Search Results (10,663)

Background: Airborne microplastics (AMPs) are an emerging air pollutant and there are growing concerns about their potential effects on respiratory health due to their persistence, inhalability and ability to carry other toxic pollutants. Methods: Relevant peer-reviewed studies released from 2015 to 2025 were located by searches on PubMed, Scopus, and Web of Science. Data from experimental, epidemiological, and review research were amalgamated to investigate sources of airborne microplastics, routes of exposure, analytical methodologies, respiratory toxicological processes, and regulatory viewpoints. Results: Modern studies suggest inhaled antimicrobic peptides can reach the lower respiratory tract and cause chronic pulmonary inflammation via induction of oxidative stress, mitochondrial dysfunction, epithelial barrier damage, inflammasome activation, immune system imbalance and extracellular matrix remodeling. These pathways have been associated with chronic respiratory diseases, such as chronic obstructive pulmonary disease, asthma, pulmonary fibrosis, and lung carcinoma. Toxicity can be increased by the accumulation of heavy metals, persistent organic pollutants and microbiological impurities. However, the lack of standardised protocols for exposure assessment, inconsistency of sampling and analytical methods and limited human epidemiological data hamper health risk assessment. Conclusions: Airborne microplastics are an emerging environmental health concern with potentially significant effects on respiratory health. Harmonised surveillance strategies, standardised analytical methods, improved inhalation exposure models and prolonged epidemiological studies are urgently needed to improve risk assessment and enable evidence-based air quality policy for the protection of respiratory health. Full article

Decisions about vector-borne zoonotic disease control often have to be made before the evidence is complete. Human surveillance, entomological observations, animal reservoir or sentinel data, environmental indicators, and modelling outputs may provide warning before human disease patterns are clear. In some settings, early action can prevent harm, yet it can also impose social, economic, ecological, animal-welfare, liberty-related, and trust-related burdens. Technical risk assessment remains necessary, although it may need to be complemented by ethical analysis. In this conceptual manuscript, we propose a seven-step One Health ethical decision-making framework that links integrated evidence and transmission plausibility to precaution, proportionality, equity, One Health trade-offs, legitimacy, feedback, impact evaluation, and adaptation. Its contribution lies not in introducing new ethical principles, but in integrating them into an iterative governance sequence and proposing medical bioethics mediation for persistent value conflict. Illustrative domains include West Nile virus, dengue, Zika, Crimean–Congo haemorrhagic fever, and other mosquito-, tick-, and sand fly-borne zoonotic threats. Full article

Leishmaniasis is an emerging zoonotic disease recognized by WHO as a priority neglected tropical disease (NTD) targeted for elimination by 2030. The disease is transmitted through bites of infected female phlebotomine sand flies and presents in three main forms: cutaneous, mucocutaneous, and visceral leishmaniasis. Visceral leishmaniasis (VL) has two distinct epidemiological cycles: anthroponotic visceral leishmaniasis (AVL) cycle, caused by L. donovani and transmitted between humans, and zoonotic visceral leishmaniasis (ZVL) cycle, caused by L. infantum, with domestic dogs as the main reservoirs. ZVL represents the most severe clinical form and poses a public health risk due to a high fatality rate. In Kenya, the epidemiology and transmission dynamics of Leishmania infection among the canine population in endemic areas such as Baringo are poorly characterized. A cross-sectional epidemiological study was conducted in Baringo County, Kenya, one of the endemic foci for human visceral leishmaniasis. Blood samples were collected from 140 dogs in Rabai, Sabor, Mbechot, Kapkuikui, and Chemolingot and analyzed using Rapid Diagnostic Test (RDT) and Enzyme-linked immunosorbent assay (ELISA). Data on potential epidemiological factors and clinical status for dogs were collected using a questionnaire. Statistical analysis was performed using Pearson’s chi-square (χ²) test or Fisher’s exact test to assess associations between Leishmania seropositivity and potential risk factors. A stepwise logistic regression procedure with an entry significance level of p < 0.20 was employed to identify factors associated with leishmaniasis seroprevalence. Cohen’s kappa (κ) agreement was used to assess the diagnostic performance and accuracy of the two serological tests in the absence of a gold standard. The overall seropositivity in dogs was 7.79% and 12.14% at 95% CI for the RDT and ELISA, respectively. Multivariate analysis identified breed and clinical signs as significant factors associated with Leishmania seropositivity in dogs. Local-breed dogs were more likely to be Leishmania seropositive than mixed-breed dogs (OR = 11.92; 95% CI: 1.79–79.37; p = 0.010). Dogs without clinical signs exhibited significantly lower odds of ELISA seropositivity (OR = 0.06; 95% CI: 0.01–0.29; p < 0.001). Dogs with proper care and housing conditions had reduced risk of Leishmania seropositivity compared with poorly managed dogs. Significant association with seropositivity was observed for sex, age, origin, and reason for keeping dogs. Diagnostic evaluation showed that the RDT had an excellent specificity and Positive Predictive Value (100%), with good overall agreement with ELISA, although sensitivity was 64.7%. Hence, RDT can be a reliable alternative screening tool compared with ELISA as the reference standard. The study demonstrated the presence of Leishmania infection in the dog population in Baringo County, Kenya, a significant public health risk. Early detection and diagnosis of infections in dogs through an integrated One Health approach during routine surveillance are essential. This will facilitate treatment and/or culling of infected dogs and vector control, subsequently reducing the risk of human transmission. Hence, it will go a long way to achieving WHO’s roadmap of eliminating leishmaniasis by 2030. Full article

