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1.
Article in English | MEDLINE | ID: mdl-38992255

ABSTRACT

RATIONALE: Preclinical studies report that drug use and social contact mutually influence the reinforcing effects of one another. Most of these studies have used same-sex dyads exclusively, and the role of factors related to biological sex and hormonal fluctuations are not well understood. OBJECTIVES: The purpose of this study was to examine the reinforcing effects of cocaine and social contact with an opposite-sex partner in male and female rats, and how these effects are modulated by ovarian hormones. METHODS: Male and female rats were trained in a nonexclusive choice procedure in which cocaine and social contact with an opposite-sex partner were simultaneously available on concurrent progressive ratio schedules of reinforcement. To examine the effects of ovarian hormones related to estrous cycling, Experiment 1 used naturally cycling, gonadally intact females, whereas Experiment 2 used ovariectomized females, and estrus was artificially induced with exogenous hormones. RESULTS: In both experiments, cocaine and social contact functioned as robust reinforcers, and there were no significant effects of biological sex or estrus status of the females. The positive reinforcing effects of both cocaine and social contact increased as a function of cocaine dose, indicating that contingent cocaine administration increases the reinforcing effects of social contact. CONCLUSIONS: These data suggest that cocaine use among opposite-sex partners may enhance factors that contribute to social bonding.

2.
J Dairy Sci ; 107(7): 4844-4854, 2024 Jul.
Article in English | MEDLINE | ID: mdl-38670342

ABSTRACT

The neonatal period for dairy calves is crucial for immune, metabolic, and physical development, which opens a window of disease susceptibility. Although the industry has relied on tools such as colostrum and vaccination to support early life immunity, there are several challenges when vaccinating neonatal calves: (1) the inability to mount an effective immune response, (2) interference with maternal antibodies, and (3) oxidative stress (OS). Oxidative stress is characterized as the imbalance of pro-oxidants to antioxidants that results in cellular oxidative damage or dysfunction. Oxidative stress has become a topic of interest in the neonatal period because it negatively affects lymphocyte function, which might affect vaccine response. Widely studied in mature cattle, antioxidant supplementation has the potential to improve reduction-oxidation balance and immune response. Evidence supporting the use of antioxidants such as vitamins and minerals in neonatal calves is far scarcer but necessary to optimize immunity and disease resistance. This review summarizes research on the effect of antioxidant supplementation on calf immunity, health, and productivity and highlights remaining gaps in knowledge. Overall, micronutrient supplementation, including vitamins and minerals, in preweaning and postweaning calves improved immune responses but there is conflicting evidence supporting the subsequent positive effect on calf health and growth performance.


Subject(s)
Antioxidants , Animals , Cattle , Antioxidants/pharmacology , Dietary Supplements , Oxidative Stress , Animals, Newborn , Colostrum/immunology
3.
J Dairy Sci ; 107(7): 4926-4941, 2024 Jul.
Article in English | MEDLINE | ID: mdl-38331183

ABSTRACT

This randomized clinical trial aimed to determine the extent to which injectable micronutrient supplementation at birth can improve intranasal vaccine response by ameliorating oxidative stress in dairy calves from birth to weaning. For this, 120 Holstein heifer calves were enrolled at birth and randomly allocated into one of 4 groups. The 4 groups included 3 commercially available micronutrient supplements (selenium, copper, zinc, and manganese; selenium and vitamin E; and vitamins E, A, and D) and one control (saline). Calves received an intranasal vaccine against the respiratory viruses parainfluenza 3, bovine herpesvirus type 1 (BHV-1), and bovine respiratory syncytial virus (BRSV) within the first week of life. Body weight and hip height (HH) were recorded, and a blood sample and nasal secretion sample were collected at birth before treatment and vaccine administration, as well as weekly until weaning at 8 wk. Health scores, including thoracic ultrasound assessment, were recorded weekly from wk 1 to wk 8. Farm treatment records were collected after the completion of the study. Serum micronutrient concentrations were determined from birth to weaning to identify micronutrient status, and serum blood metabolites were analyzed as markers of nutrient utilization. Redox balance was determined in serum as a ratio of reactive oxygen and nitrogen species to antioxidant capacity, known as the oxidant status index (OSi). Intranasal vaccine response was quantified as anti-BRSV and anti-BHV-1 IgA concentrations in nasal secretions. Linear mixed models with repeated measures were built for micronutrient concentrations, blood metabolites, redox balance, IgA concentrations, BW, and HH. Pre-planned contrasts of the control and supplemented groups were also built for the primary outcome of IgA concentrations. A logistic regression mixed model was built for health events and treatment of disease. Serum selenium concentrations were greater in calves receiving supplements containing Se throughout the first 4 wk of life. However, we did not observe any consistent differences in the other micronutrients. The metabolic biomarkers indicate that supplemented calves had better energy status, as suggested by lower BHB and nonesterified fatty acids concentrations. Supplemented calves showed improved redox balance, as indicated by lower OSi throughout the first week of life. Calves supplemented with antioxidants at birth had higher anti-BRSV IgA than control calves. Our results indicate an improved immune response to vaccines in calves supplemented with antioxidants at birth. However, this did not translate to growth and health performance, as we did not find any differences in average daily gain or incidence of health events throughout the preweaning period. This study provides evidence that improving the antioxidant capacity might improve vaccine response, and further research is required to investigate the appropriate frequency and dose of supplementation to improve calf growth and health.


