Is seasonality a risk factor associated with extremely preterm birth?In this cohort study of more than 1 million pregnancies involving 662 338 pregnant individuals in Denmark, season during gestation was associated with extremely preterm birth. Gestation during autumn was associated with the highest rate of extremely preterm birth, whereas gestation during winter was associated with the lowest rate.This study found that season during gestation was associated with extremely preterm birth, suggesting the presence of risk factors associated with seasonality that may be preventable. Preterm birth, particularly extremely preterm birth, has been associated with substantial morbidity and mortality. Research during SARS-CoV-2–related lockdowns revealed reductions in the more severe subtypes of preterm birth in some countries, suggesting the presence of preventable risk factors, such as infectious diseases or social behavior. Seasonality may provide a similar means of assessing natural changes in the daily life of pregnant individuals that were similar to those experienced during the COVID-19 lockdown period.To evaluate the association between seasonality and extremely preterm birth.This nationwide cohort study included 1 136 143 pregnancies in Denmark with onset between January 1, 1997, and December 31, 2016, in which the fetuses survived 21 completed weeks of gestation. Pregnancies were followed up until preterm birth, fetal death, or 37 completed weeks of gestation. Data were analyzed from September 2020 to September 2021.Season during gestation (primary exposure) and season of pregnancy onset.The main outcome of extremely preterm birth was defined as a live birth occurring between 22 weeks, 0 days’ gestation and 27 weeks, 6 days’ gestation. Cox regression analyses were used to estimate hazard ratios (HRs) for season during gestation and season of pregnancy onset, with adjustment for socioeconomic and demographic factors.Among 662 338 pregnant individuals, the median age at pregnancy onset was 30.0 years . Of 1 136 143 pregnancies, 2009 extremely preterm births  were identified during follow-up. Season during gestation was associated with extremely preterm birth, with cumulative incidences of 0.17%  in spring, 0.18%  in summer, 0.20%  in autumn, and 0.16%  in winter. Compared with winter, the adjusted HRs (AHRs) for the risk of extremely preterm birth were 1.11  for spring, 1.15  for summer, and 1.25  for autumn. The number of extremely preterm births associated with the increased risk in the spring, summer, and autumn was 56.1 , representing 2.8%  of all extremely preterm births in the study. Season of pregnancy onset was not associated with the risk of extremely preterm birth in spring  or summer  compared with winter, but a slight increase in risk was observed in autumn  compared with winter.In this large, national cohort study, seasonality was associated with 2.8% of all extremely preterm births. Season during gestation was associated with the rate of extremely preterm birth, suggesting the presence of potential risk factors associated with season that may be preventable. Further research to identify risk factors for extremely preterm birth associated with seasonality is warranted. This cohort study examines the association between seasonality and extremely preterm birth among pregnant individuals in Denmark. In France, extremely preterm birth has been associated with moderate to severe neurodevelopmental disabilities in 28% of children at age 5 years.2 In a Swedish cohort of children born extremely preterm between 2014 and 2016, the 1-year survival rate without any substantial morbidities was only 38%,3 and the adverse health consequences appeared to persist into adulthood.4 The identification of preventable risk factors for preterm births, particularly extremely preterm births, is of major public health importance.Preterm birth is the primary cause of death among children younger than 5 years.5 Genetic factors, maternal characteristics, previous pregnancy history, and fetal, psychosocial, environmental, and pregnancy characteristics all appear to be associated with the risk of preterm birth, but few modifiable risk factors have been identified.6 Notably, in a recent study conducted in Denmark,7 a marked decrease in the prevalence of extremely preterm births was observed during the COVID-19 lockdown period between March 12 and April 14, 2020, compared with the same 1-month period in 2015 to 2019. This decrease was not found among very premature or moderately premature births, and there was no corresponding increase in the rate of stillbirths.8 Reductions in preterm birth after national lockdowns have been observed in several other countries, including Argentina, Australia, China, Ireland, Italy, the Netherlands, and the US,16 but these reduction have not been reported in all countries,18 and notably have not occurred in Sweden, where the COVID-19 lockdown restrictions were less severe.19 A meta-analysis found an overall reduction in preterm births in high-income but not low-income countries.20The etiologic characteristics of preterm birth are, however, complex.The Danish observation of a marked decrease in extremely preterm births only could suggest that the COVID-19 lockdown had implications for risk factors that are specific to this phenotype to a greater extent than other preterm birth phenotypes. The most likely consequences of the lockdown were increases in focus on hygiene, working from home, and social distancing, potentially producing reductions in microbial exposure, changes in physical activity patterns, decreases in exposure to psychological stressors, and possible reductions in climate exposure. These and other profound changes in the daily lives of pregnant individuals may have constituted a unique natural phenomenon that facilitated the observed reduction in extremely preterm births. Seasonality appears to provide similar, although less extreme, changes in physical activity, climate exposure, and microbial exposure; thus, we hypothesized that seasonality might be associated with the risk of extremely preterm birth.To evaluate this hypothesis, we conducted a large nationwide cohort study of the seasonality of extremely preterm birth that comprised all pregnancies in Denmark between 1997, and 2016. The data permitted us to distinguish the association of season at pregnancy onset from the association of season during gestation, to discern different obstetric subtypes of preterm birth, and to identify associations with extremely preterm birth compared with very preterm and moderately preterm birth.STROBE) reporting guideline for cohort studies.Ethics approval was not required because the study used data from administrative registers and was therefore exempt from providing informed consent according to regulations for register-based studies in Denmark. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology  were identified using diagnostic codes from the International Classification of Diseases, Tenth Revision recorded in the National Hospital Register22  and smoking during pregnancy from the Danish Medical Birth Register.21 We also included information on parity (defined as previous pregnancies with at least 21 completed weeks of gestation). Because missing values were rare for most covariates, we used complete case analysis. Missing values were present to a greater extent for body mass index and smoking status; therefore, these covariates were only included in a sensitivity analysis of a subcohort with complete information.From Statistics Denmark and the Central Person Register, we obtained information on a number of demographic and socioeconomic covariates, including maternal employment status , family structure , level of education , disposable household income , location of residence in Denmark , and maternal place of birth .We analyzed the pregnancy cohort using survival analysis with a fetuses-at-risk approach. All pregnancies with fetuses surviving 21 completed weeks of gestation were followed up from week 22 to birth, to week 36 and 6 days, or to December 31, 2016, whichever event occurred first. In the analysis of preterm birth subtypes, follow-up was concluded before 28 completed weeks of gestation for extremely preterm births, before 32 completed weeks of gestation for very preterm births, and before 37 completed weeks of gestation for moderately preterm births. Stillbirths and abortive outcomes occurring during follow-up were considered competing risks. Follow-up time was classified according to season during gestation, season of pregnancy onset, and covariates of interest. Seasons were defined as winter , spring , summer , and autumn .25 Bootstrapping was used to derive 95% CIs.We used Cox proportional hazards regression analyses with gestational age as the underlying time scale to estimate hazard ratios (HRs) assessing the risk of preterm birth according to season and month during gestation as well as season and month of pregnancy onset. Potential confounding covariates were included directly in the adjusted regression models. Continuous covariates, such as birth year and maternal age, were modeled using restricted cubic splines. We used the Aalen-Johansen estimator, taking into account competing risks to estimate the cumulative incidences of study outcomes. We estimated the absolute impact of season as the unadjusted observable proportion of potentially associated preterm births.Our main analysis assessed the association between season during gestation and extremely preterm birth. Assessments of the month during gestation and the season and month of pregnancy onset were considered secondary analyses. Very preterm and moderately preterm birth were considered comparative outcomes. We conducted an exploratory interaction analysis of gestation month and pregnancy onset month, and we performed several sensitivity analyses of data from the main analysis.P = .05.Data were analyzed using R software . The threshold for statistical significance was 2-sided We identified 1 577 511 pregnancies with onset between 1997 and 2016. Of those, 402 945 pregnancies  had fetuses who did not survive 21 completed weeks of gestation. Among the resulting 1 174 566 pregnancies, 38 423 (3.2%) were excluded due to missing values . Of the resulting 1 136 143 pregnancies involving 662 338 individuals , we identified 2009 extremely preterm births over 6 777 673 fetal weeks of follow-up, 4746 very preterm births over 4 504 907 fetal weeks of follow-up, and 31 384 moderately preterm births over 5 560 081 fetal weeks of follow-up. The preterm birth prevalence was 3.4% for any preterm birth, 2.8% for moderately preterm birth, 0.4% for very preterm birth, and 0.2% for extremely preterm birth.Extremely preterm births had covariate characteristics that were broadly similar to those of very preterm and moderately preterm births . Most moThe cumulative incidence of extremely preterm birth was lowest in winter  and highest in autumn , followed by summer  and spring  . This paWhen comparing month during gestation with the reference month of January, we observed the highest risk of extremely preterm birth in September, October, and November; these monthly patterns were similarly attenuated for very preterm and moderately preterm births . FurtherIn the cohort with complete information on body mass index and smoking status during pregnancy (n = 689 680), we assessed the association between season during gestation and risk of extremely preterm birth. This approach yielded AHRs similar to those observed in the main analysis   by an exposure. When comparing the distributions of exposed and unexposed populations, a relative association in the leftmost tail of the distribution, where extremely preterm birth is located, may be observed. This association would then become more statistically significant when categorizing gestational age. We also cannot discount the possibility of the presence of a risk factor that is specific to extremely preterm birth, which would act only on the leftmost tail of the gestational age distribution. However, the clinical and public health impact would be the same, suggesting the potential identification of a preventable risk factor for extremely preterm birth. The benefits of identifying preventable risk factors are substantial for both maternal and offspring health.This cohort study found that seasonality was associated with 2.8% of all extremely preterm births, which was not observed among preterm births occurring closer to term. Given that substantial morbidity and mortality are associated with extremely preterm birth, further research to identify mechanisms and specific preventable risk factors associated with the seasonality of this adverse perinatal outcome is warranted.


