Yale Hepatology at the West Haven VA with Guadalupe Garcia-Tsao

Transcript

• 00:14Welcome to the Yale Liver Diamond
• 00:17Jubilee event. This session
• 00:18is being recorded. Thank you.
• 00:26Good morning and welcome to
• 00:28our next talking to series.
• 00:30And on speaker is going to
• 00:32be Doctor Lupe Garcia Sal,
• 00:34who's a professor of medicine at Yale
• 00:36University School of Medicine and
• 00:38Chief of Digestive Disease at the
• 00:40VA Connecticut Healthcare Center.
• 00:42So Lupe also serve as director
• 00:44of the clinical core for the
• 00:46NIH funded your Liver Center and
• 00:48is an associate that editor of
• 00:50the new International Medicine.
• 00:52So it's my pleasure to welcome Lupe and
• 00:54her the title of her talk will be ill.
• 00:56Hepatology at the West of India.
• 00:58Look, please go ahead.
• 01:06Thank you Gary.
• 01:09First of all I I would like to thank
• 01:12Michael and Mario for having invited
• 01:14me to give this presentation about
• 01:17Yale Hepatology as there with him VA,
• 01:20which is has been my academic and
• 01:24medical home for over 30 years.
• 01:26I just got my 30 year medal at the VA.
• 01:29So just to give you the the,
• 01:31the the place that the location
• 01:33this is the state of Connecticut.
• 01:36There was heaven.
• 01:37VA is in West Haven.
• 01:39Uh, part of the of the VA connected
• 01:43system is the Newington V8,
• 01:45which is a little further apart.
• 01:47But just to give you context also
• 01:49our Yale campuses in New Haven.
• 01:50So we're very near there's a shuttle
• 01:52bus that runs back and forth.
• 01:54The West Haven, VA and Yale every 15 minutes.
• 01:58So in the 75 years that spans this Diamond
• 02:04Jubilee, we have had several players.
• 02:06I will start again like Jim did.
• 02:09Would Jerry Klatskin Jerry was
• 02:11a Yale intern 1933 like he said,
• 02:14his love for the liver story in Calcutta,
• 02:16where he was serving in the Armed Services.
• 02:19He was a veteran and he performed his
• 02:21first liver biopsy at Yale in 1947,
• 02:24which is that starts this timeline.
• 02:26He was at the VA.
• 02:28He was a senior consultant at the VA
• 02:30in Newington where he like Jim said,
• 02:33learn to read boxes with Raymond Yesner,
• 02:35who was a chief of pathology
• 02:37at the VA Newington.
• 02:38He for many years.
• 02:40This Thursday around said that
• 02:41we VA and he was a patient at
• 02:43the VA where he actually died.
• 02:45Then we have how Khan,
• 02:46who was also a resident at Yale.
• 02:49He.
• 02:49It was a Jerry Klatskin fellow and then he.
• 02:54In 1959 he had his first study
• 02:56of ammonia published in the New
• 02:58England Journal of Medicine.
• 02:59At the time he was an assistant professor.
• 03:021962 he became chief of the Liver
• 03:05Research Laboratory at the VA,
• 03:06and in 1979 had started multi center trials,
• 03:09mostly with Boston it.
• 03:11If he clearly was a traveler of the world,
• 03:15he for he thought of him and actually guys,
• 03:17for he met me and Roberto and eventually.
• 03:21You know we came back to how we have met
• 03:24him in meetings in our original countries.
• 03:27He retired 1993 and acquired years later.
• 03:31Normal pressure hydrocephalus that
• 03:33was have been misdiagnosed and he
• 03:36became an expert in this topic.
• 03:37As every as everything that he did.
• 03:39He did it with great intensity.
• 03:41I also want to mention calling Atterberry
• 03:43who was probably not an academic
• 03:45but it was very influential for me.
• 03:47He collaborated with both with
• 03:49Harold and with Roberto and.
• 03:51In in,
• 03:51in recruiting pages for different trials,
• 03:54he was an incredible clinician.
• 03:56A great hypothesize that there was heaven,
• 03:58VA,
• 03:58from whom I learned a lot just from
• 04:01reading his notes from Browning with him.
