ObjectiveTo investigate the diagnostic accuracy of the placental thickness measured by ultrasound sonography test (USG) in detecting intrauterine growth restriction (IUGR) babies in the third trimester of pregnancy, keeping IUGR (by parameters using Hadlock) as the gold standard.Methods and materialsThis cross-sectional study was conducted at the radiology department of KRL Hospital from August 5, 2020, to October 25, 2021. Informed written consent was also obtained from each patient, and the hospital's ethical committee approved the study. Three hundred and sixty-two (N=362) pregnant women patients knowing of their last menstrual period, age group 20-35 years, BMI usual, and 24 weeks gestation were included. The patient's complete history was taken by clinical examination and then ultrasound was carried out to measure the placental thickness. At 24, 32, and 36 weeks, the thickness of the placenta was assessed. The Hadlock method was used to compute the predicted fetal weight by measuring biparietal diameter (BPD), head circumference (HC), abdominal circumference (AC), and femur length (FL) on the GC Logiq P/6 three-dimensional machine . SPSS v 23  was used to calculate the mean and standard deviation from the collected data.ResultsA total of 362 patients who presented in the radiology department for antenatal ultrasound in the third trimester were recruited in our study. The mean age was 27.26 ± 4.21 years (20-35 years). In our study, the mean placenta thickness at 24 gestation weeks was 24.55 ± 0.79 mm, at 32 gestation weeks was 31.84 ± 1.34 mm, and at 36 gestation weeks was 35.54 ± 2.78. Thus, ultrasound's sensitivity, specificity, positive predictive value, and negative predictive value to determine IUGR by placental thickness was 86.30%, 86.70%, 75%, and 92%, respectively. The diagnostic accuracy of ultrasound incorrectly estimating low placental thickness was 86.40%.ConclusionBetween 24 and 36 weeks of pregnancy, placental thickness rises almost linearly. As a result, measuring placental thickness and other factors is critical for estimating fetal age, particularly in the late second and early third trimesters, when the exact duration of pregnancy is uncertain. Placentas that were less than 29 mm thick at 32 weeks and 31 mm thick at 36 weeks were related to higher morbidity, lower Apgar scores, and more nursery admissions. Intrauterine growth restriction (IUGR) is described as a fetus with a birth weight that is significantly lower than the tenth percentile (the lower limit of average weight) for the gestational age . IUGR maThree critical factors contribute to a healthy baby's growth at term: genetics, a healthy mother, and a well-functioning uteroplacental system. The most vital element is the placenta. Unfortunately, it is often ignored -3. The sAny placental development problems may significantly affect fetal growth and yield. Since the 1940s, the ratio of fetal birth weight to placental weight has been used to predict normal fetal development . At ninePlacental thickness abnormality arises due to the uncertainty of the underlying pathological process. Chromosomal defects, preeclampsia, chronic fetal infections, intrauterine growth restriction, and diabetes have been linked to the small placenta . SeveralPlacental thickness anomalies with the corresponding gestational age (GA) are one of the early warning signs for developing IUGR "according to the hypothesis that reduced placental size precedes the onset of IUGR." The use of ultrasound (US) Hadlock for placental size assessment is a secure, simple, inexpensive, feasible, and non-invasive diagnostic method. This is better for developing and low-income countries .This study aims to investigate the diagnostic accuracy of the placental thickness measured by USG in detecting IUGR babies in the third trimester of pregnancy, keeping IUGR (Parameters by using Hadlock) as the gold standardThis cross-sectional study was conducted at the radiology department of KRL Hospital from August 5, 2020, to October 25, 2021. Ethical approval was obtained from the ethical review board committee of KRL Hospital, Islamabad, vide letter reference no. KRL-HI-PUB/Aug21/04 dated August 2021.The study included 362 pregnant women, including first-time mothers and those who had previously given birth. Informed written consent was also obtained from each patient. The ethical committee approved the study of the hospital.Inclusion and exclusion criteriaThe inclusion criteria for our study are the patients' known last menstrual period; age 20-35 years, BMI usual, and 24 weeks gestation. Patients with a history of irregular cycles, diabetes, severe renal disease, hypertension, obesity, placenta previa, and low placenta laying were excluded from this study.Study limitationsOur study is limited to those women who underwent ultrasound examinations at 24 weeks, 32 weeks, 36 weeks, and after the birth of their child.Data collectionThe patient's complete history was taken by clinical examination and then ultrasound was carried out to measure the placental thickness . The fetus was checked for gross anatomical defects and viability. The ultrasound determination of gestational age was determined by calculating various growth parameters (Hadlock method) "biparietal diameter (BPD), femur length (FL), abdominal circumference (AC), head circumference (HC)."The placental site had been determined in a longitudinal section using a two-dimensional, real-time mode. The placental thickness was measured at "the level of umbilical cord insertion in longitudinal course from lateral chorionic plate to the insertion of the cord apart from the retro placental area," as shown in Figure Data analysisThe estimated fetal weight was calculated by measuring BPD, AC, and FL using the Hadlock method on the GC logic P/7 three-dimensional machine . Data were analyzed using SPSS v 23  with mean and standard deviation.2). The height was 170.43 ± 10.32 cm, and the weight was 75.32 ± 6.23 kg, as shown in Table In the present study, the patient age ranged between 20 and 35 years; the mean age was 27.26 ± 4.21 years. The BMI was of the patients 26.40 ± 4.10  showed that 101 86.32%) fetus of < 2.5 kg had placental thickness < 32 (mm), 16 (13.68%) fetus of < 2.5 kg had placental thickness > 32 (mm). Similarly, 33 (13.45%) fetus of > 2.5 kg had placental thickness < 32 (mm), 212 (86.55 %) fetus of > 2.5 kg had placental thickness > 32 (mm), as shown in Table 2% fetus Thus, the sensitivity of ultrasound "ability to correctly identify fetus having a low placental thickness" was 86.30%. In contrast, the specificity of ultrasound "ability to correctly identify fetus not having low placental thickness" was 86.70%. The positive predictive value "probability of having low placental thickness babies on ultrasound when it is present" was observed as 75%, and the negative predictive value "probability of having low placental thickness babies on ultrasound when it is not present" was 92%. The diagnostic accuracy of ultrasound incorrectly estimating low placental thickness was 86.40%.The placenta is known as the "sprightliness" of the fetus in gestation, responsible for a wide range of functions that help the fetus mature. The placenta keeps the umbilical cord feto-maternal circulation going . For aveThe thickness of the placenta is closely linked to fetal development and can play a role in the perinatal outcome. The placenta is about 3 cm thick and 15-25 cm in diameter [Low birth weight neonates are predicted by a "warning limit" of 2cm placental thickness and 1.8cm placental diameter at 36 weeks. Chromosomal defects, preeclampsia, recurrent fetal infections, intrauterine growth restriction, and diabetes mellitus are linked to small placentas . Diabete2 [Our results agree with the study of Adeyekun and Ikubor , as they2 . These rPregnant women are subjected to similar stressors, and any maternal illness affects both the placenta and the fetus. Placental health and measures are thus able to represent the fetus's overall well-being and nutritional state and predict pregnancy outcomes. The most straightforward measurement is placental thickness, which reflects placental size .Balla et al. studied the thickness of the placenta in 53 pregnant women in their third trimester . They coAccording to Damodaram et al., there is a positive association between placental volume and gestational age, but it is decreased in growth-restricted fetuses . The earBecause the placental thickness is nearly equal to the gestational age in weeks, it appears to be a promising indicator of fetal gestation and a predictor of fetal outcomes when measured by ultrasound. "Placental thickness below the 10th percentile has been linked to low birth weight and IUGR," says one study.The diagnostic accuracy of ultrasound incorrectly estimating low placental thickness was 86.40%. This demonstrates that placental thickness is an outstanding predictor of IUGR. It is clear from the preceding discussion that IUGR is linked to decreased placental thickness. As a result, we believe that subnormal placental thickness can be used as an early indicator of IUGR.Between 24 and 36 weeks of pregnancy, placental thickness rises almost linearly. As a result, measuring placental thickness and other factors is critical for estimating fetal age, particularly in the late second and early third trimesters, when the exact duration of pregnancy is uncertain. Placentas that were less than 29 mm thick at 32 weeks and 31 mm thick at 36 weeks were related to higher morbidity, lower Apgar scores, and more nursery admissions. As a result, patients in this age group should give birth in a setting with appropriate nursery facilities.Placental parameters can be measured in peripheral centers that lack Doppler and 3D ultrasound capabilities, allowing for timely referral and a stable fetus.


