Background Limited ultrasound capacity in low-resource settings makes correct gestational age (GA) dating difficult. Previous work demonstrated that newborn metabolic profiles can accurately determine gestational age, but this relationship has not been evaluated in low-income countries. The objective of this study was to validate and adapt a metabolic GA dating model developed using newborn blood spots for use in a low-resource setting in rural Uganda.Methods A cohort of pregnant women was followed prospectively and heel stick blood spots were collected from 666 newborns in Busia, Uganda at the time of delivery. They were dried, frozen, and shipped to the US where they were tested for 47 metabolites. Metabolic model performance was assessed using early ultrasound determined GA as the standard. Models tested included previously built multivariable models and models specifically adapted to the Busia population.Results The previously built model successfully dated 81.2% of newborns within two weeks of their ultrasound GA. Only 4.8% of GAs were off by greater than three weeks. In the model adapted to the local population, 89.2% of GAs matched their corresponding ultrasound to within two weeks. The model-derived preterm birth rate was 7.2% compared to 5.9% by ultrasound.Conclusions These results suggest that metabolic dating is a reliable method to determine GA in a low-income setting. Metabolic dating offers the potential to better elucidate preterm birth rates in low-resource settings, which is important for assessing population-level patterns, tailoring clinical care, and understanding the developmental trajectories of preterm infants.In 2015, an estimated 1.055 million children under the age of five died from complications of preterm birth making it the leading cause of under-5 mortality worldwide , clinical assessments like the new Ballard score  and DuboRecently, the World Health Organization (WHO) prioritized the development and validation of more reliable methods of gestational age dating in order to more accurately estimate preterm birth . One sucThe goal of this study was to validate and adapt a metabolic gestational age dating model  developeThis prospective cohort study was nested within a double-blind, randomized clinical trial comparing the efficacy and safety of sulfadoxine-pyrimethamine (SP) vs dihydroartemisinin-piperaquine (DP) as intermittent preventative treatment of malaria during pregnancy . The stuThe majority of women delivered their babies at the hospital adjacent to the clinic. Women who delivered at home were seen by study staff at the time of delivery or as soon as possible after delivery. At the time of delivery, a standardized assessment including information on congenital conditions, specimens collected, birthweight, infant sex, mode of delivery, and complications  was completed. Preterm birth was defined as being born at less than 37 completed weeks of gestation.Specimens collected for this study included umbilical cord blood and blood from newborn infant heel sticks. Cord blood was collected using a syringe inserted into the umbilical vein. From the syringe, 4-5 blood spots were collected. Newborn heel stick blood spots were obtained using standardized methodology from routine newborn screening . Cord blMethods and protocols for the study were approved by the ethics committees of Makerere University School of Biomedical Sciences , the Uganda National Council for Science and Technology , and the Committee of Human Research at the University of California San Francisco.t tests and χ2 or Fischer exact tests (if n ≤5 within a category) for continuous and categorical variables, respectively.A natural log transformation was performed on all metabolites to reduce skewness and minimize the influence of outliers. Given that our sample size was too small to create a reliable small for gestational age measurement, two independent alternative methods were used to determine the 10th percentile birthweight cutoffs by gestational age and sex. The first method utilized the Intergrowth-21st international standardized growth curves ,26. The P < 0.05 was required to remain in the model. Overall model performance was evaluated using area under receiver operating characteristic curve (AUC) and odds ratios (OR) with 95% confidence intervals (CI) for individual variables. The variables that formed the final model were then input into a linear regression to obtain specific predicted gestational ages for each infant. Performance of the linear model was examined using adjusted R2. Correspondence of the model-determined gestational ages to the ultrasound-determined gestational ages was also examined specifically in infants born SGA. The ability of both models to correctly classify preterm and term birth was assessed using sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy. This same model building and evaluating process and the same comparative analyses were performed using the results from the cord blood specimens with overall results compared to those from the heel-stick samples.Models using metabolic data to predict ultrasound dated prematurity were evaluated in several steps. First, the Ryckman model developed previously to predict gestational ages of an infant cohort born Iowa was evaluated  for its ability to predict ultrasound-based gestational age in this cohort .Heel-stick blood spots were collected from 666 of the 687 (96.9%) live born infants in the trial, of those, 39 (5.9%) had been born preterm per ultrasound dating. SGA rates in this population were 17% and 13.5% by intergrowth and WHO respectively. Infants born preterm were more likely than their term counterparts to have lower birthweights, and infants born term were more likely to be singletons than those born preterm. We found no statistically significant difference in sex, SGA, or age at specimen collection between infants born term and preterm  with preterm birth in univariable analysis were C4, C4-DC, C4-OH, C5, C8, phenylalanine, tyrosine, and TSH  that differed significantly between term and preterm infants. Those most strongly associated (The Ryckman model (Table S1 in the The Busia specific multivariable model showed the strongest performance identifying preterm infants (AUC = 0.953 95% CI = 0.921-0.985) and was comprised of 8 variables including birthweight, TSH, alanine, tyrosine, C4-DC, C5, C10, and C16:1-OH (The multivariable model built using cord blood displayed good performance (AUC = 0.935 95% CI = 0.894-0.977) and consisted of 6 variables: birthweight, alanine, C4, C4-DC, C4-OH, and C16:1-OH  though it varies greatly between countries and studies based on a number of factors including access to health care, gestational age measurement tool, and differing definitions of viability and preterm birth [This study has important strengths and limitations to consider. A major strength of the study is the ability to compare our model determined gestational ages to the gold standard early pregnancy ultrasounds, which are relatively rare in low-income countries. Additionally, our study was facilitated by a research infrastructure that could acquire blood spots and maintain dry cold-chain throughout storage and shipping making the mass spectrometry analyses more reliable as we know metabolite concentrations can be affected by a number of environmental factors . LikewisWhile metabolic gestational age dating may provide an immediate impact by improving preterm birth epidemiology, there are current limitations to the utility of using metabolic profiles to inform treatment. Currently, with sufficient infrastructure, the turnaround time for newborn screening is within 1-2 days. To our knowledge, there is not currently an available facility equipped to handle high throughput mass spectrometry of newborn samples within Uganda or East Africa, which necessitated shipment of samples out of country resulting in significant delays. Future efforts should focus on capacity development in-region not only to expedite gestational age dating, but to facilitate potentially life-saving diagnoses that accompany newborn screening .Our findings support the notion that newborn screening metabolic profiles from heel-stick blood spots can reliably determine gestational age at birth with the additional utility of accurately estimating preterm birth rates. Utilizing this novel tool in a more widespread effort can improve preterm birth surveillance and epidemiology. In the future, if developed, metabolic profiles may help to inform treatment and clinical management shortly after delivery.


