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Zhou S, Li J, Liu J, Dong S, Chen N, Ran Y, Liu H, Wang X, Yang H, Liu M, Chu H, Wang B, Li Y, Guo L, Zhou L. Depressive symptom as a risk factor for cirrhosis in patients with primary biliary cholangitis: Analysis based on Lasso-logistic regression and decision tree models. Brain Behav 2024; 14:e3639. [PMID: 39099389 PMCID: PMC11298689 DOI: 10.1002/brb3.3639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 05/06/2024] [Accepted: 07/09/2024] [Indexed: 08/06/2024] Open
Abstract
BACKGROUND Depressive symptoms are frequently observed in patients with primary biliary cholangitis (PBC). The role of depressive symptoms on cirrhosis has not been fully noticed in PBC. We aimed to establish a risk model for cirrhosis that took depressive symptoms into account. METHODS Depressive symptoms were assessed by the 17-item Hamilton Depression Rating Scale (HAMD-17). HAMD-17 score was analyzed in relation to clinical parameters. Least absolute shrinkage and selection operator (Lasso)-logistic regression and decision tree models were used to explore the effect of depressive symptoms on cirrhosis. RESULTS The rate of depressive symptom in patients with PBC (n = 162) was higher than in healthy controls (n = 180) (52.5% vs. 16.1%; p < .001). HAMD-17 score was negatively associated with C4 levels and positively associated with levels of alkaline phosphatase (ALP), γ-glutamyl transpeptidase (GGT), total bilirubin (TB), Immunoglobulin (Ig) G, and IgM (r = -0.162, 0.197, 0.355, 0.203, 0.182, 0.314, p < .05). In Lasso-logistic regression analysis, HAMD-17 score, human leukocyte antigen (HLA)-DRB1*03:01 allele, age, ALP levels, and IgM levels (odds ratio [OR] = 1.087, 7.353, 1.075, 1.009, 1.005; p < 0.05) were independent risk factors for cirrhosis. Elevated HAMD-17 score was also a discriminating factor for high risk of cirrhosis in patients with PBC in decision tree model. CONCLUSIONS Depressive symptoms were associated with disease severity. Elevated HAMD-17 score was a risk factor for cirrhosis in patients with PBC.
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Affiliation(s)
- Simin Zhou
- Department of Gastroenterology and Hepatology, General HospitalTianjin Medical UniversityTianjinChina
| | - Jiwen Li
- Department of Gastroenterology and Hepatology, General HospitalTianjin Medical UniversityTianjinChina
| | - Jiangpeng Liu
- Department of Gastroenterology and Hepatology, General HospitalTianjin Medical UniversityTianjinChina
| | - Shijing Dong
- Department of Gastroenterology and Hepatology, General HospitalTianjin Medical UniversityTianjinChina
| | - Nian Chen
- Department of Gastroenterology and Hepatology, General HospitalTianjin Medical UniversityTianjinChina
| | - Ying Ran
- Department of Gastroenterology and Hepatology, General HospitalTianjin Medical UniversityTianjinChina
| | - Haifeng Liu
- Department of Gastroenterology and Hepatology, General HospitalTianjin Medical UniversityTianjinChina
| | - Xiaoyi Wang
- Department of Gastroenterology and Hepatology, General HospitalTianjin Medical UniversityTianjinChina
| | - Hui Yang
- Department of Gastroenterology and Hepatology, General HospitalTianjin Medical UniversityTianjinChina
| | - Man Liu
- Department of Gastroenterology and Hepatology, General HospitalTianjin Medical UniversityTianjinChina
| | - Hongyu Chu
- Department of Gastroenterology and Hepatology, General HospitalTianjin Medical UniversityTianjinChina
| | - Bangmao Wang
- Department of Gastroenterology and Hepatology, General HospitalTianjin Medical UniversityTianjinChina
| | - Yanni Li
- Department of Gastroenterology and Hepatology, General HospitalTianjin Medical UniversityTianjinChina
| | - Liping Guo
- Department of Gastroenterology and Hepatology, General HospitalTianjin Medical UniversityTianjinChina
| | - Lu Zhou
- Department of Gastroenterology and Hepatology, General HospitalTianjin Medical UniversityTianjinChina
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Nayagam JS, Ahmed W, Farrant M, Jefferies J, Boshell V, Simpson A, Joshi D. Clinical factors associated with illness perception, worry and mental health in sclerosing cholangitis: A single centre prospective study. Clin Res Hepatol Gastroenterol 2024; 48:102251. [PMID: 38006942 DOI: 10.1016/j.clinre.2023.102251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 11/20/2023] [Accepted: 11/23/2023] [Indexed: 11/27/2023]
Abstract
BACKGROUND A reduced quality of life and symptoms of depression and anxiety are reported in patients with primary sclerosing cholangitis (PSC), however specific risk factors and the effect of sclerosing cholangitis (SC) with autoimmune features are not known. OBJECTIVE To integrate mental wellbeing assessment into routine clinical care for patients with SC, and evaluate factors associated with measures relating to quality of life, illness perception and mental health. METHODS A prospective study of adult non-transplant patients with SC attending the outpatient clinic over a 1 year period. Self-reported questionnaires were sent to patients electronically prior to clinic to assess worry, illness perception, depression and anxiety. Demographic and clinical information was collected. RESULTS Questionnaires were completed in 52/130 (40 %) patients with SC who attended clinic. Worry related to quality of life, mental and physical health, and future health were common. There was no difference in overall worry or illness perception in patients treated with ursodeoxycholic acid; whilst patients with PSC had a higher illness perception (P = 0.04) than those with SC and autoimmune features. Both worry (P = 0.047) and illness perception (P = 0.01) were higher in patients with elevated alkaline phosphatase, whilst there was no difference in patients with and without cirrhosis. There were high screening test scores for both depression (21.1 %) and anxiety (9.6 %), with no association with patient factors. CONCLUSIONS We integrated an electronic questionnaire for completion prior to clinic for patients with SC with good uptake. We identified a high prevalence of patient worries and symptoms of depression and anxiety, which may be more common in PSC with elevated alkaline phosphatase and without autoimmune features. We recommend the adoption of similar tools into routine clinical practice for patients with SC.
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Affiliation(s)
- Jeremy S Nayagam
- Institute of Liver Studies, King's College Hospital, London, UK; Department of Inflammation Biology, King's College London, London, UK.
| | - Wafaa Ahmed
- Institute of Liver Studies, King's College Hospital, London, UK
| | - Matthew Farrant
- Institute of Liver Studies, King's College Hospital, London, UK
| | | | - Vanessa Boshell
- IMPARTS Research and Education, King's Health Partners, London, UK
| | - Anna Simpson
- IMPARTS Development Team, King's Health Partners, London, UK
| | - Deepak Joshi
- Institute of Liver Studies, King's College Hospital, London, UK
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3
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Janik MK, Wunsch E, Milkiewicz P. Health-related quality of life and symptoms in autoimmune liver diseases. Minerva Gastroenterol (Torino) 2023; 69:50-60. [PMID: 36856273 DOI: 10.23736/s2724-5895.20.02792-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
Assessment of Health-Related Quality of Life (HRQoL) has emerged as an important tool in the evaluation of both the well-being of patients and the results of their clinical management. Over the years, a large number of questionnaires focusing on various aspects of quality of life have been developed. They are frequently divided into generic questionnaires, which can be used under various conditions, disease-specific and symptom-specific questionnaires. Autoimmune liver diseases, such as autoimmune hepatitis, primary sclerosing cholangitis, or primary biliary cirrhosis, comprise a group of rare liver conditions (i.e. affecting fewer than 5 in 10,000 people in the general population). Unfortunately, HRQoL has not been well-studied in this group of patients. In this review, we comprehensively summarize the data available in the literature on HRQoL in these conditions, emphasizing the important role that quality of life plays in the successful management of such patients.
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Affiliation(s)
- Maciej K Janik
- Liver and Internal Medicine Unit, Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Warsaw, Poland.,European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Warsaw, Poland
| | - Ewa Wunsch
- Translational Medicine Group, Pomeranian Medical University, Szczecin, Poland
| | - Piotr Milkiewicz
- Liver and Internal Medicine Unit, Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Warsaw, Poland - .,European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Warsaw, Poland.,Translational Medicine Group, Pomeranian Medical University, Szczecin, Poland
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4
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Wunsch E, Krause L, Gevers TJ, Schramm C, Janik MK, Krawczyk M, Willemse J, Uhlenbusch N, Löwe B, Lohse AW, Milkiewicz P. Confidence in treatment is contributing to quality of life in autoimmune liver diseases. The results of ERN RARE-LIVER online survey. Liver Int 2023; 43:381-392. [PMID: 36177700 PMCID: PMC10091761 DOI: 10.1111/liv.15440] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 09/13/2022] [Accepted: 09/19/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND AND AIMS Autoimmune liver diseases (AILDs) are associated with impaired health-related quality of life (HrQoL). The aim of this project was to identify potentially modifiable factors related to HrQoL in a large transnational cohort of patients with AILDs. METHODS A cross-sectional online survey was conducted on patients with autoimmune hepatitis (AIH), primary biliary cholangitis (PBC) or primary sclerosing cholangitis from 15 European countries. HrQoL was measured with EQ-5D-5L and EQ visual analogue scale (EQ-VAS) and analysed in relation to demographic, psychosocial, disease- and treatment-related factors. A Patient Health Questionnaire-2 score >3 indicated relevant depression. Multivariable linear regression analyses were used to identify potentially modifiable factors associated with HrQoL and confidence in treatment whilst adjusting for known confounders. RESULTS A group of 1178 European patients (79% female, mean age 48 ± 14 years) participated in the study. HrQoL was impaired in all three diseases (mean EQ-5D-5L = 0.75, mean EQ VAS = 68.9), most markedly in PBC (mean EQ-5D-5L = 0.73, mean EQ-VAS = 66.2). Relevant depression, which was detected in 17% of patients, was prominently associated with impaired HrQoL. In the regression analysis, treatment confidence was identified as an important modifiable factor positively contributing to HrQoL. This influence was observable even after adjusting for other covariates including depression. Management in a transplant centre, treatment with azathioprine in AIH, and with ursodeoxycholic acid in PBC, was associated with increased treatment confidence. Finally, improved patient-physician relationships contributed to treatment confidence. CONCLUSION Treatment confidence is a relevant modifiable determinant of HrQoL and should be further investigated to improve the standards of care for patients with AILDs.
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Affiliation(s)
- Ewa Wunsch
- Translational Medicine Group, Pomeranian Medical University in Szczecin, Szczecin, Poland.,RARE-LIVER European Reference Network
| | - Linda Krause
- Institute of Medical Biometry and Epidemiology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Tom Jg Gevers
- RARE-LIVER European Reference Network.,Division of Gastroenterology and Hepatology, Department of Internal Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Christoph Schramm
- RARE-LIVER European Reference Network.,Department of Medicine and Martin Zeitz Centre for Rare Diseases, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany.,Hamburg Center for Translational Immunology (HCTI), Hamburg, Germany
| | - Maciej K Janik
- RARE-LIVER European Reference Network.,Liver and Internal Medicine Unit, Medical University of Warsaw, Warsaw, Poland
| | - Marcin Krawczyk
- RARE-LIVER European Reference Network.,Department of Medicine II, Saarland University Medical Center, Homburg, Germany.,Laboratory of Metabolic Liver Diseases, Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Warsaw, Poland
| | - José Willemse
- RARE-LIVER European Reference Network.,Dutch Liver Patients Association, Hoogland, The Netherlands
| | - Natalie Uhlenbusch
- RARE-LIVER European Reference Network.,Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Bernd Löwe
- RARE-LIVER European Reference Network.,Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ansgar Wilhelm Lohse
- RARE-LIVER European Reference Network.,Department of Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Piotr Milkiewicz
- Translational Medicine Group, Pomeranian Medical University in Szczecin, Szczecin, Poland.,RARE-LIVER European Reference Network.,Liver and Internal Medicine Unit, Medical University of Warsaw, Warsaw, Poland
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5
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Wellen BCM, Lin HC, Stellway JE. Psychosocial considerations in pediatric autoimmune liver disease. Clin Liver Dis (Hoboken) 2022; 20:124-129. [PMID: 36245677 PMCID: PMC9549309 DOI: 10.1002/cld.1238] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 05/10/2022] [Accepted: 05/14/2022] [Indexed: 12/12/2022] Open
Affiliation(s)
- Brianna C. M. Wellen
- Division of Pediatric Psychology, Doernbecher Children's Hospital, Department of PediatricsOregon Health & Science UniversityOregonUSA
- Department of PsychologyUniversity of UtahSalt Lake CityUtahUSA
| | - Henry C. Lin
- Division of Gastroenterology, Department of PediatricsOregon Health & Science UniversityOregonUSA
| | - Jacklyn E. Stellway
- Division of Pediatric Psychology, Doernbecher Children's Hospital, Department of PediatricsOregon Health & Science UniversityOregonUSA
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6
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Zannella A, Fanella S, Marignani M, Begini P. COVID-19 emergency: Changes in quality of life perception in patients with chronic liver disease-An Italian single-centre study. World J Hepatol 2022; 14:274-286. [PMID: 35126854 PMCID: PMC8790390 DOI: 10.4254/wjh.v14.i1.274] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 06/08/2021] [Accepted: 12/28/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND In December 2019, the coronavirus disease-2019 (COVID-19) emerged and rapidly spread worldwide, becoming a global health threat and having a tremendous impact on the quality of life (QOL) of individuals.
