I examine a speculative diagnosis made by Sigmund Freud regarding his patient's mother in his landmark 1905 paper describing a hysterical illness. Freud considered the impact of Dora's mother's mental state on her daughter, wondering whether the mother might suffer from a ‘housewife's psychosis’. Here was an emphasis on the social structures of the times and differences between the parents in terms of sexual freedom and societal limitations placed on women. Freud's description drew attention to Dora's anxieties in relation to her parents, in particular the state of their sexual relationship and the apparently sanctioned entry of another couple, Frau and Herr K, into the parental relationship. In particular, the role of syphilis in the aetiology of sexual disturbances was considered, affecting men and their sexual partners, specifically their wives, who faced lifelong risks of morbidity, inadequate treatment and psychic disturbances at this time in 19th century Vienna. In doing so, he shows us a way of entering the world of the intrapsychic, which, as we know, deepens clinical understanding and provides meaning to a socio-politico-cultural3 formulation.The case of Dora,mother's strange illness. The speculative diagnosis regarding this ‘unseen’ member of the patient's family was made by Freud, remotely, from reports made by others. Freud's brief observations, sensitive and emphatic by turns, began to sketch out the sort of mother that Dora had:1‘an uncultivated woman and above all a foolish one […] who had concentrated all her interests upon domestic affairs, especially since her husband's illness and the estrangement to which it led.’On reading the Dora case as a training psychiatrist, I was always fascinated by a seemingly minor detail: a throwaway diagnosis of Freud's regarding Dora's Before I examine his point, I briefly summarise below an outline of the Dora case.4 They revealed a conflict and repressed desires: Dora's adolescent preoccupation with and terror of sexual intimacy, resulting in repression of her sexual feelings, as well as her unconscious desire for revenge against her beloved father, who was felt to have betrayed her. The idea of the hysterical symptom being the outcome of an irresolvable sexual conflict was thus clearly shown through a case-history format. Dora's fantasies of being of central importance in the family drama, followed by bitter disappointments, made hysteria her ‘solution’ to the internal dilemma. Freud wrote ‘incapacity for meeting a real erotic demand is one of the most essential features of a neurosis. Neurotics are dominated by the opposition between reality and phantasy’.1Dora was analysed by Freud for 3 months in the autumn of 1900. Aged 18, she was brought by her father to Freud with a series of mental and physical symptoms – depression and difficulty socialising, along with a nervous cough, a loss of voice, migraines and difficulty breathing. Significantly, her father had himself been treated some years ago by Freud for syphilis, and then for some years he had suffered various other illnesses. Dora's previously idealised view of her father had turned hostile, and her relationship with her mother was full of conflict. While sifting through reports of emotional upsets and suicidal behaviour, Freud noticed the family's concurrent relationship with a young couple, Herr and Frau K, pre-dating the onset of Dora's symptoms. Here Freud began to develop his theory of the formation of Dora's hysterical symptoms. The first was a ‘reversal of affect’, where sexual excitement was turned into disgust, and the second ‘displacement of sensation’, where a stimulus felt in one part of the body, and felt to be unacceptable, was repressed and relegated to another, unrelated area. Freud described the hysterical symptom as resulting from a path taken by the psychic conflict into the body: a somatic compliance. Two dreams that emerged in treatment were analysed following what was by now an established dream interpretation technique.5 Blass writes ‘Through Dora's analysis Freud gradually passes from the seduction theory to a theory of neurosis that centres on intrapsychically originating moral conflict and on the early childhood events that make it pathogenic’.6Among Freud's five case histories, Dora's stands out as probably the most discussed and critiqued by his successors.6 Conversion came to be understood as the body becoming the stage on which an unacceptable conflict in the psyche gets staged or represented, and this mechanism was viewed as radically different from that of hypochondria and severe psychosomatic illnesses. A detailed exposition of these ideas in contemporary psychoanalysis is beyond the scope of this paper but interested readers are encouraged to read further.7There were, however, several clinical discoveries which Freud considered later, looking back on the work: Dora's underlying homoerotic conflicts, her transference to Freud, the countertransference, the brevity of the treatment. Freud's Oedipal theory was yet to be fully developed.1‘ … whenever she had reproached her father about Frau K., he had been in the habit of saying that he could not understand her hostility and that, on the contrary, his children had every reason for being grateful to Frau K. Her mother, whom she had asked for an explanation of this mysterious remark, had told her that her father had been so unhappy at that time that he had made up his mind to go into the wood and kill himself, and that Frau K., suspecting as much, had gone after him and had persuaded him by her entreaties to preserve his life for the sake of his family. Of course, Dora went on, she herself did not believe this story; no doubt the two of them had been seen together in the wood, and her father had thereupon invented this fairy tale of his suicide so as to account for their rendezvous.’Freud suggested that ‘a daughter takes her mother's love story as her model’. Dora's mother had met her future husband, a man much older than her and sexually experienced, at 17 and then waited 2 years to marry him. As a mature woman and mother, she was now exacting, preoccupied with looking after material household things and seemingly indifferent to Dora's emotional needs. She also seemed strangely cut off from evidence of her husband's infidelity, offering disinterested explanations in response to the anxious questioning of her precocious daughter. Dora was anxious about her father's relationship with Frau K, a younger, married woman and a family friend:There was clearly an unhappy, heavily disguised family drama in the backdrop of Dora's hysterical presentation. Her suicidally depressed father and rather cut-off mother seemed to have relied on Frau K to act as an intermediary in their relationship. Freud correctly gauged Dora's scorn at her mother's naivety in taking the father's account of his relations with Frau K at face value. Dora presented with hysterical symptoms alongside her conscious contempt of both her parents for their tendency to self-deception and lies.his wife when he made sexual advances towards Dora. This acted as a trigger for Dora's hysterical symptoms. The subtext seemed that this was a world where men were justified in seeking their sexual pleasures freely and at some risk, as long as they kept up appearances to save face while married. Freud deftly linked these confusing observations in young Dora's mind, giving them a voice: ‘How dare the man make an assumption about me?’. A passing reference to her mother being in Herr K's confidence, hearing bitter complaints about Frau K's relations with Dora's father, made one wonder about her complicity in Dora's predicament.Freud noted at the start how Dora's father told him ‘you know I get nothing out of my own wife’ as a justification for his involvement with Frau K: a loaded sentiment ironically echoed by Herr K in describing 1‘She presented the picture, in fact, of what might be called the “housewife's psychosis”. She had no understanding of her children's more active interests and was occupied all day long in cleaning the house with its furniture and utensils and in keeping them clean – to such an extent as to make it almost impossible to use or enjoy them.’What might be the mysterious illness that plagued Dora's mother all this while? Freud wrote:1‘This condition, traces of which are to be found often enough in normal housewives, inevitably reminds one of forms of obsessional washing and other kinds of obsessional cleanliness. But such women (and this applied to the patient's mother) are entirely without insight into their illness, so that one essential characteristic of an “obsessional neurosis” is lacking.’He noted that if the conditions were not suitable for a hysterical symptom, as was possibly the case with Dora's mother, one found instead a psychical symptom. She was caught up in a mindless trap of domesticity, posing a severe problem to her family:The lack of insight or understanding of the other and the repetitive acts which made it impossible for others to enjoy their comforts: all these seemed to be significant. Here I thought Freud was marking a lack of receptivity; instead, there seemed a marked tendency to repulse others, to keep them away from her person while keeping up a façade of housewifely devotion. This could be a projection into the other of a desperate need to get in, while thwarting this and erecting a psychic barrier. For example, Dora's father stated that he got ‘nothing out of’ his wife as a hint of a lack of sexual relations; this may be rephrased as ‘I cannot get into her’. This was also Dora's experience of an unavailable mother. Instead, her mother transformed the house, and her body, into a whirlwind of activity that did not allow for entry or habitation.1‘I do not wish to give an impression of underestimating the importance of heredity in the aetiology of hysteria or of asserting that it can be dispensed with. In the case of the present patient the information I have given about her father and his brother and sister indicates a sufficiently heavy taint; and, indeed, if the view is taken that pathological conditions such as her mother's must also imply a hereditary predisposition, the patient's heredity may be regarded as a convergent one.’Freud then considered the role of heredity in hysteria, and gave Dora's mother a place in this constellation:1‘To my mind, however, there is another factor which is of more significance in the girl's hereditary or, properly speaking, constitutional predisposition. I have mentioned that her father had contracted syphilis before his marriage. Now a strikingly high percentage of the patients whom I have treated psycho-analytically come of fathers who have suffered from tabes or general paralysis. In consequence of the novelty of my therapeutic method, I see only the severest cases, which have already been under treatment for years without any success. In accordance with the Erb-Fournier theory, tabes or general paralysis in the male parent may be regarded as evidence of an earlier luetic infection; and indeed I was able to obtain direct confirmation of such an infection in a number of cases. […] [T]he conclusion to which I have been driven by my experience as a neuro-pathologist [is that] that syphilis in the male parent is a very relevant factor in the aetiology of the neuropathic constitution of children.’One might speculate on another possibility that lent credence to