In addition, there was a negative association between maternal tCys and LAZ at birth (p < 0.01). No associations between maternal tCys and the other anthropometric indicators were found significant, although there was a tendency for maternal tCys to be associated positively with WLZ at birth among girls (p < 0.10). This is a first study evaluating transgenerational relation of tCys on growth in infants. Further, larger and more comprehensive studies are needed to determine if and how maternal tCys alters child growth.Cysteine is a semi-essential amino acid that has been positively associated with growth in children. However, transgenerational effects remain unclear. The aim of this analysis was to assess whether maternal plasma total cysteine (tCys) concentration is associated with various growth indicators in infants living in peri-urban settings in Bhaktapur, Nepal. We used data from the 561 mothers enrolled in an ongoing randomized controlled trial. We built linear regression models to evaluate the associations between maternal tCys and birth weight, length-for-age Z-scores (LAZ) and weight-for-length Z-scores (WLZ) at birth and six months of age. Maternal tCys was inversely associated with birth weight among boys after adjusting for confounders ( Malnutrition is a wide-spread health problem leading to profound short- and long-term consequences for child growth and development ,2,3, as Evidence from several studies on fetal and child growth has shown the importance of the first 1000 days—starting from conception up to the second year after birth ,6. A sigAlthough there are many risk factors associated with malnutrition ,8,9,10, cystathionase (or cystathionine γ-lyase) which is required for the final step of transsulfuration pathway in the conversion of methionine and serine to cysteine [Amino acids are the building blocks of proteins. Deficiency of amino acids was found to suppress cell and organismal growth via the mechanistic target of rapamycin complex 1 (mTORC1) sensing pathway . Cysteincysteine ,18.N-acetyl cysteine (NAC) is a supplement and precursor of cysteine shown to improve placental functions in various animal studies by upregulating placental antioxidant activity and placental growth factors, thus reducing placental oxidative stress ,20,21. NPlasma total cysteine (tCys) was associated positively with anthropometric status in a study among 6–30 months old Indian children , howeverwww.clinicaltrials.gov (ID NCT03071666), which is taking place in Bhaktapur, Nepal. The trial aims to measure the effect of vitamin B12 supplementation during pregnancy and postpartum on growth and neurodevelopment in early childhood. Details on the original study protocol have already been published [12, known cases of any chronic disease under treatment  or current users of anticonvulsant drugs, severe anemia (hemoglobin concentration <7 g/dL), suffering from any condition that requires treatment with vitamin B12 and strict vegans. In addition to vitamin B12 (50 μg) or placebo, all pregnant women are also given folic acid (0.4 mg) for the first 2 months of pregnancy followed by iron  and calcium supplements (500 mg) until 45 days after delivery according to WHO guidelines.This was a secondary analysis of data from an ongoing randomized controlled trial (RCT) registered at ublished . In brieEthical approval for the trial was obtained from Nepal Health Research Council  and the Regional Committee for Medical and Health Research Ethics of Western Norway . This study is conducted in accordance with the Declaration of Helsinki.g at room temperature for 10 min, separated and transferred into storage vials and stored at −70 °C until analyses. Plasma total cysteine (tCys) concentration was measured using a modified gas chromatography-mass spectrometry method based on methylchloroformate derivatization having a reported coefficient of variance (CV) of 1–2% within-day and 4–8% between-day [12) and plasma folate were estimated by microbiological assays using a chloramphenicol-resistant strain of Lactobacillus casei and colistin sulfate-resistant strain of Lactobacillus leichmannii, respectively, having a reported CV of 4% within-day and 5% between-day, both for cobalamin and folate [2. Maternal blood samples (3 mL) were collected into vials containing ethylenediaminetetraacetic acid (EDTA) as anticoagulant, at the time of enrollment into the trial. The plasma was centrifuged at approximately 700× ween-day . Concentd folate ,28. MateBirth weight of infants was measured and recorded by hospital staff. Copies of the original records were gathered by our study staff and the birth weight was noted in our case report forms. Anthropometric measurements of the infants were taken in their homes immediately after birth and at six months of age by the study staff. Each infant’s length and weight were measured at least twice, and the average of the two measurements were calculated and used for our analyses. Length was measured according to standard guidelines using portable board . Weight was measured with portable electronic scale  that measures to the nearest 0.01 kg. The study staff had received training before initiation of the trial and supervisors monitored all fieldwork activities, verifying 5% of measurements taken by field workers. Data were double entered into a database and checked for consistency by a supervisor. Statistical analyses were done using Stata 16.0  and R version 3.6.2 . All analyses in the present study were restricted to the group of 561 mother–infant dyads where maternal tCys concentration and anthropometric measurements of their children at birth and six months of age were available. Birth weights gathered from hospital records were in grams and used as such in our analyses. Z-scores for length-for-age (LAZ) and weight-for-length (WLZ) for infants were calculated according to WHO Child Growth Standards . A WAMI-p-value ≤ 0.05 was considered statistically significant.We built linear regression models to assess the association between maternal tCys concentration (predictor variable) and birth weight or anthropometric status (LAZ and WLZ scores) in infants at birth and at six months of age (predicted variables). Birth weight, LAZ, WLZ and maternal tCys concentration were used as continuous variables. As there is no established cut-off for tCys, we additionally categorized maternal tCys into <25th percentile, 25th–75th percentile and >75th percentile and used this variable in separate models. The categorical analyses were done to be able to better communicate our results across both ends of maternal tCys, as studies have shown negative growth outcomes with both low and high cysteine concentrations ,31,32. WIn addition, generalized additive model (GAM) analyses were performed to explore any non-linear associations between maternal tCys and birth weight or anthropometric indices (LAZ and WLZ) at birth and at six months of age. All confounders identified in the linear regression models were adjusted for and values <2.5th percentile and ≥97.5th percentile for maternal tCys were excluded to avoid overfitting at the extremes.Maternal characteristics were available for 561 enrolled mothers, and birth weight and anthropometric measurements at birth were available for 521 infants. The data for the current analyses were obtained from the ongoing intervention study; therefore anthropometric measurements at six months were available for 376 infants . Demograp < 0.05). The birth weight decreased on average by approximately 105 g among boys across the highest quartile compared to middle half of maternal tCys concentration (p < 0.01). However, stratified analyses revealed that the association reached statistical significance among boys only (ntration . Maternaoys only .p < 0.10)  . ResultsThe current analyses were undertaken to elucidate whether maternal tCys can have an impact on growth in infants until six months of age. In the past, there has been much debate regarding use of cysteine as a supplement to promote growth among premature infants and undernourished children, but the effects of cysteine have been found to be inconclusive ,35,36. AOur study indicated that maternal tCys was inversely associated with birth weight among boys and LAZ at birth. For each unit increase in maternal tCys (in μmol/L) the birth weight among boys and LAZ at birth decreased by 2.6 g and 0.005 Z-scores, respectively. This negative association was more pronounced across the highest quartile of maternal tCys concentration, where the birth weight decreased on average by >100 g among boys compared to middle two quartiles. On stratification by gender, the latter association was found significant among boys only. We did not find any statistically significant associations between maternal tCys and birth weight among girls or WLZ at birth or WLZ/LAZ at six months of age.There is no established reference range for tCys concentrations in adults . Althoug12 [12 or placebo. A recent meta-analysis of 18 studies with 11,216 observations showed no linear association of maternal vitamin B12 with birth weight, but maternal vitamin B12 deficiency was associated with increased risk for infants born with low birth weight [12 supplementation during pregnancy or postpartum on growth outcomes in early childhood has to date not been established; if there would be an effect, this could have diluted our results. Cobalamin (or vitamin B12) and folate are important cofactors involved in the re-methylation of homocysteine to methionine, and their deficiencies are associated with elevated plasma homocysteine levels and reduced transsulfuration [Our study used data from an ongoing RCT where women in the intervention arm were given 50 μg of vitamin B12 . The math weight . The efffuration ,46. ThusIn the study on newborns by Küster et al. , the motCysteine supplementation in mice resulted in increased growth plate thickness through upregulation of IGF-1 , suggestStudies on cysteine in children with severe acute malnutrition suggested reduced cysteine production  and greaOur analyses were based on the sample size of 521 and 376 infants at birth and six months of age, respectively. The moderate sample size might have limited our statistical power to detect an association. This research is a prospective cohort study. Data come from an RCT which might limit the generalizability of our findings. Although we adjusted our models for several relevant confounders, we still cannot exclude residual confounding. According to the recent reports by Nepal Demographic and Health Surveys (NDHS) 2016, 13.5% and 15.2% of infants <6 months were stunted and wasted, respectively, compared to 17.6% and 21.3%, respectively, of infants aged 6–8 months . In our All pregnant women enrolled were given iron, folic acid and calcium supplements as per WHO guidelines. We cannot exclude if these co-interventions would have affected our findings. In addition, we limited our research by focusing on measures of maternal total plasma cysteine concentration, and we did not take into account maternal dietary intakes into these analyses. Plasma tCys concentration has been shown to respond to sulfur amino acid (SAA) intake within hours, potentially masking long-term inadequate intakes of SAAs ,62,63,64Nepalese women with a high plasma total cysteine concentration had an increased tendency of giving birth to low birth weight and short statured boys, but there was no effect on girls. The mechanism behind these associations and difference based on gender remain undecipherable. However, our findings fit well with the hypothesized effect on low birth weight via vascular dysfunction as well as the observation that short birth length was associated with high maternal protein intake. Larger and more comprehensive studies with those involving detailed dietary nutrient intake evaluation are required to verify these findings in Nepalese and other populations.


