Higher birthweight is associated with higher adult body mass index (BMI). Alleles that predispose to greater adult adiposity might act in fetal life to increase fetal growth and birthweight. Whether there are fetal effects of recently identified adult metabolically favorable adiposity alleles on birthweight is unknown.We aimed to test the effect on birthweight of fetal genetic predisposition to higher metabolically favorable adult adiposity and compare that with the effect of fetal genetic predisposition to higher adult BMI.n = upto 406 063) to estimate fetal effects on birthweight  of alleles known to raise metabolically favorable adult adiposity or BMI. We combined summary data across single nucleotide polymorphisms (SNPs) with random effects meta-analyses. We performed weighted linear regression of SNP-birthweight effects against SNP-adult adiposity effects to test for a dose-dependent association.We used published genome wide association study data  averaged over 76 SNPs; P = 0.042, respectively). SNPs with greater effects on metabolically favorable adiposity tended to have greater effects on birthweight . There was no dose-dependent association for BMI .Fetal genetic predisposition to higher metabolically favorable adult adiposity and higher adult BMI were both associated with higher birthweight  averaged over 14 SNPs; Fetal genetic predisposition to both higher adult metabolically favorable adiposity and BMI is associated with birthweight. Fetal effects of metabolically favorable adiposity-raising alleles on birthweight are modestly proportional to their effects on future adiposity, but those of BMI-raising alleles are not. High birth weight (>4 kg), compared with average birth weight, is associated with an increased risk of higher adult body mass index (BMI) . MoreovePrevious twin studies and genetic association studies have failed to find strong evidence of a shared genetic association between adult BMI and fetal growth . RecentlSeveral genetic variants have been identified where one allele is associated with higher adult adiposity, but lower metabolic risk (i.e. lower risk of type 2 diabetes and cardiovascular disease), so called ‘metabolically favorable adiposity’ alleles . MetabolN = 406 063) to test whether fetal genetic predisposition to higher adult BMI affects birth weight, and the first to test the effect of fetal genetic predisposition for higher metabolically favorable adult adiposity on birth weight. A secondary aim of this study was to test the effects of the same fetal genetic predisposition to higher metabolically favorable adult adiposity or BMI on other perinatal anthropometric traits  and cord-blood markers . This secondary aim was exploratory, given the relatively small sample sizes that we have available (N = 9350). All of the fetal genetic associations tested were adjusted for maternal genotype effects  influences birth weight. To the best of our knowledge this is the largest sample size used to date  per effect allele; P-value = 0.0422; On average, alleles increasing BMI in adulthood were also related to heavier weight at birth (0.5 g (95% CI: 0–1) per effect allele; These results cannot be explained by confounding by the maternal genotype given all analyses controlled for this.R2 = 0.2912, P-value = 0.027). In contrast, there was no evidence that the BMI alleles were associated with birth weight and any adult measures of adiposity in a dose-dependent association , suggesting the presence of substantial heterogeneity of effects on birth weight across BMI-associated SNPs.To explore whether any effect on birth weight was proportionate to that on adult adiposity, we plotted the estimated SNP-birth weight effects against the estimated SNP-adult adiposity effects, measured either as body fat percentage  or as BMN = 3207–8394). We considered these novel analyses to be exploratory because of relatively limited sample sizes available . The effects of both fetal metabolically favorable adiposity and BMI pooled genetic effects on birth weight in the birth cohorts were consistent with the main (larger) analyses in EGG + UK Biobank , birth length, ponderal index, head circumference, triceps skinfolds, subscapular skinfolds and sum of skinfolds) from four pregnancy cohorts ( Biobank . Effects Biobank .N = 362–1863) . All of the fetal metabolically favorable adiposity or BMI pooled genetic effect estimates with these cord-blood markers were imprecise, with wide confidence intervals, making robust conclusions difficult . The scatter plots exploring proportionality was also similar to in these analyses to the main BMI analyses   . Our sca = 0.12) , in part = 0.12) . Therefoin utero  metabolically favorable adiposity leads to lower offspring birth weight . Considein utero , a possintiation . Our anaThis study is the first to investigate the fetal effects of the recently discovered metabolically favorable adiposity associated genetic variants on fetal outcomes independent of the corresponding maternal genetic effects. It is also the largest study to investigate the effects of BMI associated genetic variants on fetal outcomes. To do this we attempted to use all available relevant data from multiple independent cohorts, to maximize the certainty of our findings.Despite using all available mother–child cohorts with relevant data, our analyses had relatively low statistical power for outcomes other than birth weight, hence there is a need for larger cohort studies and/or GWAS of other perinatal outcomes.There was substantial overlap between the samples used to identify the metabolically favorable adiposity and birth weight SNPs, which could bias our estimates due to statistical overfitting. To further investigate the possibility that the associations between metabolically favorable adiposity SNPs and birth weight might be inflated due to selection of the metabolically favorable adiposity SNPs from UK Biobank, we performed an additional analysis with BMI SNPs identified using only UK Biobank. Results were consistent between these analyses using BMI SNPs from UK Biobank to the main analyses excluding UK Biobank data. Whilst we cannot rule it out, these findings suggest that statistical overfitting is unlikely to have had a major impact on the result for metabolically favorable adiposity.A further limitation to this study is the low response rate for UK Biobank (5.5%)  and the We have described the results of adiposity related genetic variants influencing birth weight, as the genetic variants cannot be influenced by the confounding of many social and environmental factors that confound conventional associations of non-genetic factors with outcomes, nor can genetic variants be influenced by existing disease. Our results were adjusted to avoid potential confounding by maternal genetic effects. We limited analyses to participants of European ancestry and the GWAS adjusted for principal components and center of recruitment, which should limit any confounding of the genetic effect due to population stratification. Whilst we do not think these findings are confounded, we acknowledge that we know little about the function of the adult adiposity related SNPs that we have shown here to influence birth weight.In conclusion, our results suggest that fetal genetic predisposition to both higher metabolically favorable adult adiposity and higher general adiposity (proxied by BMI) result in higher birth weight. The effects of the BMI SNPs on birth weight are heterogeneous, with many of the strongest BMI associated SNPs showing no effect on birth weight. In contrast, metabolically favorable adiposity SNP effects on birth weight are more consistent, with those with larger effects on adult adiposity tending to have larger associations with birth weight. Larger population samples are needed to investigate the effects on other birth anthropometric outcomes and cord-blood markers, in order to elucidate the mechanisms underlying these effects.The aim of this genetic association study was to explore whether fetuses with a genetic predisposition to higher adult metabolically favorable adiposity or higher adult BMI also tend to have higher birth weights. This is based on our hypothesis that such genetic predisposition could result in faster fetal growth and hence higher birth weight.We limited all analyses to participants of European ancestry, as genetic variants related to metabolically favorable adiposity and BMI were identified in GWAS of European ancestry individuals. We adjusted all analyses for maternal genotype effects to avoid confounding, since maternal and offspring genotypes are correlated and maternal genetic variants related to metabolically favorable adiposity or BMI are known to influence offspring birth weight ,18,24.Our analyses of genetic effects on birth weight used publicly available EGG consortium + UK Biobank summary GWAS data see ,25.N = 80 745, European ancestry) as well as 12 studies of maternal genotype with offspring birth weight , with some of the fetal and maternal studies overlapping . Between 2006 and 2010, UK Biobank participants were recruited from the NHS patient registers and contacted if they lived in close proximity to one of 22 assessment centers in England, Scotland and Wales. Detailed medical data was collected on 502 655 participants (5.5% response), aged between 40 and 69 at recruitment  (N = 76 SNPs) .As UK Biobank (the largest contributing study to the GWAS) does not have sufficiently powered data on maternal–offspring