A Case Report: Idiopathic or Drug-Induced Autoimmune Hepatitis-Can We Draw a Line?

Idiosyncratic drug-induced liver injury (DILI) is an unpredictable reaction of individuals exposed to a certain drug, and drug-induced autoimmune hepatitis (DIAIH) presents a DILI phenotype that mimics idiopathic autoimmune hepatitis (AIH) when considering the clinical, biochemical, serological and histological parameters. We present a case report of a 48-year-old male who was hospitalized due to severe hepatocellular liver injury two months after self-treatment with a muscle-building dietary supplement based on arginine-alpha-ketoglutarate, L-citrulline, L tyrosine, creatine malate and beet extract. His immunology panel was positive with increased IgG levels, and radiologic methods showed no signs of chronic liver disease. He underwent corticosteroid treatment with adequate response. After therapy withdrawal, a clinical relapse occurred. Seven months after the initial presentation, liver MR suggested initial cirrhotic changes in the right liver lobe. A liver biopsy revealed abundant lymphoplasmacytic infiltrate with piecemeal necrosis and grade 2 fibrosis. He responded well to the corticosteroid treatment again, and was further treated with low-dose prednisone without additional relapses. Several years later, further management confirmed the presence of liver cirrhosis with no histological or biochemical signs of disease activity. DIAIH is a DILI phenotype that is difficult to distinguish from idiopathic AIH despite a wide armamentarium of diagnostic methods. It should always be considered among the differential diagnoses in patients presenting with hepatocellular liver injury.

Plasma Drug Values of DOACs in Patients Presenting with Gastrointestinal Bleeding: A Prospective Observational Study.

Background and Objectives: Anticoagulants are a well-known risk factor for gastrointestinal bleeding (GIB). In recent years, direct oral anticoagulants (DOACs) have taken a leading role in the treatment and prevention of thromboembolic incidents. The aim of this study was to investigate the prevalence of DOAC-treated patients with GIB whose plasma drug concentrations exceeded the cut-off values reported in the literature and to evaluate their clinical characteristics. Materials and Methods: Patients who were admitted to the Intensive Care Unit in the period 2/2020-3/2022 due to GIB were prospectively included in the study and classified into three groups according to the prescribed type of DOAC (apixaban, rivaroxaban, and dabigatran). For all participants, it was determined if the measured plasma drug levels exceeded the maximum serum concentration (Cmax) or trough serum concentration (Ctrough) obtained from the available data. A comparison of clinical parameters between the patients with and without excess drug values was performed. Results: There were 90 patients (54.4% men) included in the study, of whom 27 were treated with dabigatran, 24 with apixaban, and 39 with rivaroxaban. According to Cmax, there were 34 (37.8%), and according to Ctrough, there were 28 (31.1%) patients with excess plasma drug values. A statistically significant difference regarding excess plasma drug values was demonstrated between DOACs according to both Cmax (p = 0.048) and Ctrough (p < 0.001), with the highest rate in the group treated with dabigatran (55.6% for Cmax and 59.3% for Ctrough). Multivariate logistic regression showed that age (OR 1.177, p = 0.049) is a significant positive and glomerular filtration rate (OR 0.909, p = 0.016) is a negative predictive factor for excess plasma drug values. A total of six (6.7%) patients had fatal outcomes. Conclusions: Plasma drug concentrations exceed cut-off values reported in the literature in more than one-third of patients with GIB taking DOAC, with the highest rate in the dabigatran group. Clinicians should be more judicious when prescribing dabigatran to the elderly and patients with renal failure. In these patients, dose adjustment, plasma drug monitoring, or substitution with other, more appropriate DOACs should be considered.

Detection of Sarcopenia in Patients with Liver Cirrhosis Using the Bioelectrical Impedance Analysis.

Bioelectrical impedance analysis (BIA) is a body composition assessment method. We aimed to determine its accuracy in the detection of sarcopenia in patients with liver cirrhosis (LC), using skeletal muscle index (SMI) at the level of third lumbar vertebra (L3-SMI) obtained using multislice computed tomography as the reference method. Patients with LC were enrolled in the period October 2019-March 2022 and follow-ups were conducted until January 2023. Their BIA parameters were compared against L3-SMI, and BIA cut-off values were proposed using AUROC analysis. Patients underwent outcome analysis based on obtained clinical characteristics. A total of 106 patients were included. We found a fair correlation between BIA parameters with the L3-SMI. We determined cut-off values of ≤11.1 kg/m2 for BIA-SMI (Se 73%, Sp 66%, AUROC 0.737, p < 0.001) and ≤5.05° for phase angle (PA) (Se 79%, Sp 60%, AUROC 0.762, p < 0.001) in the detection of sarcopenia. The relative risk of death was 2.2 times higher in patients with skeletal muscle mass (SMM) ≤ 36.5 kg. SMM was significantly associated with outcome in Kaplan-Meier analysis. This non-invasive and simple method that showed fair performances and a very good outcome prediction could provide for the unmet need for fast and affordable detection of sarcopenia in patients with LC and should be further evaluated.

