Comorbid illness is an important determinant of health-related quality of life in patients with chronic hepatitis C

Effects of Direct-Acting Antiviral Agents on the Mental Health of Patients with Chronic Hepatitis C: A Prospective Observational Study

In chronic hepatitis C (CHC) patients, interferon-based treatments showed toxicity, limited efficacy, and psychiatric manifestations. Direct-acting antiviral (DAA) agents appeared safer, though it remains unclear if they may exacerbate or foster mood symptoms in drug-naïve CHC patients. We evaluated 62 CHC patients' mental status, before and 12 weeks after DAA therapy, by assessment scales and psychometric instruments. We subdivided patients into two groups, CHC patients with (Group A) or without (Group B) a current and/or past psychiatric history. After DAA treatment, Group A patients showed low anxiety and improved depression, no variation in self-report distress, but worse general health perceptions. No significant difference emerged from coping strategies. Depression and anxiety improved in Group B, and no change emerged from total self-reported distress, except for somatization. Moreover, Group B increased problem-focused strategies for suppression of competing activities, and decreased strategies of instrumental social support. Contrarily, Group B reduced significantly emotion-focused strategies, such as acceptance and mental disengagement, and improved vitality, physical and social role functioning. DAA therapy is safe and free of hepatological and psychiatric side effects in CHC patients, regardless of current and/or past psychiatric history. In particular, patients without a psychiatric history also remarkably improved their quality of life.

Impact of HIV and chronic kidney disease comorbidities on hepatitis C treatment choices, drug-drug interactions and hepatitis C cure

Background Human immunodeficiency virus (HIV) co-infection and chronic kidney disease add challenges to hepatitis C virus treatment. Objective To conduct a comparative study of treatment choices, drug–drug interactions and clinical outcomes in hepatitis C mono-infected patients, or those with HIV or chronic kidney disease comorbidities. Setting Hepatitis C treatment centers of West Midlands England, United Kingdom. Method An observational study was conducted analyzing datasets of all hepatitis C patients that were referred to a large tertiary liver unit in the West Midlands, UK between July 2015 and January 2018. Patients aged ≥ 18 years with diagnosis of hepatitis C alone or co-infected with HIV or comorbid with chronic kidney disease were eligible. Main outcome measures The treatment choices, relevant potential drug–drug interactions and sustained virologic response 12 weeks post end of treatment were assessed. Results Out of 313 patients, 154 (49.2%) were hepatitis C mono-infected, 124 (39.6%) hepatitis C/HIV co-infected and 35 (11.2%) were hepatitis C/chronic kidney disease comorbid. There were 151 (98.1%) of hepatitis C mono-infected, 110 (88.7%) of hepatitis C/HIV and 20 (57.1%) of hepatitis C/chronic kidney disease patients treated with 1st line regimens. Significantly more patients who had co-morbidity with either HIV or chronic kidney disease were prescribed 2nd line regimens (8.1% and 37.1% respectively), compared to patients with hepatitis C mono-infection (1.9%) (P value < 0.05). Comorbid patients (12.1% of HIV and 25.8% of chronic kidney disease) were more likely to required drug–drug interactions advice (grade 5) than hepatitis C mono-infected (1.8%). Higher cure rates were observed in hepatitis C mono-infected (95.33%), hepatitis C/HIV (96.1%) compared to hepatitis C/chronic kidney disease patients (90.3%). Conclusion This study shows that treatment pathways permitting access to individual treatment adjustments in accordance with comorbidities and with consideration of drug–drug interaction in a multi-disciplinary team, provides successful outcomes in hepatitis C patients co-morbid with HIV or chronic kidney disease.

Patient-reported symptoms during and after direct-acting antiviral therapies for chronic hepatitis C: The PROP UP study

BACKGROUND & AIMS

A comprehensive analysis of changes in symptoms and functioning during and after direct-acting antiviral (DAA) therapy for chronic hepatitis C virus (HCV) infection has not been conducted for patients treated in real-world clinical settings. Therefore, we evaluated patient-reported outcomes (PROs) in a diverse cohort of patients with HCV treated with commonly prescribed DAAs.

METHODS

PROP UP is a US multicenter observational study of 1,601 patients with HCV treated with DAAs in 2016-2017. PRO data were collected at baseline (T1), early on-treatment (T2), late on-treatment (T3) and 3-months post-treatment (T4). PRO mean change scores were calculated from baseline and a minimally important change (MIC) threshold was set at 5%. Regression analyses investigated patient and treatment characteristics independently associated with PRO changes on-treatment and post-treatment.

RESULTS

Of 1,564 patients, 55% were male, 39% non-white, 47% had cirrhosis. Sofosbuvir/ledipasvir was prescribed to 63%, sofosbuvir/velpatasvir to 21%, grazoprevir/elbasvir to 11%, and paritaprevir/ombitasvir/ritonavir + dasabuvir to 5%. During DAA therapy, mean PRO scores improved slightly in the overall cohort, but did not reach the 5% MIC threshold. Between 21-53% of patients experienced >5% improved PROs while 23-36% experienced >5% worse symptoms. Of 1,410 patients with evaluable sustained virologic response (SVR) data, 95% achieved SVR. Among those with SVR, all mean PRO scores improved, with the 5% MIC threshold met for fatigue, sleep disturbance, and functioning well-being. Regression analyses identified subgroups, defined by age 35-55, baseline mental health issues and a higher number of health comorbidities as predictors of PRO improvements.

CONCLUSIONS

In real-world clinical practices, we observed heterogeneous patient experiences during and after DAA treatment. Symptom improvements were more pronounced in younger patients, those with baseline mental health issues and multiple comorbidities.

LAY SUMMARY

Patients who received direct-acting antiviral medications for hepatitis C at several liver centers in the US did not generally experience significant changes in baseline symptoms during treatment. We observed a full range of patient experiences with some patients experiencing substantial symptom improvements, yet others experiencing less improvements and some even experiencing a worsening of symptoms. The 1,346 patients who were cured of hepatitis C experienced improvements in fatigue, sleep disturbance, and functional well-being, and trends for improved pain and depression; whereas the 64 who were not cured experienced minimal improvements. Clinicaltrial.gov: NCT02601820.

Quality of life in patients with chronic hepatitis C infection: Severe comorbidities and disease perception matter more than liver-disease stage

Background and aims

This study evaluated the clinical and non-clinical determinants of health-related quality of life (HRQoL) associated with untreated chronic hepatitis C (CHC) in France.

Methods

From 01/2014 to 01/2015, untreated CHC patients were invited to complete a questionnaire including EQ-5D utility instrument and two visual analogue scales (VAS) measuring overall health and fatigue in three French centers (Paris, Lille and Montpellier). Answers were analyzed in mixed models (taking into account the clustering effects of centers and physicians).

Results

Five hundreds and five patients were enrolled: 52% males; the mean age was 54; 41% had BMI>25; 64% had genotype 1; 36% were at the stage of severe fibrosis (F3-F4); 38% had severe comorbidities other than liver-related. In the univariate analysis, EQ-5D utility was associated with socio-demographic variables as age, place of birth, education, and employment; CHC-related variables as conditions of HCV screening and severity of fibrosis; CHC-unrelated variables as comorbidities other than CHC, being overweight, and psychiatric disorders; feelings about CHC disease as perception of progression, lack of information on CHC and its treatments, and entourage’s feeling. In multivariate analysis, EQ-5D utility was affected by not being in employment (0.72 vs. 0.80), having severe comorbidities other than CHC (0.72 vs. 0.79), being overweight (0.73 vs. 0.78), and feeling worried about CHC progression (0.66 vs. 0.72–0.84). Similar results were found for the VAS.

Conclusions

The presence of severe comorbidities and worrying about CHC progression, but not stage of fibrosis, seem to alter significantly EQ-5D health utility in CHC French patients.

Association of IBD specific treatment and prevalence of pain in the Swiss IBD cohort study

Background

Extraintestinal manifestations (EIM) contribute significantly to the burden of disease in inflammatory bowel disease (IBD). Pain is a leading symptom in IBD and could be seen as an EIM itself. Treatment of IBD associated pain is challenging and insufficiently studied. A better knowledge on the association of pain and IBD specific treatment is warranted to improve the management of IBD patients.

Methods

All patients of the Swiss IBD Cohort Study (SIBDCS) (n = 2152) received a questionnaire regarding pain localization, pain character, and the use of IBD specific medication.

Results

1263 completed questionnaires were received. Twenty-one out of 184 patients (10%) receiving anti-TNF treatment compared to 142 out of 678 patients (21%) not receiving anti-TNF medication reported elbow pain (p = 0.002) while 28 out of 198 patients (14%) receiving steroid treatment significantly more often reported elbow pain compared to 59 from 696 patients (8%) not receiving steroids (p = 0.021). Furthermore, we found significantly more female patients under anti-TNF treatment to report knee/ lower leg pain and ankle/ foot pain compared to their male counterparts (36% vs. 20% and 22% vs. 10%, respectively, p = 0.015 for both comparisons). The frequency of knee, lower leg, ankle and foot pain was especially low in male patients under anti-TNF treatment, indicating a high benefit of male patients from anti-TNF therapy regarding EIM.

