Lack of a timely receipt of vaccines can cause uncertain immune response and under-vaccination. Hence, timely vaccination is crucial to ensure an infant’s early protection.To identify the age of presentation for the birth dose vaccines, vaccine antigens received and factors associated with vaccination presentation by day one in Northern Nigeria.A descriptive cross-sectional study involving 1 952 mother-infant pairs enrolled from 5 different states in Northern Nigeria. Data was collected using a questionnaire including the socio-demographic, antenatal care (ANC), delivery details, birth dates, vaccination presentation and birth vaccine antigens received. Data analysis was done with the SPSS-21 software.Bacille-Calmette-Guerin by 1 781 infants (91.2%), oral polio vaccine 1 703 (87.2%), and hepatitis B vaccine birth dose the lowest at 75.1% (1 565). The commonest reasons for delayed presentations were an ill baby (24.7%) and an ill mother (21.9%).The median age of the infants at presentation for birth vaccines was six (interquartile range 2–16) days. A total of 413 (21.2%) infants were brought by the day of birth (day 0) or the next day (Day one), while one-fifth (20.6%) presented after Day 28. The most frequently received antigen was the Factors associated with presentation within Day one post-birth were hospital delivery , firstborn , Christianity , and mother with tertiary education .Timely administration of the birth dose vaccines is low in Northern Nigeria. Furthermore, some babies do not get the required vaccines despite presenting for vaccination due to stockout. Strategies for early neonatal vaccination such as vaccination in hospital suites post-delivery and utilizing relatives/fathers to take the baby for vaccination when a mother is indisposed are imperative. Bacille-Calmette-Guerin (BCG), hepatitis B vaccine birth dose (HBV-BD), and oral polio vaccine (OPV°) at birth [In Nigeria, the National Programme on Immunization (NPI) recommends that newborns receive a single dose of at birth . Vaccinaat birth . UnfortuNigeria is a highly endemic country for hepatitis B (HepB) infection, with most infections in children acquired prenatally or in early childhood . The repThe timeliness of birth dose vaccination remains a significant problem in developing countries with weak immunization systems 910. Lack9Study design and setting: A descriptive cross-sectional study was conducted at 5 immunization centers in five different Northern Nigeria states. The study sites comprised 2 North-Central centers, 2 North-West centers and a North-East center . In the North-West, the study sites were Katsina town in Katsina and Gusau in Zamfara States, respectively. For the North-Central, in Bida, Niger state and Omu-Aran, Kwara State, while in the North-East, Gombe town in Gombe state were selected  is responsible for vaccine supply to each local government area. The vaccinators collect the vaccines from a central vaccine store twice to thrice weekly for utilization. The vaccine package consists of multi-dose vials for the OPV , Hepatitis B vaccine  and BCG  vaccines. Also, there are no facility or provider costs to the parent for the vaccines.Sample size determination: This is a secondary analysis of data collected for another study on parental willingness to receive reminders for routine vaccination appointments in North Nigeria; a total of 1 952 mother-infant pairs were enrolled in the study [he study .The eligibility criteria consisted of mothers/caregivers and their newborns at presentation for the birth dose vaccines and with consent to participate in the study.Data collection instrument: This was a semi-structured, interviewer-administered questionnaire deployed in English, Hausa, Nupe or Yoruba languages by research assistants at each center. It had an average time to completion of five minutes. Every mother-baby pair presenting at the immunization center who satisfied the eligibility criteria was consecutively enrolled. The interviewers collected the socio-demographic details of each mother-infant pair, such as gender, mother’s age, marital status, religion, level of education and parental occupation. Responses on ANC attendance, place of delivery of the baby and the birth order of the infant were documented. The date of birth and the date the baby was brought for the birth dose vaccination were recorded. Responses were captured on the reason for the delay in the presentation if the neonate was brought after Day one. Subsequently, the mothers were educated about the importance of vaccination and the number and timing of each vaccination appointment. Enrolment occurred between June 2019 and February 2020.Primary outcome measure- the average age of the infants at presentation for the BD vaccinesSecondary outcome measures-The proportion of children that received the B.D. vaccines within days 1, 7, 14, 28 and >28The proportion of infants that received each of the vaccine antigensThe reasons for presentation after 24 hoursData analysis: The data was analyzed using the IBM® SPSS version 20.0  2011. Differences between the date of birth and the presentation day were calculated to identify the interval (in days) to presentation. Timeliness was within Day one .p-value of less than 0.05.The mean  or median  were used to describe the continuous variables. Frequencies with percentages were used to describe categorical variables. The student t-test was used to identify significant differences between continuous variables. A binary logistic regression model was used to identify factors associated with the timely presentation within one day post-delivery. The level of significance was a Ethical Considerations: The study protocol was reviewed and approved by the relevant Ethical board at each study site . Each caregiver signed the informed consent form after a clear explanation about the study. We did not give incentives to subjects for study participation.Demographic characteristics of mother-infant pairs—The median age of the infants at presentation for the birth dose vaccines was six days (interquartile range 2–16 days). There were 956 (49.0%) males and 996 (51.0%) females.Time of presentation for the birth-dose vaccination—The majority number (78.8%) of the infants did not present for birth-dose vaccination within Day one; only 413 (21.2%) infants presented on the day of birth or the next day , and the HBV-BD was the lowest at 75.1% . Table 2Reasons for a delay in presentation—Only 28.5% of mothers proffered reasons for their delayed presentation. Factors associated with vaccination within Day one: The odds of receiving vaccination were almost 4 times and one-and-a-half times higher among petty traders and teachers, respectively, than the unemployed mothers. Infants of mothers with tertiary education had 1.6 times odds of receiving vaccination within Day one compared to infants of mothers with no formal education. Infants with birth orders less than the fifth had 1.5 times odds of receiving vaccination on day one than those with higher birth order  recommends that newborns receive HBV within 24 hours of delivery to reduce the risk of mother-to-child transmission of the virus . This cl19et al. [et al. [A significant reason for the vaccination of neonates after 24 hours in the current study was the mother’s ill health, similar to the report by Sadoh et al.  and Ibra [et al.  Delay in [et al.  and Viet [et al. .The most received vaccine was BCG, while the least was HBV-BD in the current study, similar to the report from Senegal of the crude vaccination coverage for BCG, OPV°, and HBV-BD were 95.2%, 89.3% and 88.1% , respectHospital delivery was associated with a timely presentation for vaccination within day one in the current study, which is similar to findings reported from Benin and Ilorin in Nigeria 16 and SeLow birth order of the baby had an increased odd of timely birth vaccination receipt, similar to findings from Zaria in Northern Nigeria. However, the latter study used seven days as an indicator of timeliness and reported solely for BCG . ChildreIn Ethiopia, Boulton et al.  reportedMothers’ engagement in paid employment had reportedly been identified as a determinant of timely vaccination of infants in Bangladesh , which iA major strength of the index study is that it was conducted in multiple centres across 3 geopolitical regions in Northern Nigeria. Hence, it was able to identify areas where stockouts were a significant contributor to the non-vaccination of infants.Limitations include the study sites were located in urban or semi-urban areas that render delivery and immunization services. Hence, it may not wholly represent the rural area. Another limitation is the likelihood of nonresponse bias associated with reasons proffered for presentation after 24 hours, as less than 30% of the mothers responded. Therefore, the finding must be interpreted with caution as the reasons for the delay amongst the nonrespondents are unknown.The study identified low timely presentation for birth dose vaccines with variability across Northern Nigeria. Furthermore, some neonates do not get the required vaccines despite keeping vaccination appointments due to vaccine stockouts. Factors associated with delay include ill neonates and mothers. We recommend the need for strategies to focus on early vaccination of newborns, such as vaccination in hospital suites post-delivery, and use of relatives/fathers to take the baby for vaccination when a mother is unable and improved vaccine supply distribution in Northern Nigeria.


