ABSTRACT
Background and Aim: Acute-on-chronic liver failure (ACLF) is a global health care challenge, with a 28-day mortality rate of 33.9% and 30-day readmission rate of 37%.1,2 Management of ACLF is often complicated by multiorgan involvement, need for intensive care support, sarcopenia/frailty, and lack of universally accepted diagnostic criteria.3,4 Health care resource utilization is high. Our aims were to assess the safety, efficacy, acceptability, and cost of LivR Well, a new model of intensive, multidisciplinary ambulatory care for patients with ACLF. Method(s): We conducted a prospective, single-arm, mixed-methods study at Monash Health, a large Victorian tertiary network. Adult patients were enrolled from the inpatient ward, emergency department, or outpatient clinic in the first 28 days after a formal diagnosis of ACLF. ACLF was defined using Asian Pacific Association for the Study of the Liver criteria (an acute hepatic insult manifesting as jaundice and coagulopathy, complicated by ascites and/or encephalopathy within 4 weeks).5 Study criteria and the LivR Well intervention are shown in Figure 1. Patients were admitted to hospital in the home and received nursing visits up to 3 times a week and a weekly clinic medical review. Patients accessed physiotherapy, pharmacy, dietetics, social work, addiction medicine, and neuropsychiatry if appropriate. Blood test results were monitored weekly, and patients were followed up for 12 weeks. Health-related quality of life (HRQoL) was measured using EQ-5D and the Chronic Liver Disease Questionnaire (CLDQ) at baseline and Week 6. A qualitative substudy was undertaken to assess acceptability, with interviews performed between Weeks 6 and 12. The primary outcome was safety. Secondary outcomes were readmission, liver disease severity, HRQoL, symptom burden (CLDQ), acceptability, and health care resource utilization. Result(s): Fifty-nine patients (median age, 51 years [IQR, 45-59];66% male) were enrolled between March 2021 and April 2022. Forty-four patients completed the 28-day program, with two deaths (at Days 16 and 27), one drop-out due to COVID-19 requiring isolation, eight patients discharged due to failure to attend, and four patients who remain active in the program. There were no reported adverse events. Alcohol misuse was the most frequent liver disease etiology (73%). There was a significant reduction in median Model for End-Stage Liver Disease-Sodium (MELDNa) score from 16 at baseline (IQR, 12-21) to 15 at Day 28 (IQR, 11-18;P < 0.001). Sarcopenia prevalence decreased from baseline to Day 28 but did not reach statistical significance (27% vs 19%, P = 0.48). HRQoL significantly improved from a median baseline CLDQ score of 4.34 (IQR, 3.37-5.08) to 4.75 (IQR, 3.97-5.81;P = 0.02), with specific improvement in the domains of activity (P = 0.04), fatigue (P = 0.02), and worry (P = 0.001). The qualitative study highlighted universal themes of high acceptability, improved health literacy/insight, and increased autonomy. The median self-reported health perception using a visual analog scale significantly improved from 64% (IQR, 42-77%) to 72% (IQR, 50-80%;P = 0.05). The 28-day mortality rate was 3%, and the 30-day readmission rate was 14%. The median LivRWell program cost was A$4947. The total 6-month median direct health care cost for each LivR Well patient improved from a median of A$30 913 before LivR Well (IQR, $11 201-$61 464) to $784 after LivR Well (IQR, $0-$18 117;P < 0.001). The total direct health care cost for this cohort was reduced by 71%, from $1.16 million before to $335 000 after LivR Well, largely driven by a 40% reduction in 30-day readmission. Conclusion(s): LivR Well is a world-first multidisciplinary ambulatory care program for patients with ACLF. Our feasibility study supported the safety, potential efficacy, and cost-effectiveness of such an intervention, with lower than expected 30-admission, 28-day mortality, and total health care cost for this complex cohort. There was a small, but significant improvement in MELD-Na score, HRQoL, and self-rep rted health perception. We are further evaluating the clinical and economic impact of LivR Well as part of a randomized controlled trial comparing it with standard ambulatory care.
ABSTRACT
Purpose: To estimate the prevalence of fibromyalgia (FM), 'fibromyalgianess' and fatigue six months following COVID-19 infection. Method: Consecutive consenting patients were recruited from a post-COVID-19 infection clinic. The following self-reported questionnaires were completed 6 months following COVID-19 infection: widespread pain index (WPI), symptom severity scale (SSS), 10-point visual analogue scale to assess fatigue severity (VAS-F) and 9-item, 7-point fatigue severity scale (FSS). The sum of SSS and WPI scores was used to calculate a polysymptomatic distress (PSD) score. FM was defined as per the 2016 revisions to the 2010/2011 American College of Rheumatology (ACR) criteria, and 'fibromyalgianess' was defined using polysymptomatic distress scale recognising the continuum of FM symptoms. Results: Of 25 study participants, the median age was 59 years (range 21-80), nine were female (36%) and 15 had been admitted to hospital for Covid-related complications (60%). Six months following infection, five met WPI and SSS criteria for fibromyalgia and three others had PSD scores >12 suggestive of severe symptoms;all were under 60 years. Problematic fatigue (mean FSS > 4) occurred in nine patients (36%) and although not statistically significant it was seen more frequently in females compared with males (56% vs 25%;95% CI -9% to 71%) and in those <60 years (46% vs 25%;CI -16% to 58%). Mean (± SD) FSS was 29.7 (± 15.0) and VAS-F was 6.0 (± 2.9). Compared to male patients, female patients demonstrated statistically significant higher mean WPI (8.0 vs 2.0), SSS (7.0 vs 2.1) and PSD (15.0 vs 4.1). Conclusion: Six months following COVID-19 infection, fibromyalgia, 'fibromyalgianess' and fatigue are common, with higher frequency in females and younger patients. This pattern parallels conventional fibromyalgia cohorts and may favour targeted service delivery. Further studies are needed to determine whether symptoms persist long-term.
ABSTRACT
Purpose: To correlate internet search activity for fibromyalgia (FM) and its symptoms in relation to case numbers during the COVID-19 pandemic. Methods: Search terms chosen for inclusion included 'fibromyalgia', 'pain', 'joint pain', 'muscle ache', 'extreme fatigue' and 'poor sleep', based on a review of the most common symptoms reported among patients with FM. Positive control terms of 'fever' and 'cough' were used and 'rash' was a negative control. Google Trends was used to determine the frequency of search terms as a relative search volume (RSV) and queries for selected search terms were set with filters for specific dates and location. COVID-19 case numbers in Australia were obtained from the Australian Department of Health. Results: The average 2020 FM search volume in Australia was slightly less than the previous three years (RSV 47 vs RSV 49-53). While an increase in COVID-19 cases in Australia in August and September correlated with increased search popularity, similar increases were demonstrated in 2017 and 2019. Similar trends were seen in New Zealand but not the United States or United Kingdom. The RSV of typical FM symptoms including 'pain', 'muscle ache' and 'poor sleep' remained stable throughout 2020. Increases in search volumes for 'extreme fatigue' were seen in February and September to November. Significant increases in the positive control terms occurred in March, coinciding with a rapid rise in COVID-19 cases, but negative and positive controls otherwise remained similar to previous years. Conclusion: Despite public health social distancing restrictions and high COVID-19 case numbers, infodemiology techniques did not detect any increase in fibromyalgia-related searches. This occurred despite seasonal variation in ' fibromyalgia ' searches in Southern Hemisphere countries and marked changes in positive control search terms. A large increase in disease activity appears not to have emerged, and patients with fibromyalgia and ' fibromyalgianess ' may have demonstrated surprising resilience during the COVID-19 pandemic.