https://spiral.imperial.ac.uk/bitstream/10044/1/79504/9/1-s2.0-S1201971220303933-main%20%281%29.pdf

Continuous physiological monitoring using wearable technology to inform individual management of infectious diseases, public health and outbreak responses.

https://research-information.bris.ac.uk/ws/files/150161254/Hudson_et_al_Lancet_GH._Rev_2._Manuscript_clean.pdf

Cirrhosis with ascites in the last year of life: a nationwide analysis of factors shaping costs, health-care use, and place of death in England

Background and objectives Patients with decompensated cirrhosis rarely receive palliative and supportive care interventions, which are routine in other life-limiting diseases. We aimed to design and evaluate a prognostic screening tool to routinely identify inpatients with decompensated cirrhosis at high risk of dying over the coming year, alongside the development of a supportive care intervention. Design Clinical notes from consecutive patients admitted as an emergency to University Hospitals Bristol with a diagnosis of cirrhosis over two distinct 90-day periods were scrutinised retrospectively for the presence or absence of five evidence-based factors associated with poor prognosis. These were analysed against their ability to predict mortality at 1 year. ‘Plan-Do-Study-Act’ (PDSA) methodology was used to incorporate poor-prognosis screening into the routine assessment of patients admitted with cirrhosis, and develop a supportive care intervention. Results 73 admissions were scrutinised (79.5% male, 63% alcohol-related liver disease, median age 54). The presence of three or more poor-prognosis criteria at admission predicted 1-year mortality with sensitivity, specificity and positive predictive value of 72.2%, 83.8% and 81.3%, respectively, and was used as a trigger for implementing the supportive care intervention. Following modification from six PDSA cycles, prognostic screening was integrated into the assessment of all patients admitted with decompensated cirrhosis, with the supportive care intervention (developed simultaneously) instigated for appropriate patients. Conclusions We describe a model of care which identifies inpatients with cirrhosis at significant risk of dying over the coming year, and describe development of a supportive care intervention, which can be offered to suitable patients in parallel to ongoing active management.

https://fg.bmj.com/content/flgastro/8/1/45.full.pdf

Integration of palliative and supportive care in the management of advanced liver disease: development and evaluation of a prognostic screening tool and supportive care intervention

2 Dedication and Acknowledgements 3 Author’s declaration 4 Academic output arising from this thesis 5

The integration of palliative care into the management of end stage liver disease

Primary biliary cholangitis (PBC) is a rare cholestatic immune-mediated liver disease. The clinical course varies from mild to severe, with a substantial group of patients developing cirrhosis within a decade. These patients are at risk of hepatocellular carcinoma, decompensation and liver failure. First line Ursodeoxycholic acid (UDCA) treatment improves the cholestatic surrogate markers, and was recently associated with a favorable survival free of liver transplantation, even in case of an incomplete biochemical response. However, despite adequate UDCA therapy, patients remain at risk of liver disease progression. Therefore, on-treatment multifactor-based risk stratification is necessary to identify patients in need of additional therapy. This requires a personalized approach; especially as recent studies suggest that complete biochemical normalization as most stringent response criterion might be preferred in selected patients to optimize their outcome. Today, stricter biochemical goals might actually be reachable with the addition of farnesoid X receptor or peroxisome proliferator-activated receptor agonists, or, in highly-selected cases, use of corticosteroids. Randomized controlled trials showed improvements in the key biochemical surrogate markers with the addition of these drugs, which have also been associated with improved clinical outcome. Considering this evolving PBC landscape, with more versatile treatment options and treatment goals, this review recapitulates the recent insight in UDCA therapy, the selection of patients with a residual risk of liver disease progression and the results of the currently available second line treatment options. 

Treatment in primary biliary cholangitis: Beyond ursodeoxycholic acid.

<h3>Background and Objectives</h3> To combat the increasing prevalence of liver disease in the UK, there is a need to expand the Hepatology workforce.<sup>1</sup> Previous national trainee survey of Hepatology training in the UK was conducted in 2010 and reported suboptimal Hepatology training.<sup>2</sup> This survey aims to evaluate current Hepatology training provision and trainee attitudes towards future careers in Hepatology. <h3>Method</h3> An electronic survey was designed by the British Association of the Study of the Liver (BASL) Trainees’ committee and distributed to higher specialty gastroenterology trainees in the UK between March to May 2022 through mailing lists of BASL, British Society of Gastroenterology (BSG), Gastroenterology Trainee Programme directors and social media platforms. <h3>Results</h3> 138 trainees completed the survey covering all training grades and regions of the UK. 73.7% reported receiving adequate Hepatology training currently with 55.6% intending to become future Hepatologists. Trainee preference for future Hepatology consultant jobs in Level 2 or 3 liver centres were almost three-fold higher compared to level 1 centres (60.9% vs 22.6%). All trainees irrespective of training grade reported high confidence in managing decompensated cirrhosis in both inpatient and outpatient settings. In senior trainees (grade ST6 and higher), those without Hepatology ATP experience reported significantly lower confidence in managing viral hepatitis, HCC and post-transplant patients compared to senior trainees with Hepatology ATP experience. For junior trainees (IMT3 – ST5), remaining in their current deanery was the most important factor when considering future Hepatology ATP application. <h3>Conclusions</h3> Overall, the majority of trainees in the UK were satisfied with their current level of Hepatology training. There is a need to deliver widely available training/teaching on the management of patients with; viral hepatitis, hepatocellular carcinoma and post-liver transplant. More than half of the trainees wished to pursue a career in Hepatology but most wished to work in level 2/3 liver centres rather than level 1 centres. Innovative job planning strategies are required to address this imbalance. Expansion of Hepatology ATP networks with wider geographical coverage are needed to address the growing need for more Hepatologists around the UK. <h3>References</h3> Williams R, <i>et al.</i> Addressing liver disease in the UK: a blueprint for attaining excellence in health care and reducing premature mortality from lifestyle issues of excess consumption of alcohol, obesity, and viral hepatitis. <i>Lancet</i> 2014;<b>384</b>:1953–1997. Patanwala I, Hudson M. Hepatology training in the UK. <i>Frontline Gastroenterol.</i> 2012;<b>3</b>:52–56. 

P48 UK national trainee survey of Hepatology training, research and the future workforce – BASL Trainees’ Committee

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P48 UK national trainee survey of Hepatology training, research and the future workforce – BASL Trainees’ Committee