Establishing an Evidence Synthesis Capability For Psychological Health Topics in the Military Health System.

BACKGROUND: To promote evidence-based health care, clinical providers and decision makers rely on scientific evidence to inform best practices. Evidence synthesis (ES) is a key component of this process that serves to inform health care decisions by integrating and contextualizing research findings across studies. OBJECTIVE: This paper describes the process of establishing an ES capability in the Military Health System dedicated to psychological health topics. RESEARCH DESIGNS: The goal of establishing the current ES capability was to facilitate evidence-based decision-making among clinicians, clinic managers, research funders, and policymakers, through the production and dissemination of trustworthy ES reports. We describe how we developed this capability, provide an overview of the types of evidence syntheses products we use to respond to different stakeholders, and detail the procedures established for selecting and prioritizing synthesis topics. RESULTS: We report on the productivity, acceptability, and impact of our efforts. Our reports were used by a variety of stakeholders and working groups, briefed to major committees, included in official reports and policies, and cited in clinical practice guidelines and the peer-reviewed literature. CONCLUSIONS: Our experiences thus far suggest that the current ES capability offers a needed service within our health system. Our framework may help inform other agencies interested in developing or sponsoring a similar capability.

Typologies of Combat Exposure and Their Effects on Posttraumatic Stress Disorder and Depression Symptoms.

The present study identified distinct classes of U.S. military service members based on their combat experiences and examined mental health outcomes and longitudinal growth curves of posttraumatic stress disorder (PTSD) and depression symptoms associated with each class. Participants were 551 active duty service members who screened positive for PTSD and/or depression based on DSM-IV-TR criteria. All participants completed the Combat Experiences Scale at baseline as well as PTSD and depression measures at baseline and at 3-, 6-, and 12-month follow-ups. A latent class analysis identified four classes of service members based on their combat experiences: limited exposure, medical exposure, unit exposure, and personal exposure. Service members in the personal exposure class were characterized by a distinct mental health profile: They reported a higher level of PTSD symptoms at baseline and a higher prevalence of traumatic brain injury and PTSD diagnoses during the course of the study. The limited exposure class was more likely to receive diagnoses of depression and adjustment disorders. All classes except the medical exposure class demonstrated a slight decrease in PTSD and depression symptoms over time. However, participants in the limited exposure class had a larger decrease in PTSD and depression symptoms earlier in care but did not demonstrate superior long-term symptom improvements at 12 months compared to the other groups. These results inform PTSD development models and have implications for the screening and clinical management of combat-exposed service members.

Spanish Abstracts by Asociación Chilena de Estrés Traumático (ACET) Tipologías de Exposición a Combate y sus Efectos en el Trastorno de Estrés Postraumático y Síntomas Depresivos. EXPERIENCIAS TRAUMÁTICAS DE COMBATE, TEPT Y DEPRESIÓN El presente estudio identificó clases distintivas de miembros del servicio militar de los EEUU basados en sus experiencias de combate y examinó los resultados en salud mental y las curvas de crecimiento longitudinal del Trastorno de Estrés Postraumático (TEPT) y síntomas depresivos asociados con cada clase. Los participantes fueron 551 miembros en servicio activo que resultaron positivo para TEPT y/o depresión basado en los criterios DSM-IV-R. Todos los participantes completaron la Escala de Experiencias de Combate así como también medidas de TEPT y Depresión, al inicio y a los 3, 6 y 12 meses de seguimiento. Un análisis de grupos latente identificó cuatro clases de miembros del servicio basados en sus experiencias de combate: exposición limitada, exposición médica, exposición de la unidad, y exposición personal. Los miembros del servicio en el grupo de exposición personal se caracterizaron por un perfil distintivo de salud mental: Ellos reportaron, al inicio, niveles más altos de síntomas de TEPT y prevalencias más altas de diagnósticos de lesión traumática cerebral y TEPT durante el curso del estudio. El grupo de exposición limitada tuvo mayor probabilidad de recibir los diagnósticos de depresión y trastorno de adaptación. Todos los grupos, excepto el grupo de exposición médica, demostraron una leve disminución en los síntomas de TEPT y depresión con el tiempo. Sin embargo, los participantes en el grupo de exposición limitada tuvieron una disminución mayor en síntomas de TEPT y depresión al inicio de la atención, pero no demostraron una mejoría mayor de los síntomas a largo plazo a los 12 meses en comparación con los otros grupos. Estos resultados sirven de base para los modelos de desarrollo de TEPT y tienen implicaciones para la detección y manejo clínico de los miembros en servicio expuestos a combate.

