A randomised controlled trial of Standard Of Care versus RadioAblaTion in Early Stage HepatoCellular Carcinoma (SOCRATES HCC).

BACKGROUND: Therapeutic options for early-stage hepatocellular carcinoma (HCC) in individual patients can be limited by tumor and location, liver dysfunction and comorbidities. Many patients with early-stage HCC do not receive curative-intent therapies. Stereotactic ablative body radiotherapy (SABR) has emerged as an effective, non-invasive HCC treatment option, however, randomized evidence for SABR in the first line setting is lacking. METHODS: Trans-Tasman Radiation Oncology Group (TROG) 21.07 SOCRATES-HCC is a phase II, prospective, randomised trial comparing SABR to other current standard of care therapies for patients with a solitary HCC ≤ 8 cm, ineligible for surgical resection or transplantation. The study is divided into 2 cohorts. Cohort 1 will compromise 118 patients with tumors ≤ 3 cm eligible for thermal ablation randomly assigned (1:1 ratio) to thermal ablation or SABR. Cohort 2 will comprise 100 patients with tumors > 3 cm up to 8 cm in size, or tumors ≤ 3 cm ineligible for thermal ablation, randomly assigned (1:1 ratio) to SABR or best other standard of care therapy including transarterial therapies. The primary objective is to determine whether SABR results in superior freedom from local progression (FFLP) at 2 years compared to thermal ablation in cohort 1 and compared to best standard of care therapy in cohort 2. Secondary endpoints include progression free survival, overall survival, adverse events, patient reported outcomes and health economic analyses. DISCUSSION: The SOCRATES-HCC study will provide the first randomized, multicentre evaluation of the efficacy, safety and cost effectiveness of SABR versus other standard of care therapies in the first line treatment of unresectable, early-stage HCC. It is a broad, multicentre collaboration between hepatology, interventional radiology and radiation oncology groups around Australia, coordinated by TROG Cancer Research. TRIAL REGISTRATION: anzctr.org.au, ACTRN12621001444875, registered 21 October 2021.

AI-powered prediction of HCC recurrence after surgical resection: Personalised intervention opportunities using patient-specific risk factors.

BACKGROUND: Hepatocellular carcinoma (HCC) recurrence following surgical resection remains a significant clinical challenge, necessitating reliable predictive models to guide personalised interventions. In this study, we sought to harness the power of artificial intelligence (AI) to develop a robust predictive model for HCC recurrence using comprehensive clinical datasets. METHODS: Leveraging data from 958 patients across multiple centres in Australia and Hong Kong, we employed a multilayer perceptron (MLP) as the optimal classifier for model generation. RESULTS: Through rigorous internal cross-validation, including a cohort from the Chinese University of Hong Kong (CUHK), our AI model successfully identified specific pre-surgical risk factors associated with HCC recurrence. These factors encompassed hepatic synthetic function, liver disease aetiology, ethnicity and modifiable metabolic risk factors, collectively contributing to the predictive synergy of our model. Notably, our model exhibited high accuracy during cross-validation (.857 ± .023) and testing on the CUHK cohort (.835), with a notable degree of confidence in predicting HCC recurrence within accurately classified patient cohorts. To facilitate clinical application, we developed an online AI digital tool capable of real-time prediction of HCC recurrence risk, demonstrating acceptable accuracy at the individual patient level. CONCLUSION: Our findings underscore the potential of AI-driven predictive models in facilitating personalised risk stratification and targeted interventions to mitigate HCC recurrence by identifying modifiable risk factors unique to each patient. This model aims to aid clinicians in devising strategies to disrupt the underlying carcinogenic network driving recurrence.

Broadening and strengthening the health providers caring for patients with chronic hepatitis C may improve continuity of care.