Histological Type, Cytotoxic T Cells and Macrophages in the Tumor Microenvironment Affect the PD-L1 Status of Gastric Cancer.

Gastric cancer (GC) therapies include gastrectomy and chemoradiotherapy. The tumor immune microenvironment (TME) has implications for potential immunotherapy. We analyzed the expression of PD-L1, CD8, CTLA-4 and IFN-γ in the tumor and regional lymph node (LN) of patients with GC and compared it with clinical and pathological data. Paraffin blocks were collected from 97 patients undergoing gastrectomy/lymphadenectomy for GC. Double immunohistochemistry was performed for CD8 and PD-L1 and double immunofluorescence for CTLA-4 and IFN-γ. Statistical significance was set at p < 0.05. PD-L1 expression in tumor cells was associated with intestinal GC type (p = 0.046), the density of macrophages and CD8 + T cells (p < 0.001, both). The median number of CD8+ T cells was higher in PD-L1-positive than in -negative tumors. A cut-off of 28.5 CD8 + T cells in one high-magnification field predicted PD-L1-positive tumors (AUROC 0.797, sensitivity 74.2%, specificity 77.3%). IFN-γ expression in tumor cells was found in 37 GCs and was positively associated with CTLA4+ lymphocytes in the LN (p = 0.027) and CTLA4+/IFN-γ+ in tumors and the LN (all p < 0.001). The median overall survival (OS) was 17 months. In the group of deceased patients, IFN-γ expression in metastases correlated with lower OS (RHO = -0.314, p = 0.008). PD-L1 expression in tumor cells correlated with CD8 + T cells and macrophages in the TME and IFN-γ expression with suppressive CTLA4+/IFNγ+ immune cells in the TME and LN.

Assessment of Gallbladder Drainage Methods in the Treatment of Acute Cholecystitis: A Literature Review.

Gallbladder drainage is a treatment option in high-risk surgical patients with moderate or severe acute cholecystitis. It may be applied as a bridge to cholecystectomy or a definitive treatment option. Apart from the simple and widely accessible percutaneous cholecystostomy, new attractive techniques have emerged in the previous decade, including endoscopic transpapillary gallbladder drainage and endoscopic ultrasound-guided gallbladder drainage. The aim of this paper is to present currently available drainage techniques in the treatment of AC; evaluate their technical and clinical effectiveness, advantages, possible adverse events, and patient outcomes; and illuminate the decision-making path when choosing among various treatment modalities for each patient, depending on their clinical characteristics and the accessibility of methods.

Safe and effective short-time percutaneous cholecystostomy: A retrospective observational study.

The introduction of percutaneous cholecystostomy (PCT) has shifted the paradigm in treatment of acute calculous and acalculous cholecystitis. PCT has high success and low complication rates, but there are still unresolved issues regarding the duration of the procedure. The aim of our study is to determine the characteristics and outcome of patients treated with short-term PCT drainage. Patients who were admitted to the Department of gastroenterology and the Department of Abdominal Surgery at the University Hospital Center Split under the diagnosis of acute cholecystitis and who were treated with the PCT, in a period between January 2015 and January 2020, were retrospectively included in the study. During that timeframe we identified 92 patients and have analyzed their characteristics and clinical outcomes. The statistical analysis included the Kaplan-Meier method for calculating survival curves for grades 2 and 3, the log-rank test for testing the difference between survival rates of grade 2 and 3 patients, and logistic regression to determine variables that affected the outcome of our patients. According to the Tokyo guidelines, most of the patients (74, 80.43%) met the criteria for grade 2 cholecystitis, and the minority had grade 1 (9, 9.78%) and grade 3 (9, 9.78%) cholecystitis. The average drainage duration was 10.1 ±â€…4.8 (3-28) days. We identified mild complications in 6 cases. Nine patients (10%) had lethal outcome. The mortality in the largest group of patients with grade 2 cholecystitis was 5.48% and as high as 71.43% in patients with grade 3 cholecystitis. The complication rate was 6.5%. One quarter of gallbladder aspirates showed a ciprofloxacin resistance. Short-time PCT lasting approximately 10 days can be used safely and effectively for the treatment of patients with acute cholecystitis.

