Nurse-led Clinic For Patients With Liver Cirrhosis .
Nurse-led clinic forpatients with livercirrhosis – effects onhealth-related qualityof lifeNCT02957253Date: 08/08/2018
Open access ProtocolMaria Hjorth,1,2 Daniel Sjöberg,1 Anncarin Svanberg,2,3,4 Elenor Kaminsky,3Sophie Langenskiöld,3 Fredrik Rorsman2To cite: Hjorth M, Sjöberg D,Svanberg A, et al. Nurseled clinic for patients withliver cirrhosis—effects onhealth-related quality of life:study protocol of a pragmaticmulticentre randomisedcontrolled trial. BMJ Open2018;8:e023064. on Liver cirrhosis affects health-relatedquality of life (HRQoL) even in its early stages. Morbidityis especially high when the disease decompensates andself-care actions become essential. Nurse involvementin secondary prevention in other chronic diseases hascontributed to better symptom control, less need ofinpatient care and improved HRQoL. In order to evaluatethe impact of nurse involvement in the follow-up ofpatients with liver cirrhosis, we decided to comparestructured nurse-led clinics, inspired by Dorothea Orem’snursing theory and motivational strategies, with a groupof patients receiving standard care. The primary outcomeis HRQoL and the secondary outcomes are quality of care,visits to outpatient clinics or hospitals, disease progressand health literacy.Methods and analysis This is a pragmatic, multicentrerandomised controlled study conducted at six Swedishhepatology departments. Eligible patients are adults withdiagnosed cirrhosis of the liver (n 500). Participantsare randomised into either an intervention with nurseled follow-up group or into a standard of care group.Recruitment started in November 2016 and is expectedto proceed until 2020. Primary outcomes are physical andmental HRQoL measured by RAND-36 at enrolment, after1 and 2 years.Ethics and dissemination The study is ethically approvedby the Regional Ethical Review Board in Uppsala. Theresults shall be disseminated in international conferencesand peer-reviewed articles.Trial registration number NCT02957253; Pre-results.Correspondence toMrs Maria Hjorth;m aria. hjorth@ medsci. uu. seIntroductionThe incidence of liver cirrhosis in Sweden isapproximately 14 per 100 000 citizens eachyear.1 It is a disease with high mortality aswell as high morbidity, affecting patient’shealth-related quality of life (HRQoL).Fatigue and depression are already frequentduring the early, compensated, phase of livercirrhosis and are believed to impair HRQoLby affecting the patient’s social life.2 HRQoL Prepublication history forthis paper is available online.To view these files, please visitthe journal online (http:// dx. doi. org/ 10. 1136/ bmjopen- 2018- 023064).Received 19 March 2018Revised 21 June 2018Accepted 8 August 2018 Author(s) (or theiremployer(s)) 2018. Re-usepermitted under CC BY-NC. Nocommercial re-use. See rightsand permissions. Published byBMJ.Center of Clinical Reaerch inDalarna, Falun, Sweden2Department of MedicalSciences, Uppsala UniversitetMedicinska fakulteten, Uppsala,Sweden3Department of Public Healthand Caring Sciences, UppsalaUniversity, Falun, Sweden4Dalarna University, Falun,SwedenStrengths and limitations of this study This pragmatic multicentre randomised controlledstudy design enables evaluation of a nurse-led clinic intervention in patients with liver cirrhosis in thereal-life context. All nurses involved in the study are proficient in thefield of liver diseases, having a holistic understanding of the situation of liver cirrhosis. The generic health-related quality of life instrumentRAND-36 is used as a Swedish version of a liver-specific instrument is currently unavailable. There is a risk of unwittingly transferring the intervention to the control group. This is counteracted bythe multicentre design and will shorten the time forrecruitment of participants.is further impaired in the decompensatedpatients, when symptoms of ascites, hepaticencephalopathy (HE) or variceal haemorrhage occur.3 4In the compensated stages, lifestyle changesare important to prevent or delay diseaseprogression. While in the decompensatedphase, customised lifestyle changes and selfcare become essential in the management ofthe disease.5 Unstructured follow-up in outpatient settings causes frequent readmissionsdue to the reappearance of complicationsof cirrhosis. The reason may be drug-relatedside effects, for example, diuretics, non-adherence to self-care or medical treatment.One-third of these episodes are said to bepreventable with closer follow-up in an outpatient setting.6 7Motivating patients for self-care activitiesis essential in nursing care. For this, Orem’stheory of nursing,8 consisting of the threetheories: self-care, self-care deficit and thenursing system may be applied. This theoryHjorth M, et al. BMJ Open 2018;8:e023064. doi:10.1136/bmjopen-2018-0230641BMJ Open: first published as 10.1136/bmjopen-2018-023064 on 17 October 2018. Downloaded from http://bmjopen.bmj.com/ on 8 January 2019 by guest. Protected by copyright.Nurse-led clinic for patients with livercirrhosis—effects on health-relatedquality of life: study protocol of apragmatic multicentre randomisedcontrolled trial
