First, fertilization and epigenetic resetting of each individual's organismic clock to time zero (t = 0) at the gastrulation/primitive streak stage (day 15 of embryogenesis), are two discrete unseen biological events that impact a potential individual human's attributes. Second, those two discrete unseen biological events are immersed in the continuous developmental process spanning pre-fertilization and gestation, further driving individualization of diverse attributes of each future human before the third discrete and blatant biological event of parturition and livebirth. Exposures of the gravida to multiple diverse exogenous exposures means that morphogenesis and physiogenesis of every embryo/fetus has individualized attributes for its future human lifespan. Our proposed framework based on the biological discrete events and processes spanning pre-fertilization and prenatal development, implies that personhood should be incrementally attributed, and societal protections should be graduated and applied progressively across the pre-birth timespan.Discrete events and processes influence development of individual humans. Attribution of personhood to any individual human being cannot be disconnected from the underlying biological events and processes of early human development. Nonetheless, the philosophical, sociological and legal components that are integral to the meaning of the term as commonly used cannot be deduced from biology alone. The challenge for biomedical scientists to inform discussion in this arena then rests on profiling the key biological events and processes that must be assessed when considering how one might objectively reason about the task of superimposing the concept of personhood onto the developing biological entity of a potential human being. Endogenous genetic and epigenetic events and exogenous developmental  Personhood Revisited  perspective, we support the contention that incremental accrual of attributes is the most coherent framework for personhood that encompasses prenatal individualization of humans by serial and concurrently acting endogenous and exogenous developmental factors.In chapter 7 entitled “sonhood” , Jones sFrom a philosophical perspective, the term person or personhood has been defined in numerous different ways. Some philosophers, such as John Locke, base their conception of personhood on intelligence, reason, reflection, and maintenance of a particular conscious perspective across time . Some, sAs profiled by Greasley , there aIf philosophical considerations of personhood prior to livebirth are to be rooted in observable scientific facts, then some suppositions and interpretations may necessarily change as new scientific data are gathered. For example, as regards the philosophical tractability of debate about attribution of personhood, Dworkin  has statin vivo fertilization events, then a punctualist view that personhood begins at fertilization would be severely compromised because that would mean perhaps 1/3 to ½ of all developing human embryos who might be designated as persons would undergo spontaneous death even before implantation.First, in recent research, Palmerola et al.  have demSecond, Kerepesi et al.  have demin utero development require use of ultrasonic imaging which is routinely available in many locations but is not readily available in many others. Such differences raise the specter that assignment of personhood (or not) would depend upon the geographic distribution of healthcare technology. This notion that attribution of personhood to a fetus in utero might primarily depend upon the exogenous factor of access of the gravida to medical technology is relevant to public policy and legal status but will not be further addressed in this paper. Similarly, in many global regions, extremely preterm neonates will effectively have no plausible chance to survive due to unavailability of intensive care nursery services. Additionally, over the entire embryonic and fetal intervals, endogenous maternal and exogenous exposures influence development of diverse characteristics, many with sustained effects well into postnatal life, even lifelong.In milieu effects from pre-fertilization through livebirth determine each individual's unique combination of attributes upon societal entry. For our purposes in this paper, we define two terms as follows:1.Potential human: The stages of human development spanning initial interactions of one female and one male gamete such as the spermatozoa binding to the zona pelucida up to gastrulation, formation of the primitive streak, resetting of the epigenetic clock, progression through gestation and parturition.2.Physiogenesis: The partner concept to morphogenesis; meaning the acquisition of molecular, cellular, tissue, organ, system and organismic level functions to allow future individual life. Morphogenesis and physiogenesis determine future potentialities for individual persons.We contend that there are three discrete events and multiple continual/continuous processes that determine the individual attributes of a potential human. We present our framework that during prenatal development, a potential human attains a personhood status through the overlaying of a complex individualization process onto the three known discrete determinative events, namely fertilization, the novel epigenetic time reset and livebirth. The individualization process during prenatal development is the product of a spectrum of factors, both endogenous and exogenous, that incrementally influences acquisition of multiple attributes and thus results in an incremental accrual of personhood prior to and then fully upon livebirth.Many genetic, epigenetic, and developmental Although we argue for the importance of the recently discovered biological event of resetting of the epigenetic clock (approximately Day 15 of embryonic life for human embryos) , we alsoper se, health, longevity and functional status , an incremental rather than absolutist attribution of personhood is more parsimonious with biological facts.From a biomedical point of view, characterizing the pre-birth developmental course of human beings as a parsing of observable facts into two presumptively distinct categories of events versus processes is admittedly somewhat simplistic, but does serve as a useful construct in research, organization and documentation of scientific knowledge, and in medical practice. We shall use this bipartite approach to (a) review the various events and processes that are known to be relevant to pre-birth development of humans and then to (b) argue that to the extent that biomedical facts underlie the progressive acquisition of attributes that are relevant to life It is widely understood that the genetic attributes of each individual are robustly dependent upon parental genomes and that individual diversity within a population is profoundly dependent upon random assortment of alleles and meiotic recombination that had occurred in parental gametogenesis. The key biological consequence of these processes in gametogenesis is diversification of the genomes of progeny. Each array of inherited genes provides combinations that may mimic or diverge from the phenotypic traits of the parents, because most human traits are a product of a non-Mendelian complex interaction of multiple genes .The broad consensus regarding epigenetics in human embryonic development is that there is a general “wiping the slate clean” but also a modest degree of retention of some parental epigenetic marks . This prAs an outgrowth of epigenetics research in the embryo, Kerepesi et al.  have stuOur study suggests that the germ line ages but is rejuvenated in the offspring at some point during early embryogenesis. This rejuvenation occurs during early post-implantation stages corresponding to gastrulation when the offspring reaches its minimal biological age. We propose that this minimum, the ground zero, marks the beginning of aging of an organism… The data indicate that ground zero lies between E4.5 and E10.5 in mice, most probably at E6.5/E7.5. This period corresponds to the germ-layer specification (gastrulation) accompanied by the exit from pluripotency… Our current work now pinpoints the beginning of aging to ground zero… Overall, this work identifies a natural rejuvenation event during early life and suggests that organismal aging begins during embryogenesis, approximately at the time of gastrulation.in utero development that might be affected by exogenous factors are not yet fully elucidated, but there is a global effort underway to do precisely that; namely, to create a comprehensive reference map of cells during development .The range of potential cell types during human elopment . Even thf humans , 28. Theccurring , with, fsine qua nom, as it focuses on how exposures to various physical, chemical, biological and social factors may adversely affect the health and functional well-being of an individual human.Disruptions of structural and functional development occur and there is a long history of scientific study of such variations from the normative patterns. Specifically, the scientific discipline of teratology was historically rooted in morphogenesis and disorders thereof, and we assert that the later broader term of developmental toxicology has helped add dynamic integrated elements that we herein call “physiogenesis” as its in toto, whether adverse, salutary or neutral, the effects of diverse exogenous exposures alter the developmental trajectories of each future individual human and consequently provide countless patterns of individualization of all future humans , intentional exposures , environmental/unintentional exposures , as well as maternal pre-pregnancy comorbid diseases and obstetrical disorders such as gestational diabetes, preterm labor, and early or late onset preeclampsia. All of these factors   but also metabolic and neurocognitive effects in the neonate and the child. For example, associations of maternal comorbidities during pregnancy and perinatal and childhood outcomes include , hyperglycemia or obesity with high birth-weight infant and later metabolic syndrome and obesity in the child;–Maternal overweight/obesity with higher likelihood of autism spectrum disorders or neurodevelopmental delays;–Maternal asthma (with exacerbations) with increased risk of preterm delivery and low birth-weight infant ;–Maternal sleep deprivation and sleep-related breathing disorders with low birth-weight infant  and a higher risk of mortality;–Maternal anemia with low birth-weight infant (intrauterine growth retardation) and increased risk of preterm delivery; and–Maternal hypertensive disorders of pregnancy  with higher likelihood of childhood mental disorders.While it may seem intuitive that maternal diseases during pregnancy