HIV-exposed uninfected (HEU) infants are a growing population in sub-Saharan Africa especially with the increasing coverage of more effective prevention of mother-to-child transmission (PMTCT) antiretroviral therapy regimens. This study describes the characteristics of South African HEU infants, investigates factors impacting birth weight and assesses their growth within the first 28 weeks of life.This is a retrospective cohort based on routine clinical data from two South African PMTCT programmes. Data were collected between 2007 and 2013. Linear regression assessed factors affecting birth weight-for-age z-scores (WAZ) while growth  was assessed using mixed effects models.We assessed the growth of 2621 HEU infants  and 51% were male). The feeding modalities practised were as follows: 0.5% exclusive breastfeeding, 7.9% breastfeeding with unknown exclusivity, 0.08% mixed breastfeeding and 89.2% formula feeding. Mothers with CD4 <200 cells/μl delivered infants with a lower birth WAZ  compared to mothers with aCD4 ≥500 cells/μl. Similarly, mothers who did not receive antiretroviral drugs delivered infants with a lower birth WAZ  compared to mothers who received antenatal antiretrovirals. Infants with a birth weight <2 500g  experienced faster growth within the first 28 weeks of life compared to infants with a birth weight ≥2 500g. Infants with any breastfeeding exposure experienced slower longitudinal growth compared to formula fed infants .Less severe maternal disease and the use of antiretrovirals positively impacts birth weight in this cohort of South African HEU infants. Formula feeding was common with breastfed infants experiencing marginally slower longitudinal growth. HIV-exposed uninfected (HEU) infants are a growing population in sub-Saharan Africa, particularly with increasing coverage of more effective prevention of mother-to-child transmission (PMTCT) regimens such as option B/B+, antiretroviral therapy (ART) for all pregnant and breastfeeding women either until cessation of breastfeeding or lifelong . In 2010Breastfeeding is known to transmit HIV, however its importance for infant nutritional status, growth –8 and prThere have been conflicting findings with respect to the effect of feeding on growth. McGrath et al found no differences in the rate of growth between ever breastfed and formula fed infants, with WAZ increasing in both groups during the first 6 months after which they declined . HoweverMany previous studies of growth in HEU were conducted outside South Africa, where breastfeeding practices and access to replacement feeding may be different, and prior to widespread availability of effective PMTCT regimens. The aim of this analysis was therefore to assess birth weight and growth within the first 6 months of life in HEU infants from two PMTCT cohorts in South Africa and examine the impact of maternal factors, including disease severity and the use of antiretrovirals, and feeding modality.www.iedea-sa.org) collaboration. The IeDEA-SA cohort has been previously described ; antenatal CD4 cell count  and maternal antiretrovirals grouped into any antiretrovirals  only, dual therapy and triple therapy), no antiretrovirals and missing antiretroviral information. Where maternal antiretroviral regimen was changed during the pregnancy, we included the antenatal regimen closest to the delivery date.Infant variables collected included the following: sex, gestational age  at delivery (term (≥ 37 weeks), preterm and unknown gestational age), birth weight (low (<2 500g) or normal (≥2 500g). Infant feeding, as it occurred over 28 weeks, was categorised into formula feeding (FF i.e. never breastfed), unknown feeding and any breastfeeding (BF). Any BF comprised EBF, BF with unknown exclusivity and MBF.Baseline characteristics between sites were compared using Wilcoxon rank-sum test for continuous variables and Chi-squared or Fisher’s exact tests for categorical variables.a priori and then examined the effect of maternal HIV disease severity and treatment  adjusted for the a priori variables. Univariate and multivariate analyses of the association between demographic, feeding and maternal factors affecting longitudinal postnatal growth were examined using mixed effects models with maximum likelihood estimation. A priori inclusions were similar to the linear regression model investigating birth weight outcomes. Feeding modality, infant age  and birth weight were additional a priori inclusions. The model was then adjusted for maternal age, parity, antenatal CD4 count and antiretroviral use. As growth is time dependent, interaction terms with infant age in weeks were included for all covariates. Covariates (including interaction terms) were included if the p-value was <0.1. As birth weight was a major determinant of postnatal growth, we conducted a sensitivity analysis limited to children with normal birth weight to examine the factors associated with growth in this subset of children. Owing to the nature of routine clinical data, not all variables were assessed at every visit or within the time period of this analysis. Cohort was adjusted for in all analyses.We first assessed factors affecting birth weight using univariate and multivariate linear regression. We included gestational age, infant sex, maternal age and parity, and cohort in the model There were 2948 dyads with a minimum of 2 visits, of these 327 (11.1%) were excluded as they did not have at least one visit after birth within the first 28 weeks of life. The HEU profile of the dyads included in the analyses is detailed in The median age at visits within the first 28 weeks was 2.17 months . The majority of the infants in this analysis were from RMMCH . OverallThe models investigating the factors affecting birth weight are found in Tables As a sensitivity analysis these factors  were assessed for the entire HEU cohort, not limited to dyads with complete data on all variables, , and theThe main outcome of this analysis is longitudinal growth of HEU infants. The main model is presented in As expected, infants with a low birth weight (LBW) had a lower birth WAZ compared to normal birth weight infants, but over time, growth was significantly faster among LBW infants . Similarly, infants born to women with parity ≥1 had a higher birth WAZ but experienced a slower increase in WAZ; although the latter effect was small (adjusted ß = -0.011) and only statistically significant for infants of mothers with parity ≥2. In this cohort of HEU infants, females experienced faster growth  compared to male infants.Although BF infants had a marginally greater birth WAZ compared to infants who received FF (any BF infants p = 0.298), their growth over time was slower compared to infants who received infant formula . When including all infants, thus not taking parity into account  and the direction of these effects remained the same, although the magnitude tended to be smaller . A modelIn this cohort of HEU infants, mothers with more advanced disease, and those not on antiretrovirals, delivered infants with a lower birth weight compared to mothers with less advanced disease, and those who received any antiretrovirals, whether as prophylaxis or triple ART. In contrast, in this cohort of mostly formula fed infants, no maternal HIV disease factors were associated with postnatal growth, with postnatal WAZ increasing in all children.Evidence is mixed for the effect of antiretrovirals on birth weight and preterm deliveries, although triple ART, especially the use of protease inhibitor-containing (PI) regimens, either pre-conception or initiated during pregnancy appears to increase the risk of both LBW and preterm deliveries ,28.The PMost HEU infants in the IeDEA-SA collaboration were formula fed—the predominant feeding modality at both sites. MBF infants experienced marginally slower growth compared to FF infants. Although MBF infants experienced slower growth, the effect was very small and it is difficult to draw robust conclusions particularly as less than 10% of infants in this HEU cohort received any breast milk. Furthermore, we did not have detailed data on confounding factors that could impact growth and feeding choice, such as maternal education ,8,16,17 Advanced maternal disease has been shown to negatively impact on growth ,16, althIn this analysis, female infants experienced faster growth compared to male infants. Interestingly, previous studies examining growth among HEU infants have mostly not examined the effect of infant sex ,8,16. HoThe major strength of this study is the large number of mother-infant dyads included and the description of feeding practices and growth in infants in a routine care setting. Most previous studies of growth in HEU infants in South Africa have been restricted to research cohorts and randomised controlled trial data, where results may differ compared to infants in routine care. However, the reliance on routinely collected data meant that a number of key variables were missing. For example, although only 5% of birth length and head circumference were missing, these were not regularly measured and recorded at follow-up visits so we were unable to examine length-for-age and weight-for-length z-scores over time. Furthermore, although standard practice was employed for growth monitoring, no quality assurance processes were in place. Information on antiretrovirals given to infants themselves for PMTCT was inadequate thus we were unable to take it into account. Similarly, the introduction of solids was not routinely assessed and could not be included in the multivariate analyses. A previous study evaluating infant feeding practices found that 47% of HIV-infected mothers did not initiate breastfeeding; however, 67% of these mothers who initiated FF were practising mixed formula feeding by 3 weeks of age . Mixed FAs only antenatal maternal disease-related factors were included in this analysis, it could account for our finding of an impact on birth WAZ, but not longitudinal WAZ. The impact of postnatal maternal disease severity may have an impact on infant growth outcomes, particularly if infants are breastfed, as it’s been shown that mothers who have more advanced disease have poorer infant outcomes –17,31–33In our cohort of HEU infants birth WAZ was low overall, but whether this was as a result of HIV-exposure or not is unknown. A comparison between HEU infants and unexposed uninfected infants is needed to investigate this further. Two South African studies have found that HEU infants have similar growth outcomes compared to unexposed infants, with one study only finding differences between the ages of 25–39 weeks .Despite the limitations imposed by routine clinical data, this analysis shows that maternal antiretrovirals and less severe maternal disease have a positive impact on birth weight. We also found that any breastfeeding was rare in this cohort with MBF infants experiencing only marginally slower growth compared to FF infants. With the introduction of option B/B+ it will be important to examine the impact on infant feeding pattern, infant morbidity and the impact on growth in the growing population of HEU infants.S1 Table(PDF)Click here for additional data file.S2 Table(PDF)Click here for additional data file.S3 Table(PDF)Click here for additional data file.


