All right, well thank you to Dr. Reddy and Dr. Lucy for organizing and to the previous speakers for a really excellent overview of ALD around the world. And we're gonna finish with the U.S. perspective. And I've tagged it another disease of despair. Many of you may know or may not know that in the U.S. we are really in the middle of a number of epidemics of what are called diseases of despair. So substance use disorders, opioid use, suicide. And I believe alcohol-related liver disease is also kind of adding up to be another one of these diseases of despair as I'll show you. We'll look at three major issues. The epidemiology of ALD and AUD in the U.S. Some reasons for the rise in ALD, some of which are similar to what you've heard from our previous speakers. And then some challenges and opportunities in the fight against ALD in the U.S. So to begin, like many areas around the world and like Dr. Asrani showed us in the global overview, alcohol-related cirrhosis and ALD in general are really rising. This was data that we published from a large employer-sponsored privately-insured group that showed that even in this relatively higher socioeconomic status group, even across just a seven-year period, we saw an increase in prevalence of about 43% over a very short period of time. And again, kind of echoing what we've heard from other speakers already, really rising in the young and in women. And again, this is a relatively higher socioeconomic status and so this data really gets even worse when we look across the United States. And what we see here is that, again, in the young in particular and in women, we saw really dramatic rises in a relatively short period of time, just about 15 years here, in the death rates from alcohol-related liver disease and alcoholic cirrhosis. And not only that, but in the box to your lower right, what we really saw was that, again, in that young age 25 to 34-year-old group, that millennial age group, we saw rises in alcohol use disorders. And again, these are the percentage increases. This isn't just absolute numbers. This is the percent increases in our population in alcohol use disorder, alcohol-related liver disease, and cirrhosis, and in people actually dying of these diseases in our young and in the women. And as a consequence, we've seen the burden of transplant really change in the U.S. Recently, Brian Lee published earlier this year that really for the first time in U.S. history, alcohol-related liver disease has taken the top spot. With the drop in hep C prevalence as a consequence of direct-acting antiviral therapy, we've really seen ALD rise to the top. And we've seen more transplant for alcoholic hepatitis as well, which I'll talk about in a moment. There was some findings that came out this year in the U.S. about how we might do this in a better way. So why is this happening? Well, it's largely happening because alcohol consumption has gone up in the U.S. This is data from a very large epidemiologic survey that is done roughly every five years by the NIH Alcohol Research Division, the NIAAA. And what it showed in this graphic was that overall, alcohol use just in general had risen. So you see, as we expect, that the greatest prevalence or percentage of people who are drinking are younger, so that 18 to 44 age group drinking at all, although we saw rises across all demographics and all age groups across these timeframes. But high-risk or binge drinking also rose. And again, the story is the same. It's rising mostly across all demographics, but it's rising predominantly in the young and also in women. And we actually saw a pretty decent increase in those who are over 65, interestingly. And I will say in some of my clinics, in my ALD clinic that we have, I am seeing this. I am seeing some more individuals who are in their late 50s, early 60s. They've maybe lost a job. They've had a later-in-life divorce. And whereas they had fairly well-controlled alcohol use, moderate use, suddenly it spikes. And here they are with acute alcoholic hepatitis. So the overall prevalence of that age group is a bit low, but it is rising along with the rest. And finally, and this is the one that scares me the most, this is the alcohol use disorder increase. So when we think about alcohol misuse, alcohol use disorder is the most severe. This is what we think about when we think about addiction. So people who have a compulsive, somewhat uncontrollable desire and need to consume alcohol and do so in very high levels. And what we see here is, again, across all age groups, across all racial and ethnic categories, across all, across genders, we're seeing increases fairly dramatically. In women, it went up by 80% in that five- to 10-year period, or excuse me, that 10-year period. And in the young people, we saw a commensurate large rise in this 18- to 29-year age group. Why does this really matter? The younger that people start using a substance, the tougher it is to get off of it, and the more likely they are to use more substances, use them more heavily, and be tougher to treat. So it's this really young age group that we're seeing that really has us concerned, and has many of us thinking that we have only seen the tip of the iceberg when it comes to ALD in the US. And broadly, across the US, we're seeing alcohol use disorder mortality rise in many areas. The suicide graphs look about like this, except everything is red across the US. It's really pretty bad, including with opioid use. I'm not sure what's happening in North Carolina and South Carolina down there, but they appear to be doing pretty well right down there. Anybody from there who knows, let me know, because I'm not sure