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Guerra P, Ruvoletto M, Quarta S, Boninsegna G, Biasiolo A, Cagnin S, Angeli P, Pontisso P, Martini A. The impact of serpinB3-PD polymorphism on the prognosis of patients with hepatocellular carcinoma. Transl Oncol 2025; 57:102413. [PMID: 40367592 DOI: 10.1016/j.tranon.2025.102413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2024] [Revised: 04/17/2025] [Accepted: 05/10/2025] [Indexed: 05/16/2025] Open
Abstract
BACKGROUND HCC ranks as the third leading cause of cancer-related death, yet current surveillance strategies miss over one-third of cases at an early stage. SerpinB3-PD (SB3-PD), a polymorphic isoform of a serine-protease inhibitor involved in tumorigenesis and fibrogenesis, has been related to a more rapid cirrhosis decompensation. This study investigates the prognostic role of SB3-PD in patients with HCC. METHODS SB3-PD polymorphism was assessed in 140 patients with HCC, followed up in our outpatient Clinic. Cell invasion analysis was conducted on HepG2 cells either overexpressing the SB3 wild-type (HepG2/SB3WT) or the PD isoform (HepG2/SB3PD). The effect of recombinant SB3-WT or SB3-PD on the production of molecules that impair immunosurveillance was also assessed in the THP-1 monocytic cell line. RESULTS Patients carrying SB3-PD polymorphism showed worse tumour characteristics, associated with significantly lower survival and SB3-PD was an independent predictor of mortality. HepG2/SB3PD cells had a significantly higher invasion capacity than the HepG2/SB3WT. In THP-1 cells recombinant SB3-PD induced higher levels of PDL1 and IL-13 than SB3-WT. CONCLUSION SB3-PD isoform is associated with worse clinical prognosis in patients with HCC. These findings were supported in vitro by increased cellular invasion and higher production of molecules impairing immunosurveillance.
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Affiliation(s)
- Pietro Guerra
- Unit of Internal Medicine and Hepatology, Department of Medicine, University of Padova, via Giustiniani, 2, 35128, Padova, Italy
| | - Mariagrazia Ruvoletto
- Unit of Internal Medicine and Hepatology, Department of Medicine, University of Padova, via Giustiniani, 2, 35128, Padova, Italy; European Reference Network - ERN RARELIVER, Department of Medicine, Azienda Ospedale-Università, Padova, Italy
| | - Santina Quarta
- Unit of Internal Medicine and Hepatology, Department of Medicine, University of Padova, via Giustiniani, 2, 35128, Padova, Italy; European Reference Network - ERN RARELIVER, Department of Medicine, Azienda Ospedale-Università, Padova, Italy
| | - Giulia Boninsegna
- Unit of Internal Medicine and Hepatology, Department of Medicine, University of Padova, via Giustiniani, 2, 35128, Padova, Italy
| | - Alessandra Biasiolo
- Unit of Internal Medicine and Hepatology, Department of Medicine, University of Padova, via Giustiniani, 2, 35128, Padova, Italy; European Reference Network - ERN RARELIVER, Department of Medicine, Azienda Ospedale-Università, Padova, Italy
| | - Silvia Cagnin
- Unit of Internal Medicine and Hepatology, Department of Medicine, University of Padova, via Giustiniani, 2, 35128, Padova, Italy
| | - Paolo Angeli
- Unit of Internal Medicine and Hepatology, Department of Medicine, University of Padova, via Giustiniani, 2, 35128, Padova, Italy; European Reference Network - ERN RARELIVER, Department of Medicine, Azienda Ospedale-Università, Padova, Italy
| | - Patrizia Pontisso
- Unit of Internal Medicine and Hepatology, Department of Medicine, University of Padova, via Giustiniani, 2, 35128, Padova, Italy; European Reference Network - ERN RARELIVER, Department of Medicine, Azienda Ospedale-Università, Padova, Italy
| | - Andrea Martini
- Unit of Internal Medicine and Hepatology, Department of Medicine, University of Padova, via Giustiniani, 2, 35128, Padova, Italy; European Reference Network - ERN RARELIVER, Department of Medicine, Azienda Ospedale-Università, Padova, Italy.
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2
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Tonon M, Gagliardi R, Pompili E, Barone A, Zaccherini G, Zilio G, Baldassarre M, Accetta A, Carrello D, Calvino V, Iannone G, Incicco S, Zeni N, Gambino CG, Caraceni P, Angeli P, Piano S. Validation and expansion of Baveno VII recompensation criteria in patients with cirrhosis and curable liver disease. J Hepatol 2025:S0168-8278(25)00245-4. [PMID: 40228583 DOI: 10.1016/j.jhep.2025.04.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2024] [Revised: 03/10/2025] [Accepted: 04/07/2025] [Indexed: 04/16/2025]
Abstract
BACKGROUND AND AIMS Baveno-VII consensus recently defined recompensation in patients with decompensated cirrhosis achieving etiological cure. However, incidence, predictors and clinical significance of recompensation are poorly known. This study aimed to evaluate the incidence and prognostic impact of recompensation in patients with decompensated cirrhosis. METHODS Outpatients with cirrhosis and curable etiologies (alcohol, HCV, HBV) were consecutively included and followed up. Recompensation was defined according to Baveno VII criteria. Additionally, expanded recompensation criteria were evaluated for patients on low dose diuretics and/or lactulose/rifaximin for ≥12 months. In 160 patients, inflammatory cytokines (IL-6,IL-1β, IL-10) were measured in serum samples. An external cohort was used to validate study findings. RESULTS 298 out of 525 decompensated cirrhotic outpatients achieved an effective etiological treatment and 21 (7%) achieved recompensation (Baveno-VII criteria), while 112 patients achieved expanded recompensation criteria (37.6%). MELD score (sHR=0.89; p<0.001), BMI (sHR=0.93; p=0.020), hemoglobin (sHR=1.14; p=0.010) and further decompensation (sHR=0.50; p=0.001) were independent predictors of recompensation. In multivariable analysis, mortality risk was not significantly different between patients achieving recompensation and compensated patients (HR=0.97; p=0.947), while decompensated patients had the highest mortality risk (HR=4.96; p<0.001). Mortality risk was not significantly different between patients meeting expanded recompensation criteria and Baveno-VII criteria (HR=0.97; p=0.938). Serum IL-6, IL-1beta and IL-10 were significantly higher in decompensated patients than in compensated and recompensated patients. CONCLUSION Baveno-VII criteria identify cirrhotic patients with a good prognosis, but fewer than 10% of decompensated patients achieve recompensation. Expanding these criteria to include patients receiving minimal decompensation treatment identifies those with similarly low mortality risk. IMPACT AND IMPLICATIONS In recent years, growing evidence has shown that achieving an etiological cure can significantly improve the prognosis of decompensated patients, leading to the development of the concept of recompensation. Baveno VII recently proposed a definition for recompensation; however, data on the clinical impact of this condition remain limited. In this study we evaluated Baveno VII criteria and developed and validated expanded Baveno VII criteria for recompensation. Our findings demonstrates that recompensation is associated with improved survival, reduced hyperdynamic circulation and decreased systemic inflammation in outpatients with decompensated cirrhosis. These results are valuable for hepatologists and researchers aiming to refine patient management strategies and risk stratification in cirrhosis care.
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Affiliation(s)
- Marta Tonon
- Unit of Internal Medicine and Hepatology, Department of Medicine, University of Padova
| | - Roberta Gagliardi
- Unit of Internal Medicine and Hepatology, Department of Medicine, University of Padova
| | - Enrico Pompili
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Italy; Unit of Semeiotics, Liver and Alcohol-related diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy
| | - Anna Barone
- Unit of Internal Medicine and Hepatology, Department of Medicine, University of Padova
| | - Giacomo Zaccherini
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Italy; Unit of Semeiotics, Liver and Alcohol-related diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy
| | - Gianluca Zilio
- Unit of Internal Medicine and Hepatology, Department of Medicine, University of Padova
| | - Maurizio Baldassarre
- Unit of Semeiotics, Liver and Alcohol-related diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy
| | - Antonio Accetta
- Unit of Internal Medicine and Hepatology, Department of Medicine, University of Padova
| | - Daniele Carrello
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Italy; Unit of Semeiotics, Liver and Alcohol-related diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy
| | - Valeria Calvino
- Unit of Internal Medicine and Hepatology, Department of Medicine, University of Padova
| | - Giulia Iannone
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Italy; Unit of Semeiotics, Liver and Alcohol-related diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy
| | - Simone Incicco
- Unit of Internal Medicine and Hepatology, Department of Medicine, University of Padova
| | - Nicola Zeni
- Unit of Internal Medicine and Hepatology, Department of Medicine, University of Padova
| | | | - Paolo Caraceni
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Italy; Unit of Semeiotics, Liver and Alcohol-related diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy
| | - Paolo Angeli
- Unit of Internal Medicine and Hepatology, Department of Medicine, University of Padova
| | - Salvatore Piano
- Unit of Internal Medicine and Hepatology, Department of Medicine, University of Padova.
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Hjorth M, Sjöberg D, Svanberg A, Lo Martire R, Kaminsky E, Rorsman F. Health-related quality of life in patients with liver cirrhosis following adjunctive nurse-based care versus standard medical care: a pragmatic, multicentre, randomised controlled study. BMJ Open Gastroenterol 2025; 12:e001694. [PMID: 39890127 PMCID: PMC11792282 DOI: 10.1136/bmjgast-2024-001694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2024] [Accepted: 01/20/2025] [Indexed: 02/03/2025] Open
Abstract
OBJECTIVES Patients have difficulties in understanding how to manage their liver cirrhosis. This highlights a need for support in comprehending health-related information, which remains largely lacking within liver cirrhosis care. Involvement of registered nurses (RNs) in outpatient liver cirrhosis care has potential to improve quality of care and reduce patient mortality. However, the benefits of nursing care on patients' health-related quality of life (HRQoL) are scarcely studied. This study compared HRQoL in patients receiving either standard medical outpatient care or adjunctive, nurse-led care. The risk of malnutrition, decompensation events and mortality were also compared between the two study groups. METHODS This was a pragmatic, multicentre, randomised trial, which enrolled 167 patients with liver cirrhosis. The primary outcome measure, HRQoL, was assessed using the RAND-36 questionnaire. The physical component summary (PCS) and the mental component summary (MCS) scores of RAND-36 were compared, using linear mixed-effects models for repeated measures, at 12 and 24 months. RESULTS 83 patients received standard medical care, and 84 patients received adjunctive, nurse-led care for 24 months. Due to unforeseen circumstances, the final study population of 167 participants was less than the intended 500. Group comparisons were non-significant of the PCS and MCS scores (-1.1, p=0.53 and -0.7, p=0.67, respectively), malnutrition (p=0.62) and decompensation events (p=0.46), after 24 months. However, mortality was three times higher in the control group compared with the intervention group (12 vs 4, p=0.04) after 24 months. CONCLUSIONS In this study, adjunctive nurse-led care was not superior to standard medical outpatient care regarding HRQoL, risk of developing malnutrition or decompensation. However, RN involvement contributed to early identification of decompensation and reduced mortality. TRIAL REGISTRATION NUMBER NCT02957253.
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Affiliation(s)
- Maria Hjorth
- Centre for Clinical Research, Uppsala University, Falun, Sweden
- Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden
| | - Daniel Sjöberg
- Centre for Clinical Research, Uppsala University, Falun, Sweden
| | | | - Riccardo Lo Martire
- Centre for Clinical Research, Uppsala University, Falun, Sweden
- School of Health and Welfare, Dalarna University, Falun, Sweden
| | - Elenor Kaminsky
- Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden
| | - Fredrik Rorsman
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
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Wigg AJ, Narayana S, Woodman RJ, Adams LA, Wundke R, Chinnaratha MA, Chen B, Jeffrey G, Plummer JL, Sheehan V, Tse E, Morgan J, Huynh D, Milner M, Stewart J, Ahlensteil G, Baig A, Kaambwa B, Muller K, Ramachandran J. A randomized multicenter trial of a chronic disease management intervention for decompensated cirrhosis. The A ustra l ian L iver F a i lur e (ALFIE) trial. Hepatology 2025; 81:136-151. [PMID: 38825975 DOI: 10.1097/hep.0000000000000862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Accepted: 03/01/2024] [Indexed: 06/04/2024]
Abstract
BACKGROUND AND AIMS Improving the care of decompensated cirrhosis is a significant clinical challenge. The primary aim of this trial was to assess the efficacy of a chronic disease management (CDM) model to reduce liver-related emergency admissions (LREA). The secondary aims were to assess model effects on quality-of-care and patient-reported outcomes. APPROACH AND RESULTS The study design was a 2-year, multicenter, randomized controlled study with 1:1 allocation of a CDM model versus usual care. The study setting involved both tertiary and community care. Participants were randomly allocated following a decompensated cirrhosis admission. The intervention was a multifaceted CDM model coordinated by a liver nurse. A total of 147 participants (intervention=75, control=71) were recruited with a median Model for End-Stage Liver Disease score of 19. For the primary outcome, there was no difference in the overall LREA rate for the intervention group versus the control group (incident rate ratio 0.89; 95% CI: 0.53-1.50, p =0.666) or in actuarial survival (HR=1.14; 95% CI: 0.66-1.96, p =0.646). However, there was a reduced risk of LREA due to encephalopathy in the intervention versus control group (HR=1.87; 95% CI: 1.18-2.96, p =0.007). Significant improvement in quality-of-care measures was seen for the performance of bone density ( p <0.001), vitamin D testing ( p <0.001), and HCC surveillance adherence ( p =0.050). For assessable participants (44/74 intervention, 32/71 controls) significant improvements in patient-reported outcomes at 3 months were seen in self-management ability and quality of life as assessed by visual analog scale ( p =0.044). CONCLUSIONS This CDM intervention did not reduce overall LREA events and may not be effective in decompensated cirrhosis for this end point.
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Affiliation(s)
- Alan J Wigg
- Hepatology and Liver Transplantation Medicine Unit, Southern Adelaide Local Health Network, Adelaide, Australia
- College of Medicine and Public Health, Flinders University of South Australia, Adelaide, Australia
| | - Sumudu Narayana
- Hepatology and Liver Transplantation Medicine Unit, Southern Adelaide Local Health Network, Adelaide, Australia
| | - Richard J Woodman
- College of Medicine and Public Health, Flinders University of South Australia, Adelaide, Australia
| | - Leon A Adams
- Liver Transplant Unit, Sir Charles Gardiner Hospital, Perth, Australia
- Medical School, University of Western Australia, Perth, Australia
| | - Rachel Wundke
- Hepatology and Liver Transplantation Medicine Unit, Southern Adelaide Local Health Network, Adelaide, Australia
| | - Mohamed A Chinnaratha
- Department of Gastroenterology and Hepatology, Lyell McEwin Hospital, Adelaide, Australia
| | - Bin Chen
- Department of Gastroenterology and Hepatology, Lyell McEwin Hospital, Adelaide, Australia
| | - Gary Jeffrey
- Liver Transplant Unit, Sir Charles Gardiner Hospital, Perth, Australia
- Medical School, University of Western Australia, Perth, Australia
| | - Joan-Lee Plummer
- Medical School, University of Western Australia, Perth, Australia
| | - Vanessa Sheehan
- Medical School, University of Western Australia, Perth, Australia
| | - Edmund Tse
- Department of Gastroenterology and Hepatology, The Royal Adelaide Hospital, Adelaide, Australia
| | - Joanne Morgan
- Department of Gastroenterology and Hepatology, The Royal Adelaide Hospital, Adelaide, Australia
| | - Dep Huynh
- Department of Gastroenterology and Hepatology, The Queen Elizabeth Hospital, Adelaide, Australia
| | - Margery Milner
- Department of Gastroenterology and Hepatology, The Queen Elizabeth Hospital, Adelaide, Australia
| | - Jeffrey Stewart
- Department of Gastroenterology and Hepatology, The Queen Elizabeth Hospital, Adelaide, Australia
| | - Golo Ahlensteil
- Department of Gastroenterology and Hepatology, Blacktown & Mt Druitt Hospitals, Sydney, Australia
- Blacktown Clinical School, Western Sydney University, Sydney, Australia
| | - Asma Baig
- Department of Gastroenterology and Hepatology, Blacktown & Mt Druitt Hospitals, Sydney, Australia
| | - Billingsley Kaambwa
- College of Medicine and Public Health, Flinders University of South Australia, Adelaide, Australia
| | - Kate Muller
- Hepatology and Liver Transplantation Medicine Unit, Southern Adelaide Local Health Network, Adelaide, Australia
- College of Medicine and Public Health, Flinders University of South Australia, Adelaide, Australia
| | - Jeyamani Ramachandran
- Hepatology and Liver Transplantation Medicine Unit, Southern Adelaide Local Health Network, Adelaide, Australia
- College of Medicine and Public Health, Flinders University of South Australia, Adelaide, Australia
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Hurtado-Díaz-de-León I, Tapper EB. Systems of care that improve outcomes for people with hepatic encephalopathy. Metab Brain Dis 2024; 40:50. [PMID: 39621162 DOI: 10.1007/s11011-024-01430-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2024] [Accepted: 10/31/2024] [Indexed: 12/11/2024]
Abstract
Hepatic encephalopathy (HE) is a critical neuropsychiatric complication of liver cirrhosis with a significant impact on patient quality of life and survival. The global prevalence of cirrhosis and associated HE necessitates a comprehensive understanding of the condition and effective systems of care to optimize outcomes. This review addresses the epidemiology, classification, diagnosis, and management of HE, with an emphasis on systems of care that improve outcomes for people with HE. Current diagnostic challenges include differentiating cognitive deficits attributable to HE from those caused by other etiologies, highlighting the need for accurate diagnostic methods. Traditional psychometric tests, while valuable for diagnosing covert HE (CHE), are limited in their ability to predict overt HE (OHE) due to various confounding factors. As a result, non-psychometric tools have been developed to provide outcome-based predictions aligned with the clinical course of HE. The management of HE includes addressing precipitating factors, pharmacologic interventions to reduce ammonia levels, and supportive care, with lactulose and rifaximin playing a central role. Preventive strategies with the use of remote monitoring in the outpatient management of HE, integrating technology for real-time tracking of therapy compliance and symptom evolution, could contribute to reducing hospital readmissions and improving patient care.
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Affiliation(s)
- Ivonne Hurtado-Díaz-de-León
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Elliot B Tapper
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI, USA.
