Prenatal nutrition interventions can lead to improved birth outcomes, which in turn are associated with better education and human capital outcomes later in life.We estimated the impact of scaling up iron–folic acid (IFA), calcium, multiple micronutrient (MMS), and balanced energy protein (BEP) supplementation for pregnant women, on human capital outcomes in low- and middle-income countries (LMIC).de novo meta-analyses of observational studies.We used mathematical modeling with proportional reductions in adverse birth outcomes to estimate the potential gains in school years and lifetime income due to scaling up each prenatal nutrition intervention. Estimates of intervention effects on birth outcomes were derived from meta-analyses of randomized trials. Estimates of the associations between birth outcomes and schooling and lifetime income were derived from Across 132 LMIC, scaling up prenatal nutrition interventions to 90% coverage was estimated to increase school years and lifetime income per 5-yr birth cohort by: 2.28 million y : −0.44, 6.26) and $8.26 billion  for IFA; 4.08 million y  and $18.9 billion  for calcium; 5.02 million y  and $18.1 billion  for MMS; and 0.53 million y  and $1.34 billion  for BEP supplementation. South Asia and Sub-Saharan Africa tended to have the largest estimated regional gains in school years for scaling up each intervention due to the large population size and high burden of poor birth outcomes. Absolute income benefits for each intervention were estimated to be the largest in Latin America, where returns to education and incomes are higher relative to other regions.Increasing coverage of prenatal nutrition interventions in LMIC may lead to substantial gains in schooling and lifetime income. Decision makers should consider the potential long-term human capital returns of investments in maternal nutrition. Child survival has dramatically improved over the past few decades with deaths among children <5 y of age declining from 12.6 million in 1990 to 5.6 million in 2016 . SuboptiThe 2013 Lancet Maternal and Child Nutrition Series identified several nutrition-specific interventions to reduce the burden of maternal and child mortality and morbidity due to undernutrition in LMIC, and estimated the costs and cost-effectiveness of scaling these interventions to 90% coverage based on the number of lives saved , 12. TheSupplemental Table 1). A convincing level of evidence was defined as evidence of an intervention effect based on multiple randomized controlled trials or robust cohort studies (1) iron–folic acid supplementation (IFA), 2) calcium supplementation, 3) multiple micronutrient supplementation (MMS), and 4) balanced energy protein supplementation (BEP) among undernourished women. Although we initially considered quantifying the benefits of scaling up prenatal nutrition interventions using evidence of intervention effects directly on human capital outcomes, we did not find convincing level of evidence due to lack of data for direct intervention effects on human capital  the absolute reduction in LBW/preterm birth prevalence as a function of scaling up nutrition interventions, 2) the increase in school years due to reductions in the LBW/preterm birth prevalence, and 3) the increase in lifetime income due to gains in schooling. Linear deterministic models quantify the average behavior of a population given a set of parameter values assuming that the system does not dynamically change with downstream consequences . We used pooled relative risks from recently published meta-analyses of randomized controlled trials of intervention effects on birth outcomes .We estimated the proportional reduction in LBW and preterm birth prevalence due to scaling up each prenatal nutrition intervention using the following formula:outcomes . For BEP2   in each country. For calcium, BEP, and MMS supplementation, we assumed no baseline coverage in 2015. For BEP supplementation, we estimated the impact of scaling up the intervention on human capital outcomes among the proportion of women in the general population with a body mass index (BMI) of <18.5 kg/mt women) . Notablyt women) . We decit women) . For MMSt women)  and the t women) . Given tFinally, to estimate the absolute reduction in adverse birth outcomes, we multiplied the estimated proportional reduction in LBW or preterm birth attributable to scaling up each intervention by the most recent 2015 country-specific estimates for LBW and preterm birth prevalence , 20. Thede novo systematic review and meta-analysis of the economics literature to examine the link between birthweight and human capital outcomes, including schooling and adult income . The review identified evidence only from high-income country settings, given that studies from the economics literature rely primarily on sibling and twin designs, to identify the causal effect of being born LBW on adult schooling and income. As such, to account for all available evidence on the link between birth outcomes and schooling, we used random effects meta-analysis to pool estimates from the de novo systematic review with estimates of the associations between LBW and educational attainment based on longitudinal data from 5 major cohort studies [reanalysis of data based on the COHORTS collaboration  who would complete secondary school due to the predicted population-level increases in school attendance. Assuming a 12-y education system, theoretically we would expect only grade 11 students to be eligible for crossing the threshold to secondary school completion through a marginal increase in school attendance. We derived the additional number of youths expected to complete secondary school by multiplying the proportion of the population with incomplete secondary school in the penultimate year of secondary school  by the average gains in school years per child for each country. We used the country-specific prevalence of incomplete secondary school among youth (20–24 y) from the Barro-Lee education database and assumed an equal distribution of students among all secondary grades to estimate the proportion of the population in grade 11 .To estimate gains in adult income, we multiplied the number of school years gained at the population level by the previously published country-specific estimates for returns in adult income for each additional year of schooling , 31. CouSupplemental Methods 4, page 7). Uncertainty estimates were available from published estimates for prevalence of baseline population characteristics , the effect sizes for each prenatal nutrition intervention on LBW/preterm birth, the association between preterm birth/LBW to education gains, and the returns to income per additional year of education. The 95% uncertainty intervals (UI) around the final estimates were calculated by using the 2.5th and 97.5th percentiles of the 1000 simulations. All estimates were generated using the Stata 14 Statistical Software package (StataCorp LP).We quantified parameter uncertainty by bootstrapping the SEs of each data input and effect size parameter used in each quantity, and propagated uncertainty using 1000 independently drawn simulations  school years and an additional 75.1 thousand youths  completing secondary school per birth cohort .Cumulative increase in lifetime income for scaling up each intervention to 90% coverage in LMIC was estimated to be $8.26 billion  for IFA supplementation, $18.9 billion  for calcium supplementation, $18.1 billion  for MMS supplementation, and $1.34 billion  for BEP supplementation among undernourished women . Country-specific estimated gains in human capital and lifetime income for scaling up each intervention at 50% and 90% target coverage scenarios are summarized in the Supplemental file online (pages 11–142).At the individual level, the absolute gain in future income per child born to pregnant women targeted for supplementation was estimated to be $14  for IFA, $33  for calcium, $32  for MMS, and $21  for BEP; with the largest regional gains in absolute income expected in Latin America and the Caribbean  intervention effect sizes on birth outcomes; 2) prevalence estimates of baseline population characteristics, including LBW and preterm birth; and 3) the effect sizes for associations between birth outcomes and schooling, and between schooling and lifetime income. However, we did not incorporate modeling uncertainty, which is not easily quantifiable; therefore, our uncertainty intervals may be considered as a lower boundary. It is important to note that we used a population-level modeling approach and therefore our population-level estimates of schooling and human capital benefits should not be interpreted to affect all births equally in a country. The absolute gains in future income per child born to pregnant women targeted by an intervention reflects the average gain for a child given country-level population characteristics. In addition, we estimated the human capital impacts of prenatal nutrition interventions through one specific pathway—reductions in adverse birth outcome and gains in educational attainment—and therefore may have underestimated the overall benefits that may accrue through other pathways. For example, since the uncertainty intervals of the estimated human capital benefits of scaling up IFA and BEP crossed the null, it is unclear if scaling up these interventions will improve schooling and lifetime incomes through their effect on LBW; nevertheless, it is important to note that there may be other potential pathways through which human capital benefits may accrue in addition to benefits of these interventions for other maternal and child health outcomes. As such, future studies should consider estimating the economic benefits of prenatal nutrition interventions through additional pathways, such as improved socioemotional and cognitive development, increased adult productivity, or lower healthcare costs associated with lower risk of adverse birth outcomes. We were also unable to account for education quality as we did not have data on learning-adjusted school years. Finally, our analysis focused on maternal nutritional supplements; therefore, research is needed to examine the potential role of other population-based nutrition-sensitive and nutrition-specific interventions, such as large-scale food fortification, on human capital gains throughout the life course.Our study has several strengths and important limitations. We used a population-based linear deterministic model to estimate the impact of prenatal maternal nutrition interventions on long-term human capital outcomes using the most recent, robust evidence from randomized controlled trials or longitudinal cohort studies. However, evidence for the associations between birth outcomes and schooling and between schooling and lifetime income were based on observational evidence, which may be at risk of confounding and bias. Ideally, we would be able to parameterize the model solely based on causal evidence from long-term follow-up of randomized controlled trials. However, such evidence for schooling and lifetime income, for the prenatal interventions examined in this study, is not currently available largely due to the substantial time and resource investments required for extending trial follow-up into adulthood. New data from long-term follow-up studies of randomized controlled trials and high-quality observational cohorts in LMIC are likely to improve the validity and precision of parameter estimates used in this study. In addition, current evidence for BEP supplementation is complicated by the substantial heterogeneity in the nutritional composition of the supplements and the definition of “undernourished” participants used in previous trials. We used the most recent estimates for the effect of BEP supplementation on LBW among studies conducted in LMIC; however, additional data and synthesis of BEP trials, which more consistently define the nutritional composition of BEP supplements and the target populations that may benefit from this intervention, are needed to re-evaluate the intervention effect on LBW. The large uncertainties in the estimated years of schooling and lifetime income gains therefore reflect the uncertainties in the model parameters that may be refined with new evidence on intervention effect sizes and model parameters. Of note, although we used the most recent 2015 LBW and preterm birth estimates available, updated SGA estimates for the same year would allow for greater potential to generate estimates through specific pathways of earlier timing and intrauterine growth restriction. We used uncertainty propagation methods to account for uncertainties in all model parameters, including: Overall, our findings suggest that scaling up prenatal nutrition interventions may lead to substantial gains in schooling and lifetime incomes in LMIC, with large benefits expected in countries with a high burden of adverse birth outcomes, greater estimated returns to education, and higher annual wages. Researchers, funders, and policy makers should consider the broader human capital returns that may be attained through greater investments in scaling up prenatal nutrition interventions.nqab234_Supplemental_FileClick here for additional data file.