Lymphoepithelial cyst of the oral cavity is very rare. Most intraoral lymphoepithelial cysts are observed in the floor of the mouth and very few cases have been reported of its occurrence in the palatine tonsil.A 37-year-old healthy woman with no remarkable medical history visited our department with a complaint of frequent tonsillitis.On endoscopic examination, yellowish mass was observed in the palatine tonsil and removed via an intraoral approach. The mass was completely removed with the left palatine tonsil.Histopathological examination and immunohistochemical staining confirmed a Lymphoepithelial cyst.Lymphepithelial cysts of the palatine tonsils are extremely rare and are easily overlooked because there are few reported cases. Therefore, care must be taken when examining the tonsil mass. An intraoral lymphoepithelial cyst usually presents as an asymptomatic mass and is detected on routine physical examination. It is easily misdiagnosed as lipoma, fibroma, dermoid cyst, and so on. Its histological findings are characterized by a cystic lesion lined with stratified squamous epithelium surrounded by lymphoid tissues. Surgical resection is recommended if it is symptomatic, and lymphoepithelial cyst has minimal risk of recurrence and malignant change. the most common sites for an intraoral lymphoepithelial cyst are the tongue and floor of the mouth, which account for 88.3% of cases. Lymphoepithelial cyst in the palatine tonsil is extremely rare and very few cases have been reported. This article presents a case of lymphoepithelial cyst in the palatine tonsil with a review of previously reported cases. This study was approved by the institutional review board of Kyungpook National University Chilgok Hospital.According to Xi Yang et al,2A 37-year-old healthy woman with no remarkable medical history visited our department with a complaint of frequent tonsillitis. On physical examination, the left palatine tonsil was Friedman grade III and a yellowish lesion protruded in the medial portion of the palatine tonsil Fig. . There wThe patient underwent tonsillectomy on both sides to treat frequent tonsillitis and diagnose the yellowish lesion. The mass was completely removed with the left palatine tonsil; the size of mass was 2.5 × 1.5 cm Fig. . The cys3,3 Since palatine tonsil involvement is extremely rare and clinical characteristics are non-specific, many clinicians misdiagnose intraoral lymphoepithelial cyst as a mucocele, dermoid cyst, lipoma, and so on. Therefore, pathological confirmation is crucial for diagnosing lymphoepithelial cyst in the oral cavity. There are several theories on the pathogenesis of lymphoepithelial cysts, but Knapp's theory is the most accepted. He proposed that pseudocysts develop when the tonsillar crypt opening becomes plugged, which results in enlargement of the tonsillar tissue secondary to an accumulation of purulent materials or desquamated cells and keratin.Lymphoepithelial cysts account for only 0.09% of all oral biopsy specimens.–6To our knowledge, 6 cases of intraoral lymphoepithelial cyst in the palatine tonsil have been reported in the literature Table . The age male patients with lymphoepithelial cyst in the palatine tonsil outnumbered females by 2 to 1. Moreover, there were differences in the size of the lesions and patients’ chief complaints. The size of the lesions in the palatine tonsil was mostly greater than 1.5 cm in diameter, while most intraoral lymphoepithelial cysts are smaller than 1 cm in diameter. In addition, patients with lymphoepithelial cyst in the palatine tonsil were symptomatic, mainly complaining of difficulty in swallowing. However, most patients with intraoral lymphoepithelial cysts were asymptomatic. Therefore, differences in size and location of lymphoepithelial cysts may be responsible for symptoms in the patients.The age of the patients with lymphoepithelial cyst in the palatine tonsil was within the range of that of patients with intraoral lymphoepithelial cysts. However, unlike Xi Yang's analysis of intraoral lymphoepithelial cyst cases,Compared to other cases of lymphoepithelial cyst in the palatine tonsil, our case is notable for the size of the mass, which was about 2.5 cm in diameter. However, the chief complaint of frequent tonsillitis was not related the effect of the mass. There are no reports of neoplastic transformation or recurrence after surgical excision of these cysts.Conceptualization: Sung Jae Heo.Data curation: Jae Moon, Ji Jung, Jung Kim, Namkyun Kim, Sung Jae Heo.Formal analysis: Jae Moon, Ji Jung, Jung Kim, Namkyun Kim, Sung Jae Heo.Investigation: Jae Moon, Ji Jung, Jung Kim, Namkyun Kim, Sung Jae Heo.Methodology: Jae Moon, Ji Jung, Namkyun Kim, Sung Jae Heo.Supervision: Jung Kim, Sung Jae Heo.Validation: Jung Kim, Sung Jae Heo.Writing – original draft: Jae Moon, Namkyun Kim.Writing – review & editing: Sung Jae Heo.


Plant diversity may enhance stability of ecosystem function and its satellite-derived indicators. However, its potential to stabilize phenology, or seasonal changes in plant function, is little understood, especially in understudied systems with high biodiversity potential such as wetlands. Using a large sample of U.S. wetlands and a new satellite-based indicator of phenological stability, we found that plant diversity was negatively associated with interannual phenological variability after controlling for covariates representing climate, site conditions, and spectral fluctuations. Furthermore, plant diversity and covariates better explained phenological variability than stability in annually summarized satellite-based biomass indicators used by earlier studies. Last, a subsequent path analysis indicated that phenological variability could mediate plant diversity relationship with the latter stability. Our results suggest that contributions of plant diversity to seasonality of ecosystems may have a stabilizing role in their functioning and offer a new basis for assessing biodiversity-stability relationships across broad geographic extents. Wetland plant diversity stabilizes satellite-based indicators of biomass and the timing of ecosystem functions. Biodiversity contributions to long-term stability of ecosystem functioning  across the conterminous United States (table S1) , represec)  and native (NatSpecies_S) species richness, family richness (Family_S), and Shannon-Wiener diversity index for all (TotSpecies_H) and native (NatSpecies_H) species; table S1] were included in the highest-support regression models (c) ; howeverP < 0.05 for all; c models; however, it strongly and positively correlated with its SD . Wetland type determined by NWCA hydrological status and vegetation  were included less often and not significantly related to phenological variability in the highest-support models . Most of these hot spots were in coastal regions (fig. S3F).In contrast, SD in annual temperature , soil pH (Soil_pH), indicator of the cyclicality in greenness , and presence of agricultural stressors based on wetland adjacency to agricultural areas  positively correlated with phenological variability . Shannon-Wiener diversity (TotSpecies_H) showed a negative and significant but weaker association with phenological variability . Similar effects were observed also in the highest-support SEMs for family richness and for Shannon-Wiener diversity of native species (table S6). However, in models with native species richness, diversity also had a significant, although weak, direct negative relationship with phenological variability .Path analysis with SEMs found that in the highest-support models, plant species richness (TotSpecies_S) was negatively related to phenological variability , SEMs using stability of annual maximum NDVI to test similar hypotheses were not sufficiently supported (showing the ratio of chi-square to degrees of freedom greater than 3). Together, these outcomes suggest that interannual phenological variability may be a mediator in plant diversity relationships with stability of biomass when the latter is indicated by the annually averaged greenness.r = −0.28 and −0.21, respectively, P < 0.001 for each; r = 0.20, P < 0.001). However, the associations of mean atmospheric temperature and mean annual precipitation with stability of greenness were also negative and significant but weaker than those for phenological variability , suggesting lower variation in greenness phenology in more acidic wetlands. Last, Max_PSD, related to magnitude of the main cycles in greenness fluctuations, showed a very strong positive effect on phenological variability  and a somewhat weaker but significant positive effect on stability of greenness . This evidence suggests that wetlands with greater magnitude of greenness fluctuations may exhibit both less stable seasonality and less stable interannual biomass.Among other factors, soil pH had a strong positive effect on phenological variability , phenology has long been discussed as one of the essential biodiversity variables that could be monitored with the help of remote sensing data  suggests that future efforts should consider other covariates of phenological variability not captured by our