Concomitant Disease Research Articles

Favorable Trends in Mortality among Patients with Concomitant Peripheral Arterial Disease and Diabetes Mellitus over Past Two Decades

BackgroundThis study examines the temporal trends in diabetes and peripheral artery disease (PAD)-related mortality in the United States, considering sociodemographic and regional factors, using data from death certificates in a national public database. MethodsData were extracted from the CDC WONDER (Centers for Disease Control and Prevention Wide Ranging Online Data for Epidemiologic Research) database from 1999 to 2020. Age-adjusted mortality rates (AAMR) per 100,000 individuals and annual percent changes (APC) with 95% confidence intervals (CI) were calculated. ResultsBetween 1999 and 2020, there were 2,252,252 PAD-related and 5,413,811 diabetes-related deaths, with 469,699 deaths involving both conditions. The overall AAMR for PAD and diabetes-related mortality (aged ≥ 25 years) decreased from 7.97 in 1999 to 6.37 in 2020, with a notable decline from 2001 to 2010 (APC: -6.16, 95% CI: -7.07, -5.23). The AAMR for PAD-related mortality fell from 40.25 to 30.56, while the AAMR for diabetes-related deaths rose from 76.71 to 93.63. Males and non-Hispanic (NH) Black individuals had higher AAMRs than females and other racial groups. The highest crude mortality rate (CMR) was in the 80-84 age group. Non-metropolitan areas consistently reported higher AAMRs than metropolitan areas, and states like Ohio, Vermont, District of Columbia, and West Virginia had significantly higher rates. ConclusionOver two decades, PAD and diabetes-related mortality trends show a positive overall reduction in AAMR. However, disparities persist, with higher rates among males, NH Black individuals, and residents of non-metropolitan areas. Significant state-level variations highlight the need for targeted interventions and tailored healthcare strategies.

Multimodality Imaging in the Management of Tricuspid Valve Regurgitation.

Approximately 5% of elderly patients suffer from moderate or severe tricuspid valve regurgitation, which is an independent predictor of high morbidity and mortality. Surgical treatment of isolated tricuspid valve regurgitation has been associated with elevated fatality rate, leading to a growing interest in minimal invasive, transcatheter-based therapies such as transcatheter edge-to-edge repair and transcatheter valve replacement. Nevertheless, despite high procedural efficacy and safety of transcatheter-based therapies, a number of challenges limit their rapid adoption in routine clinical practice. In particular, the wide range of transcatheter approaches to address the significant variability in tricuspid valve pathology challenges the reproducibility of clinical outcomes. Multimodality imaging is pivotal for grading the regurgitation severity, determining the underlying pathology, assessing RV function and pulmonary pressures, identifying concomitant cardiac disease, and selecting the most beneficial treatment modality and access. This article reviews the role of different imaging modalities in guiding the management of patients with significant tricuspid valve regurgitation.

Combination of closing-wedge distal femoral osteotomy and modified tibial plateau levelling osteotomy for the treatment of medial patellar luxation and concomitant cranial cruciate ligament disease in dogs

Considering the prevalence of cranial cruciate ligament disease (CCLD) and concurrent medial patellar luxation (MPL) among dogs, and the concomitant bone deviations routinely identified, the aim of this study is to evaluate the efficacy of the combination between distal femoral osteotomy (DFO) and modified tibial plateau levelling osteotomy (mTPLO) for the treatment of MPL with distal femoral varus, tibial torsion, and CCLD. Dogs with concurrent MPL and CCLD that underwent DFO and mTPLO procedures were included. Subjective clinical evaluations of gait and pre-operative and immediate post-operative radiographic examinations were performed. Surgical data were documented. The anatomical lateral distal femoral angle (aLDFA), femoral varus angle, mechanical medial proximal tibial angle, and tibial plateau angle (TPA) were compared between the pre- and post-operative periods. A total of 12 dogs were included in this study. Closing-wedge DFO and mTPLO procedures were performed on 14 limbs. The mean pre-operative and post-operative aLDFA values were 104.8 ± 3.9° and 95.4 ± 2.4°, respectively. TPA values were 26.2 ± 3.7° pre-operatively and 6.3 ± 3.2° post-operatively. Bone healing was observed in 7.1 %, 71.3 %, and 85.5 % of patients at the first, second, and third follow-up, respectively. Lameness was resolved in 28.5 %, 78.5 %, and 100 % at 30, 60, and 90 days, respectively. No major peri- or post-operative complications were reported. The combination of mTPLO and DFO aligns the stifle extensor mechanism, promoting dynamic stabilization. It can be considered for the treatment of concurrent MPL and CCLD in dogs, performed as a single procedure, and is associated with favorable short-term outcomes.

