To assess long-term results after single-session alcohol sclerotherapy of symptomatic benign liver cysts performed with maximum 20 min of exposure to alcohol.We included 47 patients aged 32–88 years  with 51 benign non-parasitic liver cysts that were exposed to ethanol for 7–20 min in a single sclerotherapy session and were followed for at least 24 months. Each cyst was emptied before injecting ethanol  into it. The patient rotated from side to side to facilitate contact between ethanol and the whole cyst wall. Pre-treatment cyst volume was defined as the volume of aspirated cyst fluid after complete emptying of the cyst. Follow-up cyst volume was estimated based on computed tomography images.p = 0.83, Mann–Whitney test). Ethanol intoxication occurred in one patient. There were no other complications except for pain.Cyst volumes were 30–4900 (median 520) mL at pre-treatment and 0–230 (median 1) mL at 24–193 (median 56) months follow-up, a reduction of 83–100% (median 99.7%). No cyst required repeated treatment during the follow-up. Median volume reduction was 99.7% at median 49 months of follow-up for 35 cysts exposed to ethanol for 7–10 min vs. 99.6% at median 75 months of follow-up for 16 cysts exposed for 20 min (Long-term results of single-session alcohol sclerotherapy performed with maximum 20 min of exposure to ethanol were satisfactory with no sign of recurrence of cyst fluid. Alcohol sclerotherapy may be an effective treatment for solitary symptomatic liver cysts and for dominant symptomatic cysts in polycystic livers –23. HoweThis study included 47 patients with at least 24 months of follow-up after alcohol sclerotherapy of symptomatic benign liver cysts performed at our hospital from 1993 to 2010 according to the procedure described below. Patient data were recorded prospectively. Among 68 consecutive patients treated with alcohol sclerotherapy for solitary symptomatic liver cysts or for dominant symptomatic cysts in polycystic livers, we excluded 17 patients followed for <24 months and 4 patients lost to follow-up. The follow-up protocol initially included imaging to assess cyst volume within 2 months, and at 6, 12, and 24 months. We later reduced follow-up imaging during the first year, since it typically showed temporary recollection of cyst fluid that did not require treatment see “” sectionPremedication  was used from 1993 to 2002. Since 2002, no premedication was used, but an anesthetic nurse was always present during the procedure and provided the sedation and analgesics needed .The patient was positioned supine on an angiographic table. The cyst was punctured under ultrasonographic guidance, usually with a 1.2-mm-diameter 20-cm-long needle. If possible, the needle was inserted through 1-3 cm of liver tissue to prevent leakage from the cyst. A stiff guide wire was introduced and a 30-cm 7 French (2.3 mm outer diameter) pigtail catheter  was pushed as far as possible into the cyst and fixed to the skin by adhesive tapes. After complete emptying of the cyst, contrast material was injected and radiographs taken to confirm the position of the catheter and to exclude communication with the biliary ducts and leakage of contrast into the peritoneal cavity. If this occurred, or aspiration of contrast material from the cyst failed, the procedure was discontinued. Otherwise, ethanol was injected in an amount of 10% of the cyst volume, but never more than 100 mL. To avoid dilution of ethanol, great care was taken to empty the cyst completely before injecting ethanol into it. To achieve satisfactory contact between ethanol and cyst wall, it was routine to change the patient position from prone to supine and right to left lateral decubitus position at least two times during the procedure. We had tested the pigtail catheter for use with alcohol ex vivo. The manufacturer  has tested the catheter in contact with 100% alcohol and found no sign of degradation or leakage up to 6 weeks . Alcohol was injected using regular plastic syringes that were usually filled with alcohol within 3 min from the injection time.Cysts were exposed to ethanol for 20 min (from 1993 to 1995) or 10 min (from December 1995 to June 1999). From June 1999, cysts smaller than 1000 mL were exposed to ethanol once for 10 min, whereas cysts with volumes of at least 1000 mL were exposed to ethanol twice in a single session, each time with 100 mL of ethanol for 10 min. We used 96% ethanol during the period 1993–1999 and 99% ethanol since July 1999.Finally, all alcohol was evacuated, the cyst was irrigated with saline , and the catheter was removed. The patient rested in bed for 4 h and if asymptomatic was discharged from the hospital the same afternoon. The patients were observed for any signs of alcohol intoxication during and after the procedure. The blood alcohol level was not measured routinely, since it was ≤0.3 mg/g in initial patients.Pre-treatment cyst volume was estimated as the volume aspirated on the date of sclerotherapy when emptying the cyst. At follow-up, one experienced radiologist measured the three largest perpendicular cyst diameters d1, d2, and d3 on computed tomography (CT) images, and calculated cyst volume using the formula of an ellipsoid: volume = d1 × d2 × d3 × 0.523 .http://www.brixtonhealth.com/pepi4windows.html) was applied for statistical analysis. The Mann–Whitney test for comparing medians was used to compare pre-treatment cyst volumes, follow-up cyst volumes, reduction of cyst volumes at follow-up, and follow-up times between cysts exposed to alcohol for 10 min and cysts exposed to alcohol for 20 min. All p values are two-tailed. p < 0.05 indicated statistical significance.WINPEPI version 11.60 (Forty-seven patients (42 women and five men) aged 32–88 (median 61) years had 51 liver cysts exposed to ethanol for 7–20 (median 10) minutes and were followed for 24–193 (median 56) months. Six cysts in five patients were in polycystic livers and 45 cysts in 42 patients were not.In the total sample, median cyst volumes were 520 mL at pre-treatment and 1 mL—or median 99.7% smaller—at the last follow-up  or time to follow up (p = 0.24)  smaller at 127–193 months (median 12 years) of follow-up.CT performed within three months after sclerotherapy of 17 cysts in 16 patients showed recollection of cyst fluid in all. The fluid later diminished in all patients without therapy . A minor complication was abdominal pain during the procedure. This was no longer a problem after we abandoned premedication and started to use analgesics according to individual needs and to irrigate the cysts with saline before removing the catheter, preventing remnants of ethanol within it to cause pain during removal.In this study, liver cysts exposed to alcohol for a maximum of 20 min in one treatment session were 83–100% (median 97.7%) smaller at 2–16 years of follow-up. No cyst required repeated treatment during the follow-up. Even for large cysts, we used maximum 100 mL of alcohol once or twice in a single session. The procedure caused alcohol intoxication in one patient (2%) with an uneventful recovery. The brief exposure of liver cysts to a relatively small amount of alcohol was thus safe and prevented recurrence of cyst fluid in the long term.Alcohol should be in contact with the whole cyst cavity during the treatment in order to fix the epithelial cells and disable their ability to secret fluid , 21, 27.Some parts of our procedure may be essential when exposing liver cysts to limited amounts of alcohol for a short time. First, in order to avoid dilution of alcohol concentration, it is important to empty the cyst completely before injecting alcohol into it. Second, after alcohol injection, the patient should rotate from side to side to facilitate contact between alcohol and every part of the cyst, especially when the cyst is large and may have a multifolded wall when emptied. Third, to make it easier for the patient to co-operate and change position, we advise effective pain management as needed during the procedure rather than general premedication.We found good results of exposing liver cysts to alcohol for only 10 min, based on treatment of 35 cysts. Larssen et al. have previously reported promising results of exposing liver cysts to ethanol for 10 min in a study comprising only 10 cysts . The preProvided the sclerotherapy remains effective, briefer exposure to alcohol during the procedure may be advantageous by reducing alcohol intoxication risk, interventional laboratory time, and duration of hospitalization. In studies of liver cysts exposed to alcohol for 60 min , 6, all Our study had strengths and limitations. It represented day-to-day radiological work, making the results highly relevant to clinical practice. Patients and data were noted prospectively, avoiding retrospective identification of patients in medical records. The follow-up period was longer and the material slightly larger  than in recent studies by Akhan et al.  (4–173 mIn conclusion, the employed procedure of alcohol sclerotherapy of liver cysts varies considerably between institutions. This study showed that there is a durable response to sclerotherapy performed with 10–20 min of exposure to ethanol in a single session.


