Progesterone soft capsules (brand name: Utrogestan) were demonstrated to be an effective oral alternative to prevent premature LH surges both in normal-ovulatory and polycystic ovarian syndrome (PCOS) patients. However, its safety in terms of neonatal outcomes is unclear. To evaluate whether Utrogestan use increase the risk of adverse neonatal outcomes compared with short protocol in patients undergoing IVF/ICSI treatments in combination with frozen-thawed embryo transfer (FET), we performed a retrospective analysis including 1008 FET cycles, with embryos originated from either Utrogestan + hMG protocol (n = 499), or short protocol (n = 509), which led to 546 live-born infants. The neonatal characteristics regarding preterm birth (PTB), low birth weight (LBW), gestational age and mode of delivery were comparable in the two groups. The incidence of live-birth defect was 0.68% (2/293) in the Utrogestan + hMG protocol compared with 0.79% (2/253) in the short protocol. No early neonatal death or intrauterine death were recorded in either group. To date, the data do not indicate an elevated rate of abnormality at birth after progesterone use during ovarian stimulation but further study with larger populations is needed to confirm these results. ART pregnancies approximately accounts for 1.7–4% of births in developed countries, in contrast with 1.013% of births according to a report from a 2011 survey on the proportion of births born after ART in mainland China1. With the rapid development of technology and service, the proportion of ART pregnancies is steadily rising every year. As a result, the safety of ART procedures has attracted more and more attention due to the possible impact on pregnancy complications and live-birth outcomes in infants conceived by ART.During the past 40 years, large scale number of infertile couples have babies through assisted reproductive technology (ART),inconsist of 2.The introduction of controlled ovarian hyperstimulation (COH) has been a vital clinical milestone to increasing the success rates of ART by virtue of increasing the number of oocytes retrieved. However, premature luteinizing hormone (LH) surge was a major issue during COH, which may result in cycle cancellation owing to premature luteinization and ovulation. The usage of gonadotropin- releasing hormone agonist (GnRH-a) and GnRH antagonist has sharply reduced the occurrence of premature LH surges. More importantly, these regimens has been accepted as being safe because the incidence of obstetrical complications and congenital malformations were similar to those conceived spontaneously based on a series of follow-up studies5, which inspired us to explore convenient alternatives to prevent premature LH surges. When fresh embryo transfer (ET) was the norm in IVF, steroidal preparation could not be considered for use during COH because of its negative impact on endometrial receptivity though it was powerful modulators of pituitary gonadotropin (Gn) secretion7. Since advanced vitrification techniques made superior quality cryopreserved embryo and precise thawing possible, frozen-thawed embryo transfer (FET) has been widely used in recent years. What’ more, the “freeze-all” strategy has been recommended due to the improved pregnancy and delivery outcomes10.However, various disadvantages still exist, e.g., the complexity of achieving consistent downregulation, an increased risk of ovarian hyperstimulation syndrome (OHSS) from a human chorionic gonadotrophin (hCG) trigger, and expensive cost, suboptimal oocyte or embryo quality induced by premature luteinization11. Moreover, our large, retrospective study of 2,060 live-born infants found that the incidence of live-birth defects in patients undergoing COH with LPS (1.02%) was comparable with the short protocol (0.64%)12.In combination with the “freeze-all” strategy, we corroborated luteal phase ovarian stimulation (LPS)—initiating ovarian stimulation in the luteal phase using letrozole and Gn—was able to achieve consistent LH suppression, thus, we postulated high doses of progesterone may transiently be feasible to suppress pituitary gland secretions16. Furthermore, compared with the short protocol, no statistically significant differences in the pregnancy outcomes of FET were found in normal-ovulatory patients while biochemical pregnancy rate, clinical pregnancy rate, and implantation rate increased in PCOS patients undergoing COH with Utrogestan + hMG protocol14. Though more studies were needed to evaluate the usage of Utrogestan from the early follicular phase, it is a new choice for patients undergoing IVF/ICSI treatments following embryo cryopreservation.A hypothesis was proposed that progesterone delivered from the early follicular phase may be used to suppress premature LH surges. Soon afterwards, we verified progesterone soft capsule (brand name: Utrogestan), as a kind of natural micronized progesterone which was capable of detecting in serum after being taken orally or vaginally was an effective oral alternative for inhibiting premature LH surges both in normal-ovulatory and polycystic ovarian syndrome (PCOS) patientsTo date, hundreds of infants were born by virtue of this novel regimen. Accompanying the desire to continuously optimize this novel protocol is a concern about whether it has any adverse effect on the safety of babies and mothers. However, there are no relevant studies addressing this problem. The aim of this study was to assess neonatal outcomes after COH using Utrogestan + hMG protocol in comparison with short protocol in women undergoing IVF/ICSI treatments following a “freeze-all” strategy.The sample of 531 pregnancy cycles resulting from 1008 FET procedures, from January 1, 2014 to December 31, 2014, consisted of 441 ongoing pregnancies, 17 ectopic pregnancies, 2 heterotrophhic pregnancies, and 74 early miscarriages, resulting in a total of 546 live-born infants (432 live-birth cycles). Among them, 277 pregnancies originating from 499 FETs led to the birth of 293 live-born neonates after treatment with Utrogestan + hMG protocol group; 254 pregnancies originating from 509 FETs led to the birth of 253 live-born babies after treatment with the short protocol group  and clinical pregnancy rate (55.51% vs. 49.9%) in the Utrogestan + hMG protocol group was higher than those in the short protocol group, these differences were not statistically significant (P > .05).The implantation rate (37.14% vs.34.47%), early miscarriage rate (14.44% vs. 13.39%), late miscarriage rate (1.81% vs. 1.57%), multiple pregnancy rate (32.85% vs. 31.1%), ectopic pregnancy rate (2.53% vs. 2.76%), intrauterine and ectopic pregnancy rate (0 vs. 0.79%), ongoing pregnancy rate (46.09% vs. 41.45%) were comparable in the two groups  are not statistically different from those in the short protocol group , What’s more, the mode of delivery was comparable in the two groups. Similarly, a nonsignificant difference was found among the 2 groups for the incidence of multiple delivery, despite the fact that more multiple pregnancies in the Utrogestan + hMG protocol group was deliveried than that in the short protocol group. No significant differences were found in the birth length and weight for the two groups, both in the single newborns and twins newborns. Similarly, LBW rate (22.96%vs. 22.92%) were comparable in the two groups. In addition, no early neonatal death was found in the participants  qualified as having congenital defects in all live-born infants, according to the definition in the International Classification of Diseases. Defects were observed in 2 of 293 (0.68%) in the Utrogestan + hMG protocol group, and 2 of 253 (0.79%) in the short protocol group; however, these values were all very low, and the differences was statistically significant (P > 0.05). Comparisons between groups of birth defects according to neonatal gender, singletons, and multiples were carried out and reached the undifferentiated outcomes presented in Table % qualifiOur previous studies have confirmed the oral delivery of Utrogestan is an effective way to block premature LH surges with component oocytes and embryos. However, with each new regimen, it must be shown not only that it is effective but also that it does not adversely affect the children’s health. The latter is the most important as the ultimate objective with ART is to efficiently achieve healthy live birth outcomes. The results of our study do not indicate an elevated rate of abnormality at birth after Utrogestan + hMG protocol compared with short protocol in patients undergoing IVF/ICSI treatments with FET.18. In addition, a recent meta-analysis including birth defect information on 92 671 ART infants confirmed an increased birth defect risk exists in ART infants19. Some researchers deem the risk may be attributable to patient characteristics related to infertility, including older age, higher BMI, longer infertile time, PCOS, serious endometriosis and other related etiology of infertility24, while others insist it is related to the treatment-related factors, such as embryo culture conditions, cryopreservation technique, endometrial preparation, COH protocol, and other potentially relevant parameters28. In our study, not only the patient characteristics in terms of maternal age, body mass index, infertility duration, infertility diagnosis, proportion of nullipara were comparable, but also type of embryos transferred, the method of fertilization, endometrial preparation, luteal support and other routine laboratory procedure were similar in the two groups, thus COH protocol differs.Since the application of ART, concerns have been raised regarding both its safety and its effect on fetal well-being. Compared with fertile women who conceived spontaneously, a significantly higher risk of adverse obstetric outcomes such as perinatal mortality, preterm delivery (PTD), low-birth-weight (LBW), very-low-birth-weight (VLBW), and small-for-gestational-age (SGA) infants was observed in pregnancies following ART26. Hu et al. corroborated that the high E2 environment resulted from COH is relevant to the increased risks of LBW and SGA. Elevated E2 level has an adverse effect on endometrial receptivity and implantation process, meanwhile, it may impair spiral artery invasion in the first trimester and compromise uteroplacental blood flow at term, leading to restricted fetal growth. Therefore, embryo cryopreservation was recommended when the maternal E2 level is extremely high on the hCG administration day and luteal support with E2 supplemention should be cautious29. The “freeze-all” strategy was indispensable because the usage of Utrogestan from the early follicular phase will affect endometrial development.Compared with natural conception, COH exposure is correlated with superphysiologic steroid hormone environment may result in altered endometrial development, in consist of histologic advancement, premature down-regulation of the P receptor, an abbreviated luteal phase, glandular-stromal dyssynchrony, genomic dysregulation, altered leukocyte localization and activation, premature nucleolar channel formation, advanced angiogenesis, increased blood vessel density, and reduced endometrial blood flow30. There has been contradictory results in previous literatures that pertain to the effects of P on the outcomes of IVF/ICSI. The occurrence of a preovulatory increase in serum P levels was reported to 12.4–52.3% in down-regulation protocol31. Some studies have concluded that P elevation has an detrimental effect on the pregnancy and implantation rate in patients undergoing fresh ET following GnRH agonist and antagonist cycles33, whereas others claimed exert no impact on pregnancy outcomes35. A better outcome was even observed in patients with PCOS or donor oocyte37. Adverse effects on IVF outcomes due to elevated P level may be associated with its effect on oocyte, embryo quality and/or endometrial receptivity. A recent meta-analysis including more than 60,000 cycles conducted by Venetis et al. confirmed the main deleterious effect of P elevation acts on endometrial receptivity38. In accordance with a functional genomics analysis study, P elevation was proved to impose a detrimental effect on endometrial gene expression40. The adverse impact of the high progesterone level on the endometrium can be neglected as all patients underwent FET in our study.In addition, it was substantiated