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Given prophylactic methotrexate (MTX) is often held in the setting of toxicity we investigated the impact of omitting minidose-MTX dose(s). Outcomes were compared between patients who had 1–3 doses omitted and those who received all four planned doses of minidose-MTX. Of 370 consecutive patients, 50 had MTX dose(s) omitted. When MTX was omitted, initial management was mycophenolate mofetil (MMF; 36/50 patients) with or without corticosteroids (14/50 patients). Rates of grade 3–4 acute GVHD were similar between groups. Omission of minidose-MTX resulted in an increased risk of chronic GVHD (cGVHD; HR 2.27; p =.024) and decreased overall survival (HR 1.61; p =.024). However, other transplant-related outcomes were comparable. In summary, omission of minidose-MTX doses was not associated with an increased risk of acute GVHD when an alternative was added (e.g. MMF ± corticosteroids). This did not abrogate the increased risk of cGVHD or decreased overall survival. [ABSTRACT FROM AUTHOR]

The role of allogeneic hematopoietic cell transplant (allo-HCT) as consolidation after initial venetoclax therapy and the efficacy of venetoclax salvage therapy for relapse after allo-HCT in patients with acute myeloid leukemia (AML) are unclear. We conducted a retrospective study of patients with AML or myelodysplastic syndrome (MDS) who received venetoclax either before or after allo-HCT at Memorial Sloan Kettering Cancer Center and Yale University from 11 August 2016 to 16 November 2020. Among 39 heavily pretreated patients who received venetoclax before allo-HCT, median OS from allo-HCT was not reached after a median follow up of 12.5 months resulting in a 12-month OS estimate of 79.0%. In 37 patients who had received venetoclax-based combinations as salvage therapy after allo-HCT, the overall response rate was 32% with a median OS of 4.7 months (12-month OS estimate: 43.4%). Four patients underwent a second allo-HCT following venetoclax-based salvage therapy suggesting it as a potential salvage treatment option. [ABSTRACT FROM AUTHOR]

Objective: Fetuses with genetic copy number variants are poorly detected through traditional prenatal screening. Microdeletions and duplications are clearly identified with diagnostic testing through chromosomal microarray, and screening of a select number of microdeletions has become available with cell-free DNA (cfDNA). Our study compares the costs and outcomes of cfDNA for five pathogenic microdeletions and aneuploidy to cfDNA for aneuploidy alone in conjunction with ultrasound.Methods: A decision-analytic model was constructed using TreeAge software to compare cfDNA with microdeletions versus traditional cfDNA in a theoretical cohort of 4,000,000 pregnancies that would also be screened with ultrasound. Probabilities, costs, and utilities were derived from literature. The primary outcomes were the incremental cost per quality-adjusted life-year (QALY), terminations, and procedure-related losses. Because the microdeletion results are available, but not reported, on all cfDNA testing we set the incremental cost of the cfDNA microdeletion screening test to zero at baseline and varied the cost in sensitivity analysis.Results: Screening with cfDNA for microdeletions among all pregnant women would result in 83 fewer anomalous neonates compared to traditional cfDNA with ultrasound. This reduction is due to increased diagnosis and termination of fetuses with microdeletions in this group. Routine use of cfDNA with microdeletions resulted in more procedure-related losses. cfDNA with microdeletions would improve effectiveness by 977 QALYs and decrease costs by $90,991,784. When we varied the specificity of the screening test, we found that it remained cost-effective down to a specificity of 91%. With a threshold of $100,000/QALY, microdeletion screening is cost-effective to an incremental increase in cost over cfDNA for aneuploidy alone of $47.10.Conclusion: For detection of fetal subchromosomal abnormalities, use of cfDNA with microdeletions is a cost-effective strategy compared to cfDNA for aneuploidy alone in conjunction with ultrasound. Cell-free DNA for microdeletions is not currently recommended as routine screening for low-risk obstetric populations by the American College of Obstetrics and Gynecologists or the Society for Maternal-Fetal Medicine. The test characteristics of cfDNA with microdeletions require greater examination before being routinely recommended. [ABSTRACT FROM AUTHOR]

