Objectives. To evaluate the association between inflammatory biomarkers, neurotrophic factors, birth conditions, and the presence of motor development abnormalities in preterm neonates. Methods. Plasma and urinary levels of cytokines , chemokines , and neurotrophic factors (BDNF and GDNF) were evaluated in 40 preterm neonates born between 28 and 32 incomplete weeks of gestation, at four distinct time points: at birth  (T0), at 48 (T1), at 72 hours (T2), and at 3 weeks after birth (T3). Biomarkers levels were compared between different time points and then associated with Test of Infant Motor Performance (TIMP) percentiles. Results. Maternal age, plasma, and urinary concentrations of inflammatory molecules and neurotrophic factors were significantly different between groups with normal versus lower than expected motor development. Higher levels of GDNF were found in the group with lower than expected motor development, while IL-1β and CXCL8/IL-8 values were higher in the group with typical motor development. Conclusion. Measurements of cytokines and neurotrophic factors in spot urine may be useful in the follow-up of motor development in preterm neonates. Preterm labor and related conditions are associated with systemic inflammatory process in the fetus or neonate –6, whichBrain development following an injury is neither static nor a direct consequence of a single event; it actually associates to innumerous cellular and molecular cascades . The resThis was a prospective observational study of preterm neonates (PTN) from 28 to 32 incomplete weeks of gestational age, who were born from June to December 2014 in a philanthropic hospital in Minas Gerais/Brazil. Infants who were admitted to the neonatal intensive care unit (NICU) and whose parents signed the free and informed consent were enrolled.Exclusion criteria were (i) 5‐minute Apgar score below 7; (ii) diagnosis of congenital malformations, syndromes, and/or associated diseases; (iii) presence of an acute disorder, including sepsis or necrotizing enterocolitis, at any of the time points; and (iv) death within the first three weeks of life.Gestational age and birth weight, gender, Apgar scores, infant's diagnosis at admission in the NICU, conditions associated with the premature birth, and antenatal exposure to glucocorticoids were collected from hospital data.The study was approved by the Ethics Committee of both the Federal University of Minas Gerais and the Sofia Feldman Hospital. The study protocol did not interfere with medical recommendations or the treatment of preterm neonates in the NICU.All study participants had biological samples collected at the following time points: at birth (cord blood), 48 and 72 hours of life, and at 3 weeks after birth. Motor development of the neonates was evaluated by means of the Test of Infant Motor Performance (TIMP) that was performed when the babies reached 34 weeks of gestational age.Umbilical cord blood (5 mL) was collected in sodium heparin tubes (T0). All other samples were obtained simultaneously with other routine laboratory tests in the NICU, without the need for extravenous punctures. At 48 hours (T1), 72 hours (T2), and 3 weeks after birth (T3), venous blood (1 mL) was collected in tubes containing sodium heparin. All samples were immediately centrifuged , and plasma aliquots were stored at −80°C until assayed.Urine samples were obtained at the same time points of peripheral blood collection after birth by using a newborn urinary collector, at 48 and 72 hours  and at 3 weeks after birth (T3). Urine samples were transferred to 15 mL plastic tubes and immediately centrifuged . The supernatant was collected and stored at −80°C until analysis.CBA Human Inflammatory Kit: interleukin‐ (IL‐) 1β, IL‐6, IL‐10, tumor necrosis factor (TNF), and IL‐12p70] and chemokines . Briefly, plasma and urine samples were incubated in capture microspheres coated with antibodies that were specific for the respective cytokines and chemokines as well the standard curve proteins. The color reagent (phycoerythrin (PE)) was then added, and the samples were incubated at room temperature for 3 hours. After incubation, samples were washed  and centrifuged . The supernatant was discarded, and the pellet containing the beads was again suspended in the wash buffer (300 μL). Acquisition was performed in a FACSCanto II flow cytometer (BD Biosciences). The instrument has been checked for sensitivity and overall performance with Cytometer Setup & Tracking beads (BD Biosciences) prior to data acquisition. Quantitative results were generated using FCAP Array v1.0.1 software . All results are expressed as pg/mL.Measurements of cytokines and chemokines in plasma and urine were performed by cytometric bead array (CBA), according to the manufacturer's instructions , using kits for quantitation of inflammatory proteins  was added, diluted in citrate buffer (pH 5.0) containing 0.02% H2O2 30 volumes (Sigma‐Aldrich). Finally, plates were incubated in the dark for 30 minutes at room temperature. Reaction was stopped with 1M sulfuric acid solution. Plates were read at 492 nm in a spectrophotometer .Neurotrophic factors [brain‐derived neurotrophic factor (BDNF) and glial cell‐derived neurotrophic factor (GDNF)] levels were determined by enzyme immunoassay (ELISA), following the manufacturer's recommendations . Briefly, monoclonal antibodies, specific for each neurotrophic factor, were incubated in 96‐well plates for 12–18 hours at 4°C. The plates were then washed 3 times with 300 β, IL‐8, IL‐10, and TNF‐α and between 3.4 and 13.9% for CXCL8/IL‐8, CCL2/MCP‐1, CCL5/RANTES, CXCL10/IP‐10, and CXCL9/MIG, respectively. Our intra‐assay variation in CBA experiments ranged from 3 to 6% for all measurements. Neurotrophic factors were measured by ELISA with an intra‐assay variation of about 5% for all measurements.All samples were assayed in duplicate in a single assay to avoid interassay variation. The CBA kits used for the simultaneous quantification of cytokines and chemokines have intra‐assay variations between 4 and 13% for IL‐6, IL‐1The Test of Infant Motor Performance (TIMP) is a functional motor behavior test used in infants that analyzes child posture and motion. TIMP can be used once the newborn reaches 32 weeks of gestational age and up to four months of corrected age . In addiZ‐scores and percentiles, and the TIMP guidelines for TIMP interpretation were established as “developmental delay” Z‐score values below −0.5 and below the 5th percentile. Infants' development was consequently classified in two groups: “typical motor development”  and “lower than expected” .In the current study, TIMP was applied when participants reached at least 34 weeks of postmenstrual age. The raw score consisted of the sum of the points obtained in each scale item. Raw scores were converted into p < 0.05, the Wilcoxon test with Bonferroni correction was utilized.Statistical analysis was performed by the statistical software SPSS version 20.0  and Medcalc version 12.2.1.0 . Continuous variables were described using measures of central tendency and dispersion, and qualitative variables were expressed as absolute frequencies and percentages. Normality was verified using the Shapiro Wilk test. For the time point analysis, the Friedman test was chosen, and for variables with values Correlation analysis between plasma and urine values, intra‐class correlation coefficient (ICC), Spearman correlation, and Bland Altman plot were used, and receiver operating characteristic (ROC) curves for the two samples were adjusted, in order to choose between the plasma and urine markers to be used in association with the motor development.t-test, Mann–Whitney test, chi‐square test of Pearson, and asymptotic chi‐square test of Pearson exact, according to parametric or nonparametric distribution. The Spearman correlation coefficient was used for correlation analysis. Model fit in the logistic regression was evaluated with the Hosmer and Lemeshow test.Groups with different motor development were compared with To verify possible confounding factors, the analyses were done with all participants and with the exclusion of three neonates who were not previously exposed to corticosteroids.This study enrolled 40 infants, 18 (45%) females and 22 (55%) males. Participants were born from 28 to 32 incomplete weeks of gestational age. Prenatal and birth conditions are shown in β, CXCL9/MIG, and GDNF, no differences were observed between different time points. Significant results are shown in Figures Newborns presented a significantly decrease in plasma levels of IL‐6, IL‐10, CXCL8/IL‐8, and CXCL10/IP‐10 during the first three weeks of life. The opposite occurred with TNF, CCL2/MCP‐1, CCL5/RANTES, and BDNF. There was a more pronounced increase of TNF and BDNF 48 h after birth (T1). Regarding IL‐12p70, IL‐1β, CXCL9/MIG, BDNF, and GDNF values significantly increased 72 hours after birth (T2) in comparison to 48 hours after birth (T1). CCL5/RANTES and GDNF levels differed significantly between T3 and T1. BDNF levels were significantly different in all time points  of 0.9 . Only GDTIMP was applied when participants reached at least 34 weeks of postmenstrual age in order to evaluate the motor development of the preterm. The quantification of the raw score was based on the sum of the values obtained in each of the items. Raw scores were converted into percentiles according to the standardization of development curves established by the test. In order to evaluate possible associations between motor development and other variables, TIMP results were stratified into two groups: “lower than expected” (below 5th percentile) and “typical development” (above 5th percentile). Older maternal age was associated with lower than expected TIMP scores .β and BDNF did not show significant differences between the two groups in both plasma and urine samples, whereas, 72 hours after birth (T2), BDNF concentrations were higher in the group with typical development. CCL5/RANTES and GDNF displayed the same behavior in both methods. However, while CCL5/RANTES levels were significantly different only in the urine samples, GDNF levels were different only in plasma samples. At three weeks postpartum (T3), GDNF showed significant difference in urine but not in plasma samples. Urinary levels of GDNF were higher in infants with lower than expected motor development (At the first time point (T0), neonates with typical motor development had higher concentrations of TNF and BDNF in the umbilical cord blood. At the other time points, plasma and urine values frequently showed similar changes. At 48 hours after birth (T1), IL‐1elopment .