Preterm infants are at high risk of diffuse white matter injury and adverse neurodevelopmental outcome. The multiple hit hypothesis suggests that the risk of white matter injury increases with cumulative exposure to multiple perinatal risk factors. Our aim was to test this hypothesis in a large cohort of preterm infants using diffusion weighted magnetic resonance imaging (dMRI).+ 1 (23+ 2–33+ 5) weeks and median postmenstrual age at scan was 42+ 1 (38–45) weeks. dMRI data were analyzed using tract based spatial statistics and the relationship between dMRI measures in white matter and individual perinatal risk factors was assessed. We tested the hypothesis that increased exposure to perinatal risk factors was associated with lower fractional anisotropy (FA), and higher radial, axial and mean diffusivity  in white matter. Neurodevelopmental performance was investigated using the Bayley Scales of Infant and Toddler Development, Third Edition (BSITD-III) in a subset of 381 infants at 20 months corrected age. We tested the hypothesis that lower FA and higher RD, AD and MD in white matter were associated with poorer neurodevelopmental performance.We studied 491 infants  without focal destructive brain lesions born at < 34 weeks, who underwent structural and dMRI at a specialist Neonatal Imaging Centre. The median (range) gestational age (GA) at birth was 30Identified risk factors for diffuse white matter injury were lower GA at birth, fetal growth restriction, increased number of days requiring ventilation and parenteral nutrition, necrotizing enterocolitis and male sex. Clinical chorioamnionitis and patent ductus arteriosus were not associated with white matter injury. Multivariate analysis demonstrated that fetal growth restriction, increased number of days requiring ventilation and parenteral nutrition were independently associated with lower FA values. Exposure to cumulative risk factors was associated with reduced white matter FA and FA values at term equivalent age were associated with subsequent neurodevelopmental performance.This study suggests multiple perinatal risk factors have an independent association with diffuse white matter injury at term equivalent age and exposure to multiple perinatal risk factors exacerbates dMRI defined, clinically significant white matter injury. Our findings support the multiple hit hypothesis for preterm white matter injury. •White matter injury was assessed in 491 preterm infants at term equivalent age.•Aberrant white matter development was associated with several perinatal factors.•Our findings support the multiple hit hypothesis for preterm brain injury. Around 15 million infants are born preterm each year, and this incidence is increasing . While sAnimal models provide evidence that preterm white matter injury may be related to more than one risk factor . These fThis hypothesis is supported in part by neuroimaging studies in human preterm infants which have shown that preterm white matter injury is related to multiple factors including low gestational age (GA), respiratory disease, male sex, poor nutrition, infection, chorioamnionitis, pain, stress and illness severity . However2The National Research Ethics Service and the Hammersmith, Queen Charlotte's and Chelsea Hospital Research Ethics Committees granted ethical permission for MRI . Written parental consent was obtained prior to imaging.2.1We studied the imaging and clinical data from 614 preterm infants, recruited as part of the Evaluation of Preterm Imaging Study (ePrime) (NCT01049594) study from hospitals within North and South West London Perinatal Network, and from on-going imaging studies within the Neonatal Intensive Care Unit at Queen Charlotte's and Hammersmith Hospitals from June 2006 to November 2012. Infants born at < 34 weeks GA and scanned at term equivalent age  without major congenital malformation or metal implants were eligible for inclusion in the study.n = 75) were excluded from analysis (Table S1). 48 subjects were excluded due to motion corrupt dMRI (> 8 dMRI volumes). The final study population consisted of 491 preterm infants  who were born at a median GA of 30+ 1 (range 23+ 2–33+ 5) weeks and PMA at scan of 42+ 1 (range 38–45) weeks. The perinatal characteristics of these infants are presented in Infants with major focal lesions such as periventricular leukomalacia, hemorrhagic parenchymal infarction and other ischemic or hemorrhagic lesions (2.2http://imd-by-postcode.opendatacommunities.org).Demographic and clinical data were collected from the Standardized Electronic Neonatal Database (SEND). Variables of interest included GA at birth, PMA at scan, gender, days spent on invasive ventilation via an endotracheal tube (up to the date of MRI), days of parenteral nutrition (up to the date of MRI), the presence of chorioamnionitis , the presence of fetal growth restriction , necrotizing enterocolitis requiring surgical intervention, the presence of a patent ductus arteriosus requiring medical or surgical treatment, and Index of Multiple Deprivation (IMD) score , determined by the postcode of the parent at the time of infant birth  were acquired on a Philips 3 Tesla  system sited on the neonatal intensive care unit using an eight-channel phased array head coil.3D MPRAGE , T2-weighted turbo spin echo  and single shot echo planar dMRI , prior to scanning and 398 infants (81%) were sedated for imaging. Pulse oximetry, temperature and electrocardiography were monitored throughout the scan and ear protection was used, comprising earplugs molded from a silicone-based putty  placed in the external auditory meatus and neonatal earmuffs .2.4www.dti-tk.sourceforge.net) (DTI-TK) (http://fsl.fmrib.ox.ac.uk/fsl/fslwiki/TBSS/UserGuide) (www.fmrib.ox.ac.uk/fsl). For each infant the diffusion weighted images were registered to their native b0 image and corrected for differences in spatial distortion using eddy correct. Non-brain tissue was removed with FSL's Brain Extraction Tool (BET v2.1 http://fsl.fmrib.ox.ac.uk/fsl/fslwiki/BET).dMRI images were assessed visually for the presence of motion artifact and if ≤ 8 volumes were corrupt, these volumes were removed. If > 8 dMRI volumes showed motion artifact, they were excluded from analysis. 143/491 datasets had at least one volume removed . Image processing and data analysis were performed using FMRIB's Diffusion Toolbox (v3.0), DTI-ToolKit (v2.3.1 (DTI-TK)  and tracerGuide)  as impleDiffusion tensors were calculated on a per voxel basis, using a simple least squares fit of the tensor model to the diffusion data. From this the tensor eigenvalues describing the diffusion strength in the primary, secondary and tertiary diffusion directions were obtained. Axial diffusivity (AD), radial diffusivity (RD), mean diffusivity (MD) and FA maps were calculated for each subject.Image registration was performed using DTI-TK and integrated within the TBSS pipeline to produce a population specific DTI template. From this template a mean FA map was derived and then thinned by perpendicular non-maximum suppression to create a mean FA skeleton. A FA threshold of ≥ 0.15 was used to limit the inclusion of voxels with high inter-subject variability and non-white matter voxels. FA, AD, RD and MD were projected onto this skeleton prior to statistical analysis.2.5Of 491 subjects who had suitable dMRI data 381 (77.6%) returned for neurodevelopmental assessment at a median of 20.23 months corrected age . Neurode2.62.6.1http://fsl.fmrib.ox.ac.uk/fsl/fslwiki/Randomise). A general linear model (GLM) was used to assess the relationship between dMRI metrics and GA at birth, PMA at scan and gender were included as covariates in the model. Differences between male and female infants were assessed using a GLM, with GA at birth and PMA at scan as co-variates. GA at birth, PMA at scan and gender were included as covariates in all subsequent analyses of perinatal risk factors; number of days requiring mechanical ventilation, number of days requiring parenteral nutrition, chorioamnionitis, fetal growth restriction, necrotizing enterocolitis requiring surgery, patent ductus arteriosus requiring medical or surgical treatment .In order to investigate the relationship between dMRI metrics in white matter at term equivalent age and clinical risk factors, cross-subject voxelwise statistical analysis was performed using Randomise in FSL (v2.9) . All statistical analyses were subject to family-wise error (FWE) correction for multiple comparisons following threshold-free cluster enhancement (TFCE) and p < 0.05 was considered significant.33.1The perinatal clinical characteristics of the infants are shown in 3.23.2.1FA values were positively correlated with GA at birth throughout the white matter . AD was 3.2.2FA values were higher in only a very few voxels in the right PLIC and the right crus cerebri in male infants a. AD was3.2.3There were no significant differences in dMRI measures between those infants who had a clinical diagnosis of chorioamnionitis and those who did not.3.2.4FA values were significantly lower in infants with fetal growth restriction in the corpus callosum, right cingulum and SLF, external capsule, ALIC, PLIC, fornix, optic radiation, ILF/IFOF, crus cerebri and cerebellar peduncles bilaterally . No sign3.2.5FA values throughout the white matter were negatively correlated with the number of days on mechanical ventilation . AD valu3.2.6With the exception of the left centrum semiovale and the left external capsule, which showed no correlations with days on parenteral nutrition, FA values throughout the white matter were significantly negatively correlated with the number of days an infant received parenteral nutrition . No sign3.2.7FA values throughout the white matter were significantly lower in those infants who had undergone surgical treatment for necrotizing enterocolitis a. RD val3.2.8There were no significant differences in dMRI measures between those infants who had undergone treatment for patent ductus arteriosus and those who had not.3.3Clinical data for all risk factors were available for 381 infants, allowing multivariate analysis of all risk factors simultaneously. There were no significant differences in GA at birth, PMA at scan, gender distribution or the proportion of infants who were singletons/multiple births between the 381 infants included in the multivariate analysis and the 110 infants who were not included (Table S2). Multivariate analysis of the relationship between dMRI measures and risk factors  demonstrated that the extent of the relationship between risk factor and dMRI measures was diminished compared to assessing each risk factor individually. However, significant relationships between fetal growth restriction, days requiring invasive ventilatory support and days requiring parenteral nutrition and FA values remained.3.3.1Multivariate analysis showed that FA values in the corpus callosum, ALIC, PLIC, external capsule crus cerebri and cerebellar peduncles were significantly lower in infants with fetal growth restriction than appropriately grown infants . No sign3.3.2FA values in the corpus callosum, cingulum and optic radiation were negatively correlated with the number of days on mechanical ventilation . There w3.3.3FA values in the corpus callosum, cingulum, right SLF, PLIC, left ALIC, optic radiation, crus cerebri and cerebellar peduncles were significantly negatively correlated with the number of days an infant received parenteral nutrition . No sign3.3.4n = 7) and those who had not when assessed using multivariate analysis including all clinical risk factors.There were no differences in FA, AD, MD or RD values between those infants who had undergone surgery for necrotizing enterocolitis  under its Programme Grants for Applied Research Programme (Grant Reference Number RP-PG-0707-10154) and the Department of Health via the NIHR Comprehensive Biomedical Research Centre award to Guy's and St Thomas' NHS Foundation Trust in partnership with King's College London and King's College Hospital NHS Foundation Trust. It was supported by the Medical Research Council (UK) (MR/K006355/1 and MR/L011530/1), and PhD studentship to MB. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health.The work summarizes independent research supported by the


