Telemedicine and fetal ultrasonography: assessment of technical performance and clinical feasibility

OBJECTIVE: Our aim was to determine the performance and clinical feasibility of telesonography for the interpretation of fetal anatomic scans sent from a remote location compared with those obtained at a tertiary care prenatal ultrasonography center. STUDY DESIGN: Routine ultrasonographic studies from 35 patients were remotely interpreted. Evaluation included a blinded comparison of the sonographer's assessment of 38 fetal structures with that of the physician at the tertiary care center. Technical evaluation included system reliability and the number of digital telephone lines required for adequate real-time visualization. RESULTS: The mean gestational age at the time of the ultrasonography was 25.84 +/- 6.8 weeks (range 14 to 38). There was complete consistency of interpretation for 25 of 38 (66%) fetal structures. Thirteen structures had discrepancies in visualization, reflecting a difference in the adequacy of visualization, not the normalcy or identity of the structures. Three digital (integrated switching digital network, ISDN) telephone lines were required for real-time visualization. CONCLUSION: Our preliminary experience supports telesonography as a clinically useful tool for remote interpretation of fetal ultrasonographic examinations. Further studies are warranted for the continued evaluation of this emerging technology.     

The impact of routine obstetric ultrasonographic screening in a low-risk population

OBJECTIVES: Our goal was to develop a framework for evaluating the current controversy regarding routine obstetric ultrasonography in a population of low-risk pregnancies. STUDY DESIGN: A retrospective chart review was performed for all low-risk pregnancies from a single obstetric practice during 1990 to 1994, to determine the accuracy of screening ultrasonography for fetal anomalies. All patients received a routine ultrasonographic examination at 18 to 20 weeks' gestation. Neonatal records for all patients were evaluated for the presence of both major and minor anomalies. The data were analyzed with attention to the classification of anomalies (all anomalies vs major anomalies, detectable vs nondetectable). RESULTS: A total of 860 fetuses in 854 pregnancies were evaluated. Anomalies were present in 5.35% (46/860); these were major anomalies in 1.16% (10/860) and minor anomalies in 4.19% (36/860). The sensitivity, specificity, and positive and negative predictive values for the diagnosis of all anomalies were 8.7%, 99.9%, 80%, and 95.7%, respectively. However, if only major anomalies detectable by ultrasonography are included, these values become 75%, 100%, 100%, and 99.9%, respectively. There was one false-positive diagnosis not affecting outcome, a small ventriculoseptal cardiac defect. Postnatal ascertainment of anomalies was excellent, as determined by an incidence of ventriculoseptal defects of 1 in 120. CONCLUSION: Distinguishing between major and minor anomalies and between ultrasonographically detectable versus nondetectable anomalies is essential in the evaluation of the diagnostic accuracy of screening ultrasonography. Any comparisons of studies examining the effectiveness of prenatal screening for congenital anomalies with ultrasonography should use the same outcome: major anomalies identifiable by ultrasonography.     

The use of umbilical artery Doppler ultrasonography in modern obstetrics

In contrast to the reduction in perinatal mortality in high-risk pregnancies, screening of low-risk pregnancies with umbilical artery Doppler ultrasonography has shown no benefit. Advances in pathophysiology question the assumption that the placenta is hypoxic in fetal growth restriction, with absent end-diastolic frequencies in the umbilical artery. The timing of delivery in relation to Doppler findings is uncertain, and so trials that relate Doppler findings to neurodevelopmental outcome are necessary to refine the role of this technique in obstetric practice.     

