News

This guidance represents the professional advice from the British Association for the Study of the Liver, British Society of Gastroenterology, British Transplantation Society, NHS Blood & Transplant and input from the British Liver Trust.

The patients in the groups below are advised to shield and should consult the government web-site for advice on what that entails:

1. Patients with chronic liver disease who are on immunosuppressants

Data: There are as yet no large enough datasets to support/refute this approach and thus this is based on clinical judgement. 

2. Any patient with liver cirrhosis and decompensation or complication as defined by presence/recent history (within 12 months) of ascites, hepatic encephalopathy, hepatocellular carcinoma, variceal bleed or synthetic liver dysfunction.

Data: This is supported by data from the COVID-HEP registry that indicates that patients with decompensated liver cirrhosis have an unadjusted mortality rate 5-28 times higher than patients with liver disease without cirrhosis.

3. Patients who are actively on the liver transplant waiting list or who have received a liver transplant

Data: This is supported by data from NHSBT that indicates that patients who have had liver transplant have an unadjusted mortality rate of 25%.

Shielding is for a patient’s protection rather than a legal obligation. The need for shielding can be flexed further on a case by case basis in consultation with your healthcare team.

Application of this guidance

There are 3 elements:
1. Categorisation as high vulnerability – the guidance above should clarify that. This should be notified to employers etc.

2. Recommended response to that categorisation – This is nationally set, under review and changing with updated guidance from PHE and the CMO. Recommendations are based on complex factors including the current national categorisation of the pandemic, geography, occupation, local and national disease prevalence, R rates, risk factors for exposure etc.

3. Patient choice – Based on the above, patients, with support from clinical teams, are equipped to make personal decisions about what they will then do. Issues to weigh up will include home and family circumstances including age range of those at home and nature of accommodation, the person’s mental health, overall wellbeing, employment status and financial position.

Each year BASL presents the Dame Sheila Sherlock research prize, one of the highlights of the annual meeting. This prize is awarded annually to recognise the enormous contribution of Dame Sheila Sherlock to the development of Hepatology as a discipline in its own right.

Dame Sheila was involved in the foundation of the British Liver Club in 1961, which subsequently evolved into The British Association for the Study of the Liver (BASL). She was one of our past presidents and the first recipient of The BASL Distinguished Service Award. In keeping with Dame Sheila’s enthusiasm for fostering young researchers, this eponymous research prize is awarded to young investigators without substantive posts in either medicine or science for their research contributions in the field of Hepatology.

The winner will receive free registration to the meeting, an award and a prize of £1,000 and an invite to deliver the prize lecture at the BASL Virtual Annual Meeting on 21st - 23rd September 2020.

To apply, please send one A4 sheet outlining your research and another A4 sheet listing up to 5 related publications.

Please send submissions to steve@basl.org.uk before the deadline of 09:00hrs on Monday 3rd August 2020.

On Friday 24th April Dr John Walshe celebrates his 100th birthday, and I am sure that we would all wish to send him our best wishes and heartfelt congratulations on this auspicious day. Reaching this age is a tremendous achievement, but his historic contributions to Medicine, and in particular to our current knowledge of Wilson’s disease, its diagnosis and treatment, are unique, and generations of patients with this condition owe their lives and health to him.

So John, we revere you beyond words, and send our best wishes and thoughts to you on this special day.

Dr John Walshe was born on the 24th April 1920 in Kensington, London, to Francis and Bertha Marie (née Dennehy) Walshe. His father was a Consultant Neurologist at the National Hospital for Nervous Diseases, Queen Square; knighted in 1953, Sir Francis was a distinguished, internationally known neurologist. He was elected FRS in 1946.

John Walshe’s first association with Cambridge University was when, as a schoolboy in 1938, he went there to sit his First MB examination. He was accepted at Trinity Hall, Cambridge to study medicine and qualified BA in 1942. He then did his clinical studies at University College Hospital in London (UCH), qualifying MA, MB BChir (Cantab) in 1945. He served with the Royal Army Medical Corps in the Middle East Command between 1946 and 1948, spending time also in Greece and Cyprus. After this he returned to UCH.

