Implementation and Impact of a Maternal-Fetal Medicine Telemedicine Program.

OBJECTIVE: The increase in maternal morbidity has resulted in higher need for maternal-fetal medicine (MFM) subspecialty care. To meet the rising demand, particularly in rural areas, the use of MFM telemedicine services has increased. This study describes the structure, implementation, and patient and child health outcomes associated with a large health system's MFM telemedicine program. STUDY DESIGN: Observational electronic health record data are used to compare maternal and childbirth outcomes between patients receiving care via telemedicine or in-person visits through regression analysis. Average patient time and resources saved are calculated, and patient satisfaction scores are reported. RESULTS: The telemedicine patients experienced similar outcomes to the in-person group, indicating that MFM telemedicine can serve as an effective substitute for in-person care. MFM telemedicine patients saved $90.28 per consult in travel and work-related expenses. An overwhelming majority of MFM telemedicine patients were satisfied with their visit and indicated that they would be interested in receiving care via telemedicine in the future. CONCLUSION: The results indicate that the patients may benefit financially and experience similar outcomes when telemedicine programs are appropriately designed to eliminate access barriers and provide high-quality care.

Kinetics of 1,2-dichloroethane and 1,2-dibromoethane biodegradation in anaerobic enrichment cultures.

1,2-Dichloroethane (1,2-DCA) and 1,2-dibromoethane (ethylene dibromide [EDB]) contaminate groundwater at many hazardous waste sites. The objectives of this study were to measure yields, maximum specific growth rates (µ), and half-saturation coefficients (K(S)) in enrichment cultures that use 1,2-DCA and EDB as terminal electron acceptors and lactate as the electron donor and to evaluate if the presence of EDB has an effect on the kinetics of 1,2-DCA dehalogenation and vice versa. Biodegradation was evaluated at the high concentrations found at some industrial sites (>10 mg/liter) and at lower concentrations found at former leaded-gasoline sites (1.9 to 3.7 mg/liter). At higher concentrations, the Dehalococcoides yield was 1 order of magnitude higher when bacteria were grown with 1,2-DCA than when they were grown with EDB, while µ's were similar for the two compounds, ranging from 0.19 to 0.52 day(-1) with 1,2-DCA to 0.28 to 0.36 day(-1) for EDB. K(S) was larger for 1,2-DCA (15 to 25 mg/liter) than for EDB (1.8 to 3.7 mg/liter). In treatments that received both compounds, EDB was always consumed first and adversely impacted the kinetics of 1,2-DCA utilization. Furthermore, 1,2-DCA dechlorination was interrupted by the addition of EDB at a concentration 100 times lower than that of the remaining 1,2-DCA; use of 1,2-DCA did not resume until the EDB level decreased close to its maximum contaminant level (MCL). In lower-concentration experiments, the preferential consumption of EDB over 1,2-DCA was confirmed; both compounds were eventually dehalogenated to their respective MCLs (5 µg/liter for 1,2-DCA, 0.05 µg/liter for EDB). The enrichment culture grown with 1,2-DCA has the advantage of a more rapid transition to 1,2-DCA after EDB is consumed.

Optimization of the solvent-based dissolution method to sample volatile organic compound vapors for compound-specific isotope analysis.

The methodology of the solvent-based dissolution method used to sample gas phase volatile organic compounds (VOC) for compound-specific isotope analysis (CSIA) was optimized to lower the method detection limits for TCE and benzene. The sampling methodology previously evaluated by [1] consists in pulling the air through a solvent to dissolve and accumulate the gaseous VOC. After the sampling process, the solvent can then be treated similarly as groundwater samples to perform routine CSIA by diluting an aliquot of the solvent into water to reach the required concentration of the targeted contaminant. Among solvents tested, tetraethylene glycol dimethyl ether (TGDE) showed the best aptitude for the method. TGDE has a great affinity with TCE and benzene, hence efficiently dissolving the compounds during their transition through the solvent. The method detection limit for TCE (5±1µg/m3) and benzene (1.7±0.5µg/m3) is lower when using TGDE compared to methanol, which was previously used (385µg/m3 for TCE and 130µg/m3 for benzene) [2]. The method detection limit refers to the minimal gas phase concentration in ambient air required to load sufficient VOC mass into TGDE to perform δ13C analysis. Due to a different analytical procedure, the method detection limit associated with δ37Cl analysis was found to be 156±6µg/m3 for TCE. Furthermore, the experimental results validated the relationship between the gas phase TCE and the progressive accumulation of dissolved TCE in the solvent during the sampling process. Accordingly, based on the air-solvent partitioning coefficient, the sampling methodology (e.g. sampling rate, sampling duration, amount of solvent) and the final TCE concentration in the solvent, the concentration of TCE in the gas phase prevailing during the sampling event can be determined. Moreover, the possibility to analyse for TCE concentration in the solvent after sampling (or other targeted VOCs) allows the field deployment of the sampling method without the need to determine the initial gas phase TCE concentration. The simplified field deployment approach of the solvent-based dissolution method combined with the conventional analytical procedure used for groundwater samples substantially facilitates the application of CSIA to gas phase studies.

