Occult cirrhosis diagnosed by transient elastography is a frequent and under-monitored clinical entity.

BACKGROUND & AIMS: Diagnosis of preclinical compensated cirrhosis (occult cirrhosis, OC) is challenging due to lack of clinical findings. We evaluated prevalence and outcomes of OC by transient elastography (TE, Fibroscan(®)). METHODS: Eight hundred and seventy-one patients with compensated chronic liver disease (CLD) and TE examination were divided into: (i) OC (TE ≥ 13 kPa and no sign of cirrhosis, including absence of thrombocytopenia and signs of advanced liver disease on ultrasound or gastroscopy); (ii) clinically evident cirrhosis (TE ≥ 13 kPa with signs of cirrhosis); (iii) non-cirrhotic CLD (TE < 13 kPa). Outcomes included hepatocellular carcinoma (HCC), esophageal varices and ascites. Late diagnosis of outcomes was defined as HCC stage ≥intermediate by BCLC or variceal bleeding. RESULTS: Occult cirrhosis represented 12% of the cohort and 37% of cirrhotic patients. Independent predictors of OC were age [odds ratio (OR) 1.15; 95% confidence interval (CI), 1.04-1.26], HIV co-infection (OR 3.53; 95% CI, 1.85-6.76) and APRI (OR 2.63; 95 CI, 1.87-3.71). During a median follow-up of 24 (interquartile range 20-37) months, OC received less surveillance than clinically evident cirrhosis, with fewer ultrasounds (2.7 ± 1.5 vs 3.6 ± 2; P < 0.001) and gastroscopies (2 ± 0.8 vs 2.6 ± 1.4; P < 0.001). Incidence of outcomes was 3.5/100 per person-years (PY) (95% CI, 0.1-6.9) in OC, 0 in non-cirrhotic CLD and 9.8/100 PY (95% CI, 0.3-19.3) in clinically evident cirrhosis (P < 0.001). Late diagnosis occurred more in OC than clinically evident cirrhosis (60 vs 15%, P = 0.01). CONCLUSIONS: Occult cirrhosis is a frequent and under-monitored clinical entity associated with short-term risk of outcomes. TE may help early diagnosis, prompt initiation of surveillance and specific therapy for an otherwise unrecognized condition.

Prevalence and perinatal outcomes of non-communicable diseases in pregnancy in a regional hospital in Haiti: A prospective cohort study.

BACKGROUND: The prevalence of non-communicable diseases (NCDs) is rising in low and middle-income countries (LMIC). We aimed to report on the prevalence of NCDs in pregnancy and their associated perinatal outcomes in a regional hospital in Haiti. METHODS: We conducted the "Diabète et hYpertension Artéerielle et leurs issues MAternelles et Néonatales" (DYAMAN) prospective cohort study in a regional hospital in Haiti. Pregnant women presenting to care at 24-28 weeks were screened and treated for diabetes (DM) and hypertensive disorders of pregnancy (HDP) using setting-adapted protocols. Prevalence of NCDs and associated maternal-neonatal outcomes were described. RESULTS: 715 women were included, of which 51 (7.1%) had DM, 90 (12.6%) had HDP, and 30 (4.2%) had both DM and HDP (DM/HDP). Of 422 (59%) women delivered in hospital, 58 (13.7%) had preeclampsia, including 5 (8.6%) with eclampsia. Preterm birth <32 weeks was more common in the HDP than the control, DM, and DM/HDP groups. More low birth weight babies (n = 20, 25.6%) were born to the HDP group than to the control (n = 20, 7.1%), DM (n = 1, 2.7%), and DM/HDP (n = 3, 12%) groups (P < 0.001). Macrosomia and hypoglycemia affected 5 (8%) neonates of women with DM. Perinatal mortality, affecting 36/1000 births, was mainly driven by maternal NCDs. CONCLUSIONS: NCDs in pregnancy led to adverse maternal and perinatal outcomes. This study will help to prepare future refinements aimed at optimizing the management of NCDs in pregnancy in LMIC. Research is required to understand barriers to patient attendance at antenatal follow-up, treatment escalation for hyperglycemia, and in-hospital delivery.

Discontinuation of acetylcholinesterase inhibitor treatment in the nursing home.

BACKGROUND: Dementia treatment guidelines are not consistent in determining how long to continue acetylcholinesterase inhibitor (AChEI) treatment in patients with Alzheimer's disease. OBJECTIVE: Our aim was to examine reasons for AChEI discontinuation in a nursing home to better understand how practitioners actually decide when to stop treatment. METHODS: A retrospective chart review was done on 107 deceased nursing home veterans who had been taking an AChEI to determine the time between discontinuation and death. RESULTS: In the majority of residents (n = 67; 63%), the AChEI was continued into the week preceding death. Reasons for discontinuation were dying or death (n = 56; 52%), admission to hospice (n = 13; 12.2%), and admission to the nursing home (n = 5; 4.7%). Admission to hospice (P = 0.01), hospice length of stay (P = 0.0004), and length of stay at Minnesota Veterans Home (P = 0.02) were significantly associated with discontinuation of AchEI before the last week of life. CONCLUSION: Our study showed that residents were significantly more likely to have their AChEI discontinued if they were either admitted to hospice, stayed longer in hospice, or stayed longer in the nursing home. In addition, the majority of residents continued AChEI treatment until sometime during the week before death occurred.