Conclusions

The frequency of elbow pain was lower in IBD patients treated with anti-TNF but higher in patients treated with steroids.

The combined polymorphisms of interleukin-6-174GG genotype and interleukin-10 ATA haplotype are associated with a poor quality of life in patients with chronic hepatitis C

PURPOSE

Chronic hepatitis C (CHC) is associated with a decreased health-related quality of life (HRQOL). More recent studies have pointed toward a genetic basis of patient-reported quality of life outcomes. Taking into account that the influence of single-nucleotide polymorphisms (SNPs) on the HRQOL of CHC patients has not been studied, we investigated the combined IL10-1082G/A, - 819C/T, and - 592C/A SNPs, and IL6-174G/C SNP. We also evaluated the association between demographic, clinical, psychiatric, virological, and genetic variables with domains and summaries of HRQOL in CHC patients.

METHODS

132 consecutive CHC patients and 98 controls underwent psychiatric evaluation by using the Mini International Neuropsychiatric Interview. HRQOL was assessed by a generic questionnaire, the Medical Outcomes Study 36-Item Short Form Health Survey (SF-36), and by the specific Liver Disease Quality of Life Questionnaire (LDQOL). IL6 and IL10 polymorphisms were evaluated by Taqman SNP genotyping assay. Multivariate analysis was used to evaluate the associations.

RESULTS

Major depressive disorder was associated with lower SF-36 and LDQOL scores in seven and ten domains, respectively. Diabetes and hypertension were also associated with reduced HRQOL. CHC patients carrying the combination of IL10 ATA haplotype/IL6-GG genotype had lower scores in the SF-36-physical functioning domain, and reduced scores in the LDQOL effects of liver disease on activities of daily living, quality of social interaction, and sexual function domains than the non-carriers of the combined haplotype/genotype.

CONCLUSION

This is the first study to demonstrate that combined IL6 high-producer GG genotype and IL10 low-producer ATA haplotype is associated with poorer HRQOL in CHC patients.

Health-related quality of life in hepatitis C patients who achieve sustained virological response to direct-acting antivirals: a comparison with the general population

PURPOSE

To compare health-related quality of life (HRQoL) between hepatitis C patients who achieve sustained virological response (SVR) to direct-acting antivirals and a sex- and age-paired sample of the general population.

METHODS

HRQoL was evaluated in patients recruited in Navarre, Spain, from May 2016 to April 2017 at baseline and after SVR, using the EQ-5D-5L questionnaire. Both results were compared to those of general population of the same sex and age obtained from the 2011/12 National Health Survey in Spain. Observed/expected (O/E) ratios for health dimensions and differences between O-E in EQ-5D utility and visual analogical scale (VAS) scores were calculated.

RESULTS

206 patients were studied. Before treatment, patients had more problems than the general population in every domain of EQ-5D-5L, except in self-care dimension (O/E = 1.1). After SVR, patients continued having more limitation, especially for usual activities (O/E = 3.1), anxiety/depression (O/E = 2.8) and EQ-5D utility (- 0.086, p < 0.001); however, differences in VAS score between patients and general population disappeared (74.8 vs 76.5, p = 0.210). F0-F1 patients with SVR had minor differences with the general population in EQ-5D-5L dimensions, utility and VAS score. Although cirrhotic patients also reduced that difference, they still had worse HRQoL, especially in usual activities, self-care, EQ-5D utility (- 0.152, p < 0.001) and VAS score (- 8.5, p = 0.005).

CONCLUSIONS

HRQoL of chronic hepatitis C patients remains lower than that of the general population despite viral clearance, with primary problems in usual activities and anxiety/depression. Knowledge of these on-going problems despite cure serves to guide healthcare interventions and patient's follow-up.

Factors improving the utility of antiviral therapy for chronic hepatitis B: A nationwide multicenter study in Japan

AIM

The consideration of patients' needs in terms of research outcomes is emphasized in research promotion to eradicate hepatitis B virus according to the Basic Act on Hepatitis Measures in Japan. This study analyzed patients' attitudes toward experienced antiviral therapies for chronic hepatitis B and their need for future therapies.

METHODS

A self-administered questionnaire comprising 124 questions was completed among patients with chronic hepatitis B from 61 core-center hospitals designated to implement and research policies on hepatitis in 47 prefectures from August 2013 to January 2014 (n = 3021, response rate = 51%).

RESULTS

In decision-tree models with 333 variables generated from the questionnaire data, patients' satisfaction with therapy and reduction in anxiety about therapy were dependent on favorable therapeutic effects, sufficient information provided by the physician, and fewer lifestyle disturbances. Medical expenses were not selected at a superior branch because subsidy for antiviral therapy started in 2010. In correspondence analysis of free text answers, patients' need for therapy and support mechanisms differed among their attributes, including a great need for novel therapy in older men, hope for avoidance of lifestyle disturbance in younger men, and alleviation of painful experience with the disease in women.

CONCLUSIONS

Continual provision of sufficient information is necessary to improve the utility of antiviral therapy for chronic hepatitis B as well as for favorable therapeutic effects. The patients believed that novel drugs and support would reduce the diverse burden of the disease on their lives.

A comprehensive assessment of patient reported symptom burden, medical comorbidities, and functional well being in patients initiating direct acting antiviral therapy for chronic hepatitis C: Results from a large US multi-center observational study

BACKGROUND

Symptom burden, medical comorbidities, and functional well-being of patients with chronic hepatitis C virus (HCV) initiating direct acting antiviral (DAA) therapy in real-world clinical settings are not known. We characterized these patient-reported outcomes (PROs) among HCV-infected patients and explored associations with sociodemographic, liver disease, and psychiatric/substance abuse variables.

METHODS AND FINDINGS

PROP UP is a large US multicenter observational study that enrolled 1,600 patients with chronic HCV in 2016-2017. Data collected prior to initiating DAA therapy assessed the following PROs: number of medical comorbidities; neuropsychiatric, somatic, gastrointestinal symptoms (PROMIS surveys); overall symptom burden (Memorial Symptom Assessment Scale); and functional well-being (HCV-PRO). Candidate predictors included liver disease markers and patient-reported sociodemographic, psychiatric, and alcohol/drug use features. Predictive models were explored using a random selection of 700 participants; models were then validated with data from the remaining 900 participants. The cohort was 55% male, 39% non-white, 48% had cirrhosis (12% with advanced cirrhosis); 52% were disabled or unemployed; 63% were on public health insurance or uninsured; and over 40% had markers of psychiatric illness. The median number of medical comorbidities was 4 (range: 0-15), with sleep disorders, chronic pain, diabetes, joint pain and muscle aches being present in 20-50%. Fatigue, sleep disturbance, pain and neuropsychiatric symptoms were present in over 60% and gastrointestinal symptoms in 40-50%. In multivariable validation models, the strongest and most frequent predictors of worse PROs were disability, unemployment, and use of psychiatric medications, while liver markers generally were not.

CONCLUSIONS

This large multi-center cohort study provides a comprehensive and contemporary assessment of the symptom burden and comorbid medical conditions in patients with HCV treated in real world settings. Pain, fatigue, and sleep disturbance were common and often severe. Sociodemographic and psychiatric markers were the most robust predictors of PROs. Future research that includes a rapidly changing population of HCV-infected individuals needs to evaluate how DAA therapy affects PROs and elucidate which symptoms resolve with viral eradication.

TRIAL REGISTRATION

(Clinicaltrial.gov: NCT02601820).

Factors influencing on health-related quality of life in South Korean with chronic liver disease

Background

The objective of this study was to determine health-related quality of life (HRQoL) among chronic liver disease (CLD) subjects in South Korea using EuroQol five-dimension questionnaire (EQ-5D).

Method

The sample consisted of 139 subjects with CLD from the sixth Korean National Health and Nutrition Examination Survey (KNHNES VI). Data were analyzed using SPSS program for descriptive statistics, t-test, ANOVA, Scheffe’s test and hierarchical multiple regression.

Results

Results indicated that marital status (P < 0.01), occupation (P < 0.01), basic livelihood security recipient status (P < 0.05), hepatocellular carcinoma (P < 0.05), subjective health status (P < 0.01), and depression (P < 0.001) were significant predictors of HRQoL. Health behaviors (alcohol intake, sleep duration) variables were insignificant.

Conclusion

In conclusion, marital status, occupation, basic livelihood security recipient status (BLSRS), hepatocellular carcinoma (HCC), subjective health status (SHS), and depression were confirmed to be factors affecting the HRQoL. We should be provide to continuous monitoring and education of adequate alcohol intake for patients with CLD. Findings of this study might be used to develop community based health programs and policies for CLD.

