Sunday Poster Sessions, October 29, 2006

Behavioral, Quality of Life, and Practice Issues

 

501. Behavior, Knowledge and Relationship: Results of a Peer Education Program in a County Correctional Facility.

D. M. Zucker.

 

Purpose:

The purpose of this study was to test a relationship-centered model of hepatitis C educational communication with incarcerated former injection drug users, using a peer education approach, based on mutual support, trust and equality.

 

Aims:

The aims of this study were to:

1.     Convey education about prevention, protection and safety related to HCV,

2.     Provide this information through relations-centered communication,

3.     Test the reliability and validity of the behavior, knowledge and relationship instruments, and

4.     Evaluate the effectiveness of this intervention by measuring changes in behavior, knowledge and relationship in the learner.

 

The long term goal of this work is to prevent the spread of HCV in the community focusing on those most at risk of spreading and contracting the disease.

 

Methods:

This study is a prospective pretest post-test descriptive pilot. A convenience sample of 30 male incarcerates participated. A hepatitis C prevention and harm reduction manual was co-created by inmates and health care providers for the peer education curriculum.

 

Evaluation:

To measure aim 1, the PI and addictions specialist used teaching scripts focused on prevention, protection and safety based on CDC guidelines and teaching materials. To measure aim 2, the Each One Teach One theory and method was used. The teacher measures three component parts; teaching, observation and feedback. Mutual support, trust and equality are measured as positive responses to relationship questions. To measure aim 3, alpha reliabilities are calculated using the Statistical Package for the Social Sciences (SPSS v 13) for each item and the entire instrument. To measure aim 4 all data will be analyzed using SPSS. Correlations between pre and post-test scores are calculated. To measure behavior and relationship learners’ scores will reflect at least a mean of 6 on those questions reflecting positive behaviors and relationships. To measure knowledge it is expected the learner will score 100% on knowledge questions.

Results:

Knowledge questions:

Pretest cumulative correct 71.4%

Post test cumulative correct 88.9%

 

Discussion:

This pilot project has significance because:

1)     It utilized an innovative, relationship-based form of communication based on Each One Teach One theory.

2)     This method is consistent with successes seen in similar peer-led initiatives.

3)     Teaching is tailored to the at-risk group and the messages are taught by peers in the learner’s everyday language.

4)     Behavior, knowledge and relationship questions evaluate the 3 main problems associated with the target population: spreading the disease, maintaining good health and preventing liver damage.

 

Conclusions:

This study has significance because it utilized an innovative, relationship-centered form of communication based on EOTO and relations common theories.  Behavior, knowledge and relationship instruments evaluated HCV prevention, protection and safety, and were found to be moderate to very strong.  Preliminary data is trending towards an increase in healthy behaviour and relationship after engaging in a 6 week HCV prevention and harm reduction curriculum.  The curriculum should be part of an overall assessment of wellness in incarcerates ready for release.

 


502. Simultaneous Provision of Pre-operative Palliative Care for Patients Awaiting Liver Transplantation.

V. Medici; J. Nakai; K. Fisher; L. Rossaro; F. J. Meyers.

 

Background

The primary goal of hospice care is the palliation of physical and emotional suffering of terminally ill patients. Liver transplant (LT) candidacy and enrollment in hospice care have always been perceived as mutually exclusive. We have previously reported a case of combined provision of pre-operative palliative care through hospice for patients awaiting LT (Rossaro, et al. Transpl Int (17: 473-75; 2004). We hypothesize that patients with end stage liver disease (ESLD) could make improve use of hospice to deliver palliative care.

 

Aims/Methods:

This is a four-year retrospective analysis on patients with ESLD admitted to hospice at UC Davis Health System. We recorded the MELD score at hospice referral, at listing for LT, and at the time of LT, using a minimum score of 17 for hospice referral. Our goal was to provide at least one month of hospice (LOS) in order to optimize end of life care.

