Towards collaborative management of non-alcoholic fatty liver disease: a 'real-world' pathway for fibrosis risk assessment in primary care.

BACKGROUND: The optimal strategy to support primary care practitioners (PCP) to assess fibrosis severity in non-alcoholic fatty liver disease (NAFLD) and thereby make appropriate management decisions remains unclear. AIMS: To examine the feasibility of using a two-step pathway that combined simple scores (NAFLD Fibrosis Score and Fibrosis-4 Index) with transient elastography (FibroScan) to streamline NAFLD referrals from a 'routine' primary care population to specialist hepatology management clinics (HMC). METHODS: The two-step 'Towards Collaborative Management of NAFLD' (TCM-NAFLD) fibrosis risk assessment pathway was implemented at two outer metropolitan primary healthcare practices in Brisbane. Patients aged ≥18 years with a new or established PCP-diagnosis of NAFLD were eligible for assessment. The pathway triaged patients at 'high risk' of clinically significant fibrosis to HMC for specialist review, and 'low risk' patients to receive ongoing management and longitudinal follow up in primary care. RESULTS: A total of 162 patient assessments between June 2019 and December 2020 were included. Mean age was 58.7 ± 11.7 years, 30.9% were male, 54.3% had type 2 diabetes or impaired fasting glucose, and mean body mass index was 34.2 ± 6.9 kg/m2 . A total 122 patients was considered 'low risk' for clinically significant fibrosis, two patients had incomplete assessments and 38 (23.5%) were triaged to HMC. Among 31 completed HMC assessments to date, 45.2% were considered to have clinically significant (or more advanced) fibrosis, representing 9.2% of 153 completed assessments. CONCLUSION: Implementation of the two-step TCM-NAFLD pathway streamlined hepatology referrals for NAFLD and may facilitate a more cost-effective and targeted use of specialist hepatology resources.

Dietetic advocacy for long-term use of exclusive enteral nutrition resulted in high-risk surgical avoidance for complicated fibrotic Crohn's disease - A case report.

BACKGROUND AND AIM: Surgery is often the only therapeutic option for the management of fibrotic Crohn's disease (FCD). Exclusive Enteral Nutrition (EEN), a nutritionally complete liquid formula, is an effective, safe, short-term treatment for Crohn's Disease. No cases were found internationally of adults with FCD on long-term EEN. We report on clinical outcomes and self-reported quality of life (QoL) after longer-term EEN provision in a patient with complex FCD. METHODS: "Billie", a 54-year-old female, was admitted with ileal FCD diagnosed in 1985. Previous treatments were unsuccessful, including multiple bowel resections. Billie was chronically bedbound with pain and depression. CDAI (Crohn's disease activity index) score was 640 (<150) with ∼3-20 liquid stools/day, and recurrent partial bowel obstructions. Radiological findings were so severe surgeons reluctantly considered surgery but "one more resection will result in short bowel syndrome". Billie trialled EEN given her QoL was "non-existent". Unable to tolerate the taste, EEN was administered via nasogastric tube. After two months, EEN was administered ongoing via percutaneous endoscopic gastrostomy given patient preference and dietetic advocacy. RESULTS: After eight weeks on EEN, Billie's pain predominantly resolved, with bowel motions of ∼1-2/day, and nil bowel obstructions. Twelve months after EEN commencement, Billie's CDAI was 52, with 'no indication for surgical intervention' and was self-reporting that "life is good". After 18 months, Billie remains asymptomatic, and in clinical remission. CONCLUSION: This unique case is a wonderful example of dietetic advocacy and showcases the positive impact long-term EEN may have on surgical avoidance, clinical outcomes and self-reported QoL.

Older adults with acute severe ulcerative colitis have similar steroid non-response and colectomy rates as younger adults.

