INTRODUCTION & BACKGROUND: 

The hepatic hilum includes the hepatic arterial supply, portal venous system, and hepatic bile ducts, which all vary in measurements and branching pattern. The complete hepatic vasculature consists of the common hepatic artery (CHA), proper hepatic artery (PHA), right hepatic artery (RHA), left hepatic artery (LHA), cystic artery (CA), and gastroduodenal artery (GDA). The arterial length and diameter have significant implications for liver transplants, liver resections, and hepatobiliary surgeries. In this study, measurements were taken of the entire hepatic arterial vasculature originating from the celiac trunk (CT) to investigate the vessels’ respective diameters and lengths. 

HYPOTHESIS: 

The measurement of variations in the length and diameter of the hepatic vasculature will contribute to existing literature and the associated hepatic clinical implications. 

METHODS: 

Data collection and dissection were performed at Tilman J. Fertitta Family College of Medicine and Baylor College of Medicine. Thirty-six cadaveric samples were dissected at the hilum of the liver along with the surrounding vasculature. The CHA measurement extended from the CT's origin to the bifurcation of the CHA. The PHA was measured beginning at the CHA bifurcation to the point of PHA bifurcation. Measurement of the GDA began at its branch point from the CHA to the Anterior Superior Pancreaticoduodenal Artery. Both the RHA and LHA were measured at the bifurcation origin point to their segmental intrahepatic branching. The CA was measured from its branching point off of the RHA to the termination point on the gallbladder. A vernier caliper was used to measure all vasculatures’ lengths and their respective external diameters. 

RESULTS: 

In thirty-six cadaveric samples, the mean distance between the CT and the CHA was 33.44 mm, with a diameter of 8.88 mm, an increase compared to other studies. The mean length of the PHA was 21.53 mm, with a diameter of 5.98 mm. The LHA measured a mean of 30.39 mm in length and 3.97 mm in diameter, revealing no substantial differences compared to other studies. The RHA had a mean length of 29.65 mm and a mean diameter of 4.76 mm. The GDA averaged 32.33 mm in length and 4.34 mm in diameter. Lastly, the CA had a mean length of 24.01 mm and a diameter of 2.33 mm. 



DISCUSSION/CONCLUSION: 

Understanding these measurements and variations in arterial anatomy can provide specific guidance and enhance safety in surgeries such as liver transplants, which are particularly vulnerable to complications like intraoperative bleeding and necrosis. Moreover, knowledge of the expected values of arterial diameter and length can contribute to hemodynamic data, potentially assisting in the early diagnosis of arterial stenosis. Further, small arterial caliber is known to contribute to hepatic artery thrombosis. Our study's findings give insight into the distances and diameters of hepatic vasculature and its tie to hepatic clinical implications.

Evaluation of Hepatic Arterial Vasculature and the Implications for Hepatic Surgery – A Cadaveric Pilot Study

Background

Takotsubo Cardiomyopathy (TTC), or broken heart
syndrome, was first described in Japan in 1990. It is a
stress-induced cardiomyopathy in which the heart
resembles a Japanese “octopus pot”, or takotsubo.
TTC is characterized by the weakening of the left
ventricle, resulting in ballooning of the heart and left
ventricular apical akinesis, causing symptoms that
mimic acute coronary syndrome (ACS). Patients may
present with myocardial infarction (MI) - like
symptoms, show ST-segment elevation on
electrocardiogram (ECG), and have elevation in
ischemic cardiac enzymes. However, no coronary
artery blockage will be seen. Onset usually follows a
significant stressor, such as the death of a loved one,
coining the term “broken heart syndrome”. It is
hypothesized to be caused by the stunning of the
myocardium via catecholamine release. Treatment
involves ruling out ACS and MI, supportive care, and
follow up with a cardiologist to ensure resolution of
the syndrome. In the rare (<5%) case that a left
ventricular thrombus forms, systemic anticoagulation
is required.