Background: Measurement reliability of the sagittal thoracic spine, e.g., thoracic kyphosis and balance, on radiographs has an unknown evidence base. This literature review aims to systematically identify and evaluate the reliability of biomechanical assessments of the sagittal thoracic spine on radiographs used in clinical practice. Methods: The study design was registered with PROSPERO (CRD42023431171). Chiropractic Biophysics Nonprofit, Inc (Eagle, ID, USA) funded this investigation. Inclusion criteria involved studies in English using human subjects, radiography, and reliability analysis of biomechanical analysis of the thoracic spine. Exclusion criteria involved animal and cadaveric studies, phantom mannequins, geometric studies, and non-radiographic studies. This review was conducted using the Peer Review of Electronic Search Strategies (PRESS) checklist to organize the search strategy. A combined approach using Medical Search Headings (MeSH) search terms and a systematic literature review (SLR) search strategy was used. This review followed the recommendations of Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Databases searched included PubMed, CINAHL, Alt HealthWatch, Web of Science, and a grey literature search. Initial search results produced 990 results. A total of 658 records were screened by two independent reviews and 197 full text articles were assessed for eligibility. Results: Sixty-six studies were included in the final analysis and assessed for methodological quality and bias using the 11-item Quality Appraisal of Diagnostic Reliability (QAREL) tool. A total of 15 studies were of low methodological quality (high risk of bias), 28 were of moderate quality (moderate risk of bias), and 23 were of high quality (low risk of bias). Conclusions: This SLR found most articles investigating the reliability of biomechanical assessment of the sagittal thoracic spine on radiographs to be of moderate-to-high quality and show good-to-excellent reliability. Full article

Heavy metal contamination in mining-affected groundwater may pose potential risks to drinking water safety and human health. In this study, 25 groundwater samples, including 18 from Aquifer IV of the Cenozoic unconsolidated porous aquifer system and 7 from the Taiyuan Formation limestone karst aquifer, were collected from the Zhuxianzhuang Coal Mine, Huaibei Coalfield, China. The Heavy Metal Pollution Index (HPI), Metal Index (MI), Positive Matrix Factorization (PMF), and oral-ingestion health risk model were applied to assess metal contamination, source contributions, and human health risks. HPI values ranged from 8.0 to 37.5, with a mean of 21.5, indicating a low overall pollution level. In contrast, MI values suggested cumulative metal contamination, with higher mean values in Taiyuan Formation limestone karst groundwater (5.60) than in Aquifer IV groundwater (2.38). PMF identified two major factors, interpreted as a natural water–rock interaction source and a combined anthropogenic and mining-related source. Health risks were consistently higher in Taiyuan Formation limestone karst groundwater. Non-carcinogenic risks were higher for children and mainly controlled by As, whereas carcinogenic risks were higher for adults and mainly associated with Cr. These findings highlight the need for aquifer-specific monitoring and source control to reduce toxic metal exposure in coal mining areas. Full article

