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Hassan A, Hurtado Diaz De Leon I, Tapper EB. Symptom burden in chronic liver disease. Gastroenterol Rep (Oxf) 2024; 12:goae078. [PMID: 39131950 PMCID: PMC11315653 DOI: 10.1093/gastro/goae078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2024] [Accepted: 07/03/2024] [Indexed: 08/13/2024] Open
Abstract
Chronic liver disease (CLD) is a significant contributor to global mortality. For people who are living with CLD, however, there is a substantial and often overlooked burden of physical and psychological symptoms that significantly affect health-related quality of life. CLD frequently presents with a multitude of interrelated and intricate symptoms, including fatigue, pruritus, muscle cramps, sexual dysfunction, and falls. Increasingly, there is interest in studying and developing interventional strategies to provide a more global approach to managing these complex patients. Moreover, in addition to established guidelines for the management of conventional complications, such as ascites and hepatic encephalopathy, there have been efforts in developing evidence-based guidance for the treatment of the more subjective yet still problematic elements. This review will address the management of these less "classical" but nonetheless important symptoms.
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Affiliation(s)
- Ammar Hassan
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan Health West, University of Michigan Medicine, Grand Rapids, MI, USA
| | - Ivonne Hurtado Diaz De Leon
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Elliot B Tapper
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
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2
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Román E, Kaür N, Sánchez E, Poca M, Padrós J, Nadal MJ, Cuyàs B, Alvarado E, Vidal S, Ortiz MÀ, Hernández E, Santesmases R, Urgell E, Juanes E, Ferrero-Gregori A, Escorsell À, Guarner C, Soriano G. Home exercise, branched-chain amino acids, and probiotics improve frailty in cirrhosis: A randomized clinical trial. Hepatol Commun 2024; 8:e0443. [PMID: 38701490 PMCID: PMC11073778 DOI: 10.1097/hc9.0000000000000443] [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: 12/19/2023] [Accepted: 03/04/2024] [Indexed: 05/05/2024] Open
Abstract
BACKGROUND Frailty is a predictive factor of hospitalization, falls, and mortality in patients with cirrhosis, regardless of the degree of liver failure. The aim was to analyze whether a multifactorial intervention consisting of home-based exercise, branched-chain amino acids, and a multistrain probiotic can improve frailty in these patients. METHODS Outpatients with cirrhosis were classified according to the Liver Frailty Index (LFI). Prefrail and frail patients were randomized into 2 groups. The intervention group was assigned to a multifactorial intervention consisting of exercise at home, branched-chain amino acid supplements, and a multistrain probiotic for 12 months. The control group received standard care. All patients were prospectively followed up every 3 months for 1 year to determine LFI, incidence of falls, emergency room visits, hospitalizations, and mortality. RESULTS Thirty-two patients were included: 17 patients were assigned to the intervention group and 15 to the control group. In the intervention group, the baseline LFI decreased at 3, 6, 9, and 12 months (p = 0.019 for overall change with respect to the control group). The change in LFI (ΔLFI) at 12 months was -0.71 ± 0.24 in the intervention group and -0.09 ± 0.32 in the control group (p<0.001). During follow-up, patients in the intervention group had a lower 1-year probability of falls (6% vs. 47%, p = 0.03) and emergency room visits (10% vs. 44%, p = 0.04) than patients in the control group. CONCLUSIONS A long-term multifactorial intervention that included exercise at home, branched-chain amino acids, and a multistrain probiotic improved frailty in outpatients with cirrhosis and was associated with a decrease in the incidence of clinical events such as falls and emergency room visits.
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Affiliation(s)
- Eva Román
- University Nursing School EUI-Sant Pau, Barcelona, Spain
- Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Universitat Autònoma de Barcelona, Barcelona, Spain
- CIBERehd, Instituto de Salud Carlos III, Madrid, Spain
| | - Naujot Kaür
- Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Elisabet Sánchez
- CIBERehd, Instituto de Salud Carlos III, Madrid, Spain
- Institut de Recerca Sant Pau (IR Sant Pau), Barcelona, Spain
| | - Maria Poca
- Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- CIBERehd, Instituto de Salud Carlos III, Madrid, Spain
| | - Josep Padrós
- Department of Physical Medicine and Rehabilitation, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Maria Josep Nadal
- Department of Physical Medicine and Rehabilitation, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Berta Cuyàs
- Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Edilmar Alvarado
- Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- CIBERehd, Instituto de Salud Carlos III, Madrid, Spain
| | - Silvia Vidal
- Universitat Autònoma de Barcelona, Barcelona, Spain
- Institut de Recerca Sant Pau (IR Sant Pau), Barcelona, Spain
| | | | - Elvira Hernández
- University Nursing School EUI-Sant Pau, Barcelona, Spain
- Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Rosalía Santesmases
- University Nursing School EUI-Sant Pau, Barcelona, Spain
- Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Eulàlia Urgell
- Department of Biochemistry, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Elena Juanes
- Department of Pharmacy at Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | | | - Àngels Escorsell
- Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Carlos Guarner
- Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Universitat Autònoma de Barcelona, Barcelona, Spain
- CIBERehd, Instituto de Salud Carlos III, Madrid, Spain
| | - Germán Soriano
- Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Universitat Autònoma de Barcelona, Barcelona, Spain
- CIBERehd, Instituto de Salud Carlos III, Madrid, Spain
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Miwa T, Hanai T, Hirata S, Nishimura K, Unome S, Nakahata Y, Imai K, Shirakami Y, Suetsugu A, Takai K, Shimizu M. Animal naming test stratifies the risk of falls and fall-related fractures in patients with cirrhosis. Sci Rep 2024; 14:4307. [PMID: 38383771 PMCID: PMC10881459 DOI: 10.1038/s41598-024-54951-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 02/19/2024] [Indexed: 02/23/2024] Open
Abstract
This study aimed to determine the relationship between animal naming test (ANT), falls, and fall-related fractures in patients with cirrhosis. Cognitive impairment and frailty were assessed using ANT and Karnofsky performance status (KPS), respectively. Factors stratifying the risk of previous falls and fall-related fractures within 1 year were assessed using a logistic regression model. Factors affecting patient performance in ANT were evaluated using multiple regression analysis. Of the 94 patients, 19% and 5% experienced falls and fall-related fractures, respectively. The performance in ANT was worse in patients who experienced falls (11 vs. 18; p < 0.001) and fall-related fractures (8 vs. 16; p < 0.001) than in those who did not. After adjustment, females, KPS, and ANT (odds ratio [OR], 0.78; 95% confidence interval [CI], 0.65-0.93; p = 0.005) were associated with falls, while ANT was significantly associated with fall-related fractures (OR, 0.56; 95% CI 0.35-0.88; p = 0.012). Age and education affected the performance in ANT, whereas the use of Oriental zodiac did not. The ANT is useful for stratifying the risk of falls and fall-related fractures in patients with cirrhosis. The effects of age and education should be considered when applying ANT in the Japanese population.
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Affiliation(s)
- Takao Miwa
- Department of Gastroenterology/Internal Medicine, Graduate School of Medicine, Gifu University, 1-1 Yanagido, Gifu, 501-1194, Japan.
| | - Tatsunori Hanai
- Department of Gastroenterology/Internal Medicine, Graduate School of Medicine, Gifu University, 1-1 Yanagido, Gifu, 501-1194, Japan
- Center for Nutrition Support and Infection Control, Gifu University Hospital, Gifu, Japan
| | - Sachiyo Hirata
- Center for Nutrition Support and Infection Control, Gifu University Hospital, Gifu, Japan
| | - Kayoko Nishimura
- Center for Nutrition Support and Infection Control, Gifu University Hospital, Gifu, Japan
| | - Shinji Unome
- Department of Gastroenterology/Internal Medicine, Graduate School of Medicine, Gifu University, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Yuki Nakahata
- Department of Gastroenterology/Internal Medicine, Graduate School of Medicine, Gifu University, 1-1 Yanagido, Gifu, 501-1194, Japan
- Department of Gastroenterology, Asahi University Hospital, Gifu, Japan
| | - Kenji Imai
- Department of Gastroenterology/Internal Medicine, Graduate School of Medicine, Gifu University, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Yohei Shirakami
- Department of Gastroenterology/Internal Medicine, Graduate School of Medicine, Gifu University, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Atsushi Suetsugu
- Department of Gastroenterology/Internal Medicine, Graduate School of Medicine, Gifu University, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Koji Takai
- Department of Gastroenterology/Internal Medicine, Graduate School of Medicine, Gifu University, 1-1 Yanagido, Gifu, 501-1194, Japan
- Division for Regional Cancer Control, Graduate School of Medicine, Gifu University, Gifu, Japan
| | - Masahito Shimizu
- Department of Gastroenterology/Internal Medicine, Graduate School of Medicine, Gifu University, 1-1 Yanagido, Gifu, 501-1194, Japan
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Taskin Gurel B, Vardar Yagli N, Calik Kutukcu E, Saglam M, Inal Ince D, Arikan H, Dogrul AB, Abbasoglu O. Long-Term Declines in Physical Fitness and Physical Activity for Individuals With Post-Liver Transplantation Compared to Healthy Controls. Percept Mot Skills 2023; 130:2450-2464. [PMID: 37643424 DOI: 10.1177/00315125231199662] [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: 08/31/2023]
Abstract
Functional changes are essential determinants of mortality and morbidity in individuals with chronic liver disease. However, there is limited information about whether these changes persist long-term after liver transplantation (LT). We aimed to compare physical fitness, physical activity, balance, kinesiophobia, and fatigue between patients with LT and healthy controls. All participants underwent evaluation with the Senior Fitness Test (SFT) for exercise capacity and physical fitness, the International Physical Activity Questionnaire (IPAQ) for physical activity, the Timed Up-and-Go Test (TUG) and the Berg Balance Scale (BBS) for balance, the Tampa Scale for Kinesiophobia (TSK) for kinesiophobia, and the Fatigue Severity Scale (FSS) and Fatigue Impact Scale (FIS) for fatigue. We studied 16 persons with LT (M age = 40.56, SD = 15.73 years; M time since LT = 66.81, SD = 72.05 months) and 16 control participants (M age = 39.87, SD = 13.98 years). Compared to controls, participants with LT showed significantly poorer performance on the SFT components assessing upper and lower body strength, aerobic endurance, agility, and dynamic balance (p < .001 for all), significantly lower IPAQ physical activity scores (p = .002) and BBS score (p = .017), and significantly higher TUG time (p < .001) and TSK, FSS, and FIS scores (p = .001, p = .001, and p = .004, respectively). Individuals with post-LT had lower exercise capacity, physical fitness, balance, and physical activity, and higher kinesiophobia and fatigue levels in the long-term compared to their peers. Future studies should focus on frailty in individuals in the long term after LT.
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Affiliation(s)
- Bilge Taskin Gurel
- Department of Physiotherapy and Rehabilitation, Faculty of Health Sciences, Lokman Hekim University, Ankara, Turkey
| | - Naciye Vardar Yagli
- Faculty of Physical Therapy and Rehabilitation, Hacettepe University, Ankara, Turkey
| | - Ebru Calik Kutukcu
- Faculty of Physical Therapy and Rehabilitation, Hacettepe University, Ankara, Turkey
| | - Melda Saglam
- Faculty of Physical Therapy and Rehabilitation, Hacettepe University, Ankara, Turkey
| | - Deniz Inal Ince
- Faculty of Physical Therapy and Rehabilitation, Hacettepe University, Ankara, Turkey
| | - Hulya Arikan
- Faculty of Physical Therapy and Rehabilitation, Hacettepe University, Ankara, Turkey
| | - Ahmet Bulent Dogrul
- Department of General Surgery, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Osman Abbasoglu
- Department of General Surgery, Faculty of Medicine, Hacettepe University, Ankara, Turkey
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5
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Farrugia MA, Le Garf S, Chierici A, Piche T, Gual P, Iannelli A, Anty R. Therapeutic Physical Exercise Programs in the Context of NASH Cirrhosis and Liver Transplantation: A Systematic Review. Metabolites 2023; 13:metabo13030330. [PMID: 36984770 PMCID: PMC10053873 DOI: 10.3390/metabo13030330] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 02/11/2023] [Accepted: 02/20/2023] [Indexed: 02/25/2023] Open
Abstract
In recent years, various physical exercise interventions have been developed with a view to reducing comorbidity and morbidity rates among patients with chronic diseases. Regular physical exercise has been shown to reduce hypertension and mortality in patients with type 2 diabetes. Diabetes and obesity are often associated with the development of nonalcoholic fatty liver disease, which can lead to liver fibrosis and then (in some cases) nonalcoholic steatohepatitis cirrhosis. We searched the literature for publications on personalized physical exercise programs in cirrhotic patients before and after liver transplantation. Eleven studies in cirrhotic patients and one study in liver transplant recipients were included in the systematic review, the results of which were reported in compliance with the preferred reporting items for systematic reviews and meta-analyses guidelines. The personalized physical exercise programs lasted for 6 to 16 weeks. Our review evidenced improvements in peak oxygen consumption and six-minute walk test performance and a reduction in the hepatic venous pressure gradient. In cirrhotic patients, personalized physical exercise programs improve quality of life, are not associated with adverse effects, and (for transplant recipients) might reduce the 90-day hospital readmission rate. However, none of the literature data evidenced reductions in the mortality rates before and after transplantation. Further prospective studies are needed to evaluate the benefit of long-term physical exercise programs in cirrhotic patients before and after liver transplantation.
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Affiliation(s)
- Marwin A. Farrugia
- Digestive Center, Centre Hospitalier Universitaire, Archet 2 Hospital, Université Côte d’Azur, 06000 Nice, France
| | - Sebastien Le Garf
- CSO PACA-Est, INSERM, C3M, Université Côte d’Azur, CEDEX 3, 06000 Nice, France
| | - Andrea Chierici
- Centre Hospitalier Universitaire de Nice—Digestive Surgery and Liver Transplantation Unit, Archet 2 Hospital, Université Côte d’Azur, 06000 Nice, France
| | - Thierry Piche
- Centre Hospitalier Universitaire, INSERM, U1065, C3M, Université Côte d’Azur, 06000 Nice, France
| | - Philippe Gual
- INSERM, U1065, C3M, Université Côte d’Azur, 06000 Nice, France
| | - Antonio Iannelli
- Centre Hospitalier Universitaire de Nice—Digestive Surgery and Liver Transplantation Unit, Archet 2 Hospital, INSERM U1065, Team 8 “Hepatic complications of obesity and alcohol”, Université Côte d’Azur, 06000 Nice, France
| | - Rodolphe Anty
- Digestive Center, Centre Hospitalier Universitaire, Archet 2 Hospital, Université Côte d’Azur, 06000 Nice, France
- Correspondence:
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Minimal Hepatic Encephalopathy Affects Daily Life of Cirrhotic Patients: A Viewpoint on Clinical Consequences and Therapeutic Opportunities. J Clin Med 2022; 11:jcm11237246. [PMID: 36498820 PMCID: PMC9736966 DOI: 10.3390/jcm11237246] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 11/21/2022] [Accepted: 11/27/2022] [Indexed: 12/12/2022] Open
Abstract
Minimal hepatic encephalopathy (MHE) is a frequent complication of hepatic encephalopathy (HE) and can affect up to 80% of patients with liver cirrhosis. It is characterized by the lack of obvious clinical signs and the presence of alterations detectable using psychometric or electrophysiological testing focused on attention, working memory, psychomotor speed and visuospatial ability. Ideally, each patient should be tested for this condition because, despite the absence of symptoms, it has severe repercussions on daily life activities. It may be responsible for an inability to drive, sleep disturbances, risk of falls and inability to work. Some studies have highlighted its prognostically unfavorable role on mortality and risk of "overt" HE (OHE). Finally, MHE severely affects the lives of patients and caregivers, altering their quality of life and their socioeconomic status. Several treatments have been proposed for MHE treatment, including non-absorbable disaccharides, poorly absorbable antibiotics, such as rifaximin, probiotics and branched-chain amino acids, with promising results. For this reason, early diagnosis and intervention with appropriate measures is essential, with the aim of improving both performance on psychometric tests, as well as clinical aspects related to this condition.
