Echocardiogram utilization among rural and urban veterans

The Application of Point of Care Ultrasound to Screen for Pulmonary Hypertension: A Narrative Review

BACKGROUND

Pulmonary Hypertension (PH) is a condition with several cardiopulmonary etiologies that has the potential of progressing to right heart failure without proper intervention. After a history, physical exam, and investigations, cases of suspected PH typically undergo imaging via a transthoracic echocardiogram (TTE). This is a resource-intensive procedure that is less accessible in remote communities. However, point of care ultrasound (POCUS), a portable ultrasound administered at the bedside, has potential to aid in the diagnostic process of PH.

METHODS

The MEDLINE, Embase, and CENTRAL databases were searched to screen the intersection of POCUS and PH. Studies involved adult patients, and only English articles were accepted. Reviews, case reports, unfinished research, and conference abstracts were excluded. Our aim was to identify primary studies that correlated POCUS scan results and additional clinical findings related to PH.

RESULTS

Nine studies were included after our search. In these studies, POCUS was effective in identifying dilatation of inferior vena cava (IVC); internal jugular vein (IJV); and hepatic, portal, and intrarenal veins in patients with PH. The presence of pericardial effusion, pleural effusion, or b-lines on POCUS are also associated with PH.

CONCLUSIONS

This review suggests important potential for the use of POCUS in the initial screening of PH. IVC and basic cardiopulmonary POCUS exams are key for PH screening in patients with dyspnea. Right-heart dilatation can be visualized, and peripheral veins may be scanned based on clinical suspicion. POCUS offers screening as an extension of a physical exam, with direct visualization of cardiac morphology. However, more studies are required to develop a statistically validated POCUS exam for PH diagnosis. More studies should also be conducted at the primary-care level to evaluate the value of screening using POCUS for PH in less-differentiated patients.

The Influence of the Degree of Rurality on EMR Adoption, by Physician Specialty

OBJECTIVE

To explore the influence of varying degrees of remoteness on practice-level electronic medical record (EMR) adoption, including whether the effect differs across practice specialty.

DATA SOURCES

Survey data on over 270,000 office-based physician practices (representing over 1,250,000 providers) collected by SK&A information services during 2012.

STUDY DESIGN

This study examined differences in EMR adoption by practices located across the nine-category rural-urban continuum. Logistic regressions and associated marginal effects are used to assess how much a move up or down the rural-urban continuum code impacts the likelihood of EMR adoption, after controlling for characteristics likely to affect EMR adoption such as practice size and specialty.

PRINCIPAL FINDINGS

Overall practice-level EMR adoption rates generally increase with the degree of rurality and range from 47 percent in the most urban counties to over 60 percent in the most rural. Moving from the most urban county to the most rural corresponded to a 7 percent increase in the likelihood of EMR adoption (p < .01).

CONCLUSIONS

EMR adoption rates do vary significantly across nonmetropolitan counties, and they generally increase as a practice becomes more rural. From a policy perspective, this suggests that urban practices may in fact be the lowest hanging remaining fruit for increasing EMR adoption rates.

Lifesaving pericardiocentesis due to purulent pericarditis with growth of Gram-negative rods in an immune-competent Inuit male

Polymicrobial Gram-negative pericarditis is a rare entity in the immune-competent patient, and purulent pericarditis due to bacteria complicated by tamponade is a life-threatening condition with high mortality rates. A prompt diagnosis and treatment is, as in this case, lifesaving and facilitated by echocardiography but is not the case in rural areas in common. Change in the infectious aetiology indicates broad-spectrum antibiotics. We describe a case of purulent pericarditis causing cardiac tamponade due to haematogenous spread of Escherichia coli (E. coli) and Proteus species in an immune-competent Inuit male treated with pericardiocentesis.

Promoting heart health in rural women

PURPOSE

To compare 2 strategies, stage-matched nursing and community intervention (SMN+CI) and community intervention (CI) alone in changing cardiovascular risk factors in up to 3 behavioral areas: diet, physical activity, and/or smoking among rural women.

METHODS

A 14-month, multisite randomized controlled trial of 117 rural women was conducted. Transtheoretical model was used in identification of stage of change and development of the SMN+CI nursing interventions. A social-ecological model was used to address issues of rurality in the development of interventions.

FINDINGS

The SMN + CI group was superior on 4 outcomes. There were significant increases in 2 measures of dietary intake; improvement in dietary stage of change for fruits and vegetables; and reduced diastolic blood pressure (DBP) in the SMN + CI group. After log transformation DBP significance was lost. The CI group had a significant reduction in change in total cholesterol; however, significance was lost after control for the initiation of lipid lowering medications. There was a significant reduction in Framingham risk scores pre- to postintervention, regardless of group.

CONCLUSIONS

There continues to be a need to improve cardiovascular risk factors in rural women. There should be an exploration of whether intensified dose and fidelity of the intervention strategies of diet and physical activity are effective in improving anthropometric and laboratory values. Further investigation is warranted into factors influencing the pre- to postreduction in Framingham risk scores.