Identifying research gaps in substance use disorder: A systematic methodology and prioritized list.

Background: This paper presents a new methodology for identifying and prioritizing research gaps, contributing to the nascent literature on systematic ways to identify research gaps. Objectives: The goal of this paper is to report on a gaps analysis of substance use disorder (SUD) research. Based on input from Military Health System stakeholders, we selected the following subtopics as priorities: alcohol use disorder (AUD) and comorbid conditions, prescription opioids, and novel synthetic drugs (NSDs), including synthetic cannabinoids, synthetic cathinones, novel synthetic opioids, and e-cigarette use. Methods: Statements of research needs were extracted from authoritative source reports. A work group of 13 subject matter experts then supplemented, consolidated, and refined the statements. Support for each statement was rated based on predetermined metrics to produce a list of high-priority potential research gaps. Work group members searched both published and ongoing research literature to determine whether these potential gaps were sufficiently addressed in the literature. Finally, to prioritize the gaps, work group members rated them on a set of metrics. Results: The work group reduced 175 statements of research needs to a list of 18 final prioritized gaps: nine for AUD, four for prescription opioids, and five for NSDs. For each topic, we present a prioritized list of gaps. Conclusions: This paper describes a method to identify and prioritize research gaps relevant to military and civilian research and presents the prioritized SUD gaps. Our methodology and findings can inform policy makers, researchers, and funding agencies as they consider investments in future research.

Evidence-based telehealth interventions for posttraumatic stress disorder, depression, and anxiety: A systematic review and meta-analysis.

INTRODUCTION: The goal of this systematic review was to examine the efficacy of behavioral health care treatments for posttraumatic stress disorder (PTSD), depression, and anxiety delivered via telehealth. METHODS: We searched a combination of keywords related to telehealth, relevant mental health disorders, and evidence-based psychotherapies in three databases (PubMed, PsycInfo, and Embase) from database inception to April 2022. We included randomized controlled trials published in English wherein at least one arm received an evidence-based psychotherapy via telehealth. To be included, studies also had to enroll an adult population with symptoms or diagnosis of PTSD, depressive disorder, or anxiety disorder. RESULTS: Moderate quality of evidence was consistent with only small differences, if any, in efficacy between video teleconferencing (VTC) and in-person delivery for patients with PTSD (d = 0.06, 95% CI -0.17, 0.28). However, for those with depression, in-person delivery was associated with better outcomes compared to VTC (d = 0.28, 95% CI 0.03, 0.54; low quality of evidence). We also found that evidence-based treatments delivered over telephone were more efficacious for depression compared to treatment as usual (d = -0.47, 95% CI -0.66, -0.28; very low quality of evidence). Very low quality of evidence supported the use of telehealth versus waitlist for anxiety (d = -0.48, 95% CI -0.89, -0.09). CONCLUSIONS: A synthesis across 29 studies indicates that the efficacy of telehealth for delivery of evidence-based behavioral health interventions varies by target diagnosis and telehealth modality. More research is needed on the efficacy of telehealth treatments for depression and anxiety.

Diagnostic and functional outcomes of adjustment disorder in U.S. active duty service members.

