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Internal jugular vein (IJV) compression influences not only intracranial but also intracochlear physiology and has demonstrated preclinical effectiveness in reducing acute audiological injury in a rodent blast model. However, the long-term effects in this model are unknown.Blast wave-induced audiological injury from an improvised explosive device is a leading cause of morbidity among service members in theater but there are limitations to the current protective measures.For this study, we exposed 20 Sprague Dawley rats to a 16.8 ± 0.3 PSI (195.3 dB SPL) right-sided shock wave in which 10 had application of a custom IJV compression collar in place at the time of injury.IJV compression at the time of injury was shown acutely to significantly reduce the incidence of tympanic membrane rupture and the initial temporary threshold shift on otoacoustic emissions in both the right and left ears of animals who had collar application immediately after and 7 days post injury. At 28 days from injury, collared animals demonstrated a return to baseline of otoacoustic emission values while the noncollared animals had persistent threshold shifts, signifying the presence of a permanent threshold shift only in those animals without collar application. IJV compression was also found to significantly reduce hair cell loss at the base of the cochlea secondary to mechanical trauma from the blast wind.Previously observed acute protective effects of IJV compression are sustained at chronic time points. IJV compression can potentially be used to reduce long-term permanent morbidity from blast-induced audiological trauma.

HYPOTHESIS Internal jugular vein (IJV) compression before blast injury will lead to reduced risk of traumatic hearing injury following exposure to a blast injury. BACKGROUND IJV compression and its effects on not only intracranial, but also intracochlear pressure may potentiate blast induced hearing injury, therefore, precluding its use as a prophylactic therapy for blast induced traumatic brain injury. METHODS Twenty Sprague Dawley rats were exposed to a 17.9 ± 0.4 PSI (195.8 dB SPL) right sided shock wave in which 10 had application of a custom IJV compression collar before injury. All rodents received baseline and post blast injury otoacoustic emission (OAE) and auditory brainstem response (ABR) testing followed by cochlear histology. RESULTS IJV compression was shown to significantly reduce ABR and OAE threshold shifts in comparison to the non-intervention group by: 14.9 ± 4.8 dB (right ear ABR 0.5 kHz Day 1 post blast, p = 0.01), 13.1 ± 4.9 dB (right ear ABR 4 kHz Day 1 post blast, p = 0.04), 16.5 ± 4.5 dB (right ear ABR click Day 1 post blast, p = 0.003), 12.1 ± 4.6 dB (right ear ABR click Day 6 post blast, p = 0.04), and 14.0 ± 3.2 dB (both ears OAE 3.2-10 kHz, p

Objective The objective of this study is to assess the opinions of Fellows of the American College of Obstetricians and Gynecologists on expanded carrier testing (molecular detection of >100 genetic diseases of variable severity) and noninvasive prenatal testing (NIPT). Methods A survey conducted between March and August 2012, assessed current use of testing, provision of genetic counseling, types of disorders that should be identified, preferences for future use, ethical aspects, and views on regulatory oversight. Results Expanded carrier testing was offered to all patients by 15% of the responders and 52.1% upon patient request. Most (67.3%) favored testing only for mutations of known significance. In this study, 79.1% supported the use of NIPT as a screen for Down syndrome for all women with 47.9% viewing NIPT as a complete substitution for invasive testing. Most supported expansion to other aneuploidies (97.5%) and severe early-onset Mendelian disorders (90.4%) but not for adult-onset disorders (29.8%) or nonmedical sex identification (15.7%). A majority (73.2%) believed that NIPT would increase pregnancy terminations for mild disease states. Respondents favored a role for professional societies in providing regulatory oversight. Conclusion Rapid incorporation of new genetic technologies may be limited by the availability of genetic counseling, concerns regarding inclusion of clinically mild disorders, results of unknown significance, and costs. © 2013 John Wiley & Sons, Ltd.

