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With the outbreak of COVID-19/Coronavirus, many patients have asked for clarification on how the COVID-19 threat affects their current liver management.
Here are some FAQs regarding the impact of COVID-19 on patients with liver disease or specifically those with cirrhosis or those undergoing treatment for Chronic Hepatitis B (CHB).
Q: What should I do if I have an existing liver condition?
A: If you have had a liver transplant or are taking immunosuppressive medication for autoimmune hepatitis, it’s critical that you stay at home and shield yourself to avoid being exposed to COVID-19. For a full list of clinically vulnerable groups advised to shield themselves for at least 12 weeks during the COVID crisis visit; https://www.gov.uk/government/publications/guidance-on-shielding-and-protecting-extremely-vulnerable-persons-from-covid-19/guidance-on-shielding-and-protecting-extremely-vulnerable-persons-from-covid-19.
Patients with cirrhosis and specifically those with decompensated cirrhosis should follow the advice on strict social distancing to protect themselves. However, if you are on antiviral therapy for CHB without established liver disease (significant fibrosis or cirrhosis), you should not be at any increased risk from COVID-19. In this case, you should continue to take your antiviral therapy and follow the advice for the general population; work from home if possible and maintain social distancing to reduce your risk of contracting the virus.
Notably, the majority of hospital and specialist clinics have made arrangements for antiviral therapy, and other medications usually prescribed in these clinics, to be prescribed in advance over the coming months. In some cases, medications will be couriered to patients to minimise hospital visits and potential exposure to COVID-19. In addition, routine laboratory tests and surveillance imaging will be deferred for many patients. Please liaise directly with your treating Physician to ascertain what plans are in place for your care during the COVID crisis.
If you are experiencing symptoms of COVID-19, such as a fever, myalgia or a dry persistent cough, you should call NHS 111 immediately. Do not visit your local GP surgery or walk-in clinic. Instead, self-isolate at home and visit the NHS website for advice: https://www.nhs.uk/conditions/coronavirus-covid-19/ .
Q: Where can I find up-to-date information about Coronavirus online?
A: It is important to get accurate, up to date information about COVID-19, please see the Public Health England website: https://www.gov.uk/government/organisations/public-health-england .
There are many fraudulent and inaccurate sources of information circulating on the internet. Therefore, it is critical that you obtain and share information from reputable sources like Public Health England.
Professor Patrick Kennedy
Consultant Hepatologist & Gastroenterologist at Barts Health NHS Trust
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
On 22nd March, the British Government announced that 1.4 million people identified by their doctors would be shielded through self-isolation for 12 weeks (https://www.gov.uk/government/publications/guidance-on-shielding-and-protecting-extremely-vulnerable-persons-from-covid-19/guidance-on-shielding-and-protecting-extremely-vulnerable-persons-from-covid-19). Recent government announcements have indicated that the liver patients to be included in the ‘shielding group’ should be those receiving immunosuppression for a liver transplant or for autoimmune hepatitis. Self-isolated patients’ clinical care should continue safely, some may also need additional support from social services (https://www.gov.uk/government/publications/covid-19-residential-care-supported-living-and-home-care-guidance/covid-19-guidance-on-home-care-provision).
All liver transplant patients will be contacted using the NHS Blood and Transplant register with information. As no central register exists for patients with autoimmune hepatitis on immunosuppressive medications, individual hospitals need to identify these patients, therefore, please prioritise writing to these patients (a draft letter template 'letter to AIH patients on Immunosuppression' can be downloaded from the website 'members area' under 'All Resources' or by request to email@example.com ). Letters sent to the patients should also be copied to GPs to permit primary care coding as COVID-19 AT RISK. Proactive day care unit therapeutic paracentesis service, tele-clinics and helplines are vital for continuing care of these patients. Reducing hospital visits and admissions for non-COVID-19 illness can reduce further spread of infection.
Thriving amidst this, Hepatology registrars at the Translational Gastroenterology Unit in Oxford have set up a registry to capture clinical outcomes of COVID-19 in patents with liver disease or transplantation (https://covid-hep.net/). Learning should continue even in crisis and conflicts.
Professor Guruprasad P. Aithal
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.