Ultrasound Methods for the Assessment of Liver Steatosis: A Critical Appraisal.

The prevalence of the non-alcoholic fatty liver disease has reached major proportions, being estimated to affect one-quarter of the global population. The reference techniques, which include liver biopsy and the magnetic resonance imaging proton density fat fraction, have objective practical and financial limitations to their routine use in the detection and quantification of liver steatosis. Therefore, there has been a rising necessity for the development of new inexpensive, widely applicable and reliable non-invasive diagnostic tools. The controlled attenuation parameter has been considered the point-of-care technique for the assessment of liver steatosis for a long period of time. Recently, many ultrasound (US) system manufacturers have developed proprietary software solutions for the quantification of liver steatosis. Some of these methods have already been extensively tested with very good performance results reported, while others are still under evaluation. This manuscript reviews the currently available US-based methods for diagnosing and grading liver steatosis, including their classification and performance results, with an appraisal of the importance of this armamentarium in daily clinical practice.

Acute Liver Failure after Treatment with Rivaroxaban for Aortic Thrombosis Associated with COVID-19 Infection and Methylenetetrahydrofolate Reductase Gene Polymorphism (C677T).

Coronavirus disease-2019 (COVID-19) has become associated with prothrombotic state that could lead to severe arterial thrombotic complications. In the case of severe COVID-19 infection, hepatic dysfunction has been observed in more than 50% of patients. In this article, we present a case of aortic thrombosis associated with COVID-19 infection and methylenetetrahydrofolate reductase gene polymorphism (C677T) treated with rivaroxaban resulting in acute liver failure with fatal outcome.

Characteristics and clinical outcomes of patients with acute gastrointestinal bleeding related to anticoagulant or antiplatelet therapy: a retrospective study.

AIM: To investigate the demographic characteristics, endoscopic and laboratory findings, comorbidities and mortality rate of patients with gastrointestinal bleeding related to anticoagulant or antiplatelet therapy. METHODS: We reviewed the records of patients admitted for gastrointestinal bleeding to the Intensive Care Unit of the Department of Gastroenterology, University Hospital Split, between 2015 and 2019. The characteristics and clinical outcomes of patients taking anticoagulant/antiplatelet therapy were analyzed. RESULTS: The study enrolled 1367 patients, 434 (31.7%) of whom received anticoagulant/antiplatelet therapy (mean age 74.9±10.7 years; 64.3% men). The most frequently prescribed drug was acetylsalicylic acid (56.7%), the most common bleeding site was the stomach (41.3%), and the most prevalent cause of bleeding was ulcer (61.6%). Patients taking anticoagulant/antiplatelet therapy who died had significantly higher creatinine (P=0.011) and lower albumin (P=0.015). In the multivariate analysis, the factors that negatively affected survival were older age, higher creatinine, and lower albumin. Patients taking anticoagulant/antiplatelet therapy had slightly lower in-hospital mortality (8.3%) compared with other patients (10.3%). CONCLUSION: Although anticoagulant/antiplatelet therapy increases the risk of gastrointestinal bleeding, it does not directly affect the outcome, which is mainly determined by age and comorbidities.

Liver disease in the era of COVID-19: Is the worst yet to come?

The global social, economic and political crises related to coronavirus disease 2019 (COVID-19) presumably had more indirect than direct negative impacts on health systems. Drastic lifestyle changes, social isolation and distancing, and individual and global financial crises resulted in robust populations forfeiting healthy habits and seeking comfort in alcoholic beverages, drugs and unhealthy diets. The inevitable consequences are increases in the incidence of nonalcoholic fatty liver disease, viral hepatitis, acute alcoholic hepatitis, liver cirrhosis decompensation and ultimately liver-related mortality. The inaccessibility of regular clinical and sonographic monitoring systems has caused difficulties in the treatment of patients with chronic liver disease (CLD) and has prevented prompt hepatocellular carcinoma detection and treatment. A dramatic reduction in the number of liver donors and the transformation of numerous transplantation centers into COVID-19 units drastically decreased the rate of orthotopic liver transplantation. The indirect, unavoidable effects of the COVID-19 pandemic in the following years have yet to be determined. Substantial efforts in the management of patients with liver disease in order to overcome the inevitable COVID-19-related morbidity and mortality that will follow have yet to be initiated. Several questions regarding the impact of the COVID-19 pandemic on liver disease remain. The most important question for general CLD patients is: How will the modification of clinical practice during this pandemic affect the outcomes of CLD patients? This article reviews the influence of COVID-19 on patients with liver disease during the pandemic, with particular emphasis on the disease course associated with pandemic resolution.

