A dual spin-controlled chiral two-/three-dimensional perovskite artificial leaf for efficient overall photoelectrochemical water splitting.

The oxygen evolution reaction, which involves high overpotential and slow charge-transport kinetics, plays a critical role in determining the efficiency of solar-driven water splitting. The chiral-induced spin selectivity phenomenon has been utilized to reduce by-product production and hinder charge recombination. To fully exploit the spin polarization effect, we herein propose a dual spin-controlled perovskite photoelectrode. The three-dimensional (3D) perovskite serves as a light absorber while the two-dimensional (2D) chiral perovskite functions as a spin polarizer to align the spin states of charge carriers. Compared to other investigated chiral organic cations, R-/S-naphthyl ethylamine enable strong spin-orbital coupling due to strengthened π-π stacking interactions. The resulting naphthyl ethylamine-based chiral 2D/3D perovskite photoelectrodes achieved a high spin polarizability of 75%. Moreover, spin relaxation was prevented by employing a chiral spin-selective L-NiFeOOH catalyst, which enables the secondary spin alignment to promote the generation of triplet oxygen. This dual spin-controlled 2D/3D perovskite photoanode achieves a 13.17% of applied-bias photon-to-current efficiency. Here, after connecting the perovskite photocathode with L-NiFeOOH/S-naphthyl ethylamine 2D/3D photoanode in series, the resulting co-planar water-splitting device exhibited a solar-to-hydrogen efficiency of 12.55%.

Expandable Cages for Lumbar Interbody Fusion: A Narrative Review.

Lumbar fusion surgery for treating degenerative spinal diseases has undergone significant advancements in recent years. In addition to posterior instrumentation, anterior interbody fusion techniques have been developed along with various cages for interbody fusion. Recently, expandable cages capable of altering height, lordotic angle, and footprint within the disc space have garnered significant attention. In this manuscript, we review the current status, clinical outcomes, and future prospects of expandable cages for lumbar interbody fusion based on the existing literature. Expandable cages are suitable for minimally invasive spinal surgeries. Small-sized cages can be inserted and subsequently expanded to a larger size within the disc space. While expandable cages generally demonstrate superior clinical outcomes compared to static cages, some studies have suggested comparable or even poorer outcomes with expandable cages than static cages. Careful interpretation through additional long-term follow-ups is required to assess the utility of expandable cages. If these shortcomings are addressed and the advantages are further developed, expandable cages could become suitable surgical instruments for minimally invasive spinal surgeries.

Identification of B cell subsets based on antigen receptor sequences using deep learning.

B cell receptors (BCRs) denote antigen specificity, while corresponding cell subsets indicate B cell functionality. Since each B cell uniquely encodes this combination, physical isolation and subsequent processing of individual B cells become indispensable to identify both attributes. However, this approach accompanies high costs and inevitable information loss, hindering high-throughput investigation of B cell populations. Here, we present BCR-SORT, a deep learning model that predicts cell subsets from their corresponding BCR sequences by leveraging B cell activation and maturation signatures encoded within BCR sequences. Subsequently, BCR-SORT is demonstrated to improve reconstruction of BCR phylogenetic trees, and reproduce results consistent with those verified using physical isolation-based methods or prior knowledge. Notably, when applied to BCR sequences from COVID-19 vaccine recipients, it revealed inter-individual heterogeneity of evolutionary trajectories towards Omicron-binding memory B cells. Overall, BCR-SORT offers great potential to improve our understanding of B cell responses.

Femoral Neck Fractures Treated by Closed Reduction and Internal Fixation with the Double Fluoroscope Technique: A Preliminary Study.

Background: Fractures of the femur require significant radiation exposure during operations using fluoroscopy (C-arm), posing a high risk of radiation exposure to the medical staff and patients. To address this concern, in this study, we investigated the efficacy of using two fluoroscopy machines simultaneously. Methods: We categorized 30 patients with femoral neck fracture (FNF) into single and double C-arm groups. The operation and radiation exposure times during a closed reduction and internal fixation operation were investigated to evaluate whether the operation and radiation exposure times were effectively audited when the operation was performed using a double C-arm. Results: The total operation times were 93.21 ± 20.70 min and 66.69 ± 13.97 min for the single and double C-arm groups, respectively. Additionally, the total radiation times were 100.43 ± 24.59 s and 83.06 ± 19.53 s for the single and double C-arm groups, respectively. Operation and radiation exposure times in the two groups showed statistically significant differences (p < 0.05). Conclusion: The use of double C-arm in FNF can reduce operation and radiation exposure times. Hence, using the double C-arm in surgical treatment could reduce the risk of radiation exposure to medical staff and patients.