• 04:04He became chief of staff of the VA,
• 04:06but he was also a philosopher in
• 04:08a very thoughtful man back in
• 04:10the early in the 70s,
• 04:11he wrote as a tourist on one one should not
• 04:13deliver biopsy, and incredibly
• 04:15has an editorial of transplant in
• 04:17patients with alcoholic hepatitis,
• 04:19A topic that is controversial to this moment.
• 04:22Then we have Roberto who was born and
• 04:25had his medical training Argentina.
• 04:28He was closed off with Jay Cohn at
• 04:31the VA and DC where he learned.
• 04:34All about the hyperdynamic circulatory
• 04:36state in in heart failure and then
• 04:39translated this into the liver,
• 04:40he escaping social unrest.
• 04:41He comes back to the VA again through
• 04:44Harold Kahn, where he gets the CDA.
• 04:46He was always at the VA.
• 04:47He established his better,
• 04:49get him on Dynamic Lab at the VA.
• 04:51That time it starts with the
• 04:53most studied with the NIH.
• 04:55And he was the chief of Divier from
• 04:581993 until his retirement in 2007.
• 05:00Then there's me.
• 05:01I was born and met and had
• 05:03medical training in Mexico in the
• 05:05same way that rural came here.
• 05:07We came through Falcon,
• 05:08and I was supposed up from 92 to 1985.
• 05:12I went back to Mexico,
• 05:14but was recruited back in 1990.
• 05:16Like Mike said this morning and
• 05:18and with Roberto, we became a team.
• 05:21He did the basic research and I did was
• 05:23the clinical counterpart to Riverdale.
• 05:25Portal hypertension program.
• 05:27In 2002 I became director of one of
• 05:30the 44V8 Appetize C Resource centers,
• 05:32which I'll talk about in a second.
• 05:34I, like Gary,
• 05:35said I'm director of the Liver
• 05:38Center clinical core and I have
• 05:40been chief of V8 Assist 2007.
• 05:42Then I have to do tomorrow.
• 05:45Teddy who did her jailing
• 05:47her fellowship at Yale,
• 05:49recruit her to the VA to hit the the
• 05:52hypercars in my program in 2009,
• 05:54has created a vocal.
• 05:56Group which I will talk about later.
• 05:58She's the vice chair of the
• 06:00HC Subcommittee and VA Central
• 06:02office in Washington DC,
• 06:04and she will be the chief of GI
• 06:06at the VA as of July of 2022,
• 06:09and we have part-time faculty prominently.
• 06:11Simona Jacob Wash Mahal,
• 06:13Joseph Lemon, met by Connell,
• 06:16and the newest addition to our full-time
• 06:19faculty is on German train off,
• 06:21like a magnificent mansion.
• 06:23So it despite these not not only
• 06:25these people are the player,
• 06:27there's many talented, dedicated technicians.
• 06:30Jim talk about Hazel Hubble and how
• 06:32she prepared to deliver biopsy slides.
• 06:34I'll call Jim,
• 06:36which was how Conn's technician Martha Shape,
• 06:39which was the Prime nurse coordinator.
• 06:42Currently, Susan patka. And there's.
• 06:45Million research coordinators that
• 06:47don't have time to mention many fellows.
• 06:50And of course our veterans.
• 06:52Now this is you all know how this goes.
• 06:55You have chronic liver disease,
• 06:56goes through, compensated cirrhosis,
• 06:58decompensated cirrhosis and then you
• 07:00state as called for decompensation
• 07:02and all of these can be complicated
• 07:04by the FDA research has been
• 07:06dedicated to all these are aspects
• 07:09of chronic liver disease.
• 07:10Start with encephalopathy by Harold Kahn.
• 07:13He published back in 1968.
• 07:16Randomized trial of of Neomycin
• 07:18versus laterals in in the treatment
• 07:20of portal systemic and several
• 07:21apathy and you can
• 07:23see how you might think which
• 07:24was the standard of capital,
• 07:26was toxic brought down the forest comma
• 07:29zero is normal mental status improved in
• 07:32all of the pages the same as Lactulose.
