Pseudoaneurysm is a known complication of penetrating arterial injuries such as catheterization, gunshot wounds, and open fractures. Vaccination is an effective method for preventing multiple, serious, infectious diseases in children. Common adverse reactions related to vaccination include fever, swelling, redness, and pain. Brachial pseudoaneurysm after vaccination has not been previously reported.Herein we describe a novel case of brachial pseudoaneurysm after vaccination in a child aged 1 year and 3 months. A pulsatile mass was formed in the medial left arm of the infant 10 days after vaccination at a community hospital and gradually grew larger. Preoperative images depicted an eccentric aneurysm in the brachial artery and a swirling flow pattern in the mass. The pseudoaneurysm was excised, and vein graft interpositioning was successfully performed. There were no short-term or long-term complications during the follow-up period.Brachial pseudoaneurysm is a rare complication of vaccination via intramuscular injection. Medical staff should avoid puncture wounds to the brachial artery during vaccination, especially in infants. Pseudoaneurysm is caused by a wide variety of paravascular infectious, inflammatory, and traumatic processes such as tuberculous lymph nodes, mycotic infection , adjacenVaccination is a necessary and safe method for preventing numerous, serious infectious diseases in infants. There are three main types of injected vaccination: intradermal, subcutaneous, and intramuscular. Adverse reactions related to vaccination include fever, redness, swelling, local pain, headache, fatigue, nausea, vomiting, diarrhea, allergic response, and systemic infection. Pseudoaneurysm arising from vaccination has never been reported. Herein, we report an unusual pseudoaneurysm of the brachial artery in an infant due to vaccination. In addition to the age of the patient, the case is notable due to the associated mechanism of injury—vaccination. This case report describes a new, possible, adverse reaction during vaccination, especially in pediatric patients.Haemophilus influenzae type b (Hib) at a community hospital. The vaccine had been administered in the proximal lateral left arm via intramuscular injection, and there were no complications at the time of vaccination. Ten days later, the patient exhibited a pulsatile mass in the proximal medial left arm. Thereafter, the mass gradually became larger. With increasing prominence of the mass, the parents visited our hospital for treatment. The patient did not undergo any related treatment before admission.A child aged 1 year and 3 months was presented with a pulsatile mass in the proximal medial left arm. Two months prior, the infant had been vaccinated against The infant was well developed, and the results of cardiopulmonary examination were normal. Physical examination revealed a non-tender, pulsatile mass in the medial left arm measuring 3 cm × 2 cm, with a clear boundary. The skin on the surface of the mass was intact, without redness or damage Fig. A. PeriphElectrocardiography, chest roentgenography, and echocardiography did not reveal any evidence of cardiac disease. Blood tests were normal. Digital subtraction angiography (DSA) revealed an eccentric aneurysm in the brachial artery Fig. B. DoppleOpen surgery was conducted under general anesthesia. The patient was placed in the supine position with the arm abducted. An incision was made along the medial upper arm. A cystic and eccentric brachial aneurysm was detected just under the median nerve, which was squeezed and stretched by the aneurysm Fig. A. The anThe surgery was successful. Dressings were changed every 2 days. The patient did not experience any complications during hospitalization. Histopathologic evaluation of the mass indicated inflammatory infiltration, hyalinization, and regions of hematoma beside the vessel wall lumen Fig. , which cThe patient was presented regularly for follow-up evaluation. No numbness, muscle atrophy, or ischemia were identified. Examination of the reconstructed artery at 5 months indicated that artery stenosis and inflammation around the artery had disappeared Fig. B, and peHib vaccine prevents meningitis, pneumonia, epiglottitis, and other serious infections caused by the Hib bacterium. It is usually injected into the deltoid muscle. According to the guidelines for Hib vaccination from the Center for Disease Control, common adverse reactions include swelling, redness, and pain; systemic reactions such as fever and irritability are infrequent, and serious reactions are rare. In a report on adverse events after Hib vaccination, other outcomes included pyrexia, vomiting, convulsions, irritability, intussusception, diarrhea, crying, hypotonia, lethargy, and apnea . PseudoaAneurysm refers to the weakening of an artery wall that creates a bulge or distention of the artery. Most aneurysms are asymptomatic and are not dangerous. At their most severe stage, however, some can rupture, leading to life-threatening, internal bleeding. Aneurysms occurring in children are rare and usually occur in the thoracic or abdominal aorta . NonaortPseudoaneurysm is a collection of flowing blood that communicates with the arterial lumen and is filled only by the adventitia or surrounding soft tissue. It is a known complication of penetrating arterial injuries such as catheterization, gunshot wounds, and fractures . It may Pseudoaneurysm can be diagnosed via Doppler ultrasonography, computed tomography angiography, DSA, and magnetic resonance angiography . DopplerPseudoaneurysm treatments include conservative measures, sonographically guided compression, embolization, and open surgery. Sonographically guided compression was introduced in 1991 and involves the placement of an ultrasound probe directly over the neck of the pseudoaneurysm in conjunction with the application of prolonged compression, thereby producing vascular stasis within the lumen and promoting thrombosis . AlthougVein graft interpositioning was preferred in the current case due to the size and rapid expansion of the pseudoaneurysm. Fortunately, the operation was performed in time, which enabled the squeezed median nerve to be released, thus avoiding further damage. Long-term follow-up indicated that the surgery was effective and without obvious complications.In the present case, preoperative image reports, intraoperative surgical findings, and postoperative pathological examination all confirmed the existence of brachial pseudoaneurysm. Because the infant did not suffer from any hereditary disease and had not experienced any other iatrogenic or traumatic injury, we speculated that vaccination into the deltoid muscle had accidentally punctured the brachial artery, leading to the formation of a pulsative mass 10 days later. Although rare, this can happen, resulting in pseudoaneurysm. Fortunately, the surgery was timely; otherwise, sensory and motor dysfunction could have occurred while the median nerve was severely squeezed. The infant recovered well with no complications.Herein, we have described a case of brachial artery pseudoaneurysm formation after vaccination in an infant, in whom resection of the pseudoaneurysm and vein graft interpositioning were successful. We emphasize that although vaccination can rarely lead to pseudoaneurysm, it is mostly safe. Efforts must be made to avoid such complications during vaccination.


Histologically, cytoplasmic deposits of lipids and glycogen are common in clear cell renal cell carcinoma (ccRCC). Owing to the significance of lipid deposition in ccRCC, numerous trials targeting lipid metabolism have shown certain therapeutic potential. The agonism of peroxisome proliferator-activated receptor-α (PPARα) via ligands, including WY-14,643, has been considered a promising intervention for cancers.First, the effects of WY-14,643 on malignant behaviors were investigated in ccRCC in vitro. After RNA sequencing, the changes in lipid metabolism, especially neutral lipids and glycerol, were further evaluated. Finally, the underlying mechanisms were revealed.Phenotypically, the proliferation and migration of ccRCC cells treated with WY-14,643 were significantly inhibited in vitro. A theoretical functional mechanism was proposed in ccRCC: WY-14,643 mediates lipid consumption by recognizing carnitine palmitoyltransferase 1 A (CPT1A). Activation of PPARα using WY-14,643 reduces lipid deposition by increasing the CPT1A level, which also suppresses the NF-κB signaling pathway. Spatially, WY-14,643 binds and activates PPARα by targeting Gly335.Overall, WY-14,643 suppresses the biological behaviors of ccRCC in terms of cell proliferation, migration, and cell cycle arrest. Furthermore, its anticancer properties are mediated by the inhibition of lipid accumulation, at least in part, through the PPARα/CPT1A axis by targeting Gly335, as part of the process, NF-κB signaling is also suppressed. Pharmacological activation of PPARα might offer a new treatment option for ccRCC.The online version contains supplementary material available at 10.1186/s12944-022-01726-7. At least 400 thousand people are identified as renal cell carcinoma (RCC) each year in the world, to which approximately half of the cases succumb . AlthougAccumulating evidence has indicated that aberrant metabolism contributes to the growth and metastasis of tumors . MoreoveWY-14,643 was recognized as a lipid-lowering agent . CurrentWhen mitochondrial oxidative phosphorylation occurs, carnitine palmitoyltransferase 1 A (CPT1A) facilitates the translocation of acyl groups, thus acting as a pivotal rate-limiting enzyme . The criSince downregulation of PPARα significantly suppresses CPT1A expression and subsequently suppresses FAO in melanoma cells , the hypWY-14,643 was sourced from ApexBio (USA). GW6471 was obtained from Topscience (China). Dimethyl sulfoxide (DMSO) was used as the solvent and was diluted to < 0.1% before use. Antibodies specific to GAPDH, CDK2, Cyclin A, Cyclin B1, Vimentin, CPT1A, Cleaved caspase-3, Cleaved PARP, Bax and Bcl-2 were purchased from Proteintech Group (China). Antibodies specific to N-cadherin, NF-κB pathway were purchased from Cell Signaling Technology (USA). Antibodies specific to Caspase-3 were purchased from Abcam (England).2. All the cells were grown in the recommended medium containing 1% penicillin/streptomycin and 10% fetal bovine serum .The human renal cell carcinoma cell lines 786-O and A498 and the human proximal tubular