A subsequent integrated (MeDIP/hMeDIP-seq/mRNA-seq) analysis was performed by comparing all online available gene sets using Gene Set Enrichment Analysis. Apoptosis, proteolysis, and mitochondrial structure and function were subsequently evaluated in vitro. Results: Differential expression (DE) analysis revealed 239 genes with higher and 236 with lower 5mC levels and 275 genes with higher and 315 with lower 5hmC levels in RAS-STCs compared to Normal-STCs . Integrated MeDIP-/hMeDIP-seq/mRNA-seq analysis identified several overlapping (DE-5mC/mRNA and DE-5hmC/mRNA levels) genes primarily implicated in apoptosis, proteolysis, and mitochondrial functions. Furthermore, RAS-STCs exhibited decreased apoptosis, mitochondrial matrix density, and ATP production, and increased intracellular amino acid concentration and ubiquitin expression. Conclusions: Renal ischemia induces epigenetic changes in apoptosis-, proteolysis-, and mitochondria-related genes, which correlate with alterations in the transcriptomic profile and corresponding function of swine STCs. These observations may contribute to developing novel targeted interventions to preserve the reparative potency of STCs in renal disease.Background: Scattered tubular-like cells (STCs) are dedifferentiated renal tubular cells endowed with progenitor-like characteristics to repair injured parenchymal cells. STCs may be damaged and rendered ineffective by renal artery stenosis (RAS), but the underlying processes remain unclear. We hypothesized that RAS alters the epigenetic landscape on DNA and the ensuing gene transcriptional profile of swine STCs. Methods: CD24+/CD133+ STCs were isolated from pig kidneys after 10 weeks of RAS or sham ( Renal artery stenosis (RAS), commonly due to atherosclerosis, is a common cause of renal failure in the elderly population  frequentSeveral injurious pathways are activated in the stenotic kidney, including the renin-angiotensin-aldosterone system, renal inflammation, and microvascular remodeling ,5. RenalEpigenetic changes, defined as alterations in gene expression that do not change the DNA sequence, have been implicated in the pathogenesis of renal ischemia and play a key role in governing the phenotype of renal tubular cells ,14,15. RIn this study, we compared the genomic-wide mapping of 5mC and 5hmC patterns between normal- and RAS- swine STCs using methylated and hydroxymethylated DNA immunoprecipitation combined with deep sequencing . We hypothesize that RAS alters the epigenetic landscape and the ensuing gene transcriptional status and function of swine STCs.®, Fort Dodge Animal Health, New York, NY, USA) and xylazine (2 mg/kg), and anesthesia was maintained with ketamine (0.2 mg/kg/min) and xylazine (0.03 mg/kg/min) to induce unilateral RAS in 3 pigs by placing a local irritant coil in one of the main renal arteries under fluoroscopy (RAS group). This intervention gradually develops hemodynamically significant RAS in 7–10 days [We studied 6 female domestic pigs  over 10-weeks. At baseline, animals were anesthetized with intramuscular tiletamine hydrochloride/zolazepam hydrochloride  was performed to determine single-kidney hemodynamics and function, including cortical and medullary volumes, perfusion, renal blood flow (RBF), and glomerular filtration rate (GFR), and data were analyzed using Analyze  and MATLAB 7.10 (MathWorks) ,24. BlooA few days after the MDCT studies, pigs were euthanized with sodium pentobarbital , and kidneys were harvested and dissected immediately using a retroperitoneal incision. STCs were isolated, characterized, and cultured, and their DNA and mRNA were isolated for MeDIP-, hMeDIP-, and mRNA-seq studies.2; [Swine STCs were isolated as previously described ,11,25. I2; . Non-adh2; .® Pico  for 7–10 cycles of 30 s on and 30 s off. The size of fragmented DNA was analyzed by the fragment analyzer  using the High Sensitivity NGS Fragment Analysis Kit (Cat. DNF-486). Fragmented DNA with an average size of 200 bp was denatured at 95 °C for 10 min. Then, 2.5–5 µg of DNA in 1× DIP buffer  was incubated with 1µg of anti-5mC antibody  or anti-5hmC antibody generated from the hybridoma clone EDL HMC 1A  for 3 h at 4 °C on a rotator. Protein-G Dynabeads  were added, and the reactions were further incubated at 4 °C on a rotator overnight. Beads-antibody-DNA complexes were extensively washed by DIP buffer and TE buffer, and enriched DNA fragments eluted from the beads, purified with the ssDNA/RNA Clean and Concentrator Kit , and quantified using the Qubit ssDNA High Sensitivity assay . Libraries were prepared  [MeDIP and hMeDIP-seq were performed as previously described . DNA was. 10024)  followinp-values. Heat maps of genes, according to 5mC and 5hmC levels in RAS-STCs versus Normal-STCs, were generated using Morpheus .Bioinformatic analysis was performed by aligning paired-end sequenced FASTQ files to the pig reference genome using bowtie2 2.3.3.1 . DuplicaODF3B, TP23, CLDN11, and ZAR1) were visualized using the Integrative Genomics Viewer (IGV) [The 5mC and 5hmC profiles of candidate genes (er (IGV) . Gene oner (IGV)  and cateTo explore whether RAS also elicited long-lasting effects on gene transcription, mRNA-seq analysis was performed in the same cultured swine STCs, followed by an integrated (MeDIP- and hMeDIP-seq/mRNA-seq) analysis.p ≤ 0.05 were classified as upregulated in RAS-STCs, and those with RPKM > 0.1, fold-change  ≤ 0.7 and p ≤ 0.05 as downregulated. To identify gene sets dysregulated at both epigenetic (MeDIP- and hMeDIP-seq) and expression (mRNA-seq) levels, these datasets were compared using GSEA. Screening analysis was run for all online available gene sets . Results were ranked by the normalized enrichment score (NES) using a threshold of ≥+1.4 and ≤−1.4. Filtered gene sets run on the mRNA-seq and MeDIP- or hMeDIP-seq datasets were cross-compared and visualized in a scatter plot. For each quadrant of the scatter plots, the filtered gene sets with the top 10 most extreme mRNA-seq NES were extracted, and the number of apoptosis- (GO:0006915), proteolysis- (GO:0006508), and mitochondria-related  genes wEBF4: ss06930836, GEN1: ss06923974, MIS18BP1: ss06917788, PEMT: ss03384368, SGO1: ss06876455, SHARPIN: ss06920790, and SMPDL3A: ss06892702 between Normal- and RAS-STCs. Gene expression was normalized to GAPDH.Using the ΔΔCt method on RNA isolation, cDNA synthesis, and qPCR, we compared expression levels of the candidate genes To explore the impact of RAS-induced epigenetic and gene expression changes on corresponding STC integrity and function, we assessed apoptosis, proteolysis, and mitochondrial structure and function in vitro. Apoptosis was evaluated by terminal deoxynucleotidyl transferase dUTP nick-end-labeling (TUNEL) and gene expression of B-cell Lymphoma (BCL)-2 by qPCR ,42.Proteolysis was assessed by protein expression of ubiquitin , and liquid chromatography-tandem mass spectrometry (LC-MS/MS) metabolomic analysis for amino acids. Briefly, STCs were grown in 10 cm dishes in Medium 199 with 3% FBS  until optimal confluency. Cells were then treated with 1.5–2 mL cold methanol to the dish (methanol was stored in a clean bottle at −20 °C), scrapped to dislodge them from the dish’s surface, and transferred to 2 mL tubes placed on dry ice. Samples were dried and reconstituted with aTRAQ Reagent 113-labeled Standard Mix, and amino acids were separated and detected by LC-MSMS. The concentrations of amino acids were established by comparing their ion intensity (121-labeled amino acids) to their respective internal standards (113-labeled amino acids) .Mitochondrial morphology was assessed by transmission electron microscopy, as previously described ,44. STCsMitochondrial superoxide production was measured in cells stained with 2 μM Mito-SOX red reagent  for 30 min at 37 °C , whereasp ≤ 0.05. The Shapiro–Wilk test was used to test for deviation from normality. Normally and non-normally distributed data were compared using Student’s t-test and nonparametric methods , respectively.Statistical analysis was performed using JMP Pro14.0 (SAS) software. Results are expressed as mean ± standard deviation and considered significant for Flow cytometry analysis showed that cultured pig STCs co-expressed CD24 and CD133 markers at a purity of 97% A. Immunop ≤ 0.05)  between RAS-STCs and Normal-STCs  A,B, incland TP23 C. GO anaand TP23 D. Proteiand TP23 E. Analysand TP23 F.p < 0.05)  between RAS-STCs and Normal-STCs  A,B, incland ZAR1 C. Gene pand ZAR1 D, possesand ZAR1 E, and weand ZAR1 F.Integrated 5mC-MeDIP-seq/mRNA-seq analysis identified 75 gene sets with higher 5mC and lower mRNA levels, and 42 gene sets with lower 5mC and higher mRNA levels in RAS-STCs versus Normal-STCs A. In conIntegrated 5hmC-MeDIP-seq/mRNA-seq analysis identified 87 gene sets with higher and 119 with lower 5hmC and mRNA levels, 50 gene sets with higher 5hmC and lower mRNA levels, and 24 gene sets with lower 5hmC and higher mRNA levels in RAS-STCs versus Normal-STCs B. Gene sEBF4, GEN1, MIS18BP1, PEMT, SGO1, SHARPIN, and SMPDL3A) followed the same direction as the mRNA-seq analysis  and dysfunction , decreased apoptosis, and increased proteolysis. Therefore, our observations suggest that epigenetic changes may modify the phenotype of STCs, which might account for their impaired tissue repair potency in RAS.Repair processes in adult kidneys involve resident renal cells, such as STCs, that survive injury and dedifferentiate to acquire clonal proliferative potential ,49. We hBCL10), which encodes a protein that contains a caspase recruitment domain and induces apoptosis, as well as Annexin A8 (ANXA8), which encodes a calcium-regulated phospholipid-binding protein that modulates caspase-3 and -7 activities [CASP8AP2), which encodes a component of the death-inducing signaling complex, and Cellular Retinoic Acid Binding Protein 1 (CRABP1), which regulates protein phosphatase 2A activity and facilitates apoptosis [TMBIM6), which attenuates endoplasmic reticulum stress response and apoptosis [Our MeDIP-seq analysis revealed that RAS-STCs exhibited differential methylation in apoptotic genes, such as the B-Cell Lymphoma/Leukemia 10 , which encodes a chaperone protein involved in protein folding and degradation [UBE2V2), which targets abnormal or short-lived proteins for degradation [UBE2L6) and Ubiquitin Conjugating Enzyme E2 E2 (UBE2E2), were higher in RAS- versus Normal-STCs, suggesting that STCs exposed to RAS shift transcriptional repression and activation towards the cleavage of proteins into small peptides or amino acids.RAS also induced epigenetic alterations in proteolysis-related genes in swine STCs. For example, 5mC levels of the Heat Shock Protein 90 Alpha Family Class B Member 1 , a mitochondrial membrane protein that modulates cellular reactive oxygen species [NDUFB9), the Translocase Of Outer Mitochondrial Membrane 20 (TOMM20), and Pyruvate Dehydrogenase Kinase 1 (PDK1), which plays an important role in regulating glycolysis and mitochondrial oxidative phosphorylation by catalyzing the oxidative decarboxylation of pyruvate [Furthermore, we found that 5mC levels of mitochondrial structural and functional genes were higher in RAS-STCs compared to Normal-STCs. Among them are the Reactive Oxygen Species Modulator 1  and stenotic kidneys develop robust renal dysfunction and parenchymal injury ,68. The In summary, our study shows that RAS induces epigenetic changes and alters the mRNA expression profile of swine STCs, dysregulating genes primarily involved in apoptosis, proteolysis, and mitochondrial function. Importantly, RAS indeed compromised the phenotype and function of swine STCs, which exhibited mitochondrial structural abnormalities and dysfunction, increased proteolysis, and decreased apoptosis. Therefore, our observations have important functional implications and support the notion that RAS-induced epigenetic changes may limit the regenerative potential of STCs, ultimately compromising this endogenous renal repair system. Our findings may also assist in developing novel approaches, such as epigenetic modifiers, to preserve the integrity and function of STCs in patients with RAS.


