alcohol-related liver disease and transplants

A Lancet article published in May 2020 [1] suggests that more research needs to be done to establish whether some patients with alcohol-related liver disease are suitable candidates for a liver transplant even if they haven't completed the six month period of abstinence that is normally required. Many transplant programmes already weigh up the severity of the disease against the period of abstinence, so that a patient at imminent risk of dying might not need to have been alcohol-free for at least six months in order to receive a transplant. The article acknowledges that more needs to be done to support these patients post-transplantation if they are to benefit from a transplant long-term, but at a time of dwindling resources, is this likely to be forthcoming? Currently, the NHS criteria for offering a liver transplant [2] are as follows:

• That expected lifespan would be shorter than normal without it, or quality of life so poor as to be intolerable.
• That there is at least a 50% chance of surviving for at least five years after the transplant with an acceptable quality of life.

The '50% chance of five-year survival' criteria might exclude some patients with alcohol use disorder who have not been abstinent for at least six months. But with fewer livers available for transplantation than there are people requiring them, is it inevitable that some patients with liver disease not resulting from lifestyle choices might not be able to receive a liver in time?

1. bit.ly/livertransplants
2. bit.ly/NHScriteria

HIV: the other global pandemic

The number of people estimated to have been infected with COVID-19 worldwide is around the 55 million mark. Of those, nearly 36 million have recovered and just over 1.3 million people died (as of 18 November 2020). [1] With the attention of governments and health organisations and professionals focussed on containing COVID, another more serious global pandemic (in terms of the number of deaths and people infected) is being sidelined. This other global pandemic has been around for much longer and is claiming the lives of around 770,000 people per year, with 1.7 million people newly infected annually and 38 million men, women and children throughout the world living with this viral disease. [2] As Christians, we have been wrongly accused (for the most part) of believing that HIV, like liver cirrhosis, is a lifestyle disease that perhaps doesn't deserve as much compassion as a virus that infects people indiscriminately. But of course HIV infects women and children as well as the communities with which it is most associated. Although developed countries have made some progress with containing the disease, worldwide there is a failure to meet the health challenges posed by the virus. Even in the UK, there are an estimated 7,500 undiagnosed cases and up to 15,600 people carrying the virus and capable of transmitting it to others. Because of this, an HIV commission has been established in the UK with the ambitious aim of eliminating transmission of the virus by 2030. This would ideally involve universal testing and reducing stigma, but the likelihood is that the high cost to government of navigating the COVID crisis will make this a pipe dream. [3]

1. bit.ly/deathsbycovid
2. bit.ly/HIVaidsstats
3. bit.ly/HIVcommission

big three nations go it alone on COVID-19 vaccine development

International cooperation is vital in the race to develop an effective and safe vaccine against the COVID-19 virus before it destroys more lives and economies worldwide. So far, 64 developed nations and 92 low and middle-income countries have signed up to ACT (Access to COVID-19 Tools (ACT) Accelerator). [1] Initiated by organisations like the World Health Organization, the Global Fund, Unitaid and the World Bank, the aim is to support 'the development and equitable distribution of the tests, treatments and vaccines the world needs to reduce mortality and severe disease, restoring full societal and economic activity globally in the near term, and facilitating high-level control of COVID-19 disease in the medium term.' [1] However, China, Russia and the USA have elected to go it alone and refused to sign up to this collaborative effort or support the COVAX facility, which is the main repository of COVID-19 vaccines currently under investigation. [2] Each of these big players in the global economy is speeding through development of their own vaccines, sometimes without adequate testing, leaving less prosperous nations to foot the estimated $100 billion cost of developing a vaccine that will be available to all. WHO Director General Tedros Adhanom Ghebreyesus said, 'COVID-19 is an unprecedented global crisis that demands an unprecedented global response. Vaccine nationalism will only perpetuate the disease and prolong the global recovery. Working together through the COVAX Facility is not charity, it's in every country's own best interests to control the pandemic and accelerate the global economic recovery.' [3]