However, the mechanisms through which aPO can interact directly with plasmalemmal ionic channels to perturb the amplitude or gating of ionic currents in excitable cells remain incompletely understood. Herein, we aimed to investigate any modifications of aPO on ionic currents in pituitary GH3 cells or murine HL-1 cardiomyocytes. In whole-cell current recordings, GH3-cell exposure to aPO effectively stimulated the peak and late components of voltage-gated Na+ current (INa) with different potencies. The EC50 value of aPO required for its differential increase in peak or late INa in GH3 cells was estimated to be 13.2 or 2.8 μM, respectively, whereas the KD value required for its retardation in the slow component of current inactivation was 3.4 μM. The current–voltage relation of INa was shifted slightly to more negative potential during cell exposure to aPO (10 μM); however, the steady-state inactivation curve of the current was shifted in a rightward direction in its presence. Recovery of peak INa inactivation was increased in the presence of 10 μM aPO. In continued presence of aPO, further application of rufinamide or ranolazine attenuated aPO-stimulated INa. In methylglyoxal- or superoxide dismutase-treated cells, the stimulatory effect of aPO on peak INa remained effective. By using upright isosceles-triangular ramp pulse of varying duration, the amplitude of persistent INa measured at low or high threshold was enhanced by the aPO presence, along with increased hysteretic strength appearing at low or high threshold. The addition of aPO (10 μM) mildly inhibited the amplitude of erg-mediated K+ current. Likewise, in HL-1 murine cardiomyocytes, the aPO presence increased the peak amplitude of INa as well as decreased the inactivation or deactivation rate of the current, and further addition of ranolazine or esaxerenone attenuated aPO-accentuated INa. Altogether, this study provides a distinctive yet unidentified finding that, despite its effectiveness in suppressing NOX activity, aPO may directly and concertedly perturb the amplitude, gating and voltage-dependent hysteresis of INa in electrically excitable cells. The interaction of aPO with ionic currents may, at least in part, contribute to the underlying mechanisms through which it affects neuroendocrine, endocrine or cardiac function.Apocynin ( The time constants of INa inactivation were estimated by fitting the inactivation trajectory of each current trace with a double exponential curve . These rate constants would be evaluated using the following equation:k*+1 or k−1, respectively, are ascribed from the slope or from the y-axis intercept at [aPO] = 0 of the linear regression in which the reciprocal time constant  versus varying aPO concentrations was interpolated. ∆τ indicates the difference in the slow component of current inactivation (τinact(S)) obtained when the τinact(S) value during exposure to each concentration (0.03–30 μM) was subtracted from that in the presence of 100 μM aPO :maxI is the maximal peak INa in the absence or presence of 10 μM aPO; V the conditioning potential in mV; V1/2 the half-maximal inactivation in the relationship of the curve; q the apparent gating charge; F Faraday’s constant; R the universal gas constant; and T the absolute temperature.The quasi-steady-state inactivation curve of peak I® 2016 program . The data are presented as the mean ± standard error of the mean (SEM), with sample sizes (n) indicating the number of GH3 or HL-1 cells from which the data were collected. The Student’s t-test (paired or unpaired) and the analyses of variance (ANOVA-1 or ANOVA-2) with or without repeated measures followed by post-hoc Fisher’s least-significant different test were performed. The analyses were performed using SPSS version 20.0 . A p value of less than 0.05 was considered to indicate the statistical difference.Curve fitting ) to various data sets was carried out with the goodness of fit by using various maneuvers, such as the Microsoft “Solver” function embedded in Excel 2019 (Microsoft) and 64-bit OriginPro2+-free Tyrode’s solution containing 0.5 mM CdCl2, the composition of which was stated in Materials and Methods, and we filled up the pipette by using the Cs+-containing solution. As the whole-cell configuration was firmly established, we voltage-clamped the tested cell at the level of −80 mV and a brief step depolarization to −10 mV was delivered to activate INa with a rapid activation and inactivation  turned out to be linear  for the binding of aPO to the Nav channels was consequently yielded to be 3.4 μM, a value which was noticeably close to the estimated EC50 value for aPO-mediated stimulation of late INa determined from the concentration-response curve . Additionally, the stimulatory effect of aPO on the steady-state inactivation curve of INa was further characterized (Na with or without the addition of aPO (10 μM) was constructed and properly fitted to a Boltzmann type sigmoidal function  by using a non-linear regression analysis. In the absence and presence of 10 μM aPO, the V1/2 value was noticed to differ significantly (−62.6 ± 1.3 mV (in the control) versus −49.2 ± 1.4 mV (in the presence of aPO); n = 7, p < 0.05); in contrast, the value of q (apparent gating charge) did not differ significantly (2.79 ± 0.12 e (in the control) versus 2.82 ± 0.13 e (in the presence of aPO); n = 7, p > 0.05). Therefore, cell exposure to aPO not only increased the maximal conductance of INa, but also shifted the inactivation curve to the rightward direction by approximately 13 mV. However, we found no evident change in the gating charge of the inactivation curve during cell exposure to aPO. As such, it is reasonable to assume that the steady-state INa inactivation curve in the presence of this compound was shifted rightward, with no clear adjustment in the gating charge of this curve.We continued to examine the stimulatory effect of cterized B. In thiaPO produces any effect on the recovery of INa from inactivation. In a two-step voltage protocol, a 50-ms conditioning step to −10 mV inactivated most of the current, and the recovery from current inactivation at the holding potential of −80 mV was examined at different times with a test step , as demonstrated in aPO was not present), the peak amplitude of INa nearly completely recovered from inactivation when the interpulse duration was set at 100 ms. The time constant course of recovery from current inactivation in the absence or presence of aPO (10 μM) was least-squares fitted to a single-exponential function with a time constant of 23.3 ± 1.1 or 11.3 ± 0.9 ms , respectively. These experimental observations indicate that cell exposure to aPO produces a significant shortening in the recovery from inactivation of INa in GH3 cells.We then examined whether the presence of Na [Na blocker as well as an inhibitor of NOX activity [Na inactivation [Na identified in GH3 cells. As demonstrated in Na. However, in the continued presence of Tef for two minutes, one minute after further addition of 10 μM aPO, peak INa was not increased further. In addition, as cells were continually exposed to 10 μM aPO, subsequent application of 10 μM RFM or 10 μM Ran was able to attenuate aPO-induced stimulation of INa one minute later. The results imply that aPO and Tef share a similarity to their stimulation of INa, and that further addition of RFM or Ran is effective in attenuating aPO-stimulated INa in GH3 cells.Tef, a type-I pyrethroid insecticide, was reported to be an activator of INa ,24,25,27activity ,28,29,30tivation ,32. For aPO on INa is engaged in either its inhibition of NOX activity or the reduction in the production of reactive oxygen species. The expression of NOX was previously reported to be distributed in pituitary cells [aPO on INa was assessed in cells preincubated with MeG or SOD for 6 h. MeG was previously recognized to be a substrate for NOX activity [3 cells preincubated with MeG for 6 h, the I-V relationship of peak INa with or without addition of aPO is illustrated in aPO (10 μM) could significantly increase the amplitude of INa measured at the level of −20 mV from 401 ± 31 to 511 ± 39 pA . Likewise, in SOD-preincubated cells, the addition of aPO (10 μM) increased INa amplitude at −20 mV from 409 ± 31 to 515 ± 41 pA . Therefore, these results allowed us to suggest that the stimulatory effect of aPO on INa that we obtained in these cells is unlikely to be due to changes in either the production of reactive oxygen species or cytosolic NOX activity.One would expect that the effect of ry cells ,15. As sactivity ,34,35, wactivity . HoweverV channels [aPO is able to modify INa(P) Vhys activated in response to the upright isosceles-triangular ramp pulse in GH3 cells. In this stage of our whole-cell current recordings, the tested cell was voltage-clamped at the level of −80 mV and we then applied it with a set of isosceles-triangular ramp pulses ranging between −110 and +50 mV (with a height of 160 mV) of varying ramp duration at a rate of 0.05 Hz through digital-to-analog conversion (Na(P) in response to such upright triangular ramp voltage was noticed to display a striking figure-of-eight Vhys  in the instantaneous I-V relationship of INa(P) with two distinct peaks, i.e., low and high threshold INa(P). Alternatively, there is an initial counterclockwise direction, which time goes by, in current trajectory  activated by the upsloping limb, and following the downsloping limb, a clockwise direction  ensued  at high or low threshold respectively activated by the upsloping triangular ramp voltage (forward or ascending) or downsloping (backward or descending) limb of upright triangular ramp voltage was increased. The augmentation of low-threshold INa(P) produced by 30 μM aPO was observed to be greater than that in the high-threshold one  amplitude measured at the