cell line HK2 were sourced from the American Type Culture Collection (USA). Cells were grown in a sterile incubator 37 °C containing 5% COIn a 6-well plate, 300 ccRCC cells per well were inoculated after administration of WY-14,643 for 24 h. When colonies were formed and large enough to be visualized (nearly 9 days), the cells were labeled with 0.1% crystal violet after fixation in formaldehyde. Finally, the colonies were counted.3 ccRCC cells seeded per well adhered, different doses of WY-14,643 were administered for specific hours. Each well was filled with 10 µl of CCK-8  reagent. After 1.5 h, the OD values at 450 nm were obtained with a microplate reader.In a 96-well plate, after 2*10Briefly, in a six-well plate, ccRCC cells were cultured until confluence was observed. After serum starvation for 6 h, a scratch was made. Following the removal of detached cells and debris with PBS, appropriate doses of WY-14,643 were applied. Images were taken at 0 and 12 h after observing the wound gap. Cell migration percentages were calculated by ImageJ.4 ccRCC cells were seeded per well. Twenty-four hours later, the bottom cells were stained after removing the upper cells. Cell migration percentages were calculated by ImageJ.24-well plates  containing 8 μm membrane filters were used for the assays. After administration of specified concentrations of WY-14,643 for 24 h, 1*10To determine lipid droplets, after fixation in 10% formaldehyde, ccRCC cells were rinsed for 5 min in 60% isopropanol. Following staining for 10 min with freshly prepared ORO , images were taken under a microscope . ORO quantification was performed by adding 300 µl of isopropanol to the dried cells, incubating for 3 min, and determining the absorbance at 490 nm.4 cells per well were seeded and inoculated. After treatment with different doses of WY-14,643, the cells were rinsed with Triton X-100. Later, intracellular neutral lipid deposits were observed by staining with Nile red, and nuclei were identified by Hoechst 33,342 . Images were then captured.To quantify the intracellular neutral lipid content, 1 µg/ml Nile red fluorescent stain was used to label ccRCC cells . Briefly, 1*10Following WY-14,643 treatment, total glycerol content was examined by a cell glycerol enzymatic assay kit . Briefly, after the cells were trypsinized, centrifuged, and lysed, and lipase was inactivated, then the absorbance at 550 nm was detected after 10 µl supernatant and 190 µl working solution were preserved in 37 °C water bath for 10 min. Finally, the total glycerol content was normalized to the total protein amount (per mg units).After extracting total protein and determining protein concentration, the SDS PAGE gels loaded with 30 µg of protein samples were transferred to polyvinylidene difluoride membranes in an ice-water bath. Incubation of membranes with diluted primary antibodies was performed following the blocking procedure. Next day, after 1.5 h-incubation in secondary antibodies, the membranes were exposed to the Bio-Rad ChemiDoc system followed by 3 min of reaction in the ECL mix.After extracting total mRNA and determining the concentration, cDNA was synthesized using the HiScript Q RT SuperMix for qPCR kit . Subsequently, water, primers, ChamQ Universal SYBR qPCR Master Mix , and cDNA templates were mixed in a Bio-Rad Real-Time PCR Detection System according to the protocols. The following is a list of primer sequences used: CPT1A, forward 5′-TTCAGTTCACGGTCACTCCG-3′, reverse 5′-TGACCACGTTCTTCGTCTGG-3′; GAPDH, forward 5′-GCACCGTCAAGGCTGAGAAC-3′, reverse 5′-TGGTGAAGACGCCAGTGGA-3′.6 786-O cells were fixed in ethanol overnight at -20 ℃. The next day, after the fixed cells were centrifuged and washed, Triton X-100 and RNase were added. Finally, propidium iodide was diluted to 100 µg/ml. After that, cell cycle distribution was analyzed by BD flow cytometry.After treatment with specified concentrations of WY-14,643 for 48 h, 1*10http://string.embl.de). To investigate the correlation between PPARα and CPT1A, gene correlation analysis was conducted by Gene Expression Profiling Interactive Analysis (GEPIA) and The University of Alabama at Birmingham Cancer Data Analysis Portal (UALCAN).Next-generation transcriptomic sequencing was conducted by the Illumina NovaSeq 6000 sequencing platform . To further analyze related pathways, Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) were both calculated by GOATOOLS and KOBAS. Protein‒protein interactions (PPIs) were estimated by The Search Tool for the Retrieval of Interacting Genes . To optimize WY-14,643, the Polak-Ribière-Polyak conjugate gradient algorithm was used along with the semiempirical PM3 method. Semiflexible docking between the ligand and the receptor was performed via AutoDockTools using the AutoDock Vina program. The docking score of the ligand molecule WY-14,643 and the protein receptor PPARα was − 7.5 kcal/mol. Finally, the results were visualized using Ligplot and PyMOL software.Whether WY-14,643 binds specifically to the PPARα protein was investigated by molecular docking. The protein receptor was accessed from the RCSB PDB protein structure database  and enriched pathways in depth in ccRCC cells after treatment with WY-14,643. As shown in Fig. It is generally acknowledged that intracellular lipid accumulation is a significant characteristic of ccRCC. The effect of WY-14,643 on lipid metabolism was next investigated. As Fig. R = 0.62 and R = 0.69, respectively (Fig. Multiple lines of evidence show that CPT1A, a core regulator in FAO in ccRCC, is bound and repressed by HIFs, resulting in the storage of fatty acids in lipid droplets, thus inducing a clear cytoplasmic phenotype –30. UsinAs discussed above, WY-14,643 treatment upregulated CPT1A. It has been confirmed that the upregulation of PPARα significantly promotes CPT1A expression and subsequently promotes FAO . In addiAs KEGG and GO enrichment analyses showed that the apoptosis pathway was activated after WY-14,643 administration (Supplementary Fig. The results above have shown that WY-14,643 regulates lipid metabolism in ccRCC by activating PPARα, which is consistent with previous research. To model the interaction between WY-14,643 and the PPARα protein complex, a molecular modeling assay was conducted. As Fig. Metastatic ccRCC patients show a poor prognosis, and their quality of life is severely impaired . AccumulIt was demonstrated that WY-14,643 inhibited ccRCC cell proliferation, suppressed ccRCC cell migration, and induced S phase arrest in the present study. Furthermore, it was shown that WY-14,643 attenuated lipid deposition via the PPARα/CPT1A axis, in the process, the NF-κB signaling was also suppressed. Moreover, it was demonstrated by molecular modeling that WY-14,643 activates PPARα by targeting Gly335. The proposed mechanism is detailed in Fig. WY-14,643 was first utilized as a lipid-lowering drug, and its antagonism effect on PPARα was found to be esponsible for this function soon after . PPARα, Inhibition of PPARα/γ by pharmaceutical means could induce EMT through PPAR signaling , which mThe DEGs after treatment with WY-14,643 were identified by transcriptomic sequencing. KEGG pathway and GO enrichment analyses showed that multiple canonical pathways were enriched, including the p53 pathway, Hippo signaling, apoptosis and retinol metabolism. These results suggested that WY-14,643 interfered with many biological or cellular processes, including development and differentiation, signal transduction, movement, metabolism, cell communication and response to stress and chemicals. These results also imply that, as a promising treatment for ccRCC, WY-14,643 is worthy of exploration due to its broad effects. Then, the maximum proportion of genes was subjected to metabolism pathways or metabolic processes according to KEGG and GO annotation, indicating that WY-14,643 interferes with metabolism processes in ccRCC, as expected; these results suggest that WY-14,643 participates in metabolic regulation in ccRCC. Therefore, the role of WY-14,643, revealed as a lipid-lowering agent, in lipid metabolism in ccRCC was next investigated in detail.Growing evidence suggests that PPARα agonism by WY-14,643 is involved in lipid metabolism in multiple organs in addition to the liver . In renaThere is growing recognition that NF-κB signaling take parts in many processes of cancer development in ccRCC . The NF-The anticancer effects of WY-14,643 via PPARα activation have recently been discovered in tumors , 60. HerThe study proposed that PPARα is a therapeutic target for ccRCC due to its role in abnormal lipid accumulation. Activation of PPARα by WY-14,643 exerts anticancer effects on ccRCC cells, which also makes WY-14,643 a promising therapeutic strategy for ccRCC. This research, however, is subject to several limitations. The first limitation concerns the stability of WY-14,643 during cell experiments. Second, the present study focused exclusively on lipid metabolism, but glucose and lipid metabolism interact with each other due to the Warburg effect . In furtWY-14,643 inhibits the biological behaviors of ccRCC in terms of cell proliferation, migration, and cell cycle arrest. Furthermore, WY-14,643 attenuates lipid deposition, which might contribute to its anticancer properties, at least in part; WY-14,643 acts through the PPARα/CPT1A axis by targeting Gly335, as part of the process, NF-κB signaling is also suppressed. The above findings strongly suggest that PPARα might be an important marker for ccRCC and that lipid regulation by targeting PPARα might be a feasible strategy to improve ccRCC prognosis. This study included in vitro pharmacodynamic experiments, providing a reference and basis for in vivo and clinical experiments of PPARα agonists, including WY-14,643, in the future.Additional file 1:Supplementary Fig. 1. WY-14643 treatment disrupts lipid metabolism in ccRCC cells. a. pathway enrichment analyses of the DEGs. b. GO enrichment analyses of the DEGs. c. A Heatmap of DEGs in lipid metabolism, including fatty acid binding and activation, fatty acid oxidation, triglyceride turnover, etc. The horizontal axis in a and b represents the enrichment factor. WY, WY-14643.Additional file 2:Supplementary Fig. 2. Inhibition of the NF-κB pathway upregulates CPT1A. a. Specified doses of PDTC, a NF-κB inhibitor, were administered to 786-O cells for 24 h, and CPT1A protein expression levels were detected by western blotting and analyzed quantitatively. *P<0.05, **P<0.01.


