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To examine the impact of Antenatal and Neonatal Guidelines, Education and Learning Systems (ANGELS) on neonatal intensive care unit (NICU) preterm delivery rates. In this longitudinal observational study, linked vital records and Medicaid claims records for 29,124 preterm births (April 2001–December 2012) to Medicaid covered women were used to examine factors predicting whether deliveries occurred at hospitals with neonatology-staffed NICUs. The factors associated with delivery are estimated and compared for baseline and three post-implementation periods. Rates for NICU preterm deliveries increased from 28 to 37% over the time period. Compared to baseline, adjusted NICU delivery rates in the middle and late implementation periods were statistically significant (p

Background There are still marked disparities in stroke care between rural and urban communities including difference in stroke-related mortality. We analyzed the efficiency of tissue plasminogen activator (tPA) delivery in the spoke sites in our telestroke network to assess impact of telecare in bridging these disparities. Methods We analyzed critical time targets in our telestroke network. These included door-to-needle (DTN) time, door-to-CT (D2CT) time, door-to-call center, door-to-neurocall, and total consult time. We compared these time targets between the larger and smaller spoke hospitals. Results Across all the 52 spokes sites, a total of 825 stroke consults received intravenous tPA. When compared with larger hospitals (>200 beds), the smaller hospital groups with 0 to 25 and 51 to 100 beds had significantly lower D2CT time (p-value 0.01 and 0.005, respectively) and the ones with 26 to 50 and 151 to 200 beds had significantly lower consult time (p-value 0.009 and 0.001, respectively). There was no significant difference in the overall DTN time when all the smaller hospital groups were compared with larger hospitals. Conclusion In our telestroke network, DTN times were not significantly affected by the hospital bed size. This shows that a protocol-driven telestroke network with frequent mock codes can ensure timely administration of tPA even in rural communities regardless of the hospital size and availability of local neurologists.

Digital health technologies improve outcomes within many health care fields. They include telemedicine and telehealth, remote patient monitoring, mobile health applications, data analytics, and social networking. Patients, providers, and insurers benefit from digital health, with time and cost savings as well as access to aggregate data, used to predict disease and outcomes and allowing tailored solutions. Some essentials of digital health implementation include champion providers, patients in need, technology, peer support system, understanding laws and regulations, seed funding, and sustainability. Successful programs can and will be established, leading health care into a more value-based future largely focused on direct-to-consumer care.

We sought to describe the implementation and effectiveness of a statewide fetal tele-echocardiography program serving a resource-limited population. In 2009, our heart center established six satellite clinics for fetal tele-echocardiography around the state. We retrospectively reviewed all fetal tele-echocardiograms performed through 2018. Yearly statewide prenatal detection rates of operable congenital heart disease were queried from the Society of Thoracic Surgeons database. In 1164 fetuses, fetal tele-echocardiography identified all types of congenital heart disease, with a sensitivity of 74% and specificity of 97%. For the detection of ductal-dependent congenital heart disease, fetal tele-echocardiography was 100% sensitive and specific. Between 2009 and 2018, annual statewide prenatal detection rates of congenital heart disease requiring heart surgery in the first 6 months of life rose by 159% (17–44%; R2 = 0.88, p

To determine the level of agreement between the advice given to an obstetric patient calling an obstetric call center and the advice given by health care providers with varying degrees of knowledge and experience.This is a retrospective quality improvement project which evaluates the level of agreement between advice from nurses at an obstetric call center using software with obstetric triage protocols compared with advice given by women's health advanced practice nurse (APN), a fourth year obstetrics and gynecology (OB-GYN) resident, and a maternal fetal medicine (MFM) specialist on the same call scenarios.The call center nurses advised emergency care more frequently (51.7%) than the MFM (44%) and the APN (31.9%) but less frequently than the OB-GYN resident (57.1%). The levels of agreement between the call center nurse and the MFM were good (Advice given by nurses at an obstetric call center was highly consistent with the most skilled specialist (MFM) followed closely by OB-GYN resident or an APN.

OBJECTIVE: To systematically review the effectiveness of telehealth interventions for improving obstetric and gynecologic health outcomes.

