Welcome to the Clinical Center Grand Rounds,
a weekly series of educational lectures for physicians and
health care professionals broadcast from the Clinical
Center at the National Institutes of Health in
Bethesda, MD.
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effort in training today's investigators and discovering
tomorrow's cures.
Learn more by visiting us online at http://clinicalcenter.nih.gov
TODAY, WE ARE HONORED TO HAVE Dr. JESSICA
MELLINGER, ASSISTANT PROFESSOR
OF GASTROENTEROLOGY AND Dr.
BIN GAO, CHIEF AND SENIOR
INVESTIGATORS OF THE LABORATORY
OF LIVER DISEASES, THE NATIONAL
INSTITUTE ON ALCOHOL ABUSE AND
ALCOHOLISM, THE NATIONAL
INSTITUTE OF HEALTH.
Dr. MELLINGER IS A
PROFESSOR AT THE UNIVERSITY OF
MICHIGAN.
SHE RECEIVED HER BACHELORS IN
ENGLISH LITERATURE AND
MICROBIOLOGY FROM THE UNIVERSITY
OF WYOMING.
SHE WAS A ROAD SCHOLAR EARNING A
MASTER OF HISTORY AND MEDIEVAL
HISTORY BEFORE THE SCHOOL OF
MEDICINE IN CHICAGO.
Dr. MELLINGER COMPLETED HER
RESIDENCY IN INTERNAL MEDICINE
AT THE HOSPITAL AND CLINICS AND
SHE COMPLETED A FELLOWSHIP IN
GASTROENTEROLOGY AND TRANSPLANT
HEHEPATOLOGY AT THE UNIVERSITY F
MICHIGAN WHERE SHE'S AN
ASSISTANT PROFESSOR.
Dr. MELLINGER'S CLINICAL
PRACTICE IS DEVELOPING NOVEL
BEHAVIORAL INTERVENTIONS TO HELP
PAY ENTERS STOP ALCOHOL USE AND
ENGAGE IN TREAT ALCOHOL
TREATMENT.
SHE FOUNDED A MICHIGAN ALCOHOL
IMPROVEMENT NETWORKS
MULTI-DISCIPLINARY ALCOHOL
ASSOCIATED LIVER DICE SEIZE AND
PERMISSIONS AND INVESTIGATORS
DEDICATED TO IMPROVING HOW
HEALTHCARE PROVIDERS AND SYSTEM
DIAGNOSE AND TREAT ALCOHOL USE
DISORDER.
THIS CLINIC IS ONE OF THE FIRST
FULLY INTEGRATED CO-LOCATED
TREATMENT CLINICS FOR ALD
PATIENTS.
SHE'S AN NIH-FUNDED INVESTIGATOR
THROUGH NIAAA TO STUDY
BEHAVIORAL TREATMENTS IN ALD.
Dr. MELLINGER IS BOARD
CERTIFIED IN TRANSPLANT HELP
HEPATOLOGY AND INTERNAL MEMBER.
SHE'S A MEMBER OF SOCIETIES
INCLUDING THE EUROPEAN
ASSOCIATION FOR THE SOCIETY OF
LIVER, THE RESEARCH SOCIETY OF
ALCOHOLISM, AMERICAN SOCIETY FOR
TRANSPLANTATION AND THE AMERICAN
ASSOCIATION FOR THE STUDY OF
LIVER DISEASE.
Dr. MELLINGER IS AN
INTERNATIONALLY RECOGNIZED
SPEAKER ON ALCOHOL-RELATED LIVER
DISEASE AS PUBLISHED OVER 50
PAPERS AND CHAPTERS FOCUSES ON
THIS EXPERTISE AND THE SUBJECT
MATTER.
OUR SECOND SPEAKERS IS Dr. BIN
GAO.
HE EARNED HIS DEGREE IN PH.D IN
CHINA POLLING POSTDOC TO BAL
TRAINING AT THE NIAAA AND
MEDICAL COLLEGE OF VIRGINIA HE
SERVED AS A TENURE TRACK ASSIST
APARTMENT PROFESSOR AT THE
MEDICAL COLLEGE OF VIRGINIA FROM
1995 TO 2000.
IN 2000, HE ACCEPTED A TENURE
TRACK POSITION AT THE NIH IN
ESTABLISHED A SESSION OF THE
LIVER BIOLOGY AT THE NIAAA.
AND IN 2009, Dr. GAO
ESTABLISHED A LABORATORY OF
LIVER DISEASES, BECAME CHIEF OF
LIVER DISEASES.
Dr. GAO'S RESEARCH FOCUS ON
LIVER IMMUNOLOGY AND BIOLOGY AND
PATHOGENS OF FATTY LIVER
DISEASES AND ARE ASSOCIATED
LIVER CANCERS.
Dr. GAO'S GROUP HAS INTRODUCED
NOVEL MORE ROBUST MOUSE MODELS
OF ALCOHOL AND SOCIAL LIVER
DISEASE, NON ALCOHOLIC FATTY
LIVER DISEASE AND ACUTE ON
CHRONIC LIVER FAILURE.
Dr. GAO'S GROUP HAS MADE
CONTRIBUTIONS OF ELECTRO
MECHANISM AND LIVER INJURY AND
REPAIR.
FATTY LIVER DISEASE AND LIVER
FAILURE AND THEIR POTENTIAL
TREATMENT.
Dr. GAO'S LAB HAS ALSO
IDENTIFIED A KEY SURVIVAL FACTOR
FOR A KEY ROLE IN LIVER FAILURE.
LEADING TO THE CLINICAL
TREATMENT FOR SEVERE ALCOHOLIC
HEPATITIS AND ACUTE CHRONIC
LIVER FAILURE.
Dr. GAO HAS PUBLISHED OVER 300
PAPERS AND IS CURRENTLY SERVING
OR HAS SERVED ON BOARD FOR
GASTROENTEROLOGY, GUT, HE A TOLL
GEE AND OTHERS AS WELL AS
ASSOCIATE EDITOR FOR SEMINARS IN
LIVER DISEASES, CELLULAR AND
IMMUNOLOGY AND THE INTERNATIONAL
FOR BIOLOGICAL SCIENCE.
Dr. GAO IS A FELLOW OF THE
AMERICAN ASSOCIATION OF STUDY OF
LIVER DISEASES AND RECEIVED
RECOGNITIONS FOR HIS WORK TO
INCLUDE ELECTIONS TO A MER
ADVERTISE SOCIETY FOR CLINICAL
INVESTIGATION.
AND IN 2020, HE RECEIVED THE
NIAAA INTRAMURAL SCIENTIFIC
ACHIEVEMENT AWARD FOR HIS
CONTRIBUTIONS AND WORK IN THE
STUDY OF ALCOHOL ASSOCIATED
LIVER DISEASE.
NOW, PLEASE WELCOME OUR FIRST
SPEAKER, Dr. MELLINGER FOR HER
TALK ENTITLED "INTEGRATED CARE
IN THE MANAGEMENT OF ALCOHOL
RELATED LIVER DISEASE.
IT'S A REAL HONOR TO BE HERE AND
I APPRECIATE THE INVITATION ON
THAT LOVELY INTRODUCTION.
THANK YOU.
THIS WAS ORIGINALLY ADVERTISED
AS THE INTEGRATED CARE
MANAGEMENT OF
ADRENOLEUKODYSTROPHY SO IF YOU
ARE HERE THAT'S NOT WHAT WE'RE
TALKING ABOUT.
I HAVE NO DISCLOSURES.
I'LL GIVE A BRIEF OVERVIEW OF
ALD TRENDS AND THE RESPECT TO
THE EPIDEMIOLOGY TO SET THE
STAGE FOR WHY WE'RE SEEING SUCH
AN UPTICK IN THE NEED FOR
INTEGRATED CARE AND WE'LL TALK
ABOUT WHAT INTEGRATED CARE IS
AND HOW THERE'S A REAL SPECTRUM
OF IT.
FOCUSING ON WHAT WE CAN DO AT
THE INDIVIDUAL AND BEDSIDE LEVEL
AND ALSO AT ORGANIZATIONAL LEVEL
AND THE TIME THAT WE HAVE TODAY.
SO, WE'LL START WITH ALCOHOL USE
AND ALD TRENDS IN THE U.S.
SO, OVER ALL, ALD IS RISING AND
ALONG WITH THAT THE MORTALITY OF
ALD IS GOING UP RATHER
DRAMATICALLY.
WHAT WE'VE SEEN OVER THE PAST 15
TO 20 YEARS IS ABOUT A
TWO-THIRDS INCREASE FOR DEATHS
FOR ALL CAUSE OF CIRRHOSIS BUT
WHEN WE LOOK AT DEATH RATES IN
YOUNG PEOPLE HERE ON THE
FAR-LEFT AND JUST FOR
ALCOHOL-RELATED DISEASE IN
GENERAL, WE REALLY HAVE SEEN
THAT RATES ACROSS ALL
DEMOGRAPHICS AGES, SEXES AND ALL
RACISM AND ETHNICITY HAVE
LARGELY SEEN INCREASES IN
CIRRHOSIS AND IN AL D AND ALD
AND WHY THIS YOUNG POPULATION
HAS HAVE MARKET INCREASES IN
ANNUAL MORTALITY BECAUSE OF
LIVER DISEASE.
IT'S BECAUSE OF ALCOHOL.
AND ALCOHOL USE DISORDERS AND
ALCOHOL-RELATED LIVER DISEASE.
THIS IS BEEN A REAL CHANGE IN
HOW WE THINK ABOUT LIVER DISEASE
AND HOW WE THINK ABOUT
CIRRHOSIS, WHICH WE PREVIOUSLY
SEEN DISEASE OF MIDDLE OR
LATER-MIDDLE AGE BUT WHICH IS
REALLY CHANGING NOW TO SHIFT TO
A YOUNGER POPULATION.