LABORATORY PARAMETERS IN PATIENTS WITH CHRONIC CEREBRAL ISCHEMIA DEPENDING ON THE PRESENCE OF CONCOMITANT CHRONIC OBSTRUCTIVE PULMONARY DISEASE

This study investigates the laboratory parameters in patients with chronic cerebral ischemia (CCI) in relation to the presence of concomitant chronic obstructive pulmonary disease (COPD). CCI is characterized by a progressive reduction in cerebral blood flow, while COPD can exacerbate hypoxia, potentially worsening brain ischemia. The research evaluates blood biomarkers, including inflammatory markers and oxygenation indices, to determine the impact of COPD on CCI patients. Results suggest that patients with both CCI and COPD present with more severe inflammatory responses and lower oxygenation levels, which may influence the progression of cerebral ischemia and overall prognosis.

Analysis of factors influencing the dose of levothyroxine treatment in adequately controlled hypothyroid patients of different etiologies

ObjectiveThe mainstay therapy of hypothyroidism is levothyroxine (LT4). In most cases lifelong treatment is warranted, therefore, choosing adequate doses are of paramount significance. The purpose of this study was to assess several factors that have been proposed to influence LT4 therapy including etiology of hypothyroidism, gender, age, bodyweight, BMI, concomitant drug use, disease severity and time since diagnosis in patients with stable, adequately controlled hypothyroidism. MethodsIn this cross-sectional study we analysed past medical history, anthropometric data and biochemical parameters reflecting thyroid function of patients with chronic hypothyroidism who were adequately treated (TSH levels in normal range) with LT4 for at least 6 months. Potential predictors of LT4 requirement were evaluated using uni- and multivariate linear modelling. Results191 individuals were enrolled in this study, who were divided into autoimmune (n=147) and post-surgery (n=44) groups. Mean age, time since diagnosis and LT4 dose (1.3 versus 1.1 mcg/kgBW) were significantly lower in the autoimmune group. In the post-surgery group age was the only significant (p=0.016) predictor of LT4 dose. In the autoimmune group BMI (p=0.001), time since diagnosis (p=0.023), as well as their interaction (p=0.012) turned out to be significant predictors of LT4 requirement. ConclusionsOur results implicate the necessity of differentiating between etiologies of hypothyroidism when starting or changing thyroxine replacement therapy. Patient in both groups required significantly lower doses of LT4 replacement, than previous reports suggest, to maintain stable euthyroidism. Distinctly different factors predicted hormone requirement in the two study groups.

Evaluation of A Non-Nucleoside Inhibitor of the RSV RNA-Dependent RNA Polymerase in Translatable Animals Models

Respiratory Syncytial Virus (RSV) causes severe respiratory infections and concomitant disease resulting in significant morbidity and mortality in infants, elderly, and immunocompromised adults. Vaccines, monoclonal antibodies, and small molecule antivirals are now either available, or in development, to prevent and treat RSV infections. Although, rodent and non-rodent preclinical animal models have been used to evaluate these emerging agents there is still a need to improve our understanding of the pharmacokinetic (PK)-pharmacodynamic (PD) relationships, within and between animal models to enable better design of human challenge studies and clinical trials. Herein, we report a PKPD evaluation of MRK-1, a novel small molecule non-nucleoside inhibitor of the RSV L polymerase protein, in the semi-permissive cotton rat and African green monkey models of RSV infection. These studies demonstrate a strong relationship between in vitro activity, in vivo drug exposure, and pharmacodynamic efficacy as well as revealing limitations of the cotton rat RSV model. Additionally, we report unexpected horizontal transmission of human RSV between co-housed African green monkeys, as well as a lack of drug specific resistant mutant generation. Taken together these studies further our understanding of these semi-permissive animal models and offer the potential for expansion of their preclinical utility in evaluating novel RSV therapeutic agents.