Open access Methods and analysisThe protocol follows the statement of Standard ProtocolItems: Recommendations for Interventional Trials 2013,18for study protocol and Template for Intervention Dscription and Replication (TIDieR).19 .Study designThe study has a pragmatic, multicentre randomisedcontrolled comparative design.Study armsPatients in the intervention group obtain structuredvisits to nurse-led clinics depending on the severity ofthe disease. The intervention is adjunctive, that is, theintervention is added to standard care. Patients in thecontrol group get standard inpatient and outpatient careaccording to clinical routines.Study sitesThe study settings consist of six outpatient clinics at hepatology departments in Sweden, two county hospitals andfour university hospitals. None of the clinics had structured nursing care for patients with liver cirrhosis at thebeginning of the study. The six outpatient clinics serve2Table 1Inclusion and exclusion criteriaInclusion criteriaExclusion criteriaDiagnosed livercirrhosis within the past24 monthsFollow-up at thehepatology departmentInsufficient knowledge of theSwedish languageAge 18–85 yearsComorbidityPersistent hepatic encephalopathygrades 2–4Chronic obstructive pulmonarydisease grades 3–4Coronary heart disease New YorkHeart Association FunctionalClassification (NYHA) classes 3–4DementiaActual advanced cancerStroke with sequelaeSevere psychiatric diseaseRenal failure requiring dialysisa population of approximately 2 000 000 individuals,comprising about 20% of Sweden’s population.Eligibility criteriaDiagnosis of liver cirrhosis is based on clinical investigation, laboratory findings, histology, MRI, computertomography, ultrasound or elastography. Factors likely tostrongly affect the primary variable due to other reasonsthan liver cirrhosis, that is, severe comorbidities and thoseunable to adhere to the study protocol, that is, persistent,overt HE, are excluded. Inclusion and exclusion criteriaare presented in table 1.Screening and recruitment of participantsInvitation letters are sent by intervention nurses (INs),offering oral information. Patients are invited to ascreening visit to IN for baseline measurements. Thosewho meet inclusion criteria are registered. Patients, whoagree to participate, hereafter denoted as participants,are randomised after giving informed consent. Newlydiagnosed patients are recruited consecutively (figure 1).INs are responsible facilitators and consecutively followparticipants.RandomisationComputerised randomisation (Randomize.Net, Interrand, Ottawa, Canada) is performed at the screening visitwith randomly mixed block sizes of 4, 6 and 8, stratifiedby study site and disease severity in terms of compensated or decompensated state (figure 1). Blinding ofthe randomisation sequence is applicable to all involvedpersonnel; allocation will be 1:1. Baseline measurementsare completed before randomisation. Further blinding isnot possible in this study.Hjorth M, et al. BMJ Open 2018;8:e023064. doi:10.1136/bmjopen-2018-023064BMJ Open: first published as 10.1136/bmjopen-2018-023064 on 17 October 2018. Downloaded from http://bmjopen.bmj.com/ on 8 January 2019 by guest. Protected by copyright.guides nurses to identify and support patients to enter selfcare for better symptom control and improved health.8–10In liver cirrhosis, management of patients with livercirrhosis is traditionally taken care of by physicians, whilenurse-led clinics are still rare. However, previous studieson liver cirrhosis, nurse-led clinics have suggested thatnurse-led clinics will contribute to better patient concordance with physician recommendations11–13 and medicaltreatment,11 12 with positive effects on patients HRQoL.12Furthermore, there are indications that nurse-led clinicsincrease the quality of care by increasing the numberof patients treated according to medical healthcareguidelines.12 Finally, the patients have reported a highdegree of satisfaction by nursing care in such outpatientsettings.12 14 Despite these reports, the significance ofadjunctive nurse-led clinic to standard care by physicianin liver cirrhosis is unclear. Conversely, in chronic heartfailure, nurse-led care is established and proved equallyeffective as traditional care by the physician withinoutpatient settings.15 The holistic and person-centredapproaches by the nurse, including motivational strategies, have been shown to be crucial in the secondaryprevention of chronic heart disease, reducing the needfor inpatient care and to increase HRQoL.16 17 Hence,the experience from nurse-led clinics in chronic heartdisease is likely to provide guidance regarding content,methods and necessary skills in the set-up of nurse-ledclinics within the field of liver cirrhosis.The aim with the present study is to compare HRQoLin patients with liver cirrhosis receiving either adjunctivenursing care based on Orem’s nursing theory or standardcare only in outpatient settings.
