The implementation of a hepatitis C testing service in community pharmacies: I-COPTIC consensus statement.

OBJECTIVES: This aimed to develop a blueprint for an effective community pharmacy Hepatitis C virus (HCV) testing service by producing a consensus statement. STUDY DESIGN: This was a modified Delphi process. METHODS: We recruited a heterogenous panel of experts (who had been involved in the setup or delivery of a community pharmacy HCV testing service) by purposive and chain referral methods. We had three rounds of a modified Delphi process. The first was a series of questions with free text responses and was analysed using thematic analysis, and the second and third were statements for the respondents to rate using a 7-point Likert scale. Consensus was predefined in a published protocol, and the results were reviewed by a public and patient involvement panel before the statement was finalised. RESULTS: We had 24 participants, including community and hospital-based pharmacists, local pharmaceutical committee members, charity representatives (Hepatitis C Trust), local clinical service lead, nurse specialists and doctors. The response rate of the first, second and third rounds were 100%, 96% and 88%, respectively. After the third round, we had 60 statements that reached consensus. We discussed the accepted statements with a patient and public involvement group. We used these statements to produce the I-COPTIC statement and a graphical summary. CONCLUSIONS: We developed a blueprint for the design of a gold standard community pharmacy HCV testing service. We believe this will support the successful implementation of community pharmacy testing for HCV. Community pharmacy testing is an important service to help achieve and maintain HCV elimination.

Complications and mortality associated with olecranon fractures in the elderly: a retrospective cohort comparison from a large level one trauma centre.

Background: Olecranon fractures in the elderly have an increasing incidence. This retrospective study aims to identify the complications and survivorship of these patients. Methods: All patients >70 years old treated for an olecranon fracture at our institution were identified between 2007 and 2019. Loss of reduction and/or metalwork loosening was recorded. Also noted were wound healing problems, deep/superficial infections, and any subsequent treatment including return to surgery and/or removal of metalwork. Results: From a total of 177 cases, 28 presented with concomitant fractures (16%), half of which were hip fractures. The largest treatment group underwent tension band wiring (n = 82, 46%, mean age 80.8 yrs). Twenty-one of these suffered failure of fixation (26%), all requiring return to surgery. The second largest treatment group underwent plating (n = 50 28%, mean age 80.1 yrs). Four of these suffered failure of fixation (8%), all requiring return to surgery. Forty-four patients were treated non-operatively (25%, mean age 83.8 yrs). Two patients suffered other complications (4.5%). Overall 1 year survivorship was 0.82. Discussion: Olecranon fractures in the elderly have higher than expected 1 year mortality rates. Operative management results in high complication rates, often requiring return to surgery for metalwork problems. Significant consideration of treatment options is required in this cohort.

Examining the effectiveness of Gateway-an out-of-court community-based intervention to reduce recidivism and improve the health and well-being of young adults committing low-level offences: study protocol for a randomised controlled trial.

BACKGROUND: Young adult offenders represent a third of the UK prison population and are at risk of poor health outcomes including drug and alcohol misuse, self-harm and suicide. Court diversion interventions aim to reduce the negative consequences of formal criminal justice sanctions and focus resources on addressing the root causes of offending. Although diversions are widely used, evidence of their effectiveness has not yet been established. Hampshire Constabulary, working together with local charities, have developed the Gateway programme, an out-of-court intervention aimed at improving the life chances of young adults. Issued as a conditional caution, participants undertake a health and social care needs assessment, attend workshops encouraging analysis of own behaviour and its consequences and agree not to re-offend during the 16-week caution. METHODS: This is a pragmatic, multi-site, parallel-group, superiority randomised controlled trial with a target sample size of 334. Participants are aged 18-24, reside in Hampshire and Isle of Wight and are being questioned for an eligible low-level offence. Police investigators offer potential participants a chance to receive the Gateway caution, and those interested are also invited to take part in the study. Police officers obtain Stage 1 consent and carry out an eligibility check, after which participants are randomised on a 1:1 basis either to receive Gateway or follow the usual process, such as court appearance or a different conditional caution. Researchers subsequently obtain Stage 2 consent and collect data at weeks 4 and 16, and 1 year post-randomisation. The primary outcome is the Warwick-Edinburgh Mental Well-being Scale (WEMWBS). Secondary outcomes include health status, alcohol and drug use, recidivism and resource use. The primary analysis will compare the WEMWBS score between the two groups at 12 months. DISCUSSION: This pioneering trial aims to address the evidence gap surrounding diversion in 18-24-year-olds. The findings will inform law enforcement agencies, third sector organisations, policymakers and commissioners, as well as researchers working in related fields and with vulnerable target populations. TRIAL REGISTRATION: International Standard Randomised Controlled Trial Register ( ISRCTN 11888938 ).