Detection, visualization and animation of abnormal anatomic structure with a deformable probabilistic brain atlas based on random vector field transformations

This paper describes the design, implementation and preliminary results of a technique for creating a comprehensive probabilistic atlas of the human brain based on high-dimensional vector field transformations. The goal of the atlas is to detect and quantify distributed patterns of deviation from normal anatomy, in a 3-D brain image from any given subject. The algorithm analyzes a reference population of normal scans and automatically generates color-coded probability maps of the anatomy of new subjects. Given a 3-D brain image of a new subject, the algorithm calculates a set of high-dimensional volumetric maps (with typically 384(2) x 256 x 3 approximately 10(8) degrees of freedom) elastically deforming this scan into structural correspondence with other scans, selected one by one from an anatomic image database. The family of volumetric warps thus constructed encodes statistical properties and directional biases of local anatomical variation throughout the architecture of the brain. A probability space of random transformations, based on the theory of anisotropic Gaussian random fields, is then developed to reflect the observed variability in stereotaxic space of the points whose correspondences are found by the warping algorithm. A complete system of 384(2) x 256 probability density functions is computed, yielding confidence limits in stereotaxic space for the location of every point represented in the 3-D image lattice of the new subject's brain. Color-coded probability maps are generated, densely defined throughout the anatomy of the new subject. These indicate locally the probability of each anatomic point being unusually situated, given the distributions of corresponding points in the scans of normal subjects. 3-D MRI and high-resolution cryosection volumes are analyzed from subjects with metastatic tumors and Alzheimer's disease. Gradual variations and continuous deformations of the underlying anatomy are simulated and their dynamic effects on regional probability maps are animated in video format (on the accompanying CD-ROM). Applications of the deformable probabilistic atlas include the transfer of multi-subject 3-D functional, vascular and histologic maps onto a single anatomic template, the mapping of 3-D atlases onto the scans of new subjects, and the rapid detection, quantification and mapping of local shape changes in 3-D medical images in disease and during normal or abnormal growth and development.     

Quantified dermal activity data from a four-child pilot field study

Thirty-three hours of videotape collected in a 1993 pilot study were quantified, via a video translation software application, to obtain left and right hand activity data of four children of farmworkers. Reported here are the children's contact duration and frequency for each object in their environment, duration spent in each location and activity exertion level, and frequency distributions of object contact durations. The pilot study provided valuable information for evaluating and improving videotaping and videotape translation methodologies as a means of gathering activity information that can be used to refine dermal exposure estimates. Although a larger database of children's videotaped activities for different ages and populations is needed before generalizations can be made, the data presented here are the most detailed information to date for children's micro-level dermal activities.     

Effects of videotape training inputs on group performance.

Assigned 135 university students to 5 experimental conditions-no verbal instructions, verbal instructions, videotape feedback, videotaped model presentation, videotaped feedback and modeling. Results show that groups which were exposed to videotape training inputs performed significantly better than did control groups. Specifically, videotape model presentations resulted in significant performance improvement, and the addition of videotape feedback to modeling resulted in a significant but relatively small incremental performance improvement. Videotape feedback alone did not result in significant performance improvement. (20 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A prospective evaluation of fetal pericardial fluid in 506 second-trimester low-risk pregnancies

OBJECTIVE: To measure fetal pericardial fluid in low-risk second-trimester pregnancies and to evaluate outcome for those with measurements greater than 2 mm. METHODS: Five hundred and six women were referred for sonography between 16 and 25 weeks' gestation for common obstetric indications (dating, fetal survey, and placental location) unrelated to an increased risk of anomalies. All cases were evaluated with two-dimensional and M-mode real-time ultrasonography with the use of a mechanical sector transducer. The maximum distance of the fetal hypoechoic cardiac rim was recorded. We reviewed maternal and infant charts for those with measurements greater than 2 mm. RESULTS: Median (range) maternal age was 25 (15-42) years. Median gravidity and parity were two (1-14) and one (0-11), respectively. Median estimated gestational age was 20.4 (16.3-24.9) weeks. Fetal pericardial fluid was seen in 360 of 506 (71%) fetuses. Of these 360 fetuses, the mean distance (+/- 2 standard deviation) of the fetal hypoechoic cardiac rim was 1.20 mm +/- 0.91 mm (95% confidence interval 1.15, 1.25). Among the 506 cases, the maximum measurement was 3 mm. Ten of the 506 (2%) cases had measurements greater than 2 mm. None of these ten fetuses had a cardiac structural abnormality or arrhythmia, and perinatal outcome was unremarkable. CONCLUSION: During second-trimester fetal ultrasonographic examination, visualization of pericardial fluid up to 2 mm in the fetus with current high-resolution technology is common and should not be regarded as pathologic.     