Freud's observations of Dora's neurosis: her mother's ‘psychosis’ and the peculiar circumstances of a sexual  couple of that time. Dora's mother had already contracted syphilis from her partner early in the marriage, like many middle-class women who seemed to have little choice other than to suffer the illness and seek treatment, risking shame and humiliation. Freud, in describing the significance of the male parents’ syphilis in their children's illnesses, is mysteriously silent on the mother's predicament:9 while psychoanalysis grew into a body of work fuelled by Freud's emphasis on patients’ fantasies around sex. In a patient's psychic elaboration of phantasy, the patient's real experience was crucial as the shameful and terrifying spectre of syphilis hung over every sexual encounter like ‘the sword of Damocles’. By the late-19th century, neurologists acknowledged that syphilis was, in its pathological manifestations, the ‘great imitator’ of maladies.The age of Freud was also the age of syphilis, as pointed out by Ropper & Burrell,Freud commented on Dora's father's luetic condition before marriage, as well as his successful involvement in treating the latter's troubling vascular and neurological syphilitic symptoms 4 years before Dora arrived as Freud's patient. But in fact, prior to the first use of penicillin against syphilis in 1943, it is well-known that mercury compounds had a prominent position in the medical practice despite a tremendous toxicity and a questionable efficiency.8 Ironically, it was in Germany in 1905 that the discovery of the spiral-shaped bacterium now known as Treponema pallidum was made by zoologist Fritz Schaudinn and dermatologist Erich Hoffmann; this changed the understanding of syphilis and general paresis of the insane.Freud, with his background in neurology before his pioneering work in psychoanalysis, would have keenly observed syphilis's twofold impact: the neurological manifestation of syphilis, a ‘general paresis of the insane’, which galvanised biological psychiatry while the psychological impact gave impetus to the study of hysteria.But the aspect of the family drama often got minimised: the terrible social and psychological impact of syphilis on the sexual relations of couples, an experience of unconscious threat, neglect and violence. Most significantly, a legitimate place for the mother's state of mind and for her sense of an interiority was lacking.10Freud speculated on a possible early transmission of Dora's father's syphilitic infection to his wife, as well as the possibility that he was later cured of his condition. But what of Dora's mother, who continued to cohabit with a man who may or may not have been cured of syphilis, may have been suffering tertiary syphilitic complications and whose further infidelity was betrayed by gonorrhoea? We do not know; Freud was never able to meet her, nor discuss what influence her situation might have had on Dora. We also do not know when the mother's venereal symptoms began or whether they were fully treated and cured; however, we can speculate on an experience of sex being fraught with danger. A phantasy of sex as destructive may have turned into reality, a fact that was perhaps not lost on Dora.11 Physicians also reported syphilophobia, or the exaggerated fear of the disease, and hydrargyrophobia, or the fear of mercury, which was one of the main medical treatments.12Syphilis was widespread enough to give rise to a special form of hypochondria known as syphilis imaginaria, or the development of imaginary symptoms of syphilis.It is also difficult to know whether a ‘vertical’ transmission of syphilis from mothers to babies as congenital syphilis, causing still-births and miscarriages, was a possibility in Dora's mother's case before the birth of Dora and her brothers.By the time Dora was brought by her father to see Freud, the parental couple had ostensibly ceased sexual relations – perhaps even as early as when she was 6 years old and her father contracted tuberculosis. Dora suggested to Freud at one point that her father was impotent. She hinted also of her knowledge of sexual activities involving other parts of the body if genital sex was inadvisable. Freud's elaboration of Dora's sexual fantasies, linking them to her hysterical symptoms, is at once a phenomenological enquiry into the individual psyche and a description of the social and family structures in 19th-century Vienna. And so he noted Dora's complaints against her father as a ‘wearisome monotony’ with an ‘incessant repetition’, at the knowledge of her father's extramarital affair. The sexual betrayal of the mother by the father thus seemed to have been experienced as something unbearable by Dora, and led to her behaving like a jealous wife, while her mother stayed silent.1‘The relations between the girl and her mother had been unfriendly for years. The daughter looked down on her mother and used to criticize her mercilessly, and she had withdrawn completely from her influence.’If the ‘housewife's psychosis’ was a disturbed relationship with reality, Dora's mother's behaviour signalled an internal disturbance that could not be articulated. Taking up the syphilitic vector as a projected experience perhaps of ‘care-lessness’ originating in the father's apparent indifference allowed another way of looking at Dora's mother's frantic avoidance of contact. Freud had already suggested the possibility that shame and humiliation, a sense of being contaminated, gave rise to a reaction formation that drove Dora's mother's incessant cleaning. The sense of being ‘dirty’ seemed to be linked to the mother's venereal infection, the white vaginal discharge and abdominal pains which needed medical treatment. But the sense of neglect and damage felt to be inflicted by the other in this way was perhaps projected into Dora by her parents. In later emphasising the significance of Frau K in Dora's fantasies, Dora's conscious alienation from her mother and alliance with her father seemed to mask, at a deeper level, an unconscious longing for an unavailable mother and rivalry with a father who pursued his own needs at a heavy cost to the family:If Dora was perhaps forced to stand on the sidelines while her mother lavished attention on material things, she eventually found herself in a similar position while her father found substitutes for her mother. Freud's final observations of Dora's father as ‘never entirely straightforward’ and Dora's dropping out of analysis seemed to confirm this and has since been used (sometimes unfairly) as a way of underlining Freud's own contentious, academic motives in this unsatisfactorily brief yet trail-blazing treatment.8 linking to femininity13 and the family matrix.12 Feminist writers argue that early psychoanalysts failed to fully acknowledge that, for many, the avoidance of sex with men was based on their fear of contracting venereal disease and, for married women, their fear of passing the disease to their children. Sexual relations outside the social contract of marriage carried dangers as well, with the added elements of guilt and punishment for transgression complicating treatment options for sexually transmitted illnesses. The secrecy and fear surrounding venereal disease influenced many social attitudes, reinforced the division between races and social classes, and significantly influenced the construction of female sexuality and the notion of family.13 Today we also speak of ‘reckless transmission’ of infection as a legal definition.14Freud's academic interest lay in working out his theories of hysteria, but one wonders about his being taken aback by the mysterious ways in which female sexuality showed itself or remained obscure, finding its peculiar diversions in a patriarchal social order. The sociocultural aspect of syphilitic infection in the 1900s has been examined extensively,intrapsychic as an inquiry into the internal forces driving the victim of a sexually transmitted infection when they contract the illness without their conscious knowledge. It is possible such a victim may feel paralysed by the threat of being invaded and taken over from the inside by something that ‘catches’, and if so, the notion of sex being dichotomised as either safe or transgressive, by both the individual and society, comes into question. One such example is a research project in the UK into women with a range of sexualities, living with HIV/AIDS.15 The findings highlight the woman's sense of being unheard, the stigma and the barriers, both internal and external, faced when she contracts a sexually transmitted infection from an infected partner and requires help and treatment. The report, drawing on focus groups and online surveys, highlights how women are often described as ‘hard to reach’ and yet there is a lack of clear guidelines regarding emotional support for sufferers. The spread of HIV among women has sociopolitical as well as biological roots: it arises from the inequity between the sexes, societies’ class structures and the inaccessibility of healthcare. In many societies, educational and employment opportunities for women are limited. Throughout the world, women are placed in subservient positions and lack the freedom to ask questions or to demand the use of condoms.16 Perhaps here, like with syphilis in the 19th century, there is still a considerable gap in understanding a patient population defined by its position in the background of the ‘actual’, or identified, disease victims.However, this paper is more concerned with the 17 may be always at risk of being relegated to obscurity in a patriarchal social setting. This is perhaps unavoidable, though one missing link may be the spectre of syphilis and its psychological impact on women of that time, with its inevitable impact on the sexual couple. But in the wonderful rapidity and prescience of his work, Freud himself does give shape to Dora's mother as a shadowy yet significant player in Dora's 19th-century teenage world, assigning a diagnosis of a ‘housewife's psychosis’ – a retreat from reality into mad domesticity as a defence, carrying with it a wealth of possible meanings for retrospective investigation.Dora's mother, like Shakespeare's sister in academia,


