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Background COVID-19 pandemic constitutes a challenge in cardiovascular disease management. Little is known about COVID-19 prevalence and incidence in cardiac rehabilitation (CR) programs. Aim To evaluate the prevalence and incidence of COVID-19 in patients undergoing CR in ambulatory setting. Methods From august to October 2020, all patients admitted in a single ambulatory CR program were screened for COVID-19 infection before and after CR, through naso-pharyngeal RT-PCR and serology assays before and after the CR. Number of patients was reduced from 9 to 4 in each group, 2 meters distancing respected, and all patients and staff had to wear surgical mask during sessions. Hand washing and material disinfection were systematic before and after each session for both patients and health professionals. Results Among the 81 patients included, 63 (76%) were male, mean age was 57 ± 11 years (Table 1). None (0%) had positive RT-PCR before entering CR and only 2 (2.7%) were tested positive after CR. These two patients were asymptomatic. After serological analysis, 3 patients (3.8%) had anti-bodies against SARS-COV-2 before and after participating CR (Fig. 1). These 3 patients were negative on nasal swab before and after CR. No seroconversion was observed. In total (before and after CR), 5 patients (6.0%) were tested positive with COVID-19. Those 5 patients were younger (mean age 51 years old versus 58, P = 0.02), with better functional capacity before and after CR: respectively 7.1 METs (versus 5.2 METs, P = 0.01) and 8.3 METs (versus 6.3 METs, P = 0.03). In COVID+ patients, improvement of functional capacity was similar to COVID–patients: respectively 0.8 METs (P = 0.9) and 15 Watts (P = 0.9). Conclusion CR is not associated with risk of infection with SARS-COV-2, provided that basic sanitary measures are stricly applied. It is also associated with functional capacity improvement, even in patients who previously had COVID-19.

Pregnant individuals infected with SARS-CoV-2 have higher rates of intensive care unit admission, oxygen requirement, need for mechanical ventilation, and death than nonpregnant individuals. Increased COVID-19 disease severity may be associated with an increased risk of viremia and placental infection. Maternal SARS-CoV-2 infection is also associated with pregnancy complications such as preeclampsia and preterm birth, which can be either placentally mediated or reflected in the placenta. Maternal viremia followed by placental infection may lead to maternal-fetal transmission (vertical), which affects 1% to 3% of exposed newborns. However, there is no agreed-upon or standard definition of placental infection. The National Institutes of Health/Eunice Kennedy Shriver National Institute of Child Health and Human Development convened a group of experts to propose a working definition of placental infection to inform ongoing studies of SARS-CoV-2 during pregnancy. Experts recommended that placental infection be defined using techniques that allow virus detection and localization in placental tissue by one or more of the following methods: in situ hybridization with antisense probe (detects replication) or a sense probe (detects viral messenger RNA) or immunohistochemistry to detect viral nucleocapsid or spike proteins. If the abovementioned methods are not possible, reverse transcription polymerase chain reaction detection or quantification of viral RNA in placental homogenates, or electron microscopy are alternative approaches. A graded classification for the likelihood of placental infection as definitive, probable, possible, and unlikely was proposed. Manuscripts reporting placental infection should describe the sampling method (location and number of samples collected), method of preservation of tissue, and detection technique. Recommendations were made for the handling of the placenta, examination, and sampling and the use of validated reagents and sample protocols (included as appendices).

Investigators have attempted to derive tools that could provide clinicians with an easily obtainable estimate of the chance of vaginal birth after cesarean delivery for those who undertake trial of labor after cesarean delivery. One tool that has been validated externally was derived from data from the Maternal-Fetal Medicine Units Cesarean Registry. However, concern has been raised that this tool includes the socially constructed variables of race and ethnicity.This study aimed to develop an accurate tool to predict vaginal birth after cesarean delivery, using data easily obtainable early in pregnancy, without the inclusion of race and ethnicity.This was a secondary analysis of the Cesarean Registry of the Maternal-Fetal Medicine Units Network. The approach to the current analysis is similar to that of the analysis in which the previous vaginal birth after cesarean delivery prediction tool was derived. Specifically, individuals were included in this analysis if they were delivered on or after 37 0/7 weeks' gestation with a live singleton cephalic fetus at the time of labor and delivery admission, had a trial of labor after cesarean delivery, and had a history of 1 previous low-transverse cesarean delivery. Information was only considered for inclusion in the model if it was ascertainable at an initial prenatal visit. Model selection and internal validation were performed using a cross-validation procedure, with the dataset randomly and equally divided into a training set and a test set. The training set was used to identify factors associated with vaginal birth after cesarean delivery and build the logistic regression predictive model using stepwise backward elimination. A final model was generated that included all variables found to be significant (P.05). The accuracy of the model to predict vaginal birth after cesarean delivery was assessed using the concordance index. The independent test set was used to estimate classification errors and validate the model that had been developed from the training set, and calibration was assessed. The final model was then applied to the overall analytical population.Of the 11,687 individuals who met the inclusion criteria for this secondary analysis, 8636 (74%) experienced vaginal birth after cesarean delivery. The backward elimination variable selection yielded a model from the training set that included maternal age, prepregnancy weight, height, indication for previous cesarean delivery, obstetrical history, and chronic hypertension. Vaginal birth after cesarean delivery was significantly more likely for women who were taller and had a previous vaginal birth, particularly if that vaginal birth had occurred after a previous cesarean delivery. Conversely, vaginal birth after cesarean delivery was significantly less likely for women whose age was older, whose weight was heavier, whose indication for previous cesarean delivery was arrest of dilation or descent, and who had a history of medication-treated chronic hypertension. The model had excellent calibration between predicted and empirical probabilities and, when applied to the overall analytical population, an area under the receiver operating characteristic curve of 0.75 (95% confidence interval, 0.74-0.77), which is similar to the area under the receiver operating characteristic curve of the previous model (0.75) that included race and ethnicity.We successfully derived an accurate model (available at https://mfmunetwork.bsc.gwu.edu/web/mfmunetwork/vaginal-birth-after-cesarean-calculator), which did not include race or ethnicity, for the estimation of the probability of vaginal birth after cesarean delivery.

