Management of hepatic hydropericardium with open drainage, maximal medical therapy and terlipressin.

We present the case of a woman in her 60s with Child-Pugh C cirrhosis who developed pericardial tamponade during an admission for a haemothorax secondary to a mechanical fall. The patient developed haemodynamic compromise with a rapid decline in renal function. During an open subxiphoid drain tube insertion, a pre-existing peritoneopericardial communication was noted, with ascites in the peritoneal cavity on view. The serum ascites albumin gradient was 14 g/L. Maximal medical therapy was commenced including diuresis and albumin, with adjunctive terlipressin infusion which restored her baseline renal function and resolved the effusion. We believe this is the first case report of using open drainage, maximal medical therapy and terlipressin to successfully treat hepatic hydropericardium and its subsequent renal compromise.

A Beta-Prototype Chatbot for Increasing Health Literacy of Patients With Decompensated Cirrhosis: Usability Study.

BACKGROUND: Health literacy is low among patients with chronic liver disease (CLD) and associated with poor health outcomes and increased health care use. Lucy LiverBot, an artificial intelligence chatbot was created by a multidisciplinary team at Monash Health, Australia, to improve health literacy and self-efficacy in patients with decompensated CLD. OBJECTIVE: The aim of this study was to explore users' experience with Lucy LiverBot using an unmoderated, in-person, qualitative test. METHODS: Lucy LiverBot is a simple, low cost, and scalable digital intervention, which was at the beta prototype development phase at the time of usability testing. The concept and prototype development was realized in 2 phases: concept development and usability testing. We conducted a mixed methods study to assess usability of Lucy LiverBot as a tool for health literacy education among ambulatory and hospitalized patients with decompensated CLD at Monash Health. Patients were provided with free reign to interact with Lucy LiverBot on an iPad device under moderator observation. A 3-part survey (preuser, user, and postuser) was developed using the Unified Acceptance Theory Framework to capture the user experience. RESULTS: There were 20 participants with a median age of 55.5 (IQR 46.0-60.5) years, 55% (n=11) of them were female, and 85% (n=17) of them were White. In total, 35% (n=7) of them reported having difficulty reading and understanding written medical information. Alcohol was the predominant etiology in 70% (n=14) of users. Participants actively engaged with Lucy LiverBot and identified it as a potential educational tool and device that could act as a social companion to improve well-being. In total, 25% (n=5) of them reported finding it difficult to learn about their health problems and 20% (n=4) of them found it difficult to find medical information they could trust. Qualitative interviews revealed the conversational nature of Lucy LiverBot was considered highly appealing with improvement in mental health and well-being reported as an unintended benefit of Lucy LiverBot. Patients who had been managing their liver cirrhosis for several years identified that they would be less likely to use Lucy LiverBot, but that it would have been more useful at the time of their diagnosis. Overall, Lucy LiverBot was perceived as a reliable and trustworthy source of information. CONCLUSIONS: Lucy LiverBot was well received and may be used to improve health literacy and address barriers to health care provision in patients with decompensated CLD. The study revealed important feedback that has been used to further optimize Lucy LiverBot. Further acceptability and validation studies are being undertaken to investigate whether Lucy LiverBot can improve clinical outcomes and health related quality of life in patients with decompensated CLD.

Healthcare utilisation and costing for decompensated chronic liver disease hospitalisations at a Victorian network.

BACKGROUND: The economic burden of decompensated chronic liver disease (CLD) on Australian healthcare services is poorly characterised. AIMS: To evaluate the in-patient healthcare utilisation costs associated with decompensated CLD at Monash Health, an Australian tertiary healthcare service. METHODS: The current retrospective cost analysis examined patients with decompensated CLD admitted between 1 January 2012 and 31 December 2018. Hospitalisations were identified using CLD-specific International Classification of Diseases, Tenth Revision, codes. Cost measures were estimated using the Victorian Weighted Inlier Equivalent Separation funding data based on the Australian Refined Diagnosis Related Groups cost weights. RESULTS: There were 707 hospitalisations in 435 adult patients. The mean age was 56.7 ± 11.7 years and the mean length of stay was 10.28 ± 11.2 days. Median survival was 31 months (interquartile range, 2-94 months) and 177 (40.8%) patients died within 1 year of admission. The cost of admission varied according to decompensation: hepatorenal syndrome ($20 162 AUD), variceal bleed ($16 630 AUD), spontaneous bacterial peritonitis ($12 664 AUD), hepatic encephalopathy ($9973 AUD) and ascites ($9001 AUD). There was no significant difference in the admissions or 30-day readmission rate from 2012 to 2018 financial year (FY). The total adjusted cost of cirrhotic admissions per year increased by 78% from FY2012 to FY2018. CONCLUSION: Hospital admission and readmission for decompensated CLD is common and associated with 40.8% 1-year mortality and high costs. Clearer delineation of goals of care and alternative ambulatory care models for decompensated CLD are urgently required to reduce the high costs and burden on health services.

