Search

Obinna O Oleribe,1,2 Andrew W Taylor-Robinson,3,4 Okey C Nwanyanwu,5 Marsha Y Morgan,6 Simon D Taylor-Robinson7,8 1Office of the Director-General, Nigerian Institute for Medical Research, Lagos, Nigeria; 2Best Health Consult Limited Liability Company, Orange, CA, USA; 3College of Health Sciences, VinUniversity, Hanoi, Vietnam; 4Center for Global Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; 5Fast Forward Africa Limited Liability Company, Austin, TX, USA; 6Division of Medicine, Royal Free Campus, University College London, London, UK; 7Departments of Medicine & Public Health, Busitema University, Mbale, Uganda; 8Department of Surgery and Cancer, Imperial College London, St Mary’s Hospital Campus, London, UKCorrespondence: Simon D Taylor-Robinson, Email str338333@gmail.comAbstract: Four years after the first case of COVID-19, the world is still determining how best to prevent and control the long-term effects of SARS-CoV-2 infection. Non-pharmaceutical interventions (NPIs) were employed at the start of the pandemic as the only available options, prior to effective vaccines and antiviral agents. The World Health Organization recommended dual vaccination for 70% worldwide as the threshold for a return to “normal” community life. Immunization rates needed to increase in all global regions, irrespective of socioeconomic status, necessitating more equitable access. During the pandemic, wealthier countries hoarded vaccine supplies even when their citizens were immunized. This highlights the already enormous difficulties in healthcare provision faced by low-income sub-Saharan African countries, which remain at risk as industrialized nations have progressed to a post-pandemic era. Thus, in addition to redoubling vaccination efforts public health policymakers should consider ongoing and future use of NPIs. In this narrative account, we advocate that various NPI practices should not be shelved; rather, more research is needed to evaluate their impact in parallel with booster vaccination. This especially applies to so-called “long COVID”. Lessons learned from implementing best practices in resource-limited settings should be incorporated into preparedness guidelines for future infectious disease outbreaks.Keywords: sub-Saharan Africa, COVID-19, health inequality, non-pharmaceutical interventions, pandemic, vaccination

Simon D Taylor-Robinson,1,2 Marsha Y Morgan3 1Department of Surgery and Cancer, Imperial College London, London, UK; 2Department of Public Health, Busitema University and Mbale Clinical Research Institute, Mbale, Uganda; 3UCL Institute for Liver & Digestive Health, Division of Medicine, Royal Free Campus, University College London, London, UKCorrespondence: Simon D Taylor-Robinson, Department of Surgery and Cancer, St Mary’s Hospital Campus, Imperial College London, London, SW7 2AZ, United Kingdom, Email str338333@gmail.comAbstract: Although the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) primarily attacks the respiratory system, other organs, such as the liver, are also affected. In this overview, the effects of SARS-CoV-2 infection on the liver in both healthy people and in those with pre-existing liver disease are documented; the relationship between coronavirus disease 19 (COVID-19) vaccination and liver injury is examined; the mechanism of SARS-CoV-2-associated liver injury is explored; and the long-term consequences of COVID-19 are delineated, both in people with and without pre-existing liver disease.Keywords: COVID-19, COVID-19 liver disease, pathophysiology, SARS-CoV-2

Aigbe Gregory Ohihoin,1 Esther Ngozi Ohihoin,2 Ifeoma Ujomu,3 Airat Bakare,4 Oladeji Olanrewaju,2 Arinze Okafor,5 Mercy Ojetunde,1 Joy Boluwatife Ayoola,6 Oluwagbemiga Aina,7 Olusola Ajibaye,7 Simon D Taylor-Robinson8 1Clinical Sciences Department, Nigerian Institute of Medical Research (NIMR), Lagos, Nigeria; 2Research Unit, HICI Healthcare Limited, Lagos, Nigeria; 3University Hospitals of Leicester NHS Trust, Leicester, UK; 4College of Medicine, University of Lagos, Lagos, Nigeria; 5School of Life Sciences, University of Nottingham, Nottingham, UK; 6Central Research Laboratory, Nigerian Institute of Medical Research (NIMR), Lagos, Nigeria; 7Biochemistry and Nutrition Department, Nigerian Institute of Medical Research (NIMR), Lagos, Nigeria; 8Department of Surgery and Cancer, Imperial College London, London, UKCorrespondence: Aigbe Gregory Ohihoin, Clinical Sciences Department, Nigerian Institute of Medical Research (NIMR), Yaba, Lagos, Nigeria, Tel +2348035604697, Email aigbe.ohihoin@yahoo.comIntroduction: There are genuine concerns that long-term use of anti-retroviral drugs may be associated with reproductive complications in females. This study aimed to ascertain the effect of highly active anti-retroviral drugs on the ovarian reserve and reproductive potential of female Wistar rats and by extension to HIV-positive human females.Methods: A total of 25 female Wistar rats, weighing between 140g and 162g, were randomly allotted into non-intervention and intervention groups, receiving the anti-retroviral drugs, Efavirenz (EFV), Tenofovir Disoproxil Fumarate (TDF), Lamivudine (3TC), and a fixed-dose combination (FDC). The dosage was administered orally at 8 am daily for 4 weeks. Serum concentrations of anti-Mullerian hormone (AMH), follicle-stimulating hormone (FSH), luteinising hormone (LH), and estradiol were measured using standard biochemical techniques (ELISA). Follicular counts were made on fixed ovarian tissue from the sacrificed rats.Results: The mean AMH level for the control group and the EFV, TDF, 3TC, and FDC groups were 11.20, 6.75, 7.30, 8.27, and 6.60 pmol/L, respectively. The EFV and FDC groups had the lowest AMH, compared to the other groups, but there was no statistically significant difference in AMH across the groups. The mean count of antral follicles was significantly lower in the group that received EFV when compared to the other groups. The corpus luteal count was significantly higher in the control group than in the intervention groups.Conclusion: The study demonstrated a disruption in the reproductive hormones of female Wistar rats receiving anti-retroviral regimens containing EFV. Clinical studies are required to determine if these changes are seen in women receiving EFV-based treatment, as this may compromise reproductive function and predispose them to early menopause.Keywords: highly active anti-retroviral therapy, HAART, estradiol, anti-Mullerian hormone, human immunodeficiency virus, HIV, Nigeria