Purpose: To describe the rate and severity of gestational hypertensive disorders (GHDs) in pregnancies complicated by trisomy 13 (T13).Materials and Methods: Retrospective cohort study of singleton deliveries in California from 2005 to 2008 using vital statistics and ICD-9 data. We were interested in gestational hypertension (gHTN), preeclampsia with and without severe features (sPREX and PREX), and gestational age at delivery. Pregnancies and maternal complications affected by prenatally diagnosed T13 were compared to unaffected pregnancies. Regression models were used to compute adjusted odds ratios for pregnancy outcomes by T13 status.Results: Of the 2,029,004 deliveries, 142 women had prenatally diagnosed T13. A diagnosis of GHD occurred in 26.8% of the T13 pregnancies versus 6% of the non-T13 pregnancies (p < .001). This remained true for gHTN (9.2% versus 3.2%, p=.001), PREX (12% versus 2.2%, p < .001), and sPREX (8.5% versus 0.9%, p < .001). After adjusting for confounders, T13 pregnancies were 6.3-times more likely to be affected by GHD, and 12.5-times more likely to have sPREX. Delivery <37 and <32 weeks in the setting of GHD was 14.1-times and 11.2-times likely among women with T13.Conclusions: Women with T13 pregnancies were significantly more likely to have gHTN, preeclampsia, sPREX, and to deliver <32 weeks. [ABSTRACT FROM AUTHOR]

Objective: To determine the optimal timing of delivery in late preterm intrauterine growth restriction (IUGR) fetuses with abnormal umbilical artery Doppler (UAD) indices.Methods: A decision-analytic model was built to determine the optimal gestational age (GA) of delivery in a theoretic cohort of 10 000 IUGR fetuses with elevated UAD systolic/diastolic ratios diagnosed at 34 weeks. All inputs were derived from the literature. Strategies involving expectant management accounted for the probabilities of stillbirth, spontaneous delivery and induction of labor for UAD absent or reversed end-diastolic flow (AREDF) at each successive week. Outcomes included short- and long-term neonatal morbidity and mortality with quality-adjusted life years (QALYs) generated based on these outcomes. Base case, sensitivity analyses and a Monte Carlo simulation were performed.Results: The optimal GA for delivery is 35 weeks, which minimized perinatal deaths and maximized total QALYs. Earlier delivery became optimal once the risk of stillbirth was threefold our baseline assumption; our model was also robust until the risk of AREDF at 35 weeks was half our baseline assumption, after which delivery at 36 weeks was preferred. Delivery at 35 weeks was the optimal strategy in 77% of trials in Monte Carlo multivariable sensitivity analysis.Conclusions: Weighing the risks of iatrogenic prematurity against the poor outcomes associated with AREDF, the ideal GA to deliver late preterm IUGR fetuses with elevated UAD indices is 35 weeks. [ABSTRACT FROM AUTHOR]