• 07:36And it's that was for just now the
• 07:38standard of care for just Lactulose.
• 07:40And this was followed by another
• 07:42double blind clinical trial of
• 07:43Lactulose in the treatment of chronic
• 07:45portal systemic encephalopathy.
• 07:46But what is very interesting is,
• 07:48as this mental state grading
• 07:50is now called worldwide,
• 07:52the West Haven criteria for
• 07:55American Civil opathy and is still
• 07:58used in RCT's of of repetitions.
• 07:59I fell off of the worldwide,
• 08:01so we're talking since back in 1968.
• 08:05Then for many,
• 08:07many years the obsession was there.
• 08:08Still hammered and current
• 08:09very still hammered.
• 08:10And of course,
• 08:12variceal hemorrhage comes from
• 08:13poor having portal hypertension,
• 08:16and this is where the richest came from,
• 08:18like Mike Matheson on mentioned most
• 08:21of the research had initially been on
• 08:23portal hypertension and versatile hemorrhage,
• 08:25and Roberto established the
• 08:27hyperdynamic circulatory state in
• 08:29portal and Portal hypertension,
• 08:31wrath mode.
• 08:32So this was the the using microsphere
• 08:34technique she demonstrated that.
• 08:36As opposed to the thought at the time
• 08:38that this was a passive congestion,
• 08:40he showed that.
• 08:43In portal hypertension with
• 08:44extensive portal systemic shunting,
• 08:46there was an increase in this
• 08:48plastic and peripheral circulation.
• 08:50There was a hyperdynamic circulatory
• 08:52state and this was due to sporatic
• 08:55and peripheral based on the location.
• 08:57So based on this,
• 08:58since there was an increase in flow,
• 09:01that key was to call somewhere
• 09:02will decrease this flow and the
• 09:04use of beta blockers like Mike
• 09:06mentioned was what it was.
• 09:07And this is a very important study
• 09:10with one of our GI fellows at the time
• 09:13that showed the effect of per panel,
• 09:16which is a nonselective beta blocker
• 09:18at technology in an experimental
• 09:20drug that was a beta two block.
• 09:22So I have beta one blocker
• 09:24and beta two blocker.
• 09:25They both decrease portal pressure.
• 09:28But the combination it beta one
• 09:30and beta 2 blockers nonselective
• 09:32beta blockers had the most intense
• 09:34effect in reducing portal pressure,
• 09:37and this is now our standard of care.
• 09:40The use of non selective beta
• 09:42blockers in the treatment of portal
• 09:44hypertension started in 1985.
• 09:46It continues turnout and like my goal
• 09:48for mentioned Roberto created the
• 09:50balloon catheter because the portal
• 09:53system is is is between 2 capillary vessels.
• 09:56To measure, the portal pressure
• 09:57won't have to go very invasive.
• 09:58Into the portal vein,
• 10:01so someone else.
• 10:03Discover that the apatitic vein
• 10:05pressure could correlate with direct
• 10:07portal pressure measurements.
• 10:08This, but there was a straight catheter,
• 10:10but Roberta did was invent this balloon
• 10:13catheter by whereas by which you
• 10:15could perform repeat measurements of
• 10:17HD without having to move the catheter,
• 10:20wedging and on wedging it,
• 10:22and this allowed.
• 10:23To have repeat measurements
• 10:25increases the accuracy of the method.
• 10:27It allows for clinical research to go on,
• 10:30so this is currently still
• 10:31the standard of care in
• 10:33the indirect measurement of portal pressure.
• 10:36Umm? Of course, then this started
• 10:39going on into in into research to
• 10:43determine the portal pressure,
• 10:45presence of viruses,
• 10:47and various hemorrhage in a in.
• 10:50In a multicenter study.
• 10:52And this is this study in particular studies.
• 10:55The cut off 12 millimeters of
• 10:58mercury so normal HPG is 3 to 5,
• 11:00but when one got to 12 berries would
• 11:03not occur the threshold this is
• 11:05currently the threshold that we use.