Sebastiana Atzori,1,2 Yasmin Pasha,1 James B Maurice,1,3 Simon D Taylor-Robinson,1 Louise Campbell,1,4 Adrian KP Lim1,5 1Department of Surgery and Cancer, Imperial College London, London, W1 1NY, UK; 2Department of Medicine, Sassari University Hospital, Sassari, 07100, Italy; 3UCL Institute for Liver and Digestive Health, Royal Free Hospital Campus, London, NW3 2QG, UK; 4Office of the Clinical Director, Tawazun Health, London, W1G 9QN, UK; 5Department of Imaging, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, W6 8RF, UKCorrespondence: Sebastiana Atzori, Department of Medicine, Sassari University Hospital, Via Enrico de Nicola, Sassari, 07100, Italy, Tel +39 3483359085, Email sebastiana_atzori@yahoo.itPurpose: The Controlled Attenuation Parameter (CAP score) is based on ultrasonic properties of retropropagated radiofrequency signals acquired by FibroscanTM (Echosens, Paris, France). Since ultrasound propagation is influenced by the presence of fat, CAP score was developed to quantify steatosis. The aim of this study was to delineate the accuracy of CAP in diagnosing hepatic steatosis, compared to the gold standard of liver biopsy.Patients and Methods: A total of 150 patients underwent same-day liver biopsy and measurement of hepatic steatosis with Fibroscan. Only examinations with 10 satisfactory measurements, and an inter-quartile range of less than 30% of the median liver stiffness values were included for data analysis. Histological staging was then correlated with median values and Spearman correlation calculated. P values of < 0.05 were considered statistically significant.Results: For diagnosis of hepatic steatosis (HS), CAP could predict the steatosis S2 with AUROC 0.815 (95% CI 0.741– 0.889), sensitivity (0.81) and specificity (0.73) when the optimal cut-off value was set at 288 dB/m. CAP detected histological grade S3 with AUROC 0.735 (95% CI 0.618– 0.851), sensitivity (0.71) and specificity (0.74), with a cut-off value of 330 dB/m. The AUROC for steatosis grade S1 was 0.741 (95% CI 0.650– 0.824), with a cut-off value of 263 dB/m with sensitivity 0.75 and specificity 0.70. Univariate analysis showed a correlation between CAP and diabetes (p 0.048).Conclusion: The performance of CAP to diagnose steatosis severity decreases as steatosis progresses. CAP is associated with diabetes but not other clinical factors and parameters of the metabolic syndrome.Keywords: fibroscan, steatosis, diabetes, ballooning, liver, fibrosis

Richard Syms,1 Simon D Taylor-Robinson,2 Guglielmo Trovato3 1Department of Electrical and Electronic Engineering, Imperial College London, London, UK; 2Department of Department of Surgery and Cancer at St Mary’s Hospital Campus, Imperial College London, London, UK; 3Faculty of Medicine, University of Catania, Catania, Sicily, ItalyCorrespondence: Simon D Taylor-Robinson, Department of Department of Surgery and Cancer, Imperial College London, St Mary’s Hospital Campus, London, W2 1NY, United Kingdom, Fax +442037249369, Email str338333@gmail.comAbstract: In the light of the COP27 Climate Change Conference, the concept of the circular economy has come to the fore with promotion of reuse and recycling of appliances and materials from electronics to clothes. This concept has not been widely taken up by healthcare systems. In this perspective article, we discuss the idea of the circular economy and how, by extension, the concept of “circular medicine” with optimised hospital and medical clinic waste recycling might be promoted in the context of better stewardship of resources in healthcare management.Keywords: circular economy, recycling, climate change

Christopher Pereira,1 Melanie Dani,1 Simon D Taylor-Robinson,2 Michael Fertleman1 1Cutrale Perioperative and Ageing Group, Department of Bioengineering, Imperial College London, London, UK; 2Department of Surgery and Cancer, Imperial College London, London, UKCorrespondence: Michael Fertleman, Cutrale Perioperative and Ageing Group, Department of Bioengineering, Imperial College London, London, UK, Tel +44 203 312 1077, Email m.fertleman@imperial.ac.ukAbstract: Following surgery, local cytokine-driven inflammation occurs, as part of the normal healing process. Cytokines in the central nervous system such as IL-6 and IL-8 may also be elevated. These cytokine changes likely contribute to neuroinflammation, but the complex mechanisms through which this occurs are incompletely understood. It may be that perioperative changes in pro- and anti-inflammatory cytokines have a role in the development of perioperative neurocognitive disorders (PND), such as post-operative delirium (POD). This review considers the current evidence regarding perioperative cytokine changes in the blood and cerebrospinal fluid (CSF), as well as considering the potential for cytokine-altering therapies to prevent and treat PND.Keywords: neuroinflammation, interleukins, central nervous system, perioperative neurocognitive disorders, blood-brain barrier, delirium

Umakant Dave,1 Simon D Taylor-Robinson2 1Department of Gastroenterology, Morriston Hospital, Swansea, Wales, SA6 6NL, UK; 2Department of Surgery and Cancer, Imperial College London, St Mary’s Hospital Campus, London, W2 1NY, UKCorrespondence: Simon D Taylor-Robinson, Department of Surgery and Cancer, Imperial College London, St Mary’s Hospital Campus, London, W2 1NY, UK, Tel +44 203 312 6254, Email str338333@gmail.comBackground: The practice of medicine is becoming increasingly more stressful, owing to technological development, increased expectations, infrastructure deficiencies, lack of resources and healthcare systems that are struggling to cope in the face of the COVID-19 pandemic around the world.Objective: In this article, we explore ways to reduce stress and improve resilience in the work place in order to enhance wellbeing in the medical profession, but also ultimately to protect patient safety.Synopsis: We discuss attention to regular mealtimes, protected sleep and daily exercise, together with consideration of mindfulness, gratefulness, self-compassion, self-care and being part of supportive networks as ways to reduce stress.Conclusion: While such techniques are not guaranteed to mitigate stress, psychology studies have shown that awareness of and attention to these components of a healthy lifestyle have the potential to reduce the adverse effects of increasing professional demands.Keywords: mindfulness, burnout, self-care, self-compassion, wellbeing, gratefulness

Simon D Taylor-Robinson,1 Guglielmo Trovato2 1Department of Surgery and Cancer, Imperial College London, London, UK; 2Department of Medicine, University of Catania, Catania, ItalyCorrespondence: Simon D Taylor-RobinsonDepartment of Surgery and Cancer, Imperial College London, South Wharf Street, London, W2 !NY, UKEmail Str338333@gmail.comAbstract: Cervical disc prolapse can be accompanied by severe pain, numbness, paraesthesiae and muscle weakness. The choice lies between a conservative approach with physiotherapy and pain modulating drugs, such as gabapentin, or a more active surgical approach, ranging from nerve decompression through vertebral foraminotomy through to cervical disc replacement. We relate the experience of a medically qualified patient in having disc prolapse at three cervical levels and what it was like to experience a lonely and difficult post-surgical recovery. Despite this, the patient would still choose active surgical decompression over a non-interventional approach. The reasons for this are discussed from the patient perspective, of which there is little directly in the medical literature.Keywords: chronic pain, neurosurgery, operative choices, cervical disc prolapse

Modupeoluwa Omotunde Soroye,1,2 Obinna O Oleribe,3 Simon D Taylor-Robinson4 1School of Public Health, University of Port Harcourt, Port Harcourt, Rivers State, Nigeria; 2Department of Preventive Dentistry, Faculty of Dentistry, University of Port Harcourt, Port Harcourt, Rivers State, Nigeria; 3Klamath Tribal Health & Family Services, Klamath Falls, OR, 97601, USA; 4Department of Surgery and Cancer, St Mary’s Hospital Campus, Imperial College London, London, W2 1NY, UKCorrespondence: Obinna O Oleribe Email obinna.oleribe@klm.portland.ihs.govAbstract: Nigeria’s mental health policy was formulated in 1991, but it did not make adequate provision for community-based psychiatric care. Since there are only seven government-owned psychiatry facilities in Nigeria and these are always overwhelmed, there is the need to overhaul the existing policy and emphasise the urgency of a shift from inpatient psychiatric mental healthcare towards a community-based multidisciplinary psychiatric healthcare system.Keywords: community psychiatry, Nigeria, depression, mental health