Cleft lip and palate are among the most common congenital anomalies worldwide. This study was conducted in order to explore the incidence and related factors of cleft lip and/or palate (CL/P) among live births in Mashhad, North-Eastern Iran.In this cross-sectional study, records of 28,519 infants born between March 1982 and March 2011 at three major hospitals in Mashhad were screened for oral clefts. Clinical and demographic factors relating to diagnosed cases, including birth date, gender, birth weight, maternal age, number of pregnancies, type and side of cleft and presence of other congenital anomalies were recorded for analysis.The overall incidence of CL/P was 1.9 per 1,000 live births. Cleft lip associated with cleft palate (CLP) was the most prevalent type of cleft (50%), followed by isolated cleft lip (35.2%) and isolated cleft palate (14.8%). A total of 92.6% of oral clefts were bilateral and 5.5% were located on the right side. In addition, clefts were found to be more common in male than female births . The rate of associated congenital anomalies in CL/P newborns was 37%. No significant differences were observed in the incidence of oral clefts across three decades of study; except for CLP which was significantly more prevalent between 2002–2011 (P=0.027). There were no significant differences with regard to season of birth, associated anomalies or maternal age of affected newborns in the three time periods of the study. Furthermore, maternal age and number of pregnancies were not significantly different among the three types of cleft . Although the mean birth weight of patients affected with isolated cleft palate was considerably lower than that of the other two types of cleft, the difference was not statistically significant (P=0.05). This study indicates a frequency of CL/P close to the findings in East Asian countries and higher than some previous reports from Iran, European and American countries. Ethnicity-related genetic factors may have a role in the conflicting results obtained from different populations. Cleft lip and/or cleft palate (CL/P) are the most common congenital anomalies in the oral and maxillofacial region and exhibit a multi-factorial etiology, including environmental factors and genetic background ,2. Not oIn general terms, the incidence of CL/P is estimated to be between 0.8 and 1.7 cases per 1,000 live births ,7. The iIn this retrospective cross-sectional study 28,519 records were randomly selected (using a simple random method) from documented files of infants born between March 1982 and March 2011 at three major hospitals  in Mashhad, North-Eastern Iran. These hospitals are the biggest hospitals in Mashhad and their delivery rate is much higher than other hospitals, among patients from all over the city and from different strata of society. This study was approved by the Ethics Committee of Mashhad University of Medical Sciences. The inclusion criteria included live births at 40 weeks of gestation. Only mothers with Iranian ethnicity were included in the study. The demographic data included birth date, gender, birth weight, age of mother, number of pregnancies, history of abortion, type and side of oral cleft and presence of other congenital anomalies. The collected data were processed using the statistical package for social science, version 11.0 . Descriptive statistics, Chi-square test and analysis of variance were used for data analysis. A P-value less than 0.05 was considered statistically significant.From a total of 28,519 cases, 54 children with CL/P were born between March 1982 and March 2011. The overall incidence of CL/P was 1.9 per 1,000 live births. Distribution of newborns affected with CL/P, according to the type and side of cleft is presented in clefts were bilateral and 5.5% were located on the right side .According to  P=0.513, . The rat  .In total, the mean age for mothers of CL/P infants was 25.72 (SD=7.14). The mean number of pregnancies was 2.79 (SD=2.54) and the mean number of abortions was 0.45 (SD=0.68). Moreover, the mean birth weight of CL/P infants was 2.11 kg (SD=1.26).As shown in Table 4, significant differences were observed among three decades with respect to number of abortions (P=0.014), number of pregnancies (P<0.001), and newborn weight (P<0.001). However, maternal age was not significantly different among the three time intervals (P=0.060).In general, no statistically significant association was detected between CL/P type and neonate gender, season of birth or presence of other congenital anomalies (Table. 5). According to Table 6, maternal age and number of pregnancies were not significantly different among the three types of cleft . Although the mean birth weight of patients affected with isolated cleft palate was considerably lower than the other two types of cleft, the difference was not statistically significant . This cross-sectional study was carried out to explore the prevalence of oral clefts over a 30-year period in Mashhad, North-Eastern Iran. The overall incidence of CL/P was found to be 1.9 per 1,000 live births. Previously, Farhud et al  and KhazInternationally, incidence rates of 1.94 per 1,000 in the Philippines , 1.81 peIt seems that the incidence of CL/P in North-Eastern Iran is similar to that in Pakistan and some Asian countries, but higher than among individuals of Caucasians and African descent. Variations in genetic susceptibility and environmental factors may be the cause of this discrepancy in the rate of CL/P among different populations .FurthermThe present study showed a nonsignificant gender difference in the frequency of oral clefts, with a male-to-female ratio of 2:3. The male dominance in the prevalence of CL/P is also shown in other reports from Iran ,31, KoreIn addition, this investigation showed no significant differences with regard to season of birth, associated anomalies and maternal age of affected newborns in the three time periods of the study. Likewise, Yassaei et al  reportedThe overall percentage of affected newborns with associated anomalies was higher than that in a previous study in Iran , but wasIn the present study, the mean birth weight of CL/P cases born between1992–2001 in Mashhad was significantly lower than the weight of affected newborns in the other two decades. However, the frequency of cleft lip and palate during these years was lower compared with other time periods. Besides, the prevalence of other types of cleft was not significantly different among the three decades. These findings do not support an association between low birth weight and oral clefts. Conversely, Lei et al (Our study has some limitations. The database provided no information on the consanguinity of parents, maternal health or peri-conceptual conditions, which may play a role in the development of orofacial clefts ,11. AddiThe overall prevalence for congenital cleft deformities in North-Eastern Iran was 1.9 per 1,000 live births, close to the findings in East Asian countries and higher than some previous reports from Iran, European and American countries. Ethnicity-related genetic factors may have a role in the frequently conflicting results regarding prevalence of cleft deformities in different populations. Therefore integrating genetic analysis into epidemiologic studies will be necessary in future studies.


Peroneal artery arteriovenous fistulas and pseudoaneurysms are extremely rare with the majority of reported cases due to penetrating, orthopedic, or iatrogenic trauma. Failure to diagnose this unusual vascular pathology may lead to massive hemorrhage or limb threatening ischemia. We report an interesting case of a 14-year-old male who presented with acute musculoskeletal pain of his lower extremity. Initial radiographs were negative. Further imaging workup revealed a peroneal arteriovenous fistula with a large pseudoaneurysm. After initial endovascular intervention was unsuccessful, the vessels were surgically ligated in the operating room. Pathology revealed papillary endothelial hyperplasia consistent with an aneurysm and later genetic testing was consistent with Ehlers-Danlos syndrome Type IV. This case illustrates an unusual cause of acute atraumatic musculoskeletal pain and uncommon presentation of Ehlers-Danlos syndrome. Arteriovenous fistulas often result from iatrogenic trauma while gaining percutaneous vascular access. Turbulent blood flow and endothelial damage may eventually lead to pseudoaneurysm formation with resulting mass effect and risk of massive hemorrhage. While several case reports have documented peroneal pseudoaneurysms resulting from iatrogenic and orthopedic trauma, there are no known reports of both an arteriovenous fistula and pseudoaneurysm presenting in a patient with an undiagnosed connective tissue disorder. Utilizing multiple imaging modalities, this case nicely documents the unique vascular findings in this interesting case.A healthy 14-year-old male presented with acute onset lower extremity calf pain and swelling that began while playing soccer. He denied trauma to the limb and on physical exam was neurovascularly intact. An MRI to evaluate possible ligamentous injury revealed a large abnormal flow void adjacent to the peroneal artery and vein thought to represent a pseudoaneurysm or arteriovenous malformation . CT angiUltrasound showed a 2.0 × 1.5 cm pseudoaneurysm with swirling of blood flow in the pseudoaneurysm sac giving the characteristic “Yin-Yang” appearance on Color Doppler . Both pePercutaneous intervention was attempted; however, a wire could not be successfully placed distally in the peroneal artery to traverse the pseudoaneurysm neck. The patient subsequently underwent open ligation of the pseudoaneurysm and arteriovenous fistula. Postoperatively his symptoms resolved and genetic analysis revealed a collagen mutation compatible with Vascular Ehlers-Danlos syndrome Type IV.Arteriovenous fistulas (AVF) and pseudoaneurysms (PSA) of the peroneal artery are uncommonly reported in the literature and are extremely rare presenting together. Most pseudoaneurysms result from orthopedic, penetrating, or iatrogenic trauma with the latter often seen after Fogarty balloon embolectomy or percutaneous vascular access , 2. CongWhile the pseudoaneurysm and arteriovenous fistula in this patient were initially thought to be traumatic in origin, genetic testing later revealed a mutation in the COL3A1 gene of collagen 3 compatible with a diagnosis of the Vascular Type 4) Ehlers-Danlos syndrome. Of the 6 major types of Ehlers-Danlos syndrome, Type 4 is one of the most serious types and is most often associated with major vascular complications  Ehlers-D. While vPeroneal artery pseudoaneurysms have been successfully treated by coil embolization of the pseudoaneurysm sac or, alternatively, embolization of the peroneal artery proximally and distally to the pseudoaneurysm neck , 7. Whil