After treatment of intrauterine adhesions, the rate of re-adhesion is high and the pregnancy outcome unpredictable and unsatisfactory. This study established and verified a decision tree predictive model of live birth in patients after surgery for moderate-to-severe intrauterine adhesions (IUAs).A retrospective observational study initially comprised 394 patients with moderate-to-severe IUAs diagnosed via hysteroscopy. The patients underwent hysteroscopic adhesiolysis from January 2013 to January 2017, in a university-affiliated hospital. Follow-ups to determine the rate of live birth were conducted by telephone for at least the first postoperative year. A classification and regression tree algorithm was applied to establish a decision tree model of live birth after surgery.Within the final population of 374 patients, the total live birth rate after treatment was 29.7%. The accuracy of the model was 83.8%, and the area under the receiver operating characteristic curve (AUC) was 0.870 (95% CI 7.699–0.989). The root node variable was postoperative menstrual pattern. The predictive accuracy of the multivariate logistic regression model was 70.3%, and the AUC was 0.835 (95% CI 0.667–0.962).The decision tree predictive model is useful for predicting live birth after surgery for IUAs; postoperative menstrual pattern is a key factor in the model. This model will help clinicians make appropriate clinical decisions during patient consultations. Intrauterine (IU) adhesions (IUAs) result from injury to the basement layer of the endometrium. Various kinds of damage can cause adhesion between the walls of the uterus with accompanying adverse morphological changes, or loss of function of the uterine cavity, or both . IUAs arIUAs seriously harm women’s reproductive, physical, and mental health. For patients with IUAs as the main cause of infertility, the degree of adhesions is closely related to the outcome of pregnancy . The facA multivariate logistic regression analysis model can predict the clinical outcome and identify risk factors, but is difficult to implement and explain, especially for clinicians without a statistical background . It is dThe main purpose of treatment for patients with IUAs is to obtain live births. To better evaluate and predict live birth after surgery for IUAs and provide clinical consultation , the prePatients with moderate or severe IUAs were selected who had been treated for infertility or recurrent abortion, from January 2013 to January 2017, at the Gynecology Minimally Invasive Center of Beijing Maternity Hospital Affiliated to Capital Medical University in China. This is a tertiary medical institution and hysteroscopic diagnosis and treatment center with nearly 1000 hysteroscopic surgeries performed annually.For inclusion, each patient was aged 20 to 40 years; with an outpatient hysteroscopic diagnosis of moderate or severe IUAs (AFS ≥ 5) ; secondaThe cervix was softened by 400 μg of misoprostol, 12 h before the operation. Tracheal intubation and intravenous general anesthesia were administered. Olympus S70 surgical hysteroscopy series equipment was used, and the perfusion medium was normal saline. Under the direct view of the hysteroscope, the shape of uterine cavity, and the position and degree of adhesion were observed. Adhesion tissue was separated via needle electrode and scar tissue by ring electrode, expanding the uterine cavity volume and removing scar tissue with care to protect the residual endometrium . SuccessThe operator was a senior doctor with a surgical team and extensive experience in the separation of IUAs. A physical barrier  was used to prevent the recurrence of IUAs . All patLive birth is defined as delivery occurring at any time between 28 and 42 completed weeks of gestation. In this study, the diagnosis and score of IUAs referred to the American Fertility Society (AFS) standard of 1988. According to the nature, scope, and menstrual pattern of adhesions, the quantitative scores were: mild, 1–4 points; moderate, 5–8 points; or severe, 9–12 points.For measurement of uterine volume and endometrial thickness, all patients were examined by vaginal color ultrasound (model: GE E8). Patients with menstruation were examined during the latter period of menstruation proliferation. Patients with amenorrhea were examined at no specific time. The length, width, and thickness of the uterine body were measured. The length was considered the distance from the bottom of the uterus to the internal orifice of cervix. The width and thickness of the uterine body were the transverse diameters of the coronal and sagittal sections, respectively. The volume of the uterus was calculated as length × width × thickness × 0.523, in cm3 . The depAccording to the modified vas method of Osada et al. , the patData was collected from the electronic database and telephone return visits of inpatients, including demographic and clinical characteristics, surgical records and hysteroscopic pictures, pregnancy outcome, and related complications after treatment. The pregnancy outcome was followed up by telephone in February 2018.Three months after the operation, menstruation was evaluated for improvement in the outpatient department, and hysteroscopy was performed . A normaA clinical pregnancy was defined as within the IU gestational sac. Live birth was ≥28 weeks of gestation, with a live birth obtained. Full term birth was considered ≥37 weeks of gestation, and premature birth < 37 weeks of gestation. Loss of pregnancy was recorded as spontaneous abortion, fetal arrest, or stillbirth.p = 0.5 of the resample function in ROSE to keep the proportion of positive sample size approximatively equal to 0.5. Consequently, the number of samples with live and non-live production is more or less balanced . The new data was used for further analyses.The final analysis comprised 374 patients , including 23 variables, with live birth as the outcome variable and 22 other related factors as the predictive variables Table . Becausewww.r-project. ORG) random Forest package was used to rank the features of the independent variables (predictive variables) according to the mean decrease accuracy index. The first 10 most important feature variables were selected. To get the best predictive efficiency, various data partition schemes were tried. We finally choose 90% of the original data to build the decision tree model, a classification and regression tree (CART) algorithm, and 10% of the data to verify the model. The decision tree model was constructed using the R language rpart (Recursive Partitioning and Regression Trees) software package. Using the rpart package, the decision tree was constructed by CART algorithm based on gini index splitting criteria. The minimum sample size of the parent node was 30, the minimum sample size of the leaf node was 10, and the depth was set to 5.The R language . From January 2013 to January 2017, 394 women were treated for moderate and severe IUAs. Of these women, 12 were lost to follow-up, and there were 4 excluded for serious adenomyosis. In addition, 2 women each had endometrial lesions or were not completely restored to normal IU morphology after surgery.Thus, the study population comprised 374 patients with complete data. The average age was 31.5 ± 4.09 20–40) years, the follow-up time was 24.1 ± 3.2 (12–58) months, and the average time from surgery to pregnancy was 7.4 ± 5.4 (1–25) months. The patients included in the study had no serious surgical complications. The overall population postoperative rates for pregnancy, live birth, and pregnancy loss were, respectively, 40.6% (152/374), 29.7% (111/374), and 10.9% (41/374). For the group with severe IUAs, rates of pregnancy and live birth were 33.6% (44/131) and 22.1% (29/131). Women with moderate IUAs showed corresponding rates of 44.4% (108/243) and 33.7% (82/243). Factors related to live birth are shown in Table 0–40 yearAfter the operation, 57 patients tried in vitro fertilization; among whom 16 became pregnant  and there were 13 full-term live births . Among 317 women who tried natural conception, 136 became pregnant , and there were 98 women with live births .Among the live births, 57 women experienced cesarean section. There were 10 cases of abnormal placentation, comprising 7, 2, and 1 case of placenta previa, placental implantation, and placental adhesion, respectively. Three women underwent premature delivery, with one case each of placenta previa bleeding cesarean section, premature rupture of membranes at 34 weeks of gestation, and cervical insufficiency at 35 weeks of gestation. There were 41 cases of early pregnancy loss, including 2 of cervical dysfunction and 3 of ectopic pregnancy .During the second look 3 months after surgery, 119 patients had various degrees of adhesion, as follows. Among 23 women with mild re-adhesion, 8 were pregnant, and 6 had given live birth (26.1%). Among 83 patients with moderate re-adhesion, 22 were pregnant, and 15 had given live birth (18.1%). There were 13 patients with severe re-adhesion, and none had become pregnant.Based on the ranking results of the average accuracy reduction index Table  with theThe postoperative menstrual patterns of women who had normal menstruation prior to surgery were assessed as normal, improved, or not improved. The pregnancy rate of patients without improvement (8.1%) was significantly lower than that of the patients with improved or normal menstruation (8.1% cf. 51.0%). Among the patients with improved menstrual volume after surgery, the live birth rate of those who had undergone a previous uterine cavity operation  was significantly higher than that of patients without a previous procedure .3. In patients with normal menstruation, the live birth rate was 63.6% and the uterine volume was ≥57.25 cm3. In the subgroup of patients with a uterine cavity depth ≥ 7.75 cm, the live birth rate of those with a postoperative AFS score < 2 was 82.1% . In the patients with a uterine cavity depth < 7.75 cm, those with improved menstruation had a significantly higher live birth rate than did those with normal menstruation. Among patients with improved menstruation, the live birth rate was 61.7% with a uterine volume ≥ 34.9 cmP = 0.130; z test).The predictive accuracy of the decision tree model is 83.8% Table ; Fig. 2.This study is the first to establish and verify a decision tree model of postoperative live birth in patients with IUAs. The accuracy of the model is 83.8%, which is similar to the accuracy of the multifactor logistic regression analysis model, and has a high predictive value. The structure of the decision tree model clearly depicts the decision-making process, the population characteristics, and the probability of live birth. By establishing a decision tree model we can preliminarily understand the probability of live birth of those with relevant characteristics. This facilitates communication between doctors and patients when deciding to further treatment. On the other hand, it was found that factors closely related to live birth, such as change in postoperative menstrual volume, were the main factors to predict live birth. The operator should pay attention to the identification and protection of the functional endometrium when performing uterine surgery. This study found that the preoperative AFS score is not the primary factor affecting live birth. Therefore, we need to establish a diagnostic scoring standard