Tap out: reducing waterborne Pseudomonas aeruginosa transmission in an intensive care unit.

BACKGROUND: Pseudomonas aeruginosa is a ubiquitous and important opportunistic pathogen in immunocompromised or critically ill patients. Nosocomial P. aeruginosa outbreaks have been associated with hospital water sources. AIM: To describe engineering interventions to minimize contamination of water outlets and the subsequent clinical impact. METHODS: New tap outlets were fitted at selected outlets across the intensive care unit (ICU). Laboratory testing demonstrated that, following artificial contamination with P. aeruginosa, these taps could be effectively decontaminated using a thermal washer-disinfector. Water samples were collected weekly from new outlets on the ICU over an eight-month period and tested for the enumeration of P. aeruginosa via membrane filtration. Surveillance of P. aeruginosa from clinical specimens was routinely undertaken. FINDINGS: Prior to the interventions, water sampling on ICU indicated that 30% of the outlets were positive for P. aeruginosa at any one time, and whole genome sequencing data suggested at least 30% transmission from water to patient. Since their installation, weekly sampling of the new tap outlets has been negative for P. aeruginosa, and the number of P. aeruginosa clinical isolates has fallen by 50%. CONCLUSION: Installation and maintenance of tap outlets free of P. aeruginosa can substantially reduce the number of P. aeruginosa clinical isolates in an ICU.

Association between skirt size and chronic liver disease in post-menopausal women: a prospective cohort study within the United Kingdom Trial of Ovarian Cancer Screening (UKCTOCS).

BACKGROUND: We investigated the association between self-reported skirt size (SS) and change in SS, and incidence of chronic liver disease (CLD) in a prospective cohort study of women recruited to the UKCTOCS trial. METHODS: Women recruited to UKCTOCS in England without documented CLD self-reported their current UK SS during trial participation and were asked to recall their SS when aged in 20s (via completion of a questionnaire 3-5 years after recruitment). Participants were followed up via electronic health record linkage and hazard ratios (HR) calculated for incident liver-related events (LRE). RESULTS: Three hundred twenty-two (0.3%) of 94,124 women experienced a first LRE. Compared to SS ≤ 16, rates of LRE were higher in the SS ≥ 18 groups (both when aged in 20s and at questionnaire completion). Event rates were higher if there was no change in SS or an increase in SS, compared to a decrease in SS. In the models adjusted for potential confounders, HRs for LRE were higher in the groups of women reporting SS ≥ 18 both when aged in 20s (HR = 1.39 (95% CI; 0.87-2.23)) and at questionnaire completion (HR = 1.37 (95% CI; 1.07-1.75)). Compared to a decrease in SS, HRs were higher in the no change (HR = 1.78 (95% CI; 0.95-3.34)) and increase (HR = 1.80 (95% CI; 1.01-3.21)) groups. CONCLUSION: CLD is associated with high SS and an increase in SS over time. These data suggest SS can be used in simple public health messages about communicating the risk of liver disease. TRIAL REGISTRATION: UKCTOCS is registered as an International Standard Randomised Controlled Trial, number ISRCTN22488978 . Registered 06/04/2000.

How did the Good School Toolkit reduce the risk of past week physical violence from teachers to students? Qualitative findings on pathways of change in schools in Luwero, Uganda.

