Postoperative pain is the most prominent concern among surgical patients. It has previously been reported that venous cannulation-induced pain (VCP) can be used to predict postoperative pain after laparoscopic cholecystectomy within 90 mins in the recovery room. Its potential in predicting postoperative pain in patients with patient-controlled intravenous analgesia (PCIA) is worth establishing. The purpose of this prospective observational study was to investigate the application of VCP in predicting postoperative pain in patients with PCIA during the first 24 h after laparoscopic nephrectomy.One hundred twenty patients scheduled for laparoscopic nephrectomy were included in this study. A superficial vein on the back of the hand was cannulated with a standard-size peripheral venous catheter (1.1 × 3.2 mm) by a nurse in the preoperative areas. Then the nurse recorded the VAS score associated with this procedure estimated by patients, and dichotomized the patients into low response group (VAS scores < 2.0) or high response group (VAS scores ≥2.0). After general anesthesia and surgery, all the patients received the patient-controlled intravenous analgesia (PCIA) with sufentanil. The VAS scores at rest and on coughing at 2 h, 4 h, 8 h, 12 h, 24 h, the effective number of presses and the number of needed rescue analgesia within 24 h after surgery were recorded.rs = 0.64) and during coughing (rs = 0.65), effective times of pressing (rs = 0.59), additional consumption of sufentanil (rs = 0.58). Patients with venous cannulation-induced pain intensity ≥2.0 VAS units reported higher levels of postoperative pain intensity at rest (P < 0.0005) and during coughing (P < 0.0005), needed more effective times of pressing (P < 0.0005) and additional consumption of sufentanil (P < 0.0005), and also needed more rescue analgesia (P = 0.01) during the first 24 h. The odds of risk for moderate or severe postoperative pain  was significantly higher in patients with venous cannulation-induced pain intensity ≥2.0 VAS units compared to those <2.0 VAS units.Peripheral venous cannulation-induced pain score was significantly correlated with postoperative pain intensity at rest  center on July 6 2019 and received the registration number:  Postoperative pain is the most prominent concern among surgical patients. If not adequately controlled, it will affect postoperative rehabilitation, health-related quality of life, and may develop into persistent long-term pain –3.Current postoperative pain management strategies apply a standardized, one-size-fits-all approach to all patients. These standardized protocols are not suitable for the significant difference in patient’s pain and may lead to insufficient analgesia in patients with high analgesic needs, or excessive analgesia, which is accompanied by increasing analgesic-related side effects. The ability to preoperative predict who is at risk for developing moderate or severe postoperative pain might allow anaesthetists to optimize pain management by offering personalized, stratified or targeted analgesic treatment protocols. Preoperative pain prediction methods are highly relevant in this regard.Numerous studies have tried to identify patients who are at risk for postoperative pain in the preoperative period and evaluated the role of psychological factors and experimental pain tests or quantitative sensory tests (QST) –8. HowevPeripheral venous cannulation, a routine procedure of preoperative preparation, induced pain intensity could be assessed easily and rapidly before surgery without specific equipment or training. It was recently shown that peripheral venous cannulation-induced pain (VCP) intensity could be used to predict the risk of postoperative pain. Patients with VCP score at or above 2.0 VAS units reported higher levels of acute postoperative pain intensity and more often have moderate or severe postoperative pain within 90 mins in the recovery room [chictro.org .This prospective clinical observational study was approved by the Institutional Scientific Research and Clinical Trials Ethics Committee of the First Affiliated Hospital of Zhengzhou University (ref.: 2019- KY-120) and registered at 2, and scheduled to undergo laparoscopic nephrectomy under general anaesthesia, agree to use postoperative analgesia pump for 48 h after surgery, agreed to cooperate and signed the informed consent were recruited.Patients who were classified as American Society of Anesthesiologists (ASA) physical status I-II, aged between 18 and 65 years, all genders, BMI 18 to 28 kg/mPatients with the following conditions were excluded: severe heart, lung and metabolic diseases, hepatic or renal dysfunction, a history of neuromuscular system disease, mental illness, and a tendency to malignant hyperthermia, preoperative existing pain, long-term use of sedative and analgesic drugs (> 3 months), drug or alcohol abusers, or severe hypertension, poor understanding or communication difficulty, failed venous cannulation, changed in surgical approach  for them and instructed on the use of PCIA bump. On the day of surgery, an experienced nurse inserted a peripheral venous catheter  with a standard-size (1.1 × 3.2 mm inner diameter) into a superficial vein on the back of the patient’s hand in the preoperative preparation room. The patients were asked to estimate, on a horizontal VAS ruler, their maximum pain intensity associated with this procedure, recorded to one decimal point (0.0–10.0). Then the nurse recorded the VAS score estimated  by the patients, and dichotomized the patients into low response group (VCP score < 2.0 VAS units) or high response group (VCP score ≥ 2.0 VAS units). The nurse was aware of whether the patient was to take part in the study.2, noninvasive blood pressure was established. Before the induction of anaesthesia, the patients were given IV Penehyclidine Hydrochloride 0.5 mg, and a loading dose of dexmedetomidine with 0.5 μg kg− 1 was infused over 10 min. The bispectral index (BIS) was used to monitor the depth of anaesthesia. Then anaesthesia was induced with midazolam 2 mg, sulfentanil 0.5 μg kg− 1, etomidate 2–3 mg kg− 1. Cisatracurium 0.2 mg kg− 1 was given to facilitate endotracheal intubation. Anaesthesia was maintained with sevoflurane (1–2%), remifentanil 0.1–0.3 μg kg− 1 min− 1. The cisatracurium was used to provide a satisfactory level of muscle relaxation. The BIS value was maintained between 40 to 60. The pneumoperitoneum pressure with carbon dioxide was set at 13–15 mmHg, and the EtCO2 was maintained at 35 to 45 mmHg. Thirty minutes before the end of the surgery, sulfentanil 10 μg and flurbiprofen axetil 100 mg were given as postoperative analgesia, and tropisetron 5 mg was given to prevent postoperative nausea and vomiting. At the end of the surgery, sevoflurane and remifentanil were stopped. Immediately after surgery, the PCIA pump was attached to the peripheral venous line by the anaesthetist. Then the patients were sent to the post anaesthetic care unit for anaesthetic resuscitation. All patients were sent to the general ward after being fully awake. Upon arrival in the general ward, all the patients were once again instructed on the use of the PCIA pump and VAS.All patients were anaesthetized by anaesthetists who were blinded to study and did not participate in data collection. Once in the operating room, the standardized monitoring of ECG, SpO− 1 and 5 mg tropisetron, mixed with 0.9% normal saline to a total volume of 150 ml. The PCIA was programmed to deliver a 2 ml bolus on demand, with a lock-out interval of 10 min, and a background infusion rate of 2 ml h− 1. In the ward, patients pressed PCA when VAS score at rest > 3.0. If patients still reported pain or the VAS scores ≥4.0, supplemental rescue boluses of intravenous flurbiprofen axetil injection of 50 mg were administered. The complete history of continuous infusion, bolus infusion, and bolus demand for the PCIA device was downloaded after surgery.The PCIA with sulfentanil regimen was applied to 48 h after surgery. The PCIA regimen consisted of sulfentanil 3.0 μg kgThe study outcomes variables and the vital parameters were recorded at 2, 4, 8, 12 and 24 h after surgery. During the studied period, pain intensity, sulfentanil consumption, pressing times of the PCIA, and the number of rescue analgesia were recorded at above time points. Overall satisfaction index of the patients was recorded at 24 h. Pain intensity was assessed with VAS at rest and during coughing.The primary outcome was maximum postoperative pain scores at rest and during coughing within the first 24 h. The secondary outcome was effective times of pressing, additional consumption of sulfentanil and satisfaction index at 24 h. Also, the number of rescue analgesia within the first 24 h was also measured.Postoperative data collector was blinded to the preoperative peripheral venous cannulation-induced pain score of the patients.The sample size was based on a pilot experiment of 20 cases resulted in our observation that patients with VCP score ≥ 2.0 VAS units was present in 8 out of 20 patients and that mean maximum postoperative pain score (VAS) at rest within 24 h after surgery was 3.9 (± 1.3). Therefore, in order to show a 20% difference between the patients with VCP score ≥ 2.0 VAS units and the patients with VCP score ≥ 2.0 VAS units, the number of patients in each group was expected to be 41 . Since the groups are unequal, assuming a 40% of patients with VCP score ≥ 2.0 VAS units, and allow for up to 15% dropouts, a total of 120 patients (48 patients with VCP score ≥ 2.0 VAS units and 72 patients with VCP score < 2.0 VAS units) would be sufficient to test our hypothesis.t-test. IF the distribution was not normal, the median with inter-quartile range (IQR) were expressed, and a Mann–Whitney U-test was used. Categorical data were expressed as frequency (n) and percentage (%) and were statistically tested using the chi-square or Fisher’s exact test. Correlations between variables were assessed with Spearman’s rank correlation coefficients. Logistic regression analysis was used to evaluate the predictive abilities of cannulation-induced pain intensity. All P values <0.05 were considered to be statistically significant.The IBM SPSS version 22.0 software packages were used for statistical analyses. The normality of the continuous data was tested by the Shapiro-Wilk test. Normally distributed continuous variables were expressed as mean ± SD and compared between groups using a two-sample Student A total of 139 patients undergoing laparoscopic nephrectomy were screened between August and October 2019, of which 19 were excluded because they did not meet the inclusion criteria, refused to participate in the trial, and failed venous cannulation. Among the remaining 120 patients, some were eliminated due to transferred to ICU, converted to open surgery, surgery duration over 3 hours, or incomplete recording, and 106 study patients were available for analysis   , additional consumption of sulfentanil  were statistically significantly correlated with peripheral venous cannulation-induced pain score, respectively.Bivariate correlations between peripheral venous cannulation-induced pain score and outcome variables are shown in Fig. 01) Fig. a, postop01) Fig. b, effectP < 0.0005) and during coughing , needed more effective times of pressing  and additional consumption of sulfentanil , and also needed more rescue analgesia  during the first 24 h. While the satisfaction index was significantly lower .Patients’ demographic characteristics and perioperative data between the two groups are shown in Table P = 0.01).The number of patients experiencing maximum pain (at rest) exceeding 4.0 VAS units during the first 24 h between high response group and low response group were shown in Table After controlling for possible factors affecting postoperative pain , the odds of risk for moderate or severe postoperative pain  was significantly higher in patients with venous cannulation-induced pain intensity ≥2.0 VAS units compared to those < 2.0 VAS units (Table This study shows that peripheral venous cannulation-induced pain score is positively correlated with postoperative maximum pain and addition consumption of sulfentanil during the first 24 h after laparoscopic nephrectomy. Patients with VCP score ≥ 2.0 VAS units are more likely to report higher postoperative pain scores and additional consumption of sulfentanil. Furthermore, patients with VCP score ≥ 2.0 VAS units have a 3.5 times higher risk for moderate or severe postoperative pain.Peripheral venous cannulation, is a routine practice before surgery, has been reported by patients to be painful. The pain intensity is associated with cannula site, cannula size, failed venipuncture attempts and process times , 11. In Prior researchers have also reported similar results to ours. Persson et al.  study reNumerous studies have been developed to predict postoperative pain in the last decade. The pain intensity of QST stimuli, including pressure, electric, and thermal stimulus, have been reported to correlate with the intensity of postoperative pain –8, 14–17Our finding has important clinical implications since pain management in the postoperative period still present a challenge. There is large individual variability in response to opioids and the potential side effects such as respiratory depression, nausea, vomiting and constipation. The ability to preoperative identification of patients at greater risk for moderate or severe postoperative pain and having higher opioids requirements is very beneficial. Using peripheral VCP intensity as a predictor of postoperative pain may allow anaesthetists more convenient to adjust the dosage of opioids and can potentially improve postoperative pain management.There are some limitations to the present study. Known risk factors of postoperative pain are female gender, lower age, preoperative pain, intraoperative factors and psychological factors, and so on , 19–21. In conclusion, peripheral venous cannulation-induced pain score was associated with postoperative pain and addition consumption of sulfentanil during the first 24 h after laparoscopic nephrectomy. Patients with VCP score ≥ 2.0 VAS units had higher postoperative pain scores, additional consumption of sulfentanil and risk for moderate or severe postoperative pain. Therefore, peripheral venous cannulation-induced pain intensity can be considered as a simple and useful method to predict postoperative pain in patients with PCIA during the first 24 h after laparoscopic nephrectomy.


