Collisions in rugby union and sevens have a high injury incidence and burden, and are also associated with player and team performance. Understanding the frequency and intensity of these collisions is therefore important for coaches and practitioners to adequately prepare players for competition. The aim of this review is to synthesise the current literature to provide a summary of the collision frequencies and intensities for rugby union and rugby sevens based on video-based analysis and microtechnology.A systematic search using key words was done on four different databases from 1 January 1990 to 1 September 2021 .n = 37) to quantify collisions. In rugby union, on average a total of 22.0 (19.0–25.0) scrums, 116.2 (62.7–169.7) rucks, and 156.1 (121.2–191.0) tackles occur per match. In sevens, on average 1.8 (1.7–2.0) scrums, 4.8 (0–11.8) rucks and 14.1 (0–32.8) tackles occur per match.Seventy-three studies were included in the final review, with fifty-eight studies focusing on rugby union, while fifteen studies explored rugby sevens. Of the included studies, four focused on training—three in rugby union and one in sevens, two focused on both training and match-play in rugby union and one in rugby sevens, while the remaining sixty-six studies explored collisions from match-play. The studies included, provincial, national, international, professional, experienced, novice and collegiate players. Most of the studies used video-based analysis (This review showed more studies quantified collisions in matches compared to training. To ensure athletes are adequately prepared for match collision loads, training should be prescribed to meet the match demands. Per minute, rugby sevens players perform more tackles and ball carries into contact than rugby union players and forwards experienced more impacts and tackles than backs. Forwards also perform more very heavy impacts and severe impacts than backs in rugby union. To improve the relationship between matches and training, integrating both video-based analysis and microtechnology is recommended. The frequency and intensity of collisions in training and matches may lead to adaptations for a “collision-fit” player and lend itself to general training principles such as periodisation for optimum collision adaptation.Trial Registration PROSPERO registration number: CRD42020191112.The online version contains supplementary material available at 10.1186/s40798-021-00398-4. In this systematic review of collision frequency and intensity in rugby union and rugby sevens, only four studies quantified collision frequencies and/or intensities in training, three focused on both training and match-play, while 66 studies quantified frequencies and/or intensities of collisions in matches. Further investigation is needed to improve and understand the relationship between training and matches.Per minute, rugby sevens players perform more tackles and ball carries into contact than rugby union players and forwards experienced more impacts and tackles than backs. Forwards also perform more very heavy impacts and severe impacts than backs in rugby union.Integrating video-based analysis and microtechnology is recommended, and the metrics and grouping variables between training and matches should be consistent.The frequency and intensity of collisions in training and matches may lead to adaptations for a “collision-fit” player and lend itself to general training principles such as periodisation for optimum collision adaptation.Rugby union and rugby sevens  are invasion team sports that are characterised by frequent high speed running and physical collisions , 2. AlthGiven the high injury incidence and burden, and the positive performance outcomes associated with winning collisions in rugby union and sevens, it is important for coaches and practitioners to adequately prepare players for competition. To do this, they need to know the frequency and intensity of these collisions in both training and matches . In matcIn sport, microtechnology typically incorporates global positioning systems (GPS) and micro-electrical mechanical systems (MEMs) that capture the external physical demands of competition and training . CommercTo benefit coaches and practitioners, and aid injury prevention and injury management strategies, a synthesis of the frequency and intensity of collisions in rugby union and sevens to date, both in training and matches, is required. For example, a coach who understands the positional match tackle frequencies and intensities can optimise tackle training sessions to meet those position specific match demands. Since one of the roles of coaches and practitioners is to ensure positive adaptations to training and reduce maladaptation, understanding the frequency and intensity of collisions may also aid optimising recovery between training and matches. Therefore, the aim of this systematic review to synthesise the collision frequencies and intensities for rugby union and rugby sevens based on video-based analysis and microtechnology.n = 73) was also examined.The search strategy was based on a similar systematic review in rugby league . The curAfter consolidating the studies from the different electronic databases, LP removed the duplicates and screened the titles and abstracts Fig.  for eligCollisions were broadly defined as any physical contact made with another player (teammate or opposition), which resulted in an alteration to the player’s momentum. This included collisions such as the tackle (tackling and being tackled), scrums, rucks and mauls , 27. Forvery heavy (8–10 g), severe (> 10 g) or another range that was specific to the device based on the nature of the collision [Data relating to participant characteristics , context , method used to quantify the collisions , the model and specifics of the device , video-based analysis characteristics , and collision characteristics were extracted from the final 73 full-text articles. Collision characteristics included type of collision, number of matches or training sessions, year of competition, absolute frequency (number), collisions in relation to playing time (number of collisions per minute) and the intensity of each collision. Collision intensity was commonly classified as ollision .The quality of the included studies was assessed using the checklist of Downs and Black’s assessment of methodological quality . QuestioI-squared (I^2) used to assess the heterogeneity of the data. I^2 of 0–40% was considered low heterogeneity, 40–75%: moderate heterogeneity and > 70% was considered high heterogeneity [All data were reported in the tables as mean ± standard deviation (SD) unless stated otherwise. Where possible, a meta-analysis  was completed to produce a pooled mean and 95% confidence intervals (CI). An analysis was only conducted if there were at least two studies with mean and standard deviations. The DerSimonian-Laird continuous random-effects analysis method was used for the meta-analysis, with ogeneity . The forThe literature search captured 1114 papers  , 91, 95and thirty-seven studies used video-based analysis 51%) [1% 5, 8,, 92–94 (Ten studies recorded collision frequency using microtechnology in match-play (14%) , 84, 91 very heavy impacts and 10.8 (4.4–17.1) severe impacts per match  severe impacts per match [impacts > 5 g per min [impacts > 5 g per min [very heavy contacts in the second half of the match in comparison to the first half of the match. Backs experience fewer impacts in the second half of the match in comparison to the first half of the match [Sixteen studies recorded the intensity of collisions by using microtechnology 22%) Table  20, 25,, 91, 95.2% Table er match , 76, 77 er match –83. On a per min , 83  , 80. Braimpacts > 10 g per match  reported collision frequency using microtechnology during match-play , 62, 78.tch Fig.  [35, 36,Only one study reported tackle frequency during training (on average 17.8 ± 4.4 tackles per week) .Thirty-seven studies recorded the collision frequency using video-based analysis methods 51%) , 92–94 1% , 92–9 41, 43,, 68, 74.Only one study reported collision frequency during training . Vaz et Eight studies recorded the collision frequency by using video-based analysis (11%) Table  3, 5, 3, 70–72. No video-based training studies were found for sevens.very heavy impacts (52.5 (29.8–75.2) vs. 41.7 (26.4–57.0) very heavy impacts) and severe impacts (10.8 (4.4–17.1) vs. 6.7 (5.1–8.4) severe impacts) than backs in rugby union. Coaches are recommended to train players specific to their positional grouping for appropriate adaptations. In both rugby cohorts, only six studies were completed on females [To our knowledge, this is the first systematic review on quantifying collision frequency and intensity in rugby union and rugby sevens. This review demonstrates that video-based analysis and microtechnology are the main methods used to quantify collisions in rugby union and sevens. Not surprisingly, the absolute collision frequency during sevens matches was lower than rugby union due to the shorter duration of the game and fewer players on the field. When comparing relative frequencies though, rugby union players seem to perform less tackles and ball carries into contact than sevens players, while rucks per minute were similar between the two rugby codes , 70. Exp females , 77, 94  females , 38. OveTo optimise training, researchers, trainers and sport practitioners typically study competition activities and demands, and attempt to replicate these demands in training , 93, 97.n = 37), microtechnology (n = 24) or both methods (n = 12). Each method has its advantages and disadvantages. For example, video-based analysis is laborious and reliant on human observation, while it may capture more contextual detail of the collision event [Collision frequency and intensities have been quantified in studies using video-based analysis  and grouping variables  between training and matches need to be consistent and more accurate. In other words, how collision demands are reported for matches should be useful to the coach and practitioner, and transferable to a training setting. Therefore, metrics and grouping variables between the two settings need to be consistent to ensure this transfer. Strong engagement with the coach and practitioner when developing reporting metrics is therefore recommended . RecentlThe purpose of this review was to synthesise the frequency and intensity of collisions during training and matches in rugby union and sevens. In both rugby cohorts, future studies should investigate training in comparison to match-play. Additionally, future studies should explore women’s rugby. Many of these groups were understudied and are very important in our rugby community. A consensus-based approach for microtechnology is warranted since grouping variables and metrics were inconsistent throughout the studies. Beyond this, there are a number of other factors that can affect how players respond and adapt to different frequencies and intensities of contact. Collision events in rugby union and sevens are dynamic and have a major technical-skill component , 103. Thvery heavy impacts) and severe impacts (10.8 (4.4–17.1) vs. 6.7 (5.1–8.4) severe impacts) than backs in rugby union. The frequency and intensity of collisions in training and matches may lead to adaptations for a “collision-fit” player and lend themselves to general training principles such as periodisation for optimum collision adaptation. Subjective measures such as RPE and RPC should be incorporated into the monitoring and management of the collision section of training to understand the internal load.In conclusion, this review found a discrepancy in the number of studies quantifying collision demands in training compared to matches. While more work on quantifying the collision demands of training is required, studies should also compare training and matches if we are to improve our understanding of the relationship between training and matches. Another key finding is that the main method for quantifying collisions was video-based analysis. To improve the relationship between matches and training, integrating both video-based analysis and microtechnology is recommended, and the metrics and grouping variables between training and matches should be consistent. Per minute, rugby sevens players perform more tackles and ball carries into contact than rugby union players and forwards experienced more tackles than backs (12.8 (7.5–18.1) tackles and 7.6 (4.3–10.9) tackles, respectively). Another key finding in this review is that forwards experience more very heavy impacts (52.5 (29.8–75.2) vs. 41.7 (26.4–57.0) Additional file 1: Table S1. Methodological quality assessment of the final full text articles according to Downs et al. [Table S2. Characteristics of studies using microtechnology to record collisions during match-play or training sessions. Table S3. Characteristics of studies using video-based analysis to record collisions during match-play or training sessions.s et al. . Table S


