Sigmoid sinus thrombosis is a relatively rare, but severe complication of acute otitis media and mastoiditis among other conditions. We report a case of a 3-year-old boy with a history of recurrent acute otitis media which was initially partially treated with antibiotics for 1 month before his admission to our department for high fever and headache. Although initially, no signs of central nervous system (CNS) involvement were present, clinical suspicion for CNS pathology led our whole work-up to conclude the diagnosis of sigmoid sinus thrombosis. The patient was subsequently treated with intravenous antibiotics, anticoagulation therapy and also underwent myringotomy, bilateral tympanostomy tube placement, and mastoidectomy. Cerebral sinus thrombosis is a life-threatening condition that usually complicates the neglected acute otitis media or mastoiditis. Optimal treatment includes antibiotic therapy, hydration, and pain management, with the debatable role of anticoagulation therapy and mastoidectomy. Sigmoid sinus thrombosis (SST) is a potentially life-threatening, although rare, clinical condition, that can affect both neonates and children . In neonHerein, we report the case of a 3-year-old boy with unilateral sigmoid sinus thrombosis (SST) as a complication of recurrent ipsilateral otitis media. Recovery was not uneventful as soon thereafter, the patient developed intracranial hypertension which needed the placement of a ventriculoperitoneal shunt. We present this case because of the rarity of complex sequelae and we discuss the etiology, predisposing factors, and natural evolution of SST due to AOM.  οC and otalgia. One month prior to his admission, he was diagnosed with recurrent AOM and was treated initially with oral amoxicillin 80mg/kg/day for 10 days by his primary care pediatrician. After a short remission, symptoms re-emerged, and he was treated with a combination of oral amoxicillin/clavulanic acid 45mg/kg/day and amoxicillin 45mg/kg/day for 4 days, which was stopped due to a reported allergy and continued on clarithromycin 15mg/kg/day for another 5 days. The patient was complaining of a headache that was not improving with either acetaminophen or ibuprofen and was accompanied by a few episodes of non-bloody, non-bilious vomit for four days before his ER visit. His mother also noticed drowsiness the day preceding his ER visit.A 3-year-old boy was admitted to our Emergency Room (ER) with 3 days of fever up to 39.7οC, O2 sat: 99%). The tympanic membranes bilaterally were erythematous and bulging. His oral cavity was erythematous and small cervical lymph nodes were palpated bilaterally. His score on the Glasgow Coma Scale (GCS) was 15/15 and there were no signs of meningeal irritation.On physical examination, the patient appeared tired, inactive, and pale, but not in distress. His vital signs were within normal limits . Comprehensive metabolic panel values were within the normal range. The patient was also evaluated by a pediatric ENT physician who clinically excluded the presence of mastoiditis bilaterally. Imaging tests such as CT or MRI of the head were not suggested and not performed at this point. The patient was then admitted to our pediatric department. Intravenous (IV) antibiotic treatment with ceftriaxone (100mg/kg/day) was administered because of failed outpatient oral antibiotic treatment twice and the patient’s reported allergy to amoxicillin/clavulanic acid.The initial workup included laboratory tests  which showed a WBC of 21910/mmOur patient, initially, responded well to the IV antibiotic treatment; he remained afebrile for the first 2 days and was clinically improving. Unexpectedly, on the third day of admission, the patient’s clinical status deteriorated. He became irritable with alternating drowsiness and severe headache. Fundoscopy was performed that showed no fundus or optic nerve edema or hemorrhage. An emergent head CT without contrast was performed that excluded an intracranial hemorrhage or cerebral infection. However, it showed the increased size of the right sigmoid sinus in comparison to the left. CSF analysis was normal . The pediatric ENTs were again consulted, and bilateral myringotomy was performed with insertion of tympanostomy tube bilaterally; culture of ear fluid was also sent. At this time point (day 4 of admission) antibiotic coverage was upgraded by substituting ceftriaxone with IV meropenem (120mg/kg/day) and vancomycin (60mg/kg/day). In the next 24 hours, both clinical (resolution of symptoms) and laboratory improvement (reduced WBC: 9540/ mm3 and reduced CRP: 11.67 mg/dl) were noticed. Subsequent imaging with MRI-MRV of the brain showed findings consistent with SST Figure .Furthermore, fluid was recognized in the mastoid cells bilaterally, a finding consistent with possible mastoiditis. The brain parenchyma, ventricles, subarachnoid space, and meninges were normal. After confirmation of the diagnosis, the patient was transferred for pediatric neurosurgery and ENT management. Subsequently, the patient underwent simultaneous bilateral mastoidectomy (day 8 of admission) and was also put on anticoagulation treatment for six months with simultaneous 6-week antibiotic therapy. However, while on anticoagulation therapy, on day 14 of admission, he developed signs of increased intracranial pressure and hydrocephalus which required the placement of a ventriculoperitoneal shunt. Thereafter, the patient showed signs of clinical and laboratory improvement and -resolution of his symptoms and was subsequently discharged. Follow up visits at 3 and 6 months revealed complete recovery and an MRI performed at 6 months showed complete resolution of his sigmoid sinus thrombosis (SST).SST is a severe cerebrovascular condition affecting children in Europe and North America with an estimated annual incidence of 0.6 per 100,000 .SST is most commonly seen in neonates and children ,4. In neThe diagnosis of SST requires a high index of clinical suspicion as the signs and symptoms can be variable and, in many cases, are vague or non-specific. Children usually present with a constellation of symptoms like fever, otalgia, headache, vomiting, and depressed mental status as in our case -8. As thIn previously healthy children with acute otitis media as the predisposing factor for SST, the presence of mastoiditis is crucial in optimizing the therapeutic approach. Several studies found that acute otitis media and mastoiditis were present in 37.5-47% of cases with SST [Timely diagnosis and treatment are critical for the outcome of SST. Imaging modalities of choice are CT angiography or MRV, as normal head CT cannot exclude SST ,7.Management in the acute phase of SST consists of pain management, IV antibiotics, hydration, and initial aggressive anticoagulation therapy . A high Anticoagulation treatment has been under debate in the recent literature. Few studies report better neurologic outcomes for those patients treated with anticoagulation ,11. On tFurthermore, surgical intervention can play a role in the management of such cases. Μastoidectomy has been the gold standard for the treatment of cholesteatoma and chronic suppurative otitis media ,14. SingTo conclude, we cited antibiotic treatment failure as a cause for retracted suppurative otitis media that led to mastoiditis and SST. It is true that our patient also had active ear discharge, adding the ASOM as a further risk factor for mastoiditis as previously reported. Existing controversy on the implementation of anticoagulation therapy, as well as the choice of surgical intervention for the management of SST further complicates their outcome. We hope that this case report will bring up this rare nosology (SST) as a consequence of a very common pediatric problem (AOM) and add to the clinical experience.