Ureaplasma (U.) and Mycoplasma (M.) species have been related to pregnancy complications (including preterm birth) and worse neonatal outcomes. The aim of our work is to evaluate neurodevelopmental outcomes in preterm infants born to mothers with Ureaplasma/Mycoplasma colonization during pregnancy.Preterm infants with gestational age (GA) of ≤ 30 weeks were included in a retrospective follow-up study. To evaluate the effects of maternal vaginal colonization, we divided preterm infants into two groups: exposed and unexposed infants. All infants were assessed at 24 ± 3 months of age using Griffith’s Mental Developmental Scales (GMDS).p = 0.46). However, exposed infants had a significantly poorer outcome than their unexposed peers in terms of locomotor abilities .Among 254 preterm infants, only 32 infants (12.6%) were exposed to U. /M. colonization during pregnancy. Exposed infants and unexposed ones had a similar Griffith′s Developmental Quotient , without significant differences (For visual and hearing impairment, exposed and unexposed infants had similar incidences of cognitive and motor impairment. However, exposed infants had significantly lower locomotor scores than unexposed peers. Ureaplasma (U.) and Mycoplasma (M.) species have been related to pregnancy complications (including preterm birth) and worse neonatal outcomes   . This hage (IVH) . Isolatifindings .Ureaplasma/Mycoplasma vaginal colonization during pregnancy.The aim of our work was to evaluate neurodevelopmental outcomes in preterm infants born to mothers with A total of 254 preterm infants with gestational age (GA) of ≤ 30 weeks  were enrolled in a previous retrospective study about the extra-uterine growth restriction and related neurodevelopmental outcomes, as previously published . All incUreaplasma/Mycoplasma colonization during pregnancy (cases) and unexposed infants (controls). We also considered unexposed infants born to mothers who were not screened, and pregnancy was uneventful until delivery , and we were able to identify U. urealyticum and M. hominis  were collected. In our hospital, culture and identification were performed until 2015 using the  hominis . Afterwaalyticum .Antibiotic treatment was stopped when samples resulted negative.Data were collected in our follow-up facility care unit, including pregnancy and newborn characteristics.The following maternal and neonatal characteristics were collected during the neonatal period: maternal age, antenatal corticosteroids, complete course of antenatal corticosteroids, multiple pregnancy, pathological umbilical artery Doppler parameters, cesarean section, preterm premature rupture of membranes, sex of the neonate, GA, birthweight, birth head circumference, Apgar at 5 min, number of days on invasive mechanical ventilation, incidence of bronchopulmonary dysplasia , postnatal steroids, presence of major brain lesions , inAll infants were assessed at 24 ± 3 months of age by an expert pediatric neurologist using Italian-validated translation of Griffith′s Mental Developmental Scales (GMDS) (0–2 years) .GMDS yields five subscales: Locomotor, Personal-Social, Hearing and Speech, Eye and Hand Coordination, and Performance. The subscales yield standardized scores for each domain and a composite developmental quotient. The cognitive developmental outcome was classified normal when Griffiths’ developmental quotient (GDQ) was > 85; borderline, when GDQ was from 70 to 85; and delayed when GDQ was less than 70 .Conversely, the motor outcome was classified as normal development, “minor neurological dysfunction”  , and cerThe onset of epilepsy was also recorded.The severity of Retinopathy of prematurity (ROP) was defined as stage of ≥ 3, according to ICROP criteria , whereasDisability was classified according to a previous scheme utilized in the EPICure studies , classifT-test was used to compare cases and controls in terms of Griffiths’ development quotient (GDQ) and neurodevelopment impairment (NDI). A p-value < 0.05 was considered significant.Data are presented as numbers and percentages for categorical variables. Continuous variables are expressed as mean ± standard deviation (SD) if they were normally distributed or as median and interquartile range if normality could not be accepted. Categorical variables were compared using the Fisher’s exact test or Chi-square with Yates correction. Multivariate analysis (by means of logistic regression in case of binary outcome or linear regression in case of continuous variable outcome) was considered when appropriate, after the correction by GA and the presence of major brain lesions (IVH ≥ III grade or cPVL).Statistical analysis was performed using software programs Microsoft Excel (2016 for Windows) and STATA/IC (version 15.1 for Windows).The study was carried out in compliance with the Declaration of Helsinki and its later amendments, approved by the Ethics Committee of Fondazione Policlinico Universitario “Agostino Gemelli,” Rome, Italy (in the context of the protocol number 0036181/20 - ID 3244), and written informed consent was obtained from parents for any clinical research purpose about clinical data.U./M. colonization during pregnancy: among these, 26 were exposed to Ureaplasma  and 6 were exposed to Mycoplasma spp. Mycoplasma cases were not typed.Maternal characteristics and neonatal characteristics of the study patients are reported in U./M. colonization. If we only consider them, the colonization rate increases up to 32/91 cases (64.8%).However, only 91 mothers were screened for U./M. detection was 19.3 ± 7.3 weeks GA (range: 7–29). The two groups of exposed and unexposed infants were similar in all maternal characteristics, except for the administration of antenatal corticosteroids (significantly higher in the exposed group) and twin pregnancies (higher in the unexposed group).Mean GA at the time of U./M. spp. Exposed infants had a higher incidence of EOS, but not statistically significant. Furthermore, we identified no cases of early-onset and late-onset sepsis due to U./M. spp.None of the preterm infants had a respiratory culture obtained after birth that resulted positive for U./M. colonization during pregnancy.In p = 0.46). Analyzing Griffith′s subscales, exposed infants had a significantly poorer outcome than their unexposed peers in terms of locomotor abilities . Conversely, unexposed infants achieved similar results in other subscales: Personal-Social interactions , Hearing and Language assessment , Eye and Hand Coordination , and Performance scale  (p = 0.04).Indeed, exposed infants and unexposed ones had a similar GDQ , without significant differences  . We testMycoplasma and Ureaplasma spp. in vaginal cultures has been associated with spontaneous miscarriage, preterm birth, and chorioamnionitis  (The association of BPD with nfection  or a hignits/ml) , rather Ureaplasma spp. stimulate the release of tumor necrosis factor-alpha (TNFα), interleukin-1beta (IL-1β), interleukin-8 (IL-8), monocyte chemoattractant-1 (MCP-1), transforming growth factor-beta 1 (TGFβ1), and other mediators by various cell types in vitro, and Ureaplasma spp. colonization is associated with increased concentrations of these cytokines in tracheal aspirates during the first week of life in infants who develop BPD  in preterm infants treated with azithromycin in the first week of life compared to placebo . Furthermore, infants whose mothers have not been screened were also included in the unexposed group, and some colonized mothers may have been missed due to a single sampling during pregnancy and their infants could have been misclassified.U./M. spp., probably due to the small sample size of exposed infants. We speculated that, probably, later colonization could have a greater weight in influencing outcomes of preterm infants. To the best of our knowledge, there are no available studies that have yet investigated this aspect.Finally, we found no significant differences according to the week of GA at diagnosis of U./M. colonization had significantly lower locomotor scores than unexposed peers.In conclusion, we analyzed a homogeneous cohort of preterm infants, without significant differences in maternal and neonatal characteristics between the exposed and unexposed groups, in the context of a correct follow-up study. We found that exposed infants to maternal Ureaplasma and Mycoplasma could affect neonatal outcomes or not, sparing improper use of antibiotics in mothers and infants.Further prospective multicenter studies in a larger population of preterm infants are needed to better understand if maternal colonization with The original contributions presented in this study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.The studies involving human participants were reviewed and approved by Ethics Committee of IRCCS Fondazione Policlinico Universitario “Agostino Gemelli” —in the context of the protocol number 0036181/20 - ID 3244. Written informed consent to participate in this study was provided by the participants’ legal guardian/next of kin.FG and DD conceptualized and designed the study, designed the data collection instruments, enrolled subjects, collected the data, analyzed the data, and drafted the initial manuscript. MC, MP, FC, and AB collected the data, analyzed the data, and revised the manuscript. DR, DMR, TS, LM, and EM critically reviewed the manuscript. GV coordinated and supervised the work and critically reviewed the manuscript for important intellectual content. All authors approved the final manuscript as submitted and agreed to be accountable for all the aspects of the work.


