Novel uterine contraction monitoring to enable remote, self-administered nonstress testing.

BACKGROUND: The serial fetal monitoring recommended for women with high-risk pregnancies places a substantial burden on the patient, often disproportionately affecting underprivileged and rural populations. A telehealth solution that can empower pregnant women to obtain recommended fetal surveillance from the comfort of their own home has the potential to promote health equity and improve outcomes. We have previously validated a novel, wireless pregnancy monitor that can remotely capture fetal and maternal heart rates. However, such a device must also detect uterine contractions if it is to be used to robustly conduct remote nonstress tests. OBJECTIVE: This study aimed to describe and validate a novel algorithm that uses biopotential and acoustic signals to noninvasively detect uterine contractions via a wireless pregnancy monitor. STUDY DESIGN: A prospective, open-label, 2-center study evaluated simultaneous detection of uterine contractions by the wireless pregnancy monitor and an intrauterine pressure catheter in women carrying singleton pregnancies at ≥32 0/7 weeks' gestation who were in the first stage of labor (ClinicalTrials.gov Identifier: NCT03889405). The study consisted of a training phase and a validation phase. Simultaneous recordings from each device were passively acquired for 30 to 60 minutes. In a subset of the monitoring sessions in the validation phase, tocodynamometry was also deployed. Three maternal-fetal medicine specialists, blinded to the data source, identified and marked contractions in all modalities. The positive agreement and false-positive rates of both the wireless monitor and tocodynamometry were calculated and compared with that of the intrauterine pressure catheter. RESULTS: A total of 118 participants were included, 40 in the training phase and 78 in the validation phase (of which 39 of 78 participants were monitored simultaneously by all 3 devices) at a mean gestational age of 38.6 weeks. In the training phase, the positive agreement for the wireless monitor was 88.4% (1440 of 1692 contractions), with a false-positive rate of 15.3% (260/1700). In the validation phase, using the refined and finalized algorithm, the positive agreement for the wireless pregnancy monitor was 84.8% (2722/3210), with a false-positive rate of 24.8% (897/3619). For the subgroup who were monitored only with the wireless monitor and intrauterine pressure catheter, the positive agreement was 89.0% (1191/1338), with a similar false-positive rate of 25.4% (406/1597). For the subgroup monitored by all 3 devices, the positive agreement for the wireless monitor was significantly better than for tocodynamometry (P<.0001), whereas the false-positive rate was significantly higher (P<.0001). Unlike tocodynamometry, whose positive agreement was significantly reduced in the group with obesity compared with the group with normal weight (P=.024), the positive agreement of the wireless monitor did not vary across the body mass index groups. CONCLUSION: This novel method to noninvasively monitor uterine activity, via a wireless pregnancy monitoring device designed for self-administration at home, was more accurate than the commonly used tocodynamometry and unaffected by body mass index. Together with the previously reported remote fetal heart rate monitoring capabilities, this added ability to detect uterine contractions has created a complete telehealth solution for remote administration of nonstress tests.

Tracking evoked responses to auditory and visual stimuli in fetuses exposed to maternal high-risk conditions.

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.

Validation of Newly Developed Surveys to Evaluate Patients' and Providers' Satisfaction with Telehealth Obstetric Services.

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.

Magnetocardiographic identification of prolonged fetal corrected QT interval in women receiving treatment for opioid use disorder.

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.

Association of State Medicaid Expansion Status With Low Birth Weight and Preterm Birth.

