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Haddadin Y, Macken L, Ufere NN, Verma S. Antibiotic prophylaxis in palliative patients with cirrhosis: Stewardship or gatekeeping? Hepatol Commun 2023; 7:e0309. [PMID: 37994503 PMCID: PMC10666976 DOI: 10.1097/hc9.0000000000000309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 09/15/2023] [Indexed: 11/24/2023] Open
Affiliation(s)
- Yazan Haddadin
- Brighton and Sussex Medical School and University Hospitals Sussex NHS Foundation Trust, Brighton, UK
| | - Lucia Macken
- Brighton and Sussex Medical School and University Hospitals Sussex NHS Foundation Trust, Brighton, UK
| | - Nneka N. Ufere
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Sumita Verma
- Brighton and Sussex Medical School and University Hospitals Sussex NHS Foundation Trust, Brighton, UK
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2
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Tavabie OD, Abbott J, Abeysekera KWM, Balachandrakumar VK, Bennett K, Brennan P, Buchanan R, Dhaliwal A, Galanakis V, Hardy T, Harris R, Kronsten VT, Leighton J, Li W, Yin JL, Macken L, Marjot T, Maurice JB, McDowell H, Navaratnam J, Pohl K, Nayagam JS, Saunsbury E, Scott J, Sheth A, Sinharay R, Sheiybani G, Subhani M, Tavabie OD, Turner L, White H, Zakeri N, Balachandrakumar VK, Cook C, Hardy T, Harris R, Navaratnam J, Saunsbury E, Tavabie OD, Abbas N, Abbasi A, Abdul R, Abdulaziz M, Abduljabbar D, Abeysekera KWM, Adamson R, Adebayo D, Adhikarla AK, Adler M, Ahmad S, Ahmed S, Afifi M, Akram A, Al Radhi B, Al-Talib I, Alele J, Ali AM, Almusai S, Appleby V, Asmat H, Astbury S, Atkinson A, Badrulhisham F, Balachandrakumar VK, Ball A, Banfa M, Barn J, Begum S, Belfield K, Bendall O, Bhandari R, Bhatti P, Bradley M, Brennan P, Brown E, Bryce K, Burke L, Campbell R, Cargill T, Carroll G, Cartledge J, Chatterjee D, Chaundry R, Choudhry Z, Clare K, Cobbold J, Coburn R, Corvan F, Cox R, Craig D, Creamer J, Curran C, De Silva S, Dean L, Dillon J, Dunn R, Eckersley R, Eike G, Elagib A, Elkholi A, Elshaarawy O, Faloon S, Fan F, Fazili M, Fernandes D, Fox J, Foxton M, Gaba W, Gaikwad G, Gairola A, Galanakis V, Gallaher C, Gautam N, Germain L, Giles B, Gill C, Glover B, Glover J, Gomez D, Gomez M, Gordon V, Gormley S, Goulder J, Goyal S, Greenham O, Guthrie S, Hackett R, Haddadin Y, Hadjinicolaou A, Hall J, Haque T, Hardy T, Harris R, Hart C, Hasnain Nadir SM, Hassall J, Hasan S, Hawker-Bond G, Hawkyard J, Healey S, Hornby C, Hamza M, Humayun M, Hutchison J, Iftikhar Z, Ismail A, James J, Jopson L, Juthani D, Kaina P, Karim A, Karim SM, Kashyap V, Kassab M, Katarey D, Kenny L, Kerry G, Khan A, Khan A, Khan A, Khan MT, Khan T, Khatib A, Khattak MF, King JJ, Korani M, Kotha S, Kooner E, Lam WL, Lateef M, Leith D, Li W, Liaros A, Lourenco F, Lyles A, Mahenthiran M, Magee C, Maggs D, Mahalingam A, Mahmood R, Mandour MO, Manocha N, Mansour D, Marks D, Marjot T, Martin C, Martin H, Martin I, Martin K, Maruthan S, Masin R, Mason D, Matthews C, Mavrou A, Maxan E, Maxfield D, McAvoy E, McColl K, McCaughan H, McCorry R, McGoran J, McDonald S, McDowell H, McIlwane S, Meakin O, Mebarek L, Merrill H, Michail S, Modarres P, Mohamedali A, Mohammed Y, Mohammed Z, Mohan J, Monnier C, Moran E, Morrison G, Moroni F, Msaddi A, Mutar S, Navaratnam J, Neto-Pereira L, Nahed I, Ng J, Nwoguh C, O’Kane R, Omar S, Ososanya A, Parambil JV, Patel J, Pericleous M, Pervais Z, Phoolchund A, Pietrzycki J, Pillay L, Prabhu K, Putri YRF, Qazi U, Rafique KK, Raman K, Ranade V, Rastelli F, Ratcliffe E, Rattehalli D, Raza T, Razak A, Raghuraman A, Read G, Robins A, Rushbrook S, Salama M, St. Aimee L, Saravan R, Sarkar S, Saunsbury E, Serna S, Shahzad H, Shamsaldeen M, Sharip M, Shearer J, Sheikh A, Sheiybani G, Sheth A, Sherwin M, Shintre N, Singhal S, Sinha R, Sinharay R, Smith G, Smith R, Spicer J, Spoor J, Sreenivasan S, Srinivasa A, Srivastava A, Stagg G, Stanley J, Stevenson J, Stokes D, Stroud R, Subhani M, Suliman H, Sultana M, Summers N, Sutherland C, Swann R, Sykes L, Taha M, Tan KE, Tariq Z, Ming Tay JJ, Taylor A, Thakor A, Tsang J, Tyler Z, Unitt E, Volcek E, Wischhusen J, Watson I, Watters C, Wells G, Widlak M, Williams M, Woodland H, Wren L, Xyda S, Yeh J, Young A, Jie Yuan JS, Abbott J, Abeysekera KWM, Galanakis V, Li W, Sheth A, Sinharay R, Sheiybani G, Tavabie OD, Abbott J, Abeysekera KWM, Galanakis V, Li W, Sheth A, Sinharay R, Sheiybani G, Tavabie OD, Abeysekera KWM, Brennan P, Li W, Marjot T, Tavabie OD, Aithal G, Bernal W, Dillon J, Hogan B, McPherson S, Jones R, Rowe I, Snowdon V. Defining characteristics and outcomes for patients with non-alcoholic fatty liver disease admitted to hospital with decompensated cirrhosis. J Hepatol 2023; 79:e165-e167. [PMID: 37315808 DOI: 10.1016/j.jhep.2023.05.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 05/14/2023] [Indexed: 06/16/2023]
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Tavabie OD, Abeysekera KWM, Brennan PN, Marjot T, Kronsten VT, Li W, Nayagam JS, Dhaliwal A, Hardy T, Maurice JB, Zakeri N, Abbas N, Abbasi A, Abbott J, Abdul R, Abdulaziz M, Abduljabbar D, Adamson R, Adebayo D, Adhikarla AK, Adler M, Afifi M, Ahmad S, Ahmed S, Aithal G, Akram A, Al Radhi B, Al-Talib I, Alele J, Ali AM, Almusai S, Appleby V, Asmat H, Astbury S, Atkinson A, Badrulhisham F, Balachandrakumar VK, Ball A, Banfa M, Barn J, Begum S, Belfield K, Bendall O, Bennett K, Bernal W, Bhandari R, Bhatti P, Bradley M, Brown E, Bryce K, Buchanan R, Burke L, Campbell R, Cargill T, Carroll G, Cartledge J, Chatterjee D, Chaundry R, Choudhry Z, Clare K, Cobbold J, Coburn R, Cook C, Corvan F, Cox R, Craig D, Creamer J, Curran C, De Silva S, Dean L, Dillon J, Dillon J, Dunn R, Eckersley R, Eike G, Elagib A, Elkholi A, Elshaarawy O, Faloon S, Fan F, Fazili M, Fernandes D, Fox J, Foxton M, Gaba W, Gaikwad G, Gairola A, Galanakis V, Gallaher C, Gautam N, Germain L, Giles B, Gill C, Glover B, Glover J, Gomez D, Gomez M, Gordon V, Gormley S, Goulder J, Goyal S, Greenham O, Guthrie S, Hackett R, Haddadin Y, Hadjinicolaou A, Hall J, Hamza M, Haque T, Harris R, Hart C, Hasan S, Hasnain Nadir SM, Hassall J, Hawker-Bond G, Hawkyard J, Healey S, Hogan B, Hornby C, Humayun MD, Hutchison J, Iftikhar Z, Ismail A, James J, Jones R, Jopson L, Juthani D, Kaina P, Karim A, Karim SM, Kashyap V, Kassab M, Katarey D, Kenny L, Kerry G, Khan A, Khan A, Khan A, Khan MT, Khan T, Khatib A, Khattak MF, King JJ, Kooner E, Korani M, Kotha S, Lam WL, Lateef M, Leighton J, Leith D, Liaros A, Liu Yin J, Lourenco F, Lyles A, Macken L, Magee C, Maggs D, Mahalingam A, Mahenthiran M, Mahmood R, Mandour MO, Manocha N, Mansour D, Marks D, Martin C, Martin H, Martin