Norethindrone acetate enhances the antiatherogenic effect of 17beta-estradiol: a secondary prevention study of aortic atherosclerosis in ovariectomized cholesterol-fed rabbits

OBJECTIVE: Premature delivery is difficult to predict and causes considerable neonatal morbidity and mortality. Despite much research, little progress has been made in timely identification of the mothers at risk. We examined the uterine cervix with ultrasonography to discover whether such a procedure would be helpful in determining which women will deliver prematurely. METHODS: We performed transvaginal ultrasound examinations in addition to routine transabdominal ultrasonography at 18 to 22 weeks' gestation in 3694 consecutive pregnant women with live singleton fetuses. We measured the length of the uterine cervix and evaluated the dilatation, if any, of the internal os. The results of cervical ultrasonography were not available to the clinicians. RESULTS: Spontaneous delivery occurred before 37 completed weeks in 88 women (2.4%) and before 35 weeks in 31 (0.8%). The relative risk of delivery before 35 weeks was 8 (95% confidence interval 3, 19) when the cervical length was 29 mm or shorter. When dilatation of the internal cervical os of 5 mm or greater was present, the relative risk of delivery before 35 weeks was 28 (95% confidence interval 12, 67). Either short cervix (29 mm or less) or dilatation of internal cervical os (5 mm or greater) was present in 3.6% of the population; this combination had a sensitivity of 29% in predicting delivery at earlier than 35 weeks. After adjusting for cervical dilatation and length by using multiple logistic regression, nulliparity also remained a risk factor for delivery before 35 weeks (odds ratio 3.6, 95% confidence interval 1.7, 7.5). CONCLUSION: Transvaginal ultrasonography performed as an addition to routine transabdominal ultrasonography at 18 to 22 weeks helps to identify many patients at significant risk for prematurity; however, low sensitivity and low positive predictive value limit its usefulness in screening low-risk obstetric populations.     

Use of hypnosis as an aid to eyewitness memory.

72 hypnotically susceptible undergraduates observed a videotape of a simulated bank robbery. One week later, Ss were interviewed in 1 of 3 conditions: hypnotized, relaxed, or waking. Half of the Ss in each of these groups received imagery instructions; the remainder were given guided memory instructions. Each S answered 47 questions, including 5 misleading ones, about both the video event and the context of the viewing room. Ss also were offered a photo identification task. Results show that overall recall accuracy for both the video and live events was high. Hypnosis had no positive effect on recall, nor were hypnotized witnesses more susceptible to misleading information. The type of memory instruction interacted with recall condition. This interaction differed for the video and live aspects of the event. Rated confidence on photo choice was positively related to both accuracy of choice and amount recalled. (39 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Televised self-confrontation and recalled affect: A new look at videotape recall.

Utilized 2 analogy studies of videotape feedback to investigate the extent to which 10 graduate students with previous video feedback training could recall feelings they experienced during a dyadic interaction, when shown a televised replay of that interaction. Pairs of Ss were trained to continuously rate their degree of comfort or discomfort during the actual ("live") interaction and, subsequently, as they watched a replay of their interaction. A push-button recording system was employed with the self-rating data from live and recall sessions, with the 2 sessions exactly synchronized for the purpose of analysis. Results of 2 studies with role-playing counseling students and with intimate male-female couples yielded moderate correlations between live self-ratings and those recalled under videotape stimulation. It was also found that playing the client rather than the counselor role (Study 1) or having one's self-ratings disclosed to a partner (Study 2) significantly increased the association between live and recalled self-ratings. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Fetal fast MR imaging: reproducibility, technical quality, and conspicuity of anatomy