Case Presentation

We present a case of a patient with a history
significant for chronic kidney disease and
hypertension presenting to the emergency
department with one-day history of unchanged acute
onset dyspnea and hypotension. She remarked that
she was “incredibly stressed'' recently. Labs were
significant for leukocytosis, increased troponins, and
lactic acidosis. Her ECG showed T-wave inversions in
the inferior and anterolateral leads.
Echocardiography was significant for findings
suggestive of TTC with an ejection fraction (EF) of 25-
30%. The patient was transferred to the intensive
care unit for cardiogenic shock. Following supportive
treatments, she was optimized based on her TTC,
and was discharged with cardiology follow up.
Currently, she is on goal-directed medical therapy,
wears a life-vest, and continues to have left
ventricular akinesis with an EF of 25-30%.

Discussion

Acute treatments are supportive, but vary based on
level of left ventricular outflow tract obstruction.
Traditional heart failure with reduced ejection
fraction (HFrEF) treatments have limited efficacy for
TTC-induced HFrEF. Some data indicates that TTC is
often underdiagnosed, and the true rate may be
closer to 5.7%. While most cases recover within 2
weeks, there is a significant recurrence rate of up to
4% per year. A consideration for prevention of
recurrence is screening and addressing mental health
comorbidities. It is important to note, that TTC is less
commonly also referred to as “Happy Heart
Syndrome,” so clinicians should be cognizant of TTC
patients presenting with positive symptoms.

A Heart-breaking Case of Takotsubo Presenting to a Community Emergency Department

Background 

Transcranial Magnetic Stimulation (TMS) has consistently demonstrated safety and effectiveness in adults, particularly for treatment-resistant depression (TRD) and its potential application in generalized anxiety disorder (GAD). Although this FDA-approved method has been in use for over a decade, studies on TMS efficacy in geriatric and pediatric populations remain inconclusive. Our research explores TMS efficacy across different age groups to determine if certain populations respond more favorably. 

Methods 

Data was extracted from the Olympia Center for TMS & Psychiatry Electronic Health Record. 288 patients with TRD who completed 36 standard repetitive TMS or theta burst stimulation treatments between 2020 and 2023 were selected. The Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder-7 (GAD-7) scores were used to assess depression and anxiety severity before and after treatments. Patients were categorized into three age groups: ≤21 years (pediatrics), 22–64 years (adults), and ≥65 years (geriatrics). 

In a clinical setting, treatment response was defined as a 50% reduction in PHQ-9 or GAD-7 scores. The percentage of responders in each age group was calculated, and a Chi-square analysis was performed. Treatment efficacy was measured by averaging the initial and final PHQ-9 or GAD-7 scores and conducting a paired t-test for each age group. 

Results 

Out of 288 patients with TRD, 39 were pediatrics, 192 were adults, and 57 were geriatrics. Overall, 74% of participants responded to treatment: 51% of pediatrics, 77% of adults, and 81% of geriatrics (p-value 0.002). Improvement in mean PHQ-9 scores was observed overall and in each age group (p-values < 0.001). Among the 288 patients, 204 had initial GAD-7 scores ≥10, indicating co-existing moderate to severe anxiety. Of these, 26 were pediatrics, 151 were adults, and 27 were geriatrics. Overall, 54% responded to treatment for anxiety: 31% of pediatrics, 58% of adults, and 56% of geriatrics (p-value 0.03). Improvement in mean GAD-7 scores was observed overall and in each age group (p-values < 0.001). 

Conclusion 

TMS treatment produced clinically meaningful changes in depressive and anxiety symptom severity across all age groups. The evidence supports the potential of incorporating TMS as a routine adjunct to pharmacotherapy in treating depression and anxiety. This result is notable given the adverse effects associated with pharmacotherapy, including increased suicide risk with SSRI use in adolescents and polypharmacy among geriatric patients. Limitations of this study include the absence of sham groups for comparison and relatively small sample sizes for certain age demographics, which warrant consideration.