what's happening, but it seems to be going down. But across the rest of the US, alcohol use disorder rates are rising, and mortality from that is rising. So why might this also be resulting in an increase in ALD? Well, as previous speakers have pointed out, obesity also acts in a synergistic way with heavy alcohol use to increase your risk of alcohol-related cirrhosis, alcohol-related liver disease. It also can portend a more severe course of alcoholic hepatitis. That data has been around for quite some time. And in the US, along with the rest of substance use, we have a very large, if you'll pardon the pun, obesity epidemic. This is the most recent data from the Center for Disease Control that shows that substantial swaths of the country are seeing more than one in three of every individual obese. The graphics, which I'm not gonna show here for the sake of time, for those of Hispanic origin and those who identify as black, are even worse than this. So those graphs look even worse. So we're seeing it also in specific racial and ethnic groups even worse. Excuse me, and again, as we saw from prior discussions, alcohol use plus central adiposity and the metabolic syndrome results in significantly greater risk of advanced liver disease. And this was actually data that was out of Northern Europe, but it does show that when individuals are drinking in kind of a fashion that increases with the amount of alcohol, in the presence of central adiposity and diabetes, or diabetes, you see an increased risk of liver cirrhosis, admissions for liver cirrhosis, and decompensation. And of course, in the U.S., we are seeing even more of this as we go forward with more metabolic syndrome, more diabetes. So this year, the AASLD released its ALD guidance. I was on the writing committee of that along with Dr. Lucy, who's here in the audience today. And when we think about patients who have comorbid liver disease, so who maybe have metabolic syndrome, NAFLD and NASH, the recommendation from the AASLD for those folks is no alcohol at all. So not even one to two drinks a day should be consumed if an individual has NAFLD, NASH, or any other type of liver disease. In the U.S., a standard drink is 14 grams per drink, and this is a graphic that shows you kind of what that looks like in terms of a can of beer, a glass of wine. It's not those nice, big, huge glasses of Chianti that you see on TV where they're relaxing with what's probably about four or five glasses of wine in there. It's also one shot. That's one drink. And certainly one thing we can all do is educate our patients on what is a drink, where we're at, where we are at in the world. In the table to your right, you can see that different countries have different definitions of how much alcohol is in one drink. So knowing that and knowing how to educate your patient about that is really important. I just had a patient in clinic the other day who said, I drink three drinks a day, that's all. She's putting about five or six shots in every drink. So she's actually consuming about 15 to 18 shots per day, but was thinking she was doing pretty good by only doing three drinks a day. So what did we recommend in terms of diagnosis? This is really critical. If we're gonna manage alcohol-related liver disease, we've gotta manage the alcohol, so we have to diagnose it. And what we recommend is screening. At every touchpoint with the healthcare system, people should be screened. You can do this by asking. There's a one question, you can ask one question from the NIAAA, so you can ask one question, how frequently do you have that binge drinking definition? More than four drinks in a session if you're a woman, more than five if you're a man, and that can send you down a pathway of asking them more. You can ask them the Audit C questions. That's really quick, really easy, and it's really accurate. It actually picks up quite a bit of drinking. You can also use, and we recommend in our guidelines, using alcohol biomarkers. And these are urine, blood, they're also our hair moieties that pick up alcohol in your urine or bloodstream to a variable degree of time before the test. The most common ones that are in use now and the two that we recommend the most in our guidance are the urinary ethylglucuronide and the phosphatidyl ethanol. Urinary ethylgluc and its companion, ethyl sulfate, are urine breakdown products of alcohol use that are excreted. This is not affected by liver disease. This has been validated in advanced liver disease. It is affected by kidney failure, so you may see more prolonged positives for this in people who have kidney failure. But it is very accurate above certain cut points. There, so we do recommend that people use these. Phosphatidyl ethanol is a blood moiety, so this gets, whereas urinary ethylgluc is getting about three to five days prior of alcohol use, this is getting about two to three weeks prior for alcohol use. So this can really help to discover alcohol use in your patients, not so you can get them into trouble, not so that we can pull them off the list or be punitive, but so that we can find slips and relapses and get them into treatment. And this is how I talk about this with my patients. This is why we do this. This is like the A1, hemoglobin A1c for diabetes, right? So it's gonna help us know if people have been drinking to get them into treatment. This also is not influenced by liver disease. It has been validated in advanced liver disease in somewhat of a yes-no fashion. There is a bit of a dose-dependent response to the level and how high a number gets, but I think about it in kind of a yes-no, did you drink, did you not drink, above a