The role of folic acid fortification in neural tube defects: a review.

The worldwide prevalence of neural tube defects (NTDs) has fallen noticeably during the past 30 years, but the specific etiology and causative mechanism of NTDs remain unknown. Since introduction of mandatory fortification of grains with folic acid, a further decrease in NTD prevalence has been reported in North America and other countries with large variations among ethnic subgroups. However, a significant portion of NTDs still persists. Population data suggest that women of childbearing age may not yet be adequately targeted, while the general population may be overfortified with folic acid. While an excessive folate intake may be associated with adverse effects, there remains uncertainty about the minimum effective folate intake and status required for NTD prevention, and the safe upper folate level. Besides folate, several other lifestyle and environmental factors as well as genetic variations may influence NTD development, possibly by affecting one-carbon metabolism and thus epigenetic events. In conclusion, mandatory folic acid fortification plays a significant part in the reduction of NTD prevalence, but possibly at a cost and with a portion of NTDs remaining. More effective preventive strategies require better understanding of the etiology of this group of birth defects.

Racism, COVID-19, and Health Inequity in the USA: a Call to Action.

The current national COVID-19 mortality rate for Black Americans is 2.1 times higher than that of Whites. In this commentary, we provide historical context on how structural racism undergirds multi-sector policies which contribute to racial health inequities such as those highlighted by the COVID-19 pandemic. We offer a concrete, actionable path forward to address structural racism and advance health equity for Black Americans through anti-racism, implicit bias, and cultural competency training; capacity building; community-based participatory research (CBPR) initiatives; validated metrics for longitudinal monitoring of efforts to address health disparities and the evaluation of those interventions; and advocacy for and empowerment of vulnerable communities. This necessitates a multi-pronged, coordinated approach led by clinicians; public health professionals; researchers; social scientists; policy-makers at all governmental levels; and local community leaders and stakeholders across the education, legal, social service, and economic sectors to proactively and systematically advance health equity for Black Americans across the USA.

Severe acute respiratory syndrome coronavirus 2: a canary in the coal mine for public safety net hospitals.

BACKGROUND: The coronavirus disease 2019 pandemic has exposed disproportionate health inequities among underserved populations, including refugees. Public safety net healthcare systems play a critical role in facilitating access to care for refugees and informing coordinated public health prevention and mitigation efforts during a pandemic. OBJECTIVE: This study aimed to evaluate the prevalence ratios of severe acute respiratory syndrome coronavirus 2 infection between refugee women and nonrefugee parturient patients admitted to the hospital for delivery. Here, we suspected that the burden of infection was disproportionately distributed across refugee communities that may act as sentinels for community outbreaks. STUDY DESIGN: A cross-sectional study was conducted examining parturient women admitted to the maternity unit between May 6, 2020, and July 22, 2020, when universal testing for severe acute respiratory syndrome coronavirus 2 was first employed. Risk factors for severe acute respiratory syndrome 2 positivity were ascertained, disaggregated by refugee status, and other clinical and sociodemographic variables examined. Prevalence ratios were calculated and comparisons made to county-level community prevalence over the same period. RESULTS: The positive test percentage at the county-level during this study period was 21.6%. Of 350 women admitted to the hospital for delivery, 33 (9.4%) tested positive for severe acute respiratory syndrome 2. When refugee status was determined, 45 women (12.8%) were identified as refugees. Of the 45 refugee women, 8 (17.8%) tested positive for severe acute respiratory syndrome 2 compared with 25 nonrefugee patients (8.19%) who tested positive for severe acute respiratory syndrome 2 (prevalence ratio, 2.16; 95% confidence interval, 1.04-4.51). In addition, 7 of the refugee women who tested positive for severe acute respiratory syndrome coronavirus 2 were from Central Africa. CONCLUSION: The severe acute respiratory syndrome coronavirus 2 outbreak has disproportionately affected refugee populations. This study highlighted the utility of universal screening in mounting a rapid response to an evolving pandemic and how we can better serve refugee communities. Focused response may help achieve more equitable care related to severe acute respiratory syndrome 2 among vulnerable communities. The identification of such populations may help mitigate the spread of the disease and facilitate a timely, culturally, and linguistically enhanced public health response.