Pulses of Potential: Assessing the Efficacy of Transcranial Magnetic Stimulation Across Age Groups

Background
The obesity paradox has been shown in many cancers, with improved overall survival in higher BMI groups. Lower incidence, better prognosis, and improved treatment response of lung cancer have been associated with increased BMI. However, these differences have varied based on age, gender, and race. This variability can be explained by the heterogeneity of fat deposition across gender and race, which is poorly captured by BMI. Other measures of central adiposity better portray the effects of obesity on lung cancer risk and prognosis. We report the results of another measure of central adiposity, liver fat, on survival and treatment tolerance in NSCLC.
Methods:
This retrospective cohort study enrolled 106 patients with stage IIIA-IIIC NSCLC treated to 60 Gy at Fox Chase Cancer Center. Liver fat percentage was assessed via CT in Hounsfield units (HU). Patients were separated into two groups, high HU and low HU, correlating to low and high liver fat percentages, respectively. The primary objective assessed mortality while secondary objectives assessed treatment response, disease progression, and acute/chronic treatment toxicities.
Results
Initial staging was the only categorical variable with significant difference in HU groups. BMI and primary tumor size varied significantly between groups. Overall survival (OS) and progression-free survival (PFS) appeared to be better in the higher HU group, but not statistically significant. No significant difference in acute or chronic treatment-related adverse events between HU groups.
Conclusion
Liver fat percentage has the potential to be used as a proxy for central adiposity to risk stratify NSCLC patients. Excess adiposity may provide an energy reserve to endure biological stress from disease progression and treatment, leading to a survival advantage. This study showed no statistical significance in OS or PFS between HU groups. One limitation is the small sample size leading to reduced statistical power and difficulty in detecting subgroup effects. Future studies should focus on involving large and diverse cohorts, considering confounding factors like BMI, smoking history, and tumor characteristics. If statistical significance can be measured, liver fat may have the potential to be used as a prognostic marker for outcomes to stratify patients into different risk categories, guiding treatment decisions and improving personalized medicine approaches.

Liver Adiposity as a Predictor of Mortality in NSCLC Patients

Nearly 30% of the population of Guam relies on the local Medicaid program for healthcare coverage. Due to a high prevalence of non-communicable disease, access to affordable chronic care management is crucial to sustaining the island territory’s healthcare system. With nearly $130 million in federal match funding, understanding the spending trends of Guam’s Medicaid program may yield insight to how these funds are being accessed by the patient population. Data was obtained from the Medicaid section of the Medicaid and MIP Expenditure and Demographic End of 4th Quarter Report available on the Guam Department of Health and Human Services Bureau of Health Care Financing Administration web page. A data set was constructed from reports published for fiscal years 2014-2023. Categories for expenditure were titled “Type of Service” on the report and all services provided in the report were included in the data set. Regression analysis was performed to determine average change in expenses over time. Between 2014 and 2023, total expenses increased from $57.9 million to $115.3 million (R2=0.84). 16 out of 24 services had an average increase in expenses. Amongst services, the greatest average increase was observed in Inpatient Hospital services with $6,601,156 (p=0.00005; R2=0.8). The greatest average annual decrease was observed in Dental services with -$897,347 (p=0.003; R2=0.6) Increases in Emergency Room services (p=0.004; R2=0.6), Outpatient Hospital services (p=0.001; R2=0.8), and Home Health services (p=0.02; R2=0.7) were also observed. No statistically significant increase was seen in FQHC with an annual average decrease of -$75,170 (p=0.2; R2=0.1) Although there has been a dramatic increase in total spending by the Guam Medicaid program, there is disparity in how this increase has been distributed across available services. Between 2014 and 2023, there have been increases in spending observed in Hospital services (Inpatient, Outpatient, and Emergency Room) with no increase in spending for primary care services (FQHC) during this time of overall spending growth. Publicly funded Dental services have observed dramatically decreased reimbursement. Information regarding disease prevalence and healthcare infrastructure must be considered to fully contextualize these findings. Local and federal policy makers should acknowledge these trends and ensure that distribution of the territorial Medicaid resources aligns with the needs of the island community.