the degree of histologic advancement increased when P levels are prematurely elevated41. Thus, whether the administration of Utrogestan from the early follicular phase had detrimental effect on oocyte or embryo quality was a major concern. The effects of progesterone on oocyte maturation and embryo development was unclear both in vitro and in vivo. In the investigation performed by Salehnia et al., where different progesterone concentrations  was added to the in vitro oocyte maturation (IVM) media of mouse GV oocytes, the maturation rate decreased in a dose dependent manner and the GV arrested rates increased42. Similar reduction of oocyte maturation rate was observed in the experiment made by Fukui et al. when supplemented progesterone to IVM culture systems of bovine43. Silva et al. found that the rate of blastocyst formation was sharply reduced by the exposure of bovine cumulus oocyte complexes to progesterone44. In contrast, no significant differences was found in canine oocyte maturation among the four groups with distinct hormonal environment45. Carter et al. have shown that addition of progesterone to culture medium did not affect the proportion of in vitro matured/in vitro fertilized zygotes that developed to the blastocyst stage in vitro46. In addition, it is intriguing that better results was obtained with the exposure of progesterone. Supplementation of canine oocyte culture media with progesterone and E2 was found to stimulate oocyte maturation48. Zhang and Armstrong reported that the addition of progesterone to porcine oocyte maturation medium could improve both fertilization and cleavage rates49. Furthermore, it was validated the high progesterone concentration in follicular fluid were associated with better embryo development in humans and rhesus monkeys50. Our previous research confirmed this possibility to some extent, as the viable embryo rate per oocyte retrieved was significantly improved both in nomal-ovulatory patients and PCOS patients using Utrogestan + hMG protocol.It was known that early embryonic survival, the establishment and maintenance of pregnancy, and even growth abnormalities is closely related to oocyte quality16. Though it was shown that oocytes aspirated during the luteal phase, a physiological context of high progesterone with an average peak level of 11.1 ng/mL, are capable of maturing in vitro and being fertilized11, no powerful evidence has proven the safety of high progesterone exposure in the early follicular phase for offspring that originate from this ovarian-stimulation regimen. Therefore, we followed up on the live-birth defects of infants born from Utrogestan + hMG protocol. In our study, the clinical pregnancy rate, implantation rate, ongoing pregnancy rate, live birth rate were comparable in the two groups, which illustrated that the high context of progesterone did not impair the pregnancy outcomes. Furthermore, various birth characteristics in consist of weeks of gestation, PTB rate, postterm delivery rate, birth weight and length, odds of LBW, multiple delivery rate, early neonatal mortality, and incidence of live-birth defects, were similar in the two groups. The results of this study indicated that the artificial high context of progesterone by taking Utrogestan was not associated with any significant increase in risk of pregnancy or neonatal outcomes compared with short protocol in patients undergoing IVF/ICSI treatments in combination with FET.The serum P values increased swiftly after Utrogestan administered orally, with a range of 0.9–47.8 ng/mL reported in our previous studies, and then maintained at stable concentrations following continuous delivery. The absorption and elimination of Utrogestan were dose independent, thus a considerable inter-individual variation was recognized51. In fact, the study indicated that Utrogestan + hMG protocol is safe for live-born infants at birth. The reason why the rate of birth defects was lower in our study can be elucidated from the following aspects. First and foremost, women with maternal diseases or adverse environmental exposure during pregnancy was excluded from the study. In addition, all the participants underwent FET, which have been reported to have a lower risk of birth defects compared with fresh ET cycles52. Furthermore, induced abortion because of detectable malformations were excluded from the study. Fetal deformities tend to be timely diagnosed and terminated due to patients’ heightened awareness and concern in an IVF-conceived pregnancy.The incidence of live-birth defects was not higher, compared with the rate in those using the traditional ovarian stimulation regimen. The total rate of congenital malformation in live-born infants was 0.73% in our study, slightly lower than the 1.09% rate for abnormalities occurring in infants within 7 days after delivery, in People’s Republic of China, as reported in another studyA major limitation of our study is the retrospective design of this study and small sample size. Although no significant differences were found between the two groups in the rate of congenital anomalies, this may have been due to a type II error in view of the small sample size. Additionally, the data about the neonatal information were collected from parent questionnaires, rather than from direct access to medical records. However, the findings offer an insight into the safety of the use of Utrogestan for ovarian stimulation in combination with FET.In conclusion, our preliminary study found that the data to date do not indicate an elevated rate of adverse neonatal outcomes after ovarian stimulation using Utrogestan + hMG protocol, but further study with larger populations is needed to confirm this finding. Application of Utrogestan for the prevention of premature LH surges has advantages of oral administration, user convenience, fee reduction and increased user compliance. These results will help the popularization and application of the new regimen as an oral alternative to GnRH analogue treatment, in combination with embryo cryopreservation.12. Briefly, a telephone interview with couples was the primary way, and family planning service agencies were contacted when connection with couples was lost.A retrospective cohort study was conducted at the Department of Assisted Reproduction of the Ninth People’s Hospital of Shanghai Jiao Tong University School of Medicine . The study was approved by the hospital’s ethics committee. Infertile couples, who underwent IVF or ICSI treatments with frozen-thawed embryo transfer (FET) using Utrogestan + hMG protocol, or the standard GnRH-a short protocol, were recruited at our center. Informed written consent was obtained from patients in accordance with the ethics committee protocol. The procedure about collecting neonatal outcome data was was extensively described elsewhereThese patients underwent the FET procedures from January 1, 2014 to December 31, 2014. Infants born to mothers with reported maternal diseases, such as gestational diabetes mellitus, hypertension, and thyroid disorders, or adverse environmental exposure during pregnancy, were excluded from this analysis because of the possible association of these factors with birth defects. The final data, involving 546 live-born infants, were stratified into groups according to the protocol of ovarian stimulation: 293 births after Utrogestan + hMG protocol and 253 births after the standard GnRH-a short protocol. The study design and participant selection procedure are presented in Fig. 2, andprogesterone concentrations were measured. When 3 dominant follicles reached 18mm in diameter, the final stage of oocyte maturation was triggered using triptorelin 0.1 mg . Transvaginal ultrasound-guided oocyte retrieval was conducted 34 to 36 hours after the trigger. All follicles with diameters of more than 10 mm were retrieved.HMG 150 to 225 IU  and Utrogestan  100 mg twice a day were administered from MC3 until the trigger day. In the study group After 6 to 7 days, follicular monitoring was performed using a transvaginal ultrasound examination to record the number of developing follicles,while serum FSH, LH, E2 and hMG 150 to 225 IU daily beginning on MC3 were administered. The ultrasound examination was started at MC9–11 and repeated every 2–4 days. The serum hormone level tests were performed on the same days as the ultrasound exams. The hMG dose was adjusted according to the follicle development and the serum hormone levels. When the dominant follicles reached 18mm in diameter, the final stage of oocyte maturation was induced with an intramuscular injection of hCG 3000 IU. Oocyte retrieval was conducted 34 to 36 hours later.In the control group,triptorelin 0.1 mg daily beginning on MCFertilization of the aspirated oocytes was performed by either IVF or ICSI, depending on the semen parameters. According to the number and regularity of blastomeres and the degree of embryonic fragmentation, good-quality embryos  were frozen by vitrification on the third day following the oocyte retrieval, and non-top-quality embryos were placed in extended culture, of which good morphological grade blastocysts were frozen on day 5 or day 6.The method of embryo and endometrium synchronization during a natural cycle, an induced ovulation cycle, or an artificial cycle; and the timing of ET are extensively described elsewhere (11–13). Once pregnancy was achieved, the progesterone supplement was continued until 10 weeks of gestation.Pregnancy outcomes included clinical pregnancy rate, early miscarriage rate, late miscarriage rate, implantation rate, ongoing pregnancy rate, ectopic pregnancy rate and live birth rate. Clinical pregnancy was defined as the presence of a gestational sac with fetal heart activity during ultrasound examination 7 weeks after FET. The early miscarriage rate was defined as the proportion of patients with spontaneous pregnancy termination before the gestational age of 12 weeks. The late miscarriage rate was defined as the proportion of patients with pregnancy termination after the gestational age of 12 weeks. The multiple pregnancy rate was defined as the number of patients with two or more gestational sacs divided by the number of pregnant patients. The implantation rate was defined as the number of gestational sacs divided by the number of embryos transferred. The live-birth rate was defined as the proportion of patients with live birth among all transfer cycles.Neonatal outcomes included preterm birth (PTB), low birth weight (LBW), gestational age, mode of delivery, early neonatal mortality and congenital malformations.12.PTB was defined as deliveries before 37 weeks of gestation. LBW was defined as birth weights within 2500 g. Early neonatal death was defined as the death of a live-born baby within 7 days of birth. Congenital anomalies were defined as all structural, functional, and genetic anomalies diagnosed in aborted fetuses, at birth or in the neonatal period. Congenital malformations were classified using the International Classification of Diseases Q codes (Q00–Q99) as conditions registered in the International Statistical Classification of Diseases and Related Health Problems2-test where appropriate. The Mann-Whitney U-test was used for the variables of non-normal distribution. P < 0.05 was considered statistically significant.Statistical analyses were carried out using SPSS 19.0 software . Data were presented as means ± SD; qualitative data were presented as percentages. Data were analyzed using the Student’s t-test, Mann-Whitney U-test, and, x