AIM To evaluate the awareness of patients with chronic liver disease (CLD) regarding the COVID-19 emergency and how it impacted on their QOL.
METHODS Patients with an established diagnosis of CLD (cirrhosis, autoimmune hepatitis, primary biliary cholangitis, and primary sclerosing cholangitis) who had been evaluated at our Outpatient Liver Disease Clinic during the 6-mo period preceding the start of Italian lockdown (March 8, 2020) were enrolled. Participants were asked to complete a two-part questionnaire, administered by telephone according to governmental restrictions: The first section assessed patients’ basic knowledge regarding COVID-19, and the second evaluated the impact of the COVID-19 emergency on their QOL. We used the Italian version of the CLD questionnaire (CLDQ-I). With the aim of evaluating possible changes in the QOL items addressed, the questionnaire was administered to patients at the time of telephone contact with the specific request to recall their QOL perceptions during two different time points. In detail, patients were asked to recall these perceptions first during time 0 (t0), a period comprising the 2 wk preceding the date of ministerial lockdown decree (from February 23 to March 7, 2020); then, in the course of the same phone call, they were asked to recall the same items as experienced throughout time 1 (t1), the second predetermined time frame encompassing the 2 wk (from April 6 to April 19) preceding our telephone contact and questionnaire administration. All data are expressed as number (%), and continuous variables are reported as the median (interquartile range). The data were compared using the Wilcoxon paired non-parametric test.
RESULTS A total of 111 patients were enrolled, of whom 81 completed the questionnaire. Forty-nine had liver cirrhosis, and all of them had compensated disease; 32 patients had autoimmune liver disease. The majority (93.8%) of patients were aware of COVID-19 transmission modalities and on how to recognize the most common alarm symptoms (93.8%). Five of 32 (15.6%) patients with autoimmune liver disease reported having had the need to receive more information about the way to manage their liver disease therapy during lockdown and nine (28.2%) thought about modifying their therapy without consulting their liver disease specialist. About the impact on QOL, all CLDQ-I total scores were significantly worsened during time t1 as compared to time t0.
CONCLUSION The COVID-19 epidemic has had a significant impact on the QOL of our population of patients, despite a good knowledge of preventive measure and means of virus transmission.
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Affiliation(s)
| | - Silvia Fanella
- Department of Gastroenterology, Sant’Andrea Hospital, Rome 00189, Italy
| | - Massimo Marignani
- Department of Gastroenterology, Sant’Andrea Hospital, Rome 00189, Italy
| | - Paola Begini
- Department of Gastroenterology, Sant’Andrea Hospital, Rome 00189, Italy
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7
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Snijders RJALM, Milkiewicz P, Schramm C, Gevers TJG. Health-related quality of life in autoimmune hepatitis. World J Hepatol 2021; 13:1642-1652. [PMID: 34904034 PMCID: PMC8637685 DOI: 10.4254/wjh.v13.i11.1642] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 06/15/2021] [Accepted: 08/16/2021] [Indexed: 02/06/2023] Open
Abstract
Autoimmune hepatitis (AIH) is a severe chronic autoimmune disease and has a significant impact on the patient’s quality of life, in particular regarding psychological problems such as anxiety and depression. Consistent evidence on which patient-related, disease-related or physician-related factors cause health-related quality of life (HRQoL) impairment in patients with AIH is lacking. Current studies on HRQoL in AIH are mainly single-centered, comprising small numbers of patients, and difficult to compare because of the use of different questionnaires, patient populations, and cutoff values. Literature in the pediatric field is sparse, but suggests that children/adolescents with AIH have a lower HRQoL. Knowledge of HRQoL and cohesive factors in AIH are important to improve healthcare for AIH patients, for example by developing an AIH-specific chronic healthcare model. By recognizing the importance of quality of life beyond the concept of biochemical and histological remission, clinicians allow us to seek enhancements and possible interventions in the management of AIH, aiming at improved health.
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Affiliation(s)
- Romée JALM Snijders
- Department of Gastroenterology and Hepatology, Radboudumc, Nijmegen 6525GA, The Netherlands
- European Reference Network RARE-LIVER, Hamburg, Germany
| | - Piotr Milkiewicz
- Liver and Internal Medicine Unit, Medical University of Warsaw, Warsaw 02-091, Poland
- Translational Medicine Group, Pomeranian Medical University, Szczecin 70-204, Poland
- European Reference Network RARE-LIVER, Hamburg, Germany
| | - Christoph Schramm
- First Department of Medicine, University Medical Center Hamburg Eppendorf, Hamburg 20246, Germany
- Martin Zeitz Center for Rare Diseases and Hamburg Center for Translational Immunology (HCTI), University Medical Center Hamburg Eppendorf, Hamburg 20246, Germany
- European Reference Network RARE-LIVER, Hamburg, Germany
| | - Tom JG Gevers
- Department of Gastroenterology and Hepatology, Radboudumc, Nijmegen 6525GA, The Netherlands
- Division of Gastroenterology and Hepatology, Maastricht University Medical Center, Maastricht 6229HX, The Netherlands
- European Reference Network RARE-LIVER, Hamburg, Germany
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8
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Hames A, Matcham F, Makin I, Day J, Joshi D, Samyn M. Adherence, Mental Health and Illness Perceptions in Autoimmune Liver Disease: Looking Beyond Liver Function Tests. J Pediatr Gastroenterol Nutr 2021; 73:376-384. [PMID: 33720085 DOI: 10.1097/mpg.0000000000003119] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Autoimmune liver disease is commonly diagnosed during adolescence; a period associated with a higher prevalence of non-adherence, mental health concerns and worse health outcomes. The aim of the study was to explore adherence patterns, mental health and illness perceptions in young people with autoimmune liver disease. METHODS Young people with autoimmune liver disease attending a multidisciplinary young adult clinic (16-25 years) completed an electronically administered questionnaire battery. Demographics and disease-related data were collected. RESULTS Sixty-eight (37 female), median age 17.9 (range 15-22) years completed the screening. Only 51.5% of patients were in remission (aspartate and alanine aminotransferase <36 IU//l) whereas 73% self-reported their adherence >80%. Compared to patients in remission, those not in remission required more immunosuppression, were more depressed and worried but reported a better understanding of their illness. A small but significant correlation was found between aspartate aminotransferase/alanine aminotransferase and adherence percentage (r = -0.27, P < 0.05 and r = -0.29, P < 0.05 respectively). Age was inversely associated with adherence (r = -0.31, P < 0.05), and older patients were more worried (r = 0.44, P < 0.001) and emotionally affected by the condition (r = 0.32, P < 0.01). Adherence behaviours such as forgetting to take medications (63%), taking medications more frequently before attending appointments (44%) and not having a routine for medications (31%) were prevalent, 7% reported intentional non-adherence. CONCLUSION Sup-optimal adherence to treatment is common in young people with autoimmune liver disease and associated with mental health problems and certain illness perceptions. Routine exploration of adherence beliefs and barriers to adherence in a non-judgmental, collaborative way is essential to improve outcome in this vulnerable population.
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Affiliation(s)
- Anna Hames
- Paediatric Liver, GI and Nutrition service, King's College Hospital NHS Foundation Trust
| | - Faith Matcham
- Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London
| | - Isobel Makin
- Paediatric Liver, GI and Nutrition service, King's College Hospital NHS Foundation Trust
| | - Jemma Day
- Paediatric Liver, GI and Nutrition service, King's College Hospital NHS Foundation Trust
| | - Deepak Joshi
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, UK
| | - Marianne Samyn
- Paediatric Liver, GI and Nutrition service, King's College Hospital NHS Foundation Trust
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9
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Olsen K, Hodson J, Ronca V, Bozward AG, Hayden J, Wootton G, Armstrong M, Adams DH, El-Sherif O, Ferguson J, Knox E, Johnston T, Thompson F, Oo YH. Type 2 Autoimmune Hepatitis and Nonadherence to Medication Correlate With Premature Birth and Risk of Postpartum Flare. Hepatol Commun 2021; 5:1252-1264. [PMID: 34278173 PMCID: PMC8279459 DOI: 10.1002/hep4.1714] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Accepted: 02/07/2021] [Indexed: 12/19/2022] Open
Abstract
Autoimmune hepatitis (AIH) is an immune-mediated chronic liver disease that affects all ages, including women of childbearing age. Optimal management during pregnancy is poorly defined. We aimed to explore the clinical and biochemical course of AIH in the antenatal and postpartum periods, and assess factors associated with premature birth and postpartum flares. Pregnant women with AIH reviewed in the autoimmune liver disease clinic at the Queen Elizabeth Hospital Birmingham between 2009 and 2020 were identified retrospectively, and clinical, biochemical, and immunological data 1 year before conception to 1 year postpartum were collected. Analysis was performed to identify trends in blood markers over the antenatal period, with an interrupted time series approach used to assess postpartum trends. Data were available for n = 27 pregnancies (n = 20 women), with median gestation of 38 weeks (30% premature) and most having type 1 AIH (78%) and delivering via caesarean section (63%). Levels of alanine transaminase, aspartate transaminase, and immunoglobulin G all declined significantly during gestation, followed by significant step-change increases after delivery. Postpartum flare developed in 58% of pregnancies. AIH type 2 was associated with a higher rate of premature births (67% vs. 19%, P = 0.044), and a trend toward a higher rate of postpartum flare (100% vs. 48%, P = 0.053). Although not significant, medication nonadherence was associated with almost double the risk of prematurity (40% vs. 24%, P = 0.415) and postpartum flare (80% vs. 44%, P = 0.109). Conclusion: Biochemical and immunological remission of AIH occurs during pregnancy, although subsequent postpartum flare is common. Type 2 AIH is associated with a higher risk of premature birth and postpartum flare, although further research is required to validate and explain this finding.
