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The aim of this study was to investigate sex-related differences in the prenatal development of early oral, lingual, pharyngeal, and laryngeal motor activities. Sonographic images of oral–upper airway regions were observed in 85 healthy fetuses (43 males, 42 females; mean gestational age 24wks 3d [SD 0.69] range 15–38wks). Biometric data on morphologic development and associated motor patterns were compared across second and third trimesters. Results showed that while males and females demonstrated statistically similar patterns of general physical growth (p>0.05), significant differences in development of specific lingual and pharyngeal structures were present (p<0.05). Significant differences were found for laryngeal and pharyngeal motor activity, and oral–lingual movements (p<0.05). Complex oral–motor and upper airway skills emerged earlier in females, suggesting a sex-specific trajectory of motor development. It was concluded that differential patterns of prenatal motor development may be important in defining sex-specific indices of oral skill maturation. [ABSTRACT FROM AUTHOR]

Despite implementing hundreds of strategies, cancer drug development suffers from a 95% failure rate over 30 years, with only 30% of approved cancer drugs extending patient survival beyond 2.5 months. Adding more criteria without eliminating nonessential ones is impractical and may fall into the "survivorship bias" trap. Machine learning (ML) models may enhance efficiency by saving time and cost. Yet, they may not improve success rate without identifying the root causes of failure. We propose a "STAR-guided ML system" (structure-tissue/cell selectivity-activity relationship) to enhance success rate and efficiency by addressing three overlooked interdependent factors: potency/specificity to the on/off-targets determining efficacy in tumors at clinical doses, on/off-target-driven tissue/cell selectivity influencing adverse effects in the normal organs at clinical doses, and optimal clinical doses balancing efficacy/safety as determined by potency/specificity and tissue/cell selectivity. STAR-guided ML models can directly predict clinical dose/efficacy/safety from five features to design/select the best drugs, enhancing success and efficiency of cancer drug development.

In this paper, we propose to advance and transform today's healthcare system using a model of networked health care called Cybercare. Cybercare means "health care in cyberspace" - for example, doctors consulting with patients via videoconferencing across a distributed network; or patients receiving care locally - in neighborhoods, "minute clinics," and homes - using information technologies such as telemedicine, smartphones, and wearable sensors to link to tertiary medical specialists. This model contrasts with traditional health care, in which patients travel (often a great distance) to receive care from providers in a central hospital. The Cybercare model shifts health care provision from hospital to home; from specialist to generalist; and from treatment to prevention. Cybercare employs advanced technology to deliver services efficiently across the distributed network - for example, using telemedicine, wearable sensors and cell phones to link patients to specialists and upload their medical data in near-real time; using information technology (IT) to rapidly detect, track, and contain the spread of a global pandemic; or using cell phones to manage medical care in a disaster situation. Cybercare uses seven "pillars" of technology to provide medical care: genomics; telemedicine; robotics; simulation, including virtual and augmented reality; artificial intelligence (AI), including intelligent agents; the electronic medical record (EMR); and smartphones. All these technologies are evolving and blending. The technologies are integrated functionally because they underlie the Cybercare network, and/or form part of the care for patients using that distributed network. Moving health care provision to a networked, distributed model will save money, improve outcomes, facilitate access, improve security, increase patient and provider satisfaction, and may mitigate the international global burden of disease. In this paper we discuss how Cybercare is being implemented now, and envision its growth by 2030.

The aim of this study was to investigate sex-related differences in the prenatal development of early oral, lingual, pharyngeal, and laryngeal motor activities. Sonographic images of oral-upper airway regions were observed in 85 healthy fetuses (43 males, 42 females; mean gestational age 24wks 3d [SD 0.69]; range 15-38wks). Biometric data on morphologic development and associated motor patterns were compared across second and third trimesters. Results showed that while males and females demonstrated statistically similar patterns of general physical growth (p>0.05), significant differences in development of specific lingual and pharyngeal structures were present (p<0.05). Significant differences were found for laryngeal and pharyngeal motor activity, and oral-lingual movements (p<0.05). Complex oral-motor and upper airway skills emerged earlier in females, suggesting a sex-specific trajectory of motor development. It was concluded that differential patterns of prenatal motor development may be important in defining sex-specific indices of oral skill maturation.

