hepatology

This conversation focuses largely on the work of the Global NASH Council, an effort of over 200 stakeholders in more than 50 countries to address a range of macro issues in the MASLD space.

Zobair Younossi, who is the Global NASH Council Chair, starts this conversation by discussing a specific Global NASH Council project on how to implement guidelines for different specialties across regions. He offers two reasons this is such an important project.

1. In general, Zobair notes, 90% of the content in guidelines is virtually identical, but the other 10% might vary widely. The goal of the Global NASH Council is to identify this last 10%, understand the reasons for these differences, and seek to align them better.
2. As he points out, guidelines are worthless without effective implementation. The second goal of this project is exactly that: to improve implementation.

Zobair goes on to discuss other Global NASH Council projects, ranging from shared biopsies to the previously mentioned modeling activities. He notes its growth in size and expresses gratitude to the other global MASLD leaders, including Jörn Schattenberg, who are part of one of more of the Council's major projects.

Roger Green asks Zobair to put the guidelines project and the Council's policy focus in the context of his earlier comments about high SDI vs. low SDI countries. He describes differences in what food insecurity means between the two types of nations and how that should affect each country’s pursuit of policy and guidelines. He also suggests that it will be more important to provide patient and provider information for specific low SDI countries.

Zobair Younossi, Chair of the Global NASL Council, publishes seminal papers  on MASLD epidemology, cost of disease, and related public health needs regularly. Co-hosts Jörn Schattenberg, Louise Campbell, and Roger Green ask questions and share perspectives from their own experiences.

00:00:00 - Surf's Up: Season 5 Episode 4
Opening introduction, including brief quotes taken directly from the episode discussion.

00:02:45 - Introduction and Groundbreaker
Panelists swap brief, lighthearted comments about where they are geographically and where they have been recently. In the groundbreaker, each shares one piece of good news from the previous week.

00:11:15 - Epidemiology article
Zobair Younossi discusses the recent review article, Understanding the Burden of Nonalcoholic Fatty Liver Disease, published earlier this month in Diabetes Spectrum. He starts by discussing incidence and growth rates for MASLD, MASH, and cirrhosis across the world, and how these differ by country. He goes on to discuss the impact of MASH on patient Quality of Life and the high correlation between multi-metabolic patients (most notably diabetics) and negative outcomes.

00:15:55 - Panel questions and comments
Jörn Schattenberg joins the conversation to praise this and other of Zobair's works for helping physicians know what to do when they decide to become more engaged in treating MASLD and MASH. This leads Zobair to discuss the Markov model they have created to evaluate burden of disease.

00:19:14 - Costliness and cost-effectiveness of therapy
In response to a question from Roger Green, Zobair describes the criteria and metrics used to evaluate the cost-effectiveness of a new drug or diagnostic. Louise Campbell comments on how high and underappreciated the social and economic burdens of disease are to every global society. Zobair notes that health economists do not focus on liver disease as a discreet set of costs and burdens.

00:27:17 - Goals and activities for the next few years
Roger states that given how fast the  MASLD and MASH populations are growing, an effort to "flatten the curve" would be heroic. Zobair replies that each country needs to fight liver disease, but that each country will have different immediate challenges.

00:31:28 - Women's health and liver health
Louise notes that the epidemiology paper refers to the high level of risks among women over 55. This leads to a discussion between Jörn, Zobair and Louise on the higher risk level post-menopausal women experience and some pathological elements that make this important.

00:34:58 - Global NASH Council
Zobair bridges this portion of the conversation to discuss the work of the Global NASH Council, a group of >200 members in >50 countries organized into different workstreams to create knowledge and awareness around MASLD and MASH.

00:38:59 - Low SDI and High SDI countries
To Zobair, one element in the global effort on MASLD and MASH is the recognition that High SDI (wealthier) and Low SDI (power) countries face dramatic differences in the challenges they face.

00:41:14 - Reducing the rate of disease growth
To Louise, educating women might be a key to driving awareness, both because post-menopausal women live at higher risks and because they cook and schedule for their families. This leads to a broader discussion about the most effective education starting with children. Finally, Zobair discusses the importance of making all stakeholders PLUS global agencies recognize the scale of this challenge and to act in concert with increasing urgency.