pairs, the authors of that study  derived 14 SNPs)  and adul76 SNPs)  at genomN = 442 278) analyzed a composite phenotype characterized by increased body fat percentage and a metabolic profile related to a lower risk of type 2 diabetes, hypertension and heart disease, identified using multivariate GWAS (P < 5 × 10−8), each marked by a SNP at which one allele was associated with higher adult body fat percentage and a ‘favorable’ metabolic profile . As. AsN = 4 profile . To try  profile .N = 322 154)  . Althoug322 154) , one SNPdiabetes , and itsR2 > 0.05) with any of the adult BMI SNPs.As an additional sensitivity analyses, we checked to make sure that none of the 14 metabolically favorable adiposity SNPs were in strong pairwise LD with any of 76 BMI SNPs. Of the 14 metabolically favorable adiposity SNPs, only one was within a 1 Mb distance of a BMI SNP. Using LDlink and CEU as the reference population , we confTo maximize power, we used random effects meta-analysis to combine the effects of multiple SNPs  on birth weight. This procedure allowed us to estimate the average effect of SNPs  on birth outcomes without requiring individual level data. To do this, we first harmonized SNP-birth weight effect estimates for each SNP so that the effect allele would correspond to the allele increasing the adult adiposity trait . Then, wFor the EGG + UK Biobank estimates, we converted the results back to grams by multiplying by 484 (the average SD for birth weight in grams for 18 studies in an early birth weight GWAS ).a priori assumption that metabolically favorable adult adiposity and BMI alleles have effects on birth weight proportional to their effects on adult adiposity. To do this, we plotted scatter plots of the fetal effect estimate of each of the SNPs on birth weight (y-axis) (x-axis)   and on a(x-axis) ,14. We fdiposity . This apTo further understand the associations between fetal genetic variants and components of birth weight or related cord-blood phenotypes, we performed exploratory analyses of other birth outcomes using individual level data from four birth cohorts . In this study, we used a maximum of 4862 unrelated and genotyped mother–child pairs with phenotype data. This cohort contributed to the analyses with the following outcomes: birth weight , birth length, birth ponderal index and birth head circumference. Mothers provided written informed consent and ethical approval for the study was obtained from the ALSPAC Ethics and Law Committee and the Local Research Ethics Committees.The Avon Longitudinal Study of Parents and Children (ALSPAC) is a birth cohort that recruited 14 541 pregnancies to women who were resident in and around the city of Bristol in the South West of the UK and who had expected dates of delivery between 1 April 1991 and 31 December 1992 ,35. Of t−6). In this study, we used a maximum of 1947 unrelated and European ancestry genotyped mother–child pairs with phenotype data. This cohort contributed to the analyses with the following outcomes: birth weight, birth head circumference, birth triceps skinfold thickness, birth subscapular skinfold thickness, sum of skinfold thickness, maternal fasting glucose, maternal 2 h post-prandial glucose levels, cord-blood insulin, cord-blood leptin  is a population-based prospective pregnancy cohort that collected detailed information from 12 450 women who experienced 13 773 pregnancies . The cohfat mass ) and corfat mass . Laboratfat mass .−6, sex mismatch, kinship errors and 4.56 SD from the cluster mean of any sub-populations cluster). In this study we used a maximum of 674 unrelated and genotyped mother–child pairs with phenotype data. This cohort contributed to the analyses with the following outcomes: birth weight , birth length, birth ponderal index, birth head circumference, birth triceps skinfold thickness, birth subscapular skinfold thickness, sum of skinfold thickness, maternal fasting glucose and cord-blood insulin. Cord blood was extracted from a vein or artery by the attendant mid-wife at delivery. The blood was stored at 4°C until being collected by the researchers. The cord blood was spun to separate out the plasma which was then stored at −80°C. The plasma was then tested for insulin levels when appropriate at the Regional Endocrine Laboratories  using immunochemiluminometric assays   is a birth cohort that recruited 1017 families who were resident in the postcode-defined area of central Exeter between 2000 and 2004, at the Royal Devon and Exeter Hospital  from whiiff, UK) ,42. All The Hyperglycemia and Adverse Pregnancy Outcome (HAPO) cohort recruited 28 562 pregnant women between 1 July 2000 and 30 April 2006 from 15 clinical study centers in 10 countries , four of the centers being in the United States, for their oral glucose tolerance test (OGTT) between 24 and 32 weeks . In totaWe selected the genetic variants for analyses and combined the effects of individual SNPs on perinatal outcomes the same way we did for the main analyses . Birth weight and all other perinatal traits were standardized within each cohort separately when estimating the metabolically favorable adiposity and BMI pooled genetic effects, in order to make the estimates for each trait comparable with each other.Within each of the four cohorts, we analyzed individual level data using linear regression of birth weight or other perinatal traits on the SNPs . Linear regression analyses were performed separately in each cohort and the results pooled using fixed-effects meta-analysis, resulting in summary data on the association between each SNP and each phenotype. Further information on these cohorts and their contribution to the study can be found in Q test and estimated I2 for each meta-analyses  (n = 210 lead SNPs and a further 183 close (R2 > 0.8) proxies) from the GIANT consortium data set (R2 > 0.4) with a metabolically favorable adiposity SNP, leaving a total of 392 SNPs.Metabolically favorable adiposity SNPs were selected from UK Biobank, whilst the BMI SNPs were not. As an additional analyses, to assess whether this could bias the metabolically favorable adiposity association estimates away from the null, we also selected SNPs associated with BMI in UK Biobank, and extract SNP-adult adiposity effect estimates for them from a UK Biobank-independent source, as we had done with metabolically favorable adiposity. There were 458 SNPs identified from a recent UK Biobank GWAS of BMI (461 460) , and of We performed the same analyses for the 392 SNPs associated with BMI identified in UK Biobank as we did for the 76 SNPs identified in the GIANT consortium .Our study used both published summary results (i.e. taking results from published research papers and websites) and individual participant cohort data as follows:The data for the GWAS of BMI are available here.https://portals.broadinstitute.org/collaboration/giant/index.php/GIANT_consortium_data_filesThe data for the GWAS of body fat percentage are available here.https://walker05.u.hpc.mssm.eduThe data for the GWAS of birth weight are available here.https://egg-consortium.org/birth-weight-2019.htmThe references to those published data sources are provided in the main paper.We used individual participant data for the genetic association analyses from the UK Biobank, ALSPAC, BiB, EFSOCH and HAPO cohorts.The data in UK Biobank, ALSPAC and BiB are fully available, via managed systems, to any researchers. The managed system for both studies is a requirement of the study funders but access is not restricted on the basis of overlap with other applications to use the data or on the basis of peer review of the proposed science.https://www.ukbiobank.ac.uk/using-the-resource/UK Biobank. Full information on how to access these data can be found here—http://www.bristol.ac.uk/alspac/researchers/data-access/documents/alspac-data-management-plan.pdf) describes in detail the policy regarding data sharing, which is through a system of managed open access. The steps below highlight how to apply for access to the data included in this paper and all other ALSPAC data.ALSPAC. The ALSPAC data management plan  that describes the process of accessing the data and samples in detail, and outlines the costs associated with doing so.You may also find it useful to browse the fully searchable ALSPAC research proposals database, which lists all research projects that have been approved since April 2011.Please submit your research proposal for consideration by the ALSPAC Executive Committee. You will receive a response within 10 working days to advise you whether your proposal has been approved.alspac-data@bristol.ac.uk.If you have any questions about accessing data, please email https://borninbradford.nhs.uk/research/how-to-access-data/BiB. Full information on how to access these data can be found here—r.freathy@ex.ac.uk) and Prof. William Lowe Jr (wlowe@northwestern.edu). The website describing the study and other data available is https://www.ncbi.nlm.nih.gov/projects/gap/cgi-bin/study.cgi?study_id=phs000096.v4.p1HAPO. For access to the data used in this study, please contact Dr Rachel Freathy (wlowe@northwestern.eduIf you have further questions, please email Dr William Lowe at crf@exeter.ac.uk.EFSOCH. Requests for access to the original EFSOCH dataset should be made in writing in the first instance to the EFSOCH data team via the Exeter Clinical Research Facility Supplementary_Material_for_infants_own_genetic_propensity_for_resubmission2_ddab356Click here for additional data file.