Health-Related Quality of Life in Dialysis Patients with HCV Infection

Measuring the impact of chronic kidney disease (CKD) treatment on patient quality of life has become increasingly recognized as an important outcome measure. Despite improvements in the treatment of chronic kidney disease, health-related quality of life (HRQOL) is lower than in the general population. HRQOL measures, particularly the Physical Component Summary (PCS), have predictive validity for risk of both mortality and hospitalization in dialysis populations. For every 10-point lower PCS score, the relative risk (RR) of death increases by 29% (RR=1.29; 95% Cl=1.23 to 1.35; p<0.001) and the risk of hospitalization increases by 15% (RR=1.15; 95% Cl=1.11 to 1.19, p<0.001), according to the Dialysis Outcomes and Practice Patterns Study (DOPPS). Hepatitis C virus (HCV) infection remains prevalent among dialysis patients with a recent meta-analysis showing that anti-HCV seropositive status was an independent and significant risk factor for death in patients on maintenance dialysis. Seven studies with 11,589 unique patients on maintenance dialysis were identified; the summary estimate for adjusted relative risk (aRR) (all-cause mortality) was 1.34 with a 95% confidence interval (CI) of 1.13–1. 59. In non-uremic populations HCV diminishes HRQOL, and individuals with HCV scored lower than controls across all scales of the short form 36 (SF-36). Patients achieving sustained virological responses (SVR) scored higher across all scales versus patients without SVR, especially in the physical health domains. Whether the adverse influence of HCV on survival in dialysis population is related to the negative impact of HCV on HRQOL requires further research. Information on HRQOL indices in patients with HCV on maintenance dialysis is extremely limited but the available evidence shows that HCV infection impairs HRQOL, especially in mental aspects, among patients on maintenance hemodialysis.

Increased hope following successful treatment for hepatitis C infection

AIMS

To evaluate hope in hepatitis C patients 9 years after curative treatment with pegylated interferon and ribavirin.

BACKGROUND

Successful treatment of hepatitis C leads to improved quality of life in responders compared with non-responders. The long-term effect of successful treatment on hope in these patients is not known.

DESIGN

Cross-sectional follow-up study of patients who displayed a sustained virological response to previous hepatitis C treatment.

METHODS

Patients infected with hepatitis C genotype 2 or 3 from a randomized controlled study during 2004-2006 were included. A representative subgroup of those who achieved a sustained virological response was re-evaluated in 2012-2014. The patients were examined, had a blood test and completed a questionnaire (Herth Hope Index and demographic and clinical characteristics). The hope level was compared between patients and an age-matched sample from the general population (N = 1,481). The data were analysed using multiple regression.

RESULTS

A total of 104 Norwegian and Swedish hepatitis C patients were included in this follow-up study; their mean age was 48 years, and 61% were men. Patients treated for hepatitis C scored higher than the general population on the total Herth Hope Index and for 11 of the 12 individual items. Age, gender, educational level, employment status and civil status were associated with a higher Herth Hope Index in those who had received hepatitis C treatment.

CONCLUSION

Patients achieving a sustained viral response had a higher hope level than the general population 9 years after successful treatment of hepatitis C virus infection.

Preventing disability in inflammatory bowel disease

Disability is a common worldwide health challenge and it has been increasing over the past 3 decades. The treatment paradigm has changed dramatically in inflammatory bowel diseases (IBDs) from control of symptoms towards full control of disease (clinical and endoscopic remission) with the goal of preventing organ damage and disability. These aims are broadly similar to rheumatoid arthritis and multiple sclerosis. Since the 1990s, our attention has focused on quality of life in IBD, which is a subjective measure. However, as an objective end-point in clinical trials and population studies, measures of disability in IBD have been proposed. Disability is defined as '…any restriction or lack (resulting from an impairment) of ability to perform an activity in the manner or within the range considered normal for a human being.' Recently, after 10 years of an international collaborative effort with the World Health Organization (WHO), a disability index was developed and validated. This index ideally would assist with the assessment of disease progression in IBD. In this review, we will provide the evidence to support the use of disability in IBD patients, including experience from rheumatoid arthritis and multiple sclerosis. New treatment strategies, and validation studies that have underpinned the interest and quantification of disability in IBD, will be discussed.

Pain in IBD Patients: Very Frequent and Frequently Insufficiently Taken into Account. PLoS One. 2016;11:e0156666. [PMID: 27332879 PMCID: PMC4917102 DOI: 10.1371/journal.pone.0156666]

Background

Pain is a common symptom related to inflammatory bowel disease (IBD). In addition to abdominal pain, pain can also be an extraintestinal manifestation of IBD. Pain treatment is challenging and a substantial part of IBD patients are treated with opioids. Therefore, a better knowledge on pain symptoms is crucial for a better therapeutic approach to this clinical problem.

Methods

Patients of the Swiss IBD Cohort Study (SIBDCS) (n = 2152) received a questionnaire regarding pain intensity, pain localization and impact of pain on daily life and social activities. Furthermore, the questionnaire investigated the use of pain-specific medication.

Results

A vast majority of patients (71%) experienced pain during the disease course. For a substantial part of patients (49% in UC and 55% in CD) pain is a longstanding problem (>5 years). Pain in UC was of shorter duration compared to CD (p < 0.01). Abdominal pain (59.5%) and back pain (38.3%) were the main pain localizations. 67% of patients took pain medication; 24% received no pain treatment. The general quality of life was significantly lower in patients suffering of pain compared to those without pain (38 vs. 77; (-100 very bad; 100 very good) p<0.0001).

Conclusions

Prevalence of pain is high in patients of the SIBDCS. It is a longstanding problem for the majority of the patients affected. Pain was found to be undertreated in the SIBDCS and was significantly associated with health-related quality of life. Thus, an increased awareness is mandatory to address this frequent complication in the course of IBD.

The impact of psychiatric and extraintestinal comorbidity on quality of life and bowel symptom burden in functional GI disorders

BACKGROUND

Functional gastrointestinal disorders (FGID) patients report poor health-related quality of life (HRQOL) and experience high rates of psychiatric and extraintestinal functional disorder (EIFD) comorbidity. The independent influence of these comorbidities on HRQOL and symptom burden remains unknown. We sought to determine whether FGID with mood or EIFD comorbidity have poorer HRQOL and greater GI symptom burdens; to determine the influence of comorbidities on HRQOL in FGID independent of bowel symptoms.

METHODS

Subjects reported on comorbidities (anxiety, depression, somatization, EIFD), FGID criteria (irritable bowel syndrome, IBS; functional dyspepsia, FD) using ROME III Research questionnaire, GI symptom burden, and HRQOL. Differences in measures were assessed between subjects with and without ROME III criteria. Multiple regression determined the relative contribution of comorbidities to HRQOL, and mediation analysis explored whether comorbidity influences HRQOL.

KEY RESULTS

In a cohort of 912 GI outpatients (47.2 ± 1.5 years, 75.8% female), 606 (66.4%) met Rome III IBS and/or FD criteria. Comorbidities were common in FGID (≥1 in 77.4%), leading to lower HRQOL and greater GI symptom burden (each p < 0.05). Poorer HRQOL was predicted by both psychiatric and EIFD comorbidity (each p < 0.05) independent of GI symptoms (p < 0.001). Comorbidities together exerted a greater effect on predicted variation in HRQOL (70.9%) relative to GI symptoms (26.5%).

CONCLUSIONS & INFERENCES

Psychiatric and EIFD comorbidities are common in FGID, decrease HRQOL and are associated with greater GI symptom burdens; these factors were stronger predictors of HRQOL than GI symptoms in FGID patients.

Predictors of mental and physical health in non-cirrhotic patients with viral hepatitis: a case control study

OBJECTIVE

To identify independent predictors of mental and physical health in patients with viral hepatitis.

METHODS

Hepatitis C (HCV) and hepatitis B (HBV) infected patients, and community control subjects with equal age and sex distribution were recruited. All subjects filled in personal characteristics questionnaire, Hospital Anxiety and Depression Scale (HADS), Iowa Fatigue Scale (IFS), and Medical Outcomes Survey Short Form-12 (SF-12). All patients had measurement of routine laboratory values, and some had recent liver biopsy. Regression analyses were used to identify predictors of physical and mental health.

RESULTS

One hundred eighty nine subjects (162 males, 27 females, for each group N=63) with mean (±SD) age of 39±11years were included. Anxiety and depression were important predictors of SF-12 (and its subscales MCS and PCS) and IFS scores, whereas IFS scores independently predicted HADS, PCS, MCS, and SF-12 scores. After controlling for confounders, HCV infection was independently associated with impairment of physical health. Moreover, creatinine showed an inverse strong relation with fatigue. Genotype 3a of HCV was independently associated with depressed and anxious states, whereas higher inflammation grade was significantly related to depression. Marital status, non-psychiatric comorbidities, and history of alcohol abuse also predicted health scores in the patients. Adjusted R(2)s for linear models were 0.571 to 0.709, whereas areas under the receiver operating characteristic (ROC) curve for logistic models were 0.90 to 0.93.