The operations were performed with use of a navigated neuroendoscope. Intraoperative magnetic resonance (iMR) cysternography was performed before and after the cystostomy. In each case, iMR cysternography was safe and could show clearly the cyst morphology and the effectiveness of performed endoscopic cystostomies. In six cases, iMR cysternography had a significant influence of the surgical decision (p = 0.027). The rate of inconsistency between the intraoperative observations and iMR imaging–based findings was 29%. A good contrast flow through the fenestrated cyst walls correlated with a good long-term clinical outcome  and good long-term radiological outcome . Intraoperative low-field MR cysternography is a safe and reliable method for assessment of the efficacy of performed endoscopic cystostomies and has significant influence on the surgical decision. It may be reliably used for prediction of the long-term clinical and radiological outcome.Endoscopic cystocysternostomy or cystoventriculostomy is the treatment of choice in patients with symptomatic intracranial arachnoid cysts. There are no objective diagnostic tests for reliable intraoperative evaluation of the effectiveness of performed stomies. The aim of this prospective open-label study is to demonstrate for the first time the usefulness of intraoperative cysternography performed with the low-field 0.15-T magnetic resonance imager Polestar N20 during endoscopic cysternostomies. The study was performed in patients operated for middle fossa arachnoid cysts ( Arachnoid cysts are congenital lesions that develop from splitting of the arachnoid membrane. Some of the cysts become symptomatic manifesting with headache, seizures, hydrocephalus (HCP), hemiparesis, visual loss, and hormonal and developmental disturbances. Presentation depends on the area they develop and the age of the patient . TreatmeThe application of image-guided navigation has increased the accuracy of targeting of the areas for cyst fenestration when normal anatomical landmarks are not identifiable, thus increasing the safety and effectiveness of the operations . Yet then = 10), suprasellar cysts (n = 4), paraventricular or intraventricular cysts (n = 6), and pineal cyst (n = 1). In all patients, the pathology was diagnosed based on high-field MRI studies. In each case, a written consent for an endoscopic procedure with use of iMR cysternography was obtained and a standardized questionnaire used routinely before MRI examinations was completed. In seven cases, the child’s parents gave the written consent for participation in the study. The study was approved by the Bioethics Committee of the Wroclaw Medical University in concordance with the Declaration of Helsinki.Twenty-one patients with symptomatic arachnoid cysts were included in this prospective uncontrolled study. The patients were operated for Galassi type II or III middle fossa arachnoid cysts  (n = 10)The patients were operated using a rigid 0° 6-mm neuroendoscope . It was used also as a navigation tool. The operations were performed in a shielded operating room adapted for iMR imaging. The 0.15-T MR imager Polestar N20  was used for intraoperative image acquisition. The detailed description of the technical considerations of use of the MR imager during the operations was described in our previous publications , 10, 12.The trephination was performed above the cyst area according to the navigation plan. The cyst was punctured with an 0.8-mm-wide needle, and 5 ml from the cyst fluid was aspirated. In the next step, 5 ml of gadoteridol  diluted in Ringer’s solution (1:40) to a concentration of 0.012 mmol/ml was delivered to the cyst. A T1-weighted axial iMRI scan  was performed to show the degree of communication of the arachnoid cyst with the neighboring basal cisterns. In case of a noncommunicating cyst, a navigated endoscope was passed into the cyst. The cyst wall was first perforated using a sharp monopolar cannula, then enlarged with a blunt forcep and finally widened with a 3-French Fogarty balloon catheter. The surgical goal was to open all cyst membranes and to pass the 6-mm-wide endoscope trocar through the opening to the basal cisterns. The cysts were fenestrated mainly in the compartments between the internal carotid artery and oculomotor nerve or below the oculomotor nerve. By the time we were convinced that the fenestration has been adequately performed, a control iMR cysternography was performed. The contrast agent was delivered through a Cavafix catheter  passed through the working channel of the endoscope. The results from the MR cysternographic studies before and after the cyst fenestration were analyzed in the navigation system. Our criterion for an effective cysternostomy was the identification of contrast flow in the interpeduncular, perimesencephalic, and prepontine cisterns.The first step of the surgical procedure was a trephination, performed 2.5–3 cm lateral to the midline and at the level of the coronal suture. After the dura mater opening, the lateral ventricle was punctured with a brain needle for cerebrospinal fluid (CSF) aspiration and for contrast delivery. We chose the T1-weighted sagittal iMRI scans for optimal evaluation of cyst anatomy and contrast flow. In case of suprasellar cysts, our approach was first to fenestrate the cyst into the ventricle compartments and then to perform ETV. In case of a pineal cyst, we started first with ETV and then opened the cyst. For the latter maneuver, a second trephination was performed 4 cm anteriorly to the coronal trephination, to enable a safe introduction of the endoscope to the posterior part of the third ventricle. The patient with a fourth ventricle cyst underwent only cyst fenestration. After completion of the cystostomy in all cases except the case of fourth ventricle cyst, we assessed the efficacy of the surgery by observation of the oscillations of the third ventricle floor and also evaluated the area below the ventriculostomy for arachnoid membrane adhesions. The control iMRI scan was also sagittal T1-weighted, but this time, 5 ml of gadoteridol contrast was delivered either into the cyst (suprasellar and fourth ventricle cysts) or at the level of the foramen of Monro . The criterion for an effective cyst fenestration, when ETV was part of the procedure, was the presence on sagittal scans of contrast agent passing into the inderpeduncular and prepontine cisterns and the presence of contrast on axial scans in the distally located arachnoid cisterns like the cerebellomedullary or Sylvian fissure cisterns. In the patient with a fourth ventricle cyst, we evaluated the quality of communication between the cyst and the ventricle.The trephination was performed as close as possible to the cyst. After the cyst was punctured and 5 ml of CSF aspirated, 5 ml of diluted gadoteridol contrast was delivered into the cyst. A T1-weighted axial iMRI scan was performed to show the cyst topography. Then, the cystoventriculostomy was performed. A control axial iMRI scan was performed at the end of the procedure.The patients’ postoperative clinical state was evaluated in the period from the day of operation to discharge and at least 6 months after surgery. In patients in whom HCP was the main manifestation of the cyst, the treatment success was defined as an absence of clinical and radiological evidence of HCP in the long-term observation. Patients treated for middle fossa cysts were assessed for the presence of headache using the VAS score and for the presence of epilepsy or neurological impairment. The infants treated for an intraventricular cyst were examined monthly by a pediatric neurologist who evaluated their psychomotor development.In each patient, a high-field 1.5-T  or 3-T MRI  study was performed in the long-term follow-up period. The presence of flow void phenomenon through the area of cyst fenestration on T2-weighted and heavily T2-weighted steady-state images (3D-FIESTA or 3D-DRIVE), the mean cyst volume, and the radiological signs of possible elevated intracranial pressure were assessed. The cyst volume was determined with the SmartBrush system  for object delineation and volume calculation. The main criteria for a good radiological result after the endoscopic procedure were the confirmation of cyst patency and the regression of radiological signs of cyst expansion like a decrease of the cyst volume, decrease of the midline shift, or the absence of HCP.ρ coefficient), Wilcoxon signed-rank test, or chi-squared test. A value of p < 0.05 was considered statistically significant.All statistical analyses were performed with TIBCO Statistica™  either by Spearman’s rank correlation test . One from these leaks resulted in subclinical meningitis (asymptomatic CSF pleocytosis) that was successfully treated pharmacologically. There was one case of transient paresis of the oculomotor nerve and one case of abducens nerve paresis that lasted several hours (patients 16 and 12), one case of transient memory deficit (patient 17), and one case of pseudomeningocele in a 3-month-old infant with an intraventricular cyst (patient 13). He underwent recysternoventriculostomy and surgical closure of the pseudomeningocele. We did not observe any adverse events directly related to the usage of the iMR cysternography.p = 0.027, Table We found iMR cysternography as a very useful tool that could demonstrate both the cyst morphology as well as the degree of cyst patency before and after its marsupialization. Figure ρ = 0.54, p < 0.05). In all patients, except three, in whom the cysternography showed good contrast across the performed cyst fenestration, a clinical improvement was observed postoperatively. In patients 8 and 19, treated for a middle fossa cyst, the headache persisted postoperatively, although there was a decrease of the cyst size and the midline shift on the follow-up imaging.The patency of the cytostomy proven by the iMR cysternography positively correlated with the long-term clinical outcome . In 13 cases (61.9%), a flow void phenomenon of CSF was detected that confirmed the cyst patency (p = 0.001). There was a high positive correlation between final postfenestration iMR cysternography result and the long-term MRI result .A summary of the preoperative and postoperative radiological findings is presented in Table In this study, we demonstrated that endoscopic fenestration of symptomatic arachnoid cysts is a safe and effective procedure, obtaining high rates of good clinical 85.7%) and radiological outcome (95%). In patients with suprasellar and pineal cysts, 100% of good clinical and radiological long-term results were observed, while the success rate in patients with paraventricular or intraventricular cysts was 83.3%, and in patients with middle fossa cysts, it was 80%. These results are in accordance with observations from other studies indicating patients with symptomatic suprasellar, quadrigeminal, and paraventricular and intraventricular cysts as most beneficial candidates for endoscopic treatment and patients with middle fossa cysts as less predictable responders to endoscopic fenestration % and rad. A confiThe high rate of good clinical and radiological improvement observed in our patients was most likely influenced by the usage of the technique of low-field iMR cysternography. The four cases where there was a clear need to continue the fenestration procedure to obtain efficient contrast flow through the stoma as well as the two cases where such procedure was not necessary at all (because the cysts were patent) or where there was no need to continue the surgery prove the potential usefulness of iMR cysternography. Similar observations in our cohort of patients who had undergone ETV with application of low-field iMR ventriculography seem to confirm this thesis even further . In threρ = 0.54, p < 0.05) and more precisely the long-term radiological outcome . Besides, it could increase the objectivity of the surgical decisions whether to carry on or not the further exploration in the region of stoma. According to our knowledge, there is no reliable method based on preoperative clinical and demographic factors or intraoperative observations that could predict the success rate of endoscopic cystocysternostomy or cystoventriculostomy. Such methods have been described only for the prediction of the ETV success rate and include the ETV success score [Intraoperative MR cysternography could predict the long-term clinical outcome , the cyst topography , and the fact of constant cyst irrigation with the endoscope) may have decreased the probability of brain shift. Thus, we could reliably use navigation based on preoperative high-field MRI scans and applied iMR cysternography mainly for evaluation of cyst morphology and the effectiveness of performed endoscopic cystostomies. Yet, in our previous work, we demonstrated that in case of lack of preoperative navigation high-field MRI images, low-field iMRI can be effectively used for intraoperative navigated endoscopy .Our study reproduces the results of others treating patients with suprasellar and quadrigeminal cysts. The lower success rate of endoscopic treatment of middle fossa cyst described in the literature and confirmed also in our study can be explained by the relatively unspecific clinical presentation as well as by the anatomical restraints limiting the possibility of obtaining an effective cystocysternostomy. The main operative approach is to perform as many as possible fenestrations and as large as possible . Certainp < 0.001) than in other age groups (4%) [The two cases of infants with intraventricular cysts deserve a special attention. Unfortunately, in both cases, a revision surgery was required. In patient 13, a pseudomeningocoele has developed postoperatively. It was most likely caused by the fact that trephination and dural opening in a cruciate fashion was used which did not allow us to perform a watertight dural closure. The pseudomeningocoele might have caused a decrease of the pressure gradient at the level of the stoma and its subsequent obliteration. A revision endoscopic fenestration through a key hole craniotomy was performed, followed by a watertight dural reconstruction using a dural substitute. The procedure was successful, and good long-term clinical outcome was noted. Patient 21 was operated for two symptomatic paraventricular arachnoid cysts, which were surgically connected with the third ventricle. The patency of stoma was proven by the iMR cysternography. Six months postoperatively, the child developed a right-sided hemiparesis. The MRI revealed a marked increase of the midline shift and cyst volume. During the revision endoscopic surgery, iMR cysternography confirmed lack of communication between the cysts and the ventricular system. A new fenestration was performed directly into the left lateral ventricle, and its patency was again confirmed with iMR cysternography. Yet, an expansive subdural hygroma developed following the surgery, requiring the insertion of a subduro-peritoneal shunt. The reason for the obliteration of the stoma remains unclear to us. In larger series of children treated for intracranial arachnoid cysts, the failure of endoscopic fenestration in infants was 44% and was significantly higher (ups (4%) . This grups (4%) , 15, 18.ups (4%)  and by tups (4%) , 21.There are few limitations to our study. Our relatively small cohort of patients was heterogeneous with regard to the cyst type and age of patients treated. That makes the statistical analysis underpowered and difficult to be directly transferred into the clinical routine. This fact also may explain the observation that while iMR cysternography significantly influenced the surgical decision in six of the described cases, it did not improve the overall outcome. Besides, it has to be noted that in two from these six cases, the change of surgical decision was not to continue the surgery, because the cysternographic study showed that the stoma was preexisting (patient 4) or good enough (patient 18). Thus, iMR cysternography improved in these cases rather the safety but not the outcome of our procedure by preventing unnecessary surgical manipulations. Another limitation of our study is that it presents a single-center experience with no control group of patients treated in a “classic” way . We compared our results with those available in the literature, and the variability of cases represents in our opinion quite well real-life clinical scenarios. In order to provide higher level of evidence, analysis of larger and more homogeneous groups of patients is warranted. At present, according to our knowledge, we introduce the very first series of patients treated with the method that may contribute to improved outcomes and safety.Endoscopic intracranial arachnoid cyst fenestration with use of low-field iMR cysternography was safe and effective for all types of treated cysts. Intraoperative cysternography essentially influenced the surgical decision and could predict adequately the long-term clinical and radiological outcome. The low-field iMR cysternography may be a very helpful adjunct in determination of the surgical goals and limiting the endoscopic manipulations to absolute minimum. A prospective multicentre study evaluating the usefulness of low-field iMR imaging during endoscopic cysternostomy conducted in a homogenic group of patients is advocated.