This investigation unearths the trait antecedents of intrinsic and extrinsic motivational drivers and their consequences on attitude towards e-WOM of social mobile app users. Additionally, this study attempts to explore the moderating role of psychological impact on attitude towards e-WOM when COVID-19 is ravaging the world. Following the descriptive research method, the survey was carried out among convenience sample respondents of 627 social mobile app users. The outcome brought out that extraversion had a favourable influence on opinion leadership, customer engagement, and self-expression for sharing consumption related information during the pandemic. Likewise, materialism also had a strong effect on self-expression. Nonetheless, extraversion and materialism failed to affect self-presentation motives. And, self-presentation was observed influencing attitude towards e-WOM negatively. The outcome of the study demonstrates that individuals with high psychological impact have a strong motivation to involve in customer engagement to participate in e-WOM communication. Motivational drivers such as self-expression, opinion leadership, and customer engagement had a significant effect on attitude towards e-WOM for the whole sample analysis. This investigation contributes to existing literature of e-WOM behaviour and widens the scope of self-presentation theory, social exchange theory, theory of planned behaviour etc. Finally, this research also assists marketers and practitioners to take better decision-making on developing a social media advertising and campaign using the framework. It has The undulating motivations to express oneself may have some underlying causes, which have been researched diligently in the past and reported in many studies, like “why people engage in e-WOM” . In addiApart from personality traits, intrinsic and extrinsic rewards  also played a crucial role in writing reviews online , e-WOM iIntrinsic motivational drivers such as customer engagement and self-expression contributes to consumer-generated content on social media enormously. Cheung et al. , showed The personality traits and their effect on e-WOM behaviour have been increasingly getting scholarly attention; yet the debate continues that whether these traits are sufficient enough to gauge human behaviour or not ,69, and Overall, past research highlighted that most of the studies so far have analysed the effect of personality traits, and intrinsic-extrinsic motivational drivers on e-WOM intention individually. Nevertheless, the studies involving a comprehensive approach considering these factors in combination, remain sparse and unattended. A deeper understanding of the consequences of personality traits on e-WOM behaviour on social media is still needed. Therefore, the central purpose of this investigation is to address the lack of personality traits research in exploring the impact of intrinsic and extrinsic motives on e-WOM behaviour of social mobile app users, adopting psychological impact as moderator in a comprehensive model during the time of pandemic. Hence, this investigation contributes to existing literature of consumer behaviour in widening the scope of self-presentation theory, social exchange theory, theory of planned behaviour etc. This work also expands the horizon of e-WOM domain integrating intrinsic-extrinsic motivation and personality following a comprehensive approach. Finally, this research also assists marketers and practitioners to take better decision-making on developing a social media advertising and campaign using this framework.The remaining part of this article is structured as follows. Chapter 2 reviews the literature on personality, social exchange theory, social presentation theory, all the constructs availed, and also illustrates the hypotheses developed. Chapter 3 describes the methodology part. Chapter 4 explains data analysis and results. Chapter 5 presents discussions, contributions and implications. Chapter 6 portrays limitations and conclusions.2According to social exchange theory (SET), individuals incline to provide valuable things for relationships to develop mutual beneﬁts . Its mai2.12.1.1Extraversion is related to energy, activity, sociability , social 2.1.2Materialism may be seen as a personal value or personality traits . In Rich2.1.3Generally, self-presentation is urged by individuals' desire to monitor their images in social interaction . It is r2.1.4Opinion leadership is recognised as an extrinsic motivational driver ,103 and 2.1.5Self-expression is often seen as intrinsic motivation . It is d2.1.6Engagement is an intrinsic motivational driver  and “def2.1.7128]. Thus, attitude towards e-WOM is viewed here as social mobile app users' overall assessment of e-WOM regarding consumption-related experience. Specifically “any positive or negative statement made by potential, actual, or former customers about a product or company which is made available to a multitude of people and institutions via the Internet” [Attitude towards the electronic word of mouth is a vital construct regarding social media context . Generalnternet” .2.1.8e-WOM is meant for information consumers gather from interpersonal sources like friends and family . General2.22.2.1H1Extraversion has a favourable influence on self-presentation.Social media users usually involve in online self-presentation . Specifi2.2.2H2Extraversion has a positive influence on opinion leadership.Individuals with extraversion traits invite others’ attention and interest, welcome them for social interaction, and are highly connected to others on social media . Note th2.2.3H3Extraversion positively influences customer engagement.Customer engagement is seen as customers' resource investment in interactions with brands . The int2.2.4H4Extraversion has a positive influence on self-expression.Extroverts are the one who reflect their personalities by enhancing more connection  because 2.2.5H5Materialism has a favourable effect on self-presentation.Materialism is an important individual difference which is greatly connected to different motives . Usually2.2.6H6Materialism has a positive influence on self-expression.Materialism and wealth possessions is a symbol of success in life . Thus, m2.2.7H7Self-presentation has a positive impact on attitude towards e-WOM.In order to reflect on their self-concept, people indulge in sharing and disclosing information online. Individuals show positive behavioural intentions toward a brand and product when they are content with the product . Consequ2.2.8H8Opinion leadership has a favourable influence on e-WOM.Opinion leadership means the degree to which a person is seen as a model for others and the extent to which the information offered by him is considered interesting . Further2.2.9H9Extraversion favourably affects customer engagement.Customer engagement is also seen as voluntary interaction with firms and contributing to business houses’ marketing activities beyond financial aspects  to meet 2.2.10H10Self-expression is positively related to attitude towards e-WOMSelf-expression is built on the general theme that consumers may recognise the satiation after their needs have been met when they gratify their needs, and this self-expression signifies the consumers’ preference for signalling identity through consuming customised products . When co2.2.11H11Social mobile app users' attitude towards e-WOM is positively related to intent to e-WOM.Attitude towards e-WOM are referred to here as a feeling of “goodness or badness” about e-WOM communication. Briefly, “person's evaluation of an object on a favourable to unfavourable continuum” . As a re2.2.12H12aThe influence of self-presentation on the propensity to e-WOM is greater for social mobile app users with high psychological impact than less psychological impact.H12bThe influence of opinion leadership on the propensity to e-WOM is greater for social mobile app users with high psychological impact than less psychological impact.H12cThe influence of customer engagement on the propensity to e-WOM is greater for social mobile app users with high psychological impact than less psychological impact.H12dThe influence of self-expression on the propensity to e-WOM is greater for social mobile app users with high psychological impact than less psychological impact.Psychological distress is referred to as the reaction of people to internal as well as external stresses and it is designated by a combination of anxiety, poor self-esteem, hopelessness, sadness and confused thinking . These p33.1This study relied on an online survey method and convenience sample to examine the research hypotheses. We recruited 627 social mobile app users in India. The respondent pool comprised 258 females (41%) and males (59%) from 16 to 52 years old. Before participating in the study, all respondents were asked to sign an informed consent form and the purpose of the study was also mentioned. Ethical approval was granted by the Doctoral scrutiny committee of “The Department of management studies, Indian Institute of Technology (ISM) Dhanbad”. For moderation (Multi-group) analysis, psychological impact measures were classified into low psychological impact and high psychological impact group. In order to test the gathered data, we examined the validity of the measurements and carried out a structural equation model.3.2The items adopted in this study were taken from previous research in the marketing domain and modified according the context. The questions were framed with a seven-point Likert scale ranging from 1 to 7. Whereby 1 is meant as totally disagree, 7 is referred to totally agree for all items. Items availed in this research are shown in 3.2.1This investigation saw no objective in developing a new scale for measuring extraversion as the previously developed items are most suitable for present situation also. Trait extraversion was measured through the inventory of items developed by Goldberg, . This me3.2.2The short version of the trait materialism items was proposed and validated by Richins and Dawson . Followi3.2.3There are scales to measure the self-presentation motives with reference to using SNS. Yet, this research exclusively borrowed the measures developed and evaluated by Kim et al. , as it i3.2.4In order to measure variable opinion leadership, the researcher availed the scale developed and tested by Flynn et al., . Recentl3.2.5In order to measure self-expression through consumption of products and service experience, 6 items scale were borrowed from Saenger et al., . The sam3.2.6Researchers had no consensus on the customer engagement scale or definition to analyse this construct . With th3.2.7Measuring attitude towards e-WOM was done with the help of items developed by Pollay and Mittal . Origina3.2.8e-WOM intention was rated using a scale developed by Ajzen . Subsequ3.3This study measured the psychological impact construct by borrowing 18 items (Cronbach's α = 0.894) from Chakraborty et al., . This co4The data was examined following a two-stage method as described by Anderson and Gerbing . First, 4.12/df = 2.686, CFI = 0.949, NFI = 0.922, IFI = 0.950, RFI = 0.912, TLI = 0.943, AGFI = 0.852, PGFI = 0.730, RMR = 0.094, RMSEA = 0.052. Next, the adequacy of the model was analysed through reliability and convergent validity tests which are exhibited in In order to test the model's goodness-of-fit, validity and reliability, CFA was carried out. The investigators followed similar procedures adopted in the recent studies ,225. The4.22/df = 3.460, CFI = 0.924, NFI = 0.896, RFI = 0.887, IFI = 0.924, TLI = 0.917, GFI = 0.855, PGFI = 0.737, AGFI = 0.832, and RMSEA = 0.063. As per Hair et al. [2) is higher than 0.2, the model is considered acceptable. In this research, R2 for social media users’ attitude towards e-WOM is 0.49 and for intention to e-WOM is 0.29. Further, intrinsic motives customer engagement and self-expression also attained the significance with values 0.40 and 0.28 respectively. However, extrinsic motives self-presentation and opinion leadership have not shown statistical significance as they have an adverse results in the model.We subsequently assessed the structural relationships  using AMr et al. , guideliThe comprehensive results of the hypotheses test and standardised path coefficients are shown in Noticeably, the personality traits constructs which include extraversion  and