To compare the effects of five different frozen-thaw embryo transfer (FET) strategies in women aged 35–40 years.Data from 1,060 patients were divided into five groups according to the number and quality of transferred blastocysts: a high-quality single blastocyst group , a high-quality double blastocysts group , a high-quality plus poor-quality double blastocysts group , a poor-quality double blastocysts group , and a poor-quality single blastocyst group . Comparative analyses were then performed between groups with regard to primary conditions, pregnancy, and neonatal outcomes.Group A had the lowest twin pregnancy rate (1.97%) and incidence of low-birth-weight infants (3.45%), which were significantly different from groups B, C, and D. In addition, the preterm birth rate (7.89%), neonatal birth weight , and neonatal birth age  in group A were different from those in groups B and C. Double blastocyst transfer (DBT) was associated with a 20.558-fold  and 3.091-fold  increased risk of twin pregnancy and preterm delivery in unadjusted analysis, respectively, when compared with single blastocyst transfer (SBT). In the adjusted analysis, we observed similar risk estimates .Although, high-quality SBT resulted in a lower live birth rate than high-quality DBT, it also significantly reduced the risk of adverse pregnancies, thus resulting in more benefits for both the mother and baby. Collectively, our data indicate that high-quality SBT remains the optimal FET strategy for women aged 35–40 years and warrants further clinical application. Since October 2015, the rate of advanced maternal age (AMA) has increased from 8.5% to 13.5% with the full implementation of the two-child policy in China, with a growth rate of 58.8% . FurtherSingle embryo transfer (SET) is considered the best choice to reduce the rate of multiple pregnancies and improve perinatal outcomes . BlastocA retrospective analysis was performed on women who underwent FET at the Reproductive Center of the Second Affiliated Hospital of Wenzhou Medical University between January 2016 and August 2021. The inclusion criteria were as follows: (i) age 35–40 years; (ii) the thickness of the endometrial layer was greater than 7 mm on the day of endometrial transformation; (iii) no more than three transplantation cycles; (iv) no more than two day 5 (D5) blastocysts were transferred; and (v) the endometrial preparation was hormone replacement therapy (HRT). The exclusion criteria were as follows: (i) uteri with abnormal ultrasound findings such as endometrial polyps, endometrial fibroids, uterine adhesion, adenomyosis, or reproductive tract malformations; (ii) malignant tumors or other systemic chronic diseases, including those of the autoimmune system or hematological system; (iii) a history of genetic disorders in either of the couple receiving treatment; (iv) a history of habitual miscarriage or repeated implant failure; and (v) blastocysts undergoing preimplantation genetic testing (PGT).in vitro fertilization and embryo transfer (IVF-ET) laboratory manipulations (2016), the infertility diagnosis guide, and the Chinese expert consensus with regard to the number of embryos transferred.A total of 1,060 eligible patients were enrolled in this study and divided into five groups according to the number and quality of transferred blastocysts: a high-quality single blastocyst group , a high-quality double blastocysts group , a high-quality plus poor-quality double blastocysts group , a poor-quality double blastocysts group , and a poor-quality single blastocyst group  Figure 1th day after endometrial transformation. The post-transplant luteal support regimen was the same as the post-transformation dosing  was taken orally (twice a day) from day 2 to day 5 of the menstrual cycle. Endometrial thickness was monitored by ultrasound every 3–5 days and the dosage of estradiol tablets was adjusted according to the thickness of the endometrium. When the endometrial thickness was greater than or equal to 7 mm, and the level of progesterone was less than 1.2 ng/mL, we added 10 mg dydrogesterone tablets  twice a day for endometrial transformation, in addition to the one tablet of estradiol . In addition, 200 mg of micronized progesterone was also administered orally or vaginally twice a day . Blastocyst transfer was performed on the 5n dosing Figure 22, and 5% O2 for 2 h before transfer.Blastocyst thawing was performed on the morning of FET using a vitrification resuscitation kit . After removing the cannulae from liquid nitrogen, the carrier rods were removed and quickly placed in thawing solution (TS) for 1 min at room temperature. Blastocysts were then transferred to dilution solution (DS) for 3 min, washing solution 1 (WS1) for 5 min, and washing solution 2 (WS2) for 5 min, respectively. Finally, blastocysts were transferred to blastocyst culture solution for observation and scoring before being placed in a three-gas incubator at 37°C, 6% COThe thawed blastocysts were graded according to Gardner’s grading criteria . In brieThe first β-hCG test was performed 12–14 days after FET. The first ultrasound was performed 26–28 days after FET and the second ultrasound was performed 40–42 days after FET Figure 2P<0.05 was considered statistically significant.SPSS  software was used for statistical analysis. Continuous variables that conformed to a normal distribution were expressed by mean and standard deviation or median, and comparisons between the five groups were performed using one-way analysis of variance (ANOVA). Measured variables that did not conform to a normal distribution were expressed by median and interquartile range (IQR), and differences between the five groups were compared using the Kruskal-Wallis H test. Differences in the measured variables between groups were analyzed by independent t-tests and Mann-Whitney U-tests. Count variables were compared using Pearson’s Chi-squared tests or Fisher’s exact tests. Log binomial regression analysis was used to analyze the main exposure factors affecting live birth, twin pregnancy, and preterm delivery, while unadjusted risk ratios (RRs), adjusted risk ratios (aRRs) and 95% confidence intervals (CI) were calculated for independent variables. P>0.05). The percentage of the first transplant cycles were statistically different in groups A and E when compared with the other three groups . The proportions of patients in the second transplant cycle in groups B, C, and D were significantly different from those in groups A and E . However, the differences among the five groups in the third transplant cycle were not statistically significant . The proportion of positive hCG tests  and the clinical pregnancy rate  were significantly higher in group B than in the other three groups, except for group C. The embryo implantation rate was significantly higher in group A (51.16%) than in groups C , D , and E . The twin pregnancy rate  in group A was significantly different from that in groups B, C, and D. The preterm birth rate was significantly lower in group A (7.89%) than in groups B  and C . Group B (52.27%) had the highest live birth rate which was significantly different from that in groups A , D , and E . In group A, the neonatal birth weight and neonatal birth age were significantly higher than in groups B and C. The incidence of low-birth weight infants was lowest in group A; this was significantly different from that in groups B, C, and D . The proportion of male infants born in group E was significantly lower than that in the other four groups . In the adjusted analysis, we observed a similar risk estimate . When stratified by the number of transplant cycles, women who received a third transplant had the lowest adjusted RR of 0.699 (95% CI: 0.545–0.897). The unadjusted RR for DBT versus SBT for live birth outcomes was 1.344 (95% CI: 1.143–1.597); the adjusted RR was 1.451 (95% CI: 1.216–1.732). Other factors associated with live birth outcomes in the unadjusted analysis included high-quality blastocyst transfer . In the adjusted analysis, women who transferred high-quality blastocysts had a 1.296-fold increase in live birth outcomes  Table 3.Several factors were associated with an increased risk of twin pregnancy in the unadjusted analysis. First, the risk of secondary infertility was lower than that of primary infertility . Second, DBT was associated with a higher risk compared to SBT . Third, the transfer of high-quality blastocysts had a higher risk of twin pregnancy than the transfer of poor-quality blastocysts  while high-quality blastocyst transfer was associated with a 1.608-fold increased risk of twin pregnancy  Table 4.In the unadjusted analysis, a BMI of 24–28 was associated with a 0.317-fold increased risk of preterm birth ; however, in our adjusted analysis, we found that a BMI of 24–28 was not significantly associated with the risk of preterm birth. The unadjusted RR for the risk of preterm birth associated with DBT when compared with SBT was 3.091 (95% CI: 1.69–5.653) and the adjusted RR was 3.586 (95% CI: 1.899–6.769) Table 5.Despite the development of ART techniques, age remains an independent risk factor for fertility and pregnancy outcomes. Thus, women of advanced age have been the focus of ART research. Although one previous study showed that fresh blastocyst transfer is associated with a better pregnancy outcome than fresh cleavage transfer, and has gradually become the mainstream of embryo transfer at present , there iSeveral studies , 13 haveIt is well known that preterm infants, especially low birth weight infants, have immature organ development and twin fetal pregnancies significantly increases the risk of perinatal diseases and complications in pregnant women, fetuses, and newborns. These factors also increase the risk of neonatal mortality and chronic diseases in adulthood, thus placing a heavy burden on the national health care system and the families involved . It has Blastocyst quality is an important factor that can affect pregnancy outcomes. Previous researchers found that high-quality embryos may secrete microRNA hsa-miR-320a prior to implantation , 18. ThiInterestingly, in our previous study of young women aged < 35 years, we found that the proportion of male offspring increased significantly only with high-quality SBT and high-quality DBT . FurtherThere are three major limitations in this study that need to be considered. First, the study objects were not stratified by age, and only the effect of women aged 35–40 years on the primary outcome was considered. There is a significant lack of strong evidence as to whether this FET strategy is applicable to the women aged >40 years. It is hoped that this limitation will be addressed in future studies when more cases are collected. Second, we only investigated pregnancy outcomes after FET and did not analyze cumulative pregnancy rates or track the mental and physical development of newborns after birth. Finally, this study was a retrospective study carried out in a single center; there was no randomization of results. Thus, our results cannot be generalized; a large sample, prospective, multicenter, randomized, and controlled trial is now needed to validate the advantages of this FET strategy.It is vital that we fully investigate the range of maternal and infant safety issues associated with AMA while following the principles of patient benefit and offspring protection. In FET cycles, the choice of high-quality SBT for women aged 35–40 years results in both a high implantation rate and a significant reduction in the rates of twin pregnancy, preterm birth, and low birth weight infants, with more maternal and infant benefits. Although the live birth rate is not as high as that for high-quality DBT, on balance, it is still considered that high-quality SBT is the best FET strategy for women aged 35–40 years; this strategy should be implemented on a wider basis. The findings of this study have significant clinical implications for blastocyst selection strategies and the effective reduction of twin pregnancy rate in women of advanced age undergoing FET cycles.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by the Ethics Committee  of the Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University (2022-K-191-01). The patients/participants provided their written informed consent to participate in this study. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.YW contributed to the conception and design of this study. XL acquired and interpreted the data. HC and YF wrote the first draft of the manuscript. JZ approved the final manuscript. All authors contributed to the article and approved the submitted version.