INTRODUCTION/PURPOSE: There are no large validation trials comparing teleultrasound to on‐site ultrasound. We aim to compare the sensitivity and accuracy of teleultrasound and demonstrate that teleultrasound is not inferior to on‐site ultrasound in the pre‐natal diagnosis of fetal anomalies. METHODS: All targeted ultrasounds performed between November 2010 and December 2012 were considered. We excluded studies performed at less than 17 weeks' gestation, on multiple gestations and for reasons other than an anatomical survey. Post‐natal diagnoses were obtained from a state level mandatory birth defects surveillance programme. Descriptive statistics (sensitivity, specificity, positive and negative predictive values and accuracy) were calculated for both groups. A test of non‐inferiority was performed, with the non‐inferiority difference set at 0.15. RESULTS: The teleultrasound and on‐site ultrasound groups consisted of 2368 and 3145 studies, respectively. The sensitivity of teleultrasound and on‐site ultrasound was 57.46% and 76.57%, and the accuracy was 95.9% and 90.97%, respectively. The observed sensitivity difference was −0.1911. The accuracy, specificity, positive and negative predictive values of teleultrasound are similar to on‐site ultrasound. DISCUSSION: Teleultrasound is inferior to on‐site ultrasound in the detection of fetal anomalies; however, it has improved accuracy, as well as higher negative and positive predictive values. A negative teleultrasound is more likely to identify a non‐anomalous fetus, and a positive teleultrasound is more likely to correctly identify an anomalous fetus. CONCLUSION: Teleultrasound has an important role in pre‐natal diagnosis for those patients unable or unwilling to travel for an on‐site ultrasound.

AIM Pregnant women undergoing treatment for opioid use disorder (OUD) may be exposed to multiple QT prolonging agents. We used magnetocardiography to measure fetal QT intervals in mothers with OUD on buprenorphine therapy. METHODS Fetal and maternal magnetocardiography was performed in pregnant women receiving buprenorphine-assisted treatment (Disorder group); these were matched by gestational age to pregnant women who were opiate naive (Reference group). Corrected QT intervals were determined using Bazett's formula and compared between groups. RESULTS A total of eight women in the Disorder group matched to eight in the Reference group. Seven of the mothers (88%) in the Disorder group were smokers; there were no smokers in the Reference group. The average fetal corrected QT was significantly longer (P = 0.022) in the Disorder group than that in the Reference group (505 milliseconds [ms] ± 68.6 [standard deviation] vs 383 ms ± 70.3 [standard deviation]). CONCLUSION Novel data from this small sample demonstrate prolongation of fetal corrected QT in women with OUD participating in buprenorphine assisted therapy. Additional investigation from a larger sample is needed to clarify if fetal buprenorphine and/or tobacco exposure is associated with changes in fetal QT which would warrant further prenatal and postnatal testing.

Objective We aim to evaluate the effects of the telemedicine program, High-Risk Pregnancy Program at University of Arkansas for Medical Sciences (UAMS), on health services utilization and medical expenditures among pregnant women with pre-existing diabetes and their newborns. Research design and methods The study sample was selected from the Arkansas Medicaid claims linked to infant birth/death certificates and UAMS telemedicine records from 2013 through 2016. We used propensity score matching based on participants’ characteristics to create three groups - UAMS telemedicine care, UAMS in-person care, and non-UAMS prenatal care. We compared inpatient and outpatient care services, medication use and caesarean section rates, severe maternal morbidity, infant mortality and preterm birth rates and medical expenditures. Results The UAMS telemedicine group had fewer inpatient admissions (1.18 vs 1.31; 95% CI: -0.27, 0.00), lower insulin use rates (41.86% vs 59.88%; 95% CI: -29.00%, -7.05%) and lower maternal care expenditures ($7,846 vs $10,644; 95% CI: -$4,089, -$1,507) compared with the UAMS in-person care group. Women receiving UAMS telemedicine had more prenatal care visits (10.45 vs 8.57; 95% CI: -2.96, -0.81), higher insulin use rates (41.86% vs 26.74%: 95% CI: 4.63%, 25.60%) and similar maternal care expenditures ($7,846 vs $7,051), compared with those receiving non-UAMS in-person care. Caesarean section, severe maternal morbidity, and infant mortality rates were similar across the three groups. Conclusion UAMS telemedicine was associated with improved utilization of prenatal care among pregnant women with pre-existing diabetes. Telemedicine services did not differ from usual in-person services in clinical outcomes and medical expenditures.

Objective: Fetal magnetocardiography (fMCG) is a non-invasive biomagnetic technique that provides detailed beat-to-beat fetal heart rate analysis, both in normal rhythm as well as in fetal arrhythmias. New cryogenic-free sensors called optically pumped magnetometers (OPMs) have emerged as a less expensive and more geometrically flexible alternative to traditional Superconducting Quantum Interference Device (SQUID) technology for performing fMCG. The objective of the study was to show the ability of OPMs to record fMCG using flexible geometry while seeking to preserve signal quality, and to quantify fetal heart rate variability (FHRV). Approach: Biomagnetic measurements were performed with OPMs in 24 healthy pregnant women with uncomplicated singleton pregnancies between 28 and 38 weeks gestation (GA). A total of 96 recordings were analyzed from OPM data that was collected using sensors placed in two different maternal configurations over the abdomen. The fMCG signals were extracted and the quality of the recordings were quantified by peak amplitudes and signal-to-noise ratio (SNR). R peaks were used to perform both time and frequency domain FHRV analysis. FHRV measures obtained from OPMs were compared descriptively to the same measures obtained from GA-matched existing SQUID data. Main results: The fMCG derived from OPMs were observed in 21 of the 24 participants. Higher detection rates (85%) of fMCG signals were observed in the data sets recorded at GA >32 weeks. Peak amplitudes and SNR values were similar between two maternal configurations, but peak amplitudes were significantly higher (p = 0.013) in late GA compared to early GA. FHRV indicators were successfully extracted and their values overlapped substantially with those obtained from SQUID recordings. Significance: Taking advantage of the geometric flexibility of the OPMs, we have demonstrated their ability to record and quantify fMCG in different maternal positions as opposed to rigid SQUID configurations.

