Foods eaten for breakfast were reported by the children each morning for 7 consecutive days, and defined according to the food categories in the Japanese Food Guide Spinning Top. Child mental health was assessed by caregivers using the Strength and Difficulties Questionnaire. The mean intake frequencies per week were six times for grain dishes, two times for milk products, and one time for fruits. Linear regression analysis revealed an inverse association between the frequent intake of grain dishes, whether rice or bread, and problem behaviors after adjustment for potential confounders. However, confectionaries, which mainly consisted of sweet breads or pastries, were not associated with problem behaviors. The intake of non-sweet grain dishes at breakfast may be effective for preventing behavioral problems in children.There is limited evidence that what children eat for breakfast contributes to their mental health. This study aimed to examine the associations between food categories for breakfast and mental health among children in Japan. A proportion of participants aged 9–10 years in the Adachi Child Health Impact of Living Difficulty (A-CHILD) study in Japan who consumed breakfast daily were included ( Mental disorders in children are a major cause of health-related burdens, with approximately one-fifth of children suffering from mental disorders ,2. In a Breakfast is one of the potential preventive factors for children’s mental health. Breakfast is generally defined as the first meal of the day and eaten within 2 h of waking up, typically no later than 10:00 a.m. . CompareMeals vary by culture and should be individually considered. Generally, breakfast has less variety and the same foods are eaten, while lunch and dinner have greater variety . WesternIn Japan, there is no clear definition of a high-quality breakfast. Japanese breakfasts are relatively complex and have more variety than western breakfasts . The JapTherefore, the aim of the present study was to investigate the types of food eaten for breakfast by children in Japan and to determine their relationships with mental health. There is consensus on the importance of eating breakfast; however, there is limited evidence that what children eat for breakfast contributes to their mental health. The goal of this study was to contribute to the improvement of children’s mental health by providing evidence about what to eat for breakfast to prevent problem behaviors in children.n = 34) or mental health status (n = 13). We included children whose breakfast data included all 7 days because our objective was to examine what food types children should be eating for breakfast among those who ate breakfast daily. The sample comprised 131 male and 150 female children. The A-CHILD protocol and use of the data for the present study were approved by the Ethics Committee at Tokyo Medical and Dental University .This study used data on dietary habits and health from the Adachi Child Health Impact of Living Difficulty (A-CHILD) project, which was initiated in 2015 to evaluate the determinants of health among children in Adachi, Tokyo, Japan . SpecifiBreakfast intake was assessed using a self-reported questionnaire in which the children were asked to fill in what food types they ate for breakfast over a 7-day period in a specified week. A registered dietitian coded each day’s breakfast menus as 0 or 1 for the inclusion or exclusion of six food categories according to the Japanese Food Guide Spinning Top, developed by the Ministry of Health, Labour and Welfare and the Ministry of Agriculture, Forestry and Fisheries of Japan to help people implement the Dietary Guidelines for Japanese . The sixWe evaluated the children’s difficult behaviors and prosocial behaviors as children’s mental health. The assessments of difficult behaviors and prosocial behaviors were conducted using the Japanese version of the Strength and Difficulties Questionnaire (SDQ) . The SDQChildren’s statuses were assessed by a self-reported questionnaire. We considered that physical activity, sleep habits, and household socioeconomic status can be associated with both the quality of breakfast and mental health through their epidemiological relevance. Physical activity was assessed by the frequency of undertaking physical activity outside of school for ≥30 min and categorized into three groups . Bedtime was categorized into three groups based on the children’s weekday habits . Household and caregiver statuses were assessed by caregiver-reported questionnaires . HousehoFirst, we performed a multivariate linear regression model to examine the associations between food categories for breakfast and mental health assessed as difficult behaviors and prosocial behaviors. Two models were constructed: Model 1 included individual food categories and was adjusted for potential confounders ; and Model 2 included further adjustment for all types of food categories  to examine the relationships independently of other food categories. Second, to conduct a detailed analysis of the grain dishes, a multivariate linear regression model was used to examine the associations between the types of grain dishes and mental health. For sensitivity analyses, the frequencies of rice and bread consumption were calculated separately and their associations with mental health were analyzed. The two models described above were used. A word cloud for the children’s breakfast menus was created on the User Local website . All anaThe characteristics of the participants are presented in The most frequently consumed food type at breakfast was grain dishes, at six times a week . The secThe word cloud for the breakfast menus reported by the children is shown in The associations between food categories for breakfast and mental health are shown in The results of the regression analyses for mental health according to the types of grain dishes are shown in To the best of our knowledge, this is the first study to examine the associations between food categories eaten for breakfast and mental health in Japanese children. Grain dishes were the main breakfast category for the children and these were consumed almost daily, with most of the children consuming rice or bread as cereals. Among the food categories at breakfast, grain dishes and fruits were associated with fewer problem behaviors. Rice and bread were both associated with a lower risk of problem behaviors.We found that rice and bread were the two major grain dishes eaten at breakfast by the children. This pattern is consistent with a study on the breakfast patterns in Japanese adults, which found four types of patterns, including two staple meal patterns, as follows: rice-based (rice/vegetable/pulse/seasoning), bread-based (bread/dairy/fruit/sugar), meat/egg/fat, and tea/coffee . AnotherThe present finding that the more frequent consumption of grain dishes, whether rice or bread, at breakfast was associated with fewer problem behaviors in children is plausible, because grain dishes are rich in carbohydrates that can be converted into glucose, which is primary fuel for the brain. The brain is sensitive to fluctuations in glucose supply, and the maintenance of adequate blood glucose concentrations between meals is thought to be beneficial for optimal cognition . A studyIn terms of glucose, many foods classified as confectionaries, such as chocolate bread, cream buns, donuts, and sugar toast, were also glucose-rich dishes. However, the consumption of confectionaries was not associated with problem behaviors in this study. One explanation may be the difference in glycemic load (GI). Compared with grain dishes high in polysaccharides, confectionaries are high in monosaccharides and have a higher GI. Lower GI values can minimize blood glucose fluctuations, and lower GI breakfasts were reported to be associated with better attention and less frustration in children compared with high-GI breakfasts . A recenThe frequent consumption of fruits at breakfast was also associated with fewer problem behaviors in children. This finding is in line with the results of several observational studies on children, although breakfast was not evaluated ,46. A stOur study has some limitations. First, the validity and reliability of the breakfast measurement method in children aged 9–10 years have not been confirmed. Instead of estimating detailed foods and nutrients from the foods described by the children, we devised a way to achieve the measurements with high accuracy by only assessing the presence or absence of food category intakes. Second, we were unable to assess the quantities of each food category eaten for breakfast. Meanwhile, for foods associated with multiple food categories, we were often unable to identify the ingredients present in the foods. For example, some children did not report the details of the ingredients in their soups and stews. Therefore, the intake of vegetable dishes and meat, fish, egg, and soybean dishes, which are often included as ingredients, were often not counted as intake, possibly leading to underestimations in the results. In the future, it is necessary to devise methods that encourage children to describe the foods in detail and to obtain evaluations from caregivers to examine the validity of the method. Third, we were unable to evaluate dietary data other than breakfast intakes. However, the children were offered the same nutritious lunch at school during the day. Finally, the generalizability of the present results is limited because meals vary from culture to culture. The children in the present study ate rice or bread dishes as their main breakfast foods, had vegetable dishes and meat/fish/egg/soybean dishes every other day, and consumed fruits less frequently. Studies in other areas are needed. Despite these limitations, the fact that we were able to obtain breakfast data for children over a 7-day period provided very valuable evidence.Elementary school children in Japan consumed more rice and bread dishes for breakfast compared with other food categories. Vegetable dishes and meat/fish/egg/soybean dishes were consumed every other day, and fruits and confectionaries were consumed about once a week. Children who consumed grain dishes or fruits had fewer problem behaviors than children who did not. Grain dishes, whether rice or bread, were associated with reduced problem behaviors, while confectionaries, which mainly consisted of sweet breads or pastries, were not associated with problem behaviors. These results should aid in the development of dietary recommendations for breakfast among Japanese children. Although further examinations are warranted in longitudinal and intervention studies, the intake of non-sweet grain dishes or fruits at breakfast may be effective for preventing behavioral problems in children. This study could add evidence that it is not only whether children eat breakfast but also the type of food they eat for breakfast matters. The public health impact of this study is to make caregivers aware of the benefits of having their children eat grain dishes or fruits for breakfast. Neither grain foods nor fruits require complex preparation and are therefore easy to prepare at home. Few schools offer breakfast in Japan, and the food contents of breakfasts served in the “school breakfast program” in Japan were shown to vary from school to school . In the