ObjectiveWomen with pregnancies complicated by hypertensive disorders of pregnancy (HDP) have increased long-term cardiovascular (CV) risk. We sought to determine if they demonstrate increased short-term CV risk.MethodsUsing administrative records, all hospital-based deliveries in Florida from 2004 to 2010 and subsequent readmission to any Florida hospital within 3 years of index delivery were identified. Deliveries and clinical diagnoses were determined using International Classification of Diseases, Ninth Revision, Clinical Modification codes. HDP included pregnancies complicated by gestational hypertension, pre-eclampsia or eclampsia. Outcomes were CV readmission (acute myocardial infarction, stroke or heart failure), non-CV readmission and any readmission within 3 years of delivery excluding subsequent deliveries. Associations were determined using multivariate logistic regression.ResultsAmong 1 452 926 records from delivering mothers of singleton infants (mean age 27.2±6.2 years; 52% white, 23% African American (AA), 18% Hispanic), there were 4054 CV and 259 252 non-CV readmissions. Women with HDP had higher CV readmission rates (6.4 vs 2.5/1000 deliveries; PConclusionWomen with HDP had twice the risk of CV readmission within 3 years of delivery, with higher rates among AA women. More work is needed to explore preventive strategies for HDP-associated events.

Randomized controlled trials are considered the highest level of evidence but fewer than half are reproducible. A rigorous methodology improves trial quality, but reproducibility may be limited by a lack of transparency in reporting. The Consolidated Standards of Reporting Trials guidelines define reporting standards, and pretrial registration requires a predefined methodology and predefined outcomes.We evaluated obstetrics and gynecology trials published in 6 journals in terms of their adherence to the Consolidated Standards of Reporting Trials guidelines. Second, we evaluated pretrial registration compliance and concordance between the registry and publication. Furthermore, we evaluated the differences in trial characteristics among randomized controlled trials with the highest level of compliance and those with lower levels of compliance and adherence to guidelines by journal type.This was a cross-sectional study of obstetrics and gynecology trials published between 2017 and 2019 in 6 journals (American Journal of ObstetricsGynecology, BJOG: An International Journal of Obstetrics and Gynaecology, ObstetricsGynecology, The Journal of the American Medical Association, The Lancet, and The New England Journal of Medicine). Randomized controlled trials were identified via PubMed and manual journal archive searches. The primary outcome was adequate compliance with the Consolidated Standards of Reporting Trials guidelines defined as ≥80% of the checklist items present. Secondary outcomes included completion of pretrial registration and concordance between the pretrial registration and publication in terms of the outcomes and sample size. We compared the characteristics between trials with adequate compliance and those with inadequate compliance. Secondary analyses included comparisons of characteristics of the trials in the top quartile for compliance with the Consolidated Standards of Reporting Trials guidelines with those of the trials in lower quartiles and compliance with guidelines in obstetrics-gynecology vs non-obstetrics-gynecology journals. In an exploratory analysis, trends in compliance with the Consolidated Standards of Reporting Trials guidelines across the study period were assessed. A post hoc sensitivity analysis evaluated the outcomes after the exclusion of 2 retracted trials.Of the 170 trials included, 80% (95% confidence interval, 74%-86%) were adequately compliant with the Consolidated Standards of Reporting Trials manuscript guidelines and 66% (95% confidence interval, 59%-73%) were compliant with the abstract guidelines. Nearly all trials (98%) reported pretrial registration. Concordance between pretrial registration and publication in terms of the primary outcomes was identified for 77% of the trials, concordance in terms of the secondary outcomes was observed in 32% of the trials, and concordance in terms of sample size was observed in 60% of the trials. Trials with adequate compliance were more likely to be preregistered, include an a priori power calculation, and use an intent to treat analysis. Trials in the top quartile for compliance with the Consolidated Standards of Reporting Trials guidelines were more likely to be multicenter, international, and government funded. More trials from non-obstetrics-gynecology journals were in the top quartile for compliance with the Consolidated Standards of Reporting Trials guidelines than trials from obstetrics-gynecology journals (64.9% vs 25.7%; P.001). No significant trends in adequate compliance were identified across the study period. Results did not differ significantly in the sensitivity analysis.Of all the trials included, 20% of obstetrics-gynecology trials published in 6 high-impact journals were not compliant with the Consolidated Standards of Reporting Trials guidelines, and there were major discrepancies between pretrial registration and publication. Transparency, reproducibility, and scientific rigor in obstetrics and gynecology trial reporting needs to be improved.