Toxic and Metabolic Kidney Injury: Focus on Energy Drinks

Currently, energy drinks on the market are represented by medium and highly carbonated, as well as non-alcoholic and low-alcohol products. More than 500 brands producing energy drinks are registered in the world. Long-term abuse of energy drinks can lead to serious consequences. Kidney damage caused by energy drinks is becoming an urgent medical and social problem, since with prolonged use there is dependence on them, numbness of the limbs, palpitations, headaches and dizziness, pain in the precordial region, increased blood clotting, frequent urination, irritability, depression, insomnia, increased fatigue, anxiety, fear and convulsions. Widespread and uncontrolled use of energy drinks can cause social imbalance in society, decreased mental and physical performance, especially in adolescents. The toxic properties of energy drinks are manifested depending on the volume and composition, presentation, duration of intake, as well as concomitant disease. Availability, wide popularization through advertising in the media, insufficient awareness of young people about the harmful effects of energy drinks serves as a condition for the development of damage to internal organs when consuming them. The article presents data from scientific literature on the epidemiology of risk factors for the development and progression of chronic renal failure. Negative effects on human health with long-term abuse of energy drinks are discussed. The article presents the results of clinical observation of patient N., 31 years old, who developed a neo-oliguric variant of acute kidney injury against the background of long-term use of energy drinks. Laboratory testing revealed hyperglycemia, dyslipidemia, hypercreatininemia (blood creatinine 161.0 μmol/l) and hypercytokinemia due to an increase in the serum concentration of interleukin-6. The glomerular filtration rate (GFR) was at the level of 48 ml/min. Against the background of the therapy, kidney function was restored: blood creatinine 85.9 μmol/l, GFR increased to 116 ml/min.

SP5.10 - Statin use during neoadjuvant therapy is an independent marker for a favourable Neoadjuvant Rectal (NAR) score in locally advanced rectal cancer when analysing common concomitant medications

Abstract Aim The extent of neoadjuvant therapy (NAT) response is an important prognosticator in locally advanced rectal cancer (LARC). The Neoadjuvant Rectal (NAR) is validated as a pseudo-continuous measurement of response, and a surrogate marker of long-term outcomes. We investigated the impact of common concomitant medications (statins, antiplatelets, metformin) on the extent of response using the NAR score. Methods A retrospective review of regional cancer centre LARC patients undergoing NAT was performed between June 2016 - 2021. The NAR score was calculated as previously described by George et al (2015). Results 253 patients were included. 104(34%), 52(17%), and 19(6%) patients took statins, antiplatelets, and metformin respectively. 90% of those on an antiplatelet are also on a statin. Of those on statins, 45.2% and 14.4% also took antiplatelets or metformin respectively. There was no significant association with concomitant medication use and disease stage or tumour size. Only metformin use associated with the absence of Extramural vascular invasion (EMVI) (p=0.031) on pre-NAT MRI. Neither antiplatelets nor metformin use associated with the extent of NAT response. Statin use associated with a favourable NAR score (p=0.008). On multivariate analysis with pre-NAT mrEMVI and nodal status, concomitant statin use independently predicted a favourable NAR score of <16 (OR 2.019, 95%CI 1.11-3.67, p=0.021). Conclusion Concomitant statin use at time of neoadjuvant therapy associates with a favourable response. Antiplatelet and metformin use does not appear to influence response. Analysis through a clinical trial of statin use combined with neoadjuvant therapy may give more insight into how it influences response.

Prevalence, Clinical Characteristics, and Treatment of Patients with Resistant Hypertension: A Single-Center Study.

Resistant hypertension (HTN) is associated with a high risk of cardiovascular complications. Our study aimed to assess the prevalence, characteristics, and treatment of patients with resistant HTN. We screened 4340 consecutive cardiovascular patients hospitalized in our clinic and identified 3762 with HTN. Of them, 128 fulfilled criteria for resistant HTN and were included in our study. We matched these patients to 128 hospitalized patients with controlled HTN. Resistant HTN patients comprised 3.4% of all hypertensive individuals. Most of these patients (67.2%) were at high or very high cardiovascular risk compared to controlled HTN patients (40.6%); p < 0001. Resistant HTN patients more commonly had concomitant chronic kidney disease (CKD) (60.9%), overweight/obesity (52.3%), dyslipidemias (35.2%), smoking (27.3%), and diabetes (21.9%) compared to controlled HTN patients (37.5%, 29.7%, 28.1%, 14.1%, and 7.8%, respectively); p < 0.001. Regression analysis showed the strongest association of resistant HTN with CKD (OR 6.64), stage III HTN (OR 3.07), and obesity/overweight (OR 2.60). In contrast, single-pill combinations (SPCs) were associated with a lower likelihood of uncontrolled HTN (OR 0.58). Resistant HTN represented a small proportion of all hypertensives in our study, but it was characterized by high/very high cardiovascular risk. Optimized therapy including increased use of SPCs could improve blood pressure control and long-term prognosis for these patients.