Subject(s)
Dietary Supplements , Micronutrients , Weaning , Animals , Cattle , Micronutrients/administration & dosage , Female
4.
Front Pharmacol ; 14: 1280289, 2023.
Article in English | MEDLINE | ID: mdl-37954845

ABSTRACT

Introduction: The recreational use of fentanyl in combination with xylazine (i.e., "tranq-dope") represents a rapidly emerging public health threat characterized by significant toxicity and mortality. This study quantified the interactions between these drugs on lethality and examined the effectiveness of potential rescue medications to prevent a lethal overdose. Methods: Male and female mice were administered acute doses of fentanyl, xylazine, or their combination via intraperitoneal injection, and lethality was determined 0.5, 1.0, 1.5, 2.0, and 24 h after administration. Both fentanyl and xylazine produced dose-dependent increases in lethality when administered alone. Results: A nonlethal dose of fentanyl (56 mg/kg) produced an approximately 5-fold decrease in the estimated LD50 for xylazine (i.e., the dose estimated to produce lethality in 50% of the population). Notably, a nonlethal dose of xylazine (100 mg/kg) produced an approximately 100-fold decrease in the estimated LD50 for fentanyl. Both drug combinations produced a synergistic interaction as determined via isobolographic analysis. The opioid receptor antagonist, naloxone (3 mg/kg), but not the alpha-2 adrenergic receptor antagonist, yohimbine (3 mg/kg), significantly decreased the lethality of a fentanyl-xylazine combination. Lethality was rapid, with death occurring within 10 min after a high dose combination and generally within 30 min at lower dose combinations. Males were more sensitive to the lethal effects of fentanyl-xylazine combinations under some conditions suggesting biologically relevant sex differences in sensitivity to fentanyl-xylazine lethality. Discussion: These data provide the first quantification of the lethal effects of "tranq-dope" and suggest that rapid administration of naloxone may be effective at preventing death following overdose.

5.
bioRxiv ; 2023 Sep 26.
Article in English | MEDLINE | ID: mdl-37808678

ABSTRACT

The recreational use of fentanyl in combination with xylazine (i.e., "tranq-dope") represents a rapidly emerging public health threat characterized by significant toxicity and mortality. This study quantified the interactions between these drugs on lethality and examined the effectiveness of potential rescue medications to prevent a lethal overdose. Male and female mice were administered acute doses of fentanyl, xylazine, or their combination via intraperitoneal injection, and lethality was determined 30, 60, 90, 120, and 1440 min (24 hr) after administration. Both fentanyl and xylazine produced dose-dependent increases in lethality when administered alone. A nonlethal dose of fentanyl (56 mg/kg) produced an approximately 5-fold decrease in the estimated LD50 for xylazine (i.e., the dose estimated to produce lethality in 50% of the population). Notably, a nonlethal dose of xylazine (100 mg/kg) produced an approximately 100-fold decrease in the estimated LD50 for fentanyl. The opioid receptor antagonist, naloxone (3 mg/kg), but not the alpha-2 adrenergic receptor antagonist, yohimbine (3 mg/kg), significantly decreased the lethality of a fentanyl-xylazine combination. Lethality was rapid, with death occurring within 10 min after a high dose combination and generally within 30 min at lower dose combinations. Males were more sensitive to the lethal effects of fentanyl-xylazine combinations under some conditions, suggesting biologically relevant sex differences in sensitivity to fentanyl-xylazine lethality. These data provide the first quantification of the lethal effects of "tranq-dope" and suggest that rapid administration of naloxone may be effective at preventing death following overdose.

