Synovial cyst of the hip joint is a rare clinical condition in need of evidence-based guidelines for its diagnosis and management. Normally, synovial cyst of the hip joint requires no treatment, but when it intrudes into surrounding structures, various clinical symptoms appear. Because of its rarity, a symptomatic synovial cyst is often confounded with a tumor as a space-occupying lesion or with other diseases, depending on its various clinical presentations. Therefore, guidelines for the precise diagnosis and appropriate management for synovial cyst of the hip joint are required.We retrospectively studied 7 cases of symptomatic synovial cyst of the hip joint, some of which showed lower limb edema due to mass effect. We compared physical exam findings on presentation, imaging findings, and size and location of the cyst.All cases were managed successfully with surgical excision. We found that, instead of the size of the cyst, the location of the cyst was an important contributor to venous compression. The recurrence rate was 0%, and some patients have significantly long follow-up of 2 years, 4 years, 6 years and 10 years, respectively.For symptomatic synovial cyst of the hip joint, surgical excision can successfully resolve the symptoms without recurrence. This retrospective study discusses the clinical presentations, diagnostic approaches, and surgical treatment of symptomatic synovial cyst of the hip joint, hence shedding more light on the clinical management of this condition. Synovial cysts are common in joints such as the knee, ankle, hand, and wrist, but uncommon in the hip joint. Histologically, a synovial cyst is an extension of the joint capsule with a lining of synovial cells, and it often communicates with the adjacent joint. The cyst contains viscous, gelatinous fluid due to the presence of hyaluronic acid and other mucopolysaccharides. Most of the synovial cysts originating from the hip joint are asymptomatic, and sometimes are incidentally found by imaging or clinical inspection . When a We reviewed 7 cases of synovial cysts of the hip joint, which we had diagnosed from January 2000 to April 2018. These cases most commonly presented as a mass of unknown cause in the inguinal area. Some patients also showed lower limb edema in the affected side. We compared physical exam findings on presentation, imaging findings, and size and location of cyst. For all patients, no tenderness of the gastrocnemius muscle was detected, and peripheral lower extremity pulses were equal and normal bilaterally . Imaging findings were also similar in all patients. Duplex ultrasonography, conducted in all patients, did not recognize any arteriostenosis or venous embolism. Computed tomography (CT), conducted in patient NO.1–5 and 7, showed a cystic lesion around the acetabular level without enhancement  showed edema of the lower limb due to compression of the common femoral artery by the synovial cyst, proven by both imaging techniques and observations during the surgery. Typically, these cases had many more adhesions encircling the synovial cyst and the common femoral vein. In case 1, part of the cystic wall was not resected because it could not be separated from the femoral vein. On the other hand, when edema was not present, there were no obvious adhesions, and the synovial cyst could be easily dissociated by blunt dissection. It is difficult to correlate the size of the cyst to the degree of venous compression, but the location of the cyst shows to be an important contributor to venous compression. As shown in Table The follow-up of all cases was uneventful, and no recurrence appeared at 2 months post-surgery, some of these patients have significantly longer follow-up of 2 years, 4 years, 6 years and 10 years, respectively.In all 7 cases of symptomatic synovial cyst in our retrospective study, surgical excision showed a favorable short-term or long-term prognosis. Symptoms, which were inguinal masses with or without edema in our study, were completely relieved within one week post-surgery, and the recurrence rate was zero.Lower limb edema caused by synovial cyst of the hip joint is a rare occurrence. To date, there are less than 40 reported cases in the literature . MelamedIn addition to edema, synovial cyst of the hip joint can cause other problems including peripheral nerve compression, or even urinary symptoms , 6. NervIn some cases, the symptomatic synovial cysts merely manifested as an inguinal mass, or pain and swelling in the inguinal area, as in cases 5 and 6 in our study, where the cysts grew superficially.Although synovial cyst of the hip joint is a clinical rarity, advances in imaging technology make diagnosis more effective and less invasive. Ultrasound is a useful tool in evaluating the degree of venous stenosis and ruling out deep vein thrombosis as a common cause of lower limb edema. On ultrasound, a synovial cyst should appear as a hypoechoic lesion near the hip joint. Radiography can help to recognize hip disorders like osteoarthritis and rheumatoid arthritis. Duplex ultrasound can exclude femoral aneurysm as a possible reason for venous compression. Contrast-enhanced CT can show characteristic rim enhancement of the cyst. MRI, a superior imaging technique for its high resolution of soft tissue, can demonstrate the exact location and extent of the cystic lesion.Multiple treatment options are available for synovial cyst of the hip joint, depending on the size of the cyst, the severity of symptoms, the primary disease or the comorbidities, and the severity of the local compression. Asymptomatic cysts should be under regular observation, and treatment for the primary disease is the priority. Studies show that if the primary disease is rheumatoid arthritis, treatment for RA reduces the size of the cyst , 14. ForOur retrospective study shows that for symptomatic synovial cyst of the hip joint, surgical excision could successfully resolve the symptoms and no recurrence appeared at 2 months post-surgery of all cases, some of the patients had significantly longer follow-up of several years. We found that, instead of the size of the cyst, the location of the cyst was an important contributor to venous compression. Until more evidence is collected to generate a comprehensive management plan, surgical excision remains a well-established and well-accepted treatment for synovial cysts originating from the hip joint. Due to the small sample size, our conclusions are preliminary, and more evidence are required to establish a guideline for the diagnosis and treatment for synovial cyst of the hip joint.


However, there has been no study to date that quantifies how many flares have been observed by combinations of various instruments. Here we describe a technique that retrospectively searches archival databases for flares jointly observed by the Ramaty High Energy Solar Spectroscopic Imager (RHESSI), Solar Dynamics Observatory (SDO)/EUV Variability Experiment (EVE – Multiple EUV Grating Spectrograph (MEGS)-A and -B, Hinode/, and Interface Region Imaging Spectrograph (IRIS). Out of the 6953 flares of GOES magnitude C1 or greater that we consider over the 6.5 years after the launch of SDO, 40 have been observed by 6 or more instruments simultaneously. Using each instrument’s individual rate of success in observing flares, we show that the numbers of flares co-observed by 3 or more instruments are higher than the number expected under the assumption that the instruments operated independently of one another. In particular, the number of flares observed by larger numbers of instruments is much higher than expected. Our study illustrates that these missions often acted in cooperation, or at least had aligned goals. We also provide details on an interactive widget (Solar Flare Finder), now available in SSWIDL, which allows a user to search for flaring events that have been observed by a chosen set of instruments. This provides access to a broader range of events in order to answer specific science questions. The difficulty in scheduling coordinated observations for solar-flare research is discussed with respect to instruments projected to begin operations during Solar Cycle 25, such as the Daniel K. Inouye Solar Telescope, Solar Orbiter, and Parker Solar Probe.The current fleet of space-based solar observatories offers us a wealth of opportunities to study solar flares over a range of wavelengths. Significant advances in our understanding of flare physics often come from coordinated observations between multiple instruments. Consequently, considerable efforts have been, and continue to be, made to coordinate observations among instruments ( The study of supernovae, for example, is facilitated by the availability of both light-curves (to understand the evolution) and spectra (to understand the composition and dynamics). The Ramaty High Energy Solar Spectroscopic Imager  event list provided by NOAA/SWPC. This defines a solar flare as a continuous increase in the one-minute averaged X-ray flux in the long-wavelength channel (1 – 8 Å) of the GOES X-ray Sensor  flux for events The SDO spacecraft is in a geosynchronous orbit allowing it to observe the full disk of the Sun continuously without interruption . For simplicity, it was assumed that both AIA and the entclass1pt{minimaHinode spacecraft  to 16 MK (Fe xxiv). It has a mirror that is tiltable in the solar EIS is a two-channel, normal-incidence EUV spectrometer. Its two channels cover the wavelength ranges 170 – 210 Å and 250 – 290 Å, selected to cover coronal emission lines with formation temperatures ranging from 8000 K  unsurprisingly were able to capture more than half of the total flares considered. The remaining instruments – which have either limited duty cycles and/or limited fields of view – were only able to capture around 20% or less of all flares during Solar Cycle 24. Similarly, the number of flares and their percentages that were observed by different combinations of instruments are listed in Table any of the seven instruments considered. Based on the search criteria defined in Section et al., i.e. the most common combinations are on the left and decrease towards the right), while the bottom panel shows the same information only now ordered by increasing number of instruments . In each plot, the total number of flares observed by each instrument are given by the horizontal black bars in the bottom-left corner. The dots connected by lines at the bottom of each figure denote the combinations of instruments considered, while the histograms above give the number of events corresponding to a given combination. The most common combination of flare datasets was RHESSI+MEGS-A+Hinode/XRT (930 flares), due to their large fields of view and high duty cycles as mentioned above. The findings of how many solar flares were observed by different combinations of instruments are displayed in Figures expect to see with each instrument, given their different science goals and operational constraints. Table random location within the area of consideration . It is difficult to give a good estimate of how many flares one would A very crude estimate of the “expected” success rate [mentclass2pt{minimmentclass2pt{minimThe measured success rates of each individual instrument in Table entclass1pt{minimaFigure i.e. the measured co-observation rate is close to that expected by chance. A scatter plot showing the expected mean number of flares out of a possible 934 that were observed [For combinations of four or more instruments, the number of flares actually observed is far larger than that expected randomly Equation . While tHinode/EIS+SOT+XRT and IRIS: a C2.3 flare on 1 February 2014, a C4.6 flare on 3 February 2014, and an M1.5 flare on 4 February 2014. The occurrence of these three events coincided with a Max Millennium Major Flare Watch campaign that ran from 30 January 2014 – 8 February 2014 on NOAA active region 11967.Max Millennium Chief Observers when trying to optimize the scientific return on solar flare datasets. Note that all seven instruments were observing contemporaneously for only 11 months, and in this time 934 events are currently listed as SSW Latest Events; therefore 0.3% of all possible GOES flares were observed with all seven instruments. While this may not seem impressive, the probability of all seven instruments observing a single flare simultaneously by chance is 0.003%. Similarly, for combinations of four, five, or six instruments the number of flares captured is often a factor of ten or more greater than random. This shows that instrument planners are intentionally co-observing the same flare-productive active regions.A statistical analysis of how many solar flares (≥C1) were observed by various combinations of instruments during the 6.5 years after the launch of SDO in Solar Cycle 24 is presented. On average, over the entire 6.5 years, each flare was observed by 2.4 instruments. Out of the 6953 flares considered, only three were observed simultaneously by RHESSI, MEGS-A+B, Max Millennium Program, or joint observing programs such as the Hinode Operations ProgramThe analysis in Section Hinode’s total telemetry since January 2008, thereby limiting its daily duty cycle. This has since been revised up to 23 – 43%Unsurprisingly the instruments with the longest duty cycles and largest