Small for gestational age (SGA) infants are at increased risk for preterm birth morbidities as well as a range of adverse perinatal outcomes that result in part from associated premature birth. We sought to evaluate the costs of SGA versus appropriate for gestational age (AGA) infants in France from pregnancy through the first year of life and separate the contributions of prematurity from the contribution of foetal growth on costs.This is a cross-sectional population-based study using national hospital discharge data from French public and private hospitals. SGA infants were defined as newborns with a birth weight below the 10th percentile of French intrauterine growth curves adjusted for foetal sex. AGA infants were defined as newborns with a birth weight between the 25th and the 75th. All births were selected between January 1st, 2011 and December 31st, 2011. Costs were calculated from the hospital perspective for both mothers and children using their diagnostic related group and the French national cost study. Hospital outcomes were extracted from the database and compared by gestational age and mode of delivery.Of 777,720 total births in 2011, 84,688 SGA births (10.9%) and 395,760 AGA births (50.8%) were identified. After adjustment for gestational age, the cost for an SGA infant was €2,783 higher than for an AGA infant. The total maternal and infant hospital cost of SGA in France was estimated at 23% the total cost for deliveries. The high cost is explained by higher complication rates, more frequent hospital readmissions and longer lengths of stay.Being small for gestational age is an independent contributor to 1-year hospital costs for both mothers and infants. Small for gestational age (SGA) infants are defined by a birth weight lower than the 10th percentile for a given gestational age. SGA infants are at increased risk for preterm birth morbidities as well as a range of adverse perinatal outcomes that result in part from associated premature birth. In adulthood, conditions such as metabolic syndrome, diabetes and hypertension develop more often in individuals born SGA regardless of whether the birth was preterm. Although the health sequelae of SGA are well-documented, relatively little is known about their economic consequences either in early or later life  weeks gestational age group  versus 628 deaths (0.16%) in AGA, up Table  regardlep < 0.001). The average length of post-partum hospitalisation was higher in the SGA group, 5.9  days versus 4.9  days (p < 0.001).Hospital admission during the prenatal period occurred in 23.6% mothers in the SGA group versus 19.6% in the AGA group. The average length of prenatal stay was 2.3  days in the SGA group versus 1.8  days in the AGA group (p < 0.001). After stratifying by gestational age, the average total cost was higher in the SGA than in the AGA infants in all age groups  and €655  in the SGA and AGA groups respectively for all mothers. The average delivery costs were €2,563  and €2,357  in the SGA and AGA groups respectively. The total average pre- and post-natal cost for mothers was higher in the SGA group €3,431  versus €3,012  in the AGA group (6) in thep < 0.001). The excess transfer and readmission rate was greater for SGA infants with preterm birth  than for full term births .The 84,688 SGA births had 1.3 hospital admissions/infant during the first year, with a readmission rate of 16.4%, while the 395,760 AGA births had 1.2 admission/infant and a 12.9% readmission rate. There were also more emergency hospital transfers in the SGA group than in the AGA group (8 vs. 3.6%) and a higher proportion of infants transferred to intensive care during the initial or subsequent admissions  with an average length of stay in intensive care of 3.4 days  versus 0.7 day  (p < 0.001). The average total length of stay during the first year was 7.8 days  versus 5.1 days , (p < 0.001).The average length of stay for the initial hospitalisation was 7 days  in the SGA group versus 4.6 days  in the AGA group (p < 0.001)  in the SGA group and €1,328  in the AGA group. The average costs by infant of all readmissions were €1,229  and €486  respectively. The total average cost for infants was €4,178  in the SGA group and €1,814  in the AGA group. All cost differences were significant  and €4,826  in the SGA and AGA groups respectively.N = 29,165 6%)  Fig. .Fig. 3HoThe total cost of pre-and post-partum (1 year) hospital admissions for SGA in France were €638 million. The additional cost for SGA compared to AGA was €1,478 million of which one-third (€493 million) was spent on preterm and two-thirds (€985 million) on full term SGA infants.The total cost from pregnancy through the first year of life of all deliveries in France was €2,756 billion for 830,000 yearly births: SGA newborns represented 10.9% of total deliveries and 23% of total costs.While there is published evidence on the economic consequences of preterm birth in several countries, the impact of being small for gestational age has seldom been assessed. Our main findings are that, of the total 779,376 births in France, the 84,688 SGA births cost on average €7,609 per infant  from pregnancy to 1 year of age, or €2,783 more in average than AGA infants; SGA infants represented 23% of total delivery costs.Regardless of the term, compared to AGA infants, SGA infants had longer hospital stays at delivery, were more likely to be admitted to an intensive care unit and were more likely to be hospitalised during the first year of life, resulting in higher costs. The mothers of SGA infants were also more likely to be hospitalised during pregnancy and had longer delivery stays. Total costs were highest for infants born between 22 to 28 weeks of gestation, and excess costs were highest for infants born between 32 to 37 weeks of gestation. After 37 weeks of gestation, the cost difference decreased as the gestational age increased. By contrast, the excess mortality increased when gestational age increased and was higher in late preterm and term infants than in infants at 28–36 weeks gestation.Several reasons may explain this finding: the outcome difference for pre-term births may be driven mostly by gestational age rather than foetal growth, thus reducing the relative effect of SGA. Additionally, the absence of early diagnosis may have led to suboptimal obstetrical and neonatal management, which in turn may have resulted in low costs but poor outcome.The strength of our study lies in the fact that we have an exhaustive French hospital database with record linkage over a 2-year period. Non-hospital births and births with coding errors or imperfect linkage were excluded; the initial dataset comprised 779,376 births of the 792,996 live births registered. Hospital costs were calculated according to national French health insurance references. We also included maternal costs, which are seldom reported in perinatal economic studies.Although the discharge database was initially developed as a tool for assessing funding related to medical activities in public and private hospitals, the main variables used in this study were recently found to be robust when compared with national vital statistics data  and to aFurthermore, reporting of the variables in our study  are legally binding on hospitals and subject to controls. We chose ‘hyper normal’ infants for the comparator group but estimated the average neonatal cost for the population with the full dataset.The main limitation was that our study considered only hospital costs. Moreover, the 1-year time horizon is too short to fully capture the economic consequences of SGA birth. The long term health impacts have been documented, and their costs will be assessed in future cohort studies.Other studies of preterm infants compared to full term infants found both higher mortality and complication rates , higher We found that being SGA predicted high hospital costs regardless of gestational age. The additional cost of SGA births was explained by higher complication rates, more frequent hospital readmissions and longer lengths of stay. SGA appears to be an independent contributor to high hospital costs in the short term. This data could be used in models to predict the costs associated with SGA .


Use or abuse of opioids and related drugs during pregnancy increases the risk of maternal and neonatal morbidities, including increased susceptibility to Neonatal Abstinence Syndrome (NAS). Severity of NAS is determined by both environmental and genetic factors, but the level of influence each one of them has in determining the severity of NAS is not fully understood. Since the incidence and severity of NAS vary a lot among susceptible infants, twin studies might give us valuable insights into understanding the relative roles of environmental and genetic factors at the onset of the disease and during its progression. Higher concordance of occurrence and severity of NAS in monozygotic twins compared to dizygotic twins would suggest a genetic role in the pathogenesis of NAS. However, comparable concordance suggests a non-genetic or an environmental basis. In this case series, we report neonatal outcomes including severity of NAS among monozygotic and dizygotic twins.A retrospective chart review was performed for all newborn twins who were at risk of developing NAS, were born in our institution between January 2006 and December 2014, and had a gestational age of 30 weeks or greater.During the study period, we identified seven sets  of eligible twins, comprising six dizygotic and one monozygotic twins, from a total of 550 infants who were at risk of developing NAS. Among the seven sets of twins, two sets were concordant for severe NAS and required pharmacological management, three sets of twins were concordant in not having severe NAS and did not require pharmacological management, and the remaining two sets were discordant, where one of the twins required pharmacological treatment.Five of the seven sets of twins in our study exhibited concordance and two sets showed discordance in withdrawal severity. Larger studies may help in understanding the roles of genetic and environmental factors in determining the severity of NAS. Maternal use, misuse, and abuse of prescription and nonprescription opioids and other illicit drugs, including heroin and cocaine, are increasing in the United States –3. With The incidence and severity of NAS have been variably reported to occur in 50–90% of infants following intrauterine exposure to drugs that are known to cause NAS . Among tTwin studies are a powerful tool in understanding the roles of genetic and environmental factors in determining the incidence and severity of diseases. Incidence of twins is about one in eighty in spontaneous pregnancy, and incidence of NAS is estimated to be 3.4–5.6 per 1,000 births, resulting in about 21,000 infants being susceptible to NAS .We hypothesized that twin studies might give us valuable information in understanding the relative roles of environmental and genetic factors in the onset and progression of NAS where incidence and severity of disease vary widely among susceptible infants. If concordance of occurrence of NAS or severity of NAS is greater in monozygotic twins than in dizygotic twins, it would suggest a genetic basis of pathogenesis of NAS. However, lack of higher concordance among