level of −0 mV ) during the ascending phase of triangular ramp pulse was significantly raised to 175 ± 29 pA  from a control value  of 151 ± 18 pA (n = 8). Meanwhile, during cell exposure to 30 μM aPO, the peak INa(P) amplitude measured at −80 mV during the descending phase of such a ramp concurrently increased from 285 ± 33 to 393 ± 54 pA . Alternatively, the subsequent application of 10 μM Ran, but still in the continued presence of 30 μM aPO, was able to attenuate the aPO-mediated increase of INa(P) taken at either high or low threshold amplitude in the Vhys loop. These observations, therefore, enabled us to indicate that the Vhys strength of INa(P) activated by isosceles-triangular ramp pulses of varying ramp duration observed in GH3 cells was enhanced in the presence of aPO  is currently a subject of extensive research, including Nachannels ,37,38. Wnversion A. Consis) ensued B. Of parhold one C, for exe of aPO B,C.Na, can be effective in inhibiting IK(erg) [aPO exercises any perturbations on IK(erg). The biophysical and pharmacological properties of IK(erg) in GH3 cells have been previously reported [+, Ca2+-free solution, and the recording pipette was filled up with K+-containing solution. The composition of these solutions was detailed under Materials and Methods. The examined cell was voltage-clamped at −10 mV and the linear downsloping ramp pulse from −10 to −100 mV with a duration of 1 s was applied to it. As shown in aPO resulted in a progressive decline in the amplitude of deactivating IK(erg) in response to such a downsloping hyperpolarizing ramp. However, in the continued presence of aPO, further application of E-4031, an inhibitor of IK(erg), was able to decease the current amplitude further. Therefore, unlike INa induced by aPO, IK(erg) residing in these cells was subject to being inhibited by its presence.Earlier studies have demonstrated that telmisartan, an activator of I IK(erg) . For thireported ,39,40,41aPO was previously demonstrated to be a chemo-preventive agent for cardiovascular disorders though the inhibition of NOX activity [Na inherently in heart cells  could still be modified by the presence of aPO. The preparation of these cells was described above under Materials and Methods. Cells were kept bathed in Ca2+-free Tyrode’s solution in which 10 mM TEA was included, and the pipette was filled with Cs+-enriched solution. Noticeably, as HL-1 cells were continually exposed to aPO at a concentration of 3 or 10 μM, the amplitude of peak INa activated by 50-ms depolarizing pulses from −80 to −10 mV was increased; concomitantly, progressive slowing of the inactivation time course of the current was seen ; concomitantly, the τinact(S) value was significantly raised to 56.3 ± 7.1 ms  from a control value of 7.1 ± 1.4 ms. After washout of aPO , current amplitude returned 892 ± 58 pA . Alternatively, in the continued presence of aPO (10 μM), further application of either ranolazine  or esaxerenone  was noticed to attenuate aPO-mediated stimulation of INa  this agent resulted in the differential stimulation of peak or late amplitude of INa activated by abrupt step depolarization with aneffective EC50 value of 13.2 or 2.8 μM, respectively; (c) aPO mildly shifted the I-V curve of INa towards the depolarized potentials , and it also made a rightward shift in the steady-state inactivation curve of the current towards the right side with no changes in the gating charge of the curve; (d) the recovery of the INa block was enhanced in its presence; (e) subsequent addition of rufinamide (RFM) or ranolazine (Ran) counteracted aPO-accentuated INa; (f) the stimulatory effect of aPO on INa remained unaltered in cells preincubated with MeG or SOD; (g) aPO was capable of increasing the high- or low-threshold amplitude of INa(P) elicited by the isosceles-triangular ramp at either upsloping (ascending) or downsloping (descending) limb, respectively; (h) the aPO presence mildly decreased the amplitude of IK(erg) activated by the downsloping ramp pulse; and (i) the exposure to aPO was effective at increasing the amplitude and inactivation time constant of INa in HL-1 atrial cardiomyocytes. Collectively, the present results allow us to reflect that aPO-stimulated changes in the amplitude, gating, and Vhys behavior of INa appear to be unlinked to and upstream of its inhibitory action on NOX activity, and that it would participate in the adjustments of varying functional activities in electrically excitable cells , presuming that similar in vivo findings exist.The distinctive findings in the present study are that (a) GHNa demonstrated here, there was a slight shift toward more negative potential in the presence of aPO. The steady-state inactivation curve of INa in its presence of aPO was also shifted to a rightward direction with no apparent change in the gating charge of the curve. The increased recovery of the INa block was demonstrated in its presence. As a result, the window current of INa in GH3 cells was expected to be increased during cell exposure to aPO. Such a small molecule may have higher affinity to the open/inactivated state than to the resting (closed) state residing in the Nav channels, despite the detailed ionic mechanism of its stimulatory action on the channel remaining elusive.From the overall I-V relationship of IaPO can inhibit NOX activity and decrease the production of superoxide oxide [aPO on INa observed in GH3 cells may actually result from either the reduction of NOX activity or the decreased level of superoxide anions [3 cells preincubated with MeG or SOD, the stimulatory effect of aPO on INa was indeed observed to remain effective. It is also noted that aPO can mildly inhibit the amplitude of IK(erg). Therefore, under our experimental conditions, the stimulation of INa caused by aPO tends to emerge in a manner largely independent of its inhibitory effect on NOX activity; hence, the aPO molecule can exert an interaction at binding site(s) inherently existing on Nav channels.Several lines of clear evidence have been demonstrated to indicate that de oxide ,3,4,16. de oxide ,15,16. AaPO-induced increase in INa is that we observed the non-linear Vhys of INa(P) in the control period  and during cell exposure to aPO or aPO plus Ran, by use of the upright isosceles-triangular ramp voltage command of varying duration through digital-to-analog conversion. In particular, when cells were exposed to aPO, the peak INa(p) activated by the forward (ascending or upsloping) end of the triangular ramp of varying duration was observed to be elevated, particularly at the peak level of 0 mV, whereas the INa(P) amplitude at the backward (descending or downsloping) end was increased at the peak level of −80 mV. In this respect, the figure-of-eight  configuration in the Vhys loop activated by the triangular ramp pulse was evidently demonstrated (Na elicited by rectangular depolarizing step. The presence of aPO was capable of enhancing the Vhys strength of INa(P) and, in its continued presence, further addition of Ran attenuated aPO-increased Vhys loop of the current. In this scenario, findings from the present observations disclosed that the triangular pulse-induced INa(P) was detected to undergo striking Vhys change  in the voltage-dependence and that such Vhys loops were subject to enhancement by the presence of aPO.Perhaps more important than the issue of the magnitude of the nstrated A,B. AddiaPO on INa is that in this study, due to its effectiveness in increasing the Vhys magnitude of INa(P), the voltage-dependent movement of the S4 segment residing in NaV channels is probably perturbed by this agent; consequently, the coupling of the pore domain to the voltage-sensor domain, which the S1–S4 segments comprise, tended to be facilitated [aPO molecule, is supposed to be a conformationally flexible region of the NaV-channel protein. Therefore, these findings can be interpreted to mean either that such INa(P), particularly during exposure to aPO, is intrinsically and dynamically endowed with “memory” of previous (or past) events, which is encoded in the conformational (or metastable) states of the Nav-channel protein, or that there is a mode shift of channel kinetics occurring regarding the voltage sensitivity of gating charge movement, which relies on the previous state (or conformation) of the Nav channel [V channels would potentially play substantial roles in interfering with electrical behavior, Na+ overload, and hormonal sretion in varying types of excitable cells [aPO, did produce a considerable reduction in the aPO-mediated increase in Vhys responding to triangular ramp voltage.Pertinent to the stimulatory effect of ilitated ,46. Inde channel ,38. Suchle cells . It is aaPO (5 mg/kg), the peak plasma aPO level was detected at 1 min to reach around 5500 ng/mL (or 33.1 μM). Additionally, aPO was reportedly a selective inhibitor of NOX2 activity with an effective IC50 of 10 μM [50 value required for the aPO-stimulated peak or late INa was 13.2 or 2.8 μM, respectively, while the KD value estimated on the basis of minimal reaction scheme was 3.4 μM. It is reasonable to assume, therefore, that aPO-induced changes in the amplitude, gating or Vhys behavior of INa presented herein could be highly achievable and of pharmacological relevance.From pharmacokinetic studies in mice , followiof 10 μM . AccordiaPO on transmembrane ionic currents, particularly on NaV channels, tends to be direct obligate mechanisms. Pyrethroids , known to activate INa, have also been reported to disrupt NOX activity in brain tissue (striatum) [aPO in various pathologic disorders, such as inflammatory or neurodegenerative diseases, and heart failure [On the basis of the present experimental observations, despite the inhibitory effect on NOX activity ,3,4, ourtriatum) . Therefotriatum) ,12,13,50 failure ,42.


