Symptomatic Ascites Research Articles

Outpatient Management of Symptomatic Ascites: Bypassing the Path of Least Resistance.

Outpatient Management of Symptomatic Ascites: Bypassing the Path of Least Resistance.

PSEUDOMYXOMA PERITONEI SECONDARY TO A VERY RARE OVARIAN CANCER: PRIMARY INFILTRATIVE INTESTINAL TYPE MUCINOUS ADENOCARCINOMA OF THE OVARY WITH INTESTINAL METASTASIS (A CASE REPORT)

Pseudomyxoma peritonei (PMP) syndrome is a disease that typically occurs from ruptured appendiceal mucocele neoplasms. PMP syndrome may arise from malignant transformation of a primary ovarian cancer. In this case study, we present the evaluation and treatment of a 48-year-old patient diagnosed with a left ovarian mass and significant symptomatic abdominopelvic mucinous ascites. Peritoneal cytology indicated paucicellularmucin. The final diagnosis confirmed the presence of diffuse peritoneal adenomucinosis. The treatment approach involved a cytoreductive surgery and chemotherapy. Our findings contribute to the existing body of literature endorsing the use of this intensive treatment approach, typically reserved for advanced abdominal malignancies. We applied this strategy to a patient presenting with a rare clinical entity, further supporting its efficacy in such cases.

The role of cytology in patients undergoing pressurized intraperitoneal aerosol chemotherapy (PIPAC) treatment for peritoneal carcinomatosis.

Cytology of ascites or peritoneal washing is a routine part of staging of peritoneal metastases (PM). We aim to determine value of cytology in patients undergoing pressurized intraperitoneal aerosol chemotherapy (PIPAC). Single-center retrospective cohort study included consecutive patients having PIPAC for PM of different primary between January 2015 and January 2020. A total of 75 patients (median 63 years (IQR 51-70), 67 % female) underwent a total of 144 PIPAC. At PIPAC 1 59 % patients had positive and 41 % patients had negative cytology. Patients with negative and positive cytology only differed in terms of symptoms of ascites (16% vs. 39 % respectively, p=0.04), median ascites volume (100 vs. 0 mL, p=0.01) and median PCI (9 vs. 19, p<0.01). Among 20 patients who completed 3 PIPACs (per protocol), cytology changed in one from positive to negative, and in two from negative to positive. Median overall survival was 30.9months in the per protocol group and 12.9months in patients having <3 PIPACs (=0.519). Positive cytology under PIPAC treatment is more frequently encountered in patients with higher PCI and symptomatic ascites. Cytoversion was rarely observed and cytology status had no impact on treatment decisions in this cohort.

Rare occurrence of pseudomyxoma peritonei (PMP) syndrome arising from a malignant transformed ovarian primary mature cystic teratoma treated by cytoreductive surgery and HIPEC: a case report

BackgroundPseudomyxoma peritonei (PMP) syndrome is a disease process that typically occurs from ruptured appendiceal mucocele neoplasms. PMP syndrome arising from malignant transformation of an ovarian primary mature cystic teratoma (MCT) is a pathogenesis rarely encountered.Case PresentationHerein, we report a 28-year-old patient evaluated and treated for a right ovarian mass and large volume symptomatic abdominopelvic mucinous ascites. Molecular profiling and genetic analysis revealed mutations in ATM, GNAS, and KRAS proteins while IHC demonstrated gastrointestinal-specific staining for CK20, CDX2, CK7, and SATB2. Peritoneal cytology showed paucicellular mucin. Diffuse peritoneal adenomucinosis (DPAM) variant of PMP arising from a ruptured ovarian primary MCT after malignant transformation to a low-grade appendiceal-like mucinous neoplasm was ultimately confirmed. Treatment included staged therapeutic tumor debulking and right salpingo-oophorectomy followed by cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC).ConclusionsOur report builds upon the existing literature supporting this aggressive treatment option reserved for advanced abdominal malignancies utilized in this patient with a rare clinical entity.