 

Patient Features:

·        Liver related diagnosis at hospice admission:

o       HCV – 33%

o       HBV – 10%

o       HCC—52%

·        Liver related complications while enrolled in the hospice program

o       Tense ascites, dyspnea – 75%

o       GI bleeding – 10%

o       Hepatic encephalophy—66%

 

Results:

169 ESLD patients were admitted to the hospice service. 29% (49 cases) were also evaluated for LT. The mean age was 58.1 years (87-31). In 24% cases, the chronic liver disease was complicated by hepatocellular carcinoma. The mean hospice LOS was 37±51.9 days.

 

At the time of hospice admission the mean MELD score of the whole group was 21±8.3.

 

Five patients were offered a liver graft while on the combined program; they revoked hospice and received LT. MELD, waiting time, and LOS in hospice are shown in Table 1. The mean time elapsed between the hospice admission and LT was 96.7 days (60-153). Four patients survived with a follow up of 7-45 months. One patient died after LT because of progressive heart and kidney failure. A significant correlation was observed between hospice LOS and MELD score at hospice admission (r= - 0.286, p= 0.004).

 

Conclusions:

1.     Timely referral to hospice/palliative care is improved using the MELD score as a guide to prognosis: referring patients with a lower MELD score to the hospice can optimize quality of care

2.     We suggest hospice care as an effective strategy to improve the care of ESLD in patients waiting for LT.

 

Patient

Listed MELD

Hospice Admission MELD

LT MELD

Waiting Time (months)

Hospice LOS (months)

1

6

17

19

9.9

3.5

2

39

35

42

0.4

2.1

3

21

22

17

6.3

5.2

4

15

23

22

15.5

3.8

5

15

18

18

13.9

2.0

Mean

19.2

23

23.6

9.2

3.1

SD

12.3

7.2

10.4

6.1

1.6

 


503. Nursing attitudes towards liver transplant: Gap between perceptions and accepted standards.. 

L. Graf; J. S. Bajaj; M. Perez; M. Adams; C. Mueller; R. Anderson; J. Franco.

 

Background

Nurses are an integral part of the multi-disciplinary care of liver transplant(LT) candidates and recipients. Therefore the study of their attitudes regarding the appropriate selection for LT candidates is essential.

 

Aim:

To determine nursing attitudes regarding candidacy for LT. Methods: In a medium-sized, midwestern transplant center, a anonymous survey inquiring about nursing attitudes towards candidacy for LT with respect to alcohol use, intravenous drug use, social support, compliance, psychiatric disorders, incarceration, illiteracy, HIV status and obesity was sent to 170 nurses (ICU and floor nurses caring for(CLT) or not caring for(NCLT) LT recipients).

 

Results:

Overall 145 of 170 (83%) nurses replied; 102 ICU (65 CLT and 37 NCLT) and 43 floor(24 CLT and 19 NCLT) nurses. There were no significant differences in the duration of nursing experience between groups. A striking minority of nurses in all 4 groups agreed with the current recommendation of 6 month abstinence from alcohol and IV drugs and compliance for 6 months (Table). The majority believed that longer periods of abstinence and compliance are needed for LT candidacy. Among ICU nurses(both CLT and NCLT), the majority believed that obese (95 vs 90%),HIV+(63 vs.54%), patients with depression(77 vs 81%), schizophrenic(57 vs 54%), illiterate(75 vs 76%) and tylenol overdose(62 vs 60%) patients should be LT candidates. Similarly among floor nurses (both CLT and NCLT),the majority believed that obese (92 vs 84%),HIV+(65 vs.64%), patients with depression(92 vs 84%), schizophrenic(57 vs 54%), illiterate (88 vs 84%) and tylenol overdose(62 vs 60%) patients should be LT candidates. The majority of nurses indicated that incarcerated patients and those without social support should not be LT candidates.

 

Conclusion:

·        Nursing opinions with respect to LT candidacy conflict with the current practice of most US transplant centers.

·        The majority of nurses feel that 12 or more months of sobriety and compliance should be required of liver transplant candidates.

·        The majority of nurses in all 4 groups favored liver transplantation for obese patients with fatty liver disease, depression, schizophrenia, HIV + status, illiteracy and acetaminophen overdose, but not incarceration.

·        Additional nursing research and education with regard to current transplant recommendations may be required to bridge the large gap that currently exists.