data. Of particular importance can be variables representing hydrological connectivity among wetland sites, which may influence synchronies of their ecological processes (2 plots within a ~0.5-ha (40 m radius) assessment area  on phenological variability estimation and more reliably characterize the latter in terms of vegetation contributions. Note that in  or a low baseline  and sites where equivalent 8-day time blocks may differ in their potential magnitudes of greenness change . For the subsequent regression analyses, phenological variability estimated using   were conducted in MATLAB software v.2022a (MathWorks Inc.) using the function fitlm. The models were subsequently ranked using a form of the AICc . We then conducted similar regression model comparisons to test the associations of plant diversity and covariates with each of the 14 alternative measures of stability (table S3).We assessed the association between phenological variability and plant diversity of NWCA wetland sites using generalized linear regression modeling with phenological variability (PhenoVariability) as a response variable, plant diversity as the main predictor variable, and several covariates  described below. The main goal of this analysis was to examine the importance of diversity at the broad scale of NWCA data after adjusting for the relevant covariates identified through the most parsimonious models as discussed below. We tested regression models with different combinations of plant diversity, and covariates . These included proxies of climate, local soil properties, cyclical variability in the greenness time series, wetland hydrological type, prevalence of medium-tall vegetation, NWCA-determined disturbance status, and severity of agricultural stressors in the wetland buffer area (table S2).Climate covariates were included to adjust for climate-induced variability in phenological timing of changes in greenness  computed from MOD11A2v.6 LST product at 1-km spatial resolution. To address the key challenge of temporal gaps in 1-km LST due to atmospheric effects, we developed a specialized gap filling approach. For each wetland site, we first identified missing values and assessed whether they formed consecutive sequences and of which length. Given the uncertainty associated with filling very large gaps, we applied gap filling only to sequences of no more than four consecutive missing values; sequences of five and more consecutive missing values were left as missing data. For portions of wetland time series that contained missing values and qualified for gap filling based on these criteria, we used MATLAB function fillmissing with the space-preserving piecewise cubic spline interpolation (“pchip” fill method of this function).i,j is the LST value for a given seasonal 8-day block i and year j in the time series and Nvalid is the count of seasonal 8-day blocks containing valid data .Next, we computed variability in LST as the average deviation in LST of the satellite pixel overlapping a wetland site from the mean value of its respective 8-day block during 2002–2019, corrected for the number of 8-day blocks that could not be robustly gap filledWe expected that greater variability in LST would be associated with greater phenological variability of greenness due to the variation in microclimate-related triggers of phenological events such as snowmelt . Such cyclical variability results from seasonal changes in vegetation biomass and flooding attenuation, which varies with plant height and cover .To perform periodogram analysis, the NDVI time series of each site were first differenced (using MATLAB diff function) to remove potential nonstationarity before periodogram estimation. Next, for each site, we computed periodogram as PSD associated with different frequencies of the signal using Welch’s method (MATLAB pwelch function)   maximum PSD across all possible signal frequencies (Max_PSD), related to the magnitude of NDVI change within the dominant greenness cycle of a wetland, and (ii) total number of clusters with significant PSD representing the total number of the most pronounced periodic cycles in the time series (NumPeaksPSD). We expected that wetlands with greater Max_PSD would show greater variation in phenological timing year to year due to a greater amount of greenness change associated with such a cycle. We further expected that temporary flooded conditions may affect Max_PSD by increasing the difference in NDVI between high-biomass stages with little attenuation and flooded conditions with low NDVI representative of water. Relatedly, frequent flooding could reduce the amplitude of greenness fluctuations by reducing the probability of remote observations of water-free plant biomass. We further expected that sites showing both lower Max_PSD and greater NumPeaksPSD would exhibit greater overall phenological variability due to more complex time series, such as in hydrologically variable sites.We also included the combined frequency of medium and tall vegetation summarized at the NWCA site level . This covariate was used to account for a potentially greater contribution of tall species (particularly woody plants) to site greenness, given a somewhat coarse 250-m spatial resolution of MODIS input data and the potential to obstruct the reflectance from herbaceous vegetation in their understory , both of which were expected to increase phenological variability but for somewhat different reasons (P > 0.05) paths to select the models where all path coefficients were significantly different from 0. We computed the standardized regression weight coefficients (r) to compare model effects and evaluated the fit of the models to hypotheses using (i) the chi-square test , (ii) the ratio of chi-square to degrees of freedom expected to be <3, and (iii) criteria of fit such as comparative fit index expected to be >0.90 for a reasonably good fit. Models not meeting these criteria were not analyzed further  and models in which the diversity variable’s regression β coefficient was not significantly different from the most negative coefficient value, indicating a higher-magnitude stabilizing effect of diversity based on the coefficient 95% confidence intervals.Last, to help interpret the statistical effects of diversity in the presence of covariates, we also compared the regression coefficients of diversity metrics between models with the highest statistical support (within 2 units of AIC


The fetal-to-neonatal transition poses an extraordinary challenge for extremely low birth weight (ELBW) infants, and postnatal stabilization in the delivery room (DR) remains challenging. The initiation of air respiration and the establishment of a functional residual capacity are essential and often require ventilatory support and oxygen supplementation. In recent years, there has been a tendency towards the soft-landing strategy and, subsequently, non-invasive positive pressure ventilation has been generally recommended by international guidelines as the first option for stabilizing ELBW in the delivery room. On the other hand, supplementation with oxygen is another cornerstone of the postnatal stabilization of ELBW infants. To date, the conundrum concerning the optimal initial inspired fraction of oxygen, target saturations in the first golden minutes, and oxygen titration to achieve desired stability saturation and heart rate values has not yet been solved. Moreover, the retardation of cord clamping together with the initiation of ventilation with the patent cord (physiologic-based cord clamping) have added additional complexity to this puzzle. In the present review, we critically address these relevant topics related to fetal-to-neonatal transitional respiratory physiology, ventilatory stabilization, and oxygenation of ELBW infants in the delivery room based on current evidence and the most recent guidelines for newborn stabilization. This is the driving force that will facilitate the extrusion of the fluid filling the conductive airways into the alveolar interstitial space. Lung aeration permits alveolar gas exchange, which subsequently causes a sudden increment of arterial partial pressure of oxygen (PaO2) [A successful fetal-to-neonatal transition relies on a series of exquisitely orchestrated physiological events that enable the switch from the placental intervillous gas exchange to lung air respiration . The inin (PaO2) ,4.2 favors the closure of the ductus arteriosus [Oxygen is a potent vasodilator that contributes to pulmonary arterial vessel dilatation, thus reducing pulmonary vascular resistance . Consequteriosus . Moreoveteriosus .In term newborns, birth asphyxia is the most common condition needing resuscitation . The maiOnly a decade ago, preterm babies needing respiratory support in the first minutes after birth were directly intubated and ventilated . HoweverIn recent years, delaying cord clamping has become a standard of care in term and preterm infants ,12. EvolPositive pressure ventilation (PPV) in the DR is of paramount importance for the resuscitation of term and the stabilization of preterm infants immediately after birth. The present review article provides