Neil Hawkes,1,2 Umakant Dave,3 Mesbah Rahman,2,3 Dafydd Richards,3 Mahmud Hasan,4,5 AHM Rowshon,4 Faruque Ahmed,4,6 M Masudur Rahman,6 MG Kibria,6 Phedra Dodds,7 Bethan Hawkes,8 Stuart Goddard,9 Imdadur Rahman,10 Peter Neville,1 Mark Feeney,11 Gareth Jenkins,12 Keith Lloyd,12 Krish Ragunath,13 Cathryn Edwards,2,11 Simon D Taylor-Robinson14 1Department of Gastroenterology, Cwm Taf Morgannwg University Health Board, Llantrisant, South Wales, UK; 2British Society of Gastroenterology Central Office, London, UK; 3Department of Gastroenterology, Swansea Bay University Health Board, Swansea, UK; 4Office of the Central Secretariat, Bangladesh Gastroenterology Society, Dhaka, Bangladesh; 5Office of Central Secretariat, Gastroliver Foundation, Dhaka, Bangladesh; 6Department of Gastroenterology, Sheikh Russel National Gastroliver Institute and Hospital, Dhaka, Bangladesh; 7Department of Endoscopy Nursing, Office of the JAG GRS Team, Powys Health Board, Brecon, UK; 8Office of the Wales Cancer Network Pathway, Welsh Cancer Network, Cardiff, UK; 9Welsh Institute of Minimal Access Therapy, Cardiff MediCentre, Welsh Institute for Minimal Access Therapy, Cardiff University, Cardiff, UK; 10Department of Gastroenterology, Southampton NHS Trust, Southampton, UK; 11Department of Gastroenterology and Liver Medicine, Torbay and South Devon NHS Foundation Trust, Devon, UK; 12Faculty of Health and Life Sciences, Medicine, Swansea University, Swansea, UK; 13Office of the Provost, Faculty of Health Sciences, Bentley Campus, Curtin Medical School, Curtin University, Perth, Western Australia, Australia; 14Department of Surgery and Cancer, Imperial College London, London, UKCorrespondence: Neil Hawkes Email neil.hawkes@wales.nhs.ukAbstract: The British Society of Gastroenterology (BSG) and the Bangladesh Gastroenterology Society (BGS) have collaborated on an endoscopy training programme, which has grown up over the past decade from a small scheme borne out of the ideas of consultant gastroenterologists in Swansea, South Wales (United Kingdom) to improve gastroenterology services in Bangladesh to become a formalised training programme with broad reach. In this article, we document the socioeconomic and historical problems that beset Bangladesh, the current training needs of doctors and how the BSG-BGS collaboration has made inroads into changing outcomes both for gastroenterologists in Bangladesh, but also for the populations they serve.Keywords: endoscopy training, Bangladesh, training programmes, gastroenterology training

Simon D Taylor-Robinson,1 Paulo A De Sousa Lopes,2 Jey Zdravkov,3 Rachel Harrison4 1Department of Surgery and Cancer, Imperial College London, London, UK; 2Department of Medicine, UAI Universidad Abierta Interamericana, Buenos Aires, Argentina; 3Dean Street Sexual Health Clinic, London, UK; 4Department of South East Asian Studies, School of Oriental and African Studies, London, UKCorrespondence: Simon D Taylor-Robinson Email Str338333@gmail.comAbstract: Bullying of whatever form should have no place in the Medical Profession. Reforms to junior doctor training and reduction in working hours have helped to control most of the individual bullying which may have existed in the past. However, the complexities of institutional bullying still exist. In the United Kingdom, centralised monitoring systems, such as Athena SWAN, are designed to reward academic and medical institutions for positive steps to introduce equality and mitigate bullying. However, the reality is that such processes may be conducted in healthcare or educational establishments that have little intention to address the problem thoroughly. We report the personal experience of both individual and institutional bullying in the medical career of a medically-qualified interviewee and reflect on ways to mitigate the problem. We also consider whether unconscious bias affects our relationships with patients. In a caring medical profession, there should be no room for intolerance, unconscious bias or bullying.Keywords: bullying, institutional bullying, personal bullying, unconscious bias

Emma Larsson,1 Mala Mawkin,1 Simon D Taylor-Robinson,1 Peter Harrington,2 Hastings Gondwe,3 Chris Watson,2,4 Joseph Gallagher,2 Mark Ledwidge,2 Griphin Baxter Chirambo,5,6 John O’Donoghue2,6,7 1Imperial College London, South Kensington, London SW7 2BX, UK; 2gHealth Research Group, University College Dublin, Dublin, Ireland; 3St John’s Hospital, Mzuzu, Malawi; 4Wellcome-Wolfson Institute for Experimental Medicine, Queens University Belfast, Belfast, Northern Ireland; 5Mzuzu University, Mzuzu, Malawi; 6Malawi eHealth Research Centre, University College Cork, Cork, Ireland; 7ASSERT Research Centre, University College Cork, Cork, IrelandCorrespondence: John O’DonoghueASSERT Research Centre, University College Cork, College Road, Cork T12 K8AF, IrelandTel +353 21 420 5616Email john.odonoghue@ucc.ieIntroduction: Safe, reliable, and effective healthcare systems are essential for all nations to ensure the health and wellbeing of their citizens. However, this is not always achievable with clinical therapies constantly evolving, resulting in a domino effect of structural, policy and training changes. For low- and middle-income countries (LMICs), implementing change is restricted. It is essential that innovative and realistic solutions are developed, so that effective change can be realised in LMICs.Materials and Methods: In this report of a global health conference held in July 2019, six perspectives are presented which aim to generate long-term positive change in Malaŵi. Perspective 1: Pneumonia – the BIOTOPE study (BIOmarkers TO diagnose PnEumonia) sought to determine the aetiology of pneumonia in children presenting in primary care. It assessed blood-based markers of bacterial infection as part of a rapid diagnostic approach to better utilise existing resources in Malaŵi. Perspective 2: Cardiovascular – the CARDIA project (CARdiac Dysfunction in Africa) was established to assess clinical and biochemical phenotypes of diabetic patients in Malaŵi. Perspective 3: Asthma – an observational study was conducted to implement a health system strengthening initiative for asthma. The use of locally adapted formularies and protocols with ongoing online mentoring through expert partnerships provided an opportunity to sustainably build capacity. Perspective 4: Sustainable Partnerships – establishing the Malaŵi electronic Health (eHealth) Research Centre, an international hub to develop education, research and innovation for long-term collaboration. Perspective 5: Part-Time PhD Studies – undertaking a part-time PhD within a LMIC provides logistic challenges, but also a number of opportunities for observational research. Perspective 6: Medical electives – an undergraduate elective allows real exposure to global health and facilitates life-long collaborations at an early stage in a medical career.Conclusion: Malaŵi is an under-doctored and resource-poor country. North-South partnerships in Malaŵi should be strengthened with particular emphasis on healthcare innovations, such as eHealth, which allow healthcare problems to be highlighted early while preventative measures are still possible.Keywords: eHealth, mHealth, non-communicable diseases, respiratory disease, cardiovascular disease, diabetes

