Effects of administration of a growth promoting implant during the suckling phase or at weaning on growth, reproduction, and ovarian development in replacement heifers grazing native range.

Management strategies utilized during pre-breeding development of replacement heifers can impact fertility and the ovarian reserve. Angus-Hereford crossbred heifers (n = 233) were utilized over a 3-yr period to determine the effects of administration of a growth promoting implant at either branding or weaning on growth, reproduction, and ovarian development. Heifer calves were randomly assigned to one of three treatments: 1) nonimplanted controls (CON; n = 79), 2) implanted at approximately 2 mo of age (average calf age = 58 d) with Synovex-C (BIMP, n = 82), or 3) implanted at approximately 7 mo of age (average calf age = 210 d) with Synovex-C (WIMP; n = 72). In years 2 and 3, a subset of heifers (year 2 n = 16; year 3 n = 14) were unilaterally ovariectomized. Heifers implanted at 2 mo of age were heavier at weaning, yearling (mid-February; average calf age = 332 d), and at the beginning of the breeding season (P < 0.01) compared to CON and WIMP heifers. Average daily gain (ADG) was similar among treatments from weaning to yearling and weaning to the start of the breeding season (P ≥ 0.61); however, WIMP heifers had increased (P = 0.05) ADG from yearling to the start of the breeding season compared to BIMP heifers. Antral follicle count and reproductive tract scores were not influenced by implant treatment (P ≥ 0.18). Response to synchronization of estrus was increased (P = 0.02) in WIMP compared to CON heifers, with BIMP heifers similar to all other treatments. First service conception rates tended to be increased (P = 0.09) in CON heifers compared to WIMP heifers, with BIMP heifers similar to CON and WIMP. Final pregnancy rates were similar (P = 0.54) among treatments. A treatment × yr interaction was detected (P = 0.01) for the number of primordial follicles/section with increased primordial follicles in WIMP heifers in year 3 compared to BIMP and WIMP heifers in year 2 and CON heifers in year 3, as well as in BIMP compared to WIMP heifers in year 2. Utilization of growth promoting implants did not negatively impact postweaning reproductive development or compromise pregnancy rates in beef heifers. Based on these results, administration of a growth promoting Synovex-C implant at 2 mo of age may allow for increased body weight at weaning, without hindering reproductive performance.

Management of beef females during the first year of life can impact fertility and reproductive longevity. Cattle producers can improve calf weight gains by using growth promoting implants; however, to be applicable, they must not negatively impact heifer reproductive performance or development. Understanding the impact of growth promoting implants on growth, fertility, and reproductive development is important to determine if they can be utilized as an effective management strategy in heifers intended to be retained in the breeding herd. To determine if growth promoting implants influence fertility, 233 heifer calves either received no implant, a Synovex-C implant at 2 mo of age, or a Synovex-C implant at 7 mo of age. Implanting heifers at 2 mo of age increased body weight at weaning. Implanting heifers at 7 mo of age did not improve body weight gains. Implanting heifers at 2 or 7 mo of age resulted in similar pregnancy rates. By using a growth promoting implant at 2 mo of age in beef heifers, producers may be able to increase heifer weaning weight without negatively affecting reproductive development or pregnancy rates. Additional body weight at weaning may provide a profit advantage for heifers not retained as replacements.

Risk Assessment and Treatment Guide for Obstetric Thromboprophylaxis: Comprehensive Review of Current Guidelines.

OBJECTIVE: Currently, there are numerous recommendations and often conflicting guidance provided for venous thromboembolism (VTE) prophylaxis in pregnancy. Our objective was to create a one-page risk assessment and treatment guide based on a review of the most recent and evidence-based publications on this subject to simplify the approach and allow all obstetric patients to be properly assessed for risk of VTE and treated if indicated. STUDY DESIGN: We identified studies by completing a PubMed and MEDLINE search from January of 1980 through March 2017 with articles utilizing a specific combination of the selected general keywords (thrombophilia, pregnancy, VTE, prophylaxis, hypercoagulability, antepartum, postpartum, risk, etc.). We completed the search at the saturation point, meaning that all combinations of the relevant words were directing us to the same articles. After collecting the relevant sources and reviewing them, a total of 10 articles/guidelines were selected for inclusion in the analysis. RESULTS: We outlined every recommendation in the identified articles and guidelines and included any recommendation that was cited in at least three different sources in the final guide. We used American College of Obstetrics and Gynecology recommendations as the base for screening and dosing guidelines and utilized known and published absolute risk values and odds ratios to stratify risk factors. This stratification was used for both antepartum and postpartum recommendations and a single-page guideline was created. CONCLUSION: This compilation of guidelines integrates the complicated topic into a simple comprehensive guide where women can be identified early and accurately for appropriate VTE prophylaxis to protect them during and after pregnancy.

