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Introduction: Many patients used telehealth services during the COVID-19 pandemic. In this study, we evaluate how different factors have affected telehealth utilization in recent years. Decision makers at the federal and state levels can use the results of this study to inform their healthcare-related policy decisions., Methods: We implemented data analytics techniques to determine the factors that explain the use of telehealth by developing a case study using data from Arkansas. Specifically, we built a random forest regression model which helps us identify the important factors in telehealth utilization. We evaluated how each factor impacts the number of telehealth patients in Arkansas counties., Results: Of the 11 factors evaluated, five are demographic, and six are socioeconomic factors. Socioeconomic factors are relatively easier to influence in the short term. Based on our results, broadband subscription is the most important socioeconomic factor and population density is the most important demographic factor. These two factors were followed by education level , computer use , and disability in terms of their importance as it relates to telehealth use., Discussion: Based on studies in the literature, telehealth has the potential to improve healthcare services by improving doctor utilization, reducing direct and indirect waiting times, and reducing costs. Thus, federal and state decision makers can influence the utilization of telehealth in specific locations by focusing on important factors. For example, investments can be made to increase broadband subscriptions, education levels, and computer use in targeted locations., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: The COVID-19 pandemic triggered policy changes in 2020 that allowed insurance companies to reimburse telehealth services, leading to increased telehealth use, especially in rural and underserved areas. However, with many emergency rules ending in 2022, patients and health care providers face potential challenges in accessing these services., Objective: This study analyzed telehealth use across specialties in Arkansas before and after the pandemic (2017-2022) using data from electronic medical records from the University of Arkansas for Medical Sciences Medical Center. We explored trends in insurance coverage for telehealth visits and developed metrics to compare the performance of telehealth versus in-person visits across various specialties. The results inform insurance coverage decisions for telehealth services., Methods: We used pre- and postpandemic data to determine the impacts of the COVID-19 pandemic and changes in reimbursement policies on telehealth visits. We proposed a framework to calculate 3 appointment metrics: indirect waiting time, direct waiting time, and appointment length. Statistical analysis tools were used to compare the performance of telehealth and in-person visits across the following specialties: obstetrics and gynecology, psychiatry, family medicine, gerontology, internal medicine, neurology, and neurosurgery. We used data from approximately 4 million in-person visits and 300,000 telehealth visits collected from 2017 to 2022., Results: Our analysis revealed a statistically significant increase in telehealth visits across all specialties (P<.001), showing an 89% increase from 51,589 visits in 2019 to 97,461 visits in 2020, followed by a 21% increase to 117,730 visits in 2021. Around 92.57% (134,221/145,001) of telehealth patients from 2020 to 2022 were covered by Medicare, Blue Cross and Blue Shield, commercial and managed care, Medicaid, and Medicare Managed Care. In-person visits covered by Medicare and Medicaid decreased by 15%, from 313,196 in 2019 to 264,696 in 2022. During 2020 to 2022, about 22.84% (33,123/145,001) of total telehealth visits during this period were covered by Medicare and 53.58% (86,317/161,092) were in psychiatry, obstetrics and gynecology, and family medicine. We noticed a statistically significant decrease (P<.001) in the average indirect waiting time for telehealth visits, from 48.4 to 27.7 days, and a statistically significant reduction in appointment length, from 93.2 minutes in 2020 to 39.59 minutes in 2022. The indirect waiting time for psychiatry telehealth visits was almost 50% shorter than that for in-person visits. These findings highlight the potential benefits of telehealth in providing access to health care, particularly for patients needing psychiatric care., Conclusions: Reverting to prepandemic regulations could negatively affect Arkansas, where many live in underserved areas. Our analysis shows that telehealth use remained stable beyond 2020, with psychiatry visits continuing to grow. These findings may guide insurance and policy decisions in Arkansas and other regions facing similar access challenges., (©Aysenur Betul Cengil, Sandra Eksioglu, Burak Eksioglu, Hari Eswaran, Corey J Hayes, Cari A Bogulski. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 18.10.2024.)

Introduction: Telehealth has the potential to mitigate the lack of health care access in rural and underserved communities; however, telehealth is only viable where sufficiently high-speed internet broadband is available to patients. Existing broadband data sets may not accurately reflect the state of broadband, particularly in rural communities. We examined consumer internet speed test data from two organizations to see if the number of tests per 1,000 residents varied across county-level rurality., Methods: We analyzed county-level data from Measurement Labs (M-Lab) and Ookla for Good (Ookla fixed and mobile) across the calendar years 2020 and 2021. We used the number of tests conducted per 1,000 residents within United States counties as the outcome variable, and Rural-Urban Continuum Codes (RUCC) as the main independent variable of interest., Results: Using negative binomial models with robust standard errors, we found that the number of fixed speed tests conducted per 1,000 residents was generally lower in rural counties relative to counties with over one million residents. However, we found no associations between any categories of county-level rurality for the number of mobile tests conducted per 1,000 residents. Patterns of association with other covariates emerged as significant in some models and not in others, suggesting key differences among users generating speed tests among these data sources., Conclusions: Our findings demonstrate the poor representation of residents from very rural counties in M-Lab and Ookla fixed data sets of user-generated internet speed tests. Additional data are needed to inform broadband infrastructure investment to identify those communities most left behind by broadband expansion efforts., (© The Author(s) 2024. Published by Mary Ann Liebert, Inc.)

Background: Telehealth is a rapidly growing modality for expanding healthcare access, especially in the post-COVID-19 era. However, telehealth requires high-quality broadband, thus making broadband a social determinant of health. The objective of this study was to evaluate the association between broadband access and telehealth utilization across the United States during the COVID-19 pandemic., Methods: Using a cross-sectional, ecological study design, we merged county-level data on broadband capacity (Microsoft's Rural Broadband Initiative), telehealth utilization among Medicare Fee-for-Service beneficiaries from January through September 2020 (CareJourney), and county-level socioeconomic characteristics (Area Health Resources Files). Multivariable linear regression was used to estimate the association between broadband capacity, county-level characteristics, and telehealth utilization., Results: Among the 3107 counties, those with the greatest broadband availability (quintile 5) had 47% higher telehealth utilization compared to counties with the least broadband availability (quintile 1). In the adjusted model, a 1 standard deviation (SD) increase in broadband access was associated with a 1.54 percentage point (pp) increase in telehealth utilization (P < 0.001). Rural county designation (-1.96 pp; P < 0.001) and 1 SD increases in average Medicare beneficiary age (-1.34 pp; P = 0.001), number of nursing home beds per 1000 individuals (-0.38 pp; P = 0.002), and proportion of Native Americans/Pacific Islanders (-0.59 pp; P < 0.001) were associated with decreased telehealth utilization., Conclusion: The association between broadband access and telehealth utilization and the decreased telehealth utilization in rural areas highlight the importance of broadband access for healthcare access and the need to continue investing in broadband infrastructure to promote equitable healthcare access across populations., Competing Interests: Declaration of conflicting interestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Ambrish A. Pandit was a PhD candidate at the University of Arkansas for Medical Sciences when this study was conducted and is currently employed at Amerisource Bergen Corporation, Conshohocken, Pennsylvania, U.S.A. Rest of the author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective. Levator ani muscles undergo significant stretching and micro-trauma at childbirth. The goal was to assess the neuromuscular integrity of this muscle group by means of magnetomyography (MMG) and correlate with Brink score-a commonly used digital assessment of pelvic floor muscle strength. Approach. Non-invasive MMG data was collected on 22 pregnant women during rest and voluntary contraction of the pelvic-floor muscles (Kegels). The mean amplitude and power spectral density (PSD) of the Kegels were correlated to Brink pressure score. Main Results. The modified Brink pressure score demonstrated medium correlations (⩾0.3) with MMG amplitude and PSD with the average Kegel of medium intensity and rest. Data showed that the 'resting state' of the pelvic floor is, in actuality, quite dynamic and may have implications for pelvic floor disorder propensity postpartum. Significance. These results confirm the ability of non-invasive MMG to reliably capture pelvic floor contraction as these signals correlate with clinical measure., (© 2024 Institute of Physics and Engineering in Medicine. All rights, including for text and data mining, AI training, and similar technologies, are reserved.)