We examined the factorial structure and validity of a Japanese version of the Parental Burnout Assessment, the PBA‐J, with 1,500 Japanese parents. The Parental Burnout Assessment measures burnout using four dimensions: exhaustion in one's parental role, contrast in parental self, feelings of being fed up, and emotional distancing. Confirmatory factor analysis on the PBA‐J supported a four‐factor model. Multiple‐group structural equation modeling with parent participants was supported for the factor‐loading invariance model. Mothers had higher parental burnout scores than fathers. We found moderate‐to‐strong correlation coefficients between the PBA‐J and the Parental Burnout Inventory , and weak‐to‐moderate correlation coefficients between the PBA‐J and job burnout, neuroticism, co‐parenting disagreement, and family disorganization. The PBA‐J was correlated with parental perfectionism, particularly with concern over mistakes rather than sociodemographic variables. Overall, our findings provide initial evidence for the validity of the PBA‐J. Parenting is fraught with difficulties worldwide. Some parents try to raise their children by holding them to high standards or avoiding parenting mistakes. Such efforts can lead to parental burnout, an emotional disorder. To assess parental burnout, Roskam, Raes, and Mikolajczak  developeFollowing the work of Roskam and colleagues, researchers evaluated the validity of the PBI in different countries . KawamotThe PBI was developed based on the Maslach Burnout Inventory ; however, we set four sub‐goals. First, we tested whether the PBA‐J had a four‐factor structure identical to that of the original PBA. Additionally, as in previous studies , who were recruited by a pooling company (Rakuten Insight), included parents living with at least one child in Japan. We used an approximately equal size allocation procedure for age and gender. Participant ages ranged from 20 to 59 years . Participants provided written informed consent, and the ethics committee of Hiroshima University approved the study protocol.Participants , type of work (full time or part time), and work hours per week. Table In consideration of the Japanese family situation, we measured several demographic variables used in previous studies  to ensure quality and content accuracy. We obtained permission to use and translate the PBA from Roskam, who developed the original version. An English–Japanese bilingual researcher compared and revised the questionnaires, paying attention to preserving the semantics and concepts of the original version. The original PBA comprises four subscales and 23 items: Exhaustion in Parental Role (EX: 9 items), Contrast with Previous Parental Self (CO: 6 items), Feelings of Being Fed Up (FU: 5 items), and Emotional Distancing (ED: 3 items). Items are rated on a 7‐point rating scale ranging from 0 = 2.3.2We included the 22‐item self‐report Parental Burnout Inventory‐Japanese version .We used the Japanese Burnout Inventory , a 15‐item scale measuring environmental confusion and disorganization in the family, such as high noise levels, crowding, and home traffic patterns . Next, we tested the four‐factor structure model by gender. Several goodness‐of‐fit indices were used to determine the acceptability of the models. In addition to the chi‐square index, the comparative fit index (CFI), root mean square error of approximation (RMSEA), standardized root mean square residual (SRMR), and Tucker–Lewis index (TLI) were used to evaluate model fit, similar to previous studies  for all samples. The analysis model included the four latent variables representing the concepts of EX, CO, FU, and ED, as well as their indicators, comprising 9, 6, 6, and 3 items, respectively. Analyses were conducted using maximum likelihood estimation. Reliability was estimated with Cronbach's alpha coefficients . If the configural invariant model provided acceptable fit indices to the data, it would suggest that the four‐factor structure of the PBA‐J was consistent across genders. Second, we tested the factor‐loading invariance model in which all factor loadings in the model were constrained to be equal using MGSEM. We calculated the fit index and checked whether the previously mentioned criterion fit index was accepted. Furthermore, we identified changes in several goodness‐of‐fit indices for the configural invariance model and factor‐loading invariance model. The difference of chi‐square . First, we conducted an analysis of variance (ANOVA) with gender as a fixed factor and total PBA‐J score as the dependent variable. Second, to control for the Type I error rate, we conducted a multivariate analysis of variance (MANOVA) with gender as a fixed factor and PBA‐J subscales as the dependent variables.2.4.4To investigate criterion‐related validity, we examined the associations among the PBA‐J and PBI‐J, job burnout, depression, neuroticism, co‐parenting disagreement, and family disorganization. We computed Pearson's correlation coefficients between the sum of the PBA‐J total and subscale scores, job burnout total and subscale scores, and scores for depression, neuroticism, co‐parenting disagreement, and family disorganization.2.4.5n = 339).Similar to Kawamoto et al. , to examWe used Mplus 8.4  = 966.15, p < .001; father and mother data is presented in Table Table 3.2SD of PBI‐J scores for the total sample and mother and father subsamples. Mothers had significantly higher PBA‐J total scores than fathers. Additionally, the MANOVA with the four factors for burnout showed that parental burnout was, on average, higher among mothers than fathers  = 18.181, p < .01). Follow‐up univariate tests revealed that compared to fathers, mothers had significantly higher EX and CO.Table 3.3Pearson's correlations coefficient among the PBA‐J scores , PBI‐J scores , JBI scores , depression, neuroticism, co‐parenting disagreement, and family disorganization are presented in Table 3.4having a child with special needs and living separately by choice were associated with PBA‐J total scores, explaining minimal variance for PBA‐J (4.0%). In step 2, perfectionism explained more variance for parental burnout (23.0%). Parental and job CM were significantly linked to the PBA‐J total score; specifically, the parental CM effect was stronger than job CM. In addition to the sociodemographic variables having a child with special needs and living separately by choice, gender significantly and positively predicted PBA‐J.Parental/job perfectionism, parental/job PS, and parental/job CM had weak positive relationships with PBA‐J scores Table . Parenta4This study examined the characteristics of parental burnout in Japan by successfully testing the validity of PBA‐J. First, similar to studies of French‐, English‐, Chinese‐, and Finnish‐speaking parents, our results provide evidence for the validity of the PBA‐J and its four‐factor structure. However, it should be noted that the current study's results supported a factor‐loading invariance model. Second, mothers were more likely to suffer parental burnout than fathers. These results were consistent with previous findings that parental burnout symptoms are, to some extent, dependent on the parent's gender (Roskam et al., 4.1We tested whether the factor structure of the PBA‐J was identical to the four‐factor structure of the original PBA. The results showed that, similar to Roskam et al. , the PBA4.2In the present study, gender associated to PBA‐J in the multiple regression analysis, and mothers’ PBA‐J total scores were higher than fathers’ scores. These results were similar to the findings of Roskam et al.  and Auno4.3Correlation analysis showed that the results were almost in line with the results of previous research, although one point of interest was the relationship between the PBA and PA in the PBI. While Roskam et al.  found a 4.4Parental perfectionism more strongly influenced parental burnout than job perfectionism did, and CM influenced parental burnout more strongly than PS did. The PBA‐J, like the PBI‐J, was associated with parental perfectionism, particularly parental perfectionistic concerns. Previous research examined the relationship between PBA and self‐oriented perfectionism, the relationship between PBA and socially prescribed perfectionism, and their interaction (Sorkkila & Aunola, 4.5having a child with special needs had a weak positive effect on PBA‐J. This finding supported the results of Roskam et al. (living separately by choice was a predictor of PBA‐J. This may be due to having less partner support and the burden of parenting alone. However, there was no effect on PBA‐J from the variable not living with a significant other or fiancé. Therefore, it is important to keep in mind networks of non‐partners. To clarify this difference in effect, it would be worth focusing on the influence of social networks other than partners (Nelson, Our findings indicated that m et al. . The parm et al. . This su Nelson, . Further4.6Future studies should further investigate validity of PBA‐J. The correlation of PBA‐J and PBI‐J could be interpreted as a convergent indication of construct validity; however, future studies should seek to provide evidence for discriminant and criterion validity, too. Criterion validity, in particular, would require investigating the prediction of clinically diagnosed burnout symptoms, along with other real life consequences of burnout. Future studies should examine which PBA‐J subscales are affected by predictor variables to deepen understanding of PBA‐J and parental burnout. Additionally, clinical cut‐off scores should be defined in order to identify when burnout really starts. As Roskam et al.  argued, 5The present research provides preliminary evidence regarding the validity and reliability of the PBA‐J. Moreover, our results revealed that parental perfectionistic concerns can be a risk factor for parental burnout.Supporting InformationClick here for additional data file.