Hypertension was significantly associated with weight for age z-scores  even after adjusting for age and sex . BP was significantly associated with the sum of four skinfolds, but not birth weight. Hypertension was significantly associated with underweight. Longitudinal studies should confirm whether the changes in body weight we found can influence the risk of cardiovascular diseases.The aim of this cross-sectional study was to investigate the association between birth weight, underweight, and blood pressure (BP) among Ellisras rural children aged between 5 and 15 years. Data were collected from 528 respondents who participated in the Ellisras Longitudinal Study (ELS) and had their birth weight recorded on their health clinic card. Standard procedure was used to measure the anthropometric measurements and BP. Linear regression was used to assess BP, underweight variables, and birth weight. Logistic regression was used to assess the association of hypertension risks, low birth weight, and underweight. The association between birth weight and BP was not statistically significant. There was a significant ( Hypertension is known to be the third major risk factor of deaths among adolescents, and recent studies have shown that the prevalence of hypertension in children is increasing from 5.4% to 19.4% ,3. AnalyNumerous studies have suggested that birth weight is a significant factor for developing BP in a later stage of life ,6,9. It The more detailed Ellisras Longitudinal Study (ELS) design has been published elsewhere . For theThe procedure for the International Society for the Advancement of Kinanthropometry was used to measure anthropometric measurements in all children . An elecBirth weight of 2500 g or less, regardless of gestational age, was regarded as the cut-off point for low birth weight (LBW) . Over faElectronic Micronta monitoring kit was used to measure three BP readings of systolic blood pressure (SBP) and diastolic pressure (DBP) at an interval of five minutes apart . The blaHypertension was defined as the measurements of SBP and DBP levels greater than or equal to the 95th percentile of height- and sex-adjusted reference levels .This study is a part of ongoing ELS that commenced in 1996 with ethical clearance number MREC/P/204/2013: IR.The absolute and relative values for intra- and inter-tester technical errors of measurements (% TEM) for stature ranged from 0.04 to 4.16 cm (0.2–5.01%). The reliability and validity of anthropometric and physical fitness measurements were reported elsewhere .p < 0.05.Descriptive statistics was provided for birth information, absolute body size, WAZ, HAZ, and WHZ Z-scores and BP for Ellisras rural children aged 5 to 15 years by sex. We assessed the ability of low birth weight (LBW) and nutritional status to differentiate hypertensive children. We then formed sex-specific receiver operating characteristics (ROC) curves and used the conforming area under curves (AUC) to assess the ability of low birth weight and nutritional status to identify children with hypertension. The ROC curve is defined as a plot of true-positive rate (sensitivity) against the false-positive rate (1-specificity). The best test has an ROC skewed at the upper left corner with an AUC of 1, while an AUC of 0.5 shows that the test performs no better than a chance ,22,23,24p < 0.05) difference between males and females in the group aged 5–7 years.p < 0.05) for hypertension, while birth weight showed non-significant results for both high BP and over fatness.The receiver operating characteristic (ROC) curve analyses on p-value for the association of mean BP with low birth weight, nutritional status and the sum of four skinfolds for the Ellisras rural children aged 5 to 15 years. There was a significantly positive (p < 0.001) association between mean BP and sum4sf . There was a further significantly positive (p < 0.001) association between DBP and gestational age  for non-adjusted values.p < 0.05) association between high SBP and wasting , while high DBP  and hypertension  were significantly associated with underweight adjusted and unadjusted for age and sex.The aim of this study was primarily to investigate the association between BP and birth weight of Ellisras rural children aged between 5 and 15 years. This study confirmed the non-significant association between birth weight and hypertension. It was reported that each 1-kg increment of weight increases the odds of high BP defined as a sex, age, and height specific BP > 90th percentiles, although no association was found between BP and birth weight . In thisNumerous studies have reported contradictory results on the connotation of birth weight and BP ever since a study by Barker first published the developmental origin of adult disease hypothesis two decades ago ,25,26,27There was a significant association between hypertension and underweight. Similar results were reported elsewhere ,29,30. AStudies of children are subjected to further confounders’ inclusion of prematurity and growth disparity , which wBP was significantly associated with the sum of four skinfolds, but not with birth weight. There was a high prevalence of underweight in the present sample. Hypertension was significantly associated with underweight. Information on physical activity, dietary intake, and lipid profile could shed more light on the health status of Ellisras rural children.


Although the majority of singleton births after in vitro fertilization (IVF) are uncomplicated, studies have suggested that IVF pregnancies may be independently associated with low birth weight (LBW), preterm birth (PTB), and perinatal mortality. These outcomes complicate multiple gestations as expected, but have also been reported in singletons. A multiple embryo implantation model allows for assessment of the early in utero environment, and therefore, assessment of any maternal constraints on developing fetuses. We question whether adverse perinatal outcomes associated with assisted reproductive techniques (ART) occur as a result of maternal physiologic adaptations.This is a retrospective, single center study of ART cycles, specifically intracytoplasmic sperm injection (ICSI) cycles during a 16-year period. For each positive pregnancy test 9–11 days after embryo transfer, an ultrasonogram was performed at 7 weeks of gestation to record the number of implanted fetal poles with cardiac activity. Controlled ovarian stimulation (COS), hCG trigger, oocyte retrieval and sperm injection were performed as per our standard protocols. First trimester implantation sites that resulted in live births were defined as “true” to distinguish them from those that spontaneously reduced called “virtual.” Birth outcomes analyzed included birth weight and gestational age at delivery.P<0.01) and shorter gestational ages (P<0.01) than those from a single implanted embryo. The number of embryos transferred did not affect the gestational length of singleton newborns. Although the birth weights of singletons from multiple implantation sites  were lower than true singletons, the birth weight of virtual singletons were comparable to the birth weights of true twin, triplet, and quadruplet live births. Multiple logistic regression revealed that virtual singletons were an independent risk factor for PTB  and LBW , even after controlling for the number of oocytes, stimulation protocol type, sperm source, total gonadotropins administered, age, embryo quality, and day of embryo transfer.A total of 17,415 cycles were analyzed. The average maternal age was 36.9 (±5.0) years. An overall fertilization rate of 73.4% generated approximately 48,708 good quality cleavage-stage embryos. In most patients (92.8%), an average of 3 embryos were transferred. The clinical pregnancy rate was 39.2% . The overall occurrence of multiple gestations was 38.2%  consisting of 2,038 twin, 511 triplet, and 59 quadruplet pregnancies. Of these multiple gestations, 18.6% of twin, 54.2% of triplet and 76.3% of quadruplet gestations spontaneously reduced. Failure of the implanted embryo to progress was not related to maternal age. Singleton newborns resulting from multiple implantation sites had lower birth weights (Our study highlights that embryonic implantation sites during early gestation set the growth profile of each embryo, dictating later growth patterns. Specifically, spontaneous reduction of an embryo after multiple embryo implantations can confer greater perinatal risk in the form of LBW and PTB to the surviving fetus. Our findings suggest that maternal constraints or physiologic adaptations maybe one of the mechanisms mediating adverse perinatal outcomes when multiple embryo implantation occurs. The use of assisted reproductive techniques (ART) to overcome infertility has gained popularity over the past 2 decades. A total of 160,521 ART procedures were performed in 2013 across 467 fertility clinics in the United States, resulting in 1.6% of all live births .Intriguingly, previous studies have reported that singletons resulting from single embryo transfer (SET) have a higher birth weight than those resulting from double-embryo transfer ,10. FurtThe Weill Cornell Medicine institutional review board approved our retrospective study protocol (IRB#1503016064). Patients initiating intracytoplasmic sperm injection (ICSI) cycles at the Ronald O. Perelman and Claudia Cohen Center for Reproductive Medicine resulting in fresh embryo transfer (ET) during a 16-year time-period were analyzed for potential inclusion. All patients undergoing frozen-thawed ET, utilizing surgically-retrieved sperm, or those utilizing donor oocytes were excluded. Patients with a positive pregnancy test on cycle day (CD) 28 i.e., 14 days after oocyte retrieval underwent transvaginal ultrasonography (TVUS) on CD49 to record the implanted embryos with cardiac activity.To address our question, we grouped ICSI cycles according to the initial number of embryos transferred, those that actually implanted, and the actual number of live birth(s). ICSI cycles with the number of implanted embryos with cardiac activity on CD49 consistent with the number of live births were defined as “true” live births to distinguish them from “virtual” live births which were associated with spontaneously reduced embryos during the first trimester. In other words, a singleton live birth was considered a true singleton when only one implanted embryo with cardiac activity was noted on CD49. In contrast, a singleton live birth after visualization of >1 embryo with cardiac activity was considered a virtual singleton. For the purpose of the study, only those implanted embryos that spontaneously reduced within the first trimester were included. Although all patients with selective reduction were excluded from the final analysis, a separate sub-analysis was carried out to compare the birth weights and gestational age at delivery for these patients.Controlled ovarian stimulation (COS) and oocyte retrieval were performed per our standard protocols . GonadotSemen samples produced after 2–5 days of abstinence were evaluated for volume, total count, concentration and motility using WHO criteria . Sperm m2) were recorded for the study cohort. In addition, ICSI characteristics recorded were total gonadotropins administered (IU), oocytes retrieved per ICSI cycle, oocytes injected per ICSI cycle, fertilization rate, mean number of embryos transferred, and day of ET. Fertilization rate was defined as the number of 2 pronuclear (2PN) embryos out of the total number of mature oocytes injected. Implantation rate was defined as number of intrauterine gestations with fetal cardiac activity detected by TVUS on CD49 out of the total number of embryos transferred. Clinical pregnancy rate was defined as the number of intrauterine gestations with fetal cardiac activity on CD49 per ICSI cycle. Any loss of pregnancy after the visualization of an intrauterine gestation with cardiac activity was considered a spontaneous miscarriage. Any birth after 24 weeks of gestational age was considered a live birth. Live birth characteristics analyzed were overall birth weight, low birth weight (LBW), very low birth weight (VLBW), incidence of term birth, and incidence preterm birth (PTB). Birth weight <2,500 g and <1,500 g irrespective of gestational age was considered LBW and VLBW ), while categorical variables were expressed as number (n) and percentage of occurrence (%). Continuous variables were expressed as mean ± standard deviation (SD). Wilcoxon rank-sum tests, McNemar’s chi-square (χ2) tests and Independent A total of 17,415 ICSI cycles were evaluated .P<0.01). The rate of spontaneous miscarriage in all singleton gestations was 7.9%, while the spontaneous miscarriage in twin, triplet and quadruplet gestations with spontaneous embryo reduction was 7.4%, 9.9%, and 14%, respectively. In spite of a comparable maternal age, the proportion of pregnancies presenting with spontaneous in utero reduction correlated with the number of embryos implanted (P = 0.14) or gonadotropins administered (P = 0.60).In these cycles, where the average age of the women was 36.9 ± 5 years (range 18–49), an overall fertilization rate of 73.4% generated 48,708 good quality embryos. Of all ICSI cycles, 15,836 (90.9%) cycles resulted in day 3 