mateFurther, the influence of opinion leadership , customer engagement , and self-expression  on attitude towards e-WOM were positive and significant, whereas the effect of self-presentation on attitude towards e-WOM was negative . Finally, the result reveals that attitudes toward e-WOM had a positive relationship with intent to e-WOM . In this way, There is not sufficient work to prove why the self-presentation  had no iThe moderator (Multi-group) analysis was performed to examine the role of psychological impact on attitude towards e-WOM, testing hypotheses 12a-12d . The outThe graph  displays5Drivers of e-WOM behaviour attracted the attention of many scholars and researchers in the recent past ,72,237. The outcomes of this study reveal that when the relationship between customer engagement motive and attitude towards e-WOM is stronger, the individuals with high psychological impact seek to engage in e-WOM behaviour more than people with low psychological impact during the COVID-19 pandemic. We argue that people engage in e-WOM to relieve their stress, loneliness, fear and cabin fever syndrome. A study carried out by Matook et al. , proclaiThe impact of self-expression on the propensity to e-WOM behaviour was the highest among the motivational drivers, implying that during the pandemic also people are interested in expressing their self-image through consumption experience. Researching individuals’ brand-related engagements on SNS, de Vries et al. , found tExtraversion had the strongest influence on customer engagement and self-expression in the model, suggesting that extroverts are closely associated with intrinsic motivation. This research also revealed the role of extraversion in predicting opinion leadership. Likewise, the study by Akdevelioglu and Kara  uneartheLikewise, materialism has also been observed to be influencing self-expression favourably and self-presentation unfavourably. Realising the important role of extraversion and materialism in e-WOM, Moisescu et al. , used pe5.1This investigation contributes to marketing literature in many ways. Personality traits materialism and extraversion were not associated with self-presentation; nevertheless, these traits’ relationship with other motives like opinion leadership, customer engagement and self-expression were significant. These relationship highlights that social mobile app users may have other major motive like need for sharing information amid of pandemic. Hence, this comprehensive approach widens the scope of SET along the line of past studies undertaken in the social media domain . Plus, tThis study demonstrates a deeper understanding of the effect of psychological impact on the relationships between intrinsic-extrinsic motivational drivers, and e-WOM behaviour. But, the moderating role of psychological impact was not significant as expected. Interestingly, the difference between the impact of customer engagement on e-WOM for the high and low groups was significant. Further, the link between customer engagement and e-WOM behaviour is also favourable. Taken together, our model brings novel addition to the customer engagement concept embracing trait theory, and social exchange theory under a framework. Moreover, this study adds value to marketing literature, examining the significance of self-expression on the propensity to engage in e-WOM on social media at the time of pandemic underpinning uses and gratification theory (UGT) .Furthermore, our findings strongly support the notion that opinion leadership motive is a critical factor in determining in e-WOM behaviour. Nonetheless, the consequence of opinion leadership on e-WOM behaviour did not differ significantly for the low and high psychological impact group. This work also confirmed that extraversion had a favourable effect on opinion leadership of social mobile app users to share consumption-related experiences. Hence, this investigation expands the horizon of theory of opinion leadership  by studyAlthough e-WOM in the social media domain is acknowledged, comprehensive analysis mapping e-WOM behaviour is scarce . In moreA study found that loneliness, social unrest, psychological distress and social distancing played a significant role in SNS usage intensity during the pandemic . Given t5.2This investigation offers several implications for social media managers, policymakers and marketing practitioners. From the study it was found that intrinsic motivational drivers had the strongest influence on attitude towards e-WOM in the model, suggesting that individuals with intrinsic motivational drivers are more into disclosing information and self-enhancement during the pandemic. Additionally, extrinsic motivation had a partial impact on the attitude towards e-WOM. Thus, marketers, policymakers and social media managers may reach to the people with intrinsic motivation to deliver the right information or review the product or situation. The results also assert that the relationship between extraversion and extrinsic motivation opinion leadership is stronger. Findings suggest that marketers may target social media users with opinion leadership motives and extraversion traits as they may be willing to review and comment on products they consumed during the pandemic. And these individuals can be a good brand ambassador for the brand they use. This implies that in some situation marketers can count on extrinsic motivational drivers in the segment to share the information.Sharing is a major activity that takes place on social media and it is a vital element in understanding individuals’ self-presentation motive on the internet . Yet, exIntrinsic motivations like self-expression and customer engagement had a remarkable effect on attitude towards e-WOM. According to the findings, generating customer engagement on social media, marketers can make individuals to e-WOM during the pandemic. This result would help brands to enhance their relationship with the customer in the short term. However, in order to develop a stronger e-WOM behaviour for consumption-related experiences, marketers may strive to develop a novel campaign, product and services to customers to engage them during the pandemic. Apart from business houses, governments can also employ engagement as a way to observe policies announced and new laws drafted before implementing the final one through social mobile app users’ participation. Specifically, people with customer engagement motives may be targeted to spread the right information during the COVID-19 pandemic.Extroverts and materialistic people prefer to indulge in social media activities invariably. Recently, Moisescu et al. , announc6Though this investigation contributes to both the theoretical and practical aspects enormously, several limitations are associated with our research. This study measured traits, self-presentation and other motivations through self-reporting which can attract inaccuracies as respondents may have a biased response to questions related to socially desirable behaviour . Since t6.1In sum, this research provides evidence that individuals with high psychological impact have a strong motivation to involve in customer engagement to participate in e-WOM communication. Nonetheless, there was no difference observed between high and low psychological impact groups for intrinsic-extrinsic motivational drivers such as self-expression, self-presentation and opinion leadership. Further, motivational drivers such as self-expression, opinion leadership and customer engagement had a notable effect on attitude towards e-WOM for the whole sample analysis. By contrast, self-presentation has influenced e-WOM behaviour negatively during the pandemic. Similarly, materialism had also affected self-presentation unfavourably. This represents a stark contrast from the past investigations. Maybe due to the prevalence of the COVID-19 pandemic, social mobile app users were more into the social exchange of information in order to relieve anxiety, loneliness, and other social issues. Although most researchers broadly agree that the impact of extraversion on self-presentation was observed to share information on social media, this investigation brought to light that the effect of extraversion on self-presentation is not significant. This implies that even the social mobile app users with extraversion traits may had been affected psychologically during the pandemic. However, trait extraversion significantly influenced opinion leadership, customer engagement and self-expression. Likewise, materialism had also formed a favourable impact on self-expression. And, attitude towards e-WOM strongly influenced intent to e-WOM. We conclude by stressing that this study offers interesting insights to practitioners and researchers in social media marketing and consumer behaviour domain.7“All research phases were reviewed and approved by Doctoral scrutiny committee of Department of management studies, Indian Institute of Technology (ISM) Dhanbad which granted ethical approval. Consent from the respondents were obtained, and the participants’ identity remained anonymous”.8“Informed consent was obtained from all respondents participated in the study. In case of participants aged less than 18, Informed consent was obtained from their parents”.Balamoorthy S; Dr.Bibhas Chandra, PhD: Conceived and designed the experiments; Performed the experiments; Analyzed and interpreted the data; Contributed reagents, materials, analysis tools or data; Wrote the paper.This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.Due to the nature of this research, participants of this study did not agree for their data to be shared publicly, so supporting data is not available”.The authors declare no competing interests.


In working ages, sickness absence is strongly related to persons’ health condition. We studied how birth order was associated with receipt of sickness allowance, distinguishing between mental disorders, musculoskeletal disorders and injuries.A follow-up study based on the entire Finnish population was conducted for sibling groups born 1969–1982, in which each sibling was observed from age 35 years in the period 2004–2018. Focus was on within-family variation in first-time sickness allowance receipt.Results of stratified Cox regressions revealed that each increase in birth order was associated with a slightly higher risk of sickness absence from any cause. For mental disorders, associations were stronger; the hazard ratio as compared to first borns was 1.03 (95% CI: 0.98–1.08) of second borns, 1.10 (0.99–1.22) of third borns, and 1.52 (1.25–1.85) of fourth or higher borns. Corresponding numbers for musculoskeletal disorders were 1.12 (1.07–1.17), 1.19 (1.09–1.30) and 1.15 (0.96–1.38), and for injuries 1.06 (1.01–1.12), 1.09 (1.21–1.14) and 0.96 (0.77–1.20), respectively.Birth order effects were generally stronger for women than men, and to some extent influenced by educational level, occupation, income, and family composition. Possible latent mechanisms behind the associations may relate to within-family dynamics at childhood. Analyses of the interrelation between birth order and various health outcomes have found that later born siblings generally perform worse than earlier born siblings. This includes depression, mental distress, psychiatric deviation, anxiety, self-esteem, physical fitness and hospitalization for alcohol use –4. HigheSimilar to studies on educational attainment, intelligence, and cognitive and non-cognitive skills –13, a nuA fundamental contribution of recent empirical studies –9 is theIn working ages, sickness absence is strongly related to a person’s health status , 24. SicThe multigenerational population register data used were based on the entire Finnish population. Sickness absence was measured by receipt of sickness allowance (SA), to which all non-retired persons are eligible after the ninth sickness day. Diagnoses were distinguished by the tenth revision of International Classification of Diseases (ICD-10). By constructing complete sibling groups, we sought to study the association between birth order and sickness absence from main cause in the working-aged Finnish population. In particular, we analysed whether any association between birth order and sickness absence manifests in mental disorders, musculoskeletal disorders, and injuries, respectively, and whether it depends on sex, mother’s