monozygotic twins compared to dizygotic twins would suggest non-genetic or environmental basis in pathogenesis of NAS. In our study, we have defined “infants at risk of NAS” as infants with intrauterine exposure to opioids and related substances. We have defined “severe NAS” as NAS requiring pharmacological management. Also, we have classified twins having concordance pattern of NAS if both or neither of the twins showed severe NAS, and discordance pattern of NAS if one of the twins, but not the other, exhibited severe NAS.We mined the database of MetroHealth Medical Center’s Mother and Child Dependency Program—a multidisciplinary treatment program for drug-dependent mothers and their infants—to identify all twins born at a gestational age (GA) of 30 weeks or greater, who were at risk of developing NAS, and were born between January 2006 and December 2015. This study was approved by the Institutional Review Board. We collected the maternal and infants’ demographics and other factors related to severity of NAS, including need and duration of pharmacological treatment, duration of hospitalization, mean NAS scores (modified Finnegan score) in the first, second, and third week of life, maximum NAS score, and cumulative dose of Morphine: the first-line medicine for treatment of NAS at MetroHealth. In demographics, we collected information including gender, birth weight, GA at birth, and types of twins: monozygotic or dizygotic. We also collected details about intrauterine exposure of the infants to methadone, buprenorphine, heroin, cocaine, marijuana, tobacco, and drugs used for treatment of underlying psychiatric conditions in the mother. Additionally, we collected information on the type of feeding: breast feeding or formula feeding. Amnionicity and chorionicity was determined based on obstetric ultrasound and, when necessary and available, infant’s blood group and gender were also used to designate zygosity of twins.This set of diamniotic-dichorionic (dizygotic) twins was born at 38 weeks of GA to a 30-year-old Caucasian woman through emergency cesarean section for non-reassuring fetal heart tracing. She had a history of heroin use (both snorting and intravenous routes), cocaine use, and tobacco smoking, as well as a history of anxiety and depression, which were not treated. She was in the Methadone maintenance program, taking 45 mg methadone daily at the time of delivery. Her last reported illicit drug use was more than 4 months prior to delivery. She tested negative for Hepatitis B, Hepatitis C, and human immunodeficiency virus (HIV). Both twin A and B were male, with a birth weight of 2,775 g  and 2,830 g , respectively. Both infants were predominantly formula fed. Their median NAS scores in the first week were 3 and 2, respectively. Neither of the twins required pharmacological management for NAS, and both were discharged home on day 8.Diamniotic-dichorionic (dizygotic) twins were born at 38 weeks of GA to a 34-year-old Caucasian woman by scheduled repeat cesarean section. The mother had a history of intravenous heroin and cocaine use, tobacco smoking, as well as a history of anxiety and depression, which were not treated. She was in the Methadone maintenance program, taking 45 mg methadone daily at the time of delivery. Her last reported illicit drug use was more than 4 weeks prior to delivery. She was tested positive for Hepatitis C but negative for HIV and Hepatitis B. Both twin A and B were male with a birth weight of 2,365 g and 2,025 g, respectively. The infants’ blood type was not available in their medical records. Both infants were predominantly formula fed. Their median NAS scores in the first week were 3 and 4, respectively. Neither of the twins required pharmacological management of NAS and both were discharged home on day 8.This set of diamniotic-monochorionic (monozygotic) twins was born at 38 weeks of GA by vaginal delivery to a 21-year-old Caucasian woman. She had a history of intravenous heroin and cocaine use, tobacco smoking, as well as a history of anxiety and post-traumatic stress disorders, which were not treated. She was in the Buprenorphine maintenance program, taking 8 mg buprenorphine daily at the time of delivery. Her last reported use of illicit drugs was more than 3 weeks prior to delivery. She was Hepatitis B, Hepatitis C, and HIV negative. Both twin A and B were female, with a birth weight of 2,861 g and 2,658 g, respectively. Both infants had O positive blood group and were exclusively formula fed. Their median NAS scores in the first week were 5 and 5, with the highest scores of 10 and 13 for twin A and B, respectively; both required NICU admission. Both infants required pharmacological treatment for NAS for 12 and 26 days and were discharged on day 26 and 36, respectively.This set of dichorionic-diamniotic (dizygotic) twins was born at 36 weeks of GA by vaginal delivery to a 29-year-old Caucasian woman. She had a history of heroin use (both snorting and intravenous routes), along with cocaine and marijuana, tobacco smoking, as well as a history of anxiety and post-traumatic stress disorder, which were not treated. She was in the Methadone maintenance program, taking 60 mg methadone daily at the time of delivery. Her last reported illicit drug use was more than 4 months prior to delivery. She was Hepatitis B, Hepatitis C, and HIV negative. Twin A was a female, with a birth weight of 2,121 g, and Twin B was a male, with a birth weight of 1,823 g. Both infants were exclusively formula fed. Twin A required pharmacological treatment for 9 days and twin B did not require any pharmacological treatment. Both infants were discharged home on day 19.This set of dichorionic-diamniotic (dizygotic) twins was born at 37 weeks of GA by vaginal delivery to a 32-year-old Caucasian woman. She had a history of using heroin, cocaine, marijuana and tobacco smoking as well as a history of unspecified mental health illness, which was not treated. She was not in any opioids assisted program. Her last reported illicit drug use was 4 weeks prior to delivery. She was Hepatitis C infected, but tested negative for HIV and Hepatitis B. Twin A was a female, with a birth weight of 2,410 g, and twin B was a male, with a birth weight of 2,505 g. Both infants were exclusively formula fed. Their median NAS scores in the first week were 2 and 3 for twin A and B, respectively, and they stayed in the normal newborn nursery (NBS). Neither of the infants required any pharmacological treatment and both were discharged home on day 8.This set of dichorionic-diamniotic (dizygotic) twins was born at 34 weeks of GA by vaginal delivery to a 27-year-old Caucasian woman. She had a history of using heroin (by snorting and intravenous route), cocaine, marijuana as well as tobacco smoking, but no history of mental health illnesses. She was in the Methadone maintenance program and was taking 120 mg methadone daily at the time of delivery. She tested negative for Hepatitis B, Hepatitis C, and HIV. Twin A was a female, with birth weight of 2,121 g, and twin B was a male, with birth weight of 2,105 g. Both infants were exclusively formula fed and both required pharmacological treatment for withdrawals for 32 days. Twin A was discharged on day 43, while twin B was discharged on day 41.This set of dichorionic-diamniotic (dizygotic) twins was born at 31 weeks of GA by vaginal delivery to a 31-year-old Caucasian woman. She had a history of heroin, cocaine, other opioids’ (not specified in chart) abuse and tobacco smoking, as well as a history of anxiety and depression, which were not treated. She was in the Methadone maintenance program and was taking 50 mg methadone daily at the time of delivery. She was tested negative for Hepatitis B, Hepatitis C, and HIV. Twin A was a female, with a birth weight of 1,440 g  and twin B was also a female, with a birth weight of 1,570 g . Both infants were exclusively formula fed. Twin A required 14 days of pharmacological treatment, whereas no pharmacological treatment was required for twin B. Both infants were discharged home on day 49. Severe NAS is not very common among preterm infants born at 31 weeks, with a birth weight of about 1,400 g. We thus looked for alternative diagnosis that could explain the need of morphine but could not find anything other than NAS.Of the seven sets of twins, there was concordance of severity of NAS in five sets of twin siblings, which included a set of monozygotic twins, and discordance in two sets of twin siblings. Among the five pairs of twins with concordance of withdrawal severity, two pairs of twins developed severe NAS and three pairs did not develop severe NAS. Although the pair of identical twin siblings developed severe NAS and required pharmacological treatment, the length of treatment and hospital stay varied greatly among the twin siblings. Twin A was treated pharmacologically for 12 days and stayed in hospital for 26 days while B was treated for 26 days and stayed in hospital for 36 days. In the two pairs of dizygotic twins with discordance of NAS severity, one pair required medical treatment while the other did not. A total of 6 out of the 14 (42%) infants required treatment.To the best of our knowledge, this is the first case series of twins with NAS. Among all twins, we found 70% concordance of severity for withdrawal as measured by requirement of pharmacological treatment and 30% discordance of severity. Adequately powered twin studies may help in delineating the influence of genetic and environmental factors in determining the severity of NAS.All authors were involved in conceptualizing and designing the work, RP prepared the initial draft and all authors revised the initial draft and agreed on the final version as submitted.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