Alterations in the anatomic and biomechanical properties of the ascending aorta (AAo) can give rise to various vascular pathologies. The aim of the current study is to gain additional insights in the biology of the AAo size and function.We developed an AI based analysis pipeline for the segmentation of the AAo, and the extraction of AAO parameters. We then performed genome-wide association studies of AAo maximum area, AAo minimum area and AAo distensibility in up to 37,910 individuals from the UK Biobank. Variants that were significantly associated with AAo phenotypes were used as instrumental variables in Mendelian randomization analyses to investigate potential causal relationships with coronary artery disease, myocardial infarction, stroke and aneurysms.THSD4 and COL6A3). Mendelian randomization analyses showed a causal association with aneurysm development, but not with other vascular diseases.Genome-wide association studies revealed a total of 107 SNPs in 78 loci. We annotated 101 candidate genes involved in various biological processes, including connective tissue development (We identified 78 loci that provide insights into mechanisms underlying AAo size and function in the general population and provide genetic evidence for their role in aortic aneurysm development. We searched Google Scholar and PubMed for articles, published up to December 2020, related to aortic traits, genetic predisposition and the role of aortic traits in the development of cardiovascular disease, using the query  AND . The search yielded 596 results, most of which are related to observational studies into blood pressure and arterial traits. These smaller-scale observational studies might be at risk of bias from confounding, reversed causation and collider bias.-Multiple clinical /observational studies show that arterial stiffness and aortic distensibility are associated with aortic aneurysms and sudden death and can potentially be used for monitoring or early detection of cardiovascular diseases.-There were limited studies in assessment of the utility of aortic biomarkers in large population-based cohorts.-Previous genome wide association studies have revealed a limited number of loci associated with aortic traits and have been carried out in relatively small cohorts.-We developed a convolutional deep neural network to obtain aortic traits, namely ascending aortic cross-sectional area and ascending aortic distensibility, from contouring of cardiovascular magnetic resonance (CMR) data, which will be made available for download to facilitate future data-analyses and to fuel further research.-We give an overview of ascending aortic traits in a large population-based cohort based on 3.8M cardiovascular CMR images from 37,910 individuals, which can be used as reference values for clinicians assessing aortic phenotypes.-We find 107 genetic variants associated with AAo traits and identify 101 candidate genes, which increases our insights in AAo biology and might act as a starting point for drug development and precision medicine.-Using a Mendelian randomization approach, we find a genetic association with aneurysms, highlighting the heritability of non-syndromic aneurysms in the general population. A genetic association with coronary artery disease, myocardial infarction, and stroke was not established.The results show that certain cardiovascular traits can easily be extracted from CMR-images using automated image assessment. Further research can focus on adding features to the algorithm in order to improve diagnosis and early detection of cardiovascular disease. In-vitro and in-vivo follow-up of the identified candidate genes for AAo size and function can be performed to validate their role and investigate possibilities for drug targeting. Randomized control trials will be necessary to confirm current Mendelian randomization analyses and to test whether treatment based on evaluation or targeting of AAo size and function improves cardiovascular disease outcomes.Alt-text: Unlabelled box,The aorta is the largest elastic artery in the human body and functions as a conduit for blood pumped from the left ventricle as well as a dampener of the pulsatile pressure by distending and relaxing during systolic and diastolic phase, respectively.,,Anatomic properties of the AAo are essential for screening for AAo aneurysm and for AAo dissection, of which the latter is a major cause of sudden death.,dist) translates into cardiovascular event reduction.,Biomechanical properties of the AAo, reflected by the distensibility or stiffness of the artery, are among the emerging biomarkers for monitoring vascular dysfunction, cardiovascular diseases and risk of all-cause mortality.,New possibilities to directly capture AAo anatomy and distensibility have emerged due to the rise of large-scale studies collecting cardiac magnetic resonance (CMR) images and rapid advances of artificial intelligence (AI). The first aim of the present study is to perform segmentation of the AAo using our custom AI pipeline, and to generate an overview of normal values of AAo dimensional and functional features in 37,910 individuals in the UK Biobank.The UK Biobank study is a population-based cohort-study in which in total approximately 500,000 participants have been included. Further details on the UK Biobank study have previously been described in detail.Supplementary Fig. 1. Further details on the CMR protocol of the UK Biobank have previously been described.MRI acquisition was scheduled during a separate imaging visit at which also other variables, such as blood pressure measurements, were acquired. Briefly, CMR scans of participants were acquired using a clinical wide bore 1·5 Tesla scanner  in the absence of a pharmacological stressor or contrast agent. To derive aortic distensibility, a loop of 100 cine images was acquired during a single cardiac cycle for each participant. The images were acquired as a cardiac cine in a transverse cut at the level of the pulmonary trunk and the right pulmonary artery. An example of a CMR image with a corresponding annotation as it was predicted by the AI pipeline is displayed in For 37,910 participants from the UK Biobank, the available imaging data was downloaded. PyDicom python library (v1.2.2) was used to extract pixel data from the source DICOM files and store the images as portable network graphics (PNG) files. NOUS  active learning software was used to make an optimal selection of informative data for training a model to segment the ascending aorta (AAo). Because of technical limitations on the maximum number of images to be used within the software, a subset was pseudo-randomly selected from all images. From a subsample of 12,325 participants, two random frames out of the loop of 100 images per participant were selected. NOUS is an active learning software tool that allows to train DL models on a minimal set of ground truth images and provides the user with a set of images that optimally helps to train the currently developed model. A subset of 464 images was selected by the software for optimal training of the model and segmented manually inside the software by a human observer.Adam with a training schedule to gradually reduce learning rate when learning performance stopped improving.The set of 464 images segmentations was exported from NOUS to PNG files, and then used outside the active learning software, to train an improved U-Net model using Pytorch machine learning platform (v1.2.0).Open-CV computer vision library (v3.4.3.18) was used to extract contours from the binary prediction masks, which was then used to obtain the contour perimeter and the surface in pixel space. Also, from the contour data, the smallest bounding ellipse was obtained, using Open-CV. Two diameter values were obtained from the bounding ellipse. We calculated the average of the two diameters in pixel space to calculate a single AAo diameter. The Pixel Spacing DICOM tag was obtained from the original DICOM file using PyDicom python library (v1.2.2), to convert extracted values from pixel space to metric units, by multiplication of horizontal and vertical pixel dimensions with their respective pixel space values (mm/pixel).max) and diastole (AAomin) by converting the squared pixel areas to squared millimetres, using the DICOM Pixel spacing.We extracted AAo anatomy represented by cross-sectional area of the lumen during systole , used iWe witnessed high inter pixel brightness variances in images with flow void artefacts, a type of motion artefact caused by blood flow that results in blurring of the vessel wall. We therefore investigated the option to use the average interpixel variance for selection of images containing this type of artefacts. To focus on high interpixel variance around the ascending aorta and the heart, an 80 × 80 centred crop of the image was used to determine inter pixel variance.QC was performed after extraction of features from predicted segmentations of AAo. Thresholds for all criteria were determined after manual inspection of 7568 images by a panel of four human observers. Further details about exclusions have been described under Statistical analyses.We implemented a fully automated pipeline, consisting of all aforementioned components, being the trained 2D convolutional neural network for segmentation of the AAo lumen, multiple quality QC steps to assess image and segmentation quality, and post-processing feature extractions, allowing the automated image analysis of 3.8M images from 37,900 individuals. The imaging pipeline ran on a set of multiple machines, each responsible for loading and analysis of a part of the total set of images, and for an update of the shared analysis results.A set of 50 participants was selected for validation of the model, independently and randomly, from the 25,586 studies whose images were not selected to train the model. From the selected studies, each tenth frame  from the loop of 100 frames were segmented manually by two independent trained medical professionals using approved medical imaging software ,). The same frames were exported from CVI42 to obtain images with the exact same zoom and pixel offset, to be automatically segmented by the model.A total of 6 of the 50 selected studies were completely removed, because one or both human observers did not contour the aorta in the study due to poor image quality. One additional image from a single study was also removed because of poor image quality, resulting in 439 images from 44 studies, to be used for model validation.Model performance was then estimated by the Sørensen-Dice similarity coefficient, also known as Dice coefficient or Dice metric ), which To assess the similarity between features extracted from manual contours, as reported by CVI42, and features extracted by the post-processing pipeline described above, we chose to use the intra-class correlation coefficient (ICC). ICC was calculated between model and each observer, as well as between the two observers. A good (0.75–0.90) or excellent (> 0.90) ICC with two-way random-effects model was used for acceptance of values extracted from the model predictions.dist (in 10−3 mmHg−1) was calculated in participants with registered blood pressure measurements during the imaging visit, as the relative enlargement of the aorta during the systolic phase, divided by the pulse pressure (PP), as defined in The extracted diameter and area values were indexed to body surface area (BSA) to correct for overall body size before use in genetic analyses.Finally, correlation between traits was estimated using STATA 15 (StataCorp LP).Genetic data of the participants