Impact of physical and psychological factors on health-related quality of life in adult patients with liver cirrhosis: a systematic review protocol

REVIEW QUESTION/OBJECTIVE

What is the impact of physical and psychological factors on health-related quality of life in adult patients diagnosed with liver cirrhosis?

BACKGROUND

All chronic liver diseases stimulate a degree of repetitive hepatocyte injury that alters the normal liver architecture and ends in cirrhosis.Liver cirrhosis and hepatocellular carcinoma secondary to livercirrhosis are a major public health burden, reporting increasing mortality and morbidity both in Australia and globally.The four leading causes of cirrhosis include harmful alcohol consumption, viral hepatitis B and C and metabolic syndromes related to non-alcoholic fatty liver disease and obesity.A cirrhotic liver is characterized by the presence of regenerative nodules surrounded by fibrous bands that inhibit the passing of molecules between blood and functional units of liver hepatocytes, leading to liver dysfunction.Additionally, the presence of fibrous bands disrupts the normal vascular architecture, increasing resistance within the liver sinusoids and contributing to increased portal vein pressure.The early stages of cirrhosis are referred to as compensated liver disease with no reported symptoms or evidence of impaired liver function.However, the signs and symptoms of liver failure, as well as the mortality rate, increase as the severity of cirrhosis increases.Transition from compensated to decompensated cirrhosis is marked by one or more physiological changes. The physiological changes include increased portal vein pressure, impaired synthetic function, electrolyte imbalance and malnourishment.These physiological changes trigger the development of physical signs and symptoms and impact on the psychological wellbeing of the individual living with cirrhosis. The physical signs and symptoms include esophageal varices, ascites, hepatic encephalopathy, jaundice, irregular sleep patterns, muscle cramps, pruritus, fatigue, impaired mobility, breathlessness, abdominal discomfort, gastrointestinal symptoms, change of body image and pitting edema.Psychological symptoms include stress, depression and anxiety.Living with liver cirrhosis has a marked impact on the quality of life of the individual. Health-related quality of life (HRQOL) is the individual's perception of their physical, cognitive, emotional and social functioning.Studies report that physical and psychological factors affect the quality of life of patients with cirrhosis which can be problematic and debilitating.There is strong evidence which indicates that disease severity is associated with an impairment of the patient's HRQOL.For example, gross ascites causes abdominal discomfort, breathlessness, increased stress and anxiety related to body image, immobility and an increased likelihood of falls. In addition, the management of ascites involves frequent invasive procedures, an increase in pill burden and implementation of dietary restrictions, all of which impact on HRQOL.Despite the clear relationship between HRQOL and severity of disease, there has been no systematic review undertaken to determine the physical, psychological and physiological factors that affect the HRQOL of patients with liver cirrhosis. This systematic review will therefore identify the best available evidence related to the impact of physical, psychological and physiological factors on the health-related quality of life of adult patients with liver cirrhosis. The results of the review will increase clinicians' knowledge and highlight areas of clinical management that may require additional strategies and treatment plans to improve symptom relief and HRQOL.

Factors associated with medication adherence in patients living with cirrhosis

AIMS AND OBJECTIVES

Medication adherence in people with cirrhosis is largely unknown. This study aims to determine adherence patterns and factors associated with adherence in patients with cirrhosis.

BACKGROUND

Prescribed medications are a pivotal component in the clinical management of cirrhosis with potential to retard disease progression and reduce complication risks. Medication adherence is necessary to optimise health outcomes. Understanding why medications are missed may help to develop strategies and inform nursing practice.

DESIGN

Prospective cohort study.

METHODS

Participants (n = 29) diagnosed with cirrhosis attending a tertiary hospital consented to complete a self-reported survey. Demographic information, adherence to medications, patient knowledge and quality of life data were collected, collated, checked and analysed using SPSS version 21.

RESULTS

Less than half of the 28 patients who completed the adherence questionnaire (n = 13, 46%) reported that they had never missed medication. Being forgetful, being away from home and falling asleep contributed to nonadherence. Having less abdominal symptoms, less fatigue and increased emotional well-being were significantly associated with patients never missing medications.

CONCLUSIONS

To our knowledge this is the first published study to describe adherent behaviour and the reasons medications are missed in this population. The percentage of nonadherent participants is of concern considering the potential morbidity risk that is associated with missed medications and rebound symptoms of cirrhosis. Strategies to improve and sustain adherence levels are required including enhanced adherence counselling offered to patients who are deteriorating or experience periodic exacerbation of symptoms.