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Affiliation(s)
- Kathryn Olsen
- University Hospitals Birmingham National Health Service Foundation TrustBirminghamUnited Kingdom.,Center for Liver and Gastro ResearchInstitute of Immunology and ImmunotherapyUniversity of BirminghamBirminghamUnited Kingdom
| | - James Hodson
- University Hospitals Birmingham National Health Service Foundation TrustBirminghamUnited Kingdom
| | - Vincenzo Ronca
- University Hospitals Birmingham National Health Service Foundation TrustBirminghamUnited Kingdom.,Center for Liver and Gastro ResearchInstitute of Immunology and ImmunotherapyUniversity of BirminghamBirminghamUnited Kingdom.,National Institute for Health Research Birmingham Biomedical Research CenterEuropean Reference Network Rare-Liver CenterUniversity Hospitals Birmingham National Health Service Foundation Trust and University of BirminghamBirminghamUnited Kingdom
| | - Amber G Bozward
- University Hospitals Birmingham National Health Service Foundation TrustBirminghamUnited Kingdom.,Center for Liver and Gastro ResearchInstitute of Immunology and ImmunotherapyUniversity of BirminghamBirminghamUnited Kingdom
| | - Jennifer Hayden
- University Hospitals Birmingham National Health Service Foundation TrustBirminghamUnited Kingdom
| | - Grace Wootton
- University Hospitals Birmingham National Health Service Foundation TrustBirminghamUnited Kingdom.,Center for Liver and Gastro ResearchInstitute of Immunology and ImmunotherapyUniversity of BirminghamBirminghamUnited Kingdom
| | - Matthew Armstrong
- University Hospitals Birmingham National Health Service Foundation TrustBirminghamUnited Kingdom.,Center for Liver and Gastro ResearchInstitute of Immunology and ImmunotherapyUniversity of BirminghamBirminghamUnited Kingdom.,National Institute for Health Research Birmingham Biomedical Research CenterEuropean Reference Network Rare-Liver CenterUniversity Hospitals Birmingham National Health Service Foundation Trust and University of BirminghamBirminghamUnited Kingdom
| | - David H Adams
- University Hospitals Birmingham National Health Service Foundation TrustBirminghamUnited Kingdom.,Center for Liver and Gastro ResearchInstitute of Immunology and ImmunotherapyUniversity of BirminghamBirminghamUnited Kingdom.,National Institute for Health Research Birmingham Biomedical Research CenterEuropean Reference Network Rare-Liver CenterUniversity Hospitals Birmingham National Health Service Foundation Trust and University of BirminghamBirminghamUnited Kingdom
| | - Omar El-Sherif
- University Hospitals Birmingham National Health Service Foundation TrustBirminghamUnited Kingdom
| | - James Ferguson
- University Hospitals Birmingham National Health Service Foundation TrustBirminghamUnited Kingdom.,Center for Liver and Gastro ResearchInstitute of Immunology and ImmunotherapyUniversity of BirminghamBirminghamUnited Kingdom.,National Institute for Health Research Birmingham Biomedical Research CenterEuropean Reference Network Rare-Liver CenterUniversity Hospitals Birmingham National Health Service Foundation Trust and University of BirminghamBirminghamUnited Kingdom
| | - Ellen Knox
- Birmingham Women's HospitalBirminghamUnited Kingdom
| | | | - Fiona Thompson
- University Hospitals Birmingham National Health Service Foundation TrustBirminghamUnited Kingdom
| | - Ye Htun Oo
- University Hospitals Birmingham National Health Service Foundation TrustBirminghamUnited Kingdom.,Center for Liver and Gastro ResearchInstitute of Immunology and ImmunotherapyUniversity of BirminghamBirminghamUnited Kingdom.,National Institute for Health Research Birmingham Biomedical Research CenterEuropean Reference Network Rare-Liver CenterUniversity Hospitals Birmingham National Health Service Foundation Trust and University of BirminghamBirminghamUnited Kingdom
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10
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Wang G, Tanaka A, Zhao H, Jia J, Ma X, Harada K, Wang FS, Wei L, Wang Q, Sun Y, Hong Y, Rao H, Efe C, Lau G, Payawal D, Gani R, Lindor K, Jafri W, Omata M, Sarin SK. The Asian Pacific Association for the Study of the Liver clinical practice guidance: the diagnosis and management of patients with autoimmune hepatitis. Hepatol Int 2021; 15:223-257. [PMID: 33942203 PMCID: PMC8144150 DOI: 10.1007/s12072-021-10170-1] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 02/27/2021] [Indexed: 02/06/2023]
Affiliation(s)
- Guiqiang Wang
- Peking University First Hospital, Beijing, China. .,Peking University International Hospital, Beijing, China.
| | | | - Hong Zhao
- Peking University First Hospital, Beijing, China.,Peking University International Hospital, Beijing, China
| | - Jidong Jia
- Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Xiong Ma
- Shanghai Institute of Digestive Disease, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Kenichi Harada
- Department of Human Pathology, Kanazawa University Graduate School of Medicine Kanazawa, Kanazawa, Japan
| | - Fu-Sheng Wang
- Fifth Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Lai Wei
- Beijing Tsinghua Changgung Hospital, Beijing, China
| | - Qixia Wang
- Shanghai Institute of Digestive Disease, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Ying Sun
- Fifth Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Yuan Hong
- Peking University First Hospital, Beijing, China
| | - Huiying Rao
- Peking University People's Hospital, Beijing, China
| | - Cumali Efe
- Department of Gastroenterology, Harran University, Şanlıurfa, Turkey
| | - George Lau
- Humanity and Health Medical Group, Hong Kong Special Administrative Region, China
| | - Diana Payawal
- Department of Hepatology, Cardinal Santos Medical Center, Manila, Philippines
| | - Rino Gani
- Department of Internal Medicine, Cipto Mangunkusumo Hospital, University of Indonesia, Jakarta, Indonesia
| | - Keith Lindor
- College of Health Solutions, Arizona State University, Phoenix, AZ, USA
| | | | - Masao Omata
- Department of Gastroenterology, Yamanashi Prefectural Central Hospital, Kofu-City, Yamanashi, Japan.,The University of Tokyo, Tokyo, Japan
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11
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Michel M, Spinelli F, Grambihler A, Labenz C, Nagel M, Kaps L, Huber Y, Galle PR, Wörns MA, Schattenberg JM. Health-related quality of life in patients with autoimmune hepatitis. Qual Life Res 2021; 30:2853-2861. [PMID: 33978892 PMCID: PMC8481193 DOI: 10.1007/s11136-021-02850-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/16/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Autoimmune hepatitis (AIH) is a rare chronic liver disease. Impaired health-related quality of life (HRQL) contributes to the overall disease burden. At current, only limited data related to the impact of treatment response on HRQL are available. OBJECTIVE The aim of the study was to determine the impact of biochemical remission on HRQL. METHODS Patients with AIH were prospectively enrolled between July 2018 and June 2019. A liver disease-specific tool, the chronic liver disease questionnaire (CLDQ) and the generic EQ-5D-5L were used to quantify HRQL. Treatment response was assessed biochemically by measurement of immunoglobulin G, ALT and AST. The cohort was divided into two groups according to their biochemical remission status in either complete vs. incomplete remission. Clinical as well as laboratory parameters and comorbidities were analysed using univariable and multivariable analysis to identify predictors of poor HRQL. RESULTS A total of 116 AIH patients were included (median age: 55; 77.6% female), of which 9.5% had liver cirrhosis. In this cohort, 38 (38.4%) showed a complete and 61 (61.6%) an incomplete biochemical remission at study entry. The HRQL was significantly higher in patients with a complete as compared to an incomplete biochemical remission (CLDQ overall score: 5.66 ± 1.15 vs. 5.10 ± 1.35; p = 0.03). In contrast, the generic EQ-5D-5L UI-value was not different between the groups. Multivariable analysis identified AST (p = 0.02) and an incomplete biochemical remission (p = 0.04) as independent predictors of reduced HRQL (CLDQ total value). CONCLUSION Patients with a complete biochemical remission had a significantly higher HRQL. Liver-related quality of life in patients living with AIH is dependent on the response to immunosuppressive treatment.
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Affiliation(s)
- Maurice Michel
- grid.410607.4Metabolic Liver Research Program, I. Department of Medicine, University Medical Centre Mainz, Mainz, Germany ,grid.410607.4I. Department of Medicine, University Medical Centre Mainz, Mainz, Germany
| | - Francesca Spinelli
- grid.410607.4Metabolic Liver Research Program, I. Department of Medicine, University Medical Centre Mainz, Mainz, Germany ,grid.410607.4I. Department of Medicine, University Medical Centre Mainz, Mainz, Germany
| | - Annette Grambihler
- grid.410607.4Metabolic Liver Research Program, I. Department of Medicine, University Medical Centre Mainz, Mainz, Germany ,grid.410607.4I. Department of Medicine, University Medical Centre Mainz, Mainz, Germany
| | - Christian Labenz
- grid.410607.4Metabolic Liver Research Program, I. Department of Medicine, University Medical Centre Mainz, Mainz, Germany ,grid.410607.4I. Department of Medicine, University Medical Centre Mainz, Mainz, Germany
| | - Michael Nagel
- grid.410607.4Metabolic Liver Research Program, I. Department of Medicine, University Medical Centre Mainz, Mainz, Germany ,grid.410607.4I. Department of Medicine, University Medical Centre Mainz, Mainz, Germany
| | - Leonard Kaps
- grid.410607.4Metabolic Liver Research Program, I. Department of Medicine, University Medical Centre Mainz, Mainz, Germany ,grid.410607.4I. Department of Medicine, University Medical Centre Mainz, Mainz, Germany
| | - Yvonne Huber
- grid.410607.4Metabolic Liver Research Program, I. Department of Medicine, University Medical Centre Mainz, Mainz, Germany ,grid.410607.4I. Department of Medicine, University Medical Centre Mainz, Mainz, Germany
| | - Peter R. Galle
- grid.410607.4Metabolic Liver Research Program, I. Department of Medicine, University Medical Centre Mainz, Mainz, Germany ,grid.410607.4I. Department of Medicine, University Medical Centre Mainz, Mainz, Germany
| | - Marcus-Alexander Wörns
- grid.410607.4Metabolic Liver Research Program, I. Department of Medicine, University Medical Centre Mainz, Mainz, Germany ,grid.410607.4I. Department of Medicine, University Medical Centre Mainz, Mainz, Germany
| | - Jörn M. Schattenberg
- grid.410607.4Metabolic Liver Research Program, I. Department of Medicine, University Medical Centre Mainz, Mainz, Germany ,grid.410607.4I. Department of Medicine, University Medical Centre Mainz, Mainz, Germany
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12
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Hayward KL, Weersink RA. Improving Medication-Related Outcomes in Chronic Liver Disease. Hepatol Commun 2020; 4:1562-1577. [PMID: 33163829 PMCID: PMC7603526 DOI: 10.1002/hep4.1612] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 08/20/2020] [Accepted: 09/08/2020] [Indexed: 12/17/2022] Open
Abstract
Patients with chronic liver disease (CLD) are becoming increasingly complex due to the rising prevalence of multimorbidity and polypharmacy. Medications are often essential to manage the underlying liver disease, complications of cirrhosis and portal hypertension, and comorbidities. However, medication-related problems (MRPs) have been associated with adverse patient outcomes, including hospitalization and mortality. Factors that can contribute to MRPs in people with CLD are variable and often entwined. This narrative literature review discusses key barriers and opportunities to modify risk factors and improve medication-related outcomes for people with CLD.