Violence against children is a serious violation of children's rights with significant impacts on current and future health and well-being. The Good School Toolkit (GST) is designed to prevent violence against children in primary schools through changing schools' operational cultures. Conducted in the Luwero District in Uganda between 2012 and 2014, findings from previous research indicate that the Toolkit reduced the odds of past week physical violence from school staff (OR = 0.40, 95%CI 0.26-0.64, p < 0.001), corresponding to a 42% reduction in risk of past week physical violence. This nested qualitative study involved 133 interviews with students, teachers, school administration, and parents, and two focus group discussion with teachers. Interviews were conducted using semi-structured tools and analysed using thematic analysis complemented by constant comparison and deviant case analysis techniques. Within a context of normative acceptance of corporal punishment this qualitative paper reports suggestive pathways related to teacher-student relationships through which reductions in violence operated. First, improved student-teacher relationships resulted in improved student voice and less fear of teachers. Second, the intervention helped schools to clarify and encourage desired behaviour amongst students through rewards and praise. Third, many teachers valued positive discipline and alternative discipline methods, including peer-to-peer discipline, as important pathways to reduced use of violence. These shifts were reflected in changes in the views, use, and context of beating. Although the GST is effective for reducing physical violence from teachers to students, violence persisted, though at significantly reduced levels, in all schools with reductions varying across schools and individuals. Much of the success of the Toolkit derives from the support it provides for fostering better student-teacher relationships and alternative discipline options. Such innovation could usefully be incorporated in teacher training syllabi to equip teachers with knowledge and skills to maintain discipline without the use of fear or physical punishment.

Systematic review with meta-analysis: coffee consumption and the risk of cirrhosis.

BACKGROUND: Liver cirrhosis is a large burden on global health, causing over one million deaths per year. Observational studies have reported an inverse association between coffee and cirrhosis. AIMS: To perform a systematic review and meta-analysis to characterise the relationship between coffee consumption and cirrhosis. METHODS: We searched for studies published until July 2015 that reported odds ratios, relative risks (RR) or hazard ratios for cirrhosis stratified by coffee consumption. We calculated RRs of cirrhosis for an increase in daily coffee consumption of two cups for each study and overall. We performed analyses by study design, type of cirrhosis and mortality. We assessed the risk of bias in each study and the overall quality of evidence for the effect of coffee on cirrhosis. RESULTS: We identified five cohort studies and four case-control studies involving 1990 cases and 432 133 participants. We observed a dose-response in most studies and overall. The pooled RR of cirrhosis for a daily increase in coffee consumption of two cups was 0.56 (95% CI 0.44-0.68; I(2) 83.3%). The RR pooled from cohort studies for a daily increase of two cups was 0.58 (95% CI 0.41-0.76; I(2) 91.1%) and from case-control studies it was 0.52 (95% CI 0.40-0.63; I(2) 0.0%). The pooled RR of alcoholic cirrhosis for a daily increase of two cups was 0.62 (95% CI 0.51-0.73; I(2) 0%) and of death from cirrhosis it was 0.55 (95% CI 0.35-0.74; I(2) 90.3%). CONCLUSION: This meta-analysis suggests that increasing coffee consumption may substantially reduce the risk of cirrhosis.

Service use and family-centred care in young people with severe cerebral palsy: a population-based, cross-sectional clinical survey.

PURPOSE: To assess healthcare use and family perception of family-centred care in children and young adults with severe cerebral palsy (CP) within a geographical region of the UK. METHOD: Young people (4-27years) with severe forms of CP; Gross Motor Function Classification System levels IV and V, were recruited via an established case register. Data were collected in the participant's home using a standardised background proforma and validated questionnaires. The Measure of Processes of Care was used to assess the family's perception of family-centred care. RESULTS: One-hundred and twenty-three children, young people and their families/guardians participated. Results showed high accessing of specialist services in childhood with a considerable decrease in young adults. Use of generalist services remained relatively constant. The reported use of formal respite services and support groups/youth clubs was relatively poor. Family-centred care was poor in the area of "providing general information" (2.8 ± 1.73) but more moderate in the areas of "providing specific information about the young person" (4.2 ± 1.94), "enabling and partnership" (4.2 ± 1.9), "co-ordinated and comprehensive care" (4.3 ± 1.95) and "respectful and supportive care" (4.7 ± 1.75). CONCLUSIONS: The accessing of specialist services and respite care notably decreases amongst adolescents with severe forms of CP and the perception of family-centred care amongst families was fair at best. In particular, the results highlight the need for families to be provided with more general information and advice. Implications for Rehabilitation In a quest to enhance the rehabilitation process in young people with severe forms of cerebral palsy: Commissioners and service providers need to a adopt a more rationalised, needs led approach to service provision across the lifespan of people with severe forms of cerebral palsy, to include an effective and efficient transitional period. Habilitation specialists working with young adults need to continue to recognise the importance of family-centred care in managing this complex and chronic condition. Professionals working within the healthcare system must provide better communication and improve their dissemination of information to the families of children and young people with complex needs.