Existing sampling methods in language typology strive to control for areal biases in typological datasets as a means to avoid contact effects in the distribution of linguistic structure. However, none of these methods provide ways to directly compare contact scenarios from a typological perspective. This paper addresses this gap by introducing a sampling procedure for worldwide comparisons of language contact scenarios. The sampling unit consists of sets of three languages. The Focus Language is the language whose structures we examine in search for contact effects; the Neighbor Language is genealogically unrelated to the Focus Language, and counts as the potential source of contact influence on the Focus Language; the Benchmark Language is a relative of the Focus Language neither in contact with the Focus nor with the Neighbor language, and is used for disentangling contact effects from genealogical inheritance in the Focus Language. Through this design, we compiled a sample of 49 three-language sets , which we present here. By switching the focus of typological sampling from individual languages to contact relations between languages, our method has the potential of uncovering patterns in the diffusion of language structures, and how they vary and change. These encounters often create scenarios of bi-/multilingualism in which linguistic features may easily diffuse . Given tFocus Language is the language whose structures we examine in search for evidence of contact effects. The Neighbor Language, which is genealogically unrelated to the Focus Language, is the potential source of contact influence on the Focus Language. Finally, the Benchmark Language is a close relative of the Focus Language, which serves as a control for disentangling contact influence from genealogical inheritance in the Focus Language. Importantly, the Benchmark Language is not in contact with either the Neighbor or with the Focus Language itself. In this technique, we use evidence of contact between language communities from the literature on areal and contact linguistics to select Focus and Neighbor Languages from different regions of the world. As such, the current sample is a phenomenon-based one, with language contact being the phenomenon at stake.The proposed sampling technique departs from existing sampling methods in language typology in two ways. First, the sampling unit consists of sets of three languages rather than individual language units. Each language in the set is associated with a specific role in the current technique. The The sampling method introduced here combines established practices in typological sampling with insights from both areal typology and language contact. Instead of using the geographical locations of languages as a proxy for the likelihood of contact , the entAs we discuss below, the procedure is easily applicable, hence offering a way of testing how linguistic structure diffuses across different contact scenarios. We argue that the use of multi-language sampling units, and the explicit inclusion of contact in the sampling technique provides a promising way of doing typological research on diverse contact settings across the world.The paper is structured as follows. In 1.1Put simply, sampling allows typologists to delimit the population of languages between which linguistic comparisons are drawn. This section presents a brief overview of a few fundamental principles for sampling in language typology, and how they relate to the overall goal of researching linguistic structure. For more detailed discussions of the vast literature on sampling methods, we recommend representativeness and independence. Representativeness criteria address how a language sample reflects linguistic diversity. The criteria for independence tackle the sources of similarities between languages, be it inheritance or diffusion.In principle, generalizations about the global distribution of language structures should rely on a carefully designed sampling procedure. In this respect, two of the most important desiderata in any sampling procedure are the criteria used to achieve Representativeness and independence criteria may interfere with one another in various ways. For instance, representativeness may increase with the size of the sample, since a larger sample is more likely to represent the distribution of cross-linguistic patterns in the total population of human languages. At the same time, increasing sample size may compromise independence since it can inflate the likelihood of genealogical and/or areal relations between the sampled languages. One way in which researchers can address issues of representativeness and independence is to consider biases in language selection.Widely addressed biases in typological sampling are genealogical and areal biases  has led to changes in the syllable structure of Estonian  . Lack of1 roughly corresponding to major continental zones: Africa, Eurasia, Southeast Asia and Oceania, Australia and New Guinea, North America, and South America. These six macro-areas are assumed to be maximally independent from each other both in terms of language history and of contact dynamics, while also reflecting comparable levels of genealogical and typological diversity. A similar approach is taken by The commonest approach to areal control in typological sampling is to use continent-wide classifications as a basis for language selection. For instance, A third areal classification in typology, which is also based on continent-wide areas, is the one adopted for the purposes of the Autotyp database . The Aut2Using the 24 Autotyp Areas is one way of sampling languages from within macro-areas. An alternative approach would be for instance randomly selecting languages from each continent. This procedure is discussed in detail in Our method uses the 24 Autotyp Areas as a grid for identifying candidate contact scenarios within diverse geographical areas of the world while also providing us with a tool for areal control at a smaller scale than the continent-wide level.3However, see  While these approaches can be useful for automatic control, and to estimate the degree of contact between languages, the current technique builds samples directly based on established contact relations between language communities. We argue that this type of phenomenon-based sample is especially useful in order to test hypotheses about contact-induced change and the socio-historical correlates of typological distributions.In addition to the use of pre-established geographical classifications such as those surveyed above, spatial statistics has become increasingly common in quantitative typology as a way to assess the degree of contact between speech communities. For instance, 1.1.24A genus is a level of classification with a time-depth spanning between 3,500 and 4,000 years. The choice of 3,500–4,000 years as a cut-off point is primarily based on the proposed time-depth of the different sub-branches of the Indo-European family such as Celtic, Germanic, Indo-Aryan, Italic, and so on. The approach rests on the observation that, within such groupings, languages tend to be typologically quite similar to each other. Moreover, controversies in language classification most often lie at deeper time depths. For instance, comparative reconstructions stretching beyond 3,000–4,000 years are less readily verifiable through the comparative method : 286. instead of languages  geographical area; (2) independently reported contact scenarios; (3) genealogical distance between languages in contact; and (4) availability of reference materials for each of the languages in the set. These four criteria enable us to build a typological dataset that is geographically and genealogically stratified, in addition to being independent of our own assessment of a given contact situation.5Of course, a language can be in contact with multiple others at any given time, as is known for many linguistic areas of the world (see  and on the existence of related languages for the Focus (see below). Importantly, the current technique is meant for studies that evaluate the extent to which contact influences the structures of Focus Languages, rather than serving as a starting point for determining whether or not contact has indeed existed.6The use of the terms ‘Focus’ and ‘Neighbor’ here also highlights the fact that Focus Languages may in turn influence structures of Neighbor Languages, given that linguistic structure may diffuse both ways. Alternative labels such ‘donor’ versus ‘replica/recipient language’, or ‘superstrate’ versus ‘substrate language’ : 171, amAs mentioned in The third language of our sampling unit is the Benchmark Language, and serves as a parameter against which to test the impact of contact on the Focus language. The Benchmark Language is as closely related to the Focus Language as possible, while at the same time not being in contact with either the Focus nor the Neighbor Language see . In our In order to fulfill the specific goals of our own ongoing project, we used a final, project-specific criterion. Since part of this research aims to produce sociolinguistic descriptions of the contact dynamics between Focus and Neighbor languages, we established that there should also be living experts on the Focus Language with whom we could collaborate. This additional criterion will be briefly discussed in 2.1This first criterion allows us to draw a sample that represents contact scenarios from all parts of the world. It thus complies with general representativeness desiderata in typological sampling . Given tThe Autotyp Areas differ from other geographical classifications in that they derive from a combination of archeological, anthropological, historical, and genetic data rather than from linguistic features alone : 6. The 7Setting the sample size to 50 sets, or 150 languages, partly derives from methodological necessities related to our project-specific goals. It constitutes a compromise between having enough data to investigate the typological distribution of various language structures in the languages of the sample, and maintaining a manageable workflow within the timespan of the project at large. For an illustration of the breadth and depth of the ongoing linguistic data collection in the context of the larger project, see  we decided to include two extra sets, one from Northeast South America, and the other from the North Coast of New Guinea. We selected South America and New Guinea as the sources for the two additional sets because of the high degree of linguistic diversity found in those areas as a whole . In order to arrive at an even 150 languages,le e.g., . For rea2.2This second parameter guides the choice of Focus and Neighbor Languages to analyze within each Autotyp Area. To fulfill this criterion, we relied on descriptions of contact scenarios in the language contact and areal linguistics literature, primarily through macro-area surveys of contact situations. For instance, we drew our Northeast South America sets based on the surveys of contact in the Amazon Region by Descriptions of individual cases of contact varied in detail across the different areas. For instance, some language contact situations have a longer history of study, such as the Pacific Northwest in North America , whereasThe task of matching contact scenarios with the Autotyp Areas was straightforward in most cases. Whenever we were uncertain where to place a case within an Autotyp Area, we relied on the geographical location of the Focus and Neighbor languages as stated in Glottolog. In a few cases, we also consulted specialists in the specific contact situations. A few Autotyp Areas presented challenges of their own. These are the three Autotyp Areas in the island of New Guinea, the North Coast Asia Area, Eastern North America, and Southern Australia.The New Guinea Areas, and North Coast Asia are all relatively small, so that finding a Benchmark proved especially challenging in some cases. Additionally, New Guinea shows less in-depth documentation given the linguistic diversity in the region compared to other parts of the world. Eastern North America showed high degrees of language obsolescence, which had some impact on sampling composition see . FinallyWe wish to underscore that aside from selecting sources that provided a detailed description of the contact scenario from a linguistic standpoint, we made no further evaluations as to the nature of the contact relations described in the literature. As such, we remain neutral to any disagreements or disputes over the plausibility of individual proposals, especially regarding larger linguistic areas. Finally, neither the type of contact profile instantiated by the candidate contact scenarios , nor the linguistic outcomes of contact reported in the literature played any role in the selection procedure.2.3In order to minimize possible confounds due to common ancestry, we established that each set in our sample would include only Focus and Neighbor Languages that belonged to distinct language families. This third criterion helps us ensure that linguistic