Trends in Local Medicaid Spending in a U.S. Pacific Island Territory

Background
An individual’s healthcare costs can provide an objective measure of overall morbidity. Quantifying the impact of genetic variation on healthcare costs can inform public health policies and help identify genetic determinants of mortality. 

Methods
We estimated inpatient, outpatient, primary care and prescription-related costs, from the perspective of healthcare systems, for a total of 1.3 million individuals across 8 different healthcare systems. The median per-patient annual healthcare cost (expressed in 2019 prices) had substantial range across countries, from €483/year in the Estonian Biobank to €458,455/year in the Mass General Brigham Biobank. 

A GWAS meta-analysis identified 27 and 106 significant, independent loci for inpatient and medication costs, respectively. Effects were overall modest, the most significant inpatient signal (rs6938239 near ILRUN) was associated with ~1% increased cost per year, per allele. Following stratified analyses, 33% of inpatient loci had sex-specific effects while 22% had an age-specific effect. E.g. homozygous carriers of variant rs62236881 in the 3’ UTR of ZNRF3 had 9% higher costs in females compared with 4% in males, potentially due to an increased risk of breast cancer.

Results
Despite differences in tariff structure and cost reimbursement across healthcare systems, we observed strong genetic correlations between inpatient studies (median rg=0.88) and 95% of significant loci did not show heterogeneity across studies. PheWAS indicated that significant loci may impact healthcare costs via either common risk factors (e.g. BMI) or chronic diseases risk (e.g. asthma, depression).

Leveraging whole-exome sequencing data from the UK Biobank (UKB), we estimated the cost for putative loss of function (pLOF) burdens for 83 clinically relevant genes. The largest effects were observed for BRCA1/2, MSH2 and APC. Annual inpatient costs were ~1.8 times higher in individuals carrying one pLOF in BRCA2 than in non-carriers. We estimated that the total annual inpatient costs attributed to BRCA2 pLOF mutations amongst those aged 40-69 in the UK would be about €26 million.

Polygenic scores (PGS) for various risk factors and diseases were linked to higher healthcare costs. In UKB, the top 10% with the highest BMI PGS had a median annual cost of €414, compared to €329 for those in the middle 40-60%. Using polygenic weights from GenCost data, PGS for ~11,000 individuals in Genomics England showed that the top 10% incurred ~€250 more than those in the middle 40-60%.

Conclusion
Genetic variation across individuals influences healthcare expenditure. Our findings are applicable across various healthcare systems and help better understanding global morbidity.

Quantifying the impact of genetic variation on healthcare cost across 1.3 million individuals from 11 studies and 8 countries: The GenCost Consortium

INTRODUCTION: Receiving over $250 million in state government support since 2022, crisis pregnancy centers (CPCs) have expanded following the Supreme Court’s overturn of Roe v. Wade, particularly in states with policies limiting abortion services. As a result, patients may have an increasingly difficult time distinguishing between CPCs and legitimate abortion providers, which may represent a significant barrier to care especially for patients looking for out-of-state abortion services. The National Abortion Federation (NAF) offers membership for providers whose abortion services meet their standardized requirements. However, it is unclear whether these providers sufficiently guarantee their services for patients unfamiliar with the NAF or if these providers clearly list their NAF membership on their website.The purpose of this study was to perform a website content analysis on NAF member facility websites to evaluate how each facility demonstrates the legitimacy of its services. 