There is no recent information about dental service utilization (DSU) among elderly in Lithuania. We examined DSU and its associated factors in Lithuanian early elderly based on the Andersen’s behavioural model.The cross-sectional study conducted in 2017–2019 included a nationally representative stratified sample of 370 Lithuanian early elderly aged 65–74 years (response rate of 54.5%). Information on predisposing factors , enabling factor (residence), need-based factors , general health, personal health practices and perceived stress was obtained from a structured, self-administered questionnaire. Clinically-assessed need-based factors included number of missing teeth and dental treatment need. Multivariable Poisson regression with robust variance estimates was used.A total of 239 study participants (64.6%) reported a dental visit during the last year and 338 (91.4%) needed dental treatments. A higher level of education , pain or discomfort in teeth/mouth  and lower number of missing teeth  were associated with DSU.Even though majority of early elderly needed dental treatments, only two-thirds visited a dentist during the last year. Predisposing and need-based factors were significant predictors of having a dental visit in the last year. A national oral health program for Lithuanian elderly with the focus on regular preventive dental check-ups is needed. More studies, both quantitative and qualitative, are warranted to investigate in depth the barriers for DSU among elderly in Lithuania. Oral health in elderly is an important public health issue. Despite significant progress in preventive measures that promote oral health in children, oral diseases and conditions such as dental caries, periodontal diseases, hyposalivation, xerostomia, and oral cancer remain prevalent and often underdiagnosed and untreated in elderly. These oral problems may lead to pain and discomfort, tooth loss, local and systemic inflammation, impairment of a person’s functional, social and psychological well-being. Availability and accessibility of dental care to elderly, their willingness to seek it are important to identify oral health problems at early stages and provide necessary preventive and curative measures .predisposing factors , enabling factors , and need-based factors . Importantly, systemic diseases and medications as sources of hyposalivation and xerostomia in elderly may also cause deterioration in oral health and quality of life and lead to seek dental care [personal health practices  were added [psychosocial factors may determine health and dental service use [Many studies examining dental service utilization (DSU) and its determinants applied the Andersen’s behavioural model of healthcare use –6. This tal care , 8. In are added –7, 9. Movice use . Indeed,vice use . Despitevice use . In adulvice use .Lithuania is one of the Baltic States in Northern Europe with a total population of 2.8 million in 2020, of whom 71% are living in urban areas . An oralThe aim of the study was to examine DSU and its associated factors in a nationally representative sample of Lithuanian early elderly aged 65–74 years using the Andersen’s behavioural model as the theoretical framework. The DSU model of the present study is presented in Fig. The current cross-sectional study was carried out as a part of the Lithuanian National Oral Health Survey conducted in 2017–2019. The study was approved by the Lithuanian Bioethical Committee (No. 158200–17–920-426) and the Personal Data Protection Authority (No. 2R-4077). Altogether, 679 early elderly people aged 65–74 years from the five largest Lithuanian cities and 10 randomly selected peri-urban/rural areas, one in each of 10 Lithuanian counties, were extracted from the patient lists at primary health care institutions and invited to participate in the study. A total of 370 participants (response rate of 54.5%) completed a structured self-administered questionnaire and underwent a clinical dental examination. More details on sampling have been published elsewhere .The World Health Organization (WHO) Oral Health Questionnaire for Adults  was usedThe variable “DSU during the last year” was the study’s outcome. Study participants reported when they visited a dentist last time. Responses included (1) less than 6 months ago, (2) 6–12 months ago, (3) more than 1 year ago, but less than 2 years ago, (4) 2 years ago or more, but less than 5 years ago, (5) 5 years ago or more, (6) never received dental care. For analysis, original responses of the “DSU during the last year” were dichotomized into yes  or no (3–6).n = 27), this data was considered missing. The variable “experienced pain or discomfort in teeth or mouth in the last year” was dichotomized into yes and no/do not know. Information on dry mouth  was also collected. Study participants reporting dry mouth sometimes, often or always were categorized as having, others as not having dry mouth. Information on number of missing teeth due to caries or for any other reason and dental treatment need was obtained from the clinical dental examination. In accordance with the WHO recommendations for oral health surveys [This set of variables consisted of predisposing, enabling, and need-based factors, self-reported general health status, personal health practices, and psychological factors. Predisposing factors included two age groups (65–69/70–74 years), sex, nationality (Lithuanian /Russian /Belorussian/ Ukrainian/Polish/other), and education (no education /less than primary/primary/secondary/higher non-university/university: Bachelor degree or higher). For analysis, the variable “education” was categorized into: less than university and university. Residence  was considered as an enabling factor. Information on need-based factors was gathered from both the questionnaire and clinical dental examination. Study participants were asked to report about their teeth status on a 6-point scale: (1) excellent, (2) very good, (3) good, (4) average, (5) poor, (6) very poor. For analysis, three categories were used: good (1–3), average (4), and poor . The question also included the response option “do not know”. If that response was chosen  and taking medications on regular basis (yes/no). Tooth-brushing frequency, using fluoride toothpaste, cigarette smoking, and alcohol use were considered as personal health practices. For analysis, tooth-brushing frequency was dichotomized into less than twice a day (never/once a month/2–3 times a month/once a week/2–6 times a week/once a day) and twice a day or more frequently. The variable “using fluoride toothpaste” was categorized as yes and no/do not know. Cigarette smoking was assessed as no (never) and yes . Moreover, study participants were asked how much alcohol they usually drank per day in the last month. Responses were: (0) less than 1 unit, (1) 1 unit, (2) 2 units, (3) 3 units, (4) 4 units, (5) 5 units and more, (6) did not drink alcohol in the last month. For analysis, this variable included two categories: yes (0–5) and no (6).Perceived stress was considered as a psychological factor and measured by the PSS-10 . The translation of the PSS-14, which contains the same 10 items as PSS-10 and four additional items, into Lithuanian was previously done . Given tThe Chi-square test was used to compare proportions of elderly people who visited a dentist during the last year and who did not report such visits among categories of independent variables. The number of missing teeth between the elderly who had and the ones who did not have a dental visit during the last year was compared employing the Mann-Whitney U test.p-values < 0.15 from the bivariable analyses. The results are presented as adjusted prevalence ratios (aPRs) with 95% confidence intervals (CIs). Significance level for all tests was set up at α = 5%.Multivariable Poisson regression with robust variance estimates was used , with thThe most of variables used in analyses had missing values that varied from 0.3 to 7.8%. Of all, 23.8% of the respondents had missing values in PSS-10 scale. To mitigate a potential bias, the missing values in the items of the PSS-10 scale were substituted by the median for any missing item. The analysis was repeated with the substituted data, and no significant differences were found between the two analyses. Final multivariable analysis was based on the complete data i.e. with no missing values.All analyses were performed using IBM SPSS Statistics version 26.0  and STATA version 15.0 .A total of 370 persons aged 64–75 years were included in the statistical analyses, of which 239 (64.6%) reported a dental visit during the last year, 122 (33.0%) did not report such visit, and 9 (2.4%) did not answer. The prevalence of DSU was 68.6 and 65.5% in early elderly aged 65–69 and 70–74 years, respectively.p = 0.018  or did not consume (48.6%) alcohol during the last month. The mean PSS-10 score was 16.4, and almost half of the study participants reported moderate level of perceived stress. No statistically significant differences were observed in DSU during the last year between different categories of personal health practices and perceived stress Table .Multivariable analysis showed that experiencing pain or discomfort in teeth or mouth in the last year was the strongest predictor of having a dental visit. A higher level of education and a lower number of missing teeth were also significant predictors of DSU Table .This is the first study in Lithuania in last 20 years to assess dental service utilization among early elderly. The response rate of 54.5% was comparable with the rate observed in a previous Lithuanian study conducted in 1997/1998 (55.0%) . A samplSome limitations should be taken into consideration when interpreting the study results. A cross-sectional study design does not allow any causal inferences. We considered only one enabling factor (residence), as information about other potential enabling factors such as perceived access to dental care, dental anxiety, and transportation or travel time was not available. Moreover, no economic determinants of DSU  such as In our study, the prevalence of dental visit in the last year among Lithuanian early elderly 64.9%) was higher than the one (42.0%) reported in the previous 1997/1998 Lithuanian study . This ti4.9% was In the present study, experiencing pain and discomfort in teeth or mouth in the last year was the strongest significant factor associated with DSU. The similar results were reported in Korean adults aged 25–79 years  and BrazOur study participants who visited a dentist in the last year had fewer missing teeth than those who did not report such visits. This finding is in line with previous reports, which showed that absence of teeth is considered an important factor of dental service non-utilization , 34, 35.In the present study, more educated elderly had a higher prevalence of DSU, and this is in agreement with other studies , 30, 32.Importantly, the same factors  that were associated with DSU in the previous 1997/1998 Lithuanian study were also significant in our study . NeverthEven though majority of early elderly needed dental treatments, only two-thirds visited a dentist during the last year. Predisposing and need-based factors were significant predictors of having a dental visit in the last year. A national oral health program for Lithuanian elderly with the focus on regular preventive dental check-ups is needed. More studies, both quantitative and qualitative, are warranted to investigate in depth the barriers for DSU among elderly in Lithuania.


