Factors Affecting Psychological Burden on the Informal Caregiver of Patients With Cirrhosis: Looking Beyond the Patient

Cerebral Aspects of Portal Hypertension: Hepatic Encephalopathy

Portal hypertension has cerebral consequences via its causes and complications, namely hepatic encephalopathy (HE), a common and devastating brain disturbance caused by liver insufficiency and portosystemic shunting. The pathogenesis involves hyperammonemia and systemic inflammation. Symptoms are disturbed personality and reduced attention. HE is minimal or grades I to IV (coma). Bouts of HE are episodic and often recurrent. Initial treatment is of events that precipitated the episode and exclusion of nonhepatic causes. Specific anti-HE treatment is lactulose. By recurrence, rifaximin is add-on. Anti-HE treatment is efficacious also for prophylaxis, but emergence of HE marks advanced liver disease and a dismal prognosis.

The social and psychological impact of hepatic encephalopathy

Hepatic encephalopathy (HE) is a brain dysfunction caused by liver insufficiency with symptoms ranging from slight cognitive changes detectable only by neuropsychiatric testing to coma. Up to 60% of patients with cirrhosis have mild forms of HE and 35% will at some point experience overt HE. Even in its milder forms, HE impacts the patient's daily routines, self-sufficiency, quality of life, and, thereby, socio-economic status. HE is a condition affecting the whole household including formal and informal caregivers, who carry a heavy burden. Early identification, prophylaxis, and treatment of HE are essential for relieving patients and informal caregivers.

Social Impact of Hepatic Encephalopathy

Hepatic encephalopathy is a medical condition that stems from liver dysfunction, leading to the accumulation of toxins in the bloodstream. This can result in cognitive impairments, mood changes, and motor dysfunction. Its social impact includes challenges in employment, relationships, and daily functioning for affected individuals. Stigma and misunderstanding around the condition can further exacerbate the difficulties faced by both patients and their caregivers. Efforts to raise awareness, improve medical management, and provide support systems can help mitigate the social impact of hepatic encephalopathy.

Etiological Spectrum of Cirrhosis in India: A Systematic Review and Meta-analysis

BACKGROUND

Cirrhosis is a significant cause of morbidity and mortality globally and in India. This systematic review and meta-analysis aimed to ascertain the etiological spectrum and changing trends of cirrhosis in India.

METHODS

We searched electronic databases, including Pubmed/Medline, Scopus, and Embase. We included original studies that reported the etiology of cirrhosis in the Indian population.

RESULTS

We included 158 studies (adults: 147, children: 11). The overall pooled estimate of alcohol as a cause of cirrhosis in adults was 43.2% (95% confidence interval (CI) 39.8-46.6%; I2 = 97.8%), followed by nonalcoholic fatty liver disease (NAFLD)/cryptogenic in 14.4%, 95% CI (11.7-17.3%; I2 = 98.4%), hepatitis B virus (HBV) in 11.5%, 95% CI (9.8-13.3%; I2 = 96.6%), and hepatitis C virus (HCV) in 6.2%, 95% CI (4.8-7.8%; I2 = 97.2%) of the included patients. The most common cause of cirrhosis in all zones was alcohol-related. Comparison of etiologies over time revealed a reduction in the viral hepatitis-related and an increase in the proportion of alcohol-related and NAFLD/cryptogenic-related cirrhosis. The overall pooled estimates of various etiologies in children were: HBV in 10.7%, 95% CI (4.6-18.7%; I2 = 91.0%), NAFLD/Cryptogenic in 22.3%, 95% CI (9.0-39.2%; I2 = 96.7%), and HCV in 2.0%, 95% CI (0.0-8.5%; I2 = 94.6%).

CONCLUSIONS

Alcohol is the most common etiology of cirrhosis in adults in India. The proportions of alcohol and NAFLD-related cirrhosis are increasing, and those of viral hepatitis-related cirrhosis are reducing. The results of our meta-analysis will help formulate health policies and the allocation of resources.

Burden of caregiving of alcohol related liver disease patients: a possible role of training and caregiver groups frequency. Proposal of a method, preliminary results

BACKGROUND

The patient with alcohol related liver disease (ALD) is an extremely complex patient who can be affected by various problems: alcohol use disorders (AUDs) (intoxication or withdrawal syndrome), psychopathological manifestations, hepatic encephalopathy (HE), family and social discomfort. Burden of caregiving for this type of patient is particularly severe. For this reason we propose our own working model.