Objective Evaluation of the Effects of Deployment on Laparoscopic Skills: The Simulation and Deployment Laparoscopic Skills Study.

OBJECTIVE: To assess the effects of deployment on basic laparoscopic skills of general surgeons and obstetrics/gynecology (OB/GYN) physicians. METHODS: This was a prospective 10-site study. Active duty Army OB/GYN and general surgery physicians scheduled to deploy were invited to participate. Before deployment, they performed fundamentals of laparoscopic surgery (FLS) tasks and specialty-specific procedures on a virtual reality laparoscopic simulator. Upon returning, physicians repeated the same evaluations. Questions about perceived comfort with laparoscopic procedures were asked before and after deployment. Statistical analysis included paired t tests for continuous variables and nonparametric for ordinal data with a p value of <0.05 considered significant. RESULTS: 121 deploying providers were invited to participate; 35 agreed and 29 completed the predeployment skills assessment. After deployment, 15 providers had postassessment evaluation data collected, and their results were used for analysis. Though physicians reported a decrease in their perception of preparedness for advanced laparoscopic procedures and complications, there was no decrement in their performance of FLS tasks or the basic laparoscopic procedures. CONCLUSION: Time away from regular clinical practice during deployments did not significantly affect surgeons' performance as measured by a virtual reality laparoscopic simulator. Additional study on effects on advanced procedures should be considered.

Self-Reported Changes in Comfort Level With Basic OB/GYN Procedures After Deployment.

OBJECTIVE: To assess the specialty-specific procedures and clinical encounters U.S. Army obstetrician/gynecologist (OB/GYN) providers felt were affected by deployment and identify skills and areas that may benefit from postdeployment training. METHODS: Active duty Army OB/GYN physicians were invited to participate in an anonymous web-based survey to rate their comfort level and experience performing specialty-specific procedures before and after military deployment. Physicians rated their comfort level on a 5-point Likert scale (1 = very uncomfortable to 5 = completely comfortable). Statistical analysis included Pearson χ(2) and McNemar's χ(2) with a p value of <0.05 considered significant. RESULTS: Of the 100 physicians eligible to complete the survey, 66 responded (response rate = 66%). Their responses demonstrated a statistically significant perception of decline in their comfort level with nearly every obstetric and gynecologic procedure and clinical encounter evaluated. CONCLUSION: Time away from regular clinical practice during deployment results in providers feeling less comfortable with many common OB/GYN procedures and clinical situations. Although these results are not a measure of actual performance, this information helps define targets to focus refresher training for providers who leave their normal scope of practice for deployment. These findings apply to civilian providers leaving practice for other reasons as well.

Perceived clinical skill degradation of Army family physicians after deployment.

BACKGROUND AND OBJECTIVES: Deployment away from regular clinical practice is necessary for Army family physicians, but no current information identifies specific procedures or clinical encounters where they feel less comfortable after deployment. This study identifies specific clinical areas and amount of perceived degradation in skills after deployment to combat zones. METHODS: Active duty Army family physicians were invited to participate in a web-based and anonymous survey rating comfort level performing clinical encounters or procedures prior to and after military deployment. Participants rated their comfort level using a 5-point Likert scale. The analysis included descriptive statistics about each physician's deployment history. The composite data for each clinical encounter or procedure were analyzed with McNemar's Chi-Square test. RESULTS: A total of 179 eligible Army family physicians (54% of total) fully completed the instrument, with 39% deploying once and 10% deploying more than five times in their career. Deployments ranged from 1 to >24 months, with 42% having a last deployment of 12 months duration. With statistical significance, providers reported being less comfortable post-deployment with managing first-trimester bleeding, ACLS codes, acute abdominal pain, asthma exacerbations, central line placement, chest pain, COPD exacerbations, CVA/hypertensive emergency, lumbar puncture, neonatal fevers, pediatric codes, sepsis/septic shock, and vaginal delivery. These physicians reported statistically significant increased comfort with the care of major trauma after deployment. CONCLUSIONS: Family physicians deploying to support combat operations feel less comfortable with critical clinical skills across the spectrum of care. Refresher training could be provided with standardized approach to these needs with a goal of maintaining full scope primary care providers.

Molecular and morphological characterization of the tapeworm Taenia hydatigena (Pallas, 1766) in sheep from Iran.