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Eshkiki ZS, Gholami M, Kadkhodaei A, Shayesteh AA. Prognostic indicators and risk factors for the in-hospital mortality rate of patients with cirrhosis. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2024; 13:91-97. [DOI: 10.18528/ijgii240032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2024] [Revised: 06/12/2024] [Accepted: 07/05/2024] [Indexed: 01/04/2025] Open
Affiliation(s)
- Zahra Shokati Eshkiki
- Alimentary Tract Research Center, Clinical Sciences Research Institute, Imam Khomeini Hospital, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Mobin Gholami
- Alimentary Tract Research Center, Clinical Sciences Research Institute, Imam Khomeini Hospital, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Ahmad Kadkhodaei
- Alimentary Tract Research Center, Clinical Sciences Research Institute, Imam Khomeini Hospital, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Ali Akbar Shayesteh
- Alimentary Tract Research Center, Clinical Sciences Research Institute, Imam Khomeini Hospital, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
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7
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Brahmania M, Rogal S, Serper M, Patel A, Goldberg D, Mathur A, Wilder J, Vittorio J, Yeoman A, Rich NE, Lazo M, Kardashian A, Asrani S, Spann A, Ufere N, Verma M, Verna E, Simpson D, Schold JD, Rosenblatt R, McElroy L, Wadwhani SI, Lee TH, Strauss AT, Chung RT, Aiza I, Carr R, Yang JM, Brady C, Fortune BE. Pragmatic strategies to address health disparities along the continuum of care in chronic liver disease. Hepatol Commun 2024; 8:e0413. [PMID: 38696374 PMCID: PMC11068141 DOI: 10.1097/hc9.0000000000000413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 01/05/2024] [Indexed: 05/04/2024] Open
Abstract
Racial, ethnic, and socioeconomic disparities exist in the prevalence and natural history of chronic liver disease, access to care, and clinical outcomes. Solutions to improve health equity range widely, from digital health tools to policy changes. The current review outlines the disparities along the chronic liver disease health care continuum from screening and diagnosis to the management of cirrhosis and considerations of pre-liver and post-liver transplantation. Using a health equity research and implementation science framework, we offer pragmatic strategies to address barriers to implementing high-quality equitable care for patients with chronic liver disease.
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Affiliation(s)
- Mayur Brahmania
- Department of Medicine, Division of Gastroenterology and Transplant Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Shari Rogal
- Department of Medicine, Division of Gastroenterology, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Marina Serper
- Department of Medicine, Division of Gastroenterology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Arpan Patel
- Department of Medicine, Division of Gastroenterology, University of California Los Angeles, Los Angeles, California, USA
| | - David Goldberg
- Department of Medicine, Division of Gastroenterology, University of Miami, Miami, Florida, USA
| | - Amit Mathur
- Department of Surgery, Division of Transplant Surgery, Mayo Clinic, Phoenix, Arizona, USA
| | - Julius Wilder
- Department of Medicine, Division of Gastroenterology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Jennifer Vittorio
- Department of Pediatrics, Division of Pediatric Gastroenterology, NYU Langone Health, New York, New York, USA
| | - Andrew Yeoman
- Department of Medicine, Gwent Liver Unit, Aneurin Bevan University Health Board, Newport, Wales, UK
| | - Nicole E. Rich
- Department of Medicine, Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Mariana Lazo
- Department of Medicine, Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Ani Kardashian
- Department of Medicine, Division of Gastrointestinal and Liver Diseases, University of Southern California, Los Angeles, California, USA
| | - Sumeet Asrani
- Department of Medicine, Division of Gastroenterology, Baylor University Medical Center, Dallas, Texas, USA
| | - Ashley Spann
- Department of Medicine, Division of Gastroenterology, Vanderbilt University, Nashville, Tennessee, USA
| | - Nneka Ufere
- Department of Medicine, Liver Center, Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Manisha Verma
- Department of Medicine, Einstein Healthcare Network, Philadelphia, Pennsylvania, USA
| | - Elizabeth Verna
- Department of Medicine, Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, New York, USA
| | - Dinee Simpson
- Department of Surgery, Northwestern University, Chicago, Illinois, USA
| | - Jesse D. Schold
- Department of Surgery and Epidemiology, University of Colorado, Aurora, Colorado, USA
| | - Russell Rosenblatt
- Department of Medicine, Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, New York, USA
| | - Lisa McElroy
- Department of Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Sharad I. Wadwhani
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
| | - Tzu-Hao Lee
- Department of Medicine, Section of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, Texas, USA
| | - Alexandra T. Strauss
- Department of Medicine, Division of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Raymond T. Chung
- Department of Medicine, Liver Center, Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Ignacio Aiza
- Department of Medicine, Liver Unit, Hospital Ángeles Lomas, Mexico City, Mexico
| | - Rotonya Carr
- Department of Medicine, Division of Gastroenterology, University of Washington, Seattle, Washington, USA
| | - Jin Mo Yang
- Department of Medicine, Division of Gastroenterology, Catholic University of Korea, Seoul, Korea
| | - Carla Brady
- Department of Medicine, Division of Gastroenterology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Brett E. Fortune
- Department of Medicine, Division of Hepatology, Montefiore Einstein Medical Center, Bronx, New York, USA
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8
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Barfod O'Connell M, Brødsgaard A, Matthè M, Hobolth L, Wullum L, Bendtsen F, Kimer N. A randomized controlled trial of a postdischarge nursing intervention for patients with decompensated cirrhosis. Hepatol Commun 2024; 8:e0418. [PMID: 38668732 DOI: 10.1097/hc9.0000000000000418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 11/22/2023] [Indexed: 05/24/2024] Open
Abstract
BACKGROUND Few randomized trials have evaluated the effect of postdischarge interventions for patients with liver cirrhosis. This study assessed the effects of a postdischarge intervention on readmissions and mortality in patients with decompensated liver cirrhosis. METHODS We conducted a randomized controlled trial at a specialized liver unit. Adult patients admitted with complications of liver cirrhosis were eligible for inclusion. Participants were allocated 1:1 to standard follow-up or a family-focused nurse-led postdischarge intervention between December 1, 2019, and October 31, 2021. The 6-month intervention consisted of a patient pamphlet, 3 home visits, and 3 follow-up telephone calls by a specialized liver nurse. The primary outcome was the number of readmissions due to liver cirrhosis. RESULTS Of the 110 included participants, 93% had alcohol as a primary etiology. We found no significant differences in effects in the primary outcomes such as time to first readmission, number of patients readmitted, and duration of readmissions or in the secondary outcomes like health-related quality of life and 6- and 12-month mortality. A post hoc exploratory analysis showed a significant reduction in nonattendance rates in the intervention group (RR: 0.28, 95% CI: 0.13-0.54, p=0.0004) and significantly fewer participants continuing to consume alcohol in the intervention group (p=0.003). After 12 months, the total number of readmissions (RR: 0.76, 95% CI: 0.59-0.96, p=0.02) and liver-related readmissions (RR: 0.55, 95% CI: 0.36-0.82, p=0.003) were reduced in the intervention group. CONCLUSIONS A family-focused postdischarge nursing intervention had no significant effects on any of the primary or secondary outcomes. In a post hoc exploratory analysis, we found reduced 6-month nonattendance and alcohol consumption rates, as well as reduced 12-month readmission rates in the intervention group.
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Affiliation(s)
- Malene Barfod O'Connell
- Gastro Unit, Medical Division, Copenhagen University Hospital Amager-Hvidovre, Hvidovre, Denmark
| | - Anne Brødsgaard
- Department of Paediatrics and Adolescent Medicine & Gynaecology and Obstetrics, Copenhagen University Hospital Amager-Hvidovre, Copenhagen, Denmark
- Nursing and Health Care, Institute of Public Health, Aarhus University, Aarhus, Denmark
- Omicron Aps, Roskilde, Denmark
| | - Maria Matthè
- Gastro Unit, Medical Division, Copenhagen University Hospital Amager-Hvidovre, Hvidovre, Denmark
| | - Lise Hobolth
- Gastro Unit, Medical Division, Copenhagen University Hospital Amager-Hvidovre, Hvidovre, Denmark
| | - Laus Wullum
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Flemming Bendtsen
- Gastro Unit, Medical Division, Copenhagen University Hospital Amager-Hvidovre, Hvidovre, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Nina Kimer
- Gastro Unit, Medical Division, Copenhagen University Hospital Amager-Hvidovre, Hvidovre, Denmark
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9
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Kahn-Boesel O, Mitchell H, Li L, Zhu E, El-Jawahri A, Levine D, Ufere NN. Hospital-Level Care at Home for Patients with Cirrhosis. Dig Dis Sci 2024; 69:1669-1673. [PMID: 38466464 DOI: 10.1007/s10620-024-08361-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Accepted: 02/17/2024] [Indexed: 03/13/2024]
Abstract
BACKGROUND Patients with cirrhosis have a 30-day readmission rate of over 30%. Novel care delivery models are needed to reduce healthcare costs and utilization associated with cirrhosis care. One such model is Home Hospital (HH), which provides inpatient-level care at home. Limited evidence currently exists supporting HH for cirrhosis patients. AIMS The aims of this study were to characterize patients with cirrhosis who received hospital-level care at home in a two-site clinical trial and to describe the care they received. Secondary aims included describing their outcomes, including adverse events, readmissions and mortality. METHODS We identified all patients with cirrhosis who enrolled in HH as part of a two-site clinical trial between 2017 and 2022. HH services include daily clinician visits, intravenous and oral medications, continuous vital sign monitoring, and telehealth specialist consultation. We collected sociodemographic data and analyzed HH stays, including interventions, outcomes, adverse events, and follow-up. RESULTS 22 patients with cirrhosis (45% Hispanic; 50% limited English proficiency, median MELD-Na 12) enrolled in HH during the study period. Interventions included lab chemistries (82%), intravenous medications (77%), specialist consultation (23%), and advanced diagnostics/procedures (23%). The median length of stay was 7 days (IQR 4-12); 186 bed-days were saved. Two patients (9%) experienced adverse events (AKI). No patients required escalation of care; 9% were readmitted within 30 days. CONCLUSIONS In this two-site study, HH was feasible for patients with cirrhosis, holding promise as a hepatology delivery model. Future randomized trials are needed to further evaluate the efficacy of HH for patients with cirrhosis.
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Affiliation(s)
| | - Henry Mitchell
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Lucinda Li
- Liver Center, Gastrointestinal Division, Massachusetts General Hospital, Boston, MA, USA
| | - Ennie Zhu
- Liver Center, Gastrointestinal Division, Massachusetts General Hospital, Boston, MA, USA
| | - Areej El-Jawahri
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA, USA
| | - David Levine
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Nneka N Ufere
- Liver Center, Gastrointestinal Division, Massachusetts General Hospital, Boston, MA, USA.
- Liver Center, Gastrointestinal Unit, Department of Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA.
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10
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Lin E, Gandhi D, Volk M. Preventing Readmissions of Hepatic Encephalopathy: Strategies in the Acute Inpatient, Immediate Postdischarge, and Longitudinal Outpatient Setting. Clin Liver Dis 2024; 28:359-367. [PMID: 38548445 DOI: 10.1016/j.cld.2024.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
Hepatic encephalopathy (HE) is a strong predictor of early hospital readmission in patients with cirrhosis. Early hospital readmission increases health care costs and is associated with worse survival. Herein we provide an overview of strategies to prevent hospital readmissions in patients with HE, divided into 3 contexts: (a) acute inpatient, (b) immediate postdischarge, and (c) longitudinal outpatient setting.
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Affiliation(s)
- Emily Lin
- Department of Gastroenterology, Loma Linda University, Loma Linda, CA, USA
| | - Devika Gandhi
- Department of Gastroenterology, Loma Linda University, Loma Linda, CA, USA.
| | - Michael Volk
- Department of Medicine, Baylor Scott and White, Central Texas Region, Temple, TX, USA
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11
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Tonon M, D'Ambrosio R, Calvino V, Tosetti G, Barone A, Incicco S, Gambino C, Gagliardi R, Borghi M, Zeni N, Piano S, Lampertico P, Angeli P. A new clinical and prognostic characterization of the patterns of decompensation of cirrhosis. J Hepatol 2024; 80:603-609. [PMID: 38110003 DOI: 10.1016/j.jhep.2023.12.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 11/21/2023] [Accepted: 12/04/2023] [Indexed: 12/20/2023]
Abstract
BACKGROUND & AIMS The prognostic impact of acute decompensation (AD), i.e. the development of complications that require hospitalization, has recently been assessed. However, complications of cirrhosis do not necessarily require hospitalization and can develop progressively, as in the recently defined non-acute decompensation (NAD). Nevertheless, there is no data regarding the incidence and prognostic impact of NAD. The aim of the study was to evaluate the incidence and the prognostic impact of NAD and AD in outpatients with cirrhosis. METHODS A total of 617 outpatients with cirrhosis from two Italian tertiary centers (Padua and Milan) were enrolled from January 2003 to June 2021 and followed prospectively until the end of the study, death or liver transplantation. The complications registered during follow-up were considered as AD if they required hospitalization, or NAD if managed at the outpatient clinic. RESULTS During follow-up, 154 patients (25.0% of total patients) developed complications, 69 patients (44.8%) developed NAD and 85 (55.2%) developed AD, while 29 patients with NAD (42.0%) developed a further episode of AD during follow-up. Sixty-month survival was significantly higher in patients with no decompensation than in patients with NAD or AD. On multivariable analysis, AD (hazard ratio [HR] 21.07, p <0.001), NAD (HR 7.13, p <0.001), the etiological cure of cirrhosis (HR 0.38, p <0.001) and model for end-stage liver disease score (HR 1.12, p = 0.003) were found to be independent predictors of mortality. CONCLUSIONS The first decompensation is non-acute in almost 50% of outpatients, though such events are still associated with decreased survival compared to no decompensation. Patients who develop NAD must be treated with extreme care and monitored closely to prevent the development of AD. IMPACT AND IMPLICATIONS This multicenter study is the first to investigate the role of non-acute decompensation (NAD) in patients with cirrhosis. In fact, while the unfavorable impact of acute decompensation is well known, there is currently a dearth of evidence on NAD, despite it being a common occurrence in clinical practice. Our data show that almost half of decompensations in patients with cirrhosis can be considered NAD and that such events are associated with a higher risk of mortality than no decompensation. This study has important clinical implications because it highlights the need to carefully consider patients who develop NAD, in order to prevent further decompensation and reduce mortality.
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Affiliation(s)
- Marta Tonon
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine (DIMED), University of Padova, Italy
| | - Roberta D'Ambrosio
- Division of Gastroenterology and Hepatology, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Valeria Calvino
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine (DIMED), University of Padova, Italy
| | - Giulia Tosetti
- Division of Gastroenterology and Hepatology, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Anna Barone
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine (DIMED), University of Padova, Italy
| | - Simone Incicco
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine (DIMED), University of Padova, Italy
| | - Carmine Gambino
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine (DIMED), University of Padova, Italy
| | - Roberta Gagliardi
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine (DIMED), University of Padova, Italy
| | - Marta Borghi
- Division of Gastroenterology and Hepatology, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Nicola Zeni
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine (DIMED), University of Padova, Italy
| | - Salvatore Piano
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine (DIMED), University of Padova, Italy
| | - Pietro Lampertico
- Division of Gastroenterology and Hepatology, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; CRC "A. M. and A. Migliavacca" Centre for Liver Disease, Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Paolo Angeli
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine (DIMED), University of Padova, Italy.
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12
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Martini A, Pontisso P. Letter: Association of polymorphic variant of SerpinB3 and faster cirrhosis decompensation in patients with cirrhosis-More evidence needed. Authors' reply. Aliment Pharmacol Ther 2024; 59:913-914. [PMID: 38462679 DOI: 10.1111/apt.17916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
Abstract
LINKED CONTENTThis article is linked to Martini et al papers. To view these articles, visit https://doi.org/10.1111/apt.17804 and https://doi.org/10.1111/apt.17901
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Affiliation(s)
- Andrea Martini
- Unit of Internal Medicine and Hepatology, Department of Medicine, Azienda Ospedaliera-Università, Padova, Italy
- European Reference Network - ERN RARE-LIVER, Department of Medicine, Azienda Ospedaliera-Università, Padova, Italy
| | - Patrizia Pontisso
- Unit of Internal Medicine and Hepatology, Department of Medicine, Azienda Ospedaliera-Università, Padova, Italy
- European Reference Network - ERN RARE-LIVER, Department of Medicine, Azienda Ospedaliera-Università, Padova, Italy
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13
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Giles B, Fancey K, Gamble K, Riaz Z, Dowman JK, Fowell AJ, Aspinall RJ. Novel, nurse-led early postdischarge clinic is associated with fewer readmissions and lower mortality following hospitalisation with decompensated cirrhosis. Frontline Gastroenterol 2024; 15:124-129. [PMID: 38486673 PMCID: PMC10935524 DOI: 10.1136/flgastro-2023-102489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 10/20/2023] [Indexed: 03/17/2024] Open
Abstract
Objective Patients hospitalised with decompensated cirrhosis have high rates of early unplanned readmission. Many readmissions are avoidable with secondary preventative strategies, but patients are often readmitted prior to outpatient review. To address this, we established a novel, nurse-led early postdischarge (EPD) clinic delivering goal-directed care for cirrhosis complications and evaluated the impact. Methods Retrospective cohort study comparing outcomes in 78 patients seen in the EPD clinic with 91 phenotypically matched controls receiving standard, consultant hepatologist care. Follow-up for 12 months from index admission with endpoints including survival, time to readmission, number of readmissions and healthcare burden. Results Median time to readmission was 51 days in controls and 98 days in the intervention group (p<0.01). The intervention cohort had significantly fewer readmissions at 30 days (12% vs 30%, p<0.01) and 90 days (27% vs 49%, p<0.01) but not significantly at 12 months (58% vs 68%, p=0.16) with an overall reduction in bed day usage of 29%. Mortality for the control group was 4% at 30 days with no deaths in the intervention group. There were significantly fewer deaths in the intervention group at 90 days (5% vs 15%, p<0.05) and 12 months (22% vs 41%, p<0.01). Conclusions Following an index hospitalisation with decompensated cirrhosis, goal-directed postdischarge care can be effectively delivered by specialist nurses, prior to outpatient review by hepatologists. This model was associated with significantly fewer readmissions, lower bed day usage and a reduced mortality. Our data suggest such models of care deserve wider implementation and further evaluation.