AND AS A CONSEQUENCE OF THAT,
THE BURDEN OF ALCOHOL LIVER
DISEASE IS CHANGING AND
TRANSPLANT AS WELL AND FOR THE
FIRST TIME, IN U.S. HISTORY, ALD
IS THE NUMBER ONE INDICATION FOR
LIVER TRANSPLANT IN THE U.S.
THIS IS A COMBINATION OF THE
FACT THAT ALCOHOL USE RATES AND
ALD RATES ARE GOING UP AND
BECAUSE HEPATITIS C IS TREATED
WITH DIRECT ACTING ANTIVIRALS
THAT THE PREPORTION OF
TRANSPLANTS BEING DONE FOR
HEPATITIS C HAS DROPPED, FAIRLY
DRAMATICALLY AND MUCH FASTER
THAN WE THOUGHT IT WOULD,
LEAVING US WITH ALCOHOL-SEWATED
LIVER DISEASE.
THIS GRAPHIC ON THE RIGHT YOU
SEE IS FOR ALCOHOLIC HEPATITIS
WHICH IS A SEVERE KIND OF ACUTE
LIVER FAILURE THAT Dr. GAO
WILL TALK ABOUT A LITTLE BIT
MORE.
THIS IS TRANSPLANTS FOR ACUTE
ALCOHOLIC HEPATITIS SO WE'RE
SEEING A PARADIGM SHIFT IN WHO
WE'RE TRANSPLANTING AND MORE AND
MORE CENTERS ARE TRANSPLANTING
PATIENTS CAREFULLY SELECTED
PATIENTS, WITH LESS THAN SIX
MONTHS OF ABSTINENCE.
SO, WHY IS ALD RISING?
BECAUSE ALCOHOL MISUSE ACROSS
THE NATION IS RISEING AND THERE
HAVE BEEN LARGE-SCALE
EPIDEMIOLOGIC SURVEYS THAT HAVE
SHOWN TRENDS IN ALCOHOL USE
RISING FOR MANY MEMBERS OF THE
POPULATION AND MANY
DEMOGRAPHICS.
AND THIS STUDY SHOWS THAT
MORTALITY FROM ALCOHOL USE
DISORDERS WAS INCREASING OVER A
20 TO 30 YEAR TIMEFRAME THAT IN
MOST OF THE COUNTRIES AND MUCH
OF THE COUNTRY WE ACTUALLY HAD
SEEN INCREASE THIS IS SOME CASES
FAIRLY DRAMATIC INCREASES IN
ALCOHOL USE DISORDER MORTALITY
WHICH INCLUDES ALD MORTALITY.
HERE WHERE I'M AT IN MICHIGAN,
KIND OF IN THIS MIDWEST AREA,
YOU CAN SEE THAT THE INCREASES
IN DEATHS FROM ALCOHOL AND USE
DISORDERS AND ALD HAVE REALLY
GONE UP.
SO WE'VE BEEN REALLY FACING THIS
CERTAINLY HERE IN MICHIGAN BUT
ELSEWHERE.
THE PANDEMIC DIDN'T MAKE THIS
ANY BETTER.
THE PANDEMIC ACTUALLY WORSENED
THESE TRENDS AND MANY OF YOU
HAVE HEARD ABOUT THE INCREASES
IN DRINKING THAT OCCURRED AS A
CONSEQUENCE OF THE COVID
PANDEMIC.
WHAT RECEIVE THEN THIS I STUDY N
PARTICULAR, THERE WAS A PEAK
ACROSS ALL RACES, ALL
ETHNICITIES, ALL AGES, SEXES, WE
SAW INCREASES IN ALCOHOL
CONSUMPTION IN THE EARLY PHASE
OF THE PANDEMIC AND THERE'S BEEN
SOME A TEN YOUATION OF THAT AS
THE PANDEMIC HAS GONE ON, AT
LEAST UP TO THIS STUDY'S TIME
POINT WHICH WAS A YEAR AND
CHANGE AFTER THE PANDEMIC BEGAN,
WHAT WE WERE FACING COMING INTO
THE PANDEMIC WAS A TSUNAMI OF
ALD AND NOW COMING OUT OF THE
PANDEMIC, IT'S GOTTEN EVEN WORSE
THAN WE EXPECT AND WE EXPECT TO
SEE MOREMENT WE PUBLISHED ON
THIS RECENTLY AND LOOKING
SPECIFICALLY WAIT LISTING AND
TRANSPLANTS FOR ACUTE ALCOHOLIC
HEPATITIS.
WE FOUND THAT IN THE EARLY
PANDEMIC PERIOD, WE REALLY DID
SEE A BIG SPIKE IN OUR WAIT
LISTINGS FOR ALCOHOLIC HEPATITIS
AND OUR TRANSPLANTS FOR ALCOHOL
AND ALCOHOLIC HEPATITIS WHICH
WERE FAR AND ABOVE WHAT WE WOULD
HAVE EXPECTED FOR THAT
TIMEFRAME.
THIS WAS CONFIRMED IN ANOTHER
STUDY THAT ALSO LOOKED AT THE
OVER ALL INCREASE IN ALD
TRANSPLANTS IN THE COVID ERA.
SO HOPEFULLY IT SETS THE STAGE
FOR WHERE WE'RE AT AND THAT
WE'RE REALLY SEEING A PROBLEM
THAT WAS A BIG PROBLEM EVEN
BEFORE COVID AND IT WAS RISING
BUT THEN WITH COVID IT'S JUST
KIND OF BEEN LIKE GASOLINE ON
FIRE IN TERMS OF WHAT WE'RE
SEEING WITH ALCOHOL USE, ALCOHOL
USE DISORDERS AND ALD.
THE SINGLE MOST IMPORTANT FACTOR
FOR ALD PATIENTS' SURVIVAL IS
ALCOHOL CESSATION.
WE DO NOT HAVE A LOT OF MEDICAL
THERAPY THAT CONSISTENTLY WILL
REVERSE THE COURSE OF THE LIVER
DISEASE AND IMPROVE MORTALITY.
WHAT REALLY WORKS IS ALCOHOL
CESSATION.
THOUGH WE CAN TRANSPLANT
PATIENTS, AS YOU CAN SEE BY THE
EPIDEMIOLOGIC CURVES WE DON'T
HAVE ENOUGH LIVES FOR THE
PATIENTS LISTED AND PATIENTS
THAT NEED THEM.
MOVING UPSTREAM AND TRYING TO
IMPROVE THOSE RATES OF ALCOHOL
CESSATION IS WHERE MANY OF US IN
THE FIELD HAVE BEEN LOOKING.
TO TRY TO GO UPSTREAM AT THIS.
NOW ALCOHOL CESSATION
INTERVENTIONS OCCUR AT MANY
DIFFERENT LEVELS.
WHAT I'LL TALK MOSTLY ABOUT IN
THE REST OF THE TALK IS THIS
YELLOW BOX, THE INTEGRATED CARE
EVERS EFFORTS THAT HELP AT THE
COMMUNITY LEVEL AND THERE ARE
MANY INTERVENTIONS, MANY OF
WHICH ARE HAPPENED ON THE
PATIENT-TO-PATIENT OR
PATIENT-TO-PRO PROVIDER LEVELS
AND OTHER POWERFUL INTERVENTIONS
IN THE FORM OF ALCOHOL AND DRUG
POLICIES.
TAX INCREASES, SETTING MINUTE
YUM UNIT PRICES ON ALCOHOL.
THERE ARE QUITE HELPFUL AT
REDUCING POPULATION-LEVEL
ALCOHOL USE AND BENDING SOME OF
THESE CURVES DOWN AND ALSO ARE
IMPORTANT BUT FOR TIME, WE WILL
FOCUS TODAY EXCLUSIVELY ON
INTEGRATING CARE EFFORTS HERE.
INTEGRATED CARE IS REALLY IS
INTER PROFESSIONAL COLLABORATION
AND COMMUNICATION AROUND THE
CARE OF A PATIENT AND WHAT WE
MEAN BY IT WHEN WE TALK ABOUT
RESPECT TO ALD IS THE COMING
TOGETHER OF ALCOHOL USE DISORDER
AND MENTAL HEALTH PROFESSIONALS
WITH MEDICAL AND HELP TOLL GEE
PROFESSIONALS TO CARE FOR THESE
PATIENTS TOGETHER AND THAT CAN
REALLY HAPPEN ON A SPECTRUM.
SO, AT OUR CENTER, WE STARTED
ONE OF THE NATION'S FIRST NON
TRANSPLANT INTEGRATED CARE
CLINICS FOR ALD PATIENTS WHERE
WE HAVE AN EMBEDDED
PSYCHOLOGIST, PSYCHIATRIST,
HEPATOLOGIST, NURSE, ALL
COLLATED IN THE CLINIC SEEING
PATIENTS TOGETHER.
NOW, THAT'S THE TOP-LEVEL OF
WHAT WE WOULD THINK ABOUT AS
INTEGRATED CARE.
MOST PATIENTS, IN FACT, MANY
PLACES CAN'T DO THAT OR DON'T
HAVE THE RESOURCES OF THE
INTEREST IN DOING THAT.
THERE ARE OTHER STEPS IN THE
INTEGRATED CARE SPECTRUM THAT GO
FROM JUST BEING COMPLETELY
UNAFFILIATE AND MAYBE NOT EVEN
UNDERSTANDING THE LINKS BETWEEN
ALCOHOL USE DISORDER TO MORE
INFORMAL INTEGRATION WHERE
PERHAPS CLINICIANS AND ADDICTION
AND HELP TOLL GEE ARE AWARE OF
ONE ANOTHER SERVICES AND PERHAPS
MAY REGULARLY REFER TO THE SAME
CLINICIAN.
ALL THE WAY UP TO, AGAIN, ACTUAL
CO-LOCATED CARE.
I'M THINKING ABOUT DIAGNOSING
THE DISORDER AND DIRECT THEM TO
AUD TREATMENT, TO GET THEM INTO
TREATMENT SO THAT DETECT,
DIAGNOSE AND DIRECT FRAMEWORK WE
USE IN OUR CLINIC AND ONE I USE
TO TRY TO GET MY PATIENTS INTO
CLINIC.
