Quality of life in the cirrhosis registry during the SARS-CoV-2 lockdown in Slovakia

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The SARS-CoV-2 coronavirus pandemic has led to several restriction measures and psychosocial consequences whose impact on QOL has combined with that of cirrhosis in an unknown way. Therefore, we have used our cirrhosis registry to assess quality of life before the pandemic (at the first admission to the tertiary liver unit) and during the most pronounced phase of the first lockdown. Materials and Methods : In this cross-sectional study conducted during the first lockdown in Slovakia (from April to May 2020), we have repeated the QOL measurement of QOL in cirrhotic patients previously enrolled in the RH7 registry. Of the entire RH7 cohort, we have identified patients who were alive (according to the national registry of deaths) and contacted them by phone with a structured and standardized interview led by trained professionals. The tool used for both QOL measurements (at enrolment to RH7 and during the lockdown) was standardized and validated EuroQol-5D (EQ-5D) questionnaire. Results : The study included 97 patients, of which 37 (38.1%) were women and 60 (61.9%) were men. Responses were achieved from 75 patients (68,18%). In general, patients have scored their quality of life significantly higher during the pandemic compared to examination at admission to RH7 (that is, on admission to our tertiary liver unit with cirrhosis) (p = 0.005). In particular, of the domains included in EQ-5D, I.) self-care was better during lockdown compared to the first record on admission to RH7 (p<0.001); II.) the ability to perform daily activities has also improved during lockdown (p = 0.002); on the other hand, III.) pain and discomfort have not changed significantly during lockdown compared with previous measurement (p = 0.882), IV.) anxiety and depression were lower during lockdown compared to admission to RH7 (p = 0.01). Conclusion : The quality of life in patients with liver cirrhosis was better during the lockdown of SARS-CoV-2 compared to the previous measurement at admission to the tertiary liver unit. liver cirrhosis quality of life COVID19 pandemic EuroQOL treatment of cirhosis Figures Figure 1 Figure 2 Figure 3 Figure 4 Introducton Liver cirrhosis is the final stage of chronic liver diseases of various etiologies, characterized by loss of functional parenchyma, compensatory regeneration, and fibrosis, leading to disorganization of liver architecture and function [ 1 , 2 ]. The global prevalence of cirrhosis has ranged from 0.15–0.27% and in Slovakia it is the highest in the world (1–6). The most common causes of cirrhosis are alcohol-associated liver disease (ALD), nonalcoholic or metabolic-associated fatty liver disease (NAFLD, MAFLD), autoimmune syndromes (autoimmune hepatitis, primary biliary cholangitis, primary sclerosing cholangitis, etc.), hepatitis B and hepatitis C, and many others (10). Cirrhosis patients have a poor prognosis which is primarily mediated by acute decompensation, especially by its subtype - acute on chronic liver failure (ACLF) [ 7 – 9 ]. In addition to its impact on hard endpoints such as mortality, cirrhosis is associated with human suffering captured in the domain of patient-reported outcomes (PRO); the most frequently measured PRO is quality of life (QOL) [ 10 – 13 ]. Quality of life is the metric of well-being associated with the severity of cirrhosis [ 14 – 16 ]. The World Health Organization has defined QOL as a subjective assessment of the perception of its reality in health [ 17 , 18 ]. Determining quality of life is essential in all areas of medicine, and quality of life was incorporated it into the main dataset of RH7 Cirrhosis Registry. The pandemic caused by SARS-CoV-2 infection and COVID- 19 disease has severely affected all aspects of the healthcare system [ 19 ]. The Slovakian government has declared restrictive lockdown measures to control the spread of the infection in March 2020. Gatherings of more than six people and all mass events were banned. Sports competitions were limited and allowed without spectators and all fitness and wellness centers had to be closed [ 20 ]. In our previous study, we evaluated the impact of lockdown on mortality in patients with cirrhosis, registered in RH7 [ 21 ]. Our results pointed to a distorted path to specialized liver care with fewer visits and admissions to a tertiary liver unit and, since we were separated from most of our locked patients, we were unable to sense their personal experiences during the most demanding period of time in our society. Therefore, we decided to take advantage of the fact that we have previously measured their QOL and, together with the most trivial telemedicine at hand (telephone), to compare their previous (baseline) QOL with the repeated assessment during the lockdown. The main objective of our study was to evaluate QOL in patients with cirrhosis during lockdown and to compare the results with the QOL as measured previously – at their enrolment in the cirrhosis registry RH7. Methods The study is a combination of the registry study (RH7, NCT04767945) in which QOL is a core baseline parameter, with the cross-sectional investigation determining QOL during the lockdown. The main objective of this study was to compare QOL at the time of enrollment in Registry HEFITO (RH7) with the QOL subsequently measured during the lockdown. The study population consisted of patients with liver cirrhosis, registered in RH7; RH7 has been operating in our liver unit since 2014 and enrols consecutive consenting adults admitted to the hospital with liver cirrhosis [ 22 ]. Patients with terminal liver disease or severe comorbidity, which can limit short-term life expectancy, are not enrolled in RH7. Among other baseline parameters recorded at admission to our liver unit and in RH7, a generic EuroQol-5D questionnaire (EQ-5D) is administered; this tool has been selected for its validity and reproducibility in liver diseases and for its brevity [ 23 ]. At the first admission to our liver unit with liver cirrhosis, patients completed their first EQ-5D and the results were recorded in the RH7 core dataset. Subsequently, in the second part of the study, which was conducted during the first lockdown in Slovakia in April-May 2020, EQ-5D was administered by healthcare professionals who have contacted all survivors in RH7 identified in the National Registry of Deceased by an investigator. Interviewing physicians were trained for a structured dialogue whose content and explicit reading were approved by the Ethics Committee of our academic hospital – F. D. Roosevelt teaching Hospital, Banska Bystrica, Slovakia The physicians have introduced themselves (most of them got familiar with patients during the previous hospitalization), asked for permission to continue, and explained the aim of the call and the study: to see how they are and to repeat the formal determination of QOL by EQ-5D (EQ-5D was explained to be the same as previously - at the entry to RH7). After a pause, the interviewing physicians asked for explicit consent and wrote it down; only then they proceeded to EQ-5D. The physicians then recorded all the responses from the patients using a pen and paper method. If there was no response to the first phone call, the call was repeated three times in three consecutive days; after that, the result was recorded as ‘No Connect’. If the patient contacted declined participation, the result was recorded as ‘Declined to participate’. Euroqol-5d (Eq-5d) EuroQol-5D (EQ-5D) is a generic questionnaire to measure QOL which has been validated in various diseases [ 24 ]. EQ-5D has been shown to be valid in liver patients comparable to our cohort [ 25 ]. EQ-5D measures five aspects underlying quality of life: mobility, self-care, daily activities, pain, anxiety, and depression, together with the patient’s assessment of perceived health status on a visual analogue scale. The final EuroQol- 5D is defined as a score between 0 and 100 recorded by an individual for their current overall quality of life. A pilot test was conducted before the start of the study to determine the feasibility of submitting a questionnaire. The owner of EQ-5D has kindly granted HEGITO permission to use it. The Sample (Flowchart) The study included 97 patients, of which 37 (38.1%) were women and 60 (61.9%) were men. An additional 22 patients (not yet listed in the National Registry of Deceased) were identified dead during the study (Figure. 1). The characteristics of the sample are shown in Table 1 . Table 1 Baseline participant´s characteristics N = 97 Age (years) 55.9 ± 11.8 Gender: Women (N) 37 (38.1%) Men (N) 60 (61.9%) Weight (kg) 79.8 ± 18.4 Height (cm) 171.6 ± 10.0 BMI (kg/m 2 ) 27.0 ± 5.6 Etiology of cirrhosis ALD (N/%) 69 (71.13%) Other (N/%) 28 (28.87%) MELD 17.84 ± 7.63 Child-Pugh Score 8.90 ± 2.44 Liver frailty index (LFI) 4.48 ± 0.94 Notes: Age was recorded at the baseline – entry into registry RH7. Data are presented as mean ± SDLFI was calculated at https://liverfrailtyindex.ucsf.edu/ Statistical analysis Patient data were recorded to an Excel spreadsheet and subsequently subjected to statistical analysis using the IBM SPSS software package. Due to the ordinal type of data of individual EuroQOL items, we assessed differences in values during the prepandemic period and the pandemic using a nonparametric paired Wilcoxon Signed Ranks test. A paired t -test was used to determine differences between the total EuroQOL score and Visual Analog Scale. Results 97 patients from the RH7 cirrhosis registry were enrolled, aged 55.9 (± 11.8) years with 38.1% of women. The median MELD score was 17.84 (± 7.63), the median Child-Pugh score was 8 9 (± 2.44). These scores are characteristic of advanced cirrhosis (Table 1 ). The median time between the two examinations was 184 days. 1). The baseline QOL was significantly worse than QOL assessed during the lockdown (Table 2 and Table 3 ). Three of the EQ-5D domains have differed significantly between the two-time points: 1) self-care, 2) usual activities, and 3) anxiety/depression have improved during lockdown (Table 2 ). The numerical decrease in mobility observed during lockdown was not statistically significant (p = 0.10). There was no change in the pain and discomfort (p = 0.882). Detailed results are shown in Tables 2 and 3 and frequencies are shown in Figs. 2 – 4 . Table 2 Values of EuroQOL scores with specification of individual domains (lower scores represent better self-perceived quality of life) Item of the EuroQOL Period Mean score Z-score* p-Value* EuroQOL score (1) (2) (3) (4) (5) Mobility Baseline 2.082 -1.631 0.103 42.3% 29.9% 13.4% 6.2% 8.2% Lockdown 1.856 48.5% 27.8% 14.4% 8.2% 1.0% Self-care Baseline 1.845 -3.462 < 0.001 61.9% 16.5% 6.2% 6.2% 9.3% Lockdown 1.320 82.5% 7.2% 6.2% 4.1% 0.0% Usual activities Baseline 2.082 -3.077 0.002 51.5% 17.5% 13.4% 6.2% 11.3% Lockdown 1.588 66.0% 13.4% 16.5% 4.1% 0.0% Pain / Discomfort Baseline 1.814 -0.148 0.882 46.4% 33.0% 14.4% 5.2% 1.0% Lockdown 1.804 55.7% 16.5% 19.6% 8.2% 0.0% Anxiety / Depression Baseline 1.639 -2.501 0.012 61.9% 18.6% 15.5% 2.1% 2.1% Lockdown 1.340 77.3% 14.4% 5.2% 3.1% 0.0% *according to paired Wilcoxon Signed Ranks Test Note: Baseline period – during the first hospitalization; Lockdown period – during the pandemic In the Visual Analog Scale for overall quality of life feeling there was a significant increase in the score in favor of the lockdown period (p = 0.017). The Final Score of EuroQoL was significantly lower during the pandemic compared with the baseline and it was consistent in both sexes (p < 0.005, Table 3 , Fig. 2 ). Table 3 EuroQOL – Summary of the scores for quality of life (QoL) in patients with liver cirrhosis on admission to the hospital (baseline) and during the lockdown. EuroQOL Period Mean t-score* p Value* Final score Baseline 