Objective: To describe COVID-19 disease course in a multistate cohort of pregnant patients and evaluate whether more severe disease is associated with worse maternal and neonatal outcomes Study Design: Cohort of all pregnant patients with a singleton gestation and positive SARS-CoV-2 nucleic acid or antigen test (either in- or out-patient), who delivered at one of 33 U S hospitals from March 1 to July 31, 2020 Disease severity was classified by NIH criteria Perinatal outcomes included death, cesarean delivery (CD), postpartum hemorrhage (PPH), hypertensive disorders of pregnancy (HDP), and preterm birth < 37 weeks’ (PTB) Centrally-trained perinatal research staff abstracted data from medical records We evaluated trends in maternal characteristics and outcomes across COVID-19 severity classes and associations between severity and outcomes by multivariable modeling Results: 1,219 patients were included: 47% asymptomatic, 27% mild, 14% moderate, 8% severe and 4% critical Those with more severe illness had an older mean age, higher median body mass index, and higher frequency of medical comorbidities (asthma/COPD, diabetes, hypertension, liver disease, seizure disorder) The majority of included patients were Hispanic ethnicity;however, there was no trend in race-ethnicity distribution by severity (Table 1) The most common symptoms were cough (34%), dyspnea (19%), and myalgias (19%) Four maternal deaths (0 3%) were attributed to COVID-19 Adverse perinatal outcomes became more frequent with increasing severity of COVID-19, including a 6% (95% CI 2 5-10 9%) VTE rate with severe/critical (Table 2) In adjusted analyses, severe/critical COVID-19 was associated with CD, PPH, HDP, and PTB compared with asymptomatic patients Approximately 1% (95% CI 0 5-1 8%) of neonates tested positive for SARS-CoV-2 before discharge Conclusion: Medical comorbidities were present more often in patients with more severe disease Compared with asymptomatic patients, those with severe/critical COVID-19, but not those with mild/moderate COVID-19, were at increased risk of perinatal complications Perinatal transmission was rare [Formula presented] [Formula presented]

In utero exposure to marijuana may cause various short- and long-term health problems, such as stillbirth, low birth weight and decreased cognitive function. Detection of in utero marijuana exposure with a relatively new specimen type, umbilical cord tissue, can be used to plan treatment and guide social management. In this study, a liquid chromatography–tandem mass spectrometry (LC–MS-MS) assay was developed for the simultaneous identification of four cannabinoids in umbilical cord tissue, including ∆(9)-tetrahydrocannabinol (THC), 11-nor-9-carboxy-∆(9)--THC (THC-COOH), 11-hydroxy-∆(9)-THC (11-OH-THC) and cannabinol (CBN). Within- and between-run imprecision, accuracy, linearity, sensitivity, carryover, recovery, matrix effects and specificity were evaluated using drug-free umbilical cord tissue spiked with non-deuterated and deuterated standards. Calibration curves were reproducible and linear (r > 0.995) for all four analytes in the range of 0.2 ng/g lower limit of quantitation (LLOQ) and 30 ng/g upper limit of quantitation (ULOQ). Total imprecisions (% coefficient of variation) were 7.8% (THC), 13.3% (THC-COOH), 11.8% (11-OH-THC) and 10.6% (CBN) at low QC (n = 15, 0.25 ng/g), and were 7.2% (THC), 10.0% (THC-COOH), 9.5% (11-OH-THC) and 5.8% (CBN) at high QC (n = 15, 4 ng/g), respectively. No interfering substances were identified, and no carryover was observed. The average accuracies (N = 25) were 94–95%. The average recoveries observed for THC, THC-COOH, 11-OH-THC and CBN were 74, 82, 58 and 86%, respectively. By analyzing authentic clinical specimens that had been previously tested for cannabinoids by enzyme-linked immunoassay, positive and negative result agreements were 100 and 53.8%. In summary, the presented method can be used for the assessment of in utero exposure to four common cannabinoids.

Equatorward-moving cold surges occur along the lee of high terrain during the cold season. Even though the east coast of Africa features high terrain, little research exists on cold surges along the African highlands despite the fact that these surges could have potentially large agricultural and societal effects. This paper examines a 5-yr climatology of the most extreme African-highlands cold surges spanning the 2008–12 period. During these years, 186 cold surges occurred to the lee of the African highlands, with 84 events extending between 30° and 35°S (type 1), 27 extending between 25° and 30°S (type 2), and 75 extending equatorward of 25°S (type 3) based on the 1000–850-hPa thickness pattern. This climatology reveals that extreme African-highlands cold surges have a climatological maximum in September. Cold surges of type 1 and type 2 tend to occur throughout the Southern Hemisphere winter and spring, whereas surges of type 3 are generally confined to the winter months. These cold surges can last from 2 to 8 days, with the highest frequency of events spanning a 3-day period. A typical cold-surge event features maximum 925-hPa meridional flow of 30.0–39.9 kt (1 kt = 0.51 m s−1) that most frequently advects cold Antarctic air to between 15.0° and 24.9°S and at times as far as the equator.

