ObjectiveFetal growth can be affected by maternal PCOS and may have an impact on offspring and childhood growth. The current findings across studies are divergent and controversial. This study aims to determine whether maternal PCOS can affect the physical measurements of newborns and to establish the differences in birth weight, length, head, and chest circumference between newborns of mothers with polycystic ovarian syndrome and those of mothers without polycystic ovarian syndrome. MethodsIn this study, we examined the gestational age, birth weight, length, head circumference, chest circumference, and ponderal index of 75 infants born to mothers with polycystic ovary syndrome (PCOS) and compared them to those of 94 infants born to mothers without PCOS. Resultth percentile. Significant differences in anthropometric indices like birth weight, head circumference, and Ponderal index were observed in SGA and LGA newborns of normal and PCOS mothers.Compared with the other groups, the PCOS group does not show significant differences in anthropometric indices compared to the control group. Infants born to normal and PCOS mothers birth weight were categorized as SGA  if birth weight was less than the 5th percentile. LGA is large for gestational age if birth weight is greater than the 90th percentile. Other appropriate for gestational age if infant birth weight is between> 5th and < 90ConclusionThe study findings indicate that neonates born to mothers with PCOS have higher rates of SGA and LGA newborns, and differences in anthropometric indices  were observed between SGA and LGA newborns of PCOS mothers.  Polycystic ovarian syndrome (PCOS) is an endocrine disorder affecting globally 5%-10% of women globally -4. A risThrough this study, an effort has been made to shed more light on the typical maternal diseases that influence alterations in different anthropometric measurements of newborns and their clinical correlates. In our study, PCOS was taken into consideration. PCOS is a condition that may affect neonatal health. Therefore, the current study is aimed at determining the influence of anthropometric parameters in newborns with PCOS and normal pregnant mothers in Indian subcontinent regions.A study was carried out on 169 mothers and their live newborn babies between 2018 and 2020 at hospitals located in and around Chennai in the Department of Obstetrics and Gynecology. The study protocol was approved by the institutional ethical board, and written informed consent was obtained from all participants before evaluation.The study participants were divided into two groups. Group I: consists of normal women and their newborn children. Group II: PCOS women and their newborn babies. Group I: Ninety-four healthy women and their newborns were chosen for the study. The women were selected based on their regular menstrual cycles and the absence of clinical signs of hyperandrogenism. Subjects with congenital anomalies, preeclampsia, and hypertension were excluded. Group II: In this study, we focused on a group of 75 women with polycystic ovary syndrome (PCOS) and their newborn babies. The Rotterdam criteria  were utiIn this study, pregnant women were followed up in the same prenatal unit, and data on the duration of gestation, initial body mass index (BMI), BMI in the third trimester, and weight gain during pregnancy were recorded. Following delivery, a pediatrician conducted a physical examination of the newborn, using standard anthropometric methods to measure length, weight, head circumference, and chest circumference. The subjects were considered for the study, irrespective of gestational age.Rohrer’s Ponderal Index is a measure of body size that is calculated by dividing the weight in kilograms of an individual by the cube of their height in meters.Instruments usedThe newborn's birth weight was measured within 12 hours of birth using an electronic balance that had a margin of error of ±10 grams. To measure the crown-heel length, the baby was positioned in a supine position with knees fully extended and soles of feet held against the footboard, while an infantometer was used to record the length to the nearest 0.1 cm. The head circumference was measured by placing a non-elastic tape over the occipital protuberance on the back and supraorbital ridges in front. The chest circumference was measured at the nipple level using the same non-elastic tape. The Ponderal index was calculated.Statistical analysisThe data analysis was performed using SAS , and statistical significance was determined by a p-value less than 0.05. The mean and standard deviation were used to express normally distributed data, while the median and interquartile ranges were used for non-normally distributed data. The normality and student's T-test were used to compare data between normal mothers with polycystic ovary syndrome (PCOS) mothers and their newborns.The Mann-Whitney test was employed to compare differences in large for gestational age (LGA) and small for gestational age (SGA) between normal newborns and those born to mothers with PCOS. Additionally, a correlation analysis was conducted between the normal and PCOS groups for variables such as initial body mass index (BMI) and BMI in the third trimester. The weight and length of the infants were also compared between the PCOS and normal groups. Furthermore, correlations were observed between gestational age in weeks and head circumference, chest circumference, and Ponderal index for both PCOS and normal groups.Table Table According to the data presented in Table Table Table Table In this study, the incidence of both SGA and LGA newborns was higher in PCOS mothers. Statistically significant higher birth weight, head circumference, and Ponderal index were observed in SGA and LGA newborns of PCOS mothers when compared to newborns of control mothers. The weight and weight gain in the third trimester were statistically significantly higher between PCOS and control women.In a study by Melo , he obseAccording to another study conducted in Sweden , mothersIn contrast, recent data illustrates that no association exists between small for gestational age (SGA) or large for gestational age (LGA) newborns and PCOS . HoweverHowever, the Danish cohort study found no difference in birth weight, Ponderal index, or abdominal circumference between control offspring and PCOS-offspring adjusted for maternal age, BMI, gestational age, and sex, which is also consistent with our study . The offThe increased head circumference and weight of the infant at birth were observed and compared with controls in a porcine model of intrauterine growth restriction ,18.Head circumference at a younger age is strongly correlated with brain volume, and at a population level, a larger brain is associated both with autism spectrum disorder and better cognitive function ,20. HeadTherefore, it may be beneficial for these individuals to receive timely interventions, such as dietary and exercise-based therapies, as an adjunct to their treatment .Fetal development is a critical period of physical development that begins at conception and ends at birth . During The primary constraints of the research revolve around the relatively small participant pool and the suboptimal response rate among those who were invited to participate. Despite the fact that the current sample size yielded statistically significant findings in the parameters under consideration, a larger number of participants would have provided a more definitive and precise depiction of the results. Another limitation encountered in this study was the inability to conduct a comparative analysis of cognitive assessments between children born to mothers with normal conditions and those with polycystic ovary syndrome (PCOS). Notably, there exists the possibility that certain children with low-to-borderline intellectual capabilities were not accounted for in the follow-up due to the overwhelming challenges experienced by both these children and their families.Therefore, it is important for expectant mothers to take care of their health and well-being during pregnancy to ensure the best possible outcomes for their offspring. This can include maintaining a healthy diet, avoiding exposure to harmful substances, and seeking medical care when needed.The study findings indicate that neonates born to mothers with PCOS have a higher combined incidence of both SGA and LGA newborns. Moreover, a notable statistically significant higher value was observed in head circumference and Ponderal index among babies born to SGA and LGA newborns of PCOS mothers when compared to those born to normal mothers. These observations suggest that the PCOS phenotype is expressed during the neonatal period, and the impact of PCOS is unable to be evident at the clinical level in the early stages of life.