Особливості перебігу хронічної хвороби нирок у пацієнтів з артеріальною гіпертензією, цукровим діабетом та хронічним гломерулонефритом

Chronic kidney disease (CKD), especially its terminal stage, is a serious problem in modern medicine. There are certain features of the course of CKD in patients with arterial hypertension (AH), diabetes mellitus (DM), and chronic glomerulonephritis (CGN). The purpose of the study was to study the course of CKD against the background of hypertension, diabetes and chronic hypertension based on clinical and laboratory examination data to assess the severity of the patients' condition. Materials and methods. 86 patients with stage V chronic renal failure (CKD) were examined, who were divided into 3 groups depending on the existing concomitant disease. Group 1 (n – 35) included patients with CKD and hypertension, group 2 (n – 28) – patients with CKD and diabetes, and group 3 (n – 23) – patients with CKD and CGN. Anthropometric, general clinical, laboratory and instrumental research methods were performed on all patients. Research results and their discussion. Analyzing the data of a general blood test, 100 % of patients in all three groups had a decrease in hemoglobin and erythrocyte levels. A significant decrease in the level of albumin (p &lt; 0.05) and an increase in the levels of urea (p &lt; 0.001) and creatinine (p &lt; 0.001) were also found, which indicated a pronounced decrease in kidney function and significant kidney damage. Analyzing the results of the ionic composition of the blood, a significant increase in the levels of phosphorus and parathyroid hormone was found in patients of the III group (CNN and CGN). Conclusions: 1. In all groups of patients with CKD of the V degree in combination with concomitant hypertension, diabetes mellitus or CGN, persistent anemia was noted, which was manifested by a progressive drop in hemoglobin to the levels of 86.22 ± 3.61 g/l, 83.89 ± 3.06 g/l and 83.22 ± 3.49 g/l, respectively. 2. In such patients, a pronounced decrease in kidney function was noted, which was manifested by a delay in the release of the products of protein metabolism from the blood due to a decrease in the levels of albumin (p &lt; 0.05), a significant increase in the levels of urea (p &lt; 0.001), creatinine (p &lt; 0.001) and a decrease glomerular filtration rate. 3. In the group of patients with a combination of CKD stage V and CGN, a significant increase in phosphorus and parathyroid hormone levels was found (p &lt; 0.01). Such an increase in the level of parathyroid hormone in blood serum may be associated with a drop in the level of calcium in the blood of such patients and the subsequent progressive increase in the level of inorganic phosphate and the development of hyperphosphatemia.

Safety and efficacy of gout treatments in people with renal impairment

Gout is common in people with chronic kidney disease and in general is sub-optimally managed. Lack of evidence due to the exclusion of people with chronic kidney disease from the majority of clinical trials, concerns about adverse effects and conflicting gout management guidelines all contribute to suboptimal management. Herein we review the evidence for the pharmacological treatment of gout, both flares and long-term urate-lowering, in people with concomitant chronic kidney disease.

Anticoagulation in device-detected atrial fibrillation with or without vascular disease: a combined analysis of the NOAH-AFNET 6 and ARTESiA trials.