age at birth, educational level, occupation, income, and family composition.We used data from the Finnish population register, which contains the entire population resident in the Finland. All data access, data preparation and analyses were performed within Statistics Finland’s remote access system Fiona, with contract number TK-52-694-18. Statistics Finland’s guidelines for handling data were followed. According to the Statistics Act in Finland, Statistics Finland decides independently on all licenses that are granted for use of data . The datEach person born in Finland can be linked to his or her mother and father, subject to that the parent ever had resided in Finland. We constructed, therefore, sibling groups based on the native-born population. These multigenerational data were linked to registries on births, deaths, migration, educational attainment, occupation, income, marriages and cohabitation. Each person was linked also to data on SA receipt from the Social Insurance Institution of Finland (KELA), covering the period 2004–2018. All non-retired persons aged 16–67 years are eligible for SA, which compensates for work incapacity. SA is paid after a waiting period of nine working days, and for a maximum period of approximately one calendar year. If the person remains in work incapacity thereafter, he or she may apply for disability pension. SA receipt is conditional on a physician’s certificate that includes the main diagnosis for work incapacity according to ICD-10. Receipt of SA is consequently a highly reliable and nationally covering objective proxy for sickness beyond a conventional flu. There is no national register on shorter sickness absence spells in Finland.Diagnoses were categorized into the three most common groups in Finland: mental disorders (F00-F99), musculoskeletal disorders (M00-M99), and injuries (S00 and T98). All remaining causes were classified into a residual group.To ensure that all siblings in a sibling group were observed from the same age in the study period 2004–2018, we restricted analyses to persons born 1969–1982. Each person was observed from age 35 years until first SA receipt, death, emigration, or end of 2018, whichever came first. Data on SA receipt with diagnosis information was not available before 2004. This implies that the study persons could have been on SA before age 35. Starting from age 35 was because the control variables should have a meaningful interpretation. By age 35, most people have completed their education, entered a profession, stabilized their income level, and formed a family. All study persons were registered as Finnish or Swedish speakers.To analyse the association between birth order and SA receipt, we applied Cox proportional hazards models with family fixed effects. In these models, siblings share the same baseline hazard. We ran parallel models in which first-time SA receipt due to mental disorders, musculoskeletal disorders, injuries, and other causes, respectively, constituted the failure event. The baseline hazard for SA receipt was time since age 35. Right-censoring occurred at death, emigration, end of the observation period, or SA receipt due to a main cause other than the studied failure event. By comparing siblings in the same family, we effectively adjusted for all time invariant observed and unobserved factors that are shared by siblings within the same family. This approach can be considered superior to the regular Cox proportional hazard model, because it minimises confounding from unobserved or unmeasured time invariant variables. A sibling group refers to the shared mother id plus father id, meaning that we analyse full-sibling groups. A requirement for the analyses is that there must be at least two siblings in the group, and at least one must have received SA due to each set of ICD-10 codes utilised in each of the parallel models.We adjusted for each sibling’s birth year, sex, mother’s age when giving birth, educational level, occupation, income quintile, and family composition, which are known health correlates. All variables were categorised, and introduced into the models in a stepwise manner. Father’s age at child birth was excluded due to lower explanatory power than mother’s age at birth. There was no need to adjust for parental factors like mother’s or father’s education or socioeconomic status, because the sibling comparison removes the confounding effect of time invariant factors shared by the siblings. We also conducted analyses where birth order and sex were interacted, in order to evaluate any sex differences on this concern. Estimates are presented as hazard ratios (HRs) with 95% confidence intervals (95% CIs). First borns serve as the reference category. All estimations were carried out with R version 3.6.3.Characteristics of the study population are presented in The stratified Cox regressions revealed that birth order was associated with a slightly higher risk of SA receipt from any cause . As compBirth order was associated with SA receipt from mental disorders, musculoskeletal disorders, and to some extent injuries, but not with other causes . As compModels that interacted birth order with sex revealed that the associations between birth order and SA receipt were notably stronger for women than men . As compFor mental disorders in women, and musculoskeletal disorders in men, significant associations with birth order remained also when we controlled for socioeconomic and demographic variables . AccordiResults were largely similar across sibling group size and birth spacing  Tables.This study is the first to provide evidence about an interrelation between birth order and sickness absence, utilising diagnose information and family fixed effects methods. We have estimated the risk of first-time SA receipt due to mental disorders, musculoskeletal disorders and injuries after age 35. A clear birth order pattern was observed for these main causes, but not for a residual group that consisted of other miscellaneous causes. Higher birth order was found associated with a higher risk of sickness absence, and particularly so for mental disorders and musculoskeletal disorders in women.To give a sense of the magnitude of the observed birth order effects on SA receipt, one may compare with the HRs by educational attainment from the same regressions. The birth order difference in the HR between third and first borns for all cause SA, for instance, is almost equal in size to the difference in the HR between secondary and primary educational levels. With regard to SA receipt due to mental disorders, the HR between fourth or higher borns and first borns is roughly of the same size as the difference in the HR between tertiary and primary educational levels. The effect sizes for birth order are thus not negligible.These findings, which are based on the total population of Finland, corroborate results from neighbouring countries, which also have applied family fixed effects methods to study the interrelation between birth order and health related outcomes. In Sweden, higher birth order has been found associated with an increased risk of all-cause sickness absence, but there has not been any study using data on the underlying cause . Later bIn terms of any interrelation with health behaviours, the picture is complex. First borns in Norway have been found more likely to have weight problems, high blood pressure and high triglycerides, but less likely to smoke daily, and more likely to report good physical and mental health . In SwedWith regard to suicide, the pattern is uniform across the Nordic countries. In Finland, Sweden and Norway the suicide risk in the general population increases with birth order, with about the same magnitude in all three countries, and the associations are slightly stronger for men than women , 6, 8. SSome results that may be at least partly contradictory to ours have nevertheless been reported. A study from Great Britain  found noEvidence that support biological mechanisms as drivers of birth order associations, and thus potentially the pattern observed here for musculoskeletal disorders, is not conclusive. This is primarily because effects may operate in different directions. Later borns come from older mothers who have higher incidence of chromosomal and congenital defects , 37. SevIn our analyses, we have adjusted for some individual-level variables that may confound the relationship between birth order and health, such as educational attainment, occupational status, income, and family composition. Birth order is known to be associated with educational attainment , 12 but However, it needs to be stressed that, for the control variables used here, except sex and birth year, causality may be disputed. A person’s health condition may affect his or her educational attainment, occupational position, income, and family composition, and not just only the other way around. Further research is needed to uncover the underlying causal mechanisms behind birth order and health, and presumably with other data and methods than those used here. Parental health and parental socioeconomic status may nevertheless largely be excluded as potential mechanisms, as we have effectively controlled for time-invariant family characteristics with the family fixed effects models. Possible reasons behind the birth order associations might instead stem from other aspects of family dynamics. Older siblings may bully younger ones, with long-term health impacts . SiblingWe have advanced the research field in some relevant respects. Apart from mortality studies, few papers have estimated the associations between birth order and health outcomes in prime working ages using sibling fixed effects . MoreoveThe study comes also with some important limitations. One is that SA is not a precise proxy for health, but it reflects also how work ability and poor health status match. Depending on the specific characteristics of the job, some people may be able to work although they are experiencing health problems, while some others may receive SA even though they might be capable of working. It is plausible that controlling for occupational status as we have done here is not a sufficient strategy to accommodate measurement issues of this kind. Receipt of SA tends also to increase during times of economic growth, which might reflect a moral hazard problem and thus variation in take-up behaviours . FurtherAnother limitation is that family fixed effect models cannot account for familial factors that are time-variant. They do not, therefore, capture that parents may treat children differently over time. Health behaviours may play a role on this concern, and register data typically lack such information. Associations between birth order and health outcomes may, thus, vary in strength over time and space , which wWe had no data on diagnose-specific SA receipt before 2004, which means not before age 35 with the setup used for the analyses. We have used additional data on sickness absence without cause, from the years 1993–2003, to evaluate whether inclusion of an indicator for sickness absence before age 35 affect the results reported, and find that they do not. Results of these additional regressions are available from the authors upon request.Finally, our analytical approach, using sibling fixed effects models, requires variation in the outcome, meaning that at least one sibling must have experienced the event that is studied, and singletons are not included into the regressions whatsoever. This implies that the study persons need not be representative for the population at large. Corresponding estimates from non-fixed regressions, that is, standard between-family models, generally display different estimates for the interrelation between birth order and health . HoweverTo conclude, some evidence for a birth order pattern in working ages was observed, where first borns were the least likely to be sick because of mental or musculoskeletal disorders, and the associations were more accentuated for women than men. The results were obtained with sibling comparison models, which certifies that the estimated interrelations stem from variation within families and not from variation between families. The underlying mechanisms constitute an avenue for future research.S1 Table(DOCX)Click here for additional data file.S2 Table(DOCX)Click here for additional data file.