Thyroid autoimmunity (TAI) has been demonstrated to be associated with adverse pregnancy including recurrent miscarriage, unexplained infertility, and implantation failure. To settle with the fertility problem, prescribing aspirin combined with prednisone (P + A) to women positive for anti-thyroid antibodies is frequent in clinical practice, but the underlying effect remains controversial.in vitro fertilization and embryo transfer (IVF-ET) cycle. Ultimately, 346 women were included of which 150 women were treated with prednisone (10 mg/d) and aspirin (100 mg/d). The remaining 196 women were untreated (control group). Treatment started on the day of embryo transfer and continued until clinical pregnancy was determined.A multicenter, retrospective study was conducted in three reproductive centers from 2017 to 2020. A total of 494 euthyroid infertile women were recruited who were positive for anti-thyroperoxidase and/or thyroglobulin antibodies  with thyroid-stimulating hormone (TSH) levels ranging 0.35-4.0mIU/L and underwent their first P = 0.414) for first fresh embryo transfer cycles and 57.8% vs. 61.8% for frozen-thawed embryo transfer cycles (P = 0.606). In addition, the live birth rate for the fresh embryo transfer was 49.6% vs. 47.3% in the control and treated groups (P = 0.762). Logistic regression revealed that aspirin plus prednisone did not improve the clinical pregnancy rate or miscarriage rate. Furthermore, it was observed that low free triiodothyronine (FT3) was associated with high miscarriage rates.The clinical pregnancy rate was 57.5% vs. 63.5% in the control and treated groups .The online version contains supplementary material available at 10.1186/s12884-022-04532-2. Successeatments –4. Thereeatments . The majeatments . In addieatments –9. Genereatments . Among teatments –12. Furteatments . When adAs a therapeutic alternative, corticosteroid hormones in combination with aspirin may potentially benefit blood perfusion to the ovaries and endometrium and decrease local inflammatory reactions to the transfer procedure, thereby inducing a more favorable microenvironment for the transferred embryo , 15. FurHence, the present study aimed to evaluate the effects of aspirin plus prednisone treatment on improving pregnancy outcomes of the first embryo transfer cycle in euthyroid infertile women who only present with positive thyroid autoimmune antibodies.In this multicenter retrospective study, a total of 5427 infertile women were included who underwent their first IVF-ET at one of three IVF centers, including the Second Affiliated Hospital of Zhejiang University School of Medicine, Ningbo Women and Children’s Hospital, and People’s Hospital of Jinhua from October 2017 to July 2020. Among them, 597 women were tested positive for TPOAb and/or TgAb. Inclusion criteria were as follows: age under 40 years old, regular spontaneous menstrual cycle (21–35 days), presence of both ovaries, normal ovarian reserve as defined by basic follicle-stimulating hormone (FSH)<10 IU/L, and antral follicle count (AFC)>5.in vitro fertilization and embryo transfer (IVF-ET) cycle were included in the study. Therefore, a total of 494 infertile women were recruited and analyzed in detail.In addition, infertile patients with thyroid-stimulating hormone (TSH) levels ranging between 0.35 and 4.0 mIU/L, receiving nothing or combined P + A, and undergoing their first n = 2), those whose thyroid function was abnormal (n = 38), those who were diagnosed with diseases affecting the uterine cavity (n = 12), and those whose infertility was caused by severe oligoasthenospermia and azoospermatism (n = 16). Similarly, eight women were excluded because they or their partners presented aberrant chromosome karyotypes with particularly significant parental balanced translocations or Turner mosaicism. One woman was excluded because of medical history of insulin-dependent diabetes mellitus (DM), seven women were excluded because of a lack of mature oocytes to retrieve, and 64 women were excluded because of not undergoing any embryo transfer for various reasons.Excluded from this study were women with other known autoimmune diseases or clinical presentations of autoimmune disorders including systemic lupus erythematosus (SLE), antiphospholipid syndrome (APS)  patients received P + A treatment.  immunoassay  in the three reproductive centers. Thyroid autoimmunity (TAI) was defined as the presence of serum antibodies directed against TPO and/or TG. The reference range was 0–5.61 IU/mL for TPOAb and <4.11 IU/mL for TgAb. Women were diagnosed with euthyroidism when serum TSH levels were within the reference range of 0.35–4.0mIU/L and none of the free thyroxine parameters (FT4) or FT3 was outside the reference values, which were 0.7-1.48ng/dL for FT4 and 1.71-3.71pg/mL for FT3. Reference values were provided by the manufacturer of the assay kits.In all groups, ovarian stimulation was performed using the following sequential regimen. Firstly, pituitary inhibition was achieved using a gonadotropin-releasing hormone (GnRH) analog  or GnRH antagonist . Secondly, patients underwent ovulation induction with recombinant follicle-stimulating hormone (FSH)  or human menopausal gonadotropin (HMG)  to obtain a cohort of mature oocytes at the time of oocyte retrieval. Furthermore, the doses of these drugs were adjusted according to the women’s age, AFC, and day3 FSH values. During that period time, cycles were monitored using transvaginal sonography together with laboratory assays. When a minimum of three leading follicles reached 17–18 mm, paired with appropriate serum E2 levels, a dose of 5000–10,000 IU of human chorionic gonadotropin (hCG)  was administered. Then Cumulus oocyte complexes were aspirated 36–38 h after hCG injection. Subsequently, whether conventional IVF or ICSI was performed was dependent on the semen condition and clinical indication. All patients were transferred good-quality embryos. Luteal phase support was added in the form of micronized progesterone capsules and oral dydrogesterone. Fourteen days after embryo transfer, serum hCG was assessed and clinical pregnancy was determined 5 weeks after embryo transfer by ultrasonography. Clinical data, including the women’s age, body mass index (BMI), duration of infertility, previous history of miscarriage, FSH, anti-Mullerian hormone (AMH), and AFC were recorded and analyzed. In addition, the following laboratory parameters and pregnancy outcomes were documented: total gonadotropin (Gn) doses, days of gonadotropin treatment, E2 levels on hCG day, endometrial thicknesses on hCG day and embryo transfer day, oocytes retrieved, fertilization rate, number of embryos for transferring, implantation rate of cleavage and blastocyst-stage embryos, pregnancy rate, clinical pregnancy rate, miscarriage rate and live birth rate.n = 196) and the treated group (n = 150). Treatment involved orally administered prednisone  and aspirin  in a daily dose of 10 mg prednisone and 100 mg aspirin. Medication was given starting on the day of embryo transfer and continued until a successful clinical pregnancy was determined by ultrasound. Meanwhile, medication was discontinued if a persistent decline in hCG value occurred.A total of 346 euthyroid infertile women with thyroid autoimmunity were divided into two groups—the control group , whereas a clinical pregnancy was defined as the existence of a viable embryo within an intrauterine gestational sac. The spontaneous abortion rate was defined as the ratio between the number of pregnancy losses after sonographic visualization of an intrauterine gestational sac and the number of clinical pregnancies. Recurrent miscarriage was determined by the loss of two or more clinical pregnancies. The implantation rate was calculated as the number of sacs with a fetal heartbeat divided by the total number of embryos transferred. A live birth rate was defined as the percentage of transfers resulting in a live birth.Data analysis was performed using the Statistics Package for Social Sciences (SPSS 24.0). First, a Kolmogorov-Smirnov test was applied to both groups and variables to evaluate whether the distribution was symmetrical. Continuous data were expressed as the median (25th–75th) when not normally distributed, and as the mean±SD for normally distributed data. Categorical data were calculated as the number (percentage) of cases. Comparisons of quantitative data were analyzed using the Mann–Whitney U test or independent T test and Chi-square or two-sided Fisher’s exact test in case of categorical data.For the logistic regression analysis, the independent variables were age and FT3 levels in the whole range. Clinical pregnancy rate and miscarriage rate were considered dependent outcomes.p < 0.05 was considered statistically significant.The significance level of alpha was defined at 0.05, and a value of P = 0.017).The characteristics of women with thyroid antibodies(+) are shown in Table No significant differences were observed in the ratio of GnRHant/GnRHa, days of ovarian stimulation, total Gn doses, E2 levels on hCG day, endometrial thicknesses on hCG day, number of oocytes retrieved, or the type of ART used between the two groups for both fresh and frozen embryo transfer cycles (Table P = 0.407). As for clinical pregnancy rate, a higher but non-significant prevalence of clinical pregnancy was observed in treated patients . More miscarriages were reported in the treated group than in the control group at the first attempt (25.5% versus 13.8%), but this difference was not significant (P = 0.118). The prevalence of live births among treated women was 47.3% compared with 49.6% among untreated women (P = 0.762). The results regarding frozen embryo transfers were comparable to those obtained with fresh embryo transfers. Notably, an increased but nonsignificant prevalence of cleavage-stage embryo implantation and clinical pregnancy was observed in treated women compared with untreated women . Additionally, the incidence of treated women that suffered a miscarriage was 27.7% vs. 18.8% in the control group (P = 0.303). At the first frozen embryo transfer, the likelihood of delivering a live birth was similar between the treated group and the control group .As for fresh embryo transfers, outcomes were observed and documented Table . The impP = 0.047). Furthermore, P + A treatment had no influence on the miscarriage rate or clinical pregnancy rate.Since there was a significant difference in FT3 at the fresh embryo transfer cycle between women with or without P + A treatment, multiple logistic regression analysis was performed. Moreover, age, the clinically relevant variable, was included in the regression analysis Table . In womeBaseline demographics and clinical characteristics were comparable between groups . Assessed infertile women exhibited normal thyroid tests and no autoimmune antibodies except anti-thyroid antibodies. These finding have not been replicated in other studies and should be interpreted with caution. In 2009, Revelli et al. performed a retrospective study of 329 euthyroid women who were positive for TPOAb, TgAb, or both. The medication prescribed was prednisolone (10 mg/d) and aspirin (100 mg/d), from the day of stimulation to 10 weeks of gestational age and, during that period, P was increased to 30 mg/d for 5 days starting from the day of embryo transfer. This approach was deemed beneficial to pregnancy and implantation rates in contrast with untreated ATA+ patients . In our In terms of the mixed correlation between TAI and infertility, a recent review published in 2020 contributed to a better understanding of its relevance. By summarizing and analyzing the latest studies since the 2017 guidelines, this review documented that anti-TPO antibodies were associated with infertility in subsets of women, mainly in those with unexplained infertility or polycystic ovarian syndrome (PCOS), but not in all women . Such a P = 0.017). Multivariable logistic regression demonstrated the negative role of FT3 in fetal loss incidence at the first fresh embryo transfer. This was consistent with a preliminary observational study that reported that low serum FT3 levels compromised the beneficial effect of levothyroxine substitution in women with Hashimoto’s thyroiditis [Additionally, in our study, it was observed that regardless of the embryo type being transferred, the incidence of abortion was higher but not significant in the treated group than in control patients. As illustrated above, the value of FT3 in the P + A treated group was 2.90 ± 0.39 pg/mL, significantly lower than that of thyroid antibodies-positive untreated subjects (roiditis . It is wroiditis . It has roiditis , whereasroiditis . By bindroiditis . To concroiditis . During roiditis . Based oin vitro models of multicellular tissue complexes or functional organ units, may help illuminate this intricate connection. Exploiting organ-on-a-chip approaches to model decidualization, implantation, and placentation would enable an in-depth study of the invasive and remodeling behavior of extravillous trophoblast cells, and of uteroplacental circulation that provides vascular supply to the growing fetus [Although progress has been made in some areas of autoimmune disorders, little is known about the underlying mechanisms of autoimmune antibodies on reproductive outcome, which represents a challenge for effective treatment research. Organs-on-a-chip, advanced ng fetus . FurtherOur study has several advantages. Firstly, by establishing strict inclusion and exclusion criteria, the possible confounding factors of other autoantibodies and severe detrimental elements of spontaneous miscarriages were controlled for, which allowed us to minimize any patient-related variation and concentrate solely on P + A effects on isolated euthyroid infertile women with TAI. Secondly, only first-time ART users were included and analyzed to investigate a homogeneous, good-prognosis population and provide relevant suggestions for targeted subjects. However, our study also had some limitations. Firstly, it was inevitably limited by its retrospective nature. Secondly, given the variation in TPOAb and TH concentrations in the context of pregnancy, the measurement of longitudinal thyroid parameters during pregnancy was reasonable and necessary, but the changes were not recorded . While tTo conclude, according to the reality of routine thyroid screening, many euthyroid women who test positive for antithyroid antibodies were discovered. Among them, patients who underwent the first IVF cycle without a history of recurrent miscarriages or unexplained infertility were not recommended for the combined treatment of prednisone and aspirin.Additional file 1.


