Prospective validation of the EASL management algorithm for acute kidney injury in cirrhosis.

BACKGROUND & AIMS: The management of acute kidney injury (AKI) in cirrhosis is challenging. The EASL guidelines proposed an algorithm for the management of AKI, but this has never been validated. We aimed to prospectively evaluate this algorithm in clinical practice. METHODS: We performed a prospective cohort study in consecutive hospitalized patients with cirrhosis and AKI. The EASL management algorithm includes identification/treatment of precipitating factors, 2-day albumin infusion in patients with AKI ≥stage 1B, and treatment with terlipressin in patients with hepatorenal syndrome (HRS-AKI). The primary outcome was treatment response, which included both full and partial response. Secondary outcomes were survival and adverse events associated with terlipressin therapy. RESULTS: A total of 202 AKI episodes in 139 patients were included. Overall treatment response was 80%, while renal replacement therapy was required in only 8%. Response to albumin infusion was achieved in one-third of episodes. Of patients not responding to albumin, most (74%) did not meet the diagnostic criteria of HRS-AKI, with acute tubular necrosis (ATN) being the most common phenotype. The response rate in patients not meeting the criteria for HRS-AKI was 70%. Only 30 patients met the diagnostic criteria for HRS-AKI, and their response rate to terlipressin was 61%. Median time from AKI diagnosis to terlipressin initiation was only 2.5 days. While uNGAL (urinary neutrophil gelatinase-associated lipocalin) could differentiate ATN from other phenotypes (AUROC 0.78), it did not predict response to therapy in HRS-AKI. Ninety-day transplant-free survival was negatively associated with MELD-Na, ATN and HRS-AKI as well as uNGAL. Three patients treated with terlipressin developed pulmonary edema. CONCLUSIONS: The application of the EASL AKI algorithm is associated with very good response rates and does not significantly delay initiation of terlipressin therapy. IMPACT AND IMPLICATIONS: The occurrence of acute kidney injury (AKI) in patients with cirrhosis is associated with poor short-term mortality. Improving its rapid identification and prompt management was the focus of the recently proposed EASL AKI algorithm. This is the first prospective study demonstrating that high AKI response rates are achieved with the use of this algorithm, which includes identification of AKI, treatment of precipitating factors, a 2-day albumin challenge in patients with AKI ≥1B, and supportive therapy in patients with persistent AKI not meeting HRS-AKI criteria or terlipressin with albumin in those with HRS-AKI. These findings support the use of this algorithm in clinical practice.

Alcoholic Foamy Degeneration, an Entity Resembling Alcohol-Associated Hepatitis: Diagnosis, Prognosis, and Molecular Profiling.

BACKGROUND & AIMS: Alcoholic foamy degeneration (AFD) is a condition with similar clinical presentation to alcohol-associated hepatitis (AH), but with a specific histologic pattern. Information regarding the prevalence and prognosis of AFD is scarce and there are no tools for a noninvasive diagnosis. METHODS: A cohort of patients admitted to the Hospital Clinic of Barcelona for clinical suspicion of AH who underwent liver biopsy was included. Patients were classified as AFD, AH, or other findings, according to histology. Clinical features, histology, and genetic expression of liver biopsy specimens were analyzed. The accuracy of National Institute on Alcohol Abuse and Alcoholism criteria and laboratory parameters for differential diagnosis were investigated. RESULTS: Of 230 patients with a suspicion of AH, 18 (8%) met histologic criteria for AFD, 184 (80%) had definite AH, and 28 (12%) had other findings. In patients with AFD, massive steatosis was more frequent and the fibrosis stage was lower. AFD was characterized by down-regulation of liver fibrosis and inflammation genes and up-regulation of lipid metabolism and mitochondrial function genes. Patients with AFD had markedly better long-term survival (100% vs 57% in AFD vs AH; P = .002) despite not receiving corticosteroid treatment, even in a model for end-stage liver disease-matched sensitivity analysis. Serum triglyceride levels had an area under the receiver operating characteristic of 0.886 (95% CI, 0.807-0.964) for the diagnosis of AFD, whereas the National Institute on Alcohol Abuse and Alcoholism criteria performed poorly. A 1-step algorithm using triglyceride levels of 225 mg/dL (sensitivity, 0.77; specificity, 0.90; and Youden index, 0.67) is proposed for differential diagnosis. CONCLUSIONS: AFD in the setting of suspicion of AH is not uncommon. A differential diagnosis is important because prognosis and treatment differ largely. Triglyceride levels successfully identify most patients with AFD and may be helpful in decision making.