effects on Focus Languages stem from the contact situation rather than from shared inheritance , meaning that a grouping such as ‘Finnic’ constitutes a subfamily in our classification, rather than a family . All Glottolog classifications used in this paper refer to the database as of April 2020  as the Focus language, and a Tucanoan language such as Macuna (myy) as the Neighbor Language . Determiog 4.2.1 .9Another related challenge concerns language families that are spread over large geographical areas. In some such cases, Benchmark Languages might themselves be in contact with a relative of the Neighbor Language, even if spoken outside the Focus-Neighbor contact zone. While we are aware that this possibility might weaken the role of the Benchmark as an external source of control, it remains to be seen the extent to which such cases occur. Such a possibility led us to establish further criteria for the selection of Benchmark Languages. First, the Benchmark Language must not be part of the Focus/Neighbor contact zone. Ensuring that the Benchmark language is not subject to the same contact influences as the Focus language strengthens its status as a source of external control. When more than one candidate was available, we chose the one that was geographically closest to the Focus Language. For the current sample, we relied on the sources described in Section 2.1.2 to rule out the Benchmark Language’s participation in the contact scenarios we sampled. More specifically, we double-checked reference materials for mentions of contact between Benchmark, Focus and Neighbor Languages, and replaced any Benchmarks that participated in contact scenarios with either FL or BL.10It is evidently impossible to rule out sporadic contact that may have gone unnoticed by authors of reference materials, as well as contact in the remote past. Based on the sources, however, we must conclude that any such events might have had a negligible effect on the languages in question, if at all. Contact between the Benchmark and other languages, possible as they may be, played no role in the selection process.The choice of Benchmark poses a challenge in itself, since two closely related languages may indeed be involved in the same contact scenario.The Vaupés contact zone once again serves as an illustration. Following the steps outlined above, we find that Yuhup’s closest relative is Hup (jup), which also belongs to the Hup-Yuhup sub-branch of the Naduhup family in the Glottolog classification. Since Hup also participates in contact scenarios involving languages in the Tukanoan family, possibly with the Neighbor Language Macuna itself, selecting Hup violates one of the criteria for selection as Benchmark. The next closest relative to Yuhup would then be Dâw (kwa). However, upon double-checking our references, we found that Dâw too played a role in this particular contact scenario. As such, we moved on to the next relative, finally selecting Nadëb as the Benchmark Language in the Hup-Macuna set. 2.4This criterion relates to the overall goals of our larger project, namely to test the effects of contact on a range of linguistic variables. Our research aims to compare given variables in the Focus Language to those of the Neighbor Language, using the Benchmark Language as a parameter for comparison. Thus, one relevant caveat that this method introduces is that each sampling unit requires three different descriptions of appropriate quality for the languages in each set. Reference materials such as grammars, journal articles, and dictionaries were deemed appropriate for the goals of our study. While we may use additional sources such as databases and data from conference presentations, we established that the three languages in each of the sets must have primary linguistic sources for them to be included in the sample.Selecting reference materials for Benchmark Languages was a relatively uncomplicated task given that there were often different options for each set. On the other hand, the lack of appropriate descriptions for Neighbor Languages posed a much greater challenge. In many cases, the Focus Language was in contact with a single language belonging to a different family, so that the lack of materials for that particular Neighbor Language led to the exclusion of the entire set. In cases for which there were two or more candidate Neighbor Languages, we selected the one we deemed had the most suitable description. As discussed in 3This section describes the sample of 147 languages obtained following the criteria explained above. In short, the central goal of our procedure is to arrive at a sample of language contact scenarios from all parts of the globe. Our sampling unit consists of three-language sets: a Focus Language, a Neighbor Language, and a Benchmark Language. The Focus and Neighbor languages are in direct contact, and they belong to distinct language families. The Benchmark Language is related to the Focus Language, but is not in contact with either the Focus or the Neighbor languages.We successfully applied the sampling methodology described above matching language selection against the four criteria introduced in Figures 5the longest, according to our sources. This was the case for the Northern Australia scenario involving Mawng (mph) as the Focus, and Kunbarlaang (wlg) as the Neighbor Language.For all of the 49 sampled contact scenarios, the criteria proposed led to the successful identification of pairs of Focus and Neighbor languages. This was the case also in highly multilingual areas of the world, such as the US-Canada Pacific Northwest, or in the Mamoré-Guaporé area. In some cases, the criterion establishing that the Focus and Neighbor Languages must belong to separate language families allowed us to select a single pair, even in those multilingual settings. For instance, in the Pacific Northwest, we selected Salishan Nuxalk (blc) and Wakashan Kwakw’ala (kwk), and for the Mamoré-Guaporé Area, we picked Tupian Mekens (skf) in contact with the isolate Aikanã (tba). In other cases, we selected the two languages whose speakers had been in contact Lastly, even though we did not explicitly control for family representation across the sampled sets, the method yielded a diverse sample of language families, with a total of 64 families. The sampled language families, and the number of Focus and Neighbor languages sampled for each of them are given in 4In this section, we outline the contribution of our method to the study of linguistic diversity  and cont4.1The dataset generated through our sampling procedure fully complies with the four criteria introduced in The sampling procedure utilizes insights from areal linguistics, areal typology, historical linguistics, and language contact research, being further guided by the contact literature. This method makes one important contribution to sociolinguistic typology . It is t4.2(1)How similar are the Focus and Neighbor Languages with respect to the parameters describing the properties of each linguistic variable?(2)How do similarities between Focus and Neighbor Languages compare to corresponding structural properties of the Benchmark Language within each set?The sample presented here is currently being used to gather linguistic data in the context of our larger project see . We are Preliminary results obtained using the current sample indicate that our method captures structural similarities between Focus and Neighbor Languages that strongly suggest explanations derived from language contact. That is, we find systematic correspondences between a range of phonological, morphosyntactic, and lexical features of the contact pairs which differ from those attested in the respective Benchmark Languages. Data from six of our sets illustrate those findings in the domain of nominal number. The examples sets were chosen to represent each continental area, that is, Africa, Australia, Eurasia, Papunesia, North America, and South America. The languages in each set, their genealogical affiliations, and a selection of possible contact effects followed by the total number of FL–NL feature matches for each set are given in One striking pattern emerges from the data presented in The scenario in which Focus and Neighbor languages share number values missing in the Benchmark is illustrated by Sets 09, 15, 21, and 49. In Set 09, from Northern Australia, both Mawng and Kunbarlang have dual inflections on independent personal pronouns , but theThe opposite pattern, where certain number values are attested in the Benchmark, but absent in the Focus and Neighbor languages, is found in Set 02 and Set 14. In Set 02, dual forms are attested in the Benchmark Lele , but abs11The absence of typologically common features in groups of languages in contact has indeed been used as indication of contact in linguistic areas. For instance, the absence of nasal phonemes in indigenous languages of present-day US/Canada Pacific Northwest e.g., : 123, as Put simply, one should be cautious to use ‘shared absences’ as the sole indication of contact. Expanding the basis of comparison to more than one Benchmark would seem especially important for better contextualizing shared absence as indication of contact.12We thank one anonymous reviewer and Patience Epps for this important remark. Nevertheless, all things being equal, both ‘shared presence’ and ‘shared absence’ contribute relevant datapoints to the overall assessment of a given contact profile.Having first described these findings, we now turn to a word of caution. While the fact that a feature is present in two unrelated languages in contact but absent in the Benchmark may be taken as indication of contact-induced change, the absence of a feature in both languages arguably constitutes less clear evidence of contact. In other words, instances when two unrelated languages in contact both lack a given feature which is present in the Benchmark Language (which would correspond to a ‘0–0–1’ in our coding method) would be less indicative of contact-induced change than when both Focus and Neighbor Languages contain a feature absent in the Benchmark (1–1–0 in our coding method). Such a conclusion is warranted especially in cases of typologically frequent properties.It should be noted that the method being proposed here does not preclude more in-depth, comparative analyses of contact effects in individual languages. Rather, our method provides a sample which researchers can use as a starting point for further investigations of contact. It mitigates the issue of similarity due to inheritance by proposing the analysis of maximally unrelated languages. It offers an additional tool for control by proposing the inclusion of a Benchmark Language against which variables should be compared.The current sampling method thus provides typologists with a testing ground for investigating contact effects on a large scale. Preliminary observations from six sets from across the globe suggest that data collection using this sampling technique allows for the detection of structural similarities between given pairs of Focus and Neighbor Languages. The addition of Benchmark Languages provides a systematic way to further ensure that any similarities uncovered may be due to contact. The next section discusses limitations in the procedure.4.3As hinted above, the current procedure does not preclude detailed areal and historical-comparative analyses of specific cases of contact, all of which remain paramount. Additionally, while successful in generating a sample of languages suitable for the study of contact from a typological perspective, the current method presents limitations, three of which we discuss here. Two limitations concern Benchmark Languages, namely how many Benchmark to consider per set, and the differing degrees of relatedness between Benchmarks and Focus Languages across the sets. The third limitation addressed in this section is the project-specific constraint that requires that we find living experts on the Focus Languages and/or contact scenarios with whom to collaborate.4.3.113One way of lowering the degree of uncertainty associated with the one-Benchmark approach would be to create a dataset for which multiple Benchmarks are only selected for