Background: Atrial fibrillation (AF) is a common cardiac arrhythmia that increases the risk of stroke. Medical therapy for decreasing stroke risk involves anticoagulation, which may increase bleeding risk for certain patients. In determining optimal therapy for stroke prevention for patients with AF, clinicians use tools with various clinical, imaging, and patient characteristics to weigh stroke risk against therapy-associated bleeding risk. Aim: Review published literature and summarize available risk stratification tools for stroke and bleeding prediction in patients with AF. Methods: We searched for English-language studies in PubMed®, Embase®, and the Cochrane Database of Systematic Reviews published between January 1, 2000, and February 14, 2018. Two reviewers screened citations for studies that examined tools for predicting thromboembolic and bleeding risks in patients with AF. Data regarding study design, patient characteristics, interventions, outcomes, quality and applicability were extracted. Results: 61 studies were relevant to predicting thromboembolic risk and 38 to predicting bleeding risk. Data suggest that CHADS2, CHA2DS2-VASc, and ABC risk scores have the best evidence predicting thromboembolic risk (moderate strength of evidence for limited prediction ability of each score) and that HAS-BLED has the best evidence for predicting bleeding risk (moderate strength of evidence). Limitations: Studies were heterogeneous in methodology and populations of interest, setting, interventions, and outcomes analyzed. Conclusion: CHADS2, CHA2DS2-VASc, and ABC stroke have the best prediction for stroke events, and HAS-BLED provides the best prediction for bleeding risk. Future studies should define the role of imaging tools and biomarkers in enhancing the accuracy of risk prediction tools. Primary Funding Source: Patient-Centered Outcomes Research Institute (PROSPERO #CRD42017069999)

).Pancreas transplantation allows for a euglycemic state in the absence of exogenous insulin. Exocrine pancreatic drainage can be achieved via the gastrointestinal or urinary tracts. Arterio-enteric fistulas constitute an infrequently encountered but potentially fatal complication associated with failed enteric-drained pancreas transplants. Case ReportOur patient is a 58-year-old woman who is presented with hematemesis. Work up inclusive of esophagogastroduodenoscopy (EGD), colonoscopy, and capsule endoscopy did not identify any site of hemorrhage. After a 48-hour observation period with no further bleeding, the patient was discharged home. Twenty days later, she was presented to an outside hospital with a severe recurrent gastrointestinal bleed, prompting an emergent transfer to our institution for further diagnosis and treatment.Her past medical and surgical histories were significant for type 1 diabetes mellitus and renal failure, for which she had undergone an isolated living donor-related kidney transplant 5 years before presentation. She underwent a cadaveric pancreas after kidney transplant, 2 years later. The methods of pancreas transplantation utilized were enteric exocrine drainage and systemic venous drainage. The pancreatic allograft functioned well initially, and the patient maintained euglycemia for 2 years. At that point, 1 year before presentation, the pancreatic allograft had failed because of chronic rejection. Her kidney allograft was still functioning normally. Her immunosuppressive regimen consisted of the following: mycophenolate mofetil 250 mg oral, twice a day; tacrolimus 3 mg oral, twice a day; and prednisone 5 mg oral, once a day.The patient was admitted to our intensive care unit and transfused 6 units of packed red blood cells and 2 units of fresh-frozen plasma with an adequate hemodynamic response. A bedside EGD showed large amounts of blood in the stomach and duodenum with no apparent source. On the basis of these findings, it was decided to proceed with an emergency angiogram to identify the source of bleeding and control it, possibly by endovascular approach. While in the radiology department, as the procedure was about to be Keywords ► arterio-enteric fistula ► enteric-drained pancreas transplant ► gastrointestinal bleeding ► endovascular stenting ► allograft pancreatectomy AbstractEnteric drainage is the preferred method of exocrine diversion in simultaneous kidneypancreas transplantation. Because of improvements in immunosuppression, enteric drainage has become the preferred method of pancreas transplantation in general.Although associated with less potential complications than bladder-drained pancreas, potentially lethal arterio-enteric fistulas in the setting of nonfunctioning allografts represent a constant threat. We herein present a case report, a review of the literature, and a call for caution.

Background: The comparative safety and effectiveness of treatments to prevent thromboembolic complications in atrial fibrillation (AF) remains uncertain. Purpose: To compare the available treatment strategies in patients with AF. Data Sources: English-language studies in multiple databases from January 1, 2000, to February 14, 2018. Study Selection: Two reviewers independently screened citations for studies examining treatments for stroke prevention in patients with AF. Data Extraction: Two reviewers independently abstracted data and assessed study quality and applicability. Data Synthesis: Data from 220 articles were included. Dabigatran and apixaban were superior while rivaroxaban and edoxaban were similar to warfarin in the prevention of stroke or systemic embolism. Apixaban and edoxaban were superior while rivaroxaban and dabigatran were similar to warfarin in reducing the risk of major bleeding. Treatment effects with dabigatran were similar in patients with renal dysfunction (interaction p>0.05) and patients less than 75 years old had lower rates of bleeding with dabigatran (interaction p<0.001). The benefit of treatment with apixaban was consistent in many subgroups including those with renal impairment, diabetes and prior stroke (interaction p>0.05 for all). The greatest bleeding risk reduction was observed in patients with GFR<50mL/min (p=0.003). Similar treatment effects of rivaroxaban and edoxaban were observed in patients with prior stroke, diabetes, or heart failure (interaction p>0.05 for all). Limitations: Heterogeneous study populations, interventions and outcomes. Conclusion: The available DOACs are at least as effective and safe when compared to warfarin. Similar benefits of treatment with DOACs were observed across multiple patient subgroups of interest, giving assurance to the safe and efficacious use of DOACs for a wide range of patients with AF. Primary Funding Source: Patient-Centered Outcomes Research Institute (PROSPERO #CRD42017069999)

The information in this report is intended to help health care decisionmakers-patients and clinicians, health system leaders, and policymakers, among others-make well-informed decisions and thereby improve the quality of health care services. This report is not intended to be a substitute for the application of clinical judgment. Anyone who makes decisions concerning the provision of clinical care should consider this report in the same way as any medical reference and in conjunction with all other pertinent information, i.e., in the context of available resources and circumstances presented by individual patients.This report is made available to the public under the terms of a licensing agreement between the author and AHRQ. This report may be used and reprinted without permission except those copyrighted materials that are clearly noted in the report. Further reproduction of those copyrighted materials is prohibited without the express permission of copyright holders. PCORI, AHRQ, or U.S. Department of Health and Human Services endorsement of any derivative products that may be developed from this report, such as clinical practice guidelines, other quality enhancement tools, or reimbursement or coverage policies, may not be stated or implied.This report may periodically be assessed for the currency of conclusions. If an assessment is done, the resulting surveillance report describing the methodology and findings will be found on the Effective Health Care Program Web site at: www.effectivehealthcare.ahrq.gov. Search on the title of the report.