9.42 2.870 0.005 Lockdown 7.91 Visual Analog Scale Baseline 65.06 -2.434 0.017 Lockdown 72.08 *according to paired t -test Note: Baseline period – during the first hospitalization; Lockdown period – during the pandemic Discussion The teleological background of this study dwells in our leveraging the once-in-a-lifetime combination of our longer-term focus on patient-reported outcomes. On the one hand, we combined it with an unprecedented psychosocial test tube milieu inflicted by the lockdown. Before the spread of the SARS-CoV-2 virus, we have been collecting data on QOL (in cirrhosis registry). It is important to note that 1) the RH7 registry was founded in 2014 as our response to cirrhosis becoming the number-one cause of death in young adults in Slovakia and 2 ) the QoL became the core variable in RH7 only in subsequent years; also that 3) of the two alternative tools assessing QOL (generic, and disease specific) we opted for the former. EuroQOL has higher sensitivity and specificity between the cirrhosis-specific instruments. It has been developed by Younoussi [ 26 ] reportedly having a cumulative advantage of reproducibility, validity, validity in Europeans, validity in liver diseases, comparability with other diseases and brevity (30–32). After an initial shock from the pandemic, we found ourselves cut from the majority of outpatients including patients with cirrhosis whom we used to see regularly after discharge. Our RH7 registry included hospitalized patients mainly with decompensated cirrhosis and a poor prognosis. We began to conceive a way to actively contact them in order to learn how they were and help them in case of need. At this stage, we decided to elevate our effort to a formal study using the EuroQOL In general, cirrhosis is associated with a low quality of life [ 13 ]. It is chronic and progressive in nature leading to deterioration in mental and physical functioning while significantly impacting on the quality of life. Also, a disease driven decrease in the quality of life can be further multiplied by other individual psychological and psychosocial factors. It is increasingly recognized as an important outcome of cirrhosis. The use of a quality-of-life questionnaire can identify high-risk patients with poor quality of life and worse prognosis. Understanding the importance of quality of life is an important factor in providing high-quality management [ 12 ]. Our main finding of an improvement in the overall quality of life during the lockdown was a great surprise. There are several generic explanations for these findings. First, at baseline we meet our patients in a very dismal physical condition with ensuring quality of life at its nadir [ 30 ]. Patients with decompensated cirrhosis are usually referred to our tertiary liver unit with a liver transplant program when first and second-line therapeutic options had failed. This may not only unabated physical suffering from decompensating events (encephalopathy, ascites, infections, frailty, bleeding, etc), but also a mental suffering. Several factors affecting QoL in patients with cirrhosis have been identified. In a study by Parkash et al. [ 31 ] low quality of life was associated with a level of hemoglobin, serum albumin, and previous decompensation of liver cirrhosis. In a study by Solà et al. [ 32 ] hyponatremia and edema were main risk factors associated with a poorer quality of life. A study by Les et al. [ 33 ] identified ascites, hypoalbuminemia, minimal liver encephalopathy, and anemia as potential factors of poor quality of life. In our study, some factors may have led to an improvement in the quality of life during lockdown. Firstly, the impact of treatment and recovery from the baseline complication. In addition, every patient was educated about the need for optimal nutrition and benefits of exercise that could lead to improved QoL. A positive change in the functional capacity of muscles could also have an effect on the daily activities. Second, a temporary increase in anxiety and depression during the first hospitalization [ 34 ] was likely followed by a gradual decrease related to the recovery from acute complications. In addition, in some patients the inner reconciliation with the diagnosis could have led to acceptance, regained hope and self-empowerment. Thus, both above-mentioned physical and psychological mechanisms would understandably be improved after discharge (33). In addition, several other unmeasured factors could have contributed to our findings: a higher care and interest from family members during the pandemic, a significant decrease in daily stressors, such as going to work or having the responsibility for administrative tasks. The impact of social isolation on quality of life is enormous and significant [ 35 , 36 ]. On the other hand, patients with liver cirrhosis may have had some degree of social isolation before the pandemic. An increased incidence of anxiety and depression during the first hospitalization may be related to anxiety about the disease [ 34 ], and a gradual decrease may be related to alleviation of the disease. Stress during the first hospitalization, and fear of an unknown illness can significantly affect the overall quality of life during the first hospitalization and can be an explanation compared to the quality of life during a pandemic. The diagnosis of a serious disease such as liver cirrhosis can cause a negative reaction in patients, which will significantly affect the quality of life of patients; however, reconciliation with diagnosis can lead to greater resistance in some patients. At admission to our liver unit, patients might be at the peak of their psychological suffering as well - such as fear of death, uncertainty if there are any further therapeutic options left, would she or he be a suitable candidate for a third-line therapeutic options such as liver transplantation. Both of the above-mentioned (physical and psychological) causes of decreased quality of life would be understandably improved after discharge from our unit by an improvement in physical state, by psychological counseling, as well as by a regained hope (33). Higher care and interest from family members during the pandemic could also help improve quality of life. The disappearance of some stressors, such as going to work during a pandemic, may have contributed to a paradoxical improvement in the quality of patients. Finally, there is yet another possible explanation for the improved QOL during lockdown: a shift of the psychological focus from a purely personal domain (my disease, my pain, my uncertainty, my mortal being, etc.), to the higher-order domains such as suffering of others, fate of the whole society or the world, future of the globe, how can I be of help to others [ 37 – 39 ]. These higher-order preoccupations of patients could have overshadowed their personal suffering to the extent, which we have been able to detect as an improvement in QOL. Domains significantly improved during lockdown compared to hospital stay (self-care, usual activities and anxiety / depression) could be similar to concepts previously described in the classical literature in Aldous Huxley’s Psychological causes of war and Paolo Coelho’s Veronika Decides to Die [ 40 ]. They have contemplated on the reasons for (real or fictional) reduction in suicide rates during the wartime and cured psychiatric illnesses against the immediate threat of death. At this point, with some degree of overstatement, we can safely hypothesize that the quality of life of our patients improved as a direct psychological consequence of the pandemic. Another factor associated with a lower quality of life in patients with liver cirrhosis is malnutrition [ 41 ]. Malnutrition is associated with an increased risk of mortality, hospitalizations, portal hypertension, and infectious complications [ 42 , 43 ]. In our study, patients were informed about the need for a healthy lifestyle that could affect their quality of life during a pandemic. Sarcopenia is a significant factor adversely affecting the quality of life in patients with liver cirrhosis [ 44 – 46 ]. During the pandemic, overall physical activity decreased, which may have led to a higher prevalence of sarcopenia. However, compared to the first hospitalization, physical activity was higher, likely contributing to improved quality of life in cirrhosis. Sarcopenia is also closely related to the appearance of frailty. Nishikawa et al. [ 47 ] studied the relationship between frailty and quality of life in patients with cirrhosis. All aspects of SF-36 were associated with frailty syndrome (p < 0.0001). A change in the functional capacity of muscles had a negative effect on the daily activities of patients. Da Silva Vieira et al. [ 48 ] tested functional capacity in patients with cirrhosis and found a correlation between quality of life and the result of a 6-minute walk test. How can we test the hypotheses generated by our results? First, we can systematically start repeating measurements of the QOL at discharge and further on to see for trends. Second, we can ask our patients for reasons for their perceived improvements in the QoL during the lockdown while being aware of inherent limitations both of these attitudes have. Our study was associated with several limitations. Twenty-two patients died during the study and the inability to evaluate the data may have affected the results. The study was monocentric with a focus on the central part of Slovakia. The study was carried out in Slovak patients; to objectively assess the quality of life with liver cirrhosis during a pandemic, it would be necessary to include more patients from different centers and countries. Conclusion The quality of life measured by the EuroQol questionnaire in patients hospitalized at tertiary liver unit with decompensated cirrhosis was low. After discharge and during the toughest pandemic-associated lockdown the QoL has improved. The explanation is not straightforward, and further investigation of the causes of this unexpected finding is warranted. Declarations Ethical Approval and Consent to participate All procedures performed were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Informed consent was obtained from all individual participants involved in the study. The study was approved by the Ethics Committee of Ethics Committee of the Roosevelt Hospital in Banská Bystrica under no. 15072. Availability of supporting data No data availability Funding Sources The authors declare that no funds, grants, or other support were received during the preparation of this manuscript Conflict of Interest Statement Authors declare no conflict of interest Contributions All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Dávid Líška, Ľubomír Skladaný, Erika Liptaková, Tomáš Koller, Janka Vnenčaková, Tatiana Tapajčiková. The first draft of the manuscript was written by Dávid Líška, Ľubomír Skladaný and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript References Schuppan, D., & Afdhal, N. H. (2008). Liver cirrhosis. Lancet (London, England) , 371 (9615), 838–851. https://doi.org/10.1016/S0140-6736(08)60383-9 Dissegna, D., Sponza, M., Falleti, E., Fabris, C., Vit, A., Angeli, P., … Toniutto, P. (2019). Morbidity and mortality after transjugular intrahepatic portosystemic shunt placement in patients with cirrhosis. European Journal of Gastroenterology & Hepatology , 31 (5), 626–632. https://doi.org/10.1097/MEG.0000000000001342 Scaglione, S., Kliethermes, S., Cao, G., Shoham, D., Durazo, R., Luke, A., & Volk, M. L. (2015). The Epidemiology of Cirrhosis in the United States: A Population-based Study. Journal of Clinical Gastroenterology , 49 (8), 690–696. https://doi.org/10.1097/MCG.0000000000000208 Sepanlou, S. G., Safiri, S., Bisignano, C., Ikuta, K. S., Merat, S., Saberifiroozi, M., … Malekzadeh, R. (2020). The global, regional, and national burden of cirrhosis by cause in 