Electroactive hydrogels that exhibit large deformation in response to an electric field have received significant attention as a potential actuating material for soft actuators and artificial muscle. However, their mechanical actuation has been limited in simple bending or folding due to uniform electric field modulation. To implement complex movements, a pre-program, such as a hinge and a multilayer pattern, is usually required for the actuator in advance. Here, we propose a reprogrammable actuating method and sophisticated manipulation by using multipolar three-dimensional electric field modulation without pre-program. Through the multipolar spatial electric field modulator, which controls the polarity/intensity of the electric field in three-dimensions, complex three-dimensional (3D) actuation of single hydrogels are achieved. Also, air bubbles generated during operation in the conventional horizontal configuration are not an issue in the proposed new vertical configuration. We demonstrate soft robotic actuators, including basic bending mechanics in terms of controllability and reliability, and several 3D shapes having positive and negative curvature can easily be achieved in a single sheet, paving the way for continuously reconfigurable materials. Thus far, most previous results have focused on sheets that can access only a single trajectory from flat to a programmed shape, which pre-defined on the material9. Integrating a responsive material10 or geometric structure design11 that can be driven independently by two or more stimuli gives access to many pre-programmed shapes, but the difficulty of making and controlling these pattern sheets increases rapidly with the number of orthogonal controllable elements. Alternatively, re-writable hydrogels13 or shape memory polymers16 or liquid crystalline polymers18 have been demonstrated to form several shapes from a single sheet. However, these approaches need many times for re-defining patterns. Electroactive materials are of great interest in this respect, as they should allow for continuous reprogramming into an arbitrary number of shapes defined by polarity and intensity of the applied electric field19. Especially, hydrogel-based actuators can be exchanged chemical components or energy for aqueous mediums and operate by the reaction of gel network response22. Also, the hydrogel network can be pre-patterned for directional operation in response to the environment. Stimulating the movement of the hydrogel using the external electric field is appealing because of reliable control of signal strength and direction. This stimulus requires only ions in the external solution to induce operation. An electric field applied to a polyelectrolyte network locked in an electrolyte solution causes an asymmetrical dispersion of the ions, creating an osmotic pressure difference that was swelling and deforms the gel. These physical and chemical processes are similar to the transfer ion exchange between the cell membrane and its environment24.Shape transformations are driven by inhomogeneous in-plane deformation of thin elastic sheets provide one of the efficient ways to reconfigurable three-dimensional (3D) structuresin-situ two-directional bendings in a single sheet.While numerous routes have been developed to drive self-actuating of polyelectrolyte hydrogel by using an electric field, the complexity of the structures achieved is yet to match even that of defining 27 or by moving a pattern of the worm-like cantilever that controls bending speed29. Notable exceptions include approaches developed by Dickey and co-workers10 and Lee and co-workers11 where the bi-directional movement is controlled with two-type of hydrogel and thickness varying of a hydrogel structure on its actuation. Although it has been proven that it uses a single-direction electric field, it has not yet been able to carry out complex deformation without external components but at the same time, multi-directional operation.Indeed, most of the work to date has focused on simple bending for microfluidic and drug delivery that are formed either by introducing uniform curvature in a patterned two-dimensional (2D) sheetHere, to achieve arbitrary and fully reprogrammable soft actuators based on local deformation within a single hydrogel sheet, we take advantage of spatial electric field modulation due to the patterned electrode, coupled with an electroactive hydrogel of sodium 4-vinylbenzene sulfonate/2-hydroxyethyl methacrylate/acrylamide (VBS/HEMA/AAm) to drive bi-directional deformation as shown in Fig. 30. Figure 30 having a single pair of electrodes. In addition, the conventional driving method of horizontal electrode configuration has difficulty in driving for a long time because air bubbles generated by electrolysis stick to the sample, but our vertical configuration method would be more free from this issue. We conducted electro-actuation experiments of hydrogel networks of equimolar composition equilibrated in 0.025 M NaCl and average swelling ratio of 14.3 was obtained. An electro-active copolymer of VBS/HEMA/AAm was patterned 30 mm by 10 mm rectangular gel bends toward the cathode in an aqueous medium. Also, the CO2 Laser cutting machine was used for electroactive hydrogel patterning as well as substrates fabrication.As many previous studies in many research groups show, electroactive hydrogel, which reacts to the electric field, has a swell-deswell characteristic depending on the intensity or polarity of the electric field, which can be used to implement shape-morphingd) between the patterned electrodes and the vertical distance (h) of between the electrodes as variables in the vertical electrode configuration. Here, w is the width of the patterned electrode. The electric field characteristics, according to the ratio of d/h, are observed as the critical parameter because the correlation between the vertical and horizontal electric fields is a significant factor in generating the spatial electric field.To calculate the distribution of the electric field in two-dimensional space, Fig. d = 0) in a vertical configuration. As shown in the distribution of electric fields along the y-axis, one can observe that the intensity of electric fields decreases as the distance from electrodes. In other words, the region close to electrodes has a larger vertical electric field. The variation of the y-axis electric field, |Ey|, is noticeable as a function of h while the x-axis electric field, |Ex|, is negligible, as shown in Fig. Ey| decreased as a function of h/2, and it is necessary to reduce the h in order to cause a large deformation with the larger |Ey| while it could be a limit to the out-of-plane deformation of the sheet.Figure d (The h was fixed). In cases of d/h < 1.7, the distinction of the |Ey| by adjacent electrode pairs is ambiguous, and it is not suitable for electroactive actuators, which are intended to induce deformation independently. Therefore, d/h should be at least 1.7 for precise electric field modulation in case of applying the same polarity, and it is challenging to control a precise electric field modulation in the same polarity.Next, we consider the distribution of electric fields when two pairs of patterned electrodes are having with the same polarity Fig.  and withEy| according to the d/h, which shows the vertical electric field is ~0 V/m at the middle region (at x = 0). In other words, it was confirmed that different polarity electric fields could be obtained between the two adjacent electrode pairs, and spatial electric field control is possible through the electrode pattern regardless of d. Even the vulnerable regions of x = 0 in terms of the |Ey|, the |Ey| could be dominant compared to |Ex| in case of d > h. To optimized multipolar electric field modulator, the electric field of |Ey| and |Ex| were verified in terms of d/h. |Ex| is a component that hinders proper deformation of the hydrogel in the vertical electrode structure, and |Ey| is a component that induces out-of-plane deformation, properly. Therefore, it is essential to find the electrode structure to realize the optimum modulation, and it can be confirmed that d/h ~ 1.6 is optimal, as shown in Fig. When a reverse voltage is applied to patterned electrode pairs, a spatially separated electric field can be generated, as shown in Fig. Ex|. Both Fig. x-axis direction can be expected to be advantageous for driving.In addition, we examined the application of voltage to minimize |31.Based on the above numerical calculation results, we observed the bending mechanics of VBS/HEMA/AAm in the vertical electric field environment. Figure r) of the hydrogel cantilever can be linearly controlled. However, the experimental results . The deformation of the hydrogel generated by the electric field and the mechanical properties of the hydrogel were found to be conflicting, and thus the minimum area necessary for the deformation was present, which can be defined as the resolution. Probably, this actuation resolution varies depending on the mechanical properties of the hydrogel used and the electric field condition. Here, the vertical distance (h) of electrodes and width (w) of the electrode are set to 30 and 5 mm, respectively.The numerical calculation shows that voltages of different polarities can achieve positive and negative curvature in a single sample as shown in Fig. lts Fig.  show tha34. The extensive electric field driving achieves relatively high curvature can be obtained, but not suitable for long-term driving stability.Using the bending of VBS/HEMA/AAm copolymer to guide our choices of driving conditions, we next consider how the bending stability according to the applied electric field. Based on the bending mechanics, it was noticed that the maximum curvature of copolymer increases as voltage increases. However, there is a limit to stability concerning voltage conditions. When operated for a long time at each driving voltage, the bending curvature is increased, but the operation is not stable after a specific point of time. Figure 2, and is made of aluminum, which was produced by cutting oil spray. The actuation system has a middle layer between the upper and lower electrodes to a sample located in the center of the vertical electric field. To adjust the distance between substrates, the 3D printed movable stage used, and the middle layer was mesh-structured to facilitate the movement of ions. As noted in the previous simulation results, when voltages of opposite polarity are applied regardless of the spacing between horizontal electrodes, the vertical electric field in the middle would be ~0 V, allowing for precise electrode patterns. Thus, electrodes labeled 1 through 5 are independently driven at voltages of different polarity regardless of the distance between adjacent electrodes. Figure We propose a reprogrammable actuation system by using patterned electrode pairs on substrates to spatial electric field control. Figure On the other hand, applying a voltage of −20 V to all the upper electrodes (0 V to the bottom electrodes) results in a positive curvature, and the shape of the canopy could be achieved. Finally, in the case of −20 V is applied to the two electrodes (2 and 5) pairs and +20 V is applied