CONCLUSION

In viral hepatitis patients, besides mental and medical comorbidities, marital status, and alcohol abuse, HCV infection itself is associated with impaired physical and possibly mental health.

Differences in health-related quality of life scores after orthotopic liver transplantation with respect to selected socioeconomic factors

One of the current ultimate goals of orthotopic liver transplantation (OLT) is the improvement of patients' health-related quality of life (HRQOL). The purpose of this study was to look at the effects of socioeconomic and demographic differences on the short-term and long-term HRQOL outcomes of OLT recipients. Three hundred three adult OLT recipients who were seen at the University of California Los Angeles were administered the Medical Outcomes Study Short Form 36 (SF-36), the Chronic Liver Disease Questionnaire (CLDQ), and a demographic survey. A parsimonious model of 12 socioeconomic and demographic predictors was identified. Their simultaneous influence on each SF-36 and CLDQ HRQOL domain score was evaluated with multivariate linear regression and backward selection. Hepatitis C virus impaired HRQOL; this was shown in the SF-36 Vitality and Bodily Pain domains and in most CLDQ domains. Females experienced more HRQOL impairment only within the CLDQ Abdominal Symptoms domain. OLT recipients who were married had better SF-36 Role-Emotion domain scores. OLT recipients with more than 12 years of education had better SF-36 Physical Functioning scores. Employed OLT recipients had less HRQOL impairment; this was evidenced by better scores in multiple domains of the SF-36 and the CLDQ. OLT patients with health maintenance organization or preferred provider organization insurance had higher HRQOL scores within almost all SF-36 and CLDQ domains. Patients with a mix of public and private insurance had significantly higher HRQOL scores in comparison with those with only public insurance. Identifying patients at higher risk for worse HRQOL scores, less satisfaction with OLT results, and greater problems with fatigue or mental health stressors will assist transplant centers in using their medical teams to develop early interventions and multidisciplinary approaches to improve HRQOL outcomes after OLT.

Hepatitis C treatment eligibility and comorbid medical illness in methadone maintenance (MMT) and non-MMT patients: a case-control study

Comorbid medical illness is common in patients with chronic hepatitis C (HCV) infection and in methadone treatment (MMT) patients, yet little is known about the impact of medical illness on HCV treatment eligibility. Medical illness and HCV treatment eligibility were compared in a case-control study of 80 MMT patients entering an HCV treatment trial and 80 matched non-MMT patients entering HCV treatment in a gastroenterology clinic. 91% of MMT and 85% of non-MMT patients had chronic medical conditions. Despite similar medical severity ratings, a significantly higher proportion (77%) of non-MMT patients were eligible for HCV treatment than were MMT patients (56%) (p<.01). Specific comorbid medical and psychiatric illness led to ineligibility in only 18% of MMT and 16% of non-MMT patients. However, failure to complete the medical evaluation process was significantly (p<.001) more likely to cause ineligibility among MMT patients (19%) than non-MMT patients (0%).

Implications of hepatitis C virus infection for behavioral symptoms and activities of daily living

Hepatitis C virus (HCV) is neurovirulent and has been shown to be associated with neuropsychological (NP) deficits in a subset of infected individuals. Despite these previous findings, little work has been done to examine neurobehavioral symptoms associated with HCV infection. We examined 34 HCV seropositive (HCV+) individuals and 35 healthy comparison participants (HCV-) with the self-rating form of the Frontal Systems Behavior Scale (FrSBe). Results showed that at the group level, only the FrSBe apathy subscale mean was clinically elevated (T score >65) among HCV+ persons; executive dysfunction, disinhibition, and total subscale means were not clinically elevated. At the individual level, a significantly higher proportion of HCV+ individuals than of HCV- individuals reported clinically elevated FrSBe T scores . Moreover, HCV+ individuals were nearly 3 times as likely to report clinically elevated FrSBe T scores of apathy, executive dysfunction, and disinhibition as compared to HCV- participants. A multiple regression that included substance use disorders, neuropsychological impairment, and age indicated that HCV status was an independent predictor of self-reported FrSBe total T scores. Across all participants, small, yet significant, correlations were found between elevated self-reported FrsBe T scores and dependence in activities of daily living. These results show that a subset of HCV-infected individuals report clinically elevated behavioral symptoms. Clinical implications for the assessment and management of elevated behavioral symptoms in HCV are discussed.

Changes in quality of life and sexual health are associated with low-dose peginterferon therapy and disease progression in patients with chronic hepatitis C

BACKGROUND

Primary analysis of the Hepatitis C Antiviral Long-Term Treatment against Cirrhosis (HALT-C) Trial showed long-term peginterferon therapy did not reduce complications in patients with chronic hepatitis C and advanced fibrosis or cirrhosis.

AIM

To assess the effects of long-term peginterferon therapy and disease progression on health-related quality of life (HRQOL), symptoms and sexual health in HALT-C patients.

METHODS

A total of 517 HALT-C patients received peginterferon alfa-2a (90 microg/week); 532 received no additional treatment for 3.5 years. Patients were followed up for outcomes of death, hepatocellular carcinoma and hepatic decompensation. Sexual health, SF-36 scores and symptoms were serially assessed by repeated-measures analyses of covariance.

RESULTS

Patients with cirrhosis (n = 427) reported lower general well-being and more fatigue (P < 0.001) than patients with fibrosis (n = 622). Physical scores declined significantly over time, independent of treatment, and patients with cirrhosis reported lower scores. Vitality scores were lower in those with cirrhosis, and treated patients experienced a greater decline over time than untreated patients; HRQOL rebounded after treatment ended. Patients with a clinical outcome had significantly greater declines in all SF-36 and symptom scores. Among men, Sexual Health scores were significantly worse in treated patients and in those with a clinical outcome.

CONCLUSION

Clinical progression of chronic hepatitis C and maintenance peginterferon therapy led to worsening of symptoms, HRQOL and, in men, sexual health in a large patient cohort followed up over 4 years (NCT00006164).

Health-related quality of life in patients with different stages of liver disease induced by hepatitis C

OBJECTIVE

Patients with hepatitis C have been shown to have impaired health-related quality of life (HRQoL). The aim of this study was to determine HRQoL in patients in different stages of hepatitis C virus (HCV) and to compare HRQoL in HCV cirrhosis with non-HCV-induced cirrhosis.

MATERIAL AND METHODS

Out of 489 consecutive patients who fulfilled the inclusion criteria, 472 (96%) agreed to participate in the study: 158 patients with mild/moderate fibrosis with chronic hepatitis C (CHC group), 76 patients with HCV compensated cirrhosis (CC), 53 patients with HCV decompensated (DC) cirrhosis, 52 non-cirrhotic patients with sustained viral response (SVR), and a control group consisting of 32 patients with non-HCV CC and 101 with non-HCV DC who completed the Short Form-36 (SF-36) and EQ-5D questionnaire.

RESULTS

The CHC group had significantly lower SF-36 scores than healthy controls, with the exception of scores for the dimensions physical function and bodily pain. HCV patients with DC had lower scores in all SF-36 dimensions in comparison with those of the CHC group, as well as in physical and mental component summaries (p<0.001). In comparison with the CHC group, the HCV CC group had lower scores on the SF-36 general health dimension (p<0.05) and lower SF-36 physical component summary (PCS) scores (p<0.05). No major differences were seen in patients with HCV- and non-HCV-induced cirrhosis.

CONCLUSIONS

Impairment in HRQoL in patients with HCV was associated with the severity of liver disease, patients with decompensated cirrhosis exhibiting the highest impairment in HRQoL. The etiology of liver disease does not seem to be important in determining HRQoL in cirrhosis.

Sustained responders have better quality of life and productivity compared with treatment failures long after antiviral therapy for hepatitis C

OBJECTIVES

We sought to compare the health status of patients with a sustained response to antiviral therapy for hepatitis C virus (HCV) infection with that of treatment failures, using health-related quality of life and preference (utility) measures.

METHODS

Sustained responders had undetectable HCV viral levels 6 months after antiviral therapy. After antiviral therapy, participants completed, by mail or interview, the hepatitis-specific Medical Outcomes Study Short-Form 36-Item Health Survey (SF-36), the Health Utilities Index Mark 2/3 (HUI2/3), and time trade-off (TTO) for current health. The respondents provided information on demographics, history of substance abuse, comorbidities, and health history. Detailed clinical information was obtained by chart review. The respondents also indicated whether they missed work, volunteer opportunities, or household activities during the previous 3 months because of hepatitis C infection or its treatment.

