Exploring awareness and prevalence of chronic viral hepatitis in a UK based Nepali population - lessons learned for future models in engaging migrant communities.

INTRODUCTION: The burden of chronic viral hepatitis (CVH) in the UK Nepali population is unknown. We aimed to determine knowledge of liver disease (LD) and prevalence of CVH in this community. METHODS: This was a mixed method (qualitative and quantitative) study guided by a multidisciplinary stakeholder group. Focus groups (FG) led by Nepali community leaders explored LD knowledge. Thereafter, a prospective community-based cohort study utilising dried-blood spot testing was conducted. Thematic analysis explored FG data with categorical data analysed with Excel and R Studio. RESULTS: FG data showed a lack of LD knowledge, with conflict between the roles of traditional and modern practices; 1,005 participants (525 male, 480 female) were tested for CVH, with a mean age of 63 years (range:19-86). Rates of CVH infection were low: 0.3% had current hepatitis B, with no active hepatitis C. DISCUSSION: Key drivers for enthusiastic participation were development of peer support networks and advisory groups to disseminate information, including hepatitis B vaccine recommendations.

Characteristics and outcomes of patients with COVID-19 at a district general hospital in Surrey, UK.

BACKGROUND: This retrospective cohort study aims to define the clinical findings and outcomes of every patient admitted to a district general hospital in Surrey with COVID-19 in March 2020, providing a snapshot of the first wave of infection in the UK. This study is the first detailed insight into the impact of frailty markers on patient outcomes and provides the infection rate among healthcare workers. METHODS: Data were obtained from medical records. Outcome measures were level of oxygen therapy, discharge and death. Patients were followed up until 21 April 2020. RESULTS: 108 patients were included. 34 (31%) died in hospital or were discharged for palliative care. 43% of patients aged over 65 died. The commonest comorbidities were hypertension (49; 45%) and diabetes (25; 23%). Patients who died were older (mean difference ±SEM, 13.76±3.12 years; p<0.0001) with a higher NEWS2 score (median 6, IQR 2.5-7.5 vs median 2, IQR 2-6) and worse renal function (median differences: urea 2.7 mmol/L, p<0.01; creatinine 4 µmol/L, p<0.05; eGFR 14 mL/min, p<0.05) on admission compared with survivors. Frailty markers were identified as risk factors for death. Clinical Frailty Scale (CFS) was higher in patients over 65 who died than in survivors (median 5, IQR 4-6 vs 3.5, IQR 2-5; p<0.01). Troponin and creatine kinase levels were higher in patients who died than in those who recovered (p<0.0001). Lymphopenia was common (median 0.8, IQR 0.6-1.2; p<0.005). Every patient with heart failure died (8). 26 (24%) were treated with continuous positive airway pressure (CPAP; median 3 days, IQR 2-7.3) and 9 (8%) were intubated (median 14 days, IQR 7-21). All patients who died after discharge (4; 6%) were care home residents. 276 of 699 hospital staff tested were positive for COVID-19. CONCLUSIONS: This study identifies older patients with frailty as being particularly vulnerable and reinforces government policy to protect this group at all costs.

Rate and Predictors of Endoscopic Mucosal Healing in Biologic Naive Patients with Inflammatory Bowel Disease by Azathioprine Treatment: A Real World, 10 Years' Experience from a Single Centre in Turkey.

BACKGROUND: There is increasing evidence that endoscopic mucosal healing (EMH) is a key target in inflammatory bowel disease (IBD) therapy. However, there is limited evidence of EMH rates with conventional IBD therapy outside of Western population groups. AIM: To evaluate the role of azathioprine (AZA) in inducing EMH in IBD patients. METHODS: Patients with inflammatory bowel disease were evaluated in terms of endoscopic mucosal healing and the incidence of surgical interventions during the azathioprine treatment between 1995 to 2014. RESULTS: A total of 120 inflammatory bowel disease patients were enrolled. Endoscopic mucosal healing was found in 37% patients with inflammatory bowel disease (42% in chronic ulcerative colitis and 33% in Crohn's disease). Male gender had a negative impact on the efficacy of azathioprine (P<0.05). Responder inflammatory bowel disease patients were older (age at the IBD diagnose) than the nonresponder (P<0.05). Azathioprine therapy reduced the number of the surgical interventions (P<0.05). CONCLUSION: We showed that azathioprine therapy significantly induced endoscopic mucosal healing in biologic naïve patients with active inflammatory bowel disease as well as decreasing the surgical interventions, with negative predictive factors identified by a younger age at IBD presentation and male gender.

Seasonal clustering in inflammatory bowel disease: a single centre experience.