Background Studying critical time interval requirements can enhance thrombolytic treatment for stroke patients in telestroke networks. We retrospectively examined 12 concurrent months of targeted time interval information in the South Central US telemedicine programme, Arkansas Stroke Assistance through Virtual Emergency Support (AR SAVES). Hypothesis: We hypothesised that consult data analysis would highlight areas for improvement to shorten overall door to Intra venous (IV) tissue plasminogen activator (tPA) administration time. Methods We analysed critical time targets for 238 consecutive telestroke neurology consults obtained over 12 months from AR SAVES spoke sites when tPA was administered. The following time intervals were analysed: emergency department (ED) door to Computed Tomography (D-CT); ED door to call centre (D-CC) for initiation of consult; ED door to neurology call (D-NC); neurology call to camera (NC-Cam); tele consult time (Con); ED door to tissue plasminogen activator (tPA)/needle (DTN). Results The median times of D-CT (13 min, inter quartile range (IQR) 6–22 min), D-CC (34 min, IQR 20–45 min), D-NC (40 min, IQR 21–71 min), NC-Cam (4 min, IQR 2–8 min), and Con (25 min, IQR 17–37 min) all contributed to a DTN median time of 71 min (IQR 50–104 min). A total of 238 patients received tPA with a 29.4% treatment rate and a DTN time of ≤60 min was achieved in 25.2% of patients. Conclusions Focusing on reducing D-CC and Con times may help to achieve the DTN time of

In January 2015, the US Secretary of Health and Human Services announced targets for the transformation of Medicare reimbursement from a fee-for-service model to payments based on alternative payment models. People now use technology for virtually everything - from paying bills to purchasing almost anything; it is therefore natural to think that they will use technology to take ownership of their own health care. The remote provision of health care, where providers and patients are not in the same location, will allow patients to receive the right care, at the right time, at the right place, and in the manner they consider right for them. To date, much of the technological advances in medicine have been led by the technology creators rather than providers or patients. A meeting of leaders from academic medical centers was convened to brainstorm and explore new opportunities to educate the workforce, expand the science, and improve the delivery of quality care to patients through the use of telemedicine. The academic community needs to develop an evidence base that can inform new care delivery models, including the role for remote monitoring and wearable technology, as well as the methods by which the best patient-centered care can be provided. It is important that the future of medicine be determined by solid research and education rather than the latest "cool toy" to reach the market. Academic medical centers are in a unique position to help shape this future direction, collaborating to create innovative and efficient solutions for patient care. Specific calls for action are summarized.

Preeclampsia is a hypertensive disorder in pregnancy where a patients' blood pressure and warning signs of worsening disease need to be closely monitored during pregnancy and the postpartum period.No studies have examined remote patient monitoring using mobile health (m-health) technologies in obstetrical care for women with preeclampsia during the postpartum period. Remote monitoring and m-health technologies can expand healthcare coverage to the patient's home. This may be especially beneficial to patients with chronic conditions who live far from a healthcare facility.The study was designed to identify and examine the potential factors that influenced use of m-health technology and adherence to monitoring symptoms related to preeclampsia in postpartum women. A sample of 50 women enrolled into the study. Two participants were excluded, leaving a total sample size of 48 women. Users were given m-health devices to monitor blood pressure, weight, pulse, and oxygen saturation over a 2-week period. Nonusers did not receive equipment. The nurse call center monitored device readings and contacted participants as needed. Both groups completed a baseline and follow-up survey.Women who elected to use the m-health technology on average had lower levels of perceived technology barriers, higher facilitating condition scores, and higher levels of perceived benefits of the technology compared with nonusers. Additionally, among users, there was no statistical difference between full and partial users at follow-up related to perceived ease of use, perceived satisfaction, or perceived benefits.This study provided a basis for restructuring the management of care for postpartum women with hypertensive disorders through the use of m-health technology.Mobile health technology may be beneficial during pregnancy and the postpartum period for women with preeclampsia to closely manage and monitor their blood pressure and warning signs of worsening disease.