were genotyped using custom arrays, Affymetrix UK BiLEVE Axiom array or Affymetrix UK Biobank Axiom array which share 95% of marker content. The genotyping methods, arrays and quality-control procedures have been extensively described previously.The sample size for training the deep learning model was determined on active learning software, as described under Image Analysis. All image data available from UK Biobank at initiation of the study were used to acquire the best representation of AAo size and function estimates from the population and were taken forward in the GWAS. Mendelian randomization analyses were performed in all non-related individuals from UK Biobank with available genetic data that were not included in the GWAS.r of the contour was below 0.85, or when AAo area was below 3 cm2, or above 20 cm2 which indicates a sub-optimal, non-perpendicular cross-sectional image acquisition of the ascending aorta, or the prediction of a physiological lumen or cavity other than the aorta. Furthermore, we decided to exclude all 100 frames from a single participant from subsequent analyses, when more than 25%–25 out of 100 frames – was excluded within that participant, or when the mean frame-to-frame difference between contour areas within one participant were above 0.3 cm2, which showed to be an additional measure for independent AAo lumen segmentations. Participants were excluded for analyses of AAo maximum area (AAomax) and derived AAo distensibility (AAodist), when one or more frames yielded an inter pixel variance σn above 4.1. Since flow void artefacts mainly appear during systolic phase, we decided, not to use the appearance of flow void artefacts as exclusion criterion for analysis of AAo minimum area (AAomin). Additionally, for AAomax and AAomin, additional individuals were excluded when BSA was missing. Finally, individuals were excluded for AAodist, when blood pressure values were missing.After manual inspection of 7568 images with the corresponding predicted segmentations and extracted features by a panel of four human observers, we defined predictions to be unreliable at the image-level when the relative roundness Rmax, AAomin and AAodist, using BOLT-LMM (version: 2.3beta2), employing a mixed linear model which can take into account several potential sources of bias such as population structure and cryptic relatedness.R2  < 0·005 within a five megabase window on variants passing the P-value threshold of 1 ×  10−5 using PLINK 1.9.P < 5 × 10−8 for selection of independent SNPs that were considered significantly associated with AAo anatomy and distensibility. We scanned in a one megabase region at either side of the independent variant to define a genetic locus. Locus determination was repeated between AAo traits to obtain the strongest set of credible loci for the AAo traits combined (Online Table 1). Manhattan plots and QQ plots were generated using R V3.4.4. Genomic inflation was assessed by calculating lambda, LD score regression intercepts and attenuation ratios using LD score regression analyses.,Genome-wide association analyses were performed on inverse rank normalized values of AAo,P < 0·05/855=5·85 × 10−5 was adopted to determine whether genetic correlations were significant. In addition, we queried the GWAS Catalog to find established genetic variants in linkage disequilibrium (LD) (R2 > 0·1) with AAo SNPs.The LD Hub platform was used to test for genetic correlations with previously performed GWAS.2R > 0·8) with the lead SNPs. Thirdly, we used DEPICT  to identify candidate causal genes whilst taking gene-gene similarities and LD structures between loci into consideration.Three methods were applied to search for candidate causal genes for each AAo trait. First, we searched for the nearest gene or any gene within a 10kb distance of the lead SNP. Secondly, we searched for coding variants in LD , myocardial infarction, stroke and aneurysms. As exposure, we used all lead SNPs at a Disease outcomes were captured based on a composite source of data from interview with a trained nurse at the visit to assessment centres (self-reported) and linked electronic health records including hospital inpatient episode data. Hospital inpatient episode data was collected at the Assessment Centre in-patient Health Episode Statistics (HES) in combination with data on cause of death from the National Health Service (NHS) Information Centre. HES and NHS data were respectively up to 31-03-2017 and 31-01-2018 for English participants, up to 29-02-2016 and 31-01-2018 for Welsh participants and up to 31-10-2016 and 30-11-2016 for Scottish participants.n = 171), those for which CMR images were available , those who failed genetic quality control (n = 1251) and exclusions based on familial relatedness . A total of 381,324 unrelated individuals that were not in any of the GWAS discovery cohorts remained available to test the SNP-outcome associations. Outcomes included coronary artery disease, myocardial infarction, any stroke, ischemic stroke, haemorrhagic stroke and aneurysms. Disease definitions are further detailed in the Supplementary File 3, Tables 11 and 12. Logistic regressions were performed to obtain SNP-outcome associations on ever having received the diagnosis in an individual's lifetime. All regression analyses were corrected for age on the date of the last follow-up, sex, the first 30 principal components and the genotyping array. Regression analyses were performed using statistical software STATA 15 (StataCorp LP).Outcomes were assessed in the participants of the UK Biobank for which no AAo CMR images were available. From the full cohort, we excluded those individuals that withdrew informed consent )/(1-R2)=  in combination with an I2 index > 25% was used as statistical evidence for at least balanced horizontal pleiotropy.,,P < 0·05, in combination with a significant non-zero intercept of the MR-Egger regression (P < 0·05) was considered to indicate unbalanced horizontal pleiotropy.2GX and, with an I2GX > 95%, indicating low risk of measurement error.An inverse variance weighted random effects model (IVW-RE) was applied to estimate the causal effect of AAo size and function on all outcomes.There are also possible scenarios in which only a small or a large proportion of the included genetic variants exert pleiotropic effects and we therefore performed several sensitivity analyses. We used the MR-Lasso, MR-RAPS (both down-weight outliers) and MR-PRESSO approaches  to provide robust MR in the situation that a small proportion of the genetic variants exert pleiotropic effects.51,,,,P-value of P < 0·05/10 outcomes = 0·005 was considered to be significant for the main IVW random effects analysis. A P-value cut-off of P < 0·05 was considered to be suggestively significant for the main analysis and to indicate a significant association for the generally weaker powered sensitivity analysis.MR analyses were performed using R (version 3.6.3), the TwoSampleMR package (version 0.5.3), MR-PRESSO package (version 1.0), MR-Lasso source code and the MR-mix package.All data provided by UK biobank was acquired after approval from North West - Haydock Research Ethics Committee (REC reference: 16/NW/0274). All participants of the UK biobank have provided written informed consent.,CARDIoGRAMplusC4D and MEGASTROKE consortia are ethically approved by local and institutional committees. For more information, see the original consortium papers.In the present study, none of the funding sources played a role in study design, data collection, data analyses, interpretation, or writing the manuscript.The model yielded a Dice score of 0.93 (SD=0.03), compared to observer 1 and 0.95 (SD=0.02) compared to observer 2, thereby passing the desired threshold of 0.90, and we deemed the model's performance to be sufficient for assessment of aortic dimensions and function in the whole set of MRI images downloaded from the UK Biobank.P < 0.001, ICC with two-way random -effects model) in comparison to observer 1 and 0.95  compared to observer 2, where a comparison between both human observers yielded an ICC of 0.99 . For distensibility the comparison between model and observer 1 yielded an ICC of 0.90 , compared to observer 2 0.85 , between both observers 0.85 . Overall, the ICC values for distensibility were lower than for area. However, in contrast to area, we observed a higher ICC between model and both individual observers than the ICC between observers for distensibility.Model vs observer comparison of extracted areas yielded an ICC of 0.96  between AAomax and AAomin. Correlations between both Area traits and AAodist were substantially lower. Correlation between AAomax and AAodist yielded a value of -0·142 , versus correlation between AAomin and AAodist of -0·365 .We estimated correlation between all three traits, measured by Pearson's product-moment correlation coefficient. We calculated a correlation coefficient of 0·959 . We found 65 SNPs in 59 loci for AAomax, 71 SNPs in 64 loci for AAomin and 4 SNPs in 4 loci for AAodist , while their respective correlation with AAodist was lower . BOLT-REML estimated high SNP-based heritability for both AAomax  and AAomin , but a lower heritability for AAodist . The identified variants explained 10·2% variance of AAomax, 10·7% for AAomin and 0·7% for AAodist.GWAS revealed a total of 107 variants in 78 loci across all three AAo traits  with previously established variants for aortic size or thoracic aneurysms (four SNPs), blood pressure traits (12 SNPs) and atherosclerosis and thrombosis (two SNPs) (Online Table 2). LDhub was queried to assess genetic correlations with other traits and showed that AAo traits were mainly correlated with blood pressure and anthropometric traits (Online Table 3).We found that the SNPs identified in the current study were in high LD . Annotation and further information of all identified genes is provided in Online Table 6. FBN1, ELN, MYH10 and ULK4 showed overlap with genes that have previously been associated with syndromic, familial and sporadic aneurysms .JMJD1C, SMG6, NOC3L, ULK4, and ADAMTS7. We assessed the likelihood of their pathogenicity according to the American College of Medical Genetics (ACMG) guidelines. There was only evidence for differences in the prevalence of one variant in SMG6 between case and control groups for coronary artery disease in the UK Biobank (Online Table 13). The relative CADD scores of coding variants of ULK4  and SMG6  were higher than 20 and therefore belong to the top 1% of most pathogenic coding variants.We searched for candidate causal genes using multiple strategies and identified a total of 101 genes for which we provide a framework for their possible involvement in AAo anatomy and function in  ADAMTS7 . ELN wasmax, 419 gene sets in 53 gene clusters for AAomin, but none for AAodist. 