SO, INTEGRATING CARE CAN BE A
SIMPLE AND ONE OF THE SIMPLEST
INTEGRATED CARE TASKS THAT ONE
CAN DO IS TO SCREEN FOR ALCOHOL
USE.
BE AWARE OF ALCOHOL AS A
PROBLEM.
EVEN IF PATIENTS DON'T SEEM
ALCOHOL MIGHT BE A PROBLEM.
WE USE THE AUDIT C REGULARLY AND
RE WWERECOMMEND THIS.
THIS IS STANDARD FOR ALCOHOL.
THIS IS A SHORTENED
THREE-QUESTION VERSION OF THE
LONGER 10-QUESTION AUDIT.
AND THIS HAS DECADES OF
VALIDATION BEHIND BOTH OF THESE,
THE SHORTER AND THE LONGER
FORM.
AND WITHOUT THESE TYPES OF
SURVEYS, WE CAN REALLY
UNDERESTIMATE DRINKING AND OVER
ESTIMATE ABSTINENCE AND THIS
STUDY IS ONE THAT I ABSOLUTELY
LOVE.
IT WAS DONE IN THE TRANSPLANT
CLINIC IN A POST TRANSPLANT
CLINIC.
THEY LOOKED AT PATIENTS WHO HAD
ALCOHOL-RELATED LIVER DISEASE
TRANSPLANTED FOR THAT AND THEY
HAD IN A BLINDED FASHION
HEPATOLOGISTS ASK THEM IF THEY
WERE DRINKING AND THE PATIENT
GOT AN AUDIT C AND ADDICTION
SPECIALIST SAW THEM AND ASKED
THEM ABOUT THEIR ALCOHOL USE AND
BETWEEN THE SPECIALISTS THEY
PICKED UP 20% MORE SO 1/5 WERE
MISSED OF PEOPLE DRINKING MISSED
BY A HEPATOLOGIST ALONE ASKING.
15% MORE WERE ACTUALLY PICKED UP
BY AN AUDIT C SO IMPLEMENTING
THAT REGULARLY IN OUR PRACTICE
BY ITSELF MAY BE A MEANS BY
WHICH WE CAN DISCOVER DRINKING
AND REALLY CONNECT PEOPLE TO THE
TYPES OF RESOURCES THAT THEY
NEED TO NOT REGAIN ABSTINENCE.
THE OTHER ASPECT OF INTEGRATED
CARE THAT WE ALWAYS REALLY WANT
TO BE DOING IN TERMS OF
SCREENING AND LOOKING FOR
ALCOHOL USE, IS USING READILY
AVAILABLE DIRECT ALCOHOL
BIOMARKERS.
SO, BIOMARKERS COME IN INDIRECT
AND DIRECT FLAVORS.
INDIRECTION ARE THINGS LIKE
ELEVATED AST TO ALT LEVELS AND
AST TO ALT RATIOS OF TWO-TO-ONE
AND GGT LEVELS AND THOSE ARE
INDIRECT BUT DIRECT ALCOHOL
BIOMARKERS ARE BREAKDOWN
PRODUCTS OF ALCOHOL.
SO THESE ARE METABOLIZED
PRODUCTS OF VOLUME EX COTTAGE
COUNTREXCRETED INTHE AND IT'S BO
FIVE DAYS.
FOR THE URINE STUDIES, YOU HAVE
TO WATCH RENAL FAILURE THAT CAN
EXTENT AND PROLONG THAT
DETECTION TIME.
BUT THEY HAVE GOOD SENSITIVITY
SPECIFICITY AND THIS DATA SCHEER
IN LIVER DISEASE PATIENTS.
THIS IS THE VALIDATION IN LIVER
DISEASE PATIENTS IN ALD
PATIENTS.
WE DON'T REALLY USE HAIR.
THIS IS USED FORENSICALLY
BECAUSE IT TAKES A GOOD CHUNK OF
HAIR SO OUR PATIENTS DON'T WANT
TO GIVE HAIR.
IT GIVES DETECTIONS BACK SEVERAL
MONTHS WITH VERY GOOD DIAGNOSTIC
STATISTICS AS WELL.
AND THEN FOSSPHAIT ALCOHOL AND
THIS IS A BLOOD PRODUCT AND THIS
IS A ATTACHED TO THE RED BLOOD
CELLS AND DETECTED AND IT
DETECTS ALCOHOL USE ABOUT TWO TO
THREE WEEKS BACK.
AS YOU CAN SEE, THE DIAGNOSTICS
STATISTICS ARE ACTUALLY QUITE
GOOD ON THIS IN ALD PATIENTS,
THIS IS A DIRECT SIDE BY SIDE
COMPARISON OF THE PERFORMANCE
CHARACTERISTICS AND PERCENT,
CASH ROW HYDRATE IN THE PURPLE
IS NOT RECOMMENDED FOR USE.
THIS IS A INDIRECT BIOMARKER AND
IT'S INACCURATE IN ADVANCED
LIVER DISEASE SO WE DO NOT USE
THIS ANY LONGER.
URINE AND ETH HE WILL AND
ETHANOL SHOW AGAIN PRETTY GOOD
DIAGNOSTIC SENSITIVITY
CHARACTERISTICS AND THE WAY WE
USE THIS IN MICHIGAN WE GET BOTH
OF THESE.
TO GET KIND OF MORE RECENT USE
AND THEN A ETHANOL AS WELL TO
PICK UP ANY LONG-TERM USE AND
THE CHARACTERISTICS OF THESE ARE
ACTUALLY FAIRLY GOOD.
FALSE POSITIVES AND FALSE
NEGATIVES OCCUR SO BE AWARE OF
THAT IF YOU USE THESE WITH YOUR
PATIENTS AND DISCUSS IT UP
FRONT.
WE WANT TO MAKE SURE OUR
PATIENTS ARE AWARE THAT WE'LL
CHECK ALCOHOL BIO MACKERS AND WE
CHECK THEM NOT TO TRY TO CATCH
THEM IN THE ACTOR GET THEM INTO
TROUBLE BUT BECAUSE WE WANT TO
DETECT UNDISCLOSED ALCOHOL USE
SO THAT WE CAN GET PATIENTS
CONNECTED TO TREATMENT AND BACK
TO ABSTINENCE.
BECAUSE ON GOING ALCOHOL USE IN
THE CONTEXT OF ALD IS ACTUALLY
THE SINGLE BIGGEST PRO
DICTIONARY OR OF MORTALITY.
ON GOING DRINKING IF SOMEONE HAS
CIRRHOSIS, DOUBLES OR MORE THEIR
RISK OF MORTALITY IF THEY DRINK
ONE TO TWO DRINKS A DAY SO IT'S
IMPORTANT PEOPLE ABSTAIN AND TOX
SCREENS, AUDIT SCORES AND THOSE
THINGS ARE A WAY WE CAN DETECT A
PROBLEM AND THEN THEM INTO
TREATMENT.
WHY IS IT IMPORTANT TO INTEGRATE
FOR CARE FOR LIVER DISEASE.
THE LIVER DISEASE IS IT A HUGE
MOTIVATOR FOR CHANGE WITH
RESPECT TO ALCOHOL.
STUDIES OF STIGMA THAT SHOWN
THAT PEOPLE WITH CIRRHOSIS FEEL
STIGMATIZED HAVING CIRRHOSIS BUT
THE REASON IS BECAUSE THEY
ASSOCIATE, MOST PEOPLE ASSOCIATE
CIRRHOSIS WITH ALCOHOL USE.
SO, HIGHLY STIGMATIZED CONDITION
AND WHEN PEOPLE GET LIVER
DISEASE FROM THEIR ALCOHOL, THIS
IS A LEVERAGE POINT AND
MOTIVATION TO CHANGE.
THIS IS A GREAT STUDY OUT OF
ENGLAND WHERE THEY LOOKED AT
PRIMARY CARE AUDIT SCREENS.
THIS IS A PRIMARY CARE CLINIC
AND THEY DID A LIVER CHECKUP
THAT WAS A ALGORITHM WITH A
GREEN, YELLOW AND RED.
IF YOU WERE IN THE YELLOW-RED
YOU WERE MORE SEVERE AND MAYBE
MORE LIVER DAMAGE FROM ALCOHOL
WAS GOING ON.
IF YOU WERE GREEN, MAYBE LESS.
AND WHAT THEY FOUND WAS THAT
JUST BY DOING THE AUDIT SCREEN
AND PROVIDING THEM WITH SOME
LIVER-SPECIFIC FEEDBACK ABOUT
WHERE THEY WERE, ON THIS LIVER
CHECKUP, PATIENTS WHO HAD MORE
SEVERE LIVER DISEASE IN THIS
YELLOW AND RED CATEGORY AT ONE
YEAR AFTER, THAT INFORMATION,
HAD TWO-THIRDS OF THEM HAD HAD
SIGNIFICANT REDUCTION THIS IS
THEIR AUDIT GRADES SO THEY WERE
DRINKING LESS.
MAYBE NOT TOTALLY ABSTINENT BUT
THEY HAD ACTUALLY REDUCED THEIR
DRINKING DRAMATICALLY AND EVEN
ABOUT ONE-THIRD OF THE PEOPLE IN
THE GREEN CATEGORY HAD REDUCED
THEIR ALCOHOL USE.
SO THIS WAS REALLY AN IMPORTANT
STUD SKI'STUDY AND SHOWS THE I L
INTEGRATIONS INTEGRATING THE
ALCOHOL DISCUSSION WITH IN A
SYSTEM TIESED AWAY HAD A GOOD
OUTCOME.
WE ALSO WANT TO TRY TO CONNECT
PATIENTS TO TREATMENT AND THAT
CAN BE A REAL CHALLENGE IN OUR
STUDY OF ADMINISTRATIVE DATA,
PRIVATELY INSURED PATIENTS AND
ALSO IN A SUBSEQUENT STUDY IN
PITTSBURG BY SHERRY RECOGNIZEEL
AND THE CV THERE WAS A REALLY
LOW RATE OF ALCOHOL USE DISORDER
TREATMENT IN PATIENTS WITH
ADVANCED ALCOHOL RELATED LIVER
DISEASE.