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Hansen MKG, Kjærgaard K, Eriksen LL, Grønkjær LL, Mikkelsen ACD, Sandahl TD, Vilstrup H, Thomsen KL, Lauridsen MME. Psychometric methods for diagnosing and monitoring minimal hepatic encephalopathy -current validation level and practical use. Metab Brain Dis 2022; 37:589-605. [PMID: 35102491 DOI: 10.1007/s11011-022-00913-w] [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: 09/07/2021] [Accepted: 01/14/2022] [Indexed: 02/07/2023]
Abstract
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?
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Affiliation(s)
- Mads Kingo Guldberg Hansen
- Department of Gastroenterology and Hepatology, University Hospital South Denmark, Finsensgade 35, 6700, Esbjerg, Denmark.
| | - Kristoffer Kjærgaard
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus, Denmark
| | - Lotte Lindgreen Eriksen
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus, Denmark
| | - Lea Ladegaard Grønkjær
- Department of Gastroenterology and Hepatology, University Hospital South Denmark, Finsensgade 35, 6700, Esbjerg, Denmark
| | - Anne Catrine Daugaard Mikkelsen
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus, Denmark
| | - Thomas Damgaard Sandahl
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus, Denmark
| | - Hendrik Vilstrup
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus, Denmark
| | - Karen Louise Thomsen
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus, Denmark
| | - Mette Munk Enok Lauridsen
- Department of Gastroenterology and Hepatology, University Hospital South Denmark, Finsensgade 35, 6700, Esbjerg, Denmark
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Effectiveness of a 12-Week Multi-Component Training Program with and without Transcranial Direct-Current Stimulation (tDCS) on Balance to Prevent Falls in Community-Dwelling Older Adults: A Study Protocol. BIOLOGY 2022; 11:biology11020290. [PMID: 35205156 PMCID: PMC8868777 DOI: 10.3390/biology11020290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Revised: 02/08/2022] [Accepted: 02/09/2022] [Indexed: 11/26/2022]
Abstract
Simple Summary Falls in community-dwelling individuals aged over 65 produce serious outcomes such as disability, morbidity, and mortality, as well as high healthcare costs. This research aims to assess whether a multicomponent training programme (McTP) combined with a transcranial direct-current stimulation device (tDCS), Halo Sport, produces improvements in balance and other gait-related parameters. Therefore, this study intends to test the efficacy of adding a tCDS device to an McTP in order to prevent falls in older adults by testing the safety, efficacy, and effectiveness of its implementation in care resources for the elderly. Abstract Approximately one-third of elderly people aged over 65 who live in the community experience falls every year, with the proportion increasing with age. Moreover, of those who fall, about half will fall again in the following year. The falls’ consequences include disability, morbidity, and mortality. Although many external and internal factors lead to falls, balance issues play a major role. Multi-component training programs (McTP) usually combine balance, strength, cardiorespiratory fitness, and flexibility, with studies reporting multiple benefits on the health-related quality of life. Halo Sport is a transcranial direct-current stimulation (tDCS) device with promising results for gait performance. This study aims to test the effectiveness of the introduction of a tCDS device to an McTP to prevent falls in older adults. The sample will consist of 46 people aged 65 years or older, randomly assigned to experimental (n = 23) and control (n = 23) groups. The experimental group will perform the McTP while wearing tDCS, and the control group will perform McTP without the device, for three sessions per week over 12 weeks. The main measures will provide information about (1) safety, (2) applicability, (3) balance, (4) number of falls, (5) physical fitness, (6) risk of falling, (7) fear of falling, (8) health-related quality of life, and (9) cognitive function. Among the practical implications of this program, it is intended to provide data on its safety and effectiveness to be implemented in different resources as a tool for the prevention of falls.
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9
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Acharya C, Bajaj JS. Hepatic Encephalopathy and Liver Transplantation: The Past, Present, and Future Toward Equitable Access. Liver Transpl 2021; 27:1830-1843. [PMID: 34018659 DOI: 10.1002/lt.26099] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Revised: 04/22/2021] [Accepted: 05/10/2021] [Indexed: 02/06/2023]
Abstract
Cirrhosis is a debilitating chronic disease with high morbidity and mortality, with the only real cure being liver transplantation (LT). Currently, we allocate organs for transplantation based on the Model for End-Stage Liver Disease-Sodium (MELD-Na) score that does not account for hepatic encephalopathy (HE). HE affects patients, families, and the health care system because of high rates of recurrence and major readmission burden. Moreover, HE casts a long shadow even after LT. Accounting for HE and incorporating it into the current allocation system has many proponents, but the framework to do this is currently lacking because of differences in consensus or in operationalization parameters. We review the latest evidence of the burden of HE, management of HE before and after LT, and evaluate pros and cons of several methods of diagnosing HE objectively to ensure early and equitable access to LT in this underserved population.
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Affiliation(s)
- Chathur Acharya
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and Central Virginia Veterans Healthcare System, Richmond, VA
| | - Jasmohan S Bajaj
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and Central Virginia Veterans Healthcare System, Richmond, VA
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10
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Román E, Poca M, Amorós-Figueras G, Rosell-Ferrer J, Gely C, Nieto JC, Vidal S, Urgell E, Ferrero-Gregori A, Alvarado-Tapias E, Cuyàs B, Hernández E, Santesmases R, Guarner C, Escorsell À, Soriano G. Phase angle by electrical bioimpedance is a predictive factor of hospitalisation, falls and mortality in patients with cirrhosis. Sci Rep 2021; 11:20415. [PMID: 34650096 PMCID: PMC8516941 DOI: 10.1038/s41598-021-99199-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 09/06/2021] [Indexed: 12/13/2022] Open
Abstract
The phase angle is a versatile measurement to assess body composition, frailty and prognosis in patients with chronic diseases. In cirrhosis, patients often present alterations in body composition that are related to adverse outcomes. The phase angle could be useful to evaluate prognosis in these patients, but data are scarce. The aim was to analyse the prognostic value of the phase angle to predict clinically relevant events such as hospitalisation, falls, and mortality in patients with cirrhosis. Outpatients with cirrhosis were consecutively included and the phase angle was determined by electrical bioimpedance. Patients were prospectively followed to determine the incidence of hospitalisations, falls, and mortality. One hundred patients were included. Patients with phase angle ≤ 4.6° (n = 31) showed a higher probability of hospitalisation (35% vs 11%, p = 0.003), falls (41% vs 11%, p = 0.001) and mortality (26% vs 3%, p = 0.001) at 2-year follow-up than patients with PA > 4.6° (n = 69). In the multivariable analysis, the phase angle and MELD-Na were independent predictive factors of hospitalisation and mortality. Phase angle was the only predictive factor for falls. In conclusion, the phase angle showed to be a predictive marker for hospitalisation, falls, and mortality in outpatients with cirrhosis.
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Affiliation(s)
- Eva Román
- Escola Universitària d'Infermeria EUI-Sant Pau, Barcelona, Spain
- Universitat Autònoma de Barcelona, Barcelona, Spain
- CIBERehd, Instituto de Salud Carlos III, Madrid, Spain
| | - Maria Poca
- Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, Mas Casanovas, 90, 08041, Barcelona, Spain
- CIBERehd, Instituto de Salud Carlos III, Madrid, Spain
| | - Gerard Amorós-Figueras
- Department of Cardiology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- CIBERCV, Instituto de Salud Carlos III, Madrid, Spain
| | - Javier Rosell-Ferrer
- Department of Electronic Engineering, Universitat Politècnica de Catalunya, Barcelona, Spain
| | | | - Juan C Nieto
- Research Institute IIB-Sant Pau, Barcelona, Spain
| | - Silvia Vidal
- Department of Immunology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Universitat Autònoma de Barcelona, Barcelona, Spain
- Research Institute IIB-Sant Pau, Barcelona, Spain
| | - Eulàlia Urgell
- Department of Biochemistry, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Andreu Ferrero-Gregori
- INCLIVA Health Research Institute, Valencia, Spain
- Foundation for the Promotion of Health and Biomedical Research of Valencia Region (FISABIO), Valencia, Spain
| | - Edilmar Alvarado-Tapias
- Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, Mas Casanovas, 90, 08041, Barcelona, Spain
- CIBERehd, Instituto de Salud Carlos III, Madrid, Spain
| | - Berta Cuyàs
- Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, Mas Casanovas, 90, 08041, Barcelona, Spain
| | - Elvira Hernández
- Escola Universitària d'Infermeria EUI-Sant Pau, Barcelona, Spain
- Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Rosalia Santesmases
- Escola Universitària d'Infermeria EUI-Sant Pau, Barcelona, Spain
- Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Carlos Guarner
- Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, Mas Casanovas, 90, 08041, Barcelona, Spain
- CIBERehd, Instituto de Salud Carlos III, Madrid, Spain
| | - Àngels Escorsell
- Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, Mas Casanovas, 90, 08041, Barcelona, Spain
| | - German Soriano
- Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, Mas Casanovas, 90, 08041, Barcelona, Spain.
- CIBERehd, Instituto de Salud Carlos III, Madrid, Spain.
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Tapper EB, Nikirk S, Parikh ND, Zhao L. Falls are common, morbid, and predictable in patients with cirrhosis. J Hepatol 2021; 75:582-588. [PMID: 33887359 PMCID: PMC8380639 DOI: 10.1016/j.jhep.2021.04.012] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 03/19/2021] [Accepted: 04/06/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS Falls are a devastating complication of cirrhosis. The risk of falls in patients without hepatic encephalopathy (HE) is unclear. Further, bedside tools for predicting falls are lacking. Thus, we aimed to internally validate a predictive model for falls and evaluate the association between incident falls and mortality. METHODS We prospectively enrolled 299 patients with currently compensated Child A-B (70% Child-Pugh A) cirrhosis and portal hypertension without prior HE from 7/2016-8/2018. We followed patients for a median of 1,003 days (IQR 640-1,102) for incident falls accounting for the competing risk of death or transplantation. Candidate baseline fall predictors included patient-reported outcomes (e.g. Short-Form-8), physical function (e.g. chair-stands), blood tests (e.g. model for end-stage liver disease-sodium [MELD-Na] and its components), and cognitive function (using inhibitory control testing). RESULTS During follow-up: 141 (47%) patients experienced falls, with 38 (13%) sustaining injuries, 49 (16%) died and 13 (4%) received transplants. Median time to a fall was 279 (98-595) days. The overall probability of falls was 28.8% and 50.2% at years 1 and 3; the probability of injurious falls was 9.1% and 16.5%, respectively. We derived a predictive model for falls. The FallSSS score (prior falls, chair-stands, sodium, and SF-8) had an AUROC for injurious falls at 6- and 12-months of 0.79 and 0.81, while MELD-Na's AUROC was 0.57 for both. Adjusting for baseline Child-Pugh class, MELD-Na, albumin level, disability status, and comorbidities, both incident falls (subdistribution hazard ratio [sHR] 2.76; 95% CI 1.46-5.24) and HE (sHR 4.25; 95% CI 2.15-8.41) were strongly and independently associated with mortality. CONCLUSION Our prospective study of patients with cirrhosis without a baseline history of HE demonstrates that falls are common, morbid, and predictable. These data highlight both the value of expanding screening to patients with cirrhosis and the potential for benefit in studies of interventions to address fall-risk in this vulnerable population. LAY SUMMARY Falls are a devastating complication of cirrhosis. Bedside tools for predicting falls are lacking. We found that falls were very common and often associated with serious injuries. Falls were also associated with an increased risk of death. Falls could be predicted with an algorithm called FallSSS - based on prior history of falls, blood sodium level, number of chair-stands performed in 30 seconds, and quality of life.
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Affiliation(s)
- Elliot B Tapper
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA.
| | - Samantha Nikirk
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Neehar D Parikh
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Lilli Zhao
- Department of Biostatistics, University of Michigan, Ann Arbor, MI, USA
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Salman T, Elsabaawy M, Omar M, Afify M, Elezawy H, Ghanem S, Abdelraouf O, Rewisha E, Shebl N. Evaluation of different diagnostic modalities of minimal hepatic encephalopathy in cirrhotic patients: case-control study. Clin Exp Hepatol 2021; 7:312-319. [PMID: 34712834 PMCID: PMC8527340 DOI: 10.5114/ceh.2021.109292] [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: 02/24/2021] [Accepted: 06/13/2021] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Minimal hepatic encephalopathy (MHE) represents one of the most overlooked complications of liver cirrhosis. AIM OF THE STUDY To compare the utility and efficacy of different MHE diagnostic modalities. MATERIAL AND METHODS This case-control study was conducted on hepatitis C virus (HCV)-related compensated cirrhotic patients. The Psychometric Hepatic Encephalopathy Score (PHES) was used to assign patients to MHE and controls. All patients were subjected to plasma ammonia, serum 3-nitrotyrosine (3-NT), critical flicker frequency (CFF), and the modified inhibitory control test (ICT). RESULTS CFF was significantly lower in the control group (38.5, 40 Hz, p = 0.003). The unweighted lures on ICT were 8.7, 4.9 in MHE and controls (p < 0.001). Moreover, ammonia was higher in the MHE group (89, 61.5 µmol/l, p < 0.001). 3-NT was also higher in the MHE group (31.5, 13.7 nmol/l, p < 0.001) respectively. CFF at cutoff < 39 Hz had sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of 57.5%, 77.5%, 71.9% and 64.6%, respectively; in modified ICT, at cutoff > 5 unweighted lures the values were 87.5%, 80%, 81.4% and 86.5%, respectively; in ammonia, at cutoff ≥ 76.45 µmol/l the values were 65%, 72.5%, 70.3% and 67.4%, respectively; for 3-NT at cutoff ≥ 14.15 nmol/l the values were 85%, 82.5%, 82.9% and 84.6%, respectively. The accuracy for MHE diagnosis was 67.5%, 83.3%, 68.8%, 83.8% relying on CFF, 3-NT, ammonia, and ICT respectively. On multivariate analysis, CFF < 39 Hz (OR = 10.2, p = 0.04), modified ICT > 5 unweighted lures (OR = 43.2, p = 0.002), and serum 3-NT levels ≥ 14.15 nmol/l (OR = 50.4, p < 0.001) were independent predictors of MHE. CONCLUSIONS 3-NT and ICT are advantageous to reveal MHE in compensated liver cirrhosis, while CFF can be only used as adjuncts, with humble merits of ammonia.