Umakant Dave,1 Anjali Dave,2 Simon David Taylor-Robinson3 1Department of Gastroenterology, Morriston Hospital, Swansea, Wales SA6 6NL, UK; 2Department of Psychology, Birmingham University, Birmingham B15 2TT, UK; 3Department of Surgery and Cancer, Imperial College London, St Mary’s Hospital Campus, London W2 1NY, UKCorrespondence: Simon David Taylor-RobinsonDepartment of Surgery and Cancer, Imperial College London, St Mary’s Hospital Campus, London W2 1NY, UKTel +44 203 312 6254Email str338333@gmail.comBackground: Work-related stress is becoming an increasingly recognised occupational hazard that can have detrimental effects on the health of both patient and doctor. The practice of gastroenterology not only includes the demands of clinics and in-patient work faced by other medical specialities but also the additional burden of complex, and often high-risk, endoscopic interventions. Mindfulness, a secular form of meditation, can relieve stress, even if only practiced for a few minutes a day.Methods and Results: We present a personal perspective of the burnout experienced in stressful gastroenterology careers and the personal use of mindfulness in the daily routine to provide a source of calm when surrounded by many different pressures. We review some of the literature exploring the role of mindfulness in clinical practice with an emphasis on gastroenterology. While the practice of mindfulness is not designed to obviate immediacy and quick decisions in a rapidly changing clinical environment, it has been held widely useful to mitigate the stress involved in making those decisions.Conclusion: Practicing mindfulness, meditation and mindful living offers many advantages to gastroenterologists’ wellbeing as well improved patient care. We advocate its teaching to both gastroenterology trainees and consultants who are not familiar with the technique.Keywords: mindfulness, gastroenterology, stress, meditation, wellbeing

Simon D Taylor-Robinson,1 Kathy Dykes,2 Bethan Hawkes3 1Department of Surgery and Cancer, Imperial College London, St Mary’s Hospital Campus, London W2 1NY, UK; 2Department of Surgery, Morriston Hospital, Swansea, Wales SA6 6NL, UK; 3Wales Cancer Network, NHS Wales Health Collaborative, Cardiff, Wales CF15 9SS, UKCorrespondence: Simon D Taylor-Robinson Email str338333@gmail.comBackground: Doctors are often ill-prepared to become patients, despite knowing the technicalities of surgical procedures and the day-to-day workings of hospital life intimately. Surrendering the decision-making process to other healthcare professionals can be an unnerving process for many of those who are medically qualified.Aim: Although the sequelae of prostatectomy have often been written about, little is in the literature from medically qualified patients about their personal experiences of the procedure. We aimed to highlight areas where communication between medically qualified patients and their carers may be strengthened.Methods and Results: We present a personal perspective of the emotional issues surrounding a potential cancer diagnosis, the experience of having a prostatectomy and what the hospital encounters were like in reality with a viewpoint of informing the medical profession in providing better patient information when they ask “what will it be like?”. From this perspective, the critical role of the cancer specialist nurse is highlighted as the lynch pin in providing a continuing source of information to medically qualified patients and in not treating them as omniscient, simply because of a medical degree.Conclusion: Prostatectomy is a common procedure, but often questions about recovery after the procedure including impotence and incontinence are left unanswered in dealing with medically qualified colleagues when they are patients. Human behaviour is predictable, and medically qualified patients are just as apt to forget what is said to them as anyone else. However, the central role of the cancer specialist nurse as the bridge between the medical team and the patient should not be underestimated.Keywords: prostatectomy, specialist cancer nursing, psychological complications, physical complications

Obinna O Oleribe,1 Princess Osita-Oleribe,2 Babatunde L Salako,3 Temitope A Ishola,4 Michael Fertleman,5 Simon D Taylor-Robinson6 1Excellence and Friends Management Care Centre, Abuja, Nigeria; 2Centre for Family Health Initiative, Abuja, Nigeria; 3Nigeria Institute for Medical Research, Lagos, Nigeria; 4Department of Biochemistry, Covenant University, Ota, Nigeria; 5Cutrale Perioperative & Ageing Group, Department of Bioengineering, Imperial College London, London, UK; 6Department of Surgery and Cancer, Imperial College London, London, UKCorrespondence: Michael Fertleman Cutrale Perioperative & Ageing Group, Department of Bioengineering, 86 Wood Lane, London W12 0BZ, UKEmail m.fertleman@imperial.ac.ukAbstract: The 2020 Coronavirus pandemic has caused countless governmental and societal challenges around the world. Nigeria, Africa’s most populous nation, has been exposed in recent years to a series of epidemics including Ebola and Lassa fever. In this paper, we document our perception of the national response to COVID-19 in Nigeria. The response to the pandemic is with a healthcare system that has changed as a result of previous infectious disease outbreaks but in the context of scarce resources typical of many low-middle income countries. We make recommendations regarding what measures should be in place for future epidemics.Keywords: Nigeria, COVID-19, pandemic, prevention

Narong Khuntikeo,1 Attapol Titapun,1 Nittaya Chamadol,2 Wuttisak Boonphongsathien,2 Prakasit Sa-Ngiamwibool,3 Simon D Taylor-Robinson,4 Christopher A Wadsworth,4 Shuo Zhang,5 Evdokia M Kardoulaki,6 Richard RA Syms6 1Department. of Surgery, Faculty of Medicine, Khon Kaen University, Khon Kaen, 40002, Thailand; 2Department of Radiology, Faculty of Medicine, Khon Kaen University, Khon Kaen 40002, Thailand; 3Department of Pathology, Faculty of Medicine, Khon Kaen University, Khon Kaen 40002, Thailand; 4Division of Surgery and Cancer, Imperial College London, Paddington, London W2 1NY, UK; 5Philips Healthcare Germany, Health Systems, Clinical Science, Hamburg, Germany; 6EEE Department, Imperial College, London SW7 2AZ, UKCorrespondence: Simon D Taylor-RobinsonDivision of Surgery and Cancer, Imperial College London, Liver Unit, St. Mary’s Hospital, South Wharf Road, Paddington, London W2 1NY, UKTel +44 20 3312 6199Email s.taylor-robinson@imperial.ac.ukAim: Diagnostic imaging of early-stage cholangiocarcinoma is challenging. A previous in vitro study of fixed-tissue liver resection specimens investigated T2 mapping as a method of exploiting the locally increased signal-to-noise ratio (SNR) of duodenoscope coils for improved quantitative magnetic resonance imaging (MRI), despite their non-uniform sensitivity. This work applies similar methods to unfixed liver specimens using catheter-based receivers.Methods: Ex vivo intraductal MRI and T2 mapping were carried out at 3T on unfixed resection specimens obtained from cholangiocarcinoma patients immediately after surgery using a catheter coil based on a thin-film magneto-inductive waveguide, inserted directly into an intrahepatic duct.Results: Polypoid intraductal cholangiocarcinoma was imaged using fast spin-echo sequences. High-resolution T2 maps were extracted by fitting of data obtained at different echo times to mono-exponential models, and disease-induced changes were correlated with histopathology. An increase in T2 was found compared with fixed specimens and differences in T2 allowed the resolution of tumour tissue and malignant features such as polypoid morphology.Conclusion: Despite their limited field of view, useful data can be obtained using catheter coils, and T2 mapping offers an effective method of exploiting their local SNR advantage without the need for image correction.Keywords: Cholangiocarcinoma, T2 mapping, catheter coil

