The Presence of a Single Nuchal Cord in the Third Trimester May Not Affect Tei Index in LGA Fetuses.

(1) Background: The aim of this study was to assess the RV (right ventricle) and LV (left ventricle) Tei index in large for gestational age (LGA) fetuses with a single 360-degree umbilical coil of the umbilical cord around the fetal neck identified by ultrasound in the third trimester of gestation. (2) Methods: The RV and LV Tei index for the cardiac function were measured in 297 singleton pregnancies, and we identified 25 LGA fetuses. There were 48% of LGA fetuses with a nuchal umbilical cord-LGA/NC-larger for gestational age fetuses with a nuchal cord. NC was detected with a color Doppler during a transverse scan of the fetal neck, when the umbilical cord formed a U shape. All fetuses had normal anatomy and normal uterine, placental, umbilical, intracardiac and cerebral Doppler waveforms values for their gestational age. (3) Results: The RV Tei index was significantly higher in the LGA subgroup vs. AGA (0.6 ± 0.2 vs. 0.50 ± 0.2; p value = 0.01), but in LGA fetuses with a single coil of the nuchal cord, there were not any significant changes in the Tei indexes. (4) Conclusions: The Tei index might not be impacted by the presence of the nuchal cord in LGA fetuses.

Reality graded exposure therapy with physiological monitoring for the treatment of combat related post traumatic stress disorder: a pilot study.

A high percentage of Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) combat veterans have been diagnosed with Posttraumatic Stress Disorder (PTSD) during and following their respective combat tours. Virtual Reality (VR) treatment has been documented as an exceptional treatment for anxiety disorders and specifically for PTSD. An Office of Naval Research (ONR) funded pilot study, completed by the Virtual Reality Medical Center and Naval Medical Center San Diego (NMCSD), investigated the use of Virtual Reality Graded Exposure Therapy (VR-GET) study with participants who had been diagnosed with PTSD following their combat deployments. A significant reduction in PTSD symptoms severity was noted. Implications for treatment with VR-GET and future research areas of investigation, including the use of VR-GET with smart phones and the internet, are suggested.

Combat-Related Post-traumatic Stress Disorder: A Case Report of Virtual Reality Graded Exposure Therapy With Physiological Monitoring in a U.S. Navy Officer and a U.S. Army Officer.

The U.S. Department of Defense (DoD) and the Department of Veterans Affairs (DVA) seek to enhance the efficacy of treatments for warriors with post-traumatic stress disorder (PTSD) secondary to their combat deployments to Iraq and/or Afghanistan. Virtual Reality Graded Exposure Therapy (VR-GET) with arousal control has shown particular promise in reducing the symptom severity of PTSD in combat veterans. In this report, we describe the outcome of VR-GET for the treatment of combat-related PTSD in two combat veterans, neither of whom had received treatment for PTSD in the initial years after their return from combat duty.

Combat-related post-traumatic stress disorder: a case report using virtual reality graded exposure therapy with physiological monitoring with a female Seabee.

In this report we describe virtual reality graded exposure therapy (VRGET) for the treatment of combat-related post-traumatic stress disorder (PTSD). In addition, we summarize the outcomes of a case study, from an Office Of Naval Research (ONR)-funded project of VRGET with an active duty female Seabee who completed three combat tours to Iraq. Details of the collaborative program involving this ONR-funded project at Naval Medical Center San Diego (NMCSD) and Naval Hospital Camp Pendleton (NHCP) are also discussed.

Cost effectiveness of virtual reality graded exposure therapy with physiological monitoring for the treatment of combat related post traumatic stress disorder.

Virtual Reality Graded Exposure Therapy (VRGET) is an effective treatment for combat-related PTSD. We summarize the outcomes of a VRGET pilot study with 12 participants who completed one to multiple combat tours in support of the War on Terrorism and who were subsequently diagnosed with combat-related PTSD. Details of the collaborative program amongst the Virtual Reality Medical Center (VRMC), Office of Naval Research, the Naval Medical Center San Diego (NMCSD) and the Navy Hospital Camp Pendleton are discussed as is the VRGET outcomes of significant reductions in PTSD symptoms severity. We also described the estimated cost-effectiveness of VRGET for the treatment of combat-related PTSD, as contrasted to Treatment as Usual (TAU) for combat-related PTSD.

Association between fetal myocardial performance index and fetal heart rate monitoring: a prospective observational cohort study.