β levels were higher at T1, while urinary levels of CXCL8/IL‐8 were increased at T1 and T2  were used. Higher urinary concentrations of BDNF and GDNF were observed in the group with lower than expected development at the time points T2 and T3, respectively. In the group with normal development, urinary IL‐11 and T2 .β and CXCL8/IL‐8 concentrations in urine were higher in those with typical motor development. There was also an association between younger maternal age and typical motor development. Sociodemographic factors including maternal age, maternal education, and maternal occupation can affect motor outcome. However, the precise relationship between these factors is not well known [In this study, maternal age and urinary and plasma concentrations of inflammatory molecules and neurotrophic factors were significantly different in preterm neonates according to TIMP scores. Higher urinary levels of GDNF were found in neonates with lower than expected motor development, while IL‐1ll known .Pregnancy disorders that lead to preterm birth may be also associated with systematic inflammation in the newborn –36. IndeThe hypothesis that an inflammatory state is associated with higher incidence of brain injury is corroborated by studies showing that elevated concentrations of cytokines are associated with neuronal lesions and developmental abnormalities , 25, 37.β levels were associated with better TIMP scores. Cytokines are involved in the control of many cellular interaction and cell life and are released under several stimuli [In contrast, higher IL‐1 stimuli . IL‐1 sy stimuli , 48, 49. stimuli , 50, 51. stimuli . The bal stimuli , 52. Thi stimuli .β, is associated with the occurrence of insult, although its concentration may vary during the first hours or weeks [The elevation of cytokine levels, as IL‐1or weeks . The infor weeks , 54, 55.or weeks , 54, 56.β in urine, was associated with typical motor development at first month of life in premature infants. This was an unexpected finding, as typically this cytokine is associated with CNS damage [In our results, a proinflammatory response, characterized by increased levels of IL‐1S damage , 51, 57.S damage , 53, 58.GDNF is a protective factor identified as essential for the survival and neuronal differentiation, by its action on the neuroplasticity, including the modulation of neuronal survival, axon guidance, synapse formation, and functioning in the developing nervous system , 59–63. β and TNF stimulate the release of neurotrophic factors, including BDNF and GDNF [There is some evidence for a beneficial role of neuroinflammation to the CNS. Some degree of neuroinflammation is necessary for remyelination, neuroprotection, and brain development. There are several inflammatory cytokines that regulate the production of multiple neurotrophic factors by neurons and glial cells , 66. Thiand GDNF . BDNF isand GDNF . Indeed,In order to control the influence of confounding factors, neonates presenting acute disorders were excluded from the study. The use of corticosteroids may also interfere with this process; however, as it is recommended to prevent respiratory distress syndrome , it was TIMP provides a reliable and valid measurement of the motor development that can be used for preterm neonates with 34 weeks gestational age –32. ThisThe originality of this study is the evaluation of inflammatory proteins and neurotrophic factors in spot‐urine samples as a noninvasive method of collection. In addition, samples collected in time points before motor development evaluation might predict alterations in TIMP.β and of GDNF may predict motor development still needs to be confirmed.Measurements of inflammatory biomarkers in spot‐urine samples seem to be useful in preterm neonates. This may become a noninvasive way to follow up the inflammatory profile of preterm newborns. Whether urinary levels of IL‐1


Women with previous terminations of pregnancy (TOPs) before their first birth have been associated with poorer perinatal outcomes. However, previous studies on the perinatal outcomes by the method in previous TOPs are inconsistent.To examine the perinatal outcomes of the first-time mothers with singleton births, by the method of previous TOP .This is a nationwide register-based study including 419,879 first-time Finnish mothers with singleton birth during the time period 1996–2013. Mothers having their first birth were identified from the Medical Birth Register and linked to the Abortion Register by their identification numbers. Multinomial logistic regression analysis was performed to examine the risk for preterm birth, low birth weight, small for gestational age and perinatal death by the method in previous TOPs.Among the first-time mothers, 87.0% had no history of TOPs, 3.2% had a history of medical TOP(s), 9.2% had a history of surgical TOP(s) and 0.6% had a history of both  TOP(s). No significant differences in perinatal outcomes were found among the women with surgical TOPs, compared to the women with no TOPs. In unadjusted analysis, increased odds for preterm birth and low birth weight were found when comparing women having previous surgical TOPs with medical TOPs. Even after the adjustment of potential confounders, odds for preterm birth < 37 weeks  and low birth weight < 2500 g  remained significant. After restricting data to the single TOP, the results were similar; OR for both preterm birth and low birth weight was 1.18 (95% CIs = 1.02–1.36 and 1.01–1.38).Perinatal outcomes did not differ among the mothers with surgical TOPs compared to the mothers with no TOPs, while the outcomes were poorer after surgical TOP(s) than after medical TOP(s). In Europe, termination of pregnancies (subsequently TOPs) are common, and in Western European countries most TOPs are performed before the first birth . FinlandA termination of pregnancy can be performed by surgical (dilatation and uterine evacuation) or medical (antiprogestin mifepristone and misoprostol) methods. In Europe, medical TOPs began in France in 1998 . MifepriWhether or not an induced termination of pregnancy prior to the first birth adversely influences the outcome of that birth has been previously debated –8. ThereFew studies have considered the method of TOPs, with regard to the outcomes in subsequent birth ,12–18. SA previous study from Finland found an increased risk for poorer perinatal outcomes after many TOPs, however data was too scant to study the outcomes by the method of abortion . Thus thThe study was approved by the ethical committee of National Institute for Health and Welfare (THL). A positive statement from THL ethics committee (22.10.2009), a positive statement with regard to the amendment of the data, and a permission to use the data were received from THL (25.10.2014). The information used in this study were anonymized prior the analysis.In this population-based cohort study, we used the nationwide Medical Birth Register (MBR) and Abortion Register (AR), which were maintained by the National Institute for Health and Welfare (THL). All the mothers having had their first birth during the time period ranging from 1996 to 2013 were identified from the MBR, and these mothers were linked to the AR to determine the TOPs (1983–2013) they had prior to their first birth. The MBR was started in 1987, and it contains information about each mother’s background characteristics, care during pregnancy and delivery, and newborn care up to 7 days of age [For this study, the mothers were divided into four study groups by their TOP histories and methods: no prior TOP, medical TOPs only, surgical TOPs only and both types of TOPs. The medical TOPs included TOPs performed using mifepristone alone, or in combination with misoprostol. Surgical TOPs included TOPs performed using either dilatation and curettage or vacuum aspiration. Mothers who had undergone multiple TOPs using both medical and surgical methods were included in both types of TOPs. Only the mothers with successful TOPs were included. The proportion of failed TOPs is very low; 0.4% in 2009–2015 according to the Abortion Register.The outcome measures, gestational age at birth, birth weight, small for gestational age and perinatal death were retrieved from the MBR. The gestational age at birth in the MBR is the clinicians’ best estimate at birth, based on ultrasound examination(s) and the date of last menstruation. The birth was defined as preterm if the gestational age at birth was less than 37 weeks, very preterm if the gestational age at birth was less than 32 weeks and extremely preterm if the gestational age was less than 28 weeks. Birth weights of less than 2,500 grams and 1,500 grams were defined as low birth weight and very low birth weight, respectively. Small for gestational age (SGA) was defined according to sex-specific Finnish standards for newborn infants between 24 and 43 gestation weeks . PerinatThe background characteristics of women were received from the MBR and they refer to the time of the birth of the baby. The urbanity of the maternal municipality of residence was categorized according to Statistics Finland, and the categories were further grouped into urban, semi-urban, rural and abroad. In the MBR, marital status of mothers was categorized into seven categories; married and living together with spouse, registered partnership, married and living separated from spouse, never married, divorced, widowed and unknown. These were further categorized into three groups; married/cohabiting, unmarried/single and unknown. In this study, we treated all variables as categorical variables. Information concerning socioeconomic status of the mothers was incomplete. So, maternal smoking and urbanity of municipality were used to explain the socioeconomic status of mothers.The statistical software, SPSS 23, was used for the analysis. Cross tabulations based on the study groups were calculated and chi-square test were used to study statistical significance. The level of statistical significance was set at p<0.05. Those mothers with previous surgical TOPs and those with previous medical TOPs were separately compared to women with no previous TOP, adjusting for differences in their background characteristics using a multivariate logistic regression . The potential confounders were selected on the basis of the previous literature on the maternal risk factors of birth outcomes, and their availability and quality in the registers. Mothers with previous TOPs  were compared to those