An inverse relationship between oocyte efficiency and ovarian response was reported in conventional IVF. The purpose of this study was to report metaphase II (MII) oocyte efficiency according to oocyte yield in minimal/mild stimulation IVF (mIVF) and to assess whether oocyte yield affects live birth rate (LBR).n = 264) aged < 39 years old with normal ovarian reserve who had mIVF were recruited. All participants received the same protocol for ovarian stimulation. All the embryos were cultured to the blastocyst stage and vitrified using a freeze-all approach. This was followed by a single blastocyst transferred to each participant in subsequent cycles over a 6-month period. Ovarian response was categorized according to the number of MII oocyte yield . MII oocyte utilization rate was calculated as the number of live births divided by the number of MII oocytes produced after only one oocyte retrieval and subsequent transfers of vitrified/warmed blastocysts. The main outcome measure was cumulative LBR over a 6-month period.Infertile women (p < 0.05). Implantation rate significantly dropped as the number of MII oocytes increased and was highest in the “low” oocyte yield group (p < 0.0001). Cumulative LBR was similar in “low,” “intermediate,” and “high” oocyte yield groups (p > 0.05). The number of MII oocytes had poor sensitivity and specificity for predicting a live birth.Among all the participants, 1173 total retrieved oocytes (4.4 ± 0.2 per patient) resulted in 1019 (3.9 ± 0.2 per patient) total MII oocytes, a clinical pregnancy rate of 48.1 % and a LBR of 41.2 %. Oocyte utilization rate was inversely related to ovarian response where it was 30.3 % in the “low” vs. 9.3 % in the “intermediate” vs. 4.3 % in the “high” oocyte yield groups (These data extend the hypothesis of oocyte efficiency reported in conventional IVF protocols to mIVF protocols.NCT00799929.Registration clinicaltrials.gov:  In the late 1980s and early 1990s, the widespread use of high doses of gonadotropins was introduced in in vitro fertilization (IVF) protocols . ConventMinimal and mild ovarian stimulation IVF usually refers to the use of low-dose gonadotropins with or without a sequential administration of clomiphene citrate –7. Minim2 were excluded. Additionally, women who had a cycle day 3 follicle stimulating hormone (FSH) ≥ 13 mIU/mL were excluded for possible diminished ovarian reserve. The study was approved by the Institutional Review Board of New York Downtown Hospital . The study protocol was approved by the institutional review boards of the New York Downtown Hospital and the Biomedical Research Alliance of New York (BRANY). Informed consent was obtained from each participant before recruitment. This study was a secondary analysis of data from a randomized controlled trial published elsewhere [Between February 2009 and August 2013, 285 participants were allocated to mIVF and freeze-all embryo strategy, followed by transfers of single frozen/thawed blastocysts. Women aged between 18 and 38 with normal menstrual cycles and requiring a first IVF cycle treatment were included. Inclusion criteria included women with infertility diagnosis of unexplained, male and tubal factors. Women with pre-existing medical conditions and those with body mass index (BMI) <18.5 or >32 kg/mlsewhere .Each participant had only one ovarian stimulation and one oocyte retrieval. All formed blastocysts were vitrified then they were transferred as one-by-one in subsequent frozen embryo transfer cycles . Thus, each participant had a single embryo transfer at the blastocyst stage.All participants had similar ovarian stimulation protocol. After oral contraceptive pill pre-treatment for approximately 3 weeks and adequate suppression, minimal/mild ovarian stimulation was started with an extended regimen (from cycle day 3 until the day before triggering) of clomiphene citrate  in conjunction with low dose of gonadotropin (75 IU’s daily) injections  starting on cycle day 4–7. No hypothalamic-pituitary suppression using gonadotropin releasing hormone (GnRH) agonist or antagonist was used. The final maturation of oocytes was induced by a nasal GnRH agonist  when the lead follicle was > 18 mm. Retrieved oocytes were fertilized by IVF or ICSI as clinically indicated. All embryos were cultured until the blastocyst stage and then vitrified.2, and 5 % O2 using Global Total media , with sterile mineral oil overlay . The embryos were placed in drops of Equilibration Solution (ES) containing 7.5 % (vol/vol) ethylene glycol (EG) + 7.5 % dimethyl sulfoxide (DMSO) at room temperature. Then, they were transferred into a Vitrification Solution (VS) drop containing 15 % EG + 15 % DMSO + 0.7 M sucrose + Ficoll 0.01 g/ml. Embryos were then placed in ES media for 10 min, and transferred into VS media for 1 min, then loaded onto cryotop (only one embryo per cryotop) and submerged into liquid nitrogen immediately. For embryo thawing, the cryotop was quickly removed from the liquid nitrogen and the tip was submerged in T1 media (1 M Sucrose + Base Solution). The embryo was then placed in T1 for 1 min before being transferred to T2 (0.75 M Sucrose + Base Solution), T3 (0.50 M Sucrose + Base Solution), T4 (0.25 M Sucrose + Base Solution), and T5 (Base Solution) media, for 3 min each. Upon completion of the thaw, the embryo was washed in several drops of ES media.All blastocysts that have distinct inner cell mass and trophectoderm were vitrified using the CryoTop method (Kitazato Biopharma) . In brieA single thawed blastocyst was transferred in a subsequent natural or artificially prepared cycle with oral Estrace   within aCycles were subdivided into three subgroups according to the number of mature MII oocyte yield following oocyte retrieval: “low” represented a yield of 1–2 oocytes; “intermediate” represented a yield of 3–6 oocytes; and “high” represented a yield of ≥ 7 oocytes. Because the aim of the study was to evaluate the efficiency of MII oocytes, patients who had no oocytes retrieved were excluded from the data analysis.over a 6-month period divided by number of MII oocytes produced following only one ovarian stimulation and only one oocyte retrieval. For continuous outcomes, data were expressed as mean ± standard error of the mean (SEM) and t-test or ANOVA were used appropriate. Chi-square test was used for categorical data. Multivariate logistic regression analyses were conducted to identify “low,’ “intermediate,” and “high” ovarian responses as independent correlates of a live birth. In order to determine the predictive ability of the number of MII oocytes and age (the strongest predictor of achieving a live birth), receiver operating characteristic (ROC) curves were performed and the area under the ROC curve (AUC) was determined. P < 0.05 was considered statistically significant. GraphPrism Software was used to perform all statistical analyses.The primary outcome was cumulative live birth rate. Secondary outcomes included cumulative implantation rate, cumulative clinical pregnancy rate, number of blastocysts formed, total dose of gonadotropins used per cycle, and number of fertilized oocytes per MII oocytes. The cumulative implantation rate was defined as the number of gestational sacs observed on ultrasound at 6 weeks of pregnancy divided by the number of embryos transferred. A cumulative clinical pregnancy was defined as at least one intrauterine sac at 6 weeks gestation and live birth was defined as a child born after 22 weeks of gestation or weighing at least 500 g. The cumulative clinical pregnancy rate over a 6-month period was calculated as the number of pregnancies divided by the total number of participants. The cumulative live birth rate over a 6-month period was calculated as the number of births divided by the total number of participants. The cumulative live birth was expressed as odds ratio (OR) with corresponding 95 % confidence interval (CI). The mean MII oocytes (3.9 ± 0.2) and the cumulative live birth rate of 41.2 % in all the cohort was used as the reference group for OR calculations. Oocyte utilization rate was calculated as the number of live births p-value = 0.6 for age, and 9.0 ± 0.2 vs. 8.5 ± 0.2 vs. 8.3 ± 0.4, respectively; p-value = 0.2 for day 3 FSH). However, participants in the “high” MII oocyte yield group had signifincalty higher BMI and received higher doses of gonadotropins (Table p > 0.05) among the three groups. The 264 participants produced a total of 1173 retrieved oocytes . Of these oocytes, a total of 1019  were MII oocytes, yielding a maturity rate of 86.9 %, a cumulative clinical pregnancy rate of 48.1 % and a cumulative live birth rate of 41.2 % over a 6-month period. The majority (86.7 %) of the participants had 6 or less MII oocytes. As seen in Table There were 264 participants out of 285 who had minimal/mild IVF treatment and had oocytes retrieved. The remaining 21 participants were excluded for reasons such as spontaneous pregnancy, persistent ovarian cysts, premature ovulation and withdrawal from the study participation. The demographics and clinical characteristics of the participants are summarized in Table p < 0.0001, Table p < 0.0001, Table p < 0.0001; Table p = 0.7, Table p = 0.6, Table vs 9.3 % in the “intermediate” vs 4.3 % in the “high” MII oocyte yield groups . In a multivariate logistic regression adjusting for the number of days of stimulation and total dose of gonadotropins used per cycle, the number of MII oocytes  did not affect the likelihood of achieving a live birth  among