Quality standards for the management of alcohol-related liver disease: consensus recommendations from the British Association for the Study of the Liver and British Society of Gastroenterology ARLD special interest group.

OBJECTIVE: Alcohol-related liver disease (ALD) is the most common cause of liver-related ill health and liver-related deaths in the UK, and deaths from ALD have doubled in the last decade. The management of ALD requires treatment of both liver disease and alcohol use; this necessitates effective and constructive multidisciplinary working. To support this, we have developed quality standard recommendations for the management of ALD, based on evidence and consensus expert opinion, with the aim of improving patient care. DESIGN: A multidisciplinary group of experts from the British Association for the Study of the Liver and British Society of Gastroenterology ALD Special Interest Group developed the quality standards, with input from the British Liver Trust and patient representatives. RESULTS: The standards cover three broad themes: the recognition and diagnosis of people with ALD in primary care and the liver outpatient clinic; the management of acutely decompensated ALD including acute alcohol-related hepatitis and the posthospital care of people with advanced liver disease due to ALD. Draft quality standards were initially developed by smaller working groups and then an anonymous modified Delphi voting process was conducted by the entire group to assess the level of agreement with each statement. Statements were included when agreement was 85% or greater. Twenty-four quality standards were produced from this process which support best practice. From the final list of statements, a smaller number of auditable key performance indicators were selected to allow services to benchmark their practice and an audit tool provided. CONCLUSION: It is hoped that services will review their practice against these recommendations and key performance indicators and institute service development where needed to improve the care of patients with ALD.

Systematic review: Interventions for alcohol use disorder in patients with cirrhosis or alcohol-associated hepatitis.

BACKGROUND: Alcohol use is the most important factor in determining the prognosis of patients with alcohol-related cirrhosis and alcohol-associated hepatitis. AIM: To conduct a systematic review of interventions for alcohol use disorder specific to patients with cirrhosis or alcohol-associated hepatitis. METHODS: We searched five databases between inception and November 2022. The primary outcomes were abstinence, hepatic decompensation and mortality. We included randomised and non-randomised studies. Risk of bias was assessed using validated tools. Where possible, meta-analysis was performed. RESULTS: Twenty-three studies met the inclusion criteria including six randomised trials and 17 non-randomised studies of interventions. These included 104,298 patients with a mean/median age range from 44 to 65, of whom 75% were male. Interventions included psychological therapy, pharmacological therapies, specialist clinics, patient education and low alcohol drinks. Baclofen was the only intervention to demonstrate a statistically significant impact on the primary outcomes in a randomised trial (abstinence OR: 6.3, 95% CI: 2.4-16.1). Three non-randomised studies reported reductions in episodes of hepatic decompensation that were significant in multivariate models. This was in response to psychological therapy, use of any pharmacotherapy, and use of any treatment. A meta-analysis of non-randomised studies that examined the impact of psychological therapies revealed statistically non-significant improvements in abstinence (4 studies, OR: 1.87, 95% CI: 0.38-9.23) and mortality (4 studies, OR: 0.47, 95% CI: 0.12-1.77). CONCLUSIONS: Baclofen is the only intervention with randomised trial evidence for significant benefit in patients with cirrhosis. Non-randomised studies also point to non-pharmaceutical interventions possibly improving clinical outcomes.

A systematic review and meta-analysis of factors for delirium in vascular surgical patients.

BACKGROUND: Delirium is a common syndrome responsible for a large burden of morbidity and mortality. In surgical settings, research into risk factors for postoperative delirium has largely focused on elective orthopedic patients. We performed a systematic review and meta-analysis to evaluate the evidence surrounding risk factors for delirium in vascular surgical populations. METHODS: Two independent reviewers searched five databases (MEDLINE, Web of Science, Embase, Cumulative Index to Nursing and Allied Health Literature, and PsycINFO) from January 1987 to December 2015. We included primary research studies for incident delirium that used validated delirium assessment tools in exclusively vascular surgical populations. RESULTS: We identified 16 studies (3817 patients) that met the inclusion criteria. There was substantial clinical heterogeneity in the populations included under a heading of "vascular surgery." Studies were high quality, with an average Newcastle-Ottawa Scale score of 6.9. Summary incidence of delirium was 23.4% (range, 4.8%-39%). Across all studies, 157 separate risk factors were examined. Ten of the included studies used multivariable models in their analysis of risk factors. Meta-analysis of risk factors with data from more than three studies identified the following factors as conferring an increased risk of delirium: American Society of Anesthesiologists score >2 (odds ratio [OR], 3.44), renal failure (OR, 2.09), previous stroke (OR, 1.87), history of neurologic comorbidity (OR, 1.57), and male sex (OR, 1.30). Delirious patients were older (mean difference [MD], +4.99 years), had lower preoperative hemoglobin levels (MD, -0.66 g/dL), and stayed longer in intensive care units (MD, +1.06 days). CONCLUSIONS: Delirium is common in vascular surgery settings. Meta-analysis has identified significant risk factors relating to the patient, the presentation, and the pathway of care. Better understanding of these risk factors may help in prediction, prevention, and early identification of delirium.

Ethics teaching on 'Beginning of Life' issues in UK medical schools.

Medical ethics forms an essential component of an undergraduate medical programme. In the UK the Institute of Medical Ethics has released a consensus statement detailing its recommendations for a minimum curriculum for ethics. One important issue it highlights for inclusion is 'Beginning of Life', which includes a wide range of themes. This paper presents an evaluation of the current teaching and assessment of these important issues in UK medical schools, complemented by a specific analysis of students' reaction to the teaching they received at the University of Edinburgh as part of their Obstetrics and Gynaecology rotation. Schools which responded to the survey reported a wide range of teaching and assessment methods. While there was a good overall coverage of topics, only one of them was covered by every institution and the religious/cultural elements of those topics were often neglected. The medical schools viewed better clinical integration of ethics teaching as the best route to improvement, but the students reported a desire for more ethics teaching in the form of specific tutorials, lectures or discussions. It is likely that a combination of these approaches will lead to significant improvements in the delivery of ethics teaching in this area and in others.