Preterm birth is a leading cause of death in children under the age of five. The risk of preterm birth is increased by maternal HIV infection as well as by certain antiretroviral regimens, leading to a disproportionate burden on low- and medium-income settings where HIV is most prevalent. Despite decades of research, the mechanisms underlying spontaneous preterm birth, particularly in resource limited areas with high HIV infection rates, are still poorly understood and accurate prediction and therapeutic intervention remain elusive.Metabolomics was utilized to identify profiles of preterm birth among pregnant women living with HIV on two different antiretroviral therapy (ART) regimens.This pilot study comprised 100 mother-infant dyads prior to antiretroviral initiation, on zidovudine monotherapy or on protease inhibitor-based antiretroviral therapy. Pregnancies that resulted in preterm births were matched 1:1 with controls by gestational age at time of sample collection. Maternal plasma and blood spots at 23–35 weeks gestation and infant dried blood spots at birth, were assayed using an untargeted metabolomics method. Linear regression and random forests classification models were used to identify shared and treatment-specific markers of preterm birth.N-acetyl-1-methylhistidine were found to be significantly altered in a treatment-specific context.Classification models for preterm birth achieved accuracies of 95.5%, 95.7%, and 80.7% in the untreated, zidovudine monotherapy, and protease inhibitor-based treatment groups, respectively. Urate, methionine sulfone, cortisone, and 17α-hydroxypregnanolone glucuronide were identified as shared markers of preterm birth. Other compounds including hippurate and This study identified previously known as well as novel metabolomic features of preterm birth in pregnant women living with HIV. Validation of these models in a larger, independent cohort is necessary to ascertain whether they can be utilized to predict preterm birth during a stage of gestation that allows for therapeutic intervention or more effective resource allocation.The online version contains supplementary material available at 10.1007/s11306-023-02055-1. Prematurity or preterm birth (PTB) is defined as birth before 37 weeks of gestation and is the leading cause of death in children under the age of five. An estimated 15 million infants are born preterm and approximately one million children die of complications of PTB annually  and transferred to Whatman 903 Protein Saver Cards. Cards were then air dried for at least four hours and then placed into gas impermeable bags with a desiccant pack and humidity card for long-term storage at − 80 °C. Following DBS preparation, the remaining blood volume was centrifuged at 400×Samples were processed by Metabolon Inc. according to published methods with modifications as described for DBS samples . There were a median of 0 and 2 samples with missing values for plasma and DBS analytes, respectively. All values were then log-transformed and standardized using a Z-transform.Principal components analysis (PCA) was performed to visualize separation by PTB across the overall metabolite profiles. Permutational multivariate analysis of variance (PERMANOVA) with Euclidean distances, was used to assess PTB, antiretroviral regimen, country of origin, and gestational age at sample as predictors. Linear regression models were built separately with each standardized metabolite value as an outcome using an interaction model with antiretroviral regimen and preterm birth (as assessed by obstetric estimate) as covariates. A sensitivity analysis was also performed with preterm birth defined via newborn examination. Linear regression results were summarized as estimated marginal means.Random forests classification models were constructed separately for each drug regimen to predict PTB. Based on our prior comparison of DBS and plasma sampling for metabolomics  , and infant DBS from 100 mother-infant dyads who were either enrolled but yet to be treated (untreated), on ZDV, or on protease inhibitor-based antiretroviral therapy (PI-ART). A strong batch effect was observed among maternal DBS samples from a single study site (see Supplementary Results in Online Resource 1) and therefore the decision was made to exclude these 21 maternal DBS samples, but not their corresponding plasma samples, from all further analyses. Three additional dyads were excluded as they were exposed to other drug regimens during the course of pregnancy. The remaining participants were used for all subsequent analyses of maternal plasma  of maternal metabolite profiles revealed weak but statistically significant segregation by PTB, antiretroviral regimen, and country of origin Fig. B. A sensTo better characterize regimen-specific signatures of PTB, we next constructed random forests classification models separately for each treatment group. Multi-omics models utilizing both maternal plasma and DBS data achieved accuracies of 95.5%, 95.7%, and 80.7% in the untreated, ZDV monotherapy, and PI-ART groups, respectively , likely due to contributions from infant metabolism. Therefore, we focused our analysis on a subset of n = 56 infants who were sampled within the first 3 days of life . Even though this analysis was performed only on infants within the first 3 days of life, the infant’s age in days still explained 3.7% of the overall variation, suggesting that the infant metabolome changes rapidly after delivery. Linear regression did not identify any significantly altered compounds in either the ZDV monotherapy or PI-ART treatment arms, nor among all preterm infants as a whole . Although classification models for preterm birth are not particularly insightful in this context, we still utilized this approach as an alternative means of feature selection Fig. B. In theWe applied an untargeted metabolomics approach to characterize metabolic signatures of preterm birth in a cohort of 100 WLH prior to treatment and on two different treatment regimens. Linear regression and random forests classification models revealed both shared and regimen-specific markers of PTB.Plasma N-acetyl-1-methylhistidine and urate were significantly increased in untreated women who delivered preterm and to a lesser extent in the preterm groups of the two other groups. N-acetyl-1-methylhistidine is a known marker of chronic kidney disease, and reduced kidney function has been associated with pregnancy complications including PTB  with different underlying assumptions gives additional confidence to the markers identified by both. Finally, by focusing on the most robust set of features, we can more easily infer biological plausibility and translation to intervention as opposed to a larger panel of hundreds of markers.A major limitation of this pilot study is the lack of data regarding the circumstances of PTB; notably, it is possible that some of the preterm births in this study were iatrogenic as opposed to spontaneous. Such cases, as well as other confounders such as diet and socioeconomic status, could introduce additional variation and limit the power of an already small sample size to detect robust markers of sPTB. Additionally, this sample size is also based on even matching between cases and controls, which does not reflect the true population distribution and therefore could lead to excessive sensitivity to preterm deliveries. Furthermore, the small sample size and large number of classifiers built in this study are susceptible to overfitting. It will be vitally important to test these preliminary findings in an independent validation cohort, and such efforts are underway. The dynamic, complex, and dramatic physiological changes associated with pregnancy also complicate our ability to detect robust signals from a cross-sectional study design. Rather, it may be necessary to characterize signatures of preterm birth as differences in metabolic trajectories over the course of pregnancy. Such a design would also obviate the need to identify the correct timing window during gestation at which the signature of preterm birth is most robust while also weighing the potential for earlier intervention. All participants in this study were on ZDV-based regimens, except a single PI-ART participant; therefore, the changes identified in the PI-ART group may reflect exposure to any component of the regimen. However, given the increased incidence of PTB with protease inhibitors as well as the known effects on progesterone metabolism, we believe these reflect true metabolic alterations in pregnant women on PI-based ART. Finally, the samples used in this study were collected during a period when ZDV monotherapy and PI-ART was still in use. While protease-inhibitor based regimens have been replaced by newer antiretroviral regimens, the association of PI-based ART with an increased rate of preterm birth allows the use of the antiretroviral agent as a probe to better understand unique and/or additional metabolic derangements associated with PTB. Understanding the potential interaction between these regimens, newer antiretroviral regimens, and PTB will be important for translation to clinical practice.Caveats aside, our preliminary study provides a number of valuable insights into potential mechanisms underlying spontaneous PTB in a complex, high-risk population. Several of the metabolites identified as markers of PTB here have been previously implicated in other cohorts but studies to better understand the mechanisms and pathways behind their modulation are needed. Potential links to the gut microbiota vis-à-vis hippurate co-metabolism and to protease inhibitor-associated disruption of progesterone availability also warrant further investigation. Finally, our findings provide a proof of concept for the use of untargeted metabolomics as a tool for hypothesis generation and biomarker discovery in complex disease processes.Supplementary file1 (DOCX 954 KB)Supplementary file2 (DOCX 1469 KB)Supplementary file3Supplementary Table 1. Demographics of the mother-infant dyads used for analysis of maternal DBS samples. P-values are derived from χ2 and one-way ANOVA tests for categorical and continuous variables, respectively.Supplementary Table 2. PERMANOVA results for maternal plasma, maternal DBS, and infant DBS metabolite profiles.Supplementary Table 3. Linear regression analysis for maternal plasma metabolites stratified by treatment group.Supplementary Table 4. Linear regression analysis for maternal plasma metabolites averaged across treatment groups.Supplementary Table 5. Linear regression analysis for maternal DBS metabolites stratified by treatment group.Supplementary Table 6. Linear regression analysis for maternal DBS metabolites averaged across treatment groups.Supplementary Table 7. Elastic net regression analysis for maternal plasma and DBS profiles.Supplementary Table 8. Features selected in random forests models of preterm birth using data from both maternal plasma and DBS profiles.Supplementary Table 9. Features selected in random forests models of preterm birth from maternal plasma profiles.Supplementary Table 10. Features selected in random forests models of preterm birth from maternal DBS profiles.Supplementary Table 11. Linear regression analysis for infant DBS metabolites stratified by treatment group.Supplementary Table 12. Linear regression analysis for infant DBS metabolites averaged across treatment groups.Supplementary Table 13. Features selected in random forests models of preterm birth from infant DBS profiles. (XLSX 1298 KB)Supplementary file4 (DOCX 76 KB)Below is the link to the electronic supplementary material.