A nurse-led day-case gastroenterology service in the emergency department

The incidence of liver disease has been steadily increasing, and patients with severe, symptomatic ascites need paracentesis (drainage) of the ascitic fluid for management. The authors and colleagues have previously developed a nurse-led and nurse-managed day-case gastroenterology service that provides paracentesis and other treatments, such as blood transfusion and specialist biologic infusions to patients with inflammatory bowel disease (IBD) and other gastroenterological conditions. This article describes the development of a similar novel nurse-led day-case service within the emergency department (ED) to provide a front-door urgent service for patients attending ED and needing paracentesis/infusions. It also reflects on the journey to developing this service, as well as the challenges faced during to the COVID-19 pandemic.

Safety and feasibility of a nurse-led ambulatory abdominal paracentesis service.

63 Background: Ascites is a common complication of cancer. Symptomatic ascites contributes to cancer-related morbidity and is distressing for patients (pts). Therapeutic abdominal paracentesis (TAP) provides symptom relief but requires specialized procedural knowledge and is usually performed in the inpatient setting with several days of hospitalization. Additionally, high hospital bed occupancy during the COVID-19 pandemic prevented timely admission for TAP. An Advanced Practice Nurse (APN)-led ambulatory TAP service was introduced at our center, with the aim of improving access to TAP and reducing hospital bed occupancy. Methods: A multidisciplinary team developed workflows and safety guidelines for TAP to enable right-siting of pts in a cancer day care unit. Pts were scheduled for radiologically guided insertion of abdominal drains in the morning before 10am to allow adequate time for drainage. Pre-procedure clinical examination and safety checks were performed by APNs in the day unit. Following the procedure, abdominal fluid was drained with concurrent administration of 20% IV albumin. Drains were removed by the APN and pts were examined before discharge on the same day. Data for all cancer pts requiring TAP in the day unit and hospital from 1 Jan to 30 Nov 2020 were extracted from the electronic medical record system. The primary outcome was length-of-stay (LOS). The primary safety outcome was adverse events in the day unit. Continuous data were compared using the t-test. Data analysis was done in SPSS version 22. Results: The number of TAPs performed in the day unit and general ward requiring hospitalization were 102 and 133, respectively. There was a significant reduction in average LOS with TAPs performed in the day unit vs. hospitalization (1.48 vs. 5.82 days, p&lt;0.001) (Table). The mean difference was 4.34 (95% confidence interval 3.33 - 5.34) days saved per pt, or a saving of 443 inpatient bed days. The TAP day unit service encountered 10 adverse events (AEs) requiring admission to the ward for continued drainage. AEs were borderline baseline blood pressure, pt frailty and inability to care for an indwelling catheter. There were no infective or bleeding complications. The majority of TAPs (86.8%) were performed in one day, with the remainder over 2-days with the abdominal drain left in-situ and reattendance at the day unit the next day for further drainage. Differences in average length-of-stay with TAP in the hospital vs. day unit. Conclusions: An APN-led ambulatory abdominal paracentesis service is a safe alternative to inpatient paracentesis. Optimal utilization of a day unit enabled reduced LOS for pts with advanced cancer. This reduction in LOS was critical during a pandemic where bed demand was high. This was possible from advanced scheduling and control over the day unit capacity.[Table: see text]

Tunnelled Peritoneal Catheter for Malignant Ascites-An Open-Label, Prospective, Observational Trial.