fields of view  performed the best individually. Reduced field-of-view instruments that require operations planning, while performing within their expected success rates, still only captured on the order of 20% or less of all flares. The possible reasons for this have already been touched upon, but may also be due to other specific factors. For example, until recently, EIS (which observed 6 – 8% of flares) only received 15% of This study raises a significant question for the solar-physics community: even though we seem to be co-observing flares at rates larger than those expected by chance, is the number of co-observed flares acceptable or not? This is not an easy question to answer. This study presents some analysis regarding the retrospective behavior of the community regarding co-observation of solar flares, but does not comment on what the solar-physics community wants to do, or should do. It seems obvious that increasing the number of co-observed flares is desirable, but there are three factors for the community to consider in relation to this question.e.g. in response to a Max Millennium Major Flare Watch). Other more “quiescent” targets  are much more commonplace and can be observed at almost any time.The first factor is the desire of the community to use limited instrumental resources to study flares compared to other solar features and phenomena. If the community decides that the study of solar flares is relatively more important than the study of other features and phenomena, then their relatively unpredictable occurrence means that a greater fraction of each instrument’s observational resources should be devoted to capturing as much data as possible when a flare-productive region appears  that could take into account solar differential rotation, overplotting it on images from many different instruments. This will enable instrument operators, scientists, and other users to understand how and why particular observations are being planned. We suggest that increased planning transparency will inevitably lead to an increased understanding of how an instrument’s operations create the revealed science priorities of an instrument, as opposed to its stated priorities. From this basis a better understanding of how to coordinate co-observations between instruments can be generated. Finally, it should be noted that co-observation of non-flaring regions is also of considerable scientific value. Co-observations that do not catch a flare are not without merit; much can be learned about the physics of active regions, the chromosphere–corona connection, polarity inversion lines, sunspots, etc., using observations from multiple instruments.Understanding how a solar flare operates is a fundamental challenge to our understanding of the Sun and the conditions of the heliosphere. In the upcoming Solar Cycle 25, the


One critical challenge of exploring flora phenology is on characterizing ecosystem phenological diversity (EPD), and thus how EPD’s performance is influenced by climate changes has also been an open macro-ecological question. To fill these two gaps, we proposed an innovative method for reflecting EPD, by taking the advantage of the often-classified inverse factor of spatial resolution discrepancy between the used remote sensing datasets of vegetation phenological dates (green-up and brown-up) and snow cover phenological dates (SPDs) (onset and end) around the Arctic, and further, we examined the cross response/feedbacks of the two kinds of EPDs to the two categories of SPDs. We found that the circumpolar green-up and brown-up EPDs both were shrinking, driven more by the delaying of the onset SPDs than the advancing of the end SPDs; North America and North Eurasia performed with inconsistent EPD response/feedbacks to the related SPD anomalies; and further, the EPD-SPD response/feedbacks in some locations exhibited the time-lag effect, e.g., the green-up EPDs made the strongest response to the onset SPDs of two years earlier. Overall, the validated method and the new findings are of implications for improving the phenology modules in Earth system models, and the contributions of the present study have enlightening significance for kicking off the new EPD branch in macrosystem phenological ecology. Examining the performance, feature, and evolution of phenological diversity, as an important indicator of biodiversity6, is of extensive significance for understanding of how species, communities, and ecosystems may make response/feedbacks to climate changes7. To characterize this phenological trait, people proposed specific parameters such as phenological synchrony4 or asynchrony5, which are quantified as the consistency or inconsistency between the phenological dates of varying biological functional groups5, respectively. With such parameters used as the indicators, it was discovered that the phenological differences among ecotypes are not related to small genetic differences but simply phenotypic adaptations to different climatic conditions8. People also realized that exploring the rules of phenological diversity offers a major avenue to advance the adaptations for ecotypes like winegrapes in agriculture to severe climate anomalies9. Further, it was noticed that phenological synchrony has some consequences for ecological interactions and biotic population dynamics10, while phenological asynchrony arising from climate warming has the high potential of affecting parasite transmission, with non-linear impacts on disease burden11. These pioneering studies all suggested that investigating phenological diversity is of considerable implications for biology and ecology.Following phenophase12. Their common scheme is to test if multiple species, hypothetically representing a community, can sustain the effect of phenological synchrony or not13. Some evidences from in-situ observations and controlling experiments alluded that maintenance of this synchrony in the context of climate changing is common16, while others demonstrated that the degrees of the changes in synchrony vary between populations18 or, at least, are larger than expected20. This contradiction has triggered a puzzle – whether shifts toward phenological asynchrony are widespread23. In other words, the evidences to date have not drawn a clear picture about how prevalent and large the shifts in phenological synchrony from species, taxonomic groups, to communities have been in response to recent climate changes7. In turn, this has set up almost no ecological theoretical bases for upscaling the phenological diversities of species and communities to infer the global performance of macro-scale ecosystems (macroecosystems), as marked by the gray-colored ‘broken road’ in Fig. However, study on phenological diversity so far is still in its infancy. That is, the limited studies on phenological diversity are yet struggling at the initial phase of stepping forward from species to communities26. In fact, it was also found that snow is another key environmental factor capable of influencing ecosystem functions27. Steltzer et al. earlier noticed that while the timing of snowmelt in spring, at least partially, depends on spring air temperature, snowmelt and temperature often act independently from one another to control the flowering timing28. Iler et al. were also aware that some species seem to be approaching their limits of phenological shifts in response to snowmelt rather than temperature29. Winkler et al. further observed that the near-term, community-wide changes in phenology responding to the variations in snowmelt timing are likely to be contingent on the legacy of past climates on community structures30. These endeavors exposed more ecological roles of snow cover phenology27 on plant seasonal timing, but their inferences were still aimed at community levels . So, the knowledge about the macroecological effect31 of snow cover phenological anomalies on ecosystem phenological diversity (EPD) is still almost void.Another evidence for this ‘infant’ point is that previous considerations of environmental forces on phenological synchrony were primarily restricted to temperature7. One of the reasons of deeming it ‘big’ is that these two levels tend to show complex phenological combinations and interactions22, particularly for the latter ones. This is illustrated by the fact that species-specific climate response within ecological communities proved to be capable of disrupting the synchrony of co-evolved mutualisms, which are generally based on the shared timing of seasonal bio-events24. This kind of disruption effects may become stronger at the ecosystem levels, investigating whose underlying ecological processes, consequently, facilitates bettering Earth system models in simulating global changes32. However, simultaneously collecting the datasets of phenological diversity at the species and macroecosystem scales based on those traditional in-situ phenological observations or small-scale experiment approaches7 is a difficult, actually almost impossible, task in practice. This, substantially, restricts quantitative assessments of EPDs from the beginning, also as the root cause of the last ‘knowledge-void’ problem.As pointed out in Fig. 33 and the global data of snow cover phenological dates (SPDs) (2001–2014)34, together as an alternative strategy for quantitatively characterizing the EPDs (green-up and brown-up) and SPDs (onset and end) over the Northern Hemisphere (>45°N) (NH), to examine: (i) whether the Arctic circumpolar EPDs performed with some trends during the study period, and (ii) whether their developments can be attributed to the interannual SPD variations. Note that the ‘interannual’ here considered the year-long phase from snow cover onset to ecosystem brown up of the next year (OB) as one ‘integral year’ for exploring the response, while ecosystem green up to snow cover end of the next year (GE) for feedbacks. Deriving both EPDs’ and SPDs’ trends and their relationships facilitates handling more mysteries about EPD, which is critical for comprehensive predictions of future shifts in EPD due to climate changes.To address these two disciplinary-foundation gaps, we creatively assumed the newly-published time-series data of plant phenological product (1999–2013)The two histograms of the statistically significant green-up and brown-up EPD trends (1999–2013) over the NH , it could be inferred that the circumpolar green-up EPDs (>45°N) were briefly affected negatively by snow cover onsets in a one-OB-year-delayed way . The responses over the NE worked in the same pattern , whereas the EPDs over the NA dominantly were influenced negatively by snow cover onsets in a within-the-same-OB-year way (DO).The simultaneous statistics of the responses and the delayed responses of the green-up EPDs to the onset SPDs . However, neither the NA nor the NE acted in the same manner. The brown-up EPDs over the NA were relatively more affected negatively by snow cover onsets, and the brown-up EPDs over the NE were more driven positively by snow cover onsets, both in a within-the-same-OB-year way (DO).Figure Rmean, it was concluded that the Arctic circumpolar green-up EPDs (>45°N) dominantly influenced snow cover ends negatively in a within-the-same-GE-year way (DE). The feedbacks over the NA behaved in the same mode (DE), whereas the green-up EPDs over the NE wholly exerted a positive effect on snow cover ends in a one-GE-year-delayed way (DE-D).The synchronous statistics of the feedbacks and the delayed feedbacks of the green-up EPDs to the onset SPDs  primarily made a positive feedback to snow cover onsets in a one-GE-year-delayed way (DO-D). The dominant feedbacks over the NE behaved similarly, but the brown-up EPDs over the NA dominantly interfered with snow cover ends negatively in a within-the-same-GE-year way (DE).Figure The specific parameters relating to all of the above-listed cases, performing with the optimal correlations statistically, are listed in Table Further, the cases with the subscripts ‘-D’ indicate that the time-lag effect existed between EPDs and SPDs in their response/feedbacks. For example, the green-up EPDs showed the strongest response to the onset SPDs of two years earlier in some locations, and this has validated the hypothesis of the time-lag effect existing. The specific situations in details would become more complicated when the scattered spatial distributions of the grids with the best correlations derived were examined Fig. –S7.Overall, the green-up and brown-up EPDs for the NH, NA, and NE were shrinking in a whole sense, and this was triggered more by the delaying of snow cover onsets, instead of the advancing of snow cover ends; the green-up EPDs over the NH, NA, and NE consistently implemented their feedbacks more closely to the end SPDs in the last decade, whereas the brown-up EPDs performed with divergent feedbacks to either of the SPDs; finally, the EPD-SPD response/feedbacks in some cases also exhibited the time-lag effect, e.g., the green-up EPDs showing the strongest response to the onset SPDs of two years earlier.7 of species-level observations for deriving community-level phenologicial knowledge16, this study directly concentrating on macrosystem phenological ecology by innovatively using the derivations from different remote sensing data34 is relatively