Interactive telecardiology for the evaluation of heart murmurs in children.

OBJECTIVE: To study the accuracy, patient satisfaction, and cost of telecardiographic evaluations of pediatric patients. MATERIALS AND METHODS: Patients referred to a rural pediatric cardiology outreach clinic were examined in person by a pediatric cardiologist. A second pediatric cardiologist who had no knowledge of the findings of face-to-face examination reevaluated the same patients utilizing a 768-Kbps telemedicine system. Any additional testing was performed by personnel who had no knowledge of the face-to-face evaluation. The main outcome measures included the final cardiac diagnosis, frequency of additional tests such as electrocardiography, (ECG) echocardiography (ECHO), and patient satisfaction. RESULTS: The diagnosis was agreed upon in 19 of the 21 patients studied. Two patients with small ventricular septal defects were missed during the telemedicine evaluation. The utilization rates of additional studies for both the face-to-face cardiologist and the telemedicine cardiologist were not significantly different. Patient satisfaction with the telemedicine encounter was good. CONCLUSIONS: Telemedicine appears to be effective and useful for the cardiac evaluation of pediatric patients. In spite of high data-transfer rates, differences between telemedicine and face-to-face patient encounters were observed.

Telemedicine expanding the scope of health care information.

The definition of health information is growing to include multimedia audio, video, and high-resolution still images. This article describes the telemedicine program at East Carolina University School of Medicine, including the telemedicine applications presently in use and the virtual reality applications currently under development' Included are the major design criteria that shape the telemedicine network some of the lessons learned in developing the network, and a discussion of the future of telemedicine, including efforts to incorporate telemedicine within a fully integrated health information system.

Telemedicine and distributed medical intelligence.

Recent trends in health care informatics and telemedicine indicate that systems are being developed with a primary focus on technology and business, not on the process of medicine itself. The authors present a new model of health care information, distributed medical intelligence, which promotes the development of an integrative medical communication system addressing the process of providing expert medical knowledge to the point of need. The model incorporates audio, video, high-resolution still images, and virtual reality applications into an integrated medical communications network. Three components of the model (care portals, Docking Station, and the bridge) are described. The implementation of this model at the East Carolina University School of Medicine is also outlined.

Ultrasonographic characteristics of first-trimester gestations in recurrent spontaneous aborters.

OBJECTIVE: To compile, for the first time, serial ultrasonographic findings during the first trimester of pregnancy in women with a history of primary recurrent spontaneous abortion so as to define the dynamics of early normal and abnormal gestations in this category of gravidas. STUDY DESIGN: Transvaginal ultrasonograms were obtained weekly from 5 to 12 weeks' gestational age in 40 women, 10 each of four groups: recurrent spontaneous aborters and primiparas (controls), with both successful and failed gestations. RESULTS: Embryonic heart motion was detected in 40-50% of successful pregnancies during the fifth week of gestation and in the balance by the sixth week, while heart motion was detected in no more than 50% of pregnancies that later failed. Of the failed pregnancies, all were evident by the eighth week of gestation, including those with previously documented viability. The gestational sac size and crown-rump length were smaller than expected in both failed groups, with the sac size difference evident as early as week 5 and the crown-rump length difference apparent by week 7. CONCLUSION: Appropriate timing of the initial ultrasonogram in recurrent aborters (i.e., 8 weeks' gestational age) can identify, by means of heart motion and gestational sac features, all pregnancies that will ultimately fail.

Decay-accelerating factor protects human trophoblast from complement-mediated attack.

Approximately one-fifth of first trimester losses can be characterized by the onset of hypocomplementemia prior to ultrasonographic loss of embryonic viability. Monoclonal antibodies to the membrane complement regulatory protein, decay-accelerating factor (DAF), were bound to the surface of trophoblastic tissues, with the estimated number of DAF molecules in tissues obtained from hypocomplementemic women less than those from normocomplementemic women (approximately 10%). While trophoblastic tissue obtained from normocomplementemic women did not decomplement normal human sera, pretreatment of this tissue with anti-DAF antibodies resulted in activation of the complement (C') system via the alternate C' pathway (ACP). If trophoblastic tissue from normocomplementemic women was pretreated with phospholipase C, decomplementation of human serum occurred. These data strongly suggest that trophoblasts evade the ACP with functional DAF, possibly through absorption of the molecule's lipophilic diacylglycerol membrane-anchored moiety into the outer lipid bilayer of the trophoblast and may be a rational means for the utilization of immunotherapy in recurrent spontaneous aborters.

Activation of complement in humans with a first-trimester pregnancy loss.

