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Alcoholic hepatitis remains a difficult condition to treat with conflicting evidence as to its best management.
The recent STOPAH trial results have had a mixed reception among the gastroenterology and hepatology community and there is a variation in clinical management across the country. We would like to document this variation and determine how to improve care for this group of patients.
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To participate in the survey click > HERE.
Thank you for your time.
Dr Ashwin Dhanda, NIHR Academic Clinical Lecturer, Plymouth Hospitals NHS Trust
Dr Stephen Atkinson, MRC Clinical Research Training Fellow, Imperial College London
Prof Mark Thursz, Professor of Hepatology, Imperial College NHS Trust
Responding to the ruling made today in the Scottish courts in relation to minimum unit pricing in Scotland, Professor Sir Ian Gilmore, chair of the Alcohol Health Alliance, said:
"We welcome this court ruling, and hope to see minimum unit pricing speedily implemented in Scotland. Now is the time to act, even if the global alcohol producers, prioritising commercial interests over Scotland’s health, try to delay further by another appeal.
Now is also the time for England and Wales to follow suit and introduce MUP. The UK government committed to introducing MUP in 2012, and the public support the measure. Government-commissioned research estimates that in the first year following the implementation of MUP in England, there would be nearly 140 fewer crimes per day.
MUP leaves pub prices untouched, and targets the cheap alcohol which is preferentially consumed by children and dependent drinkers. Recent AHA research has found that alcohol is being sold for as little as 16p per unit, with 3 litre bottles of white cider, which contain the same amount of alcohol as 22 shots of vodka, available for just £3.49.
MUP would also be of greatest benefit to those on low income, with 8 out of 10 lives saved coming from the lowest income groups, and greater harm reductions felt by these groups. The government has spoken of its commitment to even out life chances, and MUP would go a long way in furthering this agenda."
For more information visit the AHA website > here.
Research released today shows there is an abundance of high strength alcohol sold for pocket money prices in shops and supermarkets across the UK.
A review of alcohol prices in a range of retailers found products like high strength white ciders, which are predominantly drunk by dependent and underage drinkers, available for as little as 16p per unit.
This means that for the cost of a standard off-peak cinema ticket it is possible to buy almost seven and a half litres of high strength white cider, containing as much alcohol as 53 shots of vodka.
The findings are released today in a report by the Alcohol Health Alliance UK (AHA) (Download Cheap alcohol the price we pay AHA Oct 2016.pdf), a group of medical royal colleges, alcohol organisations and health bodies. The report argues that recent cuts in alcohol taxes allow supermarkets to sell alcohol at rock bottom prices, but have done little to benefit pubs and their customers.
Chair of the Alcohol Health Alliance (AHA), leading liver doctor and former President of the Royal College of Physicians, Professor Sir Ian Gilmore said:
"In spite of a government commitment to tackle cheap, high-strength alcohol, these products are still available at pocket money prices. Harmful drinkers and children are still choosing the cheapest products: predominantly white cider and cheap vodka."
"We need to make excessively cheap alcohol less affordable through the tax system, including an increase in cider duty. It's not right that high strength white cider is taxed at a third of the rate for strong beer."
"In addition, we need minimum unit pricing. This would target the cheap, high strength products drunk by harmful drinkers whilst barely affecting moderate drinkers, and it would leave pub prices untouched. In fact, pubs could benefit from minimum unit pricing, as it would prevent the proliferation of cheap alcohol in our supermarkets."
"It's time the government took action and made all high strength alcohol less attractive to vulnerable drinkers."
Each year there are almost 23,000 deaths and more than one million hospital admissions related to alcohol in England and Government figures estimate that alcohol harm costs UK society more than £21billion.
The report, Cheap alcohol: the price we pay, warns that, unless action is taken on the availability of cheap alcohol, harms associated with alcohol consumption will continue to rise, increasing the burden on the NHS and public services.
For further information, please contact Matt Chorley, the AHA's Policy and Communications Officer, at email@example.com or on 0203 075 1726.
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.