The effects of prenatal exposure to household pesticides on fetal and neonatal growth have not been fully clarified. The present study aims to determine the effects of prenatal exposure to pesticides on neonates’ body size and growth during the first month. This study included 93,718 pairs of pregnant women and their children from the Japan Environment and Children’s Study. Participants completed self-reporting questionnaires during their second or third trimesters on their demographic characteristics and frequency of pesticide use during pregnancy. Child weight, length, and sex were obtained from medical record transcripts. Birth weight and length, as well as weight and length changes over the first month, were estimated using an analysis of covariance. Frequency of exposure to almost all pesticides had no effects on birth weight and length. However, we found small but significant associations (i) between the use of fumigation insecticides and decreased birth weight, and (ii) between frequencies of exposure to pyrethroid pesticides, especially mosquito coils/mats, and suppression of neonatal length growth. Prenatal exposure to household pesticides, especially those containing pyrethroids, might adversely influence fetal and postnatal growth trajectories. Household pesticide products are ubiquitous chemicals. Since the use of organochlorine pesticides is strictly regulated due to their toxicological effects and long-term persistence in the environment, alternative pesticides, such as pyrethroids, and organophosphorus insecticides have become prevalent in agriculture ,2. Pyretcis-dimethyl-cyclopropane carboxylic acid (cis-DCAA), trans-DCAA, and 3-PBA was associated with decreased birth weight [A public health concern regarding household pesticides is whether these exposures exert any negative effects on children’s health and development. For example, animal studies have reported that pyrethroids may have thyroid-disrupting potencies ,9. Thyroh weight . Maternah weight . These fh weight ,13. Thus2 lower body mass index at age 3.5 years [The developing nervous systems of neonates may also be vulnerable to neurotoxic chemicals . Studies.5 years . HoweverHence, our study aimed to investigate the effects of prenatal exposure to various types of household pesticides on neonatal growth trajectories with regard to body weight and length occurring from birth to the first month of life using the resources of a large, longitudinal Japanese birth cohort study.Pregnant women were recruited for participation in the Japan Environment and Children’s Study (JECS) between 2011 and 2014. JECS is a nationwide birth cohort study investigating environmental factors potentially affecting children’s health and development ,18,19. TThis study was based on the jecs-ag-20160424 dataset, which includes 104,102 records, and was released restrictively to concerned parties in June 2016. Eligibility criteria for expectant mothers were as follows: (1) living in the study area at the time of recruitment ; (2) an expected delivery date after August 1, 2011; and (3) comprehension of the Japanese language and the ability to complete the self-administered questionnaire ,18. DetaThe following potential participants were excluded from this study: 29 women who dropped out of the JECS, 1994 women with multiple pregnancies, 1530 women with miscarriages and stillbirths, 2290 women with missing birth status data, and 4541 women with missing data from the questionnaire about the use of pesticides. Therefore, 93,718 pairs of mothers and their neonates with singleton live births and complete data regarding question items about pesticide use were included in this study .Data on the daily use of household pesticides during pregnancy were collected from questionnaires administered between the 2nd and 3rd trimesters (from week 22 to the end of the pregnancy). The classes of pesticides queried in this study are the same as those described in the JECS profile paper . SpecifiThe definitions of pesticides evaluated in this study are as follows: (a) indoor insecticide sprays are insecticidal agents sprayed directly onto insects, (b) mosquito coils/mats control mosquitoes by liquid insecticides that evaporate and volatilize due to high temperature/heat, (c) liquid insecticides are insecticidal agents, including those diluted with water, that control fly and mosquito larvae, (d) herbicides/gardening pesticides either kill weed leaves and stems with a weeding drug that affects the roots, or control pests by spraying pesticidal agents diluted with water, (e) insect repellents repel pests by spraying the exposed areas of the clothes or skin, (f) moth repellents for clothes repel pests attached to skin or clothes that are in storage, and (g) fumigation insecticides exterminate pests by pesticides within smoke rather than sprays, lotions, etc.The body size data of neonates were obtained from medical record transcripts. The variables evaluated as outcomes in this study are as follows: birth weight (g), birth length (cm), weight change during the first month after birth  and length change during the first month after birth .2 , weight change during pregnancy , placental weight , parity , smoking history (nonsmokers/exsmokers who quit before pregnancy/exsmokers who quit during early pregnancy/current smokers), alcohol consumption (nondrinkers/exdrinkers who quit before pregnancy/exdrinkers who quit during early pregnancy/current drinkers), gestational age , annual household income in millions of Japanese yen , gestational diabetes (no/yes), hypertensive disorders of pregnancy , mode of delivery (spontaneous delivery/induced delivery/vacuum extraction or forceps delivery/cesarean delivery), and the use of other pesticides that were beyond the focus of this analysis. Since the type and frequency of pesticides used may vary depending on the area of residence and the season, participants’ residential area was classified into one of the mean annual temperature zones  based on statistics collected between 1981−2010 by the Japan Meteorological Agency, and the date of entry into the questionnaire about pesticide use .Data regarding covariates were used in analysis of covariance (ANCOVA). Among the variables included in the JECS questionnaire, we used the covariates reported in previous studies that were associated with the exposures or outcomes used in this study ,22. The In ANCOVA analyses evaluating weight change and length change as dependent variables, we included birth weight in the weight change analyses and birth length as covariates in the length change analyses. We also included any conditions for which the children in the study were currently receiving medical treatment (no/yes), feeding methods (breastfeeding only/mixed feeding/infant formula only) and the results of congenital metabolic disorder tests  as covariates.Multiple correspondence analysis (MCA) and hierarchical cluster analysis  were used to investigate connections between the use of seven types of pesticides, residential area and date of completing the pesticide questionnaire.We used ANCOVA to evaluate differences in birth weight and birth length, as well as weight change and length change during the first month after birth, according to the level of pesticide exposure during pregnancy. Pairwise comparisons were made using Bonferroni post hoc analysis.To examine the effects of exposures to multiple pesticides, we also examined the relationship between use patterns for the top ten most frequently used pesticides among the study sample and child-body sizes. Specifically, we determined 128 pesticide use patterns based on answers of “at least one used” and “never used” for the seven pesticides and analyzed the ten most prevalent use patterns. All analyses were conducted using SPSS version 24.0 .n = 93,718).Data regarding pesticide use during pregnancy according to MCA are shown on the X–Y plane in n = 71,116, and that for birth length analyses was n = 71,019. For analyses examining the use of mosquito coils/mats, average birth length was smaller in the “sometimes” group than in the “never” group. For analyses examining the use of moth repellents for clothes, average birth length was larger in the “sometimes” and “continuously” groups than in the “never” group. Finally, for analyses examining the use of fumigation insecticides, birth weight was smaller in the “yes” group than in the “no” group. These effect sizes (p2η) ranged from <0.00001 to 0.00013 for birth weight and <0.00001 to 0.00021 for birth length. The maximum statistically significant difference between the observed mean values for the nonexposed groups (never/no) and the exposed groups  for each pesticide was 11.55 g difference in birth weight with regard to use of fumigation insecticides, and 0.06 cm difference in birth length with regard to the use of mosquito coils/mats.Differences in birth weight and length according to the frequency of pesticide use during pregnancy were examined with ANCOVA followed by a Bonferroni post hoc test . Due to n = 68,586 and n = 67,932, respectively. For analyses examining the use of mosquito coils/mats, length change was smaller in the “occasionally”, “sometimes” and “everyday” groups than in the “never” group. For analyses examining the use of insect repellents on clothes/skin, weight change was smaller in the “occasionally” group than in the “never” group; length change was also smaller in the “occasionally” and “sometimes” groups than in the “never” group. These effect sizes (p2η) ranged from 