Two severe MCSs over the upper Midwest United States resulted in >100 mm of rain in a ~24-h period and >200 severe weather reports, respectively, during 30 June–2 July 2011. This period also featured 100 (104) daily maximum high (low) temperature records across the same region. These high-impact weather events occurred in the presence of an elevated mixed layer (EML) that influenced the development of the severe MCSs and the numerous record high temperatures. The antecedent large-scale flow evolution was influenced by early season Tropical Cyclone Meari over the western North Pacific. The recurvature and subsequent interaction of Meari with the extratropical large-scale flow occurred in conjunction with Rossby wave train amplification over the North Pacific and dispersion across North America during 22 June–2 July 2011. The Rossby wave train dispersion contributed to trough (ridge) development over western (central) North America and the development of an EML and the two MCSs over the upper Midwest United States. A composite analysis of 99 warm-season days with an EML at Minneapolis, Minnesota, suggests that Rossby wave train amplification and dispersion across the North Pacific may frequently occur in the 7 days leading up to EMLs across the upper Midwest. The composite analysis also demonstrates an increased frequency of severe weather and elevated temperatures relative to climatology on days with an EML. These results suggest that EMLs over the upper Midwest may often be preceded by Rossby wave train amplification over the North Pacific and be followed by a period of severe weather and elevated temperatures.

Stillbirth is one of the most common adverse pregnancy outcomes, occurring in 1 in 160 deliveries in the United States. In developed countries, the most prevalent risk factors associated with stillbirth are non-Hispanic black race, nulliparity, advanced maternal age, obesity, preexisting diabetes, chronic hypertension, smoking, alcohol use, having a pregnancy using assisted reproductive technology, multiple gestation, male fetal sex, unmarried status, and past obstetric history. Although some of these factors may be modifiable (such as smoking), many are not. The study of specific causes of stillbirth has been hampered by the lack of uniform protocols to evaluate and classify stillbirths and by decreasing autopsy rates. In any specific case, it may be difficult to assign a definite cause to a stillbirth. A significant proportion of stillbirths remains unexplained, even after a thorough evaluation. Evaluation of a stillbirth should include fetal autopsy; gross and histologic examination of the placenta, umbilical cord, and membranes; and genetic evaluation. The method and timing of delivery after a stillbirth depend on the gestational age at which the death occurred, maternal obstetric history (eg, previous hysterotomy), and maternal preference. Health care providers should weigh the risks and benefits of each strategy in a given clinical scenario and consider available institutional expertise. Patient support should include emotional support and clear communication of test results. Referral to a bereavement counselor, peer support group, or mental health professional may be advisable for management of grief and depression.

STUDY QUESTIONIs cannabis use assessed via urinary metabolites and self-report during preconception associated with fecundability, live birth and pregnancy loss?SUMMARY ANSWERPreconception cannabis use was associated with reduced fecundability among women with a history of pregnancy loss attempting pregnancy despite an increased frequency of intercourse.WHAT IS KNOWN ALREADYCannabis use continues to rise despite limited evidence of safety during critical windows of pregnancy establishment. While existing studies suggest that self-reported cannabis use is not associated with fecundability, self-report may not be reliable.STUDY DESIGN, SIZE, DURATIONA prospective cohort study was carried out including 1228 women followed for up to six cycles while attempting pregnancy (2006 to 2012), and throughout pregnancy if they conceived.PARTICIPANTS/MATERIALS, SETTING, METHODSWomen aged 18–40 years with a history of pregnancy loss (n = 1228) were recruited from four clinical centers. Women self-reported preconception cannabis use at baseline and urinary tetrahydrocannabinol metabolites were measured throughout preconception and early pregnancy (up to four times during the study: at baseline, after 6 months of follow-up or at the beginning of the conception cycle, and weeks 4 and 8 of pregnancy). Time to hCG-detected pregnancy, and incidence of live birth and pregnancy loss were prospectively assessed. Fecundability odds ratios (FOR) and 95% CI were estimated using discrete time Cox proportional hazards models, and risk ratios (RRs) and 95% CI using log-binomial regression adjusting for age, race, BMI, education level, baseline urine cotinine, alcohol use and antidepressant use.MAIN RESULTS AND THE ROLE OF CHANCEPreconception cannabis use was 5% (62/1228), based on combined urinary metabolite measurements and self-report, and 1.3% (11/789) used cannabis during the first 8 weeks of gestation based on urinary metabolites only. Women with preconception cannabis use had reduced fecundability (FOR 0.59; 95% CI 0.38, 0.92). Preconception cannabis use was also associated with increased frequency of intercourse per cycle (9.4 ± 7 versus 7.5 ± 7 days; P = 0.02) and higher LH (percentage change 64%, 95% CI 3, 161) and higher LH:FSH ratio (percentage change 39%, 95% CI 7, 81). There were also suggestive, though imprecise, associations with anovulation (RR 1.92, 95% CI 0.88, 4.18), and live birth (42% (19/45) cannabis users versus 55% (578/1043) nonusers; RR 0.80, 95% CI 0.57, 1.12). No associations were observed between preconception cannabis use and pregnancy loss (RR 0.81, 95% CI 0.46, 1.42). Similar results were observed after additional adjustment for parity, income, employment status and stress. We were unable to estimate associations between cannabis use during early pregnancy and pregnancy loss due to limited sample size.LIMITATIONS, REASONS FOR CAUTIONOwing to the relatively few cannabis users in our study, we had limited ability to make conclusions regarding live birth and pregnancy loss, and were unable to account for male partner use. While results were similar after excluding smokers, alcohol use and any drug use in the past year, some residual confounding may persist due to these potential co-exposures.WIDER IMPLICATIONS OF THE FINDINGSThese findings highlight potential risks on fecundability among women attempting pregnancy with a history of pregnancy loss and the need for expanded evidence regarding the reproductive health effects of cannabis use in the current climate of increasing legalization.STUDY FUNDING/COMPETING INTEREST(S)This work was supported by the Intramural Research Program of the Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland (Contract numbers: HHSN267200603423, HHSN267200603424, HHSN267200603426, HHSN275201300023I). Jeannie G. Radoc has been funded by the National Institutes of Health Medical Research Scholars Program, a public–private partnership supported jointly by the National Institutes of Health and generous contributions to the Foundation for the National Institutes of Health from the Doris Duke Charitable Foundation (DDCF Grant # 2014194), Genentech, Elsevier, and other private donors. The authors report no conflict of interest in this work and have nothing to disclose.TRIAL REGISTRATION NUMBERClinicaltrials.gov NCT00467363