The purpose of this study was to investigate the curative effect of and experience with laparoscopic surgery for congenital choledochal cysts in children.This is a retrospective analysis of 33 children diagnosed with congenital choledochal cyst in the pediatric surgery department of the Affiliated Hospital of Southwest Medical University between January 2019 and December 2021. The cohort included 8 males and 25 females aged 0.25–13.7 years , including 21 cases of type I and 12 cases of type IV choledochal cyst (Todani classification). Laparoscopic choledochal cyst resection and hepaticojejunostomy with Roux-en-Y anastomosis were performed in all the patients.Laparoscopy without transit opening was successfully performed in the 33 cases. The duration of the procedure was 235–460 min , and intraoperative blood loss volume was 15–40 ml (23 ± 7.6 ml). Postoperative hospital stay was 7–14 days (9 ± 1.8 days). Postoperative biliary fistula and pancreatitis occurred in two cases each, and all four patients were successfully treated with conservative treatment. No anastomotic stenosis, delayed bleeding, cholangitis, intestinal obstruction, or other complications occurred. All the children were followed up for 2–36 months . The clinical symptoms disappeared, and no obvious hepatic dysfunction was found on abdominal color ultrasound and liver function examination.Laparoscopic surgery for congenital choledochal cyst in children is safe and effective, as it is a minimally invasive surgery that is associated with a low degree of trauma and bleeding, rapid postoperative recovery, and satisfactory aesthetic appearance. Choledochal cyst, also known as congenital biliary dilatation, is a common congenital biliary malformation in children , 2. The Radical surgery is the only reliable and effective treatment, and the standard approach is choledochal cyst resection and hepaticojejunostomy with Roux-en-Y anastomosis , 9. HoweThis retrospective analysis included the data for 33 children who underwent laparoscopic choledochal cyst resection and hepaticojejunostomy with Roux-en-Y anastomosis at the Pediatric Surgery Department of the Affiliated Hospital of Southwest Medical University between January 2019 and December 2021. The cohort included 8 males and 25 females with a median age of 3.2 years (0.25–13.7 years), and 21 had type I and 12 had type IV choledochal cyst (Todani classification). All the children had a clear diagnosis of choledochal cyst based on preoperative ultrasound B examination and magnetic resonance cholangiopancreatography. There were no contraindications for laparoscopic surgery in any of the cases, and all the procedures were performed by the same surgeon.The inclusion criteria were (1) a confirmed preoperative diagnosis of choledochal cyst and (2) successful completion of choledochal cyst resection and hepaticojejunostomy with Roux-En-Y anastomosis under laparoscopic guidance. The exclusion criteria were (1) stage I open surgery for choledochal cyst resection and (2) stage I external drainage of the choledochal cyst and stage II choledochal cyst resection.General anesthesia was induced with tracheal intubation. The patient was placed in a left-leaning supine position with the head raised. Pneumoperitoneum was established using the routine procedure, with the pressure set to 6–12 mmHg (1 mmHg = 0.133 kPa). A 10-mm trocar was used to create an opening for the laparoscope at the upper edge of the umbilicus. A 3- or 5-mm trocar was placed at three points: below the intersection of the left midline of the clavicle and costal margin, at the flat umbilicus on the outer edge of the right abdominus rectus muscle, and below the intersection of the right axillary front and costal margin. The ligamentum teres hepatis and the bottom of the gallbladder were suspended with a 3–0 absorbable suture, and pulled upward to fully expose the hepatic porta. An ultrasonic knife or electric coagulation hook was used to gradually dissociate the gallbladder from the base to the neck, ligate the gallbladder artery, and expose the choledochal cyst, as shown in The SPSS 22.0 software was used for statistical analysis. Measurement data were expressed as mean ± standard deviation (mean ± SD), and counting data were expressed as percentages.Choledochal cyst resection and hepaticojejunostomy with Roux-en-Y anastomosis was performed under laparoscopic guidance without conversion in all the 33 cases of the present cohort. The operative time was 235–460 min , and intraoperative blood loss volume was 15–40 ml . The postoperative hospital stay was 7–14 days . Postoperative complications occurred in four cases (12.2%), including two cases of biliary fistula, and both were Grade I complications (Clavien-Dindo classification), the age was 2.5 and 5.7 year, and both were type I choledochal cyst (Todani classification), which was successfully treated with continuous unobstructed drainage without surgical treatment, and two cases of pancreatitis, and both were Grade II complications, the age was 3.5 (type IV) and 7.1 (type I) years, which was symptomatically treated by fasting, acid inhibition, pancreatic enzyme secretion inhibition, and parenteral nutrition support. None of the above 4 children had any definite adverse events during the operation. Anastomotic stenosis, delayed bleeding, cholangitis, intestinal obstruction, and other complications did not occur. All the children were followed up for 2–36 months  after the procedure. Over the follow-up period, the clinical symptoms disappeared and no obvious abnormalities were found on abdominal color ultrasound or liver function examinations, as shown in In the present cohort, choledochal cyst resection and hepaticojejunostomy with Roux-en-Y anastomosis under laparoscopic guidance was successfully performed in all 33 children, and the curative effect was satisfactory. This article describes the technical details and experiences during the procedure in order to the contribute to the knowledge available regarding this fairly difficult surgery. We hope that the information provided here will be useful to surgeons who perform this technique in the future.The main steps in laparoscopic choledochal cyst resection and hepaticojejunostomy with Roux-en-Y anastomosis are the stripping and removal of the choledochal cyst and reconstruction of the digestive tract. These steps are difficult to perform, and require an adequate trocar layout and good visual field exposure. For traditional porous laparoscopic total resection of the choledochal cyst, three to five trocars are inserted at the umbilicus and bilateral upper abdomen respectively –17. We mBefore the cyst is stripped, it is routine procedure to dissociate the gallbladder from the cystic fossa, ligate the cystic artery, and then dissociate the cystic duct until the confluence of the cystic duct and the cyst is completely exposed. At this time, the cystic duct is not temporarily separated as an anatomical marker. For patients with large cysts, it is not advisable to open the anterior wall of the cyst, in order to avoid accidental injury to the left and right hepatic duct. The anterior wall of the cyst should be opened under the cystic duct opening after the positions of the left and right hepatic duct opening are confirmed. Additionally, the cystic duct or cyst wall should be carefully checked for vagal bile duct openings, so as to prevent postoperative biliary fistula that could be caused by the omission of such openings during anastomosis. Additionally, intracapsular decompression may help to expose and suspend the cyst. Conventional suspension and traction should be performed when the anterior and posterior walls of the distal cyst are dissociated. For large cysts, traction at different levels of cyst wall is feasible, so the distal cyst can be gradually dissociated and then lifted up. This is conducive to exposing the gap between the cyst wall and pancreas or portal vein. Further, the cyst should be dissociated close to the cyst wall that is slightly above the junction of the cyst wall, the duodenum, and pancreatic tissue, in order to avoid collateral damage and reduce intraoperative bleeding. The author believes that it is more convenient to use the electric coagulation hook when dissociating the cyst wall, as it not only provides a good operation angle, but also makes it possible to clearly separate stripped layers.In laparoscopic total choledochal cyst resection, bleeding mostly occurs during stripping of the cyst. First, the wound surface of the cyst wall oozes blood, which is more common when there is severe adhesion between the cyst and surrounding tissue or severe inflammation of the cyst wall with obvious congestion and edema. If the hemostatic effect of the electric coagulation hook is not good, the tissue can be electrocoagulated by separation pliers to increase the area of electric coagulation. There is also potential for vascular injury around the cyst, for example, in the gallbladder artery, right hepatic artery, superior pancreaticoduodenal artery, and portal vein. Therefore, the intraoperative procedure should be performed gently, with careful differentiation of the anatomical structures based on clear visualization of the surgical field. In particular, when dissociating the proximal cyst, the distal cyst should be completely resected and the anterior wall of the proximal cyst should be suspended by suture traction. Further, the posterior wall of the proximal cyst should be carefully dissociated from the bottom to the top under direct observation to avoid portal vein injury.End-to-end jejunal anastomosis is performed outside the body. Before anastomosis, an appropriate length of jejunal loop should be reserved; the length is determined based on the age and height of the child. At present, the straight-line distance between the umbilical nest and the hepatic porta is typically considered an appropriate length for the jejunal loop (15–25 cm) . During Hepaticojejunostomy is the core step of the entire procedure. Continuous suture is performed with a 4–0 barbed suture. First, the posterior wall of the intestinal tube and common hepatic duct are sutured at 3 o’clock. The needle is passed through the coil at the end of the wire and is tightened to complete the first knot. Then, the posterior wall of the intestinal tube and the common hepatic duct are sutured continuously from left to right until the needle emerges at 9 o’clock. The anterior wall is then continuously sutured with a second barbed suture in the same way. Since the barbed suture can produce lasting and uniform tension when suturing tissue, it can be closely interlocked with the tissue after it passes through the tissue to avoid reverse slippage. Therefore, continuous suture does not require repeated tightening of the suture as it passes back and forth; this shortens the anastomosis time and ensures the tightness of the anastomosis . Good blIn this group, there were 2 cases of postoperative biliary fistula, which occurred in the early stage of the operation. Our team considered that the suture needle distance was too large during the biliary intestinal anastomosis, and no biliary fistula occurred after the needle distance was reduced in the later stage of the operation.Laparoscopic surgery for congenital choledochal cyst in children is safe and effective, and has the advantages of being minimally invasive, causing a low degree of trauma and bleeding, and ensuring quick postoperative recovery and an aesthetic appearance. It is important for the surgeon to be skilled in laparoscopic procedures and to pay attention to the intraoperative handling of the various instruments to ensure safe and effective completion of the surgery and reduce postoperative complications.