SO THAT'S CIRRHOSIS OR ALCOHOLIC
HEPATITIS SO MOST ADVANCE FORM,
ONLY ABOUT 10%, 10% TO 15% OF
PATIENTS A YEAR AFTER THEIR
FIRST DIAGNOSIS OF
ALCOHOL-RELATED CIRRHOSIS GOT
INTO BEHAVIORAL THERAPY OR GOT
PHARMA CO THERAPY SO REALLY LOW
RATES.
BUT WHEN THEY DID GET INTO
ALCOHOL TREATMENT, THEY HAD
SIGNIFICANTLY LESS DECREASE
LIKELIHOOD OF DECOMPENSATION AND
THAT MEANS DEVELOPING GI
BLEEDING OR LIVER RELATED
CONFUSION.
THESE MAJOR CLINICAL POINTS AT
WHICH WE SAY SOMEONE IS GOING
INTO A MORE SEVERE CATEGORY OF
LIVER DISEASE THAT IS
DECOMPENSATION AND THOSE WHO GOT
INTO ALCOHOL TREATMENT WHEN THEY
WERE COMPENSATED HAD DECREASED
RISKS, 15% AT ONE YEAR OF
DECOMPENSATION AND THEY HAD A
DECREASE MORTALITY AND THERE
ISN'T MUCH THAT WE HAVE IN
ADVANCED ALCOHOL RELATED LIVER
DISEASE THAT DECREASES
MORTALITY.
BUT THIS IS IT.
GETTING INTO ALCOHOL TREATMENT,
REDUCING OR STOPPING YOUR
ALCOHOL USE IS REALLY CRITICAL
HERE.
AND THERE ARE A LOT OF REASONS
WHY PEOPLE DON'T GET INTO
ALCOHOL TREATMENT.
IT CAN BE MANY BARRIERS FROM
LOGISTICAL BARRIERS LIKE
INSURANCE COVERAGE, FINANCES,
CHILDCARE, TRANSPORTATION,
MINIMAL MENTAL HEALTH PROVIDERS,
SUBSTANCE USE PROVIDERS WHERE
YOU ARE AT BUT THE SINGLE
BIGGEST REASON IN MY STUDIES AND
IN THE BROADER ALCOHOL USE
LITERATURE, IS REALLY AN
ATTITUDINAL BARRIERS THAT IS
PEOPLE DON'T FEEL LIKE THEY NEED
TREATMENT AND THEY DON'T FEEL
LIKE THEY CAN DO IT ON THEIR OWN
AND BY AND LARGE THERE'S A SENSE
THAT THEY DON'T REALLY FEEL LIKE
THEY NEED IT.
THAT'S WHERE WE, AS MEDICAL
PROFESSIONALS, CAN COME IN AND
START TALKING ABOUT ALCOHOL
TREATMENT WHEN WE'RE TALKING
ABOUT THE MEDICAL TREATMENT.
NOT AS SOMETHING DIFFERENT.
ADDRESS THESE ATTITUDE NAL
BARRIERS UP FRONT BECAUSE PEOPLE
DON'T PAY ATTENTION TO THEIR
MEDICAL DOCTORS WHEN THEY TELL
THEM, YOU KNOW, YOU REALLY NEED
TO DO THIS FOR YOUR LIVER HEALTH
AND MEDICAL HEALTH AND TALK
ABOUT THE BENEFITS OF ALCOHOL
COUNSELING AND TREATMENT, NOT
JUST ON ALCOHOL CESSATION BUT
THEIR LIVER HEALTH, MEDICAL
HEALTH AND THE OTHER THINGS THAT
THEY CARE ABOUT LIKE, FEELING
BETTER AT WORK OR FUNCTIONING
BETTER IN LIFE OR HAVING BETTER
RELATIONSHIPS.
THAT MESSAGE COMING FROM A
MEDICAL PROFESSIONAL, IS REALLY
POWERFUL.
SO MOVING ON TO SOME KIND OF
BROADER MORE ORGANIZATIONAL
LEVEL INTERVENTIONS, WE'LL TALK
ABOUT INTEGRATED CARE KIND OF AT
THE CLINIC LEVEL OR HIGHER.
SO THIS IS A STUDY THAT LOOKED
AT, AGAIN, THAT KIND OF THE MOST
BASIC INTEGRATED CARE TASK THAT
NEEDS TO BE PERFORMED WHICH IS
SCREENING FOR THE ALCOHOL USE.
HERE AGAIN, IN ENGLAND, THIS
WAS, I BELIEVE, AT THE PORT
SMITH HOSPITAL IN ENGLAND THAT
HAS THE HIGHEST RATES OF
ALCOHOL-RELATED CONDITIONS AND
PROBLEMS OF ALL OF THE UNITED
KINGDOM.
THEY IMPLEMENTED A NURSE-LED
ALCOHOL SCREENING PROGRAM FOR
EVERYONE WHO CAME IN THEIR
HOSPITAL.
AND WHAT THEY SHOWED WITH THIS
WAS IT WAS VERY FEASIBLE, 90% OF
THE PATIENTS HAD A COMPLETED
SCREEN.
AND THEY WERE ABLE TO IDENTIFY
SOME HIGHER-RISK GROUPS
INCLUDING THOSE WERE HIGHER RISK
FOR ALD.
THEY CONNECTED THEM TO A
AUTOMATIC REFERRAL SYSTEM TO DO
A WARM HAND OFF TO AUD CARE
DEPENDING IF THEY WERE HIGH
VERSUS LOW RISK AND FOR THOSE
WERE LOWER RISK DRINKERS WHERE
THE EVIDENCE IS THE STRONGEST,
ANY MEDICAL PROFESSIONAL WAS
ENCOURAGED TO OFFER A BRIEF
INTERVENTION FOR ALCOHOL USE.
IN ADDITION, IN THE U.K. THEY
HAVE, FOR MANY YEARS, HAD
ALCOHOL CARE TEAMS AND THIS IS
REALLY KIND OF THE CREM DE LA
CREM OF INTEGRATED CARRYING
RIGHT.
YOU SEE FROM THE LIST HERE, THIS
INVOLVES A LOT OF COORDINATION
AND A LOT OF INTEGRATED CARE
TASKS THAT ARE BEING PERFORMED.
A LOT OF COMMUNICATION HAPPENING
ACROSS AWFUL THESE DIFFERENT
MULTI-DISCIPLINARY TEAM MEMBERS
BUT THEY'VE REALLY GONE TO
LENGTHS TO IMPLEMENT THESE
ALCOHOL CARE TEAMS AND WHAT THEY
SEEN IS THAT BY IMPLEMENTING
THESE, AND DOING THE RIGHT WORK
WITH IT.
LOOKING AT THEIR OUTCOMES AND
TAKING THOSE OUTCOMES AND MAKING
CHANGES ITERATING TO IMPROVE
THEIR QUALITY AND TO IMPROVE
THEIR OUTCOMES, THEY HAVE BEEN
ABLE TO SHOW REDUCTIONS IN ACUTE
HOSPITAL ADMISSIONS,
READMISSIONS AND PORTAL TEE FOR
ALCOHOL-RELATED INDICATIONS AND
THEY'VE IMPROVE T PROVED THEIR .
THIS IS A GREAT MODEL THAT MOST
OF US IN THE U.S. SHOULD BE
IMPLEMENTING.
THE NURSE-LED ALCOHOL CARE
TEAMS, AS OPPOSED TO THE
PHYSICIAN-LED CARE TEAMS
ACTUALLY HAD GREATER REDUCTIONS
AT SIX AND 12 MONTHS IN ALCOHOL
INTAKE AND GGT LEVELS SO THAT
BIO MARKER, THAT INDIRECT
BIOMARKER OF ALCOHOL USE.
SO AGAIN, JUST SHOWING THAT WE
REALLY NEED THE
MULTI-DISCIPLINARY CARE HERE.
IT'S NOT JUST PHYSICIANS DOING
T. IT'S THE ENTIRE TEAM COMING
TOGETHER.
NURSES, SOCIAL WORKERS,
PSYCHOLOGISTS, PSYCHIATRISTS AND
PHYSICIANS TO HELP THESE
PATIENTS.
IN THE TRANSPLANT WORLD, AGAIN,
THE TRANSPLANT WORLD IS OFTEN
VERY INTEGRATED JUST AT
BASELINE.
OUR TEAMS INCLUDE SURGEONS AND
SOCIAL WORKERS, NURSES,
HEPATOLOGISTS AND INCREASINGLY,
PSYCHIATRIST TREE, PSYCHOLOGY AS
WE RECOGNIZE THAT THE FACE OF
TRANSPLANT, PARTICULARLY LIVER
TRANSPLANT, IS VERY MUCH
CHANGING.
MORE AND MORE OF OUR PATIENTS
ARE COMING IN FOR TRANSPLANT
WITH VERY COMPLEX, UNDERLINING
PSYCHO, SOCIAL AND ADDICTION
ISSUES AND IT REALLY MANDATES
HAVING A STRONG, INTEGRATED
TEAM.
AND THIS STUDY, THIS WAS ABOUT
10 YEARS AGO IN ITALY, GEOVANNI
HAD SHOWN AN INTEGRATED ALCOHOL
ADDICTION UNIT IN A RIGHT IN THE
CLINIC, WITH THE TRANSPLANT
CENTER, ACTUALLY PRODUCED LOWER
RATES OF RELAPSE IN ALCOHOL AND
ALCOHOL RECURRENCE USING AN
OUTDATED TERM RECIDIVISM WHICH
WE HAVE MOVED AWAY FROM IN THE
FIELD, RELAPSE OR ALCOHOL USE
RECURRENCE AND THERE WAS NO
DIFFERENCE IN MORTALITY, THESE
DECREASES IN RELAPSE IN THE
ALCOHOL ADDICTION UNIT ARE
REALLY SIGNIFICANT.
