Hello, everyone. Welcome to the 2020 Hepatology Associates course, Bridging the Gap, All Hands on Deck, presented as part of the Liver Meeting Digital Experience. Along with my course co-director, Lisa Hardy, we hope that you are well, and we are eager to present to you topics to help you navigate the complexities of liver disease, utilizing your healthcare team members to the highest extent of their training. We will start our course with the assessment of alcohol use in the transplant candidate, and we are honored to host a presentation by Dr. Gerald Scott Winder, Clinical Assistant Professor in the Departments of Psychiatry and Surgery at the University of Michigan. He holds a medical degree from the University of Utah School of Medicine and a Master's of Science degree from the University of Michigan School of Public Health. He completed a general psychiatry residency and a consultation liaison psychiatry fellowship at the University of Michigan. As a consultation liaison psychiatrist, Dr. Winder specializes in the psychiatric care of the medically ill. In his clinical niche, he has co-founded specialty clinics embedded in organ transplantation, neurology, and hepatology, working on multidisciplinary teams providing integrated psychiatric and medical care to patients whose diseases cross medical disciplines. Next, we shall hear from Meg O'Meara, Doctorate of Nursing Practice. Before working as a family nurse practitioner for the Division of Gastroenterology and Hepatology at the University of Colorado School of Medicine, she prepared for her doctorate while working as a registered nurse in transplant surgery at the University of Colorado Hospital and graduated from Regis University in Denver in 2016. She now works with the University of Colorado Health Transplant Clinic, caring for liver transplant recipients with a clinical focus on immunosuppression and routine health maintenance management. Isabel Campos-Barrela is currently an attending hepatologist in the liver unit at the Hospital University Baldebran in Barcelona, Spain. She graduated in 2002 in medicine at Santiago de Compostela University, Spain. She completed her fellowship in internal medicine with additional training in hepatology in Baldebran Hospital in Barcelona. In 2013, she achieved her Ph.D. degree in the field of liver transplantation in Universidad de Toma de Barcelona. She followed her training in hepatology and liver transplant at University of California, San Francisco with Nora Terralt as a mentor. She has also completed master's degrees in research methodology and in public health. Dr. Campos-Barrela is an author of over 40 publications in peer-reviewed journals. She is a primary investigator of a national grant for the study of sarcopenia in the setting of liver transplantation. We will end the first session with Dr. Panita Tandon, founder and co-director of the renowned Cirrhosis Care Clinic at the University of Alberta Hospital. Dr. Tandon brings forward her expertise to help us incorporate palliative care considerations for our patients affected by liver disease. She has authored over 100 peer-reviewed journal articles focusing on the holistic care of liver disease and has been a featured presenter for numerous conferences around the world regarding frailty assessment, nutrition, and mind-body therapies in hepatology. With that, we thank you for tuning in and being a part of the 2020 Hepatology Associates course. Hello, everyone. My name is Scott Winder. I'm a clinical associate professor in the departments of psychiatry and surgery at the University of Michigan. I'm speaking today about the assessment of alcohol use in transplant candidates. I have no financial disclosures. Key takeaways from my talk today are that alcohol assessments in transplant candidates require unique perspectives and skill sets. Interprofessional teamwork with medicine and surgery colleagues is key. Focusing on the clinician-patient relationship is helpful, and surmountable barriers to this effort exist. I've divided my talk into what I believe are the essential components of transplant alcohol assessments, the first being establishing rapport, destigmatizing the interaction, and paying attention to the nuances of the transplant therapeutic alliance. Next is to assess sobriety, the details of the patient's treatment of any substance use disorders, as well as the use of toxicology. Next, querying insight, how the patient perceives their relapse risk, and whether they accept the presence of any alcohol diagnoses. How do we assess comorbidities from a general psychiatric perspective, as well as polysubstance use? And an overarching theme of interprofessional teamwork, working closely with professionals of other disciplines. There are other important variables to consider as well, including the time course over which the alcohol evaluation must take place based on disease severity and other logistic variables. Second is, what kind of personnel does a transplant center have and the team have at its disposal for these kinds of assessments? What kind of broader substance use disorder resources are available within the health system and in the surrounding area? What are the policies and cultures of the transplant teams involved in the case? How do they use toxicology? And what do we know about alcohol use disorders? Much of this literature is non-transplant, so we must be careful about extrapolating from non-transplant substance use literature. Rapport and therapeutic alliance. In my view, there is no better depiction of stigma in literature than Hawthorne's The Scarlet Letter. The protagonist, Hester Prynne, suffers for many years because of choices made earlier in her life. There are other Scarlet Letter A's within healthcare. We have to be careful we don't stigmatize. Stigma will interfere with establishing rapport and connecting with our patients. The patient-provider alliance in transplant is unique. Because patients want to qualify for transplant, many are incentivized to conceal mental health or substance use problems. Transplant teams form powerful emotional bonds with their patients, but this means that if patients slip a relapse, they can experience shame or fear of abandonment. In turn, the team can experience patient relapses as betrayal, anger, or detachment. Many transplant patients do not desire psychiatric or substance use treatment. They present for evaluation upon requirement by the team. Transplant teams must carefully manage the messages they send around substance use. If they condone use, they risk that use will be ongoing and may increase. If they avoid the topic completely, patients interpret this as substance use is unimportant. There is a need to balance the need to be good stewards of a precious resource, which are donor organs, as well as advocating for patients. Some patients who drink or use substances don't believe they deserve a transplant. Transplant teams must establish quickly that all patients are worthy of access to transplant, though there are overlapping and separate concepts of consenting and qualifying for a donor organ. Addressing these concepts early helps to establish the dimension and frame of the mental health and alcohol assessment within transplant. There are several components of the therapeutic alliance assessing alcohol problems within transplant, the first being compassion, communicating clearly how much we care about the patient and desire them to open up and trust us. What will we do with the information that they provide us? Where will it be documented? What are the limits of confidentiality in mental health and substance use assessments? What is our role? We need to be clear we don't make the transplant decision alone, but we do participate in selection conferences. We must be clear about expectations, about clinic attendance, outside treatment, toxicology, and the impact of any deception or concealment. We need to paint a long view for the patient, anticipating follow-up through the pre- and post-care phases, and prepare patients for slow and incremental change in the face of ambivalence. There are pitfalls to avoid in this effort. We should not blame the patient for their drinking or its effect in their life. We must avoid inducing shame. We should not approach use from a gotcha perspective in terms of clinical evaluations or toxicology results. And again, we must avoid stigma in ourselves, in our patients, and in their families. Conceptualizing and assessing sobriety. Some general principles. Alcohol use is pervasive in society. We have to remember that as many as 70% of American adults have had alcohol in the last year, and about 50% of us in the last month. Alcohol use is not the same thing as alcohol use disorder. The disorder is characterized by impaired control, social impairment, risky use, and medical impact like withdrawal and tolerance. It can be measured by psychometric instruments and questionnaires, or classified using the DSM or ICD. When we make these diagnoses or clinical observations, we should disclose to patients about what we are documenting and why. Abstinence from alcohol is not the same thing as being sober from alcohol. Abstinence is removing alcohol, and sobriety is building something in its place. The analogy might be tearing out a weed versus replanting