Ninety-two percent of Low Birth Weight(LBW) infants are born in developing countries, 70% in Asia and 22% in Africa. WHO and UNICEF estimate LBW in Kenya as11% and 6%by 2009 Kenya Demographic Health Survey. The same survey estimated LBW to be 5.5% in Central Province, Kenya. Data in Olkalou hospital indicated that prevalence of LBW was high. However, factors giving rise to the problem remained unknown.A cross-sectional analytic study was therefore conducted to estimate prevalence and distribution and determine the factors associated with LBW in the hospital. LBW was defined as birth of a live infant less than 2500g. We collected data using a semi-structured questionnaire and review of health records. A total 327 women were randomly selected from 500mothers. Data was managed using Epi Info 3.3.2.The prevalence of LBW was 12.3% (n=40). The mean age of mothers was 25.6±6.2 years. Mean birth weight was 2928±533 grams. There were 51.1% (n=165) male neonates and 48.9% (n=158) females. The following factors were significantly associated with LBW:LBW delivery in a previous birth , premature rapture of membranes , premature births , and female newborn . On logistic regression only delivery of LBW baby in a previous birth  and female infant were independently associated with LBW.Prevalence of LBW in the hospital was higher than national estimates. Female infant and LBW baby in a previous birth are independent factors. Local prevention efforts are necessary to mitigate the problem. Population-based study is necessary to provide accurate estimates in the area. Low birth weight (LBW) is birth of a live infant less than 2500g (up to and including 2499g) irrespective of gestational age. It is often expressed as percentage of live born infants in a given time period. It can be subdivided into very low birth weight (less than 1500g) and extremely low birth weight (less than 1000g). Birth weight should be measured within the first hour of life before significant postnatal weight loss has occurred .The global prevalence of LBW is 15.5 percent, which amounts to about 20 million LBW infants born each year, 96.5 percent of them in developing countries. Half of all low birth weight babies are born in South-central Asia where 27 percent are below 2500g at birth while LBW levels in sub-Saharan Africa are estimated at 15 percent .The fourth Millennium Development Goal of the United Nations targets to reduce child mortality by two-thirds from 1990 to 2015. The under-five mortality and the infant mortality rates are the two indicators used to monitor this goal. The global under five mortality dropped by 47 percent from an estimated 90 to 48 deaths per 1000 live births between 1990 and 2012. Neonatal mortality declined from 33 per 1000 to 21 per 1000 live births over the same period. Although these indicators have shown a declining trend, the highest burden and the least improvement was observed in Sub-Saharan Africa compared to other regions of the world [Neonatal mortality accounts for 40 percent of all deaths among children less than five years. Seventy-five percent occur during the first week of life, and between 25 to 45 percent occur within the first 24 hours. Preterm birth is the most common direct cause of newborn mortality. Preterm birth and being Small for Gestational Age (SGA) which are the reasons for low birth weight are important indirect causes of neonatal deaths. Low birth weight contributes 60 to 80 percent of all neonatal deaths . GloballThe prevalence of LBW in Kenya is estimated at 11 percent by WHO and UNICEF. The Kenya Demographic Health Survey of 2009 estimates LBW to be 6 percent . LBW is A number of factors have been identified to influence LBW. They include religious background, mother´s education, gestational age, mother´s weight, anemia, severe physical work, and tobacco chewing. In a study carried out at a tertiary care hospital in Uttar Pradesh, India, where 40% of mothers delivered low birth weight babies, Muslim mothers, mothers with no education, gestational age less than 37 weeks, mother´s weighing less than 50kg, hemoglobin less than 10gm/dl, severe physical work and tobacco chewing and history of abortion were found to be significant determinants of low birth weight .Exposure to environmental pollutants including organophosphate pesticides have also been significantly associated with low birth weight deliveries. This was evident among Hispanic and African American pregnant women studied in New York City .A study in Jimma zone South West Ethiopia found the following factors to be significantly associated with low birth weight. Mothers living in urban areas were found to be more likely to deliver low birth weights compared to their rural counterparts. The study related the association with urban residence to social lifestyles like heavy cigarette smoking and alcohol intake. Mothers who had experienced weight loss and those who had not had additional food during pregnancy had a significant increased risk of delivering low birth weight babies. Other factors including religion, ethnicity, history of a sexually transmitted infection, engaging in heavy work during pregnancy and history of chronic illness did not show any association .The study by Siza 2008 found that mothers without formal education were 4 times more likely to give birth to low weight babies compared to those with formal education, whereas the father´s level of education significantly influenced the occurrence of low birth weight. In the same study unmarried mothers were found to be more likely to give birth to low birth weights compared to their married counterparts. Pregnancy and labor complications and illness during pregnancy were also significantly associated with low birth weight infants. These included; hypertension, pre-Eclampsia and Eclampsia disease complex, bleeding, placenta praevia, abruption placenta, premature rupture of membranes, anemia, Tuberculosis and Malaria in pregnancy. HIV positive women were twice more likely to give birth to low birth weight babies than HIV negative ones . The HIVIn Kenya, factors documented to have significant influence on LBW can be summarized in two broad categories. The main factor associated with premature delivery is quality of antenatal care measured by timing, frequency of antenatal visits and tetanus injections. In addition, type of birth, birth order, region of residence and ethnicity influence premature delivery. Maternal nutritional status influences birth of small babies for gestational age. Other factors include maternal height and sex of the child. As a result shorter mothers tend to give birth to smaller babies, female babies are born smaller and multiple births are more likely to be smaller compared to single births. None of the socio-economic and cultural factors other than region were significant. Maternal age and birth order as risk factors of low birth weight have been identified in a number of population and hospital studies. In a cross-sectional analytic study that analyzed the 1993 Kenya Demographic Health Survey data, mothers aged below 20 years were found to have the smallest babies at birth. In the same study mothers aged 35 years and older had higher low birth weight babies compared to those aged 20-34 years. The distribution of low birth weights by birth order appeared to follow a similar pattern to maternal age. The highest proportion was identified among first order births with the smallest proportions reported among birth order two to five. However, after multilevel logistic regression analysis, only birth order showed significant influence on low birth weight. Quality antenatal and delivery care have been identified as important in preventing adverse pregnancy outcomes that include premature delivery, low birth weight, perinatal and maternal death. Although a strong association has been identified between premature deliveries and the baby´s size at birth, the two seem to be influenced by different sets of factors. Whereas the baby´s size at birth is influenced predominantly by maternal nutrition, premature delivery is predominantly influenced by the quality of antenatal care .In a study that explored the pathways of the determinants of unfavorable birth outcomes, a number of factors were demonstrated to influence low birth weight indirectly through intermediate factors. Marital status, the desirability of pregnancy, use of family planning, and access to health services were demonstrated to be linked to low birth weight through antenatal care. The findings showed that antenatal care constituted the central link between many of the socio-demographic factors as well as reproductive factors with low birth weight. This may be an important explanation on the inconsistencies observed from previous studies regarding the relationship between these factors and low birth weight Figure 1The contribution of low birth weight to neonatal morbidity and mortality in Kenya cannot be ignored. Neonatal intensive care is not readily available because of its initial and running costs and where available the bed capacity is extremely low. Even reasonably large rural district hospitals including those with pediatricians are poorly equipped to provide essential services to sick newborns and hence the need to implement simple, cost-effective and sustainable interventions to care for the special needs of newborns . The neeThe prevalence of low birth weights in Central region was documented as 5.5% in 2008-09 KDHS . AlthougWe conducted an institution based cross-sectional study at Olkalou District Hospital, Central region, Kenya, from 28th October 2013 to 28th January 2014 among women delivering neonates during the study period. The study was undertaken in the postnatal ward. The hospital is a 142 bed public health facility situated in Nyandarua County, approximately 187 kilometers north of Nairobi . The hospital is a referral facility serving neighboring health institutions with catchment population of 70,273. The hospital delivery services are provided 24 hours. The hospital had one gynecologist, seven medical officers, fourteen nurses and intern clinical officers providing services in maternity.0 =Z2pq/e2, where no= desired sample size; z= the standard normal deviate of 1.96, which corresponded to the 95% confidence level; p= (0.164), the proportion in the target population estimated to have LBW; 1-p= 0.836; e= degree of accuracy desired to get a 95% CI for a two-sided tails was 2.5%. The average number of deliveries per month was 167 (established in the facility). Three months were spent on the site, giving a total sampling frame of 500. Finite correction was done as appropriate using the following formula: n=n0/ (1+ (n0-1)/N), where n =sample size and N is the population size. Therefore n= 843/1+ (843-1)/500 = 314. A 10% contingency sample was added to cater for non-response giving a total sample size of 314+32= 346. The sample size for the study was therefore 346. A simple random method was used to draw a sample of 346respondents from the sampling frame of 500. Computer generated random numbers from Open Epi [The research study involved pregnant women presenting for labor and delivery at Olkalou hospital during the study period. The sample size was calculated using an assumed proportion (p) of 16.4% from the prevalence of LBW in a previous study conducted in Narok District Hospital in 2011 . The CocOpen Epi  were useThe independent variables used in the study were selected on the basis of what was found in published literature regarding their influence on low birth weight. They included age, residence, mother´s education level, partner´s education level, employment status of mother and spouse, place of employment, religious background, marital status; age at first birth, number of previous births, number of pregnancies, preceding birth interval, family size, desired family size, desirability of the pregnancy, family planning practice, last baby weight, bad obstetric history (BOH), previous history of low birth weight or prematurity, previous history of neonatal death, previous surgery on uterus and cervix; time to maternity health facility; timing of first ANC visit, number of ANC visits, tetanus immunization; history of tobacco/marijuana, history of alcohol consumption, history of exposure to agricultural spraying, source of water; history of sexually transmitted