Patients with multiple sclerosis (MS) or Crohn’s disease (CD) being treated with natalizumab  who are planning to become pregnant or discover they are pregnant after exposure to natalizumab are currently advised to balance the potential benefits and potential risks of exposure when considering treatment options. This study was undertaken to evaluate pregnancy outcomes of women with MS or CD who were exposed to natalizumab at any time within 3 months prior to conception or during pregnancy. A pregnancy registry was created to better understand the effect of natalizumab exposure on pregnancy outcomes.The Tysabri Pregnancy Exposure Registry was a global, observational exposure registration and follow-up study. Evaluations included spontaneous abortions , fetal losses , ectopic pregnancies, elective or therapeutic terminations, stillbirths, birth defects, and live births. Birth defects were reviewed and coded in accordance with the Metropolitan Atlanta Congenital Defects Program (MACDP) classification of birth defects.n = 32; 95 % confidence interval [C. I.], 6.3–12.5 %). An independent advisory committee review determined the major birth defect rate to be 5.05 % . The mean gestational age of the live-born infants was 38.3 weeks, and the mean birth weight was 3158.3 g.A total of 369 patients with MS and 7 patients with CD were enrolled prospectively, of whom 355 patients  had known pregnancy outcomes (including 8 twin sets). The spontaneous abortion rate was 9.0 % .ClinicalTrials.gov  Women of childbearing potential comprise a considerable segment of the patient population affected by multiple sclerosis (MS) and Crohn’s disease (CD) and may be exposed to therapies around conception and during pregnancy. Two-thirds of patients with MS are women, with a peak onset between 20 and 34 years of age, and approximately 10 % have disease onset during pregnancy .Natalizumab  is a humanized monoclonal antibody indicated for relapsing-remitting MS (RRMS)  that preThis study prospectively evaluated pregnancy outcomes of women with MS or CD who were exposed to natalizumab within the 3 months before conception or during pregnancy.The Tysbari Pregnancy Exposure Registry  was a global, observational, exposure registration and follow-up study of pregnant women with MS or CD. The Registry collected information routinely documented in the patient and infant medical record with no Registry-required interventions or procedures conducted.The Registry  was established in accordance with regulatory guidance for pregnancy registries –23. IndeBetween February 14, 2007, and April 24, 2011, women with MS or CD who were exposed to natalizumab at any time within the 3 months prior to conception or during pregnancy and for whom the outcome of the pregnancy was unknown at the time of enrollment were eligible to be registered prospectively in the study. Patients included women enrolled from observational studies  or who received natalizumab as a marketed product in the United States and the rest of the world (ROW). The Coordinating Center (CC) of the Registry monitored patients throughout pregnancy and monitored outcomes within 4 weeks after the estimated date of delivery (United States and ROW) and within 8–12 weeks post delivery (United States). The CC point-of-contact and schedule varied slightly based on the study setting.Information was collected about natalizumab exposure, potential confounding factors , pregnancy outcomes, spontaneous abortions, fetal losses including stillbirths, and ectopic pregnancies. In addition, data were collected for elective or therapeutic pregnancy terminations, live-born infants, and birth defects.Birth defects were reviewed and coded by an independent birth defect evaluator  in accordance with the Metropolitan Atlanta Congenital Defects Program (MACDP) classification of birth defects . A majorA target sample size of 300 pregnancy outcomes was determined based on the ability to detect a 2-fold increase in spontaneous abortion and a 3-fold increase in fetal loss and any major birth defects over general population background rates with 80 % power at the 0.05 level of significance.For the primary analysis, the major birth defect rate was calculated by dividing the number of infants with major birth defects by the total number of live births. Birth defect rates from the Registry were compared with available background rates from the MACDP in the US general population . A furthn = 19; CD INFORM, n = 2; non-study, n = 297) and 58 enrolled in the ROW . The majority of patients had MS; only 7 of 376 patients had CD. Of the 376 patients, 6 (1.6 %) withdrew consent and 15 (4.0 %) were lost to follow-up; 355 (94.4 %) patients (including 8 sets of twins) had known pregnancy outcomes, resulting in a total of 363 known outcomes . Of US patients enrolled, 73.3 % were White, 16.4 % were Black, 6.6 % were Hispanic, and 0.9 % were Asian. Of the 9 patients (2.8 %) listed as “other”, 3 identified as biracial and 1 patient each as European, Multi, Filipino, Persian, Middle Eastern, and unknown.The mean age of the study population was 30.4 years . Race was only collected in patients enrolled in the United States  had discontinued natalizumab use at the time of enrollment. Of the 376 patients enrolled, 71 (18.9 %) discontinued natalizumab during the 3-month period prior to conception, 288 (76.6 %) discontinued during the first trimester, and 7 (1.9 %) discontinued during the second trimester. Six patients discontinued natalizumab after enrollment: 2, 3, and 1 patients during the first, second, and third trimesters, respectively.Most enrolled patients  were last exposed between gestational weeks 1 and 4, while the remainder were last exposed within 90 days prior to the last menstrual period , between 5 and 8 weeks’ gestation , or between 9 and 13 weeks’ gestation . The mean age of mothers who had infants with birth defects was 31.8 years (range 24–45 years).Of the 363 pregnancy outcomes in 355 patients, 57 birth defects (minor or major) were confirmed in 30 infants (including 3 sets of twins) Tables  and 3; oOf the 57 observed birth defects Table , those cA birth defect evaluator also assessed confirmed defects (minor and major) for a possible temporal relationship to natalizumab exposure. A total of 26 major and minor defects were judged to have a possible temporal relationship , with 16 major defects in 12 infants and 10 minor defects in 7 infants Table .Table 4MAmong the 355 pregnancies resulting in 363 known pregnancy outcomes, mean gestational age at enrollment was 11.8 weeks . In the 32 spontaneous abortions observed, the mean gestational age at enrollment was 5.5 weeks . Thus, the rate of spontaneous abortion  among pregnancies with known outcomes was 9.0 % (95 % C. I. 6.3–12.5 %). Of the 355 pregnancies with known outcomes, 339 were enrolled prior to 22 weeks’ gestation; the rate of spontaneous abortion among these 339 pregnancies was 9.4 % (95 % C. I. 6.6–13.1 %). One stillbirth (0.3 %) was reported, and 14 patients (3.9 %) had elective terminations, 1 with a birth defect. No ectopic pregnancies were reported.Of the 316 live born infants, 287 (90.8 %) were born without congenital anomaly. There were 148 males (46.8 %) and 163 females (51.6 %); gender was not recorded for 5 infants (1.6 %). The mean gestational age at birth was 38.3 weeks (range 26–43 weeks). The majority of infants  were born at term (≥37 weeks); 48 (15.2 %) were born prematurely, and gestational age at birth was not recorded for 1 infant (0.3 %). At birth, mean APGAR  scores were 8.0 (range 1–10) at 1 min, 8.9 (range 2–10) at 5 min, and 9.6 (range 6–10) at 10 min; mean birth weight was 3161.7 g (95 % C. I. 3099.5–3223.9 g), mean infant length was 49.7 cm (range 34–56 cm), and mean head circumference was 35.2 cm (range 30–89 cm). Of the 290 singleton births, 22 (7.6 %) resulted in low birth weight, which compares favorably with that reported by the US National Center for Health Statistics (6.27 %) for the 2013 rate of low birth weight in singleton births [Currently, women with MS or CD being treated with natalizumab who are planning to become pregnant or discover they are pregnant after natalizumab exposure are advised to balance the potential benefits and potential risks of exposure when considering treatment options. Although some patients are able to discontinue treatment before or during pregnancy, others with more severe disease may elect to continue treatment. Thus, this Registry was undertaken to prospectively gather important information about pregnancy outcomes in patients exposed to natalizumab. In the Registry, the rate of reported birth defects in the infants of women exposed to natalizumab during pregnancy was higher than the 2.67 % observed in the MACDP. No specific pattern of malformations was seen within the observed birth defects. The rate of spontaneous abortions was consistent with the general population –28.Natalizumab prevents leukocyte migration by binding to α4 integrins that are expressed on the surface of leukocytes . HoweverAnimal studies provide valuable information, but human studies are also necessary to understand maternal and neonatal outcomes. Hellwig et al reported no decreased fetal growth or teratogenicity in 35 patients who received natalizumab for ≥8 weeks prior to their last menses and discontinued treatment as soon as they became aware of the pregnancy . In thesThe potential influence of natalizumab exposure at different gestational time points should be considered. Case reports by Mattioda et al  and TotaIn the Registry, the majority of patients discontinued treatment prior to or within the first trimester. The pregnancies resulting in live births with defects were last exposed to natalizumab within 3 months prior to conception or within the first trimester, with more than half exposed between 1 and 4 weeks of gestation. Of the 4 patients who continued natalizumab treatment during pregnancy, no congenital anomalies were observed in the resulting 4 live births. Interpretation of the Registry data is limited by the duration of natalizumab exposure during pregnancy.The Registry found no increased risk of pregnancy loss in pregnancy outcomes among women with natalizumab exposure compared with rates in the general population. The spontaneous abortion rate of patients in the Registry (9.0 %) was lower than that observed in the general population (13.1–15.9 %) , 27 and Upon review of Registry pregnancy outcomes, the Advisory Committee determined that 16 infants among the 317 (316 live births plus 1 elective termination) had defects that met criteria for major defects. The Registry birth defect rate of 5.05 %, as determined by the Advisory Committee, was higher than the 2.67 % published in the MACDP . No pattRegistry outcomes can be complicated by potential biases inherent to the study population and design. Such biases may result in an overestimate or an underestimate of the reported risk. For example, the protocol permitted enrollment of pregnant patients in the Registry after a prenatal test, as long as testing did not indicate an abnormality. However, this practice could potentially bias the results by lowering the overall risks of birth defects . Other pThe Registry prospectively evaluated pregnancy outcomes in patients treated with natalizumab within 3 months of conception or during pregnancy. The overall rate of major birth defects in the Registry was higher than that reported by the MACDP. No specific pattern of birth defects was observed that would suggest a drug effect. The rate of spontaneous abortions was consistent with the expected background rates observed in the general population –28. Alth


Recent evidence from studies performed mainly in warm climates suggests an association between exposure to extreme temperatures late in pregnancy and an increased risk of preterm delivery. However, there have been fewer studies on the effect of low temperatures. The aim of this study is to explore the potential association between both heat and cold during late pregnancy and an increased risk of preterm birth in the northern location of Stockholm, Sweden. All singleton spontaneous births that took place in greater Stockholm (1998–2006) were included. Non-linear and delayed effects of mean temperature on the risk of preterm birth were explored through distributed lag non-linear models. Extreme and moderate heat and cold were estimated separately through quasi-Poisson regression analysis in two seasonal periods . The risk of preterm birth increased by 4%–5% when the mean temperature reached the 75th percentile (moderate heat) four weeks earlier , with a maximum cumulative risk ratio of 2.50 . Inconsistent associations were obtained for cold and extreme heat. Exposure to moderately high temperatures during late pregnancy might be associated with an increase in risk of preterm birth in Stockholm. Effects of climate change on population health have barely been investigated but are a major public health concern. One of the emerging research issues gaining attention is the effect of exposure to high or low temperatures during pregnancy. A few recent studies addressed the potential association between the exposure to extreme temperatures and different birth outcomes, including preterm birth, low birth weight, stillbirth, and congenital anomalies ,6,7,8,9.Preterm birth, referring to all births with gestational age < 37 complete weeks , is the 2, with approximately 40% of the population residing in the city proper.Data on all deliveries by women residing