rare, particularly accounting for snow cover phenology27 as another essential climate force30. Those macroecological findings can help to fill the gap  tend to simultaneously cover massive regions27, while ecosystem green-up (brown-up) dates48 are distinctive for different communities and species at finer scales7. The 0.5° spatial resolution of the snow dataset34 can reflect the trait of SPDs in the former scenario, while the 4 km (~0.0357°) resolution of the plant phenological date product33 can mirror the feature of flora phenological dates in the latter one. Given that one grid in the SPD data34 corresponds to ~14 × 14 grids in the EPD-source data33, the EPD characterization was operated by unifying the resolution of the EPD-source data to the SPD data, with each grid of the derived EPD data defined as the standard deviation of phenological dates within its corresponding 14 × 14 grids, analogous to the definition of phenological synchrony4 and asynchrony5. Then, their linear correlations with the effect of characterizing the EPD-SPD response/feedbacks were examined, in the within-the-same-OB-year, one-OB-year-delayed, within-the-same-GE-year, and one-GE-year-delayed manner, respectively. This innovative remote sensing-based solution strategy is theoretically reasonable, with the high potentials of handling the problem of EPD data shortage that lead to the ‘big challenges’ targeted in this study.The rationale of operating this study was directly using the remote sensing-derived datasets in macrosystems ecology33. Specifically, based on the SPOT VGT data, Gonsamo and Chen derived the first set of phenology index-based plant dynamics product, comprising green-up and brown-up phenological dates, for the NH during 1999–201333. With the factors like snow27 possibly influencing the derivation of the phenological dates considered, the spatial resolution of the product was unified into 4 × 4 km (0.03571428 × 0.03571428°). The validation based on the data from the flux tower sites of deciduous broadleaf forests, evergreen needle-leaf forests, mixed forests, and wetlands over the NA and NE suggested good agreements between the phenological dates from this Arctic circumpolar vegetation dynamics data and the reliable estimates from CO2 flux measurements. The validation proved that the circumpolar vegetation dynamics product is an improvement over the operational global MODIS Combined Land Cover Dynamics MCD12Q2 product for the Arctic circumpolar region33. For derivation of the EPDs required in this study, the standard deviations of the phenological start and end dates for the matrix of 14 × 14 grids33 corresponding to any grid in the SPD dataset34 were calculated 32. Specifically, the correlation degrees between the derived EPDs (green-up and brown-up) and SPDs (onset and end) were explored, and further, the explorations were extended to consider the effects of delayed response/feedbacks. To characterize this time-lag effect, the year-long period briefly from snow cover onset to brown-up of the next year as one ‘effective’ OB year was defined for investigating the effect of response, and the year-long period briefly from green-up to snow cover end of the next year as one ‘effective’ GE year was defined for probing the feedback effect. The correlations between the EPDs and SPDs both from the same OB year were classified as exploring the response in the within-the-same-OB-year way, and the correlations between the EPDs and the SPDs from the earlier OB year as investigating the response in the one-OB-year-delayed way; the correlations between the EPDs and SPDs both from the same GE year as examining the feedbacks in the within-the-same-GE-year way, and the correlations between the EPDs and the SPDs from the later GE year as probing the potential feedbacks in the one-GE-year-delayed way. The latter scenarios in these response/feedback explorations could reflect the time-lag effect. Since the checking of the time-lag effect was operated onto two explicit time series of the used datasets, the autocorrelation phenomenon often met in exploring the relationships between the time series of multiple kinds of features27 could be neglected here. Note that in subject to the short term of the assumed EPD and SPD data, only the effect of one year delaying was taken into account. Correspondingly, all of the partial correlation analyses were implemented at the significance level of p < 0.1 (indicated by *) in order to extract more grids with distinguishable response/feedbacks.This study used partial-correlation analysis to probe the response/feedback effects of the green-up and brown-up EPDs to the onset and end SPDs around the Arctic. This approach can exclude the confounding effect of other climate variables  and the covariate effect between snow cover onsets and endsSupplementary information


The electric resistivity strongly depends on film thickness, which suggests that electric resistivity is a function of electric field strength. The critical electric field for polyimide and biopolyimide films are determined to be 5.8 × 107 V/m and 3.2 × 107 V/m, respectively. Humidity was found to strongly affect the electric resistivity; ~1016 Ωcm at 34% RH and ~1013 Ωcm at 60% RH for both polyimide and biopolyimide films.Biopolyimides poly(ATA-CBDA), made from of 4,4′-diamino-α-truxillic acid dimethyl ester (ATA) and 1,2,3,4-cyclobutanetetracarboxylic dianhydride (CBDA), is synthesized and measured its electric volume resistivity at various experimental conditions. The effects of film size, thickness, drying time, and the electric field strength on electric resistivity are investigated and compared with polyimide (Kapton). The electric resistivity for all polyimide and biopolyimide are distributed in the range of 10 In particular, polyethylene (PE), cross-linked PE, and polyvinyl chloride (PVC) are widely used because they are good insulators for electrical wires and are able to endure high electric voltages. Over the last few years, the development of new polymers with high electrical insulation is very active due to requirements such as super high electric voltages, weight saving of electric devices, etc. Needless to say, polymers obtained from bioresources are far more preferable as materials that have high electrical insulation in the next generation. Since the last decade, biobased polymers are widely investigated and are produced in the materials currency. For example, poly(lactic acid)s (PLA), cellulose, and poly(buthylene succinate) (PBS) are famous biopolymers, and their composites, copolymers, and polymer blends have been extensively developed in recent years [Soft polymer material is widely used as a material with electrical insulation properties. In general, the electric resistivity for polymers distributes in the range of 10nt years ,5,6,7,8.co-DHCA) with good mechanical properties [Polyimide is a typical example of an engineering plastic that shows good thermal properties, with a glass transition temperature exceeding 300 °C and a high electrical insulation with a breakdown electric field strength of 400 kV/mm, and it is widely used in electronic industries, e.g., flexible printed electric circuits, flexible substrates for a chip of a semiconductor, and a coating material for electric motors ,10,11,12operties . In addioperties . It is woperties , and it 13 Ωcm–1019 Ωcm [Another purpose of this study is to investigate the volume resistivity measurement for polymer films that are small in size. There are some international standards on the electric resistivity measurement for polymers, for example ASTM international  and IEC , etc. ,16. Acco1019 Ωcm ,21,22. WN,N-dimethylacetamide  under a nitrogen atmosphere. Tetracarboxylic dianhydrides such as 1,2,3,4-cyclobutanetetracarboxylic dianhydride  was added into the ATA solution. The reaction mixture was vigorously stirred at room temperature to produce a pale yellow solution and was further stirred for 48 h in order to yield a viscous poly(amic acid) (PAA) solution. The PAA solution was diluted in DMAc and added dropwise into ethanol in order to precipitate PAA fibrils, which were then collected by filtration, thoroughly washed with water, and dried in a vacuum oven for 12 h. For control of the thickness of the polyimide films, a concentration of PAA should be adjusted in this dilution step. The PAA film was obtained by casting a DMAc yellow solution onto a silicon wafer and heating at 60−70 °C. Thermal imidization of the PAA film was carried out by being kept in an oven under a vacuum and stepwise heated at 100, 150, 200, and 250 °C for 1 h at each step. After imidization, a pale yellow poly(ATA-CBDA) film was obtained with a quantitative yield. The detailed information for synthesis of biopolyimides, 1H NMR spectrum, and FT-IR spectrum were shown in A typical synthetic procedure for biopolyimides, poly(ATA-CBDA), is as follows . 4,4′-di® and biopolyimide films was carried out at room temperature using a super megohmmeter (HIOKI DSM-8104) with a resolution of 0.1 fA. A commercial electrode system (HIOKI SME 8311) with an electromagnetic shield was used as an electrode to measure the volume resistance for thickness dependence, electric field dependence, and the drying effect experiment. For the size dependence experiment, a laboratory-made cell with electrodes made of brass (ρv (Ωcm) was calculated by ρv = (S/t)Rm, where S is the area of the electrode, t is the thickness of the film, and Rm is the measured value of the electric resistance. The time evolution of the electric resistivity of the films was measured. All films were dried in a vacuum oven at 100 °C for at least 3 h before the electric resistivity measurement was conducted.The electric resistivity of polyimide distributed as Kaptonof brass  was used−1 using electrodes with a diameter of 20 mm; the maximum current limit was set as 10 mA.The dielectric breakdown electric voltage for the poly(ATA-CBDA) films without any drying treatment was measured using an electrical safety analyzer (SE7430 Keisoku Giken) at room temperature. A DC electrical voltage of up to 6 kV was applied along the thickness using the two terminal methods with a ramp-up time of 120 s at a rate of 1 kV s15–1017 Ωcm. These values were higher than the values in the literature, which was 1013 Ωcm [15~1016 Ωcm [10~1012 Ωcm [11 Ωcm [19 Ω cm, with a thickness of 50 μm [−6 Torr. The main reason for the variation of resistivity is probably due to the humidity and the water content in the polyimides.1013 Ωcm , 1015~101016 Ωcm , 1010~101012 Ωcm , or 1011 [11 Ωcm . It is n [11 Ωcm ,21,22. H15 Ωcm, which was slightly lower than that for the other films. However, the electric resistivity for films larger than 20 mm square was, almost independently of the film size, was approximately 1016 Ω cm. This value was one order of magnitude lower than the published value by Dupont [y Dupont . The ele7 V/m and 3.2 × 107 V/m, respectively, which suggested that the mobile ions in biopolyimide are easier to move in the film in comparison to that in polyimide. No clear change was found in the IR spectra for biopolyimide films before or after irradiation from a high electric field.The electric field strength can be varied by varying the thickness at constant electric voltage or by varying the electric voltage at a constant thickness. 15 Ωcm) at short drying times, below three hours, and the resistivity increased to 1016 Ωcm at longer drying times. This strongly indicates that polyimide and biopolyimide films stored in humidity of 30%–50% absorbed water, and the absorbed water lowers the electric resistivity. In fact, the electric resistivity for polyimide films without drying was significantly reduced to ~1013 Ωcm when the humidity was 60% RH.The electric breakdown electric voltage for polyimide 12 μm and biopolyimide 15 μm films was 3.8 kV and 4.0 kV, respectively, which corresponded to the critical electric field for the dielectric breakdown of 316 MV/m and 266 MV/m, respectively. It was clear that biopolyimide, obtained from biomass, as well as polyimide films synthesized from fossil resources, demonstrate high electrical insulation. The impact of the film sizes, thicknesses, and drying time on the breakdown voltage will be reported in a subsequent paper.The electrical insulation property, volume resistivity, and dielectric breakdown electric field, for poly(ATA-CBDA) films obtained from bioresources, was presented. It was clear that the electric resistivity of poly(ATA-CBDA) films showed high electrical insulation properties as well as synthetic polyimide. The electric resistivity measurement exhibited two futures: That a sample larger than 20 mm square is better to determine the volume resistivity and the electric resistivity decreased with the thickness or with increasing the applied electric voltage due to strong electric field strength. The volume resistivity for polyimide and biopolyimide strongly depended on the drying time, suggesting that the resistivity is dominated by the water content absorbed in the films. As mentioned in the Introduction, the poly(ATA-CBDA) film was more transparent than conventional polyimide. We believe that the biopolyimide film with high insulation properties can be used in electronic devices instead of polyimide, which is synthesized from fossil resources.


