Jay Schulkin

Obstetrician–Gynecologists and contraception: practice and opinions about the use of IUDs in nulliparous women, adolescents and other patient populations

OBJECTIVESnUse of intrauterine devices (IUDs) by US women is low despite their suitability for most women of reproductive age and in a variety of clinical contexts. This study examined obstetrician-gynecologists practices and opinions about the use of IUDs in adolescents, nulliparous women and other patient groups, as well as for emergency contraception.nnnDESIGNnA survey questionnaire was sent to a computer-generated sample of 3000 fellows who were reflective of the American College of Obstetricians and Gynecologists (College) membership.nnnRESULTSnAfter exclusions from the 1552 returned surveys (51.7% response rate), 1150 eligible questionnaires were analyzed. Almost all obstetrician-gynecologists (95.8%) reported providing IUDs, but only 66.8% considered nulliparous women, and 43.0% considered adolescents appropriate candidates. Even among obstetrician-gynecologists who recalled reading a College publication about IUDs, only 78.0% and 45.0% considered nulliparous women and adolescents appropriate candidates, respectively. Few respondents (16.1%) had recommended the copper IUD as emergency contraception, and only 73.9% agreed that the copper IUD could be used as emergency contraception. A total of 67.3% of respondents agreed that an IUD can be inserted immediately after an abortion or miscarriage. Fewer (43.5%) agreed that an IUD can be inserted immediately postpartum, and very few provide these services (11.4% and 7.2%, respectively). Staying informed about practice recommendations for long-acting reversible contraception was associated with broader provision of IUDs.nnnCONCLUSIONSnAlthough most obstetrician-gynecologists offer IUDs, many exclude appropriate candidates for IUD use, both for emergency contraception and for long-term use, despite evidence-based recommendations.nnnIMPLICATIONSnThis study shows that obstetrician-gynecologists still do not offer IUDs to appropriate candidates, such as nulliparous women and adolescents, and rarely provide the copper IUD as emergency contraception.

Obstetrician-Gynecologists and contraception: long-acting reversible contraception practices and education.

OBJECTIVESnLong-acting reversible contraception (LARC) - the copper and levonorgestrel intrauterine devices (IUDs) and the single-rod implant - are safe and effective but account for a small proportion of contraceptive use by US women. This study examined obstetrician-gynecologists knowledge, training, practice and beliefs regarding LARC methods.nnnDESIGNnA survey questionnaire was mailed to 3000 Fellows of the American College of Obstetricians and Gynecologists. After exclusions, 1221 eligible questionnaires were analyzed (45.8% response rate, accounting for exclusions).nnnRESULTSnAlmost all obstetrician-gynecologists reported providing IUDs (95.8%). Most obstetrician-gynecologists reported requiring two or more visits for IUD insertion (86.9%). Respondents that reported IUD insertion in a single visit reported inserting a greater number of IUDs in the last year. About half reported offering the single-rod implant (51.3%). A total of 92.0% reported residency training on IUDs, and 50.8% reported residency training on implants. Residency training and physician age correlated with the number of IUDs inserted in the past year. A total of 59.6% indicated receiving continuing education on at least one LARC method in the past 2years. Recent continuing education was most strongly associated with implant insertion, and 31.7% of respondents cited lack of insertion training as a barrier.nnnCONCLUSIONSnBarriers to LARC provision could be reduced if more obstetrician-gynecologists received implant training and provided same-day IUD insertion. Continuing education will likely increase implant provision.nnnIMPLICATIONSnThis study shows that obstetrician-gynecologists generally offer IUDs, but fewer offer the single-rod contraceptive implant. Recent continuing education strongly predicted whether obstetrician-gynecologists inserted implants and was also associated with other practices that encourage LARC use.