a critical update to the recently published experience of ventilation in the DR of extreme preterm defined as newborn infants born at <28 weeks gestation.During fetal life, the gas exchange between mother and fetus takes place in the intervillous spaces of the placenta. Increased pulmonary vascular resistance renders pulmonary blood flow almost inexistent. Hence, oxygenated blood is redirected through fetal shunts  to the upper part of the body and especially to the cerebral and coronary circulations, thus avoiding non-perfused lungs that are not responsible for the fetal gas exchange . Hence, At birth, physiological factors such as the interruption of cord blood flow and the initiation of inspiratory efforts will cause significant hemodynamic changes. A sudden increase in the systemic vascular resistance caused by the interruption of the umbilical arteries’ blood flow contributes to the inversion of flow in the ductus arteriosus and foramen ovale causing their functional and anatomical closure. Simultaneously, the first inspiratory efforts extrude liquid filling the lungs, favor surfactant distribution, prompt lung aeration, and establish an FRC, which triggers a decrease in pulmonary vascular resistance, increases the pulmonary blood flow and oxygenation, and reduces the work of breathing. The establishment of an FRC is the cornerstone of the postnatal adaptation of the newly born infant.Subsequently, the left heart preload with oxygenated blood increases and closes the septal layer of the foramen ovale. Hence, the sudden postnatal increase in pulmonary blood flow directly depends on lung aeration and oxygenation and is essential to prevent the drop in cardiac output that will occur if cord clamping precedes lung aeration .The fetal-to-neonatal transition establishes parallel-type circulation in which deoxygenated blood reaches the right heart and is directed to low-resistance pulmonary circulation where oxygenation takes place. By contrast, the full return of oxygenated blood from the lungs to the left heart is directed to systemic circulation to provide tissue oxygenation .There are a number of reasons why the physiological fetal-to-neonatal transition can be disrupted in preterm infants ,22,23: SOf note, fluid accumulated in the alveolar interstitium generates positive pressure against the alveoli, which translates into an increased tendency of alveolar collapse and re-introduction of fluid within the alveoli during the expiratory phase. These circumstances are aggravated by a lack of surfactants in premature infants. Therefore, a positive end expiratory pressure (PEEP) or a continuous positive airway pressure (CPAP) has to be applied as respiratory support to premature newborn infants to prevent lung edema and/or atelectasis and alveolar collapse .During fetal life, the larynx offers resistance to the efflux of lung liquid and, in contrast to postnatal life, when apnea occurs in the fetus, the glottis remains closed in an attempt to prevent the loss of intrapulmonary fluid that is essential for fetal lung growth . Recent 2 rises from 30–40 mmHg (4–5.3 kPa) in utero to 70–80 mmHg (9.3–10.6 kPa) ex utero in a few minutes. Oxygen saturation, which fluctuates from 45–55% in the fetus, rapidly increases to 85–95% in the first 10 min after birth [The initiation of breathing immediately after birth boosts the availability of oxygen in the newly born infant. The PaOer birth . It is ver birth .2) monitoring with a pulse oximeter and keeping SpO2 within recommended ranges after birth titrating FiO2 accordingly [2 targets for the first 10 min after birth were based on the percentiles reference range put forward by Dawson JA et al. [2 as the lower acceptable value. SpO2 considered “safe” evolves from levels >60–65% in 2 min to >80% in 5 min [2 in the first 10 min after birth. Ashish KC et al. [2 was 18% higher by 1 min, 13% higher by <5 min, and 10% higher by 10 min in babies in the group of prolonged cord clamping. Padilla et al. [2 and HR curves in healthy-term newborns with delayed cord clamping for a median of 111 s. Compared with Dawson’s curves, they found significantly higher SpO2 and HR already in the first minute after birth. Thus, the median and IQR of SpO2 (%) at 1, 5, and 10 min after birth were 77 (68–85), 94 (90–96), and 96 (93–98), respectively. HR (beats per minute) median and IQR at 1, 5, and 10 min after birth were 148 (84–170), 155 (143–167), and 151 (142–161). Badurdeen et al. [2 was elaborated with a total of 295 infants >35 weeks GA with delayed cord clamping ≥ 2 min. Out of these, 54.6% were born vaginally and 45.4% by C-section. The median SpO2 reached 85% at 4 min and 90% at 5 min.Current guidelines recommend preductal oxygen saturation  initial FiO2. In addition, the use of lower initial FiO2 reduced oxidative stress and inflammation as reflected by specific biomarkers [2 group, the achievement of target saturation was often delayed and therefore these babies needed an increase in the inspired fraction of oxygen. In 2015, the International Liaison Committee on Resuscitation (ILCOR) guidelines recommended initiating the resuscitation of newborns <35 weeks GA with room air and very preterm infants <32 weeks of gestation with FiO2 0.3, thus discouraging the use of a higher concentration (FiO2 0.65–1.0) [2 0.21 (43%) or 0.3 (36%) [2 to targeted SpO2. Interestingly, of the 695 respondents, while 90% had pulseoximeters in the DR, only 69% had access to oxygen blenders, rendering oxygen titration impossible [Concomitantly, a series of clinical studies summarized in omarkers ,38. Howe.65–1.0) . In a re.3 (36%) . Howeverpossible .Oei et al. , in a ra2 < 0.4) or higher (FiO2 ≥ 0.4) initial oxygen concentration titrated to targeted SpO2 improved short- and long-term mortality and/or morbidity. The study included randomized controlled trials but also cluster- and quasi-randomized trials. A total of 10 trials with 914 infants were included. The results did not show any differences in mortality compared to discharge or secondary outcomes such as bronchopulmonary dysplasia (BPD), retinopathy of prematurity (ROP), IPVH, periventricular leukomalacia (PVL), necrotizing enterocolitis (NEC), or persistent ductus arteriosus (PDA). Moreover, no differences in neurodevelopmental disability were assessed at 2 years. However, the quality of the evidence was defined as low due to the high risk of bias and imprecision. The authors concluded that there is uncertainty as to whether using higher or lower initial FiO2 in preterm <32 weeks GA targeted to SpO2 in the first 10 min after birth has a significant effect on mortality or major morbidities or long-term neurodevelopmental disability at 2 years of age [Lui K et al. , employis of age .2 [In 2019, Welsford et al.  carried 2 .2 provided during postnatal stabilization in preterm infants have been published . It was concluded that the use of 100% oxygen could be a triggering factor for brain inflammation and damage that impaired neurodevelopment in survivors in infancy [2 of 1.0 to 0.21 for the stabilization of preterm infants. Kapadia et al. [2 0.3 vs. 0.6–0.65 in two randomized controlled and blinded trials. No differences in mortality were established. Moreover, Bayley III scales motor, cognitive and language composites, neurosensorial handicaps, cerebral palsy, or language skills did not show any differences between groups.Only a few follow-up studies dealing with the long-term influence of the initial FiOshed see . Soraish infancy . In 2011a et al. , in a rea et al. . Boronat2 should be titrated to achieve targeted SpO2s at specific time points using an air–oxygen blender  or unblinded (favoring high FiO2). Although the cause of this effect is not known, the authors suggested that the adjustment of FiO2 in response to changes in SpO2 could be the key to this difference. Hence, in a recent meta-analysis performed in newborns <32 weeks, evolving SpO2 in the first 10 min after birth was assessed [2 (≥80–85%) at 5 min. Moreover, not reaching 80% SpO2 at 5 min was associated with a higher rate of severe IVH, and the longer the time needed to reach SpO2 >80%, the higher risk of death. Newborns with lower GA and lower initial FiO2 were more likely to fail to achieve a SpO2 of 80% [2 in preterm infants <32 weeks GA, Oei JL et al. [2 was not associated with differences in death and/or disability or cognitive scores <85 at 2 years of age. However, SpO2 >80% at five minutes was associated with decreased disability/death and cognitive scores >85. It may be concluded that, more so than the initial FiO2, it is achieving oxygen saturation above 80% five minutes after birth that reduces mortality and brain damage in very preterm infants.In 2006, Canada changed the resuscitation policy from 100% oxygen for all born babies to 21%. In 2015, Rabi et al. , in a re28 weeks  found noassessed . Of note2 of 80% . In an iL et al.  found thn = 24) vs. 100% (n = 20) and observed their effect on spontaneous ventilation. They retrieved detailed information on the management of oxygen titration during stabilization and measured oxidative stress biomarkers. They found that the group resuscitated with 100% O2 