Narong Khuntikeo, 1 Attapol Titapun, 1 Nittaya Chamadol, 2 Wuttisak Boonphongsathien, 2 Prakasit Sa-Ngiamwibool, 3 Simon D Taylor-Robinson, 4 Christopher A Wadsworth, 4 Shuo Zhang, 5 Evdokia M Kardoulaki, 6 Ian R Young 6,†, Richard RA Syms 6 1Department of Surgery, Faculty of Medicine, Khon Kaen University, Khon Kaen 40002, Thailand; 2Department of Radiology, Faculty of Medicine, Khon Kaen University, Khon Kaen 40002, Thailand; 3Department of Pathology, Faculty of Medicine, Khon Kaen University, Khon Kaen 40002, Thailand; 4Division of Surgery and Cancer, Imperial College London, Liver Unit, St. Mary’s Hospital, London W2 1NY, UK; 5Philips Healthcare Germany, Health Systems, Clinical Science, Hamburg 22335, Germany; 6EEE Department, Imperial College, London SW7 2AZ, UK†Ian R Young passed away on September 27, 2019Correspondence: Simon D Taylor-RobinsonDivision of Surgery and Cancer, Imperial College London, Liver Unit, St. Mary’s Hospital, South Wharf Road, Paddington, London W2 1NY, UKTel +44 20 3312 6199Email s.taylor-robinson@imperial.ac.ukAim: Cholangiocarcinoma is endemic in southeast Asia, generally developing from liver fluke infestation. However, diagnostic imaging of early-stage disease is challenging. The aim of this work is to investigate relaxometry (specifically, T2 mapping) as a method of exploiting the higher signal-to-noise ratio (SNR) of internal coils for improved reception of magnetic resonance signals, despite their non-uniform sensitivity.Methods: Ex vivo T2 mapping was carried out at 3T on fixed resection specimens from Thai cholangiocarcinoma patients using an mGRASE sequence and an endoscope coil based on a thin-film magneto-inductive waveguide and designed ultimately for internal use.Results: Disease-induced changes including granulomatous inflammation, intraepithelial neoplasia and intraductal tumours were correlated with histopathology, and relaxation data were compared with mono- and bi-exponential models of T2 relaxation. An approximately 10-fold local advantage in SNR compared to a 16-element torso coil was demonstrated using the endoscope coil, and improved tissue differentiation was obtained without contrast agents.Conclusion: The performance advantage above follows directly from the inverse relation between the component of the standard deviation of T2 due to thermal noise and the SNR, and offers an effective method of exploiting the SNR advantage of internal coils. No correction is required, avoiding the need for tracking, relaxing constraints on coil and slice orientation and providing rapid visualization.Keywords: cholangiocarcinoma, T2 mapping, internal coil

Ozbil E Dumenci, Abellona MR U, Shahid A Khan, Elaine Holmes, Simon D Taylor-Robinson Imperial College London, London, UKCorrespondence: Abellona MR UImperial College London, 660 Sir Alexander Fleming Building, London SW7 2AZ, UKTel +44 7428 274231Email mei.u11@imperial.ac.ukPurpose: Hepatocellular carcinoma (HCC) is the fourth commonest cause of cancer-related mortality; it is associated with various genetic alterations, some involved in metabolic reprogramming. This study aimed to explore the potential metabolic impact of Carbamoyl Phosphate Synthase I (CPS1) and carbamoyl phosphate synthetase/aspartate transcarbamoylase/dihydroorotase (CAD) dysregulation through the reconstruction of a network that integrates information from the Kyoto Encyclopedia of Genes and Genomes (KEGG) database, Human Metabolome Database (HMDB) and Human Protein Atlas (HPA).Methods and results: Existing literature was used to determine the roles of CPS1 and CAD in HCC. CPS1 downregulation is thought to play a role in hepatocarcinogenesis through an increased glutamine availability for de novo pyrimidine biosynthesis, which CAD catalyzes the first three steps for. KEGG, HMDB and HPA were used to reconstruct a network of relevant pathways, demonstrating the relationships between genes and metabolites using the MetaboSignal package in R. The network was filtered to exclude any duplicates, and those greater than three steps away from CPS1 or CAD. Consequently, a network of 18 metabolites, 28 metabolic genes and 1 signaling gene was obtained, which indicated expression profiles and prognostic information of each gene in the network.Conclusion: Information from different databases was collated to form an informative network that integrated different “-omics” approaches, demonstrating the relationships between genetic and metabolic components of urea cycle and the de novo pyrimidine biosynthesis pathway. This study paves the way for further research by acting as a template to investigate the relationships between genes and metabolites, explore their potential roles in various diseases and aid the development of new screening and treatment methods through network reconstruction.Keywords: metabonomics, reprogramming, bioinformatics, liquid biopsy, hepatocytes

Obinna O Oleribe,1 Jenny Momoh,2 Benjamin SC Uzochukwu,3 Francisco Mbofana,4 Akin Adebiyi,5 Thomas Barbera,6 Roger Williams,7 Simon D Taylor-Robinson6 1Excellence and Friends Management Care Centre (EFMC), Abuja, Nigeria; 2Department of Epidemiology and Community Medicine, Federal University Lafia, Nasarawa State, Nigeria; 3Department of Community Medicine, College of Medicine, University of Nigeria, Enugu, Nigeria; 4National AIDS Commission, Maputo, Mozambique; 5University College Hospital, Ibadan, Nigeria; 6Liver Unit, Department of Surgery and Cancer, St Mary’s Campus, Imperial College London, London W2 1PG, UK; 7Institute of Hepatology, London SE5 9NT, UKCorrespondence: Obinna O OleribeExcellence and Friends Management Care Centre, P.O. Box 200 PSIN, Dutse, Abuja 901101, NigeriaEmail obinna.oleribe@expertmanagers.orgIntroduction: Healthcare systems in Africa suffer from neglect and underfunding, leading to severe challenges across the six World Health Organization (WHO) pillars of healthcare delivery. We conducted this study to identify the principal challenges in the health sector in Africa and their solutions for evidence-based decisions, policy development and program prioritization.Methods: The study was conducted as part of a recent African Epidemiological Association Meeting in Maputo, Mozambique with participants drawn from 11 African countries, Cuba, Portugal and the United Kingdom. Participants were divided into 10 groups, consisting of 7 to 10 persons each. Brainstorming approaches were used in a structured, modified nominal group process exercise to identify key challenges and strategies to mitigate healthcare service challenges in Africa. Identified challenges and solutions were prioritised by ranking 1–5, with 1 most important and 5 being least important.Results: The first three challenges identified were inadequate human resources (34.29%), inadequate budgetary allocation to health (30%) and poor leadership and management (8.45%). The leading solutions suggested included training and capacity building for health workers (29.69%), increase budgetary allocation to health (20.31%) and advocacy for political support and commitment (12.31%).Conclusion: The underdeveloped healthcare systems in Africa need radical solutions with innovative thought to break the current impasse in service delivery. For example, public-private initiatives should be sought, where multinational companies extracting resources from Africa might be encouraged to plough some of the profits back into healthcare for the communities providing the workforce for their commercial activities. Most problems and their solutions lie within human resources, budget allocation and management. These should be accorded the highest priority for better health outcomes.Keywords: Africa, healthcare management, human resources, health systems

