Exposure to heavy metals such as lead, cadmium, and mercury poses serious health risks to pregnant women because of their high toxicity. In this study, we investigated the associations of heavy metal exposure with birth outcomes of Korean infants. Data of 5,215 women between 2015 and 2019 were analyzed. This study was part of the Korean Children’s Environmental Health (Ko-CHENS) study. Linear regression and logistic regression analyses were used to examine effects of concentrations of lead, cadmium, and mercury on birth weight, small for gestational age, and large for gestational age after adjusting for maternal age groups, parity, infant sex, education, income, smoking, drinking, body mass index, stillbirth, premature birth, diabetes, hypertension, and gestational diabetes. Besides adjusting for these covariates, each metal was mutually adjusted to estimate birth weight and large for gestational age status. Maternal cadmium concentrations during early pregnancy : − 63.76, − 16.17) and late pregnancy  were significantly associated with birth weight. Cadmium levels during early pregnancy  were also associated with large for gestational age status. Our findings suggest that prenatal cadmium exposure, even at a low level of exposure, is significantly associated with low birth weight. Previous studies have explored effects of lead, cadmium, and mercury on fetal growth outcomes, including small for gestational age status and low birth weight12.Lead, mercury, and cadmium are highly toxic metals associated with extensive environmental contamination and significant health problems. In particular, lead and mercury are highly toxic to fetuses because they can easily cross the blood-placental barrier, while cadmium can only partially cross it13. Suboptimal fetal growth can result from prenatal cadmium exposure14. Methylmercury (MeHg) can adversely affect fetal growth by inhibiting the antioxidant system and increasing free radical production15.Heavy metal toxicology can interfere with fetal cell division and differentiation. For example, lead exposure can interfere with calcium deposition in bones during fetal development16 and lead to health problems in adulthood, such as respiratory disorders and cardiovascular diseases17. Low infant birth weight has been associated with several chronic health consequences such as diabetes mellitus, and obesity in adulthood18. The aim of this study was to investigate the associations between heavy metal  exposure during early pregnancy, late pregnancy and at birth with birth outcomes, such as birth weight, small for gestational age and large for gestational age. Although several studies from developed countries have examined lead, cadmium, and mercury exposure in relation to birth outcomes9, our study is significant for having one of the largest samples.A number of epidemiological studies have shown that harmful effects on birth outcomes can significantly impact morbidity and disability in early childhood19. This study used data collected from a total of 5215 pregnant women from 2015 to 2019. Exclusion criteria for this study were: multiple or abnormal births (n = 145), toxemia of pregnancy (n = 29), and missing covariates (n = 3). Finally, heavy metal concentrations were measured for a total of 4948 women during early pregnancy and 4745 (missing 203) women during late pregnancy. Heavy metal concentrations were also measured for 3982 (missing 966) cord blood samples  Study, which was launched in 2015 with funding from the Ministry of the Environment and the National Institute of Environmental Research to study environmental diseases in children20. Blood metal levels were measured using an Agilent 7900 inductively coupled plasma mass spectrometer (ICP-MS) . Lead, cadmium, and mercury levels in blood samples were detected at 0.009 μg/dL, 0.05 μg/L, and 0.10 μg/L, respectively. In addition, to handle the limit of detection (LOD) effect we used LOD analysis method, LOD/21.Venous blood samples were obtained from participants during early pregnancy (12–20 weeks) and late pregnancy (> 28 weeks) upon outpatient visits. Vacuum blood collection tubes containing sodium ethylenediaminetetraacetic acid were used to collect whole blood samples . After storing samples in a refrigerator, they were transferred to the laboratory for lead, mercury, and cadmium measurements22.Birth outcomes such as birth weight and perinatal medical information were collected from prenatal care and delivery clinic medical charts. Other health outcomes were measured using questionnaire surveys, medical utilization databases, and health checkup databases. Birth weight was the first weight of the baby. It was taken soon after birth. If an infant’s weight was measured at less than the 10th percentile, it was classified as small for gestational age (SGA). If it was measured greater than the 90th percentile, it was termed large for gestational age (LGA). In this study, a chart suggested by Fenton that was consistent with the World Health Organization growth standard was used24. It has also been shown that maternal age affects birth weight. Low-birth-weight infants are more likely to be born to younger and older mothers25. Additionally, infants with low birth weight are also more likely to be preterm births26. Besides adjusting for these covariates, a mutually adjusted linear regression model for lead, cadmium, and mercury was used to estimate the association of heavy metal exposure with birth weight. Each metal was also mutually adjusted by a logistic regression model to explore the relationship of heavy metal exposure with LGA. All statistical analyses were performed using SAS 9.4 .Multiple linear regression analysis was performed to evaluate the association between prenatal heavy metal exposure and birth weight. Multiple logistic regression analysis was performed to calculate the odds ratio (OR) and 95% confidence interval (CI) for evaluating effects of heavy metal concentrations on SGA and LGA. Statistical model was adjusted for maternal age, parity, infant sex, education, income, smoking, drinking, body mass index (BMI), still birth, premature birth, diabetes, hypertension, and gestational diabetes. The main reason for choosing these variables was their influence on birth outcomes. According to various ethnic studies, maternal smoking correlates with reduced birthweight and low birthweight prevalence among different ethnic groupsMore than 95% of the samples were collected from pregnant women aged 30 years and older . Nearly three-quarters of the women had a normal BMI prior to pregnancy . Approximately 76% of the women reported studying in universities. Nearly half of them had a family income of $1500 to $3000. More than 85% of the women had never smoked. Very few reported current alcohol consumption . It was found that 1.1% of early and late pregnancy groups and 1% of the cord blood group had hypertension and 1.8% of all women had gestational diabetes. Approximately 25% of early and late pregnancy groups and cord blood group reported stillbirth. In birth outcomes, proportions of SGA and LGA were about 12% and 3%, respectively, for all three sample types. The mean birth weight was 3222.2 g (SD = 443.4 g) in the early pregnancy group, 3240.6 g (SD = 405.4 g) in the late pregnancy group, and 3249.9 g (SD = 399.8 g) in the cord blood group , cadmium level in late pregnancy , and lead level in late pregnancy . However, cord blood lead level  showed a significant positive correlation with birth weight  and mercury level  as well as cord blood lead level . However, lead, cadmium, and mercury levels in early pregnancy, late pregnancy, and cord blood samples were not significantly associated with Fenton SGA status  and late pregnancy . After adjusting for cadmium level along with other confounding factors, birth weight showed a statistically significant positive association with cord blood lead level . Also, after adjusting for mercury and other confounding factors, cadmium levels in early  and late  pregnancy showed significant negative associations with birth weight. However, birth weight showed a significant positive association with lead level in cord blood   and early pregnancy mercury level . When cadmium level was adjusted along with other confounding factors, early pregnancy mercury level  and cord blood lead level  showed significant positive associations with LGA. After adjusting for mercury and