To investigate clinical and singleton newborn outcomes in fresh cycles of embryo transfer after intracytoplasmic sperm injection (ICSI-ET) with diverse sperm sources  in patients with Oligoasthenospermia, obstructive azoospermia (OA) or non-obstructive azoospermia (NOA).Patients who received fresh ICSI-ET for the first time at the First Affiliated Hospital of Zhengzhou University Reproductive Medicine Center between June 2011 and June 2021 were selected for this 10-year retrospective cohort analysis. After propensity score matching, only 1630 cycles were included in the investigation of ICS-ET clinical and singleton newborn outcomes in patients with Oligoasthenospermia, OA, and NOA using sperm from diverse sperm sources.After propensity score matching, our data revealed a negligible difference in baseline and cycle parameters among groups. In patients with Oligoasthenospermia and OA, different sperm sources do not appear to influence clinical pregnancy rates and live birth rates, nor do they influence newborn outcomes, such as newborn weight, premature birth rate, and neonatal sex ratio in singleton births, except for OA patients who use epididymal sperm having higher low birth weight (LBW) rates in singleton pregnancies than those who use testicular sperm. In addition, clinical pregnancy rates, live birth rates, singleton gestation birth weights, premature birth rates, and neonatal sex ratios were similar between patients with Oligoasthenospermia, OA, and NOA using testicular sperm.Regardless of the type of male infertility  or sperm sources , a successful ICSI-ET procedure can result in similar clinical and neonatal outcomes, such as clinical pregnancy rate, live birth rate, abortion rate, neonatal birth weight and sex ratio of singleton pregnancies. However, the advent of Intracytoplasmic Sperm Injection (ICSI)-Embryo Transfer (ET) in 1992, which involves the surgical retrieval of sperm for fertilization, has allowed couples to have biological offspring , 11. EjaHowever, sperm from these sources differ in maturity, DNA damage, and chromosomal abnormalities, and thus may have implications for the outcomes of ICSI-ET. Testicular sperm have a lower DNA fragmentation index (DFI) than epididymal or ejaculated sperm, suggesting that once sperm are expelled from the testes, they are subjected to oxidative stress and DNA damage . NeverthBoth the type of male infertility and the source of sperm are potential factors that may impact the outcomes of ICSI-ET. However, few studies have examined the effect of sperm source in combination with male infertility type on ICSI outcomes. This research was designed to investigate clinical and neonatal outcomes of fresh ICSI-ET using ejaculated, epididymal, or testicular sperm in individuals with Oligoasthenospermia, OA, or NOA.22.1Patients who received their first fresh ICSI-ET at the Reproductive Medicine Center of the First Affiliated Hospital of Zhengzhou University from June 2011 to June 2021. The data was obtained from the Clinical Reproductive Medicine Management System/Electronic Medical Records Cohort Database (CCRM/EMRCD) of the Center for Reproductive Medicine. The Ethics Committee of the Hospital authorized this study.12,984 couples underwent ICSI-ET fresh cycles , with an initial inclusion of 7,566 cycles which were the first ones using GnRH agonist long protocols. To control for confounding factors, we sequentially excluded oocyte or sperm donation cycles (n=6), karyotype abnormalities in either spouse (n=104), female age ≥ 35 years or < 20 years (n=1456)), female BMI ≥ 28 or ≤ 18 (n=649), female endocrine disorders  (n=394), female uterine factors affecting implantation and pregnancy  (n=412), female infertility factors other than tubal  (n=50), recurrent miscarriages or recurrent implantation failures (n=6), Other male infertility factors  or cycles with no precise diagnosis (n=622). During the analysis of singleton pregnancy cycles, the exclusion criteria were applied to eliminate cases of multiple pregnancies from the study cohort (n=344).Based on the type of male infertility and sperm sources, a total of five groups were established: Oligoasthenospermia-Ejaculated sperm group (sperm retrieved from the semen of an Oligoasthenospermic patient), Oligoasthenospermia-Testicular sperm group (sperm recovered from the testis of an Oligoasthenospermic patient), OA-Epididymal sperm group (sperm recovered from the epididymis of an OA patient), OA-Testicular sperm group (sperm recovered from the testis of an OA patient), NOA-Testicular sperm group (sperm recovered from the testis of a patient with NOA).To balance the number of cases between groups and to control for confounding factors, propensity score matches were performed without replacement, with a matching caliper of 0.01. Specifically, the Oligoasthenospermia-Ejaculated sperm group was matched 4:1 with the Oligoasthenospermia-Testicular sperm group. Matching was based on pre-determined relevant variables, including the partners’ age, BMI, and basal hormone levels of the female partner . At last, the analysis incorporated the remaining 1630 instances. The specific filtering and matching details are shown in 2.2Oligoasthenospermia refers to non-azoospermia with abnormal semen parameters, including Oligozoospermia and Asthenospermia. OA is defined by blockage or partial absence of the reproductive ducts with normal spermatogenic activity due to vasectomy, congenital vas deferens deficiency, or testicular trauma. NOA is characterized by defective spermatogenesis with symptoms ranging from various degrees of maturation stagnation to Sertoli cell-only syndrome.The diagnostic criteria for Azoospermia are based on the guidelines outlined in the Fifth Edition of the WHO manual for human semen analysis. After ruling out ejaculatory disorders and retrograde ejaculation, a diagnosis of Azoospermia is made when semen is subjected to centrifugation and no sperm is detected through microscopy on more than two occasions. Azoospermia can be further classified into OA and NOA for a more specific diagnosis.The diagnosis of OA is determined by the following criteria:Normal testicular volume and FSH level.Physical examination reveals a complete epididymis and either an enlarged or absent vas deferens. Reproductive system ultrasound shows dilatation of the epididymal duct or absence of the vas deferens. Seminal plasma biochemistry demonstrates a significant reduction in neutral α-glucosidase.Testicular biopsy pathology exhibits a normal basic testicular sperm production function.NOA is diagnosed when the criteria for OA are not met. Common clinical features of non-obstructive azoospermia include:Testicular volume may be either reduced or normal.FSH levels may be decreased, normal, or elevated.No obstruction of the vas deferens is observed during male physical examination, ultrasound imaging, and seminal plasma biochemistry.Testicular biopsy reveals only supportive cell syndrome or arrested spermatogenesis. In some cases, mature sperm may still be observed.Y chromosome microdeletion is a possible contributing factor.2.3According to the patient’s ovarian function and BMI, gonadotrophin (Gn) was initially administered at doses ranging from 112.5 to 300 IU. Intramuscular hCG  was administered when transvaginal ultrasound assessment of follicular development revealed that the biggest follicles were > 20 mm in diameter, and more than two-thirds of all follicles had a diameter greater than 16 mm. The retrieval of oocytes was conducted 36-37 h following the hCG injection, and MII oocytes were selected for ICSI 4-6 hours later.2.4On the day of ovum retrieval, various methods were utilized for obtaining sperm specimens from patients. For patients in the Oligoasthenospermia-Ejaculated sperm group, a 3-7day period of sexual abstinence was observed, followed by semen specimen collection through masturbation and density gradient centrifugation. The obtained sediment was then repeatedly rinsed with sperm washing culture and a 0.5-1.0 mL volume of sperm suspension was retained for ICSI purposes. For patients in the Oligoasthenospermia-Testicular sperm group, the testicular sperm aspiration (TESA) was performed under local anesthesia with 2% lidocaine. The patient was positioned supine and a 5 mL syringe containing 2 mL of culture fluid was utilized to extract testicular tissue under negative pressure. The obtained tissue was mixed and processed through direct centrifugation, and spermatozoa were viewed under an inverted microscope. For patients in the OA-Epididymal sperm group, under local anesthesia with 2% lidocaine, the patient is positioned supine, the Percutaneous epididymal sperm aspiration (PESA) was performed with a 5ml syringe containing 2ml of culture fluid, and epididymal fluid is extracted under negative pressure. For patients in the OA-Testicular sperm group, if no motile sperm were detected following PESA, TESA was conducted as agreed. For patients in the NOA-Testicular sperm group, due to the implementation