195 countries and territories, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017. The Lancet Gastroenterology & Hepatology , 5 (3), 245–266. https://doi.org/10.1016/S2468-1253(19)30349-8 Lombardi, R., Petta, S., Pisano, G., Dongiovanni, P., Rinaldi, L., Adinolfi, L. E., … Fracanzani, A. L. (2020). FibroScan Identifies Patients With Nonalcoholic Fatty Liver Disease and Cardiovascular Damage. Clinical Gastroenterology and Hepatology: The Official Clinical Practice Journal of the American Gastroenterological Association , 18 (2), 517–519. https://doi.org/10.1016/j.cgh.2018.11.011 Ginès, P., Krag, A., Abraldes, J. G., Solà, E., Fabrellas, N., & Kamath, P. S. (2021). Liver cirrhosis. Lancet (London, England) , 398 (10308), 1359–1376. https://doi.org/10.1016/S0140-6736(21)01374-X Durand, F., & Valla, D. (2008). Assessment of prognosis of cirrhosis. Seminars in Liver Disease , 28 (1), 110–122. https://doi.org/10.1055/s-2008-1040325 Prohić, D., Mesihović, R., Vanis, N., & Puhalović, A. (2014). Prognostic markers in patients with decompensated cirrhosis. Medicinski Glasnik: Official Publication of the Medical Association of Zenica-Doboj Canton, Bosnia and Herzegovina , 11 (1), 99–104. Sharma, A., & Nagalli, S. (2021). Chronic Liver Disease. In StatPearls . Treasure Island (FL): StatPearls Publishing. Retrieved from http://www.ncbi.nlm.nih.gov/books/NBK554597/ Björnsson, E., Verbaan, H., Oksanen, A., Frydén, A., Johansson, J., Friberg, S., … Kalaitzakis, E. (2009). Health-related quality of life in patients with different stages of liver disease induced by hepatitis C. Scandinavian Journal of Gastroenterology , 44 (7), 878–887. https://doi.org/10.1080/00365520902898135 Kok, B., Whitlock, R., Ferguson, T., James Bailey, R., Warren Burak, K., Kowalczewski, J., … Tandon, P. (2020). Health-Related Quality of Life: A Rapid Predictor of Hospitalization in Patients With Cirrhosis. The American Journal of Gastroenterology , 115 (4), 575–583. https://doi.org/10.14309/ajg.0000000000000545 Orr, J. G., Homer, T., Ternent, L., Newton, J., McNeil, C. J., Hudson, M., & Jones, D. E. J. (2014). Health related quality of life in people with advanced chronic liver disease. Journal of Hepatology , 61 (5), 1158–1165. https://doi.org/10.1016/j.jhep.2014.06.034 Zhang, X., Xi, W., Liu, L., & Wang, L. (2019). Improvement in Quality of Life and Activities of Daily Living in Patients with Liver Cirrhosis with the Use of Health Education and Patient Health Empowerment. Medical Science Monitor : International Medical Journal of Experimental and Clinical Research , 25 , 4602–4608. https://doi.org/10.12659/MSM.914487 Macdonald, S., Jepsen, P., Alrubaiy, L., Watson, H., Vilstrup, H., & Jalan, R. (2019). Quality of life measures predict mortality in patients with cirrhosis and severe ascites. Alimentary Pharmacology & Therapeutics , 49 (3), 321–330. https://doi.org/10.1111/apt.15084 Post, M. W. M. (2014). Definitions of Quality of Life: What Has Happened and How to Move On. Topics in Spinal Cord Injury Rehabilitation , 20 (3), 167–180. https://doi.org/10.1310/sci2003-167 Kaplan, R. M., & Ries, A. L. (2007). Quality of life: concept and definition. COPD , 4 (3), 263–271. https://doi.org/10.1080/15412550701480356 Boggatz, T. (2016). Quality of life in old age - a concept analysis. International Journal of Older People Nursing , 11 (1), 55–69. https://doi.org/10.1111/opn.12089 McDonald, T., & Shaw, D. (2019). Benchmarking life quality support interventions in long-term care using the Long-Term Care Quality of Life scale. Nursing & Health Sciences , 21 (2), 239–244. https://doi.org/10.1111/nhs.12588 Rutkowska, A., Liska, D., Cieślik, B., Wrzeciono, A., Broďáni, J., Barcalová, M., … Rutkowski, S. (2021). Stress Levels and Mental Well-Being among Slovak Students during e-Learning in the COVID-19 Pandemic. Healthcare , 9 (10), 1356. https://doi.org/10.3390/healthcare9101356 Skladany, L., Koller, T., Adamcova Selcanova, S., Vnencakova, J., Jancekova, D., Durajova, V., … Golubnitschaja, O. (2021). Challenging management of severe chronic disorders in acute pandemic situation: Chronic liver disease under COVID-19 pandemic as the proof-of-principle model to orchestrate the measures in 3PM context. The EPMA Journal , 12 (1), 1–14. https://doi.org/10.1007/s13167-021-00231-8 Skladaný, L., Vnencakova, J., Havaj, D. J., Adamcova-Selcanova, S., Barekova, L., Bystrianska, N., … Koller, T. (2020). Increased mortality and decreased registrations in cirrhosis registry during COVID-19 era. Hepatology , 281A-281A. Skladany, L., Drotarova, Z., Vnencakova, J., Jancekova, D., Molcan, P., & Koller, T. (2021). Applicability and prognostic value of frailty assessment tools among hospitalized patients with advanced chronic liver disease. Croatian Medical Journal , 62 (1), 8–16. https://doi.org/10.3325/cmj.2021.62.8 Russell, R. T., Feurer, I. D., Wisawatapnimit, P., & Pinson, C. W. (2009). The validity of EQ-5D US preference weights in liver transplant candidates and recipients. Liver Transplantation: Official Publication of the American Association for the Study of Liver Diseases and the International Liver Transplantation Society , 15 (1), 88–95. https://doi.org/10.1002/lt.21648 Balestroni, G., & Bertolotti, G. (2012). [EuroQol-5D (EQ-5D): an instrument for measuring quality of life]. Monaldi Archives for Chest Disease = Archivio Monaldi Per Le Malattie Del Torace , 78 (3), 155–159. https://doi.org/10.4081/monaldi.2012.121 Ragusa, R., Bertino, G., Bruno, A., Frazzetto, E., Cicciu, F., Giorgianni, G., & Lupo, L. (2018). Evaluation of health status in patients with hepatitis c treated with and without interferon. Health and Quality of Life Outcomes , 16 , 17. https://doi.org/10.1186/s12955-018-0842-x Younossi, Z. M., Guyatt, G., Kiwi, M., Boparai, N., & King, D. (1999). Development of a disease specific questionnaire to measure health related quality of life in patients with chronic liver disease. Gut , 45 (2), 295–300. https://doi.org/10.1136/gut.45.2.295 EuroQol Group. (1990). EuroQol--a new facility for the measurement of health-related quality of life. Health Policy (Amsterdam, Netherlands) , 16 (3), 199–208. https://doi.org/10.1016/0168-8510(90)90421-9 Rabin, R., & de Charro, F. (2001). EQ-5D: a measure of health status from the EuroQol Group. Annals of Medicine , 33 (5), 337–343. https://doi.org/10.3109/07853890109002087 Lloyd, A., & Pickard, A. S. (2019). The EQ-5D and the EuroQol Group. Value in Health: The Journal of the International Society for Pharmacoeconomics and Outcomes Research , 22 (1), 21–22. https://doi.org/10.1016/j.jval.2018.12.002 Nagel, M., Labenz, C., Wörns, M. A., Marquardt, J. U., Galle, P. R., Schattenberg, J. M., & Nguyen-Tat, M. (2020). Impact of acute-on-chronic liver failure and decompensated liver cirrhosis on psychosocial burden and quality of life of patients and their close relatives. Health and Quality of Life Outcomes , 18 , 10. https://doi.org/10.1186/s12955-019-1268-9 Parkash, O., Iqbal, R., Jafri, F., Azam, I., & Jafri, W. (2012). Frequency of poor quality of life and predictors of health related quality of life in cirrhosis at a tertiary care hospital Pakistan. BMC research notes , 5 , 446. https://doi.org/10.1186/1756-0500-5-446 Solà, E., Watson, H., Graupera, I., Turón, F., Barreto, R., Rodríguez, E., … Ginès, P. (2012). Factors related to quality of life in patients with cirrhosis and ascites: relevance of serum sodium concentration and leg edema. Journal of Hepatology , 57 (6), 1199–1206. https://doi.org/10.1016/j.jhep.2012.07.020 Les, I., Doval, E., Flavià, M., Jacas, C., Cárdenas, G., Esteban, R., … Córdoba, J. (2010). Quality of life in cirrhosis is related to potentially treatable factors. European Journal of Gastroenterology & Hepatology , 22 (2), 221–227. https://doi.org/10.1097/MEG.0b013e3283319975 Gastroenterology, C., Depression, H., Jan 01;20194-203.e1, A. A. C. A. P. W. C. C. G. H. 2022, Hernaez, R., Kramer, J. R., Khan, A., … Medicine, a database of the U. S. N. L. of. (n.d.). Depression and Anxiety in Cirrhosis Patients. PracticeUpdate . Retrieved March 17, 2022, from https://www.practiceupdate.com/content/depression-and-anxiety-in-cirrhosis-patients/128629 Someshwar, H., Sarvaiya, P., Desai, S., Gogri, P., Someshwar, J., Mehendale, P., & Bhatt, G. (2020). Does Social Distancing During The Lock Down Due To Covid-19 Outbreak In Mumbai Affect Quality Of Life? International Journal of Clinical and Biomedical Research , 1–4. https://doi.org/10.31878/ijcbr.2020.62.01 Hwang, T.-J., Rabheru, K., Peisah, C., Reichman, W., & Ikeda, M. (n.d.). Loneliness and social isolation during the COVID-19 pandemic. International Psychogeriatrics , 1–4. https://doi.org/10.1017/S1041610220000988 Skevington, S. M., The WHOQOL SRPB Group, Bartos, M., Bonicato, S., Fleck, M., Fang, … Underwood, L. (2020). Is Culture Important to the Relationship Between Quality of Life and Resilience? Global Implications for Preparing Communities for Environmental and Health Disasters. Frontiers in Psychology , 11 . Retrieved from https://www.frontiersin.org/article/10.3389/fpsyg.2020.01492 Kyutoku, Y., Tada, R., Umeyama, T., Harada, K., Kikuchi, S., Watanabe, E., … Dan, I. (2012). Cognitive and Psychological Reactions of the General Population Three Months After the 2011 Tohoku Earthquake and Tsunami. PLOS ONE , 7 (2), e31014. https://doi.org/10.1371/journal.pone.0031014 Skevington, S. M. (2020). Is Culture Important to the Relationship Between Quality of Life and Resilience? Global Implications for Preparing Communities for Environmental and Health Disasters. Frontiers in Psychology , 11 , 1492. https://doi.org/10.3389/fpsyg.2020.01492 Paulo Coelho. (2000). Veronika Decides to Die . HarperCollins. Chiu, E., Marr, K., Taylor, L., Lam, L., Stapleton, M., Tandon, P., & Raman, M. (2020). Malnutrition Impacts Health-Related Quality of Life in Cirrhosis: A Cross-Sectional Study. Nutrition in Clinical Practice: Official Publication of the American Society for Parenteral and Enteral Nutrition , 35 (1), 119–125. https://doi.org/10.1002/ncp.10265 Maharshi, S., Sharma, B. C., & Srivastava, S. (2015). Malnutrition in cirrhosis increases morbidity and mortality. Journal of Gastroenterology and Hepatology , 30 (10), 1507–1513. https://doi.org/10.1111/jgh.12999 Sam, J., & Nguyen, G. C. (2009). Protein-calorie malnutrition as a prognostic indicator of mortality among patients hospitalized with cirrhosis and portal hypertension. Liver International: Official Journal of the International Association for the Study of the Liver , 29 (9), 1396–1402. https://doi.org/10.1111/j.1478-3231.2009.02077.x Ando, Y., Ishigami, M., Ito, T., Ishizu, Y., Kuzuya, T., Honda, T., … Fujishiro, M. (2019). Sarcopenia impairs health-related quality of life in cirrhotic patients. European Journal of Gastroenterology & Hepatology , 31 (12), 1550–1556. https://doi.org/10.1097/MEG.0000000000001472 Ebadi, M., Bhanji, R. A., Mazurak, V. C., & Montano-Loza, A. J. (2019). Sarcopenia in cirrhosis: from pathogenesis to interventions. Journal of Gastroenterology , 54 (10), 845–859. https://doi.org/10.1007/s00535-019-01605-6 Sinclair, M., Gow, P. J., Grossmann, M., & Angus, P. W. (2016). Review article: sarcopenia in cirrhosis--aetiology, implications and potential therapeutic interventions. Alimentary Pharmacology & Therapeutics , 43 (7), 765–777. https://doi.org/10.1111/apt.13549 Nishikawa, H., Yoh, K., Enomoto, H., Iwata, Y., Sakai, Y., Kishino, K., … Iijima, H. (2020). Health-Related Quality of Life and Frailty in Chronic Liver Diseases. Life (Basel, Switzerland) , 10 (5), E76. https://doi.org/10.3390/life10050076 Casales da Silva Vieira, R., Álvares-da-Silva, M. R., de Oliveira, Á. R., da Silveira Gross, J., Kruger, R. L., Dal Bosco, A., … Dias, A. S. (2018). Cirrhosis affects maximal oxygen consumption, functional capacity, quality of life in patients with hepatitis C. Physiotherapy Research International: The Journal for Researchers and Clinicians in Physical Therapy , 23 (4), e1727. https://doi.org/10.1002/pri.1727 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 11 Feb, 2023 Read the published version in Scientific Reports → Version 2 posted Editorial decision: Major revision 09 Jan, 2023 Reviews received at journal 09 Jan, 2023 Reviewers agreed at journal 30 Dec, 2022 Reviews received at journal 02 Dec, 2022 Reviewers agreed at journal 02 Dec, 2022 Reviewers invited by journal 04 Aug, 2022 Editor assigned by journal 04 Aug, 2022 Editor invited by journal 17 Jun, 2022 Submission checks completed at journal 17 Jun, 2022 First submitted to journal 13 Jun, 2022 You are reading this latest preprint version Show more versions Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-1722546","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[{"code":1,"date":"2022-06-10 20:08:25","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"articleType":"Article","associatedPublications":[],"authors":[{"id":117004293,"identity":"e9d7c23c-3788-4aa8-84c0-fb92f0247adf","order_by":0,"name":"Ľubomír Skladaný","email":"","orcid":"","institution":"Slovak Medical University, F. 