Objective To assess the frequency of surgical techniques at cesarean delivery (CD) among U.S. obstetricians. Methods Members of the American College of Obstetrician Gynecologists were randomly selected and e-mailed an online survey that assessed surgical closure techniques, demographics, and reasons. Data were analyzed using SPSS (IBM Corp., Armonk, New York, United States), descriptive statistics, and analysis of variance. Results Our response rate was 53%, and 247 surveys were analyzed. A similar number of respondents either “always or usually” versus “rarely or never” reapproximate the rectus muscles (38.4% versus 43.3%, p = 0.39), and close parietal peritoneum (42.5% versus 46.9%, p = 0.46). The most frequently used techniques were double-layer hysterotomy closure among women planning future children (73.3%) and suturing versus stapling skin (67.6%); the least frequent technique was closure of visceral peritoneum (12.2%). Surgeons who perform double-layer hysterotomy closure had fewer years in practice (15.0 versus 18.7 years, p = 0.021); surgeons who close visceral peritoneum were older (55.5 versus 46.4 years old, p Conclusion Similar numbers of obstetricians either reapproximate or leave open the rectus muscles and parietal peritoneum at CD, suggesting that wide variation in practice exists. Surgeon demographics and safety concerns play a role in some techniques.

Objective To survey generalist obstetrician-gynecologists about their satisfaction with and patterns of referral to maternal–fetal medicine (MFM) specialists. Study Design A survey was sent three times to 1030 randomly selected American Congress of Obstetricians and Gynecologists members across the country, and results were tabulated. Results A total of 516 surveys (50%) were returned; 68% of respondents were satisfied (S) with available MFM services and 31% were not satisfied (Not S). S and Not S respondents were similar with respect to age, gender, years in practice, type of practice, hours worked per week, proximity to MFM specialists, number of deliveries per year, and level of nursery in their hospital. Reasons for dissatisfaction included: MFM specialist not readily available (49%), during the day (26%), at night (35%), or on weekends (36%); MFM specialist unwilling to take care of hospitalized patients (26%); or MFM specialist does only ultrasound, chorionic villus sampling, and amniocentesis (32%). Although some generalists do not consult MFM specialists frequently, the majority of both S and Not S respondents would request an MFM consult or comanagement for 26 of 38 specific maternal, fetal, and obstetric diagnoses/complications. Conclusion The majority of obstetrician-gynecologists are satisfied with their MFM support. The dissatisfaction expressed by 31% of generalists might be ameliorated if individual MFM specialists increased their availability and/or broadened their scope of practice.

Extremely low birth weight (ELBW) is an established risk factor for poor neurocognitive outcome, particularly when severe intraventricular hemorrhage (IVH) complicates the neonatal course. Those born26 weeks gestational age (GA) are at greatest risk, their outcomes poorer than later born ELBW children. Outcomes of GA subgroups of ELBW uncomplicated by severe IVH have not been well described.To compare neurocognitive and behavioral outcomes of those bornandor=26 weeks for an ELBW cohort treated in a single center with extremely low IVH incidence.Single center retrospective observational cohort study ofor=1000 g survivors born between 1998-2000, using standardized tests of cognition, academic achievement, executive function, attention, language, memory, motor/visual-motor skill, parent and teacher behavioral questionnaires.ELBW participants (mean age: 6.85+/-0.79) had a mean General Cognitive Ability of 101.4+/-13.05; no significant differences found between26 weeks (98.19+/-12.48) andor=26 weeks (102.97+/-13.21) subgroups. No neurocognitive, achievement, or behavioral score was impaired (or=2 SDs below the normative mean). Subgroup comparisons were nonsignificant after controlling for BW and maternal education, except foror=26 week advantage for phoneme analysis. Poorer, but low average, performances were found for motor dexterity/coordination, spatial working memory, and selective attention.Age-appropriate neurocognitive and behavioral function of ELBW survivors suggests outcome may be predicted based on IVH incidence as opposed to birth weight or GA. Factors leading to decreased IVH incidence deserve further study, via single- and cross-center methodologies, to enhance decision-making regarding resuscitation and care of these highly at-risk neonates.

