Introduction: Detecting patients with undiagnosed chronic liver disease is a public health challenge. Patients with advanced fibrosis or compensated cirrhosis have much better outcomes than those with decompensated disease and may be eligible for interventions to prevent disease progression. Methods: A cloud-based software solution (‘the liver toolkit’) was developed to access primary care practice software to identify patients at risk of chronic liver disease. Clinical history and pathology results were extracted to calculate Aspartate aminotransferase to Platelet Ratio (APRI) and Fibrosis 4 (FIB-4) scores. Patients identified were recalled for assessment including transient elastography (TE). Results: Existing pathology results of more than 32,000 adults across nine general practices were assessed to identified 703 patients at high risk of liver disease (2.2% of the cohort). Patients with an existing diagnosis of cirrhosis were excluded. 179 patients (26%) were successfully recalled and 13% (n=23) were identified to have advanced fibrosis or cirrhosis (TE ≥ 10.0 kPa)(10% indeterminate results, 25% early fibrosis, 53% normal). In almost all cases the diagnosis of liver disease was new with the most common aetiology being non-alcoholic fatty liver disease (n=20, 83%). The liver toolkit was better at detecting patients who required further assessment in secondary care than direct GP referral (22.9% vs 3.6%, p = 0.021). APRI ≥ 1.0 and FIB-4 ≥ 3.25 had a positive predictive value for detecting advanced fibrosis or cirrhosis of 20% and 24% respectively. Patients who did not attend recall had markers of more severe disease with a higher median APRI score (0.46 vs 0.57, p =0.041). Conclusion: This novel IT system successfully screened a large primary care cohort using existing pathology results to identity patients at increased risk of liver disease. More than 1 in 5 patients recalled were found to have significant liver disease needing ongoing follow up.

BACKGROUND AND AIM:Most patients with cirrhosis have compensated disease and are cared for in primary care; however, the exact epidemiology within Australia remains largely unknown. The aim of this study was to assess cirrhosis care in an Australian primary care setting by evaluating rates of cirrhosis diagnosis, appropriate hepatocellular carcinoma (HCC) surveillance and specialist communication. METHODS:Electronic medical records in consenting general practices were reviewed using the "Liver Toolkit" to identify patients with an existing cirrhosis diagnosis. Individual cases were reviewed to identify outcomes of interest. RESULTS:One hundred seventy-one patients with confirmed cirrhosis across nine general practices were identified (74% male, mean age: 61.2 years). There was significant variation in the rate of cirrhosis diagnosis between practices (range 31.7-637.9 per 100 000 patients, P < 0.0001). Patients with cirrhosis had predominately compensated disease (75% Child-Pugh A) and common etiologies of cirrhosis were alcohol (49%), hepatitis C (47%), and metabolic dysfunction-associated steatotic liver disease (29%). Forty-two patients (25%) had received appropriate HCC surveillance. Predictors of inadequate HCC surveillance were time from last specialist correspondence (odds ratio [OR] = 1.06 per month increase, 95% confidence interval [CI]: 1.02-1.10, P = 0.002) and hepatitis B (OR = 0.24, 95% CI: 0.06-0.98, P = 0.047). Specialist correspondence with primary care was older than 2 years or absent in 37% of cases. CONCLUSIONS:There was a 20-fold difference in the rate of cirrhosis diagnosis between general practices within Sydney, suggesting a large proportion of patients remain undiagnosed. Three quarters of patients with diagnosed cirrhosis are not receiving appropriate HCC surveillance.

Chapter 18 The Multidisciplinary Management of Primary Hepatocellular Carcinoma Shakira Hoque, Shakira Hoque Department of Gastroenterology and Hepatology, St. George Hospital, Sydney, New South Wales, AustraliaSearch for more papers by this authorChristy Kim, Christy Kim Department of Gastroenterology and Hepatology, St. George Hospital, Sydney, New South Wales, AustraliaSearch for more papers by this authorMihir Desai, Mihir Desai Department of Interventional Radiology, Prince of Wales Hospital, Sydney, New South Wales, Australia Prince of Wales Clinical Campus, School of Clinical Medicine, University of New South Wales, New South Wales, AustraliaSearch for more papers by this authorPram Sirimana, Pram Sirimana Department of Upper Gastrointestinal and Hepatobiliary Surgery, Royal North Shore Hospital, Sydney, New South Wales, AustraliaSearch for more papers by this authorMalin Katarina Schumacher, Malin Katarina Schumacher Department of Radiation Oncology, Wollongong Hospital and, University of New South Wales, New South Wales, AustraliaSearch for more papers by this authorSri Jasti, Sri Jasti Department of Medical Oncology, St. George Hospital, Sydney, AustraliaSearch for more papers by this authorMostafa Abasseri, Mostafa Abasseri Department of