those Focus languages that belong to larger language families were several candidate sister languages exist. While we acknowledge that, in principle, this would decrease the degree of uncertainty associated with some language sets, in this paper, and for the purposes of the larger project, we opted for a conservative approach . Needless to say, this solution can be easily implemented in future applications of the sampling method and, in fact, it has already been partially applied in individual case studies within our larger project . Despite its limitations, the method proposed here is certainly expandable, and allows individual researchers to select as many Benchmark languages as are available using the same selection criteria outlined in The current method utilizes a single Benchmark language per set. This choice has the advantage of allowing for the inclusion of languages from small language families in specific sets . However, it is conceivably less powerful a check than if a greater number of languages were included as Benchmarks for the same contact pair. This choice seemingly introduces some degree of randomness in the selection procedure, which may be difficult to quantify across sets.In addition to the data on number systems presented in In the context of the project at large, The second illustration focuses on the Balkans, a contact scenario that is not featured in the dataset presented in this paper. Using a set of ‘Balkanisms’ put forward in As the table shows, Romanian and Macedonian pattern similarly while differing from Italian, with the sole exception of ‘Analytic comparative adjective formations’. The key point here is that Standard Italian, the Benchmark in this scenario, differs in almost every aspect from the Focus Language.systematic differences between the Focus and Benchmark languages stem from external influence. This is especially clear in cases like the Romanian and Italian examples above, in which the features that set Romanian apart from Italian on the one hand are the same as those that connect Romanian and Macedonian on the other.Although somewhat simplistic, the comparisons above underscore two important points that relate to the role of the Benchmark in our method. First, since the current sampling technique uses already-established contact scenarios as its starting point , this potentially reduces the need for family-wide checks. Secondly, the fact that the Benchmark language tends to be the closest possible relative of the Focus Language increases the likelihood that the extent to which contact may impact structures of the Focus Language, rather than establishing whether or not contact occurs. We contend that researchers aiming to validate claims of contact-induced change specific to individual linguistic areas and families therein would likely benefit from the systematic analysis of several benchmark languages.While this Balkan scenario would violate the sampling criteria in our method, given that both Romanian and Macedonian are Indo-European, it highlights how effective a systematic comparison with a single Benchmark can be. All things being equal, one would expect that similarities between completely unrelated languages would be even more suggestive of contact, especially when the Focus Language differs systematically from its Benchmark. As mentioned above, the current procedure aims at determining 4.3.2Because the distribution of languages within families and contact scenarios differs widely across the globe, degrees of relatedness between Focus and Benchmark languages are also uneven across our sampled sets. For instance, a Focus Language in a given set may only have distant relatives , or candidate Benchmark languages may also be in contact with the Neighbor, as discussed for Hup and Yuhup. One way to address these discrepancies across sets is to include a measure of relatedness as an independent variable in statistical analyses. One such measure already used in typology, which could also be applied to this case, is the Diversity Value .under the top level. Although we propose that the Diversity Values can be relevant for the analyses of typological distributions in the data, they would have no a priori role in the procedure of language selection as such, which is why we leave this for future implementation.While initially proposed for generating variety samples, using the Diversity Value could serve our purposes here as it would provide a way to quantify the genealogical distance between Focus and Benchmark Languages across sets. The Diversity Value is a numeric measure that considers both the depth and the width of a language family tree. The depth relates to the numbers of levels within a language family, whereas the width refers to the number of nodes across a level. The complexity of the language family tree determines the Diversity Value, which is recursively calculated from the number of levels 4.3.314When selecting experts, we strived to include researchers either from the communities under study or at least from universities located in the same country as the contact scenarios. The choice to select local experts stems from our wish to engage with different academic cultures, and with more local perspectives on the language communities under scrutiny. We acknowledge that this choice represents but a tentative step towards building more constructive and equitable relationships with indigenous populations in our field cf. . As a result, it could be argued that the sample presented here perhaps reflects more recent contact dynamics than historical scenarios known to have left an impact on the structures of the languages involved. This is because the questionnaire comprises questions that are better suited to describe the sociolinguistic patterns behind contact between Russian and Udmurt (udm), for instance, than those between Sumerian (sux) and Akkadian (akk), or Classical Nahuatl (nci) and Epigraphic Mayan (emy).The sampling composition was partly determined by the need for experts who could respond to a sociolinguistic questionnaire we developed for the project at large . That is, the sample was often tied to the existence of potential collaborators, mostly authors of reference grammars, or specialists in contact scenarios.Due to these project-specific goals, consulting with experts also resulted in a few revisions to the composition of the language sample that we present here. For instance, Set 05 initially investigated contact dynamics between the Northern Songhay language Tadaksahak (dsk) and the Afro-Asiatic language Tetserret (tez). After consulting with the expert, we updated the set so that it now investigates contact between speakers of the Northern Songhay language Korandje (kcy) and Algerian Arabic (aao) instead.Although this project-specific criterion influenced the current sample to a certain degree, the criteria behind the general selection were still the same. Indeed, the fact that replacements prompted by experts were found once again speaks to the efficacy of the method being proposed. This suggests that the procedure is fit to generate samples for typological studies that focus solely on linguistic outcomes of contact as much as it does for investigations of its sociolinguistic aspects.4.4As mentioned above, the sampling technique presented in this paper is part of the research design of a larger project investigating how various sociolinguistic contexts impact around 200 variables in the realms of morphosyntax, phonology, and the lexicon. The dataset presented in The sampling technique serves three interrelated goals within the larger project. First, the dataset resulting from the sampling procedure enables us to conduct comparisons of contact scenarios from a sociolinguistic perspective. Secondly, the sample serves as the source for data on linguistic variables in the languages of each set . Finally, the procedure can be easily re-applied. Indeed, not only did it generate the contact sets that comprise the sample presented in this paper, but also multiple alternatives.Throughout the article, we also underscored the importance of having a control regarding the issue of genealogy versus inheritance in comparative contact studies. By introducing a systematic way for selecting a benchmark against which to compare changes in a given language, this procedure provides a methodological contribution to the typological study of contact phenomena. While the proposed design cannot provide the ultimate solution to the ‘diffusion versus inheritance’ conundrum, it certainly adds a new set of resources to the typologist’s toolkit for capturing, and thereby assessing, contact signals in the languages of the world. We argue that this newly developed tool may serve as a point of departure for studies of linguistic diversity in general, and of language contact in particular.Software and packages: Figures and maps were generated in R (ted in R . All mapted in R .Supplementary Material DetailsClick here for additional data file.Supplementary Material DetailsClick here for additional data file.


Preterm birth is a major maternal complication that has a great impact on perinatal and neonatal health, with consequences suffered during childhood and adulthood. Little is known about its etiology and development, resulting in poor screening, prediction and preventive methods. The present integrative review discusses the current knowledge regarding some risk factors for preterm birth, the differences between screening and prediction methods, the limitations of some current preventive interventions, the importance of applying standardized concepts for exposures and outcomes, and why it is important to develop more accurate and reproducible methods to predict preterm birth. In addition, the authors introduce the concept of metabolomics and the technology involved in this technique, and discuss about how it has become a promising approach to identify biomarkers for spontaneous preterm birth. The birth of a preterm baby may have diverse negative consequences for the baby him/herself, (his or her) neonatal life, childhood and adulthood, the family, the healthcare system/service, and society as a whole. The present manuscript focuses on the factors associated with preterm birth, the perinatal outcomes and the ways to predict them, supported by the hypothesis that it is possible to better understand and predict the preterm birth process, creating opportunities for increased effectiveness in the prevention of this condition.It took several decades to consolidate the definition of preterm birth. At the beginning of the 20th century, newborns weighing less than 2,500 g at birth were considered preterm, based primarily on neonatal behavior and progression to neonatal mortality, intracranial hemorrhage and other morbid conditions.Preterm birth may be classified according to the clinical presentation or the motivator: spontaneous, when due to spontaneous preterm labor  or preterm premature rupture of the membranes (P-PROM); and therapeutic, when theoretically there is a condition that poses a risk to the mother and/or the fetus, generating sufficient motivation for resolution at a preterm gestational age.Therefore, at least the distinction between spontaneous and therapeutic preterm birth is highly recommended when studying the determinants and consequences of preterm birth. The recognition that not every preterm birth occurs because of the same determinants was an early step to study the causes and develop preventive strategies. Preterm birth is also categorized according to gestational age at birth, and is divided into: late preterm (between 34 weeks + 0 days and 36 weeks + 6 days), moderately preterm (from 32 + 0 weeks to 33 + 6 weeks), very preterm (from 28 + 0 weeks to 31 + 6 weeks) and extremely preterm (< 28 weeks).Pregnancy of a singleton or multiple fetuses (twins) confers great differences not only in terms of the incidence of preterm birth, but also concerning its associated factors and the maternal and perinatal outcomes.A studyComplications due to preterm births account for more than 1/3 of neonatal deaths worldwide, representing over 1 million newborn infants who died in the first month of life in 2010. The impact of