6.
J Am Coll Health ; : 1-11, 2023 Aug 15.
Article in English | MEDLINE | ID: mdl-37581944

ABSTRACT

Objective: The study aimed to identify phases of bystander intervention (BI) for problematic alcohol use (PAU) among college students. Participants: Twenty focus groups and nine interviews were conducted. Methods: Transcripts were thematically analyzed. Results: The phases of the Bystander Intervention for Problematic Alcohol Use Model (BIPAUM) include: (1) plan in advance, (2) notice and interpret a sign, (3) decide (i.e., assume responsibility, assess support/feasibility to intervene, and identify intervention strategy), (4) intervene, and (5) assess outcomes. Assessing outcomes loops to influence future behavior and each phase is influenced by barriers and facilitators. Conclusions: These unique phases should be considered when designing and evaluating intervention programs for PAU to meet students' needs and better reduce PAU. Future research should empirically test the BIPAUM. The results of the current study demonstrate a promising opportunity for applying BI to PAU, with the goal of reducing risky drinking among college students.

7.
Eur J Neurosci ; 57(8): 1241-1259, 2023 04.
Article in English | MEDLINE | ID: mdl-36840503

ABSTRACT

Alcohol use disorder (AUD) and anxiety/stressor disorders frequently co-occur and this dual diagnosis represents a major health and economic problem worldwide. The basolateral amygdala (BLA) is a key brain region that is known to contribute to the aetiology of both disorders. Although many studies have implicated BLA hyperexcitability in the pathogenesis of AUD and comorbid conditions, relatively little is known about the specific efferent projections from this brain region that contribute to these disorders. Recent optogenetic studies have shown that the BLA sends a strong monosynaptic excitatory projection to the ventral hippocampus (vHC) and that this circuit modulates anxiety- and fear-related behaviours. However, it is not known if this pathway influences alcohol drinking-related behaviours. Here, we employed a rodent operant self-administration regimen that procedurally separates appetitive (e.g. seeking) and consummatory (e.g., drinking) behaviours, chemogenetics and brain region-specific microinjections, to determine if BLA-vHC circuitry influences alcohol and sucrose drinking-related measures. We first confirmed prior optogenetic findings that silencing this circuit reduced anxiety-like behaviours on the elevated plus maze. We then demonstrated that inhibiting the BLA-vHC pathway significantly reduced appetitive drinking-related behaviours for both alcohol and sucrose while having no effect on consummatory measures. Taken together, these findings provide the first indication that the BLA-vHC circuit may regulate appetitive reward seeking directed at alcohol and natural rewards and add to a growing body of evidence suggesting that dysregulation of this pathway may contribute to the pathophysiology of AUD and anxiety/stressor-related disorders.


Subject(s)
Alcoholism , Basolateral Nuclear Complex , Humans , Hippocampus , Ethanol/pharmacology , Alcohol Drinking , Sucrose/pharmacology
8.
J Exp Anal Behav ; 119(3): 488-500, 2023 05.
Article in English | MEDLINE | ID: mdl-36788660

ABSTRACT

The progression of recreational drinking to alcohol use disorder is characterized by loss of control over seeking, which involves continued use of alcohol despite negative consequences. The present study proposes a novel maladaptive alcohol self-administration task in which animals are trained to withhold alcohol drinking in the presence of an auditory cue signaling consequence (conflict phase) but to drink freely when there is no consequence (neutral phase). These phases are performed within trial; successful performance involves waiting for the conflict phase to end and drinking during the neutral phase. We discuss the background and implementation of the task, its relation to existing models, and its relevance to the field of translational alcohol research. Importantly, we also present evidence of its efficacy. Both male and female Long-Evans rats are capable of performing the maladaptive alcohol self-administration task for both sweetened and unsweetened alcohol solutions. Finally, we show that acute injection of a pharmacological stressor (yohimbine) significantly disrupted performance of the task in both sexes and reinforcers. We suggest the maladaptive alcohol self-administration task may prove particularly useful in models of alcohol use disorder or vulnerability to this disorder where its application may reveal maladaptive neural circuit adaptations responsible for motivational perturbations associated with loss of control over alcohol seeking.