Objective: We examined the morbidities from delivery at earlier gestational ages versus intrauterine fetal demise (IUFD) for women with intrahepatic cholestasis of pregnancy (ICP) to determine the optimal gestational age for delivery.Methods: A decision-analytic model was created to compare delivery at 35 through 38 weeks gestation for different delivery strategies: (1) empiric steroids; (2) steroids if fetal lung maturity (FLM) negative; (3) wait a week and retest if FLM negative; or (4) deliver immediately. Literature review identified 18 studies that estimated IUFD in ICP; we used the mean rate, 1.74%, and assumed a uniform distribution from 34 to 40 weeks gestation. Large cohort data was used to calculate neonatal morbidity rates at each gestational age. Maternal and neonatal quality-adjusted life years (QALYs) were combined. Univariate sensitivity and Monte Carlo analyses were performed to test for robustness.Results: Immediate delivery at 36 weeks without FLM testing and steroid administration was the optimal strategy as compared to delivery at 36 weeks with steroids (+47 QALYs) and as compared to immediate delivery at 35 weeks (+210 QALYs). Our results were robust up to a 30% increase in the rate of IUFD.Conclusion: Immediate delivery at 36 weeks in women with ICP is the optimal delivery strategy. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the ongoing risk of intrauterine fetal demise (IUFD) in fetuses with gastroschisis compared to non-anomalous fetuses.Methods: This was a retrospective cohort study of all births in the United States in 2005-2006, as recorded in the National Center for Health Statistics natality database. Risk of IUFD in fetuses with gastroschisis was compared to non-anomalous fetuses, utilizing total at-risk fetuses as the denominator.Results: Risk of IUFD in fetuses with gastroschisis was 4.5%, compared to 0.6% in non-anomalous fetuses (p < 0.001). When controlling for gestational age and other confounders, the adjusted odds ratio for IUFD in fetuses with gastroschisis was 7.06 (95% CI: 3.33-14.96). After 32 weeks, risk of IUFD/ongoing pregnancy was greater at each week of gestation in fetuses with gastroschisis.Conclusions: Risk of IUFD for fetuses with gastroschisis is greater than in non-anomalous fetuses. This risk increases significantly after 32 weeks' gestation. Demographic variables are associated with higher rates of gastroschisis and ultimately IUFD. These data may be useful in consideration of timing of delivery. [ABSTRACT FROM AUTHOR]

Objective: To examine predictive characteristics for cesarean delivery (CD) in women undergoing labor induction with a Foley balloon (FB). Methods: A secondary analysis of a randomized, double-blind, control trial examining labor induction with a transcervical 30 mL or 60 mL FB. One-hundred ninety-nine women with term, vertex, singleton pregnancies and Bishop score < 5 were randomized to receive a transcervical 30 mL or 60 mL FB. Mode of delivery, labor complications and neonatal outcomes were recorded. A multivariable model was performed to determine predictive characteristics for CD. Results: Increasing maternal age ( p = 0.04), nulliparity ( p =0.002) and chorioamnionitis ( p < 0.001) were significantly associated with an elevated risk for CD. Nulliparity was associated in an almost 4-fold increased CD risk (relative risk [RR]: 3.88; 95% confidence interval [CI]: 1.22-12.3). Women aged ≥ 40 years, had an almost 3-fold increased risk of CD as compared to women aged 20-29 (RR: 2.91; 95% CI: 1.36-6.19) years. Chorioamnionitis was associated with nearly a 2-fold increased risk for CD (RR: 1.87; 95% CI: 1.06-3.32). A gestational age of ≥ 41 weeks, prostaglandin use during induction and induction indication did not affect mode of delivery. Conclusion: In patients undergoing labor induction with a FB, increasing maternal age, nulliparity and chorioamnionitis are associated with an elevated risk for CD. [ABSTRACT FROM AUTHOR]

Introduction: Velamentous cord insertion (VCI) can be identified on prenatal ultrasound with an incidence of around 1%. We set out to examine the association between VCI and perinatal outcomes. Methods: This was a retrospective cohort study of 482 812 pregnancies using the California vital statistics birth cohort dataset linked with patient discharge dataset from 2006 during which 2327 (0.48%) were complicated by VCI. Outcomes examined included intrauterine fetal demise (IUFD), small for gestational age (SGA), preterm delivery, manual removal of the placenta and cesarean delivery. Statistical analysis was performed using Chi squared tests and multivariable logistic regression analyses. Results: Pregnancies with VCI, compared to those without, were associated with an increased risk of IUFD (2.6% versus 0.28%, p = 0.001), SGA (16.93% versus 10.17%, p = 0.001), preterm delivery <37 weeks (12.5% versus 9.10%, p = 0.001), manual removal of placenta (14.47% versus 0.76%, p = 0.01) and postpartum hemorrhage (6.66% versus 2.88%, p = 0.001). Adjusting for confounders, the adjusted odds of IUFD were more than nine times in pregnancies with VCI (aOR 9.56; 95% CI 6.76-13.5) than those without. Discussion: VCI is associated with an increased risk of adverse perinatal outcomes such as IUFD, SGA, preterm delivery <37 weeks, need for manual removal of placenta and post-partum hemorrhage. Routine identification of the placental cord insertion site should be considered. Close surveillance of these pregnancies should be undertaken. Future research should focus on the optimal management including the gestational age for delivery of these pregnancies. [ABSTRACT FROM AUTHOR]

