Assessing left atrial size and pump function in ischemic stroke patients: Is cardiac MRI superior to transthoracic echocardiography?

OBJECTIVES: Current guidelines recommend transthoracic echocardiography (TTE) following an ischemic stroke as the primary technique to identify cardiac abnormalities associated with an increased risk of cerebral embolism. It is unclear whether cardiac magnetic resonance imaging (cMRI), a technique shown to provide increased imaging resolution, may also enhance the cardiac assessment of ischemic stroke patients. We compared cMRI with TTE in the evaluation of Left Atrial (LA) size and pump function in a cohort of 44 patients with ischemic stroke. MATERIALS AND METHODS: The biplane method was utilized to acquire LA diameters as well as area measurements in both TTE and cMRI. We calculated LA volume (LAV), LAV index (LAVI), LA Global Longitudinal Strain (GLS) and LA pump function. Results were compared using paired two sample for means t-test. Lin's concordance correlation coefficient (CCC) and Bland-Altman methods quantified the agreement of measurements obtained by TTE and cMRI. RESULTS: LAVI measurements by cMRI were significantly larger (34.97 v. 28.81; p = 0.001) than by TTE. The concordance correlation demonstrated only a weak agreement between LA size measured by cMRI and TTE (ρc = 0.397; p= 0.001, 95% CI 0.16 - 0.59), and the Bland-Altman plot demonstrated that LAVI measured by cMRI averaged 6.3 ml/m2 larger magnitude than those obtained by TTE. CONCLUSIONS: Using TTE alone leads to an underestimation of LA abnormalities important in the evaluation of ischemic stroke patients. Nearly one in every five ischemic stroke patients evaluated based on the current guidelines may have a missed potential source of cardiac embolism.

Pulmonary tuberculosis and Cryptococcal native knee septic arthritis with osteomyelitis in an immunocompetent patient: Mycobacterial effect on CD4 function and cellular immunity.

Clinically significant cryptococcal disease is typically seen in patients with human immunodeficiency virus (HIV). However, Cryptococcosis has also been observed among non-HIV immunocompromised hosts. Cryptococcosis and tuberculosis (TB) infections both occur due to impaired cell mediated immunity but co-infection is rare among immunocompromised patients. Co-infection of these pathogens is even less reported in immunocompetent hosts. We present a case of Cryptococcal left native knee septic arthritis with tibial osteomyelitis in an HIV negative patient with recently active tuberculosis.

Siddha fasting in obese acute decompensated heart failure may improve hospital outcomes through empowerment and natural ketosis.

BACKGROUND: Morbid obesity (BMI > 35 kg/m2 with comorbid conditions) is present in 25 - 35% of acute decompensated heart failure (AHF) patients. Prevalence of HF increases with duration of morbid obesity from 30% at 15 years to over 90% at 30 years. There is a need to develop pragmatic therapies that address the unique physical and mental challenges faced by obese AHF patients. Siddha is 5,000 year old Tamil Medicine using yoga and mind-body methods towards higher consciousness. Hunger gratitude Experience (HUGE) is intuitive Siddha fasting method which may improve in-hospital AHF outcomes independent of weight reduction. CASE SUMMARY: We present 5 cases of morbidly obese patients with cardiorenal syndrome (CRS) that began intermittent fasting either during their AHF hospitalization or in the outpatient setting for refractory symptoms despite hospitalization. Initiation of fasting correlated with reduction of respiratory distress and edema as well as improvements in psychological wellbeing and functional capacity. DISCUSSION: Siddha fasting mediates hemodynamic and anti-inflammatory effects through natural ketosis and psychological benefits through empowerment in AHF. Potential role of fasting in reducing myocardial workload, coronary steal, angina, volume overload, and CRS needs further study in cardiac patients.

Siddha fasting in morbidly obese heart failure patients achieves significant weight loss and reduces hospitalization.

Two thirds of heart failure (HF) patients are overweight or obese. Current guidelines are unclear about weight reduction goals. We explored impact of Heartful Living (HL,) a cardiologist-led Self-Inquiry (Si) mindfulness program targeting deeper insight and resilience to promote intentional weight loss in morbidly obese HF patients. The primary outcome was >10% intentional weight loss in HF achieved in 6 males and 4 females, BMI 40 (± 8.11)Kg/m2, age of 67.1 (± 10.02) years, who participated in HL and were followed for 10 months to 3 years. Two patients had systolic dysfunction, with a reduced ejection fraction of 25 and 40%. All had diabetes (7) or metabolic syndrome (3). The fasting was unsupervised, at home and intuitive without prespecified parameters. The average weight loss through HUGE fasting was 17.5% of total body weight for all 10 patients, and 25.5% for the 5 patients followed over 2 years. Diabetes, hypertension and renal parameters improved allowing reduction of medications. This prospective case series followed ten morbidly obese patients with HF, and demonstrates intentional weight loss can be achieved with mindfulness. Clinical improvement occurs when HF patients reach over 15% weight loss. Prospective studies are needed to evaluate outcomes in broader HF populations.