As a community responding to the COVID-19, you would have had a number of messages from within and outside the institutions that you work in regarding this issue. We should recognise and acknowledge there is uncertainty regarding the impact of this on individuals and groups. Accordingly, locally and nationally balanced judgements will inform regular guidance and advice. BASL has worked together with organisations that share common interest in our patients and services to provide information and advice based in the current context.
Please see news items to follow for guidance for healthcare professionals in Gastroenterology and Hepatology and for guidance to patients with a liver transplant and chronic liver disease.
Professor Guruprasad Aithal
• All healthcare professionals have a responsibility to safeguard patients, colleagues and themselves from the COVID 19 virus.
• We wish to emphasise the importance of following current guidance and advice from Public Health England, Health Protection Scotland, Public Health Wales and Public Health Agency Northern Ireland.
• You will find any updates to this document on the BSG website.
Potential Impact on Gastroenterology and Hepatology Services
• Based on developments over the last few days, it is likely that the NHS will have to manage increasing numbers of patients with COVID 19. There is a shared understanding that if COVID 19 becomes a significant epidemic in the UK, clinical services will be stretched and that this will be exacerbated by staff shortages due to sickness, imposed isolation and caring responsibilities.
• It is likely that there will be increasing requirements for healthcare professionals in gastroenterology and hepatology to support NHS Healthcare providers in managing the care of acutely ill patients. This will likely result in disruption or cancellation of clinics and endoscopy lists and other specialist activities.
Redeployment of Staff to Managing Acutely Unwell Patients
• In the event of a significant outbreak, healthcare professionals in gastroenterology and hepatology will be asked to support broader patient and population needs.
• It is important that these activities are considered in the context of patient safety. Healthcare professionals should not undertake any activity beyond their level of competence.
• Healthcare professionals should avail themselves of training opportunities to equip them to undertake specific tasks in looking after acutely unwell patients either with suspected or confirmed COVID 19 infection.
Advice for patients with Inflammatory Bowel Disease on immunosuppression
• The following advice is from Public Health England and is well summarised by Crohn’s and Colitis UK and the International Organisation for IBD (IOIBD).
• People taking immunosuppressants for their Crohn’s Disease or Ulcerative Colitis are not at increased risk of catching novel coronavirus, however they may be at extra risk of complications from the virus if they are infected.
• People on immunosuppressants should seek advice by telephone if they develop symptoms of either seasonal Influenza or novel coronavirus.
• For the majority of patients, it is advisable to continue with immunosuppressive treatment and other treatments for their inflammatory bowel disease.
• Patients are advised to take precautions to avoid infection through good personal hygiene and avoiding unnecessary close contact with people who are unwell.
• If patients stop taking immunosuppressive medicine, they may have a flare which will increase the risk of complications if infected with coronavirus.
• If patients still have concerns about continuing the medication, they should speak to the medical team.
• If patients are at an increased risk of infection, for example, if they have been in direct contact with an infected individual, have travelled to a high infectivity area, or have another serious comorbidity that increases the risk further, they should seek advice from their medical team by telephone before making any changes to their medication.
Telephone and Virtual Clinics
• In order to maintain social distancing and reduce the risk of transmission of COVID-19, we encourage telephone consultations with patients or virtual clinics to avoid patients having to attend the clinic in person.
• We suggest that in such circumstances, a clause is added to the clinics letter that the patient has not been examined and that part of the assessment is therefore limited but has been only omitted due to exceptional circumstances.
• Good IT support is necessary to support telephone or virtual clinics, for example use of Skype.
• Acute services can be helped by reducing acute admissions where possible by setting up alternative routes of care as in the case of day-case unit paracenteses services to prevent emergency admissions for paracentesis (these can be about 100/100,000 population).
• Patients suitable for telephone and virtual clinics include those with stable cirrhosis and those long-term after transplant.
• Patients post-transplant, those with AIH on second line immunosuppression, and those with decompensated cirrhosis and/or alcoholic hepatitis patients are considered high risk for COVID 19.
• Patients with compensated cirrhosis are considered to be in the intermediate risk group for COVID 19.
Advice for Patients with Liver, or Small Bowel Transplants
• We recommend that healthcare professionals looking after such patients refer to the guidance from the British Transplantation Society.
Endoscopy and COVID19
• Endoscopy Teams are advised to follow both national guidance for reducing transmission of infection with COVID19 (websites above) but also agree their own local protocols and policies in collaboration with senior management, Infectious Disease or Infection Control teams. There are both general measure that should be followed and specific measures around personal protective equipment (PPE).