Summary Summary/objectives In accordance with the Joint Committee on Infant Hearing's (JCIH, 2000) position statement regarding Universal Newborn Hearing Screenings (UNHS), the state of Illinois enacted legislation requiring all birthing hospitals to conduct UNHS by 31 December 2002. Currently 100% of birthing facilities in the state of Illinois perform newborn infant hearing screenings using otoacoustic emissions (OAEs) and/or automated auditory brainstem response (AABR) measures. This study is an attempt to document current practices in hospital-based UNHS programs, as reported by program personnel, in the state of Illinois. The goal is to compare these reported practices to the recommended standards and identify factors that could lead to further refinement of the process. Methods A modified version of the Newborn Hearing Screening Survey from the Marion Downs National Center for Infant Hearing was used to gather practice- and protocol-related data for the 2004 calendar year via the World Wide Web. Data presented here are extracted from the online survey as reported by hospital staff presumably associated with the UNHS program. Results Fifty-nine of the 140 hospitals with UNHS programs responded to the Web-based survey. Nursing staff, followed by technicians, were most commonly reported to perform initial hearing screenings in both the well-baby nursery (WBN) and the neonatal intensive care unit (NICU). Audiologists appeared to participate in re-screenings at a greater number of the facilities. Automated ABR was the most common screening tool (80%) followed by Distortion Product OAEs (32%) and Transient Evoked OAEs (5%). Eighty-six percent reported referral rates that were less than 5%, with 32% reporting a referral rate less than 1%. Conclusions At the beginning of 2004, 99% of all infants born in Illinois were being screened for hearing loss. Personnel involvement and screening measures employed were comparable to the few reports available from other states. The audiologist's role was found to be fairly limited in screening, re-screening, or managing UNHS programs. Referral rates were consistent with national standards (∼1%). Management of UNHS programs in small, rural facilities, tracking/monitoring high-risk infants, and other services provided to families emerged as areas with room for improvement.

The purpose was to assess practicing obstetrician-gynecologists' knowledge about the prenatal diagnosis and postnatal prognosis of spina bifida. Written questionnaires designed to assess practicing obstetrician-gynecologists' knowledge of spina bifida were mailed to 1000 randomly selected American College of Obstetricians and Gynecologists Fellows. More than 50% did not identify many of the sonographic features indicative of an open neural tube defect in the fetus and more than one third overestimated the risks of stillbirth, whereas more than two thirds overestimated the risk for premature delivery in a pregnancy complicated by fetal spina bifida. Just more than 50% correctly estimated the 1-year survival rate and just less than 50% correctly estimated survival at 6 years. Sixty-six percent overestimated the incidence of mental retardation associated with spina bifida. Maternal-fetal medicine specialists returning the survey exhibited a much better understanding of the prenatal issues and prognostic and outcome factors related to spina bifida. There are gaps in obstetrician-gynecologists' knowledge about the diagnostic features of and prognosis for fetal spina bifida. It is important for them to take advantage of continuing medical education opportunities to learn more about the management of pregnancies complicated by fetal spina bifida and about the prognosis for affected individuals.