PURPOSE: To evaluate the normal appearance of fetal anatomy, the conspicuity of fetal organs, the reproducibility of images, and the limitations to image quality with the use of half-Fourier, single-shot rapid acquisition with relaxation enhancement (RARE) magnetic resonance (MR) imaging. MATERIALS AND METHODS: Fifty-four fetuses of 49 pregnancies underwent MR imaging with the half-Fourier, single-shot RARE technique. Two reviewers attempted to identify 47 organs and anatomic regions in each fetus. Organ or region conspicuity, image quality, and the limitations of image quality were graded. RESULTS: Fetal anatomy was well depicted in fetuses over 20 weeks in gestational age. Fetal imaging was limited by gestational age of 20 weeks or less usually owing to the small size of the organ or region being evaluated and, less frequently, by motion. CONCLUSION: Half-Fourier, single-shot RARE MR imaging provided a detailed and reproducible evaluation of normal fetal anatomy, which can be used as a standard of reference in MR imaging of fetal anomalies.     

Three-dimensional fetal echocardiography: gated versus nongated techniques

The purpose of this study was to compare gated with nongated three-dimensional fetal echocardiography in terms of the ability to demonstrate fetal cardiac anatomy. We examined nine fetuses in utero using conventional two-dimensional sonographic imaging equipment, an electromagnetic position sensor, and a computer-graphics workstation. Free-hand sweeps were performed through the fetal heart and great vessels in either transverse or sagittal orientations with respect to the fetal heart. Seven transverse and five sagittal sweeps were selected for reconstruction and analysis. Cardiac gating was performed by using a temporal Fourier transform to determine the fundamental frequency of cardiac motion. Two-dimensional data from each sweep were reprojected to a series of volume data sets. Each series was then condensed to a single volume, so that each two-dimensional sweep could be compared with its respective gated and nongated volume data sets. The two-dimensional data were reviewed utilizing a display with forward and backward cineloop capability. The gated and nongated volume data sets were displayed interactively as a series of three orthogonal planes, with the ability of the observer to control the location of each image plane within the volume. The gated data were animated with variable display frame rates. Conventional two-dimensional imaging provided a fairly complete evaluation of the fetal heart when scanning included the four-chamber view with a sweep across the outflow tracts. Nongated three-dimensional fetal echocardiography allowed visualization of some structures and views not demonstrated with two-dimensional ultrasonography. Gated three-dimensional fetal echocardiography provided significantly better visualization and comprehension of cardiac anatomy than nongated three-dimensional fetal echocardiography. The superiority of gated over nongated three-dimensional fetal echocardiography appears to come from both improved image quality and the anatomic clues that derive from the ability to view cardiac motion.     

Ultrasound evaluation of the fetal central nervous system

Evaluation of the fetal central nervous system is an integral part of any obstetric examination. Critical to the diagnosis of central nervous system abnormalities is a basic understanding of the normal fetal anatomy. Anatomic features of a normal ultrasound examination of the fetal central nervous system are discussed. In addition, the sonographic findings associated with a variety of major central nervous system anomalies are reviewed.     

Left-sided laparoscopic para-aortic lymphadenectomy: anatomy of the ventral tributaries of the infrarenal vena cava