The liver is the most common site affected by hydatid disease. Hepatic hydatid cyst (HHC) with cystoduodenal fistula is an unusual and infrequent complication. We present a 48-year-male diagnosed with an HHC with cystobiliary communication (CBC) and cystoduodenal fistula. The patient underwent partial cystectomy. Intraoperative demonstration of CBC was done with injection propofol, followed by primary closure of the CBC. The duodenal fistula was closed primarily with an omental patch, also known as a Graham patch. The patient improved well without any complications, and there was no recurrence of the symptoms for the subsequent five-month follow-up. Hepatic hydatid cyst (HHC) is a common disease caused by Echinococcus. HHC can be of varying size and usually asymptomatic. HHC can get complicated with the formation of cystobiliary communication (CBC), rupture into the peritoneal cavity, and bronchi ,2. FistuA 48-year-old male presented in emergency with a history of abdominal mass since childhood. The abdominal mass was gradually progressive in size and rapidly increased in the last two weeks. He also complained of breathlessness for one week associated with abdominal pain. The patient never went to any hospital for the abdominal mass. There was no history of vomiting, altered bowel habits, trauma to the abdomen, melena, and passage of any membranes in the stools. There was no history of cough with sputum. On examination, the patient had tachycardia with normal blood pressure. There was no pallor or jaundice. Abdominal examination showed a large mass of almost 20cm x 20cm occupying the epigastrium, right hypochondrium, left hypochondrium, and umbilical region. It had varying consistency - soft in the upper part and firm in the lower and lateral parts. Routine blood investigations, including complete blood counts and renal function tests, were normal. A liver function test revealed mild elevation 174 IU/L) of alkaline phosphatase (ALP). Hydatid serology was positive. Abdominal USG showed the presence of a large hypoechoic cyst with air and debris. Contrast-enhanced CT of the abdomen showed a 20cm x 18cm cyst, arising from the left lobe of the liver having an air-fluid level and few septations or membranes at the inferior aspect of the cyst with debris. The left portal vein was compressed, and the left bile duct was not visualized. The gallbladder had air within it. The common bile duct (CBD) was normal in caliber, and there was no air within it  level was 230 ng/mL, and the carbohydrate antigen (CA19-9) was more than 1972 U/mL. However, serum CEA and CA19-9 levels were within the normal range.Magnetic resonance cholangiopancreatography (MRCP) showed a well-defined large cyst of 15cm x 15cm, probably arising from the left lobe of the liver with an air-fluid level in the epigastric region with pigtail inside. CBC could not be demonstrated clearly Figure .Upper gastrointestinal endoscopy showed a bulge along the lesser curvature of the stomach and fistulous opening in the first part of the duodenum Figure .The patient was prepared for laparotomy and possibly left hepatectomy. After exploration, the abdomen was packed with cetrimide-soaked pads. Intraoperatively, a large cyst was found from the liver's left lobe and had dense adhesions with the stomach, diaphragm, and transverse mesocolon. During the adhesiolysis, there was an inadvertent opening of the cyst wall. Hence the cyst wall was opened for controlled drainage. The inside of the cyst wall was covered with a whitish germinal layer. Hence, the diagnosis of the HHC was confirmed. We proceeded with a partial cystectomy of the HHC. The germinal layer of the residual cyst wall was removed by scraping.A meticulous search for the CBC was done. A cholecystectomy was performed. The cystic duct’s cannulation was done, the catheter advanced into the hepatic duct, and CBD was blocked with a clamp. Propofol was injected through the catheter. Four CBCs were very well demonstrated with leakage of the propofol through the inner surface of the residual cyst wall. All the communications were primarily sutured with polypropylene. A drain was placed into the residual cyst cavity, and omentopexy was done. The cystoduodenal fistula was visualized during the cystectomy Figure .As the size of the fistula was less than 5 mm, it was closed primarily with an omental patch.Postoperatively patient improved well without any complications. Orals were started on the fourth postoperative day and escalated gradually. The patient was continued with albendazole for three months. Repeat USG did not show any evidence of the recurrence. Postoperative histopathological features were diagnostic of hydatid cyst.Echinococcus spp, tapeworms. Although it can affect any organ, the liver is the most common organ [Echinococcus can cause hydatid disease; Echinococcus granulosus is the most common. The definitive host for Echinococcus is dog, and the intermediate host is sheep. Humans are considered accidental intermediate hosts. Humans get infected from eating raw vegetables infected with dogs’ feces or direct contact with dogs. Few professionals like slaughterhouse workers, shepherds, and butchers are at high risk of hydatid disease.Hydatid disease is a zoonotic disease caused by on organ . Four spHHC grows slowly and can be of varying sizes. A mature cyst has the inner germinal layer, a laminated layer, and an adventitial layer. Hydatid fluid is usually clear and colorless. Fluid may be bile stained if CBC is present. HHC is usually asymptomatic. The patient becomes symptomatic once the cyst attains a large size or gets complicated. HHC can get infected or rupture into the biliary tree, or a bronchial tree or peritoneum ,2. RuptuCBC occurs when there is a gradual increase in the cyst’s size and a simultaneous increase in intracystic pressure. The intracystic pressure exceeds the ductal pressure, and the cyst wall and the duct weakens at the point of contact. This leads to the formation of CBC, and bile enters into the cyst. These communications are usually small and silent. In our patient, the hydatid fluid, drained by the percutaneous drain, was bile stained, suggestive of CBC, and had a foul smell and suppuration.Enteric communication of the hydatid cyst is rare. Although HHC commonly ruptures in the stomach and duodenum, it can also involve the esophagus, colon, and small bowel. This leads to incomplete evacuation of the cyst contents and reduction of the cyst pressure. The fistulization can also occur due to the friction of the thick pericyst with the bowel wall. Our patient had spontaneous fistulization to the duodenum. This could have been due to the long duration of the cyst and its erosion into the bowel wall as the cyst had dense adhesion with the stomach and the first part of the duodenum.If HHC ruptures in the GI tract, patients may pass hydatid membranes in the stool (hydatidorrhea) and hydatid membranes in the vomitus (hydatidemesis). Few patients may have non-specific symptoms . Our patDiagnosis of the hydatid cyst is usually by clinical history, imaging, and serological studies. Liver function tests may be normal, or there may be an increase in ALP or gamma-glutamyl transferase in a few patients, which are suggestive of CBC. Many serological tests like immunoelectrophoresis (IEP) and enzyme-linked immunosorbent assay (ELISA) are used for diagnosis and post-treatment surveillance, but all have varying sensitivity and specificity. ELISA test has a sensitivity of 85-98% . There wTumor markers like CA 19-9 and CEA help differentiate cystic lesions of the liver. These tumor markers may be elevated in patients with cystic liver lesions like mucinous cystic neoplasia of the liver (MCN-L) and intraductal pancreatic mucinous neoplasm-biliary type (IPMN-B). However, serum levels of the tumor markers in such cases are usually inconsistent. There are few reports in the literature where CA19-9 was elevated in patients with HHC, suggesting occult CBC. In our patient, serum levels of these tumor markers were normal, but these were highly elevated in the cyst’s fluid. Abdominal USG may show anechoic cyst, multiseptate cyst, floating membranes within the cyst, daughter cysts, and calcifications. If the cyst gets secondarily infected, it will lose its characteristic appearance . Based oMRI is helpful in the diagnosis of HHC. It shows a hypointense pericyst on T1 weighted images, hyperintense cyst on T2 weighted images. The presence of CBC can be suggested by the presence of fat density within the cyst. It provides good visualization of the relationship of the intrahepatic and extrahepatic biliary tree with the cyst . In our Treatment of the HHC involves medical, percutaneous, and surgical methods. Pharmacological treatment of the hydatid cyst includes albendazole and mebendazole, which are given perioperatively. Percutaneous treatment includes percutaneous aspiration, injection and re-aspiration (PAIR), and its modifications. Surgical treatment can be laparoscopic or open techniques, radical or conservative. Radical surgeries include partial pericystectomy, total cystopericystectomy, left hepatectomy, right hepatectomy. Conservative surgery includes cystectomy or also called closed cystectomy. Our patient initially was planned for left hepatectomy due to uncertainty of the diagnosis. During the cyst’s dissection, there was the inadvertent opening of the cyst due to dense adhesions with surrounding organs. Then the cyst was fully decompressed, and the germinal layer’s presence within the cyst confirmed the diagnosis of hydatid cyst. Hence cystectomy was done. Intraoperatively, careful inspection of the cyst wall has to be done to see for the presence of CBC. These can be demonstrated by keeping a dry pad on the cyst’s inner surface, applying gentle pressure on the gallbladder, intraoperative cholangiography, methylene blue injection, saline injection, and indocyanine green injection through the cystic duct. As these dyes stain the surface, these can mask the additional leaks . Hence fIf HHC forms fistula with bowel, the treatment depends will on the site and size of the fistula. There are case reports in the literature where a cyst with colonic fistula was treated by resection, or by creating stoma at the fistula site or by primary closure . If the HHC can be of varying size, and patients may present later with complications. Infected HHC will lose its imaging characteristics, and it may not be easy to diagnose by imaging. The presence of air in the cyst is highly suggestive of fistulization with the bowel. There may be an elevation in the CA19-9 and CEA within the cystic fluid once CBC is established, creating confusion in the diagnosis with other diseases like MCN-L of liver or IPMN-B. Propofol can be used intraoperatively to check for CBC, as other dyes may stain the surface and mask other leaks. The presence of air in the gallbladder does not necessarily indicate communication of the cyst with the gallbladder. To the best of our knowledge, this is the first case of HHC in the literature having air in the gallbladder, which must have entered through the CBC of the HHC once the duodenal fistulization was established, and the surgeon should be aware of such a possibility.


