Background: The average annual cost of inpatient stroke care in the United States exceeds $35 billion. The lack of clear recommendations for the use of transthoracic echocardiography (TTE) in patients with Acute ischemic stroke (AIS) has made this test a universal component of every stroke work-up. We evaluated the clinical utility and cost-effectiveness of TTE performed in patients with lacunar strokes. Methods: This is a single-center retrospective analysis of AIS patients from October 2015 through December 2017 (27 months). Brain MRI was used to select patients with a single acute/subacute lacunar infarct and no T2FLAIR evidence of previous cortical embolic strokes. Patients with cardiac symptoms (chest pain, shortness of breath, pedal edema) or an abnormal ECG (Atrial fibrillation, other arrhythmias, ST-T changes) on admission were excluded. Results of TTE were reviewed and their utility in decision making was evaluated. TTE associated costs were calculated. Results: Out of the 442 patients diagnosed with AIS in the given timeframe , 98 met the above criteria for inclusion. Mean age was 55 and 40 patients were female.TTE revealed no patients with an ejection fraction below 40%. Incidence of cardiac thrombus was 0%. Small patent foramen ovale was found in 5 (5.1%) patients, out of which none had right to left shunting or associated atrial septal aneurysm. Obtaining TTE did not change the management in any of the cases. Average cost of inpatient TTE was $2616, totaling $266,832 in all patients. Based on the current incidence of lacunar strokes (15-25%), this corresponds to approximately $500 million of nationwide spending annually. Conclusion: In AIS patients with no cardiac symptoms and normal ECG, it may be safe and clinically reasonable to obtain MRI brain before deciding about the need for TTE. If MRI shows a lacunar stroke, inpatient TTE done routinely may not change the management but adds up unnecessary cost to the healthcare system. Large multi-center studies are warranted.

Diabetes mellitus is a growing concern worldwide and leads to multiple complications during pregnancy. Pharmacologic doses of chromium (Cr) have been linked with improving insulin sensitivity and other positive benefits in the treatment of diabetes in animal models. By using streptozotocin induced hyperglycemia in female CD-1 mice, reproductive outcomes of diabetic and chromium-dosed diabetic females were examined. After dosing 10 mg/kg Cr in the form of triaqua-μ3 -oxo-hexa-μ-propionatotrichromium(III) chloride or Cr3 during gestation days 8-16 (GD8-GD16), all females were sacrificed on gestation day 17 (GD17) and examined for maternal weight gain. The fetuses were examined for gross malformations and for skeletal malformations. The offspring of Cr3-dosed females tended to have a reduction in the incidence of supernumerary ribs. While hyperglycemia still had negative impacts on the health of dams and their offspring, administration of Cr led to an apparent trend in the reduction in the number of malformations and incidence of supernumerary ribs compared to those of untreated diabetic mothers.

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