could impact outcomes of her infant, some data show that paternal health also influences the health of his infant. It is reasonable to suppose that the father's health could be a heritable precursor of sorts for his infant or that cohabitation of the two parents might lead to predisposing environmental effects on their offspring. However, at least some interesting correlations that may be causations were suggested by Kasman et al.  also influence development of her offspring. Tragic large-scale disasters have served as natural (or man-made) experiments wherein many pregnant women were exposed to various forms of deprivation or other stressors, and subsequent assessments of their offspring have shown a number of important health effects.in utero developmental effect(s) that occurred. Lumey et al. . Notably, earthquake exposure during the first trimester of pregnancy showed a further increased risk of adulthood schizophrenia .Finally, a third such event was the Great Tangshan Earthquake (China) in 1976. In this instance, another recent study by Guo et al.  assessedThough such disasters illustrate the impact that external factors may have on development, societal elements that broadly affect many more individual future humans are embedded in the concept of socio-economic status (SES) as a summary of the availability of material and social resources to any individual. Childhood SES is one of the strongest predictors of lifelong well-being and appears to be associated with the duration and functional complexity of individual brain development .The cellular and molecular mechanisms that mediate such effects of SES or other social factors such as familial adversity are not fully understood, but epigenetics appear to play an important role , 61. As …there is now emerging evidence that early social-familial adversity leads to long lasting epigenetic alterations. These alterations may influence brain development, and, consequently, the ability to learn to regulate and control aggressive behaviour…the finding that many of these biological factors involved in chronic physical aggression develop very early , highlights the need to not only study the impact of the early postnatal environment on physical aggression, but also to take into account what is happening between conception and birth.per se. For example, if random implantation occurs over an underlying uterine leiomyoma (fibroid), then as the pregnancy progresses, that fetus may be subject to reduced placental perfusion or placental abruption events that could impact growth in utero, lead to premature delivery or pose a risk of hemorrhagic compromise or even stillbirth. Another variable that may be random or iatrogenic as part of infertility therapies is twinning, or higher multiple birth. This latter random pre-birth impact on the potentialities of one identical twin versus the other, has been convincingly demonstrated by Groene et al. . These findings indicate that the maternal microbiome may poise a pregnancy to either be more likely to go to term, or to deliver prematurely and thereby impact an individual neonate and modify its post-natal developmental trajectory and ofttimes compromise one or more of its life-long functional outcomes.While the fetal microbiome concept remains unsettled, there is wide acceptance in obstetrics that some vaginal organisms contribute to ascending infections that produce chorioamnionitis and preterm labor and deliveries. Recent data also show that even in the absence of intrauterine infections, the maternal vaginal microbiome influences the risk of preterm birth . In theiAll of these sources of developmental diversification of individual humans that span the time and events from maternal and paternal gametogenesis across pre-fertilization, fertilization, implantation and embryonic and fetal development up to parturition, provide the biomedical background of processes and events that largely determine the characteristics and potentialities of each person at the time of birth.The event that introduces a human into society is parturition and livebirth, and this process presents its own set of challenges that may make a penultimate impact on the developmental outcome of the neonate. For the fetus, several maternal medical and obstetrical risk factors pose risks that may influence the infant's lifelong health and functional status in diverse ways.In High Income Countries (HIC), some of the common maternal factors at the time of parturition that impact the neonate are hypertensive disorders of pregnancy (including preeclampsia), age, weight status, diabetes , substance use, depression, breech presentation and previous Cesarean birth(s) . Among tn = 1,219) with suspected or confirmed infection during pregnancy at 28 weeks or more of gestational age were followed, along with their infants, up to day 7 postpartum. Neonatal Near Miss (NNM) cases were defined by the criteria of birth-weight <1,750 g, gestational age at birth between 28 and 33 weeks, 5 min APGAR score <7, or use of any of several acute interventions . These investigators reported neonatal outcomes to be1)n = 780) babies alive without severe complications,64% (2)n = 316) were NNM cases and25.9% (3)n = 123) perinatal death ;10.1% , the recent study by Baguiya et al.  show theIn multiple ways, whether births occur in HIC or LMIC, any of these peripartum risks may impact the fetus/neonate by causing cerebral palsy, Erb's palsy, hypoxic ischemic encephalopathy (“HIE”) , cerebral hemorrhages, hematomas or periventricular leukomalacia (“PVL”) as seen in premature infants. If PVL  is seen as an overt consequence of premature birth, there is strong evidence of more subtle central nervous system developmental effects as well, since a recent study in a cohort of >4 million persons found that preterm and early term birth were associated with significantly increased risks of autism in boys and girls .In summary, all of these antecedent diverse, mostly adverse, effects change the life-long trajectories of countless humans in multiple ways prior to birth. Humans are individualized by endogenous genetic and epigenetic events but also by effects of and responses to exogenous exposures within this developmentally sensitive interval. Developmental exposures of potential humans to multiple diverse exogenous factors means that morphogenesis and physiogenesis of every embryo/fetus possesses individualized attributes for its future lifespan.in vitro fertilization procedures were developed and procedures were regularized in this area of medicine, reviews were conducted by multi-disciplinary committees that provided insightful considerations from many diverse perspectives. Two leading examples were those published in the United States , this proposal became law , a benign hydatitiform mole tumor or a malignant chorioepithelioma tumor. The committee's assessment was “There was general agreement that the earliest possible point in time for the acquisition of personhood—i.e., protection by society—occurred with the appearance of the primitive streak (The President's Council on Bioethics 2002), which itself guaranteed biological individualization and eliminated the possibility of a benign or malignant tumor” , cerebral palsy, several types of developmental delays in children , predisposal to early-in-life onset of metabolic disorders such as childhood hypertension or other cardiovascular diseases, type 2 diabetes, kidney disease, frailty or obesity, gastrointestinal diseases, immunological disorders, cancers, etc. Myriad variations among persons are a key part of the way in which society is enriched by diversity. At the same time, it is not a eugenics consideration to strive to have the largest number of neonates to have undergone a pre-birth developmental trajectory that offers breadth and depth of future potentialities later in life.We argue that it is an ethical imperative to consider more than merely selecting or endlessly debating when a human is also a person. It is also incumbent upon us to include fundamental considerations of the future human potentialities of individual persons that encompass both the duration of life (longevity) and the quality of life, such as health-related quality of life, over that individual's future lifespan. It seems likely that most persons would want as many newborns as possible to have favorable future potentialities by not being born with or at elevated risks of congenital cytomegalovirus (CMV), milieu processes that, when combined, produce the distinguishing features of a human prior to its entry into society via livebirth. Accordingly, we present the novel argument that there are now not one but two known discrete unseen biological events that are pertinent to determining a future individual's identity; namely, fertilization plus the additional discrete biological event of epigenetic resetting of that individual's biological organismic clock to time zero (t = 0) at the gastrulation stage (around day 15 of embryogenesis). Additionally, those two discrete unseen biological events are immersed in a continual complex developmental process that spans pre-fertilization and gestational intervals and drives individualization of diverse attributes of each future individual human, preceding the discrete and blatant biological event of livebirth and societal entry of that human. During prenatal development, each future human is subject to various and variable exposures of the gravida to multiple physical, chemical, biological and social factors as well as to its own unique maternal in utero environment. These diverse exogenous exposures of every embryo/fetus influence its morphogenesis and physiogenesis thereby individualizing its future attributes, health and functional well-being across its individual human lifespan within society. However, it is important to note that attribution of personhood to a developing human at or before birth is not entirely an end unto itself. Even following early development and birth, the attributes that define an individual's personhood continue to change. From the perspective of an obstetrician or pediatrician, initiation of a new individual human life is only the beginning of what is a person's life trajectory that has hopefully been developed as a consequence of favorable pre-birth factors.As modern scientific discoveries have revealed demonstrable facts about additional endogenous and exogenous biological processes and events prior to birth, scientific and ethical considerations are pertinent to assess any other discrete or continuing components that contribute to individualization before the societal entry of an individual human by livebirth. We present the endogenous genetic and epigenetic events and exogenous developmental