other confounding factors, LGA was associated with maternal blood early pregnancy cadmium level  and cord blood lead level   in 201327, in an eastern China study conducted in 209 pregnant women in late pregnancy (mean 0.48 μg/L) and cord blood (mean 0.09 μg/L)10 in 2014, in North Carolina, USA (mean 0.46 mg/L in late pregnancy) in 20145, in South Africa (mean 0.25 μg/L in late pregnancy and 0.27 μg/L in cord blood) in 20156; and in Norway in second-trimester smokers  and non-smokers (GM = 0.15 μg/L) in 201128. However, our study found lower cadmium levels in maternal blood in late pregnancy (mean 0.98 μg/L) and cord blood (mean 0.78 μg/L) than those in a Saudi Arabian study in 20147. A number of factors, such as the number of subjects and the type of covariates used, might have contributed to such differences in cadmium levels in above-mentioned results from developed and developing countries.The mean maternal blood cadmium concentration was 0.62 μg/L in early pregnancy, 0.70 μg/L in late pregnancy, and 0.24 μg/L in cord blood. The mean maternal and cord blood cadmium concentrations in this study were higher than those reported in the United Kingdom (mean 0.56 μg/L in early pregnancy) in 201629. Blood cadmium concentrations during late pregnancy were higher than those during early pregnancy. They were the lowest in cord blood . These observations were consistent with another study 7. Although cadmium levels in our study were lower than those in the above studies, cadmium is harmful even at low concentrations30. Moreover, we found that maternal and cord blood cadmium levels, even when they were low, were more strongly associated with an increased risk of low birth weight and LGA status than lead and mercury levels.The present study also showed lower cadmium concentrations than those in the Korean multi-center prospective birth cohort MOCEH study. However, our study found trends similar to those in the MOCEH study 10, another study in China of 252 mother-infant pairs 4, and a study in Saudi Arabia  in 20147. However, some studies have found similar levels, including a study in Norway  in 201128 and a study in the United States (midterm pregnancy blood lead GM = 0.7 μg/dL) in 201831. Some studies showed lower concentrations than ours, including an Australian study  in 201327 and a Puerto Rican study 9.This study found that blood lead concentrations were particularly low  compared to those in a study in China of 209 pregnant women  in 201428, China (GM = 0.84 μg/L)32, Australia (mean = 0.83 μg/L)27, and the United States (GM = 0.6 μg/L)31, but lower than in those in studies conducted in Greenland (mean = 16.8 μg/L)33 and Saudi Arabia (mean = 3.00 μg/dL)7. Mercury concentrations in our study were also lower than those in a Korean study  that was a part of the Mothers and Children’s Environmental Health Study performed between 2006 and 2008 on 417 Korean women and newborns34. Despite having lower mercury levels than the above Korean study, our study had a large sample size and showed a significant association between mercury and LGA status. We also accounted for lead and cadmium concentrations, whereas the above Korean study only focused on mercury concentrations.Maternal blood mercury concentrations in our study  were greater than those in studies conducted in Norway (mean = 1.2 μg/L)29. In our study, blood lead concentrations during late pregnancy were lower than those in early pregnancy. As lead can move from blood into bones during pregnancy, physiological factors such as increases in plasma estrogen concentrations might have contributed to this decrease36. Total blood mercury levels (GM) in late pregnancy were lower than those in early pregnancy. Previous studies have shown the same trend38. This decrease of blood mercury level during late pregnancy is due to the diluting effect of increased plasma volume39.Lead concentrations  and mercury concentrations  in this study were consistent with those of the MOCEH study 11. Among these, cadmium was found to have the most profound impact on several birth outcomes, although birth outcomes showed no correlation with lead or mercury concentrations in the same population7. Since heavy metals cause physiological immaturity during pregnancy and early life, they can pose a serious threat to fetal and infant health40. The effects of cadmium on apoptosis, oxidative stress, reactive oxygen species, and deoxyribonucleic acid (DNA) repair can be attributed to its toxicity40. Cadmium may also affect growth in fetuses by affecting 11beta-hydroxysteroid dehydrogenase type 2 activity41. During pregnancy, exposure to cadmium has been linked to decreased birth weights and premature births, and elevated levels of placental cadmium resulting from maternal exposure to industrial waste or tobacco smoke have been associated with decreased progesterone biosynthesis by the placental trophoblast42. Also, A number of potential mechanisms can contribute to cadmium-induced fetal growth restriction (FGR), including hypoxia in the fetus, disturbed fetoplacental zinc homeostasis, and reduced blood flow to the uterus and placenta43. Previous studies have shown a link between prenatal cadmium exposure and low birth weight10. A total of 408 mother-infant pairs in Hubei Province, China provided evidence of a positive association between maternal cadmium exposure and the risk of infant preterm low birth weight (PLBW)44. An earlier cross-sectional study of 209 pregnant women in Eastern China observed that maternal blood cadmium levels were inversely related to birth weight 10. Another study of 1027 pregnant women in the United States reported that high maternal blood cadmium levels (≥ 0.50 μg/L) were negatively associated with birth weight percentile for gestational age and positively associated with SGA 5. Consistent with these results, our findings also indicated that high maternal blood cadmium levels (early pregnancy 0.62 μg/L and late pregnancy 0.70 μg/L) were inversely associated with birth weight, whereas they showed no association with SGA.Several studies have examined effects of heavy metal exposure on newborn anthropometrics45. Therefore, we could not completely exclude the influence of dietary intake on metal exposure measurements46. One previous study has also detected a positive association between birth weight and nickel9. Likewise, another study reported a non-significant positive association between cadmium level and birth weight 47. However, previous studies showed a significant inverse association between lead and birth weight48 or no association12.Our analysis demonstrated that cord blood lead level was positively associated with birth weight. Although we observed a statistically significant positive association, it could be due to the impact of other factors, such as maternal nutrition that may influence birth weight. As such, nutritional intake was not considered in this study, although it could have an impact on low birth weight10. However, the majority of previous studies, including ours, demonstrated that cadmium was linked to lower birth weight7. Second, genetic information that could be correlated with birth outcomes was not included in the present study49.This study had several strengths. First, this study had a prospective Korean birth cohort design with extensive information on potential confounders. The main strength of this study was its large sample size. Moreover, heavy metals were estimated at two time points, early pregnancy and late pregnancy, to provide accurate associations between heavy metal levels and outcomes. However, this study also had some limitations. First, this study only focused on three major heavy metals. The presence of other toxic heavy metals might have affected the main result. For example, one study showed that selenium level was associated with newborn birth weight and that increased selenium intake might decrease cord blood cadmium concentrationsOur results suggest that low levels of prenatal exposure to cadmium, lead, and mercury might affect birth outcomes. This study provides further support for the need to reduce cadmium exposure among pregnant women as much as possible. Although the effect of heavy metal exposure on birth outcomes might be small, their consequences might not be negligible. Further studies on effects of prenatal exposure to a variety of metals present in the environment on birth outcomes are needed.