METHODS: First, a list of 438 NAF member names and websites was compiled from the NAF’s “Find a Provider” page. Hospitals and Planned Parenthoods were excluded from this study, in addition to facilities that were closed, did not have a website, or did not offer abortion services. The 290 remaining NAF member websites were independently reviewed by two coders, with a third coder to resolve any discrepancies. All websites were evaluated for the following variables: mentions of the right to choose, inclusions of the NAF logo or certification, warnings about CPCs and misinformation, and where each member advertised their abortion services on their website (homepage or subpage). Websites were also assessed for explicit statements guaranteeing the clinic’s legitimacy. State abortion policies were categorized as being protective, neutral, restrictive, and most-restrictive (banned) based on classifications by the Guttmacher Institute. Protective and restrictive states that have a shared border with at least one most-restrictive state were labeled Protective-Bordering-Most-Restrictive (PBMR) and Restrictive-Bordering-Most-Restrictive (RBMR) respectively. Finally, a series of logistic regression analyses were performed to compare the aforementioned variables between different state classifications. 

RESULTS: Through our analysis, we found that 91% of providers mentioned the right to choose, although only 62% had it on their homepage. 96% of clinics that offer procedural abortions advertised it on their homepage, compared to 81% for medical abortions and 84% for abortion pills by mail. 63% of clinics in protective states advertised their NAF membership compared to 79% of clinics in restrictive states (OR = 0.5, p < 0.01). Meanwhile, clinics in protective states were more likely than those in restrictive states to warn about CPCs (OR = 2.7, p < 0.01). This same disparity in CPC warnings was also observed when comparing clinics in PBMR and RBMR states (OR = 3.1, p < 0.01). While no significant differences were found nationally, clinics in PBMR states were considerably more likely to provide legitimacy statements than clinics in RBMR states (OR = 3.3, p < 0.05). 

DISCUSSION: In conclusion, our study suggests that most NAF members clearly advertise their abortion services, especially for procedural abortions. Most NAF members also clearly mention the right-to-choose and their NAF membership. However, relatively few facilities provide guarantees of their legitimacy or warnings about CPCs, especially in RBMR states. Overall, our study suggests patients in restrictive states that are unfamiliar with the NAF may have a harder time identifying legitimate clinics than patients in protective states. Furthermore, patients in restrictive states may also be less informed about CPCs. Because of our results, moving forward we will be interested in assessing how abortion providers without NAF affiliations are able to demonstrate the legitimacy of their services.


Demonstrating Legitimacy: Assessing how Abortion Providers Guarantee Their Services

Background
In June 2023, the FDA released a First Draft Guidance on Clinical Trials with Psychedelic Drugs, reflecting a reemerging interest in using psychoactive compounds like psilocybin to treat conditions such as depression, PTSD, and substance use disorders. Psilocybin, specifically, has shown promising efficacy in treating unipolar depression, with ongoing studies exploring its safety in bipolar II depression. However, its significant serotonergic activity raises concerns about potentially triggering manic episodes in susceptible individuals. Existing clinical trials of psilocybin have historically excluded patients with bipolar disorder, and literature is scarce regarding psilocybin-induced mania.

Case Presentation
The patient is a 16-year-old male with a history of depression, was brought to the emergency department by police following erratic behavior reported by his family. He had new-onset decreased need for sleep, pressured speech, grandiosity, and paranoia. On exam, he reported high energy and made several grandiose statements, such as that he believed he could achieve anything and fly if he wanted to. He admitted to consuming chocolates infused with magic mushrooms and cannabis. Despite his regular cannabis use, there had been no recent change in frequency or type. Lab work, including urine drug screen (UDS) and liver panel, were positive for THC and mildly elevated LFTs, respectively. Due to safety concerns related to his high-rise living situation, he was hospitalized. The patient was initiated on risperidone due to signs of both mania and psychosis being present and was recommended for transfer to an inpatient psychiatric facility. On day three, he continued to demonstrate elevated mood, grandiosity, tangential speech, and distractibility, although there were improvements in his sleep. 
The patient was then accepted for transfer to an external psychiatric facility, and the remainder of his clinical course is not known.