BACKGROUND: Direct-acting antiviral (DAA) therapies for hepatitis C virus infection (HCV) lead to excellent rates of sustained virological response (SVR). However, loss to follow-up (LTFU) for SVR testing remains a challenge. We examine factors associated with LTFU in a real-world setting. METHODS: Adults who received DAA therapy for HCV in one of 26 centers across Australia during 2016-2021 were followed up for 2 years. Data sources included the patient medical records and the national Pharmaceutical and Medicare Benefits Schemes. Linkage to Medicare provided utilization data of other health-care providers and re-treatment with DAAs. LTFU was defined as no clinic attendance for SVR testing by at least 52 weeks after DAA treatment commencement. Multivariable logistic regression assessed factors associated with LTFU. RESULTS: In 3619 patients included in the study (mean age 52.0 years; SD = 10.5), 33.6% had cirrhosis (69.4% Child-Pugh class B/C), and 19.3% had HCV treatment prior to the DAA era. Five hundred and fifteen patients (14.2%) were LTFU. HCV treatment initiation in 2017 or later (adj-OR = 2.82, 95% confidence interval [CI] 2.25-3.54), younger age (adj-OR = 2.63, 95% CI 1.80-3.84), Indigenous identification (adj-OR = 1.99, 95% CI 1.23-3.21), current injection drug use or opioid replacement therapy (adj-OR = 1.66, 95% CI 1.25-2.20), depression treatment (adj-OR = 1.49, 95% CI 1.17-1.90), and male gender (adj-OR = 1.31, 95% CI 1.04-1.66) were associated with LTFU. CONCLUSIONS: These findings stress the importance of strengthening the network of providers caring for patients with HCV. In particular, services targeting vulnerable groups of patients such as First Nations Peoples, youth health, and those with addiction and mental health disorders should be equipped to treat HCV.

Barriers to palliative care in hepatocellular carcinoma: A review of the literature.

Hepatocellular carcinoma (HCC) is a deadly and burdensome form of liver cancer with an increasing global prevalence. Its course is unpredictable as it frequently occurs in the context of underlying end-stage liver disease, and the associated symptoms and adverse effects of treatment cause severe suffering for patients. Palliative care (PC) is a medical specialty that addresses the physical, emotional, and spiritual needs of patients and their carers in the context of life-limiting illness. In other cancers, a growing body of evidence has demonstrated that the early introduction of PC at diagnosis improves patient and carer outcomes. Despite this, the integration of palliative care at the diagnosis of HCC remains suboptimal, as patients usually receive PC only at the very terminal phase of their disease, even when diagnosed early. Significant barriers to the uptake of palliative care in the treatment algorithm of hepatocellular carcinoma fall under four main themes: data limitations, disease, clinician, and patient factors. Barriers relating to data limitations mainly encapsulated the risk of bias inherent in published work in the field of PC. Clinician-reported barriers related to negative attitudes towards PC and a lack of time for PC discussions. Barriers related to the disease align with prognostic uncertainty due to the unpredictable course of HCC. Significantly, there exists a paucity of evidence exploring patient-perceived barriers to timely PC implementation in HCC. Given that patients are often the underrepresented stakeholder in the delivery of PC, future research should explore the patient perspective in adequately designed qualitative studies as the first step.

Liver Disease and Poor Adherence Limit Hepatitis C Cure: A Real-World Australian Treatment Cohort.