Detecting mental and physical disorders using multi-task learning equipped with knowledge graph attention network.

Mental and physical disorders (MPD) are inextricably linked in many medical cases; psychosomatic diseases can be induced by mental concerns and psychological discomfort can ensue from physiological diseases. However, existing medical informatics studies focus on identifying mental or physical disorders from a unilateral perspective. Consequently, no existing domain knowledge base, corpus, or detection modeling approach considers mental as well as physical aspects concurrently. This paper proposes a joint modeling approach to detect MPD. First, we crawl through online medical consultation records of patients from websites and build an MPD knowledge ontology by extracting the core conceptual features of the text. Based on the ontology, an MPD knowledge graph containing 12,673 nodes and 82,195 relations is obtained using term matching with a domain thesaurus of each concept. Subsequently, an MPD corpus with fine-grained severities (None, Mild, Moderate, Severe, Dangerous) and 8909 records is constructed by formulating MPD classification criteria and a data annotation process under the guidance of domain experts. Taking the knowledge graph and corpus as the dataset, we design a multi-task learning model to detect the MPD severity, in which a knowledge graph attention network (KGAT) is embedded to better extract knowledge features. Experiments are performed to demonstrate the effectiveness of our model. Furthermore, we employ ontology-based and centrality-based methods to discover additional potential inferred knowledge, which can be captured by KGAT so as to improve the prediction performance and interpretability of our model. Our dataset has been made publicly available, so it can be further used as a medical informatics reference in the fields of psychosomatic medicine, psychiatrics, physical co-morbidity, and so on.

Stable water splitting using photoelectrodes with a cryogelated overlayer.

Hydrogen production techniques based on solar-water splitting have emerged as carbon-free energy systems. Many researchers have developed highly efficient thin-film photoelectrochemical (PEC) devices made of low-cost and earth-abundant materials. However, solar water splitting systems suffer from short lifetimes due to catalyst instability that is attributed to both chemical dissolution and mechanical stress produced by hydrogen bubbles. A recent study found that the nanoporous hydrogel could prevent the structural degradation of the PEC devices. In this study, we investigate the protection mechanism of the hydrogel-based overlayer by engineering its porous structure using the cryogelation technique. Tests for cryogel overlayers with varied pore structures, such as disconnected micropores, interconnected micropores, and surface macropores, reveal that the hydrogen gas trapped in the cryogel protector reduce shear stress at the catalyst surface by providing bubble nucleation sites. The cryogelated overlayer effectively preserves the uniformly distributed platinum catalyst particles on the device surface for over 200 h. Our finding can help establish semi-permanent photoelectrochemical devices to realize a carbon-free society.

Pre-mixing of omega-3 fatty acid-containing liposomes enhances the drug release rate and therapeutic efficacy of anticancer drugs loaded in liposomes.

The therapeutic efficacy of anticancer drugs loaded in liposomes composed of rigid phosphatidylcholine (PC) is hindered by the limited release of these drugs at the tumor site, which in turn hampers delivery of the drug to its intracellular target. In an attempt to improve the therapeutic efficacy of liposomal anticancer drugs, we here explored the use of empty liposomes as "trigger" vehicles to induce drug release from drug-loaded liposomes through liposome-liposome interactions. Empty liposomes containing PC in which omega-3 fatty acids comprised both fatty acid strands (Omega-L) showed a triggering effect on drug release from doxorubicin (DOX)-loaded liposomes (Caelyx). The effectiveness of this triggered-release effect was dependent on the Omega-L composition as well as the mixing ratio of Omega-L to Caelyx. Cryo-TEM and differential calorimetry studies revealed that the Omega-L effect was associated with liposome-liposome interactions that led to loosened membrane packing and increased fluidity of Caelyx. In cultured cells, the intracellular/intranuclear DOX uptake and anticancer efficacy of Caelyx was greatly improved by Omega-L pre-mixing. Intravenous injection of rats with Caelyx, premixed with Omega-L, decreased the area under the plasma concentration-time curve from time zero to time infinity and increased clearance without significantly changing the mean residence time or terminal half-life of DOX compared with Caelyx alone. Ex vivo bioimaging showed that DOX fluorescence in tumors, but not in other organs, was significantly increased by Omega-L premixing. In the mouse xenograft model, premixing of Omega-L with Caelyx suppressed tumor growth 2.5-fold compared with Caelyx. Collectively, the data provide preliminary evidence that the Omega-L-triggered drug release that occurs before and after dosing, particularly at tumor site, improved the therapeutic efficacy of Caelyx. The simple approach described here could enhance the therapeutic value of Caelyx and other anticancer drug-loaded liposomes.