in the greater Stockholm area from 1998 to 2006 were extracted from the Swedish Medical Birth Register. The number of inhabitants in the greater Stockholm area is about 1.6 million per 3500 kmWe restricted the analysis to all singleton births whose labor had not been artificially induced and whose reported gestational age was between 22 and 42 weeks. Gestational age was estimated through ultrasound examinations in more than 98% of the births in the Swedish Medical Birth Register. For the remainder of the cases, gestational age was calculated according to the mother’s last recalled menstrual period.Greater Stockholm is located in northern Europe and borders the Baltic Sea. It has a temperate climate with very mild summer temperatures and cold winters. During the study period, daily air temperature and humidity data were derived from the monitor located in Central Stockholm and managed by the City of Stockholm Environment and Health Administration.10), nitrogen dioxide (NO2), and daily maximum eight-hour running mean of ozone (O3) were calculated using the hourly measurements taken from an urban background (rooftop) station located in Central Stockholm managed by the City of Stockholm Environment and Health Administration.Daily 24-h mean concentrations of particulate matter (PM) with aerodynamic diameter < 10 µm  , and theA modified pregnancies-at-risk approach was applied to properly account for the short-term variations of the population at risk . This coDaily mean temperature was used as the main exposure metric to explore the contribution of heat and cold on the risk of preterm birth. This decision was made with the aim of simplifying the approach and was based on the similarity to the results obtained in the preliminary analysis for mean, maximum, and minimum temperature . To do tIn each case, we obtained two different association estimates according to the range of temperature explored: the moderate heat (and cold) that was estimated in terms of risk ratio (RR) and its 95% confidence interval (CI) for the increase (or decrease) in daily mean temperature from the annual median value to the 75th percentile of the warm season distribution (or 25th percentile of the cold season). Additionally, RR estimates were obtained for the extreme heat and cold expressed as the change in risk when mean daily temperatures reached the 99th/1st percentile  of the corresponding season. In the main analysis, we reported the results as lag-specific RR estimates and the overall cumulative RR up to 30 days .According to DLNM methodology, mean daily temperature was introduced in all models as a cross-basis term. Two natural cubic spline functions with two degrees of freedom (df) were specified to accurately capture the relationship between temperature and the outcome, and across the lag-specific estimates up to 30 days, similarly to previous studies . The comWe controlled for long-term trends and seasonality through two penalized cubic splines with 1 df per year and month in each season . This was a conservative method, but it had enough flexibility to properly control for confounding. Also, factor variables such as the day of the week and holidays were introduced in the model along with a non-linear term of mean relative humidity . Again, the number of df was selected according to the q-AIC.Several additional analyses were performed to better characterize the estimated associations obtained in the main analysis. We obtained the week-specific cumulative RR for moderate/extreme heat and cold using the initial definitions of warm and cold seasons and restricting each season period to the hottest and/or coldest months. That is, we defined a restricted warm season from June to August and the corresponding cold season between November and March.3, NO2, PM10) one by one in the main model for temperature effect as a linear term of the moving average of the previous week. Additionally, we tested the linearity of this air pollution term comparing the fitting of the initial approach (using a linear term) with the fitting when a non-linear term was introduced  using the ANOVA Fisher test. Finally, we explored how the air pollution coefficient varied when mean temperature (as a cross-basis term) was or was not included in the model.We also compared the cumulative RR estimates of the main model with the ones obtained when air pollutants were considered. We introduced each air pollutant  and the DLNM package in the R software version 2.15.1  .versus 3.3% in the warm season).During the entire study period (from 1998 to 2006), a total of 134,802 births took place in the greater Stockholm area. However, only 95,069 births (70.5%) met the inclusion criteria for the present study, with an overall proportion of preterm birth during the study period of 3.5% . A highe3 (r = 0.3318) and PM10 (r = 0.2495) in the warm season, but almost no correlation for NO2 (r = −0.0685). In the cold months, NO2 seemed to be negatively correlated with temperature (r = −0.3044). Higher correlation coefficients were obtained between air pollutants and relative humidity, for example, for O3 in both seasonal periods and for PM10 in the cold season.As shown in According to Our results suggest different distribution patterns for the contribution of heat and cold on the risk of preterm birth across the 30-day lagged period . In Tabl3 (“WS + O3”) was included in the model, which produced RR values that were slightly smaller compared to the main model estimates. The same pattern was observed for the extreme heat estimates, but in this case the risk values in the O3 model were below 1 and statistically significant, and it remained constant throughout the four weeks. As expected, when we restricted the analysis to the hottest months, higher but not statistically significant RR estimates were obtained for extreme heat. The RR of moderate heat was not estimated for this restricted period due to the lack of statistical power (insufficient number of days with moderate mean temperature).In 3 and NO2 were considered in the model. However, the cumulative RR changed slightly towards zero for extreme cold when PM10 was included (“CS + PM10”) in weeks 1, 2, and 3 compared to the “CS” estimate.Focusing on the results from main analysis for cold  in the face of climate change. However, the still-unknown mechanisms triggering preterm delivery, along with the heterogeneity among study populations and climate conditions, make the assessment of the role of ambient temperature as a risk factor for preterm birth challenging.et al. [We observed different heat and cold association patterns, with non-significant changes in the risk of preterm birth due to low temperatures, which is in agreement with the results of Schifano et al. . A recenet al. . HoweverWith regard to high temperatures, several investigations in both European and non-European populations reported an immediate increase in the risk of preterm birth during the following days after the exposure to high temperatures or heat waves, with consistent effects lasting up to one week ,9,28,29.In light of our results, one might suggest that this delayed estimate of moderate temperatures would be related to a different underlying mechanism that might trigger preterm delivery. We propose several potential explanations for this delayed effect. First, it has been reported that one of the multiple risk factors of preterm delivery is the development of an inflammatory process due to an intrauterine infection, accounting for near 40% of all cases of premature birth . We arguin utero, beyond the short-term effect, when the exposure to defined ranges of temperature might alter the health status of the pregnant women and subsequently trigger preterm delivery.In the present study, the exposure to cold was not found to be associated with a higher risk of preterm birth, which is contrary to the results reported in a Swedish study where extreme cold adversely affected preterm birth . As statWe performed several additional analyses in order to shed more light on our results. We restricted the heat and cold analyses to the hottest and coldest months and, as expected, higher RR estimates were obtained in the extreme heat from the first week after exposure . However3 levels were included in the heat-effect model and when PM10 was considered in the cold-effect model compared to the main results. Because we did not observe any effect of both air pollutants on the risk of preterm birth by themselves ; therefore, the joint effect between temperature and PM10 should be further addressed in future works.We observed a slight decrease in RR estimates when weekly average Oemselves , it mighm season . Also, i outcome . Regardietc. Thus, new research performed in defined or unexplored locations contributes useful evidence. In order to continue advancing knowledge on the relationship between temperature and preterm birth, it would be necessary to perform new studies on this issue in other locations and using a common methodological framework.To our knowledge, this is the first study performed in a cold climate that explores the short-term effects of heat and cold on preterm birth. As stated previously, the consequences of exposure to both high and low temperatures during gestation have been addressed in a limited number of studies compared to the number of studies exploring the association between birth outcomes and other environmental variables such as air pollution. Likewise, a wide heterogeneity in the results has been observed across the different study locations, perhaps due to the general characteristics and habits of the population and acclimatization. This limits the generalizability of the conclusions derived in the different studies. In addition, there is no agreement in several methodological aspects, such as the explored exposure window, the definition of the study population, heat or cold indicators, i.e., maternal smoking behavior), mainly because these would need to fluctuate in the same time scale as temperature does (day by day) in order to confound our results.In the present study, we performed a time-series analysis that enabled us to control for the underlying seasonal trend in conceptions that, if not controlled for, might have introduced bias in our temperature-effect estimates. We also took into account the potential short-term variations of the population at risk by applying the modified version of the pregnancies-at-risk approach. This consists of including in the model not only the daily count of ongoing pregnancies-at-risk at each day , but also the daily distribution of the gestational age of this set-at-risk as a way to control to the variable baseline risk of giving birth depending on the week of gestation. Likewise, the influence of time-invariant confounding variables, such as individual maternal characteristics or habits, is controlled by design. Also, our estimates would not be affected by other unmeasured confounders that might vary across time (We restricted the analysis to all spontaneous births as a way to exclude planned deliveries and to better evaluate the effect of temperature as a trigger for preterm birth, as was done in other studies ,7. HowevIn conclusion, one of the key elements for improving protection of the population from temperature effects, and more generally to climate change, is to identify specific vulnerable subgroups for whom targeted prevention measures should be addressed. We observed an increased risk of giving birth prematurely after exposure to moderate heat during the last month of gestation, which suggests that pregnant women might be considered a subpopulation that is potentially susceptible to heat. Despite our small and in some cases inconsistent estimates, it should be taken into account that even small effects of a ubiquitous exposure on an important health outcome can have large public health impacts. Given the extensive contribution of preterm delivery to infant mortality estimates worldwide and the considerable impact on premature newborns’ health later in life, our results, along with the evidence obtained from previous studies, should be considered for the design of future policies combatting climate change.


