BACKGROUND:Frailty is prevalent in end-stage liver disease and predicts higher waitlist and posttransplant mortality. Despite association of frailty with poor clinical outcomes, evidence-based interventions to reverse frailty remain scarce. METHODS:In this pilot study, we tested the feasibility of a novel home-based frailty intervention using home exercise equipment, a smartphone application, and remote frailty assessments to create a dynamic and personalized exercise program for patients with cirrhosis evaluated for liver transplantation. RESULTS:Fifty-four patients (mean 57.2 [±9.9] y, 59% men) enrolled in the study, with a mean Model for End-Stage Liver Disease-Na 16.9 (±5.8; 70% decompensated). The mean baseline Liver Frailty Index (LFI) was 3.59 (±0.60). The mean follow-up time was 259 (±190) d and the mean change in LFI at the end of the intervention was -0.11 (3.59 versus 3.48, P = 0.05), representing a clinically meaningful improvement in frailty previously associated with increased survival. In comparison, the retrospective control group, which had similar demographics and clinical characteristics as the intervention group, did not show a significant change in LFI (3.97 versus 3.91, P = 0.57). Fifty-six percent of patients were adherent (fully or partially) to recommended levels of exercise, and adherence rates declined from 1 to 3 mo after enrollment, underscoring the need to maintain patient engagement in exercise. CONCLUSIONS:This study shows that a home-based frailty intervention is feasible. The intervention led to significant improvement in frailty, which was not seen in the retrospective control group. Future studies, including randomized controlled trials, are necessary to further assess the efficacy of the intervention and also determine its impact on downstream clinical outcomes.

Introduction Hepatic encephalopathy (HE) is a frequent complication of cirrhosis, leading to preventable hospitalizations and increased mortality. Despite the availability of validated neuro-psychometric tests to diagnose HE, only 10% of clinicians regularly screen for HE due to lack of time, equipment, and trained personnel. Materials and Methods We studied the association between patient-reported cognitive function and the National Institutes of Health Toolbox Cognition Battery (a validated measure of HE) in patients with cirrhosis. A single-center prospective study of adult patients undergoing liver transplantation evaluation was performed from 10/2020 to 12/2021. Cognition was assessed using the National Institutes of Health Toolbox Cognition Battery and a brief Patient-Reported Outcomes Measurement Information System (PROMIS) survey. Results Twenty-three liver transplantation candidates were enrolled; the mean age was 56.4 (±9.7) years, 39% were female and the most common etiologies of cirrhosis were primary biliary cirrhosis/primary sclerosing cholangitis/overlap syndrome (30%), hepatitis C (22%) and alcohol-associated liver disease (22%). The mean MELD-Na was 14.9 (±6.4). The mean PROMIS Cognitive Function T-score (PROMISCF) was 49.2 (±9.6). The mean T-scores for the List Sort Working Memory test, Flanker Inhibitory Control and Attention test, and Pattern Comparison Processing Speed test were 46.4 (±9.9), 37.8 (±6.2), and 50.22 (±16.4), respectively. PROMISCF correlated with the List Sort Working Memory test (r = 0.45, P = .03). The mean hospitalization rate was 1.6 days admitted per month. On adjusted multivariate analysis, PROMISCF predicted total hospitalization days (P < .001), hospital admissions (P = .01), and hospitalization rate (P < .001). Conclusions A brief survey can screen for HE and predict hospitalizations in patients with cirrhosis.

Introduction: Microscopic colitis (MC) is a subset of the inflammatory bowel disease (IBD) family of diseases. Its pathogenesis is multifactorial, and risk factors include older age, woman sex, medication use, and autoimmune disease. Symptoms include chronic, persistent watery diarrhea, and patients are not thought to be at an increased risk of colon cancer. We present a rare case of MC with adjacent colonic metastatic serous carcinoma and focal intramucosal carcinoma. Case Description/Methods: A 66-year-old woman with a history of stage IV serous endometrial carcinoma who had chemotherapy and surgical debulking 2 years prior presented with >15 episodes of watery diarrhea with daily abdominal cramping for 3 months. Computed tomography (CT) of the abdomen and pelvis obtained 2 weeks prior for evaluation of diarrhea demonstrated new rectosigmoid wall thickening. Laboratory investigations for infectious diarrhea, IBD, anemia, and celiac disease were negative. Stool osmolar gap was consistent with secretory diarrhea. The patient then underwent a colonoscopy which revealed malignant appearing mass-like lesions in the ascending and transverse colon, and a nodular rectum. Biopsies from the ascending colon lesion revealed tubulovillous adenoma with high-grade dysplasia and focal intramucosal carcinoma. Biopsies from the transverse colon lesion and nodular rectum showed metastatic endometrial serous carcinoma. Random colon biopsies were consistent with MC. Patient was discharged with instructions to complete a tapered dose of budesonide, to follow up with her gynecologic oncologist, and to undergo repeat colonoscopy to rule out primary colon cancer at the ascending colon mass-like lesion. On follow-up 2 weeks later, patient reported significant improvement in diarrhea with 2-3 formed stools daily (Figure 1). Discussion: Patients with MC usually do not experience progression of the disease. Unlike Crohn’s disease or ulcerative colitis, MC is not associated with an increased risk of colon cancer. On endoscopy, colon is grossly normal, and colonic biopsies are required to confirm the diagnosis. Interestingly, our patient’s colon had multiple distinct pathologies present which is a very rare presentation. Further studies are needed to evaluate the association between MC, primary colon cancer, endometrial cancer, and other malignancies. Treatment of MC varies based on severity, but medical therapy (e.g., budesonide) remains first-line with surgical intervention reserved for refractory cases.Figure 1.: Focal intramucosal carcinoma arising from a tubulovillous adenoma in the ascending colon is shown in A. Cells in the transverse colon with abundant cytoplasm, marked atypia, and prominent nucleoli consistent with metastatic serous carcinoma are shown in B. Colonic mucosa with moderate chronic inflammation with lymphocytosis and lymphoid aggregates compatible with microscopic/lymphocytic colitis is shown in C. Nodular rectum is shown in D, the transverse colon mass-like lesion is shown in E, and the ascending colon mass-like lesion is shown in F.

BACKGROUND:Frailty is prevalent in patients with end-stage liver disease and predicts waitlist mortality, posttransplant mortality, and frequency of hospitalizations. The Liver Frailty Index (LFI) is a validated measure of frailty in liver transplant (LT) candidates but requires an in-person assessment. METHODS:We studied the association between patient-reported physical function and LFI in a single-center prospective study of adult patients with cirrhosis undergoing LT evaluation from October 2020 to December 2021. Frailty was assessed with the LFI and 4-m gait speed. Patient-reported physical function was evaluated using a brief Patient-Reported Outcomes Measurement Information System (PROMIS) survey. RESULTS:Eighty-one LT candidates were enrolled, with a mean model of end-stage liver disease-sodium of 17.6 (±6.3). The mean LFI was 3.7 (±0.77; 15% frail and 59% prefrail) and the mean PROMIS Physical Function score was 45 (±8.6). PROMIS Physical Function correlated with LFI ( r  = -0.54, P  < 0.001) and 4-m gait speed ( r  = 0.48, P  < 0.001). The mean hospitalization rate was 1.1 d admitted per month. After adjusting for age, sex, and model of end-stage liver disease-sodium, patient-reported physical function-predicted hospitalization rate ( P  = 0.001). CONCLUSIONS:This study suggests that a brief patient-reported outcome measure can be used to screen for frailty and predict hospitalizations in patients with cirrhosis.