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Affiliation(s)
- Kelly L Hayward
- Centre for Liver Disease Research, Faculty of Medicine The University of Queensland, Translational Research Institute Brisbane QLD Australia.,Department of Gastroenterology and Hepatology Princess Alexandra Hospital Brisbane QLD Australia
| | - Rianne A Weersink
- Department of Clinical Pharmacy Deventer Hospital Deventer The Netherlands
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13
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Mack CL, Adams D, Assis DN, Kerkar N, Manns MP, Mayo MJ, Vierling JM, Alsawas M, Murad MH, Czaja AJ. Diagnosis and Management of Autoimmune Hepatitis in Adults and Children: 2019 Practice Guidance and Guidelines From the American Association for the Study of Liver Diseases. Hepatology 2020; 72:671-722. [PMID: 31863477 DOI: 10.1002/hep.31065] [Citation(s) in RCA: 446] [Impact Index Per Article: 111.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 11/25/2019] [Indexed: 02/06/2023]
Affiliation(s)
- Cara L Mack
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - David Adams
- Centre for Liver Research, University of Birmingham, Birmingham, UK
| | - David N Assis
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Nanda Kerkar
- Golisano Children's Hospital at Strong, University of Rochester Medical Center, New York, NY
| | - Michael P Manns
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Marlyn J Mayo
- Division of Digestive and Liver Diseases, University of Texas SW Medical Center, Dallas, TX
| | - John M Vierling
- Medicine and Surgery, Baylor College of Medicine, Houston, TX
| | | | - Mohammad H Murad
- Mayo Knowledge and Encounter Research Unit, Mayo Clinic College of Medicine, Rochester, MN
| | - Albert J Czaja
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, MN
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14
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Than NN, Hodson J, Schmidt-Martin D, Taubert R, Wawman RE, Botter M, Gautam N, Bock K, Jones R, Appanna GD, Godkin A, Montano-Loza AJ, Lammert F, Schramm C, Manns MP, Swain M, Burak KW, Adams DH, Hirschfield GM, Oo YH. Efficacy of rituximab in difficult-to-manage autoimmune hepatitis: Results from the International Autoimmune Hepatitis Group. JHEP Rep 2019; 1:437-445. [PMID: 32039395 PMCID: PMC7005655 DOI: 10.1016/j.jhepr.2019.10.005] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 10/21/2019] [Accepted: 10/25/2019] [Indexed: 02/07/2023] Open
Abstract
Treatment options remain limited for patients with autoimmune hepatitis (AIH), while there are still concerns over the consequences of long-term corticosteroid use. A few studies have suggested a role for B cell-driven autoimmune liver injury in AIH. This multicentre, international retrospective cohort study from the International Autoimmune Hepatitis Group aims to evaluate the clinical efficacy and safety of rituximab in difficult-to-manage AIH. METHODS Clinical data from 22 patients who received rituximab between 2007 and 2017 were collected from centres in the United Kingdom, Germany and Canada. Clinical response was assessed using changes in biochemical and immunological parameters up to 24 months post-rituximab infusion. In addition, we compared the doses of prednisolone used 3 months before and 12 months after treatment, and assessed freedom from AIH flares over the post-treatment period. RESULTS Twenty-two patients with type-1 AIH were included, with a median age of 40 years at diagnosis (range 19-79); 15/22 (68%) were female and 18/22 (82%) were Caucasian. The median period from diagnosis to the end of follow-up in these patients was 11 years (range 3-28). Values of alanine aminotransferase, aspartate aminotransferase and albumin improved significantly following rituximab therapy, and were sustained for up to 2 years (all p ≪0.001). Prednisolone doses were significantly reduced by 12 months post-treatment (p = 0.003), with 13/21 (62%) patients having a dose reduction. Over a median post-treatment follow-up period of 6 years (range 1-10), 5 patients developed AIH flares at a median of 22 months post-treatment, giving an estimated 71% freedom from AIH flare at 2 years. Four of these patients received a second course of treatment, of whom 2 had subsequent further flares. No serious adverse events attributable to rituximab were recorded. CONCLUSION In patients with difficult-to-manage AIH, rituximab appears to be clinically effective and well tolerated. Rituximab was associated with sustained improvements in serum liver tests, an absence of clinical disease flares, and a reduction in prednisolone dose. Controlled trials are warranted to further evaluate B cell-targeting therapies in patients with AIH. LAY SUMMARY Autoimmune hepatitis is an autoimmune condition of the liver, usually treated with medications that suppress the immune system, such as steroids. However, some patients do not respond to this treatment. We analysed the safety and efficacy of rituximab in patients who were not responding to first- or second-line therapies. Rituximab was safe and improved liver blood tests in 70% of patients over a 2-year follow-up period, while enabling steroid doses to be reduced in two-thirds of patients, which is a very positive clinical outcome.
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Affiliation(s)
- Nwe Ni Than
- Liver Transplant and Hepatobiliary Unit, University Hospital Birmingham NHS Foundation Trust, United Kingdom
- Centre for Liver and Gastroenterology Research & National Institute of Health Research Birmingham Biomedical Research Centre, Institute of Immunology and Immunotherapy, University of Birmingham, United Kingdom
| | - James Hodson
- Liver Transplant and Hepatobiliary Unit, University Hospital Birmingham NHS Foundation Trust, United Kingdom
| | - Daniel Schmidt-Martin
- Liver Transplant and Hepatobiliary Unit, University Hospital Birmingham NHS Foundation Trust, United Kingdom
| | - Richard Taubert
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
- European Reference Network (ERN) Rare Liver
| | - Rebecca E. Wawman
- Centre for Liver and Gastroenterology Research & National Institute of Health Research Birmingham Biomedical Research Centre, Institute of Immunology and Immunotherapy, University of Birmingham, United Kingdom
- Imperial College, London
| | - Meemee Botter
- Centre for Liver and Gastroenterology Research & National Institute of Health Research Birmingham Biomedical Research Centre, Institute of Immunology and Immunotherapy, University of Birmingham, United Kingdom
- University of Amsterdam, Netherland
| | - Nishant Gautam
- Liver Transplant and Hepatobiliary Unit, University Hospital Birmingham NHS Foundation Trust, United Kingdom
| | - Kilian Bock
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
- European Reference Network (ERN) Rare Liver
| | - Rebecca Jones
- Leeds Liver Transplant Unit, St James University Hospital, Leeds, United Kingdom
| | | | - Andrew Godkin
- University Hospital of Wales, Cardiff, United Kingdom
| | | | - Frank Lammert
- Department of Medicine II, Saarland University Medical Centre, Homburg
| | - Christoph Schramm
- University Medical Centre Hamburg-Eppendorf, Hamburg, I. Department of Medicine and Martin Zeitz Centre for Rare Diseases, Germany
| | - Michael P. Manns
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
- German Centre for Infection Research (DZIF), Partner Site Hannover-Braunschweig, Germany; Helmholtz Centre for Infection Research (HZI), Braunschweig, Germany
- European Reference Network (ERN) Rare Liver
| | - Mark Swain
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Calgary, Canada
| | - Kelly W. Burak
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Calgary, Canada
| | - David H. Adams
- Liver Transplant and Hepatobiliary Unit, University Hospital Birmingham NHS Foundation Trust, United Kingdom
- Centre for Liver and Gastroenterology Research & National Institute of Health Research Birmingham Biomedical Research Centre, Institute of Immunology and Immunotherapy, University of Birmingham, United Kingdom
- Autoimmune Liver Diseases Clinic, Centre for Rare Diseases, Institute of Translational Medicine, University of Birmingham, Birmingham, United Kingdom
| | - Gideon M Hirschfield
- University of Toronto, Canada
- Toronto Centre for Liver Disease, University Health Network, University of Toronto, Toronto, Canada
| | - Ye Htun Oo
- Liver Transplant and Hepatobiliary Unit, University Hospital Birmingham NHS Foundation Trust, United Kingdom
- Centre for Liver and Gastroenterology Research & National Institute of Health Research Birmingham Biomedical Research Centre, Institute of Immunology and Immunotherapy, University of Birmingham, United Kingdom
- Autoimmune Liver Diseases Clinic, Centre for Rare Diseases, Institute of Translational Medicine, University of Birmingham, Birmingham, United Kingdom
- European Reference Network (ERN) Rare Liver
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15
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Janik MK, Wunsch E, Raszeja-Wyszomirska J, Krawczyk M, Milkiewicz P. Depression: An Overlooked Villain in Autoimmune Hepatitis? Hepatology 2019; 70:2232-2233. [PMID: 30773711 DOI: 10.1002/hep.30568] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Maciej K Janik
- Liver and Internal Medicine Unit, Medical University of Warsaw, Warsaw, Poland
| | - Ewa Wunsch
- Translational Medicine Group, Pomeranian Medical University, Szczecin, Poland
| | | | - Marcin Krawczyk
- Laboratory of Metabolic Liver Diseases, Centre for Preclinical Research, Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Warsaw, Poland.,Department of Medicine II, Saarland University Medical Centre, Saarland University, Homburg, Germany
| | - Piotr Milkiewicz
- Liver and Internal Medicine Unit, Medical University of Warsaw, Warsaw, Poland.,Translational Medicine Group, Pomeranian Medical University, Szczecin, Poland
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16
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Chapman RW, Aspinall RJ, Trivedi P, Wright G, Heneghan M. Challenges in the use of corticosteroids in the management of autoimmune hepatitis. Br J Hosp Med (Lond) 2019; 80:594-599. [PMID: 31589514 DOI: 10.12968/hmed.2019.80.10.594] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Autoimmune hepatitis is widely assumed by health-care professionals to be a disease that is easily controlled through the use of corticosteroids and immunosuppressants but recent studies in the UK indicate highly variable treatment regimens and often unsatisfactory treatment outcomes, such as dependence on long-term high-dose steroids and ongoing need for liver transplantation in some cases. The therapeutic use of the systemically acting corticosteroid prednisolone results in unacceptable side effects in many patients. Recent evidence suggests that it is not always necessary to use high-dose steroids (>0.5 mg/kg/d) to attain remission; and side effects may also be minimised through more targeted therapy with the less systemically-absorbed corticosteroid, budesonide. The authors offer advice on the stratification of treatment for these patients and suggest changes to improve the services available for people with autoimmune hepatitis in the UK.
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Affiliation(s)
- Roger W Chapman
- Consultant Hepatologist, John Radcliffe Hospital, University of Oxford, Oxford
| | | | - Palak Trivedi
- Consultant Hepatologist and Clinician Scientist, NIHR Birmingham BRC, University of Birmingham, Birmingham
| | - Gavin Wright
- Consultant Hepatologist/Gastroenterologist, Basildon & Thurrock University Hospital, Basildon, Essex
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17
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Pape S, Schramm C, Gevers TJ. Clinical management of autoimmune hepatitis. United European Gastroenterol J 2019; 7:1156-1163. [PMID: 31700628 PMCID: PMC6826525 DOI: 10.1177/2050640619872408] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 07/31/2019] [Indexed: 02/06/2023] Open
Abstract
Autoimmune hepatitis is a rare and chronic liver disease that is characterised by increased serum transaminases and immunoglobulin G, inflammatory liver histology and presence of circulating autoantibodies. An autoimmune hepatitis diagnosis justifies life-long treatment in most patients in order to prevent development of cirrhosis and end-stage liver disease. The cornerstone of treatment is steroid induction therapy followed by maintenance therapy with azathioprine, which is effective in most cases. For patients who do not respond to standard treatment, second-line treatment with other immunosuppressants can be effective. Treatment should be aimed at biochemical remission of the disease, which is defined as normalization of transaminases and immunoglobulin G. Patients should be monitored intensively during the first months of treatment in order to monitor side-effects, assess symptoms and individualise treatment. Specialist consultation should be sought in difficult-to-treat patients. Future studies and networking initiatives should result in optimization of current treatment strategies in autoimmune hepatitis.
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Affiliation(s)
- Simon Pape
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands.,European Reference Network Hepatological Diseases (ERN RARE-LIVER), Hamburg, Germany
| | - Christoph Schramm
- European Reference Network Hepatological Diseases (ERN RARE-LIVER), Hamburg, Germany.,1st Department of Internal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Martin Zeitz Centre for Rare Diseases, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Tom Jg Gevers
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands.,European Reference Network Hepatological Diseases (ERN RARE-LIVER), Hamburg, Germany
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18
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Jüngst C, Gräber S, Simons S, Wedemeyer H, Lammert F. Medication adherence among patients with chronic diseases: a survey-based study in pharmacies. QJM 2019; 112:505-512. [PMID: 30840076 DOI: 10.1093/qjmed/hcz058] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Revised: 02/13/2019] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Poor adherence to medication leads to worsening of the disease, increased mortality and substantial rise in health care costs. AIM It was our aim to evaluate drug adherence and influencing factors in a cohort of non-selected adult pharmacy customers with various chronic diseases and following long-term treatment. DESIGN AND METHODS We conducted an 8 week anonymized survey in 152 German pharmacies using the Morisky Medication Adherence Scale to measure medication adherence and a questionnaire comprising questions on multiple factors with potential impact on adherence. Depression was assessed applying the Patient Health Questionnaire-9. RESULTS In total, 1192 patients were included showing an overall adherence rate of 59.1%. A positive association to drug adherence was found in univariate analysis for non-smoking status, retirement, less disease related complaints, positive belief in drug effects, comprehensive knowledge about the disease and high quality of care by the physician and pharmacist. Multivariate regression analysis revealed that no or minimal depression (odds ratio (OR) 2.3, 95% confidence interval (CI) 1.7-3.0), higher patient age (>63 years) (OR 2.2, CI 1.7-2.8), high perceived importance of the medication (OR 2.0, CI 1.5-2.6), good tolerability of the medication (OR 2.0, CI 1.2-3.5) and drug effect as expected or better (OR 1.6, CI 1.1-2.3) were positively correlated with adherence. CONCLUSIONS Suboptimal adherence to medication is common in pharmacy customers with chronic diseases. The determined factors influencing adherence may help to identify patients at risk for nonadherence and support the need of improvement in physicians' communication with patients to achieve adequate adherence rates.
