Understanding family dynamics of obesity: Do parents and children lose and gain weight together?

BACKGROUND: Obesity is prevalent among children and adults. Yet, understanding the relationship between parent and child weight trajectories is limited. OBJECTIVE: (1) Examine the association between parent/child undesirable body mass index (BMI) category change. (2) Assess whether parental BMI category predicts child modified BMI z-score (mBMIz) annual change. METHODS: We conducted a cross-sectional study of weight trajectories of 3821 parent-child dyads between March 2020 and December 2021 within the NYC Health + Hospitals system. Undesirability of child and parental BMI category change and the magnitude of mBMIz change by parental BMI are analysed. RESULTS: Of 3821 children (mean [SD] baseline age, 9.84 [3.51]), 1889 were female. Of the 3220 parents (mean [SD] baseline age, 39.9 [8.51]), 2988 were female. Most children (53.52%) and parents (81.94%) presented with overweight and obesity. Undesirable BMI change in children was associated with concordant change in parents (adjusted OR: 1.7, 95% CI [1.45, 2.01], adjusted p < 0.001). Children of parents with obesity (adjusted coef: 0.076, 95% CI [0.004, 0.147], p < 0.038) and severe obesity (adjusted coef: 0.1317, 95% CI [0.024, 0.239], adjusted p < 0.016) demonstrated greater change in mBMIz than those of parents with normal weight or underweight. CONCLUSION: Parents and children have concordant weight trajectories, and public health interventions targeting both populations are essential.

The Impact of Cocaine Use and the Obesity Paradox in Patients With Heart Failure With Reduced Ejection Fraction Due to Non-ischemic Cardiomyopathy.

Background Obesity and illicit drugs are independent risk factors for developing heart failure (HF). However, recent studies have suggested that patients who already have HF and are obese have better clinical outcomes. We aim to study the effect of cocaine use on this obesity paradox phenomenon as it pertains to HF readmissions. Methodology In a retrospective chart analysis, we reviewed patients with a diagnosis of HF with reduced ejection fraction (HFrEF) admitted to Metropolitan Hospital in New York. We studied the association between body mass index (BMI) categories, namely, non-obese (<30 kg/m2) and obese (≥30 kg/m2), cocaine use, and the primary outcome (time to readmission for HF within 30 days after discharge). The interaction between cocaine and obesity status and its association with the primary outcome was also assessed. Results A total of 261 patients were identified. Non-obese status and cocaine use were associated with an increased hazard of readmission in 30 days (hazard ratio (HR) = 2.28, p = 0.049 and HR = 3.12, p = 0.004, respectively). Furthermore, cocaine users who were non-obese were over six times more likely to be re-admitted in 30 days compared to non-cocaine users who were obese (HR = 6.45, p = 0.0002). Conclusions Non-obese status and continued use of cocaine have a negative additive effect in impacting HF readmissions.

COVID-19 Myopericarditis With Pericardial Effusion Complicated With Cardiac Tamponade and Rhabdomyolysis.

COVID-19 infection is a complex multi-organ disease, including the cardiovascular system, which may present with myocarditis. A 42-year-old female presented to our ED with generalized weakness, myalgia, and epigastric pain. Laboratory workup showed a positive SARS-CoV-2 polymerase chain reaction (PCR). An ECG showed sinus tachycardia with low voltage. A bedside echocardiogram showed a pericardial effusion with cardiac tamponade. An emergent pericardiocentesis was performed with immediate hemodynamic improvement. The patient was admitted to the coronary care unit (CCU), and colchicine and ibuprofen were started for pericarditis. Pericardial fluid bacterial and fungal cultures were negative, and serum antinuclear antibodies were also negative. On day 5 of hospitalization, creatine kinase (CK) level was high compared to on presentation. COVID-induced rhabdomyolysis was suspected and was dramatically improved with IV fluids. The patient was discharged on day 7 of admission. Our case shows that COVID-19 can present with an uncommon presentation like cardiac tamponade. Further studies are warranted to better understand the pathogenesis and management of COVID-19 myopericarditis.

Clozapine-Induced Myocarditis in a Young Man with Refractory Schizophrenia: Case Report of a Rare Adverse Event and Review of the Literature.