To compare thoracic musculoskeletal static alterations in adolescents bornprematurely with those born at term and investigate neonatal and post-neonatalvariables associated with thoracic alterations. This is a cross-sectional study with 57 adolescents aged 10-15 years bornprematurely and 57 adolescents born at term paired by gender and age. Photographsof the head and thorax in the front, back, and right side views were studied usinga computer program. The two groups were compared in regards to: elevation ofclavicles, elevation of shoulders, protrusion of the head, and anteroposterior andmediolateral thoracic length. Factor associated with thoracic disorders wereevaluated by linear regression analysis. o vs. 20.6±5.3o;sim, p=0.038) and the rightshoulder . Smallerprotrusion of the head ,mediolateral thoracic length  andanteroposterior thoracic length  werefound in preterm adolescents. By multiple regression analysis, factors associatedwith higher shoulder elevation were birth weight <1500 g (p<0.001) andmechanical ventilation during neonatal period >5 days (p=0.009). The Preterm group had mean gestational age of 32.0±2.8 weeks and the birth weightwas 1462±338 and 3342±430 g for the Preterm and Term adolescents, respectively.Preterm adolescents had higher elevation of the left shoulder(22.7±5.4Adolescents born prematurely presented greater thoracic musculoskeletal staticalterations compared to those born at term. Factors associated with thesealterations were: very low birth weight and longer duration of mechanicalventilation in the neonatal unit. By linearmultiple regression analysis, these authors found that bronchopulmonary dysplasia had anegative influence on the walking distance during the test-Similar to what is seen in patients with chronic lung diseaseThese findings raise questions in regard to the persistence of such alterations at olderage. However, there are no studies addressing alterations in the rib cage in adolescentsstemming from premature birth.In this context, the aim of the present study was to compare static musculoskeletalcharacteristics of the thoracic cage in adolescents born prematurely with those born atfull term and to evaluate neonatal and post-neonatal variables associated with thesethoracic disorders.A cross-sectional study was conducted involving two groups of adolescents aged 10 to 15years, matched by age and gender (1:1). The inclusion criteria for the Preterm groupwere adolescents born with a gestational age <37 weeks and a birth weight <2000 g,followed up at the Multi Disciplinary Premature Outpatient Clinic of a publicuniversity. The inclusion criteria for the Term group were healthy adolescents born atterm with birth weight >2500 g, who were discharged from the maternity within threedays of life; who neither presented any clinical complication nor required oxygentherapy in the neonatal period, had not been hospitalized after discharge from thematernity until the day they were included in the study, and were attending a publicschool.The exclusion criteria were congenital malformation, neuromuscular disease, chromosomedisorder, any orthopedic anatomical defect which could interfere with static posture orsevere neurological impairment based on magnetic resonance or computed tomographyimaging performed in the neonatal period and/or during follow up and a neurologicevaluation performed by a pediatric neurologist during follow up at the PrematureOutpatient Clinic.Universidade Federal de SãoPaulo (UNIFESP), São Paulo, SP, Brazil (#1830-07), and parents/guardianssigned an informed consent form.This study was approved by the Ethics Committee of The following demographic and clinical data were collected from the Term group: gender,birth weight, gestational age, and duration of stay in the maternity at the time ofbirth. Besides these data, the following were also collected from the Preterm group:gestational age based on the best obstetric estimate or pediatric assessmentPhotographs of the head and thorax in the front, back, and right side views weretaken using a digital camera (Sony Cyber-shot(r) DSC-T10) placed on a tripod at adistance of three meters from the participant and one meter from the floor. Theadolescents wore bathing suits for the visualization of the anatomic points markedwith half-moon polystyrene disks placed on the acromia, manubrium, and trapeziusmuscles, based on Davidson et al.Postural measures  were evaInclination of the head (1A): angle between both ear lobes and line parallelto the ground;Inclination of the shoulders (1B): angle between the acromia and lineparallel to the ground;Asymmetry of scapulae (1C): difference in distance between right and leftscapula and C7;Forward lean of head (1D): angle between C7, ear lobe, and line parallel tothe ground;Alignment of head in relation to shoulder (1E): angle between acromion, earlobe, and line perpendicular to the ground;For the evaluation of the angles and measures related to thoracic alterations, thefollowing were analyzed :Elevation of clavicles (2A): angle between the acromia and manubriumElevation of shoulders (2B and 2C): angle between acromion, trapezius, andmanubrium (right and left)Protrusion of head (2D): angle between C7, T3, and a line perpendicular tothe groundThorax dimensions (2E and 2F): mediolateral and anteroposterior distance ofthe thorax,-A postural assessment software program (SAPO) was used for the analysis of theimages, obeying the following sequence: opening of file, plumb line calibration ofimage, 100% zoom, marking of desired anatomic points and release of report. Besidesthe angles related to the thorax, the thoracic distances formed between the dermisextremities on the mammary line in the front view (2E) and side view (2F) werecalculated using the software tool, Edge Detection2) test or Fisher's exact test. Factors associated with thoracicalterations were studied by univariate linear regression analysis, consideringclinical variables that may have interfered with these alterations. Then, variableswith clinical interest and a statistical significance level of p<0.2 in theunivariate analysis were included in the multiple linear regression model.Convenience sampling was performed with the inclusion of all adolescents bornprematurely and followed at the Premature Outpatient Clinic of the institution. Thenumerical variables were expressed as mean and standard deviation or median, range,Q1-Q3 (first and third quartile) and compared using either the Student t-test  or the Mann-Whitney test . The categoricalvariables were expressed as frequency and compared using either the chi-squared. P<0.05 was considered statistically significant.During the study period, 76 adolescents aged 10 to 15 years were monitored at thePremature Outpatient Clinic. Nine (11.8%) subjects were excluded from the study; 8(10.5%) due to neurological sequel from intra-ventricular hemorrhage, periventricularleukomalacia, epilepsy or chromosome disorder, and 1 (1.3%) due to differences in thelength of the lower limbs. Among the 67 eligible adolescents, 10 (14.9%) were notincluded [4 (6.0%) due to refusals on the part of parents/guardians and 6 (9.0%) becausematching was not possible]. Thus, 57 (85.1%) adolescents in the Preterm group werematched by age and gender with 57 adolescents born at full term.st quartile - Q3:3rd quartile: 2995-3750 g). None of them presented any clinicalcomplication nor required oxygen therapy in the neonatal period and were discharged fromthe neonatal unit within three days of age.Adolescents born at term had gestational age >37 weeks, mean birth weight of 3342±430g . In the premature group, mean gestational age was 32.0±2.8 weeks, mean Apgar score at firstminute was 7±2  and mean Apgar score at fifthminute was 9±1 .Regarding clinical status in the neonatal period, 17 (29.8%) participants in thepremature group experienced respiratory distress syndrome, 6 (10.5%) developed neonatalsepsis, 1 (1.8%) developed meningitis, 18 (31.6%) intraventricular hemorrhage, 6 (10.5%)were oxygen dependent at 28 days of life, and 2 (3.5%) were oxygen dependent at 36 weeksof corrected gestational age. During hospitalization in the neonatal unit, 19 (33.3%)preterm children were submitted to mechanical ventilation for a mean of 2±7 days. Mean of days of hospital stay in theneonatal unit for those born prematurely was 37±22 days .2; p=0.916), percentage of obese adolescents ,percentage of patients with current asthma , and percentage ofadolescents with physical activities for at least twice/week .Fifty-four adolescents in the Preterm group (94.7%) were right-handed and 3 (5.3%) wereleft-handed, whereas 54 (94.7%) adolescents in the Term group were right-handed, 2(3.5%) were left-handed and 1 (1.8%) was ambidextrous (p=0.463).At study entry, the Preterm group was similar to the control group with regard to age, weight ,height , body mass index  lower; the mediolateral thoracic length was -1.46 cm shorter; and the anteroposterior thoracic length was-2.16 cm  shorter. Moreover, the degree of shoulderelevation was positively associated with birth weight <1500 grams, gestational age<37 weeks, need for mechanical ventilation for more than five days, and need foroxygen therapy for more than 10 days .By multivariate linear regression analysis, after adjustment for variables with level ofp value <0.2, gestational age <37 weeks was significantly associated with lowerhead protrusion, smaller thorax size and shoulder elevation. Moreover, the shoulderelevation was also found to be higher in adolescents with birth weight <1500 g andthose submitted to mechanical ventilation >5 days during neonatal period, compared tothose without these characteristics .To our knowledge, this is the first study to assess thoracic alterations in adolescentsborn prematurely. This study showed that such adolescents exhibit higher shoulderelevation, retracted head posture, and smaller thorax compared to adolescents born atterm. Moreover, shoulder elevation was positively associated with very low birth weightand need for mechanical ventilation for more than five days in the neonatal unit.-,Higher shoulder elevation may be due to increased respiratory effort, which affects therib cage muscles, with an increase in the activity of the erector spinae, large dorsal,greater pectoral, and trapezius muscles as previously reported in patients with chronicrespiratory problems such as asthma, mouth breathers, and chronic obstructive pulmonarydiseases,The extension of the cervical vertebrae with lesser head protrusion is believed to occurwhen there is narrowing of the pharynx. With the extension of the cervical spine, thereis the release of the airways, thereby facilitating breathing in individuals with airwayobstruction, such as those with asthma and/or mouth breathingThe higher shoulder elevation and retracted posture found in this study in adolescentsborn prematurely may be related to patterns of obstructive disorders observed inpulmonary function tests in preterm children and adolescents, mainly in those who alsodeveloped bronchopulmonary dysplasia,,,,The anteroposterior and mediolateral measures of the thorax which were smaller in thePreterm group reflect the smaller size of the thoracic cage and this may be related tolung function given that children and adolescents born prematurely can have smaller lungvolumesThe mechanics and conformation of the thorax vary depending on gender, age, and bodymass. As an integral part of the thoracic structure, the spinal column also influencesthe conformation of the rib cage. A study involving children and adolescents betweeneight and 14 years of age found changes in the vertical alignment with age; moreover,greater lordosis was found among females in comparison with males during flexion of theshoulders, which may be attributed to greater muscle weakness in girls in thepost-menarche period-,Other studies demonstrated the importance of nutritional status on lung function, whichcould indirectly affect thoracic conformation. Obese children and adolescents betweensix and 14 years of age present lesser respiratory muscle strength in comparison withthose within the ideal weight range, especially with regard to expiratory capacity,which can compromise ventilatory capacityFor these reasons, in order to control variables that could interfere with the thoracicframe and size, in this study, the two groups of adolescents were paired by age andgender, and other variables that could alter our results such as weight, height, andbody mass index were found to be similar between groups.Cervical and thoracic postures were also evaluated to verify the positioning of theadolescents during photography. In order to minimize and control the influence of globalposture, other measurements of the thorax and head position were analyzed . This evAs shown by the adjusted linear regression analysis, this study highlighted thehypothesis that preterm birth, particularly if followed by mechanical ventilation duringthe neonatal period, may lead to thoracic alterations in adolescence. In this study,after adjustment for covariate variables, very low birth weight and mechanicalventilation for more than had five days were associated with higher shoulderelevation.,It is possible that the thoracic alterations found in the present study are accompaniedby lung function impairment stemming from premature birth and associated comorbidities,as previously reported for children and adolescents with chronic lung diseaseConvenience sampling and a lack of a sample size calculation are the limitations of thisstudy. However, in the post hoc analysis, considering a two-tailed test and 5% alphaerror, the sample power of this study was greater than 95% for elevation of the rightshoulder, head protrusion, and for thorax size.While there is no standard of normality for musculoskeletal structures of the thorax,significant differences were found between adolescents born prematurely and those bornat full term. It is possible that such differences may be attributed to the prematurebirth because, in addition to the neonatal characteristics, the adolescents were similarregarding variables that could affect the conformation of the thoracic cage.This study highlights the influence of the preterm birth over respiratory systemdevelopment and reinforces the need for long-term follow up of these patients by amulti-professional team in order to search for any thoracic alterations and plan forearly interventions. Thus, it can be concluded that adolescents born prematurelypresented greater thoracic musculoskeletal static alterations compared to those born atfull term and that the factors associated with these alterations were very low birthweight and longer duration of mechanical ventilation in the neonatal unit.