Background Cannabis use is increasing in the United States. Prior work suggests tobacco use in pregnancy is much more common among those with depression. It is not known whether cannabis use is also more common among this especially vulnerable group. Identifying those at highest risk for cannabis use is required to direct prevention and intervention efforts. Methods Data were drawn from the 2005–2018 National Survey on Drug Use and Health (NSDUH), an annual, cross-sectional sample of persons ages 12 and older representative of the US. The prevalence of past-30-day cannabis use by depression status (past-12-month) and by sociodemographic factors and perception of risk associated with cannabis use was estimated among pregnant women. Results Cannabis use was significantly more common among pregnant women with, compared to without, depression (12.7 % vs. 3.7 %; odds ratio (OR) = 3.8 (95 % confidence interval 2.8, 5.0)). This was the case across all sociodemographic subgroups. The relationship between depression and cannabis use was significantly stronger among those who perceived moderate-great risk (OR = 6.9 (3.7, 13.0)) compared with no risk (OR = 1.6 (1.1, 2.4); Pint = 0.0003) associated with regular use. Conclusions Women with depression are more than three times more likely to use cannabis during pregnancy. Disparities in cannabis use among pregnant women by depression status appear to be echoing trends in tobacco use. Education about risks associated with cannabis use in pregnancy and prevention, akin to those for prenatal tobacco use, may be needed among pregnant women who are depressed to stem this increase and potentially growing disparity.

Key Points Question Has the frequency of cannabis use among pregnant women in the year before and during pregnancy increased in recent years? Findings In this serial cross-sectional study of 367 403 pregnancies among women in Kaiser Permanente Northern California who were universally screened for self-reported cannabis use as part of standard prenatal care, annual relative rates of daily, weekly, and monthly cannabis use in the year before pregnancy and during pregnancy increased from 2009 to 2017. Relative rates of self-reported daily cannabis use in the year before and during pregnancy increased fastest. Meaning Results of this study demonstrate that frequency of cannabis use in the year before pregnancy and during pregnancy has increased among women in Northern California in recent years, with relative rates of daily cannabis use increasing most rapidly., This cross-sectional study of pregnancies among women in the Kaiser Permanente Northern California health care system examines trends in daily, weekly, and monthly self-reported cannabis use in the year before and during pregnancy from 2009 to 2017., Importance As the overall prevalence of prenatal cannabis use rises, it is vital to also monitor trends in the frequency of cannabis use in the period leading up to and during pregnancy because more frequent use may confer greater health risks for mothers and their children. Objective To examine trends in the frequency of self-reported cannabis use among pregnant women in the year before and during pregnancy. Design, Setting, and Participants Cross-sectional study using data from 367 403 pregnancies among 276 991 women 11 years or older who completed a self-administered questionnaire on cannabis use during standard prenatal care in Kaiser Permanente Northern California from January 1, 2009, to December 31, 2017. The annual prevalence of self-reported daily, weekly, and monthly cannabis use among women before and during pregnancy was estimated using Poisson regression with a log link function, adjusting for sociodemographics. Data analyses were conducted from February to May 2019. Exposures Calendar year. Main Outcomes and Measures Self-reported frequency of cannabis use in the year before pregnancy and during pregnancy assessed as part of standard prenatal care (at approximately 8 weeks’ gestation). Results Among the overall sample of 367 403 pregnancies among 276 991 women, 35.9% of the women self-reported white race/ethnicity; 28.0%, Hispanic; 16.6%, Asian; 6.0%, African American; and 13.5%, other. In the sample, 1.2% of the women were aged 11 to 17 years; 15.3%, 18 to 24 years; 61.4%, 25 to 34 years; and 22.0%, older than 34 years. Median (interquartile range) neighborhood household income was $70 472 ($51 583-$92 643). From 2009 to 2017, the adjusted prevalence of cannabis use in the year before pregnancy increased from 6.80% (95% CI, 6.42%-7.18%) to 12.50% (95% CI, 12.01%-12.99%), and the adjusted prevalence of cannabis use during pregnancy increased from 1.95% (95% CI, 1.78%-2.13%) to 3.38% (95% CI, 3.15%-3.60%). Annual relative rates of change in self-reported daily cannabis use (1.115; 95% CI, 1.103-1.128), weekly cannabis use (1.083; 95% CI, 1.071-1.095), and monthly or less cannabis use (1.050; 95% CI, 1.043-1.057) in the year before pregnancy increased significantly, with daily use increasing most rapidly (from 1.17% to 3.05%). Similarly, annual relative rates of change in self-reported daily cannabis use (1.110; 95% CI, 1.089-1.132), weekly cannabis use (1.075; 95% CI, 1.059-1.092) and monthly or less cannabis use (1.044; 95% CI, 1.032-1.057) during pregnancy increased significantly from 2009 to 2017, with daily use increasing most rapidly (from 0.28% to 0.69%). Conclusions and Relevance Results of this study demonstrate that frequency of cannabis use in the year before pregnancy and during pregnancy has increased in recent years among pregnant women in Northern California, potentially associated with increasing acceptance of cannabis use and decreasing perceptions of cannabis-associated harms.