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Affiliation(s)
- Tary Salman
- National Liver Institute, Menoufia University, Egypt
| | | | - Mahmoud Omar
- National Liver Institute, Menoufia University, Egypt
| | - Mohamed Afify
- National Liver Institute, Menoufia University, Egypt
| | | | - Samar Ghanem
- National Liver Institute, Menoufia University, Egypt
| | - Osama Abdelraouf
- Faculty of Computers and Information, Menoufia University, Egypt
| | - Eman Rewisha
- National Liver Institute, Menoufia University, Egypt
| | - Nashwa Shebl
- National Liver Institute, Menoufia University, Egypt
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Kaps L, Hildebrand K, Nagel M, Michel M, Kremer WM, Hilscher M, Galle PR, Schattenberg JM, Wörns MA, Labenz C. Risk factors for poorer health literacy in patients with liver cirrhosis. PLoS One 2021; 16:e0255349. [PMID: 34314445 PMCID: PMC8315548 DOI: 10.1371/journal.pone.0255349] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Accepted: 07/14/2021] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Health literacy is a concept that refers to patients' ability to manage their disease and the health system's ability to guarantee access to services. There is evidence that health literacy impacts the health outcomes of patients with chronic diseases, but detailed information on this topic in patients with liver cirrhosis is scarce. It was the aim of this study to identify risk factors for poorer health literacy in patients with liver cirrhosis. METHODS 89 patients with liver cirrhosis were enrolled in this study and health literacy was measured using the Health Literacy Questionnaire (HLQ). Covert hepatic encephalopathy (CHE) was diagnosed clinically according to the West-Haven Criteria (HE grade 1) and the PHES (minimal HE). Depressive symptoms were assessed using the Hamilton Depression Rating Scale (HDRS). Based on the nine subscales of the HLQ, risk factors for poor health literacy were identified using linear regression models. RESULTS Normalized HLQ scores ranged between 65-76%, while appraisal of health information had lowest score (65%) and ability to actively engage with healthcare providers had highest score (76%). Multivariable regression analyses revealed an association of poorer health literacy and liver function as determined by MELD score and complications of liver cirrhosis such as a history of ascites or CHE. Additionally, we identified modifiable or preventable factors such as depressive symptoms, a history of falls, and active smoking as risk factors for poorer health literacy. CONCLUSION Multiple factors seem to impact on health literacy in patients with liver cirrhosis. Addressing modifiable and preventable factors may improve health literacy.
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Affiliation(s)
- Leonard Kaps
- Department of Internal Medicine I, University Medical Centre of the Johannes Gutenberg-University, Mainz, Germany
- Cirrhosis Centre Mainz (CCM), University Medical Centre of the Johannes Gutenberg-University, Mainz, Germany
- Institute of Translational Immunology, University Medical Centre of the Johannes Gutenberg-University, Mainz, Germany
| | - Katharina Hildebrand
- Department of Internal Medicine I, University Medical Centre of the Johannes Gutenberg-University, Mainz, Germany
- Cirrhosis Centre Mainz (CCM), University Medical Centre of the Johannes Gutenberg-University, Mainz, Germany
| | - Michael Nagel
- Department of Internal Medicine I, University Medical Centre of the Johannes Gutenberg-University, Mainz, Germany
- Cirrhosis Centre Mainz (CCM), University Medical Centre of the Johannes Gutenberg-University, Mainz, Germany
| | - Maurice Michel
- Department of Internal Medicine I, University Medical Centre of the Johannes Gutenberg-University, Mainz, Germany
- Cirrhosis Centre Mainz (CCM), University Medical Centre of the Johannes Gutenberg-University, Mainz, Germany
| | - Wolfgang Maximilian Kremer
- Department of Internal Medicine I, University Medical Centre of the Johannes Gutenberg-University, Mainz, Germany
- Cirrhosis Centre Mainz (CCM), University Medical Centre of the Johannes Gutenberg-University, Mainz, Germany
| | - Max Hilscher
- Department of Internal Medicine I, University Medical Centre of the Johannes Gutenberg-University, Mainz, Germany
- Cirrhosis Centre Mainz (CCM), University Medical Centre of the Johannes Gutenberg-University, Mainz, Germany
| | - Peter R. Galle
- Department of Internal Medicine I, University Medical Centre of the Johannes Gutenberg-University, Mainz, Germany
- Cirrhosis Centre Mainz (CCM), University Medical Centre of the Johannes Gutenberg-University, Mainz, Germany
| | - Jörn M. Schattenberg
- Department of Internal Medicine I, University Medical Centre of the Johannes Gutenberg-University, Mainz, Germany
| | - Marcus-Alexander Wörns
- Department of Internal Medicine I, University Medical Centre of the Johannes Gutenberg-University, Mainz, Germany
- Cirrhosis Centre Mainz (CCM), University Medical Centre of the Johannes Gutenberg-University, Mainz, Germany
| | - Christian Labenz
- Department of Internal Medicine I, University Medical Centre of the Johannes Gutenberg-University, Mainz, Germany
- Cirrhosis Centre Mainz (CCM), University Medical Centre of the Johannes Gutenberg-University, Mainz, Germany
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Hepatic encephalopathy increases the risk of hip fracture: a nationwide cohort study. BMC Musculoskelet Disord 2020; 21:779. [PMID: 33243187 PMCID: PMC7690159 DOI: 10.1186/s12891-020-03811-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 11/19/2020] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Osteoporotic hip fracture is a common general health problem with a significant impact on human life because it debilitates the patients and largely decreases their quality of life. Early prevention of fractures has become essential in recent decades. This can be achieved by evaluating the related risk factors, as a reference for further intervention. This is especially useful for the vulnerable patient group with comorbidities. Hepatic encephalopathy (HE), a major complication of liver cirrhosis, may increase the rate of falls and weaken the bone. This study evaluated the correlation between hepatic encephalopathy and osteoporotic hip fracture in the aged population using a national database. METHODS This retrospective cohort study used data from Taiwan's National Health Insurance Research Database between 2000 and 2012. We included people who were older than 50 years with hepatic encephalopathy or other common chronic illnesses. Patients with and without hepatic encephalopathy were matched at a ratio of 1:4 for age, sex, and index year. The incidence and hazard ratios of osteoporotic hip fracture between the both cohorts were calculated using Cox proportional hazard regression models. RESULTS The mean age of the enrolled patients was 66.5 years. The incidence ratio of osteoporotic hip fracture in the HE group was significantly higher than that in the non-HE group (68/2496 [2.7%] vs 98/9984 [0.98%]). Patients with HE were 2.15-times more likely to develop osteoporotic hip fractures than patients without HE in the whole group. The risk ratio was also significantly higher in female and older individuals. The results were also similar in the comorbidity subgroups of hypertension, diabetes mellitus, hyperlipidemia, senile cataract, gastric ulcer, and depression. Alcohol-related illnesses seemed to not confound the results of this study. CONCLUSIONS HE is significantly associated with an increased risk of osteoporotic hip fractures, and the significance is not affected by the comorbidities in people aged more than 50 years. The cumulative risk of fracture increases with age.
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15
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BE CAREFUL. DON'T FALL! Gastroenterol Nurs 2020; 42:294-295. [PMID: 31145256 DOI: 10.1097/sga.0000000000000413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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16
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Carlos-Vivas J, Pérez-Gómez J, Delgado-Gil S, Campos-López JC, Granado-Sánchez M, Rojo-Ramos J, Muñoz-Bermejo L, Barrios-Fernandez S, Mendoza-Muñoz M, Prado-Solano A, Garcia-Gordillo MÁ, Adsuar JC. Cost-Effectiveness of "Tele-Square Step Exercise" for Falls Prevention in Fibromyalgia Patients: A Study Protocol. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17030695. [PMID: 31973115 PMCID: PMC7037096 DOI: 10.3390/ijerph17030695] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 01/13/2020] [Accepted: 01/15/2020] [Indexed: 01/07/2023]
Abstract
Background: Women with fibromyalgia (FM) have 2.5 falls per year compared to the 0.5 falls in people without FM. This fact poses a significant health expense. Square Stepping Exercise (SSE) is a balance training system that has been shown to be effective in preventing falls in the elderly. However, there are neither studies in people with FM nor studies that apply SSE through video-conferencing (Tele-SSE). The objectives of this project are 1) to investigate the applicability, safety, decrease in the number of falls, and incremental cost-effectiveness ratio of prevention of falls program through Tele-SSE in women with FM, and 2) to study the transfer of obtained results to the public and private socio-health economy of Extremadura. Methods/Design: A randomized controlled trial with experimental (Tele-SSE) and control (usual treatment) groups will be carried out. The application of Tele-SSE will be performed for 12 months (three times per week) and one additional follow-up month after the intervention. A focus group including agents to identify key points to transfer the findings to the public and private sectors in Extremadura. One-hundred and eighteen women with FM will be recruited and randomly distributed into the two groups: Experimental (Tele-SSE; n = 59) and control group (Usual care; n = 59). Primary outcome measures will be: 1) Applicability; 2) safety; 3) annual number of falls; and 4) incremental cost-effectiveness ratio. Secondary outcomes will be: 1) Balance; 2) fear of falling; 3) socio-demographic and clinical information; 4) body composition; 5) physical fitness; 6) physical activity and sedentary behavior; 7) quality of life-related to health, mental health, and positive health; 8) pain; 9) disability level; 10) cognitive aspects; and 11) depressive symptoms. Regarding the focus group, the acceptability of the Tele-SSE will be evaluated in social-sanitary agents and will include Tele-SSE in their services offer. A statistical analysis will be carried out by treatment intention and protocol. In addition, a cost-effectiveness analysis from the perspective of the health system will be performed. Discussion: This project aims to improve the efficiency and equity of physical therapy services based on tele-exercise in preventing falls in people with FM. Furthermore, orientations will be given in order to transfer the obtained findings into the social-sanitary system and market.
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Affiliation(s)
- Jorge Carlos-Vivas
- Health, Economy, Motricity and Education Research Group (HEME), Faculty of Sport Sciences, University of Extremadura, Cáceres 10003, Spain; (M.M.-M.); (A.P.-S.); (J.C.A.)
- Correspondence: (J.C.-V.); (J. P.-G.)
| | - Jorge Pérez-Gómez
- Health, Economy, Motricity and Education Research Group (HEME), Faculty of Sport Sciences, University of Extremadura, Cáceres 10003, Spain; (M.M.-M.); (A.P.-S.); (J.C.A.)
- Correspondence: (J.C.-V.); (J. P.-G.)
| | - Serafín Delgado-Gil
- Social Impact and Innovation in Health (InHEALTH), University of Extremadura, Cáceres 10003, Spain; (S.D.-G.); (J.C.C.-L.); (M.G.-S.); (J.R.-R.); (L.M.-B.); (S.B.-F.)
| | - José Carlos Campos-López
- Social Impact and Innovation in Health (InHEALTH), University of Extremadura, Cáceres 10003, Spain; (S.D.-G.); (J.C.C.-L.); (M.G.-S.); (J.R.-R.); (L.M.-B.); (S.B.-F.)
| | - Manuel Granado-Sánchez
- Social Impact and Innovation in Health (InHEALTH), University of Extremadura, Cáceres 10003, Spain; (S.D.-G.); (J.C.C.-L.); (M.G.-S.); (J.R.-R.); (L.M.-B.); (S.B.-F.)
| | - Jorge Rojo-Ramos
- Social Impact and Innovation in Health (InHEALTH), University of Extremadura, Cáceres 10003, Spain; (S.D.-G.); (J.C.C.-L.); (M.G.-S.); (J.R.-R.); (L.M.-B.); (S.B.-F.)
| | - Laura Muñoz-Bermejo
- Social Impact and Innovation in Health (InHEALTH), University of Extremadura, Cáceres 10003, Spain; (S.D.-G.); (J.C.C.-L.); (M.G.-S.); (J.R.-R.); (L.M.-B.); (S.B.-F.)
| | - Sabina Barrios-Fernandez
- Social Impact and Innovation in Health (InHEALTH), University of Extremadura, Cáceres 10003, Spain; (S.D.-G.); (J.C.C.-L.); (M.G.-S.); (J.R.-R.); (L.M.-B.); (S.B.-F.)
- Department of Terapéutica Médico-Quirúgica, Faculty of Nursing and Occupational Therapy, University of Extremadura, Cáceres 10003, Spain
| | - María Mendoza-Muñoz
- Health, Economy, Motricity and Education Research Group (HEME), Faculty of Sport Sciences, University of Extremadura, Cáceres 10003, Spain; (M.M.-M.); (A.P.-S.); (J.C.A.)
| | - Angelina Prado-Solano
- Health, Economy, Motricity and Education Research Group (HEME), Faculty of Sport Sciences, University of Extremadura, Cáceres 10003, Spain; (M.M.-M.); (A.P.-S.); (J.C.A.)
| | | | - José Carmelo Adsuar
- Health, Economy, Motricity and Education Research Group (HEME), Faculty of Sport Sciences, University of Extremadura, Cáceres 10003, Spain; (M.M.-M.); (A.P.-S.); (J.C.A.)
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Labenz C, Toenges G, Schattenberg JM, Nagel M, Huber Y, Marquardt JU, Galle PR, Wörns MA. Health-related quality of life in patients with compensated and decompensated liver cirrhosis. Eur J Intern Med 2019; 70:54-59. [PMID: 31530418 DOI: 10.1016/j.ejim.2019.09.004] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 08/04/2019] [Accepted: 09/09/2019] [Indexed: 12/27/2022]
Abstract
BACKGROUND Compensated (Child-Pugh [CP] A) and decompensated (CP B/C) liver cirrhosis significantly differs in terms of impairment of health-related quality of life (HRQoL). However, sufficient data on potentially treatable factors associated with HRQoL in both stages of the disease are still lacking. Consequently, aims of this study were to determine differences in HRQoL between patients with compensated and decompensated liver cirrhosis and to identify potentially treatable factors associated with HRQoL. METHODS 218 patients with liver cirrhosis were enrolled into this study. Chronic Liver Disease Questionnaire (CLDQ) was used to assess HRQoL. Covert hepatic encephalopathy (CHE) was diagnosed according to a combination of Psychometric Hepatic Encephalopathy Score and Critical Flicker Frequency. Frailty was assessed by Clinical Frailty Scale (CFS). RESULTS HRQoL differed between patients with CP A (n = 133) and CP B/C (n = 85) liver cirrhosis (CLDQ total score: 5.6 vs. 4.8, p < 0.001). Multivariate analysis identified a history of falls in the recent year, presence of CHE, female gender, active smoking, higher CFS, and higher serum levels of CRP as independent predictors of impaired HRQoL (all p < 0.05) in patients with CP A liver cirrhosis. In patients with CP B/C liver cirrhosis, female gender, a history of overt hepatic encephalopathy, and lower hemoglobin were independently associated with impaired HRQoL (all p < 0.05). CONCLUSIONS Predictors of impaired HRQoL differ in patients with CP A or CP B/C liver cirrhosis. Focusing on treatable factors in routine clinical practice may improve HRQoL in all stages of liver cirrhosis.