infection, malaria, HIV/AIDS, Syphilis, and Tuberculosis, chronic conditions e.g. Diabetes Mellitus, hypertension, heart disease, respiratory disease and renal disease; hemoglobin level, maternal weight and height, body-mass index, mid-upper arm circumference, additional food during pregnancy, Iron and Folate supplementation, avoidance of food in pregnancy; gestational age at delivery, sex of newborn and congenital malformation. In order to determine the association between these factors and LBW in Olkalou hospital, a conceptual framework similar to that described by Magadi was adopted Figure 1Kikuyu , Kiswahili, or English subject to the choice of the client. Once the client was selected, she was interviewed in a private room in the maternity unit so as to ensure privacy. Mothers who had undergone caesarian section were not examined until after 48-72 hours. The room was positioned further from the busy side to avoid interruption. A note was fixed on the outside to indicate that an interview was in progress. Review of records and anthropometric measurements were similarly done in the same room. Gestational age was determined using the mother´s recorded or reported Last Normal Menstrual Period and the date of delivery. Where unknown, any ultrasound report was used to confirm gestation, otherwise gestation was regarded as unknown. Previous history of LBW and premature births was assessed by asking the mother if she had delivered ‘small’ or ‘very small baby’ or had given birth to a baby before term. A confirmation was made by checking the mother and child health booklet. We assessed the dietary history by asking the mother to describe the food she had eaten the previous day before admission to hospital. Other questions included whether she had had additional food during pregnancy, any nutritional problems or if any health worker had counseled her on the importance of good nutrition during pregnancy.An elaborate semi-structured interviewer administered questionnaire was used to collect data. Prior, we pretested among ten conveniently selected subjects in Karatina District Hospital postnatal ward. We designed the questionnaire in English, but we administered to the respondent in We reviewed labor and delivery notes, mother and child health booklet, and the delivery register to ascertain obstetric and gynecologic history, antenatal care, health issues during pregnancy, labor, delivery, clinical care and the outcome of birth. The records review took place during the postnatal period after other essential procedures to the client had been completed or just before discharge to minimize interruption. A study subject number was used as the unique code for the client.We measured neonatal weight using a standard beam balance (Crown), within one hour upon delivery. The mother was weighed using a standard weighing machine (Seca). We requested the respondent to remove extra clothes, remove their shoes and step on a zeroed weighing scale. Weight was recorded to the nearest 0.1kg. The height was measured using a Height board. We asked the participant to stand without shoes in front of the height board, with the head erect and the arms hanging naturally at the sides. Height was recorded to the nearest 0.1cm. The mid-upper arm circumference (MUAC) was measured using a flexible non-stretchable standard tape measure. The circumference was located and measured at the mid-point between the tip of the acromion process of the scapula and olecranon process of the ulna. For right-handed women the circumference of the left upper arm was measured while for left-handed women, the right arm was used instead. We measured the arm while hanging down at the side and relaxed. The MUAC was recorded to the nearest 0.1cm. We considered a MUAC of 23cm as the cut-off point.Two midwives experienced in delivery care were recruited to assist in accurate weighing of the newborns and measuring the weights and heights of mothers and the mid-upper arm circumference. Consequently, they were trained by the investigator for eight hours on the purpose and objectives of the study, the standard procedures of weight measurement, height measurement, the mid upper-arm circumference and the interviewing technique. They were further trained on the importance of maintaining confidentiality and obtaining consent before interviewing or obtaining anthropometric measurements, being patient, understanding, respectful and genuine when handling the respondents. The investigator interviewed the mothers and supervised the midwives while taking the anthropometric measurements.Data was entered and analyzed using Epi Info statistical software version 3.3.2. Descriptive analysis was done to determine the prevalence of low birth weight and to determine the socio-demographic characteristics of women delivering in Olkalou District Hospital. Bivariate, stratified and logistic regression analysis were performed to determine the association between the independent and the outcome variable and to control for potential confounders. A two-tailed test of significance was used. The measures of association were reported with a 95% confidence interval. Factors with a p-value ofWe obtained ethical clearance for the research from the Kenyatta National Hospital research and ethics committee. We also obtained permission from Nyandarua County Health Services Director and the Medical Superintendent of the hospital to undertake the study.The purpose of the study was explained to the mothers and subsequently consent was obtained for participation in the study. The respondent mothers were interviewed and examined in a private room. No name was recorded on the questionnaire or any other identifier relating to the respondent. A study subject number representing the randomly selected position of the subject was used as the unique identifier.A total of 327 neonate/mother pairs participated in the study constituting a response rate of 94.5%. A total of 19 clients were excluded due to having delivered a still birth, or having had a multiple delivery. Of these 327 sampled respondents, 40(12.3%) gave birth to low birth weight neonates. The mean age of the respondents was 25.6±6.2 years. Thirty seven (11.3%) of the sampled women were urban or peri-urban. One hundred and forty one (48.1%), the majority had completed secondary education while 134 (45.7%) were of primary education, 14(4.8%) were of tertiary education, while 4(1.5%) had had no formal education. Similarly, among their partners, 53.9% (n=132) had completed secondary education, 35.5% (n=87)were of primary education, while 10.6% (n=26) were in tertiary level of education. Majority  were self-employed followed by those unemployed . In contrast, majority  of their male partners were self-employed, 77(31.4%) were employed, 10(4.1%) were unemployed, while only 1(0.4%) was a student. Two hundred and twenty nine (79.5%) were protestant, 55 (19.1%) were Catholic, while 4 (1.4%) could not identify with a religious background. Two hundred and sixty forty (81.2%) of the mothers were married, 51(15.7%) were single, 5 (1.5%) had either separated or divorced, while a similar proportion were widowed The sampled mothers had the following reproductive characteristics. The mean age at first birth was 20.2±3.2. The mean gravidity was 2.5±1.6. Majority  were less or equal to gravida 2. The mean birth interval was 2.8±2.4years. Those with a birth interval greater than 2 years were more . The mean parity was 2.3±1.5, with majority  having had one or two living children. The mean desired family size was 3.4±1.2. Majority  desired a family size of three or more children. Most  of the mothers had intended to have their current pregnancy. However it is important to note that 53(18.2%) had either desired to have the pregnancy later or did not intend to have the pregnancy at all. The mean weight of the previous baby was 2932±531, with 18(10.5%) reporting having had a low birth weight baby in their previous pregnancy. Twenty four (8%) clients reported having had a previous abortion, 20(6.8%) reported a history of low birth weight or prematurity, 9(3.1%) reported history of neonatal death, while 22(7.5%) reported having had a previous surgery of the uterus or the cervix. Majority of the mothers  had attended 3 antenatal visits, the average being 3±1.1. Most mothers  had attended more than 2 antenatal visits. Two hundred and fifty five (87%) had received anti-tetanus immunisation during the pregnancy.Thirty one (10.5%) of the sampled mothers had been referred from another facility, majority  having been referred from a health centre, 4(13.8) from a dispensary and 2(6.9%) from a faith based facility. The onset of labour was mainly spontaneous, constituting 94.0% (n=283). Twelve (4%) had been induced while 6(2%) had not established labour at the time of delivery. The main mode of delivery was spontaneous vertex delivery , followed by caesarean section  while 0.9% (n=3) were delivered through assisted breech. The deliveries were mainly conducted by a nurse midwife , followed by the medical officers . Sixteen (5.0%) were conducted by clinical officer interns, while 2(0.6%) were conducted by a medical officer intern, with 1(0.3%) being conducted by an obstetrician. Majority of the mothers  were 37-42weeks gestation at the time of delivery, 27(10.1%) were more than 42 weeks, while 21(7.9%) were less than 37 weeks. For those who had caesarean section performed, the main reason was obstructed labour and cephalopelvic disproportion (CPD) at 27.3% (n=9) followed by previous scar  and foetal distress  Others included delayed second stage , ante-partum haemorrhage , bad obstetric history, cord prolapse and premature rapture of membranes (PROM) were each 3.0% (n=1). The mean Apgar score was 8±1.2. Eleven (3.5%) neonates had an Apgar score of less than 6. The mean birth weight was 2928±533 grams. There were 51.1% (n=165) male neonates and 48.9% (n=158) were females. Ten (3.1%) of the new-borns had a birth defect The mothers had the following health and nutritional characteristics; on average it took approximately 1 hour for them to reach a maternity health facility (mean 63.2±51.9 minutes). In general, slightly more than half the mothers  obtained domestic water from a well or borehole followed by tap water . Approximately a fifth  reported having been exposed to agricultural spraying during pregnancy. None reported having smoked or taken illegal drugs. Only 1(0.3%) had consumed alcohol. Maternal obstetric and medical illnesses were assessed. Among women with medical and obstetric problems, 1(0.3%) had had a sexually transmitted infection, 3(1.0%) had been treated of malaria, 9(3%) were HIV positive, 2(0.7%) had been tested VDRL positive and none had been diagnosed of Tuberculosis. Thirteen (4.4%) had a chronic disease, 6(2%) had pre-Eclampsia or Eclampsia, 5(1.7%) had experienced vaginal bleeding during pregnancy and 26(8.9%) had raptured membranes prematurely.The following were the means of the nutritional parameters that were measured: haemoglobin level 12.6±1.2g/dl, height 178±0.8cm, and weight 62.8±8kg. Thirty nine (11.9%) of the women were undernourished ((MUAC<23cm), while 77.4% (n=253)) received iron and folic acid supplements. The main nutritional complaints were nausea and vomiting , heart burn  and poor appetite . Sixty three (21.7%) reported having avoided certain foods during pregnancy. The main reason for this avoidance was nausea and vomiting , heart burn  and poor appetite . Only 4.8% (n=3) reported avoidance of eggs due to myth of giving birth to a big baby The results of bivariate analysis indicated a significant association between the weight of the previous baby, premature rapture of membranes, premature birth, Apgar score of the newborn, female infant and low birth weight. Mothers who had delivered a low birth weight baby in their previous pregnancy were almost 5 times more likely  to give birth to a LBW baby compared to those who had given birth to a normal weight baby. Additionally, premature rapture of membranes was also one of the risk factors . There was a statistically significant difference in the birth weights between mothers who gave birth in less than 37 weeks gestation  and those that delivered at 37 or more weeks gestation. Newborns with an Apgar score of less than six (asphyxia) had sevenfold  likelihood of having been born LBW compared to those that were born with a score of 6 