Screening for Hepatitis B

Patients with chronic hepatitis B virus (HBV) infection are often asymptomatic, but they are at risk for serious health consequences, including cirrhosis, liver failure, and hepatocellular carcinoma if they have active disease, and may need antiviral therapy. As primary care providers, nurse practitioners (NPs) may be the first and sometimes the only health care provider an HBV-infected individual may encounter. This article describes a new algorithm that can aid NPs in knowing whom to screen for HBV infection and how to follow up based on screening results, including what additional tests to order, necessary monitoring, and when to refer.     

7例肝硬化患者妊娠分娩的护理

报告了7例肝硬化患者妊娠分娩的护理体会。妊娠期实施高危妊娠一体化管理,监测肝硬化病情动态变化,做好伙伴式的小组护理。分娩、手术前后准确落实支持性治疗,改善病情,预防上消化道出血、产后出血、感染等并发症的发生。7例产妇均顺利渡过围产期,无孕产妇死亡。     

运用自我监控卡对肝硬化患者实施家庭护理干预的研究

目的 运用自我监控卡对75例肝硬化患者实施家庭护理干预,旨在提高患者的自我护理能力,改善生活质量.方法 将150例研究对象随机分为两组,对照组患者接受常规健康指导,观察组患者接受家庭护理干预,干预期为1年,对比两组患者在自我护理能力、并发症、生活质量方面有无差异性.结果 观察组患者自我护理能力和生活质量提高,并发症减少,与对照组相比,差异有显著性意义(P<0.01,P<0.05).结论 运用自我监控卡对肝硬化患者实施家庭护理干预,能够提高患者自我护理能力,减少并发症,从而提高生活质量,降低再住院率.     

Nutrition as Therapy in Liver Disease

PurposeThe importance of nutrition is often underrecognized in the routine clinical care of patients with chronic liver disease. Nutrition therapy plays a significant role in the management of alcohol-related liver disease and nonalcoholic fatty liver disease. In patients with cirrhosis from any etiology, malnutrition and sarcopenia are directly related to mortality, and nutritional interventions play an important role in the management of these patients. This review explores the role of nutritional intervention as adjuvant therapy across all chronic liver disease.MethodsA narrative, qualitative systematic review was performed via searches of PubMed for nutritional aspects in the care of chronic liver disease.FindingsNutritional therapy plays a critical role in the management of chronic liver disease. In nonalcoholic fatty liver disease, specific macronutrient management can lead to weight loss and improved outcomes in these patients. In patients with alcohol-related liver disease, chronic cholestatic liver disease, and decompensated cirrhosis, caloric and protein intake plays a vital role improving outcomes in these patients. Micronutrient deficencies are also common in these patients and require supplementation to prevent other complications of malnutrition. Assessment and management of nutrition should accompany the typical care plan of patients with chronic liver disease.ImplicationsThis review of nutritional therapy in chronic liver disease highlights the current evidence-based and societal recommendations of macronutrient and micronutrient management across the spectrum of all chronic liver disease.     

Pure laparoscopic hepatectomy for hepatocellular carcinoma patients with severe liver cirrhosis

Hepatocellular carcinoma often arises in cirrhotic livers. Patients with severe liver cirrhosis who undergo hepatectomy often develop postoperative liver failure, even if the hepatectomy is limited. Here, we report six patients with severe liver cirrhosis (Child-Pugh B/C and indocyanine green retention rate at 15 min ≥ 40%) who underwent pure laparoscopic hepatectomy. Their perioperative course was favorable and comparable to that of other hepatocellular carcinoma patients with mild-moderate liver cirrhosis. In patients with severe liver cirrhosis, pure laparoscopic hepatectomy minimizes the disturbance in collateral blood and lymphatic flow caused by laparotomy and liver mobilization, as well as the mesenchymal injury caused by compression of the liver. It limits complications such as massive ascites, which can lead to severe postoperative liver failure. Good candidates for the procedure include patients with severe liver cirrhosis who have tumors on the liver surface and in whom adaptation to ablation therapy is difficult and/or who experience local recurrence after repeat treatments.     