of testicular sperm extraction (TESE) and microdissection testicular sperm extraction (MD-TESE) technique in our center since November 2018, prior to that, TESA was used to retrieve testicular sperm in NOA patients. Among the 158 NOA patients in this study, 112 underwent TESA, 42 underwent MD-TESE, and 4 underwent TESE. The specific procedure for MD-TESE involved making an incision in the middle of the scrotum under anesthesia, exposing the testis, further dissecting the tunica albuginea, and then, under a microscope (10-20x magnification), observing and selecting the full and opaque seminiferous tubules. Subsequently, the selected tubules were immediately minced by laboratory personnel, and their contents were examined under a microscope (400x magnification) to determine the presence of well-shaped sperm. If no sperm were found, other areas of the testis were examined. If no sperm were found in one testicle, the other testicle was incised, and the same procedure was repeated. Finally, the tunica albuginea and skin incision were sutured. The TESE was performed without microscope and the TSEA surgical procedure was performed as previously described. Approximately 4-6 hours after ovum retrieval, a high-powered microscope was utilized to observe the sperm suspension and select motile sperm with normal morphology for ICSI.2.5The main outcome measures assessed were the clinical pregnancy rate and live birth rate. Clinical pregnancy was diagnosed through conclusive clinical indications or ultrasound confirmation of at least one gestational sac, including both intrauterine and ectopic pregnancy with medical evidence , and liv2.6P25, P75) was used to express continuous variables that were non-normally distributed. Mann-Whitney U test for comparisons between the two groups and Kruskal-Wallis H tests were employed for multiple groups with post-hoc Bonferroni corrections following comparisons between two groups. The number of instances and percentages were used to represent categorical variables. The mean of the chi-square value was calculated to analyze differences among groups, and where appropriate, Fisher’s exact tests were performed. Significant differences were defined as P < 0.05.Statistical analysis and processing were carried out using SPSS 27.0 software. The SPSS missing value Analysis (MVA) procedure with imputation by expectation-maximization (EM) was used for missing data, and propensity score matching was used for case matching. The normality and chi-square tests for continuous variables were One-sample Kolmogorov-Smirnov and Levene tests, respectively. Median (33.1P = 0.036), with a higher rate observed in the ejaculated sperm group. Among patients with OA, the testicular sperm group had a significantly higher 2PN cleavage rate compared to the epididymal sperm group . Furthermore, significant differences were observed in several indicators among different groups of male infertility patients using testicular sperm. Firstly, The testicular volume and normal fertilization rate were found to be significantly lower in the NOA group compared to both the Oligoasthenospermia and OA groups, while the blastocyst formation rate in the Oligoasthenospermia group was significantly lower than in the OA and NOA groups. Furthermore, the male basal FSH and LH levels were found to be highest in the NOA group, followed by the Oligoasthenospermia group, whereas the OA group exhibited the lowest levels (P < 0.0167). However, there were no statistically significant differences identified in other baseline and cycle characteristics among each group, such as male age and BMI, female age, female basal hormone levels , female TSH, antral follicle count at trigger timing (AFC), NO. of oocytes retrieved, normal fertilization rate, 2PN cleavage rate, high-quality embryo rate, blastocyst formation rate, NO. of transplanted embryos, and transplanted embryo stage. The results of comparison before and after matching between the Oligoasthenospermia-Ejaculated sperm group and the Oligoasthenospermia-Testicular sperm group were consistent. The data before matching can be found in 3.2The study included two Oligoasthenospermia groups, the Oligoasthenospermia-Ejaculated sperm group with 166 singleton gestational cycles in 368 fresh ET cycles and the Oligoasthenospermia-Testicular sperm group with 45 singleton gestational cycles in 92 fresh ET cycles. The fresh transplantation cycle outcomes did not differ between the two groups, including the rates of biochemical pregnancy, clinical pregnancy, live birth, and abortion. Furthermore, the neonatal outcomes of a single pregnancy cycle, including singleton live birth rate, singleton abortion rate, neonatal birth weight, gestational age at delivery, neonatal sex ratio, and preterm birth rate, also did not show any significant differences between the two groups. Furthermore, we conducted detailed analyses of neonatal health based on both gestational week and birth weight and found no significant difference in LBW, SGA, macrosomia, and LGA. Details of specific data are provided in 3.3P = 0.024). However, further detailed analysis of gestational weeks and neonatal birth weight revealed no difference in gestational weeks, premature birth rate, and SGA. In addition, both groups showed no noticeable differences in singleton live birth rate, abortion rate, neonatal birth weight, neonatal sex ratio, macrosomia, or LGA. Detailed data are shown in In the OA-Epididymal sperm group, 230 singleton gestational cycles occurred in 577 fresh ET cycles, whereas in the OA-Testicular sperm group, 195 singleton gestational cycles occurred in 435 fresh ET cycles. A comparison of fresh ICSI-ET results showed no significant intergroup differences, including the rates of biochemical pregnancy, clinical pregnancy, live birth, and abortion. When it comes to the neonatal outcome of a single pregnancy cycle, the only noteworthy difference between the OA-Testicular sperm and OA-Epididymal sperm groups is the LBW , OA (n=435), and NOA (n=158). The analysis of fresh ICSI-ET cycles showed no significant differences between the three groups in terms of biochemical pregnancy rate, clinical pregnancy rate, live birth rate, or abortion rate. The neonatal outcomes of a single pregnancy cycle were analyzed and showed that there were 45 singleton gestational cycles in the Oligoasthenospermia group, 195 singleton gestational cycles in the OA-Testicular sperm group, and 68 singleton gestational cycles in the NOA-Testicular sperm group. The analysis of these groups revealed no noticeable differences in singleton live birth rate, singleton abortion rate, neonatal birth weight, gestational age at delivery, neonatal sex ratio, premature birth rate, LBW, SGA, macrosomia, or LGA. Detailed data can be found in 4In this study, different male infertility populations and different sources of sperm were distinguished to evaluate their effects on ICSI-ET clinical outcomes and neonatal outcomes. Our data reveal that although normal fertilization and blastocyst formation rates differed to varying degrees between groups before the transfer, different male infertility populations and different sources of sperm did not appear to affect ICSI clinical and singleton neonatal outcomes after successful transfer.P > 0.05). In addition, another cohort study (P > 0.05), although the difference did not reach statistical significance. Contrary to their findings, the results of our study indicated that the live birth rates of ejaculated sperm and Testicular sperm after ICSI-ET were similar. Moreover, a study conducted by Rene H et al.  or sperm source , a successful ICSI-ET procedure can result in similar clinical and neonatal outcomes, such as the rates of clinical pregnancy, live birth, and miscarriage, neonatal birth weight and sex ratio of singleton pregnancies. We anticipate that our findings will provide male infertility patients and physicians some peace of mind when deciding on the best sperm retrieval procedure and that larger multicentre studies incorporating more patients will be conducted to validate further and complement our findings.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving humans were approved by Ethics Committee of the First Affiliated Hospital of Zhengzhou University. The studies were conducted in accordance with the local legislation and institutional requirements. Written informed consent for participation was not required from the participants or the participants’ legal guardians/next of kin in accordance with the national legislation and institutional requirements.JX selected the population to be included and excluded, completed data statistics and analysis and wrote the manuscript. QY participated in the research design, guidance, and manuscript revision. YS participated in the review and guidance of the research. WC, YJ, ZS, and HW participated in data entry and sorting. JX and QY contributed equally to this article. All authors contributed to the article and approved the submitted version.