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Affiliation(s)
- Benjamin Giles
- Gastroenterology and Hepatology, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Kirsty Fancey
- Gastroenterology and Hepatology, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Karen Gamble
- Gastroenterology and Hepatology, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Zeshan Riaz
- Gastroenterology and Hepatology, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Joanna K Dowman
- Gastroenterology and Hepatology, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Andrew J Fowell
- Gastroenterology and Hepatology, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Richard J Aspinall
- Gastroenterology and Hepatology, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
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14
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Martini A, Turato C, Cannito S, Quarta S, Biasiolo A, Ruvoletto M, Novo E, Marafatto F, Guerra P, Tonon M, Clemente N, Bocca C, Piano SS, Guido M, Gregori D, Parola M, Angeli P, Pontisso P. The polymorphic variant of SerpinB3 (SerpinB3-PD) is associated with faster cirrhosis decompensation. Aliment Pharmacol Ther 2024; 59:380-392. [PMID: 37990490 DOI: 10.1111/apt.17804] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 03/24/2023] [Accepted: 10/28/2023] [Indexed: 11/23/2023]
Abstract
BACKGROUND SerpinB3 is a cysteine protease inhibitor involved in liver disease progression due to its proinflammatory and profibrogenic properties. The polymorphic variant SerpinB3-PD (SB3-PD), presents a substitution in its reactive centre loop, determining the gain of function. AIMS To disclose the clinical characteristics of a cohort of patients with cirrhosis in relation to the presence of SB3-PD and to assess the effect of this genetic variant on fibrogenic and inflammatory cytokines in vitro. METHODS We assessed SB3 polymorphism in 90 patients with cirrhosis, prospectively followed up in our referral centre. We used HepG2 and HuH-7 cells transfected to overexpress either wild-type SB3 (SB3-WT) or SB3-PD to assess their endogenous effect, while LX2 and THP-1 cells were treated with exogenous SB3-WT or SB3-PD proteins. RESULTS Patients carrying SB3-PD had more severe portal hypertension and higher MELD scores, than patients carrying SB3-WT. In multivariate analysis, SB3-PD was an independent predictor of cirrhosis complications. Patients with SB3-PD polymorphism presented with more severe liver fibrosis and inflammatory features. Hepatoma cells overexpressing SB3-PD showed higher TGF-β1 expression than controls. The addition of recombinant SB3-PD induced an up-regulation of TGF-β1 in LX2 cells and a more prominent inflammatory profile in THP-1 cells, compared to the effect of SB3-WT protein. CONCLUSIONS The polymorphic variant SB3-PD is highly effective in determining activation of TGF-β1 and inflammation in vitro. Patients with cirrhosis who carry SB3-PD polymorphism may be more prone to develop severe liver disease progression. However, further validation studies are warranted to support the in vivo relevance of this polymorphism.
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Affiliation(s)
- Andrea Martini
- Unit of Internal Medicine and Hepatology, Department of Medicine, Azienda Ospedaliera-Università, Padova, Italy
- European Reference Network - ERN RARE-LIVER, Department of Medicine, Azienda Ospedaliera-Università, Padova, Italy
| | - Cristian Turato
- Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Stefania Cannito
- Unit of Experimental Medicine and Clinical Pathology, Department of Clinical and Biological Sciences, University of Torino, Torino, Italy
| | - Santina Quarta
- Unit of Internal Medicine and Hepatology, Department of Medicine, Azienda Ospedaliera-Università, Padova, Italy
- European Reference Network - ERN RARE-LIVER, Department of Medicine, Azienda Ospedaliera-Università, Padova, Italy
| | - Alessandra Biasiolo
- Unit of Internal Medicine and Hepatology, Department of Medicine, Azienda Ospedaliera-Università, Padova, Italy
- European Reference Network - ERN RARE-LIVER, Department of Medicine, Azienda Ospedaliera-Università, Padova, Italy
| | - Mariagrazia Ruvoletto
- Unit of Internal Medicine and Hepatology, Department of Medicine, Azienda Ospedaliera-Università, Padova, Italy
- European Reference Network - ERN RARE-LIVER, Department of Medicine, Azienda Ospedaliera-Università, Padova, Italy
| | - Erica Novo
- Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Filippo Marafatto
- Unit of Internal Medicine and Hepatology, Department of Medicine, Azienda Ospedaliera-Università, Padova, Italy
- European Reference Network - ERN RARE-LIVER, Department of Medicine, Azienda Ospedaliera-Università, Padova, Italy
| | - Pietro Guerra
- Unit of Internal Medicine and Hepatology, Department of Medicine, Azienda Ospedaliera-Università, Padova, Italy
- European Reference Network - ERN RARE-LIVER, Department of Medicine, Azienda Ospedaliera-Università, Padova, Italy
| | - Marta Tonon
- Unit of Internal Medicine and Hepatology, Department of Medicine, Azienda Ospedaliera-Università, Padova, Italy
- European Reference Network - ERN RARE-LIVER, Department of Medicine, Azienda Ospedaliera-Università, Padova, Italy
| | - Nausicaa Clemente
- Department of Health Science, Interdisciplinary Research Center of Autoimmune Diseases (IRCAD), University of Piemonte Orientale, Novara, Italy
| | - Claudia Bocca
- Unit of Experimental Medicine and Clinical Pathology, Department of Clinical and Biological Sciences, University of Torino, Torino, Italy
| | - Salvatore Silvio Piano
- Unit of Internal Medicine and Hepatology, Department of Medicine, Azienda Ospedaliera-Università, Padova, Italy
- European Reference Network - ERN RARE-LIVER, Department of Medicine, Azienda Ospedaliera-Università, Padova, Italy
| | - Maria Guido
- Unit of Internal Medicine and Hepatology, Department of Medicine, Azienda Ospedaliera-Università, Padova, Italy
- European Reference Network - ERN RARE-LIVER, Department of Medicine, Azienda Ospedaliera-Università, Padova, Italy
| | - Dario Gregori
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Maurizio Parola
- Unit of Experimental Medicine and Clinical Pathology, Department of Clinical and Biological Sciences, University of Torino, Torino, Italy
| | - Paolo Angeli
- Unit of Internal Medicine and Hepatology, Department of Medicine, Azienda Ospedaliera-Università, Padova, Italy
- European Reference Network - ERN RARE-LIVER, Department of Medicine, Azienda Ospedaliera-Università, Padova, Italy
| | - Patrizia Pontisso
- Unit of Internal Medicine and Hepatology, Department of Medicine, Azienda Ospedaliera-Università, Padova, Italy
- European Reference Network - ERN RARE-LIVER, Department of Medicine, Azienda Ospedaliera-Università, Padova, Italy
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15
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Pompili E, Baldassarre M, Bedogni G, Zaccherini G, Iannone G, De Venuto C, Pratelli D, Palmese F, Domenicali M, Caraceni P. Predictors of clinical trajectories of patients with acutely decompensated cirrhosis. An external validation of the PREDICT study. Liver Int 2024; 44:72-82. [PMID: 37718730 DOI: 10.1111/liv.15734] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 07/31/2023] [Accepted: 09/02/2023] [Indexed: 09/19/2023]
Abstract
BACKGROUND AND AIMS The PREDICT study recently showed that acutely decompensated (AD) patients with cirrhosis can present three different clinical phenotypes in the 90 days after admission: (1) pre-ACLF, developing acute-on-chronic liver failure (ACLF); (2) unstable decompensated cirrhosis (UDC), being re-admitted for AD without ACLF and (3) stable decompensated cirrhosis (SDC), not presenting readmission or ACLF. This study aimed to externally validate the existence of these three distinct trajectories and to identify predictors for the occurrence of each trajectory. METHODS Baseline data, 3-month ACLF and readmission incidence and 1-year survival were analysed in a prospective cohort of patients admitted for AD. A multinomial multivariable model was used to evaluate the association between baseline features and clinical trajectories. RESULTS Of the 311 patients enrolled, 55% met the criteria for SDC, 18% for UDC and 27% for pre-ACLF, presenting a significantly different 1-year mortality: pre-ACLF 65%, UDC 46%, SDC 21% (p < .001). The presence of hepatic encephalopathy (HE) was associated with UDC (p = .043), while the absence of ascites to SDC (p = .017). Among laboratory parameters, an increase in MELD-Na (p = .001) and C-reactive protein (p = .009) and a decrease in haemoglobin (p = .004) and albumin (p = .008) levels were associated with pre-ACLF. CONCLUSION The present study confirms that AD patients have three different clinical trajectories with different mortality rates. Besides the severity of cirrhosis, the association with C-reactive protein supports the predominant role of systemic inflammation in ACLF pathophysiology. Finally, HE is associated with the UDC phenotype highlighting the need for better management of this complication after discharge.
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Affiliation(s)
- Enrico Pompili
- Department of Medical and Surgical Sciences, Alma Mater Studiorum-University of Bologna, Bologna, Italy
- Unit of Semeiotics, Liver and Alcohol-Related Diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Maurizio Baldassarre
- Unit of Semeiotics, Liver and Alcohol-Related Diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Centre for Applied Biomedical Research (CRBA), Alma Mater Studiorum of Bologna, Bologna, Italy
| | - Giorgio Bedogni
- Department of Medical and Surgical Sciences, Alma Mater Studiorum-University of Bologna, Bologna, Italy
- Department of Primary Health Care, Internal Medicine Unit Addressed to Frailty and Aging, "S. Maria delle Croci" Ravenna Hospital, AUSL Romagna, Ravenna, Italy
| | - Giacomo Zaccherini
- Department of Medical and Surgical Sciences, Alma Mater Studiorum-University of Bologna, Bologna, Italy
- Unit of Semeiotics, Liver and Alcohol-Related Diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Giulia Iannone
- Department of Medical and Surgical Sciences, Alma Mater Studiorum-University of Bologna, Bologna, Italy
- Unit of Semeiotics, Liver and Alcohol-Related Diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Clara De Venuto
- Department of Medical and Surgical Sciences, Alma Mater Studiorum-University of Bologna, Bologna, Italy
- Unit of Semeiotics, Liver and Alcohol-Related Diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Dario Pratelli
- Department of Medical and Surgical Sciences, Alma Mater Studiorum-University of Bologna, Bologna, Italy
- Unit of Semeiotics, Liver and Alcohol-Related Diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Francesco Palmese
- Department of Medical and Surgical Sciences, Alma Mater Studiorum-University of Bologna, Bologna, Italy
- Department of Primary Health Care, Internal Medicine Unit Addressed to Frailty and Aging, "S. Maria delle Croci" Ravenna Hospital, AUSL Romagna, Ravenna, Italy
| | - Marco Domenicali
- Department of Medical and Surgical Sciences, Alma Mater Studiorum-University of Bologna, Bologna, Italy
- Department of Primary Health Care, Internal Medicine Unit Addressed to Frailty and Aging, "S. Maria delle Croci" Ravenna Hospital, AUSL Romagna, Ravenna, Italy
| | - Paolo Caraceni
- Department of Medical and Surgical Sciences, Alma Mater Studiorum-University of Bologna, Bologna, Italy
- Unit of Semeiotics, Liver and Alcohol-Related Diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
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16
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Li N, Xu M, Liu SY, Yu MQ, Ruan CF. Risk factors for hospital readmission among patients with cirrhosis and ascites in China: a retrospective observational study. J Int Med Res 2024; 52:3000605231223087. [PMID: 38258740 PMCID: PMC10807325 DOI: 10.1177/03000605231223087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 12/11/2023] [Indexed: 01/24/2024] Open
Abstract
OBJECTIVE In this investigation, we aimed to explore risk factors for 90-day hospital readmission among patients with cirrhosis and ascites in an Asian population. METHODS In this retrospective study, we included consecutive patients diagnosed with cirrhosis and ascites hospitalized in Renji Hospital between 2018 and 2022 to elucidate risk factors for 90-day readmission. We conducted multivariate logistic regression analysis to identify readmission risk factors. RESULTS We included 265 patients with cirrhosis and ascites. A 43% readmission rate was observed within 90 days. After adjustment for multiple covariates, we found that readmission within 90 days was independently linked to reduced levels of hemoglobin (odds ratio [OR] 0.96, 95% confidence interval [CI] 0.94-0.97) and serum albumin (OR 0.88, 95% CI 0.83-0.93), and higher Model for End-Stage Liver Disease and sodium (MELD-Na) scores (OR 1.04, 95% CI 1.01-1.07) at discharge. CONCLUSIONS Patients with cirrhosis who have ascites are frequently rehospitalized within 90 days after discharge. Lower hemoglobin or albumin and higher MELD-Na scores at discharge may be the main risk factors for hospital readmission.
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Affiliation(s)
- Na Li
- Department of Nursing, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Division of Gastroenterology and Hepatology, Key Laboratory of Gastroenterology and Hepatology, Ministry of Health, Shanghai Institute of Digestive Disease, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Mei Xu
- Department of Nursing, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Division of Gastroenterology and Hepatology, Key Laboratory of Gastroenterology and Hepatology, Ministry of Health, Shanghai Institute of Digestive Disease, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Shi-Ying Liu
- Department of Nursing, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Division of Gastroenterology and Hepatology, Key Laboratory of Gastroenterology and Hepatology, Ministry of Health, Shanghai Institute of Digestive Disease, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Ming-Qin Yu
- Department of Nursing, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Division of Gastroenterology and Hepatology, Key Laboratory of Gastroenterology and Hepatology, Ministry of Health, Shanghai Institute of Digestive Disease, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Chun-Feng Ruan
- Department of Nursing, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
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17
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Louissaint J, Gibbs J, Shenoy A, Cohen-Mekelburg S, Lok A, Tapper E. Patient Portal Use and Risk of Readmissions in Decompensated Cirrhosis: Retrospective Study. JMIR Form Res 2023; 7:e47080. [PMID: 38113099 PMCID: PMC10762613 DOI: 10.2196/47080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 10/09/2023] [Accepted: 10/30/2023] [Indexed: 12/21/2023] Open
Abstract
BACKGROUND Patient portals are a common electronic medical record tool that allow for the asynchronous exchange of health information between patients and their health care teams. Patients can leverage patient portals to perform tasks such as viewing test results, reviewing clinical notes, and messaging their health care team. The impact of patient portal use on clinical outcomes in cirrhosis is unknown. OBJECTIVE In this study, we evaluated the relationship between patient portal use patterns and readmissions in cirrhosis. METHODS We identified 131 patients with decompensated cirrhosis with an index cirrhosis-related admission between May 1, 2018, and May 1, 2019. We then examined patient portal enrollment and use data during the 6-month period preceding the study period. Portal functions evaluated included sending a message, reading a message, and reading a test result. Use was categorized as active (sending a message) and passive (reading a message or test result) and was further stratified as no, moderate, or frequent use based on the frequency of portal function use compared to the mean. The primary outcomes were 90-day and overall readmissions, adjusted for age, model for end-stage liver disease-sodium, alcohol-related cirrhosis etiology, ascites, and hepatic encephalopathy. Portal functions assessed included sending a message, reading a message, and reading a result; the total number of times a portal function was performed was divided by the number of months the patient was enrolled in the patient portal during the 6-month period. RESULTS The study population was 50.4% (66/131) female, with a mean age of 58 years. Enrollment in the patient portal was 63.4% (83/131), and there was no significant difference in enrollment based on clinical or demographic characteristics. For the entire cohort, 14.5% (19/131) and 22.1% (29/131) of patients were moderate and frequent active users, respectively. Of those enrolled in the patient portal, 97.6% (81/83) of patients were moderate or frequent passive users for both reading a message and reading a test result. Moderate active users had less 90-day readmissions (odds ratio 0.77, 95% CI 0.60-1.00) and overall readmissions (subdistribution hazard ratio 0.42, 95% CI 0.21-0.84), compared to nonactive users. There was no relationship between readmissions and passive use. CONCLUSIONS Passive use of the patient portal is very high but is not associated with the risk of readmissions in people with decompensated cirrhosis. However, moderately active use of the patient portal is associated with a reduced risk of readmissions. Further work is needed to identify possible confounders and refine key use behaviors that may be protective with regard to the risk of readmission in this population.
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Affiliation(s)
- Jeremy Louissaint
- Division of Digestive and Liver Diseases, University of Texas Southwestern, Dallas, TX, United States
| | - Jeffrey Gibbs
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Abhishek Shenoy
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, United States
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, United States
| | - Shirley Cohen-Mekelburg
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, United States
- VA Center for Clinical Management Research, VA Ann Arbor Health Care System, Ann Arbor, MI, United States
- Gastroenterology Section, VA Ann Arbor Healthcare System, Ann Arbor, MI, United States
| | - Anna Lok
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Elliot Tapper
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, United States
- Gastroenterology Section, VA Ann Arbor Healthcare System, Ann Arbor, MI, United States
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18
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Cagnin S, Donghia R, Martini A, Pesole PL, Coletta S, Shahini E, Boninsegna G, Biasiolo A, Pontisso P, Giannelli G. Galad Score as a Prognostic Marker for Patients with Hepatocellular Carcinoma. Int J Mol Sci 2023; 24:16485. [PMID: 38003675 PMCID: PMC10671761 DOI: 10.3390/ijms242216485] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 11/16/2023] [Accepted: 11/17/2023] [Indexed: 11/26/2023] Open
Abstract
BACKGROUND Hepatocellular carcinoma (HCC) accounts for more than 75% of primary liver cancers, which are the second leading cause of cancer-related deaths. The GALAD (gender, age, AFP-L3, AFP, and des-carboxy-prothrombin) score is a diagnostic tool developed based on gender, age, alpha-fetoprotein, alpha-fetoprotein L3, and des-gamma-carboxy prothrombin, originally designed as a diagnostic tool for HCC in high-risk patients. METHODS We analyzed 212 patients with and without cirrhosis. The population study was divided into patients with liver cirrhosis without evidence of HCC at the time of serum sample collection for GALAD score determination and patients with liver cirrhosis and a confirmed diagnosis of HCC at the time of serum sample collection for GALAD score determination. Patients were followed up until death or liver transplantation. The association between variables and HCC mortality risk was performed, and the results were presented as hazard ratio (HR). The receiver operating characteristic (ROC) curve was used to assess the performance of the GALAD HCC diagnosis. The survival probability was explored using the non-parametric test, and the equality of survival amongst categories was assessed with the log-rank test. RESULTS Biomarkers were higher in the HCC group compared to cirrhosis. Kaplan-Meier survival probability analysis for individual GALAD categories revealed that a high GALAD level was associated with decreased survival during follow-up, and the difference between the curves was statistically significant (p = 0.01). CONCLUSIONS Our findings suggest that the GALAD score has promise as a prognostic tool, with implications for improving patient management and treatment strategies for HCC.
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Affiliation(s)
- Silvia Cagnin
- Department of Medicine, University of Padova, 35123 Padova, Italy; (S.C.); (A.M.); (G.B.); (A.B.); (P.P.)
| | - Rossella Donghia
- National Institute of Gastroenterology–IRCCS “Saverio de Bellis”, 70013 Castellana Grotte, Italy; (R.D.); (P.L.P.); (S.C.); (E.S.)
| | - Andrea Martini
- Department of Medicine, University of Padova, 35123 Padova, Italy; (S.C.); (A.M.); (G.B.); (A.B.); (P.P.)
| | - Pasqua Letizia Pesole
- National Institute of Gastroenterology–IRCCS “Saverio de Bellis”, 70013 Castellana Grotte, Italy; (R.D.); (P.L.P.); (S.C.); (E.S.)
| | - Sergio Coletta
- National Institute of Gastroenterology–IRCCS “Saverio de Bellis”, 70013 Castellana Grotte, Italy; (R.D.); (P.L.P.); (S.C.); (E.S.)
| | - Endrit Shahini
- National Institute of Gastroenterology–IRCCS “Saverio de Bellis”, 70013 Castellana Grotte, Italy; (R.D.); (P.L.P.); (S.C.); (E.S.)
| | - Giulia Boninsegna
- Department of Medicine, University of Padova, 35123 Padova, Italy; (S.C.); (A.M.); (G.B.); (A.B.); (P.P.)
| | - Alessandra Biasiolo
- Department of Medicine, University of Padova, 35123 Padova, Italy; (S.C.); (A.M.); (G.B.); (A.B.); (P.P.)
| | - Patrizia Pontisso
- Department of Medicine, University of Padova, 35123 Padova, Italy; (S.C.); (A.M.); (G.B.); (A.B.); (P.P.)
| | - Gianluigi Giannelli
- National Institute of Gastroenterology–IRCCS “Saverio de Bellis”, 70013 Castellana Grotte, Italy; (R.D.); (P.L.P.); (S.C.); (E.S.)