Open accessDescription of the interventionParticipants in the intervention group offer scheduledindividual visits to INs at the nurse-led clinic, in addition to visits to a physician according to clinical practice. Intervals between visits to the nurse-led clinic arevarying from once yearly in compensated stable disease,up to two visit per month in decompensated disease(figure 2). The tailored frequency and content of visitsare individualised to promote person-centred care(table 2).Participants in the control group will receive standardcare by physicians within hepatology inpatient or outpatient clinics as required and a yearly follow-up for datacollection by IN within the study (figure 2).Figure 2 Study measurements and intervention nurse visit interval. CRT, continuous reaction time; IN, intervention nurse;MELD, Model for End-Stage Liver Disease; NVS, Newest Vital Sign; PHES-test, psychometric HE score; QPP, quality of carefrom the patient’s perspective; RFH-NPT, Royal Free Hospital-Nutritional Prioritising Tool.Hjorth M, et al. BMJ Open 2018;8:e023064. doi:10.1136/bmjopen-2018-0230643BMJ Open: first published as 10.1136/bmjopen-2018-023064 on 17 October 2018. Downloaded from http://bmjopen.bmj.com/ on 8 January 2019 by guest. Protected by copyright.Figure 1 Recruitment and randomisation of participants. CC, compensated control group; CI, compensated interventiongroup; DC, decompensated control group; DI, decompensated intervention group; LC, liver cirrhosis.
Open access Disease severityFrequency of visits Content of visitsCompensated diseaseOnce yearlyDecompensated diseasewithin 12 months orPreviously decompensateddisease1–2 visits/monthEvery third monthChild Pugh scoreModel for End-Sage Liver Disease (MELD)-scoreThe Royal Free Hospital-Nutritional Prioritising ToolAssessment of: ascites, encephalopathyMotivation to lifestyle changesPsychosocial issuesChild Pugh scoreMELD scoreThe Royal Free Hospital-Nutritional Prioritising ToolAssessment of: ascites, encephalopathy, side effects of medical treatmentMotivation to self-care and/or lifestyle changesPsychosocial issuesEach visit to INs contains assessment of disease severityto enable early action against disease progression andmalnutrition (table 2). The intervention includes treatment and nursing care inspired by Dorothea Orem’snursing theory.10 Further, motivational interviewing(MI),20 communication strategies will be used. BothOrem’s theory and MI implies that individuals have anintrinsic motivation to make appropriate choices, topromote health and prevent disease or to perform actionsto counteract disease.10 20 The task of the IN is to assess theparticipants’ self-care needs and their ability to performessential self-care in order to discover self-care deficits.To evoke participants’ motivation, INs listen and reflecton preparatory and mobilising change talk. In addition,INs give information adherent to MI techniques to facilitate participants understanding of actual self-care andmedical treatment (figure 3). When applicable, INs offernext of kin instructions to help the participant achieveself-care.Figure 34The areas of the intervention are: (1) monitoring riskfactors for deterioration of the liver disease, (2) information and motivation to perform self-care and adhere tomedical treatment, (3) nutrition assessment and support,(4) motivation of lifestyle changes essential for preventingor delaying disease progress and (5) psychosocial care.A booklet written by MH is handed to all INs describingthese five areas converted into terms of Orem’s nursingtheory.One objective of INs’ use of MI is to promote engagement and increased collaboration between IN and participant via the MI spirit concepts: partnership, evocation,compassion and acceptance. Another objective is that INsevoke participants’ own motivation and explore patients’own thoughts about a target behaviour when there isneed for behavioural change. When participants expressmobilising ‘change talk’,20 they are ready for the planning phase (figure 3). The intervention is individuallytailored and INs’ activities depend on actual needs. AnThe four processes of motivational interviewing techniques. IN, intervention nurse; MI, motivational interviewing.Hjorth M, et al. BMJ Open 2018;8:e023064. doi:10.1136/bmjopen-2018-023064BMJ Open: first published as 10.1136/bmjopen-2018-023064 on 17 October 2018. Downloaded from http://bmjopen.bmj.com/ on 8 January 2019 by guest. Protected by copyright.Table 2 Description of the intervention