certain point. Realize that there are differences in the pharmacokinetics and so you need to be aware of those when you're interpreting. So we also recommended in the guidance that, in terms of what to do about the drinking, because again, as we all know, people who keep drinking with alcoholic cirrhosis, alcoholic hepatitis, die. It's just that simple. The data is crystal clear that any amount of alcohol in people who have advanced ALD increases their mortality by at least double if they're drinking one to two drinks a day and it just goes up from there. So getting them into AUD treatment has become really important in the U.S. It's quite critical because it runs along with mental illness. So one of the other recommendations from the guidance was multidisciplinary care and integrated care within your medical clinic, if you can, produces better outcomes and this has been shown in several randomized control trials of alcohol use treatment in U.S. patients with integrated care or without it. So when the mental health professional is in the clinic with you. And this is largely because, as you can see here, the rates of mental illness and comorbid substance use disorder are very high in this population. So if we look here, almost everybody who has alcoholic cirrhosis or ALKEP, at least in my clinics, has a moderate to severe alcohol use disorder. Look at those numbers. There is a substantial comorbidity with other substance use as well as with other tobacco use disorders and other mood disorders. And that really mandates a referral to our mental health colleagues or some type of multidisciplinary care. Now obviously mental health access in the U.S. is a major challenge. I thought of putting a Jackson Pollock painting up here to show you what a graphic of the U.S. healthcare system looks like. Because it is very, very hard to navigate in many cases and it is different at the local level, at the state level, at the national level. But by and large, if you have, there are some barriers in terms of lack of insurance coverage. If you have limited mental health substance use coverage, if you're on Medicaid, there are a number of Medicaid restrictions. So Medicaid is a state level health insurance for individuals who are of lower socioeconomic status. There can be many limitations on duration, high co-pays, and the classic not having enough mental health providers. Mental health suffers in the U.S. from the exact same access issues that we do as gastroenterologists. There are significant attitudinal barriers to mental health access amongst our patients as well, mostly that they don't feel like they need it is a big one. But they also have some concerns about stigma and social anxiety and privacy issues. Treatment access rates are quite low in this population. And this was, again, a study that we performed, again, in a privately insured population, so relatively high socioeconomic status, three quarters of which had mental health substance abuse access, 90% of which had prescription drug access. But the AUD treatment access rates were very, very low at a year after your alcoholic cirrhosis diagnosis. Only about 10% of patients ever saw a psychotherapist or a mental health provider. Only about 4%, 4% to 5% actually had a relapse prevention medication prescribed for them. So these rates are very low. We have a lot of work to do in that venue. ALD patients do differ from AUD patients in that they often think that, they often have this decision to stop drinking sort of thrust upon them from the outside. And they don't really make that decision necessarily themselves. So that can certainly be a challenge when dealing with mental health providers. So the new model really is to treat this, treat the alcohol use disorder and the ALD across the life of the whole liver. So not just from the time of transplant when people are showing up and we're very aggressive about assessing them and getting them into mental health treatment, but to also think about this through the whole life of that patient, from whether they need transplant or they don't need transplant, all the way through transplant and into the after transplant period. To this end, what we have started at the University of Michigan is a multidisciplinary alcoholic liver disease clinic that is not a transplant clinic. These are the individuals that are involved in that clinic. Our structure of it is to bring together addiction psychiatry, psychology, social work, nursing, as well as a hepatologist, myself, in order to really take good care of these patients and try to provide them with the necessary care that they need to move forward and get better. I can certainly speak with any of you who are interested in kind of how we've done that and what we've been doing with that, but we hope to have some results of that out in the coming year. And then just very briefly, there was a major conference this year that Dr. Risrani organized to try to codify a bit more at the U.S. level about exactly how should we be doing transplant for alcoholic hepatitis. Obviously, the full details of that will be out in a paper coming out this coming year. But very briefly, several of the recommendations that did come out from this conference were that it was something that could be considered because outcomes were good based upon the existing published U.S. and international experience, but also that we really needed to standardize our reporting, our auditing, have a lot of transparency, and that we were really abandoning the six month rule in favor of a more detailed assessment of these patients going forward for acute alcoholic hepatitis. So some of the suggested listing criteria