Mesenteric cysts are extremely rare intra-abdominal tumors. They usually present with an array of symptoms, usually non-specific, which leads to difficulty in diagnosing them. Occasionally these can present in the emergency as an acute abdomen. We report a rare presentation of a huge mesenteric cyst with gastric perforation, misdiagnosed clinically as obstructed inguinal hernia. A 50-year male presented with complaints of sudden severe pain in the abdomen along with swelling and pain in the right groin region with absolute constipation for the last 4 days. A clinical diagnosis of obstructed inguinal hernia was made. However, on radiological investigations, it was discovered as a giant intra-abdominal cyst herniating into the inguinal canal. On exploration, we were further surprised to find a concomitant gastric perforation.In this case report, we highlight that mesenteric cysts can present as acute abdomen and, very rarely, can be associated with an accompanying cause of surgical abdomen. Mesenteric cysts are extremely rare intra-abdominal tumors . These aA 50-year-old male came to the emergency room with complaints of sudden onset pain in the abdomen and over the swelling in the right groin for four days. The swelling in the right groin had been there for the last 18 months. The pain initially started at the swelling and later on became generalized to the whole abdomen. He also complained of absolute constipation. On examination patient’s vital signs were stable except for mild tachycardia and slightly raised body temperature. The patient had a distended abdomen with diffuse guarding all over. There was a tender swelling in the right inguinoscrotal region, and the penis was seen buried inside the scrotum  of the abdomen was done, which showed a giant mesenteric cyst herniating into the right inguinal canal with minimal free fluid in the abdomen Figure .The patient had to undergo exploratory laparotomy through a midline incision. We were surprised to find co-existing prepyloric perforation of 1 X 1cm along with a huge mesenteric cyst, which was occupying almost the whole of the abdomen and was seen herniating into the right inguinal region. The prepyloric perforation was repaired by the modified Graham’s omental patch repair technique, and complete enucleation of the mesenteric cyst was done Figures -6.      The excised cyst was sent for histopathology, which showed fibro collagenous tissue lined with mesothelial lining compatible with a mesenteric cyst.Mesenteric cysts are uncommon intra-abdominal tumors with an incidence of 1 in 27,000 to 1 in 250,000 .Classically mesenteric cysts are classified into four types; 1) embryonic or developmental, 2) traumatic or acquired, 3) infective or degenerative, and 4) neoplastic . MesenteKurtz et al. analyzed 162 cases of mesenteric cysts and described that the most common location of these cysts was in the small bowel mesentery . These cMesenteric cysts presenting as strangulated umbilical and femoral hernia have also been reported in the literature . A mesenDue to varied clinical presentations, preoperative diagnosis is almost impossible to make on a clinical basis. In our case, it was further complicated by the presence of concomitant gastric perforation, which led to clinical misdiagnosis. Although ultrasound is sensitive in detecting the cyst contents, a CT scan should be the first single initial investigation because it gives information about the location of the cyst and nature of contents. Precise diagnosis and treatment are necessary owing to the malignant transformation of cyst in 3% of cases . In our Surgical management with complete excision of the cyst is the treatment of choice to prevent recurrence and treat cyst-associated obstruction, volvulus, or herniation of the bowel. Bowel resection is necessary when the cyst is in the vicinity of the bowel or involving blood supply to the bowel. Total cystectomy by open approach is a method of choice. Laparoscopic excision of cyst has also been reported. The laparoscopic approach offers the advantage of early recovery and reduced hospital stay. In our case, we enucleated the mesenteric cyst and performed omental patch repair for perforation. In some cases, when the cyst is in the vicinity of vital structures marsupialization can also be done. This procedure is suboptimal and may require a second surgery in the future for recurrence .Mesenteric cysts are rare benign intra-abdominal lesions and large cysts are even less common. It can present acutely in the emergency and sometimes may be associated with a co-existing surgical emergency.


Toxoplasma gondii, one of the most common parasites, causes toxoplasmosis, one of the most frequent zoonotic diseases worldwide. T. gondii infects about one-third of the world’s population. T. gondii infection is generally considered a major risk for spontaneous abortion, prematurity and low birth weight in the animal sphere. Less commonly, a toxoplasma serological profile is correlated with the particular data of delivery. Acute T. gondii infection during pregnancy often leads to spontaneous abortion and/or a severe injury of the eyes, brain, and other structures of the foetus. Latent T. gondii infection of pregnant women could lead to less obvious but important changes during pregnancy, including the end product of pregnancy and the timing of labour. This study aimed to contribute to the current knowledge by comparing serological T. gondii profiles of pregnant women with prematurity and low birth weights of newborns.th and 16th weeks of pregnancy. Prematurity was defined as the liveborn preterm delivery in gestational age of pregnancy <37 weeks. Low birth weight was defined as weight at birth of ≤2499 grams. The complement-fixation test (CFT) provided serological profiles for toxoplasmosis that expresses the overall levels of toxoplasma immunoglobulins of all classes. Enzyme-linked immunosorbent assay (ELISA) tests for IgG and IgM were used simultaneously. IgM positivity helped to differentiate acute from the latent stage of toxoplasmosis. Birth data, especially the week of delivery and fetal weight, were evaluated accordingly.A retrospective study design was adopted. The study participants included a cohort of 1733 pregnant women who consecutively gave birth to their children and underwent regular antenatal biochemical screening between the 142(1) = 5.471, p = .019 and between latent toxoplasmosis and low birth weight of newborns, χ2(1) = 7.663, p = .006. There was a 1.707 times higher risk of prematurity for toxoplasma-positive women, while the risk for low birth weight was 1.861 times higher. The strength of both tests of association was mild. We tested the correlation between the levels of CFT titres and week of delivery and weight of newborns. No association was found between the level of latent toxoplasmosis and the week of delivery and fetal weight.Of the 1733 pregnant women, 25% were diagnosed as latent toxoplasma positive, and 75% as toxoplasma negative. There were 87 premature deliveries versus 1646 timely births. We observed 88 low birth weights and 1645 normal fetal weights. We found a statistically significant association between latent toxoplasmosis and prematurity, χLatent toxoplasmosis was associated with premature birth rate and lower birth weight of newborns. The odds of premature delivery was 1.7 and low birth weight 1.9 times higher in women with latent toxoplasmosis compared to toxoplasma negative women. Even though the strength of the association in our large sample is relatively mild, the combination of latent toxoplasmosis with other adverse factors could cause serious harm. Whole CFT and specific IgG levels of latent toxoplasmosis are not linked to the severity of prematurity or low birth weight in newborns. Toxoplasma gondii (T. gondii), one of the most common parasites, is an obligate intracellular protozoan parasite belonging to the phylum Apicomplexa subclass coccidia that causes toxoplasmosis . T. gondA Toxoplasma serological profile is less commonly correlated with the specific data of delivery –9. Acuteth and 16th weeks of pregnancy. The participants were then offered screening that included ultrasound examinations for congenital diseases and pregnancy dating, a human chorionic gonadotropin (HCG) test, alpha-fetoprotein (AFP), estriol, and Toxoplasma serological profile test. Non-specific selection of participants was conducted. One blood sample was used for all tests.A retrospective study design was adopted. The study participants were pregnant women who consecutively gave birth to their children and underwent regular antenatal biochemical screening between the 14st, 3rd faculty of medicine, the State organization for statistics and informatics in healthcare, genetic center Gennet and National reference Laboratory for Toxoplasmosis  in the National Institute of Public Health in Prague. The study period was 20 years (1995 to 2015). All data were treated anonymously, and identification was only accessible to the principal authors of the study. The study was approved by the Ethical Committee of the Teaching Hospital, Charles University Prague. Patients’ written consent was waived as all the data were retrospectively collected from the databases described above and rendered anonymous prior to analysis.Participants’ data were acquired from databases at the teaching hospital 1Prematurity (preterm birth) was defined as the liveborn preterm delivery in the gestational age of pregnancy <37 weeks. Low birth weight was defined as a weight at birth of ≤2499 grams according to the classification of the World Health Organisation .The complement-fixation test (CFT) provided serological profiles for toxoplasmosis that expresses the overall levels of Toxoplasma immunoglobulins of all classes , 16. ThiSPSS-IBM statistical software was used for the primary analysis. The Pearson chi-square test for association was applied to identify potential associations between latent toxoplasmosis, prematurity and low birth weight. In addition, the Spearman correlation was calculated to compare quantitative levels of toxoplasmosis with specific weeks of birth and the weight of newborns.Table 1. There were 87 premature deliveries (Prem+) and 1646 timely deliveries (Prem-). There were 88 low birth weights (LowW+) and 1645 normal fetal weights (LowW-). Prevalences with percentages are summarised in Table 1. The Pearson chi-square revealed a statistically significant association between latent toxoplasmosis and prematurity, χ2(1) = 5.471, p = 0.019 (Table 2) and between latent toxoplasmosis and low birth weight of newborns, χ2(1) = 7.663, p = 0.006 (Table 3). There was a 1.707 times higher risk of Prem+ for Toxoplasma-positive women and 1.861 times higher risk for LowW+. The strength of both statistically important tests was mild (Table 4). We tested the correlation between the levels of CFT titres and the week of delivery and weight of newborns. For this purpose, we transformed the rate of CFT to its log2 form. Spearman’s correlation analysis failed to show a significant correlation between the level of latent toxoplasmosis and the week of delivery and fetal weight (Table 5). IgG levels were not compared to the birth data because of their apparent lack of comparability.In all, 1733 women were included, all of whom gave birth to a singleton baby. Multiple pregnancies were not included. Earlier delivery and lower birth weight are common in multiple pregnancies, which would have likely biased the data. Three women were not included because of a suspected acute form of toxoplasmosis (IgM positive). The mean age of the final sample was 29.6 years (range 17–46 years) at delivery. From these pregnant women, 434 (25%) were diagnosed as latent Toxoplasma-positive (T+) and 1299 (75%) as Toxoplasma negative (T-). Participant characteristics are presented in The serological results can provide relevant information about infection dating. The serological diagnosis of primary toxoplasmosis in pregnant women is mainly based on specific IgM and immunoglobulins IgG. IgMs are earliest antibodies in acute infection produced during the first week after infection. In contrast, IgGs are the last antibodies to emerge, usually a few weeks after IgMs. The diagnosis of a verified infection is only established on the appearance of IgG. The specific immunoglobulin IgA test is used by some laboratories as an additional marker of acute infection. IgG avidity and Western blot tests could provide broad information about the severity of an infection , 14.The dictum “once infected, always infected” applies to toxoplasmosis. In humans, infection is thought to persist in the body in the chronic, latent form  after prThe strength of this study is that the data collected are adequately large. Another strength is that the screening method used in this study has been employed for decades and allows long-term comparability. Patients’ data on infection/non-infection and delivery information are available. One potential limitation is that the pregnant women were mostly from urban areas. There is most likely a lesser prevalence of infection in urbanized districts than in rural areas.Our results show a statistically significant association between latent toxoplasmosis and premature birth rate and lower birth weight in newborns. The odds of premature delivery and low birth weight were 1.7 and 1.9 times higher, respectively, compared to Toxoplasma negative women. Although the strength of the association in our large sample is mild, the combination of latent toxoplasmosis with other adverse factors could cause severe harms. Whole CFT and specific IgG levels of latent toxoplasmosis are not associated with the severity of prematurity or low birth weight in newborns.