ET, while the remaining 1,579 (9.1%) cycles resulted in day 5 ET. An average of 3.01 embryos were transferred per ICSI cycle. The clinical pregnancy and spontaneous miscarriage rates for the study cohort were 39.2% and 5.12%, respectively. There were 5,725 live births, which resulted in birth of 7,817 live born neonates. The overall occurrence of multiple gestations was 38.2%  consisting of 2,038 twin, 511 triplet, and 59 quadruplet pregnancies. Of these multiple gestations, 18.6% of twin, 54.2% of triplet and 76.3% of quadruplet gestations spontaneously reduced (mplanted . The faiP<0.01) than those from a single implanted embryo i.e., true singleton. This, however, was not true when true twins were compared to virtual twins, or when true triplets were compared to virtual triplets (P<0.01). A similar trend was observed for the rates of LBW and VLBW infants with increasing implantation order . The mean gestational age at delivery for the singleton group was 38.5 weeks and for the twin group was 35.9 weeks after selective reduction.The birth outcomes and gestational age at delivery for patients undergoing selective fetal reduction was also assessed . A total® survey  fell into the category of true singletons, twins and triplets, while the remaining 68 children belonged to the category of virtual gestations. The cognitive functions of true singletons and true twins were within the normal limits. In contrast, those derived from multiple embryo implantation sites had a higher incidence of being at risk for cognitive delays  or the Bayley Mental Development Index (MDI), in person, is limited by logistical or travel reasons. In one cross-sectional study, 124 and 112 infants were assessed at 12 and 24 months after birth with the ASQ® and BSID [®, had a low sensitivity (0.20–0.60) in identifying infants with mental delay. Although the specificity (0.90–0.97) was better for the psychomotor scale, the sensitivity remained insufficient (0.25–0.52). At 24 months, the ASQ®, had good sensitivity (0.75–0.92) and specificity (0.55–0.78) for detecting mental delays. However, the sensitivity (0.31–0.50) remained unsatisfactory for detecting motor delays. At least 2 other studies [® and BSID because of which the ASQ® cannot substitute for the BSID. Despite these shortcomings, it is important to note that the ASQ® has been standardized for the general population and corrected for ICSI children up to the age of 5 years [The noticeable strengths of our study include the 16-year-long study period, large sample size of 17,415 ICSI cycles utilizing standardized ovarian stimulation protocols, as well as the use of the ASQinternal  and exteinternal ,40. Secoand BSID . At 12 m studies ,48 have icient 0.–0.52. AtIn conclusion, our study highlights that embryonic implantation sites during early gestation set the growth profile of each embryo, dictating later growth patterns. Specifically, singleton newborns resulting from multiple implantation sites had lower birth weights and shorter gestational ages than those from a single implanted embryo. Furthermore, the rates of PTB, LBW, and VLBW progressively increased with increasing implantation order. Finally, singleton newborns from multiple implantation sites had higher independent risks of PTB and LBW, even after accounting for different variables with multiple logistic regression analysis.S1 Fig(TIFF)Click here for additional data file.S2 Fig(TIFF)Click here for additional data file.S3 Fig(TIFF)Click here for additional data file.


The care for preterm infants has improved considerably in the last decades and although the outcome improved, prematurity is still a large global health issue and is ranked in the top 10 of the WHO list of leading causes of burden of disease . HistoriCurrently, technology combined with computer intelligence can support the caregiver in their daily task. Neonatal caregivers are aware that preterm infants are a very fragile patient population and that they work daily with only narrow ranges of normal and safe values, and injury can easily occur when the infant is outside the margins. Technical devices with built-in algorithms will help caregivers to maintain preterm infants within these ranges. Thus, minimizing the occurrence and duration of injurious moments can be very challenging. There is an ongoing development of technical applications specially designed to solve neonatal problems, some examples are discussed below.There is now convincing evidence demonstrating that preterm infants are most vulnerable and uniquely susceptible for injury immediately after birth . AlthougDuring admission in the NICU, many data points and parameters are collected and centrally managed. These data comprise continuous measurements, such as physiological parameters , sensor readings, data of devices , and observations and interventions of the caregivers and results of tests  are also noted. The high volume of data generated in an NICU with a velocity of hundreds of data points per patient-minute can be used for predictive monitoring. This involves analyzing physiological data to identify infants at high risk and detect illness in an early stage .Currently, potential life-threatening complications (sepsis and necrotizing enterocolitis) are often not diagnosed until the infant’s condition is significantly compromised . ContinuApnea of prematurity, often combined with hypoxia and/or bradycardia, is one of the most common and recurrent problems in preterm infants . Frequen2 between the prescribed target ranges. Titrating the oxygen to keep an infant within narrow oxygen saturation target ranges can be challenging for a nurse, especially during and after an apnea accompanied with bradycardia and desaturation. Automated regulation of FiO2 is a technology that is increasingly used in neonatal intensive care units, and currently, trials are undertaken to test the effect on long-term outcome (2 reduces the occurrence and duration of hyperoxaemia, it seems to have little effect in reducing hypoxemia (During the admission in the NICU, preterm infants often receive supplemental oxygen for a prolonged period. Unfortunately, supplemental oxygen therapy has a very narrow therapeutic range for preterm infants and they are frequently exposed to hypoxemia or hyperoxaemia . To prev outcome . Althougypoxemia . It is pThe aim of an artificial placenta is to provide an environment where the fetus can continue to develop as if remaining in the maternal uterus without the physiological stress of preterm birth. The principle of treating a preterm infant as a fetus rather than a neonate is not a new idea in neonatal care . StudiesThese were just a few examples, but it is clear that clinical problems related to preterm birth can be approached by the use of technology and computer intelligence. The possibility to have continuous surveillance and development of algorithms would help the neonatal caregiver to keep the preterm infant within its narrow therapeutic ranges and limits of safety. Using technology in an adequate manner has the potential to decrease the burden of preterm birth and reduce health costs. However, nature is complex, and it will be a big challenge to improve the applied technology to deal with this complexity. It will also be a big challenge for neonatologist to keep up as these developments in technology can go fast. To use it properly next to their clinical judgment, neonatologist should understand how the technology works and recognize malfunction and/or artifacts. Perhaps in the future, it will be necessary for neonatologists to also receive training in the technology used, next to their medical training. Parallel to this, a technical engineer could be added to the neonatal team and attend the daily rounds. Last but not least, with the increasing possibilities, technology should be used wisely and appropriately, and the potential benefit should always be weighed against the possible harm/burden. The neonatologist should be at the center of debate concerning the limits in applying this technology.The author confirms being the sole contributor of this work and approved it for publication.The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


To compare single nucleotide polymorphisms (SNPs) in the 3′-untranslated region (3′UTR) of human leukocyte antigen (HLA)-G in placentas between spontaneous preterm birth and preeclampsia pregnancies.Placental samples matched for gestational age were obtained from 20 cases of spontaneous preterm births and 19 cases of preeclampsia. Genomic deoxyribonucleic acid was extracted from placenta tissue and the 3′UTR region of HLA-G was amplified via polymerase chain reaction. Nine SNPs were analyzed by direct Sanger sequencing. There was no significant difference in gestational age at delivery or birth weight between two groups. And there were no significant differences in the allele and phenotype frequencies between two groups. Preterm births and preeclampsia (PE) are the major complications that contribute to morbidities during pregnancy; however, its pathophysiology has not been clearly identified. Immunological maladaptation in the maternal–fetal interface has accounted for the pathogenesis of adverse pregnancy outcomes, including PE, intrauterine growth restrictions, spontaneous preterm births, and congenital infections . The humWe collected placental samples from 20 cases with spontaneous preterm births and 19 cases of preeclampsia. The placental samples 1 cm × 1 cm in size were aseptically obtained from the fetal side and kept in a frozen state (− 70 °C). In all cases of preeclampsia in this study, the patients had blood pressures ≥ 140/90 mmHg, dipstick protein ≥ 1+/4+, or 24-h urine protein ≥ 300 mg/dl. For gestational age matching, cases of spontaneous preterm birth were selected with a similar gestational age at delivery for each case of preeclampsia. The indications for delivery in preterm birth group included preterm labor and preterm premature rupture of the membranes without other maternal or fetal indications. All pregnant women enrolled in this study gave written informed consent before participation. This study was approved by the Institutional Review Board (IRB) of Kyungpook National University, Daegu, South Korea (IRB File No: 2016-07-005).Genomic DNA was extracted from placenta tissue, using the Qiagen QIAamp Fast DNA tissue Kit . DNA concentration was determined using a NanoDrop ND-1000 spectrophotometer and purity was assessed based on the 260/280 nm absorbance ratio from 1.7 to 2.1.Nine SNPs in the 3′UTR of HLA-G that were previously described  were evaSanger sequencing was performed using the BigDye Terminator V 3.1 Cycle Sequencing Kit . Sequencing results were compared with reference sequences (HLA-G/NM_002127/ENSG00000204632/ENST00000428701.5), using the alignment program BLAST V2.5.0 of NCBI. The positions of nine SNP were manually compared using CodonCode Aligner V.5.1.5.The Hardy–Weinberg (HW) equilibrium and Chi square test were used to verify the significance of differences in the genotypic data and allelic frequencies between two groups. Chi square test was two-sided test and statistical significance was defined when p value was lower than 0.05. The Haploview software (V 4.2) was employed to perform the linkage disequilibrium (LD) and haplotype analysis among nine of the genotyped SNPs. LD patterns were constructed using an algorithm designed by Gabriel et al.  with a mp = 0.74, 2.19 ± 0.9 vs. 1.80 ± 0.8, p = 0.17). Haploview showed the genotype distributions were in HW equilibrium except rs17179101 in pregnancies without preeclampsia. The allele frequencies of all the SNPs did not show any statistical differences between the two groups  has been detected in both the maternal serum/plasma and amniotic fluid, and its concentrations are influenced by the gestational age and several maternal or fetal complications, including fetal gender, fetal neural tube defect, intraamniotic inflammations/infections, and preeclampsia , 22–24. HLA-G between spontaneous preterm birth and PE. Further studies with a larger cohort are warranted.In conclusion, we found that there were no significant differences in the SNPs in the 3′UTR of The presented data is limited by sample size. For gestational age matching, we did not compare preeclampsia with normal pregnancy, but compared spontaneous preterm birth with preeclampsia due to gestational age matching.