We aimed to use molecular biomarkers and clinical data and echocardiograms that were collected during admission to predict bronchopulmonary dysplasia (BPD) in preterm infants with gestational age ≤32 weeks.Eighty-two patients  admitted to the Department of Neonatology of the Children's Hospital of Soochow University between October 1, 2018, and February 29, 2020, were enrolled in this study at the tertiary hospital. Basic clinical data on the perinatal period, echocardiographic measurements, and molecular biomarkers  were collected. We used multiple logistic regression analysis to establish an early predictive model for detecting BPD development in preterm infants of gestational age ≤32 weeks. We also used a receiver operating characteristic curve to assess the sensitivity and speciﬁcity of the model.2 ≥ 40%; oxygen inhalation time; red blood cell suspension infusion volume (ml/kg); and proportion of infants who received total enteral nutrition  ≥24 d after birth were higher in the BPD group than in the non-BPD group. The levels of hemoglobin, hematocrit, and albumin in the BPD group were significantly lower than those in the non-BPD group. The total calorie intake was significantly lower in the BPD group on the 3rd, 7th, and 14th day after birth than in the non-BPD group (P < 0.05). The incidence rates of patent ductus arteriosus (PDA), pulmonary hypertension, and tricuspid regurgitation were significantly higher in the BPD group than in the non-BPD group (P < 0.05). The serum level of NT-proBNP 24 h after birth was significantly higher in the BPD group than in the non-BPD group (P < 0.05). Serum NT-proBNP levels were significantly higher in infants with severe BPD than in those with mild or moderate BPD (P < 0.05).No significant differences were found between the BPD and non-BPD groups in terms of sex, birth weight, gestational age, incidence of asphyxia, maternal age, gravidity, parity, mode of delivery, premature rupture of membranes >18 h, use of prenatal hormones, placental abruption, gestational diabetes mellitus, amniotic fluid contamination, prenatal infections, and maternal diseases. The use of caffeine, albumin, gamma globulin; ventilation; days of FiO2 ≥ 40% (d), red blood cell suspension infusion volume (ml/kg), and proportion of infants who received total enteral nutrition  ≥24 d after birth were the most practical factors considered for designing an appropriate model for predicting the risk of BPD.As there were various risk factors for BPD, a combining clinical data, molecular biomarkers, and echocardiogram measurements can be valuable in predicting the BPD. The tricuspid regurgitation flow rate (m/s), NT-proBNP (pg/ml), ventilator-associated pneumonia, days of FiO Key messages•Bronchopulmonary dysplasia seriously affects the treatment and long-term prognosis of preterm infants.•Preventing BPD is important in clinical practice.•2 ≥ 40%, red blood cell suspension infusion volume (ml/kg), and proportion of infants who received total enteral nutrition  ≥24 d after birth are BPD risk factors.Tricuspid regurgitation flow rate (m/s), NT-proBNP (pg/ml), ventilator-associated pneumonia, days of FiOBronchopulmonary dysplasia (BPD) is a common chronic lung disease and one of the most severe sequelae of respiratory system in preterm infants . More thBPD develops from the interaction of various types of damage influenced by inflammation related to chorioamnionitis, infections, ventilation, and high-concentration oxygen . HoweverPreterm and immature lung tissues are the key factors contributing to BPD development. Medical treatments, such as mechanical ventilation and the inhalation of high concentrations of oxygen, which are sometimes used to rescue preterm infants, may also cause, or aggravate BPD . CurrentThis prospective study enrolled neonates admitted to the Department of Neonatology of the Children's Hospital of Soochow University from October 1, 2018 to February 29, 2020. The inclusion criteria for the participants were preterm infants with a gestational age ≤32 weeks and a hospital stay of ≥28 d. Clinical data and echocardiographic variables were recorded at various time points. The exclusion criteria were an admission age older than 24 h, infection at admission, major congenital abnormalities, surgical intervention requirements during the NICU stay, an unplanned discharge, and incomplete clinical data.This study has already obtained an approvement from the Ethics Committee of the Children's Hospital of Soochow University. The parents of all infants provided written informed consent.in vitro fertilization, twins, or multiple births. (3) Primary diseases and complications that occurred during the hospitalization of preterm, including neonatal respiratory distress syndrome (NRDS), pneumonia, pneumothorax, ventilator-associated pneumonia (VAP), feeding intolerance, parenteral nutrition-associated cholestasis (PNAC), brain injury in premature infants (BIPI), periventricular/intraventricular hemorrhage (PVH/IVH), retinopathy of prematurity (ROP), hemodynamically signiﬁcant patent ductus arteriosus (hs-PDA), frequent apnea, sepsis, bacterial meningitis, pulmonary hemorrhage, and necrotizing enterocolitis (NEC). (4) Treatment(s) during hospitalization: caffeine, albumin, gamma globulin, complete total enteral nutrition later than 24 d, more than three blood transfusions, invasive ventilation time, days of FiO2 ≥ 40%, non-invasive ventilation time, oxygen inhalation time, and red blood cell suspension infusion volume (ml/kg). (5) Laboratory tests administered upon admission: white blood cell count , red blood cell count , platelets , hemoglobin , neutrophil absolute value , lymphocyte absolute value , red blood cells deposited , average red blood cell volume , albumin levels , and prealbumin levels . (6) Oral fluid volume 3, 7, 14, 21, and 28 d postnatal, fluid intake, caloric intake , and the times for beginning feeding and reaching total enteral nutrition.Clinical data were collected from medical records and the following maternal, infant, and prenatal factors were included: (1) maternal conditions, including maternal age, delivery mode, antenatal corticosteroid use, premature rupture of membranes (duration >18 h), placental abruption and placenta previa, gestational diabetes, gestational hypertension, gestational anemia, preeclampsia, amniotic ﬂuid contamination, prenatal infection , and other maternal diseases. (2) General conditions of the infants, including sex, gestational age, birth weight, age at admission, incidence of asphyxia, conception through (1)Definition of BPD and Clinical Grading The diagnostic criteria of BPD adopted in our study was based on the standard of the National Institute of Child Health and Human Development (NICHD) published in 2001, which defines BPD as follows: (i) preterm low birthweight infants treated with oxygen (FiO2 > 0.21) for at least 28 days; (ii) persistent or progressive respiratory insufficiency; (iii) lungs with typical x-ray or CT scan findings ; (iv) exclusion of congenital cardiopathy, pneumothorax, pleural effusion, and sputum. The clinical grading was based on the supplemental O2 of the infants at 36 weeks postmenstrual age or discharge (GA <32 weeks) and at 56 days postnatal age or discharge (GA ≥ 32 weeks).We firstly define the important clinical indicators for the sake of understanding.The clinical grading was classified as follows:2) < 0.3; severe: FiO2 ≥ 0.3 and/or positive pressure ventilation or mechanical ventilation.(2)Definition of UEGR Extrauterine growth restriction (EUGR) is a common condition in very low birth weight (VLBW) preterm infants . Most affected infants have a birth weight that is average for gestational age, but by the time of hospital discharge have a weight that is less than the tenth percentile for corrected gestational age.(3)Definition of VAP VAP was defined as a nosocomial infection happening 48 h after mechanical ventilation.(4)Diagnosis of NRDS NRDS was defined as the presensce of respiratory distress and increased oxygen requirement (FiO2 > 0.4), which cannot be explained by other causes via chest x-ray and lab findings.(4)Definition of BIPI BIPI refers to various pathologies due to prenatal, intrapartum, or/and postnatal conditions factors that lead to varying degrees of cerebral ischemia and/or hemorrhagic loss in preterm infants, it can lead to long-term nervous system sequelae and even death.(5)Definition of PNAC PNAC was defined as cholestasis attributable to PN use, with other parameters excluded.(6)Definition of has-PDA Echocardiographic evidence of a hs-PDA met one of the following criteria: ductal diameter ≥1.5 mm, unrestrictive pulsatile ductal flow (ductus arteriosus peak velocity <2.0 m/s), left heart volume loading (left atrium to aortic ratio >1.5), left heart pressure loading .Mild: breathing room air; moderate: a fraction of inspired oxygen , TR velocity, left ventricular ejection fraction (LVEF), left ventricular fractional shortening (LVFS), and pulmonary hypertension (PH). The echocardiography protocol and examination results were discussed and agreed upon by pediatric cardiologists working for >10 years at our hospital. All parameters and indicators that could be quantified, including right atrial and right ventricular dilation, were recorded.Blood samples were collected and preserved on the first day. The levels of NT-proBNP in plasma were analyzed using a commercial enzyme-linked immunosorbent assay .via the AUC. Statistical significance was set at P < 0.05.SPSS 24.0 was used for analyzing the data in this study. Categorical variable data were analyzed using either the chi-square test or Fisher's exact test; normally distributed variable data are represented as the mean ± standard deviation and processed using independent t-test. Non-normally distributed variable data were represented as the median value ± interquartile range [M ] and analyzed using non-parametric tests. Signiﬁcant factors were selected and recruited in the next step of logistic regression analysis to explore the independent risk factors for BPD occurrence in premature infants. The sensitivity and specificity of the predictive models were evaluated P > 0.05, From October 1, 2018, to February 29, 2020, 232 preterm infants ≤32 weeks were admitted to our hospital. Of these infants, 12 patients were discharged automatically, 32 were hospitalized for less than 28 d, and 15 underwent surgery during hospitalization. Among these, 40 were diagnosed with BPD. A total of 42 preterm infants with no differences in general information from the BPD group were randomly matched to the non-BPD group. In total, 82 preterm infants were enrolled in this study. In the BPD group, 19, 15, and 6 cases were classified as mild, moderate, and severe, respectively. There were no significant differences in basic and clinical data between the two groups  than in the non-BPD group. Days on oxygen inhalation (FiO2 > 40%), the proportion of infants who received total enteral nutrition  ≥24 d after birth, and the duration of enteral nutrition was longer in the BPD group (P < 0.05) than in the non-BPD group. The number of red blood cell transfusions during the stay in the NICU was higher in the BPD group , the red blood cell transfusion volume (ml/kg) , and the proportion of infants who received total enteral nutrition  ≥24 d after birth  were identified as possible risk factors for BPD development using multiple regression analysis  was significantly more frequent in the BPD group  than in those without BPD. Furthermore, TR velocity was higher in the BPD group , and congenital heart disease was ruled out. We interpreted echocardiograms for PDA, the TR velocity, LVEF, and LVFS