Friday, September 21, 2018

Niacin hasn’t lived up to its original promise in cardiovascular prevention



Results

Thirteen trials (N = 35,206) were selected for final analysis. The mean follow-up duration was 32.8 months. Overall, niacin led to significant increases in serum high-density lipoprotein cholesterol levels from baseline trial enrolment by 21.4%, 9.31 (95% confidence interval [CI] 5.11-13.51) mg/dL. However, we did not observe any differences in all-cause mortality rates (RR 0.99; 95% CI 0.88-1.12) between niacin and control arms. Further, niacin treatment was associated with a trend toward lower risk of cardiovascular mortality (RR 0.91; 95% CI 0.81-1.02), coronary death (RR 0.93; 95% CI 0.78-1.10), nonfatal myocardial infarction (RR 0.85; 95% CI 0.73-1.0), revascularization (coronary and noncoronary) (RR 0.83; 95% CI 0.65-1.06), and stroke (RR 0.89; 95% CI 0.72-1.10), compared with control.

Conclusion

Niacin therapy does not lead to significant reductions in total or cause-specific mortality or recurrent cardiovascular events among persons with or at risk of atherosclerotic cardiovascular disease.

The review also pointed out adverse effects including worsening of or increased risk of onset of diabetes.

Niacin showed promise in 15 year follow up of the coronary drug project (its use was associated with lowered all cause mortality) and is the only lipid regulating agent that has been associated with regression of atherosclerosis. [1] [2] Although the review cited an article on the 15 year follow up of the coronary drug project (CDP) the analysis of research findings only included the early report of the CDP, which did not show reduction in mortality.


Thursday, September 20, 2018

The American College of Cardiology Fourth Universal Definition of Myocardial Infarction has been published


You can access the full text of the document here. Following are some key points:


Any cardiac troponin value above the upper range limit is considered myocardial injury. If the elevation is static it is considered chronic myocardial injury. If there's a rise or fall it is considered acute. For this to be considered myocardial infarction there must be some additional clinical indicator which might be based on symptoms, ECG changes or imaging. There needs to be at least one.


The above criteria for troponin elevation apply to MI types one through three. For types four and five, different troponin cut offs apply. For these types of infarction troponin elevations must be greater than 5 or greater than 10 times the upper range limit, respectively. Troponin elevations that do not meet these cutoffs denote injury rather than infarction. (Note that a peri-PCI MI is termed type 4a. There is also a 4b and 4c MI and these terms refer to the more distant downstream complications of stent thrombosis and stent restenosis, respetively).


And now for an overview of types one through five. These categories are essentially unchanged from the prior edition of the universal definition. Type one MI is an acute coronary syndrome with plaque instability and thrombus, either occlusive or nonocclusive as indicated by the surrogates STEMI and NSTEMI respectively. Type 2 MI is not an acute coronary syndrome. It may occur in the presence or the absence of coronary disease. If coronary disease is present there is no plaque instability. The infarction is caused by an unfavorable balance and oxygen supply and demand. A couple of additional points are of note regarding type 2 MI. First of all in general patients with type 2 MI have a worse prognosis than those with type 1. This is due to the presence of comorbidity and is not surprising. Among patients with type 2 MI, those with coronary disease have a worse prognosis then those without. Of interest, studies have shown that ST elevation in type 2 MI occurs in between 3% and 24% of cases. In part this may be because coronary embolism and spontaneous coronary artery dissection (SCAD) are classified as type 2 MI. Finally it is not always possible to differentiate between type 2 MI and non-ischemic myocardial injury. In fact the two conditions may overlap. Type III MI is sudden cardiac death in which acute myocardial infarction was suspected but there was no opportunity to draw troponin levels. Type 4a is peri-PCI MI. Types 4 b and c represent the downstream manifestations already discussed. Type 5 MI is peri-CABG MI. The differences in troponin criteria for types four and five as opposed to types one through three have already been discussed.


A few special points should be made concerning perioperative ischemic events surrounding non-cardiac surgery. The ACC/AHA guidelines on perioperative evaluation and management for patients undergoing noncardiac surgery, updated in 2014, give troponin testing in the perioperative period a class I recommendation only for patients who exhibit signs or symptoms of myocardial ischemia. Troponin testing as a means of surveillance for patients deemed to be at high risk but without said signs or symptoms carries only a IIb recommendation. However a recent report and accompanying editorial published in the March 20, 2018 issue of Circulation suggest a role for pre and post operative troponin surveillance in selected high risk patients. There is still no consensus regarding this.


