Preterm birth is a major public health problem, especially in Puerto Rico where the rates are among the highest observed worldwide, reaching 18% in 2011. The Puerto Rico Testsite for Exploring Contamination Threats (PROTECT) study is an ongoing investigation of environmental factors that contribute to this condition. In the present analysis, we sought to examine common risk factors for preterm birth and other adverse birth outcomes which have not been characterized previously in this unique population. Pregnant women from the PROTECT cohort are recruited from the heavily contaminated Northern coast of the island of Puerto Rico and are free of pre-existing conditions like diabetes. We examined associations between basic demographic, behavioral , and pregnancy  characteristics as well as municipality of residence in relation to preterm birth (<37 weeks gestation), postterm birth (≥41 weeks gestation), and small and large for gestational age in univariate and multivariate logistic regression models. Between 2011 and 2017, 1028 live singleton births were delivered as part of the PROTECT cohort. Of these, 107 (10%) were preterm. Preterm birth rates were higher among women with low socioeconomic status, as indicated by education level and income, and among women with high pre-pregnancy body mass index (BMI). Odds ratios of small for gestational age delivery were higher for women who reported tobacco use in pregnancy and lower for women who delivered in the hurricane and dengue season (July-October). Overall, in pregnant women residing in Puerto Rico, socioeconomic status was associated with preterm birth but few other factors were associated with this or other adverse outcomes of pregnancy. Research to understand environmental factors that could be contributing to the preterm birth epidemic in Puerto Rico is necessary. Preterm birth is a global health problem that has major public health and economic consequences . In PuerThe Puerto Rico Testsite for Exploring Contamination Threats (PROTECT) cohort study was designed in 2010 to investigate the etiology of preterm birth on the island. This question is of critical public health importance because there is no explanation to date for the higher rates of preterm birth observed in Puerto Rico. Additionally, this study particularly aims to investigate environmental contaminants in the etiology of preterm birth because of the high density of Superfund waste sites located on the island. However, these factors cannot be examined without first understanding how the demographic and behavioral characteristics that are well-established predictors of preterm birth in the literature, including maternal age, socioeconomic factors, tobacco use in pregnancy, maternal body mass index (BMI), etc., are associated with preterm birth in this study population –9. The aThus, the objective of the present analysis was to establish whether or not demographic and behavioral risk factors that have been traditionally associated with preterm birth also exist in this study population, and to see whether these factors appear to be driving the higher preterm birth rates observed on the island. Additionally, since recruitment into PROTECT is ongoing, these data also establish rates of preterm birth within our study population prior to the devastation of Hurricanes Irma and Maria (August-September 2017) and their continued aftermath.in vitro fertilization to become pregnant, and were free of known medical or obstetrical complications, including pre-existing diabetes [PROTECT study participants are recruited on the island’s heavily contaminated northern coast at two collaborating hospitals and five nearby health clinics. All participants are recruited from clinics located in Camuy, Lares, Morovis, Quebradillas, and Ciales, and intend to deliver at one of the two collaborating hospitals: Manatí Medical Center and Arecibo’s Cayetano Coll y Toste Hospital. Pregnant women visiting the clinics or hospitals are recruited at approximately 14 weeks gestation and are eligible for inclusion in the study if they are between the ages of 18 and 40 years, reside in a municipality in the Northern karst region of the island, did not use oral contraceptives for at least three months prior to becoming pregnant, did not use diabetes . If eligFollowing the initial screening, women are invited to participate in three study visits. The first study visit is targeted for 20±2 weeks gestation and is performed in the clinic, at which point women are asked to provide urine and blood samples and fill out a questionnaire that collects information on demographic characteristics, personal care product use over the previous 48 hours, current and previous pregnancy complications, and physical activity. The second visit is targeted for 24±2 weeks and is performed in the participant’s home. At this time point a urine sample is collected, and questionnaires are administered to collect information on behavioral characteristics, medication use, physical activity, stressful life experiences, product and pesticide use, and dietary intake patterns . The third visit, targeted for 28±2 gestation, is also performed in the clinic and collects the same samples and information as the first visit, but has additional questionnaires to collect information on psychological stress and social support in pregnancy. At delivery, detailed information is collected on the pregnancy outcome along with birth weight and other newborn measurements. The research protocol for PROTECT was approved by the Ethics and Research Committees of the University of Puerto Rico and participating clinics, the University of Michigan, and Northeastern University.In order to the understand the basic risk factors for adverse birth outcomes in women residing in Puerto Rico, in the present analysis we examined associations with demographic, behavioral, and pregnancy characteristics among women who delivered live singleton births in PROTECT up until the month of Hurricane Irma (August 2017).2 calculated from self-reported pre-pregnancy weight and height at the first study visit and categorized as <25 kg/m2 , 25–30 kg/m2 (overweight), and >30 kg/m2 (obese); total household income in US dollars ; maternal education level ; employment status; and marital status. Alcohol use was assessed at the first study visit with a question about the last time the subject consumed one alcoholic beverage. If the participant reported that she does not drink alcohol, or that the previous drink was prior to pregnancy, then she was categorized as not using alcohol in pregnancy. Otherwise, she was coded as using alcohol in pregnancy. Information on smoking was also recorded at the first study visit. Participants were coded as not using tobacco in pregnancy if they reported never smoking or if they reported ever smoking but also reported quitting ≥6 months ago or prior to pregnancy. Otherwise, they were coded as smoking during pregnancy. Participants with missing information on tobacco or alcohol use were treated as missing . Number of pregnancies prior to the current pregnancy (gravidity) and number of prior births (parity) for each participant were obtained from the first study visit questionnaire as well.For the present analysis, we examined demographic, behavioral, and pregnancy characteristics as well as municipality of residence of the study population in relation to adverse birth outcomes. Most demographic factors were abstracted from initial screening or first visit questionnaires that were collected early in pregnancy ; infant sex ; and date of delivery that was used to calculate final gestational age, season of delivery , and year of delivery (2011 to 2017).st standard [th percentile and large for gestational age (LGA) was assigned based on birth weight >90th percentile for gestational age.Gestational age at delivery was assessed using self-reported date of LMP, collected at the initial screening, in combination with first ultrasound estimates of gestational age . Pretermstandard . Small fAs secondary analyses, we also investigated other adverse pregnancy outcomes including preeclampsia, gestational diabetes, low birth weight (<2500 grams), macrosomia (>4000 grams), as well as miscarriage (loss before 20 weeks of gestation) and stillbirth (loss after 20 weeks of gestation). Low birth weight and macrosomia were defined based on recorded birth weight at delivery and other adverse pregnancy outcomes were defined based on diagnosis in medical record by attending physician.All analyses were performed using SAS version 9.4 . First, we examined distributions of demographic, behavioral, and pregnancy characteristics within the study population. Second, we examined mean and standard deviation gestational age (weeks) and birth weight (grams) at delivery overall and by population characteristics listed above as well as municipality of residence. We tested for differences in gestational age at delivery and birth weight between categorical variables with linear regression models. For differences by municipality, we compared outcomes within each municipality to those in all other municipalities using T-Tests without assuming equal variances. Third, we examined associations between each characteristic and categorical pregnancy outcomes in models that were not mutually adjusted. We calculated odds ratios (OR) for preterm or postterm birth in separate models. The OR for preterm birth was calculated with postterm births excluded and vice versa. We similarly calculated OR for SGA and LGA in separate models. Finally, we created a multivariate model for each outcome to mutually adjust for all risk factors in order to contextually interpret our findings.The present analysis includes 1028 singleton live births from PROTECT participants who delivered between August 2011 and the end of July of 2017 and who had confirmed delivery and a reported date of LMP on the initial screening form . Ultraso2), with a population median (range) of 24.1 kg/m2 (14.7–50.2 kg/m2). Household income was condensed into the following categories based on small sample size in the higher income categories: <$20k; $20-40k; and >$40k. Forty percent of the study population had a household income below $20k per year; however, they were well-educated with 43 percent having a college degree or higher. Sixty-one percent of the study population was employed, and most participants were married or living together and did not smoke or drink alcohol during pregnancy . Finally, 59% of the population had more than one previous pregnancy and 