Do neighborhoods with high rates of incarceration have higher rates of adverse birth outcomes compared with neighborhoods with low rates of incarceration after adjusting for aggregated maternal and other neighborhood factors?In this cross-sectional study of 2061 US Census tracts in New York City with 562 339 births, fully adjusted models demonstrated a 13% higher incidence rate ratio of preterm birth and 10% higher incidence rate ratio of low birth weight in neighborhoods with high rates of incarceration compared with those with low rates of incarceration.These findings suggest that living in a neighborhood with high rates of incarceration may contribute to adverse birth outcomes, and these neighborhoods warrant investment and further study. This cross-sectional study examines whether neighborhoods with high incarceration rates also have higher rates of adverse birth outcomes compared with neighborhoods with lower incarceration rates. The US has high rates of adverse birth outcomes, with substantial racial disparities augmented by stress and neighborhood disadvantage. Black people are more likely to live in neighborhoods with high rates of incarceration, which is a source of both stress and neighborhood disadvantage and, thus, may contribute to adverse birth outcomes.To determine whether neighborhoods with high incarceration rates also have higher rates of adverse birth outcomes compared with neighborhoods with lower rates.This cross-sectional study used publicly available data from the New York City Department of Health (2010-2014). Censored Poisson regression, with the US Census tract as the unit of analysis, was used to examine the association of neighborhood incarceration rate and birth outcomes. Multivariable models included percentage of births aggregated to the Census tract by maternal factors  and neighborhood factors . Analyses were performed between May 2021 and October 2022.Neighborhood incarceration rate, categorized into quintiles.The primary outcome was the incidence rate ratio (IRR) of preterm birth and low birth weight. Secondary outcomes were IRRs of very preterm birth, extremely preterm birth, and very low birth weight. Hypotheses were formulated before data collection.Among 2061 Census tracts with 562 339 births, incarceration rates varied from 0 to 4545 people incarcerated per 100 000, and high-incarceration neighborhoods had more residents of Black race (54.00% vs 1.90%), living in poverty (32.30% vs 10.00%), and without a general educational development equivalent (28.00% vs 12.00%) compared with low-incarceration neighborhoods. In fully adjusted models, high-incarceration neighborhoods had a 13% higher IRR of preterm birth , 45% higher IRR of very preterm birth , 125% higher IRR of extremely preterm birth , 10% higher IRR of low birth weight , and 52% higher IRR of very low birth weight compared with low-incarceration neighborhoods .Neighborhood incarceration rate was positively associated with adverse birth outcomes, particularly those associated with infant mortality. Black people were significantly more likely to live in high-incarceration neighborhoods, suggesting that mass incarceration may contribute to racial disparities in birth outcomes. Even within the same county, 2 neighborhoods may have incarceration rates as different as 0 people and 4000 people incarcerated per 100 000 population.21 People living in high-incarceration neighborhoods experience increased stress, disruption of family and social ties, and loss of financial and social resources and collective power.22 Living in a high-incarceration neighborhood is independently associated with worse mental health23 and an over 2-year lower life expectancy at birth,19 even after adjusting for neighborhood-level factors, including poverty, education, racial demographics , violent crime, and population density.19 Thus, the indirect effects of mass incarceration on nonincarcerated individuals living in high-incarceration neighborhoods could influence birth outcomes through neighborhood disadvantage, a more stressful environment for pregnant people, and decreased availability of social or economic resources.25 Importantly, the same populations with higher rates of adverse birth outcomes—low-income and Black individuals in particular—are more likely to live in high-incarceration neighborhoods.26One structural determinant of health that may contribute to adverse birth outcomes through these pathways is mass incarceration.28 and an association with state-level incarceration rate and infant mortality.29 However, people’s social networks and neighborhood resources may be more accurately reflected at a smaller geographic level. One study30 did examine the association of incarceration rates and preterm birth at the neighborhood level, but it was limited by a small sample and overall did not find a statistically significant association. In New York City (NYC), New York, racial disparities in birth outcomes and exposure to incarceration mirror national trends: non-Hispanic Black  people are most likely to have adverse birth outcomes and to live in high-incarceration neighborhoods.31 Thus, understanding how incarceration rates are associated with birth outcomes in NYC may be informative for policy makers both locally and nationally, particularly given ongoing conversations around decarceration, bail reform, and the close of NYC’s largest jail on Rikers Island.33Prior work has found associations between county-level rates of incarceration and birth outcomesThe goal of this study was to examine the association of neighborhood incarceration rates with adverse birth outcomes. Our primary outcomes were rates of preterm birth and low birth weight; secondary outcomes were rates of very preterm birth, extremely preterm birth, and very low birth weight. We hypothesized that neighborhoods with higher rates of incarceration would have higher incidence rate ratios (IRRs) of all adverse birth outcomes, particularly more negative birth outcomes.34 Our study follows Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline35 and did not require review by the Yale University institutional review board or informed consent because data were publicly available, in accordance with 45 CFR §46.We conducted a cross-sectional study examining the association of neighborhood incarceration rates with adverse birth outcomes using data aggregated to the Census tract level. We used the Census tract as a stand-in for neighborhood, because Census tract boundaries are determined by the US Census Bureau in conjunction with cities and counties with the goal of reflecting neighborhoods.36 State prisons make up the largest share of currently incarcerated individuals. Prisons house individuals convicted of a crime with a relatively longer sentence , whereas jails primarily house those who are pretrial (>80% of the jail population) and also individuals postconviction with a relatively short sentence .37 We modeled incarceration rate as a categorical variable, because it was significant as a quadratic variable in association with all birth outcomes. We used quintiles based on findings in our prior article19 showing that incarceration rate and life expectancy did not have a linear association, and the association was better reflected categorizing incarceration rate into quintiles.Incarceration rate data were provided at the aggregate level by the Prison Policy Initiative and include 83.1% of all individuals incarcerated in New York state prisons at the time of the 2010 Census, excluding those who did not provide a prior address that could be geocoded to a Census tract in New York.38 Tracts with fewer than 50 births over this 5-year period were excluded because of NYCDOH data reporting practices. We examined 3 categories of preterm birth: all preterm births, defined as prior to 37 weeks’ gestation; very preterm births, defined as from 28 to 32 weeks’ gestation; and extremely preterm births, defined as prior to 28 weeks’ gestation. Extremely preterm newborns had a greater than 30% rate of death during this time period.3 We examined 2 categories of low birth weight: all low-birth-weight newborns, defined as less than 2500 g, and very-low-birth-weight newborns, defined as less than 1500 g. We modeled all outcomes as count data. The NYCDOH left-censors all cells with a count below 5, meaning that Census tracts with between 0 and 4 births in a given category over the 5-year data period were censored.Birth outcome data were provided by the NYC Department of Health (NYCDOH) aggregated by Census tract from January 1, 2010, to December 31, 2014.39 with 2 or more newborns,40 and that were first newborns.41 For censored tracts, we substituted 0. To account for possible confounding due to both higher rates of adverse birth outcomes among Black people and the higher percentage of Black residents in high-incarceration neighborhoods,42 we adjusted for the percentage of births to Black people. Race and ethnicity data were provided by the NYCDOH on the basis of birth certificates completed by the birthing person. For censored tracts, we substituted the neighborhood percentage of Black residents. Because NYCDOH data did not include insurance status, we used tract-level insurance rates among women aged 18 to 45 years from the US Census American Community Survey (2010-2014), modeled as a continuous variable.43 As markers of neighborhood disadvantage, we included poverty rate and percentage of the population without a general educational development (GED) equivalent.43 To adjust for the possible confounding of living in a high-crime area and increased police contact, both of which may increase stress,44 we included violent crime rate. Violent crime rates were derived through geocoding of NYC Police Department data from 2010,45 described in our prior study.19 We did not include the racial demographics of the neighborhood as a proxy for exposure to structural racism,46 a commonly included variable in studies examining population health effects of incarceration, because of the near-perfect correlation  with the racial demographics of the birthing person, which was already a covariate in the model.We included individual-level and neighborhood-level factors associated with adverse birth outcomes as covariates, aggregated at the Census tract level. From the NYCDOH birth data, we included aggregated data on the percentage of births to those younger than 18 and older than 40 years,We tested all neighborhood covariates  as quadratic terms to determine whether to include these as continuous or categorical variables in our multivariable models. Poverty and violent crime were consistently significant as quadratic terms and so were included as quintiles for ease of interpretation; education was consistently not significant as a quadratic term, so it was included