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Hou J, Sun H, Lu B, Yue Y, Li X, Ban K, Fu M, Zhang B, Luo X. Accelerated biological aging mediated associations of ammonium, sulfate in fine particulate matter with liver cirrhosis. THE SCIENCE OF THE TOTAL ENVIRONMENT 2024; 929:172638. [PMID: 38643869 DOI: 10.1016/j.scitotenv.2024.172638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 04/02/2024] [Accepted: 04/18/2024] [Indexed: 04/23/2024]
Abstract
BACKGROUND Although both air pollution and aging are related to the development of liver cirrhosis, the role of biological aging in association of the mixture of fine particulate matter (PM2.5) and its constituents with liver cirrhosis was unknown. METHODS This case-control retrospective study included 100 liver cirrhosis patients and 100 control subjects matched by age and sex. The concentrations of PM2.5 and its constituents were estimated for patients using machine-learning methods. The clinical biomarkers were used to calculate biological age using the Klemera-Doubalmethod (KDM) algorithms. Individual associations of PM2.5 and its constituents or biological age with liver cirrhosis were analyzed by generalized linear models. WQS and BKMR were applied to analyze association of mixture of PM2.5 and its constituents with liver cirrhosis. The mediation effect of biological age on associations of PM2.5 and its constituents with liver cirrhosis was further explored. RESULTS we found that each 1-unit increment in NH4+, NO3-, SO42- and biological age were related to 3.618-fold (95%CI: 1.896, 6.904), 1.880-fold (95%CI: 1.319, 2.680), 2.955-fold (95%CI: 1.656, 5.272) and 1.244-fold (95%CI: 1.093, 1.414) increased liver cirrhosis. Both WQS and BKMR models showed that the mixture of PM2.5 and its constituents was related to increased liver cirrhosis. Furthermore, the mediated proportion of biological age on associations of NH4+ and SO42- with liver cirrhosis were 14.7 % and 14.6 %, respectively. CONCLUSIONS Biological aging may partly explain the exposure to PM2.5 and its constituents in association with increased risk for liver cirrhosis, implying that delaying the aging process may be a key step for preventing PM2.5-related liver cirrhosis risk.
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Affiliation(s)
- Jian Hou
- Department of Gastroenterology, Zhengzhou University People's Hospital, Henan Provincial People's Hospital, Zhengzhou, Henan, PR China; Department of Epidemiology and Biostatistics, College of Public Health, Zhengzhou University, Zhengzhou, Henan, PR China
| | - Huizhen Sun
- Hubei Provincial Center for Disease Control and Prevention, Hubei, Wuhan, PR China
| | - Bingxin Lu
- Department of Gastroenterology, Zhengzhou University People's Hospital, Henan Provincial People's Hospital, Zhengzhou, Henan, PR China
| | - Yanqin Yue
- Department of Gastroenterology, Zhengzhou University People's Hospital, Henan Provincial People's Hospital, Zhengzhou, Henan, PR China
| | - Xianxi Li
- Department of Gastroenterology, Zhengzhou University People's Hospital, Henan Provincial People's Hospital, Zhengzhou, Henan, PR China
| | - Kangjia Ban
- School of Architecture, Zhengzhou University, Zhengzhou, Henan, PR China
| | - Mengze Fu
- School of Architecture, Zhengzhou University, Zhengzhou, Henan, PR China.
| | - Bingyong Zhang
- Department of Gastroenterology, Zhengzhou University People's Hospital, Henan Provincial People's Hospital, Zhengzhou, Henan, PR China.
| | - Xiaoying Luo
- Department of Gastroenterology, Zhengzhou University People's Hospital, Henan Provincial People's Hospital, Zhengzhou, Henan, PR China.