Objective: To evaluate whether the left myocardial performance index (MPI) changes in association with the fetal heart rate (FHR) tracing during labor. Study design: Women with term, singleton pregnancies, in labor were recruited to this prospective cohort study. Primary outcome: difference in left MPI between Category of fetal heart rate tracings. Secondary outcomes: differences in left MPI by FHR characteristics. Participants underwent ultrasound examination, during which fetal MPI was measured. Results: Twenty-four laboring patients were recruited. There were 13 patients with Category I FHR, 11 patients with Category II FHR, and 0 patients with Category III FHR. Demographics were similar between the groups. MPI was not significantly different between fetuses with Category I or Category II FHR (0.67 versus 0.65, p = .385). MPI was significantly higher in fetuses with accelerations versus those without (0.71 versus 0.59, p = .045). MPI was not significantly different for fetuses with or without decelerations (0.65 versus 0.68, p = .350), between deceleration type (0.50 versus 0.64 versus, 0.75, p = .421), or between variability type (0.56 versus 0.68, p = .113). Conclusions: MPI of fetuses in term, laboring patients did not vary with differing FHR characteristics except for the presence or absence of accelerations.

Combat related post traumatic stress disorder: a multiple case report using virtual reality graded exposure therapy with physiological monitoring.

The current report summarizes case studies from an Office of Naval Research (ONR) funded project to compare the effects of Virtual Reality Graded Exposure Therapy (VRGET) with a treatment as usual control condition in active-duty Navy Corpsmen, Navy SeaBees and Navy and Marine Corps Support Personnel. Details of the collaborative program between the Virtual Reality Medical Center (VRMC) and Naval Medical Center San Diego (NMCSD) will be discussed.

Combat-related post-traumatic stress disorder: a case report using virtual reality exposure therapy with physiological monitoring.

The current report summarizes a case study from an Office of Naval Research (ONR) funded project to compare the effects of virtual reality graded exposure therapy (VRGET) with cognitive behavioral group therapy in active-duty corpsmen. Details of the collaborative program between the Virtual Reality Medical Center (VRMC) and Naval Medical Center San Diego (NMCSD) will be discussed.

Fetuses with congenital heart disease demonstrate signs of decreased cerebral impedance.

OBJECTIVE: The purpose of this study was to determine whether fetuses with a congenital heart defect demonstrate changes in cerebrovascular impedance. STUDY DESIGN: Fetal echocardiograms from January 2001 to May 2005 were reviewed. Cases had sonographically diagnosed congenital heart defects; control subjects were gestational age-matched fetuses with normal echocardiograms. The pulsatility index in the middle cerebral artery was used to measure impedance to cerebral blood flow. Abnormal middle cerebral artery pulsatility index was defined as less than the 5th percentile. Cases were subgrouped into mixing versus nonmixing lesions. RESULTS: Of 142 total fetuses, there were significantly more abnormal middle cerebral artery pulsatility indices in the cases (5/71) than in the control subjects (0/71; P = .023); all abnormal middle cerebral artery pulsatility indices occurred in the fetuses with admixing cardiac lesions. CONCLUSION: Fetuses with congenital heart defect are significantly more likely to have decreased cerebrovascular impedance. This may represent a marker of cerebral hypoxemia that is due to intracardiac mixing of oxygenated and deoxygenated blood. Theoretically, this hypoxemia may contribute to the cause of abnormal neurologic development in these infants.

Treatment of psychiatric disorders onboard an aircraft carrier assisted with psychotropic medication: a retrospective review describing one aspect of Navy Force health protection.

Navy clinical psychologists, assigned to aircraft carriers, are playing an increasing role in not only implementing Navy force health protection, but also in further specializing the delivery of mental health evaluation, treatment, and disposition services at the "tip of the spear." An aircraft carrier's medical department, augmented with a clinical psychologist, is now better able to coordinate diagnostic, psychotropic, and psychotherapeutic treatments for both shipboard and air wing personnel. This retrospective review reports the outcomes of a 6-month treatment program for personnel, assigned to the USS Constellation (CV-64), who were prescribed a psychotropic medication while receiving psychotherapy. We concluded that psychotropic medications can be safely and effectively used onboard an aircraft carrier. Furthermore, personnel prescribed psychotropic medication successfully completed their assigned duties and obtained recommendations for advancement and retention. Lastly, our medical department proactively fulfilled the Navy force health protection tenet of preserving a healthy and fit force.

Regional hemodynamic effects of dopamine in the indomethacin-treated preterm infant.