Munirah Alsaleh,1 Thomas A Barbera,1 Helen L Reeves,2 Matthew E Cramp,3 Stephen Ryder,4,5 Hani Gabra,1,6 Kathryn Nash,7 Yi-Liang Shen,1,8 Elaine Holmes,1 Roger Williams,9 Simon D Taylor-Robinson11Division of Surgery and Cancer, Imperial College London, London; 2Northern Institute for Cancer Research, Medical School, University of Newcastle, Newcastle upon Tyne, UK; 3Liver Unit, Derriford Hospital, Plymouth, Devon , UK; 4Nottingham Digestive Diseases Centre, University of Nottingham, Nottingham, UK; 5NIHR Biomedical Research Unit, Nottingham University Hospitals NHS Trust, Queen’s Medical Centre, Nottingham, UK; 6Early Clinical Development, IMED Biotech Unit, AstraZeneca, Cambridge, UK; 7Liver Unit, Southampton General Hospital, Southampton, Hampshire, UK; 8Department of Radiation Oncology, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan; 9Institute of Hepatology, UKBackground: Outside South-East Asia, most cases of cholangiocarcinoma (CCA) have an obscure etiology. There is often diagnostic uncertainty. Metabolomics using ultraperformance liquid chromatography mass spectrometry (UPLC-MS) offers the portent to distinguish disease-specific metabolic signatures. We aimed to define such a urinary metabolic signature in a patient cohort with sporadic CCA and investigate whether there were characteristic differences from those in patients with hepatocellular carcinoma (HCC), metastatic secondary liver cancer, pancreatic cancer and ovarian cancer (OCA).Methods: Spot urine specimens were obtained from 211 subjects in seven participating centers across the UK. Samples were collected from healthy controls and from patients with benign hepatic disease (gallstone, biliary strictures, sphincter of Oddi dysfunction and viral hepatitis) and patients with malignant conditions (HCC, pancreatic cancer, OCA and metastatic cancer in the liver). The spectral metabolite profiles were generated using a UPLC-MS detector and data were analyzed using multivariate and univariate statistical analyses.Results: The greatest class differences were seen between the metabolic profiles of disease-free controls compared to individuals with CCA with altered acylcarnitine, bile acid and purine levels. Individuals with benign strictures showed comparable urine profiles to patients with malignant bile duct lesions. The metabolic signatures of patients with bile duct tumors were distinguishable from patients with hepatocellular and ovarian tumors, but no difference was observed between CCA cases and patients with pancreatic cancer or hepatic secondary metastases.Conclusion: CCA causes subtle but detectable changes in the urine metabolic profiles. The findings point toward potential applications of metabonomics in early tumor detection. However, it is key to utilize both global and targeted metabonomics in a larger cohort for in-depth characterization of the urine metabolome in hepato-pancreato-biliary disease.Keywords: cholangiocarcinoma, metabolomics, diagnostic biomarkers

Obinna Ositadimma Oleribe,1 Okey Nwanyanwu,2 Eric Yi-Liang Shen,3 Simon D Taylor-Robinson41Excellence and Friends Management Care Centre (EFMC), Abuja, Nigeria; 2Global Health Services Network, Farmington, MI, USA; 3Department of Radiation Oncology, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan 333, Taiwan; 4Faculty of Medicine, Imperial College London, London W2 1PG, UKAbstract: Public health programming has three main components – capacity development, service provision and documentation with monitoring. However, most funders and programmers now focus on just documentation and monitoring. In this communication, the authors extensively discuss the need for the full complement of public health programming and why it is important to restructure supportive site visits to make them both empowering and impactful to the health care workers resulting in higher quality of public health services and documentation with monitoring. The authors are of the view that following problem identification, comprehensive capacity development of field workers will engender quality service provision and appropriate documentation and monitoring.Keywords: programming, supervisory site visits (SSVs), capacity development

Munirah Alsaleh,1 Zoe Leftley,1 Thomas A Barbera,1 Paiboon Sithithaworn,2 Narong Khuntikeo,2 Watcharin Loilome,2 Puangrat Yongvanit,2 I Jane Cox,3 Nittaya Chamodol,2 Richard RA Syms,4 Ross H Andrews,1,2 Simon D Taylor-Robinson1 1Division of Surgery and Cancer, Imperial College London, London W2 INY, UK; 2Cholangiocarcinoma Research Centre, Faculty of Medicine, Khon Kaen University, Khon Kaen 40002, Thailand; 3Faculty of Life Sciences & Medicine, King’s College London, London SE5 9NT, UK; 4Department of Electrical and Electronic Engineering, Imperial College London, London SW7 2AZ, UK Abstract: Cholangiocarcinoma (CCA) is a tumor with increasing prevalence around the world. The prevalence of CCA is highest in East Asia and most significantly in the countries through which the Mekong River flows, owing to the presence of liver flukes, which are consumed in raw fish dishes. Outside Asia, the causes of bile duct cancers for the most part are unknown. In this review, we assess the current state of knowledge in both fluke-associated and sporadic CCA, from etiological, diagnostic, and treatment perspectives. Keywords: cholangiocarcinoma, etiology, diagnosis, treatment, bile ducts

Obinna Ositadimma Oleribe,1 Ede Enenche,1 Deborah Udofia,1 Ekei Ekom,1 Princess Ifunanya Osita-Oleribe,1 Jin Un Kim,2 Simon David Taylor-Robinson2 1Excellence and Friends Management Care Centre (EFMC), Abuja, Nigeria; 2Hepatology Unit, Imperial College London, London, UK Background: Mother-to-child transmission (MTCT) of HIV is one of the commonest avenues through which infants are infected with HIV. To achieve an HIV-free generation, MTCT of HIV should be eliminated. Nigeria began prevention of mother-to-child transmission (PMTCT) services 13 years ago, but it still contributes to over one-third of global MTCT burden. We set out to explore and define the effectiveness of PMTCT in selected sites in North Central Nigeria.Methods: We conducted a retrospective secondary data analysis at eight service delivery points in two states. One thousand four hundred and fifty-four mother–infant pair data sets from 2012 to 2016 were extracted and analyzed. Maternal/infant antiretroviral (ARV) services, early infant diagnosis (EID), and final outcomes were reviewed to examine the predictors of MTCT of HIV in these centers.Results: We retrieved 1,454 mother–infant pair data sets. While 89.5% (1,302) of positive pregnant women (PPW) and 92.2% (1,340) of HIV-exposed infants (HEIs) received ARV prophylaxis/ARV treatment (ART), 88.4% (1,285) infants were breastfed with 32.5% still receiving breast milk at the time of dry blood spot (DBS) collection. EID PCR positivity rate was 3.5% (range, 0.0%–11.1%). Facility of delivery (X2=24.99, P