English maternity care policy has supported offering women choice of birth setting for over twenty years, but only 13% of women in England currently give birth in settings other than obstetric units (OUs). It is unclear why uptake of non-OU settings for birth remains relatively low. This paper presents a synthesis of qualitative evidence which explores influences on women’s experiences of birth place choice, preference and decision-making from the perspectives of women using maternity services.Qualitative evidence synthesis of UK research published January 1992-March 2015, using a ‘best-fit’ framework approach. Searches were run in seven electronic data bases applying a comprehensive search strategy. Thematic framework analysis was used to synthesise extracted data from included studies.Twenty-four papers drawing on twenty studies met the inclusion criteria. The synthesis identified support for the key framework themes. Women’s experiences of choosing or deciding where to give birth were influenced by whether they received information about available options and about the right to choose, women’s preferences for different services and their attributes, previous birth experiences, views of family, friends and health care professionals and women’s beliefs about risk and safety. The synthesis additionally identified that women’s access to choice of place of birth during the antenatal period varied. Planning to give birth in OU was straightforward, but although women considering birth in a setting other than hospital OU were sometimes well-supported, they also encountered obstacles and described needing to ‘counter the negativity’ surrounding home birth or birth in midwife-led settings.Over the period covered by the review, it was straightforward for low risk women to opt for hospital birth in the UK. Accessing home birth was more complex and contested. The evidence on freestanding midwifery units (FMUs) is more limited, but suggests that women wanting to opt for an FMU birth experienced similar barriers. The extent to which women experienced similar problems accessing alongside midwifery units (AMUs) is unclear.Women’s preferences for different birth options, particularly for ‘hospital’ vs non-hospital settings, are shaped by their pre-existing values, beliefs and experience, and not all women are open to all birth settings.The online version of this article (doi:10.1186/s12884-017-1279-7) contains supplementary material, which is available to authorized users. Changing Childbirth [Choice of place of birth has been part of English maternity care policy since publication of ildbirth  in 1993,ildbirth . Overallildbirth  and the ildbirth .Few other high income nations, with the exception of the Netherlands, actively promote choice of place of birth. Four birth settings are potentially available to women in England: planned home birth, freestanding midwifery units (FMUs), alongside midwifery units (AMUs) and obstetric units (OUs) . The avaBirthplace study [The reasons for low uptake of non-OU birth settings are unclear. Socio-demoraphic characteristics may contribute to this; evidence from the ce study  suggestsce study –10. Therce study , althougChanging Childbirth [This qualitative evidence synthesis (QES) was conducted to explore UK women’s experiences of choosing or planning where to give birth since the publication of ildbirth , 11. It Birthplace Choices project, [What influences birth place preferences, choices and decision making amongst healthy women with straightforward pregnancies in the UK?The synthesis reported here is a component study of the project,  which waproject, , and aimGiven the policy focus for this QES, we carried out a framework synthesis , 15, speWe included empirical studies (Jan 1992 to mid-March 2015) which contained qualitative data from qualitative or mixed method design studies on the birth place preferences, choices and decision-making of women users of maternity services. Only UK studies were included because the review was designed to answer a UK policy question, and we felt that there were benefits to understanding women’s experiences in a single well-defined health care system with universal access to a full range of integrated maternity services. As far as possible, we only included data from healthy women with straightforward pregnancies. We included papers which reported on mixed-risk populations, but excluded findings which explicitly related to women with ‘higher risk’ pregnancies  appraised included papers using the CASP qualitative checklist . No papeTwo reviewers (AC and KC) extracted descriptive information about the studies using a proforma, cross-checked by RM.The analytic framework was developed using a-priori themes and sub-themes from the best-fit model, using NVIVO v10) . Main he0 . Main Birthplace Choices research team were additionally commissioned to carry out a rapid mixed-methods review of the literature on birthplace choices for the NHS England National Maternity Review [Whilst this QES was in progress, members of the y Review , findingy Review . AnalysiOut of 2983 records screened, and following checking of references from included studies, 24 full text articles were included in the review . Whilst six papers referred to AMUs as a setting available to participants, only four of these papers presented qualitative evidence about women’s experiences of choosing AMUs. Twelve papers included data from women who could choose between OU, home and a midwifery unit. Later papers were more likely to have used longitudinal or mixed methodologies. Some included explicit reference to feminist or social science theoretical perspectives , 30–32.The CASP appraisal ,I think a lot of them ) make an assumption and think well, yes, you come under …and say, ‘you will be going along there to have the baby, won’t you?’ And, people, unless they have specifically thought about it and are willing to state, ‘well, actually, no, I won’t,’ then they will not get the option at all.Those who were open to considering or preferred non-OU settings  described having a more difficult time, as their preference often meant making a case or using persuasion. Amongst women with a preference for or inclination towards home birth the situation was more complex, as another of Madi and Crow’s participants explained :I thinkThese accounts reflect evidence in the included papers that there was a difference between these two perspectives . Understanding these preferences is likely to be important when considering how to improve and promote access to choice of place of birth. For this reason, we present findings from these differing perspectives in the sections below.The predominant experience reported by women planning birth in a setting other than hospital was one of finding their preference challenged on several fronts, and therefore we discuss this experience first, before considering the experience of women who did receive support for their preference and outlining what factors or features of care were helpful to them.In interview data , women described how home birth was positioned as counter-cultural, hippy, non-normative or alternative , 43, 44 However, the response from HCPs, as well as from family and friends, was often cautious, and women described having to ‘counter the negativity’  (p.520) In view of these experiences, we propose that the socio-cultural context See Fig.  is imporWomen who received more positive support towards planning or preferring birth at home or in non-OU settings reported different experiences. In these papers, women described preferring home or non-OU birth for the reasons already outlined , 2.3 (a) and 2.4 (a)). Although they were bound to experience the same ‘risk averse’ sociocultural context as women who encountered resistance, certain factors made their preferences seem more achievable. One positive influence was knowing somebody else who had given birth at home , 38, 43 A key difference was that women felt supported in their preference by their HCP; their midwife or GP gave them information and actively offered them a home birth , 33, 38 Encountering negativity or a more positive support for home birth might occur together or at different time-points in pregnancy. In practice, most women experience elements of each, and some described having very supportive families and midwives. Nevertheless, the predominant reported experience was one of resistance to non-OU birth settings, particularly home birth , 6.2 (a), 6.3 (a)), and this impeded access to choice of place of birth.Wherever women planned to give birth, the prevalent sociocultural narrative or expectation that OU is taken for granted as the ‘right place’ to give birth was influential , 35, 47,The cultural presumption towards hospital was facilitative for women who instinctively preferred OU birth; it provided a dependable and widely accepted explanation that OU is the safest and best equipped setting for birth, being clean, clinical, with full access to pain relief and medical, midwifery and specialist staff, and escalation to more acute care without the need for transfer , 40, 41.The QES found that few women considered that they were given a ‘real’ choice of place of birth. Planning birth in hospital was considered straightforward and uncontested during pregnancy, such that it was often not considered a ‘choice’ at all, whereas a decision to give birth at home was more often experienced as tentative and uncertain throughout pregnancy and even during labour and birth. There was some evidence that this is also the case for planned FMU birth, but although six included papers came from settings where AMUs were an option, these contained little discussion of women’s experiences of choosing AMU or accessing information about AMU services. For this reason, it is unclear whether planned AMU birth provokes the same uncertainties.Non-OU services were often not routinely discussed at booking , 38, 44.This synthesis also provided confirmatory evidence that past birth experiences, beliefs about birth risks and safety, preferences for particular service attributes  and the views of family, friends, partners and health care professionals influence women’s experience of choosing where to give birth. We have presented a new conceptual model to incorporate the new observations made in our QES into the original ‘best fit’ model. We acknowledge that this is an incremental development, that further confirmation (and refutation) is needed, and that the model proposed is likely to need to be revised as gaps in the evidence are addressed by new research. A particular area which requires more clarity is the extent to which women’s preferences for birth and the birth environment are ‘set’, or might be something that women willingly revisit if they are presented with clear information about the choices open to them, and about the various attributes and potentials of different settings for birth. New evidence about women’s experiences of choosing where to give birth in localities where AMUs are provided would also be valuable to inform the model.Birthplace Choices project, conducted in parallel with a rapid mixed-methods review for the National Maternity Review [This QES was a component study undertaken as part of the y Review . The rapy Review  providesy Review . DistancWe have argued here that choosing or planning to give birth in non-hospital settings was often experienced by women as a tentative or uncertain choice. In their recent systematic review of evidence on midwives’ place of birth discussions with women, Henshall et al.  found thOur findings relate directly to UK maternity care, but similar issues have been identified in other countries. Much of the evidence reviewed here relates to choosing between home or FMU and hospital, in a context where these choices are supported, and so these findings may have relevance to other countries where efforts are being made to provide women with choice of birth at home or in FMUs, including the Netherlands, Denmark, Australia, New Zealand and Canada.In their international review of women’s perception of birth choice, Hadjigeourgiou et al.  also ideThis ‘best fit’ framework QES used a structured search strategy with clear inclusion and exclusion criteria ’ and should be advised that midwifery-led settings are ‘particularly suitable’ for them [Much of the research in this review was undertaken before the publication of the uideline , 3. Somefor them . This reMost of the evidence in this QES comes from studies involving women choosing between an OU and home birth. This makes it difficult to disentangle whether women prefer a hospital birth, have an aversion to or fear of home birth, or whether OU birth is simply the ‘default option’. The included studies were mostly undertaken before the recent rapid expansion of AMU provision in England , 58, andIn their report