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What’s Involved In Becoming An HGV Driver?

  • 11 Jan, 2017
  • Charlotte Haye
  • HGV Training

There is one thing that every single HGV driver has in common. One thing that everyone must do before they are granted their HGV licence and allowed to drive HGV’s out in the world. They have all taken and passed their Driver CPC . Driver CPC stands for Certificate of Professional Competence and means you are able to be responsible for a heavy good vehicle. If you drive an HGV without holding a Driver CPC, you could face up to £1,000 in fines and even jail time. To keep your Driver CPC up to date, you must submit to medical examinations every 5 years and undertake 35 hours of periodic hgv training every 5 years. This is just one of the ways we ensure that everyone driving an HGV is safe and capable. But let’s rewind a bit. What’s involved in achieving this fundamental qualification and become an HGV driver?

Related Article: What’s the difference between a LGV and HGV licence?

What is The Driver CPC?

Under an EU directive, any professional bus, coach or lorry driver must hold a valid Driver CPC license in addition to their standard and vocational driving licenses. This directive is very specific and applies to all HGV’s, plus lorries over 3.5 tonnes and mini bussed with 9 seats or more. In order for any individual to obtain their Driver CPC, applicants must complete 4 separate tests and assessments to judge their practical and theoretical capabilities. Drivers who obtained their license before the 10 th of September 2009, however, don’t need to take this initial qualification, as they are deemed to hold ‘acquired rights’. But they will still be required to complete periodic training and medical checks every 5 years in order to keep it valid.

Part 1 – Theory

In broad strokes, there are 2 parts to the Driver CPC – theory and practical. Within each part, there are 2 sections and all 4 must be completed before the qualification will be given. The theory section of the test is broken down into 2 parts – multiple choice and hazard perception – much like the standard driving test. But instead of cars, the footage will be applicable to larger vehicles, manoeuvrability and safety. You will be asked to sit in front of a screen and asked to answer a series of questions in a set time, and your result is instantly available at the end. Each section can be done separately or at the same time, depending on your preferences.

   

Part 2 – Case Studies

For part 2 of the theory section, you will be asked to take the case study test. This is an interactive process that usually takes around 75 minutes and covers 7 key case studies. You will be asked to view each one and then answer a series of questions on each. In order to pass this section, you will need to score at least 40 out of 50. You are allowed to take a 15-minute practice session to warm up and get used to the program you’ll be using though.

Part 3 – Driving Ability

Now that you’ve had some time to warm up with the tests and get hours of practice in with an instructor, it’s time for the first practical part of your Driver CPC test. The driving ability test will feel a lot like your initial driving test. You will sit in an HGV with an examiner, who will give you directions to follow and manoeuvres to perform. This test is all about assessing your practical ability to drive and control an HGV safely.

Part 4 – Practical Demonstration

Finally, you will come to the practical demonstration, which is different to the driving ability test, despite sounding similar. This test is designed to assess your practical knowledge of vehicle safety and manual operation. During this test, you will need to show that you can keep your vehicle and its contents safe and secure before and during transit. You will be asked about the safe use of your vehicle and what checks need to be done before it should be driven. You will be asked to demonstrate many of these, including how to load and unload your vehicle safely, how to assess emergencies and risks and the procedure for checking for criminal acts and trafficking in your vehicle. This section of the test lasts around 30 minutes, and to pass you will need to score at least 80 out of the possible 100 points (so at least 15 out of 20 for each topic).

Once you have earned your Driver CPC, you can then increase your earning potential by taking other tests for different categories of vehicle. Each extra category will make you more attractive to employers and clients, especially if you are looking to specialise in a certain industry. For more information or to book your Driver CPC training, get in touch with us today

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what is case studies hgv

  • Driving and transport
  • HGV, bus and coach drivers

Become a qualified heavy goods vehicle (HGV) or bus driver

Returning to be an hgv or bus driver.

If you previously qualified, you do not have to do the full qualification process again to bring your Driver Certificate of Professional Competence ( CPC ) up to date.

Check and renew your licence

If you’re not sure whether your licence is still valid, you can check what vehicles you’re allowed to drive .

You need to renew your licence if it’s expired .

Bring your Driver CPC up to date

What you need to do depends on when you originally got your heavy goods vehicle ( HGV ) or bus licence.

Some employers offer help with the cost of training.

If you got an HGV licence before 10 September 2009 or a bus licence before 10 September 2008

You can either:

  • complete 35 hours of Driver CPC training by finding and taking training courses
  • take and pass the Driver CPC part 2 (case studies) and the Driver CPC part 4 (practical demonstration) tests

If you’ve already taken parts 2 and 4 of the Driver CPC tests, you cannot take them again. You must take 35 hours of training instead.

If you got an HGV licence on or after 10 September 2009 or a bus licence on or after 10 September 2008

You need to complete 35 hours of Driver CPC training by finding and taking training courses .

Any training you’ve done in the last 5 years counts towards the total. The training counts for 5 years from the date you took the course.

After you’ve completed your training or tests

Your new Driver CPC card will be sent to the address on your driving licence when you’ve completed your training or tests.

Check what you need to do once you’ve requalified .

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CPC Training

What is cpc training and do i need it people new to hgv driving often ask what is cpc this page aims to answer any questions about cpc you may have, such as what is cpc do i need cpc or what is a cpc card, what is cpc, the driver cpc (which stands for driver certificate of professional competence) is a qualification required by anyone wanting to drive an hgv, bus or coach, professionally., you must have driver cpc if you drive an hgv, lgv, coach or bus for a living. you must maintain your cpc by taking 35 hours of periodic training every 5 years..

It was brought in to improve driving standards and road safety. It ensures that the driver is up to date with all health, safety and legal requirements.

It is a legal requirement for most Category C or D licence holders, but there are some exceptions, which are outlined later.

New drivers who pass the initial qualification will obtain a DQC (Driver Qualification Card, otherwise known as a CPC Card). There are 2 types of Driver CPC – Initial Driver CPC, and Driver CPC Periodic training.

It is illegal to drive professionally without CPC, and you can be fined up £1000 for driving without it.

CPC Training Courses

Drivers CPC Initial Qualification If you are driving for personal use you will not have to complete the Initial CPC Qualification.

If you passed your car test before Jan 1997 and have ‘Grandfather’ rights for a C1 vehicle, you DON’T need to do this. If you passed your Category C1, C or C+E test before Sept 2009, you DON’T need to do this.

Everyone else MUST do this. If you are required to do the Initial Qualification and you FAIL to do it, you are DRIVING ILLEGALLY and can have your licence revoked / face fines or imprisonment.

Periodic CPC Training To be completed after the Initial Qualification and is the drivers’ responsibility to ensure it’s done.

Consists of 35 Hours classroom retraining every 5 years (7 hours per year). If you fail to complete your 35 hours at the end of the 5 year period, your licence will become INVALID until the hours are completed.

If you passed your Category C, C1 or C+E test before Sept 2009, you have until Sept 2014 to complete this requirement. All other drivers will have 5 years to complete this from the date of their Module 4 pass.

Looking for more information on CPC Training?

Fill in our form below to get more information from 3 leading hgv providers, what is initial cpc, initial driver cpc is required for newly qualified drivers, and non-compulsory for those with ‘acquired rights.’ initial driver cpc can only be done as your first dqc (driver qualification card)..

It is made up of 2 sections with tests, which must both be passed in order to obtain your CPC card.

If you’re new to HGV driving, you will go through a full training programme which is split into 4 parts. These are made up of Theory and Practical side of HGV Training and tests , and these both include initial CPC modules. If you are looking to drive professionally, you’ll need to complete all 4 sections.

If you’re looking to drive for personal reasons (ie horsebox driving) you should not need the CPC qualification, and will only need to complete parts 1 and 3. There are other exemptions, which are outlined below.

By completing all 4 sections, you will gain full Driver CPC at the same time as gaining your HGV driving licence.