A prolonged active stage of labour leads to complications and adverse effects for both mother and newborn, and among of it causes is a horizontal birth position, which accounts for 91.4% to 99.7% of all vaginal births in Tanzania. The study purpose is to determine the effect of the upright birth position on reducing the duration of the second stage of labour, perineal tear, maternal birth satisfaction, and apgar score among women delivering in government hospitals in Dar es Salaam-Tanzania.t test and one-way MANOVA will be used to compare the effects of intervention between the experimental and control, and a P value of < .05 will be regarded as a statistically significant difference.This will be a randomized controlled trial that will include 116 participants in experimental and 116 participants in the control group. A simple random sampling will be used to select 4 out 6 hospitals with adjustable beds in Dar es Salaam. In each hospital, participants will be randomly allocated to an either experimental group or control group whereby, the experimental group will be directed and helped to assume an upright birth position during the second stage of labour while the control group will be allowed to assume the horizontal position. Data will be analysed using SPSS version 28. An independent The study is important in improving the birth outcome while putting a high consideration to the mothers’ birth satisfaction. In Tanzania, maternal mortality is 524 per 100,000 live births.,3 Most maternal morbidity and mortality are caused by postpartum haemorrhage, sepsis, unsafe abortion, pre-eclampsia, eclampsia, and obstructed labour.–6 Obstructed labour is said to result in prolonged labour, which occurs when the active phase of labour is longer than 12 hours. About 8.5% to 21.7% of women giving birth are affected by a prolonged active phase of labour, and the incidence is 2 to 3 times higher among primipara compared to multipara.–9 The prevalence of prolonged labour in Tanzania is 27.1%.Maternal morbidity and mortality remain a big global health challenge. The report shows in 2017, 295,000 women died from preventable maternal deaths and 94% of these deaths occurred in low resources countries whereby Sub Saharan African countries contributed 66%,.–13 Reports in Nigeria showed that prolonged labour leads to 80.97% caesarean section, 14% laparotomy, 4.9 % destructive operations, 16.5% sepsis, 13% ruptured uterus, 7.81% puerperal sepsis, 3.9% postpartum haemorrhage, 0.98% maternal mortality, 28.8%, low apgar score (<7), and 35.15% perinatal mortality. In Ethiopia, 38.05% sepsis, 38.08% stillbirth, 35.4% postpartum haemorrhage, 29.8% ruptured uterus 29.8%, and maternal 17.27% mortality. Furthermore, in Tanzania prolonged labour causes 94% caesarean section 3.5% vacuum delivery, 9 % postpartum haemorrhage, 16% low apgar score, and 8.8% stillbirth.The prolonged active stage of labour can lead to complications and adverse effects for both mother and newborn, it is associated with postpartum haemorrhage, ruptured uterus, puerperal sepsis, urine incontinence, episiotomy, and perineal tear, assisted vaginal delivery, and caesarean section. In newborn, it can cause birth injuries, low apgar score, and admission to the intensive care unit. The passenger factors like malposition, congenital anomalies, and big size compared to maternal pelvic size ,,18 and the inadequate uterine contractions that cannot produce power enough to push the baby through the birth canal causes the prolongation of the second stage of labour. The horizontal birth position is also linked to a prolonged second stage of labour as it limits pelvic outlet diameter by restricting coccyx movement, sacrum flexibility, and widening of the pubis symphysis.–25 Even though the horizontal birth position is among the causes of prolonged labour, it is the most practiced birth position in Tanzania, and it counts for 91.4% to 99.7% of all vaginal births.,26The prolonged second stage labour is caused by problems with, the passenger, birth canal, uterine contraction, psychological state of the mother, and maternal birth position.–29 Furthermore, she has adopted world health organization recommendations such as augmentation of labour, and the use of patograph in monitoring labour. Despite these efforts, still, the incidences of prolonged labour have remained quite higher, therefore the purpose of this study is to determine the effect of the upright birth position on reducing the duration of the second stage of labour, perineal tear, maternal birth satisfaction, and apgar score of neonates among women delivering in government hospitals in Dar es Salaam.To prevent incidences of prolonged labour and its associated complications, Tanzania has done several efforts including increasing birth coverage by skilled birth attendants by employing and training medical staff, ensuring the availability of adequate supplies and equipment required during labour and delivery, introducing free of charge labour and delivery services, formulation of guidelines for obstetric care, as well as introducing of maternal and perinatal death surveillance response program.This study is aimed to determine the effectiveness of the upright birth position on reducing the duration of the second stage of labor, perineal tear, maternal birth satisfaction, and apgar score of neonates among women delivering in government hospitals in Dar es Salaam, Tanzania.This study will be conducted in the selected government hospitals, of secondary and tertiary levels in Dar es Salaam. According to the ministry of health in 2022, Dar es Salaam has a total number of 1199 of operating healthcare facilities, among them, 210 are owned by the government, of which there are 155 dispensaries, 32 health centres, 18 hospitals, and 5 laboratories and clinics . This study will be conducted in hospitals with adjustable beds, among the 18 hospitals, only 6 have the adjustable beds.A randomized controlled trial will be used. There will be 2 groups in this study, the experimental and the control group. The participants will be randomly allocated to an either experimental group or control group. The experimental group will be directed and helped to assume an upright birth position during the second stage of labour while the control group will be in the horizontal position. The birth outcomes which are the duration of the second stage of labour, perineal tear, maternal birth satisfaction, and apgar score will be compared between the experimental group and the control group as shown in “Figure The study population will be all pregnant women who will be delivering in the government hospitals where this study will be carried out. To be included as a participant in this study, the following criteria should be met: term pregnancy, age between 20 and 35 years, singleton pregnancy, cephalic presentation, vaginal delivery is not contraindicated, spontaneous labour, nulliparous, multiparous, no history of any previous uterine surgery, mentally fit, in the latent phase of the first stage of labour, no surgical indication at the time of study beginning, stature ≥150 cm. The woman will be considered ineligible to participate in this study if she has either of the following characteristics: pregnancy complicated with anaemia, pregnancy-induced hypertension, diabetes, and foetal congenital malformations, grand parity (para 5 or more), history of previous assisted vaginal delivery, have more than 5 years from the last delivery, and who will refuse to participate. Proportion to reach the desired minimum sample size has been adopted from a previous scholar, who did a study on the effect of flexible sacrum position on maternal and neonatal outcomes in public health facilities in Ethiopia who found that the proportion of the short duration of labour was 84.4% and 95.9% in control and experimental groups respectively.The minimum sample size for this study will be determined using the following formula as suggested by previous studies when researchers conduct on the sample size estimation for the clinical trials.1 = the proportion of shortened duration of the second stage of labour in horizontal position 84.4 adopted from 31, P2 = The proportion of shortened duration of the second stage of labour in upright birth position 95.9 31, P = Effect size (P2 + P1)/2 = (95.9 + 84.4.)/2 = 90.15, Q = 100 – P = 100–90.15 = 9.85%, d = effect size, P2–P1 = 95.9–84.4 = 11.5%, whereas n = the Minimum sample size of the study, PA proportionate sampling will be used to allocate number of the study participants for each healthcare facility depending on the number of deliveries per month. In each healthcare facility, a randomization will be conducted to assign participants to either experimental or control group in the ratio of 1:1.The intervention will be divided into 3 phases;In this phase the study participants will be oriented to different upright birth positions. While still in the latent phase of the first stage of labour, a researcher or research assistant will teach the participants about the upright birth positions. The client centered approach will be used whereby every participant will be taught individually about the upright birth position based on meaning, types, advantages, and how to assume a different upright position. This phase will be divided into 3 parts which are, the introduction, main body, and revision.The first part will be an introductory part which will take 3 minutes; in this part, a researcher will ask the participant what she knows about the upright birth position. The researcher will have a paper where the question is written. The second part is the main body, this section will take 15 minutes. In this part with aid of printed pictures of a woman delivering different upright birth positions. The researcher will teach respondents the advantages and assist them in how to assume the positions.In the squatting position, while standing on the delivery bed with both legs apart and knees flexed, the client will hold metals on the left and right sides of the delivery bed and the trunk will be kept straight upward however she may lean forward or backward to increase flexibility.For the kneeling position participant will be told to kneel on the delivery bed then she will lean forward and supports herself on the palms of her hands. Also, the client will be taught that when she will feel the urge to push, she will do so while keeping the upright birth position under the assistance of the researcher, however she can assume any other position between contractions. In hands knees position, each participant will be taught and assisted to assume the on all 4 positions during the second stage, when there is no contraction participant will be allowed to rest in any position and the process will be repeated until the baby delivered.Third part, this will be is revision part, it will take 3 minutes. In this part the respondent will be asked to tell the importance of the upright birth position and practice by assuming either of the upright birth position that she will feel to elaborate. This will be the last part of orientation phase, then mother will wait until the second stage of labour reaches. The second stage of labour will be defined as the period from the time of full cervical dilatation to delivery of baby.As the participant reach the second stage of labour, the researcher will record the time and then will encourages and assist mother to assume either any upright birth position when she feels urge to push during contraction until delivery of the baby. Between contractions respondent be allowed to rest in any comfortable position, however during pushing she will return to upright position which she chosen.Throughout the second stage, maternal vital signs, labour progress, and fetal heart rate will be monitored. Fetal heart rate, uterine contraction and maternal vitals will be monitored at interval of fifteen minutes, thirty minutes and an hour respectively. In case during the study any condition that will need emergence intervention such as fetal distress, obstructed labour, prolonged