or more on Apgar. Female newborns had lower birth weight than males (16.6% vs 7.9%). The association between female neonate and LBW was statistically significant in the bivariate analysis . Below is summary table of the factors that were identified significantly associated with low birth weight p-value=0.03 Results from stratified analysis showed that infant sex and residence were confounders while maternal age was found to be an effect modifier.Twelve factors were taken to the unconditional logistic regression model using a backward building strategy. All variables which had a p-value less than 0.1 were included in the model. These included gestation at delivery, birth weight of previous baby, premature rapture of membranes, Apgar score. Infant sex and residence were added as confounders while maternal age was included as an effect modifier. The final model showed that only two factors were independently associated with low birth weight at Olkalou District Hospital; low birth weight of previous baby  was higher than the national 2009 KDHS value of 6.0% and 5.5% value for Central region . However.3% was hThe findings in this study show that most of the women who gave birth at Olkalou district hospital were of the 20-35 years age group. This is the recommended reproductive age group. This was consistent with findings documented elsewhere , 14, 20.In the bivariate analysis, among the reproductive and obstetric factors, a significant association was found between low birth weight and having delivered a LBW baby in the previous birth, premature rapture of membranes, premature births, Apgar score of less than 6 and female infant. This was similar to other studies , 10, 12.The study experienced a number of limitations. Being a cross-sectional study, it was not possible to show seasonal variation in low birth weight. The study is hospital based, and therefore it was not possible to generalize the results to a particular population as compared to population based studies. The hemoglobin level used to assess anemia as a risk factor in this study was what was available in record. Owing to the fact that mothers attend ANC clinic at different gestation in their pregnancy, it would have been more scientifically logical to follow the pattern of hemoglobin level from antenatal period to delivery in estimating the association of anemia and low birth weight. The Last Normal Menstrual Period (LNMP) was obtained from the mother child booklet, the delivery register or asking the mother. The LNMP was then used to calculate gestational age. For those mothers whose LNMP was recorded unknown or could not recall and no ultrasound record was available, gestation age could not be determined and was therefore regarded as non-response. However, an association was calculated to determine if there was a relationship between those with unknown gestation age and low birth weight.Despite the limitations, this study has made an important contribution on the prevalence of low birth weight in Olkalou district hospital, the socio-demographic and the reproductive characteristics of women delivering in the hospital. In particular, the study has identified the important risk factors that may contribute to the occurrence of high prevalence of low birth weight in the hospital.Recommendations: retraining and mentorship on focused antenatal care is necessary to ensure risk of low birth weight is detected early and treated appropriately. We recommend a population based study to ascertain the prevalence of low birth weight and associated risk factors in Nyandarua County.The prevalence of low birth weight in Olkalou District Hospital was 12.3%. There are no documented cut-off values of public health significance for low birth weight in Kenya or internationally. However, 12.3% prevalence represents a substantial risk to neonatal death among newborns in this hospital. It is important therefore that the newborn unit is well equipped to provide essential services to newborns at risk, including low birth weight. In this study, low birth weight births were more likely to occur among women who had delivered a low birth weight baby in the previous birth, among those who had raptured membranes prematurely, those who had given birth prematurely, and among those who gave birth to female infants. Low birth weight baby in the previous birth and female infant were identified as independent factors associated with low birth weight in Olkalou District Hospital. Whereas being female infant is a non-modifiable factor because it is biological and inherent, giving birth to a low birth weight baby in a previous birth can be altered to reduce the occurrence of low birth weight in the hospital. Asphyxia was more likely to occur among the low birth weight infants. Although the indicators of quality antenatal care, such as timing of first antenatal visit, number of antenatal visits and tetanus injections were not significantly associated with low birth weight, it is important to note that the association between low birth weight of previous birth, premature rapture of membranes and premature delivery are predominantly linked to the quality of antenatal care.


Within the normal range of birth weight (10th to 90th percentile), there was a positive association between birth weight and sensory and cognitive function . Neither adult height nor birth weight was associated with change in sensory or cognitive function. These results suggest that adverse prenatal and childhood experiences are a risk for poorer sensory and cognitive function and earlier development of sensory and cognitive impairment in adulthood. This finding could have significant implications for preventing sensory and cognitive impairment in older age.It is unclear what the contribution of prenatal versus childhood development is for adult cognitive and sensory function and age-related decline in function. We examined hearing, vision and cognitive function in adulthood according to self-reported birth weight  and adult height (an index of early childhood development). Subsets  of the UK Biobank resource were analysed according to visual and hearing acuity, reaction time and fluid IQ. Sensory and cognitive performance was reassessed after ~4 years . In statistical modelling including age, sex, socioeconomic status, educational level, smoking, maternal smoking and comorbid disease, adult height was positively associated with sensory and cognitive function (partial correlations;  Prenatal and early childhood development have a critical effect on long-term health in adulthood . Early dchange in cognitive function. Martyn et al [Birth weight and post-natal growth during early childhood and adolescence are positively associated with cognitive ability in childhood –17. Theryn et al  and Shenyn et al  reportedyn et al  found asth percentile or 97th percentile, depending on the cut-point used [To date, most research attention has focused on the long-term cognitive outcomes of low birth weight babies and birth weight within the normal range. However, there is also evidence that unusually large babies may have poorer cognitive outcomes. Large babies are defined as being outside the normal range of distribution according to weight, head circumference or length (i.e. greater than the 90int used ). Maternint used . Cesur aint used  analysedint used ,29 and pint used , adverseFew studies have investigated associations between early life development and hearing and visual sensory function. Birth weight was reported to be associated with likelihood of having state registration for hearing impairment , hearingIt may be that the association between indices of early life development and adult cognition and sensory function is due to confounding; factors including socio-economic status or birth trauma may account for the association, despite attempts to control statistically for potential confounds. However, there is evidence from experimental studies with animal models that supports observational findings in humans for the influence of early life exposures on development of cognitive and sensory systems . It is pIt is unclear what the relative contribution of prenatal versus childhood development is for adult cognitive and sensory function and decline in function with age. In the present study, we examined hearing, vision and cognitive function in middle age according to birth weight  and adult height (an index of early childhood development) in a very large sample of middle aged people, thereby increasing power for detecting small effects later in life. We also examined change in hearing, vision and cognitive function longitudinally over ~4 years as a function of birth weight and adult height. We hypothesized that i) cognitive and sensory function would be associated with birth weight, with poorer performance for low and high birth weight and better performance for larger babies within the normal range; ii) taller adults would have better cognitive and sensory function than shorter adults; iii) low and high birth weights and short adult height would be associated with a greater decline in sensory and cognitive function.http://www.ukbiobank.ac.uk/scientists-3/). Ethical approval for UK Biobank was obtained from the National Health Service North West Multi-centre Research Ethics Committee. During 2006–2010, 503,325 participants were recruited, with a response rate of 5.47%. As data collection proceeded, additional measures were added to the test protocol. Thus, different numbers of participants completed each measure (http://www.ukbiobank.ac.uk/). Data on sex, ethnicity and area of residence were collected for each participant. Areas of residence were translated to Townsend deprivation scores to provide a proxy measure of socioeconomic status. Townsend scores are widely used in health studies, and are applicable across the countries of the UK [This study utilised data from the UK Biobank resource . UK Biob measure . For thehttp://biobank.ctsu.ox.ac.uk/~bbdatan/Repeat_assessment_doc_v1.0.pdf).During 2012 and 2013, 17,819 participants were recruited for repeat assessment, with a response rate of 21%. All baseline and physical measures were repeated, including hearing, vision and cognition. The average interval between baseline testing and repeat assessment was 4 years, and ranged between 2 and 7 years. .Self-reported birth weight was recorded for those participants who reported that they knew their own birth weight. Self-reported birth weight is a valid measure of birth weight ,52. Parthttp://biobank.ctsu.ox.ac.uk/crystal/label.cgi?id=100049). Briefly, fifteen sets of three monosyllabic digits were presented over circumaural headphones (Sennheiser HD-25). Participants first set the volume of the stimuli to a comfortable level. Each ear was tested separately with the order of testing randomised across participants. Digits were presented in a background of noise shaped to match the spectrum of the speech stimuli. Noise levels varied adaptively, contingent on recognition of the three digits, to estimate the signal-to-noise ratio (SNR) for a criterion performance of 50% correct. The speech recognition threshold was calculated from the mean SNR for the last eight triplets. Lower (more negative) scores represent better performance. The recognition threshold for the better ear was used as the index of hearing.Hearing was assessed with the Digit Triplet Test (DTT), a speehttp://biobank.ctsu.ox.ac.uk/crystal/refer.cgi?id=100250). Visual acuity for the better eye was used as the index of vision.Visual acuity testing was based on reading high contrast letters with the participant seated at a distance of 4 metres. Visual acuity measures were completed on both eyes. Participants wore glasses or contact lenses that were normally worn for distance viewing. Visual acuity scores were determined as the logMAR size at which 3 out of the 5 letters presented were read correctly. A detailed description of visual acuity testing is provided elsewhere . Processing speed testing was based on the card game ‘Snap’. Participants were shown two pairs of cards out of a set of 12 pairs. If both cards displayed a matching symbol, participants pressed a response button as quickly as possible using their dominant hand. Reaction time was taken as the average time to correctly respond to a matching pair. Fluid intelligence (IQ)  was estimated via multiple choice responses