1. www.who.int/initiatives/act-accelerator
2. bit.ly/cvvaccine
3. bit.ly/vaccinenationalism

the impact of the anti-vax movement

The story of how Andrew Wakefield, a former British gastroenterologist, convinced a reputable medical journal like The Lancet to publish the results of spurious research linking the MMR vaccine to autism is well known. Even though The Lancet eventually published a retraction and the research has been thoroughly discredited, suspicion about the MMR vaccine in particular, and vaccines in general, continue to linger in the public mind, mainly because his relocation to America enabled him to find a willing audience for his false claims. [1] The result is that a year ago, the BMJ listed vaccine resistance as one of the top ten threats to global health which is already resulting in a resurgence of measles. [2] Not surprisingly, the impact has been particularly felt in the USA which in 2018 reported the highest number of cases in 25 years. Other European countries, including the UK, have lost their measles-free status. [3] The implications are particularly worrying at this time of pandemic. In the USA, a Gallup poll found that 35% of Americans would not accept a COVID-19 vaccine, even with FDA approval and population-wide availability. [4] Such is unlikely as, in the UK, any COVID vaccine is expected to be available to less than half the population. [5]

1. bit.ly/WakemaninAmerica
2. bit.ly/measlesresurgence
3. bit.ly/measlessurge
4. bit.ly/Americavaccine
5. bit.ly/vaccineavailability

medicine post-COVID

Telemedicine is not new, but the COVID crisis has given it fresh impetus as routine GP consultations have started — and sometimes ended — with a phone call. This has served to reduce the risks to both patients and healthcare professionals. But the prediction is that it will go further even after the crisis ends, and the focus of healthcare will shift from clinics and hospitals to homes and mobile devices like smartphones. There are advantages, of course, and these include reduced costs and a lower risk of cross-infection with dangerous pathogens that usually find a home in hospitals. It also potentially gives patients access to a broader range of specialists as geographical location will no longer be a barrier. [1] One GP writing in The Lancet suggests that the COVID emergency has served to reduce the amount of work that was motivated by political rather than clinical considerations. She writes 'There is perhaps an opportunity for us to capture, now. It might be one route to banish systemic tendencies to create overtreatment. The new normal could be never again allowing ourselves to agree to do work of more political than clinical importance. Divisions between departments seem to have been subsumed with common purpose, good will, and urgency. We have also been talking more with colleagues…. the priority is organising to give the best care we can to the people who need it most.' [2] We can only pray that these modest gains that are the silver lining to a global crisis persist when the crisis is over.

1. bit.ly/medicinebytech
2. bit.ly/GPquote

dementia in a time of austerity

We probably all know someone who has dementia, or someone who is caring for a relative with dementia. As medical advances and improved living conditions allow people to live longer, the incidence of dementia in all its manifestations is increasing. NHS England calls it 'one of the most important health and care issues facing the world'.[1] Already, around 850,000 people in the UK suffer from some form of dementia, and around 540,000 individuals are caring for them in England alone. One in three of us can expect to be caring for someone with this condition in our lifetimes — and it can be hugely challenging. NHS England had lofty goals, set in 2015 to be achieved by 2020. These included:

• being the best country in the world for dementia care and support for individuals with dementia, their carers and families to live; and
• the best place in the world to undertake research into dementia and other neurodegenerative diseases.

But that was before COVID and the enormous cost to the NHS and the economy of treating its victims and controlling its spread. When the dust settles and there is time to review progress, how will we find we have fared in caring for this vulnerable group as well as those who care for them? And how will we fare in the future when the disease already costs the country around £23 billion per year?

1. england.nhs.uk/mental-health/dementia

impact of period poverty

'Worldwide, on any given day, more than 800 million people will be menstruating. Although menstruating is a natural, normal process, millions of people around the world not only lack access to sanitary products and safe, hygienic spaces in which to use them, but also face deeply entrenched stigma and taboos associated with menstruation.' [1] This statement from an article in The Lancet sums up the multiple challenges that girls and women throughout the world face for several days out of every month. Where sanitary products are not freely available or affordable, menstruation can lead to absence from school and even infection from unhygienic alternatives. Most damaging of all, though, is the shame that girls are women are made to feel, and education is key to changing attitudes.

1. bit.ly/Lancetpp