Objective: To determine if serum vascular endothelial growth factor (VEGF) and ultrasonic monitoring of vascular dynamics with dynamic vascular analysis at sea level and high altitude correlate with acute mountain sickness symptoms., Methods: Nine volunteers participated in a staged ascent from sea level to 4300 m undergoing complete transcranial Doppler studies with dynamic vascular analysis. Serum VEGF levels, Lake Louise scores, Spielberger-1 scores, Subjective Exercise Experiences Scale positive scores, and Symptom Checklist-90 surveys were collected after 24 hours at each altitude., Results: Symptom scores, index of pulsatility, and dynamic flow index differentiated the subjects into 2 distinct groups. Symptomatic subjects had increased VEGF levels at sea level but decreased levels at 4300 m. The dynamic flow index increased in symptomatic subjects at 4300 m compared with the asymptomatic subjects. The mean flow velocity increased in both groups and could not be used to differentiate the subjects., Conclusions: Altered vascular physiology is associated with acute mountain sickness. Increased vascular permeability increases vascular capacitance, with an increase in dynamic flow index to meet these demands. Altered vascular dynamics were associated with high-altitude cerebral edema in 1 subject. Dynamic vascular analysis demonstrated altered vascular pathophysiology associated with acute mountain sickness. Changes in VEGF were meaningful when interpreted with the dynamic vascular analysis findings. These physiological findings may help explain the vascular changes associated with hypocarbic hypoxemia at altitude.

Objective: To describe and analyze delivery notes after a shoulder dystocia drill with a birthing simulator, Methods: A total of 33 residents from 2 university training programs underwent testing on a standardized shoulder dystocia scenario with an obstetric birthing simulator. After the completion of the delivery, each resident was informed of the infant's Apgar scores and birth weight and told that the infant was moving all extremities. The resident was then given a blank progress note and asked to write a delivery note. The notes were evaluated for 15 key components., Results: Seventy-six percent (n = 25) of residents recorded less than 10 of 15 key components of a delivery note after a shoulder dystocia. The majority of residents (91%, 30/33) included the correct order of the maneuvers used during the delivery, but most did not note which shoulder was anterior (18%, 6/33) or how long the head-to-body interval was during delivery (45%, 15/33)., Conclusion: Residents' delivery notes after a shoulder dystocia simulation often lacked critical elements. Training in documentation is needed in residency training. The addition of the delivery note and feedback regarding the note represents a simple innovation in this teaching scenario that may help identify deficiencies in documentation., Level of Evidence: III

Objective: To determine whether a simulation training scenario improves resident competency in the management of shoulder dystocia., Methods: Residents from 2 training programs participated in this study. The residents were block-randomized by year-group to a training session on shoulder dystocia management that used an obstetric birthing simulator or to a control group with no specific training. Trained residents and control subjects were subsequently tested on a standardized shoulder dystocia scenario, and the encounters were digitally recorded. A physician grader from an external institution then graded and rated the resident's performance with a standardized evaluation sheet. Statistical analysis included the Student t test, chi(2), and regression analysis, as appropriate., Results: Trained residents had significantly higher scores in all evaluation categories, including timelines of their interventions, performance of maneuvers, and overall performance. They also performed the delivery in a shorter time than control subjects (61 versus 146 seconds, P =.003)., Conclusion: Training with a simulation-training scenario improved resident performance in the management of shoulder dystocia., Level of Evidence: I

The developing fetal upper aerodigestive system provides the structural support for respiratory and ingestive functions necessary to sustain life at birth. This study investigated prenatal development of upper aerodigestive anatomy and the association of emerging functions as predictors of postnatal feeding skills. Biometric measures of oral, lingual, pharyngeal and laryngeal structures were obtained in fetuses 15-38 weeks gestational age using a four-plane sonographic technique. Accompanying ingestive behaviors were tallied across development. The data from 62 healthy controls were compared to seven cases at risk for postnatal feeding and swallowing dysfunction (Type II Arnold Chiari Malformation, trisomy 18, polyhydramnios, intrauterine growth restriction, Brachmann-de Lange Syndrome). Significant (p<0.001) linear regressions occurred in pharyngeal and lingual growth across gestation while ingestive behavior such as suckling emerged in a sequence of basic to complex movement patterns. Jaw and lip movements progressed from simple mouth opening to repetitive open-close movements important for postnatal suckling. Lingual movements increased in complexity from simple forward thrusting and cupping to anterior-posterior motions necessary for successful suckling at term. Laryngeal movements varied from shallow flutter-like movements along the lumen to more complex and complete adduction-abduction patterns. Fetal swallowing primarily occurred in the presence of concomitant oral-facial stimulatory activity. Significant variations (p<0.01) in the form and function of the ingestive system occurred in comparisons of gestational age-matched controls to at-risk cases. We postulate that prenatal developmental indices of emerging aerodigestive skills may guide postnatal decisions for feeding readiness and, ultimately, advance the care of the premature, medically fragile neonate.