labour, and cord prolapse, arise the condition will be managed according to the hospital protocol. Augmentation by oxytocin, assisted vaginal delivery by low vacuum extraction and episiotomy will be performed only if a necessary indication to do it. For either of the circumstance above, the participant will be excluded from the study however she will be reported.This will be the assessment part. Immediately after the delivery, the delivery time will be recorded, the newborn will be scored according to apgar score in the first and fifth minutes. Then the active management of third stage of labour will be done according to hospital protocol. The perineum will be inspected to rule out perineal tear, in case there will be perineal tear, it will be classified according to ACOG then repaired, the amount of blood loss will be quantified for estimation. Finally, the outcomes will be recorded. For the newborn, the outcomes will include apgar score in first and fifth minutes, admission in intensive care unit, and early neonatal death. The maternal outcome will include the duration of the second stage of labour, perineal tear, and maternal satisfaction.The researcher will monitor the progress of labour while client is in the horizontal position, as the client reaches the second stage of labour, time will be recorded and mother will be assisted to deliver in the horizontal position. Fetal heart rate, labour progress, and maternal conditions will be monitored. And in case, any condition that need emergence intervention arise it will be managed as per hospital protocol. For those who will deliver successfully vaginally, upon completion of the second stage of labour, the newborn will be scored according to the apgar score in the first and fifth minutes post-delivery. Then the third stage of labour will be managed, the perineum will be assessed to rule out a perineal tear and in case there will be a sustained perineal tear, it will be classified according to ACCOG. Outcomes under the study will be recorded. For the newborn, the outcomes will include apgar score in first and fifth minutes, and for maternal, the outcome will include the duration of the second stage of labour, perineal tear, and maternal satisfactionThe dependent variables in this study will includes;Maternal outcome: In this study maternal outcomes will include, duration of the second stage of labour, perineal tear, and maternal satisfaction.The duration of the second stage of labour will be measured in minutes by using a patograph. Duration of the second stage of labour will be categorized into 4 groups, <15 minutes, 15 to 30 minutes, 31 to 60 minutes, 61 to 90 minutes, 91 to 120 minutes, 121 to 180 minutes, and ≥ 181 minutes. In prime gravida the mean duration of the second stage of labour within 3 hours will be considered normal, however, any second stage of labour that will extend beyond 3 hours will be prolonged second stage of labour. Conversely, in multipara participants the mean duration of the second stage of labour within 2 hours will be normal while beyond 2 hours will be prolonged second stage.Perineal tear will be measured by the presence of laceration in the perineum, vagina, anal mucosal and sphincters. The absence of a tear will be termed as intact perineum, in case there will be a tear, it will be classified into degrees according to the world health organization standardized obstetric diagnostic code (ICD-10 Version:2019). First degree tear is the laceration of the superficial vaginal mucosa with or without the perineal skin. In the second degree, the laceration involves the vaginal mucosa and the perineal body. The third degree tear, the laceration involves the vaginal mucosa, perineal skin and the anal sphincter. In fourth degree perineal tear the laceration involves third degree tear plus rectal mucosa.Satisfaction. The satisfaction will be measured by 2 items using a Likert scale. participant in each group will be asked 2 questions each question will have 5 possible options; the first question will ask the patient level of satisfaction on birth position she used during this study and second question will ask about the birth position of participant would choose to assume during child birth in consecutive pregnancies. The options will be scored from 1 to 5, the highest score will be 5 and will imply highest satisfaction, .Obstetric characteristics: This variable will be measured by using 9 items  of the University of Dodoma. Then permission to conducting this study in hospitals will be obtained from regional medical officer and from the managing director. Before recruitment in the study the informed consent shall be obtained from the participants after being well informed about the purpose of the study, how it shall be conducted, anticipated impacts and all alternatives. During the study, participants will have freedom to withdraw from the study at any time. To ensure privacy, no information that reveals participant identity will be included instead all participants will be assigned numbers for anonymity. Furthermore, confidentiality will be ensured by keeping information obtained from the participant safely.The study is expected to be conducted for a period of 3 months, and on the day of submission, the status is completion of the proposal development.The strength of this study is the use of a randomized controlled trial, which is the most rigorous design of determining the cause-effect relationship for the purpose of assessing cost effectiveness of the intervention. To the best of the authors’ knowledge, this will be the first study in Tanzania. Hence, the findings from this research will help to determine the feasibility of the intervention in our local setting. But also, will lay a foundation for the other researchers to do researches on the effects of the upright birth position on the other maternal and neonatal outcomes. The limitations of this study will be the availability of midwives who are competent in assisting a woman to deliver in upright position, as majority in our settings are not used to this position. To overcome this, there will be a 1 training to all midwives from the hospitals where this research will be conducted.We acknowledge the University of Dodoma for educational support which resulted to the production of this protocol.Conceptualization: Sospeter Mkangi.Methodology: Sospeter Mkangi, Rehema Bakari, Saada A. Seif.Supervision: Saada A. Seif.Writing – original draft: Sospeter Mkangi, Saada A. Seif.Writing – review & editing: Rehema Bakari, Aisha Tambwe.In section 3, Independent Variables was mislabelled as 3.7 and has been corrected to 3.6.1. Subsequent sections have been renumbered correctly.


The lungs are considered the second-most frequent location for hydatid cyst in human. The current retrospective hospital-based study aimed to assess the epidemiological data, clinical presentation, and treatment outcomes of lung hydatid cyst in patients who underwent surgery for this disease in Fars province, southern Iran.In this retrospective study, hospital records of 224 pulmonary hydatid cyst patients were assessed in two main university-affiliated hospitals in Fars Province, southern Iran. Clinical features of patients, epidemiological data, cyst features, surgical interventions, and treatment outcomes were reviewed and analyzed.2 . Regarding the surgical method, 86 (38.6%) cases were operated by lung resection surgery while 137 (61.4%) cases had lung preserving one. The chief complaints of the patients were cough (55.4%) and dyspnea (32.6%). Relapse was documented in 25 (11.16%) of cases.A total of 224 hydatid cyst cases of the lung were reviewed. Male patients accounted for the majority of cases (60.4%). The average age of the patients was 31.13 (± 19.6), ranging from 2 to 94 years old. Of the 224 patients, 145 (75.9%) cases had only one single cyst and mostly 110 (53.9%) located in the right lung. Also, 6 (2.9%) cases had cysts in both lungs. The lower lobe of the lungs was the most common location of the hydatid cyst. The average size of lung hydatid cyst was 7.37 cm  while for the cyst areas was 42.87cmLung hydatid cyst is a common infection in southern Iran. Lung preserving surgery is the method of choice for the management of hydatid cyst. Relapse, which was not uncommon in our study, is a challenging feature of hydatid cyst management. Echinococcus granulosus, is a zoonotic helminthic disease that imposes considerable economic losses and is a major public health problem in many countries around the world. CE is endemic in the entire Mediterranean zone, including all countries from the Middle East [E. granulosus oncosphere becomes trapped in an arterial capillary of the lung, the larva develops silently during few years and transforms into a hydatid cyst [E. granulosus embryos are trapped in the liver, smaller embryos may pass over the hepatic sinusoids and, through the right heart, settle in the lungs. Transdiaphragmatic spreading due to transdiaphragmatic rupture of liver hydatid cyst is considered as the second way of lung infection. The later approach may explain the simultaneous involvement of the liver and lungs with a hydatid cyst [Cystic echinococcosis (CE) or hydatid cyst, caused by the larval stage of dle East . Humans tid cyst . Althougtid cyst . PulmonaClinical presentation of lung hydatid cysts depends on whether the cyst is ruptured or intact. In the majority of cases, asymptomatic or intact hydatid cysts are detected incidentally during chest X-ray; nevertheless, large cysts may cause symptoms in patients due to the compression of organs adjacent to the lesion. Cough is the main symptom in the majority of pulmonary hydatid cysts cases. In a study by Darwish et al. on 206 patients with pulmonary hydatid cyst, the cough was reported in 54% of cases [Large pulmonary hydatid cysts can result in complications and increased morbidity . As lungHydatid cysts are usually detected as multiple circumscribed oval or solitary masses in radiological imaging . PneumotThe optimal choice for treating lung hydatid cyst of any size is considered to be surgery. Regarding giant pulmonary hydatid cysts, some surgeons prefer pneumonectomy or lobectomy , 19 whilHydatid cyst is a major health problem in Iran where about 1% of all surgeries in hospitals are due to this relatively neglected disease –29. The This study was conducted in Shiraz, the capital of Fars Province in southern Iran Fig. . The popThe hospital medical records of all patients were carefully reviewed by members of our team which included both medical students and physicians. The demographic and clinical data existing in the patients’ records including age, sex, place of residence, cyst features , sign and symptoms, duration of hospitalization, treatment modalities, surgical procedures, the outcome of treatment, and history of relapse and other hydatid cyst relevant data were recorded. In our study, for measuring the area of the cyst, the square centimeters of the area of cysts was calculated using the area of the oval/circle formula; which was the smallest radius  multiplied by largest radius  by Pi (3.14) which was used for all imaging modalities.P < 0.05.Collected data were analyzed, using SPSS software, version 28 for Windows (SPSS Inc.). The data were checked regarding their normal distribution with the Komarov-Shapiro test, and parametric data were reported as mean and standard deviation (SD), while non-parametric data were reported as median and quartiles. Demographic and clinical data of patients were tabulated. Statistical analyses were performed, using the Chi-square test for independence or categorical dependent variables. Significance level was set at A total of 224 hydatid cyst cases of the lung were reviewed in this retrospective study. The majority of cases (60.4%) were male. The patients’ age ranged from 2 to 94 years old with a mean age of 31.13 (± 19.6) years. Figure The frequency of cysts based on the involving lobe of the lung is shown in Fig. Among the 224 reviewed records, the incidence of hydatid cyst relapse was documented in 25 (11.16%) cases in which 21 (7.6%) patients had 2 times, 3 (1%) patients had 3 times, and 1 patient (0.4%) had the experience of 4 times relapse.Among the total cases of lung hydatid cyst, 145 (75.9%) cases had only one single cyst, and mostly 110 53.9%) were located in the right lung. Also, 6 2.9%) cases had cysts in both lungs. The right lower lobe was the most common location of the cyst in the right lung while the left lower lobe was the most common location of the cyst in the left lung . Coinfection was recorded in 16 cases of hydatid cyst, 3 (1.3%) of them was due to fungal infections.The size of lung hydatid cyst varied between 2 and 24 cm  and the cyst areas varied between 2 till 488 cmConsidering the lung hydatid cyst imaging, 126 out of 127 (99.2%) CT scans reported lung hydatid cyst. Also, 42 out of 51 (82.4%) sonographies reported positive in lung hydatid cyst, 25 out of 27 (11.2%) chest X-ray reported positive hydatid cyst of the lung.Regarding the surgical method, 86 (38.6%) cases were operated by lung resection surgery while 137 (61.4%) cases underwent lung preserving (cystectomy and cavity management) surgery. Furthermore, in 90 40.2%) of cases evacuation of hydatid cyst, 24 (10.7%) excision, 26 (11.6%) resection, 18 (8%) laparotomy, 10 (4.5%) drain insertion, 30 (13.4%) unroofing of hydatid cyst have been performed  had cough, 73 (32.6%) had dyspnea, 58 (25.9%) had related pain to location of cyst, 58 (29.4%) had fever, 23 (10.3%) had hemoptysis, 17 (8.7%) had chills, 8 (3.6%) had nausea/ vomiting, 4 had weight loss (1.8%), and 3 (1.3%) had anorexia.The most frequent medications administered for patients were third generation cephalosporins (Ceftriaxone), which was prescribed for 203 (72.8%) cases. Furthermore, Lincosamides (Clindamycin) were prescribed for 213 (76.3%) patients, antihelmetic (Albendazole) for 170 (60.9%) patients, Mebendazol in 3 (1.1%), Metronidzaole for 59 (21.1%), Fluroquinolones (Ciprofloxacin) for 75 (26.9%), first generation cephalosporins  for 27 (9.7%) cases and carbapenems (Meropenem) in 6 (2.2%) patient. Aminoglycosides in 7 (2.5%), Macrolides in 2 (0.7%), and Glycopeptides in 10 (3.6%) cases were administered.Based on the laboratory findings of the patients, considering the white blood cell count (WBC), 113 of cases had leukocytosis, 9 had eosinophilia, 31 had neutrophilia, 36 had lymphopenia, and 6 cases had monocytopenia.P value = 0.749).Based on the type of surgery and the relapse of hydatid cyst among cases, 16 (53.3%) were reported among lung preserving surgery methods while 14 (46.7%) were among lung resection surgery. Also, regarding the post-op hospital stay duration, there was no significant difference among the two groups  and also cyst in the both lungs (P = 0.014) had a significant association with relapse.Based on the rehospitalization records of our patients, in which male gender  is a more common treatment for hydatid cyst and this has been the main approach for the management of the lung hydatid cyst. In a surgery report of hydatid cyst in pediatric patients, Cangir et al. recommended avoiding lung resection surgery in children , which fRegarding gender, in line with other studies , 46, 47 It has been reported that the hydatid cyst of the lung is more common than the liver in the children , 7, 8. MWith their special clinical characteristics, cysts with a large diameter are called giant hydatid cysts. In the pediatric group, giant cysts are more prominent because of the greater elasticity of the lungs in children, which enables cyst expansion , 50, 51.The hydatid cyst has been reported to be able to grow anywhere in the lung, however it resides on the right side more frequently than on the left side and has a preference for the lower lobe. While the presence of hydatid cyst in the left lobe was more prominent in some reports , severalIn the current study, most patients (75.9%) had only a single cyst while 6% of cases had more than three cysts. Aytaç et al.  reportedIn few studies, the rate of coexisting hepatic and pulmonary involvement has been reported to be between 7 and 18% , 54, whiA 10 years 1999–2009) retrospective study on human hydatid cysts cases in two main hospitals of Tehran, central Iran, revealed 177 cases, 162 with liver, and 15 cases of lung involvement . Cough w99–2009 rClarification is also required regarding the necessity of postoperative regular albendazole therapy. According a report by Akbulut et al.  regardinIn Bagheri et al. study,  among thAmong the limitations of our study, we can include the retrospective nature and incomplete hospital record documentations of these cases. Also, we only included surgical cases of hydatid cyst, and our report cannot be representative of the total number of pulmonary hydatid cysts in our region. Furthermore, our study lacks long-term follow-up and the possibility of recurrence. Further studies in this regard are warranted to increase our understanding of the exact burden of this disease, along with the most effective measures for management and treatment.Lung hydatid cyst is a common infection in southern Iran. The disease is common in children and male constitutes the majority of cases. The right lower lobe is the most common location of the cyst. Lung preserving surgery is the method of choice for the treatment of hydatid cyst. Relapse, which was not uncommon in our study, is a challenging feature of pulmonary hydatid cyst management.


Neonatal sepsis is a systemic inflammatory response to infection during the first 4 weeks of an infant's life. It is a significant cause of neonatal morbidity and mortality in low‐ and middle‐income countries. This study aimed to determine the predictors of the onset of sepsis at the Neonatal Intensive Care Unit of the Tamale Teaching Hospital, Ghana.A cross‐sectional study was conducted among 275 mothers and their singleton neonates diagnosed clinically with sepsis. A univariate and multivariate logistic regression analysis adjusted for maternal occupational status was performed to determine the maternal and neonatal predictors of early‐onset (EOS) and late‐onset sepsis (LOS), respectively.p = .08) and home delivery  were predictors of EOS, with single motherhood being the predictor for LOS  in a univariate analysis. When maternal occupation was adjusted for in a multivariate analysis, single mother  was the main predictor of EOS, with low neonatal birth weight being the main predictor of LOS .Single motherhood (AOR = 1.882, 95% CI = 0.926−3.822, Maternal marital status is a significant predictor of both EOS and LOS, with predictors of EOS being lower gestational age and low birth weight, while for LOS, low birth weight is the main predictor. Findings from this study can serve as a commencement point for developing predictive models for the onset of sepsis in neonates in the study facility. What is known: Neonatal sepsis is a medical emergency.What is new: Predictors for the identification of early and late‐onset sepsis in a resource‐poor setting have been identified in this study.The clinical implications of this study: Findings from this provide a valuable reference for the early identification of neonatal sepsis to improve clinical outcomes. Also, the findings in this study will serve as a commencement point for developing predictive models for identifying the onset of sepsis in neonates in resource‐poor settings in Sub‐Saharan Africa. Neonatal sepsis is a significant contributor to neonatal morbidity and mortality and according to a World Health Organization (WHO) report, it accounts for 15% of the 2.5 million neonatal deaths worldwide, 98% of which occur in developing nations like Ghana.Reports from many Sub‐Saharan African countries indicate varying prevalence and factors regarding neonatal sepsis.Neonatal sepsis is broadly classified into two categories based on onset time. Early‐onset sepsis (EOS) when the sepsis occurs within the first 7 days of life, and late‐onset sepsis (LOS) if it occurs after 7 days postnatally.In terms of causes associated with the onset of sepsis, conditions such as premature membrane rupture, maternal urinary tract infection, and meconium‐stained amniotic fluid have been associated with EOS's aetiology.Neonatal sepsis presents with nonspecific clinical signs and symptoms, and it is regarded as a medical emergency necessitating empirical treatment with or without laboratory confirmation in resource‐limited settings.22.1The study was conducted at the NICU of the TTH, Ghana. Tamale is the largest city and the only metropolitan area in northern Ghana. The TTH is the only tertiary referral hospital in northern Ghana and serves as a training center for health care institutions in its catchment area. The TTH has eight clinical Departments, including the Pediatrics and Child Health Department, of which the NICU is a subunit. The NICU is a 50‐crib/incubator capacity and a seven‐bed Kangaroo Mother unit with one consultant pediatrician, two medical officers, three pediatric nurses and 37 general nurses, and it provides advanced and specialized health care to neonates.2.2This cross‐sectional study was conducted from January 2020 to June 2021 among mothers and their neonates (≤28 days) admitted to the NICU. All neonates who were clinically diagnosed as having sepsis by the attending clinician using the WHO guidelines for sepsis screening and in collaboration with the definition of septicaemia by the International Pediatric Sepsis Conference2.3A purposive sampling technique was employed to select mothers and their neonates for the study.2.4A self‐designed data collection tool was used to collect maternal sociodemographic data such as age, marital status, educational status, and occupation. Neonatal clinical records such as the onset of sepsis, age on admission, birth weight, gestational age, duration of hospitalization, the axillary temperature on admission and place of delivery were extracted as recorded in the medical records books of mothers/neonates. Neonatal birth weight was classified as low birth weight (<2.5 kg), normal birth weight (2.5−4.0 kg), and high birth weight (>4.0 kg).2.5t‐test and χ2 were used to test for association between study variables where appropriate. A univariate and multivariate logistic regression analysis adjusted for maternal occupational status was performed to determine the maternal and neonatal predictors of early and LOS among neonates. A p‐value of <.05 was set as the significance level for all statistical tests.All complete data were entered into Statistical Package for the Social Science (SPSS) v23  and Microsoft Office Excel, 2019  for data analysis. Continuous variables were presented as means ± standard deviation and categorical variables were presented as frequencies and percentages. Student 33.1In all, 275 mothers with a mean age of 26.5 ± 4.3 years and their singleton neonates participated in the study. Sixty‐eight percent 187/275) of the mothers were within the age group of 20−29 years, 26.2% (72/275) were aged > 29 years and 5.8% (16/275) were aged < 20 years. Most (82.5% [227]) of these mothers were married, with 45.8% (126) having no formal education and 57.8% (159) being self‐employed , =0.14, p = .04). The average gestational age of neonates admitted with EOS (35.4 ± 3.7 days) was significantly higher than those who were admitted with LOS (34.7 ± 5.9 days) . Statistically, there was a significant association between the duration of stay at the unit and the type of sepsis, with neonates admitted with LOS (5.9 ± 9.0 days) spending more days than those admitted with EOS (2.9 ± 2.3 days). Neonates admitted with LOS had a higher mean axillary temperature (37.0 ± 1.6°C) than those admitted with EOS (36.1 ± 3.9°C). A significant proportion of neonates with EOS  and LOS  were born at the TTH. The mean number of conditions clinically diagnosed for all the neonates was 1.5 ± 0.8. Neonates who were admitted with EOS had a statistically significantly lower number of clinical diagnoses conditions  compared with neonates with LOS  were males, and 44.6% (122/275) were females, giving a male‐to‐female ratio of 1.25:1. The majority, 79.3% (218/275) of