According to the measured environment information, the proposed system can automatically send a command to a fuzzy microcontroller performed by Arduino UNO to fully or partly open the electric curtain and electric window for adapting to climate changes in the indoor and outdoor environment. Moreover, the IWS can automatically close windows for rain splashing on the window. The presented novel control method for the windowsill not only expands the SHD applications, but greatly enhances convenience to users. To validate the feasibility and effectiveness of the IWS, a laboratory prototype was built and confirmed experimentally.With the advance of science and technology, people have a desire for convenient and comfortable living. Creating comfortable and healthy indoor environments is a major consideration for designing smart homes. As handheld devices become increasingly powerful and ubiquitous, this paper proposes an innovative use of smart handheld devices (SHD), using MIT App Inventor and fuzzy control, to perform the real-time monitoring and smart control of the designed intelligent windowsill system (IWS) in a smart home. A compact weather station that consists of environment sensors was constructed in the IWS for measuring of indoor illuminance, temperature-humidity, carbon dioxide (CO With the development of science and technology and the gradual improvement of human living standards, people have a desire for convenient and comfortable living. The significant advances in sensor-based technology have led to the emergence of the smart home and Internet of Things (IoT), providing convenience, comfort and better quality of life for people .A smart home can be viewed as an environment in which computation and communication technologies are employed for the use and control of household appliances remotely or automatically through IoT, to establish an efficient but comfortable living environment for the resident . VariousThe worldwide population is aging at a fast pace. According to a report released by the United Nations , the numSHD are increasingly becoming ubiquitous due to their powerful hardware and useful features. According to the eMarketer report , there wEnergy management system is the integration of technologies and services through home networking for an intelligent living environment. There has been a surge of interest in the home energy management system (HEMS) because the IoT holds promise for making homes smarter. The main purpose of the HEMS is not just to minimize the energy consumption but also to ensure customers’ comfort ,26. The 2) concentration, outdoor rain and wind direction. Traditional curtains and windows are manually operated, which is always inconvenient to the elderly and disabled. Although electric curtains have appeared in the market, they cannot adapt to climate changes in the environment.People want curtains and windows primarily for daylight and secondarily for the view. Furthermore, curtains and windows have a significant impact on the energy consumption and living environment. The use of curtain and window can decrease the indoor temperature in a hot day, and thus saving energy can be expected. Surprisingly, it was found that in an era of ubiquitous mobile technologies, few papers showed the use of SHD in windowsills including electric curtains and electric windows. This paper proposes an innovative use of SHD to monitor and control the designed intelligent windowsill system (IWS) that provides indoor comfort and healthy environment. For the realization of this system, the IWS equips a compact weather station including a variety of off-the-shelf environment sensors that measures indoor illumination, temperature-humidity, carbon dioxide  software was developed to make the system easier to operate and to give the room greater comfort. The control strategy of the work was based on fuzzy and direct control and performed by an Arduino microcontroller. Additionally, the proposed IWS can automatically close windows for splashing rain. A laboratory prototype was built and evaluated in various scenarios. The experimental results showed that the system has a smart control on the electric curtain and electric window.The remainder of this paper is organized as follows. This section describes the backbone of the system, which comprises several modules. 2 concentration. The CO2 concentration was sensed by using the module MG811, which is a chemical sensor. It works based on the solid electrolyte cell principle. When the sensor is exposed to CO2 gas, chemical reactions occur in the cell producing an electromotive force. The CO2 detection range of this sensor is 350–10,000 ppm (parts per million) which produces 30–50 mV. In addition, to detect raindrops falling on the electric window, the rain sensor FC-37 was used and mounted on the outside of the window. It runs on a power supply of 5 V. After detecting the raindrop, the sensor board transmits an analog output to the rain sensor driver and then produces a digit output, which will drop from high to low. The digit output will rise from low to high when the raindrop is wiped off or vaporized. To detect the existence and direction of the wind, a self-made anemoscope was built and mounted on the outside of window. The self-made anemoscope shown in E (east), W (west), S (south) and N (north). When the anemoscope is on the windward side, the corresponding reed switch will be activated and a signal will be produced. Once falling raindrops splash against the collected board of the rain sensor and the electric window is on the windward side, a signal will be activated and sent to the Arduino microcontroller for closing the window.The IWS used many types of environment sensors to monitor the real-time status in the home. The measurement module is the key to the IWS and an integration of the indoor and outdoor environment sensors. A light dependent resistor (LDR) or photoresistor is used to measure the indoor illuminance from the daylight contribution and artificial lighting in real-time. The commercial grade Tokenchina’s PGM5537 was used, in which resistance decreases with increasing incident light intensity . The modThe measured information is gathered and transferred to the information processing and decision-making module, which is an important element for decision-making strategies.The module is the core of the proposed IWS. It includes two main units: information processing unit and decision-making unit. Considering the environmental conditions provided by the measurement module, the information processing and decision-making module must access the information and provide an adequate command to the windowsill drivers to regulate the plant. The decision-making module provides two ways to control. One way is fuzzy control based on the measured information from indoor sensors for maintaining indoor comfort. The fuzzy control is designed to achieve the requirements based on the designed fuzzy rule base. With the fuzzy control applied, the electric curtain and electric window can maintain their required positions for comfort. Another way is direct control based on the sensed conditions from outdoor sensors for preventing rain from splashing.Arduinos are used widely by all kinds of makers worldwide. Popularity has been driven by the Arduino’s simplicity of use and the numerous sensors and libraries available to extend the basic capabilities of these controllers . Using sAs a communication tool between the control platform and sensor nodes, wireless sensor networks (WSN) have been deployed as a reasonable and low-cost communication technology. In this work, the wireless communication was implemented using the Bluetooth module. Bluetooth is a global wireless communication standard that connects devices together over a certain distance, usually 10 m to 100 m. The work used Bluetooth HC-05 module for the communications between Arduino UNO and SHD.A SHD was used to monitor the environment information provided by the measurement module. The user can send a command to the information processing and decision-making module via the Bluetooth module for regulating the electric curtain and electric window appropriately.2 concentration is from 700 ppm to 2800 ppm in the room. The user can quickly access the measured environment information.MIT App Inventor is a drag-and-drop visual programming tool for designing and building fully functional mobile apps on the Android based platform. It allows Android apps to be built and programmed with colorful building blocks instead of programming codes. An IWS mobile app was developed using MIT App Inventor 2 for SHD. Three modes of operation can be selected when the SHD is connected to Bluetooth. In The plant consists of an electric curtain and electric window. The electric curtain used was the ready-made RAEX M300. Owing to lack of an available electric window, a two-phase six-wire stepper motor with driver module was used to simulate the controlling electric window.Fuzzy logic differs from classical logic in that statements are no longer true or false, on or off. In traditional logic, an object takes on a value of either zero or one. However, in fuzzy logic a statement can assume any real value between 0 and 1 representing the degree to which an element belongs to a given set. In contrast to the traditional control theory, fuzzy logic does not need intricate mathematical models to perform, only a practical understanding of the overall system behavior. A fuzzy logic describes a control protocol by means of if–then rules. In engineering systems, it provides a convenient and user-friendly front-end to develop control programs ,33.2 concentration is proposed to evaluate living comfort. The fuzzy inference model is Mamdani with three inputs  and two outputs (electric curtain and electric window).Designing a fuzzy controller is a simple concept that includes the three stages: fuzzification (an input stage), rule evaluation (a processing stage) and defuzzification (an output stage) . The dev2 concentration-temperature is listed in The island of Taiwan lies across the Tropic of Cancer. The north of Taiwan is situated in the subtropical region, while the southern part belongs to the tropical climate zone. The studied work was performed in Taiwan. According to the climate in Taiwan, each of the three inputs is defined on the four fuzzy sets {Low (L), Medium (M), High (H), Very High (VH)}. The membership functions of trapezoid and triangular form associated with the fuzzy sets of the input variables are presented in With regard to the importance of the SHD’s role in human life, a novel Android app was developed to perform the real-time monitoring and smart control for the designed IWS. Concerning cyber security, the first step to protect the IWS from unauthorized users is achieved by the use of passwords. Attempting to operate the IWS for the first time, the user must login with a secret password provided by the Bluetooth HC-05 module manufacturer when the SHD connects to Bluetooth. After passing the system authentication, the IWS can be operated.To verify the feasibility and effectiveness of the proposed IWS, a laboratory prototype was built and tested. The goal of this paper was to design an IWS that could monitor the indoor environment information and automatically regulate the electric curtain and electric window for providing indoor comfort and a healthy environment. This subsection is dedicated to verification of the functionality of the IWS, subject to the weather and the rain. The control strategies of the system including fuzzy and direct control will also be examined. 