Management of betablocked patients after sustained virological response in hepatitis C cirrhosis.

BACKGROUND: Current guidelines do not address the post-sustained virological response management of patients with baseline hepatitis C virus (HCV) cirrhosis and oesophageal varices taking betablockers as primary or secondary prophylaxis of variceal bleeding. We hypothesized that in some of these patients portal hypertension drops below the bleeding threshold after sustained virological response, making definitive discontinuation of the betablockers a safe option. AIM: To assess the evolution of portal hypertension, associated factors, non-invasive assessment, and risk of stopping betablockers in this population. METHODS: Inclusion criteria were age > 18 years, HCV cirrhosis (diagnosed by liver biopsy or transient elastography > 14 kPa), sustained virological response after direct-acting antivirals, and baseline oesophageal varices under stable, long-term treatment with betablockers as primary or secondary bleeding prophylaxis. Main exclusion criteria were prehepatic portal hypertension, isolated gastric varices, and concomitant liver disease. Blood tests, transient elastography, and upper gastrointestinal endoscopy were performed. Hepatic venous pressure gradient (HVPG) was measured five days after stopping betablockers. Betablockers could be stopped permanently if gradient was < 12 mmHg, at the discretion of the attending physician. RESULTS: Sample comprised 33 patients under treatment with propranolol or carvedilol: median age 64 years, men 54.5%, median Model for End-Stage Liver Disease (MELD) score 9, Child-Pugh score A 77%, median platelets 77.000 × 103/µL, median albumin 3.9 g/dL, median baseline transient elastography 24.8 kPa, 88% of patients received primary prophylaxis. Median time from end of antivirals to gradient was 67 wk. Venous pressure gradient was < 12 mmHg in 13 patients (39.4%). In univariate analysis the only associated factor was a MELD score decrease from baseline. On endoscopy, variceal size regressed in 19/27 patients (70%), although gradient was ≥ 12 mmHg in 12/19 patients. The elastography area under receiver operating characteristic for HVPG ≥ 12 mmHg was 0.62. Betablockers were stopped permanently in 10/13 patients with gradient < 12 mmHg, with no bleeding episodes after a median follow-up of 68 wk. CONCLUSION: Portal hypertension dropped below the bleeding threshold in 39% of patients more than one year after antiviral treatment. Endoscopy and transient elastography are inaccurate for reliable detection of this change. Stopping betablockers permanently seems uneventful in patients with a gradient < 12 mmHg.

Poder de explicación del diagnóstico enfermero en la actividad desarrollada en consulta de enfermería de pacientes crónicos en atención primaria / The power of explanation of the nursing diagnosis in the activity developed in the nursing consultation of chronic patients in primary health care

Objetivo: Determinar el porcentaje de actividad de la consulta de enfermería de pacientes crónicos explicado por el diagnóstico de enfermería y por el diagnóstico médico. Material y métodos: Estudio observacional retrospectivo sobre una muestra de 340 historias de pacientes crónicos atendidos en consulta de enfermería de un centro de salud. La variable dependiente fue el tiempo dedicado por la enfermera, y la independiente el número y tipo de etiquetas diagnósticas enfermeras y de diagnósticos médicos. El análisis estadístico se llevó a cabo mediante medidas de tendencia central y dispersión, frecuencias y regresión múltiple. Resultados: El modelo es capaz de explicar el 62,92 por ciento de la variable dependiente, para una p < 0,05, siendo el porcentaje de explicación de las etiquetas del 58,50 por ciento y de los diagnósticos médicos del 4,42 por ciento. Conclusión: Un porcentaje considerable de las actividades en la consulta de enfermería están explicadas por las etiquetas diagnósticas enfermeras, pudiendo plantearse la utilización de dichas etiquetas como predictor de las necesidades de cuidados (AU)