had a better respiratory effort with significantly higher tidal volumes (VT), better oxygenation with a shorter duration of hypoxemia, and a shorter duration of ventilation compared to the 30% group, with no increased risk of hyperoxia or oxidative stress [Oxygen is a potent stimulator of respiratory drive. In experimental studies, it has been shown that hypoxemia induces respiratory depression . Dekker e stress . Howevere stress . These r2 (0.21–0.30) for newborns < 35 weeks who receive respiratory support at birth . However, there are some differences between the different guidelines. While the American Heart Association (AHA) [2 of up to 0.3, the ERC [Currently, the ILCOR 2020 guidelines  recommen2 0.21–0. for newb the ERC ) recommeDespite the immaturity of the lung, thoracic cage and muscles, and respiratory drive, approximately 80% of very preterm infants (<32 weeks GA) and even extremely preterm <26 weeks GA initiate spontaneous breathing or crying at birth. ,67. The In recent years, proactive resuscitation has substantially increased the rate of survival of micro-preemies in the limit of viability (22–24 weeks GA). The ventilatory support strategies employed to enhance morbidity-free survival rates vary considerably among institutions reflecting the lack of evidence-based studies, which hampers the establishment of consensus guidelines as has been acknowledged by different international resuscitation guidelines ,59,69,70We approach different aspects of stabilization and resuscitation during the golden minutes and focus especially on the subgroup of premature infants born <25 weeks gestation.Immediately after birth, caregivers aim to stabilize preterm infants, independently of their GA, on non-invasive respiratory support . CPAP re2O and non-breathing newborns, intermittent PPV with an inflation pressure of 20 to 25 cmH2O and PEEP of 5 cmH2O at a rate of 40 to 60 breaths/min should be provided early after birth [2 [A general summary of the respiratory approach is depicted in er birth . Ideallyer birth  and the birth [2 ,74,75.2O, administered with the RAM nasal cannula  vs. face mask CPAP of 5 cmH2O, resulted in a significant reduction of the intubation rate in the DR [2O, received VT > 6 mL/kg, which can injure the lungs and contribute to IVH [For infants requiring higher supplemental oxygen, the CPAP level may be titrated higher up to 7–8 cm . It has n the DR . Increase to IVH .2O and concluded that CPAP levels >10 cmH2O improved oxygenation [2O during resuscitation significantly increased the rate of pneumothoraces [2O did not exhibit this [No optimal CPAP pressure has been established. However, preclinical studies in preterm lambs ,81 and rgenation , suggestgenation . In an Rthoraces , while ibit this . In addibit this ,76.T [It is mandatory that the ventilation devices employed in the DR provide PIP, PEEP, and/or CPAP . The selT . HoweverT .T than SIB [2 levels compared to SIB during surfactant administration [Experimental studies suggest the benefit of using devices providing controlled levels of PEEP and PIP to assist in the establishment of pulmonary FRC during the transition and reduce lung damage secondary to barotrauma ,87. In mthan SIB ,89,90. Istration . In addistration , in a restration ,93.It is currently unclear which TPR is most effective for applying CPAP at birth. The effect of pressure stability and expiratory resistance was compared with seven CPAP systems in simulated breath profiles. Neopuff  and Medijet  had the highest pressure instability and imposed work of breathing. Benveniste , Hamilton Universal Arabella , and Bubble CPAP  showed intermediate results. AirLife  and Infant Flow  showed the lowest pressure instability and imposed work of breathing and the lowest decrease in delivered pressure when challenged with a constant leak . A new TT avoiding bag and mask ventilation or CPAP [Ventilators are commonly used for CPAP delivery and PPV during transport and in the NICU rather than in the DR . However or CPAP .T [T and higher requirements for supplemental oxygen compared with the face mask [Two different types of masks are available for mask PIP or CPAP, anatomic or round masks. O’Donnell et al. found no differences in air leaks between the two different mask types . The effT . The expT . Small nT . The useace mask . Effectiace mask ,102. Howace mask .The trigeminal-cardiac reflex and laryngeal closure may reduce the effectiveness of non-invasive respiratory support in premature infants immediately after birth . ExperimHeating and humidification of inspired gases for the initial stabilization of preterm infants and during transport to the neonatal unit improve the admission temperature in preterm infants, especially below 28 weeks GA ,108. NotILCOR 2020 guidelines  recommenERC 2021 guidelines suggested considering intubation in the case of needing surfactant administration in the DR . HoweverExtremely preterm infants (<28 weeks GA) require early prophylactic non-invasive respiratory ventilation (NIV) initiated in the DR ,66,69. HAvailable evidence of the effectiveness of NIV applied to this category of patients is limited, and optimal CPAP pressure to obtain a stable FRC is not known. Of note, it is very unusual for micro-preemies to breathe spontaneously. Consequently, tracheal intubation and mechanical ventilation in infants born at 22–23 weeks GA immediately after birth has become a standard of care in centers with a proactive attitude towards the treatment of these patients in the limits of viability ,115,116.2O might be too low to effectively recruit the lungs in extremely premature infants [T levels using an RFM. Inflation pressure was the key factor producing significantly higher expiratory VT, and a longer inflation time was not necessary to increase expiratory VT [T greater than 4.4 mL/kg, but these VT were measured only for the first five inflations via ETT when adequate VT rarely occurs [T [2O. This strategy is also used regularly in Japanese groups with an active attitude toward micropremies [There are minimal data on micro-preemies in relation to the necessary ventilation pressures. On the one hand, some studies show that a peak inflation pressure of 20 cmH infants ,118,119.y occurs . On the ccurs [T  show difopremies . We suggT, SpO2, or air leaks. This information allows one to detect problems/pitfalls associated with mask ventilation early [T delivery might reduce injury and improve outcomes [p = 0.006) and IVH (RR 0.69 (0.50 to 0.96), p = 0.03) was assessed in infants receiving PPV with an RFM vs. no RFM. Moreover, these studies reported that fewer infants in the RFM-visible group had expired VT > 8 mL/kg, compared with the no-RFM group [The effectiveness of mask ventilation can be improved using an RFM. There are different models and brands of RFM but all of them provide continuous real-time information of inspiratory and expiratory graphs, the respiratory rate, Von early ,97,120. outcomes ,120,121.FM group . HoweverFM group . Long-teFM group . The monFM group ,125,126.2 and how to titrate oxygen during the stabilization of very preterm infants in the delivery room are yet unknown.At present, the optimal initial FiOOptimizing ventilation to establish a good lung capacity and cutaneous stimulation to trigger spontaneous breathing both contribute to the establishment of effective respiration in the initial minutes after birth.2, titrating oxygen to achieve SpO2 targets of 80–85% five minutes after birth seems appropriate to reduce the damage caused by hypoxia or hyperoxia during resuscitation in the DR.Despite the initial FiO2 and HR in the initial minutes after birth.Reference ranges in newborns with deferred, as compared to immediate, cord clamping show differences in SpOThe initiation of ventilation with an intact cord (physiologic-based cord clamping) seems to be a promising strategy to enhance oxygenation and achieve hemodynamic stabilization in the initial minutes after birth; however, until more evidence is available, caution is advised.The application of optimal strategies to use NIV modalities immediately after birth is important to establish an FRC to reduce the need for intubation, invasive mechanical ventilation, mortality, and BPD.Implementing a resuscitation bundle involves determining the appropriate size and sealed mask, head repositioning, the opening of the mouth, increasing the pressure when indicated and regulating it depending on the patient’s response and changes in lung compliance, and debriefing after each intubation.TPR allows accurate PPV with PEEP. There is no current evidence to suggest one interface is better than another. Evidence was insufficient to recommend the use of heated, humidified gases for assisted ventilation.Feedback devices such as RFM can help detect adverse events.To reduce unwarranted variability in the care of most extremely preterm infants between 22 and 23 weeks of GA, we propose respiratory support including immediate oral intubation, applying TPR immediately, and avoiding bag ventilation either by mask or ETT, ECG leads, or an ETT secured lip level. This approach could be considered for use in preterm infants of 24 weeks GA.


