Elimination of Hepatitis C Virus in a Dialysis Population: A Collaborative Care Model in Taiwan.

RATIONALE & OBJECTIVE: Hemodialysis facilities are high-risk environments for the spread of hepatitis C virus (HCV). Eliminating HCV from all dialysis facilities in a community may be achieved more effectively under a collaborative care model. STUDY DESIGN: Quality improvement study of multidisciplinary collaborative care teams including nephrologists, gastroenterologists, and public health practitioners. SETTING & PARTICIPANTS: All dialysis patients in Changhua County, Taiwan were treated using an interdisciplinary collaborative care model implemented within a broader Changhua-Integrated Program to Stop HCV Infection (CHIPS-C). QUALITY IMPROVEMENT ACTIVITIES: Provision of an HCV care cascade to fill 3 gaps, including screening and testing, diagnosis, and universal direct-acting antiviral (DAA) treatment implemented by collaborating teams of dialysis practitioners and gastroenterologists working under auspices of Changhua Public Health Bureau. OUTCOME: Outcome measures included quality indicators pertaining to 6 steps in HCV care ranging from HCV screening to treatment completion to cure. ANALYTICAL APPROACH: A descriptive analysis. RESULTS: A total of 3,657 patients from 31 dialysis facilities were enrolled. All patients completed HCV screening. The DAA treatment initiation rate and completion rate were 88.9% and 94.0%, respectively. The collaborative care model achieved a cure rate of 166 (96.0%) of 173 patients. No virologic failure occurred. The cumulative treatment ratios for patients with chronic HCV infection increased from 5.3% before interferon-based therapy (2017) to 25.6% after restricted provision of DAA (2017-2018), and then to 89.1% after universal access to DAA (2019). LIMITATIONS: Unclear impact of this collaborative care program on incident dialysis patients entering dialysis facilities each year and on patients with earlier stages of chronic kidney disease. CONCLUSIONS: A collaborative care model in Taiwan increased the rates of diagnosis and treatment for HCV in dialysis facilities to levels near those established by the World Health Organization.

Mediating effects of depression on anxiety and leisure constraints in patients with breast cancer.

BACKGROUND: Patients with breast cancer often exhibit high levels of anxiety and depression and a considerable decrease in their ability to participate in leisure activities, which result in the long-term disruption of their daily lives. This study intended to explore the relationships among anxiety, leisure constraints, and depression and evaluate whether depression mediates the effects of anxiety on leisure constraints in patients with breast cancer. METHOD: This prospective study included 106 patients with breast cancer. All the patients completed the Taiwanese version of the Hospital Anxiety and Depression Scale and Leisure constraints questionnaire. Path analysis was used to test the mediating role of depression. RESULTS: Leisure constraints, anxiety, and depression were positively interrelated and co-occurred in the patients. The accelerated bootstrapping confidence intervals of the indirect effect did not include zero (0.276-1.663). Moreover, depression completely mediated the effects of anxiety on leisure constraints in patients with earlier cancer stages but not in patients with advanced cancer stages. CONCLUSIONS: Depression is a crucial mechanism underlying the relationship between anxiety and leisure constraints in patients with breast cancer. Although many patients experience minimal disruption of activities and roles during survivorship, they are unable to perform functional activities and satisfactorily play their roles. This is the first study to explore leisure constraints in patients with breast cancer and investigate the mediating role of depression that underlies the relationship between anxiety and leisure constraints. The current findings are clinically crucial because they suggest the need to consider the simultaneous management of anxiety and depression for alleviating leisure constraints.

Use of a wearable device to compare subjective and objective fatigue in lung cancer patients and cancer-free controls.

PURPOSE: The study evaluates the use of heart rate variability (HRV), a measure of autonomic nervous system (ANS) modulation via wearable smart bands, to objectively assess cancer-related fatigue (CRF) levels. It aims to enhance understanding of fatigue by distinguishing between LF/HF ratios and LF/HF disorder ratios through HRV and photoplethysmography (PPG), identifying them as potential biomarkers. METHODS: Seventy-one lung cancer patients and 75 non-cancer controls wore smart bands for one week. Fatigue was assessed using Brief Fatigue Inventory, alongside sleep quality and daily interference. HRV parameters were analyzed to compare groups. RESULTS: Cancer patients showed higher fatigue and interference levels than controls (64.8% vs. 54.7%). Those with mild fatigue had elevated LF/HF disorder ratios during sleep (40% vs. 20%, P = 0.01), similar to those with moderate to severe fatigue (50% vs. 20%, P = 0.01), indicating more significant autonomic dysregulation. Notably, mild fatigue patients had higher mean LF/HF ratios than controls (1.9 ± 1.34 vs. 1.2 ± 0.6, P = 0.01), underscoring the potential of disorder ratios in signaling fatigue severity. CONCLUSIONS: Utilizing wearable smart bands for HRV-based analysis is feasible for objectively assess CRF levels in cancer patients, especially during sleep. By distinguishing between LF/HF ratios and LF/HF disorder ratios, our findings suggest that wearable technology and detailed HRV analysis offer promising avenues for real-time fatigue monitoring. This approach has the potential to significantly improve cancer care by providing new methods for managing and intervening in CRF, particularly with a focus on autonomic dysregulation as a crucial factor.