肝硬化并发上消化道出血126例诱因分析及护理

目的:探讨肝硬化患者并发上消化道出血的诱因并提出护理对策。方法:对126例肝硬化患者进行上消化道出血诱因分析,并给予抢救配合、病情观察、心理护理、用药护理等针对性护理措施。结果:本组98例出血停止,7例放弃治疗出院,6例死于多脏器功能衰竭。结论:针对肝硬化患者发生上消化道出血的诱因给予针对性护理,可有效减少并发症发生,降低病死率。     

Place de la réanimation chez le cirrhotique

In cirrhotic patients, liver insufficiency and portal hypertension represent a source of potentially life threatening complications, which may justify intensive care. In addition to specific complications (variceal bleeding, hepatic encephalopathy and hepatorenal syndrome), cirrhosis is a condition which favors non-specific complications including severe bacterial infections and acute renal failure. Apart from these complications, cirrhosis is constantly associated with dysfunctions of several organs and systems (cardiocirculatory system, respiratory system, central nervous system, immune system and coagulation). When severe complications occur, dysfunctions of these organs and system can progress and lead to multi-organ failure. As a result, the prognosis of cirrhotics in intensive care units is poor. A major issue is to determine which patients should be admitted to intensive care. Different prognostic scores have been proposed but none is perfect. Practically, admission in an intensive care unit is justified in the absence of significant hepatic insufficiency or when hepatic insufficiency is reversible, when liver transplantation is possible, and in case of iatrogenic complications. In other conditions, mortality is close to 100% and intensive care may not be justified. Theoretically, the correction of hepatic insufficiency could help to improve the results of intensive care in cirrhotic patients. The tolerance and efficacy of artificial liver support systems (albumin dialysis and bioartificial liver) remain unclear. However, these systems offer attractive perspectives.     

Outcome prediction for patients with cirrhosis of the liver in a medical ICU: A comparison of the APACHE scores and liver-specific scoringsystems

Objective To find the most adequate prognostic scoring system for predicting ICU-outcome in patients with decompensated liver cirrhosis in a medical intensive care unit (ICU).Design Retrospective analysis of patients' records over a 10-year period.Setting A medical ICU at the university medical center of Vienna.Patients and participants: 94% (n=198) of all patients with cirrhosis admitted to our medical ICU throughout the 10-year study period.Interventions None.Measurements and results From data obtained at admission and at 48 h after admission, scores were calculated using the following scoring systems: Acute Physiology and Chronic Health Evaluation (APACHE) II and III, Scale for Composite Clinical and Laboratory Index Scoring (CCLI), Mayo Risk Score, and Child's Classification. Statistical analysis for the prognostic variables was performed using the chi-square test,t-test, Youden index, and area under a receiver operating characteristic (ROC) curve. APACHE III was found to be the most reliable outcome predictor at admission and after 48 h for patients with decompensated liver cirrhosis (AUC=0.75 and 0.8, respectively).Conclusions To predict the outcome for patients with decompensated cirrhosis of the liver admitted to a medical ICU liver failure alone is not decisive. Liver-specific scoring systems (Mayo Risk Score, CCLI) are adequate, but the APACHE II and III proved to be more powerful, because they include additional physiologic parameters and therefore also take into account additional complications associated with this liver disorder.     

基于目标管理理论的优质护理在肝硬化住院患者中的应用效果

目的探讨基于目标管理理论的优质护理在肝硬化住院患者中的应用效果。方法选取我院2017年1月至2019年3月收治的肝硬化住院患者120例作为研究对象,按照随机数字表法等分为对照组和观察组,对照组实施肝硬化常规护理,观察组在对照组基础上行基于目标管理理论的优质护理,比较两组患者治疗依从性、并发症发生率。结果观察组患者依从率明显高于对照组(P<0.05),并发症发生率显著低于对照组(P<0.05)。结论将基于目标管理理论的优质护理应用于肝硬化住院患者中,可有效提高其治疗依从率,降低相关并发症发生率,提高护理质量。     