to questions such as "Bud is to Flower as Child is to?" Participants had 2 minutes to complete as many questions as possible out of 13. Correct responses scored 1 point, while questions that were answered incorrectly or that were not completed within the time limit scored zero.Cognitive tests were completed via a computerised touchscreen interface. A detailed description of cognitive testing is reported elsewhere . Maternal smoking was recorded in response to the question "Did your mother smoke regularly around the time when you were born?" Smoking status was based on self-report of previous or current tobacco smoking (current/previous/never).Participants were fractionally ranked by birth weight and adult height separately for males and females. Fractional ranks were then pooled across sexes to provide percentile ranks by birth weight and by height within the sample independent of sex. Plots of reaction time, IQ, hearing and vision acuity by percentile rank for birth weight and adult height were generated. To index change in performance over time, performance at the baseline assessment was subtracted from performance on repeat assessment. Change in performance was then divided by the time between baseline and repeat assessment to provide a figure for the average annual change in performance for the hearing, vision and cognitive tests.To analyse the association between adult height and hearing, vision and cognition, a linear regression model was applied with cognitive or sensory performance as the dependent variable, adult height as the independent variable, with age, sex, Townsend deprivation index quintile, educational level, smoking, diabetes, cardiovascular disease, hypertension, high cholesterol and maternal smoking as possible confounds. Similar analyses were carried out to analyse the association between adult height and change in hearing, vision and cognition.th to 90th percentile) of birth weight with age, sex, Townsend deprivation index quintile, educational level, smoking, diabetes, cardiovascular disease, hypertension, high cholesterol and maternal smoking as possible confounds. Similar analyses were carried out to analyse the association between birth weight and change in hearing, vision and cognition. To compare the smallest and largest extremes of the distribution by birth weight, the top and bottom 3% were compared to the 3% of the sample in the middle of the distribution (i.e. +/- 1.5% of the sample either side of the 50 percentile). An ANOVA model was applied, hearing, vision and cognition as the dependent variable and group  as the independent variable in the model, with the covariates age, sex, Townsend deprivation index quintile, educational level, smoking, diabetes, cardiovascular disease, hypertension, high cholesterol and maternal smoking. All analyses were performed with SPSS version 20.0 .To analyse the association between birth weight and hearing, vision and cognition, linear regression models were applied for those participants within the normal range  = 756, p < 0.001; Vision: r2 = 0.08, F = 402, p < 0.001; Reaction time: r2 = 0.10, F = 3642, p < 0.001; IQ: r2 = 0.16, F = 2073, p < 0.001). Adult height was a significant contributor to each regression model (pr) for height controlling for sex, age, Townsend quintile, smoking status, cardiovascular disease, diabetes, hypertension, high cholesterol and maternal smoking were: hearing 0.06; vision 0.06, reaction time 0.05; IQ 0.12.th to 90th percentile), regression models including birth weight, sex, age, Townsend quintile, smoking status, cardiovascular disease, diabetes, hypertension, hypercholesterolemia and maternal smoking and hearing, vision, reaction time and IQ were all statistically significant  = 781, p < 0.001; Vision: r2 = 0.07, F = 187, p < 0.001; Reaction time: r2 = 0.11, F = 1808, p < 0.001; IQ: r2 = 0.14, F = 837, p < 0.001). Birth weight made a statistically significant contribution to each model (pr) for birth weight controlling for sex, age, Townsend quintile, smoking status, cardiovascular disease, diabetes, hypertension, cholesterol and maternal smoking were: hearing 0.04; vision 0.01, reaction time 0.01; IQ 0.12.th percentile). For an ANOVA including birth weight category  and potential confounds there were significant differences in hearing, vision, reaction time and IQ across birth weight category (p < 0.001). The high category had significantly better performance than the low category for hearing and IQ . There was no difference between the low and high categories in reaction time or vision .The top and bottom 3% by birth weight were compared with the middle 3%  = 3.43, p < 0.001; Reaction time: r2 = 0.004, F = 4.20, p < 0.001; Fluid IQ: r2 = 0.03, F = 9.5, p < 0.001). The regression model for change in visual acuity was not statistically significant  = 0.99, p = 0.45). Height was not a significant contributor to any model. For hearing, older age and lower educational attainment was associated with improved function. Older age and high cholesterol was associated with slower reaction time at reassessment. More deprived Townsend quintile and lower educational attainment was associated with improved IQ over time.Regression models (th to 90th percentile), regression models including birth weight, sex, age, Townsend quintile, smoking status, cardiovascular disease, diabetes, hypertension, cholesterol and maternal smoking were statistically significant for change in hearing, reaction time and IQ  = 2.17, p = 0.01; Reaction time: r2 = 0.076, F = 2.62, p = 0.002; IQ: r2 = 0.032, F = 5.42, p < 0.001). The model for change in vision was not statistically significant  = 0.89, p = 0.55). Birth weight was not a significant contributor to any model (th percentile). In ANOVA including birth weight category  and potential confounders, there were no significant differences in birth weight category for change in performance (formance .th to 90th percentile), larger birth weight was associated with better hearing, vision and cognitive function. Participants with both the smallest and the largest birth weights had significantly poorer function than those within the normal range. Adult cognitive and sensory function are therefore related to prenatal experience (indexed by birth weight). It is striking that effects of early development persist into middle age, after decades of life experiences that impact on cognitive and sensory functioning. Early life factors may also interact with environmental exposures during the lifespan to increase susceptibility to cognitive and sensory impairment [In statistical models that included age, sex, socioeconomic status, educational level, diabetes, cardiovascular disease, hypertension, high cholesterol, smoking status and maternal smoking, adult height was linearly related to hearing, vision and cognitive function in middle age, with taller adults having better function. Environmental factors and nutrition in early childhood (indexed by adult height) are thus related to sensory and cognitive function in middle age. Birth weight showed a different pattern of association. Within the normal range (10pairment . Common pairment .On reassessment after ~4 years, improvements in the IQ and the hearing measure were apparent. Performance on the vision and reaction time tasks showed a more expected pattern of decline in performance. Practice effects are well-known in studies of cognitive aging and may affect some tests more than others , and it The present study has some limitations. The study was observational with cross-sectional and longitudinal measurement, and it is not possible to establish a causal link between early development factors and adult cognitive and sensory function. We attempted to control statistically for potential confounds such as socioeconomic status, educational level, age, comorbid disease, smoking and maternal smoking. However, it is possible that unmeasured confounds or insufficient control of measured confounds could impact results. For example, no information was available on gestational age or parental body size. Ideally, body size measures at birth should be corrected for parental size and gestational age in order to distinguish between growth appropriate for gestational age and growth restriction , though Sensory and cognitive impairments in older age are a substantial and increasing source of poor quality of life and economic costs globally . As with


Induced birth of fetuses with gastroschisis from 34 weeks gestational age (GA) has been proposed to reduce bowel damage. We aimed to determine the effect of birth timing on time to full enteral feeds (ENT), length of hospital stay (LOS), and sepsis.A retrospective analysis (2000–2014) of gastroschisis born at ≥ 34 weeks GA was performed. Associations between birth timing and outcomes were analyzed by Mann–Whitney test, Cox regression, and Fisher's exact test.217 patients were analyzed. Although there was no difference in ENT between those born at 34–36 + 6 weeks GA (median 28 range [6–639] days) compared with ≥ 37 weeks GA (27 [8–349] days) when analyzed by Mann–Whitney test (p = 0.5), Cox regression analysis revealed that lower birth GA significantly prolonged ENT (p = 0.001). LOS was significantly longer in those born at 34–36 + 6 weeks GA (42 [8–346] days) compared with ≥ 37 weeks GA 34 [11–349] days by both Mann–Whitney (p = 0.02) and Cox regression analysis (p < 0.0005). Incidence of sepsis was higher in infants born at 34–36 + 6 weeks (32%) vs. infants born at ≥ 37 weeks .Early birth of fetuses with gastroschisis was associated with delay in reaching full enteral feeds, prolonged hospitalization, and a higher incidence of sepsis. Gastroschisis neonates are frequently affected by varying degrees of gut dysfunction with 49% of neonates requiring > 28 days of parenteral nutrition Elective birth at 37 to 38 weeks gestational age (GA) has been suggested following report of in-utero fetal deaths in late term pregnancies The literature with regards to delivering gastroschisis pregnancies electively between 34 and 36 + 6 weeks to protect bowel from ongoing damage is conflicting with some studies in favor 1We performed a retrospective study of gastroschisis neonates born at ≥ 34 weeks GA managed antenatally at Mount Sinai Hospital, Toronto and stabilized immediately after birth at Mount Sinai Hospital and managed postnatally at the Hospital for Sick Children, Toronto between January 2000 and July 2014. Any fetus or neonate treated outside of either center was excluded from the study. Approval was granted by the Institutional Research Ethics Boards of both hospitals to collect combined antenatal and neonatal data by retrospective chart review. Gastroschisis cases were identified through interrogation of the Mount Sinai and Hospital for Sick Children databases. Fetal and neonatal data were obtained from computerized charts at the respective hospitals.During the study period pregnancies were monitored in Mount Sinai antenatal clinic at 4-weekly intervals until 30 weeks GA, 2-weekly intervals between 30 and 34 weeks, once-weekly after 34 weeks and twice-weekly after 35 weeks. Women were electively delivered vaginally by induction of labor at 37 weeks GA unless obstetric concerns necessitated conversion to cesarean section. Earlier birth was performed in the presence of nonreassuring biophysiological profile or nonstress testing, occasionally owing to presence of bowel dilatation, maternal health concerns or as a result of spontaneous labor. Emergent delivery was defined as being within 24 h of the examination that triggered concern, and semielective delivery as planned induction brought forward from original planned date, but at least 24 h later than the examination. Gestational age was estimated based on best obstetric estimate on early ultrasound, obstetric history and examination followed by pediatric estimate in that order.a.Time to full enteral feeds (ENT) defined as time taken from birth to full enteral feeds as described in the hospital notes;b.Length of hospital stay (LOS) defined as time from birth to discharge or death;c.Sepsis defined as isolation of a pathogenic organism from blood.The outcome measures were:1.1Neonates were divided in two groups: Those born between 34 and 36 + 6 weeks gestation and those born at or after 37 weeks gestation. Baseline comparison between two groups was conducted using Fisher's exact