Fatigue in chronic hepatitis C infection: Understanding patients' experience from a cognitive-behavioural perspective

Critical Realism in Symptom Science - A Scoping Review

There has been an increasing interest in research positioned within critical realism (CR). This analysis aimed to determine how CR has been applied in symptom science through a scoping review of the literature. Fifty-two articles were identified through searches in seven databases and search engines, and grey literature. Quantitative and qualitative analyses were performed using Excel and ATLAS.ti 8.0. Review findings indicate that CR has been used to examine two key aspects of symptoms - symptom experiences and symptom interventions. The details of how CR was operationalized are presented. This first scoping review highlights how a critical realist lens would help examine individual and contextual factors that influence symptom experiences, response to interventions, and outcomes.

Fatigue in Patients with Chronic Hepatitis C

This study aimed to explore the factors associated with fatigue in chronic hepatitis C patients before and at 4, 8, 12, 16, 20, and 24 weeks after antiviral therapy. The study employed a prospective and repeated-measures design. The Chinese version of the brief fatigue inventory (BFI-C) and the Pittsburg sleep quality index (PSQI) were employed to collect data. Pegylated Interferon plus Ribavirin dosages and serum values (hemoglobin, alanine aminotransferase [ALT], and aspartate aminotransferase [AST]) were monitored before and during the antiviral therapy at 4, 8, 12, 16, 20, and 24 weeks. The study enlisted 115 patients as participants. Multivariate analysis indicated that gender, educational level, body mass index (BMI), and hemoglobin level were significant determinants of patients’ fatigue. When hemoglobin levels in the patients decreased in week 4 and continued to fall to the nadir at week 12, it prompted the healthcare providers to assess their fatigue levels and initiate proactive interventions as needed.

Perceived physical health outcomes of direct-acting antiviral treatment for hepatitis C: a qualitative study

Background

Novel health promotion and treatment uptake initiatives will be necessary to ensure Australia meets 2030 hepatitis C elimination targets. Increasing treatment uptake will be assisted by a better understanding of the treatment experience and patient-perceived benefits. This study describes the perceived physical health benefits from direct-acting antiviral (DAA) hepatitis C treatment among people who inject drugs in Melbourne, Australia.

Methods

Twenty participants were recruited from a community treatment trial and community health clinics. Semi-structured interviews were performed with each participant before, during and following treatment. Interviews focused on treatment experiences, attitudes and motivations. Interviews were recorded, transcribed and thematically analysed.

Results

Two themes relating to the physical experience of treatment developed; intersection between physical and mental health and “maybe it’s working”. Participants reported various physical benefits, most prominently, reduced fatigue. Reductions in fatigue resulted in instant and meaningful changes in everyday life. Some participants did experience side effects, which they described as mild. Experiencing noticeable physical benefits during treatment was perceived as validation that treatment was working.

Conclusion

Physical health benefits of DAA treatment may have carry-on effects on cognitive, emotional or social wellbeing and should be incorporated into how treatment is promoted to those who require it.

Importance of fatigue and its measurement in chronic liver disease

The mechanisms of fatigue in the group of people with non-alcoholic fatty liver disease and non-alcoholic steatohepatitis are protean. The liver is central in the pathogenesis of fatigue because it uniquely regulates much of the storage, release and production of substrate for energy generation. It is exquisitely sensitive to the feedback controlling the uptake and release of these energy generation substrates. Metabolic contributors to fatigue, beginning with the uptake of substrate from the gut, the passage through the portal system to hepatic storage and release of energy to target organs (muscle and brain) are central to understanding fatigue in patients with chronic liver disease. Inflammation either causing or resulting from chronic liver disease contributes to fatigue, although inflammation has not been demonstrated to be causal. It is this unique combination of factors, the nexus of metabolic abnormality and the inflammatory burden of non-alcoholic fatty liver disease and non-alcoholic steatohepatitis that creates pathways to different types of fatigue. Many use the terms central and peripheral fatigue. Central fatigue is characterized by a lack of self-motivation and can manifest both in physical and mental activities. Peripheral fatigue is classically manifested by neuromuscular dysfunction and muscle weakness. Therefore, the distinction is often seen as a difference between intention (central fatigue) versus ability (peripheral fatigue). New approaches to measuring fatigue include the use of objective measures as well as patient reported outcomes. These measures have improved the precision with which we are able to describe fatigue. The measures of fatigue severity and its impact on usual daily routines in this population have also been improved, and they are more generally accepted as reliable and sensitive. Several approaches to evaluating fatigue and developing endpoints for treatment have relied of biosignatures associated with fatigue. These have been used singly or in combination and include: physical performance measures, cognitive performance measures, mood/behavioral measures, brain imaging and serological measures. Treatment with non-pharmacological agents have been shown to be effective in symptom reduction, whereas pharmacological agents have not been shown effective.