of intrauterine adhesion for predicting live birth in combination with relevant factors in the decision tree.The decision tree model we developed is valuable for clinical application, as it characterizes the population, with live birth as the outcome index. Firstly, the decision tree model has high predictive efficiency, as the test set data was validated. At the same time, a multifactor logistic regression model was established. The predictive accuracy of the two models is similar, but the decision tree model is easier to implement, understand, and explain .Secondly, the tree structure is easy to build and understand. It provides clinicians with an appropriate reference for clinical decision-making and facilitates communication with patients. The logistic regression model is displayed in the form of equations, which is difficult to apply in clinical practice. In this study, the predictive index is quantified and sequenced in advance . The decIn addition, the structure of the decision tree model clearly shows the rates of live birth in patients with various characteristics. The clinician can choose whether to operate based on the local medical technology and patient’s situation, by combining the relevant preoperative predictive factors. This avoids blind, excessive, and ineffective treatment, and simultaneously provides consultation for patients. At the same time, patients with other characteristics are classified, which is more instructive and practical than only analyzing which variables affect the outcome .The current decision tree model not only shows the probability of live birth of patients with different characteristics, but also shows the related factors and their relationships. The closer the root node is to the classification variables, the greater the influence on the outcome. The interactions among variables are shown. Using the decision tree model, we found that postoperative menstrual pattern was the main factor affecting the likelihood of live birth. Although surgery can restore the anatomical structure of the uterine cavity and expand its volume, damage of the basement layer leads to endometrial repair obstacles and local fibrosis . The lacPrevious studies have shown that AFS score is closely related to treatment outcome –32. In tThe low rates for pregnancy and live births in women with moderate and severe IUAs have always been a major problem for clinicians. In the present study, the total pregnancy and live birth rates in women with moderate and severe adhesions were relatively low. This may be because, first, the focus of our center is severe adhesions, and data for mild adhesions is not included .Secondly, some of the patients in the study experienced re-adhesions after surgery. Although mild and moderate adhesions were treated with dilated uterine pressure and blunt lens separation at 3 months after surgery, the outcomes of most of these patients are unknown, due to lack of further hysteroscopic examination. Other patients still had moderate and severe IUAs during the second exploration, but no further operation for separation of adhesions was conducted. Some patients with moderate and severe adhesions will refuse further surgery after improvement of menstruation. The patients included in the research results of Xu et al.  were conEarly assisted reproductive technology may improve the live birth outcome. Xu et al.  followedThe patients in our center have mainly moderate or severe adhesions, especially peripheral and mixed-dense adhesions. Bipolar electric resection has been used for many years. During surgery, protection of the residual endometrium results in better rates of pregnancy and live birth. However, considering that the cold knife does little damage to normal endometrium and affects pregnancy outcome , we alsoThere are some deficiencies in this retrospective study. The sample size is relatively small, and some predictive variables may not be included. Some variables need to be further quantified and standardized. The menstrual volume should be quantified, but based on the present retrospective data, the range of menstrual volume reduction is too broad. The range of patients’ features is relatively broad, although realistic. The decision tree itself has its shortcomings. The selection of parameters, the number of samples, and the algorithm all affect the stability and predictive accuracy of the decision tree . We willThe decision tree model of live birth after surgery for IUAs can identify the characteristic population and predict the probability of live birth. This model will help clinicians make appropriate clinical decisions during patient consultations.


Aim: To report the optical characteristics of the fluid in an anterior chamber iris cyst. Method: A 26-year-old male presented with blurring of vision in his right eye for two months, without any other associated ocular complaints. His visual acuity was 6/ 9 on Snellen’s chart. On slit lamp examination, a small translucent pigmented cyst was noted inferiorly in the anterior chamber, struck on to the cornea at 6 o’clock periphery, without any feeder vessel. Anterior segment optical coherence tomography (OCT) revealed a cystic lesion with hyperreflective walls and hypo reflective lumen attached to the cornea, compressing the endothelium.Results: The optical density (OD) of the cyst fluid was determined using ImageJ, an open code Java-based image processing software. The OD of cyst fluid was found comparable to the anterior chamber fluid.Conclusion: Ultrasound biomicroscopy (UBM) and OCT are useful tools for the diagnosis of cystic lesions of the anterior segment. The innovative use of an OCT image and the ImageJ software to determine the optical density of the iris cyst may aid in the diagnosis and follow-up of such cases. Primary iris cysts are clinically classified as epithelial and stromal subtypes. Epithelial cysts arise from layers of pigmented epithelium of the iris. Additionally, based on the location, cysts can be central, middle, or peripheral in relation to the pupil. The iris pigmented cysts can present at the pupillary margin, posterior layers of iris epithelium or free-floating in aqueous or vitreous [2]. Iris cysts have always fascinated ophthalmologists because of rarity of occurrence and mystery about their origin. The aetiology of primary iris cysts is poorly understood, whereas secondary cysts have an antecedent cause like the use of miotics, trauma or surgery [3]. The clinical and morphological features of such cysts are well characterized; however, the optical properties of the contents are not well documented. ImageJ software has been used in retinal images to characterize the optical density of subretinal fluid in various retinal diseases [4]. This report describes for the first time the optical density (OD) of an anterior chamber iris cyst using optical coherence tomography (OCT) and ImageJ software. Iris cysts in the anterior chamber have been well described in literature. These cysts are lined with pigment epithelium and contain clear fluid. They can be free-floating in the anterior chamber or fixed to anatomical structures. Usually, these cysts remain asymptomatic, but can lead to complications due to inflammation, glaucoma, or mass effect. At times, these mass lesions have been mistaken for malignancy, and literature has few reports of enucleation performed for the fear of malignancy . The optical density of the cyst was 21.5, which was comparable to anterior chamber fluid, suggesting clear contents inside the cyst .Anterior segment OCT revealed a cystic lesion in the anterior chamber, with hyperreflective walls and clear hypo-reflective lumen attached to the cornea compressing the endothelium  is usually the recommended modality for the imaging of iris cysts, which displays high reflectivity of the cyst wall; however, OCT characteristics are not well described in literature [7]. As documented in this report, the OCT findings substantiate similar findings, as noted in the UBM studies. The outer wall of the cyst is hyperreflective, with clear hypo reflective lumen. Besides, OCT has advantages over UBM, as it is a rapid, non-contact, and non-operator dependent imaging modality to document the characteristics of the cyst and the surrounding ocular tissues.Primary stromal cysts arise from ectopic surface epithelium, trapped in the iris during embryological development, while secondary iris cysts arise after ocular trauma or surgery [5]. The optical density describes the amount of light received by the sensor while passing through a particular medium. We found that the optical density of the cyst fluid was comparable to the anterior chamber fluid. This innovative method could be used for objective assessment and follow-up of such cases, as any change in the contents would be picked up objectively at the initial stage by the change in OCT characteristics and optical density. In this report, we adopted an innovative approach to characterize the optical properties of the fluid inside the cyst using ImageJ software [6]. Such patients should be advised to undergo a cardiological evaluation, as the same defect in smooth muscles may lead to aortic dissection. The cysts at the margin of the pupil are called floccule and are believed to be caused due to a genetic defect in smooth muscles [7].Treatment of iris cysts depends on the location and symptoms of the individual. The long-term complications of iris cyst include obscuration of the visual axis, corneal decompensation, secondary uveitis, and glaucoma. Treatment options range from observation to fine-needle aspiration, laser , or surgical excision. However, a step ladder approach should be adapted, and treatment should be individualized based on the clinical picture. The OCT seems to be a promising tool for imaging the cyst and optical properties of the fluid on imageJ software may prove to be an objective method, useful for the diagnosis and follow-up of such patients, as it was recently reported in capsular block distension syndrome [Ultrasound biomicroscopy and OCT are useful tools for the diagnosis of cystic lesions of the anterior segment. Innovative use of ImageJ software on OCT image to determine the optical density of the cystic lesion may further characterize the iris cyst, as described in this report. The measurement of the optical density of the contents of the cyst may aid in the initial diagnosis and follow-up of such cases, however further investigations are warranted in larger cohorts of patients.Conflict of Interest statementThe authors declare no conflict of interest. Informed Consent and Human and Animal Rights statementInformed consent has been obtained from all individuals included in this study.Authorization for the use of human subjectsEthical approval: The research related to human use complies with all the relevant national regulations, institutional policies, is in accordance with the tenets of the Helsinki Declaration, and has been approved by the review board of Institute of Naval Medicine, Indian Naval Hospital Ship Asvini, Colaba, Mumbai, India.AcknowledgementsNone.Sources of FundingAuthors have no competing interests to declare. No financial disclosures. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Consent was taken from patient for use of images, health data and OCT scans for the purpose of research and publication. No external funding was received.DisclosuresNone.