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Affiliation(s)
- C Jüngst
- Department of Medicine II, Saarland University Medical Center, Homburg, Germany
- Deutsche Leberstiftung (German Liver Foundation), Essen/Hannover, Germany
| | - S Gräber
- Institute of Medical Biometry, Epidemiology and Medical Informatics, Saarland University Medical Center, Homburg, Germany
| | | | - H Wedemeyer
- Deutsche Leberstiftung (German Liver Foundation), Essen/Hannover, Germany
- Department of Gastroenterology and Hepatology, Essen University Hospital, University of Duisburg-Essen, 45147 Essen, Germany
| | - F Lammert
- Department of Medicine II, Saarland University Medical Center, Homburg, Germany
- Deutsche Leberstiftung (German Liver Foundation), Essen/Hannover, Germany
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19
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Trivedi PJ, Hubscher SG, Heneghan M, Gleeson D, Hirschfield GM. Grand round: Autoimmune hepatitis. J Hepatol 2019; 70:773-784. [PMID: 30465775 DOI: 10.1016/j.jhep.2018.11.006] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2018] [Revised: 10/11/2018] [Accepted: 11/09/2018] [Indexed: 12/12/2022]
Abstract
Autoimmune hepatitis is a corticosteroid-responsive liver disease arising consequent to immunogenetic and environmental risk factors. The clinical course reflects relapsing and remitting, hepatocyte targeted immunologic damage, which is countered by reparative responses to cell injury. Appropriate and timely immunosuppressive therapy drives the disease into remission, albeit with inevitable side effects. Many challenges faced in the clinic reflect practice that must capture a heterogeneous disease presentation, course, and treatment response, as well as treatment tolerability. In this Grand Round we appraise the evidence supporting current treatment approaches, address the impact of autoimmune liver disease 'crossover or overlap' presentations, explore important clinical correlates to immune-serological classifiers, and discuss the factors influencing choice of alternative therapy in difficult-to-treat situations.
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Affiliation(s)
- Palak J Trivedi
- National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre (BRC), Centre for Liver and Gastroenterology Research, University of Birmingham, UK; Liver Unit, University Hospitals Birmingham, Birmingham, UK; Institute of Immunology and Immunotherapy, University of Birmingham, UK
| | - Stefan G Hubscher
- National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre (BRC), Centre for Liver and Gastroenterology Research, University of Birmingham, UK; Liver Unit, University Hospitals Birmingham, Birmingham, UK; Institute of Immunology and Immunotherapy, University of Birmingham, UK; Dept. of Cellular Pathology, University Hospitals Birmingham, UK
| | | | - Dermot Gleeson
- Liver Unit, Sheffield Teaching Hospitals Foundation Trust, UK
| | - Gideon M Hirschfield
- National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre (BRC), Centre for Liver and Gastroenterology Research, University of Birmingham, UK; Liver Unit, University Hospitals Birmingham, Birmingham, UK; Institute of Immunology and Immunotherapy, University of Birmingham, UK; Toronto Centre for Liver Disease, University of Toronto and University Health Network, Toronto, Canada.
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20
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Dalekos GN, Koskinas J, Papatheodoridis GV. Hellenic Association for the Study of the Liver Clinical Practice Guidelines: Autoimmune hepatitis. Ann Gastroenterol 2019; 32:1-23. [PMID: 30598587 PMCID: PMC6302199 DOI: 10.20524/aog.2018.0330] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2018] [Accepted: 10/29/2018] [Indexed: 02/07/2023] Open
Abstract
Autoimmune hepatitis (AIH) is a relatively rare acute or chronic liver disease of unknown etiology characterized by large heterogeneity. Its distribution is global, covering all ages, both sexes and all ethnic groups. The aim of the present Clinical Practice Guidelines (CPG) of the Hellenic Association for the Study of the Liver was to provide updated guidance and help to gastroenterologists, hepatologists, internists and general practitioners for AIH diagnosis and management. AIH diagnosis is based on clinicopathological characteristics: namely, polyclonal hypergammaglobulinemia, particularly of immunoglobulin G (IgG), circulating autoantibodies, interface hepatitis on liver histology, absence of viral hepatitis, and a favorable response to immunosuppression. Clinical manifestations at disease onset are variable, ranging from asymptomatic to the acute/severe form. Aminotransferase and bilirubin levels vary, while the presence of hepatitis at the histological level is a prerequisite for diagnosis. Autoantibodies are the hallmark for AIH diagnosis; therefore, the CPG describe the appropriate serological algorithm for their detection. AIH therapy should aim to achieve complete biochemical (normalization of IgG and aminotransferases) and histological remission. All patients who have active disease, even those with cirrhosis, should be treated with individualized and response-guided induction therapy using prednisolone in combination with azathioprine or mycophenolate mofetil as first-line therapy. Immunosuppression should be given for at least 3 years and for at least 2 years after the achievement of complete biochemical response, while a liver biopsy should be recommended before treatment discontinuation. Current CPG are also provided for several specific conditions and difficult-to-treat patients.
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Affiliation(s)
- George N. Dalekos
- Institute of Internal Medicine and Hepatology, Larissa (George N. Dalekos)
- Department of Medicine and Research Laboratory of Internal Medicine, University Hospital of Larissa, Larissa (George N. Dalekos)
| | - John Koskinas
- Second Department of Internal Medicine, National and Kapodistrian University of Athens, “Hippokratio” General Hospital of Athens, Athens (John Koskinas)
| | - George V. Papatheodoridis
- Department of Gastroenterology, Medical School of National and Kapodistrian University of Athens, “Laiko” General Hospital of Athens, Athens (George V. Papatheodoridis), Greece
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21
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Turan B, Crockett KB, Kempf MC, Konkle-Parker D, Wilson TE, Tien PC, Wingood G, Neilands TB, Johnson MO, Weiser SD, Turan JM. Internal Working Models of Attachment Relationships and HIV Outcomes Among Women Living With HIV. J Acquir Immune Defic Syndr 2019; 80:e1-e8. [PMID: 30272629 PMCID: PMC6289809 DOI: 10.1097/qai.0000000000001872] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Treatment adherence and viral suppression remain suboptimal in the United States. Attachment insecurity may be one understudied factor affecting adherence. According to attachment theory, people develop generalized internal working models of interpersonal relationships, which shape their perceptions of the availability of others at times of stress and how they handle stressors as an individual. Two dimensions of attachment insecurity are attachment-related avoidance (avoidance of intimacy with others and avoidance of negative emotions) and attachment-related anxiety (feeling unable to deal with stressors without others' help). For people living with chronic stressful health conditions that require life-long self-management, attachment-related avoidance and attachment-related anxiety may diminish the ability to cope with stressors as an individual leading to negative health outcomes. METHODS We examined cross-sectional associations of the 2 attachment-related insecurity dimensions with antiretroviral treatment (ART) adherence, HIV visit adherence, CD4 cell counts, and viral suppression. Survey and clinical data from 453 women living with HIV in 4 US cities were analyzed controlling for age, education, income, time on ART, illicit drug use, and race. RESULTS Attachment-related avoidance was the only unique predictor of suboptimal ART adherence, viral failure, and low CD4 count, and attachment-related anxiety was the only unique predictor of missed HIV care visits. These effects were over and above the effects of all covariates. ART adherence mediated the association of attachment-related avoidance with both viral failure and low CD4 counts. CONCLUSIONS Interventions may need to focus on the vulnerable subpopulation with high attachment insecurity and incorporate existing strategies that address insecure attachment models.
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Affiliation(s)
| | | | - Mirjam-Colette Kempf
- Family, Community and & Health Systems, Health Behavior, Epidemiology and Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Deborah Konkle-Parker
- Department of Medicine/Infectious Diseases, University of Mississippi Medical Center, Jackson, MS
| | - Tracey E Wilson
- Department of Community Health Sciences, State University of New York Downstate Medical Center, School of Public Health, Brooklyn, NY
| | - Phyllis C Tien
- Department of Medicine, University of California, San Francisco and Medical Service, San Francisco, CA
- Department of Veteran Affairs Medical Center, San Francisco, CA
| | - Gina Wingood
- Department of Sociomedical Sciences, Columbia University Mailman School of Public Health, New York, NY
| | - Torsten B Neilands
- Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - Mallory O Johnson
- Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - Sheri D Weiser
- Division of HIV, ID and Global Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - Janet M Turan
- Department of Health Care Organization and Policy, School of Public Health, University of Alabama at Birmingham, Birmingham, AL
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22
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Dyson JK, Wong LL, Bigirumurame T, Hirschfield GM, Kendrick S, Oo YH, Lohse AW, Heneghan MA, Jones DEJ. Inequity of care provision and outcome disparity in autoimmune hepatitis in the United Kingdom. Aliment Pharmacol Ther 2018; 48:951-960. [PMID: 30226274 PMCID: PMC6667893 DOI: 10.1111/apt.14968] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2017] [Revised: 01/21/2018] [Accepted: 08/08/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND Treatment paradigms in autoimmune hepatitis (AIH) have remained largely unchanged for decades. Studies report ≤20% of patients have sub-optimal treatment response with most requiring long-term therapy. AIM The United Kingdom Autoimmune Hepatitis (UK-AIH) study was established to evaluate current treatment practice and outcomes, determine the unmet needs of patients, and develop and implement improved treatment approaches. METHODS The United Kingdom Autoimmune Hepatitis study is a cross-sectional cohort study examining secondary care management of prevalent adult patients with a clinical diagnosis of autoimmune hepatitis. Enrolment began in March 2014. Prevalent cases were defined as having been diagnosed and treated for >1 year. Demographic data, biochemistry, treatment history and response, and care location were collected. RESULTS In total, 1249 patients were recruited; 635 were cared for in transplant units and 614 in non-transplant centres (81% female with median age at diagnosis 50 years). Overall, 29 treatment regimens were reported and biochemical remission rate was 59%. Remission rates were significantly higher in transplant compared to non-transplant centres (62 vs 55%, P = 0.028). 55% have ongoing corticosteroid exposure; 9% are receiving prednisolone monotherapy. Those aged ≤20 years at diagnosis were more likely to develop cirrhosis and place of care was associated with an aggressive disease phenotype. CONCLUSIONS There are significant discrepancies in the care received by patients with autoimmune hepatitis in the UK. A high proportion remains on corticosteroids and there is significant treatment variability. Patients receiving care in transplant centres were more likely to achieve and maintain remission. Overall poor remission rates suggest that there are significant unmet therapeutic needs for patients with autoimmune hepatitis.
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Affiliation(s)
- Jessica K. Dyson
- NIHR Biomedical Research CentreNewcastle UniversityNewcastle upon TyneUK,Department of HepatologyFreeman HospitalThe Newcastle upon Tyne NHS Foundation TrustNewcastle upon TyneUK
| | - Lin Lee Wong
- NIHR Biomedical Research CentreNewcastle UniversityNewcastle upon TyneUK,Department of HepatologyFreeman HospitalThe Newcastle upon Tyne NHS Foundation TrustNewcastle upon TyneUK
| | | | - Gideon M. Hirschfield
- Centre for Liver ResearchNIHR Biomedical Research CentreUniversity of Birmingham & University Hospital Birmingham NHS Foundation TrustBirminghamUK
| | - Stuart Kendrick
- Research and DevelopmentGlaxoSmithKline (GSK)HertfordshireUK
| | - Ye H. Oo
- Centre for Liver ResearchNIHR Biomedical Research CentreUniversity of Birmingham & University Hospital Birmingham NHS Foundation TrustBirminghamUK
| | - Ansgar W Lohse
- I. Department of MedicineUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| | | | - David E. J. Jones
- NIHR Biomedical Research CentreNewcastle UniversityNewcastle upon TyneUK,Department of HepatologyFreeman HospitalThe Newcastle upon Tyne NHS Foundation TrustNewcastle upon TyneUK
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23
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Takahashi A, Moriya K, Ohira H, Arinaga-Hino T, Zeniya M, Torimura T, Abe M, Takaki A, Kang JH, Inui A, Fujisawa T, Yoshizawa K, Suzuki Y, Nakamoto N, Koike K, Yoshiji H, Goto A, Tanaka A, Younossi ZM, Takikawa H. Health-related quality of life in patients with autoimmune hepatitis: A questionnaire survey. PLoS One 2018; 13:e0204772. [PMID: 30286131 PMCID: PMC6171853 DOI: 10.1371/journal.pone.0204772] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Accepted: 09/13/2018] [Indexed: 12/17/2022] Open
Abstract
Aim Health-related quality of life is impaired in patients with autoimmune hepatitis, but the association between health-related quality of life and patients’ backgrounds remains unknown. We assessed health-related quality of life in patients with autoimmune hepatitis and identified factors associated with its impairment. Methods We assessed health-related quality of life in patients with autoimmune hepatitis, patients with chronic hepatitis C, and healthy subjects using the Japanese version of the Chronic Liver Disease Questionnaire and the 36-Item Short Form Survey. We compared health-related quality of life in patients with autoimmune hepatitis with that of patients with chronic hepatitis C and healthy subjects. Results A total of 265 patients with autoimmune hepatitis, 88 patients with chronic hepatitis C, and 97 healthy subjects were enrolled; most patients were women. The median ages of patients were 65, 66, and 57 years, respectively. Of these patients with autoimmune hepatitis, 10.6% and 57.0% had cirrhosis and comorbid diseases, respectively. The overall Chronic Liver Disease Questionnaire scores (5.5 vs. 6.2, P < 0.001) and physical (48.1 vs. 54.2, P < 0.001) and mental (51.8 vs. 55.0, P = 0.004) component summaries of 36-Item Short Form Survey were significantly lower in patients with autoimmune hepatitis than in healthy subjects, and similar to scores in patients with chronic hepatitis C. Having cirrhosis, comorbid diseases, and treatment for autoimmune hepatitis were associated with impaired health-related quality of life among patients with autoimmune hepatitis. In particular, prednisolone use was associated with lower scores on the worry domain of the Chronic Liver Disease Questionnaire. Conclusions Patients with autoimmune hepatitis showed impairment in health-related quality of life, which was associated with not only disease progression, but also comorbid diseases and treatment. Ways to improve health-related quality of life should be considered in patients with AIH when disease outcome is not favorable and when using prednisolone.