0.00002 to 0.00024 with regard to weight change, and from <0.00001 to 0.00059 with regard to length change. The maximum statistically significant difference between the observed mean values of the nonexposed groups (never/no) and the exposed groups  for each pesticide was 14.36 g difference in weight change with regard to the use of insect repellents on clothes/skin, and 0.11 cm difference in length change with regard to the use of mosquito coils/mats.We examined differences in weight and length changes according to the frequency of pesticide use during pregnancy with ANCOVA followed by a Bonferroni post hoc test . Due to When analyzing all 128 pesticide usage patterns, the use of three classes of pesticides  was not confirmed within the top ten usage patterns, so these pesticides were excluded from the analysis . RegardiIn addition, we calculated the ratio of weight change divided by birth weight and the ratio of birth length change divided by birth length; significant associations with these measures were observed only for the use of mosquito coils/mats and the use of insect repellents on clothes/skin . As a ren = 10,384) and those who were included in this study . T-tests showed significant differences in age  and body mass index before pregnancy .We examined the differences in characteristics between those who were excluded from this study  might be occasionally used even after summer. With respect to these three pesticide types, reductions in length change were observed in each “occasionally” group. The use of these pesticides might therefore have a negative impact, though the magnitude of the effects on child length at the individual level was negligible; rather, these changes in effect may have significance on a population level. The pesticide use pattern identified as cluster B suggests that the use of mosquito coils/mats might increase in the summer. Based on the results of ANCOVA in this study, mosquito coils/mats containing pyrethroids as the main component had a relatively stronger effect of suppressing child length change compared to other pesticides; therefore, it is necessary to pay more attention to the use of mosquito coils/mats among pregnant women based on concerns regarding growth trajectories for newborns. The pesticide use pattern identified as cluster C in our study suggests that indoor insecticide sprays and insect repellents used on clothes/skin are used more frequently in conjunction with herbicide/gardening pesticides. Such exposure patterns can occur when house gardening is performed outside. Future studies are needed to examine in detail the relationship between pesticide exposure status according to occupation and child body sizes. Finally, the pesticide use pattern identified as cluster D, shown near the origin of the X–Y plane, was excluded from the discussion because it comprises an essentially unrelated set of items. Hence, it may be better to consider the effects of residential area and season when considering pesticide exposure.Indoor insecticide spray use was not associated with birth body sizes and child body growth one month after birth in our study. Many indoor insecticide sprays in Japan contain pyrethroids; however, we found that the use of indoor insecticide spray had no effect on child body development. Nevertheless, we acknowledge the possibility that some mothers in our study mistook freezing sprays, which stop the movement of insects such as cockroaches, for spray insecticides, leading to exposure misclassification. Most freezing sprays do not contain pyrethroids, so it is difficult to determine the effects of spray insecticides in this study.Mosquito coils/mats, for which pyrethroid is the main component, were not associated with infant body weight, but were associated with the suppression of birth length and length growth after birth. A dose–response relationship was observed, such that postnatal length development was suppressed with an increasing frequency of mosquito coil/mat use. Unlike indoor insecticide sprays, mosquito coils/mats are filled with insecticidal components such as pyrethroids that volatilize efficiently; therefore, pregnant women may be more likely to be exposed to pyrethroid through this route than via indoor insecticide sprays.Approximately 1% of our study population comprised liquid insecticide users. The usage rate of herbicide/gardening pesticides was also low, with a prevalence of approximately 9%. Therefore, our study lacked sufficient statistical power to examine associations between these pesticides and weight, length and growth trajectory parameters. Although relatively few people used these classes of pesticides, the birth weight of infants born among the “everyday” group was less than 3000 g for mothers who used liquid insecticides or herbicides/gardening pesticides during pregnancy. Therefore, future studies should prioritize evaluating the potential effects of these pesticides on child body sizes.Our results suggest that although insect repellents on clothes/skin were not associated with birth weight and length, this pesticide may suppress child body growth one month after birth. Although DEET has been considered relatively safe for humans , a studyp-DCB), the main component of clothing insect repellents. It has been suggested that urinary 2,5-dichlorophenol , a reliable biomarker for measuring p-DCB exposure, may contribute to obesity in human children and adults [p-DCB has thyroid-disrupting properties [p-DCB, because there are some kinds of moth repellents for clothes containing pyrethroid. Our findings that p-DCB, which may be associated with obesity, is associated with birth length but not birth weight needs to be examined further in future research.The positive association we observed between moth repellents for clothes and birth length growth trajectory may be related to the effect of paradichlorobenzene  were used in combination. The multiple combined effects of the active ingredients in these pesticides, such as pyrethroids, DEET, and paradichlorobenzene, on the body sizes of children may be complex, and the effects of multiple human exposures need to be studied in detail.Only mosquito coils/mats and insect repellents used on clothes/skin showed a statistically significant association with the length change ratio in our study. We also did not observe associations between pesticide exposure and placental weight, which indicates that placental development may not be a mechanism mediating the observed associations between pesticide exposure and infant weight, length and growth trajectories.An overview of the above results suggests that exposure to pesticides composed mainly of pyrethroids may contribute to the suppression of the body size of neonates. This supports the suggestion from previous studies that fetal pyrethroid exposure may continue to alter children’s thyroid hormone homeostasis even after birth . AlthougPrevious studies indicate that exposure of mothers to pesticides may affect not only the development of the body size of neonates, but also the child’s neurodevelopment relating to cognition and behavior. For example, it has been reported that exposure to pesticides such as pyrethroids during pregnancy increases the risk of neurodevelopmental disorders  . StudiesThe subjects of this study were mothers from among the general population, represented by a Japanese birth cohort enrolling nearly 100,000 participants. They are likely to be representative of the general population based on sensitivity analyses comparing included and excluded participants. Thus, we believe the results in this study are robust and have high generalizability. In our opinion, this is the primary strength of our study.p-DCB on child length development, are uncertain. In our opinion, this is the main limitation of our study. Besides, the JECS administered not only a questionnaire survey, but also estimated pesticide exposure using urinary metabolite assays. Urinary metabolite data will be used to examine further associations between the combined exposure patterns observed in this study and child body sizes and growth trajectories in future research efforts.While the self-reported questionnaires used in the JECS can provide some insight regarding dose–response relationships, we could not identify the actual chemicals contained in each pesticide based on this study design, and hence, can only speculate about the mechanisms potentially mediating the effect of each pesticide on child body size. The hypothesized effects of pesticides, such as a possible inhibitory effect of pyrethroid or a possible promoting effect of In this study, we found that the frequencies of exposure to almost all the pesticides we evaluated had no effects on birth weight and length. However, we found significant associations between the use of fumigation insecticides and decreased birth weight, and between frequencies of exposure to some pyrethroid-based pesticides and suppressed length growth of neonates, although the effect sizes were small. These results suggested that prenatal exposure to household pesticides, especially containing pyrethroids, such as mosquito coils/mats, might adversely influence fetal and postnatal growth trajectories. The key issue to evaluate further is balancing the benefits and possible risks of the use of household pesticides during pregnancy. Future studies will need to examine how the extent and timing of pesticide use and the specific pesticides used may affect the comprehensive trajectory of child development.


