Background The rising overuse of thyroid ultrasound (TUS) without clear clinical indications contributes to overdiagnosis and escalating healthcare costs. Objective This study assessed the prevalence of unwarranted TUS orders by primary care providers (PCPs) within a healthcare network, focusing on deviations from established clinical guidelines. Design A retrospective analysis reviewed 1000 randomly sampled medical charts of patients (18-65 years) who received a PCP-ordered TUS between 2018-2020. The cohort was predominantly female (77.70%) and White (91%), with a median age of 50 years. Main Measures TUS orders were classified as justified or unjustified based on AACE/ACE/AME guidelines. Subsequent diagnostic procedures and direct patient costs of unnecessary ultrasounds were analyzed. Key Results A significant 31.3% of TUSs were deemed unjustified. Common reasons included hypothyroidism (52.08%), dysphagia (12.46%), and nonspecific diagnosis (11.82%). Diagnosis codes often misrepresented true TUS reasons in 42.9% of charts. Patients with justified TUS indications were significantly more likely to undergo further workup (49.9% vs. 26.5%, p < 0.0001). Unjustified ultrasounds did not yield thyroid cancer diagnoses or explain symptoms like dysphagia, but 25% led to a chain of further TUS. Unnecessary ultrasounds generated over $80,000 in direct patient costs, indicating a substantial economic burden. Conclusions A considerable proportion of TUS orders by PCPs lack guideline support, resulting in wasteful healthcare utilization and significant financial impact. Urgent adherence to optimal TUS indication criteria is crucial to optimize resource allocation and minimize potential patient harm from unnecessary procedures.
The “Blueberry-on-Top” phenomenon is a novel echocardiographic strain pattern that has been recently described in patients with apical variant hypertrophic cardiomyopathy (ApHCM). It is identified when there is impaired global longitudinal strain (GLS) with paradoxically advanced time to peak strain (TPS) in a hypertrophied apex with relative sparing of the basal segments. On a standard polar map, GLS will have a pale center while TPS will depict a more robust blue center. While the “Blueberry-on-Top” pattern has been observed in a few prior reports, its true prevalence in patients with ApHCM is currently unknown. We sought to examine the prevalence of this strain pattern among patients with ApHCM. A series of patients diagnosed with ApHCM by cardiac MRI were included and compared to a series of normal controls. All patients underwent a standard transthoracic echocardiogram (TTE). For uniform reporting, all echocardiogram studies were post-processed using Tomtec, which is a vendor-independent speckle tracking analysis software. From a cohort of 340 patients with HCM, a total of 15 patients with ApHCM were identified and subsequently compared to 15 normal controls. The “Blueberry-on-Top” pattern was observed in 93% ( n = 14) of patients with ApHCM, while none of the normal controls had a “Blueberry-on-Top” pattern. We identified a GLS ratio threshold of 1.26 and a normalized time to peak strain (NTPS) ratio threshold of 0.09. When both thresholds are met, the “Blueberry-on-Top” phenomenon has nearly 100% sensitivity and 93% specificity for the diagnosis of ApHCM. We suggest using these parameters as an adjunctive tool for making the clinical diagnosis of ApHCM and integrating them into a more comprehensive approach. The newly recognized “Blueberry-on-Top” strain pattern is unique and can be used as a supportive diagnostic feature in ApHCM.