these neonates, were admitted with EOS, with 20.7% (57) admitted with LOS. The majority, 58.7% (128/218), of the neonates admitted with EOS were delivered with normal birth weight, while 66.7% (38/57) of the neonates who presented with LOS were delivered with normal birth weight. Though marginally, low birth weight was significantly associated with EOS 3.3p = .08), with neonates delivered at home being approximately four times more likely  to be admitted with EOS though this was not stat significant. When maternal occupation was adjusted for in a multivariate analysis, neonates delivered by single mothers were twice as likelier to be admitted with EOS, although marginally significant . Other maternal sociodemographic characteristics and neonatal clinical variables were not significantly associated with EOS (Table Presented in Table p = .14). Unemployed mothers, though marginally significant, were less likely to be associated with LOS . When mothers' occupational status was adjusted for in a multivariate regression analysis, low birth weight, though significant, was less likely to be associated with LOS .Presented in Table 4Neonatal sepsis is a medical emergency. Identifying factors predisposing neonates to this health problem can reduce the disease burden on Ghana's already constrained health care system. This study is the first prospective study to determine predictors of neonatal sepsis at the TTH, with the only previous study being retrospective.In this study, the marital status of mothers, lower gestational age and low birth weight were the main predictors of the onset of neonatal sepsis. These will provide a valuable local reference for the early identification of neonatal sepsis. In this light, this research was conducted to determine predictors of neonatal sepsis at the NICU of the TTH.Conflicting results have been reported in the literature regarding the influence of maternal age on neonatal admissions to NICUs. In Ghana, Siakwa et al.The preponderance of male neonates admitted to the NICU reported by previous studies was corroborated in this study.The association of gestational age with the incidence of EOS noted in this study was congruent with findings by Mukhopadhyay and PuopoloIt is worth noting that neonates delivered at home were at a higher risk of developing sepsis than those born at a health facility, congruent with reports by Shobowale et al.In this study, the mean duration of stay on admission was lower than the earlier mean duration of stay reported by Vaniya et al.The longer stay at NICUs reported by Bulkowstein, Ben‐Shimol5This study allows us to conclude that single motherhood is the main predictor of EOS. Low birth weight though not significant, and unemployed mothers are the main predictors of LOS. The findings from this study can serve as a commencement point for developing predictive models for identifying predictors of EOS and LOS in neonates.Kwame Opare‐Asamoah: Conceptualization; project administration; supervision; writing—original draft. Samuel E Acquah: Data curation; writing—original draft. Ezekial Kofi Vicar: Formal analysis; methodology; writing—review and editing. Lawrence Quaye: Conceptualization; data curation. Abdul‐Mumin Alhassan: Data curation. Saeed F Majeed: Writing—review and editing. Vida Nyagre Yakong: Conceptualization; writing—review and editing. Samuel Yankson: Data curation; writing—review and editing. All authors have read and approved the final version of the manuscript.The authors declare no conflict of interest.The ethical approval for the study was obtained from the Ethical Review Committee (ERC) of the Tamale Teaching Hospital, Tamale, Ghana (TTHERC/25/06/19/03). A thumb‐printed consent to participate was obtained from all mothers/caregivers of neonates.The lead author Kwame Opare‐Asamoah affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned  have been explained.


KRT8) genetic variants were associated with IPF. –/–Krt8 mice were protected from fibrosis and accumulation of the transitional state. Keratin 8 (K8) regulated the expression of macrophage chemokines and macrophage recruitment. Profibrotic macrophages and myofibroblasts promoted the accumulation of transitional AECs, establishing a K8-dependent positive feedback loop driving fibrogenesis. Finally, rare murine transitional AECs were highly senescent and basaloid and may not differentiate into AEC1s, recapitulating the aberrant basaloid state in human IPF. We conclude that transitional AECs induced and were maintained by fibrosis in a K8-dependent manner; in mice, most transitional cells and fibrosis resolved, whereas in human IPF, transitional AECs evolved into an aberrant basaloid state that persisted with progressive fibrosis.Idiopathic pulmonary fibrosis (IPF) is a progressive scarring disease arising from impaired regeneration of the alveolar epithelium after injury. During regeneration, type 2 alveolar epithelial cells (AEC2s) assume a transitional state that upregulates multiple keratins and ultimately differentiate into AEC1s. In IPF, transitional AECs accumulate with ineffectual AEC1 differentiation. However, whether and how transitional cells cause fibrosis, whether keratins regulate transitional cell accumulation and fibrosis, and why transitional AECs and fibrosis resolve in mouse models but accumulate in IPF are unclear. Here, we show that human keratin 8 (  Idiopathic pulmonary fibrosis (IPF) is a disease of aging in which progressive scarring of the lungs leads to death from respiratory failure . Highly Independent, robust lines of investigation have uncovered several pathologic processes activated in epithelial cells that drive fibrosis: senescence, expression of macrophage chemokines, integrin β6–dependent TGF-β activation, impaired proteostasis (endoplasmic reticulum stress), DNA damage, and cell death –25. SeneCldn4, Sfn, and TGF-β pathway genes including integrin β6  cover 98% of the alveolar surface  and mediegrin β6 . We and e causes , 50–56. e causes , 53, rese causes , in conthi transitional cells with ineffectual AEC1 differentiation may be the specific regenerative defect underlying the pathogenesis of human IPF , and organoid mouse models of regeneration and in human IPF (https://doi.org/10.1172/JCI165612DS1)  , 71–73, 5612DS1) , A and BFibrosis is characterized by the accumulation of transitional AECs with ineffectual AEC1 differentiation, suggesting that the critical regenerative defect underlying the pathogenesis of IPF may be persistence of the transitional state –58. HoweAn extensive body of work has established that epithelial cell senescence, impaired proteostasis, cell death, DNA damage, integrin β6–mediated TGF-β activation, and macrophage chemokine expression promote fibrosis –22. HoweKRT7, KRT8, KRT17, KRT18, and KRT19. Only KRT8 was associated with IPF (KRT8 SNPs had high Combined Annotation-Dependent Depletion (CADD) and Regulatory Mendelian Mutation (REMM) scores, which predict disease causality of genetic variants. These results suggest that KRT8 genetic variants may be pathogenic. Therefore, we hypothesized that keratin 8 (K8) promotes the accumulation of transitional cells and fibrosis.To further explore whether transitional cells promote fibrosis and whether keratins play a functional role in the accumulation of transitional cells and fibrogenesis, we interrogated a meta-analysis of 5 human IPF GWAS studies  for variwith IPF . The assKrt8-KO mice as long as Krt8 deficiency did not alter lung development or homeostasis. Adult –/–Krt8 mice appeared to have normal lung structure without inflammation or altered expression of other keratins  AEC1 state , but did attenuate the expression of multiple chemokines , impaired proteostasis, cell death, DNA damage, and integrin β6–mediated TGF-β activation that characterize the transitional state in vivo . To dete process . To asse+/+ AECs . No diff similar . Since p similar –63, we fanalysis , loss ofR stress . Finallyemokines . These cemokines –25, 38 apression  and the pression  during fCcr2 KO  and found that epithelial, endothelial, and immune cells expressed much lower levels of Col1a1 than did fibroblasts  resolved in vivo , with cells grown on a stiff substrate (plastic) coated with collagen. The collagen-coated stiff substrate, but not the soft laminin-based substrate, promoted the transitional state . To dete in vivo , we reex laminin . As ment laminin , 75–79.  laminin . In thisce of K8 , i.e., tSince fibrosis maintained the transitional state , we nexthttps://github.com/kriemo/lung-regeneration-meta). We performed unbiased clustering. Clusters were annotated on the basis of expression of canonical markers   , a highl Cdkn2a) , 27, 82. Cdkn2a) . Cluster Cdkn2a) . Of note Cdkn2a) , 53, 62  Cdkn2a) . Moreove Cdkn2a) . These r Cdkn2a) , as prev Cdkn2a)  50)..Cdkn2b, Fblim1, Palld, and Pdlim7. Interestingly, by day 7 of 2D culturing, AECs had upregulated cluster 7 genes and were highly senescent   , 58, we +) , suggest+) . Human Ias KRT17 , 58. Moras KRT17 . This dial cells . Moreovell genes . To conf markers . Of the  markers  and in v markers . Althougluster 7 . Howeverstaining . The basstaining  and in tstaining  can aris+KRT5–  and ABI2 , or “tra+KRT5– , respectll genes . Likewisll genes  and assuulturing . Thus, tid state . Taken tKRT17+KRT5– state, which was associated with loss of an AEC1 fate and nonresolving fibrosis, we next asked whether a murine model of nonresolving fibrosis would be characterized by prevalent aberrant basaloid cells with a paucity of AEC1s. We treated mice with multiple doses of bleomycin and stained lung sections for the cluster 7 markers PDLIM7 and K17. Aberrant basaloid cells were more abundant and may have existed in a histologic pattern of “bronchiolization” (hi) but not aberrant basaloid  cells  cells . We spechi transitional cells uniquely activated multiple profibrotic processes, thus unifying diverse, independent lines of investigation. Genetic variants in KRT8 were associated with IPF  were conserved in the human aberrant basaloid state  (hi), but not permanently senescent (p16+), basaloid (K17+) state  . Similar/CDKN2A) , consist/CDKN2A) –33, 82. +) state . Presuma+) state , retain +) state .Ultimately, the impact of this work will be realized by future mechanistic and clinical studies. Whether mechanisms other than chemokine expression mediate the role of K8 in fibrosis and whether keratins other than K8 regulate alveolar regeneration and fibrogenesis should be studied. Conditional-KO mice will be needed to confirm that K8 expressed by transitional cells arising from AEC2s and/or club-like cells , 54 reguIn summary, we demonstrate here that a keratin, K8, promoted fibrosis and accumulation of transitional cells at the expense of AEC1 differentiation. K8 regulated chemokine expression and the recruitment of macrophages, which, together with transitional epithelial cells, activated fibroblasts. Macrophages and activated fibroblasts in turn promoted the accumulation of transitional AECs. This positive feedback loop ultimately resolved in mice, with AEC1 differentiation and the resolution of fibrosis. However, in human IPF, transitional AECs evolved into a bonafide senescent, aberrant basaloid state that existed in a self-amplifying feedback loop of epithelium-macrophage-fibroblast crosstalk, in which fibrosis begat further fibrogenesis, driving the progressive and ultimately fatal clinical disease. Modulation of K8 or progression from the transitional to the aberrant basaloid state may be effective therapeutic strategies for pulmonary fibrosis.Details on the methods are provided in the RNA-Seq data were deposited in the NCBI’s Gene Expression Omnibus (GEO) database (GEO GSE223302). Values for all data points in graphs can be found in the Supplemental FW and RLZ designed research studies. FW, CT, MD, KF, NP, NK, JN, BMV, JAW, EC, EFR, and XZ conducted experiments. FW, CT, MD, KAR, AL, EC, DWHR, EFR, DMT, XZ, BBM, PAC, MBO, and RLZ analyzed data. DMT and MBO provided reagents. RLZ wrote the manuscript. CT, KAR, JN, BMV, EC, DWHR, XZ, DMT, BBM, PAC, and MBO revised the manuscript.