Previous studies have documented varying fertility responses to changes in parental leave provisions. We contribute to this literature by investigating the effects on the transition to second and third births of a policy reform that introduced generous earnings-dependent parental leave benefit in Estonia in 2004. Our study employs a mixture cure model, a model with some useful properties that has been seldom applied in fertility research. The advantage of the cure model over conventional event history models is the ability to distinguish the effect of the covariates on the propensity to have a next child from their effect on the tempo of childbearing. The results show that the transition to next birth accelerated as parents responded to so-called speed premium, a feature that allowed them to avoid a reduction in benefits caused by a reduction of earned income between births, through the closer spacing of births. Furthermore, the findings suggest that the introduction of generous earning-related parental leave was associated with a substantial increase in the progression to both second and third births. Sub-replacement fertility has persisted in developed nations for already several decades. From 1986 to 2015, the number of countries that report the aim to raise fertility nearly tripled . Since then, the proportion of fathers among benefit recipients has slowly increased, but the leave is still mainly used by mothers; in 2021 women constituted 84% of benefit recipients. Between 2018 and 2022, further changes were made to the system with the aim of increasing the flexibility of leave use and the proportion of fathers among leave takers  posits that the speed premium in tandem with the long duration of paid parental leave would be associated with faster progression to second and third births. The hypothesis draws on the notion that the possibility of retaining the previous level of benefits without returning to work in between closely spaced births is an option attractive to many parents.Our second hypothesis (H2) anticipates that the introduction of well-paid parental leave would lead to an increase in the quantum of childbearing. This expectation stems from the microeconomic theory of the family, according to which parents could have more children when the costs of childrearing would be lower.Our third hypothesis (H3) expects that the changes in fertility behaviour associated with parental leave reform would be more pronounced in the transition to the second birth. As regards fertility quantum, our expectation is based on the dominance of two-child families that has been as an intrinsic characteristic of low-fertility societies Frejka, , in whicOur study is based on longitudinal register data compiled by Statistics Estonia. The dataset contains childbearing and marital histories of women born between 1960 and 1990, women’s and their partners’ socio-demographic characteristics, measured at the beginning of each birth interval starting from 1993, and censoring events.The events investigated are the conception of the second and third child, backdated from live births. The exposure time, measured with monthly accuracy, starts at the birth of the first (second) child and ends at the conception of the next child; included in the study are birth intervals that start between 1993 and 2019. Observations are censored at women’s 45th birthday, death, emigration, or at the end of observation period (31 March 2019).To investigate the association between the policy reform and childbearing behaviour, we use descriptive methods and event history models. Our analysis begins with duration-specific rates and Kaplan–Meier estimates. This is followed by mixture cure models, also known as split-population models, which is an extension of conventional survival models , and zero if the exposure falls within the period preceding the reform (from 1 January 1993 to 31 December 2003). To account for changes in the composition of the population at risk and macroeconomic conditions, we included a number of control variables in the models. The choice of controls was guided by previous studies, as well as data limitations. Individual controls included woman’s age group, partnership and marital status, education, occupational/activity status, ethnicity, area of residence, birth cohort, sex of previous children, and male partner’s education. Aside from marital status, which is a time-varying covariate, other individual controls were measured at the beginning of birth intervals. Controls for macroeconomic conditions included the GDP growth rate, the unemployment rate, and the consumer confidence index. All macroeconomic controls are time-varying, measured on an annual basis. Descriptive statistics for the explanatory and control variables are presented in Table As a first step, we examine trends in duration-specific second- and third-birth rates for parity cohorts of women who gave their previous birth in the period from 1995 to 2015.At duration under 30 months, there is a noticeable increase in the progression to second birth, starting from women who had their first child in 2003  to build up? We believe that the explanation must be sought mainly from two factors. The first is the dependence of parental leave benefits on the income earned before childbirth. Võrk et al.  showed tFigure In the duration interval from 31 to 60 months, the exposure to the parental leave reform begins with the 1999 parity cohort. Parents who had a child born at the end of 1999 had experienced four years since the previous birth by the time of the reform in January 2004. This means that the members of this parity cohort were exposed to the reform only in the last year of the interval from 31 to 60 months. In the 2000 and 2001 parity cohorts, the exposure to the reform started earlier, respectively. Finally, the 2002 cohort was influenced by the reform from the beginning of the given duration interval. Results in Fig. To provide insight into the connection between the parental leave reform and fertility change in interval from 61 to 96 months since the previous birth, attention must be focused on other parity cohorts. The earliest cohort, which was exposed to the reform at the end of the considered interval, comprises parents who had their previous child in 1996. In contrast, the 1999 parity cohort was the one influenced by the reform from the beginning of the interval. Similar to the results reported above for the interval from 31 to 60 months, exposure to the reform in the interval from 61 to 96 months is also associated with an increase in second- and third-birth rates. The observation window of our study does not make it possible to provide clear evidence on the association between changes in fertility rates and the parental reform at durations over 96 months.Duration-specific fertility rates revealed an increase in second- and third-birth rates following the parental leave reform, especially at short durations since the previous birth. However, the evidence obtained from duration-specific rates is fragmented, and does not provide a clear picture of shifts in the quantum of fertility. For this purpose, we use inverted Kaplan–Meier curves to show the proportion of women who had their second or third child by time since previous birth Fig. .5Fig. 3I5We begin the examination from women who gave birth to their first child in 1996 and 2000, eight and four years before the policy reform, respectively  and the baseline cohort (1996) is small. However, this difference increases at longer durations, and thus five years after the first birth, the proportion of women in the post-reform cohorts who have progressed to second birth exceeds that of the baseline cohort by 7–8 percentage points. In the seventh and eighth years of the policy reform, the difference reaches 10 percentage points. At longer durations, it decreases somewhat, as the baseline cohort became exposed to the new system as well.The 2008 first-birth cohort follows a somewhat different pattern. At short durations, it exhibits a noticeably faster progression to second birth compared to the 2004 and 2006 cohorts, in line with the strengthening of the effect of speed premium. However, at longer durations, the progression to second birth slows down, plausibly due to the Great Recession, leading to convergence with early post-reform cohorts. In the 2012 and 2014 cohorts, the rapid progression to second birth during at short duration is even more pronounced. Rather than converging with early post-reform cohorts, the 2012 and 2014 first-birth cohorts demonstrate a noticeably higher progression to second birth until the end of observation.The inverted Kaplan–Meier curves for progression to third birth show patterns that are largely similar to those for second births  and post-reform (2004 and later) cohorts leads to similar findings regarding second births, with the exception of smaller differences between cohorts. A higher progression to the next child in the post-reform cohorts over the pre-reform cohorts persists at longer durations. For instance, at the point where observation of the 2012 cohort ends (seven years after the second birth), the proportion of women who have given birth to a third child exceeds that of the baseline cohort (1996) by 5.5 percentage points. A further increase in the progression to the third birth can be observed in the 2014 cohort; this increase is not related to the parental leave reform, but to the 2017 reform of child benefits that favoured families with three or more children.To further investigate the link between the parental reform and fertility outcomes, we employ mixture cure models. The event of interest in the models is the conception of a second or third child. Our main explanatory variable compares the incidence and timing of conception of an additional child in the periods after and before the parental leave reform.Table To allow for an interpretation of the estimates in terms of parity progression, we calculated difference in predicted probabilities of the second and third births associated with the policy variable. The results show that in the non-adjusted incidence model (M1), the policy reform is associated with a 11.0 percentage point increase in the probability of second birth, relative to the pre-reform period. In the final model (M4), the difference in the probability of second birth is 5.5 percentage points. For third birth, differences in the predicted probability are somewhat larger (13.8 percentage points) in the non-adjusted incidence model, but after adjusting for the effects of control variables, the parental leave reform makes a smaller difference for the probability of third births. In the final model, it is reduced to 3.7 percentage points.It is important to note that odds ratios and predicted probabilities create a different impression