178 gene sets were significantly enriched for both AAomax and AAomin. The central nodes of the top gene clusters for AAomax were complete embryonic lethality during organogenesis, response to nutrient levels and circulatory system processes, for AAomin the CREBBP PPI subnetwork, smooth muscle cell proliferation and anemia. (Online Table 7). Tissue enrichment analysis revealed six significantly associated tissues for AAomax and 10 significantly associated tissues for AAomin. We found no significantly enriched tissues for AAodist. Both AAomax and AAomin were strongest enriched in the arteries and all top five tissues were related to cardiovascular system. Full results of the tissue enrichment analysis can be found in Online Table 8 and are shown in Supplementary Fig. 4.Pathway enrichment analysis revealed 223 reconstituted gene sets in 30 gene clusters for AAoOnline Tables 9 and 10.A series of Two-sample MR analyses was performed to investigate the potential causal mechanisms between AAo size and function and cardiovascular diseases. Results of the heterogeneity and sensitivity analyses are described in more details in the supplement and in max, AAomin, or AAodist and coronary artery disease or myocardial infarction in the UK Biobank or in the CARDIoGRAMplusC4D cohort using an inverse variance weighted random-effects model ., but the results were not replicated in the MEGASTROKE consortium for both AAomax  and AAomin  .We found no evidence for a genetic association between AAots model . AAomax  IVW-RE) . We alsomax, AAomin, AAodist and aneurysms . The results were robust to MR-Lasso and weighted median analyses .Lastly, we studied the association between AAo size and function and aneurysms. We found strong evidence for a genetic association between AAoanalyses . Considein silico annotations provide insights in their biological background. The MR analyses provide evidence for a genetic association between AAo anatomy and development of aneurysms in a general population.In the current study, we applied automated segmentation of the AAo lumen using an AI approach, to obtain its properties on 37,910 participants from the UK Biobank. GWAS from these derived phenotypes identified a total of 107 common genetic variants in 78 loci associated with AAo anatomy and function and dist. The average AAodist was higher for women than men younger than 65 years, but this effect was attenuated within the older age categories. The reference values were similar to previous studies and provide a framework for physicians to evaluate AAo anatomy from CMR imaging.,62We provide normal values of AAo anatomy and function in the largest cross-sectional population-based cohort study to date. We additionally characterized age-related changes in the aorta for women and men and show that there is an age-dependent increase of AAo size and decline of AAomax and AAomin as indicated by the strong observational and genetic correlations, as well as the large number of shared loci. The SNP-based heritability estimates for AAomax and AAomin were approximately 50%, whereas a previous twin study reported a heritability between 0·67 and 0·82 for the diameter of various parts of the aorta.in-silico annotations revealed biologically likely gene sets that were involved in cardiac and muscle structure development and pointed to the arteries as highest enriched tissue. The gene set enrichment analysis also showed the importance of cardiac development, with the top meta-clusters revolving around heart and muscle structure development. We found the strongest genetic overlap with blood pressure and anthropometric traits, although correlations were weak in general. We identified several genes that have been previously implicated to AAo anatomy or thoracic aneurysm development, including the FBN1, ELN, MYH10, ULK4 and SMG6 genes.,CCDC100 in a previous study.PRDM6, which encodes a histone methyltransferase and can alter epigenetic gene regulation.,PRDM6 might influence AAomax through regulation of vascular smooth muscle cells contractile proteins or through its association with patent ductus arteriosus.,We then aimed to gain additional insights in the biology of interindividual differences in AAo size and identified a total of 103 common genome-wide significant genetic variants. There was a high overlap between AAodist was in line with previous GWASs, in which global arterial pressure measured by pulse wave velocity (PWV) was investigated, with estimates ranging between 0·06 and 0·28; all of which were lower than heritability estimated in twin studies (0·43–0·53).In-silico annotations only highlighted blood serum as a significantly enriched tissue, possibly pointing to the role of circulating inflammatory markers in arterial stiffening.,,,,There was little overlap of the underlying biology between AAo function and anatomy as indicated by weak observational and genetic correlations, as well as the absence of overlap between the four SNPs associated with AAo function and those associated with AAo anatomy. The SNP-based heritability of AAoJMJD1C, SMG6, NOC3L, ULK4, and ADAMTS7. We evaluated their potential pathogenicity according to the ACMG guidelines and found that high relative CADD scores for coding variants of ULK4  and SMG6 , providing one supportive argument for pathogenicity. In addition, we found that the prevalence of coronary artery disease was different between the alleles of 17:2088848_C_CCAGA, which provides evidence pathogenicity as well. However, the MR results did not support a causal relation between the investigated AAo traits and coronary artery disease development. Future research, such as functional studies and data on familial aggregation or de novo mutations in individuals with abnormal AAo traits, will be essential to provide definitive evidence on a potential causal role of these genes.We searched for genetic variants which could alter protein encoding and identified a total of six genetic variants for the AAo traits was in high LD with coding variants of COL6A3, ELN, FBN1, and THSD4), which are of importance for the resistance of the aorta to stretching during the systolic phase. Both FBN1, which encodes fibrillin-1 and is associated with Marfan syndrome, and ELN, which encodes elastin and is associated with the cutis-laxa syndrome gene, are known for their importance in syndromic thoracic aneurysms.COL6A3 gene encodes the alpha-3 chain of type VI collagen and to date there are no studies which describe a role in AAo anatomy or function. Especially the role of type I and type III fibrillar collagens have been described for their role in the tensile strength of the aortic wall to withstand the high pressure of blood pumped by the heart, as they account for 80–90% of the total collagen present in the aorta.,THSD4 gene encodes a microfibril-associated protein which binds to fibrillin-1. In vitro and in vivo experiments in mice have shown a role of THSD4 in promoting fibrillin-1 its matrix assembly.ADAMTS8, ANGPT1, ATF1, ECM1, FGD5, HAND2, HAS2, RNH1) involved directly in angiogenesis. In addition, we highlighted genes involved in smooth muscle cell contraction  and development , which might play a role in arterial vasoconstriction. Of these genes, the ADAMTS7 was identified by all gene-prioritization methods. The ADAMTS7 gene encodes a zinc-dependent protease and has been associated with coronary artery disease in numerous GWAS.,ADAMTS7 in smooth muscle cells in coronary and carotid atherosclerotic plaques.JMJD1C which was identified by all gene-prioritization methods. JMJD1C encodes a histone demethylase, and mutations in this gene are associated with Rett Syndrome, a congenital neurological disorder.JMJD1C have previously been linked to conotruncal type of congenital heart diseases commonly seen in individuals with 22q11·2 deletion or DiGeorge syndrome.Multiple strategies were applied to search for candidate causal genes and we evaluated their molecular mechanisms of action to gain insights in their potential role in the biology underlying interindividual differences in AAo traits. We found several genes involved in connective tissue development . Source data from UK biobank, CARDIoGRAMplusC4D and MEGASTROKE may be requested from the concerned consortia.The data that support the findings of this study are available from the corresponding author upon reasonable request. The GWAS datasets summary statistics generated during the current study are available in the following repository (The work of J.W. Benjamins and M.W. Yeung was supported by the Research Project CVON-AI (2018B017), financed by the PPP Allowance made available by Top Sector Life Sciences & Health to the Dutch Heart Foundation to stimulate public-private partnerships. The work of N.Verweij was supported by NWO VENI grant 016.186.125.All authors contributed to the study conception and design.Formal analyses were performed by J.W.B., M.W.Y, Y.J.V. and M.A.S.J.W.B., M.W.Y, Y.J.V., M.A.S., D.T., T.L., N.V. and P.H. were involved in interpreting the data.Writing of the first draft was performed by J.W.B., M.W.Y, Y.J.V. and M.A.S.Supervision, funding, manuscript reviewing, and editing were performed by L.J.O., N.V. and P.H.All authors read and approved the final manuscript.All authors take full responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation.Niek Verweij was employed by Regeneron Pharmaceuticals. Jan Walter Benjamins, Ming Wai Yeung, Yordi J. van de Vegte, M. Abdullah Said, Thijs van der Linden, Daan Ties, Luis E. Juarez-Orozco and Pim van der Harst declare that they have no competing interests.


Excessive productionof biomass, in times of intensification ofagriculture and climate change, is again becoming one of the biggestenvironmental issues. Identification of sources and effects of thisphenomenon in a river catchment in the space–time continuumhas been supported by advanced environmental modules combined on adigital platform (Macromodel DNS/SWAT). This tool enabled the simulationof nutrient loads and chlorophyll “a” for the NielbaRiver catchment  for the biomass productionpotential (defined here as a TN:TP ratio) analysis. Major differenceshave been observed between sections of the Nielba River with low biomassproduction in the upper part, controlled by TN:TP ratios over 65,and high chlorophyll “a” concentrations in the lowerpart, affected by biomass transport for the flow-through lakes. Underthe long and short-term RCP4.5 and RCP8.5 climate change scenarios,this pattern will be emphasized. The obtained results showed thatunfavorable biomass production potential will be maintained in theupper riverine sections due to a further increase in phosphorus loadsinduced by precipitation growth. Precipitation alone will increasebiomass production, while precipitation combined with temperaturecan even enhance this production in the existing hot spots. Modeling approach assists in currentand future water eutrophicationanalysis in a river under climate change scenarios. Currently, the main source of information on this topicis comprehensive research conducted on river basins in South Korea,30 and individual publications from other regions of the world.33 These studies clearly show that one of the promisingmethods to understand complex interactions influencing biomass productionin rivers may be the use of environmental models, such as ANNs,24 QUALKO2,34 HiddenMarkov Model (MHMM),29 or SWAT.33 Moreover, the combined capabilities of differentmodels are also increasingly used36 as well asartificial neural networks37 or machinelearning methods.38 Nevertheless, the influenceof factors, such as surface runoff or future changes in temperatureand precipitation, is rarely taken into account. Meanwhile, surfacerunoff is one of the most important processes causing the migrationof pollutants from the basin land phase to the river, and future changesin temperature and precipitation will have a major impact on thisprocess. Therefore, there is a justified risk of altering biomassproduction in river basins.40The biomass overproduction problem has been attracting the attentionof the scientific community for several decades,43 and therefore a so-called “new wave of eutrophication”is frequently reported.45 This phenomenon ismainly caused by human activity, more specifically by growing demandfor food production, leading to intensification of agriculture, andan increase in nitrogen and phosphorus loads from nonpoint sources.This also includes