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A practical approach to nutritional screening and assessment in cirrhosis
Full text linkMalnutrition is one of the most common complications of cirrhosis, associated with an increased risk of morbidity and mortality. As a potentially modifiable condition, it is of particular importance to identify malnourished patients so that nutritional therapy can be instituted. Nutrition screening and assessment are infrequently performed in patients with cir- rhosis. The reasons for this are multifactorial, including the absence of a validated “rapid” screening tool, multiple defini- tions of what constitutes malnutrition, and challenges with interpreting body composition and laboratory results in the setting of volume overload and liver dysfunction. This article summarizes the clinically relevant evidence and presents key issues, tools, and clinical options that are applicable to patients with cirrhosis. The definition, etiology, and clinically rele- vant outcomes associated with malnutrition are reviewed. Rapid nutritional screening is differentiated from more detailed nutritional assessment. Nutritional assessment in special populations, including women and the obese, and the role of inflammation are discussed. Multicenter studies using a common nutritional screening/assessment strategy are the next steps to fast-track adoption and implementation of nutrition-related evaluations into routine clinical practice
Management of Lifestyle Factors in Individuals with Cirrhosis: A Pragmatic Review.
No full textLifestyle-related factors are major determinants/modifiers of prognosis in patients with cirrhosis. Accumulating evidence indicates that malnutrition, obesity, sedentary lifestyle, alcohol and smoking habits, and likely poor oral hygiene can increase the risk of progression of the disease, and some of them are linked to higher risk of hepatocellular carcinoma. Importantly, lifestyle-related factors can be largely corrected, and as such they represent an attractive approach to be added to etiological and pharmacological therapy in patients with cirrhosis. Nonetheless, lifestyle is often neglected in this population. In this concise review, the authors present evidence supporting lifestyle changes in patients with cirrhosis-including, but not limited to, nutrition and physical activity in malnourished and obese patients. They also discuss some elements of motivational interviews as a tool to support a better interaction between hepatologists and patients in this field
Management of alcohol use disorder in cirrhosis: effect of a clinician-targeted alcohol use disorder in cirrhosis educational intervention on knowledge, attitudes, and practice habits
No full textIntroduction: Alcohol use disorder (AUD) is a common cause of liver cirrhosis. Low knowledge and comfort managing AUD among well-intentioned clinicians impacts the number of patients with cirrhosis who receive AUD treatment. Structured education focused on screening, brief intervention, referral to treatment, and prescription of pharmacotherapy for relapse prevention are proposed as key skills for clinicians caring for this patient population, but no studies to date have developed and evaluated the effect of education that employs these components. Additionally, no studies have reported on Self Determination Theory, a theory about human motivation, in the context of a clinician educational intervention about AUD in cirrhosis.
Objectives: The purpose of this study was to systematically develop and assess the effect of an AUD in cirrhosis educational intervention on clinicians’ knowledge, attitudes, and practice habits (preparedness, comfort, intention). Additionally, we wanted to assess participants perception of the learning environment using satisfaction of three basic psychological needs (autonomy, competence, and relatedness) as identified by Self Determination Theory.
Methods: Kern’s 6-step Framework for Curriculum Development was used for development of the 1.5-hour virtually delivered educational intervention. Based on a qualitative descriptive method, clinicians participated in one-on-one interviews about their experiences and perceived barriers to caring for patients with concomitant cirrhosis and AUD. Development of education objectives and implementation of a pilot educational intervention followed a literature search and interview findings. The pilot session was didactic, and the adapted session adopted a flipped classroom strategy including a 30-minute video, case-based discussion, breakout sessions, and question and answer. Participants completed questionnaires at baseline, immediately following the intervention (pilot), and four weeks following the intervention (adapted sessions).
Data analysis: A team of two coders analyzed transcripts from qualitative interviews using a deductive approach. Participant demographics were analyzed descriptively. Comfort, knowledge, and attitudinal measures were analyzed using a paired t-test after testing for normality. Self-determination theory measures were analyzed descriptively. Effect sizes were analyzed using Cohen’s d.