Rumen is a natural fermentation system and the microorganisms inside can effectively utilize plant bioresource and interact with host metabolism. Here, analysis of rumen microbiome, together with animal performance and serum metabolism in a lamb model were performed to identify the potential use of mulberry leaf silage (MS) to replace alfalfa silage (AS) as a new functional feed resource and to mining the novel specific mulberry leaf associated rumen bacteria interact with host metabolism.Bifidobacterium, Lactobacillus and Schwartzia were enhanced, and Ruminococcaceae UCG-010 and Lachnospiraceae_XPB1014_group were down-regulated in the rumen of MS group. A strong association was also found between these rumen microbial taxa and host antioxidant and immunomodulatory capacity.The lambs fed with MS diet showed improved antioxidant capacity and immune function compared to those fed AS diet. The MS diet significantly altered rumen microbiota α- and β-diversity and taxonomic composition. Microbial analysis revealed that These findings indicated that mulberry leaf silage can be a high-quality feed source or bioactive pharmaceutical that is responsible for ruminant’s health benefits. The modified rumen microbial community by mulberry leaf silage were associated with the enhanced antioxidant capacity and immunomodulatory of lambs.The online version contains supplementary material available at 10.1186/s12866-021-02311-1. Morus alba) leaf, belonging to Moraceous plant, is commonly used as a Chinese traditional medicine for human beings and the sole food source for silkworms. It has a long history of cultivation throughout the world [7 t, respectively [Mulberry  macronutrients to herbivorous animals, especially for its relative high protein content 15–28%) and good essential amino acid profiles, which are similar to those of alfalfa hay , 5. Mean–28% and 0% macronHowever, till now, mulberry leaves have not been fully utilized as animal feed source due to its high moisture content, but ensiling is an efficient method to solve this problem . It has Our questions focused on that mulberry leaf silage may have beneficial roles in the antioxidant activity and immunomodulatory of lambs. Here, this study was to assess the mulberry leaf silage that could be a high-quality feed source with important biological activity and biofeed resources for ruminants, and then to mining the potentially associated rumen microbiome accounting for its bioactive function.P < 0.05). The weight of kidney in AS group lambs had a tendency to be lower than that in MS group (P = 0.053).As shown in Table P = 0.10).Meat quality characteristics were similar between the two diets, as shown in Table P < 0.01) but not for the serum albumin and globulin. As shown in Table P < 0.05). The content of malondialdehyde (MDA) was significantly lower in the MS group than in the AS group (P < 0.05). Compared to the AS group, the serum interferon-γ (IFN-γ) concentration was significantly higher in the MS group (P < 0.05), and the concentrations of serum IL-1β and IL-6 was significantly lower in the MS group (P < 0.05). No significant difference was found for the tumor necrosis factor-α (TNF-α) and IL-2 concentrations between the two groups.Overall, serum lipid metabolite levels including the concentrations of cholesterol, triacylglycerol, and the high density lipoprotein cholesterol (HDL) and low density lipoprotein cholesterol were un-affected by the MS diet Table . The serP = 0.09).As shown in Table P = 0.007).The Good’s coverage of all samples was above 0.99. The Chao, Sobs, Shannon, and Ace indexes of bacterial richness and diversity were different between AS and MS Table . The NMDBacteroidetes, Firmicutes, Proteobacteria, Actinobacteria, and Kiritimatiellaeota, among them, Bacteroidetes was significantly lower in MS group compare with AS group , including oup Fig. a. There oup Fig. b, includLachnospiraceae_XPB1014_group and Ruminococcaceae_UCG-010 were both positively correlated with MDA , but negatively correlated with CAT , GSH-PX , SOD , and T-AOC . Fibrobacter was positively correlated with MDA , but negatively correlated with SOD  and T-AOC . The rumen_bacterium_YS3 was positively correlated with MDA , but negatively correlated with GSH-PX , SOD , and T-AOC . The Schwartzia was positively correlated with GSH-PX , CAT , and T-AOC . Ruminococcus_gauvreauii_group was positively correlated with SOD . Prevotellaceae_UCG-003 was positively correlated with MDA , but negatively correlated with SOD , T-AOC , and IFN-γ . Bifidobacterium , Howardella , and Olsenella  were positively and Prevotella_1 , was negatively correlated with IFN-γ. Fibrobacter , Lachnospiraceae_NK4A136_group , Lachnospiraceae_XPB1014_group , rumen_bacterium_YS3 , and Ruminococcaceae_UCG-010  were positively, Shuttleworthia  was negatively correlated with IL-1β. Fibrobacter , Lachnospiraceae_XPB1014_group , Prevotellaceae_UCG-003 , rumen_bacterium_YS3 , and Ruminococcaceae_UCG-010  were positively, Schwartzia , Shuttleworthia , and Mitsuokella  were negatively correlated with IL-6.It was found that the ruminal bacteria communities were related to the blood antioxidant activity ad immune function indices Fig. . In detaThe biomass yield of fresh mulberry leaves is approximately 25 to 30 tons/ha/year, and the mulberry leaf is rich in protein (15–35%) . In the Prevotella accounts to the abundant genera in sheep rumen in the present study, which was also shown in the Hu-sheep [Prevotella genus has the ability in proteolytic [Prevotella species may affect the amino acids metabolism in dairy cow [Prevotella_1 in Tan-lambs fed with mulberry leaf silage.The effective of mulberry leaf or its bioactive compounds in improving antioxidant capacity and immune function has been found in many previous studies what we talked above and was confirmed in the current study. To date, there have been few reports on the relationship between the effect roles of mulberry leaf silage on ruminal microbial community and the potential microbial targeted terminal function in antioxidant activity and immunomodulatory. In a previous study, the ruminal microbiota composition of finishing steers was not changed by partial replacement of corn grain and cotton seed meal with ensile mulberry leaves . HoweverHu-sheep . It was teolytic . It was airy cow . We alsoSchwartzia was increased in the MS group compared to the AS group. The mulberry leaf flavonoid showed the ability in methane inhibiting in sheep [Schwartzia was found to be negatively correlated with methane emissions [Schwartzia in the MS group from the current study and its positively correlated with antioxidant function might be due to the roles of Schwartzia in competing with methanogenic bacteria. Thus, these results may suggest the inhibited methane emission when lambs fed with mulberry leaf silage.It was also found that the in sheep . Schwartmissions . Thus, tBifidobacterium and Lactobacillus genera were increased by feeding mulberry leaf silage in sheep which were also positively correlated with the serum IFN-γ concentration in the current study. It was found the bacterial supernatants of the Bifidobacterium and Lactobacillus genera, are able to affect ghrelin receptor (growth hormone secretagogue receptor-1a) signaling, which plays a crucial role in maintaining energy balance and metabolism, and modulating food intake, motivation, reward, and mood in human being [Bifidobacterium and Lactobacillus genera in rumen of MS group might contribute to the improved healthy level and status of lambs fed with mulberry leaf silage. The increased Bifidobacterium in rumen of lamb were associated with the improved contents of meat nutrients comprising alpha-linolenic acid, conjugated linoleic acid and eicosapentaenoic acid [Lactobacilli and Bifidobacterium are considered by the European Food Safety Authority, indicating they can be considered possible prebiotics for improvement of gut health [Bifidobacteria was abundant in the digestive tract of humans, which has assumed health-promoting activities [Bifidobacterium strains promoted rumen health for calves in the milk-feeding period. On the other hand, Bifidobacteria can utilize a variety of isoflavones, mono- and oligo- saccharide, and polysaccharides [Bifidobacteria in the MS group might due to the feeding of mulberry leaf silage. Our findings for the increased abundance of rumen Bifidobacteria in MS group compared to AS group and its highly positively correlation with serum IFN-γ seem to indicate the beneficial effects of genus Bifidobacterium on Tan-sheep.The immunoreaction is closely related to health of animals . IFN-γ ian being . Thus, ioic acid . Lactobat health . Bifidobtivities . Vlková tivities  also foucharides . Mulberrcharides , 46, thuRuminococcac-eae_UCG_010 and Lachnospiraceae_XPB1014_group were down-regulated by feeding lambs mulberry leaf silage, which were also negatively correlated with serum antioxidant parameters and positively correlated with serum IL-1β and IL-6. Ruminococcaceae UCG-010 is reported to be associated with ruminal biohydrogenation [Lachnospiraceae_XPB1014_group were negatively correlated with body fat weight in finishing pigs, indicating its function in lipid metabolism [Ruminococcac-eae_UCG_010 and Lachnospiraceae_XPB1014_group in MS group indicated the inhibited biohydrogenation in rumen. Thus, the mulberry leaf silage may have the ability to prevent the ruminal biohydrogenation by decreasing Ruminococcaceae UCG-010 and Lachnospiraceae_XPB1014_group, then resulting in more absorption of unsaturated fatty acids that have beneficial roles in antioxidant and immune-enhancing properties [In addition, the IL-1β, a master proinflammatory cytokine, acts as an adjuvant to stimulate antigen-specific immune responses . IL-2 angenation . The abutabolism . Thus, toperties , 52.Fibrobacter, Lachnospiraceae_AC2044_group, Prevotellaceae UCG-003, and rumen_bacterium_YS3 were negatively correlated with the enhancement of serum antioxidant characteristics and immune function. In addition, we also found the increased abundance of Howardella, Pelagibacterium, Protochlamydia, Shuttleworthia, Advenella, and Planctomicrobium were achieved in the MS group. However, we did not find the related function of these bacteria. More attention should be paid in detecting their function in further studies by screening and culture methods, as most of their potential function of them in restricting rumen health and host health is still unknown. On the other hand, we have to say that the limitation of this study is that more other immune activity related parameters or cytotoxicity test were not used to evaluated the immune response of animals. In total, our research provides a preliminary view of the efficient utilization of mulberry leaf silage in lambs, and we detect several potential mulberry leaf silage-associated rumen bacteria that may interact with the host metabolism and account for the enhanced antioxidant capacity and immunomodulatory. However, the beneficial roles of these rumen bacteria should be checked and confirmed in further studies.Additionally, except for the described potentially differential functional bacterial, we observed that Bifidobacterium, Lactobacillus, and Schwartzia, and the down-regulated ruminal Ruminococcaceae UCG-010 and Lachnospiraceae_XPB1014_group were found in the MS group