Open accessIntervention nursesAt each of the six clinics, 1–2 INs are involved in theintervention. All of these are registered nurses with aminimum of 2 years experience from hepatology inpatient or outpatient care. Implementation of the intervention and training of INs include a 6-hour seminar with ashort description of MI and Orem theories followed bya 3-day training to perform MI. INs are also educated inpathophysiology of liver cirrhosis, nursing care accordingto presenting symptoms, study bias and study instruments.Scheduled tutorial group sessions to follow the intervention and MI practice will be due every 6 months for all INsduring the study period.Study pilotingA pilot of the intervention and patient questionnaire wasperformed in Falun from 2014 to 2015 with 26 participating patients. The aim was to define the actual size ofthe population available for the study and to assess thetime and budget for the INs’ assignment.Baseline sociodemographic data collectionSociodemographic data collected at enrolment arepresented in figure 2.Primary outcomePhysical and mental HRQoL are the two main outcomesin the present study measured by RAND-36.21 RAND-36consists of 36 category scale questions: the answer to eachquestion ranges from 0 to 100, a higher value predictsbetter health. From the RAND-36 questionnaire, eightsubscales are derived: (1) physical functioning, (2) rolelimitations caused by physical health problems, (3) pain,(4) energy/fatigue, (5) social functioning, (6) role limitations caused by emotional problems, (7) emotional wellbeing and (8) general health perception. Out of the eightsubscales, two summary components are derived: Physical Component Summary (PCS) and Mental Component Summary (MCS).21 22 HRQoL measurements bythe RAND-36 has high validity and reliability to identifydifferences in HRQoL over time within and comparedwith patient populations with different chronic diseases.22Secondary outcomesPatient’s perspective of quality of care due to a changein follow-up strategy: The questionnaire quality of carefrom the patient’s perspective (QPP)23 includes fourdimensions: (1) medical-technical competence, (2)physical-technical conditions, (3) identity-orientatedapproach and (4) sociocultural atmosphere. Withineach dimension, the participants first value their experience of the specific care aspects they have received Hjorth M, et al. BMJ Open 2018;8:e023064. doi:10.1136/bmjopen-2018-023064 ((1) totally agree, (2) agree in large part, (3) partlyagree or (4) do not agree) and second, the importance of these aspects ((1) of greatest importance, (2)of great importance, (3) of some importance or (4) oflittle or no importance). The difference between theexperienced care and the importance of each question is categorised as: excess of, balanced or lack ofquality of care. A short form of QOP has been foundvalid and reliable.24 In the present study, participants receive a modified QPP 38-item questionnaireadjusted for patients with liver cirrhosis in outpatientcare. The modification has been approved by theinstrument developer. The questionnaire includes avariation of yes/no questions, category scales from 1to 4 and open-ended questions.Visits at outpatient clinics and admissions to hospital:Visits at outpatient clinics, number of admissions tohospitals and days of inpatient care at medical wardsor intensive care units will be recorded as measures ofhealthcare consumption. In case of significant clinicaloutcomes, these data will later be used to perform aseparate health economic analysis.Disease progress1. Child Pugh score25 includes five variables: serumalbumin, serum bilirubin, prothrombin time,ascites and encephalopathy. Each variable gradingfrom 1 to 3 and the total range is 5–15. A highervalue means a more advanced disease. Three riskclasses are derived: A score 5–6, B score 7–9 andC score 10–15.262. The Model for End-Stage Liver Disease (MELD)27predicts the 3-month mortality of patients withchronic end-stage liver disease. Based on laboratory findings, MELD is a valid and reliable instrument. The formula for MELD is constant fordisease aetiology, the calculation score is: 9.57 x loge (creatinine mg/dL) 3.78 x log e (bilirubin mg/dL) 11.20 x log e (INR) 6.4. The score is continuous, ranging from 6 to 40, a high score predicts anincreased risk of mortality within 3 months.283. The Royal Free Hospital-Nutritional