Although Taenia hydatigena is one of the most prevalent taeniid species of livestock, very little molecular genetic information exists for this parasite. Up to 100 sheep isolates of T. hydatigena were collected from 19 abattoirs located in the provinces of Tehran, Alborz and Kerman. A calibrated microscope was used to measure the larval rostellar hook lengths. Following DNA extraction, fragments of cytochrome c oxidase 1 (CO1) and 12S rRNA genes were amplified by the polymerase chain reaction method and the amplicons were subjected to sequencing. The mean total length of large and small hooks was 203.4 µm and 135.9 µm, respectively. Forty CO1 and 39 12S rRNA sequence haplotypes were obtained in the study. The levels of pairwise nucleotide variation between individual haplotypes of CO1 and 12S rRNA genes were determined to be between 0.3-3.4% and 0.2-2.1%, respectively. The overall nucleotide variation among all the CO1 haplotypes was 9.7%, and for all the 12S rRNA haplotypes it was 10.1%. A significant difference was observed between rostellar hook morphometry and both CO1 and 12S rRNA sequence variability. A significantly high level of genetic variation was observed in the present study. The results showed that the 12S rRNA gene is more variable than CO1.

Improving knowledge about prenatal screening options: can group education make a difference?

OBJECTIVE: To determine if the addition of group education regarding maternal serum screening and diagnostic testing for aneuploidy and neural tube defects improves patient knowledge and affects the uptake of testing compared to individual education alone. METHOD: We conducted a prospective study of 443 obstetric patients to assess knowledge of prenatal testing options based on individual provider counseling (n = 331) or provider counseling with supplemental group education (n = 112). We used a chi-square test to compare the number of correct survey answers between the two groups. RESULTS: There was no difference in baseline knowledge. Patients receiving group education showed a statistically significant improvement in knowledge. After initiation of group education, the uptake of maternal serum screening declined while the uptake of amniocentesis remained unchanged. CONCLUSION: Group education in addition to individual counseling to discuss prenatal testing options appears to be effective in improving knowledge compared to individual provider counseling alone. Improved knowledge may affect uptake of prenatal screening tests due to more informed decision making.

Severe thrombocytopenia after contrast infusion in pregnancy.

BACKGROUND: Intravenous contrast-induced thrombocytopenia is a rare but potentially life-threatening complication in pregnancy. CASE: A 22-year-old woman, gravida 2 para 1, at 33 2/7 weeks of gestation presented with chest pain, shortness of breath, and tachycardia. A computed tomography angiogram was pursued to evaluate for pulmonary embolus. During contrast infusion the woman experienced facial flushing, throat tightening, and worsening dyspnea. Her platelet count was noted to decrease precipitously to 4,000/microliter several hours after the imaging study. With medical management and observation, the woman's platelet count steadily recovered without further exacerbation of thrombocytopenia during gestation. CONCLUSION: Prompt recognition and therapy for intravenous contrast-induced thrombocytopenia during pregnancy are essential to optimize maternal-fetal outcome.

Perceived effects of deployments on surgeon and physician skills in the US Army Medical Department.

BACKGROUND: The military health care system is unique in that almost every physician deploys for ≥6 months to a combat or far-forward setting. The aim of this study was to determine the perceived changes in clinical skills in this deployed population. METHODS: A survey was sent out to all specialty consultants to the Army Surgeon General to query active duty staff physicians in their specialty areas who have deployment experience in August 2007. Questions concerning specialty, length of deployment, perceived changes in skills, skill use while deployed, and time to get back to baseline clinically after deployment were asked. RESULTS: Surveys were sent to approximately 1,500 physicians, of which 673 were usable, for a 45% response rate. More than 70% of respondents were deployed for >6 months. Fifty-nine percent reported that they were used in their specialties <40% of the time deployed. Surgeons rated surgical skills before and after deployment as 6.0 ± 1.0 and 4.0 ± 1.5, respectively (on a 7-point, Likert-type scale ranging from 1 = worst to 7 = best; P = .001). Most felt that the time needed to get back to predeployment skill levels was 1 to 6 months. CONCLUSIONS: There was significant perceived degradation in both the surgical and clinical skills of those deploying for >6 months, and the degradation was correlated with the length of time deployed. Most surgical specialists felt that it took them 3 to 6 months to return to their clinical and surgical performance baseline upon returning from a deployment and that 6 months was the most amount of time they could be deployed without a significant decrement in skills.

Evaluation of force applied during deliveries complicated by shoulder dystocia using simulation.