BACKGROUND Myocarditis is cardiac muscle inflammation caused by infectious or noninfectious agents. Rarely, clozapine, an atypical antipsychotic drug used to treat resistant schizophrenia, has been reported to cause myocarditis, as we report in this case. CASE REPORT A 29-year-old man, who was known to have schizophrenia and was on olanzapine therapy, presented in our Emergency Department with active psychosis, and was subsequently admitted to the psychiatric ward for refractory schizophrenia. He was started on clozapine, which was cross-titrated with olanzapine. On day 20 of being treated with clozapine, he developed a high-grade fever and chest pain. EKG demonstrated new-onset prolonged QT corrected for heart rate (QTc), premature ventricular contractions, ST-T wave changes with an increased ventricular rate, and ventricular bigeminy with elevated troponin and inflammatory markers. Echocardiography showed a reduced left ventricular ejection fraction. Coronary angiography showed normal coronary arteries, low cardiac output, and cardiac index consistent with cardiogenic shock was also observed. Other pertinent laboratory results included negative respiratory viral panel, including COVID-19 PCR, negative blood cultures, and negative stool screen for ova and parasite. Clozapine was discontinued and the patient received management for heart failure with reduced ejection fraction. He improved clinically with return of EKG to normal sinus rhythm and improved left ventricular ejection fraction on repeat echocardiogram. CONCLUSIONS Acute myocarditis can occur due to a myriad of causes, both infectious and noninfectious; thus, determining the lesser-known causes, such as drug-related etiology, is essential to provide appropriate treatment for patients.

Tolvaptan add-on therapy and its effects on efficacy parameters and outcomes in patients hospitalized with heart failure.

INTRODUCTION: Even with the adequate use of diuretics and vasodilators, volume overload and congestion are the major causes of morbidity and mortality in patients hospitalized with acute heart failure (HF). We aim to evaluate the additive effect of tolvaptan on efficacy parameters as well as outcomes in hospitalized patients with HF. METHODS: We searched PubMed, EMBASE, Cochrane library, and Web of Science databases for randomized controlled trials that studied the effects of tolvaptan versus placebo in hospitalized patients with HF. Studies were included if they had any of the following endpoints: mortality, re-hospitalization, and in-hospital parameters like dyspnea relief, change in weight, sodium, and creatinine. RESULTS: The meta-analysis analyzed data from 14 studies involving 5945 patients. The follow up duration ranged from 30 days to 2 years. Between tolvaptan and placebo groups, there was no difference in mortality and rehospitalization. HF patients had a better dyspnea relief score (Likert score) in tolvaptan group and mean reduction in weight in the first 48 h (short-term). However, at 7 days (medium-term) the mean difference in weight was not significant. Serum sodium increased significantly in tolvaptan group. There was no difference in creatinine among the two groups. CONCLUSIONS: Our meta-analysis shows that tolvaptan helps in short-term symptomatic dyspnea relief and weight reduction, but there are no long term benefits including reduction in mortality and rehospitalization.

Cardiac Tamponade as the Initial Presentation of Metastatic Esophageal Adenocarcinoma.

Malignancy accounts for approximately 15-20% of moderate to large pericardial effusions. Pulmonary and colon are the most common primary causes. Large pleural effusions tend to present with a less dramatic clinical picture. It is because fluids tend to build up slowly, giving enough time to the pericardial sac to accommodate it until pressure reaches a critical value causing right heart chambers to collapse. In this report, we present the case of a 51-year-old male with cardiac tamponade as the first manifestation of esophageal adenocarcinoma. The patient presented with shortness of breath and pleuritic chest pain for one week, with no other associated symptoms. Early workup indicated a cardiac tamponade likely secondary to lung malignancy. Further workup demonstrated that the primary source was an esophageal malignancy. In this setting, pericardial effusions are usually related to radiation/chemotherapy, but in rare cases, cardiac tamponade can be the first manifestation of esophageal cancer.

Lyme Carditis: A Reversible Cause of Acquired Third-Degree AV Block.