Thermoregulation in newborn mammals is an essential species-specific mechanism of the nervous system that contributes to their survival during the first hours and days of their life. When exposed to cold weather, which is a risk factor associated with mortality in neonates, pathways such as the hypothalamic–pituitary–adrenal axis (HPA) are activated to achieve temperature control, increasing the circulating levels of catecholamine and cortisol. Consequently, alterations in blood circulation and mechanisms to produce or to retain heat  begin to prevent hypothermia. This study aimed to discuss the mechanisms of thermoregulation in newborn domestic mammals, highlighting the differences between altricial and precocial species. The processes that employ brown adipocyte tissue, shivering, thermoregulatory behaviors, and dermal vasomotor control will be analyzed to understand the physiology and the importance of implementing techniques to promote thermoregulation and survival in the critical post-birth period of mammals. Also, infrared thermography as a helpful method to perform thermal measurements without animal interactions does not affect these parameters. Neonatal mortality in domestic animals such as lambs, calves, foals, piglets, and rodents responds to several maternal and offspring factors. Within these, hypothermia caused by excessive heat loss or inhibition of thermoregulation and heat production is considered a major element that causes mortality of newborn animals ,2,3. HypThe separate evolution of endothermy in mammals and birds is considered an important transition in vertebrate evolution. It is a unique case of convergence between these two groups, essential to their rapid spread across the planet and their ecological success ,10. RezeThese interspecies differences respond to physiological maturity, known as the newborn’s capacity to cope with the transition between the intrauterine life and the external environment. Such maturity involves activating several neuroendocrinological and behavioral changes. Nonetheless, nutrition, genetic selection, and pharmacology can also influence maturity at birth. Similarly, factors leading to the activation of the hypothalamic–pituitary–adrenal axis (HPA) , increasDetermined mainly by physiological maturity, mammals can be classified into altricial and precocial species see . AlthougThermoregulation is one of the most complex mechanisms of the organism and a critical factor for the survival of newborn non-human mammals. However, it is not always well understood due to interspecies differences. Therefore, the present review aims to discuss the mechanisms of thermoregulation in domestic mammalian newborns, highlighting the differences between altricial and precocial species. The main thermoregulation mechanisms among domestic mammals  will be analyzed to understand their physiology. Additionally, the importance of implementing diverse techniques, such as infrared thermography, that evaluate and promote thermoregulation and survival in the critical post-birth period of mammals will be reviewed.In many species, the drop in temperature experienced at birth induces an immediate compensatory response by the neonate to modify the physiological parameters and to avoid further heat loss. It has been described that when the neonate experiences a drop of up to 2 °C in body temperature—in the case of piglets and ruminants—the body is triggered to use thermogenesis mechanisms coordinated by the Nervous System (NS) ,29,30. TExposure to cold temperatures or when the environmental temperature changes from the thermoneutral zone  induces the response of peripheral thermoreceptors located at the dermal level. Transient potential receptors (TRP) TRPM8 and TRPA1 are activated at temperatures below 27 °C and 17 °C, respectively ,35. ThesThe preceding allows the understanding that the successful compensation of hypothermia largely depends on the degree of neurodevelopment of the structures that coordinate the cited response.Heat production is the generation of heat through intensified muscular activity or shivering, or the production of metabolic heat through the breakdown of BAT, which is generated mainly in the thorax or perirenal areas ,14,22. TAdditionally, it is mentioned that the presence of insulator fur makes animals less susceptible to thermal losses than those with glabrous skin, such as human or pig newborns. In them, there is a greater heat production capacity per unit of body weight and a smaller surface area about its weight . HoweverAnother hypothalamic coordinated thermogenic response begins with reducing heat loss through peripheral vasoconstriction before catecholamine neurosecretion . Vasoconstriction preserves the central temperature in organs with high metabolic requirements, such as the brain . FurtherThe thermoregulatory capacity during the postnatal stage will primarily be dependent on the NS response to activating thermogenesis mechanisms and whether the species is altricial or precocial. In both, the compensation strategies depend on the NS maturation degree and the presence or absence of structures such as hair or fur or BAT activation, which will be discussed in detail in the following sections. Neonates of precocial species are physically mature at birth, with fully functional ears and eyes, fur-bearing , and do Oryctolagus cuniculus) in which the expression of UCP1 depends on the environmental challenges to thermoregulate, not only recurring to metabolic pathways through BAT activation but behavioral changes such as huddling [In contrast, the offspring of altricial species are small-sized, compared to precocial species, naked with little or no fur, with uncoordinated locomotion . If theyhuddling . Figure Rattus norvegicus), maturation of the prefrontal cortex, with complete synaptogenesis and myelination, occurs at approximately 90 days post-birth [Neurologically, differences in brain growth and development between precocial and altricial species are observed. The central nervous system maturation in altricial animals depends mainly on the postnatal period because the hypothalamic structures are the main thermoregulatory organs. During their fetal state, the brain reaches only 10% of its total growth, in contrast to precocial animals in which it reaches up to 50% of its adult size . In ratsst-birth . As a rest-birth . The degree of muscle development, one of the thermoregulatory characteristics that generate the shivering mechanism in newborns, is another factor that presents differences between the offspring of altricial and precocial species . Grand  has recoMonodelphis domestica), the skin in which the receptors in charge of perceiving thermal stimuli are located [M. domestica [Setonix brachyurus), an extreme case of altricial species, facilitating heat loss [(Cavia porcellus) or the African spiny mouse (Acomys cahirinus) [Similarly, skin thickness and the presence or absence of fur are relevant for thermoregulation, and they present differences between altricial and precocial animals. In altricial species such as gray short-tailed opossum   in whichhirinus) . In lambhirinus) . Mus musculus), this happens at approximately two weeks of birth [O. cuniculus), ovine (Ovis aries), bovines , and goats (Capra hircus), BAT disappears within a month, from 2 to 3 days in rabbits and ovine and from 2 to 6 days after birth in bovines [Sus scrofa). Despite having independent locomotion within a few minutes of birth [Lastly, the primary mechanism of heat production in neonates is BAT activation; however, the perinatal development of BAT differs among species. Precocial animals such as guinea pigs, lambs, and cattle calves, are born with a well-developed BAT that atrophies rapidly, and it is replaced by white adipose tissue (WAT) within a short time during the postpartum period ,75. In cof birth . Analysiof birth . This reof birth , pigletsof birth , their lof birth . In partof birth , influenof birth .To sum up, the morphological characteristics of the animals at birth will dictate their thermoregulatory capacity, either facilitating or altering it. For this reason, it is necessary to understand the specific precocial and altricial mechanisms used to preserve body temperature before we introduce any intervention to prevent neonatal hypothermia. Among the three types of adipose cells found in mammals , BAT represents the least abundant but the one with the greatest thermogenic capacity, especially at birth . NonetheUnlike WAT, BAT has more mitochondria, high cytochrome Cc content, a vast vascular network ,84, and Peromyscus maniculatus) kept at a temperatures of 5 °C. BAT utilization increased by 42% (measured in terms of oxygen consumption), suggesting it is the only mechanism responsible for maintaining thermal stability during the first days of life [Phyllotis darwini) was shown to improve the thermoregulatory capacity of neonates, achieving higher body temperatures (32.3 ± 2.41 °C) compared to animals acclimated to an ambient temperature of 30 °C, which can be attributed to higher amounts of BAT and the increased expression of UCP1 in adipocytes [An example of this was reported in 27 newborn deer mice , approximately half of the cold-induced summit metabolic rate comes from non-shivering thermogenesis. The presence of metabolic-active BAT during the early postnatal period is essential [Precocial animals, such as ruminants usually present a greater development of thermoregulatory mechanisms at birth, allowing them to maintain a constant body temperature, even in cold environments . In thesssential . Howeverssential ,96.O. aries) for up to 33 days. In these animals, the impact of cold acclimatization of the pregnant dams can influence the thermogenic capacity of the offspring. In lambs from mothers exposed to cold climates, they had a 21% greater perirenal fat, increased metabolic activity (40%), and higher oxygen consumption in cold temperatures (16%). Additionally, the thermogenesis responses of these lambs were due solely to non-shivering thermogenesis, in contrast to lambs from dams not climatized to the cold [The thermogenic activity has been measured in perirenal adipose tissue from newborn lambs  are a species born with low amounts of BAT; their main ways of heat production rely on shivering and colostrum intake shortly after birth [longissimus thoracis and rhomboideus muscle per unit tissue area), biochemical , physiological, and metabolic adaptations in the maturation of the energy production of the musculoskeletal system in piglets are an adaptive thermoregulatory mechanism [In most mammals, concurrently with non-shivering thermogenesis, colostrum intake in the first hours of life represents an energy resource that contributes to maintaining a stable temperature in neonates . In parter birth . Furtherechanism . Additioechanism .On the other hand, the fetal development of BAT, the mother’s diet during gestation, and the influence of hormones such as melatonin have been shown to influence the thermoregulation capacity of the newborn. The case of 5 to 6-day-old lambs born from dams with low melatonin profiles and exposed to 4 °C showed a reduction in BAT temperature of approximately 39.8 °C compared to the control group of 40 °C and elevated NE concentrations greater than 1000 pg/ml, as a result of thermal stress . Ursus americanus) [Thermogenesis by BAT activation is essential in the neonate of most species, and it is also essential in hibernating animals such as American black bears (ricanus) ,112, whiShivering is the universal thermogenic mechanism through the repetitive and rapid contraction of the skeletal muscle when the body is exposed to cold environments or when there is hypothermia. The muscle fibers are from resistant aerobic muscles that can produce repeated contractions . This prP. maniculatus), high-altitude habitats (4350 m.a.s.l.) reduce the capacity to generate heat by shivering. The capacity is reduced by 30%, and only when deer mice pups reach 27 days-old do they develop an aerobic muscle phenotype, predisposing them to hypothermia and mortality. However, this characteristic is also considered a physiological adaptation to reduce energy expenditure by thermoregulation [Despite being a mechanism for heat production, shivering includes consequences such as an increase in oxygen consumption of up to 20-fold, increasing the aerobic capacity of