 

Percentage of nurses agreeing with LT candidacy recommendations

Percent

Alcohol abuse

IV Drug use

Compliance

 

Abstinent≥6mths

Never

Others

Abstinent ≥6mths

Never

Others

≥6mths

1 mth

Others

ICU CLT

9

1

90

6

6

88

24

0

76

ICU NCLT

5

0.2

94.8

3

3

94

27

0

73

Floor CLT

8

4

88

4

25

73

13

0

77

Floor NCLT

5

1

94

0

5

95

21

0

79

 

NCLT:not taking care of LT, CLT:taking care of LT

 

 


504. Can HIV/HCV Coinfection be Effectively Treated in a Community Based Clinic by Midlevel Providers?

L. Shahatto; R. Pozza; A. Hefner; K. Biando; M. El-Kabany; T. Hassanein.

 

04. Can HIV/HCV Coinfection be Effectively Treated in a Community Based Clinic by Midlevel Providers?

L. Shahatto; R. Pozza; A. Hefner; K. Biando; M. El-Kabany; T. Hassanein.

 

Introduction/Aim:

Hepatitis C (HCV) infection is reported in approximately 30% of HIV infected patients. HCV disease progression is more rapid in the setting of HIV. Since the use of antiretroviral therapy, the leading cause of morbidity and mortality is chronic liver disease. The combination of Pegylated Interferon and Ribavirin is currently the standard treatment for coinfected patients. In pivotal clinical trials, the sustained virologic response (SVR) is in the range of 27% to 40%. We report a single center experience in treating HCV/HIV coinfected patients by midlevel providers (NP) with the support of attending physicians, according to the standard community practices.

 

Methods: 

119 consecutive patients with HCV/HIV coinfection were referred to the clinic for treatment of Hepatitis C. The mean age was 47.9 ± 7.6 years. 100 patients were male; 65.5% were Caucasian, 16.8% African-American, 13.5% Hispanic, and 4.2% others. 82% had HIV titer <50. 83% were HCV Genotype 1, 15% G2/3, and 4% others.

 

Results:

50 patients successfully finished treatment and followup. SVR was achieved in 30% patients, nonresponse in 28 58% and relapse occurred in 6%. 19 patients are still in therapy. 50 patients were not treated due to: advanced HIV disease (4%), decompensated cirrhosis (2%), nonadherence to clinic visits (14%), normal liver biopsy (20%), and 23% patients deferred therapy.

Summary:

a)     the majority of patients referred by their HIV caregivers were appropriate for HCV therapy;

b)    treatment of HIV/HCV coinfected patients in the community clinics achieve similar SVR rates as reported in pivotal trials;

c)     coinfected patients still underestimate the importance of treating HCV infection; d) with the support of physicians, midlevel providers can treat coinfection in the community.

Conclusion:

a)     community clinics managed by midlevel providers and supported by physicians can successfully treat patients with HIV/HCV coinfection;

b)    educational efforts about the hazards of living with HCV are needed for the HIV/AIDS community.

 

102
Referred

57
Treated

45
Not Treated

47
Finished Therapy

10
Still on Therapy

2 Advanced HIV

1 Advanced Cirrhosis

9
Clinic Non-adherence

10 Normal Liver Bx

23 Deferred Treatment

14
SVR
(29.8%)
G1(8) G2/3(6)

28
NR
(59.6%)

5
Relapse
(10.7%)

 

 

 

 

 

 

 


505. An excess of corrupted humours: healing the liver in 16th -century Europe.. 

P. Rizzi.

Introduction

The treatment of the liver in Early Modern Europe (1500-1800) has never been studied. Physicians practised Galenic medicine where health was the balance of 4 humours: blood, phlegm, yellow and black bile. Health was restored by favouring discharge or re-absorption of excessive or corrupted humours. In Galen’s physiology1, the 3 vital organs were brain, heart and liver: this was in charge of nutrition and produced 2 humours, blood and yellow bile. In 1544 Matthioli published in Venice an edition of DiscoridesMateria Medica (c.65 AD), a compendium of plants, minerals and animals with healing properties. Translated into Latin, English, French and German, it became the most authoritative pharmacopoeia in Early Modern Europe.