The survival of preterm infants has improved over the last decade, but impaired brain development leading to poor neurological outcomes is still a major comorbidity associated with prematurity. The aim of this study was to evaluate the effect of nutrition on neurodevelopment in preterm infants and identify markers for improved outcomes.Totally 67 premature infants with a gestational age of 24–34 weeks and a birth weight of 450–2085 g were included. Clinical parameters and documented diet were collected from medical records. The nutritional analysis comprised the protein, fat, carbohydrate, and energy intake during different time spans. Brain development was assessed by determining deep gray matter  and lateral ventricular (LV) volumes as measured on cerebral magnetic resonance imaging scans obtained at term-equivalent age (TEA), and potential associations between nutrition and brain volumetrics were detected by regression analysis.P = 0.007). In contrast, head circumference at a corrected age of 35 weeks gestation (P < 0.001) and mean daily fat intake in the fourth postnatal week (P = 0.004) were positively correlated with DGM volume. Moreover, mean daily carbohydrate intake in the first postnatal week (P = 0.010) and intraventricular hemorrhage (P = 0.003) were revealed as independent predictors of LV volume.We observed a negative correlation between mean daily protein intake in the third postnatal week and MRI-measured DGM volume at TEA (The study emphasizes the importance of nutrition for brain development following preterm birth. The survival of preterm infants has significantly improved over the past 10 years. However, despite major advances in neonatal care, premature birth still poses a high risk of neurodevelopmental impairment, especially to very immature neonates with a gestational age of < 32 weeks. During human brain development, two time spans with particularly rapid growth, characterized by extensive cell proliferation , neuronal and glial differentiation, and synapse formation, are known .The importance of nutrition in the improvement of postnatal brain development has been stressed for years . Since iThe aim of this study was to evaluate the effect of various clinical and nutritional parameters on brain development in preterm infants and to identify potential prognostic markers for improved outcomes. We focused on the deep gray matter , a cerebral region with a high impact on motor and sensory functions, and lateral ventricular (LV) volumes, which are often increased in very immature infants. Brain volumes were measured on cerebral magnetic resonance imaging (MRI) scans obtained at term-equivalent age (TEA) and correlated with neonatal diet composition using regression analysis.Totally 67 preterm infants born between March 2011 and December 2012 at the University Hospital Essen, Germany,  with a gestational age of < 32 weeks and/or a birth weight of < 1500 g were included. Gestational age was defined as time elapsed between the first day of the last menstrual period and the day of birth and confirmed by ultrasound. This retrospective study was approved by the Ethics Committee of the University Hospital Essen, Germany, and conducted in accordance with the Helsinki Declaration (1964) and its later amendments (17-7490-BO). The local ethics committee confirmed that parental consent to participate is not necessary due to the retrospective and anonymous character of this study.A documented neonatal diet  was used to retrospectively calculate the protein, fat, carbohydrate, and energy intake during distinct time periods. Preterm infants were fed according to an internal guideline based on current literature ). Total daily fluid intake  was gradually increased from 70–80 mL/kg on the first day of life to 150–170 mL/kg on the seventh day of life. The final volume was adjusted according to actual body weight and fluid balance and altered in special medical conditions, such as edema or polyuria.Enteral feeding was administered via a gastric tube and successively increased by 20–30 mL/kg/day. Gastric residuals of up to 25% of the total meal volume were tolerated as long as no clinical signs of abdominal problems were observed. Preterm infants with a birth weight below 1500 g received 12 meals per day. After reaching a weight of at least 1800 g, the number of meals was reduced to 8 per day, and 6 meals per day were introduced with a weight of 2000 g. Prior to discharge, infants drank ad libitum. Enteral feeding was complemented by parenteral nutrition to reach the necessary energy intake of 40–60 kcal/kg/day during the first days of life and 110–135 kcal/kg/day during the further course.Protein intake was gradually increased from 1.5–2.0 g/kg/day to 4.0–4.5 g/kg/day in infants with a weight below 1000 g or 3.5–4.0 g/kg/day in infants with a weight between 1000 and 1800 g. Further protein administration was adjusted depending on growth. Fat intake was started at 1.0 g/kg/day after birth and increased by approximately 0.5 g/kg/day until a maximum intake of 2.0–3.0 g/kg/day.Adequate nutrition and therefore growth of preterm infants was defined by a daily weight increase of 15–20 g/kg, weekly length increase of 0.8–1.0 cm, and weekly head circumference increase of 0.5–0.8 cm (ESPGHAN recommendations).The following parameters were collected from medical records: gestational age at birth (weeks); weight at birth and discharge (g); and head circumference at birth, at corrected gestational age of 35 weeks, and at discharge (cm and percentile). Subsequently, the mean weekly head circumference increase until a corrected gestational age of 35 weeks and in each of the first four weeks of life (cm) was calculated. Data about the number of days with parenteral nutrition, the day of life when the feeding was completely enteral and the number of days without enteral nutrition due to abdominal problems were collected. Additionally, we classified the infants into groups with predominantly feeding of breast milk or of formula nutrition or with both breast milk and formula nutrition. Different clinical diagnoses, such as hyperbilirubinemia, cerebral and intraventricular hemorrhages, asphyxia or severe hypoxia, periventricular leukomalacia, small for gestational age (< 10th percentile), early onset infection (< 72 hours of life), late onset infection (> 72 hours of life), persistent ductus arteriosus (PDA), necrotizing enterocolitis (NEC), operation due to PDA, NEC or hernia and bronchopulmonary dysplasia, were examined.Nutritional analysis comprised the cumulative energy , protein (g/kg), fat (g/kg) and carbohydrate (g/kg) until postnatal days 14 and 28, respectively; the mean daily energy, protein, fat and carbohydrate until a corrected gestational age of 35 weeks; and the mean daily energy, protein, fat and carbohydrate in each of the first four weeks of life.After obtaining written parental informed consent, cerebral MRI scans at TEA were performed on a 3 Tesla MR scanner  as previously published, and DGM as well as LV volumes were calculated on axial T2-weighted turbo spin echo sequences .R2 are given as measures of goodness. Test results with P values less than 0.05 were regarded as statistically significant.The statistical analysis was conducted by our statistician (C. W.) using SAS software . For quantitative variables, mean values and standard deviations (SD) together with median, minimum, and maximum values are given. Qualitative factors are presented as absolute and relative frequencies. Pearson’s correlation coefficients were calculated to quantify the strength of the relationship between DGM or LV volume and different parameters. Subsequently, the simultaneous influence of nutrition and various clinical parameters  on the dependent outcome variables DGM and LV volume was assessed by multiple regression analysis. All variables proven to be significant in the univariable analyses were considered for multiple linear regression analysis using the “selection = forward” option. The determination coefficients Totally 67 preterm infants  born in 2011 and 2012 with a gestational age of 28.9 ± 2.6 weeks  and a birth weight of 1143 ± 364 g  were included.No infant showed congenital brain malformation, asphyxia, severe hypoxia or periventricular leukomalacia. There were 37 infants with hyperbilirubinemia needing therapy, but this was mild in each case and was treated with phototherapy. Blood exchange was not necessary. Three infants had grade I intraventricular hemorrhage, and three infants had grade II intraventricular hemorrhage. One infant showed intraventricular hemorrhage III and bleeding in the surrounding parenchyma on the right cerebral side, and another infant showed cerebellar bleeding on the right side, which was only detectable by MRI but not by sonography.Head circumference was 26.06 ± 2.78 cm  at birth and 30.60 ± 1.79 cm  at a corrected gestational age of 35 weeks. The weekly increase in occipitofrontal circumference during each of the first four postnatal weeks was 0.27 ± 0.33 cm  during postnatal week 1, 0.66 ± 0.38 cm  in postnatal week 2, 0.80 ± 0.43 cm  in postnatal week 3, and 0.87 ± 0.42 cm  in postnatal week 4. The weekly increase in occipitofrontal circumference until a corrected age of 35 weeks’ gestation was 0.73 ± 0.20 cm . At discharge, we observed a head circumference of 33.52 ± 1.89 cm .To ensure adequate growth over time and detect percentile crossing, an infant’s occipitofrontal circumference is routinely tracked on reference growth charts. For our study population, a head circumference percentile with median values of 40 (range 1–99) at birth and of 20 (range 1–90) at discharge was detected, demonstrating that many preterm infants are born with a small head circumference and do not show catch-up growth until hospital dismissal.Table 3 , and approximately two-thirds of the infants had a value