IPF is an ageing‐related lung disorder featuring progressive lung scarring. IPF patients are frequently identified with short telomeres but coding mutations in telomerase can only explain a minority of cases. Sex hormones regulate telomerase activity in vitro and levels of sex hormones are related to LTL. The objective of this study was to explore whether sex hormones were associated with LTL, whether they interacted with genetic variants in telomerase and whether polymorphisms in the exon of androgen metabolism genes were associated with plasma testosterone concentrations in male IPF patients.A case–control study was performed on 101 male IPF subjects and 51 age‐matched healthy controls. Early morning plasma sex hormones were quantified, and whole‐exome sequencing was used to identify rare protein‐altering variants of telomerase and SNP in the exon of androgen metabolism genes. LTL was analysed by PCR and expressed as a T/S ratio.P = 0.001). No significant interaction (P = 0.661) was observed between rare protein‐altering variants of telomerase and testosterone. No coding SNP in androgen metabolism genes were significantly associated with testosterone concentrations.LTL, testosterone and DHT were decreased significantly in the IPF group. After adjustments for age and variant status in telomerase‐related genes, only testosterone was positively associated with LTL (Plasma testosterone is associated with LTL independent of age or rare protein‐altering variants of telomerase. No genetic variations of androgen‐related pathway genes are associated with androgen concentrations. Further studies are warranted to examine whether hormonal interventions might retard telomere loss in male IPF patients. In this case–control study, we explored the role of sex hormones in IPF. We found that plasma testosterone levels decreased in male patients with IPF, and plasma testosterone was positively associated with LTL. No coding variations of androgen‐related pathway genes were associated with androgen concentrations. ADautosomal dominantARautosomal recessiveBMIbody mass indexDHEAdehydroepiandrosteroneDHT5α‐dihydrotestosteroneE2oestradiolFDRfalse discovery rateHRCThigh‐resolution computed tomographyIPFidiopathic pulmonary fibrosisLDlinkage disequilibriumLTLleucocyte telomere lengthMAFmutant allele frequencyPARNpoly(A)‐specific ribonucleasePCRpolymerase chain reactionPMmoderate pathogenicityPPsupporting pathogenicityPUMCHPeking Union Medical College HospitalPVSvery strong pathogenicityRTEL1regulator of telomere elongation helicase 1SNPsingle‐nucleotide polymorphismSNVsingle‐nucleotide variantTtestosteroneT/S ratioratio of the copy number of telomere DNA to a single‐copy geneTERCtelomerase RNA componentTERTtelomerase reverse transcriptaseIdiopathic pulmonary fibrosis (IPF) is a chronic, progressive and fibrotic interstitial lung disease of unknown aetiology, with a median survival of 2–3 years after the diagnosis.TERT (telomerase reverse transcriptase), PARN (poly(A)‐specific ribonuclease), TERC (telomerase RNA component) and RTEL1 (regulator of telomere elongation helicase 1)) are shown to affect LTL in sporadicTelomeres are DNA–protein structures that are located at the ends of linear chromosomes and whose function is to protect chromosome ends from recombination and degradation.SRD5A1/2) to DHT and by aromatase (encoded by CYP19) to E2.TERT, PARN, TERC and RTEL1). Finally, we explored the relationship of single‐nucleotide polymorphisms (SNP) in the exon of androgen metabolism genes with plasma T.Considerable experimental evidence indicates that sex hormones regulate telomerase activity.A case–control study on 101 male IPF subjects and 51 age‐matched controls was conducted in Peking Union Medical College Hospital (PUMCH) of the Chinese Academy of Medical Sciences and Peking Union Medical College (CAMS and PUMC), Dongcheng District, China. Participants were enrolled consecutively. The diagnosis of IPF was in accordance with the American Thoracic Society/European Respiratory Society/Japanese Respiratory Society/Latin American Thoracic Association (ATS/ERS/JRS/ALAT) consensus statement from 2018.Peripheral blood samples were collected from all enrolled subjects. Plasma samples were produced by centrifugation and subsequently stored at −80°C until analysis. Plasma DHEA, T, DHT and E2 were measured by an enzyme‐linked immunosorbent assay (ELISA) using commercially available kits .Telomere lengths of leucocyte DNA samples were determined by real‐time quantitative polymerase chain reaction (PCR) in StepOne Plus real‐time PCR system , using the protocol previously described by Cawthon.Whole‐exome sequencing was performed to identify coding variants of telomerase and androgen metabolism genes. Extraction of DNA was performed following standard procedures using the QIAamp Genomic DNA mini kit . A minimum of 1 μg of DNA per sample was used for the DNA library generation. First, genomic DNA samples were randomly fragmented by sonication to an average size of 180–250 bp. Second, the DNA fragments were end‐repaired, A‐tailed and ligated to adapters, followed by PCR amplification. Lastly, the DNA libraries were sequenced on Illumina HiSeq X platform  with a paired‐end read length of 150 bp (PE150).TERT, PARN, TERC and RTEL1), include variants with mutant allele frequency (MAF) <1% in the 1000 Genomes databases and the functional predictions by SIFT, PolyPhen‐2 and MutationTaster all indicated the SNV was not benign or if it had a high impact ; and (iii) in terms of genes involved in androgen metabolism pathway , no rare damaging protein‐altering variants were found in this study, and only common coding variant with a MAF of 5% or more was included in the analysis. All SNP were in accordance with Hardy–Weinberg equilibrium in the control group ).Whole‐exome sequencing reads were mapped to GRCh37/hg19, using Burrows‐Wheeler Aligner (BWA) software to generate original BAM files.P < 0.05 was considered statistically significant and FDR was adopted to control the effects of multi‐testing. Non‐normal distribution values such as LTL and DHT were reciprocally transformed and DHEA was natural log‐transformed for the analysis. Results of continuous variables were reported as mean ± SD or median (interquartile range), while categorical variables were reported as a number with percentage. Comparison of basic data between two groups was done using Student's t‐test for continuous variables which fulfilled homogeneity of variance and using chi‐square test for categorical variables. Comparison of sex hormones levels between two groups was performed by multivariate analysis in the general linear model (GLM) with the adjustment of age. Correlations between sex hormones and LTL were analysed by partial correlation analysis to control confounding factors. The association of sex hormones with LTL was investigated using linear regression model, adjusted for age and variant status of telomerase. Subjects with rare coding variant of four telomerase‐related genes were assigned to ‘rare variant+’ group and those without mutations were in ‘rare variant−' group. This variant was included into the linear regression model as a dummy variant and its interaction with testosterone was also tested. The association of these SNP with T levels was determined using linear regression adjusted for age and case/control status. For all SNP analyses, the minor alleles were compared to the reference . Linkage disequilibrium (LD) was investigated using the 1000G Phase‐3 population data in Haploview. SNP would be considered to be in a strong LD if r2 was greater than 0.8.Statistical analysis was performed using SPSS software version 24.0 for Windows  and R statistical software . Two‐tailed P = 0.431).A total of 101 male IPF patients and 51 matched controls were included in the study. Characteristics of 152 participants are summarized in Table P < 0.001). The levels of DHEA and E2 appeared to be lower in the IPF group than in the control group, but they did not reach statistically significant difference (P > 0.05) . Six IPF patients had a rare deleterious variant in TERT, one IPF patient had a rare variant in PARN and four in RTEL1, while no one in the control group had a deleterious variant in those genes. In total, rare coding variants in TERT, TERC, PARN and RTEL1 were observed in 11 patients (10.9%) in the IPF group while none was found in the control group , while no significant association was found between other sex hormones and LTL . In addition, after the adjustment for age, positive correlation was found between testosterone and its precursor (DHEA) and its metabolite (DHT) . Then, the associations of T and DHT with LTL were further evaluated by stepwise linear regression, and only T was significantly associated with reciprocal transformation of LTL after adjusting for age and variant status in telomerase‐related genes (β = −5.757 × 10−6 (2 × 10−6), P = 0.001)  on LTL were reported in the previous studies,P = 0.661; Fig. P = 0.001), while no significant association was found in individuals with rare variants (P = 0.767)  Fig. . Next, a67) Fig. .AKR1C3, SNP rs12529 was strongly correlated with rs12387 in East Asian population (r2 = 0.959).A total of 13 SNP with MAF > 5% in the exon of genes involved in androgen biosynthesis and metabolism pathways were included for association analyses. In P‐FDR > 0.05).Table TERT, PARN, TERC or RTEL1) were reported.In this study consisting of 101 male IPF patients and 51 matched controls, significantly shorter LTL was observed in the IPF group in comparison to the matched healthy control group. However, only 10.9% of IPF patients showed rare protein‐altering variants in the exon of telomerase‐related genes, compared with none in the healthy controls. Shorter telomere in IPF patients was also confirmed in previous studies.et al.IPF patients are primarily elderly men. The level of sex hormones in IPF is almost unknown. To date, only one earlier study by Mendoza‐Milla et al.Next, we focused on the role of sex hormones. A previous study by Huang SRD5A2 rs2208532 was associated with higher level of T in prostate cancer patients,SRD5A2 (rs824811), HSD17B1 (rs12602084), HSD17B2 (rs1424151) and HSD17B3 (rs9409407) reduced T concentrations in men with prostate cancer.SRD5A2 rs9282858 significantly increased T level while the dominant allele of CYP19A1 rs17703883 was associated with decreased T concentration.SRD5A2 or CYP19A1 were significantly associated with T level in Caucasian men.Next, we explored the factors related to testosterone levels. Several previous studies evaluated the association of polymorphisms in genes involved in androgen biosynthesis and metabolism pathways with sex hormone levels in men.P‐value was corrected by FDR in terms of multiple tests, which was not achieved in most previous studies.We also present strengths and limitations to our study. This study was the first to evaluate the levels of sex hormones in male IPF patients and their relationship with LTL, as well as to explore associations between SNP in androgen metabolism genes and T levels. Blood samples were taken in the morning to minimize the effects of circadian variations on hormone levels. In addition, In conclusion, compared with matched controls, LTL, plasma level of T and DHT were significantly decreased in male IPF patients. Plasma T was associated with LTL independentl of age and rare protein‐altering variants in telomerase‐related genes. No genetic variations in the exons of androgen‐related pathway genes were associated with the T level. Our study suggests that lower level of T might play a role in the shorter LTL in male IPF patients apart from rare variants in telomerase‐related genes. Future research is needed to examine whether hormonal interventions might retard telomere loss in male IPF patients and whether such retardation is associated with clinically important outcomes.Conceptualization: C.F., H.H., Z.X. Data curation: C.F., H.H., Q.Z., N.W., X.J., M.F. Formal analysis: C.F., M.F. Project administration: Z.X. Methodology: C.F., H.H., J.G. Resources: H.H., Z.X. Visualization: Q.Z., N.W., X.J. Supervision: Z.X. Software: C.F. Writing—original draft: C.F. Writing—review and editing: C.F., H.H., Q.Z., N.W., X.J., J.G., M.F., Z.X.Figure S1. Reproducibility of average telomere length measurement by real‐time quantitative polymerase chain reaction.Click here for additional data file.Visual Abstract The role of testosterone in idiopathic pulmonary fibrosis.Click here for additional data file.


