Hepatitis E virus (HEV) is a global health problem, affecting about 20 million people worldwide. There is significant overlap of hepatitis B virus (HBV) and HEV endemicity in many Asian countries where dual infections with HEV and HBV can occur. Though the clinical course of HEV is largely self-limited, HEV superinfection in patients with chronic hepatitis B (CHB) can result in acute exacerbation of underlying CHB. HEV superinfection in patients with CHB-related cirrhosis has been identified as a risk factor for decompensated cirrhosis and an independent predictor of mortality. Whereas acute HEV infection in pregnancy can cause fulminant liver failure, the few studies on pregnant patients with dual HBV and HEV infection have shown a subclinical course. Immunosuppression is a risk factor for the development of chronic HEV infection, which can be managed by decreasing the dose of immune-suppressants and administering ribavirin. Vaccination for HEV has been developed and is in use in China but its efficacy in patients with CHB has yet to be established in the USA. In this review, we appraise studies on dual infection with HEV and HBV, including the effect of HEV superinfection and coinfection in CHB, management strategies used and the role of active vaccination in the prevention of HEV.

Globally, hepatitis B virus (HBV) infection is recognized as a major risk factor for the development of hepatocellular carcinoma, and HBV-induced liver failure is one of the leading indications for liver transplantation. Until about two decades ago, liver transplantation in patients with chronic HBV infection was a relative contraindication, due to high risk of viral replication with the use of immunosuppressants which could result in graft infection. In the 1990s, hepatitis B immunoglobulin (HBIg) use significantly reduced the risk of graft infection, improving outcomes of liver transplant in patients with chronic HBV infection. However, very high costs, especially with the need for long-term use, became a major concern. With the advent of nucleos(t)ide analogs (NAs), there was less need for high-dose, long-term HBIg use to prevent HBV recurrence. Lamivudine was initially used but resistance soon became a major issue. This was followed by more potent NAs, such as entecavir and tenofovir, emerging as the more preferred agents. Additionally, the use of these antiviral agents (HBIg and/or NAs) have made it possible to use the grafts from donors with positivity for hepatitis B core antibody, allowing for expansion of the donor pool. Nevertheless, there is no consensus on management protocols, which vary significantly amongst centers. In this review, we appraise studies on management strategies used and the role of active vaccination in the prevention of HBV recurrence in post-liver transplant patients.

Introduction Prior to the utilization of continuous flow devices in 2010, Gastrointestinal (GI) bleeding was a common adverse event related to LVADs. Background Given the drastic increase in the use of new LVADs with continuous flow (CF), we sought to determine if CF-LVADs are associated with an increased number of GI bleeds and higher mortality. Methods We analysed the data from a national inpatient sample database using the International Classification of Disease (ICD)-9 procedure code for LVAD use in end-stage heart failure among patients 18 years or older. Included were 2,359 patients with a mean age of 55±13.7 years and 77% males and 59% Caucasians. Results The Incidence of GI bleed from 2010 to 2014 was 7.46%. There was no significant yearly change in the incidence over five years (p=0.793). After controlling for age, sex, and length of stay (LOS), hierarchical multivariate logistic regression revealed that significant predictors of GI bleed were acute kidney injury (AOR=1.87, 95% CI: 1.26, 2.80), peripheral vascular disease (AOR=1.77, 95% CI: 1.02, 2.94), body mass index ≥25 (AOR=0.46, 95% CI: 0.22, 0.87), hemiplegia and paraplegia (AOR=3.01, 95% CI: 1.17, 7.05), moderate or severe liver disease (AOR=2.40, 95% CI: 0.97, 5.34), peptic ulcer disease (PUD) (AOR=18.13, 95% CI: 7.86, 42.38), surgical aortic valve replacement (AOR=2.46, 95% CI: 1.12, 5.15), and venous thromboembolism (AOR=2.58, 95% CI: 1.57, 4.15). Conclusion Earlier studies showed an increase in the rate of GI bleed in CF-LVADs when compared to pulsatile flow devices. However, our study has indicated that CF-LVADs display no improvement in rates of GI bleed over five years, but that there was an increased likelihood of mortality in patients with GI bleed. These findings pose further questions in regard to considering newer device designs and improved patient selection criteria. Funding Acknowledgement Type of funding source: None

To determine differences in frequencies of vaccine-preventable diseases between alcoholic liver disease (ALD) and non-alcoholic liver disease (NALD) patients. Methods: This population-based cohort study used USA national inpatient sample ICD-9 codes from January 2012 to September 2015. Frequencies of admissions for ALD and NALD in patients with pneumococcal pneumonia, influenza, herpes zoster virus, varicella zoster virus, hepatitis A, hepatitis B, human papilloma virus, meningococcal meningitis, diphtheria, pertussis and tetanus were measured. Frequencies and patients' characteristics were compared for ALD and NALD using χ 2 test and multivariate logistic regression analysis. Results: There was no difference in admissions for hepatitis A and pneumococcal pneumonia between the ALD and NALD groups. There were fewer admissions for hepatitis B (1.17% vs 1.80%, odds ratio [OR] 0.64, P < 0.01), herpes zoster (0.12% vs 0.17%, OR 0.69, P < 0.01), influenza (0.16% vs 0.26%, OR 0.59, P < 0.01) and all others (0.005% vs 0.015%, OR 0.36, P = 0.01) in the ALD group than the NALD group. The extreme all patient refined-diagnosis related groups mortality risk was 15.24% in ALD and 7.77% in NALD admissions (P < 0.0001). Conclusions: The most frequent vaccine-preventable disease in both groups was hepatitis B. Patients with NALD had higher odds of admissions for hepatitis B, herpes zoster virus, influenza and other vaccine-preventable disease than ALD patients. However, the ALD group had a higher risk of mortality when admitted to hospital with a vaccine-preventable disease than the NALD group. K E Y W O R D S vaccination, vaccine-preventable disease, alcoholic liver diseases, non-alcoholic liver diseases, hepatitis B 1 | INTRODUCTION Chronic liver disease (CLD) has affected over 45 million people worldwide, contributing a significant disease burden to both individuals and institutions. 1 The liver, owing to its high degree of vascularity and a capillary system that is lined with immune cells, plays a major role in the immune system and liver disease may result in decreased opsonization, reticuloendothelial cellular activity and neutrophil mobilization with increased bacterial translocation. 2 In alcoholic liver disease (ALD) in particular, hepatic dendritic cells may become impaired, impacting their cell-mediated response towards certain viral infections. 3,4 CLD, including ALD and non-alcoholic liver disease (NALD),

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