Delayed cord clamping (DCC) is practiced worldwide, as standard care in both term and preterm babies. Our aim was to determine the hemodynamic effects of DCC on transitional circulation.This prospective observational study was carried out in a tertiary care hospital, at Pune, India, from May 2018 to October 2019.Term neonates born during the study period were included. The primary outcome variables of the study were right ventricular output (RVO), left ventricular output (LVO), superior vena cava (SVC) flow (ml/kg/min) and heart rate(HR) at 12 ± 6 and 48 ± 6 h of life measured by point of care functional echocardiography. Inter-observer and intra-observer variability was calculated for these parameters.Out of a total of 2744 deliveries during the study period, 620 babies were included. Mean gestational age of the enrolled babies was 38.96 ± 1.08 weeks and mean birth weight was 2.9 ± 0.39 kg. Mean heart rate of babies recorded at 12 ± 6 h of life was 127 beats per minute (bpm) whereas it was 128 bpm at 48 ± 6 h of life. RVO {mean (SD)} was 209.55(44.89) and 205.85(46.35) ml/kg/min, LVO {mean (SD)} was 133.68(31.15) and 134.78(29.84) ml/kg/min whereas SVC flow {mean (SD)} was 106.85(26.21) and 109.29(25.11) ml/kg/min at 12 ± 6 and 48 ± 6 h of life respectively. There was good intra-observer agreement in all the variables.SGA babies had a significantly higher heart rate at 12 ± 6 h of life as compared to AGA babies, although this difference in heart rate could not be appreciated at 48 ± 6 h of life. However SGA babies had a higher LVO, RVO and SVC flow than AGA babies at both the time points of observation.After DCC there is less fluctuation in the hemodynamic parameters  at the two time points of observation.. As compared to AGA babies, SGA babies had a significantly higher baseline heart rate, LVO, RVO and SVC flow. LVO of SGA babies after delayed cord clamping is found to be significantly lower than LVO seen in other studies, favoring the cardio-stabilizing effect of DCC.This is the first study with a large sample size evaluating the hemodynamic effects of DCC in term neonates by functional echocardiography. The normative data of heart rate and cardiac output of term, stable babies with small for gestational age(SGA) as a special subgroup undergoing DCC requires further evaluation. Clamping and cutting of umbilical cord at birth is thought to be an ancient and prevalent intervention amongst humans. In spite of this, the optimal timing of umbilical cord clamping has been a debatable issue since ages . Early cThere is insufficient understanding of the hemodynamic changes after placental transfusion as a result of DCC. All the studies found in the literature search regarding cardiac output measurement till date have tried to estimate normal cardiac output in term and preterm neonates during the transitional circulation. However, the timing of cord clamping and the effect of placental transfusion, which may have a significant effect on cardiac output and may lead to an alteration of the measured normative value of cardiac output has not been taken into consideration in any of these studies. Rather the lack of acknowledgement of timing of cord clamping and its influence on cardiac output has been mentioned as a limitation of many of the reviewed studies. Moreover the innate differences in the hemodynamic adaptability during transitional circulation especially with placental transfusion in term AGA vs SGA infants has not been studied so far. So,this study was designed with an aim of measuring the hemodynamic parameters by functional echocardiographic (FnEcho), after DCC in term neonates within the first 48 h of life.A prospective observational study carried out in a tertiary care referral hospital of Pune, Maharashtra, India. The enrolment period was May 2018 to October 2019. In this study, term neonates born intramurally during the study period after 37 completed weeks of gestation, vigorous after birth and not requiring NICU care were included after informed consent by parents.Preterm neonates (< 37 weeks) and Post term neonates (> 42 weeks)Neonates with perinatal depression requiring resuscitation at birthNeonates requiring NICU admissions in first 48 h of lifeLarge for gestational age neonates (LGA)Multiple gestationNeonates with major congenital anomalies and genetic syndromeBabies were excluded based on the following criteria:The study was commenced after approval by institutional ethics committee Bharati Vidyapeeth Deemed University Vide letter number BVDUMC/IEC/66. After written, informed consent, details of demographic characteristics like name, gender, date of birth, time of birth, birth weight, and gestational age, maternal variables  were collected in the clinical record sheet. All methods were carried out in accordance with relevant guidelines and regulations. Gestational age was calculated from 1st trimester USG/ LMP / New Ballard scoring system in the same order of preference as per availability. Significant antenatal and birth history  were recorded. Cord was clamped universally after 1 min, which is a routine protocol in the institute being practiced as a standard of care. The protocol of delayed cord clamping for all neonates was followed at birth (except for neonates requiring resuscitation and immediate cord clamping at birth).Prior to enrollment of babies for the study, the routine practice of DCC in the institution was emphasized and endorsed by weekly lectures. Posters of routine policy were put up in the labor room/OT of the institution. At the time of delivery a stopwatch with alarm after 1 min was used to indicate the time of clamping of cord. In normal vaginal delivery, baby after delivery was put on mother’s abdomen for skin to skin contact and routine neonatal care was given there only. For caesarean delivery, baby was received in a pre-warmed linen and held wrapped by one member of the obstetric team for a duration of 1 min till the cord was clamped.Birth weight was measured on a digital electronic scale (Kidlee®) reading to nearest 2 g. Echocardiographic measurements were performed by a single neonatologist trained in functional echocardiography with an experience of 10 years, using a Siemens ultrasound machine  with probe (4–8 MHz transducer). First measurement was taken at 12 ± 6 h and second measurement at 48 ± 6 h of life (HOL). At each time point echocardiography was performed by a single rater and 3 readings were taken at each time point..The parasternal short axis view was used to record flow at a level just distal to the pulmonary valve by Pulsed Doppler. Maximum velocity time integral (VTI) was calculated, by averaging the values of area under the curve, for five consecutive cardiac cycles. The peak to peak intervals of the Doppler velocity time signals was used to calculate the heart rate. By using a frame to frame analysis of the grey-scale parasternal long-axis image, the diameter of the pulmonary valve insertion was measured at end systole. The average diameter was calculated from values of the five cardiac cyclesThe apical view was used to image the left ventricular outflow tract so that the full length of the ascending aorta can be incorporated. The range gate of pulsed Doppler was placed distal to the aortic valve and the maximum VTI was calculated by averaging the flow velocity time signal values of five consecutive cardiac cycles. The peak to peak intervals of the Doppler velocity time signals was used to calculate the heart rate. A parasternal long axis view was used to measure the internal diameter of the ascending aorta at the site of flow analysis, at the end of systole, from a frame by frame analysis of the Gray-scale image. An average value of the diameter was calculated from five cardiac cycles.The SVC was imaged on its entry to the right atrium, from the subcostal view. SVC diameter measurements were taken and averaged from three to five cardiac cycles. The SVC flow was identified by angling the beam anteriorly until the flow into the right atrium is seen using color Doppler. SVC flow VTI was measured and used to calculate the SVC flow. Ventricular output has been represented as mL/kg/minute. The following formula was used for measuring ventricular output:2.Flow = HR x VTI x π (diameter/2)Where, Heart Rate (HR), Velocity Time Integral (VTI), π -3.142.Heart rate was measured by a pulse oximeter attached to right hand of the baby while performing functional echocardiography.Sample size: All term neonates born intramurally undergoing DCC for 1 min were included in the study.P-value < 0.05 has been considered as significant. Intra-class correlation coefficients (ICCs) were also calculated for all measurements. Intra-observer measurement ICCs were calculated by a two-way mixed model with absolute agreement.Bland Altman plot was used to assess intra-observer variability. The limits for intra-observer variability were calculated using mean difference and standard deviation of mean difference. Data analysis was performed by using SPSS statistical software version 19:0.Descriptive statistics was used to describe the data. Mean and standard deviation was used for quantitative variables whereas frequency and percentage was used for qualitative variable. Two repeated quantitative data was compared with paired sample t test. Two independent quantitative groups were compared with unpaired t test. Bland Altman plot was used to assess intra and inter observer variability.The primary outcome variables of the study were described as right ventricular output (RVO) (ml/kg/min) at 12 ± 6 and 48 ± 6 h of life, left ventricular output (LVO) (ml/kg/min) at 12 ± 6 and 48 ± 6 h of life, superior vena cava flow (SVC) (ml/kg/min) at 12 ± 6 and 48 ± 6 h of life, heart rate (HR) (bpm) at 12 ± 6 and 48 ± 6 HOL.Flow chart of recruitment is depicted in Fig. Table Male babies were 298 (48.1%) and 322 (51.9%) babies were female. Male: Female ratio was 1:1.08. Median gestational age was 39(38.1-39.8) weeks. Mean birth weight was 2.9 ± 0.39 kg. Appropriate for gestational age (AGA) babies were 524 (84.5%) of the total whereas 96 (15.5%) babies were small for gestational age (SGA) , left ventricular output (LVO), right ventricular output (RVO) and Superior vena cava flow (SVC) were measured at two time points, 12 ± 6 h and 48 ± 6 HOL with comparison of 2 time points Table .Table 3FThe effect of birth weight for gestation on the outcome parameters in AGA and SGA groups is described in Table , and 4.TSGA babies had a significantly higher heart rate at 12 ± 6 h of life as compared to AGA babies, although this difference in heart rate could not be appreciated at 48 ± 6 h of life. However SGA babies had a higher LVO, RVO and SVC flow than AGA babies at both the time points of observation. However RVO and SVC flow in our study are comparable to RVO and SVC flow of other studies, LVO of SGA babies after delayed cord clamping is found to be significantly lower than LVO seen in other studies.There was good intra-observer agreement in the measured variables with interclass correlation co-efficient being more than 0.65 in all except for SVC diameter, where it was found to be 0.472 and 0.44 respectively at two time points.In our study heart rate at two occasions (12 ± 6 h and 48 ± 6 HOL) was 126 (12.94) bpm and 128 (13.57) bpm, left ventricular output (LVO) was found to be a mean (SD) of 133.68 (31.15) and 134.78 (29.84) ml/kg/min respectively, right ventricular output (RVO) was 209.55 (44.89) and 205.85 (46.35) ml/kg/min SVC flow was 106.85 (26.21) and 109.29 (25.11) ml/kg/min respectively.In a study by Agata et al.  1991) h91 h9]  d65 d19]  wIn a study done by Groves A.M et al.  