Results: 16 clinicians completed the one-on-one interviews. Four themes emerged related to previous experienced and perceived barriers to caring for patients with AUD and cirrhosis: (i) Practicing within knowledge constraints, (ii) Navigating limited resources and systems challenges, (iii) Balancing complexity of cirrhosis and AUD, and (iv) Acknowledging the influence of provider perceptions on care. 86 clinicians participated in the pilot sessions and 38 consented and completed pre-post questionnaires (44.2%). Participants reported significant improvements in preparedness and intention to screen, provide a brief intervention, refer patients to treatment and prescribe pharmacotherapy for relapse prevention. Minor changes in attitudinal measures included the domains of role adequacy and motivation. Relatedness was the lowest domain (2.73/5), followed by competence (4.10/5), and autonomy (4.31/5).
229 clinicians participated and 95 (30-36 per session) consented and completed pre-post questionnaires (41.5%) in the adapted sessions. Preparedness to diagnose (pretest M=2.56, posttest M=3.47, p<0.011) and manage (pretest M=2.32, posttest M=3.26, p<0.001) alcohol withdrawal significantly improved after exposure to the adapted session. Preparedness to screen and identify alcohol use (pretest M=3.17, posttest M=3.93, p=0.001), provide medical advice (pretest M=2.50, posttest M=3.33, p<0.001), and refer patients to treatment (pretest M=2.80, posttest M=3.67, p<0.001) significantly improved following participation in the adapted session. Intention to provide a brief intervention improved significantly from baseline (pretest M=5.00, posttest M=5.4, p=0.010). Comfort prescribing acamprosate (p<0.001), baclofen (p=0.032), and gabapentin (p<0.001) significantly improved from baseline despite non-significant improvement in intention to prescribe pharmacotherapy for relapse prevention. Significant improvements occurred in 4/5 attitudinal domains: role adequacy, role legitimacy, role support, and work satisfaction.
Conclusions: The 1.5-hour virtually delivered educational intervention had a positive effect on self-reported knowledge, attitudes, and practice habits. Adopting Kern’s curriculum, involving clinicians from the outset, maximizing interactivity, and assessing how interventions meet the needs of learners appear to be key components in facilitating improvements in practice habits, knowledge, and attitudes. The findings from this study warrant further investigation using administrative data to evaluate actual versus perceived changes in practice habits. Future studies should continue to work with clinicians and continuing clinician professional development bodies to create medical education focused on AUD and cirrhosis
The Validity of Patient-led Self- screens for Identifying Malnutrition in Inflammatory Bowel Disease
Full text linkBackground: Malnutrition is common in Inflammatory Bowel Disease (IBD) and is associated with significant morbidity and mortality. Identification of high-risk patients using a sensitive and reliable screen is the first step to dietitian referral for nutritional assessment and intervention.
Aim: The primary goal of this study was to determine the validity of patient led self-screens and health-care practitioner (HCP) screens against a dietitian-led nutritional assessment to detect malnutrition in outpatients with IBD. Our secondary objectives were to: i) determine the inter-rater reliability of patient-led self-screens compared to HCP screening and ii) determine the prevalence of malnutrition assessed by a range of assessment tools - subjective global assessment (SGA), body mass index (BMI), mid-arm muscle circumference (MAMC) and handgrip strength (HGS).
Methods: Patients were prospectively recruited from IBD outpatient clinics in Edmonton and Calgary. Patients completed 4 self-screening questionnaires: abridged Patient-generated Subjective Global Assessment (abPG-SGA), Malnutrition Universal Screening Tool (MUST), Canadian Nutrition Screening Tool (CNST) and Saskatchewan IBD-Nutrition risk (SaskIBD-NR) tool, followed by independent nutrition screening performed by a HCP. A dietitian blinded to the results of the screens carried out a gold standard nutritional assessment using the SGA (primary assessment modality), BMI, MAMC and HGS. We identified the proportion of patients in each category, sensitivity and specificity against SGA (dietitian-led malnutrition assessment) using contingency tables, and agreement between patient-led self-screen and HCP-led screening using kappa statistics (inter-rater reliability).