Hepatitis C in a new therapeutic era: Recontextualising the lived experience

AIMS AND OBJECTIVES

To explore the experience of adults living with hepatitis C in a new era of interferon-free treatment.

BACKGROUND

Hepatitis C is a leading cause of morbidity and mortality worldwide, posing a significant challenge to global public health. Historically, the treatment of hepatitis C was poorly efficacious and highly demanding; however, more effective and tolerable therapies have become available in high-income nations in recent years. This is the first study to explore how these significant developments in the treatment of hepatitis C may have influenced the experience of those living with the virus, and their understanding of the disease.

DESIGN

A qualitative study underpinned by social phenomenological theory.

METHODS

Data were generated through semi-structured interviews with a purposive sample of 20 hepatitis C positive adults living in a large city in Scotland.

RESULTS

Thematic analysis identified three overriding themes. "Positioning hepatitis C" illustrated how the disease was understood within wider sociocultural, medical and politico-economic contexts. "Beyond a physical burden" emphasised the emotional aspect of infection, and "a new uncertainty" revealed participants' cautious response to the advances in hepatitis C therapy.

CONCLUSIONS

Interthematic discourse portrayed the new era of hepatitis C treatment as holding little sway over constructions of the illness, as narratives resonated with previous studies. Such unmoving "lay" understandings of hepatitis C may pose potential barriers to the new therapeutic era from reaching its full potential.

RELEVANCE TO CLINICAL PRACTICE

How people living with the virus perceive and understand hepatitis C can have an adverse impact on their engagement with care and treatment. Whilst global medical discourse eulogises the arrival of a new era of therapy, there remain significant challenges for nurses engaging those with hepatitis C in therapeutic pathways.

Fatigue and Hepatitis C: a focus group study

Fatigue is often undiagnosed by health professionals as it is still seen as a nonspecific symptom without standard evaluations and effective treatments. Fatigue is present across many different diseases and has a profound effect on the quality of life of patients. However, it is still difficult to measure because of the lack of specificity of currently used self-report instruments. Patients with chronic hepatitis C infection, (HCV), experience fatigue as one of the most debilitating symptoms. The purpose of this study was to explore the types and dimensions of fatigue experienced by patients with HCV, identify specific terms they use to describe fatigue and assess how it influences everyday activities. Sixteen individuals with HCV (56% female, aged 58.1 ± 3.7 years) participated in three focus group sessions. The focus group sessions lasted between 60 and 90 minutes and were digitally recorded via audiotapes. Recorded focus groups’ audiotapes were analyzed through thematic analyses. The analysis suggested two primary categories of fatigue experiences. These were: capacity and engagement in activity. Capacity refers specifically to an individual’s sense of how much energy they have to do life activities or their maximum ability to produce energy. The word energy is the ability to perform work and includes one’s ability to access or utilize, expend, and restore it. The phrase engagement in activity, comprised two domains: initiation (getting started or being motivated) and personal satisfaction (value of the activity). This investigation helped to identify important domains of fatigue experienced by those with HCV. The findings augment our current understanding of fatigue for this group because the domains of fatigue and the terms used to describe it are not commonly represented in the most frequently used fatigue assessments.

Short article: Fatigue in the long term after HCV treatment in HIV-HCV-coinfected patients: functional limitations persist despite viral clearance in patients exposed to peg-interferon/ribavirin-containing regimens (ANRS CO13-HEPAVIH cohort)

OBJECTIVES

To analyze the impact of fatigue on individuals' global, cognitive, physical, and psychosocial functioning in the long term after hepatitis C virus (HCV) treatment and its relationship with HCV clearance among patients coinfected with HIV and HCV exposed to peg-interferon/ribavirin-containing regimens.

PATIENTS AND METHODS

The study sample included 107 coinfected patients treated for HCV during follow-up in the French ANRS CO13-HEPAVIH cohort. Analyses used scores from the Fatigue Impact Scale (FIS), assessed before treatment initiation and at last available measure after the end of treatment (2 years in median). Patient proportions with a clinically significant improvement in fatigue impact, defined as a decrease higher than 10 points in the 160-point global FIS score, were compared between HCV clearers and chronic HCV patients (Fisher's exact test). Relationships between HCV clearance and FIS scores were analyzed in linear regression models adjusted for sex, time since end of HCV treatment, and pretreatment scores.

RESULTS

Twenty-nine percent of patients showed a clinically significant improvement in fatigue (15/57 in HCV clearers vs. 16/50 in chronic HCV patients, P=0.52). HCV clearance was not significantly associated with FIS scores in multivariate models.

CONCLUSION

The role of HCV clearance in coinfected patients' functional recovery in the long term after peg-interferon/ribavirin treatment may be lesser than expected. Additional studies are needed in patients treated with direct-acting antiviral agents. In the meantime, the effectiveness of palliative care and targeted psychological treatments such as cognitive-behavioral therapy in reducing fatigue impact needs to be assessed in the many HCV-cured patients with HIV exposed to suboptimal interferon-based first-generation therapies.