Introduction Transgender individuals face potential cardiovascular risk from adverse effects of hormone replacement therapy, yet heart failure (HF) outcomes in this population remain poorly understood, particularly regarding geographic disparities in care. Hypothesis Transgender patients hospitalized for HF experience worse outcomes in urban hospitals compared to rural hospitals. Methods Using ICD-10 codes from the National Inpatient Sample (2016-2020), we identified HF hospitalizations among transgender adults (>18 years), stratified by urban and rural hospital locations. Multivariate logistic regression adjusted for baseline characteristics, comorbidities, and sample sizes. Outcomes were compared using descriptive statistics, T-tests, and Chi-square tests (p < 0.05). Results Among 4,550 transgender HF patients, 3,355 (73.7%) were hospitalized in urban settings. Urban patients were younger (58 vs. 62 years, p = 0.0013) and more racially diverse, while rural patients were predominantly white (92.3%). Urban hospitalizations were associated with significantly higher total charges ($87,862 vs. $25,648, p < 0.0001) and longer stays (6.78 vs. 4.15 days, p < 0.0001). Mortality was higher in urban hospitals (3.43% vs. 0%), as well as increased rates of sepsis (11.6%), cardiogenic shock (3.7%), myocardial infarction (7.8%), and stroke (10.6%), though some comparisons lacked statistical significance. Conclusions Transgender HF patients in urban hospitals experience worse outcomes, likely due to systemic healthcare disparities, resource strain, and differences in healthcare-seeking behavior. The predominantly white transgender population in rural hospitals showed better outcomes, though potential underreporting and misclassification may contribute to these findings. Notably, urban settings had a significant proportion of non-white transgender patients, and the worse urban outcomes may suggest additional barriers, including implicit bias and socioeconomic challenges. To achieve equity, it is crucial to expand culturally competent, gender-affirming care and enhance healthcare accessibility in both rural and urban areas. Further research is crucial to unravel the effects of race, geography, and healthcare access, enabling the development of targeted interventions that improve HF outcomes and enhance equity in transgender cardiovascular health.
Introduction People living with HIV (PLWH) have an increased risk of heart failure (HF) due to viral effects on the myocardium and medication toxicity. However, data on HF outcomes in PLWH based on rural versus urban hospitalizations remain limited. Hypothesis People living with HIV hospitalized for heart failure face worse outcomes in urban settings due to healthcare disparities. Methods Using the National Inpatient Sample (2016-2020), HF hospitalizations among PLWH were identified via ICD-10 codes. Patients aged >18 years were categorized into urban and rural hospital groups. Multivariate logistic regression adjusted for baseline characteristics, comorbidities, and sample sizes. Outcomes were compared using descriptive statistics, T-tests, and Chi-square tests (p < 0.05). Results Among 136,395 PLWH hospitalized with HF, 132,125 (96.9%) were in urban hospitals. Urban patients were more likely to be black (64.2%) and male (66.56%), with a mean age of 56 years. Compared to rural hospitalizations, urban cases had higher total charges ($87,530 vs. $40,584, p < 0.0001), longer hospital stays (6.98 vs. 4.93 days, p < 0.0001), and increased rates of acute kidney injury (30.8% vs. 22.8%, p < 0.0001), septic shock (5.1% vs. 2.6%, p = 0.0003), and cardiogenic shock (2.6% vs. 0.94%, p = 0.0008). Mortality was higher in urban hospitals (4.14% vs. 3.05%), though not statistically significant (p = 0.1394). Conclusions PLWH hospitalized with HF in urban settings experience worse inpatient outcomes. Urban hospitals, which serve as safety nets for marginalized populations, often deal with high patient volumes and complex cases, which could lead to delays in care, strained resources, and ultimately worse patient outcomes. In contrast, rural hospitals often struggle with provider shortages, geographic isolation, and stigma, which can result in underdiagnosis or undertreatment of HF in PLWH. While inpatient outcomes may be better, lower hospitalization rates may indicate a delay in seeking care, increasing the risk of adverse events outside the hospital. Addressing these disparities requires strengthening urban hospital resources, expanding rural healthcare access, and tackling social determinants of health. Future research should focus on tailored interventions to ensure equitable access and improved HF outcomes for PLWH across all geographic settings.
Purpose:To analyze the effect of peanut balls for labor support on the nulliparous term singleton vertex (NTSV) cesarean and overall cesarean birth rates in our maternity service.Study Design and Methods:Retrospective analysis of participants from a 30-bed maternity unit discharged between January 1, 2018, and December 31, 2023.Results:Among 4,005 participants, those who used a peanut ball (n = 1,680) during labor were significantly younger, more likely to be nulliparous, and more likely to give birth at term compared to nonpeanut ball users. Multivariable logistic regression showed that peanut ball use was associated with increased odds of vaginal birth (OR = 1.21, 95% CI [1.03, 1.43], p = .0239), after adjusting for age, gestational age, and parity. Age and gestational age were also significant predictors of vaginal birth, whereas race was not.Clinical Implications:Using peanut balls for labor support may support vaginal birth without compromising neonatal outcomes. Education for all members of the maternity team is an important aspect of implementing peanut balls for labor support. Continued implementation and evaluation of peanut ball use, along with other labor support strategies, shows potential for improving vaginal birth rates while maintaining safe neonatal outcomes.