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Koh J, Dowlatshahi S, Turner BJ. Transitioning from the Emergency Department to a General Internist Outpatient Clinic for Paracentesis: A Qualitative Inquiry. Dig Dis Sci 2024:10.1007/s10620-024-08358-0. [PMID: 38700627 DOI: 10.1007/s10620-024-08358-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Accepted: 02/13/2024] [Indexed: 05/14/2024]
Abstract
BACKGROUND Repeated paracentesis for ascites can place significant demands on the emergency department (ED). A new general internist-led outpatient procedure clinic to alleviate this demand required ED staff and patients to accept this transition of care. AIM This qualitative study evaluates barriers and facilitators to implementing the FLuid ASPiration (FLASP) clinic in a safety net hospital. METHODS The FLASP clinic opened during the COVID-19 pandemic in March 2021. From February to April 2022, semi-structured interviews were conducted with: 10 ED physicians and nurses; 5 FLASP clinic patients; and 4 patients receiving paracentesis in the ED. Interviews were recorded, transcribed, and analyzed using a Grounded Theory approach for themes categorized by Theory of Planned Behavior (TPB) domains including: attitudes/knowledge; social norms; and logistics. RESULTS Thematic analysis found that ED staff appreciated reduced demand for paracentesis, but barriers included: lack of knowledge; concerns about unstable patients and patient expectations (norms); and scheduling logistics. FLASP clinic patients had only favorable themes: belief in clinic safety; positive relationship with staff; and clinic efficiency. Patients using the ED for paracentesis expressed only concerns: possible need for testing or hospitalization; care usually in the ED; and unclear clinic scheduling. CONCLUSION This study reveals challenges to transitioning sites of care for paracentesis including the need for greater ED staff education and standardizing methods to triage patients to appropriate site of care. Greater support and education of ED patients about the benefits of an outpatient procedure clinic may also reduce ED burden for paracentesis.
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Affiliation(s)
- Jennifer Koh
- Department of Medicine, Keck Medical Center of University of Southern California, 2020 Zonal Avenue, Los Angeles, CA, 90033, USA
| | - Shadi Dowlatshahi
- Department of Hospital Medicine, Los Angeles General Medical Center, 2051 Marengo St, Los Angeles, CA, 90033, USA
- Department of Medicine, Keck Medical Center of University of Southern California, 2020 Zonal Avenue, Los Angeles, CA, 90033, USA
| | - Barbara J Turner
- Department of Medicine, Keck Medical Center of University of Southern California, 2020 Zonal Avenue, Los Angeles, CA, 90033, USA.
- Gehr Family Center for Health System Science and Innovation, Clinical Sciences Center, Keck School of Medicine of USC, 2250 Alcazar Street Room #261, 2020 Zonal Avenue, Los Angeles, CA, 90033, USA.
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Dallio M, Romeo M, Vaia P, Auletta S, Mammone S, Cipullo M, Sapio L, Ragone A, Niosi M, Naviglio S, Federico A. Red cell distribution width/platelet ratio estimates the 3-year risk of decompensation in Metabolic Dysfunction-Associated Steatotic Liver Disease-induced cirrhosis. World J Gastroenterol 2024; 30:685-704. [PMID: 38515952 PMCID: PMC10950628 DOI: 10.3748/wjg.v30.i7.685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 12/19/2023] [Accepted: 01/17/2024] [Indexed: 02/21/2024] Open
Abstract
BACKGROUND For compensated advanced chronic liver disease (cACLD) patients, the first decompensation represents a dramatically worsening prognostic event. Based on the first decompensation event (DE), the transition to decompensated advanced chronic liver disease (dACLD) can occur through two modalities referred to as acute decompensation (AD) and non-AD (NAD), respectively. Clinically Significant Portal Hypertension (CSPH) is considered the strongest predictor of decompensation in these patients. However, due to its invasiveness and costs, CSPH is almost never evaluated in clinical practice. Therefore, recognizing non-invasively predicting tools still have more appeal across healthcare systems. The red cell distribution width to platelet ratio (RPR) has been reported to be an indicator of hepatic fibrosis in Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD). However, its predictive role for the decompensation has never been explored.
AIM In this observational study, we investigated the clinical usage of RPR in predicting DEs in MASLD-related cACLD patients.