on an organisational study of four English AMUs, McCourt et al.  identifiThis review suggests that women do not receive consistent, balanced information about the birth settings options which are available to them, and whilst some of the papers may reflect past or dated practice, reports that access to birth in non-OU settings were not always well supported by HCPs were also present in the more recent papers. There is now good evidence of safety and policy support in the UK for choice of place of birth for healthy women with straightforward pregnancies, and a more structured and consistent approach to information provision by HCPs  is likely to enhance women’s access to choice of place of birth.Women valued receiving information from midwives and from other HCPs, and wanted to feel confident that their HCP would support them in their choices. This suggests that HCPs need to work in a context which is supportive of their providing choice of place of birth and facilitates sufficient time to engage with women’s views and perspectives, to routinely share information about the different options available and to respond to women’s questions.Women were concerned if they heard that a home birth service might not be provided, due to lack of staff or to resource issues. The provision of a range of options in localities coupled with support for service sustainability in the long term will help women to feel confident that the service will be available to them. As familiarity appears to reduce resistance to non-traditional settings, this might also help such services to be considered normal or usual for eligible women who plan home birth, or birth in other non-OU settings.The timing of information provision is also important. As birth place preferences may change over the course of pregnancy, choice might be better supported by ensuring that women have the opportunity to discuss their options at different points during pregnancy. It is also important that midwives are able to explain the risks and benefits of different settings for birth to help women decide which setting might best meet their individual needs and preferences.Finally, in the context of recommendations policymakers and commissioners of services may want to consider the findings of this review and the other linked reviews , 50 whenDespite a national policy of offering women choice about place of birth, the evidence from studies conducted between the mid-1990s and 2010 shows that it was straightforward for low risk women to opt for hospital birth in the UK. Accessing home birth was more complex and contested and although the evidence on FMUs is more limited, it suggests that women wanting to opt for an FMU birth experienced similar barriers. Most of the evidence predates the recent expansion of AMU provision and the extent to which women experienced similar problems accessing AMUs is unclear.Our findings suggest that women’s preferences for different birth options, particularly for ‘hospital’ vs non-hospital settings, are shaped by their pre-existing values, beliefs and experience, and that not all women are open to all birth settings.Additional file 1:Search strategy and structure and additional detail about selection. (DOCX 32 kb)Additional file 2: Table S1.http://www.casp-uk.net/). The first reviewer (KC) conducted a full CASP appraisal, and a second reviewer (AC) independently conducted a modified CASP appraisal focusing on the adequacy of reporting, following Carroll et al.’s method [CASP appraisals. Two reviewers (KC and AC) appraised included papers using the CASP qualitative checklist . (DOCX 50 kb)


Diffusion tensor imaging (DTI) metrics such as fractional anisotropy (FA) and mean diffusivity (MD) have been proposed as clinical trial markers of cerebral small vessel disease (SVD) due to their associations with outcomes such as cognition. However, studies investigating this have been predominantly single-centre. As clinical trials are likely to be multisite, further studies are required to determine whether associations with cognition of similar strengths can be detected in a multicentre setting. One hundred and nine patients (mean age =68 years) with symptomatic lacunar infarction and confluent white matter hyperintensities (WMH) on MRI was recruited across six sites as part of the PRESERVE DTI substudy. After handling missing data, 3T-MRI scanning was available from five sites on five scanner models (Siemens and Philips), alongside neuropsychological and quality of life (QoL) assessments. FA median and MD peak height were extracted from DTI histogram analysis. Multiple linear regressions were performed, including normalized brain volume, WMH lesion load, and n° lacunes as covariates, to investigate the association of FA and MD with cognition and QoL. DTI metrics from all white matter were significantly associated with global cognition (standardized β =0.268), mental flexibility (β =0.306), verbal fluency (β =0.376), and Montreal Cognitive Assessment (MoCA) (β =0.273). The magnitudes of these associations were comparable with those previously reported from single-centre studies found in a systematic literature review. In this multicentre study, we confirmed associations between DTI parameters and cognition, which were similar in strength to those found in previous single-centre studies. The present study supports the use of DTI metrics as biomarkers of disease progression in multicentre studies. Cerebral small vessel disease (SVD) causes a quarter of all ischaemic strokes, is the most common pathology underlying vascular cognitive impairment and dementia  and contDespite the public health importance of SVD, there are few specific treatments . FurtherDiffusion tensor imaging (DTI) has been shown to be particularly sensitive to white matter damage in SVD. Abnormalities have been shown not only within T2-WMH but also in apparently ‘normal appearing white matter’ , and theTo evaluate this, we determined the association between DTI parameters and cognition in the baseline data of a multicentre trial.The PRESERVE study  is a multicentre randomized controlled trial comparing a strategy of intensive compared with standard treatment of blood pressure on cognitive function over a 2-year follow-up period. Nested within the overall study is a DTI substudy in which patients additionally undergo multimodal MRI including DTI at baseline and at the end of the 2-year follow-up period. The baseline data from these individuals are presented in the present paper.Inclusion criteria were: a clinical lacunar stroke with an anatomically corresponding lacunar infarct on MRI, in addition to confluent WMH graded as ≥2 on the Fazekas scale . Patientn=48), site 2 (n=29), site 3 (n=14), site 4 (n=11), site 5 (n=6), site 6 (n=1). Participants underwent baseline testing at least 3 months post-stroke.One hundred and nine patients from six sites consented to participate in the PRESERVE DTI substudy. The site sample sizes are as follows: site 1 , angina, myocardial infarction, coronary artery bypass grafts (CABGs) or coronary angioplasty were recorded.Assessment was performed by a neuropsychologist and occurred on the same day as MRI scanning or as close to the scan as possible. A cognitive test battery was used which included tests sensitive to the characteristic impairments in processing speed and executive function associated with SVD , with adIn addition, following assessments of disability and quality of life (QoL) were performed; the stroke-specific QoL assessment (SSQoL)  and the Processing speed: Wechsler Adult Intelligence Scale coding total correct, TMT-A time to complete, Mental flexibility: TMT-B time to complete, Verbal fluency: total correct for ‘FAS’ letter fluency and animal fluency and Verbal memory: RAVLT ‘immediate’ and ‘delayed’ recall). Individual task z-scores were averaged across these groupings to create overall domain scores, while all domain scores were averaged to create a Global cognition domain. SSQoL , EuroQoL  and the MoCA  were analysed individually using raw scores.Performance across neuropsychological tests was made comparable by transforming raw scores into z-scores using the best available age-scaled normative data . If data were missing for any other reasons then the domain scores were calculated without that task; this applied to three participants (2.8% of the sample size).3 isotropic voxel resolution and TR and TE were optimized to ensure comparable T1 weighting and tissue contrast across sites. DTI scans (2-mm3 isotropic voxel resolution) had similar TEs and long TRs to avoid T1 relaxation effects. In addition to the b =0 s mm−2 acquisitions, all DTI acquisition included 32 equally spaced, non-collinear diffusion gradient directions (b =1000 s mm−2) to ensure identical angular resolution and noise characteristics. T2*W sequences were TE matched and kept a similar TR to ensure comparable weighting. FLAIR sequences had identical inversion times and were also TE matched with long enough TRs to ensure no T1 weighting occurred. Resolution for T2*W and FLAIR sequences varied between sites; Supplementary Table S1 gives an overview of the exact scanner and sequence details per site.The aim was to test a study design for which MRI data were acquired using clinical scanners in different sites from different manufacturers. Within the six centres, eight 3-Tesla MR scanners were used . MRI acquisition included 3D T1-weighted (T1W), and DTI, T2*-weighted (T2*W) and Fluid-attenuated Inversion Recovery (FLAIR) scans for each participant. A rigorous quality control was implemented to ensure sequence acquisition parameters were as standardized as possible. T1W scans were acquired at 1-mmIn addition to DTI, measures describing WMH, lacunes and brain volume are frequently investigated as potential markers of SVD ,12,29–31http://www.xinapse.com/j-im-7-software/). Whole brain WMH lesions maps were generated and a WMH lesion load score was calculated as the percentage of WMH lesion volume against whole brain volume. To assess intra- and inter-rater reliability, a test set of ten FLAIR scans (from a previous study in SVD) with varying degrees of WMH was used. In a randomized, blinded setting FLAIR images were each marked twice by I.D.C. and once by a second experienced rater (D.T.). The intraclass correlation coefficient [WMH were defined as areas of increased signal on FLAIR images (excluding the rims of cavitated lacunes) and segmented by a single trained rater (I.D.C.) using a semi-automated, contouring technique in Jim image analysis software version 7.0_5 -filled cavities at least 3 mm in diameter. Additional features such as T2-hyperintense rims, shape and location were also considered to differentiate lacunes from similar imaging features such as perivascular spaces. The same single rater (I.D.C.) identified lacunes after training by a consultant neuroradiologist using a combination of T1W, T2*W and FLAIR scans.http://www.fil.ion.ucl.ac.uk/spm/ [T1W scans were intensity non-uniformity corrected using ‘N4ITK’  and segm.uk/spm/ ). Brain https://fsl.fmrib.ox.ac.uk/fsl [To obtain brain volume measures sensitive to atrophy, "SIENAX"  was apphttp://fsl.fmrib.ox.ac.uk/fsl/fslwiki/FDT) was used for DTI preprocessing. Briefly, DTI scans were eddy current corrected with eddy_correct using the first acquired b =0 s mm−2 