Highlights Established blood tests can be used in primary care to stratify patients with fatty liver disease. A 2-step pathway (FIB-4 followed by ELF TM if required) reduced unnecessary referrals by 80%. This pathway also improved the detection of cases of advanced fibrosis 5-fold and cirrhosis 3-fold. This pathway can be used in primary care to identify patients who might benefit from referral to liver specialists. This should reduce unnecessary referrals while at the same time improving the detection of cirrhosis.

Background The identification of patients with advanced liver fibrosis secondary to non-alcoholic fatty liver disease (NAFLD) remains challenging. Using non-invasive liver fibrosis tests (NILT) in primary care may permit earlier detection of patients with clinically significant disease for specialist review, and reduce unnecessary referral of patients with mild disease. We constructed an analytical model to assess the clinical and cost differentials of such strategies. Methods A probabilistic decisional model simulated a cohort of 1000 NAFLD patients over 1 year from a healthcare payer perspective. Simulations compared standard care (SC) (scenario 1) to: Scenario 2: FIB-4 for all patients followed by Enhanced Liver Fibrosis (ELF) test for patients with indeterminate FIB-4 results; Scenario 3: FIB-4 followed by fibroscan for indeterminate FIB-4; Scenario 4: ELF alone; and Scenario 5: fibroscan alone. Model estimates were derived from the published literature. The primary outcome was cost per case of advanced fibrosis detected. Results Introduction of NILT increased detection of advanced fibrosis over 1 year by 114, 118, 129 and 137% compared to SC in scenarios 2, 3, 4 and 5 respectively with reduction in unnecessary referrals by 85, 78, 71 and 42% respectively. The cost per case of advanced fibrosis (METAVIR ≥F3) detected was £25,543, £8932, £9083, £9487 and £10,351 in scenarios 1, 2, 3, 4 and 5 respectively. Total budget spend was reduced by 25.2, 22.7, 15.1 and 4.0% in Scenarios 2, 3, 4 and 5 compared to £670 K at baseline. Conclusion Our analyses suggest that the use of NILT in primary care can increases early detection of advanced liver fibrosis and reduce unnecessary referral of patients with mild disease and is cost efficient. Adopting a two-tier approach improves resource utilization.

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CH-C negatively affects work productivity (WP), creating a large economic burden. The aim of this study was to model the impact of sustained virologic response (SVR) on WP in CHC genotype 1 (GT1) patients in five European countries (EU5). Work Productivity and Activity Index-Specific Health Problem questionnaire was administered to patients across the ION clinical trials (n = 629 European patients). The analysis modelled a population of GT1 CHC patients over one year, who had been either not treated or treated with LDV/SOF. Sensitivity analyses assessed the possibility that CHC patients' labour costs were lower than the general population's and presented results by fibrosis stage. Before initiation of treatment, EU patients with CHC GT1 exhibited absenteeism and presenteeism impairments of 3.54% and 9.12%, respectively. About 91.8% of EU patients in the ION trials achieved SVR and improved absenteeism and presenteeism impairments by 16.3% and 19.5%, respectively. Monetizing these data, treatment with LDV/SOF resulted in an annual productivity gain of €435 million and a weighted average per-employed patient (PEP) gain of €900 in the EU5. PEP gains from treatment are projected to be higher in cirrhotic than in noncirrhotic patients. If CHC patients are assumed to earn 20% less than the general population, gains of €348 million (€720 PEP) annually are projected. CHC results in a significant economic burden to European society. Due to improvements in WP, SVR with treatment could provide substantial economic gains, partly offsetting the direct costs related to its widespread use.