complications due to preterm birth also has repercussions regarding childhood health indicators. It is the second cause of death until age 5 globally, and the first cause of death in mid-income and high-income countries.Since the 1950s, many advances have been made in the number of options and in the level of scientific evidence-based preventive measures for neonatal complications due to preterm birth. Among those are measures of tertiary prevention, such as the use of tocolytics and corticotherapy for the prevention of hyaline membrane, intraventricular hemorrhage and necrotizing enterocolitis; magnesium sulfate for the prevention of cerebral palsy in cases of imminient preterm delivery; and antibiotic therapy for the prevention of neonatal sepsis and to prolong the latent phase in cases of P-PROM.There were also advances in the identification and institution of early therapies for neonatal complications such as neonatal sepsis, hypothermia, visual, cerebral (intra- and periventricular hemorrhage), auditory and/or neuropsychomotor impairments, providing the newborn with the possibility of earlier neonatal follow-up and better long-term results.Risk factor is a term used to designate conditions, characteristics, habits or markers that, when present, increase the probability of occurrence of a specific injury. Risk, therefore, is related to the onset of a condition.2), normal (BMI between 18.5 kg/m2 and 24.9 kg/m2), overweight (BMI between 25.00 kg/m2 and 29.9 kg/m2) and obesity (BMI ≥ 30.0 kg/m2).An example of a combination of factors is BMI and gestational weight gain. The National Academy of Medicine (NAM), in the United States, formerly known as the Institute of Medicine (IoM), categorized BMI into low weight  and the phosphorylated isoform of insulin-like growth factor binding protein (phIGFBP-1), binding proteins present between the chorion of the amniotic membrane and the maternal decidua, and cervical length measurement in the second trimester of pregnancy by transvaginal ultrasound. Systematic reviews have concluded that those markers are not sufficiently accurate to be useful in the clinical prediction of preterm birth, especially in asymptomatic women.A Dutch prospective cohort studyFetal fibronectin in the vaginal secretion does not show much superior results in asymptomatic women. A cohort studyOther propositions have attempted to address the association between multiple factors involved in the development of preterm birth. A group of expertsThe aforementioned group of experts, with the aid of other collaborators, applied this concept through a secondary analysis of an international multicenter cohort study named INTERGROWTH 21st.According to Geoffrey Rose,The identification of factors associated with a higher risk of developing spontaneous preterm birth may be useful to help physicians understand its pathophysiology and identify women at higher risk who might benefit from prevention strategies. In the latter case, it may also possible to distinguish between screening for risk and prediction of preterm birth. Although both methods use risk factors as the basis for their models or algorithms, their practical application may be quite distinct.For example, women with transvaginal ultrasound assessment of cervical length between 20 mm and 25 mm, which was measured in the second trimester by a standardized technique, had an incidence of preterm birth ranging from 22% to 32%.p-value of 0.0009) and in cerebral alterations on ultrasound . The authors of this study concluded that the subgroups of women who might benefit from progesterone are not easily identified by the current screening strategies. This should encourage studies on new prevention strategies as well as those aimed at identifying women that may be potentially eligible to undergo this treatment.The OPPTIMUM study,Another technique that has been studied for decades is cerclage, which is primarily based on suture of the uterine cervix or isthmus-cervical region to prevent early effacement/dilatation of the cervix. The Shirodkarversus expectant management) to prevent preterm birth. Selecting pregnant women at high risk based on cervical length measurement in the second trimester, with slightly more than 190 women per group, the study showed that the incidence of preterm births before 34 weeks decreased by 80%. Subsequent studies demonstrated conflicting results, and did not confirm such a reduction in the incidence of preterm births observed by Goya et al.It is also worth mentioning that another intervention was studied for the prevention of preterm birth in high-risk women. A pessary, a device made of firm silicone in the shape of a convex ring, is inserted into the posterior vaginal fornix and fastened to the cervix. The theoretical mechanism for the prevention of preterm birth is based on: 1) a change in the axis of forces resulting from the uterine body and isthmus that act on the cervix; and 2) a potential closure of the cervix with consequent strengthening of the cervical canal and the immunologic barrier of the cervix, preserving the amniotic membranes from contact with the vaginal environment.Despite the advances/benefits resulting from a combination of screening for risk and interventions, such as, progesterone, the pessary and cerclage in women selected based on risk factors, there still seem to exist limitations and heterogeneity in screening. Better results from the use of these measures may be potentially hindered. Which women might actually benefit from the use of progesterone during prenatal care? Which women might not benefit from any preventive intervention? Furthermore, there is no consensus over which level of risk estimate determines that a woman should in fact be considered at high risk. Improved identification of women at high (or low) risk of having a preterm birth with the development of prediction models that have good discriminatory performance may be quite relevant to advance the investigation of the benefits of using (or not) progesterone, the pessary or any other form of preterm birth prevention.The description of these prevention studies and their interpretations are important to highlight the fundamental role of the adequate screening of women who may benefit from prevention strategies. Distinctions must be made regarding the risk assessment model and a predictor model for an outcome. This distinction may actually help physicians understand the clinical application of a screening strategy for women at high risk of having a preterm delivery.As an example of a risk marker, the cervix is known to be independently associated with a higher risk of having a preterm birth.A prospective observational studyIn summary, systematic reviews have concluded that there are no markers in the literature that can be applied in the clinical practice to predict spontaneous preterm birth with a good performance, and that enable new preventive approaches and studies in this area.The term “omics sciences” is applied to the field of knowledge that focuses on genomic studies, gene identification, DNA sequence polymorphisms, genes and the genome; transcriptomics, which is focused on the study of gene expression – RNAs; proteomics, the large-scale study of proteins; and metabolomics, the scientific study of chemical processes involving metabolites.Metabolomics is the science that studies metabolites, small molecules present in different chains of the metabolism of an organism.By identifying and quantifying metabolites, this technique is capable of showing the fingerprint of the metabolic interactions of the organism in a certain sample at a certain time. Metabolomics is a technique known as hypothesis-free, that is, it does not require an initial hypothesis. Instead of testing a certain hypothesis, the technique may generate novel hypotheses through its results when elucidating the markers and biological pathways involved in the process of disease development, which may not have been clarified.Metabolomics has been applied in biological samples for the investigation of processes ranging from embryogenesis to the emergence of complex diseases such as cancer, Parkinson disease, diabetes and depression.After identifying 45 metabolites significantly associated with preclampsia in serum samples collected at 15 weeks of gestation from a group of ∼ 39 nulliparous pregnant women with a history of preeclampsia (compared with 40 pregnant women without complications), 14 metabolites were selected to compose the final model . The model resulted in an area under the ROC curve of 0.92, and an OR of 23 .p-value according to the number of variables (metabolites) analyzed. The false discovery rate (FDR) method may also be applied to control the number of false-positive conclusions, and significance is only assigned to the “most promising” variables.Many aspects regarding the most effective method to investigate preterm birth using metabolomic markers should be discussed. First, there is the type of sample used . Then, there is the time for sample collection . Furthermore, metabolomics demands a high methodological rigor in the collection and storage of biosamples, since this is a highly sensitive method to identify small low-weight molecules; various types of “noise”, or interference in data acquisition, may hinder the identification of these molecules. Heterogeneity in sample collection and storage may be the cause. In addition, a well-delineated study design, with well-defined outcomes, following clear classifications, associated with sequential validations of findings is crucial for the reliability and reproducibility of this technique. Finally, still in the phase of data analysis, caution regarding some important considerations is emphasized. For example, hundreds or even thousands of metabolites are usually analyzed at the same time in a sample. Since the number of variables (metabolites) is much higher than the number of samples , the analysis is very susceptible to significantly false results. To correct this effect, the Bonferroni correction may be used, attenuating the significance of the Many questions need to be answered concerning the mechanisms involved in the development of preterm birth: why do some women have early cervical remodeling  and others do not? Which and how are the interactions between different risk factors, including infection, vaginal bleeding and body mass index, and how can they determine preterm birth? In theory, metabolomics depicts the final pathway resulting from these interactions, and it seems to be a useful approach not only to predict spontaneous preterm birth, but also to elucidate the many mechanisms involved.In order to adequately address the investigation of preterm birth, its associated factors and perinatal outcomes, a robust methodological approach is required, using judicious and standardized definitions of exposures and outcomes. Based on this premise, a multifaceted comprehensive approach, albeit integrated, was proposed for data exploration on the factors associated with preterm birth, its prediction and the perinatal outcomes, which may be capable of generating new knowledge regarding this issue. It is expected that the results of this approach may contribute to the prediction of the most effective performance and better understanding of the factors associated with spontaneous preterm birth and consequent adverse perinatal results, collaborating with the development and application of public policies to prevent preterm birth and its perinatal consequences. We acknowledge the fact that the present is an integrative review based on a biased search in the literature and on the interpretation of the studies and respective findings. Although we have not used the standard tools and strategies to measure and report these biases, we consider that it is a great opportunity to raise the discussion about some of the risk factors associated with sponteaneous preterm birth, how preventive strategies based on these factors have been implemented, and the results so far. We expect that, despite the limitations of the present integrative review, it may contribute to the discussion about recognizing women at a higher risk of having sponteaneous preterm birth and how to prevent it.