BACKGROUND Lyme borreliosis, caused by spirochetes of the Borrelia burgdorferi genospecies complex, is the most commonly reported tickborne infection in North America and those infected may present with cutaneous, cardiac, articular, and neuropsychiatric abnormalities. The protean nature of many of its clinical manifestations presents a diagnostic conundrum. Lyme disease can affect the heart, albeit rarely, with cardiac abnormalities usually manifesting as varying degrees of heart block or arrhythmias. CASE REPORT We present a case of complete heart block in a young man who participated in outdoor activities in a Lyme-endemic area and developed fatigue and palpitations weeks after a flu-like illness. He noticed that his heart rate was low; he had an intermediate suspicious index in Lyme carditis (SILC) score with positive Lyme serologies. His initial electrocardiogram when he presented to the emergency department showed a complete heart block. In this case, he was successfully managed with intravenous ceftriaxone, amoxicillin, and a transcutaneous pacemaker, obviating the need for a permanent pacemaker. CONCLUSIONS Electrocardiographic changes such as heart block and arrhythmias with or without symptoms may be the initial manifestation of Lyme carditis in a patient who may or may not remember a tick bite or have a typical skin rash. The SILC score may assist in recognizing these cases and prompt initiation of antibiotics usually leads to the resolution of these electrocardiographic abnormalities and symptoms that may be present.

A 61-Year-Old Man with SARS-CoV-2 Infection and Venous Thrombosis Presenting with Painful Swelling and Gangrene of the Lower Limb Consistent with Phlegmasia Cerulea Dolens.

BACKGROUND Coronavirus disease 2019 (COVID-19) is a novel infectious disease with an evolving understanding of its clinical manifestations, complications, and therapeutic implications. Thromboembolic disease and coagulopathy are common and have been seen in COVID-19 patients. Phlegmasia cerulea dolens had been reported in previous cases associated with malignancy which is a known cause of a procoagulable state. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection may also induce a procoagulable state and be associated with PCD. CASE REPORT A 61-year-old man presented with a painful, swollen limb and gangrene, findings consistent with a diagnosis of PCD due to venous thrombosis. The patient tested positive for SARS-CoV-2 infection after a nasopharyngeal swab sample using the XPRSARS-COV2-10 reverse transcription polymerase chain reaction kit. He had bilateral leg swelling with a gangrenous left fourth digit in the presence of a palpable peripheral pulse. His venous duplex showed bilateral acute deep venous thrombosis, whereas his arterial Doppler scan was normal and his skin biopsy was negative for vasculitis. One of our screening blood tests was suggestive of an antiphospholipid-like syndrome. These clinical and radiologic findings were consistent with PCD. This patient was promptly anticoagulated; other supportive treatments were also initiated. He had a significant resolution of his pedal swelling with the associated revitalization of his previously gangrenous toe. CONCLUSIONS This case report shows the importance of testing for SARS-CoV-2 infection in patients who present with unusual thrombotic symptoms and signs and highlights the potential severity of these thrombotic complications.

Infected Right Ventricle Thrombus as a Cause of Persistent Sepsis.

The presentation of fevers in a patient with active intravenous (IV) drug use is often challenging, as there is a wide range of both infectious and noninfectious disorders that can cause fevers. A thorough diagnostic workup is essential in identifying the etiology of these fevers. We report a rare case of an infected right ventricular (RV) thrombus as a cause of persistent fever and sepsis in a 46-year-old patient with IV drug use. The patient continued to have persistent bacteremia inspite of appropriate IV antibiotics. Hence, the patient warranted a cardiothoracic surgical excision of the infected RV thrombus following which the patient showed remarkable improvement.

Prognostic Significance of Diastolic Dysfunction With Multiple Comorbidities in Heart Failure Patients.