METHODS

Thirty-one informal caregivers (ICs) of patients with ALD (28 females; mean age: 51±11) recruited in the period September-November 2021 followed prospectively were evaluated retrospectively. Those who completed all the steps (initial information/ training meeting), participation in support groups for caregivers and participation in self-help groups for AUD (club of alcoholics in treatment, anonymous family members, other realities) were selected (31/71: 43%). ICs underwent Zarit Burden Interview and a semi-structured interview.

RESULTS

From the semi-structured interview, emotional, organizational, but also constructive reflections emerge. Zarit Score (ZS) was found to be light or nil in the 13% (4/31), moderate in the 22.5% (7/31), severe in the 32% (10/31) and very serious in the 32% (10/31). The parameters that most influenced initial ZS are the presence of HE and primitive psychiatric comorbidity (PC). By dividing the caregivers into two groups (40) odds ratio is 2.4231 (95% CI: 0.4059-14.4637) in the presence of HE and odds ratio is 5.3846 (95% CI: 0.5666 to 51.1738) in the presence of PC. After the frequency to the caregiver groups (CGs) (at least 4) the ZS is significantly decreased (49.9±18 vs. 34±11; t=4.1966; P<0.0001) and this regardless of the presence of HE, PC or active alcohol consumption.

CONCLUSIONS

While waiting to increase the number of cases and to submit it to a more in-depth verification, we suggest to other health organizations to use and verify this organizational/ relational method for primary ICs, in an attempt to optimize the health and social health activity in a complex medical sector (ALD) in constant growth.

The Level of Knowledge Among Nurses Regarding Care of Patients with Hepatic Encephalopathy at Najran Hospitals, Saudi Arabia

Background/Aim

Hepatic encephalopathy (HE) is a significant complication of acute and chronic liver disease. It is crucial for nurses to have knowledge of encephalopathy symptoms to enable prompt and effective responses when caring for such patients. Therefore, this study aimed to evaluate nurses' HE knowledge in Najran hospitals in Saudi Arabia.

Methods

This cross-sectional analytical study was conducted with nurses at the Najran Hospital in Najran City, Saudi Arabia. The sample size was determined using Epi-Calc 2000, resulting in a final sample of 125 nurses from intensive care units (ICU), cardiac surgical ICU and pediatric ICU, and they were selected by convenience sampling technique. Data were collected using a self-administered questionnaire, and 125 nurses participated in knowledge assessment. The data were coded and entered into SPSS version 21.0 for descriptive and inferential statistics. Information letters and consent forms were obtained from all the participants.

Results

The majority of nurses (88.8%) were female, and 59.2% were married. The age range of participants was 20-30 years (50.4%). Approximately 36.8% had 4-6 years of work experience. The majority of the nurses (87.2%) held a bachelor's degree. More than half (56%) of the nurses demonstrated moderate HE knowledge, whereas over a quarter (28%) exhibited good knowledge. There was a highly statistically significant association between marital status, level of education, nationality, and level of nurses' knowledge regarding HE (P-value = 0.01, 0.02, and 0.02, respectively).

Conclusion

The study concludes that nurses in Najran hospitals have an adequate knowledge levels, ranging from moderate to good. This highlights the importance of tailored educational programs to enhance nurses' understanding of HE symptoms and management. Furthermore, the marital status, education level, and nationality have significant association with nurses' knowledge.

Assessing caregiving experience in COPD: content validity of the Zarit Burden Interview in Canadian and Portuguese caregivers

PURPOSE

Informal caregivers play an important role in chronic disease management but their experience is often neglected. The objective of this study was to explore the content validity of the Zarit Burden Interview (ZBI) in caregivers of individuals with COPD in Canada and Portugal.

MATERIALS AND METHODS

Cognitive debriefing interviews were conducted with informal caregivers of individuals with moderate to very severe COPD. Participants completed the ZBI and verbalised their thinking process to assess the adequacy of the questionnaire's content and instructions. Content validity was assessed using deductive content analysis of interviews and descriptive statistics of questionnaire responses.

RESULTS

Nine caregivers from Canada (age = 67 ± 8 years) and 13 from Portugal (age = 69 ± 7 years) participated. For Canadian caregivers, 3/22 items were not understood, and 8/22 items were not relevant to at least 1/3 of them. For Portuguese caregivers, 1/22 items were not understood, and 20/22 items were not relevant to at least 1/3 of them. The distribution of response choices was approximately symmetrical for 17/22 items in the Canadian sample. The response option "no/never" was selected by at least 75% of Portuguese participants for 18/22 items.

CONCLUSIONS

The instrument was well understood by caregivers of people with COPD, but its relevance is uncertain.IMPLICATIONS FOR REHABILITATIONInformal caregivers provide essential care for people living with disability and chronic disease, but their experience is often neglected.The Zarit Burden Interview assesses caregiver burden but has not been validated in caregivers of people with chronic obstructive pulmonary disease.In its current form, the Zarit Burden Interview does not adequately represent the experience of COPD caregivers.We recommend selecting tools that assess caregiver burden that have been validated in the caregiver population of interest.