RESULTS

A total of 235 patients (133 responders and 102 treatment failures) completed questionnaires at an average of 3.7 years after the end of treatment. Treatment failures had significantly lower scores on the eight SF-36 domains (P<0.01), lower scores on the hepatitis-specific domains (P<0.0001), and lower physical (42.5 vs. 49.2) and mental (40.5 vs. 46.1) component summary scores (P<0.01). HUI3 (0.57 vs. 0.70), HUI2 (0.74 vs. 0.80), SF-6D (0.65 vs. 0.71), and TTO (0.84 vs. 0.89) were lower for treatment failures (P<0.05). The regression-adjusted difference in HUI3, SF-6D, physical summary score, and mental summary score was 0.08 (P=0.04), 0.05 (P=0.004), 5.22 (P=0.001), and 5.73 (P<0.0001), respectively. Differences in the HUI2 and TTO scores were not significant after adjustment for demographic and clinical variables. Treatment failures were more likely to have missed work, volunteer opportunities, or household activities in the previous 3 months because of hepatitis C infection or its treatment (44 vs. 9%, P<0.001).

CONCLUSIONS

Patients with a sustained response to antiviral therapy for chronic HCV infection have better quality of life than treatment failures do. Our study validates the benefits associated with the sustained response to antiviral therapy in a real-world clinic population and shows that these benefits are maintained over the long term.

Socio-demographic and clinical features of Irish iatrogenic hepatitis C patients: a cross-sectional survey

BACKGROUND

A discrete sub-group of iatrogenically-acquired hepatitis C virus (HCV)-infected individuals exists in the Irish population on whom limited current research data is available. The aim of this study was to establish a current profile of the socio-demographic and clinical characteristics of the Irish iatrogenic hepatitis C population and to determine factors predicting symptoms experienced.

METHODS

An anonymous, national, cross-sectional survey was conducted to explore this populations' self-reported health and social attributes. Data were collected on 290 respondents.

RESULTS

Mean time since infection was 26 years. Eighty-four percent (n = 237) of respondents were female (mean age = 55.9 +/- 9.6 years). Hepatic and extra-hepatic symptoms were common (62% and 99% respectively). Fatigue and pain were frequent complaints while 89% reported diagnosed co-morbid disease. On logistic regression, female gender, age and co-morbid disease emerged as independent predictors of self-reported symptoms.

CONCLUSION

This study describes the current status of the iatrogenically infected patient cohort in Ireland, adding to existing knowledge regarding the clinical course and consequences of HCV infection. Changing healthcare needs were shown by comparison with earlier surveys in this same population, in terms of disease progression, development of co-morbid disease and ageing.

Health-related quality of life of Southern Chinese with chronic hepatitis B infection

BACKGROUND

Few studies have evaluated the health-related quality of life (HRQOL) of Southern Chinese with chronic hepatitis B (CHB) infection.

AIM

To evaluate the HRQOL of Chinese patients at different stages of CHB infection and to find out factors associated with HRQOL.

METHODS

520 Chinese adult CHB patients of whom 156 were uncomplicated, 102 had impaired liver function, 139 had cirrhosis and 123 had hepatocellular carcinoma (HCC) were interviewed with a structured questionnaire, the SF-36 Health Survey version 2 (SF-36v2), and the Chronic Liver Disease Questionnaire (CLDQ). The differences in SF-6D health preference values and SF-36v2 scores between each CHB group and Hong Kong population norms were assessed by t-test. ANOVA was used to compare the mean SF-6D health preference, SF-36v2 scores, and CLDQ scores among CHB groups. Multiple linear regressions were performed to identify determinants of HRQOL.

RESULTS

CHB patients had significantly lower SF-36v2 scores than the population norm. The SF-6D values of CHB patients with uncomplicated disease, impaired liver function, HCC and cirrhosis were 0.755, 0.745, 0.720 and 0.701, respectively, all significantly lower than the population norm of 0.787. Advanced stage of CHB illness, anti-viral treatment, bilirubin level, psychological co-morbidity, younger age and female were associated with poorer HRQOL.

CONCLUSION

CHB infection had a negative impact on HRQOL. There was a progressive decrease in health preference values with CHB disease progression. The results can be used for the estimation of quality adjusted life years (QALYs) for CHB patients in cost effectiveness or cost utility studies.

TRIAL REGISTRATION

http://www.hkclinicaltrials.com; HKCTR-151.

Quality of life in adults with nonalcoholic fatty liver disease: baseline data from the nonalcoholic steatohepatitis clinical research network

Nonalcoholic fatty liver disease (NAFLD) is the most common chronic liver disease in the United States. The association between NAFLD and quality of life (QOL) remains unclear. These data are important to estimate the burden of illness in NAFLD. The aim was to report QOL scores of adults with NAFLD and examine the association between NAFLD severity and QOL. QOL data were collected from adults with NAFLD enrolled in the Nonalcoholic Steatohepatitis Clinical Research Network using the Short Form 36 (SF-36) survey, and scores were compared with normative U.S. population scores. Liver biopsy histology was reviewed by a central pathology committee. A total of 713 subjects with NAFLD (male = 269, female = 444) were included. Mean age of subjects was 48.3 years; 61% had definite nonalcoholic steatohepatitis (NASH), and 28% had bridging fibrosis or cirrhosis. Diabetes was present in 27% of subjects. Subjects with NAFLD had worse physical (mean, 45.2) and mental health scores (mean, 47.6) compared with the U.S. population with (mean, 50) and without (physical, 55.8; mental, 52.5) chronic illness. Subjects with NASH reported lower physical health compared with subjects with fatty liver disease without NASH (44.5 versus 47.1, P = 0.02). Subjects with cirrhosis had significantly (P < 0.001) poorer physical health scores (38.4) than subjects with no (47.6), mild (46.2), moderate (44.6), or bridging fibrosis (44.6). Cirrhosis was associated with poorer physical health after adjusting for potential confounders. Mental health scores did not differ between participants with and without NASH or by degree of fibrosis.

CONCLUSION

Adults with NAFLD have a significant decrement in QOL. Treatment of NAFLD should incorporate strategies to improve QOL, especially physical health.

Health-related quality of life in methadone maintenance patients with untreated hepatitis C virus infection

OBJECTIVE

To assess health-related quality of life (HRQOL) in methadone maintenance treatment (MMT) patients with untreated chronic HCV infection and to determine the clinical factors that predict HRQOL.

METHOD

HRQOL was measured in 100 MMT patients entering an HCV treatment trial. Subjects were mostly male (61%) and white (81%) with a mean age of 43 (+/-10). 57% had a current non-substance use psychiatric disorder. 55% had a current (past 12 months) substance use disorder, including 44% with current opioid or cocaine abuse/dependence. HRQOL in our sample was compared to published reports for the general population as well as for non-MMT HCV patients. To assess predictors of SF-36 HRQOL, hierarchical multiple regression techniques were used to assess model improvement with four blocks of baseline predictors: Demographics, Medical Severity, Addiction Severity, and Depression Severity.

RESULTS

HRQOL scores were significantly lower than scores for the general population and were also lower than scores reported for untreated HCV patients not in MMT. Regression analysis demonstrated a consistent pattern whereby Depression Severity increased predictive accuracy for HRQOL measures over simpler models. Beck Depression Inventory scores significantly predicted quality of life across both the mental and physical composite scores and all eight sub-scales of the SF-36.

CONCLUSIONS

Untreated HCV patients in MMT had lower HRQOL than HCV patients not in MMT. Depression Severity was associated with significantly lower quality of life measures, suggesting that psychiatric evaluation and intervention prior to the start of HCV treatment may improve overall quality of life and could influence HCV treatment outcomes in MMT patients.

Cultural adaptation and validation of a questionnaire for use in hepatitis B patients

Health-related quality of life (HRQoL) is an important aspect of the overall management of hepatitis B virus (HBV) infection. The major challenge is to find a valid and reliable disease-specific HRQoL instrument designed specifically for measuring health status in hepatitis B patient. Consequently, this study was undertaken to adapt culturally the Hepatitis Quality of Life Questionnaire (HQLQ) and assess its suitability for use in English-speaking hepatitis B virus-infected (HBV) patients in Singapore. Two patient focus groups were conducted to facilitate the cultural adaptation of the HQLQ. Reliability was assessed using Cronbach's alpha coefficients and intraclass correlation coefficients. Item-to-scale correlation was assessed using Spearman's rank correlations (rho) between scale scores and their constituent items. Convergent and divergent construct validities were tested in three and two a priori hypotheses, respectively, and the correlations were assessed using Spearman's rank correlation coefficients (rho). The culturally adapted questionnaire was tested in 298 HBV patients. The test-retest reliability was supported with 10 of the 12 scales showing acceptable correlation coefficients (i.e. alpha>0.7). Item-to-scale correlations were good with most items highly correlated with their hypothesized scales. Convergent and divergent construct validities were supported by the presence of hypothesized correlations between the HQLQ and the EQ-5D domains (eight of 10 sub-hypotheses for convergent construct validity and all hypotheses for divergent construct validity were fulfilled). In conclusion, our results showed that the culturally adapted HQLQ has good validity and reliability, making it a potentially useful outcome measure in the evaluation of HBV patients in Singapore.

