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Elliot Tapper Profile picture
@ebtapper
Aug 13, 2020 • 3 tweets • 3 min read • Read on X
Hepatic encephalopathy (HE)

⬆️Mortality
⬇️Quality of life
⬆️Frailty

We want to intervene early!
But!
Predicting it is tough
No blood biomarker
Cognitive testing is <good, rarely done
There has to be a better way!

Check out: pubmed.ncbi.nlm.nih.gov/32773463/
#livertwitter #cirrhosis Image
We followed ~300 people with Child A/B #cirrhosis without prior HE.

Many developed overt HE

We derived a risk score - MASQ-HE - that outperfomed many others for prediction.

M - MELD
A - Activity impairment(0-10)
S - ChairStands/30 seconds
Q - QOL (SF-8)
#livertwitter ImageImage
Take home messages:

1⃣
We used symptoms to predict overt episodes.
And you can too!

2⃣
Listen to the patient
Ask about activity impairment
check chair-stands

These signs have prognostic power and could influence the decision to start treatment
#livertwitter

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More from @ebtapper

Elliot Tapper Profile picture
Jun 9, 2023
WHAT is the deal with Milk Thistle?
WHY is it used to treat liver disease?
HOW does it work?
DOES it work?
ARE you ready for a #tweetorial?
🧵
#medtwitter #livertwitter Image
Milk Thistle, a history:
1⃣Use to treat snake bites (Dioscorides)
2⃣To carry off bile (Pliny the Elder)
3⃣Great for liver disease (1500's: Otto Brunfels)
4⃣In 19th Century 🇺🇸, the 'Eclectics' popularized herbology, especially milk thistle, for the liver ImageImageImageImage
Fast forward to today:
1⃣Herbal supplements are a multibillion dollarindustry
2⃣A quarter of the population takes an herbal supplement
3⃣~5% of the US population is using Milk Thistle, including 12% of people with liver disease

What do they get out of it? ImageImage
Read 12 tweets
Elliot Tapper Profile picture
Jun 4, 2023
I once did a cost effectiveness analysis comparing shotgun vs deliberate testing for elevated ALT

pubmed.ncbi.nlm.nih.gov/27717864/ @JHepatology

We found that broad testing didn’t add much costs but increased false positives, especially when pretest probability of NAFLD was high
Then, In this RCT, John Dillon comparing usual care to broad evaluation of elevated liver enzymes, the cost per incremental diagnosis was 284💷 but was def cost-effective

pubmed.ncbi.nlm.nih.gov/31226388/
I don’t know of many examples of RCTs that confirm or support cost-effectiveness analyses so

A) cool!
B) understanding the differences in the results hinges on the assumptions in the model and the design of the RCT
Read 4 tweets
Elliot Tapper Profile picture
Jun 4, 2023
How to read a cost-effectiveness paper

This is a powerful method. But poorly understood, often maligned. My goal is to improve critical appraisal and help good analyses get the appreciation they deserve

🧵#MedTwitter CEA: cost-effectiveness analysis
A decision must be made!

All CEA begins with a clinical decision where we are uncertain about the best path forward. Nevertheless, when we face patients we must do something, even if that something is nothing. CEA brings our dilemma to life. Helping us quantify trade offs
Usually we compare a fair description of usual care to an alternative - make sure you agree the choice is fair, realistic, and represents an actual clinical dilemma
Read 20 tweets
Elliot Tapper Profile picture
Jun 2, 2023
An older man comes to the ED with abrupt onset nausea, & diarrhea

He is joined by her daughter whom he is visiting from abroad

Testing is below
The diagnosis is unclear
Until his daughter got just as sick too
🧵
#livertwitter #liverstory #MedTwitter Image
ALT >1000 has a narrow differential diagnosis



There's lots of tests you can order.
But most diagnoses are made in the H+P

Like this one

In fact, in this case, my attending said the diagnosis was obvious from the beginning

Just not to me
When I meet someone with ALT>1000, I think:

1⃣Ischemic hepatitis. Right 🫀failure? 🫀-genic shock? Cool legs?
2⃣Biliary 🪨. Pain? imaging!
3⃣Drug induced liver injury. Tylenol? Run every med through livertox.gov
4⃣Viral hep. Hep A/B/C

But these weren’t the answers
Read 16 tweets
Elliot Tapper Profile picture
Feb 6, 2023
The correct answer is variceal bleeding

First, the lactate is up. Take this patient seriously
Second, the obvious clues are lower hemoglobin, platelet consumption.
Third, the ammonia is crazy high. This seals the deal for variceal bleeding.

Why is that?

next slide please
Ammonia is a biomarker of badness

1. Liver dysfunction
2. Portosystemic shunting
3. Dehydration, renal injury (🫘eliminates nh3)
4. Sarcopenia (💪eliminates nh3)
5. Malnutrition

6. And upper GI bleeding
Where is all that ammonia coming from?

The answer is hemoglobin and albumin are isoleucine-poor. This means that when our blood enters the gut, it is not a nutritious source of protein. It gets broken down for waste. That waste, my friends, is ammonia
Read 9 tweets
Elliot Tapper Profile picture
Oct 12, 2022
5 steps toward a killer talk
🧵
1️⃣practice by recording yourself on the memo app. Listen next day while walking. Refine. Repeat.
2️⃣stay on time, preferably under. If 10 min slot, 9. If 15, 12. If 30, 25.
Read 6 tweets

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