 

My aim was to study the liver treatment in this text.

 

Methods

I analyzed the liver remedies listed in an anastatic copy of the 1557 edition of Materia Medica2 , keeping the original nomenclature without attemptation to modern medical terms. Results Six liver conditions were identified and 97 remedies available, with multiple action. 17 cured inflammation, 52 jaundice, 41 hydropsy, 8 coldness, 3 pain, 1 hardness; 14 healed inflammation and jaundice, 6 jaundice and hydropsia. 4/52 remedies for jaundice and 3/41 for hydropsia treated itch. Remedies were obtained from plants (58), roots (26), fungi (2), minerals (5) and animals (4), own urine and seawater. Pine cortex healed inflammation. Salt, river sand, own urine, seawater, hedgehog and snails cured hydropsia. Aloe, sulphur, millipede and deer’s horn treated jaundice. Rhubarb treated inflammation and jaundice, oregano jaundice and hydropsia. 40 remedies cleared the liver from bad humours by virtue of diuretic properties, 20 were constrictive, 13 drying, 8 mollifying; 20 were purges and 9 provoked vomit. Most remedies had multiple actions: 8 were diuretics and purges. None of the remedies were liver specific: they were also used for kidneys (17), stomach (16) and spleen (25). 90 remedies could be found in Europe; 4 plants only grew in India and 1 in Arabia, Armenia and Libya respectively. Conclusions Although disease was humour, not organ related, 16th-century European physicians recognized six liver conditions. A wide range of plants, animals and minerals was available to clear the liver from bad humours, mainly by provoking diuresis. No remedy was liver specific. This is the first study looking at liver treatment in Early Modern Europe.

 

1Galen On the usefulness of the parts of the body c.165 AD Cornell University Press Ithaca New York 1968

 

2I Discorsi di A Matthioli ne i sei libri de la materia medicinale di Discoride Venice 1557 Anastatic copy Forni Editore 1984

 


506. Prospective Audit of Liver Biopsy Practice: Is Bigger Better?. 

K. Li; G. Mortimore; M. Jackson; D. Semeraro; D. Clarke; J. Freeman; A. S. Austin.

 

Background:

Percutaneous liver biopsy remains an important tool in the diagnosis and staging of chronic liver disease. For reliable and reproducible interpretation, a specimen containing a minimum of six portal tracts and ideally more than ten is required. There is often reluctance to use wider bore needles because of potentially higher complication rates.

 

Aims:

To compare the adequacy of samples obtained using two different biopsy needles.

 

Patients and Methods:

Data was collected prospectively for 128 ultrasound-sited percutaneous biopsies for chronic liver disease over a 10 month period using a proforma.

 

Results:

Indications for biopsy were alcoholic liver disease (21%), NAFLD (21%), HCV (14%), HBV (8%), haemachromatosis (10%), autoimmune hepatitis (8%), other (22%). There were no serious adverse events in either group. Biopsy characteristics are compared in Table 1. Data are expressed as mean (CI) or median (range) and compared using t test, Mann-Whitney U test or Chi-squared.

 

Conclusions:

Liver biopsy samples obtained with a 15G Menghini needle are superior to those obtained using an 18G Trucut needle. The latter are often inadequate for assessment using accepted criteria.

 

Table 1

 

 

n=128

Trucut 18G
Achieve (n=49)

Menghini 15G
(n=79)

p value

Single pass (%)

63%

83%

 

Length (mm)

15.8 (14.4-17.2)

25.8 (23.6-28.0)

< 0.001

Number of portal tracts

6 (2-12)

8 (2-30)

< 0.001

Proportion ≥ six portal tracts

51%

73%

0.11

Proportion ≥ ten portal tracts

6%

39%

0.001

 


507. Patient Experience of Day Case Liver Biopsy: Prospective Audit. 

K. Li; G. Mortimore; M. Jackson; D. Clarke; J. Freeman; A. S. Austin.

 

Background:

Percutaneous liver biopsy remains an important tool in the diagnosis and staging of chronic liver disease. There is often reluctance to use wider bore needles because of potentially higher complication rates. There are no good prospective studies of the patient experience and morbidity associated with the procedure.