Importance: Low birth weight and preterm birth are associated with adverse consequences including increased risk of infant mortality and chronic health conditions. Black infants are more likely than white infants to be born prematurely, which has been associated with disparities in infant mortality and other chronic conditions. Objective: To evaluate whether Medicaid expansion was associated with changes in rates of low birth weight and preterm birth outcomes, both overall and by race/ethnicity. Design, Setting, and Participants: Using US population-based data from the National Center for Health Statistics Birth Data Files (2011-2016), difference-in-differences (DID) and difference-in-difference-in-differences (DDD) models were estimated using multivariable linear probability regressions to compare birth outcomes among infants in Medicaid expansion states relative to non-Medicaid expansion states and changes in relative disparities among racial/ethnic minorities for singleton live births to women aged 19 years and older. Exposures: State Medicaid expansion status and racial/ethnic category. Main Outcomes and Measures: Preterm birth (<37 weeks' gestation), very preterm birth (<32 weeks' gestation), low birth weight (<2500 g), and very low birth weight (<1500 g). Results: The final sample of 15 631 174 births (white infants: 8 244 924, black infants: 2 201 658, and Hispanic infants: 3 944 665) came from the District of Columbia and 18 states that expanded Medicaid (n = 8 530 751) and 17 states that did not (n = 7 100 423). In the DID analyses, there were no significant changes in preterm birth in expansion relative to nonexpansion states (preexpansion to postexpansion period, 6.80% to 6.67% [difference: -0.12] vs 7.86% to 7.78% [difference: -0.08]; adjusted DID: 0.00 percentage points [95% CI, -0.14 to 0.15], P = .98), very preterm birth (0.87% to 0.83% [difference: -0.04] vs 1.02% to 1.03% [difference: 0.01]; adjusted DID: -0.02 percentage points [95% CI, -0.05 to 0.02], P = .37), low birth weight (5.41% to 5.36% [difference: -0.05] vs 6.06% to 6.18% [difference: 0.11]; adjusted DID: -0.08 percentage points [95% CI, -0.20 to 0.04], P = .20), or very low birth weight (0.76% to 0.72% [difference: -0.03] vs 0.88% to 0.90% [difference: 0.02]; adjusted DID: -0.03 percentage points [95% CI, -0.06 to 0.01], P = .14). Disparities for black infants relative to white infants in Medicaid expansion states compared with nonexpansion states declined for all 4 outcomes, indicated by a negative DDD coefficient for preterm birth (-0.43 percentage points [95% CI, -0.84 to -0.02], P = .05), very preterm birth (-0.14 percentage points [95% CI, -0.26 to -0.02], P = .03), low birth weight (-0.53 percentage points [95% CI, -0.96 to -0.10], P = .02), and very low birth weight (-0.13 percentage points [95% CI, -0.25 to -0.01], P = .04). There were no changes in relative disparities for Hispanic infants. Conclusions and Relevance: Based on data from 2011-2016, state Medicaid expansion was not significantly associated with differences in rates of low birth weight or preterm birth outcomes overall, although there were significant improvements in relative disparities for black infants compared with white infants in states that expanded Medicaid vs those that did not.

Discrepancy in Insulin Regulation between Gestational Diabetes Mellitus (GDM) Platelets and Placenta.

Earlier findings have identified the requirement of insulin signaling on maturation and the translocation of serotonin (5-HT) transporter, SERT to the plasma membrane of the trophoblast in placenta. Because of the defect on insulin receptor (IR) in the trophoblast of the gestational diabetes mellitus (GDM)-associated placenta, SERT is found entrapped in the cytoplasm of the GDM-trophoblast. SERT is encoded by the same gene expressed in trophoblast and platelets. Additionally, alteration in plasma 5-HT levels and the 5-HT uptake rates are associated with the aggregation rates of platelets. Therefore, here, we investigated a novel hypothesis that GDM-associated defects in platelet IR should change their 5-HT uptake rates, and this should be a leading factor for thrombosis in GDM maternal blood. The maternal blood and the placentas were obtained at the time of cesarean section from the GDM and non-diabetic subjects (n = 6 for each group), and the platelets and trophoblasts were isolated to determine the IR activity, surface level of SERT, and their 5-HT uptake rates.Interestingly, no significant differences were evident in IR tyrosine phosphorylation or the downstream elements, AKT and S6K in platelets and their aggregation rates in both groups. Furthermore, insulin stimulation up-regulated 5-HT uptake rates of GDM-platelets as it does in the control group. However, the phosphorylation of IR and the downstream elements were significantly lower in GDM-trophoblast and showed no response to the insulin stimulation while they showed 4-fold increase to insulin stimulation in control group. Similarly, the 5-HT uptake rates of GDM-trophoblast and the SERT expression on their surface were severalfold lower compared with control subjects. IR is expressed in all tissues, but it is not known if diabetes affects IR in all tissues equally. Here, for the first time, our findings with clinical samples show that in GDM-associated defect on IR is tissue type-dependent. While IR is impaired in GDM-placenta, it is unaffected in GDM-platelet.

