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Objective: Echocardiography is frequently used as a screening test for cardiac disease in patients with syncope despite the lack of published data describing its utility in this regard. The goal of the study was to examine the frequency with which echocardiography was used in the evaluation of patients admitted to one medical center because of syncope and to examine the diagnostic information, over and above that provided by the initial history, physical examination, and electrocardiography, contributed by the echocardiogram.Design: A retrospective review was performed of all patients admitted to the study institution because of syncope over a seven-month period.Setting: University teaching hospital in an urban setting of 2.5 million population.Patients/participants: One hundred twenty-eight patients were identified: 47 men and 81 women (average age 67 +/- 17 years). Patients for whom syncope was of a known cause, those with near-syncope or vertigo, those with clinically obvious seizure, or those referred for electrophysiologic testing were excluded, leaving 128 patients for analysis. Details from the admission history, physical examination, and electrocardiography for each patient were recorded. The results of all other diagnostic tests ordered to evaluate syncope were recorded along with any consultations obtained. The cause of syncope was assigned by examining all physicians' notes and test results and with the use of previously published diagnostic criteria as guidelines.Measurements and Main Results: Ninety percent of the patients underwent cardiac testing other than routine electrocardiography and continuous telemetry monitoring while in the hospital. An echocardiogram was obtained for 64% of the patients and did not reveal an unsuspected cause for syncope in any case. The echocardiogram was normal for 52% of the patients undergoing the test. Echocardiograms of patients with syncope and no clinical evidence of heart disease by history, physical examination, or electrocardiography either were normal (63%) or provided no useful additional information for arriving at a diagnosis (37%). Nearly half (46%) of the patients undergoing echocardiography fit this clinical profile. Among the patients for whom cardiac disease was suspected after history, physical examination, or electrocardiography, the echocardiogram confirmed the suspected diagnosis for 48% and served to rule out a suspected diagnosis for the remaining 52%. In no instance did echocardiography provide an unsuspected cause for syncope. The history, physical examination, and initial electrocardiography provided sufficient information to permit a diagnosis to be made for 37 of the 48 patients (77%) for whom a cause of syncope was ultimately determined.Conclusion: Echocardiography was frequently used in the evaluation of patients admitted to the hospital because of syncope of unclear cause. For patients without suspected cardiac disease after history, physical examination, and electrocardiography, the echocardiogram did not appear to provide additional useful information, suggesting that syncope alone may not be an indication for echocardiography. For patients with suspected heart disease, echocardiography served to confirm or refute the suspicious in equal proportions. These data provide an objective basis to prospectively define the optimal role of echocardiography in the evaluation of patients with syncope. [ABSTRACT FROM AUTHOR]

Background: Despite advances in ablation and other therapies for AF, progression of atrial fibrillation (AF) remains a significant clinical problem, associated with worse prognosis and worse treatment outcomes. Upstream therapies targeting inflammatory or antifibrotic mechanisms have been disappointing in preventing AF progression, but more recently genetic and genomic studies in AF suggest novel cellular and metabolic stress targets, supporting prior studies of lifestyle and risk factor modification (LRFM) for AF. However, while obesity is a significant risk factor, weight loss and risk factor modification have not been successfully applied in a US population with AF. Metformin, a common drug that targets metabolic stress pathways, has demonstrated potential in reducing the burden of AF., Methods: The Targeting Risk Interventions and Metformin for Atrial Fibrillation (TRIM-AF, NCT03603912) is a randomized clinical trial designed to examine reduction of AF burden and progression, targeting metabolic upstream therapies. This single center trial, at the Cleveland Clinic, is designed as a prospective randomized open-label blinded endpoint (PROBE) 2 × 2 factorial study of metformin extended release up to 750 mg twice daily and lifestyle and risk factor modification (LRFM) in patients with a cardiovascular implantable electronic device (CIED) that have had at least one ≥ 5-min episode of atrial fibrillation (AF) over the prior 3 months. Randomization is stratified by pacemaker vs. ICD and rhythm at enrollment (sinus rhythm/atrial paced vs. AF)., Conclusion: TRIM-AF trial aims to determine if metformin, lifestyle, and risk factor modification (LRFM) reduce AF burden and its progression and assess whether combined therapy outperforms individual treatments., Trial Registration: URL: https://clinicaltrials.gov/ ; Unique Identifier: NCT03603912., Competing Interests: Declarations. Ethics approval: Not applicable. Informed consent: Not applicable. Conflict of interest: Dr. Bruemmer serves as a consultant for Bayer Pharmaceuticals, Inc., Eli Lilly and Company, and Esperion