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19
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Kalo E, Baig A, Gregg E, George J, Read S, Ma WS, Ahlenstiel G. A novel, nurse-led 'one stop' clinic for patients with liver cirrhosis results in fewer liver-related unplanned readmissions and improved survival. BMC Gastroenterol 2023; 23:356. [PMID: 37845625 PMCID: PMC10578021 DOI: 10.1186/s12876-023-02986-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 10/02/2023] [Indexed: 10/18/2023] Open
Abstract
OBJECTIVE Delivering effective secondary preventive and integrated care has the potential to break the revolving-door phenomenon of frequent readmissions in patients with advanced chronic liver disease. To address this, we launched the Care Coordination of Liver Disease (CCoLD) pilot, a novel nurse-led cirrhosis clinic in Western Sydney. METHODS AND ANALYSIS Following an index presentation to Blacktown or Mount Druitt hospitals (BMDH), patients (n = 89, matched by age, sex, and MELD-NA) were consecutively either followed up by the CCoLD clinical nurse consultant (intervention cohort) or received standard care (control cohort). Controlled evaluation of the impact of the nurse-led clinic was carried out for a 3-month period including readmission rates, survival, and cost effectiveness. RESULTS The inaugural nurse-led clinic led to improvement in patient-level outcomes including a reduction in unplanned liver-related readmissions (2.08% for intervention cohort vs 12.2% for control cohort, p < 0.01), and mortality at 30 days (0% for intervention cohort vs 7.3% for control cohort, p = 0.03). Similar trends were observed at 90 days from index discharge. No deaths were observed in the intervention cohort as compared to the control cohort at 90 days (0% versus 7.3%, p = 0.03), while unplanned liver-related readmissions were 10.41% for the intervention cohort vs 19.5% for the control cohort (p = 0.115). Moreover, time to readmission was significantly longer in the intervention cohort, resulting in an overall cost-effective intervention. CONCLUSION These findings highlight the significant impact of optimised care-coordination. A nurse-led clinic can deliver patient-centred, goal-directed, and cost-effective secondary prevention and care. A multicentre randomised trial for wider evaluation of these findings is warranted.
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Affiliation(s)
- Eric Kalo
- Blacktown Clinical School and Research Centre, School of Medicine, Western Sydney University, 18 Blacktown Road, Blacktown, NSW, 2148, Australia
- Blacktown Hospital, Western Sydney Local Health District, Blacktown, NSW, 2148, Australia
| | - Asma Baig
- Blacktown Hospital, Western Sydney Local Health District, Blacktown, NSW, 2148, Australia
| | - Emily Gregg
- Blacktown Hospital, Western Sydney Local Health District, Blacktown, NSW, 2148, Australia
| | - Jacob George
- Storr Liver Centre, The Westmead Institute for Medical Research, University of Sydney, Westmead, NSW, 2145, Australia
- Westmead Hospital, Western Sydney Local Health District, Westmead, NSW, 2145, Australia
| | - Scott Read
- Blacktown Clinical School and Research Centre, School of Medicine, Western Sydney University, 18 Blacktown Road, Blacktown, NSW, 2148, Australia
- Blacktown Hospital, Western Sydney Local Health District, Blacktown, NSW, 2148, Australia
- Storr Liver Centre, The Westmead Institute for Medical Research, University of Sydney, Westmead, NSW, 2145, Australia
| | - Wai-See Ma
- Blacktown Hospital, Western Sydney Local Health District, Blacktown, NSW, 2148, Australia
| | - Golo Ahlenstiel
- Blacktown Clinical School and Research Centre, School of Medicine, Western Sydney University, 18 Blacktown Road, Blacktown, NSW, 2148, Australia.
- Blacktown Hospital, Western Sydney Local Health District, Blacktown, NSW, 2148, Australia.
- Storr Liver Centre, The Westmead Institute for Medical Research, University of Sydney, Westmead, NSW, 2145, Australia.
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20
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Sherman Z, Wahid N, Wagner M, Soltani A, Rosenblatt R, Fortune B, Lucero C, Schoenfeld E, Brown R, Jesudian A. Integration of Cirrhosis Best Practices Into Electronic Medical Record Documentation Associated With Reduction in 30-Day Mortality Following Hospitalization. J Clin Gastroenterol 2023; 57:951-955. [PMID: 36730665 DOI: 10.1097/mcg.0000000000001787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Accepted: 09/24/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Hospital admissions for patients with cirrhosis continue to increase. In New York City, 25% to 30% of hospitalized cirrhotics are readmitted within 30 days. Rehospitalization is associated with increased mortality, poor quality of life, and financial burden to patients, hospitals, and payers. Preventable readmissions are partially accounted for by a well-documented quality gap between evidence-based guidelines for cirrhosis management and real-world adherence to these recommendations. METHODS We performed a prospective cohort study that compared outcomes among cirrhotic patients admitted to 4 internal medicine teams over a 6-month period. An electronic medical record (EMR) note template that outlined best-practice measures for cirrhotics was developed. Inpatient providers on 2 teams were instructed to include it in daily progress notes and discharge summaries. The recommended practices included diagnostic paracentesis and diuretics for ascites, rifaximin, and lactulose for hepatic encephalopathy, beta blockers for esophageal varices, and antibiotic prophylaxis for spontaneous bacterial peritonitis. The remaining 2 teams continued the standard of care for cirrhotic patients. The primary outcome was 30-day readmissions. Secondary outcomes included in-hospital mortality, 30-day mortality, length of stay, and adherence to best-practice guidelines. RESULTS Over a 6-month period, 108 cirrhotic patients were admitted, 83 in the interventional group and 25 in the control group. MELD-Na scores on admission did not differ between the groups (20.1 vs. 21.1, P =0.56). Thirty-day readmissions were not significantly different between the interventional and control groups (19.3% vs. 24%, P =0.61). However, 30-day mortality was significantly lower in the interventional group (8.4% vs. 28%, P =0.01). There was no difference between the 2 groups in in-hospital mortality (4.8% vs. 0%, P =0.27), 90-day mortality (15.7% vs. 28.0%, P =0.17) or length of stay (10.2 vs. 12.6 d, P =0.34). Adherence to best-practice metrics was similar between the groups, except for rates of diagnostic paracentesis, which were higher in the interventional group (98% vs. 80%, P =0.01). CONCLUSION Implementation of an EMR note template with cirrhosis best practices was associated with lower 30-day mortality and higher rates of diagnostic paracentesis among admitted patients with cirrhosis. These findings suggest that the integration of best-practice measures into the EMR may improve outcomes in hospitalized cirrhotic patients. Larger studies are required to validate these findings.
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Affiliation(s)
- Zachary Sherman
- Division of Gastroenterology and Hepatology, New York Presbyterian Hospital/Weill Cornell Medical College
| | - Nabeel Wahid
- Department of Medicine, Memorial Sloan Kettering Cancer Center
| | - Michael Wagner
- Department of Medicine, Memorial Sloan Kettering Cancer Center
| | - Amin Soltani
- Division of Gastroenterology, Massachusetts General Hospital
| | - Russell Rosenblatt
- Center for Liver Disease and Transplantation, NewYork Presbyterian Hospital/Weill Cornell Medical College
| | - Brett Fortune
- Center for Liver Disease and Transplantation, NewYork Presbyterian Hospital/Weill Cornell Medical College
| | - Catherine Lucero
- Center for Liver Disease and Transplantation, NewYork Presbyterian Hospital/Weill Cornell Medical College
| | - Emily Schoenfeld
- Center for Liver Disease and Transplantation, NewYork Presbyterian Hospital/Weill Cornell Medical College
| | - Robert Brown
- Center for Liver Disease and Transplantation, NewYork Presbyterian Hospital/Weill Cornell Medical College
| | - Arun Jesudian
- Center for Liver Disease and Transplantation, NewYork Presbyterian Hospital/Weill Cornell Medical College
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21
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Ufere NN. Home is where the liver is?: Moving beyond readmissions to time at home as a patient-centered and pragmatic quality measure in cirrhosis care. Hepatology 2023; 78:382-384. [PMID: 37078443 DOI: 10.1097/hep.0000000000000415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 04/17/2023] [Indexed: 04/21/2023]
Affiliation(s)
- Nneka N Ufere
- Liver Center, Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
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22
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Fabrellas N, Künzler-Heule P, Olofson A, Jack K, Carol M. Nursing care for patients with cirrhosis. J Hepatol 2023; 79:218-225. [PMID: 36754211 DOI: 10.1016/j.jhep.2023.01.029] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 01/25/2023] [Accepted: 01/27/2023] [Indexed: 02/10/2023]
Abstract
Cirrhosis represents a major cause of morbidity and mortality, leading to a marked impairment in the quality of life of patients and their caregivers, and resulting in a major burden on healthcare systems. Currently, in most countries, nurses still play a limited role in the care of patients with cirrhosis, which is mainly restricted to the care of patients hospitalised for acute complications of the disease. The current manuscript reviews the established and potential new and innovative roles that nurses can play in the care of patients with cirrhosis. In the hospital setting, specialised nurses should become an integral part of interprofessional teams, helping to improve the quality of care and outcomes of patients with cirrhosis. In the primary care setting, nurses should play an important role in the care of patients with compensated cirrhosis and also facilitate early diagnosis of cirrhosis in those at risk of liver diseases. This review calls for an improved global liver disease education programme for nurses and increased awareness among all healthcare providers and policymakers of the positive impacts of advanced or specialist nursing practice in this domain.
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Affiliation(s)
- Núria Fabrellas
- Department of Public Health, Mental Health, and Maternal and Child Health Nursing, Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques AugustPi-Sunyer (IDIBAPS), Barcelona, Catalonia, Spain.
| | - Patrizia Künzler-Heule
- Nursing Science, Department of Public Health, Medical Faculty, University of Basel, Basel, Switzerland; Department of Gastroenterology/Hepatology and Department of Nursing, Cantonal Hospital St Gallen, St Gallen, Switzerland
| | | | - Kathryn Jack
- Nottingham University Hospital NHS Trust, Notthingham, UK
| | - Marta Carol
- Department of Public Health, Mental Health, and Maternal and Child Health Nursing, Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques AugustPi-Sunyer (IDIBAPS), Barcelona, Catalonia, Spain
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23
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Pusateri A, Litzenberg K, Griffiths C, Hayes C, Gnyawali B, Manious M, Kelly SG, Conteh LF, Jalil S, Nagaraja HN, Mumtaz K. Randomized intervention and outpatient follow-up lowers 30-d readmissions for patients with hepatic encephalopathy, decompensated cirrhosis. World J Hepatol 2023; 15:826-840. [PMID: 37397939 PMCID: PMC10308285 DOI: 10.4254/wjh.v15.i6.826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 03/23/2023] [Accepted: 04/14/2023] [Indexed: 06/25/2023] Open
Abstract
BACKGROUND We previously reported national 30-d readmission rates of 27% in patients with decompensated cirrhosis (DC).
AIM To study prospective interventions to reduce early readmissions in DC at our tertiary center.
METHODS Adults with DC admitted July 2019 to December 2020 were enrolled and randomized into the intervention (INT) or standard of care (SOC) arms. Weekly phone calls for a month were completed. In the INT arm, case managers ensured outpatient follow-up, paracentesis, and medication compliance. Thirty-day readmission rates and reasons were compared.
RESULTS Calculated sample size was not achieved due to coronavirus disease 2019; 240 patients were randomized into INT and SOC arms. 30-d readmission rate was 33.75%, 35.83% in the INT vs 31.67% in the SOC arm (P = 0.59). The top reason for 30-d readmission was hepatic encephalopathy (HE, 32.10%). There was a lower rate of 30-d readmissions for HE in the INT (21%) vs SOC arm (45%, P = 0.03). There were fewer 30-d readmissions in patients who attended early outpatient follow-up (n = 17, 23.61% vs n = 55, 76.39%, P = 0.04).
CONCLUSION Our 30-d readmission rate was higher than the national rate but reduced by interventions in patients with DC with HE and early outpatient follow-up. Development of interventions to reduce early readmission in patients with DC is needed.
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Affiliation(s)
- Antoinette Pusateri
- Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
| | - Kevin Litzenberg
- Division of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
| | - Claire Griffiths
- Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
| | - Caitlin Hayes
- Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
| | - Bipul Gnyawali
- The Ohio State University College of Medicine, The Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
| | - Michelle Manious
- Division of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
| | - Sean G Kelly
- Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
| | - Lanla F Conteh
- Division of Gastroenterology and Hepatology, The Ohio State Wexner Medical Center, Columbus, OH 43210, United States
| | - Sajid Jalil
- Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
| | - Haikady N Nagaraja
- Division of Biostatistics, The Ohio State University, Columbus, OH 43210, United States
| | - Khalid Mumtaz
- Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
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Pompili E, Baldassarre M, Zaccherini G, Tufoni M, Iannone G, Pratelli D, Palmese F, Vizioli L, Faggiano C, Bedogni G, Domenicali M, Caraceni P. Low haemoglobin level predicts early hospital readmission in patients with cirrhosis and acute decompensation. JHEP Rep 2023; 5:100698. [PMID: 37025944 PMCID: PMC10070139 DOI: 10.1016/j.jhepr.2023.100698] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 01/24/2023] [Accepted: 01/30/2023] [Indexed: 04/08/2023] Open
Abstract
Background & Aims Patients with decompensated cirrhosis present frequent hospitalisations with a relevant clinical and socio-economic impact. This study aims to characterise unscheduled readmissions up to 1-year follow-up and identify predictors of 30-day readmission after an index hospitalisation for acute decompensation (AD). Methods We performed a secondary analysis of a prospectively collected cohort of patients admitted for AD. Laboratory and clinical data at admission and at discharge were collected. Timing and causes of unscheduled readmissions and mortality were recorded up to 1 year. Results A total of 329 patients with AD were included in the analysis. Acute-on-chronic liver failure was diagnosed in 19% of patients at admission or developed in an additional 9% of patients during the index hospitalisation. During the 1-year follow-up, 182 patients (55%) were rehospitalised and 98 (30%) more than once. The most frequent causes of readmission were hepatic encephalopathy (36%), ascites (22%), and infection (21%). Cumulative incidence of readmission was 20% at 30 days, 39% at 90 days, and 63% at 1 year. Fifty-four patients were readmitted for emergent liver-related causes within 30 days. Early readmission was associated with a higher 1-year mortality (47 vs. 32%, p = 0.037). Multivariable Cox regression analysis showed that haemoglobin (Hb) ≤8.7 g/dl (hazard ratio 2.63 [95% CI 1.38-5.02], p = 0.003) and model for end-stage liver disease-sodium score (MELD-Na) >16 at discharge (hazard ratio 2.23 [95% CI 1.27-3.93], p = 0.005), were independent predictors of early readmission. In patients with MELD-Na >16 at discharge, the presence of Hb ≤8.7 g/dl doubles the risk of early rehospitalisation (44% vs. 22%, p = 0.02). Conclusion Besides MELD-Na, a low Hb level (Hb ≤8.7 g/dl) at discharge emerged as a new risk factor for early readmission, contributing to identification of patients who require closer surveillance after discharge. Impact and Implications Patients with decompensated cirrhosis face frequent hospitalisations. In the present study, type and causes of readmissions were analysed during 1-year follow-up in patients discharged after the index hospitalisation for an acute decompensation of the disease. Early (30-day) liver-related readmission was associated with higher 1-year mortality. The model for end-stage liver disease-sodium score and low haemoglobin at discharge were identified as independent risk factors for early readmissions. Haemoglobin emerged as a new easy-to-use parameter associated with early readmission warranting further investigation.
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Affiliation(s)
- Enrico Pompili
- Department of Medical and Surgical Sciences, Alma Mater Studiorum - University of Bologna, Bologna, Italy
| | - Maurizio Baldassarre
- Department of Medical and Surgical Sciences, Alma Mater Studiorum - University of Bologna, Bologna, Italy
- Centre for Applied Biomedical Research (CRBA), Alma Mater Studiorum - University of Bologna, Bologna, Italy
| | - Giacomo Zaccherini
- Department of Medical and Surgical Sciences, Alma Mater Studiorum - University of Bologna, Bologna, Italy
| | - Manuel Tufoni
- Unit of Semeiotics, Liver and Alcohol-related Diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Giulia Iannone
- Department of Medical and Surgical Sciences, Alma Mater Studiorum - University of Bologna, Bologna, Italy
| | - Dario Pratelli
- Department of Medical and Surgical Sciences, Alma Mater Studiorum - University of Bologna, Bologna, Italy
| | - Francesco Palmese
- Department of Medical and Surgical Sciences, Alma Mater Studiorum - University of Bologna, Bologna, Italy
- Department of Primary Health Care, Internal Medicine Unit addressed to Frailty and Aging, “Santa Maria delle Croci” Ravenna Hospital, AUSL Romagna, Ravenna, Italy
| | - Luca Vizioli
- Internal Medicine Unit for the Treatment of Severe Organ Failure, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Chiara Faggiano
- Division of Internal Medicine, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Giorgio Bedogni
- Department of Medical and Surgical Sciences, Alma Mater Studiorum - University of Bologna, Bologna, Italy
- Department of Primary Health Care, Internal Medicine Unit addressed to Frailty and Aging, “Santa Maria delle Croci” Ravenna Hospital, AUSL Romagna, Ravenna, Italy
| | - Marco Domenicali
- Department of Medical and Surgical Sciences, Alma Mater Studiorum - University of Bologna, Bologna, Italy
- Department of Primary Health Care, Internal Medicine Unit addressed to Frailty and Aging, “Santa Maria delle Croci” Ravenna Hospital, AUSL Romagna, Ravenna, Italy
- Department of Medical and Surgical Sciences, Alma Mater Studiorum - University of Bologna, Department of Primary Health Care, S. Maria delle Croci Hospital, AUSL Romagna, Ravenna, Italy
| | - Paolo Caraceni
- Department of Medical and Surgical Sciences, Alma Mater Studiorum - University of Bologna, Bologna, Italy
- Unit of Semeiotics, Liver and Alcohol-related Diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Corresponding authors. Addresses: Department of Medical and Surgical Sciences, Alma Mater Studiorum - University of Bologna, Unit of Semeiotics, Liver and Alcohol-related diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy. Tel.: +39-051-214-2919; fax: +39-051-214-2930.
