Liver function tests in primary care provide a key opportunity to diagnose and engage patients with hepatitis C.

Since the advent of direct-acting antiviral therapy, the elimination of hepatitis c virus (HCV) as a public health concern is now possible. However, identification of those who remain undiagnosed, and re-engagement of those who are diagnosed but remain untreated, will be essential to achieve this. We examined the extent of HCV infection among individuals undergoing liver function tests (LFT) in primary care. Residual biochemistry samples for 6007 patients, who had venous blood collected in primary care for LFT between July 2016 and January 2017, were tested for HCV antibody. Through data linkage to national and sentinel HCV surveillance databases, we also examined the extent of diagnosed infection, attendance at specialist service and HCV treatment for those found to be HCV positive. Overall HCV antibody prevalence was 4.0% and highest for males (5.0%), those aged 37-50 years (6.2%), and with an ALT result of 70 or greater (7.1%). Of those testing positive, 68.9% had been diagnosed with HCV in the past, 84.9% before the study period. Most (92.5%) of those diagnosed with chronic infection had attended specialist liver services and while 67.7% had ever been treated only 38% had successfully cleared infection. More than half of HCV-positive people required assessment, and potentially treatment, for their HCV infection but were not engaged with services during the study period. LFT in primary care are a key opportunity to diagnose, re-diagnose and re-engage patients with HCV infection and highlight the importance of GPs in efforts to eliminate HCV as a public health concern.

Survival and re-admission of patients admitted with alcoholic liver disease to a West of Scotland hospital.

Alcoholic liver disease including cirrhosis is a major health burden with huge cost to the National Health Service due to frequent hospital admissions of patients with alcoholic liver disease. The highest morbidity and mortality from alcoholic liver disease in Western Europe is in the West of Scotland. This study analyses the mortality and re-admission rates of patients admitted with alcoholic liver disease to a Glasgow hospital and compares the outcome with a Scotland wide historic control. Mortality in the study of 124 patients admitted to the hospital with alcoholic liver disease was 18% during index admission, and was 40% when including follow-up of one year after discharge. Re-admissions were high in this population. Seventy-five per cent of patients had at least one re-admission within one year, and patients spent an average of over one month in hospital during the study period. Survival rates in the Glasgow hospital were comparable to survival in the Scottish cohort. However, re-admission rates were significantly higher in the Glasgow hospital. In conclusion, patients with alcoholic liver disease requiring hospitalisation have very high mortality and frequent re-admissions.

Pegylated interferon alpha-2b for patients with HCV recurrence and graft fibrosis following liver transplantation.

Chronic hepatitis C is a principal indication for liver transplantation. Recurrent viral infection is inevitable and graft disease is common. We report tolerability, safety and efficacy of pegylated interferon alpha 2b (PEG-IFN) monotherapy for patients with hepatitis C virus (HCV) recurrence and fibrosis after liver transplantation. Repeated measurements of serum HCV titer permitted assessment of the kinetics of the antiviral response for all patients. We screened 63 patients transplanted for HCV at our center for antiviral treatment, 14 were eligible and treated, but only 6 completed the proposed 52 weeks of therapy. Eight were withdrawn because of severe/life-threatening side effects/events, including liver dysfunction (4 patients). None of those 8 achieved a sustained virological response (SVR). Five of 6 who completed treatment were HCV RNA negative at the end of treatment, and 2 achieved an SVR. Viral kinetics were similar to published observations for treatment of non-transplanted HCV patients. Patients with genotype non-1 infection displayed a more rapid decline of viral titer than was observed for genotype 1 infection. Post-transplant HCV patients are frequently unsuitable for, or intolerant of PEG-IFN. Liver dysfunction was a major concern.

Favourable medium term outcome following hepatic vein recanalisation and/or transjugular intrahepatic portosystemic shunt for Budd Chiari syndrome.

BACKGROUND: We report our experience with management of patients with Budd Chiari syndrome over the past two decades. In 1996 we described a novel approach involving recanalisation of hepatic veins by combined percutaneous and transvenous approaches. This was incorporated into an algorithm published in 1999 in which our preferred treatment for all cases of Budd Chiari syndrome with short segment occlusion or stenosis of the hepatic veins involves recanalisation of the hepatic veins by transvenous or combined percutaneous-transvenous approaches. In symptomatic Budd Chiari syndrome where recanalisation is not possible, we perform transjugular intrahepatic portosystemic shunts (TIPS) because TIPS decompresses the portal circulation directly in an adjustable way. In this series of patients with Budd Chiari syndrome treated with radiological interventions alone, we assess their medium term outcome using two independent objective prognostic indices. METHODS: We retrospectively studied 61 patients with non-malignant Budd Chiari syndrome treated by radiological intervention alone in our centre. RESULTS: Actuarial survival for the entire cohort at one year and five years was 94% and 87%, respectively. Survival of our patients with mild disease (according to the Murad classification) was 100% at one year and at five years, with intermediate disease severity 94% at one year and 86% at five years, and with severe disease 85% at one year and 77% at five years. CONCLUSION: Management of Budd Chiari syndrome by interventional radiology resulted in excellent medium term survival for patients in all categories of disease severity.

Cytokines and chemokines in the immune response to hepatitis C infection.

Over 170 million people are infected with the hepatitis C virus worldwide, resulting in a large disease burden and significant mortality. Hepatitis C virus is rarely cleared in the acute phase of the infection and most patients become chronically infected; a proportion of these patients develop progressive liver disease and fibrosis. The outcome of infection depends on the immune responses of both the innate and cognate immune systems, and these in turn are orchestrated by networks of cytokines and chemokines. There is evidence that a vigorous type 1 immune response to viral proteins is required for viral elimination, and the recruitment of such effector cells to the liver is dependent on the local activity of specific inducible chemokines. Multiple factors determine the ability of the hepatitis C virus to survive host immune responses, including an ability to alter the cytokine profile secreted by T cells and to cause resistance to the effects of antiviral cytokines such as interferon. In the present review, we briefly cover the important advances made in this area over the past 12 months.

[Sympathy, desire and physical attraction in the student-patient relationship. Encounter with Mrs. Kelley during my internship]. / Sympathie, Lust und Körperlichkeit in der Student-Patienten-Beziehung. Begegnung mit der Patientin Mrs. Kelley während meiner Famulatur.

During an internship in pneumology the author made the acquaintance of Mrs. Kelley, a young and likeable patient. While taking the history he experienced the development of a subtle erotic tension between them. When her husband and children joined them Mrs. Kelley preferred to be examined physically and sent her family out of the room. This situation made the student insecure and he could no longer approach this patient like other patients. This article contains reflections on the incident which helped the author to cope with that particular incident and comparable situations. He also developed proposals to include this aspect in the medical curriculum.