During an epidemic, almost all healthcare facilities restrict the visiting of patients to prevent disease transmission. For hospices with terminally ill patients, the trade-off between compassion and infection control becomes a difficult decision. This study aimed to survey the changes in visiting policy for all 76 hospice wards in Taiwan during the COVID-19 pandemic in March 2020. The altered visiting policies were assessed by the number of visitors per patient allowed at one time, the daily number of visiting slots, the number of hours open daily, and requisites for hospice ward entry. The differences in visiting policies between hospice wards and ordinary wards were also investigated. Data were collected by reviewing the official website of each hospital and were supplemented by phone calls in cases where no information was posted on the website. One quarter (n = 20) of hospice wards had different visiting policies to those of ordinary wards in the same hospital. Only one hospice ward operated an open policy, and in contrast, nine (11.8%) stopped visits entirely. Among the 67 hospice wards that allowed visiting, at most, two visitors at one time per patient were allowed in 46 (68.6%), one visiting time daily was allowed in 32 (47.8%), one hour of visiting per day was allowed in 29 (43.3%), and checking of identity and travel history was carried out in 12 wards (17.9%). During the COVID-19 pandemic, nearly all hospice wards in Taiwan changed their visiting policies, but the degree of restriction varied. Further studies could measure the impacts of visiting policy changes on patients and healthcare professionals. Given its geographical proximity and close economic and cultural ties with China, Taiwan has faced an enormous epidemic threat and has been on high alert since the emergence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and the associated coronavirus disease COVID-19) in Wuhan, Hubei, China at the end of December 2019. Taiwanese authorities have taken wide-ranging early precautions to contain the outbreak. One of the many preventive efforts was an alteration of visiting policies at almost all levels of healthcare facilities, following guidance issued by the Taiwan Centers for Disease Control (Taiwan CDC) 9 in Wuha. TherefoThis environmental scan was performed for the period 16–25 March 2020. The first case of COVID-19 in Taiwan was announced on 21 January. As of 25 March, there were 235 confirmed cases. There were 81 hospice wards as of February 2020, according to the directory edited by the Taiwan Academy of Hospice Palliative Medicine (TAHAM). The website provided information on all 81 hospice wards, including the name of the hospital, the number of beds, and a link to a webpage for each hospital’s dynamic bed capacity status. We then searched the official website of each hospital to check the current visiting policy for the hospice. We found that almost all of the hospitals displayed a revised new visiting policy for ordinary or intensive care units on their websites. If the changes in visiting policy were not mentioned on the website, we then made a telephone call to the ward for such information. Telephone numbers were obtained through the official websites of the hospitals. We confirmed the altered visiting policy with the head nurse or medical director of each hospice ward. The altered visiting policies were assessed based on the number of visitors per patient allowed at one time, the daily number of visiting slots, the number of hours open daily, and requisites for hospice ward entry.A simple database (Microsoft Excel) was constructed to store the data on visiting policies at the included 76 hospice wards as well as ordinary wards at the same hospitals. The characteristics of the hospice wards were categorized according to the type of hospital (public or private) and the ward size . We also evaluated the differences between the visiting policies of hospice wards and ordinary wards. We classified the restriction on the number of visitors per patient at one time into three categories  and the daily number of visiting slots into three groups . The total hours open per day was calculated by adding up the duration of each visiting slot and stratifying the total into six categories . The requisites for entry to the ward were typically applied for all visitors at the main entrance of the hospital, including checking recent travel, occupation, contact and cluster information (TOCC history), monitoring body temperature by infrared thermal devices, and using hand sanitizer for hand hygiene. We confirmed whether any identity documents, such as identification cards (ID cards), National Health Insurance cards (NHI cards), or Taiwan resident certificates, were required to additionally check identity or travel history before visiting the hospice.Based on prior studies, we defined the visiting policy as one of three types according to the degree of restriction: an open policy sets no restrictions at all, a structured visiting policy imposes a flexible approach, and a restricted policy means that patients on the ward are not allowed visitors ,7.Descriptive statistics were calculated. Because our study included all hospice wards, we did not use inferential statistics for sampling. Only counts and percentages are displayed.Of 81 hospice wards in Taiwan, five hospice wards were excluded from our study due to being shared by two hospitals, the ward being temporarily shut down for infection control, being an unopened ward, or being a ward without current inpatients.Of the 76 wards under analysis, 35 wards (46.1%) were in public hospitals and 41 wards (53.9%) were in private hospitals. Ward size was defined by the number of beds. Of the included wards, 17 wards (22.3%) contained less than 7 beds, 24 wards (31.6%) had 7–10 beds, and 35 wards (46.1%) had more than 10 beds.During the COVID-19 pandemic, nearly all hospice wards (98.6%) in Taiwan changed their visiting policies to varying degrees. Only one hospice ward maintained an unchanged visiting policy and was open at all hours. The majority (86.8%) of hospice wards used a structured visiting policy. Visiting was completely stopped in nine hospice wards (11.8%) .The details of altered visiting policies at 67 hospice wards that allowed visitors, according to the type of hospital and ward size, are presented in The number of daily visiting slots allowed was predominantly one  or two  per day. Only seven wards (10.4%) set no limit on the number of daily visiting slots. For hospice wards in private hospitals or small wards, two visiting slots was the most common policy . However, hospice wards in public hospitals or large wards tended to have only one daily visiting slot.Visiting policies that allowed one hour of total daily visiting time were the most common . However, hospice wards in private hospitals most commonly allowed two hours of visiting daily .To gain entry to hospice wards, identification documents  were required to be presented at 12 wards (17.9%) to check visitor identity and assess travel history.Out of the 76 hospice wards analyzed in this study, 26.3% (n = 20) applied a different visiting policy to the ordinary wards of the same hospital during the COVID-19 pandemic. The differences between these two types of wards could be categorized into four types. Fifteen hospitals (75%) allowed visiting at the hospice ward but stopped visiting in ordinary wards. Only one hospital (5%) stopped patient visits in the hospice ward but permitted visiting in ordinary wards. Visiting of patients was allowed at both types of wards in the remaining four hospitals, of which three (15%) differed between the hospice and ordinary wards in the allowed numbers of visitors at one time and one (5%) differed in the total number of hours open per day .This study provides a comprehensive picture of the visiting policies of hospice wards in Taiwan during the COVID-19 pandemic. We showed that nearly all hospice wards implemented changes to their normal liberal visiting policies in response to the threat presented by the COVID-19 pandemic. As of March 2020, most of the hospice wards had imposed a structured visiting policy to strike a balance between compassion and infection control. Although approximately 10% of hospice wards used a restricted policy as the underlying principle of inpatient visiting, flexibility was offered in these wards in situations such as when a patient was in an unstable condition or dying, or when there was a need to conduct a family meeting. Among hospice wards that allowed visiting, most allowed a maximum of two visitors per patient at one time and one or two visiting slots per day. In general, hospice wards in private hospitals or small wards tended to have more liberal visiting policies with less restriction on the number of visitors per patient at one time, the daily number of visiting slots, and the total daily open hours. Identity documents are currently required for visiting hospice patients, to allow identity checks or travel history assessments.Visiting the patient is one of the most frequently identified needs of relatives caring for a loved one. Several studies have pointed out a significant correlation between the level of satisfaction with social support from relatives of a patient with a life-limiting disease and the degree of meaningfulness of the patient’s life ,10,11,12The epidemiologic characteristics of COVID-19 are not yet fully understood. Current evidence shows some similarities between severe acute respiratory syndrome (SARS) and COVID-19, including person-to-person transmission through the respiratory droplet, contact, and probably fomite routes ,19. BaseIn response to the threat of COVID-19, Taiwanese health authorities integrated each citizen’s travel history into the National Health Insurance Administration (NHIA) database from 13 January 2020. This feature allows personnel in healthcare systems to access users’ travel history records for the past 14 days by entering their National ID or inserting their NHI smart card into the system . BecauseThere are several limitations to this study. First, visiting policies might change at any time with the progression of an infectious disease. We could only take a snapshot of visiting policies at hospice wards at a particular time (March 2020). Therefore, the results in this study may not correlate with those of another similar study at a different time. Second, in consideration of the characteristics of hospice patients and their families, there is more flexibility and adaptability within restricted visiting policies. Thus, we might be overestimating the number of restricted visiting policies and underestimating the number of structured visiting policies in practice. Third, we only used the publicly available information of hospice wards on the website of TAHAM to evaluate the associations between features of the altered visiting policy and characteristics of the hospice wards . However, other variables such as the geographical area and how long the ward had been in operation might independently be associated with the degree of policy restriction. Finally, we only gave an overview of current visiting policies and did not explore the perceptions of patients, visitors, and staff members towards changes to visiting policies, which would be of value to provide a more comprehensive understanding of the impact of visiting policy changes on patients, visitors, and the multidisciplinary team. Further investigations are thus required to benefit the patients, visitors, and healthcare providers.Nearly all hospice wards in Taiwan altered their visiting policies during the COVID-19 pandemic, but the degree of restriction varied. It is challenging to modify a visiting policy to strike a balance between concerns of patients and families on the one hand and the healthcare staff on the other. The impacts of current visiting policy changes on all members of the healthcare team, as well as patients and their families, should be further investigated in the future to evaluate the effectiveness of varying policies.