Acute exacerbation of heart failure is a special case. The article recommends troponin testing in all such patients. If troponin is elevated and it is dynamic, there should be a high index of suspicion for MI. A static elevation may represent chronic myocardial injury as part of the heart failure syndrome.


Takotsubo cardiomyopathy, nowadays more appropriately referred to as stress cardiomyopathy, is considered separately. It is distinguished from MI of any kind. The mechanism of myocardial injury is the subject of controversy but it's probably at least in part catecholamine mediated injury in which case it would be nonischemic myocardial injury. Another special situation is myocardial infarction with nonobstructive coronary arteries. This is known as MINOCA and may arise as a result of either type 1 or 2 MI.


What about patients with CKD? Many of these patients who have elevated troponins have chronic myocardial injury as a result of the CKD. Diagnosis of MI may be difficult in this setting. It is based on changes in troponin along with the other clinical criteria previously discussed.


Critical illness is commonly associated with troponin elevation. Either type 1 or type 2 MI may occur. Quite often patients with critical illness experience troponin elevation due to non-ischemic myocardial injury as an organ manifestation of the underlying critical illness. These cases may be difficult to distinguish from MI, especially type 2. In such patients, whether to evaluate for coronary disease, usually after recovery from critical illness, as a matter for clinical judgment.


The document contains some discussion of the ECG changes of myocardial infarction. The section makes several important points. First, when the initial tracing is nondiagnostic in a patient having active chest pain, serial tracings 15 to 30 minutes apart for the first couple of hours are recommended. ST segment elevation in lead aVR is mentioned as an important prognostic indicator and an indication of left main or multi vessel coronary artery disease. De Winter and Wellens T waves are described in that section, without calling them by name.


Bundle branch block gets a very superficial discussion. Scarbossa like changes are hinted at without using that eponym. New bundle branch block, either right or left, is mentioned. Mention is made of electrical remodeling (otherwise known as cardiac memory) in patients with pacemakers, in reference to non-paced complexes.


Section 31 has a nice discussion of normal versus pathologic Q waves and/ or QS complexes. Section 33 discusses ST segment and T wave negativity commonly seen in rapid atrial fibrillation and SVT. It states that the cause is poorly understood but that the phenomenon does not necessarily represent myocardial ischemia. It is mentioned that some degree of anomalous ventricular activation and or electrical remodeling may somehow explain these findings. In some cases it may represent a type 2 MI but this should not automatically be classified as such without additional clinical indicators.




New in the gram negative pipeline: Imipenem-Relebactam and Meropenem-Vaborbactam


Report here.

Wednesday, September 19, 2018

Methamphetamine and pulmonary hypertension


This review describes the recently discovered association.

Tuesday, September 18, 2018

Harmful effects of raised “low T” awareness


From a recent review:

Purpose of review

To summarize the research evidence on promotion of testosterone for ‘Low T’, or age-related hypogonadism.

Recent findings

Marketing of testosterone for ‘Low T’ has relied on strategies that are inadequately regulated to prevent off-label promotion, such as unbranded ‘disease-awareness’ advertising campaigns targeting the general public, sponsored continuing medical education (CME) and ghostwriting. A recent US analysis of television advertising exposure levels versus insurance claims found that both unbranded ‘disease-awareness’ advertising and branded ads were associated with increased rates of testosterone testing, treatment initiation, and treatment without prior testing. Exposés of sponsored CME and ghostwriting indicate misrepresentation of the research evidence on the sequelae of untreated low testosterone and on treatment efficacy. In the United States, advertising to the general public ceased in 2014 after the Food and Drug Administration changed product labeling to clarify that testosterone is only indicated for pathological hypogonadism. Unbranded ‘disease-awareness’ advertising to the general public and ‘Low T’ messages for health professionals have continued elsewhere.

Summary

The review of the experience of promotion of testosterone for ‘Low T’ and research evidence on effects of advertising targeting the public highlights the need for improved regulation of unbranded ‘disease awareness’ advertising to ensure adequate protection of public.



Monday, September 17, 2018

A resurgence of Legionella


From a review:

Abstract:

Purpose of review

The present review summarizes new knowledge about Legionella epidemiology, clinical characteristics, community-associated and hospital-based outbreaks, molecular typing and molecular epidemiology, prevention, and detection in environmental and clinical specimens.