Results: A total of 204 IBD outpatients (131 Crohn’s (CD) and 73 Ulcerative colitis (UC)), 50.5% female, were assessed. According to Harvey-Bradshaw Index and partial Mayo scores, 12.8% of CD and 11.3% of UC patients had moderate to severe disease activity. The most common symptoms affecting dietary intake were diarrhea (21%), poor appetite (20%), pain (18%), and fatigue (18%). Of the 4 screening tools, the abPG-SGA and SaskIBD-NR tool showed the best predictive values (sensitivity of 89% and 70%; specificity of 75% and 81%, respectively) compared to dietitian-led SGA assessment. All self-screens demonstrated a moderate inter-rater agreement with the HCP-led screening (p < 0.001). According to dietitian-administered nutritional assessment, the prevalence of malnutrition in our IBD outpatients was 3%, 18%, 22% and 31% according to BMI, SGA, MAMC and HGS, respectively.
Conclusion: The abPG-SGA and SaskIBD-NR tools are promising nutrition screening tools in an IBD outpatient setting. They are valid and can be completed by patients in the waiting room during the clinical visit. With the high sensitivity and high negative predictive value for malnutrition detection, the majority of patients who screen at risk of malnutrition with these tools would be appropriately referred for further assessment. Future clinical practice should integrate these tools into routine IBD nutrition screening and assess the ability of the screening tools to predict clinical outcomes
Sex and Gender Considerations for Mind-Body Internet and Mobile-Based Interventions for Chronic Physical Conditions
No full textIntroduction: Mind-body mobile and internet-based interventions (IMIs) are digitally delivered wellness interventions that can include any combination of mindful movement (yoga, qi gong, or tai chi), breathwork, meditation, and/or psychoeducation (e.g., cognitive behavioural therapy or acceptance and commitment therapy). These interventions have shown promise in reducing symptoms of depression and anxiety, specifically for people living with chronic physical conditions. While participant sex and gender have been thought to influence participant adherence and experiences with mind-body IMIs, no studies have yet explored this intersection using either quantitative or qualitative methodology.
Objectives: The purpose of these studies was to (1) assess the extent and nature of reporting of sex and/or gender in randomized controlled trials retrieved by a primary systematic review of mind-body IMIs assessing depression and anxiety symptoms among adults living with chronic physical conditions (Chapter 3) and (2) explore how sex and gender factors contribute to the overall experience of participants in a 12-week mind-body IMI, EMPOWER (Chapter 4).
Methods: Chapter Three was a secondary analysis of a systematic review, where six databases were systematically searched, from database inception to March 2023. Sex and gender reporting quality was assessed across the included randomized controlled trials, and assessment tools followed published criteria. Each study was assessed on the following characteristics of sex and gender reporting: (1) non-binary use (i.e., > 2 categories used for both sex and gender definitions) (2) use of appropriate categories (i.e., sex = male/female/intersex, gender = man/woman/gender-diverse) and (3) non-interchangeable use of sex or gender terms throughout the study. A narrative review was also conducted surrounding any available attrition and recruitment data, as well as sex and/or gender-based stratification of mental health outcomes. Chapter 4 utilized a qualitative descriptive approach to explore sex and gender factors in relation to the EMPOWER trial. Participants were invited for a semi-structured interview following completion of their program, with questions guided by the Capability, Opportunity, Motivation-Behaviour (COM-B) model. Thematic analysis followed an in vivo and open coding scheme.