Fetal magnetocardiography using optically pumped magnetometers: a more adaptable and less expensive alternative?

Fetal magnetocardiography provides the requisite precision for diagnostic measurement of electrophysiological events in the fetal heart. Despite its significant benefits, this technique with current cryogenic based sensors has been limited to few centers, due to high cost of maintenance. In this study, we show that a less expensive non-cryogenic alternative, optically pumped magnetometers, can provide similar electrophysiological and quantitative characteristics when subjected to direct comparison with the current technology. Further research can potentially increase its clinical use for fetal magnetocardiography. © 2016 John Wiley & Sons, Ltd.

Teleultrasound: How Accurate Are We?

OBJECTIVES: Ultrasound serves an important role in the prenatal diagnosis of fetal structural anomalies. Recently, there has been increased use of teleultrasound protocols. We aimed to evaluate the sensitivity and accuracy of teleultrasound. METHODS: We conducted an Institutional Review Board-approved retrospective cohort study determining the sensitivity and accuracy of teleultrasound. In addition, we evaluated the number of ultrasound examinations required to complete an anatomic survey. Only ultrasound examinations performed for anatomic surveys were included. Studies were excluded if performed before 16 completed weeks' gestation, if they had multiple gestations, or for reasons other than anatomy (eg, Doppler studies and fluid assessment). Prenatal diagnoses were compared with postnatal diagnoses obtained from a robust mandatory birth defects surveillance program that records all birth defects in the entire state, from deliveries before 20 weeks' gestation through infants up to 2 years of age. RESULTS: A total of 2499 studies were evaluated; 2368 were included. The teleultrasound cohort had a congenital anomaly prevalence of 5.66%. The sensitivity of teleultrasound was 57.46%; the specificity was 98.21%; and the accuracy was 95.9%. Anatomic surveys were completed after 1 visit in 82% of patients, whereas 63% and 61% of the remaining patients required 2 and 3 visits, respectively. CONCLUSIONS: Teleultrasound for prenatal diagnosis has similar sensitivity and accuracy as the published literature for on-site ultrasound. Further studies are needed to compare the sensitivity and accuracy within the same population and further validate this potentially cost-saving modality.

GDM-associated insulin deficiency hinders the dissociation of SERT from ERp44 and down-regulates placental 5-HT uptake.

Serotonin (5-HT) transporter (SERT) regulates the level of 5-HT in placenta. Initially, we found that in gestational diabetes mellitus (GDM), whereas free plasma 5-HT levels were elevated, the 5-HT uptake rates of trophoblast were significantly down-regulated, due to impairment in the translocation of SERT molecules to the cell surface. We sought to determine the factors mediating the down-regulation of SERT in GDM trophoblast. We previously reported that an endoplasmic reticulum chaperone, ERp44, binds to Cys200 and Cys209 residues of SERT to build a disulfide bond. Following this posttranslational modification, before trafficking to the plasma membrane, SERT must be dissociated from ERp44; and this process is facilitated by insulin signaling and reversed by the insulin receptor blocker AGL2263. However, the GDM-associated defect in insulin signaling hampers the dissociation of ERp44 from SERT. Furthermore, whereas ERp44 constitutively occupies Cys200/Cys209 residues, one of the SERT glycosylation sites, Asp208 located between the two Cys residues, cannot undergo proper glycosylation, which plays an important role in the uptake efficiency of SERT. Herein, we show that the decrease in 5-HT uptake rates of GDM trophoblast is the consequence of defective insulin signaling, which entraps SERT with ERp44 and impairs its glycosylation. In this regard, restoring the normal expression of SERT on the trophoblast surface may represent a novel approach to alleviating some GDM-associated complications.