Recent findings

The incidence of Legionnaire's disease is rising and the mortality rate remains high, particularly for immunocompromised patients. Extracorporeal membrane oxygenation may help support patients with severe respiratory failure. Fluoroquinolones and macrolides appear to be equally efficacious for treating Legionnaires’ disease. Whole genome sequencing is an important tool for determining the source for Legionella infections and for understanding routes of transmission and mechanisms by which new pathogenic clones emerge. Real-time quantitative polymerase chain reaction testing of respiratory specimens may improve our ability to diagnose Legionnaire's disease. The frequency of viable but nonculturable organisms is quite high in some water systems but their role in causing clinical disease has not been defined.

Summary

Legionellosis remains an important public health threat. To prevent these infections, staff of municipalities and large buildings must implement effective water system management programs that reduce Legionella growth and transmission and all Medicare-certified healthcare facilities must have water management policies. In addition, we need better methods for detecting Legionella in water systems and in clinical specimens to improve prevention strategies and clinical diagnosis.



Sunday, September 16, 2018

When to intubate in cardiac arrest?


From a recent review:

Purpose of review

Cardiac arrest mortality remains high, and the impact on outcome of most advanced life support interventions is unclear. The optimal method for managing the airway during cardiac arrest remains unknown. This review will summarize and critique recently published evidence comparing basic airway management with the use of more advanced airway interventions [insertion of supraglottic airway (SGA) devices and tracheal intubation].

Recent findings

Systematic reviews generally document an association between advanced airway management and worse neurological outcome but they are subject to considerable bias. A recent observational study of tracheal intubation for in-hospital cardiac arrest that used time-dependent propensity matching showed an association between tracheal intubation during the first 15 min of cardiac arrest and a worse a neurological outcome compared with no intubation in the first 15 min. In a recent randomized clinical trial, tracheal intubation was compared with bag-mask ventilation (with intubation only after return of spontaneous circulation) in 2043 patients with out-of-hospital cardiac arrest. There was no difference in favorable neurological outcome at 28 days.

Summary

Most of the available evidence about airway management during cardiac arrest comes from observational studies. The best option for airway management is likely to be different for different rescuers, and at different time points of the resuscitation process. Thus, it is common for a single patient to receive multiple ‘stepwise’ airway interventions. The only reliable way to determine the optimal airway management strategy is to undertake properly designed, prospective, randomized trials. One randomized clinical trial has been published recently and two others have completed enrollment but have yet to be published.


Saturday, September 15, 2018

Hypervirulent Klebsiella pneumoniae



Abstract:

Purpose of review

Two pathotypes of Klebsiella pneumoniae cause human infections, classical (cKp) and hypervirulent (hvKp) K. pneumoniae . The present understanding of genetic elements, the need for an accurate test to identify hvKp, the clinical implications of infection, the knowledge gap on how and why hvKp colonization transitions to infection, and potential infection prevention and control issues for hvKp are discussed.

Recent findings

Infections because of hvKp are increasingly recognized worldwide. Its ability to cause organ and life-threatening disease in healthy individuals from the community merits concern, which has been magnified by increasing descriptions of multiply drug-resistant (MDR) and extensively drug-resistant (XDR) strains. Increased capsule and siderophore production by hvKp relative to cKp are critical virulence traits. Asians are most commonly infected, but whether this is mediated by a genetic susceptibility, or increased exposure and colonization is unknown. Specific studies about the epidemiology and transmission of hvKp are lacking, but precautions are appropriate for MDR/XDR strains and perhaps all infected/colonized individuals.

Summary

hvKp is evolving into an increasingly concerning pathogen, in part because of the development of XDR strains. An accurate test to identify hvKp is needed for optimal clinical care, epidemiological, and research studies. An improved understanding of how infection develops, if a genetic susceptibility exists, and appropriate infection prevention and control measures also are needed.

Friday, September 14, 2018

Home treatment of PE






From a recent review:



Abstract:



Purpose of review



Historically, because of the necessity of parenteral anticoagulation, patients with acute pulmonary embolism are hospitalized until stable oral anticoagulation is achieved. Despite improvements in prognostic risk stratification and the introduction of the direct oral anticoagulants, home treatment is still not widely applied. Main advantages of home treatment involve improvement of quality of life and significant healthcare cost reduction. In this review, we summarized recent published data on home treatment of patients with acute pulmonary embolism.



Recent findings



Although a significant decrease in mean duration of hospital admission for pulmonary embolism has been demonstrated over the last decade in Europe, most pulmonary embolism patients are currently hospitalized while they might be treated in an outpatient setting. In recent years, five major studies have been performed, in which the decision to initiate home treatment was based on the Hestia criteria in most patients. Over 98% of patients treated at home had an uncomplicated course.



