Non-alcoholic fatty liver disease (NAFLD) and COVID-19 outcomes: A systematic review, meta-analysis, and meta-regression

It is important to identify risk factors for poor outcomes of coronavirus disease 2019 (COVID-19) patients. Currently, the correlation between non-alcoholic fatty liver disease (NAFLD) and COVID-19 outcomes has not been established. This study was conducted to determine the association between NAFLD and in-hospital outcomes of COVID-19 patients. The systematic searches were conducted by using PubMed and the Europe PMC databases and particular keywords were used as of December 10, 2020. Further searches were conducted up to 2022. All articles that include data about COVID-19 and fatty liver disease were collected. Statistical analysis was performed by using Review Manager 5.4 and Comprehensive Meta-Analysis version 3 software. A total of 7,210 COVID-19 patients from 18 studies were included in the final analysis. Meta-analysis revealed that NAFLD increased the risk of developing poor in-hospital outcome (pooled both severe disease and death) in COVID-19 patients (RR 1.42;95%CI: 1.17–1.73, p<0.001, I2=84%, random-effect modeling). Subgroup analysis however found that having NAFLD only increased the chance of getting severe COVID-19 (RR 1.67;95%CI: 1.32–2.13, p<0.001, I2=86%, random-effect modeling) and not mortality (RR 1.00;95%CI: 0.68–1.47, p=0.98, I2=80%, random-effect modeling). Meta-regression suggested that age (p=0.001) and diabetes (p=0.029) were significantly influenced the relationship between NAFLD and in-hospital outcomes of COVID-19 (pooled both severe disease and mortality). The weaker association of NAFLD and in-hospital outcomes of COVID-19 was found for studies with median age ≥45 years old (RR 1.29) when compared to studies with median age <45 years old (RR 2.96). In addition, studies with the prevalence of diabetes ≥25% (RR 1.29) had a weaker association with in-hospital outcomes when compared to studies with diabetes prevalence <25% (RR 1.85). In conclusion, NAFLD increased the risk of chance of getting severe COVID-19 and therefore it should be evaluated closely to reduce the chance of getting severe COVID-19. © 2023, School of Medicine, Universitas Syiah Kuala. All rights reserved.

Young persons and healthcare professionals experience of virtual gastroenterology consultations: a multicentre survey conducted during the COVID-19 pandemic

ObjectiveTo explore Young Persons (YP) and healthcare professionals (HCP) experiences of virtual consultations (VC) and establish whether developmentally appropriate healthcare can be delivered virtually.MethodYP and HCP questionnaire surveys were designed and piloted. Electronic questionnaire links were sent by post, email or text message January–April 2021 to YP aged 13–25 years old, with predefined chronic gastrointestinal conditions, attending a gastroenterology/hepatology VC. HCP undertaking VC were invited to complete staff questionnaire. Results were anonymous and collated using Excel version 2302.ResultsFive UK hospital trusts participated, with 35 HCP responses. Of the 100 YP completing the survey 66% were female and 34% male aged between 13 years and 25 years (median: 18 years). 13% were new appointments and 87% follow ups, 29% were by video, 69% by phone and 2% gave no response. 80% of HCP spoke to YP directly but not privately (69%). 87% of YP and 88% HCP found VC useful. 83% of YP want VC again, although 20% preferred face to face. 43% of HCP required improved phone/internet connection. 77% of YP required hospital appointments for tests following VC.ConclusionsOverall respondents were satisfied with VC, finding them useful, convenient and time saving. Successful VC rely on appropriate patient selection and availability of reliable technology. Patient preference is key which may alter with time.

A Rare Case of Viridans Group Streptococci Pyogenic Liver Abscess in a Young Male With No Prior Risk Factors.

Pyogenic liver abscesses (PLAs) secondary to bacterial etiologies are rare in North America and other developed countries. The predominant etiology of PLAs is an infection extending from the hepatobiliary or intestinal system. As such, the most common pathogens isolated from PLA in the United States are Escherichia coli and Klebsiella. Viridans group streptococci (VGS), on the other hand, are a large group of commensal bacteria in the oral flora and are a significantly less common cause of infection. Here, we report a rare case of a complicated isolated VGS PLA in a patient without known comorbidities. The patient was born and raised in the United States without recent travel history. Computed tomography (CT) with contrast showed multiple hypodense multiloculated lesions in the right lobe of the liver, measuring up to 13 cm, with mild wall thickening of the distal ileum and cecum. The abscesses were confirmed later as Streptococcus viridans PLA. The patient was treated with CT-guided drainage and IV antibiotics and, after that, made a quick recovery and was discharged. Our case underlines the significance of considering liver abscess as a differential even in previously healthy individuals with no known prior comorbid conditions, as prompt recognition is imperative in preventing morbidity and mortality.