between 17.000 and 21.000 mm3. These figures are comparable to the data of Srinivasan et al. [r = 0.43886, P < 0.001).The DGM volume at TEA was 18,865.55 ± 2980.31 mm3 , whereas the right lateral ventricles had a volume of 2957.15 ± 1252.15 mm3 . The volumes of both lateral ventricles taken together ranged between 2697.64 and 16,860.80 mm3 .LV volumes showed a size difference, with left lateral ventricles often being considerably larger than right lateral ventricles. The left LV volume was 3508.18 ± 1958.03 mmP < 0.001), mean daily fat intake in the fourth week of life (P = 0.004), and mean daily protein intake in the third week of life (P = 0.007). These parameters, however, differentially influence DGM volume. Head circumference at a corrected age of 35 weeks gestation and mean daily fat intake in the fourth week of life exhibited a positive correlation, whereas for mean daily protein intake in the third week of life, a negative correlation was observed. These relationships are expressed in the following equation:Table [with R2 of 0.4978, indicating that nearly 50% of the variance in DGM volume can be explained by the combination of the three described variables.Multiple regression analysis revealed a coefficient of determination Taken together, head circumference as well as protein and fat intake are associated with DGM volume and thus brain development following preterm birth.Multiple regression analysis showed no significant association between DGM volume and the different clinical parameters of mode of feeding , hyperbilirubinemia requiring phototherapy, cerebral and intraventricular hemorrhages, small for gestational age (< 10th percentile), early onset infection (< 72 hours of life), late onset infection (> 72 hours of life), persistent ductus arteriosus (PDA), necrotizing enterocolitis (NEC), operation due to PDA, NEC or hernia and bronchopulmonary dysplasia.P value less than 0.10 in these analyses were considered for multiple linear regression analysis using forward selection. Two parameters, namely, the presence of intraventricular hemorrhage (P = 0.003) and mean daily carbohydrate intake in the first week (P = 0.038), were independently and significantly associated with LV volumes. The determination coefficient of this multiple model is R2 = 0.1919. Thus, the combination of both abovementioned parameters was only able to explain about 19% of the variance in LV volume.Analogous to DGM volume, potential correlations between different nutritional components and LV volume were examined Table . For theThe clinical parameters of mode of feeding , hyperbilirubinemia requiring treatment, small for gestational age (< 10th percentile), early onset infection (< 72 hours of life), late onset infection (> 72 hours of life), persistent ductus arteriosus (PDA), necrotizing enterocolitis (NEC), operation due to PDA, NEC or hernia and bronchopulmonary dysplasia had no significant association with lateral ventricular volume at term-equivalent age.Neurodevelopmental outcomes after preterm birth are influenced by a plethora of genetic and environmental factors. As a result, we used multiple linear regression analysis to simultaneously assess the impact of various clinical and nutritional parameters on the outcome variables in the present study. MRI-measured DGM volume at TEA was thereby positively correlated with head circumference at a corrected age of 35 weeks of gestation and mean daily fat intake in the fourth postnatal week, whereas mean daily protein intake in the third postnatal week showed a negative correlation. Taken together, the three abovementioned parameters were able to explain about 50% of the variance in DGM volume. Thus, in addition to occipitofrontal circumference and nutritional factors, other independent parameters are important to accurately predict neurodevelopmental outcome.Head circumference has long been known as a marker for brain growth in preterm infants, and several studies have described a positive association with neurodevelopment , 10–12. The present study confirms the importance of occipitofrontal circumference in the prediction of neurological outcome, and its use in daily routine care still undisputedly represents a simple, rapid, and inexpensive clinical marker to evaluate brain size. Head circumference growth in turn is closely related to adequate nutrition of preterm infants , 14.Key publications in recent years have emphasized that high energy and protein intake positively affects the neurological outcome of preterm infants. Conversely, insufficient nutrition after preterm birth is associated with slow growth (head circumference as well as weight), altered brain structure and impaired neurodevelopment , 3, 15. The caudate nucleus, a core part of the basal ganglia, is a cerebral region particularly sensitive to environmental influences. On one hand, postnatal malnutrition has been shown to have a negative impact on its development, and an association between reduced caudate volumes and learning and attention deficit disorders of preterm infants at school age was illustrated , 16. On In the present study, we examined the association between DGM volume and nutrition in preterm infants and found a positive correlation with mean daily fat intake in the fourth postnatal week. Since the human brain has a high lipid content and fatty acids are essential for cell membrane and myelin synthesis, it is obvious that sufficient fat supply is necessary to enable adequate development of cerebral structures. Accordingly, recent studies reported that increased fat and energy provision in the first weeks of life leads to improved brain growth, accelerated white matter maturation, and increased DGM and cerebellar volume , 19. MorApart from the importance of adequate fat supply, increased protein supplementation in the first 28 days of life has also been associated with improved growth between birth and TEA . EnteralRegarding carbohydrate intake, we did not observe any association with DGM volume. This finding is supported by a study from dit Trolli et al. , who couSufficient energy supply is particularly essential for adequate brain development, as the human brain consumes nearly half of the energy offered in the first weeks of life . TherefoIn addition to the impact of nutrition on DGM volume, we also studied its relationship with LV size. Kesler et al. observed enlarged LV volumes in preterm infants and reported that lateral ventricular cerebrospinal fluid volume was significantly negatively correlated with subcortical gray volume in the preterm group. Additionally, the preterm group showed a significant negative correlation between occipital horn volume and occipital white matter volume and subcortical gray matter volume, which was not seen in term infants. The authors assumed that ventriculomegaly may in part be the result of subcortical tissue loss. With a special focus on volumes of occipital horns in preterm infants, the authors assume that local reductions in occipital lobe tissue further contributed to enlargement of this region aggravating the present loss of subcortical gray matter. In conclusion, these results described enlarged lateral ventricles as a consequence of developmental and pathologic processes . Parikh We found mean daily carbohydrate intake in the first postnatal week and intraventricular hemorrhage are independent predictors of LV volume. However, both parameters only predict approximately 19% of the variance in LV volume, illustrating that nutrition plays a role and other, yet unknown, factors contribute to the size of lateral ventricles.Mean daily carbohydrate intake in the first postnatal week was negatively correlated with LV volume, which in turn implies that infants with low carbohydrate supply seem to have enlarged lateral ventricles. This finding can be explained by the clinical observation that very premature neonates usually show a reduced capability to metabolize carbohydrates and concomitantly have greater LV volumes and a higher risk of impaired neurological development than their term-born counterparts , 31. TheIn the present study, mode of feeding  showed no association with the examined brain structures. However, recent work showed a beneficial effect of enteral feeding on brain growth, as parenteral nutrition over a long period of time was associated with lower global brain, cerebellar, and deep and cortical gray matter volume , 25, 33.The present study has several limitations. First, protein, fat, and carbohydrate concentrations in breast milk vary between individuals and are subject to changes during the postpartum course. Since the measurement of nutritional components in breast milk necessitates large sample volumes of 10 mL and these are, especially in the first days of life, urgently needed for the preterm infant, mean values were drawn from the current literature. Furthermore, this study was designed retrospectively with a limited number of patients, and thus, the results should be confirmed by a prospective multicentric study. This may additionally help to reduce the interindividual differences in breast milk due to a larger study population. As this study can provide evidence for important nutritional factors with an impact on neurologic structures, the relevance of early nutrition to brain development must be demonstrated by randomized controlled studies.In conclusion, the present study highlights the importance of nutrition for brain development following premature birth. An early neonatal diet should therefore ideally consist of an optimal composition of proteins, carbohydrates, and fats, whereby adequate fat intake seems to have a beneficial effect on DGM volumes. To identify preterm infants with a high risk of neurodevelopmental impairment, head circumference can be routinely assessed as a simple marker to ensure adequate postnatal growth.