Rifaximin for prevention and treatment of hepatic encephalopathy in people with cirrhosis

BACKGROUND

Hepatic encephalopathy describes the spectrum of neuropsychiatric changes that may complicate the course of cirrhosis and detrimentally affect outcomes. Ammonia plays a key role in its development. Rifaximin is a non-absorbable antibiotic that inhibits urease-producing bacteria and reduces absorption of dietary and bacterial ammonia.

OBJECTIVES

To evaluate the beneficial and harmful effects of rifaximin versus placebo, no intervention, or non-absorbable disaccharides for: (i) the prevention of hepatic encephalopathy, and (ii) the treatment of minimal and overt hepatic encephalopathy, in people with cirrhosis, both when used alone and when combined with a non-absorbable disaccharide.

SEARCH METHODS

We searched the Cochrane Hepato-Biliary Group Clinical Trials Register, CENTRAL, MEDLINE, Embase, three other databases, the reference lists of identified papers, and relevant conference proceedings. We wrote to authors and pharmaceutical companies for information on other published, unpublished, or ongoing trials. Searches were performed to January 2023.

SELECTION CRITERIA

We included randomised clinical trials assessing prevention or treatment of hepatic encephalopathy with rifaximin alone, or with a non-absorbable disaccharide, versus placebo/no intervention, or a non-absorbable disaccharide alone.

DATA COLLECTION AND ANALYSIS

Six authors independently searched for studies, extracted data, and validated findings. We assessed the design, bias risk, and participant/intervention characteristics of the included studies. We assessed mortality, serious adverse events, health-related quality of life, hepatic encephalopathy, non-serious adverse events, blood ammonia, Number Connection Test-A, and length of hospital stay.

MAIN RESULTS

We included 41 trials involving 4545 people with, or at risk for, developing hepatic encephalopathy. We excluded 89 trials and identified 13 ongoing studies. Some trials involved participants with more than one type of hepatic encephalopathy or more than one treatment comparison. Hepatic encephalopathy was classed as acute (13 trials), chronic (7 trials), or minimal (8 trials), or else participants were considered at risk for its development (13 trials). The control groups received placebo (12 trials), no/standard treatment (1 trial), or a non-absorbable disaccharide (14 trials). Eighteen trials assessed rifaximin plus a non-absorbable disaccharide versus a non-absorbable disaccharide alone. We classified 11 trials as at high risk of overall bias for mortality and 28 for non-mortality outcomes, mainly due to lack of blinding, incomplete outcome data, and selective reporting. Compared to placebo/no intervention, rifaximin likely has no overall effect on mortality (risk ratio (RR) 0.83, 95% confidence interval (CI) 0.50 to 1.38; P = 48, I2 = 0%; 13 trials, 1007 participants; moderate-certainty evidence), and there may be no overall effect when compared to non-absorbable disaccharides (RR 0.99, 95% CI 0.49 to 1.97; P = 0.97, I2 = 0%; 10 trials, 786 participants; low-certainty evidence). However, there is likely a reduction in the overall risk of mortality when comparing rifaximin plus a non-absorbable disaccharide to a non-absorbable disaccharide alone (RR 0.69, 95% CI 0.55 to 0.86; number needed to treat for an additional beneficial outcome (NNTB) = 22; P = 0.001, I2 = 0%; 14 trials, 1946 participants; moderate-certainty evidence). There is likely no effect on the overall risk of serious adverse events when comparing rifaximin to placebo/no intervention (RR 1.05, 95% CI 0.83 to 1.32; P = 68, I2 = 0%; 9 trials, 801 participants; moderate-certainty evidence) and there may be no overall effect when compared to non-absorbable disaccharides (RR 0.97, 95% CI 0.66 to 1.40; P = 85, I2 = 0%; 8 trials, 681 participants; low-certainty evidence). However, there was very low-certainty evidence that use of rifaximin plus a non-absorbable disaccharide may be associated with a lower risk of serious adverse events than use of a non-absorbable disaccharide alone (RR 0.66, 95% CI 0.45 to 0.98; P = 0.04, I2 = 60%; 7 trials, 1076 participants). Rifaximin likely results in an overall effect on health-related quality of life when compared to placebo/no intervention (mean difference (MD) -1.43, 95% CI -2.87 to 0.02; P = 0.05, I2 = 81%; 4 trials, 214 participants; moderate-certainty evidence), and may benefit health-related quality of life in people with minimal hepatic encephalopathy (MD -2.07, 95% CI -2.79 to -1.35; P < 0.001, I2 = 0%; 3 trials, 176 participants). The overall effect on health-related quality of life when comparing rifaximin to non-absorbable disaccharides is very uncertain (MD -0.33, 95% CI -1.65 to 0.98; P = 0.62, I2 = 0%; 2 trials, 249 participants; very low-certainty evidence). None of the combined rifaximin/non-absorbable disaccharide trials reported on this outcome. There is likely an overall beneficial effect on hepatic encephalopathy when comparing rifaximin to placebo/no intervention (RR 0.56, 95% CI 0.42 to 0.77; NNTB = 5; P < 0.001, I2 = 68%; 13 trials, 1009 participants; moderate-certainty evidence). This effect may be more marked in people with minimal hepatic encephalopathy (RR 0.40, 95% CI 0.31 to 0.52; NNTB = 3; P < 0.001, I2 = 10%; 6 trials, 364 participants) and in prevention trials (RR 0.71, 95% CI 0.56 to 0.91; NNTB = 10; P = 0.007, I2 = 36%; 4 trials, 474 participants). There may be little overall effect on hepatic encephalopathy when comparing rifaximin to non-absorbable disaccharides (RR 0.85, 95% CI 0.69 to 1.05; P = 0.13, I2 = 0%; 13 trials, 921 participants; low-certainty evidence). However, there may be an overall beneficial effect on hepatic encephalopathy when comparing rifaximin plus a non-absorbable disaccharide to a non-absorbable disaccharide alone (RR 0.58, 95% CI 0.48 to 0.71; NNTB = 5; P < 0.001, I2 = 62%; 17 trials, 2332 participants; low-certainty evidence).

