Evaluation of a new concept to improve and organize clinical practice in nursing education: a pilot-study.

BACKGROUND: Nursing students may experience clinical practice as unsafe due to the interactions with patients, fear of making mistakes, lack of clinical experience and supervision, which results in anxiety and stress. Thus, interventions to improve and organize the learning environment in clinical practice for nursing students are warranted, and the aim of this pilot-study was to evaluate a new concept of clinical practice in order to get insight on the different initiatives and gain knowledge for further developing. METHODS: The new concept consisted of nursing students being affiliated to the same department during their clinical practices, reflective supervision, and participation in a self-compassion course. Data was collected using questionnaires and focus group interviews of 17 nursing students, 17 clinical supervisors, and 14 head nurses. A mixed-methods strategy was employed to give the study a pragmatic approach. Finding from the questionnaires and focus group interviews were analyzed separately and then weaved together into themes. RESULTS: The results generated four themes: Information and involvement before and during the new concept, Learning outcomes, safety, and well-being, Impact of reflective supervision and self-compassion course, and Transition from study life to working life. In general, the participating nursing students, clinical supervisors, and head nurses had positives experiences regarding the new concept. They felt well-informed, and they experienced that it contributed to a safe learning environment, increased well-being, strengthened the relationship between nursing students and clinical supervisors and healthcare staff at the department, and prepared the nursing students to working life. CONCLUSION: Our results complement the suggestion that improved quality of clinical practice for nursing students is an effective strategy to establish a safe and supportive learning environment that contribute with satisfaction, successful experiences, and attraction of future nurses. However, further intervention studies are needed to compare the effect of the new concept with traditional clinical practice.

Steatotic liver disease is the most important somatic determinant of quality of life in patients with obesity: A cross-sectional study.

BACKGROUND AND AIMS: Patients with metabolic dysfunction-associated steatotic liver disease (MASLD) are often comorbid and stigmatized. This can negatively affect quality of life (QOL). Other studies have primarily used the Chronic Liver Disease Questionnaire (CLDQ), which focuses on liver-related symptoms, to characterize QOL, but most MASLD patients have only mild liver disease, and CLDQ might overlook QOL issues pertaining to them. We aimed to determine the impact of metabolic dysfunction-associated steatohepatitis (MASH) on QOL in obese patients using a 136-item generic QOL questionnaire. METHODS: We included participants with BMI ≥ 35 kg/m2 who all fully answered the sickness impact profile (SIP, range 0-100, normal = 3.4, 100 = worst) and had a liver biopsy to diagnose MASLD. Sociodemographics, comorbidity and biometric data were obtained from all participants. RESULTS: Of 176 (mean age 45.9 years, 70% female, 12.6 years of education), 132 had no-MASH and 44 MASH. On stepwise multivariable regression analysis, divorce (p = .011), unemployment (p < .003) and hepatic steatosis (p = .01) were associated with poor overall QOL. No other somatic comorbidity was associated. MASH patients more frequently than no-MASH reported physical discomfort (48% vs. 30%, p = .04), inability to do daily activities (29% vs. 54%, p = .006) and attention problems (32% vs. 57%, p = .003). CONCLUSION: MASLD severity was the only somatic determinant of QOL in patients with obesity in this cohort, and a large fraction reported debilitating symptoms. Patients and caregivers should consider the limitations this poses when planning interventions.

Knowledge needs in patients with Liver Disease: a qualitative study.