Uncertainty, symptoms, and quality of life in persons with chronic hepatitis C

BACKGROUND

Chronic hepatitis C (CHC) is the most common blood-borne infection in the United States, but little is known about illness uncertainty in these patients.

OBJECTIVE

The authors examined the constructs of illness uncertainty.

METHOD

In this cross-sectional study, Mishel's Uncertainty in Illness Scale was used to examine these constructs (ambiguity, complexity, inconsistency, unpredictability) and their relationships with fatigue, pain, depressive symptoms, comorbidity, and quality of life (QOL) in 126 CHC patients undergoing a watchful-waiting protocol.

RESULTS

The Ambiguity subscale had the strongest relationships with depressive symptoms, QOL, and fatigue, and three of the four subscales were significantly correlated with pain.

CONCLUSION

The results suggest targets for patient self-management interventions.

Efficacy and safety of peginterferon alfa-2a/ribavirin in methadone maintenance patients: randomized comparison of direct observed therapy and self-administration

BACKGROUND

Adherence to chronic hepatitis C (CHC) treatment may be particularly challenging in methadone maintenance patients. We assessed the safety, tolerability, and efficacy of peginterferon alfa-2a/ribavirin treatment in methadone maintenance patients previously untreated for CHC.

METHODS

Patients were randomized 1:1 to direct observed therapy (DOT) or self-administration (SA) of peginterferon alfa-2a. DOT patients were seen weekly at methadone clinics; SA patients were seen less frequently, only at investigative sites. Genotype 1-infected patients were treated for 48 wk with peginterferon alfa-2a (180 microg/wk)/ribavirin (1,000/1,200 mg/day); genotypes 2- and 3-infected patients were treated for 24 wk with peginterferon alfa-2a (180 microg/wk)/ribavirin (800 mg/day).

RESULTS

Based on defined efficacy stopping rules, 77% (37/48) completed their targeted length of treatment, and 44% (21/48) achieved sustained virologic response (SVR). Two DOT and 3 SA patients were withdrawn for safety reasons and 6 and 9, respectively, for nonsafety reasons. Over 60% and 50% of each group were >80% compliant with the planned cumulative doses of peginterferon alfa-2a and ribavirin, respectively, and over 60% with overall treatment duration. SVR rates were 54% (13/24) for DOT and 33% (8/24) for SA; 23% (3/13) and 38% (6/16), respectively, for genotype 1 and 91% (10/11) and 25% (2/8), respectively, for genotypes 2 and 3. Stepwise logistic regression analysis, showed that DOT (vs SA; OR 3.27, 95% CI 0.90-11.91, P = 0.073) and Caucasian race (vs Other; OR 13.31, 95% CI 1.42-124.71, P = 0.023) were predictors of SVR.

CONCLUSION

Peginterferon alfa-2a/ribavirin can be used safely and successfully in CHC patients receiving methadone maintenance.

Quality of life, symptomatology and healthcare utilization in HIV/HCV co-infected drug users in Miami

HIV/HCV co-infection is becoming one of the main causes of death in HIV+ persons. We determined quality of life, clinical symptoms and health care utilization in HIV mono-infected and HIV/HCV co-infected chronic drug users. After consenting 218 HIV+ drug users, a physical examination and questionnaires on demographics, quality of life, drugs of abuse, and healthcare utilization were completed. Blood was drawn for HCV status, CD4 cell count, HIV viral load, CBC and chemistry. HIV/HCV co-infected participants had significantly higher risk of having poorer perceived outlook and health, presented significantly more frequent depression and physical symptoms, and used significantly more healthcare services than those infected with HIV only, after adjusting for age, gender, ethnicity, CD4 cell count, and viral load. Diminished quality of life in the HIV/HCV co-infected group was explained by increased frequency of depression, physical symptoms, healthcare utilization, and poor access to HCV treatment in this population.

The impact of chronic hepatitis C and co-morbid illnesses on health-related quality of life

OBJECTIVES

Determine the relative impact of chronic hepatitis C (CHC) and co-morbid illnesses on health-related quality of life (HRQoL) in 3023 randomly selected veterans with known hepatitis C virus antibody (anti-HCV) status who previously completed a veteran-specific HRQoL questionnaire (SF-36V).

METHODS

Multiple regression analyses were performed to measure the relative contribution of anti-HCV status, four demographic variables, and ten common medical and six psychiatric co-morbidities to HRQoL between 303 anti-HCV(+) and 2720 anti-HCV(-) patients.

RESULTS

Anti-HCV(+) veterans were younger, reported a lower HRQoL on seven of eight 36-Item Short Form Health Survey for Veterans (SF-36V) subscales (P < or = 0.001) and the mental component summary (MCS) scale (P < 0.001). The ten medical and six psychiatric co-morbidities had variable impact on predicting lower HRQoL in both groups. After adjusting for demographic variables and co-morbid illnesses, we found that anti-HCV(+) patients reported a significantly lower MCS score (P < 0.001) and a trend toward a lower physical component summary (PCS) score (P < 0.07) compared to anti-HCV(-) veterans. Among the anti-HCV(+) veterans, co-morbid medical illnesses contributed to impaired PCS but not to MCS.

CONCLUSIONS

Veterans with CHC were younger than HCV(-) veterans and hence less likely to have other co-morbid medical illnesses. Medical co-morbidities seen in those veterans with CHC contribute to impaired PCS but not MCS. Anti-HCV(+) status negatively affects HRQoL, particularly MCS, independently of medical and psychiatric co-morbidities.

Health-state utilities in liver disease: a systematic review

OBJECTIVES

Health-state utilities are essential for cost-utility analysis. Few estimates exist for liver disease in the literature. The authors' aim was to conduct a systematic review of health-state utilities in liver disease, to look at the variation of study designs used, and to pool utilities for some liver disease states.

METHODS

A search of MED-LINE, EMBASE, and CINAHL from 1966 to September 2006 was conducted including key words related to liver disease and utility measuring tools. Articles were included if health-state utility tools or expert opinion were used. Variance-weighted mean utility estimates were pooled using metaregression adjusting for disease state and utility assessment method.

RESULTS

Thirty studies measured utilities of liver diseases/disease states. Half of these estimated utilities for hepatitis viruses: hepatitis A (n = 1), hepatitis B (n = 4), and hepatitis C (n = 10). Others included liver transplant (n= 6) and chronic liver disease (n= 5) populations. Twelve utility methods were used throughout. The EQ-5D (n = 10) was most popular method, followed by visual analogue scale (n = 9), time tradeoff (n = 6), and standard gamble (n = 4). Respondents were patients (n= 16), an expert panel (n = 10), non-liver diseases adults ( n=2), patient and expert (n = 1), and patient and healthy adult (n = 1). Type of perspective included community (n=21), patient (n=4), and both (n = 5). The pooled mean estimates in hepatitis C with moderate disease, compensated cirrhosis, decompensated cirrhosis, and post-liver transplant using the EQ-5D were 0.75, 0.75, 0.67, and 0.71, respectively. The change in these utilities using different methods were -0.07 (visual analogue scale), -0.01 (health utilities index version 3), +0.04 (standard gamble), + 0.08 (health utilities index version 2), + 0.12 (time tradeoff), and + 0.15 (standard gamble-transformed visual analogue scale).

CONCLUSIONS

The authors have created a valuable liver disease- based utility resource from which researchers and policy makers can easily view all available utility estimates from the literature. They have also estimated health-state utilities for major states of hepatitis C.

Impairment of health-related quality of life in functional dyspepsia and chronic liver disease: the influence of depression and anxiety

BACKGROUND

Health-related quality of life (HRQOL) is a marker of disease severity. Data on the relative impairment of HRQOL in chronic liver disease (CLD) and functional gastrointestinal disorders are lacking and no studies have assessed the link between impairment of HRQOL and psychosocial factors yet.

AIM

To assess predictors for, and the impairment of, HRQOL in CLD and FD.

METHODS

In 181 functional dyspepsia (FD) patients, 204 CLD patients and 337 healthy blood donors, HRQOL was assessed with the Short Form-36 (mental and physical component), and anxiety and depression utilizing the Hospital Anxiety and Depression Scale.

RESULTS

Compared with HC, HRQOL is significantly lower in FD and CLD (P-value for all <0.001). The mental but not physical component of HRQOL was significantly more impaired in FD compared with CLD (P < 0.05). After adjusting for confounders, impairment of mental (P < 0.001) and physical (P = 0.005) component of HRQOL was associated with the severity of CLD and FD. In FD, the multivariate analysis revealed depression and severity of symptoms as the most important predictors of HRQOL (R2 = 21.9 and 7.1). In CLD, the mental component of HRQOL was associated with depression and anxiety (R(2) = 9.9 and 9.7).