Lactobacillus. Mother-to-child vertical transfer, as suggested by sharing, was modest, with the strongest transfer being for Clostridiales followed by Lactobacillales and Enterobacteriales. In conclusion, late gestation is associated with an increase in maternal vaginal microbiota diversity, and vaginal bacteria at birth only modestly predict the composition of the neonatal microbiota.The mother’s vaginal microbiota represents the first microbes to which a child is exposed when delivered vaginally. However, little is known about the composition and development of the vaginal microbiota during pregnancy and birth. Here, we analyzed the vaginal microbiota of 57 women in pregnancy week 24, 36 and at birth after rupture of membranes but before delivery, and further compared the composition with that of the gut and airways of the 1-week-old child. The vaginal community structure had dramatic changes in bacterial diversity and taxonomic distribution, yet carried an individual-specific signature. The relative abundance of most bacterial taxa increased stepwise from week 24 of pregnancy until birth, with a gradual decline of  Lactobacillus species, possibly to inhibit the growth of pathogens in this period of increased vulnerability ) and week 36 (p = 0.8). Conversely, the increase in Shannon diversity was pronounced between pregnancy week 24 (0.79 [0.49–1.66]) and week 36 (1.40 [0.60–1.70]) (p = 0.006) with a non-significant change from week 36 to birth . We observed a higher Shannon but a lower PD diversity in the children’s 1-week airway and fecal samples compared with the vaginal at birth, which for the fecal samples could reflect an immature composition partly due to ongoing breast-feeding.The median richness per sample was 95 for vaginal, 134 for fecal, and 67 for airway samples. During pregnancy, the median richness per sample was 92 at pregnancy week 24, 85 at week 36, and 117 at birth ), was found between the two pregnancy vaginal samples and the children’s fecal and airway samples with the birth samples placed between these two extremes Fig. . This surth Fig. . The lowac Figs. –S5, whilEnterococcus and Granulicatella  , season of birth, maternal age at birth, older children in the home, preeclampsia and gestational age at birth) did not reveal any differences regarding alpha- or beta diversity, but suggested a positive correlation between gestational age and genera 2) Table .Lactobacillus, by far the most prevalent genus, decreased successively for each time-point. This decrease was not specific to any of the major Lactobacillus OTUs but occurred across all of the most commonly identified OTUs, see Figure Moraxella, Streptococcus, Staphylococcus, Enterococcus, Corynebacterium, and Gemella all increased significantly for each successive sample time-point to fill the space corresponding to the decreased Lactobacillus abundance. These findings suggest that the perinatal vaginal microbiota does not change suddenly following rupture of membranes or initiation of labor, but rather undergoes a smooth continuous development throughout the last half of pregnancy.At the genus level, consistent stepwise increases or decreases were seen for the vaginal samples in all the major taxa from pregnancy week 24 through week 36 until birth , see Table Moraxella and Streptococcus OTUs unique to the birth samples are shown in Figs. Some taxa (314 specific OTUs) were unique to the birth samples, and were not identified in any of the earlier vaginal samples. Most of these 314 OTUs were only identified in one or few birth samples, but 11 OTUs were found in 5 or more samples. These included four p < 0.0001) and week 24 (−0.08 (0.09), p < 0.0001), while no difference existed between week 36 and week 24 (p = 0.63). However, PCo2 was dominated by inter-individual variation, where each mother was a highly significant determinant, as illustrated by the horizontality of lines in Fig. p < 0.0001). This large inter-individual as well as time-point variation was confirmed in a joint multivariate model . Similar results were found when restricting the analysis to the week 36 and birth samples , week 24 and birth samples  or rarefying to 2000 reads . Collectively, these results reinforce our findings that the vaginal microbiota undergoes major changes at birth, likely including fecal admixture, yet it clearly retains a distinctive individual signature from the earlier pregnancy time-points.Having established major changes of the vaginal microbiota occurring at birth compared with the two previous time-points, we compared the samples within each woman at the three vaginal time-points. The major direction of variation in the UniFrac PCoA Fig. , as descWe hypothesized that the vaginal microbiota at birth was a major source for the neonatal gut and airway colonization. To investigate this question, each OTU in the vaginal birth samples was tested for transfer to the neonate’s fecal and airway samples at age one week, as well as whether a certain maternal vaginal community structure promoted a certain fecal or airway community structure. The analyses were restricted to the 49 (86%) vaginally delivered children from which 36 and 45 matching neonatal fecal and airway samples were available respectively. From the total of 2327 OTUs, 536 OTUs were found pairwise between vaginal and fecal samples and 346 OTUs between vaginal and airway samples.p < 0.05) for transfer to the gut and 2 OTUs for transfer to the airways. However, none of these significant differences survived correction for multiple testing at false discovery rate (FDR) levels below 0.30. Nevertheless, the distribution of the transfer odds was observed in favor of positive transfer (OR > 1). An enrichment analysis, calculating a weighted ratio (WR) between positive and negative transfer odds revealed ratios between positively and negatively associated OTUs between mother and child samples of 2.7 (p = 0.036) and 2.3 (p = 0.003) for fecal and airway samples, respectively. This indicates a tendency of transfer that was spread across all OTUs rather than strong transfer of specific OTUs. For robustness analysis of these results see Table Transfer was first analyzed as presence/absence by Fisher’s exact test. Figure pgut = 0.05, pairways = 0.09). Furthermore, the phylogenetic placement of the individual OTUs was examined. Figure R2 = 1.9%, p = 0.001) and the airways .We examined the correlation with the hypothesis that more abundant taxa in the vaginal samples would increase the odds of transfer to the children, but interestingly, higher OTU abundances were negatively correlated with the odds of transfer. However, this was not statistically significant  whereas the other distance metrics were not significant , and the Danish Data Protection Agency (2015-41-3696). Both parents gave written informed consent before enrollment [-093, andVaginal samples from asymptomatic pregnant women were collected at the week 24 and 36 of pregnancy in the COPSAC clinic and at birth after rupture of membranes but before passage of the child either by the woman herself or by the midwife; detailed written instructions were provided. The women were sampled from the posterior vaginal fornix using flocked swabs . Hypopharyngeal airway aspirates were obtained at age one week from the child using a soft suction catheter passed through the nose into the hypopharynx in the COPSAC clinic as described in detail . Fecal sInformation was obtained during the scheduled visits to the COPSAC clinic, and included maternal age at birth, smoking and alcohol use during pregnancy, education, household income, antibiotics received during pregnancy, preeclampsia, gestational diabetes, delivery type, gestational age, asthma in the mother, hospitalization of the child after birth, antibiotics prescribed to the child, household pets, and number of older children at home. Information on intrapartum antibiotics and antibiotic use during pregnancy and childhood was validated against national registries .Fastq-files demultiplexed by the MiSeq Controller Software were trimmed for amplification primers, diversity spacers, and sequencing adapters, mate-paired and quality filtered (USEARCH v7.0.1090) . UPARSE t test or Wilcoxon rank-sum test was used for analyzing simple associations in the baseline characteristics of the cohort with reference to differences between included and excluded participants and prenatal, perinatal, social, and lifestyle-related variables. Correlations between OTUs were calculated using the sparse correlations for compositional data (sparCC) correlation metric [All data analysis was performed in the statistical software package R version 3.3.0, with the package phyloseq  to handln metric  within eThe α-diversity measures of richness (number of unique OTUs), Faith’s Phylogenetic Diversity  and ShanVertical transfer of the vaginal microbiota at birth to the infant gut and airways in the 1-week-old child was restricted to vaginal birth only, and analyzed by univariate Fisher’s exact test for presence/absence of taxa in both compartments . An enrichment analysis were conducted post-hoc using the individual OTU analysis results as input. That is: For each compartment, the univariate OTU-wide comparisons were analyzed for enrichment of positive associations by calculation of a WR between positive (OR > 1) and negative (OR < 1) associations, defined as: Under the null hypothesis of no association the expectation of WR is 1. To test this hypothesis, random permutation is performed scrambling the connection between mother and child, followed by individual OTU wise Fisher exact test and calculation of WR. This is done 999 times to construct a null distribution in which the observed WR is tested. In addition, the maternal abundance for each OTU was investigated as a descriptor for the odds of transfer. Transfer was analyzed as distances between mother–child pairs for a range of different beta diversity measures, comparing these with randomly matched mothers and children by permutation testing (999 permutations). A significance level of 0.05 was used in all analyses. Visualizations were done using ggplot2 (ver 3.1.0) and cladogram was drawn based on phylogenetic distance using the R package ggtree .https://github.com/mortenarendt/MBtransfeR) encompasses an R-packages as well as documents the analysis, including the phyloseq object including anonymized data.The sequences are available at short read archive under project number PRJNA595451 , PRJNA576765  and RJNA579012 . Further, a github (Supplemetal Material