The 4 sections are:

Driver CPC Theory 1. Module One – Theory test

This is made up of 2 parts:

  • Multiple choice: this has 100 questions and lasts around 2 hours. Current pass rate for this is around 85%.
  • Hazard perception: candidates are presented with a sequence of 19 videos, and each hazard noted is worth 5 points maximum. The pass mark is 67%.

2. Module Two – Case studies

This is an online test, which presents around 7 case studies that represent likely scenarios as an HGV driver. Each scenario has related multiple-choice questions.

The pass mark is 80% and the entire test lasts less than 2 hours.

Practical Tests 3. Module Three – Practical test

Practical test for Licence acquisition; as per a car practical test; this is to test your driving ability and includes practical road driving, off road driving, and vehicle safety questions.

It lasts approx. 90 minutes.

4. Module Four – Driver CPC Practical test

This is a practical test which involves the driver demonstrating and explain various operations, besides driving. For example:

  • emergency processes
  • loading correctly
  • vehicle safety check demonstration.

What is Periodic CPC?

Periodic cpc training is for professional, established hgv drivers. once you have obtained your initial driver cpc, you are required by law to maintain it by taking 35 hours periodic training, every 5 years..

It was introduced in 2008 as a legally required ‘Continual Professional Development’ and should reflect the type of work you as a professional HGV driver undertake, to ensure your skills and knowledge are current and up to date.

In order to maintain the DQC or CPC card, you’re required by law to complete 35 hours of Driver CPC Training over the course of 5 years.

This can be taken all together or broken up into single days.

Driver CPC Periodic Training includes varying aspects of commercial HGV driving and training modules must be approved by the governing body – JAUPT, plus the DVSA. Make sure any provider you use is JAUPT Approved.

Most providers should now offer Online CPC, meaning that you can keep your CPC updated from your own home. This has been very well received by the HGV driving community and feedback has been generally good – make sure that the provider you choose has good feedback for their online course offering.

Anyone can check the status of their Driver CPC Periodic Training at

When is my driver cpc due, existing hgv drivers who qualified before 2009 must complete their periodic training during a defined 5-year training cycle..

The current cycle started 2019 and is due to finishes on 9th September 2024.

HGV Drivers who completed their Initial CPC qualification after 10th September 2009 must maintain their training within 5 years, which start on the date of their initial qualification. 

It’s important to make time to schedule in your Driver CPC training over the five-year period – driving without valid CPC is an offence can result in a maximum fine of £1000 for the driver and operator.

Exemptions from Driver CPC

Do i need cpc is a question we hear a lot from hgv drivers. we have spoken about horsebox drivers being exempt when driving for personal use, but there are other reasons you may be exempt..

According to the Driver and Vehicle Standards Agency (DVLA), you will not need Driver CPC if you’re driving for the following reasons:

  • non-commercial carriage of passengers or goods
  • carrying material or equipment you use for your job, as long as driving is less than 30% of your rolling monthly work
  • driving for someone you work for, or your own agriculture, horticulture, forestry, farming or fisheries business, as long as driving is less than 30% of your rolling monthly work
  • driving within 62 miles (100 kilometres) of your base - but the vehicle cannot be carrying passengers or goods, and driving a lorry, bus or coach cannot be your main job
  • driving to or from pre-booked appointments at official vehicle testing centres
  • driving lessons for anyone who wants to get a driving licence or a Driver CPC
  • maintaining public order - and the vehicle is being used or controlled by a local authority
  • rescue missions or in states of emergency

You also do not need Driver CPC if the vehicle is:

  • being road tested for repair, maintenance or technical development purposes
  • either new or rebuilt and has not yet been taxed
  • being used or controlled by the armed forces, police, fire and rescue service, emergency ambulance service, prison service or people running a prison or young offender institution
  • limited to a top speed of 28mph

These examples from the DVLA are a guide to Driver CPC responsibilities, but ultimately only a court can decide on Driver CPC rules. We would always recommend you take legal advice if you are unsure on any aspects of whether you need Driver CPC.

The cost of the Period CPC qualification is dependent on location and school, but we have found the national average to be approximately £350.

The CPC qualification is a legal requirement for anyone looking to drive commercially, in addition to their licence. It ensures that the driver is up to date with all health, safety and legal requirements and is taken in a classroom environment or online, with no test afterwards.

After you have taken your ‘Initial CPC’ qualification, you will need to complete your periodic CPC qualification every 5 years. This amounts to 7 years ‘Classroom’ or ‘remote classroom’ training every year, or 35 hours training in total, over 5 years.

It is the driver’s responsibility to ensure it is done and your licence will be invalid until these hours are done.

Since Covid social distancing measures were introduced, a lot of CPC training is now delivered remotely. This has been well received by HGV drivers, who have enjoyed taking the course from their own homes.

If you are just starting out, and looking to drive an HGV commercially, you will need to take your Initial CPC Qualification.

After you have taken your ‘Initial CPC’ qualification, you will need to complete your periodic CPC qualification every 5 years. This amounts to 7 years ‘Classroom’ or ‘remote classroom’ training every year, or 35 hours training in total, over 5 years. Some exemptions apply:

  • If you passed your car test before Jan 1997, you will have ‘Grandfather rights’ and do not need a CPC qualification to drive a Class 1 vehicle.
  • If you passed a Cat C1, Cat C or C+E test before Sept 2009, you also will not need to take the CPC qualification to drive.
  • If you are driving for personal use, such as driving a horsebox, you do not need a CPC qualification.
  • The gov.uk website outlines all situations where you may be exempt

You’ll get your DCPC (Driver Certificate of Professional Competence) when you have completed your training. You have to carry this card with you while HGV driving professionally, and you have to replace your card if it is stolen or lost. You can be fined up to £1000, if you drive professionally without Driver CPC.

Make sure you update your address with the DVLA if you move to a new house, as new / replacement cards will be sent to the address they have on record.

You can still drive professionally if you’re waiting for your new CPC card to arrive after you’ve completed your periodic training.

After you have taken your ‘Initial CPC’ qualification, most professional drivers will need to complete their periodic CPC every 5 years.

Some exemptions for CPC apply, so make sure you check your circumstances with your training provider before booking. Some exemptions include

  • If you are carrying material or equipment you need for your work, so long as driving is no greater than “30% of your rolling monthly working time.”

If you are driving for personal use (“non-commercial carriage of passengers or goods”) such as driving a horsebox, you will not need a CPC qualification.

After you have taken your ‘Initial CPC’ qualification, you will need to complete your periodic CPC. This amounts to 7 years training every year, or 35 hours training in total, over 5 years.

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HGV

Everything You Need To Know ABOUT THE LGV TEST

The HGVT Training Centre has been in the business of training commercial drivers for decades. Over the years, we have noticed something curious among the vast majority of drivers who come to us for training: they assume there is a single LGV test that, if passed, sets them up for life. Nothing could be further from the truth. While obtaining an LGV licence is not particularly complicated or time-consuming, there is no single test that will qualify a driver for his/her entire career. There are actually four tests needed to obtain a licence, followed by additional training and testing every few years.

lgv-test

To be clear, most people are referring to the final practical skills exam when talking about the LGV test. But even that exam has changed within the last few years. We are now under an entirely new system thanks to the implementation of Driver CPC requirements in 2009.

If this sounds too confusing, no worries. We will explain the testing process thoroughly in this guide. By the time you finish reading, you will know everything you need to know in order to determine whether or not you have what it takes to train for the myriad of tests required to be an LGV driver.

The Comprehensive CPC Programme

We used a training system, prior to the implementation of Driver CPC, intended to prepare drivers for two basic tests: the LGV theory test and the final practical skills test. Both tests had two parts that drivers had to pass in order to obtain an LGV licence. The new system has expanded upon the old by requiring additional testing.