of parental leave reform on the quantum of second and third births. The change in odds ratios, associated with the reform, is larger for third births, while the increase in predicted probability appears larger for second births. The difference stems from the fact that the odds ratios do not take into account an approximate twofold difference in the proportion of one- and two-child mothers who have another child. Therefore, probabilities must be preferred to odds ratios for obtaining an account of changes in fertility quantum, comparable across parities.Results obtained from the duration submodel show differences in the tempo of childbearing. More specifically, the exponentiated parameter estimates indicate multiplicative effects of shortening (exponentiated coefficient under 1) or lengthening (over 1) of the time from previous birth to conception of another child. With the exception of non-adjusted model for third births, all duration submodels in Table The estimates for control variables are shown in Table Relative to the reference group (married women), women who had been cohabiting at previous birth show a higher odds ratio of having another child, as well as shorter birth intervals. This reflects a widespread acceptance of unmarried cohabitation as a context for having children in the study population . By contrast, the odds of third birth are not significantly lower for never- and formerly married women. Differences in the length of third-birth intervals are also smaller than those for second births, with only never married exhibiting slower progression to the next parity than the reference group. Smaller differences between marital status groups in the transition to third birth can be explained by the higher proportion of third children who are born in second or higher-order unions. Research into partnership dynamics in the study population has shown that higher-order unions are less frequently converted into marriage . For third births, the pattern is reversed for homemakers and the residual category, and no significant difference from the reference group in the odds of having another child can be observed for women in manual occupations or who are unemployed. Somewhat unexpectedly, elevated odds of having another child are characteristic of women who had been in education at the time of their previous birth. This can be explained by the fact that most of these women will attain high education, which is associated with higher odds of second and third births in the study population. Similar to education, the patterns for occupational/activity status do not fully match in incidence and duration submodels.People of other ethnic backgrounds than Estonians (mostly Russians and Russian-speakers) exhibit a lower propensity of having a second and third child, as well as longer birth intervals. This is in accord with previous research, which has shown that fertility behaviour of migrants from Russia to Estonia and their descendants exhibits similarity to that of the sending population  that the speed premium feature of the Estonian parental leave is associated with accelerated transition to the next birth. Interestingly, the shift towards a closer spacing of births did not fully manifest itself immediately after the reform, but took five years to build up, presumably due to adjustments in women’s labour market behaviour, and a stepwise extension of the duration of the leave. Although closer spacing of births in response to speed premium has been found in previous studies , we expected that the introduction of generous parental leave would increase fertility quantum. The results seem to support the hypothesis. The Kaplan–Meier estimates show that the exposure to policy reform was associated with elevated parity progression ratios 10 or more years after the previous birth. The mixture cure models show increased propensity in having an additional child, associated with our policy variable. Claims that a policy reform has a positive impact on fertility quantum are sometimes questioned on the grounds that the reform is not accompanied with increase in cohort fertility  posited that changes in both the quantum and tempo of childbearing associated with the parental leave reform are more pronounced in the transition to second birth. The findings on fertility quantum are in line with this assertion. However, at odds with the expectation, the shift towards shorter birth intervals is more extensive for third births. This finding can be explained by the fact that women at risk of a third birth are older on average and have less time to realise their childbearing plans than their counterparts at risk of a second birth, which may have led to a more extensive compression of birth intervals among them. This explanation is indirectly supported by the results obtained from the duration submodel for control variables, as a woman’s higher age at the beginning of the birth interval exhibits a stronger effect (in older age groups) for third births.This study is not without limitations. Although we used a large number of control variables, the individual-level controls were mostly time-fixed, measured at the beginning of birth intervals. Some of these characteristics, such as occupation/activity status and area of residence, may be quite variable over an individual’s life course. That said, it seems unlikely that the effects of the parental leave reform on the tempo and quantum would be markedly altered if we had been able to account for changes in all individual characteristics. The inclusion of time-varying marital status in the model, in addition to partnership status at the beginning of birth interval, resulted only in a marginal change in the effects of policy variable. Another limitation is that this study did not investigate variation in the effects of parental leave reform between subgroups of women, documented in previous research (Andersson et al., Notwithstanding these limitations, we can draw some important conclusions from this study. First, our findings suggest that the effects of well-paid parental leave are not limited to birth spacing, but can also affect fertility quantum. Our study thus supports a recent reappraisal of the impact of parental leave reforms by Bergsvik et al. , who con


Transcriptome analysis revealed an upregulation of nuclear factor κB, tumor necrosis factor alpha, and inflammatory pathways in STCs, whereas metabolism, especially the tricarboxylic acid cycle and oxidative phosphorylation, was downregulated, without showing signs of cellular senescence. Using immunostaining and a publicly available single‐cell sequencing database of human kidneys, we demonstrate that STCs represent a heterogeneous population in a transient state. In conclusion, STCs are dedifferentiated PTECs showing a metabolic shift toward glycolysis, which could facilitate cellular survival after kidney injury. © 2022 The Authors. The Journal of Pathology published by John Wiley & Sons Ltd on behalf of The Pathological Society of Great Britain and Ireland.Scattered tubular cells (STCs) are a phenotypically distinct cell population in the proximal tubule that increase in number after acute kidney injury. We aimed to characterize the human STC population. Three‐dimensional human tissue analysis revealed that STCs are preferentially located within inner bends of the tubule and are barely present in young kidney tissue (<2 years), and their number increases with age. Increased STC numbers were associated with acute tubular injury (kidney injury molecule 1) and interstitial fibrosis . Isolated CD13 Acute kidney injury (AKI) is a common clinical problem, estimated to occur in one in five adults and one in three children that are hospitalized with acute illness, and is associated with high morbidity and mortality rates , 2. AKI Scattered tubular cells (STCs) have a scattered distribution throughout the proximal tubule of normal human kidneys, show a less‐differentiated phenotype, and may play a role in adaptive repair processes , 6, 7, 8Next to tubular regeneration, STCs have also been linked to processes promoting failed repair. Earlier studies using mouse models showed that a subpopulation of injured dedifferentiated PTECs become arrested at the G2/M cell cycle phase and adopt a senescence‐associated secretory phenotype that may drive inflammation and fibrosis in the kidney. Single‐cell transcriptome analysis of PTEC subpopulations at different time points during ischemia–reperfusion injury (IRI) revealed a ‘failed‐repair’ population .The majority of studies contributing to our knowledge of STCs were performed using animal models. However, the mouse findings may not be directly translatable to humans because STCs are only detected during injury and are absent under healthy conditions in mice. Also, the cell phenotype can be associated with a certain disease stage since disease processes start at a single time point, whereas in human nephrectomies the still unknown trigger may be chronic and cells may therefore be in different stages of injury and repair. Therefore, this study aimed to characterize the human STC population to gain a better understanding of their origin, location, heterogeneity, and function using immunohistochemical, immunofluorescence, and transcriptome analysis of human samples.All experimental protocols were approved by the local ethics committee of the Radboud University Medical Center, Nijmegen, the Netherlands (CMO 2017‐3652), within the remit of the Medical Research Involving Human Subjects Act (WMO). All experiments were performed in accordance with the relevant guidelines and regulations. For marker analysis and isolation of PTECs as well as STCs, the unaffected pole of normal human renal cortex tissue from tumor nephrectomies was used. For the distribution analysis of STCs, normal human kidney tissue was obtained from tumor nephrectomies using the unaffected pole of 37 patients (48–85 years). Additionally, 29 kidney tissue samples were obtained from kidney transplant biopsies from donor kidneys prior to transplantation (age 23–76). Samples of 41 kidney tissues were obtained from autopsy (age 0–61 years). The paraffin samples consisted of postmortem autopsy kidney samples and surgical adult kidney samples from the Erasmus MC Tissue Bank, Rotterdam, the Netherlands. Tissues, which were selected for having no renal abnormalities in pathology and primary diagnosis, were procured at the time of autopsy within 48 h after death. In addition, all autopsy tissue was evaluated for autolysis and only included when the material had no or only mild autolysis. In total, autopsy tissue from seven patients was excluded, whereas 41 had no or only mild autolysis and were included. The Erasmus MC Research Ethics Board waived the need for formal ethics approval