00:48:42 - Question of the Week
The first Question of the Week asks what steps each of us can take to help stem the pandemic.

00:49:41 - Business report
News on audience metrics, the first Question of the Week, next week's episode and this week's Vault conversation

This conversation ties up several issues related to MASH and the new MASLD nomenclature that the panel did not touch on earlier in the episode. These range from the impact the nomenclature might have on other elements of treatment to the impact of this effort over time. Finally, the panelists grade the process to date (they admit, their views might be a bit biased) and signs of success. 

Roger Green starts this conversation by asking what impact panelists believe the new MASLD nomenclature might have on NITs. From one perspective, Meena Bansal notes that it should have no impact given that NAFLD/NASH and MASLD/MASH map so similarly on top of one another. From a different perspective, Jeff Lazarus asks whether the nomenclature and accompanying guidelines from professional societies will result in more testing. The group aligns around the idea that patients living with Type 2 diabetes are an excellent target for increased testing with NITs given the high overlap of the two groups. Maru Rinella comments specifically that all efforts to tie T2DM to MASLD as frequently common metabolic diseases will be helpful and that discussing the proper use of NITs might be one way to make this connection. Louise Campbell agrees that increased focus on "Healthy Livers, Healthy Lives" will drive exactly these kinds of discussions. The rest of the episode consists of Roger asking panelists three questions, to which they respond: 

1. What might change over the next year or two? Meena believese that approval of a drug will drive significant growth in the learning curve and, with that, enhanced disease awareness and understanding. Jeff suggests that this will not take the form of a transition from NAFLD to MASLD, but instead that people first learning about the disease will use the new nomenclature properly. Mike Betel notes that on the Fatty Liver Alliance website, ~98% of searches are simply for "fatty liver disease." Over time, he anticipates this will change and also that websites like FLA will address "fatty liver" queries in terms of new nomenclature. 
2. Impact on ICD codes. Meena, who is doing significant work in this area, answers that the goal is to have no impact but simply a smooth cutover. 
3. How the group would grade its work on this activity to date. As Jeff notes, answers from the people who led the process are likely to be quite biased, but all gave fairly high grades. 

This conversation focuses on how the new MASLD nomenclature might improve providers' explanations of MASH to patients. Louise Campbell describes new opportunities, while Meena Bansal describes how focusing on metabolism provides a richer opportunity for providers to explain to MASH patients why fat on the liver matters.

Louise Campbell starts this conversation by discussing a new NHS program providing primary care centers with VCTE units they can use to screen patients for MASLD and MASH. She points out that this will provide a unique opportunity to present the new MASLD nomenclature to primary care and allied health providers in a way that connects immediately to diagnosing patients and educating them properly about their disease. She notes that at the patient level, the discussion is still likely to focus on excess fat on the liver but presents the idea of "fat" in a less stigmatizing way.

Meena Bansal focuses more specifically on exactly how provider-patient conversations might change. For years, she suggests, physicians have written "hepatic steatosis" on patient charts, but then told patients they "just have a little fat on the liver." In her view, the new nomenclature will take the word "just" out of the discussion and present the "little fat on the liver" as part of a metabolic syndrome that requires treatment. She goes on to mention another source of excitement: the ability to consider MetALD patients as part of the same MASLD community and add them to Mt. Sinai's longitudinal patient registry, which will likely become a rich source of MetALD data.
Earlier in the episode, Jeff Lazarus had mentioned his excitement at the growing role and publicity for the "Healthy Livers, Healthy Lives" initiative. Louise notes that increasing focus on liver awareness and awareness of the importance of liver health, as discussed in Season 5 Episode 2, aligns neatly with Meena's disease description and the new communication opportunities for new physician and allied health specialties.

This conversation shifts from the rearview to the path ahead. Louise Campbell starts by asking about the role of Allied Health Providers in the process. After this issue, process leaders Maru Rinella, Jeff Lazarus and Meena Bansal discuss how this will roll out as we move ahead.