Objectives Ultrasound serves an important role in the prenatal diagnosis of fetal structural anomalies. Recently, there has been increased use of teleultrasound protocols. We aimed to evaluate the sensitivity and accuracy of teleultrasound. Methods We conducted an Institutional Review Board–approved retrospective cohort study determining the sensitivity and accuracy of teleultrasound. In addition, we evaluated the number of ultrasound examinations required to complete an anatomic survey. Only ultrasound examinations performed for anatomic surveys were included. Studies were excluded if performed before 16 completed weeks' gestation, if they had multiple gestations, or for reasons other than anatomy (eg, Doppler studies and fluid assessment). Prenatal diagnoses were compared with postnatal diagnoses obtained from a robust mandatory birth defects surveillance program that records all birth defects in the entire state, from deliveries before 20 weeks' gestation through infants up to 2 years of age. Results A total of 2499 studies were evaluated; 2368 were included. The teleultrasound cohort had a congenital anomaly prevalence of 5.66%. The sensitivity of teleultrasound was 57.46%; the specificity was 98.21%; and the accuracy was 95.9%. Anatomic surveys were completed after 1 visit in 82% of patients, whereas 63% and 61% of the remaining patients required 2 and 3 visits, respectively. Conclusions Teleultrasound for prenatal diagnosis has similar sensitivity and accuracy as the published literature for on-site ultrasound. Further studies are needed to compare the sensitivity and accuracy within the same population and further validate this potentially cost-saving modality.

Objective : We propose a method that uses minimal redundancy and maximal relevance (mRMR) based on mutual information as criteria to automatically select references for the frequency-dependent subtraction (SUBTR) method to attenuate maternal (mMCG) and fetal (fMCG) magnetocardiograms of fetal magnetoencephalography recordings. Methods : mRMR is calculated between all channels and mMCG/fMCG target channels and the most promising sensors are used as references to perform SUBTR. We measured the performance of SUBTR at removing interferences in two steps for different number of references in 38 real datasets. The evaluation was based on the MCG amplitude reduction. We compared the performance of the mRMR approach with random selection of references. Results : Significant differences in interference removal were found when a distinct number of references were chosen by mRMR compared to random selection. Conclusion : mRMR provides an effective tool to automatically select a set of featured references. Significance : Although we show the utility of the mRMR method to biomagnetic signals, the approach can easily be adapted to sensor array data from other applications.

We sought to describe the implementation and effectiveness of a statewide fetal tele-echocardiography program serving a resource-limited population.In 2009, our heart center established six satellite clinics for fetal tele-echocardiography around the state. We retrospectively reviewed all fetal tele-echocardiograms performed through 2018. Yearly statewide prenatal detection rates of operable congenital heart disease were queried from the Society of Thoracic Surgeons database.In 1164 fetuses, fetal tele-echocardiography identified all types of congenital heart disease, with a sensitivity of 74% and specificity of 97%. For the detection of ductal-dependent congenital heart disease, fetal tele-echocardiography was 100% sensitive and specific. Between 2009 and 2018, annual statewide prenatal detection rates of congenital heart disease requiring heart surgery in the first 6 months of life rose by 159% (17-44%; RThe present study provides a framework for an effective, large-scale fetal tele-echocardiography program.

Background: Drug overdose from 1999 to 2017 in the US has continued to increase. Rural America has seen an increase in methamphetamine (Meth) users. Meth usage in Arkansas and its effects on stroke incidence and treatment are all largely unknown. Drug abuse can cause an immediate stroke or increase the risk of stroke either by damage to the cerebrovasculature, hypertension, or by affecting vital organs. Here we retrospectively examined strokes from 57 rural communities that self-reported positive for drug use from a large telestroke program for age, thrombolysis, alcohol and smoking use, gender, race, deficit level and symptom to door time. Hypothesis: Incidence of drug use is greater among younger age groups and increases the incidence of stroke in younger age categories. Methods: We analyzed consult prospective data from 2015 to 2018 of the Arkansas Stroke Assistance through Virtual Emergency Support (AR SAVES) telestroke program for consults who self-reported as positive for drug use. We included all stroke assessed consults for age (ranged by decade), thrombolysis (alteplase use), alcohol and smoking use, consult gender, race, initial deficit level at presentation using the national institutes of health stroke scale (NIHSS) and symptom to door time (minutes). Results: In 2015 to 2018 the number of consults positive for drug use per person were 2,349, 1,747, 1,910 and 1,137 per 100,000, respectively. Sixty-two percent of drug users were in their 40’s and 50’s (p< 0.0001. Significantly fewer received alteplase (20%, p=0.039). There was no difference of gender in drug use (p=0.08). Almost half of the drug users were consulted for stroke but were not confirmed as stroke (46%, p=0.045). Symptom to door time average was lower in drug users, though not significant at 56.4±10 vs. 68.9±1.9 minutes, p=0.37. There was no effect of race in incidence of drug use, or deficits. Conclusion: While the incidence of drug use does persist in the rural communities, demographics suggest it is more common in the middle age group than younger patients.