all the participants. Additionally, the yield of MII oocytes according to “low,” “intermediate,” or “high” ovarian response did not affect the likelihood of achieving a live birth in a multivariate logistic regression after adjusting for the number of days of stimulation and total dose of gonadotropins used per cycle (Table p = 0.9). For age, the AUC was 0.62 . The number of MII oocytes had very poor sensitivity and specificity for predicting a live birth.Among all the participants, logistic regression showed that age was a negative predictor for achieving a live birth , success rates of both fresh and frozen-thawed embryo transfer cycles have increased over the last decade for women of all ages although the increase in success rates was greater in frozen-thawed embryo cycles (http://www.cdc.gov/art/pubs.htm). Another advantage of the freeze-all embryo strategy is that recent data showed that children born from frozen-thawed embryo cycles showed fewer perinatal morbidity and mortality compared to children born from fresh embryo cycles [In this study, all the participants had mIVF combined with single blastocyst transfer, which has the potential to reduce the risk of OHSS and the risk of multiple pregnancies without significantly lowering live birth rates . This mIo cycles –21.Increasing oocyte utilization rate will decrease the unnecessary production and retrieval of a large number of oocytes. Gonadotropins are administered to allow more follicles, which are already driven into the pool of developing follicles by gonadotropin-independent mechanisms, to escape follicular atresia. A challenging problem is to know the exact needed doses of gonadotropins and the extent of oocyte utilization rate since it is clear that not every retrieved oocyte is mature and gets fertilized to form a good quality embryo that end up being transferred or cryopreserved. In our study, the oocyte yield as categorized by low, intermediate or high did not affect the cumulative live birth rates. Thus it is reasonable to assume that gentle ovarian stimulation can produce reasonable pregnancy rates in patients similar to our participants, i.e., relatively young women with normal ovarian reserve. Another issue to consider is whether the number of retrieved oocytes influences the reproductive potential of the individual oocyte. Indeed, a study showed that although the pregnancy rate per cycle increased with the number of oocytes retrieved, the proportion of oocytes that produced good quality embryos dropped . The autOur results are consistent with other reports pertaining to fresh embryo transfer , 23 thatThere are several limitations to our study. All patients received clomiphene citrate as part of their protocol, which can potentially cause a thin endometrial lining, thus they all had a freeze-all embryo strategy. Another limitation is the fact that we did not use serum anti-Mullerian hormone or antral follicle count to exclude women with diminished ovarian reserve, rather we relied only on age and day 3 FSH. Although we did not have the semen parameters on the male partners, the rate of ICSI use was not different among the three subgroups.In conclusion, this study extends the body of literature reported on conventional IVF to include similar data on minimal/mild ovarian stimulation IVF. Producing a low number of MII oocytes demonstrated a higher oocyte utilization rate without affecting live birth rates over a 6-month period using a single embryo transfer in minimal/mild ovarian stimulation IVF. Collection of large cohorts of oocytes does not necessarily benefit the patient. This information is useful in counseling patients undergoing IVF.


A growing body of research has examined whether birth intervals influence perinatal outcomes and child health as well as long-term educational and socioeconomic outcomes. To date, however, very little research has examined whether birth spacing influences long-term health. We use contemporary Swedish population register data to examine the relationship between birth-to-birth intervals and a variety of health outcomes in adulthood: for men, height, physical fitness, and the probability of falling into different body mass index categories; and for men and women, mortality. In models that do not adjust carefully for family background, we find that short and long birth intervals are clearly associated with height, physical fitness, being overweight or obese, and mortality. However, after carefully adjusting for family background using a within-family sibling comparison design, we find that birth spacing is generally not associated with long-term health, although we find that men born after very long birth intervals have a higher probability of being overweight or obese in early adulthood. Overall, we conclude that birth intervals have little independent effect on long-term health outcomes.The online version of this article (10.1007/s13524-018-0673-8) contains supplementary material, which is available to authorized users. Recent years have seen a resurgence of interest in the long-term consequences of fertility decisions for both parents and children. Although several studies have examined how birth order, family size, and parental age at the time of birth are related to long-term cognitive development, educational and socioeconomic attainment, and health  categories measured at ages 17–20 for men, and mortality over ages 30–74 for both men and women. Our study extends the literature on this topic by examining a range of medium- and long-term health outcomes that have not been previously examined in relation to birth spacing, and we do so using a within-family sibling comparison design that allows us to minimize residual confounding and to isolate the net effect of birth interval length on long-term health. Furthermore, previous research has focused on the length of the birth interval preceding the birth of the index person; in this study, we also examine whether the length of the Despite the large and growing literature examining the relationship between family background and family structure on long-term health , and being small for gestational age (SGA)  is either completely removed or reduced substantially  that is universally used for administrative purposes. A key administrative register that we use in this study is the Swedish multigenerational register, which allows us to link individuals to their parents and siblings. We examine sibling groups where all the children were born in Sweden in order to maximize the accuracy of the parent-child-sibling linkages.We examine the relationship between birth intervals and five outcome variables: height, physical fitness, being overweight or obese, being underweight or severely underweight, and mortality. Apart from mortality, information on all the other outcome variables is drawn from the Swedish military conscription register. In Sweden, men were universally required to report to military conscription tests between ages 17 and 20 to determine their physical and psychological suitability for military service. Data on height, physical fitness, and BMI are available for cohorts born 1962–1979. Because only men were required to report to conscription tests in Sweden, we do not have data on these measures for women. However, although the outcome measures are available for men only, the measures of birth spacing and other characteristics of the sibling group are based on the whole sibling groups, including males and females.The other main register that we use is the Swedish mortality register, which contains detailed information on all deaths in Sweden between 1960 and 2012. Although the Swedish mortality register contains data for the period 1960–2012, the multigenerational registers that allow family members to be linked to one another are incomplete before the 1990s  This study is based on a population of sibling groups for which neither parent has any children with a third partner. Thus, none of the individuals included in our analysis have any half-siblings. Although this restriction reduces external validity, it also offers distinct advantages, such as increasing the degree of genetic similarity of the siblings and the likelihood that the children share the same childhood environment. We also exclude sibling groups with multiple births because it is not possible to distinguish the effect of birth interval from the presence of a twin on long-term outcomes in these families.N contribute N – 1 birth intervals to the total population of birth intervals. Therefore, in a sibling group with four children, three siblings have a younger (or older) sibling; in a sibling group with two children, only one child has a younger (or older) sibling. The four-child group therefore has three times as many intervals as the two-child group. Given the family size distribution in Sweden in the birth cohorts that we study, we estimate that by examining sibling groups with three or more children, we are examining sibling groups where more than 69 % of all birth intervals are observed.In our analyses, we compare the results from within-family sibling fixed-effects models and between-family linear regression models. We explain those models in detail in the Statistical Analyses section, but this modeling approach also has implications for our data selection. Because the fixed-effects approach requires variance in the groups in which the comparisons are conducted, we necessarily exclude the following: (1) sibling groups with only one child, given the irrelevance of birth spacing in such cases; and (2) sibling groups with two children because these sibling groups contain only one birth interval. Nevertheless, by studying birth intervals in families with three or more children, we still study the majority of birth intervals observed in the population. Sibling groups of size preceding birth interval (the time in months between the birth of the older sibling and the birth of the index person) and the subsequent birth interval (the time in months between the birth of the index person and the birth of the younger sibling). In the analyses examining the importance of the preceding birth interval, we necessarily exclude firstborn individuals given that there was no preceding interval. Thus, our analysis population for the analyses on the preceding birth interval is second and later-born children in sibling groups with at least three children. In our analyses examining the importance of the subsequent birth interval, we necessarily exclude last-born individuals because they do not have any siblings born after them. Table SIn studying the effect of birth intervals on each of the five outcomes that we address, we perform separate analyses examining the importance of the length of the The measure for the birth interval that we use in this study is the length of the birth-to-birth interval, meaning the months