Subject(s)
Alcoholism , Female , Male , Rats , Animals , Rats, Long-Evans , Ethanol/pharmacology , Alcohol Drinking , Self Administration , Conditioning, Operant
9.
Trauma Violence Abuse ; 24(5): 3732-3747, 2023 12.
Article in English | MEDLINE | ID: mdl-36514242

ABSTRACT

This review aimed to identify U.S.-based, construct-validated measures of bystander intervention. Following PRISMA-P guidelines, electronic databases were searched, and emails were solicited identifying 8,559 articles for title screening. Abstracts and full texts were double screened, resulting in 24 scales meeting inclusion criteria: (a) measured a bystander-related construct in a situation where there was a potential for actual or perceived imminent physical or emotional harm, (b) written in English, and (c) statistically validated on U.S. samples. Most scales addressed the domain of interpersonal violence (67%), with fewer relating to bias/bullying (8.2%), mental health crises (12.5%), and substance use (12.5%). Most scales (71%) assessed the "take action" step of the situational model. The modal construct represented was intent/willingness/likelihood to intervene (50%). The average number of items on a scale was 14, and most (79%) provided Likert-style response options. None of the validated scales assessing behavior first accounted for an opportunity. Sample sizes ranged from 163 to 3,397, with the modal setting from colleges. Overall, samples were young (21.8 years old), White (75%), women (64%), and heterosexual (89%). Results indicate the need to validate additional measures that capture the "interpreting the situation as problematic" step of the situational model. Scales also need to be validated using diverse samples, particularly within the mental health crisis domain. Across all domains, validated measures need to be developed that first account for an opportunity when measuring actual bystander behavior. The information gleaned can be used to assist researchers in selecting measures and guide future measure development.


Subject(s)
Intention , Students , Adult , Female , Humans , Young Adult , Students/psychology , Universities
10.
Pancreatology ; 22(8): 1126-1133, 2022 Dec.
Article in English | MEDLINE | ID: mdl-36198488

ABSTRACT

BACKGROUND: Although micronutrients modulate immunity and inflammation, it remains elusive whether they are implicated in the development and progression of chronic pancreatitis (CP). This study aimed to investigate differences in the circulating levels of selected carotenoids and vitamins between CP and controls and trends in the levels of these micronutrients across controls, early CP, and definite CP. METHODS: Demographic and lifestyle data were extracted from medical records for 53 patients with CP (13 early and 38 definite) and obtained using a questionnaire for 52 controls. Plasma ß-carotene, lycopene, cryptoxanthin, zeaxanthin, and α-tocopherol and serum 25(OH)D, folate, IL-6, TNF-α, and MCP-1 were measured with state-of-the-art methods. RESULTS: The levels of all micronutrients (except folate) were significantly lower in CP than in controls. There was a progressive decrease in the levels of these micronutrients across controls, early CP, and definite CP (all p values for trend: ≤0.0012); e.g., plasma lycopene was 36.6, 21.5, and 14.5 µg/dL for controls, early CP, and definite CP, respectively. After adjustment for confounders, there were strong, inverse associations between the levels of all micronutrients (except folate) and CP (e.g., OR (95% CI) for ≥ median vs.

Subject(s)
Carotenoids , Pancreatitis, Chronic , Humans , Micronutrients , alpha-Tocopherol , Lycopene , Tumor Necrosis Factor-alpha , Interleukin-6 , Folic Acid , Inflammation
11.
Neurosci Lett ; 771: 136417, 2022 02 06.
Article in English | MEDLINE | ID: mdl-34954115