according to the Dutch Law on Medical Research in Humans. Pediatric tissue was collected when parental written informed consent for both autopsy and the explicit use of the tissue for research was present; adult tissue was collected within a nonobjection clause.Procedures were performed according to ; see SupAfter immunohistochemical staining of consecutive slides of renal cortex tissue, light microscopic images of the whole tissue slides were made and digitized using the Panoramic P250 Flash II tissue scanner . The digitized slides were registered using the noncommercially available software HistokatFusion . The registration consisted of a prealignment, a parametric registration computed on coarse resolution, and a nonlinear, precise registration . In all For STC distribution analysis, eight random images  were taken of each patient tissue section stained for aquaporin‐1 (AQP1), phosphofructokinase‐platelet (PFKP), and nuclear counterstaining. The number of STCs was manually scored by two independent researchers. The number of PTECs was automatically counted using ImageJ (version 1.51) as outlined in the supplementary material  and collected for cell sorting using the strategy described in Supplementary materials and methods.Human renal cortex tissue from the unaffected pole of kidneys after tumor nephrectomy was cut into small pieces (≤1 mm) and further processed using enzymatic digestion and manual dissociation . The isolated cell pellet was resuspended in 1 ml PBS containing 1% BSA , and antibodies against CD133, CD24, and CD13  manufacturer protocols. Samples were eluted in 11 μl elution buffer, and the purification column was incubated for 1 min at room temperature and centrifuged for 1 min at 1,000 × Total RNA was used for library preparation using the RNA HyperPrep Kit with RiboErase . A fragmentation step was carried out for 6.5 min, and NextFlex DNA barcodes  were used for adapter ligation. Libraries were amplified using 15 amplification cycles. Library concentration was measured using the dsDNA Fluorescence Quantification Assays , and library size was determined using the BioAnalyzer High Sensitivity DNA Kit . Sequencing was performed using an Illumina NextSeq 500, and 50‐bp paired‐end reads were generated.A workflow similar to that described in  was usedt‐tests were performed in the 3D analysis of STCs. A linear regression analysis was performed to analyze the number of STCs in relation to age and α‐SMA expression. A two‐tailed unpaired t‐test (Mann–Whitney U test) was performed to determine the association between kidney injury molecule 1 (KIM‐1) expression and the number of STCs. A one‐way ANOVA with Bonferroni's multiple comparison test was used to analyze the number of STCs in relation to age clusters. To determine the statistical difference between males and females, an unpaired t‐test (two‐tailed) was applied.Statistical analysis was performed using GraphPad Prism . Two‐tailed unpaired z‐level in the tissue  harboring STCs, similar to permanent stem or progenitor cell niches described in other organs . We perfAdditionally, we identified PFKP as a novel STC marker, confirmed by co‐expression with vimentin Figure . STCs stR2 = 0.3526, Figure In our 3D analysis, STCs seemed to be a structural part of the inner bends of the proximal tubule, suggesting these bends might be a niche harboring STCs. We hypothesized that if STCs were dedifferentiated PTECs, they would not be present in young kidney tissue and increase with age, whereas a pre‐existing progenitor cell population would be present and might decrease with age. Analysis revealed that the number of STCs  was negligible in children 0–2 years old, whereas the number of STCs increases with age, arguing in favor of a dedifferentiated PTEC population rather than a pre‐existing progenitor cell population (+) present in normal human kidney tissue and the presence of acute tubular injury by the presence of KIM‐1. An increased number of STCs (PFKP+) was found in tissues with increased fibrosis (R2 = 0.3893) or KIM‐1 presence  is located around the nucleus and degraded in senescent cells. In annexin A2 (ANXA2)‐positive STCs, normal LMNB1 surrounding the nucleus can be found Figure . Tumor sTo compare the transcriptomic profile of the STC (CD13+CD24+ and CD13+CD133+) population to the PTEC (CD13+CD24‐CD133‐) population, we performed bulk RNA sequencing of the sorted populations  and nuclear factor kappa B (NFκB) signaling, interferon‐alpha (IFN‐α), and interferon‐gamma (IFN‐γ) Figure . Of note+) expressed PK‐Muscle 2(M2) and PFK‐Platelet(P)  and SLC16A7 (monocarboxylate transporter 2) were also significantly upregulated in STCs compared to PTECs  cycle, and glycolysis pathways. The majority of genes involved in these pathways are downregulated in STCs Figure . As prev) Figure  30]. RN. RN+) exet al . We. We33]. In this study, we aimed to characterize the origin and role of the human STC population. We showed that STCs are a dedifferentiated PTEC population since STCs are rarely present in young children and increase in number with age and injury. STCs are not senescent, which is a hallmark of cells contributing to maladaptive repair, and are therefore not likely to contribute to maladaptive repair. Transcriptome analysis using bulk RNA sequencing revealed an upregulation of inflammatory pathways in STCs, whereas metabolism and, especially, the TCA cycle and oxidative phosphorylation were downregulated, indicating that STCs showed a metabolic switch toward glycolysis. Furthermore, we could determine that STCs represent a heterogeneous population.et al showed a similar morphology using electron microscopy, had the same STC marker expression , and showed an absence of mitochondria [Since the origin and function of STCs are still debated, we analyzed the number of STCs in human kidney tissue in relation to age and kidney injury , 34, 35.chondria . In contFurthermore, we showed that STCs were located not in a protective niche environment but primarily at the inner turns of the proximal tubule. We hypothesized that STCs were more likely to be exposed to stressors in the inner bends, such as shear stress, because fluid flow velocity is highest in the inner bend of a tubing system . This loA second question regarding human STCs is whether they contribute to tubular regeneration or if the morphological and functional changes are irreversible, leading to cellular senescence, contributing to interstitial fibrosis and tubular atrophy , 41, 42.The RNA sequencing results, electron microscopy, and immunofluorescence staining indicated that STCs are glycolytic and rely less on mitochondrial respiration to obtain energy. STCs showed expression of both the PFKP and PKM2 isoform, instead of PKL and PFKL. The PKM2 dimer stimulates the conversion of pyruvate into lactate, whereas the tetramer of PKM2 stimulates normal entry of the TCA cycle after glycolysis and, thus, oxidative phosphorylation , 48. Furet al database, and therefore we consider these cells to be the same [et al showed that their human STC (PT‐VCAM1) cluster resembled the failed‐to‐repair proximal tubule cell cluster (FR‐PT) identified in mice [i.e. LRP2 and CUBN) important for normal PTEC function, and both STC clusters 1 and 2 show higher prosurvival EGFR activity [Our human STC samples showed STC marker expression similar to that of the human STC clusters we identified in the Muto the same . Muto et in mice . Indeed, in mice , 32, 49.activity . AltogetOne of the heterogeneously active pathways that might be involved in STC formation and PTEC survival is the EGFR pathway, which was also highly active in the bulk RNA sequencing results of our STCs compared to PTECs. Since subcluster 1 resembles the proximal tubule cluster most and has EGFR activation that was not seen in subclusters 3 and 4, EGFR might activate a downstream cascade leading to the STC phenotype. A previous study in mice identified FOXM1 as an early induced transcription factor in injured PTECs, which was dependent on EGFR stimulation . EGFR paIn conclusion, our results indicate that STCs are not a fixed progenitor cell population but are dedifferentiated PTECs. Even though STC number is related to age and renal injury, STCs are not senescent. Furthermore, STCs show a metabolic switch towards glycolysis, which could be facilitated by EGFR signaling and PKM2 expression and might be important for tubular cell survival. Importantly, STCs are a heterogeneous cell population. However, whether human STCs actively contribute to adaptive repair of the proximal tubule and whether these cells are able to redifferentiate into functional PTECs needs further investigation.JE and MB performed data acquisition, analysis, interpretation, a literature search, and figure generation, drafted the first version of the manuscript, and completed the final version of the manuscript. LM, VVM, BB, FM, BW, VLV, JD and RW carried out experiments and analyzed/interpreted data. MH and PB carried out computational experiments and data analysis. SW and SF provided crucial kidney samples and revised the manuscript. ES, RK, MM, MV, MFS and JW designed experiments and revised the manuscript. JV designed experiments, interpreted the data, and revised the manuscript. JJ and BS conceived the study and experiments, interpreted data, and aided in writing the second version of the manuscript and figure generation. All authors approved the final version of the submitted version.Supplementary materials and methodsFigure S1. Fiji workflow for automated counting of proximal tubular epithelial cells (PTECs)Figure S2. Preprocessing of single‐cell sequencing database and subsequent clusteringFigure S3. Scattered tubular cells are present in all segments of proximal tubuleFigure S4. Scattered tubular cell numbers increase with ageFigure S5. Fluorescence‐activated cell sorting strategy and exploratory bulk RNA sequencing analysisFigure S6. Immunohistochemical validation of STC markers upregulated in bulk RNA sequencing dataFigure S7. Scattered tubular cells show less mitochondria and a rudimentary brush border and basal labyrinthFigure S8. Scattered tubular cell clusters exhibit different gene expression profilesTable S1. Primary antibodies used for immunofluorescence and immunohistochemical stainingTable S2. Secondary antibodies used for immunofluorescence and immunohistochemical staining Click here for additional data file.Table S3. deseq2_upregulated_Scattered_vs_ProximalClick here for additional data file.Table S4. deseq2_downregulated_Scattered_vs_ProximalClick here for additional data file.Table S5. Monocle_markersClick here for additional data file.Table S6. LR_interactionsClick here for additional data file.Video S1. 3D reconstruction to study location of scattered tubular cells Click here for additional data file.