BACKGROUNDS AND AIMS: External stimuli are considered as possible triggers for the onset of inflammatory bowel disease (IBD), and particularly chronic ulcerative colitis (CUC) in genetically susceptible individuals. Our aims were to investigate monthly clustering-patterns in the onset of symptoms and diagnosis of IBD, as well as health seeking behavior in those individuals. MATERIALS AND METHODS: Two hundred and eighty-two consecutive patients with IBD were included. Onset of symptoms (month) and delay to diagnosis were analyzed. Kruskal-Wallis and Roger's test were used to analyze for statistical patterns in seasonal clustering. RESULTS: There were 181 males and 101 females with IBD; mean age: 40 ± 14.7 years (median: 38, range: 14-79 years). The peak number of IBD cases was seen in winter/early spring, with the lowest numbers in autumn, which reached statistical significance in the CUC group (p: 0.029). Seasonal changes were not significantly affected by gender. The time delay to diagnosis from symptom onset was 3.0 ± 2.3 months in males (median: 2, range: 0-12 months) vs 3.2 ± 3.2 months (median: 2, range: 0-18 months) in females (not statistically significant). CONCLUSION: Our results show a seasonal relation in IBD cases, particularly in CUC, which may suggest external stimuli acting as a precipitant to IBD in susceptible individuals. There was a delay between symptom onset and CUC diagnosis, which was not felt to be clinically significant.

Expansion of anti-mesothelin specific CD4+ and CD8+ T cell responses in patients with pancreatic carcinoma.

We aimed to assess the status of naturally occurring CD4(+) and CD8(+) T cell responses to a tumour associated antigen, Mesothelin, in patients with pancreatic carcinoma and study the effects of elevated IL-10 on Mesothelin-specific T cell responses. For that sake, short term T cell lines were generated from PBMCs of 16 healthy controls, 15 patients with benign pancreatic diseases and 25 patients with pancreatic carcinoma and Mesothelin-specific CD4(+) and CD8(+) T cell responses were analysed using intracellular cytokine assays for IFN-γ. Plasma levels of IL-10 and Mesothelin were measured using cytometric bead array and ELISA assay, respectively. The blocking assays were performed to assess the effects of IL-10 on Mesothelin-specific T cell responses. Here, we demonstrate that the plasma levels of Mesothelin and IL-10 are significantly increased in patients with pancreatic carcinoma. Additionally, we found that (a) Mesothelin-specific T cell responses are significantly expanded in cancer patients (p = 0.0053), (b) the multifunctional CD4(+) T cell response is directed toward a broad repertoire of epitopes within the Mesothelin protein. (c) Mesothelin-specific CD4+ T cell response is directly inhibited by elevated IL-10 in cancer patients. These data provides evidence for the use of Mesothelin as an immunogen for tumour-specific T cell response.

Patient selection criteria for primary total hip Arthroplasty in displaced intracapsular hip fractures: Are they appropriate?

INTRODUCTION: This study aims to determine, by outcome analysis, the appropriateness of current criteria employed to select patients for total hip arthroplasty (THA) as the primary treatment for displaced intracapsular hip fracture (DICHF). This study is intended to inform prospective randomised controlled trials investigating the efficacy of THA as a primary treatment. MATERIALS AND METHODS: Contemporary THA eligibility criteria were derived from recent publications relating to pre-fracture residence, mobility and independence. Outcome data were analysed for 96 patients (19% of 506 consecutive patients with DICHF between March 2003 and February 2005) who fulfilled those criteria. The variables analysed included age, gender, co-existing injuries, co-morbidities, social circumstances, mobility, independence, delay to surgery, readmission and death. The 96 patients included in the study were followed for 3 years. The primary outcome was the combined achievement of home or warden-assisted accommodation at 3 months, no patient readmission within 6 weeks of discharge and survival to 1 year. Secondary outcome was survival to 3 years. RESULTS: At 3 months, 86 patients (90%) had returned home, three (3.1%) required nursing or residential home placement, four (4.2%) were still resident in a community hospital and three (3.1%) had died. A total of ten patients failed to return to their own home. Eight patients (8.3%) were readmitted within 6 weeks. At 1 year, eight patients (8.3%) had died; by 3 years, the mortality rate was 25%. Patients not achieving return to home were older (84.8 years vs. 79.7 years, p = 0.19), prior to fracture weremore likely to use a walking aid (odds ratio [OR] 2.35) or required home support (OR 1.74). The number of co-morbidities was not an association. Backward selection applied to the above data produced an OR of 1.12 (confidence interval [CI] 1.01-1.21) for age as a variable in patients successfully discharged home, so that for each increase in age by year, the odds of home not being the final destination increased by 12%. These factors were also reflected in the patients requiring readmission within 6 weeks from discharge. CONCLUSIONS: If maintaining a high level of activity and independence is the expectation in patients considered for THA for DICHFs, then current selection criteria appear to be appropriate in identifying those capable of returning home, remaining independent and surviving to 1 year compared to the whole DICHF population. With a 75% 3-year survival, the postulated benefit of THA will not be realised in many patients and this needs to be considered. Cost-effectiveness trials are required before broad practice change occurs.

'Full-house' rheumatic heart disease.

We report the case and cardiac imaging of a 27 year old African female with every clinical feature of advanced rheumatic heart disease. The case illustrates the continuing life-threatening impact of rheumatic heart disease in young adults. Appropriate diagnosis and management of rheumatic heart disease in the UK remains relevant with increased immigration of at-risk populations.