image as the reference. A binary brain mask in DTI space was calculated for each subject using "BET" on the same b =0 acquisition. Fractional anisotropy (FA) and mean diffusivity (MD) maps were then calculated from these data using "DTIFIT". Voxels with MD values above 0.0026 mm2s−1 were removed from analyses in case they had been misclassified as CSF voxels by application of a diffusivity threshold. Likewise, spurious voxels with FA >1 were also removed. For each participant, FMRIB Linear Image Registration Tool . These affine transformation matrices were concatenated to create a third FLAIR-to-DTI transformation. TPMs and WMH lesion masks were registered into DTI space using the T1W-to-DTI (trilinear interpolation) and FLAIR-to-DTI (nearest neighbour interpolation) transforms for TPMs and binary WMH lesion masks respectively.FSL software  and all white matter (WM) were generated from the hard segmentation map.2s−1 × 10−3, bin width: 0.004 mm2s−1 × 10−3) were computed and median, peak height and peak value were extracted from these for both FA and MD. These metrics were chosen as summary measures as FA and MD are non-normally distributed in WM.Histogram analysis was performed on FA and MD maps in both NAWM and WM. Normalized histograms with 1000 bins .All analyses were performed using IBM SPSS statistics version 23  peak height and FA median were picked due to previous studies which have shown these to be correlated with cognition ,14 and sP-value was the same, the one with the largest β-value) per outcome measure, was selected and used in the Complex model. Here, NBV, WMH lesion load, n° lacunes and DTI measures were included together to assess their contributions relative to each other. Separate Complex models were performed for each outcome measure, in WM and NAWM. These models controlled for confounding effects of age, gender, premorbid IQ and were stratified by study site. Residuals were inspected for normality for all regression analyses while variance inflation factors were also calculated for the Complex models to assess multicollinearity.To compare MRI with cognitive parameters, ‘Simple’ and ‘Complex’ model linear regressions were conducted. This pipeline was structured as a method of selecting the most appropriate MRI measure per type (e.g. one brain tissue volume measurement or MD/FA histogram parameter for DTI) so that contributions of MRI metrics could be assessed together, while avoiding issues of multicollinearity. Thus, in Simple models, the association of NBV, WMH lesion load, lacunes and histogram parameters (from NAWM and WM) were separately investigated against each outcome measure . As there were multiple NBV and DTI variables, the most significant of each type  using as search terms ‘cerebral small vessel disease diffusion tensor imaging’, ‘white matter hyperintensities diffusion tensor imaging’ and ‘leukoaraiosis diffusion tensor imaging’ on 16th March, 2017. Criteria for inclusion were: (i) studies of sporadic SVD population (i.e. monogenic causes of SVD such as CADASIL were not included), (ii) studies investigating the relationship between DTI metrics and cognitive performance, (iii) studies investigating the cognitive domains analysed in the current study, (iv) analysis controlling at least one other confounding MRI measure, (v) results involved reporting of standardized β-values or partial correlation coefficients. Where a paper reported multiple associations against the same cognitive outcome, the strongest  was included. In cases where a study had published multiple papers based on the same participant data, the one which used the most similar metrics to those in the presented study was chosen.To allow comparison of the results with previous single-centre studies, a systematic review of previous literature was conducted on PubMed (n=1), site 6 was excluded from all statistical analyses. An additional six participants were excluded from analysis due to MRI data acquisition problems . Sample size was further reduced by incomplete cognitive data. Verbal fluency data was absent for one participant, Verbal memory and NART in another and (only) NART in third. Sample size was therefore reduced by further three for Verbal fluency comparisons, and by two for all other comparisons. Consequently, complete DTI data were available in 102 participants, while sample size for main statistical analyses was n=99 for testing Verbal fluency or n=100 for all other outcome measures.Due to the low sample size .The cognitive profile of the participants is shown in Mean values for MoCA, SSQoL, EuroQoL and MRI parameters are shown in Full findings are shown in ‘Complex models’ were performed to determine which MRI variables were independently associated with the outcome measures and results are shown in The number of lacunes was independently and significantly associated with Global cognition, Processing speed, MoCA and SSQoL in both tissue class models. NBV only maintained a significant association with MoCA and EuroQoL (in both tissue class models). WMH lesion load was no longer significantly related to any outcome measures.The search terms identified 230 papers, and after reading their abstracts, 37 selected for review. An additional five papers were identified from reference lists. Eight of these 42 papers met inclusion criteria –31,38–400.268, previous CIs = –0.22 to –0.06 [–0.38–0.02 [0.306, previous CIs = –0.16 to –0.06 [0.05–0.39 [0.376, previous CIs = –0.21 to –0.02 [0.099, previous CIs = –0.28 to –0.06 [0.058, previous CIs = –0.24 to –0.06 [–0.33 to 0.06 [–0.86 [0.157 to 0.355) and one case of Verbal fluency being lower than our CI (previous β = -–.11 [0.140–0.612).Two of these papers reported 95% confidence intervals (CI) with their β-values for associations between DTI metrics and cognition ,38. Compto –0.06  and –0.3to –0.06  and 0.05to –0.02 ) and Verto –0.06 ). Only tto –0.06  and –0.36 [–0.86 , our CI  = -–.11 , our CI These analyses are reported in full in the Supplementary material.P=0.424, MD: P=0.148). Comparison of all outcome measures  between sites by one-way ANOVA and Kruskal–Wallis also showed no significant findings .In order to assess any variation across individual sites, analyses were conducted on data from each site individually. FA median and MD peak height of each site were compared by one-way ANOVA, which returned a non-significant finding for each  individual site fit is included here as ‘Complex model’ analyses were also repeated at sites 1, 2 and 3 individually. These were repeated in cases where a DTI metric had been shown to have a significant relationship with a cognitive domain in the main analyses. These relationships were further visualized by scatterplot in In this analysis of baseline data from a multicentre clinical trial of SVD, we found associations between DTI metrics and cognition of a similar magnitude to those reported in previous single-centre studies. This provides support for the use of DTI measures as surrogate markers in clinical trials of SVD.We found that both DTI markers and lacunar infarct count were independently associated with Global cognition and MoCA results. Additionally, DTI markers were independently associated with Mental flexibility and Verbal fluency, and lacunes with Processing speed and SSQoL. In contrast, we found no independent associations between WMH lesion load and cognition and only two for brain volume (with MoCA and EuroQoL). This is in-line with most previous literature from single-centre studies, which have found weak or absent associations between WMH and cognition in patients with severe symptomatic SVD ,29,39. HClinical trials of new agents in SVD will need to be multicentre and if MRI is to be used as a surrogate marker, it is important to evaluate how the different markers perform in a multicentre setting. While research in other neurological disorders such as Parkinson’s  and HuntPRESERVE is one of the first studies to use advanced MRI as a surrogate marker in SVD trials. In this setting, we have shown that the magnitudes of associations between DTI and cognition are highly comparable with previous, single-centre studies, further validating the use of these metrics in this context. Additionally, while WM and NAWM DTI were always significantly associated with the same outcomes, the strengths of these associations was consistently descriptively greater in WM models. This indicates the simpler process of obtaining a WM mask is at least equally valid and may be more practical in a clinical setting. It should also be noted that previous research has indicated through power calculations that DTI parameters could detect change with much smaller sample sizes than lacunes, due to the frequency of new lacunes being relatively low . This suExamination of individual site data did demonstrate some variation in the strength of associations between MR parameters and cognition from different centres, but the majority of these effect sizes were within (or greater than) the expected ranges as determined by 95% CIs for β-values and regression slopes from the main analyses. DTI metrics and cognition did not significantly differ between sites, meaning that it is likely that a lack of power due to a low site sample size was a contributing factor to the instances where this was not the case. The similarity of DTI and cognitive metrics across sites also suggests good comparability between the centres involved in the present study. With respect to the wider literature however, the authors do note that DTI metrics have sometimes been shown to differ in magnitude between manufacturers, such as one paper where MD values were found to be systematically higher on Siemens compared with Philips scanners . AnotheThere were some limitations to the present study. There were variable sample sizes across sites, meaning the influence of some centres is much stronger than others on our findings. In particular, having a greater number of participants scanned on non-Philips hardware would have provided more information about the comparability across scanners. The lack of data on inter-scanner reproducibility is also limiting and would have been valuable in more closely judging the sensitivity of these metrics across sites. It would also have been advantageous to acquire a field map with the DTI protocol so that corrections for susceptibility induced distortions could have been made. However registration to DTI space did appear good, so this is unlikely to have caused any major problems.To conclude, in a multicentre study, we have shown that DTI metrics and lacune count correlate with cognition to a similar degree to that found in single-centre studies. Our findings support the use of DTI as a surrogate marker of SVD in multicentre studies.DTI metrics have been suggested as clinical trial markers of SVD, but studies investigating this have been single-centre and as clinical trials are likely to be multicentre. We investigate the associations between these metrics and cognition in a multicentre clinical trial of SVD.In a cross-sectional analysis, significant associations were found between white matter DTI metrics and cognition; these were of a comparable magnitude with those previously reported in single-centre studies.These findings support the use of DTI metrics as markers of SVD in multicentre clinical trials.