The Asian Cardiovascular and Thoracic Annals turns 30 in 2023. Ahistorical review since it was first published in March 1993 is presented. It was first launched in March 1993. These three decades have not been comfortable andthe path was unevenly paved, considering the difficulties in starting a scientific journalfrom scratch which aimed at covering the needs of the largest region of the world, Asia andthe Pacific, including Australia and New Zealand. Gaining credibility is not an easy taskand it takes years to reach a certain level of quality that ensures a good flow ofcontributions to support the solidity of the given publication.Out of economics, maturity is defined as the quality of behaving mentally and emotionallylike an adult or as a very advanced or developed form or state.Asian Annals hasreached its maturity. A number of changes were implemented since its start and now is thetime to sit down and reflect on what has been done and what we imagine the future ofAsian Annals will be. This look at the future has been recently addressedby the editors led by the Editor-in-Chief, Dr Yutaka Okita in a position statement thataimed at defining our goals and the expected quality.Thirty years after the first issue, it can be stated that AsianAnnals. This is an important event, an anniversary to remember, for thereadership to incorporate in full the exact meaning of the words. Then, Asian Annals is now a leading publication in cardiothoracicmedicine and surgery in Asia.The following is a summary of these first thirty years of life of  The mission did not change; however, the message was conveyed according to times andafter its launch, it was expressed as providing a continuing forum whereby clinicians fromall cardiac communities in Asia and the Pacific Rim can carefully review, interpret andguide the momentous forces of change influencing the delivery of quality, cost-effectivehealthcare to our population. A most recent wording confirms that our mission is to provide a forum forcardiovascular and thoracic surgeons, cardiologists and allied health care professionalsfrom Asia and the Pacific Rim to discuss the diagnoses and treatment of cardiovascular andthoracic diseases from a regional perspective as one can access on the website. Different wording, same message, adapted totimes.Phrased in slightly different ways over the years, wording always counts to expressfeelings, to reach the readership positively. Our initial issue confirmed that our missionwas and it is to provide an international forum focusing on topics of interest to the AsiaPacific region, emphasizing issues affecting our patient population and the medicalprofessionals and facilities that serve them.Asian Annals has been to deliver to the region a journal ofuncompromising professional and ethical standards. From the outset, AsianAnnals endeavoured to document and integrate the development and advancement ofAsian healthcare. Thirty years later, our humble progress indicates that our mission wasappropriate and the goal achieved.The goal of Asian Annals and continued to being published for eight years. After theidea was generated in 1991 to launch an Asian scientific journal for heart specialists, ittook three years of intense fieldwork, usually on late evenings and over the weekends at anapartment at Leonie Hill, a residential neighbourhood of Singapore, for two of the authors(FLT and CAM) to design, model and develop which type of journal would suit the needs of thesurgical community across Asia. A solid business model and a plan for financing the cost ofthe journal were established at that time.Frank Tamru, the founder of APEX, a Hawaiian-based enterpreneur, felt the need for an Asianvoice in cardiovascular and thoracic surgery. He launched the publishing company in 1984from his home in Hawaii after four years of calling on heart surgeons in the Asia PacificRegion representing an American cardiac device manufacturer. APEX in 1986 was incorporatedand headquartered in Singapore on Orchard Road, in the heart of downtown in Liat Towers.That first publication ‘A Cardiac Newsletter for Asia’  in JanuaInitially, to convene a credible editorial board, Tamru created the ACE (AsianCardiovascular Exchange) group comprised of the current leading heart surgeons fromSingapore, Malaysia, Indonesia, Japan, India, Thailand and Korea. He had previouslyrepresented Shiley Inc. throughout Asia and was quite familiar with a prestigious cohort ofsurgeons and cardiologists. All eagerly accepted to serve on the editorial board once theplan evolved further. The initial investment came from his industry contacts, earlyadvertisers were confirmed and the journal was launched in March 1993. APEX was a consistent (13 issues between 1985 and 1992) and focused tool forcommunication for clinicians and the industry. Varied business and surgical updates, newdevice introductions and readers’ opinions were compiled in printed ‘melting pot’ housingnews for the region. APEX became a timely and trustable vehicle that gained popularity overthe years. However, there still was a gap to fill in the form of a credible journal. WhenAsian Annals was finally launched, an appealing motto ‘The Voice ofCardiothoracic Medicine in Asia’ was chosen as it perfectly matched the Mission ofAsian Annals, to provide a forum for cardiovascular and thoracicsurgeons, cardiologists and allied health care professionals from Asia and the Pacific Rim. This holds true today.A motto is a short sentence or phrase that expresses a belief or purpose. These decisions are of critical importance for the quality and prestige of anypublication, especially in current times where scientific and academic fraud are more commonthan expected.811 Among the different responsibilities of the EIC, one of the mostimportant is to ensure that ethical standards are kept to the highest level. Furthermore,the EIC has to be instrumental in ensuring an appropriate relay when the term is over,something which might not be easy, as taking over from a predecessor implies a learningcurve, too. This, without disturbing the smooth journal process.The Editor-in-Chief (EIC) is the highest-ranking member of the Editorial Team of any givenmedia and the individual with full responsibility for its operations and policies. The EICis the final arbitrator of all decisions of a given publication, such as the decision topublish or reject a contribution, the publication's scope, inquiries and editorial priorities.  was chosen as he wasthe senior-most member of the ACE group and a respected colleague in Thailand and acrossAsia. He served as EIC between 1993 and 1994 and oversaw the birth of a truly Asian projectwhich at that time had not a societal affiliation, a goal that took some time to be reached.These first few years were marked by the difficulties of starting a journal in the region ashe highlighted in a compelling editorial .Asian Annals, whose growth remained slow. Aprimary goal was to convince the Asian readership to capture their scientific production ina homegrown publication.Prof. Hitoshi Koyanagi from Tokyo was the EIC from 1995 to 1996. He was instrumental inaccelerating the progress of AsianAnnals expanded into the international arena and was included into the CTSNetjournal collection thanks to the close relationship Publisher Tamru had with threeinfluential western surgeons who were promoting CTS membership in Asia. Of interest, both Asian Associations, the Asian Society of Cardiovascular Surgery(ASCVS) and the Association of Cardiovascular and Thoracic Surgeons of Asia (ACVTSA), weresimultaneously affiliated in different ways with Asian Annals for sometime. The three first editors cooperated with the Editorial Office in Singapore led byTamru's dedicated invaluable Managing Editor Mrs. Patricia Siow.Dr Cho Bum Koo from Seoul took over in 1997; under his seven-year tutelage, Asian Annals under itsrenewed format. The editorial production was handed over from Asia Publishing Exchange Pte.Ltd to a new team in Hong Kong supervised by Mrs. Lindy Chan, working with SAGE Publications(currently SAGE Publishing), to reduce production costs. During his tenure, Dr Cheungoversaw the transition to electronic manuscript processing, completed a few years later.This favoured a faster review process and improved the efficiency of the editorial process.The number of issues increased from four to six yearly. Dr Cheung finally transferred Asian Annals to SAGE Publications.In 2004, Dr David LC Cheung from Hong Kong took over the reins from Dr Cho and relocatedthe Editorial Office to Hong Kong, where he oversaw AsianAnnals so far. Dr Sampathkumar from Delhi, a former EIC of the IndianJournal of Thoracic and Cardiovascular Surgery, choose three dedicatedsection editors to deal with adult cardiac surgery, congenital surgery and thoracic surgery.Although associate editors were assisting the EIC since 1993, this assignment by area hasbeen active right up today. He brought in new members for the International Advisory Boardand incorporated experienced reviewers. Under Dr Sampathkumar, who worked closely with SAGE's Mr Will Rushton, AsianAnnals went to 9 issues a year, starting in 2014. Further, reciprocal ads inAnnals of Thoracic Surgery, the European Journal of CardiothoracicSurgery and the Journal of Thoracic and Cardiovascular Surgerywere exchanged to expand the journal's visibility. In 2018, in a meeting of all the journaleditors in Boston, the agreement was made to co-publish important articles on guidelines inall the journals. Additionally, Asian Annals joined the Cardiac SurgeryIntersociety Alliance (CSIA). This is an initiative of the American Association for ThoracicSurgery (AATS), the Society of Thoracic Surgeons (STS), the European Association ofCardio-thoracic Surgery (EACTS), the Asian Society of Cardiovascular and Thoracic Surgery(ASCVTS) and the World Heart Federation (WHF). The CSIA began with a desire to assistunderserved populations with cardiac surgery, particularly in Africa. The Memorandum ofUnderstanding (MOU) is signed by all association presidents. Dr Sanghoon Jheon signed theagreement to support the CSIA in his function as President of ASCVTS.Dr Arkalgud Sampathkumar's tenure started in 2011, the longest of any EIC of Asian Annalsand started publishing Special Issues18 which, together with an increasing numberof original and review articles, will hopefully reach a major goal of receiving an impactfactor which has been preliminary calculated by SAGE Journals at 1.272.Dr Yutaka Okita from Kobe, the current EIC, took over at the beginning of 2020. He hasrevamped the Editorial Board, incorporating a fourth section editor for aortic surgery. TheInternational Advisory Board has also been renewed. Through these difficult and challengingtimes of the COVID-19 pandemic, Dr Okita has successfully led The Editorial Board (EB) is a group of professionals with proven clinical and researchexperience and prominent people in the fields of interest of the journal. The EB is alsoknown by other names like Advisory Board. The importance of the EB cannot be neglected, asthis prestigious group is also a part of the Journal's corporate image. The members of theEB support the EIC in a number of different ways, from selecting reviewers to writingeditorials or another kind of articles. The EB is well scrutinized by the readership. Hence,choosing the appropriate members is also an important task for the EIC that shouldpositively revert to the journal.Asian Annals understood this from theoutset. The initial Asian Annals Board included the first three AssociateEditors, Drs. Cho Bum Koo from Seoul, Saw Huat Seong from Singapore and Naresh Trehan fromDelhi  and fully adheres to publication ethics.Asian Annals follows the IMRAD style30 in line with any other modernpublication. And, of course, the universally accepted original articles, case reports,images, review articles, editorials and editorial commentaries, and technical sections havebeen contemplated over these three decades.Asian Annalshas been receiving continuous help over three decades from the different Associate/SectionEditors, successive prominent members of the Editorial Board and a large contingent ofaltruistic reviewers that helped Asian Annals to improve quality over time.This cannot go unnoticed. The issue of quality was addressed by EIC Dr Cho and it was always the policy of Asian Annals taking reviewercomments very