Simulation of the effect of remediation on EDB and 1,2-DCA plumes at sites contaminated by leaded gasoline.

An analytical model is used to simulate the effects of partial source removal and plume remediation on ethylene dibromide (EDB) and 1,2-dichloroethane (1,2-DCA) plumes at contaminated underground storage tank (UST) sites. The risk posed by EDB, 1,2-DCA, and commingled gasoline hydrocarbons varies throughout the plume over time. Dissolution from the light nonaqueous phase liquid (LNAPL) determines the concentration of each contaminant near the source, but biological decay in the plume has a greater influence as distance downgradient from the source increases. For this reason, compounds that exceed regulatory standards near the source may not in downgradient plume zones. At UST sites, partial removal of a residual LNAPL source mass may serve as a stand alone remedial technique if dissolved concentrations in the source zone are within several orders of magnitude of the applicable government or remedial standards. This may be the case with 1,2-DCA; however, EDB is likely to be found at concentrations that are orders of magnitude higher than its low Maximum Contaminant Level (MCL) of 0.05 microg/L (micrograms per liter). For sites with significant EDB contamination, even when plume remediation is combined with source depletion, significant timeframes may be required to mitigate the impact of this compound. Benzene and MTBE are commonly the focus of remedial efforts at UST sites, but simulations presented here suggest that EDB, and to a lesser extent 1,2-DCA, could be the critical contaminants to consider in the remediation design process at many sites.

Anaerobic biodegradation of ethylene dibromide and 1,2-dichloroethane in the presence of fuel hydrocarbons.

Field evidence from underground storage tank sites where leaded gasoline leaked indicates the lead scavengers 1,2-dibromoethane (ethylene dibromide, or EDB) and 1,2-dichloroethane (1,2-DCA) may be present in groundwater at levels that pose unacceptable risk. These compounds are seldom tested for at UST sites. Although dehalogenation of EDB and 1,2-DCA is well established, the effect of fuel hydrocarbons on their biodegradability under anaerobic conditions is poorly understood. Microcosms (2 L glass bottles) were prepared with soil and groundwater from a UST site in Clemson, South Carolina, using samples collected from the source (containing residual fuel) and less contaminated downgradient areas. Anaerobic biodegradation of EDB occurred in microcosms simulating natural attenuation, but was more extensive and predictable in treatments biostimulated with lactate. In the downgradient biostimulated microcosms, EDB decreased below its maximum contaminant level (MCL) (0.05 microg/L) at a first order rate of 9.4 +/- 0.2 yr(-1). The pathway for EDB dehalogenation proceeded mainly by dihaloelimination to ethene in the source microcosms, while sequential hydrogenolysis to bromoethane and ethane was predominant in the downgradient treatments. Biodegradation of EDB in the source microcosms was confirmed by carbon specific isotope analysis, with a delta13C enrichment factor of -5.6 per thousand. The highest levels of EDB removal occurred in microcosms that produced the highest amounts of methane. Extensive biodegradation of benzene, ethylbenzene, toluene and ortho-xylene was also observed in the source and downgradient area microcosms. In contrast, biodegradation of 1,2-DCA proceeded at a considerably slower rate than EDB, with no response to lactate additions. The slower biodegradation rates for 1,2-DCA agree with field observations and indicate that even if EDB is removed to below its MCL, 1,2-DCA may persist.