According to the DVLA, the current CPC system involves a four-stage testing process as follows:

  • Stage 1: Theory – The first stage in the testing regimen contains the LGV theory test. This test is divided into two parts: multiple-choice and hazard perception. We will explain the details of both parts later on in this guide.
  • Stage 2: Case Studies – The second stage of testing is that which actually qualifies a driver under CPC regulations. It involves various case studies based on real-world experiences the LGV driver will be exposed to during his/her career. The 75-minute test works through seven case studies, each with 6 to 8 multiple-choice questions attached.
  • Stage 3: Driving Ability – Stage 3 of the testing regimen requires candidates to demonstrate their driving abilities using a full-size vehicle. We will explain in more detail later in this guide.
  • Stage 4: Practical Demonstration – The final stage of testing is known as a practical demonstration. It requires candidates to demonstrate a basic understanding of common tasks that are legally required of the LGV driver. We will later explain this in more detail as well.

As you can see, the LGV test is more than just a simple written exam conducted upon the completion of training. It involves multiple exams spread out across the entire training process. The good news is that most drivers can complete both training and the testing regimen in a matter of weeks. You are not required to take a months-long training programme to become a licenced driver. If you can learn and retain the information in just a few weeks, then you can complete your training in that short amount of time.

The LGV Theory Test

In this section of the guide, we want to provide more detail about the LGV theory test . This test consists of two separate parts that can be taken on the same day or in multiple sessions. You cannot take this test until you have your LGV provisional entitlement in hand. To make things as efficient as possible, we recommend our students apply for their provisional entitlements and then spend the next 10 to 14 days preparing for the theory test. By the time the provisional entitlement arrives in the post, the student will be ready to sit the exam.

The two parts of the LGV theory test are as follows:

  • Multiple-Choice – Candidates are given 100 multiple-choice questions designed to test their knowledge of general road safety and some of the fundamentals of commercial driving. One must answer 85 of the questions correctly in order to pass this portion of the exam.
  • Hazard Perception – This portion of the test is designed to ensure candidates possess at least a fundamental understanding of hazard perception and avoidance. It involves a series of 19 videos and 100 additional multiple-choice questions. Candidates answer questions after watching the videos. A passing grade is 67.

Any driver who decides to take the two portions of the theory test separately must do so, and earn a passing grade on both, within a two-year time frame. Doing so will result in the theory certificate being awarded. This certificate is necessary for undergoing practical skills training.

The Final Practical Skills Test

The LGV test most drivers are familiar with is the final practical skills test that one must undergo to obtain a commercial driving licence. As with the theory test, the practical skills test is divided into two parts. There is one key difference though: both parts of the practical skills test must be taken during the same session. They cannot be divided into multiple sessions as the theory test can.

The two parts of the practical skills test are as follows:

  • Driving Ability – Candidates will be tested on their ability to safely handle large commercial vehicles. The examiner takes the driver out on the road to test his or her skills in traffic, followed by a second session on a closed course where the driver demonstrates skills such as reversing and parking. The entire process takes about 90 minutes.
  • Practical Demonstration –  The second part of the test is the final test in the CPC regimen. Candidates are tested on five topics taken from the CPC syllabus. These topics cover things such as loading vehicles safely, conducting walkaround checks, preventing illegal immigrant trafficking, and assessing emergency situations. Candidates can score up to 20 points for each topic; a passing grade is 80 out of 100.

Candidates know right away whether or not they passed stages 3 and 4 of the LGV test. The examiner will render his or her decision as soon as the tests are completed. If a driver should fail, he or she can immediately book a new session of tests with one caveat: the tests cannot be re-taken for at least three business days.

We Train You to Pass

Now that you know everything you need to about the LGV test, we want to leave you with one final thought: the HGVT Training Centre will train you to pass the first time. You could say that is our number one priority. Unlike some of our competitors, we do not believe in wasting your time or money dealing with things that have nothing to do with the LGV test. Our focus is on training you in such a way that you are able to pass and get on to work as quickly as possible. By the way, our first-time pass rate across all of our training programmes is consistently above 90%.

We utilise a fast-paced and intense training approach that maximises learning, retention, and recall. The success of our training approach is demonstrated by the hundreds of drivers who pass through our classes and go on to be licenced every single month. Our training programme works; we have the numbers to prove it.

The process of training to be an LGV driver begins by contacting us and enrolling in our programme. We will provide all of the information and materials you need to get the ball rolling with your medical exam and LGV provisional entitlement. Then we will help you prepare for the theory portion of the LGV test. After that, you will move on to practical skills training and your eventual final test.

Just think, in a few short weeks you could be the proud holder of an LGV licence. That licence is your open-door to a long and productive career as a professional driver. Want to know more? Contact us right away.

Learn More About the LGV Driving Test

If you want to learn more about training to pass the UK LGV Driving test please select on from one of our articles below.

  • Top Quality Intensive Ambulance Driver Training Courses
  • The Best LGV Driver Training Schools across the UK
  • You’re Career as an LGV Driver Starts Here
  • Find the Best LGV Driver Training In Your Local Area
  • The Complete Guide to the LGV Licence
  • The Real Costs of Getting an LGV Licence
  • How Do I Get an LGV Provisional Licence?
  • Everything You Need To Know About the LGV Test
  • Facts and Top Tips on Passing the LGV Theory Test
  • Find the Best UK LGV Training Course Deals Online
  • How to Compare LGV Training Costs Like a Professional
  • What is LGV? Driving Licence Requirements Explained
  • Nationwide Low Cost Van Driver Training Schools
  • Are You Thinking About Van Driving For A Living?
  • Hiring A Van – Do You Need A Van Driving Licence?
  • The UK’s Best Intensive Van Driving Training Courses Revealed
  • Latest Van Licence Requirements for UK Drivers

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  • Heavy goods vehicle drivers
  • Pass your learner tests

Driver Certificate of Professional Competence (CPC): what it is

You must have a Driver CPC before you can drive a large or medium-sized goods vehicle for a living .

The Driver CPC test has 4 parts

Part 1 driver cpc theory test, resources - driver cpc theory test.

what is case studies hgv

Advice: Theory test preparation for heavy goods vehicle (HGV) drivers

what is case studies hgv

Practice theory test for heavy goods vehicle (HGV) drivers (1 of 2)

Part 2 driver cpc case studies.

  • 7 case studies (short stories based on situations)
  • 50 questions (6-8 multiple choice questions on each case study)
  • You have 1 hour 15 minutes
  • Questions may be single response, multiple response, audio or click on a hot-spot
  • Score at least 40 out of 50 to pass

Resources - Case studies

what is case studies hgv

Buy: Driver CPC The Official DVSA Guide for Professional Goods Vehicle Drivers

You do not need to pass the Driver CPC Part 1 theory test before you book Part 2.

If you're re-qualifying contact DVSA to book Parts 2 and 4.

Part 3 Driver CPC off-road exercises and on-road driving test

Part 3a: off-road exercises.

  • Lasts up to 30 minutes
  • Includes an ‘S’ shaped reverse into a bay
  • Show uncoupling and recoupling procedure (if taking a test with a trailer)

Part 3b: on-road driving test

  • Vehicle safety questions (see GOV.UK 'show me, tell me' links below)
  • At least 1 hour of on-road driving

Resources - CPC driving ability

what is case studies hgv

Buy: The Official DVSA Guide to Driving Goods Vehicles

Part 4 driver cpc practical demonstration test, the test covers 5 topics from the driver cpc syllabus.

  • Score at least 15 out of 20 for each topic
  • Achieve an overall score of at least 80 out of 100 .

You’re tested on being able to:

  • load the vehicle following safety rules and to keep it secure
  • stop trafficking in illegal immigrants
  • assess emergency situations
  • reduce physical risks to yourself or others
  • carry out walkaround vehicle safety checks

When you've passed all 4 parts

You’ll receive a Driver Certificate of Professional Competence (CPC) Card, which you must carry with you whenever you're driving an HGV.

Acquired rights

If you’re already a professional driver, you may have ‘acquired rights’ to Driver CPC (see GOV.UK link below) if you got your vocational licence (C, C1, C+E and C1+E) before 10 September 2009.