Summary



Home treatment of acute pulmonary embolism is suggested to be feasible and safe in 30–55% of all patients. Results of ongoing trials will provide more insight in the optimal strategy to select patients with pulmonary embolism who are eligible for home treatment and likely will result in more widespread application of this practice.


Thursday, September 13, 2018

Historical perspective and an update on the HIV pandemic: an interview with Anthony Fauci


Wednesday, September 12, 2018

Advanced dementia patients do better when their broken hips are repaired


From a recent paper in JAMA Internal Medicine, here are the data:

Importance The decision whether to surgically repair a hip fracture in nursing home (NH) residents with advanced dementia can be challenging.

Objective To compare outcomes, including survival, among NH residents with advanced dementia and hip fracture according to whether they underwent surgical hip fracture repair.

Design, Setting, and Participants We conducted a retrospective cohort study of 3083 NH residents with advanced dementia and hip fracture, but not enrolled in hospice care, using nationwide Medicare claims data linked with Minimum Data Set (MDS) assessments from January 1, 2008, through December 31, 2013.

Methods Residents with advanced dementia were identified using the MDS. Medicare claims were used to identify hip fracture and to determine whether the fracture was managed surgically. Survival between surgical and nonsurgical residents was compared using multivariable Cox proportional hazards with inverse probability of treatment weighting (IPTW). All analyses took place between November 2015 and January 2018. Among 6-month survivors, documented pain, antipsychotic drug use, physical restraint use, pressure ulcers, and ambulatory status were compared between surgical and nonsurgical groups.

Results Among 3083 residents with advanced dementia and hip fracture (mean age, 84.2 years; 79.2% female [n = 2441], 28.5% ambulatory [n = 879]), 2615 (84.8%) underwent surgical repair. By 6-month follow-up, 31.5% (n = 824) and 53.8% (n = 252) of surgically and nonsurgically managed residents died, respectively. After IPTW modeling, surgically managed residents were less likely to die than residents without surgery (adjusted hazard ratio [aHR], 0.88; 95% CI, 0.79-0.98). Among 2007 residents who survived 6 months, residents with surgical vs nonsurgical management had less docmented pain (29.0% [n = 465] vs 30.9% [n = 59]) and fewer pressure ulcers (11.2% [n = 200] vs 19.0% [n = 41]). In IPTW models, surgically managed residents reported less pain (aHR, 0.78; 95% CI, 0.61-0.99) and pressure ulcers (aHR, 0.64; 95% CI, 0.47-0.86). There was no difference between antipsychotic drug use and physical restraint use between the groups. Few survivors remained ambulatory (10.7% [n = 55] of surgically managed vs 4.8% [n = 1] without surgery).

Conclusions and Relevance Surgical repair of a hip fracture was associated with lower mortality among NH residents with advanced dementia and should be considered together with the residents’ goals of care in management decisions. Pain and other adverse outcomes were common regardless of surgical management, suggesting the need for broad improvements in the quality of care provided to NH residents with advanced dementia and hip fracture.

But now take a look at how JAMA Internal Medicine spun the data!

Key Points

Question Do outcomes for nursing home residents with advanced dementia and hip fracture differ with vs without surgical repair?

Findings In this cohort study of 3083 nursing home residents with advanced dementia and hip fracture, over 2-year follow-up, the mortality rate was 12% lower in residents whose hip fracture was treated with surgery. Among 6-month survivors, pain, antipsychotic drug use, physical restraint use, pressure ulcers, and loss of ambulation were common regardless of surgical management.

Meaning In nursing home residents with advanced dementia and hip fracture, the potential survival benefit of surgery should be considered together with the patients’ goals of care; there is an opportunity to improve quality of care regardless of how the fracture is managed.


Tuesday, September 11, 2018

Glucagon role in DM 2 and the actions of drugs that modulate glucagon


Free full text review here.

Monday, September 10, 2018

Sunday, September 09, 2018

Experimental weight gain associated with BP increase


Saturday, September 08, 2018

Friday, September 07, 2018

Outcomes after decompression cranieotomy


From a review:

Abstract:

Purpose of review

There is little doubt that decompressive craniectomy can reduce mortality following malignant middle cerebral infarction or severe traumatic brain injury. However, the concern has always been that the reduction in mortality comes at the cost of an increase in the number of survivors with severe neurological disability.