BACKGROUND: Adjustment disorder (AD) is a commonly diagnosed psychiatric disorder. However, little is known about its course, predictors of its diagnostic outcomes, or its association with functional impairment. Our primary aim was to examine diagnostic transitions of service members with an incident AD diagnosis (IADx) to one of three states: 1) another psychiatric diagnosis, 2) chronic AD, or 3) no psychiatric diagnosis. Secondary outcomes included predictors of diagnostic course and functional outcomes associated with follow-up diagnoses. METHODS: Health records of a random sample of 10,720 service members with an IADx were analyzed using multinomial logit regression and hazard rate model with competing risks. RESULTS: IADx transitions were 24.3 % to another psychiatric diagnosis, 8.9 % with chronic AD, and 43.7 % without a diagnosis. Nearly a quarter (23.1 %) separated from service. Deployment was the strongest predictor of transitioning to another diagnosis. Those who transitioned to another diagnosis separated at an increased rate and with more adverse outcomes. LIMITATIONS: Diagnostic findings are based on data in the electronic health record, and we could not specifically identify the stressor that precipitated an AD diagnosis. These findings describe the course of AD in military personnel and may not generalize to civilians. CONCLUSIONS: AD, as initially diagnosed, represents a heterogeneous disorder with an enduring impact across the military career for a considerable proportion of service members. As an early indicator of more severe psychiatric outcomes, an IADx may signal an opportunity for early intervention and screening, particularly in service members with a history of deployment.

Systematic review and meta-analysis of predictors of adjustment disorders in adults.

BACKGROUND: The diagnosis of adjustment disorder is common in clinical practice, yet there is lack of research on the etiology and epidemiology of adjustment disorders. The goal of this systematic review was to evaluate predictors of adjustment disorders in adults. METHODS: We conducted systematic searches in MEDLINE, EMBASE, and PsycINFO. We included 70 studies that examined thirteen theoretically-derived and predefined predictors of adjustment disorders with a total of 3,449,374 participants. RESULTS: We found that female gender, younger age, unemployed status, stress, physical illness and injury, low social support, and a history of mental health disorders predicted adjustment disorders. Most of these predictors differentiated individuals with adjustment disorders from individuals with no mental health disorders. Participants with adjustment disorders were more likely to have experienced accidents than were those with posttraumatic stress disorder but were less likely to have experienced assaults and abuse, neglect, and maltreatment. More research is needed to identify factors that differentiate adjustment disorders from other mental health disorders. LIMITATIONS: Because very few studies adjusted for confounders (e.g., demographic variables, mental health histories, and a variety of stressors), it was not possible to identify independent associations between predictors and adjustment disorders. CONCLUSIONS: We identified a number of factors that predicted adjustment disorders compared to no mental health diagnosis. The majority of studies were rated as moderate or high in risk of bias, suggesting that more rigorous research is needed to confirm the relationships we detected.

Outcomes and prognosis of adjustment disorder in adults: A systematic review.

Adjustment disorder (AD) is one of the most commonly diagnosed mental health disorders and is generally conceptualized to be mild and short-lived. Despite the frequent use of AD in clinical settings, little is known about the prognosis of this condition. Our goal was to systematically review research on a range of AD outcomes in order to provide a broad characterization of AD prognosis. We conducted searches in MEDLINE, EMBASE, and PsycINFO. We included 31 cohort or randomized controlled trials with a total of 1,385,358 participants. Many patients maintained an AD diagnosis or were diagnosed with another mental health disorder months to years after initial diagnosis. Patients with AD tended to show symptom improvement at higher rates and to utilize less treatment than did patients with other disorders. AD-diagnosed groups experienced subsequent development of numerous physical conditions, such as infection, cancers, Parkinson's disease, and cardiovascular events, at higher rates than did control groups. Results were mixed regarding suicidality and occupational impairment. We rated most studies as having a moderate risk of bias. Based on limited findings, AD appears to progress as a milder disorder than do other disorders, but it not uncommonly transitions to more severe mental health states and may predict the development of future health issues, both mental and physical. Future prospective research that conforms to prognosis study guidelines is needed to better understand the course of this common disorder.

Adjustment disorders: A research gaps analysis.