Most abdominal cysts derive from the ovary. The range of differential diagnoses is wide. Unfortunately, imaging studies not always determine its origin.The authors present the case of a 20-year-old female patient, admitted to the emergency department due to abdominal pain and distension, whose imaging studies revealed a gigantic abdominal cyst of unknown origin. She underwent an exploratory laparotomy that disclosed an ovarian cyst that was removed by a left adnexectomy. It weighed 10Kg and was 60 cm wide. The pathology report showed a mucinous cyst adenoma.Once a patient present with an abdominal cyst, one should always consider the extensive list of differential diagnoses. In premenopausal women, ovarian cysts are very frequent. Cysts may grow to considerable size. Our patient was symptomatic, malnourished and dehydrated. Neither ultrasonography nor computed tomography were able to define the origin of the cyst. Persistent ovarian cysts larger than 10 cm, particularly if symptomatic, should be considered for surgery.Progressive abdominal distension in premenopausal women should raise suspicion of an ovarian tumor, such as mucinous cystadenoma. These tumours are benign, but when their size is considerable, complications do arise and their surgical removal may be life threatening. The list of differential diagnoses is extensive and includes peritoneal cyst, para-ovarian cyst, appendiceal mucocele, cystic adenomyosis, liver, pancreatic or choledochal cyst, lymphocele, cystic lymphangioma, duplication intestinal cyst, bladder diverticulum, to name just a few.Ovarian cysts may become symptomatic as their size increases, presenting with abdominal, pelvic or lumbar discomfort or pain, progressive abdominal distension, nausea or vomiting.Unfortunately, imaging studies such as ultrasound (US), computed tomography (CT) and magnetic resonance (MRI), not always determine the origin of the cyst, thus limiting its diagnostic usefulness .Indications for surgery include a symptomatic or rapid growing cyst, and when its malignant potential cannot be excluded.This work is reported in line with the SCARE 2018 criteria [2A 20-year-old female patient was admitted to our emergency department (ED) due to abdominal pain and distension, nausea, vomiting and constipation. Her mother died young with breast cancer.Her skin and mucosae were pale and dehydrated. Breath sounds were diminished at the pulmonary bases. Her abdomen was significantly distended, with stretch marks and oedema of its wall, was depressible by palpation with diffuse tenderness, without guarding. Bowel sounds were diminished and percussion produced a dull note. Her limbs were thin. Blood tests were normal.She had an abdominal and pelvic US that revealed a large abdominal cyst of unknown origin, followed by an X-ray and CT , Fig. 5 Tumour biomarkers alpha fetoprotein (AFP), carcinoembryonic antigen (CEA), cancer antigen 19.9 (CA19.9), cancer antigen 125 (CA 125) and human epididymal protein 4 (HE4) were normal. The risk of malignancy algorithm (ROMA) value was 4.1 %. Echinococcus granulosus serology test was negative.Hence, she underwent an exploratory laparotomy , and it She had an uneventful recovery and was discharged home on the 5th post-operative day.The pathology report revealed an ovarian mucinous cystadenoma. The cyst had a thin wall , internaShe remains clinically asymptomatic.3Once a patient present with an abdominal cyst, one should always consider the extensive list of differential diagnoses.In premenopausal women, ovarian cysts are very frequent, and most are benign and functional. Cysts may grow to considerable size. Some cysts may be symptomatic, presenting with discomfort in the lower abdomen or severe pain from complications: torsion, rupture or haemorrhage ,4. SeverUS is the primary imaging study for an ovarian cyst . A normaTransabdominal US is better than endo-vaginal US for assessing large cysts and their complications. It also allows assessment of other intra-abdominal structures. In our patient, it became utterly impossible to describe other structures besides her cyst.Needle aspiration for cytology provides inaccurate results and owing to its associated complications , it is not recommended. Its use has largely been supplanted by US .Removing the cyst intact for histology is the gold standard and may require an oophorectomy . It shouCA125 is a protein expressed on the cell membrane of normal ovarian tissue and ovarian carcinomas. Its value, despite its low sensitivity and specificity, is raised in 85 % of patients with epithelial ovarian carcinomas . HE4 is CT is more sensitive yet less specific than US in detecting ovarian cysts . It alloStill, neither US nor CT were able to define the origin of the cyst in our patient. MRI could have been a good option since it has better soft tissue contrast than do CT.Persistent simple ovarian cysts larger than 10 cm, particularly if symptomatic, and complex ovarian cysts should be considered for surgery.To the best of our knowledge, this is one of the largest ovarian cysts being reported in such a young age, accounting for, approximately, one-fifth of the weight of the patient.4Progressive abdominal distension in premenopausal women should raise suspicion of an ovarian tumour, such as mucinous cystadenoma. These tumours are benign, but when their size is considerable, complications do arise and their surgical removal may be life threatening.Nothing to declare.No funding.Clinical case exempt from ethical approval in our institution.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.Cláudia Leite - data collection, data analysis and interpretation, writing the paper.Bruno Barbosa - data collection, writing the paper.Natália Santos - data collection, data analysis and interpretation.Ana Oliveira - operated the patient, data analysis and interpretation, writing the paper, manuscript review.Carlos Casimiro - manuscript review.Clinical case report, not formal research project.Cláudia Leite and Ana Oliveira.Not commissioned, externally peer reviewed.


Objective: To identify postnatal risk factors for bronchopulmonary dysplasia (BPD) development in preterm infants with gestational age ≤32 weeks.Methods: Seventy-two preterm infants(30 with BPD and 42 non-BPD controls) admitted in the neonatal intensive care unit (NICU) of the Children's Hospital of Soochow University during 2017 were enrolled in this prospective longitudinal study. Perinatal clinical data, a neonatal critical illness score (NCIS), different soluble B7-H3(sB7-H3), and interleukin-18 (IL-18) levels by days after birth were collected. An early predictive model for BPD development was established based on clinical data using multiple logistic regression analysis. And the sensitivity and specificity of the model were assesed by ROC curve.Results: Electrolyte disturbances, hemodynamically significant patent ductus arteriosus (hs-PDA), and the age that infants achieved 120 kcal/kg.d via enteral feeding ≥40 days after birth were found to be associated with the BPD pathogenesis. Serum sB7-H3, IL-18, and NCIS were significantly higher in the BPD group compared to the non-BPD group (p < 0.05). BPD group had significantly lower enteral fluid and caloric intake compared to the non-BPD group at 1, 7, 14, and 28 days after birth. The risk factors were analyzed by multiple logistic regression and a predictive model of a combination of sB7-H3 (day 7), IL-18 (day 14), NCIS, and clinical risk factors was evaluated via ROC curve with an area under the curve (AUC) of 0.960 having sensitivity of 86.7% and a specificity of 97.6%, respectively.Conclusion: The causes of BPD are multifactorial postnatal risk factors. And the combination of sB7-H3 (day 7), IL-18 (day 14), NCIS, and clinical risk factors  might be served as an optimal predictive model for the occurrence of BPD. Bronchopulmonary dysplasia (BPD) is a chronic lung disease mainly affecting preterm infants who require respiratory support at birth. Despite the advanced perinatal and neonatal care, the morbidity, and mortality of BPD remains stable , 2. The in vitro. The induction of TLR2 signaling in fetal lung fibroblasts may contribute to the pro-inflammatory state in the preterm neonate on supplemental oxygen , different soluble B7-H3(sB7-H3), and interleukin-18 (IL-18) levels by days after birth were collected to identify postnatal risk factors that predict the occurrence of BPD in preterm infants within a gestational age ≤32 weeks.Infants admitted to the neonatal intensive care unit (NICU) of the Children's Hospital of Soochow University from January 01, 2017, to December 31, 2017 were enrolled in this study. The inclusion criteria were infants with gestational age ≤32 weeks and hospital stays ≥28 days. The exclusion criteria included the age more than 24 h upon admission to the NICU, infection at admission, congenital abnormalities or inborn errors, surgery intervention requirement during the hospital stay, and/or incomplete clinical data.This study was approved by the ethics committee of Children's Hospital of Soochow University. Informed consent was obtained from all the parents of the included infants Under their permission.Enteral feeding, minimal feeding, and even non-nutritive sucking should begin as soon as possible within postnatal 24 h. Positive and individualized principles should be addressed either in enteral or parenteral nutrition administration.As donated breast milk was unavailable in our unit, mothers were encouraged to feed their babies with expressed breast milk (EBM). If the EBM was unavailable, infants were fed with formula.If feeding intolerance occurs, minimal feeding, and/or non-nutritive sucking would be conducted instead of suspending feeding. Once the related symptoms were improved, the feeding would be continued. The choices of formula types, such as hydrolyzed protein formula, low lactose formula, or lactose addition formula, were based upon patients' clinical conditions. The total caloric requirement would be supplemented through parenteral nutrition.The speed of feeding advancement was 20–25 ml/kg.d.When the amount of breastfeeding reached 50–80 ml/(kg.d), breast milk fortifier would fortify by 1/2. If the infant was intolerant, the proportion or even fortify by 1/3–1/4, and then gradually increased the dose according to the clinical situation.in vitro fertilization, multiple birth, small for gestational age, Apgar Score ≤7 (1 or 5min), prealbumin ≤80 mg/L, and albumin ≤30 g/L; (2) maternal conditions, including age, pregnancy induced hypertension, gestational diabetes, abortion ≤2 times, oligohydramnios, placental abruption, placenta previa, and antenatal corticosteroids use; (3) birth injuries, conditions, and comorbidities present in the infant, including NRDS, ventilator associated pneumonia (VAP), pneumothorax, CNS, periventricular/intraventricular hemorrhage (PVH/IVH), PVL, parenteral nutrition associated cholestasis (PNAC), liver damage, hemodynamically significant PDA(hs-PDA), neutropenia, anemia, retinopathy of prematurity (ROP), neonatal hypoglycemia, and electrolyte disturbances; (4) treatment modalities applied during hospitalization of the preterm infant, including invasive ventilation, duration of invasive ventilation, ventilator mode , days of oxygen inhalation, time of blood transfusion, the age when enteral feeding was initiated, the age when goal energy intake  was reached by enteral feeding, and rate of weight gain; (5) feeding of the preterm infant, including oral fluid intake, intravenous fluid intake, enteral caloric intake, intravenous caloric intake, and weight