Adjusted generalized estimating equations showed that favorable neighborhood conditions promoted the growth of longer and heavier infant bodies, and reduced the risk of intrauterine growth restriction. The associations were stronger for female versus male infants, though not significantly different. Moreover, COI was associated with better maternal mental health and diet during pregnancy; diet significantly mediated the association between COI and birth size outcomes. This study underscores the importance of considering the accumulated benefit of neighborhood assets for maternal and infant health. Interventions that capitalizes on the full range of contextual assets in which mothers live may promote pregnancy health and fetal growth.Neighborhood and individual level risks commonly co-occur for pregnant women and may cumulatively contribute to birth outcomes. Moreover, the relationship between favorable social and environmental neighborhood conditions and perinatal outcomes has been understudied. This study considered the accumulated impact of prenatal exposure to positive neighborhood social, environmental, and educational conditions in relation to maternal health during pregnancy and birth size outcomes. In a prospective study of a multi-ethnic and socioeconomically diverse cohort ( Gestation is a critical period of development, when risk and protective exposures can influence health across the life course ,2. BirthNeighborhood conditions, including social and economic disadvantage , aspectsSocial and environmental risks commonly co-occur for pregnant women and children, particularly among vulnerable populations ,25,26. AThis study examined the accumulated impact of positive neighborhood social and environmental factors, as measured by the COI, in relation to maternal health during pregnancy and birth size outcomes. We hypothesized that higher COI scores in the prenatal period would be associated with healthier birth size outcomes. Also, as much DOHaD work notes sex-specific associations for prenatal exposures and birth outcomes ,6, we hyn = 290 eligible participants completing the prenatal and birth assessments. The present analysis includes the n = 239 with complete information on residential address during pregnancy, maternal health, birth outcomes, and covariate information. Protocols and informed consent documents were approved by institutional review boards at Albany Medical Center and the University at Albany State University of New York.Participants were part of the Albany Infant and Mother Study (AIMS), a prospective observational cohort study of pregnant women and their infants born at Albany Medical Center  . Englishwww.diversitydatakids.org (accessed on 10 November 2020).Neighborhood Child Opportunity Index. Participant residential addresses during pregnancy were geocoded in ArcMap version 10  using the building geocoding function and the US Address—Single House address locator. These geocoded addresses were linked to 2015 census tracts using QGIS. Neighborhood conditions for each participant were measured using the Child Opportunity Index 2.0 ,37. ThisContinuous COI scores for each census tract were used in this analysis, with higher scores representing more neighborhood opportunity. This COI score reflects a rank order of all 72,000 neighborhoods in the United States according to child opportunity, weighted by the number of children in each census tract, resulting in 100 rank-ordered groups. The COI scores range from 1 to 100 . We also examined the distribution of neighborhood-level child opportunity according to quintiles , which were derived according to national distributions of COI scores. All COI variables used in the analysis were from 2015, the year in which the majority of AIMS participants were pregnant and/or the immediate time preceding the pregnancy.2; calculated from self-reported pre-pregnancy height and weight provided at the enrollment visit) and weight gain in pregnancy . Maternal pregnancy health factors included weight and body size metrics, pregnancy complications, behaviors, and depression. Specifically, the weight and body size metrics included pre-pregnancy body mass index , and diet during pregnancy. Diet was assessed in pregnancy with a 25-item food frequency questionnaire ,39; a weInfant characteristics. Anthropometric measurements of the newborn were conducted in the delivery room by trained clinical staff using standard protocols and instrumentation. Information on gestational age at birth (weeks), birth weight (kilograms), birth length (centimeters), head circumference (centimeters) were abstracted from medical records. In addition, a cephalization index ((head circumference cm/birth weight g)*100)) was derived. This index reflects a certain type of intrauterine growth restriction that is characterized by asymmetry . This asymmetry can signal potential brain sparing during gestation and offspring neurodevelopmental vulnerability ,42. Highp-values, and confidence intervals that accounted for this correlated data structure. This GEE modeling approach is consistent with other recent work studying the association between COI and child outcomes [p-values < 0.05 and 95% confidence intervals.First, those excluded from the complete case analysis were compared to those included in the analytic sample according to maternal sociodemographic factors and COI scores via independent t-tests and Chi-square tests. Descriptive statistics were generated for all study variables, and bivariate associations were assessed via Pearson’s correlations. Associations between neighborhood COI and infant outcomes were assessed with generalized estimating equations (GEE) with exchangeable correlation structures, adjusted for covariates. Because observations were not independent due to clustering at the census tract level, we used GEE, which provided parameter estimates, outcomes . To testoutcomes ,45. To ooutcomes ,47 were p = 0.01). The characteristics of the study population included in this analysis are listed in There were no significant differences between those included and excluded from the complete case analysis in terms of maternal age, race, education attainment (high school or less vs. higher) and child sex. Those excluded were more likely to have lower COI scores .The adjusted associations between the COI scores and infant outcomes are listed in The adjusted associations between the COI scores and maternal health during pregnancy are listed in p = 0.02) and birth length  were significantly different from zero. No evidence of mediation was observed for western diet and cephalization index (p = 0.14), or for depressive symptoms and any outcome . See Given the significant associations with COI, additional analyses were conducted to determine whether maternal depressive symptoms or western diet mediated the associations with birth weight, birth length, and cephalization. Sobel tests determined that the mediated effect of a western diet in the associations between COI and birth weight  and maternal and infant outcomes are shown in This is the first study to consider the accumulated impacts of positive neighborhood educational, social, and environmental attributes in relation to pregnancy health and birth outcomes. The results indicated that neighborhood-level opportunity was cumulatively associated with healthier infant birth size and maternal health during pregnancy, even after adjusting for individual level maternal age and race and ethnicity, as well as other known contributors to birth size outcomes including smoking during pregnancy, child sex, and gestational age at birth. The results also suggested that maternal diet during pregnancy mediated the associations between neighborhood opportunity and birth size. These findings were particularly noteworthy as we considered the role of neighborhood opportunity in maternal and child health outcomes in a unique geography that includes a heterogeneous mix of small cities, suburban neighborhoods, and rural areas. Disparities and assets in regions like this tend to be under-characterized in the literature.The associations between COI and infant birth size outcomes indicated that positive aspects of the neighborhood social and physical environment promoted the growth of longer and heavier infant bodies, but not larger head circumferences, which suggests normative symmetry in fetal growth, as well as the absence of restricted growth and brain sparing during fetal development. The associations were adjusted for gestational age, and thus do not reflect a spatial distribution of prematurity and term births in the region. These findings are novel and highlight that just as adverse gestational exposures can contribute to poor birth outcomes, positive factors can likewise influence the developing fetus and promote healthy growth. The results from the sex-stratified models suggested that the positive effect of COI on birth size outcomes may be stronger for female infants than for males. However, the interaction tests for infant sex and COI did not reach statistical significance. While much DOHaD work observes sex-specific patterning in prenatal exposure and infant outcome associations, we cannot conclusively determine if the effect of COI was different for males and females in this sample. More work with larger sample sizes is needed to test for the sex-specific effects of prenatal COI exposure on birth outcomes.To our knowledge, only one study has considered the effect of combined (adverse) social and environmental exposures during pregnancy at the neighborhood level in relation to birth size outcomes . In thatp = 0.05), suggesting that having greater access to healthy foods directly contributed to less adherence to a western diet during pregnancy. We also found that diet during pregnancy was associated with each COI domain, suggesting that educational, social and economic features of the neighborhood (apart from food access) can also promote healthy eating during pregnancy. For depression, we did not observe a mediation effect between COI and birth size outcomes, despite finding that COI contributed to better maternal mental health. It may be that in the prenatal period, the effects of COI may be relayed to the fetus through dietary intake, which can directly affect physical growth in utero, whereas the mental health pathway linking COI to child outcomes may come into play postnatally when social and emotional interactions with caregivers is paramount. We have initiated a follow-up protocol to characterize the AIMS cohort in early childhood; our future work will be able to study this question specifically.Greater neighborhood opportunity was associated with fewer maternal depressive symptoms and less adherence to