SVC flowThe relatively lower values of heart rate and left ventricular output(LVO) found in our study could be deciphered as a result of stabilizing effect of blood transfusion (by delayed cord clamping) on heart rate and cardiac output as seen in other studies.A study done by Hudson et al.  (1990) mAccording to various recent studies it has been found that small for gestational age babies are at a higher risk of neonatal morbidity and are prone to adult onset cardiovascular diseases due to various epigenetic changes in cardiac regulation which hampers a smooth cardiovascular adaptation after birth In our Study SGA babies were 15.5% of the total enrolled babies.The baseline heart rate of SGA babies found in our study at two time points (12 ± 6 and 48 ± 6 h of life) is comparable to heart rate reported by Guajardo et al.124 (1994) in their study. Left ventricular output (LVO) of SGA babies when analyzed separately was found to be 162.35 and 157.70 ml/kg/min at 12 ± 6 and 48 ± 6 h of life respectively, which is lower than left ventricular output reported by Guajardo et al.   intra-observer agreement for all the variables except for SVC diameter and SVC flow. The large intra-observer variation seen in measurement of superior vena cava diameter found in our study is in coherence with the other studies , 31, 32 The antecedent studies evaluating the cardiac functions of term neonates during transitional circulation have not considered the timing of cord clamping (early or delayed), which alter the hemodynamics of the neonate significantly. As DCC has proven benefits for term and preterm infants, subjecting few infants to ICC for the study purpose and depriving them of the benefits of DCC for would have been unethical that’s why no comparison of the two methods of cord clamping was done. This is the first study of its kind to ascertain the changes in cardiac hemodynamics of term babies undergoing DCC. With 620 babies being analyzed this is probably the largest study estimating the cardiac outputs in babies who have undergone DCC.Large sample size has been analyzedInter-observer as well as intra-observer variability in the various parameters has been measured and documented.It is an observational study involving only infants who have undergone delayed cord clamping, as a randomized controlled trial of early versus delayed cord clamping as it would have been unethical to not offer DCC.The pattern and direction of PDA which might have influenced the right and left ventricular outputs during the transitional circulation has not been documented.High intra-observer and inter-observer variability seen in measurement of SVC flow.Further study evaluating the quantitative assessment of LV function using fraction shortening (FS), ejection fraction (EF), Doppler pattern of LV filling , and tissue Doppler imaging (TDI) in infants undergoing DCC needs to be undertaken. Future studies may consider integration of information like respiratory rate and behavior of the infant , which influence VTI values obtained for various measurement. Placental transfusion by way of DCC in term infants has beneficial effects in terms of cardiovascular stabilization, similar to packed red blood cell transfusion. Given the adaption of DCC as a standard of care globally, the normative data of heart rate and cardiac output of term, stable babies requires further evaluation.During the study period, 620 neonates’ haemodynamic parameters were recorded after delayed cord clamping. Heart rate and LVO were lower than other studies, reflecting cardiovascular stability as a result of DCC. Lack of difference in the heart rate and cardiac output between 12 ± 6 and 48 ± 6 h of life implied less fluctuations and a better stability in the cardiovascular status right after birth. Small for gestational age (SGA) babies had a higher baseline heart rate and cardiac output as compared to appropriate for gestational age (AGA) babies, warranting a new nomogram for heart rate and cardiac output for SGA babies. In, conclusion delayed cord clamping by the virtue of placental transfusion reduces fluctuation in the hemodynamic parameters  at the two time points of observation. Hence, while evaluating the cardiac output of an infant, timing of cord clamping must be taken into account and a new normative data of heart rate and cardiac output for neonates after DCC needs to be established.


According to the asymmetric value in the orbitofrontal regions, there is a left dominance in the subclinical hypothyroidism group contrary to the controls (p = 0.012), and that of the cuneus areas showed significant decreases in the subclinical hypothyroidism group (p = 0.035). These findings could reflect altered neurodevelopment, which could help treatment plans using biomarkers for subclinical hypothyroidism.While thyroid disturbances during perinatal and postnatal periods in preterm infants with congenital hypothyroidism reportedly disrupt neuronal development, no study has considered the effect of thyroid disturbances in premature infants with subclinical hypothyroidism with elevations of thyroid stimulating hormone. We aimed to identify altered fiber integrity from the thalamus to cortices in preterm infants with subclinical hypothyroidism. All preterm infants born were categorized according to thyroid stimulating hormone levels through serial thyroid function tests . Diffusion tensor images were acquired to determine differences in thalamocortical fiber lengths between the groups, and cerebral asymmetries were investigated to observe neurodevelopmental changes. Thalamocortical fiber lengths in the subclinical hypothyroidism group were significantly reduced in the bilateral superior temporal gyrus, heschl’s gyrus, lingual gyrus, and calcarine cortex (all  Thyroid dysfunction in preterm infants is associated with the immaturity of the hypothalamic-pituitary-thyroid axis, impaired synthesis and metabolism of TH, increased demand for thyroid hormone due to nonthyroidal illness, and drug administration2. One such disorder related to thyroid dysfunction, congenital hypothyroidism (CH), was a common etiology of severe cognitive impairment among preterm infants3. The clinical spectrum of CH spans from developmental delay to various neurologic problems, such as squint and functional impairment of hearing, speech, and voluntary motor activity. Screening for CH is performed using dry blood spot thyroid stimulating hormone (TSH) and thyroxine (T4) in the first week after birth4. However, the incidence of the delayed elevation of TSH levels that was missed in the first screening is high among very low birth weight (VLBW) and extremely low birth weight (ELBW) infants with CH8. As preterm or LBW and VLBW infants are also at high risk of developing cognitive dysfunction, repeated screening is strongly recommended3.Thyroid hormones (TH) play an essential role in human growth and neurodevelopment from the fetus to the first 2–3 years of life3. When TSH levels are between 6 and 20 mU/L with normal free thyroxine (fT4), management decisions become controversial; however, if TSH levels remain high for more than 3–6 weeks between preterm birth and term-equivalent age (TEA), many clinicians recommend levothyroxine supplementation10. Although the neurodevelopmental outcome in compensated or relatively mild cases of subclinical hypothyroidism  is unclear, hypothyroidism is detrimental to neurodevelopment and can lead to developmental delay and cognitive dysfunction14. While CH can cause developmental disorders that clearly affect bone density, body weight, and cognitive function15, SH takes years to induce apparent physical symptoms16; hence, early thyroid symptoms indicative of SH are difficult to diagnose in a few weeks due to the absence of remarkable clinical symptoms10. Thus, reasonable clinical markers of SH in preterm newborns are needed to ensure the integrity of their neurodevelopment.Although elevated TSH levels in preterm infants are detected through consecutive screening programs, the TSH cut-off value for neonatal screening has another important reason to prevent neurodevelopmental disorders and optimize developmental outcomes. The decision to start treatment is based on the results of venous thyroid function test, TSH levels of above 20 mU/L, and/or low free thyroxine concentration17. Its damage can cause disabilities of consciousness, working memory, sensory relay, and executive control throughout life18. TH plays important roles in neuronal migration, glial cell proliferation, synapse formation, axon and dendrite sprouting, and myelination: all essential for brain development during the first 2–3 years of life1. As TH are related to the activation of subplate neurons and participate in the mid and late phases of the maturation of oligodendrocytes by establishing transient synaptic contact from the thalamus to the cortices22, TH disturbances in perinatal and postnatal infants induce the reorganization and malfunction of cortical development23. Studies of rat models of early postnatal transient and chronic hypothyroidism have observed abnormal cellular integrity and reduced myelinated axons on electron microscopy, as well as increased T2-based relative signals on magnetic resonance imaging23; levothyroxine treatment has been found to be ineffective in protecting neuronal organizations25. Moreover, brain functional alterations in neurotransmitters, such as the ratio, density, and size of glutamate and inhibitory amino acids, have been found in the neocortex of rodents with gestational and early postnatal hypothyroidism26. Thus, we hypothesized that abnormal TH in preterm infants could affect thalamocortical connectivity due to impaired neuronal myelination or activation.Thalamocortical tracts grow rapidly from 25 weeks of gestational age to TEA to become major white matter organizations that contribute to fundamental visual, auditory, motor, and somatosensory functions33. DTI studies of preterm infants have found that their thalamocortical connectivity is reduced compared to that of their term-equivalent counterparts30. The diminished connectivity was found to be positively correlated with cognitive dysfunction, as assessed through the Bayley-III , at the age of 2 years34. In addition, performance on the Bayley-II assessment of mental development and non-psychomotor outcomes is closely associated with the dysfunctional connectivity of the premature thalamus35. Although the degeneration of fiber integrity in premature brains has proven to be linked to developmental outcomes35, thyroid dysfunction commonly increases the risk of neurodevelopmental disabilities in VLBW infants16, making clinical treatments more ambiguous. Several studies regarding thyroid dysfunction have focused on morphometric analysis in children with congenital hypothyroidism36 or adults with hypothyroidism37, suggesting hypothyroidism can alter significantly white matter volume or cortical thickness. Moreover, a DTI study demonstrated an association between reduced white matter integrity in infants with CH and adverse cerebral abilities, including diminished hearing, nonverbal intelligence quotient, core language, and communication skills38. Another investigation using DTI showed high apparent diffusion