Bayfront Medical Center

Rising healthcare costs and an aging population demand innovative approaches to patient safety and operational efficiency. Artificial Intelligence-driven Virtual Observation (AI-VO) offers a scalable, cost-effective alternative to traditional one-to-one patient sitters. By combining real-time video monitoring with machine learning, AI-VO systems enable a single observer to safely monitor multiple high-risk patients—such as those with delirium, dementia, or suicidal ideation—reducing falls and optimizing staff resources. Institutions implementing AI-VO have reported significant benefits, including reduced inpatient falls, improved patient safety, and substantial cost savings. One hospital achieved a 15% fall reduction and projected annual cost avoidance exceeding $2 million. These systems also alleviate nursing strain and support workforce retention, especially amid growing shortages. Challenges remain, including setup costs, integration with electronic health records, cybersecurity, and staff adoption. Success depends on comprehensive training, interdisciplinary collaboration, and cultural change. Looking forward, AI-VO technologies are expanding beyond inpatient care into long-term and home health settings. Features such as predictive analytics, voice recognition, and wearable device integration are enhancing system capabilities. As healthcare shifts toward value-based care, AI-VO stands out as a key innovation—improving safety, reducing costs, and supporting the future of digital, patient-centered healthcare.

Objective: To report and discuss the pregnancy course and delivery of a patient who developed pneumomediastinum as a complication of hyperemesis gravidarum. Background: A significant amount of women experience nausea during pregnancy. Studies show that approximately 27-30% of women experience only nausea, while vomiting may be seen in 28-52% of all pregnancies. Nausea and vomiting during pregnancy may progress to a condition known as hyperemesis gravidarum. Hyperemesis gravidarum is a condition characterized by intractable vomiting during pregnancy, which may lead to weight loss, volume depletion, ketonuria and even ketonemia. There is no consensus on specific diagnostic criteria for hyperemesis gravidarum. It is primarily a clinical diagnosis applied to the most severe cases of nausea and vomiting during pregnancy. It occurs in approximately 2% of all pregnancies in the United States. The exact cause of hyperemesis gravidarum remains unclear. However, there are several theories for what may contribute to the development of this disease process, including higher concentrations of human chorionic gonadotropin and estrogen, lower esophageal sphincter relaxation due to estrogen and progesterone, and genetic predispositions. Case Description: A 28-year-old gravida 1 female presented to the emergency department at 13 weeks and 6 days gestation for intractable nausea and vomiting over the past several days. She had been unaware of her pregnancy until it was confirmed that day. Upon admission to the hospital, she was started on an inpatient regimen which included doxylamine and pyridoxine, ondansetron, prochlorperazine, and sucralfate. After a total of four days of treatment, she was discharged home. Her past medical history was significant for gastroesophageal reflux disease and anxiety. Her past surgical history was significant for a Nissen fundoplication six years prior to presentation. Two weeks after her initial admission, she returned to the emergency room despite having acquired an ondansetron pump and taking prochlorperazine every six hours at home. She was ultimately stabilized in the emergency department with intravenous fluids and doxylamine/pyridoxine and discharged back home. She presented to the emergency room again at 24 weeks, having vomited unremittingly for a full week prior to the visit. Shortly before arriving, she began experiencing chest discomfort that radiated to her back and neck, as well as shortness of breath. Physical exam revealed palpable crepitus in the right subclavicular region and neck. Imaging studies were performed, starting with a chest X-ray that indicated questionable soft tissue gas in the right supraclavicular region. A CT chest confirmed pneumomediastinum extending to the supraclavicular neck regions, particularly surrounding the esophagus and trachea. Subcutaneous emphysema was also observed in the neck and right supraclavicular regions. A CT esophogram reiterated the presence of pneumomediastinum with subcutaneous emphysema. An esophagogastroduoden-oscopy