RELEVANCE TO CLINICAL PRACTICE

Study findings have the potential to change clinical practice especially the way nurses target motivational adherence counselling, key treatment messages, education and adherence monitoring. The results presented here provide a basis for developing adherence strategies and nursing management plans to improve adherence and health outcomes in people with cirrhosis.

Childhood hepatitis C virus infection: An Australian national surveillance study of incident cases over five years

AIM

An estimated 1.1% of Australian adults are infected with hepatitis C virus (HCV). Many develop chronic liver disease, and some develop liver failure or hepatocellular carcinoma. HCV infection in Australian children is poorly defined. We aimed to determine the reported incidence, clinical and epidemiological features of newly diagnosed HCV infection in Australian children presenting to paediatricians.

METHODS

We undertook prospective active national surveillance, using the Australian Paediatric Surveillance Unit, of incident HCV cases in children aged <15 years between 1(st) January 2003, and 31(st) December 2007.

RESULTS

There were 45 confirmed cases of newly diagnosed HCV infection over five years (<1 per 100,000 children aged <15 years per year). Median age at diagnosis was 2.9 years. Positive maternal HCV serostatus was the most frequent reported risk factor for HCV infection in children (40/45). Three children (all aged > 14), were exposed through their own IV drug use. No children were co-infected with HIV and only one child was co-infected with HBV. All children were asymptomatic at diagnosis, although many had minor elevations in liver transaminases. Many clinicians reported difficulties with follow-up.

CONCLUSIONS

Childhood HCV infection is uncommon in Australia, although our data likely underestimate the incidence. Only a small number of children aged <18 months was identified, despite known perinatal exposure. Opportunistic investigation of children at risk for HCV, improved education regarding vertical transmission for health care providers, and increased coordination of childhood HCV services are required to improve recognition and management of children with HCV.

Spontaneous Clearance of Hepatitis C Virus during Pregnancy

Spontaneous clearance of hepatitis C virus (HCV) is expected to be unlikely in pregnancy due to the relative immunosuppression and increase in viraemia that occurs. We report the first case of spontaneous clearance of hepatitis C virus (HCV) occurring in pregnancy.

Risk factors and seroprevalence of markers for hepatitis A, B and C in persons subject to homelessness in inner Sydney

OBJECTIVE

To determine the seroprevalence of hepatitis A, B and C and the prevalence of risk factors for blood-borne infections in persons subject to homelessness attending a medical clinic in inner Sydney.

METHOD

During 2003-05, 201 clients were enrolled in a prospective study to determine the acceptance, completion rates and immunogenicity of the standard vaccination schedule for hepatitis A and B. On enrolment, clients completed a risk factor assessment questionnaire and undertook pre-vaccination serological screening for hepatitis A, B and C.

RESULTS

Forty-five per cent (85/188) of clients were positive for anti-HCV antibodies; 32% (60/189) showed evidence of past infection with HBV (anti-HBc); and 48% (89/189) were positive for anti-HAV antibodies. It was not uncommon for clients to have multiple markers of hepatitis. A past history of injecting drug use was significantly associated with markers for hepatitis B and C; age predicted presence of anti-HAV. A verbal history of infection appeared more reliable for hepatitis C, but considerably less so for hepatitis A and B.

CONCLUSION

Persons subject to homelessness are at risk of blood-borne infection. The seroprevalence of markers for hepatitis B and C are higher than in the general population.

IMPLICATIONS

Despite the high proportion of clients with serological markers for hepatitis A and B, at least 69% of clients could potentially benefit from hepatitis A and/or B vaccination.

Proteolytic cleavage and activation of pro-macrophage-stimulating protein and upregulation of its receptor in tissue injury

Macrophage stimulating protein (MSP) exists in blood as inactive pro-MSP. Cleavage yields active MSP, the ligand for a membrane receptor (RON) that is expressed on keratinocytes as well as macrophages. Because both cells have roles in tissue injury, we looked for active MSP and expressed RON in wounds. Concentration of pro-MSP + MSP in wound exudates was in the range for optimal activity. Western blot showed that MSP comprised about half the total, in contrast to less than 10% of the total in blood plasma. The presence of MSP was attributed to an exudate pro-MSP convertase that had an inhibitor profile consistent with a trypsin-like serine protease. Exudate evoked morphologic changes in macrophages in vitro like that of MSP. Removal of this activity by an anti-MSP column shows that exudate stimulation of macrophages is due to MSP. RON was infrequently detected in normal skin. RON protein was markedly upregulated in burn wound epidermis and accessory structures, in proliferating cells or differentiated cells, or both. RON was also detected on macrophages and capillaries. Tissue injury leads to cleavage of pro-MSP to MSP, which has potential to act on keratinocytes, macrophages, and capillaries, all components of the wound healing response.