• 11:07We put tips for variceal hemorrhage,
• 11:10so this is again something that
• 11:12was first discovered in 1985. Now.
• 11:17Then we of course started to have per
• 11:20panel after the experimental studies,
• 11:22we started assessed per panel and in
• 11:24the effect of per panel on NBA TV PG.
• 11:26And as you can see here,
• 11:27what we saw is that that there was
• 11:3160% of the patients that would have
• 11:34a reduction in HVPG after the after
• 11:37the use of per panel and what was
• 11:40very interesting is is that we as
• 11:42we expected and because there's
• 11:44that beta two effect,
• 11:45there was a lack of correlation
• 11:47between the decrease in heart rate.
• 11:49And decrease in age RPG and therefore
• 11:51that's why we now consider non non selective.
• 11:55They cannot just be a tunnel and
• 11:56the beta one blocker is not enough.
• 11:58We needed it combined beta one and
• 12:01beta two blocker and this is what
• 12:03our youth clinically to a maximum
• 12:05heart rate reduction.
• 12:06We cannot tailor it to a
• 12:08specific decreasing heart rate.
• 12:10We just have to tailor it to
• 12:13the maximum clinically.
• 12:14Tolerable decrease in heart rate.
• 12:18Then how Khan and and Roberta
• 12:20that was the Boston,
• 12:22New Haven Barcelona Collaborative group,
• 12:24and there's with Jaime Bosch who is going
• 12:26to be at the meeting later on and it shows.
• 12:30And it showed that Propanal was effective
• 12:32in preventing Marysville hammers,
• 12:34so this was one of several studies
• 12:36that showed that preparo was useful
• 12:38in preventing first hemorrhage,
• 12:40and is the standard of care at the time.
• 12:44And of course.
• 12:46We then proceeded to do the TIMMEL study,
• 12:49which was the objective was to see
• 12:51if we could actually even prevent
• 12:53viruses from developing,
• 12:54so it was going as that a step
• 12:56further from just preventing
• 12:57hemorrhage in those who had berries.
• 12:59But now given.
• 13:02Blockers to prevent that he's
• 13:04the study was a negative study,
• 13:06but it led to the recognition that
• 13:09not all pages with variances were risk
• 13:12of to developing them in the death.
• 13:14This dependent on the bid on the
• 13:17degree of portal hypertension.
• 13:20So if the baseline HCV was less than 10,
• 13:22the probability of developing
• 13:24variances for small,
• 13:25whereas if it was more than 10,
• 13:27the probability of of developing
• 13:30varieties both much greater.
• 13:31And eventually using the database
• 13:33to see that report who's also going
• 13:36to be at this called develop the
• 13:38using the table data determined that
• 13:41the probability of the composition.
• 13:43Also depending on what the baseline
• 13:45HVPG was and if it was fixed to 10,
• 13:48there probably was very low,
• 13:49whereas if it was more than 10
• 13:51it was actually much higher.
• 13:53And in this study the clinical decompensation
• 13:55was defined as overt as societies,
• 13:58better still hemorrhage or and overturns
• 14:00availability, which is what we.
• 14:02Defined it in the most current
• 14:04above annual conference,
• 14:05based in part in this data.
• 14:07These are complicated,
• 14:08are due to portal hypertension and
• 14:10establish the concept of clinically
• 14:12significant portal hypertension
• 14:14which is a baseline HVPG greater or
• 14:16equal to 10 millimeters of mercury.
• 14:18Clinically significant because it leads
• 14:21to the main complications of cirrhosis.
• 14:24We have also done studies now trying to
• 14:26correlate the presence of clinically
• 14:28significant portal hypertension.
• 14:30Just CSPH.
• 14:31With an atomic,
• 14:33the anatomy of patients with cirrhosis.
• 14:35So these are histologies of my patient
• 14:38with mild portal hypertension tend
• 14:40to have thin SEPTA thin fiber SEPTA,
• 14:43whereas those with clinically significant
• 14:45portal hypertension can tend to have thick,
• 14:47fibrous SEPTA,
• 14:48and this is important in terms
• 14:52of risk stratification,
• 14:53but also in terms of the possibility
• 14:56of reversals through roses and
• 14:57on more recently we we did,
• 14:59we applied the same histological
• 15:02characteristics.