BACKGROUND: Knowledge is essential for patients' disease management strategies and a critical component of healthcare. The importance of increasing patients level of knowledge has become more widely acknowledge in liver disease management in recent years, but further studies are needed to address patients experiences of unmet knowledge needs to develop appropriate patient education strategies. Therefore, the aim of this study was to explore knowledge needs in patients' with liver disease of different etiology and severity. METHODS: A qualitative study was designed and an inductive method was chosen. Thirty-three patients with liver disease of different etiology and severity were interviewed using a semi-structured interview guide. Content analysis was used as an inspiration to describe and compare patients' needs for knowledge across disease etiology and severity. The reporting followed consolidated criteria for reporting qualitative research. RESULTS: The analysis generated three categories and nine subcategories. In general, the patients described lack of knowledge related to their liver disease, which made it difficult for them to manage their disease. Patients wished to be more involved in care and treatment of the liver disease. However, patients' had difficulties to assess and understand the importance of the information they received from healthcare professionals. Due to lack of knowledge, patients' had a misconception of the liver disease. Patients' had variation in knowledge needs depending on liver disease etiology and severity. CONCLUSION: Within liver disease management, knowledge of patients' experiences is vital to meet patients' knowledge needs and to develop appropriate patient education strategies. Therefore, it is important to ascertain a patient-centered approach to accommodate patients' individual knowledge needs, involve patients in care and treatment, and insure understanding to strengthen their self-management and give the patients the necessary skills to manage their disease and everyday life. REGISTRATION NUMBER: Open Science Framework registration DOI https://doi.org/10.17605/OSF.IO/W28RC .

Are Nonalcoholic Fatty Liver Disease and Bone Mineral Density Associated? - A Cross-Sectional Study Using Liver Biopsy and Dual-Energy X-Ray Absorptiometry.

There is controversy regarding the association between nonalcoholic fatty liver disease (NAFLD) and osteoporosis. Our study aim was to assess bone mineral density (BMD) in patients with biopsy-proven NAFLD and examine if the severity of NAFLD affects BMD. A total of 147 adult women (n = 108) and men (n = 39) aged 18-76 years (mean ± standard deviation [SD] age 45.3 ± 12.5) were recruited in this cross-sectional study and underwent a liver biopsy and dual-energy X-ray absorptiometry (DXA). NAFLD activity score (NAS) based on the degree of steatosis, lobular inflammation and hepatocellular ballooning was used to assess NAFLD severity. The majority of subjects, 53%, had steatosis, 25% had nonalcoholic steatohepatitis (NASH) whereas 23% served as control subjects with no evidence of NAFLD. There were no significant differences in the lumbar spine (1.09 ± 0.12, 1.11 ± 0.18, and 1.12 ± 0.15 g/cm2, p = 0.69, in controls, steatosis, and NASH, respectively) or hip BMD (1.10 ± 0.15, 1.12 ± 0.13, and 1.09 ± 0.13 g/cm2, p = 0.48, in controls, steatosis, and NASH, respectively) between the groups. Adjusting for age, gender, body mass index, and diabetes in multiple regression models did not alter the results. There was no correlation between NAS and neither lumbar spine BMD (r = 0.06, p = 0.471), nor hip BMD (r = -0.03, p = 0.716). In conclusion, BMD was similar across the spectrum of NAFLD in both genders and not related to the severity of the underlying histological lesions, suggesting that neither steatosis nor NASH exerts a detrimental effect on BMD in these relatively young patients. © 2022 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.

Circulating TREM2 as a noninvasive diagnostic biomarker for NASH in patients with elevated liver stiffness.