OBJECTIVE: We evaluated the anatomy of the infrarenal portion of the human inferior vena cava and their ventral tributaries by video laparoscopy. STUDY DESIGN: A total of 112 patients underwent laparoscopic para-aortic lymphadenectomy for gynecologic malignancies. All procedures were videotaped. The number and anatomic distribution of the infrarenal tributaries of the anterior part of the inferior vena cava was evaluated retrospectively from videotapes. The inferior vena cava was divided into 3 levels: the area of the bifurcation of the vena cava (level 1), the area between the bifurcation and the inferior mesenteric artery (level 2), and the area between the inferior mesenteric artery and the right ovarian vein (level 3). RESULTS: Tributaries were found in level 1 in 65 (58%) patients, in level 2 in 22 (19.6%) patients, and in level 3 in 1 (0.9%) patient; in 24 (21.5%) patients no tributaries were found. A total of 237 tributaries was counted: 82.3% (195 of 237) were located at level 1, 17.3% (41 of 237) at level 2, and 0.4% (1 of 237) at level 3. Patients with tributaries had a mean of 3 tributaries in level 1, a mean of 1.7 tributaries in level 2, and 1 patient had 1 tributary in level 3. CONCLUSIONS: The ventral tributaries of the inferior vena cava show a specific distribution pattern. The knowledge of these anatomic landmarks can be important for laparoscopic surgeons to avoid accidental injury.     

Fetal assessment based on fetal biophysical profile scoring. VIII. The incidence of cerebral palsy in tested and untested perinates

OBJECTIVE: The intent of this comparative clinical study was fourfold: (1) to determine the incidence of cerebral palsy in a large obstetric population, (2) to compare the incidence of cerebral palsy in patients at high risk referred for and managed according to the fetal biophysical profile score result with the incidence among unreferred and untested patients, (3) to determine the relationship, if any, between the last fetal biophysical profile score and the incidence of cerebral palsy, and (4) to categorize cases of cerebral palsy according to the clinical parameters and the probable time and nature of the damaging insult. STUDY DESIGN: In this retrospective 5-year comparative study (1987 to 1991) the incidence of cerebral palsy was determined by analysis of International Classification of Diseases, Ninth Revision, -coded related medical services. The clinical records were then sought and reviewed in index cases and obstetric, neonatal, and postnatal clinical data were abstracted. Cross-correlation with partial registries was done to confirm completeness of capture of index cases. The population of referred high-risk patients who received serial fetal biophysical profile scoring and were managed according to test results was determined by review of a prospective computer-stored database and by review of patient log books. The population of untested patients was calculated as the residual of total cases minus tested cases. The rate of cerebral palsy for all patients and for the tested and untested population was calculated and compared. The tested and untested perinates were compared for birth age, weight, and assigned timing or etiology of cerebral palsy. In the tested population the distribution of test results by last recorded biophysical profile score was determined and the relationship between the last test result and cerebral palsy and predictive accuracy parameters of the fetal biophysical profile score were calculated. RESULTS: The incidence of cerebral palsy among the 84,947 live births was 3.68 per 1000 live births (313 cases). The rate of cerebral palsy in the 26,290 referred high-risk tested patients was 1.33 per 1000 (35 cases) compared with a rate of 4.74 per 1000 live births in the 58,657 untested mixed low-risk/high-risk patients (278 cases). These differences were highly significant. A significant declining trend in the annual incidence of cerebral palsy was observed in the total population and the untested population, whereas the rate in the tested population remained relatively constant over the 5-year study interval. The differences in the cerebral palsy rate between the tested and untested population were not related to differences in gestational age, birth weight, or assigned timing or etiology category. In the tested population the relationship between the incidence of cerebral palsy and the last test fetal biophysical profile score was inverse, exponential, and highly significant. CONCLUSIONS: Antepartum assessment by fetal biophysical profile scoring is associated with a significant reduction in the incidence of cerebral palsy compared with untested patients. The relationship between the last test score and the incidence of cerebral palsy is inverse and exponential, suggesting that antenatal asphyxia is an important and potentially avoidable cause of cerebral palsy.     