AUTHORS' CONCLUSIONS

Compared to placebo/no intervention, rifaximin likely improves health-related quality of life in people with minimal hepatic encephalopathy, and may improve hepatic encephalopathy, particularly in populations with minimal hepatic encephalopathy and when it is used for prevention. Rifaximin likely has no overall effect on mortality, serious adverse events, health-related quality of life, or hepatic encephalopathy compared to non-absorbable disaccharides. However, when used in combination with a non-absorbable disaccharide, it likely reduces overall mortality risk, the risk of serious adverse events, improves hepatic encephalopathy, reduces the length of hospital stay, and prevents the occurrence/recurrence of hepatic encephalopathy. The certainty of evidence for these outcomes is very low to moderate; further high-quality trials are needed.

Regulation of mild cognitive impairment associated with liver disease by humoral factors derived from the gastrointestinal tract and MRI research progress: a literature review

Patients with liver disease are prone to various cognitive impairments. It is undeniable that cognitive impairment is often regulated by both the nervous system and the immune system. In this review our research focused on the regulation of mild cognitive impairment associated with liver disease by humoral factors derived from the gastrointestinal tract, and revealed that its mechanisms may be involved with hyperammonemia, neuroinflammation, brain energy and neurotransmitter metabolic disorders, and liver-derived factors. In addition, we share the emerging research progress in magnetic resonance imaging techniques of the brain during mild cognitive impairment associated with liver disease, in order to provide ideas for the prevention and treatment of mild cognitive impairment in liver disease.

Current recommendations regarding evaluation of cognitive functioning in organ transplant candidates

PURPOSE OF REVIEW

Cognitive impairment is associated with negative effects on solid organ transplant candidates, recipients, and their care partners. However, because of the heterogeneity of mechanisms, presentations, and assessment measures, research suggests a wide array of impairments, patterns of impairments, and unclear trajectories posttransplant. This review provides an abbreviated synthesis of recent research on cognitive impairments observed in organ-eligible candidates and potential trajectories through posttransplant, current clinical recommendations regarding integration of assessment into routine clinical transplant practice, as well as recommendations for future research.

RECENT FINDINGS

Transplantation may resolve certain disease-contributing factors to cognitive impairments but also introduces new potential neurocognitive assaults. Recent studies in kidney and lung recipients document continued impairments in subsets of patients, particularly those identified as frail. For liver candidates, new assessment measures of hepatic encephalopathy have been developed and preliminarily tested with potential for translation into routine clinical care. Clinical implications, as well as ethical considerations are discussed.

SUMMARY

Although guidelines agree that cognitive assessment is an important part of the organ transplantation process, many questions remain of how to best assess cognition and intervene when cognitive impairment is identified in transplant populations. Further research should focus on prospective, longitudinal assessments in transplant-eligible populations through posttransplant.