as a continuous variable. One Census tract was missing violent crime data, so full models did not include this Census tract.P < .05. Analyses were performed using Stata statistical software version 16.0 (StataCorp).First, we performed univariate analyses to describe our sample and compared demographic variables across quintiles of incarceration. We used the Kruskal-Wallis test of difference between mean ranks across groups because all demographic variables were nonnormally distributed. To account for the censoring in the NYCDOH data, we modeled births data using censored Poisson regression, which is a method available in Stata that accounts mathematically for lower-limit censoring. Unadjusted models included only incarceration quintile and the outcome of interest. We constructed multivariable models for each birth outcome of interest using nested models that adjusted first for individual factors aggregated at the Census tract level , then added insurance, next neighborhood disadvantage factors, and finally the percentage of births to Black people. We performed 2 sensitivity analyses. One modeled incarceration rate as deciles instead of quintiles, and the second substituted a count of 4 instead of 0 for all censored covariates. Analyses were performed between May 2021 and October 2022. Statistical tests were 2-tailed, and statistical significance was set at 47 Incarceration rates varied from 0 to 4545 people incarcerated per 100 000. The quintile of neighborhoods with the highest incarceration rate had a median (IQR) of 698 (571-902) people incarcerated per 100 000, whereas the lowest-incarceration quintile had a median (IQR) of 19 (0-35) people incarcerated per 100 000. Neighborhoods with the most vs the least incarceration differed, including having more residents who were Black , living in poverty , and without a GED equivalent  .19.00%]) .P < .001), a 131% higher IRR of very preterm birth , and 242% higher IRR of extremely preterm birth , compared with neighborhoods with the least incarceration. After adjusting for all covariates, these associations persisted, including a 13% higher IRR of preterm birth , 45% higher IRR of very preterm birth , and a 125% higher IRR of extremely preterm birth . For all models, the covariate that explained most of the difference between unadjusted and adjusted models was the percentage of births to Black people  and a 138% higher IRR of very low birth weight , compared with neighborhoods with the lowest incarceration rates. These findings persisted after adjusting for all covariates, including a 10% higher IRR of low birth weight , and 52% higher IRR of very low birth weight . Here too, for all models, the covariate that explained most of the difference between unadjusted and adjusted models was the percentage of births to Black people (In all models, as neighborhood incarceration rate increased, there was an increased IRR of low birth weight, with the greatest difference between the first and fifth quintile of incarceration. In unadjusted models, the neighborhoods with the highest incarceration rates had a 59% higher IRR of low birth weight (IRR, 1.59; 95% CI, 1.54-1.64; k people . Finding28 Here, we used a smaller geographic area to approximate neighborhood, include all racial groups, and examine multiple adverse birth outcomes. We found a 1.5 to 4 times higher IRR for overall preterm birth in high-incarceration neighborhoods compared with what had previously been reported for high-incarceration counties.28 This finding suggests that population-level health impacts of incarceration may be best measured and understood at a neighborhood level.In this cross-sectional study, we found that neighborhoods in NYC with high rates of incarceration had significantly greater rates of adverse birth outcomes compared with neighborhoods with lower incarceration rates, even after controlling for potential confounders aggregated at the Census tract level. Our findings expand on prior work observed at the county level.29 mass incarceration may contribute to persistently high rates of infant mortality in the US. As the relative rates of infant mortality in the US compared with peer nations have increased in step with the rates of incarceration in the last 50 years, further exploration of mass incarceration as a contributing factor to infant mortality is warranted.48Furthermore, we found that extremely preterm birth had the greatest association with neighborhood incarceration rate, suggesting that, consistent with prior work at the state level,17 Our finding that the racial demographics of the birthing persons explains much, but not all, of the association between incarceration rate and birth outcomes underscores the need for a multifaceted approach to address structural racism at both the individual and community level to improve birth outcomes.The association between incarceration rates and birth outcomes persisted even after adjusting for the percentage of births to Black people, suggesting that living in a high-incarceration neighborhood is itself a factor associated with increased risk of adverse birth outcomes and not simply a proxy for neighborhood racial demographics and known racial disparities in birth outcomes. Our work extends prior county-level work, which only examined birth outcomes among Black and White birthing people. Our data suggest that living in a high-incarceration neighborhood is associated with adverse birth outcomes across racial groups. However, since Black people are significantly more likely to live in high-incarceration neighborhoods, mass incarceration may still directly contribute to racial disparities in birth outcomes and infant mortality.49 using individual birth data in NYC from 2010 to 2016 found that only 0.9% of newborns had parental jail incarceration during gestation. That study found that paternal incarceration at some point during gestation was associated with a 34% to 39% higher risk of preterm birth or low birth weight, after adjusting for parental sociodemographics, maternal health behaviors, and health care access.49 Thus, if our findings were due to only increased adverse birth outcomes among those with a parent incarcerated during gestation, rather than factors associated with living in the neighborhood even for pregnant people with nonincarcerated partners, we would expect IRRs at least an order of magnitude lower than what we found. To be clear, our results suggest that living in a neighborhood with high rates of incarceration is associated with adverse birth outcomes even for newborns who did not have an incarcerated parent.Adverse birth outcomes in neighborhoods with high rates of incarceration cannot be attributed only to newborns whose parent was incarcerated during gestation. The highest-incarceration neighborhoods had a median of less than 1% of the population incarcerated at a given time. Furthermore, a study23 and increased stress among pregnant persons in these neighborhoods may contribute to adverse birth outcomes.25 Neighborhoods with high rates of incarceration also have less social cohesion and fewer financial and community resources, as policy dollars are spent on policing rather than community building.22 One recent study50 demonstrated improved access and adherence to prenatal care in counties with decreasing rates of prison admissions. Thus, prenatal care access may be lower in high-incarceration neighborhoods.The causal mechanisms behind our findings warrant further study. Adverse birth outcomes in neighborhoods with high rates of incarceration are likely due to spillover effects of incarceration onto nonincarcerated individuals. Living in a neighborhood with high incarceration is associated with worse mental health,26 Our work demonstrates that even those individuals who do not themselves experience incarceration are harmed by population-level exposure to it, including newborns. Policy makers in New York state considering changes to incarceration policy should consider these spillover effects. New York has relatively low rates of incarceration compared with the rest of the US, yet rates in New York are still almost triple those of our peer nations.51 Furthermore, the NYC neighborhoods with the highest rates of incarceration match the average rate in the US51 and underscore the need for research on the community-level effects of incarceration.Our findings suggest a need to invest in communities that experience high rates of incarceration and to identify specific needs and barriers to care for pregnant people living there. Mass incarceration has had a profound health impact on communities, particularly communities of color, which needs to be addressed before more harm is done.Our study has some limitations. Census tracts do not perfectly reflect lived neighborhoods and social networks, but these small geographic areas are the best representation in this data set. Our data include only those incarcerated at state prisons who provided an address that could be geocoded. We expect that those missing address data are more likely to come from high-incarceration neighborhoods. Neighborhoods with high rates of state prison incarceration are also likely to have high rates of jail and federal prison incarceration. Thus, our data likely underestimate the overall prevalence of incarceration in these neighborhoods, but accurately represent the neighborhood quintiles, which are relative rates, used in this study. Our data were limited because they were aggregated, so we could not stratify by race and ethnicity. This also limits the interpretation of the contribution of teen births, because most tracts had censored data on this variable, yet our overall findings were robust to sensitivity analyses substituting the upper and lower limits of the censored data. Future work with individual-level birth data would expand on our findings. Our data are limited by the remote time frame; however, these were the most recently available birth outcomes data from the NYCDOH, and incarceration rates have been stable. In addition, these data are cross-sectional and cannot definitively identify a causal relationship. However, our findings indicate that neighborhoods with high incarceration rates are vulnerable to negative health outcomes.17 Such neighborhoods warrant increased support, investment, and further study.In conclusion, pregnant people living in neighborhoods with high rates of incarceration are at higher risk of adverse birth outcomes, suggesting that mass incarceration may contribute to high rates of adverse birth outcomes and infant mortality in the US. Furthermore, because neighborhoods with high rates of incarceration have significantly higher proportions of Black residents, mass incarceration is a likely contributor to racial disparities in adverse birth outcomes and infant mortality.