51% had one or more previous births.Demographic and pregnancy characteristics of the study population are presented in The median gestational age at delivery in the overall population was 39.1 weeks (range 23.3 to 42.7 weeks), with 10% of singleton live births occurring preterm and 6% occurring postterm . The medParticipants from PROTECT resided in 21 different municipalities. At least 50 participants resided in each of the following municipalities: Arecibo, Barceloneta, Camuy, Ciales, Manatí, Morovis, and Vega Baja. Other municipalities had fewer than 50 participants and were combined into the “Other” category, and included: Aguadilla, Corozal, Dorado, Florida, Hatillo, Isabela, Lares, Orocovis, Quebradillas, San Sebastián, Toa Alta, Toa Baja, Utuado, and Vega Alta. Distributions of gestational age at delivery as well as birth weight by municipality of residence are presented in 2 compared to women <25 kg/m2), and the association was similar in mutually adjusted models . Postterm birth, on the other hand, was only associated with parity and gravidity  mothers, 15 of whom gave birth to preterm infants. The mean (SD) gestational age at delivery among women who had preeclampsia was 36.4 (3.25) weeks, and the mean (SD) birth weight in grams at delivery was 2,500 (904). Gestational diabetes occurred in 2.3% (n = 24) of mothers. Of these, three gave birth to preterm infants and one experienced gestational diabetes in combination with preeclampsia. Among infants born to women with gestational diabetes, the mean gestational age (38.9 weeks) and birth weight  did not differ dramatically from the rest of the study population.Driven by the high preterm birth rates observed in Puerto Rico, the objective of the PROTECT study is to investigate the origins of this disease. The present analysis takes the first step toward understanding this problem by examining risk factors that have been associated with preterm birth in other study populations, and investigating them for the first time among pregnant women in Puerto Rico. We observed that low socioeconomic status, particularly as indicated by education level, was associated with increased risk of preterm birth, as was high BMI. On the other hand, maternal tobacco use in pregnancy and delivery during the hurricane and dengue season  were associated with increased risk of delivering a baby small for gestational age. These findings are consistent with results from other cohort studies in the US and worldwide, but, importantly, have not been previously shown in a population of pregnant women residing in Puerto Rico.The preterm birth rate in our study population  is lower than what has been reported recently in the March of Dimes report cards (15.1% in 2014). This is likely due to our exclusion criteria which omitted women with pre-existing conditions that are risk factors for preterm birth, including diabetes as well as IVF , 13. WomInvestigation of the risk factors for adverse pregnancy outcomes in Puerto Rico is important, given the high rates reported by the March of Dimes. However, studies of pregnancy in Puerto Rican women residing on the island or elsewhere are sparse. In a study of primarily Puerto Rican women residing in Massachusetts, USA, between 2000–2003, education, parity, pre-pregnancy BMI, weight gain in pregnancy, and history of adverse pregnancy outcomes were associated with risk of SGA  but not Some of the risk factors we identified in our study are consistent with those observed in the general US population. For preterm birth, we observed increased risk in association with lower socioeconomic status  which is a well-known risk factor . HoweverThe PROTECT study was designed to investigate factors influencing the notably higher preterm birth rates that have been observed in Puerto Rico compared to the rest of the US. The results from this analysis do little to explain the higher rates of preterm birth that have been observed on the island of Puerto Rico. The most notable difference in this population is poverty. In 2015 46.1% of the Puerto Rican population fell below the US poverty level—the lowest of all US states and territories—as compared to 14.7% of the overall US population . MississFurthermore, an important area of future investigation will be to understand which risk factors are driving the economic differences in adverse pregnancy outcomes in the Puerto Rican population. All of the women in the present study had access to health care, yet those with lower income or education level had higher risk of delivering preterm. We hypothesize that environmental exposures may be responsible for some of the socioeconomic differences observed in association with preterm birth. We have noted, for example, higher levels of some urinary phthalate metabolites and pesticides in women with lower income or education levels in pilot studies from this population , 21. We Our present analysis had a number of limitations. It should be noted that the PROTECT cohort has recruited about half of its final anticipated sample size. Thus, addressing questions about more rare pregnancy outcomes  was not possible. Investigating factors associated with these endpoints will be a priority when data collection is complete, especially because of the relatively high rates of these outcomes observed in our study population. Additionally, because of our eligibility criteria, the generalizability of our results is restricted to women without diabetes.In summary, in a large prospective study of pregnancy in Puerto Rico, we examined for the first time demographic, behavioral, and pregnancy-related risk factors for adverse birth outcomes including preterm and postterm birth as well as small- and large- for gestational age. The most notable findings were associations between low income and education level in relation to preterm birth. Environmental factors including chemical exposures may play an important in the etiology of adverse pregnancy outcomes but have yet to be explored in Puerto Rico. As recruitment into the PROTECT cohort study continues, this analysis will serve as an important reference for understanding of risk and contributing factors to adverse pregnancy outcomes prior to the spread of Zika to the island and the catastrophe of Hurricanes Irma and Maria.S1 File(PDF)Click here for additional data file.S2 File1 odds ratios (OR) and 95% confidence intervals (CI) for preterm birth in association with demographic and pregnancy characteristics in the PROTECT cohort 2011–2017. Table E. Adjusted odds ratios (aOR) and 95% confidence intervals (CI) for postterm birth in association with demographic and pregnancy characteristics in the PROTECT cohort 2011–2017. Table F. Odds ratios (OR) and 95% confidence intervals (CI) for small for gestational age (SGA) birth compared to appropriate for gestational age birth (AGA) in association with demographic and pregnancy characteristics in the PROTECT cohort 2011–2017. Table G. Odds ratios (OR) and 95% confidence intervals (CI) for large for gestational age (LGA) birth compared to appropriate for gestational age birth (AGA) in association with demographic and pregnancy characteristics in the PROTECT cohort 2011–2017. Table H. Adjusted1 odds ratios (OR) and 95% confidence intervals (CI) for small for gestational age (SGA) birth compared to appropriate for gestational age birth (AGA) in association with demographic and pregnancy characteristics in the PROTECT cohort 2011–2017. Table I. Adjusted1 odds ratios (OR) and 95% confidence intervals (CI) for large for gestational age (LGA) birth compared to appropriate for gestational age birth (AGA) in association with demographic and pregnancy characteristics in the PROTECT cohort 2011–2017.Table A. American College of Obstetricians and Gynecologists (ACOG) guidelines for redating gestational age based on ultrasonography. Adapted from ACOG Committee opinion Number 700, May 2017. Table B. Odds ratios (OR) and 95% confidence intervals (CI) for preterm birth in association with demographic and pregnancy characteristics in the PROTECT cohort 2011–2017. Table C. Odds ratios (OR) and 95% confidence intervals (CI) for postterm birth in association with demographic and pregnancy characteristics in the PROTECT cohort 2011–2017. Table D. Adjusted(DOCX)Click here for additional data file.


To calculate the frequency and evaluate the factors associated with low birth weight.Programa de Atenção às Gestantes do Programa Einstein na Comunidade de Paraisópolis, between 2011 and 2014, and who returned for the postpartum evaluation of their newborns. Variables related to the pregnant woman, pregnancy, and newborn were evaluated. The outcome variable was low birth weight, defined as <2.5kg. The associations between the independent variables and low birth weight were assessed by χ2 and Mann-Whitney tests. Logistic regression models analyzed the combined effects of the independent variables on low birth weight. A retrospective study, with data from pregnant women who participated in the  Data of 794 pregnant women and their newborns  were analyzed. The age of pregnant women varied from 13 to 44 years (median of 24 years), and the majority reported being married or living in cohabitation (74.7%), and having between 9 to 11 years of schooling (53.4%). The proportion of low birth weight was 7.6% (newborn mean weight of 3.2kg) and, in multivariate analysis, presence of twinning, age group of the pregnant women (showing protection for low birth weight between ages ≥18 years and <35 years), and cesarean section were associated with low birth weight. The proportion of low birth weight was 7.6% and twining, age of the pregnant woman, and cesarean delivery were associated with the occurrence of low birth weight. Low birth weight (LBW) is defined by World Health Organization as being lower than 2.5kg. It is estimated that 15 to 20% of newborns in the world present with LBW, which would represent more than 20 million births a year. Additionally, there are variations in the proportions of LBW among the regions, namely, 28% in South Asia, 13% in Sub-Saharan Africa, and 9% in Latin America.1Sistema de Informações sobre Nascidos Vivos (SINASC) [Information System about Liveborns] showed 8.0% of LBW in the 26 capital cities and in Brasília; in that, the highest rates were found in the Southeastern (8.4%) and Southern (8.0%) regions, and the lowest, in the Northern (7.2%), Northeastern (7.6%), and Central Western (7.4%) regions.In Brazil, evaluation of data between 1996 and 2011 from the  regions.2 In Brazil, a cohort study