Which factors influence liver stiffness measured by real-time two dimensional shear wave elastography in patients on maintenance hemodialysis?

AIM: To evaluate liver stiffness (LS) by real-time two-dimensional shear wave elastography (RT 2D-SWE) and to assess its correlation with the mean arterial pressure (MAP) in patients on maintenance hemodialysis (MHD). The secondary aim was to identify biological and biochemical parameters associated with elevated LS. METHODS: This study enrolled patients treated with MHD in the Split University Hospital from December 2017 through February 2018. LS was measured after a HD session using RT 2D-SWE. Mean arterial pressure was measured before RT-2D-SWE was performed. RESULTS: The study enrolled 47 patients with the mean±standard deviation age of 68.48±14.33 years. Arterial hypertension was diagnosed in 70.2% of patients. Liver stiffness >7 kPa, suggesting clinically relevant fibrosis, was found in 59.5% of patients. Arterial pressure was significantly correlated with LS (ρ=0.38, P=0.008). C-reactive protein (ρ=0.548, P=0.023), parathyroid hormone (ρ=0.507, P=0.038), and total bilirubin (ρ=0.423, P=0.020) were correlated with elevated LS. CONCLUSION: Mean arterial pressure is correlated with increased LS in patients on MHD. Our results emphasize the importance of proper regulation of arterial blood pressure and indicate that LS should always be interpreted in combination with laboratory parameters. Further prospective studies with larger series are needed.

Metabolism of Direct-acting Antiviral Agents (DAAs) in Hepatitis C Therapy: A Review of the Literature.

BACKGROUND: Hepatitis C virus (HCV) infection is still one of the leading causes of chronic liver disease, with chronically infected making up approximately 1% of the global population. Of those infected, 70% (55-85%) will develop chronic HCV infection. Chronic HCV infection causes substantial morbidity and mortality, with complications including cirrhosis, end-stage liver disease, hepatocellular carcinoma, and eventually death. OBJECTIVE: Therapeutic options for chronic HCV infection have evolved dramatically since 2014, with a translation from pegylated interferon and ribavirin (associated with suboptimal cure and high treatment-related toxicity) to oral direct-acting antiviral treatment. There are four classes of direct-acting antivirals which differ by their mechanism of action and therapeutic target. They are all pointed to proteins that form the cytoplasmic viral replication complex. Multiple studies have demonstrated that direct-acting antiviral therapy is extremely well tolerated, highly efficacious, with few side effects. METHODS: We performed an indexed MEDLINE search with keywords regarding specific direct-acting antiviral regimes and their pharmacokinetics, drug-drug interactions, and metabolism in specific settings of pregnancy, lactation, liver cirrhosis, liver transplantation and HCC risk, kidney failure and kidney transplantation. RESULTS: We present a comprehensive overview of specific direct-acting antiviral metabolism and drug-drug interaction issues in different settings. CONCLUSION: Despite its complex pharmacokinetics and the possibility of drug-drug interactions, direct-acting antivirals are highly efficacious in providing viral clearance, which is an obvious advantage compared to possible interactions or side effects. They should be administered cautiously in patients with other comorbidities, and with tight control of immunosuppressive therapy.

Role of endoscopic ultrasound in anticancer therapy: Current evidence and future perspectives.

The digestive system is one of the most common sites of malignancies in humans. Since gastrointestinal tumors represent a massive global health burden both in terms of morbidity and health care expenditures, scientists continuously develop novel diagnostic and therapeutic methods to ameliorate the detrimental effects of this group of diseases. Apart from the well-established role of the endoscopic ultrasound (EUS) in the diagnostic course of gastrointestinal and hepatobiliary malignancies, we have recently become acquainted with a vast array of its therapeutic possibilities. A multitude of previously established, evidence-based methods that might now be guided by the EUS emerged: Radiofrequency ablation, brachytherapy, fine needle injection, celiac plexus neurolysis, and endoscopic submucosal dissection. In this review we endeavored to provide a comprehensive overview of the role of these methods in different malignancies of the digestive system, primarily in the treatment and symptom control in pancreatic cancer, and additionally in the management of hepatic, gastrointestinal tumors, and pancreatic cysts.