Background: Pregnancy and parasitic infection are globally prevalent conditions that frequently coexist. Most pregnant patients with intestinal parasitic infections may be managed without antiparasitic chemotherapy., Case: Shortly after a visit to her nation of origin, a 22-year-old native of Ethiopia presented during her first trimester with gastrointestinal complaints and worms in her stool, which were identified as Taenia. Microscopic examination of her stool also demonstrated Strongyloides stercoralis larvae, likely the residue of an infection that had occurred several years prior to her presentation. She was treated with appropriate antihelmenthic agents, and her subsequent prenatal course has been uncomplicated., Conclusion: The ability of Strongyloides to sustain an intestinal infection through autoinvasion and to cause serious disease (hyperinfection syndrome) among certain hosts makes it unique among intestinal helminths. In this case, the patient was treated to manage her symptoms and prevent subsequent Strongyloides hyperinfection.

Objective: Our investigation of fetal swallowing has identified potential limitations in the use of color Doppler imaging for detection of amniotic fluid flow and discrimination of respiratory from ingestive activity. The objective of this study was to evaluate an alternative imaging modality, power Doppler sonography, as a technique to enhance detection of amniotic fluid flow in the upper aerodigestive tract., Methods: We applied a standardized 4-axis sonographic examination of upper aerodigestive structures and used power Doppler imaging to document amniotic fluid flow. Normal aerodigestive activities from 62 healthy control subjects were compared with 4 abnormal cases., Results: Our longitudinal experience with 66 subjects showed that a directed evaluation of the fetal upper aerodigestive tract with power Doppler imaging provided a systematic approach for studying the physiologic development of this region in both healthy and at-risk fetuses., Conclusions: A standardized 4-axis examination with power Doppler imaging is a useful adjunct in addressing ingestive and respiratory functions in the developing fetus.

In three healthy gravidas at 38 and 39 weeks gestation, fetal MR spectroscopy was performed with a breath-hold technique by using the following pulse sequences: single voxel point-resolved spectroscopy, or PRESS, for liver and heart studies and stimulated-echo acquisition mode, or STEAM, for brain studies. Signal peaks of lipid from heart and liver were detected, as were the signal peaks of choline, creatine, and N-acetylaspartate from fetal brain. Findings demonstrated the feasibility of performing proton MR spectroscopy to assess mobile fetal structures.

Advanced wearable biosensors for vital-signs monitoring (physiologic cipher) are available to improve quality of healthcare in hospital, nursing home, and remote environments. The objective of this study was to determine reliability of vital-signs monitoring systems in extreme environments. Three climbers were monitored 24 hours while climbing through Khumbu Icefall. Data were transmitted to Everest Base Camp (elevation 17,800 feet) and retransmitted to Yale University via telemedicine. Main outcome measures (location, heart rate, skin temperature, core body temperature, and activity level) all correlated through time-stamped identification. Two of three location devices functioned 100% of the time, and one device failed after initial acquisition of location 75% of the time. Vital-signs monitors functioned from 95%-100% of the time, with the exception of one climber whose heart-rate monitor functioned 78% of the time. Due to architecture of automatic polling and data acquisition of biosensors, no climber was ever without a full set of data for more than 25 minutes. Climbers were monitored continuously in real-time from Mount Everest to Yale University for more than 45 minutes. Heart rate varied from 76 to 164 beats per minute, skin temperature varied from 5 to 10 degrees C, and core body temperature varied only 1-3 degrees C. No direct correlation was observed among heart rate, activity level, and body temperature, though numerous periods suggested intense and arduous activity. Field testing in the extreme environment of Mount Everest demonstrated an ability to track in real time both vital signs and position of climbers. However, these systems must be more reliable and robust. As technology transitions to commercial products, benefits of remote monitoring will become available for routine healthcare purposes.

Background: Proton magnetic resonance spectroscopy is a noninvasive technique that detects molecules within a specified region in vivo. Lecithin, the major component of surfactant, has a characteristic magnetic resonance signal, but to our knowledge, it has never been reported in fetal lung or amniotic fluid (AF). The objective of this study was to characterize the lecithin signal in utero, which could lead to a noninvasive fetal lung maturity test., Method: Human fetal lung and AF pockets can be identified and studied with magnetic resonance spectroscopy with the use of a 1.5-tesla Vision whole-body magnetic resonance scanner (Siemens Medical Systems; Erlangen, Germany). Spectroscopy data are collected with a single-voxel-point-resolved spectroscopy sequence. After identification of fetal anatomy with the use of scout magnetic resonance images, magnetic resonance spectroscopy of human fetal lung and AF identifies a lecithin peak., Experience: Three healthy gravidas near term were studied and lecithin peaks were identified in all., Conclusion: Lecithin can be identified in vivo with the use of volume-selected proton magnetic resonance spectroscopy. Patient comfort and extremely short scan times suggest that refined magnetic resonance spectroscopy might be a safe, quick, and comfortable test of fetal lung maturity.