Results: Chapter Three included 56 randomized controlled trials. No studies met all three sex/gender criteria; two (4%) studies defined sex or gender using non-binary categorization, Twenty-eight (50%) studies used appropriate categories to define sex or gender, and twenty-five (45%) studies used sex and gender terms non-interchangeably. One study provided stratified mental health scores. Eleven (20%) studies cited sex or gender imbalances in their samples as a potential factor contributing to mental health outcome differences. Chapter 4 included 37 participants purposively sampled by gender (n = 24 (64.9%) women, n = 12 (32.4%) men, and 1 (2.7%) identifying as gender queer). Three themes emerged in which gender differences are explored: (1) perceptions of program accessibility, which highlights gender differences in how participants appreciated various aspects of program convenience, (2) reconceptualizing the relationship between mind-body exercise and wellness, which explores gender differences in responses to mind-body practices, and (3) breaking away from gender norms, which discusses gendered responses to acceptance and transitions away from gender roles and expectations in response to the EMPOWER program.
Conclusions: Despite low sex and gender uptake across mind-body IMI literature, these participant factors represent an important opportunity to explore for maximization of program adherence and experiences. Mind-body IMIs are effective for all genders of individuals living with a chronic condition, however these factors must be considered for future research in exploring areas of priority by sex and gender, as qualitative evidence revealed gender differences in priorities and experiences with the EMPOWER program. In order to fully capture sex and gender constructs, quantitative and qualitative methodologies should be utilized
The Development and Evaluation of a Frequently-Asked Question (FAQ) Answering Chatbot for an Online Mental Wellness Program for People with Chronic Disease
No full textIntroduction: Chatbots are computer programs that interact with humans through natural language conversations. Chatbots are on the rise due to numerous benefits like convenience, 24/7, personalized support, and they show promise in healthcare to support people living with chronic diseases. While chatbots, like other digital health interventions, are promising tools for chronic disease management, they also face challenges such as limited user adoption and low engagement. One way to address these challenges is to involve patients in development.
Objectives: The purpose of these studies was to report the non-technical (e.g. non-software development related) approaches for chatbot creation while examining patient engagement in these approaches and to develop the FAQ chatbot and evaluate its acceptability, usability, and user engagement through a multi-method approach.
Methods: In Chapter 3, our team conducted a scoping review following the framework proposed by Arksey and O’Malley. Nine electronic databases were searched in July 2022. Studies were selected based on our inclusion/exclusion criteria. Data were then extracted, and patient involvement was assessed. In Chapter 4, a FAQ-answering chatbot (“Liv”) was developed from May 2022 to February 2023 and evaluated through a multi-phased, multi-method design. Liv was then deployed on an online mental wellness program and evaluated for acceptability, usability, and user engagement.
Results: In Chapter 3, 16 studies were included in the review. We report several approaches to chatbot development, assess patient involvement where possible, and reveal the limited detail available on reporting patient involvement in the chatbot implementation process. In Chapter 4, Liv was deployed for 120 days, and there were 259 conversations with Liv, with 175 instances of active engagement (back-and-forth user-chatbot interaction). Engagement was highest during the first 30 days of deployment. The chatbot had a resolution rate of 33%. Liv’s usability was evaluated with an overall score of 50.8 (below average), with successes in specific areas, including its navigation and ease of use. Findings from qualitative interviews included comments on Liv’s personality, the convenience of knowing the chatbot would escalate, and experiences with Liv and her improvement over time.
Conclusion: FAQ chatbots may be an engaging way to provide patient support in online mental wellness programming. Including patients in development may improve chatbot acceptability, usability, and user engagement. Future work that prioritizes patient engagement in the development and builds upon conversation log data to create a more advanced bot is warranted
Should Sarcopenia Increase Priority for Transplant or Is It a Contraindication?
No full textPURPOSE OF REVIEW
The purpose of this review is to discuss the current evidence regarding the impact of sarcopenia on patients with cirrhosis awaiting liver transplantation and to determine if its presence should be considered a criterion for expedited transplantation or a contraindication for transplantation.