Introduction: During the COVID-19 pandemic, health care shifted to virtual interactions with health professionals. The aim of this study was to examine the determinants of telehealth use in a nationally representative sample of the United States adult population., Methods: The study used data from the 2020 National Health Interview Survey of 17,582 respondents aged ≥18. Andersen's model of health services utilization was employed to examine predisposing, enabling, and needs factors associated with past-year telehealth use. Multivariable logistic regression was conducted to examine statistical associations., Results: 32.5% of adults ( n  = 6402; mean age 51.6, SE = 0.4) reported telehealth use. Predisposing factors: Women and married/partnered adults and those with higher levels of education had greater odds of using telehealth. Adults living in Midwest and South and adults living in medium-small and non-metropolitan areas had decreased odds of using telehealth. Enabling factors: Income and having a usual source of care were positively associated with telehealth use. A negative association was found for those with no insurance and telehealth use, whereas a positive association was found for military insurance. Needs factors: Odds of using telehealth were increased for adults who had well-visits and ER visits in the past 12 months. Mental health services quadrupled the odds of telehealth use. Odds of using telehealth increased with each additional chronic disease, including COVID-19., Conclusion: There are disparities in telehealth use according to sex, education, rurality, access to care, and health needs. Tackling these disparities is pivotal to ensure barriers to telehealth use are not exacerbated post-pandemic., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: During gestation, the brain development of the fetus is affected by many biological markers, where inflammatory processes and neurotrophic factors have been of particular interest in the past decade., Aim: This exploratory study is the first attempt to explore the relationships between biomarker levels in maternal and cord-blood samples and human fetal brain activity measured with non-invasive fetal magnetoencephalography (fMEG)., Method: Twenty-three women were enrolled in this study for collection of maternal serum and fMEG tracings immediately prior to their scheduled cesarean delivery. Twelve of these women had a preexisting diabetic condition. At the time of delivery, umbilical cord blood was also collected. Biomarker levels from both maternal and cord blood were measured and subsequently analyzed for correlations with fetal brain activity in four frequency bands extracted from fMEG power spectral densities., Results: Relative power in the delta, alpha, and beta frequency bands exhibited moderate-sized correlations with maternal BDNF and cord-blood CRP levels before and after adjusting for confounding diabetic status. These correlations were negative for the delta band, and positive for the alpha and beta bands. Maternal CRP and cord-blood BDNF and IL-6 exhibited negligible correlations with relative power in all four bands. Diabetes did not appear to be a strong confounding factor affecting the studied biomarkers., Conclusions: Maternal BDNF levels and cord-blood CRP levels appear to have a direct correlation to fetal brain activity. Our findings indicate the potential use of these biomarkers in conjunction with fetal brain electrophysiology to track fetal neurodevelopment., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 The Authors. Published by Elsevier Inc.)

Introduction: The COVID-19 pandemic has led to the rapid and widespread adoption of telehealth services. Telehealth may aid in bridging gaps in access to care. The specific impact of telehealth on opioid use disorder (OUD) and its treatment remains uncertain. Methods: A retrospective review of commercial insurance claim records within the United States was conducted to investigate the association between the COVID-19 pandemic and changes in the rates of(a) OUD treatments with and without telehealth support and (b) prescriptions for medications for opioid use disorder (MOUD) with and without telehealth support among individuals diagnosed with OUD. Results: In a study population of 1,340,506 individuals, OUD diagnosis rates were 5 per 1,000 in-person and 1 per 1,000 via telehealth. COVID-19 decreased in-person OUD diagnoses by 0.89 per 1,000, while telehealth diagnoses increased by 0.83 per 1,000. In-person MOUD treatment rates increased by 0.07 per 1,000 during COVID-19, while telehealth rates remained low. The onset of COVID-19 saw a 1.13 per 1,000 higher increase in telehealth-supported MOUD treatment compared to solely in-person treatment. Conclusions: A retrospective review of commercial insurance claim records within the United States was conducted to investigate the association between the COVID-19 pandemic and changes in the rates of (a) OUD treatments with and without telehealth support and (b) prescriptions for MOUD with and without telehealth support among individuals diagnosed with OUD.

Objective: To record and extract features of fetal cardiac activities with a semi-rigid prototype optically-pumped magnetometers (OPM) sensor array., Methods: Fetal magnetocardiography (fMCG) data were collected from 15 pregnant women between 28 and 40 weeks gestation. Mothers were lying flat in a customized bed with sensors touching their abdomen from below using a prototype grid. fMCG was extracted to perform standard fetal heart rate variability (FHRV) analysis., Results: fMCG was observed in 13 of the 15 pregnant women. OPM FHRV indicators were in the range of previous SQUID studies., Conclusion: Semi-rigid prototype OPM system has the ability to record quality fMCG. fMCG is capable of identifying lethal cardiac rhythm disturbances in the fetus. Our novel application of OPM technology may lower costs and increase maternal comfort, thus expanding fMCG's generalizability., Competing Interests: Declaration of competing interest None declared., (Copyright © 2024 IPEM. Published by Elsevier Ltd. All rights reserved.)

Introduction: Telehealth is becoming integral to health care delivery, which may create a higher need for better internet. This is the first study to examine whether users are willing to spend more on their internet if they are (1) more experienced in using telehealth, (2) more optimistic about telehealth benefits, and (3) less concerned about the difficulty of using telehealth. Methods: We surveyed 5,200 Americans about their willingness to pay (WTP) for internet speed and quality on the one hand, and their (1) prior use of telehealth, (2) opinion about the benefits of telehealth, and (3) opinion about the difficulties of using telehealth. We stratified the sample using the three aspects above and conducted a conjoint analysis to estimate the WTP for internet speed and quality within each stratum. Results: Compared with respondents who had never used telehealth, respondents who had used five to six different types of telehealth services were willing to spend 50.4% more on their internet plans. Users who most firmly believed in the benefits of telehealth were willing to spend 59.2% more than the most pessimistic users. Users who had the lowest concerns about the difficulty of using telehealth were willing to spend 114% more than users with the most perceived difficulty. Discussion: We found strong ties between the WTP for internet and prior telehealth use and perceptions of telehealth benefits and barriers. Thus, internet expenditures may be influenced by users' anticipation of using telehealth. Future studies may investigate the causality of the relationship.