Objective. To compare perinatal outcomes in nulliparous women who had operative vaginal delivery early during second stage (1--3 h) to those who delivered vaginally with a prolonged second stage (>3 h). Methods. This is a retrospective cohort study of nulliparas with term, singleton, vaginal deliveries beyond the first hour of second stage. Women who underwent operative vaginal deliveries (OVD) during 1--3 h of the second stage were compared to women who delivered vaginally but with a second stage duration of >3 h. Perinatal outcomes were examined using chi-square test, and potential confounders were controlled for using multivariable logistic regression analysis. Results. Nulliparas delivered vaginally beyond 3 h of second stage had lower odds of third or fourth degree perineal lacerations (aOR == 0.63, 95%% CI 0.51--0.77), neonatal cephalohematoma (aOR == 0.48, 95%% CI 0.28--0.83) and admissions to intensive care nursery (aOR == 0.70, 95%% CI 0.49--0.99) compared to operative vaginal deliveries during 1--3 h of second stage. Conclusion. Compared to nulliparas who had operative vaginal deliveries performed early (1--3 h) in the second stage, women who delivered later (>3 h duration of second stage), either by spontaneous or operative vaginal delivery, had lower risk of third or fourth degree perineal lacerations without incurring risk of increased adverse neonatal outcomes. [ABSTRACT FROM AUTHOR]

Objective. To examine mode of delivery and perinatal outcomes in women with occiput posterior (OP) or transverse (OT) position in the second stage of labour with a trial of manual rotation compared to expectant management. Methods. A retrospective cohort study was designed to examine mode of delivery and perinatal morbidity in women who underwent a trial of manual rotation ( n = 731) compared to expectant management ( n = 2527) during the second stage of labour with the fetus in OP/OT position. Chi-square test was used to compare categorical outcomes and multivariable logistic regression models were used to control for potential confounders. Results. Compared to expectant management, women with manual rotation were less likely to have: caesarean delivery (CD) [adjusted odds ratio (aOR) 0.12; 95% confidence interval (CI) 0.09-0.16], severe perineal laceration [aOR 0.64; (0.47-0.88)], postpartum haemorrhage [aOR 0.75; (0.62-0.98)], and chorioamnionitis [aOR 0.68; (0.50-0.92)]. The number of rotations attempted to avert one CD was 4. In contrast, women who had a trial of rotation had an increased risk of cervical laceration [aOR 2.46; (1.1-5.4)]. Conclusions. Compared with expectant management, a trial of manual rotation with persistent fetal OP/OT position is associated with a reduction in CD and adverse maternal outcomes. [ABSTRACT FROM AUTHOR]