Retinopathy of prematurity (ROP) is an ophthalmologic condition that is one of the leading causes of preventable childhood blindness. Due to the premature nature of blood vessels in preterm infants, retinal vessels are prone to damage. The incidence of ROP ranges with great variation across countries, and this study aims to identify the incidence and its related risk factors.A compilation of studies investigating the incidence of ROP was acquired through the PubMed and Google Scholar databases with a full free text in English filter set. All members of the study were involved in designating studies based on continent and arranging them into a table format. Following this, reasons for the variation in the incidence of ROP were investigated by individually assessing each study.The variation of an increased incidence of ROP seen in low-income countries (LICs) was most likely due to the availability of resources. As a preterm birth can give rise to further complications such as the development of sepsis, it is important to manage preterm birth with the utmost caution. Evidence has suggested that the two key variables in reducing the morbidity and mortality of ROP are the implementation of a screening and treatment protocol with controlled use of oxygen and the availability of resources in hospitals to adequately identify and manage ROP as early as possible.Through a comprehensive overview of the incidence of ROP, it is vital to review screening and treatment protocols in each hospital for ROP, which would aid in preventing its occurrence and initiating early treatment. Retinopathy of prematurity (ROP) is identified by the World Health Organization (WHO) as a major cause of preventable childhood blindness worldwide . It is aApproximately 14,000 preterm infants in the United States alone develop retinopathy of prematurity, and between 1,100 and 1,500 cases of them progress into moderate to severe stages of the disease that requires medical attention and treatment . Long-teThere are multiple risk factors affecting the development and progression of retinopathy of prematurity, including low birth weight, preterm gestational age, appearance, pulse, grimace, activity, and respiration (APGAR) score, and especially the use of supplemental oxygen, which causes downregulation of the vascular endothelial growth factor (VEGF) due to oxidative stress and death of endothelial cells, intraventricular hemorrhage, sepsis, blood transfusions, and most importantly, lack of timely screening . RetinopManagement strategies vary depending on the ICROP classification system. Current treatment guidelines include laser peripheral retinal ablation for the early stages of the disease. Anti-VEGF inhibitors such as bevacizumab have also recently emerged with promising results, especially in the early stages of the disease. Further information and research are needed on this novel therapy as there are insufficient data on its long-term effects on infants . It is cThis study is conducted to estimate the incidence of retinopathy of prematurity and evaluate the pattern, prevalence, risk factors, and complications to achieve a better understanding of the disease and its burden to help healthcare professionals design efficient preventive measures and authorize setting basic minimum requirements for screening preterm and low-birth-weight infants for this condition to decrease its associated morbidity to accomplish a high and healthy quality of life for future babies.Worldwide incidence and prevalenceThe worldwide prevalence of ROP can be difficult to estimate due to not only a large number of patients but also a lack of standardized ROP screening protocols worldwide, which would enable a global registry to collect more accurate data. As seen in Table Risk factorsRetinopathy of prematurity has several risk factors that determine its course and presentation. These risk factors can be interlinked with the pathogenesis of the development of the different stages of the condition. Two key identifiable risk factors are infants being born at an early gestational age of less than 30-32 weeks and a low birth weight of less than 1-1.5 kg .The amount of oxygen received by the child and the duration of ventilation are examples of interlinked risk factors. This could be due to the prolonged use of nasal continuous positive airway pressure (CPAP). Exposure to oxygen for longer than seven days with a saturation of greater than 50% leads to the formation of oxygen free radicals, which in turn leads to the development of ROP . There hPulmonary conditions such as neonatal respiratory distress syndrome (NRDS), if left untreated, can lead to advanced stages of ROP. NRDS, along with early gestational age, is associated with the development of aggressive posterior ROP . In respLate-onset sepsis, including perinatal infection and inflammation, affects retinal angiogenesis via the formation of cytokines and endotoxins, which leads to retinal ischemia due to the impairment of tissue perfusion . The incThe two other factors associated with retinopathy of prematurity are poor postnatal weight gain and slower growth velocity. Slow weight gain causes a lower increase of an anabolic hormone used in the development of blood vessels called insulin-like growth factor (IGF-1) . TherefoChorioamnionitis is a bacterial infection that occurs before or during labor, which affects the chorion and the amniotic fluid. It also induces a fetal inflammatory response causing the release of the inflammatory cytokines that affect retinal angiogenesis. If this occurs in the presence of funisitis , then this increases the chance of developing ROP. Infants exposed to chorioamnionitis are found to be born preterm, have a lower birth weight, be exposed to antenatal corticosteroids, have development of early- or late-onset sepsis, and be subjected to higher rates of partial rupture of membranes (PROM). All of these are contributing factors to the development of ROP .Pre- and postnatal risk factors are very significant in the development and progression of retinopathy of prematurity. Some of these have already been mentioned and discussed above. Postnatal factors include prolonged oxygen exposure, sepsis, necrotizing enterocolitis, and intraventricular hemorrhage . NecrotiPrenatal risk factors include prolonged rupture of membranes, preterm premature ruptures of membranes, hypertensive disorders of pregnancy, and chorioamnionitis. Hypertensive disorders of pregnancy are known to cause an increase in antiangiogenic factors, which antagonizes the action of vascular endothelial growth factor 1 (VEGF-1) responsible for the growth and permeability of the blood vessels. The use of beta-blockers and antihistamines in the later stages of pregnancy are also known risk factors.The care given in higher-level hospitals or study centers of large clinical trials has shown lower rates of retinopathy of prematurity. This is due to the availability of more experienced staff able to manage premature infants . Race alGlobal relevance of retinopathy of prematurityRetinopathy of prematurity is a condition in which it has been shown that with adequate screening and timely management, the progression of the disease and mortality can be drastically reduced. One of the most commonly identified reasons for increased mortality for this condition was a lack of screening protocols and utilities in certain countries. In a study conducted by Onyango et al. in 2018 [There has been a significant progress in the reduction of neonatal mortality rates for ROP as Wang et al. in 2019 mentioned that there was a 53% reduction in mortality, especially in the first year of life, from 1990 to 2015 . Wang etA study conducted by Braimah et al. in 2020  in GhanaAs mentioned earlier, one of the major risk factors identified for the development of ROP is an early gestational age, specifically neonates born before the gestational age of 32 weeks. It was reported by Edy Siswanto and Sauer in 2017  that theIt is imperative to note that with the advancement of neonatal care, better-implemented screening protocols, and newer treatment modalities being developed for managing ROP, mortality rates have decreased since the disease was first identified. However, in countries such as low- and middle-income countries, implementing a screening protocol means the incidence of diseases such as ROP will increase; however, a sustainable method of management that is economic, effective, and easily implementable must be put into action to actively reduce both the incidence and mortality of ROP.Current management strategiesIn recent times, promising developments have been made with regard to treatment modalities and efficacies for ROP. Many large-scale studies such as the CRYO-ROP, Early Treatment for Retinopathy of Prematurity Study (ETROP), and Bevacizumab Eliminates the Angiogenic Threat of Retinopathy of Prematurity (BEATROP) have led to the formation of current guidelines for managing infants with this disease. For prethreshold type 1 disease, they recommend that laser therapy is a suitable initial step; however, as the condition progresses to an aggressive zone 1 type, anti-VEGF inhibitors such as intravitreal bevacizumab have been shown to provide the most benefit . They arDue to the extensive research and understanding of ROP progression, the current standards of care in the United States emphasize a screening program, in which at-risk infants undergo retinal examinations at specific intervals so that timely treatment can commence. These assessments would ideally be scheduled in accordance with the preterm child’s gestational age at birth, as well as the nature of the disease. The objective of this plan is to detect infants who can benefit from treatment and highlight the need for future appropriate interventions. Such a system would employ the use of wide-angle retinal images and binocular indirect ophthalmoscopes in conjunction with clinical data. The presence of skilled and experienced ophthalmologists is vital for this program, as well as the contributions of neonatologists and imaging staff. Despite the implementation of such screening protocols, there will always remain a small portion of ROP infants that still progress to blindness; however, it should not come as a surprise that presenting late to screening is the most common reason for ROP-related blindness ,28.Retinopathy of prematurity is a preventable disorder of retinal blood vessels that has caused blindness in millions of preterm children throughout the globe. Once it advances into later life, ROP can lead to several complications that include severe myopia, strabismus, cataracts, glaucoma, and retinal detachment. Due to the numerous risk factors of ROP being related to the delivery and early development of preterm infants, this disease can provide interesting insight into the quality of perinatal and postnatal services in a given health center. It should then come as no surprise that poorly developed countries continue to lag behind with regard to ROP prevalence. Fortunately, intriguing breakthrough studies have paved the way for current treatment strategies involving the use of laser therapy and low-dose intravitreal bevacizumab. These emerging methods for the management of ROP provide a considerable reason for optimism moving forward. However, the significance of implementing consistent and strict screening protocols worldwide needs to be highlighted to successfully halt the progression of this potentially debilitating disease.