Vaginal cysts are often encountered in gynaecological outpatient settings. These are usually asymptomatic in their initial course but become symptomatic when their size increases or they get infected. While evaluating such cases, clinical examination plays a vital role in ruling out their differential diagnoses. Imaging studies can complement clinical findings. However, in some instances, the nature of vaginal cysts may not be determined preoperatively until histopathology examination reveals it. We report here a rare case of a posterior vaginal wall cyst that presented as a mass protruding through the vagina. The clinical dilemma was the characterization of the cyst, owing to its huge size and rare location. The cyst was managed surgically by excision, and to our surprise, histopathological examination revealed it as a Bartholin gland cyst in the posterior vaginal wall, rare in its location. Cysts of vaginal origin are rare and are usually incidentally diagnosed during routine gynaecological examinations. The clinical presentation depends on the size and depth of the cyst. Larger cysts are often symptomatic and cause dyspareunia, vulvar pain, pressure symptoms, or an abscess. Various categories of vaginal cysts are classified based on the histology depending on the lining epithelium of the cyst wall: epidermal inclusion cyst, Mullerian cyst, endometroid cyst, Bartholin gland cyst or abscess, Gartner’s duct cyst, and unclassified types . BartholA 43-year-old para 2 living 2 presented to the outpatient department with complaints of mass coming out of the vagina for the last two months. The size of the mass increased insidiously. There were no associated bowel or bladder complaints. There was no history of an increase in the size of the mass after straining.The patient had undergone a right partial nephrectomy two years ago. Her general physical and systemic examination was unremarkable. On local examination, a cystic mass of size 6x6 cm was seen occupying the vagina and protruding through the introitus Figure . SpeculuUltrasonography showed a normal uterus with an endometrial thickness of 6 mm. An anechoic lesion of size 6.6 x 4.9 cm was visualised distal to the cervix in the vaginal cavity; however, the origin of the lesion could not be seen Figure . MagnetiA differential diagnosis of rectocele was ruled out based on the clinical examination. Enterocele was ruled out as the cyst was in the mid and lower third of the vagina and there was no associated cough impulse. The location of the cyst ruled out the Bartholin cyst, which is typically located in the postero-lateral vaginal wall, and Gartner’s cyst, which is located in the anterior or antero-lateral aspect of the vaginal wall. Inclusion cysts of the vagina are usually situated on the posterior surface, but these are small in size, and there was no history of any perineal surgery. Endometriotic cysts could be ruled out due to the absence of pain and the presence of clear cystic content based on imaging. As the cystic lesion was completely located on the posterior vaginal wall, rectal neoplasm mimicking this condition could be a possibility until clinical examination and imaging ruled it out.The patient underwent surgical excision of the cyst under spinal anaesthesia. Diluted vasopressin was injected into the tissue plane between the cyst wall and posterior vaginal wall to minimise haemorrhage and hydro dissection. A vertical incision was made on the cyst, and blunt and sharp dissections were performed Figure . The cysThe patient was followed up for one month after surgery and had a full recovery without any complications.Vaginal cysts are often diagnosed based on history and clinical examination. While performing local examinations, clinicians usually differentiate the nature and type of vaginal cyst based on the location and associated signs. Gartner cysts are usually located in the anterior or antero-lateral aspect of the vaginal mucosa. Likewise, the Bartholin gland cyst is typically located in the postero-lateral aspect of the labia majora. The Mullerian cysts arise at the level of the cervix and extend anteriorly. Various other differential diagnoses of vaginal cysts, like endometriotic cysts, inclusion cysts, rectocele, and cystocele, can also be diagnosed from history and clinical examination. In inconclusive cases, imaging modalities like ultrasonography and magnetic resonance imaging can help in delineating the origin, involvement of surrounding organs, and nature of the cyst.Bartholin gland cysts are one of the most common incidentally diagnosed vaginal cysts among patients visiting a gynecological outpatient department. However, it sometimes presents with dyspareunia, vulvar pain, pressure symptoms, or an abscess. Bartholin gland cysts and abscesses are more likely in sexually active women due to obstruction in ducts by friction during coitus . BartholThe closest differential diagnosis in our case was rectocele, but it could be easily ruled out as it was not associated with utero-vaginal prolapse and the incidence of isolated rectocele is very low. On further examination, the cyst was found to be separate from the rectal wall. Imaging studies confirmed the location to be confined to the posterior vaginal wall without the involvement of surrounding structures or the anechoic content of the cyst. Imaging is often helpful in cases where malignancy is suspected, i.e., age greater than 40 years; firm, fixed, or irregular swelling. In these conditions, biopsy with or without excision is recommended [The posterior location of the vaginal cyst, which mimics rectocele, clinical uncertainty about the origin of the cyst, and histopathology examination revealing it as a Bartholin gland cyst make our case an interesting and rare one.Bartholin gland cysts can occur on the posterior vaginal wall, contrary to their usual location on postero-lateral part of the labia majora. These cysts, when large enough, can present as rectocele protruding through the introitus. However, a thorough clinical examination is the key to eliminating the clinical ambiguity. Cyst excision is the standard treatment in these cases. The nature of the cyst can be confirmed by histopathology examination of the surgical specimen.


LMW apo(a) phenotype (odds ratio 2.3 (1.1 to 4.8), p = 0.03), but not elevated Lp(a) (1.9 (0.8–4.6), p = 0.13), was an independent predictor for the development of MI after adjustment for sex, age of CHD debut, initial lipids levels, and lipid-lowering treatment. The apo(a) phenotype also determined the relationship between Lp(a) and PCSK9 concentrations. The level of the PCSK9-Lp(a) complex was higher in LMW apo(a) patients. Conclusion. The LMW apo(a) phenotype is a risk factor for non-fatal MI in a long-term prospective follow-up of patients with premature CHD, and this link could be mediated via PCSK9.Background. Lipoprotein(a) (Lp(a)) is a genetic risk factor of atherosclerotic cardiovascular diseases (ASCVDs). Proprotein convertase subtilisin/kexin type 9 (PCSK9) is related to vascular inflammation and detected in atherosclerotic plaques. A temporary increase in the circulating concentration of PCSK9 and Lp(a) was shown in patients with myocardial infarction (MI). The aim of this study was to evaluate the role of the apo(a) phenotype and the Lp(a) concentration as well as its complex with PCSK9 in the development of cardiac events and MI in patients with a premature manifestation of coronary heart disease (CHD). Methods. In a prospective study with retrospective data collection, we included 116 patients with premature CHD who were followed for a median of 14 years. The medical history and information on cardiovascular events after an initial exam as well as data on the levels of lipids, Lp(a), PCSK9, PCSK9-Lp(a) complex, and apo(a) phenotype were obtained. Results. The patients were divided into two groups depending on the presence of a low- (LMW,  LPA gene sequence explains up to 90% of the variation in Lp(a) concentration; 40–70% of these variations are determined by the size of the apo(a) isoforms. The molecular weight of apo(a) varies in the range from 300 to 800 kDa and is inversely related to Lp(a) concentration in human plasma due to the lower rate of apo(a) synthesis with a higher-molecular-weight (HMW) apo(a). However, the relationship between apo(a) isoform size and Lp(a) concentration is not absolute and is modified by various polymorphisms, resulting in a wide variability in the Lp(a) concentration in individuals with the same isoform [Lipoprotein (a) (Lp(a)) is a genetically determined risk factor for the development of atherosclerotic cardiovascular diseases (ASCVDs) and is associated with cardiovascular events even in patients receiving optimal lipid-lowering therapy ,2. Lp(a)The contribution of apo(a) isoforms to Lp(a) atherothrombogenesis has been discussed for a long time, but the question remains open. This is mainly due to the variations in the method for determining Lp(a), the difference in the methods used for phenotyping apo(a), and the patient groups. We have previously shown that the low-molecular-weight (LMW) apo(a) phenotype is associated with severe coronary atherosclerosis