Having acquired rights does not exempt you from periodic training .

Renewing your Driver CPC card

All professional HGV drivers must complete at least 35 hours of Driver CPC training every 5 years.

The training covers various aspects of professional driving and is delivered by independent training bodies.

What’s covered in your training is up to you and your employer, but it might include :

  • fuel-efficient driving
  • defensive driving techniques
  • health and safety
  • drivers’ hours regulations
  • using tachographs.

One day’s training every year is ideal. It allows you to respond to each year’s priorities for your own continuing professional development and your employer’s changing business needs.

It can severely impact business planning and keep you off the road if too much of your training is left to the end of your card’s validity period. You also might not be able to find a trainer if demand is high.

It is illegal to drive professionally if you fail to complete your 35 hours of Driver CPC training by the deadline .

Top GOV.UK links

Driver CPC overview

Find training to become an HGV driver

Driver CPC Part 1 Theory Test

Driver CPC Part 2 Case Studies

Driver CPC Part 3a Off-road exercises

Driver CPC Part 3b On-road driving

  • Show me, tell me - vehicle safety questions without a trailer
  • Show me, tell me - vehicle safety questions with a trailer

Driver CPC Part 4 Practical Demonstration

Driver CPC Syllabus

'Acquired rights' to Driver CPC explained

The national standard for driving lorries

Other useful links

Industry Guide to Driver CPC (PDF 1.7MB)

Explore the topic

Related blog articles.

  • Study Material
  • Multiple-Choice Test
  • Hazard Perception
  • Practice Case Studies
  • Show me, Tell me
  • [email protected]

what is case studies hgv

Module 1a Theory Test

Module 1b hazard perception, module 2 case studies, d4 medicals.

Crown Copyright material reproduced under licence from the Driver and Vehicle Standards Agency which does not accept any responsibility for the accuracy of the reproduction.

LGV Module 1a Multiple-choice theory and Module 1b Hazard Perception Tests

LGV multiple-choice test and hazard perception test are two separate tests that you will need to complete before you’re able to start your practical training.

To pass the  module 1a multiple-choice theory,  you will need to score a minimum of 85%. There are 100 questions in total, and you’ll have 1 hour and 55 minutes to complete the test.

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  • World J Gastroenterol
  • v.14(30); 2008 Aug 14

Hepatitis G virus

Correspondence to: Vasiliy Ivanovich Reshetnyak, Scientific Research Institute of General Reanimatology, Petrovka str. 25-2, Moscow 107031, Russia. moc.oohay@kayntehser_v

Telephone: +7-495-6946505 Fax: +7-495-6946505

A number of new hepatitis viruses (G, TT, SEN) were discovered late in the past century. We review the data available in the literature and our own findings suggesting that the new hepatitis G virus (HGV), disclosed in the late 1990s, has been rather well studied. Analysis of many studies dealing with HGV mainly suggests the lymphotropicity of this virus. HGV or GBV-C has been ascertained to influence course and prognosis in the HIV-infected patient. Until now, the frequent presence of GBV-C in coinfections, hematological diseases, and biliary pathology gives no grounds to determine it as an “accidental tourist” that is of no significance. The similarity in properties of GBV-C and hepatitis C virus (HCV) offers the possibility of using HGV, and its induced experimental infection, as a model to study hepatitis C and to develop a hepatitis C vaccine.

HISTORY OF THE DISCOVERY OF HEPATITIS G VIRUS

GBV-C, or hepatitis G virus (HGV), was discovered by two independent groups of investigators in the study of cases of hepatitis non-A, non-B, non-E[ 1 , 2 ]. The discovery of a new viral agent associated with liver diseases has attracted considerable attention due to the fact that there are hepatitides of unknown etiology. This determined the urgency of investigations aimed at comprehensively studying the properties of the virus, its association with liver disease and infection rates in different countries of the world.

In 1966, the 34-year-old surgeon G. Barker (GB) fell ill with acute hepatitis of moderate enzymatic activity and three-week icteric period. Patient blood taken on icteric day 3 was used for intravenous inoculation of nonhuman primates (bare-faced marmosets, the Callithricidae family). Hepatitis was recorded in all animals when four monkey-to-monkey passages were performed. The findings suggested that the cause of this hepatitis was a yet unidentified viral agent that was named GBV.

Investigations of the GB agent recommenced 25 years later when new methods for qualitative viral analysis and recognition evolved. Serum taken in the acute stage of hepatitis from infected marmosets was found to contain two viral genomes: GBV-A and GBV-B belonging to closely-related viruses of the Flaviviridae family. Both viruses were able to replicate in the marmosets, but only GBV-B caused hepatitis. Attempts to detect GBV-A or GBV-B in human beings failed. A third virus GBV-C was soon isolated from patient material by means of specially designed primers to the conserved part of the NS3 region of the viruses GBV-A, GBV-B and HCV. GBV-C was assigned to the GBV group as it was slightly similar to GBV-B protein in immunoassays and largely identical to GBV-A in nucleotide sequence. GBV-C proved to be genetically related to another independent isolate that had been originally called HGV. They are virtually indistinguishable in the routine diagnosis by polymerase chain reaction (PCR). Since the signs of GBV-C/HGV became more commonly detected in patients with hepatitis and persons at risk for parenteral hepatitis, hepatitis G was considered to be an independent hepatotropic entity.

Experiments infecting chimpanzees with the GBV-C RNA-containing plasma taken from patients with chronic hepatitis G (CHG) yielded rather unexpected results. All the infected animals developed persistent and continuing (as long as 20 mo) viremia. However, no case showed a rise in the levels of indicator enzymes or detectable abnormal liver tissue changes in liver biopsy specimens taken weekly throughout the follow-up. Javan macaques were also observed to have viremia without signs of liver damage. By contrast, signs of hepatitis in the form of hyperenzymaemia and necrotic and inflammatory changes in the liver appeared by day 30 after inoculation of the marmosets that had received the same GBV-C-containing materials[ 3 ].

Further serological screening-based investigations have indicated that the GBV-C isolate is of widespread occurrence; however, there is no evidence for an association of viremia with the development of some known diseases, such as hepatitis[ 4 ].

TAXONOMY AND GENOTYPIC VARIETY OF GBV-C

GBV-C virus, like GBV-A, GBV-B, and HCV, belongs to the Flaviviridae family. Comparison of the genomes of GBV-C, GBV-A, GBV-B, and HGV has demonstrated that their RNA does not bear a more than 32% similarity, thereby supporting the hypothesis that these viruses are independent (Figure ​ (Figure1 1 )[ 5 ].

An external file that holds a picture, illustration, etc.
Object name is WJG-14-4725-g001.jpg

Affinity of HCV, GBV-C, GBV-A, and GBV-B (From Robertson BH, 2001)[ 5 ].

Five HGV genomes (the divergence between them was 12%) have been described[ 6 , 7 ]. Investigations dealing with the classification of GBV-C were conducted by measuring restriction fragment length polymorphisms. The isolates from West Africa are referred to as genotype 1 wherein 2 subtypes: 1a and 1b are identified. Genotypes 2a and 2b are more frequently detected in North America and Europe; genotypes 3, 4 and 5 are more common in Asia, South-Eastern Asia, and South Africa, respectively. Phylogenetic analysis of genomic nucleotide sequences of the 5' and NS5 regions made by Novikov in 2000[ 8 ] has established that the GBV-C isolate belonging to viral genotype 2 circulates in Russia, Kazakhstan, Kyrgyzstan, and Turkmenistan. Analysis of GBV-C 5'-untranslated region sequences revealed a new sixth genotype of virus in Indonesia[ 9 ]. In addition to genomic variability in different GBV-C isolates, some authors propose GBV-C genomic variability within one isolate, i.e. they suggest that there are quasispecies, thereby emphasizing their similarity with HCV[ 10 ]. But, the opponents of this theory argue that based on the absence of a hypervariable region in the E2 gene, the presence of quasispecies is impossible[ 11 , 12 ].