A Central Amygdala CRF Circuit Facilitates Learning about Weak Threats

Fear is a graded central motive state ranging from mild to intense. As threat intensity increases, fear transitions from discriminative to generalized. The circuit mechanisms that process threats of different intensity are not well resolved. Here, we isolate a unique population of locally projecting neurons in the central nucleus of the amygdala (CeA) that produce the neuropeptide corticotropin-releasing factor (CRF). CRF-producing neurons and CRF in the CeA are required for discriminative fear, but both are dispensable for generalized fear at high US intensities. Consistent with a role in discriminative fear, CRF neurons undergo plasticity following threat conditioning and selectively respond to threat-predictive cues. We further show that excitability of genetically isolated CRF-receptive (CRFR1) neurons in the CeA is potently enhanced by CRF and that CRFR1 signaling in the CeA is critical for discriminative fear. These findings demonstrate a novel CRF gain-control circuit and show separable pathways for graded fear processing.

Maternal regulation of offspring development in mammals is an ancient adaptation tied to lactation

The developmental origins of health and disease (DOHaD) is a paradigm for understanding metabolic diseases of modern humans. Vulnerability to disease is linked to perturbations in development during critical time periods in fetal and neonatal life. These perturbations are caused by environmental signals, often generated or transduced by the mother. The regulation of mammalian development depends to a large extent on maternal biochemical signals to her offspring. We argue that this adaptation is ancient, and originated with the evolution of lactation. Lactation evolved earlier than live birth and before the extensive placental development of modern eutherian mammals. Milk contains a host of signaling molecules including nutrients, immunoglobulins, growth factors and metabolic hormones. As evidenced by marsupials, lactation originally served to supply the biochemical factors for growth and development for what is essentially a fetus to a weanling transitioning to independent existence. In placental mammals maternal signaling in earliest life is accomplished through the maternal–placental–fetal connection, with more of development shifted to in utero life. However, significant development occurs postpartum, supported by milk. Mothers of all taxa provide biochemical signals to their offspring, but for non-mammalian mothers the time window is short. Developing mammals receive maternal biochemical signals over an extended period. These signals serve to guide normal development, but also can vary in response to environmental conditions. The ancient adaptation of lactation resulted in a lineage (mammals) in which maternal regulation of offspring development evolved to a heightened degree, with the ability to modify development at multiple time points. Modern metabolic diseases may arise due to a mismatch between maternal regulation and eventual circumstances of the offspring, and due to a large proportion of mothers that exceed past evolutionary norms in body fat and pregnancy weight gain such that maternal signals may no longer be within the adaptive range.

Stress increases GABAergic neurotransmission in CRF neurons of the central amygdala and bed nucleus stria terminalis.

Corticotrophin Releasing Factor (CRF) is a critical stress-related neuropeptide in major output pathways of the amygdala, including the central nucleus (CeA), and in a key projection target of the CeA, the bed nucleus of the stria terminalis (BnST). While progress has been made in understanding the contributions and characteristics of CRF as a neuropeptide in rodent behavior, little attention has been committed to determine the properties and synaptic physiology of specific populations of CRF-expressing (CRF(+)) and non-expressing (CRF(-)) neurons in the CeA and BnST. Here, we fill this gap by electrophysiologically characterizing distinct neuronal subtypes in CeA and BnST. Crossing tdTomato or channelrhodopsin-2 (ChR2-YFP) reporter mice to those expressing Cre-recombinase under the CRF promoter allowed us to identify and manipulate CRF(+) and CRF(-) neurons in CeA and BnST, the two largest areas with fluorescently labeled neurons in these mice. We optogenetically activated CRF(+) neurons to elicit action potentials or synaptic responses in CRF(+) and CRF(-) neurons. We found that GABA is the predominant co-transmitter in CRF(+) neurons within the CeA and BnST. CRF(+) neurons are highly interconnected with CRF(-) neurons and to a lesser extent with CRF(+) neurons. CRF(+) and CRF(-) neurons differentially express tonic GABA currents. Chronic, unpredictable stress increase the amplitude of evoked IPSCs and connectivity between CRF(+) neurons, but not between CRF(+) and CRF(-) neurons in both regions. We propose that reciprocal inhibition of interconnected neurons controls CRF(+) output in these nuclei.