I, Martin K, Maruthan S, Masin R, Mason D, Matthews C, Mavrou A, Maxan E, Maxfield D, McAvoy E, McCaughan H, McColl K, McCorry R, McDonald S, McDowell H, McGoran J, McIlwane S, McPherson S, Meakin O, Mebarek L, Merrill H, Michail S, Modarres P, Mohamedali A, Mohammed Y, Mohammed Z, Mohan J, Monnier C, Moran E, Moroni F, Morrison G, Msaddi A, Mutar S, Nahed I, Navaratnam J, Neto-Pereira L, Ng J, Nwoguh C, O'Kane R, Omar S, Ososanya A, Parambil JV, Patel J, Pericleous M, Pervais Z, Phoolchund A, Pietrzycki J, Pillay L, Pohl K, Prabhu K, Putri YRF, Qazi U, Rafique KK, Raghuraman A, Raman K, Ranade V, Rastelli F, Ratcliffe E, Rattehalli D, Raza T, Razak A, Read G, Robins A, Rowe I, Rushbrook S, Salama M, Saravan R, Sarkar S, Saunsbury E, Scott J, Serna S, Shahzad H, Shamsaldeen M, Sharip M, Shearer J, Sheikh A, Sheiybani G, Sherwin M, Sheth A, Shintre N, Singhal S, Sinha R, Sinharay R, Smith G, Smith R, Snowdon V, Spicer J, Spoor J, Sreenivasan S, Srinivasa A, Srivastava A, St. Aimee L, Stagg G, Stanley J, Stevenson J, Stokes D, Stroud R, Subhani M, Suliman H, Sultana M, Summers N, Sutherland C, Swann R, Sykes L, Taha M, Tan KE, Tariq Z, Tay JJM, Taylor A, Thakor A, Tsang J, Turner L, Tyler Z, Unitt E, Volcek E, Watson I, Watters C, Wells G, White H, Widlak M, Williams M, Wischhusen J, Woodland H, Wren L, Xyda S, Yeh J, Young A, Yuan JSJ. Regional variation in characteristics of patients with decompensated cirrhosis admitted to hospitals in the UK. Lancet Gastroenterol Hepatol 2023; 8:604-606. [PMID: 37148900 DOI: 10.1016/s2468-1253(23)00114-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 04/17/2023] [Indexed: 05/08/2023]
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Macken L, Corrigan M, Prentice W, Finlay F, McDonagh J, Rajoriya N, Salmon C, Donnelly M, Evans C, Ganai B, Bedlington J, Steer S, Wright M, Hudson B, Verma S. Palliative long-term abdominal drains for the management of refractory ascites due to cirrhosis: a consensus document. Frontline Gastroenterol 2022; 13:e116-e125. [PMID: 35812034 PMCID: PMC9234735 DOI: 10.1136/flgastro-2022-102128] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 05/15/2022] [Indexed: 02/06/2023] Open
Abstract
Palliative care remains suboptimal in advanced cirrhosis, in part relating to a lack of evidence-based interventions. Ascites remains the most common cirrhosis complication resulting in hospitalisation. Many patients with refractory ascites are not candidates for liver transplantation or transjugular intrahepatic portosystemic shunt, and therefore, require recurrent palliative large volume paracentesis in hospital. We review the available evidence on use of palliative long-term abdominal drains in cirrhosis. Pending results of a national trial (REDUCe 2) and consistent with recently published national and American guidance, long-term abdominal drains cannot be regarded as standard of care in advanced cirrhosis. They should instead be considered only on a case-by-case basis, pending definitive evidence. This manuscript provides consensus to help standardise use of long-term abdominal drains in cirrhosis including patient selection and community management. Our ultimate aim remains to improve palliative care for this under researched and vulnerable cohort.
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Affiliation(s)
- Lucia Macken
- Gastroenterology and Hepatology, University Hospitals Sussex NHS Foundation Trust, Brighton, UK
| | - Margaret Corrigan
- Hepatology, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Wendy Prentice
- Department of Palliative Care Medicine, King's College Hospital NHS Foundation Trust, London, UK
| | - Fiona Finlay
- Palliative Medicine, Queen Elizabeth University Hospital Campus, Glasgow, UK
| | | | - Neil Rajoriya
- Liver Unit, Queen Elizabeth Hospital, Birmingham, UK
| | - Claire Salmon
- Hepatology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | | | | | - Bhaskar Ganai
- Gastroenterology and Hepatology, University Hospitals Sussex NHS Foundation Trust, Brighton, UK
| | | | - Shani Steer
- Patient and Public involvement, Brighton, UK
| | - Mark Wright
- Hepatology, University Hospital Southampton, Southampton, UK
| | - Ben Hudson
- Hepatology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Sumita Verma
- Gastroenterology and Hepatology, University Hospitals Sussex NHS Foundation Trust, Brighton, UK,Clinical and Experimental Medicine, Brighton and Sussex Medical School, Brighton, UK
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Hashim A, Bremner S, Grove JI, Astbury S, Mengozzi M, O'Sullivan M, Macken L, Worthley T, Katarey D, Aithal GP, Verma S. Chronic liver disease in homeless individuals and performance of non-invasive liver fibrosis and injury markers: VALID study. Liver Int 2022; 42:628-639. [PMID: 34846794 DOI: 10.1111/liv.15122] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 11/22/2021] [Accepted: 11/25/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND/AIMS Community-based assessment and management of chronic liver disease (CLD) in people who are homeless (PWAH) remain poorly described. We aimed to determine prevalence/predictors of CLD in PWAH and assess the performance of non-invasive liver fibrosis and injury markers. METHODS The Vulnerable Adult LIver Disease (VALID) study provided a "one-stop" liver service based at homeless hostels. Our primary outcome was the prevalence of clinically significant hepatic fibrosis (CSHF; liver stiffness measurement (LSM) ≥8 kPa). RESULTS Total individuals recruited were 127, mean ± SD age 47 ± 9.4 years, 50% (95% CI 41%-59%) and 39% (95% CI 31%-48%) having alcohol dependence and a positive HCV RNA respectively. CSHF was detected in 26% (95% CI 17%-35%), independent predictors being total alcohol unit/week (OR 1.01, 95% CI 1.00-1.02, P = .002) and HCV RNA positivity (OR 2.93, 95% CI 1.12-7.66, P = .029). There was moderate agreement between LSM and Enhanced Liver Fibrosis (ELF) score (kappa 0.536, P < .001) for CSHF as assessed by LSM ≥8 kPa. Those with CSHF had significantly higher levels of IFN-γ (P = .002), IL-6 (P = .001), MMP-2 (P = .006), ccCK-18 (P < .001) and ELF biomarkers (P < .001), compared to those without CSHF. Service uptake was ≥95%. Direct acting antiviral (DAA) treatment completion was 93% (95% CI 77%-99%), sustained virological response (SVR) being 83% (95% CI 64%-94%). CONCLUSION There is a significant liver disease burden from HCV and alcohol in PWAH. Non-invasive liver fibrosis and injury markers can help in identifying such individuals in the community. Despite a challenging cohort, excellent service uptake and high DAA-based SVRs can be achieved.