GBV-C STRUCTURE

The genome of the virus is represented by single-chain RNA with positive polarity[ 13 ]. The GBV-C genome is similar to hepatitis C virus (HCV) RNA in its organization, i.e. the structural genes are located at the genomic 5' region and non-structural genes are at the 3' end (Figure ​ (Figure2 2 )[ 14 ]. The untranslated region at the 5' end may serve as an internal ribosomal embarkation site, which ensures translation of a RNA coding region[ 15 ]. The extent of the genome in different viral isolates ranges from 9103 to 9392 nucleotides[ 16 , 17 ]. An open reading frame carries information on the virus-specific polypeptide consisting of 2873-2910 amino acid residues. GBV-C RNA codes for two structural proteins (E1 and E2) which are envelope proteins. Unlike HCV, the proportion of glycosylated E2 is much lower in GBV-C. It has a total of three potential N-glycosylation sites as compared with HCV E2, which has eleven sites. The complete structure of viral nucleocapsid is still to be determined as the genomic region coding for core proteins has not been identified yet[ 18 ].

An external file that holds a picture, illustration, etc.
Object name is WJG-14-4725-g002.jpg

Schematic representation of GBV-C RNA structure, coded proteins, and their functions (from Kim JP, Frey KE)[ 14 ].

Five non-structural proteins: NS2, NS3, NS4b, NS5a, and NS5b with molecular weights of 20, 70, 28, 55, and 57 kDa, respectively, have been found[ 19 , 20 ]. These proteins perform the function of protease, helicase, and RNA-dependent RNA-polymerase. The sequencing of the E1 and E2 regions has shown that they are not hypervariable unlike the respective regions of HCV[ 12 ].Of interest are the data obtained while studying the buoyant density of GBV-C particles in a saccharose gradient before and after treatment with the nonionic detergent Tween-80. These data suggest that there is a lipid envelope in the virus whose association with lipids reduces antibody formation.

MARKERS OF GBV-C

The basic marker used to diagnose GBV-C is RNA that is detectable by the amplification technique with a preliminary stage of reverse transcription in which cDNA is synthesized [reverse-transcriptase polymerase chain reaction (RT-PCR)]. Data on the sequence of the RNA region coding for helicase (NS3) and the NS5A region are used to synthesize oligonucleotide primers. This choice is made due to the high (83%-99%) stability of this region in various viral isolates (the sensitivity was as high as 200 copies/mL).

Further investigations indicated that there might be false negative results in the testing of some samples despite the fact that the latter contained the virus. By taking this into account, primers with the information coded in the 5'-untranslated region (the sensitivity was as high as 100 copies/mL) came into additional use for the designing of diagnostic kits[ 10 ]. The above primer kits had a high sensitivity, but also a rather high level of errors due to the incomplete conservatism of respective viral RNA regions.

An alternate primer kit for the region coding for E2 has been developed. These primers had 100% specificity for this RNA region; however, their sensitivity was not greater than 76.6%. Recent investigations propose the use of the two different primer kits (for viral RNA NS3, NS5A, 5'UTR, or E2 regions) for the accurate diagnosis of GBV-C RN[ 21 ].

GBV-C RNA has been detected in hepatocytes[ 19 , 20 , 22 ], peripheral blood lymphocytes and monocytes[ 23 , 24 ], vascular endothelial cells[ 25 ], and other tissues[ 7 ]. GBV-C viremia may persist for a few years. The infection is accompanied by the formation of specific antibodies against the envelope protein E2 (anti-E2). These antibodies have a long survival and may prevent the body from reinfection.

An enzyme immunoassay has been developed to detect serum GBV-C antibodies. The envelope E2 antigen (glycoprotein) was used as a viral antigen. Analysis of the sera from healthy individuals and patients with hepatitis demonstrated that most anti-E2-positive sera were GBV-C RNA negative, which enabled anti-E2 to be regarded as a marker of previous infection[ 8 , 26 - 28 ]. As a rule, GBV-C antibodies and RNA are not simultaneously encountered in a patient despite the fact that HCV, the nearest relation of GBV-C, is typified by this an inverse correlation between anti-E2 and viremia. The presence of serum viral RNA is also indicative of continuing infection so is that of E2 protein antibodies for clearance of viral particles from the patient’s body. It has been shown that the production of GBV-C antibodies and the cessation of viremia in most (60%-75%) immunocompetent patients occur spontaneously and they are followed by the generation of antibodies to the envelope protein E2[ 29 , 30 ]. Two markers (RNA and anti-E2) of GBV-C have been concurrently detected in single studies (in 5% of cases)[ 8 ]. The highest detection rates of GBV-C antibodies are observed in individuals aged above 50 years[ 31 , 32 ].

EPIDEMIOLOGY OF GBV-C

Infection with HGV is common in the world. The detection rate of GBV-C in the population averages 1.7%. GBV-C, like other parenteral hepatitide viruses, occurs universally, but nonuniformly (Table ​ (Table1 1 )[ 8 , 11 , 33 - 41 ].GBV-C is detectable in all ethnic groups. Analysis of the results of examining 13 610 blood donors described in 30 reports revealed viral RNA in 649 (4.8%) of cases. These included Caucasians (4.5%), Asians (3.4%), and Africans (17.2%)[ 42 ]. The authors propose to test blood samples due to the high risk of infection with GBV-C[ 42 , 43 ].

Detection rate of GBV-C RNA in blood donors

An investigation of the prevalence of HGV among north-eastern Thai blood donors carrying HBsAg and anti-HCV revealed the high frequency of GBV-C RNA (10% and 11%, respectively) in the co-infected as compared with the controls (0%)[ 44 ].

The development of an anti-E2 detection method has promoted a complete definition of the prevalence of GBV-C. E2 antibodies are several times more frequently detectable than RNA in blood donors (Table ​ (Table2 2 )[ 8 , 33 , 38 , 40 , 41 , 45 ].

Detection rate of anti-E2 in blood donors

GBV-C is a parenterally transmitted infection[ 28 - 30 ]. The first verification of this fact were the experiments dealing with inoculation of primates with the blood of the surgeon who fell ill in 1966[ 2 ]. Cases of acute posttransfusion hepatitis along with the enhanced activity of serum aminotransferases and the detection of blood GBV-C RNA in the absence of other markers of viral hepatitides has been documented[ 3 , 31 , 32 ]. Indirect evidence that HGB is parenterally transmitted lies in its more frequent detection in the groups at higher risk for infection with hepatitis viruses by similar routes of transmission (Table ​ (Table3 3 )[ 8 , 11 , 34 , 36 , 38 , 41 , 46 - 51 ], as well as the increased risk for infection in patients treated with multiple hemodialysis procedures and higher units of transfused blood products[ 33 - 35 ].

Detection rate of HGV RNA in high infection-risk groups

The use of infected blood and its products promotes the prevalence of HGV. In the USA, 18%-20% of all blood preparations are infected with GBV-C, of them plasma being in 33%-84%[ 33 ]. In the United Kingdom, 94%-100% of coagulation factor VIII-IX preparations are infected with this virus[ 34 ]. Despite the fact that this persistent infection is present in a considerable number of healthy blood donors and in more than 35% of the human immunodeficiency virus (HIV)-infected, the world food and drug administration considers it unnecessary to recommend donor blood to be tested for serum GBV-C RNA.

There may be a sexual transmission in hepatitis G, as in hepatitis B and C. This is evidenced by the high detection rate of GBV-C RNA in homosexuals and prostitutes: 13.4%-63.0%[ 48 , 52 ] and 13.9%-24.8%[ 48 , 53 ], respectively. Yeo et al[ 54 ] studied sexual transmission risk in 161 hemophilic patients. 21% of the females in sexual contact with them were found to be GBV-C RNA seropositive. The more frequent detection of markers of GBV-C in persons at increased risk for sexually transmitted diseases is also indirect evidence for its sexual transmission. Wachtler et al[ 31 ] revealed HGV RNA in 27% and anti-E2 in 35% of the HIV-infected, while in the control group these were 2% and 6%, respectively.