Sustaining and Expanding Telehealth: A Survey of Business Models from Selected Prominent U.S. Telehealth Centers.

INTRODUCTION: Telehealth centers across the country, including our own center, are addressing sustainability and best practice business models. We undertook this survey to explore the business models being used at other established telehealth centers. In the literature on telehealth and sustainability, there is a paucity of comparative studies as to how successful telehealth centers function. METHODS: In this study, we compared the business models of 10 successful telehealth centers. We conducted the study by interviewing key individuals at the centers, either through teleconference or telephone. RESULTS: We found that there are five general approaches to sustaining a telehealth center: grants, telehealth network membership fees, income from providing clinical services, per encounter charges, and operating as a cost center. We also found that most centers use more than one approach. CONCLUSION: We concluded that, although the first four approaches can contribute to the success of a center, telehealth centers are and should remain cost centers for their respective institutions.

Exploring Implementation of m-Health Monitoring in Postpartum Women with Hypertension.

BACKGROUND: Preeclampsia is a hypertensive disorder in pregnancy where a patients' blood pressure and warning signs of worsening disease need to be closely monitored during pregnancy and the postpartum period. INTRODUCTION: No studies have examined remote patient monitoring using mobile health (m-health) technologies in obstetrical care for women with preeclampsia during the postpartum period. Remote monitoring and m-health technologies can expand healthcare coverage to the patient's home. This may be especially beneficial to patients with chronic conditions who live far from a healthcare facility. MATERIALS AND METHODS: The study was designed to identify and examine the potential factors that influenced use of m-health technology and adherence to monitoring symptoms related to preeclampsia in postpartum women. A sample of 50 women enrolled into the study. Two participants were excluded, leaving a total sample size of 48 women. Users were given m-health devices to monitor blood pressure, weight, pulse, and oxygen saturation over a 2-week period. Nonusers did not receive equipment. The nurse call center monitored device readings and contacted participants as needed. Both groups completed a baseline and follow-up survey. RESULTS: Women who elected to use the m-health technology on average had lower levels of perceived technology barriers, higher facilitating condition scores, and higher levels of perceived benefits of the technology compared with nonusers. Additionally, among users, there was no statistical difference between full and partial users at follow-up related to perceived ease of use, perceived satisfaction, or perceived benefits. DISCUSSION: This study provided a basis for restructuring the management of care for postpartum women with hypertensive disorders through the use of m-health technology. CONCLUSION: Mobile health technology may be beneficial during pregnancy and the postpartum period for women with preeclampsia to closely manage and monitor their blood pressure and warning signs of worsening disease.

Childhood Respiratory Morbidity after Late Preterm and Early Term Delivery: a Study of Medicaid Patients in South Carolina.

BACKGROUND: There is a growing body of research documenting an increased risk of neonatal morbidity for late preterm infants (LPI, 34(0/7) weeks to 36(6/7) weeks) and early term infants (ETI, 37(0/7) weeks to 38(6/7) weeks) compared with term infants (TI, 39(0/7) to 41(6/7) ); however, there has been little research on outcomes beyond the first year of life. In this study, we examined respiratory outcomes of LPI and ETI in early childhood. METHODS: South Carolina Medicaid claims data for maternal delivery and infant birth hospitalisations were linked to vital records data for the years 2000 through 2003. Medicaid claims for all infants were then followed until their fifth birthday or until a break in their eligibility. Infants born between 34(0/7) and 41(6/7) weeks were eligible. Infants with congenital anomaly, birthweight below 500 g or above 6000 g, and multiple births were excluded. We fit Cox proportional hazard models from which adjusted hazard ratio (HR) and 95% confidence interval (CI) were derived. RESULTS: A total of 3476 LPI, 12 398 ETI, and 25 975 term infants were included. Both LPI and ETI were associated with an increased risk for asthma (LPI: HR 1.24, 95% CI 1.10, 1.40; ETI: HR 1.12, 95% CI 1.06, 1.19), and bronchitis (LPI: HR 1.15, 95% CI 1.00, 1.34; ETI: HR 1.13, 95% CI 1.05, 1.2) at 3 to 5 years of age. CONCLUSIONS: Late preterm infants and early term infants are at increased risk for asthma and bronchitis.