Dispersion of nuclei on unsolidified aluminum appeared differently according to the shape of the cavity, which influences final shape of refined zone. The area fraction of refined zone was affected by the relative relationship between the solidification completion time and the electric current application time. This study will provide insight to control of process parameters when electrically-assisted solidification is applied to a real product with a complex shape.Grain refinement is a crucial issue in metallic materials. One of the emerging techniques to obtain equiaxed grains is to apply an electric current to the liquid metal during solidification. With this view, in this paper, the effect of electric current on the solidification behavior in various cavity shapes of mold was investigated. Cylinder-, cube-, and cuboid-shaped cavities designed to have similar cavity volume were used. By applying an electric current during the solidification of liquid aluminum, the grains were effectively refined with a grain size of approximately 350 µm for all three types of cavities. The circulating flow of liquid aluminum was observed to have a similar shear rate intensity in all three types of cavities, which is known to be sufficiently high (over hundreds of s The solidification behavior of liquid metal is influenced by various factors, such as composition, heat flow in the solidifying system, and quality of liquid metal. In particular, the cooling rate during solidification is a key parameter for determining the solidification structure5. For example, changing the size or shape of the cavity in mold can result in a different solidification structure, owing to a change in the cooling rate, even if the material has the exact same alloy composition. Consideration of thermal field gradient affecting solidification structure is also essential for the production of complex shape with various size of casting parts.Control of microstructure is essential based on the understanding of solidification behavior in liquid metal processing to obtain high strength and good ductility8 and rapid cooling methods10 have been used to control the solidification structure in the casting industry. Chemical additives have been considered a common technique to refine or modify the phase. The rapid cooling method is also frequently adopted to obtain a fine solidification structure. However, the former has a few disadvantages, namely, fading additives, and undesirable formation of defects, such as pores and intermetallics12. The latter has limitations in increasing the cooling rate, depending on the mold material, product shape, and working environment. To overcome these drawbacks, treatment of liquid metal using external energy, including mechanical vibration15, electromagnetic stirring19, and ultrasonic vibration22, have been introduced, which can be alternative methods to obtain mechanical properties that meet the requirements of the end products. Recently, a casting method using an electric current as an external energy source has been proposed26. In this method, an electric current is applied directly to the liquid metal through the electrodes during solidification. Grain refinement or modification of the phase is known to be the main effect when electric current is applied to the liquid metal. In particular, grain refinement has been confirmed by many previous studies29 since 1985, when this technique was first reported30. In various metals, including Pb–Sn alloys33 and Cu–Bi–Sn alloys35, grains were effectively refined by applying an electric current during solidification. For example, the grain size of 1700 µm in the as-cast Sn–Bi alloy was decreased to approximately 400 µm by applying an electric current during solidification. Currently, research on grain refinement in aluminum alloys is attracting attention, owing to the growing demand for lightweight materials. The grain size of pure aluminum (Al)36 and α-Al in Al–Si alloys38 is significantly reduced by applying electric current during solidification. Raiger et al.29 reported that the grain size of pure aluminum decreased by approximately 82% with an application of an electric current, as compared to that without an application of an electric current.Various techniques, such as chemical additives29. They reported that the forced flow of liquid metal due to the Lorentz force induced by the electric current could generate fragments of previously grown dendrites, leading to grain refinement by supplying additional nuclei. Wang et al.39 performed in-situ observations of the evolution of dendrite morphology during solidification under an electric current, based on the synchrotron radiation imaging technique. It was suggested that the dendrite morphology was modified by Joule heating at the dendrite tip. Li et al.24 also concluded that the current-induced Joule heating enhanced the nucleation rate, resulting in grain refinement in pure aluminum. However, the underlying mechanism of the effect of the electric current on the solidification structure remains controversial.Various hypotheses, including dendrite fragmentation and Joule heating effects, have been proposed to understand the effect of electric current on metal solidification. The dendrite fragmentation effect is frequently suggested as one of the main hypotheses for grain refinement by the application of an electric current. This hypothesis was proposed by researchers who confirmed the existence of the forced flow of liquid metal, caused by the Lorentz force, under an electric current through numerical simulation40 investigated the solidification structure of pure aluminum with different electrode configurations. The position of the electrodes and the distance between the electrodes were set as variables. They found that the portion of refined grain area could be influenced by the position of the electrode. However, few studies have considered instrumental setup through systematic studies. To the best of our knowledge, no studies have considered the cavity shape of mold under an application of electric current during solidification.Although the underlying mechanism has not yet been clearly established, practical studies are required to consider this technique in real industry. Ma et al.This study aims to determine the correlation between the cavity shape and solidification structure under the application of an electric current during solidification. Pure aluminum was selected as the representative material to minimize various factors due to alloying elements. We prepared three types of cavities with different cavity shapes while fixing the volume of the cavity. The effect of electric current on grain refinement based on macro- and microstructural observation was analyzed. Numerical modeling based on fluid dynamics was also conducted by considering the effect of the electric current on liquid aluminum. Finally, the effect of electric current on the solidification behavior has been discussed, with a focus on the cavity shape, based on experimental and numerical approaches.Sand molds with three types of cavity shapes, namely, cylinder, cube, and cuboid, were prepared, as shown in Fig. Two parallel STS304 electrodes were immersed into liquid aluminum from the top surface at depths of 60, 35, and 25 mm for the cylinder-, cube-, and cuboid-shaped cavities, respectively. The sidewall of the electrode was coated with alumina. The distance between the electrodes was set to 40 mm in the cylinder- and cube-shaped cavities, and 70 mm in the cuboid-shaped cavity. The temperature of liquid aluminum during solidification was recorded using a K-type thermocouple at both the mid- and top heights of the mold in the center of diameter or width of each mold. In the cuboid-shaped cavity, the temperature beside the electrode was additionally measured to analyze the thermogradient effect in the x-direction, as shown in Fig. Commercial pure aluminum ingots (1.5 kg) (> 99.7%) were melted in a high-frequency melting furnace using a graphite crucible. When the temperature of the liquid aluminum reached 760 °C, degassing was conducted. After stabilizing for 5 min, liquid aluminum was poured into a sand mold, and electrodes were inserted. The sand mold and electrodes were preheated to 150 °C to prevent the formation of a solid shell from the surface due to rapid solidification. In electrically-assisted solidification , when the temperature of liquid aluminum reached 665 °C at the mid-height of the mold, which is near the melting temperature, a direct current of 300 A was applied for 108 s. To reflect the effect of the inserted electrodes in the liquid metal, the electrode was inserted even during solidification without applying electric current, . All casting experiments were completed in one day to minimize experimental deviations caused by various environmental factors such as mold conditions, environmental temperature, and humidity. For this reason, the number of repetitive experiments was set to two for each experimental condition.https://imagej.nih.gov/ij/). To observe the microstructure, specimens were mechanically ground to 1 µm and electrolytically etched using a standard Barker solution at 25 V for 15 min. Five images were analyzed per specimen using a polarization microscope (NICON ECLIPSE MA200), and the grain size was quantitatively measured using image analysis software (IMT i-solution Inc I Solution DT-L).After solidification was completed, the specimen was sectioned longitudinally parallel to the electrodes to observe the macrostructure (YZ plane). The sectioned plan was etched with a solution containing 20 ml HCl, 20 ml HNO3, 20 ml H2O, and 5 ml HF. The fraction of the refined area was analyzed using an open source software ImageJ version 1.53e , and a numerical study was carried out using a time-dependent solver over a range of 0–15 s.Numerical analysis was performed using COMSOL Multiphysics 5.0  to verify the flow phenomenon of liquid pure aluminum to which an electric current was applied. The Navier–Stokes equation was introduced as the governing equation for the liquid pure aluminum flow, and an external force term was added to determine the effect of the electromagnetic force . To apply an electromagnetic effect, we also used a generalized form of constitutive relations for the electric and magnetic fields. In addition, an energy conservation equation formulated in terms of temperature was used to identify the electromagnetic heating of liquid aluminum. More details regarding the equations are given in our previous paper (see Supplementary