muscle fibers, and leading to fatty acid oxidation . Other cgulation .Canis lupus familiaris) have only 1.3% body fat [Ursus maritimus), where they are born in temperatures as low as −25 °C. Over time they increase the ability to shiver, improve their insulation traits and, in some cases, develop BAT [One of the main differences in thermogenic capacity through shivering between altricial and precocial species is caused by species-specific morphological features. For example, the intensity of shivering depends on the percentage of body fat, the surface-to-volume ratio, and the ATP necessary to maintain contractions . In the body fat ; therefobody fat ,119. A selop BAT , or resoAs stated before, thermogenesis through rapid and oscillating muscle contractions or twitching of skeletal muscle is an involuntary mechanism that produces energy released in heat . AlthougIn this sense, shivering heat production in piglets has been associated with a decrease in muscle glycogen up to 47%, as well as a decrease in total lipid content, a decrease in lactate in blood, and better muscle cytochrome oxidase activity (by 20% more), indicating the increase in muscle potential with exposure to cold .According to Alexander and Williams , in one-On the other hand, in piglets exposed to low temperatures (25 °C), thermogenesis by shivering increased its activity. However, their temperatures remained slightly lower than newborns exposed to thermoneutral temperatures (34 °C) . In a reRattus norvegicus) subjected to motility frustration . These animals showed restlessness, and the stress caused low paw temperatures due to sustained vasoconstriction.Another sympathetic-dependent response to hypothermia is vasomotor shifts in the peripheral circulation . When exS. scrofa), 2 to 4-hour-old Meishan piglets (Sus domesticus) have greater development at birth than piglets of the European breed. For example, in Meshian piglets, cardiovascular responses to cold (vasoconstriction) were observed on birth/1 day/2 days after birth. In contrast, in Pietrain, Landrace, and Large White crossbred piglets, the vasomotor response capacity was not observed until five days after birth [In precocial species, some differences in thermoregulation between breeds have been reported. In pigs , it has been observed that adopting postures such as huddling with littermates [O. cuniculus), the most frequent behaviors are huddling, rooting, climbing, and maintaining close contact with the rest of the littermate. These behaviors seek to retain a better position within the nest, ensuring a source of heat and food [O. cuniculus, F. domestica). In this study, the authors determined that BAT is the main activation mechanism of thermogenesis in newborn rabbits, and that posture changes are vital in preserving their body temperature. They reported that kits positioned on the group’s periphery had lower BAT reserves and low triglyceride concentrations (101.7 ± 24.8 mg/dL), suggesting that these animals were exposed to a greater thermal and metabolic challenge than the rabbit neonates found in central positions. IRT is a tool not limited to evaluating vasomotor thermoregulation mechanisms, and there are reports that this tool can record BAT or muscle activity in laboratory animals in different settings [O. cuniculus) pups are shown to represent altricial species and the effect that central or peripheral position has on the superficial temperature of newborn rodents and lagomorphs. As stated previously, postural changes such as adopting a central position are a thermoregulatory mechanism that prevent heat loss and facilitate heat conduction by the presence of littermates and even the dam.Most of the thermoregulatory behavioral changes observed in animals are innate activities. However, there is evidence that learning is another adaptative mechanism to adverse environmental conditions, as observed in rats who have shown their capability to learn and light lamps to generate heat . It is btermates  or assumtermates . In Euroand food . In thisand food  have stusettings . Figure settings  on the eAlces alces) that, in addition to the amount of BAT present at birth, newborns require feeding an average of 8 times a day in 130 second sessions to obtain nutrients and to thermoregulate [Alopex lagopus) in artic environments can reduce heat loss through postural and behavioral changes, increasing metabolic heat production to prevent heat transfer from the core to the surface [In precocial species such as lambs, behavior at birth greatly contributes to their thermoregulation. One of its first reflexes is standing from the floor and seeking the udder to suckle and to consume colostrum. Getting up off the ground reduces heat loss, while the vitality and they speed with which the newborn finds the nipple promote early colostrum intake necessary for energy production . Unlike regulate . Similar surface .Enhydra lutris) inhabit places with cold temperature climates to subarctic waters, while polar bears (Ursus maritimus) live in the arctic [Aptenodytes patagonicus), which with their adaptations can lower their abdominal and subcutaneous temperature to −25 °C and then return to their normal temperature through subsequent rewarming [Air-breathing marine vertebrates need to maintain thermal homeostasis in an oxygen-limited aquatic environment. That is why these animals, thanks to their phylogeny and thermoregulatory adaptations, have managed to survive in environments with changing temperatures using morphological, physiological, and behavioral traits ,148,149.e arctic . Anotherewarming . We can IRT has shown that it allows evaluating the thermal state of animals when exposed to extreme environmental conditions, but also in the newborn it allows monitoring each of the thermoregulatory mechanisms during hypothermia ,134. ItsPhodopus roborovskii). At birth, their surface temperature was similar to that of the environment (21 °C) due to their low body mass. In contrast, after 15 and 16 days, their body mass increased to 5.5 ± 0.2 g and 5.8 ± 0.2 g, respectively, facilitating metabolism and heat production [IRT has been suggested as a tool that could evaluate the compensatory thermal response to hypothermia in different species such as dogs, pigs, and ruminants ,119,135.oduction . The samoduction . Some auoduction ,158, andoduction ,123. Howoduction . Soerensoduction  mentioneoduction ,159.IRT has also been used in maternity pens to evaluate the influence of the pen characteristics  on the thermal response of sows and piglets. Dela Ricci et al.  found thOne of the situations that can affect the survival of newborns is low temperatures or cold environments since their thermoregulatory system is limited in most cases. Neonatal animals from altricial species are usually more likely to suffer from hypothermia due to their reduced maturity/development at birth. On the contrary, precocial animals tend to adapt more quickly to thermal changes at birth, except for individuals born with a lower birth weight or difficulties during parturition that cannot have adequate access to colostrum. The ability of newborn mammals to maintain their core temperature within normal parameters is fundamental for their adaptation to the extrauterine environment and survival. That is why understanding better the specific mechanisms used by each species will allow targeted interventions to develop. Moreover, implementing thermoregulation monitoring tools, such as IRT, would help to refine and to assess the success of targeted interventions to prevent hypothermia and the consequences it can generate in neonatal mammals.


Cholesteatoma is a well-known infection resembling a pearl. Its histological aspect is of an epidermal cyst formation characterized by epidermal-keratinized tissue in the middle ear and mastoid that can migrate and erode to adjacent structures.To verify epidermal cyst (cholesteatoma) growth through implantation of auricular skin of a mouse next to its femoral bone.experimental.Ten healthy rats between two and five months of age and of both sexes underwent implantation of auricular skin on the femoral bone during a three-month period. Paraffin-embedded sections were obtained from the sample and stained with hematoxylin and eosin for pathology investigation.Conclusions: Growth of epidermal cyst (cholesteatoma) may start from a transplanted epithelial tissue next to the femoral bone of rats.Macroscopic view: round soft yellowish granulation tissue. Microscopic view: keratinizing stratified squamous epithelium cystic formation. The cyst presented innermost corneal layer, resulted from keratinized skin, followed by granulated and squamous layers, and outermost basal layer.  Cholesteatoma is a well-known infection of the middle ear and was firstly reported by Curveilhier in 1829 as a pearled tumor. In fact, cholesteatoma is a squamous cell cyst, characterized by keratinized epidermoid tissue that can migrate and erode to adjacent structures frequently found in temporal bones and in people with history of chronic middle ear otitisThe squamous cell cyst presents an external matrix formed by keratinizing stratified squamous epithelium over a perimatrix of fibroconnective tissue . Histologically, the epithelium is similar to the epidermis and its four basic layers can be observed . The matrix peels off keratin scales (lamellas) into its internal own area, filling and enlarging itCholesteatoma has lytic and migrating characteristics and it may destroy both the ossicular chain and the mastoid bone cavity, leading to intra and extracranial complications.Traditionally, this cyst is classified as congenital and acquired (primary and secondary), depending on its genesis. Pathogenesis of acquired cholesteatoma is directly related to middle ear affections, either by dysfunctions or infections of the auditory tube, leading to perforation of the tympanic membrane, which is not observed in congenital cholesteatoma.Recent studies demonstrated that the onset and evolution of cholesteatoma seem to be multifactorial and are related to genetic and environmental characteristics, including aspects of molecular biology, once cytokeratins are present in epithelial cells with latent features of proliferation and migration. Moreover, a cascade performance of cytokines – proteins produced by cells in response to an inflammatory process modifying their own cellular characteristics or surrounding tissuesGiven it is an epidermal tissue, the cholesteatoma has cytokeratins 1, 2, 10  and cytokeratins 5 and 14  and magnetic resonance . Surgical treatment is generally adopted.Cholesteatoma is diagnosed by an accurate anamnesis, while history of disease is essential due to its peculiar features. At otorhinolaryngology examination, otoscopy should be performed microscopically. Attention should be given to presence of secretion in the meatus and tympanic cavity, which must be treated and fully aspirated. Aspect of the tympanic membrane should be observed, particularly the Experimental trials showed formation of epidermoid cyst when keratinized epithelium is implanted in bonesInjection of propyleneglycol in the tympanic bulla of rats induces formation of cholesteatoma probably due to migration of tympanic basal epithelium layerEventual reproduction of an epidermoid cyst in more accessible regions allows us to conduct a detailed study of disease onset and development, involving several molecular aspects. The thigh of a mouse was chosen as it is an accessible bone of manageable dimensions. Also, it does not involve vital structures and yields easy recovery of the animal after the procedure.This study aimed at verifying the growth of an epidermoid cyst (cholesteatoma) after implantation of a skin fragment from the auricular pavilion to the femoral bone of rats.Ten healthy rats aged 2 to 5 months of both sexes were selected and submitted to implantation of skin fragment from the auricular pavilion to the thigh. In the first three animals, only one paw received the implantation, and the others received skin grafts on both paws, resulting in 17 studied paws.The animals were maintained in lab cages at the Embryology Lab of the Morphology Department of Federal University of Sao Paulo, where they were fed, hydrated and kept under appropriate temperature. They were assisted by a sector employee and overseen by researchers.Animal manipulation started with general anesthesia