 

Aims:

To describe the patient experience and compare two different biopsy needles.

 

Patients and Methods:

Data collected prospectively was available for 83 ultrasound-sited percutaneous biopsies for chronic liver disease. Subjects were regularly offered analgesia and asked to rate pain on a visual analogue scale (0-10). Patients were contacted 30 days post-biopsy.

 

Results:

Indications for biopsy were alcoholic liver disease (21%), NAFLD (20%), HCV (14%), HBV (5%), haemachromatosis (10%), autoimmune hepatitis (8%), other (22%). Data are expressed as mean (CI) and compared using t-test and ANOVA.

 

Within the first 6 hours, 28 took paracetamol only, 8 required codeine-based analgesia, and 1 received pethidine. There were no episodes of bradycardia, hypotension or pyrexia and only one re-admission (for recurrent ascites). There were no serious adverse events in either group.

 

Conclusions:

The majority of patients experienced only mild discomfort after liver biopsy and 45% did not require analgesia. A small difference in pain scores was detected at one hour but did not persist to six hours and may reflect the greater use of lignocaine by one group.

 

Table 1

n=83

Trucut 18G (Achieve) (n=31)

Menghini 15G (n=52)

p value

Single pass (%)

70%

80%

 

Volume lignocaine (ml)

14.5 (13.2-15.7)

10.1 (9.5-10.6)

< 0.001

Pre-biopsy pain score

0.7 (0-1.4)

0.4 (0.1-0.7)

0.89

1h pain score

0.3 (0-0.5)

1.6 (1.1-2.0)

0.02

6h pain score

0.6 (0.2-0.9)

0.9 (0.5-1.3)

0.35

24h pain score

0.3 (0-0.6)

0.3 (0.1-0.6)

0.91

 


508. Body Composition Analysis in Peri Transplant Patients. 

V. Zacharias; B. Borjas; T. Kaiser; C. Jennings; R. Neff; N. Majoras; P. Shafeei; J. Martin; K. Hess; G. W. Neff.

 

Introduction:

Patients with end stage liver disease (ESLD) leading to liver transplantation (LTx) have a high prevalence of malnutrition. There are differing opinions regarding assessment of the LTx patient. We intend to report baseline values and changes over time in the post transplant period for this patient population.

 

Methods:

We conducted a prospective study of consecutively listed LTx patients beginning January 2006. Data collection included handgrip strength, body impedance analysis (BIA) measured at 5, 50, 100, and 200khz, along with calorie(kcals) and protein(gms) intake. Measurements were taken at baseline, then q 3 months until LTx. Post LTx values were obtained at day 1, day 10, months 1, 2, 3, 6, 9, 12.

 

Results:

Patient demographics included: Pre LTx Male (n=12), Female (n=8), post LTx Male (n=6), Female (n=2), age range for both pre and post LTx 22 - 66 years. Values obtained for n=20 pre-LTx patients, n=8 post-LTx patients. Average handgrip measurements for pre LTx was 62+/- 24 lbs; males 82+/- 29 lbs, females 36+/- 11 lbs. Post LTx average was 57+/- 21 lbs; males 66+/- 16lbs, females 29+/- 9 lbs. Average caloric intake for pre transplant patients was 1680 kcals, 60 gms protein. Post transplant was 1420 kcals, 50 gms protein. Impedance values located in table.

 

Conclusion:

The table results show a change from pre to post transplant with the impedance values decreasing across the frequency ranges between the two groups which indicates increasing lean compartment body mass after LTx. The results also show that handgrip strength in ESLD patients is poor and may be a consequence of inadequate intake pre and post LTx. It is our contention that these nutritional parameters will improve as the patient and the new liver continue to synthesize protein while given additional substrate for metabolism.

 

Impedance Values

 

Khz

5

50

100

200

PRE n=20

 

 

 

 

Avg

431

388

371

354

Low

227

201

194

186

High

609

528

488

465

POST n=8

 

 

 

 

Avg

372

278

262

250

Low

210

199

193

187

High

609

395

379

363