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Our multidisciplinary team examined published regulatory data to inform a 50-state database describing the environment for midwifery practice and interprofessional collaboration. Items (110) detailed differences across jurisdictions in scope of practice, autonomy, governance, and prescriptive authority; as well as restrictions that can affect patient safety, quality, and access to maternity providers across birth settings. A nationwide survey of state regulatory experts (n = 92) verified the 'on the ground' relevance, importance, and realities of local interpretation of these state laws. Using a modified Delphi process, we selected 50/110 key items to include in a weighted, composite Midwifery Integration Scoring (MISS) system. Higher scores indicate greater integration of midwives across all settings. We ranked states by MISS scores; and, using reliable indicators in the CDC-Vital Statistics Database, we calculated correlation coefficients between MISS scores and maternal-newborn outcomes by state, as well as state density of midwives and place of birth. We conducted hierarchical linear regression analysis to control for confounding effects of race. MISS scores ranged from lowest at 17 (North Carolina) to highest at 61 (Washington), out of 100 points. Higher MISS scores were associated with significantly higher rates of spontaneous vaginal delivery, vaginal birth after cesarean, and breastfeeding, and significantly lower rates of cesarean, preterm birth, low birth weight infants, and neonatal death. MISS scores also correlated with density of midwives and access to care across birth settings. Significant differences in newborn outcomes accounted for by MISS scores persisted after controlling for proportion of African American births in each state. The MISS scoring system assesses the level of integration of midwives and evaluates regional access to high quality maternity care. In the United States, higher MISS Scores were associated with significantly higher rates of physiologic birth, less obstetric interventions, and fewer adverse neonatal outcomes.

The transition zone (TZ) of primary cilia serves as a diffusion barrier to regulate ciliogenesis and receptor localization for key signaling events such as sonic hedgehog signaling. Its gating mechanism is poorly understood due to the tiny volume accommodating a large number of ciliopathy-associated molecules. Here we performed stimulated emission depletion (STED) imaging of collective samples and recreated superresolved relative localizations of eight representative species of ciliary proteins using position averages and overlapped with representative electron microscopy (EM) images, defining an architectural foundation at the ciliary base. Upon this framework, transmembrane proteins TMEM67 and TCTN2 were accumulated at the same axial level as MKS1 and RPGRIP1L, suggesting that their regulation roles for tissue-specific ciliogenesis occur at a specific level of the TZ. CEP290 is surprisingly localized at a different axial level bridging the basal body (BB) and other TZ proteins. Upon this molecular architecture, two reservoirs of intraflagellar transport (IFT) particles, correlating with phases of ciliary growth, are present: one colocalized with the transition fibers (TFs) while the other situated beyond the distal edge of the TZ. Together, our results reveal an unprecedented structural framework of the TZ, facilitating our understanding in molecular screening and assembly at the ciliary base.

The classical M1/M2 polarity of macrophages may not be applicable to inflammatory lung diseases including chronic obstructive pulmonary disease (COPD) due to the complex microenvironment in lungs and the plasticity of macrophages. We examined macrophage sub-phenotypes in bronchoalveolar lavage (BAL) fluid in 25 participants with CD40 (a M1 marker) and CD163 (a M2 marker). Of these, we performed RNA-sequencing on each subtype in 10 patients using the Illumina NextSeq 500. Approximately 25% of the macrophages did not harbor classical M1 or M2 surface markers (double negative, DN), and these cells were significantly enriched in COPD patients compared with non-COPD patients (46.7% vs. 14.5%, p  < 0.001). 1886 genes were differentially expressed in the DN subtype compared with  all other subtypes at a 10% false discovery rate. The 602 up-regulated genes included 15 mitochondrial genes and were enriched in 86 gene ontology (GO) biological processes including inflammatory responses. Modules associated with cellular functions including oxidative phosphorylation were significantly down-regulated in the DN subtype. Macrophages in the human BAL fluid, which were negative for both M1/M2 surface markers, harbored a gene signature that was pro-inflammatory and suggested dysfunction in cellular homeostasis. These macrophages may contribute to the pathogenesis and manifestations of inflammatory lung diseases such as COPD.

With the US Food and Drug Administration’s (FDA’s) emergency use authorization of the Pfizer-BioNTech COVID-19 vaccine for adolescents aged 12-15 years on May 10, 2021, COVID-19 vaccination is now available to all adolescents aged 12-17 years.1 Moderna has also applied for emergency use authorization approval for this age group.1 The Centers for Disease Control and Prevention strongly recommends vaccination of the adolescent population, which comprises approximately 25 million people in the United States.2 Comprehensive protection is critical to adolescent and population health and is a big step toward a return to “normal life” for young people, including in-person school. Vaccine hesitancy—the reluctance or refusal to choose vaccination—identified by the World Health Organization as a top 10 global health threat, undermines these goals.3 According to a June 2021 Kaiser Family Foundation COVID-19 poll, 42% of parents with adolescents aged 12-17 years said they had either already vaccinated their children or planned to vaccinate their children, 18% said they would “wait a while to see how it is working,” 25% were definitely opposed, and 10% would choose vaccination only if required for school. Parental vaccine refusal has posed serious challenges to optimal coverage for childhood vaccines and led to outbreaks of measles and pertussis among unvaccinated children and surrounding communities.5 Similar challenges are likely if parents refuse COVID-19 vaccination for their children, particularly as the more transmissible Delta variant continues to spread and should booster shots be recommended in the future. In response to measles outbreaks, development of COVID-19 vaccines, and vaccine resistance, in December 2020 the District of Columbia enacted a first-of-its-kind law allowing adolescents aged <18 years to give first-person informed consent to vaccines recommended by the Advisory Committee on Immunization Practices and directed development of age-appropriate information sheets for use with health care providers.6 Recognizing the decisional rights of minors has 2 core components: adolescents’ ability to give informed consent and the legal right to decide. Health care providers can and should determine that many adolescents possess the maturity and capacity to give independent consent to COVID-19 vaccination. Both health care providers and adolescents need clear legal guidance for authorizing consent over parental objection. State policy makers should enact laws, or interpret extant law, to provide this guidance.