延续性健康教育路径对肝硬化患者出院后生存状态的影响

目的了解延续性健康教育路径对肝硬化患者出院后的生存状态的影响,为提高肝硬化患者生活质量提供有效的健康教育方法。方法将124例肝硬化患者分为研究组与对照组。研究组对患者出院后仍进行系统、动态、连续而有针对性的健康管理。对照组实施肝硬化出院健康指导。观察两组患者出院后的并发症、焦虑状态及生存质量。结果 (1)研究组的上消化道出血、感染、肝性脑病等并发症的发生率小于对照组,差异有统计学意义(P<0.05);(2)研究组的焦虑自评量表(SAS)得分小于对照组,生活质量得分高于对照组,差异有统计学意义(P<0.05);(3)文化程度及合并症是影响患者SAS得分的独立因素,文化程度和并发症是影响患者生活质量的独立因素(P<0.05)。结论延续性健康教育路径可以有效减少肝硬化患者的并发症、提高患者的生活质量。     

Cirrhosis: diagnosis, management, and prevention

Cirrhosis is the 12th leading cause of death in the United States. It accounted for 29,165 deaths in 2007, with a mortality rate of 9.7 per 100,000 persons. Alcohol abuse and viral hepatitis are the most common causes of cirrhosis, although nonalcoholic fatty liver disease is emerging as an increasingly important cause. Primary care physicians share responsibility with specialists in managing the most common complications of the disease, screening for hepatocellular carcinoma, and preparing patients for referral to a transplant center. Patients with cirrhosis should be screened for hepatocellular carcinoma with imaging studies every six to 12 months. Causes of hepatic encephalopathy include constipation, infection, gastrointestinal bleeding, certain medications, electrolyte imbalances, and noncompliance with medical therapy. These should be sought and managed before instituting the use of lactulose or rifaximin, which is aimed at reducing serum ammonia levels. Ascites should be treated initially with salt restriction and diuresis. Patients with acute episodes of gastrointestinal bleeding should be monitored in an intensive care unit, and should have endoscopy performed within 24 hours. Physicians should also be vigilant for spontaneous bacterial peritonitis. Treating alcohol abuse, screening for viral hepatitis, and controlling risk factors for nonalcoholic fatty liver disease are mechanisms by which the primary care physician can reduce the incidence of cirrhosis.     

肝硬化腹水的诊治

腹水是肝硬化失代偿期主要并发症之一。腹水的形成往往提示预后不良,发生自发性细菌性腹膜炎（SBP）、肝肾综合征（HRS）等并发症的概率大大增高。规范化处理肝硬化腹水及其并发症可提高患者的生存质量和生存率。本文结合近期肝硬化相关指南对腹水诊治进行概述。     

综合护理干预对肝硬化失代偿期患者的影响

目的探讨综合护理干预对肝硬化失代偿期患者的影响,以提高临床护理治疗效果。方法选择已确诊的失代偿期肝硬化患者80例,分为观察组和对照组各40例,观察组在常规护理的基础上应用早期个体化护理干预措施,对照组实施常规的护理和教育,比较两组患者干预前后临床症状、并发症发生率和肝功能指标的变化。结果观察组患者的临床症状和肝功能生化指标的改善优于对照组（P〈0．05）,两组患者在并发症的发生率方面差异具有统计学意义（P〈Q01）。结论个体化综合护理干预对肝硬化失代偿期患者控制或减轻临床症状,促进肝功能恢复,延缓肝功能恶化,预防并发症的发生,提高生活质量有重要意义。     

Nurse practitioners and managed care: patient satisfaction and intention to adhere to nurse practitioner plan of care

PURPOSE: To explore patient satisfaction, intention to adhere to nurse practitioner (NP) plan of care, and the impact of managed care on NPs' patients in multiple settings, the final phase of a three-part study of NPs and managed care. DATA SOURCES: Postvisit questionnaires and narrative comments about patient satisfaction with NP communication, overall satisfaction with visit, recall of plan of care, intention to adhere to NP's recommendations, and impact of managed care on ease of obtaining healthcare resources. CONCLUSIONS: Patients were very satisfied with NP communication and with their healthcare visit. They mostly intended to adhere to the NP-recommended plan of care but less so to recommended lifestyle changes. Patients trusted their NPs, valued their expertise, were confident in the NPs' care, and believed that the NPs considered their best interests. They appreciated that the NPs took time to listen to their concerns and helped them to obtain healthcare resources. Most patients were not greatly impacted by managed care and obtained needed healthcare resources with little difficulty. IMPLICATIONS FOR PRACTICE: Although the first two phases of this study found that many NPs had strong negative attitudes toward managed care, these attitudes were not conveyed toward patients in this sample. NPs, however, will continue to face new challenges as third-party payers attempt to reduce healthcare costs, further testing NP adaptability and resourcefulness.     

