Nurse Led Clinics; a Novel Model of Care for Compensated Liver Cirrhosis: A Qualitative Analysis.

A nurse-led cirrhosis clinic model for management of stable, compensated cirrhotic patients is practised in our unit since 2013, wherein these patients are reviewed every six months by specialist nurses in community clinics under remote supervision of hepatologists. We evaluated the experiences of patients and healthcare providers involved in the model to understand the acceptability, strengths, and limitations of the model and obtain suggestions to improve. A qualitative design using in-depth interviews was employed, followed by thematic analysis of eight patients, one attending physician both nurse and hospital clinics, four hepatologists, and three experienced specialist nurses running the nurse-led cirrhosis clinic. Patients expressed satisfaction and a good understanding of the nurse-led cirrhosis clinic, preferring it to hospital clinics for better accessibility and the unique nurse-patient relationship. Upskilling and provision of professional care in a holistic manner were appreciated by specialist nurses. The hepatologists expressed confidence and satisfaction, although they acknowledged the difference between the medical training of specialist nurses and hepatologists. The greater availability of hospital clinic time for sick patients was welcomed. Increased specialist nurse staffing, regular forums to promote specialist nurse learning, and formalization of the referral process were suggested. No adverse experiences were reported by patients or staff. The nurse-led cirrhosis clinic model for compensated liver cirrhosis was well received by patients, hepatologists, and specialist nurses. Wider implementation of the model could be considered after further investigations in other settings.

Psychometric validation of the Partners in Health scale as a self-management tool in patients with liver cirrhosis.

BACKGROUND AND AIM: Liver cirrhosis is a chronic disease complicated by recurrent hospital admissions. Self-management skills could facilitate optimal disease management. At present there is no validated instrument for measuring self-management in these patients. Hence, we evaluated the internal reliability and construct validity of the Partners in Health (PIH) scale, a chronic condition self-management tool in cirrhotic patients. METHODS: In this prospective cohort study, the PIH scale was administered to 133 consenting patients within a Chronic Liver Failure Program of a tertiary hospital from February 2017 to May 2018. A Bayesian confirmatory factor analysis was used to evaluate a priori four-factor structure. Omega coefficients and 95% credible intervals (CrI) were used to assess internal reliability. Known-group validity was assessed in patients receiving active case management (n = 60) versus those without (n = 73). RESULTS: The mean (± standard deviation (SD)) age of the participants was 62 (±11) years. Model fit for the hypothesised model was adequate (posterior predictive P-value = 0.073) and all hypothesised factor loadings were substantial (>0.6) and significant (P < 0.001). Omega coefficients (95% CrI) for the PIH subscales of Knowledge, Partnership, Management and Coping were 0.88 (0.82-0.91), 0.68 (0.57-0.76), 0.92 (0.89-0.94) and 0.89 (0.85-0.92) respectively. The mean (±SD) overall PIH score was higher in patients receiving case management compared to those without case management (81 ± 12 vs 73 ± 17, P < 0.001). CONCLUSION: The dimensionality, known-group validity and reliability of the PIH scale for measuring self-management in patients with liver cirrhosis were confirmed. Its clinical predictive value requires further assessment.

The Chronic Liver Disease Nurse Role in Australia: Describing 10 Years of a New Role in Cirrhosis Management.

Cirrhosis of the liver is increasing, with growing patient numbers in hospital outpatient departments, as well as increasing admissions due to decompensated liver disease. Decompensated cirrhosis of the liver is a common and debilitating illness causing disability, readmissions to hospital, and decreased quality of life, and can lead to liver cancer. The advent of the chronic liver disease nurse (CLDN) position in our hospital in 2009 was the first role in Australia dedicated to providing care to patients with cirrhosis. The role incorporates the care of patients with stable compensated disease, case management of patients with complications of decompensated disease, and hepatocellular carcinoma coordination. After a pilot randomized controlled trial and almost 10 years of service, this article describes the role of the CLDN and presents key performance indicators that will assist other centers considering introducing the role or elements of it into their service.

Validation of Knowledge Questionnaire for Patients With Liver Cirrhosis.

BACKGROUND & AIMS: There is no validated questionnaire to assess disease knowledge and self-management in patients with liver cirrhosis. We developed and validated a Cirrhosis Knowledge Questionnaire (CKQ). METHODS: We created a preliminary CKQ comprising 10 questions relevant to self-management of cirrhosis, based on publications and clinical experiences. The CKQ was given to a pilot sample of 17 patients with decompensated cirrhosis to assess its face validity. In consultation with experts, we developed a second version of CKQ, comprising 14 multiple choice questions, and administered it to 116 patients with cirrhosis participating in a Chronic Liver Failure Program. The dimensionality of the construct was assessed using exploratory factor analysis and internal consistency was assessed with Cronbach's alpha. Known-group validity of the resulting instrument was assessed by comparing the performance of the CKQ in 69 patients with decompensated cirrhosis (mean age, 62 ± 13 years; 109 responses), with (n = 42) vs without (n = 67) case management. RESULTS: A 3-factor model with 7 questions related to variceal bleeding, ascites, and hepatic encephalopathy was considered the optimal dimensionality with excellent internal consistency (Cronbach's alpha = 0.82). The mean knowledge score was higher in patients with case management (5.6 ± 1.1) than in patients without case management (4.3 ± 2.1) (P = .002). CONCLUSIONS: We developed and validated a questionnaire with 7 questions on ascites, variceal bleeding, and hepatic encephalopathy to assess knowledge and self-management in patients with liver cirrhosis. Studies are needed to confirm its dimensionality and assess association of scores with patient outcomes.