BACKGROUND AND AIMS: Reliable noninvasive biomarkers are an unmet clinical need for the diagnosis of NASH. This study investigates the diagnostic accuracy of the circulating triggering receptor expressed on myeloid cells 2 (plasma TREM2) as a biomarker for NASH in patients with NAFLD and elevated liver stiffness. APPROACH AND RESULTS: We collected cross-sectional, clinical data including liver biopsies from a derivation ( n = 48) and a validation cohort ( n = 170) of patients with elevated liver stiffness measurement (LSM ≥ 8.0 kPa). Patients with NAFLD activity scores (NAS) ≥4 were defined as having NASH. Plasma TREM2 levels were significantly elevated in patients with NASH of the derivation cohort, with an area under the receiver operating characteristics curve (AUROC) of 0.92 (95% confidence interval [CI], 0.84-0.99). In the validation cohort, plasma TREM2 level increased approximately two-fold in patients with NASH, and a strong diagnostic accuracy was confirmed (AUROC, 0.83; 95% CI, 0.77-0.89; p < 0.0001). Plasma TREM2 levels were associated with the individual histologic features of NAS: steatosis, lobular inflammation, and ballooning ( p < 0.0001), but only weakly with fibrosis stages. Dual cutoffs for rule-in and rule-out were explored: a plasma TREM2 level of ≤38 ng/ml was found to be an optimal NASH rule-out cutoff (sensitivity 90%; specificity 52%), whereas a plasma TREM2 level of ≥65 ng/ml was an optimal NASH rule-in cutoff (specificity 89%; sensitivity 54%). CONCLUSIONS: Plasma TREM2 is a plausible individual biomarker that can rule-in or rule-out the presence of NASH with high accuracy and thus has the potential to reduce the need for liver biopsies and to identify patients who are eligible for clinical trials in NASH.

Psychometric methods for diagnosing and monitoring minimal hepatic encephalopathy -current validation level and practical use.

Hepatic encephalopathy (HE) is cerebral dysfunction caused by liver failure and inflicts 30-40% of patients with liver cirrhosis during their disease course. Clinically manifest HE is often preceded by minimal HE (MHE) - a clinically undetectable cognitive disturbance closely associated with loss of quality of life. Accordingly, detecting and treating MHE improve the patients' daily functioning and prevent HE-related hospital admissions. The scope of this review article is to create an overview of the validation level and usage of psychometric tests used to detect MHE: Portosystemic hepatic encephalopathy test, continuous reaction time test, Stroop EncephalApp, animal naming test, critical flicker frequency test, and inhibitory control test. Our work is aimed at the clinician or scientist who is about to decide on which psychometric test would fit best in their clinic, cohort, or study. First, we outline psychometric test validation obstacles and requirements. Then, we systematically approach the literature on each test and select well-conducted studies to answer the following questions:• Which percentage of patients with cirrhosis does the test deem as having MHE?• Is the test able to predict clinically manifest HE?• Is there a well-known test-retest variation and inter-observer variation?• Is the test able to detect a treatment response?• Is the test result affected by age, educational level, gender, or comorbidities?

Quality of life and unmet needs in patients with chronic liver disease: A mixed-method systematic review.

BACKGROUND & AIMS: In an attempt to uncover unmet patient needs, this review aims to synthesise quantitative and qualitative studies on patients' quality of life and their experience of having liver disease. METHODS: Three databases (CINAHL, Embase, and PubMed) were searched from January 2000 to October 2020. The methodological quality and data extraction of both quantitative and qualitative studies were screened and appraised using Joanna Briggs Institute instruments for mixed-method systematic reviews and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A convergent, integrated approach to synthesis and integration was used. Studies including patients with autoimmune and cholestatic liver disease, chronic hepatitis B and C, non-alcoholic fatty liver disease and non-alcoholic steatohepatitis, cirrhosis, and hepatocellular carcinoma were considered. RESULTS: The searches produced 5,601 articles, of which 95 (79 quantitative and 16 qualitative) were included in the review. These represented studies from 26 countries and a sample of 37,283 patients. The studies showed that patients´ quality of life was reduced. Unmet needs for information and support and perceived stigmatisation severely affected patients' quality of life. CONCLUSIONS: Our study suggests changes to improve quality of life. According to patients, this could be achieved by providing better education and information, being aware of patients' need for support, and raising awareness of liver disease among the general population to reduce misconceptions and stigmatisation. REGISTRATION NUMBER: PROSPERO CRD42020173501. LAY SUMMARY: Regardless of aetiology, patients with liver diseases have impaired quality of life. This is associated with disease progression, the presence of symptoms, treatment response, and mental, physical, and social factors such as anxiety, confusion, comorbidities, and fatigue, as well as limitations in daily living, including loneliness, low income, stigmatisation, and treatment costs. Patients highlighted the need for information to understand and manage liver disease, and awareness and support from healthcare professionals to better cope with the disease. In addition, there is a need to raise awareness of liver diseases in the general population to reduce negative preconceptions and stigmatisation.