BECAUSE RELAPSE OFTEN LEADS TO
DECREASED MEDICAL ADHERENCE AND
MORE REJECTIONS AND MORE OF THE
GRAPH LOSS NOWHERE RECURRENT
CIRRHOSIS.
WE HAD FOLLOW-UP OF SIX TO 12
MONTHS.
LONGER PEOPLE IF PEOPLE GO INTO
RELAPSE POST TRANSPLANT THEY CAN
GET RECURRENT ALCOHOL RELATED
CIRRHOSIS IN THAT GRAFT IN AS
LITTLE AS FIVE YEARS.
SO PREVENTING AND TREATING
ALCOHOL RELAPSE IN THE
TRANSPLANT WORLD IS INCREASE
BLEE IMPORTANT TO US.
THIS WAS A VERY INTERESTING
STUDY THAT IS DONE BY JAY LUTHER
AT MASSACHUSETTS GENERAL
HOSPITAL AND THEY DID A PILOT
STUDY OF AN INPATIENT LIVER
CONSULT SERVICE WHERE THEY WERE
INTEGRATED ALD DIAGNOSTICS WITH
ALCOHOL USE PATIENTS.
WHAT THEY DID WAS THEY HAD A
CONSULT SERVICE SAID IF SOMEONE
HAS ALCOHOL USE DISORDER OR
EXCESSIVE ALCOHOL USE IF THAT'S
IDENTIFIED, SO THE PROVIDER CAN
PLACE THIS CONSULT AND A NURSE
PRACTITIONER HEPATOLOGIST TEAM
WILL SPEAK WITH A PATIENT.
GIVE THEM LIVER FOCUSED
COUNSELING WITH THE COUNSELING
WE SAW FROM THE STUDY THAT WAS
EFFECTIVE IN PRIMARY CARE.
THEY'LL DO FIBER SKINS OR
BIOPSIES AND FIBER SKIN IS A
NON-INVASIVE WAY OF ASSESSING
FOR CIRRHOSIS AND ADVANCED
SCARRING OF LIVER DISEASE.
AND WHAT THEY FOUND IS THAT THEY
DID HAVE AN INCREASE IN THE
NUMBER OF PATIENTS WHO ARE SEEN
IN ALD CLINIC, 44% OF THOSE CAME
INTO THERE ALD CLINIC AFTER
THEIR DISCHARGE VERSUS ABOUT 27%
COMING IN WITH ACCESSORY FER
ALS.
ACCESS REFERRAL.THIS IS HOW WEE
THESE PATIENTS TOGETHER.
TIME PROVE OUTCOMES.
THIS WAS DATA THAT WE PUBLISHED
FROM THE FIRST YEAR FROM THE
FIRST 12 TO 15 MONTHS OF OUR ALD
CLINIC HERE AT UNIVERSITY OF
MICHIGAN.
AND TO SHOW FEASIBILITY IN THAT
ONE COULD DO THIS AND WHAT WE
FOUND WAS THAT, YOU KNOW, WE HAD
A LOT OF PATIENTS WHO COULD HAVE
BEEN REFERRED BUT ABOUT 89 WERE
REFERRED OVER THAT TIMEFRAME,
AND WE CERTAINLY HAD PEOPLE WHO
DID NOT COME IN BECAUSE THEY
KNOW-SHOWED OR WEREN'T INTEREST
OR BECAUSE THEY WERE TOO SICK
AND UNFORTUNATELY WE HAD
PATIENTS WHO WERE TOO SICK.
WE WERE ABLE TO FOLLOW ENOUGH OF
THOSE PATIENTS THROUGH A YEAR'S
PROCESS TO FIND THAT WE DID SEE
SOME IMPROVEMENTS, WE DID SEE
PATIENTS CONNECTED TO ALCOHOL
USE TREATMENT AND PREFERENCES
WERE LARGELY FOR ONE-ON-ONE
TREATMENT AND PEOPLE DIDN'T
ENJOY THE GROUP OR AA AS MUCH IN
OUR COHORT AND AT THE SIX-MONTH
POST VISIT, FOR SIX MONTHS AFTER
COMING IN VERSUS THE SIX MONTHS
PREVIOUSLY TO IT, WHAT WE FOUND
AND AGAIN THIS IS RETROSPECTIVE
FASHION, UTILIZATION OF THE
EMERGENCY DEPARTMENT AND THE
INPATIENT ADMISSIONS WERE DOWN
BY ABOUT 50% IN THIS GROUP WHO
GOT INTO CLINIC.
MOST OF THESE PATIENTS WERE
REFERRED FROM OUR OWN
HEPATOLOGIST SO THESE WERE NOT
PATIENTS WHO NEVER HAD LIVER
CARE AND WERE GETTING LIVER CARE
FOR THE FIRST TIME.
THE VALUE IS THE ADDICTION
SPECIALIST.
THEY ARE FOCUSED ON GETTING THAT
CO LOCATED INTEGRATED CARE FOR
THIS ADDICTION AND THEIR ALCOHOL
USE.
AND IN THIS VERY EXCITING AND
PROVOCATIVE EARLY DATA, WE FOUND
THAT WE HAD SIGNIFICANTLY 50%
LOWER RATES OF BEING SEEN IN THE
E.R. OR THE INPATIENT WARD 4
LIVER RELATED OR ALCOHOL RELATED
CONDITIONS.
SO MORE TO COME THERE.
WE'VE ALSO PUBLISHED THE COST
EFFECTIVENESS OF ALCOHOL USE
TREATMENT IN ALD.
THIS WAS REALLY THE FIRST STUDY
TO DO THIS.
WE FOUND THAT MEDICAL ASSISTED
THERAPY SO THIS IS THE RELAPSE
PREVENTION MEDICATIONS WHICH ARE
THE TWO FDA APPROVED RELAPSE
MEDICATION THAT'S CAN BE GIVEN
TO PATIENTS WITH LIVER DISEASE,
DIE SULFUR UM OR ANTIBUSE IS
INDICATED FOR RELAPSE BUT IT'S
NOT AND SHOULD NOT BE GIVEN TO
PATIENTS WITH LIVER DISEASE.
WE ANALYZED AND OFF-LABEL
RELAPSE PREVENTION MEDICATION
THAT'S HAVE DATA BEHIND THEM IN
LIVER DISEASE IN THE CASE OF
BACKLAFIN AND THE GENERAL
ALCOHOL USE DISORDER.
WE FOUND THAT ACROSS THE BOARD,
WHETHER YOU DID A RELAPSE
PREVENTION MEDICATION THAT WAS
FDA APPROVED, NON FDA APPROVED
OR JUST COUNSELING, ANY OF THOSE
SCENARIOS WAS MORE COST
EFFECTIVE THAN DOING NOTHING AND
IN MANY CASES IT WAS COST
SAVINGS TO UTILIZE THOSE IN A
POPULATION WITH ALCOHOL RELATED
CIRRHOSIS.
SO, NOT ONLY DOES INTEGRATING
THAT CARE FOR YOUR PATIENTS
GETTING THEM THE ALCOHOL USE
TREATMENT IMPROVE THEIR LIVER
DISEASE FROM ALCOHOL CESSATION
BUT GETTING THEM THAT TREATMENT
MAY BE COST EFFECTIVE AND COST
OF ACOSTSAVINGS AS A HEALTHCARE
COMMUNITY.
FINALLY, I BRING UP THIS STUDY
BY RAMONE BATIA BECAUSE THIS
SHOWED THAT THOUGH WE KNOW AND
WE HAVE A GREAT DEAL OF
KNOWLEDGE ABOUT WHAT IMPACTS
LIVER DISEASE AND WHAT IMPACTS
ALCOHOL-RELATED LIVER DISEASE
AND WE KNOW CLEARLY THAT ALCOHOL
REALLY THE LIVER DISEASE
PATIENTS GET WORSE IF THEY
DRINK, THE AMOUNT OF FUNDING
THAT IS DEVOTED TO ALD IS
NOWHERE NEAR THAT FROM OTHER
LIVER DISEASES THAT HAVE
SUBSTANTIALLY LESS CLINICAL
BURDEN.
SO ALD IS FAR AWAY, THE MOST
BURDEN SOME OF LIVER DISEASES IN
TERMS OF HOSPITALIZATIONS,
MORTALITY, NOW LIVER TRANSPLANT,
BUT IT GETS JUST A FRACTION OF
THE FUNDING FROM PHARMACEUTICAL
COMPANIES OR PUBLIC FUNDING
AGENCIES TO TREAT IT AND SO
HOPEFULLY THIS WILL CHANGE OVER
TIME.
THE TREND IN EPIDEMIOLOGY IS
CHANGING AND INCREASING BUT THE
INCREASING COST FOR INTEGRATED
CARE AND THE INCREASING NUMBER
OF PEOPLE WORKING ON THIS
CERTAINLY GIVES US A CAUSE FOR
HOPE.
WITH THAT I'LL END AND TURN IT
OVER TO Dr. GAO.
>>SO, FIRST I WANT TO THANK YOU
FOR THE INVITATION.
SO, Dr. MELLINGER JUST GAVE A
NICE OVERVIEW ABOUT ALCOHOL
ASSOCIATED LIVER DISEASE AND
ALCOHOL USE DISORDER AND THE
TREATMENTS.
SO TODAY, I WILL MAINLY DISCUSS
HOW OUR AT NIH HAS A STUDY AS A
PATHOGENESIS AND SEARCH
THERAPEUTIC TARGET FORWARD
TREATMENT OF ALCOHOLIC HEPATITIS
OVER THE LAST 20 YEARS.
SO I HAVE NOTHING TO DISCLOSE.
THE PROTEIN DISCUSSED IN THE
CLINICAL TRIALS WAS PROVIDED BY
GENARON.
