Delivery room emergencies due to birth injuries.

Delivery room emergencies due to birth injuries are serious, usually unexpected, and can be distressing situations that necessitate immediate action to reduce neonatal morbidity and prevent neonatal mortality. Birth injuries requiring immediate, urgent care in the delivery room are uncommon, hence knowledge of obstetric risk factors and prenatal conditions linked to birth injury is an important first step in the management of affected neonates. Furthermore, immediate recognition of injury and quick action upon delivery is essential in order to achieve the best possible outcomes. This chapter briefly reviews the known risk factors associated with birth injury, and then discusses the identification and management of specific injuries that may require immediate treatment in the delivery room, or hasty management within hours after birth.

Texas Pulse Oximetry Project: A Multicenter Educational and Quality Improvement Project for Implementation of Critical Congenital Heart Disease Screening Using Pulse Oximetry.

Objective Critical congenital heart disease (CCHD) is a leading cause of death in infants. Newborn screening (NBS) by pulse oximetry allows early identification of CCHD in asymptomatic newborns. To improve readiness of hospital neonatal birthing facilities for mandatory screening in Texas, an educational and quality improvement (QI) project was piloted to identify an implementation strategy for CCHD NBS in a range of birthing hospitals. Study Design Thirteen Texas hospitals implemented standardized CCHD screening by pulse oximetry. An educational program was devised and a tool kit was created to facilitate education and implementation. Newborn nursery nurses' knowledge was assessed using a pre- and posttest instrument. Results The nurses' knowledge assessment improved from 71 to 92.5% (p < 0.0001). Of 11,322 asymptomatic newborns screened after 24 hours of age, 11 had a positive screen, with 1 confirmed case of CCHD. Pulse oximetry CCHD NBS had sensitivity of 100%, specificity of 99.91%, false-positive rate of 0.088%, positive predictive value of 9.09%, and negative predictive value of 100%. Conclusion Our educational program, including a tool kit, QI processes, and standardized pulse oximetry CCHD NBS, is applicable for a range of hospital birthing facilities and may facilitate wide-scale implementation, thereby improving newborn health.

A Multicenter Initiative for Critical Congenital Heart Disease Newborn Screening in Texas Neonatal Intensive Care Units.

Objective The objective of this study was to implement a strategy for critical congenital heart disease (CCHD) newborn screening in the neonatal intensive care unit (NICU). Design A NICU-specific curriculum, screening algorithm, slide presentations, and templates of orders, policies, and procedures were developed into a toolkit for training NICU personnel. Screening was conducted on first and second screen pre- and postductal oxygen saturations (SpO2) on newborns admitted or transferred to the NICU. Results We trained 347 NICU personnel in 13 Texas hospitals, representing rural, suburban, and metropolitan settings. Key hospital staff submitted deidentified, case-based screening data. Of 4,621 NICU admissions, 80% received a first screen. Second screening rates were substantially lower in all gestational age groups. Screening rates on first and second screens were lowest among infants born < 28 weeks. For the first screen, SpO2 was lowest among the youngest gestational ages. The false positive rate was 2.3%. Conclusion CCHD screening in the NICU is challenging, given the complexities of the NICU population. A modified screening protocol that recognizes special circumstances of neonatal intensive care could facilitate a more efficient system.

Methamphetamine causes differential alterations in gene expression and patterns of histone acetylation/hypoacetylation in the rat nucleus accumbens.

Methamphetamine (METH) addiction is associated with several neuropsychiatric symptoms. Little is known about the effects of METH on gene expression and epigenetic modifications in the rat nucleus accumbens (NAC). Our study investigated the effects of a non-toxic METH injection (20 mg/kg) on gene expression, histone acetylation, and the expression of the histone acetyltransferase (HAT), ATF2, and of the histone deacetylases (HDACs), HDAC1 and HDAC2, in that structure. Microarray analyses done at 1, 8, 16 and 24 hrs after the METH injection identified METH-induced changes in the expression of genes previously implicated in the acute and longterm effects of psychostimulants, including immediate early genes and corticotropin-releasing factor (Crf). In contrast, the METH injection caused time-dependent decreases in the expression of other genes including Npas4 and cholecystokinin (Cck). Pathway analyses showed that genes with altered expression participated in behavioral performance, cell-to-cell signaling, and regulation of gene expression. PCR analyses confirmed the changes in the expression of c-fos, fosB, Crf, Cck, and Npas4 transcripts. To determine if the METH injection caused post-translational changes in histone markers, we used western blot analyses and identified METH-mediated decreases in histone H3 acetylated at lysine 9 (H3K9ac) and lysine 18 (H3K18ac) in nuclear sub-fractions. In contrast, the METH injection caused time-dependent increases in acetylated H4K5 and H4K8. The changes in histone acetylation were accompanied by decreased expression of HDAC1 but increased expression of HDAC2 protein levels. The histone acetyltransferase, ATF2, showed significant METH-induced increased in protein expression. These results suggest that METH-induced alterations in global gene expression seen in rat NAC might be related, in part, to METH-induced changes in histone acetylation secondary to changes in HAT and HDAC expression. The causal role that HATs and HDACs might play in METH-induced gene expression needs to be investigated further.

Chronic Methamphetamine Causes Differential Expression of Immediate Early Genes in the Nucleus Accumbens and Midbrain of Rats.

The present study investigated whether chronic methamphetamine (METH) would suppress METH-induced mRNA expression of immediate early genes (IEGs) in the rat brain. Rats were given METH or saline over two weeks. After an overnight withdrawal, saline- and METH-pretreated rats received an acute saline or METH challenge. The acute METH challenge increased expression of members of activator protein 1 (AP-1) and Nr4a IEG families in the nucleus accumbens (NAc) and midbrain of saline-pretreated rats. Chronic METH exposure attenuated the effects of acute METH challenge on AP-1 IEG expression in the NAc. However, chronic METH failed to attenuate acute METH-induced increases of Nr4a1 and Nr4a3 expression in the NAc. In contrast to observations in the NAc, chronic METH did not prevent acute METH-induced changes in IEG expression in the midbrain. These results suggest that these two brain regions that are implicated in neuroplastic effects of illicit substances might be differentially affected by psychostimulants.