Adjustment disorders are among the most commonly diagnosed mental health disorders in both civilian and military clinical settings. Despite their high prevalence, adjustment disorders have received little research attention. The many gaps in our understanding of this group of disorders hinder the development of adequate, evidence-based treatment protocols. This study utilizes a systematic methodology to identify and prioritize research gaps in adjustment disorders. We used authoritative source reports to identify gaps in research domains from foundational science to services research. Subject-matter experts conducted literature searches to substantiate and refine research gaps, and stakeholders assessed the importance and impact of this work for researchers and policy-makers. We identified 254 possible research-needs statements, which were ultimately reduced to 11 final, prioritized research gaps. Two gaps addressed prevention and screening and three addressed treatment and services research. Six gaps addressed foundational science, epidemiology, and etiology research domains, highlighting the need for basic research. Until some of the basic science questions are resolved (e.g., diagnostic clarity, valid screening, and assessment measures) about adjustment disorders, we may not be able to develop adequate evidence-based interventions for the disorders, and it will be difficult to understand the trajectory of these disorders throughout treatment. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Women in combat: The effects of combat exposure and gender on the incidence and persistence of posttraumatic stress disorder diagnosis.

Recent expansions in the roles of women in combat have prompted increased interest in the psychological toll combat exposure may have on female service members as compared to males. This study examined the interactive effects of gender and combat exposure on transitions in posttraumatic stress disorder (PTSD) diagnostic status (presence or absence of PTSD diagnosis). We used administrative data of 20,000 U.S. Army soldiers whose combat exposure was assessed after return from deployment between January 1, 2008 and June 30, 2014; soldiers' PTSD diagnostic status was determined using International Classification of Diseases-9 diagnoses at four time points separated by 12 months. We used a mixed-effects logit transition model to examine the effects of combat and gender on incidence, persistence, and prevalence of PTSD diagnosis. Incidence and prevalence of PTSD diagnosis were higher among women, but persistence of PTSD diagnosis was higher in men. Higher rates of new PTSD diagnosis among women were not dependent on combat exposure, suggesting that other types of trauma may be responsible for increased rates among women. Gender differences in prevalence and persistence of PTSD diagnosis were greater among combat-exposed soldiers than among those not exposed to combat. Men maintained a PTSD diagnosis over longer periods of time than women suggesting greater PTSD persistence, and this pattern was particularly pronounced among soldiers exposed to combat. These results have implications for the recent policy changes and gender-based prevention strategies, and suggest that women in combat roles may be no more vulnerable to PTSD than are their male counterparts. Though the gender differences were small, they are indicative of healthcare utilization patterns that may be important for prevention and that warrant further exploration.

A systematic analysis and prioritization of suicide prevention research gaps.

OBJECTIVE: This study identified and prioritized research gaps for suicide prevention in the Department of Defense to inform future research investments. METHODS: The 2019 VA/DoD Clinical Practice Guideline for the Assessment and Management of Patients at Risk for Suicide was the primary source document for research gaps, supplemented by an updated literature search. Institutional stakeholders rated the identified research gaps and ranked the gap categories. We used Q factor analysis to derive a list of the prioritized research gaps and category rankings. RESULTS: Thirty-five research gaps were identified and prioritized. The highest rated research gap topic was lethal means safety interventions and their effectiveness in increasing safety behaviors and/or reducing suicide-related outcomes. Research on the effectiveness of crisis response planning and several other non-pharmacological interventions (e.g., implementation of cognitive-behavioral therapy, technology-based behavioral interventions, and applications of dialectical behavior therapy to non-Borderline patients) were also rated highly by stakeholders. CONCLUSIONS: This work generated a list of priorities for future suicide research as evaluated by Departments of Defense and Veterans Affairs stakeholders. Our findings can help guide the efforts of suicide researchers and inform decisions about future research funding for suicide prevention.

Screening for Down syndrome: changing practice of obstetricians.

OBJECTIVE: We sought to assess the impact of American College of Obstetrician and Gynecologists (ACOG) guidelines on the practices and knowledge of obstetricians regarding screening for Down syndrome 1 year later. STUDY DESIGN: A questionnaire on Down syndrome screening was mailed to 968 ACOG Fellows and Junior Fellows. RESULTS: The response rate was 53%. The majority (95%) of respondents offer Down syndrome screening to all pregnant patients; 70% of general obstetricians offer the first-trimester screen and 86% the quad screen. Almost two-thirds (63%) of respondents are offering patients >/= 1 combination of first- and second-trimester screening tests. For women aged < 35 years, 70% offer amniocentesis selectively and 15% routinely. Chorionic villus sampling is offered less frequently. Respondents who more closely read the bulletin were more likely to say their practice had changed, answered more knowledge questions correctly, and felt more qualified to counsel patients. Most (85%) obstetricians personally counsel patients about Down syndrome risk and screening tests. The majority (94-95%) of respondents have access to adequate resources for screening within a 90-minute drive. CONCLUSION: Obstetricians have adopted a new paradigm for Down syndrome screening. First-trimester screening has been incorporated into prenatal care. Experience with these current screening tests will likely influence future guidelines and challenge the long-standing tradition of offering diagnostic testing based on maternal age. This study highlights the need for concise, unambiguous guidelines and a need to address unresolved issues in Down syndrome screening.