To assess practicing obstetricians' knowledge of the etiology and pathophysiology of neonatal encephalopathy and its relationship to cerebral palsy.A questionnaire designed to test both knowledge and practice patterns was mailed to 413 members of the Collaborative Ambulatory Research Network of The American College of Obstetricians and Gynecologists (ACOG), as well as 600 randomly selected non-Network ACOG Fellows. The questionnaire was composed of 15 knowledge questions and three clinical scenarios containing seven knowledge questions. Six of the questions directly assessed knowledge of cerebral palsy.Of those who returned the questionnaire, 351 practiced obstetrics and were included in the statistical analyses. For the majority of questions, "Don't know" was the most frequent response. The next most frequent response for 8/13 questions was the correct answer. Performance was strongest as regarded actual clinical practice and relatively weak regarding the antecedents of neonatal encephalopathy and cerebral palsy. The physicians' actual knowledge scores showed a significant correlation with their self-assessments of knowledge (r =.41, P.001). The majority of physicians rated their training on this topic in medical school, residency, and through continuing medical education as marginal or inadequate.The results of this survey identified large knowledge gaps in this area, suggesting a need to develop educational projects to address these deficits by both professional organizations and individual teachers.

UNLABELLED Historically, obstetrics and gynecology has been a medical/surgical specialty focusing on women's health and reproductive concerns during the childbearing years. Newer responsibilities-for example, in primary care, gerontology, and genetics-require Ob-Gyns to draw upon a base of medical knowledge that traditionally was not considered germane to their practices. Ob-Gyns are increasingly providing more primary care services to their patients; consequently, the field has expanded considerably. The Collaborative Ambulatory Research Network (CARN) was created in 1990 as a vehicle for investigating issues pertinent to women's health and to the practice of obstetrics and gynecology in the outpatient setting. This article summarizes the findings of CARN studies from 1995 to 2000, covering a range of topics related to women's health across the life cycle, including, but not limited to perinatal care. Topics include nutrition, infectious disease, hormone replacement therapy, psychosocial issues, and genetic testing in obstetric and gynecologic practice. Each study produced a picture of current practice patterns and knowledge of the physicians surveyed. Findings on knowledge, attitudes, and practices varied widely. Overall, Ob-Gyns were knowledgeable and consistent in more traditional areas of practice. Conversely, inconsistencies were observed in newer areas. TARGET AUDIENCE Obstetricians & Gynecologists, Family Physicians LEARNING OBJECTIVES After completion of this article, the reader will be able to define what the Collaborative Ambulatory Research Network (CARN) involves, describe how CARN obtains its data, and summarize some of the findings of CARN from the years 1995 to 2000.

Increased CRH secretion by the placenta of pregnant women has been associated with preterm birth. Certain indices of risk, both medical and psychosocial in nature, have been linked to preterm delivery. Levels of total, bound, and free CRH, CRH-binding protein (CRH-BP), and cortisol were measured prospectively in a large sample of pregnant Danish women who delivered preterm and term infants. Measures of maternal serum hormones were taken at 7--23 and 27--37 weeks gestation and, for those who delivered at term, at 37--43 weeks gestation. At 7--23 weeks gestation, maternal levels of total CRH (P = 0.01), bound CRH (P = 0.03), and CRH-BP (P = 0.01) were higher in the preterm than in the term group. At 27--37 weeks gestation, levels of total CRH (P < 0.0001), bound CRH (P < 0.0001), free CRH (P < 0.0001), and cortisol (P < 0.0001) were all higher in the preterm than the term group, whereas levels of CRH-BP (P < 0.0001) were lower in the preterm than in the term group. The best medical and behavioral factors associated with preterm delivery were, respectively, previous preterm delivery (P < 0.0001) and engagement in certain risk-taking behaviors (P = 0.008). The positive relations between preterm delivery and various adverse medical and socioeconomic variables with increases in placental secretion of CRH suggest that the latter may participate in the pathophysiology of preterm delivery.