without previous TOP, after adjusting for the maternal age, marital status, urbanity of the municipality of residence, history of smoking during pregnancy and the year of childbirth.Mothers with previous surgical TOPs were compared to those with previous medical TOPs, after adjusting for the maternal age, marital status, urbanity of the municipality of residence, history of smoking during pregnancy and the year of childbirth. In the second model, additional adjustments  were added. Since the number of women having had both medical and surgical TOPs was small when compared to the other groups, these mothers were excluded from the regression analysis. Lastly, a sub-analysis for those mothers having had only one previous surgical or medical TOP was conducted, after adjusting for the same confounders as above.A total of 419,879 first-time mothers having had singleton birth from 1996–2013 were identified from the MBR. According to the AR, 365,356 (87.0%) of the mothers had no history of TOP, 13,450 (3.2%) had histories of medical TOP(s), 38,659 (9.2%) had histories of surgical TOP(s) and 2,414 (0.6%) had histories of both medical and surgical TOP(s). The background characteristics differed with regard to several aspects between these subgroups . The motWhen compared to those mothers with no previous TOP, the perinatal outcomes were poorer among those mothers with previous surgical or both types of TOPs, but not among the mothers with previous medical TOPs only . The incThe unadjusted logistic regression analysis showed increased risk for all types of preterm birth and low birth weight after surgical TOPs and decreased risk for all studied perinatal outcomes after medical TOPs, when compared to the mothers without previous TOP . CompareAfter adjusting for the sociodemographic factors, the mothers with previous medical TOPs had decreased risk for preterm birth and low birth weight when compared to the mothers with no previous TOPs . The incThe mothers with previous surgical TOPs had higher risk for preterm birth and newborn with low birth weight than those mothers with previous medical TOPs . After aAfter restricting the analysis to those mothers having had only one previous TOP, and adjusting for confounders, the results did not change: the mothers having had only one previous surgical TOP had increased risks for preterm birth and low birth weight when compared to the mothers with only one previous medical TOP .The first-time mothers with previous TOP were much younger, single and more often smokers than the mothers without previous TOP. In addition, the mothers with previous medical TOPs had a reduced risk for preterm birth and low birth weight when compared with the mothers with no previous TOP. All the poor outcomes measured, with the exception of small for gestational age and perinatal deaths, were more common among the mothers with previous surgical TOPs than among the mothers with previous medical TOPs. This was also true among those mothers who had gone through only one TOP before their first birth.Our nationwide study covered all the first-time mothers having had singleton births during the time period ranging from 1996 to 2013, and all of the TOPs performed in Finland during the time period ranging from 1983 to 2013. Because our data did not include TOPs before 1983, some women might have been classified wrongly into the “no TOP group”. However, we assume that there are only few such cases and this will thus not affect our results. The quality of the data from the THL and AR is considered to be very high and reliable . Our larOverall, our findings that the demographic and reproductive profiles of first-time mothers with histories of previous TOPs differed from those of first-time mothers without histories of previous TOPs are in line with previous studies ,11,22,23Previously, it has been reported that undergoing several TOPs before a woman’s first birth correlated with poorer perinatal outcomes in subsequent births –8. HowevThere are few studies examining the long-term consequences of medical TOPs ,16. HoweAs in some prior studies, our unadjusted results showed an increased risk for preterm births among those mothers with surgical TOPs, when compared with those mothers having had no prior TOPs ,17,18,25Similar to some previous studies ,15,17,25Contrary to some of the previous research, our study reported an increased risk for low-birth weight among the mothers with previous surgical TOPs, when compared to the mothers with previous medical TOPs –14,16. HPerinatal outcomes did not differ among the mothers with surgical TOPs compared to the mothers with no TOPs, while the outcomes were poorer after surgical TOP(s) than after medical TOP(s). It is important to study the effects of the different methods used for terminating pregnancy to determine the safest method. This could be of importance for healthcare professionals in terms of clinical decision making and counselling women seeking termination of pregnancy, with respect to the method used for termination.


Mediastinal enteric duplication cysts are a rare congenital malformation encountered mainly in neonates and infants. It is a distinct entity within the family of foregut duplication cysts. It can present with respiratory distress due to mass effect and hence surgical excision is the preferred treatment. Histologically, it is characterised by a double layered smooth muscle wall with intestinal lining epithelium. We report a case of mediastinal enteric duplication cyst with aberrant pancreatic tissue in a neonate due to its rarity and early presentation. A neonate presented with respiratory distress and a cystic mass in the right posterior mediastinum. The lesion was excised and on histopathological analysis the diagnosis of mediastinal enteric duplication cyst was made. Also, aberrant pancreatic tissue which has been reported rarely was noted in this case. We discuss this case and review similar cases reported in literature. Mediastinal enteric duplication cysts are rare congenital malformations seen in neonates and infants. They are a type of foregut duplication cysts, with the other subtypes being bronchogenic and esophageal cyst . The cliA 29-day-old neonate weighing 4.2 kg was referred with respiratory distress since day four of life. The child was born of a nonconsanguineous marriage, at 37 weeks, with birth weight of 3.5 kg. The pregnancy and delivery were unremarkable. At admission, the child had poor activity with respiratory rate of 30/minute and pulse rate of 140/minute. Heart sounds were normal. There was decreased air entry on the right side. Biochemical investigations were normal. On the X-ray, a homogeneous opacity was seen in the right middle and lower lung fields with shift of mediastinum to the left . No vertOn gross pathological examination, the cyst was greyish brown, multiloculated with wall thickness of 0.5 cm . MicroscThe term duplication cyst was first introduced in 1711 by Blassius and Bremer [Mediastinal enteric cyst is rare and in 60% cases these cysts are diagnosed in neonates and infants with a slight male preponderance . In a caMediastinal enteric cyst is usually seen in the right posterior mediastinum. It normally presents with pressure symptoms like respiratory distress due to pressure on the bronchi or lung, cough, cyanosis, retrosternal pain, and dysphagia. Children may present with recurrent chest infections. Hematemesis may occur if there is a communication with the esophagus. Ectopic gastric mucosa can be present, leading to peptic ulceration, haemorrhage, or perforation. The current case also presented with respiratory distress and showed a left mediastinal shift.X-ray of a duplication cyst is an extremely important first-line investigation. Lateral and posterior-anterior views detect maximum lesions and show a homogeneous mass in the posterior mediastinum, usually on the right side. Ultrasonography has limited value; however, on endoscopic ultrasound, a duplication cyst appears as an anechoic or hypoechoic homogeneous cystic lesion with regular margins. Contrast-enhanced computerised tomography confirmed the presence of a well-defined homogeneously enhancing multilocular cystic lesion located in or adjacent to the wall of the part of alimentary canal.Histopathologically, the cyst shows smooth muscle wall lined by enteric type epithelium. Ectopic gastric lining may be present. Pancreatic tissue in the mediastinum appears as a part of germ cell tumors or as pseudocysts; its presence in the wall of enteric cysts is extremely rare and to the best of our knowledge has been reported only thrice in literature  Table 1Table 1. Differentiation from other cystic lesions of the mediastinum like neurenteric cyst, pericardial cyst, thymic cyst, bronchogenic cysts, meningocele, lymphangioma, mature cystic teratoma, cystic schwannomas, cystic thymomas, and cystic tubercular lymphadenitis is important as it has important implications in further management of the patient.Neurenteric cyst shows variable lining epithelium from respiratory, transitional to squamous. The wall shows variably thickened muscularis layer along with few nerve twigs and dystrophic neurons. There may be evidence of calcification. Pericardial cysts are usually thin walled, benign, filled with clear fluid, and lined by mesothelium. Thymic cysts may be unilocular or multilocular and are thin walled tense cysts filled with brown fluid showing pericystic fibrosis with inflammation, haemorrhage, and cholesterol clefts in the wall . LymphanThoracoscopic surgical excision of the cyst is the mainstay of treatment with comprehensive supportive care. This resolves the majority of the cases and is associated with minimal morbidity. Few cases which have esophageal or vertebral connections need thoracotomy. In our case, the cyst was quite large in size and expertise in thoracoscopy was not available; hence, the patient was taken up for thoracotomy. To conclude, early intervention is needed in these cases before the patient becomes symptomatic as these lesions, once symptomatic, tend to be associated with higher intraoperative complications and, if left untreated, may be complicated by perforation, obstruction, or haemorrhage. It is important for the pathologists to be aware of the vast differential diagnosis of mediastinal cysts on histopathology which would require thorough sampling to arrive at a correct diagnosis. An active search for ectopic gastric/pancreatic rests is recommended, for both its academic importance and clinical correlation in symptomatic patients.