It starts with Louise Campbell asking why there Allied Health Providers did not play a larger role in the Delphi process. Maru Rinella replies that, in her vision, this group’s involvement will be critical in the rollout and message development but less so in a Delphi process that was mostly about hashing out, as Maru puts it, “the nuances of the disease.” To Maru, this is also the place where patient voice brings the most pivotal value. Meena Bansal notes that there were some PAs and NPs in the Delphi process. Meena Bansal agrees that their role will be critical in discussions on how to communicate the disease to the patient (a topic we return to in later conversations). Louise appreciates, accepts and largely agrees with this discussion. 

Roger Green shifts focus from the past process to ask about the rollout phase: when it began, what it will include and when it might end. Meena says it will never end. Jeff Lazarus comments that while publication was the formal rollout, even before then groups were vying to be the first to change their names. He also noted that the article was published simultaneously in several journals with broad, rapid uptake in the literature. Since the key is to raise awareness and educate the population, he considers the speed and breadth of uptake a major sign of success. Maru Rinella comments that journal participation has been generally excellent.

This conversation focuses on the Delphi process for a new MASLD nomenclature. It starts with Jeff Lazarus describing what a Delphi process is and how it worked here. Jeff and two other key players in this process, Maru Rinella and Meena Bansal, describe what they consider some of its greatest strengths as well as one thing they wish had worked out better.

Jeff's description focuses on the four rounds of data gathering and some key activities that transpired before the formal process began. He goes on to identify what he considers some of the pivotal outputs of this one. In particular, Jeff describes the focus on patients with alcohol and diet issues, and the naming of a new discreet disease for these patients (MetALD) as being “revolutionary.” 

Roger Green agrees with Jeff's assessment that the naming of MetALD was an important outcome and that the process had clear benefits in this way. He goes on to ask why people opted out of the process. Maru Rinella comments that some people opted out after the third phase due to disagreements with the direction of the activity. Roger refines the question to ask why people opted out in the first place. Jeff and Maru note the amount of work required for this kind of activity, and he, Maru Rinella and Meena Bansal all describe that not all invitees understood how important this process would be upon first invitation. Jeff and Maru go on to mention that the participation rate was high, somewhere around 80%.

Roger asks what could have gone better. Maru, Jeff and Meena Bansal each note groups for which they wish participation had been broader, including possibly a broader representation of stakeholders (notably, more patients, although Maru notes this was not for lack of trying) and more organizations or countries.

This conversation focuses on the issues and visions that led to the identified need for a new MASLD nomenclature. Maru Rinella and Jeff Lazarus discuss the original goals of the process and how focus broadened and shifted throughout.

It starts with Maru Rinella describing what she terms “an existential crisis” for the field around a publication suggesting changing the name of the disease from “non-alcoholic” fatty liver disease to “metabolic” fatty liver disease. She considers this the main impetus for key global players to converge. Jeff Lazarus notes that stigma and several other processes came into the discussion. Maru and Jeff agree that the participant recruitment process came in two phases, one where it was hard to get participants and a later point where it was to manage the size of the exercise. Jeff felt the tipping point happened when people understood how the Delphi process would work and also the need for this to succeed. Maru felt that people had to grasp the implications of a consensus process, which Delphi is. As the conversation ends, another leader in the process, Meena Bansal and a patient advocate participant, Mike Betel of the Fatty Liver Alliance, describe how they came to enroll.

After a month off in January, SurfingMASH returns for the 2024 calendar year. In this conversation, the group explores the goal of provider and patient liver education, key goals for liver awareness and the potential for direct-to-consumer advertising of GLP-1s for weight loss to garble the "liver awareness" message. 

The dialogue underscores the concern that the convenience of telemedicine and the allure of easily accessible obesity treatments might lead patients to overlook comprehensive health assessments, especially for liver disease. The conversation reveals a broader concern about the health system's ability to ensure that treatments like Novo Nordisk's weight loss drug are used responsibly and with proper medical oversight.

Louise emphasizes the importance of being "liver aware" and advocates for integrating liver health into overall health assessments. She suggests that everyone, especially those prescribed weight loss medications, should have basic liver function tests to identify any underlying liver conditions that could be exacerbated by such treatments. The discussion also touches on the dangers of the black market and non-prescribed use of weight loss drugs, highlighting the need for education and responsible prescribing practices.