2 concentration are 158 lux, 15 °C and 5200 ppm, respectively. The control status of the IWS is shown in 2 concentration are 440 lux, 21 °C and 2200 ppm, respectively. The resulting control actions are that the electric curtain is opened five-sevenths and the electric window is opened two-sevenths. Firstly, the operation of auto mode with fuzzy rule bases was made for evaluating the controllability of the Arduino fuzzy microcontroller. In case 1, the indoor illuminance, indoor temperature and indoor CO2 concentration decreases, the opening electric window decreases. This is consistent with the fuzzy rules base in 2 concentration. The experiments show good results with fuzzy control.Observing the results of the cases 1 and 2, increase in indoor illuminance and indoor temperature cause the decrease in opening of the electric curtain. Additionally, as the COSecondly, the prevention of splashing in the rain was verified. Case 5 conducts in falling rain but the window is not on the windward side. In other words, the rain sensor is activated but the anemoscope is not. The statuses of electric curtain and electric window remain unchaged. In contrast to case 5, case 6 has no rain but the window is on the windward side. It has no impact on the electric curtain or electric window. As a result, cases 2, 5 and 6 have the same windowsill status as 2 sensor were installed in indoor sites. The rain sensor and anemoscope were placed in outdoor sites. Based on the measured environment information, an Arduino UNO microcontroller was designed to automatically regulate the electric curtain and electric window for responding to climate changes. The developed app available for Android-based SHD allowed remote users to easily browse sensor status and operate the IWS. In addition, integrating the rain sensor and anemoscope, the proposed IWS can fully close the electric window when the rain splashes on the window. A laboratory prototype has been successfully built and tested to verify the effectiveness of the control implementation. Integration of IWS and household appliances such as air conditioner, lighting fixture, air purifier and dehumidifier for creating the smart and energy-saving environment may be future work. The empirical findings may serve as valuable references for further SHD applications and smart homes.This paper has presented an implementation of IWS utilizing fuzzy control, direct control and Bluetooth wireless technology to develop a novel control method for making the system easier to operate and giving the room greater comfort. To prevent unauthorized users from entering the IWS, password authentication was provided. The remote control and monitoring function by the SHD provided help and assistance, especially to the elderly and disabled. LDR, temperature-humidity sensor and CO


DNA methylation (DNAm) plays a determining role in neural cell fate and provides a molecular link between early-life stress and neuropsychiatric disease. Preterm birth is a profound environmental stressor that is closely associated with alterations in connectivity of neural systems and long-term neuropsychiatric impairment. The aims of this study were to examine the relationship between preterm birth and DNAm, and to investigate factors that contribute to variance in DNAm. DNA was collected from preterm infants (birth<33 weeks gestation) and healthy controls (birth>37 weeks), and a genome-wide analysis of DNAm was performed; diffusion magnetic resonance imaging (dMRI) data were acquired from the preterm group. The major fasciculi were segmented, and fractional anisotropy, mean diffusivity and tract shape were calculated. Principal components (PC) analysis was used to investigate the contribution of MRI features and clinical variables to variance in DNAm. Differential methylation was found within 25 gene bodies and 58 promoters of protein-coding genes in preterm infants compared with controls; 10 of these have neural functions. Differences detected in the array were validated with pyrosequencing. Ninety-five percent of the variance in DNAm in preterm infants was explained by 23 PCs; corticospinal tract shape associated with 6th PC, and gender and early nutritional exposure associated with the 7th PC. Preterm birth is associated with alterations in the methylome at sites that influence neural development and function. Differential methylation analysis has identified several promising candidate genes for understanding the genetic/epigenetic basis of preterm brain injury. Third, inter-individual variation tends to be consistent across tissue types.16 Furthermore, sampling DNA from saliva rather than blood is informative in brain DNAm studies because: methylation profiles obtained from saliva show greater correspondence with brain tissue extracts than those obtained from blood;17 inherent properties of DNAm from buccal cells ) may make them a more favourable proxy tissue than blood for epigenome-wide association studies of non-haematological disease.18Although DNAm patterns are tissue specific, a number of recent observations suggest consistency between peripheral tissues and brain. First, DNAm profiles are altered consistently between prefrontal cortex and T cells in a rhesus macaque model of early-life stress.24 Specifically, fractional anisotropy (FA) and mean diffusivity (〈D〉) derived from dMRI provide measures of tract integrity in the newborn brain that have a predictable pattern of alteration in preterm infants at term equivalent age (TEA).27 These biomarkers are sensitive to genetic and environmental risk modulators for injury, and can detect neuroprotective treatment effects.31Structural and diffusion magnetic resonance imaging (dMRI) reveal a cerebral signature of preterm birth that includes reduced connectivity of white matter tracts, focal tissue volume reduction in deep grey matter nuclei and reduced cortical complexity.33 This tract shape modelling is unique to PNT and allows not only measurement of tract integrity parameters, such as tract-averaged 〈D〉 and FA, but also provides a metric, the absolute goodness-of-fit of the segmented tract to the reference (R), which can be used to quantify differences in tract shape between individuals. The inclusion of anatomic information in dMRI models makes PNT ideally suited to studies of genetic and epigenetic effects because brain structure is heritable.35Probabilistic neighbourhood tractography (PNT) is an automatic segmentation technique, based on single seed point tractography, that can identify the same fasciculus-of-interest across a group of subjects by modelling how individual tracts compare with a predefined reference tract in terms of length and shape.In this study, we tested the hypotheses that the stress of preterm birth leads to alterations in the methylome that are apparent early in the newborn period, and variance in DNAm is associated with dMRI parameters in major white matter tracts and clinical risk factors for adverse outcome.The study was conducted according to the principles of the Declaration of Helsinki, and ethical approval was obtained from the UK National Research Ethics Service. Written parental informed consent was obtained.The cohort consisted of two groups of neonates who received care at the Royal Infirmary of Edinburgh between January 2012 and September 2014: (1) preterm neonates  at birth <32 completed weeks gestation); and control infants born at full term (>37 weeks PMA). Infants were not eligible if they had dysmorphic features suggestive of a chromosomal abnormality that was confirmed by karyotype, a congenital malformation or a congenital infection.The DNA OG-575 kit was used for sampling of saliva at TEA, defined as 38–42 weeks PMA . DNA was extracted using an alcohol precipitation technique as per manufacturer's instructions, and was rehydrated in TE 0.5. Gel electrophoresis was used to qualify DNA extraction and Qubit 2.0 Fluorometer was utilised for quantification of DNA concentration .http://www.ncbi.nlm.nih.gov/geo/query/acc.cgi?acc=GSE72120).DNAm analysis was performed at the Genetics Core of the Edinburgh Clinical Research Facility . Bisulphite conversion of 500 ng input DNA was carried out using the EZ DNAm Kit . Four microlitres of bisulphite-converted DNA was processed using the Infinium HD Assay for Methylation ). Each sample was interrogated on the arrays against 485 000 methylation sites. The arrays were imaged on the Illumina HiScan platform and genotypes were called automatically using GenomeStudio Analysis software version 2011.1 (Illumina). The data discussed in this publication have been deposited in NCBI's Gene Expression Omnibus and are accessible through GEO Series accession number GSE72120 (3 resolution), T2-weighted STIR (~0.9 mm3 resolution), T2-weighted FLAIR (~1 mm3 resolution) and dMRI (11 T2- and 64 diffusion encoding direction (b=750 s mm−2) single-shot spin-echo echo planar imaging volumes with 2 mm isotropic voxels using a prototype sequence). All examinations were supervised by a pediatrician experienced in MRI procedures. Infants were examined in natural sleep and pulse oximetry, temperature and electrocardiography data were monitored throughout. Ear protection was used for each infant, comprising earplugs placed in the external ear and neonatal earmuffs .The preterm infants underwent brain MRI at TEA. A Siemens MAGNETOM Verio 3T MRI clinical scanner  and 12-channel phased-array head coil were used to acquire: T1-weighted MPRAGE volume , if a SNP occurred at the site of single-base extension, or if the probe had been shown to be non-specific. A further, smaller set of probes was removed where RnBeads' iterative ‘GreedyCut' algorithm identified a large number of unreliable measurements across samples.During pre-processing and using the Chen annotation, probes were removed if their CpG loci overlapped with known SNPs from the 1000 Genomes Project , and assigns promoters as the regions from 1.5 kb upstream to 0.5 kb downstream of the transcription start site. Differentially methylated positions were assessed with Limma,41 and aggregated for genes and promoters using a generalisation of Fisher's method. The false discovery rate (FDR)-corrected version of these aggregated region-level P-values was used to select genes with significantly differentially methylated