Objective. To evaluate the neonatal outcomes of infants delivered to mothers with early-onset preeclampsia. Study design. This is a retrospective cohort of 1709 infants delivered at 24 0/7 to 29 6/7 weeks gestation was examined. Neonatal outcomes of 235 infants delivered prematurely because of preeclampsia were compared with 1474 infants delivered preterm because of other etiologies. Primary outcomes examined included: small for gestational age (SGA), respiratory distress syndrome (RDS), and neonatal death (NND). Multivariable logistic regression was used to analyze the association between preeclampsia and the neonatal outcomes, controlling for potential confounders. Results. Infants of women with preeclampsia were more likely to be SGA (17.8% vs. 5.6%, AOR 3.9, CI 2.5–6.2) and have RDS (70.6% vs. 60.7%, AOR 1.5, 95% CI 1.1–2.2); however, they were less likely to suffer a NND (11.1% vs. 18.1%, AOR 0.6, 95% CI 0.4–0.9). Conclusion. Compared with neonates delivered prematurely because of other etiologies, neonates born to preeclamptic mothers were more likely to be SGA and have RDS, but had a decrease in mortality. This may be a reflection of the differences in the underlying pathophysiology behind indicated preterm birth due to preeclampsia. [ABSTRACT FROM AUTHOR]

Objective . To identify maternal and fetal risk factors associated with persistent occiput posterior position at delivery, and to examine the association of occiput posterior position with subsequent obstetric outcomes. Methods . This is a retrospective cohort study of 30 839 term, cephalic, singleton births. Women with persistent occiput posterior (OP) position at delivery were compared to those with occiput anterior (OA) position. Demographics, obstetric history, and labor management were evaluated and subsequent obstetric outcomes examined. Potential confounding variables were controlled for using multivariate logistic regression analysis. Results . The overall frequency of OP position was 8.3% in the study population. When compared to Caucasians, a higher rate of OP was observed among African-Americans (OR = 1.4, 95% CI 1.25–1.64) while no other racial/ethnic differences were noted. Other associated factors included nulliparity, maternal age ≥35, gestational age ≥41 weeks, and birth weight >4000 g, as well as artificial rupture of the membranes (AROM) and epidural anesthesia ( p 4000 g are associated with persistent OP position at delivery, with higher rates of operative deliveries and obstetric complications. This information can be useful in counseling patients regarding risks and associated outcomes of persistent OP position. [ABSTRACT FROM AUTHOR]

Identifying animal remains is the most basic aspect of zooarchaeological research; the accuracy of all subsequent interpretations hinges on this process. Recently, the zooarchaeological community reiterated the need for researchers to be explicit in reporting their identification methodology. We review this problem and provide an example from our own research showing the interpretation problems that can arise when such methods are not described in detail and how unwarranted assumptions can affect research. [ABSTRACT FROM AUTHOR]

The use of hunting disguises by Native Americans is well documented historically as a means to increase hunting success. The use of such disguises in prehistory, however, is not well documented. Four prehistoric motifs are presented here that show the use of hunting disguises approximately 900 years ago. These motifs were painted by the Mimbres‐Mogollon, a Puebloan group in southwestern New Mexico. Not only is the use of disguises shown, but so too are bows, arrows, and the hunting of various prey. [ABSTRACT FROM PUBLISHER]

Burrowing clams represent a poorly studied threat to shallowly buried and submerged archaeological sites across North America. Test excavations at a formerly submerged prehistoric terrace site in SW Texas unearthed burrowing clams (Asiatic clam, Corbicula fluminca) in, under, and around features. A review of this clam's ecology, burrowing habits, geographical distribution, and presence in this and other archaeological sites illustrates the potential for significant sediment disturbances. [ABSTRACT FROM AUTHOR]

Sugar reflotation of matrix containing archaeological material appears to be a relatively inexpensive, safe, and reliable method for the recovery of botanical remains. Using high concentrations of sugar to increase the specific gravity of water to make flotation viable for botanical recovery will, however, also saturate archaeological material (e.g., botanical, faunal, and some artifactual materials) with sugar that could damage the materials or attract pests that could damage the materials during curation. For this reason, samples processed using sugar reflotation should have the sugar removed bofore curation. This issue has not been previously addressed and will add to the time and expense involved in this process. [ABSTRACT FROM AUTHOR]