OBJECTIVE: We have previously demonstrated that dopamine induces selective renal vasodilation without affecting cerebral and mesenteric blood flow in < or = 32 weeks' gestation normotensive preterm infants during the first postnatal day. In the present study, we have examined whether pretreatment with indomethacin affects the regional hemodynamic response to dopamine in >1-day-old normotensive preterm infants with similar gestational age. STUDY DESIGN: The pulsatility index (PI) was used to assess the dopamine-induced changes in renal, mesenteric, and cerebral blood flow using color Doppler ultrasonography in 20 indomethacin-treated normotensive preterm neonates with patent ductus arteriosus (gestational age: 27.2+/-1.5 weeks; postnatal age: 35.7+/-8.2 hours). Dopamine (5 microg/kg per minute) was started 4.9+/-2.1 hours (range: 2 to 8 hours) after the first dose of indomethacin to combat oliguria and/or impaired peripheral perfusion. Blood flow velocity measurements were obtained immediately before and 10 minutes after the start of dopamine with each subject serving as his/her own control. RESULTS: Dopamine increased heart rate and urine output but did not affect blood pressure at the dose applied. Dopamine decreased the PI in the renal and superior mesenteric artery (2.6+/-1.32 vs. 1.61+/-0.7 and 2.36+/-1.12 vs. 1.76+/-0.64, respectively; p<0.05) whereas the PI in the middle cerebral artery remained unchanged. These results are consistent with a dopamine-induced increase in renal and mesenteric blood flow without an effect on cerebral blood flow. CONCLUSIONS: When started at least 2 hours after the first dose of indomethacin, dopamine induces renal and mesenteric vasodilation without affecting cerebral hemodynamics in the >1-day-old indomethacin-treated preterm infant.

Psychiatric medevacs during a 6-month aircraft carrier battle group deployment to the Persian Gulf: a Navy Force Health Protection preliminary report.

When a U.S. Navy Aircraft Carrier battle group deploys overseas, the aircraft carrier's medical department is responsible for the medical needs of over 12,000 personnel with their indigenous developmental, stress, family, alcohol, drug, and interpersonal and intrapersonal relationship difficulties. This article reviews the effectiveness of having a U.S. Navy clinical psychologist and a psychiatric technician onboard the USS Carl Vinson, the flag ship of Vinson's battle group, during this battle group's 1998/1999 Persian Gulf deployment (i.e., Western Pacific Deployment). Importantly, these two individuals reported to the USS Vinson as permanent members of the ship's company. The clinical psychologist logged 448 individual outpatient-care consults and 79 individual consults with sailors who had a history of overusing or abusing alcohol. Additionally, nine sailors with acute disabling psychiatric diagnoses were hospitalized on the ship's medical ward, and four sailors were medically evacuated (medevaced), by fixed wing aircraft, from USS Vinson to a Navy Hospital in the United States for definitive evaluation, treatment, and disposition. These four medevacs were less than the number of medevacs from two previous Aircraft Carrier Battle Group Persian Gulf deployments. Importantly, these two previous WESTPAC deployments were made without having a clinical psychologist as a full-time member of the respective aircraft carrier's medical department. Providing clinical psychology/mental health services at the "tip of the spear" is an effective, beneficial, and cost-saving landmark improvement in providing quality medical care to the fleet.

Virtual reality graded exposure therapy with arousal control for the treatment of combat related posttraumatic stress disorder: a follow up case series.

Important challenges confronting DOD/military medical care are that of maintaining or increasing quality of care and increasing the effectiveness of treatments for warriors diagnosed with Posttraumatic Stress Disorder (PTSD) secondary to their combat deployments to Iraq and/or Afghanistan. Virtual Reality Graded Exposure Therapy with Arousal Control (VR-GET) has demonstrated a positive treatment effectiveness resulting in significant reductions of PTSD symptom severity. This positive treatment effectiveness has been maintained for up to 22 weeks after VR-GET therapy was completed. A robust methodology for the assessment of Virtual Reality efficacy suggests that the ideal time for follow-up begins at twelve months. Others have suggested that follow-up should occur between two and four years post treatment. In this report we describe the outcome of VR-GET for the treatment of combat-related PTSD with three warriors between five and seven years following their having completed treatment.

Effect of virtual reality PTSD treatment on mood and neurocognitive outcomes.

Virtual reality (VR) is an emerging tool to help treat posttraumatic stress disorder (PTSD). Previously published studies have shown that VR graded exposure therapy (VR-GET) treatment can result in improvements in PTSD symptoms. Less is known about the impact on depression, general anxiety, and neuropsychological functioning in patients with PTSD. This study examined changes in self-reports of PTSD, depression, and anxiety before and after treatment, and also examined neuropsychological functioning as assessed by a computerized test of simple reaction time, procedural reaction time, and performance on the congruent, incongruent, emotional, and neutral (match the color of the "nonsense word") Stroop tests. Results showed that subjects treated with VR-GET showed significant reductions in PTSD and anxiety severity and significant improvements on the emotional Stroop test. Changes in depression and other measures of neuropsychological function were not significant. Change scores on the emotional Stroop test did not correlate with changes in self-report measures of PTSD. Overall, these findings support the use of VR-GET as a treatment for PTSD but indicate that benefits may be narrowly focused. Additional treatments may be needed after or alongside VR-GET for service members with neuropsychological impairments.