The optimal antithrombotic therapy in patients with device-detected atrial fibrillation (DDAF) is unknown. Concomitant vascular disease can modify the benefits and risks of anticoagulation. These pre-specified analyses of the NOAH-AFNET 6 (n=2534 patients) and ARTESiA (n=4012 patients) trials compared anticoagulation to no anticoagulation in patients with DDAF with or without vascular disease, defined as prior stroke/transient ischemic attack, coronary or peripheral artery disease. Efficacy outcomes were the primary outcomes of both trials, a composite of stroke, systemic arterial embolism (SE), myocardial infarction, pulmonary embolism or cardiovascular death, and stroke or SE. Safety outcomes were major bleeding or major bleeding and death. In patients with vascular disease (NOAH-AFNET 6 56%, ARTESiA 46.0%), stroke, myocardial infarction, systemic or pulmonary embolism, or cardiovascular death occurred at 3.9%/patient-year with and 5.0%/patient-year without anticoagulation (NOAH-AFNET 6), and 3.2%/patient-year with and 4.4%/patient-year without anticoagulation (ARTESiA). Without vascular disease, outcomes were equal with and without anticoagulation (NOAH-AFNET 6 2.7%/patient-year, ARTESiA 2.3%/patient-year in both randomised groups). Meta-analysis found consistent results across both trials (I2heterogeneity=6%) with a trend for interaction with randomised therapy (pinteraction=0.08). Stroke/SE behaved similarly. Anticoagulation increased major bleeding in vascular disease patients (edoxaban 2.1%/patient-year, no anticoagulation 1.3%/patient-year; apixaban 1.7%/patient-year; no anticoagulation 1.1%/patient-year; incidence rate ratio 1.55 [1.10-2.20]) and without vascular disease (edoxaban 2.2%/patient-year; no anticoagulation 0.6%/patient-year; apixaban 1.4%/patient-year; no anticoagulation 1.1%/patient-year, incidence rate ratio 1.93 [0.72-5.20]). Patients with DDAF and vascular disease are at higher risk of stroke and cardiovascular events and may derive a greater benefit from anticoagulation than patients with DDAF without vascular disease.

There is No Increased Pulmonary Risk Following Total Hip Arthroplasty in Patients Who Have Obstructive Sleep Apnea Without Underlying Lung Disease

BackgroundObstructive sleep apnea (OSA) is a frequent comorbidity. The current study evaluated whether there is a difference in the perioperative outcome after total hip arthroplasty (THA) in patients who had a low to moderate risk for OSA and high risk for OSA, respectively. MethodsAfter excluding patients who had concomitant lung disease (chronic obstructive pulmonary disease, asthma, or lung fibrosis) and those missing a STOP-Bang Score, 1,141 THA patients who had OSA were included in this retrospective study. Patients at low to moderate risk for OSA (STOP-Bang Score 0 to 4) and patients at high risk for OSA (STOP-Bang Score 5 to 8) were compared, and SpO2 (oxygen saturation) drops < 90% as well as readmission rates were compared between patients who did and did not use continuous positive airway pressure (CPAP). ResultsThere was no difference in the risk of SpO2 drop below 90% (1 versus 0%, P = 0.398) and readmission rate (2 versus 2%, P = 0.662) between patients who had low to moderate OSA risk (327 THA) and high OSA risk (814 THAs). There was no difference in SpO2 (P > 0.999) and a decrease in oxygen flow rate from the postanesthesia care unit to the morning of the first postoperative day. A CPAP device was used by 41% (467 of 1,141) of patients. There were no differences in SpO2 drop < 90% (0 versus 0%, P = 0.731) and readmission rate (2 versus 2%, P = 0.612) between patients who did and did not use a CPAP machine. ConclusionsThe current study showed no difference in perioperative outcomes between OSA patients undergoing THA who had a low STOP-Bang Score and patients who had a high STOP-Bang Score, regardless of the use of a CPAP machine. These data suggest that an elevated Stop-Bang Score does not indicate an increased perioperative risk for OSA patients when deciding on outpatient discharge.

Coronary microvascular dysfunction and autoregulatory capacity interfere with resting Dicrotic notch morphology

Coronary microvascular vasodilator capacity is substantially associated with coronary pressure waveform and dicrotic notch morphology, with or without concomitant epicardial disease. A prominent dicrotic notch is associated with preserved microvascular vasodilatory capacity and adequate resting microvascular tonus without relative hyperaemic state, cumulatively indicating a better microcirculatory health.

Liver biopsy in patients with gall stone disease and concomitant non-alcoholic fatty liver disease undergoing cholecystectomy: A prospective observational study