• 15:03Been intermediate and thick
• 15:04and found out that this boy,
• 15:05this thick SEPTA,
• 15:07are related with clinical decompensation,
• 15:10again defined per per environmental
• 15:12quiteria aside.
• 15:16Then the other thing was to start
• 15:19thinking about other ways to supplement
• 15:21or complement the portal pressure
• 15:23reducing effect of beta blocker.
• 15:24So we have been using.
• 15:25We used a the VA cohort.
• 15:29the VA data to look at status and then
• 15:33it in the in the propensity match.
• 15:35So we found that that user were less likely
• 15:38to be compensated and less likely to die.
• 15:41This was supplemented by the
• 15:42using the be a vocal cord.
• 15:45Our this art for Mohanty sorry
• 15:47was in hepatitis C pages.
• 15:49The vocal study was in all etiologies
• 15:51and showed that Satan was associated with
• 15:54decreased mortality and child A&B patients.
• 15:56There's an ongoing, multicenter,
• 15:58randomized controlled trial at the VA.
• 16:00the VA secret study on preventing the
• 16:03compensation with simvastatin and
• 16:04their future trials from DNA liver
• 16:06cirrhosis network that are the BLC and
• 16:08that are also based on these studies.
• 16:12The vocal study as I show you later on
• 16:14validate the definition of sorosis through.
• 16:16Nine Nic 10 codes using
• 16:19the VA data warehouse.
• 16:21More recently,
• 16:21and because we cannot afford to do
• 16:24measurements of HBG and all patients,
• 16:26we have trying to determine noninvasive
• 16:28measures to assess the presence of
• 16:31clinically significant portal hypertension
• 16:33and particularly Nash Saroses,
• 16:35which is our current most common etiology,
• 16:37so we have validated and
• 16:39anticipating Nash model,
• 16:40which is mostly a European model.
• 16:43Using liver stiffness and platelet
• 16:45count and we are have developed very
• 16:47recently a new model that does not
• 16:49include liver stiffness measurements
• 16:51and then notice that at the VA there's
• 16:54a lot of sites that do not have the
• 16:57device to measure liver stiffness.
• 16:59Then going back again the other area
• 17:01has been a fighting and spontaneous
• 17:04bacterial peritonitis and Harold
• 17:06Kahn was the first person to coin
• 17:09the term spontaneous peritonitis
• 17:11and carefully describe 5 patients.
• 17:14In 1964,
• 17:15as Michael also mentioned in the study,
• 17:18when I was a fellow,
• 17:19we established that the PM income
• 17:21more than 250 was the one that
• 17:24that that was associated with.
• 17:26Later on getting it bacteria or
• 17:28getting the syndrome and this cut off
• 17:31is still used now in the diagnosis
• 17:33of spontaneous spectral for Dennis.
• 17:35Other studies that have to do with
• 17:37this is that we did study some
• 17:40bacterial translocation and how
• 17:42this is the main pathogenic.
• 17:44Mechanism in the development of SBP.
• 17:48We also realized that this bacterial
• 17:50translocation with inflammation leads
• 17:52to the base of the notation that
• 17:54leads in turn to the hyperdynamic
• 17:57circulation and cirrhosis.
• 17:58More recently,
• 17:59we saw that obeticholic acid prevents
• 18:02stress location of Enterococcus recalls
• 18:04which is to be a very important
• 18:07indicator Organism in cirrhosis
• 18:08and and SDP 48 hour PMN count has
• 18:13important prognostic implications.
• 18:14In terms of HTC and this has
• 18:17been mostly doctor Tatties work.
• 18:19The vocal study group was created in
• 18:232012 that included an observational
• 18:26cohort of 130 K veterans with detailed
• 18:29clinical pharmacological laboratory
• 18:31data from VA corporate data warehouse,
• 18:34and this was validated with
• 18:36chart review so they have
• 18:37an algorithm to determine severity
• 18:39of liver disease that says burden
• 18:41and cost of HTC's affect on
• 18:43multidiscipline tumor board on survival.