To characterize the clinical decisions, knowledge, opinions, and education of obstetricians and gynecologists about antenatal corticosteroids.Questionnaires mailed to 1020 ACOG Fellows included items on demographics, knowledge, clinical practice patterns, and educational background regarding antenatal corticosteroids.The survey response rate was 47.8%. Almost all respondents (94%) reported administering antenatal corticosteroids, with reduction of respiratory distress syndrome (82%) as the primary reason for antenatal corticosteroid administration. Most (59.2%) were unaware of newly recognized associations between multiple administrations of corticosteroids and fetal growth restriction. In hypothetical clinical situations, responses by physicians who completed their residency training before 1970 indicated less likelihood to administer corticosteroids when administration is relatively indicated per National Institutes of Health (NIH) and ACOG guidelines than those trained later (P.001). Only 8% of the entire sample rated their knowledge of antenatal corticosteroids as comprehensive; most (68%) rated it as adequate. Respondents rated residency training as a much better source of antenatal corticosteroid knowledge than medical school.Most obstetrician-gynecologists reported using antenatal corticosteroids; however, in general, many were not aware of more recent information regarding potential risks. This survey suggests that a multipronged educational approach is warranted to update obstetrician-gynecologists about antenatal corticosteroids.

Our objective was to describe gynecologists' current practice patterns and opinions on genetic screening and their perceived importance of genetic screening within individual practices. A questionnaire survey was sent to 1248 American College of Obstetrics and Gynecology (ACOG) Fellows, of whom 564 (45%) responded. Results from the 428 respondents providing genetic screening for heritable diseases or disorders are reported. Forty-four percent of respondents believe advances in the treatment of genetic diseases are likely in the next 10 years. Currently, however, genetics in gynecological practice receives infrequent attention. Twenty-four percent of respondents do not routinely review family histories at gynecological visits, 39% rate genetic issues as last among priorities in the office, and only 14% obtain consent for the DNA tests that they initiate. Although 21.3% identified themselves as sole providers of genetic information and counseling to their patients, most (65.4%) note they are not confident of their knowledge of genetics, particularly concerning breast and ovarian cancer. For obstetrician-gynecologists to keep pace with the rapid changes in genetics, further education and assimilation of genetics into the routine office practice will need to occur. Not currently viewed as a priority among practitioners, issues of genetic knowledge, ethics, and test interpretation will soon need attention. National organizations, continuing medical education, and existing genetic centers will need to meet these recognized demands.

Although delayed umbilical cord clamping has been demonstrated to reduce the incidence of intraventricular hemorrhage and neonatal sepsis, and decrease the need for neonatal transfusions (without affecting cord pH, Apgar scores or the need for phototherapy), the extent to which this practice is being employed is unknown. We conducted a survey of US obstetricians to assess their attitudes and beliefs about cord clamping.Questionnaires were randomly mailed to members of the American College of Obstetricians and Gynecologists (ACOG), and the Collaborative Ambulatory Research Network (CARN). The data were analyzed using Chi-square and Student t tests.The response rates for the CARN and other ACOG members were 47% and 21%, respectively. Most (88%) responders reported their hospital had no umbilical cord clamping policy. The most frequent response for optimal timing of umbilical cord clamping, regardless of gestational age, was "don't know". Potential for neonatal red blood cell transfusion was the only concern cited as a reason for being somewhat or very inclined to delay umbilical cord clamping (51%). Delayed neonatal resuscitation (76%) was listed as a reason to clamp the cord immediately, despite the paucity of literature to support immediate cord clamping in this cohort.Despite substantial evidence supporting the practice of delayed cord clamping, few institutions have policies regarding this practice. Moreover, obstetricians' beliefs about the appropriate timing for umbilical cord clamping are not consistent with the evidence that demonstrates its beneficial impact on neonatal outcomes.

To study postnatal dexamethasone treatment effects on cognitive, neuropsychological and behavioral functioning at early school age in preterm children.We recruited 222 children born between 1998 and 2003: 114 extremely low birth weight (1000 g; 60 dexamethasone-treated; 54 untreated) and 108 term-born. Data were analyzed using multivariate methods.Preterm performed below term-born on all measures. Dexamethasone-treated performed below dexamethasone-untreated in immediate visual memory, visual-motor integration, mathematical skill and motor dexterity. However, stepwise regression indicated that medical and sociodemographic factors other than dexamethasone contributed to preterm group differences.Dexamethasone alone does not explain neurocognitive impairment in preterm children. Medical and sociodemographic factors (illness severity, male gender and parental education) are influential. Prospective longitudinal neuropsychological and behavioral study from preschool to school age that considers medical and sociodemographic variables will best address effects of dexamethasone exposure.