The vertical transmission of GBV-C from infected mother to infant may now be considered proven[ 36 , 55 - 57 ]. There may be intranatal infection of a baby at delivery by the maternal passage, as confirmed by the data on a significant reduction in the infection rates of neonates after cesarean section of their mothers[ 55 ]. There is also postnatal GBV-C infection. On examining 288 mothers, Lefrere et al revealed that 89% of the GBV-C-positive babies were infected at 3 mo after birth[ 36 ].

The level of viremia is a factor that is of importance in the transmission of the virus. By following up 24 babies born to mothers with a GBV-C RNA level of more than 10 6 copies/mL, Ohto et al revealed GBV-C in 23 (96%) of them. The viremia index in the mothers whose babies proved to be infected was significantly higher than that in those whose babies were seronegative ( P < 0.001). Most babies had no clinical or biochemical signs of liver disease despite one-year HGV persistence[ 58 ]. In the opinion of Wejstal et al, the vertical transmission of GBV-C amounts to 75%-80% of cases and that of HCV is 2.8%-4.2% ( P < 0.001)[ 56 ]. The frequent maternal-infant transmission of GBV-C may account for the high prevalence of the virus among the adult population at low risk of parenteral and sexual transmissions. The detection of GBV-C increases with age. HGV was detectable in 9% and 28.6% of the children under 15 years and above 16 years of age, respectively[ 59 ].

GBV-C TROPISM

GBV-C predominantly replicates in peripheral blood mononuclear cells, mainly in B and T (CD4+ and CD8+) lymphocytes and bone marrow[ 23 - 25 , 60 ]. The mechanism responsible for the development of GBV-C-induced hepatitis is not clear so far. Despite the described cases of acute and chronic hepatitis G, its hepatotropicity remains controversial. Table ​ Table4 4 [ 11 , 27 , 28 , 61 - 74 ] shows data that both confirm and rule out viral tropism to liver tissue.

Data on the hepatotropicity of GBV-C

Viral hepatotropicity is supported by the detection of GBV-C RNA in hepatocytes and by the development of acute and fulminant hepatitis following the transfusion of infected blood and its products. Lang et al reported interesting data on the immunohistochemical detection of GBV-C NS5 Ag in the liver biopsy specimens taken from patients with various liver diseases[ 68 ]. Like RNA-containing HCV, GBV-C does not integrate into the genome of an infected cell, but it is located in its cytoplasm and the “positive” cells are diffusely arranged. The indirect evidence for the liver tissue GBV-C replication is a considerable reduction in the serum content of viral RNA after liver transplantation (12.4 ± 3.9 × 10 7 copies/mL vs 2.8 ± 0.7 × 10 7 copies/mL)[ 69 ].

Primary replication of HGV in the hepatocytes has been questioned. Thus, the level of GBV-C RNA in the serum was higher than that in the liver tissue (there is an inverse correlation for HCV). In a third of serum-positive patients, RNA was undetectable in the hepatocytes despite the fact that tissue had been repeatedly taken from different lobes of the liver[ 73 ]. A study of liver biopsy specimens from 12 GBV-C-positive patients revealed no RNA “minus” strand responsible for replication and a RNA “plus” strand only in half the patients with low titers, which may be indicative of GBV-C contamination from blood. Laskus et al reported similar results investigating liver tissue and sera from 10 patients co-infected with HCV and GBV-C[ 74 ].

After establishing that the hepatotropicity of GBV-C was low, the next stage of elucidating the pathogenicity of the virus was to study its tropism to other tissues. Handa et al determined the presence of a RNA-“minus” strand in the vascular endotheliocytes[ 25 ]. In the authors’ opinion, isolation of GBV-C RNA from a liver biopsy specimen may reflect viral replication in the endothelium of the vessels located in the liver[ 25 ]. Tucker et al reported the detection of RNA “plus” strands in all 23 study organs taken for analysis from GBV-C-infected patients who had suddenly died[ 7 ]. However, both RNA strands were found only in the spleen and bone marrow.

The comparison of nucleotide sequences in the E2-region and the lack of occurrence of mutant viral forms during antiviral therapy with interferons suggested that the mechanisms that are responsible for persistent infection are different from those for HCV. Thus, during 2-year follow-up, the average amino acid sequence replacement in the E2-region was 100 times lower in GBV-C than in HCV[ 75 ]. Investigations indicated that viremia in GBV-C-infected patients was low and equal to 10 3 -10 4 copies/mL[ 76 ]. It has been suggested that the viral particles that are present in the blood use low-density lipoprotein receptors for penetration into the target cell and generate lipid complexes similar to those seen for HCV particles. An experiment was made on cultured peripheral blood mononuclear cells (PBMC)[ 60 , 77 ].

GBV-C may replicate in PBMC and interferon-resistant Daudi cells[ 60 ]. Experiments were carried out to inoculate human PBMC lines and hepatocytes with GBV-C RNA in vitro . The same lines were infected with HCV as a control. These experiments demonstrated that GBV-C replicates only in CD4+ cells[ 60 , 78 ]. Studies of cells from different organs of GBV-C-infected patients were conducted in parallel. They also detected traces of RNA “minus” strand virus. Thus, the in vitro and in vivo studies provide evidence that PBMC are the primary site of GBV-C replication.

The contribution of not only the immune system, but also genetic predisposition to prolonged viral circulation is suggested. HLA typing in GBV-C-infected patients with hemophilia showed that 22% of the RNA-positive patients and 72% of the anti-E2-positive patients had HLA DQ7, HLA DR15 and HLA DR8. There is also evidence for low content of CD4+ and the high level of CD8+ lymphocytes in anti-E2-positive patients, which makes it possible to predict GBV-C clearance[ 79 ].

HGV replication in peripheral blood monocytes and lymphocytes, and the spleen and bone marrow, combined with long viral persistence suggest that GBV-C replicates predominantly in the hematopoietic system. On examining 44 patients with non-Hodgkin’s lymphoma, African et al revealed markers of HCV infection in 5% of cases[ 80 ]. None of them was found to have HGV RNA. However, meta-analysis of 178 cases of non-Hodgkin’s lymphoma and 355 healthy volunteers indicated GBV-C RNA in 8.4% (15/176) and 0.8% (3/355) of the examinees, respectively, which points to the high risk of HGV in patients with lymphoma[ 81 ]. There is evidence for the frequent detection of GBV-C RNA in patients with leukemia as compared to those with myeloproliferative diseases[ 82 ]. Crespo et al reported the development of aplastic anemia in a 24-year-old male patient with acute hepatitis G[ 83 ]. Frequent transfusions in these patients may be one of the causes of HGV infection.

There are higher detection rates of GBV-C RNA (11%) and anti-E2 (17%) in autoimmune hepatitis than in the control group (2%)[ 84 ]. Heringlake et al revealed serum GBV-C RNA in 6.7%, 10.0% and 12.5% of the patients with types I, II and III autoimmune hepatitis, respectively[ 85 ]. GBV-C is typified by a long-term (as long as 16 years) persistence in human blood[ 86 ].

CLINICAL MANIFESTATIONS OF GBV-C

The clinical picture of GBV-C infection is commonly similar to that of the subclinical and anicteric types of hepatitis with normal or low aminotransferase activities[ 87 ]. GBV-C-associated hepatitis runs with normal biochemical parameters in 75% of patients[ 80 ]. There are reports on the occurrence of acute (Table ​ (Table5 5 )[ 62 - 65 , 88 , 89 ], fulminant[ 61 , 90 , 91 ] and chronic (mild and moderate)[ 32 , 76 , 92 , 93 ] hepatitis and hepatic fibrosis[ 27 , 86 ]. Some author’s note the younger age of the GBV-C-infected[ 28 , 37 , 93 ]. The incubation period of acute viral hepatitis G averages 14-20 d. The outcome of acute hepatitis may be: (1) recovery with the disappearance of serum GBV-C RNA and the emergence of anti-E2; (2) development of chronic hepatitis (CH) with serum GBV-C RNA being persistently detectable; (3) presence of GBV-C RNA without biochemical or histological signs of liver disease.