Matthew Gowshall,1,2 Simon D Taylor-Robinson1 1Division of Digestive Health, Department of Surgery and Cancer, Imperial College London, London, UK; 2Barts and the London School of Medicine and Dentistry, London, UK Abstract: Non-communicable diseases (NCDs) are the leading cause of death globally, the majority of these being due to cardiovascular disease, cancer, chronic respiratory diseases, or diabetes. Mortality from many NCDs continues to increase worldwide, with a disproportionately larger impact in low-middle income countries (LMIs), where almost 75% of global deaths occur from these causes. As a low-income African country that consistently ranks amongst the world’s poorest nations, Malawi as a case study demonstrates how transition due to societal change and increasing urbanization is often accompanied by a rise in the rate of NCDs. Other factors apart from changing lifestyle factors can explain at least some of this increase, such as the complex relationship between communicable and NCD and growing environmental, occupational, and cultural pressures. Malawi and other LMIs are struggling to manage the increasing challenge of NCDs, in addition to an already high communicable disease burden. However, health care policy implementation, specific health promotion campaigns, and further epidemiological research may be key to attenuating this impending health crisis, both in Malawi and elsewhere. This review aims to examine the effects of the major NCDs in Malawi to help inform future public health care policy in the region. Keywords: cancer, chronic respiratory disease, cardiovascular disease, diabetes, non-communicable diseases, Malawi

Simon D Taylor-Robinson, 1 Paulo Alberto De Souza Lopes, 2 Jey Zdravkov, 3 Rachel Harrison 4 1Department of Surgery and Cancer, Imperial College London, London, UK; 2Department of Medicine, UAI Universidad Abierta Interamericana, Buenos Aires, Argentina; 3Dean Street Sexual Health Clinic, London, UK; 4Department of South East Asian Studies, School of Oriental and African Studies, London, UKCorrespondence: Simon D Taylor-Robinson Email Str338333@gmail.com We thank Sharma and her co-authors for their very insightful comments on our perspective on bullying in Medicine. 1,2 We completely agree with them that bullying has been an issue at all stages in the medical career pathway, including at an undergraduate level. 1 We agree also that to be fully comprehensive, discussion of the medical student experience should have been included, but our article went through several journals before it was accepted and the advice consistently given was to concentrate on the specific experience of our “reportee”. 2 View the original paper by Taylor-Robinson and colleagues A Letter to the Editor has been published for this article.

Jin Un Kim,1 Obinna Oleribe,2 Ramou Njie,3 Simon D Taylor-Robinson1 1Division of Digestive Health, Department of Surgery and Cancer, Imperial College London, London, UK; 2Excellence and Friends Management Care Centre, Abuja, Nigeria; 3MRC, Serekunda, The Gambia Abstract: The modern concept of globalization in health care and clinical research often carries a positive message for the “Global South” nations of Africa, South America and Southeast Asia. However, bioethical abuse of participants in clinical trials still exists in the Global South. Unethical studies directed by the “Global North”, formed by the medically advanced nations in North America, Western Europe and Japan, have been hugely concerning. The issue between the Global North and South is a well-recognized socioeconomic phenomenon of globalization. Medical exploitation has its roots in the socioeconomic interactions of a postcolonial world, and solutions to reducing exploitation require a deeper understanding of these societal models of globalization. We explore the fundamental causes of imbalance and suggest solutions. Reflecting on the globalization model, there must be an effort to empower the Global South nations to direct and govern their own health care systems efficiently on the basis of equality. Keywords: global health, bioethics, clinical trials, Africa, exploitation, imperialism

Caroline R Cartlidge,1 M R Abellona U,2 Alzhraa M A Alkhatib,2 Simon D Taylor-Robinson1 1Department of Surgery and Cancer, Liver Unit, Division of Digestive Health, 2Department of Surgery and Cancer, Division of Computational and Systems Medicine, Faculty of Medicine, Imperial College London, London, UK Abstract: Hepatocellular carcinoma (HCC) is the fifth most common malignancy, the third most common cause of cancer death, and the most common primary liver cancer. Overall, there is a need for more reliable biomarkers for HCC, as those currently available lack sensitivity and specificity. For example, the current gold-standard biomarker, serum alpha-fetoprotein, has a sensitivity of roughly only 70%. Cancer cells have different characteristic metabolic signatures in biofluids, compared to healthy cells; therefore, metabolite analysis in blood or urine should lead to the detection of suitable candidates for the detection of HCC. With the advent of metabonomics, this has increased the potential for new biomarker discovery. In this article, we look at approaches used to identify biomarkers of HCC using proton nuclear magnetic resonance (1H-NMR) spectroscopy of urine samples. The various multivariate statistical analysis techniques used are explained, and the process of biomarker identification is discussed, with a view to simplifying the knowledge base for the average clinician. Keywords: hepatocellular carcinoma, biomarkers, metabonomics, urine, proton nuclear magnetic resonance spectroscopy, 1H-NMR

Nicola A Cook,1 Jin Un Kim,1 Yasmin Pasha,1 Mary ME Crossey,1 Adrian J Schembri,2,3 Brian T Harel,2,4 Torben Kimhofer,5 Simon D Taylor-Robinson1 1Liver Unit, Division of Digestive Health, Department of Surgery and Cancer, Imperial College London, London, UK; 2Cogstate, Inc., New Haven, CT, USA; 3Department of Psychology, Royal Melbourne Institute of Technology University, Melbourne, VIC, Australia; 4Child Study Center, Yale University, New Haven, CT, USA; 5Section of Biomolecular Medicine, Division of Computational and Systems Medicine, Department of Surgery and Cancer, Imperial College London, London, UK Background: Psychometric testing is used to identify patients with cirrhosis who have developed hepatic encephalopathy (HE). Most batteries consist of a series of paper-and-pencil tests, which are cumbersome for most clinicians. A modern, easy-to-use, computer-based battery would be a helpful clinical tool, given that in its minimal form, HE has an impact on both patients’ quality of life and the ability to drive and operate machinery (with societal consequences).Aim: We compared the Cogstate™ computer battery testing with the Psychometric Hepatic Encephalopathy Score (PHES) tests, with a view to simplify the diagnosis.Methods: This was a prospective study of 27 patients with histologically proven cirrhosis. An analysis of psychometric testing was performed using accuracy of task performance and speed of completion as primary variables to create a correlation matrix. A stepwise linear regression analysis was performed with backward elimination, using analysis of variance.Results: Strong correlations were found between the international shopping list, international shopping list delayed recall of Cogstate and the PHES digit symbol test. The Shopping List Tasks were the only tasks that consistently had P values of

Helen Morement,1 Rachel Harrison,2 Simon D Taylor-Robinson3 1AMMF – The Cholangiocarcinoma Charity, Enterprise House, Stansted, Essex, 2Department of South East Asia, School of Oriental and African Studies, London, 3Division of Digestive Health, Department of Surgery and Cancer, Imperial College London, London, UK Background: The multidisciplinary team (MDT) meeting has become the hallmark for cancer care in the UK. While standardizing care through adherence to guidelines, the MDT process can make the decision-making process somewhat remote from the patient perspective. The Cholangiocarcinoma Charity (AMMF) is the UK’s only cholangiocarcinoma charity and is at the forefront of patient empowerment for those with this condition and for their families. It provides much needed support not only via personal contact but also through its website and on the social media platforms, Facebook and Twitter. Methods: AMMF conducted a survey of patient attitudes to and experience of the MDT process through a simple questionnaire posted on Facebook in 2014. We report the results of the responses received, which we believe are worthy of further thought. Findings: In the main, while treatment decisions are not queried, there is distress at the lack of involvement, the lack of representation, the lack of communication and at not knowing who to approach for answers to questions. Conclusion: This snapshot, although small, provides some insight to clinicians not to forget the constituency they serve, as communication is all important. Keywords: cholangiocarcinoma, multidisciplinary team meeting, management, patient perspectives