Simple SummaryRecurrent abdominal fluid collection (ascites) is a common clinical problem in patients with advanced malignancy that causes abdominal discomfort, nausea, fatigue and dyspnoea. Repetitive large volume paracentesis is the standard procedure that relieves patients from abdominal fluid; however, the procedure is painful and needs to be repeated up to several times per week. Tunnelled peritoneal PleurX catheters are implanted in the abdominal cavity as a permanent solution to drain ascites and can be used by the patient or nursing staff at home. In this study, we prospectively investigate the feasibility and safety of tunnelled peritoneal PleurX catheters in patients with malignant ascites. Our findings show that this technique is safe and can be routinely used. Tunnelled peritoneal PleurX catheters effectively reduce ascites-associated symptoms and hospitalization rates. Therefore, this technique should be considered in patients with recurrent malignant ascites.Treatment of recurrent malignant ascites in cancer patients is a challenge. Evidence based guidelines regarding the best treatment strategy are lacking. The aim of this prospective study was to investigate the safety and efficacy of a tunnelled peritoneal catheter (PleurX) in cancer patients with symptomatic ascites. Patients with symptomatic, diuretics-refractory ascites and indication for the implantation of a tunnelled peritoneal PleurX catheter were prospectively enrolled between August 2018 and July 2020. The number of catheter days, complications, amount of drained ascites and ascites-associated symptoms and hospitalization rate pre- and post-PleurX insertion were analysed. 51 Patients (64.7% male) were prospectively enrolled. The mean age was 66.6 (±7.9) years. The most common cause of ascites was pancreatic adenocarcinoma (n = 10) followed by cholangiocellular carcinoma (n = 9) and hepatocellular carcinoma (n = 8). The technical success rate of PleurX implantation was 100%. The mean volume of weakly drained ascites was 5.44l (±4.08). Major complications included cellulitis (n = 2), peritonitis and drainage dislocation (each n = 1). The mean catheter days per patient was 59.8 (±107.4) (Min 4, Max 668). Abdominal discomfort, impaired mobility, dyspnoea, fatigue, nausea and vomiting were significantly reduced 30 days after PleurX insertion (p < 0.05). Moreover, hospitalization rate was significantly reduced (p < 0.001; 27.08% of days preimplantation vs. 11.27% postimplantation). We conclude that implantation of a tunnelled ascites catheter is a safe and effective method for the treatment of refractory ascites in cancer patients with advanced disease. Serious complications are rare. Burdensome ascites-associated symptoms and hospitalization rates can be significantly reduced over a longer period of time.

REZOLVE (ANZGOG-1101): A phase 2 trial of intraperitoneal bevacizumab to treat symptomatic ascites in patients with chemotherapy-resistant, epithelial ovarian cancer

BackgroundThe primary aim of this study was to evaluate the activity of intraperitoneal bevacizumab (IP-bev) in delaying re-accumulation of malignant ascites in women with chemotherapy-resistant epithelial ovarian cancer (CR-EOC) who have ceased chemotherapy. Secondary outcomes were safety and quality of life. MethodsWomen with CR-EOC and malignant ascites that reaccumulated within 28 days of their last paracentesis (P-1) were administered IP-bev 5 mg/kg following their first therapeutic paracentesis on study (P0). Additional doses of IP-bev were allowed at each subsequent paracentesis (P1, P2, etc) provided the interval from the last dose was 42 days or greater (median time from first to second therapeutic ascitic drainage). Results24 participants (median age 67 years [range 38–86]; median 4.5 lines prior systemic treatment [range 1–12]; ECOG performance status of 0 in 1, 1 in 8, and 2–3 in 15) were recruited. The doses of IP-bev administered were 1 in 13 participants, 2 in 5, 3 in 2, 4 in 1, and 5 in 1. The proportion with a TTP of >42 days using competing risk analysis was 77% (95% CI 58–92). Median time from P0 to P1 or death was 48 days (range 8–248). Median paracentesis-free interval (P0–P1 or death) was 4.29-fold (95% CI 2.4–5.8) higher following a first dose of IP-bev compared with the time between paracenteses prior to study entry (P-1–P0). ConclusionIP-bev was safe, active, and warrants further study as a palliative intervention for recurrent ascites in CR-EOC patients receiving best supportive care.

Revisiting Meigs Syndrome: A Typical Case Report

This case report is written concerning a patient with Meigs Syndrome. The patient initially presented with symptomatic ascites. Further investigation found evidence of a pleural effusion, ascites, and a 19-centimeter pelvic mass. The mass was surgically removed and found to be a benign mucinous cystadenofibroma. After the removal of the mass, the ascites and pleural effusion resolved spontaneously and did not recur. The clinical picture of ascites, pleural effusion, and cystadenofibroma with the resolution of fluid collections after removal of the mass is consistent with a diagnosis of Meigs Syndrome. While the clinical picture of ovarian mass with concomitant ascites and pleural effusion is concerning for malignancy, clinicians need to be reminded of Meigs Syndrome as a possible diagnosis with benign etiology.

Medically tailored meals for the management of symptomatic ascites: the SALTYFOOD pilot randomized clinical trial.