and myocardial infarction (MI) in patients with Lp(a) levels above 50 mg/dL, especially in those younger than 50 years . The sigIt has recently been shown that the use of alirocumab, which causes a slight up to 25%) decrease in Lp(a) level, is associated with a reduced risk of cardiovascular outcomes after acute coronary syndrome (ACS) despite a greater decrease in LDL cholesterol concentration % decreas. HoweverConsidering that Lp(a) is a genetically determined risk factor, its role in the secondary prevention of ASCVDs is an emergent issue. More attention is being paid to the possibility of using PCSK9 inhibitors for the treatment of ASCVDs and MI . The aimA prospective study with retrospective data collection included 116 patients with premature CHD  [Total cholesterol (TC), triglycerides (TGs), high-density lipoprotein cholesterol (HDL-C), and Lp(a) levels and apo(a) phenotypes were determined in all patients. The concentrations of PCSK9 and the PCSK9-Lp(a) circulating complex were measured in all patients at a follow-up visit. The LDL-C concentration was calculated according to the Martin–Hopkins equation . NonHDL-Apo(a) phenotyping was performed through Western blotting as previously described . The apop < 0.05.The Kolmogorov–Smirnov test was used to determine the normality of the distribution. The data are presented as mean ± standard deviation (SD) for those with normal distribution or as median and interquartile range or 95% confidential interval for those with abnormal distribution. The Spearman’s test was used for correlation analysis. We conducted logistic regression to determine the association of independent variables with cardiovascular events and MI. Survival analysis without non-fatal cardiac events was carried out through regression analysis of Kaplan–Meier and Cox. Statistical significance was considered at n = 52) or the HMW (n = 64) apo(a) phenotype. Patients did not differ by main clinical characteristics, age of CHD manifestation, and lipid values  was significantly higher in patients with LMW apo(a) phenotypes .During the observation period, cardiovascular events developed in 71 patients .The risk of cardiovascular events was independent of apo(a) phenotype and Lp(a) concentration at a cutoff value of 30 mg/dL A,B. An LThe presence of the LMW apo(a) phenotype was associated with a 4-year-earlier development of MI compared to the HMW apo(a) phenotype: 226 ± 13 months versus 276 ± 15 months, respectively. The risk of MI was 2.4 times higher in the presence of the LMW apo(a) phenotype A and twip = 0.03) was an independent predictor of earlier development of non-fatal MI, according to Cox regression analysis adjusted for sex, age at CHD manifestation, baseline LDL-C and HDL-C concentrations, and statin administration. When both Lp(a) concentration and apo(a) phenotype were simultaneously included in the model as independent variables, only the LMW apo(a) phenotype increased the risk of non-fatal MI: HR = 2.31; 1.06 to 5.00, p = 0.03. The LMW apo(a) phenotype  level and LMW apo(a) phenotype showed that the presence of the LMW apo(a) phenotype, even at Lp(a) concentrations below 30 mg/dL, predicts the risk of non-fatal MI but not cardiac events .The concentration of the circulating PCSK9-Lp(a) complex was significantly higher in patients with the LMW apo(a) phenotype than in patients with the HMW apo(a) phenotype, while the difference between the groups in terms of PCSK9 levels was not significant .r = 0.48, p = 0.0007) and in patients with the LMW apo(a) phenotype  but not the HMW apo(a) phenotype .Correlation analysis revealed the relationship between the concentration of Lp(a) and PCSK9 in the whole group (p = 0.03) only in patients with the LMW apo(a) phenotype. PCSK9 levels above the median were associated with an increased odds ratio of cardiovascular events  only in patients with the LMW apo(a) phenotype. According to logistic regression analysis, an increase in PCSK9 concentration by 1 pg/mL was associated with an increase in the odds ratio of events by 1% .In the whole cohort, we did not find a significant association between the concentration of PCSK9 or its circulating complex PCSK9-Lp(a) and risk of MI during the observation period. However, in the presence of a PCSK9-Lp(a) complex level above the median (91.8 lab units), MI occurred on average 17 years earlier in the LMW apo(a) phenotype patients compared to patients with the HMW apo(a) phenotype: 229 ± 36 months vs. 439 ± 50 months, respectively, p = 0.08 . In patiCHD and subsequent cardiovascular events in subjects under the age of 55 years represent a serious medical and social problem ,23. The 2) generates > 40 isoforms of the apolipoprotein(a) protein and determines the median concentrations of Lp(a). In the population, LMW apo(a) isoforms are associated with approximately higher average Lp(a) concentrations than HMW apo(a) isoforms [Lp(a) is one of the most important genetically determined risk factors for the development of ASCVDs ,30,31. Tisoforms ,33. For the first time, it was shown in a long-term prospective observational study that the LMW apo(a) phenotype is the most important risk factor for the development of MI in patients with early-onset CHD. In contrast, for other cardiovascular events, elevated an Lp(a) level was more significant. We have also shown for the first time a possible association between apo(a) phenotype, PCSK9-Lp(a) complex levels, and adverse CHD course. This may be due to the greater “pro-inflammatory” activity of Lp(a) with the LMW apo(a) phenotype and due to the presence of both OxPL and PCSK9 in the Lp(a) particles.p < 0.001) [We observed that Lp(a) concentrations ≥ 50 mg/dL increased the risk of cardiovascular events by 67% in patients with premature CHD (up to 55 in men and 60 in women). Our study considers a long observation period from the point of CHD manifestation. The Lp(a) level in these patients was significantly higher  than in patients without stenosing atherosclerosis (12 [1 mg/dL) < 0.001) ,34, and < 0.001) . The Men< 0.001) ,36. We have shown that, in patients with early CHD manifestation, elevated levels of Lp(a), but not LMW apo(a) phenotype, increased the risk of cardiovascular events during long-term follow-up despite ongoing statin therapy and correction of modifiable risk factors. In support of this observation, the risk of recurrent events associated with elevated Lp(a) levels was the highest in 2527 young CHD subjects from the Copenhagen General Population Study. This may be explained by the absence in young subjects of some risk factors that accumulate with age and mask a causal relationship with Lp(a) .Exposure to such risk factors as hypertension, hyperglycemia, and smoking leads to the activation of vascular smooth muscle and endothelial cells, predominantly in areas of impaired laminar blood flow. The sequential increase and activation of adhesion molecules, in particular, ICAM-1, -2; VCAM-1; and E- and P-selectins on endothelial surface, leads to attraction and infiltration of immune cells, mainly monocytes, into the intimal layer, promoting low specific inflammation in the vascular wall ,38. ExprAn Lp(a) concentration more than 20 mg/dL was associated with increasing risk of heart failure due to MI in the Copenhagen City Heart Study and the Copenhagen General Population Study . AccordiThe potential role of Lp(a) as an activator of immune system cells is actively debated . In partIn vitro experiments showed that apo(a) was able to increase the production of reactive oxygen species and MMP-9 by monocytes stimulated by type I collagen. The degree of stimulation was inversely proportional to the molecular weight of apo(a) and was maximal when stimulated with the LMW apo(a) phenotype . According to a number of studies, Lp(a) is the carrier of a major part of the total pool of OxPL . Such oxThe presence of apo(a) in atherosclerotic vascular lesions from the lipid band to plaque rupture, as well as its presence in the macrophage-enriched area, has been demonstrated in morphological and immunohistochemical studies ,61. PrevIn our study, we confirmed our earlier observation  that theThere is no doubt that an increased concentration of Lp(a) is a genetic risk factor for ASCVDs. According to the recent EAS Consensus statement, the concentration of Lp(a) should be determined at least once in a lifetime to assess the risk of cardiovascular diseases . CascadeThe limitation of our study was the small number of patients that necessitates further investigation. The lack of initial data on the concentration of PCSK9 and Lp(a)-PCSK9 complex does not allow us to conclude that there is a direct relationship between these parameters and the development of MI or cardiovascular events.We showed that the LMW apo(a) phenotype is a risk factor for non-fatal MI in a long-term prospective follow-up of patients with premature CHD. The presence of the LMW apo(a) phenotype determines the correlation of Lp(a) and PCSK9 concentrations and a higher level of circulating complex PCSK9-Lp(a). Furthermore, only in patients with the LMW apo(a) phenotype was an elevated PCSK9 concentration associated with cardiovascular events after CHD manifestation.