between one live birth and another. We categorize the length of the birth interval into 16 categories of six-month periods, ranging from a minimum of 9-12 months to 96 months or longer. The reference category for the preceding and subsequent birth interval is 25–30 months. The distribution of birth intervals in Sweden between 1938 and 1979 is shown in Fig. Height, measured in centimeters, is standardized.fysisk arbetsförmåga i watt). Maximal working capacity (MWC)— measured as the maximum resistance attained in watts when riding on a stationary bike (one of the most effective ways of measuring aerobic fitness) for 5–10 minutes—is closely related to maximal oxygen uptake (V02max), also known as maximal aerobic capacity. The correlation between these two variables has been reported to be approximately .9  divided by height (in m) squared at the time of conscription test. Using the standard cutoff points, we categorize BMI as overweight or obese (≥25), normal (18.5–24.9), and underweight or severely underweight (<18.5).We study all-cause mortality in the period 1990–2012 for Swedish men and women born in 1938–1960. Thus, conditional on survival to 1990, we study mortality over the age range 52–74 for those born in 1938 and over the age range 30–54 for those born in 1960.In addition to our main explanatory variable—the length of birth intervals—we include several covariates in our models that are likely to be associated with both birth spacing as well as long-term health. Factors such as birth order, parental age at the time of birth, and birth year may be associated with birth interval length, and are also associated with long-term health outcomes. We include controls for birth order because both the confluence hypothesis and the resource dilution hypothesis predict independent effects of birth order and birth spacing, and previous research has indicated that birth order is related to height , we use fixed-effects linear regression. Our outcome variables for physical fitness and height are continuous, but we use the categories of being overweight/obese and being underweight/severely underweight as binary variables, treating each outcome as though it were independent. In these cases, we also use a linear probability model with robust Huber-White standard errors  and the health outcome; we control for birth order, maternal age, birth year, age at the time of the conscription test, year of the conscription test, and sibling group size. PBIi is entered into the model as a series of 16 dummy variables based on six-month categories for the length of the preceding birth interval. In Model 1, our analysis population is second and later-born children in sibling groups with at least three children; that is, we exclude firstborns because they have no value for the length of the preceding interval. In Model 2, we introduce the sibling fixed effect, αj, and remove the control for sibling group size because it is adjusted for in the fixed-effects approach. We use the same analysis sample for Model 2 as used in Model 1. Models 3 and 4 follow the same format except that we substitute the variable for the preceding interval with SBI, a variable for the length of the subsequent interval. We regard Models 2 and 4 as an improvement on Models 1 and 3, respectively: the sibling comparison approach that we use in Models 2 and 4 minimizes residual confounding from unobserved factors that are shared by siblings. To this end, we are much better able to isolate the net effect of birth intervals on the multiple long-term outcomes that we study.For each outcome variable, we estimate four models:  one betwh is the hazard rate for individuals with characteristics X1, . . . , Xk at time t; h0(t) is the baseline hazard at time t; and βj, j = 1, . . . , k are the estimated coefficients. Because the failure event in our analysis is the death of the individual, the baseline hazard of our model, h0(t), is age. Individuals are censored on first migration out of Sweden, at death, or in 2012—whichever comes first. We estimate robust standard errors to account for clustering within sibling groups (Lin and Wei s takes the following form:hs0(t) is the baseline hazard for stratum s, s = 1, . . . , S. Each stratum, s, is a sibling group. In the standard Cox proportional hazard regression, the baseline hazard h0 is common to all individuals in the analysis. In the stratified Cox model (Eq. (hi(t) is the log hazard of mortality, αj is the fixed effect for sibling group j, and the index ij refers to the individual i in sibling group j. As with the linear regression analyses, PBIi is entered into the model as a series of 16 dummy variables based on six-month categories for the length of the preceding birth interval. In Model 7, our analysis population is second and later-born children in sibling groups with at least three children; that is, we exclude firstborns because they have no value for the length of the preceding interval. In Model 8, we introduce the sibling fixed effect, αj, and remove the control for sibling group size because it is implicitly adjusted for. We use the same analysis sample for Model 7 as used in Model 6. In Models 9 and 10, we substitute the variable for the preceding interval with SBIi, a variable for the length of the subsequent interval. We regard Models 8 and 10 as improvements on Models 7 and 9, respectively: the stratified approach that we use in Models 8 and 10 minimizes residual confounding from unobserved factors that are shared by siblings.To study mortality, we use survival analysis in the form of Cox proportional hazard regressions Cox . The prodel


To present the various techniques used in the management of pancreatitis-related pseudoaneurysms of visceral vessels.The retrospective clinical study was carried out at the Department of Diagnostic and Interventional Radiology at Poznan University of Medical Sciences from 2011 to 2016. The fifteen patients included in the study were diagnosed with pseudoaneurysms of visceral arteries, as a complication of chronic pancreatitis. The diagnosis was made using contrast-enhanced computed tomography, followed by angiography. On admission, all patients were symptomatic, with varying degrees of abdominal pain. One patient was haemodynamically unstable. Treatments with endovascular techniques were analysed, along with their efficacy and outcomes. Coil embolisation was performed in 5 patients. Stent graft was used in 1 patient. Liquid embolic agents were used in 7 cases, of which 5 patients were treated with thrombin injection and 2 with Squid. A combination of techniques was used in 2 patients.The most common artery affected by pseudoaneurysm formation was the splenic artery , and the size of the pseudoaneurysms ranged from 27 mm to 85 mm. Primary technical success was achieved in 14 out of 15 patients (93.3%). One patient required reintervention. Two patients required splenectomy after embolisation due to splenic ischemia. No recanalisation was present at the follow-up computed tomography performed after 1 to 3 weeks, and no mortality was observed within 30 days.Vascular complications of pancreatitis require accurate diagnosis and immediate treatment. Endovascular intervention is highly effective and is the preferred treatment option. The technique used is determined based on vascular anatomy and the patient’s haemodynamic status. Following pancreatic inflammation, the spread of proteolytic fluids, causing weakening of local vessel walls, may lead to the formation of arterial pseudoaneurysms. The formation of pseudoaneurysms occurs with a higher incidence in chronic pancreatitis 4% - 8%) than in acute pancreatitis  –3. Pseud% - 8% thThe retrospective clinical study was carried out in the Department of Diagnostic and Interventional Radiology at Poznan University of Medical Sciences from 2011 to 2016. We analysed 15 patients, aged 29–69 years, who were diagnosed with visceral artery pseudoaneurysms resulting from underlying chronic pancreatitis. The diagnosis of chronic pancreatitis was established based on the clinical cardinal symptoms and supporting radiological findings . The diaA total of 15 patients with visceral artery pseudoaneurysms presented at our institution for treatment after referral from the gastroenterology department in the five-year time frame. Inclusion criteria for patients included in this study were clinical and radiological diagnosis of underlying chronic pancreatitis (computed tomography (CT)) and evidence of pseudoaneurysm formation in visceral artery (CT angiography).Patient characteristics  were recorded in a database and retrospectively collected and made anonymous by one member of the interventional radiology team before analysis.Fourteen patients were haemodynamically stable and presenting with abdominal pain, of varying degrees of severity. One patient was admitted with symptoms of hypovolemic shock (systolic blood pressure below 60 mmHg) and massive haematemesis, due to the splenic artery rupturing into the stomach as a result of prior gastrocystostomy. The choice of endovascular therapeutic intervention was made based on the size and anatomical location of the pseudoaneurysm. In accordance with Polish law and GCP regulations, this retrospective case series did not require approval of the Bioethics Committee at Poznan University of Medical Sciences, and is not defined as a medical experiment. All data were fully anonymized before being analysed by researchers, and therefore separate informed consent to use them in an anonymized form was not required for the purpose of this report.The diagnosis of a pseuodoaneurysm was made by contrast-enhanced CT in all 15 patients. Subsequent use of angiography confirmed the diagnosis and located the arterial source of the pseudoaneurysm. Angiographic catheters (Simmons and Cobra) served as guiding catheters for microcatheters  in the endovascular intervention. Access was gained through the common femoral artery in 13 procedures, and brachial artery access was used in 1 case of a superior mesenteric artery (SMA) pseudoaneurysm. Both access sites were used in 1 case, with initial coil embolisation via the femoral artery followed by vascular plug insertion via the brachial artery. Follow-up CT examinations were performed on the following day and again 1–3 weeks after the procedures.Detachable microcoils  were delivered via microcatheter in cases in which the pseudoaneurysm neck was accessible. This was carried out using the sandwich technique or by direct delivery into the pseudoaneurysm sac. The sandwich technique was utilised in the pseudoaneurysms of the splenic arteries  and the gastroduodenal artery (37 mm), due to their expendable nature. Direct delivery of coils into the sac was required in the case of a pseudoaneurysm of the coeliac artery trifurcation (27 mm) and was the initial technique utilised in the pseudoaneurysm of the