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25
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Hamberg MLS, Dupont L, Jønsson MF, Bennick H, Teisner AS, Andersen ML, Konradsen H, Danielsen A. A Nurse-Led Outpatient Clinic for Patients With Decompensated Liver Cirrhosis: Staffing, Structure, and Patient Satisfaction. Gastroenterol Nurs 2023; 46:107-117. [PMID: 36882915 DOI: 10.1097/sga.0000000000000706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 08/29/2022] [Indexed: 03/09/2023] Open
Abstract
Patients with decompensated liver cirrhosis constitute a growing and vulnerable patient group with a particular need for easy outpatient access and close follow-up. By establishing a nurse-led clinic, we aimed to counter this need in a patient-centered manner within a multidisciplinary rehabilitating framework. This article presents the organization, staffing, and structure of this initiative as well as the patient population demographics and characteristics. Furthermore, patient satisfaction within the clinic was explored. Two complementary substudies are presented: a descriptive, registry-based journal audit, presenting data from the clinic's first years, 2017-2019, and a cross-sectional, descriptive survey, exploring patient satisfaction 2 years later. Different visit types with predefined content constitute an operable structure suitable for meeting patients' current needs. An increase in both the number of patients and visits from the first to second years indicates an existing need for nurse-led support. Data not only support the well-known characteristics of patients with cirrhosis but also add to a broader perspective with more nuances for this patient population. The survey shows an overall high score on satisfaction but also points out areas for improvement. The nurse-led clinic provides both structure and knowledge to facilitate patient-centered treatment and care for those suffering from liver cirrhosis.
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Affiliation(s)
- Marie Louise S Hamberg
- Marie Louise S. Hamberg, RN, is clinical nurse, Department of Gastroenterology and Hepatology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
- Lene Dupont, RN, is clinical nurse, Department of Gastroenterology and Hepatology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
- Marthe F. Jønsson, RN, is clinical nurse, Department of Gastroenterology and Hepatology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
- Hanne Bennick, RN, is clinical nurse, Department of Gastroenterology and Hepatology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
- Ane S. Teisner, MD, is physician, Department of Gastroenterology and Hepatology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
- Mette L. Andersen, MD, is physician, Department of Gastroenterology and Hepatology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
- Hanne Konradsen, PhD, is Professor, Department of Gastroenterology and Hepatology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark, and Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark, and Division of Nursing, Department of Neurobiology, Care Sciences and Society, Karolinska Institute, Stockholm, Sweden
- Anne Danielsen, PhD, is Associate Professor, Department of Gastroenterology and Hepatology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark, and Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Lene Dupont
- Marie Louise S. Hamberg, RN, is clinical nurse, Department of Gastroenterology and Hepatology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
- Lene Dupont, RN, is clinical nurse, Department of Gastroenterology and Hepatology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
- Marthe F. Jønsson, RN, is clinical nurse, Department of Gastroenterology and Hepatology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
- Hanne Bennick, RN, is clinical nurse, Department of Gastroenterology and Hepatology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
- Ane S. Teisner, MD, is physician, Department of Gastroenterology and Hepatology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
- Mette L. Andersen, MD, is physician, Department of Gastroenterology and Hepatology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
- Hanne Konradsen, PhD, is Professor, Department of Gastroenterology and Hepatology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark, and Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark, and Division of Nursing, Department of Neurobiology, Care Sciences and Society, Karolinska Institute, Stockholm, Sweden
- Anne Danielsen, PhD, is Associate Professor, Department of Gastroenterology and Hepatology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark, and Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Marthe F Jønsson
- Marie Louise S. Hamberg, RN, is clinical nurse, Department of Gastroenterology and Hepatology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
- Lene Dupont, RN, is clinical nurse, Department of Gastroenterology and Hepatology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
- Marthe F. Jønsson, RN, is clinical nurse, Department of Gastroenterology and Hepatology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
- Hanne Bennick, RN, is clinical nurse, Department of Gastroenterology and Hepatology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
- Ane S. Teisner, MD, is physician, Department of Gastroenterology and Hepatology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
- Mette L. Andersen, MD, is physician, Department of Gastroenterology and Hepatology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
- Hanne Konradsen, PhD, is Professor, Department of Gastroenterology and Hepatology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark, and Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark, and Division of Nursing, Department of Neurobiology, Care Sciences and Society, Karolinska Institute, Stockholm, Sweden
- Anne Danielsen, PhD, is Associate Professor, Department of Gastroenterology and Hepatology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark, and Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Hanne Bennick
- Marie Louise S. Hamberg, RN, is clinical nurse, Department of Gastroenterology and Hepatology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
- Lene Dupont, RN, is clinical nurse, Department of Gastroenterology and Hepatology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
- Marthe F. Jønsson, RN, is clinical nurse, Department of Gastroenterology and Hepatology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
- Hanne Bennick, RN, is clinical nurse, Department of Gastroenterology and Hepatology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
- Ane S. Teisner, MD, is physician, Department of Gastroenterology and Hepatology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
- Mette L. Andersen, MD, is physician, Department of Gastroenterology and Hepatology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
- Hanne Konradsen, PhD, is Professor, Department of Gastroenterology and Hepatology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark, and Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark, and Division of Nursing, Department of Neurobiology, Care Sciences and Society, Karolinska Institute, Stockholm, Sweden
- Anne Danielsen, PhD, is Associate Professor, Department of Gastroenterology and Hepatology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark, and Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Ane S Teisner
- Marie Louise S. Hamberg, RN, is clinical nurse, Department of Gastroenterology and Hepatology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
- Lene Dupont, RN, is clinical nurse, Department of Gastroenterology and Hepatology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
- Marthe F. Jønsson, RN, is clinical nurse, Department of Gastroenterology and Hepatology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
- Hanne Bennick, RN, is clinical nurse, Department of Gastroenterology and Hepatology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
- Ane S. Teisner, MD, is physician, Department of Gastroenterology and Hepatology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
- Mette L. Andersen, MD, is physician, Department of Gastroenterology and Hepatology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
- Hanne Konradsen, PhD, is Professor, Department of Gastroenterology and Hepatology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark, and Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark, and Division of Nursing, Department of Neurobiology, Care Sciences and Society, Karolinska Institute, Stockholm, Sweden
- Anne Danielsen, PhD, is Associate Professor, Department of Gastroenterology and Hepatology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark, and Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Mette L Andersen
- Marie Louise S. Hamberg, RN, is clinical nurse, Department of Gastroenterology and Hepatology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
- Lene Dupont, RN, is clinical nurse, Department of Gastroenterology and Hepatology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
- Marthe F. Jønsson, RN, is clinical nurse, Department of Gastroenterology and Hepatology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
- Hanne Bennick, RN, is clinical nurse, Department of Gastroenterology and Hepatology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
- Ane S. Teisner, MD, is physician, Department of Gastroenterology and Hepatology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
- Mette L. Andersen, MD, is physician, Department of Gastroenterology and Hepatology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
- Hanne Konradsen, PhD, is Professor, Department of Gastroenterology and Hepatology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark, and Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark, and Division of Nursing, Department of Neurobiology, Care Sciences and Society, Karolinska Institute, Stockholm, Sweden
- Anne Danielsen, PhD, is Associate Professor, Department of Gastroenterology and Hepatology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark, and Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Hanne Konradsen
- Marie Louise S. Hamberg, RN, is clinical nurse, Department of Gastroenterology and Hepatology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
- Lene Dupont, RN, is clinical nurse, Department of Gastroenterology and Hepatology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
- Marthe F. Jønsson, RN, is clinical nurse, Department of Gastroenterology and Hepatology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
- Hanne Bennick, RN, is clinical nurse, Department of Gastroenterology and Hepatology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
- Ane S. Teisner, MD, is physician, Department of Gastroenterology and Hepatology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
- Mette L. Andersen, MD, is physician, Department of Gastroenterology and Hepatology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
- Hanne Konradsen, PhD, is Professor, Department of Gastroenterology and Hepatology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark, and Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark, and Division of Nursing, Department of Neurobiology, Care Sciences and Society, Karolinska Institute, Stockholm, Sweden
- Anne Danielsen, PhD, is Associate Professor, Department of Gastroenterology and Hepatology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark, and Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Anne Danielsen
- Marie Louise S. Hamberg, RN, is clinical nurse, Department of Gastroenterology and Hepatology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
- Lene Dupont, RN, is clinical nurse, Department of Gastroenterology and Hepatology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
- Marthe F. Jønsson, RN, is clinical nurse, Department of Gastroenterology and Hepatology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
- Hanne Bennick, RN, is clinical nurse, Department of Gastroenterology and Hepatology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
- Ane S. Teisner, MD, is physician, Department of Gastroenterology and Hepatology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
- Mette L. Andersen, MD, is physician, Department of Gastroenterology and Hepatology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
- Hanne Konradsen, PhD, is Professor, Department of Gastroenterology and Hepatology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark, and Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark, and Division of Nursing, Department of Neurobiology, Care Sciences and Society, Karolinska Institute, Stockholm, Sweden
- Anne Danielsen, PhD, is Associate Professor, Department of Gastroenterology and Hepatology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark, and Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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O’Connell MB, Bendtsen F, Nørholm V, Brødsgaard A, Kimer N. Nurse-assisted and multidisciplinary outpatient follow-up among patients with decompensated liver cirrhosis: A systematic review. PLoS One 2023; 18:e0278545. [PMID: 36758017 PMCID: PMC9910708 DOI: 10.1371/journal.pone.0278545] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 11/18/2022] [Indexed: 02/10/2023] Open
Abstract
BACKGROUND AND OBJECTIVE Liver cirrhosis represents a considerable health burden and causes 1.2 million deaths annually. Patients with decompensated liver cirrhosis have a poor prognosis and severely reduced health-related quality of life. Nurse-led outpatient care has proven safe and feasible for several chronic diseases and engaging nurses in the outpatient care of patients with liver cirrhosis has been recommended. At the decompensated stage, the treatment and nursing care are directed at specific complications, educational support, and guidance concerning preventive measures and signs of decompensation. This review aimed to assess the effects of nurse-assisted follow-up after admission with decompensation in patients with liver cirrhosis from all causes. METHOD A systematic search was conducted through February 2022. Studies were eligible for inclusion if i) they assessed adult patients diagnosed with liver cirrhosis that had been admitted with one or more complications to liver cirrhosis and ii) if nurse-assisted follow-up, including nurse-assisted multidisciplinary interventions, was described in the manuscript. Randomized clinical trials were prioritized, but controlled trials and prospective cohort studies with the intervention were also included. Primary outcomes were mortality and readmission, but secondary subjective outcomes were also assessed. RESULTS AND CONCLUSION We included eleven controlled studies and five prospective studies with a historical control group comprising 1224 participants. Overall, the studies were of moderate to low quality, and heterogeneity across studies was substantial. In a descriptive summary, the 16 studies were divided into three main types of interventions: educational interventions, case management, and standardized hospital follow-up. We saw a significant improvement across all types of studies on several parameters, but currently, no data support a specific type of nurse-assisted, post-discharge intervention. Controlled trials with a predefined intervention evaluating clinically- and practice-relevant endpoints in a real-life, patient-oriented setting are highly warranted.
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Affiliation(s)
- Malene Barfod O’Connell
- Gastrounit, Medical Division, Copenhagen University Hospital Amager Hvidovre, Hvidovre, Denmark
- * E-mail:
| | - Flemming Bendtsen
- Gastrounit, Medical Division, Copenhagen University Hospital Amager Hvidovre, Hvidovre, Denmark
| | - Vibeke Nørholm
- Clinical Research Department, Copenhagen University Hospital Amager Hvidovre, Hvidovre, Denmark
| | - Anne Brødsgaard
- Department of Pediatrics and Adolescent Medicine, Copenhagen University Hospital Amager Hvidovre, Hvidovre, Denmark
- Department of Public Health, Section for Nursing, Aarhus University, Aarhus, Denmark
| | - Nina Kimer
- Gastrounit, Medical Division, Copenhagen University Hospital Amager Hvidovre, Hvidovre, Denmark
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Gananandan K, Phillips A, Chikhlia A, Old H, Sim SJY, Thakur N, Hussain I, Kazankov K, Mookerjee RP. Negative impact of the pandemic on hospital admissions, morbidity and early mortality for acute cirrhosis decompensation. BMJ Open Gastroenterol 2023; 10:bmjgast-2022-001071. [PMID: 36650007 PMCID: PMC9853150 DOI: 10.1136/bmjgast-2022-001071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 01/03/2023] [Indexed: 01/19/2023] Open
Abstract
INTRODUCTION The global pandemic has diverted resources away from management of chronic diseases, including cirrhosis. While there is increasing knowledge on COVID-19 infection in liver cirrhosis, little is described on the impact of the pandemic on decompensated cirrhosis admissions and outcomes, which was the aim of this study. METHODS A single-centre, retrospective study, evaluated decompensated cirrhosis admissions to a tertiary London hepatology and transplantation centre, from October 2018 to February 2021. Patients were included if they had an admission with cirrhosis decompensation defined as new-onset jaundice or ascites, infection, encephalopathy, portal hypertensive bleeding or renal dysfunction. RESULTS The average number of admissions stayed constant between the pre-COVID-19 (October 2018-February 2020) and COVID-19 periods (March 2020-February 2021). Patients transferred in from secondary centres had consistently higher severity scores during the COVID-19 period (UK Model for End-Stage Liver Disease 58 vs 54; p=0.007, Model for End-Stage Liver Disease-Sodium 22 vs 18; p=0.006, EF-CLIF Acute Decompensation (AD) score 55.0 vs 51.0; p=0.055). Of those admitted to the intensive care without acute-on-chronic liver failure, there was a significant increase in AD scores during the COVID-19 period (58 vs 48, p=0.009). In addition, there was a trend towards increased hospital readmission rates during the COVID-19 period (29.5% vs 21.5%, p=0.067). When censored at 30 days, early mortality postdischarge was significantly higher during the COVID-19 period (p<0.001) with a median time to death of 35 days compared with 62 days pre-COVID-19. DISCUSSION This study provides a unique perspective on the impact that the global pandemic had on decompensated cirrhosis admissions. The findings of increased early mortality and readmissions, and higher AD scores on ICU admission, highlight the need to maintain resourcing for high-level hepatology care and follow-up, in spite of other disease pressures.
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Affiliation(s)
- Kohilan Gananandan
- University College London Institute for Liver and Digestive Health, London, UK
| | - Alexandra Phillips
- University College London Institute for Liver and Digestive Health, London, UK
| | | | - Hannah Old
- Royal Free London NHS Foundation Trust, London, UK
| | | | - Niharika Thakur
- University College London Institute for Liver and Digestive Health, London, UK
| | - Ishrat Hussain
- University College London Institute for Liver and Digestive Health, London, UK
| | - Konstantin Kazankov
- University College London Institute for Liver and Digestive Health, London, UK,Aarhus University Hospital Department of Hepatology and Gastroenterology, Aarhus, Midtjylland, Denmark
| | - Rajeshwar P Mookerjee
- University College London Institute for Liver and Digestive Health, London, UK .,Aarhus University Hospital Department of Hepatology and Gastroenterology, Aarhus, Midtjylland, Denmark
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Kazankov K, Novelli S, Chatterjee DA, Phillips A, Balaji A, Raja M, Foster G, Tripathi D, Boddu R, Kumar R, Jalan R, Mookerjee RP. Evaluation of CirrhoCare® - a digital health solution for home management of individuals with cirrhosis. J Hepatol 2023; 78:123-132. [PMID: 36087864 DOI: 10.1016/j.jhep.2022.08.034] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 08/10/2022] [Accepted: 08/11/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND & AIMS Individuals with cirrhosis discharged from hospital following acute decompensation are at high risk of new complications. This study aimed to assess the feasibility and potential clinical benefits of remote management of individuals with acutely decompensated cirrhosis using CirrhoCare®. METHODS Individuals with cirrhosis with acute decompensation were followed up with CirrhoCare® and compared with contemporaneous matched controls, managed with standard follow-up. Commercially available monitoring devices were linked to the smartphone CirrhoCare® app, for daily recording of heart rate, blood pressure, weight, % body water, cognitive function (CyberLiver Animal Recognition Test [CL-ART] app), self-reported well-being, and intake of food, fluid, and alcohol. The app had 2-way patient-physician communication. Independent external adjudicators assessed the appropriateness of CirrhoCare®-based decisions. RESULTS Twenty individuals with cirrhosis were recruited to CirrhoCare® (mean age 59 ± 10 years, 14 male, alcohol-related cirrhosis [80%], mean model for end-stage liver disease-sodium [MELD-Na] score 16.1 ± 4.2) and were not statistically different to 20 contemporaneous controls. Follow-up was 10.1 ± 2.4 weeks. Fifteen individuals showed good engagement (≥4 readings/week), 2 moderate (2-3/week), and 3 poor (<2/week). In a usability questionnaire, the median score was ≥9 for all questions. Five CirrhoCare®-managed individuals had 8 readmissions over a median of 5 (IQR 3.5-11) days, and none required hospitalisation for >14 days. Sixteen other CirrhoCare®-guided patient contacts were made, leading to clinical interventions that prevented further progression. Appropriateness was confirmed by adjudicators. Controls had 13 readmissions in 8 individuals, lasting a median of 7 (IQR 3-15) days with 4 admissions of >14 days. They had 6 unplanned paracenteses compared with 1 in the CirrhoCare® group. CONCLUSIONS This study demonstrates that CirrhoCare® is feasible for community management of individuals with decompensated cirrhosis with good engagement and clinically relevant alerts to new decompensating events. CirrhoCare®-managed individuals have fewer and shorter readmissions justifying larger controlled clinical trials. IMPACT AND IMPLICATIONS As the burden of cirrhosis grows worldwide, increasing demands are being placed on limited healthcare resources, necessitating the adoption of more sustainable care models that allow for at-home patient management. The CirrhoCare® management system was developed to fill this care gap, deploying a novel combination of hardware, apps, and algorithms, to monitor and intervene in individuals at risk of new decompensation. This study highlights the possibility of reducing hospital readmissions for cirrhosis by optimising specialist community care, reducing the need for interventions such as paracentesis, while providing a more sustainable care pathway that is acceptable to patients. However, given the pilot and non-randomised nature of this study, the outcomes require further validation in a larger randomised controlled trial, to assess both clinical effectiveness and cost-effectiveness. Moreover, the data generated will also facilitate data modelling and further research to refine the CirrhoCare® algorithms to increase their detection sensitivity and utility.
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Affiliation(s)
- Konstantin Kazankov
- Liver Failure Group, Institute for Liver and Digestive Health, UCL Medical School, Royal Free Hospital, London, UK; Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Simone Novelli
- Liver Failure Group, Institute for Liver and Digestive Health, UCL Medical School, Royal Free Hospital, London, UK
| | - Devnandan A Chatterjee
- Liver Failure Group, Institute for Liver and Digestive Health, UCL Medical School, Royal Free Hospital, London, UK
| | - Alexandra Phillips
- Liver Failure Group, Institute for Liver and Digestive Health, UCL Medical School, Royal Free Hospital, London, UK
| | | | | | - Graham Foster
- Barts Liver Centre, Queen Mary University of London, London, UK
| | - Dhiraj Tripathi
- Gastrointestinal and Liver Services, University Hospitals Birmingham Foundation Trust, Birmingham, UK
| | | | | | - Rajiv Jalan
- Liver Failure Group, Institute for Liver and Digestive Health, UCL Medical School, Royal Free Hospital, London, UK; European Foundation for the Study of Chronic Liver Failure, Barcelona, Spain
| | - Rajeshwar P Mookerjee
- Liver Failure Group, Institute for Liver and Digestive Health, UCL Medical School, Royal Free Hospital, London, UK; Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark.
