Symptom Management in Patients with Cirrhosis: a Practical Guide

A prediction model for moderate to severe pain in primary hepatic carcinoma after chemotherapy: a multi-center prospective case‒control study

The incidence of moderate to severe pain after chemotherapy with primary hepatic carcinoma (PHC) patients is high. Although standardized treatment can effectively relieve pain, the control effect is poor. More attention should be paid to the prevention of pain at the beginning of symptoms, so as to reduce the incidence of pain and promote the health of patients. However, there are lack of a prospective design to predict pain before it occurs. The study is a prospective case‒control study. Population was PHC patients who received chemotherapy from April to August to 2024 in three grade 3 and first-class hospital. Data were collected in two periods (on the day of admission and within 24 h of chemotherapy). According to the Brief Pain Inventory, the patients were divided into case group and control group. Then the patients were randomly divided into a training group and an internal validation group at a 2:1 ratio. Single-factor logistics regression was used to analyze the risk factors, and the back-propagation artificial neural network (BP-ANN) model was constructed and verified. A total of 467 patients consisting of 312 training samples and 155 validation samples. BP-ANN model showed the AUC, sensitivity, specificity, and accuracy of prediction were 0.808, 70.6%, 81.7%, 93%, respectively. Internal verification also indicated these indicators were 0.783, 78.8%, 70.8%, and 94.2%, respectively. Significant predictors identified were age > 57.5, BMI > 19.9, symptoms of insomnia prior to illness, worker, Renvastinib, Child-Pugh = B, glutamic oxalacetic transaminase, other platinum drugs, cancer staging of IV, ECOG = 2, NRS-2002 = 3, Oxaliplatin, and Donafenib. The BP-ANN model holds high predictive value for the moderate to severe pain of PHC patients after chemotherapy. In the future, the model can be further visualized to facilitate clinical screening and to provide a basis for subsequent intervention.

Health-related quality of life and frailty in liver cirrhosis

BACKGROUND AND OBJECTIVES

There is limited evidence concerning the predictive value of health-related quality of life (HRQoL) on the presence of frailty in the context of cirrhosis. We aimed to elucidate the relationship between HRQoL and multidimensional frailty and to determine which HRQoL dimension independently impacted frail phenotype in our established cohort.

METHODS

This was a prospective observational study by consecutively enrolling 355 patients with cirrhotic with decompensated signs in China. The HRQoL and frail phenotype were evaluated by the EuroQol-5D (EQ-5D) Questionnaire and Frailty Index, respectively. The relationship between EQ-5D utility index, as well as respective EQ-5D dimension, and Frailty Index was analysed according to the multiple linear regression analyses.

RESULTS

More than half of the patients (56.3%) reported problems in any dimension of the EQ-5D, suggestive of impaired HRQoL. Moreover, the proportion of patients experiencing some/extreme problems significantly increased across all five dimensions (all p<0.001) in correspondence to transition from the robust to frail phenotype. Multiple linear regression analyses demonstrated that age, ascites and hepatic encephalopathy were positively associated with Frailty Index, while EQ-5D utility index (standardised β coefficient= -0.442, p<0.001) negatively associated with Frailty Index. Notably, usual activities, self-care and mobility were the most influencing predictors associated with frailty.

CONCLUSIONS

Our results support a rapid HRQoL assessment via EQ-5D may assist in predicting multidimensional frailty, and usual activities, self-care and mobility tend to be remediable targets while taking their effect on frail phenotype into consideration among patients with cirrhosis.

Commonly encountered symptoms and their management in patients with cirrhosis

This exhaustive review, explored the multifaceted symptoms and their management in patients with cirrhosis. Patients frequently endure pain, muscle cramps, sleep disturbances, psychological distress, and gastrointestinal issues, significantly impairing their quality of life. Pain is prevalent, often requiring analgesics, while muscle cramps affect up to 68% of patients, treated with supplements like zinc and taurine despite limited evidence. Sleep disturbances, including insomnia and excessive daytime sleepiness, afflict up to 80% of patients, managed through lactulose, melatonin, and cognitive behavioral therapies. Gastrointestinal symptoms, affecting 80%, include abdominal pain and bloating, necessitating lifestyle and dietary adjustments. Mental health disorders, such as depression and anxiety, are common, managed with a combination of pharmacotherapy and psychotherapy. Sexual dysfunction, often overlooked, profoundly impacts both men and women, requiring holistic treatment approaches. Pruritus, another distressing symptom, is managed with moisturizers and antihistamines, though many treatments show limited success. Hair loss and skin changes add to the psychological burden, highlighting the need for a comprehensive, multidisciplinary approach. The review underscores the imperative for tailored, compassionate care to enhance patient outcomes and quality of life in cirrhosis.