seriously as it has to be.The Editors-in-Chief understand that the first milestone of Asian Annals publishers.As known, Frank Tamru was the Founder and Publisher for its first decade. Theenterpreneurial creation of APEX, based first in Hawaii and moved to Singapore in 1986, laidthe groundwork for the launch of Asian Annals. Mrs. Patrica Siow, hired byTamru for an unrelated project, was the Managing Editor until the office was relocated toHong Kong. During these years, APEX was assisted by Silent Partners in Austin, Texas, USA.In Hong Kong, Dr David Cheung had invested his funds to manage Asian Annalsand transferred to SAGE. SAGE owns Asian Annals and has an affiliation withthe ASCVTS.Another milestone has been the relationship with Asian Annals into what istoday, an Asian Journal with international projection beyond the extensive regional limits.They can be summarized as follows: Asian Annals was indexed/abstracted in the EMBASE/ExcerptaMedica database, which allowed authors around the world to access our publishedpapers.Despite significant shortcomings in terms of managing staff and limited budget, in1998, Asian Annals joined the Annals of ThoracicSurgery, The Journal of Thoracic and CardiovascularSurgery and the European Journal of Cardio-ThoracicSurgery on the Cardiothoracic Surgery Network (CTSNet) with full-textonline via a simple click on www.ctsnet.org. Having Asian Annals placed side-by-sidewith these publications greatly encouraged the publisher and editorial board membersto continue. The perceived value of being on CTSNet transformed into a reality andtranslated into a three-fold increase in the number of submissions/year immediatelyafter being posted on CTSNet. Being on the Internet via CTSNet allowed AsianAnnals to fully represent the interests of Asian cardiothoracic surgeons inwhat was quickly becoming a worldwide international network of increasing value withan estimated current membership in the range of 40,000 worldwide. AsianAnnals owes a debt of gratitude to some prestigious individuals whosupported us in this endeavour. Still, we are particularly grateful to the late DrThomas B. Ferguson (1923–2013), past president of the STS and the AATS for hiscontinuous advice and guidance even before Asian Annals was launched. This was a long and difficult process.In March 2001, Asian Annals wasaccepted for MEDLINE Indexing by the prestigious National Library of Medicine in theUnited States of America. This was a major scientific milestone and encouraged ourcontributors and readership to submit more scientific production aiming at increaseits quality.After several failed attempts, in March 2002 The Asian Society of Cardiovascular and Thoracic Surgery (ASCVTS).Incidentally, the ASCVTS was founded in 1993 as Asian Society ofCardiovascular Surgery (ASCVS), the same as Asian Annalswas launched. The parent organization of the ASCVS was the Asian Chapter ofInternational Society of Cardiovascular Surgery (ISCVS), created in1972, which changed its name to Asian Society for CardiovascularSurgery (ASCVS) in 1993. In 2008, it turned into the current ASCVTS. The brief historical summary of Furuse is an elegant description of the sequence of events until ties werestrengthened between the then ASCVS and Asian Annals. Early on, FrankTamru sought a close relationship with ASCVTS as activity from their annual meetingwas highlighted in the Regional News section, and several members already served onthe Asian Annals Editorial Board. The direct affiliation betweenASCVS and Asian Annals had to wait until the year 2000 whenAsian Annals became the official publication of ASCVS, laterASCVTS, a relationship that lasts until today and will hopefully last forever.Asian Annals transitioned tonine issues.The year 2006 witnessed the transition from four to six issues, which is the minimumto aspire to be recognized as a major international journal and eventually get animpact factor. And, in the year 2014, Transition to electronic manuscript processing started after 2008. This representedalso a major step forward to improve efficiency and adapt to modern manuscripthandling.Asian Annals became an online-only journal. This isa trend in the current publishing business. Online-only has superior benefits versusprinted publications, including immediate access to recently published articles. Thislatest step of Asian Annals is in line with other prominentpublications in the field, which have readapted to cope with changes over time and new demands of thereadership.In January 2021, Having said that, some milestones have modeled The Asian Cardiovascular and Thoracic Annals, the official journal of theAsian Society for Cardiovascular and Thoracic Surgery, is a youngpublication that has reached maturity. However, the process has been bumpy, and instabilitywas sometimes a concern. Structural changes and editorial policies observed and implementedduring these three decades have made Asian Annals progress to a level ofinternational recognition, making us, readers, staff and editors proud of what has been doneuntil now. Everything began with an enterprising American devoting his career to Asia andsomeone able to overcome roadblocks and produce the region's first scientific journalcovering surgical treatment and the care for the heart.Asian Annals will continue to move forwardmaintaining the highest standards of quality. This depends, of course, of readers andcontributors submitting the best of their work. Thank you!The future starts today and


Embryonal rhabdomyosarcoma (ERMS) is a rare malignancy and occurs primarily in the first two decades of life. Botryoid rhabdomyosarcoma is an aggressive subtype of ERMS that often manifests in the genital tract of female infants and children. Due to its rarity, the optimal treatment approach has been a matter of debate. We conducted a search in the PubMed database and supplemented it with a manual search to retrieve additional papers eligible for inclusion. We retrieved 13 case reports and case series, from which we summarized that the current trend is to approach each patient with a personalized treatment plan. This consists of a combination of local debulking surgery and adjuvant or neoadjuvant chemotherapy (NACT). Effort is made in every approach to avoid radiation for the sake of preserving fertility. Radical surgeries and radiation still have a role to play in extensive disease and in cases of relapse. Despite the rarity and aggressiveness of this tumor, disease-free survival and overall prognosis is excellent, especially when it is diagnosed early, compared with other subtypes of rhabdomyosarcoma (RMS). We conclude that the practice of a multidisciplinary approach is appropriate, with favorable outcomes; however, larger-scale studies need to be organized to have a definite consensus on optimal management. Rhabdomyosarcoma (RMS) is the most common soft tissue tumor of early childhood and young adulthood, accounting for 4 to 6% of all malignancies in this age group, with boys being affected 1.5 times more frequently than girls. The primary sites of origin are in the region of the head and neck 35–40%), followed by the genitourinary tract 25%)  or botryoid rhabdomyosarcoma [tiab].Observational cohort studies, both prospective and retrospective; case series; case reports; and narrative and systematic reviews that reported on the management and the prognosis of botryoid sarcoma were included in the present review. Studies were included irrespective of stage of disease at initial diagnosis and use of adjuvant therapy. The exclusion criteria concerned studies with incomplete data that did not permit definitive conclusions, non-English studies, and published abstracts without available full text.The main outcomes of interest to identify in the included studies were age at diagnosis, primary location of the tumor, main symptom, size, stage, presence of metastases, treatment, status after treatment, diagnosis of relapse, treatment of relapse, follow up in months, and outcome as well as the main immunohistochemistry biomarkers used for final diagnosis.Systematic search initially identified 221 papers potentially eligible for inclusion in the present analysis. After adjusting for inclusion and exclusion criteria, there were finally 13 case series or case reports included in the present review.According to the literature search, female patients with a diagnosis of botryoides sarcoma are most commonly admitted to the hospital due to abnormal vaginal bleeding or a “grape-like” polypoid or prolapsing mass protruding from the vaginal introitus. In some cases, additional symptoms have also been described such as leukorrhea and malodorous discharge . In addiAs with most malignancies, the key prognostic factor for the prognosis of botryoid RMS is the extent of disease and early disease stage at diagnosis. Overall, soft tissue sarcomas tend to have a dismal prognosis with a high recurrence risk for all stages, ranging from 45 to 73% . Furthermore, a great number of patients present with recurrence within the first 2 years after primary therapy ,38. HoweRMS is a rare tumor in childhood and adolescence, accounting for 4–6% of pediatric cancers. The female genital tract is considered the prognostically favorable site, given the improved outcomes during the last several decades. Botryoid sarcoma accounts for the majority of cases of the most common RMS histologic subtype: embryonal RMS. It is found under the mucosal surface of body orifices such as the vagina, bladder, and cervix and accounts for around 10% of all RMS cases. Until today, no clear risk factor for botryoid sarcoma could be identified with certainty due to the low number of published cases. The vast majority of cases occur sporadically. Data from a number of literature reports mention the following risk factors: aging, a certain race (African-American women have double the incidence of White Americans), 5 or more years of tamoxifen prescription, and history of radiation exposure. However, the parity, age of menarche, and menopause were not identified to affect the occurrence of RMS . ChemicaThe pathophysiology behind the formation of sarcoma botryoides remains unknown until today. The greater percentage of children who present with this malignancy have no antecedent risk factors. However, it is more likely to develop in individuals with familial diseases that induce mutations in genes responsible for cell proliferation and death (such as Li–Fraumeni syndrome). Despite the mainly sporadic character of the malignancy, a small portion of cases have been associated with genetic diseases such Li–Fraumeni cancer susceptibility syndrome, familial pleuropulmonary tumor, neurofibromatosis Type I, and Beckwith–Wiedemann syndrome. However, the incidence may be higher in patients diagnosed with RMS before the age of 3 . SpecifiAccording to the literature, the diagnosis of this tumor is difficult to make, but as far as the management of this tumor is concerned, there are a variety of approaches in the treatment armamentarium, ranging from extreme, radical procedures to more conservative ones. Nuclear MRI is the gold standard for determining where the tumor originates from  as well as the spread and involvement of neighboring structures. Because of its rarity and high-risk, malignant nature originating in the embryonic mesenchyme, botryoid sarcoma should be suspected in young-age females with vaginal bleeding or a prolapsed mass, since typically the tumor develops behind the mucosal membrane of the organs, forcing the growth to take on a characteristic grape-like form. The importance of histology in RMS prognosis cannot be overstated. Although there are three types of RMS , the embryonal type is the more prevalent and has a better prognosis than the alveolar type, which is rare and has a worse prognosis . The IntIt is of paramount importance to organize a personalized treatment plan, considering the extent of the disease and the fertility preservation. The management of botryoid rhabdomyosarcoma poses a great challenge for gynecologists. In the past, the traditional treatment for these types of tumors involved exenterative procedures, but today, modalities such as fertility-sparing methods, e.g., polypectomy, conization, local excisions, and robot-assisted radical trachelectomy, are offered and are the ones mostly implemented for the preservation of the reproductive ability. In