here that came out from Dallas, I will let you read. Most notably, however, was really the need to be able to speak to the patient and assess their insight, assess their acceptance of their diagnosis, and to really be able to know what type of alcohol use treatment they've had before. So if they've had many, many rehab attempts, perhaps this isn't quite the right individual that we want to go forward with transplanting. But more to come from that great conference that was earlier this year in April, I think will provide us with some good guidance on how to help these very severely ill patients. So I appear to have lost my summary slide, but in sum, alcohol use disorders and ALD in the U.S. are really rising along with some of these other diseases of despair, but with some of these more local solutions of more multidisciplinary care, and moving towards increasing transplant for LCAP, we hope that we can begin to turn the tide on that. So thank you. All right, now we'll have some time for discussion. If I may, could I ask the speakers to come up to the podium, and we'll open it up for discussion. Mike? Yes. All right. Yes, this session is open for discussion, and if I may, well, start off by asking a question. Well, I wanna ask a question of Shiv, and perhaps someone from Africa can address this as well. So Shiv and Sumit as well, so if you look at the data, there are certain mortality assigned to alcoholic liver disease, but I guess the question is, could that be an overestimate? Because in these areas, there is a high prevalence of hepatitis B and C, so how certain are you that the death is from alcoholic liver disease, and it's not from, say, viral hepatitis, which could be easier to compare? I'll start off with a junior opinion, then the senior can correct me. So it's interesting you bring that up. What we had actually done, actually 10, 15 years ago, we had looked at hepatitis C and alcohol liver disease, and what we had seen is that in the 19, or early, in 1980s, alcohol was high, and then in the 1990s, suddenly alcohol went down, and hep C went high, and that was not really because the epidemiology changed, but we were just misclassifying patients, and that's why it rose, so part of this could actually be misclassification. I'll take your point of view, but it is clearly, during my last 30, 35 years, I see there's a substantial increase in our own. We started at maybe 5% or 10% of alcoholic liver disease, or alcohol-associated liver disease, of the 100, and hepatitis B used to be 40 to 60%, but now, almost 40 to 50% of the hospital admissions for liver are due to alcohol. You take it China, you take it India, you take any part of that, so there may be some overlap, but clearly, alcohol has become a dominant player. Just a follow-up question to that, so in your region, you have Pakistan, you have Bangladesh, clearly on religious grounds, there's little to no consumption, so do you see any difference in mortality per, whatever, 100,000 population related to cirrhosis, so that would be one way of explaining, because demographics are similar, India and Pakistan, right, so can you address that? I saw there are still some people in Pakistan dying of alcoholic liver disease, but. It's a very important point and worth exploring further. We don't have adequate data, whatever they have provided from Pakistan, but once cirrhosis has developed, I guess the outcomes may be the same, but as a cause of cirrhosis, I think these two countries, Pakistan and Bangladesh, are outliers. Okay, we'll have a question from. Thank you, Elizabeth Brunt from St. Louis, Missouri. Well, I'm a pathologist, and I've noticed that the ESL guidelines and the AASLD guidelines, both of which have been very recently published, differ significantly in that the ESL guidelines recommend liver biopsy in alcohol use disorder, and the AASLD guidelines strongly discourage liver biopsy, so I'd like to hear from both sides on that. Thank you. Well, I'll speak to the AASLD guidance, which both Jessica and I were authors of, and it's worth pointing out that we didn't just write the guideline. We wrote a guideline, which then went to the Guidelines Committee, which then went to the board of the AASLD, so there are many hands making that guideline a finished product. Why were we less than enthusiastic about liver biopsy? I think there really are two reasons. The first is we're not doing a lot of liver biopsies, so to be advocating something that is not really part of everyday practice to a great degree is unlikely to be successful, and in the course of your career, I'm sure you saw a change in the attitude of practicing hepatologists where you were working in St. Louis to the frequency with which they were advocating biopsy in individual patients, and it's at the same time as the rise of the non-invasive methods to determine the surrogates for fibrosis. The second reason came from the NIAAA consensus definitions meeting that happened in 2016 specifically to alcoholic hepatitis, and it was to describe patients who were appropriate for admission to studies of alcoholic hepatitis, and there, liver biopsy was not discouraged. It was recognized that it was a way of recognizing alcoholic steatohepatitis as an element in the patient's presentation, but there were many patients who might be recruited to trials who hadn't had biopsies and might not get biopsies, and so then two further categories were described. One was probable alcoholic hepatitis, and one was possible. The probable was that there's sufficient grounds in the clinical scenario to be confident that they do have alcoholic hepatitis and therefore would be suitable to enter into