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Applications are invited for these travelling fellowships, which are funded by a donation from Dr Geraint James in memory of his wife, Dame Sheila Sherlock.
The fellowships offer consultants and trainees the opportunity to learn new techniques and acquire new experiences, ideas and stimulation through travel and the exchange of ideas.
Two travelling fellowships are available, covering a period of 1 month each, and will be offered to one consultant and one trainee. Each fellowship will be for a maximum of £2,000, with the recipients being responsible for funding any additional costs.
Who can apply?
You must have current membership of the RCP.
Applications are open until 16 January 2017 and details on how to apply can be found the the RCP website > HERE.
Due to the current post holder having served their tenure, BASL are seeking nominations/ expressions of interest for one Committee post. Please send your nominations by Monday 3rd October 2016, 17:00.
• British Viral Hepatitis Group (BVHG) Committee Chair
The BVHG Chair is elected by the BASL / BVHG membership to serve for a period of up to three years and may be re-elected once.
The BVHG is commissioned by the Governing Board to:
• a) promote research and the exchange of scientific information concerning viral hepatitis;
• b) foster multicentre scientific studies pertaining to viral hepatitis within the UK;
• c) promote education of physicians, surgeons, clinical nurse specialists and scientists
• with regard to viral hepatitides and their management;
• d) Promote interaction between clinical disciplines to promote good care of patients and foster research and clinical trials.
The BVHG Chair shall be registered with Companies House in the United Kingdom as a Director of BASL and registered with the Charities Commission as a Trustee.
If you need any more information about the post please contact the current BVHG Committee Chair Dr Andrew Ustianowski at Andrew.Ustianowski@pat.nhs.uk .
Candidates wishing to be considered for election will require one BASL member to propose them and a second member to confirm their suitability for the role in writing.
Please email Judy Hawksworth at the Secretariat; Judith@execbs.com with your nominations by 17:00 on Monday 3rd October 2016. Following this time, candidate statements will be sought and voting will take place if necessary.
More integration is needed between primary and secondary care, said Dr John O’Malley, GP and Medical Director at Mastercall, Stockport.
Mastercall is a NHS social enterprise providing out-of-hours services in the Stockport area. In his presentation, Dr O’Malley used findings from a survey of 150 doctors to support his call for more integration between primary and secondary care in providing palliative care for end-of-life liver disease patients.
Most GPs are good at palliative care and, together with others in the primary care team, give the continuity of care needed, he said. Sophisticated computer databases have been developed to help coordinate care and are used to track the trajectory of many organ failures. However, whilst renal, heart or lung failure may follow a predictable model, many GP’s feel “out of their comfort zone” when it comes to liver failure.
Liver disease presents many problems in primary care; often, patients are (or are seen to be) homeless, intravenous drug users or with alcohol problems, and many do not have contact with their GPs. There is an uncertain illness trajectory which does not fit well with the palliative care model: liver patients do not do behave as they should in the textbooks. Periods of relative wellness between decompensation can lull carers into a false sense of security. Furthermore, there is a problem with the pharmacology. Primary care providers are well versed in symptom control for cancer etc, and have strong evidence that they are using these drugs correctly. But when it comes to liver disease, there are no manuals.
Palliative care is often seen as a “last gasp” when everything else has been done. The default position was to send the end-of-life liver patients into hospital (although evidence shows that only three percent of patients would prefer to die in hospital). Specialist advice and support is often sadly lacking, and GPs would welcome the support of liver outreach teams which could make it possible to keep patients at home.
Dr O’Malley ended by pleading for more cooperation between specialist and primary care. True multidisciplinary work and integration is needed, he said. And GPs want more education, especially evidence based methods of identification for end of life in liver disease.
By 2020, it is estimated that non-alcoholic steatohepatitis (NASH) will be the leading indication for liver transplantation.
During the Sheila Sherlock Lecture, Dr Matthew Armstrong of Queen Elizabeth University Hospital Birmingham, reminded delegates NASH is the most common form of liver disease, especially in the Western world, and that up to 20% of cases progress to cirrhosis
So far, there have been no licensed therapies for NASH; Dr Armstrong’s presentation focused on research into the glucagon-like peptide-1 (GLP-1) analogues and their potential role in the management of the condition.
GLP-1 analogues were developed as treatments for type 2 diabetes, however, Trevaskis et al (2012) provided evidence to suggest that liver fibrosis had regressed on histological assessment and collagen-1 immunostaining (marker of fibrogenesis) with GLP-1.