This case demonstrates an endoscopic fenestration of an enlarging giant occipital arachnoid cyst. The patient is a 42-year-old woman presenting with headache, progressive vision loss, and nausea and vomiting. MRI demonstrates a large, nonenhancing cystic lesion in the right occipital lobe measuring up to 8.3 cm, consistent with an arachnoid cyst. This surgical video illustrates the technique for an endoscopic fenestration into the native ventricular system utilizing stereotactic MRI-guided stealth navigation. Postoperatively, the patient had full recovery with improvement of headaches and vision and was discharged on postoperative day 1 without complications.https://stream.cadmore.media/r10.3171/2023.1.FOCVID22129The video can be found here:  This is a surgical video demonstrating endoscopic fenestration of an enlarging right occipital arachnoid cyst in a lady in her 40s with worsening headaches, as well as visual field loss and optic disc swelling.5 The shunt was not the first choice, given the need to leave permanent hardware.The cyst measured approximately 8 cm with progressive enlargement over the years between 2010 and 2021, which had started significant mass effect and displacement of the ventricular system as well as of the occipital and temporal lobes. Given her worsening symptoms, the cyst, which is now being seen in different views, including the axial, coronal, and sagittal views, was considered for surgical intervention. The options considered were placement of a cystoperitoneal shunt, craniotomy for release of the cyst contents, as well as endoscopic fenestration.The surgical plan included having the patient prone, the use of stereotactic navigation, and using an endoscope on a preplanned trajectory, as shown below, to navigate down to the ventricle and to fenestrate the cyst.Here the endoscope is being introduced to the burr hole and we’re using electrocautery to find the spot, based on navigation, where the cyst contents come closest to the ventricular system. After using electrocautery to create an entry point, alligator forceps are used to enlarge the opening of the cyst to create the maximal opening and connection between the cyst as well as the ventricular system. This is a technique that is used sequentially to provide the biggest window of access, and after the first entry point, we use electrocautery, joining the area to further increase the size of this fenestration site, which is being seen over here. After electrocautery, we will follow that up with an alligator forceps clamp to further enlarge the created opening, and irrigation is constantly used, which provides a visual and tactile feel of the success of the fenestration depending on the billowing and movement of the cyst wall contents, which often indicates flow of fluid and creation of a connection.Microscissors are here being used to take down additional tissue between the two areas of electrocautery and the site of fenestration to maximize the creation of a bigger opening and chances of success. And again, this is the irrigation that is demonstrating the movement of the cyst walls and the flow of fluid from the cyst into the ventricular system. It is hard to understand the anatomy when inside a giant occipital arachnoid cyst, given the lack of anatomical landmarks and using navigation is helpful in understanding these locations. These thin cyst walls are further being divided with the use of microscissors to continue enlarging the site of opening at the fenestration. This further highlights the need for high-resolution endoscopy and accurate targeting in completion of some of this endoscopic microsurgical work that allows us to create these passages of fenestration for these lesions.Hemostasis is achieved with constant irrigation to stop any bleeding and to promote formation of blood clots, and a ventricular drain is placed under vision through the area of fenestration, which helps in the clearance of blood products, for keeping the fenestration open in the first 24 hours and also for monitoring of postoperative intracranial pressures at the site of fenestration.Placement of this ventricular drain under vision allows for safe, accurate placement of these monitoring devices.This is the imagining preoperatively and postoperatively, approximately 3 months apart, that demonstrates decrease in the size of the cysts and reconstitution of normal ventricular anatomy. The patient was discharged the next postoperative day, had improvement of headaches, and the visual improvement continued at 2 years’ follow-up, with improvement in the optic disc edema as well as the visual fields seen by the ophthalmologist.The occipital arachnoid cysts are rare lesions, but they can be symptomatic, especially with massive enlargement, as in this case. The treatment can be targeted and precise, using stereotactic navigation and high-resolution endoscopy, which allows us to make a large enough opening for accurate rerouting of cyst fluid into the ventricular system, and use of an external ventricular drain is useful for the reasons mentioned before. These are the references, thank you.The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this publication.Primary surgeon: Choudhri. Assistant surgeon: Blue. Editing and drafting the video and abstract: all authors. Critically revising the work: Ahmad, Choudhri. Reviewed submitted version of the work: Blue, Choudhri. Approved the final version of the work on behalf of all authors: Blue. Supervision: Choudhri.The necessary patient informed consent was obtained in this study.


The identification of factors impeding normal fetal development and growth is crucial for improving neonatal health. Historical studies are relevant because they show which parameters have influenced neonatal health in the past in order to better understand the present. We studied temporal changes of neonatal health outcomes  and the influence of different cofactors in two time periods. Moreover, we investigated particularly neonatal health in the wake of the 1918/19 influenza pandemic. Data were transcribed from the Bern Maternity Hospital and consists of two time periods: A) The years 1880, 1885, 1890, 1895 and 1900 ; B) The years 1914–1922 . Linear regression models were used to estimate the effect of birth year on birth weight, and logistic regression models to estimate the effect of birth year and of the exposure to the pandemic on premature birth, stillborn and low birth weight (LBW). Mean birth weight increased only minimally between the two datasets; whereas, in the years 1914–1922, the preterm birth and stillbirth rates were markedly reduced compared with the years 1880–1900. Sex, parity, gestational age and maternal age were significantly associated with birth weight in both time periods. The probability of LBW was significantly increased in 1918 (OR 1.49 (95% CI 1.00–2.23)) and in 1919 (OR 1.55 (95% CI 1.02–2.36)) compared to 1914. Mothers who were heavily exposed to the influenza pandemic during pregnancy had a higher risk of stillbirth (OR 2.27 (95% CI 1.32–3.9)). This study demonstrated that factors influencing neonatal health are multifactorial but similar in both time periods. Moreover, the exposure to the 1918/19 pandemic was less associated with LBW and more associated with an increased risk of stillbirth. If this trend is confirmed by further studies, it could indicate some consistency across pandemics, as similar patterns have recently been shown for COVID-19. Currently, impaired neonatal health remains an ongoing cause for concern for public health worldwide . IdentifNeonatal body dimensions are determined by various factors, such as genetics of the fetus   and mateRegarding infection, there is a body of literature showing that in utero exposure to influenza has, depending on the trimester, a negative effect on premature births and thus, on neonatal health –17. Studth century reflect both economic improvement of the standard of living and demographic changes [The changes in the size, shape, capability, and longevity of the human body since the 19 changes . During  changes –29.th century [th century , while adult height increased [The first descriptive studies on newborn size date back to the 19 century , 31. The century , 33. In  century . In anth century –40. In r century , 41. Att century –44. The  century  or to onncreased –47.th/early 20th centuries with modern means [However, the conclusion that birth weights have been relatively stable over the past 150 years has been reached by comparing means from the late 19rn means –44. Veryrn means . In Switrn means , 50. Swirn means . HoweverTherefore, the aim of this study, was to analyse for the first time two time-shifted samples from an identical data source, the maternity hospital in Bern: an early sample (1880–1900), when only approximately 20% of births occurred in maternity hospitals, and a later sample (1914–1922), when the coverage was higher (ca. 40–50%). We studied and compared the association between birth weight and different cofactors in the two time periods. Furthermore, we investigated whether there were temporal changes in terms of neonatal health  and particularly if there were neonatal health changes in the wake of the 1918–1919 influenza pandemic in Switzerland, a country that was severely affected by the 1918/19 pandemic.The data were transcribed from the original birth records of the maternity hospital in Bern (state archive inventory numbers StaBE BB 2.4.151–173). Access to the over 100 years old individual data was allowed by the Staatsarchiv Bern. After transcribing and data cleaning, the data have been fully anonymized. No ethics approval was required from the Canton of Bern for comparable studies by the same group of authors using these data collected over 100 years ago with an expired protection period. More detailed information about the canton of Bern and the maternity hospital can be found in the These records in both datasets include the following individual information for all deliveries that occurred at the hospital in the corresponding years: maternal age, place of residence  and “rural”), parity , birth date of the newborn, infant sex, stillbirth (yes or no), and the infant’s birth weight . In the To estimate the possible impact of the 1918/19 pandemic on neonatal health, we proceeded as follows: individual influenza-like illness symptom (ILI) information (and not confirmed influenza infection) was available (n = 40 cases with ILI symptoms around the time of childbirth). However, this individual sample was presumably small and imprecise. For that reason, we also estimated on an ecological level the flu intensity that the individual women were potentially exposed to during pregnancy. The weekly reported ILI cases from 1918/19 were transcribed from the State Archives of the Canton of Bern using the reported number of ILI cases in the city of Bern  components using moving averages and additive seasonal components was performed . In addiTo estimate the effect of year of birth on preterm birth (> = 38 weeks vs < 38 weeks), stillbirth  and low birth weight (LBW <2500 g vs > = 2500g) rates, we used a logistic regression model adjusted for sex, parity, birth month, maternal age, marital status, insurance status and urbanicity. In the model for preterm birth and LBW, stillbirth cases were excluded. The stillbirth model was additionally adjusted for gestational age. In addition, the effect of flu intensity on preterm birth, stillbirth and LBW rates was estimated and adjusted for the cofactors described above. Because year and flu intensity are highly correlated, year is not included in the latter model. In addition, this analysis is performed for each trimester individually. Furthermore, we reduced the dataset to the period in which ILI symptoms were documented  and descriptively compared whether there were differences in birth weights between women with and without documented influenza-like illness symptoms. Due to the small sample size, statistical tests were not performed.All statistical analyses were performed using R Version 4.2.2. The R package “dpylr”  was usedThe sample used for the analysis