• 18:44Surgical risk course in cirrhosis.
• 18:47In fact those States and metformin
• 18:49and cirrhosis already showed you
• 18:50some of the data on statins.
• 18:52And, importantly,
• 18:53this study group aims to develop a
• 18:56consortium of young investors interested
• 18:59in developing clinical trials for
• 19:01patients with cirrhosis at the VA.
• 19:04Ongoing research studies and
• 19:05I don't have time to go over.
• 19:07This is like the sacred study.
• 19:10RCT of of a quick MRI versus standard
• 19:13of care in the screen of HTC and RCT.
• 19:16FHL 2 inhibitors in the treatment
• 19:19of Saratoga sites that are based
• 19:21on prevalence of different types
• 19:23of AI and cirrhosis.
• 19:24We're very interested in
• 19:26recompensation and regression.
• 19:27Looking at service of physiological
• 19:30and hemodynamic correlations,
• 19:32evolution of portal hypertension
• 19:33and non invasive tests and pages
• 19:36war whose ecology is being treated.
• 19:38Non invasive like I mentioned predictive.
• 19:40Then at least it could make fricking
• 19:43portal hypertension and palliative
• 19:44care in serosa. We have it.
• 19:47Corey grant.
• 19:48Throughout the years,
• 19:50the Yale hepatology,
• 19:51the West Haven VA faculty,
• 19:54have had many national and
• 19:56international collaborations.
• 19:57Here I show one of our first multi
• 20:01center center multi investigator
• 20:03meetings at Reston in Virginia which
• 20:07was the counterpart of Baveno in the US.
• 20:10Here is Harold Kahn.
• 20:13My Roberto is here and and and.
• 20:18And and work together with international
• 20:20investigators and portal hypertension.
• 20:22But so you know, this is the Boston
• 20:23new and highly boss is here.
• 20:25Who's actually right here?
• 20:26Who will be with us later on.
• 20:29We are now part of the ventral corporation.
• 20:32The International Societies Club,
• 20:33the North American Consortium for
• 20:35the study of end stage liver disease.
• 20:37Tribe a cab,
• 20:38which is a multicenter consortium,
• 20:40non acute kidney injury and cirrhosis.
• 20:42The harmony construction,
• 20:44which is about hepatorenal syndrome
• 20:46in team with whom.
• 20:48We collaborate on alcoholic hepatitis
• 20:50and I like I mentioned the vocal study group.
• 20:52Now,
• 20:53let's talk about.
• 20:54We've talked about the research,
• 20:56let's talk about the clinical
• 20:58practice the VA has been amazing
• 21:01in terms of treating liver disease,
• 21:03specifically hepatitis C.
• 21:05So in 1998 the VA mandated that
• 21:09every veteran had to be assessed
• 21:12for certain HIV risk factors,
• 21:15and there was the mandatory
• 21:16initiation of the HCV.
• 21:18Clinical reminders I would remind
• 21:20clinical providers if the patient
• 21:22had risk factors to screen for HD
• 21:24then they they put on a lot of money
• 21:27to screen and treat these patients,
• 21:29and in 2001 the national hepatitis
• 21:31C period created the four hepatitis
• 21:34C resource centers at West Haven,
• 21:37VA was one of them and we created
• 21:39an implemented performance measures
• 21:41and initiatives to ensure that all
• 21:44patients with HCV were diagnosed
• 21:46and treated was the AB.
• 21:48I'm available the HRC will got
• 21:50converted into many hepatitis
• 21:52innovation teams so that we could
• 21:55expand treatment of the A12 patients
• 21:57and as a result of this this is DAY study.
• 22:0290% of all veterans have been
• 22:05screened and 90% of the veterans
• 22:08in care have been treated,
• 22:10so this is much better than
• 22:12any other court in the world.
• 22:15We have treated and cheered.
• 22:1790% of our veterans with hepatitis C.
• 22:20And because this has now happened in in,
• 22:23we are not.