Impact of the implementation of a telemedicine program on patients diagnosed with asthma.

BACKGROUND: Asthma is one of the most common respiratory ailments worldwide. Despite broad understanding of the illness and of the available therapeutic options for it, patients with serious asthma suffer poor monitoring of their illness in 50% of cases. AIM: To assess the impact of the implementation of a mobile application (ESTOI) to control asthma in patients diagnosed with the illness, their adherence to treatment, and their perceived quality of life. METHODOLOGY: Randomized clinical trial with 52 weeks' follow-up of patients with asthma seen in a specialized hospital for their treatment in Spain. Some 108 included patients will be divided into two groups. The intervention group will undergo more exhaustive follow-up than normal, including access to the ESTOI application, which will have various categories of attention: control of symptoms, health recommendations, current treatment and personalized action plan, PEF record, nutritional plan, and chat access with a medical team. The asthma control questionnaire ACT is the main assessment variable. Other variables to be studied include an adherence test for the use of inhalers (TAI), the number of exacerbations, maximum exhalation flow, exhaled nitric oxide test, hospital anxiety and depression scale, asthma quality-of-life questionnaire, forced spirometry parameters (FVC, FEV1, and PBD), and analytic parameters (eosinophilia and IGE). The data will be collected during outpatient visits. TRIAL REGISTRATION: This trial has registered at ClinicalTrials.gov (Identifier: NCT06116292).

Activity, triage levels and impact of the pandemic on hospital emergency departments: A multicentre cross-sectional study.

AIM: Describe the activity of hospital emergency departments (EDs) and the sociodemographic profile of patients in the eight public hospitals in Spain, according to the different triage levels, and to analyse the impact of the SARS-CoV-2 pandemic on patient flow. DESIGN: An observational, descriptive, cross-sectional and retrospective study was carried out. METHODS: Three high-tech public hospitals and five low-tech hospitals consecutively included 2,332,654 adult patients seen in hospital EDs from January 2018 to December 2021. Hospitals belonging to the Catalan Institute of Health. The main variable was triage level, classified according to a standard for the Spanish structured triage system known as Sistema Español de Triaje. For each of the five triage levels, a negative binomial regression model adjusted for year and hospital was performed. The analysis was performed with the R 4.2.2 software. RESULTS: The mean age was 55.4 years. 51.4% were women. The distribution of patients according to the five triage levels was: level 1, 0.41% (n = 9565); level 2, 6.10% (n = 142,187); level 3, 40.2% (n = 938,203); level 4, 42.6% (n = 994,281); level 5, 10.6% (n = 248,418). The sociodemographic profile was similar in terms of gender and age: as the level of severity decreased, the number of women, mostly young, increased. In the period 2020-2021, the emergency rate increased for levels 1, 2 and 3, but levels 4 and 5 remained stable. CONCLUSION: More than half of the patients attended in high-technology hospital EDs were of low severity. The profile of these patients was that of a young, middle-aged population, mostly female. The SARS-CoV2 pandemic did not change this pattern, but an increase in the level of severity was observed. IMPACT: What problem did the study address? There is overcrowding in hospital EDs. What were the main findings? This study found that more than half of the patients attended in high-technology hospital EDs in Spain have low or very low levels of severity. Young, middle-aged women were more likely to visit EDs with low levels of severity. The SARS-CoV2 pandemic did not change this pattern, but an increase in severity was observed. Where and on whom will the research have an impact? The research will have an impact on the functioning of hospital EDs and their staff. PATIENT OR PUBLIC CONTRIBUTION: Not applicable.