Bovine adenovirus (BAdV)-based vectors, particularly those derived from bovine adenovirus 3 (BAdV-3), are emerging non-human adenoviral platforms for veterinary vaccine development. Adenoviral vectors are attractive for vaccination because they mediate efficient transgene expression, remain largely episomal, and induce robust innate and adaptive immune responses. However, widely used human adenoviral vectors, especially human adenovirus 5 (HAdV-5), may be compromised by pre-existing anti-vector immunity, supporting the development of rare human serotypes and non-human adenoviral alternatives. BAdV-3 is the best-characterized BAdV for recombinant vector engineering and has been used to express heterologous antigens from bovine herpesvirus-1, bovine respiratory syncytial virus, influenza virus, and Mycobacterium tuberculosis. Available evidence indicates that BAdV-based vectors can induce humoral, cellular, and mucosal immune responses and support intranasal antigen delivery. Protective efficacy has been demonstrated in selected experimental models, including mice and ferrets for influenza and tuberculosis vaccine candidates, whereas cattle challenge evidence remains more limited and is primarily represented by BHV-1 gD-expressing BAdV-3 vectors. These features make BAdV vectors relevant to bovine respiratory disease control, livestock vaccination, and One Health-oriented vaccine preparedness. Nevertheless, the platform remains at an early developmental stage. Key gaps include limited target-species efficacy data, pre-existing BAdV immunity in cattle, vector shedding, recombination risk, genetic stability, producer cell optimization, manufacturing scalability, and regulatory feasibility. Full article

Rising temperatures and the occurrence of heat waves due to climate change can increase the risk of various skin disorders. Moreover, elevated temperatures worsen oxidative damage and inflammation caused by other climate change stressors, such as UV exposure. Consequently, there is growing interest in innovative solutions to protect skin health from the effects of pollution and climate change stressors. Among natural cosmeceuticals, carotenoids are recognized for their antioxidant and anti-inflammatory properties. This study evaluated the thermoprotective effects of Hematococcus lacustris (the microalga formerly called Hematococcus pluvialis) extract (HLE), which is considered the richest natural source of carotenoid astaxanthin, against acute hyperthermia, which mimics the conditions of heat waves. In addition, we separately assessed the effects of HLE against UVA and hydrogen peroxide stress, complementing the antioxidant profile of the extract under study. The evaluation was conducted using in vitro tests on human HaCaT keratinocytes and the nematode Caenorhabditis elegans, which is a model organism sensitive to environmental stressors. The treatment of HaCaT keratinocytes with HLE counteracted the intracellular formation of reactive oxygen species and cytotoxicity induced by hyperthermia, UVA, and hydrogen peroxide exposure. Under the same experimental conditions, HLE also restored the impaired expression of stress-sensitive genes, such as matrix metalloproteinase-1, in HaCaT keratinocytes and promoted wound closure mimicking the process of re-epithelization. Lastly, experiments in C. elegans confirm that HLE reduces heat stress-induced oxidative damage and preserves motility, supporting a systemic protective effect consistent with dietary uptake of the extract. These findings suggest that HLE, rich in carotenoid astaxanthin, can protect keratinocytes against oxidative damage and cytotoxicity induced by thermal stress, indicating its potential role in mitigating thermal aging. Full article

The intestinal epithelium is a dynamic tissue renewed by intestinal stem cells (ISCs) within the crypt niche. ISC behavior is regulated not only by intrinsic genetic programs but also by dietary composition, nutrient availability, microbial metabolites, and feeding rhythms. This narrative review synthesizes mechanisms through which diet influences ISC self-renewal, proliferation, differentiation, metabolic programming, and regenerative capacity. Dietary patterns exert context-dependent effects: caloric restriction, fasting, and structured feeding–fasting cycles may enhance epithelial regeneration through nutrient-sensing pathways, mitochondrial adaptation, and circadian regulation, whereas Western-type and high-fat diets may promote niche remodeling, inflammation, metabolic reprogramming, and tumorigenic risk. Macronutrients regulate ISC fate through carbohydrate metabolism, amino acid sensing, fatty acid oxidation, and lipid-derived signaling molecules. Micronutrients, including vitamins A, D, and B and minerals such as iron, zinc, selenium, and magnesium, contribute to epithelial differentiation, redox balance, and barrier integrity. Phytochemicals may modulate ISC function through Wnt/β-catenin, Nrf2, SIRT1, and epigenetic pathways or by stabilizing the epithelial microenvironment. The gut microbiota mediates diet–ISC interactions via short-chain fatty acids, bile acids, indole derivatives, and other metabolites. However, human evidence remains limited, and studies integrating human organoids, single-cell analyses, metabolomics, and chrononutrition are needed to inform personalized nutritional strategies for intestinal health. Full article