• 22:24We're still screening pages we see,
• 22:26but the focus of the appetizing
• 22:28Novation team team program is now to
• 22:30ensure that patient with cirrhosis are
• 22:32screened and treated for varices or in
• 22:35clinical significant for our provision
• 22:37and our screen and treated for HCC.
• 22:39So we have poorly snapshot measurements
• 22:42of how each sender isn't doing,
• 22:44and this is just an example,
• 22:46so this is the national rate and we have
• 22:48certain standards that we have to meet.
• 22:51But you can see here.
• 22:52This is the vision one our VA
• 22:54is part of the of this network
• 22:56which is called this and one and
• 22:59we have for HCC surveillance.
• 23:01We have 48% have been surveyed
• 23:03and for various field surveillance
• 23:0664% at the West Haven VA.
• 23:08But we get these these dashboards
• 23:11to ensure that every VA is following
• 23:14this on on a regular basis.
• 23:16The other thing that we have is
• 23:18because many of the VA sites are
• 23:20far away from the West Haven, VA.
• 23:22They cannot come,
• 23:23so we have now started a telepathology
• 23:25clinic and we're just piloting it
• 23:28with central Western Massachusetts,
• 23:30where where we just several miles
• 23:32away where we have made McConnell
• 23:34and our two great new.
• 23:36This is a pack,
• 23:37but in in in Neeraja and these
• 23:40are the these are this is not
• 23:41is sort of like a scanning go,
• 23:43but we're actually seeing the patient.
• 23:45These are the two nurses in
• 23:46central Western Massachusetts.
• 23:47So we have two clinics a week where
• 23:50we can actually see the patient talk
• 23:53to the patient and and and and and
• 23:56come up with it with a joint plan
• 23:58with the other center so that we can
• 24:01take care of these patients if need be,
• 24:03they would be transferred
• 24:04over to for us to see them,
• 24:05but for now we can save the patient
• 24:08a lot of travel to come to us.
• 24:11The other thing that we have is
• 24:13education and for this we have
• 24:15biweekly what we call VA scan ECHO.
• 24:18This is a VA specialty care
• 24:20access network with extension of
• 24:22community healthcare outcomes.
• 24:23This goes to primary care providers.
• 24:27And we have different is that the
• 24:30topics are all about cirrhosis.
• 24:32For example,
• 24:33palative care and cirrhosis tips
• 24:35for portal hypertension of intersex
• 24:37consensus conference debrief.
• 24:38And this is all led by our own
• 24:40Simona Jacob who has done an
• 24:42amazing job at this educational
• 24:44activities throughout the VA.
• 24:48These are also these.
• 24:49These are a list of clinical
• 24:51practice guidelines that have
• 24:53been authored by West Haven,
• 24:55VA faculty and includes different
• 24:57topics that are related mostly to
• 24:59cirrhosis and portal hypertension.
• 25:01International ones like the
• 25:03international side club guidelines.
• 25:05Barbano consensus conference.
• 25:06They're most recent one,
• 25:08the one that has just been published in 2022.
• 25:11We have a VA guideline which just needs
• 25:16to be updated, but then we have been.
• 25:18Involved in portal hypertension.
• 25:19Vascular disease of the liver.
• 25:21Elastography,
• 25:21the source of mesenteric circulation.
• 25:25Again tips, palliative care and two
• 25:28guidelines on fetal cellular carcinoma.
• 25:31And we have something that's
• 25:33called cirrhosis.
• 25:34Quick notes,
• 25:35and this is these are algorithm.
• 25:37There's just three and a half pages
• 25:39that talk about compensated and
• 25:41Gray and decompensated sorosis and
• 25:43the close up because he managed
• 25:45not compensated cirrhosis and
• 25:47managed of decompensated and just
• 25:49for variceal surveillance for
• 25:50example we see if the pay has
• 25:52small viruses and it's a child.
• 25:54Pugh Class B then we go to
• 25:56non selective beta blockers.
• 25:58If beta blockers are given repeated
• 26:00those three more years so that.
• 26:01This goes on for every complication
• 26:04of sorosis and we have been generous
• 26:06to give these quickness to their
• 26:09different other centers across
• 26:10the USA and actually to Europe.
• 26:13The other thing that we have.
