Biomarkers of liver fibrosis

Currently the only accepted method (gold standard) for the diagnosis of the fibrotic stages of chronic liver disease (CLD) is liver biopsy, to allow histological assessment. Liver biopsy is an invasive investigation associated with a range adverse events (e.g. pain, haemorrhage) limiting its serial usage in clinical practice. Additionally, its use is further reduced by sampling error and because histology is in effect a surrogate for clinical outcomes. Over recent years, alternative non-invasive biomarkers for the diagnosis of liver fibrosis have been developed. Initially developed in chronic viral hepatitis these have since seen their use expanded to include all aetiologies of CLD. Such markers can be divided into indirect ‘simple’ markers (e.g. transaminases, gamma-glutamyl transferase, platelet count), direct ‘complex’ markers (e.g. procollagen peptides I/III, Type IV collagen), cytokines (e.g. interleukin-10, transforming growth factor alpha) and imaging. Here, we discuss the clinical utility, limitations and development of non-invasive biomarkers in their use as diagnostic and prognostic tests

Facilitators and barriers to asylum seeker and refugee oral health care access: a qualitative systematic review

Objectives Asylum seekers and refugees (ASRs) encounter barriers when accessing oral health care (OHC). A qualitative systematic review was conducted to understand the perceptions, attitudes, behaviours and experiences of ASRs regarding their OHC. Themes were extracted to identify the barriers and facilitators ASRs face when accessing OHC. Data sources PubMed, APA PsycInfo, Cochrane Database, Web of Science and CINAHL were searched on 4 and 5 October 2022. Data selection Primary studies including ASRs of any age or nationality were included. Qualitative data of ASRs' lived experiences of oral health (OH) and accessing OHC were extracted. The Critical Appraisal Skills Programme quality appraisal tool was applied. Data synthesis Data findings were extracted and meta-aggregation performed using inductive reasoning. A total of 13 primary qualitative studies were included. Three barriers were identified, including difficulty accessing treatments and appointments, cultural and language changes, and ASRs' lack of OHC knowledge or incongruous beliefs surrounding OH. Two facilitators were identified as good OH education and support from care providers or government. Conclusions Decision-makers should adapt policy to facilitate access to OHC and educate ASRs on OH. More research is needed to understand the barriers and facilitators to OHC for other people groups who experience health inequalities

Completeness of primary intracranial tumour recording in the Scottish Cancer Registry 2011-12

IntroductionA high level of case ascertainment by cancer registries is essential to allow estimation of accurate incidence rates and survival. Nearly 20 years ago, researchers assessed the completeness and accuracy of registration of primary intracranial tumours (Scottish Cancer Registry [SCR]) compared to a database assembled in the context of a detailed incidence study carried out in the Lothian region of Scotland covering the period of diagnosis, 1989–1990.1 and 2 Disappointingly, SCR identified only 54% of cases, although the registry at that time did not attempt to collect information on ‘benign’ intracranial neoplasms which were included in the detailed incidence study. Even so, only 84% of neuro-epithelial tumours were identified by SCR, probably related in part to the fact that the cancer registry was not receiving neuropathology data from the regional neuro-oncology centre. An English study reported similar findings with only 52% of cases appearing in the regional cancer registry.3Over time, access to diagnostic techniques has improved alongside improvements and changes in classification and clinical coding. Furthermore, SCR now receives neuropathology data from all neuro-oncology centres in Scotland, and has sought to collect information on benign tumours of the brain and spinal cord since the year of diagnosis, 2000. In light of these developments, we aimed to determine the completeness of ascertainment of primary intracranial tumours by SCR through independent/clinical case ascertainment in NHS Lothian for the period of diagnosis, 2011–2012.MethodsScottish Cancer RegistrySCR operates by bringing together predominantly electronic information from hospital patient administration systems including patient discharges from hospital (Scottish Morbidity Record 01), radiotherapy, oncology, and pathology records; death records from National Records Scotland; and private hospital records.4 All primary malignant and benign brain tumours are recorded on the SCR.Inclusion and exclusion criteriaThis retrospective cohort study was restricted to the period of diagnosis between 1 January 2011 and 31 December 2012 and limited to adults (age ≥18 years on the date of diagnosis) with a postcode within the NHS Lothian health board region (mid-year population ∼650,000). The date of diagnosis was taken as i) the date of the first abnormal imaging, or ii) the date of biopsy/resection. Patients in whom there was no neuro-radiology or histology were excluded, i.e. diagnosis of prolactinoma had to be supported by blood tests and imaging.All suspected and histologically proven primary intracranial tumours (benign and malignant) of the brain and cranial nerves were counted, including primary central nervous system lymphoma. Meningeal, pituitary region and pituitary gland tumours were also included. Cerebral metastases, tumours of the spinal cord and spinal nerves, and recurrent intracranial tumours of any type were excluded.Extraction from the SCRData were extracted for the study period for all records including the following anatomical site codes selected from the third edition of the International Classification of Diseases for Oncology (ICD-O-3): C70.0; C70.9; C71; C72.2; C72.3; C72.4; C72.5; C72.8; C72.9; C75.1; C75.2; and C75.3 (all behaviour codes).Clinical case ascertainmentThree clinical sources were trawled as follows: i) neuro-oncology multidisciplinary team meeting (MDTM) minutes; ii) an endocrinology database; and iii) neuropathology records (sources i and ii are independent of the SCR data collection system). The neuro-oncology MDTM aims to discuss all intracranial tumours identified via any means including both benign and malignant tumours. The endocrinology database records all patients attending the endocrine outpatient clinics in the NHS Lothian region and each is assigned a diagnosis by a Consultant Endocrinologist. Both sources i and ii for the period 1 January 2011 – 31 March 2013 were reviewed manually by JRM. The neuropathology records hold information on all tissue samples analysed in the pathology system for NHS Lothian hospitals and an electronic extract was obtained using Systematized Nomenclature of Medicine codes matching those above. To ensure cases were true incident cases meeting the full inclusion criteria, each was cross-referenced with the patient's electronic secondary care medical record.AnalysisClinically ascertained cases were reconciled against the SCR extract. We have previously quantified the extent of misclassification of incidence year in the Scottish Cancer Registration database.5 We did not regard misclassifications of incidence year as missed or ‘over-diagnosed’ cases as there is no reason to believe that such misclassification is other than random.Completeness was defined as the proportion of intracranial tumours included in the SCR out of all those identified as diagnosed in residents of NHS Lothian area during the study period. Confidence intervals (95%) for completeness were calculated using the exact method.Completeness was calculated for all intracranial tumours with secondary analysis of completeness by tumour morphology and tumour grade (see Supplementary File for coding definitions).ResultsThere were 320 records of primary intracranial tumours registered on the SCR for the period of interest and 264 clinical cases were ascertained. Fig. 1 shows the final ascertainment of clinical cases missing from the SCR