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Affiliation(s)
- Atsushi Takahashi
- Department of Gastroenterology, Fukushima Medical University School of Medicine, Fukushima, Japan
- * E-mail:
| | - Kei Moriya
- Department of Gastroenterology and Hepatology, Nara Medical University School of Medicine, Kashihara, Nara, Japan
| | - Hiromasa Ohira
- Department of Gastroenterology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Teruko Arinaga-Hino
- Department of Medicine, Kurume University School of Medicine, Kurume-shi, Fukuoka, Japan
| | - Mikio Zeniya
- Sanno Medical Center, International University of Health and Welfare, Minato-ku, Tokyo, Japan
| | - Takuji Torimura
- Department of Medicine, Kurume University School of Medicine, Kurume-shi, Fukuoka, Japan
| | - Masanori Abe
- Department of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Ehime, Japan
| | - Akinobu Takaki
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Kita-ku, Okayama City, Japan
| | - Jong-Hon Kang
- Center for Gastroenterology, Teine Keijinkai Hospital, Teine-ku, Sapporo, Japan
| | - Ayano Inui
- Department of Pediatric Hepatology and Gastroenterology, Saiseikai Yokohama Tobu Hospital, Tsurumi-ku, Yokohama City, Kanagawa, Japan
| | - Tomoo Fujisawa
- Department of Pediatric Hepatology and Gastroenterology, Saiseikai Yokohama Tobu Hospital, Tsurumi-ku, Yokohama City, Kanagawa, Japan
| | - Kaname Yoshizawa
- Department of Gastroenterology, National Hospital Organization, Shinshu Ueda Medical Center, Ueda City, Nagano, Japan
| | - Yoshiyuki Suzuki
- Department of Hepatology, Toranomon Hospital, Minato-ku, Tokyo, Japan
| | - Nobuhiro Nakamoto
- Department of Internal Medicine, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Kazuhiko Koike
- Department of Gastroenterology and Hepatology, The Third Hospital of Jikei University School of Medicine, Komae-shi, Tokyo, Japan
| | - Hitoshi Yoshiji
- Department of Gastroenterology and Hepatology, Nara Medical University School of Medicine, Kashihara, Nara, Japan
| | - Aya Goto
- Center for Integrated Science and Humanities, Fukushima Medical University, Fukushima, Japan
| | - Atsushi Tanaka
- Department of Medicine, Teikyo University School of Medicine, Itabashi-ku, Tokyo, Japan
| | - Zobair M. Younossi
- Betty and Guy Beatty Center for Integrated Research, Inova Health System, Falls Church, VA, United States of America
| | - Hajime Takikawa
- Department of Medicine, Teikyo University School of Medicine, Itabashi-ku, Tokyo, Japan
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24
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Wong LL, Fisher HF, Stocken DD, Rice S, Khanna A, Heneghan MA, Oo YH, Mells G, Kendrick S, Dyson JK, Jones DEJ. The Impact of Autoimmune Hepatitis and Its Treatment on Health Utility. Hepatology 2018; 68:1487-1497. [PMID: 29663477 PMCID: PMC6585808 DOI: 10.1002/hep.30031] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Revised: 03/22/2018] [Accepted: 04/10/2018] [Indexed: 12/17/2022]
Abstract
Patient reporting suggests that the physical and psychological effects of autoimmune hepatitis (AIH) can be substantial. However, health-related quality of life (HRQOL) in patients with AIH remains incompletely characterized, and health utility remains to be explored. Treatment for AIH often includes the use of corticosteroids, which are agents that can be associated with significant adverse effects. Here we explore the impact of AIH and its treatments on patient-reported HRQOL and health utility in a large cohort of prevalent cases from the United Kingdom Autoimmune Hepatitis (UK-AIH) national study. Data were collected from 990 adult participants with a clinical diagnosis of AIH using validated HRQOL tools including the European Quality-of-Life 5-Dimension 5-Level (EQ-5D-5L) and clinical data forms. The EQ-5D-5L dimension scores were compared with UK population norms and with a disease control cohort with primary biliary cholangitis (PBC). Within the AIH cohort, regression analysis was used to explore associations between HRQOL and demographic and clinical variables with a particular focus on the impact of AIH therapies including corticosteroid use. HRQOL, measured by the EQ-5D-5L utility index, is shown to be significantly impaired in our cohort of AIH patients compared with population norms. Within the AIH cohort, corticosteroid use was found to be significantly associated with impaired HRQOL, even when controlling for biochemical disease activity status. CONCLUSION Our data show evidence of HRQOL impairment in a large cohort of AIH patients compared with the general population. Furthermore, corticosteroid use is strongly associated with decreased HRQOL, independent of remission status. This highlights the need for better corticosteroid-free therapy approaches and it emphasizes the need for future novel therapeutic trials in AIH. (Hepatology 2018; 00:000-000).
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Affiliation(s)
- Lin Lee Wong
- Institute of Cellular MedicineNewcastle UniversityNewcastle upon TyneUnited Kingdom
- Liver Unit, Freeman HospitalThe Newcastle upon Tyne NHS Foundation TrustNewcastle upon TyneUnited Kingdom
| | - Holly F Fisher
- Institute of Health and SocietyNewcastle UniversityNewcastle upon TyneUnited Kingdom
| | - Deborah D Stocken
- Leeds Institute of Clinical Trials ResearchUniversity of LeedsLeedsUnited Kingdom
| | - Stephen Rice
- Institute of Health and SocietyNewcastle UniversityNewcastle upon TyneUnited Kingdom
| | - Amardeep Khanna
- Institute of Cellular MedicineNewcastle UniversityNewcastle upon TyneUnited Kingdom
- Liver Unit, Freeman HospitalThe Newcastle upon Tyne NHS Foundation TrustNewcastle upon TyneUnited Kingdom
| | | | - Ye Htun Oo
- Centre for Liver Research and NIHR BRCUniversity of Birmingham and Liver Unit, University Hospital Birmingham NHS Foundation TrustUnited Kingdom
| | - George Mells
- Academic Department of Medical GeneticsUniversity of Cambridge and Addenbrooke’s HospitalCambridge Biomedical CampusUnited Kingdom
| | - Stuart Kendrick
- GlaxoSmithKline (GSK)Research and DevelopmentHertfordshireUnited Kingdom
| | - Jessica Katharine Dyson
- Institute of Cellular MedicineNewcastle UniversityNewcastle upon TyneUnited Kingdom
- Liver Unit, Freeman HospitalThe Newcastle upon Tyne NHS Foundation TrustNewcastle upon TyneUnited Kingdom
| | - David E. J. Jones
- Institute of Cellular MedicineNewcastle UniversityNewcastle upon TyneUnited Kingdom
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25
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Pericleous M, Kelly C, Ala A, De Lusignan S. The role of the chronic care model in promoting the management of the patient with rare liver disease. Expert Rev Gastroenterol Hepatol 2018; 12:829-841. [PMID: 29976101 DOI: 10.1080/17474124.2018.1497483] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
INTRODUCTION The chronic care model (CCM) provides a holistic approach for managing chronic illnesses. Patients with rare liver diseases (RLD) have complex needs, impaired quality of life and often life-threatening complications. Most RLD meet the criteria for a long-term chronic condition and should be viewed through the prism of CCM. We aimed to ascertain whether the CCM has been considered for the frequently-encountered RLD. METHODS MEDLINE®/PubMed®/Cochrane/EMBASE were searched to identify publications relating to the use of the CCM for the management of six RLD. We identified 33 articles eligible for inclusion. RESULTS Six, eleven, one, thirteen, two and zero studies, discussed individual components of the CCM for autoimmune hepatitis (AIH), primary biliary cholangitis (PBC), primary sclerosing cirrhosis (PSC), Wilsons disease (WD), alpha-1 antitrypsin deficiency (A1AD) and lysosomal acid lipase deficiency (LALd) respectively. We have not identified studies using the full CCM for any of the aforementioned RLD. DISCUSSION Unlike in common chronic conditions e.g. diabetes, there has been limited consideration of the use of CCM (or its components) for the management of RLD. This may reflect a reluctance of the clinical community to view these diseases as chronic or lack of healthcare policy investment in rare diseases in general.
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Affiliation(s)
- Marinos Pericleous
- a Department of Gastroenterology and Hepatology , Royal Surrey County Hospital NHS Foundation Trust , Guildford , UK.,b Department of Clinical and experimental medicine , University of Surrey , Guildford , UK
| | - Claire Kelly
- a Department of Gastroenterology and Hepatology , Royal Surrey County Hospital NHS Foundation Trust , Guildford , UK.,b Department of Clinical and experimental medicine , University of Surrey , Guildford , UK
| | - Aftab Ala
- a Department of Gastroenterology and Hepatology , Royal Surrey County Hospital NHS Foundation Trust , Guildford , UK.,b Department of Clinical and experimental medicine , University of Surrey , Guildford , UK
| | - Simon De Lusignan
- b Department of Clinical and experimental medicine , University of Surrey , Guildford , UK
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26
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Krasuska M, Lavda A, Thompson A, Millings A. The role of adult attachment orientation and coping in psychological adjustment to living with skin conditions. Br J Dermatol 2018; 178:1396-1403. [DOI: 10.1111/bjd.16268] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/15/2017] [Indexed: 11/30/2022]
Affiliation(s)
- M. Krasuska
- Department of Psychology; University of Sheffield; Sheffield U.K
- Usher Institute of Population Health Sciences and Informatics; University of Edinburgh; Edinburgh U.K
| | - A.C. Lavda
- Central Chesterfield Neighbourhood Team; Derbyshire Healthcare NHS Foundation Trust; Chesterfield U.K
| | - A.R. Thompson
- Department of Psychology; University of Sheffield; Sheffield U.K
| | - A. Millings
- Department of Psychology; University of Sheffield; Sheffield U.K
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27
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Jones D, Manns MP, Terracciano L, Torbenson M, Vierling JM. Unmet needs and new models for future trials in autoimmune hepatitis. Lancet Gastroenterol Hepatol 2018; 3:363-370. [DOI: 10.1016/s2468-1253(18)30043-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 01/30/2018] [Accepted: 02/01/2018] [Indexed: 12/18/2022]
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28
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Mieli-Vergani G, Vergani D, Czaja AJ, Manns MP, Krawitt EL, Vierling JM, Lohse AW, Montano-Loza AJ. Autoimmune hepatitis. Nat Rev Dis Primers 2018; 4:18017. [PMID: 29644994 DOI: 10.1038/nrdp.2018.17] [Citation(s) in RCA: 235] [Impact Index Per Article: 39.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Autoimmune hepatitis (AIH) is a severe liver disease that affects children and adults worldwide. The diagnosis of AIH relies on increased serum transaminase and immunoglobulin G levels, presence of autoantibodies and interface hepatitis on liver histology. AIH arises in genetically predisposed individuals when a trigger, such as exposure to a virus, leads to a T cell-mediated autoimmune response directed against liver autoantigens; this immune response is permitted by inadequate regulatory immune control leading to a loss of tolerance. AIH responds favourably to immunosuppressive treatment, which should be started as soon as the diagnosis is made. Standard regimens include fairly high initial doses of corticosteroids (prednisone or prednisolone), which are tapered gradually as azathioprine is introduced. For those patients who do not respond to standard treatment, second-line drugs should be considered, including mycophenolate mofetil, calcineurin inhibitors, mechanistic target of rapamycin (mTOR) inhibitors and biologic agents, which should be administered only in specialized hepatology centres. Liver transplantation is a life-saving option for those who progress to end-stage liver disease, although AIH can recur or develop de novo after transplantation. In-depth investigation of immune pathways and analysis of changes to the intestinal microbiota should advance our knowledge of the pathogenesis of AIH and lead to novel, tailored and better tolerated therapies.