Use of Non-Invasive Biomarkers and Clinical Scores to Predict the Complications of Liver Cirrhosis: A Bicentric Experience

Background and objectives: Liver cirrhosis is a chronic, progressive condition characterized by fibrosis and architectural distortion of the liver, leading to impaired liver function and severe complications. Accurately predicting these complications is crucial to the improvement of patient outcomes. Therefore, this study aimed to evaluate the accuracy of various non-invasive biomarkers and clinical scores in assessing the risk of complications among cirrhotic patients. Materials and methods: We conducted an observational retrospective study involving 236 cirrhotic patients from two tertiary care hospitals in Italy and Romania, in a timespan ranging from January 2021 to March 2024. Data on clinical characteristics, liver function tests, hematological indices, various non-invasive biomarkers, and clinical scores were collected and analyzed. Receiver operating characteristic analysis was performed to assess the accuracy of these biomarkers and clinical scores in predicting complications, including the presence of varices and hepato-renal syndrome. Results: The Child-Pugh score showed the highest accuracy for cirrhosis-related complications, with an area under curve (AUC) = 0.667. The red cell distribution width coefficient of variation followed closely with an AUC = 0.646. While the Child-Pugh score had a high specificity (85.42%), its sensitivity was low (37.97%). In patients with varices, non-invasive scores such as platelet distribution width (PDW) and the RDW-to-platelet ratio (RPR) showed modest predictive ability, with an AUC = 0.594. For hepato-renal syndrome, the Model for End-Stage Liver Disease (MELD) score showed the highest diagnostic accuracy with an AUC = 0.758. Conclusions: The most reliable biomarkers for detecting complications, varices, and hepato-renal syndrome, are, respectively, the Child-Pugh Score, PDW along with RPR, and the MELD score. However, while these scores remain valuable, the moderate diagnostic accuracy of other indices suggests the need for a more integrated approach to risk stratification. Future research should focus on validating these tools across different populations and incorporating emerging biomarkers to enhance predictive accuracy and inform more effective clinical decision-making.

Opioid and Nonopioid Analgesic Prescribing Patterns of Hepatologists for Medicare Beneficiaries

INTRODUCTION

Opioids are commonly prescribed to patients with chronic liver disease, but little is known regarding medication prescribing patterns of hepatologists. Opioid use increased until national guidelines limited opioid prescriptions in early 2016. We aimed to describe rates of opioid and nonopioid analgesics to Medicare beneficiaries by hepatologists from 2013 to 2017 and identify demographic characteristics associated with higher prescribing.

METHODS

Prescription data from 2013 to 2017 by 761 hepatologists identified in the Centers for Medicare and Medicaid Services Part D Public Use File were analyzed. Annual prescription volumes were compared for providers with >10 annual prescriptions of a given drug type. Provider characteristics associated with opioid prescriptions were identified through multivariate logistic regression analyses.

RESULTS

The proportion of hepatologists prescribing >10 annual opioid prescriptions decreased from 29% to 20.6%. Median annual opioid prescriptions per hepatologist significantly decreased from 24 to 20. Tramadol remained the most prescribed analgesic. Nonopioid analgesic prescription volume did not increase significantly. Provider characteristics associated with increased opioid prescriptions included male sex, practice location in the South and Midwest (vs West), more years in practice, and a greater proportion of beneficiaries who are white or with low-income subsidy claims. Characteristics associated with fewer prescriptions included non-university-based practice, having a greater proportion of female beneficiaries, and later prescription year.

DISCUSSION

Hepatologists are prescribing less opioids. However, the prevalence of tramadol use and the lack of increase in nonopioid analgesic use highlights the need for advancing the science and training of pain management in chronic liver disease and targeted implementation of nonopioid treatment programs.