Autosomal dominant polycystic kidney disease (ADPKD) is the most frequent genetic kidney disease and polycystic liver disease is its major extrarenal manifestation, however biliary peritonitis due to a liver cyst rupture is extremely rare.The patient was a 71-year-old Japanese woman who was diagnosed with ADPKD 3 years previously and developed right abdominal pain suddenly 1 month previously. As abdominal computed tomography (CT) showed a ruptured liver cyst in the right lobe, she was admitted to our hospital. Her symptoms improved with conservative management and she was discharged from the hospital after 1 week. Although she was asymptomatic for a while, she noticed abdominal distension and general malaise at 1 month after hospital discharge. Since abdominal CT showed massive ascites, she was admitted to our hospital again. A physical examination revealed abdominal distention without tenderness. Her serum creatinine, alkaline phosphatase, γ-glutamyl transpeptidase, total bilirubin, and CA19-9 were elevated. Abdominal paracentesis revealed amber transparent ascites and the bilirubin and CA19-9 concentrations were high. She was diagnosed with biliary peritonitis due to a ruptured liver cyst. Hemodialysis treatment was initiated with drainage of the ascites. The outflow of the ascites was no tendency to decrease and drip infusion cholangiography (DIC)-CT revealed a communication between the ruptured cyst and an intrahepatic bile duct. On day 31, she was transferred to a university hospital and abdominal surgery was performed. After removing the necrotic roof of the ruptured cyst on the right liver lobe, the orifice of the bile leakage was sutured. Cholecystectomy was performed and cholangiography showed no stones in the common bile duct. Abdominal CT one month after the operation showed no recurrence of ascites and she was discharged on day 49. Hemodialysis treatment was discontinued immediately after discharge because urine volume increased and her creatinine level decreased. There has been no recurrence of ascites since then.While rare, biliary peritonitis can occur in association with the rupture of a liver cyst in ADPKD patients due to communication between the cyst and the intrahepatic bile duct, and DIC-CT should be recommended when biliary cyst rupture is suspected. Autosomal dominant polycystic kidney disease (ADPKD) is the most frequent genetic kidney disease; the prevalence is 1 in 500–1000 .Extrarenal manifestations, include polycystic liver disease (PLD), intracranial aneurysm, mitral valve prolapse, and colon diverticulosis . While PThe patient was a 71-year-old Japanese woman who was diagnosed with chronic kidney disease due to ADPKD 3 years previously. She received surgical clipping for an unruptured aneurysm of the right middle cerebral artery 4 years earlier. She did not drink alcohol and was a non-smoker. She was taking amlodipine for hypertension, topiroxostat for hyperuricemia, and ferric citrate hydrate for hyperphosphatemia. Continuous erythropoietin receptor activator was administered subcutaneously for renal anemia once a month. She was followed up in an outpatient clinic and suddenly developed right abdominal pain one month previously. As abdominal computed tomography (CT) showed a ruptured liver cyst in the right lobe, which had not been observed seven months previously (Fig. On admission, her height was 166 cm, and her body weight was 62 kg. A physical examination revealed the following: body temperature, 37.2 °C; blood pressure, 114/73 mmHg; pulse, 94 beats/min; and oxygen rate, 97% on room air. Abdominal distention was observed without tenderness, and pitting edema was observed in the bilateral legs. The laboratory data are shown in Table Enterococcus faecalis. Abdominal surgery was performed. The surface of the liver became yellowish due to bile leakage and a ruptured necrotic cyst was observed on the right liver lobe (Fig. Abdominal paracentesis revealed amber transparent ascites Fig. d and theobe Fig.  h. Afterobe Fig. i. As galWe experienced a rare case of biliary peritonitis due to a ruptured liver cyst in an ADPKD patient. While the first episode of liver cyst rupture improved with conservative management, the second episode caused massive ascites. Abdominal paracentesis was useful for confirming the diagnosis of biliary peritonitis, which was successfully treated with abdominal surgery.Liver cysts are asymptomatic in most settings and liver cyst rupture is rare . Marion Enterococcus faecalis. Abdominal surgery instead of laparoscopy, or non-operative approaches, such as percutaneous transhepatic biliary drainage, was chosen in the present case for several reasons. First, massive leakage of the bile was suspected because the amount of biliary ascites exceeded 1000 mL per day. Second, the ascites culture was positive for E. faecalis before operation. Third, the ruptured cyst was a small cyst located among multiple cysts, so there was a possibility that the orifice would not be visible under laparoscopy. Abdominal surgery to close the orifice that was the source of the bile leakage in the ruptured cyst achieved a favorable outcome without severe bacterial infection in the present case. We do not think the present case was indicated for liver transplantation, as closure of the orifice of the bile leakage was successful; however, liver transplantation may be a viable option in cases of repetitive biliary peritonitis due to many hepatobiliary communications after controlling the infection and taking into account the patient’s age and other comorbidities.While ruptures of the gallbladder, common bile duct , extraheIn conclusion, while rare, biliary peritonitis can occur in association with the rupture of a liver cyst in ADPKD patients due to communication between the cyst and the intrahepatic bile duct, and DIC-CT should be recommended when biliary cyst rupture is suspected.


In New South Wales (NSW), Australia there are three settings available for women at low risk of complications to give birth: home, birth centre and hospital. Between 2000 and 2012, 93.6% of babies were planned to be born in hospital, 6.0% in a birth centre and 0.4% at home. Availability of alternative birth settings is limited and the cost of providing birth at home or in a birth centre from the perspective of the health system is unknown.The objective of this study was to model the cost of the trajectories of women who planned to give birth at home, in a birth centre or in a hospital from the public sector perspective.This was a population-based study using linked datasets from NSW, Australia. Women included met the following selection criteria: 37-41 completed weeks of pregnancy, spontaneous onset of labour, and singleton pregnancy at low risk of complications. We used a decision tree framework to depict the trajectories of these women and Australian Refined-Diagnosis Related Groups (AR-DRGs) were applied to each trajectory to estimate the cost of birth. A scenario analysis was undertaken to model the cost for 30 000 women in one year.496 387 women were included in the dataset. Twelve potential outcome pathways were identified and each pathway was costed using AR-DRGs. An overall cost was also calculated by place of birth: $AUD4802 for homebirth, $AUD4979 for a birth centre birth and $AUD5463 for a hospital birth.The findings from this study provides some clarity into the financial saving of offering more options to women seeking an alternative to giving birth in hospital. Given the relatively lower rates of complex intervention and neonatal outcomes associated with women at low risk of complications, we can assume the cost of providing them with homebirth and birth centre options could be cost-effective. In New South Wales, Australia’s most populous state, there were 95 825 births to 94 449 mothers in 2017 . When we proposed an up-scaling of services to enable women to plan a birth at home or in a birth centre, the cost to the public health service resulted in a slight decrease in cost over a 12-month period. While the increase in homebirth options were considerable comparatively (scenarios 2 and 4 represented a 250% increase and scenarios 3 and 5 were a 625% increase in homebirth) the proportions remained very small. Considering the absolute increase of services was modest, it would be feasible to offer a greater number of women options including publicly supported homebirth and birth centre care while utilising the existing infrastructure. There may be additional costs related to training and accreditation of staff and facilities, which would ultimately be recouped over time with the prospected decrease in intervention. A limitation of proposing this increase in service options is that there exists only anecdotal reports of the demand by women to enter into a program which offers an alternative to hospital birth; reports of waiting lists cannot be quantified and further research into the apparent demand is warranted.This study represented the provision of homebirth services in a publicly-funded model however, in NSW, more than half of homebirths were attended by midwives in private practice. Smooth transfers to hospital require a networked or integrated service. Additionally, transfer costs were not included in the total cost for women who transferred to hospital from home as not all transfers occur via ambulance. If an ambulance was required, we calculated an additional $416 for transfer assuming a ten-kilometre distance from the nearest maternity facilityThe findings from this study offer some clarity into the financial saving of offering greater options to women seeking an alternative to giving birth in hospital. Maternity service provision is complex and admission for intrapartum care drives the costs related to overheads, interventions and outcomes. Given the relatively lower rates of complex intervention and neonatal outcomes associated with women at low risk of complications, we can assume the cost of providing them with homebirth and birth centre options could be cost-effective.