In the past few decades, coronaviruses have risen as a global threat to public health. Currently, the outbreak of coronavirus disease‐19 (COVID‐19) from Wuhan caused a worldwide panic. There are no specific antiviral therapies for COVID‐19. However, there are agents that were used during the severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS) epidemics. We could learn from SARS and MERS. Lopinavir (LPV) is an effective agent that inhibits the protease activity of coronavirus. In this review, we discuss the literature on the efficacy of LPV in vitro and in vivo, especially in patients with SARS and MERS, so that we might clarify the potential for the use of LPV in patients with COVID‐19. LPV is an effective agent inhibiting coronavirus in vitro and animal studies.The treatment of LPV improved outcomes of SARS and MERS patients.LPV may be a potential treatment option for COVID‐19. Severe acute respiratory syndrome coronavirus (SARS‐CoV) occurred in 2002, infecting 8422 people and causing 916 deaths during the epidemic.SARS‐CoV, MERS‐CoV, and COVID‐19 belong to the same genera of CoV and all are beta‐CoV. COVID‐19 shares 79.5% sequence identity with SARS‐CoV.Proteinase is a key enzyme in CoV polyprotein processing. In recent years, research on SARS‐CoV and MERS‐CoV protease inhibitors has been carried out in vitro and in vivo. Lopinavir (LPV) is a proteinase inhibitor. Both peak (9.6 µg/mL) and trough (5.5 µg/mL) serum concentrations of LPV inhibit SARS‐CoV.22.1An analysis of molecular dynamics simulations showed that the SARS‐CoV 3CLpro enzyme could be inhibited by the combination of lopinavir and ritonavir.50) of LPV for the plaque reduction assay is 6 µg/mL in the Vero cell line. The selectivity index (SI) of LPV is 8 to 32.However, studies have revealed that lopinavir has antiviral activity. The 50% effective inhibitory concentration , and a maximal protective effect (89% inhibition) was observed at a dose of 12 μM.50 in the initial cytopathic effect inhibition assay and was therefore not evaluated further.50 values generated for lopinavir and ritonavir were 11.6 and 24.9 μM with CC50 values > 50 μM, the SI for LPV and RTV was > 4.3 and > 2, respectively.In an in vitro study, LPV inhibited MERS‐CoV‐induced cytopathic effect (CPE) with an EC2.450 = 160 IU/mL) was indistinguishable from that of IFN‐β alone . This suggests that the observed in vitro antiviral activity of the LPV/r‐IFN‐β combination against MERS‐CoV is dominated by IFN‐β when LPV/r is used at clinically relevant concentrations.For the MERS‐CoV mouse model, prophylactic LPV/r combined with IFN‐β slightly reduced the viral loads.Chan et alThe in vitro and animal studies of SARS and MERS are summarized in Table 33.1In a preliminary report, there were no deaths at 30 days after the onset of symptoms among 34 patients treated with LPV/r (400 mg ritonavir and 100 mg lopinavir) in combination with ribavirin initially, compared to 10% mortality in 690 patients taking only ribavirin. Twenty‐one percent of 33 patients who received LPV/r as a rescue therapy died, whereas 42% of 77 patients who received ribavirin alone died.P < .05).A retrospective matched cohort study including 1052 SARS patients (75 treated patients and 977 control patients) showed that the addition of LPV/r as an initial treatment was associated with a reduced death rate (2.3%) and intubation rate (0%) compared with that in a matched cohort who received standard treatment  or death was significantly lower in the LPV/r combination treatment group 1/41, 2.4%) than the historical controls  on day 21..4% than 3.2A MERS patient who received LPV/r, ribavirin, and interferon had a resolution of viremia after 2 days of treatment.A retrospective study enrolled healthcare workers (HCWs) with high‐risk exposure to MERS‐CoV pre‐isolation pneumonia and revealed that an effective post‐exposure prophylaxis (PEP) strategy including LPV/r may limit the spread of infection.3.3P = .79). The efficacy of LPV/r antiviral treatment warrants further verification in future studies. Nine randomized controlled trials of LPV/r in patients with COVID‐19 have been registered in China up to February 22 (Table There are no reported in vitro studies of COVID‐19. Four patients with COVID‐19 were given antiviral treatment including LPV/r. After treatment, three patients showed significant improvement in pneumonia‐associated symptoms, two of whom were confirmed to be COVID‐19 negative and discharged, and one of whom was negative for the virus at the first test.22 Table . Current450 of LPV is acceptable. Furthermore, two retrospective matched cohort studies of SARS patients revealed that LPV/r plays an essential role in the clinical outcome, especially in the early stage. LPV/r‐treatment alone or in combination with interferon had improved clinical outcomes in experiments involving common marmosets and in some MERS patient. However, we need to wait for more clinically valid evidence to confirm the positive value of LPV for COVID‐19 treatment.Currently, there are no FDA‐approved treatments for any human CoV infection. Upon the emergence of SARS‐CoV and MERS‐CoV, patients were administered off‐label antivirals. Most in vitro studies have shown that SARS‐CoV could be inhibited by LPV and that the ECAlthough most of the data indicate the efficacy of LPV, adverse reactions should be kept in mind. Diarrhea, nausea, and asthenia are the most frequently reported reactions in patients receiving LPV therapy.The protease inhibitor LPV could be an effective treatment based on the experience accumulated from the SARS and MERS outbreaks. The treatment of CoV patients with LPV/r improved their outcomes. LPV/r may be a potential treatment option for COVID‐19. Additional studies are needed to gain further insights into the origin, tropism, and pathogenesis of COVID‐19.The authors declare that there are no conflict of interests.TTY and JDQ wrote the article, include the concept of this article, definition of intellectual content, and data acquisition; WYZ contributed for data acquisition; YW and GQW designed and reviewed the manuscript for its intellectual content.


Nocardia genus is rare and usually found in immunocompromised patients. The most common subtype implicated is Nocardia farcinica while brain abscess due to Nocardia brasiliensis is comparatively rare. Diagnosis of brain abscess is based mainly on bacteriological culture from pus collected at the site of infection, and brain imaging. Stereotaxic aspiration or surgical resection combined with adequate duration of treatment with antibiotics to which the bacteria are sensitive represent effective treatment strategies.Brain abscess due to the Nocardia brasiliensis in a non-immunocompromised patient. He admitted to our hospital twice with a headache. Stereotaxic aspiration was performed at the patient’s first appointment at the hospital, and a craniotomy was used to excise the lesion during subsequent abscess recurrence.We report a rare case of brain abscess caused by Early diagnosis, reasonable surgical intervention, and adequate duration of treatment with effective antibiotics are critical for treating brain abscess. Brain abscess caused by infectious disease is a common and severe intracranial condition. In previous decades, it was associated with high incidence, disability, and mortality rates , owing tNocardia species are aerobic, gram-positive, branching, and filamentous bacteria, and can be introduced into a host through inhalation. Nocardia infections comprise only 2% of all intracranial abscesses [Nocardia farcinica species are responsible for more than 80% of nocardial brain abscesses, and brain abscess caused by Nocardia brasiliensis species is rarely reported. Here, we report a brain abscess caused by N.brasiliensis infection in a patient without known risk factors. The publication of this case report obtained written informed consent from the patient.Nocardial brain abscess is rare and typically found in immunocompromised patients . Nocardibscesses , but the9/L, 7.5% lymphocytes, 88.3% neutrophils and a C-reactive protein level of 1.1 mg/L. Head magnetic resonance imaging (MRI) showed a sharply defined lesion (3.1 cm × 2.4 cm × 2.9 cm) in the right temporal lobe with long T1-weighted and T2-weighted signals shadows and a circular equisignal  and did not report any foci of infection, sinusitis, or head trauma. The patient was hospitalized with severe headache as an inpatient in our department. Physical examination showed that the patient was conscious with a Glasgow Coma Scale score of 15, had sensitivity to light reflex, and a soft neck. He reported no vomiting or blurred vision. The patient reported muscle weakness in the left lower limb (4/5). His body temperature was 36.7 °C. His complete blood count indicated a white blood cell count of 11.4 × 10nal Fig. .Fig. 1HN. brasiliensis by 16S ribosomal RNA (rRNA) sequencing after 3 days cultured. 16S rRNA gene sequencing revealed 99% homology with that of strain N. brasiliensis at the GenBank database. A drug sensitivity test (E-test method) showed that the bacterium was sensitive to amikacin, ceftriaxone, trimethoprim, gentamycin, doxycycline, linezolid, piperacillin–tazobactum, meropenem. The patient was then treated with amikacin (2 g i.v. every 12 h) and ceftriaxone (2 g i.v. every 12 h). After 10 days, the patient’s temperature returned to normal and his headache completely disappeared. The complete blood count results were also normal. The head MRI showed that the space-occupying lesion in the right temporal lobe had disappeared  was left untreated. The patient’s headache was alleviated, but he had a low-grade fever that fluctuated around 37.3 °C after the operation. The patient was initially treated with meropenem (1 g intravenous (i.v.) every 8 h) according to standard practice. Pus culture showed Gram positive, partially acid-fast, and strictly aerobic filamentous bacilli and was further identified as 9/L, 10.5% lymphocytes, 83.5% neutrophils, and a C-reactive protein level of 0.5 mg/L. Head MRI showed multiple irregular lesions (the maximum lesion measured 2.1 cm × 1.4 cm × 0.8 cm) in the right temporal lobe and occipital lobe with slightly long T1-weighted and T2-weighted signals shadows  and ceftriaxone (2 g i.v. every 12 h). After seven days, his temperature returned to normal and the headache completely disappeared. The complete blood count results were also normal. The head MRI showed that the space-occupying lesions in the right temporal lobe and occipital lobe had disappeared  was not visible. The patient’s headache was alleviated; however, he again had a low-grade fever that fluctuated around 37.5 °C after operation. The patient was treated with amikacin (2 g i.v. every 12 h) and ceftriaxone (2 g i.v. every 12 h) according to his previous postoperative therapy. Pus culture results again indicated the presence of red Fig.  and the red Fig. c, d. Thered Fig. . PhysicaNocardia affects the lungs more frequently than the central nervous system [N. brasiliensis is rare compared with that due to other species, which generally results from direct traumatic inoculation into the skin and hematogenous spread from the primary location to the central nervous system where a brain abscess is formed. However, rare cases of meningitis or spinal abscess