Performance of Enhanced Liver Fibrosis test and comparison with transient elastography in the identification of liver fibrosis in patients with chronic hepatitis B infection.

Assessment of liver fibrosis is important in determining prognosis, disease progression and need for treatment in patients with chronic hepatitis B (CHB). Limitations to the use of liver biopsy in assessing fibrosis are well recognized, and noninvasive tests are being increasingly evaluated including transient elastography (TE) and serum markers such as the Enhanced Liver Fibrosis (ELF) test. We assessed performance of ELF and TE in detecting liver fibrosis with reference to liver histology in a cohort of patients with CHB (n = 182), and compared the performance of these modalities. Median age was 46 and mean AST 70 IU/L. Cirrhosis was reported in 20% of liver biopsies. Both modalities performed well in assessing fibrosis at all stages. Area under receiver operator characteristic (AUROC) curves for detecting METAVIR fibrosis stages F ≥ 1, F ≥ 2, F ≥ 3 and F4 were 0.77, 0.82, 0.80 and 0.83 for ELF and 0.86, 0.86, 0.90 and 0.95 for TE. TE performed significantly better in the assessment of severe fibrosis (AUROC 0.80 for ELF and 0.90 for TE, P < 0.01) and cirrhosis (0.83 for ELF and 0.95 for TE, P < 0.01). This study demonstrates that ELF has good performance in detection of liver fibrosis in patients with CHB, and when compared, TE performs better in detection of severe fibrosis/cirrhosis.

A late haemorrhagic complication in an arteriovenous malformation cured with radiosurgery. Case report.

Radiosurgery is a recognized safe form of treating and usually curing arteriovenous malformations (AVMs). Complications related to radiosurgery, especially late sequelae, are rare. Such sequelae may be secondary to incomplete treatment of the original lesion such as haemorrhage, or secondary to the radiation damage to the tissue, or both. Sometimes treatment may induce new lesions. We report a patient who had an AVM cured with radiosurgery, but developed hemisensory loss acutely and had changes on MRI in keeping with a haematoma. We discuss the possible differential diagnosis that should be considered.

The journey from despair to hope: an exploration of the phenomenon of psychological distress in women residing in British secure mental health services.

This paper reports the findings of a descriptive phenomenological study that aimed to elicit and describe the experience of psychological distress as expressed by a group of women compulsorily detained within secure mental health services in the U.K. A fundamental objective of the study was to contribute to the existing evidence base that supports the care and treatment needs of this severely traumatized and challenging patient group. We argue that service providers and clinical practitioners could be better informed about the unique care and treatment needs of this severely traumatized and challenging patient group when working with them. A descriptive phenomenological approach developed by Giorgi was used to elicit the lived experiences of 'psychological distress' from a sample of female patients resident within a high secure hospital and an independent medium secure hospital. The findings indicate that a treatment plan which includes a combination of prescribed medication, informal support networks, intensive individual therapy and active engagement in a therapeutic life skills programme can be extremely beneficial. Most notably in helping to reduce the frequency of both internally and externally directed violent behaviour in this vulnerable client group.

Review of invasive cervical cancers and uptake of disclosure of results: an audit of procedures and response.

OBJECTIVE: To audit the process and outcome of case reviews performed for invasive cervical cancers diagnosed between 2003 and 2007, and the timely disclosure of results to the respective patients. METHODS: Invasive cervical cancer reviews were performed on all cases of cervical cancer diagnosed between 2003 and 2007. Following the review, women were classified into two categories: a group who developed invasive cancer despite adherence to the screening programme or in whom a management or diagnostic decision was determined to have been a principal factor in the development of their disease (Group A), and a second group who either had never undergone a cervical smear or had been established defaulters from the screening programme (Group B). RESULTS: Ninety-seven of the 98 cases of invasive cervical cancer diagnosed in the 4-year study period were reviewed. Sixty of the 61 women in Group A were sent an invitation to discuss the results of their case review. Thirty-six (37%) were classified as Group B, and it was deemed neither appropriate nor possible to invite the patients for a review consultation. Of the women sent an invitation, only 24 (40%) chose to attend. CONCLUSION: A policy of selective invitation for the disclosure of invasive review results is feasible. Less than one-half of patients diagnosed with cervical cancer appear to want to know how they developed cervical cancer despite previously participating in a screening programme.