trials. This was really to address a separate problem, which is the inadequate recruitment to trials, and one of the aspects of all our work is the lack of really strong data, and so one of the inhibitions is if we make liver biopsy a requirement for trials, we feel we will not get patients in, so there were the two things that went for the US, but Helena might like to address these. Yes, in fact, I was also one of the authors of the ESL guidelines. So we had a lot of discussion on this issue, but we still consider that in fact liver biopsy could be a major advantage, mostly in the setting of the syndrome of alcoholic hepatitis because often there are doubts about the diagnosis, and we feel much more comfortable if we have a confirmatory liver biopsy, and also there is increasingly evidence from the prognostic factors that we can take from the liver biopsy itself. So, of course, putting this in the guidelines is not assuring that everybody's going to do a liver biopsy, but we consider that this would be the more correct way of managing a patient with alcohol-related disease, mostly with alcoholic hepatitis, and in fact, let me say that in my practice, I've had some surprises that is maybe undoubtful, but we tend to do trans-tubular liver biopsy in patients with suspected alcoholic hepatitis, and sometimes these are not exactly what we expect. This is a practice difference between France, Spain, Germany, and Italy, particularly, and the United Kingdom and United States. We are in a low-biopsy prevalence group. They are a high-biopsy prevalence group. It's a difference of practice. I know that. I know that. All right, another question? Omer Goldstein from Haifa, Israel. So it was very interesting to see that alcoholic liver disease is a problem around all the world. We used to drink alcohol thousands of years from beginning in China, maybe in China, maybe in Turkey, like six, 7,000 years ago, and let's say that last 1,000 year, we are able to distill alcohol, so this makes from alcohol a major problem, but still, the major problem of drinking too much alcohol is all about education. If we will convince our young guys to drink less because we'll not be able to avoid at all drinking alcohol, I don't think it will be possible. In certain places, in certain times of the history, states tried to avoid alcohol at all. It didn't succeed, but we can try to educate young people, and then we can try to educate even older people, so this is a preventable disease if people will understand and succeed to drink less. I don't say stop drinking at all. Myself, I drink, and after this session, I will think I'll drink less a bit, but I think drinking less is supposed to be also a real, for us, a real effort. We have to make a real effort to bring people to drink a bit less. Sometimes, even if we show them their liver enzymes and their GGT going up, and sometimes they're not afraid to die, but they're afraid of the liver enzymes, so everything that we can use can help us to educate our patient, and I wanted to add a few things about Africa because we have, in Israel, many Ethiopians that come, and many of them become drunk. About the gut, I'm sure the gut is not a problem. We have many Yemenites also that eat gut. Nobody of them is sick, so gut is not a problem, but the problem in Africa is serious. Other diseases, but especially drinking, becomes a serious problem in Africa because it's easier to get alcohol nowadays in Africa, and do you distill also teff in Africa, or you just use teff that you use for the injera? Yeah, teff, as you said, is the main staple diet for Ethiopians, which they consume three times per day. It passes some sort of fermentation, but it's not like an alcohol, but there are some other cereals which are fermented, and people consume them like a diet. They consider them as a diet. They have lower alcohol content, but when it's consumed like a meal, it could have also alcohol-related or ulcerative diseases, but teff is a gluten-free diet which we consume daily, and it's not associated with liver disease. I'd just like to comment on what you said, two things. The first is that, in fact, one of the problems of alcohol is that it's so much put in all our roots, cultural roots, that, of course, it's not thinkable to take out alcohol from the equation. Opposite, for example, for tobacco. All the campaigns on tobacco was putting it out. On alcohol, that is not possible, so it is not something that we can think, and the other is about education, and fortunately, most of the studies have shown that education and teaching the young people about the values has had almost no effect. What's really effective is increasing the price. I'm sorry to say, but that's what the studies show, and there are studies in many different areas of the world because I think that most people, or probably some people are aware it's just the availability, the facility to drink, mostly with young people, that makes it possible for them to drink more and to be excessive because I think, I agree with you, that it's only a problem of balance and of the amount that one person drinks. For this reason, George Bernard Shaw said, youth is wasted on the young. So it's only when you grow old that you know what education really means. I just wanna make one more comment to the last speaker really quickly. Sorry, is this on? That often when we're dealing with patients who have advanced alcoholic cirrhosis and alcoholic hepatitis, you are dealing with an alcohol use disorder, so you're dealing with an addiction, and that's an order of magnitude more complex than just heavy drinking occasionally every now and again, and so that really