To determine the birth prevalence, trend, and characteristics of external structural birth defects occurrence in Enugu Metropolis, Nigeria.Cross-sectional study involving review of delivery records.The study was conducted at three tertiary hospitals, one public and two missionary, in Enugu Metropolis.Mothers and their babies delivered between 1 January 2009 and 31 December 2016 in the study facilities.Birth prevalence of defects presented as frequency/10,000 births. Other descriptive variables are presented as frequencies and percentages.There were 21530 births with 133 birth defects  and 1176 stillbirths (stillbirth rate: 54.6/1000 births). The frequencies and birth prevalence  of recorded defects were: Limb deformities 60(27.9), Neural tube defects (NTDs): 36(16.7), Urogenital system defects: 12(5.6), Gastrointestinal system defects 10(4.6) and Orofacial clefts 4(1.9). Birth defects occurrence showed a rising trend from 2009 to 2016. The mean (SD) age of mothers whose babies had Birth defects was 29.1(4.7) years. Only 62(46.6%) of 133 antenatal clinic folders of these women were traceable for further review. Eighteen (29.0%) had febrile illness in early pregnancy, 9(14.5%) had Malaria, 17(27.4%) had <4 antenatal clinic attendance, 7(11.3%) did not take folic acid and 6(9.7%) took herbal medications during pregnancy.Birth defects occurrence showed a rising trend with limb deformities and NTDs having the highest prevalence. Record keeping was poor at the facilities. Birth defects preventive interventions like folic acid supplementation for women-of-childbearing age should be promoted in Enugu Metropolis.This work was supported by the non-communicable disease Minigrant from the Task Force for Global Health, Decatur, Georgia, USA (TPN-FE-NCD-C2-IFO-9). Birth defects are important public health problems which contribute significantly to infant and childhood disability and deaths.1Although birth defect is a global problem, its impact is particularly severe in low- and middle-income countries (LMICs). Over 94 per cent of births with serious defects and 95 per cent of deaths in affected children occur in LIMCs due to high fertility rates and high prevalence of birth defects.2Robust surveillance systems are necessary for effective planning, evaluation and control of birth defects. Unfortunately, national surveillance of birth defects remains limited worldwide.4In an effort to promote global birth defects surveillance, the World Health Assembly in 2010 issued a resolution urging member states to develop and strengthen registration and surveillance systems for birth defects.Studies from different sub-Saharan African countries have reported birth prevalence of congenital defects varying from 0.4 to 28.1 cases per 1000 births.The study was conducted in three tertiary healthcare facilities  located in Enugu Metropolis, the capital city of Enugu State in Southeast geopolitical zone of Nigeria. Enugu state has 17 local government areas (LGAs); five urban and twelve rural. Three urban LGAs  make up Enugu Metropolis. The year 2020 projected population of Enugu Metropolis is 779,879 with women of childbearing age constituting 20% of this population.23The government-owned teaching hospital and one of the missionary hospitals are in Enugu North LGA while the other missionary hospital is in Enugu south LGA. These three facilities, among other services, offer specialist medical, surgical, emergency, delivery, paediatric and immunisation services. They receive referrals from other lower cadre healthcare facilities in the state. The labour wards in these facilities maintain surveillance data on birth defects occurrence unlike most of the lower cadre hospitals. Two of the selected facilities have high delivery rates (each has an average of 150 deliveries per month) while one of the missionary hospitals have an average of 60 deliveries per month. There is neither surveillance system nor registry for birth defects in Enugu State.We conducted a cross-sectional study involving review of labour ward delivery registers for all deliveries conducted in three study facilities over an eight-year period . For infants identified to have external structural birth defect(s), the mothers' clinic folders were traced and reviewed for more information.A whole population study was conducted in three specialist healthcare facilities in Enugu Metropolis purposively selected because they were the only facilities in the metropolis that capture data on the occurrence of birth defects in their delivery registers. The records of all deliveries conducted in these selected facilities from 2009 – 2016 were reviewed.The selected facilities keep hard copy delivery registers which contain the following information: patient name, age, folder number, address, booking status, date and time of delivery, mode of delivery , parity, live or stillbirth, baby's sex, birth weight, Apgar score and description of birth defects if any.These facilities also have antenatal/ postnatal clinic folders in which detailed patient information were captured. The extent of information captured in these folders varies within and between healthcare facilities .Case ascertainment was from diagnosis and verbatim case description documented by unit specialist doctors and nurses with or without archived pictures.The researcher and four trained research assistants used a pre-tested aggregate data abstraction sheet (S1) and proforma (S2) adapted from the WHO/CDC/ICDBSR Birth Defects Surveillance Manual and other similar studiesData were entered and analysed with Microsoft Excel spreadsheet and Epi Info version 7.1. The occurrence of birth defects was summarised as frequencies, percentages and birth prevalence (incidence) computed thus:Birth prevalence of birth defects =  x 10,000The trend of birth defects occurrence over eight years was illustrated with a line graph and the characteristics of babies and the mothers of babies with birth defects were described and summarised with frequencies and percentages.Ethical approval was obtained from the Human Research Ethics Committee of Enugu State Ministry of Health (reference: CON/MHPHD/1772/84). Informed consent was not sought for this study because it involved retrospective review of anonymised surveillance data, however consent to review treatment records was obtained from the hospital authorities and all retrieved data were de-identified.External structural birth defect(s) are anatomical congenital defects identifiable by health workers by observation or through physical examination of neonate as routinely carried out immediately after delivery without necessarily conducting diagnostic investigations.During the 8 years review period, 21,530 births were recorded in the three study facilities with 133 birth defects  and 1176 stillbirths, giving a stillbirth rate of 54.6/1000 births. Ninety-eight (73.7%) of the babies with defects were born in the state teaching hospital out of the 11,155 (51.8%) deliveries that took place there. The mean ±SD birth weight of babies with defects was 3.1 ±1.1 kg, the median (IQR) gestational age at birth was 38.0  completed weeks and majority 78 (58.7%) of these babies were males. The mean ±SD age of mothers whose babies had birth defects was 29.1 ±4.7 years and majority 129 (97.7%) of them were of the Igbo ethnic group. Limb deformities had the highest birth prevalence of 27.9/10,000 births, followed by neural tube defects (NTDs) with a prevalence of 16.7/10,000 births. Among the NTDs, Anencephaly had the highest prevalence of 6.5/10,000 births while Polydactyly had the highest prevalence  among the limb deformities.The prevalence of Urogenital system defects was 5.6/10,000 births while that of Gastrointestinal defects and Orofacial clefts were 4.6 and 1.9/ 10,000 births respectively. Six babies  had Down syndrome while four had unclassified birth defects. The overall trend of annual birth defects prevalence in the state was that of a slow but progressive rise, with undulating birth prevalence between 2009 and 2016. Two peaks  occurred in 2010 and 2015 respectively, with a significant dip  in 2013. Only 62 out of the 133 folders of mothers of babies with birth defects were traceable for further analysis. Eighteen (29.0%) of these mothers had fever in the first trimester, half of which were confirmed to be due to Malaria, 17 (27.4%) did not attend antenatal clinic up to four times before delivery and 7(11.3%) did not take folic acid during the index pregnancy. Six (9.7%) women took herbal medications while 9 (15.5%) took alcohol during the index pregnancy. This study determined the birth prevalence and characterised the occurrence of external structural birth defects among babies delivered selected private and government-owned healthcare facilities in Enugu metropolis from 2009 to 2016. The