Yale Liver - Going Forward with Mario Strazzabosco

Transcript

• 00:19Welcome to the Yale Liver
• 00:21Diamond Jubilee event.
• 00:22Please feel free to connect with
• 00:24speakers or attendees in between
• 00:26sessions by sending a direct
• 00:28message through the attendee tab.
• 00:29This session is being recorded. Thank you.
• 00:38Good morning again and our next
• 00:41speaker is Mario Strasser.
• 00:43Bosco, who is Professor of medicine at
• 00:45Yale University and currently serves
• 00:47as director of the Yield Liver Cancer
• 00:49program and could director of the Year
• 00:52Liver Center now before coming to Yale.
• 00:54As you know, Mario was was the
• 00:57founding chief end of the GI section
• 00:59of Osteopathy Riante of Bergamo,
• 01:02and was also medical director
• 01:04of Transportation.
• 01:05Transplantation,
• 01:05I am so glad to welcome all of you to
• 01:08the podium today and his talk will
• 01:10is entitled your liver going forward.
• 01:13Mario, please go ahead.
• 01:15Thank you very much.
• 01:17Get it for the introductions
• 01:19we have heard from Jim.
• 01:25Michael and Lupe.
• 01:26The terrific advancement and the
• 01:29contributions that came from from
• 01:32Yale and it's glorious history.
• 01:36Now we're going to shift gears,
• 01:38however, because.
• 01:40In order to transmit this legacy and
• 01:45increase the impact of this legacy.
• 01:48We need to look forward and
• 01:50we need to look forward with.
• 01:53Trying to think out of the box
• 01:55so the rest of the meeting will
• 01:57be actually a conversation.
• 01:59About how do we?
• 02:01How do we move on?
• 02:03To maintain this legacy
• 02:05and and of course I will,
• 02:07I will try to drop down
• 02:10some conversation items.
• 02:11And as Gary mentioned,
• 02:15I remind you that I was fortunate
• 02:19enough to spend 15 of the last 30
• 02:22years at year and also in Europe.
• 02:25So my view will clearly be
• 02:28a combination of the two.
• 02:31Umm? So.
• 02:33Give me.
• 02:39The present. Of of the pathology
• 02:43as being clearly highlighted
• 02:44by the previous speakers,
• 02:46we have had fantastic. UM?
• 02:51Achievement and they have been all mentioned,
• 02:55so I'm not going to go through them.
• 02:57But clearly Hepatology became
• 03:00from a discipline where we
• 03:04had very limited treatment,
• 03:06possibility to discipline that where we
• 03:09have an array of very sophisticated.
• 03:14Me and my wife.
• 03:19Sizes. And later, on Scott Friedman
• 03:24will talk about the future.
• 03:28We what is expected to be.
• 03:31We have a tremendous
• 03:34possibilities that still are not.
• 03:37With us, but it's clearly we can see
• 03:40in in the fog the impact of official
• 03:45intelligence microbiome based therapy,
• 03:48gene therapy.
• 03:49Janitorial, pathology and so on.
• 03:52And I don't want to.
• 03:54Anticipate the sculptor.
• 03:57A lecture, but in the meanwhile we are.
• 04:02In between the present,
• 04:04the present runs away very fast and
• 04:07the future and we need to look at
• 04:09the landscape that we have and in
• 04:11front of us there is a mountain.
• 04:14A mountain that we need to claim,
• 04:16and it's a long and winding Rd before
• 04:21reaching adequate treatment for all
• 04:23patient will leave at this years.
• 04:26And so the present task,
• 04:28the task of the present day
• 04:31is in looking forward,
• 04:32is really to try to understand.
• 04:36How to best deliver the present care
• 04:40while bringing home the future science?
• 04:42Because if we continue.
• 04:45As we did,
• 04:46we will not be as successful as we were.
• 04:52So the question of receiving the
• 04:55legacy and transmitting a legacy.
• 04:57By increasing this legacy is what we
• 05:00need to discuss and it is clear that
• 05:03academic pathology has generated a
• 05:05tremendous therapeutic advances, however.
• 05:07Liver disease remains to this day
• 05:11and increasing global and national
• 05:14healthcare and social terms.
• 05:16And this is the second leading cause
• 05:19of years of working life lost.
• 05:21It is second only to cardiovascular disease.
• 05:25Well, the rise that well because
• 05:28liver disease that is actually the
• 05:30result of a syndemic of the number
• 05:34of epidemics that are preventable.
• 05:38We have millions and millions of people.