A study in type 2 diabetes (Armstrong et al 2013) had demonstrated a dose -dependent improvement in liver enzymes. However, as Dr Armstrong pointed out, these findings were retrospective and the study was diabetes-focussed and not powered for liver endpoints.
However, the LEAN double-blinded, randomised, placebo-controlled phase 2 trial assessed the GLP-1 analogue, liraglutide, in overweight patients with clinical evidence of NASH (Armstrong et al 2016). The primary outcome measure was resolution of definite NASH with no worsening in fibrosis from baseline to end of treatment (48 weeks), as assessed by two independent pathologists.
Nine of 23 patients who received liraglutide and underwent end-of-treatment liver biopsy had resolution of definite NASH compared with two of 22 patients in the placebo group (relative risk 4·3). Two of 23 patients in the liraglutide group versus eight of 22 patients in the placebo group had progression of fibrosis. Most adverse events were grade 1 or 2, and were self-limiting in the first 12 weeks with the exception of gastrointestinal disorders in 21 liraglutide patients and 17 placebo patients.
Dr Armstrong summarized that GLP-1 agonists achieve histological clearance of NASH, reduce fibrosis progression and improves key metabolic risk factors with a direct and indirect mechanism of action. And they are well tolerated with an acceptable safety profile.
Binge drinking culture was created deliberately to aid falling profits and public health is picking up the bill.
In a blistering attack on the Government and the drinks industry, Professor Nick Sheron, a consultant hepatologist, traced the current “epidemic of liver disease” to the 1990s, when marketing campaigns targeted a generation that had shunned alcohol in favour of “party drugs”.
“The drinks industry got worried because young people stopped drinking, so they changed their marketing and targeted 18 year olds with a new type of drink: alco-pops.
“At the beginning of the 1990s, children did not drink any spirits at all. By the end, 10 to 15 year olds are drinking at last one double vodka a week.”
Talking at the annual meeting of the British Association for the Study of the Liver in Manchester this week, he used the Government’s own figures to slam the U-turn on introducing a minimum price per unit (MUP) in 2014. In the same year there were 8,697 alcohol-related deaths in the UK.
“If we are going to stop people dying of liver disease we have to stop people drinking alcohol,” he said.
Far from MUP penalising moderate drinkers, as critics of the policy claimed, it would disproportionally impact those drinking at harmful levels, he said.
“Back in the 1980s, a litre of spirits would have cost more than £90. Today, the equivalent price is £28. The mean consumption of one of my patients with cirrhosis is 150 units a week.
“People with cirrhosis spent 30p a unit, others, on average, spend £1 a unit. Patients with cirrhosis on the whole are not drinking frozen mojitos for £7 a go in a rooftop bar.”
Charging 70p a unit, Prof Sheron said, would take the average weekly alcohol bill of his caseload from £23.25 to £105.
There is a direct correlation between the price of alcohol and deaths from liver disease, Prof Sheron said.
In 2008 in the midst of the economic downturn and to the backdrop of rising deaths from liver disease, a 2% tax escalator policy was introduced by the then Chancellor Alistair Darling.
The policy, which saw duty on wine and spirits automatically rise by 2% above inflation each year, was hotly opposed by the drinks lobby, but Prof Sheron said the number of deaths started to level out.
The policy was dropped in 2014 following extensive lobbying from the Wine and Spirits Association.
“Everything was going in the right direction and now we are back to an 8% year-on-year increase in alcohol related deaths,” said Dr Sheron, adding there was a very simple reason the industry had been opposed to MUP.
Just 1.3% of the population, those who are consuming 75+ units a week, are drinking 16% of all alcohol – and accounting for more than 50% of all alcohol-related deaths.
“Quite simply, the drinks industry does not want to lose these customers,” said Prof Sheron.
And it is public health, not to mention the public purse, which is missing out.
In 1980, 4% of the Government’s income came from alcohol taxation, but that has halved – that equates to £3.55billion of lost tax revenue a year since 2013.
“Shall we compare that to the £4billion hole in NHS?,” Prof Sheron asked.
Not everyone who drinks will become dependent, not everyone who becomes dependent will get fibrosis and not everyone who gets fibrosis will progress to cirrhosis and liver disease.
During the BASL annual meeting, Dr Marsha Morgan looked at the genetic predisposition for becoming alcohol dependent "versus being susceptible to cirrhosis".
“Only 40-50% of alcohol misusers are going to develop dependence over time and less than 20% of misusers will develop cirrhosis,” she said.
“It is so complex – there is a genetic susceptibility for alcohol misuse and one for cirrhosis what is unclear is where they overlap.”