test. Outcomes were compared between two groups, with and without taking into account corrected GA. Mann Whitney, Cox regression analysis, and Fisher's exact test were utilized and data are presented as median [range]. Statistical analysis was performed using GraphPad Prism v6. and SPSS v22 software. A p value of < 0.05 was considered statistically significant.2A total of 232 gastroschisis neonates were born during the study period, of whom 15 were born at < 34 weeks and excluded from the study. Of the 217 neonates born at ≥ 34 weeks GA, 30 were complex including 14 who had associated atresia, 6 who had stenosis, 4 who had perforation and 15 who had necrosis (6 patients had two or more concomitant bowel pathologies). Five neonates died for the following reasons; 1 patient owing to necrotic bowel and multiorgan failure, 1 owing to necrotizing enterocolitis, 2 owing to parenteral nutrition associated liver failure and 1 owing to overwhelming sepsis. At the time of data collection, 4 complex patients were still increasing on feed volumes in hospital (3 necrosis and 1 atresia patient). A further 4 complex patients require home PN owing to short bowel syndrome . These 217 neonates were divided into two groups: those born at 34 to 36 + 6 weeks GA (n = 114) and those born at ≥ 37 weeks GA n = 103, . There wAnalysis of time to achieve ENT and LOS showed that there was no difference in ENT between those born at 34 to 36 + 6 weeks GA (median 28 range [6–639] days) compared with neonates born at ≥ 37 weeks GA (27 [8–349] days), p = 0.5. However, LOS was significantly longer in those born at 34 to 36 + 6 weeks GA (42 [8–346] days), compared with neonates born at ≥ 37 weeks GA (LOS 34 [11–349] days), p = 0.02 . In order to account for the effect of prematurity, we analyzed corrected GA at ENT and LOS. The corrected GA at ENT was significantly lower in neonates born at 34 to 36 + 6 weeks GA (ENT 40 [36–125]) compared with those born ≥ 37 weeks GA . However, corrected GA at discharge from hospital was similar for neonates born at 34 to 36 + 6 weeks GA (42 [37–84] weeks) compared with those born ≥ 37 weeks GA . Additionally, the proportion of infants having at least one episode of sepsis was significantly higher in infants born at 34 to 36 + 6 weeks GA  than those born at ≥ 37 weeks GA .To determine the effect of GA on ENT and LOS across the entire cohort we performed a Cox regression analysis, adjusting for complexity and GA and censoring for death, not achieving full feeds or not being discharged from hospital as appropriate. As expected, complexity at birth significantly prolonged ENT  and LOS  compared with simple gastroschisis. Birth at lower GA was associated with a significantly prolonged ENT  and LOS . In order to illustrate the effects of lower birth GA on ENT and LOS, we divided the patients into categories of birth GA and repeated the Cox regression analysis with the categorical GA variable. Cox regression curves are shown for each GA category for ENT A and LOSAs many of the neonates born before 37 weeks were delivered for obstetric reasons, rather than planned early induction of labor, we also repeated the analysis for those neonates born at 34 to 36 + 6 weeks GA to examine the effect of mode of labor onset, although it should be noted that this is a post hoc analysis that is lacking in statistical power owing to small patient numbers in some of the labor mode categories. We compared spontaneous labor  with: (i) semielective early induction of labor/cesarean section ; and (ii) emergency . The effect of lower GA at birth remained significant for ENT  and LOS . However, there was no significant effect of birth mode on ENT , or on LOS . We also analyzed the effect of labor onset mode in patients born at ≥ 37 weeks GA comparing spontaneous labor  with planned induction of labor/caesarean section ; there was only one patient with emergent caesarean section in this GA group. There was no effect of planned induction/caesarean section compared with spontaneous labor on ENT  or LOS . Within the ≥ 37 weeks group, there was no effect of lower GA at birth on ENT ) or LOS .3This large single center cohort shows a significant association between early GA at birth and prolonged ENT, LOS and increased risk of sepsis.Analysis of the corrected gestational age at time to full feeds would suggest that delivery earlier than 37 weeks improves neonatal gut function. However, this is not owing to a faster time from birth to full enteral feeds, as time to full feeds is similar between those born before 37 weeks and those born after 37 weeks. Overall, younger GA in these gastroschisis infants is associated with a longer time postnatally to achieve full enteral feeds, as indicated by Cox regression analysis. As this cohort only includes gastroschisis infants, we are unable to determine whether this effect of younger GA on prolonging enteral feeds is specific to gastroschisis or is a general effect of prematurity. Although corrected GA at full enteral feeds is lower in the group born at less than 37 weeks, these infants are discharged from hospital at a similar corrected GA to those born at greater than 37 weeks, and therefore spend longer in hospital before discharge, as indicated by the Cox regression analysis of length of hospital stay. The longer time before achieving full feeds, and the longer time in hospital, place infants born before 37 weeks at increased risk of sepsis, as indicated by the nearly doubled (32% vs. 17%) proportion of infants having an episode of blood-culture positive sepsis in those born at less than 37 weeks.We must acknowledge limitations of our study. Our study was a retrospective analysis including patients delivered at < 37 weeks GA on an emergent or semiurgent basis owing to maternal–fetal concerns, patients delivered at < 37 weeks owing to spontaneous labor and patients delivered at ≥ 37 weeks GA as per standard induction. Such comparisons could be affected by the overall health of the neonates with those delivered early for maternal or fetal concerns possibly having poorer outcomes as a result. We have tried to control for this in post hoc analyses adjusting for reason for early delivery, in which mode of labor onset did not significantly affect neonatal outcomes; however, we cannot be certain regarding the reasoning behind the decision to give birth in some women at 34 to 36 + 6 weeks while allowing others to progress to 37 weeks GA. There may have been additional confounders that we were unable to take account of. We are also unable to recommend elective delivery at approximately 37 weeks rather than later spontaneous delivery or induction of labor after 37 weeks. The effect of lower birth GA on ENT and LOS is consistent with other large 4Early birth of otherwise healthy gastroschisis fetuses did not appear to reduce bowel damage or improve bowel function and was not associated with differences in corrected postnatal age at which patients reach full feeds or are discharged from hospital.


The MEMS device used for this study could prove to be a reliable, low cost, low power and high temperature micro-hotplate for the thermo-optical characterisation of sub-micron sized particles. The temperature-sensitive nanosensors could find potential application in the measurement of temperature in biological and micro-electrical systems.A custom designed microelectromechanical systems (MEMS) micro-hotplate, capable of operating at high temperatures (up to 700 °C), was used to thermo-optically characterize fluorescent temperature-sensitive nanosensors. The nanosensors, 550 nm in diameter, are composed of temperature-sensitive rhodamine B (RhB) fluorophore which was conjugated to an inert silica sol–gel matrix. Temperature-sensitive nanosensors were dispersed and dried across the surface of the MEMS micro-hotplate, which was mounted in the slide holder of a fluorescence confocal microscope. Through electrical control of the MEMS micro-hotplate, temperature induced changes in fluorescence intensity of the nanosensors was measured over a wide temperature range. The fluorescence response of all nanosensors dispersed across the surface of the MEMS device was found to decrease in an exponential manner by 94%, when the temperature was increased from 25 °C to 145 °C. The fluorescence response of all dispersed nanosensors across the whole surface of the MEMS device and individual nanosensors, using line profile analysis, were not statistically different ( For example: heaters for resistive/catalytic gas sensing Rhodamine B (RhB) is an example of a molecular probe, which has been extensively studied for its temperature dependent fluorescence response In this article we describe the development of a custom built complementary metal-oxide semiconductor (CMOS) MEMS micro-hotplate used to characterise the thermo-optical response of fluorescent temperature-sensitive nanosensors. The nanosensors, composed of RhB fluorophores conjugated to a silica sol–gel matrix, were dispersed and dried on the surface of the MEMS micro-hotplate, which was mounted on a conventional slide holder of a fluorescence confocal microscope. Temperature dependent changes in the fluorescence response of the nanosensors were evaluated by controlling the electrical power used to heat the MEMS micro-hotplate.2Tetraethyl orthosilicate (TEOS) and (3-aminopropyl) triethoxysilane (APTES) were obtained from Sigma-Aldrich . Absolute ethanol was purchased from Fisher Scientific . Ammonium hydroxide 30 wt% was obtained from Acros Organics . Rhodamine B isothiocyanate (RhB-ITC) was purchased from MP Biomedicals . Deionised water (18.2 MΩ) generated by Maxima HPLC grade USF Elga.33.1RhB-ITC  was stirred in absolute ethanol (0.98 mL) for 10 min. APTES  was added in excess and stirred at 4 °C overnight. Aliquots of RhB-APTES conjugate solution were used for nanoparticle synthesis.3.2A catalysis mixture was prepared by stirring ethanol (5.25 mL) and ammonium hydroxide  together for 10 min. In a separate container, a monomer solution was prepared by stirring TEOS  and RhB-APTES conjugate (250 μL from Rhb-APTES conjugate solution) together for 10 min. Nanosensor synthesis was initiated through the addition of monomer solution to the stirring of the catalysis solution at a controlled rate . The reaction was stirred for 1 h, producing an opaque nanoparticle suspension. Nanosensors were washed (10 times) through suspension in ethanol (30 mL) and centrifugation . Nanosensors were dried using vacuum filtration . The resultant solid was placed in a desiccator overnight to remove any remaining solvent.3.33.3.1Nanosensors were suspended in deionised water  and dried on an aluminium scanning electron microscopy stub . A Carl Zeiss EVO HD15 scanning electron microscope was used to image dry nanosensors . The measured diameters were validated using dynamic light scattering.3.3.2® Analytics quartz cuvette (1.5 mm diameter). The mean hydrodynamic diameter of the particles was computed from the intensity of the scattered light using the OmniSize 3.0 software.Dynamic light scattering was performed using a Viscotek (802) system. The system is equipped with a 50 mW laser source (830 nm), operating at an angle of 90°. Nanosensors were suspended in deionised water . Measurements  were made using a Hellma3.4The temperature-sensitive nanosensors were suspended in deionised water . The suspension was deposited (1 μL) onto the MEMS micro-hotplate using a pipette and was allowed to evaporate to leave a thin film of dispersed nanosensors on the surface. An additional aliquot of nanosensors (1 μL) was also deposited on a glass coverslip  so that they could be visualised as a high resolution image, using a fluorescence microscope and a high magnification oil immersion objective.3.5n = 6) using line profile analysis, placed at the centre of a nanosensors surface intensity plot. Student's t test was used to identify significant differences between the full width half max (FWHM) of temperature-sensitive nanosensors and commercially available fluorescent nanoparticles (see supporting information), as well as the fluorescence response of particles spread across the whole area of the MEMS micro-hotplate and dispersed individual nanosensors.A Leica SP2 confocal fluorescence microscope coupled with a Leica HC PL FLUOTAR 50 × 0.8 NA (air) ) was used to image temperature-sensitive nanosensors. A Krypton 568 nm laser