Synthesis and Structural Characterization of Macrocyclic α-ABpeptoids and Their DNA-Encoded Library.

The first synthesis of macrocyclic α-ABpeptoids with varying lengths is described. X-ray crystal structures reveal that cyclic trimer displays a chair-like conformation with a cct amide sequence and cyclic tetramer has a saddle-like structure with an uncommon cccc amide arrangement. The creation of a DNA-encoded combinatorial library of macrocyclic α-ABpeptoids is described.

Association of Functional Gastrointestinal Disorders with Adolescent Idiopathic Scoliosis.

Numerous adolescents diagnosed with adolescent idiopathic scoliosis (AIS) often manifest symptoms indicative of functional gastrointestinal disorders (FGIDs). However, the precise connection between FGIDs and AIS remains unclear. The study involved adolescents drawn from sample datasets provided by the Korean Health Insurance Review and Assessment Service spanning from 2012 to 2016, with a median dataset size of 1,446,632 patients. The AIS group consisted of individuals aged 10 to 19 with diagnostic codes for AIS, while the control group consisted of those without AIS diagnostic codes. The median prevalence of FGIDs in adolescents with AIS from 2012 to 2016 was 24%. When accounting for confounding factors, the analysis revealed that adolescents with AIS were consistently more prone to experiencing FGIDs each year (2012: adjusted odds ratio (aOR), 1.21 [95% confidence interval (CI), 1.10-1.35], p < 0.001; 2013: aOR, 1.31 [95% CI, 1.18-1.46], p < 0.001; 2014: aOR, 1.24 [95% CI, 1.12-1.38], p < 0.001; 2015: aOR, 1.34 [95% CI, 1.21-1.49], p < 0.001; and 2016: aOR, 1.35 [95% CI, 1.21-1.50], p < 0.001). These findings suggest that AIS is correlated with an elevated likelihood of FGIDs, indicating that AIS may function as a potential risk factor for these gastrointestinal issues. Consequently, it is recommended to provide counseling to adolescents with AIS, alerting them to the heightened probability of experiencing chronic gastrointestinal symptoms.

Identifying mental health discussion topic in social media community: subreddit of bipolar disorder analysis.

Online platforms allow individuals to connect with others, share experiences, and find communities with similar interests, providing a sense of belonging and reducing feelings of isolation. Numerous previous studies examined the content of online health communities to gain insights into the sentiments surrounding mental health conditions. However, there is a noticeable gap in the research landscape, as no study has specifically concentrated on conducting an in-depth analysis or providing a comprehensive visualization of Bipolar disorder. Therefore, this study aimed to address this gap by examining the Bipolar subreddit online community, where we collected 1,460,447 posts as plain text documents for analysis. By employing LDA topic modeling and sentiment analysis, we found that the Bipolar disorder online community on Reddit discussed various aspects of the condition, including symptoms, mood swings, diagnosis, and medication. Users shared personal experiences, challenges, and coping strategies, seeking support and connection. Discussions related to therapy and medication were prevalent, emphasizing the importance of finding suitable therapists and managing medication side effects. The online community serves as a platform for seeking help, advice, and information, highlighting the role of social support in managing bipolar disorder. This study enhances our understanding of individuals living with bipolar disorder and provides valuable insights and feedback for researchers developing mental health interventions.

A Small-Molecule Fluorescence Probe for Nuclear ATP.

Fluorescence monitoring of ATP in different organelles is now feasible with a few biosensors developed, which, however, show low sensitivity, limited biocompatibility, and accessibility. Small-molecule ATP probes that alleviate those limitations thus have received much attention recently, leading to a few ATP probes that target several organelles except for the nucleus. We disclose the first small-molecule probe that selectively detects nuclear ATP through reversible binding, with 25-fold fluorescence enhancement at pH 7.4 and excellent selectivity against various biologically relevant species. Using the probe, we observed 2.1-3.3-fold and 3.9-7.8-fold higher nuclear ATP levels in cancerous cell lines and tumor tissues compared with normal cell lines and tissues, respectively, which are explained by the higher nuclear ATP level in the mitosis phase. The probe has great potential for studying nuclear ATP-associated biology.