Detection rate of GBV-C RNA in acute nonA-nonE hepatitis

The alanine aminotransferase (ALT) activity in GBV-C unlike HCV, does not correspond to the degree of viremia and the severity of hepatic histological changes. By examining 1075 patients with isolated hypertransaminasemia for 6 mo, Berasain et al revealed GBV-C RNA in 74 (6.9%) patients[ 94 ]. Only one (0.09%) patient was monoinfected. There is also evidence for two-fold increases in the activity of alkaline phosphatase (AP) and γ-glutamyl transpeptidase (γ-GTP) in GBV-C positive patients[ 95 ].

HISTOLOGICAL CHANGES

Fibrosis of the portal tract without lymphoid-cell infiltration[ 96 ], steatosis and insignificant inflammatory infiltration of the portal tract[ 67 , 97 , 98 ] were detectable in isolated persistent GBV-C infection. The histological activity index in patients infected with GBV-C alone was observed to be much lower than that in patients with HCV+GBV-C or HCV[ 37 , 99 , 100 ]. In GBV-C monoinfected patients, moderate or mild focal portal hepatitis was prevalent with slight periportal infiltration and lobular components being found in single cases. The bile tract displayed epithelial fragmentary swelling and flattening and no nuclei in some epitheliocytes. Some bile ducts demonstrated partially desquamated epithelium in the case of higher activities[ 99 , 101 ].

Intraoperative biopsies from GBV-C positive patients with cholelithiasis who were monoinfected with GBV-C, indicated that they had mild chronic hepatitis and, in some cases, viral RNA in the liver tissue and gallbladder mucosa. It is suggested that GBV-C may play a role in the production of lithogenic bile and in the development of cholelithiasis[ 102 ].

Coinfection of HGV with hepatitis B, C, and D viruses is significantly more frequently detected than monoinfection[ 103 ]. In patients with acute viral hepatitis A (HAV), -B (HBV), -C (HCV), the detection rate of GBV-C RNA was 2.9%-25%, 19%-32%, and 20%-48.3%, respectively[ 88 , 89 ]. GBV-C RNA was detectable in 8%-16% of patients with chronic hepatitis (CH) B[ 30 , 77 , 100 ], 5.6%-21% of CH C[ 30 , 77 , 100 ], and 58% of CH B+D[ 98 ]. No differences were found in the clinical manifestations (including those in the chronic pattern and outcome) of the disease, biochemical parameters, or the severity of hepatic histological changes in patients with HBV and/or HCV as compared in those with HBV+GBV-C and/or HCV+GBV-C[ 104 - 106 ]. Patients with CHC alone and in combination with HGV have been meticulously examined. By examining 420 patients, Tanaka et al revealed a higher ALT activity in the group of patients coinfected with HCV and GBV-C than in those infected with HCV[ 107 ].

By comparing histological changes in the liver tissue of patients with HCV and HCV + GBV-C, Moriyama et al detected more significant bile duct damages, perivenular and pericellular fibrosis in the latter group[ 108 ]. These data were supported by the examination of 312 patients with CH[ 99 ]. Of them 28 (9%) patients were found to have RNA for HCV and GBV-C. Complaints and clinical symptoms did not differ in the groups of patients with HCV and HCV+GBV-C. There was no evidence for the impact of HGV on the clinical manifestations and the course of concomitant HCV infection. However, analysis of liver tissue morphological changes in patients coinfected with HCV and GBV-C revealed slightly more frequent epithelial damage in the bile duct (89%) than in those infected with HCV (67%), which manifested itself as lysis of the epitheliocytic nuclei, as well as flattening, destruction, and swelling of the epithelium and its lymphocytic infiltration.

Whether GBV-C influences the course of CHC and whether therapy with interferon is effective are currently being discussed. Most studies demonstrate no differences in the clinical course of the disease, biochemical parameters, or the magnitude of hepatic histological changes in both HCV alone and in combination with GBV-C[ 109 - 111 ]. A study for the therapy of HGV is based on the evaluation of interferon treatment in patients coinfected with HCV+GBV-C. HGV was ascertained to be sensitive to interferon. Administration of α-interferon (α-IFN) to patients at a dose of 3 000 000 IU thrice weekly for 6 mo resulted in ALT activity normalization and serum GBV-C RNA clearance in 18%-40% of the patients treated with α-IFN[ 112 , 113 ]. Six months after termination of a course of therapy, there were persistent biochemical and virological responses in 55%-57% of patients[ 114 ]. The therapeutic efficiency was observed to depend on baseline GBV-C RNA levels. The patients who had a low RNA titer (mean, 3.3 × 10 5 copies/mL) more frequently responded to the therapy than those who had a higher one (mean, 3.5 × 10 8 copies/mL)[ 104 , 109 ]. There is now a prevailing opinion that GBV-C has no impact on the efficiency of α-interferon treatment for chronic hepatitis C[ 114 , 115 ]. At the same time some investigations suggest that the therapy causes more frequent adverse reactions in patients with HCV+GGV-C and that after its termination, this group of patients has a higher histological activity index[ 116 , 117 ].

The implications of HGV for the development of chronic liver diseases has not been appraised to date. As for GBV-C infection, investigators could not trace the clinical stages characteristic of HBV and HCV: acute hepatitis-chronic hepatitis-liver cirrhosis (LC)-hepatocellular carcinoma (HCC). A long-term (less than 16 years) follow-up of patients permitted discussion only of the likelihood of development of chronic hepatitis. GBV-C RNA was detectable in 8%-25.4% of patients with chronic hepatitis non-A-non-E[ 118 ], 6%-15% of patients with cryptogenic liver cirrhosis[ 119 , 120 ], and 3.1%-8.3% with HCC[ 121 , 122 ].

The similarity of the properties of GBV-C and HCV offers a possibility of using HGV and its induced experimental infection as a model to study hepatitis C. Unlike hepatitis C, hepatitis G infection may be modeled in nonhuman primates, which considerably reduces the cost these studies that are in great demand for the designing of hepatitis C vaccine.

Unexpected results were obtained while studying the impact of GBV-C on the course of HIV infection[ 123 , 124 ]. Co-infection with GBV-C in the HIV-infected was established to cause a reduction in mortality rates and better clinical parameters of infection. Furthermore, the efficiency of high-activity antiretroviral therapy significantly increased. The positive effect of GBV-C is accounted for by the fact that the envelope proteins of this virus bind CD8l+ on T cells and induce dose-dependent secretion of RANTES (regulated on activation, normal T-cell expressed and secreted), the natural ligand that binds CCR5 on the target cell, thereby blocking the penetration of HIV[ 21 , 125 ]. In vitro studies showed an increase in the expression of the chemokines-RANTES, macrophage inflammatory proteins (MIP-1α, MIP-1β), and stromal-cell derived factor (SDF-1) in the blood of patients. There was also a reduction in the expression of CCR5 onto the surface of GBV-C-infected cells. All these factors may provide indirect evidence for the diminished sensitivity of GBV-C-infected cells to HIV[ 125 - 127 ].

A review of available data in the literature and the authors’ own data suggest that the new HGV discovered in the late 1990s has been rather well studied. The structure of the virus is almost completely known; its genotypes have been ascertained; its prevalence (epidemiology) shown and the clinical picture of the disease, routes of viral transmission, and the types of coinfection described. The predominant site of replication of the virus in the blood mononuclear cells, spleen, and bone marrow has been indicated. The lack of hepatotropicity of virus G (which is rarely detected in the the liver), its frequent detection in the body and tissues of a patient without any clinical signs of hepatitis, and clinical improvement in the HIV-infected patients coinfected with GBV-C cast doubt on the appropriateness of the concept “viral hepatitis G”. The interest shown in HGV is likely to be associated with the similarity of its properties to those of HCV.