Pathogenesis, diagnosis, and treatment of alcoholic liver disease

Alcohol-related liver disease is a major cause of morbidity and mortality in the United States. Alcoholic liver disease encompasses a clinicohistological spectrum, including fatty liver, alcoholic hepatitis, and alcoholic cirrhosis. Fatty liver is a benign and reversible condition, but progression to alcoholic hepatitis and cirrhosis is life-threatening. Alcoholic hepatitis is diagnosed predominantly on clinical history, physical examination, and laboratory testing, although liver biopsy is often necessary to secure the diagnosis. The major focus of management is abstinence from alcohol, supportive care, treatment of complications of infection and portal hypertension, and maintenance of positive nitrogen balance through nutritional support. Corticosteroid therapy is controversial but should be considered in patients with a discriminant function greater than 32 and/or presence of spontaneous hepatic encephalopathy in the absence of infection, gastrointestinal bleeding, and renal failure. The only curative therapy for advanced alcoholic cirrhosis is liver transplantation. Several recent advances in understanding the pathogenesis of alcoholic liver disease may lead to novel future treatment approaches, including inhibition of tumor necrosis factor a, antioxidant therapy, stimulation of liver regeneration, and stimulation of collagen degradation.     

胃癌并肝硬化患者行根治术后腹水的处理

目的探讨胃癌合并肝硬化患者行根治术的安全性和腹水的处理。方法回顾性分析26例胃癌合并肝硬化患者围手术期情况。结果本组患者围手术期无死亡,术前肝脏功能评级Child．Pugh均为A级,其中行D2淋巴结清扫25例（96．2％）,切除淋巴结数目平均（33±11）个,12例术后放置了腹腔引流（46．2％）,平均引流量为463ml／d,平均拔出引流天数为11d,8例患者应用了利尿剂（30．8％）。结论胃癌根治术时行较广泛的淋巴结清扫术,对胃癌合并肝硬化患者是安全的,对手术前及术后腹水应用利尿剂治疗是有效的。     

肝硬化病原学分析和乙肝肝硬化中HBeAg阳性与阴性患者的临床特点比较

目的 通过大样本横断面回顾性调查，了解临床肝硬化患者病原组成及临床所见HBeAg(－)和HBeAg(＋)两类肝硬化患者临床相关因素的异同。 方法 对599例肝硬化患者的住院病历进行回顾性调查，分析肝硬化患者病因构成及占主要病因的乙肝肝硬化中的HBeAg(－)和HBeAg(＋)肝硬化组年龄、ALT、HBV DNA定量、CTP评分、PLT等指标的组内和组间差异。 结果 在肝硬化病因中以病毒性肝炎后肝硬化常见，有557例，占93.0％，其中又以乙肝肝硬化居多。在乙肝肝硬化中HBeAg (－)乙肝肝硬化306例，占62.3％；HBeAg(＋)肝硬化185例，占37.7％。HBeAg(＋)组ALT、HBV DNA总体上均高于HBeAg(－)组。HBeAg(－)组患者年龄明显高于HBeAg(＋)组。两组之间Child-Pugh，（CTP）积分无明显差异。 结论 目前我国临床所见肝硬化病例以病毒性肝炎感染后所致占绝大多数，乙肝肝硬化中又以HBeAg(－)者占多数。HBeAg(－) 与HBeAg(＋)肝硬化患者在病情轻重方面无明显差异，无论HBeAg是否阳性，病毒载量高时，抗病毒治疗及控制肝脏炎症能减轻病情恶化。     