caused by N. brasiliensis have also been reported [s system ; infectis system , 6, 7. Ireported .Nocardia is typically gradual, with symptoms presenting over months or even years. Imaging evidence contributes to identifying brain abscesses in the cases of tumors and cystic or necrotic foci. The abscess usually develops a vascularized wall composed of astrocytes and glia that can be identified by CT scan or MRI as a ring enhancement depending on the capsular phase [The clinical course of brain abscess caused by ar phase . During ar phase , 11. TheIn the capsule stage, brain abscesses are similar to gliomas and cystic or necrotic foci on imaging modalities and require further tests for differential diagnosis. MRS is a useful method for distinguishing between brain abscess, gliomas, and cystic or necrotic foci  . The ceN. brasiliensis infection that was sensitive to amikacin and ceftriaxone. We continued to administer amikacin and ceftriaxone treatment for10 days after surgery the patient was discharged. Standard medical treatment for Nocardia brain abscess is trimethoprim/sulfamethoxazole; accordingly, we prescribed oral trimethoprim to the patient for three months. However, three months after discharge, the abscess recurred and the patient returned to the hospital.Brain abscess diagnosis is mainly based on bacteriological cultures from pus . In our Nocardia infection [Surgical treatment options for brain abscess include craniotomy excision and puncture aspiration. Craniotomy for excision of the entire abscess and capsule is more effective than aspiration. During our patient’s first admission to the hospital, we performed puncture aspiration surgery to treat the abscess, but the capsule wall was left. Retention of the capsule is an important factor in recurrence, when we performed a craniotomy to fully clear both the abscess and capsule at the patient’s second admission to the hospital, there was no further recurrence at one year of follow up. We found that the abscess capsule was located near the original lesion and there were multiple additional lesions. Multiple abscesses are found in 38% of patients with brain abscess due to nfection . In our nfection . In the nfection . After hN. brasiliensis in non-immunocompromised individuals is rare. In the present case, craniotomy for abscess excision was a more effective surgical method than aspiration. Complete excision of the abscess capsule was an efficient precaution against recurrence. It is necessary to choose antibiotics according to drug sensitivity tests results, and to ensure adequate duration of intravenous treatment for 4–6 weeks and until postoperative body temperature has remained within a normal rang level for 10–14 days. It is also essential for the patient to continue to take oral antibiotics (trimethoprim/sulfamethoxazole) for at least 3 months after discharge.In conclusion, brain abscess caused by


Metabolic syndrome (MetS) is common in China, which has a multi-ethnic population of 1·3 billion. We set out to determine the prevalence of MetS and its components in different ethnic groups.This nationwide cross-sectional survey involved 24,796 participants from eight ethnicities in six provinces in China from 2008 to 2011. MetS was defined using the modified National Cholesterol Education Program Adult Treatment Panel III criteria. Results were analysed using SPSS version 22·0 in 2018. Logistic regression was used for deriving odds ratios and 95% confidence intervals of risk factors for the MetS.The prevalence of MetS increased with age from 3·60% to 21·68%. After age standardization, the prevalence of MetS, in descending order, was 35·42% (Korean), 22·82% (Hui), 19·80% (Han), 13·72% (Miao), 12·90% (Tujia), 12·04% (Li), 11·61% (Mongolian), 6·17% (Tibetan). Korean ethnicity was associated with a higher prevalence in five components of MetS, while Tibetan ethnicity was associated with lower prevalence except decreased HDL cholesterol. Logistic regression analyses showed that age, drinking and being non-Tibetan were associated with a higher risk of MetS.Within one country, albeit a large one, the prevalence of MetS can vary greatly. Chinese of Korean ethnicity had a much higher prevalence than Tibetan ethnicity. Measures to tackle MetS should be tailored to the ethnic groups within a population. Metabolic Syndrome (MetS) is a cluster of related abnormalities that include abdominal obesity, insulin resistance, dyslipidaemia and elevated blood pressure , 2. The While the natural history of MetS and how it develops have been well described in Hong Kong Chinese, a large number of observational studies have also been conducted in China, the population of which is mostly of Han ethnicity , 10. A mBuilding on the Expansion Investigation of Human Physiology Constant Study in China , we madeThe Expansion Investigation of Human Physiology Constant was a nationwide cross-sectional, random and multistage clustering sampled survey in China that is part of the National Constitution and Health Database in 2008–2011 . Our preParticipants aged 8–86 years were recruited from six provinces  using a random, multistage cluster-sampling method as shown in Fig. Participants were required to complete a demographic questionnaire and a health behaviour questionnaire, which included smoking, alcohol consumption and physical activity. Trained personnel assisted the participants in completing the questionnaires.All participants were asked to avoid smoking and heavy physical activity for at least 2 h before the physical examinations, which included resting blood pressure, height, weight, and waist circumference (WC). Two blood pressure measurements were taken using OMRON HEM-7000 electronic sphygmomanometer  after the participants had rested in a sitting position for at least 5 min.Participants were required to fast for 8 to 12 h before blood sampling. Fasting blood glucose (GLU), total cholesterol, triglycerides, high-density lipoprotein cholesterol (HDL cholesterol), and low-density lipoprotein cholesterol (LDL cholesterol) were analysed using a Hitachi 7020 chemistry analyser . Body mass index (BMI) was a person’s weight in kilograms divided by the square of height in meters.< 1·03 mmol/L in men and < 1·29 mmol/L in women; (iv) systolic blood pressure (SBP) ≥130 mmHg or diastolic blood pressure (DBP) ≥ 85 mmHg; (v) GLU ≥5·6 mmol/L as impaired fasting glucose (IFG).The modified ATP III criteria were applied in the diagnosis of MetS, which requires the presence of at least three out of five factors : (i) AbdP < 0·05 and removed if P > 0·10. Exercise was added as a covariate in the second adjusted model and ethnicities, drinking status, smoking status were applied in the third adjusted model. Odds ratios (ORs) and 95% confidential interval (95% CI) were estimated. A two-tailed P < 0·05 was considered statistically significant. Data from the Sixth National Population Census of the People’s Republic of China provided by the National Statistics Bureau of China were used as the standard population. Age-specific prevalence and age-standardized prevalence were estimated from the standard population.Results were analysed using SPSS version 22·0  in 2018. Descriptive statistics were expressed as frequency (percentage) for categorical data or mean ± SD or median (interquartile range) for continuous variables. Missing data were less than 3% for all included variables. Continuous variables were compared among groups using one-way ANOVA and Kruskal-Wallis tests as appropriate. Categorical variables were compared among groups using Chi-square test. Logistic regression was used to identify the predictors for MetS. Gender, age, ethnicities, exercises, smoking status, drinking status were included in the model. Age groups and gender were entered into the first adjusted model. Other predictor variables were entered stepwise if P < 0·001).A total of 24,796 participants were enrolled in this study Fig. , 2 and 3P = 0·28). The prevalence of MetS was substantially higher above age 25 (24·7%) compared with age ≤ 25 (2·3%) (P < 0·001). There was a significant difference in MetS prevalence among ethnic groups (P < 0·001). Korean Chinese had the highest prevalence of 35·42, followed by Hui, Han, Miao, Tujia, Li, Mongolian and Tibetan . Compared to females, males had an increased risk of MetS . However, maleness  and smoking  were not significant factors for MetS after multivariable adjustment. Compared to participants aged 8 to 12 years, the OR increased with age, and was highest in participants aged 60 to 86 years . Relative to Tibetans, all other ethnicities were associated with increased risk of MetS. Korean Chinese had the highest adjusted risk for MetS , followed by Hui , Han , Li , Miao , Mongolian  and Tujia  ethnicities. MetS was not significantly associated with exercise in both crude and adjusted models .Predictors for MetS are summarized in Table This study is the first large-scale multi-ethnic investigation of the prevalence of MetS in China. With 24,796 participants, it had sufficient power to estimate and compare prevalence in subgroups. Such comparisons are also valid and reliable because we had standardised protocols, rigorous quality control and a central clinical laboratory for measurements. The large sample size, standardised measurements and the quality control allowed us to have accurate estimates of the prevalence of MetS in the general population in China. It is a strength of the study to recruit from the age of 8 to 86, which is an uncommonly wide range for an epidemiological study. The study did not recruit subjects below the age of 8 or above the age of 86 for practical reasons.The prevalence of MetS in Hans in the present study was higher than a previous national study in China , but lowThe prevalence of MetS in Korean, Hui and Mongolian Chinese in our study is relatively higher than previous studies’ in these ethnicities –26. A stThis study revealed that the prevalence of the components of MetS varied greatly in different ethnicities. These differences may be due to genetic factors and environmental factors, which include diet and lifestyle. A randomized dietary and behavioural interventional study showed that a Tibetan diet reduced body weight and BMI in patients with CAD and MetS . This miThe association of gender with MetS is controversial –32. In tThere were some limitations in this study. China is a large country, so 24,796 participants represent only a small fraction of the total population. We were unable to study minorities in very remote parts of China. Different ethnic groups have different religious beliefs and customs, and these may account for some of the differences.In this large multi-ethnic population-based survey, the age-standardized prevalence of MetS varied greatly in different ethnic groups, ranging from 6·18% to 35·43%. Korean ethnicity was associated with a higher prevalence of MetS and its components, while Tibetan ethnicity was associated with a lower prevalence of MetS and its components except decreased HDL cholesterol.Additional file 1: Table S1. Characteristics of included participants stratified by ethnic groups. Table S2. Characteristics of included participants stratified by provinces. Table S3. Region, ethnicity and gender specific characteristics of participants stratified by provinces.