Systematic review of clinical practice guidelines in the diagnosis and management of thyroid nodules and cancer.

BACKGROUND: Given the uncertainties regarding thyroid nodule assessment and management, physicians require systematically and transparently developed recommendations. This systematic review assesses the quality and consistency of the recommendations of international clinical practice guidelines (CPGs) for the diagnosis and management of thyroid nodules and cancer to assist physicians in making appropriate recommendations. METHODS: The CPGs on the management of thyroid nodules and cancer published before June 2013 were retrieved. All the reviewed guidelines were in English. Four reviewers independently assessed the rigor of guideline development by using the Appraisal of Guidelines Research and Evaluation II (AGREE-II) instrument, and their reported evidence was evaluated. RESULTS: Ten eligible guidelines were included: nine had been developed by professional organizations, and the remaining guideline was endorsed by an independent regional body. Three guidelines achieved a score of greater than 50% in all six AGREE-II domains. Guidelines scored highest on the measurement of 'scope and purpose' (≥61.1% for eight CPGs) and lowest on the measurement of 'applicability' (≤38.5% for five CPGs). The overall quality ranged from 3.0 to 6.25 on a seven-point scale on the AGREE-II tool. Most CPG recommendations on the management of thyroid cancer were relatively consistent. Guidelines varied regarding the indication of fine-needle aspiration for thyroid nodules, as well as in their suggestions for postoperative radioiodine ablation. CONCLUSIONS: Our analysis showed that the current CPGs varied in methodological quality. More effort is needed to improve the quality of recommendations on the diagnosis and management of thyroid nodules and cancer.

Cancer-related fatigue classification based on heart rate variability signals from wearables.

Background: Cancer-related fatigue (CRF) is the most distressing side effect in cancer patients and affects the survival rate. However, most patients do not report their fatigue level. This study is aimed to develop an objective CRF assessment method based on heart rate variability (HRV). Methods: In this study, patients with lung cancer who received chemotherapy or target therapy were enrolled. Patients wore wearable devices with photoplethysmography that regularly recorded HRV parameters for seven consecutive days and completed the Brief Fatigue Inventory (BFI) questionnaire. The collected parameters were divided into the active and sleep phase parameters to allow tracking of fatigue variation. Statistical analysis was used to identify correlations between fatigue scores and HRV parameters. Findings: In this study, 60 patients with lung cancer were enrolled. The HRV parameters including the low-frequency/high-frequency (LF/HF) ratio and the LF/HF disorder ratio in the active phase and the sleep phase were extracted. A linear classifier with HRV-based cutoff points achieved correct classification rates of 73 and 88% for mild and moderate fatigue levels, respectively. Conclusion: Fatigue was effectively identified, and the data were effectively classified using a 24-h HRV device. This objective fatigue monitoring method may enable clinicians to effectively handle fatigue problems.

Pan-Genotypic Direct-Acting Antiviral Agents for Undetermined or Mixed-Genotype Hepatitis C Infection: A Real-World Multi-Center Effectiveness Analysis.

Although the pan-genotypic direct-acting antiviral regimen was approved for treating chronic hepatitis C infection regardless of the hepatitis C virus (HCV) genotype, real-world data on its effectiveness against mixed-genotype or genotype-undetermined HCV infection are scarce. We evaluated the real-world safety and efficacy of two pan-genotypic regimens (Glecaprevir/Pibrentasvir and Sofosbuvir/Velpatasvir) for HCV-infected patients with mixed or undetermined HCV genotypes from the five hospitals in the Changhua Christian Care System that commenced treatment between August 2018 and December 2020. This retrospective study evaluated the efficacy and safety of pan-genotypic direct-acting antiviral (DAA) treatment in adults with HCV infection. The primary endpoint was the sustained virological response (SVR) observed 12 weeks after completing the treatment. Altogether, 2446 HCV-infected patients received the pan-genotypic DAA regimen, 37 (1.5%) patients had mixed-genotype HCV infections and 110 (4.5%) patients had undetermined HCV genotypes. The mean age was 63 years and 55.8% of our participants were males. Nine (6.1%) patients had end-stage renal disease and three (2%) had co-existing hepatomas. We lost one patient to follow-up during treatment and one more patient after treatment. A total of four patients died. However, none of these losses were due to treatment-related side effects. The rates of SVR12 for mixed-genotype and genotype-undetermined infections were 97.1% and 96.2%, respectively, by per-protocol analyses, and 91.9% and 92.7% respectively, by intention-to-treat population analyses. Laboratory adverse events with grades ≥3 included anemia (2.5%), thrombocytopenia (2.5%), and jaundice (0.7%). Pan-genotypic DAAs are effective and well-tolerated for mixed-genotype or genotype-undetermined HCV infection real-world settings.

Real-World Experience of Chronic Hepatitis C-Related Compensated Liver Cirrhosis Treated with Glecaprevir/Pibrentasvir: A Multicenter Retrospective Study.