Symptom burden in chronic liver disease

Chronic liver disease (CLD) is a significant contributor to global mortality. For people who are living with CLD, however, there is a substantial and often overlooked burden of physical and psychological symptoms that significantly affect health-related quality of life. CLD frequently presents with a multitude of interrelated and intricate symptoms, including fatigue, pruritus, muscle cramps, sexual dysfunction, and falls. Increasingly, there is interest in studying and developing interventional strategies to provide a more global approach to managing these complex patients. Moreover, in addition to established guidelines for the management of conventional complications, such as ascites and hepatic encephalopathy, there have been efforts in developing evidence-based guidance for the treatment of the more subjective yet still problematic elements. This review will address the management of these less "classical" but nonetheless important symptoms.

Quality of death in patients in advanced chronic liver disease and cancer patients managed by gastroenterologists in Portugal: are we doing it right?

INTRODUCTION

The incidence of chronic progressive diseases is rising and investment on quality of death and dying is of utmost importance to minimize physical and emotional suffering. There is still a gap in palliative care (PC) between patients with cancer and those with advanced chronic liver disease (ACLD). Our objectives were to characterize clinical attitudes and therapeutic interventions and to evaluate the differences in end-of-life care between inpatients with cancer and ACLD under gastroenterology care.

METHODS

Retrospective cohort study, including patients with cancer or ACLD who died in a Gastroenterology department between 2012 and 2021. Demographic characteristics, clinical and endoscopic procedures and symptom control were compared between the groups.

RESULTS

From 150 patients, 118 (78.7%) died with cancer and 32 (21.3%) died from ACLD without concomitant hepatocellular carcinoma. ACLD patients were more frequently male ( P  = 0.001) and younger ( P  = 0.001) than patients with cancer. Median time of hospitalization in the last month of life was 16 days for both groups. Discussion of prognosis with the patient was more frequent for cancer patients (35.6% versus 3.2%, P  < 0.001). Referral to PC occurred in 18.8% and 61% of the patients with ACLD and cancer respectively ( P  < 0.001). Endoscopic procedures were performed in half of the patients and were more likely to be unsuccessful in those with cancer.

CONCLUSION

Clinical decisions were different between groups in terms of PC access and discussion of prognostic with the patient. It is urgent to define and implement metrics of quality of death and dying to prevent potentially inappropriate treatment.

Effect of short-term mindfulness-based stress reduction on sleep quality in male patients with alcohol use disorder

Background

Sleep disturbance is one of the most prominent complaints of patients with alcohol use disorder (AUD), with more than 70% of patients with AUD reporting an inability to resolve sleep problems during abstinence. Mindfulness-based stress reduction (MBSR) has been shown to improve sleep quality and as an alternative therapy to hypnotics for sleep disorders.

Objective

The aim of the present study was to evaluate the effect of short-term MBSR on sleep quality in male patients with AUD after withdrawal.

Methods

A total of 91 male patients with AUD after 2 weeks of routine withdrawal therapy were randomly divided into two groups using a coin toss: the treatment group (n = 50) and the control group (n = 41). The control group was received supportive therapy, and the intervention group added with MBSR for 2 weeks on the basis of supportive therapy. Objective sleep quality was measured at baseline and 2 weeks after treatment using the cardiopulmonary coupling (CPC). Indicators related to sleep quality include total sleep time, stable sleep time, unstable sleep time, rapid eye movement (REM) sleep time, wake-up time, stable sleep latency, sleep efficiency, and apnea index. These indicators were compared by an analysis of covariance (ANCOVA) between the two groups, controlling for individual differences in the respective measures at baseline.

Results

The results showed that there were no significant differences in the age [t (89) = -0.541, P = 0.590), BMI [t (89) = -0.925, P = 0.357], educational status [t (89) = 1.802, P = 0.076], years of drinking [t (89) = -0.472, P = 0.638), daily intake [t (89) = 0.892, P = 0.376], types of alcohol [χ2 (1) = 0.071, P = 0.789], scores of CIWA-AR [t (89) = 0.595, P = 0.554], scores of SDS [t (89) = -1.151, P = 0.253), or scores of SAS [t (89) = -1.209, P = 0.230] between the two groups. Moreover, compared with the control group, the total sleep time [F (1.88) = 4.788, P = 0.031) and stable sleep time [F (1.88) = 6.975, P = 0.010] were significantly increased in the treatment group. Furthermore, the average apnea index in the patients who received MBSR was significantly decreased than in the control group [F (1.88) = 5.284, P = 0.024].