METHODS Fourty controls and 150 MASLD-cACLD patients were consecutively enrolled and followed up (FUP) semiannually for 3 years. At baseline, biochemical, clinical, and Liver Stiffness Measurement (LSM), Child-Pugh (CP), Model for End-Stage Liver Disease (MELD), aspartate aminotransferase/platelet count ratio index (APRI), Fibrosis-4 (FIB-4), Albumin-Bilirubin (ALBI), ALBI-FIB-4, and RPR were collected. During FUP, DEs (timing and modaities) were recorded. CSPH was assessed at the baseline and on DE occurrence according to the available Clinical Practice Guidelines.
RESULTS Of 150 MASLD-related cACLD patients, 43 (28.6%) progressed to dACLD at a median time of 28.9 months (29 NAD and 14 AD). Baseline RPR values were significantly higher in cACLD in comparison to controls, as well as MELD, CP, APRI, FIB-4, ALBI, ALBI-FIB-4, and LSM in dACLD-progressing compared to cACLD individuals [all P < 0.0001, except for FIB-4 (P: 0.007) and ALBI (P: 0.011)]. Receiving operator curve analysis revealed RPR > 0.472 and > 0.894 as the best cut-offs in the prediction respectively of 3-year first DE, as well as its superiority compared to the other non-invasive tools examined. RPR (P: 0.02) and the presence of baseline-CSPH (P: 0.04) were significantly and independently associated with the DE. Patients presenting baseline-CSPH and RPR > 0.472 showed higher risk of decompensation (P: 0.0023).
CONCLUSION Altogether these findings suggest the RPR as a valid and potentially applicable non-invasive tool in the prediction of timing and modalities of decompensation in MASLD-related cACLD patients.
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Affiliation(s)
- Marcello Dallio
- Department of Precision Medicine, Hepatogastroenterology Division, University of Campania Luigi Vanvitelli, Naples 80138, Italy
| | - Mario Romeo
- Department of Precision Medicine, Hepatogastroenterology Division, University of Campania Luigi Vanvitelli, Naples 80138, Italy
| | - Paolo Vaia
- Department of Precision Medicine, Hepatogastroenterology Division, University of Campania Luigi Vanvitelli, Naples 80138, Italy
| | - Salvatore Auletta
- Department of Precision Medicine, Hepatogastroenterology Division, University of Campania Luigi Vanvitelli, Naples 80138, Italy
| | - Simone Mammone
- Department of Precision Medicine, Hepatogastroenterology Division, University of Campania Luigi Vanvitelli, Naples 80138, Italy
| | - Marina Cipullo
- Department of Precision Medicine, Hepatogastroenterology Division, University of Campania Luigi Vanvitelli, Naples 80138, Italy
| | - Luigi Sapio
- Department of Precision Medicine, Clinical Biochemistry Division, University of Campania Luigi Vanvitelli, Naples 80138, Italy
| | - Angela Ragone
- Department of Precision Medicine, Clinical Biochemistry Division, University of Campania Luigi Vanvitelli, Naples 80138, Italy
| | - Marco Niosi
- Department of Precision Medicine, Hepatogastroenterology Division, University of Campania Luigi Vanvitelli, Naples 80138, Italy
| | - Silvio Naviglio
- Department of Precision Medicine, Clinical Biochemistry Division, University of Campania Luigi Vanvitelli, Naples 80138, Italy
| | - Alessandro Federico
- Department of Precision Medicine, Hepatogastroenterology Division, University of Campania Luigi Vanvitelli, Naples 80138, Italy
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Koh J, Dowlatshahi S, Turner BJ. Transitioning from the Emergency Department to a General Internist Outpatient Clinic for Paracentesis: A Qualitative. RESEARCH SQUARE 2023:rs.3.rs-3793244. [PMID: 38234824 PMCID: PMC10793502 DOI: 10.21203/rs.3.rs-3793244/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2024]
Abstract