PrioritisingTool (RFH-NPT)29 assesses the risk of malnutritionin liver cirrhosis as a predictor of disease deterioration and transplant-free survival. RFH-NPT correlates with deterioration of the liver disease anddivides participants into low (0 points), medium(1 point) or high (2–7 points) risk groups formalnutrition. Parameters taken into account arenutritional history (unplanned weight loss, dietaryintake body mass index) and current complicationsof liver cirrhosis (acute alcoholic hepatitis, ascites,general fluid overload). The instrument used in thestudy is a translation into Swedish from the Englishversion. Validation of the translation is made in aresearch seminar within the research group.4. Appearance of decompensation episodes (eg,ascites, overt HE and variceal bleed) is assessed atscreening, after 12 months and after 24 months5BMJ Open: first published as 10.1136/bmjopen-2018-023064 on 17 October 2018. Downloaded from http://bmjopen.bmj.com/ on 8 January 2019 by guest. Protected by copyright.information booklet about liver cirrhosis is available toparticipants as a complement to oral information.Standard care includes flexible visits or telephonefollow-up by physicians, gastroscopies, ascites drainage,registered nurse telephone counselling by a nurse notparticipating in the study and inpatient care.
Open access Participant flow through the studyStudy time for each participant is 24 months (figure 2),after which participants in the intervention groupmay continue their follow-up at the nurse-led clinic ifthey want to. Participants in the control group may beoffered follow-up at the nurse-led clinic after the end ofstudy. Data collection and frequency of visits to INs arepresented in figure 2. Reasons for withdrawal from thestudy are liver transplantation, move out of follow-up areaor mortality. In case of two consecutive cancelled visits6to an IN, a reminder will be sent, asking participants tocontact INs for further participation in the study.Data analysis and sample size calculationAnalysis includes the two primary variables in RAND-36:the PCS and the MCS. These components will be calculated based on weights from the oblique method,36 toavoid potential problems in interpretation due to negative weights. A repeated measurements model will be usedfor analysis of baseline, 12 and 24 months values of thecomponent summary score. Treatment group, time (baseline, 12, 24 months) with interaction, and decompensated/compensated state will be fixed effects, while sitewill be a random effect in the model. The main contrastof interest to be estimated with this model is change frombaseline to month 24 for both treatment groups. For thetreatment group comparison, Bonferroni-Holm methodusing a corrected alpha 2.5% will be used to compensatefor multiple testing of both PCS and MCS.All tests will be two sided. For analyses of secondary variables, p values 0.05 are considered significant. Multipleimputation will be used for missing values.For the power calculation, a SD of 9 points was usedbased on back-calculated residual variances from CIs forMCS.37 A change of 3–5 points is estimated to be a minimally clinically important difference and corresponds toan effect size of 0.09–0.28.22 It is argued that even smallerchanges are important,38 and a change of 2.5 points istherefore considered to be potentially relevant for thepower calculation. To ensure a power of 0.80 for theeffect size of 2.5 points and a Bonferroni-corrected alphalevel of 2.5%, the recommended sample size is 250 participants per treatment group, that is, 500 in total.39 With acalculated 33% non-inclusion rate, enrolment time is estimated from November 2016 to December 2020 or until500 participants are included.Patient involvementFive patients contributed with comments on the questionnaire that resulted in changes in tree of the 78 questions.No patients were involved in study design, research question or recruitment. The results will be disseminated tothe study participants in a short summary after the publication of the study.Strengths and limitationsThis randomised controlled trial in the field of nursing isa complex intervention with a pragmatic design and has ahigh risk of confounding factors. In a pragmatic design,40the research aim is to reflect the clinical practice. Participant heterogeneity and a minimum of exclusion criteriaare therefore allowed to a larger extent. The researchermust be aware of factors