to the other three electrodes , the shape is shown in Fig. Vinv) was applied to the adjacent electrode, as shown in Fig. Vinv, it could be seen that only the hydrogel hair of the electrode pair to which Vact was applied was banded, but without Vinv, some deformation could be observed in other hydrogel hair. Also, it was confirmed that the width affected by the |Ey| in the case of application and full width at half maximum (FWHM) was found to be reduced by about 18%, and the electric field is confined in case of with Vinv while the |Ey| is partially reduced as shown in Fig. Vact to the electrode pair where the hydrogel hair to be bent is located while applying Vinv to the adjacent electrode pair. This example is remarkable because it highlights the ability to operation freeform electroactive hydrogel through patterned spatial electric field modulation without any pre-programming on the material. Bi-directional electroactive hydrogel control has not been thoroughly explored in a single sheet because of the difficulty of actuating nodes independently with the uniform electric field. Our proposed method removes this restriction with multipolar spatial electric field modulation, and we expect that with the actuation scalability provided by our approach, vastly more complex structures may now be readily explored.As a final example, we consider moving the log that was controlled the polarity of the electric field as well as intensity independently. The log was rolled through the patterned hydrogel hair to confirm sequential bending, as shown in Fig. We have developed a technique to dynamically transform and reconfigure 2D hydrogel copolymer sheets into predictable and sophisticated 3D shapes not limited by pre-programmed patterns within the material. Using the multipolar spatial electric field modulation, rapid and localized bending deformation occurs in the vertical electric field applied regions due to an osmotic pressure difference that was swelled and deforms the electroactive hydrogel. A number of 3D shapes having+/− curvature can easily be achieved from a single pattern free sheet, paving the way for continuously reconfigurable materials for soft robotics, biomedical devices, and mechanical metamaterials. Further improvements in the mechanical properties of the hydrogels are expected to enable a significant range of applications.2 gas for 20 min. TMEDA  and APS  were then added in the monomer mixture. The mixture solution was poured into the glass mold (100 × 100 × 1 mm) and placed under 365 nm UV light for 25 min. The crosslinked hydrogel sample was taken out from the mold and washed with deionized water to eliminate unreacted residues. The synthesized hydrogels were cut into the appropriate size and used in subsequent experiments. The hydrogel is measured 111.08 ± 0.98 KPa in terms of compressive strength.Electro-active VBS/HEMA/AAm hydrogels were prepared by free-radical polymerization. In brief, a mixture of monomers containing VBS , HEMA  and AAm  was dissolved in deionized water (9.917 ml). PEGDA (poly(ethylene glycol) diacrylate, 0.282 mmol) was then added as a crosslinking agent. Oxygen was removed by bubbling NGels were placed in 0.025 M NaCl solution and allowed to stabilize for one h or longer. Rectangular and starfish were laser cut for the gel sheets, and all samples designed by computer-aided design  Gels with initial thicknesses of 1.8 mm were prepared using identical procedures. The electrodes used 0.5 mm-thick aluminum as the top and bottom electrodes, and all electrodes were designed through the computer-aided design (CAD) for cutting oil spray. The patterned electrodes were attached to 2 mm-thick acrylic substrates, and each electrode was carbon tape, and copper wires were used for a voltage applied. The middle layer utilizes mash-shaped fabric and frame using 3D printing to support the material.Supplementary Information.Supplementary Information video


Mannheimia haemolytica serotype A2 is the principal cause of pneumonic mannheimiosis in ovine and caprine livestock; this disease is a consequence of immune suppression caused by stress and associated viruses and is responsible for significant economic losses in farm production worldwide. Gram-negative bacteria such as M. haemolytica produce outer membrane (OM)-derived spherical structures named outer membrane vesicles (OMVs) that contain leukotoxin and other biologically active virulence factors. In the present study, the relationship between M. haemolytica A2 and bovine lactoferrin (BLf) was studied. BLf is an 80 kDa glycoprotein that possesses bacteriostatic and bactericidal properties and is part of the mammalian innate immune system. Apo-BLf (iron-free) showed a bactericidal effect against M. haemolytica A2, with an observed minimal inhibitory concentration (MIC) of 16 µM. Sublethal doses (2–8 µM) of apo-BLf increased the release of OMVs, which were quantified by flow cytometry. Apo-BLf modified the normal structure of the OM and OMVs, as observed through transmission electron microscopy. Apo-BLf also induced lipopolysaccharide (LPS) release from bacteria, disrupting OM permeability and functionality, as measured by silver staining and SDS and polymyxin B cell permeability assays. Western blot results showed that apo-BLf increased the secretion of leukotoxin in M. haemolytica A2 culture supernatants, possibly through its iron-chelating activity. In contrast, holo-BLf (with iron) did not have this effect, possibly due to differences in the tertiary structure between these proteins. In summary, apo-BLf affected the levels of several M. haemolytica virulence factors and could be evaluated for use in animals as an adjuvant in the treatment of ovine mannheimiosis. Mannheimia haemolytica is a normal inhabitant of the nasal cavity and tonsil crypts of healthy ruminants. However, when animals suffer from shipping stress and/or an acute infection by Mycoplasma bovis (in cattle) or viruses , they become immunocompromised. This condition leads to the rapid proliferation of M. haemolytica, which subsequently reaches the lungs and infects the alveolar epithelium. M. haemolytica serotype A2 causes acute pneumonic mannheimiosis in lambs, sheep and goats. Several studies have demonstrated the importance of mannheimiosis as a cause of mortality in these livestock species, as well as the negative effects on weight gain and a low efficiency in feed conversion in chronically affected sheep , where atypical bubbling and increased permeability of the inner membrane were observed. In E. coli K12, Lfcin and Lfampin (20 µM each) also lead to OM breakage in such a way that the inner and OM fused and protrusions from the surface were observed. In this case, the authors reported vesicle-like structures of approximately 50 nm in diameter in more than 50% of the cells [Multiple reports have described the damage caused by Lf to the OM of different bacterial species, which has also been observed to be caused by Lf N-terminus-derived peptides named lactoferricins (Lfcins) –33, 35. he cells . Taken the cells –48. SuchM. haemolytica A2 grown in medium supplemented with apo- and holo-BLf. Apo-BLf-mediated LPS release occurred in a concentration-dependent manner, and holo-BLf also promoted LPS release, although to a much lesser degree than apo-BLf. Additionally, M. haemolytica grown in the presence of apo-BLf displayed diminished MIC value for SDS and polymyxin B. Apo-BLf decreased the functions of the OM, causing this structure to be more susceptible to external compounds. In contrast, holo-BLf permeabilized the OM of M. haemolytica to a lesser degree, a result that was consistent with our previous data and electron microscopy images. We suggest that the increase in OMVs released by M. haemolytica grown in medium supplemented with apo-BLf is in part due to its ability to remove divalent cations, such as Ca2+ and Mg2+ [The OM has an asymmetric lipid bilayer with negatively charged LPS molecules that are primarily localized on the outer leaflet and are stabilized by the presence of divalent cations . Multipland Mg2+ , 34, theM. haemolytica lkt gene promoter was increased more than threefold. These authors performed a detailed study of the transcriptional regulation of this gene through the development of plasmid-borne chloramphenicol acetyltransferase (cat) operon fusions and concluded that the lkt gene is negatively regulated by iron [Aggregatibacter actinomycetemcomitans, another member of the Pasteurellaceae family, is increased in low-iron medium. M. haemolytica is capable of reaching the lungs, where the microenvironment is low in iron. Thus, as a mechanism for M. haemolytica to obtain iron for growth, it seems reasonable that iron limitation leads to increased Lkt production, which destroys cells and releases iron. This mechanism has been reported in other bacterial species [The ability of bacterial pathogens to adapt to the environment within the host is essential for their virulence , and env by iron . Balasho by iron  also sho species .M. haemolytica. The difference between these observations and our results may be due to apo-BLf being a multifunctional protein with activities other than as a bacteriostatic agent as an iron-chelator, since it has bactericidal activity by being able to bind and damage the bacterial OM. Therefore, the apo-BLf iron-chelating effect may not be the only one involved in the regulation of Lkt secretion.Other researchers , 54 haveM. haemolytica A2, many of which could not be detected by flow cytometry. Thus, it is necessary to use other methods to accurately evaluate this effect, such as nanoparticle tracking analysis.Interestingly, only holo-BLf increased the level of Lkt present in OMVs. Perhaps this result is due to its ability to promote the production of smaller vesicles than those typically produced by M. haemolytica A2 components (OM and LPS), as well as the effect on some virulence factors, such as Lkt and OMVs, our results can be informative for further studies of the use of apo-BLf in the treatment of ovine mannheimiosis. In the future, assays with animals could be performed to determine the appropriate apo-BLf doses for its possible use as an adjuvant in the treatment of ovine mannheimiosis and assess its synergy with antibiotics.Although this study reports the basic interactions between BLf and some M. haemolytica A2. At sublethal concentrations, apo-BLf promotes OMV release, which is dependent on the apo-BLf concentration, induces OM damage and affects its permeability. Apo-BLf increases Lkt secretion via an iron-chelating effect, and Lkt and OMVs released from M. haemolytica grown in medium supplemented with apo- or holo-BLf maintains its toxic effect toward ovine macrophages. Due to these effects, the use of apo-BLf can be recommended for the treatment of ovine mannheimiosis, but the appropriate doses must be determined.In summary, the results of this study demonstrates that apo-BLf is bactericidal toward Additional file 1. 2′2-Dipyridyl increases leukotoxin (Lkt) secretion intoM. haemolyticaA2 culture supernatants (CS). Bacteria were grown in BHI supplemented with 2′2-dipyridyl. A Western blotting of Lkt in the CS of M. haemolytica A2. B Graph of Lkt (densitometry). ****P < 0.0001.