and found that TR and Hs-PDA were more frequent in patients with BPD . Serum NT-proBNP levels gradually increased with BPD severity  ≥24 d after birth indicated that these variables can be considered potential predictors or risk factors of BPD. The AUC, sensitivity, specificity, and Youden index values for these variables are shown in ROC analysis using the TR velocity, NT-proBNP, VAP, days of FiO2 > 40%, transfusion volume of red blood cells, and proportion of infants who received total enteral nutrition  ≥24 d after birth were included to yield a predictive model for BPD. The X2-value of the model was 89.203 (P < 0.001), suggesting these variables may predict the risk of BPD. The Hosmer-Lemeshow test was conducted using the classification interaction table , which demonstrated that the model was consistent with the indicators well. The test results indicated that the combination of these variables in the model yielded an AUC of 0.986. The sensitivity and specificity were 97.60% and 92.50%, respectively. The predictive model yielded a higher AUC value, sensitivity, and specificity than any individual variables , and proportion of infants who received total enteral nutrition  ≥24 d after birth were practical risk factors contributing to the development of BPD.Prenatal and postnatal factors, among others, can influence the development of BPD in preterm infants. In this study, we systematically analyzed the clinical data, echocardiographic measurements, and molecular biomarkers of preterm infants of gestational age ≤32 weeks. We found that the TR flow rate (m/s), NT-proBNP (pg/ml), VAP, days of FiOBPD is a serious pulmonary disease caused by multiple factors, including volume injury, infection, inflammation, and abnormal repair of the lung . ExploriEchocardiography is widely regarded as a useful and valuable screening tool for assessing the possibility of BPD in preterm infants, and echocardiographic measurements can be used to evaluate elevated pulmonary pressure (PAP). Echocardiography can be used to evaluate the elevated pulmonary vascular resistance index (PVRi) and classify severity based on pressure measurements. Mourani et al.  assessedIn this study, the TR velocity was higher in patients with BPD than in those without BPD. Although TR velocity has not been reported to be related to the occurrence of BPD, elevated pulmonary arterial pressure leads to an increased and continuous deterioration of pulmonary circulation resistance and abnormal developments in pulmonary capillaries.in vitro and can also remain in stable in blood samples after being drawn or preserved for over 72 h (NT-proBNP has been widely used to diagnose heart failure and is often recognized by cardiomyocytes in response to excessive pressure and volume overload . NT-proBver 72 h . NT-proBver 72 h , 32. In ver 72 h , which cver 72 h . Serum Bver 72 h . Severalver 72 h . TherefoNutrition supplementation has an important function in the treatment and growth of infants; preterm infants with a higher volume of daily fluid and calorie intake and less body weight loss are at a higher risk for BPD in the early days of the first postnatal week . Greater2 > 40% and the proportion of preterm infants diagnosed with VAP was significantly higher in the BPD group; this result is consistent with previously reported results (Our study found that the number of preterm infants with oxygen inhaled days of FiO results . High co results .VAP is a severe mechanical ventilation complication that represents the second most common and difficult-to-cure infection in NICUs . NeonataAnemia is commonly observed in preterm infants. Transfusions of RBC represent one of the most important methods of treating preterm infants; however, RBC transfusions are related to serious illnesses, especially BPD and cerebral hemorrhage, and they can also cause other diseases, such as NEC . Patel eBPD is a multifactorial disease that is evolved by a complex combination of prenatal risk factors. Therefore, the present study aimed to establish a multifactorial prediction model for early detecting the BPD using a combination factors. The model that including molecular biomarkers and clinical data and echocardiograms can help to predict the development of BPD.This study has many limitations, including the small number of cases considered from a hospital and single clinical center. Although the incorporated multi-factor multifactorial model may help predict the occurrence and development of BPD in preterm infants with a relatively high sensitivity and specificity, it also displayed some disadvantages in that it could not predict the severity of BPD in preterm infants. Multicenter studies with variable grades of hospitals as well as a large sample size are needed to improve and enhance the BPD prediction models; this research could potentially increase prediction accuracy and improve effectiveness in preventing the progression of BPD.In summary, inflammation, hyperoxia, blood transfusion, and malnutrition can lead to the development of BPD. TR flow rate and NT-proBNP levels were positively correlated with the occurrence of BPD. No single factor was effective in predicting BPD, but a combined regression model constructed using multiple indicators may predict the occurrence of BPD with an increased accuracy.


In April 2000, a series of wildfires occurred simultaneously in five adjacent small cities located on the eastern coast of Korea. These wildfires burned approximately 23,794 hectares of forestland over several days. We investigated the effects of prenatal exposure to the by-products generated by wildfire disasters on birth weight.Birth weight data were obtained for 1999-2001 from the birth registration database of the Korean National Statistical Office and matched with the zip code and exposed/unexposed pregnancy week for days of the wildfires. Generalized linear models were then used to assess the associations between birth weight and exposure to wildfires after adjusting for fetal sex, gestational age, parity, maternal age, maternal education, paternal education, and average exposed atmospheric temperature.Compared with unexposed pregnancies before and after the wildfires, mean birth weight decreased by 41.4 g  after wildfire exposure during the first trimester, 23.2 g  for exposure during the second trimester, and 27.0 g  during the third trimester. In the adjusted model for infants exposed in utero during any trimester, the mean birth weight decreased by 32.5 g .We observed a 1% reduction in birth weight after wildfire exposure. Thus, exposure to by-products generated during a wildfire disaster during pregnancy may slow fetal growth and cause developmental delays. Wildfire exposure is an important and increasing risk factor for public health that is particularly relevant in Korea, where forests occupy 65% of the land and the risk of wildfires is always present . From 20Forest fires are especially prevalent in the Gangwon Province of Korea. This province accounts for 22% of the country’s total forest area and predominantly comprises coniferous 31%), mixed (60%), and broad-leaved (10%) forests. Including mixed forests, more than half of the province’s area is planted with coniferous trees. Coniferous leaves are particularly vulnerable to forest fires because they contain highly volatile components 1%, mixed. Moreove2.5) is a particular health concern: it is known to infiltrate the human body through the airway and cause respiratory and cardiovascular symptoms by inducing oxidative damage to the body and inflammatory reactions in organs [Wildfire smoke contains various components that worsen air quality, including fine particulate matter (PM), nitrogen dioxides, carbon monoxide, volatile organic carbon, and other metals and toxins. This worsened air quality adversely affects health ,7. Largen organs . The popPrevious research has shown that PM produced by wildfires is more toxic than that generated in urban environments . Infant We obtained birth weight data from January 1, 1999 to December 31, 2001, from the birth registration database of the Korean National Statistical Office. We excluded preterm (< 37 weeks gestation), and post-term births (> 42 weeks gestation), births with a reported birth weight below 1 kg or above 6 kg, and births with multiple (two or more) fetuses. Gestational age at birth was based on the number of days since the mother’s last menstrual period (LMP).After matching the zip codes, which formed the geographic basis of this study, our sample included the Yeongdong region , encompassing Samcheok, Donghae, and Goseong, in Gangwon Province. These areas were selected as the boundaries for the study based on satellite imagery of the fire that occurred in April 2000. By comparing the satellite photos before (A), during (B and C), and after the wildfire in the study areas (D), one can confirm the changes in the area where the wildfires occurred . We selein utero, while additional births assigned an LMP later than April 15 were classified as unexposed. All remaining births  were classified as exposed based on the temporal overlap between the wildfire exposure window and gestational period.The window of potential wildfire exposure was April 7 to April 15, 2000. Most births in the study population  that were delivered before April 7 could not have been exposed iy) as a continuous outcome and ijx as an indicator of exposure for birth i in trimester j. For our primary analysis, we defined ix as a categorical variable with four levels as a dummy variable: exposed in the first trimester, exposed in the second trimester, exposed in the third trimester, or unexposed or delivered before or conceived after a wildfire event (iz) associated with birth weight and included terms based on the date of the LMP (it) to control for the average exposed daily temperature (t).Because birth weight had a distribution that was close to normal, a generalized linear model (GLM) with a Gaussian distribution was used. In this model, the main exposure variable was whether exposure to wildfires occurred during gestation and gestational weeks at the time of exposure. We fit the data to a GLM with birth weight . Statistical analyses were performed using R version 4.2.0 . To compare the impact with other areas that were not exposed to wildfires during the same period, we conducted a sensitivity analysis. Inje, Jeongseon, and Taebaek areas in Gangwon Province, which were not exposed to wildfires, were selected. Since these areas are located at the same latitude as the coastal areas damaged by wildfires and are located inland beyond the Taebaek mountain range, there was little chance of residents being exposed to wildfires. In the sensitivity analysis, we examined the impact of birth weight by assuming that newborns in other areas  were exposed or not exposed to wildfires during the same period frame as the main study, even if they were not actually affected by the wildfires .This study was approved by the Institutional Review Board of Sungkyunkwan University School of Medicine (No. SKKU 2018-01-007).Of the 6,921 sampled births, 5,067 (73.2%) were unexposed during the prenatal period. Of the remaining 1,854 who were exposed, 774 (11.2%) were exposed in the first trimester, 527 (7.6%) in the second trimester, and 553 (8.0%) in the third trimester . Most inBoth the unadjusted and adjusted estimated effects of wildfire during gestation on birth weight are reported in Wildfires occur sporadically and irregularly, and the probability of occurrence varies depending on weather and vegetation conditions. Surface temperature, humidity, precipitation, and wind strength greatly influence the initiation, spread, and frequency