Gastroenterology and Hepatology, St. George Hospital, Sydney, New South Wales, Australia School of Medicine, University of New South Wales, Sydney, AustraliaSearch for more papers by this authorOliver M.Fisher, Oliver M.Fisher Department of Surgery, St. George Hospital Sydney and University of New South Wales, New South Wales, AustraliaSearch for more papers by this authorFrancis Chu, Francis Chu Department of Upper Gastrointestinal and Hepatobiliary Surgery, St. George Hospital, Sydney, AustraliaSearch for more papers by this authorSuhrid Lodh, Suhrid Lodh Department of Interventional Radiology, Prince of Wales Hospital, Sydney, AustraliaSearch for more papers by this authorNatalie Collier, Natalie Collier Department of Radiation Oncology, Wollongong Hospital and, University of New South Wales, New South Wales, AustraliaSearch for more papers by this authorWinston Liauw, Winston Liauw Department of Medical Oncology, St. George Hospital, Sydney, Australia Translational Medicine Group, Pomeranian Medical University, Szczecin, PolandSearch for more papers by this authorPiotr Milkiewicz, Piotr Milkiewicz Liver and Internal Medicine Unit, Medical University of Warsaw, Warsaw, PolandSearch for more papers by this authorAmany Zekry, Amany Zekry Translational Medicine Group, Pomeranian Medical University, Szczecin, Poland Department of Gastroenterology and Hepatology, St. George Hospital, Sydney, New South Wales, AustraliaSearch for more papers by this author Shakira Hoque, Shakira Hoque Department of Gastroenterology and Hepatology, St. George Hospital, Sydney, New South Wales, AustraliaSearch for more papers by this authorChristy Kim, Christy Kim Department of Gastroenterology and Hepatology, St. George Hospital, Sydney, New South Wales, AustraliaSearch for more papers by this authorMihir Desai, Mihir Desai Department of Interventional Radiology, Prince of Wales Hospital, Sydney, New South Wales, Australia Prince of Wales Clinical Campus, School of Clinical Medicine, University of New South Wales, New South Wales, AustraliaSearch for more papers by this authorPram Sirimana, Pram Sirimana Department of Upper Gastrointestinal and Hepatobiliary Surgery, Royal North Shore Hospital, Sydney, New South Wales, AustraliaSearch for more papers by this authorMalin Katarina Schumacher, Malin Katarina Schumacher Department of Radiation Oncology, Wollongong Hospital and, University of New South Wales, New South Wales, AustraliaSearch for more papers by this authorSri Jasti, Sri Jasti Department of Medical Oncology, St. George Hospital, Sydney, AustraliaSearch for more papers by this authorMostafa Abasseri, Mostafa Abasseri Department of Gastroenterology and Hepatology, St. George Hospital, Sydney, New South Wales, Australia School of Medicine, University of New South Wales, Sydney, AustraliaSearch for more papers by this authorOliver M.Fisher, Oliver M.Fisher Department of Surgery, St. George Hospital Sydney and University of New South Wales, New South Wales, AustraliaSearch for more papers by this authorFrancis Chu, Francis Chu Department of Upper Gastrointestinal and Hepatobiliary Surgery, St. George Hospital, Sydney, AustraliaSearch for more papers by this authorSuhrid Lodh, Suhrid Lodh Department of Interventional Radiology, Prince of Wales Hospital, Sydney, AustraliaSearch for more papers by this authorNatalie Collier, Natalie Collier Department of Radiation Oncology, Wollongong Hospital and, University of New South Wales, New South Wales, AustraliaSearch for more papers by this authorWinston Liauw, Winston Liauw Department of Medical Oncology, St. George Hospital, Sydney, Australia Translational Medicine Group, Pomeranian Medical University, Szczecin, PolandSearch for more papers by this authorPiotr Milkiewicz, Piotr Milkiewicz Liver and Internal Medicine Unit, Medical University of Warsaw, Warsaw, PolandSearch for more papers by this authorAmany Zekry, Amany Zekry Translational Medicine Group, Pomeranian Medical University, Szczecin, Poland Department of Gastroenterology and Hepatology, St. George Hospital, Sydney, New South Wales, AustraliaSearch for more papers by this author Book Editor(s):Professor Janusz A. Z. Jankowski JP MBChB (Glasgow) MSc (Oxford) MD (Dundee) PhD (London) PCME (Cambridge) PGCM (C Lancs.) PGCC (Warwick) AGAF (USA). FACG (USA) FRCP (Edinburgh & London) SFHEA (UK), Professor Janusz A. Z. Jankowski JP MBChB (Glasgow) MSc (Oxford) MD (Dundee) PhD (London) PCME (Cambridge) PGCM (C Lancs.) PGCC (Warwick) AGAF (USA). FACG (USA) FRCP (Edinburgh & London) SFHEA (UK)Search for more papers by this author First published: 23 January 2024 https://doi.org/10.1002/9781119756422.ch18 AboutPDFPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShareShare a linkShare onEmailFacebookTwitterLinkedInRedditWechat Abstract This chapter outlines a practical approach to the multidisciplinary management of hepatocellular carcinoma. Hepatocellular carcinoma can often be a challenging management entity, given its unpredictable course and risks of liver decompensation needing to be outweighed with