a dynamic development of urbanized areas and anincrease in industrial and municipal wastewater discharges. Moreover,it is due to the acceleration of climate change,48 defined asthe possibility of biomass production, described by selected factors. Local and regional environmental variables  are also important. While the anthropogenicfactors influencing biomass production are well described, the impactof climate change is still ambiguous.49 The processes contributing toward eutrophicationin a river can be distinguished between the land and river bed phases.In the land phase, a precipitation increase in selected months ofthe year will contribute to intensification of the surface runoffand pollutant wash-out40 and their subsequent transportinto a river. This process may be partially limited by an increasein temperature, leading to, among the others, an extension of thevegetation period.30 This will result ina longer plant cover occurrence that will enhance nutrient uptakefrom soils and offer protection against erosion caused by rainfalls.51 In the river bed phase, however, climate change may contribute tothe extension of the period with conditions favorable for the accelerationof in situ biomass production .53Concomitantlyoccuring anthropogenic and climate pressures exertedon river system are increasing,The aim of this research was to trace current and future biomassproduction in a river, resulting from nitrogen and phosphorus dischargesfrom its basin. For the purposes of this article, the concept of “biomassproduction potential” has been defined and related to the nitrogenand phosphorus ratios. Moreover, the impact of climate change on theeutrophication potential of the river, using an advanced environmentalmodel was used, based on these nitrogen and phosphorus load ratios.For this purpose, a small but strongly agricultural basin of the NielbaRiver in central-western Poland was selected, featuring three flow-throughlakes on the main watercourse. The numerical model of the Nielba Riverbasin was created in the Macromodel DNS/SWAT (Discharge-Nutrient-See/Soil& Water Assessment Tool) digital platform and its chlorophyll“a” module (CHLA) and was used to track the biomassproduction potential in time and space along the entire river continuum.Ultimately, the question on present chlorophyll “a”concentrations in the specified calculation profiles of the analyzedriver and their changes in the near and distant future have been answered.Moreover, mathematical description of these changes has been appliedas a first stage of the biomass production potential analysis. Theimportance of our method lies in the simplicity of our approach, whichcan be applied without additional complicated tools for the TN, TP,and chlorophyll “a” data analysis to assess future changesin biomass production.22.12)  1 is loca2.26 which became thebasis for the basin models58 and researchon biomass production.61 The SWAT model and the CHLA simulation module wereused for the analyses  and closing (out) calculation profiles of eachdesignated basin. Due to the fact that the concentration of CHLA islargely an effect caused by the loads TN and TP and their interdependence(TN:TP ratio), therefore, loads of TN and TP (in) and CHLA (out) havebeen simulated in the current study.To estimate the concentrationof chlorophyll “a” (CHLA), in selected calculation profilesof the analyzed river, the assumption that the concentration of CHLAis to be directly proportional to the concentration of phytoplanktonalgal biomass was used,analyses 2, and th2.363 predictions have been based on the data from the Euro-CORDEX, Regionalclimate models (RCM), and the Global Climate Models (GCM) on a regulargrid with a resolution of 0.11° (approx. 125 km).66 Data from the Poznań-Ławica synoptic station  has been used, which is located 48.5 km away from the NielbaRiver basin, and there is a 22 m difference in altitude between bothlocations. The statistical postprocessing 68 was performed using the tools available in the R environment.69 The climate condition analysis in the UAP projectcovered the moderate (RCP4.5) and extrapolative (RCP8.5) scenariosand two future time horizons: a short-term perspective (average ofthe 2026–2035 time period) and a long-term perspective (averageof the 2046–2055 time period).72 Therefore, four climatevariant scenarios, with a monthly time step, were prepared to combinethe RCP predictions and adopted time horizons: VS1 (RCP4.5: 2026–2035),VS2 (RCP4.5: 2046–2055), VS3 (RCP8.5: 2026–2035), andVS4 (RCP8.5: 2046–2055)  project46–2055) 3.2.4To discuss thecurrent and future biomass production issues in the Nielba River,the obtained modeling results have been presented in a form of 2Dscatter plots 5 and 6. 33.173 The total nitrogen loads (TN) constantlyincreased from the source of the river  to the inflow of the ŁęknoLake (sub-basin 63), in total, by over 4900 kg/month .A similar pattern has been displayed by total phosphorus (TP), withloads increasing by 130 kg/month (180%) in the same section of theriver. As for the ratio of both nutrient loads (TN:TP), it variedfrom 65 in sub-basin 49 up to 76 in sub-basin 62.The averagemonthly nutrient load predictions in the Macromodel DNS/SWAT for theNielba River sub-basins for 2005–2007 have been presented in The presence of the Łękno Lake drasticallychangesthe nutrient dynamic in the Nielba River. The decrease by 99 and 96%for both TN and TP, respectively, is visible at the opening calculationprofile of sub-basin 64, directly downstream from the lake. The changein the nutrient loads also brings a decrease in the TN:TP ratio, whichfor this sub-basin, is 18. Along with the subsequent river course,another increase in TN and TP loads is visible, despite the presenceof the two other lakes (Bracholińskie and Rgielskie). However,the load values reached only 2504 and 78 hg/month for TN and TP, respectively1.Figure S2) showed elevated values of nutrientloads in the winter and early spring months, with the maximum valuesin March  and the minimum ones in August . Largefluctuations of nutrient loads during the year directly translatedinto the TN:TP ratio with a variability range from 9 in sub-basin64 in May to even 253 in December in sub-basin 62.Apartfrom the spatial variability of nutrient loads among theNielba River sub-basins, the temporal one shall also be noticed. Thepronounced monthly variabilities of TN and TP loads, expressed ascoefficients of variation (CV), ranged from 124% up to 135% and from118% up to 179% for TN and TP, respectively 1. The mo3.273). Moreover, a decreasing trend along the river course towardthe Łękno Lake has been observed, until the value reached0.2 μg/L at the river outflow to the lake (sub-basin 62). Simultaneously,with the depletion of nutrients due to rapid eutrophication in thelake, the increase in CHLA concentration reaching almost 580 μg/Lat the outlet of the Łękno Lake was observed. The CHLAconcentrations remained at a high level also in the riverine sectionconnecting the Łękno Lake, with the BracholińskieLake . Downstream from the lastlake on the river course , a noticeabledecrease in CHLA values was visible, and by the last urbanized sectionof the Nielba River basin (sub-basin 76), the CHLA value was reducedeven further down to 29.3 μg/L.The simulatedchlorophyll “a” (CHLA) concentrationswere very low in the upper part of the Nielba River with a maximumvalue of 1.3 μg/L for sub-basin 47 , with an averagevalue of 9.28 μg/L in March at sub-basin 47 4. Downst3.373 The forecastedchanges of meteorological conditions in the Nielba River basin willaffect both nitrogen and phosphorus loads, especially under the RCP8.5long-term scenario (VS4). Generally, the average TN and TP loads willincrease along the entire length of the studied river. However, thehighest changes in TN should be expected in the last two sub-basinsof the river (71 and 76) for VS1–VS3 scenarios by 15–21%of the baseline scenario values and by 80% is sub-basin 64 for theVS4 scenario , an increase in the CHLAconcentrations is predicted by 9–24% of the baseline scenariovalues in the sub-basins 47–64 and by 73–138% in thesub-basins 71 and 76 2. Under The range of the variant scenarios’ impacts on the discussedvariables  for the first time was estimated throughthe 2D and 3D analysis, which allowed for result interpretation onthe spatial and temporal scale. This analysis included assessmentof 95% confidence ellipses (2D) positioning in relation to the TN:TPratio lines as well as the 95% confidence ellipsoid volumes (3D) forindividual clusters 3. GeneraThe biggestchanges in volume compared to the baseline scenarioare to be expected for A–C ellipsoids. For the VS4 long timehorizon scenario, these changes will even amount to over 1200%, whilefor cluster D, they will not exceed 85%. Generally, volume changesof all four ellipsoids will be primarily controlled by the TP loads,reaching even 465% . Cluster C will be alsocharacterized by the highest increase in biomass production (evenby 52%), while again in cluster D, this increase will not exceed 17%.475 For these methods,modeling plays a complementary role, allowing not only predictionof spatial and temporal distribution of nutrients but also simulationof processes responsible for excessive biomass growth in surface waters.Although this problem is well discerned for lakes and reservoirs,18 attempts to verify and apply numerical models to analyze nutrientloads and chlorophyll “a” concentrations in flowingsurface waters are still scarce.76 This is mainly dueto the multiplicity and complexity of processes taking place and thelimited amount of monitoring data in such systems.38 By using thechlorophyll “a” specific module (CHLA) incorporatedin the Macromodel DNS/SWAT, we were able to track intricacies of spatialand temporal changes in biomass production in the river’s entirecontinuum from its source to the outlet cross-section.The existing methods of inlandwater eutrophication counteractionfocus mainly on nutrient load determination and development of abatementmeasures in the affected basins.4.1Figure S2). However,intensive agriculture and lack of proper wastewater management alsoplay important roles in the nutrient delivery in this basin,77 which is clearly visible as a rapid increasein nutrient loads in the upper part of the river from the source tothe discharge into the Łękno Lake is seen. The NielbaRiver displays a snow-rain hydrological regime that controls temporalvariability of contaminant loads. Surface runoffs above 10–5 m3/s (Supporting Information Ch1), caused by snow melt, coincide with a spring fertilization period,resulting in the increase in nutrient delivery. It should also benoticed that the fertilization rate in this area is considered asthe most intense in Poland, and therefore the local soils are extremelyabundant in phosphorus compounds.78 Moreover,the small river flows, 0.25 m/s on average, in the upper part of theNielba River do not guarantee proper dilution of nutrients and limitthe self-purification processes.79 Despitesuch enrichment of the upper Nielba River waters with biogenic compounds,biomass production is practically negligible in this section of theriver and does not exceed 1.3 μg/L of chlorophyll “a”as a mean monthly concentration. Therefore, this section can be consideredre-oligotrophic.80 Since the TN:TP ratiosvary in a range of 65–76 in this section of the river, thelimiting role of phosphorus is very likely. Moreover, the dense shruband tree canopy along the river banks reduces light access, furtherreducing the chlorophyll “a” development.82 The river flow effect is alsoconsidered to be a limiting factor for CHLA