RECENT FINDINGS
Sarcopenia is a negative predictor of survival in patients on a waiting list and after liver transplant. The gut-liver axis and the liver-muscle axis have been explored to understand the complex pathophysiology of sarcopenia. Sarcopenia is a frequent finding in patients with cirrhosis. The diagnosis is ideally based on cross-sectional image analysis (CT or MRI) and treatment consists of optimization of caloric and protein intake. To date, prioritizing tools for liver transplantation have not included nutrition or sarcopenia parameters. Patients with a low Model for End-Stage Liver Disease (MELD) or MELD-Na score and sarcopenia would benefit from prioritization for transplant in order to reduce time on waiting list and therefore mortality
Improving self-management with eHealth in cirrhosis using a patient-centered approach
Full text linkRapid adoption of internet-connected technology (ICT) by society has supported an unprecedented rate of change in hardware, software, and connectivity making the technology more accessible and user friendly. In turn, the application of this technology has reshaped how people communicate, acquire information, and integrate it into their daily lives. The ubiquitous nature of ICT has also impacted healthcare and self-care in a range of ways, from the presence of patient portals and access to healthcare professionals, to applications (“apps”) and wearable devices that support healthy lifestyles. For those who are ill or have chronic diseases, ICT can provide disease-related information, medications, and apps to support self-management.
My dissertation explores the interface of ICT and individuals living with a chronic disease, cirrhosis and asks a series of contingent questions answered by four studies: (1) Are patients proficient with either computer and smart devices and, if so, why are they using it? A survey-based study (n=117) using validated tools (Computer and Mobile Device Proficiency Questionnaires) was conducted in cirrhosis. Patients were moderately proficient and high rates or internet usage and device ownership. (2) Next, I asked: is online cirrhosis information targeted to patients and care partners and, if so, how is it presented? A critical review of cirrhosis-specific webpages evaluated information accessibility, reliability, and transparency using validated tools (Web Resource Rating Tool and Quality Evaluation Scoring Tool). Low levels for these measures were found for all webpages and much could be done to improve online resources specifically targeted to patients and care partners. An in-depth look at hepatic encephalopathy webpages revealed complex medicalese language, inaccuracies, or negligible mention of non-pharmaceutical therapies. (3) For those living with cirrhosis, I asked what gaps, if any, were there about the self-management of hepatic encephalopathy? Following a systematic search and retrieval of the literature, the EPPI-Centre’s mixed methods synthesis approach to analyse quantitative (n=16) and qualitative (n=7) articles from published research. Findings highlighted the need for repeated practitioner-initiated dialogue with consistent messaging about this common complication to prepare, learn, and share information and skills to improve health outcomes and quality of life. Online resources and tools could be valuable for non-pharmaceutical and pharmaceutical self-management. (4) What did individuals living with cirrhosis think of a web-based application for improving nutrition and exercise behaviours? The three domains of the capability, opportunities, motivation – behaviour change model (COM-B) were used to investigate the application. After interviewing 20 persons and exploratory descriptive analysis of the data, several opportunities were identified to improve the application in consideration of COM-B. An unexpected finding was the preference for more online classes and the universal curiosity to learn more about other patients and have online interactions. These two elements were helpful to retain users and support adherence in the first 4-6 weeks of app use; this correlates with the opportunity-social subdomain of the model. Inclusion of gamification elements, streamlining data entry and progress reporting, and more online classes were suggested by the users as other mechanisms to increase enjoyment, retention, and adherence.
While ICT has changed greatly in a short period of time, how we use it to support health needs is still evolving. App development and online content is driven by for-profit industries which are slowly evolving to meet user needs and user abilities. Research, like the series of findings presented here, is needed to describe the current landscape, gaps, and opportunities so that research can inform and benefit from advances in ICT.
Findings presented in this dissertation highlight the acceptability and potential utility of ICT to support self-management, which is greatly needed in complex, chronic diseases, such as cirrhosis. However, effective initiatives should be user-centered if they are to improve health outcomes and quality of life of patients and care partners. There is much opportunity for follow-on studies to continue the work presented here to advance the scope and accessibility of greatly needed eHealth self-management tools
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