Comparing the performance of a new disposable pneumatic tocodynamometer with a standard tocodynamometer.

INTRODUCTION: The goal was to test a newly developed pneumatic tocodynamometer (pTOCO) that is disposable and lightweight, and evaluate its equivalence to the standard strain gauge-based tocodynamometer (TOCO). MATERIAL AND METHODS: The equivalence between the devices was determined by both mechanical testing and recording of contractile events on women. The data were recorded simultaneously from a pTOCO prototype and standard TOCO that were in place on women who were undergoing routine contraction monitoring in the Labor and Delivery unit at the University of Arkansas for Medical Sciences. In this prospective equivalence study, the output from 31 recordings on 28 pregnant women that had 171 measureable contractions simultaneously in both types of TOCO were analyzed. The traces were scored for contraction start, peak and end times, and the duration of the event was computed from these times. RESULTS: The response curve to loaded weights and applied pressure were similar for both devices, indicating their mechanical equivalence. The paired differences in times and duration between devices were subjected to mixed-models analysis to test the pTOCO for equivalence with standard TOCOs using the two-one-sided tests procedure. The event times and duration analyzed simultaneously from both TOCO types were all found to be significantly equivalent to within ±10 s (all p-values ≤0.0001). CONCLUSION: pTOCO is equivalent to the standard TOCO in the detection of the timing and duration of uterine contractions. pTOCO would provide a lightweight, disposable alternative to commercially available standard TOCOs.

Mobilizing a Statewide Network to Provide Ebola Education and Support.

BACKGROUND: Healthcare providers require the latest information and procedures when a public health emergency arises. During the fall of 2014, when the Ebola virus was first identified in a patient in the United States, education about Ebola virus disease (EVD) and procedures for its identification and control needed widespread and immediate dissemination to healthcare providers. In addition, there was a need to allay fears and reassure the public and providers that a process was in place to manage Ebola should it arrive in Arkansas. The state health department engaged multiple interest groups and provided a variety of educational and management activities. The Arkansas Department of Health and the only academic medical center in the state began offering time-consuming, one-on-one education over the phone, which reached too few providers. A solution was needed to educate many providers across the state in the protocols for identification, isolation, and management of patients with EVD. In response, the Arkansas Department of Health and the University of Arkansas for Medical Sciences leveraged the interactive video and Webinar capabilities of the state's telemedicine network to educate both providers and the public of this public health emergency. MATERIALS AND METHODS: Six interactive video events were staged over 5 days in October 2014. RESULTS: In six events, 82 individual healthcare facilities (67 of which were hospitals) and 378 providers attended via the Webinar option, whereas 323 healthcare professionals received continuing education credits. CONCLUSIONS: A statewide videoconferencing infrastructure can be successfully mobilized to provide timely public health education and communication to healthcare providers and the public in multiple disciplines and practice settings.

Application of a Telecolposcopy Program in Rural Settings.

BACKGROUND: Individuals in rural areas are often restricted by the amount of physicians' availability, thus limiting access to healthcare in those settings. INTRODUCTION: While Pap smear screening has increased across the United States, the rural South still reports high rates of cervical cancer and mortality. One solution to improve patient outcomes related to cervical cancer in rural settings is telecolposcopy. MATERIALS AND METHODS: Women with abnormal Pap results or an abnormal visual examination needing an evaluation by colposcopy were referred to a hospital-based telecolposcopy program. Descriptive data are provided that include patients' access to care based on travel time and transportation costs. RESULTS: Over a 15-month time period, 940 unique patients were seen using telecolposcopy. Telecolposcopy was done at eight spoke sites across Arkansas representing patients from 72 of the 75 counties. Data for risk factors that include smoking, first sexual experience, and number of sexual partners in past 12 months and in a lifetime are discussed. Pap results and impression are provided. In addition, avoided transportation costs and travel time have been calculated and included. DISCUSSION: Cervical cancer is important public health concern especially for women residing in rural areas. We were able to demonstrate that our telecolposcopy program has provided sustainability statewide since its inception and that patients are willing to participate. In addition to providing increased access to care, the program also reduced travel time and costs associated with a face-to-face visit. CONCLUSION: Telecolposcopy should be further explored and utilized in rural settings as a way to reduce patient costs and improve cervical cancer outcomes.