about neonatal mortality between 2011 and 2012 also showed that LBW is one of the associated factors. Besides neonatal mortality, LBW is associated with some morbidities, such as asthma and hypertension.Low birth weight is an important public health problem, because it is associated with neonatal mortality. A systematic review of the literature up to 2011 and meta-analysis reported an odds ratio of 8.5 associated with neonatal mortality in full-term newborns (≥37 gestation weeks) with a birth weight <2.5kg.3 In B Yet, female newborns and a mother who smokes were factors associated with increased risk of LBW, in the Pesquisa Nacional de Demografia e Saúde da Criança e da Mulher (PNDS) of 2006 [National Demographics and Children’s and Women’s Health Survey] .Therefore, efforts have been made to identify the factors associated with LBW. In the investigation with SINASC data, between 1996 and 2011, improvements in maternal schooling levels and coverage of prenatal care were associated with reduction in risk of LBW in all regions of Brazil.2 Yet,To calculate the frequency and evaluate the factors associated with low birth weight.Programa de Atenção às Gestantes (PAG) [Pregnant Women Care Program] from the Programa Einstein na Comunidade de Paraisópolis (PECP) [Einstein Program in Paraisópolis Community], between 2011 and 2014, and who returned for an evaluation of their newborn after birth. The study was approved by the Research Ethics Committee of Hospital Israelita Albert Einstein , number 1.449.675, CAAE: 53647316.9.0000.0071.This is a retrospective study, with information obtained from spreadsheets with data from records of pregnant women who participated in the The PAG promotes educational activities, with information about care in pregnancy and with the newborn, acting as a complementary to prenatal care service.2 test for qualitative variables and Mann-Whitney test for quantitative or ordinal qualitative variables. The combined effects of factors associated with LBW were evaluated by logistic regression model, in which all independent variables were verified by a stepwise process in both directions; that is, including and excluding variables one by one, until reaching a model that contained only variables with a p value less than 5% in the final model. Also, we verified possible first-degree interactions between the independent variables. The results of the final multiple model were presented in odds ratios, followed by 95% confidence intervals and p values, with the level of significance set at 5%.The variable outcome was LBW, defined as <2.5kg, and the independent variables were those related to the pregnant woman, and her past history and housing conditions, to the gestation, and to the newborn. Frequency distributions were verified by means of histograms and boxplots. The qualitative variables were described by absolute and relative frequencies, and the quantitative variables by their minimum and maximum values and medians, as they do not present with a normal frequency distribution. Due to the possible dependence that could occur in cases of the existence of the same pregnant woman participating in PAG/PECP in different years and/or twins, a random drawing was made in these situations, to choose which newborn would participate of the sample. This process was done using the software Excel 2010 and its random function, and the criterion to include the newborn in the analysis was the one that was attributed lower random value. The associations of the independent variables and LBW were evaluated by χDuring the period from January 2011 to November 2014, a total of 1,692 pregnant women were registered at PAG/PECP, and among these, 812 returned for the assessment of their newborns. Eighteen information were excluded related to newborns from the same mother and/or twins, with a total sample size of 794 participants.The general proportion of LBW was 7.6%, and the newborn weight varied from 1.3 to 4.9kg, with a mean of 3.2kg (standard deviation of 0.5kg).The age of the pregnant women ranged from 13 to 44 years (median of 24 years), and most reported being married or living in cohabitation (74.7%), did not work (57.3%), did not study (82.7%), and had between 9 and 11 years of schooling (53.4%). Most pregnant women lived in homes they owned (57.0%), with three to four [all-purpose] rooms (58.8%), which housed three or more residents (65.0%), with 1.3 resident per room. We noted no statistically significant associations of the variables analyzed, in the comparison between newborns with and without LBW   .versus 0.4%) and of cesarean sections (62.7% versus 39.2%) among the newborns with LBW  and not twins (98.5%). Most pregnant women were primigravidae (51.6%), had not experienced any miscarriages (81.0%), had received prenatal care within the public services (93.6%), and had delivered vaginally or with forceps (59.0%). There was a significantly higher proportion of twins  Thus, to compare our results with data from the Brazilian literature, we chose to evaluate the studies carried out in these regions of the country, since the pregnant women and the newborns of our sample belonged to the neighborhood of Paraisópolis, located in the city of São Paulo (SP). Nevertheless, the different dates, locations and samples evaluated, which could have influenced the characteristics of research participants, should be taken into consideration. One should also consider that the outcome variable was birth weight, regardless of the presence or not of prematurity, or of the evaluation of the newborn weight relative to the gestational age.The general profile the sample comprised women with a median age of 24 years, most of them were married or in living in cohabitation, and with 9 to 11 years of schooling. In Brazil, the largest rates of LBW are in the Southeastern and Southern regions.,7 Th in the city of Divinópolis (MG), it ranged from 8.9% to 9.2%, between 2008 to 2011; and in the city of Taubaté (SP), between 2006 and 2010, it varied from 9.3% to 9.8%. In these comparisons, one should take into account that in the last two studies, twin birth were excluded from analyses, which could have influenced the proportions of LBW.The proportion of LBW observed (7.6%) is below that reported in literature. In the city of São Paulo (SP), between 2007 and 2013, the rates of LBW varied from 9.6% to 9.8%;8 in tversus 3.1kg), and a smaller proportion of females relative to the study done in the city of São Paulo (SP) (47.9% versus 51.2%). It is worth mentioning that we only evaluated newborns that returned to the program; non-return could have been due to birth or health conditions of these newborns, among other reasons, which could have influenced both their characteristics and the LBW rates.Regarding the characteristics of newborns, our study showed a mean weight similar to that of the study conducted in the city of Divinópolis (MG) (3.2kg s 3.1kg),9 and  the pregnant women of this sample were younger (24.0 years versus 27.5 years), had less cesarean sections (41.0% versus 56.5%), and a similar proportion of single gestations (98.5% versus 97.3%). Relative to the study on the spatial distribution of liveborns in the same city in 2008, our sample showed smaller proportions of pregnant women with up to 11 years of schooling (53.4% versus 58.2%), and similar extent of primigravidae (51.6% versus 53.9%). We should consider, however, that participation of the pregnant women in the program was spontaneous, and they belong only to one neighborhood in the city of São Paulo.In the comparison with the study carried out in the city of São Paulo (SP),8 the  However, we should remember that socioeconomic factors can influence the risk of LBW associated with maternal age. Despite this, a systematic review of the literature on the complications of pregnancy in adolescence demonstrated this age group would present a higher frequency of other maternal and neonatal complications.There was an association between age of the pregnant woman and the chance of LBW, a result that is in accordance with the literature. A systematic review with meta-analysis of the studies conducted in Latin America, up to 2008, showed that maternal age (<20 years and >35 years) was a risk factor for LBW.12 How and in Campinas (SP), in 2001, where double and triple pregnancies of full-term newborns presented with odds ratios of 19.9 and 21.4 for LBW, respectively.As to twinning, the association with LBW has been noted in other studies, such as the one conducted in Botucatu (SP), between 2004 and 2008, with an odds ratio of 20.0 in twin pregnancies,15 and However, one should bear in mind that this association is complex, since the procedure can be indicated in clinical or obstetric conditions related to complications for the mother or the fetus, and such conditions could be associated with LBW newborns. Additionally, the association between LBW and cesarean section might depend on other factors, such as the procedure rate.The association of cesarean delivery and LBW observed here has also been reported in the literature. In the State of Rio Grande do Sul, cesarean deliveries represented a risk for LBW, with an odds ratio of 1.1 among single newborns.17 How As to maternal nutrition, a study with puerperal women of the city of Rio de Janeiro (RJ) showed that pre-gestational low weight was a risk factor, and weight gain during the gestation was a protection factor for LBW. In addition to these factors, the regional differences in the proportions of LBW in Brazil showed an association with the indicators that reflected the availability of the perinatal care services, socioeconomic factors, infant mortality rate, multiple births and newborns with very low weight, and neonatal mortality rate. In this way, one can perceive that the occurrence of LBW is multifactoral and involves maternal, newborn, gestational, and local context factors, among others.Several other variables have been identified in the literature as being associated with LBW; the most often cited are age and schooling level of the mother, number of prenatal care visits, sex of the neonate, and duration of gestation.20 As Our study presented the frequencies of low birth weight, and the characteristics of the pregnant women and their past history, housing conditions, gestations, and newborns. The variables twinning, age of the pregnant woman, showing protection for the newborns of pregnant women aged ≥18 years and <35 years, and cesarean section births were associated with the occurrence of low birth weight.