Microstructural alterations in white matter are evident in obsessive–compulsive disorder (OCD) both in adult and paediatric populations. Paediatric patients go through the process of maturation and thus may undergo different pathophysiology than adult OCD. Findings from studies in paediatric obsessive–compulsive disorder have been inconsistent, possibly due to their small sample size or heterogeneous populations. The aim of this review is to provide a comprehensive overview of white matter structures in paediatric obsessive–compulsive disorder and their correlation with clinical features. Based on PRISMA guidelines, we performed a systematic search on diffusion tensor imaging studies that reported fractional anisotropy, mean diffusivity, radial diffusivity, or axial diffusivity alterations between paediatric patients with obsessive–compulsive disorder and healthy controls using voxel-based analysis, or tract‐based spatial statistics. We identified fifteen relevant studies. Most studies reported changes predominantly in the corpus callosum, cingulum, arcuate fasciculus, uncinate fasciculus, inferior longitudinal fasciculus, superior longitudinal fasciculus, inferior fronto-occipital fasciculus, corticospinal tract, forceps minor and major, and the cerebellum in paediatric obsessive–compulsive disorder. These alterations included increased and decreased fractional anisotropy and radial diffusivity, and increased mean and axial diffusivity in different white matter tracts. These changes were associated with obsessive–compulsive disorder symptoms. Moreover, specific genetic polymorphisms were linked with cerebellar white matter changes in paediatric obsessive–compulsive disorder. White matter changes are widespread in paediatric OCD patients. These changes are often associated with symptoms however there are controversies in the direction of changes in some tracts.The online version contains supplementary material available at 10.1007/s11682-023-00761-x. Obsessive–compulsive disorder (OCD) is the fourth most common mental disorder with a lifetime prevalence of approximately 2–3%. OCD is characterized by recurrent obsessive thoughts and intrusions (obsessions) and habitual behaviours (compulsions). These symptoms disturb patients’ daily activity and affect their quality of life Drubach, . Around The aetiology of OCD has been linked to various brain systems. Earlier hypotheses were based on clinical observations from pallidal and frontal lobe lesions  allows the assessment of WM integrity within the brain major tracts. The method has been applied to study white matter changes in the OCD  is the most common indicator among these and represents the degree of anisotropy, which in turn is computed from the eigenvalues of the diffusion tensors in each of the axes. FA is particularly affected by density, orientation, WM integrity and myelination in each voxel. It decreases in neural pathology that affects myelination and orientation of the fibres. The highest FA values are found in corpus callosum and internal capsule, and the lowest values are in the grey matter and in voxels containing crossing fibers  is probably the most common approach. In this method, diffusion data is aligned with a high-resolution template, which is spatially normalized and smoothened prior to running statistical tests. As a result, the outcomes are highly reliant on a variety of parameters, such as the accuracy of the registration, smoothing filter size, etc.  . PubMed, EMBASE, and Scopus databases were screened till January 2022 to identify studies with the issue of DTI changes in paediatric OCD patients, applying the search term:  AND ("Diffusion Tensor Imaging"[Mesh] OR "Diffusion Tensor Imaging" OR DTI OR "diffusion MRI" OR "dMRI" OR "diffusion magnetic resonance imaging") in PubMed website. ('obsessive–compulsive disorder' OR OCD OR neurosis) AND ('Diffusion Tensor Imaging' OR DTI OR 'diffusion MRI' OR 'diffusion magnetic resonance imaging') in Embase and Scopus websites. This search was completed with no prior restrictions. Obtained results were added to the Covidence website (https://www.covidence.org). Figure We performed a systematic review of the literature based on the PRISMA framework (This review was not pre-registered.The screening was performed by two investigators (M.H and S.P.M). First, titles and abstracts were screened, and eligible studies were chosen for full-text screening. Then, we obtained full text of the eligible articles. Finally, paediatric OCD whole brain or ROI DTI studies with full text were included in this study. After performing data extraction, we recorded the demographic and clinical profile of participants in these studies Table  and usedRisk of bias assessment: We used the “Newcastle – Ottawa Quality Assessment Scale” (NOS)  , the severity of symptoms in patients had a significant negative correlation with AD in the left cingulum bundle, superior longitudinal fasciculus, and bilateral posterior limb of internal capsule ), dopamine transporter gene , dopaminergic receptor D3 , nerve growth factor receptor gene  and the cadherin 9 gene . Rs3087879 polymorphism of SLC1A1 gene had a significant correlation with higher MD value in paediatric OCD patients, especially in those with major allele homozygous (GG) for SLC1A1, rs3087879. The association of two polymorphisms of SLC6A3 rs4975646 and DRD3 rs3773679 with the MD value of WM also supported the involvement of the dopaminergic system. They also showed polymorphisms of NGFR, rs734194 and rs2072446, and CDH9 rs6885387 in association with WM microstructure. However, no association between these polymorphisms was found with FA.These results show that there are several dopamine-related polymorphisms and glutamate-related polymorphisms linked to OCD and imply a polygenic model of OCD in which several genes contribute subtly and gradually to the likelihood of developing the condition. Interestingly, these polymorphisms are related to WM alterations. These findings highlight the crucial roles of dopamine and glutamate and WM integrity in the pathophysiology of OCD and support the participation of cortico-striatal-thalamic-cortical bundles in this process. They also support the participation of tracts outside the orbitofronto-striatal circuit including the cerebellum and occipital lobe.Studies included in this review support the classic model of orbitofronto-striatal circuit alterations in OCD, however, it is insufficient in explaining all OCD WM changes. These fifteen studies reported widespread alterations in WM tracts that are beyond orbitofronto-striatal circuit. They also reported the involvement of tracts in the temporal, parietal, and occipital lobes. Association fibers that anatomically connect areas of the brain classically known to be involved in OCD include the cingulum, uncinate fasciculus, and arcuate fasciculus. However, the superior longitudinal fasciculus, inferior longitudinal fasciculus, and inferior-fronto-occipital fasciculus also showed altered integrity in paediatric OCD  score. Mild symptoms are between 0–13, moderate 14–25, moderate-severe 26–34, and severe symptoms by 35–40 Below is the link to the electronic supplementary material.


Severe premature birth (<32 weeks) is a risk factor for the development of maternal perinatal depression, while also affecting dyadic interactions and child outcomes. Although several studies have examined the impacts of prematurity and depression on early interactions, only a few studies have investigated the features of maternal verbal input. Furthermore, no study has investigated the relationship between the effect of severity of prematurity according to birth weight and maternal input. This study aimed to explore the effects of the severity of preterm birth and postnatal depression on maternal input during early interactions. The study included 64 mother–infant dyads, classified into three groups: 17 extremely low birth weight (ELBW) preterm infants, 17 very low birth weight (VLBW) preterm infants, and 30 full-term (FT) infants. At 3 months postpartum (corrected age for preterm infants), the dyads participated in a 5-min free interaction session. Maternal input was analyzed using the CHILDES system in terms of lexical and syntactic complexity  and functional features. Maternal postnatal depression (MPD) was assessed using the Edinburgh Postnatal Depression Scale. The results showed that in high-risk conditions , maternal input was characterized by a lower frequency of affect-salient speech and a higher proportion of information-salient speech, specifically as directives and questions, suggesting that mothers in these conditions may experience more difficulty in conveying affective content to their infants. Moreover, the more frequent use of questions may reflect an interactive style characterized by a higher level of intrusiveness. These findings provide preliminary evidence of the impacts of prematurity severity and maternal depression on maternal verbal input, highlighting the importance of assessing both factors in clinical practice. Understanding the mechanisms underlying the impacts of prematurity and depression on early interactions may inform the development of tailored interventions aimed at promoting positive parent–infant interactions and child development. Prematurity is a condition that occurs in cases of infants born alive before the 37th week of pregnancy , and it Studies that analyzed the effect of the severity of prematurity on early dyadic interactions have highlighted a significant relationship between lower birth weight and the quality of mother–infant interactions in the first postpartum period ,24. SpecInfant-directed speech (IDS) represents a particular spontaneous register used by parents and caregivers to interact with infants and young children . This foAs regards the lexical features, IDS is described as simpler, more concrete, and characterized by a lower variability in its semantic contents compared to ADS ,34. VocaSocial–pragmatic aspects of IDS cover an important function in facilitating early dyadic interactions, because they allow infants and young children to infer the caregiver’s communicative or affective intent . InteresAs mentioned above, IDS plays a key role in promoting closeness and early social interactions between the caregiver and the infant during the first years. At the same time, both formal and functional aspects of maternal speech addressed to the infant are influenced by the quality of mothers’ affective states. Studies focused on depressed mothers have reported different IDS patterns and features compared to non-depressed mothers’ speech . As regFocusing on the contents of IDS, some studies have highlighted a significant relationship between the presence of depressed mood and the functional aspects of mothers’ speech addressed to the infant. Specifically, in their study, Herrera et al.  reportedAs previously mentioned, previous studies have examined the characteristics of early mother–child interactions in cases of prematurity ,24. Of tAs research has shown that both prematurity and maternal postnatal depression can have significant impacts on infant development, we could hypothesize that one of the factors involved in this effect might be the quality of maternal input addressed to the infant during the first years postpartum. In this paper, we explore the effects of the severity of prematurity (based on birth weight) and maternal postnatal depression on the lexical, syntactic, and functional features of infant-directed speech at 3 months postpartum. It is possible to hypothesize that the presence of higher-risk situations, such as severe prematurity and higher levels of maternal postnatal depression, may influence the input directed towards the infant. Specifically, these conditions might lead to the development of different interactive modalities, which could be expressed in terms of significant differences in the syntactic, lexical, or functional features of the maternal IDS.The present pilot, prospective, exposed and non-exposed study is part of a broader research and follow-up project that aims to investigate the effects of severe prematurity on infant developmental trajectories, the presence of parental postpartum symptomatology, and the quality of early dyadic exchanges during the first year postpartum.A total of 64 mother–infant dyads participated in the study. Of these, 30 mothers of full-term (FT) infants  were recruited at the antenatal classes held in Cesena during the third trimester of pregnancy, while 34 were mothers of severely preterm infants , who had been hospitalized at the Neonatal Intensive Care Unit (NICU) of the Bufalini Hospital of Cesena . Preterm dyads were differentiated into two subgroups on the basis of the infants’ birth weight: 17 infants with a birth weight between 1500 and 1000 g were included in the very low birth weight (VLBW) group, and 17 infants with a birth weight less than 1000 g were included in the extremely low birth weight (ELBW) group. The exclusion criteria were the same for all of the groups, including the presence of infant neurological disease or complications, genetic syndromes or diseases, the presence of pre-existing maternal psychiatric disorders, multiple pregnancies, and lack of fluency in the Italian language.Before starting the study, the research project obtained approval from the Ethics Committee of the University of Bologna (Protocol Number: 0001092/2023).Data were collected at 3 months postpartum (corrected ages were considered for preterm infants) at the Laboratory of Developmental Psychodynamics “Anna Martini” . During the assessment, all participants were asked to provide