New dimensions for hospital services and early detection of disease: a Review from the Lancet Commission into liver disease in the UK.

This Review, in addressing the unacceptably high mortality of patients with liver disease admitted to acute hospitals, reinforces the need for integrated clinical services. The masterplan described is based on regional, geographically sited liver centres, each linked to four to six surrounding district general hospitals-a pattern of care similar to that successfully introduced for stroke services. The plan includes the establishment of a lead and deputy lead clinician in each acute hospital, preferably a hepatologist or gastroenterologist with a special interest in liver disease, who will have prime responsibility for organising the care of admitted patients with liver disease on a 24/7 basis. Essential for the plan is greater access to intensive care units and high-dependency units, in line with the reconfiguration of emergency care due to the COVID-19 pandemic. This Review strongly recommends full implementation of alcohol care teams in hospitals and improved working links with acute medical services. We also endorse recommendations from paediatric liver services to improve overall survival figures by diagnosing biliary atresia earlier based on stool colour charts and better caring for patients with impaired cognitive ability and developmental mental health problems. Pilot studies of earlier diagnosis have shown encouraging progress, with 5-6% of previously undiagnosed cases of severe fibrosis or cirrhosis identified through use of a portable FibroScan in primary care. Similar approaches to the detection of early asymptomatic disease are described in accounts from the devolved nations, and the potential of digital technology in improving the value of clinical consultation and screening programmes in primary care is highlighted. The striking contribution of comorbidities, particularly obesity and diabetes (with excess alcohol consumption known to be a major factor in obesity), to mortality in COVID-19 reinforces the need for fiscal and other long delayed regulatory measures to reduce the prevalence of obesity. These measures include the food sugar levy and the introduction of the minimum unit price policy to reduce alcohol consumption. Improving public health, this Review emphasises, will not only mitigate the severity of further waves of COVID-19, but is crucial to reducing the unacceptable burden from liver disease in the UK.

Inverse association between gastroesophageal reflux and blood pressure: results of a large community based study.

BACKGROUND: In a cross-sectional community based study, as part of a randomised controlled trial of eradication of Helicobacter pylori infection, the association between blood pressure and symptoms of gastro-oesophageal reflux was examined. METHODS: Linear regression was used to examine the association between systolic and diastolic blood pressure and the frequency of heartburn and acid regurgitation in 4,902 of 10,537 participants aged 20-59 years. RESULTS: In multivariable analyses, adjusted mean systolic blood pressure was 4.2 (95% confidence interval 1.5 to 7.0) mm Hg lower in participants with daily acid regurgitation compared to those with less frequent symptoms. Similarly, for diastolic blood pressure, a reduction of 2.1 (0.0 to 4.3) mm Hg wasobserved. CONCLUSION: People who experience daily symptoms of gastro-oesophageal reflux have lower blood pressure than people with less frequent or no symptoms. It is possible that factors influencing nitric oxide concentrations both at the lower oesophageal sphincter and within the vasculature may be involved. This hypothesis requires confirmation. TRIALS REGISTRATION NUMBER: ISRCTN44816925.

Prevalence of epigastric pain, heartburn and acid regurgitation in adolescents and their parents: evidence for intergenerational association.

BACKGROUND AND AIMS: Little is known of the epidemiology of upper gastrointestinal symptoms in adolescents. We examined the prevalence of, and the risk factors for, epigastric pain, heartburn and acid regurgitation in adolescents from Northern Ireland. PARTICIPANTS: A total of 1133 adolescents aged 12-18 years participated in this study. METHODS: Questionnaires were mailed to 2017 randomly selected individuals gathering information on symptoms of epigastric pain, heartburn and acid regurgitation. Prevalences of the symptoms in the individuals and their parents were calculated. Associations between potential risk factors such as age, sex, body mass index category, smoking and frequency of symptoms were examined for both adolescents and their parents. Logistic regression was used to examine the relationship between adolescent and parental symptoms. RESULTS: Symptoms of epigastric pain, heartburn and acid regurgitation were infrequent in adolescents, but were substantially more common in parents. Adolescents were more likely to experience these symptoms if either parent experienced them, the association being much stronger if both parents were symptomatic, for example, the odds ratio (95% confidence interval) for the individual having acid regurgitation if both parents had this symptom was 6.89 (1.32, 35.7). Symptoms were more likely in adolescents who smoked and whose parents smoked, who were from lower socioeconomic backgrounds, and who had higher body mass index. For parents, smoking was positively associated with all symptoms, whereas being overweight was related to frequency of heartburn and acid regurgitation. CONCLUSIONS: Strong relationships were seen between adolescent and parental reporting of dyspeptic symptoms. Although this could be due to intrafamilial clustering of environmental factors, the associations persisted after adjusting for these. Psychosocial factors or genetic predisposition may underlie the relationships. Further research is required to explore these relationships more fully.

Economic modelling of early transjugular intrahepatic portosystemic shunt insertion for acute variceal haemorrhage.

INTRODUCTION: Early insertion of transjugular intrahepatic portosystemic shunt (TIPS) in high-risk patients with acute variceal haemorrhage reduces rebleeding and mortality. However, the economic benefit of utilizing this approach remains unclear. We evaluated the economic implications of introducing early TIPS into routine algorithms for the management of variceal bleeding. METHODS: Consecutive patients admitted in 2009 with variceal haemorrhage to two liver units and eligible for early TIPS insertion were identified retrospectively. The costs of a 12-month follow-up from index bleeding admission were calculated--the actual cost of follow-up and rebleeding in this cohort was compared with the theoretical 12-month follow-up costs of instead inserting an early TIPS at index admission. Our findings were subjected to a sensitivity analysis to assess the cost effectiveness of early TIPS insertion compared with standard care. RESULTS: In 2009, 78 patients were admitted to our units with variceal haemorrhage; 27 patients (35%) were eligible for early TIPS insertion. The actual cost of a 12-month follow-up was £138 473.50. Early TIPS insertion, assuming a 3.2% rebleeding rate, would save £534.70 per patient per year (P<0.0001). On sensitivity analysis, early TIPS dominated standard care up to an early TIPS rebleeding rate of 6% and remained cost-effective up to a rebleeding rate of 12%. CONCLUSION: Early TIPS insertion for high-risk patients with acute variceal bleeding is a cost-efficient intervention. This has important implications for the introduction of early TIPS as standard care and the organization of interventional radiology services.