BackgroundAscites is a costly, morbid complication of cirrhosis. Although a low-sodium diet is central to the clinical management of ascites, its efficacy is limited by poor adherence. We aimed to determine the feasibility and impact of low-sodium medically tailored meals (MTM) intervention.MethodsWe enrolled 40 persons with cirrhosis and ascites at the time of a paracentesis in a 12-week, 1:1 randomized trial of standard of care (SOC) (low-sodium diet educational handout) or MTM with <2,000 mg of sodium, >2,100 kcal, and >80 g of protein including a nocturnal protein supplement. We determined the proportion of eligible candidates recruited and adherence to MTM. The primary outcome was the number of paracenteses performed during weeks 0–12. We also collected ascites-specific quality-of-life (ASI-7) scores.ResultsThe median age of the enrolled subjects was 54 (IQR, 47–63) years, 46% were female, with median MELD-Na 18 (IQR, 11–23) and albumin 2.7 (IQR, 2.5–3.3) g/dL. At baseline, subjects reported a median of two (IQR, 1–3) paracenteses in the prior 4 weeks. Adherence to the meal schedule was excellent save for when hospitalizations occurred. After 12 weeks, patients in the MTM arm required fewer paracenteses per week than those in the SOC group [median (IQR): 0.34 (0.14–0.54) vs 0.45 (0.25–0.64)]. During the trial, four (20%) SOC patients died, whereas two (10%) died and one (5%) was transplanted in the MTM arm. Ascites-specific quality of life improved to a greater degree in the MTM arm compared to the SOC arm, by 25% (IQR, –11% to 61%) vs 13% (IQR, –28% to 54%).ConclusionA trial of MTM for persons with ascites is feasible and potentially effective. Both arms experienced benefits, highlighting the role for improved education and closer monitoring in this challenging condition.

Invasive Procedure Use for Symptomatic Ascites and Pleural Effusions Management in Recurrent Epithelial Ovarian Cancer Patients in the Era of Vascular Endothelial Growth Factor (VEGF) Inhibitor Therapy

Invasive Procedure Use for Symptomatic Ascites and Pleural Effusions Management in Recurrent Epithelial Ovarian Cancer Patients in the Era of Vascular Endothelial Growth Factor (VEGF) Inhibitor Therapy

Palliative Paracentesis in the Home Setting: A Case Series.

Management of ascites-related symptoms in home hospice and palliative care patients can be challenging. Ultrasound-guided paracentesis is a standard intervention for this indication, but generally requires transfer to a hospital or outpatient interventional-radiology (IR) setting; thus, such interventions are often not practical or attainable for home hospice and palliative care patients. To describe a mobile, in-home service that provides home-based palliative paracentesis (HBPP) as an interventional palliative option for patients with distressing symptoms related to ascites. Retrospective case series. Setting/Subjects: Thirty patients with ascites, confirmed by portable bedside ultrasound, who underwent HBPP at their residence. Thirty-three patients were referred for HBPP for symptomatic abdominal distention from March 1, 2019 to March 1, 2020. Thirty (91%) patients had ultrasound-confirmed ascites and received HBPP. All 30, verbalized appreciable symptom relief post-intervention. There were no reported post-procedural complications. Home-based palliative paracentesis is a safe, effective, and convenient intervention for hospice and palliative care patients with symptomatic ascites.

Use of indwelling pleural/peritoneal catheter in the management of malignant ascites: a retrospective study of 48 patients.

Patients suffering from malignant ascites usually require repeated large volume paracentesis (LVP) for symptomatic relief. This often requires hospital admission and has inherent risks. To report the first Australian experience of placing tunnelled indwelling peritoneal catheters (IPeC) for management of recurrent malignant ascites. A retrospective study was conducted of tunnelled IPeC use in patients with symptomatic malignant ascites in four hospitals in Western Australia (from 2010 to 2018). Procedure data, success rate and safety profile were collected from a database. Forty-eight patients (median age 65 years; female 56%) underwent 51 peritoneal catheter insertion procedures that were performed mostly by pleural specialists. The majority of patients (96%) had prior LVP (median two drainages, interquartile range (IQR) 1-4) before IPeC insertion. The IPeC was inserted successfully under ultrasound guidance in all patients. The median length of hospital stay for IPeC insertion and initial ascites drainage was 2 days (IQR 2-3 days) and most patients (96%) did not require further paracentesis after IPeC placement. The majority (96%) of patients experienced relief from ascites symptoms after catheter insertion. Most IPeC-related adverse events were self-limiting, including pain (in 25% cases), transient hypotension after initial fluid drainage (10%), peritoneal fluid leakage (10%), bacterial peritonitis (8%), fluid loculation (2%) and catheter dislodgement (2%). Six (12%) patients had IPeC removed. All patients with bacterial peritonitis responded to antibiotics and one required catheter removal. Use of tunnelled IPeC improves symptoms and can minimise further invasive drainage procedures in patients with symptomatic malignant ascites. Placement of IPeC was associated with a low rate of adverse events, most of which could be managed conservatively.