Patient perceptions of obstetrician-gynecologists' practices related to HIV testing.

OBJECTIVES: The objectives of this study were to (1) determine the percentage of obstetrician-gynecologists' patients who have been tested for HIV; (2) examine patient attitudes about HIV testing and patients' knowledge about their own risk status; (3) determine primary reasons patients decline an HIV test; and (4) learn patient recall of how their obstetrician-gynecologists approach the topic of HIV testing. METHOD: Survey packets were mailed to each of 687 obstetrician-gynecologists who are members of the Collaborative Ambulatory Research Network (CARN) to distribute to their patients. Data are reported from 851 patient respondents (297 pregnant and 554 non-pregnant), and were analyzed utilizing independent samples t-tests, chi2 analysis, and linear regression. RESULTS: Two-thirds of respondents (65%/n = 534) reported having been tested for HIV at some point, although the majority (72%) did not recall that their current obstetrician-gynecologist had recommended HIV testing. Among pregnant respondents specifically, 61% did not recall that their current obstetrician-gynecologist had recommended HIV testing, although 82% reported having had an HIV test at some point and 71% stated they had received their most recent HIV test results from their obstetrician-gynecologist during their current pregnancy. Age, race, and pregnancy status were linked to likelihood of patient recall of receiving an HIV testing recommendation from their obstetrician-gynecologist; with young, pregnant, Hispanic, and African-American patients most likely to recall a test recommendation. Perceived low risk was the primary reason given for declining an HIV test. Only 2% of respondents considered themselves high-risk for HIV despite almost half of the sample reporting having had unprotected sex at some point with more than one partner. CONCLUSIONS: Many patients did not recall that their obstetrician-gynecologist had ever recommended HIV testing, although the majority had been tested. Efforts should be made to increase communication between obstetrician-gynecologists and their patients related to HIV risk status and HIV testing.

Discrepancies in diagnostic records of military service members with self-reported PTSD: Healthcare use and longitudinal symptom outcomes.

OBJECTIVE: The study compared healthcare utilization and posttraumatic stress disorder (PTSD) symptom trajectories of active duty service members (ADSM) with self-reported PTSD based on whether they had a PTSD diagnosis in the electronic health record (EHR). METHODS: ADSM meeting study criteria for self-reported PTSD (N = 470) were grouped according to EHR-PTSD diagnostic status. Participants completed PTSD symptom assessments over a 12 month period. We used log binomial regression and linear mixed model to examine predictors of receiving an EHR-PTSD diagnosis and to analyze healthcare utilization and symptom trajectories based on diagnostic status. RESULTS: Thirty percent of ADSM with study-identified PTSD had an EHR-PTSD diagnosis. Combat exposure and PTSD severity predicted EHR-PTSD diagnosis. ADSM without the diagnosis were more likely to have an adjustment disorder diagnosis. Participants with an EHR-PTSD diagnosis utilized more healthcare and reported worse PTSD symptoms over 12 months. CONCLUSIONS: Findings suggest providers are more likely to record PTSD diagnoses for more severe, complex cases. While less severe cases may be less likely to receive a PTSD diagnosis, they may still access and benefit from care. Findings have implications for use of EHRs to describe health patterns and inform practices and policy in the Military Health System.

Obstetrician-gynecologists' screening and management of preterm birth.