a written consent form and to complete a sociodemographic questionnaire and the Edinburgh Postnatal Depression Scale , so as All mothers completed an ad hoc sociodemographic questionnaire, which included information about their age, years of education, type of delivery, marital status, and employment status. Perinatal data were also collected for all dyads. The presence of maternal depressive symptomatology in the postpartum period was assessed by using the Edinburgh Postnatal Depression Scale  self-reThe Griffiths Mental Development Scales—Revised Version  were inThe total amount of maternal speech addressed to the infant was analyzed considering the number of utterances produced during the free interaction session. The utterance, which is any sequence of speech separated from the following utterance by a pause longer than 1 s , was conWord tokens, i.e., the total number of words produced;Word types, i.e., the total number of different words produced;Mean length of utterance (MLU), i.e., the ratio of words to utterance, representing a measure of syntactic complexity.The lexical and syntactic features of maternal input were examined by analyzing the following measures:The analysis of all of these variables was conducted using the CHILDES system , a speciAffect-salient speech, which includes utterances whose aim is to maintain the conversation ;Information-salient speech, which includes utterances whose aim is to convey contents, giving or asking information. This functional category was included in the model, divided into four mutually exclusive subcategories: questions, labelling, descriptions, and directives;Attention getter, which includes utterances whose aim is to attract the infant’s attention ;Other, which includes incomplete or unintelligible utterances, or maternal speech that is not directed to the infant.Functional characteristics of the maternal input were evaluated by using an ad hoc coding scheme previously used in studies on maternal speech e.g., ,51). Acc. Acc51])For each category and subcategory, the proportion of maternal speech in the total of maternal utterances produced during the interaction was computed.According to the objectives of the study, the main analysis strategy was to compare the characteristics of IDS according to the three birthweight categories, the absence/presence of depressive symptomatology, and the interaction between these two variables.Preliminarily, the presence of differences between the three groups regarding both maternal and infant demographic characteristics was investigated by running a series of analyses of variance (ANOVAs). Specifically, the groups were compared in terms of maternal age, years of education, civil status, type of delivery, employment status, infant’s gender, infant’s (corrected) age, infant’s gestational age, and developmental quotient. The results revealed statistically significant differences between groups in terms of the mothers’ years of education, the type of delivery, and the infant’s gestational age. To assess the effects of birth status and postpartum depression on the characteristics of maternal input, a multivariate analysis of covariance (MANCOVA) was run. Both birth weight  and maternal depression (depressed and non-depressed) were set as between-subject factors, and speech characteristics  were set as dependent variables. p-value < 0.05 was considered statistically significant.A Data analysis was conducted using IBM SPSS Statistics 24 software . p = 0.01; Bonferroni post hoc FT vs. ELBW, p = 0.02). The groups showed statistically significant differences regarding the infant’s gestational age at birth and the type of delivery. Specifically, in both the ELBW and VLBW groups compared to FT, cesarean delivery was more frequent than spontaneous delivery . Furthermore, gestational age was significantly smaller in the ELBW group compared to the VLBW and FT groups, and in the VLBW group compared to the FT group  = 326; Bonferroni post hoc comparisons between all groups, p = 0.00). Since these two variables are strictly connected to prematurity, these results were expected. Maternal and infant descriptive characteristics are reported in p = 0.01); therefore, this variable was included as a confounding variable in the subsequent analyses.Analyzing the impacts of these three variables on IDS features, a significant effect emerged only for maternal years of education  = 2.99, Sociodemographic differences between depressed and non-depressed mothers were also explored; no statistically significant differences emerged between the two groups.p = 0.03, partial η2 = 0.28), but neither birth status  = 1.02, p = 0.45, partial η2 = 0.12) nor the interaction between maternal depression and birth status  = 0.66, p = 0.87, partial η2 = 0.11) was statistically significant. As the mean years of education differed among the three groups, this variable was set as a covariate in the analysis of the variance of the features of maternal speech. Overall, multivariate analysis of covariance showed a statistically significant effect of maternal depression  = 2.15, ps > 0.05; In terms of univariate analyses, no significant effects of either birth status or maternal depression emerged with respect to both the syntactic and lexical complexity of maternal speech  and more questions  = 3.32, p = 0.04) when talking to their babies, compared to the mothers of VLBW and FT infants. It is interesting to note that a similar and statistically significant pattern was observed between depressed mothers and non-depressed ones  = 10.83, p = 0.00; questions: F  = 6.61, p = 0.01). Furthermore, the results showed a significant effect of maternal depression on the proportion of directives  = 4.39, p = 0.04) addressed to the infant, as depressed mothers were more directive with their babies compared to non-depressed ones , could affect the interaction between severe prematurity and maternal depressive symptoms. These findings highlight the importance of analyzing each factor separately when studying maternal verbal input in high-risk contexts, and of assessing multiple and different risk factors.As mentioned above, this was an exploratory study aiming to investigate the influence of both maternal postnatal depression and the severity of prematurity on the features of IDS. One of the main limitations of this study is the limited sample size, which restricts the generalizability of its results and reduces the power of data analyses; therefore, future research would benefit from an increase in the number of subjects. Another limitation of this study is represented by the exclusion of fathers from the research design. The follow-up program offered by the Laboratory of Developmental Psychodynamics  involves the participation of both parents but, due to the low number of fathers who agreed to participate, they were not included in the present study. Future research should consider the influence of both maternal and paternal affective states, as these might represent important risk or protective factors for child development and wellbeing, as suggested by the literature . UnderstTaken together, these results suggest that different adverse conditions during the perinatal period, such as the ones represented by maternal postnatal depression and severe premature birth, can have significant impacts on a mother’s communication style. This, in turn, can affect the mother’s ability to engage in developmentally appropriate and sensitive interactions with her infant. From a clinical perspective, this research highlights the relevance of providing psychological support during the perinatal period to mothers who are experiencing depressive symptomatology or who have given birth to a severely premature baby. This study also suggests how important it is to promote awareness and provide sufficient training to the hospital staff, in order to create an environment that supports early mother–infant interactions, especially acknowledging the relevant role played by maternal vocal input during the first few weeks postpartum. In this way, it becomes possible to identify potential risk factors for the baby’s and mother’s mental health, and to implement early interventions to support the parenting functions and foster mother–infant bonding.


Estimates of birth defect–associated hospitalization costs must be updated as detection, diagnosis, and treatment evolve for numerous birth defects. During 2019, among patients aged <65 years, 4.1% of all hospitalizations and 7.7% of related inpatient medical costs were associated with birth defects. The total estimated cost of birth defect–associated hospitalizations was $22.2 billion.These updated estimates of hospitalization costs illustrate the importance of continually determining the health care needs of persons with birth defects to ensure optimal health for all.Changing treatments and medical costs necessitate updates to hospitalization cost estimates for birth defects. The 2019 National Inpatient Sample was used to estimate the service delivery costs of hospitalizations among patients aged <65 years for whom one or more birth defects were documented as discharge diagnoses. In 2019, the estimated cost of these birth defect–associated hospitalizations in the United States was $22.2 billion. Birth defect–associated hospitalizations bore disproportionately high costs, constituting 4.1% of all hospitalizations among persons aged <65 years and 7.7% of related inpatient medical costs. Updating estimates of hospitalization costs provides information about health care resource use associated with birth defects and the financial impact of birth defects across the life span and illustrates the need to determine the continued health care needs of persons born with birth defects to ensure optimal health for all.In the United States, major structural birth defects attributable to genetic, chromosomal, teratogenic, or unknown etiologies affect approximately 3% of live births , the National Inpatient Sample (NIS) is the largest publicly available, all-payor inpatient care database in the United States.Cost estimates were calculated as the product of the amount billed for a hospitalization and the corresponding hospital-level cost-to-charge ratios. HCUP-provided cost-to-charge ratios are computed on an annual basis for each hospital .International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM). Patent ductus arteriosus (Q25.0) and atrial septal defect (Q21.1) were not considered birth defects when occurring in neonates aged <28 days or with an associated indicator of preterm birth (P07.2 or P07.3). In addition, 23 conditions classified within the Q00–Q99 code range that are commonly considered benign or are otherwise unlikely to contribute to hospitalization costs were not considered birth defects for the purposes of this analysis .Birth defects were identified by scanning up to 40 available diagnosis code fields associated with each hospitalization among codes Q00–Q99  of the Sampling weights were applied to calculate national estimates of hospitalization frequency and cost. Mean, median, and total costs were calculated by patient demographic and birth defect code characteristics. Mean hospitalization costs were stratified by age group for selected individual birth defects and birth defect categories. If a hospitalization was associated with more than one defect included in the table, the full cost of the hospitalization was included for each defect. The individual birth defects listed include those defined in the National Birth Defects Prevention Network Congenital Malformations Surveillance Report.During 2019, a total of 937,295 birth defect–associated hospitalizations incurred a total cost of $22,204,754,855 , represeNonbirth hospitalizations of persons aged <1 year at admission were associated with the highest mean  and median  costs per hospitalization among all age groups . Among bThe most prevalent birth defect category was cardiovascular defects (22.3%), which were associated with a total cost of $9,833,000,308  . CriticaDuring 2019, the cost of hospitalizations for persons aged <65 years with a birth defect diagnosis code was estimated at $22.2 billion. These hospitalizations were associated with disproportionately high costs, constituting 4.1% of all hospitalizations among persons in the United States aged <65 years and 7.7% of total costs. Nearly one half of hospitalization costs associated with birth defects occurred among neonates and infants, and these costs disproportionately affected persons aged <1 year during nonbirth hospitalizations. Defects of the cardiovascular system were the most prevalent birth defects, were associated with disproportionately high ($9.8 billion) hospitalization costs, and included many of the costliest individual birth defects.Using 2013 NIS data, the total cost of birth defect–associated hospitalizations was estimated to be $22.9 billion for all ages and $19.1 billion for persons aged <65 years (The findings in this report are subject to at least five limitations. First, determining which costs are directly attributable to birth defects is challenging because of difficulties in identifying all sequelae of birth defects and their respective codes, the coding of minor birth defects, and the possible miscoding of some acquired structural or functional abnormalities as birth defects (Updated estimates of hospitalization costs for specific birth defects provide critical information about health care resource use. These data highlight the financial impact across the life span and illustrate the need to understand the continued health care needs of persons born with birth defects to ensure optimal health for all.