BACKGROUND AND AIMS: In 2016, direct-acting antiviral (DAA) treatment for hepatitis C (HCV) became available through Australia's universal health care system, with the aim of HCV elimination. We report real-world effectiveness of DAA HCV treatment in Australia from a clinically well-informed cohort, enriched for cirrhosis and prior HCV treatment. METHODS: 3413 patients were recruited from 26 hospital liver clinics across Australia from February 2016 to June 2020. Clinical history and sustained viral response (SVR) were obtained from medical records and data linkage to the Australian Pharmaceutical Benefits Scheme. Factors associated with SVR were assessed by multivariable logistic regression (MVR). RESULTS: At recruitment, 32.2% had cirrhosis (72.9% Child Pugh class B/C), and 19.9% were treatment experienced. Of the 2,939 with data, 93.3% confirmed SVR. 137 patients received second-line therapy. Patients with cirrhosis had lower SVR rate (88.4 vs. 95.8%; p < 0.001). On MVR, failure to achieve SVR was associated with Genotype 3 (adj-OR = 0.42, 95%CI 0.29-0.61), male gender (adj-OR = 0.49, 95%CI 0.31-0.77), fair/poor adherence (adj-OR = 0.52, 95%CI 0.28-0.94), cirrhosis (adj-OR = 0.57, 95%CI 0.36-0.88), FIB-4 > 3.25 (adj-OR = 0.52, 95%CI 0.33-0.83) and MELD score ≥ 20 (adj-OR = 0.25, 95%CI 0.08-0.80). Consistent results were seen in cirrhotic sub-analysis. CONCLUSIONS: Excellent SVR rates were achieved with DAAs in this real-world cohort of patients with chronic HCV infection. More advanced liver disease and clinician impression of poor adherence were associated with HCV treatment failure. Supports to improve liver fibrosis assessment skills for non-specialist DAA prescribers in the community and to optimize patient adherence are likely to enable more effective pursuit of HCV elimination in Australia.

Radiological Diagnosis of Chronic Liver Disease and Hepatocellular Carcinoma: A Review.

Medical image analysis plays a pivotal role in the evaluation of diseases, including screening, surveillance, diagnosis, and prognosis. Liver is one of the major organs responsible for key functions of metabolism, protein and hormone synthesis, detoxification, and waste excretion. Patients with advanced liver disease and Hepatocellular Carcinoma (HCC) are often asymptomatic in the early stages; however delays in diagnosis and treatment can lead to increased rates of decompensated liver diseases, late-stage HCC, morbidity and mortality. Ultrasound (US) is commonly used imaging modality for diagnosis of chronic liver diseases that includes fibrosis, cirrhosis and portal hypertension. In this paper, we first provide an overview of various diagnostic methods for stages of liver diseases and discuss the role of Computer-Aided Diagnosis (CAD) systems in diagnosing liver diseases. Second, we review the utility of machine learning and deep learning approaches as diagnostic tools. Finally, we present the limitations of existing studies and outline future directions to further improve diagnostic accuracy, as well as reduce cost and subjectivity, while also improving workflow for the clinicians.

Hepatitis C treatment outcomes for Australian First Nations Peoples: equivalent SVR rate but higher rates of loss to follow-up.

BACKGROUND: First Nations Peoples of Australia are disproportionally affected by hepatitis C (HCV) infection. Through a prospective study we evaluated the outcome of direct-acting antiviral (DAA) therapy among First Nations Peoples with HCV infection. METHODS: Adults who initiated DAA therapy at one of 26 hospitals across Australia, 2016-2019 were included in the study. Clinical data were obtained from medical records and the Pharmaceutical and Medicare Benefits Schemes. Outcomes included sustained virologic response (SVR) and loss to follow-up (LTFU). A multivariable analysis assessed factors associated with LTFU. RESULTS: Compared to non-Indigenous Australians (n = 3206), First Nations Peoples (n = 89) were younger (p < 0.001), morel likely to reside in most disadvantaged (p = 0.002) and in regional/remote areas (p < 0.001), and had similar liver disease severity. Medicines for mental health conditions were most commonly dispensed among First Nations Peoples (55.2% vs. 42.8%; p = 0.022). Of 2910 patients with follow-up data, both groups had high SVR rates (95.3% of First Nations Peoples vs. 93.2% of non-Indigenous patients; p = 0.51) and 'good' adherence (90.0% vs. 86.9%, respectively; p = 0.43). However, 28.1% of First Nations Peoples were LTFU vs. 11.2% of non-Indigenous patients (p < 0.001). Among First Nations Peoples, younger age (adj-OR = 0.93, 95% CI 0.87-0.99) and treatment initiation in 2018-2019 vs. 2016 (adj-OR = 5.14, 95% CI 1.23-21.36) predicted LTFU, while higher fibrosis score was associated with better engagement in HCV care (adj-OR = 0.71, 95% CI 0.50-0.99). CONCLUSIONS: Our data showed that First Nations Peoples have an equivalent HCV cure rate, but higher rates of LTFU. Better strategies to increase engagement of First Nations Peoples with HCV care are needed.