of the 1880–1900 data set comprised N = 1,530 births  and N = 6,924 births for the 1914–1922 dataset . The sample size ranged between N = 275 (1880) and N = 829 (1917). The crude annual mean birth weight varied only very slightly among the years, ranging between 3058.48 gr (SD 542.53) in 1895 and 3172.66 gr (SD 535.76) in 1921  according to the unadjusted and adjusted linear regressions is shown in Only 1919 shows a significant higher risk of LBW (OR 1.55 (95% CI 1.02–2.36) compared to 1914 . HoweverThe higher the flu exposure was, the higher the risk of stillbirth in the unadjusted (OR 2.02 (95% CI 1.2–3.4)) and adjusted (OR 2.27 (95% CI 1.32–3.9)) model . The OR The results of the time series analysis show that there was seemingly no decrease in birth weight during the pandemic in the second half of 1918 but that birth weight increased from week 27 in May 1919 onwards ) and third trimester (OR 2.73 (95% CI 1.42–5.24)) were found to have an increased risk of stillbirth .The boxplots show a slightly reduced birth weight  and a reWe analyzed two datasets of individual data of mothers and their newborns from the maternity hospital of the canton of Bern. Even though comparisons between the two data sets should only be made with caution due to the difference in births coverage, similarities and differences can be seen: Mean birth weight increased only minimally between the two datasets 1880–1900 and 1914–1922. However, in the years 1914–1922, the preterm birth and stillbirth rates were markedly reduced compared with the years 1880–1900. Sex, parity, gestational age and maternal age were significantly associated with birth weight in both datasets. For the period toward the end of the First World War and the 1918 influenza pandemic negative effects on the health of newborns were observed.Analysis of the cofactors in our two datasets reveals certain comparable patterns that are well known and documented in the literature on historical and modern birth weights, such as the finding that male newborns are heavier than female newborns and that increased parity or maternal age is associated with heavier birth weights , 40. In The mean birth weights we documented for the 1880–1900 are in the same range as those described for other European and US cities at the end of the 19th century  , 42, 57.th century [Our main finding concerning the impact of indirect influenza exposure (measured by the intensity of flu cases to which a woman has been exposed) is an increase in the stillbirth rate by a factor of 2.2. This is consistent with the evidence from demographic studies on the population level for the USA, Scandinavian countries or Japan –25. In t century . DependiOur study has several limitations. When working with historical birth weight data, it is central to discuss the issue of selection bias , 42, 44.Furthermore, maternal occupation was only documented for the earlier dataset from 1880–1900; for the years1914-1922, these data were no longer available, and marriage status and insurance status were the only proxies for socioeconomic status. Another limitation is that maternal body height, which is an important influencing factor , 64, wasAlthough the representativeness of our dataset increases across the two observation periods and the results need to be interpreted accordingly, our study shows that the factors influencing neonatal health were similar across the two datasets. The data on influenza infection during pregnancy were too imprecise in this source to be conclusive at the individual level. However, it appears that “Spanish flu” infections were less associated with lower birth weight and more associated with an increased risk of stillbirth. If this trend is confirmed by further studies, it could indicate some consistency across pandemics, as similar patterns have recently been shown for COVID-19 .S1 Text(TXT)Click here for additional data file.S1 File(PDF)Click here for additional data file.


Birth-related fractures are an important differential diagnosis of child abuse in early infancy. While fractures associated to vaginal deliveries are well known, cesarean section is not necessarily known to cause such injuries. Nevertheless neonatal fractures have been described after cesarean sections. To give an overview over the frequency and typical locations of such fractures, the appearance of symptoms and the timespan until diagnosis, a literature research was conducted via Google scholar and Pubmed, using the key words “cesarean section” and “fractures”. Birth-related fractures after cesarean sections are rare but can occur, with the long bones being particularly affected. Therefore, birth injuries should always be considered in the forensic medical assessment of fractures in early infancy, even after cesarean section. To enable a differentiation between birth trauma and physical abuse, birth and operation records should be checked for surgical manoeuvres, possible difficulties during the procedure or other risk factors. Birth-related fractures are usually detected early; in rare cases, the diagnosis is made only weeks after birth. Birth injuries are one of the differential diagnoses that regularly have to be considered when evaluating fractures suspicious of child abuse in an infant. A reliable forensic evaluation of the relevant findings is of considerable importance, both for the assessment of a possible endangerment of the child’s welfare and with regard to legal consequences. In the case of abuse-related fractures in a child without bone disease, it must generally be assumed that the trauma was very severe whereas birth related injuries can result from — not always avoidable—mechanical forces during birth. Accidental trauma as a cause of fractures in infancy is rare because of the restricted mobility of infants and the elasticity of the child’s bones. Usually an accidental trauma only comes into question as a differential diagnosis if a correspondingly significant and otherwise suitable event is described .The general incidence of birth-related fractures — independent of the delivery mode — was given in a recent population-based study with 2.9 per 1000 live births , 4 or caWhile the causation of fractures in vaginal deliveries is easy to understand against the background of the child’s passage through the mother’s bony pelvis, this does not necessarily apply to fractures in cesarean sections (c-sections). Nevertheless, neonatal fractures have also been described in the context of c-sections , 8. In fIn the present article, essential findings on neonatal fractures after c-sections are summarized in the form of a narrative review of the relevant literature.A selective literature search was carried out via Pubmed and Google Scholar for the keywords “cesarean section” and “fractures” taking into account publications of the last 40 years. The publications identified were only included in the further evaluation if they contained information on birth-related fractures in newborns specifically after c-section. Studies or case reports involving fractures in newborns with bone disease such as osteogenesis imperfecta and other than English or German language publications were not included. When evaluating the remaining work, the following points were addressed in particular: frequency of fractures, types of fractures, underlying mechanisms, length of time until the occurrence of clinical abnormalities and/or until the radiological diagnosis.The literature research resulted in a total of 35 evaluable and thematically suitable papers on bony injuries after c-section, including 11 clinical and 2 population-based studies as well as 22 case reports. Table Bony injuries after c-section are rare in children without bone disease, but are repeatedly described in the literature .In a 2006, prospective cohort study that included 37.110 cesarean deliveries at thirteen US university hospitals, injuries in newborns were identified in 418 cases (1.1%) . Only 25n = 6, 21.4%) in this study were diagnosed after c-section. In contrast, only one in seven clavicle fractures occurred during c-section.Nadas and Rheinberg  reportedMorris et al.  found anToker et al. (2009)  undertooPavone et al.  performeSherr-Lurie et al.  studied n = 412.066, 17.1%) than in vaginal births . However, there was an equal proportion of skeletal injuries in their study , with clavicle fractures being listed separately.Moczygemba et al.  found inn = 18) in their study taking into account 36.286 c-sections. Ulici et al. [Choi et al.  found ani et al. .Table There is a number of case reports on c-section–associated fractures of the femoral shaft, predominantly as a result of c-sections in breech pregnancies , 37, 40.Mileto et al.  reportedHumeral fractures after c-section have been described as a result of energetic traction during delivery from the uterus . Sherr-LSkull fractures after c-section are very rare and predominantly occur when forceps or vacuum delivery attempts preceded the c-section , 29. In Fractures of the clavicle sometimes even occur after elective c-sections . The undIn forensic medical casework, medical records such as birth or operation reports should be analysed with special regard to risk factors, delivery techniques suitable as a cause for trauma or the description of a difficult development of the child from the uterus.There are rare cases published in which the origin of the fracture was witnessed in real time by noticing a “cracking” sound or the feeling of a “snap” during delivery of the child from the uterus , 40. In Nevertheless in the vast majority of cases, birth-related fractures are diagnosed immediately or at the latest within the first two days after birth , 16. An Rather unspecific clinical signs of a fracture are irritability, feeding problems and increased crying, whereas reduced mobility of the affected body part as well as palpable step formation or crepitation represent more specific indications of a bone injury , 29.A special group of cases that have been reported were newborns who presented with (non-specific) clinical symptoms from birth, but who nevertheless had a delayed diagnosis of fractures, for example . The preAs is shown in Table In forensic medical casework, it should be emphasized that obstetric fractures diagnosed only weeks after birth are rare. In addition, from a forensic medical perspective, the question arises as to how a later occurrence of the bone injuries, possibly as a result of a subsequent child abuse, could even be ruled out in the cases mentioned above. Högberg et al.  describeWhen assessing fractures in newborns, obstetric injuries are not the only possible differential diagnosis to child abuse. In any case of a suspected child abuse with a bone injury in an infant an underlying bone disease should be ruled out. Medical guidelines such as the German AWMF S3( +) guideline on child abuse and neglect  give valIt has to be mentioned that bone injuries diagnosed in newborns not always occur at birth. They can also represent prenatal alterations as for example a so called “ping-pong” deformity of the fetal skull which can be a result of in utero pressure on the head . The posBirth-related fractures after c-sections are rare but can occur, with the long bones being particularly affected . Therefore, birth injuries should always be considered in the forensic medical assessment of fractures in early infancy, even after c-section. This requires a careful inspection of the birth and medical records, with particular attention being paid to information about difficulties in the development of the fetus from the uterus. Regarding the differentiation between birth trauma and physical abuse, it has to be considered that cases with an  clinically silent course have been described — even if it is not always clear from the clinical literature how reliably abuse has been ruled out. Nevertheless, such clinically silent cases are very rare; birth-related fractures are usually detected early. So far there is no defined age up to which fractures have to be considered birth related. If unspecific bridging symptoms are present, they can be evaluated as an indication of birth trauma.


