INTRODUCTION:Patients with significant liver fibrosis (SF) are likely to progress to advanced chronic liver disease (ACLD). Therefore, liver-directed therapy is indicated. The European Association for the Study of the Liver-2024 (EASL) recommends annual screening of patients with diabetes for SF/ACLD using the FIB-4 score, followed by vibration-controlled transient elastography (VCTE) in patients with FIB-4 ≥ 1.3 in ≤65-year-olds and ≥2.0 in > 65-year-olds. Because VCTE is not freely available in resource-limited settings, we revised the EASL algorithm to prioritise referrals for VCTE in such settings and validated it in an external cohort. METHODS:We conducted a cross-sectional study of adults with type 2 diabetes (T2DM) and ultrasonographic evidence of steatotic liver disease (SDL) attending three outpatient medical clinics in the Gampaha District, Sri Lanka. FIB-4 scores were calculated, and those with scores ≥1.3 underwent VCTE. SF was defined as liver stiffness measure (LSM) ≥ 8.0 kPa. Factors significantly associated with SF/ACLD were identified using multiple logistic regression (LR). We then developed a new criterion for VCTE referral and compared the number of referrals for VCTE when using the new criterion-based algorithm with the EASL algorithm. We validated the new criterion-based algorithm in an external cohort of 372 patients with MASLD. RESULTS:We studied 363 patients, and 128 had an FIB-4 score of≥1.3. Of them,121 underwent VCTE, and 76 had an LSM ≥ 8.0 kPa. On multivariable LR, VCTE-diagnosed SF/ACLD was independently associated with diabetes of ≥ 5 years duration (OR 3.8, p = 0.035), micro/macrovascular complications (OR 19.4, p = 0.016), and BMI of ≥ 25 kg/m2(OR 6.2, p = 0.003). We revised the VCTE referral criterion as "patients having EASL FIB-4 criterion plus one or more of the three other factors: diabetes of ≥ 5 years duration, presence of micro/macrovascular complications or BMI≥25 kg/m2,". The number of VCTE referrals indicated using the EASL algorithm was 96, compared to 83 with the new criterion, resulting in a 13.5% reduction. In the external validation cohort, the new algorithm reduced the number requiring VCTE referral by 15.5%. CONCLUSIONS:Adopting the new criterion for VCTE referral in patients with MASLD appears more cost-effective for detecting SF/ACLD in low-resource settings in South Asia.
BackgroundSleep quality is a common and often overlooked clinical issue among hemodialysis patients, which can affect physical and psychological quality of Life. This study intended to evaluate sleep quality and its determinants among patients receiving hemodialysis.MethodsA cross-sectional study was conducted at three hemodialysis centers in Anuradhapura and Polonnaruwa districts of Sri Lanka, including a random sample of 310 maintenance hemodialysis patients. The Pittsburgh Sleep Quality Index (PSQI) was used to assess the sleep quality of the patients. Socio-demographic information, dialysis and medical data, dietary and lifestyle information were also recorded. Several laboratory investigations were conducted before and after dialysis. Dialysis adequacy was calculated using single pool Kt/V. Multiple linear regression was performed to identify significant predictors of poor sleep quality.ResultsA significant majority (83.3%) of the population exhibited poor sleep quality. According to the PSQI, poor sleep latency and low sleep duration were key contributing factors. A significant association was observed between the sleep quality of patients and the number of dialysis sessions per week (p = 0.001), serum phosphorus level (p = 0.016) and several dialysis side effects. Total number of dialysis side effects and complications (p < 0.01), recovery time (p < 0.01) and post dialysis urea concentration (p = 0.027) depicted a significant positive correlation, while dialysis adequacy (p = 0.001), post dialysis sodium level (p = 0.006) and hemoglobin level (p = 0.005) had a notable negative correlation with global PSQI score of patients. A significant difference in overall sleep quality was observed among the categories of patients’ dialysis vintage (p = 0.032), appetite (p < 0.01) and dialysis center (p < 0.01). Dialysis vascular access depicted a marginal significance.ConclusionThe study revealed a striking prevalence of poor sleep quality in the population. According to the multiple linear regression model, dialysis center, dialysis access, number of dialysis side effects and complications, appetite and post dialysis serum urea level were identified as significant predictors of poor sleep quality in the population. Subsequent research should develop appropriate interventions to address inadequate sleep quality among hemodialysis patients.
Effective clinical communication has a significant impact on the continuity of treatment, minimi-sing errors and harm within healthcare settings.1,2 This is recognised as a core non-technical skill.3,4 Despite its critical importance, communication is frequently executed poorly, often characterised by the omission of vital information and the inclusion of unnecessary details.5 This deficiency highlights a pressing need for improved practices in both hospital and community environments. Evidence consistently demonstrates that employing a structured, standardised framework for clin-ical communication, such as ISBAR (Introduction, Situation, Background, Assessment, Recom-mendation), substantially enhances patient care.5-8 ISBAR provides a versatile communication tool suitable for use across various clinical practices. Its efficacy is maximised when all healthcare professionals involved are experienced in its use. Both healthcare students and practitioners should be provided with comprehensive education and training in ISBAR to ensure consistent delivery of high-quality communication.1 This paper aims to elucidate the key components of effective clinical communication, utilising the ISBAR framework as a guiding principle.