A carbohydrate-rich diet stimulates glucose-6-phosphate dehydrogenase expression in rat hepatic sinusoidal endothelial cells

OBJECTIVE: To describe an anatomic and surgical approach to the efferent parasympathetic branches of the pterygopalatine ganglia in sheep, with particular reference to the ethmoidal nerve and innervation of nasal and cerebral blood vessels. ANIMALS: 12 adult sheep used for monolateral (n = 7) or bilateral (n = 5) ethmoidal neurectomy; 2 sheep used for angiography (1 live sheep for digital subtraction angiography, 1 embalmed cadaver for injection studies); and 5 embalmed cadavers, 4 frozen specimens, and 2 dry skulls used for dissection, x-rays, and computed tomographic (CT) or magnetic resonance (MR) scans. PROCEDURE: Transverse (coronal) MR scans, transverse, sagittal, and dorsal CT scans, radiography, angiography, photographic images, and dissections of embalmed material were used to study the topographic anatomy of the temporal and pterygopalatine fossae of the head. RESULTS: Images were stored, then compared with photographs of frozen sections from the same or a similar specimen to plan a surgical approach to the ethmoidal nerve. Mono- and bilateral experimental ethmoidal neurectomies were performed, allowing characterization of a safe and reliable method. The series of pterygopalatine ganglia typical of this species was localized, dissected, and analyzed for topographic relations. CONCLUSIONS: From the results, a new approach to the efferent branches of the pterygopalatine ganglia (ethmoidal nerve) for experimental parasympathectomy of the cerebral and nasal circle is proposed. This experimental approach could be used for studies involving thermoregulation of the face, and in experimental control of blood flow in the nasal cavity and rostral part of the brain.     

Some stable characteristics of family therapists' interventions in real and simulated therapy sessions.

Coded the interventions of 19 family therapy trainees with a videotaped simulated family and with families they were treating, and compared them at 3 points in time. The coding categories were drive, interpretation, average length of speech, number of speeches, and average silence. Spearman rhos revealed stability over time for all categories except drive and interpretation, within real and simulated situations. Drive was stable only in the real situation and interpretation only in the simulated one. Correlations between situations within categories were largely nonsignificant, suggesting that therapists differ in their responses to the absence of feedback from a family. Available evidence suggests that the frequency with which family therapists trained in the dynamic interactional approach use interpretation might predict their success with families otherwise likely to terminate treatment prematurely. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Computer-assisted video evaluation of surgical skills

Compact video cameras have allowed the review of operations in self-directed learning sessions. Controlling the video viewing process by computer allows the selection of specific videotape segments containing the desired psychomotor skills to be evaluated--in this study, the steps involving laparoscopic tubal banding. Six faculty members were able to evaluate 23 videotapes efficiently without knowledge of the resident operator's identity. Because the computer allowed selection of only those frames of the videotape containing the skills to be evaluated, the duration of videotape seen was reduced by an average of 34% from the actual surgical time, with an increase in time saved as experience with the system was gained. Faculty members evaluated these events using a self-made checklist. It was possible to calculate the performance scores of each resident for the individual psychomotor skill components of the reviewed procedure. Computer-assisted video evaluation of surgical skills is technically feasible, allowing time-efficient review by multiple evaluators. With the development of psychometrically valid checklists for use with this technology, computer-assisted video evaluation of surgical skills may provide a new, innovative means of assessing surgical skills and training.     

Prenatal diagnosis

The enormous progress witnessed in the field of prenatal diagnosis during the past two decades is likely to continue into the future. Improved imaging techniques are likely to enhance the resolution of noninvasively obtained fetal images considerably over their current excellent quality. Although this undoubtedly will be true for ultrasonography, the increased speed of magnetic resonance equipment may offer a new realm of imaging possibilities. Computerized image processing, analysis, and three-dimensional reconstructions all should make interpretation of fetal images easier and more understandable to the nonspecialist. Advances in molecular genetics will continue to accelerate, greatly expanding the range and accuracy of prenatal diagnosis. The alert pediatrician who is sensitive to genetic issues may, by early detection of pediatric disorders and careful family history assessment, be in a position to identify families at risk for serious genetic conditions and provide the opportunity to make informed decisions on reproductive options that avert a major tragedy. The pediatrician, working with obstetric colleagues, should be part of a team effort to support families going through prenatal testing. Familiarity with these rapidly changing technologies will make it far easier to support the family needing additional explanation about prenatal diagnosis issues.