of wildfires ,19.In April 2000, wildfires broke out on the eastern coast of Korea when there was high atmospheric pressure in the southern part and low pressure in the northern part of the Korean Peninsula. This was caused by a southwesterly wind in a direction perpendicular to the Taebaek mountain range . This arAt the time of the wildfire in 2000, the temperature rose 3°C from 8.1°C before crossing the Taebaek Mountains to approximately 11.2-11.4°C in the Yeongdong region. Before crossing the Taebaek Mountains, weak wind speeds of less than 0.5 m/s accounted for 27.9% of the total, and most of the rest were weak southwest winds of less than 3.4 m/s. However, after crossing the Taebaek Mountains, a strong westerly wind over 8.0 m/s or more blew as it reached the coast due to the Föhn phenomenon. .Wildfire smoke poses a greater risk to pregnant women than to other population groups. The greater susceptibility is due to an increase in the respiratory rate due to diaphragmatic compression from the fetus and increased blood volume. Another factor is the reduced ability to compensate for anemia that occurs in pregnant female as they must maintain the oxygen supply needed for the normal growth of the fetus . While tIndeed, we found a birth weight loss of approximately 32.5 g for exposure during the entire period of pregnancy and a significant loss of 41.4 g for exposure during the first trimester of pregnancy. These results are in line with existing research. One study in Brazil reported that wildfire exposure during the first and third trimesters had the highest association with low birth weight . In a st2.5. Air pollution monitoring sites are concentrated around large cities and main roads, with few being installed in rural areas with low population density. An alternative can be remote sensing. One study on the analysis of major atmospheric aerosol species using Earth observation satellite data noted that major aerosol compounds  could be detected using aerosol optical thickness, fine mode fraction, and the ultraviolet absorbing aerosol index. Those authors analyzed the California and Russian wildfires, with the aforementioned aerosols classified as carbonaceous aerosols [In general, the health impact assessment of wildfire smoke exposure in rural areas near mountainous terrain is hindered by unmeasured PM concentrations during high-concentration episodes from wildfires, called smoke waves, and limited information on population exposure to ambient PMaerosols . RecordsAccording to a health impact study conducted in San Diego in 2007, wildfires have been shown to cause health problems, especially in children and elderly people who already have respiratory problems. In particular, the frequency of hospital visits tended to increase more frequently in younger children, such as infants between 0-1 years, than in the elderly . A systeThis study has several limitations. First, because PM monitoring in this study area has been conducted since 2001, we did not perform a sensitivity analysis to distinguish between births located in areas with high and low PM levels during wildfires based on quantitative monitoring measurement data. Therefore, our results may have been mediated by air pollution, including PM. Alternatively, associations with reduced birth weight can be speculated for wildfires that occurred when atmospheric monitoring was available. Second, some unmeasured confounders may not have been completely controlled for because seasonal variation-related factors were not considered. Nevertheless, it should be noted that the examined wildfires started on April 7, 2000, and were extinguished on April 15; since it was a short period, which may perhaps reflect the real impact adjusting for the average temperature at the LMP.Nonetheless, this study also has several strengths. First, it is the first to provide evidence on the relationship between wildfires and birth weight in Korea. Second, it underscores the necessity of creating a policy against wildfires that not only focuses on the general populace but also on specific susceptible groups, such as mothers and fetuses.Stakeholder collaboration, including the Ministry of Environment, the Korea Disease Control and Prevention Agency, the Forest Service, the National Fire Agency, the National Disaster Management Research Institute, and local governments, is needed to assess and control the health effects of wildfires. Crucially, Korea has no guidelines for public health approaches to health impacts in the event of wildfires. As wildfire smoke is a mixture of toxic substances, including PM, appropriate guidelines are needed, including evacuation strategies, appropriate masking practices for respiratory protection, and recommendations for susceptible populations.


Electroporation is a biophysical phenomenon involving an increase in cell membrane permeability to molecules after a high-pulsed electric field is applied to the tissue. Currently, electroporation is being developed for non-thermal ablation of cardiac tissue to treat arrhythmias. Cardiomyocytes have been shown to be more affected by electroporation when oriented with their long axis parallel to the applied electric field. However, recent studies demonstrate that the preferentially affected orientation depends on the pulse parameters. To gain better insight into the influence of cell orientation on electroporation with different pulse parameters, we developed a time-dependent nonlinear numerical model where we calculated the induced transmembrane voltage and pores creation in the membrane due to electroporation. The numerical results show that the onset of electroporation is observed at lower electric field strengths for cells oriented parallel to the electric field for pulse durations ≥10 µs, and cells oriented perpendicular for pulse durations ~100 ns. For pulses of ~1 µs duration, electroporation is not very sensitive to cell orientation. Interestingly, as the electric field strength increases beyond the onset of electroporation, perpendicular cells become more affected irrespective of pulse duration. The results obtained using the developed time-dependent nonlinear model are corroborated by in vitro experimental measurements. Our study will contribute to the process of further development and optimization of pulsed-field ablation and gene therapy in cardiac treatments.  Electroporation is the underlying mechanism in a new promising cardiac ablation method—Pulsed Field Ablation (PFA)—currently being developed for the treatment of atrial fibrillation and other cardiac arrhythmias ,2,3. EleElectroporation is a phenomenon where the application of high-voltage electric pulses to isolated cells or tissues transiently increases membrane permeability allowing the transport of ions and molecules otherwise deprived of or having hindered transmembrane transport mechanisms ,8. FolloCardiac tissue is composed of different types of cells , wherebMilan et al.  studied A time-dependent nonlinear numerical model was developed, including the phenomenon of electroporation, to study the effect of the external applied electric field on a cardiomyocyte. The model was developed using COMSOL Multiphysics 5.6 software . Two different geometries, prolate spheroid A and theAC/DC module, Electric Currents physics by solving the Laplace equation:i) or extracellular (subscript e) medium. The cell membrane was modeled using the Contact Impedance Boundary Condition:n is the normal vector, J is the current density, eV and iV are the electric potentials at the outer and inner surfaces of the membrane, respectively. The induced transmembrane voltage (TMV) is calculated as the difference between the extracellular, eV, and intracellular, iV, electric potential, TMV = iV − eV.The electric potential distribution, flc1hs [5 V/cm.A monophasic electric pulse with different pulse durations of 10 ms, 1 ms, 100 µs, 10 µs, 1 µs, and 100 ns was applied on the two opposite boundaries of the simulation cube, either parallel or perpendicular to the main axis of the cardiomyocyte. The remaining four faces of the cube were modeled as insulating surfaces. The electric pulse was obtained by subtracting two Heaviside functions using the COMSOL’s built-in function flc1hs . The pulWeak Form Boundary partial differential equation:N represents the pore density (number of pores per unit area), mU denotes the TMV, N0 is the pore density when mU = 0 V, and epV, a, and q are model parameters, respectively. The first term of Equation (3) represents pore creation and the second one the pore annihilation [Pore formation was calculated as a function of time and thus can only be added in the time-dependent simulations. The pore formation was described by the following differential Equation (3) implemented in COMSOL Multiphysics as a hilation ,38.epσ, was calculated as:pr and pσ are the radius and conductivity of a single pore, respectively. The first term of Equation (4) represents the passive membrane conductivity and the second one is the increase in conductivity due to electroporation [The increase in cell membrane conductivity during electroporation, poration ,38. The p < 0.05) in Fura-2 responses were determined by paired t-test. In very rare occasions (2 out of 60 groups), the distribution was not normal, and instead, the Wilcoxon signed-rank test was used; however, in these two cases, the differences were not significant. We compared our numerical model with experimental results previously published by Dermol-Černe et al. . The eleA detailed methodology was provided before . BrieflyA time-dependent nonlinear numerical model was developed to investigate the phenomenon of electroporation when exposing a cardiomyocyte to a single monophasic electric pulse of different pulse durations, i.e., 10 ms, 1 ms, 100 µs, 10 µs, 1 µs, and 100 ns. Numerical simulations were performed for a prolate spheroid, which was previously used as a simplified model of cardiomyocyte geometry ,30,42,435 V/cm when exposing the cell to a single monophasic pulse of different durations . Simulations were again performed for both prolate spheroid and real-shaped geometry and in both parallel and perpendicular orientations. The results are presented on the left side of The total number of pores formed in the cell membrane was evaluated as a function of the applied electric field strength from 10 V/cm to 10In addition, the model suggests that the orientation, at which cells form more pores due to electroporation, depends not only on the pulse duration but also on the electric field strength. Interestingly, for pulses with a duration of ≥10 µs, parallel orientation is the one in which pores start forming preferentially (at lower electric field strengths); however, as the electric field is increased beyond a certain value, cells in perpendicular  orientation achieves a greater pore number and thus become more electroporated. This can be observed both for the real-shaped geometry and the prolate spheroid, suggesting that such behavior would be observed for any cell of elongated shape. Thus, the model suggests there is another “crossover” at which the orientation of cells that are more electroporated shifts from parallel to perpendicular. This crossover appears as the electric field is increased and can be observed only for pulses with a duration of ≥10 µs, 2 to 5 µF/cm2 and 10 µF/cm2. The number of pores in the cell membrane was again evaluated as a function of the applied electric field from 10 V/cm to 105 V/cm at different pulse durations , Cardiomyocytes have a complex membrane shape with many t-tubules, which results in a higher effective membrane capacitance ,40. T-tu2, 5 µF/cm2, and 10 µF/cm2 as membrane