Background: Patient and/or provider satisfaction and experience are among the most important indicators for quality assurance of health care services, including telehealth. Validated surveys should be used for this purpose to provide reliable information for a program evaluation. Objective: To validate the newly developed satisfaction surveys, report patient, and provider satisfaction with Antenatal and Neonatal Guidelines, Education and Learning Systems (ANGELS) telehealth services. Methods: Two self-administered paper surveys were developed by a multidisciplinary team. The surveys were validated among obstetric patients who received telehealth services in 2016 and providers in Arkansas from July to August 2017. Psychometric testing was performed to establish reliability and validity of both the surveys. Descriptive statistics was performed to describe patient and provider satisfaction. Results: A total of 89 patient- and 66 provider surveys were analyzed. Construct validity and internal consistency reliability (Cronbach's α >0.7) were confirmed on both the surveys. The majority of patients were highly satisfied with telehealth services and reported positive perceptions toward future use of services. In the past 12 months, telehealth (78.6%) was the most used ANGELS service by providers. Finally, >90% of the providers reported high satisfaction and rated telehealth services as "excellent." Conclusions: The newly developed patient and provider telehealth surveys were reliable and valid. The surveys also demonstrated that the telehealth services were well-accepted and highly valued in a sample of obstetric patients and providers. As both surveys are short, they can be used in routine evaluation of patient and provider satisfaction with similar telehealth programs in the country.

To examine the impact of Antenatal and Neonatal Guidelines, Education and Learning Systems (ANGELS) on neonatal intensive care unit (NICU) preterm delivery rates.In this longitudinal observational study, linked vital records and Medicaid claims records for 29,124 preterm births (April 2001-December 2012) to Medicaid covered women were used to examine factors predicting whether deliveries occurred at hospitals with neonatology-staffed NICUs. The factors associated with delivery are estimated and compared for baseline and three post-implementation periods.Rates for NICU preterm deliveries increased from 28 to 37% over the time period. Compared to baseline, adjusted NICU delivery rates in the middle and late implementation periods were statistically significant (p 0.001). Negative impacts of long travel times were reduced, while impacts of obstetrician prenatal care changed from negative to positive association.Findings validate the ANGELS initiative premise: academic specialists, working with community-based care providers, can improve perinatal regionalization.

Objective To explore perceptions and attitudes of postpartum women with pre-eclampsia towards remote monitoring (mHealth) and communication with the call center. Methods A non-randomized cohort study was conducted in postpartum hypertensive women, recruited from a tertiary hospital between October 2015 and February 2016. Participants were categorized into users (using mHealth) and non-users (not using mHealth) to monitor vital signs at home over a 2-week period after discharge. Non-users were informed about functionality of mHealth. Both groups participated in a 30-minute phone interview at the end of the study. Directed content analysis of interview transcripts was conducted. Results In total, 21 users and 16 non-users participated in the interview. Both groups perceived that mHealth helped manage their condition. However, non-users were concerned about the challenge of incorporating mHealth into their routine, whereas users mentioned that they liked using mHealth on a daily basis. They also stated that communication with nurses in the call center was helpful. Barriers identified by users included size of the blood pressure cuffs, size of the equipment set, wireless connection, and stress associated with mHealth monitoring. Users stated that they would have preferred using mHealth during pregnancy. Conclusion The findings provide useful insights to inform a successful remote monitoring program among perinatal and postpartum women.

Magnetoencephalography (MEG) has been successfully applied to record fetal auditory (auditory evoked response [AER]) and visual evoked responses (VER). In this study, we report the AER and VER development trajectory by tracking the evoked response detectability and latency from recordings starting at 27 weeks of gestation in pregnancies classified as high risk. Fetal MEG and ultrasound recordings were performed on 158 pregnant women, and the total number of fetal auditory and visual tests conducted was 321 and 237, respectively. The overall evoked response analysis showed 237 AER (73.8%) and 164 VER detections (69.2%). The mean AER latency was 290.7 (SD 125.5) ms and the mean VER latency was 293.7 (SD 114.5) ms. The rate of decrease (95% confidence limits) in average AER and VER first-peak latency between 100-350 ms was 1.97 (-1.86, +5.81) ms/week and 1.35 (-3.83, +6.53) ms/week, respectively. This trend in high-risk fetuses conforms to the general trajectory of decrease in latency with gestational age progression, even though this decrease was non-significant, as reported in the case of normal growing fetuses. Although there was a significant difference in detection rates between male and female fetuses, this was not reflected in either latency values or the sensory modality applied. Furthermore, the main factors that had the most significant effect on response detectability included the presence of intervening layers of adipose tissue between the fetal head and stimulus source and an increase in the maternal body mass index.