was used as excitation source. A photomultiplier tube  was used to collect fluorescence between 580 nm and 625 nm. Acquired images were analysed using FIJI open source software. Background fluorescence was estimated by determining the fluorescence on MEMS devices coated without any particles and subtracted from images used for temperature analysis. Some warping of the membrane was found to occur due to thermal expansion, which can cause errors in the fluorescence intensity measurements especially when the sample becomes out of focus. This is more critical when using high magnification objectives with a short working distance. In order to correct for warping, the sample was refocused at each temperature point. Measurements of the focal point show that the movement of the membrane is of the order of 0.5 μm/°C . Temperature induced fluorescence intensity changes for temperature-sensitive nanosensors were collected over the whole MEMS micro-hotplate area, and for individual dispersed nanosensors (2 charged coupled device camera (6.45 × 6.45 μm) pixel cell, 1000 kHz), interfaced Resolve3D softWoRx Acquire (version 5.5.0) software was used to acquire images . An InsightSSI solid state ﬂuorescence light source was used to excite red ﬂuorescence at 542/27 nm (85 mW), while collecting emitted ﬂuorescence at 594/45 nm. Transmission intensity and exposure times used were 50% and 0.10 s, respectively. The theoretical resolution of this optical system, calculated using the Rayleigh criterion, is 250 nm.A DeltaVision Elite (Applied Precision) with Olympus IX71 stand inverted microscope coupled with an Olympus U-Plan S-Apo 100 × 1.40 NA  objectives were used to visualise temperature-sensitive nanosensors dispersed on a glass coverslip, to show a representative high resolution distribution of nanosensors on a MEMS device surface. A CoolSNAPHQ3.6The MEMS micro-hotplate was electrically controlled using a Thurlby Thandar Instrument (PL303) power supply. The voltage and current to the device were monitored using an Agilent (34401A) multi-meter. The electrical temperature sensor of the micro-hotplate was characterised using a Signatone QuieTemp (S-1060R) hot chuck (±1 °C absolute accuracy). The electrical resistance was monitored using a Keithley (2400) source meter. Thermal simulations of the micro-hotplate were performed using the finite element method (FEM) with ANSYS (8.0). Thermal conductivity was modelled, by taking air convection into account, and the following material parameters; Tungsten 177 W/mK, Silicon Oxide 1.4 W/mK, Silicon Nitride 2.2 W/mK and Silicon 150 W/mK (25 °C).42, and is thermally isolated in the centre of a 560 μm diameter membrane, The MEMS micro-hotplate was developed by Cambridge CMOS Sensors Ltd and used as a tool to characterize the fluorescence response of temperature-sensitive nanosensors. The device consists of a multi-ring shaped resistive heater element, fabricated using CMOS tungsten metallization, embedded in a silicon dioxide membrane, R and RT are the micro-hotplate and track resistances, at elevated temperature (T) and 25 °C (T0), α and β are the temperature coefficients of resistance (TCR), which were experimentally determined to be 2.05 × 10−3 Ω/°C and 0.30 × 10−6 Ω/°C, respectively. The micro-hotplate is highly efficient, due to the thermal insulation provided by the silicone dioxide membrane surrounding the heater, and achieves an operating temperature of 200 °C at a power level of only 8.67 mW, The MEMS micro-hotplate's electrical resistance at 25 °C is 60 Ω. To further describe the temperature dependent resistance, the following expression was used:55.1Temperature-sensitive silica sol–gel nanosensors are spherical probes, composed of orthosilicate substituted monomers, tetraethylorthosilicate (TEOS) and the transducer RhB (3-aminopropyl)-triethoxysilane (APTES) conjugate. The RhB-APTES conjugate was formed through a nucleophilic addition reaction between RhB isothiocyanate (ITC) and APTES, The monomers undergo a two-step hydrolysis and condensation reaction to produce a three-dimensional matrix Nanoparticles with diameters ranging between 300 nm and 1000 nm were synthesized, so that they could be visualised using fluorescence confocal microscopy. Scanning electron microscopy (SEM) images show mono-dispersed nanoparticles, with a diameter of 529 ± 42 nm, 5.2et al. RhB based temperature-sensitive nanosensors have peak excitation and emission wavelengths at 554 nm and 573 nm, respectively The fluorescence response of temperature-sensitive nanosensors decreases as the temperature of the MEMS micro-hotplate is increased from 25 °C to 145 °C, inset. The distribution of fluorescence from the surface intensity plot is related to the number of fluorophores present at the centre and the edge of a spherical particle when imaged as a single in focus plane, rather than a change in temperature High-resolution fluorescence images of temperature-sensitive nanosensors show spherical mono-size dispersed particles present, either as clusters or individual nanosensors, p < 0.05), inset. At 145 °C the fluorescence response of individually imaged temperature-sensitive nanosensors appears to be fully quenched as the nanosensors do not exhibit a detectable fluorescence signal. Therefore, this temperature could be considered as temperature detection limit of RhB based silica sol–gel temperature-sensitive nanosensors.When a line profile is placed at the center of the surface intensity plot the temperature dependent fluorescence response of individual nanosensors can be determined for a range of temperatures, 6In conclusion, we have demonstrated the application of a custom designed CMOS MEMS device for the thermo-optical characterization of an RhB based temperature-sensitive nanosensor. The MEMS device is a low power, high temperature, micro-hotplate which is small enough to be mounted on a conventional slide holder of a microscope and can be manufactured using low cost, high volume, CMOS fabrication processes. Simulations of the temperature profile of the whole surface of the micro-hotplate show 99.5% temperature uniformity at 200 °C. Application of the Rayleigh criterion confirmed individual nanosensors, approximately 550 nm in diameter, could be resolved using our optical imaging system. The temperature dependent fluorescence intensity of nanosensors dispersed across of the surface of the micro-hotplate, demonstrated a 94% drop in fluorescence intensity when the temperature was increased from 25 to 145 °C. Individual nanosensors did not exhibit any observable fluorescence at 145 °C and this temperature was taken to be the detection limit of the nanosensors. Temperature-sensitive silica sol–gel nanosensors are simple and inexpensive to manufacture and may find potential applications in the thermal characterization of nano/micro scale electronic, mechanical and biological systems. Through modification of the nanosensor synthesis protocol


Several studies indicate that infants prefer individuals who act prosocially over those who act antisocially toward unrelated third parties. In the present study, we focused on a paradigm published by Kiley Hamlin and Karen Wynn in 2011. In this study, infants were habituated to a live puppet show in which a protagonist tried to open a box to retrieve a toy placed inside. The protagonist was either helped by a second puppet (the “Helper”), or hindered by a third puppet (the “Hinderer”). At test, infants were presented with the Helper and the Hinderer, and encouraged to reach for one of them. In the original study, 75% of 9-month-olds selected the Helper, arguably demonstrating a preference for prosocial over antisocial individuals. We conducted two studies with the aim of replicating this result. Each attempt was performed by a different group of experimenters. Study 1 followed the methods of the published study as faithfully as possible. Study 2 introduced slight modifications to the stimuli and the procedure following the guidelines generously provided by Kiley Hamlin and her collaborators. Yet, in our replication attempts, 9-month-olds’ preference for helpers over hinderers did not differ significantly from chance . Two types of factors could explain why our results differed from those of Hamlin and Wynn: minor methodological dissimilarities , or the effect size being smaller than originally assumed. We conclude that fine methodological details that are crucial to infants’ success in this task need to be identified to ensure the replicability of the original result. The study of sociomoral sensitivity in early infancy is one of the most productive and successful lines of inquiry in the last decade of developmental science. Ever since the seminal studies by Premack and Premack  and by KThe manual choice paradigm proved to be a valuable methodology for charting out the complexities of infants’ socio-moral evaluations. The picture that eight years of research employing this paradigm revealed is that of a remarkably precocious and sophisticated sociomoral sensitivity in infancy. As soon as they begin to reach for objects (by around 5 months of age), infants already show a systematic preference for helpers over hinderers in a variety of contexts. Whether the Protagonist attempts to climb a steep hill, persistently tries to open a box to retrieve a toy, or needs assistance to have her dropped ball returned, infants systematically prefer the agent facilitating the achievement of this goal ,7,8. FurAdding to the remarkable context-dependence of infants’ evaluations, further work demonstrated that infants’ evaluative inferences are not inflexibly linked to either the local valence of the observed action, or the actual production of outcomes compatible with the Protagonist’s goal. For instance, presented with a scenario in which two individuals respectively facilitate and obstruct the goal of another agent who has in turn hindered a third party, infants as young as 4.5 months of age already show a marked preference for the “Punisher” . LiImportantly, the manual-choice paradigm has been successfully adopted in domains other than instrumental helping, such as distributive fairness , sympathGiven the impact and success of the manual choice paradigm in demonstrating infants’ sociomoral evaluation of agents, we sought to replicate one of the first “morality plays” in which this methodology has been tested. We selected the “box scenario” from a paper by Hamlin and Wynn , in whicHere we report two attempted replications, conducted by two different groups at the same research facility. The first replication followed as faithfully as possible the methodological details reported in Hamlin and Wynn . The secInfants were habituated to a live puppet show, during which a character (the Protagonist) was helplessly trying to open the lid of a transparent plastic box to retrieve a rattle placed inside. The Protagonist was alternately either aided or thwarted by two characters, who helped to open the box (the “Helper”) or slammed the box lid closed (the “Hinderer”), respectively. Once the child habituated to the prosocial and antisocial events, habituation trials were terminated and followed by a test, which consisted in presenting infants with the Helper and the Hinderer, and encouraging them to choose one of them by reaching for it.The methods of this study followed the description provided by Hamlin & Wynn  as closen = 3); parental interference (n = 1), failing to choose either puppet (n = 7), choosing both puppets (n = 3), procedural error (n = 8), or equipment failure (n = 1). . The sample-size was set to ensure stronger statistical power than that of the original study (in which 16 participants were tested). Twenty-three additional infants were excluded from analyses, due to: fussiness (Stimuli were presented to infants on a puppet-theatre stage (60 x 80 cm). A dark blue curtain, which could be raised and lowered by means of a pulley, covered the opening of the stage before and in-between events. A transparent plastic box (15 x 20 x 7 cm), a rattle, and three puppets were involved in the events. A lion puppet played the role of the Protagonist, and two dog puppets, one wearing a red shirt and the other wearing a blue shirt, played the Helper and the Hinderer roles (varied across infants).Three experimenters were present in the room. E1 was in charge of the online coding of infants’ looking