Objective Substance use disorders often coexist with depression. The objective of this study was to establish whether pregnant women who report depressive symptomatology were more likely to report use of alcohol, tobacco, and marijuana during pregnancy. Study Design This was a secondary analysis of prospectively collected data from the Maternal-Fetal Medicine Units Network Preterm Prediction Study. Self-reported history of alcohol, tobacco, and marijuana use was compared between pregnant women with and without depressive symptomatology with adjustment for demographic factors. Results After adjustment for demographic factors, women with depressive symptomatology were more likely to report: any alcohol use (odds ratio [OR]: 1.4, 95% confidence interval [CI]: 1.1–1.8), >1 drink per week (OR: 1.3, 95% CI: 1.0–1.8), and >1 drink per day (OR: 2.2, 95% CI: 1.5–3.4). Women with depressive symptomatology were also more likely to report use of marijuana (OR: 1.8, 95% CI: 1.2–2.6) and cigarettes (OR: 1.4, 95% CI: 1.1–1.7). Conclusion Depressive symptomatology was associated with an increase in self-reported the use of alcohol, tobacco, and marijuana during pregnancy. These data reveal the importance of targeted screening of pregnant women with depressive symptomatology for substance use.

Author(s): Iskandar, W; Gatton, AS; Gaire, B; Sturm, FP; Larsen, KA; Champenois, EG; Shivaram, N; Moradmand, A; Williams, JB; Berry, B; Severt, T; Ben-Itzhak, I; Metz, D; Sann, H; Weller, M; Schoeffler, M; Jahnke, T; Dorner, R; Slaughter, D; Weber, T | Abstract: We have conducted an experimental study on the photo double ionization (PDI) of carbon-dioxide dimers at photon energies of 37 and 55 eV and oxygen dimers at photon energies of 38, 41.5, and 46 eV, while focusing on the dissociation dynamics upon single-photon absorption. The investigation was performed by applying the cold-target recoil-ion momentum spectroscopy method in order to collect and record the three-dimensional momenta of the ionic fragments and emitted electrons from the dissociating dimer in coincidence. The kinetic-energy release upon fragmentation and the electron angular distributions in the laboratory and body-fixed frames, as well as the relative electron-electron emission angle, show unambiguous experimental evidence of intermolecular Coulombic decay (ICD) in carbon-dioxide dimers upon photoionization below and above the double-ionization threshold of CO2 monomers. The PDI of oxygen dimers is less conclusive and shows contributions from ICD and knock-off ionization mechanisms. As for atomic dimers, the present results reveal that ICD in CO2 dimers after valence PDI can also serve as a source for low-energy electrons, known to be very relevant in biological systems, cells, and tissues.

Stimulant use, including cocaine, methamphetamines, ecstasy, and prescription stimulants, in pregnancy is increasingly common. In the United States, stimulants are the second most widely used and abused substances during pregnancy and pregnant women using stimulants in pregnancy are at increased risk of adverse perinatal, neonatal, and childhood outcomes. In this review, we describe the pharmacology, pathophysiology, and epidemiology of stimulants, summarize the maternal and neonatal effects of perinatal stimulant use, and outline treatment options for stimulant use disorders among pregnant women. Development of effective treatment strategies for stimulant use disorders identified among pregnant women are urgently needed.

Intense lake-effect snowstorms regularly develop over the eastern Great Lakes, resulting in extreme winter weather conditions with snowfalls sometimes exceeding 1 m. The Ontario Winter Lake-effect Systems (OWLeS) field campaign sought to obtain unprecedented observations of these highly complex winter storms. OWLeS employed an extensive and diverse array of instrumentation, including the University of Wyoming King Air research aircraft, five university-owned upper-air sounding systems, three Center for Severe Weather Research Doppler on Wheels radars, a wind profiler, profiling cloud and precipitation radars, an airborne lidar, mobile mesonets, deployable weather Pods, and snowfall and particle measuring systems. Close collaborations with National Weather Service Forecast Offices during and following OWLeS have provided a direct pathway for results of observational and numerical modeling analyses to improve the prediction of severe lake-effect snowstorm evolution. The roles of atmospheric boundary layer processes over heterogeneous surfaces (water, ice, and land), mixed-phase microphysics within shallow convection, topography, and mesoscale convective structures are being explored. More than 75 students representing nine institutions participated in a wide variety of data collection efforts, including the operation of radars, radiosonde systems, mobile mesonets, and snow observation equipment in challenging and severe winter weather environments.