Treatment of patients with malignancy sometimes be delayed due to various reasons. Several studies revealed that an influence of diagnosis-to-treatment interval (DTI) on outcomes differs depending on the type of malignancy. In this study, we evaluated the influence of DTI on clinical outcomes in newly diagnosed patients with diffuse large B-cell lymphoma (DLBCL). A total of 199 patients were identified with a median DTI of 22 days. At 2 years, patients with short DTI (0–22 days) showed significantly poorer OS (62.7% vs 86.4%) and PFS (55.1% vs 75.9%) compared to those with long DTI (over 22 days). Although short DTI was strongly correlated with several known adverse factors, it remained to be an independent prognostic factor by multivariate analysis. In conclusion, our study confirmed the importance of DTI in patients with DLBCL. Researchers should consider DTI as one of the important prognostic factors and plan clinical trials to be able to enroll patients with aggressive disease requiring urgent treatment. It can be cured with immunochemotherapy by rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisolone (R-CHOP)2. Although the International Prognostic Index (IPI), which incorporates clinical variables such as age, Ann Arbor stage, extranodal lesions, high serum lactate dehydrogenase (LDH), and performance status (PS), is a valuable prognostic tool, newer prognostic factors continue to be reported1.Diffuse large B-cell lymphoma (DLBCL) is the most common subtype of non-Hodgkin’s lymphoma. It typically presents with aggressive behaviour, progressing over months, and becomes fatal without treatment3. For breast cancer5 and colorectal cancer6, long DTI is reported to be associated with poor overall survival (OS). On the other hand, short DTI is associated with poor OS for lung cancer7.Treatment of patients with malignancy sometimes can be delayed due to various reasons . Several studies revealed that an influence of diagnosis-to-treatment interval (DTI) on outcomes differs depending on the type of malignancy12. However, other studies reported opposite result13 or no association14, and the influence of DTI to outcomes in patients with DLBCL has been controversial. In the present study, we evaluated the influence of DTI and other parameters on clinical outcomes in newly diagnosed patients with DLBCL.Several studies reported the association between short DTI and poor outcomes in patients with DLBCLWe conducted a retrospective analysis using a database from our hospital. Patients were eligible if they are aged 20 years or older, are newly diagnosed with DLBCL between April 2007 and March 2017, and have received CHOP or dose-reduced CHOP-like regimen with or without rituximab. Patients with HIV infection, central nervous system lesion, intravascular lymphoma, primary mediastinal large B-cell lymphoma, and transformation of indolent lymphoma, who did not receive anthracycline-containing chemotherapy, and who received treatment before pathological diagnosis were excluded from analysis. The timing and choice of treatment were left to the physicians’ clinical judgment. This study was approved by the Institutional Review Board of the Osaka City General Hospital.2, doxorubicin 50 mg/m2, and vincristine 1.4 mg/m2 on day 1 and prednisolone 100 mg/day on days 1–5) for patients younger than 70 years and a dose-reduced THP-COP-based regimen16  for patients over this age. The dose-reduced THP-COP regimen for the elderly was revealed to have a similar effect to that of a CHOP regimen for younger patients in our previous study15.At our hospital, we usually employ a CHOP-based regimen  and corresponding 95% confidence intervals (CI) were also obtained. p-values < 0.05 were considered statistically significant. The above statistical analyses were performed with EZR17 , a graphical user interface for R . More precisely, it is a modified version of R commander (version 2.0-4), designed to add statistical functions frequently used in biostatistics. The evaluation of nonlinear association with OS and DTI was performed with Microsoft Excel 2016 .The endpoints of this study were OS and progression-free survival (PFS). The OS was defined as the time from diagnosis to the last visit with the patient or death from any cause. The PFS was defined as the time from diagnosis to disease progression or death. Data were analyzed as of June 2018. DTI was defined as the time from report date of pathological diagnosis to the initiation of treatment. Comparisons of baseline characteristics were performed using Fisher’s exact test for categorical variables and Student’s This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the medical ethics committee of the Osaka City General Hospital.Informed consent was obtained by the opt-out method on the web-site.Informed consent was obtained by the opt-out method on the web-site.A total of 199 patients were identified (Table A median DTI was 22 days (range 0–393) Fig. . SeventyWith a median follow-up of 1091 days (range 31–3951), 69 patients had died and 88 patients had PFS events (75 progression and 13 death without progression). The 2-year OS and PFS were 74.6% and 65.4%, respectively. The median survival was not reached. The median PFS was 91 months.At 2 years, patients with short DTI (0–22 days) showed significantly poorer OS , poorer PS, B symptoms, lower serum albumin, elevated LDH, higher Ann Arbor stage, extranodal lesions, higher IPI score, and nonuse of rituximab , B symptoms, lower serum albumin, higher IPI score, nonuse of rituximab, and dose-reduced THP-COP regimen were evaluated with multivariate analysis for OS. Short DTI (0–22 days) , nonuse of rituximab , and IPI score  were revealed as independent factors affecting OS  showed significantly worse outcomes  compared to those with long DTI (over 22 days). However, the association of DTI and outcomes does not seem to be linear. The 2-year OS was lowest for patients with DTI of 5–15 days, highest for those with DTI of 30–40 days, and decreased afterward. The reason of the delay for six patients whose DTI was over 100 days seems to due to comorbidities (n = 5) and poor economy (n = 1). In Japan, all citizens are provided a universal health insurance system and free to choose a medical institution. Although, the economic barriers to medical care are low, it is possible that socioeconomic status and comorbidities are related to too long DTI. Additionally, the nonlinear association of DTI and outcomes is consistent with our feelings as a clinician, because it is easily predicted that DLBCL progresses without treatment and results in worse prognosis.Although the threshold of acceptable treatment delay is difficult to determine, it seems to be around 30–40 days according to our data.8 analyzed 689 patients with DLBCL using the British Colombia Cancer Registry and reported that DTI longer than 8 weeks is significantly associated with poor OS compared with shorter DTI in patients with DLBCL. They also revealed the association with shorter DTI (0–4 weeks) and poor OS. Patients with intermediate DTI (5–8 weeks) tended to have better OS than those with shorter or longer DTI. Olszewski et al.9 reported similar results using data of 104,405 patients with DLBCL from National Cancer Data Base and revealed that a hazard ratio of OS was 1.38  in patients with DLBCL who were treated within 7 days compared to those treated > 30 days from diagnosis. The hazard ratio was lowest for patients treated around day 45–60 from diagnosis and increased afterward. Phipps et al.13 reported partially consistent results. They analyzed the association with DTI and outcomes in 581 patients with DLBCL who were treated in two major hospitals in Singapore. The median DTI was 14 days. Analyzing DTI as two categories, longer DTI was associated with poor OS and PFS. They did not find an association between short DTI and poor OS. We speculate that they could reveal nonlinear association between DTI and OS, if they analyzed DTI as much more categories.Hay et al.12. Maurer et al.10 analyzed two cohorts, 986 patients in the United States and 1444 patients in Europe. The median DTI was 15 days in the American cohort and 23 days in European cohort. They revealed an association between short DTI and poor event-free survival at 24 months (EFS24). The association remained significant after adjustment for IPI. Examination of functional form revealed approximately linear association of increasing DTI and achieving EFS24. They also analyzed EFS by DTI grouped by week, and DTI over 35 days was shown to be associated with best EFS. Camus et al.11 analyzed 345 patients with DLBCL as a real-life monocentric study. The median DTI was 30 days. They revealed an association between shorter DTI and poor OS and PFS. The influence of DTI on OS appears to be a continuous effect. Blunt et al.12 analyzed 9446 patients with DLBCL using population-based databases in Canada. The median DTI was 37 days. They revealed an association between shorter DTI and poor OS.Three studies reported the association between short DTI and poor outcomes14 reported an opposite conclusion. They analyzed the impact of treatment delay (the same as DTI) on clinical outcomes in 278 patients with DLBCL. The median DTI was 3 weeks. DTI was divided into three groups  and was analyzed. In conclusion, the delay did not impact OS and PFS.Nikonova et al.10, our study revealed a nonlinear association between DTI and OS. Although the median DTI of our study is comparable with that of the European cohort in Maurer’s study, ours included more patients with longer DTI. This may have contributed to the decreased OS in patients with longer DTI. Contrary to the results of Nikonova et al14, which reported no association between DTI and outcomes, our study and other previous studies12 revealed the association between short DTI and poor outcomes. This might be due to the difference in categorization of DTI. If they analyzed DTI as much more categories or examine nonlinearity, the result may have been different.The discrepancies of results between our study and previous studies may be caused by variance of DTI and statistical method. Contrary to the results of Maurer et al.In this study, short DTI was strongly correlated with several known adverse factors. Although the correlation may affect the association between short DTI and poor OS, short DTI remained to be an independent prognostic factor by multivariate analysis. We speculate that patients with short DTI were judged to need urgent treatment due to disease aggressiveness which is not appropriately included in standard prognostic tools. Therefore, in addition to well-known prognostic factors, DTI should be considered when reporting outcomes of clinical trials.More challenging, patients who require treatment soon after diagnosis cannot participate in prospective clinical trials which usually take time to perform additional examination or randomization. Patients with short DTI tend to have poor prognostic factors, and there are high unmet medical needs. In clinical trials to examine new treatment strategies and solve such unmet medical needs, enrollment of patients with short DTI is essential. Researchers should consider DTI as one of the important prognostic factors and plan clinical trials to be able to enroll patients who require treatment soon after diagnosis.This study has several limitations due to its retrospective nature. First, it is possible that unmeasured residual confounding factors may affect outcomes. There are no data about DLBCL subtypes by gene expression profiles or immunophenotyping. In addition, multivariate analysis is not able to fully compensate for differences between patients due to unexpected covariates. Second, we could not collect data about causes of treatment delay, because it was not fully recorded. It should be noted that there is a possible association between the cause of treatment delay and outcomes. However, performing prospective randomized study is not possible due to ethical problem. Nonetheless, this study makes an important contribution in that it revealed the importance of DTI.In conclusion, our study confirmed the importance of DTI. Short DTI (0–22 days) is associated with poor OS and PFS. Besides that, it is possible that too long DTI is a poor prognostic factor. DTI should be considered when reporting outcomes of clinical trials.