Despite the gender difference, arginine in the amniotic fluid from gestational weeks 13–15 was the strongest predictor for birth weight, length, and head circumference. ADMA was a strong predictor for birth weight and length, SDMA for birth weight, while Arg/ADMA and Arg/SDMA only predicted head circumference in multiple linear regression models. Due to increased arginine demands, pregnancy is considered a state of relative arginine deficiency. Our findings reflect the importance of a good maternal arginine status in early pregnancy, an observation that should be evaluated in an intervention study.Arginine is a constituent of proteins and a precursor for polyamines and nitric oxide, and is essential for placentation, angiogenesis, and growth. Maternal plasma arginine concentrations are found to be lower in pregnancies complicated by fetal growth restriction, and arginine supplementation in later pregnancy is reported to increase birth weight. We measured arginine and the metabolites asymmetric dimethylarginine (ADMA) and symmetric dimethylarginine (SDMA) in the amniotic fluid obtained in pregnancy weeks 13 to 15 from 363 pregnancies with a documented normal outcome and related the concentrations to birth weight, length, and head circumference. Arginine was higher in the amniotic fluid from female (mean 40.8 (SD 10.6) µmol/L) compared to male fetuses (37.4 (SD 11.2) µmol/L,  Arginine plays an essential role in fetal and placental development and is reported to be abundant in the amniotic fluid in early pregnancy ,2,3 ArgiGN)-dimethylated derivate of arginine, is a strong direct inhibitor of nitric oxide synthase (NOS). Symmetric dimethylarginine (SDMA) is an indirect and weaker inhibitor of NOS and a marker of renal function. The ratio Arg/ADMA is considered to be a marker of NOS activity [Arginine is additionally the substrate for the production of nitrix oxide (NO), and asymmetric dimethylarginine (ADMA), a guanindine . Birth before gestational week 37 was defined as premature birth, and a birth weight below 2500 grams at term was defined as small for gestational age (SGA).Samples of amniotic fluid taken by transabdominal amniocentesis for genetic prenatal diagnosis at Haukeland University Hospital, Bergen, Norway, during 1995 through 1998 were eligible for this observational study. The gestational age was determined by menstrual dates and checked by ultrasound examination. The information about pregnancy outcomes was collected from questionnaires routinely returned after delivery. Samples from singleton pregnancies with a documented normal outcome, obtained at gestational weeks 13, 14, and 15 were included in the study .www.bevital.no).The samples were centrifuged after amniocentesis and stored at −20 °C until analyses were done in 1999. Amniotic fluid concentrations of arginine, ADMA, and SDMA were measured using a LC-MS/MS method  by the lData are presented as mean and SD and compared by ANOVA test, or as median and interquartile range (IQR) and compared by Kruskal–Wallis test. Multiple linear regression models, corrected for gender, gestational age at sampling, and storage period were used to explore the relationships between amniotic fluid arginine, ADMA, or SDMA concentrations and growth parameters at birth . Graphical illustrations of the relationships between arginine or the methylarginines and birth weight were obtained by generalized additive models (GAM), corrected for gender, gestational age at sampling, and storage period.R, version 3.3  were used for the statistical analyses. Two-sided p-Values < 0.05 were considered statistically significant. The SPSS statistical program (version 23) and the package “mgcv” in The main indication for amniocentesis was maternal age . The infp = 0.03), and the same pattern was seen for birth length (50.8 (SD 2.8) versus 49.9 (SD 2.4) cm, p = 0.005) and head circumference (35.7 (SD 1.4) versus 35.2 (SD 1.5), cm, p = 0.008). The mean birth weight was higher in boys compared to girls (3713 (SD 562) versus 3592 (SD 468) g, p = 0.41).The mean arginine (−13%), ADMA (−15%), and SDMA (−10%) concentrations decreased significantly from gestational week 13 to 15, while no such trend was seen for the ratios Arg/ADMA and Arg/SDMA . The stop = 0.003), whereas no differences were seen for ADMA (p = 0.16) and SDMA (p = 0.30) according to gender. The mean arginine concentrations were higher in the amniotic fluid from female (40.8 (SD 10.6) μmol/L) compared to male fetuses (37.4 (SD 11.2) μmol/L, p = 0.007), whereas no significant difference according to gender was seen in the Arg/SDMA ratio (p = 0.07). The mean Arg/ADMA ratio was higher in the amniotic fluid from female (15.3 (SD 3.3)) compared to male fetuses (14.4 (SD 3.5), r = 0.23, p < 0.001) and ADMA , weakly correlated to SDMA , and not correlated to Arg/ADMA (p = 0.26) and Arg/SDMA ratios (p = 0.21) by Spearman correlation. Positive correlations were also seen for birth length versus arginine , ADMA , and SDMA , but not versus Arg/ADMA (p = 0.97) or Arg/SDMA (p = 0.66) ratios. Head circumference was positively correlated only to arginine . Birth weight was positively correlated to arginine , length (p = 0.19), and head circumference (p = 0.05) increased with increasing arginine concentrations in the amniotic fluid  for 1–4 years before analysis, which may influence arginine and metabolite concentrations. However, under these conditions, ADMA and SDMA are stable in both serum and plasma, whereas arginine may increase about 2.5% per year in serum (but not in plasma), a change that has been attributed to proteolysis . HoweverAs this study was done on anonymous samples, the information on the maternal status was limited, and factors known to be related to birth outcome, like prepregnancy body mass index, parity, smoking, and socioeconomic status, were not available . HoweverWe found higher concentrations of arginine, no difference in ADMA and SDMA, and a higher Arg/ADMA ratio in the amniotic fluid in pregnancies from female compared to male fetuses. The same gender difference, with higher plasma arginine concentrations in females, was observed in mice . Amniotic fluid testosterone concentration is reported to be higher in male than female fetuses at gestational week 15 . As testPublished data on amniotic fluid arginine concentrations are scarce, and data on ADMA and SDMA are missing. We found that arginine concentrations decreased from gestational week 13 to 15, and the mean concentration obtained in week 15 (36.0 (SD 8.3) µmol/L) resembles published data from one study on amniotic fluid from pregnancy week 15, mean 34.8 (SD 12) µmol/L . Amniotic fluid volume increases from about 25 mL at 10 weeks to about 400 mL at 20 weeks. Before keratinization of the fetal skin, amino acids and other nutrients diffuse into the amniotic fluid from the placenta through the placental membranes, and from the fetal circulation through the fetal skin, and the composition of the amniotic fluid is considered to reflect that of fetal plasma [However, the concentrations of arginine, ADMA, and SDMA that we observed in the amniotic fluid differed substantially from the published concentrations in maternal plasma in early pregnancy and in cord blood at term. The mean amniotic fluid arginine concentration at week 15 (36.0 (SD 8.3) µmol/L) was less than half 42%) of the one that was reported in maternal plasma at pregnancy week 16 (estimated mean 85.5 (SE 4.6) µmol/L) , and in 2% of theThe mean ADMA concentration in the amniotic fluid at week 15 (2.28 (SD 0.38) µmol/L) was substantially higher (585%) compared to maternal plasma ADMA concentrations at pregnancy week 16 (estimated mean 0.39 (SE 0.02) µmol/L) , and subIt has been suggested that the placenta is the primary source of ADMA present in fetal circulation and that the observed high ADMA concentration may be a compensatory mechanism to stabilize the high NO concentrations in the fetoplacental unit . The amniotic fluid Arg/ADMA ratio at week 15 (16.1 (SD 4.0) was only 7% of reported maternal plasma ratio in pregnancy week 16 ) . Arginine was the strongest predictor for birth weight, length, and head circumference, followed by gender. The metabolites ADMA and SDMA were weakly related to birth weight and length, while the ratios Arg/ADMA and Arg/SDMA were weakly related to head circumference. Published data on the relation between birth weight and amniotic fluid concentrations of arginine, ADMA, and SDMA are missing. No significant correlations between circulating arginine, ADMA, SDMA levels, and birth weight were seen in 130 neonates born premature  with a very low birth weight (<1500 grams) . HoweverOur findings reflect the importance of arginine in pregnancy, derived from its diverse functions, both as a constituent of proteins and as a precursor for polyamines and NO, which make it essential for growth and angiogenesis. An adequate concentration of arginine was shown to be crucial for placentation, utero–placental blood flow and transfer of nutrients to the fetus, embryogenesis, and fetal growth and development . ArgininBoth animal and human studies have shown enhanced placental–fetal development and growth after arginine supplementation in pregnancy ,32,33. TArginine in the amniotic fluid from gestational weeks 13 to 15 was found to be a strong predictor of birth weight, length, and head circumference, while ADMA was a predictor for birth weight and length and SDMA only for birth weight. Our findings reflect the importance of arginine metabolism in pregnancy, because of its diverse functions, both as a constituent of proteins and as a precursor for polyamines and NO, which make it essential for placentation, angiogenesis, and growth. Whether an improved maternal arginine status in early pregnancy may enhance fetal growth, should be evaluated in an intervention study.