The aim of this study is to evaluate the relationship between chronic endometritis (CE) and a personalized window of implantation (WOI), identified by results of endometrial receptivity analysis (ERA), and pregnancy outcomes following embryo transfer (ET) based on the ERA outcomes.The single‐center, cross‐sectional study was designed. The study population consisted of 101 infertile women who underwent endometrial sampling between June 2018 and February 2020. We recruited 88 patients who underwent ERA testing and immunohistochemistry of the plasma cell marker CD138 to diagnose CE within 3 months of testing. Subjects were divided into three groups as follows: 33 without CE (non‐CE group); 19 with untreated CE at ERA testing (CE group); and 36 successfully treated for CE before ERA testing (cured‐CE group). CE diagnosis was defined as ≥5 CD138‐positive plasma cells per 10 random stromal areas at ×400 magnification.p < .001). The rates of “receptive” endometrium in non‐CE and cured‐CE groups were 57.6% (19 women) and 50.0% (18 women), respectively; however, in the CE group, this rate was significantly lower than the other two groups (p = .009) at only 15.8% (3 women). After CE were treated prior or posterior to the ERA test in cured‐CE or CE groups, the clinical pregnancy rates at the first ET in non‐CE, CE, and cured‐CE groups were 77.8% (21/27 cycles), 22.2% (4/18 cycles), and 51.7% (15/29 cycles), respectively (p < 0.001).In non‐CE, CE, and cured‐CE groups, the numbers of CD138‐positive cells were 0.7 ± 1.0, 28.5 ± 30.4, and 1.3 ± 1.3, respectively  at only 15.8% (3 women). CE had detrimental effects on the ERA results.To confirm an impact of chronic endometritis (CE) on the results of endometrial receptivity analysis (ERA) testing, subjects were divided into three groups as follows: 33 without CE (non‐CE group); 19 with untreated CE at ERA testing (CE group); and 36 successfully treated for CE before ERA testing (cured‐CE group). The rates of “receptive” endometrium in non‐CE and cured‐CE groups were 57.6% (19 women) and 50.0% (18 women), respectively; however, in the CE group, this rate was significantly lower than the other two groups ( As for pregnancy outcomes, ET was performed after CE were treated prior or posterior to the ERA test in the cured‐CE or CE group. We focused on 74 women, including 27, 18, and 29 women in the non‐CE, CE, and cured‐CE groups, respectively, who underwent ET at least once in our clinic, of whom 63 underwent two or more ETs or conceived at the first ET to derive the cumulative ongoing pregnancy rate. The study protocol was approved by the Ethics Committee of Sugiyama Clinic, Tokyo, Japan (No.18‐004).This was a single‐center, cross‐sectional study. All endometrial biopsies for immunohistochemistry (IHC) of CD138 and the ERA test were performed in the Sugiyama Clinic Shinjuku in Tokyo, Japan, between June 2018 and February 2020  at the day of ovulation or later, within 3 months before or after ERA. The tissue samples were divided into two; one was fixed in 10% formaldehyde for immunostaining using anti‐CD138 antibody  and the other was kept in the tube for intrauterine bacterial culture with drug sensitivity. Both samples were sent to BML, Inc. The pathologists counted CD138‐positive plasma cells in 10 nonoverlapping random stromal areas visualized at 400‐fold magnification (BML), from which we diagnosed CE as the presence of ≥5 CD138‐positive cells.For the ERA test, the preparation of the endometrium was accomplished via a hormone replacement cycle. From Day 3 of the menstrual cycle, a transdermal estradiol patch  and conjugated estrogen tablets  were administered. At Day 13, ≥7 mm of endometrial thickness was confirmed, and the patients were started on 30 mg dydrogesterone tablets  three times daily and 90 mg vaginal progesterone gel  once daily from day 14 for 5 days. Endometrial tissue was biopsied using Pipet Curet 5 days after initiation of progesterone administration (P + 5). The biopsied endometrial tissue was placed in a cryotube, shaken a few times, and stored at 4°C for 4 h or more according to the manufacturer's protocol. It was then transferred at room temperature to Igenomix Japan, where the ERA analysis was performed. The expression of the endometrial receptivity‐associated genes was analyzed using a customized microarray, as described previously.2.3Lactobacillus spp. or Bifidobacterium spp., we selected appropriate antibiotics according to the results of drug sensitivity and administered bacterium‐sensitive antibiotics for 2 weeks as the second‐line. When a specific bacterium could not be determined, a combination of amoxicillin , azithromycin , metronidazole , and antibiotic‐resistant lactic acid bacteria , were administered twice a day for 2 weeks. If CD138‐positive plasma cells had not disappeared after 2–3 cycles of antibiotic therapy and specific bacteria were not detected, uterine endometrium was shed artificially by dilatation and curettage (D&C).The treatment protocol for CE was administration of oral doxycycline , 100 mg twice a day for 2 weeks as the first‐line according to previous reports.2.4Procedures for ovarian stimulation, oocyte retrieval, and IVF‐ET were described previously.2.5p < .05.Statistical analysis was performed using the GraphPad Prism 5 (GraphPad Software Inc.). Differences among continuous variables of three groups were analyzed using the Kruskal–Wallis test or Fischer's exact test, as appropriate. The level of significance was defined as a 33.1p < .001). The ERA results revealed proportions of endometria rated as receptive to non‐receptive in the non‐CE and cured‐CE groups to be 57.6% (19/33 women) and 50.0% (18/36 women), respectively; however, in the CE group, only 15.8% (3/19 women) were receptive (p < .001 compared with the other two groups). Although most of the patients with CE had non‐receptive endometria, the rates of receptive endometria in the non‐CE and cured‐CE groups were essentially the same. This result suggests that appropriate treatment of CE may allow recovery from an impaired WOI.The characteristics of the patients are summarized in Table 3.2Two patients out of three in the CE group who underwent the ERA twice (once before and once after CE treatment) showed ERA‐receptive endometria after antibiotic therapy. One of these cases is described below and the treatment timeline is depicted in Figure S1.Candida glabrata on intrauterine bacterial culture. As a precaution, fluconazole  100 mg once daily for 2 weeks was administered. The patient underwent two ET cycles using two morphologically good blastocysts at 90 h after starting progesterone in a hormonal replacement cycle; however, serum hCG levels were not detected at 9 days after ET. Considering the improved intrauterine environment and endometrial function following treatment for CE, we conducted a fourth biopsy for the ERA. It demonstrated an optimal WOI, with receptive endometria and 126 ± 3 h as the recommended timing for ET. Finally, ET using blastocyst (Grade 5AB) at 126 h after starting progesterone resulted in successful pregnancy.Case: The patient was a 42‐year‐old woman with a history of RIF after four ET cycles in a previous hospital who underwent endometrial biopsy for the ERA test IHC of CD138, and intrauterine bacterial culture to test for RIF at our hospital. The first biopsy showed post‐receptive endometria with 90 ± 3 h as the recommended timing of ET, 98 CD138‐positive cells in 10 nonoverlapping random stromal areas, and no specific bacteria by intrauterine bacterial culture. The patient was diagnosed with CE and administered doxycycline, 100 mg twice daily for 2 weeks. The second biopsy, which was obtained one week later after antibiotic therapy, showed 30 CD138‐positive cells and no specific detectable bacteria; thus, a combination of amoxicillin, azithromycin, metronidazole, and antibiotic‐resistant lactic acid bacteria, twice daily for 2 weeks, was further administered as our treatment protocol. At the third biopsy, CE was finally considered cured based on results of CD138‐positivity (1 cell) and identification of 3.3p < .001), and cumulative ongoing pregnancy rates of 85.2% (23/27 women), 30.8% (4/13 women), and 78.3% (18/23 women), respectively, in two ET cycles , 30.8% /13 women4prolactin) and insulin‐like growth factor binding protein‐1 in vitro compared with those from women without CE.Endometrial stromal cells from women with CE show impaired secretion and lower messenger RNA expression of the decidual markers prolactin (Human endometrium transiently acquires a specific phenotype for receiving a competent embryo at implantation.The ERA results and pregnancy outcomes in patients who were treated and recovered from CE were similar to those who had never been diagnosed with CE (the non‐CE group). A WOI that is impaired by CE may be reversible with appropriate therapies. Previous studies also showed that pregnancy and live birth rates in women after recovery from CE were significantly higher than those with active CE.This study has some limitations. The patients had undergone endometrial samplings for the ERA test and IHC for CD138 within 3 months, but they were not the same biopsy. Additionally, there are still no global standard diagnostic criteria for CE. Therefore, we defined ≥5 CD138‐positive cells per 10 nonoverlapping random stromal areas as CE; however, it should be noted that different diagnostic criteria may yield different results. With regard to pregnancy outcomes, some of the data for patients who did not undergo ET in our clinic were lost to follow‐up.In conclusion, CE modified the individual WOI, leading to embryo–endometrial asynchrony; therefore, it is not recommended to transfer embryos based on the WOI obtained by performing ERA in the presence of CE. Diagnosis and treatment of CE should be done before ERA testing. Prospective controlled trials are required to confirm the impact of CE on ERA results and pregnancy outcomes following personalized ET.The authors declare that there are no conflict of interests.Conceptualization, formal analysis, investigation, methodology, resources, supervision, visualization, and writing: Keiji Kuroda. Collecting resources and discussion: all authors. Project administration: Rikikazu Sugiyama.Supporting information.Click here for additional data file.Supporting information.Click here for additional data file.