treatment benefit. This chapter includes the key steps to consider in therapeutic decision making processes for primary liver tumours, including the role of surgical resection and liver transplant, local radiological therapies, systemic treatment and palliative care. We have included patient cases to provide a helpful springboard for discussion in each section, hoping to emulate real-life multidisciplinary meetings. We also highlight the most recent advances in management across both interventional and medical disciplines, that will ultimately ensure holistic and evidence-based care is provided to our patients. References Abou-Alfa , G.K. , Meyer , T. , Cheng , A.L. et al. ( 2018 ). Cabozantinib (C) vs. placebo (P) in patients (pts) with advanced hepatocellular carcinoma (HCC) who have received prior sorafenib: results from the randomized phase III CELESTIAL trial . J Clin Oncol 36 . PubMedGoogle Scholar Abulkhir , A. , Limongelli , P. , Healey , A.J. et al. ( 2008 ). 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Portal hypertension and the outcome of surgery for hepatocellular carcinoma in compensated cirrhosis: a systematic review and meta-analysis . Hepatology 61 ( 2 ): 526 – 536 . 10.1002/hep.27431 PubMedWeb of Science®Google Scholar Bolondi , L. , Cillo , U. , Colombo , M. et al. ( 2013 ). Position paper of the Italian association for the study of the liver (AISF): the multidisciplinary clinical approach to hepatocellular carcinoma . Dig Liver Dis 45 ( 9 ): 712 – 723 . 10.1016/j.dld.2013.01.012 PubMedGoogle Scholar Brahmer , J.R. , Lacchetti , C. , and Thompson , J.A. ( 2018 ). Management of immune-related adverse events in patients treated with immune checkpoint inhibitor therapy: American society of clinical oncology clinical practice guideline summary . J Oncol Pract 14 : 247 – 249 . 10.1200/JOP.18.00005 PubMedWeb of Science®Google Scholar Brown , K.T. , Do , R.K. , Gonen , M. et al. ( 2016 ). Randomized trial of hepatic artery embolization for hepatocellular carcinoma using doxorubicin-eluting microspheres compared with embolization with microspheres alone . J Clin Oncol: Off J Am Soc Clin Oncol 34 ( 17 ): 2046 – 2053 . 10.1200/JCO.2015.64.0821 CASPubMedWeb of Science®Google Scholar Bruix , J. , Chan , S.L. , Galle , P.R. et al. ( 2021 ). Systemic treatment of hepatocellular carcinoma: an EASL position paper . J Hepatol 75 ( 4 ): 960 – 974 . 10.1016/j.jhep.2021.07.004 CASPubMedWeb of Science®Google Scholar Cescon , M. , Colecchia , A. , Cucchetti , A. et al. ( 2012 ). Value of transient elastography measured with FibroScan in predicting the outcome of hepatic resection for hepatocellular carcinoma . Ann Surg 256 ( 5 ): 706 – 712 . discussion 12–3. 10.1097/SLA.0b013e3182724ce8 PubMedWeb of Science®Google Scholar Cescon , M. , Cucchetti , A. , Ravaioli , M. , and Pinna , A.D. ( 2013 ). Hepatocellular carcinoma locoregional therapies for patients in the waiting list. 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Background: Identifying patients with undiagnosed advanced chronic liver disease (ACLD) is a public health challenge. Patients with advanced fibrosis or compensated cirrhosis have much better outcomes than those with decompensated disease and may be eligible for interventions to prevent disease progression. Methods: A cloud-based software solution ("the Liver Toolkit") was developed to access primary care practice software to identify patients at risk of ACLD. Clinical history and laboratory results were extracted to calculate aspartate aminotransferase-to-platelet ratio index and fibrosis 4 scores. Patients identified were recalled for assessment, including Liver Stiffness Measurement (LSM) via transient elastography. Those with an existing diagnosis of cirrhosis were excluded. Results: Existing laboratory results of more than 32,000 adults across nine general practices were assessed to identify 703 patients at increased risk of ACLD (2.2% of the cohort). One hundred seventy-nine patients (26%) were successfully recalled, and 23/179 (13%) were identified to have ACLD (LSM >= 10.0 kPa) (10% found at indeterminate risk [LSM 8.0-9.9 kPa] and 77% low risk of fibrosis [LSM <8.0 kPa]). In most cases, the diagnosis of liver disease was new, with the most common etiology being metabolic dysfunction-associated steatotic liver disease (n=20, 83%). Aspartate aminotransferase-to-platelet ratio index >= 1.0 and fibrosis 4 >= 3.25 had a positive predictive value for detecting ACLD of 19% and 24%, respectively. Patients who did not attend recall had markers of more severe disease with a higher median aspartate aminotransferase-to-platelet ratio index score (0.57 vs. 0.46, p=0.041). Conclusions: This novel information technology system successfully screened a large primary care cohort using existing laboratory results to identify patients at increased risk ACLD. More than 1 in 5 patients recalled were found to have liver disease requiring specialist follow-up.

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.

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.