Background Smoking marijuana has been reported to increase risk of myocardial infarction (MI) immediately after use, but less is known about the long-term impact of marijuana use among patients with established coronary disease. Methods The Determinants of MI Onset Study (MIOS) is a multicenter inception cohort study of MI patients enrolled in 1989–1996 and followed for mortality using the National Death Index. In an initial analysis of 1935 MI survivors followed for a median of 3.8 years, we found an increased mortality rate among marijuana users. The current paper includes 3886 MIOS patients followed for up to 18 years. We used Cox proportional hazards models to calculate the hazard ratio and 95% confidence interval for the association between marijuana use and mortality and a propensity score matched analysis to further control confounding. Results Over up to 18 years of follow-up, 519 patients died, including 22 of the 109 reporting marijuana use in the year prior to their MI. There was no statistically significant association between marijuana use and mortality. Compared to non-users, the mortality rate was 29% higher (95% confidence interval 0.81 to 2.05, p=0.28) among those reporting any marijuana use. Conclusions Habitual marijuana use among patients presenting with acute MI was associated with an apparent increased mortality rate over the following 18 years that did not reach nominal statistical significance. Larger studies with repeated measures of marijuana use are needed to definitively establish whether there are adverse cardiovascular consequences of smoking marijuana among patients with established coronary heart disease.

Objective The possible connection between COVID-19 and hypertensive disorders of pregnancy (HDP) remains unclear (1). Elucidating these outcomes is important both to better understand COVID-19 pathophysiology and to improve patient care in pregnant patients with COVID-19. Our objectives were to test the hypothesis that COVID-19 infection is associated with an increased risk of HDP and to examine the association between the gestational age at COVID-19 infection and delivery and HDP risk. Study Design This was a retrospective cohort study at Barnes-Jewish Hospital in St. Louis, which has a universal COVID-19 testing policy on admission to labor and delivery. All women admitted for delivery from June 1, 2020-November 30, 2020, with a positive Sars-CoV-2 test at any time during pregnancy were compared 1:2 with randomly selected controls who had a negative SARS-CoV-2 test and were matched for race and parity. COVID-19 was diagnosed with nasopharyngeal RT-PCR or rapid antigen testing. HDP was diagnosed using standard criteria. Cox proportional hazards models with left truncation to account for the varying gestational age at COVID-19 diagnosis, and random effects (frailty) to account for the matching design and small cluster sizes, were used to examine the association between COVID-19 and HDP (2). As a sensitivity analysis we also examined early (before 32 weeks gestation) vs. late COVID-19 infection and HDP development. The study was deemed exempt from review by the Institutional Review Board. Results Of 1856 births, there were 83 women (4.5%) with COVID-19 infection. There was no significant difference in baseline characteristics between COVID-19 infected women and controls. Patients with COVID-19 infection had almost a two-fold risk of HDP (HR 1.93 (95%CI 1.13, 3.31). However, COVID-19 infection was not associated with severity of HDP, and severity of COVID-19 (3) was not associated with HDP development. Among patients with COVID-19 and HDP at delivery, the median interval from COVID-19 diagnosis to delivery was 3.8 weeks (IQR 0.29, 11.5). In additional analysis, early, but not late, COVID-19 infection was associated with HDP development (HR for early COVID-19 2.17 (95%CI 1.11, 4.24), HR for late COVID-19 1.68, (95%CI 0.79, 3.57). Conclusions Early COVID-19 infections are associated with HDP, even when accounting for differential exposure and delivery times, suggesting that COVID-19 infection may alter pregnancy physiology and increase the risk of HDP development over time. Infection closer to term is not associated with HDP, which likely reflects our high proportion of asymptomatic infections found at the time of delivery from a universal testing policy (4) and insufficient time to develop HDP in these cases. Furthermore, emerging evidence suggests that COVID-19 modulates placental ACE2 expression, which may be related to HDP development (5). Our study is limited by sampling in a single institution with a high HD...

Background-The relationship between residential proximity to roadway and long-term survival after acute myocardial infarction (AMI) is unknown. We investigated the association between distance from residence and major roadway and 10-year all-cause mortality after AMI in the Determinants of Myocardial Infarction Onset Study (Onset Study), hypothesizing that living closer to a major roadway at the time of AMI would be associated with increased risk of mortality. Methods and Results-The Onset Study enrolled 3886 individuals hospitalized for AMI in 64 centers across the UnitedStates from 1989 to 1996. Institutionalized patients, those providing only post office boxes, and those whose addresses could not be geocoded were excluded, leaving 3547 patients eligible for analysis. Addresses were geocoded, and distance to the nearest major roadway was assigned. Cox regression was used to calculate hazard ratios, with adjustment for personal characteristics (age, sex, race, education, marital status, distance to nearest acute care hospital), clinical characteristics (smoking, body mass index, comorbidities, medications), and neighborhood-level characteristics derived from US Census block group data (household income, education, urbanicity). There were 1071 deaths after 10 years of follow-up. In the fully adjusted model, compared with living Ͼ1000 m, hazard ratios (95% confidence interval) for living Յ100 m were 1.27 (1.01-1.60), for 100 to Յ200 m were 1.19 (0.93-1.60), and for 200 to Յ1000 m were 1.13 (0.99 -1.30) (P trend ϭ0.016). Conclusions-In this multicenter study, living close to a major roadway at the time of AMI was associated with increased risk of all-cause 10-year mortality; this relationship persisted after adjustment for individual and neighborhood-level covariates. (Circulation. 2012;125:2197-2203.)