The Ward triangle is an important area used clinically to diagnose and assess osteoporosis and its fracture risk in the proximal femur. The main objective of this study was to investigate the rules of development and maturation of the trabeculae of Ward's triangle to provide a basis for the prevention and treatment proximal femur fracture.From January 2018 to December 2019, individuals from 4 months to 19 years old who underwent hip growth and development assessments at the Third Hospital of Hebei Medical University were selected retrospectively. The outpatient electronic medical record system was used to collect information such as age, gender, imaging images, and clinical diagnosis. The development score and maturity characteristics of the trabecular bone were analyzed using hip radiograph data. Correlation analysis was performed to identify the relationship among age, neck‐shaft angle and development and maturity score of the trabecular bone.A total of 941 patients were enrolled in this study, including 539 males and 402 females. Primary compression trabeculae were all present at 1 year of age and matured at 7 years of age and older; primary tension trabeculae were all present at 4 years of age and matured at 18 years of age. Secondary compression trabeculae were present at 4 years of age and matured at 18 years of age. In addition, the neck‐shaft angle progressively decreases from 4 months to 14 years of age but barely changes between 15 and 19 years of age.In short, the development and maturation of the trabeculae in the ward’ triangle followed a specific temporal pattern that was related to the neck‐shaft angle. Therefore, these findings can help us understand structure and mechanical characteristics of proximal femoral trabeculae, and improve our understanding of the mechanism and treatment of proximal femoral fractures. This study aimed to identify age‐related changes with the trabecular bone of Ward's triangle and neck‐shaft angle in the proximal femur, to quantitatively determine the rules of development and maturation of the trabeculae of Ward's triangle, so as to guide clinical treatment. The number of hip fractures is expected to reach 6.3 million by 2050, with osteoporosis accounting for 80%.et al.The proximal femur developed a special system of medial and lateral trabeculae as humans progressed from crawling to standing, allowing it to respond to tension and compression forces of proximal femur.Due to its mechanical characteristics and special structure, there are currently many studies on Ward's triangle trabeculae from macroscopic and microscopic levels, including bone tissue, imaging examination, and biomechanical study, and so forth.This was a retrospective study using the outpatient electronic medical record system the Third Hospital of Hebei Medical University in China. Between January 2018 and December 2019, patients aged 4 months to 19 years were included in this study. The inclusion criteria were: (i) individuals from 4 months to 19 years old; (ii) normal growth and development of proximal femur; and (iii) complete outpatient data. Exclusion criteria were: (i) out of age range; (ii) patients with abnormal hip growth and development; and (iii) hip osteoporosis; fractures.A total of 951 patients were assessed for hip growth and development. In this study, demographic data of the patient population, including diagnosis and hip X‐ray films, were collected and recorded from the outpatient care system. Once patients were enrolled in the study, their guardians were contacted to consent to the possible use of imaging for clinical research. All data were analyzed anonymously to protect patient privacy. This study was approved by the Ethics Committee of the Third Hospital of Hebei Medical University (2014‐015‐1).The primary exposure variable in this study was age. To observe the progression of the earliest appearance of trabeculae in children under 1 year of age, we divided the children into three groups: those aged 4–6 months, 7–9 months, and 10–12 months.The femur images included in this study were a plain film of both hip joints, which were used to assess bone morphometry and trabecular differentiation and maturation in individuals aged 4 months to 19 years. The neck‐shaft angle  was also measured. Many data points were analyzed to determine the appropriate time point for trabecular differentiation and maturation. A trabecular differentiation and maturation table was developed to diagnose the proximal femur trabecular bone. Based on the earliest time point of appearance and mature of trabecular bone, this study divided the development process into three stages: no appearance (there were no regular bundles of trabeculae on the hip radiograph), not fully mature (a state between non‐ appearance and full mature on the hip radiograph), and fully mature (adult hip trabecular bone imaging was defined as fully mature). All radiological parameters were measured and scored by two orthopedic surgeons using our PACS (medSynapse version 5.0.1.3) with the exception of the femoral neck‐shaft angle and trabecular maturation score. For a fair and comparable assessment, a third observer was selected when there were differences between the two.Time points for trabecular appearance and maturation were defined in this study as regular bundles of trabeculae and trabecular meshwork, respectively, with normal bone mineral density. The criteria classify the trabecular development process as non‐emerging, partially mature, and fully mature stages according to the trabecular emergence and maturation nodes. Partial maturation means just emerging, incomplete trabecular but intact length, and incomplete trabecular but intact density. Based on the Singh criteria,T‐test was used to evaluate the between sex‐related neck‐shaft angle difference. Categorical data were statistically analyzed using Pearson's correlation coefficient or the Spearman correlation coefficient. consistency test to the inter‐observer comparisons. p < 0.05 was considered statistically significant.Statistical software SPSS 25.0  and Origin 2021  was used for data processing and statistical analysis. Continuous data with a normal distribution were expressed as mean ± standard deviation. The inter‐observer comparisons were analyzed using consistency test. A total of 941 eligible individuals, including 539 male young children and 402 female young children, were included according to the inclusion and exclusion criteria from January 2018 to December 2019 in the outpatient system . However, there was no significant change from 14 to 19 years of age . The femoral neck‐shaft angle of male children was higher than that of female children at the age of 4, 8 and 12 years. The intraclass correlation coefficient (ICC) value of the two observers was 0.84 (p < 0.001), and the repeatability was high. , and the repeatability was high.Primary compression, primary tension and secondary compression are the most characteristic trabeculae in the proximal femoral trabeculae. In terms of the earliest time of appearance of trabeculae, the results showed that compared with primary tension and secondary compression, primary compression trabeculae were found in children aged 4 months. Infants aged 4–6 months had 15.28% (18/72), children aged 7–9 months had 22.81% (21/57) and older children aged 10–12 months had 44.44% 19/36). In children aged 1 year and older, the primary compression trabeculae were found in all included children, and the trabecular development scores increased with increasing age. Up to 7 years of age and above, the trabecular development score is stable for all children and is the highest score (20 points) . The kappa value of the two observers' evaluation of development and maturation of primary tension trabeculae was 0.856 (p < 0.001), and the repeatability was high.However, the percentage of primary tension or secondary compression was 0.00% in children less than 1 year old. In children aged 4 years and older, all primary tension trabeculae were found. And in children aged 6 years and older, all the secondary compression trabeculae were found. Up to the age of 18 years and above, the trabecular development scores and the percentage of individuals with both are shown in Figure r = 0.900; p < 0.001). Maturation of secondary compression trabeculae occurs as early as 5 years of age and is fully mature in children 18 years of age and older . The kappa value of the two observers' evaluation of development and maturation of secondary compression trabeculae was 0.918 (p < 0.001), and the repeatability was high.According to the maturation time of the trabeculae, the maturation of primary tension trabeculae first appeared at the age of 3 years and was fully mature in children aged 7 years and older. Primary tension trabeculae first matured at the age of 5 years and were fully mature at the age of 18 years and older ; primary tension trabeculae ; and secondary compression trabeculae .Primary compression, primary tension and secondary compression trabeculae gradually develop and mature with decreasing neck‐shaft angle. Spearman correlation coefficient was as follows: primary compression trabeculae , the Hebei National Science Foundation‐Outstanding Youth Foundation (Grant No. H2021206329). The funding source has no role in study design, conduction, data collection or statistical analysis.Written informed consent was obtained from patients/guardians to authorize the publication of their data.