Nursing care for patients with cirrhosis.

Cirrhosis represents a major cause of morbidity and mortality, leading to a marked impairment in the quality of life of patients and their caregivers, and resulting in a major burden on healthcare systems. Currently, in most countries, nurses still play a limited role in the care of patients with cirrhosis, which is mainly restricted to the care of patients hospitalised for acute complications of the disease. The current manuscript reviews the established and potential new and innovative roles that nurses can play in the care of patients with cirrhosis. In the hospital setting, specialised nurses should become an integral part of interprofessional teams, helping to improve the quality of care and outcomes of patients with cirrhosis. In the primary care setting, nurses should play an important role in the care of patients with compensated cirrhosis and also facilitate early diagnosis of cirrhosis in those at risk of liver diseases. This review calls for an improved global liver disease education programme for nurses and increased awareness among all healthcare providers and policymakers of the positive impacts of advanced or specialist nursing practice in this domain.

Population screening for liver fibrosis: Toward early diagnosis and intervention for chronic liver diseases.

Cirrhosis, highly prevalent worldwide, develops after years of hepatic inflammation triggering progressive fibrosis. Currently, the main etiologies of cirrhosis are non-alcoholic fatty liver disease and alcohol-related liver disease, although chronic hepatitis B and C infections are still major etiological factors in some areas of the world. Recent studies have shown that liver fibrosis can be assessed with relatively high accuracy noninvasively by serological tests, transient elastography, and radiological methods. These modalities may be utilized for screening for liver fibrosis in at-risk populations. Thus far, a limited number of population-based studies using noninvasive tests in different areas of the world indicate that a significant percentage of subjects without known liver disease (around 5% in general populations and a higher rate -18% to 27%-in populations with risk factors for liver disease) have significant undetected liver fibrosis or established cirrhosis. Larger international studies are required to show the harms and benefits before concluding that screening for liver fibrosis should be applied to populations at risk for chronic liver diseases. Screening for liver fibrosis has the potential for changing the current approach from diagnosing chronic liver diseases late when patients have already developed complications of cirrhosis to diagnosing liver fibrosis in asymptomatic subjects providing the opportunity of preventing disease progression.

Autonomous competences and quality of professional life of paediatric nurses in primary care, their relationship and associated factors: A cross-sectional study.

AIMS AND OBJECTIVES: To identify the autonomous competences and quality of professional life of paediatric nurses in primary care, their relationship and possible associated factors. BACKGROUND: The autonomous competences of paediatric nurses vary among healthcare providers in Catalonia, Spain. Autonomy is related to quality of professional life, but little is known about autonomous competences and other factors contributing to paediatric nurses' quality of professional life. DESIGN: A cross-sectional study following the STROBE statement. METHODS: Data from 206 paediatric primary care nurses were analysed. A self-administered survey consisting of an ad hoc questionnaire and a validated instrument to measure quality of professional life (QPL-35 questionnaire) was conducted. Descriptive, bivariate and general multivariate regression analyses were used to identify the relationship between autonomous competences and quality of professional life, and its predicting factors. RESULTS: 47.6% nurses reported a medium level of autonomous competences, 46.6% a high level, and 5.8% a low level. Quality of professional life was medium-high for the domains perception of managerial support and global perception of workload and for the item disconnect from work after work shift, and very high and high values for the domain intrinsic motivation and for the item quality of work life, respectively. Autonomous competences and perceived autonomy were factors associated with quality of professional life. Other associated factors were academic background, specific training and being a paediatric nurse specialist. CONCLUSIONS: Paediatric nurses in primary care have a medium-high level of autonomous competences and they perceive a high level of autonomy. Autonomous competences and level of perceived autonomy are predictors of quality of professional life. RELEVANCE TO CLINICAL PRACTICE: Enhancing paediatric nurses' autonomous competences and academic background, receiving specific training and being paediatric nurse specialists might improve their quality of professional life, healthcare quality and outcomes for the child population.

Construction of nursing knowledge in commodified contexts: Views and experiences of nurses regarding primary care.

