How to manage alcohol-related liver disease: a case-based review
Alcohol related liver disease is a major cause of morbidity and mortality. Management can be challenging particularly in the later stages. In this issue James Maurice and colleagues take us through the management of a case. The paper - which summarises the evidence and discusses pratical management – takes the reader from risk stratification and fibrosis assessment in the community through to managing decompensated disease, escalation to critical care and assessment for liver transplantation. The authors expand on areas of controversy including the indications for liver transplantation and future research priorities. Multidisciplinary input is essential at all stages. In conjunction with this excellent review the authors emphasise continued public health efforts are required to implement effective policies to reduce alcohol consumption and prevent disease. (See page 435)
Hepatitis C: recent advances and practical management
Hepatitis C virus (HCV) remains a leading cause of morbidity and premature death worldwide. Injecting drug use is the most important risk factor in the UK, more prevalent in high risk populations, although many are unaware they are infected. In this issue Rebecca O’Kane and colleagues discuss recent advances and practical management. This includes sections on detection, disease assessment and management. There is a useful table on the interpretation of screening tests. Short courses of oral direct acting antivirals achieve cure in>90% of people regardless of genotype and stage of liver disease (table 3). Liver transplantation remains the treatment of choice for patients with decompensated cirrhosis, and for selected patients with Hepatocellular Carcinoma. The authors state that the UK is on track to eliminate HCV as a public health threat by 2030 (defined by a 90% reduction in new infections and 65% reduction in mortality) although this will require identification and engagement of vulnerable individuals who do not access traditional healthcare systems and may be apprehensive to consider treatment. Editor’s Choice this month. (See page 415)
Guidance document: risk assessment of patients with cirrhosis prior to elective non-hepatic surgery
The increasing incidence (and therefore prevalance) of cirrhosis means more patients with chronic liver disease are being referred for non-hepatic surgery. This excellent document provides considered guidance for the risk assessment and so issues that need to be considered prior to elective surgery. This includes discussion of the well recognised risks including those of general anaesthesia, bleeding, infections, impaired wound healing, acute kidney injury and cardiovascular compromise. Careful clinical assessment will aid risk stratification including blood tests, imaging, liver stiffness measurement, endoscopy and assessment of portal pressure. The type of surgery planned need to be considered. There are a number of prognostic scoring systems (detail is in the paper) although these may overstimate risk particulalry in the patient with compensated cirhhosis. Measures to mitigate risk include careful management of varices, nutritional optimisation and where possible addressing any ongoing aetiological drivers such as alcohol consumption. There is a useful algorithm and summary guidance statements with full discussion of all the issues listed. This will be an invaluable resource for clinicians. (See page 359)
Establishing key performance indicators for inflammatory bowel disease in the UK
There have been multiple quality improvement initiatives in Inflammatory Bowel Disease which have led to improvements in clinical care and outcomes. In this paper using stakeholder meetings - including clinicians, professional groups and patients - and then a two stage Delphi process Quarashi and colleagues establish and refine four key performance indicators that can be used to benchmark clinical care within a quality improvement framework. The methodology is detailed in the paper inclduing the methodology for national implementation. The key performance indicators include
Time from primary care referral to diagnosis in secondary care
Time to treatment recommendation following a diagnosis
Appropriate use of steroids
Advanced therapies prescreening and assessment
The authors discuss each in detail. The Delphi consensus reported>85% agreement on the feasibility of local adoption of the QI process and>75% agreement on the utility of benchmarking of the KPIs. These KPI’s can be used for benchmarking to improve and reduce the individual variation in IBD care across the UK. (See page 407)
Quality in colonoscopy: time to ensure national standards are implemented?
This is an interesting paper. We all agree that high quality colonoscopy is crucial to ensure complete mucosal visualisation and to maximise detection of pathology. How do we assess this. There has been considerable work done to develop quality assurance standards and key performance indicators (KPIs). In this paper Rees and colleagues investigate the most widely used marker of mucosal visualisation the adenoma detection rate (ADR). Data were collected from colonoscopists in eight hospitals over a 6 month period - number of colonoscopies, caecal intubation rate (CIR), ADR and polyp detection rate (PDR). ADR requires histological confirmation. 9265 colonoscopies were performed by 118 endoscopists. Mean ADR and PDR per endoscopist were 16.6% (range 0–36.3, SD 7.4) and 27.2% (range 0–57.5, SD 9.3), respectively. Mean number of colonoscopies conducted in 6 months was 78.5 (range 4–334, SD 61). Mean CIR was 91.2% (range 55.5–100, SD 6.6). Total number of colonoscopies and ADR>15% were significantly associated (p=0.04). CIR, endoscopist grade, % male patients, mean patient age and CIR were not significantly related to ADR<15%. The authors conclude colonoscopists who perform fewer than the nationally stipulated minimum of 100 procedures per year have significantly lower ADRs and suggest they should either increase their numbers or stop doing endoscopies. The potential use of PDR as an alternative marker is discussed. (See page 392)
Teaching medical students about nutrition: from basic principles to practical strategies
It is well known that poor nutrition is one of the key modifiable risks to short and long term health although well recognised that nutrition training within medical schools is extremely varied and in many cases inadequate. There is a similar inconsistent approach to this in post graduate training. This is despite the fact that doctors are in an ideal position to recognise when suboptimal nutrition is impacting on their patients’ health and provide them with advice and support to create sustainable and achievable diet and lifestyle modifications and so improve short and long term health. Patients increasingly look to us for this. In this paper Glenys Jones and colleagues discuss three key ways in which medical schools – supported by us as interested clinicians - can support the implementation of nutrition into their teaching - incorporating nutrition within the core medical curriculum, the use of subject specific experts to support and deliver nutrition training, and the inclusion of nutrition within formal assessment so as to reinforce and cement learnings into practical, applicable actions and advice. These same principles should be adopted into post graduate training programmes. There strategies are essential to support the embedding of nutrition into clinical care and so modifying this risk factor and improving outcomes for our patients. (See page 422)
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