a western diet during pregnancy. The Sobel tests indicated that maternal diet significantly mediated the association between the COI and birth weight and birth length in this sample. These findings suggest that favorable social and environmental neighborhood conditions may help promote maternal mental health and healthy dietary practices during pregnancy, which, at least for diet, has implications for birth size. One component of the COI score was access to healthy foods . This neighborhood characteristic was negatively correlated with a western diet . Given these distributional concerns, we hesitate to conclude that favorable neighborhood conditions do not influence maternal weight, pregnancy complications, or smoking behavior during pregnancy. Rather, we encourage future work with larger samples and a broader distribution of maternal health experiences to replicate these analyses and consider the role of COI in promoting pregnancy health.This study has some limitations. The sample size was relatively small, which may have reduced the power to detect associations; the sample size also precluded the possibility of examining patterning of COI associations among subgroups of the population, including racial and ethnic minorities. Moreover, as the complete case analysis excluded more socially vulnerable areas and individuals, the associations reported here likely represent underestimates of the true population associations. In addition, while the Sobel tests provide some preliminary evidence that the observed mediated effect of COI on infant outcomes according to diet was significantly different from zero, Sobel tests do not estimate the magnitude of the mediated effects nor account for the possibility of multiple mediators working simultaneously. We encourage future work to build on this study to identify social and environmental neighborhood assets that could promote healthy pregnancies and favorable infant outcomes in minority communities, and to use mediation methods that can better characterize the pathways linking neighborhood opportunity to maternal and child health.These limitations notwithstanding, this study has a number of strengths. It is among the first to consider the accumulated impacts of favorable social, environmental, and educational community assets in relation to maternal health during pregnancy and birth size outcomes. We used a multimodal prospective design that included area level measures of neighborhood context, maternal self-reported and physician-assessed clinical characteristics, and directly assessed anthropomorphic measures of infant body size. Moreover, we rigorously controlled for potential confounding by including several sociodemographic and clinical characteristics in the multivariate models.This study demonstrated that positive social, educational, and environmental neighborhood attributes cumulatively contributed to healthy pregnancies and favorable birth outcomes. While the identification of individual and community level hazards in relation to perinatal risk is an important public health priority, this work underscores the utility of also considering the accumulated benefit of positive social, environmental, and educational assets for maternal and infant health. Interventions that capitalize on the full range of contextual assets in which mothers live during pregnancy may not only promote healthy births, but may also support child development as well.


Data of premature neonates born between 2001 and 2015 from the research database of Chang Gung Memorial Hospital with corresponding individual medical records up to July 2020 were analyzed. Long-term neurodevelopmental outcomes were defined by the international classification of disease codes −9 or −10. The prevalence of diseases was compared between LIPO and SMOF groups at five and five years old and further analyzed by stratification of 1500 g birth weight. The LIPO and SMOF groups each included 1120 neonates. Epilepsy, cerebral palsy, developmental disorder and attention-deficit hyperactivity disorder (ADHD) were significantly decreased at age two years in the SMOF group, and epilepsy, language delay (LD), ADHD and autism spectrum disorder (ASD) were significantly decreased in the SMOF group at age five years. In children with birth weight < 1500 g, ADHD was decreased in the SMOF group at ages two and five years, and ASD was decreased in the SMOF group at age five years. In children with birth weight ≥ 1500 g, epilepsy, LD and ADHD were decreased in the SMOF group at age two years. LD was decreased in the SMOF group at age five years. We conclude that lipid emulsions with fish oil improve the neurodevelopmental outcomes of children born prematurely.Neurodevelopmental morbidities developed more commonly in low-birth-weight premature infants. We sought to determine the effects of different lipid emulsions on the neurodevelopmental outcomes of children born prematurely. This retrospective cross-sectional study had two intervention legs, Lipofundin HoweverAside from cognitive and motor deficits, behavioral and psychological problems are also more likely for children born preterm than those born at term . Data ofFish oil is rich in α-linolenic acid (omega-3), such as DHA and eicosapentaenoic acid (EPA). DHA can be transferred to the fetus through the placenta and cross the blood-brain barrier and is rapidly accumulated in the fetal brain to promote brain growth during the third trimester of pregnancy . Humans ® MCT/LCT, mainly composed of soybean oil and medium-chain triglycerides, was used before 2010. After that year, Smoflipid®, made up of soybean oil, olive oil, fish oil and medium-chain triglycerides, has been used instead. The compositions of the main fatty acids in Lipofundin® MCT/LCT and Smoflipid® are shown in ® MCT/LCT or Smoflipid® by retrospectively reviewing data from the Chang Gung research database.DHA is accumulated from the mother and then intake continues postnatally, derived from the diet . Preterm® MCT/LCT or Smoflipid®, were enrolled in this study. These enrolled babies were born either at CGMH or born at other hospitals, but all were admitted to CGMH within three days after birth. Patients who died during their first admission or were denied follow-up visits after first discharge were excluded. Patients’ medical records were reviewed retrospectively until July 2020 for neurodevelopmental outcomes, including language delay (LD) , developmental disorder , CP , autism spectrum disorder  and attention-deficit hyperactivity disorder . Covariate diseases were documented as meningitis , perinatal asphyxia , hydrocephalus , intraventricular hemorrhage , periventricular leukomalacia , patent ductus arteriosus , retinopathy of prematurity , bronchopulmonary dysplasia  and necrotizing enterocolitis . LD, ASD and ADHD were diagnosed by pediatric psychologists, whereas developmental disorders and CP were diagnosed by pediatric neurologists. Developmental disorders were diagnosed based on at least two delays of motor function, speech, language, cognitive, play or social skills. A speech-specific delay was defined as a language delay. PVL and IVH were documented by both ICD codes and neurosonographic reports. Surgical records were also reviewed if PDA ligation and laser surgery, scleral buckling or bevacizumab injection for ROP had been performed. All covariate diseases occurred before the diagnosis of neurodevelopmental outcomes. Demographic data were collected, including gestational age, birth weight, birth length, head circumference, body temperature at admission and APGAR scores at 1 and 5 min after birth.This multi-center cross-sectional hospital-based study was conducted using data from the Chang Gung research database, which provides comprehensive computerized information from all patients who have ever visited CGMH. CGMH has six branches, including two tertiary medical centers. The branches are located in the north, center and south of Taiwan, and occupy more than 10% of the medical costs of the National Health Insurance of Taiwan. All premature babies who were born between 2001 and 2015 and met the international classification of disease (ICD)-9 codes between 765.20 and 765.28, and that had received Lipofundin® MCT/LCT  or Smoflipid® . Every neonate only received one of those; a mixed lipid emulsion was not administered. The feeding protocol in the NICU was to introduce breast milk soon after birth. For those mothers who were unable to express sufficient breast milk for full enteral feeding, or when donor human milk is not available, preterm formula was used instead. Usually, breast milk/preterm formula was started from trophic feeding 10mL/kg/day for 3–5 days and then advanced to a feeding amount of 10–20 mL/kg/day in ELBW infants or 20–30 mL/kg/day in very low birth weight  infants. Low-osmolality preterm formula, at a 20 kcal/oz concentration, was used for very low birth weight neonates and advanced to 24 kcal/oz later. When enteral feeding reached 100 mL/kg/day, the lipid emulsion supplementation would be discontinued and fortification with fortified human milk was initiated. The enteral ferrous-drop supplement was started at 4–8 weeks after birth to prevent anemia of prematurity. Micronutrients were not added into TPN until 2016 at CGMH.The nutrition guidelines for preterm babies at CGMH follow the recommendations of the American Academy of Pediatrics. The American Academy of Pediatrics Committee on Nutrition advises that the nutritional goal of preterm infants is to achieve postnatal growth that approximates the growth of a normal fetus at the same postconceptional age . The rec® or Lipofundin® MCT/LCT were divided into a SMOF and a LIPO group, respectively. The gestational age was entered into a logistic regression to create a propensity score for matching. These two groups were matched by a frequency of 1:1 on the basis of gestational age to control its effect on neurodevelopmental outcomes. A flow chart of included and excluded patients is presented in All patients who received Smoflipidt-test for continuous data. Neurodevelopmental outcomes are shown at two points: two and five years of corrected age. Patients in each group were further stratified by birth weight and divided into ≥1500 g and <1500 g subgroups. Neurodevelopmental outcomes were further analyzed by logistic regression after adjusting for comorbidities. All data were analyzed statistically using IBM SPSS statistics software  and p < 0.05 was considered statistically significant.Demographic and clinical (morbidity) data were compared between the SMOF and LIPO groups using the chi-square test for dichotomous variables and the ® or Lipofundin® MCT/LCT for lipid supplementation after birth. After 1:1 frequency