A home-based, multidisciplinary liver optimisation programme for the first 28 days after an admission for acute-on-chronic liver failure (LivR well): a study protocol for a randomised controlled trial.

BACKGROUND: Acute-on-chronic liver failure (ACLF) represents a rising global healthcare burden, characterised by increasing prevalence among patients with decompensated cirrhosis who have a 28-day transplantation-free mortality of 33.9%. Due to disease complexity and a high prevalence of socio-economic disadvantage, there are deficits in quality of care and adherence to guideline-based treatment in this cohort. Compared to other chronic conditions such as heart failure, those with liver disease have reduced access to integrated ambulatory care services. The LivR Well programme is a multidisciplinary intervention aimed at improving 28-day mortality and reducing 30-day readmission through a home-based, liver optimisation programme implemented in the first 28 days after an admission with either ACLF or hepatic decompensation. Outcomes from our feasibility study suggest that the intervention is safe and acceptable to patients and carers. METHODS: We will recruit adult patients with chronic liver disease from the emergency departments, in-patient admissions, and an ambulatory liver clinic of a multi-site quaternary health service in Melbourne, Australia. A total of 120 patients meeting EF-Clif criteria will be recruited to the ACLF arm, and 320 patients to the hepatic decompensation arm. Participants in each cohort will be randomised to the intervention arm, a 28-day multidisciplinary programme or to standard ambulatory care in a 1:1 ratio. The intervention arm includes access to nursing, pharmacy, physiotherapy, dietetics, social work, and neuropsychiatry clinicians. For the ACLF cohort, the primary outcome is 28-day mortality. For the hepatic decompensation cohort, the primary outcome is 30-day re-admission. Secondary outcomes assess changes in liver disease severity and quality of life. An interim analysis will be performed at 50% recruitment to consider early cessation of the trial if the intervention is superior to the control, as suggested in our feasibility study. A cost-effectiveness analysis will be performed. Patients will be followed up for 12 weeks from randomisation. Three exploratory subgroup analyses will be conducted by (a) source of referral, (b) unplanned hospitalisation, and (c) concurrent COVID-19. The trial has been registered with the Australian New Zealand Clinical Trials Registry. DISCUSSION: This study implements a multidisciplinary intervention for ACLF patients with proven benefits in other chronic diseases with the addition of novel digital health tools to enable remote patient monitoring during the COVID-19 pandemic. Our feasibility study demonstrates safety and acceptability and suggests clinical improvement in a small sample size. An RCT is required to generate robust outcomes in this frail, high healthcare resource utilisation cohort with high readmission and mortality risk. Interventions such as LivR Well are urgently required but also need to be evaluated to ensure feasibility, replicability, and scalability across different healthcare systems. The implications of this trial include the generalisability of the programme for implementation across regional and urban centres. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12621001703897 . Registered on 13 December 2021. WHO Trial Registration Data Set. See Appendix 1.

Pyopneumopericarditis from a gastropericardial fistula: a case report.

BACKGROUND: Pyopneumopericarditis is a very rare diagnosis that requires prompt recognition and urgent treatment. It denotes the presence of pus and air in the pericardium with associated inflammation of the fibrous pericardial sac. CASE SUMMARY: A 49-year-old gentleman was admitted with pyopneumoperciarditis on a background of a previous uncomplicated Roux-en-Y gastric bypass surgery performed 7 years prior. He underwent emergency surgery for an omental patch repair of an ulcer perforation involving the diaphragm and pericardium. His inpatient stay was complicated by persistent seropurulent output from the pericardial drain, loculated pleural effusion, and deconditioning. DISCUSSION: Management is extrapolated from the literature regarding purulent pericarditis. This condition albeit rare, requires swift recognition as without treatment mortality approaches 100%. Colchicine is an important adjunctive therapy postoperatively to prevent constrictive physiology.

Metal stents are safe and cost-effective for preoperative biliary drainage in resectable pancreaticobiliary tumours.