肝移植手术出血特点及对移植后呼吸功能恢复的影响

背景:肝移植手术容易导致致命性大出血,如何评估肝移植手术过程的出血、止血、凝血功能以及使用怎样的止血措旌解决凝血问题,目前还没有常规止血指导方案.呼吸功能监测和呼吸道管理是肝移植后首先遇到的重要问题,因此呼吸机治疗和呼吸系统并发症的处理在ICU期间显得尤为重要.目的:回顾性分析肝移植手术中的出血特点以及出血/输血量对移植后呼吸功能恢复的影响.设计、时间及地点:回顾性病例分析,于2001-02/2006-09在中山大学附属第二医院肝胆外科完成.对象:资料完整的成人肝移植患者48例.根据病因将患者分为4组,单纯肝硬化组8例,肝硬化合并肝癌组32例,单纯肝癌不合并肝硬化组5例,急性炎症组3例.以出血量大于5 000 mL为界将患者分为2组,大量失血组9例,小量失血组39例.方法:了解不同病因患者移植手术中出血量对术后呼吸功能恢复的影响.回顾性分析手术各时期的出血量,包括切肝期,无肝期和新肝期,对各期的出血量进行统计分析,了解在肝移植手术过程中不同病因的患者手术不同时期出血的特点.主要观察指标:患者手术各时期的出血量.大量失血组及小量失血组手术后呼吸功能等恢复情况,围手术期并发症、死亡率.结果:病肝切除阶段是主要的出血时间段,以广泛渗血为主要特点.不同病因患者手术出血量明显不同,出血量最多为肝癌合并肝硬化、其他依次为肝硬化、急性重症肝炎及无肝硬化肝癌(P<0.05).出血量较大(>5 000 mL)明显影响患者移植后呼吸功能的恢复,并且造成较高的围手术期并发症发生率及死亡率(P<0.05).结论:在肝移植手术中,尤其是对肝癌合并肝硬化实施肝移植手术,控制切肝时间相广泛渗血是手术中主要的防止出血手段;大量出血、输血可能造成患者移植后呼吸功能恢复延迟,并且造成较高的呼吸系统并发症发生率及死亡率.     

Heavy chronic alcohol abuse has no additional adverse effect on the function of extrahepatic organs and ICU mortality in patients with liver cirrhosis

BACKGROUND AND AIMS: We questioned whether heavy chronic alcohol abuse influences extrahepatic organ failure and ICU mortality in cirrhotic patients admitted to a medical intensive care unit. PATIENTS AND METHODS: Medical records of 208 consecutive cirrhotic critically ill patients were reviewed. Patients were classified into two groups. Group A comprised 144 patients with liver cirrhosis due to heavy chronic alcohol abuse and group B, 64 patients with liver cirrhosis due to non-alcoholic causes. The presence of extrahepatic organ failures in patients of both groups was assessed with parameters determined on the day of admission to the ICU. Furthermore, ICU mortality was determined. RESULTS: The occurrence of extrahepatic organ failure was similar in group A and group B (83% vs. 80%; p = NS). The rate of extrahepatic organ failure was 1.7 +/- 1.2 organs in group A, compared to 1.4 +/- 1 organs in group B (p = NS). ICU mortality was 53% in group A and 44% in group B (p = NS). An increase in the number of extrahepatic organ failures was associated with a concomitant increase in ICU mortality in both groups of patients. CONCLUSION: The occurrence of extrahepatic organ failure and ICU mortality was not different between patients with liver cirrhosis secondary to heavy chronic alcohol abuse and patients with liver cirrhosis due to nonalcoholic causes. Cirrhotic patients should be admitted to a medical intensive care unit for extended intensive care treatment prior to the occurrence of extrahepatic multiple organ failure, independent of the underlying aetiology.     

人文关怀对肝硬化病人用药依从性的影响

目的评价人文关怀对肝硬化病人用药依从性的效果。方法选择132例肝硬化住院病人随机分为对照组（n=66）和观察组（n=66）,对照组采取常规治疗,观察组在常规治疗的基础上应用人文关怀,通过开展对医务人员加强自身素质的培养,注重传播技巧与心理沟通对病人进行健康教育和护理服务。观察两组用药依从性的变化。结果观察组通过人文关怀后,肝硬化病人用药依从性明显高于对照组（P〈0．05）。结论人文关怀能提高肝硬化病人用药依从性,有利于肝硬化病人的治疗和康复。