First, I have mentors to thank. Dr Michelle Lai who gave me my start and launched me. @SenguptaNeil who taught me everything I know. And the reason I moved my family from Boston to a suburb of Detroit known away from good food, Dr Lok, the greatest mentor I will ever know
Second, I have advice. Find a place where you are surrounded by greatness and absorb it. It has been the great fortune of my life to work alongside and learn from people like JMellinger, @AkbarWaljee, and above all @NDP1001
Third, hepatology is special, everyday my patients inspire me. I have been lucky to work directly with my original inspirations - like Michael Volk and @KanwalFasiha. And my heroes in HE, @DebbieShawcros1 and the legend himself, @JasmohanBajaj
Finally, as anyone would attest, I would happily send one person a pile of old papers. Now I do that at scale. I am very thankful for my Twitter friends who have allowed me a platform to share in my love for the liver, people with livers, and those who do liver medicine
The end
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We find that a clinicians' pre-test probability of HE is the same as the post-test probability. But! not only does Nh3 add nothing diagnostically, when high it leads to excess lactulose use even when tested in people without #cirrhosis
Now we need to design the QI intervention
I have always wanted to do this study. Huge thanks to @juanjgonMD 4 doing it. Even if u dont care about Nh3, we are very proud of our design, which allowed us to assess the value of a test using the clinician's real-time reasons for testing and prior probability
👋Described~60 yrs ago by Adams/Foley
👋Methods:60pts w/impending hepatic coma vs controls
👋Flapping flexion/extension, best @ the🤚but happens even 2 the 👁️lids! Has intervening tremor (mini-asterixis)
Look 4 it while checking handgrip! #livertwitter 1/4
Why asterixis?
1⃣Adams/Foley:🤷
2⃣Ammonia? Unlikely!(fig1)
3⃣Precipitating factors? Asterixis, like HE itself, is a biomarker of badness: bleeding, infection, sedatives(Fig2)
4⃣They looked @🧠; swollen astrocytes! Particularly in the basal ganglia!(Fig3) #livertwitter 2/4
Why asterixis part 2
A study using magnetoencephalography showed:
1⃣There is 'excessive corticomuscular motor coherence' 2⃣Diseased basal ganglia fail to select and pace the motor areas
This seems to confirm what Adams/Foley found in the brain