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Affiliation(s)
- Giorgina Mieli-Vergani
- Paediatric Liver, GI and Nutrition Centre, MowatLabs, King's College Hospital, Denmark Hill, SE5 9RS London, UK
| | - Diego Vergani
- Institute of Liver Studies, MowatLabs, King's College Hospital, Denmark Hill, SE5 9RS London, UK
| | - Albert J Czaja
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Michael P Manns
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany.,Helmholtz Centre for Infection Research (HZI), Braunschweig, Germany
| | - Edward L Krawitt
- Department of Medicine, University of Vermont, Burlington, VT, USA.,Department of Medicine, Geisel School of Medicine at Dartmouth College, Hanover, NH, USA
| | - John M Vierling
- Division of Abdominal Transplantation and Section of Gastroenterology and Hepatology, Departments of Medicine and Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Ansgar W Lohse
- Department of Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Aldo J Montano-Loza
- Division of Gastroenterology and Liver Unit, University of Alberta, Edmonton, Alberta, Canada
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29
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Sunil S, Santiago VA, Gougeon L, Warwick K, Okrainec A, Hawa R, Sockalingam S. Predictors of Vitamin Adherence After Bariatric Surgery. Obes Surg 2017; 27:416-423. [PMID: 27448232 DOI: 10.1007/s11695-016-2306-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Vitamin supplementation in bariatric aftercare is essential to prevent nutrient deficiencies; however, rates of vitamin adherence have been as low as 30 % 6 months post-surgery. Preliminary literature suggests non-adherence to prescribed treatments can be linked to demographic and psychological factors. We aimed to determine the relationship between these factors to vitamin adherence in post-bariatric surgery patients. METHODS A total of 92 bariatric patients were assessed 6 months post-surgery. Patients were administered a questionnaire collecting demographic information, psychological scores, and self-reported adherence. Nutrient deficiencies were analyzed through serum vitamin levels measured 3 and 6 months after surgery. Wilcoxon rank-sum and chi-square tests were used for analysis. RESULTS Non-adherence was associated with male sex and full-time employment (p = 0.027, p = 0.015). There were no differences with respect to living situation, education level, or relationship type. Non-adherent patients did not have significantly higher scores for generalized anxiety, depressive symptoms, or avoidant behaviors. However, non-adherent patients displayed greater attachment anxiety than their adherent counterparts (p = 0.0186). Non-adherence was also associated with lower vitamin B12 levels 6 months post-surgery (p = 0.001). CONCLUSIONS Male gender and full-time work have previously been shown to be associated with non-adherence. This is the first study to demonstrate that attachment anxiety is associated with poor multivitamin adherence in the post-surgical bariatric population. This result is concordant with recent literature that has demonstrated attachment anxiety is associated with poor adherence to dietary recommendations in bariatric patients 6 months postoperatively. Presurgical screening for attachment anxiety could facilitate early interventions to promote better bariatric aftercare in this group.
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Affiliation(s)
- Supreet Sunil
- Toronto Western Bariatric Surgery Program, University Health Network, University of Toronto, 399 Bathurst Street, Toronto, Ontario, M5T 2S8, Canada
| | - Vincent A Santiago
- Toronto Western Bariatric Surgery Program, University Health Network, University of Toronto, 399 Bathurst Street, Toronto, Ontario, M5T 2S8, Canada
| | - Lorraine Gougeon
- Toronto Western Bariatric Surgery Program, University Health Network, University of Toronto, 399 Bathurst Street, Toronto, Ontario, M5T 2S8, Canada
| | - Katie Warwick
- Toronto Western Bariatric Surgery Program, University Health Network, University of Toronto, 399 Bathurst Street, Toronto, Ontario, M5T 2S8, Canada
| | - Allan Okrainec
- Toronto Western Bariatric Surgery Program, University Health Network, University of Toronto, 399 Bathurst Street, Toronto, Ontario, M5T 2S8, Canada
- Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, 399 Bathurst Street, Toronto, Ontario, M5T 2S8, Canada
| | - Raed Hawa
- Toronto Western Bariatric Surgery Program, University Health Network, University of Toronto, 399 Bathurst Street, Toronto, Ontario, M5T 2S8, Canada
- Centre for Mental Health, University Health Network, University of Toronto, 200 Elizabeth Street, Toronto, Ontario, M5G 2C4, Canada
| | - Sanjeev Sockalingam
- Toronto Western Bariatric Surgery Program, University Health Network, University of Toronto, 399 Bathurst Street, Toronto, Ontario, M5T 2S8, Canada.
- Centre for Mental Health, University Health Network, University of Toronto, 200 Elizabeth Street, Toronto, Ontario, M5G 2C4, Canada.
- Toronto General Hospital, University Health Network, 200 Elizabeth Street, Room 8EN-228, Toronto, Ontario, M5G 2C4, Canada.
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30
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Alosaimi FD, AlMulhem A, AlShalan H, Alqazlan M, Aldaif A, Kowgier M, Balasundaram J, Sockalingam S. Psychosocial predictors of patient adherence to disease-modifying therapies for multiple sclerosis. Patient Prefer Adherence 2017; 11:513-518. [PMID: 28331298 PMCID: PMC5352251 DOI: 10.2147/ppa.s129678] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVES Our aim was to identify the impact of psychosocial predictors, specifically relationship style, depressive symptoms, anxiety symptoms, cognitive impairment, and culture-specific disease beliefs, on treatment adherence for multiple sclerosis (MS) patients. METHODS In this cross-sectional observational study, patients from two MS clinics in Saudi Arabia completed self-reported questionnaires focused on MS treatment adherence, physical symptom burden, relationship style, cultural beliefs, depressive symptoms, anxiety, and cognitive impairment. RESULTS A total of 163 MS patients participated, 81.6% of them were female, and the mean age of the patients was 31.6 years. Mean patient-reported adherence to their MS treatment regimen was 79.47%±25.26%. Multivariate linear regression analysis only identified patients' belief that their MS was due to "supernatural" forces as being significantly negatively associated with MS medication adherence. CONCLUSION This study demonstrates the importance of cultural interpretations to MS medication adherence in comparison to psychosocial factors. Education and family involvement in the treatment planning may address this issue and warrant further research.
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Affiliation(s)
| | | | | | - Mohammad Alqazlan
- Department of Mental Health, King Faisal Specialist Hospital and Research Centre
| | | | | | | | - Sanjeev Sockalingam
- Centre for Mental Health, University Health Network
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
- Correspondence: Sanjeev Sockalingam, Toronto General Hospital, 200 Elizabeth Street-8EN-228, Toronto, ON M5G 2C4, Canada, Tel +1 416 340 3762, Fax + 1 416 340 4198, Email
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31
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Alosaimi FD, Asiri M, Alsuwayt S, Alotaibi T, Bin Mugren M, Almufarrih A, Almodameg S. Psychosocial predictors of nonadherence to medical management among patients on maintenance dialysis. Int J Nephrol Renovasc Dis 2016; 9:263-272. [PMID: 27826207 PMCID: PMC5096770 DOI: 10.2147/ijnrd.s121548] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND A number of reports suggest a link between depression and nonadherence to recommended management for end-stage renal disease (ESRD) patients on maintenance dialysis. However, the relationship between nonadherence and other psychosocial factors have been inadequately examined. OBJECTIVES To examine the prevalence of psychosocial factors including depression, anxiety, insecure attachment style, as well as cognitive impairment and their associations with adherence to recommended management of ESRD. METHODS A cross-sectional observational study was carried out from 2014 to 2015. Chronic dialysis patients were recruited conveniently from four major dialysis units in Riyadh, Saudi Arabia. Nonadherence was defined as decreased attendance in dialysis sessions, failure to take prescribed medications, and/or follow food/fluid restrictions and exercise recommendations. RESULTS A total of 234 patients (147 males and 87 females) were included in this analysis, with 45 patients (19.2%) considered as nonadherent (visual analog scale < 8). Approximately 17.9% of the patients had depression (Patient Health Questionnaire score ≥10), 13.2% had anxiety (Hospital Anxiety and Depression scale-anxiety >7), while 77.4% had cognitive impairment (Montreal Cognitive Assessment score <26). Nonadherence was significantly associated with depression and anxiety (p<0.001 for both) but not cognitive impairment (p=0.266). The Experiences in Close Relationships - Modified 16 (ECR-M16) scale score was 27.99±10.87 for insecure anxiety and 21.71±9.06 for insecure avoidance relationship, with nonadherence significantly associated with anxiety (p=0.001) but not avoidance (p=0.400). CONCLUSION Nonadherence to different aspects of ESRD continues to be a serious problem among dialysis patients, and it is closely linked to depression and anxiety. The findings from this study reemphasize the importance of early detection and management of psychosocial ailments in these patients.
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Affiliation(s)
| | - Mohammed Asiri
- College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Saleh Alsuwayt
- College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Tariq Alotaibi
- College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | | | | | - Saad Almodameg
- College of Medicine, King Saud University, Riyadh, Saudi Arabia
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Abstract
Autoimmune hepatitis (AIH) is a complex autoimmune disease characterized by immune-mediated destruction of hepatic parenchyma which can result in cirrhosis, liver failure, and death. Current American Association for the Study of Liver Diseases (AASLD) and European Association for the Study of Liver (EASL) guidelines recommend corticosteroids alone or in combination with azathioprine as first-line treatment strategies. However, a significant proportion of patients may not be able to tolerate or achieve complete biochemical response with these options. In this article, we discuss approaches to these patients and other challenging AIH patient groups such as the asymptomatic, pregnant, elderly, and liver transplant recipients.
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33
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Janmohamed A, Hirschfield GM. Editorial: autoimmune hepatitis - identifying options for treatment. Aliment Pharmacol Ther 2016; 43:1236-7. [PMID: 27137725 DOI: 10.1111/apt.13607] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- A Janmohamed
- Centre for Liver Research, NIHR Liver Biomedical Research Unit, University of Birmingham, Birmingham, UK
| | - G M Hirschfield
- Centre for Liver Research, NIHR Liver Biomedical Research Unit, University of Birmingham, Birmingham, UK.
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Dyson JK, Webb G, Hirschfield GM, Lohse A, Beuers U, Lindor K, Jones DEJ. Unmet clinical need in autoimmune liver diseases. J Hepatol 2015; 62:208-18. [PMID: 25234946 DOI: 10.1016/j.jhep.2014.09.010] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2014] [Revised: 09/04/2014] [Accepted: 09/05/2014] [Indexed: 02/08/2023]
Abstract
Despite recent advances in understanding and treatment, there remain significant areas of unmet clinical need in each of the autoimmune liver diseases (AILDs). The evolving research landscape and emerging large patient cohorts are creating unique opportunities to translate science into new therapies and care pathways, with the potential to significantly improve the lives of AILD patients. However, the areas of unmet need represent real challenges, which need to be addressed, if this vision is to be realised. This review describes the areas of unmet need in AILD in adults relating to diagnostic and prognostic assessment, primary therapy, symptom management, trial design and delivery, and structured care delivery, with the aim of focusing future research prioritisation.