mandates expert treatment by an addiction professional to help with that because as I showed, they have almost always have, in my ALD clinic, we're running the numbers right now, 90% of these people have moderate to severe alcohol use disorder, 85 to 90% of them have a comorbid substance use disorder, and 85 to 90% of them have a comorbid mental health disorder, depression, anxiety, bipolar, PTSD, sexual trauma. These are very complicated individuals from a psychosocial standpoint, so I completely agree with Dr. Pinto about the education. It's good to educate patients, but it's unfortunately ineffective, and it absolutely won't work with alcohol use disorder patients alone by itself. For the heavy drinkers, it will not work as Antoine de Saint-Exupéry told us about the drinker that drinks to forget, and forget that he drinks, it does not work for them, but there is a slippery slope for the mild drinkers that can fall also to cirrhosis, and I'm speaking about those patients, to them we can help with education, not to the real heavy drinkers. Our next question there, okay, good. Thank you, hello, I'm Anastasia Volovets, I'm a hepatologist and addiction doctor from Australia, and I really enjoyed this panel, it's wonderful. My question was, in the last couple of years, we've had a real increase, it's more for my American and European colleagues, we've had a real increase in the number of services who deliver alcohol directly to the house. They call it Jimmy Brings, they advertise it wonderfully, and basically you call up a number, and someone will come and deliver whatever alcohol you want to your house, less than 30 minutes, that's their model, and they're extremely effective. I've just tried to do a quick Google to actually have a look at what that's done to our numbers, and there's nothing published on it, but you actually have this service here in Boston, as I've just found out thanks to mr. Dr. Google so I guess I was just wondering whether this is something that you're starting to see in the States or Europe and if so if this is something that's going to be addressed from a population public health level because it's terrifying so I haven't seen it that's like basically order an enabler like to your door effectively is what that is yeah there's uber eats I've heard of which is a problem for the obesity epidemic and I think one of the problems is you know in the past we've had patients who at least got too sick to drink or too sick to get up and go to the pub and they had a little bit of some enforced abstinence at home and that doesn't happen anymore because people can literally have alcohol delivered to their door and they can drink whilst they're intoxicated and it is awful and there's no way of actually putting any limits on it so but the thing is that what you're describing has been in other countries for decades where you can get alcohol delivered to your house it's now maybe hitting Europe and the US but yeah growing up you could order it in in Bombay so I mean not that I ordered it I'm just telling you I've heard other people order it if I may ask a Jessica question you made it clear that these people have mental health behavior issues at all to that end is the suicide rate higher in alcoholics versus the general population what is it like yeah I actually don't know the answer to that question but I do know that often alcohol is implicated in suicide so very often when patient when individuals are committing suicide they are the alcohol is in their system to some level it's also implicated to a great extent in the open opioid overdose so it's kind of it's it runs along behind everything but it doesn't get quite the attention that a lot of things get but it is involved in those two things a lot Sam Moussa from Tucson comment on the liver biopsy and alcoholic fatty liver is an alcoholic liver disease actually in many cases I find this part of the treatment and I do liver biopsies all the time first especially was a rise in young people and and I have had so many just a thumbs up from dr. Brunt back there yeah so many especially a woman refused to really acknowledge that wine will cause them alcoholic liver disease and I find doing liver biopsy on these patients it confirmed that this is their diagnosis and from that economic aspect of this liver biopsy is very cheap I mean we do them in our surgery center we get $95 for the doctor and about $350 for the surgery center if you order MRI PDFF or whatever you're just telling the patients you know you have a lot of fat you have this and that but to convince these young people that they truly have alcoholic liver disease I find liver biopsy very valuable and I have to tell you I've been doing liver biopsies for 30 years the worst thing that ever happened was by a leak so and which was conservatively treated and so I am very a big proponent of easels recommendations well I accept what you say but I don't agree with you actually I just think it's yes I'm going to say why though because it comes back to something that Jessica was saying about the nature of alcohol use disorder so we should not be doing a test to frighten a patient into come to coming to some sort of recognition of their condition so so liver biopsy should never be a sort of punitive intervention in order to waken the patient up or bring them to their senses so just as no other test should be the the ability to explain to the patient what is going on is a part of building a relationship with that patient and as one of the people who taught me Tom Beresford pointed out to me these patients are not in denial the part certainly the patients with alcohol related liver disease because