EXCESSIVE ALCOHOL CONSUMPTION IS
TO THE FATTY LIVER SOME OF THEM
MAY PROGRESS INTO MORE SEVERE
FORMS OF LIVER INJURIES SUCH AS
ALCOHOLIC AND HEPATITIS AND
CIRRHOSIS AND THE LIVER CANCER.
MANY ARE PATIENTS WITH FATTY
LIVER OR ALCOHOLIC HEPATITIS DO
NOT HAVE SIGNIFICANT CLINICAL
SYMPTOMS.
SOME PATIENTS WITH ALCOHOLIC
LIVER DISEASE DO DEVELOP ACUTE
ALCOHOLIC HEPATITIS WITH A
SIGNIFICANT CLINICAL SYMPTOMS
SUCH AS JAUNDICE.
SO THE ALCOHOLIC HEPATITIS WAS
FIRST REPORTED IN 1961 AS ACUTE
LIVER DISEASE.
JAUNDICE IN ALCOHOLICS BY A
GROUP OF PHYSICIANS FROM THE
U.K.
SO THAT DETAILED DIAGNOSIS OF
ALCOHOLIC HEPATITIS WAS
PUBLISHED IN 2016 GASTRO
NEUROLOGY BY THE NIAAA CONSORTIA
THAT INCLUDED ALCOHOL DRINKING
HISTORY AND JAUNDICE AND THE LAB
TESTS.
SO THE SEVERE ALCOHOLIC
HEPATITIS HAS HIGH SHORT-TERM
MORTALITY.
FOR EXAMPLE, ON THE PATIENT WITH
DIS CRIMINAL INVESTMENT FUNCTION
MORE THAN EQUAL TO 32 ONE MONTH
MORTALITY IS 20 TO 50%.
IF THE MALE SCORES MORE THAN
THEN THE 90-DAY MORTALITY IS
20%.
SO THE CURRENT ONLY EFFECTIVE
THERAPY FOR THE END-STAGE OF A
SEVERE ALCOHOLIC HEPATITIS IS
LIVER TRANSPLANTATION.
THERE'S NO EFFECTIVE FORM
LOGICAL THERAPY FOR THE
TREATMENT OF SEVERE ALCOHOLIC
HEPATITIS.
SO THE ONE OF THE MAJOR PROJECTS
IN OUR LAB IS TO STUDY THE
PATHOGENESIS AND TARGETS FOR THE
ALCOHOLIC HEPATITIS.
SO WHAT IS THE MAJOR PROBLEM IN
THE LIVER OF THE SEVERE
ALCOHOLIC HEPATITIS?
THIS IS THE HISTOLOGY FROM THE
SEVERE ALCOHOL HEPATITIS AND YOU
CAN SEE THE LARGE NUMBER OF
INFLAMMATORY CELLS INFILTRATING
THAT LIVER.
SO THE FIRST IS A PROBLEM, MAJOR
PROBLEM IS TOO MUCH
INFLAMMATION.
IN ADDITION, YOU CAN SEE ON THE
PARASITES WAS DETECTED IN THE
LIVER SO THE SECOND MAJOR
PROBLEM IS NOT ENOUGH IN THE
REGENERATION.
SO WHAT OTHER TRIGGER FO FOR
INFLAMMATION.
THE TRIGGERS OF LIVER
INFLAMMATION ARE NOT CLEAR.
SO, HERE JUST LISTED SEVERAL
POTENTIAL TRIGGERS FOR THE
INFLAMMATION.
MANY PATIENTS WASTE ALCOHOLIC
HEPATITIS HAVE REASON TO BINGE
DRINKING.
SO, THOSE BINGE DRINKING COULD
COWS ACUTE HEPATOCYTE DAMAGE AND
TRIGGER INFLAMMATION.
MANY PATIENTS WITH ALCOHOLIC
HEPATITIS ARE ASSOCIATED WITH
BACTERIAL INFECTION WHICH CAN
TRIGGER LIVER INFLAMMATION.
THE BACTERIA OVER GROWS IS
ASSOCIATED WITH ALCOHOLIC LIVER
DISEASE CAN CAUSE GUT LEAKAGE
AND THE TRIGGER LIVER
INFLAMMATION.
FINALLY, ADAPTIVE IMMUNE
RESPONSES MAY OCCUR COME SOME
PATIENTS WITH SEVERE ALCOHOLIC
HEPATITIS DUE TO OXIDATED
MORTIFIED PRO.
THE TYPE OF INPRACTICE MISSION
IN ALCOHOLIC LIVER DISEASE ARE
STILL NOT CLEAR.
SO, WHETHER INNATE IMMUNE OR
ADAPT IMMUNE SPONSOR BOTH, ARE
IN ALCOHOL PICK AND LIVER
INFLAMMATION IN SEVERE ALCOHOLIC
HEPATITIS IS NOT CLEAR.
MANY METHODS CAN BE USE TO
EXAMINE THE INFLAMMATION.
SUCH AS IMMUNO CHEMISTRY,
QUANTITIVE REAL-TIME PCR, THIS
IS MANY PUBLISH DATASETS SUCH AS
MICRO ARRAY, RNA-SEQ AND SINGLE
CELL SEQ AND PROTEOMICS.
THEY CAN BE USED TO ANALYZE THE
INFLAMMATORY MARKERS IN SEVERE
HEPATITIS.
RECENTLY, WE PERFORMED THIS
MULTI-PLEX IMMUNO SO WE CAN
DETECT THE MANY CELL TYPES AT
THE SAME TIME AND ENABLE US TO
PHENOTYPE THE FOR SET OF OF
DIVERSITY OF THE SEVERE
ALCOHOLIC HEPATITIS AND THIS IS
A SPECIAL CONTEXT.
SO WE PERFORMED ON THIS MARKET
PLEX AND OF THE SEVERE ALCOHOLIC
HEPATITIS BY USING MULTIPLE
CELLULAR SURFACE MARKERS SUCH AS
CDA TO CD4 AND CD20 AND IBA ONE
FOR THE MACROPHAGES.
THIS IS REPRESENTATIVE IMAGE
FROM MULTI PLEX IMMUNO OF ONE
ALCOHOLIC HEPATITIS SAMPLE.
AS YOU CAN SEE, THE LARGE NUMBER
OF INFLAMMATORY CELLS ARE IN THE
MIDDLE.
ON THE HIGH, YOU CAN SEE MANY
ARE MACROPHAGES, T CELLS, AND B
CELLS.
ONE THING WE NOTICED THE
INFLAMMATION IS VERY DIFFERENT
FROM PATIENTS TO PATIENTS.
PARTICULARLY WE NOTICED THE
ACTIVE CORRELATION BETWEEN THE
NUMBER OF T-CELLS IN THOSE
PATIENTS.
HERE, ON THIS SLIDE, SUMMARIZES
A NUMBER OF NEUTROPHIL AND T
CELLS FROM 40 PATIENTS.
THIS PATIENT HAS A HIGH NUMBER
OF NEWT ROW FILLS.
SO THE CORRELATION BETWEEN THE
NEWT ROW FILL AND THE CD 4:00
CELLS WAS OBSERVED.
ON TYPES OF KNEW TREE FILL HIGH
AND THE NEUTROPHILS HIGH AND
LOW.
THEY SHOW FOR NEUTROPHILS AND
THE T CELLS IS ASSOCIATED WITH
THE STAGE OF LIVER FIBRO SIS.
SO HERE, BASED ON THOSE STUDIES,
WE PROPOSED TWO DIFFERENT HYSTE
PATHO LOGICAL PHENOTYPE OF
ALCOHOLIC HEPATITIS WHICH
SUGGESTED A DIFFERENT MECHANISMS
MAY CONTRIBUTE TO THE LIVER
INJURY AND THE FAILURE IN THOSE
PATIENTS.
IN PATIENTS WITH LESS FIBRO SIS,
NEUTROPHILS MAY PLAY MORE
IMPORTANT ROLE IN PROMOTING THE
LIVER INJURY.
BUT A PATIENTS WITH MORE FIBRO
SCISSOR CIRRHOSIS THE T CELLS
ARE HIGHER AND THE T-CELL MAY
PLAY A MORE IMPORTANT ROLE THAN
NEUTROPHILS.
TO STUDY THE IMMUNE CELLS IN THE
ALCOHOL PICK AND LIVER DISEASE,
SO WE NEED ANIMAL MODELS.
UNFORTUNATELY THERE'S NO GOOD
MOUSE MODELS WITH A SEVERE FIBRO
SIS CIRRHOSIS AND THE T-CELL
INFILTRATION SO IT'S A DIFFICULT
TO DISSECT THE FUNCTION OF A T
CELLS IN ALCOHOLIC HEPATITIS IN
MOUSE MODELS.
LUCKILY, WE DEVELOPED A MOUSE
MODEL WITH LESS FIBRO SIS BUT A
SIGNIFICANT NEUTROPHILS
INFILTRATION.
SO, WE CAN STUDY THE ROLE OF A
NANEW TREE FILLS IN MOUSE MODEL.
A CHRONIC LIVER INJURY MODEL WAS
DEVELOPED ON FIVE DECADES AGO
AND THE MICE WAS CHRONIC ALCOHOL
FEEDING FOR SIX TO EIGHT WEEKS
AND THOSE CHRONIC ALCOHOL
FEEDING LEADS TO THE FATTY LIVER
AND MILDER LIVER INJURY.
AND MACROPHAGE ACTIVATION BUT A
VERY FEW NEUTROPHIL IN THE LIVER
AND THEY HAVE THE MACROPHAGES.
SO RECENTLY, WE DEVELOPED ACUTE
AND CHRONIC LIVER INJURY MODEL
BY INTRODUCING INTAKE ON MICE
AND THE DETAILED PROTOCOL WAS
PUBLISHED IN NATURE PROTOCOLS.
THIS FEEDING PROTOCOL IS
DRINKING PATTERNS IN SOME
ALCOHOLIC HEPATITIS PATIENTS
RAISES SIGNIFICANT NEUTROPHILS
IN THE WATER.