a garden in its place. It's important to remember that durable sobriety in the substance use literature is measured on the order of years, a timetable that might not be fully compatible with transplant. Alcohol complicates any liver diagnosis, not just ALD. We have to be open to alcohol as a health behavior with its hazards and harms in all people, rather than just a diagnosis for the select few. Active substance use and psychiatric complexity is common within the liver population. As many as one in five liver transplant candidates with ALD present for their liver transplant evaluation with a positive alcohol biomarker. One study found that 1.4% of their liver transplant recipients drank on the day of their liver transplant. This sharpens our awareness of the importance of careful and thorough psychiatric diagnosis. These data show that addiction specialists and audit questionnaires are more likely to pick up true abstinence as well as accurate patterns of drinking. We see here the high prevalence and risk of psychiatric comorbidities of a variety of different types that commonly occur in patients with alcohol-related liver disease as compared to other patient populations. There are several helpful elements to assess and document during our clinical evaluations. Patients' chronology and pattern of drinking over time, last use, and longest period of sobriety, patients' treatment history, their response, and any preferences for ongoing treatment. We should pay attention to any full doses of treatment, which we might think of as stints in rehab, completed intensive outpatient programs, and any long-term psychotherapy, medical consequences coming from use, insight, which we'll discuss more in a moment, hazardous drinking, particularly any drinking after a known liver diagnosis, and any formal disorder classification we might describe. Use of rating scales like the Stanford Integrated Psychosocial Assessment for Transplant can also be helpful. Predicting post-transplant drinking is difficult, if not impossible, and this literature is quite heterogeneous as to what predictive factors are. A meta-analysis in 2006 found that social stability, no addiction family history, older age, no history of any alcohol use disorder treatment failures, and no psychiatric comorbidity were more often than not predictive of post-liver transplant sobriety. Interestingly, the duration of pre-liver transplant sobriety was not predictive of post-transplant use. Alcohol use in transplant is not only a matter of considering sobriety, but also accepting the reality of relapse, and several trends are worthy of consideration in this regard. ALD is now the leading indication for liver transplant in the U.S., and there is a bias towards severe alcohol use disorder within ALD. Liver transplant for acute alcohol-associated hepatitis increased five-fold between 2014 and 2019, and there are substantial post-liver transplant drinking rates, as high as 50% by 10 years post-transplant for any use, and 25% by 10 years post-transplant for heavy use. Many patients binge within six months of their first drink, and drinking proximally to liver transplant portends chronic and sustained use. There are many unfavorable clinical consequences for post-transplant drinking. Alcohol use disorder treatment before and after liver transplant reduces relapse rates. Alcohol toxicology is invaluable in monitoring sobriety and relapse in transplant. Urinary ethylglucuronide and ethyl sulfate are highly correlated biomarkers that may increase sensitivity when used together. Their performance in detecting drinking within the last three days and seven days appears below in green and yellow, respectively. On the right-hand side is phosphatidylethanol, a lipid species with a detection window of two to four weeks. Its performance in males and females is depicted in these graphs with different patterns of drinking. The quantitative value of phosphatidylethanol correlates with the severity of drinking as measured by the audit questionnaire. It is imperative to understand the purpose, utility, and limits of toxicology when used in transplant. This is a consensus paper from the American Society for Addiction Medicine that reminds us toxicology is a tool for supporting recovery rather than exacting punishment, that it should be used to explore denial, motivation, and actual substance use. Positive tests are not sufficient evidence for a substance use disorder diagnosis. We mustn't over-interpret a negative test result since it doesn't mean that a patient has not used substances. And if testing results contradict patient reports of use, therapeutic discussions should take place. Following these guidelines will require an interprofessional approach, which we will discuss momentarily. Transplant teams must be aware of and warn patients about over-the-counter and household products that contain enough alcohol to be detectable in toxicology. Other useful sources of information during an alcohol evaluation include prescription drug monitoring programs, EMRs and outside hospital records, family reports, psychiatry providers, and the recovery community. All this information is highly protected and confidential and appropriate release of information should be obtained. Patient insight. Insight is a broad concept that can be defined in many ways. We won't focus on the ontological approach or the epistemological approach, but instead we'll focus on the clinical approach. Insight is a mental state, not a symptom, at a particular time, comprised of a mixture of emotions, thoughts, worries, reflections, etc. Insight itself likely has many components, such as social consequences of illness, changes in self and interactions, attitude towards experiences, the need for medical treatment, comparisons with previous function, resemblance of one's case to others, and the implications of specific test results. Patient insight is dynamic and assessing it requires artful and thorough interviewing. Successful interviewing will depend on the integrity of rapport and patient-provider alliance, as described previously. These are some examples of the types of questions that may elicit helpful information about various components of a patient's alcohol insight and will help the evaluator report accurately to the transplant team and form an appropriate treatment plan. Tell me about your chances of drinking again. Is your drinking a problem? Do you need treatment for your drinking? What caused your liver disease? We have found that analogy and metaphor are helpful tools engaging patient insight, but also building it. We compare alcohol treatment to wearing a seat belt. This is helpful because most people wear one and understand the prevention principles it's based on. This also helps acknowledge existing sobriety rather than making patients feel that we believe they will imminently drink. Patients can also understand the many sources of risk while driving, only some that we can control, similar in many respects to drinking. In the end, we can help them see that relapse, like a car crash, may be a rare event, but it is a dangerous one that we want to prevent at all costs. Another helpful analogy is that of coaches who crowd the sidelines. Football players are elite athletes who still require intensive coaching to reach their goals. This analogy helps us introduce the idea that ongoing alcohol treatment is important, even when patients have already made admirable change. We sidestep ideas about pathologies or disorders that can raise defenses and focus instead on improvement rather than curing illness. We have found the principles of practice and mastery helpful in building patient insight about alcohol treatment in transplant. Comorbidity. Alcohol and transplant can be too psychiatrically complex for hepatology, given the comorbid psychiatric conditions, polysubstance use, and benzodiazepine use that commonly occur. This is a population with many pain symptoms of neuropathic and other etiologies who might be taking opioids or using marijuana. They are often not coping well. Sleep disturbances are common. Insomnia mimics many psychiatric conditions, and pharmacotherapy may worsen hepatic encephalopathy. And alcohol use in transplant may be too medically complex for psychiatry. Psychiatrists will hesitate using alcohol use disorder medications given concerns about reduced metabolism and clearance, as well as drug interactions. They may not understand the intricacies or scope of the patient's disease burden. Alcohol therapists are challenged by patients with encephalopathy or those with low insight who may only be attending therapy because the transplant team requires it. Patients who have already gained some level of sobriety may be deemed too well to receive services. These factors create deep holes between specialties into which alcohol patients fall. These gaps are characterized by poor collaboration, low access to care, poor care quality, and deficits in expertise, ownership, and continuity. We need new alcohol care models and paradigms in transplant, a bridge between specialties, and there are numerous terms we could use to describe such a bridge. How to construct one is where we will finish the talk. Interprofessional teamwork. Interprofessional teamwork is an established idea supported