Preterm and low birth weight infants are at greater risk for mortality and a variety of health and developmental problems. Data from the Finger Lakes Perinatal Data System database on 316,956 deliveries occurring between 2004–2014 and pregnancy outcomes were analyzed to assess the association of periodontal (gum) disease with depression, other maternal factors and adverse birth outcomes. Adjusted effects of periodontal disease and depression on adverse birth outcomes were estimated using multiple logistic regression models and path analysis. Having preterm delivery was associated significantly with depression , having adequate health care , smoking during pregnancy , and being less educated . Having low birth weight was significantly associated with depression , smoking during pregnancy , and being less educated . Periodontal disease was significantly associated with alcohol use during pregnancy  and white race . Depression was significantly associated with periodontal disease  and alcohol use during pregnancy . We concluded that a positive association existed between depression during pregnancy and adverse birth outcomes, and that depression served as a mediator in the association of periodontal disease with adverse birth outcomes. Maintaining good oral health during pregnancy is an important aspect of maintaining overall good health during pregnancy and throughout a woman’s lifespan. According to the Advisory Committee for Oral Health Care During Pregnancy, in years 2007–2009, 35% of U.S. women did not attend a dental visit within the past year and 56% of women did not visit a dentist during pregnancy . NumerouAccording to the literature, maternal depression during pregnancy is also associated with adverse perinatal and infant outcomes. A systematic review and meta-analysis of thirty studies suggested that premature delivery was significantly associated with maternal depression . A largePoor oral health, especially gingivitis and periodontitis, is recognized as a source of systemic inflammation. Currently, there is emerging evidence that depression is also an inflammatory disorder, indicated by increased levels of CRP and other pro-inflammatory factors; persons diagnosed with depression have been found to have higher levels of proinflammatory cytokines, acute phase proteins, chemokines and cellular adhesion molecules. Additionally, proinflammatory cytokines have been found to interact with many of the pathophysiological domains that characterize depression, including neurotransmitter metabolism, neuroendocrine function, synaptic plasticity and behavior . There aConsidering similar mechanisms related to systemic inflammation that are associated with depression and periodontal disease, we hypothesize that there is a positive association between periodontal disease and adverse birth outcomes and there is a positive association between depression and adverse birth outcomes. Further, we examine the positive association of periodontal disease with adverse birth outcomes mainly through the mediating effect of depression. A mediator is a variable that is in a causal sequence between two variables . MediatiIn this study, we therefore sought to examine the association between periodontal disease and depression and between adverse birth outcomes among women who gave birth between 2004–2014 in thirty counties surrounding Rochester and Syracuse, New York.The Perinatal Data System (PDS) initiative began in New York State (NYS) in the early 1990s as a perinatal quality improvement initiative funded by the New York State Department of Health. The Upstate New York Regional Perinatal Centers in Albany, Syracuse, Rochester, and Buffalo were among the first demonstration centers for the regionalization of perinatal services in the United States; all evolved into NYS-supported Regional Perinatal Centers with both quality of care and regional perinatal service responsibilities. The PDS effort was envisioned to support a data infrastructure to serve the quality improvement and evaluative needs of the Perinatal Centers, resulting in the PDS demonstration projects starting in 1993. The PDS database includes information on demographics of both infants and parents, access to care, pre-pregnancy risks, antepartum risky behaviors, antepartum infections, antepartum risks, maternal and birth outcomes. The PDS data used for the current analysis was collected between 2004 and 2014. The PDS database contains data on more than 345,000 deliveries that occurred between 2004 and 2014 in thirty counties surrounding Rochester and Syracuse and includes data on pregnancy outcomes; data on 316,956 deliveries formed the basis for the analyses. The University of Rochester Research Subject Review Board (RSRB) approved the study prior to its initiation. The data used in the study were fully anonymized before retrieval.The database includes a dichotomous survey question asked of all postpartum mothers that states: “Did you have any problems with your gums at any time during pregnancy, for example, swollen or bleeding gums?” The depression information was collected using the following question in the PDS survey questionnaire: “During your pregnancy, would you say that you were (select one): Not depressed at all, A little depressed, Moderately depressed, Very depressed, Very depressed and had to get help”. The depression question was adopted from the CDC’s PRAMS (Pregnancy Risk Assessment and Monitoring System) –19. The Characteristics of subjects with and without periodontal disease in the perinatal database were compared using Chi-Square tests for categorical variables and Student’s t-tests or Wilcoxon rank sum tests for continuous variables. Unadjusted effects of periodontal disease and depression on adverse outcomes such as small for gestational age (yes/no), large for gestational age (yes/no), preterm delivery (yes/no), and low birth weight (yes/no) were examined using both chi-square tests and logistic regression. Adjusted effects of periodontal disease and depression were estimated from multiple logistic regression models using SAS version 9.4  and path analysis using Mplus, version 7.3 . The covariates adjusted in multiple logistic regression models and path analysis included mother’s age at delivery, parity, adequacy of health care during pregnancy , insurance type , mother’s race, tobacco use during pregnancy (yes/no), alcohol use during pregnancy (yes/no), and mother’s education level . A P-value <0.05 was considered statistically significant. Odds ratios (OR) and their 95% confidence intervals (CI) were calculated from both simple and multiple logistic regression models to assess the unadjusted and adjusted effects of periodontal disease and depression on adverse birth outcomes. The pathway analysis coefficients are the estimated coefficients from the logistic regression models in the pathway analysis that are equivalent to the log of estimated odds ratios.The distribution of maternal characteristics in the study population is presented in The distribution of birth outcomes characterized by maternal periodontal disease is presented in As presented in The results from path analysis are presented in In Our findings obtained from a large perinatal database in the Finger Lakes region of NY State suggest that depression during pregnancy is associated with all adverse birth outcomes under study, including being small for gestational age, being large for gestational age, being preterm and having low birth weight. Depression often remains untreated during pregnancy despite the fact that the prevalence of psychosocial stress is substantial . ContrarPositive associations between periodontal disease and adverse birth outcomes are well documented in the literature, however treatment of periodontal disease during pregnancy does not prevent preterm birth, fetal growth restriction, or preeclampsia –5, 23. IOur results also suggest that adverse birth outcomes were associated with smoking and alcohol use during pregnancy. Smoking and alcohol use during pregnancy are detrimental for the developing fetus and pregnancy outcomes; our analyses suggest that they were both harmful for pregnancy outcomes; women who reported smoking during pregnancy and use of alcohol were more likely to have preterm delivery and deliver babies with low birth weight. Reporting socially undesirable lifestyles occurring during pregnancy may have resulted in under-reported, yet significant findings. The key strength of our study was the analysis of data from a large, well-characterized sample from the general population of women who delivered babies in the Finger Lakes region of New York State, thereby enhancing the robustness and generalizability of the findings. A further strength was the availability of birth outcome data, including detailed information on infant weight, gestational age and preterm or term delivery of the baby. Limitations, in addition to the cross-sectional nature of the study, included the self-reported information about periodontal status and depression during pregnancy, and lack of data on use of anti-depressive medications. Thus, data must be interpreted cautiously with respect to the potential for recall bias and over- or under-estimation of the findings. Although the PDS database is broadly representative, our data may not be generalizable beyond the Finger Lakes region of New York State.We conclude that a positive association exists between depression during pregnancy and adverse birth outcomes, and that depression serves as a mediator in the association of periodontal disease with adverse birth outcomes. Considering the theorized link between infection, inflammation and adverse pregnancy outcomes, it is biologically plausible to consider depression as a mediator in the association of periodontal disease with adverse pregnancy outcomes. Potential pathways identified may include behavioral, infectious, endocrine and inflammatory mechanisms , especiaPreterm and low birth weight infants are at greater risk for mortality and a variety of health and developmental problems. As a result, the birth of a preterm or low birth weight infant may have significant emotional and economic effects on the infant’s family. The infant mortality rate for low birth weight infants is about 25 times that of the infant mortality rate for normal weight babies . Rates oConsidering the results of our study, depression may serve as a mediator in the association of periodontal disease with adverse birth outcomes. As such, obstetricians and dental providers caring for pregnant women should be made aware that women who have periodontal issues are more likely to be depressed during pregnancy and more likely to experience adverse birth outcomes. Future studies should include prospective studies that focus on oral health assessment of expectant mothers, administration of diagnostic interviews to assess depression during pregnancy, consideration for the use of anti-depressive medications during pregnancy, and counseling related to detrimental health behaviors such as smoking and alcohol use during pregnancy.


Hydatid cysts primarily involve the liver and lung, but could be presented in any site of the body including the muscles which is very rare.We report a 50-year-old woman with hydatid cyst in biceps femoris presenting as growing painful mass. There was also a small cyst in the liver. The cyst was completely excised and patient was treated with albendazole 15 mg/kg daily before and after surgery. The patient was symptom free during the three months follow-up.Hydatid cyst should be considered as differential diagnosis of any growing mass or cyst in the body in the endemic areas. It isDue to the benign and asymptomatic progression of the hydatid cyst, it usually presents in its advanced form . AlthougHere we report a case of hydatid cyst in biceps femoris presented as a painful mass in the back of the right thigh. The work has been reported in line with the SCARE criteria .2A 50-year-old woman presented with the complaint of pain in the back of right thigh for 2 month to our institute in 2019. The pain was worsened with daily activity and get better with rest. The patient had no history of medical disease. In physical examination, there was a swelling 7*7 cm in the middle of the back of the right thigh with no erythema, tenderness or warmness. Neurologic and other examinations were normal.Chest x-ray was normal. Ultrasonography of the abdomen showed 12*19 mm cystic lesion with multiple fine septations in the right lobe of the liver. US of the right thigh showed 8 cm mm cystic lesion in the back of the right thigh with multiple septations indicative of daughter cysts. Magnetic resonance imaging of the right thigh also showed multi locular muscle mass inside the semimebranous muscle with mass effect on semitendinous and long head of biceps femoralis. There was hyposignal intensity in T1 and hypersignal intensity in T2 with small round shape cyst with double layer wall inside of it suggestive for hydatid cyst a,b. OtheDue to the intense and persistent pain, the patients was subjected to surgical cystectomy. Albendazole 15 mg/kg daily were administered for two weeks prior to surgery. Under spinal anesthesia, en block surgical excision of the mass was performed with care without perforating the cyst wall a,b,c. Th3Hydatid cyst is endemic in most parts of the world, especially sheep- or cattle-raising regions and considered as a health problem in developing countries due to the lack of the appropriate programs to prevent its transmission . Liver aThe unusual sites of presentation may lead to nonspecific symptoms and the disease is usually diagnosed in its advanced stages. The common presentation in muscle involvement is painful muscle mass and thus is usually mistaken with soft tissue tumors. Although difficult to diagnose preoperatively, it is important to rule out hydatid cyst before biopsy to prevent cyst leakage and consequent anaphylaxis .The common imaging modalities are ultrasonography, computed tomography to identify the characteristic findings of the cyst, but for muscle, MRI is more sensitive . Which iTotal surgical excision is recommended for hydatid cysts more than 5 cm, especially when they are in the unusual sites . Treatme4Hydatid cyst should be considered as differential diagnosis of any growing mass or cyst in the body in the endemic areas.No funding source to report.This case report was exempt from ethical approval in our institution.We have the patient’s consent for publication of the submitted article and images.MirSalim SeyyedSadeghi and AmirAhmad Arabzadeh conceived the idea for the study. All authors were involved in data collection. Afshin Habibzadeh wrote the first draft of the manuscript. All authors edited and approved the final version of the manuscript.NA.MirSalim SeyyedSadeghi and AmirAhmad Arabzadeh.Not commissioned, externally peer-reviewed.We have no conflicts of interest.