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Affiliation(s)
- Christian Labenz
- Department of Internal Medicine I, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany; Cirrhosis Center Mainz (CCM), University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Gerrit Toenges
- Institute of Medical Biostatistics, Epidemiology and Informatics, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Jörn M Schattenberg
- Department of Internal Medicine I, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany; Cirrhosis Center Mainz (CCM), University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Michael Nagel
- Department of Internal Medicine I, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany; Cirrhosis Center Mainz (CCM), University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Yvonne Huber
- Department of Internal Medicine I, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany; Cirrhosis Center Mainz (CCM), University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Jens U Marquardt
- Department of Internal Medicine I, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany; Cirrhosis Center Mainz (CCM), University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Peter R Galle
- Department of Internal Medicine I, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany; Cirrhosis Center Mainz (CCM), University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Marcus-Alexander Wörns
- Department of Internal Medicine I, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany; Cirrhosis Center Mainz (CCM), University Medical Center of the Johannes Gutenberg-University, Mainz, Germany.
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Li IF, Huang JC, Chen JJ, Wang TE, Huang SS, Tsay SL. Factors related to the quality of life in liver cancer patients during treatment phase: A follow-up study. Eur J Cancer Care (Engl) 2019; 28:e13146. [PMID: 31433531 DOI: 10.1111/ecc.13146] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Revised: 06/13/2019] [Accepted: 08/01/2019] [Indexed: 02/06/2023]
Abstract
OBJECTIVE This study aims to explore the predictive value of demographic and clinical factors in changes in quality of life (QoL) in liver cancer (LC) patients over time. METHODS We performed a prospective cohort study in 128 patients who had 4 time point data newly diagnosed with LC at two hospitals in Taiwan. Different functional QoL was measured by QLQ-C30. Specific characteristics were predictors for distinct functional QoL, estimated by a generalised estimating equation (GEE). RESULTS Patients who received liver resection or radiofrequency ablation therapy (RFA) versus transarterial chemoembolisation (TACE) or transcatheter arterial embolisation (TAE) experienced a decrease in physical function from baseline to 1 month. In addition, patients who underwent liver resection versus RFA experienced a significant recovery in cognitive functioning from baseline to 6 months. Patients with advanced stage compared to those in early stage had a reduction in physical functioning from baseline to 1 month. The alcohol intake, hepatitis C infection and the job also affected the changes in physical and cognitive functioning. CONCLUSION Healthcare professionals should pay attention to changes after treatment in the short term; additionally, they need to provide health education to modifiable factors such as alcohol intake attributed to the deterioration in QoL.
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Affiliation(s)
- In Fun Li
- Department of Nursing, MacKay Memorial Hospital, New Taipei City, Taiwan
| | - Jen-Chien Huang
- Division of Gastroenterology, Cheng Ching Hospital, Taichung City, Taiwan
| | - Jyh-Jou Chen
- Department of Internal Medicine, Chi Mei Hospital, Liouying, Tainan City, Taiwan
| | - Tseng En Wang
- Division of Gastroenterology, Department of Internal Medicine, Mackay Memorial Hospital, Taipei City, Taiwan
| | - Sheng-Shiung Huang
- College of Nursing and Health Sciences, Da-Yeh University, Changhua, Taiwan
| | - Shiow-Luan Tsay
- College of Nursing and Health Sciences, Da-Yeh University, Changhua, Taiwan
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Abstract
BACKGROUND Current EASL/AASLD guidelines recommend treatment of covert hepatic encephalopathy (HE) only in symptomatic patients, for example, in those with impaired quality of life or with affected driving abilities. GOALS Because testing for impaired quality of life is time consuming, the aim of the present study was to identify simple clinical predictors for poor quality of life in patients with covert HE (CHE). STUDY In total, 139 cirrhotic in- and outpatients without a history of overt hepatic encephalopathy were enrolled. Diagnosis of HE grade 1 (HE1) was diagnosed clinically according to the West-Haven Criteria. Critical flicker frequency and the Psychometric Hepatic Encephalopathy Score were used to detect minimal HE (MHE). Chronic Liver Disease Questionnaire was used to assess health-related quality of life (HrQoL). RESULTS CHE was detected in 51 (36.7%) patients. Multivariate analysis identified a history of falls in the previous year (P=0.003) and female gender (P=0.030) as independent predictors of reduced HRQoL in patients with CHE. Comparison of patients with and without a history of falls revealed relevant differences in the subdomains-abdominal symptoms, fatigue, systemic symptoms, emotional functions and worries. CONCLUSIONS A history of falls and female gender are associated with impaired HRQoL in patients with CHE. These data indicate that a history of falls should be considered as a treatment indication in patients with CHE to improve HRQoL and ultimately prognosis.
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Fritsch MA, Shelton PS. Geriatric Polypharmacy: Pharmacist as Key Facilitator in Assessing for Falls Risk: 2019 Update. Clin Geriatr Med 2019; 35:185-204. [PMID: 30929882 DOI: 10.1016/j.cger.2019.01.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
This article highlights the significant health impact of falls among older adults. An emphasis is placed on the vital role of the pharmacist, regardless of practice setting, in assessing and reducing falls risk for this growing population. In addition, the importance of a stepwise comprehensive approach to falls assessment by pharmacists in collaboration with other clinicians is elucidated.
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Affiliation(s)
| | - Penny S Shelton
- North Carolina Association of Pharmacists, 1101 Slater Road, Suite 110, Durham, NC 27703, USA
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21
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Román E, Nieto JC, Gely C, Vidal S, Pozuelo M, Poca M, Juárez C, Guarner C, Manichanh C, Soriano G. Effect of a Multistrain Probiotic on Cognitive Function and Risk of Falls in Patients With Cirrhosis: A Randomized Trial. Hepatol Commun 2019; 3:632-645. [PMID: 31061952 PMCID: PMC6492476 DOI: 10.1002/hep4.1325] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 01/30/2019] [Indexed: 12/11/2022] Open
Abstract
Probiotics can modulate gut microbiota, intestinal permeability, and immune response and could therefore improve cognitive dysfunction and help avoid potential consequences, such as falls, in patients with cirrhosis. The aim of this study was to evaluate the effect of a multistrain probiotic on cognitive function, risk of falls, and inflammatory response in patients with cirrhosis. Consecutive outpatients with cirrhosis and cognitive dysfunction (defined by a Psychometric Hepatic Encephalopathy Score [PHES] < -4) and/or falls in the previous year were randomized to receive either a sachet of a high-concentration multistrain probiotic containing 450 billion bacteria twice daily for 12 weeks or placebo. We evaluated the changes in cognitive function (PHES); risk of falls (Timed Up and Go [TUG] test, gait speed, and incidence of falls); systemic inflammatory response; neutrophil oxidative burst; intestinal barrier integrity (serum fatty acid-binding protein 6 [FABP-6] and 2 [FABP-2] and zonulin and urinary claudin-3); bacterial translocation (lipopolysaccharide-binding protein [LBP]); and fecal microbiota. Thirty-six patients were included. Patients treated with the probiotic (n = 18) showed an improvement in the PHES (P = 0.006), TUG time (P = 0.015) and gait speed (P = 0.02), and a trend toward a lower incidence of falls during follow-up (0% compared with 22.2% in the placebo group [n = 18]; P = 0.10). In the probiotic group, we observed a decrease in C-reactive protein (P = 0.01), tumor necrosis factor alpha (P = 0.01), FABP-6 (P = 0.009), and claudin-3 (P = 0.002), and an increase in poststimulation neutrophil oxidative burst (P = 0.002). Conclusion: The multistrain probiotic improved cognitive function, risk of falls, and inflammatory response in patients with cirrhosis and cognitive dysfunction and/or previous falls.
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Affiliation(s)
- Eva Román
- Department of Gastroenterology Hospital de la Santa Creu i Sant Pau Barcelona Spain.,Escola Universitària d'Infermeria EUI-Sant Pau Barcelona Spain.,Institut de Recerca IIB-Sant Pau Barcelona Spain.,CIBERehd Instituto de Salud Carlos III Madrid Spain
| | | | | | - Sílvia Vidal
- Institut de Recerca IIB-Sant Pau Barcelona Spain.,Department of Immunology Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona Barcelona Spain
| | - Marta Pozuelo
- Fundació Hospital Universitari Vall d'Hebron-Institut de Recerca Barcelona Spain
| | - Maria Poca
- Department of Gastroenterology Hospital de la Santa Creu i Sant Pau Barcelona Spain.,CIBERehd Instituto de Salud Carlos III Madrid Spain
| | - Cándido Juárez
- Institut de Recerca IIB-Sant Pau Barcelona Spain.,Department of Immunology Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona Barcelona Spain
| | - Carlos Guarner
- Department of Gastroenterology Hospital de la Santa Creu i Sant Pau Barcelona Spain.,CIBERehd Instituto de Salud Carlos III Madrid Spain
| | - Chaysavanh Manichanh
- Fundació Hospital Universitari Vall d'Hebron-Institut de Recerca Barcelona Spain.,CIBERehd Instituto de Salud Carlos III Madrid Spain
| | - Germán Soriano
- Department of Gastroenterology Hospital de la Santa Creu i Sant Pau Barcelona Spain.,CIBERehd Instituto de Salud Carlos III Madrid Spain
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22
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Allampati SK, Mullen KD. Understanding the impact of neurologic complications in patients with cirrhosis. SAGE Open Med 2019; 7:2050312119832090. [PMID: 30834114 PMCID: PMC6396044 DOI: 10.1177/2050312119832090] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Accepted: 01/29/2019] [Indexed: 12/15/2022] Open
Abstract
Patients with cirrhosis may experience neurologic complications, including hepatic encephalopathy. Hepatic encephalopathy may be classified as covert (mild symptoms (e.g. lack of awareness)) or overt (moderate to severe symptoms (e.g. confusion or coma)), and symptoms may overlap with other neurologic conditions (e.g. epilepsy, stroke). Managing hepatic encephalopathy includes identifying and treating precipitating factors (e.g. dehydration). First-line treatment for patients with overt hepatic encephalopathy is typically lactulose; to reduce the risk of overt hepatic encephalopathy recurrence, lactulose plus the nonsystemic antibiotic rifaximin is recommended. Rifaximin reduced the risk of breakthrough overt hepatic encephalopathy by 58% versus placebo over 6 months (p < 0.001; 91% of patients in each group were on concomitant lactulose). However, neither pharmacologic hepatic encephalopathy treatment nor liver transplantation may completely reverse neurologic impairment in patients with hepatic encephalopathy. Additional neurologic considerations for patients with cirrhosis include preventing falls, as well as managing sleep-related issues, hyponatremia, and cerebral edema. Thus, monitoring neurologic impairment is an important component in the management of patients with cirrhosis.
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Affiliation(s)
- Sanath K Allampati
- Department of Internal Medicine, West Virginia University School of Medicine, Morgantown, WV, USA
| | - Kevin D Mullen
- Department of Internal Medicine, West Virginia University School of Medicine, Morgantown, WV, USA
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23
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Murphy SL, Tapper EB, Blackwood J, Richardson JK. Why Do Individuals with Cirrhosis Fall? A Mechanistic Model for Fall Assessment, Treatment, and Research. Dig Dis Sci 2019; 64:316-323. [PMID: 30327964 DOI: 10.1007/s10620-018-5333-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 10/09/2018] [Indexed: 12/12/2022]
Abstract
Falls are prevalent for people with cirrhosis and commonly lead to loss of independence, reduced quality of life, and mortality. Despite a critical need for fall prevention in this population, cirrhosis-specific fall-related mechanisms are not well understood. We posit that most falls in this patient population are due to a coalescence of discrete subclinical impairments that are not typically detected at the point of care. The combined effect of these subtle age- and disease-related neurocognitive and muscular impairments leads to the inability to respond successfully to a postural perturbation within the available 300 to 400 ms. This article provides a conceptual model of physiological resilience to avoid a fall that focuses on attributes that underlie the ability to withstand a postural perturbation and their clinical evaluation. Evidence supporting this model in cirrhosis and other high fall risk conditions will be synthesized and suggestions for fall assessment and treatment will be discussed.
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Affiliation(s)
- Susan L Murphy
- Department of Physical Medicine and Rehabilitation, University of Michigan, 24 Frank Lloyd Wright Drive, PO Box 344, Ann Arbor, MI, 48106, USA. .,Geriatric Research, Education and Clinical Center, Veterans Affairs Ann Arbor Health Care System, Ann Arbor, MI, USA.
| | - Elliot B Tapper
- Department of Internal Medicine, Division of Gasteroenterology, University of Michigan, Ann Arbor, MI, USA. .,Veterans Affairs Ann Arbor Health Care System, Ann Arbor, MI, USA.
| | - Jennifer Blackwood
- Department of Physical Therapy, University of Michigan - Flint Campus, Flint, MI, USA
| | - James K Richardson
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, MI, USA
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24
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Peng JK, Hepgul N, Higginson IJ, Gao W. Symptom prevalence and quality of life of patients with end-stage liver disease: A systematic review and meta-analysis. Palliat Med 2019; 33:24-36. [PMID: 30345878 PMCID: PMC6291907 DOI: 10.1177/0269216318807051] [Citation(s) in RCA: 128] [Impact Index Per Article: 25.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND: End-stage liver disease is a common cause of morbidity and mortality worldwide, yet little is known about its symptomatology and impact on health-related quality of life. AIM: To describe symptom prevalence and health-related quality of life of patients with end-stage liver disease to improve care. DESIGN: Systematic review. DATA SOURCES: We searched eight electronic databases from January 1980 to June 2018 for studies investigating symptom prevalence or health-related quality of life of adult patients with end-stage liver disease. No language restrictions were applied. Meta-analyses were performed where appropriate. RESULTS: We included 80 studies: 35 assessing symptom prevalence, 41 assessing health-related quality of life, and 4 both. The instruments assessing symptoms varied across studies. The most frequently reported symptoms were as follows: pain (prevalence range 30%–79%), breathlessness (20%–88%), muscle cramps (56%–68%), sleep disturbance (insomnia 26%–77%, daytime sleepiness 29.5%–71%), and psychological symptoms (depression 4.5%–64%, anxiety 14%–45%). Erectile dysfunction was prevalent (53%–93%) in men. The health-related quality of life of patients with end-stage liver disease was significantly impaired when compared to healthy controls or patients with chronic liver disease. Compared with compensated cirrhosis, decompensation led to significant worsening of both components of the 36-Item Short Form Survey although to a larger degree for the Physical Component Summary score (decrease from average 6.4 (95% confidence interval: 4.0–8.8); p < 0.001) than for the Mental Component Summary score (4.5 (95% confidence interval: 2.4–6.6); p < 0.001). CONCLUSION: The symptom prevalence of patients with end-stage liver disease resembled that of patients with other advanced conditions. Given the diversity of symptoms and significantly impaired health-related quality of life, multidisciplinary approach and timely intervention are crucial.