Objectives To identify the range of waveform abnormalities in the ductus venosus (DV) characterized by their timing in the cardiac cycle and to evaluate if they can be categorized into distinct patterns. Methods DV velocity ratios were calculated from peak velocities during ventricular systole (S), endsystolic ventricular relaxation (v), early diastole (D) and atrial systole (a) (S/v, S/D, v/D, S/a, v/a and D/a ratios). The ratios were converted to their Zscores and elevation > 2 SD was assigned as abnormal. Combinations of ratio abnormalities were grouped to define distinct waveform patterns and their distribution was related to the clinical presentation. Results Five-hundred and forty-two abnormal DV waveforms fell into three principal patterns. In Pattern 1 only the a-wave-related ratios were abnormal (180, 33.2%), in Pattern 2 the v/D ratio was abnormal (143, 26.3%) and in Pattern 3 combinations of a-wave abnormalities in the presence of a normal v/D ratio were normal (94, 17.3%). Conclusions Interpretation of venous waveform patterns is complex because the multiphasic waveforms reflect

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Background-In 2010 the Consortium on Safe Labor published labor curves. It was proposed that the rate of cesarean delivery (CD) could be lowered by avoiding the diagnosis of arrest of dilation before 6 cm. However, there is little information on the uptake of the guidelines and on changes in CD rates that may have occurred.Objective-To test the hypotheses that: 1) among patients laboring at term, rates of arrest of dilation disorders have decreased leading to a decrease in the rate of CD; 2) in the second stage, pushing duration prior to diagnosis of arrest of descent has increased also leading to reduction in the rate of CD for this indication. As a secondary aim, we investigated changes in maternal and neonatal morbidity.Study Design-This was a secondary analysis of a prospective cohort study of all patients presenting at ≥ 37 weeks' gestation from 2010-2014 with a non-anomalous vertex singleton and no prior history of CD. Rates of CD, arrest of dilation, and changes in rates of maternal and neonatal morbidity were calculated in crude and adjusted models. Cervical dilation at diagnosis of arrest of dilation, time spent at the maximal dilation prior to diagnosis of arrest of dilation, and time in the second stage prior to diagnosis of arrest of descent were compared over the study period.Results-There were 7845 eligible patients. The CD rate in 2010 was 15.8% and in 2014 17.7% (p-trend 0.51). In patients undergoing CD for arrest of dilation, the median cervical dilation at the time of CD was at 5.5 cm in 2010 and 6.0 cm in 2014 (p-trend 0.94). In these patients, there was an increase in the time spent at last dilation: 3.8h in 2010 to 5.2h in 2014 (p-trend 0.02). There was no change in the frequency of patients diagnosed with arrest of dilation at <6 cm: 51.4% in 2010 and 48.6% in 2014 (p-trend 0.56). However, in these patients, the median time spent at the last

OBJECTIVE: To estimate whether severe maternal morbidity is associated with increased risk of psychiatric illness in the year after delivery hospital discharge. METHODS: This retrospective cohort study used International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes within Florida's Healthcare Cost and Utilization Project's databases. The first liveborn singleton delivery from 2005 to 2015 was included; women with ICD-9-CM codes for psychiatric illness or substance use disorder during pregnancy were excluded. The exposure was ICD-9-CM codes during delivery hospitalization of severe maternal morbidity, as per the Centers for Disease Control and Prevention. The primary outcome was ICD-9-CM codes in emergency department encounter or inpatient admission within 1 year of hospital discharge of composite psychiatric morbidity (suicide attempt, depression, anxiety, posttraumatic stress disorder, psychosis, acute stress reaction, or adjustment disorder). The secondary outcome was a composite of ICD-9-CM codes for substance use disorder. We compared women with severe maternal morbidity with those without severe maternal morbidity using multivariable logistic regression adjusting for sociodemographic factors and medical comorbidities. Cox proportional hazard models identified the highest risk period after hospital discharge for the primary outcome. RESULTS: A total of 15,510 women with severe maternal morbidity and 1,178,458 without severe maternal morbidity were included. Within 1 year of hospital discharge, 2.9% (n=452) of women with severe maternal morbidity had the primary outcome compared with 1.6% (n=19,279) of women without severe maternal morbidity, resulting in an adjusted odds ratio (aOR) 1.74 (95% CI 1.58–1.91). The highest risk interval was within 4 months of discharge (adjusted hazard ratio [adjusted HR] 2.53 [95% CI 2.05–3.12]). Most severe maternal morbidity conditions were associated with higher risk of postpartum psychiatric illness. Women with severe maternal morbidity had nearly twofold higher risk of postpartum substance use disorder (170 [1.1%] vs 6,861 [0.6%]; aOR 1.91 [95% CI 1.64–2.23]). CONCLUSION: Though absolute numbers were modest, severe maternal morbidity was associated with increased risk of severe postpartum psychiatric morbidity and substance use disorder. The highest period of risk extended to 4 months after hospital discharge.