Intellectual functioning is a critical determinant of economic and personal productivity. Identifying early neural predictors of cognitive function in infancy will allow us to map the neurodevelopmental pathways that underpin individual differences in intellect. Here, in three different cohorts we investigate the association between a putative neurophysiological indicator of information encoding  in infancy and later general cognitive outcome. In a discovery cohort of 12-month-old typically developing infants, we recorded EEG during presentation of dynamic movies of people and objects. Frontal theta power (3–6 Hz) significantly increased during the course of viewing each video. Critically, increase in frontal theta during viewing of a video was associated with a differential response to repetition of that specific video, confirming relation to learning. Further, individual differences in the magnitude of change in frontal theta power were related to concurrent nonverbal cognitive level. We then sought to extend this association in two independent samples enriched for variation in cognitive outcome due to the inclusion of infants at familial risk for autism. We observed similar patterns of theta EEG change at 12 months, and found a predictive relation to verbal and nonverbal cognitive skills measured at 2, 3 and 7 years of age. For the subset of high-risk infants later diagnosed with autism, infant theta EEG explained over 80% of the variance in nonverbal skills at age 3 years. We suggest that EEG theta change in infancy is an excellent candidate predictive biomarker that could yield substantial insight into the mechanisms that underlie individual differences in childhood intelligence, particularly in high risk populations. Cognitive delays are commonly associated with most developmental risk factors, including premature birth10, low birth weight11, under-nutrition12, toxin exposure13, and genetic conditions14. Identifying the brain mechanisms that underpin individual differences in information encoding in infancy could lead to substantial theoretical insights into developmental origins of core cognitive skills, and improve our ability to rapidly identify children at heightened risk for poor cognitive development.By school start, most children have an extensive vocabulary, recognise colours and shapes, and can remember and match pictures and objects. Such abilities are acquired through interaction between the child and his or her environment. Individual differences in childhood cognitive function predict longer term outcomes (e.g.16). Measures such as habituation or attention to novelty show moderate correlations (of around 0.4) with later cognitive function19 that are partially mediated through processing speed and memory skills21. However, such associations are restricted to early infancy and may only be useful in a relatively brief developmental window19. Further, the degree of variance captured by early looking time measures is relatively small . Progress requires looking beyond behaviour to the new availability of infant-friendly methods to directly measure brain activity. Electroencephalography (EEG) provides a non-invasive method that measures the oscillatory states involved in memory and learning. EEG is sensitive to the dynamics of neural processing, and thus the effects of information encoding on brain systems. Advances in EEG technology allow brain activity to be recorded during natural behaviour, raising the possibility of real-time access to the brain rhythms underpinning information encoding.In the late twentieth century, the search for infant predictors of later cognitive functioning focused on looking time  is also modulated by theta power32. Selective33 and spatial attention34 have also been linked to theta oscillations and their relation to gamma activity. Further, in infancy, frontal theta power measured during object manipulation correlates with subsequent recognition of that object35. Infants show increases in theta power during events likely to be associated with learning or memory, including anticipation of a face reappearing during peekaboo36, during active exploration of new toys or people37, when expectations are violated38, and while infants are waiting to retrieve a hidden object39. Taken together, this literature provides preliminary evidence that changes in theta power  are associated with information encoding in infancy, but to date there are no reports that individual differences in these responses are related to later cognitive outcome.In the present study, we focused on a theoretically motivated analysis of dynamic changes in theta power elicited by ecologically valid stimuli. A substantial body of evidence links increases in theta power to processes important in information encoding , particularly in the low-theta range . In a subset of these infants, we then tested whether changes in theta power relate to concurrent cognitive skills. Cohorts 2 and 3 were independent studies of 12-month-old infants at low and high familial risk for autism followed longitudinally. In these cohorts, we examine whether dynamic modulation of frontal theta power predicts later intelligence at 2, 3 and 7 years in a population at heightened risk for cognitive delay. For all cohorts, parents provided informed consent for study participation. All data is available from the authors on request.In the present study, we test whether dynamic modulation of theta power in response to ecologically valid stimuli is related to individual differences in general intelligence later in development in populations enriched for varied cognitive outcome. We introduce a method of measuring theta modulation suitable for application in naturalistic contexts that simulate a child’s natural learning environment. We focus on 41. Each video set was repeated twice, separated by around 10 min of other stimuli (static faces and toys). Within this dataset, we first established that our stimuli produce increases in frontal theta over time; that this change predicts specific responses to that video on repetition (consistent with learning and memory); and asked whether individual differences in frontal theta response are associated with concurrent measures of cognitive skill.Cohort 1 was a cross-sectional study of typically developing 12-month-old infants. From a larger dataset, we focused on EEG data recorded while infants watched dynamic videos of women talking and toys moving41, but we did not examine dynamic change within a video. The study was ethically reviewed and approved by the University of Washington Institutional Review Board and conducted in accordance with all relevant guidelines and regulations; all parents provided informed consent.Participants were 106 12-month-old  typically developing full-term infants (see SI1.1 for inclusion/exclusion). Infants were only included if they had sufficient artifact-free data for each analysis (see SI1.2 for details). Parents and their infants were recruited using a University Infant Participant Pool. Table SI1 shows demographic and descriptive data for the full sample. Of note, we have previously reported overall condition and region effects on EEG-theta in these infants42, EEG data were segmented into continuous 1-s segments with no overlap and epochs of visual attention to the screen selected; artifacts  were identified; bad channels were interpolated (Netstation 4.1); and the remaining data was re-referenced to the average. We then extracted natural-logged power in the theta (3–6 Hz) frequency band using fast-fourier transform. Of note, definitions of frontal theta in infancy vary between studies within the range of a lower bound of 2–3 and an upper bound of 5–6; we selected 3–6 Hz because it represents the modal definition of theta in previous work43. Our primary index was percent change in theta power between the first and second halves of the first presentation of each video , because the second repetition would be contaminated by familiarity. When examining associations with cognitive skill, we addressed the question of specificity by additionally examining %change in posterior theta power , %change in scalp high alpha power (band specificity) and %change in the proportion of clean attended segments, a proxy for a behavioral measure of focused attention44 that provides an indication of whether similar effects could be obtained from measuring behavior alone. EEG was recorded in a shielded room from 128-channel Geodesic sensor nets; recorded online with reference to the vertex; digitization at 500 Hz; amplification at 1,000 × and band-pass filtering at 0.1 to 100 Hz. Children were presented with two movie sets of 1-min duration repeated twice during the session; order of presentation was counterbalanced. Movies were (a) Social: 4 nursery rhymes with gestures told by two women; (b) Non-Social: 5 vignettes of child-appropriate dynamic toys . Following gold-standard procedures described fully in SI1.2.145 is a cognitive assessment for infants from birth to 5 years. The measure was administered by a trained experimenter (EJ) for approximately half the sample. Scores fall into five scales measuring fine motor and visual reception skills , receptive and expressive language skills  and gross motor skills. Raw scores were converted into t scores using age-appropriate norms. Of note, all statistical tests are two-tailed.The Mullen Scales of Early Learningwww.basisnetwork.org.uk).Data and Matlab code will be made available on request to the corresponding author, subject to conformance with the ethical approvals with which it was collected. This process is managed through the BASIS network policies and procedures  = 11.14, p = 0.002, η2 = 0.24), and region  = 7.05, p = 0.012, η2 = 0.17); and confirmed that theta power increased between the first and second halves of the video  = 7.02, p = 0.012, η2 = 0.17). The magnitude of the half effect did not interact with condition or region (ps > 0.3). Thus, for subsequent analyses we collapsed across condition and region to maximise the sample size. This allowed us to include additional infants who had sufficient data in only one of the two conditions.We first established that our semi-naturalistic videos produced an increase in frontal theta between the first and second halves of the first presentation of each video  = 10.87, p = 0.002). We then computed Pearson correlations between change in frontal theta and verbal and nonverbal cognitive level. Greater frontal theta change was related to higher nonverbal cognitive level (r(34) = 0.39, p = 0.022; Fig. r(34) = 0.27, p = 0.12; Fig. t(33) = 0.93, p = 0.36) and was not associated with nonverbal cognitive level (r(34) = − 0.06, p = 0.63) or % frontal theta change (r(34) = 0.089, p = 0.62) indicating similar effects could not be observed purely from related behavioral measures.To establish whether frontal theta power relates to cognitive skills, we used a subset of the infants n = 34, 18 female) who had theta data and the verbal and nonverbal subdomains of the Mullen Scales of Early Learning . In this subsample, frontal theta also increased during the video presentation  = − 0.22, p = 0.22; verbal r(34) = − 0.21, p = 0.23). Of note the trends were negative, in line with the proposed inverse relation between theta and alpha power, and between alpha suppression and increased semantic encoding47. Given this sign difference, the correlations between theta and alpha power and cognitive skills were significantly different . Further, to establish that our results were specific to frontal scalp regions, we examined relations between cognitive skills and change in theta power over posterior cortex. This revealed no significant association  = 0.16, p = 0.38; verbal r(34) = 0.20, p = 0.27).To test specificity to the theta band, we computed power in the upper alpha band . There were no significant relations between frontal alpha change and cognitive skills at 12 months  = 0.40, p = 0.007; Fig. r(32) = − 0.08, p = 0.65; Fig. r(38) = 0.56, p < 0.001; Fig. r(30) = 0.12, p = 0.52; Fig. To establish whether change in frontal theta power during the first presentation of a video reflects learning, we examined correlations with change in frontal theta power between the first and second presentations of that specific video in all infants with data available . A greater change in frontal theta during the first social video predicted a greater change in theta between the first and second repetitions of the social video . The study was ethically reviewed and approved by the University of Washington Institutional Review Board and conducted in accordance with all relevant guidelines and regulations; all parents provided informed consent. Cohort 3 was an independent sample of 54 high risk and 50 low risk infants with EEG recorded at 14 months and cognitive and developmental skills measured at 36 months and 7 years (see SI3.1 and 3.2). The study was ethically reviewed and approved by the London Central NHS Research Ethics Committee; all parents provided informed consent. All infants at high risk for autism had an older sibling with a community clinical diagnosis of ASD; all low risk infants had an older sibling with typical development. Cognitive assessments used the Mullen Scales of Early Learning. Assessment of autism outcome was made based on ADOS, ADI, and the clinical judgement of highly experienced clinical teams. For Cohort 2, the EEG paradigm was identical to Cohort 1. For Cohort 3, videos were remade to suit the UK context (SI3.2.2). Processing pipelines were substantially similar to Cohort 1, though since data were initially processed at a different Centre, minor details of the processing pipeline were different (SI3.2.2). Given the findings in Cohort 1, we collapsed across condition and region and simply tested the relation between change in frontal theta and later cognitive skills. We chose to use existing data for comparability to other reports49; if our effects are robust, they should generalise across common variability in EEG processing pipelines. Full details of both samples, children included in final analyses and associated methods can be found in the SI.Using data from two independent cohorts assessed with a comparable EEG protocol, we built on the findings from Cohort 1 to ask whether dynamic change in frontal theta power at 12 months could predict cognitive skills later in development in cohorts enriched for varied cognitive development. Specifically, we used data from cohorts of infants at high familial risk for ASD because they have an older sibling with a diagnosis; such infants are at risk for a range of outcomes including lower verbal and nonverbal skillr(14) = 0.55, p = 0.043; Fig. r(11) = 0.51, p = 0.08). This was also true for verbal skills (r(14) = 0.58, p = 0.029; Fig. r(11) = 0.69, p = 0.009); this was not confounded by data quantity (SI2.3). Infants later diagnosed with ASD are depicted in Fig. r(14) = 0.57, p = 0.034; verbal: r(14) = 0.70, p = 0.006) but not for scalp alpha power (r(14) = 0.28, p = 0.33; verbal: r(14) = 0.31, p = 0.28), indicating a degree of specificity to the frequency band but less specificity to the scalp region. Neither 24 m outcome associated with proportion change in clean attended segments, indicating that measures of behaviour alone are unlikely to capture the same effect  = − 0.21, p = 0.48; verbal: r(14) = − 0.18, p = 0.55).In Cohort 2, frontal theta change in n = 14 12-month-old high risk infants with EEG and cognitive data correlated with greater nonverbal skills at 24 months  = 14.18, p = 0.001, η2 = 0.34; Fig. F = 13.02, p = 0.001, η2 = 0.33). There was a significant interaction with group  = 5.46, p = 0.01, η2 = 0.28, controlling for 12-month nonverbal skills F = 4.97, p = 0.015, η2 = 0.28). Figure r(7) = 0.91, p = 0.005); this was not confounded by data quantity (SI3.3.1). Across the cohort, 36 m nonverbal cognitive skills did not associate with proportion change in posterior theta power  = 0.47, p = 0.50, η2 = 0.017), associated weakly with scalp alpha power  = 3.57, p = 0.069, η2 = 0.11), and did not associate with proportion change in clean attended segments  = 1.25, p = 0.27, η2 = 0.043), indicating a degree of specificity.In Cohort 3, we had sufficient power to examine whether the relation between infant theta and later cognition varied by risk or outcome status. We used an ANCOVA to examine the relation between percent change in frontal theta and nonverbal cognitive skills at 36 months by outcome group , the latest time-point with cognitive data available for the whole sample . Greater change in frontal theta related to higher nonverbal cognitive skills at 36 months across groups  = 2.84, p = 0.1, η2 = 0.09, controlling for 12-month nonverbal skills F = 2.32, p = 0.14, η2 = 0.08), but this varied by group  = 3.77, p = 0.036, η2 = 0.21; controlling for 12-month nonverbal skill F = 3.95, p = 0.032, η2 = 0.23). Relations were only significant within the ASD group (r(7) = 0.81, p = 0.029; Fig. F = 1.32, p = 0.26, η2 = 0.045), associated weakly with scalp alpha power  = 3.64, p = 0.067, η2 = 0.12), and did not associate with proportion change in clean attended segments  = 0.38, p = 0.54, η2 = 0.014), indicating a degree of specificity.Greater change in frontal theta also marginally related to higher verbal skills  = 5.27, p = 0.03, η2 = 0.2); this did not significantly vary by risk group  = 0.34, p = 0.57, η2 = 0.016 ; r values shown in Fig. F = 0.43, p = 0.52, η2 = 0.019), or scalp alpha power  = 0.65, p = 0.43, η2 = 0.029) and did not associate with proportion change in clean attended segments  = 1.16, p = 0.29, η2 = 0.052), indicating specificity.Children in Cohort 3 were also followed up at age 7 years (see SI4), at which point their IQ was measured using the Weschler Abbreviated Intelligence Scale (WASI). For children with sufficient data (n = 14 high risk and n = 11 low risk) we used an ANCOVA with risk group as a factor to test whether relations between infant frontal theta change and later WASI total score varied by risk status . There was a significant overall relation between 14-month frontal theta and 7-year IQ , suggestive of an encoding-related signal. Indeed, a wide body of literature indicates that 12-month-old infants can learn information similar to that presented in our semi-naturalistic videos (nursery rhymes with actions and object functions) through passive observation52, and indeed learn one to two novel behaviors a day through watching and imitating53. Thus, observations from the present study are consistent with the possibility that change in frontal theta during the first presentation of a novel video can index encoding-relevant processes.We interpret our results as consistent with a process that is the outcome of the coordinated functioning of learning, memory and attention systems. The semi-naturalistic design of the study means we cannot precisely elucidate the cognitive mechanisms that underlie the observed changes in frontal theta power. However, we believe that the frontal theta changes observed in response to the first novel video are most likely to closely track the encoding of information, rather than its retrieval. The videos used in the present study were novel to the infant, and the five individual vignettes that made up the videos were each different. Thus, the change in frontal theta between the first and second half of the video does not reflect recognition of repeated content. Interestingly, we have recently replicated the observation that change in frontal theta during an unfamiliar video predicts later cognitive ability in infancy in a pre-registered study that used a series of cartoon vignettes with which infants were highly unlikely to be previously familiar54. Indeed, increased cross-frequency coupling between frontal theta and parietal gamma oscillations has been linked to better subsequent memory in adults55; as has coherence between frontal and occipital theta oscillations56. While identification of neural generators is not feasible in our data set, frontal theta power during heart-rate defined epochs of sustained attention at 10- and 12- months has been sourced to generators in the orbital frontal, temporal pole, and ventral temporal areas57; stimuli presented during heart-rate defined epochs of sustained attention are subsequently better remembered58. Direct bidirectional connections between the medial prefrontal cortex and the hippocampus exist in both rodents and humans that facilitate encoding and retrieval of memories from contextual details59 and memory traces are formed in frontal cortex during an initial experience60. The dynamic changes in theta power observed in the present study may reflect the coordinated action of attention and memory systems in service of encoding the semi-naturalistic events presented. This may represent an important canalization process through which multiple individual cognitive challenges  could result in impoverished learning and thus compromise later outcomes. Further, the observed relation between change in theta power at 12 months and cognitive function at 2, 3 and 7 were present when concurrent cognitive ability was covaried. This is consistent with the possibility that modulation of theta power by naturalistic stimuli is a causal mechanism that leads to optimal learning and better later cognitive development. Identifying processes that may mediate the effects of a range of risk factors on cognitive development is critical to finding generalizable mechanisms to target for early intervention, an approach that could also provide a test of our causal hypothesis.Previous work also indicates an important role for frontal theta in learning/encoding. Frontal theta may guide learning in conditions of uncertainty, such as when stimuli are novel10; 30% of children who experience malnutrition12; and up to 50% of children with ASD, although these are less apparent in our familial risk sample61. However, we currently have a very poor ability to predict which infants will experience a poor prognosis. Predicting later trajectories would allow us to focus interventions more effectively. Further, we need outcome measures in infancy that can determine whether our interventions are affecting the cognitive systems that will shape long term outcomes. Current behavioural assessments of infant cognitive development are often affected by environmental opportunity62, and child willingness to engage with the testing process63. Behavioural cognitive assessments measure what a child has learned, and thus are very hard to make culturally ‘fair’. Moving from a focus on domain-general measures of the skills an infant has already learned towards measuring the brain systems that shape their capacity to learn over time will be a critical step for translational research.We propose that our findings on the dynamic modulation of EEG theta open up new avenues for the discovery of biomarkers that predict cognitive development from infancy. Our demonstration of promise at 12 months is valuable, because this is a common age for developmental screening in many countries . This goal is critically important. Significant cognitive delays are seen in up to 40% of children born extremely prematurely50 that again uses a set of existing data initially pre-processed for another purpose confirms the robustness of our effects. Although we selected the modal definition of the theta band (3–6 Hz) used in previous studies43, optimisation may also include determining the precise frequency band in which modulation occurs through using paradigms designed to elicit longer segments of data that afford greater frequency resolution. Further, the specificity of the observed results to particular scalp regions or frequency bands is important to further probe. Although frontal theta was most consistently associated with cognitive skill, in some analyses additional relations were observed with alpha power or with posterior theta. The degree to which this may reflect spillover from the target frequency band or volume conduction should be examined in future work with protocols optimised for source analysis. However, it was notable that a highly comparable proxy measure for behavioral attention (percent change in the number of clean attended segments) was not associated with cognitive function in any analysis. This highlights the importance of more direct measures of brain function, although future work should examine whether the use of a greater number of video angles would allow the use of a more nuanced behavioural coding scheme that might be more sensitive than the proxy measure used here. Coupling measures of infant theta power with early predictors of ASD outcome64 would be important. Further, relations between infant theta power and cognitive skills were observed across three independent cohorts. Intriguingly, relations with the high-risk group and particularly children with autism were stronger than in the low risk group, in line with other evidence that the stability of IQ over time is higher in high risk populations9. Combining EEG theta with other measures that may be sensitive to categorical autism outcome64 may further improve predictive validity. Infants will vary on a series of dimensions, and developing a measure battery that is sensitive to the most important of those may ultimately tell us which infants are at relatively greater risk for a particular set of cognitive outcomes65.We propose that focusing on dynamic modulation of EEG theta could deliver substantial advances in our ability to identify children at risk for a poor cognitive prognosis. We need to optimise our protocols to enable measurement of EEG theta change in a larger proportion of infants tested. However, our data are highly promising—although the group size is small, infant theta power predicted 82% of the variance in verbal skills at age 3 years within children with ASD. Because we utilised data from existing studies, there were small differences in the pipelines between Cohorts (particularly 2 and 3). We view this as a strength of the study, in that similar results were obtained despite minor methodological differences. Indeed, our recent pre-registered replication of these effects66, and interventions that improve verbal IQ in children with ASD also strengthen theta responses to faces46. Our emerging understanding of the mechanisms shaping theta oscillations in the brain67, could also create the possibility for developing and testing medications for children at high risk.In our search for biomarkers, we should be looking for the mechanisms that shape learning from the environment in infancy; determine association with later functioning; and finally testing whether an intervention that targets the purported mechanism can improve later cognition. Indeed, in a recent study, we showed that indices of theta power during the same videos appeared to be altered by parent-mediated intervention in infants at familial risk for ASDWe show that dynamic modulation of frontal theta power in response to novel semi-naturalistic stimuli predicts cognitive skills at age 1, 2, 3 and 7 years in low and high-risk populations. Our work yields new insight into the neural substrates underlying increasing top-down control of learning and memory in infancy, and generates new directions for the stratification of cognitive outcomes in at-risk populations.Supplementary information