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Affiliation(s)
- Jen-Kuei Peng
- 1 Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King's College London, London, UK.,2 Department of Family Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan.,3 Department of Family Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Nilay Hepgul
- 1 Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King's College London, London, UK
| | - Irene J Higginson
- 1 Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King's College London, London, UK
| | - Wei Gao
- 1 Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King's College London, London, UK
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25
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Corona G, Norello D, Parenti G, Sforza A, Maggi M, Peri A. Hyponatremia, falls and bone fractures: A systematic review and meta-analysis. Clin Endocrinol (Oxf) 2018; 89:505-513. [PMID: 29920727 DOI: 10.1111/cen.13790] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Revised: 06/06/2018] [Accepted: 06/14/2018] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To perform a meta-analysis based on published studies that compared falls and bone fractures between patients with and without hyponatremia. CONTEXT There is evidence suggesting that hyponatremia is associated with an increased risk of falls and bone fractures. DESIGN An extensive Medline, Embase and Cochrane search was performed to retrieve all studies published up to, 30 April 2017, using the following words: "hyponatremia" or "hyponatraemia" AND "falls" and "bone fractures." A meta-analysis was performed including all studies comparing falls and bone fractures in subjects with or without hyponatremia. PATIENTS AND RESULTS Of 216 retrieved articles, 15 studies satisfied inclusion criteria encompassing a total of 51 879 patients, of whom 2329 were hyponatremic. Across all studies, hyponatremia was associated with a significantly increased risk of falls (MH-OR = 2.14[1.71; 2.67]. This result was confirmed when only hospitalized patients were considered (MH-OR = 2.44 [1.97; 3.02]). A meta-regression analysis showed that the hyponatremia-related risk of falls was higher in those studies considering a lower serum [Na+ ] cut-off to define hyponatremia. Interestingly, the estimated risk of falls related to hyponatremia was already significantly higher when a serum [Na+ ] cut-off of 135 mmol/L was considered (MH-OR = 1.26[1.23;1.29]). The presence of hyponatremia was also associated with a higher risk of fractures, particularly hip fractures (MH-OR = 2.00[1.43;2.81]). CONCLUSIONS This study confirms that hyponatremia is associated with an increased risk of falls and bone fractures. The clinical, social and economic relevance of such association is strengthened by the increased incidence of hyponatremia in older people.
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Affiliation(s)
- Giovanni Corona
- Endocrinology Unit, Maggiore-Bellaria Hospital, Bologna, Italy
| | - Dario Norello
- Endocrine Unit, Department of Experimental and Clinical Biomedical Sciences "Mario Serio", "Center for Research, Transfer and High Education on Chronic, Inflammatory, Degenerative and Neoplastic Disorders for the Development of Novel Therapies" (DENOThe), University of Florence, Florence, Italy
| | | | | | - Mario Maggi
- Sexual Medicine and Andrology Unit, Department of Experimental and Clinical Biomedical Sciences "Mario Serio", "Center for Research, Transfer and High Education on Chronic, Inflammatory, Degenerative and Neoplastic Disorders for the Development of Novel Therapies" (DENOThe), University of Florence, Florence, Italy
| | - Alessandro Peri
- Endocrine Unit, Department of Experimental and Clinical Biomedical Sciences "Mario Serio", "Center for Research, Transfer and High Education on Chronic, Inflammatory, Degenerative and Neoplastic Disorders for the Development of Novel Therapies" (DENOThe), University of Florence, Florence, Italy
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26
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Rudler M, Weiss N, Perlbarg V, Mallet M, Tripon S, Valabregue R, Marjańska M, Cluzel P, Galanaud D, Thabut D. Combined diffusion tensor imaging and magnetic resonance spectroscopy to predict neurological outcome before transjugular intrahepatic portosystemic shunt. Aliment Pharmacol Ther 2018; 48:863-874. [PMID: 30178870 DOI: 10.1111/apt.14938] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 05/14/2018] [Accepted: 07/18/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Hepatic encephalopathy (HE) may occur after transjugular intrahepatic portosystemic shunt (TIPSS) placement. Multimodal magnetic resonance imaging (MRI), combining anatomical sequences, diffusion tensor imaging (DTI) and 1 H magnetic resonance spectroscopy, is modified in cirrhotic patients. AIMS To describe multimodal MRI images before TIPSS, to assess if TIPSS induces changes in multimodal MRI, and to find predictors of HE after TIPSS in patients with cirrhosis. METHODS Consecutive cirrhotic patients with an indication for TIPSS were prospectively screened. Diagnosis of minimal HE was performed using psychometric HE test score. Multimodal MRI was performed before and 3 months after TIPSS placement. RESULTS Twenty-five consecutive patients were analysed (median age = 59, male gender 76%, median Child-Pugh score = 8 [5-8], MELD score = 12 [9-17], indication for TIPSS placement: ascites/secondary prophylaxis of variceal bleeding/other 20/3/2), no HE/minimal HE/overt HE: 21/4/0. 8/25 patients developed HE after TIPSS. Before TIPSS placement, metabolite concentrations were different in patients with or without minimal HE (lower myo-inositol, mI, higher glutamate/glutamine), but there were no differences in DTI data. TIPSS placement induced changes in metabolite concentrations even in asymptomatic patients, but not in DTI metrics. Baseline fractional anisotropy was significantly lower in patients who developed HE after TIPSS in five regions of interest. CONCLUSIONS TIPSS placement induced significant changes in cerebral metabolites, even in asymptomatic patients. Patients who developed HE after TIPSS displayed lower fractional anisotropy before TIPSS. Brain MRI with DTI acquisition may help selecting patients at risk of HE.
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Affiliation(s)
- Marika Rudler
- Brain-Liver Pitié-Salpêtrière Study Group (BLIPS), Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Paris, France.,Intensive Care Unit, Hepatology Department, Pitié-Salpêtrière Charles Foix Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Nicolas Weiss
- Brain-Liver Pitié-Salpêtrière Study Group (BLIPS), Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Paris, France.,Intensive Care Unit, Department of Neurology, Pitié-Salpêtrière Charles Foix Hospital, Assistance Publique-Hôpitaux de Paris, Sorbonne University, Pierre et Marie Curie University, Paris, France
| | - Vincent Perlbarg
- Bioinformatics and Biostatistics Platform, IHU-A-ICM, Brain and Spine Institute, Paris, France
| | - Maxime Mallet
- Brain-Liver Pitié-Salpêtrière Study Group (BLIPS), Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Paris, France.,Intensive Care Unit, Department of Neurology, Pitié-Salpêtrière Charles Foix Hospital, Assistance Publique-Hôpitaux de Paris, Sorbonne University, Pierre et Marie Curie University, Paris, France
| | - Simona Tripon
- Brain-Liver Pitié-Salpêtrière Study Group (BLIPS), Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Paris, France.,Intensive Care Unit, Department of Neurology, Pitié-Salpêtrière Charles Foix Hospital, Assistance Publique-Hôpitaux de Paris, Sorbonne University, Pierre et Marie Curie University, Paris, France
| | - Romain Valabregue
- CENIR, ICM, Inserm U 1127, CNRS, UMR 7225, Sorbonne University, Pierre et Marie Curie University, UMR S 1127F, Paris, France
| | - Małgorzata Marjańska
- Center for Magnetic Resonance Research and Department of Radiology, University of Minnesota, Minneapolis, Minnesota
| | - Philippe Cluzel
- AP-HP, UPMC, Department of Radiology, La Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris, Pierre et Marie Curie University, Paris, France
| | - Damien Galanaud
- Brain-Liver Pitié-Salpêtrière Study Group (BLIPS), Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Paris, France.,AP-HP, UPMC, Department of Radiology, La Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris, Pierre et Marie Curie University, Paris, France.,Institut-Hospitalo-Universitaire-A-Institut du Cerveau et de la Moelle (IHU-A-ICM), Paris, France
| | - Dominique Thabut
- Brain-Liver Pitié-Salpêtrière Study Group (BLIPS), Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Paris, France.,Intensive Care Unit, Hepatology Department, Pitié-Salpêtrière Charles Foix Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
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27
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Primary Prophylaxis to Prevent the Development of Hepatic Encephalopathy in Cirrhotic Patients with Acute Variceal Bleeding. Can J Gastroenterol Hepatol 2018; 2018:3015891. [PMID: 30079329 PMCID: PMC6069577 DOI: 10.1155/2018/3015891] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Revised: 05/25/2018] [Accepted: 05/31/2018] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND AND AIM Variceal bleeding is the second most important precipitating factor related to the development of episodic hepatic encephalopathy; but to date there are no recommendations to prevent this complication. The aim of this study was to compare if primary prophylaxis with lactulose or L-ornithine L-aspartate or rifaximin, in cirrhotic patients with variceal bleeding, is better than placebo for avoiding the development of hepatic encephalopathy. METHODS A randomized, double-blind, placebo-controlled clinical trial (ClinicalTrials.gov identifier: NCT02158182) which included cirrhotic patients with variceal bleeding, without minimal or clinical hepatic encephalopathy at admission. FINDINGS 87 patients were randomized to one of four groups. The basal characteristics were similar between groups. Comparatively with placebo, the frequency with regard to the development of hepatic encephalopathy was as follows: lactulose (54.5% versus 27.3%; OR = 0.3, 95% CI 0.09-1.0; P = 0.06); L-ornithine L-aspartate (54.5% versus 22.7%, OR = 0.2, 95% CI 0.06-0.88; P = 0.03); rifaximin (54.5% versus 23.8%; OR = 0.3, 95% CI 0.07-0.9; P = 0.04). There was no significant difference between the three groups receiving any antiammonium drug (P = 0.94). In the group receiving lactulose, 59.1% had diarrhea, and 45.5% had abdominal discomfort, bloating, and flatulence. Two patients (10%) treated with lactulose and a patient (4.5%) in the placebo group developed spontaneous bacterial peritonitis due to E. coli; one of them died due to recurrent variceal bleeding. There were no other adverse effects. CONCLUSIONS Antiammonium drugs, particularly L-ornithine L-aspartate and rifaximin, proved to be effective in preventing the development of hepatic encephalopathy in those cirrhotic patients with variceal bleeding.
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Tapper EB, Kanwal F, Asrani SK, Ho C, Ovchinsky N, Poterucha J, Flores A, Smith JE, Ankoma-Sey V, Luxon B, Volk ML. Patient-reported outcomes in cirrhosis: A scoping review of the literature. Hepatology 2018; 67:2375-2383. [PMID: 29272043 DOI: 10.1002/hep.29756] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Revised: 11/27/2017] [Accepted: 12/18/2017] [Indexed: 01/05/2023]
Abstract
UNLABELLED Patients with cirrhosis seek improvement in their symptoms, functioning, quality of life, and satisfaction with the care they receive. However, these patient-reported outcomes (PROs) are not routinely measured for clinical care, research, or quality improvement. The members of the American Association for the Study of Liver Diseases Practice Metrics Committee, charged with developing quality indicators for clinical practice, performed a scoping review of PROs in cirrhosis. The aim is to synthesize a comprehensive set of PROs for inclusion into a standard patient-centered outcome set. We searched Medline, Embase, the Cumulative Index to Nursing and Allied Health Literature, PsycINFO, and the Cochrane Trial Library since inception, with final searches run between April 20 and June 1, 2017. Studies were included if they reported the construction and/or validation of a PRO instrument for patients with cirrhosis or if they assessed the clinical (case-mix) variables determining responses to established PRO scales. Eleven studies were selected that yielded 259 items specific to patients with cirrhosis. After removing duplicates, 152 unique items were isolated. These items were consolidated into seven domains: physical symptoms, physical function, mental health, general function, cognition, social life, and satisfaction with care. The seven domains included 52 subdomains (e.g., physical domain, abdominal pain subdomain). Twelve variables were identified that independently modified established PRO scales. These included clinical factors (severity of liver disease and its complications, medication burden, and comorbidities), specific PROs (cramps, pruritis), and surrogate outcome measures (falls, hospitalization). CONCLUSION This scoping review identified and categorized a large existing set of PRO concepts that matter to patients with cirrhosis; these outcomes may now be translated into usable measures both for the assessment of the quality of cirrhosis care in clinical practice and to perform research from the patient's perspective. (Hepatology 2018;67:2375-2383).