Objective: Stillbirth affects a large portion of the population and results in mortality rates comparable to those of preterm delivery and sudden infant death syndrome combined. Despite the large burden, little information is available to offer patients regarding etiology, treatment or prevention for a subsequent pregnancy. Methods: We surveyed a sample of Fellows of the American College of Obstetricians and Gynecologists to determine the practice patterns in the management of stillbirth. Results: The majority of Fellows agreed on the definition of stillbirth; however, their approach to treatment and prevention varied. A majority of Fellows believed that research on understanding stillbirth was of national importance. Conclusions: A comprehensive educational effort to include current knowledge regarding causes and management, standardized diagnostic procedures, death registration and case review is recommended to improve obstetric care of those with a stillbirth.

Objective: To describe group B streptococcal (GBS) disease prevention practices of obstetrician-gynecologists. Methods: We surveyed 1019 ACOG Fellows—the 419 members of the Collaborative Ambulatory Research Network (CARN) and 600 randomly selected non-CARN Fellows. Results: There were 601 eligible respondents. More than 95% in both the CARN and the non-CARN groups reported adopting one of three GBS prevention strategies. The most commonly reported strategy was a combination approach not described in the consensus guidelines. The second most common strategy was the screening-based strategy; the risk-based strategy was third. Most respondents provided GBS information to all prenatal patients, but those using a risk-based strategy and those in solo practice were less likely to do so. Less than 60% in each group used penicillin as their first choice for GBS prophylaxis. More than 20% in each group who routinely screened for GBS did not collect both vaginal and rectal cultures. Respondents rated ACOG publications as the most important influence on their GBS prevention approach. Conclusion: Almost all ACOG Fellows have adopted a GBS prevention strategy. The importance of providing GBS prevention information to all patients, use of penicillin, and collection of both vaginal and rectal cultures should be reinforced.

Vaginal birth after cesarean delivery (VBAC) is an increasingly controversial procedure. Apart from medicolegal issues, there is uncertainty about identifying patients at risk and questions about what is an appropriate emergency response time. The risk of uterine rupture, although small, is very significant. This study surveyed a random sample of 1200 fellows of the American College of Obstetricians and Gynecologists in mid-2003 to define trends over the past 5 years in the management of VBAC. The 639 responses received after 3 mailings represented a response rate of 53%. No gender differences were found between those who did and those who did not respond. Respondents in general felt that they were familiar with the benefits and risks of VBAC as well as with ACOG guidelines for identifying the best candidates and for properly using oxytocin to induce labor in the setting of VBAC. There was a strong consensus that encouraging the procedure will lower overall rates of operative delivery. Respondents were less certain that they can reliably determine which patients would be successes. Nearly all of them reported being more confident if there had been a previous vaginal birth. Multifetal gestation, obesity, and diabetes all were thought to compromise the outcome of VBAC. Nearly three fourths of respondents reported that more than half of women having a previous cesarean again had an operative delivery. Male physicians were likelier than females to do repeat cesarean deliveries. Nearly half the group reported doing more cesareans at present than 5 years earlier, and approximately one third were doing about the same number. The same trends were evident for repeat section deliveries. Respondents cited liability risk and patient preference as major reasons for increasing rates of repeat cesarean section. Only 29% of respondents believe that that the current U.S. rate of cesarean delivery is too high. Uncertainty continues about whether elective repeat section is the safest procedure for the infant. Obstetricians/gynecologists appear to be well aware of the benefits and risks of VBAC, but doubt remains about which women should be offered a trial of labor and about what factors predict successful VBAC.