Objective The standard procedure of transcatheter aortic valve implantation involves transfemoral access. Nevertheless, the use of this access route is limited by the vessel diameter, calcification, and tortuosity, making a subgroup of patients ineligible for peripheral access. We report the first use of direct aortic transcatheter aortic valve implantation with the Direct Flow Medical valve (Direct Flow Medical, Inc, Santa Rosa, Calif) in 15 patients at the Halle-Wittenberg University. Methods Between January 2014 and May 2015, 55 patients with severe aortic valve disease underwent transcatheter aortic valve implantation with the Direct Flow Medical valve at the Halle-Wittenberg University. Subgroups of 15 patients were treated using direct aortic access because of small vessel diameter, excessive calcification, or extreme tortuosity of the iliofemoral vessels. Results The mean patient age was 79.1 ± 6.72 years, and 10 patients (66%) were male. The mean logistic European System for Cardiac Operative Risk Evaluation was 23.4% ± 16.9%, and the mean Society of Thoracic Surgeons score was 7.8% ± 6.8%. Access related to redo-sternotomy during transcatheter aortic valve implantation was required in 4 patients (27%). Valve retrieval was performed in 2 patients (13%). There was no conversion to surgical aortic valve replacement and no incidence of major stroke. The postimplant mean gradient was 9.3 ± 2.5 mm Hg. No patient had moderate or severe paravalvular leakage. All patients survived the first 30 days. Conclusions Direct aortic access seems to be a feasible and safe endovascular alternative for implantation of the Direct Flow Medical valve. This access provides direct and accurate control of the entire implantation procedure.

To ascertain demographic and clinical characteristics of maternal deaths from self-harm (accidental overdose or suicide) to identify opportunities for prevention.We report a case series of pregnancy-associated deaths resulting from self-harm in the state of Colorado between 2004 and 2012. Self-harm deaths were identified from several sources, including death certificates. Birth and death certificates along with coroner, prenatal care, and delivery hospitalization records were abstracted. Descriptive analyses were performed. For context, we describe demographic characteristics of women with a maternal death from self-harm and all women with live births in Colorado.Among the 211 total maternal deaths in Colorado over the study interval, 30% (n=63) resulted from self-harm. The pregnancy-associated death ratio from overdose was 5.0 (95% confidence interval [CI] 3.4-7.2) per 100,000 live births and from suicide 4.6 (95% CI 3.0-6.6) per 100,000 live births. Detailed records were obtained for 94% (n=59) of women with deaths from self-harm. Deaths were equally distributed throughout the first postpartum year (mean 6.21±3.3 months postpartum) with only six maternal deaths during pregnancy. Seventeen percent (n=10) had a known substance use disorder. Prior psychiatric diagnoses were documented in 54% (n=32) and prior suicide attempts in 10% (n=6). Although half (n=27) of the women with deaths from self-harm were noted to be taking psychopharmacotherapy at conception, 48% of them discontinued the medications during pregnancy. Fifty women had toxicology testing available; pharmaceutical opioids were the most common drug identified (n=21).Self-harm was the most common cause of pregnancy-associated mortality, with most deaths occurring in the postpartum period. A four-pronged educational and program building effort to include women, health care providers, health care systems, and both governments and organizations at the community and national levels may allow for a reduction in maternal deaths.

Geostationary Operational Environmental Satellite (GOES) visible imagery was used to identify lake-effect (LE) clouds in the North American Great Lakes region for the cold seasons (October–March) of 1997/1998 through 2013/2014 to provide a comprehensive climatological description of the seasonal and interannual variability of LE cloud bands. During the average cold season, at least 60% of days each month had LE clouds over some portion of the Great Lakes region and nearly 75% of all LE days had LE clouds present over several lakes simultaneously. Wind-parallel bands (WPB) are observed far more frequently than any other type of LE over Lakes Superior, Michigan, and Huron during the months of December, January, and February. Over Lake Erie, the occurrence of days per month with WPB was found to be approximately 5–10% greater than days with shore-parallel bands (SPBs) throughout the entire cold season. The greatest frequency of SPB occurrences in the Great Lakes region was over Lake Ontario during the months of January and February (∼20% of days). In addition, Lake Ontario was the only lake where the frequencies of WPB and SPB occurrences were fairly similar each month. The annual frequency of WPB occurrences are the most variable among the Great Lakes, decreasing in frequency from the western lakes toward the eastern lakes. Lake Ontario has the largest annual frequency of SPB occurrences and the greatest variation in SPB annual frequency. Lake Huron has the second largest annual frequency of SPB days with small interannual variation. The primary differences of the annual frequency of lake-to-lake (L2L) LE occurrences when compared with previous research were a greater variability in the L2L annual frequency of Superior-to-Michigan connections, greater frequency of Michigan-to-Huron connections, and less frequent occurrences for Superior-to-Huron and Michigan-to-Erie connections.