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Affiliation(s)
- Elliot B Tapper
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI
| | - Fasiha Kanwal
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, TX.,Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX.,Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Sumeet K Asrani
- Division of Hepatology, Baylor University Medical Center, Dallas, TX
| | - Chanda Ho
- Division of Gastroenterology, California Pacific Medical Center, San Francisco, CA
| | - Nadia Ovchinsky
- Division of Pediatric Gastroenterology, Children's Hospital at Montefiore, Bronx, NY
| | - John Poterucha
- Division of Gastroenterology, Mayo School of Medicine, Rochester, MN
| | - Avegail Flores
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, MO
| | - Judith E Smith
- Taubman Health Sciences Library, University of Michigan, Ann Arbor, MI
| | | | - Bruce Luxon
- Department of Medicine, Georgetown University, Washington, DC
| | - Michael L Volk
- Division of Gastroenterology and Transplantation Institute, Loma Linda University, Loma Linda, CA
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29
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Polis S, Fernandez R. Impact of physical and psychological factors on health-related quality of life in adult patients with liver cirrhosis: a systematic review protocol. ACTA ACUST UNITED AC 2018; 13:39-51. [PMID: 26447006 DOI: 10.11124/jbisrir-2015-1987] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
REVIEW QUESTION/OBJECTIVE What is the impact of physical and psychological factors on health-related quality of life in adult patients diagnosed with liver cirrhosis? BACKGROUND All chronic liver diseases stimulate a degree of repetitive hepatocyte injury that alters the normal liver architecture and ends in cirrhosis.Liver cirrhosis and hepatocellular carcinoma secondary to livercirrhosis are a major public health burden, reporting increasing mortality and morbidity both in Australia and globally.The four leading causes of cirrhosis include harmful alcohol consumption, viral hepatitis B and C and metabolic syndromes related to non-alcoholic fatty liver disease and obesity.A cirrhotic liver is characterized by the presence of regenerative nodules surrounded by fibrous bands that inhibit the passing of molecules between blood and functional units of liver hepatocytes, leading to liver dysfunction.Additionally, the presence of fibrous bands disrupts the normal vascular architecture, increasing resistance within the liver sinusoids and contributing to increased portal vein pressure.The early stages of cirrhosis are referred to as compensated liver disease with no reported symptoms or evidence of impaired liver function.However, the signs and symptoms of liver failure, as well as the mortality rate, increase as the severity of cirrhosis increases.Transition from compensated to decompensated cirrhosis is marked by one or more physiological changes. The physiological changes include increased portal vein pressure, impaired synthetic function, electrolyte imbalance and malnourishment.These physiological changes trigger the development of physical signs and symptoms and impact on the psychological wellbeing of the individual living with cirrhosis. The physical signs and symptoms include esophageal varices, ascites, hepatic encephalopathy, jaundice, irregular sleep patterns, muscle cramps, pruritus, fatigue, impaired mobility, breathlessness, abdominal discomfort, gastrointestinal symptoms, change of body image and pitting edema.Psychological symptoms include stress, depression and anxiety.Living with liver cirrhosis has a marked impact on the quality of life of the individual. Health-related quality of life (HRQOL) is the individual's perception of their physical, cognitive, emotional and social functioning.Studies report that physical and psychological factors affect the quality of life of patients with cirrhosis which can be problematic and debilitating.There is strong evidence which indicates that disease severity is associated with an impairment of the patient's HRQOL.For example, gross ascites causes abdominal discomfort, breathlessness, increased stress and anxiety related to body image, immobility and an increased likelihood of falls. In addition, the management of ascites involves frequent invasive procedures, an increase in pill burden and implementation of dietary restrictions, all of which impact on HRQOL.Despite the clear relationship between HRQOL and severity of disease, there has been no systematic review undertaken to determine the physical, psychological and physiological factors that affect the HRQOL of patients with liver cirrhosis. This systematic review will therefore identify the best available evidence related to the impact of physical, psychological and physiological factors on the health-related quality of life of adult patients with liver cirrhosis. The results of the review will increase clinicians' knowledge and highlight areas of clinical management that may require additional strategies and treatment plans to improve symptom relief and HRQOL.
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Affiliation(s)
- Suzanne Polis
- 1 St George Hospital, Kogarah, Sydney, New South Wales2 Center for Evidence based Initiatives in Health Care: an Affiliate Center of the Joanna Briggs Institute3 School of Nursing and Midwifery, University of Wollongong, New South Wales
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30
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Trivedi HD, Tapper EB. Interventions to improve physical function and prevent adverse events in cirrhosis. Gastroenterol Rep (Oxf) 2018; 6:13-20. [PMID: 29479438 PMCID: PMC5806401 DOI: 10.1093/gastro/gox042] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Revised: 11/26/2017] [Accepted: 12/01/2017] [Indexed: 12/12/2022] Open
Abstract
Cirrhosis is associated with debilitating complications that significantly impact on a patient’s physical function and reduce quality of life. Owing to highly prevalent sarcopenia, malnutrition and hepatic encephalopathy, functional impairment or frailty is a common complication of cirrhosis. Frailty in turn increases the patient’s risk of hospitalization, accidental falls and fractures, and death. The management of frailty and its associated adverse effects is imperative in improving the overall prognosis of patients with advanced liver disease. The cornerstone of therapy revolves around optimizing physical function with appropriate nutrition and exercise. Nutritional therapy with protein supplementation has shown significant benefit, while studies on exercise have been controversial. However, newly emerging studies trend towards a beneficial effect of physical exercise with improvement in quality of life. The implementation of technology in liver disease management shows future promise. Fitbits and other wearable devices can be used to help monitor a patient’s personal progress in physical exercise and nutritional optimization. Additionally, the progressive development of new smartphone applications to help aid in the diagnosis and monitoring of complications of cirrhosis provides a sophisticated avenue for improving care of patients with cirrhosis.
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Affiliation(s)
- Hirsh D Trivedi
- Liver Center, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Elliot B Tapper
- Department of Hepatology, University of Michigan, Ann Arbor, MI, USA
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Ventura-Cots M, Carmona I, Moreno C, Ampuero J, Simón-Talero M, Sanpedro F, Les I, Romero-Gómez M, Genescà J. Duration of the acute hepatic encephalopathy episode determines survival in cirrhotic patients. Therap Adv Gastroenterol 2017; 11:1756283X17743419. [PMID: 29383024 PMCID: PMC5784576 DOI: 10.1177/1756283x17743419] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Accepted: 10/16/2017] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Episodes of hepatic encephalopathy (HE) have been related to low survival rate. However, the relation between its clinical evolution and mortality has not been assessed. METHODS A retrospective analysis of 245 cirrhotic patients admitted for an acute episode of HE (⩾grade 2) or who developed an HE episode after an upper gastrointestinal bleeding (UGIB) event was performed to assess the relation between time in HE and transplant-free survival. RESULTS Median (IQR25-75) time in HE was 48 h (24-96 h) in the whole cohort. Patients who presented a longer time in HE (>48 h; n = 89) exhibited a lower transplant-free survival at 28 days (67.2% versus 88.9%, p < 0.001), 90 days (48.7% versus 73.8%, p < 0.001) and 365 days (30.3% versus 53.2%, p < 0.001), as compared to those with less time in HE (⩽48 h; n = 156). Survival rates remained significantly different, with lower percentages in the group with time in HE >48 h, when comparing patients according to baseline HE grade (2 versus ⩾3) or model for end-stage liver disease (MELD) function (⩽15 versus >15). Time in HE was also an independent risk factor for mortality at each time point, hazard ratio (HR) (95 CI%) 28 days 2.59 (1.39-4.84); 90 days 1.98 (1.28-3.1) and 365 days 1.5 (1.08-2.19). CONCLUSIONS The duration of the acute HE episode determines survival in cirrhotic patients independently of liver function and baseline HE grade.
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Affiliation(s)
- Meritxell Ventura-Cots
- Liver Unit, Department of Internal Medicine, Hospital Universitari Vall d’Hebron, Vall d’Hebron Institut de Recerca (VHIR), Universitat Autònoma de Barcelona, Barcelona, Spain Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid
| | - Isabel Carmona
- UCM Intercentres Digestive Diseases, Virgen Macarena University Hospital, Sevilla
| | - Carolina Moreno
- UCM Intercentres Digestive Diseases, Virgen Macarena University Hospital, Sevilla
| | - Javier Ampuero
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid UCM Intercentres Digestive Diseases, Virgen del Rocío University Hospital and Institute of Biomedicine of Seville, Sevilla
| | - Macarena Simón-Talero
- Liver Unit, Department of Internal Medicine, Hospital Universitari Vall d’Hebron, Vall d’Hebron Institut de Recerca (VHIR), Universitat Autònoma de Barcelona, Barcelona, Spain Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid
| | - Francesc Sanpedro
- Emergency Department, Hospital Universitari Vall d’Hebron, Universitat Autònoma de Barcelona, Barcelona
| | - Iñigo Les
- Department of Internal Medicine, BioAraba Health Research Institute, Hospital Universitario Araba, Vitoria
| | - Manuel Romero-Gómez
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid; UCM Intercentres Digestive Diseases, Virgen Macarena University Hospital, Sevilla UCM Intercentres Digestive Diseases, Virgen del Rocío University Hospital and Institute of Biomedicine of Seville, Sevilla
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Chen TL, Lin CS, Shih CC, Huang YF, Yeh CC, Wu CH, Cherng YG, Liao CC. Risk and adverse outcomes of fractures in patients with liver cirrhosis: two nationwide retrospective cohort studies. BMJ Open 2017; 7:e017342. [PMID: 28993387 PMCID: PMC5640047 DOI: 10.1136/bmjopen-2017-017342] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE The aim of this study is to evaluate fracture risk and post-fracture outcomes in patients with and without liver cirrhosis (LC). DESIGN Retrospective cohort study and nested fracture cohort study. SETTING This study was based on Taiwan's National Health Insurance Research Database that included information on: (1) 3941 patients aged 20 years and older newly diagnosed with LC between 2000 and 2003; (2) 688290 hospitalised fracture patients aged 20 years and older between 2006 and 2013. PRIMARY AND SECONDARY OUTCOME MEASURES Followed-up events of fracture from 2000 to 2008 were noted from medical claims to evaluate adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) of fracture associated with LC. Adjusted odds ratios (ORs) and 95% CIs of adverse events after fracture were compared among patients with and without LC RESULTS: The incidences of fracture for people with and without LC were 29.1 and 17.2 per 1000 person-years, respectively. Compared with controls, the adjusted HR of fracture was 1.83 (95% CI 1.67 to 2.01) for patients with LC. Previous LC was associated with risks of septicaemia (OR 1.77, 95% CI 1.60 to 1.96), acute renal failure (OR 1.63, 95% CI 1.33 to 1.99), and 30-day in-hospital mortality (OR 1.61, 95 %CI 1.37 to 1.89) after fracture. CONCLUSION LC was associated with higher risk of fracture; patients with LC in particular had more complications and 30-day in-hospital mortality after fracture. Fracture prevention and attention to post-fracture adverse events are needed for these susceptible populations.
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Affiliation(s)
- Ta-Liang Chen
- Department of Anesthesiology, Taipei Medical University Hospital, Taipei, Taiwan
- Anesthesiology and Health Policy Research Center, Taipei Medical University Hospital, Taipei, Taiwan
- Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Chao-Shun Lin
- Department of Anesthesiology, Taipei Medical University Hospital, Taipei, Taiwan
- Anesthesiology and Health Policy Research Center, Taipei Medical University Hospital, Taipei, Taiwan
- Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Chun-Chuan Shih
- The School of Chinese Medicine for Post-Baccalaureate, I-Shou University, Kaohsiung, Taiwan
- Ph.D. Program for Clinical Drug Discovery from Botanical Herbs, Taipei Medical University, Taipei, Taiwan
| | - Yu-Feng Huang
- Department of Anesthesiology, Taitung Mackay Memorial Hospital, Taitung, Taiwan
| | - Chun-Chieh Yeh
- Department of Surgery, China Medical University Hospital, Taichung, Taiwan
- Department of Surgery, University of Illinois, Chicago, Illinois, USA
| | - Chih-Hsing Wu
- Department of Family Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Yih-Giun Cherng
- Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Department of Anesthesiology, Shuan Ho Hospital, Taipei Medical University, Taipei, Taiwan
| | - Chien-Chang Liao
- Department of Anesthesiology, Taipei Medical University Hospital, Taipei, Taiwan
- Anesthesiology and Health Policy Research Center, Taipei Medical University Hospital, Taipei, Taiwan
- Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Department of Anesthesiology, Shuan Ho Hospital, Taipei Medical University, Taipei, Taiwan
- School of Chinese Medicine, College of Chinese Medicine, China Medical University, Taichung, Taiwan
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Daigre C, Grau-López L, Rodríguez-Cintas L, Ros-Cucurull E, Sorribes-Puertas M, Esculies O, Bones-Rocha K, Roncero C. The role of dual diagnosis in health-related quality of life among treatment-seeking patients in Spain. Qual Life Res 2017; 26:3201-3209. [PMID: 28786018 DOI: 10.1007/s11136-017-1668-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/26/2017] [Indexed: 01/22/2023]
Abstract
PURPOSE The comorbidity of any substance use disorder and another mental disorder is defined as dual diagnosis. Dual diagnosis is very common and clinical and therapeutic consequences have been described. This cross-sectional study aimed to analyse health-related quality of life (HRQoL) according to clinical characteristics and psychiatric comorbidities in patients with substance dependence. METHODS A total of 1276 substance-dependent patients seeking treatment were recruited. HRQoL was evaluated by the Short-Form 36 (SF-36) questionnaire. The SCID-I, SCID-II and Conners' adult ADHD diagnostic interview were used to evaluate dual diagnosis. A visual analogue scale was used to measure craving. Bivariate and multivariate analyses were performed, and correction for multiple tests was conducted. RESULTS Substance-dependent patients had impaired quality of life, especially in the mental component. SF-36 physical and mental component scores were 47.7 ± 10.9 and 36.1 ± 14.1, respectively. Furthermore, 65% of the patients had dual diagnosis, 51% had an Axis I DSM-IV-TR mental disorder and 35% had some personality disorder. Impaired physical quality of life was independently associated with medical condition, age, being female, depressive disorder and anxiety disorder. Depression disorder, any personality disorder, active consumption last month, Attention deficit hyperactivity disorder, anxiety disorder, suicide attempt were independently associated with worse mental quality of life. CONCLUSION These findings emphasize the significance of dual diagnosis in the impairment of HRQoL in substance-dependent patients, particularly with regard to mental component. In addicted patients with low scores on SF-36, psychiatric comorbidity should be evaluated and treated in an integrated approach.
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Affiliation(s)
- Constanza Daigre
- Addiction and Dual Diagnosis Unit, Psychiatry Deparment, Vall d' Hebron University Hospital, Universitat Autònoma de Barcelona, Agencia de Salud Pública de Barcelona, CIBERSAM, Barcelona, Spain.
| | - Lara Grau-López
- Addiction and Dual Diagnosis Unit, Psychiatry Deparment, Vall d' Hebron University Hospital, Universitat Autònoma de Barcelona, Agencia de Salud Pública de Barcelona, CIBERSAM, Barcelona, Spain
| | - Laia Rodríguez-Cintas
- Addiction and Dual Diagnosis Unit, Psychiatry Deparment, Vall d' Hebron University Hospital, Universitat Autònoma de Barcelona, Agencia de Salud Pública de Barcelona, CIBERSAM, Barcelona, Spain
| | - Elena Ros-Cucurull
- Addiction and Dual Diagnosis Unit, Psychiatry Deparment, Vall d' Hebron University Hospital, Universitat Autònoma de Barcelona, Agencia de Salud Pública de Barcelona, CIBERSAM, Barcelona, Spain
| | - Marta Sorribes-Puertas
- Addiction and Dual Diagnosis Unit, Psychiatry Deparment, Vall d' Hebron University Hospital, Universitat Autònoma de Barcelona, Agencia de Salud Pública de Barcelona, CIBERSAM, Barcelona, Spain
| | | | - Katia Bones-Rocha
- Faculty of Psychology, Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, Brazil
| | - Carlos Roncero
- Addiction and Dual Diagnosis Unit, Psychiatry Deparment, Vall d' Hebron University Hospital, Universitat Autònoma de Barcelona, Agencia de Salud Pública de Barcelona, CIBERSAM, Barcelona, Spain
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Feltracco P, Cagnin A, Carollo C, Barbieri S, Ori C. Neurological disorders in liver transplant candidates: Pathophysiology and clinical assessment. Transplant Rev (Orlando) 2017; 31:193-206. [DOI: 10.1016/j.trre.2017.02.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2016] [Revised: 12/29/2016] [Accepted: 02/20/2017] [Indexed: 12/14/2022]
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Urios A, Mangas-Losada A, Gimenez-Garzó C, González-López O, Giner-Durán R, Serra MA, Noe E, Felipo V, Montoliu C. Altered postural control and stability in cirrhotic patients with minimal hepatic encephalopathy correlate with cognitive deficits. Liver Int 2017; 37:1013-1022. [PMID: 27988985 DOI: 10.1111/liv.13345] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Accepted: 12/07/2016] [Indexed: 02/13/2023]
Abstract
BACKGROUND & AIMS Cognitive dysfunction in cirrhotic patients with minimal hepatic encephalopathy (MHE) is associated with falls. Alterations in postural control and stability could contribute to increase falls risk in these patients. We aimed to assess whether postural control and direction-specific limits of stability are altered in cirrhotic patients with MHE compared to patients without MHE and controls. We also assessed if alterations in postural control correlate with neurological impairment and/or blood biomarkers. METHODS Posturography analysis, attention Stroop test and bimanual and visuo-motor coordination tests were performed in 18 controls, 19 patients with cirrhosis without MHE and 17 with MHE, diagnosed by PHES. Posturography was assessed by NedSVE® /IBV system under four sensory conditions. Limits of stability and rhythmic weight-shifting tests were also performed. Blood ammonia and serum interleukins were also measured. Falls were assessed after 12-24 months follow-up. RESULTS MHE patients show impaired balance, mainly on unstable surface with eyes open, with longer reaction and confinement times and lower success in Limits of Stability test compared to patients without MHE. Performance in attention and motor coordination tests correlated with most posturography parameters alterations. Logistic regression analysis shows that posturography parameters and bimanual coordination test are good predictors of falls. CONCLUSION Balance patterns and limits of stability in MHE patients are impaired compared to patients without MHE and controls. This seems to contribute to a higher falls risk. Attention and motor coordination deficits could contribute to balance impairment in patients with MHE.