Gastroenterology hospital outpatients report high rates of satisfaction with a Telehealth model of care.

AIMS: This study aimed to capture patient satisfaction with a Telehealth model of care in a tertiary hospital gastroenterology outpatient setting. An in-depth patient questionnaire addressed patients' experience with telephone based consultations, as well as capturing demographic data to predict patients who may benefit from a Telehealth model of care. METHODS: Patients aged ≥ 18 years who had a telephone appointment from 1st March 2020 to 1st September 2020 at the St George Hospital and Sutherland Hospital Gastroenterology Clinics in Sydney, Australia, were invited to complete an anonymous online survey detailing their experience. Clinics included general gastroenterology, inflammatory bowel disease, hepatology and swallow disorders. Chi squared analysis was used to investigate if demographic data (age, gender, educational status, English-spoken at home, and presence of IBD or cirrhosis) impacted on a patients rating of care they received. RESULTS: 1894 patients were invited to complete with survey, with 302 responses. 294 respondents (88.4%) rated the care they received as "very good" or "good". 254 (84.1%) stated the main reason for attending the clinic was dealt with to their satisfaction. There was no statistical relationship between age, gender, educational status and the rating of care received. 49.7% preferred their telephone appointment, and 63.6% would like the option of a telephone appointment in the future. CONCLUSION: Gastroenterology outpatients reported a very high satisfaction with Telehealth, demonstrating a potential for Telehealth to be incorporated into usual care.

Selective internal radiation therapy for hepatocellular carcinoma: A 15-year multicenter Australian cohort study.

BACKGROUND AND AIM: The exact place for selective internal radiation therapy (SIRT) in the therapeutic algorithm for hepatocellular carcinoma (HCC) is debated. There are limited data on its indications, efficacy, and safety in Australia. METHODS: We performed a multicenter retrospective cohort study of patients undergoing SIRT for HCC in all Sydney hospitals between 2005 and 2019. The primary outcome was overall survival. Secondary outcomes were progression-free survival and adverse events. RESULTS: During the study period, 156 patients underwent SIRT across 10 institutions (mean age 67 years, 81% male). SIRT use progressively increased from 2005 (n = 2), peaking in 2017 (n = 42) before declining (2019: n = 21). Barcelona Clinic Liver Cancer stages at treatment were A (13%), B (33%), C (52%), and D (2%). Forty-four (28%) patients had tumor thrombus. After a median follow-up of 13.9 months, there were 117 deaths. Median overall survival was 15 months (95% confidence interval 11-19). Independent predictors of mortality on multivariable analysis were extent of liver involvement, Barcelona Clinic Liver Cancer stage, baseline ascites, alpha fetoprotein, and model for end-stage liver disease score. Median progression-free survival was 6.0 months (95% confidence interval 5.1-6.9 months). Following SIRT, 11% of patients were downstaged to curative therapy. SIRT-related complications occurred in 17%: radioembolization-induced liver disease (11%), pneumonitis (3%), gastrointestinal ulceration, and cholecystitis (1% each). Baseline ascites predicted for radioembolization-induced liver disease. CONCLUSION: We present the largest Australian SIRT cohort for HCC. We have identified several factors associated with a poor outcome following SIRT. Patients with early-stage disease had the best survival with some being downstaged to curative therapy.

Virtual clinic for positive faecal occult blood tests enhances early access to bowel cancer screening and is well received by patients.