Objective We sought to identify factors influencing a woman's decision to have an elective repeat cesarean delivery (ERCD) versus vaginal birth after cesarean (VBAC). Methods and Materials A prospective study at two academic medical centers of women with one prior cesarean, and no contraindication to a trial of labor, delivered by ERCD from October 2013 to June 2014. Participants completed anonymous surveys during their delivery hospitalization. Counseling was considered adequate if women reported being counseled, recalled being quoted a VBAC success probability, and this probability was within 20% of that derived from an established VBAC success prediction model. Participants were also asked why they chose ERCD. Results Of 68 participants, only 8 (11.8%) had adequate counseling. Of those with inadequate counseling, 21.7% did not recall being counseled, 63.3% were not quoted a chance of success, and 60.0% had more than a 20% discrepancy between their recalled and predicted success rates. Eighteen women were calculated to have more than 70% chance of successful VBAC. Of these, 16 (88.9%) were not adequately counseled. Conclusion Most women were inadequately counseled about delivery options. The most important factors influencing the choice of ERCD over VBAC were patient preferences, risk for fetal injury, and perceived physician preference.

Uveal melanoma (UM), a tumor of the eye, can be divided into 2 major classes correlating with patients' prognosis. Gene expression profiles and chromosome 3 status are correlated with tumor classification and prognosis. Somatic BAP1 mutations are another feature largely restricted to metastatic UM. Here we performed thorough BAP1 mutation analysis including sequencing and gene dosage analysis of all BAP1 coding exons as well as methylation analysis of the promoter CpG island in a set of 66 UMs. The results were compared with the BAP1 protein expression as determined by immunohistochemistry and the tumor-related survival of the patients. BAP1 sequencing and gene dosage analysis of BAP1 exons by multiplex ligation-dependent probe amplification revealed a mutation in 33 (89%) of 37 tumors with monosomy 3 (M3) or isodisomy 3. BAP1 mutations were not detected in any of the 28 tumors with disomy 3 or partial monosomy 3 (partM3). Most of the sequence mutations (21 of 28) were frame-shift, splice-site, or nonsense mutations leading to a premature termination codon. BAP1 protein as determined by immunohistochemistry was absent in all samples with a BAP1 mutation irrespective of the functional type of mutation. Kaplan-Meier analysis revealed a highly significant association between BAP1 protein staining and patients' survival (P=0.0004). The association between BAP1 mutation status and tumor-related survival was less pronounced but still significant (P=0.0023). We conclude that BAP1 protein staining is favorable over BAP1 mutation screening by Sanger sequencing for prognostic testing of UM patients.

Objective We aimed to determine if obese women undergoing trial of labor after cesarean (TOLAC) were more likely to undergo repeat cesarean for arrest disorders prior to active labor, and whether this was due to decreased use of standard interventions to achieve vaginal birth. Study Design This was a secondary analysis of a prospective registry. Women undergoing TOLAC with one prior cesarean and a singleton, term gestation who had a repeat cesarean for an arrest disorder were included. The primary outcome was repeat cesarean prior to active labor (cervical dilation

Purpose To collect comprehensive data on choroidal and ciliary body melanoma (CCBM) in children and to validate hypotheses regarding pediatric CCBM: children younger than 18 years, males, and those without ciliary body involvement (CBI) have more favorable survival prognosis than young adults 18 to 24 years of age, females, and those with CBI. Design Retrospective, multicenter observational study. Participants Two hundred ninety-nine patients from 24 ocular oncology centers, of whom 114 were children (median age, 15.1 years; range, 2.7–17.9 years) and 185 were young adults. Methods Data were entered through a secure website and were reviewed centrally. Survival was analyzed using Kaplan-Meier analysis and Cox proportional hazards regression. Main Outcome Measures Proportion of females, tumor-node-metastasis (TNM) stage, cell type, and melanoma-related mortality. Results Cumulative frequency of having CCBM diagnosed increased steadily by 0.8% per year of age between 5 and 10 years of age and, after a 6-year transition period, by 8.8% per year from age 17 years onward. Of children and young adults, 57% and 63% were female, respectively, which exceeded the expected 51% among young adults. Cell type, known for 35% of tumors, and TNM stage (I in 22% and 21%, II in 49% and 52%, III in 30% and 28%, respectively) were comparable for children and young adults. Melanoma-related survival was 97% and 90% at 5 years and 92% and 80% at 10 years for children compared with young adults, respectively ( P = 0.013). Males tended to have a more favorable survival than females among children (100% vs. 85% at 10 years; P = 0.058). Increasing TNM stage was associated with poorer survival (stages I, II, and III: 100% vs. 86% vs. 76%, respectively; P = 0.0011). By multivariate analysis, being a young adult (adjusted hazard rate [HR], 2.57), a higher TNM stage (HR, 2.88 and 8.38 for stages II and III, respectively), and female gender (HR, 2.38) independently predicted less favorable survival. Ciliary body involvement and cell type were not associated with survival. Conclusions This study confirms that children with CCBM have a more favorable survival than young adults 18 to 25 years of age, adjusting for TNM stage and gender. The association between gender and survival varies between age groups.

Obesity in pregnancy confers morbidity to both the mother and neonate. Obese women are at increased risk of cesarean delivery, operative vaginal delivery, and failed trial of labor after cesarean delivery. In addition to impacting the mode of delivery, obesity is associated with hemorrhage, infection, and thromboembolic complications in the peripartum period. The risk of these complications increases with increasing maternal body mass index. In this chapter, we discuss evidence-based strategies to mitigate these risks and to manage complications that occur at the time of delivery in obese parturients.

A 28-year-old woman, gravida 3 para 2, with two previous cesarean deliveries presents for prenatal care. Her second pregnancy was complicated by a uterine rupture at 36 weeks of gestation. She asks, "When should I be delivered during the current pregnancy?"