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Affiliation(s)
- Amparo Urios
- Instituto de Investigación Sanitaria-INCLIVA, Valencia, Spain.,Laboratory of Neurobiology, Centro Investigación Príncipe Felipe de Valencia, Valencia, Spain
| | | | - Carla Gimenez-Garzó
- Instituto de Investigación Sanitaria-INCLIVA, Valencia, Spain.,Laboratory of Neurobiology, Centro Investigación Príncipe Felipe de Valencia, Valencia, Spain
| | | | | | - Miguel A Serra
- Unidad de Digestivo, Hospital Clínico de Valencia, Departamento Medicina, Universidad de Valencia, Valencia, Spain
| | - Enrique Noe
- Servicio de Daño, Cerebral del Hospital Valencia al Mar, Valencia, Spain
| | - Vicente Felipo
- Laboratory of Neurobiology, Centro Investigación Príncipe Felipe de Valencia, Valencia, Spain
| | - Carmina Montoliu
- Instituto de Investigación Sanitaria-INCLIVA, Valencia, Spain.,Departamento de Patología, Facultad de Medicina, Universidad de Valencia, Valencia, Spain
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Fritsch MA, Shelton PS. Geriatric Polypharmacy: Pharmacist as Key Facilitator in Assessing for Falls Risk. Clin Geriatr Med 2017; 33:205-223. [PMID: 28364992 DOI: 10.1016/j.cger.2017.01.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
This article highlights the significant health impact of falls among older adults. An emphasis is placed on the vital role of the pharmacist, regardless of practice setting, in assessing and reducing falls risk for this growing population. In addition, the importance of a stepwise comprehensive approach to falls assessment by pharmacists in collaboration with other clinicians is elucidated.
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Affiliation(s)
| | - Penny S Shelton
- North Carolina Association of Pharmacists, 1101 Slater Road, Suite 110, Durham, NC 27703, USA
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Abstract
Liver cirrhosis is a public health problem and hepatic encephalopathy is one of its main complications, which can be either overt meaning thereby evident and readily diagnosed, or covert/minimal (covert hepatic encephalopathy-CHE) needing psychometric testing for diagnosis. Patients with CHE hepatic encephalopathy have deficits in multiple domains including visuospatial assessment, attention, response inhibition, working memory, along with psychomotor speed to name a few areas. These patients have poor navigational skills, get fatigued easily, and demonstrate poor insight into their driving deficits. The combination of all these leads them to have poor driving skills leading to traffic violations and crashes as demonstrated not only on the simulation testing but also in real-life driving events. There are multiple psychometric tests for CHE testing but these are not easily available and there is no uniform consensus on the gold standard testing as of yet. It does not automatically connote that all patients who test positive on driving simulation testing are unfit to drive. The physicians are encouraged to take driving history from the patient and the caregivers on every encounter and focus their counseling efforts more on patients with recent history of traffic crashes, with abnormal simulation studies and history of alcohol cessation within last year. As physicians are not trained to determine fitness to drive, their approach toward CHE patients in regards to driving restrictions should be driven by ethical principles while as respecting the local laws.
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Affiliation(s)
- Jawaid Shaw
- Department of Medicine, McGuire VA Medical Center, Richmond, Virginia, 23249. Tel: 804-675-5000 Ext 3535; Fax: 804-675-6473
| | - Jasmohan S Bajaj
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, Virginia
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Abstract
Health-related quality of life (HRQOL) has become an important outcome for patients with liver cirrhosis as the number of transplantation candidates increases by the progression of treatment strategies. Falls and fall-related injuries are common in patients with liver cirrhosis and negatively affect HRQOL. Many factors increase the risk for falls such as minimal hepatic encephalopathy, psychoactive drugs, muscle strength, autonomic dysfunction, hyponatremia, and sleep problems. It is important to understand the underlying mechanisms for falls in cirrhotic patients to prevent severe injuries such as fractures, decrease healthcare costs, and improve HRQOL. Healthcare professionals, including physiotherapists and nurses, should be aware of the higher risk for falls in this population and therapeutic interventions must be designed for patients, especially those waiting on the transplant list.
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Badea MA, Drug VL, Dranga M, Gavrilescu O, Stefanescu G, Popa I, Mihai C, Cijevschi-Prelipcean C. Diagnosis of minimal hepatic encephalopathy in a tertiary care center from eastern Romania: validation of the psychometric hepatic encephalopathy score (PHES). Metab Brain Dis 2016; 31:1463-1471. [PMID: 27461111 DOI: 10.1007/s11011-016-9878-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Accepted: 07/19/2016] [Indexed: 12/11/2022]
Abstract
The psychometric hepatic encephalopathy score (PHES) is frequently used as a "gold standard" for the diagnosis of minimal hepatic encephalopathy (MHE). In Romania, there are currently no widely available tests for the detection of MHE. In this study we aimed to standardize the PHES in a healthy Romanian population and to estimate the prevalence of MHE in a group of Romanian patients with liver cirrhosis. A total of 260 healthy volunteers and 106 patients with liver cirrhosis were included in the study. The five neuropsychological tests comprising the PHES were administered to all enroled subjects. Blood samples for routine tests and serum ammonia were collected. In the healthy volunteer group age and education years were found to be predictors of all tests and gender only in two tests: digit symbol test and serial dotting test. The PHES of the healthy volunteer group was 0,43 ± 1,37 and the cut-off between normal and pathological values was set at -3 points. In the liver cirrhosis group the mean PHES was -2,44 ± 3,41, significantly lower than in the control group (p = 0,001). The estimated prevalence of MHE was 34,7 % (37 patients). In patients with cirrhosis there was a significant correlation between PHES and the severity of the liver disease according to Child-Pugh classification (r = 0,529, p = 0,001) and MELD score (r = -0,525, p = 0,001). According to our results, accurate Romanian PHES norms for the diagnosis of MHE have been developed. MHE was diagnosed in a significant proportion of Romanian patients with liver cirrhosis.
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Affiliation(s)
- Mircea Alexandru Badea
- Department of Gastroenterology, University of Medicine and Pharmacy "Grigore T. Popa" Iasi, Strada Universitatii, Nr. 16, code, 700115, Iasi, Romania.
- Institute of Gastroenterology and Hepatology, Iasi, Romania.
| | - Vasile Liviu Drug
- Department of Gastroenterology, University of Medicine and Pharmacy "Grigore T. Popa" Iasi, Strada Universitatii, Nr. 16, code, 700115, Iasi, Romania
- Institute of Gastroenterology and Hepatology, Iasi, Romania
| | - Mihaela Dranga
- Department of Gastroenterology, University of Medicine and Pharmacy "Grigore T. Popa" Iasi, Strada Universitatii, Nr. 16, code, 700115, Iasi, Romania
- Institute of Gastroenterology and Hepatology, Iasi, Romania
| | - Otilia Gavrilescu
- Department of Gastroenterology, University of Medicine and Pharmacy "Grigore T. Popa" Iasi, Strada Universitatii, Nr. 16, code, 700115, Iasi, Romania
- Institute of Gastroenterology and Hepatology, Iasi, Romania
| | - Gabriela Stefanescu
- Department of Gastroenterology, University of Medicine and Pharmacy "Grigore T. Popa" Iasi, Strada Universitatii, Nr. 16, code, 700115, Iasi, Romania
- Institute of Gastroenterology and Hepatology, Iasi, Romania
| | - Iolanda Popa
- Department of Gastroenterology, University of Medicine and Pharmacy "Grigore T. Popa" Iasi, Strada Universitatii, Nr. 16, code, 700115, Iasi, Romania
- Institute of Gastroenterology and Hepatology, Iasi, Romania
| | - Catalina Mihai
- Department of Gastroenterology, University of Medicine and Pharmacy "Grigore T. Popa" Iasi, Strada Universitatii, Nr. 16, code, 700115, Iasi, Romania
- Institute of Gastroenterology and Hepatology, Iasi, Romania
| | - Cristina Cijevschi-Prelipcean
- Department of Gastroenterology, University of Medicine and Pharmacy "Grigore T. Popa" Iasi, Strada Universitatii, Nr. 16, code, 700115, Iasi, Romania
- Institute of Gastroenterology and Hepatology, Iasi, Romania
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Hyponatremia in patients with liver diseases: not just a cirrhosis-induced hemodynamic compromise. Hepatol Int 2016; 10:762-72. [DOI: 10.1007/s12072-016-9746-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Accepted: 05/27/2016] [Indexed: 12/19/2022]
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Román E, García-Galcerán C, Torrades T, Herrera S, Marín A, Doñate M, Alvarado-Tapias E, Malouf J, Nácher L, Serra-Grima R, Guarner C, Cordoba J, Soriano G. Effects of an Exercise Programme on Functional Capacity, Body Composition and Risk of Falls in Patients with Cirrhosis: A Randomized Clinical Trial. PLoS One 2016; 11:e0151652. [PMID: 27011355 PMCID: PMC4807034 DOI: 10.1371/journal.pone.0151652] [Citation(s) in RCA: 104] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Accepted: 03/02/2016] [Indexed: 12/12/2022] Open
Abstract
UNLABELLED Patients with cirrhosis often have functional limitations, decreased muscle mass, and a high risk of falls. These variables could improve with exercise. The aim was to study the effects of moderate exercise on functional capacity, body composition and risk of falls in patients with cirrhosis. Twenty-three cirrhotic patients were randomized to an exercise programme (n = 14) or to a relaxation programme (n = 9). Both programmes consisted of a one-hour session 3 days a week for 12 weeks. At the beginning and end of the study, we measured functional capacity using the cardiopulmonary exercise test, evaluated body composition using anthropometry and dual energy X-ray absorptiometry, and estimated risk of falls using the Timed Up&Go test. In the exercise group, cardiopulmonary exercise test showed an increase in total effort time (p<0.001) and ventilatory anaerobic threshold time (p = 0.009). Upper thigh circumference increased and mid-arm and mid-thigh skinfold thickness decreased. Dual energy X-ray absorptiometry showed a decrease in fat body mass (-0.94 kg, 95%CI -0.48 to -1.41, p = 0.003) and an increase in lean body mass (1.05 kg, 95%CI 0.27 to 1.82, p = 0.01), lean appendicular mass (0.38 kg, 95%CI 0.06 to 0.69, p = 0.03) and lean leg mass (0.34 kg, 95%CI 0.10 to 0.57, p = 0.02). The Timed Up&Go test decreased at the end of the study compared to baseline (p = 0.02). No changes were observed in the relaxation group. We conclude that a moderate exercise programme in patients with cirrhosis improves functional capacity, increases muscle mass, and decreases body fat and the Timed Up&Go time. TRIAL REGISTRATION ClinicalTrials.gov NCT01447537.
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Affiliation(s)
- Eva Román
- Gastroenterology Department, Institut de Recerca-IIB Sant Pau, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Escola Universitària d’Infermeria EUI Sant Pau, Barcelona, Spain
- Universitat Autònoma de Barcelona, Bellaterra, Cerdanyola del Vallès, Spain
- CIBERehd, Instituto de Salud Carlos III, Madrid, Spain
| | - Cristina García-Galcerán
- Gastroenterology Department, Institut de Recerca-IIB Sant Pau, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Teresa Torrades
- Physical Medicine and Rehabilitation Department, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Silvia Herrera
- Internal Medicine Department, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Ana Marín
- Internal Medicine Department, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Maite Doñate
- Cardiology Department, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Edilmar Alvarado-Tapias
- Gastroenterology Department, Institut de Recerca-IIB Sant Pau, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Jorge Malouf
- Internal Medicine Department, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Laura Nácher
- Gastroenterology Department, Institut de Recerca-IIB Sant Pau, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Ricard Serra-Grima
- Cardiology Department, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Carlos Guarner
- Gastroenterology Department, Institut de Recerca-IIB Sant Pau, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Universitat Autònoma de Barcelona, Bellaterra, Cerdanyola del Vallès, Spain
- CIBERehd, Instituto de Salud Carlos III, Madrid, Spain
| | - Juan Cordoba
- Universitat Autònoma de Barcelona, Bellaterra, Cerdanyola del Vallès, Spain
- CIBERehd, Instituto de Salud Carlos III, Madrid, Spain
- Liver Unit, Internal Medicine Department, Hospital Vall d’Hebron, Barcelona, Spain
| | - German Soriano
- Gastroenterology Department, Institut de Recerca-IIB Sant Pau, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Universitat Autònoma de Barcelona, Bellaterra, Cerdanyola del Vallès, Spain
- CIBERehd, Instituto de Salud Carlos III, Madrid, Spain
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Hirano H, Saito M, Yano Y, Momose K, Yoshida M, Tanaka A, Azuma T. Chronic Liver Disease Questionnaire would be a primary screening tool of neuropsychiatric test detecting minimal hepatic encephalopathy of cirrhotic patients. Hepatol Res 2015; 45:994-1003. [PMID: 26234673 DOI: 10.1111/hepr.12442] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2014] [Revised: 10/16/2014] [Accepted: 10/20/2014] [Indexed: 12/11/2022]
Abstract
AIM The neuropsychiatric test (NP test) is a clinically available modality to confirm minimal hepatic encephalopathy (MHE), but it takes at least 30 min for outpatients to complete. An easier primary screening tool of the NP test would be helpful to predict MHE in routine testing on the public. METHODS We performed a prospective cohort study on 59 cirrhotic outpatients at Kobe University Hospital. Laboratory measurements, the NP test and the Chronic Liver Disease Questionnaire (CLDQ) were performed. As an indicator of MHE, cases with and without two abnormal subsets or more in the NP test were compared, and the independent risk factors were statistically examined. Predictive scoring systems of the risk of MHE were established using multivariate logistic regression. RESULTS CLDQ worry (WO) was the best predictive factor of MHE diagnosed by the NP test (P = 0.006). The predictive model using CLDQ WO discriminated well between patients with and without MHE (area under the curve, 0.714; 95% confidence interval, 0.582-0.824). The predictive scores of MHE enable the patient-specific probability to be easily looked up. CONCLUSION CLDQ WO was shown to be an independent factor associated with the NP test to diagnose MHE in cirrhotic patients. The easy predictive scoring system of the risk of MHE using CLDQ WO could become a primary screening tool before performing the NP test in a social setting.