with ether.A skin fragment measuring approximately 4 × 4 mm was incised from a non-hairy area of the auricular pavilion. Incision of the thigh mid third was performed and the musculature was directed up to the femur. At this site, the periosteum was removed and part of the skin fragment was implanted over. After that, skin suture was performed using a 0-4 mononylon thread.For comparative criterion, in the right thigh, the epithelium's side was placed in contact with the femur and, from the fourth animal on, the subcutaneous side of the left thigh was placed in contact with the bone.Once the procedures were over, the animals were put back in their cages and maintained in the same environment for 3 months. After this period, the animal was sacrificed and the implanted tissue was removed. Each fragment was separately fixed according to Bouin's procedure, paraffin-embedded and stained with hematoxylin and eosin (H-E). The slides were prepared and sent for clinical pathology.Out of 17 paws, 16 presented epithelial tissue along with muscle, showing evidences of bone tissue migration to outermost layers.No implanted tissue could be found on 1 paw.Tissues' aspect was granulated, yellowish, round and soft, measuring about 3 mm in diameter.Histological H-E-stained sections showed a cystic structure covered by squamous stratified epithelium . CornealCholesteatoma is a destructive lesion of the temporal bone that gradually expands and leads to complications by erosion of the bone surrounding structures. Bone reabsorption may result in destruction of the ossicular chain and optical capsule followed by hearing loss, vestibule dysfunction, facial muscle paralysis and intracranial complications. Surgery is the treatment of choice. However, cholesteatoma pathogenesis is rather controversialStudies indicate that the epidermoid tissue of the middle ear is originated in the epidermis of the external auditory canalEpidermoid formation was again investigated in fragments of temporal bones in order to find a relation with congenital cholesteatoma. The findings confirm that the epidermoid tissue is precursor of the congenital cholesteatomaA similar study was conducted in rats, although skin implantation of external auditory meatus was transplanted in the middle ear. The result was formation of an epithelial cyst or gradual transition in the middle ear epithelium. In addition, expressive epithelial growth was observed when over imposed infection occurredAnother investigation with the same characteristics of our research study had also verified formation of epidermoid cysts (cholesteatoma) in part of animals, presenting inflammatory reaction that was associated with formation of cholesteatomaOtology procedures have been described as etiological factors in development of epidermoid cyst of the middle ear and the tympanic membrane. Case reports present history of cyst formation on the same side of otological surgeries, postulating that it may arise from epidermal elements and that implantation of keratinized epithelium may have occurred in the middle ear at the time of surgeryIn trials, pathogenesis of cholesteatoma was also predominantly associated with bone reabsorption induced by a cyst and mediated by osteoclastic activity occurring within the middle ear. It is important to emphasize that this osteoclastic activity is a criterion to understand the cholesteatomaThe study revealed basic events of osteoclastic activity with localized bone reabsorption and promoted new findings for understanding induced resorption by cholesteatomaIn Antunes' studyIn the same study, the author used trans-retinoic acid in one of the ears of these animals, keeping the other side as control. On the side that received trans-retinoic acid, growth of cholesteatoma was very reduced, indicating that this drug should inhibit growth process of cholesteatomaIn our study, only 1 out of 17 paws did not show a cyst, which may be explained by possible absorption or migration to a distant region. On the other 16 paws with epidermoid cysts, they were rounded, soft and yellowish. The material was not found next to the femur and did not present bone erosion by the cyst, but was rather found superficially on the muscular layer, indicating that the organism was trying to expulse the cyst. Regarding the epithelium in contact with the bone, no difference in the behavior of skin or subcutaneous superficial layer was observed, leading to formation of a cyst without bone lesion. Skin fragment encysting to its uppermost layer inside the cyst shows that the organism tries to isolate keratin as if it was a foreign body.In the last decade, the osteoclastic activity was broadly discussed as the main factor to induce bone destruction in chronic middle ear otitis due to cholesteatoma. Cellular inflammatory factor, such as cytokines, could play a role as a trigger for onset of osteoclastic activity. Following, local concentration of lipopolysaccharides could make cytokines locally available. This fact turns local concentration of lipopolysaccharides an important factor for bone resorption in the cholesteatomaA study covering expression and distribution of transforming growth factor alpha (TGF) in the middle ear suggests that autocrine and paracrine stimulation of TGF in the cholesteatoma squamous epithelium may contribute for its proliferationSince epidermoid cyst may be experimentally reproduced in accessible sites, molecular aspects in the formation and growth of cholesteatoma may be investigated.We came to the conclusion that the epidermoid cyst (cholesteatoma) may arise from an epithelial tissue transplanted onto femoral bone of rats. This study in experimental models shows that internalization of keratinized epithelium (skin) stimulates the organism's defense mechanism to isolate the foreign tissue to the center, forming a cyst to expel it.


Onset of BPD was not associated with differences in serum HRG levels. Further, the serum HRG levels increased significantly after birth in extremely preterm infants.Histidine-rich glycoprotein (HRG) has been reported to inhibit signaling leading to the release of high mobility group box 1 protein, a damage-associated molecular pattern. The present study aimed to determine the longitudinal change in HRG levels in extremely preterm infants and assess whether complications such as bronchopulmonary dysplasia (BPD) were associated with differences in HRG levels. In this multicenter, prospective, observational study, we measured serum HRG levels every 2 weeks from birth to 8 weeks of age. Serum HRG was measured using an enzyme-linked immunosorbent assay. We included 19 extremely preterm infants in the study and 74 samples were analyzed. The median gestational age was 26.0 weeks, and the median birth weight was 858 g. Serum HRG levels showed a significant upward trend after birth ( Histidine-rich glycoprotein (HRG) is a plasma protein with a molecular weight of 75 kDa, synthesized in the liver, monocytes, macrophages, and megakaryocytes ,2,3,4. HHRG has been reported to inhibit signals leading to the release of high mobility group box 1 protein (HMGB-1) and damage-associated molecular patterns (DAMPs) linked to various pathologies, including sepsis ,10. HMGBAlthough preterm infants have been reported to have lower HRG values at birth than adults, no studies have measured subsequent trends over time . We hypoThe purpose of this study was to determine the longitudinal change in HRG in extremely preterm infants and evaluate whether comorbidities such as BPD were associated with differences in HRG. Identifying changes in the HRG of infants with comorbidities may lead to the development of new treatments, such as HRG-rich fresh frozen plasma, for diseases in extremely preterm infants.This prospective, observational study was planned at Okayama University  and was conducted with the cooperation of the Okayama Medical Center . We included infants born at less than 28 weeks of gestation and admitted to either institution between April 2016 and March 2022. Written informed consent was obtained from the parents of the patients. Infants with chromosomal abnormalities, complex cardiac malformations, central nervous system abnormalities, inborn errors of metabolism, or immunodeficiency syndromes, as well as any infants deemed unsuitable for participation by the attending physicians, were excluded.Comorbidities were defined as follows. Respiratory distress syndrome (RDS) was diagnosed using a stable microbubble rating and chest radiograph before surfactant replacement . BPD wasUsing electronic medical records, we obtained the following data: gestational age, birth weight, sex, presence or absence of the aforementioned complications, gravidity, parity, cesarean section, Apgar score, umbilical cord artery blood pH and its base excess.Specimens were collected from the umbilical venous blood at birth and peripheral venous blood every 2 weeks until 36 corrected weeks (maximum 8 weeks old). Sample collection was delayed for up to 1 week, depending on the infant’s condition. After the specimens were collected, the serum was centrifuged and stored at −20 °C. HRG was measured using an enzyme-linked immunosorbent assay kit .The primary endpoint was the difference in HRG between infants with and without comorbidities such as BPD36. The secondary endpoint was serum HRG concentration at each time point.p < 0.05. The statistical software used were R 4.1.1  and the lmerTest package.For statistical analysis, the Mann–Whitney U test and Fisher’s exact test were used to compare baseline characteristics. Values are presented as number (percentage) or median (interquartile range). Comparison of HRG values with and without comorbidities was performed by repeated measures analysis of variance using a mixed-effects model. Statistical significance was set at This study was approved by the Ethics Committee of Okayama University (No. K1902-036 approved on 1 March 2019 and No. K1510-016 approved on 27 October 2015).This study included 19 extremely preterm infants with parental consent. Blood samples were collected from the cord blood at birth to 8 weeks of age, and 74 samples were analyzed. The median gestational age was 26.0 weeks, and the median birth weight was 858 g. Comparisons of the primary endpoint are shown in p < 0.001) (p = 0.023); blood collected at 2 weeks old and 6 weeks old (p = 0.049); blood collected at 2 weeks old and 8 weeks old (p = 0.044).Serum HRG levels showed a statistically significant upward trend after birth (< 0.001) . Post-hoThis is the first study to measure the postnatal course of serum HRG levels in extremely preterm infants. The HRG concentration at birth was 1.07 μg/mL, which was lower than the concentrations reported in term infants and adults in previous studies  . AdditioHRG was discovered by Heimburger et al. in 1972 ,19. HoweRecently, HRG has been reported to be associated with HMGB-1 and DAMPs. Gao et al. demonstrated that HRG suppressed HMGB-1-induced inflammatory responses and identified the associated HRG receptors . HMGB-1 This study may be one of the first to clarify the connection between comorbidities in extremely preterm infants and HRG. The association between shorter postmenstrual weeks and lower HRG levels led to the expectation that the suppression of the activity of HMGB-1, a DAMP, would be less effective in extremely premature infants. However, in the present study, there was no clear difference in HRG values based on the presence or absence of comorbidities. We speculated on two reasons for these negative results. First, the number of study participants in the present study was small; there was a trend toward slightly lower HRG levels in the BPD group, which could be significant with a larger number of study participants. Second, premature infants who develop BPD and/or other comorbidities are often given blood products, including fresh frozen plasma. Because HRG is contained in these products, the administration of such products may affect the HRG level of the infant.To compensate for the small sample size in the present study, we used a mixed-effects model . While tIn conclusion, serum HRG levels were not different between BPD infants and non-BPD infants. Serum HRG levels significantly increased after birth in extremely preterm infants. Additional research and analysis of more cases might reveal differences in HRG due to comorbidities.