BACKGROUND: Colorectal cancer is the second most common cause of cancer-related mortality in Australia. As such, timely access to colonoscopy following a positive faecal occult blood test (FOBT) is an important aspect of the National Bowel Cancer Screening Program to reduce morbidity and mortality related to this condition. To reduce waiting times, a Sydney-based referral centre introduced a nurse-led virtual clinic (VC) in order to facilitate direct access colonoscopy for patients referred with a positive FOBT. AIMS: To evaluate the efficacy of a nurse-led VC model to reduce waiting time to colonoscopy and to determine the patient experience of the model. METHODS: The VC model, piloted for a 14-month period, was compared with the standard outpatient clinic (SOC) model over the 14-month period preceding the VC. Primary outcomes included time to colonoscopy and secondary outcomes included adverse events, bowel preparation and cancellation rates. Patient experience was evaluated through an emailed survey. RESULTS: Compared to the SOC model, the VC model reduced waiting time to colonoscopy from date of positive FOBT by 71 days (P = 0.0006) and from date of referral by 66 days (P < 0.0001). There was no significant difference in secondary outcomes. All respondents to the survey (n = 30) reported a positive experience. CONCLUSIONS: Nursing-led VC, with direct access colonoscopy for patients at increased risk of colorectal cancer, reduce waiting times to colonoscopy without an increase in adverse events and is well received by patients.

Community screening identifies undiagnosed chronic liver disease in high-risk populations.

BACKGROUND AND AIM: Liver cirrhosis is the primary risk factor for the development of hepatocellular carcinoma. Most conditions that lead to cirrhosis are treatable, or modifiable. Therefore, a community-based screening program targeting high-risk groups was designed for early diagnosis and intervention of liver disease, to offset the rising burden of hepatocellular carcinoma in Australia. METHODS: Two nurse consultants from a tertiary liver center performed community screening of pre-identified cohorts at risk of viral hepatitis and chronic liver disease, with transient elastography and/or serology testing for chronic hepatitis B virus (HBV) and hepatitis C virus (HCV), in addition to standard blood tests. A positive screening result was defined as any of the following: liver stiffness measurement (LSM) ≥ 9.5 kPa, positive HCV RNA, or positive HBV surface antigen. Individuals who screened positive were linked to the liver center for management. RESULTS: Nine hundred and twenty-six subjects were screened over a 6-year period, of which 122/926 (13.2%) had evidence of chronic liver disease. Chronic viral hepatitis was diagnosed in 91 participants (HBV = 23, HCV = 67, and co-infection = 1), while non-alcoholic fatty liver disease was diagnosed in 14 participants. Advanced fibrosis (LSM ≥ 9.5 kPa) was detected in 42/866 (4.9%) subjects with available LSM. Loss to follow-up occurred in 36/91 (39.6%) participants with chronic viral hepatitis. CONCLUSIONS: Targeting high-risk populations for community screening and intervention increases early identification of chronic liver disease. This may reduce the incidence of liver cirrhosis and hepatocellular carcinoma. Loss to follow-up remains an ongoing challenge, requiring better strategies.

Non-alcoholic fatty liver disease: a review of epidemiology, risk factors, diagnosis and management.

Due to the rising prevalence of obesity and type II diabetes mellitus, non-alcoholic fatty liver disease is becoming the leading cause of chronic liver disease in the Western world. In some patients, simple steatosis can result in non-alcoholic steatohepatitis which over time can lead to liver cirrhosis and its associated sequelae, including hepatocellular carcinoma. Early identification and management of patients at risk with intensive dietary and lifestyle modification are essential to prevent the development of advanced liver disease and its complications. In this review, we will discuss the epidemiology of non-alcoholic fatty liver disease, pathogenesis, diagnosis, management and surveillance strategies to offset the morbidity and mortality of this disease, as well as liver and non-liver-related complications.

Chemokine-Regulated Recruitment of Antigen-Specific T-Cell Subpopulations to the Liver in Acute and Chronic Hepatitis C Infection.