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Roosevelt Teaching Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Ľubomír","middleName":"","lastName":"Skladaný","suffix":""},{"id":117004294,"identity":"2c717e4d-6cf3-4d0f-9c0d-184590802b21","order_by":1,"name":"Dávid Líška","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA/0lEQVRIiWNgGAWjYDCCA0DEw2DBw8DDwPj4TwVQhJm5gRgtEiAtzAY8Z0BaGAlrAaqWABFsErxtICECWviOnzE88IZBQka+5/ADCcl5tdH87UAtPyq24dQieSbH4OAcoMMMzrYZGBhuO5474zBjA2PPmds4tRgcSEs4DPKLAT+DQULitmO5DUAtzIxteLScfwbRIt/P/uHAwTnHcucT1HIj+QBYC8PZHsPGxoaa3A2EtEjeeAw02wDosDNnipkZjh3I3QjUchCfX/jOJzZ/eFNhYy/fk779N0NNXe6884cPPvhRgVsL1Hlw1mEweYCAehRQR4riUTAKRsEoGCEAAClmXU+WFmspAAAAAElFTkSuQmCC","orcid":"","institution":"Matej Bel University","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Dávid","middleName":"","lastName":"Líška","suffix":""},{"id":117004297,"identity":"2ed268ab-ef21-44d5-a5f1-29ea912504cb","order_by":2,"name":"Erika Liptáková","email":"","orcid":"","institution":"Technical University in Košice (TUKE)","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Erika","middleName":"","lastName":"Liptáková","suffix":""},{"id":117004298,"identity":"1faa1907-0236-4bb5-a547-af5ab5835f0b","order_by":3,"name":"Tatiana Tapajčiková","email":"","orcid":"","institution":"Slovak Medical University in Bratislava","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Tatiana","middleName":"","lastName":"Tapajčiková","suffix":""},{"id":117004299,"identity":"c460a587-68a0-4a2c-9d50-e350917948ee","order_by":4,"name":"Janka Vnenčaková","email":"","orcid":"","institution":"Slovak Medical University, F. 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Roosevelt Teaching Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Janka","middleName":"","lastName":"Vnenčaková","suffix":""},{"id":117004300,"identity":"f18002d0-0c8e-404d-8cc8-c162543b3892","order_by":5,"name":"Tomáš Koller","email":"","orcid":"","institution":"Commenius university","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Tomáš","middleName":"","lastName":"Koller","suffix":""}],"badges":[],"createdAt":"2022-06-03 11:44:13","currentVersionCode":2,"declarations":"","doi":"10.21203/rs.3.rs-1722546/v2","doiUrl":"https://doi.org/10.21203/rs.3.rs-1722546/v2","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1038/s41598-023-29510-2","type":"published","date":"2023-02-11T18:44:59+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":23229619,"identity":"055fdb0f-3cf5-4ab8-96f8-9cbb5204195c","added_by":"auto","created_at":"2022-06-29 14:17:22","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":43298,"visible":true,"origin":"","legend":"\u003cp\u003eFlow chart\u0026nbsp;\u003c/p\u003e","description":"","filename":"Fig1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-1722546/v2/0f2591803ae6f37c2985e279.jpg"},{"id":23228945,"identity":"55c1df6b-b308-4f1c-80ce-8dbc2f7f7bc2","added_by":"auto","created_at":"2022-06-29 14:12:23","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":37823,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eEuroQOL final score\u003c/strong\u003e – mean values for baseline and lockdown period (Women, p\u0026nbsp;=\u0026nbsp;0.002; Men, p = 0.249)\u003c/p\u003e\u003cp\u003e\u003cem\u003eNote: Baseline period – during the first hospitalization; Lockdown period – during the pandemic (NOTE: the lower score signifies better QOL)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cbr\u003e\u003c/p\u003e","description":"","filename":"Fig2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-1722546/v2/c0cfe2a7197330ed853dd3bf.jpg"},{"id":23229620,"identity":"f2380e92-9d13-4e1c-86e6-af17d1a5202f","added_by":"auto","created_at":"2022-06-29 14:17:22","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":70629,"visible":true,"origin":"","legend":"\u003cp\u003eFrequencies of EuroQOL scores for individual areas – baseline period (during the first hospitalization).\u003c/p\u003e\u003cp\u003e\u003cem\u003eNote: EuroQOL individual scores are on scale from 1 (no problem) to 5 (maximum problems).\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cbr\u003e\u003c/p\u003e","description":"","filename":"Fig3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-1722546/v2/bf8ab87cb9b556db066e543c.jpg"},{"id":23228943,"identity":"2e371415-2816-4e9a-9d84-40ce5680c54c","added_by":"auto","created_at":"2022-06-29 14:12:23","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":70636,"visible":true,"origin":"","legend":"\u003cp\u003eFrequencies of EuroQOL scores for individual areas – lockdown period (during the pandemic).\u003c/p\u003e\u003cp\u003e\u003cem\u003eNote: EuroQOL individual scores are on scale from 1 (no problems) to 5 (maximum problems).\u003c/em\u003e\u003c/p\u003e","description":"","filename":"Fig4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-1722546/v2/eb47ba233bed7f87e3360f37.jpg"},{"id":44719369,"identity":"85e9cf58-5870-46d4-9a30-82e298b59277","added_by":"auto","created_at":"2023-10-16 18:54:43","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":457724,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-1722546/v2/7de8d615-e51d-470c-a001-a487a812f13d.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Quality of life in the cirrhosis registry during the SARS-CoV-2 lockdown in Slovakia","fulltext":[{"header":"Introducton","content":"\u003cp\u003eLiver cirrhosis is the final stage of chronic liver diseases of various etiologies, characterized by loss of functional parenchyma, compensatory regeneration, and fibrosis, leading to disorganization of liver architecture and function [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The global prevalence of cirrhosis has ranged from 0.15\u0026ndash;0.27% and in Slovakia it is the highest in the world (1\u0026ndash;6). The most common causes of cirrhosis are alcohol-associated liver disease (ALD), nonalcoholic or metabolic-associated fatty liver disease (NAFLD, MAFLD), autoimmune syndromes (autoimmune hepatitis, primary biliary cholangitis, primary sclerosing cholangitis, etc.), hepatitis B and hepatitis C, and many others (10).\u003c/p\u003e \u003cp\u003eCirrhosis patients have a poor prognosis which is primarily mediated by acute decompensation, especially by its subtype - acute on chronic liver failure (ACLF) [\u003cspan additionalcitationids=\"CR8\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. In addition to its impact on hard endpoints such as mortality, cirrhosis is associated with human suffering captured in the domain of patient-reported outcomes (PRO); the most frequently measured PRO is quality of life (QOL) [\u003cspan additionalcitationids=\"CR11 CR12\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Quality of life is the metric of well-being associated with the severity of cirrhosis [\u003cspan additionalcitationids=\"CR15\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. The World Health Organization has defined QOL as a subjective assessment of the perception of its reality in health [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Determining quality of life is essential in all areas of medicine, and quality of life was incorporated it into the main dataset of RH7 Cirrhosis Registry.\u003c/p\u003e \u003cp\u003eThe pandemic caused by SARS-CoV-2 infection and COVID- 19 disease has severely affected all aspects of the healthcare system [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. The Slovakian government has declared restrictive lockdown measures to control the spread of the infection in March 2020. Gatherings of more than six people and all mass events were banned. Sports competitions were limited and allowed without spectators and all fitness and wellness centers had to be closed [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. In our previous study, we evaluated the impact of lockdown on mortality in patients with cirrhosis, registered in RH7 [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Our results pointed to a distorted path to specialized liver care with fewer visits and admissions to a tertiary liver unit and, since we were separated from most of our locked patients, we were unable to sense their personal experiences during the most demanding period of time in our society. Therefore, we decided to take advantage of the fact that we have previously measured their QOL and, together with the most trivial telemedicine at hand (telephone), to compare their previous (baseline) QOL with the repeated assessment during the lockdown.\u003c/p\u003e \u003cp\u003eThe main objective of our study was to evaluate QOL in patients with cirrhosis during lockdown and to compare the results with the QOL as measured previously \u0026ndash; at their enrolment in the cirrhosis registry RH7.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThe study is a combination of the registry study (RH7, NCT04767945) in which QOL is a core baseline parameter, with the cross-sectional investigation determining QOL during the lockdown. The main objective of this study was to compare QOL at the time of enrollment in Registry HEFITO (RH7) with the QOL subsequently measured during the lockdown. The study population consisted of patients with liver cirrhosis, registered in RH7; RH7 has been operating in our liver unit since 2014 and enrols consecutive consenting adults admitted to the hospital with liver cirrhosis [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Patients with terminal liver disease or severe comorbidity, which can limit short-term life expectancy, are not enrolled in RH7. Among other baseline parameters recorded at admission to our liver unit and in RH7, a generic EuroQol-5D questionnaire (EQ-5D) is administered; this tool has been selected for its validity and reproducibility in liver diseases and for its brevity [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAt the first admission to our liver unit with liver cirrhosis, patients completed their first EQ-5D and the results were recorded in the RH7 core dataset. Subsequently, in the second part of the study, which was conducted during the first lockdown in Slovakia in April-May 2020, EQ-5D was administered by healthcare professionals who have contacted all survivors in RH7 identified in the National Registry of Deceased by an investigator. Interviewing physicians were trained for a structured dialogue whose content and explicit reading were approved by the Ethics Committee of our academic hospital \u0026ndash; F. D. Roosevelt teaching Hospital, Banska Bystrica, Slovakia\u003c/p\u003e \u003cp\u003eThe physicians have introduced themselves (most of them got familiar with patients during the previous hospitalization), asked for permission to continue, and explained the aim of the call and the study: to see how they are and to repeat the formal determination of QOL by EQ-5D (EQ-5D was explained to be the same as previously - at the entry to RH7). After a pause, the interviewing physicians asked for explicit consent and wrote it down; only then they proceeded to EQ-5D. The physicians then recorded all the responses from the patients using a pen and paper method. If there was no response to the first phone call, the call was repeated three times in three consecutive days; after that, the result was recorded as \u0026lsquo;No Connect\u0026rsquo;. If the patient contacted declined participation, the result was recorded as \u0026lsquo;Declined to participate\u0026rsquo;.