ContextNeonatal birth/perinatal asphyxia is a serious condition with the potential to cause damage to various tissues of the body especially the brain. Hypoxia can cause metabolic disturbances, which in turn can lead to imbalances in the levels of glucose, electrolytes, and calcium, which can further worsen the condition. Early detection of these biochemical derangements and immediate correction can prevent the complications and lifelong disabilities of birth asphyxia due to injury to vital organs particularly the brain. The aim is to assess any correlation between the cord blood glucose, electrolytes, and calcium levels and the severity of birth asphyxia.Methods and materialIn this study, 50 birth asphyxia neonates with birth weight >2.5 kg, and a 5-minute Apgar score ≤ 6 at birth with clinical evidence of asphyxia were compared with healthy neonates with birth weight > 2.5 kg, and a 5-minute Apgar score > 7. In all the cases and controls, cord blood glucose was estimated by glucose oxidase and peroxidase (GOD-POD) method, total calcium by Arsenazo method, and sodium and potassium were estimated by ion-selective Electrode (ISE) method using fully automated biochemistry analyzers.ResultsThe mean cord blood concentrations of glucose, sodium, potassium, and calcium were significantly lower among birth asphyxia neonates in comparison with that of controls (p < 0.05). The correlation coefficient (r) for the study variables among cases indicates that there is a low to moderate positive correlation between the 5-minute Apgar score which is a measure of severity of birth asphyxia and cord blood concentrations of glucose, sodium, and calcium.ConclusionIn our study, birth asphyxiated neonates were found to have statistically significant low levels of cord blood glucose and electrolytes like sodium and calcium except for potassium. There was a low to moderate positive correlation between cord blood glucose and electrolyte concentrations with the severity of birth asphyxia. Analysis of cord blood for these simple biochemical tests can help pediatricians in the active management of birth asphyxia cases. Birth asphyxia is characterized by “the failure to establish breathing at birth” . The NatBirth asphyxia is a common neonatal health problem and contributes significantly to neonatal morbidity and mortality. Worldwide, every year 4 million deaths among newborns and 3.2 million stillbirths occur and out of which, perinatal hypoxia contributes 23% and 29%, respectively. Around 1 million children who survive after being affected by birth asphyxia, continue to suffer from long-lasting neurological and developmental disabilities . In the APGAR score is the most convenient and commonly used tool for the evaluation of asphyxia in neonates. Five elements, the APGAR score considers are color, heart rate, reflexes, muscle tone, and respiration, each of which is given a score of 0, 1, or 2. It is reported at 1 minute and 5 minutes after birth and the total score can range from 0 to 10. In a term neonate, a 5-minute Apgar score of 7-10 is interpreted as reassuring, a score of 4-6 as moderately abnormal, and a score of 0-3 as low . SeveralIn a biological system, sodium, potassium, and calcium are the most important electrolytes, and any significant fluctuations in the blood concentrations can lead to metabolic derangements causing convulsions and shock. Calcium has many crucial functions in the body such as acting as an important second messenger, required for normal muscle contraction and many enzyme reactions. Tight regulation and maintenance of normal blood concentrations of these electrolytes are important for optimal functioning of the body .Assessment and management of electrolyte status in the newborn is a very crucial and difficult task. Water and electrolyte levels in the body can vary largely during the transition from fetal to newborn life. Before birth, the fetus receives the nutrients including fluid and electrolytes from the maternal blood and their levels are predominantly controlled by the maternal regulatory system. After the birth, the neonate should quickly take over the charge of water and electrolyte balance independently and efficiently in an outside unfavorable environment. Therefore, transitory alterations in the fluid and electrolyte levels can be expected and even a minor change in the absolute concentrations of these electrolytes can suggest proportionately substantial variation for the newborn considering its relatively small size .In 90% of term babies, the asphyxia occurs during antepartum and/or intrapartum period. The important maternal/fetal conditions associated with perinatal asphyxia are eclampsia, diabetes mellitus, Rh isoimmunization, antepartum hemorrhage, renal or pulmonary disease, cephalopelvic disproportion, IUGR, meconium-stained liquor, prolonged labor .An adequate amount of oxygen is required for the cellular metabolic processes. During perinatal hypoxia, there is a shift in the metabolic process from aerobic to anaerobic glycolysis, wherein the energy yield will be less and increased production of lactic acid which can lead to metabolic acidosis. When the hypoxia is prolonged, the cardiac output falls and blood flow to the brain, kidney, and other vital organs may be compromised leading to hypoxic-ischemic organ damage. The blood glucose levels may fall due to increased utilization of glucose for anaerobic glycolysis. Serum potassium levels may be high because of increased cellular damage, which can further lead to lower serum sodium levels due to increased secretion of ADH and water retention. Serum calcium levels tend to drop due to hypoxic-ischemic damage to parathyroid glands .Earlier studies have found a higher incidence of hypoglycemia, low sodium and calcium levels, and high potassium levels in asphyxiated neonates as compared to healthy controls ,13-17. MDespite increasing knowledge regarding the underlying mechanisms for birth/perinatal asphyxia, early detection of hypoxic-ischemic organ damage remains challenging in neonatal care. Hence, the purpose of this study was to determine any association between the cord blood glucose, electrolytes, and calcium levels and the severity of birth asphyxia, so that complications related to hypoxic-ischemic injury can be anticipated early and appropriate treatment can be initiated at the earliest to reduce the neonatal morbidity and mortality.ObjectivesThe first is to estimate the cord blood concentrations of glucose and electrolytes namely sodium, potassium, and calcium in asphyxiated neonates and compare them with those of normal non-asphyxiated control newborn babies. The second is to ascertain any correlation between cord blood concentrations of glucose, sodium, potassium, and calcium with a 5-minute Apgar score which is a measure of severity of birth asphyxia in both asphyxiated and non-asphyxiated neonates.Study designThis is a hospital-based cross-sectional study.Study settingDepartment of Obstetrics and Gynecology, Department of Pediatrics and Department of Biochemistry, BLDE (Deemed to be University) Shri. B. M. Patil Medical College, Hospital and Research Centre, Vijayapura, Karnataka during the period from January 2012 to December 2014.Sample sizeN=100; n=50 full term (>37 weeks) birth asphyxia neonates, n=50 full term (>37 weeks) healthy newborn babies.Prior to the commencement of the study clearance from the Institutional Ethical Committee was obtained . Guidelines of the revised (2013) Helsinki Declaration of 1975 were followed. Before recruitment of cases and controls, the pregnant women/parents/guardian of all the cases and controls have explained the purpose of the study in their local language, and their written informed consent was obtained. Trained obstetricians conducted deliveries and all the neonates were duly taken care of by the neonatologists.The full-term (37 to 40 weeks of gestation) pregnant mothers aged between 20 and 45 years who are in the first stage of labor under the supervision of a trained & experienced obstetrician and pediatrician were closely monitored during and after delivery until discharge. The data regarding socio-demographic characteristics including age, parity, and literacy, maternal risk factors such as the history of diabetes, hypertension, stillbirths, infections, anemia, etc., presence of antenatal risk factors such as antepartum hemorrhage, pregnancy-induced hypertension, premature rupture of membranes and information regarding intrapartum events such as induction of labor, prolonged labor, meconium staining of amniotic fluid, presentation, cord around the neck instrumental delivery and cesarean section and neonatal particulars like sex, birth weight of the baby were noted in a predesigned proforma. An experienced pediatrician and neonatologist assessed the neonates at 1 minute and 5 minutes after birth for heart and respiratory rates, muscle tone, reflexes, and color, and Apgar score was calculated. Later, a detailed clinical and neurological examination was done to detect any clinical signs of hypoxic-ischemic encephalopathy (HIE).Neonates with birth weight >2.5 kg, and Apgar score ≤ 6 at 5 minutes of birth with minimum two or more of the following criteria such as blood pH ≤ 7.2, abnormal fetal heart rate (<100/min or > 160/min) and/or meconium-stained amniotic fluid, seizures, and/or coma or those who required resuscitation with >1 min of positive pressure ventilation were considered as birth asphyxia cases. Controls were those neonates with birth weight > 2.5kg, and Apgar score ≥ 7 at 5 minutes of birth with normal fetal heart rate and clear amniotic fluid. Neonates having birth anomalies, suspected inborn errors of metabolism, born to mothers who were on diuretics/anti-hypertensives/hypoglycemic drugs or had a history of pregnancy-induced hypertension or eclampsia, lower section cesarean section (LSCS) on General anesthesia or on drugs such as phenobarbitone, pethidine, MgSO4 and any such medications which can lead to neonatal respiratory distress and history of maternal pyrexia within two weeks prior to delivery were excluded from the study.From all the cases and controls, after Inclusion in the study as per the above-mentioned inclusion and exclusion criteria, 2 mL of cord blood samples were drawn using all sterile precautions in an appropriate container. A blood sample was subjected to centrifugation half an hour after collection and serum was isolated and used for study investigations immediately. Cord blood serum level of glucose was estimated by glucose oxidase and peroxidase (GOD-POD) method  and totaStatistical analysisThe data obtained from the present study were analyzed using Statistical Package for the Social Sciences statistical software (SPSS) for Windows . Continuous variables are expressed as mean ± Standard deviation (SD) and range values and categorical data are presented as percent frequency of occurrence. Two-tailed unpaired t-test was used to compare the difference between the means of the two study groups. Association between two variables was assessed using Pearson’s correlation coefficient for parametric variables and Spearman’s coefficient for non-parametric variables. P-values of ≤0.05 were treated as statistically significant.Table Table Table Neonatal birth/perinatal asphyxia is a serious condition with the potential to cause damage to various tissues of the body especially the brain which is more prone to hypoxic-ischemic injury. Hypoxia can cause metabolic disturbances, which in turn can lead to imbalances in the levels of glucose, electrolytes, and calcium, which can further worsen the condition. Early detection of these biochemical derangements and immediate correction can prevent the complications and lifelong disabilities due to brain injury, renal cortical necrosis, etc. So early diagnosis and timely fluid and electrolyte management are required for a better outcome in neonates.In the present study, the cord blood glucose, sodium, potassium, and calcium levels were assessed among 50 asphyxiated and 50 normal-term neonates whose birth weight was 2.5 kg or more. Birth asphyxia was more common among male neonates and also those born by normal/instrumental delivery when compared to females and the caesarian section, though the difference is not statistically significant. Among the 50 hypoxia cases, 34 (68%) developed HIE Table . Of the In our study, we used a cord blood sample immediately after birth for biochemical analysis in contrast to the venous blood sample at 24-48 hours after birth as in most of the previous studies. Analysis of the cord blood has the advantage of detecting the electrolyte and other biochemical derangements at the early stage before the clinical/radiological signs appear or the irreversible damage sets in .The mean cord blood glucose concentration in birth asphyxia cases was considerably lower in our study 35.03 ± 4.14 mg/dL) when compared to controls 83.4 ± 23.8 mg/dL) (p < 0.001)  when compared to controls (138.3 ± 6.7 mEq/L) and the difference was statistically significant p = 0.002) (Table  (Table 2The mean cord blood potassium concentration was slightly higher in birth asphyxia babies (4.7 ± 0.6 mEq/L) in comparison with the normal babies (4.6 ± 0.7 mEq/L). However, statistically, the difference between the two groups was not significant (p = 0.445) Table . EarlierThere was a significant reduction in the mean cord blood calcium concentration among birth asphyxia babies (8.5 ± 1.6 mg/dL) in comparison with their control counterparts 9.6 ± 2.2 mg/dL) (p < 0.001) (Table .2 mg/dL Apgar scores among the cases Table . SimilarLimitationsIntravenous fluid and oxytocin used at the time of delivery were not taken into account, which might affect the electrolyte status in the mother and hence in the cord blood.It is critical to diagnose and treat newborns with birth asphyxia as early as possible in order to avoid lasting neurological and developmental disabilities. In our study, birth asphyxiated neonates were found to have statistically significant low levels of cord blood glucose and electrolytes like sodium and calcium except for potassium. There was a low to moderate positive correlation of cord blood glucose and electrolyte concentrations with the severity of birth asphyxia. Analysis of cord blood for these simple biochemical tests can help pediatricians in the active management of birth asphyxia cases. Further research with a large sample size is required to ascertain the cause-effect relationship between the study variables and the disease.