CONCLUSIONS

In tertiary care, HRQOL is more severely impaired in FD compared with CLD. Co-morbid psychiatric conditions significantly contribute to the impairment of HRQOL.

Impairments in fine-motor coordination and speed of information processing predict declines in everyday functioning in hepatitis C infection

Research increasingly supports the neurovirulence of chronic infection with the hepatitis C virus (HCV). For example, HCV infection has been associated with neuropsychological impairment in several ability areas, including psychomotor skills. This study aimed to examine whether HCV-associated neuropsychological impairment is predictive of declines in the independent performance of physical (PADLs) and instrumental (IADLs) activities of daily living. A total of 106 volunteers with HCV infection completed a comprehensive neuropsychological, medical, and psychiatric research evaluation. As compared to 30 HCV-seronegative comparison participants, the HCV-infected group reported significantly greater declines in both PADLs and IADLs. Within the HCV cohort, individuals with impaired speed of information processing reported significantly greater IADL declines, whereas impaired fine-motor coordination was associated with declines in both IADLs and PADLs. In a series of regression analyses, impaired speed of information processing and depressive symptoms (as measured by the Beck Depression Inventory) were the only independent predictors of IADL declines, whereas general affective distress (as measured by the Profile of Mood States), sex, and fine-motor coordination impairment were predictive of declines in PADLs. Although the clinical assessment of HCV typically emphasizes both affective (e.g., depression) and physical factors, findings from the present study suggest that cognitive impairment is an important contributor to everyday functioning in persons living with HCV infection and therefore warrants consideration in clinical and research evaluations.

[Self-assessed pain intensity and disability in subjects diagnosed with fibromyalgia claiming retirement pension]

INTRODUCTION

The clinical experience that subjects claiming retirement pension tend to aggravate their symptoms in psychometric tests has not yet, to our knowledge, been empirically tested.

METHODS

Pain intensities and the summary score of the Pain Disability Index (PDI) of 83 consecutive subjects diagnosed with fibromyalgia syndrome (FMS) claiming retirement pension in medical assessment for the German Social Court were compared with 43 consecutive patients diagnosed with FMS of an outpatient pain department who did not claim retirement pension. Moreover, the relative predictive value of claiming retirement pension compared to other potential sociodemographic and clinical predictors of pain intensity and self-assessed disability was determined.

RESULTS

Subjects claiming retirement pension within the context of medical testimony stated higher pain intensities and disabilities than patients who did not claim retirement pension (P<0.01 in all cases). Claiming disability pension was an independent predictor of minimum pain intensity (r(2)=0.10, P=0.02), of maximum pain intensity (r(2)=0.16, P=0.002) and of the summary score of the PDI (r(2)=0.08, P=0.008).

CONCLUSIONS

The association between claiming retirement pension and high self-assessed pain and disability should be kept in mind in the context of pain therapy as well of medical expertise.

Therapy expectations and physical comorbidity affect quality of life in chronic hepatitis C virus infection

Hepatitis C virus (HCV) infection is associated with a significant reduction of health related quality of life (QOL), the causes and mechanisms of which are still unknown. To explore whether treatment history could affect QOL, we examined patients with detectable HCV viraemia who had a different therapeutic background. Two hundred sixty-four consecutive subjects with chronic HCV infection and detectable viraemia were enrolled. Of these, 163 were untreated patients, 43 were relapsers, 58 were nonresponders (NR) to nonpegylated interferon (IFN) therapy. To assess QOL, three self-report instruments were employed: the Short Form-36 (SF-36), the Chronic Liver Disease Questionnaire (CLDQ-I) and the World Health Organization Quality of Life assessment (WHOQOL-BREF). Clinical and demographic data were collected, and the QOL scores of HCV-positive patients were compared with those of an Italian normative sample and healthy controls. Further antiviral treatment was offered to untreated and relapsed patients but not to NR. All patient groups displayed lower QOL scores compared with the normative sample and controls. NR displayed lower QOL scores in several areas compared with untreated patients and relapsers. In multivariate regression analyses, being NR and having a physical comorbidity were significantly associated with poorer QOL.

CONCLUSIONS

Treatment history and expectations and physical comorbidity may affect QOL in HCV-positive patients. Untreated and relapsed patients have comparable levels of QOL and higher scores than NR.

Health-related quality of life in patients with chronic hepatitis B

Although chronic hepatitis C (CH-C) has consistently been shown to impair patients' health-related quality of life (HRQL), the impact of chronic hepatitis B (CH-B) on HRQL has not been fully explored.

AIM

Compare HRQL between patients with CH-B, CH-C, primary biliary cirrhosis (PBC) and healthy controls.

DESIGN

Three HRQL questionnaires [Chronic Liver Disease Questionnaire (CLDQ), Short Form 36 (SF-36) and the Health Utility Index (HUI Mark-2 and Mark-3)] were administered prospectively. Additional clinical and laboratory data and normative data for healthy individuals, were available.

ANALYSIS

Scores were compared using analysis of variance and multiple regression.

RESULTS

One hundred and forty-six patients with CH-B, CH-C and PBC were included [mean age 47.1 years (+/-11.6), 41% female, 33% cirrhosis]. CH-C and PBC patients scored the lowest on all CLDQ, SF-36 and HUI domains compared with CH-B patients and healthy controls. CH-B patients had scores similar to the healthy population, measured by most CLDQ and SF-36 scales. However, the HUI scores for CH-B patients showed more impairment than population norms. Having CH-B and not having cirrhosis were predictive of utility and HRQL scores in multivariate models.

CONCLUSIONS

CH-B patients have better HRQL than CH-C, PBC and population norms. CH-B patients' overall utility scores are lower than population norms.

Health-related quality of life in patients with non-alcoholic fatty liver disease

BACKGROUND

The relative impact of non-alcoholic fatty liver disease (NAFLD) on health-related quality of life (HRQL) compared to other chronic liver diseases has not been fully explored.

AIM

To compare the domain scores of the 29-item Chronic Liver Disease Questionnaire (CLDQ) for patients with NAFLD to those with chronic hepatitis B and chronic hepatitis C.

METHODS

A HRQL questionnaire, CLDQ, was routinely administered to patients attending a liver clinic. Additional clinical and laboratory data were obtained on patients with NAFLD, chronic hepatitis B, and chronic hepatitis C from our quality of life database. Scores for each of the six CLDQ domains were compared using one-way anova and multiple regression.

RESULTS

Complete data were available for 237 patients. NAFLD patients scored lowest on multiple CLDQ domains. Based on the bivariate data, NAFLD patients have the poorest HRQL, followed by chronic hepatitis C and chronic hepatitis B patients. Multivariate analysis showed that some specific domain score correlations remained significant for NAFLD diagnosis, cirrhosis, gender, and body mass index.

CONCLUSION

NAFLD patients had significantly lower quality of life scores compared with patients with hepatitis B or hepatitis C on multiple CLDQ domains, suggesting that HRQL was severely impaired in patients with NAFLD.

Predictors of irritable bowel-type symptoms and healthcare-seeking behavior among adults with celiac disease

OBJECTIVES

To assess the frequency of irritable bowel syndrome (IBS)-type symptoms and consecutive healthcare-seeking behavior, their impact on health-related quality of life (HRQOL), and their possible biopsychosocial determinants in adult patients with celiac disease (CD).

METHODS

A total of 1000 adult patients with CD from the German Celiac Society completed a medical (including bowel) and a sociodemographic questionnaire, the Short Form Health Survey (SF-36), and the Hospital Anxiety and Depression Scale through a postal survey.

RESULTS

Of 412 respondents with reported biopsy-proven diagnosis with major adherence to a gluten-free diet (GFD) for > or =1 year, 96 (23.3%) patients fulfilled the modified Rome I criteria for IBS. Of these 96 patients, 76 (79.2%) sought help (medical and/or nonmedical) due to bowel symptoms (referred to as patients with IBS). IBS-type symptoms had a significant negative impact on the physical summary score of the SF-36 (p = .05). Mental disorder (OR = 2.29; beta = 0.83; p = .006); female sex (OR = 2.34; beta = 0.85; p = .03), and occasional nonadherence to GFD (OR = 1.74; beta = 0.56; p = .05) were risk factors for IBS-type symptoms. Active medical comorbidities predicted IBS-patient status (OR = 0.40; beta = -0.92; p = .001).

CONCLUSIONS

The data support the biopsychosocial model of IBS: IBS-type symptoms in adult patients with CD can be explained through an interaction of clinical and sociopsychological mechanisms.