regions (DMR) in bodies and/or promoters. Gene function annotation was determined from the National Center for Biotechnology Information Gene database (http://www.ncbi.nlm.nih.gov/gene/about-generif).Finally, differential methylation between term and preterm individuals was assessed in gene bodies and promoters. RnBeads includes gene-level annotations from Ensembl  between preterm infants at TEA and term controls: SLC7A5, SLC1A2, NPBWR1 and QPRT. APOL1 was included in validation studies because of its functional relevance and the significance value from the array was marginal (P=0.05). Bisulphite conversion was performed on 500 ng of genomic DNA with the EZ DNAm kit . The converted DNA was amplified using the AmpliTaq Gold 360 kit  with primers mapping to target regions containing CpGs assayed within the array. PCR primers were designed using PyroMark Assay Design Software 2.0 . Pyrosequencing was performed using PyroMark Q24Gold reagents on a PyroMark Q24 Pyrosequencer (Qiagen) according to the manufacturer's instructions. Data were extracted and analysed using PyroMark Q24 1.0.10 software (Qiagen). Background non-conversion levels were ~1–3%.Pyrosequencing was used to validate DNAm at five selected genes that showed differential methylation (http://www.fmrib.ox.ac.uk/fsl) to extract the brain and eliminate bulk patient motion and eddy current-induced artifacts by registering the diffusion-weighted to the first T2-weighted echo planar imaging volume of each subject. Using DTIFIT, 〈D〉 and FA volumes were generated for every subject. From the underlying white matter connectivity data, eight major white matter fasciculi , and left and right inferior longitudinal fasciculi) were identified using PNT optimised for neonatal dMRI. As described in detail in the study by Anblagan et al.,33 this optimisation principally involved using reference tracts created from a group of 20 term controls.After conversion from DICOM to NIfTI-1 format, the dMRI data were preprocessed using FSL tools  analysis was used to inspect the dataset for signal in the methylation values that is related to clinical variables and imaging features that are associated with neurodevelopmental outcome (implemented in RnBeads). The clinical variables tested were: gender, PMA at birth, PMA at scan, chorioamnionitis, exposure to antenatal steroids, exposure to antenatal magnesium sulphate, number of days requiring parenteral nutrition and one/more episodes of late-onset sepsis. The image features tested were tract-averaged FA, tract-averaged 〈D〉, and http://bioinf.wehi.edu.au/limma/), with methylation as a function of the variable in question.Variables indicated as interesting via PCA were modelled directly using Limma  at TEA , and from 36 sex-matched controls born at term . Seventy out of 72 mothers (97%) reported taking folic acid supplements around the time of conception to at least 12 weeks gestation.We collected genomic DNA from 36 sex-matched preterm infants (mean PMA at birth 284 and 11 (31%) had histological chorioamnionitis. The mean duration requiring parenteral nutrition after birth was 11 days (range 5–25).Of the preterm infants, 9 (25%) had intrauterine growth restriction, 35 (97%) had been exposed to antenatal steroids, 20 (56%) had been exposed to antenatal MgSO4 or steroids for threatened preterm labour at any stage in pregnancy. None received parenteral nutrition.Of the controls, none had intrauterine growth restriction, and none was exposed to MgSO−1 (13.4–95.9) from preterm infants and 36.35 ng μl−1 (8.12–80) from term infants.The mean (range) DNA yield was 45.9 ng μln=66,877); non-specific probes ; sites with excess high detection P-values ); and second, post-filtering (non-CpG probes (n=1130); and probes on sex chromosomes ). The remaining probes were used to calculate aggregate P-values for DMRs in two categories: gene bodies and promoters. About 87 genes were assigned as differentially methylated by this approach ; FA in the genu of the corpus callosum was associated with the 5th PC ; right CST R and chorioamnionitis were associated with the 6th PC ; and both gender (P=0.0016) duration of parenteral nutrition use (P=0.0017) were associated with the 7th PC (2.6% variance). After correction for multiple tests, three associations remained: right CST R with the 6th PC (P=0.036); and both gender (P=0.028) and duration of parenteral nutrition (P=0.028) with the 7th PC. No variable was significantly associated with any DMR when tested directly .Ninety-five percent of the variance in the preterm methylome was explained by 23 components, with most variance explained by the first two PCs , . In explIn a deeply phenotyped representative sample of newborns, preterm birth was associated with significant alterations in the methylome in 10 protein-coding genes whose products influence neural cell function and are associated with behavioural traits/neuropsychiatric disease. We found that specific risk modulators of neurodevelopmental outcome after preterm birth  explained a modest, but significant proportion of the variance in DNAm. Furthermore, there was an association between DNAm and white matter tract tissue integrity and shape inferred from dMRI, suggesting that epigenetic variation may contribute to the cerebral phenotype of preterm birth.65 but to our knowledge this is the first epigenome-wide association studies in preterm infants and healthy controls to identify differential methylation at loci that influence neural development. The magnitude of the DNAm differences between preterm and term infants varied between and within genes; however, in support of a potential biological role for these changes, differential methylation was identified at multiple CpGs on the array for most loci. Pyrosequencing analysis for all genes selected for validation confirmed the differences at individual CpGs seen on the array and also identified additional differentially methylated neighbouring CpGs, suggesting that preterm birth associates with widespread effects on DNAm at these loci. For the majority of these genes, differential DNAm was identified in the gene promoter, although for LRG1 and SLC7A5 differential methylation also extended into the gene body. In general, DNAm at DMRs has a negative correlation with gene expression, with recent studies reporting that this correlation is stronger not only for CpGs close to the transcription start site but also for intragenic DMRs, which do not necessarily mark intragenic CpG islands or CGI shores and may instead represent functional elements.66Epigenome-wide association studies have provided new insights into genes whose regulation pattern varies in the context of child abuse, post-traumatic stress disorder, schizophrenia and autism spectrum disorder,SLC7A5 and SLC1A2. In preterm infants, a significant reduction (~10%) in DNAm was seen at multiple CpGs in the SLC7A5 promoter and gene body on the array, and more were identified on pyrosequencing. SLC7A5  is a member of the solute transporter family of membrane transport proteins and is involved in the transport of large amino acids, including methionine, across the blood–brain barrier.67 Methionine is a key component of S-adenosylmethionine, the major methyl donor and very recent data suggests that SLC7A5 can act as an indirect regulator of the epigenome, at least in terms of histone modification through effects on the availability of methionine and the subsequent availability of S-adenosylmethionine.68SLC1A2  is predominantly expressed in astrocytes but is also expressed by oligodendroglia and macrophages, and on neurons during development. It has a role for clearing glutamate throughout the neuroaxis and can be both transcriptionally and post-transcriptionally regulated.44 The expression of SLC1A2 is reported to be developmentally regulated, particularly at the window of peak vulnerability for the development of periventricular leukomalacia.70A particularly large number of differentially methylated CpGs were identified in two members of the solute transporter family of membrane transport proteins, 71). The pathogenesis includes death of pre-myelinating oligodendrocytes (pre-OLs) because of vulnerability to inflammatory mediators, reactive oxygen and nitrogen species, and glutamate excitotoxicity. This is followed by defective pre-OL regeneration and repair, leading to hypomyelination. In pre-clinical and human post-mortem studies the diffuse form of white matter injury coincides with enrichment of reactive glia (activated microglia/macrophages and reactive astrocytes) that inhibit the maturation of pre-OLs to myelin-forming oligodendrocytes. The neuronal population is not thought to degenerate under conditions that generate pre-OL loss , but rather there is a dysmaturation response characterized by aberrant dendritic arborisation, disturbances in synaptic activity and reduced spine density. The functional profiles of the 10 genes that we found to be differentially methylated in preterm infants include neuronal and glial signalling, neurotransmission, apoptosis and cellular energetics. Our findings focus attention on the role of these genes in mediating injury and regeneration/repair processes after preterm birth, and their candidacy is further strengthened by the neuropsychiatric disease associations in later life ; and of the clinical factors tested, gender and number of days requiring parenteral nutrition, both associated with the 7th principal component (2.9% of variance). However, none of these three variables was significantly associated with any DMR when tested directly, which indicates that if an effect is present, it is subtle and distributed over many loci.PPT2, GABBR1, PLEKHB1.72 We did not identify DMRs in these genes, which may be explained by differences in study population, timing of sampling or tissue-type sampled. A multiple sampling design that includes parental samples, placental tissue, cord blood and extends across the life-course would be required to investigate the relative contributions of in utero and postnatal exposures to changes in DNAm, and the extent to which preterm birth leaves a legacy on the methylome.73We sampled the methylome at a single time point chosen to reflect the allostatic load of preterm birth and neonatal intensive care among children who survive to hospital discharge, but this leaves uncertainty about the temporal cues for epigenetic modification in the perinatal period. A recent study of DNAm in umbilical cord blood of 11 preterm infants and 11 term controls demonstrated 20 DMRs between the groups, including loci in 3 genes that are involved with neuronal development: In conclusion, these novel data show that the profound early-life stress of preterm birth is associated with differential methylation at sites in several protein-coding genes. The analysis of differential methylation has identified provide promising candidate genes for understanding genetic influences on brain development after preterm birth.