The association between maternal serum total bile acid (TBA) levels and small-for-gestational-age (SGA) infants is unclear. We investigated the association between various degrees of serum TBA levels and the risk of SGA infants in a Chinese population. The current study performed a cohort study among 11811 mothers with singleton pregnancy. Subjects were divided into seven categories according to maternal serum TBA levels. Interestingly, birth sizes were reduced, whereas the rate of SGA infants was increased across increasing categories of serum TBA. Compared to category 1, adjusted ORs (95%CI) for SGA infants were 0.99 (0.82–1.21) in category 2, 1.22 (0.97–1.53) in category 3, 1.99 (1.53–2.58) in category 4, 2.91 (2.16–3.93) in category 5, 4.29 (3.33–5.54) in category 6, and 9.01 (5.99–13.53) in category 7, respectively. Furthermore, adjusted ORs (95%CI) for SGA infants for each 1-SD increase in serum TBA levels were 1.36 (1.29–1.43) among all subjects, 2.40 (1.82–3.45) among subjects without cholestasis, and 1.13 (1.06–1.22) among subjects with cholestasis, respectively. These results suggest that gestational cholestasis increases the risk of SGA infants. Additionally, our results indicate strong, continuous associations of serum TBA levels below those diagnostic of cholestasis with a decreased birth sizes and an increased risk of SGA infants. ICP occurs usually in the second half of pregnancy until delivery. The incidence of ICP ranges from 0.4% to 15% in different countries, ethnic populations and climatic conditions4. The majority of studies had demonstrated that ICP was associated with adverse maternal outcomes, including 3-fold increased risks of gestational diabetes mellitus and pre-eclampsia7. A large cohort study from Sweden showed that women with ICP had increased risks of later liver and biliary tree cancer, later specifically diabetes mellitus, later autoimmune-mediated and cardiovascular diseases after childbirth8. On the other hand, several epidemiological studies reported the association between ICP and the increased risks of adverse fetal outcomes, including spontaneous and iatrogenic preterm delivery, a low (<7) 5-minute Apgar score, respiratory distress syndrome, meconium-stained fluid, stillbirth and intrauterine fetal death11. In addition, a report on human and rodent animal demonstrated that ICP was also associated with sex-specific increased susceptibility to severe obese, diabetic phenotype with hepatosteatosis in adult offspring, indicating a programming effect of the high bile acid exposure in utero13.Intrahepatic cholestasis of pregnancy (ICP), also named gestational cholestasis, is defined as the presence of pruritus in combination with elevated serum total bile acid (TBA) levels (≥10 μmol/L). ICP is one of the most prevalent obstetric disease16. Several epidemiological reports showed that the risks of autism in childhood and cardiovascular and metabolic diseases in adulthood were increased in people born with SGA20. Nevertheless, no report analyzed the association between ICP and an increased risk of SGA infants in a cohort study. It is more obscure whether maternal serum TBA levels less severe than that in cholestasis are associated with an increased risk of SGA infants.Small for gestational age (SGA), defined as fetal weight less than the 10th percentile based on gender and gestational age, is one of the leading causes for stillbirth, neonatal death and perinatal morbidityThe present study conducted a birth cohort study to investigate the risk of SGA infants associated with various degrees of serum TBA levels. The present study found that ICP elevated the risk of SGA infants. Additionally, our results indicate strong, continuous associations of serum TBA levels below those diagnostic of cholestasis with a decreased birth sizes and an increased risk of SGA infants.The demographic characteristics of study participants were presented in Table Subjects were divided into seven categories according to maternal serum TBA levels. Birth weight was compared among seven categories. As shown in Table Participants were divided into seven categories according to maternal serum TBA levels. The rate of SGA infants across serum TBA levels categories is shown in Fig. Table The aim of the present study was to clarify the risk of SGA infants associated with various degrees of serum TBA levels, especially less severe than that in overt cholestasis in a birth cohort study. The present study found that birth sizes, including birth weight, birth length, head circumference and chest circumference, were decreased across increasing categories of serum TBA levels. The association between serum TBA and the risk of SGA infants was analyzed. After adjustment for confounders, there were strongly associations with SGA infants that increased across the increasing serum TBA levels categories.23. Several reports indicated that the risk of SGA was higher in low educational subjects compared with high educational subjects25. On the other hand, pregnancy complications, such as gestational diabetes mellitus, gestational hypertension and pre-eclampsia, were also associated with birth weight and the risk of SGA. Several reports showed that gestational hypertension and pre-eclampsia elevated the risk of SGA infants27. In contrast, gestational diabetes mellitus was significantly associated with higher birth weight and 2-fold increased risk of large for gestational age (LGA) infants and macrosomia29. The present study further estimated the adjusted ORs with 95%CI with respect to the incidence of SGA infants using multiple logistic regression models. After adjustment for these confounders, our results still found that the risk of SGA infants was increased across the increasing serum TBA levels categories.Maternal demographic characteristics, such as maternal age, pre-pregnancy BMI, parity and maternal education, were associated with birth weight and the risk of SGA infants. A number of epidemiological studies demonstrated that advanced maternal age, primiparity and low BMI before pregnancy elevated the risks of SGA and low birth weight infants31. Reports in vivo and in vitro found that bile acids stimulated the expression of a series of inflammatory cytokines and reactive oxygen species via activating both signal 1 and 2 of the NLRP3 inflammasome and NF-κB pathway34. These studies indicated that cholestasis was associated with inflammation and oxidative stress. Indeed, many epidemiological studies showed that maternal serum and umbilical cord serum TNF-α, C-reactive protein and IL-8 levels were significantly higher in the SGA group than in the control group36. According to a recent nest case-control study, strongly nuclear NF-κB p65 immunoreactivity was observed in placentas from pregnant women with SGA infants37. Animal experiments also found that maternal inflammation and oxidative stress resulted in FGR in rodents39. Therefore, we guess that inflammation and oxidative stress may play a vital role in TBA-mediated SGA. On the other hand, recent evidence suggested that the deficiency or downregulation of selective miRNA may be involved in placental-induced diseases, such as pre-eclampsia and fetal growth restriction, through the epigenetic mechanism42. Indeed, several studies found that bile acid, such as deoxycholic acid, inhibited miRNA expression in cell lines44. Consequently, we speculate downregulation of miRNA in placentas may be play a key role in TBA-mediated SGA. Moreover, a recent study reported that maternal serum TBA levels at diagnosis and at delivery were correlated positively with umbilical cord blood TBA levels, which provides evidence that bile acids could transport across the placenta45. Recently, numerous reports found that bile acids induced oncosis, necrotic cell death and apoptosis47. Thus, the present study does not exclude that elevated TBA-associated SGA is due to the direct toxic effect of bile acids.The mechanism by which elevated serum TBA increases the risk of SGA remains obscure. Several case-control studies showed that the levels of proinflammatory cytokines and chemokines in placenta and maternal serum were significantly higher in the cholestasis group as compared to the control group49.The present study laid emphasis on whether serum TBA levels less severe than that in cholestasis was associated with an increased risk of SGA infants. However, the present study has three faults. Firstly, the nutritional status, drinking and smoking during pregnancy could affect fetal growth, but we did not have data on the variable. Secondly, the present cohort included only Chinese population, so our results should be treated cautiously when branched out to other ethnic populations. Another potential fault is the lack of information on treatment to pregnant women with cholestasis. Although previous reports demonstrated that treatment with ursodeoxycholic acid, a common drug for treating cholestasis during pregnancy, did not reduce adverse perinatal outcomes in pregnant women with ICP, it was associated with the reduction of serum TBA levels in ICP patientsIn summary, the present study investigated the risk of SGA infants associated with various degrees of serum TBA levels in a large birth cohort study. The present study demonstrated that birth sizes were decreased across increasing categories of serum TBA levels. Further analysis found that ICP elevated the risk of SGA infants. Additionally, our results indicate strong, continuous associations of serum TBA levels below those diagnostic of cholestasis with a decreased birth sizes and an increased risk of SGA infants. There were no obvious thresholds at which risk increased. Thus, our study suggests the need to reconsider current criteria for diagnosing and treating ICP.21. Total 13801 pregnant women who delivered at First Affiliated Hospital of Anhui Medical University between January 2011 and December 2014 were recruited. Maternal demographic characteristics and obstetric records were recorded by midwives on the Birthing Outcomes System and all data included in the study was extracted from this database. Maternal nonfasting blood samples were obtained before labor. The exclusion criteria of the current study included the following: unavailable data of detailed delivery records (n = 897), fetal deaths or stillbirths (n = 270), pregnant women giving birth to multiple births (n = 294), induced-abortions (n = 147) and unavailable serum TBA data (n = 382). Finally, 11811 (85.6%) mothers with singleton pregnancy were eligible for this study. The present study obtained ethics approval from the ethics committee of Anhui Medical University (No. 20160010). All participants signed a written informed consent for this study. All methods were carried out in accordance with the approved guidelines.We conducted a retrospective birth cohort in Hefei, a city of central China50.Serum TBA levels were measured using enzymatic cycling method by an automatic biochemical analyzer  according to a previous protocolth percentile for gender and gestational age from a reference population for Chinese51.The cutoff value used for defining the small-for-gestational age (SGA) is birth weight of live-born infants below the 10p-value of <0.05 (two-tailed) or a 95%CI not including 1 and 0 (for relative risk) was considered statistically significant.SPSS 17.0 was used to analysis the data. The mean differences were analyzed using one-way ANOVA and least significant difference (LSD) post hoc test. Categorical variables were analyzed using χ2 tests. The median differences were analyzed using non-parametric statistics (Mann-Whitney U test). The incidence and odds ratio (OR) of SGA infants were calculated in different groups. Multiple logistic regression models were used to estimate the risks of SGA infants in relation to lowest TBA category by crude and adjusted ORs with 95% confidence intervals (95% CI). Linear regression was used to explore the association between serum TBA levels and birth sizes. A