PNPLA3 has a confirmed pivotal role, said Dr Morgan: “It has got nothing to do with alcohol dependence but everything to do with alcohol-related cirrhosis.”
It is also a risk factor for HCC: the cancer tends to occur at an earlier age, lead to multiple lesions and a worse outcome.
“It carries a population attributable risk of 27%, meaning it could be giving us 200,00 more cases of alcohol-related cirrhosis,” said Dr Morgan.
In her presentation “Improving outcomes following paediatric liver transplantation”, Professor Deidre Kelly (Birmingham) had stressed the importance of issues involved in the transition to adult services. These themes were expanded on by Dr Alison Darcy, Clinical Research Psychologist at Stanford University, and Dr Marianne Samyn, Consultant Paediatric Hepatologist at King’s College Hospital, in their joint presentation.
Dr Darcy specialises in developing models that specifically target individuals who are difficult to reach. In her presentation, which centred on adolescent neurocognitive development in the context of chronic Illness, she explained that neuroimaging studies have shown how adolescence is a distinct period. Higher-order cognitive functioning matures later than “primary” function regions and the development of subcortical regions is also pronounced at that age.
Adolescence is a turbulent period, with 75% of mental illnesses arising before age 24 and with 8% reporting a suicide attempt in the previous year. However, she noted, most adolescents do not get treated for mental illness problems.
Most adolescents exist on a different space-time continuum and experience danger differently. Most importantly, they value their peer groups very highly (this, she noted, has also been observed in some higher primates). As the quality of the peer group matters, this has implications for clinicians. She suggested that clinicians should not tell adolescents NOT what not to do: negative messages inhibit learning and messages should be framed positively. Clinicians could also adjust expectations around self-management, adherence and adaptability, and adopt a “growth mindset” rather than a “fixed mindset.
Dr Samyn is the Clinical Lead at King’s multidisciplinary liver transition service and, in her presentation “Looking after young people: getting it right”, she told delegates that a study by Sagar et al (2015) had concluded that the outcomes were good for young liver transplant patients who transferred to the adult services.
She reminded delegates that other transitions are occurring at the same time, such as leaving school, leaving home, or starting work or college. Furthermore, IMPARTS had shown that amongst young people attending a liver transition clinic, prevalent anxiety and depression were higher than in the general adolescent population (17.7% versus 4-6%) and were similar across liver transplant, AILD and other liver conditions. And they were likely to interact with treatment adherence.
Based on her experience at King’s, she stressed the importance of the multidisciplinary team. She emphasised the need to foster a positive patient/provider relationship, with collaborative decision-making. Therefore, the multidisciplinary transition team should adopt a proactive individualised and flexible approach and be aware of psychosocial, educational and vocational needs.
Liver transplantation (OLT) in children is now highly successful, with a more than 80% 20-year survival.
Deidre Kelly, Professor of Paediatric Hepatology at Birmingham Children’s Hospital NHS Trust, explained that most paediatric liver diseases are potentially curable with OLT and that long-term (i.e. over 10 years) histological outcome of liver allografts is evolving. Innovative surgery has allowed the extension of transplantation to under one year and under 10kg and include split liver and living related transplantation.
These techniques have been matched by improved specialised medical and nursing care, pre-operative nutritional therapy and post-operative immunosuppression. There have been many advances in therapy including anti-oxidant cocktail and iron chelation, exchange transfusions and IV immunogloblulin, primary bile salt therapy and nitisinone.
An example of a major advance has been the centralization, at Birmingham, Leeds and London, of the diagnosis and management of biliary atresia, Kasai portoenterostomy and liver transplantation. From 15 centres (1993-1995) to the three centres (2009-2013), changes in the clearance of jaundice have been 55% to 64%, five-year native liver survival, 27% to 56%, and five-year overall survival, 84% to 93%, respectively.
Prof Kelly believes that current challenges in paediatric liver transplantation include long term outcomes, indeterminate graft hepatitis and fibrosis, the detection and prevention of adverse cognitive or psychological functioning, and adherence and transition to adult care. She stressed that future pre-plant initiatives should include the optimization of nutrition and the time of transplant to prevent neurocognitive damage. And further research was needed on the aetiology of graft hepatitis/fibrosis.
Prof Kelly emphasized the crucial role of managing the transition to adult care. Young people’s anxiety about transition to adult care related to difficulties forming new relationships once in adult care and a lack of continuity of care. A BSPGHAN research project had found that young people with a liver transplant diagnosis felt different from their peers. They adopt different coping strategies in order to manage and cope with their condition. And they identify building relationships with healthcare professionals and having continuity of care as being important for their transitional care.