Summary Following the introduction of direct‐acting antivirals (DAA), there have been reports of declining incidence of hepatitis C (HCV)‐related liver disease as a liver transplantation indication. In this study, we assessed the impact of DAA on liver transplant indications in the UK and waiting list outcomes for patients with HCV. We assessed UK adult elective liver transplant registrants between 2006 and 2017. The aetiology of liver disease at registration was reclassified using an accepted hierarchical system and changes were assessed over time and compared before and after the introduction of DAA. Registration UKELD scores and 1‐year waiting list outcomes were also compared. The proportion of waiting list patients registered with HCV‐related cirrhosis reduced after the introduction of DAA from 10.5% in 2013 to 4.7% in 2016 (P < 0.001). Alcohol‐related liver disease (ARLD) was the leading indication for liver transplantation followed by liver cancer (26.1% and 18.4% in 2016, respectively). The proportion of registrations with Hepatocellular carcinoma (HCC) associated with HCV reduced from 46.4% in 2013 to 33.7% in 2016 (P = 0.002). For patients with HCV‐related cirrhosis at one year the outcomes of death, transplantation, delisting due to improvement or deterioration and awaiting a graft at 1 year were similar. For patients with HCV‐related HCC, the proportion dying at 1 year reduced significantly from 2.9% to 0.0% (P = 0.04). These data demonstrate an association between DAA and reduced listing rates for HCV‐related cirrhosis and HCC, but no significant changes in waiting list outcomes other than reduced mortality in the HCC group.
Background Prescribing errors are common and costly. Technology should enable safer prescribing. The two main current methods of doing so are computer initiated clinical support software (CDSS) and the user initiated information retrieval (IR) systems. However, despite the near universal availability of computerised prescribing support in the UK, errors continue. Objective To evaluate the experience of UK primary health care professionals using CDSS and to consolidate current technical opinion and literature in this area with the aim of creating useful hypotheses for guiding future academic investigation and industrial development. Study design The study was a synthesis, drawing together a literature review and views from experts in the field to explore from a qualitative perspective where and how CDSS and IR could be used to improve prescribing safety in primary care. We conducted a literature review, held a workshop to explore issues in practice and had a follow-up expert panel meeting to confirm the findings. The workshop was recorded, transcribed verbatim and analysed thematically. Participants and setting The study involved primary care practitioners, system developers, information suppliers and academics.
Various uses of posterior knee arthroscopy have been shown, including all-inside repair of posterior meniscal lesions, posterior cruciate ligament (PCL) reconstruction or PCL avulsion fixation, extensile posterior knee synovectomy for pigmented villonodular synovitis or synovial chondromatosis, posterior capsular release in the setting of knee flexion contractures, and loose bodies removal. Posterior arthroscopy provides direct access to the posterior meniscal borders for adequate abrasion and fibrous tissue removal. This direct view of the knee posterior structures enables the surgeon to create a stronger biomechanical repair using vertical mattress sutures. During PCL reconstruction, posterior arthroscopy gives the surgeon proper double access to the tibial insertion site, which can result in less acute curve angles and the creation of a more anatomic tibial tunnel. Moreover, it gives the best opportunity to preserve the PCL remnant. Arthroscopic PCL avulsion fixation is more time-consuming with a larger cost burden compared to open approaches, but in the case of other concomitant intra-articular injuries, it may lead to a better chance of a return to pre-injury activities. The high learning curve and overcaution of neuromuscular injury have discouraged surgeons from practicing posterior knee arthroscopy using posterior portals. Evidence for using posterior portals by experienced surgeons suggests fewer complications. The evidence suggests toward learning posterior knee arthroscopy, and this technique must be part of the education about arthroscopy. In today's professional sports world, where the quick and complete return of athletes to their professional activities is irreplaceable, the use of posterior knee arthroscopy is necessary.
SUMMARYA 55-year-old man with a history of diabetes mellitus, hypertension and hypercholesterolaemia developed increasing peripheral oedema over the course of several months. He was found to have nephrotic range proteinuria (15.7 g/24 h). His renal ultrasound scan was normal and the autoimmune screen was negative. His renal biopsy demonstrated evidence of membranous glomerulonephritis and increased iron deposition. At this juncture, a serum ferritin was checked which showed an initial value 933 mg/L with transferrin saturation at 96.6%. A subsequent liver biopsy also showed evidence of iron overload but without fibrotic changes. Genetic studies including C282Y HFE, ferroportin and DMT1 studies were also negative. He was subsequently treated with interval venesection which was associated with significant symptomatic and biochemical evidence of improvement in oedema and proteinuria. BACKGROUND
IntroductionThe gastroenterology team at Watford General Hospital provides a daily reach in service to the acute medical department every weekday morning. The role of these reviews is to expedite specialist input to patients acutely admitted to the hospital with the aim of improving clinical outcomes and time to discharge.A proposal has been suggested to provide an evening service in addition with a gastroenterology reach in at 5 pm on weekdays to provide a second round of reviews to patients who may have been identified as needing specialist input since the morning round. In order to provide such a service resources (Consultant or Specialist Registrar time) will need to be diverted from other pressured clinical work such as clinics or endoscopy. The aim of this report is assess the potential utility of providing such a service so as to better inform future decisions on the topic.MethodsOn behalf of the gastroenterology department the author has collected data on patients flagged as requiring gastroenterological input on 7 consecutive weekdays from the 07/12/2015 to 15/12/2015. The notes were briefly reviewed and an assessment was made on the basis of this as to the likelihood of the patient being immediately discharged following specialist input.ResultsThere were no referrals for gastroenterology review on 3 of the 7 evenings assessed. The range of case numbers referred on other days was between 1 and 3. It was not felt that any of the patients would have had a same day discharge if gastroenterological review was provided due to a variety of factors such as frailty, pending radiological or serological testing or ongoing poorly controlled symptoms. The breakdown of patient demographics and presentations are summarised in the table below.Abstract PTH-137 Table 1DateAge and GenderPresentation or DiagnosisLikelihood of same day discharge08/12/201556 FemaleSuprapubic pain and UTINo08/12/201520 MaleCyclical vomiting syndromeNo11/12/201580 FemaleAnorexia and weight lossNo14/12/201557 FemaleDiarrhoea and vomitingNo15/12/201550 FemaleAbdominal painNo15/12/201561 MaleDecompensated CirrhosisNo15/12/201587 FemaleSepsis and deranged LFTsNoConclusionOverall in the authors opinion following analysis of the collected data an evening review is unlikely to result in a significant increase same day discharges. The likely time and resource commitment is probably unlikely to result in significant improvement in clinical outcomes given the already intense input the gastroenterology department has every weekday morning with the reach in services to the acute medical unit as well as the liaison the gastroenterology registrars provide for urgent cases in the afternoon and the provision of specialist opinion at local tertiary hospitals via telephone out of hours.Disclosure of InterestNone Declared
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