The demand for a high-resolution metal-oxide-semiconductor (CMOS) image sensor has increased in recent years, and pixel size has shrunk below 1.0 μm to allow accumulation of numerous pixels in a limited area. However, shrinking the pixel size lowers the sensitivity and increases crosstalk because the aspect ratio is worsened by maintaining the height of the pixel. This work introduces a high-sensitivity pixel with a quad-WRGB  color filter array (CFA), spatial deep-trench isolation (S-DTI), and a spatial tungsten grid (S-WG). The optical performance of the suggested pixel was analyzed by performing 3D optical simulations at 1.0, 0.9, and 0.8 μm pixel pitches as small-sized pixels. The quad-WRGB CFA is compared with the quad-Bayer CFA, and the S-DTI and S-WG are compared with the conventional DTI and WG. We confirmed an improvement in the sensitivity of the suggested pixel using the quad-WRGB CFA with S-DTI and S-WG to a maximum of 58.2%, 67.0%, and 66.3% for 1.0, 0.9, and 0.8 μm pixels, respectively. The advances in camera technology now necessitate the development of a high-resolution complementary metal-oxide-semiconductor (CMOS) image sensor. However, a high-resolution camera requires a pixel pitch smaller than 1.0 μm to allow accumulation of numerous pixels in the limited sensor area , and makMany approaches are available for enhancing the sensitivity and crosstalk for a small pixel. Particularly good examples include new optical pixel structures, such as the stacked grid structure between color filters, the lensed CF, and the front-inner lens image sensor ,5,6. TheConversely, different approaches are available to obtain high sensitivity by changing the color filter array (CFA) ,8,9,10. In this work, we propose a quad-WRGB structure with spatial-deep trench isolation (S-DTI) and a spatial-tungsten grid (S-WG) to solve the small pixel problems, such as low sensitivity and high crosstalk. The quad-WRGB CFA provides a four-fold expansion of each color filter. The S-DTI and S-WG are located every four pixels for efficient reduction of the crosstalk. The optical performance is investigated by simulating the suggested structure and comparing it with typical structures with the CFA, DTI, and WG using a commercial 3D optical simulator for precise analysis. As previously mentioned, the aspect ratio worsens with shrinking pixel size in high-resolution camera. Accordingly, the crosstalk increases due to the narrower and longer optical path and the sensitivity decreases because of the narrowed pixel pitch. Therefore, the sensitivity in low light environments becomes increasingly worse because of poor light incidence. The quad-Bayer filter is used for high sensitivity, especially in low light, even though the resolution is effectively divided by four ,14. The Conversely, deep trench isolation (DTI) and tungsten grid (WG) are commonly used to block crosstalk . DTI usux- and y-axis in Numerical analysis of the suggested structure was conducted using the finite-difference time-domain (FDTD) method . This meA comparison of the sensitivity improvement by the incident angle and pixels is shown by the enhancement rate of the photon density depicted in For clearly showing the enhancement, the absorbed photon density by the wavelength is shown in In summary, a high sensitivity and low crosstalk pixel structure having quad-WRGB CFA with S-DTI and S-WG has been introduced. The quad-WRGB CFA indicates a four-fold expansion of the WRGB CFA. The sensitivity is improved by binning the photon from the four pixels having the same CF and by using white CF. The use of spatial DTI (S-DTI) and spatial WG (S-WG) surrounding the four same-colored pixels is suggested for efficient blocking of the crosstalk. The S-DTI and S-WG can block the signals only from different CF; therefore, the absorption area increases for the same CF pixels. The performance of the suggested structure was investigated by 3D optical simulation using 16 × 16 backside-illuminated pixels having the quad-Bayer CFA and the quad-WRGB CFA structure with DTI/WG and S-DTI/S-WG for the 1.0, 0.9, and 0.8 μm pixel pitches. The simulation results indicated that the sensitivity, which is the photon density absorbed in the photodiode, is improved by over 42% by changing from the quad-Bayer CFA to the quad-WRGB CFA for all pixel sizes. Moreover, the sensitivity is improved by 58.2%, 67.0%, and 66.3% by adding S-DTI and S-WG to the quad-WRGB CFA pixels of 1.0, 0.9, and 0.8 μm pixel pitches. The crosstalk is also enhanced by 0.21%, 0.22%, and 0.45%, respectively, by changing the DTI/WG to S-DTI/S-WG for the 1.0, 0.9, and 0.8 μm pixels with the quad-WRGB CFA. Therefore, the quad-WRGB CFA pixel structure with S-DTI and S-WG can promise high sensitivity for small pixels.The advances in camera technology require the development of a high-resolution camera. Thus, a high-resolution CMOS image sensor is developed in a small pixel pitch as below 1.0 μm to allow accumulation of numerous pixels in the limited sensor area. However, the aspect ratio is worsened in a small pixel pitch and causes low sensitivity and high crosstalk. Although the various CFAs are developed, some CFAs such as quad-Bayer were not preferred, caused by deterioration of resolution. According to advance of compensating resolution technology such as pixel binning, novel demosaicking method, CFAs consisting of the adjacent same color filter are gradually preferred. However, a high crosstalk is still a problem despite solving low sensitivity. Therefore, the optical pixel structure having high sensitivity needs to be developed in a very small pixel without any deterioration. We suggested the novel DTI and WG for the quad-CFA and a small pixel. The suggested S-DTI and S-WG not only induce to absorb the crosstalk from the same color pixels, but also block the crosstalk causing color error from the different color pixels. Moreover, the available area for light absorption in the pixel is expanded, because the S-DTI and S-WG occupy the outside part of the four pixels. Therefore, our work is meaningful for the very small pixels, such as next generation image sensor, as well as 0.7, 0.8, and 0.9 μm pixels.


The patient was a 49-year-old woman with a chief complaint of hip and buttock pain that had persisted for 3 years. She visited our hospital for aggravation of the pain. Percussion tenderness of the spinous process was observed and a T1-low, T2-high cystic lesion was detected on the dorsal side of the dural canal at the 12th thoracic vertebral level on MRI performed by a previous physician. Plane CT showed severe scalloping at the same level. During laminectomy for the 11th and 12th thoracic vertebrae, a cystic lesion of about 60 × 25 mm was noted on the dorsal side of the dural canal, with a communication pathway with the cyst present near the left 12th nerve root bifurcation. This pathway was ligated and the cyst was excised. The histopathological diagnosis was an arachnoid cyst. Pain improved after surgery, and as of 10 months after surgery, the cystic lesion has not recurred. A spinal extradural arachnoid cyst (SEAC) is a relatively rare disease. This case shows that surgical ligation of a communicating tract and cystectomy are necessary and contrast-enhanced CT was useful for the identification of the position of the communication pathway before surgery. A spinal extradural arachnoid cyst (SEAC) is a relatively rare disease in which the arachnoid membrane prolapses through a dural defect and expands to form an extradural cyst that induces spinal cord symptoms , 2. In tThe patient was a 49-year-old woman with a chief complaint of hip and buttock pain. This pain had developed without an inducer in April 2014. A cystic lesion in the spinal canal had been pointed out by a physician. The patient received conservative treatment, but pain gradually aggravated and walking and taking a supine position at home became difficult. The patient first visited our department in October 2017. She had not particularly relevant familial or past medical history.Physical findings on admission showed percussion tenderness in the thoracolumbar junction. There is no obvious range of motion restriction in the hip joint, and the Patrick test was negative. The score on a manual muscle test of the bilateral lower limbs was 5/5, and there was no sensory disturbance or bladder and rectal disturbance. The femoral nerve stretching test (FNST) and straight leg raising (SLR) test were both negative. The patellar tendon reflex (PTR) was normal on the bilateral sides, but the Achilles tendon reflex (ATR) was enhanced on the bilateral sides.Plain radiography showed that the T12 vertebral arch was partially lost and the space between the vertebral arches was expanded . MRI shoSurgery was performed to ligate the communication pathway and excise the cyst. The anesthesia was total intravenous anesthesia (TIVA) and the body position was prone. And we use a nerve stimulator. In laminectomy for T11 and T12, the bone cortex of the T12 vertebral arch was excluded by the cyst and thinned and a bulging cyst was present just below the resected arches. When the cyst was dissected from the dura under a microscope, a communication pathway for cerebrospinal fluid was present in the axillary region of the left T12 nerve root. Thus, this region was ligated and the cyst was excised. The cyst did not adhere to the dural canal . HistoloSEAC accounts for 1% of spinal tumors , with itCho et al. showed that visualization of the communication pathway to the cyst using myelography was important for preoperative planning . SimilarExcision of the cyst with obliteration of the communicating dural defect is the mainstay of treatment in symptomatic patients . ConcomiWe encountered a patient with SEAC with a chief compliant of low back pain. CT myelography was useful for diagnosis and preoperative planning. A favorable outcome was achieved by surgery for total excision of the cyst and repair of the dural defect.