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Dahiya DS, Sanaka MR, Kichloo A, Singh A, Wachala J, Perisetti A, Goyal H, Garg R, Shaka H, Pisipati S, Inamdar S, Al-Haddad M. Early readmissions of spontaneous bacterial peritonitis in the USA: Insights into an emerging challenge. J Gastroenterol Hepatol 2022; 37:2067-2073. [PMID: 35869617 DOI: 10.1111/jgh.15965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 06/30/2022] [Accepted: 07/18/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIM Early readmissions of spontaneous bacterial peritonitis (SBP) are often associated with poor outcomes. We compared characteristics and outcomes for index and 30-day readmissions of SBP in the USA. METHODS We analyzed the Nationwide Readmissions Database for 2018 to identify all adult (≥ 18 years) 30-day readmissions of SBP in the USA. Hospitalization characteristics and outcomes for index and 30-day readmissions of SBP were compared. Independent predictors of 30-day readmissions were also identified. RESULTS In 2018, of the 5,797 index admissions for SBP, 30% (1726) were readmitted within 30 day. At the time of readmission, the most common admitting diagnosis was alcoholic cirrhosis of the liver with ascites (11.8%) followed by sepsis due to an unspecified organism (9.2%). SBP as an admitting diagnosis was identified for only 8.3% of these 30-day readmissions. Compared with index admissions, 30-day readmissions of SBP had a lower mean age (56.1 vs 58.6 years, P < 0.001) without a statistically significant difference for gender. Furthermore, 30-day readmissions of SBP were associated with significantly higher odds of inpatient mortality (10% vs 4.9%, OR: 2.15, 95% CI: 1.66-2.79, P < 0.001), and mean total hospital charge ($85,031 vs $56,000, mean difference: 29,032, 95% CI: 12,867-45,197, P < 0.001) compared with index admissions. The presence of chronic pulmonary disease, liver failure, inpatient dialysis, and discharge against medical advice were identified as independent predictors for increased 30-day readmissions of SBP. CONCLUSION The 30-day readmission rate of SBP was 30% and these readmissions were associated with higher odds of inpatient mortality compared with index admissions.
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Affiliation(s)
- Dushyant Singh Dahiya
- Department of Internal Medicine, Central Michigan University College of Medicine, Saginaw, Michigan, USA
| | - Madhusudhan R Sanaka
- Director of Third-Space Endoscopy, Department of Gastroenterology, Hepatology and Nutrition, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Asim Kichloo
- Department of Internal Medicine, Central Michigan University College of Medicine, Saginaw, Michigan, USA.,Department of Internal Medicine, Samaritan Medical Center, Watertown, New York, USA
| | - Amandeep Singh
- Department of Gastroenterology, Hepatology and Nutrition, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Jennifer Wachala
- Department of Internal Medicine, Samaritan Medical Center, Watertown, New York, USA
| | | | - Hemant Goyal
- The Wright Center for Graduate Medical Education, Scranton, Pennsylvania, USA.,Department of Internal Medicine, Mercer University School of Medicine, Macon, Georgia, USA
| | - Rajat Garg
- Department of Gastroenterology, Hepatology and Nutrition, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Hafeez Shaka
- Department of Internal Medicine, John H. Stroger, Jr. Hospital of Cook County, Chicago, Illinois, USA
| | - Sailaja Pisipati
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Sumant Inamdar
- Department of Gastroenterology and Hepatology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Mohammad Al-Haddad
- Division Chief and Professor of Medicine, Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
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Kaplan A, Rosenblatt R. Symptom Management in Patients with Cirrhosis: a Practical Guide. CURRENT TREATMENT OPTIONS IN GASTROENTEROLOGY 2022; 20:144-159. [PMID: 35313484 PMCID: PMC8928010 DOI: 10.1007/s11938-022-00377-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 02/14/2022] [Indexed: 12/03/2022]
Abstract
Purpose of the review
Though it is well known that cirrhosis is associated with significant morbidity and mortality, management of symptoms in cirrhosis can be difficult. This review serves to offer practical guidance in the management of liver-specific symptoms of cirrhosis as well as other symptoms with special hepatic considerations. Recent findings We discuss liver-specific symptoms and management, including ascites and refractory ascites, hepatic encephalopathy, pruritus, and muscle cramping. We also discuss the challenges of treating more generalized symptoms in cirrhosis, including pain, depression/anxiety, appetite, and fatigue. Medication management is, especially complex in this population given the altered metabolism of drugs, and we consider some strategies to approach this. Summary With the right tools, provided throughout this review, hepatologists should be well equipped to manage the nuanced liver-specific and generalized symptoms in patients with cirrhosis.
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Affiliation(s)
- Alyson Kaplan
- Department of Gastroenterology and Hepatology, New York Presbyterian, Weill Cornell Medicine, New York, NY USA
| | - Russell Rosenblatt
- Department of Gastroenterology and Hepatology, New York Presbyterian, Weill Cornell Medicine, New York, NY USA
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Orman ES, Ghabril MS, Desai AP, Nephew L, Patidar KR, Gao S, Xu C, Chalasani N. Patient-Reported Outcome Measures Modestly Enhance Prediction of Readmission in Patients with Cirrhosis. Clin Gastroenterol Hepatol 2022; 20:e1426-e1437. [PMID: 34311111 PMCID: PMC8784569 DOI: 10.1016/j.cgh.2021.07.032] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 06/29/2021] [Accepted: 07/19/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND & AIMS Patients with cirrhosis have high rates of hospital readmission, but prediction models are suboptimal and have not included important patient-reported outcome measures (PROMs). In a large prospective cohort, we examined the impact of PROMs on prediction of 30-day readmissions. METHODS We performed a prospective cohort study of adults with cirrhosis admitted to a tertiary center between June 2014 and March 2020. We collected clinical information, socioeconomic status, and PROMs addressing functional status and quality of life. We used hierarchical competing risk time-to-event analysis to examine the impact of PROMs on readmission prediction. RESULTS A total of 654 patients were discharged alive, and 247 (38%) were readmitted within 30 days. Readmission was independently associated with cerebrovascular disease, ascites, prior hospital admission, admission via the emergency department, lower albumin, higher Model for End-Stage Liver Disease, discharge with public transportation, and impaired basic activities of daily living and quality-of-life activity domain. Reduced readmission was associated with cancer, admission for infection, children at home, and impaired emotional function. Compared with a model including only clinical variables, addition of functional status and quality-of-life variables improved the area under the receiver-operating characteristic curve from 0.72 to 0.73 and 0.75, with net reclassification indices of 0.22 and 0.18, respectively. Socioeconomic variables did not significantly improve prediction compared with clinical variables alone. Compared with a model using electronically available variables only, no models improved prediction when examined with integrated discrimination improvement. CONCLUSIONS PROMs may marginally add to the prediction of 30-day readmissions for patients with cirrhosis. Poor social support and disability are associated with readmissions and may be high-yield targets for future interventions.
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Affiliation(s)
- Eric S Orman
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana.
| | - Marwan S Ghabril
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Archita P Desai
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Lauren Nephew
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Kavish R Patidar
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Sujuan Gao
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, Indiana
| | - Chenjia Xu
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, Indiana
| | - Naga Chalasani
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana
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Rising Healthcare Costs and Utilization among Young Adults with Cirrhosis in Ontario: A Population-Based Study. Can J Gastroenterol Hepatol 2022; 2022:6175913. [PMID: 35308801 PMCID: PMC8926479 DOI: 10.1155/2022/6175913] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 01/26/2022] [Accepted: 01/28/2022] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVES Chronic diseases account for the majority of healthcare spending. Cirrhosis is a chronic disease whose burden is rising, especially in young adults. This study aimed at describing the direct healthcare costs and utilization in young adults with cirrhosis compared to other chronic diseases common to this age group. METHODS Retrospective population-based study of routinely collected healthcare data from Ontario for the fiscal years 2007-2016 and housed at ICES. Young adults (aged 18-40 years) with cirrhosis, inflammatory bowel disease (IBD), and asthma were identified based on validated case definitions. Total and annual direct healthcare costs and utilization were calculated per individual across multiple healthcare settings and compared based on the type of chronic disease. For cirrhosis, the results were further stratified by etiology and decompensation status. RESULTS Total direct healthcare spending from 2007 to 2016 increased by 84% for cirrhosis, 50% for IBD, and 41% for asthma. On a per-patient basis, annual costs were the highest for cirrhosis ($6,581/year) compared to IBD ($5,260/year), and asthma ($2,934/year) driven by acute care in cirrhosis and asthma, and drug costs in IBD. Annual costs were four-fold higher in patients with decompensated versus compensated cirrhosis ($20,651/year vs. $5,280/year). Patients with cirrhosis had greater use of both ICU and mental health services. CONCLUSION Healthcare costs in young adults with cirrhosis are rising and driven by the use of acute care. Strategies to prevent the development of cirrhosis and to coordinate healthcare in this population through the development of chronic disease prevention and management strategies are urgently needed.
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Monitoring for Ascites in Cirrhosis Using Patient-Generated Health Data: No Longer a Remote Possibility. Dig Dis Sci 2022; 67:742-744. [PMID: 34008115 DOI: 10.1007/s10620-021-07020-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/14/2021] [Indexed: 02/06/2023]
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Yoder L, Mladenovic A, Pike F, Vuppalanchi R, Hanson H, Corbito L, Desai AP, Chalasani N, Orman ES. Attendance at a Transitional Liver Clinic May Be Associated with Reduced Readmissions for Patients with Liver Disease. Am J Med 2022; 135:235-243.e2. [PMID: 34655539 PMCID: PMC8840978 DOI: 10.1016/j.amjmed.2021.09.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 09/16/2021] [Accepted: 09/17/2021] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Patients with liver disease have high rates of early hospital readmission, but there are no studies of effective, scalable interventions to reduce this risk. In this study, we examined the impact of a Physician Assistant (PA)-led post-discharge Transitional Liver Clinic (TLC) on hospital readmissions. METHODS We performed a cohort study of all adults seen by a hepatologist during admission to a tertiary care center in 2019 (excluding transplant patients). We compared those who attended the TLC with those who did not, with respect to 30-day readmission and mortality. Propensity score-adjusted modeling was used to control for confounding. RESULTS Of 498 patients, 98 were seen in the TLC; 35% had alcoholic liver disease and 58% had cirrhosis. Attendees were similar to non-attendees with respect to demographics, liver disease characteristics and severity, comorbidities, and discharge disposition. Thirty-day cumulative incidence of readmissions was 12% in TLC attendees, compared with 22% in non-attendees (P = .02), while 30-day mortality was similar (2.0% vs 4.3%; P = .29). In a model using propensity score adjustment, TLC attendance remained associated with reduced readmissions (subhazard ratio 0.52; 95% confidence interval, 0.27-0.997; P = .049). The effect of TLC was greater in women compared with men (P = .07) and in those without chronic kidney disease (P = .02), but there were no differences across other subgroups. CONCLUSIONS Patients with liver disease seen in a PA-led TLC may have a significant reduction in the 30-day readmission rate. Randomized trials are needed to establish the efficacy of PA-led post-discharge transitional care for this population.
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Affiliation(s)
- Lindsay Yoder
- Division of Gastroenterology & Hepatology, Indiana University School of Medicine, Indianapolis; Digestive & Liver Disorders, Indiana University Health, Indianapolis
| | - Andrea Mladenovic
- Division of Gastroenterology & Hepatology, Indiana University School of Medicine, Indianapolis
| | - Francis Pike
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis
| | - Raj Vuppalanchi
- Division of Gastroenterology & Hepatology, Indiana University School of Medicine, Indianapolis; Digestive & Liver Disorders, Indiana University Health, Indianapolis
| | - Haleigh Hanson
- Digestive & Liver Disorders, Indiana University Health, Indianapolis
| | - Laura Corbito
- Digestive & Liver Disorders, Indiana University Health, Indianapolis
| | - Archita P Desai
- Division of Gastroenterology & Hepatology, Indiana University School of Medicine, Indianapolis; Digestive & Liver Disorders, Indiana University Health, Indianapolis
| | - Naga Chalasani
- Division of Gastroenterology & Hepatology, Indiana University School of Medicine, Indianapolis; Digestive & Liver Disorders, Indiana University Health, Indianapolis
| | - Eric S Orman
- Division of Gastroenterology & Hepatology, Indiana University School of Medicine, Indianapolis; Digestive & Liver Disorders, Indiana University Health, Indianapolis.
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Karlsen TH, Sheron N, Zelber-Sagi S, Carrieri P, Dusheiko G, Bugianesi E, Pryke R, Hutchinson SJ, Sangro B, Martin NK, Cecchini M, Dirac MA, Belloni A, Serra-Burriel M, Ponsioen CY, Sheena B, Lerouge A, Devaux M, Scott N, Hellard M, Verkade HJ, Sturm E, Marchesini G, Yki-Järvinen H, Byrne CD, Targher G, Tur-Sinai A, Barrett D, Ninburg M, Reic T, Taylor A, Rhodes T, Treloar C, Petersen C, Schramm C, Flisiak R, Simonova MY, Pares A, Johnson P, Cucchetti A, Graupera I, Lionis C, Pose E, Fabrellas N, Ma AT, Mendive JM, Mazzaferro V, Rutter H, Cortez-Pinto H, Kelly D, Burton R, Lazarus JV, Ginès P, Buti M, Newsome PN, Burra P, Manns MP. The EASL-Lancet Liver Commission: protecting the next generation of Europeans against liver disease complications and premature mortality. Lancet 2022; 399:61-116. [PMID: 34863359 DOI: 10.1016/s0140-6736(21)01701-3] [Citation(s) in RCA: 351] [Impact Index Per Article: 117.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Revised: 07/10/2021] [Accepted: 07/15/2021] [Indexed: 02/07/2023]
Affiliation(s)
- Tom H Karlsen
- Department of Transplantation Medicine and Research Institute for Internal Medicine, Division of Surgery, Inflammatory Diseases and Transplantation, Oslo University Hospital Rikshospitalet and University of Oslo, Oslo, Norway.
| | - Nick Sheron
- Institute of Hepatology, Foundation for Liver Research, Kings College London, London, UK
| | - Shira Zelber-Sagi
- School of Public Health, Faculty of Social Welfare and Health Sciences, University of Haifa, Haifa, Israel; Department of Gastroenterology, Tel Aviv Medical Center, Tel Aviv, Israel
| | - Patrizia Carrieri
- Aix-Marseille University, Inserm, Institut de recherche pour le développement, Sciences Economiques et Sociales de la Santé et Traitement de l'Information Médicale (SESSTIM), ISSPAM, Marseille, France
| | - Geoffrey Dusheiko
- School of Medicine, University College London, London, UK; Kings College Hospital, London, UK
| | - Elisabetta Bugianesi
- Department of Medical Sciences, Division of Gastroenterology, University of Torino, Torino, Italy
| | | | - Sharon J Hutchinson
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK; Clinical and Protecting Health Directorate, Public Health Scotland, Glasgow, UK
| | - Bruno Sangro
- Liver Unit, Clinica Universidad de Navarra-IDISNA and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Pamplona, Spain
| | - Natasha K Martin
- Division of Infectious Diseases and Global Public Health, University of California San Diego, San Diego, CA, USA; Population Health Sciences, University of Bristol, Bristol, UK
| | - Michele Cecchini
- Health Division, Organisation for Economic Co-operation and Development, Paris, France
| | - Mae Ashworth Dirac
- Department of Health Metrics Sciences, University of Washington, Seattle, WA, USA; Department of Family Medicine, University of Washington, Seattle, WA, USA; Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Annalisa Belloni
- Health Economics and Modelling Division, Public Health England, London, UK
| | - Miquel Serra-Burriel
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Cyriel Y Ponsioen
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam University Medical Centers, Amsterdam, Netherlands
| | - Brittney Sheena
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Alienor Lerouge
- Health Division, Organisation for Economic Co-operation and Development, Paris, France
| | - Marion Devaux
- Health Division, Organisation for Economic Co-operation and Development, Paris, France
| | - Nick Scott
- Disease Elimination Program, Burnet Institute, Melbourne, VIC, Australia
| | - Margaret Hellard
- Disease Elimination Program, Burnet Institute, Melbourne, VIC, Australia; Department of Infectious Diseases, Alfred Hospital, Melbourne, VIC, Australia; Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia; Doherty Institute and School of Population and Global Health, University of Melbourne, Melbourne, VIC, Australia
| | - Henkjan J Verkade
- Paediatric Gastroenterology and Hepatology, Department of Paediatrics, University Medical Centre Groningen, University of Groningen, Netherlands; European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Hamburg, Germany
| | - Ekkehard Sturm
- Division of Paediatric Gastroenterology and Hepatology, University Children's Hospital Tübingen, Tübingen, Germany; European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Hamburg, Germany
| | | | | | - Chris D Byrne
- Department of Nutrition and Metabolism, Faculty of Medicine, University of Southampton, Southampton, UK; Southampton National Institute for Health Research, Biomedical Research Centre, University Hospital Southampton and Southampton General Hospital, Southampton, UK
| | - Giovanni Targher
- Department of Medicine, Section of Endocrinology, Diabetes, and Metabolism, University of Verona, Verona, Italy
| | - Aviad Tur-Sinai
- Department of Health Systems Management, The Max Stern Yezreel Valley College, Yezreel Valley, Israel
| | - Damon Barrett
- School of Public Health and Community Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | | | - Tatjana Reic
- European Liver Patients Organization, Brussels, Belgium; Croatian Society for Liver Diseases-Hepatos, Split, Croatia
| | | | - Tim Rhodes
- London School of Hygiene & Tropical Medicine, London, UK
| | - Carla Treloar
- Centre for Social Research in Health, University of New South Wales, Sydney, NSW, Australia
| | - Claus Petersen
- Department of Pediatric Surgery, Hannover Medical School, Hannover, Germany
| | - Christoph Schramm
- Martin Zeitz Center for Rare Diseases, Hamburg Center for Translational Immunology (HCTI), and First Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Hamburg, Germany
| | - Robert Flisiak
- Department of Infectious Diseases and Hepatology, Medical University of Białystok, Poland
| | - Marieta Y Simonova
- Department of Gastroenterology, HPB Surgery and Transplantation, Clinic of Gastroentrology, Military Medical Academy, Sofia, Bulgaria
| | - Albert Pares
- Liver Unit, Hospital Clinic of Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; CIBEREHD, Madrid, Spain
| | - Philip Johnson
- Department of Molecular and Clinical Cancer Medicine, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
| | - Alessandro Cucchetti
- Department of Medical and Surgical Sciences-DIMEC, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Isabel Graupera
- Liver Unit, Hospital Clinic of Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; CIBEREHD, Madrid, Spain; Faculty of Medicine and Health Sciences, University of Barcelona, Spain
| | - Christos Lionis
- Clinic of Social and Family Medicine, Medical School, University of Crete, Heraklion, Greece
| | - Elisa Pose
- Liver Unit, Hospital Clinic of Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Faculty of Medicine and Health Sciences, University of Barcelona, Spain
| | - Núria Fabrellas
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; CIBEREHD, Madrid, Spain; Faculty of Medicine and Health Sciences, University of Barcelona, Spain
| | - Ann T Ma
- Liver Unit, Hospital Clinic of Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Juan M Mendive
- Prevention and Health Promotion Research Network (redIAPP), Institute of Health Carlos III, Madrid, Spain; La Mina Health Centre, Catalan Institute of Health (ICS), Barcelona, Spain
| | - Vincenzo Mazzaferro
- HPB Surgery and Liver Transplantation, Istituto Nazionale Tumori IRCCS Foundation (INT), Milan, Italy; Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Harry Rutter
- Department of Social and Policy Sciences, University of Bath, Bath, UK
| | - Helena Cortez-Pinto
- Clínica Universitária de Gastrenterologia and Laboratório de Nutrição, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Deirdre Kelly
- Liver Unit, Birmingham Women's and Children's Hospital and University of Birmingham, UK
| | - Robyn Burton
- Alcohol, Drugs, Tobacco and Justice Division, Public Health England, London, UK
| | - Jeffrey V Lazarus
- Barcelona Institute for Global Health (ISGlobal), Hospital Clínic, Barcelona, Spain
| | - Pere Ginès
- Liver Unit, Hospital Clinic of Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; CIBEREHD, Madrid, Spain; Faculty of Medicine and Health Sciences, University of Barcelona, Spain
| | - Maria Buti
- CIBEREHD del Instituto de Salud Carlos III, Madrid, Spain; Liver Unit, Hospital Universitario Valle Hebron, Barcelona, Spain
| | - Philip N Newsome
- National Institute for Health Research Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust, University of Birmingham, Birmingham, UK
| | - Patrizia Burra
- Multivisceral Transplant Unit, Gastroenterology, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
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Bloom PP, Ventoso M, Tapper E, Ha J, Richter JM. A Telemonitoring Intervention for Cirrhotic Ascites Management Is Cost-Saving. Dig Dis Sci 2022; 67:854-862. [PMID: 34018070 PMCID: PMC8136259 DOI: 10.1007/s10620-021-07013-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 01/23/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Patients with cirrhosis and ascites experience frequent hospital admissions, leading to poor quality of life and high healthcare costs. Monitoring weight is a component of ascites care and telemonitoring may improve outcomes and costs. Goals We aimed to evaluate the cost and outcomes of current care compared to a telemonitoring system for ascites. Study We developed a decision-analytic model that examined 100 simulated patients over a 6-month horizon. We compared usual care to a new telemonitoring program, which we estimate costs $50,000/6 months. RESULTS The cost of standard of care for 100 patients with cirrhotic ascites over a 6-month period is $167,500 more expensive than telemonitoring. By varying parameter probabilities by ± 10% and outcome costs by ± 20%, we found that standard of care remains more expensive than care with a telemonitoring intervention by $9400 to $340,200 per 6-month period. Standard of care leads to 9 more admissions (range 4 to 12) than a telemonitoring intervention, while telemonitoring leads to 9 more outpatient visits (range 6 to 9) and 28 additional outpatient large volume paracenteses (LVPs) (range 17 to 28). With more and less expensive telemonitoring interventions, standard of care remained more expensive. With 50% adherence to the intervention, standard of care was $89,848 more expensive. CONCLUSIONS In almost all probability and cost scenarios, a telemonitoring intervention is cost-saving for the management of cirrhotic ascites. Using hospital admissions as a surrogate for quality of care, patient outcomes are improved primarily though more proactive medical intervention and more LVPs.