BACKGROUND: In hepatitis C virus (HCV) infection, virus-specific CD8+ T cells are recruited to the liver for antiviral activity. Multiple chemokine ligands are induced by the infection, notably interferon-inducible chemokine, CXCL10. In HCV, intrahepatic T cells express chemokine receptors (CCRs), including CXCR3, CXCR6, CCR1, and CCR5, but CCR expression on antigen-specific effector and memory T cells has not been investigated. METHODS: Paired blood and liver samples were collected from subjects with chronic HCV for flow cytometric analysis of CCR expression on CD8+ T cells. Expression of these CCRs was then examined on HCV-specific CD8+ T-cell subpopulations in the blood from subjects with acute or chronic HCV. RESULTS: Relative to peripheral blood, the liver was enriched with CD8+ T cells expressing CCR2, CCR5, CXCR3, and CXCR6 either singly or in combinations. CXCR3 was preferentially expressed on HCV-specific CD8+ T cells in both acute and chronic phases of infection in blood. Both CXCR3 and CCR2 were overexpressed on HCV-specific CD8+CCR7+CD45RO+ (central memory) cells, whereas effector memory (CD8+CCR7-CD45RO+) cells expressed more CXCR6. CONCLUSIONS: CXCR3-mediated signals support the accumulation of HCV-specific CD8+ memory T cells in the infected liver, and emphasize the importance of the CXCL10/CXCR3 trafficking pathway during acute and chronic HCV infection.

Medical complications of homelessness: a neglected side of men's health.

BACKGROUND: Homelessness is an increasing societal and health issue associated with high rates of substance abuse and mental health disorders. Homeless people die more often and at a younger age than others. AIM: To identify health needs and improve healthcare for homeless men. METHODS: A physician-led clinic was established on-site at the Mission Australia Centre in Sydney, incorporating: (i) liver screening, including portable fibroscan testing, and on-site treatment of hepatitis C; (ii) a mental health clinic, staffed by a psychiatrist; and (iii) a nurse-led clinic to follow up medical issues and deliver vaccinations. Patient data were recorded prospectively to determine what medical problems were encountered so as to drive future healthcare planning. RESULTS: A total of 257 men was assessed between November 2011 and December 2017. In that time, 561 men resided at the Centre. Of these 257 men who attended the clinic, 61% were <45 years old; 69% were current and 8% former smokers; 62% had a history of chronic alcoholic abuse and 66% other substance abuse; 64% had one or more of depression, anxiety, psychosis or another mental health disorder and 44% had metabolic syndrome features, 38% cardiovascular disease, 29% hepatitis C and 21% a respiratory disorder. CONCLUSION: The main health needs of homeless men fall into the categories of mental health; cardiovascular, respiratory and metabolic disorders and addictions and hepatitis C. Establishing on-site clinics at homeless shelters with expertise to address these issues will likely improve the well-being of these men, reduce hospital admissions and prolong their lives.

Efficacy and Safety of Mycophenolate Mofetil in Patients With Autoimmune Hepatitis and Suboptimal Outcomes After Standard Therapy.

BACKGROUND & AIMS: Little is known about outcomes of patients with autoimmune hepatitis (AIH) who have a suboptimal outcome to standard therapy and are then given mycophenolate mofetil as rescue therapy. We evaluated the efficacy and safety of mycophenolate mofetil in patients failed by or intolerant to corticosteroids, with or without azathioprine. METHODS: We performed a retrospective study of 105 patients with AIH who received mycophenolate mofetil therapy after an inadequate response or intolerance to standard therapy (98% received combination therapy with corticosteroids plus thiopurines). Patients were recruited from 17 liver clinics via the Australian Liver Association Clinical Research Network. We reviewed records for baseline demographic features and characteristics of liver disease, initial therapy, mycophenolate mofetil indications, treatment outcome, and side effects. The primary outcome was biochemical remission, defined as levels of alanine and aspartate transferase and IgG level within the normal reference range, with or without normal liver histology within the first 2 years of treatment. RESULTS: The indication for mycophenolate mofetil therapy was non-response to treatment for 40% of cases and intolerance to therapy for 60%. Overall, 63 patients (60%) achieved biochemical remission following a median 12 weeks treatment with mycophenolate mofetil. The proportion of patients who achieved biochemical remission was similar between patients receiving mycophenolate mofetil for non-response to standard therapy (57%) and patients with intolerance to standard therapy (62%). However, a lower proportion of patients with cirrhosis achieved biochemical remission (47%) than patients without cirrhosis (6%) (P = .07). Serious adverse events occurred in 3 patients (2.7%) including 1 death, and 10 patients (9.2%) discontinued mycophenolate mofetil because of adverse events. CONCLUSION: In this retrospective study of patients with AIH who received mycophenolate mofetil as a rescue therapy, we found the drug to be well tolerated and moderately effective, inducing biochemical remission in 60% of subjects. Rates of response are lower and rates of infection are higher in patients with AIH and cirrhosis. Prospective studies of mycophenolate mofetil are warranted for this population.