Background: Hypertension management is complex in older adults. Recent advances in remote patient monitoring (RPM) have warranted evaluation of RPM use and patient outcomes., Objective: To study associations of RPM use with mortality and healthcare utilization measures of hospitalizations, emergency department (ED) utilization, and outpatient visits., Design: A retrospective cohort study., Patients: Medicare beneficiaries aged ≥65 years with an outpatient hypertension diagnosis between July 2018 and September 2020. The first date of RPM use with a corresponding hypertension diagnosis was recorded (index date). RPM non-users were documented from those with an outpatient hypertension diagnosis; a random visit was selected as the index date. Six months prior continuous enrollment was required., Main Measures: Outcomes studied within 180 days of index date included (i) all-cause mortality, (ii) any hospitalization, (iii) cardiovascular-related hospitalization, (iv) non-cardiovascular-related hospitalization, (v) any ED, (vi) cardiovascular-related ED, (vii) non-cardiovascular-related ED, (viii) any outpatient, (ix) cardiovascular-related outpatient, and (x) non-cardiovascular-related outpatient. Patient demographics and clinical variables were collected from baseline and index date. Propensity score matching (1:4) and Cox regression were performed. Hazard ratios (HR) and 95% confidence intervals (CI) are reported., Key Results: The matched sample had 16,339 and 63,333 users and non-users, respectively. Cumulative incidences of mortality outcome were 2.9% (RPM) and 4.3% (non-RPM), with a HR (95% CI) of 0.66 (0.60-0.74). RPM users had lower hazards of any [0.78 (0.75-0.82)], cardiovascular-related [0.79 (0.73-0.87)], and non-cardiovascular-related [0.79 (0.75-0.83)] hospitalizations. No significant association was observed between RPM use and the three ED measures. RPM users had higher hazards of any [1.10 (1.08-1.11)] and cardiovascular-related outpatient visits [2.17 (2.13-2.19)], while a slightly lower hazard of non-cardiovascular-related outpatient visits [0.94 (0.93-0.96)]., Conclusions: RPM use was associated with substantial reductions in hazards of mortality and hospitalization outcomes with an increase in cardiovascular-related outpatient visits., (© 2023. This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply.)

Introduction: Unmanaged hypertension in pregnancy is the second most common cause of direct maternal death and disproportionately affects women in rural areas. While telehealth technologies have worked to reduce barriers to healthcare, lack of internet access has created new challenges. Cellular-enabled remote patient monitoring devices provide an alternative option for those without access to internet., Objective: This study aimed to assess maternal and neonatal clinical outcomes and patient acceptability of an integrated model of cellular-enabled remote patient monitoring devices for blood pressure supported by a 24/7 nurse call center., Methods: In a mixed-methods study, 20 women with hypertension during pregnancy were given a cellular-enabled BodyTrace blood pressure cuff. Participants' blood pressures were continuously monitored by a nurse call center. Participants completed a baseline survey, post-survey, and semi-structured interview after 8 weeks of device use., Results: Participants reported a significant decrease in perceived stress after device use ( P = .0004), high satisfaction with device usability (mean = 78.38, SD = 13.68), and high intention to continue device use (mean = 9.05, SD = 1.96). Relatively low hospitalization and emergency department rates was observed (mean = 0.35, SD = 0.59; mean = 0.75, SD = 0.91). Participant-perceived benefits of device use included convenience, perceived better care owing to increased monitoring, and patient empowerment. Perceived disadvantages included higher blood pressure readings compared to clinical readings and excessive calls from call center., Conclusion: Remote patient monitoring for women whose pregnancies are complicated by hypertension can reduce barriers and improve health outcomes for women living in rural and low-health-resource areas., (© 2024 Heart Rhythm Society.)

Fetal sex has been associated with different development trajectories that cause structural and functional differences between the sexes throughout gestation. Fetal magnetocardiography (fMCG) recordings from 123 participants (64 females and 59 males; one recording/participant) from a database consisting of low-risk pregnant women were analyzed to explore and compare fetal development trajectories of both sexes. The gestational age of the recordings ranged from 28 to 38 weeks. Linear metrics in both the time and frequency domains were applied to study fetal heart rate variability (fHRV) measures that reveal the dynamics of short- and long-term variability. Rates of linear change with GA in these metrics were analyzed using general linear model regressions with assessments for significantly different variances and GA regression slopes between the sexes. The fetal sexes were well balanced for GA and sleep state. None of the fHRV measures analyzed exhibited significant variance heterogeneity between the sexes, and none of them exhibited a significant sex-by-GA interaction. The absence of a statistically significant sex-by-GA interaction on all parameters resulted in none of the regression slope estimates being significantly different between the sexes. With high-precision fMCG recordings, we were able to explore the variation in fHRV parameters as it relates to fetal sex. The fMCG-based fHRV parameters did not show any significant difference in rates of change with gestational age between sexes. This study provides a framework for understanding normal development of the fetal autonomic nervous system, especially in the context of fetal sex., (© 2023. The Author(s), under exclusive licence to Society for Reproductive Investigation.)

Objectives: This study aims to show the relation between biomarkers in maternal and cord-blood samples and fetal heart rate variability (fHRV) metrics through a non-invasive fetal magnetocardiography (fMCG) technique., Methods: Twenty-three women were enrolled for collection of maternal serum and fMCG tracings immediately prior to their scheduled cesarean delivery. The umbilical cord blood was collected for measurement of biomarker levels. The fMCG metrics were then correlated to the biomarker levels from the maternal serum and cord blood., Results: Brain-derived neurotrophic factor (BDNF) had a moderate correlation with fetal parasympathetic activity (0.416) and fetal sympathovagal ratios (-0.309; -0.356). Interleukin (IL)-6 also had moderate-sized correlations but with an inverse relationship as compared to BDNF. These correlations were primarily in cord-blood samples and not in the maternal blood., Conclusions: In this small sample-sized exploratory study, we observed a moderate correlation between fHRV and cord-blood BDNF and IL-6 immediately preceding scheduled cesarean delivery at term. These findings need to be validated in a larger population., (© 2024 Walter de Gruyter GmbH, Berlin/Boston.)