coefficient values in the cerebral regions of premature infants with CH, which implies decreased cellular activity39. DTI can provide meaningful insight into SH-induced abnormalities in the fiber integrity of preterm infants, since SH are not only difficult to diagnose or treat in a few weeks because of the lack of remarkable clinical signs but are also connected to the advent of the CH16. However, whether these findings apply to preterm infants with SH remains unclear, and DTI investigations of the fiber connectivity of thalamocortical pathway in preterm infants with SH are needed. This study aimed to determine whether altered fiber integrity and asymmetries in thalamocortical pathways can distinguish preterm infants with SH from their healthy counterparts.Diffusion tensor imaging (DTI) using magnetic resonance imaging (MRI) is a sensitive method for evaluating myelination abnormalities of white matter in the premature brainp = 0.001). The individual TFT at each time point differed significantly between the SH group and CN group at the first  and second time points , but not at the third  (Table p = 0.191), second , and third  time points. Gestational age, age at scan, birth weight, and body weight at MRI scan were not significant differences between the SH group and CN group (p > 0.05). Pre and postnatal treatment with steroid had no significant effect on the SH group and CN group (p > 0.05). The incidence of respiratory distress syndrome, necrotizing enterocolitis, and bronchopulmonary dysplasia were not significant differences in preterm infants with SH than in the controls (p > 0.05) , periventricular leukomalacia (n = 4), small for gestational age (n = 3), Down syndrome (n = 1), Russell-silver syndrome (n = 1), and maternal thyroid diseases (n = 1). In a cohort of 79 infants, we have classified infants with normal TSH levels  and infants with abnormal TSH levels  based on TSH levels within 6 weeks of life. Finally, after excluding 14 insufficient MR, the final cohort consisted of 29 preterm infants with SH and 36 preterm infants without SH  . Significant reductions in fiber lengths of 49.5 ~ 82.8% were observed in unilateral regions between the CN and SH groups: right ORB, 82.8%; the left SOG, 73.3%; left CUN, 68.2%; left MCG, 68.2%; left MFG, 65.7%; and left ROL, 49.5% , heschl’s gyrus (HES), calcarine cortex (CAL), and lingual gyrus. Abnormalities found only in the right and left hemispheres included the right orbitofrontal (ORB) and the left middle frontal gyrus (MFG), rolandic operculum (ROL), middle cingulate gyrus (MCG), superior occipital gyrus (SOG), and cuneus (CUN), respectively. In both cerebral regions, fiber lengths were 62–73% shorter in infants with SH relative to their CN counterparts . In addition, the CUN was significantly lower in the SH group (0.395 ± 0.100) than in the CN group . The lateralization values in the other regions showed slight increases or decreases, but none were significant , the test was repeated after 1 or 2 weeks according to careful consideration by the pediatric endocrinologists at our hospital. The TSH levels measured through serial TFTs were calculated as average values with standard deviations for each and total steps. The Hanyang University Hospital Institutional Review Board (IRB No. 202101015) approved this study protocol, and informed consent for participation in this study was acquired by the parents. All procedures were performed in compliance with the principles of the Declaration of Helsinki.All preterm infants who were admitted to the neonatal intensive care unit of Hanyang University Clinic for Developmental Disorders were initially recruited to investigate their cerebral development between February 2016 and January 2019. Preterm birth was defined as being born before 32 weeks of gestation with a birth weight of < 1.5 kg. All recruited infants were confirmed through MRI and ultrasonography screenings to have no brain injuries at near-term ages , such as focal abnormalities, intraventricular hemorrhage, chromosomal abnormalities, congenital infections, cystic periventricular leukomalacia, and Down syndrome. Infants with SH were distinguished from those without SH by TSH values of > 6 and < 20 μU/mL; the measurements were averaged across three serial TFT administered at 1, 3, and 6 weeks of life. Clinical characteristics included gestational age, age at scan, birth weight, body weight at MRI scan, Apgar scores at 1 and 5 min, cesarean section, patent ductus arteriosus and it with requiring surgery, prenatal and postnatal steroid, respiratory distress syndrome, culture-proven sepsis, necrotizing enterocolitis and it with requiring surgery, and bronchopulmonary dysplasia. Serial TFTs measuring both serum TSH and fT4 levels were routinely performed at 1, 3, and 6 weeks of postnatal age for all VLBW infants. Even if the initial TFT values obtained at 7 days of life were normal, we repeated the screening test at 3 weeks (from 14 to 21 days) and 6 weeks (from 42 to 49 days of life) because delayed elevations of TSH elevation is common among premature infants2, voxel sizes = 1.56 × 1.56 mm2, slice thickness = 2 mm, slice numbers = 50, flip angle = 90 degrees, water-fat shift = 4.68 Hz/pixel, number of average = 2, directions = 16, b-values = 1000, total acquisition time = 6 min 17 s. In addition, structural T2-weighted images were obtained to exclude preterm infants with white matter abnormalities. The parameters for the scan were as follows: TR = 4800 ms, TE = 90 ms, FOV = 180 × 180 mm2, voxel sizes = 0.5 × 0.5 mm2, slice thickness = 3 mm, slice numbers = 25, flip angle = 90 degrees, water-fat shift = 4.68 Hz/pixel, number of average = 1, total acquisition time = 6 min 30 s.The CN and SH groups were examined at near-term ages (PMA 36–41 weeks) using whole-body 3 T MRI  with a 16-channel phase-array head coil during natural sleep while they were covered with a blanket to maintain body temperature. Their safety was ensured by monitoring pulse oximetry, respiratory rate, and heart rate by a trained pediatrician during the MR scans. For the DTI, three-dimensional (3D) echo-planar images with a single-shot spin-echo type were acquired with volume B0-shimming. The scan parameters of the DTI were as follows: TR = 4800 ms, TE = 75 ms, field of view (FOV) = 120 × 120 mmhttps://fsl.fmrib.ox.ac.uk/fsl/fslwiki)57. First, we implemented motion correction using mcflirt, which is a part of the FSL58. Twenty preterm infants whose fractional anisotropy maps showed motion artifacts were removed from the DTI analysis 60 from 16 directional DTI images, applied linear registration from diffusion space to a neonatal T2-weighted image of the University of North Carolina (UNC) atlases61, and vice versa. Subsequently, the bedpostx GPU-version62, which default corrects partial volume effect63 since the slice thickness of this study was a bit thick, was executed with the advanced options (Fibers 3 and Rician option for uniform noise levels) to rapidly estimate fiber distributions for each voxel of the brain. The GPU-based probtrackx was also employed to extract information related to fiber connectivity between the thalamus and various cerebral regions64. The thalamus in the neonatal UNC-labels was assigned as the main seed, and each cerebral UNC region was allotted as a stop criterion to check the left and right thalamocortical integrity. The regions of interest from the thalamus to each cortex were defined by Ball et al.30, as illustrated in Fig. 65 of the FSL was determined with randomize to find the significant thalamocortical tracts between the control and the SH. The parameters for the TFCE were designed for a two-sample unpaired t-test without not modeling mean values in the design matrix. Subsequently, the threshold value was selected with 0.95; it is equivalent to p < 0.05. We controlled family-wise error rate after TFCE.The 3D-DTI images were used to reconstruct the thalamocortical connectivity based on fiber length using the FMRIB Software Library (FSL, 66. In addition, the cerebral regions of newborns feature neurodevelopmental asymmetries. Some regions, such as the superior temporal gyrus and orbitofrontal gyrus, develop independently to become dominant in the left or right hemisphere48. This extent of this difference is determined by lateralization evaluations46. Thus, we utilized the lateralization index and TFCE analysis to check whether the developmental processes of the significant thalamocortical tracts were changed:Cerebral myelination in term-born neonates progresses rapidly in the whole brain between 6–20 months; between 21–48 months of life, myelination gradually escalates in the frontal and temporal lobes relative to the parietal and occipital lobesp value was assigned to a significant range of < 0.05.Although the significant thalamocortical tracts of the fiber lengths were extracted through the TFCE in the FSL, the differences in subject populations and cerebral asymmetries were evaluated using SPSS 22.0. The statistical analysis was conducted with the 5000 permutations and two-group differences. The analysis was adjusted for the covariates of gestational weeks and age at scan. The corresponding values for the significant UNC tracts were extracted using the cluster function of the FSL, which was calculated as average values with standard errors. The chi-squared distributions and independent t-tests were implemented for demographic and clinical characteristics. We also analyzed each LI value of the significant thalamocortical regions calculated with fiber lengths, which were evaluated by ANCOVA adjusting the gestational age and the age at scan. The comparison of the main effect was conducted with Bonferroni correction, and the adjusted


Juvenile idiopathic arthritis (JIA) is the most common inflammatory disease influenced by genetic as well as environmental factors. Prior studies from Israel and USA suggested that JIA had a seasonality of birth, with birth peaking in winter and especially in January.The aim of the study was to evaluate the impact of month of birth and season, and the onset of JIA in Tunisian children.We conducted a case-control study including 27 children with JIA compared with a homogeneous control group of 27 children hospitalized in a pediatric orthopedic unit for traumatic reasons and healthy for any chronic inflammatory rheumatism. Statistical differences between groups were also analyzed by non-parametrical tests.n = 2), polyarticular rheumatoid factor negative (n = 5), psoriatic arthritis (n = 1), enthesitis-related arthritis (n = 11) and oligoarthritis (n = 8). Although the majority of children with JIA were born in November (22.2%) and December (18.5%), there was no significant difference in month of birth distribution between the cases and the controls. Likewise, there was no significant correlation between season of birth and the onset of the disease .Fifty-four patients  were enrolled. The mean age was 11.04 ± 5.58 years and the mean duration of the diseases was 5.29 ± 3,18 years. The frequency of each JIA subset was at follows: polyarticular rheumatoid factor positive (This study didn’t show any correlation between season and month birth, and the onset of JIA. Our result may be explained by the weather in Tunisia which is relatively warm with little variation in temperature between seasons compared with the country where they found a significant correlation. It also may be due to the limited number of our cases.