overall birth prevalence of external structural birth defects was 61.8/10000 births.The prevalence in the two private (missionary) hospitals (28.2 and 34.4 cases /10000 births) were much lower than the prevalence in the government-owned teaching hospital (87.9/10000). The higher prevalence observed in the teaching hospital could be because it receives most referrals of high-risk pregnancies from the lower-level primary healthcare facilities and maternity homes in the state. Moreover, the cost of maternal and child health services in the teaching hospital is subsidised by the government, thereby attracting more pregnant women in the low-income group whose living conditions might increase their likelihood of exposure to teratogenic substances. Indeed, low-income have been shown to be an indirect determinant of congenital defects.In our study, limb deformities had the highest prevalence followed by neural tube defects (NTDs). Polydactyly, a minor limb deformity, was the single most frequent birth defect while anencephaly was the most common neural tube defect. The high prevalence of NTDs found in our study is disturbing because this group of defects are largely preventable through pre-natal screening, pre-conception and pre-natal folate supplementation in women of childbearing age.31Similar to the finding in our study, some studies assessing the prevalence of birth defects in different parts of Nigeria and other sub-Saharan African countries have reported anomalies of the musculoskeletal system Anencephaly was the most common NTD in our study, followed by hydrocephalus and spina bifida. Sadly, almost half of the babies in the NTDs group had Anencephaly, a condition with an estimated mortality of 100%, thus increasing the perinatal and neonatal mortality rates in this area. Likewise, a cross-sectional study involving review of one-year delivery records in a teaching hospital in Accra Ghana, reported Anencephaly to have the highest prevalence (8.4/10000 births) followed by spina bifida.Moreover, orofacial clefts had a prevalence of 1.9 cases per 10000 births in our study. Babies with orofacial clefts usually have problems with feeding, speaking or hearing.This study further revealed a rising trend of birth defects in the metropolis, with a sharp increase noticed from 2013 (22.2/10000 births) to 2015 (90.1/10000 births) with only a small decrease (73.3/10000) in 2016. The rising birth prevalence of defects could be a pointer to increasing levels of potentially harmful exposures among women of childbearing age in our environment. About 15% of women whose babies had birth defects in our study reported taking alcohol during the index pregnancy, while 10% reported taking herbal concoctions. Raising awareness about birth defects and the need to minimise exposure to avoidable risk factors among adolescent girls and women of childbearing age is important in our environment.There was male preponderance (M: F ratio of 1.6:1) among babies with birth defects in our study. Several studies Our study, being hospital-based, may have under-ascertained the occurrence of birth defects in our environment compared to population-based studies which give better estimates. Furthermore, data completeness was a challenge in this study as about half of the antenatal clinic folders of mothers whose babies had birth defects could not be found for analysis. Moreover, information captured in maternal folders and delivery registers varied across facilities as there was no uniform surveillance tool available in the state. The above limitations notwithstanding, this study happens to be the first to assess the occurrence of birth defects in private healthcare facilities where most pregnant women in the state are known to give birth.The overall birth prevalence of external structural birth defects in Enugu Metropolis was 61.8 cases per 10000 births; with higher rates in the government-owned tertiary hospital compared to the missionary hospitals. Musculoskeletal and Neural tube defects (NTD) had the highest birth prevalence with anencephaly being the most common NTD. Majority of babies with birth defects had normal birth weight while one-in-four of such babies were stillborn. Record keeping was poor at the facilities and some of the mothers whose babies had birth defects were exposed to potential risk factors during pregnancy. We recommend establishment of birth defects surveillance system and population-based registries to enable more robust estimation of the prevalence of birth defects in the state. Birth defects preventive measures including folic acid supplementation among women of childbearing age should also be promoted in the state.


In recent years, cocoa and dark chocolate have attracted the interest of consumers not only for their sensory characteristics but also for their nutritional properties and positive impact on health. The baobab is a fruit of African origin with a sour and slightly sweet flavour, widely consumed by local communities due to its unique nutritional features. The aim of this work was to evaluate the impact of the concentration of baobab flour in the development of functional dark chocolate, including physical, chemical, nutritional and sensory evaluations. The results presented a positive correlation between the incorporation of baobab flour and the antioxidant activity (up to 2297 mmol TE/100 g), vitamin C content (up to 49.7 mg/100 g), calcium (up to 1052 mg/kg), potassium , phosphorus (up to 795.9 mg/kg), chlorine (up to 235.4 mg/kg) and sulphur (up to 1158 mg/kg). The sensory evaluation of dark chocolate with 3% baobab presented the highest evaluation on the parameters “texture” and “overall flavour”, while the parameter “overall flavour” presented the lowest evaluation on chocolate with 9% baobab. No influence was observed on fatty acid profile, protein, fat and hardness. The use of cocoa, in food or as a ritual element, is referenced among the native populations of Central America since 1800 BC . In factNowadays, chocolate is a widely distributed food in its pure form, or used in the production of a spectrum of other foods, with great consumer acceptance . Some avMany authors already consider chocolate as a functional food , i.e., aFunctional foods and novel foods are increasingly a trend of choice among consumers . They foAdansonia digitata L.) is part of the Malvaceae family, mostly found in sub-Saharan Africa [The African baobab ) by mixing and homogenizing the baobab in the tempered dark chocolate. Commercially branded baobab of Senegalese origin  was used. A control batch was also included, i.e., dark chocolate without baobab pulp flour. Each batch was distributed in polycarbonate moulds (with 15 cavities of 7 g), followed by cooling and solidification in a refrigerator  at 6 °C for 15 min. After, samples were unmoulded, packed in oriented polypropylene (OPP) film and stored at 20 °C for 20 days. The chocolate samples were prepared at Sugar Bloom/Mestre Cacau facilities .The production of chocolate samples was started by melting dark chocolate 51%  overnight in a tempering machine  at 43 °C. Then, dark chocolate was tempered, decreasing temperature to 29.5 °C under constant agitation. Then, three batches of chocolate were prepared in which baobab pulp flour was incorporated in different concentrations  in a Soxhlet extractor . After extraction, the solvent was evaporated in a rotary evaporator with a water bath at 40 °C . Then, the fat was placed inside an oven  at 85 °C for 1 h, cooled and weighed. Samples were evaluated in duplicate and expressed as a mass percentage according to previous studies on baobab samples by Azzatul et al. .After fat determination, triglycerides contained in the extracts were converted in methyl esters following the transesterification method described in ISO 5509:2000. To 0.1 g of fat 4 mL of isooctane was added and stirred to dissolve the sample. Then, 2 mL of potassium hydroxide solution in methanol  was addeThe elemental determination of chocolate samples, expressed in mg/kg, was performed in triplicate by using an X-ray analyser  as described in ,30. Deteg; 4 °C; 20 min; Sigma, 2K15, Osterode am Harz, Germany). Supernatants were filtered with Whatman 41 filter paper and stored at −20 °C for further analysis. Total phenolic content in the methanolic extract was determined by spectrophotometry at 725 nm, based on published literature [Methanolic extracts of the chocolates for determination of TPC were prepared based on the protocol described by Cerit et al. . About 1terature ,33,34,35Antioxidant Activity was determined in the methanolic extracts of the samples using the DPPH reagent  by spectrophotometry at 580 nm, based on Brand-Williams et al. . A calibw/v) and trisodium phosphate solution (20% w/v). Samples for extraction of vitamin C were weighed