Cyanobacterial harmful algal blooms have increased globally, likely in part due to climate change and anthropogenic eutrophication, elevating exposure of humans and other terrestrial and aquatic animals to cyanotoxins through drinking water, food chains, and recreational activities. Microcystin-LR (MC-LR), the most prevalent microcystin congener, is well known for its hepatotoxicity, yet accumulating evidence indicates that it also exerts reproductive and developmental toxicity in mammals. This review summarizes recent experimental and epidemiological studies indicating that MC-LR disrupts reproductive function through direct cellular injury to germ and somatic cells, dysregulation of gonadal steroidogenesis, and impairment of the hypothalamic-pituitary-gonadal (HPG) axis. In males, MC-LR disrupts spermatogenesis and sperm quality, while in females it impairs oocyte competence, uterine receptivity, and placental function, leading to adverse pregnancy outcomes. Importantly, exposure during critical developmental windows can influence developmental trajectories and contribute to long-term, multi-organ dysfunction in offspring via endocrine imbalance and epigenetic reprogramming. Mechanistically, MC-LR toxicity involves convergent oxidative stress, mitochondrial dysfunction, inflammatory signaling, DNA damage, and chromatin remodeling. Collectively, these findings indicate that reproductive and developmental toxicity should be considered in assessments of the health risks associated with MC-LR and support the incorporation of reproductive endpoints into human health and ecological risk assessment frameworks. Full article

The widespread use of neonicotinoids (NEOs) poses a significant risk to school-aged children. However, critical knowledge gaps remain regarding their comprehensive exposure profiles and associated health risks. This study assessed the co-exposure levels and non-carcinogenic risks of 16 NEOs (including both traditional and emerging compounds) in 184 school-aged children recruited from a typical rural and urban area of South China. The sum concentrations of 16 NEOs (∑₁₆NEOs) ranged from 0.648 to 227 μg/L (median: 8.99 μg/L). The predominant compounds were clothianidin (CLO, 1.93 μg/L), N-desmethyl-acetamiprid (N-dm-ACE, 1.64 μg/L), thiamethoxam (THM, 0.792 μg/L), and dinotefuran (DIN, 0.222 μg/L). To our knowledge, this is the first report of emerging NEOs—paichongding (IPP), sulfoxaflor (SUL), and flonicamid (FLO)—in children urine, with detection frequencies of 11.4%, 68.2%, and 53.4%, respectively. Significant rural–urban disparities in urinary concentrations were observed. The metabolite-to-parent ratios (e.g., N-dm-ACE/ACE, 5-OH-IMI/IMI, and THCP-AM/THCP) may serve as a useful biomarker for assessing human exposure to NEOs, as it provides valuable insight into the metabolic fate of the target compounds and aids in distinguishing exposure pathways. The median estimated daily intake (EDI) values for CLO, N-dm-ACE, THM, and ∑₁₂NEOs were 0.127, 0.117, 0.046, and 0.696 μg/kg-bw/day, respectively. Although the hazard quotient for individual compounds was below 1 for vast majority of school-aged children, cumulative exposure assessment indicated that 1.09% of participants had a hazard quotient exceeding 1 for both IMI_eq and ∑₁₂NEOs, suggesting potential health concerns under co-exposure scenarios. Using a multi-criteria Toxicological Priority Index (ToxPi) model, CLO, THM, thiacloprid-amid (THCP-AM), and N-dm-ACE were identified as the high-priority compounds requiring regulatory attention in children’s environmental health. This study provides the first comprehensive biomonitoring and ToxPi-based prioritization of both traditional and emerging NEOs in school-aged children in South China. The findings highlight the urgent need for continued monitoring, refined mixture risk assessment, and regulatory consideration of emerging substitutes and their metabolites, which are not adequately covered by current safety guidelines. Full article