OBJECTIVE: We sought to objectively evaluate the amount of force applied during deliveries complicated by shoulder dystocia among different providers. STUDY DESIGN: Providers who do deliveries at our institution were approached for participation. The simulation exercise used a childbirth mannequin that measures the amount of force the provider applies to the fetal head during delivery. The amount of force applied and information regarding the provider's level of experience, height, weight, and gender was recorded. This study was approved by the hospital institutional review board. RESULTS: A total of 47 providers participated. The mean force applied during each situation was not associated with the provider's experience, height, weight, or gender. CONCLUSION: Provider experience, gender, and body habitus were not associated with the amount of force applied during delivery. We found differences between family medicine and obstetrics/gynecology providers. In addition, a significant number of all providers (19/47, 40%) pulled >100 N.

Effects of deployment on depression screening scores in pregnancy at an army military treatment facility.

OBJECTIVE: To estimate the relationship of positive screening for depression during and after pregnancy with deployment status of the spouse. METHODS: We conducted a retrospective cohort study by reviewing a departmental database of women who completed the Edinburgh Postpartum Depression Scale during pregnancy from 2007 to 2009. Per departmental protocol, screening is offered at the initial obstetric visit, at 28 weeks of gestation, and at 6 weeks postpartum. A score of 14 or higher was considered high risk for having depression, and referral for additional evaluation was recommended. Included in our survey was an additional question that asked if the patient's spouse was currently deployed, returning from deployment, preparing to deploy, or if no deployment was planned. All data were entered into an electronic database and statistical analysis performed comparing Edinburgh Postpartum Depression Scale scores at each time period and deployment status. RESULTS: A total of 3,956 surveys were complete and available for analysis. The risk of a positive screen was more than doubled compared with the control group (no deployment planned) if the spouse was deployed during the 28-32 week visit (4.3% compared with 13.1%, P=.012) or the postpartum period (8.1% compared with 16.2%, P=.006). CONCLUSION: Deployment status has a measurable effect on the prevalence of elevated depression screening scores during pregnancy and in the postpartum period. These findings suggest that more intense monitoring, assessment, and treatment may be warranted for this at-risk population. LEVEL OF EVIDENCE: II.

Improvement in documentation using an electronic checklist for shoulder dystocia deliveries.

OBJECTIVE: To estimate if using an electronic checklist improved the documentation of shoulder dystocias that occurred at our institution. METHODS: A standard checklist of key elements that should be included in the delivery note after a shoulder dystocia was added to the electronic delivery note at our institution. We identified shoulder dystocia deliveries from the department's delivery database for 3 years before and after the checklist was included and compared delivery notes written from these time periods with respect to their content. RESULTS: Forty-six shoulder dystocia deliveries were identified before the checklist being available and 82 after. There was a significant increase noted in the frequency with which several elements were documented after the checklist was implemented including McRoberts maneuver (before checklist 69%, compared with after checklist 90%, P=.003), head-to-body interval (22% compared with 84%, P<.001), which shoulder was anterior (48% compared with 96%, P<.001), and if the neonate was moving its arms after delivery (50% compared with 93%, P<.001). CONCLUSION: Use of a standard checklist for shoulder dystocia in the delivery note resulted in a significant improvement in the documentation of several critical elements. LEVEL OF EVIDENCE: II.

Female soldiers' gynecologic healthcare in Operation Iraqi Freedom: a survey of camps with echelon three facilities.

OBJECTIVE: To describe female soldiers' predeployment gynecologic healthcare screening, common symptoms, and availability of gynecologic care during Operation Iraqi Freedom. METHODS: A questionnaire distributed to U.S. military females presenting to outpatient facilities in level 3 echelon of care between August 2005 and March 2006. RESULTS: Three-hundred ninety seven of 401 surveys (99%) were returned. Ten percent of deployed females (40) had no cervical cytology screening 1 year before deployment and 27% of the 399 required additional treatments for abnormal cervical cytology during deployment. Thirty-five percent reported a gynecologic problem and 44% received care at their base. Irregular bleeding was the most common gynecologic problem. Forty-four percent of women used some form of hormonal contraception; however, 43% changed methods because of unavailability. One-third of soldiers received pre-deployment menses regulation counseling, with 48% of those using continuous oral contraceptive pills for cycle control. CONCLUSION: Gaps remain in predeployment gynecologic screening and counseling. These critical predeployment medical evaluations must remain a priority for all female soldiers to ensure unit readiness.

Improved ultrasonographic estimation of birth weight in macrosomic fetuses by application of a correction factor to the gestation-adjusted projection method.