Genomic analysis of neuroendocrine development of fetal brain-pituitary-adrenal axis in late gestation.

The present study was performed to identify the changes in genomic expression of critical components of the hypothalamus-pituitary-adrenal (HPA) axis in the second half of gestation in fetal sheep. We isolated mRNA from pituitary, hypothalamus, hippocampus, and brain stem in fetal sheep at 80, 100, 120, 130, and 145 days of gestation and 1 and 7 days after delivery (n = 4-5/group). Using real-time RT-PCR, we measured mRNA expression levels of glucocorticoid receptor (GR), mineralocorticoid receptor (MR), serum- and glucocorticoid-induced kinase-1 (sgk1), proopiomelanocortin (POMC), CRF, and arginine vasopressin (AVP). Both MR and GR were highly expressed in pituitary and hippocampus; in all tissues GR was more highly expressed than MR. AVP was more highly expressed than CRF in hypothalamus. MR, GR, and sgk1 expression were increased postnatally in brain stem, and sgk1 expression was increased postnatally in hypothalamus. GR expression was reduced in pituitary in term fetuses compared with younger ages. Hypothalamic CRF expression was increased at the end of gestation compared with younger ages, and AVP expression was increased in newborn lambs. Pituitary POMC was increased at 100 days of gestation compared with 80 days; hypothalamic POMC was increased at 120 days. Overall, the results demonstrate the expression of both MR and GR in brain regions important for control of the HPA axis. Decreases in expression of GR in pituitary at the end of gestation might contribute to the decreased corticosteroid negative feedback sensitivity at term in this species.

Ethical Issues in Maternal-Fetal Care Emergencies.

Ethical issues that arise in the care of pregnant women are challenging to physicians, especially in critical care situations. By familiarizing themselves with the concepts of medical ethics in obstetrics, physicians will become more capable of approaching complex ethical situations with a clear and structured framework. This review discusses ethical approaches regarding 3 specific scenarios: (1) the life of the fetus versus the life of the mother and situations of questionable maternal decision making; (2) withdrawal of care in a brain-dead pregnant patient; and (3) domestic violence and the pregnant patient.

Ontogenetic changes in the extra-pituitary expression of pro-opiomelanocortin in the developing ovine fetus.

Previous studies performed in this laboratory have demonstrated that the fetal lung contains immunoreactive adrenocorticotropin (irACTH), and that the lung both clears and secretes irACTH under basal and stimulated conditions. Furthermore, we have demonstrated that the irACTH in fetal lung is accounted for by proopiomelanocortin (POMC), and that there is an evidence of post-translational processing that is distinct from the pattern of processing typical of the anterior pituitary. The present study was designed to test the hypothesis that POMC is synthesized in the fetal lung, and that there is decreased synthesis in the late-gestation ovine fetal lung. Lungs were collected from fetal sheep at 80, 100, 120, 130, and 145 days gestation (n=4/group; term=147 days). POMC mRNA was measured using reverse transcription and real-time polymerase chain reaction with probe and primers designed in this laboratory. The greatest abundance of POMC mRNA was in the 80-days fetal sheep, and the relative abundance decreased as a function of fetal gestational age. POMC protein was measured using immunoblot analysis in lungs from 80, 120, and 145-days fetal sheep. The pattern of POMC protein abundance was consistent with that of the mRNA (highest at 80 days, lowest at 145 days). The POMC immunoblot revealed specific staining of a peptide with molecular weight of 27 kDa and another peptide with a molecular weight slightly higher than that of native POMC (32 kDa). For comparison, we measured POMC mRNA in skeletal muscle and small intestine. We found POMC expression in both fetal tissues, but no statistically significant ontogenetic pattern of expression. We conclude that POMC is synthesized in the ovine fetal lung, and that the rate of synthesis decreases as the fetus matures in utero. We speculate that the decreasing abundance of POMC mRNA and protein reflects decreased release of POMC and POMC-related peptides into the fetal bloodstream.