There was no difference in survival or other major morbidity in the hyperthermic babies compared to the normothermic babies. There was no association between hypothermia and survival or any major morbidity, although this probably reflects the low power of the study given the low rates of significant hypothermia. Higher admission temperature was associated with an increase in the risk of major cranial ultrasound abnormality using multiple logistic regression analysis (p = 0.007) with an increased odds ratio (95% CI) of 1.48 (1.11 to 1.97) for each degree of increase. We conclude that admission hyperthermia is independently associated with an increased risk of preterm brain injury. It is not possible to state whether this is a causative association, or whether the association is a consequence of a shared aetiology of perinatal infection.National and international recommendations for thermal care at preterm birth include recommendations to avoid hypothermia and hyperthermia. There is limited evidence demonstrating harm resulting from admission hyperthermia. Our aim was to assess the relationships between admission temperature and outcomes in very low birth weight (VLBW) babies in a unit with low rates of hypothermia and a higher rate of hyperthermia. This was an observational study based on routinely collected data including demographics, admission temperature, survival and major morbidity outcomes. Subjects were 1104 consecutive inborn VLBW babies admitted to a Neonatal Intensive Care Unit in United Kingdom between 2010 and 2017. Results: 155 (14%) of babies were hypothermic (<36.5 °C) with only 21 (1.9%) < 36 °C, and 254 (23%) of babies were hyperthermic (>37.5 °C). The rate of major abnormality on cranial ultrasound scan was increased in the hyperthermic babies compared to the normothermic babies (37/239 (15.5%) vs. 54/601 (9%), relative risk (95% CI) 1.723 (1.166 to 2.546),  It is well established that hypothermia on admission to the neonatal unit is an independent predictor of mortality in preterm babies. This association continues to be described in the recent literature from many countries including UK , Europe In our unit, we have achieved a low rate of admission hypothermia in preterm babies over recent years, but have seen a higher rate of hyperthermia as a consequence. Our aim was to investigate whether the admission temperatures for inborn very low birth weight (VLBW) babies admitted to our neonatal intensive care unit (NICU) between 2010 and 2017 predicted mortality or major morbidity before discharge.Data are routinely collected prospectively on all VLBW babies admitted to our unit for the purposes of benchmarking. For the purposes of this study we collected patient demographics, NICU admission temperature, survival to discharge and major morbidity data for all babies in the study period from between January 2010 and December 2017 inclusive. All inborn babies admitted to the NICU with a birth weight below 1500 g were included. Morbidity definitions included: the presence of a major abnormality on cranial ultrasound , bronchopulmonary dysplasia (BPD) , necrotising enterocolitis (NEC) and sight threatening Retinopathy of Prematurity (ROP) (defined as stage 3 or higher).Initial analysis was performed in order to explore differences in outcomes by the temperature groups defined by NNAP. Babies were classified into groups as either hypothermic (<36.5°C), normothermic (36.5 °C to 37.5 °C) or hyperthermic (>37.5 °C) based on admission temperature. Clinical outcomes of the hypothermic and hyperthermic groups were compared with the outcomes of the normothermic groups using Chi-squared with Yates’ correction and calculation of relative risk compared to the rates in the normothermic group.Analyses were also performed with admission temperature as a continuous variable using regression analysis for other continuous variables or Mann–Whitney test for dichotomous variables as appropriate. Significant associations observed on univariate testing were entered into multiple regression analyses to determine which were independent associations.All analysis was performed by using SPSS v26 .This study was approved as a service evaluation by the Effectiveness Senate of our institution in May 2021 .Data were available for 1104 babies. Demographics and admission temperatures are shown in A total of 695 (63%) babies were normothermic on admission; 155 (14%) were hypothermic, with 21 (1.9%) below 36 °C and only 1 baby below 35 °C; 254 (23%) were hyperthermic with 121 (11%) being above 38 °C.p = 0.006). There was no evidence of an increased risk of death in the hypothermic group, although this is likely to be a type 2 error due to lack of study power because of the low rate of hypothermia <36 °C in our cohort.Clinical outcomes in the hypothermic and hyperthermic groups were compared to the outcomes of the normothermic group . The onlThe relationship between admission temperature and clinical outcomes is shown in There were no statistically significant relationships between admission temperature, analysed as a continuous variable, and either death or NEC.p = 0.001) as well as lower birth weight (p < 0.001), shorter gestation (<0.001) and male gender (p < 0.001). Only birth weight, gestation and gender were found to be independently associated during multiple logistic regression analysis.On univariate testing, an increased risk of BPD was associated with higher admission temperature (p = 0.028) as well as lower birth weight (p < 0.001), shorter gestation (p < 0.001) and lower Apgar score at 5 min (p = 0.047). Only birth weight, gestation and Apgar score at 5 min were found to be independently associated during multiple logistic regression analysis.Similarly, on univariate testing an increased rate of sight-threatening ROP was associated with higher admission temperature (p = 0.001) as well as lower birth weight (p < 0.0001), shorter gestation (p < 0.0001) and lower Apgar score at 5 min (p = 0.0003). Higher admission temperature remained independently associated with an increased risk of major cranial ultrasound abnormality during multiple logistic regression analysis (p = 0.007) as well as the associations with shorter gestation (p < 0.001) and lower Apgar score at 5 min (p = 0.007). For each degree of increase in admission temperature, the likelihood of an abnormal cranial ultrasound scan increased by an odds ratio (95% CI) of 1.48 (1.11 to 1.97) or 48%.On univariate testing, an increased risk of major cranial ultrasound abnormality was associated with higher admission temperature The use of polythene bags in babies born before 30 weeks’ gestation since 2005. This practice was adopted based on a randomized controlled trial reported by Vohra et al., which demonstrated a reduced incidence of hypothermia . We have(b)The use of an exothermic gel mattress  in babies born before 28 weeks’ gestation since 2007. A recent meta-analysis has described the effectiveness of this approach  and we hWe did not find any increase in mortality or neonatal morbidity in association with hypothermia in our study. This is likely to be because our study lacks the power to find such a relationship due to the very low rates of hypothermia in our population (14% < 36.5 °C and only 1/1104 below 35 °C). The rate of hypothermia in our study population is much lower than that described in other recent studies, in which hypothermia rates of 40% to 50% are reported ,9. We beThe combined effect of these practices appears to have resulted in the higher rate of admission hyperthermia in our patients 23%) than the rates of less than 4% described in the recently reported studies 3% than t,8,9.It is likely that as strategies to reduce admission hypothermia are implemented into practice, there will be an increase in admission hyperthermia. For example: normothermia on admission at preterm birth has been a standard adopted across England and Wales as part of the NNAP since its inception. This has resulted in a 47% relative reduction in the rate of admission hypothermia (from 28% in 2015 to 14.7% in 2020). This has, however, been accompanied by a 13% relative increase in the rate of admission hyperthermia (from 10% in 2015 to 11.3% in 2020) [When a baby is found to be hyperthermic on admission, it could be due either to iatrogenic overheating during the period of stabilisation and transfer to NICU or due to the prevention of cooling during that period in a baby who is already pyrexial. Fetal intrapartum temperature is higher than maternal temperature by between 0.1 °C and 3.2 °C , so it iThere is very little published evidence relating to neonatal outcomes and admission hyperthermia at preterm birth. The most recent ILCOR evidence review states “Hyperthermia and its outcome remain less well studied with limited new evidence”. The current ILCOR recommendation is “We suggest that hyperthermia (greater than 38.0 °C) be avoided due to the potential associated risks ” .Lyu et al. found an increased rate of a composite adverse outcome  in babies with an admission temperature above 38 °C . The CliWe have found in this study that babies with hyperthermia at admission have an increased rate of major cranial ultrasound abnormality. Whilst it is possible that this reflects a causal association between admission hyperthermia and brain injury, it does not of course prove that there is a causal association.Chorioamnionitis, the most common cause of intrapartum pyrexia, is strongly associated with preterm brain injury. There are numerous studies that demonstrate a link between the presence of periventricular leukomalacia and perinatal infection. These studies and potential mechanisms of injury have been described by Strunk et al. . A meta-Maternal pyrexia will lead to hyperthermia at birth and this will result in admission hyperthermia in units that have good systems in place to prevent cooling during stabilisation and transfer. As units improve thermal care to reduce the rate of hypothermia, it is likely that they will see an increase in the rate of hyperthermia, which is likely to be a consequence of reduced cooling of already pyrexial babies rather than iatrogenic overheating.We have demonstrated an association between admission hyperthermia in VLBW babies and adverse cranial ultrasound outcome. We think it is probable that the association we have seen between admission hyperthermia and brain injury results from a shared aetiology of maternal infection rather than there being a direct causal relationship between the two, although further work is required to allow us to understand this association betterCurrent recommendations relating to thermal care at preterm birth advise the avoidance of hyperthermia as well as the prevention of hypothermia. We believe that, on the basis of current knowledge, the avoidance of hypothermia should be the priority.