matching of gestational age, there were 1120 infants in each group. The demographic and clinical characteristics of these two groups are shown in p = 0.0168, 0.0179, 0.0335, 0.00001, respectively). These children were further stratified by their birth weights into ≥1500 g and <1500 g subgroups. In children with birth weights of less than 1500 g, ADHD in the SMOF group was less prevalent than that in the LIPO group . In children with birth weights of more than 1500 g, epilepsy, LD and ADHD were less prevalent in the SMOF group than that in the LIPO group . When the premature children were five years old, 343 and 568 children were left in the SMOF and LIPO groups. The prevalence of epilepsy, LD, ADHD and ASD were significantly lower in the SMOF group after adjusting for comorbidities . In children with birth weights of less than 1500 g, the prevalence of ADHD and ASD in the SMOF group was less than that in the LIPO group . In children with birth weights of more than 1500 g, the prevalence of LD in the SMOF group was less than that in the LIPO group .From the year 2001 to 2015, there were 22,842 premature neonates admitted to CGMH. A total of 18,965 neonates who did not receive lipid emulsions were excluded. Of the remaining 3877 neonates, 1031 neonates died during the first admission and 23 were lost to follow-up. Among the surviving infants, 1240 and 1583 infants received Smoflipid® parenterally in the early life of premature neonates was associated with a difference in long-term neurodevelopment outcomes, including reducing epilepsy, CP, LD, developmental disorder, ADHD and ASD. Remarkably, in neonates with birth weights of less than 1500 g, developmental psychiatric disorders, ADHD and ASD were significantly decreased in the SMOF group compared to the LIPO group. A previous study also showed that Bayley-III language scores <85 and <70 were significantly lower in the SMOF group [In this large cohort study, we found that administration of SmoflipidOF group . A pilotOF group .Extremely premature babies cannot be enterally fed smoothly in their early life. Premature babies lose their standard placental supply of nutrients, have very low-fat stores and have immature digestive and metabolic functions , accountPreterm babies are born with life-threatening conditions that may cause brain injury, including respiratory distress, IVH, neonatal sepsis, PDA and NEC. It is worth mentioning that the prevalence of BPD was higher in the SMOF group than in the LIPO group in this study, which was in agreement with previous studies ,26. The ASD is usually diagnosed around 2–3 years old when children present apparent signs. Impairments in social and communication skills and restricted and repetitive behaviors when it comes to interests and activities are two main characteristics of ASD. The prevalence of ASD in the very preterm population studied in Taiwan correlated to the 7% prevalence rate in a meta-analysis study of children born preterm ,31. The The strengths of the present study are the large cohort and long-term follow-up. Data were analyzed after matching gestational age and adjusting for morbidities of premature infants. Gestational age and small birth weight have a strong association with neurodevelopmental outcomes. Any management during admission could improve or worsen neurodevelopmental outcomes or other morbidities. Thus, if the sample size is small, or we do not adjust for morbidities before analysis, the results could be over-or underestimated. As the enrolled patients were from six branches of CGMH, the content of TPN for all premature neonates was similar. Moreover, the average durations of lipid therapy in the two groups were 17.1 and 15.2 days, respectively, without significant difference . BesidesThe results of this large cohort study have demonstrated that lipid emulsions with fish oil improve the long-term neurodevelopmental outcomes of children born prematurely. In particular, the prevalence of ADHD and autism were significantly decreased in neonates with birth weights below 1500 g. Though not comprehensively analyzed, big data analysis has been used reliably. Further investigation of more methodological rigor using a randomized controlled trial is needed.


S’) obtained using time-resolved near-infrared spectroscopy from the forehead of infants is associated with gestational age, body weight and Apgar scores, presumably reflecting subtle changes of the brain related to foetal growth and birth transition. One hundred twenty-eight preterm and term infants were studied to test whether μS’ obtained from the head at term-equivalent age is associated with foetal growth, birth transition and nutritional status after birth, which are key independent variables of developmental outcomes. As potential independent variables of μS’, birth weight, Apgar scores, age at full enteral feeding and post-conceptional age at the study were assessed to represent foetal growth, birth transition and nutritional status after birth. Subsequently, higher μS’ values were associated with higher Apgar scores (p = 0.003) and earlier establishment of enteral feeding (p < 0.001). The scattering property of near-infrared light within the neonatal brain might reflect changes associated with birth transition and nutritional status thereafter, which might be used as a non-invasive biomarker to identify covert independent variables of brain injury in preterm infants.If the brain structure is assessed at neonatal intensive care units, covert clinical events related with subtle brain injury might be identified. The reduced scattering coefficient of near-infrared light (μ However, a considerable fraction of extremely preterm infants develop cognitive impairments even in the absence of major cerebral lesions, such as intracranial haemorrhage and periventricular leukomalacia4. Magnetic resonance imaging (MRI) studies in preterm infants have demonstrated the relationship between subtle brain lesions at term equivalent age and long-term cognitive impairments7. However, because of the cost, time and safety associated with the scan, MRI is usually performed only once before discharge from the hospital, causing difficulty in identification of the upstream events associated with subtle brain lesions. Reliable tools for the assessment of subtle change of the brain structure, which can be assessed before and after clinical events at the cot-side, may help distinguish the upstream events responsible for subtle cerebral lesions and cognitive impairments in preterm infants.Advances in neonatal intensive care have significantly improved the survival rate of preterm infants11. Near-infrared light penetrates the intact scalp, skull and cerebral tissue more efficiently than visible light, and is mainly absorbed by blood haemoglobin, the level of which depends on the binding of haemoglobin to oxygen12. Thus, fractions of oxygenated and deoxygenated haemoglobin are calculated using light absorption coefficient (μa) obtained from the near-infrared light of different wavelengths13. Time-resolved near-infrared spectroscopy (TR-NIRS) is a relatively new technique, which enables simultaneous quantification of μa and reduced scattering coefficient (μS’)15. Unlike μa predominantly provides information regarding tissue oxygenation, μS’ is an index of light scattering, which is theoretically determined by the structural complexity of tissue13. When preterm infants were studied shortly after birth, μS’ values obtained from the forehead showed a positive linear correlation with gestational age16. Our study in preterm and term infants further confirmed that μS’ values obtained shortly after birth were associated with variables, such as antenatal glucocorticoid, emergency delivery, gestational age, body size, Apgar scores, requirement for mechanical ventilation and blood gas data at birth, suggesting the possibility that μS’ might reflect subtle structural changes in the brain associated with antenatal growth, peripartum stress and birth transition17. However, little is known regarding the relationship between μS’ values obtained from the head of newborn infants and their downstream clinical outcomes.Near-infrared spectroscopy (NIRS) is a handy, non-invasive tool, which has been used to analyse the tissue oxygen metabolism in the brains of newborn infantsS’ measured at term-equivalent period with intrauterine growth, birth transition and nutrition after birth, which are short-term surrogate markers for neurodevelopmental outcomes of hospitalised newborn infants21.The aim of this study was to test the association of μFour infants, who developed grade III/IV intraventricular haemorrhage, and one infant, who developed hypoxic-ischaemic encephalopathy, were excluded, leaving 128 infants within the final study cohort , poor probe contact (n = 4) and the use of a cap device for non-invasive respiratory support (n = 2). No further data were excluded because of their poor quality or reproducibility. The mean μa values, whereas the wavelength of 791 nm was associated with lower μa values compared to those of 761 nm (both p < 0.001) .The wavelength of 836 nm was associated with higher μ1) Table . The rigS’ values compared to those of 761 nm (both p < 0.001). The left and right temporal and posterior regions of the head were associated with higher μS’ values compared to the anterior region .The wavelengths of 791 and 836 nm were associated with lower μa values were positively associated with gestational age (p = 0.001), body weight at birth (p < 0.001), blood haemoglobin level at study (p < 0.001) and μS’ values (p < 0.001), and negatively associated with antenatal glucocorticoid (p < 0.001), cord blood pH (p = 0.003) and postnatal age at study (p = 0.001); relationships with multiple pregnancy (p = 0.016), head circumference at birth (p = 0.005) and body weight at study (p = 0.036) were lost after correction for multiple comparisons  and μa values (p < 0.001), and negatively associated with indomethacin for patent ductus arteriosus (p < 0.001) and postnatal age to achieve full enteral feeding (p < 0.001); relationships with antenatal glucocorticoid (p = 0.013), body weight and head circumference at birth (both p = 0.012), Apgar scores at 1 and 5 min  and postnatal age at study (p = 0.003) were lost after correction for multiple comparisons , greater post-conceptional age at study (p = 0.015), higher blood haemoglobin levels at study (p < 0.001) and higher μS’ values (p < 0.001) , smaller age to achieve full enteral feeding (p < 0.001) and higher μa values (p < 0.001). See Online Supplemental Tables Higher μ1) Table . Higher S’ values obtained at term-equivalent age were associated with higher Apgar scores and earlier establishment of enteral