according to the percentage of added baobab to the chocolate, namely 6 g (for 6% and 9% of added baobab (w/w)), 8 g (for 3% of added baobab) and 10 g (for control without baobab). Extractions were performed in triplicate and results were expressed as mg of ascorbic acid/100 g of sample.Vitamin C content was determined by high-performance liquid chromatography, HPLC, based on Monteiro et al.  after exTexture determination was performed using a texture analyser  with 100 N load cell at 20 ± 1 °C. A 3 mm diameter aluminium cylindrical probe was used at a penetration depth of 5 mm and a test speed of 1.0 mm/s. Texture parameter hardness (maximum force in N) was calculated. Samples were evaluated ten times.L* for brightness and a* and b*, which define the colour between red-green and blue-yellow, respectively. The parameter whiteness index (WI) was calculated according to Equation (1) [Colour evaluation, using 10 replicates, was performed instrumentally using a Minolta CR-300R colorimeter , with reference to the CIE-LAB coordinate system: tion (1) :(1)WI=10The characterization of the sensory profile of the samples was based on the quantitative descriptive analysis described by Belščak-Cvitanović et al.  with somThe statistical analysis of the data referring to the multiple comparisons of the constituents’ means across the different baobab concentration groups  was performed using the statistical software R, version 4.1.2 .In order to assess the pairwise differences in the means of the several constituents across the different concentration groups, the following statistical tests were performed:Because statistical tests usually rely on data population assumptions, these should ideally be assessed prior to the comparative analysis. In this way, for testing the hypotheses in Equations (2) and (3): (i) the F-ANOVA plus the Tukey tests, respectively, should be used in the case of data normality within concentration groups and variance homogeneity across concentration groups ; (ii) thPrincipal component analysis (PCA) allows a dimension reduction of a large dataset of variables and establishes a correlation between samples and the variables under analysis. Principal component analysis was performed to search for possible correlation between samples and the difference that the addition of baobab flour induces in the samples produced and to understand how the variables in analyses induce this difference. For such analysis software STATISTICA 8.0  was used.The F-ANOVA test (used to test the hypotheses in Equation (2)) identified 13 constituents as having at least one significant difference between the group means. For these constituents, Tukey’s test (used to test the hypotheses in Equation (3)) identified differences between at least two groups in 12 out of the 13 constituents. In particular, constituent TPC, which was declared as having at least one significant difference in group means in Equation (2), was not declared significant in Equation (3), a fact that can be related to the lack of power of Tukey’s test for small samples. One should also acknowledge the possibility of the presence of some atypical data points (outliers) having a deleterious effect on the power of both the F-ANOVA and Tukey’s tests in detecting significant differences across concentration groups. Indeed, it takes just one outlier to spoil the sample average and standard deviation. Plus, the smaller the sample, which is the case here, the greater the effect of an outlier in the subsequent statistical analysis.In all the tables presented throughout this section, only the constituents declared significant while testing Equation (2) re assigned with superscript letters a, b and c, which refer to the results of Tukey’s test   and 2297 mmol TE/100 g (9% baobab). In fact, the available literature refers to the high AA values of baobab pulp flour when compared with other fruits such as oranges or strawberries , mainly The vitamin C content ranged from a value below the limit of quantification in the control sample to 49.7 mg ascorbic acid/100 g (9% baobab), proportional to the incorporation of baobab flour in dark chocolate, a consequence of the high levels of vitamin C in baobab flour , about 3a* and b* presented an influence due to the incorporation of baobab: colour parameter a* increased from 5.3 (control) to 6.4 (6% baobab), increasing the intensity of red colour, while parameter b increased from 5.5 (control) to 6.3 (6% baobab), increasing the intensity of yellow colour. Despite the differences between the control and samples with baobab, colour parameters were not affected, which agrees with previous results on chocolate [a* and b* parameters was also observed on surface colour, resulting in a higher intensity of red and yellow. Parameter WI, calculated from lab values, varied between 27.1 (6% baobab) and 27.5 (9% baobab), with no significant differences at a 0.05 significance level. The observed values, similar to previous works with plain dark chocolate [The hardness values were not influenced by the different percentages of baobab pulp flour, with levels similar to previous results on plain dark chocolate ,61 and dhocolate ,71, wherhocolate ,68,72, da*, b*, AA, moisture, ash and vitamin C. However, the hardness, L*, WI, fat and protein showed no significant differences.The results show significant differences between the samples with different percentages of baobab in relation to the parameters The fat content  was not cis 11), higher in samples with 6% and 9% baobab  presented the highest mineral content, ranging from 8058 mg/kg (control) to 10175 mg/kg (9% baobab), higher than reported values for plain dark chocolate . PotassiPrincipal component analysis (PCA) was carried out  in orderThe similarity map defined by the first two principal components accounted for 88.8% of the total variance. The first component (PC1) condensed 75.1% and the second component (PC2) represented 13.7% of the total variance. The first component was correlated negatively with AA, TPC, ash, vitamin C and minerals  and positively with fat. The second component was correlated only with mineral P. Here is a clear separation between the control and the samples produced according to the percentage of incorporation of the baobab pulp flour in the chocolate.The incorporation of baobab in chocolate decreases the correlation of the samples produced with the fat variable, evidenced by the tendency of negative correlation in PC1, and proves the decrease in fat in the samples.There is a strong correlation between K, vitamin C, AA, Ca, ash and TPC that, due to its projection in PC1, shows the correlation between this set of variables and the incorporation of baobab in chocolate.With the principal component analysis it was possible to perform the integration of results from different variables and it was possible to highlight the following findings:The correlation between the incorporation of baobab and the variables with relevance to the evaluation of the functional capacity of the baobab, namely K, vitamin C, AA, Ca and TPC, is clear; the increase in incorporated baobab turns dark chocolate into a potential functional food with the ability to suppress specific nutritional needs.The sensory analysis of sample chocolates was performed through a hedonic evaluation comparing chocolates with different baobab concentrations and a control sample. The results are shown in a* and b* , higher in 6% and 9% baobab. Principal component analysis supports the cause–effect relationship between the incorporation of bobab in chocolate and the variables of interest in functional foods, especially P, Ca, vitamin C, AA and TPC. Finally, the sensory evaluation presented similar results on the parameters “odour” and “acidic taste”. Chocolate with 3% baobab presented higher classifications on the parameters “texture” and “overall flavour”, while chocolate with 9% baobab presented the lowest classification on “overall flavour”.The baobab fruit is widely used by local communities in Africa, mostly as a foodstuff due to its high nutritional value; however, applications outside Africa are still scarce. An increase in the antioxidant activity and vitamin C of chocolates with the incorporation of baobab flour, especially at a concentration of 9%, was observed. The incorporation of baobab flour triggers the possibility of nutritional enhancement compared with conventional dark chocolates, namely in Ca and K. On the other hand, the fatty acid profile was not affected; the consequence of the reduced lipid content of baobab flour is insufficient to promote changes in the final product. The only exception was C20:1 (In conclusion, the use of baobab flour could be a valid option in the development of new chocolate products, combining the beneficial characteristics of these two ingredients.