A randomized, controlled trial of virtual reality-graded exposure therapy for post-traumatic stress disorder in active duty service members with combat-related post-traumatic stress disorder.

Abstract Virtual reality (VR)-based therapy has emerged as a potentially useful means to treat post-traumatic stress disorder (PTSD), but randomized studies have been lacking for Service Members from Iraq or Afghanistan. This study documents a small, randomized, controlled trial of VR-graded exposure therapy (VR-GET) versus treatment as usual (TAU) for PTSD in Active Duty military personnel with combat-related PTSD. Success was gauged according to whether treatment resulted in a 30 percent or greater improvement in the PTSD symptom severity as assessed by the Clinician Administered PTSD Scale (CAPS) after 10 weeks of treatment. Seven of 10 participants improved by 30 percent or greater while in VR-GET, whereas only 1 of the 9 returning participants in TAU showed similar improvement. This is a clinically and statistically significant result (χ(2) = 6.74, p < 0.01, relative risk 3.2). Participants in VR-GET improved an average of 35 points on the CAPS, whereas those in TAU averaged a 9-point improvement (p < 0.05). The results are limited by small size, lack of blinding, a single therapist, and comparison to a relatively uncontrolled usual care condition, but did show VR-GET to be a safe and effective treatment for combat-related PTSD.

Lessons learned from 350 virtual-reality sessions with warriors diagnosed with combat-related posttraumatic stress disorder.

Virtual-reality (VR) therapy has been distinguished from other psychotherapy interventions through the use of computer-assisted interventions that rely on the concepts of "immersion," "presence," and "synchrony." In this work, these concepts are defined, and their uses, within the VR treatment architecture, are discussed. VR therapy's emphasis on the incorporation of biofeedback and meditation, as a component of the VR treatment architecture, is also reviewed. A growing body of research has documented VR therapy as a successful treatment for combat-related Posttraumatic Stress Disorder (PTSD). The VR treatment architecture, utilized to treat 30 warriors diagnosed with combat-related PTSD, is summarized. Lastly, case summaries of two warriors successfully treated with VR therapy are included to assist with the goal of better understanding a VR treatment architecture paradigm. Continued validation of the VR treatment model is encouraged.

Perinatal echocardiography: protocols for evaluating the fetal and neonatal heart.

This Protocol for Evaluating the Fetal and Neonatal Heart details the indications, views, and measurements to be obtained for both (1) the basic screening examination of the fetal heart (a necessary component of all complete fetal anatomy evaluations) and the specialty study called (2) echocardiography as applied to either the fetus or neonate, using 2D and Doppler ultrasound. While the purpose of the screening study is to detect or exclude the possibility of a cardiac abnormality, echocardiography attempts to diagnose the specific anatomic and physiologic disruption. Also emphasized is the value of a collaborative team approach to management of the fetus and its parents when a cardiovascular anomaly is present, in an effort to achieve a smoother transition from fetus to neonate across the continuum of perinatal care.

Prenatal prediction of lethal pulmonary hypoplasia: the hyperoxygenation test for pulmonary artery reactivity.

OBJECTIVE: The purpose of this study was to determine the predictive accuracy of a test for neonatal death from pulmonary hypoplasia by measuring changes in fetal pulmonary artery blood flow on room air and during maternal hyperoxygenation. STUDY DESIGN: Women who were carrying fetuses with congenital anomalies that may cause pulmonary hypoplasia were offered participation in the study as part of a comprehensive fetal echocardiogram. Each fetus at > or =30 weeks of gestation underwent Doppler measurement of the blood flow pattern in the first branch of either the right or the left pulmonary artery before and again during exposure to maternal breathing of 60% oxygen by mask. An increase in the fetal pulmonary blood flow with oxygen (a decrease of > or =20% of the pulsatility index) was considered a reactive test. A change of <20% in the flow pattern during maternal hyperoxygenation was a nonreactive test and suggested pulmonary hypoplasia. The primary outcome for this study was neonatal death from pulmonary hypoplasia. RESULTS: Twenty-nine pregnancies met the criteria for inclusion in our study. Of the 14 fetuses who had a nonreactive hyperoxygenation test, 11 fetuses (79%) died of pulmonary hypoplasia. Of the 15 fetuses who had a reactive hyperoxygenation test, only one fetus (7%) died in the neonatal period. Sensitivity, specificity, and positive and negative predictive values were 92%, 82%, 79%, and 93%, respectively, with an odds ratio of 51 (95% CI, 4.6-560). CONCLUSION: Testing fetal pulmonary vascular reactivity with maternal hyperoxygenation is highly predictive of pulmonary hypoplasia. A reactive test predicted 92% of surviving infants; a nonreactive test predicted 79% of fetal deaths from pulmonary hypoplasia.