Trends in indirect liver function marker testing in Wales from 2000 to 2017 and their association with age and sex: an observational study

Objective If non-invasive markers of liver fibrosis were recorded frequently enough in clinical practice, it might be feasible to use them for opportunistic community screening for liver disease. We aimed to determine their current pattern of usage in the national primary care population in Wales.Design Using the Secure Anonymised Information Linkage (SAIL) Databank at Swansea University (2000–2017), we quantified the frequency of common liver blood tests (aspartate aminotransferase (AST), alanine aminotransferase (ALT), platelet count and albumin) used in fibrosis marker algorithms. We examined measurement variation by age and sex.Results During the 18-year study period, there were 2 145 178 adult patients with at least one blood test available for analysis. Over the study period, the percentage of SAIL patients receiving an ALT test in each year increased from 2% to 33%, with platelet count and albumin measurement increasing by a similar factor. AST testing, although initially rising, had decreased to 1% by the end of the study. AST and ALT values varied by age and sex, particularly in males with the upper normal range of ALT values decreasing rapidly from 90 U/L at age 30 to 45 U/L by age 80.Conclusion The reduction in AST testing to only 1% of the adult population limits the use of many non-invasive liver marker algorithms. To enable widespread screening, alternative algorithms for liver fibrosis that do not depend on AST should be developed. Liver fibrosis markers should be modified to include age-specific and sex-specific normal ranges

The effect of Covid-19 on alcohol use disorder and role of universal alcohol screening in an inpatient setting: a retrospective cohort control study

AimTo assess the impact of Covid-19 on alcohol use disorders (AUD) and the role of universal alcohol screening (UAS) in an inpatient setting.MethodsRetrospective cohorts were defined as pre-pandemic and pandemic admitted to Nottingham University Hospitals (April to October; 2019 and 2020) and had alcohol assessment by AUDIT-C. AUDIT-C score was assessed against age, sex, ethnicity, admission type, speciality and primary diagnosis of mental disorders. Subgroup analysis for Covid-19 positive patients was performed.ResultsA total of 63,927 admissions (47,954 patients) were included. The pandemic period compared to pre-pandemic had fewer overall admissions (27,349 vs 36,578, P < 0.001), fewer with AUD (17.6% vs 18.4%, P = 0.008) but a higher proportion of alcohol dependents (3.7% vs 3.0%, P < 0.0001). In the pandemic those with AUD were more likely to be male (P = 0.003), white (P < 0.001), in relationship (P < 0.001), of higher socioeconomic background (P < 0.001), have alcohol-related mental disorders (P = 0.002), emergency admission (P < 0.001), medical speciality admission (P < 0.001) and shorter length of stay (P < 0.033) compared to pre-pandemic AUD. Covid-19 positive patients with concomitant AUD died at younger age (P < 0.05) than Covid-19 positive patients at low risk for AUD.ConclusionsThe pandemic changed the characteristics of inpatients with AUD. There was a higher proportion of alcohol-dependent admissions with evidence that a younger, less deprived group have been significantly impacted. UAS provides a useful tool to screen for AUD and to identify the change when facing sudden health crises