This study aims to design, develop, and evaluate the traction performance of an electric all-wheel-drive (AWD) tractor based on the power transmission and electric systems. The power transmission system includes the electric motor, helical gear reducer, planetary gear reducer, and tires. The electric system consists of a battery pack and charging system. An engine-generator and charger are installed to supply electric energy in emergency situations. The load measurement system consists of analog (current) and digital  components using a controller area network (CAN) bus. A traction test of the electric AWD tractor was performed towing a test vehicle. The output torques of the tractor motors during the traction test were calculated using the current and torque curves provided by the motor manufacturer. The agricultural work performance is verified by comparing the torque and rpm (T–N) curve of the motor with the reduction ratio applied. The traction is calculated using torque and specifications of the wheel, and traction performance is evaluated using tractive efficiency (TE) and dynamic ratio (DR). The results suggest a direction for the improvement of the electric drive system in agricultural research by comparison with the conventional tractor through the analysis of the agricultural performance and traction performance of the electric AWD tractor. An electric vehicle using an electric motor can be classified as hybrid electric vehicle (HEV), such as serial hybrids and parallel hybrids, and battery electric vehicle (BEV) [The fuel consumption of agricultural machinery continues to increase in Korea, increasing the seriousness of environmental pollution ,2; accorle (BEV) ,9,10. Thle (BEV) . By contle (BEV) . The devle (BEV) ,14,15. Hle (BEV) . The parle (BEV) . In addile (BEV) . Becausele (BEV) ,20. An ele (BEV) . It detele (BEV) . A tractle (BEV) . Tractorle (BEV) . Typicalle (BEV) . The TE le (BEV) . A numbele (BEV) ,26, but le (BEV) ,28. PerfThe electric motor of the AWD tractor used in this study replaced the conventional Diesel engine, which is the driving source of the agricultural tractor. A power transmission system consisting of electrical and mechanical components for each axle is shown in 3 (length × width × height); the empty vehicle mass was 7440 kg. The weight distribution ratio of the front and rear was designed to be as similar as possible when developing the platform. 4, which has a long cycle and can adequately cope with the high power output of the electric motor during operation [The electric AWD tractor uses a platform developed in previous research . Figure peration . The tot−1 per channel; detailed specifications are shown in The data measurement system consisted of current sensors, a controller area network (CAN) logging system, and a data acquisition (DAQ) device, as shown in 3 (length × width × height), respectively. The traction performance test was conducted on concrete with a slip ratio of 15% or less. The test was conducted at the driving circuit located in Wansan-gu, Jeonju-si, and Jeollabuk-do, Republic of Korea (35°49′41.5″ N 127°03′13.7″ E). The travel speed of the electric AWD tractor was maintained at 4 km/h by driving the electric motor at a constant rotational speed. The electric AWD tractor traveled straight for about 100 s, and the brake system of the traction performance test vehicle was operated irregularly under the condition that the slip ratio did not exceed 15% to measure the traction force under severe conditions.A traction performance test vehicle was connected through a drawbar configured at the rear of the electric AWD tractor to perform the traction test, as shown in The axle torque generated the traction of the tractor by the rotation of the drive wheel. The net traction force was calculated from the axle torque during the test, tire diameter, and rolling resistance. Thus, traction performance is closely related to axle load and performance . The traformance . The netformance , represeThe DR is calculated using the traction force and weight , represeThe driving wheel power of the tractor is calculated using the torque and rotational speed of the axles ,33, summThe drawbar power is calculated by the traction force and travel speed , represeTE is an index indicating the ratio of the drawbar power calculated by the net traction force and axle power , represeThe motors of the electric AWD tractors connect to the same mechanical systems; therefore, the output torque of the motors did not vary significantly from axle to axle. However, when skid steering is adopted , a diffeR-squared (R2). R2 is a statistical measure that represents the proportion of the variance for a dependent variable, and it is explained by an independent variable or variables in a regression model. The R2 through regression analysis was calculated through Equation (9).R2 is the coefficient of determination of the regression equation, In order to validate the drawbar power, axle power, tractive efficiency, and dynamic ratio for the electric AWD tractor, the linear regression analysis were performed. The linear regression analysis was performed using statistical software, IBM SPSS Statistics . The correlation of the data between slip and each factor was compared and analyzed using The agricultural work performance was evaluated using the axle torque of the conventional tractor during plowing tillage, which generated the largest load during operation, and it was compared with the T–N curve of the electric motor applying a reduction ratio, as shown in R2 was found to be 0.58. The increase in tractive efficiency due to slip indicates that the axle power is converted into drawbar power in harsh conditions with a small loss. The tractive efficiency of electric AWD tractors can be increased by improving the motor output.The TE of the electric AWD tractor was calculated through the drawbar power and axle power, as shown in The DR is the ratio of traction to the weight acting on the axle. The DR of the electric AWD tractor was calculated from the net traction force and the load applied to the left and right axles, as shown in In this study, the traction performance of the electric AWD tractor was evaluated using a traction performance test vehicle. The torque of the electric motor generated during the traction test was found to be within the possible output range of the electric motor through comparison with the performance curve. Since this study was conducted on concrete, the workload of a conventional tractor was used to evaluate the potential to performing agricultural operations. In addition, the traction performance on concrete of the electric AWD tractor should be compared and analyzed by referring to previous traction test studies (on concrete) for conventional tractors. The TE of the conventional tractor in the concrete condition refers to the data of previous studies ,40,41. BThis study aimed to design, develop, and evaluate the traction performance of an electric AWD tractor based on the power transmission and electric systems. A load measurement system was employed to collect the data for traction performance evaluation during the traction test. The traction was calculated using torque that was measured using the load measurement system. Traction performance was evaluated using two metrics—TE and DR—of the electric AWD tractor. The TE was calculated using drawbar power and axle power, and the DR was calculated using net traction force and the weight of the tractor. The results indicate that the proposed electric AWD tractor demonstrates improved traction performance under high-load conditions, based on the output torque of the electric motor, TE, and DR. The TE of the electric AWD tractor was in the range of 0.60 to 0.80. The DR of the electric AWD tractor was in the range of 0.17 to 0.30. The traction performance of the electric AWD tractor was compared to that of a conventional tractor, as per the results of a previous study, and the range of slip was 0 to 15% considering the motor and conditions of the traction test. The average TE of the conventional tractor and electric AWD tractor were approximately 0.84 and 0.70, respectively, and the difference was around 0.14. The average DR of the conventional and electric AWD tractors were 0.77 and 0.22, respectively, and the tendency and difference were high. This result was due to the motor’s self-protection algorithm. A low DR means that the output power per weight is insufficient; therefore, the power-limiting algorithm of the electric motor must be improved according to slip. In a future study, an improved motor control algorithm will be applied to allow the performance of actual agricultural operations, and the traction performance of AWD tractors in various conditions  will be evaluated.