Psychiatric morbidity and its effect on the quality of life of patients with chronic hepatitis B and hepatitis C

OBJECTIVE

The primary aim of our study was to determine the prevalence of psychiatric morbidity in a cohort of consecutive chronic hepatitis patients not receiving antiviral therapy. The secondary aim of our study was to determine if psychiatric morbidity, type of hepatitis, and the level of depression correlated with health-related quality of life (HRQL).

METHODS

The study was conducted in collaboration with Hepatology and Infectious Disease Clinics at three-major university hospitals. One hundred seven patients who met the criteria for being diagnosed with either chronic hepatitis B or C, had non-cirrhotic compensated liver disease, had not received antiviral treatment in the preceding 6 months, and had no accompanying physical illness were included in the study. The Structured Clinical Interview for DSM-IV Axis I Disorders, the Short Form--36 for measuring HRQL, and semi-structured interviews for assessing psychosocial variables were used. Sixty-seven healthy adults formed the control group.

RESULTS

43.9% of the patients had hepatitis B, 56.1% hepatitis C. A psychiatric diagnosis was made in 48.6%, of which 15% was depression. No significant difference was found in the rate of psychiatric diagnosis between hepatitis B and hepatitis C patients. Hepatitis B and C patients were found to vary significantly (p < 0.001) from the control group on all subcategories of quality of life criteria. Psychiatric morbidity (mainly depression) was the major variable on lowering HRQL (p = 0.000).

CONCLUSIONS

Chronic hepatitis B and C patients presented a high rate of psychiatric disorder. HRQL was significantly decreased in patients with psychiatric morbidity.

The effects of HCV infection and management on health-related quality of life

Infection with HCV leads to an array of symptoms that compromise health-related quality of life (HRQL). Chronic hepatitis C is treated primarily with pegylated interferon (peg-IFN) and an inosine 5' monophosphate dehydrogenase inhibitor, ribavirin (RBV), with the goal of achieving a sustained virologic response (SVR). SVR reduces the rate of hepatic fibrosis and other disease-related complications and, in turn, increases HRQL. Although combination therapy with peg-IFN and RBV produces SVRs in more than 50% of treated patients, it is associated with side effects that can reduce short-term HRQL, can lead to dose reductions and discontinuations, and may impair treatment response. Fatigue and depression are common symptoms of chronic HCV infection that may also be caused by IFN-based therapy. Hemolytic anemia and IFN-mediated bone marrow suppression are well-known consequences of IFN/RBV therapy, often resulting in dose reductions or discontinuations, and have the potential to affect SVR rates. Management of these symptoms is vital to successful outcomes and generally relies on therapy that is adjunctive to the primary treatment of the viral infection itself. Several new drugs with the potential to increase SVR rates without compromising HRQL are in development.

CONCLUSION

The relationship of chronic HCV infection, treatment, and HRQL is complex. Successful treatment of chronic hepatitis C requires an understanding of the intricacies of this relationship and appropriate management of treatment-related symptoms.

Health-related quality of life in patients with chronic hepatitis C and advanced fibrosis

BACKGROUND/AIMS

Although the antiviral and histological benefits of peginterferon/ribavirin therapy are well established, the effects on health-related quality of life (HRQOL) and sexual health are less certain. This study assessed HRQOL and sexual health in patients with advanced fibrosis or cirrhosis in the HALT-C Trial.

METHODS

Subjects completed SF-36 and sexual health questionnaires prior to and after 24 weeks of peginterferon/ribavirin therapy (n=1144). Three hundred and seventy-three (33%) subjects were HCV RNA negative at week 20 and continued therapy through week 48; 258 were seen at week 72. One hundred and eighty achieved sustained virological responses (SVR) and 78 relapsed.

RESULTS

At baseline, patients had poorer scores for all eight SF-36 domains compared to healthy controls. Patients with cirrhosis had lower HRQOL scores than those with bridging fibrosis, as did patients with higher depression scores. SVR patients had significant improvements in seven domains, whereas relapsers had significant worsening in one domain. Sexual scores improved in SVR patients and decreased in relapsers (p=0.03). In multivariate analyses, improvements in HRQOL and sexual scores were significantly associated with SVR but were less striking in patients with lower depression scores.

CONCLUSIONS

Achievement of SVR after peginterferon/ribavirin therapy improves HRQOL and sexual health in chronic hepatitis C patients with advanced fibrosis or cirrhosis.

Predictors of reduced health-related quality of life in adults with coeliac disease

BACKGROUND

Data available on predictors of reduced health-related quality of life in coeliac disease are not consistent.

AIM

To test predictors of reduced health-related quality of life, described in the literature, by a multivariate approach.

METHODS

1000 adult coeliacs of the German Coeliac Society completed a medical and a sociodemographic questionnaire, the Short-Form Health Survey (SF-36), the Coeliac Disease Questionnaire and the Hospital Anxiety and Depression Scale within a postal survey. Predictors of reduced health-related quality of life were tested for by logistic regression analysis.

RESULTS

Physical comorbidities (beta = -0.41; OR = 0.66, P < 0.001) and mental disorder (beta = 0.88; OR = 2.4, P = 0.03) were associated with a reduced physical summary score of the SF-36. Mental disorder (beta = 2.5; OR = 11.9, P < 0.001), physical comorbidities (beta = -0.26; OR = 0.77, P = 0.004) and younger age at diagnosis (beta = -0.10; OR = 0.91, P = 0.05) predicted a reduced mental summary score of the SF-36. Mental disorder (beta = 0.90; OR = 2.5, P = 0.03), non-compliance with gluten-free diet (beta = 0.44; OR = 1.6, P = 0.009), active medical comorbidities (beta = -0.28; OR = 0.76, P = 0.007) and dissatisfaction with doctor-patient communication (beta = 0.55; OR = 1.7, P = 0.03) were associated with reduced Coeliac Disease Questionnaire scores.

CONCLUSIONS

Reduced health-related quality of life in coeliac disease is associated not only with physical and mental comorbidities, but also with non-compliance with gluten-free diet and dissatisfaction with doctor-patient communication.

Clinical Relevance of Cognitive Scores in Hepatitis C Patients with Advanced Fibrosis

Mild neuropsychological impairment has previously been reported in chronic hepatitis C (CHC) patients. The aim of this study was to assess the presence and severity of cognitive impairment among a cohort of CHC patients with advanced fibrosis using clinician ratings compared to classification based upon statistical methods. In addition, we set out to determine the relationship between cognitive scores and functional status. Two experienced neuropsychologists provided "clinician ratings" on a battery of 10 neuropsychological tests performed in 100 randomly selected patients participating in the HALT-C clinical trial. The overall kappa between the 2 graders on level of impairment was 0.59. Clinician ratings (the gold standard) were similarly sensitive to identifying cognitive impairment as was classification based on standard scores (44% vs. 40%). Global Deficit Scores (GDS), derived from pooling standard scores, also identified 44% of patients as having mild impairment and were highly correlated with clinician ratings (r = .81 p = < 0.0001). Neither clinician ratings nor deficit scores correlated with SF-36 subscale or summary scores but did correlate with depression scores (p < .0007). In summary, clinician ratings and deficit scores identified a similar prevalence of cognitive impairment amongst CHC patients with advanced fibrosis. There was a significant correlation between cognitive impairment and self-reported depression.

Development and validation of the Celiac Disease Questionnaire (CDQ), a disease-specific health-related quality of life measure for adult patients with celiac disease

BACKGROUND AND GOALS

To develop and validate a disease-specific instrument for measuring health-related quality of life (HRQOL) in patients with adult celiac disease (CD).

STUDY

Based on a Medline search of the literature, responses from 10 CD patients and 4 medical experts items potentially affecting HRQOL in CD were identified. This pool was reduced and pretested by 10 other patients and 4 medical experts constructing a preliminary version of the Celiac Disease Questionnaire (CDQ). In a national survey involving 522 respondents of 1000 CD patients (median age 45 y; 78% female) posted by the German Celiac Society completed a medical and sociodemographic questionnaire, the CDQ, the Short Form Health Survey (SF-36), the Hospital Anxiety and Depression Scale German Version HADS-D and the Giessener Symptom List (GBB 24). Subscales were constructed by a principal factor analysis following predefined criteria and validated with other HRQOL measures. Forty-seven out of one hundred patients answered the CDQ a second time 4 weeks after the first posting for the assessment of test-retest reliability.

RESULTS

The factor analysis suggested 4 domains with 7 items each: emotional and social problems, disease-related worries, and gastrointestinal symptoms. The Cronbach alpha for the subscales ranged from 0.80 to 0.91. Test-retest reliability correlations ranged from 0.45 to 0.89. The correlation coefficients with comparable subscales of other instruments ranged between 0.26 and 0.79. The CDQ discriminated in all subscales patients with CD-associated diseases from patients without CD-associated diseases (P<0.001).

CONCLUSIONS

The CDQ is an instrument suited for future use in clinical and research settings.