Cognitive Dysfunction in Non-Alcoholic Fatty Liver Disease-Current Knowledge, Mechanisms and Perspectives.

Non-alcoholic fatty liver disease (NAFLD) has emerged as the hepatic component of the metabolic syndrome and now seemingly affects one-fourth of the world population. Features associated with NAFLD and the metabolic syndrome have frequently been linked to cognitive dysfunction, i.e. systemic inflammation, vascular dysfunction, and sleep apnoea. However, emerging evidence suggests that NAFLD may be a cause of cognitive dysfunction independent of these factors. NAFLD in addition exhibits dysbiosis of the gut microbiota and impaired urea cycle function, favouring systemic ammonia accumulation and further promotes systemic inflammation. Such disruption of the gut-liver-brain axis is essential in the pathogenesis of hepatic encephalopathy, the neuropsychiatric syndrome associated with progressive liver disease. Considering the growing burden of NAFLD, the morbidity from cognitive impairment is expected to have huge societal and economic impact. The present paper provides a review of the available evidence for cognitive dysfunction in NAFLD and outlines its possible mechanisms. Moreover, the clinical challenges of characterizing and diagnosing cognitive dysfunction in NAFLD are discussed.

Impact of liver disease on patients' quality of life: a mixed methods systematic review protocol.

OBJECTIVE: The objective of this systematic review is to explore the impact of liver disease on patients' quality of life in an attempt to develop effective evidence-based recommendations and strategies useful for clinical practice and health care professionals. INTRODUCTION: Liver diseases are common worldwide and a major cause of illness and death due to health problems and serious complications, which not only cause hospitalization and death, but also emotional distress, depression, and impaired quality of life. INCLUSION CRITERIA: This review will consider qualitative and quantitative studies on patients with liver disease of different severity and type. The qualitative component of this review will consider all studies that describe patients' lived experience and perception of having liver disease. The quantitative component will include studies that explore the quality of life in patients with liver disease. METHODS: CINAHL (EBSCO), Embase (Ovid), MEDLINE (Ovid), PsycINFO (Ovid), Scopus (Elsevier), and Web of Science (Ovid) will be searched for articles published in Danish and English without any restriction in terms of year of publication. Articles describing both qualitative and quantitative studies will be screened for inclusion, critically appraised for methodological quality, and have data extracted using JBI instruments for mixed methods systematic reviews. A convergent integrated approach to synthesis and integration will be used. SYSTEMATIC REVIEW REGISTRATION NUMBER: PROSPERO CRD42020173501.

Periodontitis in patients with cirrhosis: a cross-sectional study.

BACKGROUND: Many patients with cirrhosis have poor oral health but little is known on periodontitis, and its clinical significance is largely unknown. This study aimed to examine the prevalence and predictors of periodontitis, and evaluate the association of periodontitis with nutritional and systemic inflammation status. METHODS: 145 patients with cirrhosis were consecutively enrolled. Clinical, oral examination of plaque, pocket depth, clinical attachment level, and bleeding on probing was performed. Patients were categorized as having no-or-mild, moderate, or severe periodontitis. Predictors of severe periodontitis and the association with nutritional and systemic inflammation status were analyzed using univariable and multivariable logistic regression analyses. RESULTS: The large majority of patients had periodontitis, 46% of them severely and 39% moderately. Predictors of severe periodontitis included smoking (odds ratio (OR) 2.93, 95% confidence interval (CI) 1.29-6.63), brushing teeth twice daily (OR 0.30, 95% CI 0.11-0.79), and visiting the dentist annually (OR 3.51, 95% CI 1.22-10.81). Cirrhosis etiology or severity was not predictors of severe periodontitis. The patients with severe periodontitis had a higher nutritional risk score than patients with moderate, mild, or no periodontitis (3, interquartile range (IQR) 3-5 vs. 3, IQR 2-4, P = 0.02). CONCLUSIONS: Most cirrhosis patients had significant periodontitis, the severity of which was related to life style factors and was associated with higher nutrition risk score. Our results emphasize the need for further research to establish the effect of periodontitis on cirrhosis.