In "expected" group, logistic regression analysis showed that female age , treatment cycles , duration of Gn administered  and transferable embryos  is independent predictive factors of live birth. In "expected" group, logistic regression analysis showed that female age , AFC , total dosage of Gn administered , duration of Gn administered , MII number  and transferable embryos  is independent predictive factors of live birth. We also established a smooth curve fit to predict the probability of live birth among the POSEIDON "unexpected" and "expected" group. These independent predictive factors on the pregnancy outcome of IVF/ICSI and the successful establishment of smooth curve fit can provide valuable reference for treats poor ovarian reserve patients in clinical work.We retrospectively analyzed the clinical data from 39,185 cycles who undergoing  Despite numerous research efforts, there is no consensus on factors that accurately predict the outcome of VF/ICSI) , 2. ThisVF/ICSI) , 4, whicVF/ICSI) .The new POSEIDON stratification guidelines which classify patients with infertility condition in to "expected" or "unexpected" groups with regard to successful live birth have been embraced by reproductive endocrinologists worldwide. They provide a more nuanced picture for the management of POR individuals in need of reproduction assistance , 7. The Evidence-based medicine has progressively transformed in to the standard approach for numerous diagnosis and treatment of several health complications . AccordiPOR patients were divided in to "unexpected" group (n=3337) and "expected" group (n=2667). Live birth was observed in 1134 (33.98%) women in the "unexpected" group. The rest of the 2203 (66.02%) women didn't get a live birth. In the "expected" group, 220 (8.25%) women delivered live babies, whereas 2447 (91.75%) of them didn't get a live birth.Baseline characteristics of patients in the "unexpected" group and likely predictive factors for successful pregnancies are shown in The baseline characteristics of patients in the "expected" group are shown in Herein, we analyzed factors that potentially predicts pregnancy outcome after IVF/ICIS among POSEIDON "unexpected" and "expected" groups in POR patients. Assisted reproductive technologies (ART) have significantly improved pregnancy outcomes in POR patients. However, intervening factors for pregnancy outcome in these group of individuals remain uncertain . Also, hStudies have shown that age of female is the most important factor affecting female fecundity and oocyte quality, all which directly affects pregnancy outcome whether in "unexpected" and "expected" group. Herein, we found a strong relationship between female age and the likelihood of live birth, consistent with previous findings. Particularly age and the propensity of live birth display an inverse relationship. Ovarian function decline with age, which positively correlates with decrease in the number and quality of oocytes . Fewer aMultivariate logistic regression analysis revealed that age of female, treatment cycles, duration of Gn administered and transferable embryos were independent predictive factors of live birth in the "unexpected" POSEIDON group. our study show that the chances of achieving a successful pregnancy outcome decreases with increasing female age and increasing treatment cycles, however, there is a positive correlation association between the chance of pregnancy and duration of Gn administered and transferable embryos. It is worth emphasizing that there are no simple linear relationship between them observed through smooth curve fit, threshold effects and nonlinear association were found between female age, treatment cycles, duration of Gn administered and live birth, through the integration of large sample data and the smooth curve fit, we can predict the live birth rate more accurately and successfully. And we can found female age maybe in 20 to 30 years had the highest live birth among the "unexpected" group, Meanwhile, the probability of females older than 45 years in the "unexpected" POSEIDON group getting pregnant was generally zero. Also, we found a strong relationship between live birth rate and number of treatment cycles, duration of Gn administration and the number of transferable embryos in POR patients.Age of female, AFC level, total dosage of Gn administered, duration of Gn administration, number of MII and transferable embryos were independent predictors of live birth in the "expected" group. We found age of female, duration of Gn administration and MII number influences the probability of live birth, whereas AFC, total dosage of Gn administered and number of transferable embryos protective factor for live birth rate. Smooth curve fit revealed that these independent predictors can accurately predict the probability of live birth in POR patients, thus useful in clinical management of these group of individuals. Even so, many factors and functioning of many systems continuous change during pregnancy, coupled by numerous confounding factors. Also, retrospective trials suffer substantial selection bias issues, which impacts on the outcome, we will conduct RCT to confirm this hypothesis in the future.Overall, the POSEIDON classification system of individuals with infertility complication in to "expected" or "unexpected" groups is useful in clinical diagnosis and management of these patients , 25. ThiClinical data for 39,185 women undergoing IVF/ICSI at reproductive medical center of the First People's Hospital of Shangqiu were enrolled for this study. Eligible participants were categorized into "unexpected" (n=3337) or "expected" group n=2667) based on POSEIDON criteria. According to POSEIDON guidelines, patients with antral follicle count (AFC) ≥ 5, anti-Mulller hormones(AMH) ≥ 1.2 ng/ml and ≤ 9 oocytes retrieved in the first simulation cycle are (not expected) to have successful deliveries, whereas those with AFC < 5, AMH < 1.2ng/ml are (expected/ not expected) to have successful pregnancies 67 based .The patients either received prolonged GnRH agonist or GnRH antagonist treatment, short GnRH agonist treatment or natural cycle of IVF/ICSI followed by embryo transfer in the same cycle. The starting gonadotropin dose was based on the AFC, age of female patient, body mass index (BMI) and previous history of ovarian response to stimulation. The doses were adjusted progressively according to patient`s response. When dominant follicles measuring > 16mm reached 60% or the mean follicle diameter reached 20 mm, (ovulation) triggering was performed using 250ug r-hCG (Merck Serono) in combination with 2000IU u-HCG . Oocyte were retrieved 37 hours after triggering using transvaginal ultrasound . SuccessVarious parameters and likely intervening factors for successful birth were compared between groups. The data used in this study was downloaded from the Clinical Reproductive Medicine Management System/Electronic Medical Record Cohort Database (CCRM/EMRCD) of the First People's Hospital of Shangqiu, Reproductive Medical Center. The patients had attended the hospital between January 2013 and December 2018. The protocol for this study was approved by the Ethics Committee of Reproductive Medicine Centre of the First People's Hospital of Shangqiu, China. Approved consents were not necessary. The research was performed in accordance with the First People's Hospital of Shangqiu guidelines and regulations.http://www.empowerstats.com) and SPSS V. 19.0 . Continuous variables were expressed as means ± standard deviation. Differences between groups were compared using Student’s t test or the Wilcoxon rank sum test. The relationship between various factors such as age of the female, years of infertility, BMI, AMH, AFC, number of transferable embryos, treatment cycles, Gn dosage, Gn duration, number of Oocytes, number of MII and number of transferable embryos among others, and pregnancy outcome was analyzed using univariate and multivariate logistic regression analyses. P < 0.05 was considered statistically significant. P-values were adjusted based on the Holm-Bonferroni method to control for Type I error.Data was analyzed using R software, V. 3.2.3, EmpowerStats (


Aggressive retinopathy of prematurity (A-ROP), formerly known as aggressive posterior retinopathy of prematurity (APROP), occurs generally in extremely premature infants less than 28 weeks gestational age with extreme low birth weight of ≤1000g. We report a case of A-ROP occurring in a larger and less preterm infant. The possible risk factors that lead to the occurrence of A-ROP in this infant will be discussed.Ureaplasma infection.An infant born vaginally at 30 weeks gestational age weighing 1550g was diagnosed with A-ROP. Retinopathy of prematurity (ROP) screening was performed due to the presence of risk factors: prematurity, low birth weight, received supplemental oxygen, intraventricular hemorrhage and history of maternal chorioamnionitis. Following a single injection of intravitreal ranibizumab, significant regression of A-ROP was observed. A-ROP was unexpected in this infant and was believed to have developed as a result of receipt of supplemental oxygen, maternal chorioamnionitis, and  Retinopathy of prematurity (ROP) is a vision-threatening disease and a well-known cause of childhood blindness worldwide. It is estimated that blindness caused by this disease occurred in at least 50,000 children globally . In a suUreaplasma urealyticum pneumonia and completed 14 days of oral azithromycin therapy.A premature male infant at 30 weeks period of gestation was delivered via vaginal delivery with birth weight of 1550 grams. His Apgar score was 6 and 9 at one and five minutes, respectively. He had respiratory distress syndrome at birth and required invasive ventilator support for 14 hours. He received a dose of intra-tracheal surfactant therapy. He was subsequently extubated to non-invasive ventilator support for the next 18 days. His highest oxygen requirement while receiving ventilator assistance was 30%. On day 19 of life, he was placed on low oxygen therapy at 1L/min which was subsequently weaned off at day 27 of life. At seven weeks of life, he was diagnosed with Serial cranial ultrasounds performed during his stay in the Neonatal Intensive Care Unit showed presence of bilateral intraventricular hemorrhage grade II, which subsequently resolved by two months of age. He was also diagnosed with gastro-esophageal reflux disease (GERD) which was confirmed with a pH study. As a result, he had recurrent episodes of significant apnoea.His mother was diagnosed with chorioamnionitis prior to delivery. She had preterm premature rupture of membrane (PPROM) associated with fever. High vaginal swab culture grew Group B Streptococcus (GBS). However culture of placenta was negative and histopathological examination of the placenta did not reveal significant abnormality.The baby was screened for ROP due to the presence of risk factors. Upon review at 34 weeks and five days corrected gestational age (CGA), anterior segments of both eyes were normal and pupils were well dilated pharmacologically. However, fundus examination revealed pre-retinal hemorrhage at posterior zone 2, nonphysiologic vascular loop, arteriovenous shunt and dilated and tortuous vessels in both eyes Figures , 2. TherA diagnosis of APROP was made and after thorough counseling given to both parents, intravitreal anti-vascular endothelial growth factor (anti-VEGF) was administered. Intravitreal ranibizumab  0.2mg/ 0.02ml was injected at 1.5mm distance from the limbus at inferonasal and inferotemporal of right eye and left eye, respectively, to the sedated infant. Post injection, the baby was started on moxifloxacin 0.5%  eye drop every six hours. Five days later, fundus examination showed regression of pre-retinal hemorrhage on the left eye with less dilated and less tortuous vessels. Right eye still showed persistent pre-retinal hemorrhage at this time. At 36 weeks CGA, pre-retinal hemorrhage on the right eye had reduced in size and the vessels were less dilated and tortuous, while pre-retinal hemorrhage on the left eye had resolved completely Figures . Nine weA-ROP may lead to poor vision at an early age if not treated promptly. It is crucial to recognize the importance of ROP screening in at-risk premature babies to prevent devastating complications such as blindness. Numerous studies have been done to identify the risk factors associated with A-ROP, formerly known as APROP, which generally occurs in extremely premature and low birth weight infants ,10. A stReceipt of supplemental oxygen has been reported to be a significant risk factor associated with APROP . Shah etMycoplasma hominis or Ureaplasma urealyticum in placental tissue, maternal vaginal swab, or infant gastric juice [Ureaplasma colonization in postnatal premature infants was also reported independent risk factor for severe ROP requiring treatment [Ureaplasma urealyticum pneumonia. These could be risk factors for the baby to develop APROP. Ahn et al. reported that intrauterine growth retardation was found to be associated with the occurrence of APROP. Normal in utero retinal vascular growth that is inhibited during perinatal maternal environment may contribute to increasing the risk of APROP [Intra-amniotic infection or chorioamnionitis have also been reported to be associated with development of APROP. Compared to non-APROP infants, chorioamnionitis was seen more frequently in APROP infants . The Ameic juice . Normal ic juice . Besidesreatment . In our of APROP . HoweverWith the improving survival of neonates across the world, there is a likelihood of increasing cases of ROP including APROP, recently addressed as A-ROP. APROP, which was previously observed in more immature infants with extreme low birth weight, is currently seen to develop in bigger and more mature infants, especially in developing countries. Due to its rarity, not many studies have reported the significant risk factors for APROP. It is important to study the risk factors of this disease especially in bigger and more mature infants as more numbers of cases have been reported. In our case, the risk factors involved in the development of APROP were preterm at 30 weeks gestation, receipt of supplemental oxygen, presence of maternal chorioamnionitis and postnatal ureaplasma infection.APROP can occur in larger and more mature preterm infants especially if they have received prolonged oxygen supplements and there is history of maternal chorioamnionitis or ureaplasma infection. A high level of vigilance is needed to ensure that APROP/A-ROP is not missed and treatment is constituted promptly.