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Affiliation(s)
- Ahmed Hashim
- Department of Clinical and Experimental Medicine, Brighton and Sussex Medical School, Brighton, UK.,Department of Gastroenterology and Hepatology, University Hospitals Sussex NHS Foundation Trust, Brighton, UK
| | - Stephen Bremner
- Department of Primary Care and Public Health, Brighton and Sussex Medical School, Brighton, UK
| | - Jane I Grove
- NIHR Nottingham Biomedical Research Centre, University of Nottingham and Nottingham University Hospitals NHS Trust, Nottingham, UK.,Nottingham Digestive Diseases Centre, School of Medicine, University of Nottingham, Nottingham, UK
| | - Stuart Astbury
- NIHR Nottingham Biomedical Research Centre, University of Nottingham and Nottingham University Hospitals NHS Trust, Nottingham, UK.,Nottingham Digestive Diseases Centre, School of Medicine, University of Nottingham, Nottingham, UK
| | - Manuela Mengozzi
- Department of Clinical and Experimental Medicine, Brighton and Sussex Medical School, Brighton, UK
| | - Margaret O'Sullivan
- Department of Gastroenterology and Hepatology, University Hospitals Sussex NHS Foundation Trust, Brighton, UK
| | - Lucia Macken
- Department of Clinical and Experimental Medicine, Brighton and Sussex Medical School, Brighton, UK.,Department of Gastroenterology and Hepatology, University Hospitals Sussex NHS Foundation Trust, Brighton, UK
| | | | - Dev Katarey
- Department of Hepatology, Royal Free Hospital, London, UK
| | - Guruprasad P Aithal
- NIHR Nottingham Biomedical Research Centre, University of Nottingham and Nottingham University Hospitals NHS Trust, Nottingham, UK.,Nottingham Digestive Diseases Centre, School of Medicine, University of Nottingham, Nottingham, UK
| | - Sumita Verma
- Department of Clinical and Experimental Medicine, Brighton and Sussex Medical School, Brighton, UK.,Department of Gastroenterology and Hepatology, University Hospitals Sussex NHS Foundation Trust, Brighton, UK
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Affiliation(s)
- Lucia Macken
- Department of Clinical and Experimental Medicine, Brighton and Sussex Medical School, Brighton, UK.,Department of Gastroenterology and Hepatology, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Naaventhan Palaniyappan
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK.,Nottingham Digestive Diseases Centre, School of Medicine, University of Nottingham, Nottingham, Nottinghamshire, UK
| | - Sumita Verma
- Department of Clinical and Experimental Medicine, Brighton and Sussex Medical School, Brighton, UK.,Department of Gastroenterology and Hepatology, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Guruprasad Aithal
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK .,Nottingham Digestive Diseases Centre, School of Medicine, University of Nottingham, Nottingham, Nottinghamshire, UK
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Cooper M, Pollard A, Pandey A, Bremner S, Macken L, Evans CJ, Austin M, Parnell N, Steer S, Thomson S, Hashim A, Mason L, Verma S. Palliative Long-Term Abdominal Drains Versus Large Volume Paracentesis in Refractory Ascites Due to Cirrhosis (REDUCe Study): Qualitative Outcomes. J Pain Symptom Manage 2021; 62:312-325.e2. [PMID: 33348031 DOI: 10.1016/j.jpainsymman.2020.12.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 12/06/2020] [Accepted: 12/08/2020] [Indexed: 12/14/2022]
Abstract
CONTEXT Palliative care remains suboptimal in end-stage liver disease (ESLD). OBJECTIVES We report qualitative outcomes from the REDUCe study. We aimed to explore and contrast experiences/perceptions/care pathways of patients with refractory ascites due to ESLD randomized to either palliative long-term abdominal drains (LTADs) (allow home drainage) vs. large volume paracentesis (LVP) (hospital drainage). METHODS Concurrent embedded qualitative study in a 12-week feasibility randomized controlled trial. Telephone interviews were conducted, data being recorded, transcribed verbatim, and analyzed using applied thematic analysis, considered in terms of a pathway approach toward accessing health care. Quantitative outcomes were collected (integrated palliative outcome scale, short-form liver disease quality of life, EQ-5D-5 L, Zarit Burden Interview-12). RESULTS Fourteen patients (six allocated LTAD and eight LVP) and eight nurses participated in the qualitative study. The patient journey in the LVP group could be hindered by challenges along the entire care pathway, from recognizing the need for drainage to a lengthy wait in hospital for drainage and/or to be discharged. These issues also impacted upon caregivers. In contrast, LTADs appeared to transform this care pathway at all levels across the patient's journey by removing the need for hospital drainage. Additional benefits included personalized care, improved symptom control of ascites, being at home, and regular support from community nurses. Nurses also viewed the LTAD favorably, though expressed the need for additional support should this become standard of care. CONCLUSION Patients and nurses expressed acceptability of palliative LTAD in ESLD and preference for this approach in enabling care at home. Proceeding to a definitive trial is feasible. TRIAL REGISTRATION ISRCTN30697116, date assigned: 07/10/2015.
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Affiliation(s)
- Max Cooper
- Department of Primary Care and Public Health, Brighton and Sussex Medical School, Brighton, UK
| | - Alex Pollard
- Department of Primary Care and Public Health, Brighton and Sussex Medical School, Brighton, UK
| | - Aparajita Pandey
- Research & Development Department, Sussex Partnership NHS Foundation Trust, Brighton, UK
| | | | - Lucia Macken
- Department of Clinical and Experimental Medicine, Brighton and Sussex Medical School, Brighton, UK; Department of Gastroenterology and Hepatology, Brighton and Sussex University Hospitals Trust, Brighton, UK
| | - Catherine J Evans
- Kings College, Cicely Saunders Institute, Department of Palliative Care, Policy and Rehabilitation, London, UK; Sussex Community NHS Foundation Trust, Brighton, UK
| | - Mark Austin
- Department of Gastroenterology and Hepatology, Brighton and Sussex University Hospitals Trust, Brighton, UK
| | - Nick Parnell
- Department of Gastroenterology and Hepatology, Brighton and Sussex University Hospitals Trust, Brighton, UK
| | - Shani Steer
- Department of Gastroenterology and Hepatology, Brighton and Sussex University Hospitals Trust, Brighton, UK
| | - Sam Thomson
- Department of Gastroenterology and Hepatology, Western Sussex NHS Foundation Trust, Worthing, UK
| | - Ahmed Hashim
- Department of Clinical and Experimental Medicine, Brighton and Sussex Medical School, Brighton, UK; Department of Gastroenterology and Hepatology, Brighton and Sussex University Hospitals Trust, Brighton, UK
| | - Louise Mason
- Department of Palliative Medicine, Brighton and Sussex University Hospitals Trust, Brighton, UK
| | - Sumita Verma
- Department of Clinical and Experimental Medicine, Brighton and Sussex Medical School, Brighton, UK; Department of Gastroenterology and Hepatology, Brighton and Sussex University Hospitals Trust, Brighton, UK.