\u003c/p\u003e\n\u003ch2\u003eEuroqol-5d (Eq-5d)\u003c/h2\u003e\n\u003cp\u003eEuroQol-5D (EQ-5D) is a generic questionnaire to measure QOL which has been validated in various diseases [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. EQ-5D has been shown to be valid in liver patients comparable to our cohort [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. EQ-5D measures five aspects underlying quality of life: mobility, self-care, daily activities, pain, anxiety, and depression, together with the patient\u0026rsquo;s assessment of perceived health status on a visual analogue scale. The final EuroQol- 5D is defined as a score between 0 and 100 recorded by an individual for their current overall quality of life. A pilot test was conducted before the start of the study to determine the feasibility of submitting a questionnaire. The owner of EQ-5D has kindly granted HEGITO permission to use it.\u003c/p\u003e\n\u003ch2\u003eThe Sample (Flowchart)\u003c/h2\u003e\n\u003cp\u003eThe study included 97 patients, of which 37 (38.1%) were women and 60 (61.9%) were men. An additional 22 patients (not yet listed in the National Registry of Deceased) were identified dead during the study (Figure. 1). The characteristics of the sample are shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBaseline participant\u0026acute;s characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;97\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e55.9\u0026thinsp;\u0026plusmn;\u0026thinsp;11.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender: Women (N)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e37 (38.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMen (N)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e60 (61.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWeight (kg)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e79.8\u0026thinsp;\u0026plusmn;\u0026thinsp;18.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHeight (cm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e171.6\u0026thinsp;\u0026plusmn;\u0026thinsp;10.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI (kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27.0\u0026thinsp;\u0026plusmn;\u0026thinsp;5.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEtiology of cirrhosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eALD (N/%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e69 (71.13%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther (N/%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28 (28.87%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMELD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17.84\u0026thinsp;\u0026plusmn;\u0026thinsp;7.63\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChild-Pugh Score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8.90\u0026thinsp;\u0026plusmn;\u0026thinsp;2.44\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLiver frailty index (LFI)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.48\u0026thinsp;\u0026plusmn;\u0026thinsp;0.94\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eNotes: Age was recorded at the baseline \u0026ndash; entry into registry RH7. Data are presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SDLFI was calculated at \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://liverfrailtyindex.ucsf.edu/\u003c/span\u003e\u003cspan address=\"https://liverfrailtyindex.ucsf.edu/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003ePatient data were recorded to an Excel spreadsheet and subsequently subjected to statistical analysis using the IBM SPSS software package. Due to the ordinal type of data of individual EuroQOL items, we assessed differences in values during the prepandemic period and the pandemic using a nonparametric paired Wilcoxon Signed Ranks test. A paired \u003cem\u003et\u003c/em\u003e-test was used to determine differences between the total EuroQOL score and Visual Analog Scale.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003e97 patients from the RH7 cirrhosis registry were enrolled, aged 55.9 (\u0026plusmn;\u0026thinsp;11.8) years with 38.1% of women. The median MELD score was 17.84 (\u0026plusmn;\u0026thinsp;7.63), the median Child-Pugh score was 8 9 (\u0026plusmn;\u0026thinsp;2.44). These scores are characteristic of advanced cirrhosis (Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). The median time between the two examinations was 184 days. 1). The baseline QOL was significantly worse than QOL assessed during the lockdown (Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e and Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e). Three of the EQ-5D domains have differed significantly between the two-time points: 1) self-care, 2) usual activities, and 3) anxiety/depression have improved during lockdown (Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e). The numerical decrease in mobility observed during lockdown was not statistically significant (p\u0026thinsp;=\u0026thinsp;0.10). There was no change in the pain and discomfort (p\u0026thinsp;=\u0026thinsp;0.882). Detailed results are shown in Tables \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e and \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e and frequencies are shown in Figs. \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e.\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" id=\"Tab2\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eValues of \u003cstrong\u003eEuroQOL\u003c/strong\u003e scores with specification of individual domains (lower scores represent better self-perceived quality of life)\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eItem of the EuroQOL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003ePeriod\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eMean score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eZ-score*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003ep-Value*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"5\"\u003e\n \u003cp\u003eEuroQOL score\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e(1)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e(2)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e(3)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e(4)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e(5)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eMobility\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBaseline\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.082\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e-1.631\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e0.103\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e42.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e29.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLockdown\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.856\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e48.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e27.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eSelf-care\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBaseline\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.845\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e-3.462\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e61.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLockdown\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.320\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e82.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eUsual activities\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBaseline\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.082\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e-3.077\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e51.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLockdown\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.588\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e66.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003ePain / Discomfort\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBaseline\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.814\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e-0.148\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e0.882\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e46.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e33.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLockdown\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.804\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e55.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eAnxiety / Depression\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBaseline\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.639\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e-2.501\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e0.012\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e61.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLockdown\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.340\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e77.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"10\"\u003e*according to paired Wilcoxon Signed Ranks Test\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n\u003c/table\u003e\n\u003cdiv class=\"Section2\" id=\"Sec7\"\u003e\n \u003cp\u003eNote: Baseline period \u0026ndash; during the first hospitalization; Lockdown period \u0026ndash; during the pandemic\u003c/p\u003e\n \u003cp\u003eIn the Visual Analog Scale for overall quality of life feeling there was a significant increase in the score in favor of the lockdown period (p\u0026thinsp;=\u0026thinsp;0.017). The Final Score of EuroQoL was significantly lower during the pandemic compared with the baseline and it was consistent in both sexes (p\u0026thinsp;\u0026lt;\u0026thinsp;0.005, Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e, Fig. \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003ctable border=\"1\" id=\"Tab3\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003e\u003cstrong\u003eEuroQOL \u0026ndash;\u003c/strong\u003e Summary of the scores for quality of life (QoL) in patients with liver cirrhosis on admission to the hospital (baseline) and during the lockdown.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEuroQOL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePeriod\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMean\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003et-score*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ep Value*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eFinal score\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBaseline\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9.42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e2.870\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e0.005\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLockdown\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7.91\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eVisual Analog Scale\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBaseline\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e65.