The conversation shifts to the potential impact of drug approval publicity and the need for health systems to educate both patients and healthcare providers on the comprehensive management of obesity, including liver health considerations. The speakers express concern that the hype around new treatments could overshadow the importance of holistic health assessments and lead to missed opportunities for diagnosing and treating liver disease.

After a month off in January, SurfingMASH returns for the 2024 calendar year. In this conversation, Jörn Schattenberg describes the challenges, opportunities and experiences that he has found in assuming Department leadership  at the University of the Saarlandes. 

Jörn shares his early experiences and aspirations as the new chair of a department, emphasizing the joys and challenges of transitioning into this leadership role. He lists the department's strengths and identifies 
opportunities for growth based on his own prior experiences. 

Jörn provides specific focus on his aim of enhancing clinical trials and diagnostic capabilities within the department. He discusses the importance of building a clinical study team and ensuring that physicians have the support and time needed to engage in patient recruitment for clinical trials. 

Separately, Jörn highlights innovative patient navigation systems already in place at Saarlandes, like the pager system that enables patients to move from appointment to. appointment within the hospital seamlessly. He discusses his desire to streamline outpatient diagnostics and improve collaboration with the radiology department for advanced imaging techniques. Jörn's approach is patient-centric, focusing on better treatment options and diagnostics, and he has received positive feedback from colleagues. 

The conversation underscores the significance of leadership in driving clinical and administrative improvements, fostering a collaborative environment, and enhancing patient care through innovative practices and a focus on liver diseases.

In continuation of the Surfing NASH interview series, this week Roger Green talks to Professor Oren Shibolet, Head of Gastroenterology and Hepatology at the Tel Aviv Medical Center. This is a powerful discussion which touches on the Hamas invasion on October 7 and its aftermath on the Israeli people and the practice of medicine today. Surf on to learn more about this current complex issue and more.

If you have questions or comments stemming from this episode, or the interview series in general, we kindly ask that you submit reviews wherever you download the discourse. Alternatively, you can write to us directly at questions@SurfingNASH.com.

Stay Safe and Surf On!

 Drs. Jennifer Lee and Temara Hajjat talked to Dr. Mercedes Martinez, a Professor of Pediatrics and Pediatric Gastroenterologist and Transplant Hepatologist from Columbia University, about diagnosing and managing pediatric patients with portal hypertension and esophageal varices.
 
Learning Objectives:

1. Learn the clinical and diagnostic signs of portal hypertension and varices in pediatric patients. 
2. Learn the management of portal hypertension in pediatric patients
3. Learn the management of acute variceal bleeding 

Produced by: Temara Hajjat

This episode is eligible for CME credit! Once you have listened to the episode, click this link to claim your credit. Credit is available to NASPGHAN members (if you are not a member, you should probably sign up). And thank you to the NASPGHAN Professional Education Committee for their review!

Links for this episode:
***

This episode is eligible for CME credit! Once you have listened to the episode, click this link to claim your credit. Credit is available to NASPGHAN members (if you are not a member, you should probably sign up). And thank you to the NASPGHAN Professional Education Committee for their review!

As always, the discussion, views, and recommendations in this podcast are the sole responsibility of the hosts and guests and are subject to change over time with advances in the field.

Check out our merch website!

Follow us on Twitter, Facebook and Instagram for all the latest news and upcoming episodes.

Click here to support the show.

In another special JPGN episode, hosts Drs. Jennifer Lee and Jason Silverman talk to Dr. Jennifer Vittorio about the important topic of healthcare transition for adolescents following liver transplantation, which is covered in the recent NASPGHAN position paper: Health Care Transition for Adolescents and Young Adults With Pediatric-Onset Liver Disease and Transplantation: A Position Paper by the North American Society of Pediatric Gastroenterology, Hepatology, and Nutrition.

This episode is eligible for CME credit!  Once you have listened to the episode, click this link to claim your credit.  Credit is available to NASPGHAN members (if you are not a member, you should probably sign up).  And thank you to the NASPGHAN Professional Education Committee for their review!

Links for this episode:

1. Transition post-transplant position paper
2. Got Transition

Learning Objectives:

1. Understand the important differences between healthcare transition and transfer of care
2. Discuss the six core components of healthcare transition
3. Review the dimensions of transition readiness and tools for their assessment

Produced by: Jason Silverman

This episode is eligible for CME credit! Once you have listened to the episode, click this link to claim your credit. Credit is available to NASPGHAN members (if you are not a member, you should probably sign up). And thank you to the NASPGHAN Professional Education Committee for their review!