The commodification of health care, particularly primary care, presents challenges to care and knowledge development. The purpose of this study is to examine how nurses perceive and develop their knowledge in a commodified context. A mixed-methods study was conducted that included a closed-question survey and in-depth interviews with nurses in public primary care in Catalonia. There were 104 valid responses to the questionnaire and 10 in-depth interviews. The main findings of the survey were related to workload and limited time for nursing care. Six themes emerged from the in-depth interviews: (1) limited time for nursing, (2) feelings of burnout, (3) awareness of patient and family satisfaction, (4) organizational factors that favor nurses' needs, (5) organizational factors that hinder nurses' needs, and finally (6) public administration requirements. Participants perceive excessive workload and time constraints and feel that this affects their nursing care and their physical and mental health. However, nurses purposefully use knowledge patterns to cope with the problems associated with commodification. Nurses have multidimensional, contextualized, and integrated knowledge that allows them to optimize their care based on the needs of their patients. This research examines many challenges related to nursing practice and the nursing discipline and opens the door for further research that encompasses all areas of nursing.

Urinary L-FABP is a promising prognostic biomarker of ACLF and mortality in patients with decompensated cirrhosis.

BACKGROUND & AIMS: Decompensated cirrhosis (DC) is associated with high mortality, mainly owing to the development of acute-on-chronic liver failure (ACLF). Identifying the patients with DC who are at high risk of mortality and ACLF development is an unmet clinical need. Liver fatty acid-binding protein (L-FABP) is expressed in several organs and correlates with liver and systemic inflammation. Herein, we aimed to assess the prognostic value of L-FABP in patients with DC. METHODS: A prospective series of 444 patients hospitalized for DC was divided into 2 cohorts: study cohort (305 patients) and validation cohort (139 patients). L-FABP was measured in urine and plasma samples collected at admission. Neutrophil gelatinase-associated lipocalin (NGAL) was also measured in urine samples for comparison. RESULTS: Urine but not plasma L-FABP correlated with 3-month survival on univariate analysis. On multivariate analysis, urine L-FABP and model for end-stage liver disease (MELD)-Na were the only independent predictors of prognosis. Urine L-FABP levels were higher in patients with ACLF than in those without and also predicted the development of ACLF, together with MELD-Na, during follow-up. In patients with ACLF, urine L-FABP correlated with liver, coagulation, and circulatory failure. Urine L-FABP levels were also increased in patients with acute kidney injury, particularly in those with acute tubular necrosis. The ability of urinary L-FABP to predict survival and ACLF development was confirmed in the validation cohort. Urine NGAL predicted outcome on univariate but not multivariate analysis. CONCLUSIONS: Urinary L-FABP levels are independently associated with the 3-month clinical course in patients with DC, in terms of mortality and ACLF development. Urinary L-FABP is a promising prognostic biomarker for patients with DC. LAY SUMMARY: Increased levels of liver fatty acid-binding protein (L-FABP), a protein related to lipid metabolism, have been associated with liver-related diseases. The present study analyzed urinary L-FABP levels in 2 independent groups of patients with decompensated cirrhosis and showed that higher urinary L-FABP levels correlated with increased mortality and risk of acute-on-chronic liver failure development. Therefore, urinary L-FABP levels could be useful as a new tool to predict complications in patients with decompensated cirrhosis.

Liver cirrhosis.

Cirrhosis is widely prevalent worldwide and can be a consequence of different causes, such as obesity, non-alcoholic fatty liver disease, high alcohol consumption, hepatitis B or C infection, autoimmune diseases, cholestatic diseases, and iron or copper overload. Cirrhosis develops after a long period of inflammation that results in replacement of the healthy liver parenchyma with fibrotic tissue and regenerative nodules, leading to portal hypertension. The disease evolves from an asymptomatic phase (compensated cirrhosis) to a symptomatic phase (decompensated cirrhosis), the complications of which often result in hospitalisation, impaired quality of life, and high mortality. Progressive portal hypertension, systemic inflammation, and liver failure drive disease outcomes. The management of liver cirrhosis is centred on the treatment of the causes and complications, and liver transplantation can be required in some cases. In this Seminar, we discuss the disease burden, pathophysiology, and recommendations for the diagnosis and management of cirrhosis and its complications. Future challenges include better screening for early fibrosis or cirrhosis, early identification and reversal of causative factors, and prevention of complications.