Objectives: This study aims to elucidate the influence of race, ethnicity, and nativity on macrosomia rates, hypothesizing that higher rates are observed among White non-Latina mothers and United States (US)-born mothers.Study Design: We analyzed data from 1,791,718 US births sourced from the National Center for Health Statistics of the Centers for Disease Control and Prevention. Logistic regression analyses were conducted to examine the associations between macrosomia rates and maternal race, ethnicity, and nativity.Results: After excluding non-singleton, preterm, post-term births, and those with missing data, six maternal cohorts were identified: White non-Latina US-born  and foreign-born , Black non-Latina US-born  and foreign-born , and Latina US-born  and foreign-born . White non-Latina US-born mothers had the highest rates of excessive gestational weight gain (58.9%). Black non-Latina US-born mothers exhibited the highest rates of pre-pregnancy diabetes (0.7%) and obesity (29.5%). Macrosomia rates were highest among White non-Latina US-born mothers (10.7%) compared to other cohorts. After adjusting for socioeconomic and health-related factors, this group maintained the highest odds of macrosomia .Conclusion: Our findings reveal that White non-Latina US-born mothers experience the highest macrosomia rates, which persist after adjusting for known confounders. These results have significant implications for the development of gestational surveillance tools and targeted public health interventions aimed at improving pregnancy outcomes among high-risk cohorts. Fetal macrosomia is defined as a birth weight greater than 4000g or greater than the 90th percentile for gestational age ,2. AccorThe mechanism of fetal overgrowth involves the transplacental passage of glucose and subsequent stimulation of insulin secretion by the fetal pancreas. The combination of hyperglycemia and hyperinsulinemia produces an increase in fetal protein and fat stores, resulting in macrosomia ,9. It haOther factors that influence macrosomia risk include older maternal age, male gender of infant, post-term pregnancy, and a previous macrosomic infant ,6,15-17.This study evaluated the hypotheses that the incidence of macrosomia is higher among (a) White mothers compared to other races, (b) non-Latina mothers compared to Latina mothers, and (c) mothers born in the US compared to mothers born outside of the US. The primary objective was to calculate the incidence of macrosomia among cohorts of mothers stratified by race, ethnicity, and nativity, while the secondary objective was to calculate the odds ratios (ORs) for developing macrosomia in these different groups after adjusting for known clinical risk factors.Data and study populationNatality data for 11,862,780 live births among infants born in the US between 2011 and 2013 were obtained from the National Center for Health Statistics (NCHS) of the CDC. The de-identified data were accessed in accordance with CDC data use agreements through a special request process. As the provided dataset did not include patient identifiers, this study received Institutional Review Board (IRB) exemption.The extracted data encompassed various factors, such as birth weight, sex of the infant, gestational age at birth, and maternal characteristics including age, race, ethnicity, nativity, and socioeconomic factors . Exclusions were applied to non-singleton births, singleton preterm births, births with unstated gestational age, and births from the 14 US states that either did not collect data for one or more study variables or collected data in a non-standard format. The following US states were excluded from the study due to missing data: Alabama, Arkansas, Alaska, Arizona, Connecticut, Hawaii, Maine, New Jersey, Rhode Island, West Virginia, Michigan, Mississippi, Georgia, and Virginia. Infants with missing nativity data or mothers with any self-identified race other than Black or White  were excluded, as there are currently insufficient birth and census data on these populations, some of which comprise significantly smaller portions of the US population. Additionally, singleton term births of Black and White mothers with any of the following criteria were excluded: a gestational age >42 weeks; a gestational age ≤42 weeks and a total birth order >1; a gestational age ≤42 weeks, a total birth order >1, and a birth weight <3000g; or a gestational age ≤42 weeks, a total birth order >1, and a birth weight <3000g where maternal race was imputed using statistical methods . To enable comparison with the current literature and due to insufficient birth and census data among certain racial populations, data analysis was limited to mothers who self-identified as Black or White, as recorded on the infant's birth certificate. Regarding ethnicity identification , infants of Latina US-born and Latina foreign-born mothers were not further stratified by race  to maintain consistency and comparability with similar studies utilizing natality data. Maternal nativity variables were foreign-born and US-born, with the latter defined as birth within any of the 50 states (including New York City and the District of Columbia).The independent (or "group") variable of interest for analysis was derived from mothers representing six different cohorts of maternal race, ethnicity, and nativity: White US- and foreign-born non-Latina individuals, Black US- and foreign-born non-Latina individuals, and Latina US-born and Latina foreign-born.Other independent variables included marital status, paternal acknowledgment, and maternal characteristics such as age , education (<12 years or ≥12 years), gestational weight gain , gestational age (37-40 weeks or >40 weeks), and obesity (yes (BMI≥30) or no (BMI≤30)) . The timOnly 857 (0.05%) births had missing data for birth weight. Among the 14 risk factors studied, the two variables with the highest percentages of missing values were gestational weight gain (4.43%) and obesity (3.03%), while the variables of race, nativity, maternal age, marital status, sex of infant, and gestational age had no missing values  and the incidence of fetal macrosomia was analyzed using chi-square (χ²) tests. We investigated the association between each group  and fetal macrosomia using four different logistic regression models in which Black non-Latina US-born mothers served as the reference group. Model 1 was a crude analysis that included only the "group" variable (unadjusted model), while Model 2 adjusted for the effects of measured demographic and medical risk factors for fetal macrosomia . Model 3 added major socioeconomic risk factors for fetal macrosomia  to Model 2. Model 4 adjusted for all factors in Model 3 and for prenatal care initiation, medical disease during pregnancy, sex of infant, and gestational age. Finally, Model 5 adjusted for maternal smoking status. All data processing/preparation and statistical analyses were conducted using SAS version 9.4 .Study population and data availabilityAfter applying numerous exclusion criteria detailed in Figure The 1,791,718 mothers analyzed in this study were categorized into six groups based on race, ethnicity, and nativity: White non-Latina US- and foreign-born mothers , Black non-Latina US- and foreign-born mothers , and Latina US-born and Latina foreign-born mothers .Risk factors for fetal macrosomiaTable Incidence of fetal macrosomiaWhen stratified by ethnicity and nativity, the incidence of fetal macrosomia was 10% for US-born non-Latina mothers and 9.27% for foreign-born non-Latina mothers. There was no significant difference in fetal macrosomia rates between US-born and foreign-born Latina mothers  , regardless of the model used in the analysis Table . For eacEven after adjustment, Latina US-born and White non-Latina US-born mothers had 41%  and 88%  higher odds, respectively, of delivering a macrosomic infant than Black non-Latina US-born mothers. In the unadjusted model (Model 1), White non-Latina foreign-born mothers had 78% higher odds of having a macrosomic baby than Black non-Latina US-born mothers , and these odds remained nearly unchanged after adjustment for demographic, medical and socioeconomic risk factors ORs . In all models, White non-Latina US-born mothers had higher odds of delivering a macrosomic infant than Black non-Latina US-born mothers   . Their rOur findings on the relationship between ethnicity and macrosomia were similarly striking. Ethnicity is known to influence BMI and gestational weight gain and thus neonatal birth weights; there is some evidence to suggest that maternal ethnicity impacts infant birth weight in a manner that cannot solely be explained by differences in maternal weight or underlying health conditions ,28. In oThere are numerous possible explanations for why race and ethnicity appear to have an independent impact on macrosomia rates. Genetic differences, including single nucleotide polymorphisms (SNPs) associated with birth weight  have been implicated in macrosomia risk . These SThe higher odds of macrosomia among US-born mothers compared to foreign-born mothers in our study may be explained by a corresponding finding of a higher prevalence of advanced maternal age and decreased utilization of supplementary nutritional services among the cohort of women born outside the United States. Additionally, foreign-born mothers have been commonly identified as being at increased risk of receiving diminished access to optimal prenatal care after reaching their country of destination - in part due to lack of health insurance, language barriers, lower socioeconomic class, or undocumented or refugee status -38. ReduClinical and research implicationsAfter adjusting for all significant, established socioeconomic and clinical risk factors for developing fetal macrosomia, White non-Latina US-born mothers had the highest odds of delivering a macrosomic infant while Black non-Latina US-born mothers had the lowest risk of delivering a macrosomic infant. These findings highlight independent racial and ethnic influences over macrosomia risk which potentially refute the traditional understanding of macrosomia as a predominantly diabetes- and obesity-driven disease. Our findings have significant implications for the development of gestational surveillance tools as well as targeted public health interventions, protocols, or policies to improve pregnancy outcomes among particularly high-risk racial, ethnic, and nativity cohorts. Based on the findings of our study, these particularly high-risk cohorts should be more frequently assessed through prenatal ultrasounds, employing sonographic measurements of fetal head circumference , abdominFurther study is required to elucidate the relationship between macrosomia risk and race, ethnicity, and nativity, specifically how these variables influence macrosomia risk both with and without respect to previously established contributing variables such as pre-pregnancy weight, gestational weight gain, and diabetes. Moreover, longitudinal studies are needed to evaluate macrosomia-related sequelae  among populations of different races or ethnicity. Furthermore, intergenerational studies should be initiated to evaluate the risk for macrosomia among subsequent generations of these different cohorts. Strengths and limitationsThe predominant strength of our study lies in its utilization of a large dataset of maternal demographics and fetal characteristics associated with 1,791,718 births. This robust dataset allows for multi-variable analysis of fetal macrosomia, providing a means to assess the correlation of large fetal birth weight with race and ethnicity as well as the novel variable of maternal nativity.The limitations of our current study are similar to the limitations in our previous study investigating the influence of race, ethnicity, and nativity on LBW outcomes . PrimariOur study investigated the association between race, ethnicity, and nativity as independent risk factors for macrosomia in US maternal populations. Our major findings revealed that these factors significantly contribute to macrosomia risk, with White non-Latina US-born mothers experiencing the highest odds of delivering a macrosomic infant. This research adds valuable insight to the limited existing literature on this topic, as national and global rates of macrosomia continue to rise.