capacitance, respectively, when the electric field is applied parallel (solid line) or perpendicular (dashed line) to the long axis of the cell. When the membrane has a greater capacitance (representative of t-tubules), a higher electric field is needed to observe the onset of electroporation when using pulses of 100 ns, 1 µs, (for both orientations), and 10 µs , which is directly related to the longer membrane charging time. When 100 µs, 1 ms, and 10 ms pulses are used, the different values of capacitance do not affect the number of pores in the cell membrane, as their pulse durations are all considerably longer than the membrane charging time, even for the highest value of the capacitance. The charging time of the cardiomyocyte using the prolate spheroid geometry is ~2 µs  and ~0.8 µs (perpendicular orientation). Another interesting observation is that the pulse duration, at which electroporation is not very sensitive to cell orientation , shifts from 1 µs to 10 µs, as the membrane capacitance increases from 1 µF/cm2 to 10 µF/cm2. This means that the above-mentioned “crossover” with respect to pulse duration would be observed at roughly 10× longer pulse duration in cardiomyocytes compared to other cell types with similar aspect ratios but are devoid of t-tubules.The cyan, magenta, and black curves in 2+ ions to cells from the extracellular medium due to electroporation [The numerical results that have been presented so far have shown that the total number of pores predicted by the model depends on cell orientation, pulse duration, and electric field strength, whereby the results are very similar in both prolate spheroid and real-shaped cardiomyocyte geometries. In continuation, our modeling results are compared to experimental results from cardiomyocyte-derived cell lines and primary cardiomyocytes later in . Dermol-poration . Most ofOur model considering the prolate spheroid geometry was used to plot the ratio of the number of pores formed in the cell membrane when the cell is oriented either parallel or perpendicular  for pulse durations and the electric field strengths used in the experiments C. Assumi2+ are saturated. Unavoidably the use of high electric field strengths will induce cellular Ca2+ influx approaching the saturation level of the Fura-2 dye, whereby such saturation can mask the above-discussed crossover with respect to electric field strength. Thus Fura-2 calcium measurements in In addition, to further support the modeling prediction of a crossover as the electric field strength is increased, we decided to show the Fura-2 ratio 340/380 peak change observed when the cells are oriented parallel or perpendicular to the applied electric field  oriented parallel and perpendicular when exposed to a 10 ms or 100 µs pulse. Then, we indicated the lethal electric field strengths obtained in experiments, as shown in 2+ uptake using Fura-2 dye in rat primary cardiomyocytes exposed to 100 µs pulse but of lower  electric field strengths. Otherwise, the electroporation protocol was the same as in Chaigne et al. [2+ measured after exposure to an electric pulse. We consider that the level of diastolic Ca2+ can be best compared to our model, which predicts the number of pores in the membrane formed by the electric pulse. Indeed, the experiments show that the level of diastolic Ca2+ becomes more increased in parallel cells compared to perpendicular cells for these lower electric field strengths, consistent with the model  become preferentially affected by electroporation pulses depends both on pulse duration and the electric field strength. According to the model, there are two crossovers were preferentially affected orientation shifts from parallel to perpendicular. One crossover can be observed for relatively low electric fields  when reducing the pulse duration from milliseconds to nanoseconds. The other crossover can be observed for pulses with a duration of >1 µs when increasing the electric field strength. The first crossover has been confirmed previously by measurements of calcium uptake into cardiomyocyte-derived cell lines . The secNevertheless, the existing electroporation models, including the one used in this study, have several limitations . Electro5 pores) compared to a 10 ms pulse (>2 × 103 pores), cf. Our electroporation model in principle considers only lipid pores that form in the cell membrane during the pulse. Nevertheless, it is reasonable to assume that other effects, including the post-pulse increased membrane permeability, intracellular calcium uptake, and effects leading to cell death, are at least roughly correlated with the number of pores that we simulate with our model. Indeed, the model predictions are found to be qualitatively in agreement with experimental measurements of calcium uptake and lethal electric field strength when assessing the orientation in which the cell is preferentially affected for a given pulse duration and electric field strength. However, the total number of pores returned by the model has limited utility for predicting lethal electric field strength (irrespective of orientation) for different pulse durations. Specifically, the model predicts a considerably greater number of pores at electric field strengths that are lethal when applying a 100 µs pulse .Finally, in our model, we consider the effects of t-tubules only by changing the values of membrane capacitance since the explicit representation of t-tubules is computationally much more demanding due to their small and elongated size, which requires a potentially large number of discretization elements (finite elements in our case) and more importantly difficult validation of the results. However, in the future, it would be interesting to model the realistic structure of t-tubules in the cardiomyocyte studying how they affect electroporation. Understanding the effect of orientation with regard to sensitivity to electrical fields in anisotropic tissues, such as the cardiac tissue, is important, and this particular study further informs translational research aimed at developing novel and improved PFA device therapies. One issue that has become apparent in the PFA literature is the relatively high variability in lesion size using PFA devices, a finding that merits further investigation ,62,63,64While the present investigation has focused on modeling ventricular cells, the primary anatomical targets for PFA are currently the pulmonary veins (PVs) to isolate PVs from the rest of the atrium. Rapid electrical activity in PVs has been suggested as a key mechanism for focal atrial fibrillation . The myoInterestingly, the orientation of the atrial myocytes in the PVs will likely be perpendicular to applied fields due to their circumferential orientation in the PV sleeves, assuming circular or balloon-shaped PFA ablation electrodes. Based on the present data, it could then be argued that a pulse duration of 100 ns might be advantageous as cells oriented perpendicular  to the electric field become electroporated at lower electric field strengths. Thus, a relatively lower electric field strength would be needed to achieve electroporation in perpendicularly oriented PV cardiomyocytes when a 100 ns pulse was used, which could, at least in theory, further improve the safety profile of the therapy. Conversely, in tissues where the orientation of tissue relative to the ablation electrodes is difficult to control, a 1–10 µs pulse may be advantageous as the electric fields at which electroporation onsets are comparable for both perpendicular and parallel orientation per , so in aIt needs to be understood that the aforementioned is a little bit of an oversimplification as at higher field strengths perpendicular cardiomyocytes become more electroporated. In this respect, it should also be stressed that the electric field around the catheter will always be high and decrease with distance from the catheter, so the simultaneous presence of high and low electric fields is unavoidable. Therefore, the complex interplay between pulse durations, electric field strengths, and cell orientation should in general always be taken into account. These examples in principle demonstrate how findings from numerical models describing electroporation at the single-cell level can inform translational PFA research efforts. To study the effect of electroporation on a single cardiomyocyte we developed a time-dependent nonlinear numerical model of electroporation building upon Milan et al. model . In partThe modeling results show that prolate spheroid geometry is a reasonable approximation of a real-shaped cardiomyocyte geometry when modeling electroporation. In addition, prolate spheroid geometry (simple geometry) is computationally less demanding than using real-shaped geometry (complex geometry). The main difference between both geometries is at intermediate electric field strengths, where the onset of electroporation slightly differs for a prolate spheroid and real-shaped cardiomyocyte. The presence of t-tubules effectively increases the membrane capacitance and thus affects electroporation when 100 ns, 1 µs, and 10 µs pulses are used. Thus, t-tubules should be taken into account when modeling electroporation of cardiomyocytes exposed to pulses with a duration less or equal to ~10 µs. This becomes relevant for cardiac cell types which have many t-tubules, such as ventricular cardiomyocytes being targeted in ventricular ablations, which may thus require longer pulses. The orientation at which the cells are preferentially affected by electroporation depends on both pulse duration and electric field strength. For sub-microsecond pulses, cells are more affected in the perpendicular orientation at all electric field strengths. For pulses with duration on the order of 1 µs, the onset of electroporation is observed at comparable electric field strengths regardless of the orientation; however, as the electric field is increased considerably beyond the onset, perpendicularly oriented cells become more affected. For pulses on the order 10 µs and longer, the onset of electroporation is observed at lower electric field strengths for parallel orientation; however, perpendicularly oriented cells become more affected as the electric field is increased. The presence of t-tubules shifts these crossovers to the right towards longer pulse durations. Thus, our modeling findings show that for low electric fields with 100 µs pulse duration, the parallel orientation is more affected than the perpendicular one according to Dermol-Černe et al. . HoweverOur results are important for developing electroporation for cardiac treatments, including irreversible electroporation for cardiac ablation, i.e., Pulsed Field Ablation , and rev