• 05:41Affected by hepatitis B and hepatitis C,
• 05:45we have a cure for hepatitis C,
• 05:47But still haven't really implemented
• 05:50his eradication. Alcohol is.
• 05:53Two 2.3 billion people habitually
• 05:58consume alcohol. 8% of them get.
• 06:03I call abuse.
• 06:05Alcohol use disease of the liver.
• 06:10650 million people classified the
• 06:14stabilizer 700 millions of diabetes,
• 06:17and in addition to this. 5 epidemics.
• 06:21The inequalities and the difficult access
• 06:24to care the presence of millions of
• 06:29population that are underserved is another.
• 06:33Goals contributing to live everything is
• 06:35and we know the contribution of the risk
• 06:38factor exponentially increases the risk.
• 06:41So if you look at the data for
• 06:44chronically with disease in the US,
• 06:45this data always with some
• 06:47kind of approximation.
• 06:48However,
• 06:49what is reported is that 4.5 million people
• 06:53are living with chronic liver disease.
• 06:5690,000 dash.
• 06:59Recorded 70% for cirrhosis,
• 07:0230% dying with liver cancer and
• 07:05this is increasing as respect to.
• 07:082007 in addition, chronic liver
• 07:11disease caused the loss of 2.3 million
• 07:15disease adjusted life here in 2017.
• 07:19And on the right you can see
• 07:21this very interesting publication
• 07:24from the University Group.
• 07:27That look at the liver.
• 07:33Related loss in.
• 07:36Do you think Adjustive life here
• 07:38but 100,000 people and classify
• 07:41them by States and condition?
• 07:44And align them in a way of
• 07:47which you can see improving
• 07:50social demographic index.
• 07:51So you can see that.
• 07:55Poor social demographic condition
• 07:58in the US impact tremendously.
• 08:02Delay the disability adjusted life years
• 08:06for liver disease in the US and in fact.
• 08:10We know that leaving these years
• 08:13frequently affects the most vulnerable
• 08:16and underrepresented sector of society.
• 08:20And devices as these people.
• 08:23I don't know likely to remain unheard. So.
• 08:30The future is already here,
• 08:32but an evenly distributed. And.
• 08:36What we need to do? And this is a.
• 08:41Something that I heard from our own.
• 08:44Harlan krumholz.
• 08:46We need to realize that improving
• 08:48how we deliver care is perhaps as
• 08:51important as discovering new technology.
• 08:54There's no point in discovering
• 08:56new technologies that we cannot
• 08:57apply or apply only to. Few people.
• 09:02Well, Yale has always been. Value.
• 09:06Receptive to this concept and and and
• 09:09and try to also to be innovative and in
• 09:12fact back in 2012 and then in 2014 we.
• 09:16Already start thinking about how to
• 09:20apply the principle of value based.
• 09:23Medicine to have pathology.
• 09:24This was a meeting that we held
• 09:27under the edges of the liver center
• 09:29and when I say value based here,
• 09:31I don't imply value in terms of money.
• 09:35But as in the portal definition.
• 09:38Increase.
• 09:39Patient level value increased
• 09:42level level for the patient.
• 09:45We also, you know,
• 09:47published one of the first.
• 09:50Paper on on on the concept of value
• 09:54based care in a pathology and and back.
• 09:57At that time we we were considering
• 10:00the hepatology that highly intensity
• 10:03connective subspecialty that require
• 10:05multidisciplinary coordination,
• 10:06labor intensive support for critically,
• 10:09I'll patient and effective
• 10:12chronic disease management.
• 10:13And under the current system some.
• 10:17It could be difficult
• 10:19to align patient values,
• 10:20medical success and financial success.
• 10:23Now the formula that is on the right is the
• 10:25very well recognized as a formula value,
• 10:28but.
• 10:28There is more than that under
• 10:31the paradigm or the value care
• 10:33in a pathology in particular,
• 10:36the value based care requires team based
• 10:40multidisciplinary integrated service.
• 10:42Mike Matheson has alluded to
• 10:45that when he showed the variety
• 10:48and number of liver clinic.
• 10:51That we have that are devoted to specific.
• 10:56Conditions.
• 10:56In fact, the value based math is saying.
• 11:01Calls for liver services.
• 11:02Designed to meet the need of patient
• 11:04having in common and specific condition.
• 11:07That's requires integration of care.
• 11:10Difficult practice unit of program and
• 11:12this program must be designed around
• 11:15the Natural History of liver disease.
• 11:17But
• 11:21enable to collect.
• 11:24The value of which means the outcomes,
• 11:27the quality of life and the cost and.
• 11:30Have and be designed to facilitate
• 11:33the research and teaching on
• 11:36those specific conditions.