Earlier findings have identified the requirement of insulin signaling on maturation and the translocation of serotonin (5-HT) transporter, SERT to the plasma membrane of the trophoblast in placenta. Because of the defect on insulin receptor (IR) in the trophoblast of the gestational diabetes mellitus (GDM)-associated placenta, SERT is found entrapped in the cytoplasm of the GDM-trophoblast. SERT is encoded by the same gene expressed in trophoblast and platelets. Additionally, alteration in plasma 5-HT levels and the 5-HT uptake rates are associated with the aggregation rates of platelets. Therefore, here, we investigated a novel hypothesis that GDM-associated defects in platelet IR should change their 5-HT uptake rates, and this should be a leading factor for thrombosis in GDM maternal blood. The maternal blood and the placentas were obtained at the time of cesarean section from the GDM and non-diabetic subjects (n = 6 for each group), and the platelets and trophoblasts were isolated to determine the IR activity, surface level of SERT, and their 5-HT uptake rates.Interestingly, no significant differences were evident in IR tyrosine phosphorylation or the downstream elements, AKT and S6K in platelets and their aggregation rates in both groups. Furthermore, insulin stimulation up-regulated 5-HT uptake rates of GDM-platelets as it does in the control group. However, the phosphorylation of IR and the downstream elements were significantly lower in GDM-trophoblast and showed no response to the insulin stimulation while they showed 4-fold increase to insulin stimulation in control group. Similarly, the 5-HT uptake rates of GDM-trophoblast and the SERT expression on their surface were severalfold lower compared with control subjects. IR is expressed in all tissues, but it is not known if diabetes affects IR in all tissues equally. Here, for the first time, our findings with clinical samples show that in GDM-associated defect on IR is tissue type-dependent. While IR is impaired in GDM-placenta, it is unaffected in GDM-platelet.

Fetal magnetocardiography provides the requisite precision for diagnostic measurement of electrophysiological events in the fetal heart. Despite its significant benefits, this technique with current cryogenic based sensors has been limited to few centers, due to high cost of maintenance. In this study, we show that a less expensive non-cryogenic alternative, optically pumped magnetometers, can provide similar electrophysiological and quantitative characteristics when subjected to direct comparison with the current technology. Further research can potentially increase its clinical use for fetal magnetocardiography. © 2016 John Wiley & Sons, Ltd.

Earlier findings have identified the requirement of insulin signaling on maturation and the translocation of serotonin (5-HT) transporter, SERT to the plasma membrane of the trophoblast in placenta. Because of the defect on insulin receptor (IR) in the trophoblast of the gestational diabetes mellitus (GDM)-associated placenta, SERT is found entrapped in the cytoplasm of the GDM-trophoblast. SERT is encoded by the same gene expressed in trophoblast and platelets. Additionally, alteration in plasma 5-HT levels and the 5-HT uptake rates are associated with the aggregation rates of platelets. Therefore, here, we investigated a novel hypothesis that GDM-associated defects in platelet IR should change their 5-HT uptake rates, and this should be a leading factor for thrombosis in GDM maternal blood. The maternal blood and the placentas were obtained at the time of cesarean section from the GDM and non-diabetic subjects (n = 6 for each group), and the platelets and trophoblasts were isolated to determine the IR activity, surface level of SERT, and their 5-HT uptake rates. Interestingly, no significant differences were evident in IR tyrosine phosphorylation or the downstream elements, AKT and S6K in platelets and their aggregation rates in both groups. Furthermore, insulin stimulation up-regulated 5-HT uptake rates of GDM-platelets as it does in the control group. However, the phosphorylation of IR and the downstream elements were significantly lower in GDM-trophoblast and showed no response to the insulin stimulation while they showed 4-fold increase to insulin stimulation in control group. Similarly, the 5-HT uptake rates of GDM-trophoblast and the SERT expression on their surface were severalfold lower compared with control subjects. IR is expressed in all tissues, but it is not known if diabetes affects IR in all tissues equally. Here, for the first time, our findings with clinical samples show that in GDM-associated defect on IR is tissue type-dependent. While IR is impaired in GDM-placenta, it is unaffected in GDM-platelet.

Earlier findings have identified the requirement of insulin signaling on maturation and the translocation of serotonin (5-HT) transporter, SERT to the plasma membrane of the trophoblast in placenta. Because of the defect on insulin receptor (IR) in the trophoblast of the gestational diabetes mellitus (GDM)-associated placenta, SERT is found entrapped in the cytoplasm of the GDM-trophoblast. SERT is encoded by the same gene expressed in trophoblast and platelets. Additionally, alteration in plasma 5-HT levels and the 5-HT uptake rates are associated with the aggregation rates of platelets. Therefore, here, we investigated a novel hypothesis that GDM-associated defects in platelet IR should change their 5-HT uptake rates, and this should be a leading factor for thrombosis in GDM maternal blood. The maternal blood and the placentas were obtained at the time of cesarean section from the GDM and non-diabetic subjects (n = 6 for each group), and the platelets and trophoblasts were isolated to determine the IR activity, surface level of SERT, and their 5-HT uptake rates.