Natural overexpression of CAROTENOID CLEAVAGE DIOXYGENASE 4 in tomato alters carotenoid flux.

Carotenoids and apocarotenoids function as pigments and flavor volatiles in plants that enhance consumer appeal and offer health benefits. Tomato (Solanum lycopersicum.) fruit, especially those of wild species, exhibit a high degree of natural variation in carotenoid and apocarotenoid contents. Using positional cloning and an introgression line (IL) of Solanum habrochaites "LA1777', IL8A, we identified carotenoid cleavage dioxygenase 4 (CCD4) as the factor responsible for controlling the dark orange fruit color. CCD4b expression in ripe fruit of IL8A plants was ∼8,000 times greater than that in the wild type, presumably due to 5' cis-regulatory changes. The ShCCD4b-GFP fusion protein localized in the plastid. Phytoene, ζ-carotene, and neurosporene levels increased in ShCCD4b-overexpressing ripe fruit, whereas trans-lycopene, ß-carotene, and lutein levels were reduced, suggestive of feedback regulation in the carotenoid pathway by an unknown apocarotenoid. Solid-phase microextraction-gas chromatography-mass spectrometry analysis showed increased levels of geranylacetone and ß-ionone in ShCCD4b-overexpressing ripe fruit coupled with a ß-cyclocitral deficiency. In carotenoid-accumulating Escherichia coli strains, ShCCD4b cleaved both ζ-carotene and ß-carotene at the C9-C10 (C9'-C10') positions to produce geranylacetone and ß-ionone, respectively. Exogenous ß-cyclocitral decreased carotenoid synthesis in the ripening fruit of tomato and pepper (Capsicum annuum), suggesting feedback inhibition in the pathway. Our findings will be helpful for enhancing the aesthetic and nutritional value of tomato and for understanding the complex regulatory mechanisms of carotenoid and apocarotenoid biogenesis.

Biomechanical Comparison of Multilevel Lumbar Instrumented Fusions in Adult Spinal Deformity According to the Upper and Lower Fusion Levels: A Finite Element Analysis.

Multilevel lumbar fusion with posterior pedicle screw fixation is a widely performed surgical procedure for the management of adult spinal deformity. However, there has not been a comprehensive biomechanical study on the different types of fusion levels in terms of stability and possible complications. We aimed to investigate the biomechanical properties of multilevel lumbar fusion according to different types of upper and lower fusion levels. Six different types of fusions were performed using three-dimensional finite element models. Type A and B referred to the group of which upper fusion level was L1 and T10, respectively. Subtype 1, 2, and 3 referred to the group of which lower fusion level was L5, S1, and ilium, respectively (A1, L1-L5; A2, L1-S1; A3, L1-ilium; B1, T10-L5; B2, T10-S1; B3, T10-ilium). Flexion, extension, axial rotation, and lateral bending moments were applied, and the risk of screw loosening and failure and adjacent segment degeneration (ASD) was analyzed. Stress at the bone-screw interface of type B3 was lowest in overall motions. The risk of screw failure showed increasing pattern as the upper and lower levels extended in all motions. Proximal range of motion (ROM) increased as the lower fusion level changed from L5 to S1 and the ilium. For axial rotation, type B3 showed higher proximal ROM (16.2°) than type A3 (11.8°). In multilevel lumbar fusion surgery for adult spinal deformity, adding iliac screws and increasing the fusion level to T10-ilium may lower the risk of screw loosening. In terms of screw failure and proximal ASD, however, T10-ilium fusion has a higher potential risk compared with other fusion types. These results will contribute for surgeons to provide adequate patient education regarding screw failure and proximal ASD, when performing multilevel lumbar fusion.

Obesity and periodontitis: A systematic review and updated meta-analysis.