• General measures include checking patient’s travel history at admission, providing a COVID19 information sheet about symptoms to report and checking patients temperatures upon arrival. Where there is concern, elective procedures should be postponed and rebooked as soon as possible once the patient no longer poses a risk. Units should develop standard operating procedures (SOP) for COVID19 control measures and share these widely among staff groups.
• PPE for endoscopy procedures – advice is that standard infection control measures should be followed except for aerosol generating procedures (AGP) in patients at high risk of or with confirmed COVID19 infection. AGP in this context means upper GI procedures and for patients who fall into this category, enhanced PPE is recommended including FFP3 masks. Endoscopy teams should also consider enhanced PPE for emergency and out-of-hours procedures and also consider arrangements for the most appropriate location to perform these within their hospital. Units are encouraged to ensure staff know how to be fitted for the appropriate size of FFP3 mask and how to put on PPE correctly.
• Official advice is that enhanced PPE is not currently felt to be necessary for upper endoscopy in patients at low risk or for lower GI procedures. Concerns have been raised that the virus may be faecally transmitted but there is presently insufficient evidence to recommend the use of enhanced PPE measures for lower GI procedures. Stocks of FFP3 masks are also limited and their use needs to be carefully prioritised. This is, however, a rapidly changing situation and teams should check regularly for updates to both local and national guidance
• Units should discuss locally and consider whether or not to suspend some endoscopic activity e.g. low-risk surveillance scopes (non-dysplastic Barrett’s, polyp follow-up, IBD etc) for a period to help reduce or delay virus spread but also as it is likely there will be staff shortages through illness, absence to care for others or redeployment.
Individual hospital trusts and health boards will be looking to implement local guidance based on national and international best practice. For reasons mentioned above, we encourage telephone or virtual clinics. This guidance aligns with the current data available but as the situation changes further guidance may be required. Individual treatment decisions about patient care will be between the patient and the treating physician.
Dr Tony Tham
Clinical Services & Standards Committee Chair
Liver Transplantation and COVID-19
We know that a lot of the information about COVID-19 for the general public may not answer the concerns of people with a liver transplant. So far, experience from other countries have not shown that immunosuppressed patients are at increased risk of severe lung infection. However, it is important that you take all precautions to reduce your risk of exposure to the virus.
Reducing the exposure:
Like the common cold, COVID-19 infection usually occurs through close contact with a person with the virus, via cough, sneezes or hand contact. Washing your hands frequently reduces the contamination risk. The benefits of using masks in public is unclear even for transplant recipients and wearing a mask on its own may not prevent infection. Most masks are not tightfitting so aerosols can get through, but they may prevent you touching your nose and mouth.
To reduce your visit to hospitals and GP surgeries, doctors are looking at clinic lists to see if you could have a telephone consultation instead. You will be notified if there are any changes to your hospital appointments. We would recommend the following measures to try to reduce your risk of exposure to COVID-19 as much as possible until the pandemic is over;
Please do not stop any treatment for your liver transplant (especially your immunosuppression) without discussing this with your consultant or a member of their team first.
We want to reassure you that doctors & nurses are doing all they can to ensure that they can continue your care & treatment safely. If you have specific questions about your treatment or hospital appointments please get in touch with your local team.
If you think you might have been exposed to the virus, you should follow the same instructions as those for the general public & phone NHS 111.
Make sure you tell the person you speak to about your liver transplant & treatment. If on immunosuppression or chemotherapy you should also phone your normal liver and chemotherapy team so they are aware.
For the latest NHS information: https://www.nhs.uk/conditions/coronavirus-covid-19/common-questions/ .
These guidelines on Transjugular Intrahepatic Portosystemic Stent-Shunt (TIPSS) in the management of portal hypertension have been commissioned by the Clinical Services and Standards Committee (CSSC) of the British Society of Gastroenterology (BSG) under the auspices of the Liver Section of the BSG. The guidelines are new and have been produced in collaboration with the British Society of Interventional Radiology (BSIR) and British Association for the Study of the Liver (BASL). The guidelines development group (GDG) comprises elected members of the BSG Liver Section, representation from British Association for the Study of the Liver (BASL), a nursing representative, and two patient representatives. The quality of evidence and grading of recommendations was appraised using the GRADE system.