Racial inequities in maternal health outcomes, the result of systemic racism and social determinants of health, require maternity care systems to implement interventions that reduce disparities. One such approach may be support from a community doula, a health worker who provides emotional support, peer education, navigation, and advocacy for pregnant, birthing, and postpartum people who share similar racial identities, cultural backgrounds, and/or lived experiences. While community support during birth has a long tradition within communities of Black Indigenous and People of Color (BIPOC), the reframing of community doula support as a social intervention that reduces disparities in clinical outcomes is recent.We conducted a pragmatic randomized trial at an urban safety net hospital, comparing standard maternity care with standard care plus enhanced community doula support. We tested the effectiveness of a community doula program embedded in a safety net hospital in improving birth outcomes and explored the association between community doula support and health equity. Participants were nulliparous, insured by publicly funded health plans, and had lower risk pregnancies. The primary outcome was cesarean birth. Secondary outcomes included preterm birth and breastfeeding outcomes. Exploratory subgroup analysis was conducted by race–ethnicity.p=0.08). There was a statistically nonsignificant 12% absolute reduction in cesarean birth and 11.5% increase in exclusive breastfeeding during delivery hospitalization among Black non-Hispanic participants.Three hundred sixty-seven participants were included in the primary analysis. In the intent-to-treat analysis, outcomes were similar between groups. There was a trend toward increased breastfeeding initiation (While outcomes for the study sample were similar between randomization groups, health outcomes were improved for Black birthing people in cesarean and breastfeeding rates.Clinicaltrials.gov ID: NCT02550730.This study demonstrates the need for larger studies of community doula support for Black birthing people.  Doulas provide physical and emotional support during pregnancy, childbirth, and the postpartum period. In the prenatal and postpartum periods, community doulas assist with navigation of health care and social services, provide peer education, and give social support. During labor, they provide continuous presence to promote physical comfort and support the birthing person's emotional needs.Community doulas have reclaimed this support role over the last few decades.17 an aspect of reproductive justice, which names “the human right to maintain personal autonomy…” for Black birthing people.17 Doulas accomplish this through a variety of approaches.16–19 They navigate clients through resources essential for healthy social determinants of health (SDoH) such as housing, employment, nutritious food, and health care services that are less accessible compared with White pregnant and birthing people due to structural racism.19 They provide affirming and nonjudgmental support that may buffer the effects of relationship stressors, discrimination, and inadequate social support.17 In addition, they serve as advocates by amplifying the voice of the birthing person during labor and birth.17Community doulas practice within a framework of birth justice,20 which may impact morbidity and mortality in both current and future pregnancies.21 Additionally, some studies show that doulas increase breastfeeding and improve the experience of maternity care.22 For low-income people and Black, Indigenous, People of Color (BIPOC), doulas provide a sense of physical and emotional safety, reduce stress related to experiences of discrimination in health care, and amplify the voice of the pregnant person.17A growing literature frames outcomes of community doula support as efficacious in reducing cesarean births,The effectiveness of community doula programs integrated into maternity care has not been studied. To understand the effectiveness of a doula program in improving health outcomes in a racially diverse low-income setting, a pragmatic, randomized controlled trial was conducted. The aims of the trial were to evaluate the effectiveness of doula support in reducing rates of cesarean and preterm births, as well as on breastfeeding outcomes. Additionally, the study aimed to explore the impact of the doula on health equity for Black birthing people, specifically focusing on cesarean birth outcomes.We conducted a parallel-group, pragmatic single-center trial with 1:1 randomization to assess the impact of community doula support on cesarean birth, preterm birth, and breastfeeding outcomes for nulliparous, lower-risk pregnant people with public insurance coverage. The study was conducted at an urban safety net hospital serving a racially and linguistically diverse population of ∼2700 births per year, of which 85% are publicly financed.Clinicaltrials.gov on June 23, 2015 (NCT02550730). We enrolled participants from August 2015 through November 2017. Data collection occurred through June 2018.The institutional review board of the study site approved this study on April 29, 2015. Participants provided written informed consent. The study follows the Consolidated Standards of Reporting Trials (CONSORT) guidelines. We submitted our registration to After completing the baseline survey, participants were randomized 1:1 in blocks of eight to either the Birth Sisters Best Beginnings for Babies (BBB) enhanced doula intervention or routine care. Computer-generated randomization was performed by an outside statistician and group allocation was placed in sequentially numbered opaque envelopes. The envelope was opened by the research assistant in front of the participant. The sequence was not revealed until enrollment was complete. Follow-up survey assessors were blinded to the allocation assignment of each participant.People pregnant with their first child, insured by Medicaid or other public insurance, and between 16 and 24 weeks of pregnancy were eligible. Research assistants assessed eligibility during routine ultrasound visits and obtained informed consent. Exclusion criteria were age <18 years, multiple gestation, known fetal anomaly, or high-risk pregnancy condition, defined by prenatal care attendance in the site's high-risk obstetric clinics.This excluded people with substance use disorder, pre-existing diabetes, HIV infection, and other comorbidities requiring prenatal care from a maternal–fetal medicine specialist. Participants who developed gestational hypertension or diabetes after enrollment at 24 weeks of pregnancy were not excluded. Suicidal ideation during the baseline interview was also an exclusion criterion.23The intervention group received an enhanced model of Birth Sisters Program services starting at 24 weeks, known as the Birth Sisters BBB intervention. The Birth Sisters Program is one of the few hospital-based doula programs in the country. It has provided racially and ethnically diverse doula support to low-income pregnant and birthing people in an urban safety net hospital since 1999. The program and setting have been described in detail elsewhere.Briefly, Birth Sister services include between one and eight 2-h prenatal home visits determined by the client's preference; continuous support through labor and birth; and between one and four 2-h postpartum home visits through 6–8 weeks postpartum. Prenatal and postpartum activities include peer education, navigation of social and medical services, and social support. During labor, Birth Sisters provide physical and emotional comfort measures, as well as amplify the voice of the birthing person with the health care team.Birth Sisters received training to maximize fidelity to the practice model before the study launch. Because this was an effectiveness study, strict adherence to the study protocol was not monitored. Instead, routine program management systems ensured fidelity. These include monthly group meetings and individual staff supervision at the beginning and close of each assignment with the Program Director, a midwife.In addition to standard Birth Sister services, those in the intervention group received the enhancement of Medical Legal Partnership | Boston (MLPB) services to augment the ability of the Birth Sisters to address legally relevant SDoH. MLPB is a team of legal experts who integrate legal assistance into the medical setting so that low-income patients can meet legal needs that impact health. This enhancement aimed to maximize the role of the doula as an advocate around structural barriers to health and well-being for the individual client.MLPB activities included training of Birth Sisters around SDoH resources, as well as serving as a consultant to the Birth Sister around individual participant needs. The training included an initial 3-h information session before participant enrollment on the basics of advocacy and a second 4-h training session on resources for unhoused clients. In the second year, a two-part training session, totaling 5 h, on resources around family law was provided.In each year of the study, one to three Birth Sister group consultations during Birth Sister staff meetings were provided by MLPB lawyers to address individual case questions that might benefit the knowledge base for the entire doula staff. Additionally, each study participant assigned to the Birth Sisters Best Beginnings intervention was screened by the Birth Sister at 24 and 36 weeks for housing insecurity, food insecurity, and need for support around filling out the birth certificate.pro bono formal consultation directly with the lawyer.When participants screened positive, the Birth Sister received a phone consultation with the MLPB lawyer for support around navigation resources. In the rare case that the participant required legal counsel, the Birth Sister was then able to refer the participant to MLPB for a Participants randomized to usual care had access to standard, interdisciplinary maternity care services at the safety net study site, including individual physician and midwifery care, group prenatal care that includes social support from other pregnant patients, childbirth education classes, social work support, in-patient lactation consultants, and 24-h interpreter services.The primary outcome was the proportion of cesarean births. This outcome was selected for its potential effect on health equity since cesarean birth rates are highest among Black birthing people, correlated with increased rates of morbidity and mortality, and tied to obstetric racism. This outcome also aligned with prior doula research.Secondary outcomes were preterm birth (<37 weeks 0 days of gestation), low birth weight (<2500 g at birth), breastfeeding initiation (any breast milk) and exclusivity (only breast milk) at delivery hospitalization, continuation of breastfeeding at the postpartum interview, Apgar scores <4 at 5 min, neonatal intensive care unit (NICU) admissions, and postpartum depression screening score defined by a score >9 on the Edinburgh Postnatal Depression Scale (EPDS) at the postpartum interview.24 Positive depression screen defined as a score >9 on the EPDS was chosen based on literature demonstrating high sensitivity and specificity at this cutoff.25The definition of low Apgar score was selected based on the literature demonstrating correlation between an Apgar score of <4 and poor outcomes.26–28Obstetrical hemorrhage (quantitative blood loss >1000 mL) and hypertension  were added as outcome measures during the analysis phase due to increased focus nationally on reducing severe maternal morbidity and mortality.Data for outcomes measured at the delivery hospitalization were obtained from the electronic medical record. Breastfeeding continuation and postpartum depression outcomes were gathered at the postpartum interview.A priori exploratory subgroup analyses were conducted by race to determine the differential impact by ethnic background and potential to reduce disparities, particularly for Black birthing people. Categories included Black non-Hispanic compared with all other races/ethnicities.Using a test of two independent proportions with a two-tailed alpha error of 0.05 and 80% power to detect a 10% absolute reduction in the rate of cesarean births, we required a sample size of 247 in each group of laboring participants. Assuming a loss to follow-up rate of 10%, a dropout rate of 5%, and scheduled cesarean rate  of 5%, we estimated a need for 297 participants in each group.p-Values for the primary outcome and odds ratios with 95% confidence intervals for all outcomes were calculated.Data were