High Prevalence of New Clinically Significant Findings in Patients With Embolic Stroke of Unknown Source Evaluated by Cardiac Magnetic Resonance Imaging.

BACKGROUND: Embolic stroke of unknown source (ESUS) accounts for 1 in 6 ischemic strokes. Current guidelines do not recommend routine cardiac magnetic resonance (CMR) imaging in ESUS, and beyond the identification of cardioembolic sources, there are no data assessing new clinical findings from CMR in ESUS. This study aimed to assess the prevalence of new cardiac and noncardiac findings and to determine their impact on clinical care in patients with ESUS. METHODS AND RESULTS: In this prospective, multicenter, observational study, CMR imaging was performed within 3 months of ESUS. All scans were reported according to standard clinical practice. A new clinical finding was defined as one not previously identified through prior clinical evaluation. A clinically significant finding was defined as one resulting in further investigation, follow-up, or treatment. A change in patient care was defined as initiation of medical, interventional, surgical, or palliative care. From 102 patients recruited, 96 underwent CMR imaging. One or more new clinical findings were observed in 59 patients (61%). New findings were clinically significant in 48 (81%) of these patients. Of 40 patients with a new clinically significant cardiac finding, 21 (53%) experienced a change in care (medical therapy, n=15; interventional/surgical procedure, n=6). In 12 patients with a new clinically significant extracardiac finding, 6 (50%) experienced a change in care (medical therapy, n=4; palliative care, n=2). CONCLUSIONS: CMR imaging identifies new clinically significant cardiac and noncardiac findings in half of patients with recent ESUS. Advanced cardiovascular screening should be considered in patients with ESUS. REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifier: NCT04555538.

Atrial CARdiac Magnetic resonance imaging in patients with embolic stroke of unknown source without documented Atrial Fibrillation (CARM-AF): Study design and clinical protocol.

Background: Initiation of anticoagulation therapy in ischemic stroke patients is contingent on a clinical diagnosis of atrial fibrillation (AF). Results from previous studies suggest thromboembolic risk may predate clinical manifestations of AF. Early identification of this cohort of patients may allow early initiation of anticoagulation and reduce the risk of secondary stroke. Objective: This study aims to produce a substrate-based predictive model using cardiac magnetic resonance imaging (CMR) and baseline noninvasive electrocardiographic investigations to improve the identification of patients at risk of future thromboembolism. Methods: CARM-AF is a prospective, multicenter, observational cohort study. Ninety-two patients will be recruited following an embolic stroke of unknown source (ESUS) and undergo atrial CMR followed by insertion of an implantable loop recorder (ILR) as per routine clinical care within 3 months of index stroke. Remote ILR follow-up will be used to allocate patients to a study or control group determined by the presence or absence of AF as defined by ILR monitoring. Results: Baseline data collection, noninvasive electrocardiographic data analysis, and imaging postprocessing will be performed at the time of enrollment. Primary analysis will be performed following 12 months of continuous ILR monitoring, with interim and delayed analyses performed at 6 months and 2 and 3 years, respectively. Conclusion: The CARM-AF Study will use atrial structural and electrocardiographic metrics to identify patients with AF, or at high risk of developing AF, who may benefit from early initiation of anticoagulation.

Impact of catheter ablation versus medical therapy on cognitive function in atrial fibrillation: a systematic review.

PURPOSE: Atrial fibrillation is associated with an increased risk of cognitive impairment. It is unclear whether the restoration of sinus rhythm with catheter ablation may modify this risk. We conducted a systematic review of studies comparing cognitive outcomes following catheter ablation with medical therapy (rate and/or rhythm control) in atrial fibrillation. METHODS: Searches were performed on the following databases from their inception to 17 October 2021: PubMed, OVID Medline, Embase and Cochrane Library. The inclusion criteria comprised studies comparing catheter ablation against medical therapy (rate and/or rhythm control in conjunction with anticoagulation where appropriate) which included cognitive assessment and/or a diagnosis of dementia as an outcome. RESULTS: A total of 599 records were screened. Ten studies including 15,886 patients treated with catheter ablation and 42,684 patients treated with medical therapy were included. Studies which compared the impact of catheter ablation versus medical therapy on quantitative assessments of cognitive function yielded conflicting results. In studies, examining new onset dementia during follow-up, catheter ablation was associated with a lower risk of subsequent dementia diagnosis compared to medical therapy (hazard ratio: 0.60 (95% confidence interval 0.42-0.88, p < 0.05)). CONCLUSION: The accumulating evidence linking atrial fibrillation with cognitive impairment warrants the design of atrial fibrillation treatment strategies aimed at minimising cognitive decline. However, the impact of catheter ablation and atrial fibrillation medical therapy on cognitive decline is currently uncertain. Future studies investigating atrial fibrillation treatment strategies should include cognitive outcomes as important clinical endpoints.