The EMPA-REG OUTCOME ) trial evidenced the potential of sodium-glucose cotransporter 2 (SGLT2) inhibitors for the treatment of patients with diabetes and cardiovascular disease. Recent evidences have shown the benefits of the SGLT2 inhibitor empagliflozin on improving liver steatosis and fibrosis in patients with T2DM. Metabolomic studies have been shown to be very useful to improve the understanding of liver pathophysiology during the development and progression of metabolic hepatic diseases, and because the effects of empagliflozin and of other SGLT2 inhibitors on the complete metabolic profile of the liver has never been analysed before, we decided to study the impact on the liver of male Zucker diabetic fatty (ZDF) rats of a treatment for 6 weeks with empagliflozin using an untargeted metabolomics approach, with the purpose to help to clarify the benefits of the use of empagliflozin at hepatic level. We found that empagliflozin is able to change the hepatic lipidome towards a protective profile, through an increase of monounsaturated and polyunsaturated glycerides, phosphatidylcholines, phosphatidylethanolamines, lysophosphatidylinositols and lysophosphatidylcholines. Empagliflozin also induces a decrease in the levels of the markers of inflammation IL-6, chemerin and chemerin receptor in the liver. Our results provide new evidences regarding the molecular pathways through which empagliflozin could exert hepatoprotector beneficial effects in T2DM. Type 2 diabetes mellitus (T2DM) is highly connected to metabolic liver disease, that is a chronic condition that implies hepatic fat accumulation associated to underpinning metabolic dysregulation  and low-We have demonstrated earlier that, in Zucker diabetic fatty (ZDF) rats, the treatment with empagliflozin modifies the cardiac metabolome, greatly reducing the content of lipid species associated with cardiac lipotoxicity . In the All reagents and materials are from Sigma-Aldrich (United States) except where stated otherwise.In Vivo Experiments)   and the fa/fa) are a model of early stage T2DM with high insulin and glucose intolerance in liver and skeletal muscle (fa/fa rats with a body weight ranging 200–250 g were obtained from Charles River Laboratories (United States). In order to induce T2DM, animals were fed ad libitum with the diabetogenic diet Formulab 5008  according to the supplier instructions, starting at 7-weeks of age. Rats were housed at the Animal House of the CiMUS  under controlled room temperature (22 ± 2°C), relative humidity (40–5%) and illumination (12-h light/12-h dark cycle), with free access to chow and water.Zucker Diabetic Fatty (ZDF) rats  and treated ) (n = 15) (Once ZDF rats reached fasting glucose levels of 350.75 ± 18.59 mg/dl (12-weeks old), they were divided in 2 random groups: control  ((n = 15) . After 6(n = 15) .Animal nourishments were retired at 20:00 h, and after 12 h of fasting, a blood sample from the tail vein was collected and measured using the glucometer GlucoDr auto™  once a week.2 SYBR Green qPCR Mastermix and specific primers provided by Thermo Scientific using a Stratagene MX3000p thermocycler according to manufacturer’s instructions .The hepatic gene expression of interleukin-6 (IL-6) , retinoic acid receptor responder 2 or chemerin (RARRES2) (RefSeq NM_001013427.1), chemerin chemokine-like receptor 1 (CMKLR1)  and 18S ribosomal RNA (18S)  as a housekeeping gene were determined by RT-qPCR. The NucleoSpin RNA Mini kit for RNA purification  was used to extract total RNA. Subsequently, the extracted RNA was measured in a NanoDrop 1000 spectrophotometer  to quantify and evaluate its purity. cDNA was synthetized performing a reverse transcription from 1 µg of RNA, using the Transcriptor First Strand cDNA Synthesis Kit  according to manufacturer’s instructions. RT-qPCR was performed using RTn = 10) was carried out by OWL Metabolomics S.L. (ESP) as previously described (www.lipidmaps.org).Liver metabolomics analysis . For gene expression analysis, the fold change vs. control in the expression of target genes was calculated using the 2Ct−ΔΔ method.All data are expressed as mean ± standard error of the mean (SEM), and significance was defined as https://cran.r-project.org/).For metabolomics analysis, data were pre-processed using the TargetLynx application manager for MassLynx 4.1 . Intrabatch and interbatch normalization followed the protocol detailed in p < 0.0001, n = 15)  .n = 15). After 6 weeks of treatment, we observed a slight increase in body weight in the empagliflozin group compared to control , without affecting food intake. As well, fat distribution and muscle volume were unaltered after empagliflozin treatment compared to control , cholesterol , LDL , HDL , and the hepatic enzymes alanine transaminase (ALT)  and gamma-glutamyl transferase (GGT)  were unaltered after empagliflozin treatment .We also determined if empagliflozin could affect liver weight by normalizing liver weight by whole body weight. We observed that empagliflozin did not affect liver weight compared to control rats  vs. log2(fold-change)] was also generated for comparison between empagliflozin vs. control  and total triglycerides (63.70 ± 5.38 (a.u.) and 54.01 ± 7.81 (a.u.); p: 0.320, n = 10) content in the liver.A total of 400 metabolites were detected in the analyzed liver samples. Among these, 16 metabolites were found to be outliers and were excluded from the statistical analysis. The heatmap in  control . This vo control . Changesugmented , 2. In cvs. control are summarized in Regarding other metabolic species, increased levels of amino acids, a fatty acid, monoacylglycerophosphoethanolamines, succinate and xanthosine were found in livers from rats treated with empagliflozin , 2. OnlySimilarly, in order to know the potential enzyme activities related to hepatic lipid metabolism, we calculated several enzyme ratios . We founEmpagliflozin treatment induces a reduction on hepatic gene expression of the pro-inflammatory markers chemerin, chemerin receptor and IL-6  in diabeThe most relevant result in our present work is the demonstration that the treatment with empagliflozin is able to modify the hepatic metabolome of male ZDF rats into a more favorable profile, and that this SGLT2 inhibitor is also able to decrease the gene expression of pro-inflammatory markers in the liver of those animals.The ZDF rat is a model of T2DM well established, and it is also used as a model for the study of metabolic fatty liver disease . In our in vivo and in vitro conditions . To note, a reduction of arachidonic acid-containing species has been recently tightly associated to the pathogenesis of hepatic fibrosis and liver damage . This imIn this work, we show that empagliflozin treatment increases liver LPC levels in diabetic ZDF rats compared to untreated controls. Interestingly, elevated plasma levels of LPC in patients with non-alcoholic fatty liver have been associated with anti-inflammatory and glucose-lowering effects, and with metabolically benign disease , while dRegarding other metabolic features altered in the liver of ZDF rats by the treatment with empagliflozin, we would like to highlight the decrease in the hepatic content of taurochenodeoxycholic acid, a bile acid whose levels have been positively associated with liver injury  and cirrInflammation is a common feature in metabolic disorders, including fatty liver disease . The infTo note, we have previously described a robust SGLT2 hepatic gene expression in both control and empagliflozin-treated ZDF rats, which is lower but comparable with its expression levels in kidney . AccordiIn conclusion, the results of this work evidence that the treatment with empagliflozin is able to modify the hepatic metabolome of ZDF rats towards a protective profile, while diminishing the expression of pro-inflammatory molecules tightly involved in the physiopathology of liver metabolic disease. Since SGLT2 inhibitors seem to be an attractive therapeutic opportunity for metabolic liver disease management, these findings come in support of a beneficial effect for empagliflozin in the regulation of hepatic metabolism in a context of obesity and diabetes.


Birth weight, an indicator of fetal growth, is associated with cognitive outcomes in early life (which are predictive of cognitive ability in later life) and risk of metabolic and cardiovascular disease across the life course. Brain health in older age, indexed by MRI features, is associated with cognitive performance, but little is known about how variation in normal birth weight impacts on brain structure in later life. In a community dwelling cohort of participants in their early seventies we tested the hypothesis that birth weight is associated with the following MRI features: total brain (TB), grey matter (GM) and normal appearing white matter (NAWM) volumes; whiter matter hyperintensity (WMH) volume; a general factor of fractional anisotropy (gFA) and peak width skeletonised mean diffusivity (PSMD) across the white matter skeleton. We also investigated the associations of birth weight with cortical surface area, volume and thickness. Birth weight was positively associated with TB, GM and NAWM volumes in later life (β ≥ 0.194), and with regional cortical surface area but not gFA, PSMD, WMH volume, or cortical volume or thickness. These positive relationships appear to be explained by larger intracranial volume, rather than by age-related tissue atrophy, and are independent of body height and weight in adulthood. This suggests that larger birth weight is linked to more brain tissue reserve in older life, rather than age-related brain structural features, such as tissue atrophy or WMH volume. Birth wBirth weight within the normal range (2.5 – 4.5 kg) correlates with cognitive performance in childhood (Pearson’s r ~0.17), and this influence may extend into adulthood and later life . Birth wTo better understand the value of birth weight value as a perinatal indicator of later life brain health it is important to establish the neurobiological correlates of birth weight into older age. We investigated the following global measures, each of which is reliably associated with cognitive ability in later life with modest effect sizes: total brain (TB), grey matter (GM) and normal appearing white matter (NAWM) which are also linked to cognition, as well as white matter hyperintensity (WMH) volume, a marker of cerebrovascular disease in older age, is associated with cognitive decline . In oldehow birth weight has an impact on brain structure we considered the potential roles of i) body size ii) age-related brain tissue atrophy, and iii) cardiovascular and metabolic disease, which is also linked to low birth weight and may mediate the relationship between birth weight and brain structure.To test the hypothesis that birth weight is associated with brain macrostructure and white matter microstructure in older age, we linked these MRI features of brain structure at 73 years of age with perinatal data using a well-characterised single-year-of-birth cohort of healthy community dwelling-older adults (the Lothian Birth Cohort 1936). To understand 22.1Data were collected from the Lothian Birth Cohort 1936 (LBC1936), a longitudinal study of aging comprising individuals who were born in 1936. They mostly took part in the Scottish Mental Survey 1947 (SMS1947) and most were resident in Edinburgh and its surrounding area (the Lothians) at about age 70 years when recruitment for follow-up testing began. The recruitment, brain