RESUMEN
BACKGROUND AND AIMS: Improving the care of decompensated cirrhosis is a significant clinical challenge. The primary aim of this trial was to assess the efficacy of a chronic disease management (CDM) model to reduce liver-related emergency admissions (LREA). The secondary aims were to assess model effects on quality-of-care and patient-reported outcomes. APPROACH AND RESULTS: The study design was a 2-year, multicenter, randomized controlled study with 1:1 allocation of a CDM model versus usual care. The study setting involved both tertiary and community care. Participants were randomly allocated following a decompensated cirrhosis admission. The intervention was a multifaceted CDM model coordinated by a liver nurse. A total of 147 participants (intervention=75, control=71) were recruited with a median Model for End-Stage Liver Disease score of 19. For the primary outcome, there was no difference in the overall LREA rate for the intervention group versus the control group (incident rate ratio 0.89; 95% CI: 0.53-1.50, p=0.666) or in actuarial survival (HR=1.14; 95% CI: 0.66-1.96, p=0.646). However, there was a reduced risk of LREA due to encephalopathy in the intervention versus control group (HR=1.87; 95% CI: 1.18-2.96, p=0.007). Significant improvement in quality-of-care measures was seen for the performance of bone density (p<0.001), vitamin D testing (p<0.001), and HCC surveillance adherence (p=0.050). For assessable participants (44/74 intervention, 32/71 controls) significant improvements in patient-reported outcomes at 3 months were seen in self-management ability and quality of life as assessed by visual analog scale (p=0.044). CONCLUSIONS: This CDM intervention did not reduce overall LREA events and may not be effective in decompensated cirrhosis for this end point.
RESUMEN
Human pluripotent stem cells (hPSCs) are capable of differentiating into any type of somatic cell, a characteristic that imparts significant therapeutic potential. Human embryonic stem cells and induced pluripotent stem cells are types of hPSCs. Although hPSCs have high therapeutic potential, their clinical relevance is limited by the requirement for animal feeder layers, which maintain their pluripotency and self-renewal. hPSCs grown on animal feeder cells are at high risk for pathogen contamination and can be affected by the immunogenicity of the feeder layer. The presence of animal feeder cells also limits the scalability of hPSCs in culture because of the high cost of culturing and batch-to-batch variations. Therefore, development of feeder-free systems is imperative for robust, lower-cost, xeno-free, scalable culture of hPSCs. Biomaterials engineered with bioactive molecules such as adhesion proteins and extracellular matrix proteins, or synthetic materials such as peptides and polymers, may provide alternative substrates to animal feeder cells. This article reviews biomaterial-based, feeder-free systems for hPSC growth and maintenance, which provide clinically relevant alternatives to feeder cell systems.