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Aithal GP, Palaniyappan N, China L, Härmälä S, Macken L, Ryan JM, Wilkes EA, Moore K, Leithead JA, Hayes PC, O'Brien AJ, Verma S. Guidelines on the management of ascites in cirrhosis. Gut 2021; 70:9-29. [PMID: 33067334 PMCID: PMC7788190 DOI: 10.1136/gutjnl-2020-321790] [Citation(s) in RCA: 151] [Impact Index Per Article: 50.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 08/27/2020] [Accepted: 09/04/2020] [Indexed: 12/15/2022]
Abstract
The British Society of Gastroenterology in collaboration with British Association for the Study of the Liver has prepared this document. The aim of this guideline is to review and summarise the evidence that guides clinical diagnosis and management of ascites in patients with cirrhosis. Substantial advances have been made in this area since the publication of the last guideline in 2007. These guidelines are based on a comprehensive literature search and comprise systematic reviews in the key areas, including the diagnostic tests, diuretic use, therapeutic paracentesis, use of albumin, transjugular intrahepatic portosystemic stent shunt, spontaneous bacterial peritonitis and beta-blockers in patients with ascites. Where recent systematic reviews and meta-analysis are available, these have been updated with additional studies. In addition, the results of prospective and retrospective studies, evidence obtained from expert committee reports and, in some instances, reports from case series have been included. Where possible, judgement has been made on the quality of information used to generate the guidelines and the specific recommendations have been made according to the 'Grading of Recommendations Assessment, Development and Evaluation (GRADE)' system. These guidelines are intended to inform practising clinicians, and it is expected that these guidelines will be revised in 3 years' time.
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Affiliation(s)
- Guruprasad P Aithal
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK
- Nottingham Digestive Diseases Centre, School of Medicine, University of Nottingham, Nottingham, UK
| | - Naaventhan Palaniyappan
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK
- Nottingham Digestive Diseases Centre, School of Medicine, University of Nottingham, Nottingham, UK
| | - Louise China
- Institute of Liver Disease and Digestive Health, University College London, London, UK
| | - Suvi Härmälä
- Institute of Health Informatics, University College London, London, UK
| | - Lucia Macken
- Department of Clinical and Experimental Medicine, Brighton and Sussex Medical School, Brighton, UK
- Department of Gastroenterology and Hepatology, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Jennifer M Ryan
- Institute of Liver Disease and Digestive Health, University College London, London, UK
- Royal Free London NHS Foundation Trust, London, UK
| | - Emilie A Wilkes
- Nottingham Digestive Diseases Centre, School of Medicine, University of Nottingham, Nottingham, UK
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Kevin Moore
- Institute of Liver Disease and Digestive Health, University College London, London, UK
| | - Joanna A Leithead
- Liver Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Peter C Hayes
- Hepatology Department, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Alastair J O'Brien
- Institute of Liver Disease and Digestive Health, University College London, London, UK
| | - Sumita Verma
- Department of Clinical and Experimental Medicine, Brighton and Sussex Medical School, Brighton, UK
- Department of Gastroenterology and Hepatology, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
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Macken L, Bremner S, Sheridan D, Verma S. Letter: long-term abdominal drains in refractory ascites-evolving concept of palliative care in decompensated cirrhosis. Authors' reply. Aliment Pharmacol Ther 2020; 52:1268-1269. [PMID: 33016545 DOI: 10.1111/apt.15983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
- Lucia Macken
- Department of Clinical and Experimental Medicine, Brighton and Sussex Medical School, Brighton, UK.,Department of Gastroenterology and Hepatology, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | | | - David Sheridan
- Institute of Translational & Stratified Medicine, University of Plymouth, Plymouth, UK.,South West Liver Unit, University Hospital Plymouth NHS Trust, Plymouth, UK
| | - Sumita Verma
- Department of Clinical and Experimental Medicine, Brighton and Sussex Medical School, Brighton, UK.,Department of Gastroenterology and Hepatology, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
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Macken L, Bremner S, Sheridan D, Verma S. Editorial: palliative long-term abdominal drains in refractory ascites-a step in the right direction, but not the complete solution. Authors' reply. Aliment Pharmacol Ther 2020; 52:723-724. [PMID: 32886369 DOI: 10.1111/apt.15928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
- Lucia Macken
- Department of Clinical and Experimental Medicine, Brighton and Sussex Medical School, Brighton, UK.,Department of Gastroenterology and Hepatology, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | | | - David Sheridan
- Institute of Translational & Stratified Medicine, University of Plymouth and South West Liver Unit, University Hospital Plymouth NHS Trust, Plymouth, UK
| | - Sumita Verma
- Department of Clinical and Experimental Medicine, Brighton and Sussex Medical School, Brighton, UK.,Department of Gastroenterology and Hepatology, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
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Macken L, Bremner S, Gage H, Touray M, Williams P, Crook D, Mason L, Lambert D, Evans CJ, Cooper M, Timeyin J, Steer S, Austin M, Parnell N, Thomson SJ, Sheridan D, Wright M, Isaacs P, Hashim A, Verma S. Randomised clinical trial: palliative long-term abdominal drains vs large-volume paracentesis in refractory ascites due to cirrhosis. Aliment Pharmacol Ther 2020; 52:107-122. [PMID: 32478917 DOI: 10.1111/apt.15802] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 02/12/2020] [Accepted: 04/28/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Palliative care remains suboptimal in end-stage liver disease. AIM To inform a definitive study, we assessed palliative long-term abdominal drains in end-stage liver disease to determine recruitment, attrition, safety/potential effectiveness, questionnaires/interview uptake/completion and make a preliminary cost comparison. METHODS A 12-week feasibility nonblinded randomised controlled trial comparing large-volume paracentesis vs long-term abdominal drains in refractory ascites due to end-stage liver disease with fortnightly home visits for clinical/questionnaire-based assessments. Study success criteria were attrition not >50%, <10% long-term abdominal drain removal due to complications, the long-term abdominal drain group to spend <50% ascites-related study time in hospital vs large-volume paracentesis group and 80% questionnaire/interview uptake/completion. RESULTS Of 59 eligible patients, 36 (61%) were randomised, 17 to long-term abdominal drain and 19 to large-volume paracentesis. Following randomisation, median number (IQR) of hospital ascitic drains (long-term abdominal drain group vs large-volume paracentesis group) were 0 (0-1) vs 4 (3-7); week 12 serum albumin (g/L) and serum creatinine (μmol/L) were 29 (26.5-32.5) vs 30 (25-35) and 104.5 (81-115.5) vs 127 (63-158) respectively. Total attrition was 42% (long-term abdominal drain group 47%, large-volume paracentesis group 37%). Median (IQR) fortnightly community/hospital/social care ascites-related costs and percentage study time in hospital were lower in the long-term abdominal drain group, £329 (253-580) vs £843 (603-1060) and 0% (0-0.74) vs 2.75% (2.35-3.84) respectively. Self-limiting cellulitis/leakage occurred in 41% (7/17) in the long-term abdominal drain group vs 11% (2/19) in the large-volume paracentesis group; peritonitis incidence was 6% (1/17) vs 11% (2/19) respectively. Questionnaires/interview uptake/completion were ≥80%; interviews indicated that long-term abdominal drains could transform the care pathway. CONCLUSIONS The REDUCe study demonstrates feasibility with preliminary evidence of long-term abdominal drain acceptability/effectiveness/safety and reduction in health resource utilisation. TRIAL REGISTRATION ISRCTN30697116, date assigned: 07/10/2015.