Preterm birth is one of the main causes of perinatal morbidity and mortality and imposes a heavy burden on families and society. The aim of this study was to identify risk factors and analyze birth conditions and complications of newborns born at < 32 gestational weeks for extremely preterm (EP) and very preterm (VP) birth in the clinic to further extend the gestational period.We performed a retrospective cohort study and collected data from 1598 pregnant women and 1660 premature newborns (excluding 229 premature babies who died due to severe illness and abandonment) admitted to the Obstetrics and Gynecology Hospital Affiliated with Nanjing Medical University in China from 2016 to 2020. We compared women’s and newborns’ characteristics by t-tests and Chi-square tests for continuous and categorical variables, respectively. Multivariable logistic regression was performed to estimate the effects of risk factors on EP and VP birth.P < 0.001); multiple pregnancy (P < 0.01), primipara (P < 0.001). Additionally, we identified 4 independent risk factors for VP birth: gestational diabetes mellitus (GDM) (P < 0.05), preterm premature rupture of membrane (PPROM) (P < 0.01), fetal intrauterine distress (P < 0.001), and hypertensive disorder complicating pregnancy (HDCP) (P < 0.001). In addition, pairwise comparisons revealed statistically significant differences in the incidence rates of neonatal pneumonia, bronchopulmonary dysplasia (BPD) and sepsis between the 28–28 + 6 and 29–29 + 6 weeks of gestation groups (P < 0.05). Compared with 28–28 + 6 weeks of gestation, neonatal complications were significantly more common at < 26 weeks of gestation (P < 0.05). The incidence rates of neonatal intracranial hemorrhage(NICH), patent ductus arteriosus(PDA), patent foramen ovale(PFO), pneumonia, BPD and sepsis were significantly higher in the 26–26 + 6 and 27–27 + 6 gestational weeks than in the 28–28 + 6 gestational weeks (P < 0.05).We identified 3 independent risk factors for EP birth: cervical incompetency (PPROM, is the most common risk factor for EP and VP birth, and cervical insufficiency, multiple pregnancy, and primipara are independent risk factors for EP birth. Therefore, during pregnancy, attention should be devoted to the risk factors for PPROM, and reproductive tract infection should be actively prevented to reduce the occurrence of PPROM. Identifying the risk factors for cervical insufficiency, actively intervening before pregnancy, and cervical cervix ligation may be considered to reduce the occurrence of EP labor. For iatrogenic preterm birth, the advantages and disadvantages should be carefully weighed, and the gestational period should be extended beyond 28 weeks to enhance the safety of the mother and child and to improve the outcomes of preterm birth.The online version contains supplementary material available at 10.1186/s12884-022-05119-7. Preterm birth, especially extremely preterm (EP) birth and very preterm (VP) birth, is a major challenge for newborns and their families as well as for perinatologists and neonatologists . The WorIn recent years, the rate of preterm birth has increased in many counties . PretermOur primary hypothesis was that there would be a difference in factors related to EP and VP birth. We performed a retrospective cohort study and collected data from 2062 pregnant women admitted to Obstetrics and Gynecology Hospital Affiliated with Nanjing Medical University in China from 2016 to 2020. Gestational age was determined based on the last menstruation and the earliest available reliable ultrasound data; if the last menstruation was unknown or uncertain, gestational age was determined using standard ultrasound data. A total of 241 women with incomplete information were excluded. We excluded 79 women with chronic diseases  and immune diseases. We also excluded 21 women who had a history of smoking. A total of 123 women who experienced abortions, induced labor, or stillbirths were also excluded in Fig. The study followed the Declaration of Helsinki and was conducted in accordance with the relevant local guidelines and regulations. The study was approved by theMedical Ethics Committee of Nanjing Maternal and Child Health Hospital, and informed consent was waived .P < 0.05 was considered significant .In this study, we compared women’s and newborns’ characteristics by t-tests and Chi-square tests for continuous and categorical variables, respectively. Multivariable logistic regression was performed to estimate the effects of risk factors on EP and VP birth, i.e., scarred uterus, preterm premature rupture of membranes (PPROM), multiple pregnancy, cervical incompetency, hypertensive disorder complicating pregnancy (HDCP), gestational diabetes mellitus (GDM), and abnormal fetal position. Risk factors for EP birth were identified by using binominal logistic regression models. We included scarred uterus, PPROM, multiple pregnancy, cervical incompetency, HDCP, GDM, and abnormal fetal position in the models. Odds ratios (ORs) were used to estimate relative risk with 95% confidence intervals (CIs). Adjusted ORs and 95%CIs were calculated to present the risk. All analyses were conducted using R software . We also retrospectively analyzed the complications, birth weight, apgar score 1–5 min after birth, rate of abandonment during treatment, rate of recovery and hospital stay in the neonatal intensive care unit (NICU) of infants born at < 32 gestational weeks. Categorical variables are presented as frequencies, and continuous variables are expressed as the mean (standard deviation). P > 0.05). The probability of EP and VP births differed in pregnant women with the following risk factors: scarred uterus, PPROM, GDM, multiple pregnancy, abnormal fetal position, cervical insufficiency, fetal intrauterine distress, hypertensive disease during pregnancy, abnormal amniotic fluid, abnormal umbilical cord blood flow, and chorioamnionitis (P < 0.05).Furthermore, we analyzed the risk factors for EP and VP births. The study cohort consisted of 1598 pregnant women. Demographic and clinical characteristics for EP (n = 287) and VP (n = 1311) births are shown in Table P < 0.20 in the single-factor analysis , while other complications, including neonatal respiratory distress syndrome (NRDS), neonatal intracranial hemorrhage (NICH), neonatal hyperbilirubinemia (NHB), patent ductus arteriosus (PDA), patent foramen ovale (PFO), sepsis, and neonatal necrotizing enterocolitis (NEC), did not differ significantly (P > 0.05). Compared with the 28–28 + 6 weeks of gestation group, neonatal complications were more common among the < 26 weeks of gestation group (P < 0.05). There was no significant difference in the incidence of complications such as NRDS, NHB and NEC between newborns born at 26–26 + 6 and 27–27 + 6 weeks of gestation and those born at 28–28 + 6 weeks of gestation (P > 0.05). The incidence rates of NICH, PDA, PFO, pneumonia, BPD and sepsis were significantly higher among newborns born at 26–26 + 6 and 27–27 + 6 weeks of gestation than among those born at 28–28 + 6 gestational weeks (P < 0.05). The incidence rates of complications such as NRDS, NICH, PFO and NEC were not significantly different between neonates born at 30–30 + 6 gestation and those born at 28–28 + 6 gestation (P > 0.05). The incidence of NHB, PDA, pneumonia, BPD and septicemia were significantly lower among neonates born at 30–30 + 6 gestation weeks than among those born at 28–28 + 6 gestational weeks (P < 0.05). Compared with newborns at 28–28 + 6 gestation weeks, the rate of neonatal complications significantly decreased at 31–31 + 6 weeks of gestation (P < 0.05).We excluded 229 premature babies who died due to severe illness and abandonment during the treatment, as shown in Fig. P < 0.01), while the rates of hospital transfer, severe disease and mortality were significantly higher than those in the VP infant group (P < 0.001).As shown in Fig. P > 0.05) in discharge weight of infants between the two groups.Then, we analyzed the birth status of surviving preterm infants, including 266 EP infants and 1394 VP infants , which were similar to those of a previous study [P < 0.001). Premature births due to an immature organ system are prone to many complications. A decrease in gestational age has been shown to be strongly associated with mortality and moderately associated with major neonatal morbidity [The comparison with extremely preterm and very preterm births, which have poorer neonatal outcomes compared to full-term births , 24, mayus study , and hosorbidity . In our Although we included many factors, there were some factors that may be missing or ignored due to not recorded in the medical record. For example, we did not consider smoking as a risk factor , these dPPROM is the most common risk factor for EP and VP births, and cervical insufficiency/multiple pregnancy/primipara is an independent risk factor for EP birth. The morbidity and mortality of premature infants are closely related to gestational age. The mortality and mortality of infants born at < 28 weeks of gestation were significantly higher. Therefore, during pregnancy, attention should be given to the risk factors for PPROM, and reproductive tract infection should be actively prevented to reduce the occurrence of PPROM. Identifying the risk factors for cervical insufficiency, actively intervening before pregnancy, and cervical cervix ligation may be considered to reduce the occurrence of EP birth. For iatrogenic preterm birth, the advantages and disadvantages should be carefully weighed, and the gestational period should be extended beyond 28 weeks to enhance the safety of the mother and child and to improve the outcomes of preterm birth.Below is the link to the electronic supplementary material.Supplementary Material 1Supplementary Material 2