Antibiotic exposure in term infants has been associated with later obesity. Premature, very-low-birth-weight (birth weight ≤ 1500 g) infants in the neonatal intensive care unit frequently are exposed to antibiotics. Our hypothesis was that in preterm infants, there is a positive linear and dose-dependent relationship between antibiotic exposure and growth from birth through 12 months’ corrected age.Retrospective analysis of prospectively collected data of all antibiotic use among inborn, preterm (≤32 weeks’ gestation), very-low-birth-weight infants admitted to the neonatal intensive care unit at Parkland Memorial Hospital and followed in the Low Birth Weight Clinic at Children’s Medical Center, Dallas, TX. Antibiotic use was quantified by days of therapy which was compared with weight and length parameters at birth, 36 weeks’ postmenstrual age, and 2, 4, 6, and 12 months’ corrected age. The change in weight and length z-scores from birth to all subsequent age points was calculated. Stepwise multivariate regression analysis was performed to determine predictors of weight, length, and weight-for-length delta z-scores from birth to each subsequent age point.During the 18-month study, 161 infants received a median of 11  antibiotic days of therapy which was not associated with weight or length delta z-scores from birth through 12 months’ corrected age.Association of prolonged antibiotic use and neonatal morbidities and mortality may override the potential association with increased weight gain in the NICU and beyond. Antibiotic exposure in early infancy has been associated with later obesity, presumably from alteration of the intestinal microbiome that leads to decreased bacterial biodiversity and modulation of host metabolism , 2. AntiThis study was a retrospective analysis of prospectively collected data of all antibiotic use among inborn, preterm (≤32 weeks’ gestation), and VLBW infants admitted to the NICU at Parkland Memorial Hospital, Dallas, TX, from 7/1/2011 to 12/31/2012 and subsequently followed in the Low Birth Weight Follow-up Clinic at Children’s Medical Center (CMC), Dallas as their medical home. Antibiotic use was quantified by days of therapy (DOT) which was determined by multiplying the number of antibiotic doses by the dosing interval, then dividing by 24 h  . DOT werPertinent clinical, laboratory, microbiologic, and outcome data were collected on all infants from the electronic health record. Severity of illness was calculated for all infants using the Clinical Risk Index for Babies (CRIB)-II score, a validated risk-adjustment instrument for prediction of mortality among VLBW infants that incorporates gestational age, birth weight, sex, temperature on admission, and initial base deficit . CRIB-IIIntrauterine growth restriction (IUGR) was defined as a ponderal index < 10% for gestational age  while smWeight and length z-scores at birth and 36 weeks’ postmenstrual age were calculated using the 2013 Fenton growth chart . The WHOp-value < 0.05 was considered significant. Univariate linear regression was used to evaluate the relationship between change in z-score for weight and length from birth to each subsequent age point and demographic and clinical variables, including days of antibiotic therapy. A stepwise multivariate regression model was performed for weight, length and weight-for-length delta z-scores at each age point. Pearson correlations were calculated for all variables; p-value < 0.05 was considered significant. To control for severity of illness, bronchopulmonary dysplasia, patent ductus arteriosus, necrotizing enterocolitis, and late-onset sepsis were included in the multivariate analysis. Since the study was a secondary analysis of a prospective evaluation of all antibiotic use in the NICU, a post hoc power analysis was performed that showed that a sample size of 126 patients produced a two-sided confidence interval with a lower limit of 0.13 and an upper limit of 0.45 when the sample correlation was 0.30.Descriptive analyses, including mean and standard deviation or median and interquartile range, were performed as indicated. All tests were two-tailed, and a The study was approved by the Institutional Review Board of the University of Texas Southwestern Medical Center with waiver of informed consent.During the 18-month study period, 187 inborn, preterm, VLBW infants were admitted to the NICU  had at least 1 follow-up visit to the CMC Low Birth Weight Follow-up clinic. Complete weight and length data were available for 151 (94%) infants at ~ 2-month visit, 134 (83%) infants at ~ 4 months, 136 (84%) infants at ~ 6 months, and 129 (80%) infants at ~ 12 months. Weight alone was available for an additional 1 infant at 2 months, 1 infant at 4 months, 3 infants at 6 months, and 1 infant at 12 months.The weight and length z-scores at birth were within the standard range for gestational age by the Fenton curves, with the average weight and length z-scores being 0.074 ± 0.91 and 0.096 ± 0.93, respectively. The weight and length z-scores decreased by an entire standard deviation from birth to 36 weeks’ corrected age, to − 0.98 ± 0.92 and − 1.18 ± 0.82, respectively. After 36 weeks’ corrected age, there was a steady increase toward a normal average z-score of zero for both weight and length, although the length z-score remained lower than the weight z-score. At 2 months’ corrected age, there was an elevated weight-for-length z-score of 0.997 ± 1.08 but by 12 months’ corrected age, the average weight-for-length z-score approached zero.Univariate linear regression was performed to evaluate the impact of antibiotic exposure as well as demographic features and clinical diagnoses on growth patterns Tables , 3. TherFactors associated with a change in length z-score from birth to each subsequent age-point also were assessed. Antibiotic exposure had no relationship with length delta z-score at any age point. IUGR, CRIB-II score, BPD, PDA and total days of TPN all showed small negative relationships for at least one of the early age points: 36 weeks’, 2 months’ and/or 4 months’ corrected age. Gestational age and SGA had a positive relationship with length delta z-score at all age points except 36 weeks’ corrected age, indicating that infants born at older gestational ages or SGA had improved catch-up growth over the first year of age.Stepwise multivariate regression analysis was performed to predict weight delta z-scores from birth to each subsequent age point using the variables that were significant on at least one time point by univariate analysis (antibiotic exposure, gestational age, sex, delivery mode, IUGR, SGA, CRIB-II score, BPD, late-onset sepsis, total days of TPN, and total days NPO; Table Unlike other studies that have associated antibiotic use in term infants, older children, and animals with increased weight, length, and body mass index, , 17–19 tThe substantial decrease in weight and length percentiles during the NICU hospitalization is a well-documented phenomenon in premature infants, and it is believed to be due to inadequate nutritional intake in combination with co-morbidities such as BPD, NEC, late-onset sepsis, and PDA which increase metabolic demand , 21. InaThe lack of correlation between antibiotic exposure and weight gain may be due to low overall use of antibiotic therapy as measured by DOT or the type of antibiotics used , 28, 29.One of the limitations of this study is its retrospective analysis which precludes any determination of a causal relationship between antibiotic exposure and alteration in growth parameters. Nevertheless, the information on antibiotic use was obtained prospectively and included every agent used during the study period. Moreover, the optimal metric to study antibiotic use in the NICU is not known, and it is possible that other measures may yield different results. However, DOT has been used in adult and neonatal populations and encompasses not only the days that the infant received antibiotic therapy, but the quantity utilized. The study also did not account for antibiotic therapy that the infant may have received after discharge from the NICU. Another limitation was that complete weight and length data were available for only 84 and 80% of infants at ~ 6 and 12 months’ corrected age, respectively, and longer follow-up may be necessary to detect alterations in growth percentiles especially with respect to obesity. In addition, there currently is no universally accepted and validated measure for body mass index, weight-for-length, or ponderal index in the neonatal population . StrengtIn conclusion, among the study population of VLBW infants ≤32 weeks’ gestational age, the study hypothesis of a linear and dose-dependent relationship between antibiotic exposure and weight or length z-scores from birth through 12 months’ corrected age was not confirmed. The previously described negative association of prolonged antibiotic use and increased risk of NEC, late-onset sepsis, BPD, retinopathy of prematurity, invasive fungal disease, neurodevelopmental impairment, and death may override any potential benefit with improved weight gain in the NICU and beyond –39.