Increased incidence and prevalence of autism spectrum disorder (ASD) over the last two decades have prompted considerable efforts to investigate its aetiological factors. We examined an association between month of birth and ASD incidence.In a retrospective cohort of male children born from January 1999 to December 2008 in a large health organisation in Israel , ASD was followed from birth through December 2015.Of 108 548 boys, 975 cases of ASD were identified. The highest rates  were recorded for children born in May and August, respectively, and the lowest rates for February . Among lower socioeconomic status households, boys born in August were more likely  of being diagnosed with ASD than children born in January. Significantly higher rates were not observed for other months.In line with several previous studies, we found a modestly higher likelihood of autism occurrence among male children of lower socioeconomic levels born in August. Validated source of information of autism spectrum disorder (ASD) diagnosis.The use of systematic data that were collected prospectively on a large population.No information was available regarding ASD disease severity.nly boys were included, contrasting with other studies that included both sexes.Lack of information in our population on influenza infections and vaccines.Autism spectrum disorder (ASD) is a biologically based neurodevelopmental condition characterised by (A) deficits in social communication and social interaction, and (B) restricted repetitive patterns of behaviour, interests and activities.3Analyses of season of birth or conception can provide clues about causes of diseases with unknown aetiology as in ASD. Patterns of seasonal variation in births have been found in several disorders; schizophrenia, mood disorders, epilepsy, language disorders, attention deficit hyperactivity disorder and neurodevelopmental disabilities.In one of the first studies on season of birth and ASD to be carried out in a region other than the USA and western Europe, a study in IsraelThe objective of the present study was to examine a relationship between autism and seasonality in a large population in Israel, using the computerised databases of a single health provider and its standardised coding system. Male to female ratio among patients with ASD is reported between 3 to 1 and 4 to 1,The 1994 National Health Insurance Law mandates compulsory universal health coverage for all Israeli residents in a health maintenance organisation (HMO) of their choice. Israeli citizens are obliged to choose one of four non-for-profit HMO’s in the Israeli medical system, who provide equivalent medical services that are based on national medical standards. For this review, we examined data on ASD diagnosis from the computer database of the second-largest HMO, Maccabi Healthcare Services (MHS), which provides care to 2 million people (31% under 18 years of age) .Using the computerised databases of MHS, we identified a total of 147 171 male children who were born between January 1999 and December 2008 . Children’s parents were identified using data on household members in MHS. Children with missing paternal data  were excluded from the study. Comparison of excluded (n=38 875) and eligible (n=1 10 093) children showed no statistically significant (p>0.05) differences in mean birth weight , mean gestational week (39.0 weeks and 39.1 weeks) or mean mother’s age at birth (29.4 years and 30.5 years) and a similar distribution of socioeconomic status (SES). To avoid inaccurate paternal identification, an additional 1545 children were excluded because more than one man was registered in the child’s household. Hence, the total study population was 108 548 boys of 83 452 households.A case was defined as a child with a physician-recorded diagnosis of autistic disorder, Asperger’s syndrome orpervasive developmental-not otherwise specified (PDD-NOS), based on the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (American Psychiatric Association 1994). In MHS, children with suspected ASD are referred to child development centres for a multidisciplinary assessment for diagnosis validation. The MHS registry of patients with ASD and validation processes were previously described.32SES was assessed according to the poverty index of the child’s address enumeration area, as defined by the 2008 national census.First, bivariate analyses were conducted between month of birth and other covariates previously reported to be associated with increased risk of autism.Multivariable logistic regression analyses were performed to determine the OR and 95% CI for ASD by month of birth, using January as the reference month. For the purpose of comparison with previous studies, we fitted alternative logistic regression models, with season of birth, month and season of conception (rather than birth), first month of the second trimester.The mean number of monthly births ranged from 8318 in February to 9654 in August. In bivariate analyses, number of births, maternal age, paternal age, birth weight, gestational length and SES were not associated with the month of birth . Of the In a multivariable model, birth months of August and May were associated with a non-significantly  increased OR . When thIn this retrospective cohort of boys born in Israel during a period spanning 10 years, children of low SES together with birth in August were associated with an increased likelihood of being diagnosed with ASD. This is the one of the largest studies outside the USA to describe the relationship between ASD incidence and month of birth.The literature with respect to season of birth and risk of ASD is inconsistent. Of the 15 studies  summarised in There are several mechanisms by which season of birth may affect the developing brain, either directly on the fetus and newborn or indirectly through the mother during pregnancy or the postpartum period. Seasonal environmental factors that could be associated with ASD include viral or other infections,47A few studies found influenza infection during pregnancy to be a factor that increases risk for infantile autism56Strengths of the current study include the investigation of a large and unselected population that is similar in its characteristics  to a large cohort of a recently published US study that examined autism and seasonality,In line with several previous studies, we found modestly higher likelihood of ASD occurrence among male children of lower SES levels born in August. Month of birth may indicate seasonal causal factors that could be associated with autism. The fact that these patterns appear to differ by SES may also be aetiologically significant.10.1136/bmjopen-2016-014606.supp2Supplementary data 2


Balint's syndrome is well described in adults, but not in children. It is caused by bilateral posterior parietal lobe damage and comprises a triad of simultanagnosia , optic ataxia , and apraxia of gaze  often associated with homonymous lower visual field loss. We, here, describe five children  who presented to the Cerebral Visual Impairment Clinic at a tertiary care center in South India with clinical features remarkably consistent with the above description. In all children neuroimaging showed bilateral parietooccipital gliosis with regional white matter volume loss and focal callosal thinning, consistent with perinatal hypoxic ischemic encephalopathy and possible neonatal hypoglycemia. Balint's syndrome is well described in adults . It is cThis retrospective observational study was done after obtaining permission from the institutional review board. These children were referred to the clinic by their clinician, who provided salient information regarding their neurological/cognitive status. A pediatric ophthalmologist trained in CVI vision assessment assessed these children. The clinical assessment began the moment children walked into the waiting room with their parents/caregivers. Spontaneous visual responses like what the child was looking at, the size, the nature of the object, and the distance at which the child appreciated the object of regard were closely observed. Visual-perceptual disorders were initially identified, based on in-depth history taking, using spontaneously volunteered information about visual behaviors, and also using the Structured Clinical Question Inventory . DetaileThe parents/caregivers described their children as being “clumsy and careless” in their activities of daily living. All had difficulty in reading and copying the text. They were “poor performers” in school with three of them dropping out of school as they could not “cope” with the school environment. All five would probe the floor before they took a confident step as they had difficulty negotiating steps, stairs, pavements, and unfamiliar patterned floors. All five children had features suggestive of optic ataxia of upper limb by placing objects inaccurately on the edge of the table . CrowdedAn 8-year-old boy, born of caesarian section (mother had pregnancy induced hypertension) at 32 weeks of gestation with a birth weight of 1.2 kg, neonatal period being uneventful, was brought to the CVI clinic with complaints of being a poor performer in school. He needed help in performing his activities of daily living (ADL) like dressing himself up and tying his shoes. He had to drop out of school, as he was not able to cope with busy school environment and was termed a “bad boy.” His magnetic resonance imaging (MRI) showed bilateral parietooccipital gliosis with corpus callosal thinning . OphthalA 4-year-old boy referred to the clinic for being “clumsy.” He had been born at 40-week gestation (pregnancy was uneventful) by spontaneous vaginal delivery and birth weight of 2.5 kg. There is history suggestive of birth asphyxia. MRI showed biparietooccipital gliosis with callosal thinning . He was A 7-year-old boy, born by spontaneous vaginal delivery, at 36 weeks of gestation with a birth weight of 1.8 kg and history of respiratory distress at birth, was seen in the CVI clinic with complaints of poor performance in school. He developed seizure disorder and spastic diplegia. He was able to carry out self-care skills to a large extent on his own. He never liked going to school, as he could not keep up with reading and writing work. He spent most of his free time playing with his toys or coloring pictures. He got upset when furniture in the house or his toys were rearranged. He could not appreciate fast moving things and watched only music channels on television. Ophthalmological examination showed BCVA  6/24 with alternate divergent squint; the rest of the anterior and dilated posterior segment examination was unremarkable. On CVI assessment, he had features suggestive of lower field defect, simultanagnosia, optic ataxia, apraxia of gaze, and impaired visual guidance of upper limbs. Radiological features showed biparietal occipital gliosis .An 11-year-old boy, with a BCVA (binocular) of 6/6 with Snellen's visual acuity chart and the rest of the ophthalmological examination being within normal limits, was assessed in the CVI clinic for his learning and intellectual disability. The pregnancy was uneventful and he was born at 32 weeks of gestation by caesarian section. His birth weight was 2.25 kg and had history suggestive of perinatal asphyxia. At 7 years of age he developed seizure disorder. He was mostly independent in self-care skills and was studying in Grade 1. CVI assessment showed that he had difficulty in handling complex visual scene, problems with clutter and impaired visual guidance of hands, body, and legs, and lower field defect. He knew his letters, but when asked to write he was very hesitant and wrote vertically downwards, missing a few letters in between. He had difficulty with recognition of faces or shapes or objects. His MRI is shown in A 7-year-old girl was seen in CVI clinic for her intellectual disability and poor performance in school. She was born from an uneventful pregnancy at 36 weeks of gestation by spontaneous vaginal delivery with a birth weight of 2.0 kg. Her neonatal period was uneventful. She was able to carry out her activities of daily living on her own, but owing to her “careless” nature her parents did most of the work for her. She had to discontinue her school education, as she did not cope with school environment. She lacked confidence and needed constant prompting while carrying out any tasks. While walking on the pedestrian path she always tugged at her parents clothes. She would bump into objects like trees or electric pole while having a conversation with her parents when out on a walk. Her social interaction was poor as she disliked crowded places and avoided all social gatherings. She watched television from very close distance and watched only slow moving cartoon shows. Ophthalmology examination showed BCVA (binocularly) with Snellen's visual acuity chart being 6/24 with the rest of the examination including dilated fundus examination being within normal limits. On CVI assessment, she had features suggestive of lower field defect, simultanagnosia, optic ataxia, apraxia of gaze, and impaired visual guidance of upper limbs. Her MRI scans showed a near normal scan with only mild shortening of the corpus callosum and splenium and thinning of the splenium .Cerebral Visual Impairment (CVI) comprises visual malfunction due to retrochiasmatic primary visual and visual association pathway pathology. This can be isolated or accompany anterior visual pathway dysfunction . It is aHabilitation approaches suggested to these patients involved simple multicontext adaptive strategies that made use of the strengths of the patients to compensate for their difficulties as described in the literature . It is i