Psychological impact of stillbirths on obstetricians.

Abstract Objective: To assess the psychological impact on US obstetricians when they care for women who have suffered a stillbirth and explore whether demographic (e.g. age, gender) and practice (e.g. number of patients, practice type) variables were related to the extent of psychological impact for obstetricians following stillbirth. Methods: Using a questionnaire that could be completed in about 20u2009min, we surveyed 1000 American College of Obstetricians and Gynecologists (ACOG) members. Physicians were asked about how stillbirths have affected them personally. Results: Half of those surveyed responded (499) and of those 365 currently practiced obstetrics. Virtually all obstetricians have looked after women who have had a stillbirth. Grief was the most common reaction experienced with 53.7% reporting that they personally “very much” experienced grief. Other common and significant reactions were self-doubt (17.2%), depression (16.9%) and self-blame (16.4%). Significant psychological impact on the obstetrician was associated with older age, solo practice, higher volume practices and higher proportion of Medicaid patients; gender was not found to be associated with psychological impact when controlling for age. Further, greater self-reported performance and training regarding maternal and family counseling, management of stillbirth, and knowledge of stillbirth evaluation was associated with greater levels of grief. Conclusion: Physician grief is a common reaction among obstetricians after caring for a patient who has had a stillbirth.

Antenatal corticosteroid timing: accuracy after the introduction of a rescue course protocol

BACKGROUNDnAntenatal corticosteroid administration is a critical fetal intervention, and the use of a rescue protocol is now standard practice. Rescue antenatal corticosteroid may improve overall accuracy of antenatal corticosteroid administration timing, but this observation and its effect on the initial course is unknown.nnnOBJECTIVEnWe sought to compare the accuracy of antenatal corticosteroid administration before and after the implementation of a rescue antenatal corticosteroid protocol.nnnSTUDY DESIGNnWe performed a retrospective cohort study of patients who received a minimum of 1 dose of antenatal corticosteroid from 2006-2012 at the University of Washington Medical Center with the use of the University of Washington Medical Center Pharmacy Database. For inclusion, subjects were required to be admitted, receive the initial antenatal corticosteroid course at 24-34 weeks gestation, and deliver at University of Washington Medical Center. We designated 2 groups that were based on when rescue antenatal corticosteroid became standard practice at University of Washington Medical Center: before rescue antenatal corticosteroid (2006-2008) and after rescue antenatal corticosteroid (2009-2012). Primary outcome was delivery within any optimal antenatal corticosteroid window, which was defined as 48 hours to 7 days after the first dose or third dose. We also compared delivery within the optimal window of the initial and rescue antenatal corticosteroid courses independently and assessed antenatal corticosteroid timing by the indication for delivery. Chi squared and independent sample t-tests were used to compare results.nnnRESULTSnFrom 2006-2012, 1356 women met inclusion criteria, 601 before and 755 after rescue antenatal corticosteroid. The study groups demonstrated similar demographics, with the exception of more white women in the group after rescue antenatal corticosteroid (47% vs 60%; Pxa0< .01) and delivered at comparable gestational ages (32.7 vs 32.6 weeks; Pxa0= .59). Availability of a second course did not increase total subjects who delivered within any optimal window (26.5% vs 28.5%; Pxa0=xa0.41). Frequency of delivery within the initial course optimal window did not change after the introduction of the rescue course protocol (26.1% vs 26.4%; Pxa0= .92). Similarly, of the 73 subjects who received rescue antenatal corticosteroid, 24.7% delivered in the optimal window of the second course. Delivery within the optimal window varied by indication for antenatal corticosteroid, with highest accuracy among maternal indications (41.2% in any optimal window), followed by preterm premature rupture of membranes (32.1%). Lowest administration accuracy was among women with antenatal cervical shortening and advanced cervical dilation; only 2.8% and 6.3% delivered within the optimal window, respectively. Furthermore, for women with antenatal cervical shortening, the mean gestational age of delivery was 35.1 weeks, and the median interval from antenatal corticosteroid administration to delivery was 55 days (interquartile range, 34-72 days).nnnCONCLUSIONSnThe opportunity for a second course of antenatal corticosteroid did not improve the number of women who delivered within any optimal antenatal corticosteroid window. Administration timing was similar for the initial course and the rescue course, with approximately one-quarter of women delivering within the optimal antenatal corticosteroid window. These findings likely reflect the few circumstances in which rescue antenatal corticosteroid is useful and the poor predictability of preterm birth. Future focus should be aimed at tools to predict the timing of preterm birth to optimize antenatal corticosteroid administration.