Low Accuracy of FIB-4 and NAFLD Fibrosis Scores for Screening for Liver Fibrosis in the Population.

BACKGROUND & AIMS: Fibrosis-4 (FIB-4) and the nonalcoholic fatty liver disease fibrosis score (NFS) are the 2 most popular noninvasive blood-based serum tests proposed for widespread fibrosis screening. We therefore aimed to describe the accuracy of FIB-4 and NFS to detect elevated liver stiffness as an indicator of hepatic fibrosis in low-prevalence populations. METHODS: This study included a total of 5129 patients with concomitant measurement of FIB-4, NFS, and liver stiffness measurement (LSM) by Fibroscan (Echosens, France) from 5 independent population-based cohorts from Spain, Hong Kong, Denmark, England, and France; 3979 participants from the general population and 1150 from at-risk cohorts due to alcohol, diabetes, or obesity. We correlated LSM with FIB-4 and NFS, and calculated pre- and post-test predictive values of FIB-4 and NFS to detect elevated LSM at 8 kPa and 12 kPa cutoffs. The mean age was 53 ± 12 years, the mean body mass index was 27 ± 5 kg/m2, and 2439 (57%) were women. One in 10 patients (552; 11%) had liver stiffness ≥8 kPa, but 239 of those (43%) had a normal FIB-4, and 171 (31%) had normal NFS. The proportion of false-negatives was higher in at-risk patients than the general population. FIB-4 was false-negative in 11% of diabetic subjects, compared with 2.5% false-negatives with NFS. Waist circumference outperformed FIB-4 and NFS for detecting LSM ≥8 kPa in the general population. Almost one-third (28%-29%) of elevated FIB-4/NFS were false-positive in both the general population and at-risk cohorts. CONCLUSIONS: FIB-4 and NFS are suboptimal for screening purposes due to a high risk of overdiagnosis and a non-negligible percentage of false-negatives, especially in patients with risk factors for chronic liver disease. Waist circumference emerged as a potential first step to identify patients at risk for liver fibrosis in the general population.

Alterations in Gut Microbiome in Cirrhosis as Assessed by Quantitative Metagenomics: Relationship With Acute-on-Chronic Liver Failure and Prognosis.

BACKGROUND AND AIMS: Cirrhosis is associated with changes in gut microbiome composition. Although acute-on-chronic liver failure (ACLF) is the most severe clinical stage of cirrhosis, there is lack of information about gut microbiome alterations in ACLF using quantitative metagenomics. We investigated the gut microbiome in patients with cirrhosis encompassing the whole spectrum of disease (compensated, acutely decompensated without ACLF, and ACLF). A group of healthy subjects was used as control subjects. METHODS: Stool samples were collected prospectively in 182 patients with cirrhosis. DNA library construction and sequencing were performed using the Ion Proton Sequencer (ThermoFisher Scientific, Waltham, MA). Microbial genes were grouped into clusters, denoted as metagenomic species. RESULTS: Cirrhosis was associated with a remarkable reduction in gene and metagenomic species richness compared with healthy subjects. This loss of richness correlated with disease stages and was particularly marked in patients with ACLF and persisted after adjustment for antibiotic therapy. ACLF was associated with a significant increase of Enterococcus and Peptostreptococcus sp and a reduction of some autochthonous bacteria. Gut microbiome alterations correlated with model for end-stage liver disease and Child-Pugh scores and organ failure and was associated with some complications, particularly hepatic encephalopathy and infections. Interestingly, gut microbiome predicted 3-month survival with good stable predictors. Functional analysis showed that patients with cirrhosis had enriched pathways related to ethanol production, γ-aminobutyric acid metabolism, and endotoxin biosynthesis, among others. CONCLUSIONS: Cirrhosis is characterized by marked alterations in gut microbiome that parallel disease stages with maximal changes in ACLF. Altered gut microbiome was associated with complications of cirrhosis and survival. Gut microbiome may contribute to disease progression and poor prognosis. These results should be confirmed in future studies.