Information)42, which reflects the difference in shape as well as cavity volume.Cooling curves of non-EA solidification that were measured at the mid-height of the mold for three types of cavity shapes, are presented in Fig. When an electric current is applied to liquid aluminum, a fluctuation in the cooling curve is observed Fig. a–c. The The macrostructure of the YZ plane in non-EA and EA solidification is shown in Fig. In EA solidification, the morphology of refined grains shows an equiaxed shape in both the center and side areas, and the grains are uniformly distributed within the refined zone, as shown in Fig. 5, 1.50 × 105, and 1.73 × 105 N/mm3 for the cylinder-, cube-, and cuboid-shaped cavities, respectively.A numerical simulation was conducted to investigate the effect of the application of an electric current on solidification based on fluid dynamics. When electric current is applied to liquid aluminum, a flow of the density field of electric current is generated in all three types of cavities; in particular, a streamline of the density field of electric current is densely developed in the downward direction of the electrode Fig. a. Betwee41. The configuration of the circulating flow depends on the cavity shape. In the cylinder-shaped cavity, the downward flow of liquid aluminum occurs from beneath the electrodes, and the upward flow in a direction rotated 90° from the downward flow. Circulation flow developed in the form of four divisions. , it can be assumed that Regarding the cavity shape in EA solidification, refined grain size shows similar values at all three types of cavities. The number of nuclei per unit volume can be predicted from the grain sizeAs shown in Fig. −1 for the left, center, and right regions of the YZ plane, respectively. It is in the order of 10 lower than the shear rate formed in the region below the electrodes (~ 400 s−1). Therefore, in the inter-electrode region, rather than new nuclei generated by shear rate, the nuclei can be delivered to the inter-electrode region by the circulating flow, resulting in a uniform grain size within the refined zone despite the long inter-electrode distance.In the cuboid-shaped cavity with the longest inter-electrode distance among three cavity shapes, the grain size was approximately 390 μm in each section of the YZ plane of the left, and right regions , and equiaxed grains with lower aspect ratio are uniformly distributed with a small deviation of grain size in the refined zone, by applying an electric current during solidification in the cylinder-, cube-, and cuboid-shaped cavities. In the numerical simulation, the occurrence of circulating flow was observed, and the form of circulating flow in liquid aluminum depends on the cavity shape. In addition, it was confirmed that the Lorentz force generated by the interaction between electric current and liquid metal showed similar values in each cavity shape, and the shear rate was also similar as 400 sThe use of electric current as a process parameter to obtain a refined microstructure is an emerging technology. Because the shape of a real product is complex, there are many considerations to control the microstructure of a cast product. By applying an electric current to the liquid metal, the circulating flow is developed, and it depends on the cavity shape and electrical conditions. Therefore, to effectively control the microstructure using electric current, the electric current-induced phenomenon related to nucleation and solidification should be carefully considered. This study can provide insight into the microstructural control considering various cavity shapes using electric current-assisted solidification.Supplementary Information.


Studies have reported significant effect of geographically shared variables on new-born baby weight. Although there is growing use of community-based child health interventions in public health research, such as through provinces, schools, or health facilities, there has been less interest by researchers to study outlying communities to child birth weight outcomes. We apply multinomial logistic regression model diagnostics to identify outlier communities to child birth weight in Malawi. We use a random sample of 850 clusters, each with at least 7 households based on 2015-16 Malawi demographic and health survey data. There were a total of 11,680 children with measured birth weight, that was categorised as either low ( Birth weight is the weight of the baby at birth, measured in grams or kilograms. This has implications on the baby’s future morbidity and mortality outcomes. For the baby’s health assessment’s sake, the child birth weight is categorised into three groups in accordance with World Health Organisation (WHO) standard: low birth weight  were analysed in this study. The survey engaged two-stage stratified sampling, where 850 emuneration areas (clusters) were randomly sampled from across the country at first stage and 27,516 households were sampled from these clusters at second stage using rural and urban stratification . The houDuring analysis, the outcome variable - birth weight was split into three categories, based on WHO standards as indicated in Section mentclass2pt{minim0 grams) –21. Othe0 grams) , howeveri-th child’s birth weight falls in category ji-th child in a particular survey cluster c and one of the two strata, where c and i-th child, j-th category given the covariates as:svy command was used in Stata version 15 to define the sampling weights. There were 2, 645, 948 children under the age of five years in Malawi as of 2018, this, along with the DHS sample size of 11, 680, was used to compute the finite population correction (fpc) factor, A survey weighted multinomial logit regression model was used to analyse the data because the reponse variable, birth weight, had three levels as highlighted in the previous paragraph and was assumed to follow a multinomial probability distribution . Let \do process , 22, 23.ficients .j-th category relative to 3rd category, when comparing one level of a covariate X to the other.Then, for the 13,448 independently observed children, stimates . The MLEstimates . The expp-values in Model 1. Finally, the third model, Model 3 excluded covariates that had MLE estimates with large p-values in Model 2. In each case, the AIC value was computed, and later compared with the other values across the three models. The ultimate best model was the one that had lowest AIC among the three.We used Akaike Information Criterion (AIC) to select the best model. The initial model, i.e. Model 1 included all the available covariates in the data set that were described in first paragraph. Then, the second model, i.e. Model 2, excluded the covariates whose MLE estimates had the largest j is used as a Chi-squared goodness-of-fit statistic for the model. The univariate outliers were also assessed using the deviance residual [c-th cluster sample size. The value of Now, to identify the outlying clusters to the fitted multinomial logit model, we first computed model residuals at individual level of the data. A Pearson’s residual for multinomial logit model (3)  is givenresidual  given byent}±2.5 . To idenent}±2.5  was usedi-th diagonal element of the leverage matrix V as estimated variance of To assess influence of individual observations on estimated regression coefficients to model (3), a generalised Cook’s distance for model (3) , 27 was stimates . Similarstimates  through stimates .p-value < 0.001).The results in Table p-value = 0.764). The MLE estimates in Table The results in Table Furthermore, children of birth order 2 and above had significantly increased relative chances of being born with normal birth or high birth weight compared to birth order 1. Essentially, these chances almost doubled for high birth weight from the normal birth weight. Further, the relative chances of being born with normal birth weight were higher in children from mothers with primary education and above compared to no education. Similar trend was observed for high birth weight versus mother’s education, although the estimates were not statistically significant. The results also showed that children from richer households had 26% higher relative chances of being born with normal birth weight compared to children from poor household. Finally, there was no significant difference in chances of being born with normal or high birth weight when comparing different levels of mother’s age.The univariate deviance residual estimates in Fig. Now, considering the clustered mean deviance residuals in Fig. This study applied univariate model diagnostic statistics to analyse unusual child birth weight outcomes at community level, upon fitting a multinomial logit model to data. The findngs showed that none of the observations deviated from the fitted model both at individual and cluster levels. This reflects the fact that majority of the babies that were studied were born with normal birth weight and very few had low or high birth weight. However, it was observed that two clusters had overly influence on estimated effects of socio-demographic factors on birth weight. Influence of a subject to the fitted model reflects impact the subject causes to the estimates of the regression coefficients, and it is the product of outlierness of that subject on the fitted line or curve and its leverage on the fitted response , 16. TheThe model estimates showed that birth order of 2 and above had increased chances for a baby to be born with normal and high birth weight relaitve to low birth weight compared to birth order 1. This is a common observation in most studies, but there has been little scientific explanation in research attached to it . The resThis study investigated unusual communities to child birth weight in Malawi using the multinomial regression model diagnostics. The study has identified two clusters from rural parts of Southern Malawi that had excessive influence on effects of various socio-demographic factors on birth weight, which biased the estimates. The two rural clusters had children with normal or high birth weight, with no cases of low birth weight, which was not common in rural locations of the study population. We recommend a follow-up qualitative study to investigate child healthcare practices that mothers of the area follow, which may be replicated in the other rural parts of the country. These findings imply that some classical statistical diagnostic methods can be utilised further to understand the outlying patterns of children’s health outcomes at community level.