Financial burden in adults with chronic liver disease: A scoping review

The economic burden of chronic liver disease is rising; however, the financial impact of chronic liver disease on patients and families has been underexplored. We performed a scoping review to identify studies examining financial burden (patient/family health care expenditures), financial distress (material, behavioral, and psychological consequences of financial burden), and financial toxicity (adverse health outcomes of financial distress) experienced by patients with chronic liver disease and their families. We searched MEDLINE, Embase, Cochrane Library, and the Web of Science online databases for articles published since the introduction of the Model for End-Stage Liver Disease score for liver transplantation allocation in February 2002 until July 2021. Final searches were conducted between June and July 2021. Studies were included if they examined the prevalence or impact of financial burden or distress among patients with chronic liver disease and/or their caregivers. A total of 19 observational studies met inclusion criteria involving 24,549 patients and 276 caregivers across 5 countries. High rates of financial burden and distress were reported within the study populations, particularly among patients with hepatic encephalopathy, hepatocellular carcinoma, and liver transplantation recipients. Financial burden and distress were associated with increased pre- and posttransplantation health care utilization and poor health-related quality of life as well as caregiver burden, depression, and anxiety. None of the included studies evaluated interventions to alleviate financial burden and distress. Observational evidence supports the finding that financial burden and distress are underrecognized but highly prevalent among patients with chronic liver disease and their caregivers and are associated with poor health outcomes. There is a critical need for interventions to mitigate financial burden and distress and reduce financial toxicity in chronic liver disease care.

Severe Hepatic Steatosis by Controlled Attenuation Parameter Predicts Quality of Life Independent of Fibrosis

BACKGROUND & AIM

Liver fibrosis is associated with poor patient-reported outcomes (PROs), but the impact of steatosis is unknown. We aimed to evaluate the impact of steatosis on PROs independent of liver fibrosis.

METHODS

We evaluated the impact of steatosis, measured by Controlled-Attenuation Parameter (CAP) on transient elastography, and PROs using the 2017-2018 National Health and Nutrition Examination Survey (NHANES) database. We used univariate and multivariate logistic and ordinal regression to evaluate categorical CAP score with PROs measuring physical disability, general health and depression.

RESULTS

Of 4,509 participants included, 38% had severe steatosis (> 280 dB/m). Those with severe steatosis were older and more likely to be male (56% vs. 43% and 51%). On univariate analysis, severe steatosis was associated with more difficulty walking (P = 0.01), dressing (P = 0.005), lifting objects (P = 0.02), bending (P < 0.001), and moving large objects (P = 0.0006). After multivariate adjustment, severe steatosis remained associated with difficulty lifting objects (odds ratio [OR]: 1.7, 95% confidence interval [CI]: 1.2-2.4, P = 0.01) and difficulty bending (OR: 1.8, 95% CI: 1.2-2.7, P = 0.006). Severe steatosis increased risk of having any of the disabilities (OR: 1.7, 95% CI: 1.2-2.4, P = 0.008) and had higher ordinal disability index (OR: 1.6, 95% CI: 1.2-2.2, P = 0.007). Lastly, severe steatosis was also associated with worse self-perceived health status (OR: 1.5, 95% CI: 1.2-1.9, P = 0.002), while general health compared to one year ago and depression trended toward significance.

CONCLUSION

Patients with severe steatosis are at increased risk of physical disability and have worse self-perceived health status independent of liver fibrosis.

Extremely Distant and Incredibly Close: Physical Proximity, Emotional Attachment and Caregiver Burden

Informal caregivers are at risk of caregiver burden, and physical proximity to the care recipient may add to this negative outcome. Yet, individual differences in emotional proximity to the care recipient such as attachment orientations may contribute to caregivers’ comfort towards different degrees of physical proximity, leading to varying levels of burden. The current study is the first to explore the role of physical proximity on caregiver burden as moderated by attachment orientations. A sample of 162 Israeli caregivers who are active users of the Camoni website completed our online survey. Sociodemographic characteristics, including a self-reported questionnaire on the physical proximity to the care recipient, were collected. Caregivers’ attachment orientations were assessed with the Experiences in Close Relationships–Relationship Structures questionnaire. Caregiver burden was assessed using the Caregiver Burden Inventory. Multiple regression and simple slope analyses were conducted. Attachment anxiety and avoidance were positively associated with burden, whereas physical proximity was not. Attachment avoidance, but not attachment anxiety, moderated the association between physical proximity and caregiver burden, with caregivers who live closer to their care recipient experiencing greater burden when high levels of avoidance were present. Our findings reveal the complex dynamics between attachment orientations and physical proximity in the context of informal care, highlighting the need for better integration of these two interlinked constructs in both care research and practice.