These guidelines are aimed at health care professionals considering referring a patient for a TIPSS. They comprise the following subheadings: (1) indications; (2) patient selection; (3) procedural details; (4) complications; and (5) research agenda. They are not designed to address: (1) the management of the underlying liver disease; (2) the role of TIPSS in children; or (3) complex technical and procedural aspects of TIPSS.
The 2020 ACCEA round opens on Friday 13th March 2020 and closes at 17:00 on Thursday 7th May 2020.
DEADLINE for applying for BASL support is 09:00 WEDNESDAY 8th APRIL 2020.
BASL will need to have completed the process of selecting those applicants who will receive our support well before the ACCEA deadline date.
If you wish to be considered for a national award in the 2020 round and seek BASL support, you should submit a copy of your ACCEA Application Form, along with any other supplementary CVQs; Research & Innovation (Form D), Teaching & Training (Form E), Leadership & Management (Form F).
Applications should be sent to the BASL Secretariat to Judy Hawksworth at firstname.lastname@example.org .
When submitting your application to BASL, please provide the name of an individual who has agreed to write your supporting citation. Please note: we will need to request a citation for every applicant even if the member is not successful in gaining BASL support, in order to meet the tight deadlines imposed by the ACCEA.
ACCEA regard the citations provided by BASL as important: they give added value to the process. The citation helps clarify information in the application and can put an individual's contribution into the wider context.
As in previous years BASL are able to support colleagues (BASL members) directly by nomination for national Gold, Silver and Bronze awards. As a specialist society, BASL cannot make nominations for Platinum awards; this must be done through the applicant’s University/Research Body and Universities UK. BASL can however provide a citation to support an application for a Platinum award.
How to apply for BASL support:
1. Send a copy of your completed ACCEA Application Form and other supplementary CVQs to the BASL Secretariat to email@example.com . BASL also requires a short piece on your work with BASL and why you feel you should be supported by them.
Deadline to submit your application to BASL is 09:00 WEDNESDAY 8th APRIL 2020.
All applications are completed through the ACCEA on line system. Downloadable copies of the application form and CVQ’s will be on the ACCEA website from 20th February 2020 and are intended to help those who wish to work on their application offline before completing online.
2. When submitting your application to BASL, please provide the name and email address of an individual who has agreed to write your supporting citation.
3. Applications are scored independently by a panel of 3 or 4 members of the BASL Committee.
4. If you are successful of BASL support we will upload your citation to your application on the ACCEA website. It is your responsibility to ensure that you have completed your on line application to ACCEA as per their instructions and regulations.
5. BASL will upload their supporting citations separately to their ranked lists. Individual scores are not submitted to the national panel but a ranked order for each award category is stated.
Please understand that in fairness to all applicants, late submissions will not be considered.
Further information on how BASL decides whom to support can be found in the document below:
Download How BASL Decides_ACCEA 2020.pdf
Should you have any questions, please do not hesitate to contact firstname.lastname@example.org .
The year 2020 has been designated as the ‘Year of the Nurse and the Midwife’ by the World Health Organization (WHO) in recognition of the contributions they make. The most desperate of problems for the National Health Service is of nursing shortages and WHO’s chief nurse Elizabeth Iro called for countries to recognise that ‘it is the only way they can achieve universal health coverage in which everyone has access to quality and affordable healthcare services that they need’.
Historically, nurses took up advanced practices to serve remote rural areas as a part of Grenfell Mission in 19th century; fallout of World War II and shortage of experienced nurses necessitated formal development of these roles. Internationally, specialist nurses have filled the gaps in family practice as well as hospital residency programmes (Download History of advanced nursing1.pdf). In Hepatology, the role of specialist nurses became established with the recognition of hepatitis C and advances in its treatment. Now nurses lead key services in Hepatology across the UK co-ordinating cancer care, performing transient elastographies, ascites drainage, and liver biopsies as well as contributing to advances through research. Nurse-led services are associated with superior performance indicators such as lower rate of emergency admission to hospitals for paracentesis.
The global shortage of nurses is predicted to reach 9 million by 2030, albeit, Pope Francis enthusiastically supporting the ‘noblest of the professions’ by hailing nurses ‘the most numerous’!
In the ‘Year of the Nurse’ and 200th anniversary of the birth of Florence Nightingale, BASL will celebrate this nursing achievement through an award during BASL2020, 8-11th September Plymouth.