• 11:38As as Michael mentioned,
• 11:40we have several programs here at Yale.
• 11:45For for roses metabolically,
• 11:47the disease liver cancer,
• 11:50autoimmune cholestatic,
• 11:51transfer pathologist plus other
• 11:53that don't fit into the slide
• 11:57like viral potatis diseases.
• 11:59I could use a disorder and dependency and
• 12:02and in this table I'm trying to show.
• 12:06The multidisciplinarity of of this
• 12:10programs how many departments and.
• 12:15Section and subspecialty actually
• 12:18contributes to the success of
• 12:20this clinic and you just said.
• 12:23To read through and understanding
• 12:25how each of these program actually is
• 12:28embedded and integrated in in a multi
• 12:31departmental and multidisciplinary activity.
• 12:35Just want to give you the
• 12:36example of one of them,
• 12:38which is the.
• 12:41Liver cancer program and it
• 12:43really takes a village.
• 12:46To deliver care to this complex patient.
• 12:48And the multi disciplinary approach
• 12:51includes the hepatology intervention and
• 12:53then osteology hepatobiliary surgery,
• 12:56pathology, medical oncology,
• 12:58transport theology,
• 12:59surgical and transplant surgery and
• 13:01you can see that you you hear you
• 13:05see like 30 colleagues and each of
• 13:08them is really a leader in his own.
• 13:11Field and skill.
• 13:12It's an amazing thing,
• 13:14and through this we can offer.
• 13:17Everything from resection through
• 13:21locoregional treatment to.
• 13:26Systemic treatment and transplant.
• 13:28Not only that, but we can,
• 13:31you know, monitor the patient,
• 13:33give a. Holistic approach and.
• 13:39Address the comorbidities and so on.
• 13:45In addition, a program like this has
• 13:48also the ability to collect outcomes,
• 13:51and this can be very important
• 13:52and I give you an example.
• 13:54So this is the output collection for.
• 13:57The epiphyseal casino mat seen
• 14:00in our clinic and stratified by.
• 14:04Treatment so it is well known that the
• 14:08treatment is determined by the by the cancer,
• 14:12but as you can see we can see the effect
• 14:15of people that are transplanted through
• 14:17a 10 year look and and the effect of
• 14:20people that receive other treatment.
• 14:23So this way we can do research and we
• 14:26can also understand what we are doing.
• 14:31And and the fundamental thing here is that.
• 14:34There is. Healthcare in cancer.
• 14:38And excuse me, that is healthcare
• 14:41and science and there is
• 14:43science in the healthcare.
• 14:44And and and the point is.
• 14:47Going forward, given the.
• 14:53Size of the epidemiological
• 14:55problem that we need to face.
• 14:57We need to learn how to.
• 15:00Embed learning and science
• 15:02into the healthcare.
• 15:06In some way this is already happening.
• 15:10Because. I look at the publications
• 15:14that confirms believer.
• 15:16In the last 18 months. And divided
• 15:20by the affiliation of the lead out.
• 15:23So I have to say that many of
• 15:25these publications are actually.
• 15:26Very collaborative,
• 15:27but if you look at it.
• 15:32Hepatology is responsible
• 15:34for 44% of the publication,
• 15:37while the rest is actually distributed
• 15:41between internal medicine.
• 15:43Department of Imaging Endocrinology
• 15:46basically departments.
• 15:48Pathology School of Public Health.
• 15:52And so on and so forth.
• 15:53So mainly that there are hepatologists.
• 15:56In almost all of our departments,
• 16:00and they contribute not only
• 16:03to the care of the patient,
• 16:05but also to the science. And.
• 16:09So the other thing that we can establish
• 16:12is that leave a scholarship and
• 16:15practice at the transcend specialty.
• 16:17And Saxena and departmental boundaries.
• 16:24And I'm not alone in thinking
• 16:28this because recently.
• 16:30The Lancet, the Commission.
• 16:32Generated the work in collaboration
• 16:34with the European Association
• 16:36for the Study of the Liver.
• 16:38On, you know the future of.
• 16:42Care for liver patients and.
• 16:45Comcast and the leader.
• 16:47Also I'm quoting and I will quote in
• 16:50in a few a few times clearly says
• 16:52that although improvement in medicine
• 16:54have been driven by specialization,
• 16:56there is an increasing realization of the
• 16:59importance of multiple morbidities and
• 17:02hence the need for multidisciplinarity.
• 17:05And then we need to challenge
• 17:08the protectionist and invite
• 17:10the broad range of stakeholder.
• 17:12And including.