SARS-CoV-2 Infection Precipitates the Discovery of Underlying Liver Disease: A Case Report.

Since the onset of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic, numerous sequelae of this devastating virus have come to light. One organ known to be impacted by SARS-CoV-2 is the liver, as many SARS-CoV-2 patients demonstrate elevated liver enzymes on routine laboratory tests. In this case report, we present a patient with SARS-CoV-2 whose liver enzymes remained persistently elevated throughout his hospitalization. Due to the duration of his elevated liver enzymes, etiologies outside of SARS-CoV-2 were explored. This workup revealed that the patient had alpha-1 antitrypsin (A1AT) deficiency. Thus, this case serves to remind clinicians to continue investigating lab abnormalities despite a presumed etiology, such as SARS-CoV-2, so as not to miss the presentation of new diagnoses.

INSIGHT OF PANDEMIC COVID-19: DEVELOPMENTS AND CHALLENGES

This review focuses on the characteristics of coronavirus disease-19 (COVID-19) including virus structure, ecoepidemiology and pathophysiology, signs and symptoms in infected people, and data on virus pathogenicity, severity, and survivability in COVID-19 infected patients. The emphasis is on immunological reactions, diagnosis, prophylactic methods, and the zoonotic significance of COVID-19. The authors feel that the review's contents will be valuable to epidemiologists, virologists, public health officials, diagnosticians, laboratory workers, environmentalists, and socioeconomic experts. It has information on the many types of coronavirus variants, the disease situation in Pakistan and the WHO criteria for COVID-19 prevention is given. Moreover, lessons learned from the COVID-19 pandemic are also outlined.

Orthoptic liver transplantation in a patient with a positive SARS-CoV-2 test and its postoperative complications. Case report / Trasplante ortóptico de hígado en un paciente con una prueba positiva de SARS-CoV-2 y sus complicaciones posoperatorias. Reporte de caso

Resumen Objetivo: describir un caso de trasplante hepático en un paciente con resultado positivo en la prueba del coronavirus del síndrome respiratorio agudo grave de tipo 2 (SARS-CoV-2) con éxito en el postrasplante temprano, pero que desarrolló complicaciones asociadas a la inmunosupresión y trombosis portal sin una trombofilia identificada en un centro de alta complejidad de un país latinoamericano. Descripción del caso: paciente de 48 años con diagnóstico de cirrosis hepática secundaria a esteatohepatitis no alcohólica (NASH) complicada por varios episodios de ascitis portal hipertensiva y encefalopatía hepática, ingresada para trasplante hepático ortóptico. En los exámenes iniciales tuvo una prueba positiva para SARS-CoV-2 y era asintomático respiratorio. El trasplante se realizó con éxito luego de la autorización del comité de infección. Después del primer mes posoperatorio presentó diarrea, ascitis y daño renal agudo. Los niveles de tacrolimus en el reingreso fueron superiores a 10 ng/mL y hubo una mejoría clínica significativa con la suspensión del fármaco. Finalmente, el paciente requirió retrasplante por trombosis de la vena porta y de las venas suprahepáticas, aunque no se identificó la etiología. Conclusión: se describe uno de los primeros informes de trasplante de hígado en un paciente con recuperación reciente de COVID-19 y pruebas persistentemente positivas. En el postrasplante temprano hubo una buena respuesta; sin embargo, luego del primer mes presentó complicaciones relacionadas con la inmunosupresión. Este caso también plantea la posible asociación entre el SARS-CoV-2 y el desarrollo de trombosis en la circulación portal hepática.

Abstract Objective: To describe a case of liver transplantation in a patient with a positive result in the severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) test with success in the early post-transplantation, but who developed complications associated with immunosuppression and portal vein thrombosis without thrombophilia identified at a tertiary referral center in a Latin American country. Case: A 48-year-old patient diagnosed with liver cirrhosis secondary to non-alcoholic steatohepatitis (NASH) complicated by several episodes of portal hypertension ascites and hepatic encephalopathy was admitted for orthoptic liver transplantation. On initial examinations, he had a positive test for SARS-CoV-2 and was asymptomatic in the respiratory tract. The transplant was carried out successfully after the authorization of the infection committee. After the first postoperative month, he presented with diarrhea, ascites, and acute kidney injury. Tacrolimus levels at readmission were more significant than 10 ng/mL, and there was a significant clinical improvement with drug discontinuation. Finally, the patient required re-transplantation due to thrombosis of the portal vein and suprahepatic veins, although the etiology was not identified. Conclusion: One of the first reports of liver transplantation in a patient with recent recovery from COVID-19 and persistently positive tests is described. In the early post-transplant, there was a good response; however, after the first month, he had complications related to immunosuppression. This case also posits the possible association between SARS-CoV-2 and the development of thrombosis in the hepatic portal circulation.