LiverScreen project: study protocol for screening for liver fibrosis in the general population in European countries.

BACKGROUND: The development of liver cirrhosis is usually an asymptomatic process until late stages when complications occur. The potential reversibility of the disease is dependent on early diagnosis of liver fibrosis and timely targeted treatment. Recently, the use of non-invasive tools has been suggested for screening of liver fibrosis, especially in subjects with risk factors for chronic liver disease. Nevertheless, large population-based studies with cost-effectiveness analyses are still lacking to support the widespread use of such tools. The aim of this study is to investigate whether non-invasive liver stiffness measurement in the general population is useful to identify subjects with asymptomatic, advanced chronic liver disease. METHODS: This study aims to include 30,000 subjects from eight European countries. Subjects from the general population aged ≥ 40 years without known liver disease will be invited to participate in the study either through phone calls/letters or through their primary care center. In the first study visit, subjects will undergo bloodwork as well as hepatic fat quantification and liver stiffness measurement (LSM) by vibration-controlled transient elastography. If LSM is ≥ 8 kPa and/or if ALT levels are ≥1.5 x upper limit of normal, subjects will be referred to hospital for further evaluation and consideration of liver biopsy. The primary outcome is the percentage of subjects with LSM ≥ 8kPa. In addition, a health economic evaluation will be performed to assess the cost-effectiveness and budget impact of such an intervention. The project is funded by the European Commission H2020 program. DISCUSSION: This study comes at an especially important time, as the burden of chronic liver diseases is expected to increase in the coming years. There is consequently an urgent need to change our current approach, from diagnosing the disease late when the impact of interventions may be limited to diagnosing the disease earlier, when the patient is asymptomatic and free of complications, and the disease potentially reversible. Ultimately, the LiverScreen study will serve as a basis from which diagnostic pathways can be developed and adapted to the specific socio-economic and healthcare conditions in each country. TRIAL REGISTRATION: This study is registered on Clinicaltrials.gov ( NCT03789825 ).

Quality of professional life of primary healthcare nurses: A systematic review.

AIMS: To identify and critically appraise the available evidence on the overall quality of professional life of primary care nurses worldwide and its main influencing factors. BACKGROUND: Quality of professional life of healthcare workers is a keystone that influences the quality of healthcare services provided by healthcare organisations. Nurses have a key role as healthcare services providers given the growing shortage of doctors in primary care. DESIGN: A systematic review design in accordance with the PRISMA statement. METHODS: The search was conducted through MEDLINE (PubMed), CINAHL, SCOPUS, Scientific Electronic Library Online (SciELO) and Web of Science databases. The grey literature was reviewed at OpenGrey. The search was limited to human studies published from April 2010-April 2020. No limit of original language publication was applied. Three independent reviewers analysed the methodological quality of the studies. RESULTS: Ten studies were included from five countries. Five studies reported nurses were satisfied with their quality of professional life and the influencing factors identified were Workload, Job autonomy, Demographic variables, Management support, Recognition, Intrinsic motivation, Interpersonal relations, Compassion fatigue, Burnout, Turnover intention, and work was reported as a component of Quality of life. CONCLUSION: Primary healthcare nurses reported a high level of quality of professional life, but the scarce studies found do not provide solid consistency to assess the overall quality of professional life. Perception of high workload was the most frequently identified factor to negatively influence the quality of professional life of nurses. RELEVANCE TO CLINICAL PRACTICE: Quality of professional life of primary care nurses is a key issue because of nurses' important relation with patient's care and satisfaction. Healthcare organisations should strive to address primary care nurses' quality of professional life to enhance their well-being and consequently patients' safety and high-quality healthcare services.

Nursing Care of Patients With Cirrhosis: The LiverHope Nursing Project.