Background Heart failure poses a significant burden on health care and economy. In recent years, diastolic dysfunction has been increasingly recognized as a significant predictor of readmission in heart failure patients. Objectives We aimed to identify factors predicting readmission in patients with clinical heart failure at 30 days and six months. Methods A retrospective chart review was performed at a single urban medical center, including 208 patients in our final analysis. Results A higher Charlson comorbidity index (CCI) and moderate anemia (hemoglobin [Hb] < 10 g/dL) were significant predictors of readmission at both 30 days and six months. In addition, advanced chronic kidney disease (CKD) stage (4 or 5) and follow-up in a cardiology clinic were significant predictors at six months. During multivariate analysis, worsening diastolic dysfunction (grade 3 or 4) (OR: 2.09; 95% CI: 1.03 to 4.23), higher CCI (OR: 1.18; 95% CI: 1.03-1.36), and Hb < 10 g/dL (OR: 3.42; 95% CI: 1.44-8.13) were independent predictors of readmission at 30 days. Higher CCI (OR: 1.37; 95% CI: 1.19-1.58) and CKD stage 4 or 5 (OR: 3.05; 95% CI: 1.40-6.62) were independent predictors of readmission at six months. Conclusions Worse diastolic dysfunction (grade 3 or 4) was a significant predictor of all-cause readmission at 30 days post-discharge in heart failure patients. Higher CCI precisely predicted readmission as an independent variable at 30 days and six months. Anemia (Hb < 10 g/dL) and CKD stage 4 or 5 were significant predictors of readmission at 30-days and six months, respectively.

Rare Association of Takotsubo Cardiomyopathy with Right Bundle Branch Block in the Dual Setting of Asthma Exacerbation and Psychiatric Illness.

BACKGROUND Takotsubo cardiomyopathy is characterized by a transient left ventricular dysfunction without obstructive coronary artery disease that mimics an acute myocardial infarction. The electrocardiogram findings of Takotsubo cardiomyopathy usually present with ST-segment elevation or depression, T-wave inversion, left bundle branch block or high-grade atrioventricular block. CASE REPORT This is a report of a case of a 58-year-old male diagnosed with Takotsubo cardiomyopathy that occurred in the setting of an acute asthma exacerbation and psychiatric exacerbation with novel electrocardiogram findings of right bundle branch block. Transthoracic echocardiogram showed a preserved ejection fraction with left ventricular apical ballooning and hyperkinesis of the basal segments. The nuclear stress test showed a fixed perfusion defect at the apical segment, but the patient refused further testing such as coronary angiography. The patient was managed medically, and a repeat echocardiogram done after 8 weeks from discharge showed a complete resolution of the apical ballooning. CONCLUSIONS It is important to recognize that patients with psychiatric illness and asthma exacerbation are predisposed to develop Takotsubo cardiomyopathy. It is also reasonable to suspect Takotsubo cardiomyopathy in the presence of new electrocardiogram findings aside from those typically seen in acute myocardial infarction, especially if it is associated with apical ballooning.

Prognostic Utility of Troponin I and N Terminal-ProBNP among Patients with Heart Failure due to Non-Ischemic Cardiomyopathy and Important Correlations.

BACKGROUND: Heart Failure (HF) is accompanied by a high cost of care and gloomy prognosis despite recent advances in its management. Therefore, efforts to minimize HF rehospitalizations is a major focus of several studies. METHODS: We conducted a retrospective cohort study of 140 patients 18 years and above who had baseline clinical parameters, echocardiography, NT-ProBNP, troponin I and other laboratory parameters following a 3-year electronic medical record review. Patients with coronary artery disease, preserved ejection fraction, pulmonary embolism, cancer, and end-stage renal disease were excluded. RESULTS: Of the 140 patients admitted with HF with reduced Ejection Fraction (HFrEF) secondary to non-ischemic cardiomyopathy, 15 were re-hospitalized within 30 days of discharge while 42 were rehospitalized within 6 months after discharge for decompensated HF. Receiver operating characteristic (ROC) cutoff points were obtained for NT-ProBNP at 5178 pg/ml and serum troponin I at 0.045 ng/ml. After Cox regression analysis, patients with HFrEF who had higher hemoglobin levels had reduced odds of re-hospitalization (p = 0.007) within 30 days after discharge. NT-ProBNP and troponin I were independent predictors of re-hospitalization at 6 months after discharge (p = 0.047 and p = 0.02), respectively, after Cox regression analysis. CONCLUSION: Troponin I and NT-ProBNP at admission are the best predictors of re-hospitalization 6 months after discharge among patients with HFrEF. Hemoglobin is the only predictor of 30 -day rehospitalization among HFrEF patients in this study. High-risk patients may require aggressive therapy to improve outcomes.