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Affiliation(s)
- Hirotaka Hirano
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Masaya Saito
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yoshihiko Yano
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan.,Center for Infectious Diseases, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Kenji Momose
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Masaru Yoshida
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan.,Division of Metabolomics Research, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Atsushi Tanaka
- Department of Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Takeshi Azuma
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
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43
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Abstract
Minimal hepatic encephalopathy (mHE) is diagnosed in patients with severe liver disease but no clinical symptoms of encephalopathy if either neuropsychological or neurophysiological tests indicate cerebral dysfunction and other possible causes of brain dysfunction have been excluded. mHE is characterized by deficits in attention, visuospatial orientation, visuoconstructive abilities and motor function. Accordingly, mHE can be expected to interfere with a subject's working ability, especially in those occupations that require handiwork, and driving ability. Indeed, about 60% of blue-collar workers with mHE have been shown to be assessed as unfit for work compared to only 20% of white-collar workers, and about 50% of patients with mHE have been judged unfit to drive a car in several studies. mHE interferes with a patient's quality of life and is associated with an increased risk of developing overt HE as well as increased mortality. Whether mHE is of importance for cognitive function after liver transplantation has still to be clarified.
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Gómez-Ansón B, Román E, Fernández de Bobadilla R, Pires-Encuentra P, Díaz-Manera J, Núñez F, Martinez-Horta S, Vives-Gilabert Y, Pagonabarraga J, Kulisevsky J, Cordoba J, Guarner C, Soriano G. Alterations in cerebral white matter and neuropsychology in patients with cirrhosis and falls. PLoS One 2015; 10:e0118930. [PMID: 25793766 PMCID: PMC4368732 DOI: 10.1371/journal.pone.0118930] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2014] [Accepted: 01/07/2015] [Indexed: 12/15/2022] Open
Abstract
Background & Aim Falls are frequent in patients with cirrhosis but underlying mechanisms are unknown. The aim was to determine the neuropsychological, neurological and brain alterations using magnetic resonance-diffusion tensor imaging (MR-DTI) in cirrhotic patients with falls. Patients and methods Twelve patients with cirrhosis and falls in the previous year were compared to 9 cirrhotic patients without falls. A comprehensive neuropsychological and neurological evaluation of variables that may predispose to falls included: the Mini-Mental State Examination, Psychometric Hepatic Encephalopathy Score (PHES), Parkinson’s Disease-Cognitive Rating Scale, specific tests to explore various cognitive domains, Unified Parkinson’s Disease Rating Scale to evaluate parkinsonism, scales for ataxia and muscular strength, and electroneurography. High-field MR (3T) including DTI and structural sequences was performed in all patients. Results The main neuropsychological findings were impairment in PHES (p = 0.03), Parkinson’s Disease-Cognitive Rating Scale (p = 0.04) and in executive (p<0.05) and visuospatial-visuoconstructive functions (p<0.05) in patients with falls compared to those without. There were no statistical differences between the two groups in the neurological evaluation or in the visual assessment of MRI. MR-DTI showed alterations in white matter integrity in patients with falls compared to those without falls (p<0.05), with local maxima in the superior longitudinal fasciculus and corticospinal tract. These alterations were independent of PHES as a covariate and correlated with executive dysfunction (p<0.05). Conclusions With the limitation of the small sample size, our results suggest that patients with cirrhosis and falls present alterations in brain white matter tracts related to executive dysfunction. These alterations are independent of PHES impairment.
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Affiliation(s)
- Beatriz Gómez-Ansón
- Neuroradiology Unit, Department of Radiology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Institut de Recerca IIB-Sant Pau, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Eva Román
- Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Institut de Recerca IIB-Sant Pau, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Escola Universitària d’Infermeria EUI-Sant Pau, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain
| | - Ramón Fernández de Bobadilla
- Movement Disorders Unit, Department of Neurology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Institut de Recerca IIB-Sant Pau, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | | | - Jordi Díaz-Manera
- Neuromuscular Disorders Unit, Department of Neurology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), Spain
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Valencia, Spain
| | - Fidel Núñez
- Neuroradiology Unit, Department of Radiology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Saül Martinez-Horta
- Movement Disorders Unit, Department of Neurology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Institut de Recerca IIB-Sant Pau, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Yolanda Vives-Gilabert
- Port d’Informació Científica (PIC), Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), Spain
- Institut de Física d’Altes Energies (IFAE), Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), Spain
- Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), Spain
| | - Javier Pagonabarraga
- Movement Disorders Unit, Department of Neurology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), Spain
- Centro de Investigación Biomédica en Red Enfermedades Neurodegenerativas (CIBERNED), Madrid, Spain
| | - Jaume Kulisevsky
- Movement Disorders Unit, Department of Neurology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Institut de Recerca IIB-Sant Pau, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), Spain
- Centro de Investigación Biomédica en Red Enfermedades Neurodegenerativas (CIBERNED), Madrid, Spain
| | - Juan Cordoba
- Department of Internal Medicine, Hospital Vall d’Hebron, Barcelona, Spain
- Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain
| | - Carlos Guarner
- Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Institut de Recerca IIB-Sant Pau, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain
| | - Germán Soriano
- Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Institut de Recerca IIB-Sant Pau, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain
- * E-mail:
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45
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Weissenborn K. Diagnosis of minimal hepatic encephalopathy. J Clin Exp Hepatol 2015; 5:S54-9. [PMID: 26041959 PMCID: PMC4442856 DOI: 10.1016/j.jceh.2014.06.005] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2013] [Accepted: 06/05/2014] [Indexed: 12/12/2022] Open
Abstract
Minimal hepatic encephalopathy (mHE) has significant impact upon a liver patient's daily living and health related quality of life. Therefore a majority of clinicians agree that mHE should be diagnosed and treated. The optimal means for diagnosing mHE, however, is controversial. This paper describes the currently most frequently used methods-EEG, critical flicker frequency, Continuous Reaction time Test, Inhibitory Control Test, computerized test batteries such as the Cognitive Drug Research test battery, the psychometric hepatic encephalopathy score (PHES) and the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS)-and their pros and cons.
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Key Words
- CDR, cognitive drug research
- CFF, critical flicker frequency
- CRT, continuous reaction time test
- EEG, electroencephalography
- ICT, inhibitory control test
- PHES, psychometric hepatic encephalopathy score
- PSE, portosystemic encephalopathy
- RBANS, repeatable battery for the assessment of neuropsychological status
- TA, target accuracy
- WL, weighted lures
- diagnostic means
- diagnostic use
- mHE, minimal hepatic encephalopathy
- minimal hepatic encephalopathy
- sensitivity
- specificity
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Affiliation(s)
- Karin Weissenborn
- Address for correspondence: Karin Weissenborn, Department of Neurology, Hannover Medical School, 30623 Hannover, Germany. Tel.: +49 511 532 2339; fax: +49 511 532 3115.
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Mina A, Moran S, Ortiz-Olvera N, Mera R, Uribe M. Prevalence of minimal hepatic encephalopathy and quality of life in patients with decompensated cirrhosis. Hepatol Res 2014; 44:E92-9. [PMID: 24033755 DOI: 10.1111/hepr.12227] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2013] [Revised: 08/11/2013] [Accepted: 08/12/2013] [Indexed: 12/20/2022]
Abstract
AIM Minimal hepatic encephalopathy (MHE) affects more than 30% of patients with cirrhosis, and it has been suggested that despite no recognizable clinical symptoms of neurological abnormalities, it may affect health-related quality of life (HRQL); however, this fact remains controversial. The aim of our study was to evaluate the prevalence of MHE and HRQL in patients diagnosed with decompensated cirrhosis. METHODS Patients with liver cirrhosis were selected independent of the etiology of the disease. All patients underwent a complete clinical history, and only patients with decompensated hepatic cirrhosis were included. Psychometric tests were applied to evaluate the presence of MHE along with the Chronic Liver Disease Questionnaire. Appetite was measured by verbal and visual analog scales. RESULTS One hundred and twenty-five patients were included with a median age of 56.0 years. They were classified according to the Child-Pugh index as A, (n = 56), B, (n = 51) and C (n = 18). Prevalence of MHE was 44.0% (n = 55). In patients with MHE, a significant reduction was observed in domains of activity (3.3 [2.0] vs 4.8 [2.8]), fatigue (3.2 [2.0] vs 3.9 [2.3]), systemic symptoms (3.8 [2.0] vs 4.8 [1.7]), emotional function (3.6 [1.9] vs 4.0 [1.9]) and global scoring (3.7 [1.7] vs 4.3 [1.8]) when compared with non-MHE patients (n = 70). Twenty-two percent of the patients with MHE reported little appetite compared with 11% in the non-MHE group. CONCLUSION The results suggest that MHE and a reduction in appetite are associated with deterioration in HRQL in patients with decompensated cirrhosis.
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Affiliation(s)
- Aline Mina
- Laboratory of Gastro-hepatology Research, Hospital de Pediatría and Gastroenterology Department, CMN Siglo XXI, Mexican Institute of Social Security, Mexico City, Mexico
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Román E, Torrades MT, Nadal MJ, Cárdenas G, Nieto JC, Vidal S, Bascuñana H, Juárez C, Guarner C, Córdoba J, Soriano G. Randomized pilot study: effects of an exercise programme and leucine supplementation in patients with cirrhosis. Dig Dis Sci 2014; 59:1966-75. [PMID: 24599772 DOI: 10.1007/s10620-014-3086-6] [Citation(s) in RCA: 131] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2013] [Accepted: 02/18/2014] [Indexed: 12/25/2022]
Abstract
BACKGROUND Physical exercise could improve functional limitations, muscle mass, and health-related quality of life (HRQoL) in patients with cirrhosis. AIM The purpose of this study was to evaluate the efficacy and safety of an exercise programme and leucine supplementation to increase exercise capacity, muscle mass, and HRQoL in patients with cirrhosis. PATIENTS AND METHODS Seventeen outpatients with cirrhosis were randomized to an exercise group (n = 8) or a control group (n = 9) in a pilot study. The programme of moderate exercise was performed for 12 weeks under supervision of a physiotherapist. All patients received oral leucine (10 g/day) during the study. At baseline and at the end of the study, we determined exercise capacity (6-min walk and 2-min step tests), anthropometric measurements, and HRQoL by Short Form-36 (SF-36) questionnaire. We also analyzed safety regarding complications of cirrhosis, liver and renal function, inflammatory response and oxidative stress. RESULTS In the exercise group, exercise capacity improved, as shown by the increase in the 6-min walk test from 365 (160-420) to 445 m (250-500) (p = 0.01), and in the 2-min step test (p = 0.02). Lower thigh circumference also increased, from 41 (34-53) to 46 cm (36-56) (p = 0.02), and the domains of SF-36 general health (p = 0.03), vitality (p = 0.01) and social function (p = 0.04) improved significantly. In the control group, no statistically significant changes were observed in any of the parameters. We did not observe complications of cirrhosis in either group during the study. CONCLUSIONS A programme of moderate physical exercise together with leucine supplements in patients with cirrhosis is safe and improves exercise capacity, leg muscle mass and HRQoL.
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Affiliation(s)
- Eva Román
- Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, Mas Casanovas 90, 08041, Barcelona, Spain
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Hepatic Encephalopathy: From the Pathogenesis to the New Treatments. ISRN HEPATOLOGY 2014; 2014:236268. [PMID: 27335836 PMCID: PMC4890879 DOI: 10.1155/2014/236268] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/20/2013] [Accepted: 01/28/2014] [Indexed: 02/07/2023]
Abstract
Hepatic encephalopathy is a frequent and serious complication of liver cirrhosis; the pathophysiology of this complication is not fully understood although great efforts have been made during the last years. There are few prospective studies on the epidemiology of this complication; however, it is known that it confers with high short-term mortality. Hepatic encephalopathy has been classified into different groups depending on the degree of hepatic dysfunction, the presence of portal-systemic shunts, and the number of episodes. Due to the large clinical spectra of overt EH and the complexity of cirrhotic patients, it is very difficult to perform quality clinical trials for assessing the efficacy of the treatments proposed. The physiopathology, clinical manifestation, and the treatment of HE is a challenge because of the multiple factors that converge and coexist in an episode of overt HE.
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In patients with liver cirrhosis, proinflammatory interleukins correlate with health-related quality of life irrespective of minimal hepatic encephalopathy. Eur J Gastroenterol Hepatol 2013; 25:1402-7. [PMID: 24025977 DOI: 10.1097/meg.0b013e328365a447] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Liver cirrhosis is associated with latent systemic inflammatory response syndrome as evidenced by elevated levels of proinflammatory cytokines. It has been proposed that inflammatory mediators play a role in the pathogenesis of minimal and overt hepatic encephalopathy (HE); hence, they may also have an effect on health-related quality of life (HRQL). The aim of this study was to investigate the relationship between serum levels of interleukin-1β (IL-1β), IL-6, and IL-18 and the occurrence of minimal HE and HRQL. METHODS Forty-two consecutive patients with liver cirrhosis were prospectively enrolled to the study. Minimal HE was detected by the Psychometric Hepatic Encephalopathy Score (PHES) and critical flicker frequency. HRQL was assessed with Chronic Liver Disease Questionnaire and 36-Item Short Form Health Survey (SF-36) questionnaires. The interleukins studied were determined using colorimetric sandwich enzyme-linked immunosorbent assay. RESULTS Serum levels of interleukins correlated with liver dysfunction, but did not discriminate patients with minimal HE from those with overt or absent HE. IL-1β and IL-6 showed significant correlations with PHES, but showed no relationship with critical flicker frequency. Serum IL-6 and IL-18 correlated with both physical-related general health and mental component summary evaluated by the SF-36 questionnaire. CONCLUSION This study shows that chronic inflammation plays a role in impaired HRQL in patients with cirrhosis irrespective of minimal HE.
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