by decades of literature and spanning multiple professional fields. It impacts patient safety and care delivery across the health system. It impacts patient satisfaction, length of stay, and mortality, as well as clinician retention, morale, and sick leave. Alcohol-related discussions within the transplant environment can potentially be combustible given the nature of what's being discussed. Alcohol problems are largely subjective and potentially stigmatized. Many health care professionals will have their own personal experiences and family experiences with the problems related to drinking. We all have experienced past bad outcomes. Drinking and other human behaviors are uncertain, and the impact of within transplant is risky. To the degree that a team does not share mutual respect and trust, this only amplifies the problem. We believe that strong personal and professional relationships among team members are essential to appropriate and thorough and productive alcohol-related discussions. Clearly defined professional roles will help to avoid confusion, redundancy, and frustration with the tasks surrounding monitoring and treating alcohol use. This is important among all transplant specialties, but may be most important among psychosocial specialists like social work, psychology, and psychiatry. Alcohol use over time and among many patients generates enormous amounts of data, much of it subjective. A team needs a shared vernacular and vocabulary and appropriate methods of communication to transfer and analyze this information. That vernacular and vocabulary will depend on a shared understanding of alcohol problems, which can be established by ongoing interprofessional education around substance use disorders and other mental health topics. We have already spoken about the amount, complexity, and subjectivity of the data generated from alcohol problems. Storing this data and regularly reviewing it and processing it are integral to appropriate management of alcohol problems in transplant. Disagreements about patient alcohol use among transplant team members are inevitable. They can be valuable or destructive. Transplant will remain a high-stakes population, so appropriate and effective conflict resolution strategies and methods are important. Clinician burnout, substance use, and mental health problems are pervasive throughout health care. It's imperative that clinician wellness be a priority, particularly among clinicians who commonly interact with challenging transplant populations, including those who use alcohol. We have just reviewed important, but general principles about interprofessional care of alcohol patients with end-stage disease, like those encountered in transplant. Time doesn't permit a more detailed exploration of how to build and maintain such an effort, but I would refer you to our paper published earlier this year that gives much more detail about a unique effort we undertook to confront alcohol-related problems within the liver population. Thank you for this speaking invitation and for your attention. Hello, everyone. My name is Meg O'Mara, practitioner from University of Colorado. For the next 20 minutes, I will be talking to you about infections in the post-transplant patient and pearls for the non-transplant community provider. I first want to thank the AASLD for the opportunity to speak today and for supporting advanced practice providers in the world of hepatology. Also, a special thank you to my colleagues at University of Colorado for all their support throughout the years. I have no financial disclosures. First, let us talk about the basics of assessing infection. I think everyone here is well-versed in how to assess infection. Patients can, of course, present with a myriad of infectious symptoms such as fever, chills, night sweats, painful urination, diarrhea, or even abdominal pain. So, how does this change when you're assessing the transplant patient? All the basic assessment techniques are the same. However, we need to think about a few different things with a transplant recipient. We need to think about their transplant history. Time from transplant, current immunosuppression regimen, and current prophylactic medications are important to note. Also, what is their infection history? This is not only their infection history before or after transplant, but also if they were told about any infections in their donor. It's also important to ask if they have been on any recent treatments for other infections post-transplant. Other things to consider are environmental exposures. Do they live in an area where they're at more risk for certain funguses, bacteria, or viruses? Do they have any pets that could put them at higher risk for certain infections? We often think of cats and their litter boxes being an increased exposure risk for toxoplasmosis or those that have an iguana being at higher risk for salmonella infection. When you're first looking at the infected transplant patient, you will look at the common infectious lab workup. When you look at the CBC, you might see a leukocytosis suggestive of a bacterial infection, whereas you may see leukopenia more so in viral infection. The CMP will guide towards insult in different areas of the body, such as an elevated creatinine suggesting dehydration or urinary tract infection. Elevated transaminases make you think about potential infection to the liver tissue directly, but these numbers can also be simply elevated in an acutely ill patient without localized infection to the liver. An elevated bilirubin or alkaline phosphatase may suggest more of a blockage and infection of the bile ducts, also known as cholangitis, which transplant patients are at higher risk for at the surgical anastomosis of the bile ducts. Of course, other common infectious workup techniques should be completed, such as blood and urine culture, along with chest x-ray for anyone with pulmonary symptoms. Lactate can assess how severe a current illness is. Transplant patients can present late with infection and be much sicker than they initially appear. If they're having diarrhea, a GIPCR and stool culture is a great way to look for viral or bacterial infection. It is not uncommon to see recurrent C. diff in the post-transplant patient. Let us think about the transplant patient and what unique infections we should consider. Of course, transplant patients get pneumonia, UTI, bacteremia, and viremia, just like the general public, but it's important to think about what type of infections are more prevalent in the transplant population. This way, you know what to look for, thus diagnose and treat quicker. With leukopenia, we often think about viral infection, such as CMV, HSV, and EBV. We might see more of an elevated white count with bacterial infections, such as cholangitis, C. diff, pneumonia, and bacteremia. It's also important to think about UTI, even in males, when patients are septic. If the patient is a little closer to time of transplant, look at the surgical site and drain sites directly, as they could have cellulitis. Another special thing to consider with the transplant population is dual infections. Although you might treat one, you're still left with another infection that could be making the patient persistently ill. In general, it is more common to see bacterial infections in the first month post-transplant, whereas viral, fungal, and parasitic infections often present a little later. Now let's say you know what infection you're dealing with. There are certain things we need to take into consideration with treatment choice. Considering if the patient has been recently treated for something else is very important in the transplant world. This can be a sign that you have potentially treated with the wrong agent previously, there's a component of drug resistance, or there's actually a different etiology of this patient's acute illness you have yet to diagnose. Creatinine clearance is especially important to consider in the transplant patient, as there are anti-rejection medications that can impair renal function and renal dose adjustments may be needed. Drug-drug interactions are especially important to consider. Macrolides and antifungals can increase immunosuppression drug levels. This is especially important to consider with patients who are on tacrolimus or cyclosporine, as high levels of these medications can lead to significant acute kidney injury. The transplant center may advise on temporary dose adjustments of immunosuppression, depending on what treatment agents are being used. Another important thing to take into consideration is that the transplant patient may require treatment for a longer duration. Route of administration should be considered, especially when patients are vomiting or having horrendous diarrhea, as treatment medications and immunosuppression agents may not be absorbed correctly. Depending on how ill the patient is, you might consider empiric treatment of urinary tract infection versus waiting for cultures and sensitivities to come back. This is especially important to consider in patients with known resistance. In the post-transplant world, it's not uncommon for patients to have been infected with C. diff once, twice, or even many times. If patients are quick to mention their history of C. diff, you may want