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 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

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/

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

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 ALT >1000 has a narrow differential diagnosis

https://twitter.com/ebtapper/status/1031555677095948289?s=20

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

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

https://twitter.com/ebtapper/status/1622263807128092674

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

5 steps toward a killer talk
🧵 1️⃣practice by recording yourself on the memo app. Listen next day while walking. Refine. Repeat.

The best way to ensure best outcomes for your patient with variceal bleeding is to treat it

Sadly: 1 in 7 bleeds receives no endoscopic therapy

Why? 🧵

#livertwitter The top reasons I have seen are:

🚫But the varices weren’t bleeding at the time
✅varices bleeding can be intermittent. #cirrhosis plus hemetemesis and varices at EGD = band

🚫I couldn’t visualize with all the 🩸
✅take time, reposition patient, use eryrhromycin

Why do portal vein thromboses happen?

🧵#livertwitter minireview of recent studies This study showed that clots in the portal vein are associated with severity of portal hypertension

Not clotting factors or mutations
Not inflammation

https://twitter.com/ebtapper/status/1456954647214690312

A patient with diabetes and recent NSTEMI treated with stent, clopidogrel, and atorvastatin ~2 months ago is transferred from OSH with ALT 1500, bilirubin 15

The leading diagnosis is statin liver injury

But that's not what it is.

Not at all
🧵
#livertwitter #liverstory When she went to OSH, a bunch of tests were ordered

Blood tests (HCV ab, HAV, HBV surface antigen and core IgM, ANA, ASMA, IgG...) - all negative

Imaging (ultrasound, MRI) - nothing, no stones

OSH: It had to be the statin!

Narrator: But it wasn't

A patient with #cirrhosis and hepatic hydrothorax was admitted to an ICU 3 times for severe shortness of breath and hypoxia for urgent thoracentesis and diuretics

So we put in an indwelling catheter

Within weeks the output was minimal

What happened?

🧵
#livertwitter This patient had ascites (weekly paras), hydrothorax, & high MELD including INR of 1.9, and plt 32.

She was small, weak. Sarcopenic.

Her creatinine 1.3.

Preparing a talk

Some tips🧵 1. Stay under time

Going over is bad. Dont

If you feel you have too much to say, cover less. Focus your talk more.

Strip out unnecessary examples or explanation. How? See point number 2👇

some memories from liver clinic that make me happy when I think about them in this challenging year

#livertwitter "I'm me again!"
- A text from a patient after I prescribed lactulose

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Tomorrow is the last meeting of the @AASLDtweets Practice Metrics Committee (PMC) chaired by @AsraniSumeet

He is the kindest, most committed collaborator and has done so much to shape and support the future of #cirrhosis quality

#livertwitter @serperm 2/
Sumeet was chair of this committee after Michael Volk and @KanwalFasiha. Under their leadership, we:

1. Defined the key PROs in #cirrhosis: pubmed.ncbi.nlm.nih.gov/29272043/
2. Developed quality metrics for #cirrhosis that included the patient voice: pubmed.ncbi.nlm.nih.gov/30586188/
and

The hepatitis B vaccine is amazing.

It also has a wild backstory
Want to hear it?

A #tweetorial

1/

#livertwitter #MedTwitter First:

Hepatitis B sucks
1⃣About 3-4 in every 100 people have it
2⃣It causes liver cancer, #cirrhosis

But the vaccine rocks!
1⃣Prevents liver cancer!
2⃣Was first recombinant vaccine!

So let's get into it

2/

#livertwitter I don’t get the vitamin k thing. There is no known benefit (pubmed.ncbi.nlm.nih.gov/23080365/). And the harm is that It sends mixed signals. It undoes the teaching about the #cirrhosis coagulopathy. Because iv vit k is special and novel, it’s a consult rec that sticks. Needs reconsidering

1/

WHY are steroids used for alcoholic hepatitis?
SHOULD we?
WHAT is the deal with prednisolone vs prednisone?
WHERE did the discriminant function come from?
ARE you ready for a #tweetorial

#livertwitter #medtwitter #meded #cirrhosis 2/

Alcoholic hepatitis is a life-threatening acute liver injury featuring a liver full of necrotic cells, "Mallory bodies" of cellular junk, & severe inflammation (neutrophils)

Fig1: Mallory's original description
Fig2: Alc hep Mortality in 1966 according to bilirubin

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Why do we use NAC (n-acetylcysteine) for tylenol overdose?

A #tweetorial

tylenol is also known as paracetamol, acetaminophen, APAP
#livertwitter #meded #medtwitter 2/

Every year in the US alone, >50,000 acetaminophen overdoses are reported to poison centers, causing >110 deaths. Overdose can be intentional, though often accidental, always tragic.

There's an antidote: NAC. It saves lives.

Want to know how it was discovered?

We wanted to⬆️engagement with @JHepatology research
🤔Hypothesis: people are ⬆️ likely to connect with the people behind the research than the research itself
🧐Plan: Randomize papers to personal story tweets or graphical abstracts
🧐Primary Outcome: paper downloads
#livertwitter We found that story tweets garnered more downloads and tweet impressions

We conclude that showcasing the authors and their motivations in paired tweets is an effective strategy for research engagement

journal-of-hepatology.eu/article/S0168-…

Here is some unsolicited #TipsForNewDocs advice on the job search

#medtwitter #livertwitter #GITwitter
1/ 2/
Wrong: You'll have "all the resources you need"
What are these? Stats, research cores, coordinator pools...
These are...people!
You cant promise a person!

Right: Meet X, 25% of their effort will be directed towards your work if you gel. Or here is $$$ to hire Y.

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WHY is there a BABOON in my room?

A #tweetorial about the outcomes of hepatic coma, how far we have come, and how wild things got along the way
#livertwitter 2/

Up first: the lingo

Hepatic encephalopathy (HE) presents as a spectrum with subtle cognitive/motor deficits at one end (AKA "Covert HE") and coma at the other

HE/Coma can be caused by #cirrhosis (Type C, more common) and acute liver failure (Type A)

1/

WHAT the heck is GGT?

#tweetorial #livertwitter #medtwitter 2/

GGT = gamma-glutamyl transpeptidase

It’s an enzyme that transfers amino acids to proteins. It's found anywhere things need transferring (liver cells, bile ducts, kidneys, heart....)

No big deal, right?

Wrong!