Intrauterine growth restriction (IUGR) may directly affect cardiovascular function in early life. Longitudinal data on left ventricular longitudinal strain (LVLS), a key measure of cardiac function independent of body size, is not available. We hypothesize impaired cardiac function among IUGR newborns and persistence of the impairment until age 3 months.This is a prospective cohort study of consecutive pregnancies where IUGR was identified at 18–38 weeks gestational age (GA) with healthy controls randomly selected at 18–20 weeks GA. Echocardiograms were performed at birth and at age 3–4 months, and then compared.N = 19; − 15.76 (3.12) %] and controls . The IUGR group demonstrated no significant change in LVLS at age 3–4 months [− 17.80 (3.82) %], while the control group [− 20.91 (3.31) %] showed a significant increase (P < 0.001). Thus, LVLS was lower in the IUGR group at age 3–4 months (P = 0.003).At birth, mean (SD) LVLS did not differ between the IUGR group [The lack of increase in LVLS may suggest that IUGR has a direct impact on cardiac function as early as during the first months of life.Trial registration Clinical trials.gov Identifier: NCT02583763, registration October 22, 2015. Retrospectively registered September 2014–October 2015, thereafter, registered prospectively. No change in left ventricular longitudinal strain (LVLS) was observed among IUGR infants between birth and age 3–4 months.LVLS significantly increased in controls during the same period, resulting in the finding of lower LVLS among IUGR infants compared with controls at age 3–4 months.Lack of increase in LVLS among IUGR infants may suggest an impact on cardiac function as early as the first few months of life.Low birthweight is associated with development of ischemic heart disease, hypertension, and type 2 diabetes later in life . CardiovIUGR neonates have smaller, more spherically shaped hearts at birth than do controls , 11. TheEchocardiographic parameters reported from studies of the fetus and newborns with IUGR demonstrate a difference in left ventricular stroke volume, cardiac output, and the myocardial performance index between IUGR neonates and controls as early as the first days after birth. Diastolic left ventricular function is affected by IUGR, showing a tendency toward an elevated ratio between early mitral inflow velocity and mitral annular early diastolic velocity, as well as impaired left ventricular isovolumetric relaxation time , 15.Children born preterm show changes in both cardiac morphology and cardiac function similar to those described among IUGR children at birth and in childhood , 5.Most prior studies of left ventricular systolic function in IUGR children have not demonstrated alterations in ejection fraction (EF)  while ecIn normal pregnancy, fetal LVLS does not change significantly with gestational age (GA) . SystemaThus, previous cross-sectional data indicate that IUGR infants, often born preterm as well, have impaired cardiac function involving a variety of morphological and echocardiographic parameters at birth and during childhood compared with unaffected infants. LVLS varies with age, although changes in LVLS with repeated examinations of the same cohort over time have not been reported.Among fetuses identified as having IUGR, we studied cardiac function in the newborn and longitudinally in the growing child with assessment of LVLS and other echocardiographic parameters. Here, we present data obtained at birth and at age three months and compare them with data from controls from normal pregnancies. Our overarching hypothesis is that cardiac function is impaired in the IUGR newborn and that this impairment persists through the first 3 months of life.This is a prospective cohort study of consecutive IUGR pregnancies, as defined by a fetal weight at least 2.5 SD under or 22% lower than predicted fetal weight for GA , and/or From pregnancies where fetal weight was estimated to be within normal limits [at 18 weeks a mean (SD) of 196 (20) g and at 20 weeks 293 (35) g]  during rExclusion criteria included significant malformations, twin pregnancy, intrauterine infections during pregnancy, and serious maternal disease requiring treatment, as well as participation in any interventional study.Echocardiography was performed 12–72 h and 3–4 months after birth in both IUGR and control infants. Standardized 4-chamber cine loops were recorded for blinded off-line analysis . Velocity vector imaging v. 2.0  was used to determine cardiac motion by tracking the grey scale image.Images of high-technical quality were selected from each examination and anonymized. Loops of 1–3 beats were analyzed three times (one observer) and the mean values were calculated. Longitudinal velocity, displacement, and LVLS were assessed tangential to the endocardial outline. When analyzing the 4-chamber cine loops, the left ventricle was divided into six segments; longitudinal velocity and displacement were calculated from the basal segments. LVLS was calculated for all six segments, from which the average of the two basal segments and the two middle segments was reported as LVLS. Apical segments were excluded due to software limitations. Sufficient quality of the 2-chamber and 3-chamber views were not obtained in all subjects. To avoid missing data, we therefore, report LVLS obtained from the 4-chamber view. Data from the 2-and 3-chamber images with good quality did not differ systematically from those obtained in the 4-chamber view.We follow the EACVI/ASE/Industry Task Force recommendation referring to strain as an absolute value, which means that increasingly negative values were reported as increases in LVLS .The sphericity index (SI) was calculated by measuring left ventricular length in diastole and dividing by maximum diameter in diastole, as obtained from the standard 4-chamber view. Left ventricular mass was calculated from measurements in the parasternal long axis projection using the Devereux formula .Birth weight corrected for GA and postnatal weight SD were calculated by extrapolation using reference values obtained from standard Swedish growth charts .To assess interobserver variability, 10 randomly selected subjects were identified—3 IUGR infants and 7 controls. Two operators carried out LVLS measurements on the same images at birth and at 3–4 months of age. The population mean for the two assessors was 17.31 with a mean difference of 0.788 and an intraclass correlation coefficient (ICC) of 0.90, which is consistent with high agreement.Sample size and power calculations were performed based on publications showing annular velocity data , 32, obtT test and paired sample T test were used to analyze normally distributed data. Mann–Whitney U test and the Wilcoxon Signed Rank test was used for skewed data. The results include data on all subjects remaining at any particular timepoint and were analyzed using IBM SPSS Statistics software, RRID:SCR 019096, .The data in this report are presented as a mean (SD) or a median  as appropriate. Normal distribution was checked with the Shapiro–Wilk test. For comparison independent samples Ethical approval was obtained from the Regional Ethical Review Board in Linköping Sweden (Ref. No. 2012/257-31). Written informed consent was obtained from the parents prior to inclusion of the infant and the study was registered at clinical trials.gov, Identifier: NCT02583763, registration October 22, 2015. Retrospectively registered September 2014–October 2015, thereafter, registered prospectively.The study included 21 IUGR infants, mean GA 33.3 (range: 29.5–35.2) weeks, of whom 19 were available for follow up  hours post-delivery and on controls at 47 24) hours (Table 4 hours (P < 0.001). Thus, LVLS was lower in IUGR infants than in controls (P = 0.003) at age 3–4 months. Figure LVLS did not differ between the groups at birth Table . In IUGRR = 0.310, P = 0.032) and birth weight . In addition, the increase in LVLS (birth to 3–4 months) correlated positively with GA , but not with birth weight standard deviation score (SDS) . We also found that LVLS at age 3–4 months correlated positively with both weight deviation at inclusion  and birthweight , but correlated negatively with weight SDS gain between birth and age 3–4 months . However, LVLS at age 3–4 months also showed a positive correlation with GA at birth . Children in whom LVLS was lower did not differ on an individual basis from the remaining children with increasing LVLS regarding GA, birth weight, birth weight SDS, or weight gain SDS. None of these variables showed significant correlation in a multivariate regression model.To analyze the lack of a normal increase in LVLS in the IUGR group, we performed univariate correlation analysis in all subjects, considering the two groups as a continuum. This showed a positive correlation between the increase in LVLS (birth to 3–4 months) and both prenatal weight deviation at inclusion  .The left ventricular mass index (LVMI) in the newborn was significantly lower in the IUGR group with smaller hearts (28.2 vs. 33.7 g/mP < 0.05). However, the sphericity index decreased in the IUGR group and by age 3–4 months there was no longer any difference compared with controls.The left ventricular sphericity index was higher at birth in IUGR newborns compared with controls, indicating a less spherical ventricle in the IUGR group   Table . No chanWe have observed that LVLS increases in normal non-affected newborns during the first 3–4 months after birth, but such changes were not seen among IUGR infants. This paper is the first to present longitudinal data on normal developmental changes in LVLS during the first 3–4 months of life among infants from non-IUGR pregnancies. Furthermore, our finding that left ventricular systolic deformation in IUGR infants does not increase may indicate a propensity for cardiovascular disease later in adult life. Since the metabolic programming associated with IUGR may require time before heart function is impacted, our findings may suggest that IUGR also has a direct impact on cardiac function as early as during the first months of life.However, it’s too early to make any clear conclusion about the adult consequences of these early findings and future studies needs to confirm the lack of increase in LVLS in the early life of newborn IUGR children. Longitudinal follow-up of cardiac function into later childhood and adult life is necessary.Few studies address LVLS among IUGR infants. In the cross-sectional study by Akazawa et al. , small fIn preadolescent IUGR children, an 18-segment model demonstrated a significant ≈ 5% lower LVLS compared with controls, suggesting that these changes persist, at least partially, over time .Although this suggests that IUGR affects cardiac function, children with growth restriction are also more prone to preterm birth , for whiJames et al. reported that extremely preterm children (born week 26–30), who were less affected by IUGR than our cohort (12% of the study group below the 10th percentile birth weight SD), had a small but significant increase in LVLS between birth and reaching a GCA of 36 weeks . HoweverThe study by Akazawa et al.  collecteWe noted rapid weight gain during the first few months of life in our IUGR group; catch-up growth has previously been suggested to be an independent risk factor for cardiovascular disease in adult life . We founOur study also examined heart measurements and found that the controls were born with more spherical ventricles than the IUGR infants and that this difference disappeared at age 3–4 months. This finding contrasts with one previous study that found a more spherical heart shape among IUGR infants at age 1 month [We found that the IUGR-associated differences in myocardial longitudinal velocity and displacement of basal segments were related to cardiac size, as has been previously reported. After correcting for ventricular length, no significant group differences were found other than the lack of change in displacement or velocity in the left lateral ventricular wall among IUGR infants between birth and age 3–4 months; such changes during this time interval were found to be significant in the control group. When comparing average LVLS in the left lateral ventricular wall, a larger difference was noted at age 3–4 months between the IUGR group and controls than any changes seen in the septal wall. Earlier studies have indicated the presence of a more spherical heart and left ventricular dilatation secondary to early cardiac remodeling among IUGR infants [The strength of our study lies in its design of longitudinal pre- and postnatal examinations of infants who were identified in utero as having or not having IUGR. IUGR pregnancies were diagnosed as early as GA week 20 and up to week 37, thereby representing a spectrum of early to late onset of growth restriction. Very few infants were excluded or lost to follow-up at the 3–4-month visit. However, the number of infants in the IUGR and control groups is limited, which is typical for this kind of study, but this imposes limitations on the ability to analyze subgroups .In summary, the IUGR infants in our study, born slightly preterm on average, demonstrate an attenuated increase in left ventricular longitudinal strain during their first “preterm” months of life.