analyzed with SAS, version 9.4, using an intention-to-treat approach. A significance level of 0.05 was used. Analysis of the primary outcome included all participants who delivered at the study site, except for two postrandomization exclusions who were noted after enrollment to not meet inclusion criteria. Categorical variables were compared using either chi-square or Fisher's exact test, as appropriate. For the outcomes of breastfeeding continuation and postpartum depression, logistic regression was used to control for prenatal breastfeeding intention and prenatal depression scores, respectively, as well as timing of the postpartum interview, as they were independent predictors of those outcomes.Exploratory analyses stratified by race/ethnicity were preplanned and emphasized the estimation of subgroup-specific effects. We focused on exploring the historically large inequities in birth outcomes for Black birthing people. Hispanic, White, Asian, and Middle Eastern ethnicities were combined into a single category as the effect was similar between these groups.We used the same statistical analysis approach for the intent-to-treat model described in the previous paragraph for the subgroup analysis. This exploratory analysis was not powered to detect statistically significant differences in outcomes.post hoc per-protocol analyses were conducted using logistic regression models. The issue of multiple testing was addressed by applying a reduced alpha level of 0.01 to assess statistical significance. The per-protocol intervention group consisted of all participants who delivered at the study site, who were assigned to the intervention group, and received at least one Birth Sister prenatal visit and labor support.To evaluate the treatment received, The control group consisted of all participants who delivered at the study site, who were assigned to the control group, and who did not receive any Birth Sister support. For breastfeeding continuation and postpartum depression outcomes, the per-protocol intervention group consisted of all participants who delivered at the study site, who were assigned to the intervention group, and received at least one Birth Sister prenatal visit, labor support, and at least one Birth Sister postpartum visit.Three hundred thirteen of those who remained in the analysis for birth outcomes also completed a postpartum survey (85%). One hundred sixty of those participants completed the survey before 12 weeks postpartum. One hundred fifty-three completed the survey after 12 weeks of giving birth. The proportion of participants completing the survey before 12 weeks was similar between groups (51.6% in the intervention group compared with 52.6% in the control group).29 Our design achieved balanced groups, as noted in 30–32 as well as social isolation.33We follow standard guidelines for reporting randomized trials.Of 187 people included in the intervention group analysis, 172 (92%) participants received a prenatal visit, 142 (76%) received labor support, and 132 (71%) had a Birth Sister postpartum visit. Primary reasons for no labor support are as follows: 14 delivered at another hospital, 1 was lost to follow-up, 9 declined services after enrollment in the study, 4 delivered precipitously before the Birth Sister arrived, 12 gave birth without the Birth Sister being notified, and 5 were unknown.The mean number of prenatal meeting hours was 5.3 (range 0–18.8), mean number of hours of labor support was 10.7 (range 0–25.5), and mean number of postpartum meeting hours was 3.1 (range 0–12.5). There was no difference in program fidelity by individual Birth Sisters. The mean caseload by Birth Sister was 13.2 (range 1–34) over the 28 months of enrollment. One hundred twenty-seven (91%) participants were matched with a doula who was racially congruent.In the control group, 25 participants received a referral for the hospital's Birth Sisters Program through their clinical provider, although these participants did not receive the full BBB intervention, including MLP | Boston, since they were not enrolled in the intervention arm of the study. Thirteen received a Birth Sister prenatal visit, five had Birth Sister labor support, and eight had a Birth Sister postpartum visit. Typical program uptake is more reflective of the BBB intervention uptake described above.p=0.72). Overall breastfeeding initiation rates were high, but there was a trend  toward increased breastfeeding initiation (p=0.08). Differences in Apgar scores <4 at 5 min were not statistically significant, but all fell in the control group. There were no differences in the other outcomes.As shown in Baseline characteristics by subgroups were balanced . For BlaFor participants who were not Black non-Hispanic, the direction of the effect was reversed, with a 4.4% absolute increase in cesarean births overall and a similar increase of 4.7% for NTSV cesarean births. There was also a reversal of direction for exclusive breastfeeding, decreasing from 52.1% to 40.0%.p=0.39) or any of the secondary outcomes. Preterm birth, low birth weight, and NICU admissions were lower for the intervention group, which is a change in the direction of the effect from the intent-to-treat analysis.In the per-protocol analysis, 138 of 187 (73.7%) participants in the intervention group and 156 of 180 (86.7%) in the control group were included . There w34This effectiveness trial did not show significant differences in outcomes between randomization groups. The single-site intention-to-treat analysis, while maximizing the internal validity of the study, limits its generalizability to other settings. Additionally, nonadherence to the assigned treatment and loss to follow-up in pragmatic trials can make interpretation of the intent-to-treat analysis unclear.34 However, a per-protocol analysis loses the benefits of randomization in reducing bias.Our per-protocol analysis attempts to understand how participants would benefit from the intervention with full adherence to the randomized treatment.34 The larger magnitude of absolute reduction in cesarean births in the per-protocol compared with the intent-to-treat analysis (4.6% vs. 1.7%) and reversal of direction for preterm birth outcomes are more consistent with prior studies.20We followed standard statistical analysis recommendations for per-protocol analyses by adjusting for confounders and specifying a more restrictive definition of significance.The subgroup analysis by race suggests that the BBB intervention may improve cesarean and breastfeeding outcomes for Black non-Hispanic participants. These results are exploratory and were not powered to find statistically meaningful differences between groups. However, based on a scan of the literature in PubMed, this study is the first trial to examine the relationship between racially/culturally congruent doula support and maternal health outcomes.35The reduction in racial disparities for Black non-Hispanic people in this trial has important implications for advancing health equity. As noted previously, cesarean birth rates are higher in Black non-Hispanic populations, are correlated with higher rates of morbidity and mortality, and are related to obstetric racism. Breastfeeding rates are also lower for Black populations as a result of historical and current systemic racism.36 The finding that community doulas may improve these rates is important for understanding the potential intergenerational impact of doulas on health and gives support to the call for doulas as an integral part of birthing care for Black people.37The important advantages of breastfeeding for the health of both infant and mother are well documented.38Health equity, according to the CDC, is defined as “the state in which everyone has a fair and just opportunity to attain their highest level of health. Achieving this requires focused and ongoing societal efforts to address historical and contemporary injustices; overcome economic, social, and other obstacles to health and healthcare; and eliminate preventable health disparities.”The BBB intervention achieves this definition of health equity in three ways. First, it addresses historical injustices rooted in the systematic elimination of Black birth workers in the United States by recognizing the experience and expertise of Black birthing people and their communities. Second, the BBB intervention helps birthing people connect with resources that reduce economic and social barriers to health. Third, it reduces disparities in cesarean birth and breastfeeding outcomes between Black birthing people and those of other races/ethnicities.39We did not compare disparities in outcomes between Black and White groups due to the small number of White non-Hispanic participants. Nationally, White, non-Hispanic, nulliparous birthing people have a low-risk cesarean rate of 24.9% similar to the low-risk cesarean birth rate of 25.9% for Black non-Hispanic participants in the intervention group, down from 41.3% in the control group.37 Emotional support may particularly influence Black maternal health since anti-Black racism is pervasive and emotionally draining.The literature offers suggestions about why the use of community doulas may be an effective strategy to achieve health equity for Black birthing people. Community doulas ensure that racially and culturally congruent emotional, physical, and informational support is available for those most at risk for experiencing structural racism and bias in health care.41 Survey research also suggests that the presence of the doula improves the experience of respectful care for Black people,42 potentially reducing unnecessary cesarean births. This outcome is also important for reducing disparities in maternal morbidity since cesarean births have higher rates of hemorrhage and complications in both current and future pregnancies.21Qualitative studies of doulas serving Black people show that racial congruence and shared lived experience are valued by doula clients and promote a trusting relationship that mitigates the effects of racism in maternity care.It is unclear why the subgroup analyses showed worse outcomes in the other subgroups. Perhaps cesarean rates in the control group were low enough that further reduction would require a different type of intervention. Alternatively, since the exploratory analyses were not powered to find statistically significant differences in outcomes, the stratified analysis results could be due to chance.The primary limitation of this study is that it enrolled 411 rather than the 494 participants needed to find the expected change in the primary outcome. Additionally, the 10% absolute reduction anticipated for the power calculation overestimated the magnitude of change. The exploratory study, by definition, was also not powered to find statistically meaningful differences between groups for the primary outcome of cesarean birth.44 Finally, the exclusion of higher risk pregnancies is also a limitation for fully understanding the impact of doulas on Black birthing people since they suffer a disproportionate burden of pre-existing diabetes and hypertension.Additionally, obstetric racism in and of itself is a negative outcome and the narrow focus on the primary outcome of cesarean birth is a limitation for understanding the larger impact of doulas on health equity.This trial provides useful information for future research on the impact of doulas on advancing health equity. Future trials should enroll larger numbers of Black birthing people and anticipate smaller changes in cesarean birth. Qualitative and ethnographic research should also investigate why community doula support is particularly impactful for Black birthing people.