IT DERIVED ACTIVE O OXYGEN PLAYA
ROLE IN ALCOHOLIC HEPATITIS
WHICH INHIBITING A MP KINASE OR
METABOLISM AND INHIBITING THE
ANTI INFLAMMATORY AND ANTI
MYCRON IN TWO AND THREE.
SO IN SUMMARY, WE THINK A SEVERE
ALCOHOLIC HEPATITIS HAVE TWO SUB
TYPES BASED ON THE RACIAL OF T
CELLS.
THE MACROPHAGES.
THE MACROPHAGES ARE THE MOST
ABUNDANT IMMUNE CELLS AND THEY
HAVE PROMOTING LIVER INJURY AND
ALSO PROMOTING THE LIVER REPAIR.
SO DEFINITELY WE NEED MORE STUDY
TO CHARACTERIZE THE FUNCTION OF
MACRO PAGES IN THE SEVERE
ALCOHOLIC HEPATITIS.
RECENT STUDY FROM OUR
COLLABORATOR AND DREW AND ALSO
ANDREW CAMERA FROM THE JOHNS
HOPKINS DEMONSTRATED THE B CELLS
ALSO PLAY A ROLE IN PROMOTING
ALCOHOLIC HEPATITIS BY PRODUCING
THE CROSS RADIO ANTIBODIES
AGAINST THE BACTERIA IN
ALCOHOLIC HEPATITIS.
MANY OTHER TYPES OF IMMUNE CELLS
WAS ALSO DETECTED IN ALCOHOLIC
HEPATITIS BUT THEY ARE FUNCTION
IN THE PATHOGENESIS OF ALCOHOLIC
HEPATITIS REMAINS UNKNOWN.
SO THE NEXT QUESTION WHETHER WE
CAN TARGET INFLAMMATION TO TREAT
ALCOHOLIC HEPATITIS.
YOU CAN SEE THERE ARE STEROID
THAT HAS BEEN USED FOR THE
TREATMENT OF ALCOHOLIC HEPATITIS
FOR MANY YEARS, SINCE 1970s.
THE TREATMENT IS STILL INCLUDED
TODAY FOR THE TREATMENT OF
ALCOHOLIC HEPATITIS.
BUT AS WE KNOW, THE STEROID
TREATMENT CAN CAUSE MANY SIDE
EFFECTS.
SO THUS THERE ARE SPECIFIC
INHIBITORS FOR THE INFLATION TO
TREAT ALCOHOL HEPATITIS ON EX
TENSE I HAVELY STUDIED OVER THE
LAST DECADE.
THERE IS PEP TOE SIS RECOGNIZING
TRIGGER THE LIVER INFLAMMATION
AND SO THUS IS INHIBITOR HAS
TEST IN CLINIC FOR THE TREATMENT
OF ALCOHOLIC HEPATITIS.
THE TRIAL WAS STOPPED DUE TO
BECAUSE THERE'S NO BENEFICIAL
EFFECT IT WAS OBSERVED.
SEVERAL YEARS AGO, A GROUP
DEMONSTRATORS INTRODUCED ONE
PLAY IMPORTANT ROLE IN PROMOTING
ALCOHOLIC LIVER INJURY IN MOUSE
MODELS SO THEY'RE TESTING THE
INHIBITOR FOR THE TREATMENT OF
ALCOHOL LIVER DISEASE.
THE TRIAL DATA WAS RECENTLY
PUBLISHED IN THE HELP HEPATOLOY
MARCH ISSUE.
THE PLUS ZINC PROVIDES A
SURVIVAL BENEFIT COMPARED TO
COURT CO STEROID THERAPY IN
ALCOHOL HEPATITIS.
AS YOU CAN SEE THE DATA FROM OUR
STUDY IS THE INFLAMMATION IS
VERY DIFFERENT FROM THE PATIENT
TO PATIENT.
THE PROBLEM IS A PERSON ANALYZED
MEDICINE IS THE REQUIRE TO
TARGET INFLAMMATION FOR THE
TREATMENT OF ALCOHOLIC
HEPATITIS.
BECAUSE THE BACTERIAL INFECTION
IT'S OFTEN ASSOCIATED WITH A
SEVERE ALCOHOLIC HEPATITIS SO
THERE AREN'T ANTIBIOTICS
TREATMENT ARE IMPORTANT TO
REDUCE INFLAMMATION IN ALCOHOLIC
HEPATITIS.
SO NEXT I WILL SWITCH GEARS TO
DISCUSS HOW WE TARGET ANOTHER
MAJOR PROBLEM HAVING IMPAIRED
REGENERATION IN THE LIVER.
BUT WITH THE LAST DECADES, TWO
DECADES OUR LAB HAVE EXTENSIVELY
SEARCHED FOR THE PROTECT OR
PROTEINS FOR THE TREATMENT OF
ALCOHOLIC HEPATITIS.
WE HAVE STUDIED MANY CYTOKINES
IN THE LIVER AND MOST OF THE
THOSE DATA SUMMARIZED IN ONE OF
THE REVIEW ARTICLES WE PUBLISHED
IN THE LAST YEAR CELLULAR.
ONE IS IN '22 AND WE THINK SIGH.
IT WAS CLONE FROM THE T CELLS IN
2000.
BASED ON THE STRUCTURE, IL-22
BELONGS TO IL-10 FAMILY BUT
IL-22 DOES NOT HAVE IL-10
INFLAMMATORY FUNCTIONS SO THE
FUNCTION OF IL-22 REMAINED
UNCLEAR AT THAT TIME.
SO OUR LAB WAS FIRST REPORTED
THAT IL-22 AND A PROTECT AGAINST
LIVER INJURIES IS SEVERE MODELS
SO WE TEST.
SO WE PUBLISHED THOSE DATA IN
2004 AND SINCE THEN, WE HAVE
EXTENSIVELY STUDIED THE I-22
BIOLOGY IN THE LIVER AND TEST
THE PROTECTIVE FUNCTION OF IL-22
IN SEVERAL MODELS OF LIVER
INJURY SUCH AS ALCOHOLIC LIVER
AND DRUG INDUCED INJURY, ACUTE
AND CHRONIC FAILURE AND THE NASH
AND THERE WAS A PHASE 2B TRIAL
FOR ALCOHOLIC HEPATITIS AND ON
GOING TRIALS FOR ACUTE AND
CHRONIC LIVER FAILURE.
THE IL-22 IS ALSO EPITHELLIAL
CELLS SO IT'S A CLINICAL TRIALS
FOR IL-22 TREATMENT OTHER ORGAN
FAILURE.
SO MOLECULAR MECHANISMS THAT ARE
TURNED INTO PROMOTE THE IS TO
ACTIVATE A STATUS 3 AND
EPITHELIAL CELLS WHICH IS
SIMILAR TO THE SO THE MAJOR
DIFFERENCE BETWEEN AND IL-6 IS
THE TARGET IN SPECIFICITY.
AS CAN YOU SEE HERE, IL-2 USES
THE RECEPTORS 2 AND IL-22
RECEPTORS 1.
THE IL-22 RECEPTOR 1 IS MANY
EXPRESSED IN THE EPITHELIAL
CELLS.
AND THE IL-6 AND THE GP130 AND
THE IL-6 AND THE GP-130 IS RIDE
WE EXPRESSED SO THEY TARGET
ALMOST ALL TYPE OF CELLS IN THE
BODY.
HERE JUST TO SUMMARIZE A KEY
FEATURE OF IL-22.
IT'S THE SAME USE IL-10 COMPLEX
AND IL-22 IS SPECIFICALLY
TARGETS EPITHELIAL CELLS AND NOT
IMMUNE CELLS.
IT'S A SIMPLE AND SPECIFIC
STATUS 3 AND IL-22 THERAPY
EXPECTED ON MINOR SIDE EFFECTS.
SO IR22 IS CYTOKINES PRODUCED BY
IMMUNE CELLS BUT DOES NOT TARGET
IMMUNE CELLS.
SO WE THINK THAT IL-22 MAY HAVE
THERAPEUTIC POTENTIAL FOR THE
TREATMENT OF ALCOHOLIC
HEPATITIS.
IN ADDITION, THE ALCOHOLIC
HEPATITIS IS ASSOCIATED WITH
BACTERIAL INFECTION AND ALSO AS
A COMPLICATIONS SUCH AS RENAL
FAILURE OR INJURY.
IL-22 MAY GENERATE ADDITIONAL
BENEFITS SUCH AS INHIBITING
BACTERIA INFECTION AND
PROTECTION AGAINST EPITHELIAL
CELLS IN OTHER ORGANS SO THAT'S
THE SHOT FROM MAYO CLINIC AND I
PROPOSED COMBINATION THERAPY FOR
THE TREATMENT OF ALCOHOLIC
HEPATITIS BY USING IL-22 AND
INFLAMMATION INHIBITORS.
Dr. SHAW LED A CLINICAL TRIAL
OF USE FC AND IL-22FC IS A TIME
OF MOLECULES AND BY FC AND AS
YOU CAN SEE THE IT'S LESS THAN
200 BUT AFTER INJECTION OF THIS
IL-22FC THE PEAK LEVEL CAN REACH
TO 900 PREMIERE AND ALMOST MORE
THAN 4,500 HIGHER THAN
INDIGENOUSES SO THE 18 PATIENTS
WERE TESTED AND THERE WAS A
SIGNIFICANT DECREASE IN THE
SCORE AND TOTAL WOULD BE AND
IMMUNO TRANSFERASE AT A DAY OF
42 AFTER I-22FC TREATMENT AND SO
INCONCLUSION, IT'S SAFE AND IT'S
ASSOCIATED WITH A CLINICALLY
SIGNIFICANT CHANGE IN THE SCORE
AND MULTI CENTER RANDOMIZED
CONTROL TRIAL IS WARRANTED COULD
CONFIRM THE EFFICACY TREATMENT
FOR THE ALCOHOLIC HEPATITIS.