Utilisation of hepatocellular carcinoma screening in Australians at risk of hepatitis B virus-related carcinoma and prescribed anti-viral therapy.

AIMS AND OBJECTIVES: To investigate hepatocellular carcinoma screening utilisation and factors associated with utilisation among patients prescribed hepatitis B virus anti-viral therapy and at risk of hepatocellular carcinoma. BACKGROUND: The incidence of hepatocellular carcinoma has increased in Australia over the past three decades with chronic hepatitis B virus infection a major contributor. hepatocellular carcinoma surveillance programs aim to detect cancers early enabling curative treatment options, longer survival and longer times to recurrence. DESIGN: Multi-site cross-sectional survey. METHODS: An online study questionnaire was administered to eligible participants attending three Sydney tertiary hospitals. Data were grouped into six mutually exclusive hepatocellular carcinoma risk factor categories as per American Association for the Study of Liver Diseases guidelines. All analyses were undertaken in STATA. Logistic regression was used to assess the associations between covariates and screening utilisation. Multivariate models described were assessed using the Hosmer-Lemeshow goodness of fit. RESULTS: Of the 177 participants, 137 (77.4%) self-reported that US had been performed in the last six months. Awareness that screening should be performed and knowing the correct frequency of US screening were independently associated with screening utilisation. Participants who knew that screening should be undertaken were three times more likely to have had pretreatment education or were prescribed hepatitis B virus anti-viral treatment for >4 years. Participants reporting a family history of hepatocellular carcinoma were less likely to know that screening should be undertaken every 6 months. CONCLUSION: While utilisation of hepatocellular carcinoma surveillance programs was higher in this study than in previous reports, strategies to further improve surveillance remain necessary. RELEVANCE TO CLINICAL PRACTICE: Findings from this research form the basis for proposing strategies to improve utilisation of hepatocellular carcinoma screening, inform hepatitis B virus-related clinical practice and for the delivery of care and nursing education to people receiving hepatitis B virus anti-viral therapy and at risk of developing hepatocellular carcinoma.

Role of capsule endoscopy and fecal biomarkers in small-bowel Crohn's disease to assess remission and predict relapse.