Discussion
This case underscores the potential of psilocybin to induce manic episodes, especially in individuals with a personal or family history of bipolar disorder. Healthcare providers should prioritize obtaining comprehensive substance use histories and evaluating past medical and family histories when assessing patients presenting with acute manic or psychotic symptoms. Such practices are essential for assessing the risk of psilocybin-induced mania and formulating appropriate management strategies.
Future research is critical to elucidate the safety profile of psilocybin, particularly in populations with existing bipolar disorder or heightened susceptibility to mania. Understanding these risks is paramount for informing clinical decisions regarding the therapeutic use of psilocybin and mitigating potential adverse outcomes, as highlighted by this case.

Unmasking the Silent Danger: Manic Symptoms in an Adolescent Following Psilocybin Use

Recurrent Mucosal Melanoma: Clinical Complexities and Socioeconomic Barriers
Ishita Gupta Kaushal, Arshdeep Singh, Le Yen Ly Nguyen, Pragti Garg, Raziullah Riaz, Ajaybir Singh Buttar, Chandan Sona Bevara,Youngsang You, Ansa Ali, Onkardeep Kaur, Aparna Malireddi, Ratesh Khillan MD

Background
Mucosal melanoma of the oral cavity (MMO) constitutes less than 1% of all melanomas. The majority of MMO occur in upper alveolus and hard palate (70%) followed by lower alveolus. The etiology, risk factors and pathogenesis for MMO are poorly understood. Patients with MMO can present with bleeding, local discoloration, facial pain, ulceration, with localized swelling being the most common. Due to the diversity of initial symptoms and histological pleomorphism, immunohistochemical staining is crucial to confirm the diagnosis. Mucosal melanoma (MM) has a very poor prognosis and most patients develop incurable metastatic disease, irrespective of surgical excision.
Due to poor prognosis, staging starts from T3 for lesions confined to mucosa and adjacent soft tissue and T4 for moderately advanced and very advanced lesions, as recommended in 8th edition of AJCC. For tumors limited to mucosa, NCCN recommends postoperative radiotherapy within 6 weeks of resection with consideration for systemic therapy.
In this study, we present a unique case of a 64-year-old Hispanic female with multiple recurrences of MMO.

Case presentation
A 64-year-old Hispanic female presented to our clinic with a possible recurrence of malignant melanoma of hard palate. It started as an irregularly shaped discoloration of gums and the hard palate. She underwent 3 surgical resections in her home country. Adjuvant chemo and radiotherapy were recommended, which proved to be financially challenging.
On presentation to our clinic, she had a tender bluish patch approximately 1 cm in diameter with ulcers on hard palate and a soft bluish bumpy left upper gum lesion approximately 1 cm in diameter, which bled on touching. Following the punch biopsies and various radiographic studies, left maxillectomy was done, the pathology report and immunohistochemistry of which confirmed stage ypT3N0 residual malignant melanoma. Again, patient could not undergo adjuvant chemo and radiotherapy due to financial constraints.

Discussion
Due to the condition’s rarity, rapid progression, and hence delayed diagnosis and poor prognosis, it is essential to complete the treatment regimen, which includes surgical resection followed by chemo and radiotherapy. This case shows the inequitable distribution of medical resources in patients with low socioeconomic status. The lack of medical insurance can hinder patient care in basic cancer treatment like surgery and radiotherapy. This issue is of even greater relevance in the treatment of cancer which is rapidly debilitating and fatal. Even in instances of potentially curable cancers, socioeconomic status, lack of available therapies and cultural stereotypes can impede treatment.

Recurrent Mucosal Melanoma: Clinical Complexities and Socioeconomic Barriers

Background: 
Acute coronary syndrome describes various conditions related to sudden, reduced blood flow to the heart. Some traditional risk factors for ACS include older age, diabetes (DM), hypertension (HTN), hyperlipidemia (HLD), smoking, and obesity. Rheumatoid arthritis (RA) is an autoimmune disease which is a novel risk factor for ACS. Therefore, to better understand the impact of this disease, we investigated whether RA is associated with increased mortality, readmission, and length of stay (LOS) in patients with ACS alongside traditional risk factors.