His journey towards Wilson’s disease started in the early 1950s at UCH. He was working under Professor Charles Dent, a pioneer in metabolic diseases, and studying changes in amino acid metabolism in liver disease, and in particular in urine using paper chromatography. In one study he found an additional band in the urine, and thought that he might have discovered a new amino acid. However, the patient involved was on penicillin and it transpired that this was ‘penicillamine’, a metabolic product of penicillin. This work was published in the Quarterly Journal of Medicine in 1953. He moved on.

The next event, central to Wilson’s disease and involving his extraordinary mind and insight – an exceptional example of ‘translational medicine’ – occurred in the USA. During his year as a Fulbright Scholar on the Liver Unit at Boston City Hospital (Harvard Medical Unit) in 1955, the hepatology team were approached by the neurological team for advice on the management of a patient with Wilson’s Disease who was not improving as they had hoped on the treatment then available (parenteral British Anti-Lewisite). John Walshe’s scientific insight, knowing the chemical structure of penicillamine, led him to suggest (while crossing a walkway on the way back to their laboratory) that penicillamine might bind copper and lead to its excretion. A small amount of penicillamine was procured. He took some himself (remembering one of Professor Dent’s sayings: ‘You must never give an unknown compound to a patient if you are not prepared to take it yourself’) (see Walshe, 2019), and having no untoward effects, some was then given to the patient. Urine analysis showed an increase in copper excretion.

When he returned to England, he continued to study penicillamine in patients with Wilson’s disease and published the first pivotal papers on a group of patients in 1956. The place of D-penicillamine as an oral treatment for Wilson’s disease has remained ever since, has saved lives and improved the lives of innumerable patients in the ensuing 60 plus years. Many patients have remained in touch with him from those early and subsequent years.

Penicillamine may be associated with adverse effects, and it was because of a patient’s inability to continue with treatment that John Walshe (on the advice of Dr HBF [Hal] Dixon, in the Department of Biochemistry at Cambridge University) chose triethylenetetramine (trientine) dihydrochloride as an alternative copper chelator, and this has also become one of the mainstays of the treatment of Wilson’s disease. Dr Walshe also published early observations on zinc treatment (developed by others in Holland and the USA) and on ammonium tetrathiomolybdate.

In his long career he has published more than 150 papers and book chapters on Wilson’s disease and its link with copper metabolism, both from his own unit and with collaborators abroad. Many deserve mention, but space does not allow. I would, however, like to make note of his invaluable research assistant Kay Gibbs, and his collaboration with Professor Diane Wilson Cox in Canada, a pioneer in molecular genetics of Wilson’s disease.

Most of his career was spent in Cambridge, as Reader in Metabolic Disease and Director of Research in the Department of Medicine between 1957 and 1987. He was also an Honorary Consultant Physician at Addenbrooke’s Hospital, Cambridge, during this period.

He obtained his MRCP in 1952/3, and was awarded his FRCP in 1964, and Doctor of Science (ScD, University of Cambridge) in 1965. He was honoured with an MD (honoris causa) by the University of Uppsala in 1994. He was the Bertram Louis Abrahams lecturer at the Royal College of Physicians of London (‘The Biochemical Lesion in Wilson’s Disease’) in 1966. He has also given the Hudson Memorial Lecture in 1983, and the Worshipful Company of Pewterers’ Lecture at the National Hospital of Nervous Diseases, Queen Square, in 1995. In 1977, he was awarded the gold medal in therapeutics of the Worshipful Company of Apothecaries.

After his retirement from the University of Cambridge and Addenbrooke’s Hospital in 1987, he was given an honorary senior lectureship at UCL and became an Honorary Physician at UCH, allowing him to continue Wilson’s disease clinics at UCH and then the Middlesex Hospital, until finally ‘retiring’ in 2000. Dr Godfrey Gillett, a Consultant in Metabolic Medicine from Sheffield, joined Dr Walshe in these specialist clinics, and continues with them today.

Since this final retirement, Dr Walshe has continued to take an interest in his former patients from his home in Cambridgeshire and regularly attends the annual meeting of the Wilson’s Disease Support Group – UK (a support group for patients, their friends and families, founded in 2000) of which he is Honorary President.

In 1958 he and his wife Ann, who sadly died in 2011 after 55 years of marriage, settled in a wonderful 17th Century Grade II listed house in Hemingford Grey, north of Cambridge. He still lives there cared for by his daughter Susan and son-in-law Philip. His other daughter Clare lives near Oxford.