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Affiliation(s)
- Patricia P. Bloom
- Gastrointestinal Unit, University of Michigan, Taubman Center, Floor 1, Reception G, 1500 E. Medical Center Dr., Ann Arbor, MI USA
| | - Martin Ventoso
- Department of Medicine, Harvard Medical School, Boston, USA
| | - Elliot Tapper
- Gastrointestinal Unit, University of Michigan, Taubman Center, Floor 1, Reception G, 1500 E. Medical Center Dr., Ann Arbor, MI USA
| | - Jasmine Ha
- Gastrointestinal Unit, Massachusetts General Hospital, Boston, USA
| | - James M. Richter
- Department of Medicine, Harvard Medical School, Boston, USA ,Gastrointestinal Unit, Massachusetts General Hospital, Boston, USA
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37
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Tapper EB, Parikh ND. The Future of Quality Improvement for Cirrhosis. Liver Transpl 2021; 27:1479-1489. [PMID: 33887806 PMCID: PMC8487907 DOI: 10.1002/lt.26079] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 04/01/2021] [Accepted: 04/15/2021] [Indexed: 01/21/2023]
Abstract
Cirrhosis has a significant and growing impact on public health and patient-reported outcomes (PROs). The increasing burden of cirrhosis has led to an emphasis on the quality of care with the goal of improving overall outcomes in this high-risk population. Existing evidence has shown the significant gaps in quality across process measures (eg, hepatocellular carcinoma screening), highlighting the need for consistent measurement and interventions to address the gaps in quality care. This multistep process forms the quality continuum, and it depends on clearly defined process measures, real-time quality measurement, and generalizable evaluative methods. Herein we review the current state of quality care in cirrhosis across the continuum with a focus on process measurement methodologies, developments in PRO evaluation on quality assessment, practical examples of quality improvement initiatives, and the recent emphasis placed on the value of primary prevention.
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Affiliation(s)
- Elliot B Tapper
- Division of Gastroenterology and Hepatology University of Michigan Ann Arbor MI
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Bruno R, Cammà C, Caraceni P, D'Amico G, Grattagliano I, La Mura V, Riggio O, Schepis F, Senzolo M, Angeli P, de Franchis R. Portal Hypertension and Ascites: Patient-and Population-centered Clinical Practice Guidelines by the Italian Association for the Study of the Liver (AISF). Dig Liver Dis 2021; 53:1089-1104. [PMID: 34321192 DOI: 10.1016/j.dld.2021.06.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 05/30/2021] [Accepted: 06/20/2021] [Indexed: 02/06/2023]
Abstract
Portal hypertension and ascites are two crucial events in the natural history of liver cirrhosis, whose appearance marks a downward shift in the prognosis of the disease. Over the years, several international and national societies have issued clinical practice guidelines for the diagnosis and management of portal hypertension and ascites. The present document addresses the needs of an updated guidance on the clinical management of these conditions. Accordingly, the AISF Governing Board appointed a multi-disciplinary committee of experts for drafting an update of the most recent EASL Clinical Practice Guidelines. The aim of this work was to adapt the EASL recommendations to national regulations and resources, local circumstances and settings, infrastructure, and cost/benefit strategies to avoid duplication of efforts and optimize resource utilization. The committee defined the objectives, the key issues and retrieved the relevant evidence by performing a systematic review of the literature. Finally, the committee members (chosen on the basis of their specific expertise) identified the guidelines' key questions and developed them following the PICO format (Population, Intervention, Comparison, Outcomes). For each of the PICO questions, the systematic review of the literature was made on the most important scientific databases (Pubmed, Scopus, Embase).
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Biggins SW, Angeli P, Garcia-Tsao G, Ginès P, Ling SC, Nadim MK, Wong F, Kim WR. Diagnosis, Evaluation, and Management of Ascites, Spontaneous Bacterial Peritonitis and Hepatorenal Syndrome: 2021 Practice Guidance by the American Association for the Study of Liver Diseases. Hepatology 2021; 74:1014-1048. [PMID: 33942342 DOI: 10.1002/hep.31884] [Citation(s) in RCA: 434] [Impact Index Per Article: 108.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 04/07/2021] [Indexed: 12/13/2022]
Affiliation(s)
- Scott W Biggins
- Division of Gastroenterology and Hepatology, and Center for Liver Investigation Fostering discovEryUniversity of WashingtonSeattleWA
| | - Paulo Angeli
- Unit of Hepatic Emergencies and Liver TransplantationDepartment of MedicineDIMEDUniversity of PadovaPaduaItaly
| | - Guadalupe Garcia-Tsao
- Department of Internal MedicineSection of Digestive DiseasesYale UniversityNew HavenCT
- VA-CT Healthcare SystemWest HavenCT
| | - Pere Ginès
- Liver Unit, Hospital Clinic, and Institut d'Investigacions Biomèdiques August Pi i SunyerUniversity of BarcelonaBarcelonaSpain
- Centro de Investigación Biomèdica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD)MadridSpain
| | - Simon C Ling
- The Hospital for Sick Children, Division of Gastroenterology, Hepatology and Nutrition, and Department of PaediatricsUniversity of TorontoTorontoOntarioCanada
| | - Mitra K Nadim
- Division of NephrologyUniversity of Southern CaliforniaLos AngelesCA
| | - Florence Wong
- Division of Gastroenterology and HepatologyUniversity Health NetworkUniversity of TorontoTorontoOntarioCanada
| | - W Ray Kim
- Division of Gastroenterology and HepatologyStanford UniversityPalo AltoCA
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Louissaint J, Foster C, Harding-Theobald E, Lok AS, Tapper EB. Social Support Does Not Modify the Risk of Readmission for Patients with Decompensated Cirrhosis. Dig Dis Sci 2021; 66:1855-1861. [PMID: 32578043 PMCID: PMC7755706 DOI: 10.1007/s10620-020-06421-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Accepted: 06/14/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Patients with decompensated cirrhosis are at high risk of frequent hospitalizations. Whether the level of perceived social support impacts this risk is unknown. We sought to determine the relationship between social support and burden of hospitalization in patients with decompensated cirrhosis. METHODS A total of 73 patients, all with decompensated cirrhosis and an index cirrhosis-related admission between 7/1/2017 and 7/1/2019, completed the modified medical outcomes study social support (mMOS-SS) survey. We retrospectively assessed the relationship between mMOS-SS scores and probability of readmission 90-days after the index admission. Additionally, we prospectively analyzed the association between mMOS-SS scores at enrollment and risk of 90-day hospitalization. RESULTS At enrollment, 50.7% were female, median age 61 years, and median mMOS-SS score was 87.5. Median model for end-stage liver disease sodium (MELD-Na) at the time of the index admission was 15 and was 13 at the time of enrollment. The mMOS-SS score did not modify the rate of readmission 90 days after the index admission date (adjusted HR 1.01, 95%CI 0.98-1.03) nor was it associated with the rate of admission 90 days after enrollment prospectively (adjusted HR 0.99, 95%CI 0.96-1.02). The MELD-Na score at enrollment was the only significant predictor of hospitalization during prospective follow-up (adjusted HR 1.18, 95%CI 1.09-1.27). CONCLUSIONS Social support, as measured by the mMOS-SS survey, in patients with decompensated cirrhosis was high. However, this did not modify the risk of cirrhosis-related hospitalizations. Future investigation to define the specific components of social support that could modify readmission risk is needed.
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Affiliation(s)
- Jeremy Louissaint
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan, 3912 Taubman, SPC 5362 1500 E Medical Center Dr., Ann Arbor, MI, 48109, USA.
| | - Chelsey Foster
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan, 3912 Taubman, SPC 5362 1500 E Medical Center Dr., Ann Arbor, MI, 48109, USA
| | - Emily Harding-Theobald
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan, 3912 Taubman, SPC 5362 1500 E Medical Center Dr., Ann Arbor, MI, 48109, USA
| | - Anna S Lok
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan, 3912 Taubman, SPC 5362 1500 E Medical Center Dr., Ann Arbor, MI, 48109, USA
| | - Elliot B Tapper
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan, 3912 Taubman, SPC 5362 1500 E Medical Center Dr., Ann Arbor, MI, 48109, USA
- Gastroenterology Section, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
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Piano S, Marzioni M, Angeli P. Effects of a reorganization of cirrhosis care during the lockdown for SARS-CoV-2 outbreak. JHEP Rep 2021; 3:100229. [PMID: 33496684 PMCID: PMC7816870 DOI: 10.1016/j.jhepr.2021.100229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 12/16/2020] [Indexed: 11/18/2022] Open
Affiliation(s)
- Salvatore Piano
- Department of Medicine – DIMED, University and Hospital of Padova, Padova, Italy
| | - Marco Marzioni
- Clinic of Gastroenterology and Hepatology, Università Politecnica delle Marche –“Ospedali Riuniti” University Hospital, Ancona, Italy
| | - Paolo Angeli
- Department of Medicine – DIMED, University and Hospital of Padova, Padova, Italy
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Tonon M, Rosi S, Gambino CG, Piano S, Calvino V, Romano A, Martini A, Pontisso P, Angeli P. Natural history of acute kidney disease in patients with cirrhosis. J Hepatol 2021; 74:578-583. [PMID: 32918956 DOI: 10.1016/j.jhep.2020.08.037] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Revised: 08/24/2020] [Accepted: 08/26/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND & AIMS In 2012, the KDIGO group proposed new definitions for acute kidney injury (AKI), acute kidney disease (AKD) and chronic kidney disease (CKD). According to the definition adapted by the International Club of Ascites, AKI has been extensively investigated in patients with cirrhosis. On the contrary, there are currently no data on the epidemiology and clinical outcomes associated with AKD. The aim of the study was to assess the prevalence and the impact of AKD on the clinical course and survival of patients with cirrhosis. METHODS A total of 272 consecutive patients with cirrhosis attending our outpatient clinic were included in the study. Clinical and laboratory data were collected at inclusion. Patients were followed-up until death, liver transplant or the end of follow-up. RESULTS During follow-up, 80 patients developed AKD (29.4%). Forty-two (52.5%) recovered from the first episode of AKD and 26 maintained a normal renal function up to the end of follow-up. Sixteen patients developed a second episode of AKD. Globally, 36 patients (45.0%) died with AKD. Finally, AKD progressed to CKD in 11 patients (13.8%). The 5-year survival rate was significantly lower in patients who developed AKD than in those who did not (34.8% vs. 88.8%, p <0.001). The 5-year rates of complications of cirrhosis and of hospitalizations were also higher in patients with AKD than in those without AKD. CONCLUSIONS AKD is frequent in patients with cirrhosis. It can be reversible, but it may recur and progress to CKD. AKD has a very negative impact on morbidity and mortality in patients with cirrhosis. LAY SUMMARY Renal impairment has a very negative impact on patients with cirrhosis. Renal impairment seems to be characterized by a very dynamic course, which is defined according to renal function and length of the impairment as acute kidney injury, acute kidney disease and chronic kidney disease. The role of acute kidney disease is currently unknown. Our study shows for the first time that acute kidney disease is frequent in patients with cirrhosis and has a very negative impact on survival.
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Affiliation(s)
- Marta Tonon
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine, University of Padova, Padova, Italy
| | - Silvia Rosi
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine, University of Padova, Padova, Italy
| | - Carmine Gabriele Gambino
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine, University of Padova, Padova, Italy
| | - Salvatore Piano
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine, University of Padova, Padova, Italy
| | - Valeria Calvino
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine, University of Padova, Padova, Italy
| | - Antonietta Romano
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine, University of Padova, Padova, Italy
| | - Andrea Martini
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine, University of Padova, Padova, Italy
| | - Patrizia Pontisso
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine, University of Padova, Padova, Italy
| | - Paolo Angeli
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine, University of Padova, Padova, Italy.
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Khan A, Maheshwari S, Gupta K, Naseem K, Chowdry M, Singh S. Rate, reasons, predictors, and burden of readmissions after transjugular intrahepatic portosystemic shunt placement. J Gastroenterol Hepatol 2021; 36:775-781. [PMID: 32710679 PMCID: PMC8385676 DOI: 10.1111/jgh.15194] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 06/22/2020] [Accepted: 07/18/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND AIM Nationwide data on readmissions after the transjugular intrahepatic portosystemic shunt (TIPS) procedure are lacking. We aimed to investigate the 30-day readmission rate after TIPS procedure, reasons, and predictors for readmissions and its impact on resource utilization and mortality in the USA. METHODS We identified all adults who underwent an inpatient TIPS procedure between 2010 and 2014 using the National Readmission Database. Outcomes included all-cause 30-day readmission rate, reasons and predictors of readmissions, mortality rate, and mean hospitalization charges. RESULTS Out of a total of 31 230 hospitalizations with TIPS procedure, 28 021 patients met the study criteria and were finally included. The mean age of patients was 56.90 years, and 63.84% were men. All-cause 30-day readmission rate was 27.81%. Hepatic encephalopathy with or without coma was the most common reason for readmissions in at least 36.43% patients. The in-hospital mortality for index hospitalization and 30-day readmission was 10.69% and 5.85%, respectively. The mean hospitalization charges for index hospitalization and readmissions were $153 357 and $45 751, respectively. Advanced age, Medicaid insurance, higher Charlson comorbidy index, ascites as indication of TIPS, and nonspecific or hepatitis C cirrhosis etiologies for cirrhosis were found to be independent predictors of 30-day readmissions after a TIPS procedure. CONCLUSIONS Our study found a high rate of readmission for patients undergoing TIPS procedure, and the majority of these readmissions were related to hepatic encephalopathy. Further studies highlighting areas for improvement, particularly for patient selection and post-discharge care, are needed to reduce readmissions.
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Affiliation(s)
- Ahmad Khan
- Department of Medicine, West Virginia University Health Sciences Center Charleston Division, Charleston, West Virginia
| | - Sanjay Maheshwari
- Department of Medicine, Maimonides Medical Center, New York, New York
| | - Kamesh Gupta
- Department of Medicine, Baystate Medical Center, Springfield, Massachusetts, USA
| | - Khadija Naseem
- Department of Medicine, Charleston Area Medical Center, Charleston, West Virginia
| | - Monica Chowdry
- Department of Medicine, West Virginia University Health Sciences Center Charleston Division, Charleston, West Virginia
| | - Shailendra Singh
- Charleston Gastroenterology Associates, Charleston, West Virginia
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Carbonneau M, Davyduke T, Congly SE, Ma MM, Newnham K, Den Heyer V, Tandon P, Abraldes JG. Impact of specialized multidisciplinary care on cirrhosis outcomes and acute care utilization. CANADIAN LIVER JOURNAL 2021; 4:38-50. [PMID: 35991472 PMCID: PMC9203164 DOI: 10.3138/canlivj-2020-0017] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 09/27/2020] [Indexed: 09/15/2023]
Abstract
Background Multidisciplinary care has the potential to improve outcomes among patients with cirrhosis, yet its impact on this population remains unclear, with existing studies demonstrating discrepant results. Using data from the multidisciplinary outpatient Cirrhosis Care Clinic (CCC) at the University of Alberta Hospital, we aimed to evaluate acute care utilization and survival outcomes of patients followed by the CCC compared with those receiving standard care (SC). Methods We performed a retrospective chart review of 212 patients with cirrhosis admitted to University of Alberta Hospital between 2014 and 2015. CCC patients (n = 36) were followed through the CCC before index admission. SC patients (n = 176) were managed outside of the CCC. Readmission time in hospital was collected until 1 year, death, or liver transplant. Results CCC patients had more advanced liver disease (higher prevalence of ascites, encephalopathy, and varices). Despite this, acute care utilization was significantly lower among CCC patients (adjusted length of stay lower by 3 days, p = 0.03, and adjusted survival days spent in hospital lower by 9%, p = 0.02). CCC patients also had improved 1-year transplant-free survival, with an adjusted 1-year relative risk reduction of 53% (p = 0.03). Total mean cost of care was lower in the CCC group by $2,280 per patient-month of life. Discussion For patients admitted with cirrhosis, specialized post-discharge multidisciplinary outpatient care is associated with decreased acute care utilization, improved 1-year transplant-free survival probability, and the potential for cost savings to the system.