the last decades, a variety of procedures have been added to the options of pediatric genitourinary and anorectal reconstruction. Buccal mucosa grafts are now widely employed in both adult and pediatric urology for urethral reconstruction with acceptable results. Recent reports have established that buccal mucosa vaginoplasty leads to good outcomes in patients with Mayer–Rokitansky–Kuster–Hauser syndrome (MRKH—agenesis of the Mullerian structures and vagina), complete androgen insensitivity syndrome, and repair of urogenital sinus, as far as cosmetic and functionality results are concerned. Evidence suggests that the grafts retain favorable characteristics over time and adapt well to rapid growth demands such as those imposed by puberty. Harvesting the graft is straightforward and associated with minimal morbidity. In addition, buccal grafts greatly resemble the vaginal tissue that they are to replace. Nevertheless, as with every newly introduced procedure, long-term follow up is necessary to assess the oncological outcomes since it does not represent a standard of care but rather an intervention that holds promise as a viable option with minimal esthetic impact.It was the first IRGS trial (1972 and 1978) that recommended systematic chemotherapy following extensive surgery such as radical hysterectomy or pelvic exenteration for ERMS of the genital tract . The secOther regimens consist of VAC plus VAI  plus VAC for 12 months. A randomized controlled trial by Amdt et al. compared the VAC regimen and the combination of vincristine, topotecan, and cyclophosphamide for the treatment of moderated-risk rhabdomyosarcoma. The results suggest that topotecan was not indicated to be more efficient than actinomycin D, with 68% and 73% 4-year survival rates, respectively. Irinotecan is another drug that is currently under examination for its efficacy in the treatment of pediatric rhabdomyosarcoma when combined with the VAC regimen .Surgery and/or radiation still play an important role in the management of high-risk RMS with oligometastatic disease to minimize treatment failures. Aggressive surgical local control most of the time offers the advantage of sparing these young patients radiation-associated complications. However, it should be kept in mind that surgical resection is not without its own possible complications, including wound infections, fistulas, and stenosis . In caseThe present summative review is, to the best of our knowledge, the first one trying to summarize the main literature outcomes about therapeutic management and prognosis. The main limitation of the present manuscript is the fact that it is a narrative review only summarizing results of relatively low-level evidence, such as retrospective series and case reports, as no prospective RCTs or large prospective cohorts were identified through the literature search. However, despite the fact that the level of evidence is low, this is relatively reasonable because the rarity of the disease poses reasonable difficulties in the conduct of level-I evidence studies. Furthermore, as our review finally summarized the main conclusions about the therapeutic modalities and prognostic outcomes, this might be the initial step to organize prospective observational cohorts, rather than multicenter ones, in an attempt to globalize the standards of practice and, thereafter, improve the outcomes of such a demanding clinical entity.


There is a dearth of research on the nature and extent of variation in patterns of health service use in Saudi Arabia. This is an important gap in knowledge, given ongoing efforts to improve service provision and delivery. This study examined the relationship between the region of residence and socio-demographic factors and patterns of health service use in Saudi Arabia.Data were taken from the 2013 Saudi Health Interview Survey (SHIS), a national multistage survey of individuals aged 15 years and above in Saudi Arabia. Data included measures of service use, respondent health, socio-demographic characteristics, and region or area of residence. Descriptive statistics, Chi-square tests, and multivariable logistic regression analyses were used to describe the data and examine the likelihood of a respondent visiting a doctor or healthcare professional in the preceding 12 months. In addition, the analyses examined the role of health and socio-demographic characteristics within selected regions.p < 0.01). Residents who lived in Riyadh, Al Medina, Baha, or Aseer demonstrated a higher likelihood of service utilization compared to respondents residing in other regions (p < 0.05). In sub-group analyses, there was variation between regions with respect to socio-demographic status and distance to service.The increased likelihood of using health services in terms of visiting a doctor or healthcare professional was related to poor health status, being female, married, having a low income, and residing in particular regions. Respondents aged <65 and who lived furthest from service providers were less likely to visit a doctor or other health professionals  of health service use. The findings from this study underscore the importance of considering region or area of residence when seeking to understand the utilization of health services, particularly primary care services. Primary care services are central to maintaining overall population health . They maIn Saudi Arabia, primary care services are provided free at the point of use to all citizens through a system of primary care clinics operated across the country . The Minper se  has been used to examine differences in the use of healthcare services in a variety of contexts –19. In bThis study examines the relationship between regional and socio-demographic factors and patterns of health service use in Saudi Arabia. It extends the existing literature by explicitly incorporating individual income, region of residence, and a broader range of health characteristics using data collected from across Saudi Arabia.assumed questions related to doctor/other health professional for “illness, injury, immunization, other preventive service, and other” were likely to be primary care visits by virtue of the staff providing the service and the service being provided. The visits to a doctor or other healthcare professional constituted our measure of service use, though it is accepted that this was based on an assumption. No distinction was made between public and privately funded care. Descriptive statistics, Chi-square test, and multivariable logistic regression analyses were used to examine the relationship between the likelihood of visiting a doctor or other healthcare professional in the preceding 12 months. Respondent health and socio-demographic characteristics, including income and the region of residence, were included among the list of covariates. In subsequent analyses, the sample was categorized by region to examine the role of health and socio-demographic characteristics within selected regions. Analysis was confined to respondents for whom complete records were available. Further details about the survey are available on the SA Ministry of Health website , a national survey of individuals aged 15 and above in Saudi Arabia, was used to investigate the study's aims. The SHIS uses a multistage stratified probability sample to select study participants, ensuring representation from each region of the Kingdom of Saudi Arabia. The Kingdom was divided into clusters of households known as enumeration units, serving as primary sampling units (PSUs). The number of households in each PSU varied based on population, density, and geography. A probability proportional to size method was employed to randomly select PSUs from each of the 13 administrative regions. Within each PSU, 14 households were randomly chosen, totaling 12,000 households contacted. Out of these, 10,827 completed the survey. An additional 1,173 either partially completed or completed some sections but not the entire survey. Data included aspects of respondent health, socio-demographic characteristics, and region of residence. The survey explored the use of a range of services in sequence. Questions were grouped under separate headings, with individuals being asked if they used a clinic, hospital, or doctor/other health professional as options and asked after each option questions on the purpose of the visit and how recently it was made. We  website .p ≤ 0.05 level. As we were interested in differences between groups rather than reporting national estimates of use for groups, no attempt was made to weigh responses. All analyses were conducted in Stata version 16.0.The use of services was based on response to the question of whether the respondent had visited a doctor or health professional in the past 12 months (yes or no). Descriptive statistics  were used to describe the sample. Chi-square tests were used to compare groups differentiated with respect to morbidity, self-reported health, and income in terms of service use. Multivariable logistic regression analyses were undertaken in which the use of services in the preceding 12 months was specified as a function of a range of variables. Variable selection was determined by availability in the dataset and previous literature examining utilization with services . These wIn most healthcare systems, primary care is the first and most frequent point of contact between the public and the health service. It occupies a pivotal role in referral to secondary services and is central to the efficient and equitable operation of the entire service. There is a paucity of research about variations in the use of health services  in SaudiThe use of ABM allows us to interpret results in terms of the influence of specific variables as contributing to need, predisposing, and enabling factors and to relate our findings to those of others. Our findings that older and married respondents and those with poorer health are more likely to use services, as shown in Within the context of the ABM model, it is easy to conceptualize the increased likelihood of use related to health as related to needs. Thus, older individuals and those who report poor health or have been diagnosed with morbidity would be likely to exhibit a greater need for medical care. Our finding echoes those from other studies , 30. WitThat place of residence/region is significant see  and thatThe role of sex, seen within the ABM as a predisposing factor, warrants comment. In Saudi Arabia, it remains customary for females to be accompanied by a male family member when visiting health facilities to seek medical care. Males in our sample were ~20% less likely to have visited a doctor or other health professional in the past 12 months than females , controlThe study has a number of strengths. That the sample covers the entire country allows for an examination of regional effects, on which there is currently a dearth of studies in the Kingdom of Saudi Arabia. The sample size is large, significantly larger than several previous studies –13, 33. Our study sheds light on the need for more research into healthcare utilization in the Kingdom of Saudi Arabia, particularly given the limited literature in this area. Our findings emphasize the importance of considering regional influences when interpreting the role of specific variables in healthcare utilization. We suggest that future studies should pay careful attention to regional differences when examining the role of specific variables and explore the potential impact of cultural and social factors on healthcare utilization. Overall, our study highlights the need for more research in order to enhance the understanding of variations in service use and increase the evidence-based redesign of services that will improve health outcomes and reduce healthcare disparities in the Kingdom of Saudi Arabia.Maljohani01@qub.ac.uk.The data analyzed in this study is subject to the following licenses/restrictions. Data sharing is restricted as the data belongs to Ministry of Health in Saudi Arabia and only is available from corresponding author upon reasonable request. Requests to access these datasets should be directed to MA, MD, and CO'N conceived and drafted the study. MA and CO'N designed the research. MA analyzed the data. MA, MD, CO'N, and IA contributed to the drafting of the paper. All authors approved the final draft of the manuscript.