The Diesel Exhaust in Miners Study is unquestionably the most suitable data material to date to examine a possible link between diesel engine emissions and lung cancer risk. But the results do not appear to be consistent in themselves. The crucial methodological problem in this study, however, has yet to be discovered, to which the lack of any description of age related information  for the cohort as well as for the cases might have contributed. This information is important to understand the flaws in the analysis. It turns out that the year of birth is associated with the exposure, i.e. with the chance to be exposed over a certain period of time as well as with the chance to be an ever-smoker. A further important issue for the interpretation of the results is the validity of the data on smoking, which are mainly obtained from next of kin for decedents up to 50 years after death. Taking all these aspects into account, it can be concluded that only the SMR-analysis can be considered from all published results. The results of the Diesel Exhaust in Miners Study (DEMS), which was based on a cohort and a nested case–control approach, were published in 2012 [Given its outstanding data base, the DEMS became the key study for the reclassification of DEE from group 2A (probably carcinogenic to humans) to group 1 (carcinogenic to humans) by the International Agency for Research on Cancer in 2012 . The stuThe cohort has some of the following characteristics, which are important for the analysis of the data and for the interpretation of the available results.First, according to the definition of the cohort and the follow-up period from the year of dieselization (range 1947–1967) to 1997, the year of birth of all cohort members ranges from 1888 to 1978, assuming a retirement age of 60 years. Taking into account the age-specific mortality rates for lung cancer, it can be concluded that most lung cancer cases were born before 1920. The birth cohorts from 1940 and later are probably of no importance for the analysis.pi is the share of prevalent hires in the mine i, ydi and myfei are the corresponding year of dieselization and mean year of first exposure to DEE, respectively. The estimate of pi is then given bySecond, diesel technology was introduced in the mine virtually independently of the miner’s year of hire. Hence, the later the miner was born (assuming the same age at hire and the same length of employment), the longer was the maximum possible duration of underground employment under exposure to DEE. Consequently, the share of prevalent hires at the beginning of follow-up is of interest. It can be estimated for the cohort from the following equation, assuming a uniform fluctuation in the mines i.e. an equal annual number of incident hires in the period from the year of dieselization to 1 year before the end of follow-up:The weighted average of the mine-specific estimates yields the estimate for the whole cohort, which is about 25% based on the available data from the cohort study  Table 11. The shThird, smoking habits have also changed considerably over the birth cohorts. The maximum prevalence of smoking  in U.S. males increases from 55% for men born in 1890 to a plateau of about 76% for the 1915–1920 birth cohorts and then decreases continuously to 34% for those born in 1970 [Thus, the year of birth is associated with the exposure, i.e. with the chance to be exposed over a certain period as well as with the chance to be an ever-smoker. Fortunately, however, the year of birth was used as a matching variable and thus cases and controls have comparable conditions in all of the 198 risk sets, even if a closer matching (the closest in terms of date of birth or at least within 1 year) would have been more favorable. An adjustment for smoking, as it is usually done by adding smoking as a categorical variable into the regression model, would have therefore been sufficient.3-years. But a surface worker with an exposure concentration of 1.7 µg/m3 . ConsequBecause the DEMS currently provides the world’s most comprehensive data for the analysis of lung cancer risk due to DEE, a reanalysis with an adequate adjustment for smoking would be useful. In addition to the original exposure estimates, the proposed alternative estimates  should aFinally, a comparison of the revised DEMS results with those of the study in German potash mining  would be


Background: Executive function (EF) refers to cognitive abilities used to guide goal-directed behavior. Diffusion Tensor Imaging (DTI) provides quantitative characterization of white matter tracts in the brain. Children with preterm birth often have EF impairments and white matter injury.Aim: To examine the degree of association between EF scores and white matter fractional anisotropy (FA) as measured by DTI in children born preterm and termStudy design: Cross-sectional studySubjects: Participants, 9–16 years of age, born preterm , and full term (n = 20)Outcome measures: White matter FA analyzed with Tract-Based Spatial Statistics, a technique that generates a skeleton representing the core of white matter tracts throughout the brain. Behavioral scores from EF tasks examining working memory, spatial memory capacity, and multiple skills from the Stockings of Cambridge.Results: The groups performed comparably on all tasks. In both groups, unfavorable working memory strategy scores were associated with lower FA. Other measures of EF were not associated with whole skeleton FA in either group in either direction.Conclusions: Strategy score on a spatial working memory task was associated with FA in preterm and full term children, suggesting common underlying neurobiology in both groups. Associations were found in frontal-parietal connections and other major tracts. Lack of associations between other EF tasks and FA may be due to variation in how children accomplish these EF tasks. Future research is required to fully understand the neurobiology of EF in children born preterm. Executive Function (EF) refers to interrelated cognitive abilities  used to guide goal-directed behavior . EF skilEF impairments are common in preterm children , 11. TheDiffusion tensor imaging (DTI) generates quantitative measures to characterize white matter . FractioTechniques such as resting state functional MRI and structural connectivity may also be combined to better understand the relationship between white matter maturation and the development of functional connectivity among brain networks , 29. A s2). In this sample, we previously reported group differences in FA , a whole-brain, mean white matter FA skeleton approach. We focused on FA rather than other DTI metrics, such as axial diffusivity (AD) or radial diffusivity (RD), since both AD and RD are reflected in FA 2). In thes in FA , and pares in FA . Therefoes in FA –36.n = 25) were born at ≤34 weeks gestation with birth weight <2,500 grams. Controls were born ≥37 weeks (n = 20). Participants included in the current study are those who had complete EF data and concurrent DTI data. Due to protocol changes in the larger study, not all subjects completed EF testing, resulting in a smaller number of controls. Exclusions included seizures; hydrocephalus; receptive vocabulary score <70; hearing loss; and non-English speaker. Controls were also excluded for language, learning, or psychiatric disorders. Three preterm subjects were excluded due to extremely enlarged ventricles , a computerized EF battery used in studies of preterm children . Spatialapproach ] and Fort-tests, and Mann-Whitney U tests were used to evaluate between-group differences on demographic variables and outcome measures.Chi-square, independent Details for MRI and DTI protocols/processing were previously reported  and are We used the voxel-wise “Tract Based Spatial Statistics” (TBSS) method from the Oxford Center for Functional MRI of the Brain (FMRIB) Diffusion Toolbox . TBSS idA tensor model was fit to each voxel , and FA t-tests of FA in subjects compared with controls. We assessed the degree of association between EF scores and FA of the mean skeleton within the preterm group and the control group separately in both the positive and negative directions as well as group by task interactions, covarying by age. We set significance at p < 0.05 after correction for multiple comparisons using Threshold-Free Cluster Enhancement, a method that avoids using an arbitrary threshold for initial cluster-formation or identification of signal  to assess group related differences . This mef signal . Signifif signal  to deterNo significant behavioral differences were found between groups on raw scores on any EF measure Table . On voxeIn both groups, tracts associated with strategy score included the superior longitudinal fasciculus (SLF), cingulum, inferior fronto-occipital fasciculus (IFOF), inferior longitudinal fasciculus (ILF), forceps major, and corticospinal tracts. The preterm group also had associations with the corpus callosum and forceps minor, whereas full term children had additional associations with the anterior thalamic radiations. Figure In summary, we found that FA in multiple tracts was associated with a single measure of EF—strategy score. Lower FA was associated with poorer strategy in both preterm and full term groups. Similar tracts were identified for both groups, although unique tracts were also associated with each group.Our results are similar to another report of associations between lower FA and EF measures of problem solving and cognitive flexibility in a preterm sample within the cingulum and bilateral IFOF . The cinThe association between FA and strategy score in both preterm and full term groups suggests a common neurobiological basis for memory strategy. In both groups, FA in the SLF was also associated with strategy score. These findings are similar to those in a study of typical children age 7–13 years that used the same CANTAB Spatial Working Memory task . AnotherAssociations of FA and strategy score were also found within the ILF, forceps major, and corticospinal tracts for both groups. The ILF courses from the occipital to temporal lobes. Adult DTI studies showed associations between the ILF and a memory composite score in healthy adults  and workIn the preterm group, the corpus callosum and forceps minor were also significantly associated with SWM strategy score. The corpus callosum provides bi-hemispheric connections, and the forceps minor extend from the corpus callosum to connect homologous regions of the anterior frontal lobe in each hemisphere. A study of healthy 8–18 year olds found correlations between FA in frontal-parietal connections and neural activation on functional MRI in the superior frontal sulcus and inferior parietal lobe . In the We did not find associations between FA and SS or SOC in either the preterm or full term groups. These findings are in sharp contrast with other studies using the same