Development of the autonomic nervous system may play a role in myocardial repolarizationlability in infants, but its relationship to repolarization abnormalities remains unclear.Thus, the aim of the present study was to evaluate the relationship between gestational ageand ventricular repolarization lability using the variability ratio (VR).Infants who underwent electrocardiography at a 1-month check-up were included. Gestational age and the following four VR parameters at 1 month of agewere compared: VR-I, SDQT/SDRR; VR-II, SDQT/rMSSD; VR-III, SDQTc/SDRR; and VR-IV, SDQTc/rMSSD;where SD, QTc, and rMSSD are standard deviation, QT interval corrected using Fridericia’sformula, and root mean square difference of successive RR intervals, respectively.Twenty-eight preterm infants born at <37 weeks of gestation and 181 full-term infants wereincluded.Significant correlations were observed between gestational age and VR-I, -III, and-IV . All VR values were significantly higher in preterm infants compared withfull-term infants .VR assessed at 1 month after birth was impaired in preterm infants, suggestingimmaturity of their cardiac autonomic nervous system and ventricular myocardialrepolarization. Although the pathology of SIDS is not fully understood,dysfunction of autonomic nervous control of the respiratory and cardiovascular systems mightcontribute.4Japan is currently appreciated as the “nation with the world’s lowest neonatalmortality rate”.7 Notably, reduced frequency power was observed for theHRV of infants who suddenly died because of SIDS.10 The QT interval reflects the actionpotential duration of the ventricular myocardium. Instability in the repolarization process can make the substrate susceptible to fatalarrhythmia.11 However, few studies haveexamined temporal variations in the repolarization process among infants, or their developmentof autonomic nervous function.9 In adults, QT interval variability has been extensively investigatedto identify abnormalities in the repolarization process.11 In these studies, the variability ratio  wascalculated from a single lead. VR can also be applied in infants if electrocardiogram (ECG)recordings have a stable baseline.13Heart rate variability (HRV), a parameter of autonomic nervous control of the heart,involves variations in RR interval.15 However, changes in the autonomic nervous systemrelated to the ventricular myocardium, which can be evaluated by assessing the QT interval, havenot been reported for preterm infants.We previously reported physiological changes in ventricular repolarizationvariability using body surface ECG, and assessed developmental changes in the autonomic nervoussystem of infants and school-aged children.In the present study, we hypothesized that VR in 1-month-old infants is affected bytheir gestational age. Thus, we investigated the association between myocardial repolarizationlability index, namely the VR, and the perinatal profile of healthy 1-month-old infants.The sample population comprised 230 infants who were delivered and underwent a1-month postnatal checkup at Fujita Health University from October 2014 to November 2015. Oneinfant with patent ductus arteriosus was excluded, as were 20 full-term infants with rapidheart rates exceeding 180 beats per minute because the P wave overlapped the end of thepreceding T wave, which made their record unsuitable for automated analysis. Accordingly, 209infants were included in our analysis. All procedures involving human participants wereperformed in accordance with institutional ethical standards (No. 14-188) and/or NationalResearch Committee, and with the 1964 Helsinki declaration and its later amendments orcomparable ethical standards. Informed consent was obtained in writing from each child’sparents/guardians.15 Data wererecorded from 2 to 3 pm before feeding, with the subject quiet, awake, and placed in the supineposition. Automated analysis of the RR interval was performed on ECG recordings of 60heartbeats with a stable baseline using AcqKnowledge ver. 3.9 analysis software (Biopac SystemsInc.). The endpoint of the T wave was identified using a first-order differentiation processingmethod, and QT intervals and preceding RR intervals were measured (We recorded single-lead ECG (CM5 lead) using a Biopac MP-150 bio-polygraphacquisition unit  as previously reported.measured .13 The Fridericia formula (QTc=QT/3√RR) was used for heart ratecorrection. Based on the proposal of the American College of Obstetricians andGynecologists,16 preterm infants weredefined as neonates born at <37 weeks of gestation.Standard deviation (SD) of the QT interval (SDQT), SD of the corrected QT interval(SDQTc), SD of the RR interval (SDRR), and root mean square difference of successive RRintervals (rMSSD) were calculated. VR (I–IV) was obtained using the formula proposed by Jensenet al. and Krauss et al. .Data are presented as mean±SD. Comparisons between two groups of data weremade with the unpaired Student’s t-test or Mann–Whitney U-test, as appropriate. Frequencieswere compared using a chi-squared test. Linear regression analysis was performed by Pearson’scorrelation. Further, a multivariable model was constructed to adjust for gestational age, sex,and birth weight. P values of <0.05 were considered statistically significant. Thestatistical software package JMP  was used for analyses.Twenty-eight preterm infants and 181 full-term (control) infants were included inthe study. Birth weight and height, as well as height and weight at 1-month postnatal checkup,were significantly lower in preterm infants compared with full-term infants . There wThere were no significant differences in ECG parameters  between the two groups .Associations between VR and gestational age, birth weight, and Apgar score wereassessed using linear regression analysis .Weak neAll VR values (mean±SD) were significantly higher in preterm infantscompared with full-term infants .12 is a parameter in whichthe QT interval varies according to the preceding RR interval in the cardiac cycle. Theyreported that, in patients with old myocardial infarction, arrhythmic events commonly occurredin patients with a high VR.17 Krausset al. modified Jensen et al.’s original VR-I equation by replacing SDRR with rMSSD,which represents vagal nerve activity in the heart and respiratory sinus arrhythmia, in theirnew equation for VR-II and VR-IV.18In the present study, we analyzed the ECG parameters of 1-month-old healthy infants.We found that VR was impaired in preterm infants and showed a moderately negative correlationwith gestational age, but not birth weight. This suggests that autonomic nervous control of theheart could be dependent on gestational age rather than weight at birth. The VR proposed byJansen et al.In this study, heart rate variability (SDRR) was significantly decreased in preterminfants, which might contribute to the increase in VR-I. Similarly, rMSSD, which is an index ofrespiratory vagal nerve activity that causes fluctuation of RR interval, was decreased inpreterm infants, thus contributing the increase in VR-II. Regardless, VR could be understood bythe ventricular myocardial electrical instability (SDQT) modulated by autonomic tone. In ourstudy of apparently healthy infants, consistent results were obtained when using VR-I,VR-III/VR-II, or VR-IV, suggesting that heart rate correction might not affect the results.Thus, whether heart rate correction is needed in assessing QT variability or VR remains to beelucidated.9 SIDS infants show poor vagal nerve activity orelevated sympathetic nerve activity, a long QT interval, low HRV, and elevated basic heart ratecompared with healthy infants.20 Theoretically, HRV can be used to identify autonomicdysfunction of the sinus node, but cannot detect abnormal ventricular repolarization of theheart, which leads to lethal ventricular arrhythmias. However, VR can be used to detectautonomic nervous dysfunction and repolarization instability of the ventricular myocardium.Furthermore, VR can detect proarrhythmic substrates associated with ion channel-relateddiseases, such as long QT syndrome and other cardiac repolarization abnormalities. Few studieshave reported the VR of infants who have cardiac disease. Interestingly, Eryu et al.demonstrated a positive correlation between VR and left-to-right shunt ratio in patients withatrial septal defects.21 They suggested thathemodynamic abnormality may affect SDQT and variance of the QT interval, and noted that VR canbe used to determine the extent of latent heart failure. Thus, evaluation of VR will be a usefulmethod for assessment of pediatric disease in the future.As previously demonstrated in clinical studies, the autonomic nerve balancepredominantly elicits sympathetic nerve activity in infants with a low gestational age.Currently, autonomic nervous dysfunction is considered to be one cause of SIDS.This study has some limitations. First, this was a single-center study with alimited number of patients. Second, all ECG recordings were performed in the supine positionwith the subjects quiet and awake. Therefore, the results cannot be applied to infants whilethey are asleep. Third, detailed information that could potentially affect maturation of theautonomic nervous system, such as fetal, placenta/umbilical cord, and maternal factors, was notincluded in our analysis. Finally, as our study included only apparently healthy infants, it isunclear whether our results could be applied to infants with latent or subclinical myocardialabnormalities such as hereditary channelopathies. As such, this should be explored in the futurestudies.VR was impaired in preterm infants assessed at 1 month after birth, suggestingimmaturity of their cardiac autonomic nervous system and ventricular myocardialrepolarization.All authors have read and approved the final version of the manuscript.