Pneumocystis jirovecii in mother-infant pairs of very low birth weight newborns <32 weeks gestation. Molecular and microscopic methods were used for detection of P. jirovecii in patients’ specimens. Pneumocystis DNA was detected in 8 nasopharyngeal aspirates (14%) of 56 newborns and in 7 oral washes (21%) of 34 mothers. Pneumocystis detection immediately after birth suggests the possibility of its transplacental transmission. Compared to noncolonized infants, more frequent occurrence of bronchopulmonary dysplasia was seen in colonized infants (P = .02), suggesting a potential clinical importance of this pathogen in abnormal lung development.We describe the prevalence of  Pneumocystis jirovecii may be transmitted from mother to infant [P. jirovecii [P. jirovecii among pregnant women in the third trimester [P. jirovecii among newborns with respiratory distress syndrome, born prematurely, and/or with very low birth weight. Respiratory specimens were also collected from mothers to investigate genetic homology with isolates from their newborns.Previous reports suggest that o infant . Moreoveirovecii , emphasirimester  may poserimester . The aimPneumocystis again. Inclusion criteria for newborns were (1) birth weight <1500 g and/or gestational age <32 weeks, and (2) respiratory distress syndrome, defined as respiratory failure in the first hours of life of a preterm newborn presumably caused by lung surfactant deficiency. Diagnosis of respiratory distress syndrome was made based on clinical symptoms, chest X-ray, and blood gas analysis results. All patients during stabilization at the delivery room were started on nasal continuous positive airway pressure (nCPAP) as the initial respiratory support. In cases with (1) arterial blood pH < 7.20, (2) Paco2 ≥ 60 mmHg, (3) Sao2 < 90% at O2 concentration above 30% and nCPAP of 6–10 cmH2O, and (4) persistent or severe apnea, respiratory failure was diagnosed. According to European guidelines [o2 > 0.30 on nCPAP pressure of at least 6 cmH2O. After stabilization, mechanical ventilation was used in babies with respiratory distress syndrome when noninvasive methods of respiratory support had failed. When the intubation was required as part of stabilization, surfactant was given immediately. Demographic, clinical, and laboratory data were recorded upon inclusion for all study participants. Informed consent, approved by the Human Research Ethics Committee of Wroclaw Medical University (agreement No. KB-725/2017), was obtained from parents or statutory representatives of infants, as well as from mothers whose samples were included in the study.Respiratory specimens from human immunodeficiency virus (HIV)-negative (1) preterm infants n = 56) who had been under the care of the Department and Clinic of Neonatology, Wroclaw Medical University, Wroclaw, Poland, and 2) their mothers  were examined between January 2018 and June 2019. Nasopharyngeal aspirates were obtained from newborns immediately after birth (approximately 10–15 minutes after birth), and oral washes were collected from mothers shortly after labor, as described previously [ their mo6 who hadP. jirovecii mtLSU rRNA gene, followed by sequencing and phylogenetic analyses [Pneumocystis DNA presence in at least 1 independent analysis were considered positive. Microscopic examination of fixed smear slides of centrifuged respiratory specimens was performed using a direct immunofluorescence assay .Samples collected from all patients were tested by both molecular and microscopic techniques. Molecular detection was performed by nested polymerase chain reaction (PCR) amplifying partial sequence of analyses , 7. Nestt test were used to compare variables between Pneumocystis-positive and -negative individuals. The duration of the oxygen therapy (with time to therapy termination as outcome) was analyzed using the Kaplan-Meier method, censoring those infants who died and reweighting by inverse probability of censoring weights. This enabled consideration of the Kaplan-Meier curves as representing the duration of oxygen therapy in a group of infants who all survived. The duration of oxygen therapy was compared between colonized and noncolonized patients with the use of the log rank test for univariate analysis in the R environment (R version 4.0.4). A value of P < .05 was considered significant. The analysis of the duration of oxygen therapy was performed with the use of the R packages pec, prodlim, and RISCA [Fisher exact test and Student nd RISCA . Due to P. jirovecii DNA was detected in 8 (14%) of 56 newborns immediately after birth and in 7 (21%) of 34 mothers, but no matched mother-newborn pairs were detected. Children of 8 mothers from whom specimens were not available were Pneumocystis negative. Among infants tested more than once, 2 were positive in 2 samplings . Median duration of oxygen therapy in colonized infants was 41.0 days  and in noncolonized 19.0 days  was implemented in 1 patient due to persistent respiratory failure and prolonged requirement for mechanical ventilation. Seven infants died due to complications connected with extreme prematurity, but they all tested Pneumocystis negative.A significant association was demonstrated between colonization and bronchopulmonary dysplasia .Fourteen (33%) of the 42 pregnancies were multiple. Among them, mtLSU rRNA genotype 1 was detected, except in 1 case in which genotype 2 was present; in infants, genotype 1 was predominant (detected in 7 children), while genotypes 2 and 3 were recorded in 1 infant each. The isolates in the twin pair were genetically identical.In most mothers’ samples P. jirovecii colonization and bronchopulmonary dysplasia—a common complication in very low gestational age newborn infants requiring supplemental oxygen for at least 28 days  was higher than in previous reports from women in the third trimester (5.4%–16.5%) [Pneumocystis was also higher among the group of mothers when compared to the infants (14%). The opposite was observed by Vera et al in full term infants [Pneumocystis in mothers of very low birth weight preterm infants in our study compared to the series of term mother-infant pairs in the literature may suggest that colonization is associated with premature delivery. In this respect, the significance of P. jirovecii carriage in pregnant women requires further thorough analysis.The prevalence of %–16.5%) , 13, 14.P. jirovecii in humans provided by examinations of formalin-fixed tissues of aborted fetuses suggests the possible dissemination of the fungus from mother to fetus via the blood route [Pneumocystis was transmitted to the fetus and persisted until delivery, while the mother’s infection resolved spontaneously in the following weeks and therefore showed a negative result post partum. It is also possible that Pneumocystis-positive mothers were infected shortly before the specimen collection and the time frame was too short for their infants to become infected before delivery. The absence of matched pairs in our study could also be attributed to differences in types of collected specimens. It has been suggested that the number of organisms reaching the oral cavity may be insufficient for Pneumocystis detection in patients with low pulmonary fungal burden [The scant evidence for transplacental transmission of od route . The spel burden . It can mtLSU rRNA genotype 1 was the predominant in all samples investigated in this study, finding of genetically identical isolates in the twin pair cannot exclude sibling-to-sibling Pneumocystis transmission or a common infective source for both of them. On the other hand, mtLSU rRNA genotyping does not provide a sufficiently high discriminatory power for pathogen transmission analysis, thus it can also be assumed that there was another, external infective source for the second twin. Therefore, it should be borne in mind that children born prematurely are potentially at risk of various infections, including Pneumocystis, during infancy. Genotype 1 was also most commonly observed in the mothers’ specimens in the study of Vera et al [Although ra et al , suggestPneumocystis DNA shortly after birth in very low birth weight premature infants that did not enter into close contact with their mothers, providing further support that Pneumocystis is highly common in premature infants and suggesting that blood-borne transmission via the transplacental route may be an alternative route for transmission of this fungus. Pneumocystis colonization in preterm infants may be associated with bronchopulmonary dysplasia, suggesting a potential clinical importance of this pathogen in abnormal lung development. Because prevalence of Pneumocystis among pregnant women and newborns is relatively high, this pathogen should be considered in the etiologic workup of newborns with respiratory disorders, especially in infants born prematurely.In conclusion, our study documents The Journal of Infectious Diseases online. Consisting of data provided by the authors to benefit the reader, the posted materials are not copyedited and are the sole responsibility of the authors, so questions or comments should be addressed to the corresponding author.Supplementary materials are available at jiab209_suppl_Supplementary_Figure_S1Click here for additional data file.