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Macken L, Hashim A, Mason L, Verma S. Permanent indwelling peritoneal catheters for palliation of refractory ascites in end-stage liver disease: A systematic review. Liver Int 2019; 39:1594-1607. [PMID: 31152623 DOI: 10.1111/liv.14162] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 05/26/2019] [Accepted: 05/28/2019] [Indexed: 02/13/2023]
Abstract
BACKGROUND & AIMS The incidence and mortality from end-stage liver disease is increasing, with a minority eligible for liver transplantation. Ascites is the commonest complication of end-stage liver disease and large volume paracentesis (LVP) the accepted management strategy where refractory to medical treatment. In malignant ascites, permanent indwelling peritoneal catheters (PIPC) are an established palliative intervention. The aims are to describe available data using permanent indwelling peritoneal catheters in refractory ascites due to end-stage liver disease. METHODS Using systematic review methodology, databases were searched (MEDLINE, EMBASE, CINAHL [The Cumulative Index to Nursing and Allied Health Literature], Google Scholar and Cochrane Database of Systematic Reviews from inception-March 2018), for studies combining ascites and palliative care. Inclusion and exclusion criteria were applied to results. RESULTS Following initial and updated searches, 225 studies were identified for full text review, 18 were eligible for final analysis. The studies displayed heterogeneity in design, reported on different indwelling catheters and were overall of low quality. Only one pilot randomised controlled trial was identified, of PIPC versus LVP, recruiting one patient into each arm. Technical insertion success was 100%, with low rates of non-infectious complications (<12%), none life threatening. Rates of bacterial peritonitis were not unacceptably high (12.7%), considering this was an end-stage liver disease population and only a minority utilising long-term prophylactic antibiotics. Only one study attempted quality-of-life assessments; none addressed potential health economic benefits. CONCLUSIONS Despite lack of well-designed studies, preliminary data suggests low significant complication rates; however safety and efficacy of permanent indwelling peritoneal catheters in end-stage liver disease remains to be confirmed. Further prospective randomised controlled trials are warranted, potentially translating permanent indwelling peritoneal catheters into improved palliative care in end-stage liver disease.
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Affiliation(s)
- Lucia Macken
- Department of Clinical and Experimental Medicine, Brighton and Sussex Medical School, Brighton, UK.,Department of Gastroenterology and Hepatology, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Ahmed Hashim
- Department of Clinical and Experimental Medicine, Brighton and Sussex Medical School, Brighton, UK.,Department of Gastroenterology and Hepatology, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Louise Mason
- Department of Palliative Care, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Sumita Verma
- Department of Clinical and Experimental Medicine, Brighton and Sussex Medical School, Brighton, UK.,Department of Gastroenterology and Hepatology, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
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Macken L, Gelson W, Priest M, Abouda G, Barclay S, Fraser A, Healy B, Irving W, Verma S. Efficacy of direct-acting antivirals: UK real-world data from a well-characterised predominantly cirrhotic HCV cohort. J Med Virol 2019; 91:1979-1988. [PMID: 31329295 DOI: 10.1002/jmv.25552] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 07/15/2019] [Indexed: 12/16/2022]
Abstract
Direct-acting antivirals (DAAs) have revolutionised the management of chronic hepatitis C virus (HCV) infection. We describe UK real-world DAA experience. Individuals commencing HCV treatment containing a DAA regimen (Mar 2014-Nov 2016), participating in the National HCV Research UK (HCVRUK) Cohort Study were recruited from 33 UK HCV centers. The data were prospectively entered at sites onto a centralised database. The data were reported as median (Q1-Q3). Of the 1448 treated patients, 1054 (73%) were males, the median age being 54 years (47-60), 900 (62%) being genotype 1 and 455 (31%) genotype 3. The majority, 887 (61%) had cirrhosis, and 590 (41%) were treatment-experienced. DAA regimens utilised: genotype1 sofosbuvir (SOF)/Ledipasvir/±Ribavirin (625/900, 69%) and Ombitasvir/Paritaprevir/Dasabuvir/±RBV (220/900, 24%), and in genotype 3 SOF/Daclatasvir + RBV (256/455, 56%) and SOF/pegylated interferon/RBV (157/455, 35%). Overall, 1321 (91%) achieved sustained virological response (SVR12), genotype 1 vs 3, 93% vs 87%, P < .001. Prior treatment, presence of cirrhosis and treatment regimen did not impact SVR12. Predictors of treatment failure were genotype 3 infection, OR, 2.015 (95% CI: 1.279-3.176, P = .003), and male sex, OR, 1.878 (95% CI: 1.071-3.291, P = .028). Of those with hepatic decompensation at baseline (n = 39), 51% (n = 20) recompensated post-treatment, lower baseline serum creatinine being associated with recompensation (P = .029). There were two liver-related deaths, both having decompensated disease. This real-world UK data, comprising of a predominantly cirrhotic HCV genotype 1/3 cohort, confirms DAA efficacy with an overall 91% SVR12, with 51% recompensating post-treatment. Genotype 3 infection was a predictor of treatment failure.
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Affiliation(s)
- Lucia Macken
- Department of Clinical and Experimental Medicine, Brighton and Sussex Medical School (BSMS), Brighton, UK.,Department of Gastroenterology and Hepatology, Brighton and Sussex University Hospital (BSUH) NHS Trust, Brighton, UK
| | - William Gelson
- Cambridge Liver Unit, Cambridge University Hospitals NHS Trust, Cambridge, UK
| | - Matthew Priest
- Department of Gastroenterology and Hepatology, Greater Glasgow and Clyde Hospitals NHS Trust, Scotland
| | - George Abouda
- Department of Gastroenterology and Hepatology, Hull and East Yorkshire Hospitals NHS Trust, Hull, UK
| | - Stephen Barclay
- Department of Gastroenterology and Hepatology, Greater Glasgow and Clyde Hospitals NHS Trust, Scotland.,School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, Scotland
| | - Andrew Fraser
- Department of Gastroenterology and Hepatology, Grampian Hospitals NHS Trust, Scotland
| | - Brendan Healy
- Department of Gastroenterology and Hepatology, GIG CYMRU NHS Wales, Wales
| | - Will Irving
- National Institute for Health Research (NIHR) Nottingham BioMedical Research Unit, Nottingham University Hospitals NHS Trust and the University of Nottingham, UK
| | - Sumita Verma
- Department of Clinical and Experimental Medicine, Brighton and Sussex Medical School (BSMS), Brighton, UK.,Department of Gastroenterology and Hepatology, Brighton and Sussex University Hospital (BSUH) NHS Trust, Brighton, UK
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Macken L, Mason L, Evans C, Gage H, Jordan J, Austin M, Parnell N, Cooper M, Steer S, Boles J, Bremner S, Lambert D, Crook D, Earl G, Timeyin J, Verma S. Correction to: Palliative long-term abdominal drains versus repeated drainage in individuals with untreatable ascites due to advanced cirrhosis: study protocol for a feasibility randomised controlled trial. Trials 2018; 19:488. [PMID: 30213268 PMCID: PMC6136225 DOI: 10.1186/s13063-018-2883-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Accepted: 08/28/2018] [Indexed: 11/30/2022] Open
Affiliation(s)
- Lucia Macken
- Department of Clinical and Experimental Medicine, Brighton and Sussex Medical School, University of Sussex, Main Teaching Building, North South Road, Falmer, Brighton, East Sussex, BN1 9PX, UK.,Department of Gastroenterology and Hepatology, Brighton and Sussex University Hospitals Trust, Royal Sussex County Hospital, Eastern Rd, Brighton, East Sussex, BN2 5BE, UK
| | - Louise Mason
- Department of Palliative Medicine, Brighton and Sussex University Hospitals Trust, Royal Sussex County Hospital, Eastern Rd, Brighton, East Sussex, BN2 5BE, UK
| | - Catherine Evans
- King's College, Cicely Saunders Institute, Department of Palliative Care, Policy and Rehabilitation, Bessemer Road, London, SE5 9PJ, UK.,Sussex Community NHS Foundation Trust, Brighton General Hospital, Elm Grove, Brighton, BN2 3EW, UK
| | - Heather Gage