behavior; E2 was in charge of performing the puppet show; and E3 was in charge of instructing the parents, performing the familiarization and the manual choice test, and operating the stage curtain during the habituation phase. E1 was visible to the infants only while entering the room, being otherwise separated from the testing area by means of a wide curtain. E2 was never visible to the infants, as she was fully hidden behind the stage. She was also wearing black gloves to prevent infants from being distracted by her hands appearing from behind the curtains during the puppet manipulation. E3, who interacted with the infants before the study, was hidden behind the stage during the habituation phase, and only reappeared for the manual choice phase. Crucially, only E2 was aware of the identity of Helper and Hinderer, since E3 had no visual access to the puppets during the habituation phase, and E1 monitored the habituation events via a monochrome camera that did not allow discriminating the two puppets on the basis of their t-shirt color. Three cameras, hidden to the infant’s sight, one pointing to the stage, and two on the infant , were used to record the participants during the habituation and the manual choice phases.The study consisted of three phases: familiarization, habituation, and manual choice. Before entering the testing room, parents were instructed to keep their eyes closed throughout the habituation and manual choice phases and to avoid interacting with the infants, unless explicitly told so by E3. We let parents soothe their infants briefly during the inter-trial pause in the habituation phase (in which the curtain stage was down for 5–10 s) if the infants started showing clear signs of distress. Once in the testing room, parents were instructed to sit the infants on their laps, 100 cm from the stage.Familiarization: Infants were presented with a transparent plastic box containing a rattle. E3 approached the infant, holding the box in front of their faces, and said, “Look!” (shaking box), “Look!” (grabbing the edge of the box), “Look!” (opening the box), and “Ooh!” (lifting the toy out of the box and shaking it). Afterwards, she said, “Should we put it in again? Look!” (putting the toy back in the box), “Look!” (closing the lid), “It’s in there again!” (shaking the box). Finally, she said, “Should we take it out again?” and repeated the familiarization once more.Habituation phase: Each trial of the habituation phase started with raising the curtain, revealing the stage with the rattle in the transparent box in the middle and the two dogs sitting at the back corners of the stage, equidistantly from the box. The Protagonist entered from the center of the back of the stage, in between the two dogs, moving to one side of the box, and looking twice at the toy inside. The Protagonist then jumped on the front part of the lid and tried to open the box five times. In the first two attempts, the Protagonist shook the lid before dropping it shut. In the third and fourth attempts the Protagonist lifted and lowered the lid down while continuously holding it. In the fifth attempt, one of the two dogs either helped or hindered the Protagonist’s attempt to open the box , infants’ looking to the still stage was measured online by E1 using Psyscope. The trial ended when infants (a) looked away for 2 consecutive seconds, or (b) 60 s elapsed. At this point the curtain was lowered by E3 in response to a vocal signal whispered by E1. The inter-trial interval lasted until E2 prepared the stage for the following trial (5 to10 s). Habituation was reached when (1) the sum of infants’ looking time at three consecutive trials was less than half of the sum of their looking time at the first three trials, or (2) a maximum of 14 trials was completed. To indicate to E3 that the infant reached habituation, E1 whispered a second vocal command.Manual choice: E3, who was blind to the identity of the puppets, came out of the curtains, hiding the two dog puppets behind her back, and asked parents to rotate their chairs about 30 degrees to their right. E3 kneeled down at about a meter away from the infant, and said ‘Hi’ in order to get the infant’s attention. Then she showed to the infants the two dogs simultaneously while saying ‘Look!’ Puppets were held at about 50 cm away from infants, and kept still until a choice was made.n = 7), the remaining infants took on average 9.58 s to express their choice (SD = 7.13). The choice was independently coded offline by E1, E2, and a third coder blind to the identity of the puppets. The inter-coder agreement was 100%.In order for a choice to be considered valid, infants had to (a) look first at both puppets; (b) perform a visually guided reach; and (c) show a preference for only one puppet within 40 s. In case infants failed to look at both puppets, E3 slightly wiggled the puppets and repeated the hiding-revealing procedure one more time. Since no information about the time limit for producing a manual choice was provided by Hamlin & Wynn , we arbiAcross infants, the following three factors were orthogonally counterbalanced: (1) identity of the puppets (Helper wearing red or blue shirt), (2) order of events during habituations (Helper first or second), and (3) side during habituation (Helper left or right). In addition, (4) the puppets' side during manual choice was equalized .SD = 2.29 trials). During the manual choice test, infants did not significantly prefer the Helper over the Hinderer puppet . Infants’ choice was not significantly influenced by the puppets’ t-shirt color , or by the puppets’ location at test .All the statistics reported in this paper are two-tailed. The infants habituated in an average of 8.75 trials .n = 6), equipment failure (n = 1), procedural errors (n = 3), making no identifiable choice , or because the participant fell asleep (n = 1). . Fifteen additional infants were excluded from analyses because of fussiness (A new transparent box (size 12 x 22 x 10 cm), a novel rattle, and a different set of puppets were used. An elephant hand puppet played the role of the Protagonist. Two cat hand puppets that differed only in color (black vs. orange) were used as Helper and Hinderer. Following advice from K. Hamlin and her team, the stage curtain was decorated with a few small animal stickers to make it more infant-friendly. Moreover, an additional video camera was installed to get a better view of the infants’ behavior during manual choice.We introduced several procedural modifications based on advice from Kiley Hamlin and her team. First, background music was played softly throughout the experiment. Second, a “curtain familiarization” was added to make infants comfortable with the operation of the stage curtain. Third, the manual choice procedure was revised using a detailed script provided by Kiley Hamlin .Familiarization: After the box familiarization (ran as in Study 1), E3 familiarized infants with the curtain’s movements by raising it and lowering it two times. While raising the curtain, E3 shook a toy containing a small bell and said: “The curtain is going up.” While lowering the curtain she said: “The curtain is going down.” At the end of familiarization, E3 disappeared behind the stage and the habituation procedure started.Habituation phase: The procedure matched to that of Study 1, except that E1 signaled the end of each habituation trial and of the entire habituation phase with a visual signal instead of whispering vocal commands.Manual choice: The procedure for this phase was thoroughly revised based on detailed instructions and video examples provided by Kiley Hamlin. The test started by E3 coming out from behind the curtain, holding the puppets behind her back. She asked the caregiver to turn their chair to face her (a rotation of about 30 degrees to the caregiver’s left). Moreover, E3 checked that the infant was appropriately positioned, and if necessary she asked the caregiver to make corrections. The caregiver had to place the infant close to her knees and to hold her at the level of her chest so that the infant would sit straight and would be able to move her arms without leaning on his/her parent’s body. Instructions about how to position the infant during test were given before the experiment to reduce the delay between the end of habituation and the manual choice test. Once the infant was appropriately positioned, E3 kneeled down at about 1 meter in front of him/her. She said “Hi [name of the baby]”, and established eye contact with the infant. Once this was achieved, E3 pulled the puppets from behind her back and said, “Look!” She held the puppets by their back so that her hands were not visible to the infant during choice. E3 placed both puppets at equidistance from the infants, at their eye level and out of their reach. At this point, E3 waited for the infant to glance at each puppet. If after about 3 seconds the participant looked only at one puppet or at her face, E3 gently shook both puppets simultaneously to attract infant’s attention to them. Once the infant had glanced at each puppet, E3 stopped shaking the puppets. E3 then attracted the infant’s attention to herself by moving her head slightly forward, saying “Hi,” and pulling the puppets about 10 cm back. E3 re-established eye contact with the participant, and said: “Who do you like?” She then positioned the puppets for the choice, moving them within the infant’s reach by extending her arms. While moving the puppets towards the child, E3 stopped making eye contact and moved her gaze towards the infant’s chest. Puppets were held about 50 cm apart from each others.For a contact between the infant and a puppet to count as a choice, the infant had first to look at one puppet, and then reach for this puppet while still looking at it. Thus, touching one or both puppets without looking at them did not count as a choice. Conversely, if infants looked at one puppet and then reached for both while continuing to look at the same puppet, this counted as a choice. If infants did not make a choice within 60 seconds, E3 pulled back the puppets. She then repeated the choice procedure from the moment she pulled the puppets from behind her back. Infants who produced no choice after 60 additional seconds during this second attempt were coded as making no choice. The choice was independently coded offline by E1, E2, and by a third coder blind to the identity of the puppets. The inter-coder agreement was 100%.The variables counterbalanced in Study 2 were the same as in Study 1.SD = 2.69). During the manual choice test, infants did not significantly prefer the Helper over the Hinderer . Similarly, infants displayed no tendency to prefer the black over the orange puppet . Infants showed a marginally significant tendency to select the puppet located on their right side during test .Infants habituated in an average of 9.00 trials  for an expert opinion on what distinguished the original paradigm from our replications. She noted that in her hindering events the protagonist jumped off the box about one second after the slamming action, paused on the ground, and later put its head down  noted that the impression that the Helper is doing all the work in pulling up the lid (while the Protagonist remains passively holding onto it) is weaker in our studies than in the original one. This may be due to the fact that the lid of the boxes was smaller in our replications than in the original study, resulting in a shorter trajectory of the Protagonist when the box was successfully opened.Despite our best efforts, we cannot discount the possibility that infants’ performance might have been affected by any of the factors highlighted above, or that our replications may have omitted further crucial methodological details. Importantly, however, none of the above-reported differences between our replication attempts and the original study have been recognized as necessary to infants’ success in the paradigm used by Hamlin and Wynn . If thisAlternatively, we may have found non-significant results not because of minute methodological factors, but because the size of the effect driving infants’ preferences is smaller than what we anticipated. In the study of Hamlin and Wynn , 12 out S1 Appendix(DOCX)Click here for additional data file.S1 Movie(MOV)Click here for additional data file.S2 Movie(MOV)Click here for additional data file.