Cigarette smoking is one of the major causes of coronary heart disease with a thirty percent mortality rate in the United States. Cigarette smoking acting on the central nervous system (CNS) to stimulate the sympathetic nervous system (SNS) through, which facilitates the secretion of serotonin (5-HT) and catecholamines to supraphysiological levels in blood. The enhanced levels of 5-HT and catecholamines in smokers' blood are associated with increases in G protein-coupled receptor signaling and serotonylation of small GTPases, which in turn lead to remodeling of cytoskeletal elements to enhance granule secretion and promote unique expression of sialylated N-glycan structures on smokers' platelets. These mechanisms enhance aggregation and adhesion of smokers' platelets relative to those of non-smokers. This review focuses on the known mechanisms by which 5-HT and SERT, in coordinated signaling with catecholamines, impacts cigarette smokers' platelet biology.

Background: Telestroke rural networks are comprised of micro>small>medium>large sized hospitals without specialized neurology support. Many times the micro hospitals are < 25 beds. In an examination of spoke hospitals in the Arkansas Stroke Assistance through Virtual Emergency Support (AR SAVES) telestroke program, we determined program efficacy correlating bed number. Efficacy was determined by the mean Door-to-ED physician (D2MD) time and door-to-needle (D2N) Alteplase time, and numbers of Alteplase administrations (#Alteplase), mock scenario sessions (#Mocks) and consults (#Consults). Hypothesis: All hospitals would perform equally well with the larger hospitals with slight tendencies to outperform the smaller hospital sites in the #Consults and #Alteplase. Methods: We retrospectively reviewed 2015-2017 spoke hospital data from AR SAVES, the largest statewide telestroke program. The #Mocks and #beds were comparatively analyzed using regression analysis for D2MD, D2N, #Consults and #Alteplase. Spoke sites were categorized by bed numbers; 0-25, 26-50, 51-100, 101-150, 151-200 and > 200. Results: Data from 53 spokes encompassing 2,555 consults over three years indicated that sites > 151 beds were significantly higher in #Alteplase (p < 0.01) and #Consults (p < 0.002). Although the #Mocks were not different among the smaller vs. larger hospitals (p > 0.19), nor was the D2MD time (p=0.82). However, the hospitals < 50 beds had significantly shorter D2N mean time (p < 0.03). The micro (0-25 beds) vs the largest hospitals ( > 200 beds) D2N mean times, were significantly less (76.0±2.5 vs 87.5±4.0 min, p=0.01, respectively). Conclusions: Although the smaller hospitals receive less volume of consults and #Alteplase, with training they perform equally if not better than their larger counterparts.

Background: Mock drills of stroke triage care is an essential training component of most telestroke programs. Another potential component for telestroke programs is community stroke awareness education. While stroke-mocks improve the timeliness and care in rural spoke emergency departments (ED), community stroke awareness education may also improve treatment. Mocks and community education information was evaluated in the Arkansas Stroke Assistance through Virtual Emergency Support (AR SAVES) telestroke program. Correlations were made with mean Door to ED physician (D2MD) time and door-to-needle (D2N) Alteplase time and administration numbers (#Alteplase) and consult numbers (#Consults). Hypothesis: Total number of mocks (#Mocks) and community education events (#Community-events) will independently increase #Consults and #Alteplase, and improve the D2MD and D2N time. Methods: We retrospectively reviewed 2017 spoke hospital data from AR SAVES, the largest statewide telestroke program. The total number of #Mocks, #Community-Events was comparatively analyzed using regression analysis for D2MD, D2N, #Consults and #Alteplase. Results: Data from 51 spoke sites and 1,002 consults, indicated #Mocks were positively correlated to the D2MD time (R=0.31; p=0.03) and the #Alteplase (R=0.28; p=0.04); however, increasing the #Mock sessions did not influence the D2N time or the #Consults (p=NS). Community-Events were significantly associated with #Consults (R=0.48; p=0.0004) and #Alteplase (R=0.47; p=0.0006); however not to D2MD time or D2N time (p=NS). Conclusions: Mocks and Community stroke awareness education played crucial roles in the AR SAVES program improving #Consults and #Alteplase administrations. Both education components are warranted for telestroke programs.

Introduction The goal was to test a newly developed pneumatic tocodynamometer (pTOCO) that is disposable and lightweight, and evaluate its equivalence to the standard strain gauge-based tocodynamometer (TOCO). Material and methods The equivalence between the devices was determined by both mechanical testing and recording of contractile events on women. The data were recorded simultaneously from a pTOCO prototype and standard TOCO that were in place on women who were undergoing routine contraction monitoring in the Labor and Delivery unit at the University of Arkansas for Medical Sciences. In this prospective equivalence study, the output from 31 recordings on 28 pregnant women that had 171 measureable contractions simultaneously in both types of TOCO were analyzed. The traces were scored for contraction start, peak and end times, and the duration of the event was computed from these times. Results The response curve to loaded weights and applied pressure were similar for both devices, indicating their mechanical equivalence. The paired differences in times and duration between devices were subjected to mixed-models analysis to test the pTOCO for equivalence with standard TOCOs using the two-one-sided tests procedure. The event times and duration analyzed simultaneously from both TOCO types were all found to be significantly equivalent to within ±10 s (all p-values ≤0.0001). Conclusion pTOCO is equivalent to the standard TOCO in the detection of the timing and duration of uterine contractions. pTOCO would provide a lightweight, disposable alternative to commercially available standard TOCOs.