Introduction: Telehealth services have the potential to increase healthcare access among underserved populations, such as rural residents and racial/ethnic minority groups. The COVID-19 public health emergency led to unprecedented growth in telehealth utilization, but evidence suggests the growth has not been equitable across all patient populations. This study aimed to explore whether telehealth utilization and expansion changed equitably from 2019 to 2020 among sub-groups of Medicare beneficiaries., Methods: We conducted an analysis of telehealth utilization among a 20% random sample of 2019-2020 Medicare beneficiaries on a national level. We fit multivariable logistic regression models and calculated average marginal effects (AME) to assess the association between demographic and clinical characteristics on telehealth utilization., Results: We found telehealth utilization was less likely among non-Hispanic Black/African-American (2019: adjusted odds ratio [aOR] = 0.77, AME = -0.15; 2020: aOR = 0.85, AME = -3.50) and Hispanic (2019: aOR = 0.79, AME = -0.13; 2020: aOR = 0.87, AME = -2.89) beneficiaries, relative to non-Hispanic White beneficiaries in both 2019 and 2020, with larger disparities in 2020. Rural beneficiaries were more likely to utilize telehealth than urban beneficiaries in 2019 (aOR = 2.62, AME = 0.84), but less likely in 2020 (aOR = 0.57, AME = -14.47). In both years, dually eligible Medicare/Medicaid beneficiaries were more likely than non-dually eligible beneficiaries to utilize telehealth (2019: aOR = 4.75, AME = 0.84; 2020: aOR = 1.34, AME = 2.25). However, the effects of dual eligibility and rurality changed in both models as the number of chronic conditions increased., Discussion: We found evidence of increasing disparities in telehealth utilization among several Medicare beneficiary sub-groups in 2020 relative to 2019, including individuals of minority race/ethnicity, rural residents, and dually eligible beneficiaries, with disparities increasing among individuals with more chronic conditions. Although telehealth has the potential to address health inequities, our findings suggest that many of the patients in greatest need of healthcare are least likely to utilize telehealth services., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Introduction: Telehealth use in obstetrics has been demonstrated to improve efficiency, access to care, and pregnancy outcomes. Despite reported successful implementation of these programs, information regarding the program variations and its impact on health care costs and outcomes are scarce. Methods: This is a scoping review of pregnancy-related telehealth studies to understand the current landscape of pregnancy-related telehealth interventions as well as to subset those that are used in high-risk pregnancies. We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses framework to guide this review. Results: A total of 70 articles were included in this scoping review. Of those, 53 (75.7%) studies included a pregnant population and 17 (24.3%) studies focused on a rural and/or urban population. Most studies ( n  = 56; 80%) included some form of synchronous interaction between provider and participant. Patient outcomes included maternal/infant health outcomes ( n  = 41; 44.1%), patient satisfaction ( n  = 9; 9.7%), and attendance/compliance ( n  = 5; 5.4%). Provider-level outcomes included knowledge change ( n  = 11; 11.8%) and self-efficacy ( n  = 3; 3.2%). Other outcomes included assessment of costs and patient/provider feasibility and acceptability of the intervention. Overall, there has been a growing trend in articles published on pregnancy-related telehealth studies since 2011, with 2018 having the most publications in a single year. Conclusion: This review suggests a steadily growing body of literature on pregnancy-related telehealth interventions; however, more research is needed to better understand outcomes of telehealth for pregnancy-related care, especially related to patient satisfaction, health disparities, and cost-benefit.

Background: The rates of SMM have been steadily increasing in Arkansas, a southern rural state, which has the 5th highest maternal death rate among the US states. The aims of the study were to test the functionality of the Bateman index in association to SMM, in clustering the risks of pregnancies to SMM, and to study the predictability of SMM using the Bateman index., Study Design: From the ANGELS database, 72,183 pregnancies covered by Medicaid in Arkansas between 2013 and 2016 were included in this study. The expanded CDC ICD-9/ICD-10 criteria were used to identify SMM. The Bateman comorbidity index was applied in quantifying the comorbidity burden for a pregnancy. Multivariable logistic regressions, KMeans method, and five widely used predictive models were applied respectively for each of the study aims., Results: SMM prevalence remained persistently high among Arkansas women covered by Medicaid (195 per 10,000 deliveries) during the study period. Using the Bateman comorbidity index score, the study population was divided into four groups, with a monotonically increasing odds of SMM from a lower score group to a higher score group. The association between the index score and the occurrence of SMM is confirmed with statistical significance: relative to Bateman score falling in 0-1, adjusted Odds Ratios and 95% CIs are: 2.1 (1.78, 2.46) for score in 2-5; 5.08 (3.81, 6.79) for score in 6-9; and 8.53 (4.57, 15.92) for score ≥10. Noticeably, more than one-third of SMM cases were detected from the studied pregnancies that did not have any of the comorbid conditions identified. In the prediction analyses, we observed minimal predictability of SMM using the comorbidity index: the calculated c -statistics ranged between 62% and 67%; the Precision-Recall AUC values are <7% for internal validation and <9% for external validation procedures., Conclusions: The comorbidity index can be used in quantifying the risk of SMM and can help cluster the study population into risk tiers of SMM, especially in rural states where there are disproportionately higher rates of SMM; however, the predictive value of the comorbidity index for SMM is inappreciable.

Introduction: The COVID-19 pandemic brought about renewed interest and investment in telehealth, while also highlighting persistent health disparities in the Southern states. Little is known about the characteristics of those utilizing telehealth services in Arkansas, a rural Southern state. We sought to compare the characteristics of telehealth utilizers and nonutilizers among Medicare beneficiaries in Arkansas before the COVID-19 public health emergency to provide a baseline for future research investigating disparities in telehealth utilization. Methods: We used Arkansas Medicare beneficiary data (2018-2019) to model telehealth use. We included interactions to assess how the association between the number of chronic conditions and telehealth was moderated by race/ethnicity and rurality, adjusted for covariates. Results: Overall telehealth utilization in 2019 was low ( n  = 4,463; 1.1%). The adjusted odds of utilizing telehealth was higher for non-Hispanic Black/African Americans (vs. white, adjusted odds ratio [aOR] = 1.34, 95% confidence interval [CI] = 1.17-1.52), rural beneficiaries (aOR = 1.99, 95% CI = 1.79-2.21), and those with more chronic conditions (aOR = 1.23, 95% CI = 1.21-1.25). Race/ethnicity and rurality were significant moderators, such that the association between the number of chronic conditions and telehealth was strongest among white and among rural beneficiaries. Discussion: Among the 2019 Arkansas Medicare beneficiaries, having more chronic conditions was most strongly associated with telehealth use among white and rural individuals, while the effect was not as pronounced for Black/African American and urban individuals. Our findings suggest that advances in telehealth are not benefiting all Americans equally, with aging minoritized communities continuing to engage with more strained and underresourced health systems. Future research should investigate how upstream factors such as structural racism perpetuate poor health outcomes.

Background: Type 1 and type 2 diabetes during pregnancy requires intensive glucose monitoring to ensure optimal health outcomes for mothers and infants. Standard practice includes patients monitoring their glucose four to six times a day using a standard glucometer and paper diary. Remote patient monitoring (RPM) offers an alternative method for diabetes management. This study aimed at measuring the patient's satisfaction with and feasibility of using a cellular-enabled RPM device for glucose management in pregnancies complicated by type 1 or type 2 diabetes., Methods: In a mixed-methods pilot study, 59 pregnant women with type 1 or type 2 diabetes were given a cellular-enabled iGlucose glucometer. Participants completed a pre-survey, used the device for 30 days, and then completed a post-survey and semi-structured interview., Results: Participants were divided into two groups based on duration of device use: high-use >50 days and low-use ≤50 days. A significant difference ( p  < 0.0001) in Appraisal of Diabetes scores was seen between the pre- and post-survey for both groups, which indicates that the use of iGlucose glucometer significantly improved participants' appraisal of their diabetes. There was a significant difference ( p  = 0.0409) in pre-post General Life Satisfaction in the high-use group, which indicates that iGlucose glucometer significantly improved participants' life satisfaction when used for an extended amount of time. Participants scored high on system usability for all groups and reported positive associations with iGlucose use., Conclusion: The use of cellular-enabled RPM glucometers is a valuable tool for the management of type 1 diabetes mellitus and type 2 diabetes mellitus during pregnancy., Competing Interests: No competing financial interests exist., (© Rebecca D. Jones et al., 2023; Published by Mary Ann Liebert, Inc.)