Improved Survival of Hepatocellular Carcinoma Patients Diagnosed with a Dedicated Screening Programme-a Propensity Score Adjusted Analysis.

AIM: To assess the overall survival (OS) in those with hepatocellular carcinoma (HCC) diagnosed within a programmatic, centrally co-ordinated, regional screening programme. METHODS: A retrospective cohort analysis of consecutive HCC patients diagnosed between 2004 and 2013. Patients were followed up till death or end of study period (30 April 2015). A dedicated screening programme was commenced in 2009 to screen high-risk patients for HCC. Primary objective is to compare the OS between HCC patients diagnosed within the screening group versus those diagnosed outside this group. Other objectives were to compare tumour stage at diagnosis and the proportion having curative treatments in the two groups. Propensity score adjustments were performed to assess the survival benefit. RESULTS: HCC was diagnosed in 130 subjects during the study period (82.3% males, median [IQR] age 62 [± 19] years and median [IQR] follow-up of 11.3 (± 23.5) months). Ninety-six patients (73.8%) died during the follow-up, and the median (95%CI) OS was 15.7 (9.7-21.8) months. HCC diagnosed within the screening programme had a better OS compared to those diagnosed outside this programme (26.8 vs 11.5 months, p = 0.01). Further, those diagnosed within the programme had an earlier stage HCC ([58.3% vs 23.6%], Ó¼2 = 11.3, p = 0.001), and a significant proportion were treated with curative intent ([62.5% vs 31.1%], Ó¼2 = 8.3, p = 0.004). Propensity score adjustment showed a 58% reduction in mortality for HCC diagnosed within the screening programme (HR [95%CI] 0.42 [0.20-0.89], p = 0.02). CONCLUSION: A programmatic, regional HCC screening programme improved the OS and detected tumours at an earlier stage enabling more patients to have curative therapies.

Efficacy of High-Dose, Rapid, Hepatitis A and B Vaccination Schedules in Patients With Cirrhosis.

Patients with cirrhosis have increased morbidity from hepatitis A virus (HAV) and hepatitis B virus (HBV) infections, and vaccination against these infections is an important standard of care.1,2 However, vaccination in patients with cirrhosis is hindered by immune dysfunction and there is limited high-quality literature available. The aim of this work therefore was to compare immune responses of standard dose (SD) with high-dose accelerated (HDA) vaccination in cirrhotic patients.

Efficacy of a chronic disease management model for patients with chronic liver failure.

BACKGROUND & AIMS: Despite the economic impacts of chronic liver failure (CLF) and the success of chronic disease management (CDM) programs in routine clinical practice, there have been no randomized controlled trials of CDM for CLF. We investigated the efficacy of CDM programs for CLF patients in a prospective, controlled trial. METHODS: Sixty consecutive patients with cirrhosis and complications from CLF were assigned randomly to groups given intervention (n = 40) or usual care (n = 20), from 2009 to 2010. The 12-month intervention comprised 4 CDM components: delivery system redesign, self-management support, decision support, and clinical information systems. The primary outcome was the number of days spent in a hospital bed for liver-related reasons. Secondary outcomes were rates of other hospital use measures, rate of attendance at planned outpatient care, disease severity, quality of life, and quality of care. RESULTS: The intervention did not reduce the number of days patients spent in hospital beds for liver-related reasons, compared with usual care (17.8 vs 11.0 bed days/person/y, respectively; incidence rate ratio, 1.6; 95% confidence interval, 0.5-4.8; P = .39), or affect other measures of hospitalization. Patients given the intervention had a 30% higher rate of attendance at outpatient care (incidence rate ratio, 1.3; 95% confidence interval, 1.1-1.5; P = .004) and significant increases in quality of care, based on adherence to hepatoma screening, osteoporosis and vaccination guidelines, and referral to transplant centers (P < .05 for all). CONCLUSIONS: In a pilot study to determine the efficacy of CDM for patients with CLF, patients receiving CDM had significant increases in attendance at outpatient centers and quality of care, compared with patients who did not receive CDM. However, CDM did not appear to reduce hospital admission rates or disease severity or improve patient quality of life. Larger trials with longer follow-up periods are required to confirm these findings and assess cost effectiveness.

A fluorous, Pummerer cyclative-capture strategy for the synthesis of N-heterocycles.

A fluorous, cyclative-capture strategy based on a new Pummerer cyclization process allows rapid access to tagged, heterocyclic frameworks. Convenient modification of the fluorous, heterocyclic scaffolds by using a variety of approaches including Pd-catalyzed cross-couplings is possible. Traceless, reductive cleavage of the fluorous-phase tag or oxidative cleavage and further elaboration, completes a strategy for the high-throughput, fluorous-phase synthesis of a diverse range of N-heterocycles.