Preterm birth is a syndrome with many causes . The ratPerinatal mortality, neonatal mortality, and neonatal and long-term morbidity are inversely associated with gestational age at birth. Frequent neonatal complications include periventricular leukomalacia, necrotizing enterocolitis, respiratory distress syndrome, jaundice and kernicterus, neonatal infections, and prolonged hospitalization. Since the quality of neonatal care additionally affects the outcome, there is a vicious circle of poor perinatal and neonatal healthcare with long-term consequences for the economy in all societies, but mainly within poor countries or within subgroups of low socioeconomic status of higher income countries. A history of preterm birth is the most dominant risk factor; however, most determinants from the maternal history such as smoking, nutritional depletion, short interpregnancy interval, or advanced maternal age are only weakly associated with PTB. Meanwhile, transvaginal sonography of the cervix is used as a screening tool to indicate precocious cervical ripening by using centile values of the cervical length.Iatrogenic preterm birth as caused by fetal growth restriction and/or preeclampsia has to be differentiated from spontaneous onset of preterm birth. The purpose of the present special issue is to highlight specific aspects of PTB.In a first review article, B. Staude et al. investigated the pathophysiologic background that correlates altered microbiome to neonatal complications, including retinopathy, necrotizing enterocolitis, disrupted psychomotor development, and autonomic regulation. The authors report that breast milk is of detrimental importance during early human development as the maternal microbes that are excreted from the mammary gland and absorbed by direct contact of the skin surrounding the areola support the neonate to establish a rich diverse microbiome. The authors conclude that this is an ongoing field of research. Respiratory distress syndrome (RDS) is a predominant complication of prematurity. Its prevalence remains high in preterm neonates, despite the institution of tocolytics, corticosteroids, and surfactant in current clinical practice. In the present article A. Niesluchowska-Hoxha et al. investigated the impact of several risk factors on the rate of RDS by multivariable analysis . Their fResearch in gestational diabetes (GDM) has proven the emerging role of adipokines in high risk pregnancies . In theiκB (NF-κB) has been implicated in the pathogenesis of PTB as a mediator. Downstream regulatory element antagonist modulator (DREAM) is a regulator of the NF-κB in nongestational tissues. P. Goradia et al. investigated DREAM expression in primary myometrial and amnion cells and observed that DREAM mRNA expression is increased and that, in myometrial and amnion cells, DREAM regulates proinflammatory and prelabour mediators. The authors conclude that DREAM is a promising factor that may be used in the future in the diagnosis and management of preterm labour.Inflammation is a significant determinant of PTB. The nuclear factor-In vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) have also been associated with an increased risk of PTB. N. Jancar et al. investigate this correlation in a large population sample that included 267 718 women from Slovenia. They observed that IVF-ICSI nearly tripled the risk of early PTB (OR 2.8) and doubled the risk of late PTB (OR 1.7). Given this information, the authors suggested that women undergoing IVF-ICSI should be closely followed during pregnancy to allow early identification and management of cases at risk.Next to cervical length the detection of the uterocervical angle (UCA) by transvaginal sonography has been investigated to detect a risk for PTB. In our systematic review we sought to investigate the published evidence and identified 11 relevant articles. Thereby it was observed that reduced UCA during the second trimester of pregnancy seems to be an independent factor that may help predict PTB <34 weeks. Nevertheless, significant heterogeneity was noted in terms of the investigated outcomes and UCA cut-off values.Several methods have been introduced as preventive strategies for PTB in women with a shortened cervix, including vaginal progesterone, 17OH progesterone caproate, cervical cerclage, and cervical pessary . Among tIn conclusion, we hope that the present issue helps to provide some update in the field of PTB that may be used to guide current clinical practice and expand future research.


To analyze the risk factors for extensive cardiopulmonary resuscitation in the delivery room and develop a prediction model for outcomes in very low birth weight (VLBW) infants.The sample was 5298 VLBW infants registered in the Korean neonatal network database from 2013 to 2015. Univariate and multivariate analyses were used to analyze the risk factors for extensive resuscitation. In addition, a multivariable model predicting extensive resuscitation in VLBW infants was developed.Univariate regression analysis of antenatal factors showed that lower gestational age, lower birth weight, birth weight less than third percentile, male sex, maternal hypertension, abnormal amniotic fluid volume, no antenatal steroid use, outborn, and chorioamnionitis were associated with extensive resuscitation at birth. Lower gestational age , birth weight less than 1000 g (OR and 95% CI: 1.509 [1.013–2.246]), male sex (OR and 95% CI: 1.329 [1.002–1.761]), oligohydramnios (OR and 95% CI: 1.820 [1.286–2.575]), polyhydramnios (OR and 95% CI: 6.203 [3.185–12.081]), and no antenatal steroid use (OR and 95% CI: 2.164 [1.549–3.023]) were associated on multivariate regression analysis. The final prediction model for extensive resuscitation included gestational age, amniotic fluid, and antenatal steroid use. It presented a sensitivity of 0.795 and specificity of 0.575 in predicting extensive resuscitation at birth, corresponding to a score cut-off of 2. The area under the receiver operating characteristic curve was 0.738.Lower gestational age, abnormal amniotic fluid volume, and no use of antenatal steroid in VLBW infants are important predictors of extensive resuscitation in the delivery room. Most newborn infants make the transition from intrauterine to extrauterine life without difficulty. About 10% need some assistance, and fewer than 1% require cardiac compression or medication in the delivery room –5.The 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care recommend that every birth be attended by at least one person, and that additional personnel with full resuscitation skills should be immediately available for infants with significant perinatal risk factors that increase the likelihood of needing resuscitation ; less than 25 gestational weeks, OR and 95% CI: 4.921 [2.926–8.276]), birth weight less than 1000 (OR and 95% CI: 1.509 [1.013–2.246]), male sex (OR and 95% CI: 1.329 [1.002–1.761]), oligohydramnios (OR and 95% CI: 1.820 [1.286–2.575]), polyhydramnios (OR and 95% CI: 6.203 [3.185–12.081]), and no antenatal steroid use (OR and 95% CI: 2.164 [1.549–3.023]) were associated with extensive resuscitation at birth. Birth weight < 3rd percentile, maternal hypertension, outborn, and histologic chorioamnionitis were associated with the need of extensive resuscitation on univariate analysis, but not on multivariate analysis  and diabetes 15–20%) . Polyhyd% . PolyhOur study aim was to develop a prediction model for extensive resuscitation using factors that can be clinically established before delivery. The variables we included were: gestational age, amniotic fluid, and antenatal steroid use. Our data suggest that the delivery by a woman with abnormal amniotic fluid volume, or in whom less antenatal steroid has been administered—despite gestational age > 27 weeks—should be prepared for extensive delivery room resuscitation. It should be attended by a team composed of at least three well-trained personnel with full resuscitation skills, and that equipment and supplies needed for extensive resuscitation should be prepared.The present study was limited by only including risk factors available in the KNN database that could be determined before birth. Important variables that would allow assessment of the fetus, such as fetal heart rate, biophysical profile, fetal presentation, placenta abruptio, emergency Cesarean section, were not included in the KNN database. Male sex and extremely low birth weight infant were associated with extensive resuscitation at birth but were not used in the predictive model, because those factors cannot be clearly determined before labor. Another weakness of our predictive model is the low PPV. It results from the very low rate of extensive resuscitation. If a resuscitation team prepare for extensive resuscitation by using our model at a score cut-off of 2, only 8 out of 100 would be used. It could be safe for VLBW infants but not efficient, especially in hospitals with limited medical resources. Additional data and a larger sample, might improve the model for predicting extensive resuscitation in the delivery room.The present study outlines factors that significantly increase the need for extensive resuscitation. These findings may be beneficial for developing strategies to anticipate circumstances that require more medical personnel and individuals with advanced neonatal resuscitation skills. Identifying risk factors and anticipating adequate levels of resuscitation that may be needed in the delivery room of a VLBW infant may better facilitate adequate preparation and prompt neonatal resuscitation, as well as target limited medical resources for those at the highest risk.This study is the first to propose a clinical scoring system to predict extensive delivery room resuscitation in VLBW infants. Lower gestational age, abnormal amniotic fluid volume, and less use of antenatal steroid in VLBW infants are important predictors of extensive resuscitation in the delivery room. However, further studies are required to improve the performance of the prediction model and increase sensitivity of extensive resuscitation in VLBW infants.