development.29The spatial analysis revealedelevated values of the TN and TP loads already at the source of theriver, which resulted mainly from the connection of the Nielba Riversource with the heavily polluted Stępuchowskie Lake throughthe system of canals . As for most of the lower Nielba River area,agriculture continues to be the main environmental pressure and islargely responsible for the increase in nutrients in this short sectionof the river (2.1 km) preceding the Bracholińskie Lake. Moreover,the presence of fish ponds in this area can be attributed as an additionalsource of pollution for this portion of the river.85 Despite the increase in nutrient loads, the TN:TP ratio remainsat a more favorable level for the biomass production (around 50).This is directly reflected in the chlorophyll “a” concentrations,reaching over 360 μg/L, which corresponds to eutrophic conditions,80 causing the eutrophication phenomena. In thefollowing section of the river, the two-lake system, Bracholińskieand Rgielskie, is connected by a 40 m-long stretch of the Nielba River(which in the past formed one lake)86 andaffects the biomass production. The small and shallow BracholińskieLake receives high nutrient loads from the Nielba River and localsources of pollution, which results in hypereutrophic conditions.87 On the contrary, the depth of the RgielskieLake (over 5 m) clearly reduces the effectiveness of the eutrophicationprocesses.92 Therefore, despite the still high nutrient loads discharged intothis water body from the surface runoff and local point sources, thechlorophyll “a” concentration in the lake’s outletis relatively low (54.2 μg/L). The last section of the studiedriver (sub-basin 76) differs significantly from the previous in termsof land use and is dominated by urban areas. However, the river channelremains still heavily bushed and forested. Even with TN:TP ratio valuespotentially promoting the eutrophication processes (below 50), richdelivery of nutrients from the municipal surface runoffs,94 and discharges from the local wastewater treatment plant, the biomassproduction is relatively low here (below 30 μg/L of chlorophyll“a”). The same range of chlorophyll “a”concentrations has been observed in many similar, in terms of lengthand land use, rivers across Europe.96In the lower part of the river, the nutrientand biomass production patterns are controlled mainly by the lakes’presence and the basin land use. The first lake on the river course,the Łękno Lake, serves as a receiver of nutrient dischargesfrom the upper Nielba River and the local wastewater treatment plant.Therefore, it is well recognized for its highly hypertrophic waters.4.299 Defined this way, biomass production potential was analyzed forindividual identified 2D clusters along with significant featuresdistinguishing it from the others. Cluster A contains outputs exclusivelyfrom sub-basin 64 with considerably large chlorophyll “a”concentrations, localized directly downstream from the ŁęknoLake (sub-basin 63). In this cluster, the increase in the biomasspotential when compared with the upstream sub-basin is noticeable(average TN:TP ratio of 15). This increase is most likely inducedby the transport of biogens from the local hot spot (ŁęknoLake) and to chlorophyll mobility characteristic for flowing surfacewaters.102 The most numerous cluster B comprises mostlysummer/autumn modeling outputs from almost all the analyzed sub-basins.The majority of its records lie between TN:TP ratio 9 and 50 lineswith the low chlorophyll “a” concentrations for theriverine sub-basins. The elevated chlorophyll “a” valuesfor the Łękno Lake confirm all-year-round strongly eutrophicconditions in this sub-basin (63). In cluster C, covering exclusivelywinter/spring months, the biomass production potential based on theTN:TP ratios could be qualified as unfavorable (above 50). However,again, the impact of highly eutrophic conditions in the ŁęknoLake (sub-basin 63) is evident, marking this cluster with infrequenthigh chlorophyll “a” concentrations. The rest of thiscluster’s outputs indeed cover low biomass production fromthe riverine sub-basins. Cluster D encompases modeling outputs coveringextremely high TN and TP loads. This cluster is almost entirely limitedby the 9 and 50 TN:TP ratio lines that signify eutrophication favorableconditions. However, the sparse outputs with the elevated chlorophyll“a” concentrations in this cluster again belong to thelacustrine sub-basin (63). The rest of this cluster represents mostlylow biomass production in the upper parts of the Nielba River. Similarrelationships have been also observed in the other riverine systems.103To estimatea potential for biomass changes in the particular reaches of the studiedriver, the TN:TP ratios between 9 and 50 have been adopted as favorableconditions for biomass development.4.3The four adopted scenariosallowed us to track the impact of climatechanges under the RCP4.5 and RCP8.5 forecasts in two time horizons(2026–2035 and 2046–2055). Foreseen changes in meteorologicalconditions in the Nielba River basin affected nitrogen and phosphorusloads and also chlorophyll “a” concentrations. In ourapproach, these changes have been traced following shifts in the designatedellipsoids volumes for each of the clusters.In cluster A, containingdata exclusively from the sub-basin located downstream from the ŁęknoLake, the 3D ellipsoid volume changes (by 282–378%) resultmainly from the TP load increase, especially for the long-term predictionsof RCP4.5 and RCP8.5 scenarios (VS2 and VS4). Although that causesa decrease in the TN:TP ratio, the increase in chlorophyll “a”concentrations is still visible since this is related to the biomasstransport from the lake. The range of ellipsoid changes is also similarin cluster C, covering exclusively the winter/spring months. However,in this case, the forecasted increase in temperatures possibly moderatesnutrient delivery from the basin, bringing the TN:TP ratio into themore favorable eutrophication zone. Changes of nutrient load deliveryfor the basin are also explicit in cluster D, containing results bothfor extremely eutrophication unfavorable conditions for the upperNielba River and the highly eutrophic Łękno Lake. However,here the impact of variant scenarios is different than in the otherclusters. For the majority of scenarios (VS1–VS3), the decreasein TN loads is visible, most likely caused by the decrease in precipitation-inducedrunoff. In cluster B, ellipse/ellipsoid changes manifest themselvesmostly in dispersion of its outputs, especially for the long-termRCP8.5 scenario . Since this cluster contains mostlysummer/autumn modeling outputs from all the sub-basins, the detailedanswer which factors control this process should be subjected to furthermultiparameter analysis including other parameters, not only nutrientloads. It should also be noted that extreme changes of ellipsoid valuesare mainly controlled by the outlier values, which mark mainly highlyelevated chlorophyll “a” concentrations. This signifiesmodel reaction depicting exceptionally favorable biomass productionconditions, which could be induced by climate change in the future.105 As for the lower part of the Nielba River,the present and future biomass production issues are controlled bythe presence of lakes, wherein the intensity of future biomass productioncan be enhanced by the predicted increase in the nutrient load delivery.The TN:TP imbalances, and especially TP impact on biomass productionshould be further investigated. In general, the relationship betweenphosphorus and biomass seems to be closer for rivers than for lakes,and the phosphorus variability may result in a rapid river ecosystemreaction.107 Our mathematical approach, althoughlimited to only three factors, shall be very beneficial for extensivedatabase analysis and capturing relevant biomass production relationships.This approach allowed us for simultaneous analyses of nitrogen andphosphorus loads and chlorophyll “a” concentrationsand showed that the increase in nutrients due to climate change doesnot necessarily lead to a parallel biomass development. However, ourresults clearly indicate that high chlorophyll “a” episodeswill become more frequent and more dependent on the phosphorus changesthan the nitrogen ones.Our results show that future climate changes, expressed in termsof temperature and precipitation, will in general amplify the existingpattern of biomass production. For the riverine sections of the upperNielba River, the chlorophyll “a” concentrations willbe increased only during the winter/spring months when surface runoffsare already high and will be elevated in the future by the precipitationincrease. As for the remaining months of the year, despite the favorableTN:TP ratios (between 9 and 50), the biomass production remains negligibledue to the surface runoff decline and self-purification processes.Such a pattern is characteristic for many rivers with a similar hydrologicalregime.4.4108 the next researchstep should be focused on elucidation of the other factors responsiblefor the biomass production potential within a river .Moreover, such multiparameter analysis could provide leads on extremechlorophyll “a” concentrations, which as shown by thecurrent study, can appear more and more frequently. In the futurestudies, special attention shall be also paid to the land use changessince in the case of biomass production, they are equally importantas the climate ones. Also, the future modifications in farming activitiesand cultivation patterns following climate alterations should be takeninto consideration. However, the latter would require more detailedinformation from the local/regional studies, which is still scarce.Also, the climate changes predictions require the utmost attentionin terms of their reliability and spatial resolution. Despite manyyears of research, there is still a lack of reliable data on the localpatterns of climate change, and climate adaptation is still lagging.109Our findings areextremely important for land and water management in basins vulnerableto eutrophication. Since their identification and precise delineationis already possible,