Serum complement (C') activity in recurrent spontaneous aborters and primiparous controls with successful and unsuccessful pregnancies was quantified so as to define the dynamics of C' activation in early pregnancy loss. C' hemolytic activity was shown to be stable throughout the first trimester of pregnancy and did not differ from preconception levels in all of the successful pregnancies of recurrent aborters and controls and in the majority of pregnancy losses. However, 30% of recurrent aborters and 20% of controls with a pregnancy loss demonstrated activation of C' by the alternate pathway as early as the 7th week with a progressive decline in C' activity until abortion was clinically completed. Circulating levels of C3 dropped from 1.34 to 0.53 mg/dl, and factor B levels declined from 0.34 to 0.14 mg/dl in these hypocomplementemic women. Pregnancy loss is therefore associated with C' activation in a subset of both recurrent and nonrecurrent aborters and this occurs largely before loss of fetal viability.

Risk of eye splash in obstetric procedures.

A prospective cross-sectional study was designed to determine the rates of upper facial splash during obstetric deliveries. Macroscopic splashes on the attached eye shields of surgical masks, worn for obstetric deliveries were enumerated for a sample of parturients during a 3-month period. Masks were collected for 68 vaginal and 44 cesarean deliveries, 31% of all deliveries during the study period. For cesarean deliveries, 68% (30) of all masks worn by primary surgeons had at least one splash; 57% (17) of which were heavily contaminated (more than five splashes). For the first assistant, 68% (30) of all masks had at least one splash; 23% (7) of which were heavily contaminated. During vaginal deliveries 44% (30) of masks worn by the delivering physician had at least one splash; 20% (6) of which were heavily contaminated. The primary surgeon in a cesarean section was 1.6 times as likely to be splashed (P < 0.04) when compared with vaginal deliveries and 4.6 times as likely to be heavily contaminated (P < 0.003). Estimated blood loss and the rate of eye splash were linearly related. Method of delivery was not independently associated with eye splash. These findings suggest that the risk of contamination by splash during obstetric procedures is high, particularly for cesarean deliveries because these deliveries tend to have greater blood losses.

Treatment of type I decompression sickness using the U.S. Navy treatment algorithm.

The effectiveness of the U.S. Navy (USN) Diving Manual treatment algorithm in treating pain-only decompression sickness (DCS) was analyzed. Treatment logs from the Naval Diving and Salvage Training Center and the Navy Experimental Diving Unit during the decade 1976-1986 were examined. Two hundred and ninety-two cases diagnosed initially as pain-only DCS were identified. Using the treatment algorithm, 208 cases were completed on USN Treatment Table 5 (TT-5), and 84 cases completed on USN Treatment Table 6 (TT-6). Recurrence of symptoms was 4.3% after TT-5, and 3.6% following TT-6. Difference in rate of recurrence was not statistically significant between treatment tables. Overall, the success rate for following the USN treatment algorithm was 95.9%. These data support the use of the shorter TT-5 in accordance with the Navy treatment algorithm.

The Swedish "Children born to women denied abortion" study: a radical criticism.

PIP: The data of a study conducted in 1966 of 120 children born to women denied abortion were reexamined. Forssman and Thuwe compared 120 children born to women denied abortions in Sweden and 120 controls on a number of variables on which, with but 1 exception, the group of children born to the mothers denied abortion compared unfavorably to the control group. If the control group had been equivalent in major respects to the group denied abortion, these comparisons would lead to the Forssman and Thuwe conclusion that the prospective child runs the risk of having to surmount greater social and mental handicaps than his/her peers. But the groups differed on 2 important dimensions: the group denied abortion was of lower socioeconomic status than the controls; and the mothers more frequently sought psychiatric assistances. Such differeances appear to account for the differences in social outcome for the progeny of the 2 groups. Post hoc comparisons indicate that the mothers denied abortion had lower status than the general population but did not have a lower occupational status than the control mothers. Of progeny of the women denied abortion, 66% (versus 28% of the control progeny) met a least 1 of the criteria of what Forssman and Thuwe termed "circumstances pointing to an insecure childhood." These circumstances included: report to children's aid bureaus about unsatisfactory conditions at home; child removed from home by authorities; placement in foster home; placement in children's home; parents divorced before child was 15; parent(s) died before child was 15; and born out of wedlock and never legitimized. 48% of the mothers who were denied abortion and who maintained residence in Goteborg had sought psychiatric assistance at municipal facilities after denial of the abortion versus 16% of the control mothers. 10 of the progeny of women denied abortions and none of the controls' progeny visited municipal psychiatric centers. Of the 7 "circumstances pointing to an insecure childhood," the first 4 circumstances were most likely affected by the more frequent psychiatric consultation at municipal facilities of the mothers denied abortion. Forssman and Thuwe's occupational Group 3 includes practically all of the nonprofessional members of the working class ranging from skilled to semiskilled to unskilled to unemployed to unemployable workers. If Group 3 had been partitioned by kind of nonprofessional, the group denied abortion would almost certainly have disproportionately occupied the lower categories than the control group.^ieng