Conclusion

These results suggest that short-term MBSR could improve sleep quality and may serve as an alternative treatment to hypnotics for sleep disturbance in patients with AUD after withdrawal.

The relationship between patient-reported health-related quality of life and malnutrition risk in cirrhosis: an observational cohort study

Patients with cirrhosis experience worse health-related quality of life (HRQoL), and attempts are warranted further exploration of modifiable factors to improve HRQoL. Data on the impact of malnutrition risk on HRQoL among cirrhosis are limited; thus, we aimed to strengthen understanding by clarifying the relationship between nutritional status and low HRQoL in patients with decompensated cirrhosis. Consecutive inpatients with cirrhosis attending our department within a tertiary hospital were studied. Generic health profiles and malnutrition risk were evaluated by the EuroQol-5D (EQ-5D) and Royal Free Hospital-Nutritional Prioritizing Tool (RFH-NPT) score, respectively. Multiple linear regression analysis was used to determine association of malnutrition risk with low HRQoL. In this cohort of 364 patients with median age of 64 years and 49·5 % male, 55·5 % of the study population reported impairment pertinent to HRQoL in at least one dimension in terms of the EQ-5D. Moreover, malnutrition risk (RFH-NPT score: β coefficient = -0·114, P = 0·038) was proved to be independently associated with poor HRQoL in multiple analysis, after adjustment for significant variables like age, BMI and markers of decompensation. Notably, we found that health dimensions representing physical function (i.e. mobility, self-care and usual activities) are substantially affected, while malnourished patients reported less frequencies of complaints in other domain such as anxiety/depression. In conclusion, the risk of malnutrition assessed by the RFH-NPT score is independently associated with low HRQoL. It is operational to improve HRQoL by identifying patients at high malnutrition risk and providing timely nutrition treatment.

Neutrophil-to-Lymphocyte Ratio Can Distinguish Patients with Liver Cirrhosis from Healthy People but Cannot Distinguish Patients with Cirrhotic Hepatocellular Carcinoma from Patients with Liver Cirrhosis

PURPOSE

Identifying cirrhotic hepatocellular carcinoma (HCC) during liver cirrhosis (LC) stage is pivotal for improving the clinical outcomes of cirrhotic HCC patients. Inflammation-driven markers play a crucial role in tumorigenesis and tumor progression. Neutrophil-to-lymphocyte ratio (NLR) is an inflammatory response marker. This study aimed to evaluate the ability of NLR to distinguish cirrhotic HCC from LC.

METHODS

Data of healthy control (HC) people, LC patients, cirrhotic HCC patients, and non-cirrhotic HCC patients were retrospectively analyzed. Mann-Whitney U test and Chi-squared test were used to compare demographic and clinical parameters in different groups. Spearman correlation analysis was used to assess correlations. Receiver operating characteristic (ROC) curves were performed to determine diagnostic accuracy.

RESULTS

A total of 419 participants were enrolled in this study, including 152 HC people, 131 LC patients, 96 cirrhotic HCC patients, and 40 non-cirrhotic HCC patients. Level of NLR was elevated significantly in LC compared with HC (P < 0.001). No significant differences were found for NLR between LC and cirrhotic HCC (P = 0.083), as well as between cirrhotic HCC and non-cirrhotic HCC (P = 0.729). NLR was positively correlated with platelet-to-lymphocyte ratio (r = 0.33, P < 0.001). The area under the ROC curve (AUC) value for NLR to distinguish LC from HC was 0.759 (P < 0.001), and AUC value to distinguish cirrhotic HCC from LC was 0.567 (P = 0.083), and AUC value to distinguish non-cirrhotic HCC from cirrhotic HCC was 0.519 (0.415-0.623) (P = 0.729).

CONCLUSION

NLR can distinguish LC from HC but cannot not distinguish cirrhotic HCC from LC.