All participants had three clinic visits with a dietitian and one obstetric consultation. In total, 50 women were enrolled in the study between June 2018 and October 2019–26 in MR and 24 in DA. Study retention at the end of 10 week intervention 81% in the MR arm and 75% in the DA arm. In the-intention-to-treat analysis, women using meal replacements lost on average 5.4 ± 3.1% body weight compared to 2.3 ± 4.2% for women receiving conventional advice (p = 0.029). Over 80% of women in the MR arm rated the support received as excellent, compared to 39% in the DA arm (p < 0.001). Women assigned to the MR intervention were more likely to achieve pregnancy within 12 months of the 10 week intervention (57% (12 of 21) women assigned to MR intervention vs. 22% (4 of 18) assigned to the DA group (p = 0.049) became pregnant). The findings suggest that a weight loss intervention using meal replacements in the preconception period was acceptable and may result in greater weight loss than conventional dietary advice alone.About half of Australian women have a body mass index in the overweight or obese range at the start of pregnancy, with serious consequences including preterm birth, gestational hypertension and diabetes, caesarean section, stillbirth, and childhood obesity. Trials to limit weight gain during pregnancy have had limited success and reducing weight before pregnancy has greater potential to improve outcomes. The PreBabe Pilot study was a randomised controlled pilot trial to assess the feasibility, acceptability and potential weight loss achieved using a commercial online partial meal replacement program, (MR) vs. telephone-based conventional dietary advice, (DA) for pre-conception weight-loss over a 10-week period. Women 18–40 years of age with a BMI ≥ 25 kg/m Australia is one of the most overweight developed nations, with two-thirds of adults and a quarter of children having overweight or obesity . At a naDespite the impact of obesity in pregnancy, systematic reviews of randomized controlled trials (RCTs) have concluded that interventions to limit or reduce weight gain in pregnancy do not succeed in substantially reducing risk of adverse pregnancy outcomes ,7. TherePrevious studies in men and women with overweight and obesity have demonstrated that the amount of weight loss is greater with meal replacement products than with conventional dietary food restriction ,7. In a Pre-conception weight loss is a key research priority in high income countries . Althoug2 who were planning a pregnancy within the next 6 to 12 months. We hypothesised that women would achieve greater weight loss on the partial meal replacement diet compared with standardised healthy dietary advice, and that the program would be acceptable to the women and feasible to scale-up for a larger RCT.The PreBabe Pilot study is a pilot RCT that aimed to assess the feasibility and acceptability of a partial meal replacement diet versus healthy diet advice for a duration of 10 weeks in women with a BMI ≥ 25 kg/mhttp://www.anzctr.org.au ACTRN12620000597998; Date Registered: 22 May 2020) and approved on 15 February 2018 by the Sydney Local Health District RPA Zone Human Research Ethics Committee (Protocol X17-0382 & HREC/17/RPAH/579).The trial was registered with the Australian New Zealand Clinical Trials Registry , New South Wales, Australia, who were planning a pregnancy within 6 to 12 months were eligible to participate. Inclusion criteria were: aged between 18 and 40 years inclusive; Body Mass Index (BMI) ≥ 25 kg/m2 from measured height and weight; intending a pregnancy within the next 6 to 12 months; being weight stable  in the past 2 months and willing and able to attend the Charles Perkins Centre- Royal Prince Alfred Hospital Clinic (RPAH), University of Sydney on three occasions. Exclusion criteria were BMI < 25 kg/m2; currently pregnant, breastfeeding or <6 months postpartum; currently taking weight loss medication; diagnosed pre-existing medical condition that is contra-indicated for a weight loss study, e.g., Type 1 diabetes, severe depression, malignancy, previous weight loss surgery. Recruitment strategies included: flyer distribution within the Sydney Local Health District including the pregnancy planning clinic, antenatal, gestational diabetes post-partum and fertility clinics; local medical centres and pharmacies; and local childcare/playgroup facilities. Both paid and free study advertisements were distributed via pregnancy social media and targeted websites, as well asa webpage within the University of Sydney with optimised Google Search and newspaper articles. The study team also gave presentations to primary health care networks aligned with the Sydney Local Health District. Recruitment material directed women to the study team via a research telephone or email account. Interested women were sent the participant information sheet and study flyer and completed an online questionnaire assessing study eligibility. Women meeting eligibility criteria were then contacted by the study team to arrange consent, randomisation and baseline assessment. Women provided signed informed consent prior to data collection and were able to withdraw from the trial at any time. Recruitment commenced in June 2018 and finished in December 2019. Follow up of conception and pregnancy continued until December 2020. Women with a BMI ≥ 25 kg/m2 and BMI ≥ 30 kg/m2, and undertaken by staff not involved in the intervention. Staff responsible for data analyses were also blinded, but the nature of the intervention meant the participants and the research dietitian could not be blinded. This was a single site randomised controlled trial. Eligible women were randomised to a 10-week protocol of either a partial meal replacement diet   or to thProtocol timeline and data collection are shown in At visit 2 (week 5), usual dietary intake and physical activity were reviewed by the dietitian. Participants were weighed and received personalised dietary recommendations from the dietitian based on the assigned intervention and the results generated by the Australian Eating Survey. At visit 3 (week 10), women completed anthropometric assessments and a repeat blood sample was drawn. Four to 6 weeks after visit 3, participants were asked to complete the online Australian Eating Survey for a second time to assess post-intervention diet. Thereafter, participants were contacted at monthly intervals for 12 months to collect data on conception and pregnancy. ad libitum eating. Individual estimated energy requirements were calculated at study commencement based on body weight and then reduced by 30% to determine the exact number of permitted sachets per week. Goal weight loss was set at 5% of starting body weight. Participants randomised to the meal replacement (MR) intervention group followed a partial meal replacement diet for 10 weeks, using shakes (liquid beverages) provided by Blackmores Australia. The program  was deve−1 body weight/day−1) and advised of optional low energy beverages, vegetables and condiments with minimal kilojoule content that could be consumed as needed to manage hunger. On the ad libitum day (one day a week), women were advised that they could eat to appetite, choosing the type and quantity of food and beverages they desired (intake was not recorded). Exercise advice was based on Australian and World Health Organisation guidelines . As this was not a total meal replacement diet, a refeeding phase was not considered necessary.Meal replacements were reconstituted with 250 mL of either skim milk or dairy-free alternative . The nutrient composition as consumed was therefore ~1000 kJ, 25 g protein, 4 g fat, 27 g carbohydrate, and 6 g fiber, with each containing 25% recommended daily intake for vitamin A, thiamin, riboflavin, niacin, folate, vitamin B6, vitamin B12, vitamin C, vitamin D, vitamin E, calcium, iodine, iron, magnesium, phosphorus, and zinc . Partici® Information & Coaching Service provided by the New South Wales Department of Health, Australia [Participants in the conventional dietary advice (DA) arm received healthy diet advice via the Get Healthyustralia . This goDemographic characteristics were collected via questionnaire at baseline, including age, education, occupation (day shift/night shift), marital status, ethnicity, medical history, previous pregnancies. Weight was measured in light clothing and without shoes on a digital scale (Wedderburn BC-418). Height was measured in metres to the nearest millimeter using a Holtain Harpenden stadiometer . Waist circumference (cm) was measured midway between the bottom of the ribcage and the top of the iliac crest using a metal tape measure. ® (Version 10), a validated Food Frequency Questionnaire [® research management system , a secure web application supported by the University of Sydney and Sydney Local Health District.Dietary intake was assessed using the Australian Eating Surveyionnaire . The intThe purpose of the pilot study was to assess feasibility and acceptability of the partial meal replacement diet intervention, and therefore not powered on clinical outcomes. A total of 50 women was considered adequate to provide realistic feedback, recruitment, compliance and retention as well as average weight loss per arm. The findings will inform a larger pragmatic trial designed to assess the effect of weight loss preconception on clinical, maternal and newborn outcomes.Data are presented as mean ± SD, unless otherwise indicated. Independent samples t-test was used to determine equality of means A repeated measures ANOVA with a Greenhouse-Geisser correction was also used to determine within-group differences in mean body weight and waist circumference from baseline and week 10 (MR vs. DA). Pearson chi-square test of independence was used to determine differences in categorical outcomes, including completion rate. Fishers exact test was used where cell sizes were less than 5. An intention-to-treat analysis was used with missing values considered missing at random. 2), education, marital status, occupation, medical history, parity and any previous pregnancy loss (miscarriage or stillbirth) (Flow of participants through the study is shown in llbirth) . On a scllbirth) . p = 0.623). In the intention-to-treat analysis, women in MR lost (mean ± SD) 5.3 ± 3.9% of body weight compared to 2.8 ± 3.9% in the DA group  in the MR arm vs. 75% (18 of 24) in the DA group (1c) or lipidemia , either at baseline or at the end of the intervention (week 10)  . Triglycweek 10) . p < 0.001). In the evaluation survey 95% of the women assigned MR would recommend the program to a friend compared with 58% in the DA arm (p < 0.001). There were no significant differences in dietary intake over time for either group other than percentage of energy eaten as protein (p = 0.049).There were differences in the women’s ratings of the quality of support . Over 80 protein . 57% (12p = 0.029). Retention was similar in both groups (81% and 75% respectively) and within normal bounds for nutrition intervention studies in this population [The aim of this pilot randomized controlled trial was to explore the feasibility and acceptability of a partial meal replacement program in the preconception period for women with overweight or obesity and the potential weight loss acheived. Our findings indicate that a commercially available online partial meal replacement program was feasible in that it was both achievable and highly acceptable to women with overweight or obesity who were planning a pregnancy. Average weight loss was 1.9 times higher in the meal replacement arm (5.3%) than conventional advice group  [n = 1556). Despite improvements in diet, there was minimal change in gestational weight gain (mean difference 0.55 kg) and no demonstrable impact on clinical outcomes for the mother  or the baby  [The finding that a weight loss program is both feasible and acceptable to women with overweight and obesity planning pregnancy and that greater weight loss can be achieved through the use of meal replacements is consistent with prior data in adult populations ,7 and an = 2212) . This wemission) . These fmission) , RCTs beThe strengths of this pilot study include its randomised, controlled trial design and the inclusion of women with overweight or obesity in the general population rather than those already seeking treatment through fertility services. We ran the trial through existing clinical services to ensure it was translatable to clinical settings. The trial included face-to-face collection of critical data by trained individuals, informed all participants about preconception health and had the same number of visits with a professional in both groups . We succThis pilot study in 50 women provides the evidence of feasibility and acceptability of a commercially available meal replacement weight loss program for women with overweight and obesity planning a pregnancy. Further, the program was more acceptable to women compared to currently available phone counselling options. The findings are relevant to the planning of larger trials of safety and efficacy.