Presence and consequence of tooth periapical radiolucency in patients with cirrhosis.

BACKGROUND: Periapical radiolucency is the radiographic sign of inflammatory bone lesions around the apex of the tooth. We determined the prevalence and predictors of periapical radiolucency in patients with cirrhosis and the association with systemic inflammation status and cirrhosis-related complications. METHODS: A total of 110 cirrhosis patients were consecutively enrolled. Periapical radiolucency was defined as the presence of radiolucency or widening of the periapical periodontal ligament space to more than twice the normal width. Predictors of periapical radiolucency and the association with systemic inflammation markers and cirrhosis-related complications were explored by univariable and multivariable logistic regression analyses. RESULTS: Periapical radiolucency was present in one or more teeth in 46% of the patients. Strong predictors were gross caries (odds ratio [OR] 3.12, 95% confidence interval [CI] 1.43-6.79) and severe periodontitis (OR 3.98, 95% CI 1.04-15.20). Also old age (OR 1.10, 95% CI 1.01-1.19) and smoking (OR 3.24, 95% CI 1.02-17.62) were predictors. However, cirrhosis etiology (alcoholic vs nonalcoholic) or severity (Model of End-Stage Liver Disease score) were not predictors. The patients with periapical radiolucency had higher C-reactive protein (15.8 mg/L vs 8.1 mg/L, P=0.02) and lower albumin contents (25 g/L vs 28 g/L, P=0.04) than those without. Furthermore, the patients with periapical radiolucency had a higher prevalence of cirrhosis-related complications such as ascites, hepatic encephalopathy, and/or variceal bleeding (46% vs 27%, P=0.05). CONCLUSION: Periapical radiolucency is often present as an element of poor oral health status and likely has an adverse clinical significance, which should motivate diagnostic and clinical attention to the findings.

Periodontal disease and liver cirrhosis: A systematic review.

OBJECTIVES: Studies suggest that periodontal disease, a source of subclinical and persistent infection, may be associated with various systemic conditions, including liver cirrhosis. The aim of this study was to examine the literature and determine the relationship between periodontal disease and liver cirrhosis and to identify opportunities and directions for future research in this area. METHODS: A systematic review of English articles in the PubMed, EMBASE, and Scopus databases was conducted using search terms including 'liver cirrhosis', 'end-stage liver disease', 'liver diseases', 'oral health', 'periodontal disease', 'mouth disease', 'gingivitis', and 'periodontitis'. RESULTS: Thirteen studies published between 1981 and 2014 were found to include data on oral health and periodontal disease in cirrhotic patients. Studies indicated an increased incidence of periodontal disease in patients with liver cirrhosis, measured with several different periodontal indices. The reported prevalence of periodontal disease in cirrhosis patients ranged from 25.0% to 68.75% in four studies and apical periodontitis was found in 49%-79% of the patients. One study found that mortality was lower among patients who underwent dental treatment versus non-treated patients. Another study suggested an association between periodontal disease and the progression of liver cirrhosis, but data are sparse and conflicting as to whether periodontal disease is correlated to cirrhosis aetiology and severity. CONCLUSION: Despite the clinical reality of periodontal disease in liver cirrhosis patients, there are few published studies. Before clinical implications can be addressed, more data on the prevalence of and correlation between periodontal disease and liver cirrhosis aetiology, duration, and progression are needed.