The introduction of the hospitalist co-management model represents an opportunity to improve care by changing the system as it applies to a small group of patients. Eighty-six consecutive patients with multiple comorbidities were selectively enrolled in an academic medical center hospitalist-orthopedic surgery co-management patient care program. Patients were stratified by all patient refined diagnosis-related groups, severity of illness, and risk of mortality. Hospital length of stay, cost of care, in-hospital mortality, complications, and intensive care unit admissions were compared with a retrospectively constructed control group of 54 patients undergoing similar surgery during the period immediately preceding initiation of the program. The University Health System Consortium observed-to-expected ratio for hospital length of stay was 0.693 compared to 0.862 for the control group. The severity of illness and risk of mortality scores represented a relatively higher risk stratification in the study group. While the overall observed-to-expected cost of care remained virtually unchanged, the positive impact of the study model revealed an increased positive effect on the more severely affected severity of illness and risk of mortality patients. The results of this study suggest that a proactive, cooperative, co-management model for the perioperative management of high-risk patients undergoing complex surgery can improve the quality and efficiency metrics associated with the delivery of service to patients.

II.

Historically, hysterectomy has been the recommended treatment for patients with adenomyosis. However, in the past two decades, various uterine-sparing treatment methods have emerged. These range from excisional techniques such as adenomyomectomy or wedge resection to uterine artery embolization, radiofrequency thermal ablation, hysteroscopic excision, endometrial ablation, and high-intensity focused ultrasound. While largely investigative for the treatment of adenomyosis, these procedures have demonstrated improvement in symptoms including abnormal uterine bleeding, dysmenorrhea, pelvic pain, and overall quality of life. However, long-term data including fertility and obstetric outcomes are needed. Future research is needed to better understand the impact of these uterine-preserving techniques to expand our armamentarium for the treatment of adenomyosis.

Objective Fetuses measuring below the 10th percentile for gestational age may be either constitutionally small for gestational age (SGA) or have pathologic fetal growth restriction (FGR). FGR is associated with adverse outcomes; however, identification of low-risk SGA cases is difficult. We performed a pilot study evaluating maternal markers of pathologic FGR, hypothesizing there are distinct amino acid signatures that might be used for diagnosis and development of new interventions. Study Design This was a cohort study of healthy women with sonographic fetal estimated fetal weight <5th percentile divided into two groups based upon umbilical artery (UmA) Doppler studies or uterine artery (UtA) Doppler studies. We collected maternal blood samples prior to delivery and used ion pair reverse phase liquid chromatography-mass spectrometry or gas chromatography-mass spectrometry to assess 44 amino acids. Results Among 14 women included, five had abnormal UmA, and three had abnormal UtA Doppler results. Those with abnormal UmA showed elevated ornithine. Those with abnormal UtA had lower dimethylglycine, isoleucine, methionine, phenylalanine, and 1-methylhistidine. Conclusion We found several amino acids that might identify pregnancies affected by pathologic FGR. These findings support the feasibility of future larger studies to identify maternal metabolic approaches to accurately stratify risk for small fetuses.

Objective The article aimed to estimate differences in electronic fetal monitoring (EFM) patterns in term gestations attributable to fetal sex. Study Design We conducted a prospective cohort study of consecutive, singleton, nonanomalous, term gestations that labored during admission. EFM characteristics in the 30 minutes prior to delivery were evaluated. Logistic regression models estimated adjusted risks for EFM features by sex. To further estimate the impact of sex, we limited the analysis to gestations without composite morbidity (morbidity defined as arterial cord pH <7.20, 5-minute Apgar <7, or neonatal intensive care unit admission). Results Of 2,639 deliveries, 1,400 (53%) were male. Male fetuses had a higher number of decelerations (median [interquartile range]: 8 [5, 11] vs. 7 [4, 10], p < 0.003) and increased total deceleration area (adjusted odds ratio [aOR]: 1.11, 95% confidence interval [CI] :1.04, 1.18). Male fetuses were at increased risk for prolonged decelerations (aOR: 1.21, 95% CI: 1.03, 1.42) and repetitive variable decelerations (aOR: 1.24, 95% CI: 1.05, 1.47). Among neonates without composite morbidity (n = 2,446, 92.7%), male sex conferred an increased risk of late decelerations (aOR: 1.21, 95% CI: 1.02, 1.43) and increased total deceleration area (aOR: 1.12, 95% CI: 1.05, 1.20). Conclusion There are significant sex differences in EFM patterns at term among pregnancies without evidence of acidemia. This suggests that interpretation of EFM patterns may need to take into account factors such as fetal sex.