Current guidelines for second stage management do not provide guidance for community birth providers about when best to transfer women to hospital care for prolonged second stage. Our goal was to increase the evidence base for these providers by: 1) describing the lengths of second stage labor in freestanding birth centers, and 2) determining whether proportions of postpartum women and newborns experiencing complications change as length of second stage labor increases.This study is a retrospective analysis of de-identified client-level data collected in the American Association of Birth Centers Perinatal Data Registry, including women giving birth in freestanding birth centers January 1, 2007 to December 31, 2016. We plotted proportions of postpartum women and newborns transferred to hospital care against length of the second stage of labor, and assessed significance of these with the Cochran-Armitage test for trend or chi-square test. Secondary maternal and newborn outcomes were compared for dyads with normal and prolonged second stages of labor using Fisher’s exact test.Second stage labor exceeded 3 hours for 2.3% of primiparous women and 2 hours for 6.6% of multiparous women.Newborn transfers increased as second stage increased from < 15 minutes to > 2 hours  Postpartum transfers for multiparous women increased from 1.4% after second stage < 15 minutes to greater than 4% for women after second stage exceeding 2 hours (p for trend < 0.0001.)Complications requiring hospitalization of postpartum women and newborns become more common as the length of the second stage increases. Birth center guidelines should consider not just presence of progress but also absolute length of time as indications for transfer. Complmetritis . Newbornmetritis , 8. In 2metritis . This stmetritis .The consensus statement, however, did not address all the needs of providers who attend births in community settings. Midwives attending community births (births occurring at home or in a freestanding birth center) must decide not only when a woman might need a cesarean for arrest of the second stage, but also whether there is a time when she is safer laboring in the hospital, even though she may continue to push. The consensus guidelines offer no guidance for this. Additionally, the guidelines are based solely on research done in hospital settings, limiting their generalizability to births at home or in freestanding birth centers. Freestanding birth centers are facilities separate from hospitals designed to facilitate physiologic  birth , 12. TheConsequently, birth center staff are in the position of devising evidence-based practice guidelines for prolonged second stage labor without national guidelines addressing their practice site or research done in their setting. We designed our project to expand the evidence base about safety of prolonged second stage labor in community settings by describing the frequency and outcomes of prolonged second stages as currently managed in US birth centers. Our specific objectives were to: 1) determine the lengths of the second stage of labor for births occurring in freestanding birth centers, and 2) describe whether the proportions of postpartum women and newborns who experience complications, including transfer to hospital care, change as length of second stage labor increases.TM (PDR). Currently, 102 birth centers voluntarily contribute data to the PDR, representing approximately 1/3 of known US birth centers. Contributing birth centers enter data on all pregnant clients, beginning with the first pregnancy visit, and continue data collection through postpartum care for all clients who remain in care. Staff enter data into the PDR prospectively, and quality assurance mechanisms ensure systematic client enrollment, timely completion of data, minimization of loss to follow-up, and data consistency [This study is a retrospective analysis of de-identified client-level data collected in the American Association of Birth Centers (AABC) Perinatal Data Registry v.2.0 and 3.0 sistency , 20. Datsistency . A 2010 In the United States, freestanding birth centers are primarily regulated at the state level. Some states prescribe clear guidelines for choice of appropriate clients and specific criteria for hospital transfer, some have more vague criteria, and some do not regulate freestanding birth centers. Accreditation by CABC requires adherence to some common guidelines but is optional in most states. Clinical practice guidelines differ among birth centers, but common elements include care largely provided by licensed midwives, admission of women at term free of significant complications, exclusive use of intermittent auscultation for fetal surveillance in labor, and support for physiologic birth. Accreditation does not require specific management guidelines for the third stage of labor, other than prohibiting manual placenta removal unless the client is unstable for transport after use of first-line interventions for hemorrhage, but CABC standards do state that active management of the third stage with prophylactic administration of intramuscular oxytocin is appropriate in birth centers . Birth cThe sample included women who gave birth in a freestanding birth center contributing data to the PDR between January 1, 2007 and December 31, 2016. The inclusion criterion was documented length of the second stage. Exclusion criteria included multiple gestation, non-vertex presentation, prior cesarean birth, newborns with major congenital anomalies, and known fetal demise prior to birth center admission. Women signed a written consent form permitting inclusion of their data in the registry and its use for research purposes. As this was an analysis of preexisting de-identified data, the Institutional Review Board at the University of Pittsburgh, Human Research Protection Office, deemed the study exempt from approval. All study methods were in accordance with the relevant institutional and national ethics guidelines.The primary exposure was length of second stage labor, categorized in the PDR as less than 15 minutes, 15-30 minutes, 31-60 minutes, 61-90 minutes, 91 minutes to <2 hours, 2-3 hours, 4-5 hour and greater than 5 hours. We also categorized second stage labor as normal or prolonged according to the consensus guidelines, as greater than 3 hours for nulliparous women and greater than 2 hours for parous women. When comparing indications for transfer, there were too few transfer in the prolonged second stage group to perform significance testing, so we compared transfers for second stages lasting more and less than 2 hours for first births and for second stages lasting more and less than 1 hour for subsequent births. Instructions for the PDR define length of second stage as “Time from full cervical dilation to birth of infant,” with further instructions for people entering data that, “If you do not know the exact time patient was fully dilated, use the time she began to push spontaneously or the time she was found to be fully dilated.” Our previous qualitative research on management of second stage in birth centers found that many birth center midwives rarely performed cervical exams to confirm cervical dilatation before pushing, and that onset of second stage is often a retrospective diagnosis often based on signs including spontaneous pushing .The primary outcomes were maternal postpartum and newborn transfers. Postpartum transfers were defined as transfer of the postpartum woman to a hospital after the birth for a medical reason, and newborn transfers as transfer of the newborn to a hospital for a medical reason. These serve as natural composite outcomes, because women and newborns are transferred to the hospital for management of any severe complication. Situations in which a postpartum woman or newborn was admitted to the hospital for a non-medical reason  were not considered transfers.0C), 3rd or 4th degree perineal lacerations, and indication for postpartum transfer. Indications for postpartum transfer included hemorrhage and retained placenta as above, hematoma, and repair of episiotomy or laceration, which included any laceration or episiotomy of any degree unable to be repaired by the provider or in the birth center setting. Secondary outcomes for newborns included use of positive pressure ventilation, endotracheal intubation, antibiotic administration, diagnosis of sepsis, intrapartum and neonatal deaths, and indication for newborn transfer.As secondary outcomes for women, we considered hemorrhage (estimated blood loss greater than 500 cc), active management of the third stage of labor (coded as yes/no), retained placenta , fever  Summary statistics were presented as means and standard deviations or numbers and percentages, as appropriate. For primary outcomes, we plotted proportions of postpartum women and newborns transferred to hospital care against length of second stage of labor, and assessed significance either with the Cochran-Armitage test for trend if the relationship appeared linear or with the chi-squared test if it did not. Proportions of secondary outcomes were compared for dyads with normal and prolonged second stages of labor using Fisher’s exact test. Indications for transfers for dyads with shorter and longer second stage of labor were compared using the chi-squared test. Given the exploratory nature of our secondary outcomes, we did not adjust for multiple comparisons. Analysis was performed using SAS statistical software release 9.4 . Clinical practice guidelines for different birth centers were categorized by content.The original dataset consisted of 34,097 births. After eliminating labors with exclusion criteria and missing data about the length of the second stage, 27,843 births remained. The analytic sample consisted of 2196 first births and 22,093 births to parous women occurring in birth centers , maternal fever , and severe perineal lacerations  Similarly, newborns born to multiparous women after a second stage greater than 2 hours were more likely to require positive pressure ventilation , and be diagnosed with sepsis  Perinatal deaths were few, but were more common for newborns of multiparous women born after second stages of labor exceeding 2 hours (1 intrapartum death (0.1%) vs. 0 (0.0%), 2 neonatal deaths (0.2%) vs. 3 (0.02%), p=0.005.)Complications were more common after prolonged second stages than after normal second stages for women giving birth in birth centers Table . These dIndications for transfers were different for multiparous women (p<0.01) and their newborns (p<0.01) after longer second stages Table . Repair Thirty birth centers provided clinical practice guidelines for management of second stage labor, and these varied considerably. Eight birth centers had no written guidelines for when to transfer women to the hospital for prolonged second stage. Guidelines for nulliparous women ranged from transfer after 1 hour of second stage with no progress (2 birth centers) to transfer after 4 hours without progress (3 birth centers.) Guidelines for parous women ranged from transfer after 1 hour without descent (3 birth centers) to transfer after 3 hours if birth not imminent (6 birth centers.) Most guidelines included an element of subjectivity, enabling providers to determine what qualified as “change” or “progress.”The goals of our research were to describe the frequency and outcomes of prolonged second stage of labor in freestanding birth centers, under current practice conditions. We