Objective: Gallstone disease (GSD) and non-alcoholic fatty liver disease (NAFLD) share common risk factors. NAFLD can progress to non-alcoholic steatohepatitis (NASH), which may lead to severe liver conditions. This study aimed to assess the prevalence of NASH and associated factors in patients with GSD and fatty liver undergoing cholecystectomy. Material and Methods: This prospective observational study was conducted from March 2021 to June 2023 and included 134 patients diagnosed with GSD and fatty liver based on preoperative ultrasound. Core liver biopsies were obtained during cholecystectomy. Preoperatively, clinical, anthropometric, demographic, biochemical variables, and FibroScan parameters were recorded. Results: NASH was found in 21 (15.67%) patients, while 50 (37.31%) patients had probable NASH, and 63 (47.01%) had non-NASH scores. Metabolic syndrome was present in 63.6% of the patients. Univariate analysis revealed significant differences in AST and ALT values between the NASH and nonNASH groups. In multivariate analysis, AST was statistically significant (p= 0.041). Mean controlled attenuation parameter in patients with non-NASH was 219.40 ± 60.44 dB/m, and in patients with NASH, it was 265.48 ± 63.47 dB/m (p= 0.006). Fibrosis was present in 33 of the 82 slides examined, with 17 patients having grade 2 and two patients with grade 3 fibrosis. Conclusion: The high prevalence of NASH among GSD patients highlights a significant public health issue, prompting consideration for liver biopsy in individuals with NAFLD and GSD undergoing laparoscopic cholecystectomy.

A rare deleterious case of concomitant renal disease associated with IgG4-associated systemic disease

In IgG4-associated disease, several organs and tissues are often affected, especially kidney tissue, and is characterized by interstitial nephritis, obstructive nephropathy, and in rare cases glomerulopathy (including membra[1]nous nephropathy).IgG4-associated disease was isolated as an independent nosological form in 2003, when patients with type 1 autoimmune pancreatitis were found signs of systemic damage (involvement of the biliary tract, salivary glands, retroperitoneal space), and in 2012 the first international nomenclature of the disease was proposed.The clinical manifestations of IgG4-associated disease are nonspecific and diverse, which determines the difficulties of differential diagnosis, including infections and tumors, and increases the period from the onset of the disease to diagnosis to an average of 2 years. IgG4-associated disease is more likely to develop in middle age and old age. The prevalence of the disease is higher among men than among women. Thus, autoimmune pancreatitis type 1, retroperitoneal fibrosis and tubulointerstitial nephritis are more common in men, and sialoadenitis, dacryoadenitis and thyroiditis are more common in women.In this article, we present a clinical case of IgG4-associated systemic disease with a combined lesion of the tubulo-interstitial and glomerular compartments of kidney tissue with nephrotic syndrome as the only initial manifestation. The combination of IgG4-tubulo-interstitial nephritis with membranous nephropathy is an ex[1]tremely rare pathology. Nephrobiopsy was crucial in the diagnosis of this condition, which allowed the patient to be prescribed proper and timely treatment.

Comorbidities and Monitoring in Patients with Chronic Hepatitis B on Nucleos(t)ide Analogues Attending a Tertiary Hospital in Malaysia, Southeast Asia: A Critical Perspective.

Chronic hepatitis B (CHB) is a significant global public health concern in Malaysia. It is a potentially life-threatening liver disease caused by the hepatitis B virus (HBV), which can lead to long-term complications such as cirrhosis, liver failure and hepatocellular carcinoma. In managing CHB, nucleos(t)ide analogues (NAs) have become the preferred treatment due to their ability to suppress viral replication and prevent disease progression. The question of liver-associated comorbidities related to patients with CHB on NAs remains unresolved in Malaysia despite the impending burden of CHB in the country. This study intends to address this and related aspects. We assessed 136 CHB patients on NAs in one centre, the Hospital Universiti Sains Malaysia. Demographic and epidemiological data on the treatment, concomitant disease and monitoring strategies were collected and analysed. Patients on NAs aged 50 years old-70 years old had the highest proportion of CHB (45.59%), with males representing 61.03% of that age group. There was a statistical significance in CHB acquisition and presence of comorbidities at P > 0.005. Our cohort displayed seven comorbidities (diabetes, obesity, rheumatoid diseases, renal impairment, spontaneous bacterial peritonitis, hypertension, non-hepatocellular malignancies and carcinoma); hypertension had the highest incidence (69.12%), while renal impairment had the lowest incidence (8.09%). Whole blood count, liver function and creatinine tests were the major monitoring tests used in over 90% of the cohort compared to viral load (6.1%). Diabetes, hypertension and obesity were independent risk factors for acquiring liver cirrhosis and hepatocellular carcinoma. Malaysian CHB patients treated with NAs have several comorbidities that could affect disease outcomes. Therefore, careful monitoring is required.

Cardiovascular disease assessment and management in liver transplantation.