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e-2.434\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e0.017\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLockdown\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e72.08\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\"\u003e*according to paired \u003cem\u003et\u003c/em\u003e-test\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003eNote: Baseline period \u0026ndash; during the first hospitalization; Lockdown period \u0026ndash; during the pandemic\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe teleological background of this study dwells in our leveraging the once-in-a-lifetime combination of our longer-term focus on patient-reported outcomes. On the one hand, we combined it with an unprecedented psychosocial test tube milieu inflicted by the lockdown. Before the spread of the SARS-CoV-2 virus, we have been collecting data on QOL (in cirrhosis registry). It is important to note that \u003cem\u003e1) the\u003c/em\u003e RH7 registry was founded in 2014 as our response to cirrhosis becoming the number-one cause of death in young adults in Slovakia and 2\u003cem\u003e) the\u003c/em\u003e QoL became the core variable in RH7 only in subsequent years; also that \u003cem\u003e3)\u003c/em\u003e of the two alternative tools assessing QOL (generic, and disease specific) we opted for the former. EuroQOL has higher sensitivity and specificity between the cirrhosis-specific instruments. It has been developed by Younoussi [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e] reportedly having a cumulative advantage of reproducibility, validity, validity in Europeans, validity in liver diseases, comparability with other diseases and brevity (30\u0026ndash;32).\u003c/p\u003e \u003cp\u003eAfter an initial shock from the pandemic, we found ourselves cut from the majority of outpatients including patients with cirrhosis whom we used to see regularly after discharge. Our RH7 registry included hospitalized patients mainly with decompensated cirrhosis and a poor prognosis. We began to conceive a way to actively contact them in order to learn how they were and help them in case of need. At this stage, we decided to elevate our effort to a formal study using the EuroQOL\u003c/p\u003e \u003cp\u003eIn general, cirrhosis is associated with a low quality of life [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. It is chronic and progressive in nature leading to deterioration in mental and physical functioning while significantly impacting on the quality of life. Also, a disease driven decrease in the quality of life can be further multiplied by other individual psychological and psychosocial factors. It is increasingly recognized as an important outcome of cirrhosis. The use of a quality-of-life questionnaire can identify high-risk patients with poor quality of life and worse prognosis. Understanding the importance of quality of life is an important factor in providing high-quality management [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Our main finding of an improvement in the overall quality of life during the lockdown was a great surprise. There are several generic explanations for these findings. First, at baseline we meet our patients in a very dismal physical condition with ensuring quality of life at its nadir [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Patients with decompensated cirrhosis are usually referred to our tertiary liver unit with a liver transplant program when first and second-line therapeutic options had failed. This may not only unabated physical suffering from decompensating events (encephalopathy, ascites, infections, frailty, bleeding, etc), but also a mental suffering. Several factors affecting QoL in patients with cirrhosis have been identified. In a study by Parkash et al. [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e] low quality of life was associated with a level of hemoglobin, serum albumin, and previous decompensation of liver cirrhosis. In a study by Sol\u0026agrave; et al. [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e] hyponatremia and edema were main risk factors associated with a poorer quality of life. A study by Les et al. [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e] identified ascites, hypoalbuminemia, minimal liver encephalopathy, and anemia as potential factors of poor quality of life.\u003c/p\u003e \u003cp\u003eIn our study, some factors may have led to an improvement in the quality of life during lockdown. Firstly, the impact of treatment and recovery from the baseline complication. In addition, every patient was educated about the need for optimal nutrition and benefits of exercise that could lead to improved QoL. A positive change in the functional capacity of muscles could also have an effect on the daily activities. Second, a temporary increase in anxiety and depression during the first hospitalization [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e] was likely followed by a gradual decrease related to the recovery from acute complications. In addition, in some patients the inner reconciliation with the diagnosis could have led to acceptance, regained hope and self-empowerment. Thus, both above-mentioned physical and psychological mechanisms would understandably be improved after discharge (33). In addition, several other unmeasured factors could have contributed to our findings: a higher care and interest from family members during the pandemic, a significant decrease in daily stressors, such as going to work or having the responsibility for administrative tasks.\u003c/p\u003e \u003cp\u003eThe impact of social isolation on quality of life is enormous and significant [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. On the other hand, patients with liver cirrhosis may have had some degree of social isolation before the pandemic. An increased incidence of anxiety and depression during the first hospitalization may be related to anxiety about the disease [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e], and a gradual decrease may be related to alleviation of the disease. Stress during the first hospitalization, and fear of an unknown illness can significantly affect the overall quality of life during the first hospitalization and can be an explanation compared to the quality of life during a pandemic. The diagnosis of a serious disease such as liver cirrhosis can cause a negative reaction in patients, which will significantly affect the quality of life of patients; however, reconciliation with diagnosis can lead to greater resistance in some patients. At admission to our liver unit, patients might be at the peak of their psychological suffering as well - such as fear of death, uncertainty if there are any further therapeutic options left, would she or he be a suitable candidate for a third-line therapeutic options such as liver transplantation. Both of the above-mentioned (physical and psychological) causes of decreased quality of life would be understandably improved after discharge from our unit by an improvement in physical state, by psychological counseling, as well as by a regained hope (33). Higher care and interest from family members during the pandemic could also help improve quality of life. The disappearance of some stressors, such as going to work during a pandemic, may have contributed to a paradoxical improvement in the quality of patients.\u003c/p\u003e \u003cp\u003eFinally, there is yet another possible explanation for the improved QOL during lockdown: a shift of the psychological focus from a purely personal domain (my disease, my pain, my uncertainty, my mortal being, etc.), to the higher-order domains such as suffering of others, fate of the whole society or the world, future of the globe, how can I be of help to others [\u003cspan additionalcitationids=\"CR38\" citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. These higher-order preoccupations of patients could have overshadowed their personal suffering to the extent, which we have been able to detect as an improvement in QOL. Domains significantly improved during lockdown compared to hospital stay (self-care, usual activities and anxiety / depression) could be similar to concepts previously described in the classical literature in Aldous Huxley\u0026rsquo;s Psychological causes of war and Paolo Coelho\u0026rsquo;s Veronika Decides to Die [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. They have contemplated on the reasons for (real or fictional) reduction in suicide rates during the wartime and cured psychiatric illnesses \u003cem\u003eagainst the\u003c/em\u003e immediate threat of death. At this point, with some degree of overstatement, we can safely hypothesize that the quality of life of our patients improved as a direct psychological consequence of the pandemic.\u003c/p\u003e \u003cp\u003eAnother factor associated with a lower quality of life in patients with liver cirrhosis is malnutrition [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. Malnutrition is associated with an increased risk of mortality, hospitalizations, portal hypertension, and infectious complications [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. In our study, patients were informed about the need for a healthy lifestyle that could affect their quality of life during a pandemic. Sarcopenia is a significant factor adversely affecting the quality of life in patients with liver cirrhosis [\u003cspan additionalcitationids=\"CR45\" citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. During the pandemic, overall physical activity decreased, which may have led to a higher prevalence of sarcopenia. However, compared to the first hospitalization, physical activity was higher, likely contributing to improved quality of life in cirrhosis. Sarcopenia is also closely related to the appearance of frailty. Nishikawa et al. [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e] studied the relationship between frailty and quality of life in patients with cirrhosis. All aspects of SF-36 were associated with frailty syndrome (p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001). A change in the functional capacity of muscles had a negative effect on the daily activities of patients. Da Silva Vieira et al. [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e] tested functional capacity in patients with cirrhosis and found a correlation between quality of life and the result of a 6-minute walk test.\u003c/p\u003e \u003cp\u003eHow can we test the hypotheses generated by our results? First, we can systematically start repeating measurements of the QOL at discharge and further on to see for trends. Second, we can ask our patients for reasons for their perceived improvements in the QoL during the lockdown while being aware of inherent limitations both of these attitudes have.\u003c/p\u003e \u003cp\u003eOur study was associated with several limitations. Twenty-two patients died during the study and the inability to evaluate the data may have affected the results. The study was monocentric with a focus on the central part of Slovakia. The study was carried out in Slovak patients; to objectively assess the quality of life with liver cirrhosis during a pandemic, it would be necessary to include more patients from different centers and countries.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe quality of life measured by the EuroQol questionnaire in patients hospitalized at tertiary liver unit with decompensated cirrhosis was low. After discharge and during the toughest pandemic-associated lockdown the QoL has improved. The explanation is not straightforward, and further investigation of the causes of this unexpected finding is warranted.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical Approval and Consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll procedures performed were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Informed consent was obtained from all individual participants involved in the study. The study was approved by the Ethics Committee of Ethics Committee of the Roosevelt Hospital in Bansk\u0026aacute; Bystrica under no. 15072.