Background: Social media is used as a source of information and platform to discuss health care; however, there is little research on discussion of telehealth in social media. Past research has looked at individual platforms, but a comparison of discussion on two platforms (Reddit and Twitter) has not been performed. Understanding telehealth-related social media discourse and the differences between platforms may provide insights into how telehealth is characterized online and which platforms provide patient perspectives. The COVID-19 pandemic provides a unique case study to examine how social media users approached both Reddit and Twitter during an international health crisis. This study used natural language processing tools and two social media platforms to (1) characterize and contrast each platform's telehealth-related posts according to themes and (2) assess the frequency of telehealth and telehealth-related terms posts before and during the onset of the COVID-19 pandemic., Methods: We collected 6 years (2016 through 2021) of social media posts from Twitter and Reddit. The themes of the corpus were extracted using hashtags, subreddits, and Latent Dirichlet Allocation (LDA) and were analyzed using descriptive statistics., Results: Both Twitter and Reddit showed exponential growth in the use of the term "telehealth" and telehealth-related terms in early 2020. The use of telehealth-related terms and discussion of COVID-19 coincided in both social media sites; however, other themes were discussed, including how to use telehealth. Reddit LDA clusters showed greatest usage of "telehealth" when associated with using or suggesting telehealth for receiving therapy, counseling, or psychoanalysis while Twitter focused on sharing telehealth news, products, and services., Discussion: Twitter and Reddit had extensive growth in the use of telehealth-related terms after the COVID-19 pandemic. Twitter and Reddit showed themes connecting COVID-19 to telehealth, especially in reference to services, therapy, and counseling, however, Reddit had more discussion suggesting use of telehealth services or requesting peer insights into how to use telehealth as compared with Twitter, which appeared more focused on telehealth as a business or product., Competing Interests: No competing financial interests exist., (© Catherine C. Shoults et al., 2023; Published by Mary Ann Liebert, Inc.)

Objective: The purpose of this study was to determine if uterine electrophysiological signals gathered from 151 non-invasive biomagnetic sensors spread over the abdomen were associated with successful induction of labor (IOL)., Study Design: Uterine magnetomyogram (MMG) signals were collected using the SARA (SQUID Array for Reproductive Assessment) device from 33 subjects between 37 and 42 weeks gestational age. The signals were post-processed, uterine contractile related MMG bursts were detected, and parameters in the time and frequency domain were extracted. The modified Bishop score calculated at admission was used to determine the method of IOL. Wilcoxon's rank-sum test was used to compare IOL successes and failures for differences in gestational age (GA), parity, modified Bishop's score, maximum oxytocin, and electrophysiological parameters extracted from MMG., Results: The average parity was three times (3x) higher (1.53 versus 0.50; p = 0.039), and the average modified Bishop score was 2x higher (3.32 versus 1.63; p = 0.032) amongst IOL successes than failures, while the average GA and maximum oxytocin showed a small difference. For the MMG parameters, successful IOLs had, on average, 3.5x greater mean power during bursts (0.246 versus 0.070; p = 0.034) and approximately 1.2x greater mean number of bursts (2.05 versus 1.68; p = 0.036) compared to the failed IOLs, but non-significant differences were observed in mean peak frequency, mean burst duration, and mean duration between bursts., Conclusion: The study showed that inductions of labor that took less than 24 h to deliver have a higher mean power in the baseline electrophysiological activity of the uterus when recorded prior to planned induction. The results are indicative that baseline electrophysiological activity measured prior to induction is associated with successful induction., Competing Interests: The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Hari Eswaran reports financial support was provided by 10.13039/100000002National Institutes of Health., (© 2023 The Author(s).)

Introduction: Hypertension affects 5-10% of pregnancies in the United States. Chronic hypertension during pregnancy can have a significant impact on maternal and neonatal outcomes, especially in rural populations. Pregnancies complicated by hypertension are currently managed through frequent clinic visits or extended hospital stays. Cellular-enabled remote patient monitoring devices provide an alternative treatment method for women in rural areas., Research Aim: This study aimed to measure the feasibility of and patient satisfaction with using an integrated model of cellular-enabled remote patient monitoring devices for blood pressure supported by a 24/7 nurse call center., Methods: In a mixed methods pilot study, twelve women with chronic hypertension during pregnancy were given cellular-enabled BodyTrace ™ blood pressure cuffs and weight scales. Participants' blood pressures were continuously monitored by a nurse call center. Participants completed a survey and a brief semi-structured interview after two weeks., Results: Participants scored low on stress and anxiety with mean scores of 5.45 (SD = 3.56) and 8.09 (SD 3.62), respectively. Participants scored high on behavioral intention, system usability, and perceived benefits with mean scores of 8.73 (SD = 2.53), 75.91 (SD = 23.70), and 19.64 (SD = 5.92), respectively. Participants perceived benefits to using the device, including increased monitoring by health professionals, increased self-awareness, decreased number of clinic visits, and convenience of use. Perceived disadvantages included higher readings when compared to clinical readings., Discussion: Cellular-enabled remote patient monitoring devices for blood pressure are a valuable tool for managing treatment of pregnancies complicated by hypertension., (© 2023. The Author(s).)

Purpose: To assess the factors associated with offering remote patient monitoring (RPM) services. Methods: We integrated three datasets: (1) 2019-2020 Area Health Resource Files, (2) 2019 American Community Survey, and (3) 2019 American Hospitals Association annual survey using county Federal Information Processing Standards code to evaluate associations between hospital characteristics and county-level demographic factors with provision of (1) post-discharge, (2) chronic care, (3) other RPM services, and (4) any of these three RPM service categories. These outcomes were analyzed using multi-level, mixed-effects multivariate logistic regression modeling to account for county-level clustering of hospitals. Findings: Among 3,381 hospitals, 1,354 (40.0%) provided any RPM services. Being part of a clinically integrated network (CIN) and private, non-profit (vs. public) ownership were respectively associated with 104.5% (95% confidence interval [CI]: 69.4-146.8%; p < 0.001) and 30.4% (95% CI: 2.5-66.0%; p  = 0.031) higher odds of providing any RPM services. Critical access hospital (CAH) designation, for-profit (vs. public) ownership, and location in the South (vs. Northeast) were associated with significantly lowering odds of providing any RPM services by 36.2% (95% CI: 14.2-52.6%; p  = 0.003), 70.1% (95% CI: 56.0-79.6%; p < 0.001), and 34.0% (95% CI: 2.8-55.1%; p  = 0.035), respectively. Similar trends were found with the various RPM service categories. Conclusions: The factors most associated with provision of any RPM services were hospital-level factors. Specifically, being part of a CIN and private, non-profit ownership had the highest positive associations with offering RPM services whereas location in the South and CAH designation had the strongest negative associations. Further studies are needed to understand the reasons behind these associations.

Heart rate variability assessment of neonates of pregestational diabetic mothers have shown alterations in the autonomic nervous system (ANS). The objective was to study the effect of maternal pregestational diabetes on ANS at the fetal stage by combining cardiac and movement parameters using a non-invasive fetal magnetocardiography (fMCG) technique. This is an observational study with 40 participants where fetuses from a group of 9 Type 1, 19 Type 2 diabetic, and 12 non-diabetic pregnant women were included. Time and frequency domain fetal heart rate variability (fHRV) and coupling of movement and heart rate acceleration parameters related to fetal ANS were analyzed. Group differences were investigated using analysis of covariance to adjust for gestational age (GA). When compared to non-diabetics, the Type 1 diabetics had a 65% increase in average ratio of very low-frequency (VLF) to low-frequency (LF) bands and 63% average decrease in coupling index after adjusting for GA. Comparing Type 2 diabetics to non-diabetics, there was an average decrease in the VLF (50%) and LF bands (63%). Diabetics with poor glycemic control had a higher average VLF/LF (49%) than diabetics with good glycemic control. No significant changes at p < 0.05 were observed in high-frequency (HF) frequency domain parameters or their ratios, or in the time domain. Fetuses of pregestational diabetic mothers exhibited some differences in fHRV frequency domain and heart rate-movement coupling when compared to non-diabetics but the effect of fHRV related to fetal ANS and sympathovagal balance were not as conclusive as observed in the neonates of pregestational diabetic mothers., (© 2023 The Authors. Physiological Reports published by Wiley Periodicals LLC on behalf of The Physiological Society and the American Physiological Society.)