Recent findings

There has been a number of large multicentre randomized trials investigating surgical efficacy of the procedure. These trials have clearly demonstrated a survival benefit in those patients randomized to surgical decompression. However, it is only possible to demonstrate an improvement in outcome if the definition of favourable is changed such that it includes patients with either a modified Rankin score of 4 or upper severe disability. Without this recategorization, the results of these trials have confirmed the ‘Inconvenient truth’ that surgery reduces mortality at the expense of survival with severe disability.

Summary

Given these results, the time may have come for a nuanced examination of the value society places on an individual life, and the acceptability or otherwise of performing a procedure that converts death into survival with severe disability.

Thursday, September 06, 2018

Myocardial dysfunction in sepsis


Both systolic and diastolic dysfunction occur. Diastolic dysfunction seems to be more associated with mortality. Ionotropic agents have been disappointing.

Wednesday, September 05, 2018

Another review on acute pancreatitis


Form the paper:

Purpose of review

Acute pancreatitis is a common condition that affects patients with varying degrees of severity and may lead to significant morbidity and mortality. The present article will review the current paradigm in acute pancreatitis management within the first 72 h of diagnosis.

Recent findings

Patients presenting with acute pancreatitis should be evaluated clinically for signs and symptoms of organ failure in order to appropriately triage. Initial management should focus on fluid resuscitation, with some data to support Ringer's lactate over physiological saline. Routine use of prophylactic antibiotics in acute pancreatitis is not recommended, nor is urgent endoscopic retrograde cholangiopancreatography in the absence of concomitant acute cholangitis. Early oral feeding should be encouraged, not avoided, and use of parenteral nutrition is discouraged. Cholecystectomy during the same admission of biliary pancreatitis should be performed in order to prevent future acute pancreatitis episodes. Patients with acute pancreatitis secondary to alcohol should receive alcohol counseling. Finally, there is ongoing interest in the development of prognostic laboratory tests in acute pancreatitis and pharmacological therapies to reduce the inflammation that occurs in acute pancreatitis.

Summary

Acute pancreatitis is a common and heterogeneous condition with the potential for significant morbidity. Best practices in acute pancreatitis management focus on triage, hydration and enteral feeding.

Tuesday, September 04, 2018

Concerns about adverse effects of PPIs: current status




First introduced in 1989, proton pump inhibitors (PPIs) are among the most widely utilized medications worldwide, both in the ambulatory and inpatient clinical settings. The PPIs are currently approved by the US Food and Drug Administration for the management of a variety of gastrointestinal disorders including symptomatic peptic ulcer disease, gastroesophageal reflux disease, and nonulcer dyspepsia as well as for prevention of gastrointestinal bleeding in patients receiving antiplatelet therapy. PPIs inhibit gastric acid secretion, and the most commonly associated adverse effects include abdominal pain, diarrhea, and headache. Although PPIs have had an encouraging safety profile, recent studies regarding the long-term use of PPI medications have noted potential adverse effects, including risk of fractures, pneumonia, Clostridium difficile diarrhea, hypomagnesemia, vitamin B12 deficiency, chronic kidney disease, and dementia. These emerging data have led to subsequent investigations to assess these potential risks in patients receiving long-term PPI therapy. However, most of the published evidence is inadequate to establish a definite association between PPI use and the risk for development of serious adverse effects. Hence, when clinically indicated, PPIs can be prescribed at the lowest effective dose for symptom control.


Monday, September 03, 2018

Andexxa approved for reversal of NOACs (direct Xa infibitors)


Saturday, September 01, 2018

The EMR and other “systems improvements”: unfounded optimism


Thursday, August 30, 2018

Post arrest PCI: the earlier the better



Background

Timely post-resuscitation coronary reperfusion therapy is recommended; however, the timing of immediate coronary reperfusion for out-of-hospital cardiac arrest (OHCA) has not been established. We studied the effect of the time interval from arrest to percutaneous coronary intervention (PCI) on resuscitated OHCA patients.

Methods

All witnessed OHCA patients with a presumed cardiac etiology received successful PCI at hospitals between 2013 and 2015, excluding cases with unknown information regarding the time from arrest to PCI and survival outcomes. The main exposure of interest was the time interval from arrest to ballooning or stent placement in coronary arteries, and cases were categorized into five groups of 0–90, 90–120, 120–150, and 150–180 min and 3–6 h. The endpoint was survival with good neurological recovery. Multivariable logistic regression analysis was performed, adjusting for patient-community, prehospital, and hospital factors.