Multiorgan Failure and Omicron: A Suspected Case of Post-COVID-19 Cholangiopathy.

Since the declaration of a global pandemic by the World Health Organization on March 11, 2020, coronavirus disease 2019 (COVID-19) has impacted millions worldwide. This complex disease process has been primarily associated with respiratory illness. As we continue to learn about COVID-19, there appears to be a growing spectrum of non-pulmonary manifestations. A major topic of interest is hepatic dysfunction related to COVID-19, specifically the growing number of cases involving acute liver failure in the setting of COVID-19. Here, we present a rare case of a patient with COVID-19 antibodies, negative inpatient COVID-19 testing, jaundice, and elusive multiorgan dysfunction.

Remdesivir-Associated Acute Liver Failure in a COVID-19 Patient: A Case Report and Literature Review.

There is a broad classification of the causes of acute liver failure (ALF) that include drug-induced liver injury (DILI). In this report, we aim to discuss the association between remdesivir, a novel therapeutic drug for hypoxic coronavirus disease 2019 (COVID-19) pneumonia, and DILI with subsequent ALF in a patient who was recently treated with the drug in question. Remdesivir, which is a direct-acting nucleoside RNA polymerase inhibitor, is one of the only FDA-approved drugs on the market for COVID-19 pneumonia associated with hypoxia. Our case describes a patient with an extensive past medical history who was treated for COVID-19 pneumonia with remdesivir and subsequently developed ALF in the absence of all other possible etiologies. This association has only been highlighted in anecdotal case reports in the past and to a lesser degree in the safety documentation of remdesivir.

Impact of COVID-19 on Liver Transplant Activity in the USA: Variation by Etiology and Cirrhosis Complications

BACKGROUND AND AIMS: The COVID-19 pandemic has impacted the care of patients with liver disease. We examined impact of COVID-19 on liver transplant (LT) activity in the USA. METHODS: LT listings in the United Network for Organ Sharing (UNOS) database (April 2018-May 2021) were analyzed to examine the impact of COVID-19 pandemic on the LT activity based on etiology: hepatitis C virus (HCV), alcohol-associated liver disease (ALD), alcoholic hepatitis (AH), and nonalcoholic steatohepatitis (NASH) complications: hepatocellular carcinoma (HCC) and acute-on-chronic liver failure (ACLF) grade 2 or 3) and Model for End-Stage Liver Disease (MELD) score. Joinpoint regression models assessed time trend changes on a log scale. RESULTS: Of 23,871 recipients (8,995 in the COVID era, April 2018-February 2020), mean age 52 years, 62% men, 61% Caucasian, 32% ALD, 15% HCC, 30% ACLF grades 2-3, and mean MELD score 20.5), monthly LT changes were a decrease of 3.4% for overall LTs and 22% for HCC after September 2020, and increase of 4.5% for ALD since 11/2020 and 17% since 03/2021 for ACLF grade 2-3. Monthly MELD scores increased by 0.7 and 0.36 after June 2020 for HCV and HCC respectively. CONCLUSIONS: The COVID-19 pandemic has impacted LT activity, with a decrease of LTs especially for HCC, and an increase of LTs for ALD and severe ACLF. Strategies are needed to reorganize cirrhosis patients to overcome the aftereffects of COVID-19 pandemic.

Clinician barriers, perceptions, and practices in treating patients with hepatitis C virus and substance use disorder in the United States.