revealed Los Angeles Grade A esophagitis without rupture and chronic gastritis, which was biopsied and showed no malignancy or dysplasia. Once her vomiting was controlled, her neck discomfort subsided within days. At her detailed anatomy ultrasound at 25 weeks gestation, fetal growth restriction (FGR) was diagnosed with an estimated fetal weight (EFW) in the 5th percentile. Umbilical artery dopplers were normal, and no structural abnormalities were noted. Severe FGR was diagnosed on follow-up ultrasound at 29 weeks. By 31 weeks, the EFW had dropped to less than the 1st percentile. Following several visits to obstetrical triage and the emergency department, and multiple admissions for nausea and vomiting, she was induced at 37 weeks due to severe FGR. At this point, she was on the maximum settings of her ondansetron pump. She delivered at 37 weeks and 2 days via vaginal delivery. The newborn weight was 1.81 kilograms (less than the 1st percentile). At the time of induction, maternal weight was 78.8kg, which was 3.2kg less than her weight at the start of her pregnancy. Her postpartum course was uncomplicated and she recovered well. By her six week postpartum visit, she had regained the weight she had lost and her nausea had completely resolved. Discussion: Pneumomediastinum is a rare condition characterized by the presence of air in the mediastinum. Diagnosis is typically confirmed via chest X-ray or CT scan of the thorax, with central chest pain being the most common presenting symptom. Pneumomediastinum can also manifest with subcutaneous emphysema, where air collects beneath the skin, affecting the face, neck, and chest. In this case, the patient presented with concomitant pneumomediastinum and subcutaneous emphysema. Notably, unlike most cases of pneumomediastinum which predominantly involve males (up to 76% of recorded cases), this patient was a pregnant female. Management of pneumomediastinum is largely supportive and targeted towards symptom relief. In this case, the patient’s symptoms resolved following supportive care and aggressive treatment of her nausea and vomiting. Pneumomediastinum resulting from intractable vomiting is rarely seen, especially in pregnancy. Fortunately, it is a condition that typically self-resolves and is an overall benign entity.

Introduction: Fetal sacrococcygeal teratomas (SCGT), the most common fetal neoplasm diagnosed in fetuses, are a rare condition with an estimated incidence of 1 in 40,0000 live births. Fetal SCGT is usually suspected when characteristic findings are seen on ultrasound such as a mass that is cystic and/or solid and is located in the sacral region. MRI may also be used to more accurately characterize the tumor and to help distinguish between SCGTs and distal neural tube defects like sacral meningomyelocele. Despite advances in ultrasound and MRI, only approximately 50% are diagnosed prenatally. The detection of fetal SCGT is important because it changes pregnancy monitoring and management as it is associated with fetal hydrops, intrauterine death, polyhydramnios, mirror syndrome, and mortality rates as high as 43%. Once an SCGT has been identified, serial ultrasound evaluation of the fetus, placenta, and SCGT is important to identify early signs of fetal hydrops, fetal anemia, or cardiac failure and to intervene as appropriate. Case Report: A 40-year-old G5P4004 was referred to Maternal Fetal Medicine (MFM) due to findings of a 1 cm mass near the fetal bladder on first trimester ultrasound. She had a level II ultrasound performed by MFM at 16.2 weeks where a 3.6 x 2.3 x 2.6 cm mass was identified. This mass was adjacent to the sacrococcygeal region. Due to its location and characteristic appearance, with both cystic and solid components with high vascularity, a fetal sacrococcygeal teratoma was suspected. There were no signs of hydrops or fetal anemia. At this time, the recommendation for management was: ultrasounds every 2 weeks to assess for hydrops and fetal anemia, growth ultrasound every 4 weeks, an echocardiogram by pediatric cardiology at 22-24 weeks, a fetal MRI at 28 weeks, and delivery between 37-39 weeks or earlier pending clinical course. At 24.2 weeks, she developed polyhydramnios with a maximum vertical pocket (MVP) of 10.5 cm. She had also failed her 1-hour glucose tolerance test with a value of 287 mg/dL. Due to the new finding of polyhydramnios and diagnosis of gestational diabetes, her monitoring was increased to weekly, with biophysical profile (BPP) starting at 28 weeks and weekly nonstress tests (NST) at 32 weeks. A fetal MRI was performed at 26.4 