Safety and efficacy of ultrasound-guided pigtail catheter insertion in pediatric intensive care unit: A single-center experience

Objective: The study objective was to describe the safety and efficacy of ultrasound (US)-guided pigtail catheter (PC) (USGPC) placement at bedside for symptomatic pleural effusion and ascites in acute critically ill children in pediatric Intensive Care unit. and not critical care unit (PICU).Study Design: This was a descriptive study.Place: This study was conducted at the pediatric critical care unit (PICU) of The Indus Hospital, Karachi, Pakistan, from January 2018 to December 2019.Subjects and Methods: We retrospectively reviewed the electronic medical records of critically ill children who underwent USGPC insertion for symptomatic pleural effusions and ascites on bedside. Demographic data, clinical indication, success rate, and complications of procedures were collected using a structured questionnaire approved by the institutional ethical committee. The PC of 10–14 French size was placed under US guidance, using Seldinger technique by a pediatric intensivist team on bedside with procedural sedation and analgesia.Results: Forty patients (3.7% of the total admission) required PC insertion. The mean age of the patients was 8.3 years, and 55% (n = 22) were male. Nearly 85% (n = 34) of the patients had an underlying malignancy and presented as respiratory distress/failure secondary to either large pleural effusion and/or massive ascites. Indications were pleural effusions (n = 26, 65%) and ascites (n = 14, 35%). The procedure was successful in 92.5% of the patients. The mean duration of PC insertion was 13.9 days. Pneumothorax developed in three cases (7.5%) as a procedure-related complication, which resolved after chest tube insertion. None of the patients developed bleeding, or visceral injury. Resolution occurred in all cases.Conclusion: USGPC placement at bedside by intensivists for percutaneous drainage in symptomatic pleural effusion and ascites is a simple, safe, and an effective modality for critically ill children.

Early Paracentesis in High-Risk Hospitalized Patients: Time for a New Quality Indicator.

Symptomatic ascites is the most common indication for hospitalization in patients with cirrhosis. Although guidelines recommend paracentesis for all inpatients with ascites, the timing of paracentesis is likely to be crucial. Performance of an early paracentesis and its relationship to outcomes are unknown, particularly among patients at high risk of spontaneous bacterial peritonitis (SBP). We included 75,462 discharges of adult patients with cirrhosis presenting with ascites who underwent paracentesis from the State Inpatient Databases of New York, Florida, and Washington from 2009 to 2013. High-risk patients were identified as having concomitant hepatic encephalopathy or acute kidney injury present on admission. The primary outcome was performance of early paracentesis (within 1 hospital day) with secondary outcomes being inpatient mortality, SBP-related mortality, and 30-day readmission. Multivariable logistic regression models included a priori covariates known to impact outcomes. There were 43,492 (57.6%) patients who underwent early paracentesis. High-risk patients (27,496) had lower rates of early paracentesis (52.8% vs 60.5%, P < 0.001). On multivariable analysis, high-risk patients had significantly decreased odds of undergoing early paracentesis (odds ratio [OR] 0.74, 95% confidence interval [CI] 0.71-0.78, P < 0.001). Early paracentesis was associated with a reduced inpatient all-cause mortality (OR 0.68, 95% CI 0.63-0.73, P < 0.001), SBP-related mortality (OR 0.84, 95% CI 0.73-0.94, P = 0.01), and 30-day readmission (OR 0.87, 95% CI 0.82-0.92, P < 0.001). Early paracentesis is associated with reduced inpatient mortality, SBP-related mortality, and 30-day readmission. Given its impact on outcomes, early paracentesis should be a new quality metric. Further education and interventions are needed to improve both adherence and outcomes.