The likelihood of clinicians prescribing direct-acting antiviral (DAA) therapy for patients with chronic hepatitis C virus (HCV) and substance use disorder (SUD) was assessed via a survey emailed throughout the United States to clinicians (physicians and advanced practice providers) in gastroenterology, hepatology, and infectious disease specialties. Clinicians' perceived barriers and preparedness and actions associated with current and future DAA prescribing practices of HCV-infected patients with SUD were assessed. Of 846 clinicians presumably receiving the survey, 96 completed and returned it. Exploratory factor analyses of perceived barriers indicated a highly reliable (Cronbach alpha = 0.89) model with five factors: HCV stigma and knowledge, prior authorization requirements, and patient- clinician-, and system-related barriers. In multivariable analyses, after controlling for covariates, patient-related barriers (P < 0.01) and prior authorization requirements (P < 0.01) were negatively associated with the likelihood of prescribing DAAs. Exploratory factor analyses of clinician preparedness and actions indicated a highly reliable (Cronbach alpha = 0.75) model with three factors: beliefs and comfort level; action; and perceived limitations. Clinician beliefs and comfort levels were negatively associated with the likelihood of prescribing DAAs (P = 0.01). Composite scores of barriers (P < 0.01) and clinician preparedness and actions (P < 0.05) were also negatively associated with the intent to prescribe DAAs. Conclusion: These findings underscore the importance of addressing patient-related barriers and prior authorization requirements-significant problematic barriers-and improving clinicians' beliefs (e.g., medication-assisted therapy should be prescribed before DAAs) and comfort levels for treating patients with HCV and SUD to enhance treatment access for patients with both HCV and SUD.

Soaring rates of alcohol-related hepatitis in the latter phase of the COVID-19 pandemic: A new normal?

Background: Studies have reported that the COVID-19 pandemic has led to an increase in alcohol consumption and alcohol-associated health problems in the general population. Our previous study documented a rise in severe alcohol-related hepatitis cases requiring inpatient admission in our hospital system in the early pandemic (2019 vs. 2020). This study assesses the rates of severe alcohol-related hepatitis in the latter part of the pandemic (2021). Methods: We performed a retrospective chart review via an electronic medical record to evaluate the number of cases of alcohol-related hepatitis in patients presenting to three community hospitals in Fresno, California, between 2019 (pre-pandemic) and 2021. A total of 547 patients were included in the study. We compared the demographics, clinical course, and outcomes of patients with alcohol-related hepatitis pre-pandemic (2019), early pandemic (2020), and during the later phase of the pandemic (2021). Results: The number of cases increased from 131 in 2019 to 201 in 2020 and 215 in 2021 (53% and 64% increase, respectively). The number of young patients (age <40 years) increased from 30 in 2019 to 61 in 2020 and 71 in 2021 (103% and 136% increase, respectively) (p = 0.13). The number of admissions of women increased from 24 in 2019 to 55 in 2020 and 67 in 2021 (129% and 179% increase, respectively) (p = 0.026). Deaths during hospitalization increased from 20 in 2019 to 26 in 2021 (p = 0.674). The number of rehospitalizations within 3 months increased 4.5 times from 18 in 2019 to 80 in 2021 (p < 0.001). Conclusion: Our study revealed that the admissions for alcohol-related hepatitis remained significantly above the pre-pandemic levels through the end of 2021. We believe this sustained increase in cases of alcohol-related hepatitis in our hospital system reflects a much larger national problem. Alcohol-related hepatitis is associated with significant morbidity, mortality, and societal cost. Urgent public health interventions are needed at a national level to prevent this rise in cases from becoming a new normal.

Timing of endoscopic intervention in patients with cirrhosis with acute variceal haemorrhage (TEACH trial): protocol for a randomised clinical trial (RCT).

INTRODUCTION: Acute variceal haemorrhage (AVH) in patients with cirrhosis remains a topic of great interest. Although several guidelines recommend endoscopy within 24 hours after AVH, there is no consensus on the most appropriate time to perform this intervention. The purpose of this study is to identify whether urgent endoscopy (within 6 hours after gastroenterological consultation) is superior to non-urgent endoscopy (between 6 hours and 24 hours after gastroenterological consultation) in reducing the rebleeding rate of these patients. METHODS AND ANALYSIS: This is a single-centred, prospective, randomised clinical trial. Between March 2021 and December 2023, an estimated 400 patients will be randomised in a 1:1 ratio to receive endoscopic intervention either within 6 hours or between 6 and 24 hours after gastroenterological consultation. Randomisation will be conducted by permuted block randomisation, with stratification by age, systolic blood pressure and pulse rate. The primary efficacy endpoint is rebleeding within 42 days after control of AVH. The secondary efficacy endpoints mainly include all-cause mortality within 42 days after randomisation, persistent bleeding, length of hospitalisation, etc. ETHICS AND DISSEMINATION: The study protocol was approved by the Ethical Committees of Jinling Hospital (authorised ethics no. DZQH-KYLL-21-01). This trial will provide valuable insights into the timing of endoscopic intervention for AVH in patients with cirrhosis. Furthermore, the trial results and conclusions could provide high-quality evidence to guide clinical research and treatment. TRIAL REGISTRATION NUMBER: NCT04786743.