Optimizing appointment template and number of staff of an OB/GYN clinic--micro and macro simulation analyses.

BACKGROUND: The Department of Obstetrics and Gynecology (OB/GYN) at the University of Arkansas for Medical Sciences (UAMS) tested various, new system-restructuring ideas such as varying number of different types of nurses to reduce patient wait times for its outpatient clinic, often with little or no effect on waiting time. Witnessing little progress despite these time-intensive interventions, we sought an alternative way to intervene the clinic without affecting the normal clinic operations. AIM: The aim is to identify the optimal (1) time duration between appointments and (2) number of nurses to reduce wait time of patients in the clinic. METHODS: We developed a discrete-event computer simulation model for the OB/GYN clinic. By using the patient tracker (PT) data, appropriate probability distributions of service times of staff were fitted to model different variability in staff service times. These distributions were used to fine-tune the simulation model. We then validated the model by comparing the simulated wait times with the actual wait times calculated from the PT data. The validated model was then used to carry out "what-if" analyses. RESULTS: The best scenario yielded 16 min between morning appointments, 19 min between afternoon appointments, and addition of one medical assistant. Besides removing all peak wait times and bottlenecks around noon and late in the afternoon, the best scenario yielded 39.84 % (p<.001), 30.31 % (p<.001), and 15.12 % (p<.001) improvement in patients' average wait times for providers in the exam rooms, average total wait time at various locations and average total spent time in the clinic, respectively. This is achieved without any compromise in the utilization of the staff and in serving all patients by 5 pm. CONCLUSIONS: A discrete-event simulation model is developed, validated, and used to carry out "what-if" scenarios to identify the optimal time between appointments and number of nurses. Using the model, we achieved a significant improvement in wait time of patients in the clinic, which the clinic management initially had difficulty achieving through manual interventions. The model provides a tool for the clinic management to test new ideas to improve the performance of other UAMS OB/GYN clinics.

Maternal pregravid obesity changes gene expression profiles toward greater inflammation and reduced insulin sensitivity in umbilical cord.

BACKGROUND: Maternal obesity is associated with unfavorable outcomes, which may be reflected in the as yet undiscovered gene expression profiles of the umbilical cord (UC). METHODS: UCs from 12 lean (pregravid BMI < 24.9) and 10 overweight/obese (pregravid BMI ≥ 25) women without gestational diabetes were collected for gene expression analysis using Human Primeview microarrays. Metabolic parameters were assayed in mother's plasma and cord blood. RESULTS: Although offspring birth weight and adiposity (at 2 wk) did not differ between groups, expression of 232 transcripts was affected in UC from overweight/obese compared with those of lean mothers. Gene-set enrichment analysis revealed an upregulation of genes related to metabolism, stimulus and defense response, and inhibitory to insulin signaling in the overweight/obese group. We confirmed that EGR1, periostin, and FOSB mRNA expression was induced in UCs from overweight/obese mothers, while endothelin receptor B, KLF10, PEG3, and EGLN3 expression was decreased. Messenger RNA expression of EGR1, FOSB, MEST, and SOCS1 were positively correlated (P < 0.05) with mother's first-trimester body fat mass (%). CONCLUSION: Our data suggest a positive association between maternal obesity and changes in UC gene expression profiles favoring inflammation and insulin resistance, potentially predisposing infants to develop metabolic dysfunction later on in life.

Assessing uterine electrophysiology prior to elective term induction of labor.

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.