ABSTRACT

Overconsumption, or eating beyond the point of homeostasis, is a key feature in the development of obesity. Although people are consuming beyond the point of homeostasis, they are not consuming constantly or indefinitely. Thus, there is likely a mechanism that acts to terminate periods of food intake at some point beyond satiation and prior to aversion, or the negative effects of extreme excess (nausea, bloating, etc.). The purpose of the present study was to assess the lateral habenula as a candidate region for such a mechanism, due to its connectivity to midbrain reward circuitry, sensitivity to metabolic signaling, and pronounced role in drug-related motivated behaviors. Two groups of male Sprague-Dawley rats were surgically implanted with bilateral guide cannula targeting the LHb. Rats were then habituated to feeding chambers, wherein locomotion and food intake were monitored throughout a two-hour session. One experimental group was tested in the presence of rat chow; the second group was instead given access to a sweetened fat diet. Each subject separately received a 0.2 µL vehicle (0.9% saline solution) and baclofen-muscimol (50 ng/0.2 µL of each drug dissolved in 0.9% saline) injection. Additionally, on a third injection day, each rat received an injection of mu-opioid agonist DAMGO (0.1 µg/0.2 µL) prior to placement in the chamber. LHb inactivation did not result in significant alterations in feeding behavior, but produced a consistent increase in locomotor activity in both experimental groups. Mu-opioid receptor stimulation increased feeding on standard chow, but decreased intake of the sweetened-fat diet. Although LHb inactivation did not increase feeding as predicted, the novel finding that mu opioid receptor stimulation decreased feeding on a highly palatable diet, but increased intake of rat chow, highlights a differential role for the LHb in regulating hedonic consummatory behavior.


Subject(s)
Analgesics, Opioid/pharmacology , Eating , Feeding Behavior , GABA Agonists/pharmacology , Habenula/drug effects , Receptors, Opioid, mu/agonists , Animals , Baclofen/pharmacology , Enkephalin, Ala(2)-MePhe(4)-Gly(5)-/pharmacology , Habenula/metabolism , Habenula/physiology , Locomotion , Male , Motivation , Muscimol/pharmacology , Rats , Rats, Sprague-Dawley , Receptors, GABA/metabolism , Receptors, Opioid, mu/metabolism
12.
Sci Rep ; 11(1): 8749, 2021 04 22.
Article in English | MEDLINE | ID: mdl-33888757

ABSTRACT

The hippocampus, particularly its ventral domain, can promote negative affective states (i.e. stress and anxiety) that play an integral role in the development and persistence of alcohol use disorder (AUD). The ventral hippocampus (vHC) receives strong excitatory input from the basolateral amygdala (BLA) and the BLA-vHC projection bidirectionally modulates anxiety-like behaviors. However, no studies have examined the effects of chronic alcohol on the BLA-vHC circuit. In the present study, we used ex vivo electrophysiology in conjunction with optogenetic approaches to examine the effects of chronic intermittent ethanol exposure (CIE), a well-established rodent model of AUD, on the BLA-vHC projection and putative intrinsic vHC synaptic plasticity. We discovered prominent BLA innervation in the subicular region of the vHC (vSub). CIE led to an overall increase in the excitatory/inhibitory balance, an increase in AMPA/NMDA ratios but no change in paired-pulse ratios, consistent with a postsynaptic increase in excitability in the BLA-vSub circuit. CIE treatment also led to an increase in intrinsic network excitability in the vSub. Overall, our findings suggest a hyperexcitable state in BLA-vSub specific inputs as well as intrinsic inputs to vSub pyramidal neurons which may contribute to the negative affective behaviors associated with CIE.


Subject(s)
Basolateral Nuclear Complex/drug effects , Ethanol/pharmacology , Hippocampus/drug effects , Alcoholism/physiopathology , Animals , Basolateral Nuclear Complex/physiology , Ethanol/administration & dosage , Hippocampus/physiology , Male , Neuronal Plasticity/drug effects , Optogenetics , Rats , Rats, Long-Evans , Synaptic Transmission/drug effects
13.
Int Rev Neurobiol ; 157: 69-142, 2021.
Article in English | MEDLINE | ID: mdl-33648676

ABSTRACT

Alcohol use disorder (AUD) and (PTSD) frequently co-occur and individuals suffering from this dual diagnosis often exhibit increased symptom severity and poorer treatment outcomes than those with only one of these diseases. Although there have been significant advances in our understanding of the neurobiological mechanisms underlying each of these disorders, the neural underpinnings of the comorbid condition remain poorly understood. This chapter summarizes recent epidemiological findings on comorbid AUD and PTSD, with a focus on vulnerable populations, the temporal relationship between these disorders, and the clinical consequences associated with the dual diagnosis. We then review animal models of the comorbid condition and emerging human and non-human animal research that is beginning to identify maladaptive neural changes common to both disorders, primarily involving functional changes in brain reward and stress networks. We end by proposing a neural framework, based on the emerging field of affective valence encoding, that may better explain the epidemiological and neural findings on AUD and PTSD.