It is known that idioms, proverbs, and slogans can become integrated into feelings like irritation, contemptuous attitudes, and even anger and disgust. Idioms making reference to insects, spiders, and other invertebrates occur in all languages, but they convey mostly negative content in people of Western cultural orientation. By analyzing a subgroup of insect and spider idioms related to food, eating, and digestion, the authors suggest that mirror neurons are activated in people that are exposed to the largely unfavorable content of such idioms. This could then lead the listener of such idioms to adopt the kind of negative attitude towards insects that is expressed in the idioms and to project it towards edible species. There is no single reason that explains why people would accept or reject insects as food. Vabø and Hansen  in conneIdioms and proverbs, for example, occur in all languages and according to Casas et al. , constitTurning now specifically to idioms that incorporate references to insects and other terrestrial arthropods like spiders, it has repeatedly been shown that amongst people with Western cultural backgrounds these idioms convey predominantly negative attitudes, but that in East Asia more positive attitudes prevail ,17,18,19What seemed pertinent in connection with this question is the recent realization of so-called mirror neurons in the human brain, discovered by Rizzolatti and Sinigaglia . Such neThe aim of this paper has been to show that idioms containing negative references to insects and other invertebrates could possibly influence a person’s attitude, especially in connection with insects as a novel food item in Western countries. Therefore, this paper must not be seen as a comprehensive and detailed study on insect containing idioms and their effects on people, but is meant to serve as a ‘wake-up-call’ to conduct further studies into this question.The target subgroup of insect, spiders, and other invertebrate-related idioms were those that show a relationship to food, eating, and digestion in the widest sense. Although a variety of such idioms from different languages were investigated by us, the idioms that we have most thoroughly examined belonged predominantly to the Finnish language for three reasons: firstly, Finns have largely been a rural people living in close contact with Nature and their language is therefore particularly rich in idioms that contain references to insects; secondly, the authors’ own familiarity with the language provided us with considerable insight into use and meaning of such idioms; thirdly, in agreement with other people of Western cultural backgrounds, Finns until very recently, did not consider insects and other terrestrial arthropods as edible, seeing in fact most of them as pesky and annoying creatures. Since Finnish idioms and proverbs have been the subject of several books, the ten most relevant books ,30,31,32Finnish language speakers may find some of the expressions and spellings unusual, because often idioms are connected with local dialects that somewhat differ from the standard Finnish. Moreover, urbanized Finns may not recognize some of the older idioms, especially those used by rural folk.Kyllä se kärsii, mitä tai järsii  = He is Täi lihalla elää, mies muulla ruuvalla  = A lousTäi aina lihhoo syö  = A lousEi sääsken saaresta paljon paisteta  = One foKussa vähä kimalaisia, siinaä vähä hunajata  = Where Jaakko paarmat kokoo ja keittää niistä hutun  = John cSirkan reisi ja kirpun hanta koyhan miehen rasjas on  = The thTyyristä kärpäsen mesi  .Parempi mato omenassa kuin puolikas puremassa [other] = Better a whole worm in an apple than half of the worm in the bitten place .Ei madon syöma makee, eikä hiiren syömä hipee [other] = Worm eating is not sweet and mouse nibbling is not good (having little to eat is not funny).Mehiläinen meidän lintu, herhiläinen hiiden lintu [other] = Bee is our bird, hornet is the Devil’s bird (expresses dislike of hornets as evil in comparison with something good like bees).Lisänä rikka rokassa, hämähäkki taikinassa  = More mOle on omituinen kuin olisi perhosia vatsassa  = LivingSirkan reisi ja paarman jalka köyhän aitasta löytyy  = The thKirpum potku ei paljoo tunnu  = CookinPaskakakkokim makosta haukatas sontiaisen suulla  = Even sSe on niin nuuka et se kirputki halkasee ja pitää itte molemmat puolet  = She/heOn niin ahne ett otais kirpultaki kolmppari koippei  = So greAin se avuks on ikä kärväne kaalfaris  = It is On niinku kärväne siirapis  = To be Käy niinko mato raatoo  = To eatMeni ku mato rasvonee  = She/heSyä kun hevonen ja paskantaa kun peronen  = Eat liNielöö kun variksenpoeka sittapörrijä  = To swaOn vatta nin täysi että täin päälla tappas  = The stSyöö kun hevone ja tekköö kun täe  = Eat liKun sirkka pääsee suurukselle, niinse laulaa  = When aVennyy kun vesimato piimäsä  = To lieNiin nuuk, et pannee kirpun poikki ja pittää molemap päätitte  = So greVattuvaha se on vatun matokii  = A raspNäläkästä se torakka sillon siälii kun mökinseinästä vellipataan tipahtaa  = The coLithuanian :Alkanam šuniui ir grambuolys mėsa = a hungry dog sees a cockchafer as meat.To show that Finnish is not the only language that possesses idioms in the category of insects and spiders related to food, eating, and digestion, a few examples shall be given of such idioms of other languages.Flies come to feasts unasked.A louse in the cabbage is better than no meat at all.When the bee sucks, it makes honey; when the spider, it’s poison.English : Flies cIn der Not frisst der Deubel (= Teufel) Fliegen = in times of need the Devil consumes flies .Besser eine Laus im Topf als gar kein Fleisch. = Better a louse in the pot than no meat at all.Da ist der Wurm drin= There’s a worm in it (it can be maggot or caterpillar) .Der/sie macht‘n Gesicht als haett er‘ne Spinne gefressen. = He makes a face as if he’d swallowed a spider (a person’s expression when something unpleasant has occurred to him/her).German : In der 구데기 무서워 장 못담굴가 = Goodeogi mooseoweo jang motdamgeunda (one can make soybean paste sauce even in the presence of maggots).Korean : 구데기 무서워蓼食う虫も好き好き Tade kuu mushi mo sukizuki. Literally: There are even bugs that eat knotweed (tastes differ and that there’s no accounting for taste).蟻 の 甘き に 就く が ごとし Ari no amakini tsukuga gotoshi. Literally: ants stick to sweet things (people gather together where there is something to be got).Japanese : 蓼食う虫も好きAlthough assigning idioms to categories designated as ‘negative’, ‘neutral’, and ‘positive’ is a subjective exercise that is likely to show some variation depending on who makes the distinction, our view is that of the 40 Finnish idioms related to insects and eating, feeding and food, 20 contained predominantly negative, 9 neutral, and 7 positive information . Clearly negative are idioms like “Kirpum potku ei paljoo tunnu” and “On niinku kärväne siirapi” while “Kussa vähä kimalaisia, siinaä vähä hunajata” and “Yksin tehty työ on kun tervaa, kaksin kun hunaja” are seen as neutral and positive, respectively. Although we did not have complete comparative lists of insect idioms in connection with food and eating from other languages, what we can nevertheless state with confidence is, that it is the negative content which is always more dominant in Western than Eastern cultures. One idiom each from Korea and Japan has served as an example of the more positive attitudes towards insects in these countries.We need to stress that in Finnish and other languages there are many more idioms referring to insects, spiders, and worms than those we mention in this article. We deliberately selected only idioms that had some connection with food, eating, and digestion. It was, after all, our intention to demonstrate that the use of these figuratively explicit idioms could affect the attitude of people towards accepting insects as food. Therefore: did our study provide evidence for a role of insect idioms in the mindset of people with Western cultural backgrounds?Most people would agree that if a happy and smiling one-year-old infant sees and hears another, unrelated baby cry, the mood of the former, happy infant will change and it may also start to cry for no apparent reason other than seeing and hearing another baby cry. Likewise, as Stadler  explainsDuda and Brown  thoroughGiven that idioms with references to insects and spiders in Western cultures are predominantly negative, but less so in Eastern cultures ,18,19,42An aspect not to be ignored is ‘familiarity’ with insects and other arthropods. Urbanization certainly leads to an increasing alienization regarding insects and one consequence of this is that nowadays fewer people know and use idioms that make reference to insects and other arthropods as seen especially in the cases with English and German speakers when compared, for example, with the Japanese . This, hIn conclusion, to establish insects as a regular food item (even if it is simply as a component of some other food) in countries that in the distant past had given up the consumption of insects and other arthropods and now enjoy no shortage of other food items, is likely to be an uphill struggle. A number of reasons have been documented and predictions on the intentions of eating insect-based products have recently been formulated , but a p


The neurological examination was normal, and the blood pressure was at 130/80 mmhg. A cranial CT scan was performed discovering a small isodense round lesion in the posterior fossa, in front of the brainstem. MRI scans confirmed an iso intense T1 hyper intense T2 extra-axial cystic lesion, with no contrast enhancement, and no diffusion restriction on DW images. It was located on the midline, anterior to the ponto-medullary junction, and seemed to have a cyst conduct through the inferior clivus . ConsideOn MRI imaging, they are typically round and/or lobulated, well margined extra-axial lesions ,3. The sNeuroenteric cyst should be considered as a differential radiological diagnosis in the posterior fossa with the epidermoid cyst, arachnoid cyst and the neurocysticercosis. The treatment strategy depends on the clinical symptoms.