The work of Deng et al. , 2 is inMy intention in writing this letter to the editor is not so much as a psychiatrist, but more as a physicist, to point out a fundamental problem in the calculation of electric field strength distributions in the human brain. The modeling of the electric field strength distribution in this study was done according to a method that was used in a tDCS study . This imIt is historically evident that ECT is an alternating current method, since sinusoidal wave generators were initially used. The sine waves were replaced by the modern short-pulse technology, but the frequencies used remained in the same spectrum. With an alternating current, however, it is not the electrical resistance that is crucial for Ohm’s law, as with a direct current, but the electrical impedance. However, the electrical impedance is not only determined by the electrical resistance, but also by inductivity and capacity of the current-carrying medium. These two parameters (capacity might be more important than inductivity), which are necessary for a correct modeling of the electric field, were not considered in the study. In addition, the portion of the electrical impedance determined by inductivity and capacity is strictly frequency dependent. In ECT, however, frequency typically differs depending on the applied charge (“dose”). This aspect is also not addressed in the study. Another very critical aspect is that the cited methodology study  uses curIn summary, I would like to point out that the models for calculating the electric field distribution in the human brain should currently be interpreted with care, taking into account that they are not validated by direct measurements. In this regard, it would be desirable to first model electric field distributions in animals and then validate them by direct electric field measurements before implicating consequences for therapeutic decisions of ECT practitioners.


The dynamic development of the automotive market entails the need to understand its characteristics. The purpose of this publication is to indicate the changes in the automotive sector resulting from the approaching electromobility. In order to achieve this goal, the market of electric and conventional vehicles in Poland are discussed. This paper discusses issues related to employment in the automotive industry, analyses the location of factories of the largest vehicle manufacturers and analyzes the structure of sales. The development of electromobility in Poland against the background of other EU countries was analyzed in detail. The analysis was based on data from September 2022. The analysis has been conducted by means of computations of the correlation of individual variables . The presented results show that the number of BEVs and PHEVs is increasing, and the infra-structure is developing. The number of PHEV cars is usually higher than BEV ones. The results of the analysis of the vehicle market in Poland show occurrence of the variety of vehicle types and variety of the types of vehicle power supplies with alternating current (AC) or direct current (DC). It can be concluded that standardization would be helpful for further development. The number of charging stations is small compared to the number of vehicles, and the advantage of AC stations is evident. This means investing in infrastructure is necessary to enable further development. One of the priorities of the European Union’s environmental policy is to reduce greenhouse gas emissions ,2. IncreThe term electromobility is usually understood as the totality of issues relating to the use of electric vehicles. This term refers to both the technical and operational aspects of electric vehicles, including technology and charging infrastructure. It also covers social, economic and legal issues related to the development, manufacture, purchase and use of electric vehicles. Overcoming social, financial and technical barriers requires coordination at the national, corporate and social level. According to the legal regulations for electromobility and alternative fuels, it is urban mobility that is driven by electric vehicles ,7. ThereWhen analyzing the issue of electromobility, it is important to emphasize the importance of aspects related to environmental protection, consumer awareness and knowledge of e-mobility and consumer purchasing behavior . When reThe rapid development of electromobility in the world has been observed for many years. Scientific papers examine regions of the EU, the US, Japan and other parts of the world ,13. EachConsumer purchasing power and marketing support for electromobility are noticeable . GovernmTo combat climate change, the European Parliament adopted the European Climate Law, raising the 2030 emission reduction target to at least 55%—“Fit for 55 in 2030”. Achieving climate neutrality is planned by 2050 .One of the solutions promoted by the EU is electromobility, which has driven technological development in the automotive industry for several years. Car manufacturers have more electric vehicles in their offers, and with the increase in the number of cars, the public charging infrastructure is also expanding. The development of electromobility is essential for the environment and has a positive impact not only on the automotive industry, but also on the entire economy ,23,24. NThe dynamic increase in the number of electric vehicles predicted by experts will contribute significantly to increased electricity demand in the electricity grid. If the charging patterns of electric vehicles can be correlated with the needs of the electricity system, it is possible to manage these needs through flexibility on the demand side. The issue of flexible energy management is particularly important today, with a precarious market situation where trends in electricity prices are currently very hesitant, with a strong growth trend in the near future.There are no emission-free cars. Electric cars are locally emission-free. This means that they do not emit any fumes and do not pollute the surrounding air in the place where they are used. The extent to which an electric car is truly emission-free depends on the source of energy used to power the battery.The development of the level of implementation of electromobility solutions in the individual EU Member States varies ,28.Electromobility is one of the fastest developing branches of the Polish economy. According to the source of “Licznik Elektromobilności” (Electromobility Counter), run by PZPM (Polish Association of the Automotive Industry) (PZPM) and PSPM (Polish Association of Alternative Fuels), there were 54,795 electric passenger cars on Polish roads as of the end of September 2022 . Fully eParallel to the fleet of electric vehicles, the charging infrastructure is also developing . In addiAt the end of September 2022, there were 2460 generally available charging stations for electric vehicles in Poland (4738 charging outlets). Approximately 28% of them were fast DC charging stations and 72% were slower AC chargers with a power less than or equal to 22 kW. In September 2022, 33 new public charging stations (79 charging outlets) were launched.Should the experts’ predictions come true, in 2023, every fifth Pole will decide to buy an electric car .The National Reconstruction Plan (NRP), funded by the European Union, will be of great help. The financial support includes investments in transport and electromobility and, thus, in a clean environment. Among other things, the NRP includes investments in electric mobility, the conversion of the urban transport fleet from diesel to electric or hydrogen, and incentives for the purchase of electric cars for individual drivers. The NRP includes proposals that were already adopted in the Electric Mobility Act 2018, long before the outbreak of the pandemic .In addition, according to the Polish NRP, clean traffic zones are established in cities with more than 100,000 inhabitants where air pollution standards are exceeded. According to the Law on Electric Mobility and Alternative Fuels, electric, hydrogen and natural gas cars and combustion cars complying with the highest Euro standards will enter the clean traffic zones, the first of which in Poland will be established in Krakow and Warsaw. The first of these cities will probably do so in 2024 .An electric car consists mostly of the same components as a combustion car. The main difference is in the batteries which are much larger than those of traditional petrol and diesel cars.Currently, almost all electric vehicles in the world use mainly three types of lithium-ion batteries ,36. NMC The use of e-cars raises other problems, such as the recycling of batteries after their end-of-life. According to Greenpeace, between 2021 and 2030, 12.85 million tons of lithium-ion batteries worldwide will have become unusable in electric vehicles . At the Currently, there are three main methods of recovering materials from used lithium-ion batteries used in electric cars ,39. The From the point of view of economic profitability, the sense of recycling is strongly dependent on the prices of metals that are obtained as a result of recycling .There are many studies, reports and expert analyses concerning the analysis and development of the electromobility market in the European Union and in the world, e.g., the EY (Ernst & Young) and Eurelectric report, EV Readiness Index ,42,43.According to a report prepared in 2022 jointly by EY and Eurelectric, by 2030 the number of zero-emission vehicles in Europe will have increased from 5 to 65 million, and in the next five years it will have doubled to reach 130 million cars . This crThe EV Readiness Index is a comprehensive analysis that shows the readiness of the European Union countries to transform in the field of transport electrification . The EV In recent years, consumers in Poland and around the world have increasingly used services as part of the so-called sharing economy. It is a new social and economic phenomenon, which requires a shift away from the ownership of goods and resources towards the sharing of goods and resources. The sharing economy covers transport services , tourism , financial services (coconut), catering (Quertes), labour market (ShareSpace) and automotive industry (car sharing). According to estimates by PwC (PricewaterhouseCoopers), the global turnover of the sharing economy will reach USD 335 billion in only five key sectors by 2025 ,45.The main scientific contribution to this article is to provide an overview of potential types of electric vehicle charging used in Polish conditions, and to indicate the growth trend in this area. Both the number of electric vehicles and the number of charging stations are increasing, which seems to be a natural consequence of the development of the electromobility market. Nevertheless, it should be clearly emphasized that the development of the automotive market in the area of electromobility is slower than economic and political assumptions. The automotive market requires observation and adjustment in the area of production, infrastructure development and a change in the awareness of drivers who are also consumers.Based on official reports from the field of electromobility and power supply systems in Poland and Europe, the team conducted its own scientific studies. In order to conduct a detailed and up-to-date analysis (as of September 2022), other source studies held by the scientific team were used for in-depth analysis. In the context of the collected source material, a detailed analysis was made of the development of the sector, which covered Poland and Europe ,49,50,51The manuscript is particularly focused on the case of Poland due to its geographical location and the observed energy transformation and the relatively short membership period among the European Union Member States .The statistical analysis that was conducted to verify the collected data was performed using the Statistica 13.3 SW. For this purpose, an analysis of the correlation of individual variables  was conducted. The correlation of linear relationship between the X and Y variables was investigated. Further research was conducted by analyzing the correlation relationship between the studied characteristics. This was done by starting with calculating the correlation between the variables, then drawing a graph. The relationship between variables is shown in graphs, called scatterplots. In the rectangular coordinate system on the abscissa axis, we mark one variable and on the ordinate axis the values of the second variable. The points corresponding to the individual values of the features form a correlation scatter plot. It rarely happens that the selected points lie exactly on a straight line (full correlation), the more common configuration consists of many selected points lying more or less along a specific curve . As the correlation becomes less and less excellent, then the points begin to disperse and move until they reach a shapeless point cloud (no correlation). Positive correlation occurs when the increase in the value of one feature corresponds to an increase in the mean values of the other feature. The strength of the interdependence of two variables can be expressed numerically by means of many measures. The most popular is the Pearson’s linear correlation coefficient-marked with the symbol r  and assuming values in the range . If both variables are measurable and have a distribution close to normal, and the relationship is rectilinear then it gives the possibility to calculate