- Surrey Health Economics Centre, School of Economics, Faculty of Arts and Social Sciences, University of Surrey, Guildford, Surrey, GU2 7XH, UK
| | - Jake Jordan
- Surrey Health Economics Centre, School of Economics, Faculty of Arts and Social Sciences, University of Surrey, Guildford, Surrey, GU2 7XH, UK
| | - Mark Austin
- Department of Gastroenterology and Hepatology, Brighton and Sussex University Hospitals Trust, Royal Sussex County Hospital, Eastern Rd, Brighton, East Sussex, BN2 5BE, UK
| | - Nick Parnell
- Department of Gastroenterology and Hepatology, Brighton and Sussex University Hospitals Trust, Royal Sussex County Hospital, Eastern Rd, Brighton, East Sussex, BN2 5BE, UK
| | - Max Cooper
- Department of Clinical and Experimental Medicine, Brighton and Sussex Medical School, University of Sussex, Main Teaching Building, North South Road, Falmer, Brighton, East Sussex, BN1 9PX, UK
| | - Shani Steer
- Brighton & Sussex Clinical Trials Unit, University of Brighton, Room 204 Bevendean House, Falmer, BN1 9PH, UK
| | - Justine Boles
- Brighton & Sussex Clinical Trials Unit, University of Brighton, Room 204 Bevendean House, Falmer, BN1 9PH, UK
| | - Stephen Bremner
- Brighton & Sussex Clinical Trials Unit, University of Brighton, Room 204 Bevendean House, Falmer, BN1 9PH, UK.,Department of Primary Care and Public Health, Brighton and Sussex Medical School, Mayfield House, Brighton, BN1 9PH, UK
| | - Debbie Lambert
- Brighton & Sussex Clinical Trials Unit, University of Brighton, Room 204 Bevendean House, Falmer, BN1 9PH, UK
| | - David Crook
- Brighton & Sussex Clinical Trials Unit, University of Brighton, Room 204 Bevendean House, Falmer, BN1 9PH, UK
| | - Gemma Earl
- Brighton & Sussex Clinical Trials Unit, University of Brighton, Room 204 Bevendean House, Falmer, BN1 9PH, UK
| | - Jean Timeyin
- Brighton & Sussex Clinical Trials Unit, University of Brighton, Room 204 Bevendean House, Falmer, BN1 9PH, UK
| | - Sumita Verma
- Department of Clinical and Experimental Medicine, Brighton and Sussex Medical School, University of Sussex, Main Teaching Building, North South Road, Falmer, Brighton, East Sussex, BN1 9PX, UK. .,Department of Gastroenterology and Hepatology, Brighton and Sussex University Hospitals Trust, Royal Sussex County Hospital, Eastern Rd, Brighton, East Sussex, BN2 5BE, UK.
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Macken L, Mason L, Evans C, Gage H, Jordan J, Austin M, Parnell N, Cooper M, Steer S, Boles J, Bremner S, Lambert D, Crook D, Earl G, Timeyin J, Verma S. Palliative long-term abdominal drains versus repeated drainage in individuals with untreatable ascites due to advanced cirrhosis: study protocol for a feasibility randomised controlled trial. Trials 2018; 19:401. [PMID: 30053891 PMCID: PMC6062920 DOI: 10.1186/s13063-018-2779-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2017] [Accepted: 06/29/2018] [Indexed: 01/28/2023] Open
Abstract
Background UK deaths due to chronic liver diseases such as cirrhosis have quadrupled over the last 40 years, making this condition now the third most common cause of premature death. Most patients with advanced cirrhosis (end-stage liver disease [ESLD]) develop ascites. This is often managed with diuretics, but if refractory, then the fluid is drained from the peritoneal cavity every 10–14 days by large volume paracentesis (LVP), a procedure requiring hospital admissions. As the life expectancy of patients with ESLD and refractory ascites (if ineligible for liver transplantation) is on average ≤ 6 months, frequent hospital visits are inappropriate from a palliative perspective. One alternative is long-term abdominal drains (LTADs), used successfully in patients whose ascites is due to malignancy. Although inserted in hospital, these drains allow ascites management outside of a hospital setting. LTADs have not been formally evaluated in patients with refractory ascites due to ESLD. Methods/design Due to uncertainty about appropriate outcome measures and whether patients with ESLD would wish or be able to participate in a study, a feasibility randomised controlled trial (RCT) was designed. Patients were consulted on trial design. We plan to recruit 48 patients with refractory ascites and randomise them (1:1) to either (1) LTAD or (2) current standard of care (LVP) for 12 weeks. Outcomes of interest include acceptability of the LTAD to patients, carers and healthcare professionals as well as recruitment and retention rates. The Integrated Palliative care Outcome Scale, the Short Form Liver Disease Quality of Life questionnaire, the EuroQol 5 dimensions instrument and carer-reported (Zarit Burden Interview) outcomes will also be assessed. Preliminary data on cost-effectiveness will be collected, and patients and healthcare professionals will be interviewed about their experience of the trial with a view to identifying barriers to recruitment. Discussion LTADs could potentially improve end-of-life care in patients with refractory ascites due to ESLD by improving symptom control, reducing hospital visits and enabling some self-management. Our trial is designed to see if such patients can be recruited, as well as to inform the design of a subsequent definitive trial. Trial registration ISRCTN, ISRCTN30697116. Registered on 7 October 2015. Electronic supplementary material The online version of this article (10.1186/s13063-018-2779-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Lucia Macken
- Department of Clinical and Experimental Medicine, Brighton and Sussex Medical School, Main Teaching Building, North South Road, University of Sussex, Falmer, Brighton, East Sussex, BN1 9PX, UK.,Department of Gastroenterology and Hepatology, Brighton and Sussex University Hospitals Trust, Royal Sussex County Hospital, Eastern Rd, Brighton, East Sussex, BN2 5BE, UK
| | - Louise Mason
- Department of Palliative Medicine, Brighton and Sussex University Hospitals Trust, Royal Sussex County Hospital, Eastern Rd, Brighton, East Sussex, BN2 5BE, UK
| | - Catherine Evans
- King's College, Cicely Saunders Institute, Department of Palliative Care, Policy and Rehabilitation, Bessemer Road, London, SE5 9PJ, UK.,Sussex Community NHS Foundation Trust, Brighton General Hospital, Elm Grove, Brighton, BN2 3EW, UK
| | - Heather Gage
- Surrey Health Economics Centre, School of Economics, Faculty of Arts and Social Sciences, University of Surrey, Guildford, Surrey, GU2 7XH, UK
| | - Jake Jordan
- Surrey Health Economics Centre, School of Economics, Faculty of Arts and Social Sciences, University of Surrey, Guildford, Surrey, GU2 7XH, UK
| | - Mark Austin
- Department of Gastroenterology and Hepatology, Brighton and Sussex University Hospitals Trust, Royal Sussex County Hospital, Eastern Rd, Brighton, East Sussex, BN2 5BE, UK
| | - Nick Parnell
- Department of Gastroenterology and Hepatology, Brighton and Sussex University Hospitals Trust, Royal Sussex County Hospital, Eastern Rd, Brighton, East Sussex, BN2 5BE, UK
| | - Max Cooper
- Department of Clinical and Experimental Medicine, Brighton and Sussex Medical School, Main Teaching Building, North South Road, University of Sussex, Falmer, Brighton, East Sussex, BN1 9PX, UK
| | - Shani Steer
- Brighton & Sussex Clinical Trials Unit, Room 204 Bevendean House, University of Brighton, Falmer, BN1 9PH, UK
| | - Justine Boles
- Brighton & Sussex Clinical Trials Unit, Room 204 Bevendean House, University of Brighton, Falmer, BN1 9PH, UK
| | - Stephen Bremner
- Brighton & Sussex Clinical Trials Unit, Room 204 Bevendean House, University of Brighton, Falmer, BN1 9PH, UK.,Department of Primary Care and Public Health, Brighton and Sussex Medical School, Mayfield House, Brighton, BN1 9PH, UK
| | - Debbie Lambert
- Brighton & Sussex Clinical Trials Unit, Room 204 Bevendean House, University of Brighton, Falmer, BN1 9PH, UK
| | - David Crook
- Brighton & Sussex Clinical Trials Unit, Room 204 Bevendean House, University of Brighton, Falmer, BN1 9PH, UK
| | - Gemma Earl
- Brighton & Sussex Clinical Trials Unit, Room 204 Bevendean House, University of Brighton, Falmer, BN1 9PH, UK
| | - Jean Timeyin
- Brighton & Sussex Clinical Trials Unit, Room 204 Bevendean House, University of Brighton, Falmer, BN1 9PH, UK
| | - Sumita Verma
- Department of Clinical and Experimental Medicine, Brighton and Sussex Medical School, Main Teaching Building, North South Road, University of Sussex, Falmer, Brighton, East Sussex, BN1 9PX, UK. .,Department of Gastroenterology and Hepatology, Brighton and Sussex University Hospitals Trust, Royal Sussex County Hospital, Eastern Rd, Brighton, East Sussex, BN2 5BE, UK.
