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Frailty, a multidimensional construct, has been associated with poor outcomes in patients receiving maintenance dialysis. This study assessed the association of frailty with dialysis vascular access patency.Multicenter prospective cohort study.761 prevalent patients receiving hemodialysis at 9 centers in Taiwan as of January 2018.Performance-based frailty was defined as 3 of the following: unintentional weight loss, weakness, exhaustion, low physical activity, and slow gait speed. Patients were categorized as prefrail if they had 1 or 2 of these characteristics.Rate of and time to dialysis access thrombosis. Data regarding vascular access events were collected for 30 months after enrollment through December 31, 2020.Logistic regression analysis was used to estimate the association of clinical characteristics with frailty. Cox proportional hazards regression analysis was used to estimate the association of frailty with vascular access thrombosis adjusted for known clinical risk factors.The patients' mean age was 66 years, 46% were female, 18% had synthetic graft accesses, and 82% arteriovenous fistulas. Overall, 31% were frail, 35% were prefrail, and 34% were not frail. The frailty phenotype was associated with age, female sex, low body mass index, diabetes mellitus, and prior stroke. During a median follow-up of 731 days, 161 patients (21%) had access thrombosis events (not frail, 14%; prefrail, 20%; frail, 30%; P0.001). Frail patients had a higher risk of vascular access thrombosis than nonfrail patients (HR, 2.31 [95% CI, 1.55-3.39], P 0.001). After multivariable adjustment for age and comorbidities, frailty remained significantly associated with access thrombosis for both fistulas and grafts.Limited generalizability and potential residual confounding.Frailty is associated with an increased risk of vascular access thrombosis. These findings highlight the risks of access failure experienced by frail patients receiving hemodialysis.

Background No randomized controlled trials evaluating metformin therapy efficacy in patients with type 2 diabetes mellitus (DM) and acute coronary syndrome (ACS) have been reported. We aimed to examine the mortality benefit of metformin therapy in patients with type 2 DM and ACS, compared with non-metformin anti-diabetes agents users. Methods Data were extracted from the prospective nationwide ACS-DM Taiwan Society of Cardiology registry. Propensity score (PS) matching on baseline characteristics and treatment measures was performed for metformin versus non-metformin users. The Cox proportional hazards model was used to compare mortality outcomes among the PS-matched cohort as the primary analysis. The Cox proportional hazards models adjusting for all pre-determined covariates and quintiles of the PS among the overall population were performed as the secondary analyses. Results Of 1157 patients with type 2 DM and ACS receiving anti-diabetes agents, 78 patients (6.7%) died over the 2-year follow-up period. After PS matching, 318 metformin users were matched with 318 non-metformin users. Metformin users had a lower all-cause mortality rate (adjusted hazard ratio [aHR] 0.50, 95% confidence interval [CI] 0.26–0.95) in the primary analysis. The survival benefit of metformin therapy was consistent in the secondary analyses (aHR 0.30, 95% CI 0.17–0.54 while adjusting for all pre-determined covariates, and aHR 0.34, 95% CI 0.19–0.59 while adjusting for quintiles of the PS). Conclusions Among patients with type 2 DM and ACS, metformin was associated with lower all-cause mortality. However, a detrimental effect of any of the comparators could not be excluded.

Background: No randomized controlled trials evaluating metformin therapy efficacy in patients with type 2 diabetes mellitus (DM) and acute coronary syndrome (ACS) have been reported. Well-designed retrospective studies controlling for imbalance in baseline patient characteristics are scarce. We aimed to examine the mortality benefit of metformin therapy in patients with type 2 DM and ACS, compared with non-metformin anti-diabetes agent users. Method: Data were extracted from the prospective nationwide ACS-DM Taiwan Society of Cardiology registry. Propensity score (PS) matching on baseline characteristics and treatment measures was performed for metformin versus non-metformin users. Cox proportional hazard models were used to compare mortality outcomes among the PS-matched cohort as a primary analysis. Traditional Cox proportional hazard models adjusting for all pre-determined covariates and quintiles of the PS among the overall population were performed as a secondary analysis. Findings: Of 1157 patients with type 2 DM and ACS receiving anti-diabetes agents, 78 patients (6.7%) died over the 2-year follow-up period. After PS matching, 318 metformin users were matched with 318 non-metformin users. Metformin users had a lower all-cause mortality rate (adjusted hazard ratio [aHR] 0·50, 95% confidence interval [CI] 0·26-0·95) in the primary analysis. The survival benefit of metformin therapy was consistent in the secondary analyses (aHR 0·30, 95% CI 0·17-0·54 while adjusting for all pre-determined covariates, and aHR 0·34, 95% CI 0·19-0·59 while adjusting for quintiles of the PS). Interpretation: Among patients with type 2 DM and ACS, metformin was associated with lower all-cause mortality. Funding Statement: This work was supported with grants from the Hsin-Chu branch of the National Taiwan University Hospital (HCH-106036). The funding source also provided technical help (Biotechnology R&D Center) with data analysis and interpretation of the findings. Declaration of Interest: All authors report no relationships that could be construed as a conflict of interest. Ethics Approval Statement: Patients are treated according to international or local guidelines and evidence-based strategies. The protocol and consent forms used in this study were consistent with the Declaration of Helsinki and relevant regulations. The ethics committees of each participating hospital approved the study, and all enrolled patients provided written informed consent.

Patient Initials or Identifier Number H. Y., 68 years old gentleman ### Relevant Clinical History and Physical Exam This 68 years old man has the underlying diseases as hypertension, and cataract s/p operation. He was quite well before with independent life. He visited neurological clinics

Arteriovenous graft (AVG) dysfunction is mainly caused by neointimal hyperplasia. Endovascular intervention can salvage the stenosis. But the long-term patent rate doesn’t improve due to repeated restenosis. Paclitaxel-coated balloon (PCB) is used to reduce neointimal hyperplasia in patients with

Patient initials or identifier number 607300 ### Relevant clinical history and physical exam A 33-year-old man came for a 12-hour history of totally occluded arteriovenous fistula (AVF). Past history: polycystic kidney disease with regular hemodialysis since childhood and active smoker.

Patient initials or identifier number CSC ### Relevant clinical history and physical exam A 52 y/o man with hyperlipidemia presented with exertional chest tightness and dyspnea for 1 year. He had received PCI with a BMS implanted in LAD one year ago in a local hospital; however, his chest

Patient initials or identifier number HF97051 ### Relevant clinical history and physical exam A 79-year-old man presented with acute ischemic stroke and received systemic thrombolysis immediately at the emergency department. He had a sudden onset of left drooling with left limbs weakness

Patient Initials or Identifier Number Mr. C. and Mr. W. ### Relevant Clinical History and Physical Exam Case 1: A 62-year-old man with hypertension. He presented to ER for left side weakness, binocular diphoplia and dysarthria. Right midbrain to pons infarction was impressed. However

Acute mesenteric ischemia carries high morbidity and mortality rates unless urgently treated. In patients without evident bowel necrosis on computer tomography, the treatment remained conservative in less experienced hospital. When a suspicious case progressed into septic shock, the patient was

Patient initials or identifier number Huang, MRN: 807803 ### Relevant clinical history and physical exam A 45-year-old man, with left leg claudication for 1 year. Pulseless left common femoral artery, popliteal artery, and below the knee vessels. ### Relevant test results prior to