Duplication cysts are an uncommon finding. Majority of these cases are found in the region of the midgut, and many have been reported in literature. However, there has been only one previous case of a midgut duplication cyst lined by respiratory epithelium. This is a rare pathology, of which very little is known about. The pathophysiology of these cases is also difficult to explain. We aim to present a case of a midgut duplication cyst in a paediatric patient, who had other abnormalities as well. We also aim to offer a hypothesis for this case. Duplication cysts of the gastrointestinal tract are a rare anomaly and have been reported in literature mostly as incidental findings following investigations for symptomology that have not been explained by other pathology –5. A dupA 16-year-old male presented from his general practitioner (GP) to the orthopaedic surgical department as he was complaining of back pain, and clinical examination had picked up a mild degree of scoliosis. The initial consultation with the orthopaedic surgeon had not revealed any abnormality; however, the patient was re-referred to the same department a year later, this time with marked scoliosis. A magnetic resonance image (MRI) was requested, which confirmed the presence of scoliosis but had also picked up an incidental cyst near the ileum, attached to the appendix .A repeat MRI was performed 6 months later, which showed an unchanged cyst . UnfortuThe cyst was excised as an elective procedure . An appeHistology was performed, which showed a unilocular cyst, lined by pseudostratified ciliated columnar epithelium, with a discoloured wall showing no submucosa . The musDuplication of the ileum, as discussed, are the most common cysts found in this population; however, an ileal duplication cyst lined by respiratory epithelium is rare . There hThe embryological theories behind these cysts are plenty; however, most theories suggest some kind of anatomical relation between the location of the duplication cyst and the histopathological findings of these cysts. The split notochord theory proposes a neural tube traction mechanism as an explanation for the 15% of enteric duplications associated with vertebral defects. Specifically, an embryologic error may result in abnormal diverticularization of the GI endoderm through the developing notochord at 4 weeks' gestation. This explains neurenteric cysts, which are proposed to be impaired separation of the notochord from intestinal endoderm and formation of neurenteric bands that, with embryonal growth, produce traction diverticula. This is currently in favour and has been demonstrated experimentally in amphibian embryos .In the embryogenesis of the foregut, a respiratory diverticulum appears at the ventral wall of the pharyngeal gut at 4 weeks. This is slowly divided into a ventral and dorsal part of the foregut, becoming the respiratory primordium and the upper gastrointestinal tract, respectively . The oesThis cyst was thought to be a duplication cyst due to the typical findings on histology. The fact that it was found completely in the mesoappendix, without any communication with the gastrointestinal tract, was also unexpected. This could possibly be due to the aforementioned abnormal diverticulisation of this cyst. However, the presence of respiratory epithelium in this cyst is one that is unusual, and might represent a developmental abnormality. The patient had genetic testing done to check for relevant syndromes; however, that was negative. Further case series will be beneficial in expanding our knowledge of this condition, especially with regard to the pathophysiology of the formation of a duplication cyst.


Most recently, a novel myokine, named irisin, was identified in human that expressed by skeletal muscle after exercise. Irisin increases energy expenditure by turning white adipose tissue into brown adipose tissue. Thus improves carbohydrate homeostasis in humans. Irisin is considered as a potential biomarker for obesity and metabolic syndrome. In recent years, numerous studies have been conducted about irisin with adults, although number of studies with newborns is limited.To evaluate cord blood irisin level with small gestational age (SGA) and appropriate gestational age (AGA) in term newborns.A cross-sectional study of 34 AGA and 34 SGA term newborns who were born in (1–30) December 2015 in Fatih University Hospital. Estimated fetal weight were calculated using the Hadlock formula by gynecologists to pregnant women in second trimester. All the babies were classified at birth as SGA or AGA. SGA was defined according to the Lubchenco scale for gender and gestational age. We collected umbilical cord blood at the time of delivery. Cord blood irisin levels were measured using commercial enzyme-linked immunosorbent assays in our hospital laboratory.Cord blood irisin levels were significantly lower in SGA group [median 30 (25 ± 8) ng/ml] than in AGA group . No statistically significant differences were observed among the groups in terms of the demographic features  (p > 0.05). Mothers with gestational diabetes, hypertension, asthma, chronic disease, use of drug or a history of smoking exposure were excluded from the study. When the study data were evaluated, Yates Continuity Correction and Fisher’s exact tests were used in descriptive statistical methods and for comparison of qualitative data.Our results support the idea that irisin have a physiologic role in neonates. Low level of irisin is associated with the impaired carbohydrate metabolism in term infants with SGA. However, further studies with larger series are warranted to confirm this. In recent years, the interaction between adipose and muscle tissues has been increasingly recognized to play an important role in body weight regulation and carbohydrate homeostasis. Because the largest organ in the body skeletal muscle accounts for the majority of glucose uptake in response to insulin, and is quantitatively the most important site of insulin resistance. During the past decade, skeletal muscle has also been identified as a secretory organ, secreting myostatin, IL-6, IL-15 and other factors  and impaired insulin sensitivity with the development of diseases such as type 2 diabetes, cardiovascular diseases or the metabolic syndrome later in life has been demonstrated in several studies  and 34 AGA  infants who were born in (1–30) December 2015 in Fatih University Hospital.Estimated fetal weight (EFW) were calculated using the Hadlock formula by gynecologists to pregnant women in second trimester in our hospital, which includes abdominal, head circumferences, and femur length measurements , Rubella, Cytomegalovirus (CMV), Herpes infections], congenital malformation, neonatal sepsis and meconium aspiration that could affect fetal growth were excluded. Mothers with gestational diabetes, hypertension, asthma, chronic disease, use of drug or a history of smoking exposure were excluded from the study.All the babies were classified at birth as SGA or AGA. SGA was defined as birth weight ≤−1.5 SD and AGA >−1.5 SD according to the Lubchenco scala for gender and gestational age  in our hospital laboratory. Intra- and inter-assay variances were <4–6 and <8–10 %, and the range of detectable concentration was 0.066–1024 ng/ml.2 test was used. For group comparisons, the Student t test was used with a normal distribution, and the Mann–Whitney U and Kolmogorov–Smirnov tests with abnormal distributions. Kruskal–Wallis test was used for continuous variables for comparison between the two different birth weight categories (SGA and AGA). Variance analyses and Friedman variance analyses were used for repeated measurements. For descriptive statistics, percent, minimum–maximum–median, mean, and standard deviation were used in accordance with the type and distribution of the variable. Normality of irisin was tested with Shapiro–Wilk test, and the data were transformed to logarithmic scale to obtain normality. A result was considered statistically significant for values of p < 0.05.Statistical analyses were performed using the Statistical Package for Social Sciences-SPSS version 15 software . For categorical variables, the χThe median birth weight were lower in the SGA (2280 ± 221 g) group compared to AGA (3263 ± 329 g). There was a strongly significant difference between the two groups in terms of birth weight of the babies (p < 0.01). However, no statistically significant differences were observed among the groups in terms of the demographic features  (p > 0.05).But cord blood irisin levels were significantly lower in SGA group [median 30 (25 ± 8) ng/ml] than in AGA group [median 40 39 ± 13) ng/ml, p < 0.001, Table 3 ng/ml, There was not a statistically significant difference between the groups in the number of conceptions and gestational age (p > 0.05). Mothers with gestational diabetes, hypertension, asthma, chronic disease, use of drug or a history of smoking exposure were excluded from the study. Multivariate linear regression analysis was not carried out, because the pregnants carrying maternal risk factors that could affect irisin level.Our prospective study shows that cord blood irisin levels are positively correlated with birth weight in term infants and the levels are decreased in SGA compared to AGA infant. Today number of the studies about serum levels of irisin in term infants with SGA and AGA is limited. We believe that it would provide contribution to the literature.Because the underlying mechanisms and the relationship between SGA infants who have lower muscle and BAT tissue, impaired glucose tolerance still remain unclear. Also irisin is considered as a potential biomarker for obesity and metabolic syndrome.Studies from the literature have usually emphasized the excess nutrition during early life include resetting of hypothalamic energy sensing and appetite regulation, altered adipose tissue insulin sensitivity and impaired BAT function , and birth weight Z-score   (Park et al. I think that, likewise the study by Joung et al., lower cord irisin levels found SGA infants in our study might be influenced by the smaller muscular mass as well as lower BAT (Joung et al. Based on all these studies and the present study; I have thought that irisin which is recently rather emphasized for its association with insulin resistance and obesity and released by muscle tissue, regulating glucose homeostasis by influencing the BAT might be a physiopathological factor in explanation of the impaired carbohydrate metabolism which is more common in SGA infants. Because both muscular mass and BAT are low in SGA infants.Low levels of irisin in term infants with SGA may be a factor in explanation of the impaired carbohydrate metabolism in these infants. However, further studies with larger series are warranted to confirm this.