to consider prophylactic vancomycin in addition to whatever antibiotic you're using to treat the current infection. Lastly, it's incredibly important to remind the transplant patient to have a very low threshold to return if treatment is not working, if symptoms were to worsen, or if new symptoms present themselves. So what we've discussed so far, let us take a look at a first case study. You're working in your local emergency room when a 60-year-old male who received a liver transplant about five months ago for alcohol cirrhosis comes in with weakness, worsening heartburn sensation, for which he reports already taking multiple over-the-counters for. Because he's having such painful swallowing, he's not taking in many fluids nor calories. He's endorsing diarrhea and had fever at home. The patient also mentions to you he was seen about a week ago in another ED, at which time he received a GI cocktail and some IV fluids because his creatinine was elevated. So you get his first set of labs. You notice a mild leukopenia, anemia, elevated creatinine, as he tells you that his kidney function has always been normal. You notice liver function tests are quite normal, and think to yourself that this is likely not a liver-specific infection. His vital signs are actually stable on presentation, and he has not had fever today. However, on physical exam, you're looking at a gentleman who is cachectic and has dry mucous membranes. He is quite tender to palpation of the epigastric area of the abdomen, but his other organs are not as active. You plan for upper endoscopy because he continues to report painful swallowing, and the oropharynx is unremarkable on your exam. While you're waiting for your upper endoscopy, you start thinking about his transplant history. You know that this gentleman is only five months from transplant and is still on two transplant medications at relatively high doses. The patient's blood pressure is still low, and he's not taking any fluids nor calories. The patient tells you he was on an antiviral and antibiotic, which were stopped a couple months ago by his transplant center, recalling being told that these were medications to prevent infection. He states his donor had some sort of virus that he had never been exposed to, but cannot recall what this virus was. Many transplant centers prescribe CMV and PCP prophylaxis, which is often stopped at either three or six months post-transplant. The gentleman also tells you he lives in the Denver area without recent travel and has no pets. So why is this information important? We know this patient is at higher risk for infection as he is on increased levels of immunosuppression. We know he is not currently being protected by any prophylactic medications. That virus his donor had was likely cytomegalovirus, which means he's at high risk for CMV infection, as he is not currently on any medication. As his donor was known to be CMV positive, whereas the recipient had never been exposed prior to transplant. In Colorado, it is important for us to consider our patients living in New Mexico, that they are at higher risk of what is called valley fever or coccidioidomycosis, but this does not apply to this patient. So what do you think is going on with this patient? You're left feeling a little bit stumped until the endoscopist reports there were lesions throughout the patient's body. The endoscopist reports there were lesions throughout the esophagus. This patient was found to have CMV esophagitis. In this case, the patient was actually found to have CMV viremia, esophagitis, and colitis. He was quite ill and required admission for IV treatment of his CMV and TPM while his esophagitis improved. Here you can see the lesions along the esophagus, which can be biopsied and stained for CMV specifically. It is important to ask for CMV staining on random biopsies if you're concerned for tissue invasive disease. I want to spend some time talking about CMV as this is a very common infection you will see in the acutely ill post-transplant patient. CMV for the immunocompetent patient is underwhelming and usually does not cause symptoms. Providers outside of transplant are likely not thinking about checking for CMV, but this is important to evaluate in the transplant patient. Transplant patients whose donor were exposed to CMV, but the recipient had never been exposed to CMV prior to transplant, are at the highest risk for CMV infection. CMV comes in a couple of varieties. CMV viremia is often not treated with antivirals until PCR quantification is greater than 1500. Patients with CMV viremia can be completely asymptomatic. CMV syndrome is more commonly what you will see with patients reporting malaise, fever, and somewhat of a general, I just don't feel good, but I can't exactly tell you why. CBC will often show anemia and leukopenia with white blood cell counts as low as one to two thousand when patients are actively infected with CMV. There's also CMV tissue invasive disease, which is much more serious and can require admission to the hospital for IV treatment. CMV tends to invade the GI tract, but can also infect the liver, lung, or even the retina. There is also a rare potential of what is called compartmentalized disease, in which people have tissue invasive disease, however, CMV PCR in the blood is negative. In general, treatment for CMV often starts with oral valsite, but with tissue invasive disease, one might consider admission for IV ganciclovir. The transplant center should also consider lowering baseline immunosuppression for patients infected with CMV. However, there has to be careful consideration, as this will put these patients at higher risk for rejection, especially if the patient is within their first year of transplant or has history of rejection. Hypothetically, let's say CMV was not found on upper endoscopy. What other infectious etiology should you be thinking about? It's not uncommon for painful lesions in the esophagus to be the result of either herpes simplex virus, or even more commonly, candida, in the transplant population. Let's take a look at a second patient, since not every infection is going to be CMV. Now we have a 65-year-old female who is 12 years from transplant for non-alcoholic steatohepatitis. She presents to the ED with shortness of breath, chills, night sweats, and hypoxia with exertion. She mentions to you that she was seen in urgent care a few days prior and was diagnosed with a UTI. She's been on Augmentin for the past three to four days. While you're waiting for chest x-rays, since you have a strong clinical suspicion for pneumonia, you get back some of this lady's labs. Her white blood cell count is normal, and creatinine is 1.6, which is actually her baseline because she has known renal insufficiency. She does have a mildly elevated transaminases, and UA continues to show trace leukocyte esterases. Her lactate was unremarkable, which is reassuring that she is not septic. Vital signs show that she is mildly hypotensive, and she is afebrile. On room air at rest, her pulse ox is 94%, but dips down to 86% with exertion. On physical exam, she is tired appearing. However, when you listen to her lungs, they are clear to auscultation, and she does not really appear to be in respiratory distress. Her abdomen is non-tender, and there's nothing really jumping out at you with her physical exam. You get the chest x-ray back. It's unremarkable with only the commonness and scarring in her left middle lobe. You also evaluate for pulmonary embolism, but are unable to do CTA given her renal function, so a VQ scan was performed showing that there is a very low probability for PE. Now you take into consideration that transplant twist. She's 10 years from transplant and only on one anti-rejection medication. She denies any prophylactic medication and only reports being on Augmentin for the UTI. She lives in New Mexico and has no pets at home. With this transplant information, you feel she's at lower risk for infection given time from transplant and being on lower immunosuppression. Her current antibiotic for UTI treatment could also be her current antibiotic for UTI treatment could also be providing cross coverage to other areas of the body. Because you now have your transplant goggles on, you think about the fact that she's from a coccidio-mycosis endemic area and recognize that coccy can cause pulmonary symptoms, but are not concerned for this infection today with negative imaging. With reassuring imaging results, you chalk this case up to resolving community-acquired pneumonia. Know that she was prescribed Augmentin days prior for UTI, but take into consideration that if she had a brewing pneumonia that Augmentin could be covering this disease process simultaneously. You discharge the patient without adding any new medications and let her know to have a low threshold to present back to the ED if she's continuing to not feel well. A couple weeks later, you see the same patient and she continues to describe shortness of breath. She's been checking oxygen levels at home, which remain low with exertion. This time you decide to do a CT of her chest. Remember that little bit of scarring in her left lung seen on chest x-ray? On CT, you're able to appreciate this is a ground glass opacity, which is noted to be in both sides of