gain (percentage of birth weight) on 3, 7, 14, and 28 days after birth; and (6) the neonatal critical illness score (NCIS) on the admission day of the preterm infant.The following data were collected from hospital records: (1) general condition of the infant, including infant gender, gestational age  at birth, birth weight, mode of delivery, age at admission, We firstly define the important clinical indicators for the sake of understanding.Diagnosis of BPD and Clinical Grading 2 >0.21) for at least 28 days; (ii) persistent or progressive respiratory insufficiency; (iii) lungs with typical X-ray or CT scan findings ; (iv) exclusion of congenital cardiopathy, pneumothorax, pleural effusion, and sputum. The clinical grading was based on the supplemental O2 of the infants at 36 weeks postmenstrual age or discharge (GA <32 weeks) and at 56 days postnatal age or discharge (GA ≥32 weeks). The clinical grading was classified as follows: mild: breathing room air; moderate: a fraction of inspired oxygen (FiO2) <0.3; severe: FiO2 ≥0.3 and/or positive pressure ventilation or mechanical ventilation.The diagnostic criteria of BPD adopted in our study was based on the standard of the National Institute of Child Health and Human Development (NICHD) published in 2001, which defines BPD as follows: (i) preterm low birthweight infants treated with oxygen , which can not be explained by other causes via chest x ray and lab findings.NRDS was defined as the presensce of respiratory distress and increased oxygen requirement , hypernatremia (serum sodium >150 mmol/L), hypokalemia (serum potassium <3.5 mmol/L), hyperkalemia (serum potassium >5.5 mmol/L), hypocalcemia , hypercalcemia , hypochloremia (serum chloride <95 mmol/L), and hyperchloremia (serum chloride >105 mmol/L).Diagnosis of NCIS 2 (PaO2), pH, respiration, blood sodium, blood potassium, blood urea nitrogen, creatinine (Cr) levels, hematocrit, and gastrointestinal bleeding/bloating. NCIS Scores >90 are non-critical, 70–90 are critical, and <70 are extremely critical. NCIS is important for determining prognosis and guiding newborns' treatment and prognosis.NCIS was defined by Chinese Medical Association Emergency Branch Pediatrics Group, Chinese Medical Association Pediatric Branch Emergency Department, Neonatal Group. It includes heart rate (HR), systolic blood pressure (SBP), arterial partial pressures of ODiagnosis of hs-PDA Echocardiographic evidence of a hs-PDA met one of the following criteria: ductal diameter≥1.5 mm, unrestrictive pulsatile ductal flow (ductus arteriosus peak velocity <2.0 m/s), left heart volume loading , left heart pressure loading .The puncture of the peripheral vein was performed on days 1, 7, 14, and 28 after admission and 1–1.5 ml of peripheral venous blood was collected. The blood was centrifuged at 4°C and 3,000 rpm for 5 min. The supernatant was removed and stored in 2–3 separate Eppendorf tubes in −80°C until use. All blood samples were either processed immediately after collection or stored in 4°C and processed within 6 h. The levels of sB7-H3 and IL-18 in the serum was quantified with corresponding ELISA kits  following the manufacturer's instructions.2-test or Fisher's exact test while normal distributed variables were expressed as mean ± sdandard diviation(m ± sd) and processed by independent t-test or one-way analysis of variance (ANOVA), variables did not comply with normal distribution were expressed as median  and non-parametric test such as MU and KW were adopted for statistical analysis. Significant factors were picked out by p < 0.05 and recruited in logistic regression to determine the risk factors of patients having BPD. A receiver operating characteristic curve (ROC) was drawn to evaluate the predictive power of the risk factors by obtaining the area under the curve (AUC). Youden's J statistic (Youden's index = sensitivity + specificity – 1) was used to calculate the cut-off points. A p < 0.05 was considered As statistical significant. All statistical analyses were carried out using SPSS 17.0 software.Categorical variables were expressed as percentage and processed with either χFrom January 2017 to December 2017, 91 infants were involved in by total and 3 were excluded due to short hospital stay while 2 were out owing to surgery during hospitalization. Among the remaining 86 infants, 30 were diagnosed with BPD. Another 56 infants were non-BPD patients, among which, 14 were excluded attributed to incomplete clinical data collection and non-standard blood samples. Eventually, 42 infants were classified as non-BPD group . The gen2 >0.4, and blood transfusion≥ 3 times were significantly more common in the BPD group (p < 0.05) (The cut-offs of “days of FiO2 >0.4” and “blood transfusion ≥3 times” were decided based on the data). Compared with non-BPD group, the BPD group was more later on enteral feeding and with a higher rate of the age that infants achieved 120 kcal/kg.d via enteral feeding ≥40 days after birth , PNAC, hs-PDA, electrolyte disturbance, invasive ventilation, days with FiOElectrolyte disturbances , hs-PDA and the age that infants achieved 120 kcal/kg.d via enteral feeding ≥40 days after birth  were identified as the risk factors of BPD devement by the stepwise multiple logistic regression .p < 0.05). On day 14, their intravenous fluid intake, and, on day 28, both intravenous fluid and caloric intake were higher than those of the non-BPD group (p < 0.05). The difference of weight gain between the BPD group and the non-BPD group was insignificant .The NCIS score was significantly lower in the BPD group (100.62 ± 7.81) compared to the non-BPD group (88.20 ± 12.99). The NCIS score of preterm infants with mild, moderate, and severe BPD was 101.33 ± 11.55, 88.36 ± 11.34, and 79.60 ± 16.09, respectively. No significant difference was found among the three different severity groups , IL-18 (14d), NCIS, electrolyte disturbance, hs-PDA, and the age that infants achieved 120 kcal/kg.d via enteral feeding ≥40 days after birth (and the non-BPD group as a reference), revealed that all these factors can be potential predictors of BPD . The areP =(3.109 + 0.179X1 – 0.001X2 – 0.122X3 + 1.232X4 + 3.805X5 + 3.177X6). X1, X2, X3, X4, X5, and X6 represent sB7-H3 (7d), IL-18 (14d), NCIS, electrolyte disturbance, hs-PDA, and the age that infants achieved 120 kcal/kg.d via enteral feeding ≥40 days after birth, respectively. P is the predicted probability of logistic regression. The χ2-value of the logistic regression prediction model was 60.330 (p < 0.001), suggesting that the above 6 variables could significantly explain the development of BPD. Hosmer-Lemeshow was calculated by the classification interaction table  indicating that the BPD prediction model fits the observed data well. Using the predictor variables as the test variables, the results showed that the combination of the above six variables with the logistic regression model gives an AUC value of 0.960 in the ROC curve. The sensitivity was 86.70%, and the specificity was 97.60%. The prediction model gave a higher AUC, sensitivity, and specificity than any of the six individual variables alone (sB7-H3 (day 7), IL-18 (day 14), NCIS, electrolyte disturbance, hs-PDA, and the age that infants achieved 120 kcal/kg.d via enteral feeding ≥40 days after birth were brought into the stepwise multiple logistic regression analysis to yeild a predictive model for BPD development. The regression equation was es alone , Table 7BPD is a multifactorial induced disease affected by antenatal, postnatal as well as genetical factors. Known risk factors include maternal smoking, preeclampsia, intrauterine growth restriction, chorioamnionitis, perinatal hypoxia, mechanical ventilation, oxygen supplementation after birth, perinatal and postnatal infections, and the presence of cardiovascular comorbidities  , 24. AndThe present study collected extensive clinical data from 30 preterm infants with BPD and 42 matching controls. The data collection included the general charactiristics of the infants, maternal conditions, birth injuries, conditions and comorbidities present in the infant, treatment modalities applied during hospitalization of the preterm infant, feeding of the preterm infant, and NCIS on the admission day of the preterm infant. The results revealed that the presence of hs-PDA, electrolyte disturbances, and the age that infants achieved 120 kcal/kg.d via enteral feeding ≥40 days after birth was independent risk factors for the development of BPD.The finding that PDA is a risk factor for BPD is consistent with existing literature . PDA is 2 >0.4, and the percentage of patients diagnosed with VAP were significantly higher in the BPD group compared to the non-BPD group. This is consistent with what is reported in the literature (The present study found that the use of invasive ventilation, the number of days with FiOterature . Mechaniterature , 30. A hterature .In the logistic regression analysis, the incidence of hs-PDA was one of the risk factors for BPD. In animal models of BPD using preterm baboons, pharmacologic closure of PDA using ibuprofen is associated with improved alveolar development . While eAn electrolyte disturbance is also identified as an independent risk factor for the development of BPD. Electrolytes are of crucial importance in maintaining intracellular and extracellular fluid balance and the normal function of cells. As the present study is observational, it is impossible to say if electrolyte imbalance actually causes BPD. Nevertheless, the present results indicate the importance of close monitoring and correction of serum electrolyte levels in preterm infants.Nutrition is critical for lung development. A previous study suggests that high daily fluid intake and less weight loss during the first 10 days of life increase the risk of BPD in extremely low birth weight infants . The patBrain injury in preterm infants mainly includes intracranial hemorrhage and cerebral white matter injury, with PVH/IVH and PVL being the most prevalent . Both miB7-H3 is a new member of the B7 superfamily and has been shown to play a key role in the regulation of T cell-mediated immune responses and also innate immunity by augmentation of lipopolysaccharides and bacterial lipoprotein-induced NF-kappaB activation and proinflammatory cascade via TLR 2 and 4 , 41. sB7IL-18 is a member of the IL-1 cytokine family and an important proinflammatory mediator with special importance in pulmonary infection and inflammation. IL-18 has been proposed to be a novel biomarker of ARDS in humans, and its plasma level has been shown to be correlated to ARDS severity and mortality . In muriNCIS is a scoring system for critically ill neonates proposed by the Group of Neonatology of the Chinese Pediatric Society, which is a part of the Chinese Medical Association in 2001. The scoring system is predominately applied clinically in mainland China . The preBPD is known to be a multifactorial disease that is affected by a complex combination of prenatal, antenatal, and postnatal risk factors, as well as genetics . TherefoThe present study is limited by the relatively small cases from a single-center. Although the proposed multifactorial model could predict the development of BPD with relatively high sensitivity and specificity, it could not predict the severity of the disease. Multicenter studies with a large sample size are therefore necessary to produce improved prediction models that can predict and prevent the development of BPD in preterm infants.The datasets generated for this study are available on request to the corresponding author.The studies involving human participants were reviewed and approved by Children's Hospital of Soochow University medical ethics committee. Written informed consent to participate in this study was provided by the participants' legal guardian/next of kin.LD had primary responsibility for protocol development, patient screening, enrollment, outcome assessment, preliminary data analysis, and writing the manuscript. HW participated in the development of the protocol and analytical framework for the study and contributed to the writing of the manuscript. HG, NC, and FH contributed in the same ways as HW and were responsible for patient screening. XuZ and XiZ supervised the design and execution of the study, performed the final data analyses, and contributed to the writing of the manuscript. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