Background: Marshallese Pacific Islanders residing in the United States have higher rates of adverse perinatal outcomes than the general population and experience numerous barriers to prenatal care. CenteringPregnancy is a group prenatal care model which occurs in the patient's community. CenteringPregnancy, when applied to the Marshallese population, presents a potentially highly successful group-based intervention that can mitigate adverse perinatal outcomes among Marshallese Pacific Islanders., Methods: This article describes the protocol of a mixed-methods study designed to examine the feasibility, acceptability, and preliminary effectiveness of the implementation of CenteringPregnancy for Marshallese Pacific Islander women. The mixed-methods design collects qualitative and quantitative data at the onset of CenteringPregnancy and during their last session and then augments the data with post-partum data abstraction., Conclusion: This will be the first study to culturally adapt and implement CenteringPregnancy with Marshallese pregnant women in the United States. This study will be an important first step to exploring the feasibility, acceptability, and preliminary effectiveness of CenteringPregnancy and will better prepare the research team to assess and refine the intervention moving forward., Trial Registration: This study was registered at ClinicalTrials.gov on September 22, 2020 under identifier NCT04558619 and can be accessed at https://clinicaltrials.gov/ct2/show/NCT04558619?term=K%C5%8Dmmour+Prenatal&draw=2&rank=1., Competing Interests: The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Dr. Sheena CarlLee reports owning some Pfizer stock. All other authors declared no conflicts of interest. Dr. Sheena CarlLee reports owning some Pfizer stock. All other authors declare they have no competing interests. The study protocol has not undergone peer-review by the funding body, and no funding is from a commercial organization., (©2023PublishedbyElsevierInc.)

Introduction: Limited information exists on the landscape of studies and policies for remote patient monitoring (RPM) in the United States. Methods: We conducted a scoping review to assess (1) for which adult patient populations and health care needs is RPM being used and (2) the landscape of national- and state-level reimbursement policies for RPM. This study was guided by the Arksey and O'Malley methodological framework for scoping reviews and the Joanna Briggs Institute Manual for Evidence Synthesis. Results: A total of 399 articles were included in our final sample: 268 study articles and 131 articles of gray literature (e.g., websites, legislative bills). RPM-related articles rose drastically from 2015 to 2021, and the vast majority of articles were peer-reviewed journal articles. Of the study articles, prospective cohort studies were the most common study method, with m-health/smart watches being the most common RPM modality. RPM was found to be most commonly tested within patients with cardiovascular diseases, and the most common outcomes measured were usability and feasibility. Gray literature found 36 U.S. state Medicaid programs had reimbursement policies for RPM in 2021; however, 28 of those had at least one restriction on reimbursement (e.g., limited to specific providers). Conclusions: Despite the rapid growth in the literature on RPM and the adoption of reimbursement policies, retrospective, population-level studies, large randomized controlled trials, studies with a focus on additional favorable outcomes (e.g., quality of life), and studies evaluating trends in RPM reimbursement policies are lacking in the current literature.

Background: The American Academy of Pediatrics recommends exclusive breastfeeding for the first 6 months of life; however, a lack of access to breastfeeding resources influences breastfeeding initiation and continuation. Tele-lactation services may reduce some of these barriers to access., Research Aims: To identify facilitators and barriers of two modes of tele-health service utilization and to compare the differences between two modes of providing tele-lactation services on breastfeeding knowledge, breastfeeding intention, perceived social support, and 3-month breastfeeding continuation behavior., Methods: We conducted a mixed method, longitudinal pilot study utilizing prospective convenience sampling and random assignment of postpartum women recruited from two medical centers in Little Rock, Arkansas. Participants ( N = 43) were randomized into telephone-only ( n = 23) or audio-visual ( n = 20) intervention groups. Participants completed a self-administered pre- and post-intervention survey, as well as a semi-structured qualitative phone interview at 4-6 weeks post-discharge., Results: No significant difference in demographic characteristics across groups was found. At 3 months after discharge, both groups reported continued breastfeeding (telephone-only: n = 17, 81%; audio-visual: n = 18, 90%) with no significant difference between the two groups ( p = .663). Additionally, no group differences were found for breastfeeding knowledge or perceived social support. Overall, participants reported positive experiences with tele-lactation, emphasizing the convenience, accessibility, education, and support provided., Conclusion: We found that both telephone-only and audio-visual delivery of tele-lactation services were equally effective. Both methods of tele-lactation services should be considered by health care providers to encourage and sustain breastfeeding behavior in mothers.

Background: 17 alpha-hydroxyprogesterone caproate (17OHP) is used to reduce the recurrent risk of preterm delivery in women with a history of preterm delivery. Meis et al. conducted a double-blind placebo controlled trial to evaluate the effectiveness of 17OHP and observed a significant reduction in the risk of recurrent preterm delivery. The FDA granted 17OHP a conditional approval on 2011. A second study observed that 17OHP did not decrease the risk of a recurrent preterm delivery. Criticism of the second study derived from a dissimilarity of the study population., Objective: Our investigation examined the effectiveness of 17OHP in women with a prior preterm delivery in a rural US state with a patient population similar to the original Meis trial., Study Design: 17OHP became largely unavailable (due to cost and local pharmacies no longer compounding 17 OHP) and the University of Arkansas for Medical Sciences, Department of Health, and Arkansas Medicaid co-operated to make 17OHP available to women with a prior PTB in our state. This study was a retrospective review of the 17OHP that was offered to women with a prior preterm delivery. For our retrospective review, logistic regression was used on cases of prior preterm delivery between January 2014 and December of 2018 to examine the relationship between 17OHP injections and preterm delivery., Results: A total of 268 women were analyzed for this review. They were divided into three groups: 0 injections, 1-10 injections, and > 10 injections. We found no relationship between 17OHP injections with preterm delivery., Conclusion: Although our patient population was similar to that of the original Meis trial, our results were more similar to the second study by Blackwell.

Objective: 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., Study Design: 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., Results: 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 ( κ  = 0.71; 95% CI: 0.57-0.85). The levels of agreement between the call center nurses and the resident and APN were considered moderate with κ  = 0.60 (95% CI: 0.42-0.77) and κ  = 0.60 (95% CI: 0.45-0.76)., Conclusion: 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.