• 26:15There's of clinical practice is the
• 26:17creation of regional liver tumor boards.
• 26:20We were the first one and now
• 26:22it has expanded to other VA.
• 26:23The first one that was created by
• 26:26Tamar Taddy involves Connecticut,
• 26:27Rhode Island,
• 26:28Central Western Mass and Vermont and
• 26:31this is we see we valid every single
• 26:35patient with imaging abnormalities
• 26:37and the ones that are detected
• 26:40as HC come to us for treatment.
• 26:43So this has made the VA Connecticut.
• 26:46System a regional referral Center for
• 26:48local regional therapy in all of New England.
• 26:52The other thing that Tomark creators
• 26:54is this tumor tracking system,
• 26:56which is the system that that is
• 26:58used using all the the reports the
• 27:01radiological reports from every
• 27:03VA we started with ours VA,
• 27:06Connecticut in 2010 and this has
• 27:08now been expanding to all of of many
• 27:12more centers in the hope of getting
• 27:14an idea of what are outcomes in
• 27:17patients with HCC and and what who
• 27:20are the senders that this may be.
• 27:23Where this might be improved?
• 27:25What then we have the trainees?
• 27:29That we have already jam already
• 27:31talked about them this morning,
• 27:33but this year fellows training that
• 27:36case specifically to the VA to be
• 27:38trained we have 118 fills up 25%
• 27:42are currently in academic medicine,
• 27:44performing research and hepatitis.
• 27:45There we come from 18 different places
• 27:48in the world, most of them from the US.
• 27:50Of course we also have Mountain Canada,
• 27:52Mexico, Brazil, Argentina, Spain,
• 27:55Barcelona and Madrid, Switzerland, Germany.
• 27:59On I forget Lebanon, Africa, India.
• 28:06We also have them from Thailand,
• 28:09mainland China,
• 28:10Japan and Taiwan and the I cannot
• 28:13mention all of them of course,
• 28:15but among them we have Heimbach who
• 28:17has been with us throughout the whole
• 28:20years and Christina report as well.
• 28:22Who will be later on at this meeting.
• 28:24And of course I will not use all of
• 28:27these are mentioning here are either
• 28:29chiefs of of of their section or
• 28:32chairmans of medicine and have continued.
• 28:35The role of investigating prohibition
• 28:38and of course,
• 28:40those who are no longer with us
• 28:42like Antibi and David Kraft.
• 28:45Now, in terms of leadership,
• 28:47we have had over prominence in in
• 28:50terms of visibility across the world.
• 28:52Dairy classifying was ASV President
• 28:541957 and got the American College of
• 28:58Physicians Distinguished Teacher Award twice.
• 29:00And like Jim mentioned,
• 29:01despite him not being a member,
• 29:03he thought the aging a Freedom Wall Award.
• 29:06Harold Comma was president of the ASLD.
• 29:08Roberto Grossman was the founder of
• 29:10the Barbano Portal Hypertension group
• 29:12and got the Alf the ASLD and the easel.
• 29:15Teen Awards I was president of the
• 29:18SLD in 2012 and also got the easel
• 29:21ASLD Alf Awards and I'm currently at
• 29:24the Governor's Executive Committee.
• 29:27This is the end.
• 29:28I mostly want to thank the VA.
• 29:31I want to thank again Mario and Mike
• 29:33for inviting me to this and allowing
• 29:36me to highlight how important the
• 29:38VA has been in the mission of of
• 29:40advancing liver research and education.
• 29:42And I thank the VA because that has
• 29:45allowed me to do all these things.
• 29:47Thank you very much for your attention.
• 29:50Lupe, thank you very much for really
• 29:52a wonderful talk and highlighting
• 29:54the great work that's been at the VA.
• 29:57Just treating hepatitis C and and
• 29:59and screening for liver cancer
• 30:02and having the tumor registry.
• 30:04Really great achievements.
• 30:05Thanks very much.
• 30:08Thank you, it's it's. I'm very proud of you.
• 30:12All right, well thank you to
• 30:14the audience and we'll move to
• 30:15the next stop. See you soon.