Hepatic encephalopathy

Hepatic encephalopathy (HE) is a prognostically relevant neuropsychiatric syndrome that occurs in the course of acute or chronic liver disease. Besides ascites and variceal bleeding, it is the most serious complication of decompensated liver cirrhosis. Ammonia and inflammation are major triggers for the appearance of HE, which in patients with liver cirrhosis involves pathophysiologically low-grade cerebral oedema with oxidative/nitrosative stress, inflammation and disturbances of oscillatory networks in the brain. Severity classification and diagnostic approaches regarding mild forms of HE are still a matter of debate. Current medical treatment predominantly involves lactulose and rifaximin following rigorous treatment of so-called known HE precipitating factors. New treatments based on an improved pathophysiological understanding are emerging.

Psychometric methods for diagnosing and monitoring minimal hepatic encephalopathy -current validation level and practical use

Hepatic encephalopathy (HE) is cerebral dysfunction caused by liver failure and inflicts 30-40% of patients with liver cirrhosis during their disease course. Clinically manifest HE is often preceded by minimal HE (MHE) - a clinically undetectable cognitive disturbance closely associated with loss of quality of life. Accordingly, detecting and treating MHE improve the patients' daily functioning and prevent HE-related hospital admissions. The scope of this review article is to create an overview of the validation level and usage of psychometric tests used to detect MHE: Portosystemic hepatic encephalopathy test, continuous reaction time test, Stroop EncephalApp, animal naming test, critical flicker frequency test, and inhibitory control test. Our work is aimed at the clinician or scientist who is about to decide on which psychometric test would fit best in their clinic, cohort, or study. First, we outline psychometric test validation obstacles and requirements. Then, we systematically approach the literature on each test and select well-conducted studies to answer the following questions:• Which percentage of patients with cirrhosis does the test deem as having MHE?• Is the test able to predict clinically manifest HE?• Is there a well-known test-retest variation and inter-observer variation?• Is the test able to detect a treatment response?• Is the test result affected by age, educational level, gender, or comorbidities?

Continued alcohol consumption and hepatic encephalopathy determine quality of life and psychosocial burden of caregivers in patients with liver cirrhosis

Background

Patients with liver cirrhosis suffer from significantly reduced health-related quality of life and are often dependent on support from caregivers. In this context, caregivers often suffer from impaired quality of life (QoL) as well as psychosocial burden (PB). The aim of the present study was to identify factors influencing QoL and PB of caregivers in order to improve the social care of patients and caregivers.

Methods

In this cross-sectional study, 106 patients with liver cirrhosis and their caregivers were included. (Health-related) QoL was surveyed in patients (CLDQ) and caregivers (SF-36) and PB was determined by Zarit Burden Interview.

Results

Alcohol related liver cirrhosis (55%) was the predominant etiology of liver cirrhosis and the median MELD of the cohort was 14. QoL did not differ between patients with and without alcohol-related liver cirrhosis (p = 0.6). In multivariable analysis, continued alcohol consumption (p = 0.020), a history of hepatic encephalopathy (HE) (p = 0.010), poorer QoL of patients (p = 0.030) and poorer QoL of caregivers (p = 0.005) were associated with a higher PB of caregivers. Factors independently associated with poorer QoL of caregivers were continued alcohol consumption (p = 0.003) and a higher PB of caregivers (p = 0.030).

Conclusion

Caregivers of patients with liver cirrhosis suffer from impaired QoL and PB, especially in case of continued alcohol consumption or the occurrence of HE.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12955-022-01923-z.

The relationship between the care burden and burnout levels of primary caregivers of patients undergoing liver transplantation

PURPOSE

This study was conducted to determine the relationship between the care burden and burnout level of primary caregivers of patients undergoing liver transplantation.

DESIGN AND METHODS

The sample size of this descriptive and correlational was determined to be 202 primary caregivers via the power analysis.

FINDINGS

It can be asserted that the primary caregivers had high burnout and had moderate care burden. It was found that there was a statistically positive moderate correlation between the caregivers' care burden and burnout (p ˂ 0.05).

PRACTICE IMPLICATIONS

In the study, it was determined that primary caregivers of patients undergoing liver transplantation had higher burnout and moderate care burden. Also, care burden affected burnout.

Health care utilization among patients with oesophageal and gastric cancer: the impact of initial treatment strategy and assignment of a contact nurse

Background

Patients diagnosed with oesophageal and gastric cancer face a poor prognosis and numerous challenges of symptom management, lifestyle adjustments and complex treatment regimens. The multifaceted care needs and rapid disease progression reinforce the need for proactive and coherent health care. According to the national cancer strategy, providing coherent health care and palliative support is an area of priority. More knowledge is needed about health care utilization and the characteristics of the health care service in order to understand the readiness, accessibility and quality of current health care. The aim of this study was to describe individuals’ health care use from the time of treatment decision until death, and investigate the impact of the initial treatment strategy and assignment of a contact nurse (CN) on health care use among patients with oesophageal and gastric cancer.