Demographic data and information on smoking status, residence location, and pre-pregnancy body mass index were obtained for all participants, and birth records were used to gather information on newborns’ sex, birth weight, gestational age, and delivery. For one-quarter of the INMA participants and all ENVIRONAGE participants, placentas were collected at birth, and their nuclear DNA and mtDNA content was measured.The current study draws on data collected through two independent birth cohort studies conducted in Europe: Infancia y Medio Ambiente (INMA) in Spain, and Environmental Influence on Ageing (ENVIR2) concentrations. Exposures were averaged for each trimester and for the whole pregnancy.Ambient air pollution exposure for both cohorts was represented by nitrogen dioxide , which could be explained by differences in factors such as exposure assessment methods, population characteristics, and study design.2 was measured by outdoor passive samplers distributed throughout the study areas, with land use regression models accounting for residential location. The NO2 exposure estimates in the ENVIRONAGE cohort depended on residential address, satellite data, and a dispersion model that incorporated ground-based data.The association between NO2 exposures were also inversely associated with placental mtDNA content, and placental mtDNA and birth weight were positively correlated. Based on these results, the authors concluded that placental mtDNA content may mediate the relationship between prenatal NO2 exposure and birth weight.Prenatal NO“We saw very clearly that the mtDNA was indeed related to birth weight,” says lead investigator Tim Nawrot, an assistant professor of environmental epidemiology at Hasselt University in Belgium. “Babies with a lower mtDNA content in the placenta showed a lower birth weight in both cohorts.” The authors point to the lack of data on indoor air exposures—which also have been associated with changes in birth weight—as a limitation of the study.“Overall, I see this study as an important piece of the puzzle as far as the weight of evidence on air pollution and pregnancy outcomes,” says David Stieb, a public health physician and epidemiologist at Health Canada, who was not involved in the study. “There have been dozens of epidemiological studies looking at these associations, and there does seem to be a fairly consistent signal now, especially for air pollution and reduced birth weight.” With limited evidence for the mechanisms that could explain that association, “this study could definitely help fill the gap,” says Stieb.The results will need to be confirmed through further epidemiological investigations, long-term prospective studies, and experimental research. “We will certainly look at whether the mitochondrial function in the placenta is related to future aspects of development,” says Nawrot. “What we want to establish is whether the mitochondrial-related weight reduction in early life is related to disease development later in life.”


Spontaneous preterm birth is a complex syndrome with multiple pathways interactions determining its occurrence, including genetic, immunological, physiologic, biochemical and environmental factors. Despite great worldwide efforts in preterm birth prevention, there are no recent effective therapeutic strategies able to decrease spontaneous preterm birth rates or their consequent neonatal morbidity/mortality. The Preterm SAMBA study will associate metabolomics technologies to identify clinical and metabolite predictors for preterm birth. These innovative and unbiased techniques might be a strategic key to advance spontaneous preterm birth prediction.Preterm SAMBA study consists of a discovery phase to identify biophysical and untargeted metabolomics from blood and hair samples associated with preterm birth, plus a validation phase to evaluate the performance of the predictive modelling. The first phase, a case–control study, will randomly select 100 women who had a spontaneous preterm birth (before 37 weeks) and 100 women who had term birth in the Cork Ireland and Auckland New Zealand cohorts within the SCOPE study, an international consortium aimed to identify potential metabolomic predictors using biophysical data and blood samples collected at 20 weeks of gestation. The validation phase will recruit 1150 Brazilian pregnant women from five participant centres and will collect blood and hair samples at 20 weeks of gestation to evaluate the performance of the algorithm model  in predicting spontaneous preterm birth .The Preterm SAMBA study intends to step forward on preterm birth prediction using metabolomics techniques, and accurate protocols for sample collection among multi-ethnic populations. The use of metabolomics in medical science research is innovative and promises to provide solutions for disorders with multiple complex underlying determinants such as spontaneous preterm birth. Despite improvements in antenatal and neonatal care, the number of premature newborns each year has not significantly decreased since the 1960s. Preterm birth (PTB) is the leading cause of neonatal morbidity and mortality and a major contributor to loss of life, long-term disability, and health care costs . The assDespite the enormity of the health economic burden of preterm birth, and many years of focused research, a common aetiology and/or predictive test have not yet been identified. Spontaneous preterm birth (sPTB) is considered one of the “Great Obstetrical Syndromes”, which are conditions resulting from complex interactions between the maternal and fetal genome and the environment and which have a long preclinical period, fetal involvement and adaptive functioning in nature . This reThere are many clinical –13 and bCurrently, the selection of women likely to deliver prematurely from clinical risk factors alone lacks the sensitivity required to effectively identify the majority of patients at risk of idiopathic sPTB . FurtherThe development of a predictive test for spontaneous preterm birth would help to accurately identify a high-risk population. To be effective, therapies need to be commenced at a gestational age in which they are likely to be of benefit. A sensitive early pregnancy-screening test would facilitate the timely administration of prophylactic treatments to those women at highest risk. The development of physics, biology and medicine translational research can provide a comprehensive approach for biological processes with complex pathways and regulations. Metabolomics offers an unbiased hypothesis generating approach to identify and validate potential candidate metabolomic biomarkers , 25.We propose a multi-strategy approach to biomarker discovery and validation through the establishment of a large early pregnancy biobank of appropriate samples, in conjunction with the application of analytical methods capable of quantifying multiple blood-borne species simultaneously, and using some clinical and epidemiological markers to identify women at highest risk of spontaneous preterm birth.The development of predictive tests that translate into clinical care can be divided into two distinct phases; (i) hypothesis generation after acquisition of data, a non-biased process where no or limited biological knowledge is required and (ii) validation of generated hypotheses . The PrePreterm SAMBA, an international collaborative multicentre study for the development of predictive tests that translate into clinical care, can be divided into two distinct phases: The first component (Discovery phase) is a case–control study that aims to identify clinical and metabolomics biomarkers related to spontaneous preterm birth. For this initial phase, untargeted metabolomics techniques will be employed to identify and quantify potential predictor’s metabolites that can be associated to potential clinical predictors. The second component  is a cohort study developed to validate the algorithm of prediction using the clinical and metabolomics biomarkers discovered in the first component of the study. Thus, to evaluate the performance of the prediction model developed at the first phase, targeted metabolomics techniques will be employed to analyse participants’ blood and hair samples to quantify those specific metabolites identified as potential predictors of preterm birth.The initial phase of the project consists of a case–control study utilizing data and samples collected for the SCOPE study (Screening for Pregnancy Endpoints study). The SCOPE consortium was an international effort to determine the causes and potential predictors for pregnancy complications and its methodology had already been previously published –29. BrieExtensive sociodemographic and physical data will be collected including age, ethnicity, socio-economic status, dietary and lifestyle questionnaire, parity, BMI (body mass index) and cigarette smoking.Plasma and serum samples will be collected at 20 weeks of gestation using stringent standard operating procedures designed for metabolomics studies, barcoded and stored at −80 °C within 2–4 h; the timing between collection and freezing will be known for all specimens.Several Standard Operating Procedures (SOP) for sample preparation by removal of proteins via ultrafiltration were developed and validated. The analysis of deproteinized plasma samples will be performed employing gas chromatography and liquid chromatography mass spectrometry (GC-MS and LC-MS). GC-MS and LC-MS techniques will be performed as described previously , 31. Quan = 100) whose pregnancies reached term as compared to fifty randomly sampled pregnancies (n = 50) complicated by spontaneous preterm birth prior to 37 weeks gestation, in each of the Cork Ireland and Auckland New Zealand SCOPE cohorts , were chosen to participate in the Brazilian cohort Table . PreviouAssuming a type I error rate, α, of 5 % and an estimated area under ROC curve of at least 0.68, then in order to test hypotheses to a suitable level of power , the sample size sufficient should approximate to 80 cases of spontaneous preterm birth (<34 weeks gestation), calculated using MEDCALC®. Based on a minimum expected preterm birth rate of 7 %, the total cohort size should therefore be of approximately 1150 subjects, around 230 women at each participating centres.The recruitment strategies include approaching existing pregnant women in participating facilities during prenatal care visits and with website/internet, flyers and local community advertisings. After the identification of potential participants, the research assistant will invite women and obtain an informed consent form of those who meet the inclusion criteria and agree to participate. Maternal age and ethnicity will be recorded from all approached women to facilitate a comparison of those who are recruited and those who decline.All collected data will preferably be entered directly into the database, but printed forms will also be available in case of inability to access the internet-based database. In such cases, the data will be then entered later and completed printed forms will be stored, according to the required ethical principles.First Visit (19–21 weeks): similarly to the SCOPE study, detailed information of sociodemographic characteristics , maternal medical and obstetric history, infertility history, drugs and medications use, family medical and obstetric history and current pregnancy  