BACKGROUNDS: To compare the complication rates and overall costs of self-expandable metal stents (SEMS) and plastic stents (PS) in clinically indicated preoperative biliary drainage (PBD) prior to a pancreatoduodenectomy (PD). METHODS: We conducted an Australian multicentre retrospective cohort study using the databases of four tertiary hospitals. Adult patients who underwent clinically indicated endoscopic PBD prior to PD from 2010 to 2019 were included. Rates of complications attributable to PBD, surgical complications and pre-operative endoscopic re-intervention were calculated. Costing data were retrieved from our Financial department. RESULTS: Among the 157 included patients (mean age 66.6 ± 9.8 years, 45.2% male), 49 (31.2%) received SEMS and 108 received PS (68.8%). Baseline bilirubin was 187.5 ± 122.6 µmol/L. Resection histopathology showed mainly adenocarcinoma (93.0%). Overall SEMS was associated less complications (12.2% vs. 28.7%, p = 0.02) and a lower pre-operative endoscopic re-intervention rate (4.3 vs. 20.8%, p = 0.03) compared with PS. There was no difference in post-PD complication rates. On multivariate logistic regression analysis, stent type was an independent risk factor of PBD complication (OR of SEMS compared to PS 0.24, 95% CI 0.07-0.79, p = 0.02) but not for any secondary outcome measures. Upfront material costs were $56USD for PS and $1991USD for SEMS. Accounting for rates of complications, average costs were similar ($3110USD for PS and $3026USD for SEMS). CONCLUSION: In resectable pancreaticobiliary tumours, SEMS for PBD was associated with reduced risk of overall PBD-related complications and pre-surgical endoscopic reintervention rates and was comparable to PS in terms of overall cost.

Implementation of an Educational iPad Application for Patients With Chronic Hepatitis B.

Chronic Hepatitis B (CHB) contributes to a high public health burden in Australia from chronic liver disease and hepatocellular carcinoma. Health literacy impacts on multiple aspects of long term management, including surveillance and long term follow up. We designed and implemented a multilingual educational iPad application for outpatients to use while in the clinic waiting room. The application employed an interactive and multimodal approach to education. It utilized graphics, audio and text to convey practical information regarding transmission of disease, long term complications, treatment and surveillance. Participants were recruited from a tertiary liver clinic and assigned to either standard treatment (routine clinical consult only) or the iPad group (clinical consult and additional education with the iPad app). There were 54 participants (control n = 29, iPad n = 25). Knowledge was assessed at baseline, secondly after the clinician appointment and finally at 6 months. Median follow up time was 6.1 months (range 0-18 months) and 87% of participants completed the final survey. At baseline, there was no difference in age, gender, proportion of newly referred patients, or use of antivirals. Baseline knowledge was similar in the two groups (61.4 vs. 55.1%, p = 0.33). The iPad group scored significantly higher after the first consult (79.5 vs. 61.5%, p = 0.0005). This improvement remained significant by the end of follow up (72.6 vs. 61.0%, p = 0.0472). To conclude, interactive education with iPads may be an effective way to improve patient knowledge.

Could Adherence to Quality of Care Indicators for Hospitalized Patients With Cirrhosis-Related Ascites Improve Clinical Outcomes?

OBJECTIVES: The diagnosis of cirrhotic ascites is associated with significant morbidity, mortality, and reduced health-related quality of life. Adherence by health professionals to quality indicators (QIs) of care for ascites is low. We evaluated the effect of adherence to ascites QIs on clinical outcomes for patients hospitalized with new onset cirrhotic ascites. METHODS: The medical records of 302 patients admitted with new onset cirrhotic ascites were interrogated for demographic and clinical data and adherence to eight Delphi panel-derived QIs for ascites management. Associations between adherence to each QI and 30-day emergent readmission and 90-day mortality were analyzed. RESULTS: The majority of patients were males (68.9%) over 50 years of age (mean 57±12.83 years) with alcohol-related cirrhosis (59%). Twenty-nine percent were readmitted within 30 days. Patients who received an abdominal paracentesis within 30 days of ascites diagnosis (QI 1, relative risk (RR) 0.41, P=0.004) or during index hospitalization (QI 2, RR 0.57, P=0.006) were significantly less likely to experience a 30-day emergent readmission. Baseline serum bilirubin >2.5 mg/dl was associated with increased 30-day cirrhosis-related readmission (RR 1.51, P=0.03). A total of 18.5% of patients died within 90 days of index admission; median interval to death was 139 days (37-562 days). Pneumonia was the most frequent cause of death. Independent predictors of 90-day mortality included older age (odds ratio (OR) 1.03, P=0.03), increased Model for End-stage Liver Disease (MELD)-Na score (OR 1.06, P=0.05), primary SBP prophylaxis (QI 7, OR 2.30, P=0.04), and readmission within 30 days (OR 30.26, P<0.001). Discharge prescription of diuretics (QI 8, OR 0.28, P=0.01) was associated with reduced 90-day mortality. CONCLUSIONS: Early paracentesis in patients with new onset cirrhotic ascites lowers 30-day readmission rates, and early initiation of diuretic therapy lowers 90-day mortality.