The relevance of serum albumin among elderly patients with acute decompensated heart failure.

OBJECTIVE: To assess the prognostic utility of serum albumin among elderly patients admitted for acute decompensated heart failure (ADHF) in terms of all-cause mortality and also to identify the predictors of hypoalbuminemia. METHODS: Retrospective cohort study of 119 elderly patients admitted for ADHF. Elderly patients were defined as patients over the age of 65 years. The patients were followed up for approximately 11 years. Patients with advanced renal failure, liver disease not due to HF, cancer and other causes of low life expectancy were excluded. Hypoalbuminemia was defined as serum albumin ≤ 2.9 g/dL. RESULTS: The study was made up of 65 females and 54 males with age ranging from 65 to 96 years. Of the 119 elderly patients with ADHF, there were 26 deaths. A significantly higher proportion of patients in the mortality group had an admission serum albumin level of ≤ 2.9 g/dL than those surviving (P = 0.011). After Cox's logistic regression, low albumin (P = 0.016), elevated direct bilirubin (P = 0.03), age greater than 85 (P = 0.008), lack of use of beta blockers (P = 0.0001) and left ventricular ejection fraction less than 35% (P = 0.005) increased the risk of death. Elevated serum creatinine (P = 0.0357) was the only predictor of hypoalbuminemia following multiple linear regression. CONCLUSIONS: Hypoalbuminemia may be an unrecognized marker of death in elderly patients with ADHF.

Heart Failure and Cognitive Impairment: Clinical Relevance and Therapeutic Considerations.

Heart failure (HF) is a devastating condition characterized by poor quality of life, numerous complications, high rate of readmission and increased mortality. HF is the most common cause of hospitalization in the United States especially among people over the age of 64 years. The number of people grappling with the ill effects of HF is on the rise as the number of people living to an old age is also on the increase. Several factors have been attributed to these high readmission and mortality rates among which are; poor adherence with therapy, inability to keep up with clinic appointments and even failure to recognize early symptoms of HF deterioration which may be a result of cognitive impairment. Therefore, this review seeks to compile the most recent information about the links between HF and dementia or cognitive impairment. We also assessed the prognostic consequences of cognitive impairment complicating HF, therapeutic strategies among patients with HF and focus on future areas of research that would reduce the prevalence of cognitive impairment, reduce its severity and also ameliorate the effect of cognitive impairment coexisting with HF.

Relationship between pulmonary hypertension and outcomes among patients with heart failure with reduced ejection fraction.

Objectives: To identify predictors of pulmonary hypertension (PHT) and the predictive value of PHT for rehospitalization among patients with heart failure with reduced ejection fraction (HFrEF). Methods: A retrospective study of 351 hospitalized patients with heart failure (HF). Patients 18 years and above with HFrEF secondary to non-ischemic cardiomyopathy were reviewed. Patients with coronary artery disease, preserved ejection fraction and other secondary causes of PHT apart from HF were excluded. PHT as a predictor of 30-day and six-month re-admission was assessed as well as important possible predictors of PHT. Cox regression analysis, multiple linear regression as well as other statistical tools were employed as deemed appropriate. Results: Thirty-seven (37) and 99 patients were re-hospitalized within 30 days and 6 months after discharge for decompensated HF, respectively. After Cox regression analysis, higher hemoglobin reduced the odds of rehospitalization for decompensated HF (p = 0.015) within 30 days after discharge while higher pulmonary artery systolic pressure (PASP) (p = 0.002) and blood urea nitrogen (BUN) (p = 0.041) increased the odds of rehospitalization within 6 months of discharge. The predictors of the PHT among patients with HFrEF after multiple linear regression were low BMI (p = 0.027), increasing age (p = 0.006) and increased left atrial diameter (LAD) on echocardiography (p = 0.0001). Conclusion: Patients with HFrEF have a high predisposition to developing PHT if at admission, they have low BMI, dilated left atrium or are older. Patients with one or more of these attributes may need more intensive therapy to reduce the risk of developing PHT and in turn reduce readmission rates.