Acceptability of chronic liver disease screening in a UK primary care setting: a qualitative evaluation

© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ. OBJECTIVES: The increasing incidence of chronic liver disease (CLD) in the UK may be attributed to a rise in preventable risk factors, including hazardous alcohol use and type 2 diabetes. Transient elastography (TE) can rapidly stratify risk of CLD in primary care populations and provide an opportunity to raise patient awareness of risk factors.This study explores patients' experiences of TE screening in a primary care setting. In addition, patient awareness of CLD risk is explored. STUDY DESIGN AND SETTING: This study used a qualitative process evaluation of a community screening pathway for CLD (Nottingham, UK). Participants completed semistructured interviews, which were audio-recorded, transcribed verbatim and analysed thematically. PARTICIPANTS: Twenty adults were purposively recruited 6 months to 2 years after TE screening. Inclusion criteria included (1) hazardous alcohol use, (2) type 2 diabetes and/or (3) persistently elevated liver enzymes without known cause. RESULTS: Undergoing TE in primary care was seen as acceptable to most participants. Hazardous alcohol use was identified as the primary cause of CLD; no participants were aware of metabolic risk factors. TE improved understanding of personal risk factors and prompted contemplation of lifestyle changes across all TE stratifications. However, participants' perceptions of risk were altered by the healthcare providers' communication of TE scores. CONCLUSIONS: High acceptability of TE, regardless of the risk factor, provides strong support for inclusion of TE stratification in primary care. Findings highlight the positive impact of receiving TE on risk awareness. Future clinical iterations should improve the structure and communication of TE results to patients

Young people, mental health and COVID-19 infection: The canaries we put in the coal-mine

Background: The number of people testing positive for SARS-COV-2 in the UK, particularly among young adults, is increasing. We report here on the mental health of young adults and related psychological and behavioural responses to the pandemic, and consider the role of these factors in fuelling the increase in Coronavirus 2019 (COVID-19) in this group.Methods: An online survey was completed during the first six weeks of the first UK-wide lockdown by 3097 respondents, including data for 364 respondents between the ages of 18-24 years. The survey included measures of mental health and indices capturing related psychological and behavioural responses to the pandemic.Results: The mental health of 18-24 years olds in the first 6 weeks of lockdown was significantly poorer than that of older respondents and previously published norms: with 84% reporting symptoms of depression and 72% reporting symptoms of anxiety. Young adults also reported significantly greater loneliness and reduced positive mood, both of which were also associated with greater mental health difficulties.Conclusions: We contend that the combination of mental health, social and economic considerations may have contributed to the rise of COVID-19 infections in young adults and ascribing blame to this group will not aid our efforts to regain control of the disease

Cardiovascular disease, cancer and mortality among people with type 2 diabetes and alcoholic or non-alcoholic fatty liver disease hospital admission

OBJECTIVE: To describe associations between alcoholic fatty liver disease (ALD) or non-alcoholic fatty liver disease (NAFLD) hospital admission and cardiovascular disease (CVD), cancer, and mortality in people with T2DM. RESEARCH DESIGN AND METHODS: We performed a retrospective cohort study using linked population-based routine data from the diabetes register, hospital, cancer and death records for people aged 40-89 years, diagnosed with T2DM in Scotland 2004-2013 who had one or more hospital admission records. Liver disease and outcomes were identified using International Classification of Diseases codes. We estimated hazard ratios from Cox proportional hazards models, adjusted for key risk factors (aHRs). RESULTS: There were 134,368 people with T2DM (1707 with ALD and 1452 with NAFLD) with mean follow-up of 4.3 years for CVD and 4.7 years for mortality. Among people with ALD, NAFLD or without liver disease hospital records respectively there were: 378, 320 and 21,873 CVD events, 268, 176 and 15,101 cancers and 724, 221 and 16,203 deaths. For ALD and NAFLD respectively, aHRs (95% CIs) compared to the group with no record of liver disease were: 1.59 (1.43, 1.76) and 1.70 (1.52, 1.90), for CVD; 40.3 (28.8, 56.5) and 19.12(11.71 31.2), for hepatocellular cancer (HCC); 1.28 (1.12, 1.47) and 1.10 (0.94, 1.29) for non-HCC cancer; 4.86 (4.50, 5.24) and 1.60 (1.40, 1.83) for all-cause mortality. CONCLUSIONS: Hospital records of ALD or NAFLD are associated, to varying degrees, with increased risk of CVD, cancer and mortality in people with T2DM