will be collected.Anthropometric measurements of maternal body mass index, height, weight, head circumference, arm circumference and triceps, biceps subscapular and suprailiac skinfolds will be performed according to standardized techniques. Height and weight of lightly clothed women will be measured to the nearest 0.1 mm and 0.1 kg respectively. Head and arm circumferences will be measured with an inelastic tape and skinfold thicknesses will be measured on the same side of the body to the nearest 0.2 mm using Harpenden (and/or Lange) skinfold calliper. The calliper is placed 1 cm distal to the firmly grasped skinfold, using the thumb and the index finger, at 90° to the skin. A single measurement is taken after 2 s.Dietary intake will be assessed using a 24-h dietary recall administered by a trained professional who will query participants about food and beverage consumption in the previous 24 h. A trained nutritionist will then estimate calories, macro and micronutrient intake using computer-based standard tables allowing for appropriate ethnic, social and regional variations.Furthermore, three consecutive manual blood pressure measurements will be recorded, using an appropriate cuff size for different arm circumferences and using Korotkoff phase V for diastolic blood pressure.Second and third Visit : three consecutive manual blood pressure measurements, anthropometric parameters  and occurrence and characteristics of infection, vaginal bleeding, dipstick proteinuria, intercourse and hospital admissions will be recorded.Postpartum data: data will be collected from the participant’s medical record, the prenatal chart and/or from a personal interview with the participant during hospital admission to minimize missing information. The main outcome is spontaneous preterm birth, defined as a birth before 34 weeks of gestational age due to preterm labour or premature rupture of membranes. Secondary outcomes will also be evaluated: spontaneous preterm birth alternatively defined as a birth before 37 weeks of gestational age due to preterm labour or premature rupture of membranes, provider-initiated preterm birth, defined as preterm birth due to medical indication on account of maternal or fetal conditions; pre-eclampsia, defined as having systolic blood pressure ≥ 140 or systolic blood pressure ≥ 90 mmHg after 20 weeks gestation on at least two occasions apart of 20 min, and/or proteinuria (24-h urinary protein ≥ 300 mg or urine dipstick ≥ ++) and/or severe maternal complications [ications ; gestatiications ; fetal gications . NeonataNon-fasting blood samples will be collected at 20 (between 19 and 21) weeks of gestational age  and HIPAA  compliant, which allows continuous data entry and monitoring of study progress. Completeness of clinical data and specimen collection will be constantly monitored, with incomplete fields ‘flagged’ for attention. The database allows several monitoring procedures with hierarchical access licenses and tracking system for all specimen aliquots stored. To comply with biobank regulatory issues, patients will only be identified by a unique study number. Pseudo-anonymised metadata and interim data will be stored using our laboratory information management system. The identifying information about participants will be kept in a separate and secure local database.Several procedures to enhance and assure data and sample quality will be adopted. All entered data will be prospectively and retrospectively monitored. During data entry, internal consistency of variables is performed and error messages are automatically flagged. After completing the collection of data from a participant, all information needs to be reviewed by a local monitor. Then, the final form has to be signed by the local principal investigator (PI) in order to be incorporated in the final database. The coordinating centre  will also perform a centralized monitoring of data and samples. An initial meeting with all researchers from Brazilian participating centres has been held to discuss the final protocol, procedures to be implemented, their particular characteristics and necessary approaches to be used to guarantee the implementation of the study. Another general meeting at the end of study is planned in order to discuss results, strategies for manuscripts’ writing and submission and other related topics.The coordinating centre will randomly select approximately 10 % of printed completed forms to carry out a check and validation of data from the forms and database entry during the first and second half of the study. This double-check procedure enhances data quality and decreases typing errors.The record of information regarding sample collection, processing (precentrifugation and centrifugation) and storage processes will follow the Standard Preanalytical Coding for biospecimens (SPRECs) protocol, developed and recommended by the International Society for Biological and Environmental Repositories Biospecimen (ISBER) Science Working Group . This prThe precise methodology to be used in the validation phase will depend on the ongoing discovery studies. As detailed above we anticipate that it will be based on a targeted triple quad MS (QQQ-MS) platform, as previously described . We will2), adjusted R2 , sensitivity, specificity, positive and negative predictive values, likelihood ratio and the area under the ROC curve.The performance of the final algorithm developed in the discovery phase will be evaluated by its capacity to predict spontaneous preterm birth occurrence in women from the Brazilian cohort. The validation will be performed using the average squared difference between predicted and observed outcome  and of all other Brazilian participating centres. All women who will be enrolled in the Preterm SAMBA Brazilian cohort  will sign an informed consent form, also allowing for future additional studies with their biological samples without any additional consent.The SCOPE study, whose data and samples will be analysed for the Preterm SAMBA discovery phase, was approved by local ethics committees in New Zealand and Ireland and registered in the Australian and New Zealand Clinical Trial Registry (ACTRN12607000551493) . All womThe ethical principles stated in the Brazilian National Heath Council (Resolution CNS 466/12) will be respected in every stage of this study. The anonymity of the source of information will be guaranteed and the care for the women will be provided independent of her agreement to participate in the study. All ethical principles related to biobank storage and transport will be followed according to national and international rules related to research with human beings. The study also complies with the Declaration of Helsinki amended in Hong Kong in 1989. The methodological and ethical aspects of Preterm SAMBA study protocol were developed following STROBE guidelines .“Omics” Science comprises genomics, transcriptomics, proteomics and metabolomics technologies, which each provide valuable translational surveys in biological processes. A metabolomics approach enables the evaluation of metabolic pathways and the correlation of biochemical changes related to pathophysiology of disease, providing a downstream result of gene expression and higher sensitivity to phenotype of disease [The  disease –45. Unde disease .The development of a two-phase metabolomics research program that includes two large cohorts of nulliparous women is not an easy task. The network collaboration is essential to develop, implement and analyse such complex data and, more importantly, to achieve reliable results. Precise protocols for sample collection, processing, storage and biobank management will be essential to assure high quality data and results.Metabolomics profiling requires different techniques to address the detection and quantification of different classes of metabolites once there is no current method capable to identify all of them. Preterm SAMBA study will employ different untargeted techniques that require very carefully and standardized protocols for sample preparation . StudyinThe identification of spontaneous preterm birth predictors using multi-ethnic data/samples and the evaluation of performance in a culturally and ethnically different population is desirable and meaningful for external validation. The use of quality control records and SPREC protocol is another important recommendation for metabolomics studies due to the necessity to evaluate confounders for analytical measures such as the time between sample collection, storage and processing conditions and the occurrence of haemolysis, lipaemia and metabolic degradation on account of inadequate temperature or solar exposure .In the context of translational research, metabolomics may enhance understanding of the underlying pathways, which lead to obstetric complications. Preterm SAMBA aims to identify and validate a predictive model for spontaneous preterm birth, but will also develop a biobank and database that will enable research on pre-eclampsia (PE), fetal growth restriction (FGR) and gestational diabetes mellitus (GDM). The possibility to combine biochemical, genetics and clinical information that can be large-scale and replicable empowers the development of knowledge for clinical practice in preterm birth prevention. This would be especially worthwhile and helpful for countries with a high proportion and high absolute number of preterm births as is the case of Brazil where around 12 % of all births occur prematurely .A recent clustered designed study showed that 30 % of all spontaneous preterm births do not have any maternal, fetal or placental conditions identified that could be related to its occurrence . The appAt the end of the study, if we are successful in the identification of such an effective algorithm, certainly several other topics should be carefully considered. Can this knowledge be really translated into a commercially available kit for screening purposes? Would the costs derived from this process be acceptable for low and middle-income countries? How will this be made available for populations in public sector? For discussing a future implementation of such a screening strategy, the following necessary points to be covered are to know if a concrete package of interventions to reduce preterm birth among those women identified as high-risk is available, and if it is cost-effective to be supported by the public health system. Finally, in this study we are planning to transfer the technology developed for the algorithm from New Zealand to Brazil, including lab technologies for assessing the biomarkers identified by metabolomics for preterm birth. Hopefully, if this is proved to be feasible, we believe that an important step for reducing the burden of preterm birth will have been achieved.ADA, American Diabetes Association; BMI, body mass index; CONEP, Brazilian National Committee for Ethics in Research; FAME, fatty acid methyl esterification; FDA, Food and Drug Administration; FGR, fetal growth restriction; GC, gas chromatography; GDM, gestational diabetes mellitus; LC, liquid chromatography; MS, mass spectrometry; PE, pre-eclampsia; PI, principal investigator; pPROM, preterm premature rupture of membranes; PTB, preterm birth; SAMBA, Screening and Metabolomics in Brazil and Auckland; SCOPE, Screening for Pregnancy Endpoints study; SOP, standard operation procedures; sPTB, spontaneous preterm birth; WHO, World Health Organization