The role of glucocorticoids and corticotropin-releasing hormone regulation on anxiety symptoms and response to treatment

The stress response has been linked to the expression of anxiety and depression, but the mechanisms for these connections are under continued consideration. The activation and expression of glucocorticoids and CRH are variable and may hold important clues to individual experiences of mood disorders. This paper explores the interactions of glucocorticoids and CRH in the presentation of anxiety and depressive disorders in an effort to better describe their differing roles in each of these clinical presentations. In addition, it focuses on ways in which extra-hypothalamic glucocorticoids and CRH, often overlooked, may play important roles in the presentation of clinical disorders.

Paternal deprivation affects the functional maturation of corticotropin-releasing hormone (CRH)- and calbindin-D28k-expressing neurons in the bed nucleus of the stria terminalis (BNST) of the biparental Octodon degus

AbstractnWhile the critical role of maternal care on the development of brain and behavior of the offspring has been extensively studied, our knowledge about the importance of paternal care for brain development of his offspring is still comparatively scarce. The aim of this study in the biparental caviomorph rodent Octodon degus was to analyze the impact of paternal care on the development of corticotropin-releasing hormone (CRH)-expressing neurons in the bed nucleus of the stria terminalis (BNST) and hypothalamic paraventricular nucleus (PVN). Both brain areas are key players in neuronal circuits that regulate hypothalamic–pituitary–adrenal axis (HPA) activity. At the age of postnatal day (PND) 21, we found that paternal deprivation resulted in a decreased density of CRH-containing neurons in the medial, but not in the lateral BNST, whereas no changes were observed in the PVN. These deprivation-induced changes were still prominent in adulthood. At PND 21, the density of Ca-binding protein calbindin D28K (CaBP-D28K)-expressing neurons was specifically increased in the medial, but not lateral BNST of father-deprived animals. In contrast, adult father-deprived animals show significantly decreased density of CaBP-D28K-expressing neurons in the lateral, but not medial BNST. Taken together, these results may have important implications for our understanding of the experience-driven development of neural circuits that regulate HPA activity mediating acute responses to stress and chronic anxiety.n

Obstetrician–gynecologists' knowledge and opinions about the United States Preventive Services Task Force (USPSTF) committee, the Women's Health Amendment, and the Affordable Care Act: National study after the release of the USPSTF 2009 Breast Cancer Screening Recommendation Statement

OBJECTIVEnInvestigate the knowledge and opinions of obstetrician and gynecologists (ob-gyns) regarding the USPSTF committee and statement, and to assess their reactions to healthcare legislation.nnnMETHODSnA national cross-sectional survey study of ob-gyns was conducted six months after a controversial USPSTF recommendation statement was released in November 2009. Ob-gyns opinions about the Womens Health Amendment (WHA) and the Affordable Care Act (ACA) were also assessed.nnnRESULTSnA total of 54% of ob-gyns knew that the USPSTF recommendations do not represent the position of the U.S. government and 40% knew that the USPSTF is not comprised of federal employees. A majority (60%) thought that the USPSTF was influenced by potential costs more than guidelines should be. When examining ob-gyns opinions about new national health policies, 88% support the mammography coverage provided by the WHA but support for the ACA varied.nnnCONCLUSIONnThis study provides a snapshot of ob-gyns knowledge and opinions about the USPSTF and breast cancer screening guidelines at a controversial point in time. Our findings are a unique contribution to larger efforts to understand health and political policy as the culture of medicine continues to evolve.