Increasing rates of postpartum haemorrhage and obstetric transfusion mean that more women are entering subsequent pregnancies with a history of blood transfusion. This study investigates subsequent pregnancy outcomes of women with a prior obstetric red cell transfusion, compared to women without a transfusion.All women with a first pregnancy resulting in a liveborn singleton infant of at least 20 weeks gestation delivering in hospitals in New South Wales, Australia, between 2003 and 2012 were included in the study, with followup for second births until June 2015. Linked hospital and births data were used to identify women with a transfusion and/or postpartum haemorrhage in their first birth, time to second pregnancy and adverse birth outcomes  in their subsequent birth.There were 358,384 singleton births to primiparous women, with 1.4% receiving an obstetric blood transfusion. Sixty-three percent of women had at least one subsequent birth. The relative risk (RR) of requiring a transfusion in a second birth was 4.9  for women with a previous transfusion compared with women without. The risk (RR) of severe morbidity in a second birth was 4.1 times higher  for those receiving a transfusion without haemorrhage in their first birth compared with women with neither haemorrhage nor transfusion.It is important to consider a woman’s history of transfusion and/or haemorrhage as part of her obstetric history to ensure management in a manner that minimises risk in subsequent pregnancies. Rates of excessive bleeding post-childbirth  and obstetric transfusion continue to rise.–4 One coAlthough it is difficult to predict which women will experience postpartum haemorrhage, risk factors for haemorrhage are an important consideration in planning the appropriate place of birth in subsequent pregnancies. As much of the initial decision making around place of birth occurs early in pregnancy, there is benefit to both clinician and the woman in assessing a future risk of haemorrhage based on factors known from the woman’s prior pregnancy.While a number of studies have investigated recurrence risk of haemorrhage in a subsequent pregnancy, few studies have also considered other outcomes including the likelihood of subsequent pregnancy and the development of other complications . Although reasons for recurrent haemorrhage are not fully understood, recurrent haemorrhage may occur due to recurrence of predisposing factors .  RoutinelThis study aims to use routinely collected data to determine (1) the likelihood of a second birth following blood transfusion at the first birth, (2) to examine pregnancy outcomes in a second birth among women who received a blood transfusion in their first birth and (3) to identify the relative importance of transfusion compared to other first birth factors in a woman’s risk for complications in her second pregnancy.The study population included all primiparous women delivering a liveborn singleton infant of at least 20 weeks gestation in New South Wales (NSW) hospitals between 2003 and 2012 (‘index birth’). Women with bleeding or platelet disorders were excluded. Women were followed until 30 June 2015 (minimum 2.5 years followup) to identify subsequent (second) birth of one or more infants >20 weeks. Women with incomplete pregnancy history (for example only having first and third birth records) were excluded.Maternal and pregnancy characteristics were available from the NSW Perinatal Data Collection (‘birth data’), which is a statutory collection of data on all births of at least 20 weeks gestation or 400 grams birthweight in NSW. The Admitted Patients Data Collection  contains data on all inpatient hospital admissions in NSW with diagnoses and procedures coded according to the International Classification of Diseases version 10 –Australian Modification, and the Australian Classification of Health Interventions respectively. The hospital data were used to obtain information on medical conditions , red blood cell transfusion and other procedures. The exposure of interest was blood cell transfusion occurring at any time during the first pregnancy . This was further divided by whether or not the woman had experienced a PPH. Transfusion is reliably recorded in the hospital data , specificity 99.9 95%CI), and postpartum haemorrhage has some underreporting , Sp 98.9 95%CI). [The primary outcomes were interpregnancy interval , red blood cell transfusion , PPH at the second birth and severe maternal morbidity at the second birth. The specific timing of the transfusion relative to the delivery for each pregnancy is not available in the data. Severe maternal morbidity was measured using a validated composite indicator of diagnoses and procedures indicative of an adverse outcome, including mechanical ventilation, dialysis, cardiac arrest, cerebro-vascular accident, obstetric embolism and shock.  The indird/4th degree tears and obstetric trauma, severe delivery and postnatal complications, intrapartum haemorrhage and placental abruption) were classified as PPH.As PPH is known to be under-reported, a sensitivity analysis was conducted where conditions commonly associated with PPH (3th centile), morbidly adherent placenta, maternal age, socioeconomic status (quintiles), year of birth and PPH type identified at the first birth, with categories as shown in Trends over time were assessed using the Cochran Armitage test. Kaplan Meier curves and log rank tests were used to compare time to second pregnancy between study groups. Among women with no second births recorded before 30 June 2015 interpregnancy intervals were censored at 1 September 2014. Modified Poisson regression with robust error variances was used to examine the relationship between first birth characteristics and: (1) transfusion, (2) PPH, and (3) severe maternal morbidity at the second birth. This method adjusts for potential confounding factors, producing adjusted relative risks (aRR), which are directly interpreted as the rate of the outcome in one group relative to the other group. In order to determine the relative importance of first birth factors on second birth outcomes, transfusion with or without haemorrhage (the primary exposure) and non-modifiable first birth factors such as women’s characteristics or complications  that are likely to also be present in a second birth were included in the models. Management factors (including mode of birth and induction of labour) were not included in modelling as they likely lie on the causal pathway between various medical conditions and adverse events. AlthoughBetween 2003 and 2012 there were 358,384 singleton births to primiparous women. Of these 5125 (1.4%) received a blood transfusion during their pregnancy, birth or the postnatal period, with the rate increasing from 1.0% in 2003 to 1.7% in 2012 (p<0.0001). The postpartum haemorrhage rate in primipara increased from 7.1% to 10.2% (p<0.0001) in the same period. Those receiving transfusions in their first pregnancy were more likely to have had hypertension or a chronic medical condition, and to give birth preterm, and were less likely to have private insurance  and thesWith followup until June 2015, 63% of women had a subsequent birth conceived before 1 September 2014, with a median interpregnancy interval of 31.2 months . The interpregnancy interval was longest in women receiving a transfusion in the absence of haemorrhage in the index pregnancy  followed by those who received a transfusion and experienced haemorrhage , those with haemorrhage but no transfusion  and those with neither haemorrhage nor transfusion  .Of the 227,247 women who had a first and second birth recorded in the dataset, 2890 (1.3%) had a transfusion in their first pregnancy and 2153 (1.0%) in their second pregnancy, and there was a recurrence risk of 4.9 . Of women receiving a transfusion in their first birth, 571 (19.8%) experienced a postpartum haemorrhage in their second pregnancy, with 127 (4.4%) also receiving a subsequent transfusion. Of the 19,268 (8.5%) women with a PPH in their first pregnancy, 3319 (17.2%) had a PPH in their second pregnancy, giving a recurrence risk of 2.8 .Severe maternal morbidity in the second birth was highest (2.2%) for those who received a transfusion without haemorrhage in their index birth . Women rWomen experiencing either haemorrhage or transfusion at a public hospital for their first birth were more likely to change to a private hospital for their second birth compared with women with uncomplicated first deliveries .severe morbidity in their second birth, with women receiving transfusion other than in the context of PPH at higher risk (adjusted relative risk (aRR) 4.1 ) than women receiving a transfusion in the context of PPH ) or those with PPH alone ) ) . ChronicPPH at the second birth, PPH with transfusion at the first birth was associated with a threefold increase in risk ), while PPH with no transfusion (aRR 2.4 (2.4–2.5)) and transfusion with no PPH ) were associated with a lower degree of increased risk ), followed by those with transfusion in the absence of PPH diagnosis ) and those with PPH alone ). The risk of transfusion at the second birth for women with PPH alone was similar to those with morbidly adherent placenta or placenta praevia at their first birth  at her second birth. While blood transfusion is an appropriate medical treatment for some women, these findings highlight the importance to the clinician of obtaining a complete obstetric history relating to a woman’s history of transfusion and haemorrhage, and using this to ensure the woman is managed in such a way as to minimise her risk in subsequent pregnancies. Despite higher risks in the subsequent births, most women receiving transfusion in their first birth continue on to have uncomplicated second deliveries.S1 FigWomen with first, liveborn singleton deliveries in New South Wales, Australia, 2003–2012.(TIF)Click here for additional data file.