The nasolabial cyst is a rare, non-odontogenic, soft tissue cyst that develops submucosally in the anterior nasal floor. This cyst accounts for 0.7% of all non-odontogenic cysts. Bilateral nasolabial cyst represents only 10% of the cases. This cyst originates from the remnants of embryonic nasolacrimal duct tissue. Generally, patients present with swelling and facial deformity and rarely local pain. The definite diagnosis should be based on clinical, radiological and above all histopathologic findings. The treatment is enucleation of the cystic tissue. Following is a case report of a bilateral nasolabial cyst in a 40-year-old woman who presented with a chronic nasal obstruction. The nasolabial cyst is also known nasoalveolar cyst, fissural cyst, nasal vestibular cyst and nasal wing cyst. It was first described by Zuckerkandl in 1882 [A 40–year-old woman presented to our department with a chief complaint of bilateral nasal obstruction and rhinorrhea. Neither epistaxis nor pain was noted. The patient had stated her symptoms had been present for over a year. Past medical history was notable for breast cancer treated with surgery and radio chemotherapy under remission.Extra-oral inspection revealed facial asymmetry, with elevation of the right alar base. There was mild tenderness on palpation.Anterior rhinoscopy identified a bilateral submucosal smooth fluctuant mass obstructing the nostrils. The right-sided mass measured 2 × 2 cm and the left-sided mass measured 1.5 × 1 cm.Intra-oral examination revealed bulging of the upper gingivolabial sulcus consistent with the extra-oral findings.Computed tomography without injection showed bilateral mass on the inferior nasal alar region, measuring 2.1 × 2.2 × 1.9 cm on the right side and 1.7 × 1.5 × 1.2 cm on the left side. The masses were rounded, well defined and exhibiting soft tissue density. There was mass effect upon the maxilla causing scalloping on the right side .On the basis of the clinical and radiographic characteristics, diagnosis of bilateral nasolabial cyst was established.The patient was subjected to enucleation of the bilateral cysts under general anesthesia . A full-Histopathological examination of the specimens showed respiratory (ciliated pseudostratified columnar epithelium) with goblet cells compatible with nasolabial cysts.No sign of recurrence was observed 8 months after surgery .Maxillary cysts are divided into two major groups: odontogenic cysts and non-odontogenic cysts. The first group is characterized by specific odontogenic markers, histological similarities with odontogenic structures and anatomical considerations .Nasolabial cyst is a soft tissue cyst that is often located submucosally in the anterior nasal floor . These cThe etiology of nasolabial cysts is still debated. The cyst was initially thought to originate from the retention cysts arising from inflamed mucous glands. The current prevailing theory is that the cysts are the remnants of embryonic nasolacrimal duct tissue .This hypothesis is reinforced by the fact that nasolacrimal ducts are lined with pseudostratified columnar epithelium, the same epithelium frequently found in nasolabial cysts .Most cases occur between the fourth and fifth decades of life. Male-to-female ratio is 1:3.6 . NasolabThe diagnosis of nasolabial cyst is essentially clinical. The difficulty in diagnosing this lesion is their rarity. It may be asymptomatic, however, it usually manifests as swelling in the gingivolabial sulcus leading to facial asymmetry. Pain is an uncommon sign denoting an infected cyst. Our patient experienced chronic nasal obstruction. Few cases of nasolabial cysts presenting in this manner have been reported in the literature . BimanuaThe differential diagnosis is made with odontogenic lesions such as follicular, periodontal and residual cysts, canine space abscess and salivary gland neoplasms. Dermoid and epidermoid cysts should also be considered in the differential .et al., 170 (54.7%) patients were diagnosed with CT scan. It typically reveals a homogeneous, cystic lesion anterior to the piriform aperture [Radiographic films, computed tomography (CT) and magnetic resonance imaging (MRI) have been used to aid in the diagnosis of nasolabial cysts . Radiogral., 170 4.7% patiOn histopathological examination, The cyst consists of respiratory epithelium, stratified ciliated cylindrical epithelium with goblet cells or pseudostratified ciliated cylindrical . SquamouTreatment for nasolabial cysts is generally the removal of cyst trough an intra-oral sublabial excision under local or general anesthesia . Other tAn endoscopic transnasal approach have been recently described . In thisOtolaryngologist should consider the diagnosis of nasolabial cysts in the presence of chronic nasal obstruction. This will prevent delay in diagnosis and ensure proper treatment of the disease.None declared.The authors declared that this study has received no financial support.Written informed consent for publication of their clinical details and/or clinical images was obtained from the patient’s parent. Ethical approval has been exempted by our institution.


Botrytis cinerea is largely unknown, and few studies have been performed on their effect on the JA-mediated defense mechanism against B. cinerea. This study explored the effect of FaWRKY25 on the JA-mediated strawberry resistance against B. cinerea. Results showed that the JA content decreased significantly as the fruits matured, whereas the FaWRKY25 expression rose substantially, which led to heightened susceptibility to B. cinerea and in strawberries. External JA treatment significantly increased the JA content in strawberries and reduced the FaWRKY25 expression, thereby enhancing the fruits’ resistance against B. cinerea. FaWRKY25 overexpression significantly lowered the fruits’ resistance against B. cinerea, whereas FaWRKY25 silencing significantly increased resistance. Moreover, FaWRKY25 overexpression significantly lowered the JA content, whereas FaWRKY25 silencing significantly increased it. FaWRKY25 expression level substantially affects the expression levels of genes related to JA biosynthesis and metabolism, other members of the WRKY family, and defense genes. Accordingly, FaWRKY25 plays a crucial role in regulating strawberries’ resistance against B. cinerea and may negatively regulate their JA-mediated resistance mechanism against B. cinerea.WRKY genes and jasmonic acid (JA) play a crucial role in plants’ responses against biotic and abiotic stress. However, the regulating mechanism of WRKY genes on strawberry fruits’ resistance against  Fragaria × ananassa “Benihoppe”) is an important horticultural crop worldwide, being rich in vitamins and antioxidants and having excellent commercial value and health benefits [Botrytis cinerea is an extremely destructive pathogen to strawberries; it causes B. cinerea on strawberries before and/or after harvest. B. cinerea has been regarded as the second largest fungal pathogen of strawberries due to its severe damage to the strawberry fruits [B. cinerea under a humid environment without fungicides [B. cinerea are lacking [Strawberry , jasmonic acid (JA), and ethylene (ET), which regulate the defensive response to efficiently face the different pathogens . JA/ET sbidopsis ,13. The bidopsis ,15. Crosbidopsis , while rTranscription factors (TFs) are considered key regulators of gene expression, playing important roles within this complex defense molecular network and leading to plant immunity ,17. To dB. cinerea and are critical for hormone-regulated disease resistance and defense signaling networks [Arabidopsis thaliana react to the infection of pathogens [AtWRKY70 expression in A. thaliana strengthens the plant’s resistance against B. cinerea and is a negative regulator of jasmonic acid (JA)-inducible genes [AtWRKY18, AtWRKY40, and AtWRKY60 positively coregulate the plant’s resistance reaction against B. cinerea [AtWRKY33 controls the balance of multiple hormones and phytoprotection to regulate plants’ defense reaction against the pathogen [A. thaliana, AtWRKY50 and AtWRKY51 are positive regulators of salicylic acid-mediated signals and negative regulators of JA-mediated signals [A. thaliana, AtWRKY3 and AtWRKY4, which have similar structures, have been regarded as positive regulators of the plant’s resistance against necrotic pathogens such as B. cinerea; AtWRKY4 also negatively regulates plants’ resistance against biotrophic pathogens such as Pseudomonas syringae [B. cinerea in individual, collaborative, or complex forms. Although numerous studies have been conducted on members of the WRKY family in various crops, few have examined their functions in and regulations of the defense mechanism of strawberries, particularly that of the fruits.WRKYs are the largest transcription regulator family in land plants. They can regulate the growth and development of plants as well as their response to biotic and abiotic stress . WRKY genetworks ,23,24. Fathogens  and posiathogens . The uprle genes . The gen cinerea . AtWRKY3pathogen . WRKY TF signals . In the syringae . AccordiFaWRKY1 was the first strawberry WRKY identified as a mediator of defense response against Colletotrichum acutatum in cultivated strawberry [FaWRKY1 encodes an AtWRKY75-like transcription factor type IIc, which is upregulated after Colletotrichum infection and responds to defense-related hormones such as SA, JA, ABA, and wounding, with its expression being dependent on strawberry cultivar and tissue [FvWRKY42 is a positive regulator of the resistance of wild strawberries against powdery mildew [B. cinerea. Furthermore, a few studies have examined the functions of a single gene in the disease resistance of strawberries, and the gene functions have been verified through heterogeneous verification—the gene function verification method employed in A. thaliana. However, species differences may cause the regulatory function of a gene in pathogen biology to vary according to the plant species or tissues. Therefore, the aforementioned verification method cannot effectively identify the specific effects of genes in strawberries.Currently, 59 WRKY genes at different fruit growth stages of forest strawberries and 62 WRKY genes responding to biotic and abiotic stress have been identified ,32; morerawberry ,35. FaWRd tissue . A receny mildew . These rA. thaliana and poplars. It is related to plants’ resistance against fungal pathogens and plays a critical role in their defense against them [WRKY25 is a class I WRKY protein and features a highly conserved WRKY domain . WRKY25 nst them ,41,42,43FaWRKY25 in strawberries’ resistance against B. cinerea and to clarify the functional mechanism of this gene and its interaction with JA during different