Peer reviewers: Mario U Mondelli, Professor, Department Infectious Diseases, Fondazione IRCCS Policlinico San Matteo and University of Pavia, Laboratori Area Infettivologica, Dipartimento di Malattie Infettive, Fondazione IRCCS Policlinico San Matteo, via Taramelli 5, Pavia 27100, Italy; Vasiliy I Reshetnyak, MD, PhD, Professor, Scientist Secretary of the Scientific Research Institute of General Reanimatology, 25-2, Petrovka str. 107031, Moscow, Russia

S- Editor Zhong XY L- Editor Lalor PF E- Editor Yin DH

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  6. Case Studies

    what is case studies hgv

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  1. Become a qualified heavy goods vehicle (HGV) or bus driver

    The case studies are short stories based on situations that you're likely to come across in your working life.

  2. HGV Case Studies/CPC Module 2/Mock Exam

    Father Maguire 238 subscribers Subscribe 2.3K views 1 year ago #hgv #cpc #module2 In the final part of the mock tests for HGV's I have done the CPC Module 2 Case Studies mock test.

  3. Driver CPC for lorries/buses: part 2

    The official DVSA step-by-step guide to make sure you're ready to pass the Driver CPC part 2 case studies test.© Crown copyright, Driver and Vehicle Standard...

  4. CPC Module 2 Case Study Revision

    The case study test allows you to demonstrate your knowledge and understanding and assesses you on how to put your knowledge and skills into practice. Remember, this module requires you to use what you have learned to make your own judgements on each scenario.

  5. CPC Case Study Practice Test

    There are 12 multiple choice questions in this free CPC case study practice mock test. Read this carefully and ensure you fully understand the scenario before starting the test. You need to score at least 9 out of 11 to pass this test. Begin Test Statistics Register to track your progress Tests Taken Last Score Average Score Your Progress

  6. Module 2 case studies

    The module 2 case studies test involves a series of questions based on real-life scenarios that a student may encounter during their day to day work as the driver of a large goods vehicle. The test is made up of seven case studies consisting of between 5-10 questions.

  7. 3. Case study test

    Case study test. 3. Case study test. In order to drive professionally you must also pass the driver CPC case study test (also known as the Driver CPC case study theory test - Step 2). Both the truck and the bus case study tests ask you to look at three real-life situations a professional driver might face. Each case study test is computer-based ...

  8. How to get your HGV licence

    Driver CPC part 2: Case studies. You only need to take this part of the test if you're going to be driving HGVs for a living. You can book the CPC part 2 case studies test as soon as you've got your HGV provisional licence. This assessment contains 7 case studies based on situations you're likely to come across while driving a large vehicle.

  9. Free CPC case studies

    Free CPC case studies | Free module 2 case studies LGV Initial Driver CPC Theory Free CPC Case Studies Practice Test Trevor and John are multi-manning a vehicle from the UK to France. They work for TSD Haulage who have been contracted to deliver car exhausts to a manufacturing plant.

  10. What's Involved In Becoming An HGV Driver?

    Part 2 - Case Studies . For part 2 of the theory section, you will be asked to take the case study test. This is an interactive process that usually takes around 75 minutes and covers 7 key case studies. You will be asked to view each one and then answer a series of questions on each.

  11. Become a qualified heavy goods vehicle (HGV) or bus driver

    Qualify as an HGV or bus driver, requalify if you used to drive an HGV or bus, get a provisional licence, ... (case studies) and the Driver CPC part 4 (practical demonstration) tests;

  12. Part 2 Case Studies HGV / LGV » LGV Theory

    The module 2 case studies test involves a series of questions which are based on real life scenarios that a student may encounter during their day to day work as the driver of a large goods vehicle. The test is made up of seven case studies consisting of between 5-10 questions. The maximum mark for the test is 50 and a minimum of 40 is required ...

  13. Driver CPC

    Consists of a theory test based on case studies lasting 1.5 hours. Modules 1 and 2 can be taken in any order but must be completed before moving on to modules 3 and 4. Module 3. Consists of a practical driving ability test lasting 1.5 hours broken down into 3 parts: Reversing exercises at the test centre; A minimum of 1 hour on the road

  14. HGV Theory Test

    The CPC Case Study MULTIPLE CHOICE What's Included in the Multiple-Choice Questions? The multiple-choice element of the test involves a total of 100 questions. Module 1 is made up of these questions and the hazard perception test. What Topics are Covered in the Theory Test?

  15. CPC Training

    2. Module Two - Case studies. This is an online test, which presents around 7 case studies that represent likely scenarios as an HGV driver. Each scenario has related multiple-choice questions. The pass mark is 80% and the entire test lasts less than 2 hours.

  16. CPC Module 2 Case Studies

    HGV Theory Test > CPC Module 2 Case Studies. Free Case Study. Case Study 1. Case Study 2. Case Study 3. Case Study 4. Case Study 5. Case Study 6. Case Study 7. Case Study 8. Case Study 9. Case Study 10. Case Study 11. Case Study 12. Case Study 13. Case Study 14. Case Study 15. Case Study 16.

  17. Everything You Need To Know About the LGV Test

    Stage 2: Case Studies - The second stage of testing is that which actually qualifies a driver under CPC regulations. It involves various case studies based on real-world experiences the LGV driver will be exposed to during his/her career. The 75-minute test works through seven case studies, each with 6 to 8 multiple-choice questions attached.

  18. What is CPC for HGV drivers

    Case studies Off-road exercises up to £40 On-road driving test £115 weekdays (£141 other) Practical demonstration £55 weekdays (£63 other) Resources - Driver CPC theory test Advice: Theory test preparation for heavy goods vehicle (HGV) drivers Resources to help you prepare for your theory test.

  19. Multiple-Choice Theory & Module 2 Case Studies

    Multiple-Choice Theory & Module 2 Case Studies - HGV Module 1a Theory Test The latest module 1a theory test practice questions provided by the Driver & Vehicle Standards Agency A question bank of over 1000 questions Module 1b Hazard perception Twenty CGI practice Hazard Perception clips Provided by the Driver & Vehicle Standards Agency

  20. How to become an HGV driver in 8 steps (With skills)

    The Driver CPC is a set of standards that govern HGV drivers' road competence. You can get this certificate after completing an HGV training course. The licencing agency may require four tests, including a theoretical assessment, a case study, a driving ability assessment and a practical demonstration. With this certificate, you can begin ...

  21. Hepatitis G virus

    A number of new hepatitis viruses (G, TT, SEN) were discovered late in the past century. We review the data available in the literature and our own findings suggesting that the new hepatitis G virus (HGV), disclosed in the late 1990s, has been rather well studied. Analysis of many studies dealing with HGV mainly suggests the lymphotropicity of ...

  22. Case-control study

    A case-control study (also known as case-referent study) is a type of observational study in which two existing groups differing in outcome are identified and compared on the basis of some supposed causal attribute. Case-control studies are often used to identify factors that may contribute to a medical condition by comparing subjects who have the condition with patients who do not have ...

  23. What is an HGV?

    What is an HGV? A Heavy Goods Vehicle (HGV) is a classification for a large truck, the term common across the European Union (EU). HGV drivers need an HGV licence, which is a Category C driving licence, allowing trucks with a gross vehicle weight over 3.5 tonnes (but less than 7.5 tonnes) to be driven.

  24. Heavy duty, HGV resisting asphalt and porous asphalt for ...

    ULTIPHALT HD is a dense, heavy duty asphalt that combines high grade aggregates and a specialist modified binder. It delivers enhanced resistance to deformation and surface abrasion associated with heavy goods vehicles and provides excellent long term durability. ULTIPOROUS, Tarmac's fast-draining porous asphalt, was chosen for the parking ...