Background Repeated paracentesis for ascites can place significant demands on the emergency department (ED). A new general internist-led outpatient procedure clinic to alleviate this demand required ED staff and patients to accept this transition of care. Aim This qualitative study evaluates barriers and facilitators to implementing the FLuid ASPiration (FLASP) clinic in a safety net hospital. Methods The FLASP clinic opened during the COVID-19 pandemic in March 2021. From February to April 2022, semi-structured interviews were conducted with: 10 ED physicians and nurses; 5 FLASP clinic patients; and 4 patients receiving paracentesis in the ED. Interviews were recorded, transcribed, and analyzed using a Grounded Theory approach for themes categorized by Theory of Planned Behavior (TPB) domains including: attitudes/knowledge; social norms; and logistics. Results Thematic analysis found that ED staff appreciated reduced demand for paracentesis, but barriers included: lack of knowledge; concerns about unstable patients and patient expectations (norms); and scheduling logistics. FLASP clinic patients had only favorable themes: belief in clinic safety; positive relationship with staff; and clinic efficiency. Patients using the ED for paracentesis expressed only concerns: possible need for testing or hospitalization; care usually in the ED; and unclear clinic scheduling. Conclusion This study reveals challenges to transitioning sites of care for paracentesis including the need for greater ED staff education and standardizing methods to triage patients to appropriate site of care. Greater support and education of ED patients about the benefits of an outpatient procedure clinic may also reduce ED burden for paracentesis.
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Affiliation(s)
- Jennifer Koh
- Keck Medical Center of University of Southern California
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Elhence H, Dodge JL, Farias AJ, Lee BP. Quantifying days at home in patients with cirrhosis: A national cohort study. Hepatology 2023; 78:518-529. [PMID: 36994701 PMCID: PMC10363198 DOI: 10.1097/hep.0000000000000370] [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: 12/09/2022] [Accepted: 03/04/2023] [Indexed: 03/31/2023]
Abstract
BACKGROUND AND AIMS Days at home (DAH) is a patient-centric metric developed by the Medicare Payment Advisory Commission, capturing annual health care use, including and beyond hospitalizations and mortality. We quantified DAH and assessed factors associated with DAH differences among patients with cirrhosis. APPROACH AND RESULTS Using a national claims database (Optum) between 2014 and 2018, we calculated DAH (365 minus mortality, inpatient, observation, postacute, and emergency department days). Among 20,776,597 patients, 63,477 had cirrhosis (median age, 66, 52% males, and 63% non-Hispanic White). Age-adjusted mean DAH for cirrhosis was 335.1 days (95% CI: 335.0 to 335.2) vs 360.1 (95% CI: 360.1 to 360.1) without cirrhosis. In mixed-effects linear regression, adjusted for demographic and clinical characteristics, patients with decompensated cirrhosis spent 15.2 days (95% CI: 14.4 to 15.8) in postacute, emergency, and observation settings and 13.8 days (95% CI: 13.5 to 14.0) hospitalized. Hepatic encephalopathy (-29.2 d, 95% CI: -30.4 to -28.0), ascites (-34.6 d, 95% CI: -35.3 to -33.9), and combined ascites and hepatic encephalopathy (-63.8 d, 95% CI: -65.0 to -62.6) were associated with decreased DAH. Variceal bleeding was not associated with a change in DAH (-0.2 d, 95% CI: -1.6 to +1.1). Among hospitalized patients, during the 365 days after index hospitalization, patients with cirrhosis had fewer age-adjusted DAH (272.8 d, 95% CI: 271.5 to 274.1) than congestive heart failure (288.0 d, 95% CI: 287.7 to 288.3) and chronic obstructive pulmonary disease (296.6 d, 95% CI: 296.3 to 297.0). CONCLUSIONS In this national study, we found that patients with cirrhosis spend as many, if not more, cumulative days receiving postacute, emergency, and observational care, as hospitalized care. Ultimately, up to 2 months of DAH are lost annually with the onset of liver decompensation. DAH may be a useful metric for patients and health systems alike.