compared to the AS group. Furthermore, these specific changed bacteria that were correlated with the enhanced animal antioxidant capacity or immunomodulatory might be the functional microbes associated with ruminant health. Altogether, evidence from the results of the current study suggest that the naturally mulberry leaf silage could be an alternative functional supplement in maintaining ruminant health and changing the rumen bacterial community. Further experiments should be conducted to verify the function of these rumen bacteria in antioxidant capacity or immunomodulatory.We here identify a potent effect of mulberry leaf silage-associated ruminal microbiota interact with host metabolism and physiology. The enriched ruminal 6 colony forming units (cfu)/g of fresh material Lactobacillus plantarum (GenBank accession number: WCFS1) [The seeds of alfalfa  and mulberry  were obtained commercially. Alfalfa and mulberry were cultivated and harvested on Wuzhong, Ningxia Hui Autonomous Region . The fresh alfalfa and mulberry leaf were collected and chopped to 2–3 cm using a forage cutter . Then, both of the alfalfa and mulberry leaf were mixed with 1% glucose and ensiled with 1 × 10: WCFS1) . Both ofOvis aries) with average age of 75 d (± 3), BW of 15.3 kg (± 1.92 SD) were selected from were selected from 5000 sheep fed in Tianyuan Liangzhong Sheep Farm . The sheep were blocked into 20 groups based on the BW and were randomly allocated within the blocks to 1 of 2 treatments (on a DM basis): 1) alfalfa silage based diet , 2) mulberry leaf silage based diet , the other ingredients were identical  before the implementation. Forty healthy Tan lambs , six lambs in each group were then selected for blood sampling and slaughtering based on the average BW. Blood was collected from the jugular vein of the sheep to separate serum (centrifuged for 10 min at 3000×g). All the lambs were sacrificed in a public abattoir using carotid bleeding on day 80 at 10:00 am (3 h after morning feeding). After slaughtering, the weight of carcass, head, skin, limbs, internal organs  were measured and recorded. All the collected samples were then stored at liquid nitrogen for subsequent analysis.2 + b2)0.5), and Hue angle (H* = arctan (b*/a*) × (180/π)) at 45 min and 24 h were measured. Meat colour of longissimus thoracis was measured using a high-quality spectrophotometer NS800  with illuminant D65 and a viewing angle of 10 °. Each sample was determined three times at different positions on the meat surface and the average value was obtained. Serum metabolite concentrations, including total protein, albumin, BUN, triacylglycerol, total cholesterol, high density lipoprotein cholesterol, low density lipoprotein cholesterol, immunoglobin G, immunoglobin A, and immunoglobin M were measured using an automatic analyzer  with a commercial kits  [The detail information of the meat quality detection was according to a previous study of Liang et al. . In brie, China) . The actRumen fluid (20 mL) was collected from the ventral part of the rumen by straining the ruminal content through four layers of cheesecloth. Rumen fluid pH was measured immediately. Rumen fluid samples were then stored at liquid nitrogen for subsequent analysis. The concentrations of volatile fatty acids were measured by gas chromatography . The ammonia nitrogen was determined by the method described in Broderick and Kang .Microbial DNA from rumen fluid was extracted by a HiPure Stool DNA Kit  according to manufacturer’s protocols. The 16S rDNA V3-V4 region of the ribosomal RNA gene were amplified by PCR using primers 341F: CCTACGGGNGGCWGCAG; 806R: GGACTACHVGGGTATCTAAT following the procedure described by Sun et al. . The ampPurified amplicons were pooled in equimolar and paired-end sequenced (PE250) on an Illumina platform (Illumina Novaseq 6000 sequencing) according to the standard protocols. Raw reads were further filtered using FASTP to get high quality clean reads . The noiP < 0.05, and the trends were declared at 0.05 ≤ P ≤ 0.10.The animal performance, blood parameters, and rumen fermentation characteristics data were analyzed for a completely random design using the PROC MIXED procedure of SAS . The means of each treatments are presented as least squares means and statistical significance was defined at Additional file 1: Table S1. Ingredients and nutrient composition of the total mixed ration containing alfalfa silage (AS) and mulberry leaf silage (MS) as the main forage. Table S2. Alpha diversity indices of rumen bacteria in lambs fed alfalfa silage (AS) and mulberry leaf silage (MS) based diets.


To evaluate the anatomical variations of dural venous sinuses in children with external hydrocephalus, proposing a radiological grading of progressive anatomic restriction to venous outflow based on brain phase-contrast magnetic resonance venography (PC-MRV); to evaluate the correlation between positional plagiocephaly and dural sinuses patency; and to compare these findings with a control group to ascertain the role of anatomical restriction to venous outflow in the pathophysiology of external hydrocephalus.Brain MRI and PC MRV were performed in 97 children  diagnosed with external hydrocephalus at an average age of 8.22 months. Reduction of patency of the dural sinuses was graded as 1 (stenosis), 2 (complete stop) and 3 (complete agenesis) for each transverse/sigmoid sinus and sagittal sinus. Anatomical restriction was graded for each patient from 0  through 6 . Ventricular and subarachnoid spaces were measured above the intercommissural plane using segmentation software. Positional plagiocephaly (PP) and/or asymmetric tentorial insertion (ATI) was correlated with the presence and grading of venous sinus obstruction. These results were compared with a retrospective control group of 75 patients .p ≤ 0.001).Both the rate (84.53% vs 25.33%) and the grading (mean 2.59 vs mean 0.45) of anomalies of dural sinuses were significantly higher in case group than in control group. In the case group, sinus anomalies were asymmetric in 59 cases (right-left ratio 1/1) and symmetric in 22. A significant association was detected between the grading of venous drainage alterations and diagnosis of disease and between the severity of vascular anomalies and the widening of subarachnoid space (SAS). Postural plagiocephaly (39.1% vs 21.3%) and asymmetric tentorial insertion (35.4% vs 17.3%) were significantly more frequent in the case group than in the control group. When sinus anomalies occurred in plagiocephalic children, the obstruction grading was significantly higher on the flattened side (Decreased patency of the dural sinuses and consequent increased venous outflow resistance may play a role in the pathophysiology of external hydrocephalus in the first 3 years of life. In plagiocephalic children, calvarial flattening may impact on the homolateral dural sinus patency, with a possible effect on the anatomy of dural sinuses and venous drainage in the first months of life.The online version contains supplementary material available at 10.1007/s00381-021-05322-5. External hydrocephalus, also known as subarachnomegaly, benign pericerebral collections or benign enlargement of the subarachnoid spaces (BESS), is a childhood condition, characterized by macrocrania and widening of the subarachnoid spaces, especially in the frontal area, frequently associated with mild ventricular dilatation and with generally benign and self-limiting course –12. Its The venous system represents the main CSF-outflow pathway both in “major” (via arachnoid villi) and in “minor” (via extra-arachnoid villi sites) CSF pathways . The traThe clinical records, neuroimaging, surgical findings, and clinical follow-up of ninety-seven patients with diagnosis of macrocrania and widened subarachnoid spaces admitted to our department between 2006 and 2020 were retrospectively reviewed. Inclusion criteria were age below 26 months at time of diagnosis, head circumference greater than 95th percentile on the standard growth curve in the first year of life, typical enlargement of subarachnoid spaces documented by neuroimaging, and at least one venographic study with brain magnetic resonance phase-contrast venography (PC MRV) in the diagnostic work up. Exclusion criteria were craniosynostosis, achondroplasia, and unavailability of PC MRV sequences.In our department, PC MRV sequences are not part of the panel of basal brain MR sequences performed and are included in the sequence list by the neuroradiologist according with the original clinical requests. For this reason, radiological archives of the years 2007–2020 were retrospectively searched for children matching inclusion criteria for age and available PC MRV sequences acquired with the same technique as case group. Macrocrania, achondroplasia, hydrocephalus, subdural hygromas, posterior fossa tumors, vascular malformations, and craniosynostosis were considered as exclusion criteria.Neuroradiological diagnosis of the pericerebral collections was firstly obtained by either ultrasound, computed tomography (CT) scan, or MRI. In all included cases, brain MRI was performed on a 1.5 T scanner  in supine position, with pharmacological sedation and without gadolinium administration. Standardized protocol of brain MRI consisted of axial, sagittal, and coronal fast spin-echo T2-weighted imaging, axial spin-echo T1-weighted imaging. Other sequences were performed as clinically indicated. Images were systematically and independently reviewed by two pediatric neuroradiologists and two pediatric neurosurgeons.Intracranial volume, subarachnoid space (SAS) volume, and ventricular volumes were calculated per each patient by segmentation software ) on axial T2-weighted images 2 mm thick. Brush ROI method was used for segmentation of subarachnoid spaces and pencil ROI for intracranial volume and ventricular volume segmentation.The entity of widening of subarachnoid spaces was evaluated measuring the amount of cerebrospinal fluid of the convexity from the intercommissural plane until the last cut of the vertex where SAS were visible . AccordiMRV was performed by using phase-contrast (PC) MRV in the three standard spatial orientations . Post-processing of PC MRV images for 3D reconstructions was performed by using the maximum intensity projection (MIP) and creating 12 MIP projections at 13° intervals. Venogram assessment included superior sagittal sinus, torcular herophili, straight sinus, transverse and sigmoid sinuses, jugular bulbs, occipital sinuses, and major intracranial veins . Collateral circle was also evaluated. In particular, for sagittal sinus and each transverse-sigmoid-jugular venous territory, we researched the presence of stenosis (scored 1), flow gap (scored 2), and agenesis (scored 3) Fig.  or focalP-values were based on two-tailed test, with a statistical significance set at P ≤ 0.05.All variables were previously checked for missing data and outliers. The Wilcoxon signed-rank test was used to assess the differences in clinical and neuroradiological data between patients and control group. In detail, SAS volumes, ventricular volumes, intracranial volumes, positional plagiocephaly, and asymmetric tentorial insertion (ATI) were compared between cases and control group. The Spearman’s rank correlation coefficient (ρ), corrected for ties, was used to evaluate the correlation between