Introduction. Statins’ established cardiovascular benefits are often undermined by hepatic adverse effects in obese diabetic patients with suspected non-alcoholic fatty liver disease. We evaluated whether cannabis plant treatment is a safe and effective alternative to atorvastatin in a metabolically challenged rodent model. Methods. Fourteen obese and diabetic Wistar rats received either atorvastatin for 30 days or cannabis plant extract for 30 days. Main outcome: lipid profile; secondary outcomes: renal function, glycemia and endothelial health assessed through atherogenic indices. Safety was assessed using plasma liver enzyme concentrations. Results. Baseline biochemical profiles were similar between groups. Atorvastatin increased HDL-Col more than cannabis plant (MD: 44.3; IQR [33, 57.5] mg/dL, Hedges’ g 2.713 vs. MD: 14.3; IQR [14, 17] mg/dL, Hedges’ g 5.049), and cannabis plant did not change LDL-Col. Atherogenic index of plasma and Castelli Risk Index 1 improved with both interventions, more so with atorvastatin. Liver enzymes increased with atorvastatin (ALAT, MD: 15.9; IQR [12.5, 19.5] U/L; ASAT, MD: 33; IQR [26.5, 38] U/L) but remained virtually unchanged with cannabis. Serum creatinine increased with cannabis plant, with moderate effect size (Hedges’ g 0.798), but negligibly with statins (Hedges’ g 0.122). Conclusions. Cannabis plant extract modestly improved the lipid profile and atherogenic indices, with differences often not exceeding the change in control groups. Despite apparent liver safety, the undesired renal and neurological consequences limit applicability in humans. Further studies should prioritize addiction development and renal function. Full article

Low-level radioactive wastewater requires effective treatment to minimize risks to human health and the environment. This study evaluated the performance of activated carbons derived from regional biomass (Gurgurey, Pine, and Debregeasia woods) and Thar coal for the simultaneous removal of radionuclides (¹³⁷Cs, ¹³⁴Cs, ¹²⁴Sb, and ¹²²Sb) from real low-level radioactive wastewater. The activated carbons were characterized by proximate analysis and Fourier Transform Infrared Spectroscopy (FTIR), and their adsorption performance was investigated through batch experiments followed by kinetic and isotherm modeling. Among the investigated materials, activated carbons derived from Gurgurey wood, Pine wood, and Thar coal exhibited superior physicochemical properties, including low moisture (3.8–4.8%), low volatile matter (10.7–15.3%), high fixed carbon content (77.8–84.3%), and adsorption capacities ranging from 205.6 to 251.9 Bq g⁻¹. In contrast, Debregeasia-derived activated carbon showed the poorest performance owing to its high moisture, volatile matter, and ash contents, resulting in adsorption capacities of only 53.4–161.2 Bq g⁻¹. FTIR analysis confirmed the presence of phosphate-containing functional groups on all biomass-derived activated carbons except Thar coal. The adsorption data were best described by the pseudo-second-order kinetic model and the Langmuir isotherm, indicating that chemisorption and monolayer adsorption were the dominant removal mechanisms. These findings demonstrate that activated carbons derived from Gurgurey wood, Pine wood, and Thar coal are promising low-cost adsorbents for the simultaneous removal of multiple radionuclides from real low-level radioactive wastewater and provide a sustainable approach for radioactive wastewater treatment. Full article

Canine dirofilariosis caused by Dirofilaria immitis and Dirofilaria repens is a vector-borne zoonotic infection of considerable veterinary and public health importance. Despite reports of the circulation of Dirofilaria spp. in neighboring countries, data on the molecular prevalence, species composition, and genetic diversity of these parasites in dogs from Kazakhstan remain limited. In the present study, owned, shelter, and stray dogs, which serve as the principal reservoirs of infection, were examined for the presence of microfilariae in blood, and the circulation of Dirofilaria spp. was molecularly confirmed. The study was conducted between September 2024 and January 2026 and included 751 canine blood samples collected from 10 regions of Kazakhstan. Initial screening was performed using the modified Knott test. Molecular identification was carried out through amplification of the mitochondrial cox1 gene, followed by DNA sequencing and comparative analysis with reference sequences available in GenBank. Phylogenetic analysis was performed to assess the genetic relationships of the detected isolates. The overall molecular prevalence of Dirofilaria spp. was 3.6% (27/751). The highest infection rate was recorded in the Aktobe region (22.3%), while positive cases were also detected in the Akmola (2.7%), Kostanay (1.7%), and West Kazakhstan (1.8%) regions. Species identification revealed the predominance of D. repens, whereas D. immitis was detected only in Aktobe region. Phylogenetic analysis confirmed the species identity of all obtained sequences and demonstrated a high degree of genetic similarity with Dirofilaria isolates previously reported from Europe and Asia. These findings confirm the circulation of Dirofilaria spp. among dogs in several regions of Kazakhstan and indicate the ongoing expansion of canine dirofilariosis in Central Asia. This study provides the first molecular genetic data on Dirofilaria spp. in dogs from Kazakhstan and highlights the need for continued epidemiological surveillance and assessment of potential risks to animal and human health. Full article