that may bias study results. In thisstudy, participants may have other chronic diseases thatmay affect HRQoL. Patients with severe comorbidity arenot included in this trial as it would have required a largersample than available. A prolonged study of 5 years raisesthe risk of unwitting transfer of the intervention on toHjorth M, et al. BMJ Open 2018;8:e023064. doi:10.1136/bmjopen-2018-023064BMJ Open: first published as 10.1136/bmjopen-2018-023064 on 17 October 2018. Downloaded from http://bmjopen.bmj.com/ on 8 January 2019 by guest. Protected by copyright. through medical records. HE is common in livercirrhosis with a cumulative risk of 30%–40%.30According to the West-Haven criteria,31 HE rangesfrom 0 to 4. Grades 0–1 mean subclinical or minimalsymptoms (covert HE) and grades 2–4 meansevere neuropsychiatric symptoms (overt HE).30Even milder grades of HE affect HRQoL.30 31 Inthe majority of cases, HE is treatable. Two psychometric tests in combination are recommended todetect covert HE.30 In this study, the psychometricHE score (PHES) and continuous reaction time(CRT) are used:a. PHES consists of five-step paper and penciltests,32 and includes a line drawing test, a serialdotting test and a digit symbol test to examinemotor speed and accuracy, visual perception,visuospatial orientation, visual construction,concentration and attention. The test ends upwith a score ranging from 6 to 18; 4 or less isthe cut-off for a pathological result.b. CRT33 is a 10 min test with auditory stimuli inheadphones in intervals of every 2–6 s. It teststhe reaction time and endurance by pushing atrigger button after a signal. Using the softwareEKHO reaction-time analysis tool, an index 1,9 with 150 repetitions separate HE from otherbrain dysfunctions with a specificity of 0.92 andsensitivity of 0.93.Health literacy (HL): involves a person’s abilityto receive, process and understand basic medicalinformation in making decisions and taking actionsto promote health.34 The grade of HL may influence the intervention as it impacts the participants’ability to understand and translate information intopractice. The instrument Newest Vital Sign,35 whichconsists of six standardised questions about nutritionlabel information, is used. The questions is asked byINs, the correct answer scores 1 point, a score of 4or above indicates no limits of HL and scores below4 indicate limited HL. The instrument is translatedfrom English to Swedish within another study (Healthliteracy among Swedish lung transplant recipients 1–5years after transplantation, A Lennerling, A Kisch andA Forsberg, personal communication, 2018). Validation of the translation has been made in a researchseminar within our research group and the risk oftranslation errors was judged to be low.
Open accessDisseminationThe study result will be published in peer-reviewed journals and presented at international conferences. Theresult will be used for education and competence development within the field. Study results are reported on thegroup level.Acknowledgements To Frank Miller for statistical support and to patient advisersfor comments in development of the patient questionnaire.Contributors MH has contributed to the design, implementation of the study andresponsible for drafting the manuscript. DS has taken part in the design of thestudy and supervised MH in drafting the Manuscript, and has approved the finalmanuscript. AS has taken part in the design of the study and supervised MH inHjorth M, et al. BMJ Open 2018;8:e023064. doi:10.1136/bmjopen-2018-023064drafting the manuscript, and has approved the final manuscript. EK has taken partin the design of the study and supervised MH in drafting the Manuscript, and hasapproved the final manuscript. SL has taken part in the design of the study andsupervised MH in drafting the manuscript, and has approved the final manuscript.FR has taken part in the design of the study and supervised MH in drafting themanuscript, and has approved the final manuscript.Funding This work was supported by Ester Åsberg Lindberg foundation and Centrefor Clinical Research in Dalarna. The CRT equipment was funded by Norgine.Competing interests None declared.Patient consent Obtained.Ethics approval The study has been approved by the Regional Ethical ReviewBoard in Uppsala (Dnr: 2016/146) and is performed according to the Declaration ofHelsinki and to the Swedish Ethical Review Act.Provenance and peer review Not commissioned; externally peer reviewed.Open access This is an open access article distributed in accordance with theCreative Commons Attribution Non Commercial (CC BY-NC 4.0) license, whichpermits others to distribute, remix, adapt, build upon this work non-commercially,and license their derivative works on different terms, provided the original work isproperly cited, appropriate credit is given, any changes made indicated, and the useis non-commercial. See: http:// creativecommons. org/ licenses/ by- nc/ 4. 