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Affiliation(s)
| | - Tracy Davyduke
- Hepatology Department, Alberta Health Services, Edmonton, Alberta, Canada
| | - Stephen E Congly
- Liver Unit, Division of Gastroenterology, University of Calgary, Calgary, Alberta, Canada
| | - Mang M Ma
- Liver Unit, Division of Gastroenterology, Centre of Excellence for Gastrointestinal Inflammation and Immunity Research, University of Alberta, Edmonton, Alberta, Canada
| | - Kim Newnham
- Hepatology Department, Alberta Health Services, Edmonton, Alberta, Canada
| | - Vanessa Den Heyer
- Hepatology Department, Alberta Health Services, Edmonton, Alberta, Canada
| | - Puneeta Tandon
- Liver Unit, Division of Gastroenterology, University of Calgary, Calgary, Alberta, Canada
- Liver Unit, Division of Gastroenterology, Centre of Excellence for Gastrointestinal Inflammation and Immunity Research, University of Alberta, Edmonton, Alberta, Canada
| | - Juan G Abraldes
- Liver Unit, Division of Gastroenterology, University of Calgary, Calgary, Alberta, Canada
- Liver Unit, Division of Gastroenterology, Centre of Excellence for Gastrointestinal Inflammation and Immunity Research, University of Alberta, Edmonton, Alberta, Canada
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Tonon M, Piano S, Gambino CG, Romano A, Pilutti C, Incicco S, Brocca A, Sticca A, Bolognesi M, Angeli P. Outcomes and Mortality of Grade 1 Ascites and Recurrent Ascites in Patients With Cirrhosis. Clin Gastroenterol Hepatol 2021; 19:358-366.e8. [PMID: 32272250 DOI: 10.1016/j.cgh.2020.03.065] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2019] [Revised: 03/05/2020] [Accepted: 03/30/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Ascites has been classified according to quantity and response to medical therapy. Despite its precise definitions, little is known about the effects of grade 1 ascites or recurrent ascites (i.e. ascites that recurs at least on 3 occasions within a 12-month period despite dietary sodium restriction and adequate diuretic dosage) on patient outcome. We studied progression of grade 1 ascites and recurrent ascites in a large cohort of outpatients with cirrhosis. METHODS We performed a post-hoc analysis of data from 547 outpatients with cirrhosis (259 without ascites, 54 patients with grade 1 ascites, 234 with grade 2 or 3 ascites) who participated a care management program study in Italy from March 2003 through September 2017. We collected demographic, clinical, and laboratory data and patients were evaluated at least every 6 months. Patients received abdominal ultrasound analysis at study inclusion and at least twice a year. Number and volume of paracentesis were collected, when available. Patients were followed until death, liver transplantation, or March 2018. The median follow-up time was 29 months. Primary outcomes were mortality and development of complications of cirrhosis. RESULTS There was no significant difference in 60-month transplant-free survival between patients with grade 1 vs grade 2 or 3 ascites (36% vs 43%) but survival was significantly lower when both groups were compared with patients without ascites (68%; P < .001 for both comparisons). However, the grade of systemic inflammation and the rate of complications were significantly greater in patients with grade 1 ascites than in patients without ascites, but significantly lower than in patients with grade 2 or 3 ascites. Development of grade 2 or 3 ascites did not differ significantly between patients with no ascites vs grade 1 ascites (10% vs 14%). There was no significant difference in 36-month transplant-free survival between patients with ascites responsive to medical treatment vs recurrent ascites (78% vs 62%), whereas patients with refractory ascites had significantly lower survival than patients with responsive or recurrent ascites (23%; responsive vs refractory ascites P<.001; recurrent vs refractory ascites P = .022). CONCLUSIONS In an analysis of data from a large cohort of outpatients with cirrhosis, we found that grade 1 ascites is associated with systemic inflammation, more complications, and increased mortality compared with no ascites. Mortality does not differ significantly between patients with recurrent ascites vs ascites responsive to medical treatment.
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Affiliation(s)
- Marta Tonon
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine (DIMED), University of Padova, Padova, Italy
| | - Salvatore Piano
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine (DIMED), University of Padova, Padova, Italy
| | - Carmine G Gambino
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine (DIMED), University of Padova, Padova, Italy
| | - Antonietta Romano
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine (DIMED), University of Padova, Padova, Italy
| | - Chiara Pilutti
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine (DIMED), University of Padova, Padova, Italy
| | - Simone Incicco
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine (DIMED), University of Padova, Padova, Italy
| | - Alessandra Brocca
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine (DIMED), University of Padova, Padova, Italy
| | - Antonietta Sticca
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine (DIMED), University of Padova, Padova, Italy
| | - Massimo Bolognesi
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine (DIMED), University of Padova, Padova, Italy
| | - Paolo Angeli
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine (DIMED), University of Padova, Padova, Italy.
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Bloom PP, Miller SJ, Nayak RK, Hussain MS, Arvind A, Bay C, Chung RT. Cognitive Tests and Stool Frequency at Hospital Discharge Do Not Predict Outcomes in Hepatic Encephalopathy. South Med J 2020; 113:578-584. [PMID: 33140112 DOI: 10.14423/smj.0000000000001172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES Hepatic encephalopathy (HE) is associated with hospital readmissions and mortality. We sought to determine whether cognitive testing and stool frequency at discharge predicted 30-day readmission or death in cirrhotic patients admitted with overt HE. METHODS We approached consecutive inpatients with cirrhosis and overt HE when they were within 48 hours of discharge. Patients underwent cognitive tests, including Psychometric Hepatic Encephalopathy Score (PHES), and stool frequency was documented. Chart review identified Model for End-Stage Liver Disease-sodium (MELD-Na) and the presence of non-HE extrahepatic organ failures. Cox proportional hazards models were used to evaluate predictors of time to the primary composite outcome of hospital readmission for HE or death within 30 days, censoring for liver transplantation. RESULTS Of 51 patients consented and enrolled, 14 patients met the primary composite outcome. In unadjusted Cox models, 4 variables predicted HE readmission or death: MELD-Na (hazard ratio [HR] 1.10 [1.01-1.20], P = 0.03), respiratory failure (HR 4.26 [1.47-12.35], P = 0.008), total number of HE extrahepatic organ failures (HR 1.79 [1.12-2.88], P = 0.02), and score on a PHES subtest, Number Connection Test A (per 30 seconds; HR 1.25 [1.06-1.47], P = 0.01). PHES and 24-hour stool frequency did not predict the primary outcome. When controlling for MELD-Na, respiratory failure predicted the primary outcome (HR 3.67 [1.24-10.86], P = 0.02). CONCLUSION Cognitive testing and stool frequency at discharge did not predict poor outcomes in patients admitted with HE, while respiratory failure appeared to be a strong predictor.
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Affiliation(s)
- Patricia P Bloom
- From the Liver Center, Division of Gastroenterology, Massachusetts General Hospital, Boston, Harvard Medical School, Boston, and the Center for Clinical Investigation, Brigham and Women's Hospital, Boston, Massachusetts
| | - Samuel J Miller
- From the Liver Center, Division of Gastroenterology, Massachusetts General Hospital, Boston, Harvard Medical School, Boston, and the Center for Clinical Investigation, Brigham and Women's Hospital, Boston, Massachusetts
| | - Rahul K Nayak
- From the Liver Center, Division of Gastroenterology, Massachusetts General Hospital, Boston, Harvard Medical School, Boston, and the Center for Clinical Investigation, Brigham and Women's Hospital, Boston, Massachusetts
| | - Muhammad Sarib Hussain
- From the Liver Center, Division of Gastroenterology, Massachusetts General Hospital, Boston, Harvard Medical School, Boston, and the Center for Clinical Investigation, Brigham and Women's Hospital, Boston, Massachusetts
| | - Ashwini Arvind
- From the Liver Center, Division of Gastroenterology, Massachusetts General Hospital, Boston, Harvard Medical School, Boston, and the Center for Clinical Investigation, Brigham and Women's Hospital, Boston, Massachusetts
| | - Camden Bay
- From the Liver Center, Division of Gastroenterology, Massachusetts General Hospital, Boston, Harvard Medical School, Boston, and the Center for Clinical Investigation, Brigham and Women's Hospital, Boston, Massachusetts
| | - Raymond T Chung
- From the Liver Center, Division of Gastroenterology, Massachusetts General Hospital, Boston, Harvard Medical School, Boston, and the Center for Clinical Investigation, Brigham and Women's Hospital, Boston, Massachusetts
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Chiang RS, Parish A, Niedzwiecki D, Kappus MR, Muir AJ. Impact of Malnutrition on Outcomes in Patients Undergoing Transjugular Intrahepatic Portosystemic Shunt Insertion. Dig Dis Sci 2020; 65:3332-3340. [PMID: 31965391 DOI: 10.1007/s10620-019-06038-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Accepted: 12/30/2019] [Indexed: 12/09/2022]
Abstract
BACKGROUND Malnutrition is common in patients with cirrhosis and is associated with poor outcomes after hepatic resection and liver transplantation. Transjugular intrahepatic portosystemic shunt (TIPS) is performed for complications of cirrhosis. AIM To assess the impact of malnutrition on TIPS outcomes. METHODS A retrospective analysis was performed using the Healthcare Cost and Utilization Project: National Inpatient Sample database for TIPS procedures from 2005 to 2014. The primary end point was in-hospital mortality. The association of specific malnutrition diagnostic codes and race-ethnicity on mortality was evaluated with survey-weighted logistic regression adjusted for age, gender, admission type, insurance payer, hospital region, comorbidities, and length of stay (LOS). RESULTS From 2005 to 2014, an estimated 53,207 (95% CI 49,330-57,085) admissions with TIPS occurred. A diagnosis of malnutrition was present in 11%. In-hospital death post-TIPS occurred in 15.0% versus 10.7% (p value < 0.001) of patients with and without malnutrition, respectively. Patients with malnutrition had longer post-procedural LOS (median 6.7 vs. 2.9 days, p value < 0.001) and greater total hospital charges (median $144,752 vs. $79,781, p value < 0.001) and were more likely to be discharged to a skilled nursing facility (21.6% vs. 9.7%) than patients without malnutrition. Patients with malnutrition had increased odds of mortality (OR 1.31, 95% CI 1.07, 1.59) compared to patients with no malnutrition. CONCLUSION Malnutrition was associated with worse outcomes after TIPS. Further research is needed to understand the mechanism of malnutrition in post-procedure outcomes and the ability of interventions for nutritional optimization to improve outcomes.
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Affiliation(s)
- Ryan S Chiang
- Duke University School of Medicine, 2530 Erwin Road APT 254, Durham, NC, 27705, USA
| | - Alice Parish
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, DUMC 2721, Durham, NC, 27710, USA
| | - Donna Niedzwiecki
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, DUMC 2721, Durham, NC, 27710, USA.,Duke Cancer Institute-Biostatistics, Hock Plaza I, 2424 Erwin Rd, Suite 802, Room 8040, Durham, NC, 27705, USA
| | - Matthew R Kappus
- Division of Gastroenterology, Department of Medicine, Duke University School of Medicine, DUMC 3923, Durham, NC, 27710, USA
| | - Andrew J Muir
- Division of Gastroenterology, Department of Medicine, Duke University School of Medicine, DUMC 3923, Durham, NC, 27710, USA. .,Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA.
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Tapper EB, Asrani SK. The COVID-19 pandemic will have a long-lasting impact on the quality of cirrhosis care. J Hepatol 2020; 73:441-445. [PMID: 32298769 PMCID: PMC7194911 DOI: 10.1016/j.jhep.2020.04.005] [Citation(s) in RCA: 152] [Impact Index Per Article: 30.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 04/08/2020] [Accepted: 04/09/2020] [Indexed: 02/08/2023]
Abstract
The coronavirus disease 2019 (COVID-19) pandemic has shattered the meticulously developed processes by which we delivered quality care for patients with cirrhosis. Care has been transformed by the crisis, but enduring lessons have been learned. In this article, we review how COVID-19 will impact cirrhosis care. We describe how this impact unfolds over 3 waves; i) an intense period with prioritized high-acuity care with delayed elective procedures and routine care during physical distancing, ii) a challenging 'return to normal' following the end of physical distancing, with increased emergent decompensations, morbidity, and systems of care overwhelmed by the backlog of deferred care, and iii) a protracted period of suboptimal outcomes characterized by missed diagnoses, progressive disease and loss to follow-up. We outline the concrete steps required to preserve the quality of care provided to patients with cirrhosis. This includes an intensification of the preventative care provided to patients with compensated cirrhosis, proactive chronic disease management, robust telehealth programs, and a reorganization of care delivery to provide a full service of care with flexible clinical staffing. Managing the pandemic of a serious chronic disease in the midst of a global infectious pandemic is challenging. It is incumbent upon the entire healthcare establishment to be strong enough to weather the storm. Change is needed.
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Affiliation(s)
- Elliot B. Tapper
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan,Gastroenterology Section, VA Ann Arbor Healthcare System, Ann Arbor, Michigan,Corresponding author. Address: 3912 Taubman, SPC 5362, 1500 E Medical Center Dr, Ann Arbor, MI 48109. Tel.: (734) 647-9252, fax: (734) 936-7392.
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Spiewak T, Taefi A, Patel S, Li CS, Chak E. Racial disparities of Black Americans hospitalized for decompensated liver cirrhosis. BMC Gastroenterol 2020; 20:245. [PMID: 32727386 PMCID: PMC7391571 DOI: 10.1186/s12876-020-01392-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2019] [Accepted: 07/21/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Racial disparities have been reported in liver transplantation and chronic hepatitis C treatment outcomes. Determining causes of these disparities is important given the racially diverse American population and the economic burden associated with chronic liver disease. METHODS A retrospective study was performed among 463 patients diagnosed with cirrhosis admitted from (January 1, 2013 to January 1, 2018) to a tertiary care academic medical center. Patients were identified based on the International Classification of Diseases (ICD-10) for cirrhosis or its complications. Demographic information, laboratory data, medical comorbidities, insurance and adherence to cirrhosis quality care indicators were recorded to determine their relationship to readmission rates and other healthcare outcomes. RESULTS A total of 463 individual patients with cirrhosis were identified including Whites (n = 241), Hispanics (n = 106), Blacks (n = 50), Asian and Pacific Islander Americans (API, n = 27) and Other (n = 39). A significantly higher proportion of Blacks had Medicaid insurance compared to Whites (40% versus 20%, p = 0.0002) and Blacks had lower median income than Whites ($45,710 versus $54,844, p = 0.01). All groups received high quality cirrhosis care. Regarding healthcare outcomes, Black patients had the highest mean total hospital admissions (6.1 ± 6.3, p = 0.01) and the highest mean number of 30-day re-admissions (2.1 ± 3.7, p = 0.05) compared to all other racial groups. Multivariable proportional odds regression analysis showed that race was a statistically significant predictor of 90-day readmission (p = 0.03). CONCLUSIONS Black Americans hospitalized for complications of cirrhosis may experience significant disparities in healthcare outcomes compared to Whites despite high quality cirrhosis care. Socioeconomic factors may contribute to these disparities.
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Affiliation(s)
- Ted Spiewak
- Department of Internal Medicine, UC Davis Medical Center, Sacramento, California, USA
| | - Amir Taefi
- Department of Gastroenterology and Hepatology, UC Davis Medical Center, 4150 V Street, PSSB 3500, Sacramento, CA, 95817, USA
| | - Shruti Patel
- Department of Internal Medicine, UC Davis Medical Center, Sacramento, California, USA
| | - Chin-Shang Li
- School of Nursing, The State University of New York at Buffalo, Buffalo, New York, USA
| | - Eric Chak
- Department of Gastroenterology and Hepatology, UC Davis Medical Center, 4150 V Street, PSSB 3500, Sacramento, CA, 95817, USA.
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Tennakoon L, Baiu I, Concepcion W, Melcher ML, Spain DA, Knowlton LM. Understanding Health Care Utilization and Mortality After Emergency General Surgery in Patients With Underlying Liver Disease. Am Surg 2020; 86:665-674. [PMID: 32683972 DOI: 10.1177/0003134820923304] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Mortality and complications are not well defined nationally for emergency general surgery (EGS) patients presenting with underlying all-cause liver disease (LD). STUDY DESIGN We analyzed the 2012-2014 National Inpatient Sample for adults (aged ≥ 18 years) with a primary EGS diagnosis. Underlying LD included International Classification of Diseases, Ninth Revision, Clinical Modification codes for alcoholic and viral hepatitis, malignancy, congenital etiologies, and cirrhosis. The primary outcome was mortality; secondary outcomes included complications, operative intervention, and costs. RESULTS Of the 6.8 million EGS patients, 358 766 (5.3%) had underlying LD. 59.1% had cirrhosis, 6.7% had portal hypertension, and 13.7% had ascites. Compared with other EGS patients, EGS-LD patients had higher mean costs ($12 847 vs $10 234, P < .001). EGS-LD patients were less likely to have surgery (26.1% vs 37.0%, P < .001) but for those who did, mortality was higher (4.8% vs 1.8%, P < .001). Risk factors for mortality included ascites (adjusted odds ratio [aOR] = 2.68, P < .001), dialysis (aOR = 3.44, P < .001), sepsis (aOR = 8.97, P < .001), and respiratory failure requiring intubation (aOR = 10.40, P < .001). Odds of death increased in both surgical (aOR = 4.93, P < .001) and non-surgical EGS-LD patients (aOR = 2.56, P < .001). CONCLUSIONS Underlying all-cause LD among EGS patients is associated with increased in-hospital mortality, even in the absence of surgical intervention.
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Affiliation(s)
- Lakshika Tennakoon
- 6429 Department of Surgery, Division of General Surgery, Stanford University Medical Center, Stanford, CA, USA
| | - Ioana Baiu
- 6429 Department of Surgery, Division of General Surgery, Stanford University Medical Center, Stanford, CA, USA
| | - Waldo Concepcion
- 6429 Department of Surgery, Division of Abdominal Transplantation, Stanford University Medical Center, Stanford, CA, USA
| | - Marc L Melcher
- 6429 Department of Surgery, Division of Abdominal Transplantation, Stanford University Medical Center, Stanford, CA, USA
| | - David A Spain
- 6429 Department of Surgery, Division of General Surgery, Stanford University Medical Center, Stanford, CA, USA
| | - Lisa M Knowlton
- 6429 Department of Surgery, Division of General Surgery, Stanford University Medical Center, Stanford, CA, USA
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