OBJECTIVE: The purpose of this study was to improve estimated birth weight (EBW) determination in macrosomic fetuses (estimated fetal weight >or=4000 g) by application of a correction factor to the gestation-adjusted projection (GAP) method. METHODS: A review was performed of 411 singleton pregnancies delivered at term. On the basis of ultrasonographic examinations previously performed between 34.0 and 36.9 weeks' gestation, an EBW was calculated for each patient by the GAP method (EBW(GAP)). Using linear regression, a correction factor was developed that minimized the systematic error in the EBW(GAP). The model was then tested retrospectively on a second group of 317 patients. RESULTS: The GAP method systematically overestimated weights of the heavier fetuses in our population. The model we derived showed improved accuracy compared with the GAP method. When applied to a second group of 317 patients, our correction to the GAP method improved specificity for macrosomia from 94.7% to 98.6% (P = .003). Stated differently, the false-positive rate was reduced from 5.3% to 1.4%. The difference in sensitivity for macrosomia was not significant: 41.2% and 35.3% (P = .68). CONCLUSIONS: Application of our model to our study population reduced the number of false-positive results for fetal macrosomia.

Use of a postpartum hemorrhage simulator for instruction and evaluation of residents.

OBJECTIVE: Postpartum hemorrhage is a common and potentially life-threatening obstetric emergency. We sought to create a realistic simulation and validate a standardized grading form to evaluate competency in the management of postpartum hemorrhage. METHODS: Residents from 3 programs underwent training with a postpartum hemorrhage simulation using a standard obstetric birthing model equipped with an inflatable uterus to simulate uterine atony. All simulations were graded by staff physicians with a standardized grading sheet constructed from the current literature on the topic. Residents were expected to recognize the hemorrhage and take appropriate steps, including asking the assistant to administer medications, to correct the problem. Objective and subjective performance was measured with standardized grading sheets, and results were analyzed for reliability using Cronbach α and intraclass correlation coefficients. This project was conducted in accordance with the hospital Institutional Review Board policies at each institution. RESULTS: Forty residents from 3 institutions underwent simulation training. The majority were unable to correct the hemorrhage within 5 minutes and almost half also made at least 1 error, either the dose or route, in the medications they requested. Reliability was evaluated with Cronbach α and demonstrated the grading sheets were valid and had good interrater reliability. DISCUSSION: A simulated postpartum hemorrhage scenario can identify important deficiencies in resident knowledge and performance, with no risk to patients. The standardized grading form worked well for our purposes and was reliable in our study. Further testing is needed to evaluate whether the training improves performance in real-life hemorrhages.

Validation of a tool to measure and promote clinical teamwork.

OBJECTIVE: Human factors and teamwork are major contributors to sentinel events. A major limitation to improving human factors and teamwork is the paucity of objective validated measurement tools. Our goal was to develop a brief tool that could be used to objectively evaluate teamwork in the field during short clinical team simulations and in everyday clinical care. STUDY DESIGN: A pilot validation study. Standardized videos were created demonstrating poor, average, and excellent teamwork among an obstetric team in a common clinical scenario (shoulder dystocia). Three evaluators all trained in Crew Resource Management, and unaware of assigned teamwork level, independently reviewed videos and evaluated teamwork using the Clinical Teamwork Scale (CTS). Statistical analysis included calculation of the Kappa statistic and Kendall coefficient to evaluate agreement and score concordance among raters, and Interclass Correlation Coefficient (ICC) to evaluate interrater reliability. The reliability of the tool was further evaluated by estimating the variance of each component of the tool based on generalizability theory. RESULTS: There was substantial agreement (Kappa 0.78) and score concordance (Kendall coefficient 0.95) among raters, and excellent interrater reliability (interclass correlation coefficient 0.98). The highest percentage of variance in scores among raters was because of rater/item interaction. CONCLUSION: The CTS was developed to efficiently measure key clinical teamwork skills during simulation exercises and in everyday clinical care. It contains 15 questions in 5 clinical teamwork domains (communication, situational awareness, decision-making, role responsibility, and patient friendliness). It is easy to use and has construct validity with median ratings consistently corresponding with the intended teamwork level. The CTS is a brief, straightforward, valid, reliable, and easy-to-use tool to measure key factors in teamwork in simulated and clinical settings.

Post-partum exacerbation of idiopathic pulmonary hemosiderosis.

Idiopathic pulmonary hemosiderosis is a disease causing diffuse alveolar hemorrhage and has rarely been reported in pregnancy. We present the first described case of a post-partum exacerbation after an uncomplicated prenatal course.