the grading of venous drainage abnormalities and the diagnosis of CSF collections and between the grading of venous drainage abnormalities and SAS and ventricular volume in the patients’ group, both in absolute and normalized values. All Among 119 patients with diagnosis of external hydrocephalus, admitted to our department between 2006 and 2020, we excluded 22 cases who did not meet the inclusion criteria. The 97 patients remaining (76 boys and 21 girls) ranged in age at diagnosis from 2 to 26 months (mean age 8.24 months). Mean head circumference was 99.18 percentile (median 99.8)  patients Table . Flow abp ≤ 0.001) and on the left side (p ≤ 0.001) . In 7 cases, venous grading remained the same as MRV performed at diagnosis; in 5 cases, the obstruction/stenosis improved ; in 6 cases, the grading worsened  . Reasons for performing MRI exam were cerebral malformations not involving the posterior fossa in 11 cases, maxillofacial lesions in 9 cases, developmental delay in 7 cases, suspicion of anoxic/hypoxic injury in 9 cases, seizures in 5 cases, suspicion of intracerebral hemorrhage in 3 cases, skull vault lesions in 3 cases, follow up of small (< 1 cm) intracerebral lesions in 4 cases, head trauma in 2 cases, and miscellaneous in 22 cases. As already stated, MRV sequences were performed by the neuroradiologist in addition to the basal sequences according with original clinical request. Mean age at MRV was 14.65 months (range 1–36).In the control group, standard MRI imaging showed minor or mild parenchymal anomalies confined to the supratentorial compartment and not impacting the venous drainage in 25 cases. Positional plagiocephaly was present in 8 cases on the right side and in 8 cases on the left side. ATI was observed in 13 cases. Four patients presented both anatomical variants.On MRV studies, relevant alterations of intracranial venous drainage were observed in 19 cases (25.33%). In all but one sinus anomalies were asymmetric. Ten of them had grade 1 alterations, five patients had grade 2 alterations, three patients had grade 3 alterations, and one patient had grade 5 alterations. No significant differences in venous drainage alterations were observed between the subgroup of 25 patients presenting supratentorial anomalies and the 50 patients with normal brain MRI.p < 0.001). As expected, the case group had significantly larger intracranial volumes (p ≤ 0.001), larger ventricular volumes (p ≤ 0.001), and larger subarachnoid fluid volumes (p ≤ 0.001) than the control group . Also, the grading of anomalies was significantly higher than the control group . A significant correlation  was found between the presence of venous drainage alterations and diagnosis of external hydrocephalus.The rate of abnormal intracranial venous pathways was significantly higher in the case group than in the control group , ventricular volume , and subarachnoid spaces volume . After normalization for intracranial volume , correlation remained not significant for ventricular volumes  whereas significant correlation was found in the case group between the grading of vascular anomalies and subarachnoid space volume . . Fig. .Fig. 8Hip = 0.004) more frequent in the case group (39.17%) than in the control group (21.33%). Asymmetric tentorial insertion was significantly (p = 0.0096) more frequent in the case group (35%) than in the control group (17.33%), but, somehow surprisingly, this anatomical variant had no significant impact on the symmetry of dural sinus anatomy (p > 0.05).Postural plagiocephaly overall was significantly Below is the link to the electronic supplementary material.


Gestational Diabetes Mellitus (GDM) is common in South East Asia, occurring at relatively lean Body Mass Index (BMI). Outside pregnancy, cardiometabolic risks increase at lower BMI in Asian populations, justifying Asian-specific thresholds for overweight and obesity. We aimed to explore the effects of GDM and obesity on perinatal outcomes using a WHO expert consultation-recommended Asian-specific definition of obesity.+ 0-22+ 6 weeks gestation and followed until delivery. GDM screening occurred between 24 and 28 weeks using WHO criteria. Obesity was defined as BMI ≥ 27.5 kg/m2, based on weight and height at recruitment. We assessed associations between GDM  and perinatal outcomes. Participants were categorised into four groups: no GDM/non-obese (reference group), GDM/non-obese, no GDM/obese and GDM/obese. Outcomes included primary caesarean section, hypertensive disorders of pregnancy (HDP), large-for-gestational-age (LGA), birth weight, preterm birth, and composite adverse neonatal outcome. Logistic and linear regressions were performed with adjustment for differences in baseline characteristics.This is a secondary analysis of a prospective, hospital-based, cohort study in Ho Chi Minh City. Participants were recruited from antenatal clinics between 19p = 0.027), and LGA . GDM without obesity was associated with an increased risk of preterm birth . Obese women without GDM were more likely to deliver by caesarean section and have an LGA baby . The highest risks were observed amongst women with both GDM and obesity: caesarean Sect. , LGA  and preterm birth .Among 4,970 participants, 908 (18%) developed GDM. Compared to women without GDM, GDM increased risks for preterm birth , higher birthweight  for Asian women can identify women who will benefit from intensified diabetes, nutritional, and obstetric care. This has relevance for obstetric service delivery within Asia, and other health systems providing pregnancy care for Asian expatriate women.GDM was associated with an increased risk of preterm birth and larger newborn size. Using an Asian-specific definition of obesity, we demonstrate obese women with GDM are at the highest risk of adverse outcomes. Using a BMI threshold in pregnancy of 27.5 kg/m Gestational Diabetes Mellitus is associated with adverse pregnancy outcomes . These outcomes are exacerbated by obesity (as defined by Asian BMI thresholds) in a Vietnamese population.Gestational diabetes mellitus (GDM) is the new onset of glucose intolerance during pregnancy and affects around 15% of pregnancies worldwide, equivalent to 21 million births annually , includiFor decades there has been controversy over glycaemic thresholds used to define GDM. The WHO/IADPSG criteria for diagnosis of GDM was released following the Hyperglycaemia and Adverse Pregnancy Outcomes (HAPO) Study , and is To date, most research on the consequences of GDM has been conducted in western populations. GDM is common in South-East Asia (SEA), affecting up to 18% of pregnant women , however2).During pregnancy, obesity and GDM are found to act synergistically to increase the risk of adverse perinatal outcomes in Western populations . However2 as recommended by a WHO expert consultation for Asian populations) modulates these risks in an Asian (Vietnamese) urban population.Therefore, we aim to examine the association between GDM and adverse pregnancy outcomes and explore how obesity,  Project. The PBB was a prospective cohort study conducted between October 2016 to October 2018 in Tu Du Hospital in Ho Chi Minh City, the largest maternity hospital in Viet Nam. Viet Nam is a rapidly developing country with a population of 90 million, GDP per capita of USD 10,755 (Purchasing Power Parity) in 2020, and a maternal mortality ratio of 211 per 100,000 live births in 2017 .+ 0 to 22+ 6 weeks gestation were recruited from the hospital’s antenatal outpatient service. Inclusion criteria were maternal age > 18 years, singleton pregnancy, intention to deliver at Tu Du Hospital, ability to give written informed consent, certainty in pregnancy dating from ultrasound scan < 14 weeks gestation, and no signs or symptoms of a threatened miscarriage. Participants were followed up through pregnancy, labour and birth, until the last mother-newborn pair was discharged (last participant October 2018). For this secondary analysis, further exclusions were applied to women who delivered at < 24 weeks gestation (as this preceded the gestation of GDM diagnosis).From October 2016 until May 2018, women between 19The primary exposure for this study was GDM, studied both singly and in combination with obesity. We felt this two-step approach in studying these risk factors (GDM and obesity) is appropriate as GDM has a high prevalence in Asian populations so it is important to look at its associated adverse outcomes. However, it is also important to isolate any independent effects of BMI, particularly given the metabolic overlaps between GDM and obesity.+ 0 to 22+ 6 weeks gestation). Height was measured using an Adult Stadiometer , and weight measured using an Adult Scale  at recruitment. The definition of BMI in Asian populations is controversial [2, normal 18.5–23 kg/m2, overweight 23-27.5 kg/m2, obese ≥ 27.5 kg/m2) [GDM screening is universal in this hospital as part of routine clinical care. GDM was defined using the IADPSG/WHO criteria . The diagnosis was by 75-gram OGTT between 24 and 28 weeks gestation. BMI was measured from height and weight measurements collected at recruitment  . Given tTo study the associations of GDM and obesity in combination, participants were divided into four mutually exclusive groups: (1) no GDM, no obesity; (2) GDM, no obesity; (3) no GDM, obesity; and (4) GDM, obesity. Multivariable logistic regression was used to study the association of GDM and obesity on the three most common adverse outcomes . Women with no GDM and no obesity were used as the reference group.We excluded women with pre-existing diabetes (either Type 1 or Type 2 Diabetes). Potential confounding exposures included: maternal age, gestational weight gain from either self-reported pre-pregnancy or weight measured early in conception until recruitment, socioeconomic status (using occupation as a proxy measure), parity, history of hypertension, and history of preterm birth.Maternal and newborn outcomes associated with GDM were selected based on previously observed associations ranked by consensus . OutcomeAll data were recorded by trained research midwives on paper case record forms and electronically transcribed. Data were collected at two time points: recruitment, and after birth before discharge from the hospital. Trained research midwives interviewed the women at each visit, with medical details obtained from medical records. Women who delivered in other hospitals were interviewed by telephone for basic delivery information. Data were transcribed and stored in a secure database (CliRes).p-value of < 0.05.The sample size was based on the PBB study’s primary objectives. Post hoc, we estimated that for 900 women with GDM compared to 4,000 controls, for outcomes at 5% prevalence in the control group, a risk difference of 2% could be demonstrated, with 80% power and statistical significance set at a two-tailed Participants loss-to-follow-up were excluded, yielding a complete case analysis. As loss-to follow-up rates were extremely low (0.2%), no imputation was performed for missing values. For weight-related outcomes (LGA and weight z-score), implausible outliers for weight z-score with > or < than three standard deviations (SD) from the mean were dropped. Participant recruitment and subsequent exclusion are presented in a flow diagram.U-test for skewed continuous variables, chi-squared test of homogeneity