found that 2.3% of healthy nulliparous women giving birth in freestanding birth centers, and 6.6% of parous women, had prolonged second stages of labor. Even in this low-risk group of women, as the length of the second stage of labor increased, transfers for complications were significantly more frequent for all newborns, and maternal postpartum transfers for complications were significantly more frequent for multiparous women. For multiparous women, hemorrhage, retained placenta, maternal fever, and severe perineal lacerations were more common with longer second stages of labor; for their newborns, use of positive pressure ventilation and sepsis were more common. Hemorrhage and retained placenta were more common for multiparous women despite more frequent use of active third stage management for women with prolonged second stage of labor, suggesting use of active third stage management was suboptimal in this sample. Indications for transfers also differed with longer second stages for multiparous women; higher proportions of maternal postpartum transfers were for repair of severe laceration and higher proportions of newborn transfers were for respiratory problems.Incidence of some of the outcomes in the study differ from generally quoted incidence of these complications, likely reflecting distinctive aspects of the population. Reported postpartum hemorrhages in our dataset, between 9.7% and 16.1% depending on group, are higher than nationally reported incidence of 1 to 5% . In thisThis is the first study demonstrating that for births in a community setting, postpartum and neonatal complications requiring transfer to the hospital are more common as the length of the second stage of labor increases. Consistent with data from hospital studies, even in this low risk, low-intervention population, maternal , 28–31 aOur finding that indications for transfer change for multiparous women and their newborns after longer second stage labor is novel, but consistent with research performed in hospital settings. A higher proportion of women transferred for repair of severe perineal lacerations after a long second stage; this is consistent with hospital studies finding that these lacerations are more common with prolonged second stage , 8, 29. This study should not be interpreted as making general statements about complications of prolonged second stage, which have been well-established. The sample we analyzed was highly censored. Women who began labor in the birth center transferred to the hospital during both the first and second stages for various indications, including prolonged second stage of labor itself. Thus, we cannot make general statements about outcomes of prolonged second stage. Rather, results should be interpreted in light of the aims of the study, to describe outcomes of prolonged second stage as it currently occurs in freestanding birth centers. When interpreted in this light, its value is highlighting that even when midwives follow clinical practice guidelines and use their best clinical judgment to transfer women at high risk, complications are still more frequent in women with prolonged second stages.without progress. Given the findings that even with continually progressive second stages resulting in spontaneous vaginal births, medical indications for postpartum and newborn transfer to a hospital increase with longer second stage of labor, birth center providers and their consulting physicians should consider guidelines that include transferring women to hospital after a fixed number of hours of pushing. Consistent with research on prolonged second stage in hospitals, there does not appear to be an inflection point where outcomes worsen dramatically, but rather a steady increase in complications [This study represents the first time birth center providers have data from their practice setting to use for development of clinical practice guidelines. We found that most birth centers have practice guidelines for management of the second stage of labor that include transfer to the hospital setting after a certain length of time ications . PreciseIn future analyses using this dataset we will explore further questions. The first is whether outcomes would be better if women were transferred to the hospital sooner during prolonged second stage of labor. For newborns, the most common indication for transfer was respiratory issues. These could potentially be mitigated by operative birth to end the second stage of labor and so might support earlier transfer. The most common indication for postpartum transfer for multiparous women was for repair of severe perineal lacerations. It is possible that perineal outcome for a spontaneous vaginal birth would be similar regardless of birth site, but exploration of this complication could provide information to guide clinical decision-making. A second area of research is whether we can identify characteristics that are associated with better or worse outcomes after prolonged second stage of labor. Perhaps better risk stratification could guide decision-making about transfers.This study benefits from the use of a large, validated, national dataset that allows us to explore relatively rare outcomes. It has the limitations of any observational study based on a clinical dataset. While transfers, the primary outcomes, are required fields in the PDR and are consistently documented and have been validated , there iThe second stage of labor can be long in freestanding birth centers, and while most women had good outcomes, complications requiring hospitalization of the postpartum woman and her newborn become more common as the length of the second stage increases. Birth center staff and their consulting physicians can use these results when developing evidence-based practice guidelines for birth centers, and should consider not just presence of progress but also the absolute amount of time as indications for transfer.


Echinococcus granulosus. The liver is the most commonly affected organ. Soft tissue localization has been reported in 2.3% of cases. Herein, we present a patient with a fat-containing hydatid cyst located in the left thigh. There are only a few reports in the literature on the presence of the fat-fluid level within a hydatid cyst. Previous studies have suggested that fat-containing hydatid cysts occur due to their cysto-biliary communication in the liver. In our case, we describe a fat-containing hydatid cyst in the extrahepatic location and discuss the pathophysiologic mechanism of fat inside it.A hydatic cyst is a zoonosis caused by the larva of a tapeworm  Echinococcus tapeworms. Echinococcus granulosus is the most frequently encountered type of hydatid disease in humans. Echinococcosis cysts are found in the liver in approximately 75% of cases, but they can be located anywhere in the body.1 Soft tissue localization with the fat-fluid level is rarely described in the literature. This report presents a patient with a fat-containing hydatid lesion in the extrahepatic location and discusses the pathophysiologic mechanism.Hydatid disease is a global endemic parasitic disease produced by the larval stage of the A 54-year-old female presented with a palpable mass and swelling in the upper leg. She stated that she had palpable swelling at this level for a long time, but it became apparent for about a month. A well-circumscribed heterogeneous hypoechoic cystic lesion on the medial side-of the left thigh was observed on ultrasonographic examination. Afterwards, magnetic resonance imaging (MRI) revealed a cystic lesion with daughter vesicles and the fat-fluid level in the medial part of the left thigh . The indEchinococcus tapeworm. Echinococcus granulosus and Echinococcus multilocularis are the two main types of hydatid disease. Hydatid disease is widespread in many areas worldwide, but it is endemic in the Middle East, Africa, South America, and Australia. Humans are infected by the ingestion of food or water contaminated by dog stool containing the parasite’s eggs. The patient’s symptoms depend on the location and size of the cyst and usuallydue to the cyst’s compressive effect.1Hydatid disease is a global zoonosis produced by the larval stage of the 1The liver is the most commonly affected organ in hydatid disease. A soft tissue hydatid cyst is seen in 2.3% of the patients in endemic regions. This low incidence in soft tissue is because of the cyst’s difficulty growing inside the muscle due to lactic acid and muscle contraction.2; therefore, the presence of lipid material in the cyst was an indirect finding of biliary communication.A hydatid cyst can present with various findings and signs. The radiological appearance of hydatid disease ranges from a purely cystic to a completely solid lesion, depending on the stage of cyst growth, maturation, and degeneration. In addition, it can be partially or entirely calcified. It may also contain fat globules and fat-fluid levels, which are rarely described in the literature. There are two theories to explain the presence of fat in hydatic cysts. First, Montero et al suggested that the fat within the cyst was generally caused by the rupture or erosion of the cyst into the biliary system3 Hence, it is essential to determine whether there is a rupture of the biliary system. The second theory concerns cyst degeneration and maturation. Beric and Blomley stated that the fat-fluid level within the cyst was related to the degeneration of hydatid membranes since histopathological and biochemical evidence suggest that lipids play an essential role in metabolism of hydatid disease.4 This is supported by the fat-fluid level within the hydatid cyst outside the liver in our case. It may indicate that the fat found within the hepatic hydatid cyst can be related to its maturation and degeneration. This should be taken into account when considering the patient’s treatment options.Nonetheless, the biliary communication of the cyst changes the treatment options of these patients. In uncomplicated cysts, percutaneous ultrasonography-guided drainage techniques such as puncture-aspiration-injection-reaspiration and other treatment options include catheterization techniques involving the injection of scolicidal agents such as alcohol. However, surgery is the preferred treatment in complicated cyst cases of cysto-biliary communication and rupture.In the literature, fat-containing hydatid cysts are generally seen in the liver, but soft tissue localization is not found. Therefore, we consider that our case will contribute to the literature.5,6 However, the treatment preferences of these lesions are not the same, and to prevent possible complications, it is critical to consider the possibility of a hydatid cyst in the differential diagnosis of fat-containing lesions.The differential diagnosis of fat-containing cystic lesions includes mature cystic teratoma, dermoid cyst, epidermoid cyst, and fat necrosis.In conclusion, the presence of fat within a hydatid cyst is a rare finding, most probably related to the maturation and degeneration of hydatid membranes. This information can change the treatment approach to fat-containing hydatid cysts of the liver, and it is also essential for the differential diagnosis of fat-containing cystic lesions located in other parts of the body to prevent possible complications.Hydatic cysts can be encountered in any organ in endemic regions.Hydatic cysts can contain fat even in the extrahepatic locations without biliary connection.