Cirrhosis is a complex disease that is associated with disturbances in different organs besides the liver, including kidneys, heart, arterial circulation, lungs, gut, and brain. As a consequence, patients develop a number of complications that result in frequent hospital admissions and high morbidity and mortality. Patients with cirrhosis require constant and rigorous monitoring both in and outside the hospital. In this context, the role of nurses in the care of patients with cirrhosis has not been sufficiently emphasized and there is very limited information about nursing care of patients with cirrhosis compared with other chronic diseases. The current article provides a review of nursing care for the different complications of patients with cirrhosis. Nurses with specific knowledge on liver diseases should be incorporated into multidisciplinary teams managing patients with cirrhosis, both inpatient and outpatient. Conclusion: Nurses play an important role in the management and prevention of complications of the disease and improvement in patients' quality of life and bridge the gap between clinicians and families, between primary care and hospital care, and provide medical education to patients and caregivers.

From NAFLD to MAFLD: Nurse and allied health perspective.

Fatty liver disease associated with metabolic dysfunction is the most prevalent liver disease worldwide, though both patient and health professional still lack awareness of it. An international consensus panel has produced what is sure to be an influential report renaming the disease from non-alcoholic fatty liver disease (NAFLD) to metabolic (dysfunction) associated fatty liver disease (MAFLD) and suggesting how the disease should be diagnosed. This viewpoint explores the call from the perspective of nurse and allied health practitioners. This group have raised serious concerns on the existing nomenclature, which labels the disease as NAFLD, and its diagnostic criteria, including provoking nurse role confusion and representing a major barrier to various key aspects; patient-nurse communications, patient awareness, partnership working, motivation of patients to undertake lifestyle changes and multiple health behaviour change promotion and nurse-led clinics. Therefore, they are enthusiastically supportive of this call to reframe the disease that we believe will ultimately have a positive impact on nurse-patient communication, and through this, improve patient care and quality of life and reduce burden on health system.

Interaction between metabolic syndrome and alcohol consumption, risk factors of liver fibrosis: A population-based study.

BACKGROUND AND AIMS: Alcohol and metabolic syndrome (MS) coexist frequently as cofactors of liver disease. Previous studies suggest a deleterious effect of MS in advanced alcohol-related liver disease (ArLD). However, it is unknow whether MS can increase the risk of liver fibrosis in early stages of ArLD. The aim of this study was to investigate the effect of MS on liver fibrosis in subjects with alcohol consumption from a population-based cohort. METHODS: The number of subjects include 1760(58%) of 3014 who were randomly selected from the community consumed alcohol and were classified as current drinkers, divided in moderate (n = 1222) or high-risk drinkers (n = 275) (>21 units/week men, >14 units/week women for high-risk drinkers), or former drinkers (n = 263). Liver fibrosis was estimated by measuring liver stiffness(LS) with transient elastography (TE). RESULTS: Prevalence of significant LS using cutoff values of TE of 8 and 9.1kPa was increased in high-risk compared with moderate or former drinkers and lifetime abstainers. In subjects with alcohol consumption, LS was associated with male gender, AST, ALT, years of consumption, and MS. In high-risk drinkers, MS and intensity of consumption were the only factors associated with significant LS (OR 3.7 and 4.6 for LS ≥ 8 kPa and 3.9 and 9.2 kPa for LS ≥ 9.1 kPa, respectively). Presence of significant liver fibrosis in the liver biopsy was higher among high-risk as compared with moderate or former drinkers. CONCLUSION: MS increases the risk of liver fibrosis in subjects with alcohol consumption. Among high-risk drinkers, only MS and consumption of high amount of alcohol are associated with risk of liver fibrosis.

Sequential changes in urinary biomarker levels in patients with cirrhosis and severe hepatorenal syndrome.