The “Latina paradox” describes the unexpected association between immigrant status, which is often correlated to low socioeconomic status, and low prevalence of unfavourable birth outcomes. Social  and/or non-social factors related to country of origin are potentially responsible for this paradox.Questionnaire survey of 6413 women delivering in three large obstetric hospitals in Berlin (Germany) covering socioeconomic and migration status, country of origin , and acculturation. Data was linked with routine obstetric data. Logistic regressions were performed to assess the effect of acculturation, affinity to religion and country of origin on preterm birth and small-for-gestational-age (SGA).Immigrant women with a low level of acculturation (reference) were less likely to have a preterm birth than those who were highly acculturated , as were women from Turkey compared to non-immigrants . For SGA, we found no epidemiologic paradox; conversely, women from Lebanon had a higher chance  of SGA. Affinity to religion had no influence on birth outcomes.There is evidence that low acculturation (but not affinity to religion) contributes towards explaining the epidemiologic paradox with regard to preterm birth, emphasising the influence of socioeconomic characteristics on birth outcomes. The influence of Turkish origin on preterm birth and Lebanese origin on SGA suggests that non-social factors relating to the country of origin are also at play in explaining birth outcome differences, and that the direction of the effect varies depending on the country of origin and the outcome.The online version of this article (10.1186/s12889-019-6523-9) contains supplementary material, which is available to authorized users. A set of immutable factors related to the genetics on population level that we will call “non-social factors”. Non-social factors are not immediately affected by migration. These factors, which include maternal height and genetic polymorphisms among others on population level, stem from the country of origin. They probably vary across different countries of origin , 6.Social factors brought along from the country of origin such as culture and affinity to religion, which may change over time.Social position of immigrants in the target country of the migration, in particular the socioeconomic status of immigrants from a particular country or region relative to the host population – a confounder that needs to be controlled for when analysing the “Latina paradox” , 7.Immigrants tend to have a lower socio-economic status and poorer health than the majority population of the country they migrated to . HoweverSocial factors include religion, culture, and related behaviours. Such factors vary between countries of origin , 6. ImmiSeveral studies have sought to explore a potential Latina Paradox in Europe, looking at the relationship between birth outcomes and country of origin. For example, in Belgium, Jacquemyn et al. 2012) and Racape et al. (2016) found that being of Turkish or North African origin had a protective influence on preterm birth and low birth weight, respectively. , 11. In  and RacaTo better disentangle the role of the different sets of influencing factors including the role of the cultural factors and country of origin in explaining the Latina paradox, we take two steps. First, we investigate whether a Latina paradox regarding two birth outcomes commonly examined in this context, preterm birth and SGA, can be observed in immigrant women stemming from countries or regions other than Mexico or Latin America , North Africa, Sub-Saharan Africa, Far East, Latin America and Caribbean and North America), and in a target country different from the US (here Germany). We then examine whether the effect differs between countries of origin after adjusting for socioeconomic status in the target country. If this is the case, non-social components may play a role in explaining the Latina paradox.Second, we assess whether the Latina paradox is (at least partly) explained by social factors which non-immigrant women are not exposed to, e. g. religion and culture of the country of origin. Effects of social factors linked to the country of origin are more likely to be causally associated with the birth outcomes if they vary with degree of acculturation, after adjusting for socioeconomic status. If social factors play a role in the Latina paradox, evidence that non-social differences matter as well will become stronger when – after adjusting for socioeconomic status, acculturation and religion – differences in outcomes remain.The study is set in Berlin, Germany. In 2014, 20.3% of Germany’s population (16.4 out of 80.9 million persons) and 25.3% of Berlin’s population  had a migration background. This term comprises persons who immigrated themselves as well as persons born in Germany who have at least one immigrant parent . The larData were collected between January 2011 and January 2012 at three large maternity hospitals in Berlin. Inclusion criteria were age 18 years and above, giving live birth at 24+ completed weeks of gestation and permanent German residency . Women wWe selected preterm births and SGA newborns as outcomes of interest as both have been used in previous studies exploring the Latina Paradox , 5. PretPreterm birth was defined as a birth which takes place before the end of the 37th week of pregnancy. SGA was defined as a birth weight below the defined limit for gestational age and sex (10th percentile). Adjusted data that served as reference dataset are available from the 23rd to the 43rd week of gestation for Germany .Immigrant status of the women was defined based on their own and their parents’ country of birth [n = 302) were grouped with the non-immigrant women  [of birth . Women wt women) .Acculturation was measured with items of the “Frankfurt Acculturation Scale” (FRAKK) [ (FRAKK) . The reqAffinity to religion was grouped as following: no religion, no affinity to religion, low affinity to religion, medium affinity to religion and high affinity to religion. No religion served as reference group. Reporting of an affinity to religion was found to be consistent with answers to another question regarding religion in the FRAKK questionnaire.Country of origin was used to single out women from the two largest immigrant groups in the dataset, i.e. women from Turkey and Lebanon. Non-immigrant women served as reference group.acculturation, affinity to religion and the country of origin we consider the following covariates, which may influence birth outcomes:Monthly household income  and education (low (no degree/primary education), medium (lower secondary education) and high (upper secondary/high education)) reflect social status [l status , 37Maternal age , diabetes mellitus  and preterm birth in anamnesis (only for preterm birth) [m birth) , 28Presence of family members in Berlin (at least one vs. none) reflects social support [ support , 23Smoking  [egnancy) , 25Besides The smoking status defined through responses to our questionnaire was found to be consistent with the smoking-related variable in the routine perinatal data set. For the variable “smoking” values were missing for 288 women. Those data sets were excluded from the analysis. Missing data for other variables were imputed. Information on monthly household income was missing in 10.2% and on affinity in religion in 5.2%. Imputation procedures using the average of five iterations based on linear or polytomous regression analyses were conducted. The imputations were based on age, migrant status and education.p < 0.05.Chi Square Tests were conducted to determine the relation of the different countries of origin to the outcomes. Separate logistic regressions were conducted to estimate Odds Ratios (OR) for the influence of acculturation, affinity to religion and country of origin on preterm and SGA births while controlling for potential confounders. Linear regression analyses were used to check for multicollinearity of confounders . The dependent variables were the birth outcomes: preterm birth and SGA birth. Regression models were adjusted for the following confounders: smoking, maternal age, diabetes mellitus, family members in Berlin and possible predictors: education, monthly household income and migrant status. For the analysis of preterm birth, preterm birth in anamneses is an additional potential confounder. Adjusted odds ratios (aOR) were calculated with 95% confidence intervals (CI). The software “IBM SPSS Statistics 23” was used for the analysis. Statistical significance was defined as 8157 women delivered in the three hospitals in the period of data collection. 7100 women participated in the study (response rate 89.6%) . CompletA table of countries of origin shows the distribution of 1st generation immigrants grouped in EU15, EU27, other Europe, Middle East (excluding Turkey and Lebanon), North Africa, Sub-Saharan Africa, Far East, Latin America and Caribbean and North America  . When trStill with regard to preterm birth, we found that women from Latin America and Sub Saharan Africa have higher odds of having a preterm birth than German women. Although a study which investigated factors for preterm birth in Germany found no significant association between a Latin American or Sub Saharan African origin and the outcome , evidencIn line with some of the existing literature, we found no epidemiological paradox with regard to SGA , 39. On Data were collected in a highly-standardised way in a large sample of women with a high response rate, comprising information on migrant status and other socioeconomic parameters which are lacking in routine perinatal data. A limitation is the restriction to Berlin where the proportion of immigrants in the population is high. Hence, the results cannot be generalised to rural areas or smaller cities where social support for immigrant women may be smaller. The absolute numbers of immigrant women from countries other than Turkey and Lebanon were too small for stratified analyses. Diabetes mellitus recorded on the antenatal card was used for analyses. This may lead to an underestimation of the gestational diabetes prevalence. Acculturation is difficult to measure and may be conflated with specific social determinants of health . HoweverWe excluded nearly 21% from all deliveries in the hospitals (gross sample size). 9.2% of the women did not consent or could not be reached. 3.8% of the women were excluded based on the inclusion and exclusion criteria  and 8% oThere is evidence that a social factor, namely the level of acculturation of pregnant women with a migration background, contributes to explaining the epidemiological paradox regarding preterm birth. Furthermore, independently of social factors, Turkey as country of origin has a protective influence on preterm birth whereas Lebanon as country of origin has a negative influence on SGA. Hence, the direction of the observed effect varies depending on the country and the outcome. This suggests that non-social factors that relate to the country of origin contribute to explaining differences in birth outcomes. Service providers therefore need to take a more differentiated view of the potential risks immigrant women face than what might be implied by a broad term like “Latina paradox” or “healthy migrant effect”.Additional file 1:Distribution of socio-demographic characteristics and obstetric indicators among 1st generation immigrant women, Berlin, Germany, 2011/12. Additional information about 1st immigration women. (DOCX 20 kb)Additional file 2:Chi Square Test for premature birth, by region of origin, Berlin/Germany, 2011/12. Results from Chi Square Test for premature birth, by country of origin (DOCX 13 kb)Additional file 3:Chance (expressed as Odds Ratios) to give birth prematurely, by region of origin, Berlin/Germany, 2011/12. Additional regression analyses for Latin America & Caribbean and Sub Saharan Africa (countries which had significant associations with preterm birth in Chi Square Tests) (DOCX 16 kb)