OBJECTIVE: To define obstetrician-gynecologists' screening for potential preterm birth risk factors and interventions they use when indicators suggest the patient may be at increased risk. METHODS: Questionnaires were mailed to 1,193 American College of Obstetricians and Gynecologists members. RESULTS: The response rate was 59%. Respondents most frequently report screening for previous preterm birth (98%) and cone biopsy (95%) as risk factors for preterm birth. Twenty-one percent do not screen for asymptomatic urinary tract infection and 57% screen for group B streptococci in an attempt to prevent preterm birth. Almost one third (31%) routinely recommend bed rest in twin pregnancies. Most (98%) use tocolytics (primarily magnesium sulfate, 94%) for women with intact membranes in preterm labor. Nearly 100% use corticosteroids in anticipated preterm births, and few (4%) repeat the dosing if delivery has not occurred within 1 week. Twenty-four percent of respondents did not have access to a newborn intensive care unit (ICU); they were more likely to refer a patient with an impending preterm delivery to a maternal-fetal medicine specialist for complete care than were those with a newborn ICU available (79% compared with 9%; P<.001). CONCLUSION: Most obstetrician-gynecologists are practicing in accord with current findings on preterm birth risk factors and interventions. However, there may be overscreening and underscreening for various infections and overuse of bed rest as a preterm birth intervention. When preterm birth is imminent, physicians often and appropriately seek the most specialized care possible for their patients. LEVEL OF EVIDENCE: III.

Chronic corticosterone administration does not potentiate unconditioned freezing to the predator odor, trimethylthiazoline.

Chronic high levels of corticosterone (CORT) are known to facilitate learning and memory of aversive events. Whether this effect of chronic CORT also generalizes to unconditioned or unlearned fear behavior is not known. The present study investigated whether high levels of chronic CORT enhance unconditioned fear to a predator odor, trimethylthiazoline (TMT), an innate fear stimulus to rodents. TMT induces a dose-related freezing response, a prototypical behavior to fearful stimuli, in rats. The first experiment demonstrated that dose-related freezing to repeated exposures of TMT does not habituate, sensitize or produce contextually conditioned fear, and therefore can be used to measure the effects of chronic CORT on unconditioned fear to repeated exposures of TMT. In Experiment 2, 21-day release corticosterone pellets (200mg) were implanted subcutaneously in male, Sprague-Dawley rats. Control rats received sham implantation. On days when TMT was not present, chronic CORT rats froze significantly more than sham rats. However, while TMT-induced freezing in both chronic CORT and sham rats, freezing during exposure to TMT was not further enhanced in chronic CORT rats. Thus, chronic CORT appears to increase fear as measured by freezing, possibly by enhancing vigilance, but does not facilitate fear behavior induced by the innate fear stimulus, TMT.

United States obstetrician-gynecologists' accuracy in the simulation of diagnosing anxiety disorders and depression during pregnancy.

The objective of this study was to examine obstetrician-gynecologists' diagnostic accuracy for mental health issues during pregnancy through utilization of clinical vignettes describing depressive and anxiety symptoms, as well as to explore factors associated with increased diagnostic accuracy and related practice patterns. Questionnaires were mailed to 1193 American College of Obstetricians and Gynecologists Fellows and Junior Fellows. The response rate was 44% after three mailings. Depression was correctly identified by over 90% of respondents, whereas significantly fewer correctly diagnosed panic disorder (55%) and generalized anxiety disorder (32%). Confidence ratings significantly predicted diagnostic accuracy in some cases. Approximately half of respondents reported referring anxiety disordered patients to a mental health professional. There may be an education gap in ob-gyns' diagnostic knowledge of anxiety disorders, which may addressed by increasing physician confidence in diagnosis through increased training.

Obstetrician-gynecologists' practices regarding preterm birth at the limit of viability.

OBJECTIVES: To assess obstetrician-gynecologists' judgments of gestational age of viability and earliest age of medical intervention for preterm delivery, and to associate these practice decisions with physician characteristics. METHODS: Questionnaires were mailed to 1193 members of the American College of Obstetricians and Gynecologists (ACOG). RESULTS: The response rate was 59%. The majority of respondents considered 24 weeks the earliest age a fetus is potentially viable (57%) and at which they would routinely perform cesarean section for fetal distress (58%). Those respondents who judged viability as 23 weeks or less were more likely to have been in practice for a shorter period (p < 0.05), be a maternal-fetal medicine specialist (p < 0.005), and be from southern or central states (p < 0.005). Similarly, those respondents who would not intervene for fetal distress until 26 weeks gestation were more likely to have been in practice for longer (p < 0.01), to have performed fewer deliveries (p < 0.05), to be in solo practice (p < 0.01), and not to be a maternal-fetal medicine specialist (p < 0.01); males and females did not differ when controlling for age (p = 0.552). CONCLUSION: Obstetrician-gynecologists' judgment of viability threshold is consistent with standard estimates of 24 weeks. Viability judgment and reported earliest age for routine intervention both differ by physician characteristics.