Dielectric actuators (DEAs), because of their exceptional properties, are well-suited for soft actuators (or robotics) applications. This article studies a multi-stimuli thermo-dielectric-based soft actuator under large bending conditions. In order to determine the stress components and induced moment (or stretches), a nominal Helmholtz free energy density function with two types of hyperelastic models are employed. Non-linear electro-elasticity theory is adopted to derive the governing equations of the actuator. Total deformation gradient tensor is multiplicatively decomposed into electro-mechanical and thermal parts. The problem is solved using the second-order Runge-Kutta method. Then, the numerical results under thermo-mechanical loadings are validated against the finite element method (FEM) outcomes by developing a user-defined subroutine, UHYPER in a commercial FEM software. The effect of electric field and thermal stimulus are investigated on the mean radius of curvature and stresses distribution of the actuator. Results reveal that in the presence of electric field, the required moment to actuate the actuator is smaller. Finally, due to simplicity and accuracy of the present boundary problem, the proposed thermally-electrically actuator is expected to be used in future studies and 4D printing of artificial thermo-dielectric-based beam muscles. Nowadays, soft robots, because of their capabilities involving movement and degrees of freedom, are attracting more and more scientific attention. They have several advantages over conventional robots. Soft robots can interact with humans and the environment more safely, and also could be employed in wearable devices. These robots are being developed to overcome the weakness of conventional robots in interacting with human and fragile biological objects ,2,3,4. SDielectric-based soft actuators have been investigated both experimentally and numerically. From a modeling point of view, few studies have been reported on modeling of multi-trigger thermo-dielectric-based soft actuators in the presence of a coupling between the thermal and dielectric effects ,24,25. MHistorically, many researchers have investigated the behavior of these actuators. Due to the viscoelastic properties of these materials, the elastic modulus of dielectric actuators changes during operation . A numbeMost of the soft actuators in the literature have been investigated under single-stimuli conditions, while, recently multi-responsive soft actuators have attracted a great deal of interest due to their high controllability upon to different stimulus . In thisThis paper is organized as follows. In E, D and P stand for electric field vector, electric induction or electric displacement vector and polarization density vector, respectively. For a condensed material, it can be expressed as:ε0 denotes electric permittivity of the free space. The simplified form of Equation (1) for an isotropic material is [rε is dielectric constant (or elastomer specific relative permittivity). It is noted that at free current, free electric charge and quasi static condition, the Maxwell’s equation is recast as:F as follows:In current configuration, erial is :(2)D=ε0εConsidering Equations (3) and (4), the Maxwell’s equation in the reference configuration  is written as:T, followed by a Maxwell’s concept for an electro-elastic material, can be expressed as:I is the second-order identity tensor. In addition, the total Cauchy stress tensor T, is a combination of mechanical (S) polarization, and electrostatic Maxwell stress tensors. But this superposition of electric and mechanical stresses under large deformations can be inaccurate. To overcome this issue, some researchers such as Dorfmann and Ogden [b is the left Cauchy-green deformation tensor. Unlike the superposition of stresses, it is preferred to apply superposition of the strain energy function. Thus, the general relation between the total stress tensor, electric induction vector and magnetic induction vector with strain energy function for an incompressible isotropic electro-elastic material may be written as:p is a Lagrange multiplier associated with the incompressibility constraint. Since strain energy function is in terms of invariants (I1:I6), they can be defined as [T can be expressed as [Following ,52 and bnd Ogden  and Kumand Ogden  introducfined as ,54:(9)I1essed as ,54:(10)TIn addition, the dielectric displacement vector in the current configuration can be derived as:Finally, based on the work of Kumar and Sarangi  and adapSimilarity, the complete form of the free energy density –(13) and specifying the deformation gradient tensor, the stress and electric displacement vector could be identified.F and electric field vector E for the experimental condition of Wissler and Mazza’ work [To determine the electric parameters of the model, the experiments from Wissler and Mazza  for VHB za’ work  can be eThus, considering Equations (11) and (12), the electric displacement vector is found as:In addition, we have Comparing Equation (16) and experimental data in z. The axial true stress tensor In addition, to calibrate the hyperelatic part of the model, the experimental analysis done by Hossain et al.  for VHB n ΩHE as :(18)σHE=For the hyperelastic behavior of the actuator, two strain energy functions namely Mooney-Rivlin Similarity, for the exp-exp model, in light of Equation (18), and Equation (19), the corresponding true and first Piola  stresses are calculated as:Finally, by performing a fitting procedure for Equations (20) and (21) and experimental data in X, Y, Z) and  are cartesian and cylindrical coordinate systems used in reference and current configurations, respectively. The relation between reference and current configurations for large bending of the actuator can be written as:As mentioned previously, in this paper, as an application of thermally and electrically responsive actuators, large bending of a beam is examined. In this regard, an incompressible hyperelastic rectangular beam subjected to a plane-strain thermo-electro-mechanical bending is considered as depicted in F is introduced as:X, Y, Z). For a thermo-elastic analysis, the total deformation gradient is In the cylindrical coordinates, the deformation gradient tensor n theory .(25)F=FF(T) is a scalar-valued scalar function determining the thermal volume change, and If the thermo-electric-elastic material is thermally isotropic, considering a non-isothermal deformation process, for a mechanically incompressible isotropic material, the deformation gradient rding to  as:(26)Fsolution  as:(27)FThe steady state heat-conduction equation in absence of any heat source is written as:Considering the following Dirichlet boundary conditions:Regarding Equations (25) and (31), one may argue that According to r and X is found as:In Equation (34), if we use direct integration, the relation between The corresponding left Cauchy–Green deformation tensor Also, the quasi-static equilibrium equation in the radial direction in absence of body forces (in the current configuration) is expressed as:r, the following equation is found:Taking into account the incompressibility condition, and integrating Equation (36) with respect to Accounting for the boundary condition at a and b as the current internal and external radii of the structure. By employing a second-order Runge-Kutta method for Equation (36) and considering corresponding boundary conditions, parameters of p, a and b, the stresses can be determined. This process has been carried out by solving a nonlinear set of algebraic equations. Moreover, the moment . In another word, it is assumed that the electrodes are connected at the upper and lower sides of the actuator see . Thus, tFinally, all necessary parameters for this problem are listed in In this section, firstly, under a zero electric field and thermal effects , the problem is verified using finite element software ABAQUS. Then, under coupling between thermal and mechanical loading, the proposed solution is verified. A moment is applied to one side of the actuator, while at the same time, a temperature difference is applied to the lower and upper surfaces of the actuator  is investigated through FEM and the developed semi-analytical method. At mean radius of curvature 0.5 m, the radial and hoop stress for both hyperelastic models are depicted in ρ = 0.5 m), in radial stress, an asymmetric response arising from the nonlinearity of the deformation is observed.The comparison between the FEM and analytical method results for each strain energy functions reveals a good correspondence. Since the value of radial stress is small, a significant difference between two hyperelastic models can be observed. Under a fixed mean radius of curvature, the exp-exp model compared to Mooney-Rivlin model, predicts higher radial stresses. In other words, the exp-exp model gives more conservative results than Mooney-Rivlin model. In addition, the value of hoop stress for both strain energy functions are close see b. MeanwhT = 50 °C and ρ = 0.5 m, the radial and hoop stresses for both strain energies are depicted in In this section, the large bending of the beam under thermo-mechanical loadings is examined through FEM and the proposed formulation. At a constant temperature difference of ΔAs shown in ρ = 0.3 m, in different temperature gradients, the radial, hoop stresses and induced moment are illustrated in In this section, in the absence of an electric field, the effect of temperature gradients on the performance of the dielectric-based actuator under a large bending is examined especially on the induced moment and stress components. By adopting Mooney-Rivlin model for T = −60 °C, the radial stress is larger. It is noted that for a negative temperature gradient, an opposite thermal moment is produced; thus, an extra mechanical moment should be imposed to the beam to compensate this thermal moment. As shown in T = −60 °C.As shown in ρ = 0.5 m is reported in In this section, in the absence of thermal loading , the effect of the electric field on the actuator response at finite bending is examined. In this regard, the effect of uni-axial electric filed ρ = 0.5 m, the amount of radial and hoop stresses are reduced, leading to a more symmetric form. Similar to the reasoning given for the effect of temperature gradients, under larger electric fields, an electric-induced moment is generated which means a lower mechanical moment is required. Consequently, lower hoop and radial stresses are developed in the structure. From As shown in E1 =20 MV·m−1).ρ in the presence of an electric field. To be more specific, from ρ = 0.3 to ρ = 0.5 m, the radial stress in the presence of electric field is reduced by 62%, while the radial stress in the absence of an electric field is lowered by 72%. As shown in T = 40 °C, are shown in In this section, the response of a soft structure under thermo-electro-mechanical loading at large deformation is examined. The effects of uniform radial electric field on the radial stress, hoop stress and induced moment at a fixed specified mean radius of curvature for Mooney-Rivlin strain energy for ΔLike in E1 = 20 MV.m−1 and ΔT = 40 °C and the relevant results are illustrated in In this section, the effect of applied mean radius of curvature on the stress components and induced moment are investigated for exp-exp model at ρ leads to a smaller induced moment.As depicted in In this section, the effect of electric field and temperature gradients on the electric induction for exp-exp model is studied in E1 = 10 MV·m−1 on the electric induction is depicted in T = 0 °C and ρ = 0.4 m, where a higher electric field results in a higher electric induction. Furthermore, the variation of the electric induction along the beam thickness is almost linear. T = 0 °C and E1 = 10 MV·m−1. In addition, the variation of radial electric displacement in different mean radius of curvature is illustrated in The effect of temperature gradient at a fixed electric field (1)By increasing the temperature differences in both sides of the actuator, in the absence of electric field, the amount of radial stress, hoop stress and applied moment are reduced. Moreover, at higher mean radius of curvature, the quantity of both radial and hoop stress is decreased.(2)Imposing a negative temperature gradient to the beam results in an opposite thermal moment which means a larger mechanical moment should be applied to bend the beam to a desired mean radius of curvature.(3)Radial stress, hoop stress, and applied moment decrease, with increasing the electro field in the absence of temperature differences, also the radial stress curve becomes more symmetric.(4)ρ = 0.3 m to ρ = 0.5 m, although in the absence of an electric field, the radial stress drop is 72%.The radial stress decreases by 62% in the presence of a fixed electric field and absence of temperature difference where the applied strain varies from (5)The effect of electric field on the stress components and applied moment at specified temperature gradients shows that the effect of temperature gradient is entirely in line with the electric field which means at higher temperature gradients we have lower stresses.(6)The results reveal that due to the thermal expansion of the VHB 4910, the temperature gradient does not have a significant effect on the electric induction, while by increasing the electric field, the amount of the electric induction increases.In this paper, a multi-stimuli thermo-dielectric-based soft actuator under large bending was investigated. In this regard, the total deformation gradient tensor was calculated by decomposing two entirely separate parts: an electro-mechanical part and a thermal part. Firstly, a nominal Helmholtz free energy density function was adopted to pinpoint the electric-elastic-dependent stress part. Two strain energy density functions, i.e., Mooney-Rivlin and exp-exp models were considered in order to represent the hyperelastic term of the model. Finally, the nonlinear differential equations of the actuator were derived analytically, and then solved by utilizing the Runge–Kutta second-order to evaluate the total stress components, applied moment and electric induction. The boundary value problem results were verified by employing the FEM method in two purely mechanical and thermo-mechanical loading conditions. In this regard, a user-defined subroutine was developed to implement the exp-exp model into ABAQUS. FEM results confirmed the semi-analytical solution predictions. The semi-analytical solution of the actuator results in following remarks: