BACKGROUND AND AIMS:Despite the critical importance of alcohol abstinence for patients with advanced liver disease, rates of returning to alcohol remain high and engagement with relapse prevention interventions is low. This study explores the potential barriers to relapse prevention in these patients. METHODS:Semi-structured interviews were conducted with patients who had alcohol-related cirrhosis or alcohol-associated hepatitis. Interviews took place during a hospital admission. The study methodology was informed by a constructivist grounded theory approach. RESULTS:Thirty-three participants were recruited from two sites. Participants had a mean age of 52 (range 30-60) and there were 10 female participants (30%). Most participants were actively drinking alcohol at time of admission (n = 26) and 16 participants were interviewed during their index admission with alcohol-related liver disease.A renewed understanding of the health risk posed by future alcohol made participants confident that they would not return to alcohol use and participants felt that the most important factor in relapse prevention was their own motivation and willpower. However, many rejected the identity label of 'alcoholic' and drew a distinction between themselves and 'bad drinkers'. These factors combined to create a barrier to relapse prevention therapies, since participants felt these were neither appropriate nor necessary for them. CONCLUSIONS:Enhanced self-efficacy, a belief in the importance of willpower, and a rejection of the alcoholic identity can together act to reduce engagement in relapse prevention in patients with advanced liver disease. Relapse prevention interventions should be reframed or redesigned to address these barriers.

Objective Liver transplant guidelines in the UK mandate a minimum of 3 months of abstinence for patients with alcohol-related liver disease. We assessed the outcomes of patients in our region during an admission to hospital with decompensated alcohol-related cirrhosis and in the subsequent, critical, 3 months.Design A network of clinicians and nurse specialists in East Anglia collected prospective data on admissions for this regional service evaluation. We included patients aged 18-70 years admitted with decompensated alcohol-related cirrhosis. Data were collected between 1 February 2023 and 30h April 2023, and outcomes analysed at 3 months post admission.Results Data were provided for 203 patients from 10 centres. Patients were 59% male with a median UK Model for End-stage Liver Disease (UKELD) score of 57 (range 43-67), 93% having a UKELD >= 49 and 47% having Child Pugh C disease. On admission, 72% of patients were consuming alcohol. Of those, 48% were reviewed by an Alcohol Care Team during their admission and 47% were engaged with alcohol services at 3 months. The relapse rate to alcohol at 3 months was 65%. At 3 months, 10% of the total cohort were transplanted or referred for transplant assessment. Mortality at 3 months was 24%. 47% of the surviving cohort were ineligible for transplant consideration due to ongoing alcohol use. 8% of the cohort had been lost to follow-up.Results Data were provided for 203 patients from 10 centres. Patients were 59% male with a median UK Model for End-stage Liver Disease (UKELD) score of 57 (range 43-67), 93% having a UKELD >= 49 and 47% having Child Pugh C disease. On admission, 72% of patients were consuming alcohol. Of those, 48% were reviewed by an Alcohol Care Team during their admission and 47% were engaged with alcohol services at 3 months. The relapse rate to alcohol at 3 months was 65%. At 3 months, 10% of the total cohort were transplanted or referred for transplant assessment. Mortality at 3 months was 24%. 47% of the surviving cohort were ineligible for transplant consideration due to ongoing alcohol use. 8% of the cohort had been lost to follow-up.Results Data were provided for 203 patients from 10 centres. Patients were 59% male with a median UK Model for End-stage Liver Disease (UKELD) score of 57 (range 43-67), 93% having a UKELD >= 49 and 47% having Child Pugh C disease. On admission, 72% of patients were consuming alcohol. Of those, 48% were reviewed by an Alcohol Care Team during their admission and 47% were engaged with alcohol services at 3 months. The relapse rate to alcohol at 3 months was 65%. At 3 months, 10% of the total cohort were transplanted or referred for transplant assessment. Mortality at 3 months was 24%. 47% of the surviving cohort were ineligible for transplant consideration due to ongoing alcohol use. 8% of the cohort had been lost to follow-up.Conclusions In the critical 3 months following an admission to hospital with decompensated cirrhosis, patients experienced high levels of mortality, relapse to alcohol and drop out from follow-up.

Background. Alcohol-related liver disease (ArLD) is the most common indication for liver transplantation in Europe and the United States. Few studies have examined the characteristics of patients with ArLD formally assessed for liver transplants. Methods. We collected prospective data on every patient with ArLD formally assessed for liver transplantation in the United Kingdom during a 12-mo period. Results. Five hundred forty-nine patients with ArLD were assessed for liver transplantation. The median Model for End-Stage Liver Disease (MELD) score was 15 and the UK MELD score was 54. 24% were women. The median duration of abstinence was 12 mo. Listing outcomes were 59% listed, 4% deferred, and 37% not listed. The reasons for not listing were medical comorbidities (29%), too early for transplantation (20%), potential recoverability (18%), recent alcohol use (12%), and other (21%). Patients listed for transplant had a higher median MELD (16 versus 13; P < 0.001) and UK MELD scores (55 versus 53; P < 0.001), longer duration of abstinence (median 12 versus 10 mo; P = 0.026), and no differences in sex (P = 0.258), age distribution (P = 0.53), or deprivation deciles compared with those not listed. Comparing patients assessed for transplantation to national data on deaths from ArLD revealed a lower proportion of female patients (24% assessed versus 36% deaths; P < 0.001) and patients from areas of high deprivation (assessments: deaths, most deprived decile 1:20 versus least deprived decile 1:9). Conclusions. This study provides the first complete national profile of evaluations for liver transplantation for patients with ArLD. Women and patients from the most deprived deciles of the population may be relatively underrepresented.

OBJECTIVE:Preventing return to alcohol is of critical importance for patients with alcohol-related cirrhosis and/or alcohol-associated hepatitis. Acamprosate is a widely used treatment for alcohol use disorder (AUD). We assessed the impact of acamprosate prescription in patients with advanced liver disease on abstinence rates and clinical outcomes. METHODS:This was a retrospective case-control study. We reviewed data on all patients admitted to a large tertiary centre in the UK with alcohol-related cirrhosis and/or alcohol-associated hepatitis. We used propensity risk score matching to match patients prescribed acamprosate to controls. The primary outcome was repeat hospitalisation. RESULTS:There were 451 patients who met the inclusion criteria of whom 55 patients were started on acamprosate during their admission. Before matching there were significant differences between the cohorts. Patients who received acamprosate were younger (median age 51 vs 57, p<0.005), more likely to have a purely alcohol-related admission (53% vs 24%, p<0.001), and more likely to suffer from a comorbid psychiatric diagnosis (42% vs 20%, p<0.001). On average patients who were started on acamprosate consumed more alcohol (median 155 units/week vs 80 units/week, p<0.001), were less likely to have a partner (35% vs 54%, p 0.006) and more likely to be unemployed (67% vs 44%, p<0.001). After matching for factors with significant differences between groups, we generated a cohort of 53 patients prescribed acamprosate and 53 matched controls. At 1 year there was a significantly higher rate of readmission (85% vs 57%, p<0.001) in the acamprosate group. There were no statistically significant differences in abstinence rates or mortality at 1 year. CONCLUSION:Acamprosate prescription was associated with higher rates of readmission in patients with cirrhosis and/or alcohol-associated hepatitis. This may reflect a greater severity of AUD in those patients or might indicate the limited ability of acamprosate to alter the disease course in this population.

The rate of return to alcohol consumption after liver transplantation is challenging to ascertain. Patients may not be asked or tested consistently and may not reliably report alcohol consumption. Additionally, when patients do return to alcohol consumption the frequency of resultant harm is unclear. We retrospectively reviewed the electronic records of all patients who received liver transplantation at our centre from 2015–01-04 to 2023–03-08. All patients with alcohol recorded as a contributing factor leading to liver transplantation were included other than those receiving a concurrent intestinal graft. Those who underwent repeat transplantation were included once from the point of their first transplant. 901 patients were reviewed. 251 (28%) patients with an alcohol aetiology were included, 6 (2%) of whom underwent retransplantation during follow-up. 70% were male and median age was 57 years (IQR 51–61). Follow up was a median of 1135 days (IQR 449–1775). 132 (53%) had documented assessment as to whether they had returned to any quantity of alcohol. Of these, 38/132 (29%) had returned to alcohol consumption with a median time to recorded relapse of 1007 days (IQR 557–1527). The cumulative incidence of return to alcohol by 5 years post-transplant was approximately 25%. Of those who were known to have returned to drinking alcohol, 15 had a record of the number of units consumed with a median of 10 units/day (IQR 4–14). Among the 38 who returned to alcohol, 19 (50%) had disturbed liver chemistry ascribed to alcohol; 9 (24%) were hospitalised from complications of alcohol use (alcoholic hepatitis, pancreatitis, trauma whilst intoxicated, alcohol withdrawal syndrome); 1 (3%) died from causes related to alcohol at a little over 3 years post-transplant. These data demonstrate that a significant proportion of patients at our centre undergoing liver transplantation with alcohol considered to be of aetiological significance returned to some form of alcohol consumption post-transplant. This was apparent despite only a little over half having documented evidence of being asked about relapse and all signing agreeing to our standard listing agreement detailing a requirement for lifelong abstinence from alcohol. Despite this frequent return to alcohol consumption in some degree, rates of allograft dysfunction, hospitalisation for alcohol, and of death from complications of alcohol were relatively low.

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.

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.

P01 Table 12019 (n=363) 2020 (n=421) p value Male 62.8% 63.4% 0.91 Age (mean ± SD) 62 62 0.40 BMI 29 29 0.64 NAFLD cofactor 2.8% 6.4% NA Previous HCV cofactor 2.2% 2.6% 0.89 HCC 3.6% 1.9% 0.21 Alcoholichepatitis 6.3% 6.9% 0.87 Drinking within last 12 months 61.7% 58.8% 0.40 Drinking at time of clinic 35.8% 40.2% 0.30 Units/Week (mean) 69 67 0.99 Duration of abstinence (months) (mean) 28 29 UKELD > 49* 48% 52.7% 0.15 Telephone clinic 0.3% 78.1% <0.001 Ascites 9.9% 15.0% 0.03 Encephalopathy 1.1% 5.5% 0.002 Mortality at 1 year 5.8% 9.7% 0.03 Transplants 0.3% 1.4% NA ConclusionThis study highlights the impact of the COVID pandemic on mortality of patients with known alcohol related cirrhosis seen in the specialist outpatient clinic. Mortality increased despite insignificant changes in reported alcohol intake. Pre-pandemic mortality was below the expected 9% for patients with UKELD⩾49, challenging the use of UKELD⩾49 as an independent indication for transplant assessment in this cohort. Furthermore, significant levels of ongoing alcohol intake in these patients indicates additional alcohol support is clearly merited.

Background Alcohol-related liver disease (ArLD) accounts for the majority of liver-related death and is the most common indication for liver transplant in the UK1. There is no systematic data collection for patients who are being assessed for liver transplantation until the point of entry to the waiting list1. This study aimed to collect detailed information from patients during the assessment stage. Method Data were collected prospectively for all patients with a diagnosis of ArLD assessed for liver transplant at the seven UK liver transplant centres from 1st Aug 2020 to 31st July 2021. Data included: gender, age category, postcode (first half), indication for transplant, Model for End-Stage Liver Disease Score (MELD), United Kingdom Model for End-Stage Liver Disease Score (UKELD), co-factors for liver disease, duration of abstinence, listing decision and reasons for decline or deferral. We looked for any differences between patients listed for transplant and those not listed. Results 549 patients were included (table 1). Median UKELD was 54 (range 41–76) and median MELD was 15 (range 4–39). 134 patients (24%) were female. Using postcode data a map was produced demonstrating approximate locations of included patients (Image 1). Median duration of abstinence was 12 months (range 0–240), with 14% of assessments having ≤6 months abstinence. 326 (59%) patients were listed for transplantation, with 202 (37%) not listed, and 21 (4%) deferred. Indications for transplant assessment were UKELD≥49 (90%), ascites (31%), hepatic encephalopathy (18%), hepatocellular carcinoma (16%) and other (11%) with most patients having multiple indications. The most common co-factor was non-alcoholic steatohepatitis (n = 58) with hepatitis C virus infection second most common (n = 23). Most common reasons for not listing were: medical co-morbidities (30%), too early to need transplant (20%), potential recoverability (18%), active or recent alcohol use (12%), concern about return to harmful drinking (8%) and surgical risk (5%) (figure 1). Comparing patients listed for transplant with those not listed we noted higher UKELD (p < 0.001) and MELD (p < 0.001). Patients with ascites were less likely to be listed than those without (49.7% vs 66.8% p < 0.001). There were no significant differences in listing rates based on age, gender, short (< 6 months) vs long (>6 months) period of abstinence, or on any other parameters. Conclusion This study provides for the first time a profile of all patients with ArLD assessed for liver transplantation over a 12-month period in the UK. Reference NHS Blood and Transplant. Annual Report on Liver Transplantation. Report for 2020/21. Available: https://nhsbtdbe.blob.core.windows.net/umbraco-assets-corp/24593/nhsbt-liver-transplant-report-2021-final.pdf

Background Post-operative delirium is an important, yet under-researched complication of surgery. Patients undergoing urological surgery may be at especially high risk of POD, as they are often older, and interventions can be associated with conditions that trigger delirium. The main aim of this systematic review was to evaluate the available evidence for risk factors in this patient group. Methods Five databases were searched (MEDLINE, Web of Science, EMBASE, CINAHL and PsychInfo) between January 1987 and June 2019. The Newcastle–Ottawa Scale was used to assess for risk of bias. Pooled odds ratio or mean difference (MD) for individual risk factors were estimated using the Mantel–Haenzel and inverse variance methods. Results Seven articles met the inclusion criteria, giving a total population of 1937. The incidence of POD ranged from 5 to 29%. Three studies were deemed low risk of bias and four at a high risk of bias. Nine risk factors were suitable for meta-analysis, with age (MD 4.314 95% CI 1.597, 7.032 p = 0.002) and the clock drawing test (MD − 2.443 95% CI − 3.029, − 1.857 p < 0.001) having a statistically significant association with POD in pooled analyses. Conclusion Delirium is common in urological patients. This review has identified a lack of studies in this surgical population, with wide heterogeneity and high risk of bias. It also highlights a number of potential risk factors for post-operative delirium, of which some are modifiable. However, the strength of evidence is weak at present and so future research should focus on assessing comparable risk factors in this patient group in order to inform future clinical practice. Review registration The review protocol was prospectively registered with the PROSPERO database (reference CRD42017054613)

Introduction Patients referred under the 2-week wait (2WW) pathway for gastrointestinal cancer with iron deficiency anaemia (IDA) are investigated in our centre with colonoscopy, upper GI endoscopy and CT scanning; it is necessary to justify these investigations given the burden they place upon radiology and endoscopy services. Our aim was to examine the predictive role of ferritin in such referrals and to assess whether this might be used to better streamline investigations. Methods Referrals to the upper and lower GI cancer pathway over a period of one year were screened for referrals made exclusively for IDA. Data was collected on ferritin level, age, gender, cancer detection and modality of cancer detection. Low ferritin was defined as <15 µg/L. Categorical variables were compared using a chi-squared test. Results 3669 referrals to the upper and lower GI cancer pathway between May 2017 and May 2018 were screened for inclusion. 199 patients were referred exclusively for IDA of which 35 (17.5%) were found to have a malignancy. This compares to a local colorectal cancer detection rate of 5.0% for all referrals to the lower GI pathway. 119 patients (59.8%) had a low ferritin. There was no statistically significant difference between rate of cancer detection in the low and normal ferritin groups (16.8% vs 20% p=0.572). These cancers included several non-GI malignancies in both low ferritin and normal ferritin groups (5/20 vs 8/15, p=0.157) (See table 1). Males were more likely to have a cancer detected than females (26.1% vs 10.3%, p= 0.005). CT scanning missed the malignancy 6 cases of colorectal cancer subsequently detected on colonoscopy. Only 2 cancers were detected using upper GI endoscopy and both of these had been visible on CT scanning. Conclusions This study demonstrated a high rate of cancer detection for anaemia referrals but there was no correlation between ferritin level and detection of cancer. Ferritin may not be a helpful marker in screening anaemia referrals. These results support our current practice of investigations however future studies could seek to validate the role of upper GI endoscopy in these referrals.

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.

Systematic review and meta-analysis of risk factors for post-operative delirium among older patients

Postoperative delirium (POD) is common after surgery. As age is a known risk factor, the increased ageing of the population undergoing surgery emphasizes the importance of the subject. Knowledge of other potential risk factors in older patients with surgical gastrointestinal diseases is lacking. The aim here was to collate and synthesize the published literature on risk factors for delirium in this group.