Methods: 
33,223 patients who were admitted with ACS to the West Florida division of a large health system from 1/1/2016 to 12/31/2023 were retrospectively included in the study. The association of risk factors, including RA, age, sex, Black ethnicity, other non-Caucasian ethnicities, current tobacco use, former tobacco use, alcohol use disorder, body mass index (BMI), HLD, and DM, with in-hospital mortality and 30-day readmission was evaluated via logistic regression and with LOS via negative binomial regression. 

Results:
- For RA:
The odds of in-hospital mortality was 0.779 times as likely (p-value .2252) and the odds of 30-day readmission was 0.948 times as likely (p-value .5671). RA resulted in a 1.034 factor increase in LOS (p-value .3369). 
- For traditional risk factors:
The odds of in-hospital mortality were 1.071 times as likely for every 1-year increase in age (p-value <.0001), 1.285 times as likely for current smokers (p-value 0.0020), 0.970 times as likely for every 1-point increase in BMI (p-value <.0001), 0.647 times as likely for patients with HLD (p-value <.0001), and 1.349 times as likely for patients with DM (p-value <.0001). 
Age, DM, and alcohol use disorder resulted in statistically significant increased 30-day readmission. 
Age, male sex, Black ethnicity, other non-Caucasian ethnicities, former tobacco use, current tobacco use, DM, and alcohol use disorder resulted in statistically significant increased LOS. 

Conclusion:
In terms of the discrete odds and incident rate ratios, RA was surprisingly associated with decreased in-hospital mortality and 30-day readmission in the setting of ACS despite an associated increased LOS. In terms of statistical significance, there was no difference in these outcomes in patients with RA versus patients without RA. Meanwhile, the traditional risk factors continued to show worse outcomes with statistical significance in the same patient population. Knowledge of this may prevent over-utilization of time, equipment, and resources when addressing hospitalized patients with RA presenting with ACS.

Rheumatoid Arthritis and Traditional Risk Factors on Outcomes in Acute Coronary Syndrome

Background
Women Veterans are one of the fastest growing groups of new VA users and are younger and more racially diverse than their male counterparts. Yet services such as obstetric care continue to be purchased from the community due to concerns regarding capacity and quality given the limited demand at any one VA site. Understanding whether or not racial and ethnic disparities in reproductive health care and outcomes are evident among women Veterans is critical for ensuring that VA meets its goal of providing high quality, equitable care to all Veterans. The purpose of this scoping review was to examine the evidence with respective to racial and ethnic disparities in reproductive health care and outcomes among women Veterans.

Methods
Databases were queried for articles addressing reproductive health and health care of women Veterans between 2008 and 2023, pertinent to reproductive health care or outcomes of women Veterans that also included outcome frequencies by race or ethnicity or measures of association for race or ethnicity with the outcome of interest. Articles were sorted into six categories based on topic: contraception, infertility, pregnancy, reproductive health screenings, gynecology, menopause. Outcomes were defined as structural, process, or clinical or behavioral outcome measures.

Results
Of 438 original articles, 49 articles were included. The topics with the greatest number of articles included pregnancy (43%) and contraception (24%). In terms of types of measures, only two studies included at least one structural measure (7%) and the remainder were split nearly evenly between process measures (53%) and clinical and behavioral outcomes (57%, n=28). In nearly two thirds of the studies racial and ethnic disparities were not the primary focus of the analysis and were reported only as secondary outcomes. In terms of process measures for pregnancy, non-White Veterans were less likely than White Veterans to return to VA primary
care postpartum, but results were mixed for other measures. With respect to clinical and behavioral measures, although Black versus White Veterans were consistently found to be more likely to have a low birthweight baby, results were variable regarding preterm birth, breast feeding, prenatal smoking, and perinatal mental health.

Conclusion
This scoping review identified numerous racial and ethnic disparities in reproductive health care and outcomes among women Veterans. These findings suggest a need to ensure that Veterans receive culturally competent, patient-centered contraceptive counseling and a need to potentially address social determinants in the context of reproductive health care.