Biochar and compost equally improve urban soil physical and biological properties and tree growth, with no added benefit in combination.

Soil compaction can be a major impediment to tree growth as it damages soil physical and biological properties and reduces plant available water. This may result in trees that are more vulnerable to seasonal water stress. Improving soil physical and biological properties by increasing soil organic matter content may lead to improved tree establishment. Organic matter (OM), in the form of municipal green waste compost (MGWC) or biochar was incorporated into compacted urban soils at two sites. We established six soil treatments: 1) unamended, 2) tillage only, 3) tillage with MGWC (20% v/v), 4) tillage with biochar (10% v/v), 5) tillage with MGWC + biochar (10% & 5% v/v - low), and 6) tillage with MGWC + biochar (20% & 10% v/v - high) (one site only). The treatments were established to a depth of 0.5 m in 2 × 2 m plots. One Corymbia maculata sapling was planted into each plot. Bulk density, hydraulic conductivity, stem diameter growth and tree water status were measured during tree establishment. At the end of the 30-month experiment, development of water stable aggregates, the rate of microbiological decomposition of OM, and tree size (diameter at breast height; DBH, and canopy growth index) were measured. All OM amended treatments improved soil physical and biological properties. There were no significant differences among the OM treatments. At the end of the experiment, tree DBH and canopy growth index were greater in the OM treatments than tillage only and unamended. As such, we recommend using local and sustainable forms of OM to improve soils and assist tree establishment in challenging sites where soil water is limited, or evapotranspiration demand is high.

Effects of deep tillage and municipal green waste compost amendments on soil properties and tree growth in compacted urban soils.

Large trees are often seen as a means of offsetting negative consequences of growing urban densification. To increase the tree canopy cover of dense urban landscapes, developers, planners and urban tree managers are often forced to plant into damaged and compacted sites. Compacted urban soils can hinder the establishment and growth of deep rooted, woody plants by: 1) impeding root exploration and development which is critical for water and nutrient acquisition; 2) reducing infiltration of water into the soil and the availability of water to plants; and 3) reducing gas exchange and the balance between anaerobic and aerobic conditions. At three sites in Melbourne, Australia with compacted and damaged soils, we established four soil remediation treatments: 1 & 2) tillage to 0.25 m with and without 50% (v/v) municipal green waste compost (MGWC) additions, and 3 & 4) tillage to 0.5 m with and without 50% MGWC addition, plus a non-remediated control. Each treatment was replicated (n = 3), and one Corymbia maculata (spotted gum) tree was planted into the centre of each 2 × 2 m treatment plot (n = 15), at all three sites (n = 45). Bulk density and field-saturated hydraulic conductivity were improved by tillage, at least in the short-term. The use of MGWC may maintain these changes for longer. Depending on site soil conditions tree growth may be improved by tillage alone. At one site, we found that additions of MGWC lead to nitrogen immobilisation due to site soil conditions. At another site, deep tillage (with or without MGWC) led to significantly improved tree growth. Compacted and degraded urban soils may be improved through simple tillage and/or organic amendment strategies for the successful establishment of deep rooted woody plants. However, site soil conditions will dictate whether the addition of MGWC is beneficial or not, as one site showed no positive response to any tillage or MGWC. This research has examined a technique that can be used by landscape managers to improve soil physical characteristics and, in certain circumstances, can improve deep-rooted woody plant establishment and growth in challenging compacted urban soil conditions.

Changing homelessness services: revanchism, 'professionalisation' and resistance.

This paper argues that the increasing international salience of homelessness can be partially explained by reference to the revanchist thesis (involving processes of coerced exclusion and abjection), but the situation on the ground is more complex. It reports on interviews with 18 representatives of 11 homelessness service providers in one city in England. As Cloke et al. found, these providers tended to be either larger, more 'professional', 'insider' services or smaller, more 'amateur', 'outsider' services. However, this does not mean that the former were necessarily more revanchist and the latter less so. Rather, the actions of both types of organisation could, in some cases, be construed as both advancing and counteracting a revanchist project.

Hypocomplementaemic immune complex tubulointerstitial nephritis.

We report a rare cause of rapidly progressive renal failure associated with low complement, positive ANA but negative anti DS-DNA. A renal biopsy demonstrated tubulointerstitial nephritis with positive immunoglobulin staining involving the interstitium and tubular basement membrane but glomerular sparing. A review of the literature and differential diagnosis are discussed.