Deoxynivalenol (DON) and patulin (PAT) are common mycotoxins in cereals and fruits, posing health risks for animals and human beings. In order to study their liver toxicity, 24 mice were randomly assigned to four groups, with six replicates in each group (one mouse per cage). The mice were intragastrically administered with DON, PAT, DON + PAT (DP), or without DON and PAT (the control group) for 28 days, respectively. The results showed that body weight gain was significantly reduced by all toxin treatments, compared with the control group, and the lowest body weight gain was observed in the DP group. Histopathology revealed that hepatocyte damage and inflammatory infiltration were more serious in the DP group, exhibiting the highest mRNA abundances of MyD88, IFN-γ, and JAK2. The severity of hepatocyte apoptosis induced in each group followed the order: DON > DP > PAT; the severity of oxidative stress was ranked as DP > DON > PAT. Transcriptomic analysis revealed that numerous differentially expressed genes were regulated by DP treatment, which were mainly enriched in the MAPK, JAK-STAT, and transforming growth factor (TGF)-β signaling pathways. In conclusion, individual exposure to DON or PAT triggered hepatic injury, and their co-exposure further exacerbated liver damage. Full article

Nanomaterials are increasingly used in manufacturing, medicine, consumer products, and environmental technologies due to their unique physicochemical properties. Although these materials offer substantial technological and societal benefits, their widespread use has raised concerns about potential health risks. Of particular importance is exposure during pregnancy, as certain nanoparticles can cross the placental barrier and reach the developing embryo. Fetal tissues are highly sensitive to environmental insults, so maternal exposure to nanoparticles may disrupt normal development and increase the risk of abnormal pregnancy outcomes. This review examines the current understanding of nanoparticle-induced developmental toxicity, with a focus on the vulnerability of the maternal–fetal unit. We discuss the structure and function of the placental barrier and the mechanisms that enable nanoparticle transfer from mother to fetus. Particular attention is given to how nanoparticle characteristics, including size, shape, composition, and surface chemistry, influence biodistribution, placental transport, tissue accumulation, and toxicity. We summarize the major molecular and cellular mechanisms implicated in fetotoxicity, highlighting oxidative stress, apoptosis, autophagy, and DNA damage as recurring pathways identified across experimental studies. These interconnected processes contribute to placental dysfunction, impaired fetal growth, developmental abnormalities, and adverse pregnancy outcomes. We also compare findings across different classes of nanoparticles, including metal, metal oxide, carbon-based, and polymeric nanomaterials, identifying both shared toxicological mechanisms and material-specific effects. Evidence from animal models demonstrates that susceptibility varies according to nanoparticle properties, exposure conditions, and species, underscoring the complexity of nanoparticle–biological interactions and the limitations of extrapolating experimental findings directly to humans. Overall, the available evidence indicates that nanoparticle exposure during pregnancy represents a potential risk to fetal health, although important knowledge gaps remain regarding human exposure and long-term developmental outcomes. A better understanding of the mechanisms underlying nanoparticle-induced fetotoxicity is essential for improving human health risk assessment, refining experimental models, informing regulatory policies, and supporting the safe-by-design development of nanomaterials. Such knowledge will help ensure the responsible application of nanotechnology while minimizing potential risks during pregnancy. Finally, this review is distinguished by its integrated analysis of how the chemical characteristics of nanoparticles govern placental transfer and the mechanistic pathways of fetotoxicity across multiple nanomaterial classes, providing a unified framework that connects material properties with their potential for abnormal fetal development and adverse pregnancy outcomes. Full article