Sex ratio, body length, and weight of 2,456 live-birth deliveries after transfer of 9,624 embryos were noted. The proportion of males at birth was significantly associated with mode of in vitro culture of embryos only among women aged 40 years and older. The rate “body length” was significantly associated with mode of in vitro culture of embryos only among women aged 29 and younger. In the same time, among twins, this ratio positively associated with in vitro culture of embryos under microvibration only among women aged 30–34 years as well as ≥40 years and negatively among women aged 35–39 years. It was concluded that birth weight of infants was positively associated with mode of in vitro culture of embryos under microvibration among women of all age groups. This trial registration number is ISRCTN13773904, registered 6 April 2016.Aim was to determine whether there is any difference in the sex ratio, body length, and body weight of 2,456 deliveries after transfer of 9,624 embryos derived using in vitro culture under static and mechanical microvibration conditions. Pronuclear embryos from 4435 patients were cultured in vitro under two different conditions: without ( Epigenetic reprogramming is critical during gametogenesis and at preimplantation stage and involves DNA (deoxyribonucleic acid) methylation, imprinting, RNA (ribonucleic acid) silencing, covalent modifications of histones, and remodeling by other chromatin-associated complexes. Epigenetic regulation is involved in early embryo development, fetal growth, and birth weight. Disturbances in epigenetic reprogramming may lead to developmental problems and early mortality. There is concern about the health of children who are conceived with the use of assisted reproductive technologies (ART). It is reported that low birth weight and chromosomal anomalies can be associated with increased epigenetic disorders in the infants who are conceived using these procedures .All fertilization steps in nature  and embryo development with subsequent transport to the uterus take place inside the Fallopian tube. The tubal mucosa is arranged as longitudinal folds and consists of a single layer of cuboidal or columnar epithelium. The major cell types of this epithelium are secretory and ciliated cells , whose cVibration is a natural phenomenon that refers to mechanical oscillations about an equilibrium point. Since life began, the Earth has subjected all living things to a natural pulsation frequency. This natural phenomenon was predicted in 1952  and namen  =  159 cycles) and a microvibration culture group (n  =  166 cycles) in poor responders. A microvibrator was set at a frequency of 42 Hz , 5 s/60 min duration human embryo development , whereas [Ca2+] increased in neighboring cells. Additionally, iontophoretic injection of inositol 1,4,5-trisphosphate (IP3) in treated epithelial cells in culture evoked a communicated Ca2+ response that was similar to that produced by mechanical stimulation. These data allowed these authors to postulate that IP3 acts as a cellular messenger that mediates communication through gap junctions between ciliated epithelial cells [It was clearly shown that mechanical stimulation of ciliated epithelial cells in culture induces a wave of increasing Caal cells .Taking into account the fact that for “naturalization” of routine ART we have used the culture of embryos under microvibration, the aim of our investigations was to determine whether there is any difference in the sex ratio, body length, and weight of live-birth deliveries after transfer of embryos derived using in vitro culture under static and mechanical microvibration conditions.The proportion of males at birth was significantly associated with mode of in vitro culture of embryos only among women aged 40 years and older: in “Static” and “Vibration” groups 50% and 40%, respectively.Among singletons the rate “body length at birth” was significantly associated with mode of in vitro culture of embryos only among women aged 29 and younger: percent of babies with body length 48–54 cm in “Static” group comparatively to “Vibration” group was 63% and 74%, respectively. In the same time, among twins this ratio positively associated with in vitro culture of embryos under microvibration only among women aged 30–34 years as well as ≥40 years and negatively among women aged 35–39 years.Birth weight of infants was positively associated with mode of in vitro culture of embryos under microvibration among women of all age groups.


Cardiomyocytes orientation was quantified on both DTI and 3D histology. Helix angle (HA) and global HA transmurality (HAT) were calculated, and the DTI findings were confirmed with 3D histology. Global HAT was significantly reduced in the ischemic group  compared with controls . On direct comparison of DTI with 3D histology for the quantitative assessment of cardiomyocytes orientation, significant correlations were observed in both per-sample (R2 = 0.803) and per-segment analyses (R2 = 0.872). We demonstrated the capability and accuracy of DTI for mapping cardiomyocytes orientation by comparison with the intact 3D histology acquired by tissue-clearing technique. DTI is a promising tool for the noninvasive characterization of cardiomyocytes architecture.We characterized the microstructural response of the myocardium to cardiovascular disease using diffusion tensor imaging (DTI) and performed histological validation by intact, un-sectioned, three-dimensional (3D) histology using a tissue-clearing technique. The approach was validated in normal (n = 7) and ischemic (n = 8) heart failure model mice. Whole heart fiber tracking using DTI in fixed  Visualization and quantitative analysis of this complex, three-dimensional (3D) microstructure could improve the understanding of heart-structure relationships in normal development and cardiovascular disease. Nevertheless, this underlying cardiomyocytes architecture has mostly been inferred using invasive biopsies or methods that rely on destructive histological sectioning5.The left ventricle contains laminar helical structures positioned in a left-handed (epicardium) to right-handed (endocardium) orientation8. Recent technological advances have also enabled the application of DTI to a beating human heart, allowing for clinical applications10. However, the ability of DTI to delineate the tissue microstructure of the heart has not been fully validated through direct comparison with 3D non-destructive histological analysis of an intact heart, hence limiting its clinical application.Imaging techniques such as diffusion tensor imaging (DTI) made it possible to directly visualize these tissue microstructure of the heart12, which allow the molecular phenotyping and imaging of intact tissues, may address the current limitations of studying the heart microstructure and histologically validating cardiac DTI. These techniques clear the intact tissue of light-scattering lipids13. Because both connective tissue and cardiomyocytes are aligned in the same direction, forming a laminar structure2, simple auto-fluorescence of non-specific myocardial proteins can directly reveal cardiomyocytes orientation, the same vector calculated by DTI. Therefore, tissue-clearing techniques can be used to validate the accuracy of DTI for assessing cardiac microstructure.Tissue-clearing techniques11, in intact, normal mouse hearts to confirm whether microstructural information acquired by DTI is comparable to that provided by optical imaging of a cleared, intact heart.We aimed to validate the integrity of DTI using CLARITY, a tissue-clearing technique2 = 0.83, p < 0.001) and substantial agreement (ICC = 0.90) in the calculated in-plane cardiomyocytes angle between 3D tissue-clearing histology and gold-standard 2D histology with H&E staining. A non-significant negative bias  was found, and the Bland-Altman plot revealed no systematic (Type I or II) errors.The in plane cardiomyocytes angle calculated from the optical image showed no difference from the in-plane cardiomyocytes angle calculated from the section stained with H&E Fig. . There wp < 0.001). Figure The tissue-clearing technique was applied in seven normal and eight ischemic adult mouse hearts. Echocardiography at the day of sacrifice revealed reduced left ventricular systolic function in ischemic hearts, compared with controls .At each voxel, DTI images were reconstructed to model the self-diffusion tensor, and cardiomyocytes orientation was assumed as parallel to the primary eigenvector of the tensor Fig. . SimilarDTI: 1.31 ± 0.20°/%TD vs. 0.79 ± 0.13°/%TD and optical imaging: 1.36 ± 0.27°/%TD vs. 0.84 ± 0.26°/%TD, all p < 0.001).Figure 2 = 0.80, p < 0.001) was observed across all heart samples. Both control and ischemic groups also demonstrated significant agreement  between optical imaging-based and DTI-based HAT   and Bland-Altman limits of agreement  with bias of −0.054°/%TD for all samples .Overall, excellent correlation between the two imaging modalities was observed in regional analysis based on AHA segmentation in both controls and ischemics (R05) Fig. .This corp < 0.05) . Correlation between DTI and optical images was maintained at both per-infarct and remote areas .In ischemic hearts, peri-infarct areas, demarcated based on previously reported MD threshold, exhibited more perturbed HA, compared with remote areas, in both DTI and optical images  since it is used for 24, which occurs only at the final stage of cardiac remodeling25. Therefore, non-invasive imaging techniques that enable serial monitoring of myocardial remodeling from earlier stage are highly desirable as an alternative to conventional biopsy. Although there have been efforts to non-invasively describe tissue characteristics over disease progression27, the clinical use of previously reported modalities has been limited due to the requirement for contrast, low spatial resolution, long acquisition time, and risk of radiation exposure. In this regard, cardiac DTI is already an established method for the characterization of myocardial microstructure in animal models28. To validate DTI acquired at clinically translatable protocol, and to expand the clinical applicability of DTI in real clinical field, we used 12-diffusion directions to mirror the in vivo cardiac DTI protocols8. DTI may enable earlier detection of the progression of various cardiac diseases and help understanding the structure-function relationship.To date, cardiac biopsy remains the gold standard method with which to identify structural remodeling, including diffuse fibrosis29, which can explain both the less than excellent agreement between 2D and 3D histology and the poorer agreement at the smaller transmural depth between DTI and optical images, as cells at the external surface of the heart are more free to expand. However, segmental analysis revealed overall good correlation between DTI and optical images across the entire myocardium. More importantly, established image analysis tools, such as non-rigid co-registration, can be reliably and efficiently used to compare