they tend to have this more severe drinking behavior pattern are not in denial about the dangers of alcohol what they are is they are in a state of ambivalence as to whether to choose to continue to drink at the moment in which they're faced with the opportunity to drink or to stop and so what we have to try to do is provide both an environment that makes it less likely that they drink and the support and the medical and the psychiatric support that they can stop drinking that raising the minimal price is one way to reduce the environmental risk that they drink to excess they are these are patients who tend to be using all of their discretionary income on alcohol so if their discretionary income can buy less alcohol the the injury to them is less is less but as well as that we're looking we want to look at four ways to intervene at their point of ambivalence so that when they're faced with the choice between alcohol or non alcohol they have the ability either to get assistance or through their through their own decision-making process not to drink I fully agree with the idea of giving them as full an account of their liver condition as possible and so that comes down to the question of whether a liver biopsy is a necessary part of providing that information in the cases where it is I fully support a biopsy and that is actually what is in the ASLD guideline it's with regard to alcoholic hepatitis what it says in the case of possible alcoholic hepatitis where you are not sure of the condition then a biopsy is a valuable addition I take Helena's points that they're particularly from Ramon Bata Bata layers group this study suggesting that they're also prognostic values to a biopsy so there may be additional values but if in in cases where it's probable alcohol alcohol-related hepatitis you do not actually need a biopsy to make that decision so you can give the information to patient even in the absence of a biopsy I would just say one more thing about that to what you just said and I originally started in my ALD research thinking that much of the reason why people drank was because they didn't know how much damage they were doing to their liver and that's not true everybody knows that alcohol damages the liver it's the biggest reason why cirrhosis is stigmatized it's stigmatized because everybody thinks that cirrhosis is from alcohol so if we think that they just need to know about that alcohol damages the liver that's not the case they already know that to some degree what they really need help with figuring out from a misconception standpoint is the benefit of alcohol use treatment to them especially when they're in this severe category because what I run into more than anything is my patients who think they can quit on their own and they can't they've had multiple quit attempts or that their risk of relapse is so low that they don't need to think about it that they don't need to prepare for it and the alcohol use disorder literature tells us that in the first year after maximal treatment for alcohol use disorder therapy this is inpatient or residential rehab or intensive outpatient therapy the relapse rate is 60% for people who've gone through treatment so the relapse rate for our patients is very high and they are at high risk of this but they often don't know this and have a significant overconfidence and that's where we can be of help to them and helping to reach it as dr. Lucy was talking about reconfigure that ambivalence I'd encourage you to get yourself trained in motivational interviewing so this is a technique that are my therapy colleagues use frequently it has been established for with over 50 years of research in addiction and alcohol use as effective at helping patients resolve ambivalence and choose a positive course of action and that is absolutely something that we can do as medical providers to help our patients sitting in front of us Amanda Johnson I don't know if she's here is she here there she is Amanda is Amanda is the nurse that works with me in my multidisciplinary ALD clinic who took it upon herself to get trained in motivational interviewing to be able to speak to our patients in a helpful way in between clinic and it's been hugely helpful to have a whole team that does that so anybody can do that the in the US there's the motivational interviewing network of trainers I'd really encourage anybody here and elsewhere to get trained in that shift yeah I just wanted to point out two or three things one is raising prices sometime doesn't help especially in countries with lower middle-income groups they use illicit alcohol the huge number of hooch deaths and all that so several parts of India have gone through and they finally realize that this is not going to work so raising prices does not help always in all communities I mean it means some the second point is about liver biopsies and I think it's a huge debate which cannot be resolved but most of us as a pathologist generally would do a liver biopsy for prognostication and it is not for the patient as a punitive action just with all humility but the family also comes around and says oh you're going for a liver biopsy and half the time we defer it we actually do not do it but the mere fact that you have come to a stage that liver biopsy is likely to be done has helped me in my practice and therefore we say okay you behave and come after three months and in three months is very sober the third part is for Jessica you showed a graph where the Indian drink was eight grams and I thought and zero might be missing in that usually the largest of the drinks and dr. Asrani and dr. Reddy would say so I would like to send you