group of participants and methods , 31, 32.The study utilized a small, heterogeneous convenience sample of preterm children who may not be representative of all preterm children. The EF tasks did not differentiate the groups behaviorally. The wide age range may have limited the ability to find brain-behavior relationships and group differences, as the groups may have different developmental trajectories for EF skills in middle childhood and early adolescence.Use of a systematic strategy on a spatial working memory task was correlated with white matter FA in preterm and full term children, suggesting common underlying neurobiology in both groups. Better performance was associated with higher FA. Associations were found in frontal-parietal connections and other major tracts. Our study adds to the relatively small body of literature on EF and white matter in preterm children. Replication with a larger, more homogeneous sample may provide insight into the neurobiology underlying EF in children in general. Unexpectedly, no other associations between EF scores and FA were found in either group. Future work should focus on smaller age groups and adjust tasks and DTI methodology, including advanced imaging and analysis methods such as combined functional MRI and structural connectivity, to better understand the neurobiology of EF.IL conceptualized the study, analyzed and interpreted data, drafted the initial manuscript and critically reviewed, and revised the manuscript. JA contributed to conceptualization and interpretation of data, literature review, and critically reviewed and revised the manuscript. HF conceptualized the study, analyzed and interpreted data, and critically reviewed and revised the manuscript. All authors are responsible for the reported work and have approved the final manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Decompression is an approved alternative to cystectomy in the treatment of jaw cysts. This study aimed to evaluate its effectiveness as an initial procedure, as well as factors with potential to influence outcome.The frequency of decompression was analysed, whether completed in one session or followed by enucleation at the Division of Oral Surgery and Orthodontics, Department of Dental Medicine and Oral Health, Medical University of Graz, from 2005 to 2015. Further analysis focussed on factors potentially influencing outcome: cyst location, histopathology, means of preserving the cyst opening, cyst size, patient age.In all, 53 patients with 55 jaw cysts (mean age of 35.1) were treated by initial decompression in the ten-year period. In the majority of cases, histopathological analysis revealed a follicular cyst (43.6%), followed by odontogenic keratocysts (23.7%), radicular cysts (21.8%), residual cysts (7.3%) and nasopalatine cysts (3.6%) Treatment was completed with a single decompression in 45.5% of the cases. Among those, 72.0% were follicular cysts and 8.0% odontogenic keratocysts. Subsequent enucleation was needed in 54.5% of all cases, with a majority in the keratocystic group (36.7%). Histological findings, means of keeping the cyst open, and patient age were found to influence the effectiveness of decompression.Decompression could be performed as a procedure completed in one session or combined with subsequent enucleation, mainly dependent on histopathological findings. Subsequent enucleation of odontogenic keratocysts is highly recommended. Key words:Jaw cysts, decompression, enucleation, histopathology, obturator. Cystic lesions occur more frequently in the upper and lower jaws than in other bones of the human body, mainly due to the presence of cells that are remnants of the embryonal neuroectoderm. One further explanation is that the embryonic teeth are located in the jaw bones. Triggers are either inflammatory stimuli or developmental disorders . BecauseTreatments range from single decompression, marsupialization, enucleation and bone resection to a combination of these approaches ,5. WhileDecompression as initial procedure is a common conservative approach requiring preparation and preservation of a cyst opening. The aim is to decrease intracystic pressure by constant drainage, so allowing new centripetal bone growth from the bony cyst walls . The cysThe main advantages of decompression are that it spares tissue, minimizes the likelihood of damage to adjacent structures, and avoids the cost of hospitalization ,10. CompDisadvantages of decompression include the duration of treatment, discomfort, and reliance on patient compliance. Further, remnants of the epithelial lining can lead to cyst recurrence requiring further surgical treatment ,17.Some authors have suggested subsequent enucleation for aggressive cysts with a high relapse rate, and when the outcome of decompression is unsatisfactory ,19.This retrospective study aimed to evaluate the effectiveness of decompression for treatment of jaw cysts with consideration of possible outcome-influencing factors including patient age, cyst location and size, histopathology, and means of preserving the cyst opening.After approval of the study by the local ethics committee, data were collected and analysed from patients who had undergone decompression at the Division of Oral Surgery and Orthodontics, Department of Dental Medicine and Oral Health, Medical University of Graz, from 2005 to 2015.The inclusion criteria for the study were cyst in the upper or lower jaw treated with decompression and complete medical records.The exclusion criteria were cyst in the upper or lower jaw treated initially with enucleation or resection, soft tissue cysts, and incomplete medical records.The following data were collected and analysed: frequency of decompression and decompression followed by enucleation, patient’s age and gender, location and size of the cyst, histopathological findings, means of preserving the cyst opening.Histopathology reports were obtained from the Institute of Pathology of the Medical University of Graz.After surgical decompression, the cyst was kept open with iodoform gauze for the first few postoperative days. Thereafter, besides continued gauze packing, obturators, brackets with chains, and drains were used. Patients were advised to follow all postsurgical instructions scrupulously, rinsing the cyst opening twice a day with 0.9% NaCl solution using a syringe, and cleaning dental devices mechanically with a toothbrush or swabs. For the first 2 days, postoperative care included cryotherapy with cold packs and for pain management, dexibuprofen 200 mg for children and 400 mg for adults  3 times a day. Routine follow-up included clinical and radiological studies at least every three months. Additional appointments were arranged depending on individual needs and compliance. Digital panoramic x-rays were taken with the Orthophos XG plus DS  with 60–70kVp and 14-17 mA.Those patients with insufficient cyst shrinkage after decompression later underwent enucleation Figs. ,2.-Statistical analysisData were presented with descriptive statistics. The statistical analyses were performed with SPSS software  at a 5% significance level. The chi-square test and Student’s t-test were applied to quantitative and continuous variables.There were 53 patients (55 cysts) in the ten-year study period with a mean age of 35.1 years; 39 were male (73.6%) and 14 female (26.4%) . Cysts wA single decompression completed treatment in 45.5% of cases, mostly in the frontal region of the jaws and in patients under 30 years (56.0%). Among these patients, follicular cysts were most frequent (72.2%) and the most commonly used devices were brackets with chains (44.0%) .Subsequent enucleation was needed in 54.5% of the cases, mostly in the posterior region. Patients were usually 30-60 years old (60%) and odontogenic keratocysts (36.7%) were most common. An obturator was often used after decompression followed by enucleation (63.3%) .p=0.003, p=0.020 and p=0,025). More detailed information is presented in The effectiveness of decompression was found to correlate with histopathology, the means of keeping the cyst open, and patients’ age (p=0.399) (The cyst’s diameter was not found to have an influence on the effectiveness of the procedure (p=0.399) .This retrospective study focused on the evaluation of the effectiveness of decompression for jaw cyst treatment over a ten-year period and the influence of different factors thereon. The main limitations of this study were that it was retrospective and that medical data were not always complete.The study included 53 patients with a mean age of 35.1 years and 55 cystic lesions treated initially with decompression. In accordance with the literature, the most frequent cystic lesions occurred in anterior maxilla in male patients -22, thoup=0.003), with decompression followed by enucleation applied mostly for odontogenic keratocysts. As a single procedure, decompression was most frequently used for follicular cysts (72%), but only for 8% of odontogenic keratocysts. Some authors have advocated decompression for odontogenic keratocysts . The literature indicates that radicular cysts are the most frequent cysts in the jaws ,22. Histatocysts , althougatocysts .p=0.020). Decompression showed more success when brackets and chains were used rather than other devices. The reason could that brackets with chains are mostly used for follicular cysts. Although obturators can be custom made, it may not be easy to create a precise obturator due to the position of the opening in the mouth, tissue remodelling and imprecise impressions of the inner lumen. Iodoform gauze packing and drain tubes might be used less often due to the surgeon’s preference and the need for extensive after-care. Some patients have difficulty keeping appointments to have their iodoform gauze changed, while others may be over-challenged with keeping a drain clean . However, decompression followed by enucleation was used more often when the cyst’s diameter exceeded 40 mm. Jeong et al. made three-dimensional cyst measurements while Anavi et al. made cyst measurements on panoramic records . Decompression was more successful in patients under 30 years of age than in older patients, which could be explained by the higher occurrence of follicular cysts in younger patients. Follicular cysts are not as aggressive as odontogenic keratocysts, which is why the process is likely to succeed when decompression is the chosen treatment.The relationship between patient age and the reduction rate of the cyst’s size after treatment is still unclear. Some studies have found patient age to be an important factor in the cyst’s healing process ,27, whilDecompression is mainly performed to avoid morbidity. It can be performed as a single complete procedure or combined with subsequent enucleation, mainly depending on histopathological findings. Enucleation after decompression is highly recommended for odontogenic keratocysts.