BACKGROUND AND AIMS: Capsule endoscopy (CE) is the most sensitive test to diagnose small-bowel Crohn's disease (CD). Conventional parameters poorly assess CD remission, and although fecal biomarkers assess colonic activity, their role in assessing remission is uncertain. We report CE findings in small-bowel CD patients in clinical remission compared with fecal biomarkers and standard clinical tools to determine mucosal remission and predict relapses. METHODS: Forty-three adult small-bowel CD patients in clinical remission (Crohn's Disease Activity Index [CDAI] <150) were prospectively enrolled at 4 academic centers and followed clinically for 12 months. Baseline CE studies were scored using the Capsule Endoscopy Scoring Index (CESI or Lewis score). Baseline and endpoint fecal biomarkers were assayed. RESULTS: CE findings were normal in 17 patients (40%), mild inflammation in 19 (44%), and moderate to severe inflammation in 7 (16%). Of the 26 patients (60%) with mucosal inflammation on CE, 85% had elevated baseline fecal calprotectin and 77% elevated lactoferrin level. Calprotectin and lactoferrin were normal in all patients without inflammation and elevated in all with moderate to severe inflammation. CESI correlated significantly with calprotectin, lactoferrin, and S100A12 levels but not either CDAI or C-reactive protein. During follow-up, 14% of patients exhibited a clinical flare; all had mucosal inflammation at CE and 83% had elevated baseline calprotectin and lactoferrin levels. CONCLUSIONS: In small-bowel CD patients in clinical remission, many had ongoing mucosal inflammation assessed by CE and fecal biomarkers. Only some developed a clinical flare during medium-term follow-up. These findings suggest CE and fecal biomarkers are useful in monitoring small-bowel CD progress.

Adherence to Hepatitis B Antiviral Therapy: A Qualitative Study.

Hepatitis B virus (HBV) antiviral therapies potentially suppress HBV viral load to an undetectable level reducing the risk of progressive liver disease and the development of HBV-related hepatocellular carcinoma. Adherence to antiviral therapies is imperative to achieve and maintain viral suppression. To date, there has been limited research on adherence to HBV therapies. Our study aimed to explore factors influencing adherence to antiviral therapy. A total of 29 participants consented to in-depth qualitative interviews at three outpatient clinics in Sydney, New South Wales, Australia. Interviews were digitally recorded and transcribed. Transcripts were initially classified as adherent or nonadherent and thematic analysis was used to identify dominant themes. Adherent behavior was reported by 59% (n = 17) of participants. Several themes influenced adherence including routine, fear of HBV-related disease progression, clinician-patient communication, treatment knowledge, and forgetfulness. To our knowledge, this is the first qualitative study to explore adherence to HBV antiviral therapy. An interplay of several dominant themes emerged from our data including fear of chronic HBV disease progression, clinician-patient communication, treatment knowledge, routine, and forgetfulness. Study findings have the potential to change nursing clinical practice, especially the way nurses and other clinicians target key HBV treatment messages and education, while monitoring adherence.

Factors associated with medication adherence in patients living with cirrhosis.

AIMS AND OBJECTIVES: Medication adherence in people with cirrhosis is largely unknown. This study aims to determine adherence patterns and factors associated with adherence in patients with cirrhosis. BACKGROUND: Prescribed medications are a pivotal component in the clinical management of cirrhosis with potential to retard disease progression and reduce complication risks. Medication adherence is necessary to optimise health outcomes. Understanding why medications are missed may help to develop strategies and inform nursing practice. DESIGN: Prospective cohort study. METHODS: Participants (n = 29) diagnosed with cirrhosis attending a tertiary hospital consented to complete a self-reported survey. Demographic information, adherence to medications, patient knowledge and quality of life data were collected, collated, checked and analysed using SPSS version 21. RESULTS: Less than half of the 28 patients who completed the adherence questionnaire (n = 13, 46%) reported that they had never missed medication. Being forgetful, being away from home and falling asleep contributed to nonadherence. Having less abdominal symptoms, less fatigue and increased emotional well-being were significantly associated with patients never missing medications. CONCLUSIONS: To our knowledge this is the first published study to describe adherent behaviour and the reasons medications are missed in this population. The percentage of nonadherent participants is of concern considering the potential morbidity risk that is associated with missed medications and rebound symptoms of cirrhosis. Strategies to improve and sustain adherence levels are required including enhanced adherence counselling offered to patients who are deteriorating or experience periodic exacerbation of symptoms. RELEVANCE TO CLINICAL PRACTICE: Study findings have the potential to change clinical practice especially the way nurses target motivational adherence counselling, key treatment messages, education and adherence monitoring. The results presented here provide a basis for developing adherence strategies and nursing management plans to improve adherence and health outcomes in people with cirrhosis.