fruit development stages, we investigated the transient overexpression and silencing of FaWRKY25 in strawberries by using improved transient gene transformation technology. The modes of expression in the potential disease-resistant genes regulated by FaWRKY25 and effects of external JA treatment to FaWRKY25 expression were also analyzed.In order to further clarify the biological functions of Fragaria × ananassa Duch.), was employed. The experiment was conducted in an elevated strawberry planting base in a glass greenhouse in the agricultural expo park of Jiangsu Vocational College of Agriculture and Forestry from November 2018 to March 2020. No pesticides were used during the experiment. The experiment was performed at the daytime/nighttime greenhouse temperature of 20–23 °C/10–15 °C, with the strawberries growing in favorable conditions and without diseases or pests. The fruit development stages of the strawberries were divided into 7 periods: small green , medium green , big green , white , turn red , half red , and fully red  [w/v) sodium hypochlorite for 1 min, washed with distilled water 3 times, and air-dried in a laminar flow cabinet before being processed.An octaploid strawberry cultivar, “Benihoppe” (owering) ,45,46. AB. cinerea strains were acquired through separation from the fruits afflicted with B. cinerea gathered from the base of Jiangsu Agricultural Expo Garden by Jiangsu Horticultural Modern Engineering Center [v/v) of Tween-80 at a concentration of 106 spores per milliliter. A sterile filter paper with 3 layers was then used to remove the mycelia, and Neubauer cell chamber was employed to quantify the conidia concentration. Finally, the suspension with a B. cinerea concentration of 105 spore/mL was prepared to infect the strawberries. Strawberries of even sizes, consistent levels of maturity, and normal shapes were harvested at different growth periods, with carpopodia of certain lengths preserved. They were then brought to the laboratory for B. cinerea inoculation. The fruits were treated with different concentrations of MeJA before being inoculated with B. cinerea, and the optimal MeJA concentration was determined according to the incidence of the fruits. The strawberries in the HF period were used for MeJA treatments, and fruits were inoculated with B. cinerea right after they were treated with different concentration of MeJA. The experiment was repeated 3 times, and 30 fruits were used in each batch for each treatment.The g Center . The sepg Center . MyceliaAn inoculating needle was used to form 2 holes in the center (about 0.2 cm depth) of each strawberry fruit. The pathogen solution was filled into a wide mouth glass jar. Held at the carpopodia, the strawberries were immersed in the solution for 1 min before being placed in culture media for culturing at the appropriate humidity. The incidence of the fruits was followed up through photography and text recording.Strawberries at different growth periods were harvested from the field. The achenes were rapidly removed from the fruits, which were then frozen using liquid nitrogen. The JA contents were measured using 200 mg of the evenly mixed homogenates of all fruits from each growth period; the experiment was performed according the method described by Kilam , with spB. cinerea, and the optimal MeJA concentration was determined according to the incidence of the fruits. The experiment was repeated 3 times, and 30 fruits were used in each batch for each treatment.Fruits at HF stage were treated with different concentrations of MeJA before being inoculated with Clustal X 2.1 and ESprint 3.0 were implemented for the multiple alignment of amino acid sequences in the WRKY25 genes in the strawberries with the WRKY proteins of other plant species. The neighbor connection in MEGA X was applied to construct the phylogenetic tree.FaWRKY25. The cloned gene fragments had their sequences verified. FaWRKY25 was constructed in the forward orientation on the Gateway expression vector pH7WG2D [FaWRKY25 overexpression, 25-OE. To generate the FaWRKY25 silent expression construct, we used vector pFGC5941 [FaWRKY25 (pFGC5941/FaWRKY25/RNAi (ribonucleic acid interference)). Then FaWRKY25/RNAi was PCR amplified using specify primers , we applied DNAMAN to design the full-length primers of the target gene  primers , which w2 solution), and oscillated at room temperature for 2 h before being injected into the strawberries. In vitro injection was performed on the strawberries during their Wh period. Through the use of a sterile syringe, we evenly injected 1 mL of the bacterial solution into the hollow strawberry fruit through the fruit stalk. The injection depth was approximately half of the longitudinal diameter of the fruit and the injection volume of Agrobacterium suspension was adjusted according to the size of the fruit to ensure the Agrobacterium suspension completely infected the fruit. Since the vectors used in the transient transformation study carried the e-GFP gene, the FaWRKY25 gene expression was easy to be recorded through a fluorescence observation system, once successfully transformed.Transient gene transformation experiment was performed according the method described by Geng , with spFaActin. The reaction system was 20 µL in volume and comprised 1 µL of complementary deoxyribonucleic acid, 10 µL of Til RNase Plus (2×), 1 µL of mixture of upstream and downstream primers, and 8 µL of ddH2O without nucleic acid contamination. Through the use of the 2−∆∆CT method, we analyzed the relative gene expression data. The FaWRKY25 expression during the green period was established as a control group to those of other growth periods and was defined as 1. For the gene expression after B. cinerea infection, the first day of infection was designated as the control group, with each gene expression defined as 1.A Roche light cycler was applied in the real-time quantitative PCR system to measure the expression of all genes, and the internal reference gene was FaWRKY25 overexpression or silencing: FaLOX, FaAOS, FaAOC, FaOPR2, FaOPR3, FaJAR1, FaJAR2, FaCOI1, FaMYC2, FaJAZ1, FaJAZ4, FaJAZ5, FaJAZ8, FaJAZ10, and FaJAZ12 for those related to the path of JA signal transduction; FaWRKY1, FaWRKY2, FaWRKY11, FaWRKY33, FaWRKY40, FaWRKY57, FaWRKY70, and FaWRKY75 for those related to the WRKY family and the disease; and FaBG2-1, FaBG2-2, FaBG2-3, FaPGIP1, FaPGIP2, FaCHI2-2, and FaCHI3-1 for those related to the structure of pathogen defense. The relative expression of these genes was depicted using a heat map. With the wild strawberries without bacterial injection as the control group, the relative gene expression in the empty vectors (EV-OE or EV-As), FaWRKY25-OE, and FaWRKY25-RNAi groups were calculated. The expression in the FaWRKY25-OE and FaWRKY25-RNAi groups was than divided by that in the empty vector group, and the results were used to create a heat map. All the gene information and primer sequences are shown in The following genes were selected for analysis in the fruits with p ≤ 0.05 indicating statistical significance (least significant difference and Fisher’s method). SPSS 12 was used to complete the statistical analysis.The experiment was conducted with a completely randomized design. Analysis of variance was performed to compare the samples’ incidence and the means of gene expression. The gene expression was normalized through logarithmic transformation to compensate for the abnormal distribution of data, with FaWRKY25 and PtrWRKY25 were clustered more closely than FaWRKY25 and CpWRKY25, indicating that the FaWRKY25 in strawberries shares a close relationship with those in papayas and poplars and a distant relationship with those in Camelina sativa and Zea mays. The genetic codes of FaWRKY25 encompass 627 amino acids, which include two typical WRKY domains and a C2H2 zinc finger with a structure consistent with that in the group I TF , a higher JA concentration did not necessarily lead to more effective B. cinerea containment. Within the range of 100–250 µM, a higher JA concentration delayed B. cinerea occurrence further; at 250 µM, the effectiveness of JA was the highest. However, a higher JA concentration beyond 250 µM led to earlier B. cinerea occurrence; observations revealed that increased JA concentrations led to fruit rot, which can render fruits vulnerable to B. cinerea. The severity of B. cinerea on the fruits according to the JA concentration was also examined . In the control group, 48 h after infection, 10% class I lesion and 10.2% class II lesion were detected; by the 120th hour after infection, 21.8% class IV lesion was identified, and most of the fruits were afflicted with B. cinerea. When the JA concentration was <250 µM, a higher concentration delayed and mitigated B. cinerea occurrence more effectively; however, when the concentration was >250 µM, the fruits became susceptible to the disease. At the 144th hour after B. cinerea infection, the fruits treated with 350 µM of JA exhibited 0.9% class IV lesion and 23.3% class I–III lesion. Accordingly, only within a certain range of concentration can JA effectively delay and mitigate the occurrence of B. cinerea on strawberries and increase the fruits’ resistance against B. cinerea. According to the results of this experiment, 250 µM is the optimal JA concentration, and thus this concentration was adopted in the following experiments.As illustrated in examined . The sevFaWRKY25 expression also varied considerably during the growth of strawberry fruits. As shown in FaWRKY25 expression increased continually even though it decreased slightly in the HF period; starting from the Wh period, the expression increased rapidly and reached the highest point when the fruits were thoroughly red. The JA content in strawberries changes significantly during fruit growth. From the SG to Re periods, the JA content rose first but dropped subsequently. During the BG period, the concentration was the highest; it decreased sharply starting from the Wh period and reached the lowest level in the Re period B. The leFaWRKY25 on strawberries’ B. cinerea resistance, we applied external JA and B. cinerea to the Re fruits in this study. The results revealed that B. cinerea occurred in the control group 120 h after infection; B. cinerea began to appear at the 48th hour in the B. cinerea infection group and grew increasingly severe over time, and at the 144th hour, more than 60% of the fruits were infected, and they rotted severely. The fruits that received JA treatment before B. cinerea infection remained healthy until the 144th hour, at which point visible B. cinerea began to appear on the surfaces of the fruits  and the empty vector (EV), the FaWRKY25 transcription level in the fruits with agrobacterium injection increased substantially because of FaWRKY25 overexpression. FaWRKY25-ribonucleic acid interference (-RNAi) caused the transcription level to decrease, and no significant differences were observed between the fruits without injection and the empty vector in terms of FaWRKY25 expression . The results revealed that the disease began to occur on the no injection group and control group on the fourth or fifth day after infection (DABI); the fruits with FaWRKY25 overexpression had a significantly advanced time of disease occurrence and increased disease severity. On the sixth DABI, most of the fruits exhibited lesions, and over 50% had rotted severely  and RNAi techniques  signaling pathway that plays a complex role in the cross-response process [AtWRKY18, AtWRKY40, and AtWRKY60 genes jointly regulate the resistance response of Arabidopsis to