common hepatic artery variant (60 mm).Stent grafts provided an exclusion of the pseudoaneurysm in situations in which the parent artery was nonexpendable, such as the SMA. The 6-mm balloon-expandable stent graft  was utilised to keep the vessel patent. It was delivered through a 6F 90cm sheath  via the brachial artery access.Bovine thrombin  was injected through a microcatheter into the pseudoaneurysm. No percutaneous injections with ultrasound (US) guidance were carried out. In cases in which arterial patency was required and a collateral supply was not yet established, thrombin was used, alone or in conjunction with coils, to occlude the pseudoaneurysm cavity. Thrombin injection was used in 5 patients presenting with pseudoaneurysms in various coeliac branches, including the gastroepipoloic, right hepatic, splenic, and common hepatic artery. The amount of thrombin used was determined based on pseudoaneurysm size and the size of its perfusion zone. In pseudoaneurysms with a perfusion zone diameter of up to 20 mm, 1 ampoule of thrombin (2 ml of 200U/ml per ampoule) was initially utilized. Pseudoaneurysms with perfusion zones above 20 mm were initiated with 2 ampoules of thrombin. Thrombin injection was adjusted according to the neck size and flow velocity in each particular case. Additional ampoules were added, when necessary, to stabilize the ongoing thrombosis. An extra diagnostic run was performed 20 minutes after the procedure to exclude immediate revascularisation.In cases in which the pseudoaneurysm neck was not easily accessible or the patient’s own coagulation was insufficient, a non-adhesive liquid embolic agent  was used. Standard viscosity SquidPeri 18 formula was injected proximal to the pseudoaneurysm neck, using a DMSO-compatible microcatheter, to effectively block any feeding vessels distal to the injection site. Embolisation was continued until occlusion of affected vessel segment was achieved.Amplatzer vascular plug (AVP) type II  was delivered through the JR4.0 6 F guide catheter  advanced through a 6F sheath access site in the left brachial artery. Two AVPs II were used in one case of a pseudoaneurysm of the common hepatic artery. The vascular plugs were deployed proximal and distal to the pseudoaneurysm neck, causing the self-expanding Nitinol meshes to completely seal off the pseudoaneurysm from the feeding vessel. As the high-velocity blood flow of the hepatic artery increases the risk of non-target embolisation when using liquid embolic agents and coils, the AVPs were deemed a more optimal choice. The plugs provide a well-controlled and stable occlusion, and is a more cost-effective option when compared to the utilization of a large number of coils and stent grafts in this scenario. AVPs are also appropriate for the common hepatic artery due to its flexible delivery system when compared to stent grafts.Diagnostic CT identified the splenic artery as the most common pseudoaneurysm site  in this study, followed by the common hepatic artery , and right gastroepiploic artery . Measurements of pseudoaneurysm diameter ranged from 27 mm to 85 mm, with an average of 57.3 mm.Catheter-directed endovascular delivery of microcoils was utilised in 5 cases. In 2 cases of a pseudoaneurysm of the splenic artery, the sandwich method was successfully employed. This technique was effective in preventing backflow from the collateral circulation. No ischemic complications were observed, as collateral circulation to the spleen was sufficient. The sandwich technique was also utilised in a case of a gastroduodenal artery pseudoaneurysm. The pseudoaneurysm showed thrombosis and a bleeding area of 10 mm, with vasospasm of the originating artery. Saline injection was initially used to expose the bleeding site before coil delivery . A pseudIn the case of a pseudoaneurysm involving the common hepatic artery (60 mm), the initial method of intervention was coil embolisation. This proved to be ineffective when enlargement of the pseudoaneurysm was later observed. The patient had an anatomical variant, in which the right hepatic artery originated from the SMA . This anStent graft was used in the treatment of a pseudoaneurysm of the SMA . PersistBovine thrombin injections were administered alone in 5 cases. Two additional cases combined coils and thrombin to stabilise the thrombus. In the case of a pseudoaneurysm of the distal common hepatic artery, thrombin injection directly into the pseudoaneurysm was unsuccessful due to high blood flow within the sac. Coils were therefore administered, reducing the velocity of the blood flow within the sac and facilitating thrombosis . In a caSquid embolisation was used in 2 patients. The first case was a pseudoaneurysm involving the splenic artery (34 mm), near the hilum, and was treated successfully using the liquid non-adhesive agent . The secPrimary success, defined by complete exclusion of pseudoaneurysm from systemic circulation after initial intervention, was achieved in 14 out of 15 cases (93.3%). Reintervention was required in 1 case, where a successful outcome was observed after secondary treatment. Complications were observed in 2 cases, in which splenectomy was indicated.Follow-up imaging was done using contrast-enhanced CT on the following day and within 3 weeks of the procedure. Abdominal CT showed no evidence of recanalisation or bleeding in any of the treated patients in the post-interventional follow-up period. No further intervention besides two splenectomies was necessary. There was no periprocedural mortality, defined by death occurring within 1 month of procedure. None of the patients were referred back to our hospital after the follow-up period due to recurrence of pseudoaneurysm.Endovascular procedures allow rapid control of bleeding through minimally invasive techniques. It is a common initial choice in the treatment of pancreatitis-related pseudoaneurysms, with a reported success rate ranging from 79–100% , 3, 8, 9Preference for a specific technique takes into consideration the anatomical location of the affected vessel, the size of pseudoaneurysm sac, and the patient's haemodynamic status. Contrast-enhanced CT is a highly sensitive imaging technique in the primary detection of pseudonauerysm extravasation. Subsequent angiography allowed the evaluation of the anatomy of the visceral vessels and their collateral circulation, and measurement of the pseudoaneurysms prior to choosing the optimal endovascular technique. Several studies have shown that angiography is extremely valuable in locating bleeding pseudoaneurysms, with sensitivity rates of over 90% , 11Treatment with coil embolisation can be administered with minimal risk of gastrointestinal ischemia in expendable arteries. These include arteries with an extensive collateral circulation, such as the splenic and gastroduodenal arteries. The sandwich technique employed in three cases successfully excluded the pseudoaneurysms in all cases. A clinical success rate of approximately 89% has been reported in current literature . DetachaNonexpendable arteries required the preservation of distal blood flow. Embolisation of the pseudoaneurysm sac itself was applicable in cases of a narrow neck, such as in the pseudoaneurysm of the coeliac artery trifurcation. In cases of a wide neck, placing coils directly into the sac posed a significant risk of coil migration into the parent artery, reported in other literature to occur in up to 3% of cases . In thesThe use of stent graft in the treatment of a SMA pseudoaneurysm maintained the patency of the nonexpendable artery, preventing bowel ischemia. This technique has a long-term patency rate of approximately 82% . BrachiaThrombin injection is another technique used particularly for pseudoaneurysms that are not easily accessible using a transcatheter technique, and in which the parent vessel cannot be identified . If diagLiquid non-adhesive ethylene vinyl alcohol (EVOH) copolymers (e.g. Squid and Onyx) provide a high degree of control when treating pseudoaneurysms, but require the operator to be familiar with the solution used. It is highly effective in occluding vessels distal to the injection site, especially when anatomy does not allow for direct access to pseudoaneurysm sac. EVOH copolymers are not dependent on the patient’s coagulation status, unlike thrombin and coils, and can be used to embolise a vessel even if the patient’s coagulation is disrupted. The primary disadvantage of this treatment option is the difficulty associated with administration and the possibility of human error, especially in critical situations. If the injection is not well-controlled, non-target embolisation may lead to ischemic complications, which was observed in our case of a pseudoaneurysm of the splenic artery treated with Squid embolic agent. Risk of such complications is even higher when using adhesive embolic agents such as n-butyl-cyanoacrylate embolic glue (NBCA). An increased risk is also seen when the target vessel has a high blood flow, making the injection harder to control .The use of AVPs is ideal for the embolisation of large vessels with high flow. In these vessels, limited control of coils or a liquid embolic agent can lead to coil migration and non-target embolisation, respectively. The larger delivery systems of AVPs and their limited flexibility make them problematic for smaller and more convoluted vessels, an exception being AVP 4, the size and flexibility of which enables it to be delivered to more distal and tortuous vasculature. The manufacturer’s recommendation to oversize the plugs by 30–50% relative to the size of target vessel significantly decreases the risk of device migration , 22. ThePseudoaneurysms of visceral vessels as a complication of chronic pancreatitis are associated with a high mortality risk, requiring urgent intervention which can be achieved through minimally invasive endovascular techniques with a high rate of success. When planning the endovascular procedure, it is essential to take into consideration vascular anatomy, characteristics of the pseudoaneurysm, and the patient’s general condition. In expendable vessels, the sandwich technique with parent vessel occlusion provides an effective and stable occlusion. Embolisation of the pseudoaneurysm sac itself with either coils or liquid embolic agents, as well as complete exclusion using stent grafts, can be considered when patency of the target vessel is desired. It is important to thoroughly assess the target vessel, as high blood flow increases the risk of non-target embolisation, especially if the clinician is unfamiliar with the embolic agent used. The management techniques presented in this study aim to help guide vascular interventionalists in providing the highest standard of care in the treatment of visceral pseudoaneurysms in different clinical scenarios.S1 Table(XLSX)Click here for additional data file.