her lungs, however worse on the left. You talk with your pulmonary team and they recommend bronchoscopy to better understand the etiology of the infectious process this woman has. Bronchoscopy ultimately shows no infectious etiology. So what is causing her shortness of breath? Come to find out she has drug-induced pneumonitis from her transplant medication sirolimus. Patients on mTOR inhibitors such as sirolimus or everolimus do have a rare potential risk for drug-induced pneumonitis, which should be a differential diagnosis for patients with chronic cough, shortness of breath, and hypoxia. Of course, we should talk about what pulmonary infections should be considered in the transplant patient. Hoxidomycosis is important to think about in the southwest region of the United States, which can be assessed on blood work with IgG and IgM serologies. Aspergillus is another fungus to consider. These infections are most notable for having what is called a halo sign on CT chest. Oftentimes patients with aspergillus are sick enough that bronchoscopy is already being done and cultures will confirm diagnosis. Going back to CMV, we remember that there can be tissue invasive disease into the lungs. Toxoplasmosis and histoplasmosis can be donor-derived infections. Donors are often screened for toxo and histo, and if positive, recipients receive extended prophylaxis. PCP should be thought about in any immunocompromised patient. When treating the infected patient, it's really important to keep in mind that treatment options can truly impact immunosuppression levels. As mentioned earlier, if the patient is on a calcineurin inhibitor such as tacrolimus or cyclosporine, antifungals and macrolides can significantly increase these drug levels, resulting in severe acute kidney injury. These medications can also increase mTOR inhibitor levels, so you will see worse in cytopenias with patients on sirolimus and everolimus. You should contact the transplant center if you're using agents that can impact drug levels so they can make immunosuppression adjustments if needed. It is also very important to consider cross-sectional imaging when the patient is having recurrent pulmonary symptoms even when chest x-ray is normal. There should be consideration for early referral to pulmonology and infectious disease. To finish up, I just want to emphasize that considering the patient's transplant history is crucial in caring for the infected transplant recipient. There is nothing wrong with thinking about infections that are common in the community first when assessing the transplant patient, but also taking into consideration some of the more common transplant infections we reviewed today. Recurrent infections are often a sign. It's either a sign of resistant infection or that the incorrect diagnosis was made at the time of first treatment. The most important thing to emphasize is when you have a transplant patient in your urgent care, ED, or clinic room, never hesitate to call the transplant center to get more information or guidance. Trust me, we do like it when you call. Thank you. Good morning. It's an honor to be here to speak to you, so thanks so much for this opportunity to talk. First, we'll start with nutrition, more specifically malnutrition. Because of time limitation, I will not be covering obesity or giving recommendations as we talk only about assessment. Malnutrition is one of the most common complications associated with cirrhosis, but its true prevalence in cirrhotic patients is not clear. But we may say that it is present in about 20% of the patients with compensated disease and about 50% of the patients with the compensated disease when usual clinical methods are used. But depending on the assessment method used, the diagnosis can rise up to 99% of the patients. So we might be assuming that if precise methods were used routinely, almost all our patients would be diagnosed with malnutrition. Malnutrition increases with worsening liver disease severity, and its relevance lies in the fact that its presence increases the risk of mortality. It is also related to higher portal hypertension complications, to an increased risk of infections, a longer hospital stay, and to an increased morbidity after surgery. In the setting of liver transplantation, malnourished patients have an increased waiting list mortality and following transplantation, have longer in-hospital and ICU stay, longer time of intubation, and an increased risk of infection compared to those patients who are well nourished. And what makes cirrhotic patients to be so vulnerable to malnutrition? Starvation is a key point in this process. Patients are not eating well, might be malabsorbing, nutrients biosynthesis is impaired, and increased protein loss might be present. Also, there's an alteration in substrate utilization and in metabolism. Additionally, the level of pro-inflammatory cytokines is elevated, and the patients are in high chakrabolic state that burns the glycogen storage. And gluconeogenesis from amino acids is increased, contributing to muscle mass loss and to an increase in energy needs, as gluconeogenesis is a high-energy expenditure process. This complex and well-assembled factory that is the non-cirrhotic liver is impaired, and the abnormal pattern of metabolism reflects this mini-septic glucose release secondary to decrease hepatic glycogen storage and resembles the metabolic pattern associated with prolonged starvation. This might be partially responsible for the cachexia, particularly the muscle wasting observed in these patients. In other words, a 12-hour period of non-eating, such between dinner and breakfast for a person with cirrhosis, is equivalent to starving a healthy person for three days. I hope I have given you a sense of what malnutrition represents for our patients, so that we are ready to be moved to the clinical setting. We'll be dealing first with difficulties, starting with the definition, and second with some particularities of our patient. As the hepatic function is impaired, leading to low albumin level, albumin will not be a good marker of malnutrition, and it is seen in other diseases. Also, cirrhotic patients can be receiving IV albumin, so they have a false elevated level. And fluid retention will be another difficulty. There is no standard definition of malnutrition in cirrhotic patients, and which parameters should be evaluated for the definition. This has been nicely reflected in this well-understandable review. This table shows which parameters have been considered definitories of malnutrition by different scientific societies. Being muscle mass loss the only common parameter to all the definitions. BMI is also one of the most frequently components evaluated. Trying to make it systematic and to make it easy, three instruments have been considered to screen malnutrition in cirrhotic patients. Low BMI, along with advanced disease stage and the recent score for malnutrition for the Royal Free Hospital Nutritional Prioritizing Tool, are well accepted for the identification or screening of cirrhotic patients at risk of malnutrition. And we face here one of the previously mentioned limitations. This is a picture of a genetic patient that is illustrative of the malimitation of body composition evaluation in hepatic-rotated patients, as cirrhotics can be, and the magnitude of the inaccuracy when relying on BMI if fluid retention is not taken into account. This patient has a normal BMI, and following the BMI criteria does not deserve further evaluation. But after a large volume parasynthesis, this patient becomes to be at risk of malnutrition, so we have to take into account asides and edema with our most simple and routine evaluation. The Royal Free Hospital Nutritional Prioritizing Tool takes about three minutes to be completed and establishes three categories of risk, and importantly, BMI is considered only in the absence of fluid retention. Once we have our patients at risk identified, a detailed nutritional assessment is indicated. It is recommended that patients at risk receive a detailed evaluation every one to six months in the outpatient setting and at admission and periodically throughout the admission in the patient setting. Regarding evaluation, we will be going through five points. First, the evaluation of the nutritional status. With the intention to improve evaluations not focused on cirrhotic patients, the Royal Free Hospital Global Assessment was developed. This algorithm includes three aspects, BMI, mid-arm muscle circumference, and dietary intake. It is considered a good tool, but it still needs validation to be widely accepted. Next would be to collect a detailed dietary intake. To make a detailed collection, we have to ask about food, fluids, and supplementation intake, the number of meals and their timing through the day, from the timing they are going to be targeted nutritional interventions. We have to record also calories and quality and quantity of protein intake. We should also ask about barriers to eating. So, commonly in our patients, just think about your last inpatient visit or last clinic, patients with nausea, vomiting, aversion to certain foods, taste, low sodium diet, early satiety, gastrointestinal pain, and diarrhea, with many of our patients on lactulose or constipation. Reach out a detailed collection, including at least all the aspects I just showed you, is not an easy task. It's time-consuming, skill personal is needed, and unfortunately, most care providers do not have enough time and nutritional knowledge to incorporate this approach to the daily clinical practice. And also, we need to have patient collaborations. Some of them are going to be too ill to collaborate, or even encephalopathic. And we also need to rely on our patient recall, again, some of them with hepatic encephalopathy. We have some questionnaires to help us. A good one is the three-day food diary. It's a method that relies the least on patient recall, but needs cooperation, as required to fill in a three-day diary, and to follow instructions, so that the patient has to be literate. Another limitation is that being prospectively collected might have the ability to modify patient's habits. In order to fit expectations, patient might be biased when they know that they are being observed and that they are going to be evaluated. Another good option is the 24-hour dietary call. It needs only short-term recall, as we'll be asking about the intake in the last 24 hours. It is less bothersome for patient, and it's not supposed to be affected by behavior. And there's no need of literacy, as it's going to be done and collected by the interviewers. But they need to be trained, and it's time-consuming. And one difficult aspect is to translate what our patient means to be a normal-sized pasta dish in grams and calories and proteins and so on. Examples like this, or resources like this, might be helpful, but again, it takes time to do it properly and to do the math. And what about micronutrients? They are not assessed by any dietary report, but we can assume that with advanced liver disease, the risk of deficit is high. Magnesium and zinc deficit is common and related to diuretic use, but they are easy to be tested. Fat-soluble vitamin deficit is also common, including vitamin K deficit in jaundice or cholestatic diseases. Also, water-soluble vitamin deficit is common, and its status is not easily determined, and supplementation is generally well accepted. There are a few recommendations, but a six-monthly testing might be encouraged. Next, muscle mass. Its definition is deficit, known as sarcopenia. It can be evaluated by different strategies. First, the simplest, anthropometry. With very simple and low-cost equipment, we can perform a pretty good muscle evaluation. Triceps skin thickness correlates well with visceral fat. I know fat is not muscle, but it's also related to malnutrition, and is necessary to the next evaluation. It is simple to measure, and has prognostic value in cirrhotic patients. Mid-arm muscle circumference correlates well with muscle mass, and it is extremely easy to calculate. Only mismeasuring mid-arm circumference, triceps skin fold, and a simple math, and has prognostic value among cirrhotic patients and impact after liver transplantation. The North American expert group has worked to standardize and promote the use of common definitions, and could also improve the study of sarcopenia. And the consensus recommends the use of L3 scleral muscle index as the marker of sarcopenia for outcome prediction. The scleral muscle index seems to be a more complete and robust measurement than individual measurement of the psoas muscle or the psoas muscle index. So total abdominal scleral muscle area at the L3 vertebral level standardized to height is preferred. Among the different cut-offs evaluated in different studies, the consensus advocates for a unique cut-off, but it did in a large multi-center North American study, being 39 square centimeters per square meter for women and 50 for men, identifying in this study a 33% of sarcopenic women and a 50% of sarcopenic men. A parietal cut differs by sex. Sarcopenia represents for women a 182% increased risk of weightless mortality and a 70% increased risk of weightless mortality for men. However, CT scan has, and despite being accepted as the gold standard, has some limitations. A disease associated to a significant risk of ionizing radiation and contrast exposure is not portable, and its low availability and high cost makes CT unsuitable for repeated longitudinal and frequently evaluation. Another tool that I think is of interest is DEXA. In favor, it has, as contrary to CT, patients are exposed to low radiation level, it has a good safety profile, it has a low cost, and results have proven to be reproducible. On the other hand, it fails when it has to differentiate water from muscle, and it is interfered by low lymphedema and has a good concordance with CT to identify sarcopenia. It's not a portable device, and depending on the center, it might be not so available. A bioelectrical impedance analysis is another interesting option to evaluate sarcopenia, and with the composition, it's an easy technique, has a reasonable cost, it is easily and rapidly performed, patients are not exposed to radiation, and the device might be portable. Here you can see an example of a portable device. On the other hand, it is affected by fluid retention, diuretic use, intake, BMI, and exercise. But newer models do have programs to take into account the patient's fluid status, and recent data has shown that its prognostic accuracy is comparable to that to the skeletal muscle index, and seems not to be affected by acidity, despite that correlation with CT scan is low. Ultrasound is another option that I think is of great interest. We'll start with thigh ultrasound. It is a safe, low-cost technique. It is also easy to perform. The device might also be portable and may be also quite accessible to clinicians, not depending on radiologists, and it is reliable. However, the data is scarce and reproducibility has to be proven. Regarding ultrasound, another option would be the psoas ultrasound. It is also safe, but the applicability is lower, and as in a quite large study, psoas ultrasound measurement was applicable in only 72% of the patients, and the reproducibility is not known, and I think we have a few data. Up to this point, we have been talking about the amount of the muscle, but we can also evaluate and measure the function. The simplest test is the hand grip test. It is extremely easy and accessible, and its prognostic value amongst aortic patients has been well documented. But we can do better and try to have a more global thinking and evaluation, and this leads us to the concept of frailty. Frailty is a multidimensional construct and represents the end manifestation of disorders of multiple physiological systems as well as psychological factors. Main components of frailty include, among others, sarcopenia, immobility, and malnutrition. Frailty in patients with cirrhosis is a more complete and global concept than sarcopenia alone, and the inclusion of functional measurements suggests that the influence of muscle mass alone may be modified by factors related to muscle function. Frailty has demonstrated to be a great discriminator. It is related to an increase with less mortality, mortality after hospitalization, and after liver transplantation. It also increases the need for hospitalization and the length of stay, and the need for a discharge location and rehabilitation. And it also increases the risk of acute cellular rejection after liver transplantation. The main message of the recent and excellent consensus is first to encourage us to evaluate our patients, and second to present us the different options we have to carry out the evaluation. Given that there is not a single frailty tool validated in all the clinical scenarios involving cirrhotic patients, what the frailty study group recommends is what has come to be called the frailty toolkit, providing us with different tools to be used depending on the resources of the health provider or the division and the clinical setting. And this kit contains four tools. First, Karnovsky performance status is a well-known test, easy and fast to perform and with no cost, correlates well with 90-day mortality, and has been validated in both the inpatient and the outpatient setting, but is subjective. Second, the evaluation with the activities of daily living is also an easy score to establish with no subjective component and with no cost, and correlates well with 90-day and overall weight loss mortality, and has also been validated in the inpatient and the outpatient setting, and it takes less than five minutes to be calculated. And third, the liver frailty index developed at UCSF. It's an objective tool. It's a continuous scale that can be repeated at each visit, correlates well with weight loss mortality and acute cellular rejection after liver transplantation, and to date has been validated in the outpatient setting, but I'm sure that new data is coming soon. The liver frailty index is composed of performance-based tests that can be done in the clinic. It consists of three tests, a group strength using a hand dynamometer, the chair stand, so you ask a patient to stand up and sit down five times without using their hands, and you just time them, and then balance testing. You ask them to balance 10 seconds in three different positions in escalating difficulty, and then you just go to the calculator online and calculate