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of supporting data\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo data availability\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding Sources\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that no funds, grants, or other support were received during the preparation \u0026nbsp; of this manuscript\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interest Statement\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAuthors declare no conflict of interest\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eContributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by D\u0026aacute;vid L\u0026iacute;\u0026scaron;ka, Ľubom\u0026iacute;r Skladan\u0026yacute;, Erika Liptakov\u0026aacute;, Tom\u0026aacute;\u0026scaron; Koller, Janka Vnenčakov\u0026aacute;, Tatiana Tapajčikov\u0026aacute;. The first draft of the manuscript was written by D\u0026aacute;vid L\u0026iacute;\u0026scaron;ka, Ľubom\u0026iacute;r Skladan\u0026yacute; and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eSchuppan, D., \u0026amp; Afdhal, N. H. (2008). Liver cirrhosis. \u003cem\u003eLancet (London, England)\u003c/em\u003e, \u003cem\u003e371\u003c/em\u003e(9615), 838\u0026ndash;851. https://doi.org/10.1016/S0140-6736(08)60383-9\u003c/li\u003e\n\u003cli\u003eDissegna, D., Sponza, M., Falleti, E., Fabris, C., Vit, A., Angeli, P., \u0026hellip; Toniutto, P. (2019). Morbidity and mortality after transjugular intrahepatic portosystemic shunt placement in patients with cirrhosis. \u003cem\u003eEuropean Journal of Gastroenterology \u0026amp; Hepatology\u003c/em\u003e, \u003cem\u003e31\u003c/em\u003e(5), 626\u0026ndash;632. https://doi.org/10.1097/MEG.0000000000001342\u003c/li\u003e\n\u003cli\u003eScaglione, S., Kliethermes, S., Cao, G., Shoham, D., Durazo, R., Luke, A., \u0026amp; Volk, M. L. (2015). The Epidemiology of Cirrhosis in the United States: A Population-based Study. \u003cem\u003eJournal of Clinical Gastroenterology\u003c/em\u003e, \u003cem\u003e49\u003c/em\u003e(8), 690\u0026ndash;696. https://doi.org/10.1097/MCG.0000000000000208\u003c/li\u003e\n\u003cli\u003eSepanlou, S. G., Safiri, S., Bisignano, C., Ikuta, K. S., Merat, S., Saberifiroozi, M., \u0026hellip; Malekzadeh, R. (2020). The global, regional, and national burden of cirrhosis by cause in 195 countries and territories, 1990\u0026ndash;2017: a systematic analysis for the Global Burden of Disease Study 2017. \u003cem\u003eThe Lancet Gastroenterology \u0026amp; Hepatology\u003c/em\u003e, \u003cem\u003e5\u003c/em\u003e(3), 245\u0026ndash;266. https://doi.org/10.1016/S2468-1253(19)30349-8\u003c/li\u003e\n\u003cli\u003eLombardi, R., Petta, S., Pisano, G., Dongiovanni, P., Rinaldi, L., Adinolfi, L. E., \u0026hellip; Fracanzani, A. L. (2020). FibroScan Identifies Patients With Nonalcoholic Fatty Liver Disease and Cardiovascular Damage. \u003cem\u003eClinical Gastroenterology and Hepatology: The Official Clinical Practice Journal of the American Gastroenterological Association\u003c/em\u003e, \u003cem\u003e18\u003c/em\u003e(2), 517\u0026ndash;519. https://doi.org/10.1016/j.cgh.2018.11.011\u003c/li\u003e\n\u003cli\u003eGin\u0026egrave;s, P., Krag, A., Abraldes, J. G., Sol\u0026agrave;, E., Fabrellas, N., \u0026amp; Kamath, P. S. (2021). Liver cirrhosis. \u003cem\u003eLancet (London, England)\u003c/em\u003e, \u003cem\u003e398\u003c/em\u003e(10308), 1359\u0026ndash;1376. https://doi.org/10.1016/S0140-6736(21)01374-X\u003c/li\u003e\n\u003cli\u003eDurand, F., \u0026amp; Valla, D. (2008). Assessment of prognosis of cirrhosis. \u003cem\u003eSeminars in Liver Disease\u003c/em\u003e, \u003cem\u003e28\u003c/em\u003e(1), 110\u0026ndash;122. https://doi.org/10.1055/s-2008-1040325\u003c/li\u003e\n\u003cli\u003eProhić, D., Mesihović, R., Vanis, N., \u0026amp; Puhalović, A. (2014). Prognostic markers in patients with decompensated cirrhosis. \u003cem\u003eMedicinski Glasnik: Official Publication of the Medical Association of Zenica-Doboj Canton, Bosnia and Herzegovina\u003c/em\u003e, \u003cem\u003e11\u003c/em\u003e(1), 99\u0026ndash;104.\u003c/li\u003e\n\u003cli\u003eSharma, A., \u0026amp; Nagalli, S. (2021). Chronic Liver Disease. In \u003cem\u003eStatPearls\u003c/em\u003e. Treasure Island (FL): StatPearls Publishing. Retrieved from http://www.ncbi.nlm.nih.gov/books/NBK554597/\u003c/li\u003e\n\u003cli\u003eBj\u0026ouml;rnsson, E., Verbaan, H., Oksanen, A., Fryd\u0026eacute;n, A., Johansson, J., Friberg, S., \u0026hellip; Kalaitzakis, E. (2009). Health-related quality of life in patients with different stages of liver disease induced by hepatitis C. \u003cem\u003eScandinavian Journal of Gastroenterology\u003c/em\u003e, \u003cem\u003e44\u003c/em\u003e(7), 878\u0026ndash;887. https://doi.org/10.1080/00365520902898135\u003c/li\u003e\n\u003cli\u003eKok, B., Whitlock, R., Ferguson, T., James Bailey, R., Warren Burak, K., Kowalczewski, J., \u0026hellip; Tandon, P. (2020). Health-Related Quality of Life: A Rapid Predictor of Hospitalization in Patients With Cirrhosis. \u003cem\u003eThe American Journal of Gastroenterology\u003c/em\u003e, \u003cem\u003e115\u003c/em\u003e(4), 575\u0026ndash;583. https://doi.org/10.14309/ajg.0000000000000545\u003c/li\u003e\n\u003cli\u003eOrr, J. G., Homer, T., Ternent, L., Newton, J., McNeil, C. J., Hudson, M., \u0026amp; Jones, D. E. J. (2014). Health related quality of life in people with advanced chronic liver disease. \u003cem\u003eJournal of Hepatology\u003c/em\u003e, \u003cem\u003e61\u003c/em\u003e(5), 1158\u0026ndash;1165. https://doi.org/10.1016/j.jhep.2014.06.034\u003c/li\u003e\n\u003cli\u003eZhang, X., Xi, W., Liu, L., \u0026amp; Wang, L. (2019). Improvement in Quality of Life and Activities of Daily Living in Patients with Liver Cirrhosis with the Use of Health Education and Patient Health Empowerment. \u003cem\u003eMedical Science Monitor : International Medical Journal of Experimental and Clinical Research\u003c/em\u003e, \u003cem\u003e25\u003c/em\u003e, 4602\u0026ndash;4608. https://doi.org/10.12659/MSM.914487\u003c/li\u003e\n\u003cli\u003eMacdonald, S., Jepsen, P., Alrubaiy, L., Watson, H., Vilstrup, H., \u0026amp; Jalan, R. (2019). Quality of life measures predict mortality in patients with cirrhosis and severe ascites. \u003cem\u003eAlimentary Pharmacology \u0026amp; Therapeutics\u003c/em\u003e, \u003cem\u003e49\u003c/em\u003e(3), 321\u0026ndash;330. https://doi.org/10.1111/apt.15084\u003c/li\u003e\n\u003cli\u003ePost, M. W. M. (2014). Definitions of Quality of Life: What Has Happened and How to Move On. \u003cem\u003eTopics in Spinal Cord Injury Rehabilitation\u003c/em\u003e, \u003cem\u003e20\u003c/em\u003e(3), 167\u0026ndash;180. https://doi.org/10.1310/sci2003-167\u003c/li\u003e\n\u003cli\u003eKaplan, R. M., \u0026amp; Ries, A. L. (2007). Quality of life: concept and definition. \u003cem\u003eCOPD\u003c/em\u003e, \u003cem\u003e4\u003c/em\u003e(3), 263\u0026ndash;271. https://doi.org/10.1080/15412550701480356\u003c/li\u003e\n\u003cli\u003eBoggatz, T. (2016). Quality of life in old age - a concept analysis. \u003cem\u003eInternational Journal of Older People Nursing\u003c/em\u003e, \u003cem\u003e11\u003c/em\u003e(1), 55\u0026ndash;69. https://doi.org/10.1111/opn.12089\u003c/li\u003e\n\u003cli\u003eMcDonald, T., \u0026amp; Shaw, D. (2019). Benchmarking life quality support interventions in long-term care using the Long-Term Care Quality of Life scale. \u003cem\u003eNursing \u0026amp; Health Sciences\u003c/em\u003e, \u003cem\u003e21\u003c/em\u003e(2), 239\u0026ndash;244. https://doi.org/10.1111/nhs.12588\u003c/li\u003e\n\u003cli\u003eRutkowska, A., Liska, D., Cieślik, B., Wrzeciono, A., Broď\u0026aacute;ni, J., Barcalov\u0026aacute;, M., \u0026hellip; Rutkowski, S. (2021). Stress Levels and Mental Well-Being among Slovak Students during e-Learning in the COVID-19 Pandemic. \u003cem\u003eHealthcare\u003c/em\u003e, \u003cem\u003e9\u003c/em\u003e(10), 1356. https://doi.org/10.3390/healthcare9101356\u003c/li\u003e\n\u003cli\u003eSkladany, L., Koller, T., Adamcova Selcanova, S., Vnencakova, J., Jancekova, D., Durajova, V., \u0026hellip; Golubnitschaja, O. (2021). Challenging management of severe chronic disorders in acute pandemic situation: Chronic liver disease under COVID-19 pandemic as the proof-of-principle model to orchestrate the measures in 3PM context. \u003cem\u003eThe EPMA Journal\u003c/em\u003e, \u003cem\u003e12\u003c/em\u003e(1), 1\u0026ndash;14. https://doi.org/10.1007/s13167-021-00231-8\u003c/li\u003e\n\u003cli\u003eSkladan\u0026yacute;, L., Vnencakova, J., Havaj, D. J., Adamcova-Selcanova, S., Barekova, L., Bystrianska, N., \u0026hellip; Koller, T. (2020). Increased mortality and decreased registrations in cirrhosis registry during COVID-19 era. \u003cem\u003eHepatology\u003c/em\u003e, 281A-281A.\u003c/li\u003e\n\u003cli\u003eSkladany, L., Drotarova, Z., Vnencakova, J., Jancekova, D., Molcan, P., \u0026amp; Koller, T. (2021). Applicability and prognostic value of frailty assessment tools among hospitalized patients with advanced chronic liver disease. \u003cem\u003eCroatian Medical Journal\u003c/em\u003e, \u003cem\u003e62\u003c/em\u003e(1), 8\u0026ndash;16. https://doi.org/10.3325/cmj.2021.62.8\u003c/li\u003e\n\u003cli\u003eRussell, R. T., Feurer, I. D., Wisawatapnimit, P., \u0026amp; Pinson, C. W. (2009). The validity of EQ-5D US preference weights in liver transplant candidates and recipients. \u003cem\u003eLiver Transplantation: Official Publication of the American Association for the Study of Liver Diseases and the International Liver Transplantation Society\u003c/em\u003e, \u003cem\u003e15\u003c/em\u003e(1), 88\u0026ndash;95. https://doi.org/10.1002/lt.21648\u003c/li\u003e\n\u003cli\u003eBalestroni, G., \u0026amp; Bertolotti, G. (2012). [EuroQol-5D (EQ-5D): an instrument for measuring quality of life]. \u003cem\u003eMonaldi Archives for Chest Disease = Archivio Monaldi Per Le Malattie Del Torace\u003c/em\u003e, \u003cem\u003e78\u003c/em\u003e(3), 155\u0026ndash;159. https://doi.org/10.4081/monaldi.2012.121\u003c/li\u003e\n\u003cli\u003eRagusa, R., Bertino, G., Bruno, A., Frazzetto, E., Cicciu, F., Giorgianni, G., \u0026amp; Lupo, L. (2018). Evaluation of health status in patients with hepatitis c treated with and without interferon. \u003cem\u003eHealth and Quality of Life Outcomes\u003c/em\u003e, \u003cem\u003e16\u003c/em\u003e, 17. https://doi.org/10.1186/s12955-018-0842-x\u003c/li\u003e\n\u003cli\u003eYounossi, Z. M., Guyatt, G., Kiwi, M., Boparai, N., \u0026amp; King, D. (1999). Development of a disease specific questionnaire to measure health related quality of life in patients with chronic liver disease. \u003cem\u003eGut\u003c/em\u003e, \u003cem\u003e45\u003c/em\u003e(2), 295\u0026ndash;300. https://doi.org/10.1136/gut.45.2.295\u003c/li\u003e\n\u003cli\u003eEuroQol Group. (1990). EuroQol--a new facility for the measurement of health-related quality of life. \u003cem\u003eHealth Policy (Amsterdam, Netherlands)\u003c/em\u003e, \u003cem\u003e16\u003c/em\u003e(3), 199\u0026ndash;208. https://doi.org/10.1016/0168-8510(90)90421-9\u003c/li\u003e\n\u003cli\u003eRabin, R., \u0026amp; de Charro, F. (2001). EQ-5D: a measure of health status from the EuroQol Group. \u003cem\u003eAnnals of Medicine\u003c/em\u003e, \u003cem\u003e33\u003c/em\u003e(5), 337\u0026ndash;343. https://doi.org/10.3109/07853890109002087\u003c/li\u003e\n\u003cli\u003eLloyd, A., \u0026amp; Pickard, A. S. (2019). The EQ-5D and the EuroQol Group. \u003cem\u003eValue in Health: The Journal of the International Society for Pharmacoeconomics and Outcomes Research\u003c/em\u003e, \u003cem\u003e22\u003c/em\u003e(1), 21\u0026ndash;22. https://doi.org/10.1016/j.jval.2018.12.002\u003c/li\u003e\n\u003cli\u003eNagel, M., Labenz, C., W\u0026ouml;rns, M. A., Marquardt, J. U., Galle, P. R., Schattenberg, J. M., \u0026amp; Nguyen-Tat, M. (2020). Impact