In this study, we simulated the electric field distribution of side-by-side electrospinning by using the finite element method (FEM), and studied the effects of spinneret wall thickness, spinning voltage and receiving distance on the distribution of the electrostatic field. The receiving distance was selected as a variable in the experimental, a series of PAN/PSA composite nanofiber membranes were prepared by using a self-made side by side electrospinning device. The membranes were tested by Fourier-transform infrared (FTIR), thermogravimetric analysis (TG), and scanning electron microscope (SEM). The prepared membranes were also treated by high-temperature treatment, and the change of fiber diameter and conductivity of the membrane before and after high-temperature treatment were studied. It was found that the PAN/PSA carbonized nanofibers could achieve a better performance in heat resistance and conductivity at 200 mm receiving distance. Due to its unique versatility, composite nanomaterials have attracted great attention in many fields—such as solar cells, sensors, magnetism, luminescence, catalysis, medical treatment, and other numerous fields ,3,4,5,6.2 composite nanofibers Chen et al. [l-lactide) by electrospinning. However, there is insufficient research conducted on the influences of electric field on the side by side electrospinning.Zeng et al.  presenten et al.  found thn et al.  preparedPolysulfone amide (PSA) is a representative polymer for new-type high-temperature resistant fibers, and the micron-sized PSA fibers have been widely used ,27,28,29In the present study, the effect of electric field distribution on the yarn formation and the properties of electrospun PSA nanoyarns were systematically studied ,29. SomePolyacrylonitrile (PAN), with an average molecular weight (Mw) of 90,000, was obtained from Sigma-Aldrich Co., Ltd., Saint Louis, MO, USA. Polysulfonamidefiber (PSA), with an average molecular weight (Mw) of 150,000~200,000, was obtained from Shanghai Tanlon Fiber Co., Ltd., Shanghai, China. The precursor solutions of PAN and PSA with the concentrations of 12 wt% were prepared by dissolving the PAN and PSA in corresponding solvents respectively. PAN was dissolved in DMF, meanwhile PSA was dissolved in DMAc. PAN and PSA with the weight ratios 1:1 are prepared to form the spinning solution. All experiments were performed at about 25 °C and 40~60%RH.The PAN/PSA carbon nanofibers were prepared through side by side electrospinning and subsequent carbonization. A side by side spinneret was used for electrospinning as illustrated in 2 flow in the tube furnace, and the carbonized membranes denoted was PAN/PSA CNFs.The obtained precursor PAN/PSA nanofiber membranes were first treated at 80 °C for 1 h to remove the solvent and then stabilized at 280 °C in air for 2 h. Afterwards, the obtained nanofibrous membranes were calcined at 800 °C for 2 h with the heating rate of 5 °C/min under NThe morphologies of the PAN/PSA CNFs were observed by scanning electron microscopy . In order to form a high-quality image, the sample is sputter coated with a thin layer of gold (~5 nm), the magnification was 20 K. The diameters of the fibers were calculated based on SEM images using image-analysis software .−1 at a resolution of 4 cm−1. The stretching vibration between 2260 and 2210 cm−1 is the best indicator for identifying nitrile groups, the stretching vibration between 3500 and 3300 cm−1 is the best indicator for identifying amine groups and the stretching vibration between 1170 and 1140 cm−1 is the best indicator for identifying sulfone groups [The chemical structures of the membranes were analyzed by using Fourier-transform infrared spectroscopy  with KBr crystal in the infrared region 5000–400 cme groups ,44,45.2 at a heating rate of 5 °C/min with nitrogen flow rate at 20 mL/min. TGA temperature range was from 30 °C to 850 °C at a heating rate of 5 °C /min with a sample about 5 mg, and the nitrogen flow rate was 20 mL/min.The thermal stability of the membranes was carried out using both differential scanning calorimetry  and thermogravimetric analysis . DSC curves of the membranes were obtained using a DSC 4000 by heating from −60 °C to 350 °C in NElectrically conductivity of the PAN/PSA CNFs was measured by using a four-point probe system with a linear probe head , each membrane was measured five times in the vertical and horizontal direction, and the average value was used for evaluation, the tests were carried out in a constant temperature and humidity chamber with a temperature of 25 °C and a humidity of 50 °C.The three-dimensional (3D) electric fields generated from the spinneret to collector were analyzed by COMSOL Multiphysics  software using the finite element method (FEM). The physical geometries of the electrospinning setups  and polymer solution were established according to their practical dimensions, locations, and relative permittivities. The electric field simulation with different spinnerets needle thicknesses , different receiving distances , and different spinning voltages  were simulated respectively. The different spinnerets and the simulations of spinneret needles with different thickness were as shown in x-axis at 2 mm below the spinneret and along the z-axis from the spinneret to the collector with three different needle thickness. As illustrated in the x-axis, the electric field intensity increased firstly to the maximum at the spinneret position and then decreased symmetrically, with the increase of the thickness of the spinnerets, the electric field intensity strengthened except at the position of the spinneret, and the most obviously change was at the top of the spinneret, and the intensity decreased from 2.96 × 106 V/m to 2.8 × 106 V/m with 5.4 presents reduction. The increase of needle thickness expands the volume of the electric field generator which in turn increases the electric field intensity while it makes the electric field distribution more uniform with a small attenuation of the electric field intensity at the spinneret along the x-axis. The change of the electric field along the y-axis is the same as the x-axis. The electric field intensity along the z-axis was also affected by the change of needle thickness, it was strengthened with the needle thickness increase except at the spinneret and the collector. z-axis from the spinneret to the collector, corresponding to the electric field intensity along the x-axis. At the spinneret, a strong electric field concentrates on this surrounding area, when the needle thickness is small, the electric field intensity is large. Finally, the electric field intensity decreased almost to zero at the edge of the collector. The increase of the needle thickness increases the electric field intensity and improve the electric field uniformity, which is more convenient to form a stable and uniform electric field in the electrospinning process.The distribution of electric field is an important factor that affects the electrospinning process. For comparison, the electric fields effected by the three types of needle size were simulated. Spinning voltage is also a very important factor affecting the electric field of electrospinning. ε is the permittivity, ρ is the space charge density and the ∇V is the spinning voltage.The static electric field was calculated using Equation (1), where ε and ρ are constant, the electric field intensity is only determined by the ∇V. The electric field intensity under different voltages are as shown in x-axis and z-axis, especially at the area around the spinneret. A higher spinning voltage makes the electric field intensity stronger, which leads to more energy being obtained for the spinning process.As shown in Equation (1), the In the electrospinning electric field, receiving distance also affect the distribution of the electric field. When the receiving distance is short, the polymer jets movement is unstable, some beads appeared on the membranes, while long receiving distance is suited to prepare nanofibers with smaller diameters. In this study, three receiving distances between the spinneret and the collector were studied, and the spinning voltage was set as 20 kV and the receiving distances were 100, 150, and 200 mm respectively. x-axis at 2 mm below the needles, the receiving distance has no obviously effect on the electric field intensity. Along the z-axis, the same effect on the intensity of electric field affected by three different receiving distance could be obtained, with the intensity decreasing from 7.1 × 106 V/m to 2.0 × 106 V/m at almost 15 mm below the needles. Then with the increase of the receiving distance, the decreasing rate of electric field intensity decreased, which means that when the receiving distance is 200 mm, the electric field still has a relatively high intensity at the position of 100 mm to 200 mm along the z-axis, it provides a guarantee for the drafting of the fibers to form finer fibers.As illustrated in the −1 is the characteristic C–H stretching band of methylene and the peak at 2936 cm−1 of C–H stretching vibration. The vibration at 2244 cm−1 belongs to C≡N. In the spectrum of pure PSA fiber, the peak at 3368 cm−1 is the characteristic N–H stretching band of amide, in addition, the peak at 1148 cm−1 is the S=O stretching vibration and the peak at 1654 cm−1 is the C=O stretching vibration, the absorption peaks at 1504, 1528, and 1590 cm−1 belong to benzene ring skeleton vibration. After combining PAN and PSA by side by side electrospinning, both the main peaks of PAN and PSA can be found in the infrared spectrum of the composite fiber membrane, some slight shifts happened such as N–H stretching band of amide shifted from 3368 cm−1 to 3384 cm−1.Fourier-transform infrared measurement is an effective mean to reflect some information about the chemical composition of the fibers. The composition of fiber membrane and the effect of receiving distance was confirmed by FTIR spectra as shown in After stabilization and carbonization, the morphology of nanofiber membrane was changed. After stabilization, the diameter of the fiber is decreased; and after carbonization, the fiber diameter becomes even smaller. In addition, the diameter is decreased compared with the membrane before carbonization as can be seen in The surface morphology of PAN/PSA nanofibers with the receiving distances before or after stabilized and carbonized stage were illustrated in As can be seen from the DSC curve in Corresponding to the DSC test results, the same conclusion can also be drawn from the TGA curve of the nanofiber membrane as As illustrated in a) and conductivity (b) properties of the membrane. As shown in In summary, we report a side-by-side electrospinning system to study the effect of spinneret size, spinning voltage, and receiving distance on electric field distribution and intensity by using simulation methods. The results showed that the electric field distribution and intensity can be greatly influenced by the needles thickness, spinning voltage, and receiving distance.The receiving distance was selected as a research parameter in the experimental verification by using PAN and PSA as the materials, and the prepared membranes were treated under high-temperature for carbonization. It was observed that the membranes spun with different receiving distances show different performance. When the receiving distance was 200 mm, PAN/PSA membrane not only had a good morphology, but also showed good heat resistance, and the electrical conductivity of carbonized membranes was also the best in this study.


We present a rare case of retroperitoneal rupture of an infected renal cyst secondary to a renocolic fistula in a patient with autosomal dominant polycystic kidney disease (ADPKD). Intraperitoneal rupture of infected cysts in ADPKD resulting in peritonitis has been described, but to our knowledge, this is the first reported case of retroperitoneal rupture. Cyst infections are a common complication of ADPKD and are difficult to treat, potentially leading to sepsis and death. Cyst infections are a very serious and relatively common complication affecting patients with ADPKD. Approximately 30%-50% of patients with autosomal dominant polycystic kidney disease (ADPKD) experience some form of renal infection -3. A rarA 60-year-old Caucasian man with a history of ADPKD status post renal transplant (on immunosuppression therapy), history of diverticulitis, and hyperparathyroidism status post parathyroidectomy presented to the emergency department with intractable left lower quadrant abdominal pain and occasional chills. He denied fever but did endorse loss of appetite. He was hypotensive and in atrial fibrillation with a rapid ventricular response at presentation with mean arterial pressures in the 70s. On physical examination, his abdomen was soft and tender to palpation in his left lower quadrant. White blood cell count was 10,500 per cubic millimeter , and urinalysis and urine culture were negative for infection. He was admitted to the intensive care unit for septic shock and required vasopressor support.Computed tomography of the chest, abdomen, and pelvis (CT CAP) with intravenous contrast showed markedly enlarged polycystic native kidneys consistent with ADPKD with air in a few cysts in the lower pole of the left kidney concerning for an infected cyst/emphysematous pyelonephritis. Extensive sigmoid colonic diverticulosis was also present, and there was new inflammatory stranding of a sigmoid diverticulum which was contiguous with the lower pole of the left kidney, concerning for a possible renocolic fistula from acute vs. chronic diverticulitis Figure . The pat3). Repeat CT CAP . Also, the thick cyst wall may be nodular and demonstrate enhancement, raising concern for renal cell carcinoma, for which these patients are at increased risk . The diaInfections involving cysts are particularly difficult to treat, as antibiotic penetration of cysts is generally poor. Lipid soluble intravenous antibiotics show the best cyst penetration . InfectiInfected renal cysts should be in the differential diagnosis of any patient with ADPKD with leukocytosis and/or fever. Diagnosis of a renal cyst infection by imaging may be challenging due to the potential complexity of the cysts in ADPKD. The etiology of the infection should be sought, as management is different if a fistula is present, necessitating a nephrectomy rather than intravenous antibiotics alone.