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Macken L, Joshi D, Messenger J, Austin M, Tibble J, Mason L, Verma S. Palliative long-term abdominal drains in refractory ascites due to end-stage liver disease: A case series. Palliat Med 2017; 31:671-675. [PMID: 27707955 DOI: 10.1177/0269216316671281] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Ascites, the commonest complication of cirrhosis, leads to frequent hospitalisations. Refractory ascites confers a median survival of 6 months without liver transplantation. In many, the management remains palliative (large-volume paracentesis). Despite calls for improvement, palliative and end-of-life care is not yet integrated into end-stage liver disease. Long-term abdominal drains are a palliative strategy in malignant ascites, but not end-stage liver disease. CASE PRESENTATION A retrospective, single centre, case series review was performed of patients undergoing long-term abdominal drain placement for refractory ascites secondary to end-stage liver disease at a large teaching hospital between August 2011 and March 2013. Case management: Patients with end-stage liver disease and refractory ascites, where liver transplantation was not an option, were considered for long-term abdominal drains. Seven patients underwent successful long-term abdominal drain insertion after multi-professional assessment. Case outcome: Following long-term abdominal drain insertion, mean hospital attendances reduced to 1 (0-4) from 9 (4-21), with none for ascites management. Median survival after long-term abdominal drain insertion was 29 days (8-219). The complication rate was low and none life threatening. CONCLUSION Palliative and end-of-life care needs in end-stage liver disease remain under-addressed. Our data suggest that long-term abdominal drains may be a safe and effective palliative intervention in end-stage liver disease. Prospective randomised controlled trials comparing large-volume paracentesis versus long-term abdominal drains in refractory ascites secondary to end-stage liver disease are warranted.
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Affiliation(s)
- Lucia Macken
- 1 Department of Gastroenterology and Hepatology, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK.,2 Department of Medicine, Brighton and Sussex Medical School, Brighton, UK
| | - Deepak Joshi
- 3 Institute of Hepatology, King's College Hospital NHS Foundation Trust, London, UK
| | - Jenny Messenger
- 4 Department of Medicine, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Mark Austin
- 1 Department of Gastroenterology and Hepatology, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Jeremy Tibble
- 1 Department of Gastroenterology and Hepatology, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Louise Mason
- 5 Department of Palliative Care, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Sumita Verma
- 1 Department of Gastroenterology and Hepatology, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK.,2 Department of Medicine, Brighton and Sussex Medical School, Brighton, UK
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Rampton DS, Goodhand JR, Joshi NM, Karim AB, Koodun Y, Barakat FM, Macken L, Ward DG, Iqbal TH, Epstein J, Fell JM, Sanderson IR. Oral Iron Treatment Response and Predictors in Anaemic Adolescents and Adults with IBD: A Prospective Controlled Open-Label Trial. J Crohns Colitis 2017; 11:706-715. [PMID: 27932449 PMCID: PMC5881709 DOI: 10.1093/ecco-jcc/jjw208] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Accepted: 11/14/2016] [Indexed: 12/16/2022]
Abstract
BACKGROUND Because of previous concerns about the efficacy and safety of oral iron for treating iron deficiency anaemia in inflammatory bowel disease [IBD], particularly in young people, we compared the effects of ferrous sulphate on haemoglobin response, disease activity and psychometric scores in adolescents and adults with IBD. We also assessed the relation of baseline serum hepcidin to haemoglobin response. METHODS We undertook a prospective, open-label, 6-week non-inferiority trial of the effects of ferrous sulphate 200 mg twice daily on haemoglobin, iron status, hepcidin, disease activity (Harvey-Bradshaw Index, Simple Colitis Clinical Activity Index, C-reactive protein [CRP]), faecal calprotectin and psychometric scores in 45 adolescents [age 13-18 years] and 43 adults [>18 years]. RESULTS On intention-to-treat analysis, ferrous sulphate produced similar rises in haemoglobin in adolescents {before treatment 10.3 g/dl [0.18] (mean [SEM]), after 11.7 [0.23]: p < 0.0001} and adults (10.9 g/dl [0.14], 11.9 [0.19]: p < 0.0001); transferrin saturation, ferritin [in adolescents] and hepcidin [in adults] also increased significantly. On per-protocol univariate analysis, the haemoglobin response was inversely related to baseline haemoglobin, CRP and hepcidin. Oral iron did not alter disease activity; it improved Short IBDQ and Perceived Stress Questionnaire scores in adults. CONCLUSION Oral ferrous sulphate was no less effective or well-tolerated in adolescents than adults, and did not increase disease activity in this short-term study. The inverse relation between baseline CRP and hepcidin levels and the haemoglobin response suggests that CRP or hepcidin measurements could influence decisions on whether iron should be given orally or intravenously. [ClinTrials.gov registration number NCT01991314].
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Affiliation(s)
- David S. Rampton
- Centre for Immunobiology, Institute of Cell and Molecular Science, Barts and the London School of Medicine and Dentistry, London,UK
| | - James R. Goodhand
- Centre for Immunobiology, Institute of Cell and Molecular Science, Barts and the London School of Medicine and Dentistry, London,UK
| | - Neerav M. Joshi
- Centre for Immunobiology, Institute of Cell and Molecular Science, Barts and the London School of Medicine and Dentistry, London,UK
| | - Abu-Bakarr Karim
- Centre for Immunobiology, Institute of Cell and Molecular Science, Barts and the London School of Medicine and Dentistry, London,UK
| | - Yasmine Koodun
- Centre for Immunobiology, Institute of Cell and Molecular Science, Barts and the London School of Medicine and Dentistry, London,UK
| | - Farah M. Barakat
- Centre for Immunobiology, Institute of Cell and Molecular Science, Barts and the London School of Medicine and Dentistry, London,UK
| | - Lucia Macken
- Centre for Immunobiology, Institute of Cell and Molecular Science, Barts and the London School of Medicine and Dentistry, London,UK
| | - Douglas G. Ward
- Department of Gastroenterology, University Hospital Birmingham, Birmingham, UK
| | - Tariq H. Iqbal
- Department of Gastroenterology, University Hospital Birmingham, Birmingham, UK
| | - Jenny Epstein
- Department of Paediatric Gastroenterology, Chelsea and Westminster Hospital, London, UK
| | - John M. Fell
- Department of Paediatric Gastroenterology, Chelsea and Westminster Hospital, London, UK
| | - Ian R. Sanderson
- Centre for Immunobiology, Institute of Cell and Molecular Science, Barts and the London School of Medicine and Dentistry, London,UK
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Abstract
Ulcerative colitis (UC) presents as an acute severe flare in 10-15% of new cases and it occurs in 15% of patients with established disease. Acute severe UC can lead to significant morbidity and mortality in predominantly younger patients without other comorbidities. Inpatient hospital admission and a multidisciplinary approach are vital in appropriate and timely management. Important but simple aspects in the initial work-up and treatment of such patients are frequently overlooked during the acute medical take. An overview of the general and more specialist management of this important presentation are discussed herein.