Racial and Ethnic Disparities in Reproductive Health Care Among Female Veterans:
A Scoping Review

Background
Sex-specific research dealing with the impacts of the endocrine system and menopause on the cardiovascular health of women is essential. In this work, we assess the effects of hypothyroidism and menopause on physiologic metrics (i.e. weight, temperature), blood pressure, cardiac function (i.e. ejection fraction, cardiac output), and degree of hypertrophy (i.e. myocyte size, heart weight) in a female rodent model of heart failure. This study aims to harness the positive cardioprotective effects of thyroid hormones and estrogen to identify heart failure treatment strategies and improve the heart health of women.

Methods
We examine the difference in cardiac repair responses to exogenous administration of triiodothyronine (T3), 3,3’-diiodothyronine (3,3′-T2), and estrogen (E2) in hypothyroid, postmenopausal female rats that have surgically induced myocardial infarctions (MI) via permanent ligation of the Left Anterior Descending (LAD) artery. Hypothyroidism was induced via daily propylthiouracil (PTU) administration (1 mg/mL in their drinking water), and menopausal state induced surgically via ovariectomy (OVX). Rats were weighed daily, and blood pressure, thyroid hormone levels, and temperature were monitored weekly for 9 weeks. Echocardiograms and electrocardiograms were performed pre- and post-LAD ligation to confirm MI, establish exclusion criteria, and evaluate differences in cardiac function. Rat hearts and thyroids were harvested, weighed, and stained using H&E and Picrosirius Red to assess for hypertrophy. Serum was analyzed for T3, T4, and TSH using a Luminex Assay to determine the effects of exogeneous hormone replacement therapy on endogenous hormone levels.

Results
PTU administration resulted in significant reductions in rodent body weight and temperature as well as thyroid gland size. Blood pressure measurements showed a significant reduction in pulse in the hypothyroid rats. After MI, both euthyroid and hypothyroid rats experienced similar levels of decreased cardiac function. However, while T3 treatment resulted in a lower left ventricular ejection fraction (LVEF) % in euthyroid rats compared to saline and 3,3’-T2 treated rats, in hypothyroid rats it resulted in a higher LVEF%. Cardiac output was higher when hypothyroid rats were treated with T3 when compared to saline and 3,3’-T2 treatment.

Conclusion
We show that T3, in the euthyroid status has a detrimental effect, decreasing LVEF while in the hypothyroid status improves LVEF. Therefore, administration of thyroid hormones in hypothyroid individuals could be used productively for the treatment of heart failure, despite current contraindications. This study will evaluate if underlying estrogen hormone imbalances affect cardiac repair and better determine any confounding effects when administered with thyroid hormones.

Underline digital video library

Evaluation of Hepatic Arterial Vasculature and the Implications for Hepatic Surgery – A Cadaveric Pilot Study

A Heart-breaking Case of Takotsubo Presenting to a Community Emergency Department

Pulses of Potential: Assessing the Efficacy of Transcranial Magnetic Stimulation Across Age Groups

Liver Adiposity as a Predictor of Mortality in NSCLC Patients

Trends in Local Medicaid Spending in a U.S. Pacific Island Territory

Quantifying the impact of genetic variation on healthcare cost across 1.3 million individuals from 11 studies and 8 countries: The GenCost Consortium

Demonstrating Legitimacy: Assessing how Abortion Providers Guarantee Their Services

Unmasking the Silent Danger: Manic Symptoms in an Adolescent Following Psilocybin Use

Recurrent Mucosal Melanoma: Clinical Complexities and Socioeconomic Barriers

Rheumatoid Arthritis and Traditional Risk Factors on Outcomes in Acute Coronary Syndrome

Racial and Ethnic Disparities in Reproductive Health Care Among Female Veterans: A Scoping Review

Effects of Hypothyroidism and Menopause on Cardiac Repair in Female Rats Post-Myocardial Infarction

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