations of the digestive system, malformations of the genitourinary system polydactyly, etc.; (c) Low birth weight: < 2500g; (d) Premature birth: gestational age < 37-weeks.(1) Duplicate reports for the same study population. In this case, the literature with the largest sample size was included; (2) Study subjects with other autoimmune diseases, such as systemic lupus erythematosus; (3) Studies with design flaws; (4) Incomplete data on outcome indicators; (5) Incorrect statistical methods; (6) Literature review studies, conference reports, animal experiments, clinical interventional studies.Two investigators independently conducted literature screening and extracted data from the included literature and negotiated to resolve disagreements. A data collection form was developed, and the extracted information included authors, year of publication, study duration, sample size, age of study subjects, and outcome indicators.The Newcastle-Ottawa Scale (NOS),2 values. Outcome indicators with p > 0.1 and I2 < 50% were used for meta-analysis using a fixed-effects model; outcome indicators with p < 0.1 and I2 > 50% were used for meta-analysis using a random-effects model. Publication bias was analyzed using Begg's test with Egger's test. Statistical significance was considered at p < 0.05.Stata15 software was used for data analysis. Relative Risk (RR) was used as an effect statistic for each outcome indicator . A Chi-Square test was used to analyze the heterogeneity of the literature, combined with I,The study cumulatively included nine eligible papers, two in Chinese and seven in English. Two were prospective studies,,,,Five papersNine papers,,Five papers,Four papersIn the meta-analysis of the correlation between pSS and spontaneous abortion, preterm birth, low birth mass, and congenital malformation, the literature with the largest RR value and the smallest RR value were excluded and then meta-analysis was performed to compare the RR values with 95% CI before and after the exclusion, and the results are shown in The publication bias was quantified using Begg's test and Egger's test, and the results of Egger's test showed that there was a publication bias in the meta-analysis of the correlation between pSS and spontaneous abortion (p = 0.016), while there was no publication bias for the rest of the outcome indicators (p > 0.05). The specific data are shown in SS can lead to the involvement of many exocrine glands and tissues, and the placenta is also one of the target organs during pregnancy, and placental dysfunction can occur after injury, and maternal IgG such as anti-SSA, anti-SSB, and anti-nuclear antibodies can also enter the fetus through the placental barrier and affect its intrauterine development, leading to a variety of adverse pregnancy outcomes such as miscarriage, congenital malformations, stillbirth, and preterm delivery.Some studies have evaluated the association of pSS with adverse pregnancy outcomes, but its risk is difficult to assess relative to the general population, mainly because of the high number of confounding factors such as age, body mass index, and comorbidities, and the difficulty of dealing with confounding factors. C Ballester et al.SS can also have multiple negative effects on neonatal outcomes. Compared to healthy pregnant women, SS women have shorter gestation times, a higher incidence of preterm delivery, a lower percentile birth weight, and a higher proportion of Small for Gestational Age (SGA) infants. A cohort study by Chen JS et al.,It was found that SS can also increase the risk of birth defects such as congenital heart disease.In conclusion, SS can increase the risk of spontaneous abortion, preterm delivery, low birth weight, and birth defects, and the clinic should provide scientific and comprehensive preconception counseling and prenatal testing for female patients with SS, actively treat SS and gestational comorbidities, detect birth defects at an early stage, and choose the appropriate timing and mode of pregnancy termination to improve the prognosis of pregnant women and newborns. However, it is important to note that the existing studies on the association between SS and adverse pregnancy outcomes are relatively few, and most of the existing studies have failed to adequately manage confounding factors. On the other hand, this meta-analysis did not include articles written in other languages except for Chinese and English, which may lead to selection bias. Researchers still need to further analyze the association between SS and adverse pregnancy outcomes through high-quality cohort studies to provide a basis for the development of clinical intervention strategies.Baoqing Geng, Keyue Zhang and Yong Chen designed and performed the experiments. Xianqian Huang and Yong Chen performed the experiments and analyzed the data. Baoqing Geng and Yong Chen wrote and revised the manuscript.No funding was received.The authors declare no conflicts of interest.