Background: By law, elective terminations of pregnancy are not performed in U.S. military institutions. However, in the civilian sector, more than a million abortions are performed each year, some of which are on military beneficiaries. Although complications are relatively rare, patients not uncommonly present for follow-up care to their military installation. We report the case of a patient who presented after a second-trimester elective abortion and was found to have suffered uterine perforation with mesenteric and bowel injury that required bowel resection., Case: An 18-year-old gravida 1 para 0 female presented from an outlying facility 1 week after elective termination at 18 weeks of gestation with complaints of severe abdominal pain, nausea, and vomiting. Exploratory laparotomy for presumed bowel obstruction revealed uterine perforation and bowel devitalization and necrosis, which required small bowel resection. Fetal bones were discovered within the surgical specimen., Conclusion: Morbid, even potentially fatal, complications can occur as a result of pregnancy termination. With second-trimester procedures, perforation can result in injury to abdominal viscera from the perforating instruments or even from sharp fetal bony structures. Military gynecologic surgeons, who are not in abortion practice, must nevertheless be cognizant of the potential for perforation leading to serious visceral injury.

Purpose: We used telemedicine in providing cross-coverage for a clinical cytogenetics laboratory. A genetic teleconsultation system was used to provide expert cross-coverage for a laboratory in a neighboring metropolitan region for a 6 month period while the usual provider of these services was on military reserve duty., Methods: The teleconsultation system was a commercially available Perceptive Scientific Instruments (PSI) workstation. Five hundred thirty-nine cytogenetic cases were performed during the study period in the home laboratory in Baltimore, Maryland., Results: Karyotypes and supporting metaphase spreads were transmitted by modem to the covering director, whereas work sheets and reports were faxed. Physical transfer of data was not necessary, and turn-around-time was not increased., Conclusion: This ability to employ a remote part time director has significant benefits for the laboratory with an absentee director for short or even extended periods of time. We conclude that the use of telemedicine in clinical cytogenetics proved to be an efficient and a cost effective means of providing genetics services to a region during a time of cross-coverage need.

The prenatal determination of fetal lung maturity is currently assessed by chemical analysis of surfactant associated lipids from aminotic fluid obtained by amniocentesis. This is an invasive procedure with rare but occasionally serious morbidity. Magnetic resonance spectroscopy (MRS) is a non-invasive method for the in vivo localization and identification of molecules with known resonance peaks at specified chemical shifts. In this report we examine the in vitro MRS of a lecithin/saline solution as well as term and preterm amniotic fluid samples with the use of a 1.5 T whole body scanner and a flexible surface coil. We found that amniotic fluid at term demonstrates a resonance peak at 3.2 ppm which was the same as the chemical shift of lecithin in saline. The lecithin peak is not observed in preterm amniotic fluid. This demonstrates the feasibility of using MRS with a whole body scanner to detect lecithin, one of the markers for fetal lung maturity.

The proliferation of new imaging technologies is having a profound impact on all surgical specialties. New means of surgical visualization are allowing more surgeries to be performed less invasively. Three-dimensional ultrasound is a technology that has potential as a diagnostic tool, as a presurgical planning simulator, and as an adjunct to image-directed surgery. This article describes how three-dimensional ultrasound is being used by the United States Department of Defense and how it may change the role of the perioperative nurse in the near future.

Converging technologies in the areas of networks, volume visualization algorithms, and computer performance have made possible the development of a new tool for collaboration, which extends the reach of health professionals, and other consumers of volumetric data around the world. TeleInViVo(tm) is a three-dimensional (3D) collaborative volume visualization tool for medical applications. It extends the capabilities of InViVo(tm), a fast volume visualization tool developed at the Fraunhofer IGD, Darmstadt, Germany [1-3], with efficient and intuitive network collaboration features for remote consultation and new modes of interaction. The software runs on both UNIX and Windows NT platforms. TeleInViVo provides a high degree of interactivity for the medical professional when interacting with the patient data, facilitates explanation and communication between field personnel and medical experts located far from the field, and permits viewing of the data in a multitude of ways designed to support rapid and accurate diagnosis. Current efforts involve architectural enhancements to support multiuser, distributed telemedical scenarios. The application includes the following features: Volume and subvolume data transmission at user specified resolution, Synchronization cues, Integration of Immersion Probe(tm), a 6 degree-of-freedom input device, for ergonomic 3D data exploration, Tools for measuring distances, Tools for planning instrument path, Arbitrary cutting planes in real time, Interactive segmentation tools, Virtual video recorder and playback (cine loops), 3D stereo mode. TeleInViVo is an essential part of the MUSTPAC-1 portable 3D ultrasound system developed by Battelle Pacific Northwest Labs, Richland, WA.