Methods

This population-based cohort study included patients who died from oesophageal and gastric cancer in Sweden during 2014–2016. Through linking data from the National Register for Oesophageal and Gastric Cancer, the National Cause of Death Register, and the National Patient Register, 2614 individuals were identified. Associations between the initial treatment strategy and CN assignment, and health care use were investigated. Adjusted incidence rate ratios (IRRs) with 95% confidence intervals (CIs) were calculated using Poisson regression.

Results

Patients receiving palliative treatment and those receiving no tumour-directed treatment had a higher IRR for unplanned hospital stays and unplanned outpatient care visits compared with patients who received curative treatment. Patients receiving no tumour-directed treatment also had a lower IRR for planned hospital stays and planned outpatient care visits compared with patients given curative treatment. Compared with this latter group, patients with palliative treatment had a higher IRR for planned outpatient care visits. Patients assigned a CN had a higher IRR for unplanned hospital stays, unplanned outpatient care visits and planned outpatient care visits, compared with patients not assigned a CN.

Conclusions

A palliative treatment strategy and no tumour-directed treatment were associated with higher rates of unplanned health care compared with a curative treatment strategy, suggesting that a proactive approach is imperative to ensure quality palliative care.

Creating Effective Models for Delivering Palliative Care in Advanced Liver Disease

Purpose of Review

The current healthcare system is not fully equipped to provide comprehensive support for patients with advanced liver disease (ALD) and their caregivers resulting in concomitant suffering and reduced quality of life (QoL). Integration of palliative care (PC) within routine care has demonstrated benefits in improving symptoms and QoL and reducing healthcare utilization for other serious illnesses but has been underutilized or delayed for ALD care. The purpose of this article is to outline the domains and benefits of PC and discuss the misconceptions and barriers for PC integration, and healthcare delivery models supporting PC integration within ALD care.

Recent Findings

PC has eight key domains related to physical and mental health, goals for future care, and care of the caregivers. PC offers benefits to improve health outcomes and patient satisfaction and reduce healthcare utilization. To date there have been successful models of PC that are primarily hospital- or community-based; successful models have been PC specialist- or primary/generalist-led.

Summary

Concurrent PC within oncology has formed the basis for most evidence-based guidelines. PC integration within ALD care is still in its infancy. While amassing evidence in ALD, hepatology organizations can promote consensus-based integrated PC models that can guide research and practice efforts to increase supportive care for these patients in need and their family caregivers.

AGA Clinical Practice Update on Palliative Care Management in Cirrhosis: Expert Review

Care with palliative care principles (aka Palliative Care, PC) is an approach to care that focuses on improving the quality of life of patients and their caregivers who are facing life-limiting illness. It encompasses the assessment and management of symptoms and changes in functional status, the provision of advance care planning and goals of care discussions, prognostication and caregiver support. PC is applicable across the spectrum of cirrhosis regardless of transplant eligibility. Although a common misconception, PC is not synonymous with hospice care. Unfortunately, despite a high symptom burden and challenges with predicting disease course and mounting evidence to support the benefits of PC in patients with cirrhosis, comprehensive PC and referral to hospice are carried out infrequently and very late in the course of disease. In order to meet the needs of our increasingly prevalent cirrhosis population, it is important that all clinicians who care for these patients are able to work together to deliver PC as a standard of care. To date there are limited guidelines/guidance statements to direct clinicians in the area of PC and cirrhosis. Herein we present an evidence-based review of ten Best Practice Advice statements that address key issues pertaining to PC in patients with cirrhosis.

Quality of life, caregiver burden and mental health disorders in primary caregivers of patients with Cirrhosis

BACKGROUND AND AIMS

Caregivers are needed for cirrhotic patients as there is progressive decline in cognition and self-care. We intend to study the quality of life (QOL), psychosocial burden and prevalence of mental health disorders among caregivers.

METHODS

Cross-sectional study where caregivers, defined as person who takes responsibility of providing care to patient, of cirrhotic patients were included. Short form 36 health survey (SF-36) to assess QOL, Zarit Burdern Index12 (ZBI) for caregiver burden (CB). Patient Health Questionnaire (PHQ) identified depression and Generalized Anxiety Disorder (GAD-7) questionnaires, anxiety.