Additionally, the inflammatory cytokines mediate a negative feedback regulation on themselves. Collectively, these regulations may increase the proinflammatory cytokines while decreasing the anti-inflammatory cytokines. This may further activate NF-κB and increase the proinflammation cytokines, which in turn reduce the inflammatory responses, contributing to various diseases.Sustained stress triggers series of changes in the brain and the body. At the early stage of stress, the activated hypothalamus-pituitary-adrenal (HPA) axis and sympathetic nervous system (SNS) axis can upregulate the levels of glucocorticoid (GCs) and catecholamines (CAs), respectively, and then they in turn inhibit the secretion of proinflammatory cytokines directly or indirectly while promoting the secretion of anti-inflammatory cytokines. At the prolonged stage, the sustained activated HPA demonstrates cortisol-resistance. At the same time, the inflammation related transcription pathway, such as nuclear-factor kappa-B (NF- Chronic stress leads to various diseases, mainly through the activation of hypothalamus-pituitary-adrenal (HPA) axis and sympathetic nervous system (SNS) axis, with upregulation of glucocorticoid (GCs) (cortisol in human) and catecholamines (CAs) , respectively. These secreted molecules then function through separate receptors on different types of cells, including both the nerve cells and immune cells –9. In adInterestingly, inflammation is a key pathogenic mechanism in many diseases –16. IndeChronic stress exerts the effects on paraventricular nucleus (PVN) and locus coeruleus-noradrenaline center (LC-NA) of hypothalamus as well as brain stem. In response, the hypothalamus secretes corticotropin-releasing factor (CRF) and arginine vasopressin (AVP), which activate the HPA axis and ultimately upregulate GCs from the adrenal cortex. At the same time, the activated locus coeruleus-secreted-noradrenaline can further promote sympathetic-adrenal-medullary (SAM) axis and thereby provoke the release of catecholamines  from the adrenal medulla to the brain and peripheral blood.α-AR and β-AR) on the surfaces or in the cytoplasm of immune cells; monocytes and neutrophils are mainly included, which in turn inhibit the secretion of the proinflammatory cytokines, such as IL-1β, IL-6, TNF-α, and INF-γ, while promoting the secretion of the anti-inflammatory cytokines, such as IL-4, IL-10, and IL-13 [κB), activator-protein 1 (AP-1), JAK-STAT factors, mitogen-activated protein kinases (MAPKs), signal transducer and activator of transcription 3 (STAT3), and other pathways [β, IL-6, and TNF-α [GCs and CAs, respectively, act on glucocorticoid receptors (GR) and adrenergic receptors . However, several studies recently indicated that glucocorticoid promotes the secretion of IL-1β, IL-6, and TNF-α, but they did not rule out other potential signaling pathways downstream of GR activation, which are involved in the inflammatory process [In summary, GCs and CAs inhibit the proinflammatory cytokines , 24, whichildren . At the  process . In addi process , 10, supα, INF-γ, EGF, VEGF, TGF-α, and so forth, while other cytokines are less involved. This might be because there are few cytokines at high circulating levels in vivo, compared to other stress hormones, especially in asymptomatic individuals. For example, IL-6, whose circulating levels are often higher than those of other cytokines in asymptomatic individuals, is only reliably detectable using high-sensitive assay kits [There are fewer studies about chronic stress impacting on the cytokines compared with the studies about that on chronic hormones, especially that the cytokines involved are relatively limited, including IL-1, IL-2, IL-6, TNF-say kits .γ during the chronic stress, compared with the control groups. Although a variety of paradigms are adopted, conclusions are quite consistent [At present, the research about that has included caregiver stress, job stress and burnout, low socioeconomic status (SES), childhood adversity and life event, lack of social support, loneliness, and so forth. These researches have demonstrated that chronic stress increases the proinflammatory cytokine , 27–32. nsistent .Hence, it is obvious that there is a conflict between the mechanism of chronic stress acting on inflammatory cytokines and the outcomes observed in quite a few studies. These inconsistencies are suggested to be results of the type, duration and intensity of stressors, detection methods, and individual differences , 33.Hans Selye described the “general adaptation syndrome,” activated by an organism in order to overcome various challenges , 35. AltWhether the chronic stress evoke nonspecific responses or not is not further discussed here, but a basic fact, based on the present studies, is that the proinflammatory cytokines have been observed a consistent increase in many chronic stress studies; for this reason, we believe that identical reactions to a certain extent can be activated by different stressors. Accordingly, excluding the individual differences, what mainly cause the inconsistencies in these studies? Does chronic stress upregulate or downregulate the proinflammatory cytokines? We consider that the prolonged stress can be divided into serial stages, and in each stage the inflammatory cytokines are influenced in different ways. We will mainly discuss this problem in the following.At the early stage, chronic stress downregulate the proinflammatory cytokines while upregulating the anti-inflammatory cytokines (see above the mechanism in detail).β, IL-6, TNF-α, et cetera, secretion declines [β antagonizing the action of GRα [κB), induced by glucocorticoid stimulation to block the NF-κB activation, is diminished with the blunted HPA axis and glucocorticoid-resistance. Accordingly, the inflammation related pathways are activated, and they in turn activate the genes responsible for proinflammatory cytokine production [Sustained stress may lead to HPA axis “fatigue,” that is, the response of HPA axis to sustained stress can be blunted . Meanwhideclines , 44, 45.declines , such asdeclines , GRβ antn of GRα , and phon of GRα . Besidesn of GRα . So whatoduction , 18. Addoduction , 49–52. oduction .κB on cytokines cause the proinflammatory cytokines to increase further, which to a certain level induce inflammatory response. In addition, IL-1β, IL-6, TNF-α, and other cytokines in turn activate NF-κB, in which the mechanism includes the proinflammatory cytokines leading to phosphorylation and loss of I-κB [κB/AP-1 activation [The second stage is followed by the next stage, unless the sustained stress exposure is removed. The lasting impacts of HPA axis “fatigue,” glucocorticoid-resistance, and activated NF- of I-κB , oxidatitivation . All theIn these current days, the second and the third stage in our presentation, to some extent, equal the “low-grade inflammation” in some research. This “low-grade inflammation” is not the acute inflammation accompanies acute inflammation symptom, such as fever, swelling, and acute infection, but a systematic low-grade inflammation with a longer term phenomenon and an increase in the circulating levels of inflammatory markers, and this state is more sensitive and susceptible to acute stress and other stimuli [We consider that there are three serial stages in the chronic stress, based on all the above (the contradiction between the mechanism of chronic stress impacting on cytokines and the outcomes observed in the current human studies ).At the  stimuli , 57.Increasing amounts of data suggest that inflammatory responses have an important role in the pathophysiology of a variety of diseases, including depression, diabetes, cardiovascular disease, and cancer.κB is activated by kinds of pathways  to boost the proinflammatory mediators secretion, including proinflammatory cytokines , chemokines, CAM, and APP [Inflammation is characterized by a cellular response whereby the proinflammatory cytokines of the innate immune response promote the expression and release of chemokines and cellular adhesion molecules (CAM) in the local environment. And inflammatory response related immune cells include macrophages, neutrophils, and NK cells, as well as the activated T-helper and T-cytotoxic cells, which are recruited by the proinflammatory mediators to the inflammation region. The proinflammatory mediators also enter the peripheral circulation and promote the liver cells to produce acute-phase reactive proteins , and activate the HPA axis, interact with the neural transmitters, and induce behavioral changes: the “sickness behavior” . And all the above reactions subserve the metabolic demand of inflammation , 31, 58.α-induced depressive symptom, and IFN-α is the inducer of IL-6, TNF-α, and IL-1β [The proinflammatory cytokines in the peripheral blood go through the weak region of blood-brain barrier or by their specific transport proteins on the brain endothelial cells (the circumventricular organs) or transmit the signals to the specific regions of the brain by the vagus nerve fibers . In the nd IL-1β .α, and IL-1β has been observed in people with diabetes [α or inhibiting its receptor induces the increased sensitivity of insulin [α, could induce insulin-8 resistance [κB pathway and several relevant serine/threonine kinases, such as c-Jun N-terminal kinase (JNK) and inhibitor of NF-κB (IKK) [κB, or damaged by inducible nitric oxide synthase (iNOS), which is stimulated by the proinflammatory cytokines [Diabetes is considered as a kind of inflammatory and metabolic diseases, so the overproduction of IL-6, TNF-diabetes , 63. The insulin . Recent sistance , 64. TheκB (IKK) . In factκB (IKK) . Additioytokines .β, IL-6, TNF-α, and IFN-γ [κB induces cardiac hypertrophy [Cardiovascular diseases, including atherosclerotic heart disease, coronary heart disease (CHD), congestive heart-failure (CHF), and other cardiovascular diseases, have been associated with elevated levels of IL-1nd IFN-γ –69. Thesertrophy , 69.κB promotes osteoclast activity and bone reabsorption [κB, have been implicated in the neoplastic process, for they play a role in the tumor cells growth and proliferation as well as in resistance to chemotherapeutic agents [α, and IL-1β, and other proinflammatory cytokines are overexpressed in variety of age-related diseases and are positively associated with age. Research suggests that the elevated IL-6 levels lead to high mortality in the elderly [Additionally, inflammatory processes are well known to contribute to the onset and progression of immune diseases, including allergic diseases, autoimmune diseases, and infections; there has been increasing data suggesting that inflammatory responses take a role in other diseases. For instance, they may induce osteoporosis. The proinflammatory cytokines can block the vitamin D receptors to disturb the role of vitamin D in the bone formation, and meanwhile, the activated NF-sorption . Besidesc agents . Finally elderly . Additio elderly .κB activation, and the negative feedback, which in turn promote the proinflammatory cytokines; in the third stage, the continued stress further increases the proinflammatory cytokines and ultimately cause inflammation, which may induce various diseases.In conclusion, there is a serial of changes in the proinflammatory cytokines under the sustained stress. At the early stage, chronic stress activates the HPA axis, SAM axis, and the vagus fiber, which in turn secrete GCs, CAs, and Ach to disturb the inflammatory cytokines in their homeostasis and downregulate the proinflammatory cytokines while upregulating the anti-inflammatory cytokines; in the second stage, the lasting stress exposure induce HPA “fatigue,” glucocorticoid-resistance, NF-