Background: A previous 2014 meta-analysis reported a positive association between obesity and periodontitis. It was considered necessary to update the recently published papers and to analyse subgroups on important clinical variables that could affect the association between obesity and periodontitis. Therefore, we updated the latest studies and attempted to derive more refined results. Methods: All observational studies were eligible for inclusion. The Newcastle-Ottawa scale was used to qualitatively evaluate the risk of bias. Subgroup analyses were conducted for patients aged 18-34, 35-54, and 55+ years and the countries (European countries, USA, Brazil, Japan, Korea, and other Asian countries). Results: Thirty-seven full-text articles were included. Obesity conferred increased odds of periodontal disease with an odds ratio (1.35, 95% CI: 1.05-1.75). In the subgroup analysis by age, the odds ratio was the highest in the 18-34 years group (2.21, 95% CI: 1.26-3.89). In the subgroup analysis by country, European countries had the highest odds ratio (2.46, 95% CI: 1.11-5.46). Conclusion: Despite the differences in degree, a positive association between obesity and periodontitis was found regardless of country or age. Therefore, medical professionals should try to prevent periodontitis by controlling patient weights, and more studies should be conducted to determine the association between obesity and oral health. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/, identifier CRD42022301343.

Biomechanical Comparison and Three-Dimensional Analysis of Cement Distribution Patterns for Different Pedicle Screw Designs.

The purpose of this study to explore strategies for reducing cement leakage during cement-augmented pedicle screw fixation, we compared the cement distribution patterns and biomechanical strengths of different types of cement-augmented fenestrated screws and traditional cement-augmented techniques. We compared five screw groups in this study: (1) Cannulated screws (Cann); (2) distal one-hole screws (D1); (3) distal two-hole screws (D2); (4) middle two-hole screws (M2); and (5) traditional screws with a traditional cement injection technique (Trad). The screws were inserted into cancellous bone blocks using a controlled, adequate cement injection pressure (1.6-2.0 kg), and an appropriate cement viscosity. Center to screw tip distance, three-dimensional distribution, and pull-out strength for cement were compared between groups. The average distance between the cement center and the screw tip was highest in the M2 group, suggesting a higher risk of cement leakage into the spinal canal. The Trad group had the highest migration distance in the z-axis, also reflecting a higher risk of leakage into the spinal canal. The D1 group had the highest pull-out strength (253 ± 48.82 N and 797 ± 58.31 N) in bone blocks representing different degrees of osteoporosis, and the D2 group had the second highest pull-out strength in the severe osteoporosis model. Overall, D1 screws appeared to be the best option for optimizing biomechanical function and minimizing the risk of cement leakage into the spinal canal in patients with osteoporotic bone undergoing spinal surgery.

Real-Time Stress Analysis Affecting Nurse during Elective Spinal Surgery Using a Wearable Device.

Successful spinal surgery demands high levels of concentration and cooperation from participating health care workers. The intraoperative stress levels and concentration levels of surgeons have been studied previously; however, those of nurses are rarely studied. Therefore, the purpose of this study is to understand the stresses affecting surgical nurses by their participating role during spinal surgery. A total of 160 surgical stress records were obtained during 40 surgeries, including electroencephalography (EEG) signals and heart rate variability (HRV) from three orthopedic spinal surgeons and six nurses; concentration, tension level and physical stress were analyzed. Levels of both concentration and tension were significantly higher in circulating nurses during all surgical stages (p < 0.05). Both beats per minute and low frequency/high frequency ratios, which reflect physical stress, were higher in scrub nurses (p < 0.05). As the surgical experience of scrub nurses increased, the key parameters related to stress tended to decrease (p < 0.01). These results will contribute to understanding the pattern of intraoperative stress of surgical nurses, and therefore help in enhancing the teamwork of the surgical team for optimal outcomes.

Superior therapeutic activity of TGF-ß-induced extracellular vesicles against interstitial cystitis.

Interstitial cystitis/bladder pain syndrome (IC/BPS) is a chronic disease characterized by incapacitating pelvic pain. Mesenchymal stem cell-derived extracellular vesicles (MSC-EVs) are considered key mediators of the paracrine action of MSCs and show better biological activities than the parent MSCs, especially in the bladder tissue, which may be unfavorable for MSC survival. Here, we produced MSC-EVs using advanced three-dimensional (a3D) culture with exogenous transforming growth factor-ß3 (TGF-ß3) (T-a3D-EVs). Treatment with T-a3D-EVs led to significantly enhanced wound healing and anti-inflammatory capacities. Moreover, submucosal layer injection of T-a3D-EVs in chronic IC/BPS animal model resulted in restoration of bladder function, superior anti-inflammatory activity, and recovery of damaged urothelium compared to MSCs. Interestingly, we detected increased TGF-ß1 level in T-a3D-EVs, which might be involved in the anti-inflammatory activity of these EVs. Taken together, we demonstrate the excellent immune-modulatory and regenerative abilities of T-a3D-EVs as observed by recovery from urothelial denudation and dysfunction, which could be a promising therapeutic strategy for IC/BPS.