weeks and showed a large lesion extending off the sacrococcygeal region measuring 9.6 x 6.3 x 7.7 cm that was composed of both solid and cystic components. By 32.2 weeks, she developed severe polyhydramnios with an AFI of 36.0 cm and accelerated fetal growth due to an AC > 99th percentile. The last ultrasound she had at 34.2 weeks the SCGT measured 17.7 x 13.3 x 13.6 cm and severe polyhydramnios persisted. The patient went into preterm labor at 35.2 weeks and had a cesarean section due to known SCGT measuring greater than 5 cm. Immediately after delivery, the neonate was evaluated by the neonatal team and transferred to the Neonatal Intensive Care Unit. The infant had surgical resection of the mass and will have tumor markers, AFP and LDH, monitored for development of recurrent immature or mature teratoma. The pathology report confirmed the diagnosis for benign sacrococcygeal teratoma. Discussion: Failure to diagnose a fetal sacrococcygeal teratoma has potentially catastrophic consequences for the fetus and mother. Maternal complications include hyperemesis, preeclampsia, mirror syndrome, preterm labor, and HELLP syndrome. Significant obstetric complications can be as high as 81%. Intrauterine fetal complications include fetal hydrops from high-output failure, fetal anemia, intratumoral hemorrhage, polyhydramnios, genitourinary obstruction leaking to hydronephrosis and or hydroureter. SCGT size >10 cm or tumor with rapid growth has > 50% perinatal mortality. Tumor characteristics associated with higher mortality rates are early diagnosis, solid components, high vascularity, tumor size > 10 cm, and rapid growth > 150 cm3/week. Another way to risk stratify these patients is by calculating a tumor volume to fetal weight ratio (TFR), which if > 0.12 at < 24 weeks is predictive of an overall poor prognosis. When comparing this case to literature review of sacrococcygeal teratomas, the patient’s fetal SCGT would be classified as high risk of mortality due to the tumor characteristics of early diagnosis, TFR at 20 weeks being 0.16, large size, rapid growth, and pronounced vascularity. Overall, in this high risk case of SCGT, the close follow up and evidence-based management with utilization and collaboration of a multidisciplinary team including Maternal Fetal Medicine, NICU, and Pediatric Surgery in a tertiary center resulted in a successful outcome.

Purpose: To describe the successful management of a rare non-obstetric vulvar hematoma. Background: While vulvar hematomas are common in obstetric cases, vulvar hematomas due to non-obstetric trauma are rare, representing only 0.8% of all gynecological emergencies. The vulva is made primarily of loose connective tissue richly supplied by branches of the pudendal artery, so it is susceptible to injury by multiple different types of trauma. Because non-obstetric vulvar hematomas are so rare, there is no established consensus for management. In this article, we shall present a patient who, after sustaining multiple injuries from a motor vehicle collision, developed a large vulvar hematoma that was successfully treated with surgical evacuation. Case Description: A healthy 26-year-old female presented to the emergency department following a broadside motor vehicle collision. CT with contrast described multiple pelvic fractures as well as a small volume retroperitoneal hemorrhage anterior to the bladder. There was no evidence of bladder injury or other areas of extravasation. On hospital day 1, she underwent uncomplicated open reduction and internal fixation of pelvic and sacral ring fractures. On hospital day 3, the patient began noticing a painful, rapidly expanding labial hematoma, and OBGYN services were consulted. Despite conservative management with ice and analgesics, the patient described the pain as 10 out of 10. On physical exam the right vulva was found to have a 14 cm hematoma expanding down to the perineum and extending to include the labia majora and labia minora. The area was extremely edematous and tender to light palpation. Swelling distorted the anatomy, occluding the vaginal introitus and obscuring the left labia. A Foley catheter was draining clear urine from the bladder. The following morning, the hematoma had continued to expand and Hgb significantly decreased, so the decision was made to proceed with surgical management. Pre-operative antibiotics were given, and the patient was prepped and draped according to hospital protocol. Hart’s line was injected with a marcaine/lidocaine/epinephrine premixed solution for hemostasis. A 3 cm vertical incision was created along