POF represents a separate entity with diverse histological presentation. Considerable overlapping of clinical and histological features are present among different reactive gingival lesions, which warrant a meticulous review for the diagnosis of POF. Peripheral ossifying fibroma represents a separate entity with diverse histological presentation. Considerable overlapping of clinical and histological features is present among different reactive gingival lesions, which warrant a meticulous review for the diagnosis of POF. Here, we present a series of twenty‐three cases of peripheral ossifying fibroma highlighting epithelial and connective tissue variations, which is significant in critical evaluation of the pathology. Peripheral ossifying fibroma (POF) is a focal, slow growing, reactive lesion arising from pluripotent cells of periodontal ligament, which was first reported by Shepherd as alveolar exostosis in 1844.Peripheral ossifying fibroma presents as a painless, hemorrhagic, and often lobulated mass of gingiva or alveolar mucosa, with area of surface ulcerations. There is variability in the size of the lesion depending upon amount of superficial inflammation and edema.The variability of clinical appearance, resemblance to other gingival lesions, and difference in histopathological presentation have created diagnostic dilemma. Here, we present a series of twenty‐three cases of peripheral ossifying fibroma highlighting the variation in clinical presentation and histopathological characteristics.22.1nd, 3rd, and 4th decade, respectively. The lesions presented clinically as uni‐focal nodular mass or a swelling present since 1 month–1.5 years, with a case present since 4 years. The size of the lesion ranged from 0.3–3 cm in maximum dimension of which majority were pedunculated (12 cases). Five of the cases were sessile whereas rest of the cases lacks the clinical details to this regard. Anterior region of the jaw was the predominate site (12 cases) of which upper jaw was the most common (10 cases). The cases were heterogeneously associated with all the teeth, that is, incisor, canine, premolars, and molars however central and lateral incisors predominated followed by canine and first premolar with prevalence on right side of the jaw. The lesions were mostly associated with labial and buccal gingiva with five cases, three in palatal and two in lingual gingiva. Two cases in anterior maxilla were extensive to involve both labial and palatal aspect. One case was associated with edentulous ridge in relation to 16.The present study included 23 diagnosed cases of peripheral ossifying fibroma, which included 16 females (69.56%) and 7 males (30.43%), of age range from 10–70 years, prevalent among 2History of previous excision was noted in four cases of 1 month, 6 months, 1.5 years, and 4 years back. One of the cases among reoccurrence, patient failed to recall the exact duration for reoccurrence. Operative diagnosis of pyogenic granuloma was made for 19 samples (82.6%), one case of irritational fibroma and only three of POF, of which one had a documented histopathological report of peripheral ossifying fibroma on incisional biopsy . Ulcerated epithelium was covered with fibrinous exudate intermixed with acute inflammatory cells infiltrates, neutrophils. Sub‐epithelial zone showed numerous small‐sized blood vessels with red blood cells Table .2.1.3Field‐wise variations were noted within the connective tissue stroma. Few areas were fibrous whereas few were highly cellular. Fibrous component was basically of two patterns, one with thin delicate fibers strands in sparsely cellular background and another with thick collagen fibers arranged in bundles. Thin strands of fibers were mainly seen in cases with complete ulceration. Dense cellularity of the stroma was mainly credited to the active fibroblasts of the stroma Figure . Fibrobl2.1.4Inflammatory component was both acute and chronic type predominated by neutrophils, lymphocytes, and plasma cells, respectively. Neutrophils were mainly in the superficial layers showing epithelial ulceration admixed with fibrinous exudates; whereas chronic inflammatory cells showed either diffusely distributed throughout the stroma or present in multifocal aggregates. Few cases showed focal aggregation of precisely of plasma cells with Russell body formations.2.1.5All three patterns of calcification were evident in present review. Type I, that is, woven and lamellar type trabeculae, was a common finding in all 23 cases however was predominated by woven bone. Woven bone mainly presented as intense eosinophilic, irregular, short interconnected trabeculae with randomly distributed osteocytes and basophilic rim at the periphery of variable size Figure . Areas oCementum‐like globules and dystrophic calcification were always seen along with trabeculae pattern. Few of the cases showed brush border pattern in the cementum‐like calcification Figure . Two of Irrespective of detail histopathological variations, a comprehensive evaluation of microscopic presentation for cases of POF showed three identifiable layers from surface epithelium to deep connective tissue. The first being the surface epithelial layer, second being the fibro‐cellular layer with vasculature, inflammatory cells, and active fibroblast, and the third deep layer with bone or calcification along with adjacent proliferating fibroblast Figure .3Peripheral ossifying fibroma is a focal, slow growing, reactive lesion arising from pluripotent cells of periodontal ligament.The study conducted by Buchner et al in 1987,The three zones identified were as follows:Zone I: The superficial ulcerated zone covered with fibrinous exudate with enmeshed polymorphonuclear neutrophil and debris. Adjacent epithelium is of parakeratinized and often hyperplastic.Zone II: The zone beneath surface ulceration composed of proliferating fibroblast with dystrophic and globular pattern of calcification. Varied presentation for collagen, vascularity, and inflammatory cells.Zone III: The deepest zone with more collagen and less vascular connective tissue. Chronic inflammatory cells ranging from few to absent. Spindle‐shaped fibroblast with fasciculate arrangement.Epithelial ulceration is a common presentation of POF.Calcification, one of the characteristic finding of POF is supposed to be initiated around the wall of blood vessels.Pyogenic granuloma is the most common differential diagnosis with closest resemblance to POF both clinically and histopathologically. The initial stage of POF characterized by ulcerated epithelium, active fibroblast, and few dystrophic type calcification simulated to pyogenic granuloma.Reactive and non‐neoplastic nature of POF4Peripheral ossifying fibroma is a slow‐growing lesion with limited growth potential characterized by metaplasia of the connective tissue leading to production of bone, cementum, or dystrophic calcification. Uniform clinical presentations with occurrence among both males and females and among wide age range with varying histopathological features have increased the need to meticulously review the differential diagnoses before formulating a definite histopathological diagnosis, considering the recurrent nature of the pathology.None.All authors contributed to the design of this manuscript. AS, SK, NJ, and TR prepared the first draft. AS, TR, SLS, and MRJ prepared the final manuscript. SLS and MRJ: involved in direct patient management of the cases. AS, SK, and NJ: pathologists involved in the diagnosis of the cases.Written informed consent was obtained from the patient for publication of this case report and accompanying images.


A shorter grazing time and supplementation have been demonstrated to increase the grazing efficiency and growth performance of lambs. However, the effects of a shorter grazing time on the gastrointestinal development and carcass quality of growing lambs are poorly understood. In the present study, lambs were offered 2, 4, 8 or 12 h of grazing and separately fed supplementation when off pasture. The results showed that, in comparison to longer grazing times, shorter grazing times—especially 4 h of grazing per day with supplementation—best improved gastrointestinal tract and carcass quality. Therefore, restricting the grazing of lambs to 4 h per day instead of grazing for more extended periods is a better grazing management approach in Inner Mongolia.n = 8, body weight = 21.86 kg) corresponding to 2, 4, 8 and 12 h of grazing per day. When off-pasture, all lambs were housed and fed concentrate and hay. When the grazing time decreased from 12 h to 2 h, the abomasum weight and large intestine length decreased . Compared to lambs grazed for 12 h, animals grazed for 2–4 h had a greater villus height and villus-to-crypt ratio in the duodenum, jejunum and ileum segments (p < 0.05); the 2 h lambs had superior carcass quality and a smaller diameter and area of the gluteus medium muscle fibers (p < 0.05), with no significant change after 4 h of grazing. The results indicated that shorter grazing times and supplementation were beneficial for the gastrointestinal tract development and carcass quality of growing lambs. Therefore, a better grazing management approach in Inner Mongolia could be to restrict the grazing of lambs to 4 h per day instead of grazing for more extended periods.The effects of restricted grazing durations on the gastrointestinal development and carcass quality of growing lambs are poorly understood. In this study, 32 lambs were randomly assigned to four groups ( Grazing management should be a win–win situation for both pasture and animals. However, the pursuit of higher animal production by traditional grazing management approaches has led to considerable overgrazing and the unsustainable utilization of grassland in Inner Mongolia, China. In local, traditional grazing systems, animals spend considerable time grazing, which exacerbates trampling damage to the grassland and increases the energy demand for maintenance instead of growth . On the n-3 unsaturated fatty acids in muscle tissue  statAs mentioned above, lambs that grazed for a shorter time and received more concentrated supplementation had higher DM digestibility and greater absorption of nutrients from the gut, which resulted in higher slaughter performance, especially carcass weight and backfat thickness. Studies have generally established that the supplementation of grazing animals with concentrates containing protein, energy or a protein–energy combination promotes DM digestibility, forage use efficiency and even weight-related carcass traits due to a better balance between energy and nitrogen ,27. On tThis study suggests that, compared with longer grazing durations, shorter grazing durations—especially restrictions to 4 h of grazing per day with supplementation—promote gastrointestinal tract development, optimize muscle fiber characteristics and consequently improve the carcass quality of growing lambs. Therefore, in typical pastoral livestock systems in Inner Mongolia, there is the potential for better grazing management to be achieved by restricting the grazing of lambs to 4 h per day instead of grazing for more extended periods.