of acute-on-chronic liver failure and decompensated liver cirrhosis on psychosocial burden and quality of life of patients and their close relatives. \u003cem\u003eHealth and Quality of Life Outcomes\u003c/em\u003e, \u003cem\u003e18\u003c/em\u003e, 10. https://doi.org/10.1186/s12955-019-1268-9\u003c/li\u003e\n\u003cli\u003eParkash, O., Iqbal, R., Jafri, F., Azam, I., \u0026amp; Jafri, W. (2012). Frequency of poor quality of life and predictors of health related quality of life in cirrhosis at a tertiary care hospital Pakistan. \u003cem\u003eBMC research notes\u003c/em\u003e, \u003cem\u003e5\u003c/em\u003e, 446. https://doi.org/10.1186/1756-0500-5-446\u003c/li\u003e\n\u003cli\u003eSol\u0026agrave;, E., Watson, H., Graupera, I., Tur\u0026oacute;n, F., Barreto, R., Rodr\u0026iacute;guez, E., \u0026hellip; Gin\u0026egrave;s, P. (2012). Factors related to quality of life in patients with cirrhosis and ascites: relevance of serum sodium concentration and leg edema. \u003cem\u003eJournal of Hepatology\u003c/em\u003e, \u003cem\u003e57\u003c/em\u003e(6), 1199\u0026ndash;1206. https://doi.org/10.1016/j.jhep.2012.07.020\u003c/li\u003e\n\u003cli\u003eLes, I., Doval, E., Flavi\u0026agrave;, M., Jacas, C., C\u0026aacute;rdenas, G., Esteban, R., \u0026hellip; C\u0026oacute;rdoba, J. (2010). Quality of life in cirrhosis is related to potentially treatable factors. \u003cem\u003eEuropean Journal of Gastroenterology \u0026amp; Hepatology\u003c/em\u003e, \u003cem\u003e22\u003c/em\u003e(2), 221\u0026ndash;227. https://doi.org/10.1097/MEG.0b013e3283319975\u003c/li\u003e\n\u003cli\u003eGastroenterology, C., Depression, H., Jan 01;20194-203.e1, A. A. C. A. P. W. C. C. G. H. 2022, Hernaez, R., Kramer, J. R., Khan, A., \u0026hellip; Medicine, a database of the U. S. N. L. of. (n.d.). Depression and Anxiety in Cirrhosis Patients. \u003cem\u003ePracticeUpdate\u003c/em\u003e. Retrieved March 17, 2022, from https://www.practiceupdate.com/content/depression-and-anxiety-in-cirrhosis-patients/128629\u003c/li\u003e\n\u003cli\u003eSomeshwar, H., Sarvaiya, P., Desai, S., Gogri, P., Someshwar, J., Mehendale, P., \u0026amp; Bhatt, G. (2020). Does Social Distancing During The Lock Down Due To Covid-19 Outbreak In Mumbai Affect Quality Of Life? \u003cem\u003eInternational Journal of Clinical and Biomedical Research\u003c/em\u003e, 1\u0026ndash;4. https://doi.org/10.31878/ijcbr.2020.62.01\u003c/li\u003e\n\u003cli\u003eHwang, T.-J., Rabheru, K., Peisah, C., Reichman, W., \u0026amp; Ikeda, M. (n.d.). Loneliness and social isolation during the COVID-19 pandemic. \u003cem\u003eInternational Psychogeriatrics\u003c/em\u003e, 1\u0026ndash;4. https://doi.org/10.1017/S1041610220000988\u003c/li\u003e\n\u003cli\u003eSkevington, S. M., The WHOQOL SRPB Group, Bartos, M., Bonicato, S., Fleck, M., Fang, \u0026hellip; Underwood, L. (2020). Is Culture Important to the Relationship Between Quality of Life and Resilience? Global Implications for Preparing Communities for Environmental and Health Disasters. \u003cem\u003eFrontiers in Psychology\u003c/em\u003e, \u003cem\u003e11\u003c/em\u003e. Retrieved from https://www.frontiersin.org/article/10.3389/fpsyg.2020.01492\u003c/li\u003e\n\u003cli\u003eKyutoku, Y., Tada, R., Umeyama, T., Harada, K., Kikuchi, S., Watanabe, E., \u0026hellip; Dan, I. (2012). Cognitive and Psychological Reactions of the General Population Three Months After the 2011 Tohoku Earthquake and Tsunami. \u003cem\u003ePLOS ONE\u003c/em\u003e, \u003cem\u003e7\u003c/em\u003e(2), e31014. https://doi.org/10.1371/journal.pone.0031014\u003c/li\u003e\n\u003cli\u003eSkevington, S. M. (2020). Is Culture Important to the Relationship Between Quality of Life and Resilience? Global Implications for Preparing Communities for Environmental and Health Disasters. \u003cem\u003eFrontiers in Psychology\u003c/em\u003e, \u003cem\u003e11\u003c/em\u003e, 1492. https://doi.org/10.3389/fpsyg.2020.01492\u003c/li\u003e\n\u003cli\u003ePaulo Coelho. (2000). \u003cem\u003eVeronika Decides to Die\u003c/em\u003e. HarperCollins.\u003c/li\u003e\n\u003cli\u003eChiu, E., Marr, K., Taylor, L., Lam, L., Stapleton, M., Tandon, P., \u0026amp; Raman, M. (2020). Malnutrition Impacts Health-Related Quality of Life in Cirrhosis: A Cross-Sectional Study. \u003cem\u003eNutrition in Clinical Practice: Official Publication of the American Society for Parenteral and Enteral Nutrition\u003c/em\u003e, \u003cem\u003e35\u003c/em\u003e(1), 119\u0026ndash;125. https://doi.org/10.1002/ncp.10265\u003c/li\u003e\n\u003cli\u003eMaharshi, S., Sharma, B. C., \u0026amp; Srivastava, S. (2015). Malnutrition in cirrhosis increases morbidity and mortality. \u003cem\u003eJournal of Gastroenterology and Hepatology\u003c/em\u003e, \u003cem\u003e30\u003c/em\u003e(10), 1507\u0026ndash;1513. https://doi.org/10.1111/jgh.12999\u003c/li\u003e\n\u003cli\u003eSam, J., \u0026amp; Nguyen, G. C. (2009). Protein-calorie malnutrition as a prognostic indicator of mortality among patients hospitalized with cirrhosis and portal hypertension. \u003cem\u003eLiver International: Official Journal of the International Association for the Study of the Liver\u003c/em\u003e, \u003cem\u003e29\u003c/em\u003e(9), 1396\u0026ndash;1402. https://doi.org/10.1111/j.1478-3231.2009.02077.x\u003c/li\u003e\n\u003cli\u003eAndo, Y., Ishigami, M., Ito, T., Ishizu, Y., Kuzuya, T., Honda, T., \u0026hellip; Fujishiro, M. (2019). Sarcopenia impairs health-related quality of life in cirrhotic patients. \u003cem\u003eEuropean Journal of Gastroenterology \u0026amp; Hepatology\u003c/em\u003e, \u003cem\u003e31\u003c/em\u003e(12), 1550\u0026ndash;1556. https://doi.org/10.1097/MEG.0000000000001472\u003c/li\u003e\n\u003cli\u003eEbadi, M., Bhanji, R. A., Mazurak, V. C., \u0026amp; Montano-Loza, A. J. (2019). Sarcopenia in cirrhosis: from pathogenesis to interventions. \u003cem\u003eJournal of Gastroenterology\u003c/em\u003e, \u003cem\u003e54\u003c/em\u003e(10), 845\u0026ndash;859. https://doi.org/10.1007/s00535-019-01605-6\u003c/li\u003e\n\u003cli\u003eSinclair, M., Gow, P. J., Grossmann, M., \u0026amp; Angus, P. W. (2016). Review article: sarcopenia in cirrhosis--aetiology, implications and potential therapeutic interventions. \u003cem\u003eAlimentary Pharmacology \u0026amp; Therapeutics\u003c/em\u003e, \u003cem\u003e43\u003c/em\u003e(7), 765\u0026ndash;777. https://doi.org/10.1111/apt.13549\u003c/li\u003e\n\u003cli\u003eNishikawa, H., Yoh, K., Enomoto, H., Iwata, Y., Sakai, Y., Kishino, K., \u0026hellip; Iijima, H. (2020). Health-Related Quality of Life and Frailty in Chronic Liver Diseases. \u003cem\u003eLife (Basel, Switzerland)\u003c/em\u003e, \u003cem\u003e10\u003c/em\u003e(5), E76. https://doi.org/10.3390/life10050076\u003c/li\u003e\n\u003cli\u003eCasales da Silva Vieira, R., \u0026Aacute;lvares-da-Silva, M. R., de Oliveira, \u0026Aacute;. R., da Silveira Gross, J., Kruger, R. L., Dal Bosco, A., \u0026hellip; Dias, A. S. (2018). Cirrhosis affects maximal oxygen consumption, functional capacity, quality of life in patients with hepatitis C. \u003cem\u003ePhysiotherapy Research International: The Journal for Researchers and Clinicians in Physical Therapy\u003c/em\u003e, \u003cem\u003e23\u003c/em\u003e(4), e1727. https://doi.org/10.1002/pri.1727\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"liver cirrhosis, quality of life, COVID19 pandemic, EuroQOL, treatment of cirhosis ","lastPublishedDoi":"10.21203/rs.3.rs-1722546/v2","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-1722546/v2","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction\u003c/strong\u003e: Liver cirrhosis is associated with a poor quality of life (QOL). The SARS-CoV-2 coronavirus pandemic has led to several restriction measures and psychosocial consequences whose impact on QOL has combined with that of cirrhosis in an unknown way. Therefore, we have used our cirrhosis registry to assess quality of life before the pandemic (at the first admission to the tertiary liver unit) and during the most pronounced phase of the first lockdown.\u0026nbsp;\u0026nbsp;\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eMaterials and Methods\u003c/strong\u003e: In this cross-sectional study conducted during the first lockdown in Slovakia (from April to May 2020), we have repeated the QOL measurement of QOL in cirrhotic patients previously enrolled in the RH7 registry. Of the entire RH7 cohort, we have identified patients who were alive (according to the national registry of deaths) and contacted them by phone with a structured and standardized interview led by trained professionals. The tool used for both QOL measurements (at enrolment to RH7 and during the lockdown) was standardized and validated EuroQol-5D (EQ-5D) questionnaire. \u003c/p\u003e\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: The study included 97 patients, of which 37 (38.1%) were women and 60 (61.9%) were men. Responses were achieved from 75 patients (68,18%). In general, patients have scored their quality of life significantly higher during the pandemic compared to examination at admission to RH7 (that is, on admission to our tertiary liver unit with cirrhosis) (p = 0.005). In particular, of the domains included in EQ-5D, I.) self-care was better during lockdown compared to the first record on admission to RH7 (p\u0026lt;0.001); II.) the ability to perform daily activities has also improved during lockdown (p = 0.002); on the other hand, III.) pain and discomfort have not changed significantly during lockdown compared with previous measurement (p = 0.882), IV.) anxiety and depression were lower during lockdown compared to admission to RH7 (p = 0.01). \u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e: The quality of life in patients with liver cirrhosis was better during the lockdown of SARS-CoV-2 compared to the previous measurement at admission to the tertiary liver unit.\u003c/p\u003e","manuscriptTitle":"Quality of life in the cirrhosis registry during the SARS-CoV-2 lockdown in Slovakia","msid":"","msnumber":"","nonDraftVersions":[{"code":2,"date":"2022-06-29 14:12:21","doi":"10.21203/rs.3.rs-1722546/v2","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2023-01-09T08:36:54+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2023-01-09T08:15:47+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"0edee413-1f36-4fe8-a9ec-1d4adafda6d2","date":"2022-12-30T07:33:43+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2022-12-02T15:22:19+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"389a2a72-e63c-4c0f-8ec0-66dfde64dd5a","date":"2022-12-02T15:09:53+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2022-08-04T07:40:52+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2022-08-04T07:35:12+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2022-06-17T15:45:13+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2022-06-17T15:34:21+00:00","index":"","fulltext":""},{"type":"submitted","content":"Scientific Reports","date":"2022-06-13T14:21:16+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"7ad4dd4c-3379-4c6f-8b3d-b70006652034","owner":[],"postedDate":"June 29th, 2022","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2023-10-16T18:54:03+00:00","versionOfRecord":{"articleIdentity":"rs-1722546","link":"https://doi.org/10.1038/s41598-023-29510-2","journal":{"identity":"scientific-reports","isVorOnly":false,"title":"Scientific Reports"},"publishedOn":"2023-02-11 18:44:59","publishedOnDateReadable":"February 11th, 2023"},"versionCreatedAt":"2022-06-29 14:12:21","video":"","vorDoi":"10.1038/s41598-023-29510-2","vorDoiUrl":"https://doi.org/10.1038/s41598-023-29510-2","workflowStages":[]},"version":"v2","identity":"rs-1722546","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-1722546","identity":"rs-1722546","version":["v2"]},"buildId":"WrCJVZZCHTDjtuVLN7oU0","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}