Background: Mitigation efforts to prevent the spread of COVID-19 included the robust utilization of telehealth. However, racial/ethnic minority populations have demonstrated low telehealth utilization in the past. The aim of this study was to examine the first-time use of telehealth by Marshallese adults during the COVID-19 pandemic, using online survey data collected from 109 Marshallese respondents between July and November of 2020. Methods: To evaluate the relationships between sociodemographic characteristics, health care access, physical/mental health, and COVID-19-specific measures and the decision to use telehealth, we use bivariate analyses, including t -tests and chi-square analysis. Results: Eighteen respondents (16.5%) indicated they utilized telehealth for the first time during the pandemic. The number of chronic conditions reported was positively associated with the first-time use of telehealth ( p  = 0.013). Although not statistically significant, a higher proportion of Marshallese first-time telehealth users reported limited English proficiency, changes in health status, and changes in health insurance. Discussion: Although telehealth has been shown to reduce the absolute gaps in health disparities for minority populations, there is limited utilization by Marshallese communities. Conclusions: Significant research remains on the utilization of telehealth by Marshallese during the COVID-19 pandemic and to increase utilization in the future., Competing Interests: No competing financial interests exist., (© Jennifer A. Andersen et al., 2021; Published by Mary Ann Liebert, Inc.)

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., (Copyright © 2021. Published by Elsevier Inc.)

While telemedicine had been utilized in varying ways over the last several years, it has dramatically accelerated in the era of the COVID-19 pandemic. In this article we describe the privacy issues, in relation to the barriers to care for health care providers and barriers to the obstetric patient, licensing and payments for telehealth services, technological issues and language barriers. While there may be barriers to the use of telehealth services this type of care is feasible and the barriers are surmountable., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Investigation of fetal evoked response to auditory or visual stimuli is an important means of understanding the developmental stages and potential problems in prenatal life. It is, however, not without certain imperfections. The biggest challenge with fetal evoked response is its low signal to noise ratio. Under noisy conditions, the detected fetal evoked response should, therefore, be further investigated to confirm that the source of the signal is from fetal brain and is not related to random noise. Existing methods for verification are: (1) visual inspection of magnetic field maps, which requires user intervention and expert knowledge which can be highly subjective; (2) simultaneous ultrasound measurement, which is expensive and technically difficult to manage; and (3) equivalent current dipole fitting, which requires knowledge of the orientation of fetal head and its dimensions that may not be available at all times., Objective: To verify that the detected fetal evoked response signal is originating from the fetal head by using an objective and feasible method that employs magnetic dipole fitting to fetal evoked response., Study Design: From raw fetal magnetoencephalography data, the cardiac interference was removed by frequency dependent subtraction. After averaging over stimulus triggers, the resulting signal was taken as the candidate fetal evoked response. The fetal evoked response was investigated for the highest peak in between 0.2-0.5 s, which is the expected latency of the response to the stimulus. The magnetic field at this highest peak was used for magnetic dipole fitting. The validation of peak was based on the closeness of the magnetic dipole fit to vicinity of fetal head location determined by ultrasound and the anatomically reasonable distance from the fetal heart. The methodology was first tested on a sample neonatal data before application to fetal data., Results: The results of neonatal application confirmed that the source localization by magnetic dipole fitting for the brain produced meaningful results. When applied to fetal data, auditory and visual evoked response was detected in 27 of the 38 recordings. This implied that with our verification method, fetal evoked responses were detected in 71% of fetuses., Conclusion: Detection rate of the evoked responses were similar to earlier reports where subjective visual inspection or simultaneous ultrasound measurement were used. Our method using magnetic dipole fitting for verification is more feasible and objective compared to the earlier methods., (Copyright © 2021 Elsevier B.V. All rights reserved.)

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.

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., (© 2020 Wiley Periodicals LLC.)

Background. Developmental origin of health and disease states that an adverse intrauterine environment can lead to different diseases in later life. In this study, we aimed to explore the effect of maternal pregestational diabetes on the fetal brain activity using magnetoencephalography (MEG). Methods. Forty participants were included in an observational study with 9 type 1 and 19 type 2 diabetic pregnant women compared with data from 12 nondiabetic participants. Spontaneous fetal MEG signals were recorded and power spectral density was computed in 4 standard frequency bands. Group differences were investigated using analysis of covariance. Results . Our results showed that type 1 group was significantly different ( P < .05) from the reference group for 3 of the 4 brain activity frequency bands, while in type 2 group, 2 bands exhibited this trend. When dichotomized based on the maternal glycemic control, significant differences in all bands were observed between the poor-control and reference groups. Conclusion . The fetal background brain activity parameters appear to be altered in diabetic pregnancy in comparison with the reference low-risk group. The study showed that maternal pregestational diabetes could potentially influence in utero neurodevelopment.

Background: Auditory steady-state responses (ASSRs) are ongoing evoked brain responses to continuous auditory stimuli that play a role for auditory processing of complex sounds and speech perception. Transient auditory event-related responses (AERRs) have previously been recorded using fetal magnetoencephalography (fMEG) but involve different neurological pathways. Previous studies in children and adults demonstrated that the cortical components of the ASSR are significantly affected by state of consciousness and by maturational changes in neonates and young infants. To our knowledge, this is the first study to investigate ASSRs in human fetuses., Methods: 47 fMEG sessions were conducted with 24 healthy pregnant women in three gestational age groups (30-32 weeks, 33-35 weeks and 36-39 weeks). The stimulation consisted of amplitude-modulated (AM) tones with a duration of one second, a carrier frequency (CF) of 500 Hz and a modulation frequency (MF) of 27 Hz or 42 Hz. Both tones were presented in a random order with equal probability adding up to 80-100 repetitions per tone. The ASSR across trials was quantified by assessing phase synchrony in the cortical signals at the stimulation frequency., Results and Conclusion: Ten out of 47 recordings were excluded due to technical problems or maternal movements. Analysis of the included 37 fetal recordings revealed a statistically significant response for the phase coherence between trials for the MF of 27 Hz but not for 42 Hz. An exploratory subgroup analysis moreover suggested an advantage in detectability for fetal behavioral state 2F (active asleep) compared to 1F (quiet asleep) detected using fetal heart rate. In conclusion, this pilot study is the first description of a method to detect human ASSRs in fetuses. The findings warrant further investigations of the developing fetal brain., Competing Interests: The authors have declared that no competing interests exist.

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.

Fetal magnetocardiography (fMCG) is a noninvasive method of measuring magnetic signals generated by the depolarizing heart. fMCG has proved to have superior signal-to-noise ratio characteristics and enables precise detection of the R-R intervals for fetal heart rate variability (FHRV) analysis. FHRV is one of the most useful clinical indicators for investigating fetal neurodevelopment. Currently, fMCG recordings rely on superconducting quantum interference devices (SQUIDs) which require cryogenics leading to a high cost device. New cryogenic-free sensors called optical pump magnetometers (OPMs) have emerged as alternative to SQUIDs. To take advantage of the flexibility of the OPM sensors, we explored the ability of OPM sensors to measure the fMCG at different maternal positions and sensor locations. Data were collected with a 14-channel OPM array using different sitting positions (mother leaning forward, backward, and prone). Projection operator algorithm based on minimum norm (POMN) was applied to extracted fMCG. R peaks were obtained to perform standard FHRV analysis. We were able to configure a standalone array of the OPMs that conforms to the shape of the maternal abdomen to obtain signals with sufficient quality. We extracted and quantified FHRV parameters in three low-risk fetuses. Results showed that FHRV values are in the range of previous SQUID studies.

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., (© 2020 International Federation of Gynecology and Obstetrics.)