B. cinerea [Arabidopsis have shown that AtWRKY33 is required for resistance to B. cinerea, implicating this factor to positively regulate JA- and ET-mediated defenses while negatively affecting SA-mediated signaling [B. cinerea infection is independent of AtWRKY33 function, while AtWRKY33 acts as a negative regulator of SA signaling and thereby prevents subsequent SA-mediated suppression of the JA pathway [B. cinerea in a variety of forms, such as single, cooperative, or complex. The diversity and complexity of WRKY regulation also reflected that the defense response of plants to B. cinerea is related to many factors. Transcription factors and hormones play an important role in plant regulation of B. cinerea.Many studies have shown that the WRKY family plays an important role in hormone regulation of disease resistance and defense signal transduction network. WRKY gene expression can be induced by pathogenic bacteria and hormone signal molecules such as jasmonic acid (JA)  For exam process ; AtWRKY1 cinerea . Earlierignaling . Later r pathway ,29,53. TFaWRKY1 is related to strawberry C. acutatum [FvWRKY42 is a positive regulator of the resistance of wild strawberries against powdery mildew [B. cinerea. As an important member of WRKY family, the function of FaWRKY25 in strawberry resistance to B. cinerea and its relationship with the JA pathway are still unknown. To gain insight into the role of FaWRKY25 in the strawberry fruit defense response to B. cinerea, we first confirmed the incidence of B. cinerea in strawberry fruits at different developmental stages. The results showed that green fruits were not susceptible to B. cinerea, while red fruits were susceptible to the B. cinerea -JA is formed [FaWRKY25 gene decreased the expression of FaLOX, FaAOS, FaAOC, FaOPR2, and FaOPR3; the content of JA in fruit was also decreased. Contrary, in the fruits with FaWRKY25 silencing, the JA content increased and the expression of five genes increased significantly  proteins β-1,3-glucanases , chitinases (FaCHI2-2 and FaCHI3-1), and polygalacturonase-inhibiting proteins (FaPGIP1 and FaPGIP2) were analyzed. PGIP and chitinase play a defensive role in strawberry fruit. PR proteins also exert a critical effect in the course of disease and necrosis of plants [FaWRKY25 gene might enhance the defensive function of strawberry against B. cinerea through raising the level of PR and PGIP genes, thereby delaying the occurrence of B. cinerea in strawberry fruit.f plants ,46. Our FaWRKY25 gene was accomplished in strawberry fruit. We provide evidence of the relevance between FaWRKY25 and strawberry fruit disease resistance against B. cinerea. In sum, we found that FaWRKY25 acts as a negative regulator of strawberry fruit resistance to B. cinerea. In summary, in this paper, a functional characterization of the FaWRKY25 plays an important role in regulating strawberries’ resistance against B. cinerea. Manipulating FaWRKY25 expression modulated the strawberry fruits’ resistance against B. cinerea; the JA content in fruit was highly influenced by manipulating FaWRKY25 expression as well, indicating that FaWRKY25 may negatively regulate the JA-mediated resistance mechanism against B. cinerea. However, strawberry fruit resistance to B. cinerea is a complicated biological phenomenon, and further studies need to be done to identify the upstream and downstream signaling components of FaWRKY25 in the stress response to B. cinerea.The present study demonstrated that


Early discharge of preterm very low birth weight (VLBW) infants is at times inevitable in low resource settings. The implication of such practice on the growth of this high-risk population is not known. We conducted a retrospective chart review to describe the growth of preterm VLBW infants discharged with a weight of less than 1500 g.To describe the growth of discharged preterm VLBW infants over the first 12 weeks.P-value of < 0.05 was considered significant at a 95% confidence interval.Between June 2013 and January 2014; 164 discharged preterm VLBW infants were followed up for 3 months. Among the survivors (132), we identified 111 infant records for this study. Relevant data was entered in STATA for analysis. Growth percentiles were determined at approximately 4 weeks, 8 weeks, and 12 weeks post-discharge using the intergrowth 21st growth charts. Growth velocities were computed using the 2-point average weight model. Regression analysis was used to identify factors associated with growth failure. Growth failure was defined as occipital frontal circumference (OFC), weight, and length < 10th centile by 12 weeks post-discharge. Among the study infants the median gestational age and weight at birth were 32 weeks (range 28-35 weeks) and 1250 g(range 850-1500 g) respectively; 60/111(54%) were Small for Gestational Age (SGA). The median discharge postmenstrual age (PMA) was 34 weeks (range 30-38 weeks) and weight was 1140 g (range 830-1490 g). The majority 88.2% had not recovered birth weight at discharge of whom 59.1% recovered by 2 weeks and 40.9% recovered between 2 and 4 weeks after discharge. By 12 weeks post-discharge the median PMA and weight were 46 weeks (range 37-51 weeks),and 3110 g (range 1750-5000 g) respectively, 38.7% of the infants had growth failure and 36.9% had OFC <3rd centile. Growth velocity < 15 g/kg/d in the first 4 weeks  and subsequent 4 weeks  post-discharge were independently associated with growth failure.Slow birth weight recovery was observed and growth failure was prevalent by 12 weeks post-discharge with more than a third having severe microcephaly. Poor post-discharge growth velocity was associated with subsequent growth failure.Growth velocity monitoring among preterm VLBW infants should be emphasized. The implication and interventions of this early growth failure needs to be explored. It was estimated in 2015 that approximately 20.5million babies were born with low birth weight and the majority 91% occurred in low and middle-income countries  of theseOne of the concerns among surviving preterm infants is their growth and its health implications. Various studies have demonstrated that poor growth among preterm very low birth weight infants (VLBW) is associated with poor neurodevelopmental outcomes hence emphasizing the need for promotion and maintaining close to normal early growth among these infants , 9, 10. In the developed countries preterm and VLBW infants are commenced on parenteral nutrition early in life and once on full feeds, their nutritional requirements are adjusted to meet the European Society Paediatric Gastroenterology Hepatology and Nutrition (ESPHAGAN) recommendations . In Low At the Mulago National referral hospital, VLBW infants do not routinely receive parenteral nutrition and are discharged home early due to lack of space in the hospital. Parents are educated on how to gavage and breastfeed their infants. Feeding and weight gain are reviewed weekly. Escalation of feeding to fortified breast milk does not happen even among poorly growing LBW infants due to cost and availability.A previous follow-up of LBW infants at Mulago hospital kangaroo clinic observed the majority of babies not recovering birth weight by 21 days of life . We descThis study was conducted at the Mulago Hospital SCBU. The SCBU is a level II neonatal unit that admits approximately 4500 babies annually of whom 20% are VLBW. Mulago hospital is a National Referral Hospital for Uganda and a teaching hospital for Makerere University.In terms of nutrition; neonates in the unit are commenced on intravenous fluids containing dextrose as breast milk feeds are introduced slowly. Total fluid requirements are computed daily and are provided as feeds together with supplemental intravenous fluids. Electrolytes are added to intravenous fluids from day 3 of life. Neither intravenous lipids nor amino acids are given routinely. When a neonate is tolerating full feeds (150 ml/kg/day) then intravenous fluids are discontinued.Once preterm and low birth weight babies are stable , they are discharged home on oral aminophylline, multivitamin drops (Grovit), iron syrup with follow-up once weekly in the Kangaroo clinic located in the SCBU. Most preterm infants are discharged while still tube feeding.In the Kangaroo clinic anthropometry is done by a trained nurse. Length is measured using an infant length board calibrated to +/− 0.5 cm accuracy, naked weight by a digital weighing scale calibrated to +/− 10 g accuracy, and OFC by a none stretchable tape measure. All measurements are performed according to WHO guidelines . Babies Babies found with any complication may be readmitted for care while for stable ones; parents are advised on continued care and are given their next appointment. Feed volumes are readjusted (maximum feeding volume is 220 ml/kg/day), and nasogastric tubes are replaced. Breast milk is never fortified.Cup feeding and breastfeeding are introduced once the infant shows sucking gestures. If cup feed volume exceeds half daily volume then the nasogastric tube is removed and once sucking on the breast is perceived strong and sustained then full breastfeeding is commenced.The infants included in this cohort were VLBW (birth weight < 1500 g), had been discharged home with a weight of < 1500 g, and did not have comorbidities.Data sheets of all infants enrolled in the previous study on mortality among VLBW infants following hospital discharge were reviewed . InfantsData were entered into the computer using the Microsoft Excel program and subsequently exported into the STATA software package for analysis. The intergrowth online tool was used to compute weight, OFC, and length centile at the different postmenstrual ages.Growth velocity was computed asGV = Growth Velocity.Wte = weight at end of assessment.Wts = weight at start of assessment.P = Period of assessment in days (age at Wte less age at Wts).The Pearson Chi-square test was performed to compare baseline characteristics between included and excluded study participants.P values of < 0.05 were considered significant and the confidence interval of 95% was used. The results were summarized in tables.Using baseline variables logistic regression was run to identify factors independently associated with growth failure. Of the 132 preterm VLBW (< 1500 g), infants born between June 2013 and January 2014 who were known to be alive at 12 weeks post-discharge, we identified 111 infants  with complete records. The median gestational age and weight at birth were 32.5 weeks (range 28-35 weeks) and 1250 g (range (850-1500 g) respectively. Sixty were SGA of whom 45/111 (40.5%) and 15/111(13.5%) were symmetrically and asymmetrically SGA respectively at birth. Baseline cohort characteristics are shown in Table Although most of infants excluded from analysis were female 19/21 (p 0.008), the baseline characteristics among included and excluded infants were not statistically significant Table The average duration of hospital stay was 12 days (range 4-41 days). The median discharge PMA and weight were 34 weeks (range 30-38 weeks) and 1140 g (range 830-1490 g). Birth weight was recovered in only 13(11.7%) infants at discharge, in whom the average time to birth weight recovery was at 12.6 days (range7-21 day).The majority of the infants at discharge were still tube feeding 100/111. By 12 weeks after discharge 107/111 infants were exclusively breastfeeding directly from the breast and 4 were taking formula feeds.Of the infants who had not recovered birth weight at discharge 98 (88.2%); 70 (71.4%) weighed ≤1200 g at discharge. Among these infants 58(59.1%) recovered