imaging, and cognitive testing protocols for the LBC1936 have been reported previously in detail .At Wave 2, 866 participants returned , 728 of whom underwent brain structural and diffusion MRI, upon which the current study is based. Ethical approval for the LBC1936 study came from the Multi-Centre Research Ethics Committee for Scotland  and the Lothian Research Ethics Committee (LREC/2003/2/29). All participants, who were volunteers and received no financial or other reward, completed a written consent form before any testing took place.2.2Birth weight was retrieved from original archival hospital records from the time of birth, accessed from the Lothian Health Service Archive at the Centre for Research Collections in the University of Edinburgh. Participants were born at the Edinburgh hospitals Royal Maternity Simpson Memorial Hospital (n = 74), Elsie Inglis Memorial Maternity Hospital (n = 60), Bellshill Maternity Hospital in Lanarkshire (n = 2) and Aberdeen Maternity Hospital (n = 1). Birth weight was recorded in the original records in lb and oz and subsequently converted to grams. Analysis was performed with birth weight as a continuous variable.2.32) was calculated from height (cm) and weight (kg) which were measured at the same time as the medical interview.During a structured medical history interview at Wave 2, participants were asked whether they had a history of cardiovascular disease or stroke, or had received a diagnosis from a doctor of diabetes, hypercholesterolemia, or hypertension. They were also asked about their smoking history (current/ex/never). BMI  located at the Brain Research Imaging Centre, University of Edinburgh, soon after cognitive testing and plasma collection. T1-, T2-, T2* and FLAIR-weighted MRI sequences were collected and co-registered (voxel size = 1×1×2 mm). Intracranial (ICV), total brain (TB), grey matter (GM), total white matter and white matter hyperintensity (WMH) volumes were measured using a semi-automated multispectral fusion method for segmentation of brain tissue volumes from the four structural scans, that is, T2-, T1-, T2*- and FLAIR-weighted MRI,  Valdés . Normal-−2) were acquired in 64 non-collinear directions, together with seven T2-weighted volumes (b = 0 s mm−2). This protocol was run with 72 contiguous axial slices with a field of view of 256×256 mm, an acquisition matrix of 128×128 and 2 mm isotropic voxels  . The folPSMD is the 95th percentile minus the 5th percentile of an individual’s MD within the white matter skeleton. Automatic calculation of PSMD followed the procedure described by Finally, each of the T1-weighted volumes were processed using FreeSurfer v5.1. Following visual quality control in which the outputs for each participant were inspected for aberrant surface meshes, skull stripping and tissue segmentation failures, their estimated cortical surfaces were registered to the ‘fsaverage’ template, yielding a measure of regional volume, surface area and thickness at each of 327,684 vertices across the cortical mantle.2.5lavaan (2(48) = 106.341, p <0.001. Tract loadings are reported in Unless otherwise stated, all analyses were conducted in R 3.4.3 (R Core Team 2015). We conducted t-tests of continuous variables  and chi square tests of categorical variables  between the cohort subsample with birth weight data and those without birth weight data. For regression models we report standardised regression coefficients and corrected p-values for multiple comparisons using the False Discovery Rate FDR; . A generlavaan . A latenInitially, we conducted linear regression models of birth weight and global brain image features, with a separate model for each of TB, GM, NAWM and WMH volumes, and PSMD and gFA as the outcome variable. Sex and age in days at MRI acquisition were included as covariates in all models. These models were then conducted with the inclusion of anthropometric covariates height and weight to isolate unique effects of birth weight from late life body size. Pearson correlations were calculated for birth weight with height and weight in later life. Next, because associations between smaller brain volumes in later life with lower birth weight may be explained by increased atrophy in later life, or by having a smaller maximal brain size, prior to age-associated atrophy, we re-ran the associations using the global brain volumes  with ICV as a covariate in addition to age at scan and sex. ICV is a reliable archaeological metric for estimating maximal healthy brain size . There aDue to the relationship between birth weight and cardiovascular disease in later life, and the association between cardiovascular disease and brain structural outcomes, we conducted a set of models adjusting for age and sex and the following health covariates to control for the potential influence on results of cardiovascular and metabolic disease risk: Body Mass Index (BMI), hypertension, diabetes, hypercholesterolemia, smoking status , and cardiovascular disease history.http://www.math.mcgill.ca/keith/surfstat) for Matrix Laboratory R2018a , for which 130 participants had complete MRI, birth weight and covariate data. Results are reported in the form of t-statistics and FDR-corrected q-maps displayed on the ‘fsaverage’ cortical surface.Associations between birth weight and cortical measures  were investigated in vertex-wise analyses across cortical mantle, using data smoothed at 20 FWHM to the FreeSurfer average surface (brainstem removed). Age and sex were included as covariates in all models. We additionally included height and weight to control for adult body size. In a separate analysis ICV was included in addition to age and sex to investigate whether the effect of birth weight on brain volumes was accounted for by larger head size/maximal brain size. Cortical volume, thickness and surface area vertex-wise analyses were performed across the average surface with linear models to investigate the effect of birth weight on cortical surface area using the SurfStat toolbox  image bank governance process: www.brainsimagebank.ac.uk . Code us33.1One hundred and thirty-seven participants of the Lothian Birth Cohort 1936 (LBC1936), a cohort of community dwelling older participants, had both birth weight recorded and structural and diffusion MRI, out of a total of 866 participants in the second wave of data collection . In this3.2We first performed linear regression models corrected for age and sex to test the association between birth weight and the following brain MRI features: total brain (TB), grey matter (GM), normal appearing white matter (NAWM), and white matter hyperintensity (WMH) volumes, a general factor of fractional anisotropy (gFA) and peak width skeletonised mean diffusivity (PSMD). The results of age- and sex-corrected associations between birth weight and global brain measures are presented in Next, we investigated whether the effect of birth weight on brain volumes was accounted for by larger body size by controlling for height and weight in addition to age at scan and sex. Following adjustment for height and weight, TB and NAWM volumes remained significantly associated with birth weight, though the strength of the association was reduced by 27% and 23%, respectively. GM volume was no longer significantly associated with birth weight (effect size was attenuated by 31.9%). Birth weight was significantly associated with later life height  but not with later life weight .Results for associations between global volumetric measures corrected for ICV are presented in a posteriori regression to verify the association between birth weight and ICV directly. ICV was significantly associated with birth weight  in a linear regression that included age at MRI, sex, height and weight as covariates.As the inclusion of ICV as a covariate attenuated the relationship between birth weight and brain volumes, we performed an 3.3When we additionally corrected the associations between birth weight and global brain measures for cardiovascular risk factors and self-report history of cardiovascular disease , the ini3.4Vertex wise analysis revealed positive associations between birth weight and surface area on the bilateral temporal (inferior and middle), cingulate (anterior and posterior segments) and anterior frontal , supramarginal and medial occipital cortices, as well as evidence for associations in the motor and somatosensory cortices and right-sided medial and lateral orbitofrontal, posterior fusiform, angular gyrus and supramarginal gyrus A. These 4In this well-characterised cohort of older community-dwelling adults, we report that higher birth weight is associated with larger TB, GM and NAWM volumes seven decades later. Importantly, these associations become non-significant with inclusion of ICV as a covariate, whereas associations with WMH, a brain marker of older age neurodegenerative processes among healthy adults, were null. This suggests that the association between birth weight and brain tissue volumes are likely due to the influence of brain size in early life, rather than brain tissue atrophy in later life. This indicates that higher birth weight may confer brain reserve in older age, operating by preserved differentiation rather than differentiated preservation.Birth weight is positively correlated with adult height and weight, and so we controlled for these to test whether the positive associations between birth weight and brain volumes were due to overall body size . ControlDespite consistent findings that low birth weight is associated with diffuse white matter injury from the neonatal period through to early adulthood, captured by measures of white matter microstructure, we did not observe a relationship between birth weight and WMH volume or global measures white matter microstructure in late life . Howeverin utero, or both. Due to the historical nature of the birth data, we do not have reliable and precise information about gestational age at birth, and so we could not estimate the prevalence of fetal growth restriction  in our sample. A previous study showed a significant association between birth weight and cortical surface area even when controlling for parental height (as an indicator of genetic contributors to growth), which suggests that the relationship we observed between birth weight and brain structure may, at least in part, be independent of genetic growth potential  (to distinguish between atrophy that began early and proceeded slowly and that which began late and proceeded quickly), would require multiple imaging assessments from across the period from early adulthood to current age.The present manuscript offers an extensive examination of the relationship between birthweight and brain structure across 6 decades of life. Whereas prior well-powered work indicates the importance of brain volume and surface area for differences in cognitive function, the evidence in the current study for birthweight as a marker of brain reserve with respect to subsequent cognitive functioning is indirect . Future,Birth weight demonstrates a modest, positive association with brain tissue reserve in later life, which is likely established in early life. It is not a protective factor against estimated brain tissue atrophy, age-related white matter damage (indicated by WMH volume) or differences in white matter microstructure (measured through diffusion MRI). Our results support a developmental origin of brain tissue reserve that survives into old age.The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.