nutrition. μS’ can be a unique and clinically useful biomarker of subtle changes in the brains of newborn infants with respect to antenatal stress, birth transition and nutritional status after birth.Building on previous studies of TR-NIRS, which suggested that the light scattering within the brain shortly after birth is dependent on variables related to foetal growth, antenatal stress and birth transition, we have demonstrated that higher μ14. Thus μS’ has a potential to provide microstructural information of the brain. Ijichi and colleagues first reported that μS’ values of near-infrared light obtained shortly after birth from the foreheads of newborn infants with a gestation age of 30–41 weeks depended on gestational age16. Our previous study confirmed that μS’ values obtained from the foreheads of preterm and term infants assessed shortly after birth were dependent on body size and Apgar scores, as well as on gestational age. These findings suggest the possible utility of μS’ values as a non-invasive marker to evaluate subtle differences in the brain subsequent to foetal maturation, antenatal stress and birth transition17. Our current study further verified that the μS’ value obtained at term equivalent period is associated with both clinical variables at birth and those related to the nutritional status of the infant after birth. Intrauterine growth and maturation, intrapartum stress and response and postpartum nutrition and growth constitute key independent variables of the neurodevelopmental outcomes of the infant21. If the consequence of the intrinsic maturity, extrinsic stress, birth transition and nutritional status of the infant can be assessed using μS’ values obtained from the heads of newborn infants, along with other substantiations, μS’ might serve as a clinically useful biomarker of cerebral maturation and damage. Future studies need to address the contribution of other potential independent variables of light scattering as measured from the scalp, such as the gyration of the brain and developmental changes in the layer of cerebrospinal fluid.Light scattering within a tissue theoretically increases with relatively more complex microstructures due to increased reflection and path length of near-infrared lighta values and longer time to achieve full enteral feeding and greater post-conceptional age at the time of the study; robust correlations were only observed between μa values and priori covariates of the wavelengths of light, head position and blood haemoglobin concentration at the time of the study. Given that absorption of near-infrared light within the range of 750–850 nm is primarily determined by the tissue haemoglobin concentrations15, μa values might reflect the maturation of the cerebral tissue via increased complexity of the cerebral vessels and subsequent blood volume. Progression of anaemia and increase in the cerebral blood flow and volume with increasing postnatal age might also affect the dependence of μa values on clinical variables12.With regard to the absorption of near-infrared light, only modest relationships were observed between higher μS’ values and microstructure of the brain. As described in the previous section, the observed relationships between μS’, μa and clinical variables can be affected by a range of clinical biases. For example, extremely preterm infants are relatively anaemic at birth and the anaemia progresses with postnatal age without transfusion, potentially leading to lower blood haemoglobin and μa levels with greater gestational age at birth and greater postnatal age at the time of TR-NIRS study. Although we carefully selected independent variables and covariates to minimise the bias, the findings might still be affected by the bias derived from the collinearity between the variables. Our study cohort comprised newborn infants, who were hospitalised at a tertiary neonatal intensive care unit. Although the observed μa and μS’ values were comparable to those reported in healthy newborn infants22, extrapolation of our findings into physiological transition and growth in healthy newborn infants must be done cautiously. Finally, the longitudinal follow-up study of the study population is still underway, resulting in the lack of outcome information in association with the light absorption and scattering properties.We were able to elucidate the clinical variables potentially determining the property of light absorption and scattering within the brain in a relatively large cohort of newborn infants. However, we were unable to present a direct association between μS’ values of the near-infrared light obtained at term-equivalent period from the heads of newborn infants were associated with Apgar scores and postnatal age when full enteral feeding was achieved, suggesting a correlation between the light scattering property and stress-response at birth and nutritional status of the infant thereafter. With further validations, μS’ might serve as a biomarker to distinguish the variation of the microstructural complexity of the brain tissue subsequent to different maturational stage, antenatal stress, tissue damage and repair, nutritional status and growth. Associations between the μS’ values and detailed clinical courses, macro- and microstructural MRI findings and neuro-developmental outcomes need to be addressed to assess the clinical utility of this non-invasive cot-side tool.The μThis study was conducted in compliance with the Declaration of Helsinki under the approval of the Ethics Committee of Kurume University School of Medicine (reference number: 12128). Informed parental consent was obtained for each participating newborn infant. All methods were carried out in accordance with relevant guidelines and regulations.S’ values obtained shortly after birth from a part (n = 60) of the current cohort have been reported in a previous study17. Of 136 newborn infants within the original study cohort, 132 infants, who had TR-NIRS data obtained between 34 and 42 weeks postconceptional age, were considered. Infants with chromosomal aberration, malformation syndrome, grade III/IV intraventricular haemorrhage, hypoxic-ischaemic encephalopathy, congenital hydrocephalus and other major cerebral anomalies were excluded.This study was performed as a secondary analysis of a prospective longitudinal study, which was performed between June 2009 and January 2015 to serially collected the TR-NIRS data of preterm and term infants hospitalised at a tertiary neonatal intensive care centre of Kurume University Hospital . Independent variables of μa and μS’ values were obtained from the heads of the infants for three wavelengths, 761, 791 and 836 nm, using a TR-NIRS system 17. This system employs the time-correlated single photon counting method to create time response profiles of pulsed laser light penetrating an object. The time response profiles were then fitted into a photon diffusion equation using the nonlinear least square fitting method to obtain μa and μS’ for each wavelength14. Although the data acquisition for the original study was repeated with intervals of approximately 1 week from birth to discharge, for the current study, a particular value obtained between 34 and 42 weeks of post-conceptional age (closest to 40 weeks gestation if there were multiple records) was used to represent each infant.The μ17, standard deviations of μa and μS’ values for five successionally obtained data within the same head position and infant were, in average, 2.4% and 2.7%, respectively. Based on these small intra-individual and intra-regional differences in μa and μS’ values, five readings each of μa and μS’ were averaged for each brain region. We confirmed the degree of fit to the photon diffusion equation using the conversion chi-square value index of between 0.8 and 1.223. Data were not collected for brain regions with poor probe contact , poor fit to the photon diffusion equation or insufficient signal-to-noise ratio with the count rate < 100 K counts/s or relative dark- to peak-count ratio of > 0.1. The data were retrospectively assessed to identify those with poor quality or intra-regional reproducibility before being processed for further analysis.Data were acquired when the infant was clinically stable and asleep or calmly awake. The TR-NIRS probes were inserted into a rubber holder, with an inter-optode distance of 3 cm, and was applied to a relatively flat part of the head. Data acquisition (10 s) was repeated five times for each of the frontal, left and right temporo-parietal and occipital regions by repositioning the probe each time. In our previous study, which acquired TR-NIRS data using the same protocol to the current oneS’ values, body weight and head circumference at birth were expressed as z-scores in accordance with the New Japanese Neonatal Anthropometric Charts for Gestational Age at Birth24.The clinical background information was obtained from the electronic records of the patients, including (1) maternal and antenatal variables , (2) variables at and shortly after birth  variables associated with clinical variables of infants after the transitional period . In order to assess the influence of intrauterine growth on μa and μS’) was performed (n = 5 imputations), based on the correlation between variables with missing values and other characteristics of the participants . Although the property of μa was out of our study scope, independent variables of both μa and μS’ were assessed to clarify the possible influence of light absorption to the relationship between μS’ values and clinical variables. The generalised estimating equation with a linear model was used to account for repeated sampling of TR-NIRS data for three near-infrared light wavelengths and four head regions. Although the influence of the wavelength is much greater on μa than on μS’17, the three wavelengths were incorporated within the model for consistency in the analytical procedure. Crude effects of clinical variables on μa and μS’ values were assessed using the univariate model adjusting for the wavelengths and head positions. p values < 0.002 were assumed to be significant, correcting multiple comparisons of 25 variables. The final models to explain μa and μS’ values were developed based on our hypothesis, which employed the body weight at birth, Apgar scores at 5 min, age to achieve full enteral feeding and post-conceptional age at study; the model was also adjusted for priori covariates, which were known independent variables of clinical outcomes , μa  and μS’ . Data were presented as mean ± standard deviation unless specified otherwise.To minimise biases owing to missing data, multiple imputation of the missing values of less than 10% (excluding for μSupplementary Tables.