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Affiliation(s)
- Lucia Macken
- Tunbridge Wells Hospital at Pembury, Pembury, UK
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Goodhand JR, Kamperidis N, Sirwan B, Macken L, Tshuma N, Koodun Y, Chowdhury FA, Croft NM, Direkze N, Langmead L, Irving PM, Rampton DS, Lindsay JO. Factors associated with thiopurine non-adherence in patients with inflammatory bowel disease. Aliment Pharmacol Ther 2013; 38:1097-108. [PMID: 24099471 DOI: 10.1111/apt.12476] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2013] [Revised: 06/05/2013] [Accepted: 08/15/2013] [Indexed: 12/22/2022]
Abstract
BACKGROUND Medication non-adherence seems to be a particular problem in younger patients with inflammatory bowel disease (IBD) and has a negative impact on disease outcome. AIMS To assess whether non-adherence, defined using thiopurine metabolite levels, is more common in young adults attending a transition clinic than adults with IBD and whether psychological co-morbidity is a contributing factor. We also determined the usefulness of the Modified Morisky 8-item Adherence Scale (MMAS-8) to detect non-adherence. METHODS Seventy young adults [51% (36) male] and 74 [62% (46) male] adults were included. Psychological co-morbidity was assessed using the Hospital Anxiety Depression Scale (HADS) and self-reported adherence using the MMAS-8. RESULTS Twelve percent (18/144) of the patients were non-adherent. Multivariate analysis [OR, (95% CI), P value] confirmed that being young adult [6.1 (1.7-22.5), 0.001], of lower socio-economic status [1.1 (1.0-1.1), <0.01] and reporting higher HADS-D scores [1.2 (1.0-1.4), 0.01] were associated with non-adherence. Receiver operator curve analysis of MMAS-8 scores gave an area under the curve (95% CI) of 0.85 (0.77-0.92), (P < 0.0001): using a cut-off of <6, the MMAS-8 score has a sensitivity of 94% and a specificity of 64% to predict thiopurine non-adherence. Non-adherence was associated with escalation in therapy, hospital admission and surgeries in the subsequent 6 months of follow up. CONCLUSIONS Non-adherence to thiopurines is more common in young adults with inflammatory bowel disease, and is associated with lower socio-economic status and depression. The high negative predictive value of MMAS-8 scores <6 suggests that it could be a useful screen for thiopurine non-adherence.
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Affiliation(s)
- J R Goodhand
- Centre for Digestive Diseases, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
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Bird S, Macken L, Flower O, Yarad E, Bass F, Hammond N, LaCour D, Strasma P, Finfer S. Successful use of a novel continuous intra-arterial blood glucose monitoring device under development in ICU patients following cardiac surgery. Aust Crit Care 2013. [DOI: 10.1016/j.aucc.2013.02.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Bird S, Macken L, Flower O, Bass F, Hammond N, Webb S, Kennedy N, Baker A, Yarad E, Chau C, Librande M, Strasma P, Finfer S. Continuous arterial and venous glucose monitoring by quenched chemical fluorescence in ICU patients after cardiac surgery. Crit Care 2013. [PMCID: PMC3643151 DOI: 10.1186/cc12399] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Affiliation(s)
- Neerav M Joshi
- Centre for Digestive Diseases, Blizard Institute of Cell & Molecular Science, Barts & the London School of Medicine & Dentistry, Queen Mary, University of London
| | - Lucia Macken
- Centre for Digestive Diseases, Blizard Institute of Cell & Molecular Science, Barts & the London School of Medicine & Dentistry, Queen Mary, University of London
| | - David S Rampton
- Centre for Digestive Diseases, Blizard Institute of Cell & Molecular Science, Barts & the London School of Medicine & Dentistry, Queen Mary, University of London
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Bird S, Macken L, Flower O, Yarad E, Bass F, Hammond N, LaCour D, Strasma P, Finfer S. Initial experience with continuous intra-arterial fluorescent glucose monitoring in patients in the ICU following cardiac surgery. Crit Care 2012. [PMCID: PMC3363592 DOI: 10.1186/cc10781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- S Bird
- Royal North Shore Hospital, St Leonards, NSW, Australia
| | - L Macken
- Royal North Shore Hospital, St Leonards, NSW, Australia
| | - O Flower
- Royal North Shore Hospital, St Leonards, NSW, Australia
| | - E Yarad
- Royal North Shore Hospital, St Leonards, NSW, Australia
| | - F Bass
- Royal North Shore Hospital, St Leonards, NSW, Australia
| | - N Hammond
- Royal North Shore Hospital, St Leonards, NSW, Australia
| | - D LaCour
- GluMetrics, Inc., Irvine, CA, USA
| | | | - S Finfer
- Royal North Shore Hospital, St Leonards, NSW, Australia
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Laurent S, Franchimont D, Coppens JP, Leunen K, Macken L, Peeters M, Plomteux O, Polus M, Poppe B, Sempoux C, Tejpar S, Van Den Eynde M, Van Gossum A, Vannoote J, Kartheuser A, Van Cutsem E. Familial adenomatous polyposis: clinical presentation, detection and surveillance. Acta Gastroenterol Belg 2011; 74:415-420. [PMID: 22103047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Colorectal cancer (CRC) is a leading cause of cancer related death in the western countries. It remains an important health problem, often under-diagnosed. The symptoms can appear very late and about 25% of the patients are diagnosed at metastatic stage. Familial adenomatous polyposis (FAP) is an inherited colorectal cancer syndrome, characterized by the early onset of hundred to thousands of adenomatous polyps in the colon and rectum. Left untreated, there is a nearly 100% cumulative risk of progression to CRC by the age of 35-40 years, as well as an increased risk of various other malignancies. CRC can be prevented by the identification of the high risk population and by the timely implementation of rigid screening programs which will lead to special medico-surgical interventions.
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Affiliation(s)
- S Laurent
- Belgian Polyposis Project, Familial Adenomatous Polyposis Association (FAPA), Brussels.
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Macken L. Emergency Medicine: Diagnosis and Management, 2nd edn. Intern Med J 2003. [DOI: 10.1046/j.1445-5994.2002.00318.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Morris R, Macken L, Tall G. Failure of exhalation during ventilation with the Dräger Oxylog 2000 ventilator. Anaesth Intensive Care 1999; 27:400-4. [PMID: 10470397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
Abstract
We describe three cases in which there was failure of exhalation during mechanical ventilation with the Dräger Oxylog 2000 ventilator. Two potential mechanisms for this failure were identified, and were then experimentally reproduced on a test lung. First, a manufacturing fault in the silicone diaphragm in the ventilation valve was discovered. When a small hole in the diaphragm was incompletely perforated, a possible flap valve was formed, limiting exhalation. Second, failure of the one-way rubber disc valve to seat properly in its housing also prevented exhalation. These two previously unreported modes of ventilator failure have been identified. Careful checking of the ventilator circuit before each use is required.
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Affiliation(s)
- R Morris
- Department of Trauma, St George Hospital, Sydney, N.S.W
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