Pregnant women are exposed to a mixture of endocrine disrupting chemicals (EDCs). Gestational EDC exposures may be associated with changes in fetal growth that elevates the risk for poor health later in life, but few studies have examined the health effects of simultaneous exposure to multiple chemicals. This study aimed to examine the association of gestational exposure to five chemical classes of potential EDCs: phthalates and bisphenol A, perfluoroalkyl substances (PFAS), polychlorinated biphenyls (PCBs), polybrominated diphenyl ethers (PBDEs), and organochlorine pesticides (OCPs) with infant birth weight.Using data from the Health Outcomes and Measures of Environment (HOME) Study, we examined 272 pregnant women enrolled between 2003-2006. EDC concentrations were quantified in blood and urine samples collected at 16 and 26 weeks gestation. We used Bayesian Hierarchical Linear Models (BHLM) to examine the associations between newborn birth weight and 53 EDCs, 2 organochlorine pesticides (OPPs) and 2 heavy metals.For a 10-fold increase in chemical concentration, the mean differences in birth weights ) were 1 g  for phthalates, -11 g  for PFAS, 0.2 g  for PCBs, -4 g  for PBDEs, and 7 g  for OCPs.Gestational exposure to phthalates, PFAS, PCBs, PBDEs, OCPs or OPPs had null or small associations with birth weight. Gestational OPP, Pb, and PFAS exposures were most strongly associated with lower birth weight.The online version of this article (10.1186/s12940-017-0332-3) contains supplementary material, which is available to authorized users. Endocrine disrupting chemicals (EDC) are synthetic compounds found in many consumer products –3 that aThe vulnerability of the developing fetus  coupled Many investigators have explored the relationship between EDC exposures and birth weight . LentersThese inconsistencies may be due to a shortage of statistical tools to explore the effects of multiple chemical exposure mixtures on birth weight. One way to model multi-exposure mixtures is to collapse the exposures into a summary term that is included in regression models for the outcome  or use pβ and standard deviation σβ, which are informed by the data and can be quantified when fitted to the data. The quantity μβ is the average association between all regression coefficients and the outcome, whereas σβ captures the heterogeneity of effects.Bayesian hierarchical linear models (BHLMs) are one possible solution to analyzing the effect of multiple correlated exposures . BHLM isThe objective of this study was to use BHLM to simultaneously examine the association between exposure to 5 different EDC classes , 2 organophosphate pesticides (OPPs) and 2 heavy metals, lead (Pb) and mercury (Hg), with birth weight among women and their children in the Health Outcomes and Measures of Environment (HOME) Study .The HOME Study is a prospective birth cohort study in the Cincinnati, Ohio area. Women were recruited between 13 and 19 weeks of pregnancy from prenatal clinics between 2003 and 2006. Inclusion criteria for the HOME Study included women who were >18 years old, <19 weeks gestation at the time of enrollment, and living in a residence built before 1987. Additional details about study eligibility, recruitment, and follow-up are described elsewhere . The CinThe outcome variable was birth weight, measured in grams (g). Birth weight was abstracted from birth records and analyzed as a continuous variable.10 transformed and treated as continuous variables. If a woman provided multiple urine or blood samples at both 16 and 26 weeks gestation, then the sample concentrations were averaged following log10 transformation and treated as continuous variables [Blood and urine samples were collected from participants at approximately 16 weeks and 26 weeks gestation. We used sensitive and specific liquid or gas chromatography mass spectrometry  to measuariables , 37. Bioariables , we examariables  toxin thariables  and so iWe drew a directed acyclic graph to select confounders based on the relationships between the HOME Study , 34 cova0 + βx1X1....βxpXp +βc1C1+....+βckCk +spline(GA)+ error, where Y is the outcome birth weight, β0 is the y-intercept, βx1...βxp are the exposure variable regression coefficients, X1...Xp are the exposure variables, spline(GA) is the non-parametric spline for GA, and C1…Ck are the 9 covariates. All 53 exposure variables from 5 chemical classes were included in the final BHLM model for analysis. BHLM assumes that βxi are Gaussian random effects with group specific mean μβ and standard deviation σβ. The hyperparameter μβ is the average association between the exposure variables within a chemical class and the outcome, whereas σβ governs the heterogeneity of effects for the class regression coefficients. The hyperparameters for the different chemical classes were assigned uninformative prior distributions: μβ normal with mean 0 and variance 105, and σβ normal with mean 0 with variance 105 such that σβ>0. Hamilton Monte Carlo sampling was used to obtain 2 chains of 20,000 iterations with 500 warm-up iterations. The 2 OPPs, Pb and Hg were included in the model as covariates without hierarchical modeling.We used descriptive analyses to examine the distribution of EDC variables, birth weight, and participant characteristics. We calculated basic descriptive statistics for participant variables Table , EDC conThe final results included both 95% and 50% equi-tailed posterior credible intervals  for parameter estimates. The 50% CI is the smallest interval that contains 50% posterior probability of containing the true parameter. Using 50% CIs gives higher power to detect small effects in the data and they can serve as a screening tool for identifying weak effects that may warrant further study . ReportiAdditionally, to better understand the impact of the BHLM shrinkage on the regression coefficients, we re-analyzed the data using both LASSO and Elastic Net. We used the R package ‘glmnet’ , and incOf 389 singleton live births, 272 (69.9%) had all covariates and were included in analysis. The study participants were mostly white 61%), married (64%), and university educated (50%) , median concentrations among HOME Study participants tended to be similar to concentrations observed in US women Table . The GM β posterior mean for the phthalates and BPA was 1 g with 95% CI , meaning the average association between the 9 phthalates and BPA and birth weight was 1 g. Another way to interpret this is that for every 10-fold increase in exposure to phthalates and BPA as a whole, there was a 1 g increase in birth weight. This increase was not statistically significant at the 0.05 level based on a frequentist hypothesis test using the posterior credible interval. The σβ posterior mean was 10 g, which indicated heterogeneity in the phthalate and BPA effects around this estimate, and that roughly two thirds of the beta coefficients were within 10 g (one standard deviation) of μβ. In contrast, for PFAS exposure, the μβ and σβ posterior means were larger in magnitude and equal to -11 g, 95% CI  and 24 g, respectively. Although the 95% CI for μβ for PFAS did cover zero, the estimate was significantly lower than zero based on the upper limit of the 50% CI . For PCB exposure, the μβ posterior mean was 0.2 g, 95% CI . The PBDE μβ estimate was -4 g, 95% CI . Finally, OCP exposure was associated with a μβ of 7 g, 95% CI  with an estimated σβ of 18 g.The phthalates and BPA, PFAS, PCBs, PBDEs, OCPs, OPPs, Pb and Hg were examined using BLHM Table . The μβ β, given by the posterior distribution of the BHLM regression coefficients βx1 ... βxp  out of a possible 53. The LASSO results are given in Additional file GA is a potential mediating variable on the causal pathway between EDC exposure and birth weight, while sex is a potential modifier. Controlling for mediators may attenuate the total effect of EDCs on birth weight. Accordingly, we conducted sensitivity analyses without controlling for GA Table  and straIn this study we examined the relationship between gestational exposure to 53 different EDCs and birth weight in a prospective birth cohort of mother-infant pairs. We found that exposure to phthalates and BPA, PFAS, PCBs, PBDEs or OCPs had null or small associations with birth weight. Other investigators have reported similar small or statistically non-significant associations between birth weight and phthalates , PCBs 1, PBDEs , and OCPWe found some evidence that PFAS, DMP and Pb were associated with small reductions in birth weight. On average, a 10-fold increase in exposure to the PFAS class was associated with an -11 g change in birth weight, 50% CI . However, due to the higher Type I error rate associated with using alpha level = 0.5, this association should be interpreted with caution. Similar findings concerning PFAS exposure have been reported elsewhere . While tβ, which is less susceptible to random variation [β is that it prevents the investigator from only reporting chemicals that are significantly related to birth weight by virtue of it being an average association between a class and the outcome. For example, rather than sorting through 23 PCBs to identify those that are significant, we simply reported the average association of all 23 PCBs and birth weight. Additionally, Bayesian modeling produces the σβ value that measures the heterogeneity of EDC class effects. A final advantage of Bayesian modeling is that posterior distributions of the regression coefficients are shrunk towards pooled mean μβ, reducing the Type I error  rate when the interval estimates are used for frequentist hypothesis testing.The BHLM approach has advantages compared with other analytic techniques including LASSO and Elastic Net. First, each EDC class contains between 4 to 23 chemicals with varying associations between any given chemical and birth weight. Having many exposure variables complicates the interpretation of associations between the 5 EDC classes and birth weight when using traditional multi-variable linear methods. However, BHLM examines the average effect of EDC exposure on birth weight at the class level using the parameter μariation . A seconβ and σβ. We used priors following recommendations of a recent study of vague priors for random effects models [There were several limitations to the study. First, the BHLM model did not account for interactions between classes, and we assumed that all chemicals within a class share a similar mode of action and arise from a common prior distribution. Second, the model also excluded non-linear relationships, including potential threshold effects that could yield important information about the relationships between EDC exposure and birth weight. Third, BHLM results are sensitive to the assigned prior distributions of hyperparameters μs models . BHLM, bs models . To redus models . Fifth, s models  and semis models . Lastly,This paper introduces BHLM as a method for tackling multiple correlated exposures in relation to health outcomes and compared this method with LASSO and Elastic Net. LASSO and Elastic Net regression coefficients were larger in size but with less precise 95% intervals compared to BHLM. BHLM uses shrinkage estimation to bias the regression coefficient estimates towards the group mean parameter. Statistical theory demonstrates that the estimators have smaller mean squared error than ordinary least squares estimators . BHLM al