Application of latent variable models in medical research are becoming increasingly popular. A latent trait model is developed to combine rare birth defect outcomes in an index of infant morbidity.This study employed four statewide, retrospective 10-year data sources (1999 to 2009). The study cohort consisted of all female Florida Medicaid enrollees who delivered a live singleton infant during study period. Drug exposure was defined as any exposure to Antiepileptic drugs (AEDs) during pregnancy. Mothers with no AED exposure served as the AED unexposed group for comparison. Four adverse outcomes, birth defect (BD), abnormal condition of new born (ACNB), low birth weight (LBW), and pregnancy and obstetrical complication (PCOC), were examined and combined using a latent trait model to generate an overall severity index. Unidimentionality, local independence, internal homogeneity, and construct validity were evaluated for the combined outcome.P < .0001), and the valproate only subgroup . The combined outcome was significantly correlated with the length of hospital stay during delivery in both the total AED group  and the valproate only subgroup . The mean score for the combined outcome in the total AED group was significantly higher  than AED unexposed group, whereas the valproate only subgroup was not.The study cohort consisted of 3183 mother-infant pairs in total AED group, 226 in the valproate only subgroup, and 43,956 in the AED unexposed group. Compared to AED unexposed group, the rate of BD was higher in both the total AED group  contains supplementary material, which is available to authorized users. AEDs have significant effects on all four component birth outcomes, and as well as the combined outcome.Valproate has significant effects on two out of four component outcomes, and no association with the combined outcome.Latent Trait Modeling is an effective tool to combine rare birth defect outcomes.Evaluation of selected components is essential to ensure the validity of the combined outcome.Birth defects (BDs), involving major congenital malformation (MCM) and minor anomaly (MA) are the leading causes of infant mortality, morbidity, and years of potential life lost. In the USA, the association of infant BDs and pregnancy and obstetrical complications (PCOCs) with maternal exposure to antiepileptic drugs (AEDs) has been investigated extensively –3. HowevLatent variable models have increasingly been applied in medical research, including measurement of quality of life, diagnostic testing, survival analysis, and joint modeling of longitudinal data . Latent A debate remains over the use of combined or individual outcomes in drug safety studies. A combined outcome may lead to incorrect results and threaten the validity of the study if the components are selected inappropriately , 13. TheThe objective of this study is to apply a latent trait model to generate a valid combined outcome  to assess the overall adverse pregnancy and perinatal risks for mothers and infants exposed to AEDs.This study used four statewide, retrospective 10-year databases: Florida Medicaid claims, Florida Birth Vital Statistics, Florida Birth Anomalies, and Florida Hospital Discharge Inpatient and Outpatient records .This study includes all female Florida Medicaid enrollees who delivered a live singleton infant between April 1, 2000 and December 31, 2009. Exclusion criteria for maternal-infant pairs are: mothers with dual eligibility for Medicare, HMO, or private insurance; mothers having multiple births (twins or higher order); mothers with diabetes mellitus , hypertension , or HIV pre-pregnancy ; infants who were twins, triplets, quadruplets or more; infants with birth weight lower than 350 g or higher than 6000 g; mothers or infants with critical information missing .The index date is the infant’s birth date. The drug exposure window was defined as the preceding 9-month pregnancy period after the first day of the last menstrual date. A six month baseline period before the first date of the last menstrual date was utilized to determine the baseline demographic and clinical characteristics. BD outcomes were detected 0–365 days after live birth.Drug exposure was determined from Medicaid pharmacy claims using national drug codes. Two drug exposure groups, valproate and AEDs , were employed to develop two scenarios with different patterns of association with the four component outcomes. Valproate use was defined as prescriptions dispensed for valproate, sodium valproate, or divalproex. AEDs included: carbamazepine, ethosuximide, felbamate, gabapentin, lamotrigine, levetiracetam, oxcarbazepine, phenobarbital, phenytoin, pregabalin, primidone, tiagabine, topiramate, valproate, and zonisamide.The birth anomalies are related to exposure time during pregnancy:  MCM assoth edition of the International Classification of Diseases-Clinical Modification (ICD-9 CM) code (740–759.9) from Florida Hospital Discharge Inpatient and Outpatient data. It has been confirmed that Hospital Discharge data, along with other Children’s Medical Services diagnostic information, efficiently enhanced case ascertainment for BD cases from Florida Birth Vital Statistics data [We investigated four adverse pregnancy and infant outcomes: BD (involving MCM and MA), abnormal condition of new born (ACNB), LBW, and PCOC from multiple data sources. The operational definition for each component outcome was listed in Additional file ics data –20. ACNBics data –25. Gestics data , 23. Preics data . GestatiSelected component outcomes were evaluated for similarity of importance, frequency rate, and treatment effect. The importance of the component outcome was assessed by computing Spearman correlations between individual outcomes and a clinically meaningful endpoint, defined as infant’s length of hospital stay following delivery .A reference group, defined as infants with no maternal exposure to any AEDs during pregnancy and termed “AED unexposed group”, was selected for the estimation of treatment effects of the combined and component outcomes. The potential confounding factors were controlled using propensity score matching techniques. Previous studies have documented that common risk factors for adverse maternal and infant outcomes include socioeconomic status, infant gender, maternal age, race, BMI, smoking, alcohol consumption, parity, and drug exposure during pregnancy –30. SignStep 1. Calculate initial estimates of the model parameters. First, we selected initial estimates to make the iteration process converge. We obtained 32 independent levels by combining 3 dichotomous component outcomes: BD (Yes/No), ACNB (Yes/No), PCOC (Yes/No), and 1 polytomous component outcome: Birth Weight (BW): 2500 ~ 5999 g, 1500 ~ 2499 g, 1000 ~ 1499 g, 350 ~ 999 g. The frequencies and proportions for each level of the combination of four component outcomes were calculated and utilized to deduce the initial estimates of the model parameters.−9. All final parameters were estimated from the iteration process.Step 2. Derive the final estimates of the model parameters. Using the set of initial values and the modified Gauss-Newton algorithm, final estimates of the model parameters were obtained. The modified Gauss–Newton algorithm was run in SAS Proc IML, starting from the initialized value at iteration 0, until the difference of the last two estimates was less than 10Step 3: Calculate the conditional probabilities given the latent variable S for each component outcome. Substituting the final estimates into the latent trait model, we calculated expected probabilities and counts for each level of the combination of four component outcomes.ŝ). The final estimate, APO, is a rescaled ŝ, to adapt for measurement of severity of health status.Step 4: Derive the combined outcome, the severity index of adverse perinatal and pregnancy outcome (APO). Substituting final estimates and conditional probabilities into the latent trait model, we further obtained the posterior distribution of latent variable S, and the mean of the posterior distribution . After applying all inclusion and exclusion criteria, the final study cohort consisted of 3183 mother-infant pairs in the AED exposure group, 226 mother-infant pairs in the valproate exposure subgroup, and 43,956 mother-infant pairs in the AED unexposed group. A comparison of the demographic and clinical characteristics of the three groups is presented in Table P < .0001), but not for the valproate subgroup . The valproate subgroup (n = 226) was smaller than the total AED group (n = 3183), which could have affected the statistical results due to insufficient power.The combined outcome, APO scores were compared between AED, valproate only, and AED unexposed group Fig. . The aveP < .0001) and ACNB . The rate of PCOC was not significantly higher in the valproate subgroup compared to the AED unexposed group . The valproate subgroup had the highest rates of BD, significantly higher than the AED unexposed group . ACNB in valproate subgroup was not different than the AED unexposed group .Figure P < .0001). The valproate subgroup did not differ significantly in the distribution of BW categories from AED unexposed group .Figure P < .0001) or valproate only .In Table ŝ and final estimate APO for 32 combinations of four component outcomes, each of which is associated with an unique score of APO, ranging from 1 to 8.Expected and observed frequencies and percentages of each combination of the four observed outcomes were enumerated in Additional file 3 Statistics. The internal homogeneity was confirmed in all four component outcomes. They all significantly correlate with each other and the combined outcome APO. APO was significantly correlated with the length of hospital stay during delivery , and no correlation with infant breast fed status  indicate that APO was associated with a well-established health status measure. The higher the APO score, the longer the hospital stay for the mothers and infants during delivery.There was no correlation between the four component outcomes after controlling for the latent variable. Thus, local independence of the four component outcomes was established according to Yen’s QWe re-defined the pregnancy period calculating gestational age +10 day, 20 days, and 30 days to examine the change in association between AED exposure during pregnancy and four component outcomes. There were no significant differences between these time windows.The total AED group was significantly different from the AED unexposed group on all observed outcomes, whereas valproate subgroup differed statistically from AED unexposed group only on BD and PCOC. These two exposure groups had varied patterns of observed outcomes that were combined using the latent trait model. The psychometric properties of the combined outcome were evaluated and compared among the two exposed groups and one healthy comparison group. The four component outcomes were found to be not significantly different on the incidence rates. One exception was PCOC, which had the highest incidence out of the three component outcomes. However, neither the differences of AED effects on PCOC nor the correlation between PCOC and the length of the hospital stay during delivery was significantly different between the total AED group and AED unexposed group. Thus, these four component outcomes exhibited a high level of homogeneity and demonstrated the validity of component selection for the AED safety study.Table Figures To our knowledge, combining outcomes using a latent variable model has not been utilized in any pharmaco-epidemiological studies previously. This model was first described in 2008 for combining four birth defect outcomes to construct an infant morbidity index . We emplS^ ranged from 0.08 for normal infant-mother pairs to 0.61 for the mother-infant pairs with different patterns of BD, ACNB, PCOC, and ELBW. These estimates are similar in magnitude to those documented previously [The final estimate of the latent variable eviously .http://ufdc.ufl.edu/UFE0046207/00001).This article is based on a thesis published by one of the authors in 2013 (Several limitations should be considered as a consequence of using linked claims data and the nature of the study. First, by combining MCM, MA, LBW, and PCOC, the latent variable APO is an overall adverse outcome for both mothers and infants. The association between drug exposure and each individual component outcome is unknown if latent variable APO is used as a dependent variable in the model. Second, the power to detect differences in the valproate only subgroup is a concern due to small sample size. The insignificant difference in APO between valproate only subgroup and health unexposed group might be due to the inadequate statistical power. Third, MAs might be underestimated in this study, which could cause underestimation of APO score. However, the misclassification of MAs is non-differential, so it should not affect the assessment of differences between drug use groups. Finally, this latent variable model combines manifest outcomes based upon the probability of occurrence in the study population. The severity of each outcome is not mathematical weighted in the combining process. Future studies are needed to develop more advanced statistical models to combine more specific outcomes based upon not only the probability of occurrence, but also the severity of each outcome.This study used a latent trait model to assess adverse pregnancy and perinatal outcomes in women exposed to antiepileptic drugs during pregnancy. We recommend using this latent trait model in other drug studies examining similarly related component outcomes. If the study drug, is only weakly associated with any of the selected component outcomes, the study drug’s effects on the combined outcome may be diluted and be statistically non-significant compared to the reference group. Such an approach is detrimental to any drug safety study as the results move towards the null and the true teratogenic effects of the drug can be masked. Hence, evaluation of selected components is essential before a latent trait model can be used to assess a combined outcome.