• 17:15Physician trained in a pathology,
• 17:18obesity, diabetes and so on, and so forth.
• 17:22So to achieve care models oriented more
• 17:26towards the patient center liver care.
• 17:29Across classic America boundaries.
• 17:33And the lever center is the
• 17:36motor of all this as Michael.
• 17:40Showed in great detail. And all that.
• 17:45I believe if expanded could
• 17:47also inform the liver practice.
• 17:50You you saw already disliked and
• 17:52show how this research team is
• 17:56actually integrates many of our.
• 18:01Clinical programs.
• 18:04With the strong. The research base.
• 18:07And how they live?
• 18:10A center is multidisciplinary by.
• 18:13Definition and I'm gonna go into this slide
• 18:17again because Michael has shown you this,
• 18:19but what that says is that.
• 18:23This multidisciplinarity and multi
• 18:26departmental approach is really ingrained.
• 18:30Into the motor of Yale,
• 18:32which is the liver center.
• 18:36But if pathology is most field of medicine
• 18:39is actually at the edge of a revolution.
• 18:42That will drastically change how we
• 18:45prevent diagnosis purely with disease,
• 18:47and this is something that we need
• 18:51to appreciate. And we need to also.
• 18:56Highlight the most liver disease is
• 18:59actually preventable and treatable.
• 19:01And also the risk factors of
• 19:03liver disease can be preventable.
• 19:05However, the clinical focus is impatiently,
• 19:09liver disease is oriented towards
• 19:12advanced disease and their complication.
• 19:15Rather than towards early
• 19:20irreversible disease.
• 19:22And this.
• 19:25Will require a fundamental shift.
• 19:29In which health promotion prevention
• 19:32and proactive case finding leading
• 19:34to early the identification of
• 19:37progressive disease and fibrosis.
• 19:39An early treatment will replace the emphasis.
• 19:43On the hospital base management of
• 19:46end stage liver disease complication.
• 19:49And this is a.
• 19:51Again, a beautiful picture from The Lancet
• 19:54Commission that I kind of rearranged,
• 19:58but it shows you on the left.
• 20:00The paradigm of liver disease.
• 20:04And progression so several insult to
• 20:07deliver generates fibro inflammatory
• 20:10response that can lead to cirrhosis and
• 20:13about the circus sinoma and a number
• 20:17of population based risk factors.
• 20:21Will concur to this.
• 20:24Outcome that we need to prevent.
• 20:27And to prevent this outcome,
• 20:29we need to stage.
• 20:32Intervention at 7:11 from population level.
• 20:36Management always factor treatment of
• 20:38early disease and early fibrosis and then.
• 20:44Hospital based treatment.
• 20:45So this is going to be a reversal
• 20:49of the current focus,
• 20:52which is increasingly focused on
• 20:55the management of complication.
• 20:57As we heard from a prior speakers.
• 21:00To a condition in which we will need to
• 21:03focus our our activity on the prevention,
• 21:06screening,
• 21:07early diagnosis and early therapy
• 21:09early this year.
• 21:10And this.
• 21:13To be achieved, we require sharing
• 21:16our responsibility for liver disease
• 21:18management between community based
• 21:20and hospital based providers.
• 21:22And you know to do this.
• 21:25We'll be facilitated by the digital
• 21:28transformation of a pathology.
• 21:30This is a beautiful.
• 21:34Paper just published on a pathology by.
• 21:37Our brothers and sisters from the Mayo
• 21:40Clinic and specifically by Vijay Shah,
• 21:43another year alumnus.
• 21:45That shows the impact that the
• 21:49appropriate use of information
• 21:52technology can impact the follow up.
• 21:56The early recognition of complication,
• 22:00the treatment of the preventive treatment
• 22:04of our patient, believe the disease.
• 22:08That could then be reached
• 22:11in a more effective way.
• 22:13Will be left to.
• 22:15Fight the stigma that.
• 22:21Is often given to patients with liver
• 22:24disease. We have working on that.
• 22:28We are beginning to change certain definition
• 22:30to change how certain diseases are called
• 22:33and this is important because stigma.
• 22:35Stigma is a bad bad effect on outcomes
• 22:38will lead to delayed care and avoidance to
• 22:42increase in the healthy behavior increase
• 22:45in healthcare and social inequality.
• 22:47Social isolation and increase
• 22:49in number of people will live.
• 22:52Who's the 360 degree? Effort that.
• 22:57Will be based not only on hospitals,
• 23:02but also outside. So.
• 23:07And and we are used to think
• 23:12to sustainability. You know,
• 23:14as a as as a balance between the the best
• 23:18possible outcomes and the affordable cost.