Hydatid disease is a major health concern in the Mediterranean countries and many other parts of the world. The route of transmission is fecal-oral, and then spread by the portal venous system almost all part of the body.The liver is the most commonly involved organ, followed by the lungs, and other organs are involved in order of decreasing frequency.A middle-age male patient presented with acute abdominal pain and repeated vomiting after blunt abdominal trauma. CT-scan showed a large hydatid cyst of the right lobe of the liver with features of intraperitoneal rupture. Emergency laparotomy was performed with extraction of a countless number of daughter cysts from the peritoneal cavity. We further examined the bowel and found no abnormalities. The cyst was not causing any compression on the bile duct. Omentoplasty was performed for the cavity. The patient was discharged home eight days after the operation and the drain removed after twenty-five days when the bile leak stopped, anthelminthic drugs were given for three months after the surgery.Prevention of hydatid disease is the most effective way to control the disease, the cyst may reach a very large size and be asymptomatic. Intraperitoneal rupture may occur as a result of blunt abdominal trauma which could be trivial. It is caused by a tape worm belonging to the ocularis ,2.The route of transmission is fecal-oral, the eggs of the parasites are hatched and spread by the portal venous system and lymphatic system to almost all part of the body.The liver is the most commonly involved organ, followed by the lungs, and other organs are involved in order of decreasing frequency ,3.The work of this case report has been reported in line with the SCARE criteria, 2018 .2A-46-year old male presented to the emergency department complaining from abdominal pain and repeated bilious vomiting after blunt abdominal trauma due to a car accident.2.1The patient was admitted to the emergency ward, during examination the patient had tachycardia with normal blood pressure, the patients had no features of allergic reaction. Abdominal examination showed asymmetrical counter of the abdomen with visible bulging in the right flank, the patient had generalized abdominal tenderness with guarding, the patient had umbilical hernia for three years, 2.2CT-scan of the abdomen showed a large hydatid cyst (24 cm x 14 cm) in the right lobe of the liver, with free fluid in the peritoneal cavity suggesting ruptured of the cyst, 2.3During laparotomy the peritoneal cavity was filled with bile stained fluid with multiple floating daughter cysts inside, Aspiration of the fluid was done and extraction of a countless number of daughter cysts from the peritoneal cavity and from the cyst cavity in the right lobe of the liver was done, areas of bile leak from the inside of the cyst were sutured with slowly absorbable suture material, 2.4The patient was discharged eight days later, the drain remained inside for twenty-five days when the bile leak stopped then. The patient received anthelminthic drugs for three months after the operation.3Hydatid cysts of the liver may be discovered incidentally during routine investigations or patients may present with right hypochondrial pain, the presentation of ruptured hydatid cyst include abdominal pain, fever, vomiting, jaundice, and anaphylaxis. Falls are the most common cause of rupture followed by blunt abdominal trauma .Some authors classify cyst rupture into 3 types; contained rupture which occurs when the cyst rupture partially but contained within the host tissue, communicating rupture occurring when the rupture occurs into the biliary tree, and direct rupture when the rupture occurs to the peritoneal cavity. Rupture of the cyst should be treated with urgent surgery especially the direct one combined with adjuvant medical treatment to decrease the risk of peritoneal hydatidosis .Ultrasound is one of the most useful tools in diagnosing this disease in the liver. CT-scan and MRI add more anatomical details about the cyst, the presence of membrane inside, hydatid sand, daughter cysts, calcifications, and communication with the biliary tree, CT-scan in the most useful diagnostic tool in diagnosing intra-peritoneal cyst rupture. Serological tests also may help in the diagnosis ,5.Hydatid disease should be one of the differential diagnoses in any cystic lesion of the liver and other organs .The treatment of hydatid cyst of the liver depends on the presentation and the presence of complications that are associated with the cyst .Medical treatment with anthelminthic drugs such as albendazole was effective in some patients regardless to the size of the cyst .Complications of hydatid disease include intra-peritoneal or intra-biliary rupture, rupture into the lumen of the bowel, trans-diaphragmatic chest involvement and involvement of the portal veins. Death may occur in some complicated cases or from anaphylaxis .Intra-biliary rupture of the hydatid cyst may occur and the patient may present with jaundice or cholangitis, the presence of bile stained fluid inside the cyst indicates communication with the biliary tree, trans-duodenal sphincterotomy or T-tube drainage may be done with excision of the liver cyst or partial liver resection .Recurrence of the cyst may occur and may be due to previous rupture of the cyst, failure to remove or kill all the viable cysts and protoscolices. It is very important to use meticulous technique during operation to prevent spillage of the contents to the peritoneal cavity to prevent a recurrence ,12.After the car accident, I was afraid of immediate death because I had severe abdominal pain and it was strange for me that the first times the cyst in the liver was discovered after this accident.None.Ethical approval has been exempted by my institution for reporting this case.Written informed consent was obtained from the patient for publication of this case report and accompanying images.Dr Ayad Ahmad Mohammed and Dr Sardar Hassan Arif are the surgeons who performed the operation.The concept of reporting the case, data recording, and drafting the work done by Dr Ayad Ahmad Mohammed and Dr Sardar Hassan ArifDr Sardar Hassan Arif took the consent from the patient for publishing the case.Final approval of the work to be published was done by Dr Ayad Ahmad Mohammed.This work is case report and there is no need of registration.Dr Ayad Ahmad Mohammed is guarantor for the work.Not commissioned, externally peer-reviewed.The author has no conflicts of interest to declare.


The World Health Organization currently defines severe acute malnutrition (SAM) in infants aged under 6 months of age using weight-for-length Z score (WLZ). Given widespread use of mid-upper arm circumference (MUAC) for identifying SAM in older children and weight-for-age (WAZ) for growth monitoring, there is increasing debate about the optimal anthropometric criteria to best identify infants u6m at-risk of mortality.To determine the discriminatory value for mortality during the first 12 months of life of anthropometry taken at birth and at age two months (approximate age of routine vaccination).Data were analyzed from a birth cohort recruited between April and December of 2004 at four health facilities within Bansalogho District in Burkina Faso. Infants were followed up for 12 months. Mortality risks were estimated using hazards ratios (HR). Discriminatory value was assessed using receiver operating characteristic curves.Of 1,103 infants, 227 (21%) were low birthweight (LBW). During 12 months, 86 (7.8%) infants died; 38 (44%) among the LBW group. At birth, MUAC<9.0cm, weight<2.5kg, length<44.2cm and incalculable WLZ were associated with mortality. Sixty (70%) deaths occurred after the age of two months; 26 (43%) among LBW infants. At age two months, any MUAC <11.5cm, weight <3.8kg (WAZ<-3) and length <52.4cm (LAZ<-3) were associated with risk of mortality. WLZ was not associated with mortality at any threshold.Birth weight did not modify the effect of the association between month two MUAC and one-year mortality (P = 0.33).Infants at heightened risk of mortality and are better identified during early infancy by MUAC or WFA than by WLZ. LBW infants with low anthropometry at the age of routine immunizations remain at elevated risk than normal birth weight (NBW)infants and require intervention. Effectiveness, cost-effectiveness and coverage of applying proposed thresholds should be investigated as a priority to inform policy and practice. Undernutrition in early infancy has important consequences for survival, long-term health and neurodevelopment. It is estimated that in low and middle income countries (LMICs), 8.5 million infants aged below 6 months (u6m) are wasted (weight for length Z score (WLZ) < -2). Low-birThe diagnosis of severe acute malnutrition (SAM) among infants u6m is currently based on WLZ, using the same threshold of <-3SD applied for older children . HoweverBurkina Faso is a resource-poor land-locked country in West Africa. This analysis utilized data from a birth cohort within an urban area of Barsalogho Health District, part of the Kaya Health Region in Central North Burkina Faso. The District is located at the edge of the Sahel with a population of predominantly subsistence farmers. Data were collected between April and December of 2004 in four different health centers including Barsalogho, Basma, Dablo, and Foubé.rd trimester. Only women who consented were included in the study. This analysis, included data from all live hospital and home births within the cohort who were followed up for one year, loss to follow up or death. The primary outcome of this analysis was death within 12 months from the date of birth. In this study, LBW was defined as birth weight <2.5kg, and prematurity was defined as estimated gestational age <37 weeks. The exposures examined at birth were birth weight (kg), MUAC (cm) and length (cm); while exposures examined at month two were weight (kg), MUAC (cm), length (cm), WLZ, concurrent wasted and underweight, concurrent wasted and stunted, and concurrent stunted, wasted and underweight.This was a secondary analysis of a prospective birth cohort. The parent study recruited pregnant women attending scheduled antenatal care (ANC) in their 3Parental demographic characteristics were collected at birth. Infant anthropometry was measured within 2 hours after a hospital birth, and within 48 hours for a home birth, then monthly for twelve months. MUAC in cm was measured using a 1 mm graded non-elastic measuring tape, weight was measured within 10 grams using a SECA baby scale while length was measured using a 1cm graded measuring stick. Deaths were recorded at every visit, ascertained using hospital documents for hospital deaths and verbal autopsy for community deaths.With the fixed sample of 1103 infants and 86 deaths after 12 months of age, there was >90% power to detect a hazard ratio >3.0 of association between birth MUAC cut-off of 9.0cm and 12 months’ mortality with 0.05 level of precision.Weight-for-age (WAZ), weight-for-length (WLZ) and length for age (LAZ) at birth and month were calculated two using the 2006 WHO growth references that are not adjusted for gestational age, which could not be precisely ascertained, as in routine practice. Stunted, wasted and underweight were defined as LAZ<-2, WLZ<-2 and WAZ<-2 respectively. Concurrently wasted and stunted were defined as infants with WLZ<-2 and LAZ<-2, concurrent wasted and underweight as WLZ<-2 and WAZ<-2, and concurrent stunted, wasted & underweight as LAZ<-2, WLZ<-2 and WAZ<-2. Non-malnourished infants were defined as those with Z scores ≥-2 for these parameters. Missing anthropometric data was analyzed as a separate category. Infant’s anthropometry at birth, at month two and at month twelve were summarized using means and standard deviations and compared children with LBW and NBW (birth weight ≥2.5kg) using z-test with α<0.05 considered as the statistical level of significance.In this cohort, because anthropometric measures for all infants were taken at the same intervals i.e. at birth, age month 1, age month 2 and so on up to month 12, the use of age standardized Z scores such as WAZ and LAZ was not seen to add any practical benefit. Hence, absolute weight and length cut-offs corresponding to <-2 and <-3 WAZ and LAZ standards at each month of age were used instead . MUAC cua priori confounders  selected during the development of the