Echinococcus graunlosus in an ELISA system. Multivariate logistic regression analysis was used to find out the independent risk factor for CE seropositivity. Anti-hydatid cyst antibodies were detected in the sera of 131 out of 1500 participants, corresponding to a seroprevalence rate of 8.73%. With a statistically significant difference (p < 0.05), the seroprevalence of hydatid cyst in males and females was 5% and 7%, respectively. Differences in the seropositivity of hydatid cysts were also statistically significant by occupation (p < 0.05). The seroprevalence of hydatid cyst was significantly higher in the age group of 35-45 years than in other age groups (p < 0.05). Multivariate logistic regression showed that only age was associated with seropositivity to CE . Moreover, there was a statistically significant association between seropositivity to hydatid cysts and underlying diseases such as hypertension (p = 0.049) and fatty liver (p = 0.048). The findings of this study indicate that the seroprevalence rate of CE is relatively high in the Fars province, southern Iran, and this high rate of infection is mainly linked to people's jobs and lifestyles.Cystic echinococcosis (CE) is a common zoonotic infection in all provinces of Iran, especially in areas where people live on agriculture and animal husbandry. The current cross-sectional population-based study is aimed at determining the seroprevalence of CE in Kavar County, Fars province, southern Iran. Blood samples were collected from 1500 individuals . Anti-hydatid cyst antibodies were detected, using a recombinant B8/1 antigen of  Echinococcus granulosus. CE is one of the most important health challenges in Iran, and the disease exists throughout the 31 provinces of the country. The overall seroprevalence of human hydatid cyst in Iran is reported to be 4.2% while the prevalence of Echinococcus infection in definitive hosts is reported to be 23.6% [Echinococcus infection in the final hosts (mainly dogs), has been reported in the southern regions of the country [Cystic echinococcosis (CE) is a zoonotic neglected parasitic infection of humans and some other mammals caused by the larval stages of the cestode In Iran, about one percent of surgeries performed in hospitals are on patients with hydatid cysts . In addiFars province is one of the most important centers of hydatid cysts in Iran due to favorable climatic conditions and the people's livelihood of agriculture and animal husbandry. Although there have been various studies on the prevalence of hydatid cyst in different regions of Iran in different population groups, a comprehensive study that shows the status of this disease in a relatively large population in a society with agricultural and animal husbandry livelihood in Iran, especially in Fars province, as one of the main endemic areas for CE, is missing. Hence, the current study is aimed at assessing the seroprevalence of hydatid cyst and related risk factors for infection in residents of Kavar County in Fars province, where the largest and the most comprehensive Persian population cohort on noncommunicable diseases is running.The present cross-sectional population-based study was performed in collaboration with the Kavar Persian population cohort and the Department of Parasitology at Shiraz University of Medical Sciences, Shiraz, Iran, in Kavar County in Fars province. Two main research centers, the Endocrine Research Center and Gastroenterohepatology Research Center, affiliated with Shiraz University of Medical Sciences (SUMS) are implementing the comprehensive Persian cohort study. Kavar has a population of about 71,856 and is located 35 kilometers southeast of Shiraz the capital of Fars province .Kavar's geographical coordinates are latitude 11°29′N and longitude 42°52′E. The average annual precipitation and temperature in this area are 400 mm and 22°C, respectively. Kavar County has a large number of stray dogs that are in close contact with humans and other animals, including sheep and goats. On the other hand, the majority of people who live in Kavar, due to their employment in agriculture, horticulture, and animal husbandry, are prone to soil-transmitted parasitic infections, especially hydatid cyst and toxocariasis.In coordination with the implementers of the Persian cohort project in Kavar County, blood samples were taken from 1500 participants in the cohort project from the residents of the district. As the participants in the cohort study had a specific code, the participants were randomly selected from the numbers assigned to each person.Ethical approval of the study was obtained from the Ethical Review Committee of Shiraz University of Medical Sciences . After signing a written informed consent and filling out a questionnaire containing sociodemographic data and risk factors related to hydatid cyst, a blood sample (5 mL) was taken from each subject. The isolated sera were kept at -20°C until sampling was completed. Frozen sera were transferred to Shiraz University of Medical Sciences (parasitology laboratory) where the samples were tested for anti-hydatid cyst antibodies.E. granulosus recombinant B8/1 antigen (rEgAgB8/1) was produced in our previous study which had a sensitivity of 93% and specificity of 92% for the diagnosis of human CE [μL/well) with a concentration of 5 μg/mL of the recombinant antigen in 0.1 M carbonate/bicarbonate (coating) buffer at 4°C overnight. The next day, after washing the microplate with PBST , wells were blocked with 3% skimmed milk for 2 h at room temperature (RT). Serum samples (1/100 dilution in PBST) were added to each well and incubated for 1 h at RT. Then, the plates were washed as before, and 100 μL of a predetermined dilution (1/4000) of the horseradish peroxidase-conjugated goat anti-human IgG  was added to the wells and incubated at RT for an hour. The plate was washed as before and incubated with a substrate solution containing 0.4 mg/mL OPD and 0.3% H2O2 in 0.1 M citrate buffer (100 μL/well) for 30 min in darkness at RT. The absorbance at 450 nm was measured, using a microplate reader . In each run, positive and negative control sera were included. Finally, the cutoff point was set at 2SD from the mean of control samples.human CE . ELISA wp < 0.05.SPSS ver. 20 software  was applied for statistical analyses of the data. The chi-square test was used to determine the association between the seropositivity to hydatid cyst and individuals' demographic characteristics. Multivariate logistic regression analysis was used to find out the independent risk factor for CE seropositivity in the recruited subjects. Also, univariate logistic regression analysis was employed to determine the association between the different risk factors and seropositivity to CE. Statistical significance was considered as a value of p = 0.02). Also, seropositivity to hydatid cyst had a statistically significant association with people occupation (p = 0.008). The rate of seropositivity was significantly higher among the age group of 35-45 years (p = 0.01). Univariate analysis showed a significant association between sex, age, and occupation with seropositivity to hydatid cyst. Multivariate logistic regression analysis indicated that only the age group of 35-45 years with OR = 2.23  was associated with seropositivity to hydatid cyst. It is noteworthy that a statistically significant association was found between seropositivity to hydatid cyst and two underlying diseases, including hypertension (p = 0.049) and fatty liver (p = 0.048), while the association between seropositivity to hydatid cyst and other underlying diseases, including psychiatric disorder, epilepsy, cancers, rheumatic disease, chronic lung disease, renal disease, cardiac disease, and diabetes, was insignificant (p > 0.05). Of the 1500 recruited subjects, 749 (49.9%) were males, and 751 (50.1%) were females. The mean age of the subjects was 50.04 (±8.3) years, ranging from 35 to 70 years. Most of the subjects (41.1%) belonged to the 46-55-year-old group. Most of the recruited subjects (32%) were illiterate or had elementary (32.9%) education. Anti-hydatid cyst antibodies were detected in the sera of 131 out of 1500 participants, corresponding to a seroprevalence rate of 8.73%. The seroprevalence rate of hydatid cyst in males and females was 6.94% (52/749) and 10.51% (79/751), respectively, and the difference was statistically significant  in the Zagros Mountains of southwestern Iran, Khuzestan in the south (13.78%), Lorestan, a province of western Iran (15.4%), and Kermanshah (8.02%) in the western part of the country , 14–17. Rural life is always considered an important risk factor in obtaining the hydatid cyst. The type of livelihood of people, which is mainly animal husbandry and agriculture, keeping dogs, and low level of health and access to health services, contributes to the higher prevalence of the disease in rural areas , 27.Findings of the current study revealed higher seropositivity of hydatid cyst in women (10.51%) than in men (6.94%). In most areas of Iran especially in rural areas, women are more likely to be infected with hydatid cyst than men due to their risky behaviors such as close contact with dogs, cleaning vegetables, contact with soil, animal husbandry, and working on farms , 29.Kavar County, where the present study was conducted, has a suitable climate for agriculture and animal husbandry. People in this area have not yet given up rural life, and many people have close contact with livestock and dogs, which justifies the high prevalence of hydatid cyst in the area.Echinococcus infection in the final host (mainly dogs) in the Fars province in Iran, where the current study has been undertaken, has been reported to be relatively high. In Mehrabani et al. study, the infection rate of dogs with Echinococcus adult worms in 105 dogs studied in Shiraz, the capital of Fars province, was reported to be as high as 36.19% [In the previous studies, the rate of s 36.19% . A recens 36.19% .Echinococcus genotypes in dogs in Iran have documented that dog in different regions of the country is mainly infected with G1-G3 genotypes which is the dominant genotype in humans in Iran [Studies on the  in Iran .In the present study, the subjects were divided into three age groups: 35-45, 46-55, and 56-70 years. The highest seropositivity (11.8%) was observed in the 35-45 age group. Also, multivariate logistic regression showed that the age group of 35-45 years old was 2.23 times more likely to be seropositive for CE than other age groups. In several serosurveys conducted in Iran, the age groups of 20 to 40 years old had the highest seroprevalence rate of hydatid cyst which is somewhat consistent with the findings of our study , 25, 28.We also found a statistically significant association between a few underlying diseases and seropositivity to hydatid cyst. In some studies, cases of arterial hypertension due to pressure from hydatid cysts have been reported , 38. HowE. granulosus is the most appropriate antigen for serodiagnosis of CE [It has been documented that the native antigen B of is of CE . In receis of CE , 41, 42 is of CE . This anis of CE .One of the shortcomings of this study is the limited age range of the subjects, which is due to the population under study in the Persian cohort, which does not include children.The findings of the current study determined the serostatus of hydatid cyst in a relatively large population in Kavar County in Fars province, southern Iran. The findings indicated a relatively high rate of seropositivity to hydatid cysts and highlighted the importance and related risk factors of the disease, in a CE-endemic area in Iran. Considering the findings of the study, educating people and implementing preventive measures for the control of the disease in the region seem necessary.