Early amplitude-integrated electroencephalography (aEEG) has been widely used in term infants with brain injury to predict neurodevelopmental outcomes; however, the prognostic value of early aEEG in preterm infants is unclear. We evaluated how well early aEEG could predict brain damage and long-term neurodevelopmental outcomes in very preterm infants compared with brain imaging assessments. We found that severe aEEG abnormalities (p = 0.000) and aEEG total score < 5 (p = 0.006) within 72 h after birth were positively correlated with white-matter damage, but aEEG abnormalities were not associated with intracranial hemorrhage (p = 0.186). Severe abnormalities in aEEG recordings, head ultrasound, and cranial magnetic resonance imaging (MRI) were all positively correlated with poor outcome at 18 months corrected age. The predictive power of poor outcomes of the aEEG and MRI combination was the same as the aEEG, MRI, and head ultrasound combination with a sensitivity of 52.4%, specificity of 96.2%, positive predictive value of 78.6%, and negative predictive value of 88.4%. These results indicate that severely abnormal aEEG recordings within 72 h after birth can predict white-matter damage and long-term poor outcomes in very preterm infants. Thus aEEG can be used as an early marker to monitor very preterm infants. Preterm birth rates have increased globally since 1990, and about 15 million preterm neonates are currently born every year1256Early diagnosis and early treatment of brain damage in preterm infants has the potential to improve their long-term quality of lifeAmplitude-integrated electroencephalography (aEEG) has the advantages of being simple to perform, of allowing continuous bedside monitoring, and of providing easily interpreted results, all of which make this an important method in the neonatal intensive care unit for monitoring brain function. It has also been shown that aEEG classifications correlate strongly with the clinical degree of hypoxic-ischemic encephalopathy and neurological outcomes in full-term infants161718The aim of this study was to evaluate whether aEEG recordings within 72 h after birth predict brain damage and neurodevelopmental outcome in preterm infants with gestational age (GA) less than 32 weeks, and to compare these outcomes to head ultrasound and MRI assessments.A total of 346 infants were admitted to the NICU during the study period. Four infants were excluded based on the exclusion criteria and 342 were eligible, of which 18 were lost to follow-up and excluded from the analysis. A total of 324 preterm infants with an average GA of 30.0 ± 1.1 weeks (27.1–31.6 weeks) and average birth weight of 1377 ± 288 g (700–2200 g) were included . The malThere was a significant association between the classification of aEEG recordings within 72 h after birth and the degree of WMD in preterm infants. Although aEEG recordings were severely abnormal in 77.8% (7/9) of the infants with grade III or IV ICH, the degree of abnormality of the aEEG recordings in the first 72 h of life were not associated with ICH classification . LogistiOf the 152 preterm infants who underwent aEEG within 72 h after birth, 5 were lost to follow-up, 13 died (5 of them from brain damage), 134 surviving infants were followed up to 18 months of age, and 139 infants (including 5 that died from brain damage) were included in the statistical analysis of poor outcome. Abnormal aEEG recordings within 72 h were significantly associated with poor outcomes, including cerebral palsy and hypophrenia in preterm infants at 18 months corrected age .Of 337 infants who underwent head ultrasound within 1 month after birth, 13 were lost to follow-up, 31 died (15 from brain damage), 293 surviving infants were followed up to 18 months of corrected age, and 308 infants were included in the statistical analysis of poor outcome. Abnormalities in the head ultrasound within 1 month were statistically associated with poor outcomes, including cerebral palsy, hypophrenia, and death from brain injury in preterm infants at 18 months corrected age .Of 210 infants who underwent head MRI at 40 weeks corrected age, 3 infants died from brain damage, 207 surviving infants were followed up to 18 months of age, and 210 infants were included in the statistical analysis of poor outcome. Abnormality of head MRI at 40 weeks corrected age was statistically associated with poor outcomes, including cerebral palsy, hypophrenia, audio-visual disorder, and death in preterm infants at 18 months corrected age .The combined examinations and long-term outcomes were analyzed for different combinations of assessments . Of 101 Univariate analysis of poor outcome was performed considering 22 items, including GA, birth weight, severe asphyxia, mechanical ventilation >7 days, respiratory distress syndrome grade 3 or 4, severe anemia, persistent hypoxemia, persistent hypercapnia, persistent hypoglycemia, sepsis, bronchopulmonary dysplasia, necrotizing enterocolitis, cholestasis, family socioeconomic status, parent education level, severe abnormality in aEEG, HUS, MRI, aEEG + HUS, aEEG + MRI, HUS + MRI, and aEEG + HUS + MRI. All combinations of examinations were analyzed separately, and p-values < 0.05 were required for inclusion in the logistic regression analysis. Logistic regression analyses showed that severe aEEG abnormality , severe HUS abnormality , and severe MRI abnormality  were significantly high risk factors of poor outcome. Severe abnormality of aEEG + MRI was a significantly high risk factor of poor outcome , which was the same as aEEG + HUS + MRI. Severe abnormalities of aEEG + HUS  and HUS + MRI  were also positively correlated with poor outcome. We took severe abnormalities of different combinations as predictors, and there was no significant predictive difference among different combinations of the assessments . The senThis study used a relatively large sample to show that severe abnormalities of early aEEG can predict white-matter injury and long-term outcomes in preterm infants. The specificity of aEEG to predict poor outcomes was similar to head ultrasound but lower than cranial MRI, and the sensitivity of aEEG was highest compared to MRI and HUS.The survival of premature infants has improved dramatically due to advances in neonatal intensive care. However, preterm infants are at increased risk of dangerous complications occurring during the neonatal period that often cause brain injury such as ICH and PVL, and these are the most important risk factors for long-term neurologic sequelae such as cerebral palsy, cognitive deficits, and learning impairments1622The optimal time after birth for taking aEEG recordings to predict adverse outcomes is still unclear17181822The abnormal aEEG recordings had no association with the classification of ICH. This means that a preterm infant with severely abnormal aEEG recordings soon after birth will not necessarily develop severe ICH, which is different from other reports showing that early aEEG recordings are associated with ICH17The predictive value of early aEEG for long-term outcomes is still controversial. Recent studies22Neuroimaging of preterm infants has become part of routine clinical care in the NICU, and HUS is still considered the method of first choice. However, sequential HUSs are required to evaluate preterm brain injury and to predict outcome. The sensitivity and specificity of HUS in preterm infants ranges from 45% to 90%In summary, severe abnormalities in aEEG recordings within 72 h after birth could predict WMD in preterm infants with GA less than 32 weeks. Severe abnormalities in aEEG recordings, HUS, and cranial MRI were all positively correlated with poor outcome at 18 months corrected age. The predictive value of combined aEEG and MRI for poor outcome in preterm infants less than 32 weeks is similar to all three examinations combined together. We conclude that aEEG has the potential for use as an early marker to monitor preterm infants in the NICU.Neonates with GA < 32 weeks admitted to the NICU within 72 h after birth at the Third Affiliated Hospital of Zhengzhou University, China, from January to December 2012 were screened for eligibility for this prospective study cohort. Neonates with congenital brain malformations, chromosomal diseases, genetic diseases, or metabolic diseases were excluded. This study was approved by the Human Research Ethics Committee and Clinical Trials Committee of the hospital in accordance with the Helsinki Declaration. Written informed parental consent was obtained for all neonates.TM device . Each recording lasted for 4–24 hours . The average recording time was 10.9 ± 5.5 h, and all aEEG recordings were obtained by two investigators. The aEEG recordings were assessed using a combination of criteria for amplitude, background activity, and sleep-wake cycling (SWC): (1) normal: continuous normal amplitude (upper margin >10 μV and lower margin >5 μV), SWC matched to corresponding age, and no electrographic seizures; (2) mildly abnormal: discontinuous activity and mildly abnormal amplitude (upper margin >10 μV and lower margin <5 μV) with immature and delayed SWC or normal amplitude with electrographic seizures; (3) severely abnormal: discontinuous activity and severely abnormal amplitude (upper margin <10 μV and lower margin <5 μV) without SWC, including burst-suppression (discontinuous activity with lower margin at 0–1 μV constantly and a burst amplitude >25 μV), flat trace , continuous low voltage (continuous very low amplitude activity at about 5 μV or below 5 μV), or mildly abnormal amplitude with electrographic seizures33et al. to assess brain maturityaEEG traces were recorded within 72 h  after birth using a NicoletOneTM Voluson  with a 7.5-MHz transducer. ICH was classified as grade I to IV according to Papile et al.HUS was performed within 3 days after birth and then weekly until 4 weeks after birth with a GEHead MRI was performed at 40 weeks corrected age using a 1.5 T MRI . Abnormalities on MRI at term equivalent were assessed blindly by the scores of white matter and gray matterAll of the preterm infants were tracked every month for 6 months and then every 3 months until 18 months corrected age. All of the surviving preterm infants were evaluated through gross neurologic assessment and mental developmental index (MDI) testing. Assessment of neuromotor disability was based on the presence of cerebral palsy and functional disability. Mental or psychological development was evaluated with the Bayley Scales of Infant Development, Second Editiont-test. A p-value < 0.05 was considered significant. Qualitative data were compared using the chi-square tests, and a p-value < 0.05 suggested an association between the two groups. Logistic regression analyses were used to assess risk factors of WMD and poor outcome. Sensitivity, specificity, positive predictive value, and negative predictive value were calculated using diagnostic tests.Statistical analysis was performed using SPSS version 19.0. Quantitative data are presented as means ± standard deviation. Differences between groups were evaluated using one-way ANOVA and LSD How to cite this article: Song, J. et al. Early amplitude-integrated electroencephalography predicts brain injury and neurological outcome in very preterm infants. Sci. Rep.5, 13810; doi: 10.1038/srep13810 (2015).