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Affiliation(s)
- Hirsh Elhence
- Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Jennifer L. Dodge
- Department of Population Public Health Sciences, University of Southern California, Los Angeles, California
- Division of Gastroenterology and Liver Diseases, University of Southern California, Los Angeles, California
| | - Albert J. Farias
- Department of Population Public Health Sciences, University of Southern California, Los Angeles, California
| | - Brian P. Lee
- Division of Gastroenterology and Liver Diseases, University of Southern California, Los Angeles, California
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Kehar M, Griffiths R, Flemming JA. Impact of decompensated cirrhosis in children: A population-based study. CANADIAN LIVER JOURNAL 2023; 6:278-282. [PMID: 37503518 PMCID: PMC10370729 DOI: 10.3138/canlivj-2022-0031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 11/02/2022] [Indexed: 07/29/2023]
Abstract
Background We describe the proportion of children with compensated cirrhosis who develop decompensation in Ontario, Canada over the past two decades. Methods This is a retrospective population-based cohort study using routinely collected health care data from Ontario, Canada held at ICES during 1997-2017. Diagnosis of cirrhosis was made using validated ICES definition, and decompensation events were defined according to validated coding. Rates of decompensation, type of decompensation, and incidence of liver transplantation after decompensation were analyzed. Databases were linked at the individual level and analyzed at ICES-Queen's. Results A total of 2,755 children with compensated cirrhosis were included and 9% (253) developed decompensation over a median follow-up of 7 years. Children most likely to suffer decompensation were younger (median age 10 versus 4 years, p < 0.001) and female (45% versus 52%, p = 0.03). Ascites (137/253, 54%) was the most frequent complication. 199/2755 (7%) of children with cirrhosis received liver transplantation, of which 64% (128/199) occurred after a decompensation event. Overall, a total of 132 (4.7%) deaths occurred during the study period, with 55 deaths following a decompensating event. Conclusion We present the first study to describe rates of decompensation, type, and rate of liver transplantation after decompensation in pediatric cirrhosis at the population level. To improve the care of children with liver disease, early detection of liver disease, early initiation of specific treatments as well as identification of children who are at risk of becoming decompensated are crucial.
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Affiliation(s)
- Mohit Kehar
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
| | | | - Jennifer A Flemming
- ICES-Queen’s
- Department of Medicine, Queen’s University, Kingston, Ontario, Canada
- Department of Public Health Sciences, Queen’s University, Kingston, Ontario, Canada
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Liu YB, Chen MK. Epidemiology of liver cirrhosis and associated complications: Current knowledge and future directions. World J Gastroenterol 2022; 28:5910-5930. [PMID: 36405106 PMCID: PMC9669831 DOI: 10.3748/wjg.v28.i41.5910] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Revised: 09/30/2022] [Accepted: 10/20/2022] [Indexed: 02/06/2023] Open
Abstract
Cirrhosis causes a heavy global burden. In this review, we summarized up-to-date epidemiological features of cirrhosis and its complications. Recent epidemiological studies reported an increase in the prevalence of cirrhosis in 2017 compared to in 1990 in both men and women, with 5.2 million cases of cirrhosis and chronic liver disease occurring in 2017. Cirrhosis caused 1.48 million deaths in 2019, an increase of 8.1% compared to 2017. Disability-adjusted life-years due to cirrhosis ranked 16th among all diseases and 7th in people aged 50-74 years in 2019. The global burden of hepatitis B virus and hepatitis C virus-associated cirrhosis is decreasing, while the burden of cirrhosis due to alcohol and nonalcoholic fatty liver disease (NAFLD) is increasing rapidly. We described the current epidemiology of the major complications of cirrhosis, including ascites, variceal bleeding, hepatic encephalopathy, renal disorders, and infections. We also summarized the epidemiology of hepatocellular carcinoma in patients with cirrhosis. In the future, NAFLD-related cirrhosis will likely become more common due to the prevalence of metabolic diseases such as obesity and diabetes, and the prevalence of alcohol-induced cirrhosis is increasing. This altered epidemiology should be clinically noted, and relevant interventions should be undertaken.
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Affiliation(s)
- Yuan-Bin Liu
- Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan 430000, Hubei Province, China
| | - Ming-Kai Chen
- Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan 430000, Hubei Province, China
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