Newborns of primiparous women with birth plans obtained better results on 1 min Apgar scores, umbilical cord pH and advanced neonatal resuscitation. No significant differences were found on 5 min Apgar scores or other variables for multiparous women. Conclusions: Birth plans were related to less intervention, a more natural process of birth and better outcomes for mothers and newborns. Birth plans can improve the welfare of the mother and newborn, leading to birth in a more natural way.Background: Birth plans are used for pregnant women to express their wishes and expectations about childbirth. The aim of this study was to compare obstetric and neonatal outcomes between women with and without birth plans. Methods: A multicentre, retrospective case–control study at tertiary hospitals in southern Spain between 2009 and 2013 was conducted. A total of 457 pregnant women were included, 178 with and 279 without birth plans. Women with low-risk gestation, at full-term and having been in labour were included. Sociodemographic, obstetric and neonatal variables were analysed and comparisons were established. Results: Women with birth plans were older, more educated and more commonly primiparous. Caesarean sections were less common in primiparous women with birth plans (18% vs. 29%,  In today’s society, the entire process of pregnancy, childbirth and breastfeeding has been medicalised. The development of medicine has brought benefits and a decrease in maternal and infant mortality, but the use of drugs and other medical interventions in pregnant women have predisposed them to unnecessary practices. In the 1980s, a humanisation-oriented mobilisation began in childbirth care, which questions medical intervention and its adverse effects on the birth process [In 1985, the World Health Organization (WHO) was urged to review the pregnancy and childbirth biomedical care model, characterised by increasing interventionism and medicalisation in developed countries. The WHO presented recommendations highlighting the importance of respecting the normal course of these processes, limiting interventions to cases supported by scientific evidence. Some of the most important recommendations (among others) were: (i) the caesarean section rate should not exceed 10–15%, as there is no justification for exceeding this rate; (ii) electronic foetal monitoring should not be routine; (iii) systematic use of episiotomy and artificial early amniotomy are not justified; (iv) vaginal deliveries after a caesarean section should be encouraged to avoid a repeat caesarean section; (v) women must be involved in decisions about their childbirth process; and (vi) breastfeeding should be established immediately after birth, before the mother leaves the delivery room .In Spain, the “Normal Childbirth Care Strategy” of the National Health System, approved in 2007, is driving a profound transformation in the delivery care model. The new model considers birth as a physiological process and tries to offer personalised and comprehensive care to women based on scientific evidence, respectful of the leading role and the right to information and informed decision-making that the legislation recognises . ConcretTherefore, this strategy includes the birth plan as a tool that can contribute to reduced labour intervention. This plan is a written document that a pregnant woman and her partner prepare before birth and use to express their wishes and expectations regarding the development of the birth process . It provThe most frequently requested requirements of the birth plan are to avoid oxytocin use, episiotomy and a caesarean section, permit the ingestion of liquids, freedom of movement, intermittent monitoring, a comfortable expulsive position, immediate contact with the newborn, early breastfeeding and other conditions ,9. There are only a few studies that relate birth plan use with results associated with the mother and newborn. Some authors showed a lower percentage of caesarean sections in women who presented birth plans ,11; howeSome parallelism could be established between the care for women with a birth plan and women enrolled in birth or alternative centres, where low-risk births are attended to in women who wish to give birth in a more intimate and different environment. In these centres, the professionals are mostly midwives who provide care based on a model of individual and family awareness and consider the birth process physiologically and naturally . Since bThis is a multicentre case–control study conducted at several tertiary hospitals of the Andalusia Health Public System with women who attended for birth between 2009 and 2013. The case group is composed of women who presented a birth plan document. The control group is composed of women who did not present a birth plan and gave birth with standard care. This study was conducted at four tertiary public hospitals with the greatest coverage in each province. In the study period, the estimated number of deliveries was 60,000 in the 4 hospitals. The sample size was determined by power analysis using EpiData software version 3.1 , with the following data considered: 1–2 controls per case, 29% exposure between controls, 16% exposure between cases, 80% statistical power and a confidence interval of 95%. A total of 500 women were estimated as statistically significant. Data were collected directly from medical records selected using systematic random sampling.Inclusion criteria were established for both groups: low-risk pregnancy at term (37–42 weeks). Those excluded were women with high-risk gestation, elective caesarean birth or emergency caesarean without labour, multiple gestations, out-of-hospital birth or women who gave birth in hospitals different to those studied and birth occurring before 37 weeks of gestation. Sociodemographic, obstetric and neonatal variables were analysed between the two groups using SPSS statistical software . Sociodemographic variables were maternal age (years), education level (primary/secondary/university studies), employment  and marital status (married/stable partner/single). Obstetric variables were parity (primiparous/secondary/≥3), gestational age (weeks), onset of labour (spontaneous/induced), epidural analgesia (yes/no), oxytocin use (yes/no), early amniotomy practice (yes/no), meconium, intrapartum maternal fever (yes/no), monitoring type , duration of first phase (hours), duration of second phase (minutes), type of birth , 3rd–4th-degree tears (yes/no) and episiotomy (yes/no). Neonatal variables were 1 min and 5 min Apgar scores, umbilical cord artery blood pH (<7.20 and mean) and neonatal advanced resuscitation (presence or not).p-values were adjusted using Fisher’s method. Bilateral contracts were performed using the chi-square statistic, Fisher’s exact test and Student’s t-test. Quantitative variables were described based on the mean value and standard deviation (SD). Analysis data considered the parity due to its ability to significantly influence the results. For data analysis, we used a statistical test of hypothesis contrast, according to the type of variable. A 95% alpha error was assumed. In the data analysis corresponding to result variables, The ethics committees of the hospital centres studied gave their approval to carry out the study. This study was conducted in accordance with the ethical standards of the Helsinki Declaration (2013 review), the Council of Europe on Human Rights and Biomedicine, the UNESCO Universal Declaration on the Human Genome and Human Rights and the Oviedo Council on Human Rights and Biomedicine and after formal approval from the Ethics Committee for Research. All data were processed with confidentiality and with no third-party unauthorised access, as established under current legislation: Organic Law 15/1999 of 13 December on the Protection of Personal Data, Royal Decree 994/99 of 11 June approving the regulations on security measures for automated files that contain personal data and Organic Law 3/2018 of 5 December on the Protection of Personal Data and Guarantee of Digital Rights, a realignment of Spanish law, according to Regulation (EU) 2016/679 of the European Parliament and of the Council of 27 April, 2016 with regard to the processing of personal data and the free movement of such data. n = 457), with 178 cases or women who presented a birth plan, and 279 controls or women who did not present a birth plan document, and therefore, received standard care. Of the 500 women initially included in the study sample, 43 were excluded. Of those 43 exclusions, 12 had elective caesareans, 11 had emergency caesarean without labour, 12 experienced premature birth and eight had high-risk pregnancies. The final sample comprised 457 women (p < 0.001), and the differences were significant in nulliparous and multiparous women. The percentage of women with university-level education was significantly higher in the birth plan group than the control group . In addition, there was a higher percentage of women who were salaried employees in the birth plan group . Sociodemographic data  show an p = 0.036).Regarding obstetric variables , the perp = 0.009); these differences were more significant among primiparous women. Early amniotomy was practised in 55.6% of the control group women versus 34.3% in the case group (p < 0.001). Oxytocin use was significantly higher in the control group, both in primiparous and multiparous women . The length of the first phase of birth was significantly higher in the birth plan group, with a duration of 6.28 ± 3.60 (mean ± SD) h compared to 5.20 ± 3.31 h in the control group. The length of the second phase, however, did not show significant differences between both groups.The proportion of women who used epidural analgesia was higher in the control group than in the birth plan group ; however, no significant differences were found among multiparous women. In comparison, there were no significant differences in instrumented births, 3rd–4th-degree tears and episiotomy in either primiparous and multiparous women. In regard to birth results , the perp = 0.010), in umbilical cord arterial blood pH < 7.20  and neonatal advanced resuscitation . No significant differences were found among multiparous women.Neonatal results  showed iRegarding the sociodemographic results, the data show some parallelisms with other studies. Several authors found that the ages of women who presented birth plans were higher than those who did not ,15, and Analgesia preferences are often some of the most frequent requests in birth plans. As in other studies, women with birth plans are more likely to reject epidural analgesia ; howeverThe neonatal results of this study were found to be relevant, as suggested by the results on newborns of primiparous women, in which the variables of 1 min Apgar scores, umbilical cord blood pH values and neonatal resuscitation had better results in the birth plan group subjects. Although few studies examining neonatal results and birth plan use exist, and the authors did not find significant differences in Apgar scores ,20, a prTo our knowledge, there are few studies that relate the use of birth plans to maternal and newborn outcomes (this aspect being the main novelty of the present study). Many studies focus on assessing maternal satisfaction, birth experience or other related aspects. For this reason, data from this study were compared with data obtained from birth or alternative centres, where midwives attend births naturally and with low interventional care. In this context, some authors compared umbilical cord blood pH  and caesAnother important result in this study is the reduction of caesarean births in the birth plan group women, in agreement with similar results that were found by other authors , who conAlthough our study shows data from previous years, it is no less true that recent information on the implementation of the birth plan corroborates that there is still a low implementation at present and, on the other hand, clarifies that the birth plan has benefits for both the mother and the newborn, that it has low adherence and that it is important to encourage its use.These results must be viewed with caution due to the limitations of this study. First, the heterogeneity of professionals who attend births may influence the degree of compliance with the birth plan. This diversity has been observed in all hospitals where this research was performed. Second, data were collected from four hospitals, corresponding to four provinces of Andalusia .In conclusion, our study results suggest that birth plans are used only by a minority of women giving birth. These women tend to be older, better educated and have a higher employment rate. In addition, women with birth plans had a higher rate of primiparity, induction of labour and experienced a longer mean duration of the first phase of labour. They also required less use of oxytocin, early amniotomy, epidural analgesia and general monitoring. The results obtained, both obstetrical and neonatal, were better in primiparous women.In clinical practice, the results of this study can be of interest to professionals in this area. Birth plans can be utilised in women as informed consent to obtain a more natural birth process and could be an effective tool not only in achieving better satisfaction and birth experience, as some studies have shown, but also in obtaining better results for the mother and newborn. There are some important challenges related to birth plan use. Important efforts must be made to raise awareness of women during pregnancy (including family) and healthcare professionals. The midwife is the professional who must be present with the pregnant woman in the preparation of the document. Further research is necessary regarding the benefits of birth plan use on maternal and child health and how the knowledge acquired by women can influence subsequent pregnancy.