Hart’s line, and the space was bluntly entered using a hemostat. Clotted blood was evacuated from the labial space, and active bleeding was ligated with using Vicryl. Once hemostasis was noted, the incision was loosely closed with interrupted stitches placed widely apart to allow for drainage. The vagina and left labia were examined and found to be normal. The right labial space was packed using kerlix, and the patient was prescribed a 7-day course of oral antibiotics. The patient tolerated the procedure well and reported no vulvar pain on post-op day 1. The vulvar packing was removed without incident, and no bleeding was noted from the incision site. The patient was reevaluated by the OBGYN team on post-op day 8 and was healing very well. She reported very little pain and had no issues with spontaneous urination. On physical exam, the hematoma was nontender to palpation and measured approximately 10 x 5 x 2.5 cm with decreased bruising and areas of discoloration. The patient was discharged with no further issues. Despite multiple attempts to schedule an outpatient appointment, the patient was unfortunately lost to follow-up. Discussion: Non-obstetric vulvar hematomas due to non-obstetric trauma are rare, and with improper management, may lead to significant morbidity. However, there is no established consensus for management, and little literature is available for guidance. Some small studies have reported success with conservative management. Benrubi et al, however, observed that conservative management of vulvar hematomas may be associated with longer hospital stays and increased need for antibiotics and blood transfusions10. A recent retrospective analysis also suggests a preference for surgical management, as a significantly reduced mortality rate was observed in patients who underwent surgical intervention for non-obstetric vulvar trauma. The same study found that while the surgical cohort tended to require a slightly longer hospital stay, there were no differences in ICU days, ventilator days, or rates of UTI between cohorts who had undergone surgical management and those who had undergone conservative management1. Arterial embolization has also been described as an alternative to surgical intervention in select patients, but this approach requires equipment and specialized personnel that may not be readily available to all institutions. Some case studies suggest using rate of expansion or hemodynamic instability as indications for surgical management. Size of the hematoma may also be considered as evidence suggests vulvar hematomas with a diameter greater than 4 cm have a higher potential for skin necrosis. Even when surgical management is clearly indicated there is little data regarding an optimal surgical approach. Conclusion: In this article, we discuss the successful surgical management and short-term follow up of a very large non-obstetric vulvar hematoma. We hope that our surgical approach can add to the small pool of literature available on these rare gynecological cases and help guide future research into developing standardized management guidelines.

ABSTRACTRadiofrequency catheter ablation of the cavotricuspid isthmus is a proven therapy for typical atrial flutter (AFl); however, in some patients, new atrial arrhythmias (AA) may occur after AFl ablation. This study explored the difference in the occurrence of spontaneous AA after AFl ablation as a function of the patient's presenting rhythm on the day of the AFl ablation. A retrospective study of consecutive patients who underwent AFl ablation at Baylor University Medical Center at Dallas was performed. A total of 188 subjects were included; 50% (94) presented in AFl (Group AFl) on the day of the ablation procedure and 94 presented in sinus rhythm (SR; Group SR). Group AFl patients were older (P < 0.001), more likely to have diabetes (P = 0.03), and more likely to have undergone previous heart surgery (P = 0.03). The median size of the left atrium was 4 cm (range 2.8–6.8) in Group AFl compared with 3.8 cm (range 2.6–5.6) in Group SR (P = 0.009). Atrial fibrillation was induced during the ablation procedure in 7.5% and 21.3% of patients in Groups AFl and SR, respectively (P = 0.007). Overall, 29 of 188 (15.4%) patients developed new AA within 1 year of the procedure, 13.8% in Group AFl vs 17.0% in Group SR (P = 0.57). In conclusion, patients presenting for AFl ablation in SR were younger and healthier but had more atrial fibrillation induced during their ablation procedure, with a trend toward more postablation AA due to additional arrhythmia substrate.