birth weight by 2 weeks after discharge. Among those who recovered birth weight between 2 and 4 weeks after discharge 40(40.8%) the majority 34/40 were those discharged with weight of ≤1200 g.In the first 4 weeks post-discharge, 28mothers were practicing Kangaroo Mother Care (KMC) for 12-20 h per day; by 8 weeks post-discharge; 9 mothers were doing so  and 3110 g (range 1750-5000 g) respectively. The majority of the infants had weight 73.8% and length 72.6% below 10th centile. Growth failure was evident in 43/111 (38.7%) infants. Forty-one (36.9%) infants had OFC < 3rd centile  compared to 15/51(29.4%) of non-SGA infants although this difference was statistically not significant (p 0.06) (Table 6.6% compOnly 13 (11.7%) of the study infants had recovered birth weight at the time of hospital discharge. Of these 8 were appropriately grown for gestational age and 5 were SGA at birth. This very slow birth weight recovery is comparable to findings from a study conducted in the same facility among none SGA low birth weight infants –19. ThisOf the 98/111(88.2%) discharged home before birth weight recovery; 58(59.1%) recovered birth weight by 2 weeks after discharge and 40(40.9%) recovered 2-4 weeks after discharge. Whereas discharge weight of ≤1200 g did not seem to be significantly associated with growth failure (OR 1.34 p 0.48) (Table By 4 weeks post-discharge 28/111 (25.2%) infants were reportedly receiving KMC for 12-20 h/day  and subsequent 4 weeks  post-discharge were independently associated with growth failure (Table The majority of our study infants 59/111 53.1%) had normal OFC at birth of these 1728.8%) had OFC below the 10th centile by 12 weeks post-discharge while those who had OFC below 10th centile at birth 52/11146.9%) by 12 weeks post-discharge 26 (50%) still had OFC <10th centile (Table .1% had n6.9% by 18.8% had th centile compared to 13.2% of boys (Table We noted both boys and girls drifted off their centile lines by 4 weeks post discharge Figs.  and 2, bSlow birth weight recovery was observed with growth failure prevalent by 12 weeks post-discharge in the majority of VLBW infants in this study with more than a third having severe microcephaly. Enhanced early nutrition has been shown to ameliorate poor postnatal head growth a practice that LMIC should consider in the care of preterm VLBW infants to avert poor early head growth and improve long term neurodevelopmental outcome.Growth velocity monitoring among preterm VLBW infants should be emphasized. The implication and interventions of this early growth failure needs to be explored.We could not ascertain accurately the volume of feeds the study infants received since some of them were breastfeeding as well as receiving top-up feeds by tube/cup. The duration KMC was as reported by the mothers and subject to recall bias.Considering a large proportion of our study infants were SGA with 40.5% being symmetrically growth restricted and these infants showing higher tendency to growth failure, other intrinsic factor beyond this study for growth failure among this population cannot be excluded.We did not analyze for factors associated with growth failure among SGA because of a small sample size and possibility of intrinsic factors for which our study was not design to identify.Preterm very low birth weight infants are at risk for growth failure.Early discharge with weight of less than 1500 g may results in slower birth weight recovery and high growth failure.


Skilled health professional assisted delivery is an effective strategy to reduce maternal and newborn mortality. Skilled assistant delivery can prevent about 16–33% of maternal and newborn mortality. Despite the commitments of the government to assure home free delivery, majority of the births in Sub-Saharan Africa are attended by traditional birth attendants. As to our search of the literature, there is limited evidence on the prevalence and determinants of skilled delivery in East African countries. Therefore, this study aimed to estimate the pooled prevalence and determinants of skilled birth attendant delivery in East Africa Countries.Pooled analysis was done based on Demographic and Health Surveys conducted in the 12 East African countries from 2008 to 2017. A total weighted sample of 141,483 women who gave birth during the study period was included in the study. The pooled prevalence of skilled birth attendance was estimated using STATA version 14. Intra-class Correlation Coefficient, Median Odds Ratio, Proportional Change in Variance, and deviance were used for model fitness and comparison. The multilevel multivariable logistic regression model was fitted to identify determinants of skilled birth attendance in the region. Adjusted Odds Ratio with its 95% Confidence Interval was used to declare significant determinants of skilled birth attendants.The pooled prevalence of skilled birth attendant in East African countries were 67.18%  with highest skilled birth attendant in Rwanda (90.68%) and the lowest skilled birth attendant in Tanzania (11.91%). In the Multilevel multivariable logistic regression model; age 15–24 (Adjusted Odds Ratio (AOR) = 1.14, 95%CI:1.09, 1.18), age 25–49, primary women education , secondary and above women education , primary husband education , secondary and above husband education , middle wealth index ,rich wealth index , had ANC visit ,multiple gestation , parity 2–4, parity 5 + , accessing health care not big problem , residence  and being Burundi resident  were significantly associated with skilled assisted delivery.Skilled birth attendance at birth in the East Africa countries was low. Maternal age, women and husband education, wealth index, antenatal care visit, multiple gestations, parity, accessing health care, residence, and living countries were major determinants of skilled attendant delivery. Strategies to increase the accessibility and availability of healthcare services, and financial support that targets mothers from poor households and rural residents to use health services will be beneficial. Health education targeting mothers and their partner with no education are vital to increasing their awareness about the importance of skilled birth attendance at birth. Every day, about 830 women die from preventable causes related to pregnancy and childbirth, of which 99% of all maternal deaths occur in developing countries . WorldwiSkilled Birth Attendant (SBA) offers a safety and life-sustaining environment for both mothers and newborns thereby reducing the chance of complications . AlthougThe East African countries that include Burundi, Ethiopia, Comoros, Uganda, Rwanda, Tanzania, Mozambique, Madagascar, Zimbabwe, Kenya, Zambia, and Malawi are among the world’s poor countries with poor accessibility and affordability of maternal health care services .Different scholars studied skill birth attendants at a specific population in different parts of East African Country. Studies conducted in Zambia reported that at least one ANC visit and poor economic status of respondents were associated with SBA . Other sDespite the implementation of intensive public health interventions to skilled assisted delivery, the majority of the birth in SSA particularly in East African countries are attained by traditional birth attendants and continued to share the largest portion of global maternal, and newborn mortality. As to our search of literature, there is limited evidence on the magnitude and factors associated with skilled assistant delivery in East African countries.Therefore, this study aimed to estimate the pooled prevalence and determinants of skilled birth attendance in the 12 East Africa Countries from 2008 to 2017 using recent Demographic and Health Surveys. This could help to design evidence-based public health decisions for enhancing skilled birth attendance at birth to reduce maternal and newborn mortality in these countries.www.measuredhs.com after prepared concept notes about the project. The Demographic and Health Survey (DHS) data were pooled from the 12 East Africa Countries from 2008 to 2017. The recent DHS of Country-specific dataset was extracted during the specified period. The 12 East Africa Countries in which data extracted include Burundi, Ethiopia, Kenya, Comoros, Madagascar, Malawi, Mozambique, Rwanda, Tanzania, Uganda, Zambia, and Zimbabwe (Table The data was obtained from the measure DHS program at The response (outcome) variable of this study was a skilled birth attendant. The response variable was generated from the question asked to the women who gave birth within 5 years preceding the survey question “who assisted the delivery?” The response was dichotomized as a health professional and another person. Health professionals include doctors, nurses, nurse/midwife, auxiliary midwife, and others . Other persons include traditional birth attendance (TBA), traditional health volunteer, community/village health volunteer, neighbors/friends, relatives, others. If a women delivery were assisted by health professional coded as “1”, otherwise coded as “0”.Based on the literature, the independent variables included in this were two types of variables. Individual-level and community-level variables. Community-level variables include country and residence. The individual-level variables are age group, marital status, maternal and husband educational status, occupational status, wealth index, parity, ANC visit, wanted pregnancy, number of gestation, accessing health care wealth index, and birth interval.Accessing health care: most studies have isolated the travel time and transport cost when looking at access to health facilities. In the DHS data, women were asked whether a range of factors would be a big problem for them in accessing health care. We generated a composite variable using each country DHS standard questions. The questions included: getting the money needed for treatment (big problem/not a big problem) distance to a health care facility (big problem/not a big problem) having to take transport (big problem/not a big problem) Not wanting to go alone (big problem/not a big problem)If women face at least one or more of the problems  we considered as there is health care accessing problem that was our primary interest and we coded as 1 and If they reported no health care accessing out of four  we code 0.Wealth index is calculated by using principal components analysis (PCA) that involves assigning scores on the indicator variables. In the dataset, the index has five quintiles such as; the lowest quintile (poorest), 2nd quintile (poorer), 3rd quintile (middle), 4th quintile , and the 5th quintile . In this study for ease of analysis this variable was recategorized as ‘poorest’ and ‘poorer’ were coded as (1) ‘poor’, the middle was coded as (2) ‘middle’, and ‘wealthier’ and ‘wealthiest’ were coded as (3) ‘rich” .Auxiliary midwife:-is a village-level female health worker who is known as the first contact.The data was cleaned by STATA version 14.1 software. Sample weighting was done for further analysis.Since the outcome variable was binary two-level mixed-effects logistic regression analysis was employed. Sampling weight was applied as part of a complex survey design using primary sampling unit, strata, and women’s individual weight (V005).p-value 0.20 in the bi-variable multilevel mixed-effects logistic regression analysis were considered for the final individual and community level model adjustments. In the multivariable multilevel analysis, variables with a p-value≤0.05 were declared as significant determinants of skilled assistance delivery.The individual and community