Subjects with metabolic syndrome (MetS) exhibit impaired lipoprotein metabolism and have an increased risk of cardiovascular disease. Although the risk is attributed primarily to the risk associated with individual components, it is also likely affected by other associated metabolic defects. Remnants of postprandial lipoproteins show potent atherogenicity in cell and animal models of insulin resistance and in pre-diabetic subjects with postprandial dyslipidemia. However, few studies have considered regulation of chylomicron remnant homeostasis in MetS per se. This study measured the plasma concentration in Caucasian men and women of small dense chylomicrons following fasting and explored associations with metabolic and anthropometric measures.A total of 215 Australian Caucasian participants (median age 62 years) were investigated. Of them, 40 participants were classified as having MetS. Apolipoprotein (apo) B-48, an exclusive marker of chylomicrons, metabolic markers and anthropometric measures were determined following an overnight fast.r = 0.445, P < 0.0005), non-HDL cholesterol  and HDL cholesterol concentration  were weakly associated with apo B-48 concentration. In subjects with MetS, the association of apo B-48 with triglyceride and non-HDL cholesterol was enhanced, but neither were robust markers of elevated apo B-48 in MetS (r = 0.618 and r = 0.595 respectively). There was no association between apo B-48 and HDL cholesterol in subjects with MetS.The fasting apo B-48 concentration was 40 % higher in subjects with MetS than those without MetS. In all subjects, triglyceride (This study demonstrates a substantial accumulation of pro-atherogenic remnants in subjects with MetS. We have shown that in a Caucasian cohort, the fasting plasma concentration of triglyceride or HDL/non-HDL cholesterol serves as poor surrogate markers of atherogenic chylomicron remnants. These findings suggest that subjects with MetS exhibit a chronic defect in chylomicron metabolism that is likely to contribute to their increased CV risk. It is recognised that patients with metabolic syndrome (MetS) are at risk developing CVD –3. IncreA substantial body of evidence supports the contention that hydrolysed remnants of postprandial chylomicrons are highly atherogenic , 5. Apo Subjects with MetS have been found to have greater fasting concentrations of apo B-48 –20. HoweThe metabolic aberrations leading to an accumulation of chylomicron remnants in MetS are unclear, but studies in animal models and insulin resistant subjects suggest exaggerated rates of constituent biosynthesis as a consequence of intestinal hypertrophy ; decreasPlasma triglyceride is commonly utilized as a marker of postprandial lipaemia and indeed fasting levels have been reported to correlate with fasting apo B-48 concentration , 21, 22.Apo B-48 is produced exclusively by absorptive cells of the small intestine and is an obligatory moiety of nascent chylomicrons. In normolipidemic subjects with coronary artery disease and in subjects with familial hypercholesterolemia, apo B-48 is markedly elevated despite otherwise normal levels of plasma triglyceride , 26. TheTwo hundred and fifteen Australians with European ancestry were sampled randomly from a larger cross sectional study investigating the relationship between serum vitamin D, bioactive calcium, parathyroid hormone homeostasis and cognitive performance conducted at our institute in 2011 . An addiAfter having fasted for at least 8 h, prior to fasting blood collection, a range of anthropometric measurements were performed. Body weight was measured after voiding, with participants wearing limited clothing on a digital balance and recorded to the nearest 100 g. Standing height was measured using a portable stadiometer fixed to the wall, without shoes and recorded to the nearest 0.1 cm. Waist circumference and ratio was measured and calculated as described by Norton and Olds . SagittaFasting serum samples were collected by low-speed centrifugation of serum separator Vacutainer™ tubes  that were left to clot for 30 min. All samples were then either analysed immediately or stored at −80 °C prior to analysis. Fasting serum triglyceride, cholesterol and glucose were determined by Pathwest Laboratories using their routine automated procedures on an Architect c1600 analyser. Serum triglyceride, total cholesterol, HDL cholesterol and glucose concentration were measured by using specific enzyme-based colorimetric reagents . LDL cholesterol was estimated by using a modified version of Friedewald formula .Chylomicron concentration was measured by determining apo B-48 concentration. Apo B-48 is the major structural protein for chylomicron assembly and it is not interchangeable . Apo B-4th and 75th interquartile range) if the data was skewed. Data that were not normally distributed were natural log transformed when necessary. Statistical significance was assessed using Independent-samples T test, Mann-Whitney test (between 2 groups) and ANOVA (3 groups or more). Post-hoc comparison between each group was assessed using Bonferroni test. To assess the significant difference in apo B-48 between the MetS and no-MetS group, GLM univariate were used. Spearman correlations were computed to assess the association between parameters. The strength of association between apo B-48 and a range of anthropometric and metabolic determinants adjusted for age and gender were calculated by using Z score derived regression coefficient between apo B-48 and other variables. Regression coefficient denotes the standard deviation change in apoB-48, as a result of 1 standard deviation change in the variable. A p value < 0.05 was considered significant.All data were analysed using SPSS version 21 . The results are all presented in the tables as mean values ± standard error (SE) for normally distributed data and median (25The subject characteristics are shown in Table P < 0.01). The difference between groups remained significant following adjustment for age and gender (Table The median serum apo B-48 concentration for the whole group was 4.8 μg/mL (3.4–7.9) Table . Subjecter Table . In subjr = 0.445, p < 0.0005), non-HDL  and HDL cholesterol concentrations   and total cholesterol . Apo B-48 concentration was also weakly associated with waist circumference and WHR . However no association was observed between apo B-48 and either insulin concentration, or HOMA-IR level in all subjects.The association between fasting apo B-48 and the range of outcome measures was examined in all subjects and also after grouping based on the presence of MetS. When examined on the whole group, apo B-48 concentration was found to correlate with triglyceride (5) Table . Weak cor = 0.618, p < 0.0005), non-HDL  and LDL cholesterol  than those without MetS  in subjects without MetS and 45.1 % (R2 = 0.451) in those with MetS.Since apo B-48 concentration was associated with age, we then assessed the association with correcting for age and gender  compared to control subjects without MetS . InteresIn subjects without MetS, there was a relatively weak correlation of triglyceride with apo B-48, contrasting the result observed in the MetS group. Since triglyceride concentration in plasma is mainly contributed by the triglyceride associated with VLDL particles, the association between apo B-48 and triglyceride concentration suggests a common metabolic defect that is more pronounced in those with MetS, leading to accumulation of these triglyceride-rich lipoproteins. In order to standardise for the magnitude of these parameters we also examined the association between the Z scores of apo B-48 and anthropometric and lipid/metabolic determinants. This allowed us to compare the slope of these relationships when standardised for one standard deviation change in each parameter, and also to correct for age and gender. However the slope of the association of Z-scores for most of these parameters was remarkably low, and although triglyceride had the highest slope for association with apo B-48 in the no MetS group, it had a low coefficient of variation suggesting that triglyceride is a poor surrogate marker of chylomicron remnant homeostasis. In subjects with MetS, the slope of the association of Z scores for apo B-48 with triglyceride and non-HDL cholesterol and the coefficient of variation were increased, nonetheless these measures were still not predictive of chylomicron remnant homeostasis.In subjects with MetS the elevated triglyceride concentration is suggestive of a lipolytic defect. Although not directly measured in this study, subjects with MetS may have decreased expression of LPL as a consequence of insulin resistance . A defecClearance of chylomicron remnants post hydrolysis is a highly efficient process that occurs principally via internalization by LDL receptor and LDL receptor-related protein 1 after remnants were bound to the HSPG of the surface of hepatocytes facilitated by apo E . InsulinNon HDL cholesterol is defined as the cholesterol associated with LDL, VLDL remnants, Lp(a), and chylomicron remnants and as these represent all the lipoproteins currently believed to contribute to atheroma development  this meaSubstantial evidence has indicated that an altered chylomicron metabolism might relate to insulin resistance , 46. OurThe results from this study have extended the findings from previous studies , 21, 22 In summary, our investigation confirms previous reports that fasting apo B-48 concentration is strongly associated with triglyceride concentration. Although we observed that this association was stronger in subjects with MetS there still remains a significant proportion of the variability in apo B-48 that is not predicted by components of MetS. These observations are suggestive of the importance of assessing TRL remnants, in particular chylomicron remnants in subjects with MetS. These findings suggest that subjects with MetS exhibit a lipoprotein metabolic defect the manifestation of which affects the metabolism and clearance of triglyceride-rich lipoproteins likely contributing to increased cardiovascular risk.