Whether tubular injury develops in patients with acute kidney injury owing to hepatorenal syndrome (AKI-HRS) is controversial. We performed repeated measurements of biomarkers of tubular injury during a 14-day period in 60 patients with cirrhosis and AKI (34 with AKI-HRS meeting the classical definition of type 1 HRS and 26 with AKI owing to acute tubular necrosis, AKI-ATN). Nineteen of 34 patients had resolution of AKI-HRS, while the remainder had persistent AKI-HRS. The persistence of AKI-HRS was associated with remarkably high short-term mortality. There were no significant differences in urinary NGAL or IL-18 between patients with resolution vs those with persistent AKI-HRS throughout the 14-day period. By contrast, biomarker levels were significantly lower in AKI-HRS, even if persistent, compared to AKI-ATN. These findings are highly suggestive of lack of significant tubular injury in AKI-HRS and could be of value in the clinical decision between combined liver-kidney or liver transplantation alone in patients with cirrhosis and AKI candidates to transplantation.

Paediatric nursing clinical competences in primary healthcare: A systematic review.

AIMS: To identify and critically appraise the available evidence on paediatric nurses' clinical competencies performed autonomously regarding disease prevention and health promotion activities for children and adolescents in primary healthcare worldwide. DESIGN: A systematic review design in accordance with the Preferred Reporting Items Systematic Reviews and Meta-Analyses statement. DATA SOURCES: The search was conducted through MEDLINE (PubMed), Cumulative Index to Nursing and Allied Health Literature, SCOPUS, The Cochrane Library, Scientific Electronic Library Online, Web of Science and The Joanna Briggs Institute EBP (Ovid) databases. The grey literature was reviewed at OpenGrey. Additional studies were located through a references list of selected studies identified on first search. REVIEW METHODS: Database search employed MeSH terms: (paediatric nursing) AND (primary healthcare) AND ((clinical skills) OR (clinical competences)). Studies published from inception to October 2019 exploring paediatric nurses' clinical competencies in primary healthcare were eligible for inclusion. No language restrictions were applied in the main search. Selection was made by two reviewers independently. Three independent reviewers assessed the methodological quality of included studies. RESULTS: Eighteen studies were included from six countries. The most common nursing competencies independently performed identified and described in studies were Health education and advice, Child and adolescent health and development assessment, Immunizations and Child health checks. CONCLUSION: Studies describe clinical competencies of nurses in children care. No consistent scientific evidence is available about clinical competencies of paediatric nurses performed autonomously in primary care. IMPACT: Few scientific studies identifying and assessing nurses' child primary healthcare skills were found and therefore recorded. Studies describe nurses' clinical skills in childhood, but results do not show firm consistency assessing their practice scope. Health policy-makers should encourage the development of nurses' competencies if they wish to preserve quality and equity of healthcare services to children. Therefore, the first step is to identify the autonomous competencies of paediatric nurses in primary care.

Implementing dedicated education units in 6 European undergraduate nursing and midwifery students clinical placements.

BACKGROUND: Undergraduate students' clinical experience, working directly with patients and the healthcare team is essential to ensure students acquire the necessary competence for practice. There are differences in the quality of clinical environments and in students' clinical placement experiences and not all clinical sites are optimal learning environments. The Dedicated Education Unit clinical education model allows students to develop the practical knowledge, skills and professionalism they will need as nurses/midwives. METHODS: We employed the Consolidated Framework for Implementation Research to identify and compare barriers and facilitators in the implementation of the Dedicated Education Unit in 6 European undergraduate nursing/midwifery student clinical placement settings and to describe the experience of nurses/midwives involved in the Dedicated Education Unit model implementation and evaluation. A pre-post implementation interpretive assessment was based on participants' responses to the Consolidated Framework for Implementation Research construct questions. RESULTS: Although Dedicated Education Unit model implementation in our project was heterogeneous, no main implementation barriers were perceived. Qualitative data showed that educational-service collaboration, including a focus on mutual goals, organizational communication and networking, satisfaction of educational and healthcare professionals, and the establishment of a safe space for professional discussion and feedback, were considered facilitators. CONCLUSIONS: This study describes the key elements guiding educational and healthcare stakeholders in Dedicated Education Unit implementation, engaging participants in the entire process, and offering other organizations the opportunity to consider the benefits of this clinical education model.