A neuroendocrine mechanism for sustaining fear.

Fear is an adaptive response to recognition of a potentially dangerous event. Glucocorticoids are essential for maintaining a wide variety of behavioral events by their regulation of numerous genes; one such gene encodes corticotrophin-releasing hormone (CRH). CRH is involved in diverse behavioral responses to changing environmental demands. In this review, we focus on one aspect of glucocorticoid regulation of CRH--namely, fear-related responses to diverse classes of adverse events, such as those represented by contextual and cue-specific stimuli. Three extra-hypothalamic forebrain sites appear crucial for fear-related behavioral responses: the amygdala and the bed nucleus of the stria terminalis for sustaining adaptive fear-related behaviors, and the medial prefrontal cortex for modulating fear-related behaviors. Central regulation of CRH by glucocorticoids is important for adaptive and sustained fear-related behaviors, and its aberration is associated with anxiety and depressive disorders.

Obstetrician gynecologists' knowledge and practice regarding human immunodeficiency virus screening.

OBJECTIVE: To gather more information regarding prenatal human immunodeficiency virus (HIV) testing by examining the practice patterns of obstetrician-gynecologists. METHODS: Survey questionnaires were sent to 1,032 American College of Obstetricians and Gynecologists (ACOG) Fellows and Junior Fellows in practice. Questionnaires included inquiries about obstetrician-gynecologist characteristics, testing practices, and knowledge regarding HIV screening. RESULTS: A total of 582 surveys (56%) were returned. We found that 1) most (97%) obstetrician-gynecologists reported recommending HIV testing to all of their pregnant patients, 2) almost half (48%) of the physicians reported using the opt-out approach to prenatal HIV testing, and 3) respondents were sometimes unaware of whether their state requires recommending HIV testing during pregnancy. CONCLUSION: The finding that some obstetrician-gynecologists are unaware of their state regulations regarding prenatal HIV testing suggests that they would benefit from an increased awareness of state laws and regulations and having timely access to these requirements. The finding that most obstetrician-gynecologists offer HIV testing to all of their pregnant patients is consistent with the literature regarding prenatal HIV screening and with federal and national recommendations. However, study results also suggest that obstetrician-gynecologists may benefit from additional information to increase knowledge and strengthen perinatal HIV testing practice patterns. LEVEL OF EVIDENCE: III.

Obstetrician-gynecologists' knowledge of preterm birth frequency and risk factors.

OBJECTIVES: To assess obstetrician-gynecologists' knowledge of preterm birth, including prevalence, risk factors, and utility of various tests in predicting increased risk. METHODS: A questionnaire was mailed to 1193 members of the American College of Obstetricians and Gynecologists. RESULTS: The response rate was 59%. The majority of respondents were familiar with basic preterm birth prevalence rates. However, 21% underestimated the proportion of women with presumptive preterm labor in whom preterm birth will not occur. The majority (55%) overestimated the proportion of preterm births accounted for by multiples. Twelve percent indicated bed rest as a proven method for improving newborn outcome. Respondents were fairly accurate as to which factors produce the biggest increased risk of spontaneous preterm labor or rupture of membranes; however, they tended to overestimate the risk associated with smoking, hypertension, and non-gestational diabetes. They tended to underestimate, or were unsure of, the predictive value of positive fetal fibronectin (fFN) test results or short cervical length. CONCLUSIONS: Obstetrician-gynecologists' basic knowledge concerning preterm birth prevalence and risk factors was adequate. However, they tended to overestimate the risk associated with various maternal factors and underestimate the predictive value of various test results.