Design and rationale of a randomized-controlled trial of home-delivered meals for the management of symptomatic ascites: the SALTYFOOD trial.

BackgroundWhen patients with cirrhosis develop ascites, it is associated with sharply increased mortality and healthcare utilization with decreased quality of life. Dietary salt restriction is first-line therapy for ascites but it is limited by poor adherence.MethodsWe will recruit 40 patients with cirrhosis and ascites who have received a recent paracentesis or hospitalization for a 1:1 randomized trial of standard care (education on salt restriction) versus home-delivered meals. Our primary outcome is the number of paracenteses needed over 12 weeks. Secondary outcomes include hospital-bed days, health-related quality of life (HRQOL, Ascites Symptom Inventory-7 and Visual Analogue Scale) and performance on batteries of physical function including hand grip (kg) and walk speed (m/s). All subjects follow up through a series of calls where any paracenteses, hospital readmissions, weight changes and diuretic dosage changes are recorded. In a final Week 12 visit, knowledge of dietary sodium intake, quality of life and frailty are reassessed, and satisfaction with the meal-delivery program is evaluated. Paired comparison testing will be conducted between the two arms.DiscussionA nutritionally standardized meal-delivery program for patients with cirrhosis and ascites post discharge has a variety of potential patient-based benefits, including the effective management of ascites, reduction of healthcare utilization and improvement of HRQOL. We have three core hypotheses. First, patients will report interest in and satisfaction with a home-delivered meals program. Second, subjects on a salt-restricted (2 g sodium) meal-delivery program will have fewer therapeutic paracenteses and all-cause readmissions than subjects receiving standard of care. Third, subjects on a salt-restricted (2 g sodium) meal-delivery program will report increased HRQOL compared to subjects receiving standard of care.

The Decision for TIPS for Refractory Ascites: How to Weigh the Social Aspects Involved in Undocumented Patientsʼ Care

Transjugular intrahepatic portosystemic shunt (TIPS) insertion is associated with a number of serious complications and thus necessitates a careful consideration of the risks and benefits to the procedure individualized to each patient. Such assessments usually include relevant clinical characteristics of a patient, but the social dynamics may need to be considered as well. We present the case of an undocumented 45—year—old male with a history of former alcohol abuse and alcoholic cirrhosis (MELD 16, Child—Pugh Class B) who presented with symptomatic massive ascites. One month prior to the admission, the patient's diuresis regimen had been increased to maximum intensity. However, the patient upon admission was unsure whether he had been taking the correctly increased regimen or the prior one. After multiple large—volume paracenteses, the patient expressed that after discharge he would return to his native country in order to be with his family given his relatively poor prognosis. Furthermore, he requested for any definitive intervention that would decrease the likelihood of further episodes of symptomatic ascites, as he did not trust the medical care in his home country. TIPS procedure was considered in order to hopefully provide the patient a resolution to his refractory ascites, though it was unclear whether the patient had truly failed a maximized diuretic regimen. Furthermore, the patient's urinary sodium excretion suggested diuretic sensitivity. Upon suggestion of an appropriate diuretic trial after discharge with subsequent follow up for TIPS consideration as an outpatient, the patient responded that his plan was to leave for his home country immediately after discharge in order to not waste any of his remaining time left with his family. The decision regarding TIPS as an inpatient given the social circumstances despite the ambiguity regarding the patient meeting clinical criteria was deliberated extensively by all providers involved in the patient's medical care. Ultimately, the decision was made to avoid TIPS as an inpatient based on the principle to avoid possibly causing harm to the patient from a complication of a procedure that may not have been medically indicated. Our case demonstrates an ethical dilemma with regard to how strictly medical professionals should abide by criteria indicating when a procedure is necessary. While other providers may disagree, we felt the principle of “Do no harm” prevailed in our estimation of the patient's care.