Low Skeletal Muscle Mass Independently Predicts Mortality in Patients with Chronic Heart Failure after an Acute Hospitalization.

BACKGROUND: Heart failure (HF) is a syndrome associated with exercise intolerance, and its symptoms are more common in patients with low skeletal muscle mass (SMM). Estimation of muscle mass can be cumbersome and unreliable, particularly in patients with varying body weight. The psoas muscle area (PMA) can be used as a surrogate of sarcopenia and has been associated with poor outcomes in other populations. OBJECTIVES: The aim of this study was to assess if sarcopenia is associated with the survival of patients with HF after an acute hospitalization. METHOD: We retrospectively studied a cohort of 160 patients with HF who had abdominopelvic computed tomography during an acute hospitalization. We obtained standardized measurements of their PMA and defined sarcopenia as the lowest gender-based tertile of the said area. The patients were followed until death or discontinuation of care. We used Kaplan-Meier estimates and Cox regression analysis to assess the relationship between sarcopenia and all-cause mortality. RESULTS: We found that the 52 patients with sarcopenia had 4.5 times the risk of all-cause mortality at 1 year compared to the rest of the cohort (CI 1.784-11.765; p = 0.0016) after adjusting for significant covariates. Stratification by age and sex revealed that this association could be limited to males and patients < 75 years old. CONCLUSION: The PMA, used as a surrogate of low SMM, is independently associated with an increased risk of late mortality after an acute hospitalization in patients with HF.

Clinical outcomes of Β-blocker therapy in cocaine-associated heart failure.

BACKGROUND: Cocaine is associated with deleterious effects in the heart, including HFrEF. Although ß-blockers are recommended for this condition in other populations, their use is discouraged in cocaine users due to the possibility of exacerbating cocaine-related cardiovascular complications. This study was designed to determine if patients with heart failure and a reduced ejection fraction (HFrEF) who continue to use cocaine have better outcomes when they receive ß-blocker therapy than when they do not. METHODS: We performed a retrospective analysis of 72 ß-blocker-naïve patients with HFrEF and active cocaine use. Patients who were prescribed ß-blockers as part of their therapy were compared to those who were not, and clinical and structural outcomes were compared after 12 months of treatment. RESULTS: When patients with HFrEF and active cocaine use received ß-blocker therapy, they were more likely to have an improvement in their New York Heart Association functional class (p = 0.0106) and left ventricular ejection fraction (p = 0.0031) than when they did not receive ß-antagonists. In addition, the risk of cocaine-related cardiovascular events (p = 0.0086) and of heart failure hospitalizations (p = 0.0383) was significantly lower in patients who received ß-blockade than those who did not. CONCLUSIONS: ß-Blocker therapy is associated with improvement in the exercise tolerance and the left ventricular ejection fraction in patients with HFrEF and active cocaine use. They are also associated with a lower incidence of cocaine-related cardiovascular events and HFrEF-related readmissions.

Brugada Phenocopy Induced by Recreational Drug Use.

Recreational drugs are commonly abused in all age groups. Intoxication with these substances can induce silent but significant electrocardiographic signs which may lead to sudden death. In this case study, we present a 49-year-old male with no medical comorbidities who came to the emergency department requesting opioid detoxification. Toxicology screen was positive for cocaine, heroin, and cannabis. Initial electrocardiogram (EKG) showed features of a Brugada pattern in the right precordial leads, which resolved within one day into admission. This presentation is consistent with the recently recognized clinical entity known as Brugada phenocopy.

Gastrocardiac syndrome: A forgotten entity.

Symptomatic bradycardia due to gastric distension is a rarely reported entity in the field of medicine. The mechanism of gastrointestinal distention that contributes to bradycardia is complex. A 75-year-old female with recurrent episodes of dizziness in the setting of gastric distension was found to have severe sinus bradycardia which resolved upon resolution of gastric distension. No structural or functional abnormality of heart was found. The patient was treated with permanent pacemaker implantation due to recurrent episodes of dizziness in the setting of sinus bradycardia.