As always, the discussion, views, and recommendations in this podcast are the sole responsibility of the hosts and guests and are subject to change over time with advances in the field.

Check out our merch website!

Follow us on Twitter, Facebook and Instagram for all the latest news and upcoming episodes.

Click here to support the show.

Co-hosts Louise Campbell and Roger Green are joined by friend of the podcast, Naim Alkhouri, and new guest, Professor James O’Beirne, to discuss learning from liver disease in Australia and developing improved models for patient identification and risk stratification.

This conversation starts with an introduction to James both personally and professionally. A Consultant Hepatologist at the Sunshine Coast University Hospital, James describes how he came to his work and interests around risk stratification in liver disease, particularly in NAFLD, hepatocellular carcinoma and portal hypertension. From here Louise shares a bit about why she feels the LOCATE-NAFLD study is compelling and well-worth an investigation on the podcast. Among her notes, Louise praises the study for its integration and comparison of different pathways and outcomes. At the bottom of the session, James provides a high-level overview of the study:

Rationale
NAFLD is the most common type of chronic liver disease in Australia. NAFLD is associated with a reduction in health-related quality of life, and as the number of NAFLD cases increase, the health system will incur increased costs associated with its diagnosis, management and disease progression. Currently, many patients who present to primary care with abnormal liver function tests or steatosis on liver ultrasound are referred for assessment in secondary care. Due to the large number of patients with NAFLD, this results in long waits for clinical and fibrosis assessment, placing unnecessary burden on the public hospital system. The study proposes to introduce better and faster assessment and stratification of patients in the community. As a result, the study aims to significantly reduce referrals for hospital-based appointments, and improve surveillance of high-risk disease, resulting in enhanced management of complications that result in avoidable, high cost admissions.

Study Design
The LOCATE-NAFLD study is a 1:1 parallel randomized trial to compare two alternative models of care for NAFLD (usual care versus LOCATE-NAFLD).

Usual care group

• Patients will attend a specialist hepatology clinic for their care.

LOCATE-NAFLD group

• Patients will be assessed by a specialist study nurse in the primary care setting, such as local general practice clinic.
• The specialist nurse will assess patients using mobile transient elastography, using a FibroScan machine.
• Scan results will be reviewed by the specialist nurse and hepatologist
• Patients with low levels of liver scarring will be referred back to their GP for care
• Patients with high levels of liver scarring will be followed up in secondary care hepatology clinics

Quality of life will be assessed for all patients at baseline and at 12-month follow-up via a questionnaire. The study will analyse intervention costs, hospital outpatient clinic utilization, hospital admissions, hospital costs and patient death data.

If you have questions or comments around the LOCATE-NAFLD study or any other ideas addressed in this episode, we kindly ask that you submit reviews wherever you download the discourse. Alternatively, you can write to us directly at questions@SurfingNASH.com.

Stay Safe and Surf On!

This episode covers coeliac disease.

Written notes can be found at https://zerotofinals.com/medicine/gastroenterology/coeliac/ or in the gastroenterology section of the 2nd edition of the Zero to Finals medicine book.

The audio in the episode was expertly edited by Harry Watchman.

This episode covers irritable bowel syndrome.

Written notes can be found at https://zerotofinals.com/medicine/gastroenterology/ibs/ or in the gastroenterology section of the 2nd edition of the Zero to Finals medicine book.

The audio in the episode was expertly edited by Harry Watchman.

This episode covers inflammatory bowel disease.

Written notes can be found at https://zerotofinals.com/medicine/gastroenterology/ibd/ or in the gastroenterology section of the 2nd edition of the Zero to Finals medicine book.

The audio in the episode was expertly edited by Harry Watchman.

This episode covers upper gastrointestinal bleeding.

Written notes can be found at https://zerotofinals.com/medicine/gastroenterology/uppergibleed/ or in the gastroenterology section of the 2nd edition of the Zero to Finals medicine book.

The audio in the episode was expertly edited by Harry Watchman.