Non-alcoholic fatty liver disease (NAFLD) is a globally prevalent health problem, associated in its more severe forms with increased liver-related and cardiovascular-related morbidity and mortality. We established a multidisciplinary metabolic hepatology clinic in 2014 and have analysed the clinical data to evaluate the effectiveness of this service.Patients with NAFLD (n=165) who had attended two or more appointments were included. Prespecified clinical data were collected prospectively at clinic appointments and analysed retrospectively. Interventions offered included lifestyle advice, signposting to weight loss services and pharmacological treatment of diabetes and cardiovascular risk factors.Median follow-up was 13 months (range: 2–34). 59% (n=97) of patients had type 2 diabetes mellitus (T2DM). 53% (n=87) underwent liver biopsy of whom 18% (n=16) had cirrhosis. Median alanine aminotransferase (ALT) reduced by 11 IU/L (p<0.0001), median weight reduced by 3.3 kg (p=0.0005). There were significant reductions in HbA1c, total cholesterol and liver stiffness. Specifically, in patients with T2DM, HbA1c decreased by 4 mmol/mol (p=0.01) with significant reductions in ALT, weight and total cholesterol. Relative cardiovascular risk assessed by the QRISK3 score reduced in the whole cohort and in those with T2DM. Health economic modelling suggested the clinic intervention among those patients with poorly controlled T2DM was cost-effective.In conclusion, a multidisciplinary approach to the management of patients with NAFLD in this observational cohort study was associated with improvements in liver-related and cardio-metabolic related health parameters and with evidence of cost-effectiveness in patients with poorly controlled T2DM.

The ongoing COVID-19 pandemic is unprecedented in the modern age both due to its scale and its disruption to daily life throughout the world. Widespread social isolation and restrictions in the age of modern communicative technology, coupled with some early successes for makers, have united the open-source community towards a common goal in a way not previously seen. Local hospitals and care facilities are turning to makers to print essential consumable parts, such as simple visors, while in the hardest hit areas, critical pieces of medical technology are being fabricated. While important and effective innovations are appearing almost daily, there are also some worrying trends towards hobbyists attempting manufacture of complex medical devices with little understanding of the clinical or scientific rationale behind their design. The nature of the open-source community, an area of intensive innovation, fluidity, and experimentation, jars with the exacting standards of medical device regulation. Here, we review the involvement of rapid prototyping and the open-source community in the key areas of personal protective equipment (PPE), diagnostics, critical care technology, and information acquisition and sharing, highlighting where makers and hackers have clashed with medical device regulations, and areas where the system has worked well to facilitate change. ARTICLE HISTORY

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liver and spleen stiffness in 3 patient groups. Group 1: HIV and NCPH, defined as the presence of portal hypertension manifestations in the absence of cirrhosis; Group 2: HIV and past ddI exposure (without known NCPH), Group 3: HIV and no history of liver disease. Groups were matched for age, HIV chronicity and antiretroviral treatment (including cumulative ddI exposure in Groups 1 and 2). Clinical and demographic information was collected. Differences in liver and spleen stiffness (in kPa) between groups were analysed using the Mann-Whiney U test Results 25 patients were recruited (Group 1: n=11, Group 2: n=5, Group 3: n=9). Patients were well matched for age, HIV chronicity and all had HIV RNA levels<20 copies/mL. Cumulative ddI exposure in Groups 1 and 2 was 56 and 53 months respectively (p=0.91). Median (IQR) ARFI liver and spleen stiffness in Group 1, 2 and 3 was 5.5 (4.8-9.8), 4.3 (4.0-5.3) and 4.8 (3.8-5.2) kPa (p=0.031) and 46.3 (29.5-143.2), 21.3 (14.6-26.8) and 18.3 (14.6-21.6) kPa (p=0.001) respectively. Liver and spleen stiffness were both significantly higher in NCPH vs ddI-exposed (p=0.019 and p=0.005) and ddI-unexposed controls (p=0.038 and p<0.001). Spleen stiffness was more effective than liver stiffness at predicting NCPH, AUROC 0.812 vs 0.948. Combining the two variables improved the diagnostic performance, AUROC 0.961. The optimal cut-off for predicting NCPH using splenic stiffness was 25.4 kPa, with sensitivity 91%, specificity 93%, PPV 91%, NPV 93%, positive likelihood ratio 12.73, negative likelihood ratio 0.10. Spleen and liver stiffness scores were strongly correlated (p=0.0004 95% CI 18, 59). Conclusions Elevated spleen stiffness is observed in HIV patients with NCPH and can be quantified easily using ARFI with high diagnostic accuracy. Novel strategies such as ARFI for longitudinal monitoring of patients with HIV and NCPH should be considered.

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