Enhanced Liver Fibrosis (ELF) test accurately identifies liver fibrosis in patients with chronic hepatitis C.

Assessment of liver fibrosis is important in determining prognosis and evaluating interventions. Due to limitations of accuracy and patient hazard of liver biopsy, non-invasive methods have been sought to provide information on liver fibrosis, including the European liver fibrosis (ELF) test, shown to have good diagnostic accuracy for the detection of moderate and severe fibrosis. Access to independent cohorts of patients has provided an opportunity to explore if this test could be simplified. This paper reports the simplification of the ELF test and its ability to identity severity of liver fibrosis in external validation studies in patients with chronic hepatitis C (CHC). Paired biopsy and serum samples from 347 naïve patients with CHC in three independent cohorts were analysed. Diagnostic performance characteristics were derived (AUROC, sensitivity and specificity, predictive values), and clinical utility modelling performed to determine the proportion of biopsies that could have been avoided if ELF test was used in this patient group. It was possible to simplify the original ELF test without loss of performance and the new algorithm is reported. The simplified ELF test was able to predict severe fibrosis [pooled AUROC of 0.85 (95% CI 0.81-0.89)] and using clinical utility modelling to predict severe fibrosis (Ishak stages 4-6; METAVIR stages 3 and 4) 81% of biopsies could have been avoided (65% correctly). Issues of spectrum effect in diagnostic test evaluations are discussed. In chronic hepatitis C a simplified ELF test can detect severe liver fibrosis with good accuracy.

Implementing the national invasive cervical cancer audit: a local perspective.

OBJECTIVE: To monitor the effectiveness of the cervical screening programme and identify suboptimal management in order to improve patient care. DESIGN: Retrospective study. SETTING: A university hospital serving a population of 1 million people. POPULATION: All women diagnosed with a cervical cancer between 2003 and 2006. METHODS: Analysis of data from invasive cervical cancer reviews. MAIN OUTCOME MEASURE: Categorisation of cervical cancer cases according to the Invasive Cervical Cancer Audit classification. RESULTS: Eighty-seven women were diagnosed with cervical cancer during the 3-year study period. The 'lapsed attender' group accounted for the greatest number of cases (30%), followed by screen detected (26%), interval cancers (13%), never attended (12%), lost to follow-up (10%) and never invited (9%). Women who had never attended for cytology presented with higher stage disease, stage-II or above, compared with the screen-detected cases: 60% were stage II or above, compared with 13.0%, Chi-square P = 0.018. The most frequently identified screening programme problem was patient compliance, which was determined to be the principle contributing factor in 39 cases (45%) and a secondary factor in a further ten cases. CONCLUSIONS: The categorisation of cervical cancer cases has the potential of yielding invaluable information for improving programme effectiveness. Patient compliance is the greatest challenge to the screening programme, and the need for regular screening and adherence to follow-up regimens needs to be reinforced in order to maximise the efficacy of the national screening programme.

Cervical cytology/histology discrepancy: a 4-year review of patient outcome.

OBJECTIVE: To investigate the diagnosis, review and management of women identified as having a cytology/histology discrepancy. METHODS: A review of all patients diagnosed with a discrepancy between referral smear and cervical histology was performed between January 2003 and December 2004. Cases were followed for a minimum of 4 years and patient management and outcome reviewed. RESULTS: A significant discrepancy was identified in 79 cases, 0.1% of all smears (n = 80,926) analysed during the study period. A discrepancy between cytology and histology, obtained from large loop excision of the transformation zone (LLETZ), was confirmed by multidisciplinary review in 42 cases (53.2%). In 37 cases (46.8%) the cytological and/or histological diagnosis was revised; the cytology was significantly more likely than the histology to be amended (chi square P = 0.005), most often because cytology had been overcalled. Of the confirmed discrepancy cases, 33 (78.6%) were due to high-grade squamous cell or glandular abnormalities on cytology with a negative, inflammatory or human papillomavirus (HPV) infection on histology (HGC/NH). HGC/NH cases were managed by cytological follow-up in 29 (87.9%), of which 72.4% of the smears were negative when performed at least 6 months post-excision. During the 4-year follow-up period six women with a confirmed HGC/NH underwent a repeat cervical excision (hysterectomy or LLETZ), and of these, HPV effect was seen in two cases but no cervical intraepithelial neoplasia was detected in any of the histological specimens. CONCLUSION: Cytology overcall was responsible for the majority of cytology/histology discrepancies. A confirmed discrepancy is not an indication for a further excisional biopsy but follow-up is essential because a small percentage of patients may have disease that has been missed.