BACKGROUND: Glecaprevir/pibrentasvir is a protease inhibitor-containing pangenotypic direct-acting antiviral regimen that has been approved for the treatment of chronic hepatitis C. The present study aimed to evaluate the safety and efficacy of glecaprevir/pibrentasvir in patients with compensated cirrhosis in a real-world setting. METHODS: We evaluated the real-world safety and efficacy of glecaprevir/pibrentasvir in patients with compensated cirrhosis from five hospitals in the Changhua Christian Care System, who underwent treatment between August 2018 and October 2020. The primary endpoint was a sustained virological response observed 12 weeks after completion of the treatment. RESULTS: Ninety patients, including 70 patients who received the 12-week therapy and 20 patients who received the 8-week therapy, were enrolled. The mean age of the patients was 65 years, and 57.8% of the patients were males. Sixteen (17.8%) patients had end-stage renal disease, and 15 (16.7%) had co-existing hepatoma. The hepatitis C virus genotypes 1 (40%) and 2 (35.6%) were most common. The common side effects included anorexia (12.2%), pruritus (7.8%), abdominal discomfort (7.8%), and malaise (7.8%). Laboratory adverse grade ≥3 events included anemia (6.3%), thrombocytopenia (5.1%), and jaundice (2.2%). The overall sustained virological response rates were 94.4% and 97.7% in the intention-to-treat and per-protocol analyses, respectively. CONCLUSIONS: the glecaprevir/pibrentasvir treatment regimen was highly effective and well tolerated among patients with compensated cirrhosis in the real-world setting.

Relationship Between Diurnal Cortisol Profile and Sleep Quality in Patients With Hepatocellular Carcinoma.

PURPOSE: Hepatocellular carcinoma (HCC) is the second leading cause of cancer mortality worldwide. Sleep problems are common in HCC patients and may be attributable to disturbances in the circadian rhythm. Research into the role of circadian rhythms in sleep quality among HCC patients is lacking, however. This study investigated the relationship between the diurnal cortisol profile and sleep quality among HCC patients. We aimed to identify alterations in the diurnal cortisol profile in patients with HCC compared to healthy controls and investigate whether they were associated with poor sleep quality among HCC patients. METHODS: Participants comprised 75 HCC patients and 33 healthy individuals. The Taiwanese version of the Pittsburgh Sleep Quality Index (PSQI-T) was administered to assess sleep quality. Saliva samples were collected on 3 consecutive days at five time points daily to measure diurnal cortisol levels. RESULTS: In the HCC group, 89.3% of individuals were poor sleepers (PSQI-T > 5), whereas among healthy individuals, 30.3% were poor sleepers. While the healthy participants' diurnal cortisol profile followed a typical pattern that peaked 30 min after waking and declined gradually throughout the day, the cortisol level in the HCC patients rebounded at bedtime. Higher cortisol levels were marginally correlated with poor sleep quality (OR = 1.00007, p < .05). CONCLUSIONS: Our study suggests a potential association between disturbed circadian rhythm and poor sleep quality in HCC patients. Further investigation of the causal relationship between sleep and circadian rhythm is warranted.

A systematic review and meta-analysis of randomized controlled trials comparing interventions for peristomal skin care.

Standard skin care procedures for percutaneous endoscopic gastrostomy (PEG) tubes and peristomal skin care for colostomy and ileostomy patients are not always sufficient to prevent peristomal skin problems. A systematic review and meta-analysis of randomized controlled trials (RCTs) was conducted to compare the effectiveness of standard peristomal skin care to adjunctive techniques or barriers (including glycogel dressings, gelatin- and pectin-based skin barriers, glycerin hydrogel wound dressing, Acacia senegal fiber pockets, hydrocolloid powder crusting, and German chamomile) to manage or treat patients with a stoma. Using systematic literature search techniques, all healthcare databases were searched up through September 2014. No language restrictions were applied. Studies were included if they met criteria for published RCTs or quasi-RCTs that evaluated the outcome of standardized peristomal skin care and other adjunctive techniques or barriers used among patients with a stoma or PEG tube. A meta-analysis was performed to calculate a pooled effect size by using random-effect models for the primary (skin irritation/reaction) and secondary (length of pouch wear time) outcomes. Six RCTs comprising 418 total patients were identified. Four evaluated the outcome of colostomy or ileostomy peristomal skin care, and no significant differences were detected in the incidence of skin problems (RR 0.67; 95% CI: 0.31-1.41). In the two studies that included length of pouch wear time, no significant differences were observed (RR 0.48; 95% CI: 0.03-7.97). No significant differences were seen in the rate of skin irritations of gastrostomy patients (RR 0.56; 95% CI: 0.20-1.59), but the difference in treatment outcomes of peristomal damage in patients with a colostomy was significant (P = 0.01). The limited number of studies, study quality, heterogeneity of variability in peristomal care strategies and techniques, clinical factors, and nonuniform reporting of clinical parameters contributed to the heterogeneity among the trials. Well-designed RCTs are needed to investigate the efficacy of various barriers and techniques for peristomal skin care and to help develop evidence-based standards of caring for the skin of patients with a colostomy, ileostomy, or gastrostomy.