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Affiliation(s)
| | - Gwilym Webb
- Centre for Liver Research and NIHR Biomedical Research Unit, University of Birmingham, UK
| | - Gideon M Hirschfield
- Centre for Liver Research and NIHR Biomedical Research Unit, University of Birmingham, UK; UK-PBC Research Consortium, UK
| | - Ansgar Lohse
- Universitat Klinikum Eppendorf, Hamburg, Germany
| | - Ulrich Beuers
- Department of Gastroenterology & Hepatology, Amsterdam Medical Centre, Amsterdam, Netherlands
| | - Keith Lindor
- Arizona State University Medical Centre, AZ, USA
| | - David E J Jones
- Liver Unit, Freeman Hospital, Newcastle-upon-Tyne, UK; UK-PBC Research Consortium, UK; Institute of Cellular Medicine, Newcastle University, Newcastle-upon-Tyne, UK.
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Fagundes CP, Jaremka LM, Glaser R, Alfano CM, Povoski SP, Lipari AM, Agnese DM, Yee LD, Carson WE, Farrar WB, Malarkey WB, Chen M, Kiecolt-Glaser JK. Attachment anxiety is related to Epstein-Barr virus latency. Brain Behav Immun 2014; 41:232-8. [PMID: 24945717 PMCID: PMC4304069 DOI: 10.1016/j.bbi.2014.04.002] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2013] [Revised: 04/03/2014] [Accepted: 04/05/2014] [Indexed: 12/22/2022] Open
Abstract
Attachment theory provides a framework for understanding individual differences in chronic interpersonal stress. Attachment anxiety, a type of relationship insecurity characterized by worry about rejection and abandonment, is a chronic interpersonal stressor. Stress impacts cellular immunity, including herpesvirus reactivation. We investigated whether attachment anxiety was related to the expression of a latent herpesvirus, Epstein-Barr virus (EBV), when individuals were being tested for breast or colon cancer and approximately 1 year later. Participants (N=183) completed a standard attachment questionnaire and provided blood to assess EBV viral capsid antigen (VCA) IgG antibody titers. Individuals with more attachment anxiety had higher EBV VCA IgG antibody titers than those with less attachment anxiety. The strength of the association between attachment anxiety and antibody titers was the same at both assessments. This study is the first to show an association between latent herpesvirus reactivation and attachment anxiety. Because elevated herpesvirus antibody titers reflect poorer cellular immune system control over the latent virus, these data suggest that high attachment anxiety is associated with cellular immune dysregulation.
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Affiliation(s)
- Christopher P Fagundes
- Department of Health Disparities, University of Texas MD Anderson Cancer Center, United States.
| | - Lisa M Jaremka
- The Institute for Behavioral Medicine Research, The Ohio State University College of Medicine, United States
| | - Ronald Glaser
- The Institute for Behavioral Medicine Research, The Ohio State University College of Medicine, United States
| | - Catherine M Alfano
- Office of Cancer Survivorship, National Cancer Institute, National Institute of Health, United States
| | - Stephen P Povoski
- Department of Surgery, The Ohio State University College of Medicine, United States
| | - Adele M Lipari
- Department of Radiology, The Ohio State University College of Medicine, United States
| | - Doreen M Agnese
- Department of Surgery, The Ohio State University College of Medicine, United States
| | - Lisa D Yee
- Department of Surgery, The Ohio State University College of Medicine, United States
| | - William E Carson
- Department of Surgery, The Ohio State University College of Medicine, United States; Department of Molecular Virology, Immunology, and Medical Genetics, The Ohio State University College of Medicine, United States
| | - William B Farrar
- Department of Surgery, The Ohio State University College of Medicine, United States
| | - William B Malarkey
- Department of Internal Medicine, The Institute for Behavioral Medicine Research, The Ohio State University College of Medicine, United States; Department of Molecular Virology, Immunology, and Medical Genetics, The Institute for Behavioral Medicine Research, The Ohio State University College of Medicine, United States; The Institute for Behavioral Medicine Research, Comprehensive Cancer Center, and Department of Psychiatry, The Ohio State University College of Medicine, United States
| | - Min Chen
- The Institute for Behavioral Medicine Research, The Ohio State University College of Medicine, United States
| | - Janice K Kiecolt-Glaser
- The Institute for Behavioral Medicine Research, The Ohio State University College of Medicine, United States; The Institute for Behavioral Medicine Research, Comprehensive Cancer Center, and Department of Psychiatry, The Ohio State University College of Medicine, United States
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Schramm C, Wahl I, Weiler-Normann C, Voigt K, Wiegard C, Glaubke C, Brähler E, Löwe B, Lohse AW, Rose M. Health-related quality of life, depression, and anxiety in patients with autoimmune hepatitis. J Hepatol 2014; 60:618-24. [PMID: 24240053 DOI: 10.1016/j.jhep.2013.10.035] [Citation(s) in RCA: 75] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2013] [Revised: 10/17/2013] [Accepted: 10/31/2013] [Indexed: 12/23/2022]
Abstract
BACKGROUND & AIMS Improving health related quality of life (HrQoL) in patients with chronic diseases such as autoimmune hepatitis (AIH) should be a major treatment goal. However, little is known on the HrQoL in patients with AIH, and the topic is not given attention in current practice guidelines. We therefore conducted a single center study evaluating HrQoL in 103 consecutive outpatients with AIH. METHODS Patient-reported HrQoL data were analysed in relation to clinical disease parameters and compared to representative data of the German population as well as control patients. RESULTS Based on patient-reported data, a major depressive syndrome (10.8%) was found to be five times more frequent in AIH patients compared to the general population (p<0.001). The rate of severe symptoms of anxiety was also found to be significantly increased compared to the general population (p=0.006). In seven of the eleven patients who scored for a major depressive syndrome a psychiatric comorbidity had not been diagnosed before. Major factors associated with depression and anxiety were concerns with regard to the progression of the liver disease. CONCLUSIONS This study identified--for the first time--a high rate of previously unrecognized severe symptoms of depression and anxiety in patients with AIH. Of importance for daily clinical practice, the factors associated with these symptoms may in part be amenable to targeted counselling and adequate treatment of the disease, thereby offering the chance to improve the care and HrQoL of AIH-patients.
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Affiliation(s)
- Christoph Schramm
- Ist Department of Medicine, University Medical Center Hamburg Eppendorf, Martinistr. 52, 20246 Hamburg, Germany.
| | - Inka Wahl
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg Eppendorf, Martinistr. 52, 20246 Hamburg, Germany; Schön Klinik Hamburg Eilbek, Dehnhaide 120, 22081 Hamburg, Germany
| | - Christina Weiler-Normann
- Ist Department of Medicine, University Medical Center Hamburg Eppendorf, Martinistr. 52, 20246 Hamburg, Germany
| | - Katharina Voigt
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg Eppendorf, Martinistr. 52, 20246 Hamburg, Germany; Schön Klinik Hamburg Eilbek, Dehnhaide 120, 22081 Hamburg, Germany
| | - Christiane Wiegard
- Ist Department of Medicine, University Medical Center Hamburg Eppendorf, Martinistr. 52, 20246 Hamburg, Germany
| | - Claudia Glaubke
- Ist Department of Medicine, University Medical Center Hamburg Eppendorf, Martinistr. 52, 20246 Hamburg, Germany
| | - Elmar Brähler
- Department of Medical Psychology and Medical Sociology, University of Leipzig, Philipp-Rosenthal-Str 55, 04103 Leipzig, Germany
| | - Bernd Löwe
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg Eppendorf, Martinistr. 52, 20246 Hamburg, Germany; Schön Klinik Hamburg Eilbek, Dehnhaide 120, 22081 Hamburg, Germany
| | - Ansgar W Lohse
- Ist Department of Medicine, University Medical Center Hamburg Eppendorf, Martinistr. 52, 20246 Hamburg, Germany
| | - Matthias Rose
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg Eppendorf, Martinistr. 52, 20246 Hamburg, Germany; Schön Klinik Hamburg Eilbek, Dehnhaide 120, 22081 Hamburg, Germany
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Zachou K, Muratori P, Koukoulis GK, Granito A, Gatselis N, Fabbri A, Dalekos GN, Muratori L. Review article: autoimmune hepatitis -- current management and challenges. Aliment Pharmacol Ther 2013; 38:887-913. [PMID: 24010812 DOI: 10.1111/apt.12470] [Citation(s) in RCA: 113] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2013] [Revised: 03/22/2013] [Accepted: 08/12/2013] [Indexed: 12/14/2022]
Abstract
BACKGROUND Autoimmune hepatitis (AIH) is a disease of unknown aetiology characterised by interface hepatitis, hypergammaglobulinaemia, circulating autoantibodies and a favourable response to immunosuppression. AIM To review recent advancements in understanding aetiopathogenesis, clinical, serological and histological features, diagnostic criteria and treatment strategies of AIH. METHODS Published studies on AIH extracted mainly from PubMed during the last 15 years. RESULTS Autoimmune hepatitis has a global distribution affecting any age, both sexes and all ethnic groups. Clinical manifestations are variable ranging from no symptoms to severe acute hepatitis and only seldom to fulminant hepatic failure. Autoimmune attack is perpetuated, possibly via molecular mimicry mechanisms, and favoured by the impaired control of regulatory T-cells. A typical laboratory finding is hypergammaglobulinaemia with selective elevation of IgG, although in 15-25% of patients - particularly children, elderly and acute cases - IgG levels are normal. Liver histology and autoantibodies, although not pathognomonic, still remain the hallmark for diagnosis. Immunosuppressive treatment is mandatory and life-saving; however, to meet strict response criteria, the conventional therapy with prednisolone with or without azathioprine is far from ideal. CONCLUSIONS Autoimmune hepatitis remains a major diagnostic and therapeutic challenge. The clinician, the hepato-pathologist and the laboratory personnel need to become more familiar with different expressions of the disease, interpretation of liver histology and autoimmune serology. According to the strict definition of treatment response issued by the 2010 AASLD guidelines, many patients are nonresponders to conventional treatment. Newer immunosuppressive agents targeting pathogenetic mechanisms can improve patient management, which needs to be tailored on a case-by-case basis.
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Affiliation(s)
- K Zachou
- Department of Medicine and Research Laboratory of Internal Medicine, Medical School, Thessaly University, Larissa, Greece
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Sockalingam S, Cassin S, Hawa R, Khan A, Wnuk S, Jackson T, Okrainec A. Predictors of Post-bariatric Surgery Appointment Attendance: the Role of Relationship Style. Obes Surg 2013; 23:2026-32. [DOI: 10.1007/s11695-013-1009-9] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Trivedi PJ, Hirschfield GM. Treatment of autoimmune liver disease: current and future therapeutic options. Ther Adv Chronic Dis 2013; 4:119-41. [PMID: 23634279 DOI: 10.1177/2040622313478646] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Autoimmune liver disease spans three predominant processes, from the interface hepatitis of autoimmune hepatitis to the lymphocytic cholangitis of primary biliary cirrhosis, and finally the obstructive fibrosing sclerotic cholangiopathy of primary sclerosing cholangitis. Although all autoimmune in origin, they differ in their epidemiology, presentation and response to immunosuppressive therapy and bile acid based treatments. With an ongoing better appreciation of disease aetiology and pathogenesis, treatment is set ultimately to become more rational. We provide an overview of current and future therapies for patients with autoimmune liver disease, with an emphasis placed on some of the evidence that drives current practice.
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Affiliation(s)
- Palak J Trivedi
- Centre for Liver Research and NIHR Biomedical Research Unit, University of Birmingham, Birmingham, UK
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Weiler-Normann C, Lohse AW. Autoimmune hepatitis: a life-long disease. J Hepatol 2013; 58:5-7. [PMID: 23063571 DOI: 10.1016/j.jhep.2012.10.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2012] [Accepted: 10/03/2012] [Indexed: 12/23/2022]
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Weiler-Normann C, Lohse AW. Treatment adherence - room for improvement, not only in autoimmune hepatitis. J Hepatol 2012; 57:1168-70. [PMID: 22989563 DOI: 10.1016/j.jhep.2012.09.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2012] [Accepted: 09/02/2012] [Indexed: 12/14/2022]
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