We examined the relationship between obstetrical intervention and preterm birth in the United States between 2014 and 2019. This observational study analyzed 2014–2019 US birth data to assess changes in preterm birth, cesarean delivery, induction of labor, and associated risks. Logistic regression modeled the odds of preterm obstetrical intervention (no labor cesarean or induction) after risk adjustment. The percentage of singleton preterm births in the United States increased by 9.4% from 2014–2019. The percent of singleton, preterm births delivered by cesarean increased by 6.0%, while the percent with induction of labor increased by 39.1%. The percentage of singleton preterm births where obstetrical intervention (no labor cesarean or induction) potentially impacted the gestational age at delivery increased from 47.6% in 2014 to 54.9% in 2019. Preterm interventions were 13% more likely overall in 2019 compared to 2014 and 17% more likely among late preterm births, after controlling for demographic and medical risk factors. Compared to non-Hispanic White women, Non-Hispanic Black women had a higher risk of preterm obstetric interventions. Preterm infants have higher morbidity and mortality rates than term infants, thus any increase in the preterm birth rate is concerning. A renewed effort to understand the trends in preterm interventions is needed to ensure that obstetrical interventions are evidence-based and are limited to those cases where they optimize outcomes for both mothers and babies. Preterm birth (birth before 37 completed weeks of gestation) has long been a critical measure of infant health. After a decline from 2006–2014, the United States preterm birth rate increased from 9.57% of U.S. births in 2014 to 10.23% in 2019 [One study estimated the annual cost of preterm birth as $25 billion in 2016 , air polAn earlier paper explored the role obstetrical interventions might have played in the 1991–2006 rising trend in preterm births and found much of the increase associated with increasing use of preterm cesarean section and induction or labor . The purWe analyzed data from the National Center for Health Statistics natality data files from 2014–2019. These files contain detailed information on each of the nearly 4 million births in the United States each year . GestatiWe examined trends in singleton preterm births and in cesarean and induction of labor among singleton, preterm births overall and by demographic and medical variables Tables  and 2. VThe method of delivery , induction of labor , and “If cesarean, was a trial of labor attempted?”  variables available from the birth certificate  were useLogistic regression was used to examine the odds of preterm obstetrical intervention (induction or no labor cesarean) among all singleton births in 2014 and 2019, with 2014 as the reference year. Three models were run with variable categories as shown in In 2014, there were 297,460 singleton preterm births out of 3,848,214 singleton births at any gestational age registered in the United States. In 2019, the numbers were 306,646 and 3,623,963, respectively. Numbers were similar from 2015–2018.The overall proportion of preterm births in the United States increased from 9.57% in 2014 to 10.23% by 2019, a percentage increase of 6.9%. Among our study population of singleton births, the increase between 2014 (7.73%) and 2019 (8.46%) was 9.4% . The perWhen examined by race/ethnicity, we found that increases in singleton preterm births were largest for Native American (12.6%) and Hispanic (11.5%) women, and moderate for non-Hispanic Black (7.8%) and non-Hispanic White women (7.7%). Compared to non-Hispanic White women, the 2019 singleton preterm birth rate was 62.9% higher for non-Hispanic Black women, 38.0% higher for Native American women, and 34.6% higher for Pacific Islander women. Increases were also larger for women aged 35–44, those with 4 or more prior births, were obese, had pre-pregnancy diabetes, or whose births were paid for by Medicaid.The percentage of singleton preterm births delivered by cesarean section increased from 43.2% in 2014 to 45.8% in 2019 –an increase of 6.0% . IncreasThe percentage of all singleton preterm births with induction of labor increased substantially from 13.6% in 2014 to 18.9% in 2019 –an increase of 39.1% . CompareIn Next, we examined births by method of delivery as a proportion of all singleton preterm births. We found that the two categories that did not involve interventions that might alter gestational age  declined from 52.5% to 45.2% of all singleton preterm births . TogetheWhen late preterm births were examined as a proportion of total births, we found that the percent of singleton late preterm births with spontaneous vaginal delivery declined by 5.4% from 2014 (2.80%) to 2019 (2.65%) . In contWhen examined as a proportion of all late preterm births, we found that the two categories that did not involve interventions that might alter gestational age  declined from 54.6% of total late preterm births in 2014 to 46.5% in 2019. Conversely, the percentage of singleton late preterm births where obstetrical intervention potentially impacted the gestational age at delivery increased from 45.4% in 2014 to 53.5% in 2019.Adjusted odds ratios for the likelihood of preterm obstetrical intervention (no labor cesarean or induction of labor) from 2014–2019, with 2014 as the reference category, are presented in decreased by 5.8% and there was no change in cesareans following a trial of labor, meaning all of the increase in preterm births was associated with labor interventions. More than half (56%) of that increase was associated with inductions of labor, either in vaginal or cesarean births, while the remainder involved cesareans with no labor. Both preterm cesareans and preterm inductions have increased between 2014 and 2019, though in the case of inductions, the increases were much larger. While the percent of singleton preterm births with cesarean section increased by 16.1%, the percent with induction of labor increased by 52.3%, with more than one in five (21.9%) deliveries among late preterm (34–36 weeks) births now involving an induction. While overall cesarean rates have remained steady since 2007, induction rates, which also remained steady from 2008 to 2014 at 27%, began a steady climb in 2014 and have now reached 29.4% of all births and 36.6% among planned vaginal births  in 2019 [The percentage of singleton preterm births increased by 9.4% from 2014–2019, and much of this increase involved increases in obstetrical intervention. In a period when the overall preterm rate was increasing, the preterm rate for spontaneous vaginal births More than one half 54.9%) of singleton preterm births in 2019 had an obstetrical intervention that could have affected the gestational age at delivery. Preterm inductions and cesareans save lives if the circumstances necessitate the procedure. The 2021 ACOG Committee Opinion on Medically Indicated Late-Preterm and Early-Term Deliveries provides an excellent summary of the indications which may necessitate preterm cesarean or induction 4.9% of s. Vital sFrom 2009–2014, The March of Dimes and other organizations ran the “Think 39” campaign to prevent non-medically indicated cesareans and inductions prior to 39 weeks gestation , 22. ThePreterm interventions were 13% more likely overall in 2019 compared to 2014 and 17% more likely among late preterm births, after controlling for demographic and medical risk factors. Some of the rise in preterm interventions during this period may be associated with increasing rates of chronic illness, including hypertension among women, although we did control for hypertensive disorders in the multivariate modeling. For example, data indicate increasing rates of preeclampsia, which is a leading indication for preterm intervention , 26. AddWhile increases in rates of preterm births were relatively similar among White and Black women from 2014 to 2019, we did find overall disparities in use of preterm interventions by race and ethnicity. After controlling for a wide range of demographic and medical risk factors, including obesity, diabetes and hypertension, non-Hispanic Black women were 42% more likely to receive an obstetrical intervention prior to 37 weeks gestation and 24% more likely between 34 and 36 weeks gestation than were White women. Our finding of higher use of obstetrical intervention in preterm deliveries to non-Hispanic Black women is consistent with prior research documenting higher rates of cesarean deliveries for Black women overall –30 and hThe strengths of the study include the comprehensive population-based data set which included all births in the United States for a given year together with many demographic and medical variables. Limitations include concerns about the accuracy of reporting of some items on the birth certificate. Most demographic items and some medical items , are considered to be well reported on birth certificates –36. OtheThe United States prematurity rate increased by 20% between 1990 and 2006 . After t


Echinococcus granulosus in predominantly rural areas of the Mediterranean region, South East Asia, Australia, and South America. This report discusses a unique case of a 32-year-old lady who presented to the Emergency Surgery Department with complaints of abdominal pain, distension, and constipation for five days. Radiological investigations showed air-fluid levels within a large cyst originating from the liver. Surgical exploration revealed a large hepatic hydatid cyst communicating with the transverse colon with the presence of multiple peritoneal hydatid cysts. Evacuation of the cyst contents, lavage, and excision of the rest of the hydatid cysts was done. Dense adhesions were present involving the liver, large bowel, and duodenum. Therefore, a terminal ileum diversion loop ileostomy was made. Ileostomy was reversed after checking the large bowel anatomy with a distal loopogram.Hydatid disease is a prevalent parasitic infestation caused by the cestode  Echinococcus granulosus, is a significant health problem in places where animal husbandry is common [The infestation with the cestode,s common . Though s common ,3. Hydats common . The diss common . Hydatids common . Direct s common -9. Ruptus common -14.A 32-year-old lady presented to the Emergency Surgery Department, Lok Nayak Hospital, New Delhi with complaints of generalized abdominal pain, distension, vomiting, and constipation for five days and fever for two days. There was no history of any similar complaint in the past. There was no history of the passage of any mucoid material in the vomitus or the stools. There was no history of any prior hospital admission for any surgical procedure. She did not suffer from diabetes mellitus, hypertension, or tuberculosis. The patient was a non-smoker, non-alcoholic and did not chew tobacco. She had normal menstrual cycles. The family history was non-contributory.On examination, she was dehydrated, and her vitals were stable. The abdomen was distended and bowel sounds were sluggish. However, there were no signs of peritonitis.Echinococcus antibodies was positive. X-ray abdomen (erect)  of the patient showed a white blood cell (WBC) count of 12,000 with neutrophilia (75%), eosinophilia (15%), hemoglobin of 8.6 gm/dL, and normal platelet counts. The renal and liver function tests were normal. The coagulation profile was normal. Enzyme-linked immunosorbent assay (ELISA) for anti-Requisition for a contrast-enhanced computed tomography (CECT) abdomen was sent to the Radiology Department and the patient was scheduled for the scan after one week. However, on day 5 of admission, the patient developed tachycardia and severe abdominal pain. The abdomen showed signs of localized peritonitis in the right hypochondrium, epigastrium, right lumbar and umbilical segments. After discussing the case with the radiologist, the patient was shifted for an urgent CECT abdomen. The scan showed a large cystic lesion with air-fluid level arising from the liver with probable rupture of cyst into the colon. Multiple hydatid cysts in the liver, omentum, and pelvis were noted Figures -2c.The patient underwent an exploratory laparotomy. Intraoperatively, a cystic lesion of 12×7×9 cm was seen in the right lobe of the liver, filled with daughter cysts. The cyst was isolated with sponges soaked in the povidone-iodine solution. The cyst densely adhered to the hepatic flexure of the colon with minimal fecal content within the cyst cavity. However, it was extremely difficult to delineate and dissect out the fistulous tract due to dense inter-bowel and hepato-colic adhesions. The entire contents of the liver cyst cavity were evacuated, and thorough lavage was performed. A drain was placed within the cavity thereafter. Keeping in mind the high likelihood of occurrence of iatrogenic injuries and hemodynamic instability of the patient, it was decided not to proceed further with adhesiolysis. The remaining hepatic, omental and pelvic hydatid cysts Figures , 3b wereThe post-operative period was uneventful, and the cyst cavity drain was removed on the 13th post-operative day when the output was reduced to nil. Histopathology report confirmed the diagnosis of hydatid disease in the liver, omentum, and pelvis Figure .The patient was discharged thereafter; with a plan to close the diversion ileostomy after a contrast distal loopogram study for confirming the absence of any fistulous communication between the colon and liver or peritoneal cavity. She was discharged on the 14th postoperative day after fully tolerating an oral diet. She was prescribed tablet albendazole 400 mg BID on discharge and was advised to follow up on a regular basis. Distal loopogram after six weeks did not reveal any fistulous communication of colon to the liver or peritoneal cavity. The patient underwent ileostomy closure after three months of the index operation. She made an uneventful recovery and was doing well at the end of three months follow-up.Clinically, the hydatid cyst rupture into a hollow organ can be diagnosed by the passage of hydatid membranes in the stools (hydatidorrhea or hydatidenteria) or the vomitus (hydatidemesis) . HoweverSeveral diseases may have a similar clinical presentation to the case discussed herein. These include ruptured amoebic or pyogenic liver abscess, ruptured hydatid cyst, abdominal abscess, intestinal duplication cyst, and mesenteric cyst. Three types of hydatid cyst rupture have been described in the literature: contained, communicating, and direct. When the endocyst ruptures and the fluid seeps through space in between the pericyst and endocyst resulting in the collapse of the endocyst, it is known as a contained rupture. Communicating rupture refers to a rupture into the biliary tree and is the most common variant . RuptureTwo mechanisms have been suggested, which may be responsible for the rupture of a hydatid cyst into the surrounding structures. Infection of the cyst content and swelling of the outer membranes result in adhesions between the cyst and surrounding viscera. Continuous mechanical friction by the pericyst can result in erosion into the hollow viscus wall . It was There are only a very limited number of reports describing hydatid cyst rupture into the gastrointestinal tract. Hepatic hydatid cysts fistulizing into the duodenum have been described in English literature. Patients were managed by surgical exploration and made successful recovery . RuptureA report describes perforation of a hepatic hydatid cyst into the right colon, which was managed by partial cystectomy, omentoplasty, right hemicolectomy, and side-to-side ileocolic anastomosis. The patient had an uneventful recovery . Casto eTreatment following rupture of a hydatid cyst is always surgical. Total resection of the cysts is the treatment of choice. If that is not possible, then cyst enucleation, deroofing of the cyst with omentoplasty or external drainage may be done . Free inHepatic hydatid cyst rupturing into the transverse colon is a very rare complication of hydatid disease. A patient with a ruptured hydatid cyst may present with a variety of signs and symptoms, ranging from dull aching pain and mild abdominal distension to peritonitis. A pre-operative diagnosis of cyst rupture into the gastrointestinal tract can be supported with the aid of the CECT abdomen showing the characteristic findings. Surgical exploration is the definitive treatment of a ruptured hydatid cyst and is usually followed by a good prognosis.