SO, IN SUMMARY, THE TOO MUCH
LIVER INFLAMMATION IN THE
ALCOHOLIC HEPATITIS BUT AGAIN,
STILL ON THE EXACTLY WHAT TYPE
OF INFLAMMATION, WHAT TRIGGER
INFLAMMATION IS STILL NOT CLEAR.
SO THE FURTHER STUDY REQUIRED TO
IDENTIFY THE TYPE OF
INFLAMMATION OR THE TRIGGER
INFLAMMATION.
SO THEY'RE NOT ENOUGH HELP OWE
SIGHT IN THE REGENERATION SO I
IL-22 MAY HAVE A GOOD THEY ARE
PEWS I CAN POTENTIAL TO PROTECT
AGAINST INJURY AND PROMOTE THE
LIVER REGENERATION.
OF COURSE, AS A TREATMENT SUCH
AS ARTIFICIAL LIVER SUPPORT
SYSTEMS, TRANSPLANTATION, LIVER
STEM CELL TRANSPLANTATION MAY BE
REQUIRED TO SOLVE THIS PROBLEM.
LASTLY, I WANT TO THANK MY
FORMER LAB MEMBERS AND THE
CURRENT LAB MEMBERS FOR
CONTRIBUTE TO GO THE WORK I
PRESENTED TODAY.
I WANT TO THANK MANY
COLLABORATORS, Dr. SHAH AND
Dr. SUN AND Dr. SEW AND
Dr. CAMERON AND FROM INDIANA
AND Dr. BATALLAR AND SEVERE
ALCOHOLIC HEPATITIS AND PAL AND
GEORGE FOR THE MOUSE MODEL
STUDIES AND MY LAB IS SUPPORTED
BY THE INTRAMURAL PROGRAM OF
NIAAA.
I STOP HERE.
THANK YOU SO MUCH.
>> THANK YOU Dr. GAO AND Dr.
MELLINGER.
WE APPRECIATE YOUR VERY ELEGANT
PRESENTATIONS OFFERING US A
COMPREHENSIVE UNDERSTANDING AND
INSIGHTS INTO ALCOHOLIC LIVER
DISEASE.
FROM THE BOLD INFORMATION WITHIN
ALD AND ALSO THE CHALLENGES AND
THE TREATMENTS OF ALCOHOL USE
DISORDERS AND THOSE PATIENTS
WITH ALCOHOLIC LIVER DISEASE.
ESPECIALLY AFTER LIVER
TRANSPLANTATION.
WE HAVE TIME FOR A FEW
QUESTIONS.
THE FIRST ONE WE HAVE, THIS IS
ACTUALLY FOR Dr. GAO.
QUESTION -- DOES IL-22 INHIBIT
GUT LEAK?
>> YES.
SO, THE THEY EXPRESS HIGH LEVEL
OF ITR2.
MY COLLABORATOR.
THE DATA STUDY, PROTECT AGAINST
THE GUT LEAKAGE.
>> THANK YOU.
ON THE SAME LINES, MANY PATIENTS
WITH SEVERE ALCOHOLIC HEPATITIS
HAVE CIRRHOSIS WHICH IS A MAJOR
RISK FOR LIVER CANCER.
CAN YOU COMMENT ON THE POTENTIAL
EFFECT OF IL-22 THERAPY IN LIVER
CANCER IN PATIENTS WITH SEVERE
ALCOHOL HEPATITIS OR ACUTE LIVER
FAILURE.
>> Dr. Bin Gao: THIS IS A GREAT
QUESTION.
THE FIRST IL-22 IS NOT A CAR SIN
CARCINOGEN.
YOU CAN LIVER CANCER
PROLIFERATION AND FOR THE
TREATMENT OF ACUTE ALCOHOLIC
HEPATITIS, WITH IR-22 IS A SHORT
TIME.
IT'S THREE OR FOUR WEEKS.
SO IF THE PATIENT HAS POTENTIAL
LIVER CANCER WE PROBABLY WILL
NOT USE IL-22 TO TREAT THEM.
>> Tom: GREAT.
OK.
THANK YOU.
FOR Dr. MELLINGER, YOU
MENTIONED BIOMARKERS.
HOW DO YOU USE ALCOHOL
BIOMARKERS IN THESE INTEGRATED
CARE MODEL TEAMS?
IS IT ROUTINE OR SUSPECTED BY
INDIVIDUALS AND DO YOU HAVE A
PREFERRED ONE AND YOU KNOW, HOW
DO YOU USE THOSE IN
COMMUNICATIONS, THIS INFORMATION
TO PATIENTS WHO MAY BE
RELAPSING?
>> I THINK THE FIRST THING WE DO
IS MY ALD CLINIC IN MY
TRANSPLANT CLINIC WHEN I SEE A
PATIENT WHERE COLOR USE IS PART
OR ALL OF THEIR LIVER DISEASE.
I TELL THEM WE CHECK THESE
BIOMARKERS SO WE TELL THEM UP
FRONT WE'LL CHECK IT.
LIKE PEOPLE CHECK A HEMOGLOBIN
A1C IF YOU ARE DIABETIC.
THIS IS HOW WE FRAME IT.
IT'S LIKE ANOTHER MEDICAL
CONDITION.
WE'RE NOT TRYING TO DO THIS TO
CATCH YOU OR CATCH YOU OUT OR
ANYTHING LIKE THAT.
BUT THAT WE DO KNOW THIS IS A
CHRONIC CONDITION THAT OFTEN CAN
IN MANY PATIENTS RELAPSE OVER
TIME AND WE WANT TO HELP DETECT
THAT, IF THAT'S HAPPENING, AND
GET PEOPLE INTO TREATMENT.
SO, I START BY UP FRONT AND OPEN
COMMUNICATION WITH MY PATIENTS.
I DON'T SNEAK IT IN ON PEOPLE.
THAT IS A GOOD WAY TO DAMAGE
YOUR RELATIONSHIP WITH YOUR
PATIENTS.
AND WE TYPICALLY USE, AS I SAID,
PATH ETHANOL AT THE UNIVERSITY
OF MICHIGAN.
WE GET BOTH OF THOSE AND THE ONE
URINARY IS GETTING SHORT TERM
THREE TO FIVE DAY USE AND THE
PATH IS A LONGER TERM BACK USE
TWO OR THREE WEEKS BACK.
PATIENTS ARE OFTEN NOT USED TO
GETTING URINE FOR TOX TESTING
AND SOMETIMES MAYBE DON'T WANT
TO GIVE URINE OR WON'T GIVE
URINE BUT BLOOD IS MORE AMENABLE
BECAUSE WE'RE GETTING BLOOD FOR
OTHER THINGS SO THE PATH HAS
BEEN USEFUL IN THAT SENSE IF
PEOPLE CAN'T URINATE.
IT'S WHAT WE'VE BEEN USEING AND
HOW WE'VE BEEN USING THEM AND
COMMUNICATING BACK TO PEOPLE IS
ALWAYS A DELL INDI DELICATE, WAE
ANYTHING YOU FORGOT ABOUT OR ANY
ALCOHOL CONSUMPTION THAT MIGHT
HAVE SLIPPED YOUR MIND OR NOT
BEEN DISCLOSE AND WE CAN TALK
ABOUT YOU KNOW, WHAT MAY OR MAY
NOT HAVE HAPPENED.
FALSE POSITIVES OCCUR SO WE TALK
ABOUT THAT TOO.
>> Tom: THANK YOU, VERY MUCH.
YOU SHOWED SOME DATA SHOWING IN
SOME NURSING LED INTEGRATION
CARE TEAMS MAY HAVE BETTER
OUTCOMES COMPARED TO THE
PHYSICIAN-LED TEAMS.
I INSIGHTS WHY THAT MIGHT BE?
>> WELL, IN THAT STUDY, THEY
DIDN'T REALLY SAY, GET INTO THE
MECHANISM OF IT.
SO, I DON'T KNOW WHY IN THAT
STUDY IN PARTICULAR IT WAS THE
CASE.
IN MY OWN EXPERIENCE WITH THE
NURSING TEAMS THAT I WORK WITH
IN OUR ALD CLINIC, THEY'RE JUST
OUR NURSES ARE JUST PHENOMENAL
AND OUR PATIENTS OFTEN IDENTIFY
AND WILL TALK TO THE NURSES JUST
IN A DIFFERENT WAY THAN THEY
WERE WITH THEIR PHYSICIANS, YOU
KNOW, OFTEN TIMES, THE NURSES
ARE CALLING OUR PATIENTS AND
TALKING TO THEM IN BETWEEN THE
VISITS.
SO, PATIENTS MAY FEEL MORE
COMFORTABLE DISCLOSING SOMETHING
ABOUT ALCOHOL USE OR FEEL LESS
INTIMIDATED BY SOMEONE IN A
NURSINGEL ROLE AS OPPOSED TO THE
PHYSICIAN IN THE WHITE COAT WHO
INTIMIDATEING AND WHO MAYBE THEY
FEEL LIKE THEY HAVE TO IMPRESSES
SO THEY CAN GET A TRANSPLANT AND
THOSE TYPES OF THINGS.
SO, I THINK NURSING AS A
PROFESSION, IS TRAINED TO REALLY
HAVE THAT INTERACTION AND HAVE
THAT GOOD RELATIONSHIP WITH THE
PATIENTS AND I THINK IT SHOWS IN
DATA LIKE THAT AND HOW IMPORTANT
THAT IS.
>> Tom: WONDERFUL.
WELL, THAT TAKES US UP TO THE
HOUR.
I WANT TO SAY Dr. MELLINGER
AND Dr. GAO THANK YOU FOR
SHARING THE EXPERTISE WITH OUR
COMMUNITY.
I WISH BOTH OF YOU A GOOD
AFTERNOON AND TO EVERYBODY GOOD
AFTERNOON AND WE'LL SEE EVERYONE
NEXT WEEK FOR OUR NEXT TALK IN
OUR GRAND ROUNDS SERIES.
IT WILL BE ON SIMULATION
TRAINING AND HEALTHCARE.
THANK YOU, VERY MUCH AND
GOOD-BYE.