Psychological problems in children with hemiplegia: a European multicentre survey.

OBJECTIVE: To describe the prevalence and determinants of psychological problems in European children with hemiplegia. DESIGN: Cross-sectional survey. SETTING: Home visits in nine European regions by research associates who administered standard questionnaires to parents. PATIENTS: 279 children with hemiplegia aged 8-12 years were recruited from population-based case registers. OUTCOME MEASURE: Strengths and Difficulties Questionnaire comprising emotion, conduct, hyperactivity, peer problems and prosocial domains. An "impact score" (IS) measures the social and psychological impact of the child's difficulties. RESULTS: Children with hemiplegia had higher mean scores on the total difficulties score (TDS) compared with a normative sample (p<0.001). 48% and 57% of children, respectively, had borderline-abnormal TDS and IS. Significant, independent associations were observed between intellectual impairment and an increased risk for hyperactivity (odds ratio; OR 8.4, 95% CI 3.4 to 20.8), peer problems (OR 3.1, 95% CI 1.7 to 5.5), psychological and social impact (OR 3.0, 95% CI 1.6 to 5.6) when children with an intellectual quotient (IQ) <50 were compared with those with an IQ >70. Boys had an increased risk for conduct (OR 2.1, 95% CI 1.2 to 3.7) and hyperactivity disorders (OR 2.5, 95% CI 1.4 to 4.6). Poor self-esteem was associated with an increased risk for peer problems (OR 5.8, 95% CI 2.5 to 13.4) and poor prosocial skills (OR 7.5, 95% CI 2.4 to 23.2) compared with those with high self-esteem. Other determinants of psychological adjustment were impaired communication, severe pain and living with a single parent. CONCLUSIONS: Many of the psychological problems identified are amenable to treatment. Special attention should be given to those at highest risk of developing psychological difficulties.

Health status of children with cerebral palsy living in Europe: a multi-centre study.

AIM: The aim of this report is to describe the health status of 8-12-year-old children with cerebral palsy (CP) of all severities in Europe using the Child Health Questionnaire (CHQ). METHOD: A total of 818 children with CP from nine centres in defined geographical areas participated. CP type, gross and fine motor function, additional impairments were classified and family data were obtained. The CHQ was used to measure the parent's perception of their child's physical (PHY) and psychosocial (PSY) health. RESULTS: PHY scores were lower than the reference samples with a median of 46. The severity of gross motor function influenced the CHQ scores significantly in the PHY scale with the lowest scores for children with least gross motor function. There were significant differences between the CP types in PHY with the higher scores for children with unilateral spastic and the lowest scores for children with bilateral spastic and dyskinetic CP type. Fine motor function severity significantly affected both the PHY and PSY scales. The severity of intellectual impairment was significantly associated with CHQ scores in most dimensions with higher scores for higher IQ level in PHY and PSY. Children with seizures during the last year had a significantly lower health compared with children without seizures. The results of the multivariate regression analyses (forward stepwise regression) of CHQ scores on CP subtype, gross and fine motor function, cognitive function, additional impairments, seizures, parental education and employment revealed gross motor function, cognitive level and type of school attended were significant prognostic factors. CONCLUSION: This report is based on the largest sample to date of children with CP. Health status as measured using the CHQ was affected in all children and was highly variable. Gross motor function level correlates with health from the PHY well-being perspective but the PSY and emotional aspects do not appear to follow the same pattern.

Non-invasive markers associated with liver fibrosis in non-alcoholic fatty liver disease.

The diagnosis of fibrosis within liver disease is important for prognosis, stratification for treatment, and monitoring of treatment efficacy. The rising incidence and prevalence of non-alcoholic fatty liver disease (NAFLD) has driven the search for accurate non-invasive tools of liver fibrosis within this condition. With the aid of a systematic review, we explore how the field has evolved from the discovery of simple blood parameters to panel markers of liver fibrosis. We will discuss the biological plausibility, limitations, potential uses, and emerging diagnostic techniques of non-invasive markers in this rapidly expanding field.