Subject(s)
Alcoholism , Stress Disorders, Post-Traumatic , Alcoholism/epidemiology , Alcoholism/physiopathology , Alcoholism/psychology , Animals , Comorbidity , Humans , Stress Disorders, Post-Traumatic/epidemiology , Stress Disorders, Post-Traumatic/physiopathology , Stress Disorders, Post-Traumatic/psychology
14.
Behav Brain Res ; 399: 112999, 2021 02 05.
Article in English | MEDLINE | ID: mdl-33161034

ABSTRACT

The nucleus accumbens (NAc) is critical for regulating the appetitive and consummatory phases of motivated behavior. These experiments examined the effects of dopamine and opioid receptor manipulations within the NAc during an effort-based choice task that allowed for simultaneous assessment of both phases of motivation. Male Sprague-Dawley rats received bilateral guide cannulas targeting the NAc core and were tested in 1-hr sessions with free access to rat chow and the choice to work for sugar pellets on a progressive ratio 2 (PR2) reinforcement schedule. Individual groups of rats were tested following stimulation or blockade of NAc D1-like or D2-like receptors, stimulation of µ-, δ-, or κ-opioid receptors, or antagonism of opioid receptors. Behavior was examined under ad libitum conditions and following 23-h food restriction. NAc blockade of the D1-like receptors or stimulation of the D2 receptor reduced break point for earning sugar pellets; D2 receptor stimulation also modestly lowered chow intake. NAc µ-opioid receptor stimulation increased intake of the freely-available chow while simultaneously reducing break point for the sugar pellets. In non-restricted conditions, δ-opioid receptor stimulation increased both food intake and breakpoint. There were no effects of stimulating NAc D1 or κ receptors, nor did blocking D2 or opioid receptors affect task behavior. These data support prior literature linking dopamine to appetitive motivational processes, and suggest that µ- and δ-opioid receptors affect food-directed motivation differentially. Specifically, µ-opioid receptors shifted behavior towards consumption, and δ-opioid receptor enhanced both sugar-seeking and consumption of the pabulum chow when animals were not food restricted.


Subject(s)
Behavior, Animal/drug effects , Choice Behavior/drug effects , Motivation/drug effects , Nucleus Accumbens/drug effects , Receptors, Dopamine/drug effects , Receptors, Opioid, delta/drug effects , Receptors, Opioid, kappa/drug effects , Receptors, Opioid, mu/drug effects , Animals , Male , Rats , Rats, Sprague-Dawley , Reinforcement Schedule
15.
West J Nurs Res ; 36(8): 975-88, 2014 09.
Article in English | MEDLINE | ID: mdl-24347308

ABSTRACT

Pitocin, a synthetic form of the hormone oxytocin, is a high-alert medication that heightens patient harm when used incorrectly. This investigation examined the outcomes of an evidence-based Pitocin administration checklist used for labor augmentation at a tertiary-level hospital. Data came from patient records. Using the Perinatal Trigger Tool, N = 372 clinical records (n = 194 prior to and n = 178 following checklist implementation) were reviewed. Checklist implementation resulted in statistically significant reductions in the duration of hospitalization (1.72 vs. 2.02 days, p = .0005), presence of meconium (23.7% vs. 6.7%, p < .001), maternal fevers (7.2% vs. 2.3%, p = .030), and episiotomies (8.8% vs. 1.7%, p = .002), and clinically important reduction in APGAR scores < 7 at 5 min (3.6%-0.6%, p = .069) and instrumented deliveries (11.9%-8.4%, p = .307). A universal Pitocin checklist implementation can improve birth outcomes and costs of care.


Subject(s)
Checklist/standards , Evidence-Based Practice/methods , Oxytocin/administration & dosage , Treatment Outcome , Adolescent , Adult , Checklist/methods , Checklist/statistics & numerical data , Evidence-Based Practice/statistics & numerical data , Female , Humans , Infant , Infant Mortality , Infant, Newborn , Labor, Induced/methods , Labor, Induced/standards , Oxytocin/pharmacology , Oxytocin/therapeutic use , Pregnancy , Retrospective Studies , Tertiary Care Centers/organization & administration , Tertiary Care Centers/statistics & numerical data
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