• 23:21But there are new paradigms that are.
• 23:24Coming in here.
• 23:26And it's clearly shown in a paper also that.
• 23:31Two of the authors are
• 23:33actually from from Yale.
• 23:34Have chair.
• 23:36Generative pollution is a big problem.
• 23:414.5% of CO2 generation
• 23:44is created by healthcare.
• 23:48And we will soon be.
• 23:50In a condition in which we will have
• 23:53to decide whether or not to ask
• 23:55for an ultrasound versus an MRI,
• 23:56not only the basis of the cost.
• 24:00But also whether we want to.
• 24:03Generate 2 kilos of fuel,
• 24:052 or 300 kilos of CO2 so that
• 24:10will add further complexity.
• 24:13To what we need to do,
• 24:14I have so in in in finishing.
• 24:18I think they look at what
• 24:19the future will hold for.
• 24:21For a lever we can.
• 24:25Staff from Sam.
• 24:26Basis and statement that
• 24:28hopefully will be shared.
• 24:31There is a terrific amount
• 24:32to leave a scholarship,
• 24:33but yeah,
• 24:34but this and this presents the section
• 24:36on the departmental boundaries.
• 24:38But it's very natural.
• 24:40Hepatology is a multidisciplinary
• 24:43multisystemic knowledge base.
• 24:44Medicine that is practiced that
• 24:48by scientists and physician
• 24:51with diverse background.
• 24:53The maintaining advantage excellence of
• 24:56the liver will require understanding
• 24:58of the challenge, innovative thinking,
• 25:00planning, investment and the vision.
• 25:04That is different from the
• 25:06vision that we had.
• 25:08To get to this point.
• 25:10Also,
• 25:10the clinical pathology is one of
• 25:12those discipline that cannot be
• 25:13separated from their research space.
• 25:15This is very important and I
• 25:17hope it transpires from the talk
• 25:19before the research and clinical
• 25:21pathologists must be fully integrated.
• 25:24But to achieve this goal,
• 25:25we need to develop a theme approach
• 25:27and the culture of mutual support.
• 25:31Because liver is at distracted.
• 25:34Calls for a collaborative model.
• 25:37And the NIH.
• 25:39And I did give you the center
• 25:42grant is an essential component,
• 25:44and it's likely a blueprint.
• 25:47For the future,
• 25:49but it still has a so-called has to
• 25:52have a narrow scientific cover focus,
• 25:55and so it will not cover all the
• 25:57needed opportunities and probably
• 25:59to achieve this goal we should
• 26:01create the House or yeah, leave it.
• 26:03That would be instrumental.
• 26:04To overcome sectional department
• 26:06of Barriers and meet the need of a
• 26:09patient from prevention to cure.
• 26:10And if we will be able to do this.
• 26:14Then the torch will be passed.
• 26:19In due time, again,
• 26:21whenever a new generation of libraries.
• 26:24Thank you very much.
• 26:35Thank you Mario 4IN.
• 26:37Very eloquent call to action and much needed.
• 26:40There was one question in the chat.
• 26:42I'd like to ask you and if you could
• 26:44give us a brief answer to it and
• 26:46then we would move to a short break.
• 26:48The question is about what do you
• 26:51think the role of tissue biorepository
• 26:53is in advancing clinical patient
• 26:55care as part of the integrated
• 26:57approach to solving liver disease.
• 27:00Yeah, I think it is an essential
• 27:04component in the afternoon.
• 27:07At 10 you will will speak about the
• 27:12effort that made that we are making to
• 27:16have an institutional biorepository,
• 27:18but I would like to spend one
• 27:23word about the real importance of.
• 27:27I wouldn't call it biopsy.
• 27:28It is a biopsy, but it's called tissue based.
• 27:32Analysis and research.
• 27:34Because now we are going match
• 27:37beyond the emetophilia housing
• 27:39and and specific staining.
• 27:41We can apply omics technology.
• 27:44We can apply single cell technology.
• 27:46There's a lot that the wealth
• 27:49of information to gather from
• 27:52that and to gather from.
• 27:55Institutional biorepositories that
• 27:57combine outcomes data and so on.
• 27:59So great question Gary,
• 28:01and I think this is part of the.
• 28:03What the future will hold?
• 28:05Great, thanks very much.
• 28:06And now for the audience.
• 28:08We will be taking a short break until
• 28:1011:00 AM today in 15 minutes or so,
• 28:13so I'd appreciate if you take a few
• 28:15minutes to view the congratulation
• 28:17videos under the thank You Video tab.
• 28:20And I'll see you soon.