BACKGROUND: There is paucity of data on outcomes of acute severe ulcerative colitis (ASUC) in older adults (≥ 60 years of age). AIM: To assess steroid non-response rates during the index admission for ASUC in older adults. Secondary outcomes were response to medical rescue therapy and colectomy rates; at index admission, 3 and 12 mo. METHODS: This retrospective multicentre cohort study included ASUC admissions who received intravenous steroids between January 2013 and July 2020 at two tertiary hospitals. Electronic medical records were reviewed to collect clinical, biochemical, and endoscopic data. A modified Poisson regression model was used for analysis. RESULTS: Of 226 ASUC episodes, 45 (19.9%) occurred in patients ≥ 60 years of age. Steroid non-response rates were comparable in older adults and patients < 60 years of age [19 (42.2%) vs 85 (47%), P = 0.618, crude risk ratio (RR) = 0.89 [95% confidence interval (CI): 0.61-1.30], adjusted RR = 0.99 (0.44-2.21). Rates of response to medical rescue therapy in older adults was comparable to the younger cohort [76.5% vs 85.7%, P = 0.46, crude RR = 0.89 (0.67-1.17)]. Index admission colectomy [13.3% vs 10.5%, P = 0.598, crude RR = 1.27 (0.53-2.99), adjusted RR = 1.43 (0.34-6.06)], colectomy at 3 mo [20% vs 16.6%, P = 0.66, crude RR = 1.18 (0.61-2.3), adjusted RR = 1.31 (0.32-0.53)] and colectomy at 12 mo [20% vs 23.2%, P = 0.682, crude RR = 0.85 (0.45-1.57), adjusted RR = 1.21 (0.29-4.97)], were similar between the two groups. CONCLUSION: In older adults with ASUC, the steroid non-response rate, response to medical rescue therapy, and colectomy rate at index admission, 3 and 12 mo is similar to patients less than 60 years of age.

Changing Prevalence of Medication Use in People with Cirrhosis: A Retrospective Cohort Study Using Pharmaceutical Benefits Scheme Data.

BACKGROUND: Safe and appropriate use of medicines is essential to improve health outcomes in cirrhosis. However, little is known about the number and type of medicines dispensed to people with cirrhosis in Australia, as this predominantly occurs in the community. We aimed to characterise the prescriptions dispensed to people with cirrhosis and explore changes in the use of medication groups over time. METHODS: Pharmaceutical Benefits Scheme data between 1 January 2016 and 30 June 2020 was extracted for consenting CirCare participants (multi-site, prospective, observational study). Prescriptions dispensed from cirrhosis diagnosis until liver transplant or death were included. Safety classifications for dispensed medicines were defined using published evidence-based recommendations. The pattern of medication use was analysed in 6-monthly time intervals. Generalised estimating equations models were used to estimate the change in consumption of medicines over time. RESULTS: Five hundred twenty-two patients (mean age 60 years, 70% male, 34% decompensated at recruitment) were dispensed 89,615 prescriptions during the follow-up period, representing a median of 136 [interquartile range (IQR) 62-237] prescriptions and a median of 16 (IQR 11-23) unique medicines per patient (total n = 9306 medicines). The most commonly used medicines were proton pump inhibitors (PPIs) (dispensed at least once to 73% of patients), opioids (68%) and antibiotics (89%). Polypharmacy was prevalent, with 59-69% of observed participants in each time period dispensed five or more unique medicines. Prescription medication use increased over time (p < 0.001) independently of age, comorbidity burden and liver disease aetiology. The likelihood of taking PPIs, opioids, antidepressants and inhaled medicines also increased with each successive time period. Use of angiotensin therapies, metformin and statins differed over time between patients with compensated versus decompensated cirrhosis. General practitioners prescribed 69% of dispensed medicines, including a higher proportion of 'unsafe' and 'safety unknown' medicines compared with consultants/specialists (p < 0.001). CONCLUSIONS: Polypharmacy is common in people with cirrhosis and some medication groups may be overused. Pharmacovigilance is required and future medication safety efforts should target high-risk prescribing practices and promote medication rationalisation in the community.

Malabsorption Secondary to Gout-Induced Amyloidosis.

Many chronic inflammatory conditions can lead to systemic amyloidosis. However, secondary amyloidosis has rarely been associated with gout, and the literature reports only a handful of cases, all presenting with renal disease. We report a patient with a history of poorly controlled gout who presented with malabsorption. Endoscopic biopsies confirmed a diagnosis of small intestinal amyloidosis. This was believed to be a consequence of gout. Interestingly, renal involvement was subclinical. Our case raises awareness of this rare association and highlights the importance of considering a diagnosis of amyloidosis in patients who present with the combination of gout and gastrointestinal symptoms.