Thyroglossal duct cyst (TGDC) is the most common congenital anomaly of midline neck masses. A thyroglossal duct cyst is especially difficult to diagnose and is treated differently when it appears in the sublingual area. Here, we report a rare case of TGDC extending to the sublingual space.A 42-year-old female presented with a history of neck swelling in the submental region.The final pathologic diagnosis was a TGDC.Sistrunk operation was performed.Recurrence of the disease has not been seen for the past year.Clinical awareness of the thyroglossal duct cyst in the sublingual area or on the oral floor area is important for an accurate diagnosis and the appropriated management. A thyroglossal duct cyst is especially difficult to diagnose when it appears in the sublingual area or on the oral floor area because it is often difficult to differentiate from other cysts such as dermoid cysts, epidermoid cysts, ranula and cystic hygromas.,4 Preoperative imaging is important to differentiate thyroglossal duct cyst from other lesions, to confirm the diagnosis, to identify the presence of functioning thyroid tissue in the neck, and to detect any possibility of malignant change within the cyst.It commonly presents as a painless midline neck mass below the level of the hyoid bone, and it rarely occurs in the oral cavity.Here, we report a case of a 42-year-old female with a rare occurrence of a thyroglossal duct cyst extending to the sublingual space.2This human study was approved by Gyeongsang National University Hospital Institutional Review Board and informed consent was waived by the Institutional Review Board.A 42-year-old female presented with a history of neck swelling in the submental region. On physical examination, a 3-cm mass was palpated in the midline submental region and was soft on palpation. The mass was mobile in the vertical direction upon swallowing. Laryngoscopy was normal.A CT scan showed a well-defined thin walled cystic lesion measuring 2.6×1.8×3.4 cm. The cystic lesion was located in the midline infrahyoid region extending into the hyoid bone, reaching to the left mouth floor, between the genioglossus muscle and the mylohyoid muscle , suprahyoid 24.1%), thyrohyoid (60.9%) and suprasternal (12.9%).%, suprah.1%, thyr–13 In our patient, there were no functional impairments, only neck swelling. In this study, sublingual extension was not suspected on clinical grounds before the CT scan, and we would have missed the sublingual lesion if we did not do a CT scan. Preoperative imaging such as CT is important to confirm the diagnosis of atypical cases, to differentiate thyroglossal duct cysts from other lesions, to identify the presence of functioning thyroid tissue in the neck and to detect any possibility of malignant change within the cyst; additionally, it plays a supplementary role in more accurately delineating the anatomy of the lesion. Failure to detect a thyroglossal duct cyst may be associated with inadequate performance of a surgical procedure, such as simple incisional biopsy or enucleation, both of which are associated with significant recurrence rates.A thyroglossal duct cyst classically presents as a mobile, painless mass in the midline of the neck, usually in proximity to the hyoid bone. Movement of the cyst with swallowing is often cited as a reliable diagnostic sign. Occasionally, a thyroglossal duct cyst can show atypical presentation either clinically or radiologically, which may pose a diagnostic challenge. Thyroglossal duct cysts that occur in the sublingual region or the oral floor are associated with functional impairments such as dyspnea, dysphagia, dysphonia and difficulty feeding.,4 Dermoid cysts are more often seen in the submandibular space than on the floor of the mouth. They are lined by keratinizing squamous epithelium and appear as well-demarcated cysts. They may contain fatty and calcific components as well as fluid. Epidermoid cysts are lined by a simple squamous epithelium and are more frequently seen in the floor of the mouth than in the submandibular space. With imaging, they appear as simple midline cystic lesions. A simple ranula is manifested clinically by swelling in the floor of the mouth and occasionally occurs in the submandibular space by either herniating through a mylohyoid defect or arising from an ectopic sublingual gland. The ruptured ranula (plugging ranula) usually extends posteriorly from the sublingual space into the submandibular space, with a narrower posteriorly from the sublingual space into. Cystic hygromas are characteristically infiltrative in nature and do not respect fascial planes typically involving contiguous anatomic regions in the neck.A thyroglossal duct cyst is especially difficult to diagnose when it appears in the sublingual area or on the oral floor area because it is often difficult to differentiate from other cysts such as dermoid cysts, epidermoid cysts, ranula and cystic hygromas. In this case, we performed a Sistrunk operation, and there has been no recurrence to date.When a thyroglossal duct cyst occurs in the neck, recurrence is likely following simple enucleation; therefore, the need for concurrent resection of the hyoid bone has been suggested.Conceptualization: Hwa Seon Shin, Jung Je Park.Data curation: Mi Jung Park, Hye Young Choi, Ho Cheol Choi, Jeong-Hee Lee, Jung Je Park.Investigation: Hye Young Choi, Sang Min Lee, Jeong Ho Jang.Methodology: Mi Jung Park, Hwa Seon Shin, Dae Seob Choi, Jung Je Park.Supervision: Dae Seob Choi.Validation: Hye Young Choi.Writing – original draft: Mi Jung Park.Writing – review & editing: Hwa Seon Shin, Dae Seob Choi, Jeong Ho Jang, Jeong-Hee Lee, Sung Eun Park.


The quantification of tricuspid regurgitation(TR) using three-dimensional(3D) proximal isovelocity surface area (PISA) derived effective regurgitant orifice area (EROA) is feasible in functional TR. The aim of our study was to explore the diagnostic accuracy and utility of 3D PISA EROA in a larger population of different etiologies.One hundred and seven patients with confirmed TR underwent 2D and 3D transthoracic echocardiography (TTE). 3D PISA EROA was calculated and EROA derived from 3D regurgitant volume (Rvol) was used as the reference.P < 0.01). 3D PISA EROA differentiated severe TR with comparable accuracy in patients with primary and functional etiology , but with different cut-offs (0.49cm2 vs. 0.41 cm2). The chi-square value for incorporated clinical symptoms, positive echocardiographic results and 3D PISA EROA to grade severe TR was higher than only included clinical symptoms or incorporated clinical symptoms and positive echocardiographic results .3D PISA EROA showed better correlation in primary TR than in functional TR(r = 0.897, TR quantification using 3D PISA EROA is feasible and accurate under different etiologies. It has incremental diagnostic value for evaluating severe TR. The unfavorable effect of TR has been gradually recognized –3. PreviEchocardiography is the test of choice in diagnosing TR . However2 for severe TR in the existing guidelines is not applicable to 3D PISA EROA [Although EROA has been widely used and recommended in the assessment of mitral regurgitation(MR), due to the irregular shape of the tricuspid regurgitation orifice and the low flow velocity of TR compared to MR, the use of this method in quantitative TR is still to be studied , 10. PreISA EROA –13. In aISA EROA . Our stuFrom March 2019 to May 2020, we prospectively reviewed 107 patients at the Cardiac Surgery Department, Zhongshan Hospital who met the following inclusion criteria: (1) presence of TR verified by 2D transthoracic echocardiography(TTE) at the Department of Echocardiography in our hospital, (2) plan of isolated tricuspid valve surgery or mitral valve surgery combined with tricuspid valve surgery in a week, and (3) presence of a recognizable proximal flow convergence region of the tricuspid valve in the four-chamber view. The definition of TR was determined by echocardiographic findings, qualitative parameters and semiquantitative parameters. Exclusion criteria were: (1) absence of a recognizable proximal flow convergence region, (2) pulmonary regurgitation or pulmonary stenosis (mild and more), (3) intracardiac shunt, (4) presence of prosthetic tricuspid valve, (5) poor acoustic window, and (6) less than 18 years of age. According to the etiology, presence of atrial fibrillation and TR jet location based on 2D TTE, we divided patients into primary TR group and secondary TR group, with atrial fibrillation group and without atrial fibrillation group, and centric TR group and eccenric TR group [Each patient in the left lateral position underwent a standard 2D TTE examination , 15. In Each patient in the left lateral position underwent a 3D TTE examination focusing on the tricuspid valve and the right ventricle(RV). In patients with sinus rhythm, 3 consecutive cardiac cycle images were acquired; in patients with atrial fibrillation, atrial flutter, or pre-systolic systole, 6 consecutive cardiac cycle images were acquired , 15, 16.On GE Vivid E95, a 3D full-volume data set of the entire RV and the tricuspid valve covering right ventricular outflow tract (RVOT) was acquired using 3D TTE. RV was traced in a 3D data set by dedicated software tools Fig. a. The RVOn Siemens Acuson SC2000 Prime, we selected the frame with peak velocity during systole, adopted eSie Flow preset and adjusted color baseline from 30.0 to 40.0 cm/sec. We set first point at the valve coaplation, drew arrow in direction of regurgitation and used zoom as needed Fig. b.Images from Siemens Acuson SC2000 Prime were analyzed on-cart. Images from GE Vivid E95 were analyzed offline on TomTec  workstation.2*Valiasing/Vmax  [RV) was calculated by RV EDV subtracted RV ESV   was calculated by VTIRVOT * SRVOT . Rvol is calculated by subtracting SVRVOT from SVRV. The 3D Rvol EROA was calculated using the following formula: Rvol/VTITR (VTITR is TR VTI).On TomTec, 2D PISA EROA was calculated using the following formula: 2*π* rTR Vmax) . Stroke aliasing)/ peak TR velocity  [On Siemens Acuson SC2000 on-cart, Fig. 3D PISA) .2 was used to define severe TR. Model 1 was clinical symptoms of right heart failure, such as lower limb edema, jugular vein distension and dyspnea. The positive echocardiographic results referring to the guideline [2. As the Model 3, a 3D PISA EROA≥cut-off value was forced into the Model 2 to access the incremental diagnostic value. To examine the reproducibility of 3D PISA EROA measurements, the same observer and another independent blinded observer remeasured 3D PISA EROA of 20 randomly selected cases 1 month later, respectively. The reproducibility of 3D PISA EROA was tested using intraclass coefficient (ICC). All P values were tested by two-sided test, P < 0.05 was considered statistically significant.The data analysis was performed using SPSS 20.0 and MedCalc. The normality of continuous variables was tested by Kolmogorov-Smirnov test. Continuous variables were expressed as mean ± standard deviation. Categorical variables were expressed as percentages or frequency. Categorical variables were compared using Chi-square test. Continuous variables were compared using ANOVA test. Post hoc test of continuous variables adopted the Tukey test for normal distribution data and the Games-Howell test for non-normal distributions