Helicobacter pylori infection and severity of coronary atherosclerosis in patients with chronic coronary artery disease.

AIM: Controversy exists concerning the relation between Helicobacter pylori (HP) infection and coronary artery disease (CAD). We aimed to examine the relationship between HP infection and severity of coronary atherosclerosis in patients with chronic CAD. PATIENTS AND METHODS: A total of 150 patients (109 [73%] men; mean age 62.61±10.23 years) scheduled for coronary artery bypass grafting surgery were consecutively enrolled in the cross-sectional study. According to rapid urease test and/or gastric biopsy samples stained with hematoxylin and eosin and according to Giemsa, patients were classified as HP positive (n=87; 58%) or HP negative (n=63; 42%). Coronary angiograms were scored by quantitative assessment, using multiple angiographic scoring system: 1) vessel score (number of coronary arteries stenosed ≥50%), 2) Gensini score (assigning a severity score to each coronary stenosis according to the degree of luminal narrowing and its topographic importance) and 3) angiographic severity score (number of coronary artery segments stenosed ≥50%). RESULTS: In comparison to HP-negative patients, HP-positive patients were more frequently hypertensive (P=0.014), had higher values of systolic (P=0.043) and diastolic (P=0.005) blood pressure and total cholesterol (P=0.013) and had lower values of high-density lipoprotein-cholesterol (HDL-C; P=0.010). There were no significant differences between the groups in the severity of coronary atherosclerosis: vessel score (P=0.152), Gensini score (P=0.870) and angiographic severity score (P=0.734). CONCLUSION: It is likely that HP infection is not a risk factor for the severity of coronary atherosclerosis in chronic CAD patients.

Hamate hook nonunion initially mistaken for ulnar nerve compression: a case report with review of literature.

BACKGROUND: Hamate hook (HH) stress fractures are rare, often presenting with misleading symptoms and easily overlooked/misdiagnosed. These fractures occur frequently in individuals participating in sports activities involving racquets, bats, or clubs. Symptoms are non-specific and often mimic other clinical conditions, such as ulnar nerve entrapment or ulnar vessel thrombosis. CASE REPORT: A 17-year-old tennis player with no history of trauma presented with dominant hand weakness together with pain and paresthesia on the ulnar side, which exacerbated with tennis play. The patient was treated for ulnar nerve compression with activity cessation and rest for 2 months. After 6 months of persistent symptoms, the patient underwent open Guyon tunnel release, although preoperative electromyoneurography revealed no signs of nerve damage and bone scans showed a small area of increased uptake in the hypothenar region. Postoperatively, symptoms resumed and the patient reported to our department for a second opinion. Point tenderness over HH, hypothenar muscles hypotrophy, paresthesia, hand weakness and pain with ulnar deviation, and flexion of distal phalanges of the two ulnar fingers were observed. HH fracture was suspected. Computerized tomography scan revealed fractured HH and the patient underwent hook excision. One month postoperatively, the pain intensity reduced together with function and strength improvement; 2 months postoperatively, the patient was pain free and had returned to tennis. CONCLUSIONS: In patients involved in racquet sports with hypothenar pain and paresthesia of the ulnar side of the hand, HH fracture should be suspected. Symptoms can mimic ulnar nerve entrapment and may lead to overlooking the correct diagnosis. Treatment of choice is fractured fragment excision.

OSTEOID OSTEOMA OF THE CORACOID PROCESS: CASE REPORT WITH LITERATURE REVIEW.

Osteoid osteoma (OO) is the most common benign osteogenic bone tumor that predominantly affects young adults. OO is commonly localized in long bones, and therefore, it is rarely considered in differential diagnosis of chronic shoulder pain. We report a case of a 22-year-old male athlete, without history of previous trauma, who presented to our Department with chronic shoulder pain, which escalated during the night and responded to nonsteroidal anti-inflammatory drug treatment. Considering these typical symptoms, diagnostic pathway was immediately directed towards OO, with magnetic resonance and computed tomography confirming the diagnosis of OO of the coracoid process (CP). Since neurovascular structures are in the proximity of CP, and this very delicate area does not support radiofrequency ablation, we decided to perform an open procedure with drilling of the lesion and excochleation. The pain withdrew immediately after the procedure, and on six-month follow up the patient remained pain free. In the treatment of OO of the CP, we recommend open surgical procedure with tumor ablation by drilling instead of CP resection, presenting a safe, simple and low-cost method that simultaneously completely destroys the lesion and preserves the anatomical and functional role of CP

[Long-term glucocorticoid therapy and the rapid development of squamous cell carcinoma in systemic sclerosis: Is there a connection?].