We use Ice, Cloud, and land Elevation Satellite 2 (ICESat‐2) laser altimetry crossovers and repeat tracks collected over the North Slope of Alaska to estimate ground surface‐height change due to the seasonal freezing and thawing of the active layer. We compare these measurements to a time series of surface deformation from Sentinel‐1 interferometric synthetic aperture radar (InSAR) and demonstrate agreement between these independent observations of surface deformation at broad spatial scales. We observe a relationship between ICESat‐2‐derived surface subsidence/uplift and changes in normalized accumulated degree days, which is consistent with the thermodynamically driven seasonal freezing and thawing of the active layer. Integrating ICESat‐2 crossover estimates of surface‐height change yields an annual time series of surface‐height change that is sensitive to changes in snow cover during spring and thawing of the active layer throughout spring and summer. Furthermore, this time series exhibits temporal correlation with independent reanalysis datasets of temperature and snow cover, as well as an InSAR‐derived time series. ICESat‐2‐derived surface‐height change estimates can be significantly affected by short length‐scale topographic gradients and changes in snow cover and snow depth. We discuss optimal strategies of post‐processing ICESat‐2 data for permafrost applications, as well as the future potential of joint ICESat‐2 and InSAR investigations of permafrost surface‐dynamics. ICESat‐2 altimetry can resolve surface subsidence that is related to changes in snow‐cover depth and seasonal thawing of the active layerICESat‐2 measurements of surface‐height change are affected by along‐track topographic gradients and complex surface roughnessComplementary ICESat‐2 and InSAR datasets can be jointly leveraged for future studies in periglacial environments This short length‐scale topographic bias can introduce surface‐height change biases on the order of, or larger, than expected deformation signatures and represents a major error source that must be corrected before a robust ICESat‐2 surface‐height change product over typically rough periglacial terrains can be generated. Finally, we discuss several possible methods of further refining surface‐height change estimates and suggest future steps for expanding ICESat‐2 data analysis to pan‐Arctic estimates of Arctic permafrost change.In this work, we provide an initial assessment of the capability of the ICESat‐2 mission to quantify spatial patterns of surface‐height change in periglacial environments. We derive estimates of surface‐height change from ICESat‐2 crossovers and repeat transects over a region of the Alaskan North Slope near the 2007 Anaktuvuk River Fire scar. We demonstrate a linear relationship between ICESat‐2‐derived surface‐height change estimates from crossover analysis and changes in the normalized accumulated degree days (NADD), a proxy for differential thaw, which suggests that ICESat‐2 altimetry crossover‐derived height change is directly sensitive to the seasonal thaw and refreeze of the active layer. We also show that ICESat‐2 observations are sensitive to the depth of snow cover and apply a correction based on independent reanalysis data to remove this snow‐cover bias from ICESat‐2 repeat transects. Integrating ICESat‐2 crossover estimates of surface‐height change yields an annual, region‐wide time series of surface height, which exhibits temporal agreement with both an independent InSAR‐derived time series, as well as temperature and snow‐cover reanalysis datasets. We further find that ICESat‐2 estimates of surface‐height change are significantly impacted by short length‐scale (and sub‐footprint) topographic gradients, even for effectively overlapping  and has a 12‐day temporal repeat in the high Arctic. We processed raw data (L1.0) collected in the interferometric wide swath mode using the “geocoded single‐look complex” (SLC) backprojection method  of the phase estimation, resulting in interferograms with a spatial resolution of After applying the above calibrations to the InSAR data, we generated a pixel‐wise time series across the comparison region using the small baseline subset (SBAS) method over a network of 14 interferograms spanning the 2019 thaw season  as the difference of the profile elevations at the crossover location, subtracting the later observation in time from the earlier observation. We filtered crossover dh results to remove estimates that were further than 2 standard deviations from the mean of the entire set of crossover dh estimates. We propagated uncertainties on individual ATL06 elevations through to the final dh estimates.To examine the sensitivity of our crossover estimation to our choice of interpolation distance, we tested distances ranging from 20 to 100 m for fitting lines to ATL06 segments on either side of the crossover location. We used two metrics to assess the performance of a given interpolation distance. The first is the median propagated uncertainty for all crossovers calculated, which is a function of both the uncertainty of each ATL06 surface‐height estimate and of the residuals of the linear fit. The second is the standard deviation of crossovers with a time interval of 14 days or less, a period over which we assume surface‐height change is negligible.To assess the ability of crossover estimates to characterize large‐scale subsidence patterns over time, we searched for crossovers over the entire time period of available ATL06 data, which spanned October 14, 2018 to November 10, 2020. We also examined the 2019 and 2020 thaw seasons individually, to assess the ability of crossover estimates to detect thaw‐season subsidence. When selecting the time interval over which to define the thaw season, we sought to limit the amount of snow‐cover change, while maintaining a sufficient number of crossovers for our analysis. To this end, we calculated the number of crossovers and relevant statistics in four different time intervals, using different data constraints. The first time interval corresponds to the date range of the interferograms used for the SBAS inversion. The second time interval starts with the onset of thaw of the active layer and ends with autumnal refreeze, corresponding to the time period over which the seasonal accumulated degree days (ADD) were positive. We calculated ADD from a daily time series of air temperature at 2 m height above the surface from NASA's Daily Surface Weather and Climatological Summaries (DAYMET) reanalysis temperature data set  and freezing (uplift) of the active layer, we assumed that surface deformation due to seasonal thaw and refreeze follows a Stefan's Law relationship; that is, deformation is proportional to the square root of the ADD between any two observation times  and smoothness (with weight λs). We estimated model uncertainty in two ways: (a) we propagated uncertainties in the individual crossovers using a Monte Carlo simulation with 200 realizations of the input crossovers, generated from the observed crossover dh by applying random Gaussian error scaled by the crossover standard deviation; and (b) we used a jackknife approach to uncertainty estimation, in which we discarded a random selection of up to 50% of the observed crossover values and re‐estimating the model since uneven spatial sampling of the study domain is another potential error source.We estimated annual time series of surface‐height change over the study site from crossovers for both the 2019 and 2020 seasons. We assumed that the surface moves uniformly everywhere throughout the study site and invert for the height change time series that best fits the crossover data in a least squares sense. For fitting, we used a functional form that minimized the sum of the residual between modeled and observed dh with constraints on model size  and one of the 182‐day repeats tracks (RGT 274) for direct comparison with the InSAR results. In order to reduce the noise in our final results, we applied a boxcar filter over 2 km. We estimated the change in snow depth between the two dates by differencing the MERRA‐2 mean monthly snow depths for each month and subtracting this value from our height‐change estimates.We identified potential repeat tracks by flagging tracks from the same Reference Ground Track (RGT) with different collection dates and corresponding beams that had an across‐track distance difference of 33.1∼1.5 cm difference in subsidence between the burned tundra and unburned tundra  as a function of radius. The median uncertainty increases sharply with interpolation distance. When interpolating using only the nearest two points, the propagated uncertainty is a function of the uncertainty in each of the ATL06 segments. When interpolating over more than two points, the propagated uncertainty is also dependent on the residuals of the linear fit. Although we would expect interpolations over longer length scales to reduce the uncertainty for flat areas, the topography in this region is complex, leading to high residuals when interpolating over several ATL06 segments, which results in high propagated uncertainties. The short‐period standard deviation is a function of both cross‐track bias and the accuracy of the estimate of the elevation at the crossing location. In areas where the topography is non‐linear, such as the example shown in Figure For the bulk statistics reported in this work, we compared 1,018 individual ICESat‐2 beams from 185 ascending and descending tracks spanning the full ICESat‐2 study period, and identified 33,975 potential crossovers. From this set, there were between 13,728 and 16,021 crossovers with the required point density, depending on the interpolation radius. The crossovers spanned time periods ranging from 3 to 157 days, with 463 to 533 “short‐period” crossovers spanning 14 days or less. Figure nthaw) or a decrease in ADD (nfreeze). For the interferogram‐based range, crossovers that occurred entirely before thaw or after refreeze, and consequently have a zero change in ADD, were not counted in either nthaw or nfreeze. By scaling each crossover dh estimate by the time interval, we generated a time series of the surface‐height change, dh/dt, for 2019 and 2020 . We performed a linear regression and a Deming regression–a total least squares method which accommodates errors in both variables in the regression. Both regressions resulted in statistically significant linear relationships between surface‐height change and change in NADD (p<0.001), although accounting for uncertainties in surface‐height in the Deming regression (λ=0.01) resulted in a significant reduction in the standard error of the regression  complicated any direct analysis of individual crossovers. Instead, we performed a regional, spatiotemporal analysis of all crossover‐derived surface‐height changes. Plotting a two‐dimensional density plot between ICESat‐2‐derived vertical deformation of the ground surface and change in the square root of NADD reveals a clear temporal relationship  to explain observed crossover heights dh in terms of uniform changes in surface‐height across the study