Pearson’s correlation coefficient. Hence the name Pearson’s linear correlation coefficient. When interpreting the Pearson’s linear correlation coefficient, it should be remembered that the value of the coefficient close to zero does not always mean no dependence, but only no linear relationship. The important point is that its absolute value informs about the strength of the relationship, while the sign of the correlation coefficient informs about the direction of the correlation. If r  = 0, it means a complete lack of correlation between the examined variables X and Y. It is noted that the correlation between variables is stronger the closer the absolute value of the correlation coefficient is to one.As the analyses interpret, the strongest correlation was noticed between the data on BEV and PHEV vehicles. In addition, the manuscript also performed a correlation analysis of the various variables .Employment and the level of remuneration for work undoubtedly affect the development of electromobility.In July 2022, the unemployment rate in the euro zone was 6.6%, compared to 6.7% in in June 2022. The unemployment rate in the EU was 6.0% in July 2022 and 6.1% in June 2022. Poland is among the countries with the lowest unemployment rate. In July it was 2.6% .Positive changes can also be seen in the labour market of people under 25 years old. There was a decrease from 8.6% in June 2022 to 8.4% in July 2022, with an average of 14% youth unemployment in the EU. Eurostat estimates that 12.931 million men and women in the EU, of which 10.925 million in the euro zone countries, were unemployed in June 2022. Compared to the same month a year earlier, unemployment fell by 2.311 million people in the EU and by 1.957 million people in the euro area. In June 2022, 2.546 million people under 25 were unemployed in the EU, including 2.073 million in the euro zone. The youth unemployment rate was 13.6% in both the EU and the euro zone. Compared to June 2021, unemployment in this age group decreased by 527,000 people in the EU and 450,000 in the euro area.The automotive industry is one of the pillars of the Polish economy. Currently, it accounts for 8% of GDP and about 13.5% of export value. Depending on the scenario, the share of electromobility in Poland’s GDP in 2050 could range from below 3% (passive option) to around 4%  to almost 6% (active option). In 2021, almost 439,000 new vehicles were made in Poland ,55.Employment in the Polish automotive industry in related industries is about 400,000. people, i.e., 7.6% of all employees in industry. This puts Poland in the third place in the European Union . Most peIn Poland, batteries and electric buses are mainly produced. Lithium-ion batteries account for more than 2% of all Polish exports ,59. In tSince 2017, Poland has been the leader in the European Union in terms of electric buses manufactured and exported. Between 2017 and 2021, a total of 1937 electric buses were exported from the factories located in Poland to the EU countries. Overall, the sector’s exports in 2017–2021 amount to more than EUR 750 million, i.e., 37.9% of the value of e-bus exports from the European Union .As of 2022, there are 301 car engine assembly and production plants in Europe: 134 factories in Europe produce passenger cars, 41 produce light commercial vehicles (vans), 52 build heavy goods vehicles (trucks), 66 produce buses, 72 make engines and 18 produce batteries . It shouThe drive system of an electric vehicle is responsible for delivering the stored energy in the battery to the engine. The enormous amount of energy that the drive system provides to the motors keeps the electric vehicle efficient and effective. Producing enough batteries can be a problem for many car manufacturers. Below  is a lisAccording to analyses from January to September 2022, batteries for electric vehicles with a total capacity of 341.3 GWh were installed worldwide . The leaThe semi-annual summary of the results shows the growth rate of battery production. CATL ended the year 2021 with an output of 96.7 GWh (market share of 32.6%) and reached 119.8 GWh this year. In return, BYD recorded a significant increase in its market share from 8.8% in 2021  to 12.8% in 2022 .In the first half of 2022, car sales in Europe fell by 13.7%, compared to 2021. However, the share of electric cars in new registrations is constantly growing and diesel cars are decreasing. This may be due to the length of use of the vehicle and the planned ban on registration of combustion cars after 2035. According to the ACEA report, the average age of passenger cars in Europe is 11.5 years. In Poland, 14.1. Slovaks and Latvians  and Croatians (14.6) have cars of similar age. Slovenians use newer cars—on average 11.7 years old, which is slightly above the European average. Lithuanians (16.8), Estonians (16.7) and Romanians (16.5) drive older cars and these are the highest average ages of passenger cars in Europe. The situation is not much better in Greece—16.0 years .In the first half of 2022, sales of battery electric vehicles in the EU accounted for 9.9% of all passenger car registrations . Plug-inFrom the point of view of the share of the brand and the automotive concern in 2022, the best result on the European market was recorded by the BMW Group  70]..70].In the six months of 2022, there were 5,027,547 new cars in Europe—13.7% less than in the corresponding period of 2021. In 2021, 5,864,951 units were registered. The largest decreases were recorded in Lithuania (−25.1%) and Italy (−22.7%)  71]..71].There are still very few electric car charging stations in Europe. There are far too few of them for the entire European Union to move away from the sale of new internal combustion cars in favor of electric cars in 2035. In 2020, there were over 307,000 charging stations for electric cars in the EU . The difIn September 2022, there were 58,474 electric vehicles registered in Poland  73]. Am. Am73]. At the end of August 2022, the fleet of electric vans and trucks consisted of 2403 vehicles. The fleet of electric mopeds and motorcycles continued to grow and consisted of 15,446 vehicles. The fleet of electric buses in Poland increased to 789 vehicles.A detailed analysis of the development of electromobility in Poland, broken down by individual provinces, is presented in p < 0.05—indicates that the value of the correlation coefficient is statistically significantly different from 0. This means that the relationship is significant while the correlation coefficient is not statistically significant [As shown by the statistical test, the null hypothesis H0—Pearson’s linear correlation coefficient is 0, while the alternative hypothesis H1 ≠ 0, i.e., nificant .According to the data presented in A summary of the statistical values of each variable is provided in From the study results presented, it is clear that the correlation is strong (r = 0.99332). However, the dependency itself suggests that both electric vehicles (BEV) and hybrid vehicles (PHEV) are becoming increasingly popular.p < 0.05 and amounts to p = 0.00.In further statistical analysis, a fairly strong correlation was also noticed between AC vehicle charging stations and DC vehicle charging stations . Table 4The correlation between the number of charging stations for DC vehicles and the number of charging stations for AC vehicles for the period 2019–2021 is shown in The results of the statistical correlation analysis of the charging station variables AC vs. charging station DC are shown in 2 square of the correlation coefficient) is 0.948739. This is a descriptive measure of accuracy that indicates the fit of the regression to the empirical data. It takes values in the range <0, 1> and reports how much of the total variation in Y observed in the sample was explained (determined) by the regression against the variable X.The individual fields of the results sheet contain arithmetic means of selected variables  and the standard deviation values . From the data in 2 is, the better the dependency and the confidence in a possible regression line is also expected to be greater. The value of the t-statistics, which examines the significance of the correlation coefficient, is, therefore, 23.95313, while the test probability value is p = 0.0000, the group size is 33 cases and the linear regression of Y versus X is 17.74039. In addition, the coefficient of linear regression of the variable Y with respect to the variable X is 0.447761 and the intercept linear regression of X with respect to Y is 5.659202, while the coefficient of linear regression of variable X with respect to Y is 2.118851.The data submitted also show that the larger rThe data presented in In the final part of this study presents basic descriptive statistics (location measures) comprising median, quartile and minimum and maximum for the following variables: vehicle charging type 1 and 2 , CHAdeMOIn the case of charging vehicles with TYPE 1 and 2 connectors, which allow charging electric cars with alternating current (AC), it can be seen in Type 2 plugs  have become a standard on the European market—the vast majority of currently produced vehicles are equipped with this type of connector. Such plugs have some models of brands such as Mercedes, BMW, Volvo, Tesla and Renault. Of course, there are also electric cars with a type 1 plug on our roads, but they are in the vast minority. Type 1 connector can be found mainly in vehicles of French or Japanese manufacturers. However, in their case, type 2 plugs are becoming increasingly popular.The CHAdeMO (charge de move) connector was initially used only in cars intended for the Asian market. Over time, it appeared on other continents, mainly due to the popularity of the Nissan Leaf car.The standard in Europe today is the extended version of the type 2 connector, i.e., CSS Combo 2, while in the USA the standard is the type 1 extension—CSS Combo 1. CSS Combo 2 differs from the standard type 2 by the presence of two additional risers ensuring faster loading. The CSS Combo 1 solution is popular in cars, such as the Chevrolet Spark, BMW i3 (intended for the US market) and numerous vehicles of other brands intended for the American market. Due to the fact that the share of Tesla vehicles on the Polish market is not very common, it is also confirmed by the share of Tesla Charging Connector in the market of charging station solutions presented in Electric cars are not a very new technology, but the electromobility sector in the context of private transport is still a novelty on the market. As a result, the prices of this type of vehicle are relatively high compared to cars with conventional drives. The overriding problem is the access to infrastructure. There are still no economically viable methods to recycle the residues from electric cars.At the end of 2021, there were 2,571,359 people employed in the automotive industry in the European Union, of which, 214,642 in Poland. Most people were employed in Germany—919,002 people.In the European Union and in Poland, the entire automotive sector is developing very dynamically. It is a significant employer and one of the largest branches of the economy. Currently, the automotive industry in Poland accounts for 8% of GDP and approx. 13.5% of export value. The automotive industry is currently undergoing the fourth industrial revolution. Technologies that help optimize production and artificial intelligence which drives the development of autonomous cars, have a key impact on the industry.In 2022, there are 301 car engine assembly and production plants operating in Europe, of which 194 are located in the European Union (EU-27). Most factories are located in Germany. Among the countries outside the EU, Russia should be mentioned with 33 factories producing cars and components.In the first half of 2022, 5,027,547 new cars appeared in Europe, 13.7% less than in the same period of 2021. Sales of battery electric vehicles in the EU accounted for 9.9% of all passenger car registrations.In 2021, across Europe, there were over 380,000 charging outlets.In September 2022, there were 58,474 electric vehicles registered in Poland, including BEV (49%) and PHEV (51%). The fleet of electric buses in Poland has increased to 789 units.At the end of September 2022, there were 2460 charging stations in Poland for 58,474 electric vehicles.Based on the analysis conducted, it can be concluded that:The future of electric and hybrid vehicles depends on many factors, including from technological progress, adaptation of road infrastructure and improvement of the methods of obtaining electricity . Most liTaking into account the current trends and conditions of vehicle use, in the future we can expect faster development of technologies related to their electric propulsion . The parOne more important issue to be solved is the problem of energy storage and the capacity of the batteries that serve this purpose.The cheapest way to charge an electric car is to have your own charger and a properly selected photovoltaic installation . By connThe electric vehicle market is likely to develop dynamically in the coming years, which is confirmed by numerous observations and studies. Nevertheless, it is necessary to observe the situation and analyze its potential, because these are huge industrial and infrastructure investments, so in order for the solutions to be widely used, they must be conscious and thoughtful. In addition, the benefits must compensate for the costs incurred and there are many of these in the area of electromobility development.