Systemic sclerosis (SSC) is an autoimmune disease associated with the risk of malignancies, especially lung cancer, among which adenocarcinoma and squamous cell carcinoma are the most frequent. A 63-year-old female patient with SSC was hospitalized due to blackouts, poor general condition, and changes in her fingers. Because of subsequent epileptic seizures resulting in weakness of the left side of her body, computerized tomography (CT) of the neurocranium was performed which showed metastatic lesions. A CT scan of the thoracic organs displayed pulmonary neoplasia in the right hilum, which were histologically evaluated as grade 2 squamous cell carcinoma. After one month of hospitalization with supportive therapy, the patient's clinical condition improved, and she was discharged into home care with recommendations for further oncological treatment. However, the patient died several days later. In comparison to adenocarcinomas, squamous cell carcinomas of the lungs usually develop through a significantly longer period. We consider that the unusually rapid development of the carcinoma in this patient was stimulated by the immunosuppressive effect of high doses of glucocorticoids that she had been taking for several years on her own initiative.

[LEFT VENTRICULAR NON-COMPACTION]. / NEKOMPAKTNA LIJEVA KLIJETKA.

Left ventricular non-compaction (LVNC) is a rare cardiomyopathy, which is today, due to modern ultrasound technology more frequently detected in clinical practice. It is caused by the failure of normal embryonic development of the myocardium from loosely arranged muscle fibers to the mature compacted form of myocardium. Morphologic presentation consists of unique two-layered structure, a thick noncompacted endocardial and a thin compact epicardial layer, in infero-lateral and apical segments. The endocardial layer contains loosely arranged muscle fibers, prominent trabeculations and deep perfused intertrabecular recesses. It could be diagnosed both as an infantile or adult type, appearing sporadically or among families where it is transferred x-linked or autosomal dominant. The recognition of the disease is mandatory because of its high mortality and morbidity due to the progressive heart failure, thromboembolic events and lethal arrhythmias. Echocardiography is the procedure of choice to confirm the diagnosis and in the follow-up of patients with LVNC. A literature review about LVNC pathogenesis, diagnostis, and treatment was discussed.

[Anticoagulant therapy in patients with permanent atrial fibrillation - evidence based medicine and clinical practice]. / Antikoagulantno lijecenje u bolesnika s trajnom fibrilacijom atrija - medicina utemeljena na dokazima i klinicka praksa.

Objective of study was to assess the concordance of the tromboprophylactic treatment in patients with permanent atrial fibrillation (pAF) with guidelines of the European Society of Cardiology. Prospective cross-sectional study consecutivelly included 674 patients (400 S59%C male) discharged from cardiology department with the diagnosis pAF. The thromboembolic risk (TE) has been established according to CHA2DS2-VASc score, whereas the bleeding risk has been assessed according to HAS-BLED score. 578 (86%) belonged to the group of high, 57 (8%) to the group of moderate, and 39 (6%) patients to the group of low TE risk. 601 (89%) patients received thromboprophylaxis: 310 (46%) warfarin, 258 (38%) acetylsalicylic acid, and 33 (5%) patients clopidogrel. Warfarin has been prescribed to 47% of patients with high, 49% of patients with moderate and to 26% of patients with low TE risk (P=0.03). Acetylsalicylic acid (ASA) has equally been prescribed to patients of all TE risk groups: low, moderate and high (39% vs. 39% vs.38%/o; P=0.998). ASA (P<0.001) and warfarin (P=0.007) have been used more frequently in the group of patients with high bleeding risk, in which the same incidence of warfarin and ASA administration has been registered (53% vs. 47%; P=0.416). Age > or =75 has been an independent predictor of non-administration (OR 1.7; 95% CI 1.2-2.4; P=0.003), whereas the history of stroke was for warfarin administration (OR 0.47; 95% CI 0.29-0.76; P-0.002). In prescribing thromboprophylaxis to patients with pAF, cardiologists do not observe the recommended clinical guidelines. Despite nonexistence of contraindications, a significant number of patients with high TE risk has not been administered warfarin. At the same time, warfarin has been administered to the patients with low TE risk, exposing them unnecessarily to the undesired effect of anticoagulant treatment.