the correct one it's not eight grams I think your point about raising the prices is a very valid one it's one of the reasons why we wanted to have speakers from the all the continents because the the factors that are going to work in in Ireland where I'm from or Scotland are not the same as the practice practices that are going to work in Delhi or in Ethiopia there is effectively no illicit production of alcohol anymore in Ireland it's almost like a folk tale making poaching from potatoes so so raising the price in Ireland is not is going to have an effect on the other hand in societies where 25 to 35 maybe even 40 percent of the actual alcohol consumed is personally produced then you're going to find a difference so you so so that's why these solutions need to be both culturally and and societal in their specificity the question there okay hi thank you so much this was a really great session I had a quick question about sort of low-risk drinking guidelines and kind of I know that in general education isn't really as effective that's been well established but I think that clinically the place where I've seen sort of a big educational gap is the gender disparity between sort of the drink the low risk which is not no risk but low risk drinking guidelines for men and women and I was just wondering about whether what types of initiatives can sort of on a public health level we take to kind of address that gap as well as kind of the considerations of the genetic variants into the low-risk drinking guidelines because clearly risk is different based on sort of the PNP LA 3d stuff like I'm going to ask this question to Juan Pablo because you show those extraordinary data that the PNP LA polymorphism that puts you at greatest risk of fibrosis of the liver was the highest in any your data are yet to be published but in any recorded population group so what do you say about safe drinking levels to you to in Chile so yeah thank you that's a great question so we didn't consider like genetic disparities for these guidelines in the Latin American guidelines we can see there men or female and then we can see also overweight and obesity so for overweight and obesity we take one less drink so it's saying three drinks is risk for a man will be two if this guy is overweight or obese then the pinnable three is a very important thing we saw this 80% of prevalence of the allele of risk in our native Native American population and in the same population we have seen no only more fatty liver more cirrhosis and also more HCC so that's kind of confirming that the importance of the gene variation in our population with our same group with Marco Arrece we are also looking for the other genetic polymorphism like the TM6SF2 and the 17 beta so and all of them can try to correlate so I think there is a genetic predisposition of our Native American population to develop more liver disease so this should be considered in the recommendation for for like in the clinical practice indeed in our place we are when we are running labs we are taking samples to try to genotype these patients and maybe we can do a better tailored counseling for them but it's not a very extended practice it's just locals thanks in the interest of time we'll take one more question appreciate it so please go ahead thank you very much it's a little period of from Brazil first of all it's very nice pioneer is a very good opportunity to know what's happening around the world I had like I had like to mention three points in Brazil what's happening about alcoholic disease first of all a couple years ago Brazil introduced rulers forbidding the drive after alcoholic consumption reduced tremendous trafficking problems but the people still drink too much because now you get taxi uber and people still drink too much there the second one about education is is not allowed in Brazil to buy any alcohol consumption in 18 years old but the parents or the old friends might buy behaviors in private parties in education is not working in Brazil anymore about rulers in the under 18 years old in the third the third point is about increasing the price I think you could know that in Brazil has a very traditional cachaça that is produced in the distillery it's very cheap everybody buy directly from the distillery and enjoy to do cachaça in the tropical disease that is the big problem in Brazil now you not know exactly how you forbidding alcohol consumption the moment thanks very much for your comments so did you did anyone want to respond to it I was I was just commenting that in fact the measures that could seem to be very useful can turn out not to be this is very paradoxical and it's very interesting that in fact by forbid if I prohibiting drink driving you can have people drinking more because they drink at home or because they can be taxed so you always have to think that these things are all interconnected and by putting one measure you can have an unexpected yeah only to comment looks like Latin America always found the way around that's one and the second one is is this is probably a multi disciplinary and multifocal approach I don't think we will hunt we will find one measure will really impact but probably multiple measure of multiple levels will make the difference well thanks so much on that note we'll end the session on behalf of Mike Lucia and myself I'd like to thank the speakers for outstanding talks and you know the discussion thanks very much well I certainly will have a glass of wine tonight though thanks

alcohol-related liver disease

ALD

alcohol consumption

mental health

addiction disorders

motivational interviewing

interventions

multifaceted approach