RESULTS

Of 132 caregivers, mean age of caregiver was 41.2 ± 10.3 years, with female preponderance. Mean MELD was 21.4 ± 7, majority belonged to CHILD C. Comparing the SF36 score of caregivers to normal population showed lower level of QOL for caregivers. Mean ZBI score - 14 ± 5.8. Mean GAD score - 8.1 ± 5.1, 54 (41%) had anxiety. Mean PHQ score - 7.8 ± 5.2, 45 (34%) had depression.

REGRESSION ANALYSIS

Alcoholic cirrhosis, history of hepatic encephalopathy (HE), Anxiety, Depression and recidivism predicted CB. Treatment costs (ODDS-1.15), alcoholic cirrhosis (ODDS -8.9), history of HE (ODDS-7.5) and caregiver duration (ODDS-0.25) predicted anxiety. Treatment costs (ODDS-1.5), caregiver age (ODDS-0.87), spouse as caregiver (ODDS-10.9) and higher education (ODDS-0.79) predicted depression.

CONCLUSIONS

Caregivers of cirrhotic patients have high prevalence of CB with low QOL and high incidence of anxiety and depression, compared with the general population. Alcoholism in patients precipitates while higher education helps cope up with these disorders.

Hepatitis C-related cirrhosis will be a marginal cause of hospital admissions by 2025

BACKGROUND & AIMS

Complications of cirrhosis are the main cause of hospital admissions in liver units. In areas where HCV is prevalent, most of these admissions are attributable to HCV-related cirrhosis (HCV-cirrhosis). This study assessed the impact of direct-acting antivirals (DAA) in the profile of patients with liver disease admitted to a referral liver unit from a university hospital.

METHODS

We registered hospital admissions resulting from cirrhosis to the Liver Unit of the Hospital Clinic of Barcelona, from 2011 to 2014 (pre-DAA period) and from 2015 to 2019 (post-DAA period).

RESULTS

From a total of 14,865 hospital admissions, 10,053 resulted from cirrhosis (corresponding to 6,272 patients). The number and proportion of hospital admissions because of HCV-cirrhosis remained stable during the period 2011-2014 (525 per year, 48.8% of the total), but decreased progressively after 2015 (p <0.001), reaching <300 (27.1%) admissions in 2019. Similarly, HCV-cirrhosis accounted for 3,885 inpatient days per year (44.9%) during the pre-DAA period and decreased steadily after 2015 (p >0.001), reaching only 1,909 inpatient days (22%) in 2019. The figures for intensive care unit admissions followed a similar pattern. By means of a slope analysis (binomial regression model), we predicted that HCV-cirrhosis hospital admissions will be residual by 2025 (2.3%, 95% CI 0-10.9%). By contrast, we observed a significant increase in hospital admissions because of metabolic-associated fatty liver disease (5-fold) and autoimmune hepatitis (4-fold) during the study period.

CONCLUSIONS

In summary, our data showed a profound reduction in HCV-cirrhosis hospitalisation burden since 2015, coincident with the wide use of DAAs in Spain. Our predictions suggest that, by 2025, HCV-cirrhosis will be a marginal cause of hospital admissions for patients with liver disease.

LAY SUMMARY

Over the past few years, the wide use of antiviral drugs that cure HCV has had a significant effect on patients being admitted to hospital. Most patients with HCV and cirrhosis are treated (and often cured) in the community and, thus, the number of hospital admissions because of severe forms of HCV has decreased drastically. HCV is no longer the first cause of admission into liver units and, in only a few years from now, it is likely to be only a residual cause of hospitalisation.

Acceptance and use of a smartphone application in cirrhosis

BACKGROUND AND AIMS

The development of cirrhosis-related smartphone applications for remote monitoring is increasing. Whether patients with cirrhosis will welcome such new technology, however, is uncertain.

METHODS

We prospectively enrolled patients with cirrhosis (N = 102) to determine predictors of acceptance and utilization of a smartphone application for cirrhosis management using a 12-item Technology Acceptance Model (TAM) survey. Patients were then shown the EncephalApp© and evaluated for their willingness to download and use the application.

RESULTS

Patients had a median age of 61.3 years and 63.7% had a history of hepatic decompensation. Intention to use the hypothetical application was associated with perceived usefulness (β: 0.4, 95% CI: 0.3-0.5) and the presence of a caregiver (β: 1.1, 95% CI: 0.2-2.0). Of the eligible participants, 71% agreed to download the EncephalApp© and the decision was influenced by computer anxiety, behavioural intent, caregiver presence and disease state factors. Actual usage was 32% and not associated with baseline characteristics or the technology acceptance model.

CONCLUSIONS

Patient acceptance of smartphone applications for the management of cirrhosis is high and related to their attitudes towards technology and the presence of a caregiver. However, usage was low. Future research must employ behavioural interventions to optimize uptake and utilization of remote monitoring technology.