data, respectively. The correlation between 3D PISA EROA and 2D PISA EROA and the correlation between 3D PISA EROA and 3D Rvol EROA were tested using Spearman test. The differences between their correlation coefficients were tested using Wolfe Test. The data of 3D PISA EROA and 3D Rvol EROA first underwent the normality test again after logarithmic transformation, and then verified their consistency by Bland-Altman analysis . Correlauideline  were forA total of 107 patients were enrolled in our study, 8 were excluded because of incomplete images and 99 were finally included in the statistical analysis.RVOT and SVRVOT. TR VTI and TR Vmax show significant differences (P < 0.001 and P = 0.013 respectively). As expected, the severe TR group had a greater number of following positive 2D echocardiographic findings : abnormal/flail/large coaptation defect tricuspid valve, VCW ≥ 0.7 cm, PISA radius > 0.9 cm, systolic reversal of hepatic vein flow and dilated RV with preserved function.The distribution of etiology of TR was listed in Table RV and Rvol were significantly larger in severe TR patients.The 3D echocardiographic parameters were summarized in Table The results of three quantitative methods: 2D PISA EROA, 3D PISA EROA and 3D Rvol EROA were reported in Table P = 0.85 in Wolfe Test). Irrespective of methods, the correlations demonstrated both high agreement in primary TR and secondary TR . Although Bland-Altman analysis showed unacceptable agreement between 3D PISA EROA and 3D Rvol EROA in the total patient population and the subgroups of etiology, the systematic bias was negligible  . However, the optimal cut-off values of 3D PISA EROA in primary TR group and secondary TR group were different. The primary TR group showed the cut-off value of 0.49cm2  with the AUC of 0.956   with the AUC of 0.968   showed that 3D PISA EROA was affected by several 2D echocardiographic indicators  to evaluate severe TR is higher than that only based on the clinical symptoms and combining clinical symptoms and positive echocardiographic results (120.1 vs 78.0 and 46.0).In Fig. The intra-observer ICC was 0.943 (95% CI: 0.919–0.987), and the inter-observer ICC was 0.843 (95% CI: 0.728–0.957). There was good intra-observer consistency as well as good inter-observer consistency for 3D PISA EROA.Our study demonstrates the following points for the first time: (1) 3D PISA EROA correlates well with 3D Rvol EROA in different etiological subgroups of TR; (2) the optimal cut-off values differ, being higher in primary TR; and (3) 3D PISA EROA has incremental diagnostic value over clinical symptoms and positive echocardiographic results for the integrated approach in grading TR severity.The low-speed characteristics and irregular regurgitant orifice of TR deviate from the hypothetical model of the PISA method, leading to a possibility of underestimation theoretically . And preAs expected, 3D PISA EROA can be affected by atrial fibrillation and TR jet location. In TR with atrial fibrillation and eccentric jet, 3D PISA EROA correlates weak with both 2D PISA EROA and 3D Rvol EROA.3D PISA EROA is measured on the frame of peak velocity during systole. However, the EROA is dynamically changing and the single-frame snapshot of it may not represent the regurgitation severity of the entire systole , 26. PrePrevious study showed that the correlation between 3D vena contracta area(VCA) and 2D PISA-EROA demonstrated significantly better agreement in patients with primary TR than secondary TR . de AgusAs 2D PISA EROA is relatively inaccurate in quantification of TR owing to its hemispheric assumption , 28–30, Our study finds that VCW, PISA radius, TR Vmax and hepatic vein systolic reversal are all factors that can affect 3D PISA EROA. 3D PISA EROA has an added diagnostic value for severe TR on the basis of clinical symptoms and positive 2D echocardiographic results. The 3D PISA EROA value of severe TR obtained in our study has high sensitivity and high specificity. In the sequential logistic regression analysis, combining clinical symptoms, positive 2D echocardiographic results and 3D PISA EROA has the highest chi-square value. As a result, the incremental diagnostic value of 3D PISA EROA may be considered in treatment selection for TR in the future.Our study didn’t engage cardiac magnetic resonance as the reference for volume measurement. Previous study showed that 3D echocardiography underestimated the volume of the RV . HoweverRVOT calculated was based on the diameter of RVOT from a single 2D view, which may be different from the actual shape of RVOT [The handling of papillary muscles in RV volume calculation may also cause over- or underestimation of the regurgitant volume. The SV of RVOT .3D PISA EROA is still a method based on Doppler technology, resulting in its angle dependency. The surface it displays may still not be a true surface of isovelocity, but a surface of iso-Doppler velocity .When the images obtained are not optimal, the utility of 3D transthoracic echocardiography is limited, especially affecting atrial fibrillation patients and eccentric TR patients. Cardiac magnetic resonance will be more ideal under these circumstances.3D PISA EROA is a reliable method in quantification of TR. The performance of 3D PISA EROA in primary TR and secondary TR differs and based on the difference, the diagnostic value of grading severe TR is high. These results may help in treatment selection for TR in the future.


More than one third of the neonatal deaths at Neonatal Intensive Care Unit (NICU) in Debre Tabor General Hospital (DTGH) are attributable to birth asphyxia. Most of these neonates are referred from the maternity ward in the hospital. Concerns have also been raised regarding delayed intrapartum decisions for emergency obstetrics action in the hospital. However, there has been no recent scientific evidence about the exact burden of birth asphyxia and its specific determinants among live births at maternity ward of DTGH. Moreover, the public health importance of delivery time and professional mix of labor attendants haven’t been addressed in the prior studies.Hospital based cross sectional study was conducted on a sample of 582 mother newborn dyads at maternity ward. Every other mother newborn dyad was included from December 2019 to March 2020. Pre-tested structured questionnaire and checklist were used for data collection. The collected data were processed and entered into Epidata version 4.2 and exported to Stata version 14. Binary logistic regressions were fitted and statistical significance was declared at p less than 0.05 with 95% CI.The prevalence of birth asphyxia was 28.35% . From the final model, fetal mal-presentation , premature rupture of fetal membranes , meconium stained amniotic fluid , vacuum delivery , night time delivery  and labor attendance by medical interns alone  were positively associated with birth asphyxia at 95% CI.The prevalence of birth asphyxia has remained a problem of public health importance in the study setting. Therefore, the existing efforts of emergency obstetric and newborn care should be strengthened to prevent birth asphyxia from the complications of fetal mal-presentation, premature rupture of fetal membranes, meconium stained amniotic fluid and vacuum delivery. Moreover, night time deliveries and professional mixes of labor and/delivery care providers should be given more due emphasis.Supplementary information accompanies this paper at 10.1186/s12884-020-03348-2. However, it was only about half of the mothers 254(51.3%) who had four and above antenatal care visits. About one tenth of the mothers 61(10.5%) ever used substance during their gestation of which ever alcohol users accounted for the most majority 48(78.7%). In the antenatal period, about one quarter, 135(23.2%) mothers were found to have obstetric complications. From these complications, preeclampsia/eclampsia accounted for the highest percentage 54 (40.0%)  had spontaneous labor onset. Majority of the mothers 48483.2%) had intrapartum rupture of fetal membranes whereas premature rupture of membrane was reported among 98 (16.8%) mothers. Following membrane rupture, meconium stained amniotic fluid was observed among 149 (25.6%) mothers and similar report was obtained to the presence of night time delivery 150 (25.8%). At labor, about one fifth of the fetuses 111 (19.1%) were malpresented  were females. The mean gestational age at birth was 38.5 (±2.4) weeks and more than half of the newborns 325(55.8%) were term. Moreover, the mean birth weight was 2687.3 (±1481.3) grams and about one quarter of the newborns 144(24.7%) had low birth weight. At birth, there were 105(18.0%) newborns with health problems. About two third 69 (65.7%) of these problems was constituted by neonatal sepsis followed by birth injury 57(54.3%). There were 88(15.1%) twin newborns. Among the second twins, there were 16 (36.4%) neonates not in a cephalic presentation, all of which were delivered by vaginal breech extraction    more likelihood of being asphyxiated at birth as compared to those of vertex presentations. Neonates born to mothers with premature rupture of fetal membranes were 6.3 times  more prone to be asphyxiated at birth when compared to those with intrapartum rupture of membranes. Similarly, neonates born to mothers having meconium stained amniotic fluid were 7.2 times  as likely to have birth asphyxia as compared to those born without being meconium stained. Regarding mode of delivery, neonates delivered by vacuum assisted vaginal route had 6.2 times  higher odds of association with birth asphyxia as compared to those born spontaneously. Furthermore, neonates delivered at night time had 6 times  higher odds of association with birth asphyxia as compared to those delivered during the day time. Birth asphyxia was 3.3 times  higher among neonates delivered by medical interns alone than those delivered by the attendance of midwives with IESO  is consistent with a study at Dilla Referral Hospital in Southern Ethiopia (32.8%) . HoweverIn the analysis of associated factors, neonates born with fetal mal-presentation were 4.5 times more likely of to be asphyxiated as compared to those with vertex presentations. This finding was congruent with other Ethiopian studies , 40 wherNeonates born to mothers with premature rupture of fetal membranes (PROM) were 6.3 times more prone to be asphyxiated at birth as compared to those with intrapartum rupture. A consistent finding was obtained from studies at Cameroon , Uganda Pertaining to mode of delivery, vacuum delivery had 6.2 times higher odds of association with birth asphyxia as compared to the spontaneous vaginal deliveries. This could be due to the fact that vacuum delivery may result in hemorrhagic cranial injuries such as cephalhematoma and subgaleal hemorrhage, which could in turn be accompanied with birth asphyxia from the hemorrhagic anemia .Additional file 2: Supplementary file 2. Questionnaire: A structured questionnaire used for interviewing selected mothers about their socio-demographic and antenatal characteristics, DTGH, North Central Ethiopia, 2020 [n = 582].Additional file 3: Supplementary file 3. Checklist: A structured checklist used for abstracting intra-partum and neonatal related characteristics from the delivery summary of maternal chart at DTGH, North Central Ethiopia, 2020 [n = 582].