area. Our method used least‐squares inversion to minimize the residual between expected and observed crossover differences, initially implementing no smoothing and a minimal size constraint obtained by increasing the weight of the size regularization term in small increments from 0 until the shape of the model stabilized  than that for the 91‐day repeats . We selected one 91‐day repeat (RGT 1280) and one 182‐day repeat (RGT 0274) for comparison to the InSAR results. Applying the 2 km boxcar filter reduced both the variance and the propagated uncertainty in the data. For RGT 0274 spot 1L, the smoothing filter reduced the standard deviation and median uncertainty from 19 and 3.2 cm to 7.8 and 0.4 cm, respectively. For track 1280 spot 2L, the smoothing filter reduced the standard deviation and median uncertainty from 21 and 6.4 cm to 12 and 1.3 cm. The spatial distribution of the averaged dh values after removing the snow signal for each of the two RGTs is shown in Figure The 10 total repeat tracks in this study yielded surface‐height changes ranging from −315 to 329 cm, with uncertainties between 0.8 and 95 cm. Overall, repeat‐track comparisons showed net subsidence over the study region, with a mean of −9.8 cm. As expected, the magnitude of height changes from 182‐day repeat tracks were higher , which suggests that ICESat‐2 is directly sensitive to either differences in surface scattering properties or differential deformation patterns between burned and unburned tundra. Additionally, ICESat‐2 surface‐height changes displayed a moderate correlation with InSAR‐derived surface‐height changes within the Anaktuvuk River Fire scar (R2 = 0.194), whereas the correlation between these two measurements outside the fire scar is lower (R2 = 0.014). When comparing the sampled distribution of transect‐derived surface‐height changes between the burned and surrounding unburned tundra (as measured between 69.19° N and 69.45° N), we note that the ICESat‐2 surface‐height changes display a lower standard deviation in the burned tundra (σ=3 cm) compared to the unburned tundra (σ=5.5 cm). However the mean subsidence is approximately equal in both regions (dh=17 cm).Both the spatial pattern and sign of observed surface‐height changes  were broadly consistent with InSAR observations on flat terrain Figure . HoweverPrior to correcting for snow depth, the magnitude of deformation from the 182‐day repeat was systematically higher than those from the 91‐day repeat. MERRA‐2 data indicated a decrease in snow depth of 27–32 cm in the area between April and October. After removing this change in snow depth, the corrected dh estimates were much closer to the InSAR‐based estimates, and the areas where they diverge appeared to correspond with high along‐track slopes  wide, yielding comparable deformation estimates to the InSAR results. Further, the sensitivity of ICESat‐2 altimetry to snow cover, although an important geophysical signal itself, can significantly degrade surface‐height change estimates without empirical corrections derived from independent datasets or models, such as MERRA‐2.R2 = 0.308) and strong correlation between dh and across‐track slope (R2 = 0.578). For RGT 274, we also find a weak correlation with along‐track slope (R2 = 0.09) and a strong correlation with across‐track slope (R2 = 0.624)  and a moderate correlation for RGT 0274 1L (R2 = 0.325). This observation further reinforces the hypothesis of a topographic‐gradient bias, but a 2 m DEM may be insufficient to quantify this effect, due to the small size (<5 m) of typical ICESat‐2 misregistration offsets . The distribution of scattering elements within any one individual resel may result in a noisy phase estimate, but considerable spatial averaging (“multilooking”) in both the along‐track and across‐track of the radar image results in a larger signal‐to‐noise ratio (SNR) and more precise phase estimate (Goldstein et al., ∼2 km. As such, InSAR and ICESat‐2 estimates of deformation will agree better in flatter regions such as the northern Arctic coastal plain, whereas topographically rough areas like the Brooks Range foothills exhibit larger differences in inferred deformation. Therefore, a large amount of along‐track filtering over complicated topography challenges assumptions of signal ergodicity and may result in biased estimates of deformation with large uncertainties. The ATL06 data product was designed primarily for surface slopes of 1° or less (B. Smith et al., 5°; however, stricter surface slope restrictions may be needed. Alternatively, uncertainties in ICESat‐2‐derived deformations could be reduced by adaptively varying the crossover interpolation and along‐track smoothing based on local topography. Employing these strategies could help refine ATL06‐based height‐change estimates in complex terrain, but there is also the possibility of sub‐40 m topographic variations that limit the accuracy of ATL06 segment heights. In this case, a higher‐level surface‐height data product derived directly from the geolocated photons that considers the unique topographic and roughness characteristics of permafrost regions would improve ICESat‐2's utility for long‐term thaw monitoring.Moreover, because ICESat‐2 transects provide a one‐dimensional, along‐track measurement rather than a two‐dimensional image like SAR, achieving a comparable number of statistical samples as a 100 m InSAR pixel necessitates boxcar‐filtering ICESat‐2 data in the along‐track direction with a spatial resolution of ICESat‐2 observations can retrieve estimates of surface deformation that are consistent with independent InSAR estimates, but achieving this result requires appropriate statistical averaging and is expected to work better in regions exhibiting more uniform surface topography and permafrost distribution at the km spatial scale. In regions that exhibit a large degree of spatial heterogeneity, the assumptions of signal ergodicity inherent to any statistical averaging techniques break down, and biases in estimated deformation can manifest (Michaelides, Consideration should be given to the differing roles of crossovers and repeat tracks. Crossovers can provide a large spatial and temporal distribution of surface‐height change measurements, particularly in areas where ICESat‐2 is operating in mapping mode. Our regional, spatiotemporal analysis of crossovers reveals that crossover‐derived surface‐height changes are sensitive to the seasonal freeze/thaw dynamics of the active layer and can be used to generate regional‐scale time series of ground subsidence due to active layer thaw. However, the success of such an analysis is dependent upon a sufficient number of crossovers from which statistically significant relationships can be inferred, and crossover surface‐height change estimates can be significantly biased by snow cover. ICESat‐2 repeat tracks provide profiles of along‐track surface‐height changes over seasonal to yearly time scales. This can be useful for investigating deformation of specific features, at potentially a higher spatial resolution than most multilooked InSAR deformation products. An important consideration for future ICESat‐2 operations is the trade‐off between crossovers and repeat track coverage: increasing the number of repeated tracks in the Arctic will increase the spatial coverage of repeats while reducing the spatial coverage of crossovers.Future work is needed to explore the full complementarity of ICESat‐2 and InSAR datasets over periglacial regions. Whereas ICESat‐2 height estimates are sensitive to snow‐cover depth, InSAR signals often decorrelate in the presence of snow. Coherent surface‐height change estimates from 182‐day repeat tracks can provide a complementary data set to InSAR‐based studies. The direct sensitivity of ICESat‐2 observations to snow cover and snow‐cover depth changes is itself an important geophysical signal, which may require periglacial‐specific methods that account for the significant deformation exhibited by the ground surface through the year. Whereas the sidelooking viewing geometry of conventional SAR imaging systems makes them insensitive to surface water bodies, the nadir geometry of ICESat‐2 allows for precise estimates of surface water height levels and changes (Cooley et al., 5This study provides a preliminary investigation into the effectiveness of using ICESat‐2 ground surface‐height changes to study thaw subsidence of the active layer in a periglacial environment. We compared InSAR deformation estimates of the ground surface to ICESat‐2‐derived surface‐height changes from crossovers and 91‐day and 182‐day transect intervals from 2019–2020 across a region of the Alaskan North Slope.Both crossovers and repeat tracks are capable of detecting large‐scale subsidence patterns over the thaw season, although additional repeat‐track data collection is necessary to better assess the short length‐scale noise characteristics of ICESat‐2 altimetry over periglacial terrains. The magnitude of crossover‐derived surface‐height changes exhibited a linear relationship with the change in normalized accumulated degree days. Further, we integrated crossover surface‐height changes into a regional‐scale time series of surface‐height change over the years 2019 and 2020, capturing both changes in snow‐cover depth in spring, snow melt in late spring, and subsidence of the thawing active layer through summer and early autumn. Analysis of ICESat‐2 repeat tracks revealed a clear sensitivity of the ATL06 product to snow cover and snow‐cover depth; removal of the snow‐cover depth bias from independent estimates of snow‐cover depth from MERRA‐2 yielded a closer correspondence between ICESat‐2 and InSAR estimates of surface‐height change over the 91‐day and 182‐day transects. ICESat‐2 surface‐height change estimates appear to be impacted by a significant bias that is correlated with the along‐track topographic gradient; accurate characterization of this bias term and its removal from ICESat‐2 crossovers and repeat tracks represents a major outstanding step towards the development of a dedicated technique of estimating surface‐height changes over periglacial terrains characterized by topographic complexity. Finally, we have demonstrated that ICESat‐2 is sensitive to changes in surface scattering properties associated with tundra wildfire events, although future work is needed to fully understand the relevant physical scattering mechanisms.It may be possible to further refine ICESat‐2‐derived estimates of surface‐height change by limiting analysis to topographically smoother areas, such as the Arctic Coastal Plain to the north of our study site or by developing adaptive algorithms that account for more local topography variations during statistical averaging. Further investigation into the fundamental nature of the scattering physics which gives rise to radar and photon backscatter over tundra terrain is also warranted. Given the importance of permafrost dynamics to the global carbon cycle, we advocate for investigation into the full potential of using ICESat‐2 data products to quantify surface dynamics in permafrost and periglacial environments.