Heath literacy, illness perception and NAFLD/NASH awareness in primary care patients in Crete, Greece

Background and Aims

Patient health literacy (HL), illness perception and awareness are key factors driving health behaviour. This observational study aims to assess the level of HL, illness perception and awareness about non-alcoholic fatty liver disease (NAFLD)/steatohepatitis (NASH) in high-risk primary care (PC) patients in Greece, Spain and the Netherlands.

Methods

Eligibility criteria included: 1) aged ≥50 years, and 2) obesity, and/or metabolic syndrome, and/or diabetes. Patients consecutively visiting PC practices completed a questionnaire assessing socio-demographic characteristics and health habits. HL, illness perception and NAFLD/NASH awareness were assessed using the European Health Literacy Survey Questionnaire, the Brief Illness Perception Questionnaire and the Public Awareness of NAFLD Questionnaire respectively.

Results

Data are available at this moment from the Greek setting. Among the Greek participants (N = 141, 53.2% females, mean age 66 years) 66.7% had diabetes, 78% obesity and 71.6% metabolic syndrome, with 22.7% reporting active smoking. Most (71.6%) had heard about NAFLD by their personal physician. Obesity (78%), excess alcohol intake (45.8%), lack of exercise (38.7%) and diabetes (32.4%) were recognized as the commonest determinants of fatty liver disease, while 78% were aware of ultrasound as the main diagnostic modality and 47% did not know whether there is an available treatment. Only 39% of the participants find information of their treatments easily.

Conclusions

Our preliminary results show that the majority of patients seem to be aware about NAFLD/NASH and their determinants. It's alarming that a lot do not know about treatment, although they are high-risk.

Key messages

Our preliminary results show that the majority of patients seem to be aware about NAFLD/NASH and their determinants. It’s alarming that a lot of patients do not know about their treatment, although they are high-risk.

Cirrhosis patients have a coagulopathy that is associated with decreased clot formation capacity

BACKGROUND

The coagulopathy in cirrhosis is associated with thrombosis and bleeding.

OBJECTIVES

To gain better insights into the coagulopathy in patients with cirrhosis, we evaluated plasma thrombin generation and whole blood clot formation in a cross-sectional study.

METHODS

Blood was collected from 73 patients with all-cause cirrhosis (Child-Pugh-A n = 52, B n = 15, C n = 6) and 20 healthy controls. Activity of the coagulation pathways was measured with assays for factor (F) VIIa and FIXa-antithrombin and FXa-antithrombin complexes, respectively. Thrombin generation by calibrated automated thrombography was determined in platelet-poor plasma using a 1 or 5 pm tissue factor trigger with/without thrombomodulin. ROTEM measurements were performed in whole blood triggered with 35 pm tissue factor without/with 175 ng mL(-1) tissue plasminogen activator (the latter refered to as 'tPA-ROTEM').

RESULTS

We observed an increased generation of FVIIa and a moderately elevated amount of FIXa (in complex with antithrombin) without apparent increase in FX activation in patients with cirrhosis. In accordance with this prothrombotic state, markers of thrombin generation potential were also increased upon increasing severity of cirrhosis. In the whole blood clotting assay we observed delayed clot formation and decreased clot strength associated with increased severity of cirrhosis. No significant differences were found for tPA-ROTEM parameters of clot degradation.

CONCLUSION

These results indicate that cirrhosis patients have an overall procoagulant plasma milieu but a decreased whole blood clot formation capacity with an apparently unaltered resistance to clot lysis.

Gastroesophageal reflux disease poorly responsive to single-dose proton pump inhibitors in patients without Barrett's esophagus: acid reflux, bile reflux, or both?

OBJECTIVES

Studies using ambulatory pH and esophageal bile reflux monitoring (Bilitec) have shown that both acid reflux and duodeno-gastro-esophageal reflux (DGER) frequently occur in patients with gastroesophageal reflux disease (GERD). A subset of patients with GERD has persistent reflux symptoms in spite of standard doses of proton pump inhibitors (PPIs). The aim of the present study was to investigate the role of acid and DGER in patients with reflux disease poorly responsive to PPIs.

METHODS

Sixty-five patients (32 men, 44 +/- 2 yr) without Barrett's esophagus and with persistent heartburn or regurgitation during standard PPI doses were studied. They underwent upper gastrointestinal endoscopy and simultaneous 24-h ambulatory pH and Bilitec monitoring while PPIs were continued.

RESULTS

Thirty-three patients (51%) had persistent esophagitis. Seven patients (11%) had only pathological acid exposure, 25 (38%) had only pathological DGER exposure, and 17 (26%) had pathological exposure to both acid and DGER. Acid exposure under PPI was positive in only 37%, but adding Bilitec increased the diagnoses of persistent reflux to 75%. Patients with persistent esophagitis had similar acid exposure, but significantly higher DGER exposure than those without esophagitis. The highest prevalence of esophagitis was found in patients with pathological exposure to both acid and DGER; symptoms did not differ according to the type of reflux.

CONCLUSIONS

Combined pH and Bilitec monitoring is superior to pH monitoring alone in demonstrating ongoing pathological reflux in patients with medically poorly responsive reflux disease.

Analysis of ambulatory duodenogastroesophageal reflux monitoring

Some methodological in vitro observations concerning bile reflux monitoring (Bilitec) suggested that Bilitec monitoring is underestimating reflux in an acid environment. Moreover, other studies showed that the area above the cutoff level of bilirubin absorbance would provide an adequate quantitative marker for reflux of duodenal contents. Our aim was to study whether correction for intraesophageal acidity and the area above cutoff during Bilitec monitoring affects the results and the correlation with pH measurement and esophageal lesions. In 84 patients (46 men; mean age 46 +/- 2.7 years) evaluated for suspected gastroesophageal reflux disease, we performed ambulatory 24-hr esophageal pH and Bilitec monitoring after an upper gastrointestinal endoscopy. We obtained total area, percent total time, and correction by computer software. The correction factor for bilirubin absorbance was based on literature data for acidified bile (0.06 for pH < 3.6; 0.21 for pH < 2.6). Endoscopy revealed esophagitis grade 1-2 (E1-2) and 3-4 (E3-4) in 23 and 16 patients, respectively. A progressive increase of mixed (acid + bile) reflux occurred with increasing severity of endoscopic lesions (E3-4 vs no esophagitis, P < 0.05). A pathologic Bilitec monitoring result was present in the same 35 patients before and after correction and the correlation between the pH measurement and percent time of bile reflux was not improved by correction for intraesophageal pH (r = 0.386 and r = 0.391; P < 0.05). The total area of bilirubin absorbance above 0.14 (abs x min) was 7.8 +/- 2.2 in patients without esophagitis, and 11.7 +/- 4.4 and 17.0 +/- 4.2 in the E1-2 and E3-4 groups, respectively (E3-4 vs no esophagitis, P < 0.05). The correlation between the Bilitec monitoring and pH measurement regarding percent (r = 0.427, P < 0.01) or area of time below 4 (r = 0.280, P < 0.05) was not improved by considering the area of bilirubin absorbance above the cutoff level. Correction for intraesophageal pH has only a minor effect on the results of ambulatory Bilitec monitoring. Taking into account the surface rather than the percent of time above the cutoff level for bilirubin absorbance does not improve the correlation of Bilitec with acid reflux and with esophageal lesions.