Respiratory Syncytial Virus Associated Hepatitis in Pregnancy.

Respiratory syncytial virus (RSV) predominantly affects children and typically manifests as an upper respiratory tract infection. Primary RSV infection in immunosuppressed adults may increase risks of disseminated infection manifesting as RSV hepatitis. A 29-year-old pregnant woman of 10 weeks gestation presented with mild right upper quadrant abdominal pain, intractable nausea, and vomiting, requiring hospitalization. Due to initial lab work showing significantly elevated liver transaminases, she underwent a thorough workup to evaluate for causes of hepatitis. Common viral and autoimmune etiologies of hepatitis were excluded with appropriate serologies. A respiratory viral molecular panel (RVP) was obtained to evaluate for SARS-CoV-2/coronavirus disease 2019 (COVID-19) infection, despite lack of typical respiratory symptoms. No structural pathologies were detected on abdominal imaging with ultrasound and magnetic resonance imaging. No other etiologies for the patient's hepatitis were detected other than RSV infection detected on RVP. The patient's care required close coordination between multiple different subspecialties. Her condition improved due to the early detection of RSV infection and prompt initiation of supportive care. This case highlights the need for providers to consider obtaining an RVP early in workup of hepatitis to evaluate for RSV infection, even when patients have minimal respiratory symptoms. A high index of suspicion is required for early identification of RSV hepatitis as timely supportive care may prevent progression to acute liver failure.

COVID-19 Exposure Unmasking Systemic Amyloidosis With Hepatic Predominance.

Amyloidosis is characterized by depositing insoluble fibrillar proteins that misfold into beta-pleated sheets. This phenomenon occurs on a systemic or local level and may interfere with the function of various organs, including the heart, kidneys, and liver. Among those presenting with amyloidosis, hepatic, gastrointestinal, renal, cardiac, vitreous, and immunological involvement may occur. These manifestations are linked to several clinical presentations, varying from abdominal pain and hepatomegaly to restrictive cardiomyopathy and chronic renal failure. The two most common types of amyloid proteins are amyloid light chain (AL) and serum amyloid A (AA) proteins. AL produced by immunoglobulin light chains kappa and lambda (κ, λ) circulate systemically and accumulate in organs. At the same time, serum AA proteins are acute-phase reactants seen in infectious, chronic inflammatory states. In an immune-mediated infection such as COVID-19, serum AA levels may be a predictive factor of disease severity and a valuable biomarker to monitor the clinical course of COVID-19 patients. This report highlights a case in which infection with COVID-19 provoked an effective immune response that may have contributed to the accelerated progression of systemic amyloidosis with hepatic involvement. The study further investigates the involvement of AL and AA proteins in COVID-19 infections, including their role in synergistically exacerbating an already grueling clinical course.

Challenges and ways of coping of parturient women with chronic hepatitis B in Ghana during COVID-19 pandemic: a qualitative inquiry.

OBJECTIVE: To explore the psychosocial concerns and ways of coping of pregnant women with chronic hepatitis B infection in Ghana. SETTING: Participants were selected from public health facilities in the Tema Metropolis. DESIGN: Exploratory descriptive qualitative design was employed. PARTICIPANTS: Fourteen pregnant women were purposively selected to participate in face-to-face interviews. The data were analysed using the content analysis procedure. RESULTS: The participants' psychosocial concerns and coping strategies were diverse. A significant number of the participants were concerned about the impact their hepatitis B seropositivity would have on their relationships, finances, and general well-being. Specifically, they feared that their social network, especially their spouses, would perceive them as having led a promiscuous lifestyle in the past to acquire hepatitis B infection. Also, fear of transmitting the infection to their infants and the effects of the infection on their infants later in life were identified as major concerns by nearly all participants. The participants further reported feelings of distress and diminished self-esteem. These psychosocial afflictions reported were attributed to lack of pre-test counselling during the antenatal care period. However, the participants coped using different strategies, including avoidance/denial, spirituality, and alternative treatment use. CONCLUSION: To achieve optimal psychological and social well-being of pregnant women with chronic hepatitis B, it is important that their unique challenges are considered in their care and treatment cascade. Explicitly, protocols for supportive care addressing the specific needs of pregnant women with chronic hepatitis B should be implemented in the study setting.