New therapeutic approach with extracellular vesicles from stem cells for interstitial cystitis/bladder pain syndrome.

Interstitial cystitis/bladder pain syndrome (IC/BPS) is a debilitating chronic disorder characterized by suprapubic pain and urinary symptoms such as urgency, nocturia, and frequency. The prevalence of IC/BPS is increasing as diagnostic criteria become more comprehensive. Conventional pharmacotherapy against IC/BPS has shown suboptimal effects, and consequently, patients with end-stage IC/BPS are subjected to surgery. The novel treatment strategies should have two main functions, anti-inflammatory action and the regeneration of glycosaminoglycan and urothelium layers. Stem cell therapy has been shown to have dual functions. Mesenchymal stem cells (MSCs) are a promising therapeutic option for IC/BPS, but they come with several shortcomings, such as immune activation and tumorigenicity. MSC-derived extracellular vesicles (MSC-EVs) hold numerous therapeutic cargos and are thus a viable cell-free therapeutic option. In this review, we provide a brief overview of IC/BPS pathophysiology and limitations of the MSC-based therapies. Then we provide a detailed explanation and discussion of therapeutic applications of EVs in IC/BPS as well as the possible mechanisms. We believe our review will give an insight into the strengths and drawbacks of EV-mediated IC/BPS therapy and will provide a basis for further development. [BMB Reports 2022; 55(5): 205-212].

Medial Pedicle Pivot Point Using Preoperative Computed Tomography Morphometric Measurements for Cervical Pedicle Screw Insertion: A Novel Technique and Case Series.

This study describes a new and safe freehand cervical pedicle screw insertion technique using preoperative computed tomography (CT) morphometric measurements as a guide and a medial pedicle pivot point (MPPP) during the procedure. This study included 271 pedicles at 216 cervical spine levels (mean: 4.75 pedicles per patient). A pedicle diameter (PD) ≥ 3.5 mm was the cut-off for pedicle screw fixation. The presence and grade of perforation were detected using postoperative CT scans, where perforations were graded as follows: 0, no perforation; 1, perforation < 0.875 mm; 2, perforation 0.875-1.75 mm; and 3, perforation > 1.75 mm. The surgical technique involved the use of an MPPP, which was the point at which the lines representing the depth of the lateral mass and total length of the pedicle intersected, deep in the lateral mass. The overall success rate was 96.3% (261/271, Grade 0 or 1 perforations). In total, 54 perforations occurred, among which 44 (81.5%) were Grade 1 and 10 (18.5%) were Grade 2. The most common perforation direction was medial (39/54, 72.2%). The freehand technique for cervical pedicle screw fixation using the MPPP may allow for a safe and accurate procedure in patients with a PD ≥3.5 mm.

Maternal and Neonatal Outcomes of Elective Induction of Labor at 39 or More Weeks: A Prospective, Observational Study.

The purpose of our study is to compare the maternal and neonatal outcomes of induction of labor (IOL) versus expectant management at 39 weeks of gestation. We conducted a single-centered, prospective, observational study of nulliparous singleton women at 39 weeks or more. We compared the maternal and perinatal outcomes. Of 408 nulliparous women, 132 women were IOL group and 276 women were expectant management group. IOL and expectant group had similar cesarean delivery rate (18.2% vs. 15.9%, p = 0.570). The delivery time from admission was longer in IOL group (834 ± 527 vs. 717 ± 469 min, p = 0.040). The IOL group was less likely to have Apgar score at 5 min < 7 than in expectant group (0.8% vs. 5.4%, p = 0.023). Multivariate analysis showed that IOL at 39 weeks was not an independent risk factor for cesarean delivery (relative risk 0.64, 95% confidence interval: 0.28−1.45, p = 0.280). Maternal and neonatal adverse outcomes, including cesarean delivery rate, were similar to women in IOL at 39 weeks of gestation compared to expectant management in nulliparous women. IOL at 39 weeks of gestation could be recommended even when the indication of IOL is not definite.