the score. Just one slide to show you how when we add the concept of frailty to our weighting list evaluation, we improve our ability to predict mortality in the celerotic patients and in an objective way. So that a patient with a MELA score of 14, but frail, has a similar mortality as a patient with a MELTA score of 23, but robust. For us who have been trained in the relevance of MELTA and trying to score to evaluate the severity of the disease and the risk of death and to indicate liver transplantation, it turns out that what really discriminates the risk is frailty. Finally, the six-minute walk test, it is an objective evaluation, requires only a smartphone to time the patient, correlates well with weightless mortality, and has been validated in the outpatient setting. So as a summary, in the same way that we have objective tools that we order continuously to evaluate cardiac or renal function, or to evaluate any other comorbidity, why don't we incorporate objective measurements to integrate what has just proven to be a real determinant of morbidity and mortality to improve our decision making. So to conclude, and as a take-home message, I would like to underscore the following points. Malnutrition and frailty increase mortality and vulnerability to health stressors. Ulcerative patients should be evaluated, just choose your centre adapters, simple or complex, whatever, your centre adapted strategy, and monitor patients over time. Thanks so much for your attention. Thank you so much for the opportunity to present today. I'm going to be speaking about helping patients with palliative care and I really want to thank my palliative care colleagues across North America and of course also a tremendous thanks to all of my patients for being the inspiration for pushing some of this work forward. For the objective today I want to get us a little closer to Dame Saunders vision for helping our patients to die peacefully but also really seeing that palliative care is helping patients to live until they die and we'll be covering a few of the obstacles to that and hopefully some solutions. Now before we start I want to start with a video and this video is from the Cleveland Clinic on empathy and I absolutely love it. It's a cropped version but you know it brings to mind for me every time I watch it why this is so important to bring to our patients lives. All of our patients have so much going on and if we can do what we can do to try and improve their quality of life through it I I know you would agree that that's that's the direction we should head in. So let's look at the first obstacle and the first obstacle is the biggest one I think and it's a misunderstanding of what palliative care actually means. We know that palliative care is looking at providing a good death in the end days of life and that's where it often gets confused with hospice but it is much more than that and palliative care as defined by the World Health Organization actually looks at improving the quality of life of patients and their caregivers across the duration of their illness and it's not only looking at physical issues that we're trying to help with but also psychosocial and spiritual support. And the core of palliative care is something that we do every day so we are practicing with these palliative principles or a palliative approach to care in supporting our patients. The main things that that we deal with with palliative care are advanced care planning and goals of care documentation, symptom management and assessment and that includes things that we do already the most important ones being hepatic encephalopathy and ascites management that significantly impact quality of life and then of course needs assessment and care coordination for example assisting with transitions and all of this happens with very effective communication skills underlying it. Now this is the traditional approach then to palliative care particularly with transplantation where you have a curative intent and you have a palliative intent and these things cannot occur together but as we've gone through the definition I would hope that you can see that disease modifying therapies like transplantation and palliative principles like the symptom management of course need to occur together our patients on the transplant list have tremendous suffering that requires palliative care to be involved. And it's not just specialty palliative care this is the other major misconception so with that broader definition of what palliative care is of providing support you can see that we do that as well there are not enough specialists in palliative care to be able to provide care to all of our patients needs including for example advanced care planning or goals of care directives especially as the prevalence of cirrhosis increases so it is going to be up to all of us to integrate palliative principles and to really get better at this if we aim to improve the quality of life of the people that we care for. The second major obstacle I think is an unclear understanding of why this is so important in cirrhosis particularly and as you probably experience in your day-to-day practice our patients have a tremendous symptom burden that is on par with patients who have advanced malignancy. This was data from a study that that we recently published looking at several hundred patients with fairly early disease actually for cirrhosis and despite that look at the percentage of abnormal scores in pain and in mobility and in anxiety and depression and mean quality of life scores of only about 59 out of a hundred. They have tremendous worries when you talk to them and when you look at the qualitative work that's been done in the literature about worries around family around psychological stresses to do with finances and social stigma and also tremendous stresses about being on the transplant list and the hope that they have to get a transplant but the fear that that won't come true. Thankfully we can do something and so palliative care referral makes a difference and this was a nice study by Bauman et al where they showed that a palliative care visit at the time of transplantation actually resulted in a significant reduction in symptoms such as pruritus, well-being, appetite, fatigue and depression and across diseases in the literature we know palliative care works so it reduces anxiety, it increases the understanding of a patient's illness, it improves quality of life, it reduces costs of care and this was nicely shown by Arpan Patel in an administrative database study and in some studies it's actually increased survival as well. When we don't do things like talking to our patients about what their wishes are so advanced care planning or goals of care designations that certainly leads to inappropriate care and unfortunately our patients who are listed for transplant likely because of that curative palliative black and white box have lower rates of advanced care planning even than non-listed patients. Moreover these patients who are delisted, so our sickest patients who are delisted for being unwell have aggressive care often and suboptimal symptom management and this has been shown in several studies now I'll just highlight a few of them this one from our site where despite being delisted 48% were still referred to the ICU and almost 20% still had dialysis done and then in another study from UCSF 17% so a small number were actually referred to palliative care after being delisted but half of them were within 72 hours of death and fitting with that we know that these patients have late hospice referrals so this is not something that's at the top of our minds for caring for these patients. Moreover we know that if we have non-informed surrogates or no surrogate decision-makers so someone who can speak for the patient when they can't speak for themselves that leads to inappropriate care as well and this is not uncommon that patients admitted to hospital at their last days are unable to speak for themselves that's 80% of patients and unfortunately our family members and friends if we don't talk to them specifically about what our wishes are non-informed surrogates in several studies only about a third of them are actually able to identify the treatments the patient is willing to accept. Informed surrogates on the other hand they are able to because they've been to appointments with the patient and they are able to know who the patient is they've had those discussions they can't figure out every single scenario in the beginning with the patient but certainly they know how to work with the team to make the best possible decisions in the moment. Third obstacle I think is this misconception that patients don't want palliative care and they don't want to discuss their disease and it'll cause a loss of hope and so this was some really nice work done by Nneka Oferi and this is just a very small portion of the of the survey that she did of ASLD members what if physicians believe that patients think and that the overwhelming response was when patients hear the term palliative care they're going to feel scared and they're going to feel anxious and think that nothing more can be done and physicians also worried that patients had unrealistic expectations and that prognostication was sort of