the 3D volumes acquired by 3D histology and DTI across millions of pixels. Second, sheetlet analysis used in several recent studies could not be verified due to the second and third eigenvector of the structure tensor of the cleared tissue was difficult to distinguish. We believe optimized light sheet acquisition via isotopic imaging or improved clearing will hopefully realize better distinction between secondary and tertiary eigenvectors leading to more accurate structure tensor-based sheetlet angle. Like sheetlet angle, HA also reflects the angular orientation of cardiomyocytes architecture, and have been incorporated in both animal and clinical studies30. Lastly, because this study was conducted ex vivo, serial imaging to detect temporal changes was not performed, and further study is definitely warranted in this area. In this regard, the current study could serve as a basis for designing and conducting studies using DTI as an indicator of cardiomyocytes microstructure.The current study is not without limitations. First, the agreement between conventional 2D histology with 3D histology using mirror section was good, but not high. For mirror sectioning, omitting a few slices from each section is inevitable to make surfaces flat. As a result, there was a gap of a few-slices-thick between the two mirror images compared, which can cause disagreement. In addition, a certain degree of tissue swelling is unavoidable during the process of polymerizationin vivo examination of the microstructural response of the myocardium in various cardiac diseases.In conclusion, the current study demonstrated that multi-layered helical cardiomyocytes architecture can be ascertained with DTI, by exhibiting concordance with 3D-histology obtained by tissue-clearing technique. By establishing concordance between a novel 3D histology method and DTI in revealing cardiomyocytes architecture, DTI-based characterization of cardiomyocytes orientation represents a promising tool for For the control group, male C57/B6 mice (n = 7) were sacrificed at 12 weeks old to match the ischemic model (n = 8). For the ischemic heart failure model, 8-week-old male C57/B6 mice were anesthetized with 2% isoflurane inhalation using an isoflurane delivery system. After making a small skin incision (1.2 cm) over the chest, the major and minor pectoral muscles were dissected and retracted. The fourth intercostal space was exposed. With a mosquito clamp, a small hole was made at the fourth intercostal space to open the pericardium. The left coronary artery was located and permanently ligated approximately 1 mm from its origin using a 6–0 silk suture. If the anterior wall of the left ventricle became pale, the ligation was considered successful.The heart was then returned to the intrathoracic space, and the muscle and skin were closed. Mice in ischemic group were recovered in a warm environment. No analgesic was administered during recovery. Mice were checked daily, and body weights were recorded twice a week to monitor the general health of mice until the sacrifice. Ischemic model mice were sacrificed 30 days after surgery to allow for myocardial remodeling. Ischemic heart failure and cardiac remodeling were confirmed by M-mode and 2-dimensional echocardiography immediately before sacrifice.All procedures were performed in accordance with institutional guidelines and the study was approved by the ethical review board of the Yonsei University for the animals involved in the study.®, Virbac) and xylazine . Retrograde heart perfusion was then performed on mice with 20 mL of phosphate-buffered saline (PBS) and 20 mL of hydrogel monomer solution . Hearts were extracted and incubated in hydrogel monomer solution at 4 °C for 3 days. Polymerization reaction was carried out by increasing the temperature to 37 °C for 3 hours using an Easy-Gel system . After polymerization, the heart samples were scanned with DTI.Male C57BL/6 mice were anesthetized with an intraperitoneal injection of zolazepam-tiletamine  SDS , and 100 V was applied across the samples at 37 °C for 3 days, using the Life Canvas incubation system . After clearing, heart samples were washed in PBS at 37 °C for 2 days. Finally, heart samples were incubated in EZ-index buffer , a custom-made refractive index matching solution with a refractive index of 1.45 in order to make the refractive index of the sample uniform overall, to be optically cleared.To clear tissue using the CLARITY technique31.The cleared hearts were scanned using light-sheet fluorescence microscopy, achieving an approximately 5-mm penetration depth. Optical images of clarified intact mouse hearts were mounted with the apex facing the objective lens. The hearts were imaged using a light-sheet fluorescence microscope  equipped with a 5× objective (EC Plan-Neofluar 5×) at 638-nm excitation32. Conventional structure tensor analysis was performed on the filtered images to calculate cardiomyocytes orientation at each voxel35. Briefly, image gradients  of the optical images were calculated in all dimensions using a Sobel filter to accentuate edges, and image intensity gradients increased the contrast of the cardiomyocytes structure. The following matrices shows the two-dimensional (2D) and 3D structure tensors populated by the image gradients in each dimension defined by   and one non-diffusion-weighted (b = 0 s/mm2) single spin echo MRI images36 were acquired using a 9.4-T small animal scanner  with the same imaging parameters . DTI images were acquired in short-axis orientation, defined as the planes perpendicular to long-axis in both 4- and 2-chamber view, with the most basal image containing at least 50% of circumferential myocardium37.After initial perfusion and polymerization, each heart was placed in a 15-ml tube filled with hydrogel-monomer solution. Twelve diffusion-weighted . 2-dimentional acquisition was used with number of slices varied depending on the long axis length of the heart with a few hearts requiring up to 60 slicies at 300 µm slice thickness.38. Briefly, a log-linear least squares fit was used to yield the apparent diffusion coefficients  of the self-diffusion tensor defined below 40. Helix angle (HA) was calculated using the same geometric definition applied by Streeter et al.1, with the local tangent vector defined from the center of mass of the left ventricular blood pool to the voxel of interest for each short-axis plane. For 3D visualization, DTI tractography was performed using a FACT algorithm41.Eigenvalue decomposition was performed to yield the eigenvectors and eigenvalues. The eigenvector associated with the largest eigenvalue (primary eigenvector) of the estimated self-diffusion tensor at each voxel was assumed to be parallel to the cardiomyocytes orientation42. Normal mouse cadaveric hearts were paraffin-embedded and cut into halves at mid-level. The lowest section of the upper part was processed with H&E staining, and the highest section of the lower part was processed with the tissue-clearing technique. The in-plane cardiomyocytes angle was calculated from each section and compared.To confirm whether the tissue-clearing technique preserves the original cardiomyocytes orientation, we compared the in-plane cardiomyocytes angle, ⊖, calculated from the cleared heart with conventional 2D histological analysis using hematoxylin and eosin (H&E) staining as the gold standard method. As a single tissue cannot undergo two different histologic processes, the comparison was done using the mirror section method43. The cardiomyocytes angles were calculated relative to the axes defined by the following two vectors: vector v, defined by the center of masses of the left and right ventricle cavities, and vector u, orthogonal to v. Regional mean cardiomyocytes angles were compared between conventional histology and tissue-clearing imaging partitions by anatomically segmenting the left ventricular myocardium into 20 radial segments.In-plane cardiomyocytes angles, ⊖, were calculated using a 2D structure tensor analysis for both conventional histology and tissue-clearing imaging partitionsHA maps were used to compare cleared 3D optical imaging and DTI. For each heart sample, light-sheet images were down-sampled to match the resolution of DTI. Binary masks were created for both optical and MRI-based HA maps using simple thresholding to identify the myocardium from background.3), compared with 3D optical imaging (2.28 × 2.28 × 7.67 µm3), 3D tractography of the diffusion tensor data, which subdivided each voxel into 1000 sub-voxels, was used to further qualitatively visualize the helical twisting of the cardiomyocytes from apex to base. Co-registration was performed on the binary masks using a conventional non-rigid, intensity-based mutual information algorithm to obtain a transform matrix that maps the optical binary mask to the MRI binary mask44. The transform matrix was applied to the HA maps, and voxel-wise comparison was performed only including voxels for the myocardium .To compensate for the coarse (1/2600) resolution of DTI  was calculated for each heart, defined as the mean of the fitted slopes of HA plotted against transmural depth (TD) along 20 equidistant radial projections in the short-axis plane for all slices. The global HAT reflects the degree of helical microstructure present, with lower absolute HAT indicating less helical winding.45.For control hearts, the equidistant radial projections for all short axis slices used to calculate HAT were binned into 16 AHA segments and averaged within each segment for regional comparison between DTI and light-sheet optical images2/ms > MD > 0.9 um2/ms; non-infarct regions: MD <9 um2/ms)23. Infarct regions (MD > 1.12 um2/ms) were ignored, as the tensor model for both DTI and light-sheet optical imaging does not adequately characterize the complex tissue microstructure therein46. Regional HATs of ischemic hearts were also binned into AHA segments with the infarcted segments omitted.For ischemic hearts, the equidistant radial projections in the remote regions were binned according to the peri-infarct and non-infarcted regions identified by thresholding the mean diffusivity (MD) maps  optical imaging imaging and conventional histology and (2) DTI and optical imaging. Correlations were assessed using Spearman’s correlation coefficient, and ICCanalysis was conducted to examine the relationship between HA calculated from (1) optical imaging and conventional histologic analysis, as well as (2) DTI and optical images. ICC for inter-variability of DTI-determined HA was also calculated.For regional analysis, correlation between HA values derived from DTI and optical images was calculated using Spearman’s correlation coefficient. For the ischemic model, paired t-test was applied to evaluate differences between peri-infarct areas and remote areas.p < 0.05 was considered statistically significant, with 95% confidence intervals also calculated. Statistical analyses were performed using SPSS software, version 23.0  and MedCalc software, version 16.4.3 .All comparisons were two sided, and Video 1