for categorical variables, and chi-squared test for linear trend for ordinal variables. A 5% two-sided significance level was used for all p-values. Box-and-whisker plots were constructed for newborn weight (grams) and weight z-score. Multivariable logistic regression reported Odds Ratios (OR), and multivariable linear regression reported beta coefficients with 95% confidence intervals (CI). Continuous variables were checked for the assumption of log-linear association by testing for departure from linearity using the Likelihood Ratio Test. Covariates that showed a significant association with both exposure and outcome and were not on the causal pathway were assessed for confounding using the chi-squared values from the Likelihood Ratio Test of each serial adjustment for covariates with and without the primary exposure. This helped to gauge how much statistical information the primary exposure contributed to model fit. The decision for adjusting for relevant confounders were informed by both statistical criteria and biological plausibility based on our clinical knowledge and understanding of the literature, Variance Inflation Factors were used to check for multicollinearity, and model diagnostics for linear regression included homoscedasticity, assumption of linearity, and normality of residuals.Univariate analyses used Student T-test for normally distributed variables, Mann-Whitney To assess the potential of unmeasured confounders explaining away an observed association, the E-Value was computed for outcomes with evidence of significant association .All analyses and plots were performed using STATA 16.1 .From 10,711 pregnant women screened, 5,000 met the PBB entry criteria and gave consent for participation. After enrolment, 12 women were loss-to-follow-up, and four withdrew. In addition, we excluded nine women with pre-existing diabetes and five who delivered < 24 weeks gestation, leaving 4,970 women and babies for analysis, Fig. There were 908 women (18%) diagnosed with GDM, of whom 19 (2%) were treated with insulin.2 in women without GDM, compared to 23.5 kg/m2 in those with GDM (p < 0.001). Among the 267 (5.4%) women classified as obese as per the Asian threshold (27.5 kg/m2); 189 (4.7%) did not have GDM, while 78 (8.6%) had GDM. Among the 1,895 women classified as overweight as per the Asian threshold (23–27.5 kg/m2); 1,466 (36%) did not have GDM, while 429 (47%) had GDM. Among 4,970 women, 78% were neither diagnosed with GDM nor obese, 17% had GDM but were not obese, 3.8% did not have GDM but were obese, and 1.6% had both GDM and obesity. Compared to women without GDM and who were not obese, women with GDM and were obese were significantly older (p < 0.001), Table p < 0.001). In order to account for the fact that women were recruited at slightly different gestational ages (19–22 weeks), we also looked at the average weight gain per week throughout gestation, and this difference remained significant; obese and GDM women gained more weight per week than women without GDM and not obese (p < 0.001). In addition, obese women with GDM were more likely to have had a history of hypertension compared to women who had neither GDM nor obesity . Women with both GDM and obesity were also more likely to be multiparous compared to those women with neither GDM nor obesity , as well as more likely to have a history of giving birth to a macrosomia baby/ies; 11% versus 2%, p < 0.001.The mean BMI was 22.5 kg/m p < 0.00. Among tp = 0.3), Table p = 0.03). However, after adjustment for confounders, this difference was no longer significant .Women with GDM experienced similar rates of primary C-section compared to those without GDM , and this association remained significant after adjustment for potential confounders; GDM-women were at 40% significantly increased odds of delivering preterm .More women with GDM delivered preterm , Fig. The proportion of male babies was 52% and 50% in non-GDM and GDM-women, respectively. Whilst the mean birth weight was similar, after accounting for gestational age and gender, babies exposed to GDM had higher birthweight z-scores , or LGA , Table p = 0.2) or risk of NICU admission in babies born to women with GDM , Table No significant differences were observed in the individual components of neonatal mortality or severe morbidity. There was no difference in the overall composite neonatal adverse outcome , but not C-section or LGA, Fig. Overall, 267 (5.4%) women were classified as obese as per the Asian threshold, and these women were overrepresented amongst the GDM group 8.6%, compared to non-GDM 4.7%, rth OR 1.5, but noThe E-Value for GDM’s impact on preterm birth was 2.15, and for GDM and obesity’s collective impact on C-section, LGA, and preterm birth was 2.49, 3.07, and 2.49, respectively. These E-Values affirm the validity of these estimates, indicating they are relatively robust against unmeasured confounding.This study aimed to elicit the burden of GDM (both singly and in combination with obesity) on adverse perinatal outcomes in an urban Asian population. As such, we used Asian-specific cut off points for BMI, as recommended by the WHO in order to more accurately reflect the synergistic adverse impact of obesity. We present evidence that women and babies affected by GDM in Ho Chi Minh City experienced higher preterm birth and were born LGA. The most striking associations however were amongst women who had GDM and were also obese, in whom the risks of C-section, LGA and preterm birth were all increased. The overall prevalence of GDM in this study was high (18%), consistent with other reports from SEA populations .2, and GDM act synergistically towards three pregnancy outcomes: C-section delivery, LGA, and giving birth preterm. Whilst this is consistent with the risks in obese women with GDM reported by the HAPO group [2). BMI was calculated in our study at 19–22 week’s of gestation rather than before pregnancy, meaning that potentially adverse effects would have been observed at even lower pre-pregnancy BMIs. Among women who were both GDM and obese, we observed an increased risk for C-section delivery of 2.43, compared to 1.71 in the HAPO cohort, and the risk of delivering an LGA baby was 3.36 compared to 3.62 [2). Our study supports the hypothesis that adverse maternal and fetal metabolic effects of GDM that are associated with obesity occur at lower BMI in Asian women.We add new insights into the synergistic effects of BMI, specifically obesity on perinatal outcomes, defined using an Asian specific threshold. We demonstrate that obesity, defined ≥ 27.5 kg/mPO group , it is n to 3.62 . While t2 [2 threshold used outside pregnancy, or the 32 kg/m2 suggested for use in pregnancy (as per HAPO), are not sensitive indicators of pregnancy risk in this population. Given that the measurement of body fat percentage is challenging during pregnancy, we feel the lower BMI threshold is a practical alternative. This study observed that GDM mothers were at 16% increased odds for delivering LGA babies, with the association modulated by maternal obesity. Therefore, identifying the women at greatest risk of complications could help target nutritional support and intensive blood glucose monitoring in a resource constrained setting.This finding is consistent with observations outside pregnancy  and has 2 . Our finOur work adds to a growing body of work on GDM in Viet Nam and the association with adverse perinatal outcomes Fig. . Two othThe strengths of this study include a relatively large sample size, which enabled sufficient power to test for GDM’s association with primary C-section, LGA, and preterm birth. This study was conducted using a prospective design with very low loss-to-follow-up (0.2%), minimising selection bias. GDM and BMI were measured objectively, before and without knowledge of the outcomes, reducing information bias. In addition, we used international definitions of GDM (WHO/IADPSG) and size at birth (INTERGROWTH-21st ), enabling comparison with other studies. Pregnancy dating by early-pregnancy ultrasound enabled accurate estimation of risk of preterm birth and calculation of birthweight for gestational age.2 in this study was very low (n = 20). Whilst ideally we would have liked to compare pre-pregnancy BMI, this data was largely based on maternal recall. Since we had objective measures from recruitment (early second trimester) we chose to define BMI at this point. Our results should therefore be interpreted with caution particularly when comparing to studies where BMI was measured pre-pregnancy. While women could change BMI category between conception and 19–22 weeks, we believe that the key message of this paper that those who are obese women, and particularly obese women with GDM, are at highest risk for adverse outcomes remains valid. The relatively high reported rate of previous neonatal death (5-8.7%) was also based on maternal self-report, thus we cannot verify if there was misclassification with other forms of loss .We acknowledge this study has some limitations. We were unable to account for differences in individual test results of the OGTT or subsequent blood glucose monitoring and management during pregnancy. Data were also not available for neonatal hypoglycemia, an important outcome. As this was a hospital-based study, we cannot extrapolate the prevalence of GDM to the population, although the rate observed is in keeping with that from other studies in Viet Nam. Long-term effects on the mother and baby were not collected. We were not able to compare our results with previously published obesity risk definitions, as the number of women with BMI > 32 kg/m2measured between 19 and 22 weeks gestation can be used to risk-stratify women with GDM. The study was conducted in a resource limited setting, and thus identifying the highest risk group (i.e. women who are obese with GDM) is important for clinical prioritization. For example, obese women with GDM could be recommended more intense antenatal surveillance, earlier GDM screening, or daily blood glucose monitoring.Our findings support that BMI > 27.5 kg/mTo our knowledge, our study is the first to specifically study the individual and synergistic effects of GDM and obesity in an Asian population using an Asian specific BMI threshold for obesity. This is important for those caring for women with GDM in SEA countries, as well as those caring for expatriates living abroad. While there may be physiological and metabolic heterogeneity among Asian populations, it is an important step to quantify perinatal risks with parameters relevant to an Asian population, as recommended by an WHO expert panel. As such, we believe our study’s implications could extend beyond women of Vietnamese ethnicity.Before pregnancy, BMI is a potentially modifiable factor, hence public health and preventative medicine should be directed at helping women maintain their weight in the healthy range. During pregnancy, BMI risk stratification could be used to target more intensive glucose monitoring or dietary support. GDM is a complex condition, and not all women with GDM are at the same risk of adverse outcomes. Evidence is needed to understand the phenotypes of GDM in different populations. We need to move towards offering personalised care approaches in pregnancy that can also optimise the life-long health of women and their children.