To establish the most convenient and effective method to dry tangerine peels, different methods  were exploited. Our results indicated that medium- and short-wave infrared drying was the best method to preserve nutraceutical components; for example, vitamin C was raised to 6.77 mg/g (D.W.) from 3.39 mg/g (sun drying). Moreover, the drying time can be shortened above 96% compared with sun drying. Importantly, the efficiency of DPPH radical scavenging was enhanced from 26.66% to 55.92%. These findings would provide a reliable and time-saving methodology to produce high-quality dried tangerine peels. Citrus reticulata [Tangerine (mandarin) is the second most important citrus genera, whose specific species isticulata . The datticulata . Tangeriticulata , 3. Currticulata . Citrus reticulata Blanco or its cultivars collected between September and December in sun or at low temperatures [It is also well known that tangerine peels are the main raw material to produce dried tangerine peel that can be used as an ingredient in traditional Chinese medicine as well as functional foods. Dried tangerine peel could be produced by drying fresh peels oferatures . It has eratures , 8. Freseratures  and the eratures . Literateratures . Synephreratures . Similareratures . With alThe main preparation method of dried tangerine peel, sun drying, has the advantages of low cost and simple operations. However, the quality of tangerine peels dried in the sun was inhomogeneous and unstable because it was very susceptible to weather and environments variations, such as natural disasters, insects, and dust . MoreoveIn spite of previous studies on drying processes of tangerine peels , 16, 17,Folin & Ciocalteu's phenol reagent, 1,1-diphenyl-2-picrylhydrazyl radical (DPPH), 2,4,6-tripyridyl-1,3,5-triazine (TPTZ), 2,2′-azinobis-(3-ethylbenzthiazoline-6-sulfonic acid) (ABTS), 6-hydroxy-2,5,7,8-tetramethylchroman-2-carboxylic acid (Trolox), gallic acid monohydrate, 2,6-dichloroindophenol, (+)-catechin hydrate, and vitamin C were purchased from Sigma-Aldrich . The hesperidin was purchased by Chengdu Institute of Biology, Chinese Academy of Sciences . The synephrine was purchased from National Institute for the Control of Pharmaceutical and Biological Products . All other reagents of HPLC-grade and analytical grade were purchased from Sinopharm Chemical Reagent Co., Ltd. .Citrus reticulata v. tangerine) were grown in Jiangmen city  and purchased (November 2014) from a local market in Beijing. The ripe tangerines, with an average weight of 151.83 ± 4.65 g, were washed, dried, cut into eight pieces, and peeled carefully by hand without destroying their shape. The initial moisture content of tangerine peels was 2.50 ± 0.10 g water/g dry material and the thickness of tangerine peels was 2.68 ± 0.11 mm measured with Vernier caliper.Fresh tangerines (2) with 60 holes whose diameter was 5 cm to form a layer of 0.5 cm before being dried. The process of each drying method was briefly described as follows.The tangerine peels were dried by 5 methods, which were sun drying (SD), freeze drying (FD), hot-air drying (HAD), vacuum drying (VD), and medium- and short-wave infrared drying (IRD). The weight loss was recorded by a CPA-125 digital electronic balance purchased from Sartorius Instrument System Co., Ltd. , with the precision of 0.1 mg. Tangerine peels were dried until the moisture content was less than 0.05 g water/g dry material. Thirty grams of tangerine peels was placed in a sample steel tray (30 × 50 cm1) SD. The sample tray was exposed to sunlight from 9 am to 4 pm at the ambient temperature (15~20°C) with relative humidity within 30%–40%. The sample was taken out every 5 hours and weighed.(2) FD. It was carried out in a freeze dryer  at −30°C under 10−3 Mpa. The sample was taken out every 2 hours and weighed.(3) HAD. HAD was performed in an oven  at 60, 70, 80, and 90°C with a fixed air velocity of 2.1 m/s. Hot air was supplied in vertical model. The samples were taken out every 10 minutes and weighed.(4) VD. The drying was carried out in vacuum dryer  at 60, 70, 80, and 90°C with a fixed vacuum degree of 3 × 10−3 Mpa. The samples were taken out every 20 minutes and analyzed for weight loss.(5) IRD. IR was conducted in a medium- and short-wave infrared radiation dryer . The drying was performed at different temperatures  with a power consumption of 1350 w and fixed air velocity of 2.1 m/s. The samples were taken out every 5 minutes and weighed. was shown in the following [W0 is the dry weight of sample and Wt is the weight at any time.The initial water content is associated with a reduction in weight of tangerine peels before and after drying. The initial moisture content of tangerine peels was obtained by comparing the amount of evaporated water with drying samples at 105 ± 1°C until the weight was not changed. The moisture content at any time (ollowing :(1)Xt=WtX0 is the initial moisture content, Xf is the final moisture content (0.05 g water/g dry weight), and Xt is the moisture content at any time.The moisture ration (MR) was obtained by the following :(2)MR=XtRi) was obtained by the following [The drying rate (ollowing :(3)Ri=dXThe soluble solid was measured by using a digital-display refractometer  and the results were obtained by refractive index multiplied by the dilution ratio . Total sAs shown in −1 d.w.). While the total flavonoids content was measured, the absorbance was 510 nm. The detection of total flavonoids content was based on the standard curve of (+)-catechin hydrate, which was expressed as mg (+)-catechin hydrate equivalents (CHE) per g dried sample weight (mg GHE g−1 d.w.).Folin-Ciocalteu method and colorimetric assay were used to determine the total phenolic content and total flavonoids content of tangerine peels with some modification, respectively . When thμL and flow rate was maintained at 1 mL/min. The mobile phase system was comprised of methanol as mobile phase A and 0.1% (v/v) formic acid in deionized water as mobile phase B. The linear solvent gradient was composed of 30% A from the beginning to 5 min, 5% A at 15 min, 7% A at 20 min, and 30% A from 25 min to 30 min.HPLC was used to determine hesperidin and synephrine as previously designed methods with some modifications , 22. TheμL, the flow rate was maintained at 1 mL/min, and absorbance was set up at 245 nm. The linear solvent gradient was composed of 100% B at the beginning, 20% B at 9 min, 20% B at 9.1 min, and 100% B from 14.1 min to 20 min.The vitamin C content was determined by two methods, namely, 2,6-dichloroindophenol titration method  and HPLC∙+ radical scavenged, and μmol Trolox equivalent antioxidant capacity per 100 mg dried sample weight (μmol TE/100 mg dw) for DPPH, ABTS, and FRAP assays, respectively.One gram of dried tangerine peels was mixed with 20 mL MeOH and sonicated for 2 h. After being centrifuged for 10 min at 10000 r/min, the supernatant was obtained. This process is repeated and the supernatant was combined and stored in 4°C. Before determination, the supernatant was diluted 40 times with MeOH. Antioxidant capacity was evaluated by three assays: free radical scavenging activity by DPPH method, total antioxidant capacity by ABTS method, and ferric reducing ability by FRAP method . The detP < 0.05) and least significant difference (LSD) method. The figures were plotted by the origin 8.0.All measurements were performed in triplicate. The experimental data were analyzed by the SPSS 19.0. Differences between quality indexes affected by different treatments were determined by ANOVA procedure , hot-air drying (HAD), freeze drying (FD), vacuum drying (VD), and infrared drying (IRD), respectively. The drying time with respect to moisture ratio and moisture content with respect to drying rate were investigated to evaluate the effect of different drying methods, respectively.The results of FD and SD were not shown in Figures Soluble solids in different dried tangerine peels were in the range of 41%~54%, while those in fresh tangerine peels were 14%. It is known that dried samples had higher soluble solids than the fresh ones. The tangerine peels had the most soluble solids after IRD and FD treatment, while the peels had the least soluble solids after SD treatment. The soluble solids are a relatively important index because dried peels were always soaked in water to drink. So IRD and FD were suitable ways to store soluble solids.The sugar in tangerine peels might be the substrate of other compounds, such as vitamin C and glycoside. The investigation of sugar content is beneficial in providing the change mechanism of the other compounds. The reducing sugar content of tangerine peels after different drying processes was in the range of 489.43~545.59 mg/g dw, and the total sugar content of tangerine peels after different drying processes was in the range of 325.86~553.45 mg/g dw. The reducing sugar and total sugar content of the dried peels were both lower than those of fresh ones . The sugars might be degraded while heating the samples for a long time during SD treatment. The samples dried by SD had the lowest total sugar content, while samples after FD had the highest one (553.45 mg/g dw).The crude fiber was the major ingredient of cell walls. The change of its content could reflect the cell's membrane damage degree. The crude fiber content in fresh samples was 12.8%, while that in dried samples was lower in the range of 10.5%~11.1%, in line with previous report . The resThe titratable acid content had a great effect on the flavor quality of dried tangerine peels. Compared with 0.875% in fresh peels, the titratable acid content in dried samples was in the range of 0.355%~0.835%. Of all drying methods, the titratable acid content was the highest after IRD and HAD treatment and was the lowest after SD treatment. The organic acids degrade much more rapidly during sun drying.The storage and flavor quality of tangerine peels was also affected by the mineral content. When 80°C was set as the dried temperature of HAD, IRD and VD, the amounts of Na, Mg, Ca, Mn and Zn in fresh samples were higher than those in dried samples. Moreover, the amounts of Fe and Se in fresh ones were higher than those in dried samples except ones dried by SD while the amounts of K and Cu in fresh samples were lower than those in dried samples. The contents of Na and Cu were the highest in dried samples after IRD. The contents of Mg, Ca, Fe and Se were the highest after SD treatment. The contents of K and Zn were the highest after FD, while the level of Mn was higher in samples dried by VD treatment than others. So it can be seen that the mineral contents were influenced by the treatments.The ash content is an important index of inorganic substances in food. The ash contents in dried samples were in the range of 2.574%~2.874% in comparison with 2.881% in fresh ones. The tangerine peel had high ash content after VD, whereas it had low ash content after HAD. The ash content consistently decreased after drying. Ash content represents the total content of minerals . SimilarOverall all, FD and IRD were the best to preserve soluble solid, reducing sugar, total sugar, crude fiber, and titratable acid for tangerine peels, while SD is better at preserving the minerals in tangerine peel, which is in agreement with previous report on strawberry . HoweverP < 0.01). The contents of total phenolic compounds after drying ranked from most to least are IRD/FD/HAD > SD > VD (P < 0.05), respectively. With the increase in drying temperatures, a slightly increase in the total phenolics content of tangerine peels was observed in IRD, HAD, and VD. When the plants were dried, the phenolic compounds stored in the plant vacuole are more freely released [Among the natural functional components, phenolic compounds have attracted wide attention for their promising antioxidant activity and potential roles in the treatment of chronic and degenerative diseases. It was revealed that tangerine peels after drying with different methods presented variable total phenolic contents ranging within 15.66~17.24 mg GAE/g dw , which ireleased . IRD coureleased , 34.P < 0.05), whereas the lowest content was achieved in tangerine peels after VD at 90°C (6.99 mg GHE/g dw). A considerable