Therapeutic, Inc. DB performs research with Novartis. Dr. Chung has received funds for service on the American Board of Internal Medicine and as an Associate Editor for Circulation:Arrhythmia & Electrophysiology; she has received royalties from UpToDate and Elsevier. She receives funding as noted under Sources of Funding. Dr. Laffin serves/served as a consultant or on steering committees for Recor, Medtronic, Eli Lilly, Mineralys, Crispr Therapeutics, Idorsia, Novo Nordisk, Arrowhead Pharmaceuticals, Ripple Medical, and Stability Health. He has received research funding from AstraZeneca for studies of rosuvastatin. He receives royalties from Belvoir Media Group, Elsevier, and Springer Nature. Dr. Mehra has received an honorarium from the American Academy of Sleep Medicine; has received funds for service on the American Board of Internal Medicine writing group and as associate editor of the American Journal of Respiratory and Critical Care Medicine; has received National Institutes of Health funding (R21HL170206); funding from the Women in Alzheimer’s Movement; funds from Eli Lilly and Mineralys; and has received royalties from UpToDate. Dr. Nissen reports that the Cleveland Clinic Center for Clinical Research has received funding to perform clinical trials from Abbvie, AstraZeneca, Amgen, Arrowhead, Bristol Myers Squibb, Eli Lilly, Esperion, Medtronic, MyoKardia, New Amsterdam Pharmaceuticals, Novartis, Pfizer, and Silence Therapeutics. Dr. Nissen is involved in these clinical trials but receives no personal remuneration for his participation. Dr. Nissen consults for these pharmaceutical companies, but does not accept compensation. Dr. Saliba serves on advisory boards for Boston Scientific and Biosense Webster. Dr. Sanders is supported by an Investigator Grant Fellowship from the National Health and Medical Research Council of Australia. Dr. Sanders reports serving on the advisory board for Medtronic, Abbott Medical, Boston-Scientific, CathRx and Pacemate. PS reports that the University of Adelaide receives on his behalf research funding from Medtronic, Abbott Medical, Boston-Scientific, and Becton Dickenson., (© 2024. The Author(s).)

Purpose: We aim to determine the current treatment patterns and recommendations among physicians for cutaneous lymphomas and to identify the types of skin lymphomas for which existing radiation regimens need improvement., Methods and Materials: A questionnaire from the European Organisation for Research and Treatment of Cancer was distributed to all members of the Cutaneous Lymphoma Tumour Group and Radiation Oncology Scientific Council. This online survey included 13 questions regarding treatment practices for patients with cutaneous lymphoma. The survey was conducted from August 21 to December 18, 2023. Frequency distributions and subgroup comparisons were calculated and analyzed., Results: We collected 51 completed questionnaires from investigators from 19 countries specializing in cutaneous lymphoma treatment. Radiation doses varied significantly (range, 4-60 Gy). Based on the histologic entity, up to one-third of the investigators delivered hypofractionated regimens (range, 14%-35%). Reduced-dose radiation therapy (RT) was considered by 27% to 63% of investigators. Meanwhile, 18 (35%) investigators considered adapting the radiation dose to the response to immunochemotherapy when treating primary cutaneous diffuse large B cell lymphoma-leg type. Regarding total skin electron beam therapy, 91% of centers delivered reduced-dose regimens, and 18% of investigators applied ultrahypofractionated protocols., Conclusions: RT in patients with cutaneous lymphoma is highly heterogeneous among the European Organisation for Research and Treatment of Cancer centers. The development of evidence-based recommendations for RT dose, fractionation, and technique for cutaneous lymphomas is required for optimization and standardization of treatment., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background Heart failure with improved ejection fraction (EF) is increasingly recognized as a sizable and distinct entity. While the features associated with improvedEF have been explored and new guidelines have emerged, factors associated with sustaining an improved EF over time have not been defined. We aimed to assess factors associated with maintenance of an improved EF in a large real-world patient cohort. Methods and Results A total of 7070 participants with heart failure with improved EF and a subsequent echocardiogram performed after at least 9 months of follow-up were included in a retrospective cohort study conducted at the Cleveland Clinic in Cleveland, Ohio. Multiple logistic regression models, adjusted for demographics, comorbidities, and medications were built to identify characteristics and therapeutic interventions associated with maintaining an improved EF. Mean age (SD) was 64.9 (13.8) years, 62.7% were men, and 75.1% were White participants. White race and the use of angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, or angiotensin receptor-neprilysin inhibitors were associated with maintaining the EF at least 9 months after EF improvement. In contrast, male sex or having atrial fibrillation/flutter, coronary artery disease, history of myocardial infarction, presence of an implanted cardioverter-defibrillator, and use of loop diuretics were associated with a decline in EF after previously documented improvement. Conclusions Continued use of renin-angiotensin-aldosterone system inhibitors was associated with maintaining the EF beyond the initial improvement phase.