The University of Arkansas for Medical Sciences (UAMS), like many rural states, faces clinical and research obstacles to which digital innovation is seen as a promising solution. To implement digital technology, a mobile health interest group was established to lay the foundation for an enterprise-wide digital health innovation platform. To create a foundation, an interprofessional team was established, and a series of formal networking events was conducted. Three online digital health training models were developed, and a full-day regional conference was held featuring nationally recognized speakers and panel discussions with clinicians, researchers, and patient advocates involved in digital health programs at UAMS. Finally, an institution-wide survey exploring the interest in and knowledge of digital health technologies was distributed. The networking events averaged 35-45 attendees. About 100 individuals attended the regional conference with positive feedback from participants. To evaluate mHealth knowledge at the institution, a survey was completed by 257 UAMS clinicians, researchers, and staff. It revealed that there are opportunities to increase training, communication, and collaboration for digital health implementation. The inclusion of the mobile health working group in the newly formed Institute for Digital Health and Innovation provides a nexus for healthcare providers and researches to facilitate translational research., Competing Interests: The authors have no conflicts of interest to declare., (© The Association for Clinical and Translational Science 2020.)

Background: A frequency dependent subtraction method, SUBTR, is developed to remove maternal and fetal magnetocardiography (mMCG and fMCG) interference from fetal magnetoencephalography (fMEG). But channels close to fetal head cannot be used as references for SUBTR in order to protect fMEG from subtraction and this results in cardiac residual when these channels have important fMCG frequency components. Cardiac residual creates noise in evoked response (ER) which results in poor ER detection., New Method: We developed an enhanced SUBTR algorithm, which we call SUBTR with minimum norm projection operator (SUBTRwMNPO), by employing covariance based minimum norm projection operators (MNPO). mMCG and fMCG signals are extracted from the raw data using MNPO and they are subtracted in the frequency domain from raw data to extract fetal Evoked Response (fER)., Results: When tested on 87 datasets, SUBTRwMNPO is shown to attenuate cardiac interference almost totally resulting in a clean fER signal., Comparison With Existing Methods: Cardiac attenuation with SUBTRwMNPO is either as good as or better than SUBTR. SUBTRwMNPO has higher attenuation rate for the datasets where SUBTR leaves cardiac residual., Conclusions: SUBTRwMNPO is successful in removing cardiac interference regardless of the orientation of fMCG and fMEG signal spaces. It can also be used to remove cardiac interference when there is no prior knowledge of fetal head location., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Objective: Prepregnancy obesity and extensive weight gain can lead to diseases in the offspring later in life. The aim of this study was to evaluate the effect of anthropometric and metabolic factors on the fetal autonomic nervous system (ANS) in uncomplicated pregnancies., Methods: A total of 184 pregnant women in the second or third trimester were included, and for 104 women, maternal insulin sensitivity (ISI) was determined. Fetal heart rate (HR) and heart rate variability (HRV) were determined by magnetic recording. Associations of maternal prepregnancy BMI, weight gain, and ISI with fetal HR and HRV were evaluated by ANCOVA, partial correlation, and mediation analysis., Results: HR was increased and HRV decreased in fetuses of mothers with overweight or obesity in comparison to normal-weight mothers. Fetal HR was negatively correlated with maternal weight gain. Maternal prepregnancy BMI was positively correlated with fetal high frequency and was negatively correlated with low frequency and low/high frequency ratio. Maternal ISI showed a negative correlation with fetal HR., Conclusions: The results show that the fetal ANS is sensitive to alterations of prepregnancy BMI, weight changes, and glucose metabolism. These findings highlight the importance of the intrauterine environment on the developing ANS and the possible programming of obesity., (© 2019 The Authors. Obesity published by Wiley Periodicals, Inc. on behalf of The Obesity Society (TOS).)

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 naïve (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., (© 2019 Japan Society of Obstetrics and Gynecology.)

The levator ani muscles (LAM) are integral to pelvic floor support and injury to this muscle complex has been associated with pelvic floor disorders, but our ability to evaluate their neuromuscular integrity is limited. During pregnancy, gravidas undergo systemic functional and anatomic modifications, including pelvic floor muscular adaptations. Magnetomyography (MMG) is a novel and non-invasive tool to passively measure the magnetic fields generated by depolarization activity of muscles and offers a unique method to evaluate the LAM. We collected serial MMG data in a pregnant woman with singleton gestation. Pregnant woman performed LAM contractions (Kegels) with intervening rest periods. Kegel signals were isolated by using the frequency dependent subtraction (SUBTR) and independent component analysis (ICA) methods. Concurrent body-surface electromyography (EMG) was used to evaluate for accessory-muscle recruitment by placing bipolar electrodes on the perineum, abdomen, and thigh. Amplitude and spectral-related indicators were computed across moderate intensity MMG Kegel epochs: root-mean square (RMS) amplitude, power spectrum density (PSD) and relative PSD (rPSD) in three frequency bands. Indicators were extracted from two pregnancy recordings and one postpartum. Parameters were represented in terms of gestation and postpartum weeks. We observed that postpartum RMS Kegel amplitudes had lower values than seen in pregnancy. Changes in spectral indicators were observed between pregnancy and postpartum.

Introduction: Public awareness of electronic nicotine delivery systems (ENDS) has increased over time, and the perception that ENDS offer a safer alternative to cigarettes may lead some pregnant women to use them to reduce cigarette smoking during pregnancy. No previous studies have used metabolite levels in hair to measure nicotine exposure for ENDS users during pregnancy. We aimed to measure and compare levels of nicotine, cotinine, and tobacco-specific nitrosamines (TSNAs) in hair samples from pregnant women who were current ENDS users, current smokers, and current non-smokers. We also aimed to estimate the association between ENDS use/smoking and smallness for gestational age (SGA)., Methods: We used hair specimens from pregnant women who were dual users (ENDS and cigarettes), smokers, and non-smokers from a prospective cohort study to estimate exposure to nicotine, cotinine, and TSNAs. The exposure biomarkers and self-reports of smoking and ENDS use were used in log-binomial regression models to estimate risk ratios (RRs) for SGA among offspring., Results: Nicotine concentrations for pregnant dual users were not significantly different from those for smokers (11.0 and 10.6 ng/mg hair, respectively; p=0.58). Similarly, levels of cotinine, and TSNAs for pregnant dual users were not lower than those for smokers. The RR for SGA was similar for dual users and smokers relative to nonsmokers, (RR=3.5, 95% CI: 0.8-14.8) and (RR=3.3, 95% CI: 0.9-11.6), respectively. Using self-reports confirmed by hair nicotine, the RR values for dual ENDS users and smokers were 8.3 (95% CI: 1.0-69.1) and 7.3 (95% CI:1.0-59.0), respectively., Conclusions: We did not observe lower levels of nicotine, cotinine, and TSNAs for current dual users compared to smokers during pregnancy. The risk of SGA for offspring of pregnant dual users was similar to that for offspring of pregnant smokers. Future studies are needed to further estimate the magnitude of the association between ENDS use and smallness for gestational age., Competing Interests: The authors declare that they have no competing interests, financial or otherwise, related to the current work. U. Ekanem reports grants from Arkansas Department of Health, personal fees from University of Arkansas for Medical Sciences Fay W. Boozman College of Public Health, grants from National Institutes of Health (NIH) - National Center for Research Resources and National Center for Advancing Translational Sciences, during the conduct of the study. The rest of the authors have also completed and submitted an ICMJE form for disclosure of potential conflicts of interest.