secondary data analysis were added. There were 14 pairs of twins recruited, therefore twin clustering was adjusted for in the regression models. Survival curves were fitted using Kaplan-Meier method and log-rank test used to compare survival distributions between different groups. To test for effect modification of birth weight on the association between birth MUAC (cm) and one-year mortality, likelihood-ratio tests comparing models with and without interaction terms were used. Premature and twin infants are known to have a higher risk of mortality and different growth trajectory, therefore, a sub-analysis to evaluate the effect of anthropometry on risk of death on infants who are not known to be born premature or twins was performed.To estimate discrimination of mortality risks by anthropometric measures taken at birth and at month 2 for mortality up to 12 months of age, the area under receiver operating characteristics curves (AUC) was calculated. To test for an association of birth and month 2 anthropometry with one-year mortality, single event survival analysis was used. Time at risk was defined as time from birth or month two to date of death, lost-to-follow-up or last day of follow-up (one year after birth) for mortality after birth and month two analysis respectively. Cox proportional hazards regression was used to determine the association between anthropometry and mortality, and reported hazard ratios (HR) with 95% confidence intervals. The Schoenfeld residuals test was used to test for proportional hazard assumption. For univariable regression analysis, each anthropometric indicator was analyzed separately as the only independent variable in the model and for the multivariable regression analysis, To identify a MUAC proxy for LBW, two approaches were used; A) assessed a linear association using the Pearson correlation coefficient and plotted a scatter plot with the estimated line of best linear fit and checked the MUAC cut-off where a reference line of birth weight of 2.5kg intersected with the best line fit; and B) computed sensitivity and specificity at different MUAC cut-offs, and determined the statistically optimal MUAC cut-off using the square of distance method .Stata version 15.1  was used to perform all the statistical analysis.Approval for data collection was granted by the Ministry of Health of Burkina Faso in 2003  in accordance with national procedure. All data were anonymized before being shared for this analysis.A total of 1,103 infants u6m  recruiteMothers’ median (IQR) age was 24 (20–30) years; mothers of infants born with LBW were younger (21 (IQR 19–27) years) than the mothers of infants born with NBW (25 (IQR 20–30) years; p = 0.001). The median (IQR) height of mothers was 163 (159–168) cm. Eight hundred and fifty-four (77%) mothers were illiterate and 822 (75%) were Muslim. The median (IQR) age ofthe infants’ fathers was 39 (31–49) years, and 568 (53%) fathers were illiterate. The mean (sd) father’s BMI was 21.5 (2.6).Fifty-nine (5.3%) infants had incalculable WLZ at birth as their birth length was below 45cm. The risk of death associated with missing birth WLZ was analyzed separately. One hundred and forty-seven infants had missing month 2 anthropometry as they failed to attend their month 2 visit. Two infants measured at month two had length <45cm and therefore has incalculable WLZ.83/1103 (7.5%) infants were lost-to-follow-up after median 210 (IQR 93–304) days. There were no significant differences in birth weight (P = 0.35), length (P = 0.50) and MUAC (P = 0.24) between the infants lost-to-follow-up and those not lost-to-follow-up.A total of 661 (60%) infants were not stunted, wasted or underweight at birth. The prevalence of being wasted among all infants at birth was 30% by WLZ<-2 and 7.2% by MUAC<9.0cm, 10% were stunted (LAZ<-2) and 17% were underweight (WAZ<-2). . Wasted,SI Fig). There were 38/227 (17%) deaths amongst infants born with LBW during the 12 months of follow-up during 199.8 cyo; 190.1  per 1000 cyo; and amongst infants born NBW, 48/876 (5.5%) deaths occurred during 815 cyo; 58.9  deaths per 1000 cyo (P<0.001). The hazards ratio for death associated with LBW, adjusted for gender, month and facility of recruitment, was 3.12   infants died during 1,015 child-years of observation (cyo), mortality rate 84.8 (95% CI 68.6–104.7) deaths per 1000 cyo. A total of 26/86 (30%), 31/86 (36%) and 51/86 (59%) deaths occurred by two, three and six months after birth  . However1, 4.88) . The proThe AUCs for birth anthropometry for discriminating mortality were greater than 0.5 except for WLZ . MissingandA birth MUAC of <9.0cm was associated with elevated hazard of death; HR 3.97 . Birth MUAC of between 9.0 to 10.0cm was not associated with mortality compared to ≥10.0cm; HR 1.25  and.Birth weight of between 2.0–2.5kg was associated with risk of death; HR 2.75  compared to birth weight of ≥2.5kg. Birth length <42.2cm (denoting birth LAZ<-3) was associated with risk of death; HR 3.93  was associated with 2.71  compared to birth length of ≥ 46.1cm). .There was evidence that birth weight modified the effect of the association between birth MUAC and one-year mortality (P = 0.001). When infants were stratified by LBW, birth MUAC was associated with one-year mortality amongst LBW infants and not NBW infants .In the sub-analysis, of the 89 infants born either premature or a twin, 20/89 (23%) died in the first year of life; 270.3  deaths per 1000 cyo. The adjusted  risk of mortality associated with being premature or twin was HR 3.83 (95% CI 2.30 to 6.38). Excluding known premature births and twins, birth MUAC thresholds below 9.0cm and birth length <44.2cm (LAZ <-3) were not associated with mortality; HR 1.03 (95% CI 0.25 to 4.31) and HR 2.10 (95% CI 0.65 to 6.81) respectively. However, birth weight below 2.5kg was associated; HR 2.32 (95% CI 1.34 to 4.03) .Birth MUAC had a strong positive correlation with birth weight; Pearson correlation coefficient was 0.68 .The linear best fit, adjusted for gender, was; birth MUAC (cm) = 5.72 + 1.60  (birth weight in kg). The predicted birth MUAC by the linear regression equation was 9.7cm for birth weight of 2.5kg as shown by intersection of the two reference lines on Overall, the MUAC cut-off of <9.7 cm at birth that best discriminated LBW was associated with a hazard ratio  for death of 1.98  compared to infants ≥9.7cm .A total of 60/86 (70%) deaths occurred after the first two months of life, during 837 cyo; 71.7  deaths per 1000 cyo. Of these 60 deaths, 26/60 (43%) occurred among LBW infants; 158.6  per 1000 cyo and amongst the infants born with NBW 34/60 (57.0%) deaths occurred; 50.5  deaths per 1000 cyo; adjusted hazards ratio 2.89  .At month two, any MUAC thresholds below 11.5cm, weight threshold below 3.8kg (WAZ<-3) and length thresholds below 52.4cm (LAZ<-3) were associated with increased risks of subsequent death . NotablyAt month two, MUAC, weight and length discriminated subsequent mortality as the AUCs and their confidence intervals were greater than 0.5 . ImportaIn the sub-analysis excluding premature infants and twins, the association between MUAC threshold below 11.5cm and weight <3.8kg with mortality was maintained; HR 2.85 (95% CI 1.14 to 7.13) and HR 4.18 (95% CI 1.68 to 10.38) respectively . NotablyAnthropometric thresholds for intervention are typically based on their association with the risk of mortality in untreated populations. Prior cohort studies of this kind have usually excluded young infants. As a result, in the absence of evidence, WHO and international recommendations for infants under 6 months have adopted the criteria used for older children . A key qWe found that at birth and at 2 months of age, current weight, birth weight, MUAC and length discriminated subsequent mortality. However, WLZ, the current diagnostic criterion for acute malnutrition did not; at birth likely because many WLZ values were incalculable using 2006 growth standards. Rather than being associated with lower risk, LBW modified the effect of birth anthropometry on the risk of death, and did not alter risk at any given MUAC or WAZ taken at 2 months and remained a strong risk factor for death throughout the first year of life.st growth curves aim to help resolve this problem by creating separate preterm postnatal growth standards [Our results indicate a high prevalence of low anthropometry at birth; 21% of the infants were born LBW, which was higher than the global prevalence of 16% at the time of the study , howevertandards , 25. howIdeally, an appropriate anthropometric cut-off should depend on how effective or cost-effective an intervention is when applied using that threshold. However, in the absence of such data, predictive and discriminatory values for mortality are used. From our analysis, birth weight <2.5kg, birth MUAC <9.0cm and birth length <44.2cm were strongly associated with mortality. In most resource poor settings, birth length is not routinely measured due to lack of appropriate equipment (infantometer) and home deliveries. Birth weight is commonly recorded in facilities and our results support that it is a useful marker of survival. Birth MUAC is not routinely measured as consensus on its interpretation is lacking. Among infants u6m, lay health workers measured MUAC more reliably and accurately than they did length [proxy of proxy). Our findings suggest that the risk of death associated with birth MUAC<9.0cm was similar to that associated with birth weight<2.5kg, likely because it captured prematurity. However, a MUAC threshold of <9.7cm was statistically optimal to identify LBW. Our results slightly differ from findings for Uganda and Ghana where MUAC<10.1cm and MUAC <9.4cm respectively better predicted LBW [Different anthropometric measures have previously been studied for ability to predict LBW. LBW is an indicator of mortality and disability risks, hence other anthropometric measures aiming to predict LBW become indicators of an indicator of risk  old but would identify a large proportion 17%) of the infants u6m for treatment. Importantly, below 6 months, the recommended nutritional intervention focuses on re-establishing exclusive breastfeeding % of the –30. HencThe practical challenge in these recommendations is the introduction of a new MUAC cut-off among infants u6m which differs from that currently applied in children >6m. This challenge can be overcome by proper training of implementing health workers and understanding of the concepts of risks and the types and intensity of interventions.We also found that weight<3.8kg (WAZ<-3 at age 2 months) was very strongly associated with mortality. As weight is most commonly measured at this age using routine road-to-health charts , our resThis study had 59 infants with incalculable birth WLZ. This was strongly associated with mortality and is a major challenge in early identification of malnourished infants if applying WLZ , 32. At This study was a large longitudinal birth cohort in a resource-poor area with systematically collected data in the absence of specific intervention. Infants were enrolled at birth irrespective of anthropometric classification at birth. There was minimal loss to follow-up and mortality was accurately determined, although exact cause of death could not be ascertained.Among infants u6m, MUAC and weight thresholds are better discriminators of subsequent mortality than WLZ. At birth, where gestational age is unknown and weight is not possible to measure, birth MUAC can be applied to identify infants at risk. At the age of first vaccinations (approximately2 months), MUAC and WFA should be considered as the primary means of assessment to identify infants at high risk of mortality and thus intervention. Further research into the effectiveness, cost-effectiveness and coverage of using the proposed thresholds should be prioritized to further inform policy and practice.S1 Table(PDF)Click here for additional data file.S2 Table(PDF)Click here for additional data file.S3 Table(PDF)Click here for additional data file.S4 Table(PDF)Click here for additional data file.S1 Fig(PDF)Click here for additional data file.S2 Fig(PDF)Click here for additional data file.S1 Dataset(CSV)Click here for additional data file.