Throughout his life John Walshe has had a wealth of interests in many areas, but was a very keen photographer particularly of churches and stained glass windows. In his early years at Cambridge he took a particular interest in brass rubbings, making a record of those at Ely Cathedral which he later gave to the Dean of Ely, and which he believes are now stored at the University Library. His house is packed with historic artefacts from around the world, including model elephants – a connection with Wilson’s disease, since patients were asked to draw an elephant to give an assessment of the neurological features of their condition. This appealed to both children and adults.

John Walshe is a polymath, a translational scientist and expert clinician who has changed the lives of patients with Wilson’s disease worldwide. He has remained focussed on this often neglected, challenging and rare disease for much of his professional life. His latest paper on Wilson’s disease (published in the Quarterly Journal of Medicine) was in 2016 when he was 96 years old: incredible – and rarely matched by any other clinician scientist.

John – we are honoured to have benefitted from knowing you, to have enjoyed your encyclopaedic knowledge and to have been able to apply your lifetime’s work to the benefit of our patients.

Many, many congratulations on this very, very, special birthday.

Dr James Dooley
Emeritus Reader in Medicine
UCL Institute of Liver and Digestive Health
(Royal Free Campus)
Hampstead, London NW3

I would like to acknowledge the help of Professor Graeme Alexander, Dr Godfrey Gillett, Dr Bill Griffiths and Dr Rupert Purchase, and the following sources, in writing this account:

JM Walshe. Copper: Quest for a Cure. Bentham Books, eBook, 2009

JM Walshe. Wilson Disease: My Involvement – A Brief Reminiscence. In: Clinical and Translational Perspectives on Wilson Disease. Ed Kerkar N, Roberts EA. Academic Press, 2019.

Dr John Walshe. Biography on the Hemingford Grey Parish Council Website. By Esther Harrod

Rupert Purchase. Dr John Walshe and the treatment of Wilson’s disease (prepared for the Wilson’s Centenary Meeting in 2012).

Rupert Purchase. An Archive of Dr John Walshe’s Publications

Shorvon S, Compston A. Queen Square. A History of the National Hospital and its Institute of Neurology. Cambridge University Press, 2019.

The government previously had asked patients receiving immunosuppression for a liver transplant or autoimmune hepatitis to be shielded. As no central register exists for patients with autoimmune hepatitis on immunosuppressive medications, individual hospitals with the help of specialists have been identifying these patients for shielding.

NHS England is asking that both lists of these patients should be passed onto the COVID19 lead within their hospital by Monday 13th April. They will then pass this information onto NHSE.

Can you please ensure this information is passed onto the relevant person within your Trust?

Professor Guruprasad Aithal
President, BASL

Important update from the BSG VP Hepatology and the BASL and BSG Presidents

During the COVID-19 outbreak the NHS is doing everything it can to keep patients with liver disease safe. However, risks relate not just to the infection itself, but also to the significant disruption of routine care due to the pandemic. Information from China and Italy suggest that hospital admissions for non-COVID-19 illness can lead to further spread of infection. Changes in routine care are now required to keep vulnerable patients with liver disease out of hospital as much as possible. However, changes to the way care is delivered for patients with liver disease must be balanced against the risks of undertreating them.

‘Social distancing’ and ‘self-isolation’ are measures to reduce spread within a population and to protect high risk groups. The impact of immunosuppression on the severity of COVID-19 disease remains unclear. Factors associated with more severe disease are older age and presence of other medical conditions. These are also an understandable source of anxiety for patients with liver disease. Government guidance in this area is dynamic and all people in the UK should follow up to date recommendations from the government.

The government recommends social distancing for all in the UK, but this guidance defines a ‘high-risk’ group of patients with liver disease who are advised to take additional measures and go into self-isolation for 12 weeks.

Patients with liver disease in high risk group*:

`Shielded group` Advise mandatory self – isolation:

1) Patients having undergone liver transplantation and taking immunosuppression and

2) Patients with autoimmune hepatitis taking immunosuppression

The consensus view in our specialty acknowledges the higher risk for patients with decompensated cirrhosis, who are not included in the shielding cohort. We recommend that these patients with decompensated cirrhosis should be advised to adhere strictly to social distancing measures in order to protect themselves. Clinicians will not, however, have to identify this group to their GPs for coding as COVID at RISK.

*There may be others not in the above groups felt by the treating physician to also be at higher risk and these should be assessed on a case-case basis.