Background/aims Non‐invasive fibrosis tests (NITs) can be used to triage non‐alcoholic fatty liver disease (NAFLD) patients at risk of advanced fibrosis (AF). We modelled and investigated the diagnostic accuracy and costs of a two‐tier NIT approach in primary care (PC) to inform secondary care referrals (SCRs). Methods A hypothetical cohort of 1,000 NAFLD patients with a 5% prevalence of AF was examined. Three referral strategies were modelled: refer all patients (Scenario 1), refer only patients with AF on NITs performed in PC (Scenario 2) and refer those with AF after biopsy (Scenario 3). Patients in Scenarios 1 and 2 would undergo sequential NITs if their initial NIT was indeterminate (FIB‐4 followed by Fibroscan®, enhanced liver fibrosis (ELF)® or FibroTest®). The outcomes considered were true/false positives and true/false negatives with associated mortality, complications, treatment and follow‐up depending on the care setting. Decision curve analysis was performed, which expressed the net benefit of different scenarios over a range of threshold probabilities (Pt). Results Sequential use of NITs provided lower SCR rates and greater cost savings compared to other scenarios over 5 years, with 90% of patients managed in PC and cost savings of over 40%. On decision curve analysis, FIB‐4 plus ELF was marginally superior to FIB‐4 plus Fibroscan at Pt ≥8% (1/12.5 referrals). Below this Pt, FIB‐4 plus Fibroscan had greater net benefit. The net reduction in SCRs was similar for both sequential combinations. Conclusions The sequential use of NITs in PC is an effective way to rationalize SCRs and is associated with significant cost savings.

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Background: Carpal tunnel syndrome (CTS) is a sporadic event with compression of the median nerve (MN). Persistent median artery (PMA) thrombosis is an exceptionally rare cause of CTS. Case report: 38‐year‐old male presented with acute on subacute right wrist pain with positive Tinel's sign. An ultrasound and computed angiography study confirmed a PMA with thrombosis. The patient was treated with intravenous heparin then discharged home on enoxaparin and warfarin crossover. Discussion: PMA can lead to CTS by compression from the adjacent median nerve. Thrombosis of the PMA can also lead to CTS. Surgical intervention is needed in cases of severe CTS. Carpal tunnel release is usually successful. Excision of the PMA can risk vascular compromise of the digits. Ultrasound is excellent for detecting rare causes of CTS. Conclusion: Ultrasound examination for CTS should include search for PMA and associated anatomical variations.

mortality. 4,5 NAFLD is the most rapidly increasing aetiology on the liver transplant waiting list; a retrospective study in the USA found that the incidence of NAFLD on the liver transplant list had increased by 170% between 2004 and 2013. 6 Over the past 5 years, NAFLD accounted for between 10-15% of patients listed annually for orthotopic liver transplants (OLTs) in the UK. 7 An index presentation with hepatocellular cancer or a decompensating event, such as ascites, hepatic encephalopathy or variceal haemorrhage, has a profound impact on morbidity and mortality and has a significant negative impact on the patient's quality of life. 8 Earlier detection of NAFLD provides opportunities to instigate interventions such as lifestyle modifications with the aim of sustained weight loss resulting in fibrosis regression, potentially averting or reducing the likelihood of the serious lifethreatening complications of portal hypertension. 9-14 Furthermore, earlier detection of hepatocellular cancers creates possibilities for interventions with curative potential such as resection and radiofrequency ablation rather than transplantation or palliation that are often the only option with late diagnosis. Despite the rising incidence and burden of NAFLD and its associated comorbidities, there remains a poor awareness regarding its recognition and management. Concerningly, the Veterans Administration primary care centre study highlighted that patients at highest risk of NAFLD were not being evaluated for this condition. 15 Only 21.5% of patients who were identified by study investigations had a confirmed diagnosis of NAFLD in primary care, 14.7% were counselled regarding diet and exercise and 10.4% were referred to a specialist. We hypothesise that many patients reaching liver transplant listing are only diagnosed with NAFLD at a point where liver disease has resulted in irreversible complications. We have conducted a retrospective analysis of patients with NAFLD cirrhosis referred for OLT assessment, aiming to determine their disease status at their first presentation to healthcare, and their subsequent clinical outcomes. Methods This was a cross-sectional analysis of all patients who underwent OLT assessment for a sole indication of NAFLD at the Royal Free London NHS Foundation Trust between January 2003 and December 2017. NAFLD was defined by the sonographic demonstration of hepatic steatosis in the presence of metabolic risk factors and the exclusion of significant alcoholic consumption