A retrospective review of a nurse-led cirrhosis programme in tertiary care during the first year of the Covid-19 pandemic

BackgroundThe CNS team reflected and evaluated the adaption of the hepatology CNS service during the pandemic, exploring new ways of working. During the pandemic many multispecialty elective admissions were cancelled and despite the team redeploying staff we were able to continue to provide ascites management and face-to-face reviews of patients, which significantly increased during this time.AimThe data provides a service review a Clinical Nurse Specialist (CNS) team in reducing hospital admissions and A&E attendances.MethodsA retrospective analysis was completed for 160 “Hot clinic” patients (face-to-face) and 134 HCC surveillance screening patients (converted to a telephone clinic). The data was analysed between January 2020 and December 2020. The data demonstrates how patients continued to access face-to-face reviews and planned day-case drains. Working closely with the medical hepatology team we were able to provide an ongoing service for all patients within hepatology, who following a virtual appointment, needed clinical review. The data was obtained from four CNS-led referral pathways:(i) a “Hot clinic” for liver unit ward discharge follow-ups, (ii) day-case LVPS (Managed by CNS team fed in from “Hot clinic” reviews), (iii) a joint cirrhosis/palliative care MDT for referral of patients between the specialties of gastroenterology, liver and palliative care (iv) a nurse-led alcohol-related (ArLD) cirrhosis clinic.The data collected focused on patient characteristics, length of hospital stay, emergency department attendance avoidance, admission avoidance, fast-track paracentesis rate and compliance with HCC/Variceal surveillance in Cirrhosis.Results294 patients were managed via the nurse-led programme during 2020, service distribution 49% “Hot clinic” reviews;6% referred via other specialities via MDT;45% HCC surveillance clinic.ArLD 48% was the most common aetiology seen in “Hot clinic”, followed by NASH/NAFLD 12%. The most common reason for referral to “Hot clinic” was ascites management 46%, which resulted in 31% of patients having a medication change by the CNS (76% of which were diuretics) 4% were admitted directly to the ward from “Hot clinic” (i.e. disease progression, urgent paracentesis). Of the 74 patients referred for ascites management 49% were enrolled into the day-case paracentesis programme. 200, electively planned drains were inserted as daycase during this timeframe by the CNS team.ConclusionDuring a pandemic the Birmingham liver team were able to adapt their working environment to continue to ensure patients could access specialist care and continue to be seen face-to-face in a safe manner. This led to decreased pressure on emergency admissions.

Adoption of a Clinical Assessment Service in Hepatology

P49 Table 1The impact of the clinical assessment service on the hepatology outpatient service2020 % Total ‘New appts 190 100% Total pts seen 134 71% Total DNAs 56 29% Total pts seen 134 100% Of pts seen & F/Up 113 84% Of pts seen & D/C’d 21 16% Total DNAs 56 100% DNA & Reschedule 33 59% DNA & D/C’d 23 41% 2022 % Total ‘New’ appts 181 100% Total pts seen 141 78% Total DNAs 40 22% Total pts seen 141 100% Of pts seen & F/Up 100 71% Of pts seen & D/C’d 41 29% Total DNAs 40 100% DNA & Reschedule 25 62.5% DNA & D/C’d 15 37.5% Since CAS has been introduced there have been several positive outcomes: in 2021, 18% of the referrals were appropriately repatriated to primary care with advice;30% of the referrals were managed without needing a face-to-face appointment;the waiting time reduced from 8 weeks to 5 weeks for a clinical review, and from 16 weeks to 15 weeks for a follow-up appointment;from 2020 to 2022 the proportion of patients discharged after the first clinical review has increased from 16% to 29%;specialist treatment is instigated more quickly;patients can be discharged following their first face-to-face visit as all information is to hand, it has eliminated unnecessary follow-up and has resulted in a clear and concise pathway to refer the patients into the service, with the diagnostic tests being performed at an earlier stage In summary CAS was introduced as an urgent service response to COVID-19 but we have identified key benefits and intend to continue it.

Liver cirrhosis and palliative medicine: the potential impact of COVID-19 on patient care and how progress can be sustained

OP27 Figure 1The authors propose a model, summarised in Figure 1, to integrate palliative and supportive care alongside and within standard hepatology care for patients with end stage liver disease who are ineligible for transplant, in an era where remote and distant review requires innovation to provide care in the right place and at the right time, to safeguard the previous progress made.