To investigate the relationship between sweating from hot flashes, anxiety, depression, and sleep quality in peri- and postmenopausal women. And also the role of anxiety and depression in mediating sweating from hot flashes and sleep quality.467 women aged 40–60 years with menopausal problems were enrolled. The sleep quality; hot flashes; sweating; anxiety and depression symptoms were quantitatively evaluated by Pittsburgh Sleep Quality Scale (PSQI), Kupperman Menopause Index, Self-rating Anxiety Scale and Self-rating Depression Scale. Spearman correlation analysis and mediating effect model were used to analyze the relationship between the three.P < 0.01) and depression symptoms accounted for 5.36% (P < 0.01).262 patients’ PSQI score were higher than 6 (58.2%). Total scores of sleep quality were positively correlated with hot flashes, sweating and anxiety and depression symptoms. Anxiety and depression played a mediating role between hot flashes, sweating and sleep quality where the mediating effect of anxiety symptoms accounted for 17.86% (The hot flashes, sweating, anxiety and depression of peri/postmenopausal women are risk factors affecting sleep quality. By alleviating these risk factors, the sleep quality of peri- and postmenopausal women could be improved, which prevents the physical and mental diseases due to long-term severe insomnia. Perimenopausal and postmenopausal women usually complain a series of physical and psychological symptoms, called the Menopause Syndrome, resulting from declined ovarian function with fluctuating or decreasing estrogen level. About two-thirds of women suffer from these menopause-related symptoms . And theThere are many factors affecting the sleep quality of peri- and postmenopausal women, such as age, family history of insomnia, previous insomnia episodes, stress, poor health, chronic pain, vasomotor symptoms during menopausal transition period, and neuropsychiatric symptoms which are also strongly related to sleep problems –7. AlthoFrom March 2016 to February 2017, outpatients from climacteric clinic of International Peace Maternity and Child Health Hospital (IPMCH) were included. The Including criteria were as follows: (1) 40–60 years old; (2) still menstruating with menstrual frequency changes more than twice and/or menstruation period lasting more than 7 days over the last 10 months; (3) at least 1 year after menopause (4) with menopausal syndrome symptoms; (5) conscious and able to fill in the questionnaires. The excluding criteria: (1) Women with primary insomnia before menopause; (2) the woman complains of anxiety or depression, and is taking anti-anxiety drugs or antidepressants.This is a hospital-based cross-sectional survey study, using face-to-face questionnaire to survey peri-and postmenopausal women who come to the climacteric clinic for treatment and meet the including criteria.The Pittsburgh Sleep Quality Scale (PSQI), Kupperman Menopausal Index (KMI), Self-rating Anxiety Scale (SAS) SRS.14 and Self-rating Depression Scale (SDS) SRS.11 were used to quantify the sleep quality, hot flashes and sweating symptoms, depressive symptoms and anxiety symptoms of the subjects. These scales were under license, and licenses were obtained each survey.The investigator was fully trained and certified. All the subjects signed the informed consent form. The experiment was approved by Ethics Committee for Medical Research of International Peace Maternity and Child Health Hospital .The Pittsburgh Sleep Quality Score Scale consists of 19 self-rated items and 5 other-rated items. The 19th self-rated item and the 5 other-rated items were not counted in the scoring. The 18 self-rated items were combined into 7 components, including sleep quality, sleep time, sleep efficiency, sleep disorder, hypnotic drugs and daytime dysfunction. Each component was rated as 0, 1, 2, 3 and was ultimately added together. The higher the score, the poorer the sleep quality. The scale had higher reliability and validity in evaluating sleep quality .The vasomotor symptoms were assessed by the KMI scale which was comprised of 13 indicators. It aimed to evaluate vasomotor symptoms, somatic symptoms, psychiatric symptoms and uro-genital symptoms. Each item has a basic score and a 4-grade degree score (0–3 points). Each item score is equal to the basic score multiplied by the 4-grade degree score and the total KMI score of KMI is the summation of the scores of the 13 indicators.SAS and SDS are two widely used self-assessment tools to quantify anxiety and depression symptoms. They were easy to comprehend and showed good reliability and validity. The scale consists of 20 items with four-grade scoring system. The anxiety scale has 5 reverse scoring points and the depression scale has 10 reverse scoring points. After the addition of each score, the total rough score was multiplied by 1.25. The integer part was applied as total standard score. The standard score of SAS and SDS was 50. 50–59 represented mild anxiety (depression), 60–69 referred to moderate anxiety (depression), and score higher than 70 meant severe anxiety (depression).P < 0.05 indicated that the difference was statistically significant.SPSS version 24.0 was used for the statistical analysis. Continuous variables were expressed as mean ± standard deviation and categorized variables were expressed as frequency and percentage. Spearman’s rank correlation test was used to analyze the correlation, using a two-sided α = 0.05 as standard. The model of mediation effect was fitted by AMOS 24.0; the mediation effect was tested by Bootstrap method and 2 were enrolled in this study. They were all menopausal outpatients from International Peace Maternity and Child Health Hospital, including 181 postmenopausal (38.8%) and 286 perimenopausal (61.2%) cases. Of the 467, 125 cases (26.8%) were complicated with hypertension, diabetes mellitus, hyperlipidemia and thyroid diseases. The basic clinicopathological characteristics are shown in Table A total of 467 women with an average age of 49.68 ± 4.5 years old and an average body mass index of 22.27 5.6 kg/m450 patients completed the sleep quality scale, accounting for 96.4% of all the participants. The overall score of sleep quality was PSQI (6.89 ± 50 p). 262 subjects (58.2%) had PSQI ≥ 6). The details about the 7 components; sleep quality, time of sleep, sleep duration, sleep efficiency, sleep disorder, use of soporific agents and daytime dysfunction are shown in Table 450 subjects completed the Kupperman Menopause Index Scale, Self-rating Anxiety Scale (SAS) and Self-rating Depression Scale (SDS), accounting for 96.4% of the total respondents. The mean ± standard deviation of the three symptoms was 4.21 ± 3.06 for hot flashes, 44.57 ± 6.49 for anxiety and 54.65 ± 12.45 for depression.P < 0.001), anxiety symptoms were rs = 0.327 (P < 0.001), and depression symptoms were rs = 0.265 (P < 0.001), which indicated that more severe hot flashes and anxiety and depression symptoms were associated with worse sleep quality.Spearman correlation analysis showed that the total PSQI score was significantly positively correlated with the symptoms of anxiety and depression in hot flashes and sweating. The correlation coefficients with sweating symptoms of hot flashes were rs = 0.496   . The direct effect, intermediate effect and overall effect of hot flashes and depression on insomnia were also statistically significant (P < 0.01). Part of the mediating effect between heat sweating and PSQI was established. The indirect effect of hot flashes on sleep disorder was 17.86% through anxiety symptoms  had PSQI ≥ 6, which is very consistent with the reported incidence of sleep disorders in perimenopausal women. The epidemiological studies of Terauchi et al.  and Xu eP < 0.001). Vousoura et al. [P < 0.001), and decreased the overall sleep quality . Freedman et al. [The results showed that sweating symptoms of hot flashes were positively correlated with sleep quality: Heavy sweating symptoms of hot flashes significantly affected the sleep quality proportionally. Several studies have suggested that hot flashes were associated with sleep disorders and insomnia –19. Freea et al.  showed tn et al.  studied n et al. . It shoun et al. .P < 0.001). The subjects of our study are middle-aged women aged between 40 and 60 years old: With the increase in age, the health status of middle-aged women becomes compromised, sub-health status increases while the incidence of chronic co-morbidities increases. At the same time, work stress and family burden can easily contribute to anxiety and depression. Anxiety and depression cause hyperfunction of hypothalamus–pituitary–adrenal axis (HPA axis) [Our results also show that anxiety and depression scores are significantly positively correlated with sleep quality. Zervas et al.  suggest PA axis) , 26, incThe mediating effect model was used to analyze the mediating relationship between anxiety and depression in hot flashes sweating and sleep quality. The results showed that sweating symptoms from hot flashes could affect sleep quality indirectly through anxiety and depression. The effect of anxiety on sleep indirectly accounted for 17.86%, the effect of depression on sleep indirectly accounted for 5.36%, and the influence of anxiety on sleep quality was more significant. Vousoura et al.  showed tThere are some limitations in this study. First, this is a cross-sectional study, which has limitations in confirming the causal relationship between the three. Longitudinal cohort research can be designed in the future to further reveal the relationship between the three factors. Second, the sleep quality in this study is self-reported subjective parameter, which may be biased. In the future, a variety of methods, especially objective evaluation of sleep quality can be used for more scientific, accurate and unbiased evaluation.This study was the first time to investigate and determine the mediating effect of anxiety and depression between hot flashes, sweating symptoms and sleep quality. This discovery helps to understand the relationship between sleep quality, vasomotor symptoms, anxiety and depression, and provides a new perspective and theoretical basis for improving the sleep quality of perimenopausal and postmenopausal women.