Spinal meningeal cysts (SMCs) are currently classified into three types: extradural cysts without nerve root fibers (Type I), extradural cysts with nerve root fibers (Type II), and intradural cysts (Type III). However, the sacral terminal filar cyst is a distinct subtype with the filum terminale rather than nerve roots within the cyst. This study aimed to investigate the clinicoradiological characteristics and surgical outcomes of sacral terminal filar cysts.A total of 32 patients with sacral terminal filar cysts were enrolled. Clinical and radiological profiles were collected. All patients were surgically treated, and preoperative and follow-up neurological functions were evaluated.P < 0.0001). The cyst recurrence was noted in only 1 (3.1%) case.Chronic lumbosacral pain and sphincter dysfunctions were the most common symptoms. On MRI, the filum terminale could be identified within the cyst in all cases, and low-lying conus medullaris was found in 23 (71.9%) cases. The filum terminale was dissociated and cut off in all cases, and the cyst wall was completely resected in 23 (71.9%) cases. After a median follow-up period of 26.5 ± 15.5 months, the pain and sphincter dysfunctions were significantly improved (both Sacral terminal filar cysts are rare, representing a distinct variant of SMCs. Typical MRI features, including filum terminale within the cyst and low-lying conus medullaris, may suggest the diagnosis. Although the optimal surgical strategy remains unclear, we recommend a combination of resection of the cyst wall and dissociation of the filum terminale. The clinical outcomes can be favorable. Spinal meningeal cysts (SMCs) refer to extradural cystic lesions communicating with the subarachnoid space via a focal dural defect , 2. SMCsThis retrospective study has been approved by the Institutional Review Board and Ethics Committee of Peking University Third Hospital. A total of 32 patients with sacral terminal filar cyst were enrolled, including 13 males and 19 females. The average age was 36.1 ± 11.7 years, ranging from 16 to 64 years. The duration of symptoms prior to surgery was 30.2 ± 25.9 months, ranging from 10 days to 10.5 years.Inclusion criteria included: (1) A definitive diagnosis of sacral terminal filar cyst based on spinal MRI; (2) symptomatic sacral cyst manifesting as pain, lower-extremity weakness, and/or sphincter disturbance; (3) the sacral cyst was surgically treated, and filum terminale was found within the cyst intraoperatively; and (4) complete follow-up data including clinical symptoms, physical examinations, and radiological imaging. Exclusion criteria were as follows: (1) accompanied other type SMCs; (2) concomitant other spinal diseases; or (3) a previous history of operation on the SMCs.The pain intensity was evaluated as per the Visual Analogue Scale (VAS). Sphincter dysfunctions were assessed using the Japanese Orthopaedic Association (JOA) scoring system: 0 point represents urodialysis or urinary incontinent; 1 point, sense of retention, difficulty with micurature, prolonged urination, or dysuria; 2 points, delayed urination, or frequent urination; 3 points represent normal functions . The JOACombined intravenous and inhalation anesthesia, as well as intraoperative neurophysiological monitoring, was routinely performed. The patient was placed in a prone position with the lumbosacral portion at the highest level. A laminotomy was performed in the posterior wall of the sacral canal, following which the cyst was exposed. Next, the adhesion between the cyst and the inner wall of the spinal canal was dissected under a microscope. Then, the cyst was incised dorsally and unfolded, and the filum terminale was found passing through the orificium in the caudal end of the dural sac. From the orificium, cerebrospinal fluid constantly flowed out. To expose the filum terminale internum in the dural sac and to identify the orificium where the filum terminale internum breaks through the dural sac, a posterior midline incision of the dorsal dura was made. Subsequently, the caudal portion of the filum terminale internum was cut off, and a small part of the surrounding dural sac was resected. The cyst wall and the filum terminale externum were also dissociated and resected . During U-test or Student t-test for continuous variables, as appropriate. The threshold for significance was set as a P value less than 0.05.GraphPad Prism 9.3.1  was used for statistical analyses. The normality of data was examined using the Kolmogorov–Smirnov test. Continuous variables were presented as “mean ± standard deviation (SD)” when normally distributed or “medians ” when non-normally distributed. Categorical variables were presented as percentages. Statistical comparisons were performed using Mann–Whitney Among the 32 patients, 24 (75.0%) presented with chronic lumbosacral or perineal pain, among whom 13 had radiating pain spreading along the affected nerve root. Additionally, other onset symptoms included numbness in the lower extremities , weakness in the lower extremities , and sphincter dysfunctions .Physical examinations revealed that 11 (34.4%) patients had decreased acupuncture sensation at the saddle area, 18 (56.3%) patients had decreased muscle strength in the gastrocnemius, 3 (9.4%) patients had muscle atrophy, and 25 (78.1%) patients had weakened Achilles tendon reflex. No pathological reflection of Babinski's sign was induced. The VAS scores ranged from 0 to 7 points (mean 3.9 ± 2.5 points). The mean JOA score for sphincter dysfunctions was −1.8 ± 1.8 points . The mean JOA score for the lumbar neurological functions was 17.0 ± 7.9 points .Spinal MRI demonstrated an isolated cystic lesion in the sacral canal in all cases. The locations included: L5-S2 levels in 4 cases, S1-S3 levels in 11 cases, S2-S3 levels in 9 cases, S2-S4 levels in 6 cases, and S1-S4 levels in 2 cases. The cystic lesions showed hypointensity on T1-weighted imaging and hyperintensity on T2-weighted imaging; no enhancement was observed after the administration of contrast medium. The filum terminale was identified within the cyst in all (100%) cases, which was thickened with fatty infiltration, and low-lying conus medullaris was found in 23 (71.9%) cases .The operations lasted for 1.5–3 h (mean 1.6 ± 0.3 h). Intraoperative blood loss ranged from 30 ml to 250 ml (mean 76.3 ± 43.8 ml). The filum terminale was dissociated and cut off in all (100%) cases, and the cyst wall was completely resected in 23 (71.9%) cases and subtotally resected in 9 (28.1%) cases. The postoperative course was uneventful in all cases, and there were no significant motor complications or sphincter deterioration. Only 8 patients reported mild perianal numbness, which was gradually recovered within 3 months.All resected specimens were subjected to pathological examinations. The cyst wall showed fibrous connective tissue with a cyst wall-like structure, and a small part of it was lined with squamous epithelium, which was consistent with the diagnosis of meningeal cysts. The resected filum terminale was thickened with fibrous tissue and adipose hyperplasia.t = 7.673; P < 0.0001). The postoperative mean JOA score for sphincter dysfunctions was −0.28 ± 0.89, which was significantly better than the preoperative score . The postoperative mean JOA score for lumbar neurological functions was 24.9 ± 3.0, which was significantly higher than the preoperative score . The JOA improvement index was 9.4 ± 6.6 (range 1.0–20.0), and the improvement rate was 68% ± 13% (range 33%–100%). The detailed neurological function assessment results are summarized in The follow-up period ranged from 12 months to 7 years . The pain, sensorimotor disturbances, and sphincter dysfunctions were all significantly improved. The postoperative mean VAS score was significantly lower than that before surgery  with nerve roots , 8, follThe etiology and pathogenesis of sacral terminal filar cysts remain unclear. We found that the neck of cysts was mostly located at the site where the filum terminale breaks through the dural sac, and thus we speculated that the focal weakness of the dura mater may be the anatomical basis for the occurrence of sacral terminal filar cysts. Generally, the filum terminale internum transitions into the filum terminale externum at the caudal end of the dural sac, accordingly the focal dura mater in this site is similar to the nerve root sleeve. Therefore, we consider that sacral terminal filar cysts may share a similar pathogenetic mechanism with sacral Tarlov cysts.Clinically, sacral terminal filar cysts are relatively rare. With the enlargement of the sacral terminal filar cyst and progressively increasing intracystic pressure, the cyst may compress the surrounding structures and causes pain in the perineum , 11. AddMRI is the preferred imaging modality for the diagnosis of sacral cysts , 14. TheSacral nerve root irritation and tethered spinal cord symptoms are indications of surgical treatment of sacral terminal filar cysts . The surSurgical outcomes of sacral terminal filar cysts are satisfactory. Neurological deficits were all recovered, and cyst recurrence was only noted in one case after a mean follow-up period of 26.5 ± 15.5 months. Therefore, we propose that surgical treatment combining resection of the cyst wall and releasing the tethered spinal cord by dissociation of the filum terminale is a safe and efficient approach leading to a favorable prognosis. Furthermore, reconstruction of the terminal cistern is a crucial procedure for eliminating cerebrospinal fluid leakage and reducing the probability of cyst recurrence.Sacral terminal filar cysts represent a distinct subtype of SMCs, with typical MRI characteristics including filum terminale within the cyst and low-lying conus medullaris. A combination of resection of the cyst wall and dissociation of the filum terminale is a safe and effective surgical approach, and the clinical outcomes are favorable.