amount of total flavonoids contents was also achieved by HAD but was lower than those of FD and IRD at 70°C (P < 0.05). Compared with those of fresh ones, the total flavonoids contents of tangerine peels were increased after drying at different temperatures. It was reported that heating and radiation could break down certain types of bonds and release antioxidants such as flavonoids and polyphenols from polymers [Flavonoids in tangerine peels  are used to treat various physical symptoms such as high cholesterol level, cardiovascular disease, and gastrointestinal function. The total flavonoids contents of tangerine peels dried by 5 drying methods were shown in polymers . Figure polymers , 36. It P < 0.05). FD, HAD, and IRD were all beneficial in preserving hesperidin.Hesperidin was the main flavonoid while synephrine was the most important alkaloid in citrus. So the effect of different drying methods was studied on hesperidin and synephrine. As shown in P < 0.05) as shown in Like hesperidin, the synephrine content in tangerine peels after drying was significantly higher than that in fresh ones (P < 0.05). As it is generally known that vitamin C is susceptible to heat and oxygen. Heating and oxidation might accelerate the degradation of vitamin C during the drying process. Therefore, the content of vitamin C decreased gradually along with the increase of temperature [P < 0.05). Among the drying methods, the IRD was an economical and effective way to preserve vitamin C.The vitamin C content of peels was determined by 2,6-dichloroindophenol titration and HPLC methods . The treperature , 37. TheP < 0.001). This result was inconsistent with the low contents of vitamin C and phenolic compounds in the peels dried by sunlight. It means the antioxidant activities of dried tangerine peels obtained by traditional methods (SD) had been greatly reduced. The total antioxidant capacity evaluated by ABTS of the peels after VD at 90°C was stronger than others (P < 0.05). The peels after IRD had stronger total antioxidant capacity than FD (P < 0.05). Similarly, the peels dried by SD and FD had the lowest ability on free radical scavenging (P < 0.001) evaluated by DPPH. The ability on free radical scavenging of peels after IRD was stronger than HAD and VD (P < 0.05). On reducing ferric, the peels after SD were markedly inferior to other drying methods (P < 0.001). Hence, our findings suggested that IRD was a suitable drying method to obtain the high antioxidant activities due to the lower temperatures and shorter drying time necessary for the desired moisture content compared to the other drying methods.The antioxidant activities of fresh and dried tangerine peels were evaluated by ABTS, DPPH and FRAP assays . The antThe impact of the 5 drying methods on nutraceutical components and antioxidant activity of tangerine peels were studied. In general, IRD was an appropriate choice for drying tangerine peels. Compared with the traditional drying method (SD), IRD not only was beneficial in preserving the nutraceutical components of tangerine peels but also shortened the drying time to a greater extent. Altogether, different drying methods may have different advantages to maintain optimal concentrations of the desired components in the dried peels, but the IRD method was found as the most efficient and convenient drying method in preserving main compositions, nutraceutical compositions, and antioxidant activity for tangerine peels. Overall, this study would provide useful information for the preparation method of dried tangerine peel and its industrial applications.


Birth asphyxia is a significant global health problem, responsible for ~1.2 million neonatal deaths each year worldwide. Those who survive often suffer from a range of health issues including brain damage—manifesting as cerebral palsy (CP)—respiratory insufficiency, cardiovascular collapse, and renal dysfunction, to name a few. Although the majority of research is directed toward reducing the brain injury that results from intrapartum birth asphyxia, the multi-organ injury observed in surviving neonates is of equal importance. Despite the advent of hypothermia therapy for the treatment of hypoxic–ischemic encephalopathy (HIE), treatment options following asphyxia at birth remain limited, particularly in low-resource settings where the incidence of birth asphyxia is highest. Furthermore, although cooling of the neonate results in improved neurological outcomes for a small proportion of treated infants, it does not provide any benefit to the other organ systems affected by asphyxia at birth. The aim of this review is to summarize the current knowledge of the multi-organ effects of intrapartum asphyxia, with particular reference to the findings from our laboratory using the precocial spiny mouse to model birth asphyxia. Furthermore, we reviewed the current treatments available for neonates who have undergone intrapartum asphyxia, and highlight the emergence of maternal dietary creatine supplementation as a preventative therapy, which has been shown to provide multi-organ protection from birth asphyxia-induced injury in our preclinical studies. This cheap and effective nutritional supplement may be the key to reducing birth asphyxia-induced death and disability, particularly in low-resource settings where current treatments are unavailable. AKI is Acute kidney injury has long been recognized as an almost inevitable consequence of intrapartum asphyxia, due to the shunting of blood away from peripheral organs to maintain cerebral, cardiac, and adrenal perfusion during the episode of hypoxia, thereby reducing oxygen supply to the kidney , 49. TheThere are currently no FDA approved therapies that specifically target kidney damage after intrapartum asphyxia . Four, lFor those newborns who are accurately diagnosed with AKI, a range of management strategies can be put in place to ensure that the poorly functioning kidney does not exacerbate injury in other organs, particularly the brain , 47. Pos3). Severity of AKI (stage 3 AKI) was a potential predictor of CKD (P = 0.08). It should be noted that 24% of the patient population in this study were neonates, and these cases made up the majority of the AKI stage 3 population (median age 0.3 years). In addition to those who presented with CKD, 46.8% of follow-up patients were described as being at risk of developing CKD, based on a mildly reduced GFR, presence of hypertension and/or hypofiltration  later in life , 67. A rltration . The cliltration . While tTerm neonates take their first breaths by creating a sub-atmospheric intrathoracic pressure as high as −80 mmHg, which is essential for the clearance of lung liquid, thus facilitating lung aeration and the formation of the functional residual capacity (FRC) –72. HoweHowever, despite the crucial role it plays in lung aeration, FRC formation and the initiation of breathing at birth, the respiratory musculature has been essentially overlooked. Some recent studies have investigated the effect of different suboptimal fetal environments on the diaphragm, concluding that intrauterine inflammation caused significant impairment of diaphragm contractility in the fetal sheep , 75. Thein utero. During this time, biochemical and histochemical changes show there is a significant fast-to-slow fiber type transition, together with substantial muscle fiber hypertrophy, which begins in the immediate neonatal period and continues postnatally  that follow hypoxic events results in significant oxidative stress at a cellular level. This is particularly deleterious for the diaphragm, which generates high levels of oxidants due to the continuous contractile activity of this highly oxidative muscle , 89, 92.The body is composed of almost 40% skeletal muscle, and this tissue is not only essential for locomotion, but also plays an important role in the metabolism of proteins and amino acids for various organ systems . HypoxiaGiven the obvious susceptibility of the skeletal muscle to hypoxic damage, the possibility that deficits in skeletal muscle function could be contributing to the functional motor deficits observed in survivors of intrapartum asphyxia with CP should not be overlooked. As discussed previously, CP is the most common deleterious morbidity associated with birth asphyxia. It is a condition characterized by hypotonia in the neonate , and chiA large body of work has been dedicated to the development of treatments for the muscular symptoms of CP; for example, the use of botulinum toxin A injection to treat limb muscle spasticity, which has been shown to improve movement for children with lower limb spasticity –106. WhiA major issue faced by researchers and clinicians focusing their efforts on understanding the effects of birth asphyxia is the availability of an appropriate research model. Conventional altricial laboratory rodents such as mice and rats are commonly used to study the biochemical and pathological changes within the gray and white matter regions of the brain following intrapartum asphyxia. However, use of these species poses significant limitations due to the immaturity of their offspring at the time of birth. Therefore, any findings regarding tissue damage or alterations in normal organ development following a hypoxic episode at birth must be interpreted with caution. These would not be considered as appropriate models to study damage to peripheral organs such as the kidney after intrapartum asphyxia.Large precocial models are much more useful in this regard as their advanced stage of development at the time of birth closely mimics the human physiological response to intrapartum asphyxia [see review in Ref. ]. IndeedAcomys cahirinis). This is a precocial rodent native to the deserts of Africa and Middle East, where after a relatively long gestation (39 days) the neonate has completed organogenesis of major organ systems -activated force , xenon, and argon. However, these have either provided disappointing results (ascorbic acid and xenon), require specialized ventilatory equipment (xenon and argon), revealed unfavorable safety profiles (NAC), or, while showing promise , currently lack full clinical evaluation, including their capacity to target hypoxic injury in organs other than the brain. Pharmacokinetically, all of these agents have a short duration of action and cannot be expected to provide a benefit lasting through birth into neonatal life unless their administration continues throughout the entire ante-, intra-, and postpartum periods.A number of antenatally applied treatments that aim to prevent intrapartum hypoxic The gold standard would be a safe treatment that could be administered maternally before birth to provide protection in the event of a hypoxic episode during labor. Such a treatment should be cheap and easily administered so that it could be made available in the areas where the incidence of birth asphyxia is highest. It must also have the capacity to minimize the initial energy failure that occurs at the time of the insult, as well as having potent antioxidant capabilities to reduce the oxidative stress that ensues in the period immediately after birth. This would reduce or prevent the second wave of energy failure and oxidative stress and prevent the multi-organ injury that results. It will also need to be benign should intrapartum hypoxia not arise.Elsewhere, we have proposed that antenatally administered creatine can provide the fetus and neonate with an additional pool of anaerobic energy during severe hypoxia, and it is a treatment that will provide protection not only to the brain but also to the other major organs that often damaged by “oxygen starvation” at birth . CreatinDespite these interesting and promising results, to date there have been no clinical studies investigating the potential for creatine to prevent birth asphyxia-induced injury. However, this was the subject of a recent review in which the limited amount of data available was highlighted . A full Reducing the under-five mortality rate by two-thirds by 2015 was a Millennium Development Goal that unfortunately was not achieved . While aAll authors contributed to writing and drafting this review.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.