Validation of the Edmonton Symptom Assessment System: Ascites Modification

ContextFew patient-reported outcomes are available to measure the symptoms associated with malignant-related ascites in patient care and clinical research. Although the Edmonton Symptom Assessment System: Ascites Modification (ESAS:AM) is a brief tool to measure symptoms associated with malignant-related ascites, it remains to be fully validated. ObjectivesThe objective of the study was to validate the ESAS:AM in Japanese cancer patients. MethodsWe assessed the internal consistency, test-retest reliability, concurrent validity, and construct validity in 292 Japanese adult patients with cancer. They completed Japanese versions of the ESAS:AM, M.D. Anderson Symptom Inventory, European Organization for Research and Treatment of Cancer Quality of Life Questionnaire–Core 30, and abdominal pain/ascites subscales of the EORTC Core Quality of Life Questionnaire, 26-item pancreatic cancer module. ResultsCronbach's alpha coefficient of the ESAS:AM was 0.89. The intraclass correlation coefficient on test-retest examination of its total score was 0.93 (P < 0.001). Pearson correlation coefficients of the total score of the ESAS:AM with the total score of the M.D. Anderson Symptom Inventory and abdominal pain/ascites subscales of the EORTC Core Quality of Life Questionnaire, 26-item pancreatic cancer module ranged from 0.44 to 0.81 (P < 0.001) and those with global health status/quality of life and functional subscales of the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire–Core 30 ranged from −0.40 to −0.61 (P < 0.001). The total scores of the ESAS:AM were significantly higher in 20 patients with symptomatic ascites (34 [SD, 26]) than 267 patients without symptomatic ascites (23 [SD, 19]) (P = 0.018). ConclusionThe ESAS:AM is a reliable and valid tool for measuring symptoms associated with malignant-related ascites and can be used in daily patient care and future epidemiological studies and clinical trials.

The Role of Ultrasound-Guided Therapeutic Paracentesis in an Outpatient Transitional Care Program: A Case Series.

Patients with ascites suffer from distressing symptoms and are at high risk for readmission after hospitalization. Timely paracentesis is an important palliative tool in managing this vulnerable population. At our institution, we have developed a multidisciplinary transitional care program for patients discharged from the hospital with a wide range of complex conditions including refractory ascites. We present a case series of 10 patients with symptomatic ascites who were enrolled in our transitional care program and treated with ultrasound-guided therapeutic paracentesis in our clinic. Patient medical records were retrospectively reviewed to collect procedure details, outcomes, and follow-up data on emergency department (ED) visits and readmissions. Cost data were obtained from the hospital financial system. Over the span of 9 months (September 2016 to July 2017), 22 total therapeutic paracenteses were performed on 10 unique patients in the transitional care clinic. Median age of the patient cohort was 52.5 years (range: 27-71 years). All patients reported immediate relief of ascites-related discomfort following the procedure. We did not observe any major adverse effects due to the in-clinic procedure. Nine of the 10 patients did not have any ED visits or readmissions within 30 days of discharge. The cost of performing ultrasound-guided paracentesis in the transitional care clinic was US$546.77 compared to US$978.32 when performed in the hospital. Our experience suggests that outpatient paracentesis may be a safe, feasible, and cost-effective means of providing symptom management for patients with ascites during their transition from hospital to home.

Tackling 30-Day Readmissions in Patients with Cirrhosis

Many patients with decompensated cirrhosis will be re-admitted within 30 days after discharge. Why many of these readmissions reflect the severity of the patients underlying disease—and can be lifesaving—others may be preventable, revealing gaps in systems of care. This review summarizes reasons for and interventions designed to improve readmission rates and why they work (or do not). The principle reasons for readmission include hepatic encephalopathy, symptomatic ascites, complications of medical management, and substance abuse-related admissions. Strategies to reduce readmissions generally succeed in two ways: (1) developing and providing viable alternatives to hospitalization for early decompensations and (2) optimal utilization of proven therapeutic modalities for the treatment of hepatic encephalopathy. Interventions can be targeted (aiming to improve one component of care), structural (reorganizing care delivery to improve quality), and comprehensive (structural with multiple targeted approaches). Recent literature has shown how smartphone applications may be developed to help reduce readmissions. Interventions that aim to reduce readmissions among patients with decompensated cirrhosis should be developed with reference to the lessons from prior published reports.