Thomas Hughes,1,* Thomas O’Connor,1,* Anchalee Techasen,2,3 Nisana Namwat,2,3 Watcharin Loilome,2,3 Ross H Andrews,2–4 Narong Khuntikeo,3,5 Puangrat Yongvanit,3,6 Paiboon Sithithaworn,3,7 Simon D Taylor-Robinson1 1Division of Digestive Health, Department of Surgery and Cancer, Imperial College London, London, UK; 2Department of Biochemistry, Faculty of Medicine, Liver Fluke and Cholangiocarcinoma Centre, 3Cholangiocarcinoma Screening and Care Program (CASCAP), Khon Kaen University, Khon Kaen, Thailand; 4Faculty of Medicine, St Mary’s Campus, Imperial College, London, UK; 5Department of Surgery, 6Department of Biochemistry, 7Department of Parasitology, Faculty of Medicine, Liver Fluke and Cholangiocarcinoma Centre, Khon Kaen University, Khon Kaen, Thailand *These authors contributed equally to this work Abstract: The prevalence of cholangiocarcinoma (CCA) in Southeast Asia is much higher than other areas of the world. Eating raw, fermented, or undercooked cyprinid fish, infected with the liver fluke, Opisthorchis viverrini sensu lato (sl), results in chronic biliary inflammation, periductal fibrosis, and increased cancer risk. There may be associated glomerulonephritis. The process of infection is difficult to disrupt because eating practices have proven extremely difficult to change, and the life cycle of the fluke cannot be broken due to high prevalence in canine and feline reservoir hosts. Fecal analysis and enzyme-linked immunosorbent assay tests can be used to diagnose opisthorchiasis. Diagnosis of CCA is complex, partly due to the lack of definitive imaging characteristics but also due to the difficulty of obtaining samples for cytology or histology. This cancer has proven to be resistant to common chemotherapy treatments and so the two avenues of treatment available are surgical resection and liver transplantation, both requiring early detection of the tumor for the best chances of success. Late presentation of symptoms reduces the chances of successful surgical intervention. While liver fluke infections can be treated with praziquantel, individuals will often become reinfected, and multiple reinfections can be more harmful than a singular, long-term infection. A key research on the detection and characterization of novel biomarkers in all parts of the carcinogenic pathway for early diagnosis is needed. Keywords: Opisthorchis viverrini, CCA, Thailand, Laos, treatment, parasite, carcinogen, public health, helminth

Nicholas J Burstow,1 Zameer Mohamed,1 Asmaa I Gomaa,2 Mark W Sonderup,3 Nicola A Cook,1 Imam Waked,2 C Wendy Spearman,3 Simon D Taylor-Robinson1 1Liver Unit, Department of Surgery and Cancer, Imperial College London, London, UK; 2National Liver Institute, Menoufiya University, Shbeen El Kom, Egypt; 3Division of Hepatology, Department of Medicine, Faculty of Health Sciences, University of Cape Town and Groote Schuur Hospital, Cape Town, Republic of South Africa Abstract: Chronic hepatitis C infection affects millions of people worldwide and confers significant morbidity and mortality. Effective treatment is needed to prevent disease progression and associated complications. Previous treatment options were limited to interferon and ribavirin (RBV) regimens, which gave low cure rates and were associated with unpleasant side effects. The era of direct-acting antiviral (DAA) therapies began with the development of first-generation NS3/4A protease inhibitors in 2011. They vastly improved outcomes for patients, particularly those with genotype 1 infection, the most prevalent genotype globally. Since then, a multitude of DAAs have been licensed for use, and outcomes for patients have improved further, with fewer side effects and cure rates approaching 100%. Recent regimens are interferon-free, and in many cases, RBV-free, and involve a combination of DAA agents. This review summarizes the treatment options currently available and discusses potential barriers that may delay the global eradication of hepatitis C. Keywords: hepatitis C, protease inhibitors, directly acting antivirals, interferon-free regimens, ribavirin-free regimens, hepatitis C eradication

Ahmed Elgharably,1,2 Asmaa I Gomaa,2 Mary ME Crossey,1,2 Peter J Norsworthy,1 Imam Waked,2 Simon D Taylor-Robinson1 1Division of Digestive Health, Department of Surgery and Cancer, St Mary’s Hospital, Imperial College London, London, UK; 2National Liver Institute, Menoufiya University, Shebeen El Kom, Egypt Abstract: Hepatitis C viral infection is endemic in Egypt with the highest prevalence rate in the world. It is widely accepted that the implementation of mass population antischistosomal treatment involving administration of tartar emetic injections (from 1950s to 1980s) led to widespread infection. What is less well known, however, is that these schemes were implemented by the Egyptian Ministry of Health on the advice of the World Health Organization. There has been a spectrum of treatments to target the public health disaster represented by the hepatitis C problem in Egypt: from the use of PEGylated interferon to the recent use of direct acting antiviral drugs. Some new treatments have shown >90% efficacy. However, cost is a key barrier to access these new medicines. This is coupled with a growing population, limited resources, and a lack of infection control practices which means Egypt still faces significant disease control issues today. Keywords: hepatitis C, Egypt, schistosomiasis

Vijay PB Grover, Joshua M Tognarelli, Nicolas Massie, Mary ME Crossey, Nicola A Cook, Simon D Taylor-Robinson Liver Unit, Division of Diabetes, Endocrinology and Metabolism, Department of Medicine, Imperial College London, London, UK Abstract: Hepatic encephalopathy is a common neuropsychiatric abnormality, which complicates the course of patients with liver disease. It was probably first described by Hippocrates over 2000 years ago, who said that "those whose madness arises from phlegm are quiet and neither shout nor make a disturbance, while those whose madness arises from bile shout, play tricks and will not keep still, but are always up to some mischief". He was presumably describing the differences between patients with pneumonia and acute liver failure. Despite the fact that the syndrome was probably first recognized thousands of years ago, the exact pathogenesis still remains unclear. Furthermore, a precise definition of the syndrome is lacking, as are definitive methods of diagnosing this condition. It is important as both patients with cirrhosis and the general population with whom they interact may be affected as a consequence. At a minimum, the individual may be affected by impaired quality of life, impaired ability to work, and slowed reaction times, which are relevant to the population at large if affected individuals operate heavy machinery or drive a car. Pathogenic mechanisms, diagnostic tools, and treatment options are discussed. Keywords: hepatic encephalopathy, cirrhosis, ammonia, pathology, treatment, rifaximin, lactulose

Background: A previous pilot study showed that early arrival time of a microbubble in a hepatic vein is a sensitive indicator of cirrhosis. Aim: To see if this index can [...]