Background There is a growing body of research documenting an increased risk of neonatal morbidity for late preterm infants (LPI, 340/7 weeks to 366/7 weeks) and early term infants (ETI, 370/7 weeks to 386/7 weeks) compared with term infants (TI, 390/7 to 416/7); however, there has been little research on outcomes beyond the first year of life. In this study, we examined respiratory outcomes of LPI and ETI in early childhood. Methods South Carolina Medicaid claims data for maternal delivery and infant birth hospitalisations were linked to vital records data for the years 2000 through 2003. Medicaid claims for all infants were then followed until their fifth birthday or until a break in their eligibility. Infants born between 340/7 and 416/7 weeks were eligible. Infants with congenital anomaly, birthweight below 500 g or above 6000 g, and multiple births were excluded. We fit Cox proportional hazard models from which adjusted hazard ratio (HR) and 95% confidence interval (CI) were derived. Results A total of 3476 LPI, 12 398 ETI, and 25 975 term infants were included. Both LPI and ETI were associated with an increased risk for asthma (LPI: HR 1.24, 95% CI 1.10, 1.40; ETI: HR 1.12, 95% CI 1.06, 1.19), and bronchitis (LPI: HR 1.15, 95% CI 1.00, 1.34; ETI: HR 1.13, 95% CI 1.05, 1.2) at 3 to 5 years of age. Conclusions Late preterm infants and early term infants are at increased risk for asthma and bronchitis.

Background: Hormone replacement therapy (HRT) for post-menopausal women is associated with increased incidence of ischemic stroke risk. Effects of HRT on stroke related deficits and functional outcomes in acute ischemic stroke (AIS) are uncertain. We retrospectively examined female consult data for HRT use and National Institutes of Health Stroke Score (NIHSS) at baseline and recovery for 2015 and 2016 in a large stroke telemedicine program. Hypothesis: The age of women on HRT will affect stroke severity and outcomes. Methods: We analyzed consult data from two consecutive years for women HRT use, age, and baseline and 24 hour NIHSS’s. We included all treated with IV Activase. Results: In two years 235 women received Activase therapy. Women without HRT use numbered 208 and 27 women listed HRT use. All 235 consults regardless of HRT use had significantly improved 24 h NIHSS vs. baseline (7.5 +/- 0.5 vs. 11.2 +/- 0.5, pfigure A ) p=0.028. Women placed in decade age ranges showed that 24 h NIHSS’s (40-80 years) with HRT use were lower vs. women >80 years ( figure B ). p=0.084. Conclusion: While controversy persists on the use, route and dosage of HRT for risks of ischemic stroke, positive HRT benefits could include moderation of AIS deficits and improved outcomes in women

Background: To improve rural population access to telestroke sites for referral and treatment, hospitals are required to fulfill monthly educational outreach. Telehealth sites that provide stroke outreach through awareness educational campaigns remain unaware of the efficacy of their outreach efforts. This study sought to apply a measurable scale to their outreach efforts and determine if the values correlated to the sites referral and treatment rates. Hypothesis: Measurable differences of outreach efforts in rural populations positively correlate to referral and treatment rates at telestroke hospital sites. Methods: A large telestroke network (n=48 spoke sites) had 12 consecutive months during 2016 of community outreach efforts evaluated on an educational gauge scale. Events were categorized as active or passive depending on the type of event. All events were assigned a value based on the type of event, audience size and the crowd’s level of attention/participation. Total monthly values for all spoke sites were calculated and compared by month and category. Regression analysis was used to determine significance of correlative analysis of education vs. number of referrals and vs. number of tissue plasminogen activase (tPA) treatments. Results: Outreach efforts promoting stroke awareness from all 48 sites totaled 2,625 educational points. There was a temporal trend of active events occurring in the spring (April through June) and in the fall (October). In regression analysis there was a positive correlation in the number of referrals vs. educational gauge (R=0.23; P=0.0013) and in the number of tPA treatments (R=0.20; P=0.0055). One spoke site was evaluated for their community events due to their high referral rate in the first quarter of the year. Outreach efforts during these months included stroke awareness events at local high schools, a sporting race event and to apartment residents. Conclusion: Targeted outreach efforts can now be measured for efficacy of reaching diverse populations with direct effects on referral and treatment rates.