0/.References1. Nilsson E, Anderson H, Sargenti K, et al. Incidence, clinicalpresentation and mortality of liver cirrhosis in Southern Sweden:a 10-year population-based study. Aliment Pharmacol Ther2016;43:1330–9.2. Nardelli S, Pentassuglio I, Pasquale C, et al. Depression, anxietyand alexithymia symptoms are major determinants of healthrelated quality of life (HRQoL) in cirrhotic patients. Metab Brain Dis2013;28:239–43.3. Arguedas MR, DeLawrence TG, McGuire BM. Influence of hepaticencephalopathy on health-related quality of life in patients withcirrhosis. Dig Dis Sci 2003;48:1622–6.4. Younossi ZM, Boparai N, Price LL, et al. Health-related quality of lifein chronic liver disease: the impact of type and severity of disease.Am J Gastroenterol 2001;96:2199–205.5. Tsochatzis EA, Bosch J, Burroughs AK. New therapeutic paradigmfor patients with cirrhosis. Hepatology 2012;56:1983–92.6. Agrawal K, Kumar P, Markert R, et al. Risk factors for 30-dayreadmissions of individuals with decompensated cirrhosis. SouthMed J 2015;108:682–7.7. Volk ML, Tocco RS, Bazick J, et al. Hospital readmissions amongpatients with decompensated cirrhosis. Am J Gastroenterol2012;107:247–52.8. Orem D. Nursing: concepts of practice. United States of America:McGraw-Hill Book Company, 1980:225.9. Aish AE, Isenberg M. Effects of Orem-based nursing intervention onnutritional self-care of myocardial infarction patients. Int J Nurs Stud1996;33:259–70.10. Orem DE, Renpenning KM, Taylor SG. Self care theory in nursing:selected pap
care for better symptom control and improved health. 8–10 In liver cirrhosis, management of patients with liver cirrhosis is traditionally taken care of by physicians, while nurse-led clinics are still rare. However, previous studies on liver cirrhosis, nurse-led clinics have suggested that nurse-led clinics will contribute to better patient .
Aug 21, 2019 · philips lytecaster 344dstx-302mrex-42017-4 led 120 led 120 led 120 led 120 led 120 led 120 led 120 led 120 led 120 led 120 led 120 led 120 led 120 led 120 led 120 led 120 led 120 . recessed white 4" recessed downlight led, 1160 delivered lumens, 3000k, 90 cri cree lighting eaton mcgraw-edison ist-af-350-
Bruksanvisning för bilstereo . Bruksanvisning for bilstereo . Instrukcja obsługi samochodowego odtwarzacza stereo . Operating Instructions for Car Stereo . 610-104 . SV . Bruksanvisning i original
Clinic County Clinic Name Clinic Address Clinic City Clinic Zip Participant County Participant Gender Enrollment Status Fax Received Date BLACK HAWK CHRIST, MEREDITH - IAM 1015 S HACKETT RD WATERLOO 50701 BLACK HAWK Female Unreachable 4/21/2014
4,994 Alamosa VA Clinic 24,091 Aurora VA Clinic 1,430 Burlington VA Clinic 17,685 Denver VA Clinic: 63,884 Golden VA Clinic: 2,311 IDES 15,372 Jewell VA Clinic 4,343 La Junta VA Clinic 1,580 Lamar VA Clinic 172,745 PFC Floyd K. Lindstrom VA Clinic 66,385 PFC James Dunn VA Clinic 583,038 Rocky Mountain Regional VA Medical Center 874 Salida VA .
10 tips och tricks för att lyckas med ert sap-projekt 20 SAPSANYTT 2/2015 De flesta projektledare känner säkert till Cobb’s paradox. Martin Cobb verkade som CIO för sekretariatet för Treasury Board of Canada 1995 då han ställde frågan
service i Norge och Finland drivs inom ramen för ett enskilt företag (NRK. 1 och Yleisradio), fin ns det i Sverige tre: Ett för tv (Sveriges Television , SVT ), ett för radio (Sveriges Radio , SR ) och ett för utbildnings program (Sveriges Utbildningsradio, UR, vilket till följd av sin begränsade storlek inte återfinns bland de 25 största
Hotell För hotell anges de tre klasserna A/B, C och D. Det betyder att den "normala" standarden C är acceptabel men att motiven för en högre standard är starka. Ljudklass C motsvarar de tidigare normkraven för hotell, ljudklass A/B motsvarar kraven för moderna hotell med hög standard och ljudklass D kan användas vid
IBM Security Directory Integrator Version 7.2 Installation andAdministrator Guide SC27-2705-02