Furthermore, there is a parameter range that electric current can drive spherical particles to split into smaller ones.The elongated droplets and grains can break up into smaller ones. This process is driven by the interfacial free energy minimization, which gives rise to a breakup limit. We demonstrated in this work that the breakup limit can be overpassed drastically by using electric current to interfere. Electric current free energy is dependent on the microstructure configuration. The breakup causes the electric current free energy to reduce in some cases. This compensates the increment of interfacial free energy during breaking up and enables the processing to achieve finer microstructure. With engineering practical electric current parameters, our calculation revealed a significant increment of the obtainable number of particles, showing electric current a powerful microstructure refinement technology. The calculation is validated by our experiments on the breakup of Fe Some materials, e.g. surfactant and micelleσ < 0). In those materials a spherical droplet may turn itself into cylindrical or split into smaller ones in order to increase the total interfacial area and hence to reduce the total system interfacial energy. However, most other materials  are with positive interfacial tension (σ > 0). The breakup is limited by the interfacial area minimization (δs ≤ 0). The breakup limit restrains the microstructure refinement by stretch and breakup processing mean.Fabrication of nanoscale grains2δs ≤ 0, can be lifted up to a new level. Electric current free energy (gelec) is different from the chemical free energy in a way being dependent on the microstructure configuration. The breakup causes the change of electric current free energy (δgelec). The irreversible thermodynamics gives the new breakup limit as δs + δgelec < 0. When δgelec < 0, it allows δs > 0 as far as δs < −δgelec. The stretched thin plates or thin films are able to break up into more number of finer pieces with each piece has smaller diameter after spheroidization. This pushes the refinement processing toward the fabrication of much finer microstructure.Our aim was to introduce an extra free energy term into the system so that the microstructure breakup limit, In the present work, a breakup of high electrical resistivity phase in a low electrical resistivity matrix is considered. The real materials parameters are implemented in the calculation for a purpose of comparison with experimental validation. The work focuses on thermodynamics. The results are generic for the breakup of any grains, droplets and bubbles submerged in a higher conductive matrix.6 S · m−1 and magnetic permeability 300μ0 at ambient conditions, where μ0 = 1.26 × 10−6N · A−2 is the vacuum permeability1213143C cementite crystals which has electrical conductivity 1.22 × 106 S · m−1 and magnetic permeability 30μ01213143C cementite is 1043 K and 480 K, respectively. Without losing generality, the input parameters were selected in such a way that experimental validation can be performed easily in our laboratory. The results, however, are able to indicate the generic breakup of the higher electrical resistivity plates inside a lower electrical resistivity matrix. Numerical calculations were performed on 200 × 90 × 80 cubic grid with a lattice distance 10 nm. An electrical potential of 20 volts were applied to the sample along the longest axis. The interfacial tension between ferrite iron and Fe3C is 2.8 J · m−2 according to literatureσ > 0, where the interfacial free energy increases along the particle numbers monotonically, as that showing in 11A · m−2. In many electronic devises, e.g. the reading and writing system in computer hard disk9A · m−2 and 1014A · m−2. Structural instability may happen from the thermodynamic point of view if those devises are with the similar microstructure. When the system is scaled up from Δx = 10 nm to Δx = 10 μm while the rest parameters remain unchanged, the electric current free energy is magnified by a factor of Δx3 but the interfacial free energy is magnified by a factor of Δx2. The desirable electric current free energy is reduced by a factor of 10−4, which indicates a change of critical electric current density by a factor of 10−2 because the free energy is proportional to the current density square189A · m−2.9 × 109A · m2− to a cold drawn pearlitic steel rod of 15 cm long and 2.84 mm diameter at ambient temperature and pressure. The strained cementite plates break up into nanoscale particles without change the integrity of the materials. The electric current free energy is represented as18r is a spatial position. r before and after the microstructural breakup, respectively. μ is the magnetic permeability. Where j0 = V0 · σ0/Δx, where σ0 = 1.0 × 107 Sm−1 and V0 = 1 volt. When the ellipsoid particles are broken to form spherical particles, the distribution of local electrical resistivity is changed. The distribution of electric current density is hence altered. It can be seen from 3C is smaller than that of outside due to its high electric resistivity. t is the current load duration, ρ is the mass density of grain and c is the specific heat of the suspension phase. It can be seen that the temperature rising inside the high electrical resistivity grain is higher than that of the outside. The higher temperature promotes the carbon diffusion, which accelerate the microstructure transformation such as breakup and spheroidization.The electric-current-induced surpass of conventional breakup limit is applicable for the breakup of higher electrical resistivity phases in a lower electrical conductivity matrix. This is also suitable for gas bubble and liquid droplets submerged in a high conductive fluid such as plasma, ionic solution or other materials. Electric current helps to surpass the conventional breakup limit and enables to fabricate much finer microstructures.It is reported in literature that electric field promotes the change of the spherical particles into ellipsoidal ones20It is also known that electric current helps to generate refined microstructure during liquid-liquid 27293C crystals and body-centered-cubic (bcc) ferrite crystals are subsequently nucleated and grown from the austenite crystals without penetration of fcc austenite grain boundary. The number of nuclei and growth rate (isotropic or anisotropic growth) of Fe3C crystals are input parameters. The orientation between Fe3C and bcc ferrite obeys Pitsch-Petch relationship of 3C phase is obtained as either ellipsoid thin plates with an aspect ratio between shortest and longest axis of 0.1 or spherical particles. The volume fraction of Fe3C in the material is defined as 12.21% exactly. The particles are not guaranteed to be in the same size due to the compliment of the phase volume fraction but the maximum difference is 1 grid only.The microstructure construction follows phase field scheme31σ(r) and the local electric field r is a spatial position in material. The electric field is determined by the gradient of the local electric potential φ(r) by 0 the permeability of free space. For the materials considered in the present work, nowhere has net charge. This enables Gauss’s law to reduce to Poission’s equation, as expresses in followingsAccording to Ohm’s law, the local electric current density is determined by the local electrical conductivity The distribution of the electric potential can be obtained by solving 9 A/m2 was implemented to the sample at ambient temperature. The pulse was generated by a capacitor discharging. The wave-shape of the pulse is recorded by an oscilloscope. It is in a damped shape oscillations with initial period around 20 μs and total duration of 110 μs. The peak current was measured based on a calculation using discharging voltage and total resistance in the circuit. Electric current flows along the longitudinal direction of the sample wire from anode to cathode. After the treatment, the sample was cut along the longitudinal and cross-sections, polished and etched in natal for metallographic analysis and examined by Carl Zeiss made Ultra-55 scanning electron microscope (SEM).Commercial pearlitic steel wires of chemical composition Fe–0.8C–0.2Si–0.5Mn (wt.%) were received and then cold-drawn to a true strain of 1.61 and cut into 15 cm length samplesThe three-dimensional visual analysis of the computational data was generated using an in-house developed MatVisual software.How to cite this article: Qin, R. Using electric current to surpass the microstructure breakup limit. Sci. Rep.7, 41451; doi: 10.1038/srep41451 (2017).Publisher's note: Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.