Results

A total of 765 patients (24.1% received PCI within 90 min; 31.0% in 90–120 min; 17.8% in 120–150 min; 12.3% in 150–180 min; 14.9% in 3–6 h after arrest) were included. Good neurological recovery was more frequent in the early PCI groups than the delayed PCI group (63.6%, 55.3%, 47.8%, 33.0%, and 42.1%, respectively). The adjusted OR (95% CI) for good neurological recovery compared with the most early PCI group was 0.86 (0.53–1.39) in the PCI group between 90 and 120 min; 0.76 (0.45–1.31) in the PCI group between 120 and 150 min; 0.42 (0.22–0.79) in the PCI group between 150 and 180 min; and 0.53 (0.30–0.93) in PCI group after 3 h.

Conclusions

Among resuscitated OHCA patients with a presumed cardiac etiology and successful PCI, patients who received a delayed coronary intervention after 150 min from arrest were less likely to have neurologically intact survival compared to those who received an early intervention.


UAMS Grand Rounds video archives


For archived events prior to 4/19/18 click here.

8/2/18 Histoplasmosis, blastomycosis. Michael Saccente MD

7/26/18 The Hospitalized Parkinsons patient. Rohit Dhall MD


6/24/18 What’s so diff-icult about C diff? Atul Kothari MD

6/21/18 Update in perioperative medicine. Latha Achanta MD




5/10/18 CAR-T cell therapy toxicity management. Appalla Naidu Sasapu MD



Saturday, August 11, 2018

Update on neurosarcoidosis


From a recent review:

Recent findings

Clinical presentation is heterogeneous with most patients presenting with cranial nerve palsy, headache, or sensory abnormalities. Patients are classified according to probability of the diagnosis with the Zajicek criteria. In these criteria, histopathological confirmation of noncaseating granulomas in affected tissue outside the nervous system is key. Radiological abnormalities on neuroimaging are nonspecific. No biomarkers have been described that adequately identify patients with sarcoidosis. However, soluble interleukin-2 receptor is a relatively novel biomarker that may be useful. In addition to HRCT scan, 18 F-FDG PET-CT scanning can identify occult locations of disease activity and aid in obtaining pathological confirmation. Despite the use of new therapies, still a third of patients remains stable, deteriorate, or die.

Summary

Diagnosing and treating patients with neurosarcoidosis remains a challenge. Long-term prospective studies evaluating patients suspected of neurosarcoidosis are needed to assess sensitivity and specificity of ancillary investigations and diagnostic criteria. Furthermore, future studies are needed to evaluate the prognosis and the optimal treatment strategy.

Friday, August 10, 2018

Thursday, August 09, 2018

Neuropsychiatric complications of dopaminergic therapy


As pointed out in this free full text review the neuropsychiatric side effects go beyond impulsive gambling to a variety of impulse control phenomena and other psychiatric disturbances. Moreover, it’s not just in patients treated with Parkinson disease but also some of those treated for restless leg syndrome and prolactinoma. There are a number of poorly understood metabolic effects as well, largely favorable it would seem.

Wednesday, August 08, 2018

Is there an association between COPD and NAFLD?


From a recent paper:

Abstract

Nonalcoholic fatty liver disease (NAFLD) is independently linked to cardiometabolic morbidity and mortality. Low-grade inflammation, oxidative stress and ectopic fat, common features of chronic obstructive pulmonary disease (COPD), might contribute to the development of NAFLD.

We aimed to investigate the prevalence of NAFLD and to evaluate the relationship between various types of liver damage and COPD severity, comorbidities and circulating inflammatory cytokines. Validated noninvasive tests (FibroMax: SteatoTest, NashTest and FibroTest) were used to assess steatosis, nonalcoholic steatohepatitis (NASH) and liver fibrosis. Patients underwent an objective assessment of COPD comorbidities, including sleep studies. Biological parameters included a complete lipid profile and inflammatory markers.

In COPD patients the prevalence of steatosis, NASH and fibrosis were 41.4%, 36.9% and 61.3%, respectively. In multivariate analysis, SteatoTest and FibroTest were significantly associated with sex, body mass index (BMI), untreated sleep apnoea and insulin resistance, and, in addition, COPD Global Initiative for Chronic Obstructive Lung Disease stage for SteatoTest. Patients with steatosis had higher tumour necrosis factor-α levels and those with NASH or a combination of liver damage types had raised leptin levels after adjustment for age, sex and BMI.

We concluded that NAFLD is highly prevalent in COPD and might contribute to cardiometabolic comorbidities.