very challenging to do. And this is perhaps not that far from the truth depending upon how we define palliative care and I really enjoyed this qualitative study which looked at a small group of patients and they asked them what they thought palliative care meant what did that term actually mean before they explained what it consisted of in the newer way of defining it and things like you're at the end it's the exit door you've given up hope on me those sort of sentiments came out. After explaining what palliative care was overwhelming again that the patients wanted this done I wish I'd known sooner it gives me hope wow you're actually here to support me and I didn't realize that that could happen if I was on the transplant list. So again it's a matter of just not understanding what this is. And we found similar findings as have others in the literature looking at advanced care planning and goals of care designation readiness research that we've done in a hundred of our patients when we talk to them about again defining what palliative care is properly and then talk to them about how important it is to know the truth about their health 100% want to know the truth about their health. Again this is not everybody and there will be cases where they're not quite ready to to hear about prognostication etc and those things need to be dealt with in a in a special way. But overwhelmingly the majority yes do want to know about their disease and their trajectory and then when we ask them about the preferred timing of advanced care planning discussions when they know what that is again they want to know from someone they trust in a stable clinic setting as opposed to in hospital about having these conversations. Advanced care planning across many studies does not affect hope or anxiety and in fact decreases patient anxiety and decreases caregiver bereavement outcomes so after the patient has passed. Fourth obstacle is uncertainty about who needs this like so yeah it seems to make sense that we need to do this who needs palliative care or approach to palliative care principles. And I think this sort of sums up why it's so important number one to do this in all of our patients and to do it early. This looks at different deteriorations in function sorry deteriorations in function over time with with different diseases. So with frailty you can see there's a slow undulating trajectory downwards. With advanced cancer there's a slow rate of decline and then they declare themselves and become sicker. And then with our patients with organ failures and other organ failures there are these dips in function that happen when they get hospitalized or they get a variceal bleed or an infection and it's never quite clear if that's going to be their last dip or if they're going to come out of it but they're always a little bit weaker when they come out. And with hepatic encephalopathy in the background wow do we have to get to these patients early if we actually want to know what their wishes are. So it's suggested triggers in the literature I think are very reasonable and this is just one of them but things like decompensated cirrhosis, people awaiting liver transplant, people delisted for transplant. I would argue that the approach to palliative care and the principles that I've talked about like discussing the disease with the patient their natural trajectory those things need to happen regardless of decompensation. They need to happen at diagnosis for everyone. But certainly with limited resources who do you want to put your focus into? Yes the sicker population for now. And the last obstacle is you know she's making sense but I don't know how to start this stuff or what to do and I guess first reassurance is that we're already again doing a lot of this and I think we need to be congratulated for that and continue doing a really good job with symptom management in our patients but let's get a little bit better. So big journeys, small steps. You know aim to provide your patients with educational materials, all of them. And I know sometimes we are lacking these materials but they are out there. There's a fantastic cirrhosis guide from the VA which is available online. I've put the link there. We've developed some materials and we're developing some more materials which I'm looking forward to sharing hopefully next year at this Cirrhosis Care Alberta which will include videos and lots of information for patients and for health care providers as well. So give your patients materials. Work on your advanced care planning skills. This was one of the best things that I did actually. So we know that right now two-thirds of these advanced care planning discussions occur in hospital. Median time of one minute which is absolutely inadequate to discuss someone's values, goals, beliefs, really get to know them as a person. It's meant to be a process over time with a surrogate decision maker. We're really comfortable talking about tests and percentages and diagnoses but we're much less prepared, many of us, to discuss things like dying or maintaining independence or impact on family and how do patients maintain some control in their life. So those sort of things are also very important to our patients. And when we have challenges with prognostication which can be difficult there's lots of variables to consider when you're prognosticating. That uncertainty often leads to providing vague information or a tendency to overestimate outcome if we haven't really been trained in how to do that. Thankfully there are lots of resources out there for us to do it and it won't take too much time but I promise you it is definitely worth it to advance your skills. I've personally done the Cirrhosis Illness Conversation Guide, thought it was fantastic and others you know are also very, very good. So see what's available locally for you. Learn other strategies to enhance communication skills with patients to get them, have them really learn and understand the messaging that we're trying to get across. And I love this as well, I don't have time to show you the video on it but it's called the Best Case Worst Case Scenario and it is, if you just google that, it's a YouTube video online and then links to courses that you can take with it. But instead of discussing again percentages with patients about this, for example admission to ICU with hepatic encephalopathy and variceal bleeding, instead of saying this is a percentage chance that you're going to get renal failure with this or this is a percentage chance you're going to come out of this, it's discussing real scenarios, making a story for the patient and making it for them in the context of their goals and values. So, so important and again this is the other most important thing I've done personally is to liaise with other members of the team and this is a paper that's coming out soon that was written by myself and some fantastic colleagues in the area and it really points out the need for collaboration and communication and role clarity because none of us are doing this alone, this is a team game. Specialty Palliative Care is going to lead the direction on how we do this well and help to teach us a lot about this but they can't take over the entire load for us. So liaise, it really makes a difference for integration. I'm going to ask you, I've talked about a lot, I'm going to ask you to aim for one small change in your practice for next week. So if that's keeping that video in mind in your clinic, if it's talking to all of your patients about who their surrogate decision maker is, if it is providing your patients or aiming to provide them with the cirrhosis educational materials and an offer to sort of discuss that on the next visit, if it's signing up for a course in advanced care planning or communication skills like the best case, worst case or like motivational interviewing, that was another fantastic skillset to develop. If it's calling up a palliative care specialist and just taking them a cup of coffee and really talking to them about what they do, you know, maybe shadowing them even in the clinic to see how they speak to patients, they're incredible. And trying to bring together the local structures that you have and for family physicians and other people who are going to help with this. And eventually then working towards integrating a model of specialty palliative care into clinics and transplant and also enhancing primary palliative care. So take home points, the majority of patients want information, no doubt about their health and their prognosis. And almost all have unaddressed fears and many, many have a high symptom burden. I don't want to forget in this our caregivers who also have a tremendously high symptom burden and need to be thought of when we're when we're doing all of this as well. The meaning of palliative care is often misunderstood. And I think working together we can start with small steps to start to overcome these barriers so that our patients and our caregivers all are better supported through the cirrhosis journey.

Hepatology Associates course

Liver disease management

Tailored treatment

Interprofessional teamwork

Post-transplant infections

CMV

Candida

Case studies

Personalized treatment approaches

Infection management

Palliative care

End-of-life care