The prevalence and mortality related to end-stage liver disease (ESLD) continue to rise globally. Liver transplant (LT) recipients continue to be older and have inherently more comorbidities. Among these, cardiac disease is one of the three main causes of morbidity and mortality after LT. Several reasons exist including the high prevalence of associated risk factors, which can also be attributed to the rise in the proportion of patients undergoing LT for metabolic dysfunction-associated steatohepatitis (MASH). Additionally, as people age, the prevalence of now treatable cardiac conditions, including coronary artery disease (CAD), cardiomyopathies, significant valvular heart disease, pulmonary hypertension, and arrhythmias rises, making the need to treat these conditions critical to optimize outcomes. There is an emerging body of literature regarding CAD screening in patients with ESLD, however, there is a paucity of strong evidence to support the guidance regarding the management of cardiac conditions in the pre-LT and perioperative settings. This has resulted in significant variations in assessment strategies and clinical management of cardiac disease in LT candidates between transplant centres, which impacts LT candidacy based on a transplant centre's risk tolerance and comfort level for caring for patients with concomitant cardiac disease. Performing a comprehensive assessment and understanding the potential approaches to the management of ESLD patients with cardiac conditions may increase the acceptance of patients, who appear too complex, but rather require extra evaluation and may be reasonable candidates for LT. The unique physiology of ESLD can profoundly influence preoperative assessment, perioperative management, and outcomes associated with underlying cardiac pathology, and requires a thoughtful multidisciplinary approach. The strategies proposed in this manuscript attempt to review the latest expert experience and opinions and provide guidance to practicing clinicians who assess and treat patients being considered for LT. These topics also highlight the gaps that exist in the comprehensive care of LT patients and the need for future investigations in this field.

Association of Anticoagulant Choice on mortality in the Primary Treatment of Non-Cancer Venous Thromboembolism: Medicare 2011-2018.

Direct oral anticoagulants (DOACs; rivaroxaban, apixaban) and warfarin are approved for venous thromboembolism (VTE) treatment. Few direct comparisons of DOACs on risk of mortality among VTE patients exist, and for patients with concomitant conditions (e.g., kidney and liver disease) clinical guidelines are unclear. We evaluated 6-month all-cause mortality by anticoagulant prescribed for primary treatment of VTE. Using Medicare 20% sample data, we created a propensity score matched analytic dataset of 47,860 beneficiaries with non-cancer incident VTE. We used Cox regression to estimate adjusted hazard ratios (HRs) of OACs with 6-month mortality, and tested interactions by liver/kidney disease. There were 3,422 deaths over 6 months of follow-up. In adjusted models, patients prescribed rivaroxaban [HR: 0.82 (95% CI: 0.76-0.90)] had lower rates of mortality versus warfarin. There was no association comparing apixaban to warfarin [HR: 0.96 (95% CI: 0.87-1.07)]. In head-to-head comparisons of apixaban versus rivaroxaban the HR was 1.14 (95% CI: 1.01-1.28)]. Findings were similar among patients with liver and kidney disease. Overall, risk of death was similar by OAC prescribed. Though it is possible residual confounding remained, there was some suggestion of lower risk with rivaroxaban than warfarin. DOACs appear safe among VTE patients with concomitant kidney or liver disease.

A randomized comparison of the treatment sequence of percutaneous coronary intervention and transcatheter aortic valve implantation: Rationale and design of the TAVI PCI trial

About half of patients with severe aortic stenosis present with concomitant coronary artery disease. The optimal timing of percutaneous coronary intervention (PCI) and transcatheter aortic valve implantation (TAVI) in patients with severe aortic stenosis and concomitant coronary artery disease remains unknown. The TAVI PCI trial is a prospective, international, multicenter, randomized, 2-arm, open-label study planning to enroll a total of 986 patients. It is designed to investigate whether the strategy "angiography-guided complete revascularization after (within 1-45 days) TAVI" is noninferior to the strategy "angiography-guided complete revascularization before (within 1-45 days) TAVI" using the Edwards SAPIEN 3 or 3 Ultra Transcatheter Heart Valve in patients with severe aortic stenosis and concomitant coronary artery disease. Patients are randomized in a 1:1 ratio to one of the 2 treatment strategies. The primary end point is a composite of all-cause death, nonfatal myocardial infarction, ischemia-driven revascularization, rehospitalization (valve- or procedure-related including heart failure), or life-threatening/disabling or major bleeding at 1 year. The TAVI PCI trial tests the hypothesis that the strategy "PCI after TAVI" is noninferior to the strategy "PCI before TAVI" in patients with severe aortic stenosis and concomitant coronary artery disease.