level variables associated with skilled birth attendant were checked independently in the bi-variable multilevel logistic regression model and variables which were statistically significant at Four models were fitted. The first was the null model containing no exposure variables which was used to check variation in community and provide evidence to assess random effects at the community level. Then model I was the multivariable model adjustment for individual-level variables and model II was adjusted for community-level factors. In model III, possible candidate variables from both individual and community-level variables were fitted with the outcome variable.The fixed effects (a measure of association) were used to estimate the association between the likelihood of skilled birth attendant and explanatory variables at both community and individual level and were expressed as odds ratio with 95% confidence interval. Regarding the measures of variation (random-effects), Community-level variance with standard deviation, intracluster correlation coefficient (ICC), Proportional Change in Community Variance (PCV), and median odds ratio (MOR) was used.The aim of the median odds ratio (MOR) is to translate the area level variance in the widely used odds ratio (OR) scale, which has a consistent and intuitive interpretation. The MOR is defined as the median value of the odds ratio between the area at the highest risk and the area at the lowest risk when randomly picking out two areas. The MOR can be conceptualized as the increased risk that (in median) would have if moving to another area with a higher risk.It is computed by; MOR = exp[√(2×Va)×0.6745] .Where; VA is the area level variance, and 0.6745 is the 75th centile of the cumulative distribution function of the normal distribution with mean 0 and variance 1. See elsewhere for a more detailed explanation . WhereasWhere; where VA = variance of the initial model, and VB = variance of the model with more terms.A total of 141,483 women who gave birth in the 5 years preceding each country’s DHS survey were included in this study. The median age of women was 28 with IQR of 10 with the majority of women underlie in the age group of 25–34. Most of the women were from Kenya 19,563(13.83%) and the smallest number of women were included from Comoros 2880(2.04%). Majority 110,471(78.08%) of women were from rural residents. A high number of women 100,261 (70.86%) were married. Two out of three women had antenatal care visit 93,360(65%). A large number of 80,769(57.09%) responded that they faced accessing health care service problems  with the highest skilled birth attendant in Rwanda (90.68%) and the lowest skilled birth attendant in Tanzania (11.91%) Fig. .Fig. 2Fp-value = p < 0.001). Similarly, the ICC in the empty model implied that 19.39% of the total variability in skilled assistant delivery was attributed to the differences between communities. Moreover, the MOR was 2.32  which implied that the odds of giving birth by the skilled birth attendant were 2.32 times higher when respondents moved from low to high-risk communities. This showed that the existence of significant heterogeneity in skilled assistant delivery across different communities. In the full model  community variance , remained significant but reduced. About 7.50% of the total variance of skilled birth attendant delivery can be attributed to the contextual-level factors that remained significant even after considering some contextual risk factors. The proportional change in variance (PCV) in this model was 90.50% which showed that 90.50% of community variance observed in the null model was explained by both community and individual level variables (Table The fixed effects (a measure of association) and the random intercepts for skilled birth attendants are presented in Table The model with smaller deviance and the largest likelihood (model IV) was best fit the data and the interpretation of the fixed effects was based on this model. Model four was adjusted for both individual and community-level factors. Consequently, respondent’s age group, maternal education, husband education, wealth index, ANC visit, multiple gestations, parity, accessing health care, birth interval, residence, and living Country were significantly associated with the skilled birth interval in the East Africa Counties. The odds of SBA delivery among women aged 25–34 and 35–49 years were increased by 14 and 16% as compared to women age group 15–24 and  respectively. The odds of obtaining SBA among women of primary and secondary and above educational level were 1.57 and 2.85 times higher as compared to women with no education  and  respectively. The odds of obtaining SBA among women of their husband’s educational level primary and secondary and above educational level were increased by 11 and 46% as compared to women with no education  and  respectively. The odds of seeking SBA among women wealth status middle and rich were 1.43 and 2.38 times higher as compared to poor women  and  respectively. The odds of seeking SBA among women who had ANC visits were increased by 68% as compared to women who had no ANC visit . The odds of seeking SBA among women who faced multiple births were 2.06 times higher as compared to women who faced single birth . The odds of obtaining SBA among women of para 2–4 and para 5+ were decreased by 35 and 56% as compared to para1 and  respectively. The odds of obtaining SBA among women of not a big problem in accessing health care were increased by 32% as compared to women of big problems in accessing health care . The odds of obtaining SBA among women deliver with a birth interval greater than 2 and above years were decrease by 9% as compared to women deliver with less than two-year birth spacing . The odds of seeking SBA among women of the rural resident were decreased by 57% as compared to urban women . Living countries had a significant effect on the likelihood of obtaining SBA in the East Africa Countries  with the highest skilled birth attendant in Rwanda (90.68%) and the lowest skilled birth attendant in Tanzania (11.91%). This was lower than studies conducted in Namibia 80.3% . The finIn East Africa, skilled birth attendance at birth was significantly varied across counties, ranging from 11.91%% in Tanzania to 90.68% in Rwanda. Since 2010, Rwanda has seen a 55% decline in the maternal death ratio. An enormous success that qualified Rwanda to be among the nine developing countries which achieved the millennium development goals 4 and 5 (MDGs). Though skilled birth attendance stands high at 91%, the coverage of completed 4 Ante Natal Care visits remains low at 44% . While iIn the multilevel multivariable logistic regression analysis age group, maternal education, husband education, wealth index, antenatal care visit, number of gestation, parity accessing health care, birth interval, residence, and living countries were determinants of skilled birth attendance at birth in the East Africa Countries.This study evidenced that as the women age group increases the likelihood of obtaining skilled birth attendance at birth also increases. This finding was supported by study findings from Nepal  and contWomen and her husband who have achieved primary education and higher were more likely to skilled birth attendants than women her husband who didn’t have formal education. This finding is supported by different studies conducted in Vietnam, Togo, Bangladesh, Sub-Saharan Africa, Ethiopia , 19, 22.Wealth index had a significant association on the likelihood of skilled birth attendance at birth in the East Africa Countries. This study evidenced that likelihood of obtaining skilled birth attendance at birth was higher among women of middle and rich wealth status as compared to poor women. This finding was supported by studies conducted in Vietnam , Togo 1, BangladThis study revealed that women who had antennal care visits had a significant association with the likelihood of obtaining skilled birth attendance at birth as compared to women who had no antenatal care visits. This finding was supported by studies Zambia , Sierra The other most significant determinants of skilled birth attendance at birth in this study was the type of gestation. Mothers who have multiple gestations were more likely to obtain skilled birth attendants at birth than singletons. This finding was supported studies conducted from 60 low and middle-income countries . This miThere is a strong relationship between parity and skilled birth attendance at birth. This study evidenced that as the number of children in the family increases the likelihood of obtaining skilled birth attendance at birth decreases. This finding was supported by studies conducted in Nigeria , EthiopiAccessing health care had a significant effect on the likelihood of obtaining skilled birth attendance at birth. The current study evidenced that women who reported accessing health care not big problem increases the likelihood of obtaining skilled birth attendance at birth as compared to women who reported accessing health care big problem. This finding was supported by studies conducted in Ethiopia , Ghana . This coThis study evidenced that the odds of obtaining skilled birth attendance at birth among women deliver 2 years and above birth interval were decreased as compared to women deliver less than two-year birth interval. This finding was supported by studies conducted in South East Asia . The posOther important determinants of skilled birth attendance at birth in the East Africa counties were residence. The current study evidenced that the odds of obtaining skilled birth attendance at birth among women who reside in the rural area decrease as compared to urban women. This finding was supported by studies conducted in Bangladesh , 22, GhaPertaining to the strengths, the dataset used in this study was obtained from nationally representative and the variables in the 12 East Africa DHS dataset were the same hence comparable across all countries. The study was population-based with a response rate of > 90%. The data were pooled together to create a large sample size and increase the generalizability of skilled birth attendant reported within 5 years preceding each country survey which ranges from 2008 to 2017 and was able to identify the significant determinants of skilled birth attendant across the 12 East African Countries to inform policymakers and planners for their intervention to prioritize.Regarding the limitations, the finding from this study may not establish a true causal relationship between the outcome variable and independent variables due to the cross-sectional nature of the study design. The data was collected based on self-report from mothers within 5 years preceding the survey and this could be a potential source of recall and misclassification bias. Six countries had no DHS data in East Africa and the result of this study may not representative of the entire East Africa country.Skilled birth attendance at birth in the East Africa countries was low. Age, women and husband education, wealth index, ANC visit, number of gestation, accessing health care, residence, and living countries were major determinants of skilled birth attendance. Strategies to increase the accessibility and availability of healthcare services, and financial support that enables mothers from poor households to use health services will be beneficial. Health education targeting mothers and their partner with no education are vital to increasing their awareness about the importance of skilled birth attendance at birth.