Welcome, everyone, to the 2021 academic debates, annually one of the real highlights of the Liver Meeting. I'm Jack Lake, and I'll be our Master of Ceremonies tonight. We're coming to you live this year from the Liver Meeting DX with two exciting debate topics. Four teams will enter our debate Thunderdome tonight, but only two will leave victorious. And it's up to you, the viewers at home, to decide who will take home bragging rights for this year. But before we get to those exciting matchups, let's go over some quick housekeeping notes. Next slide. Our program is eligible for AMA PRA Category 1 credits and American Board of Internal Medicine Maintenance of Certification points. These are my disclosures. Let's give a virtual round of applause to this year's organizers, or as we call them, the AASLD Debate League Commissioners. Next slide. Oren Fix, Uchenna Ogden, and Nicholas Lim. Next slide. We've invited an expert panel of hepatologists and one surgeon to challenge and critique our debate teams following their initial arguments and rebuttals. Fair warning to our teams, our panelists are tough as nails and as demanding as a two-year-old child. Our panelists are Andres Cardenas from Barcelona, Lorna Dove from Columbia in New York, Julie Heimbach, a surgeon from the Mayo Clinic, Louis Roberts, also from the Mayo Clinic in Rochester, and Jim Trotter with Baylor Health. Next slide. These are the disclosures for our organizers and panelists. Next slide. And of course, let's not forget our sixth man, you. Everyone watching tonight will be asked to vote on the best argument presented. As you listen to each argument presented, as you listen to each team, critique them on the following. First, construction of the argument. Second, quality of their argument slides. Third, mastery of the topic. Fourth, their presentation styles. And fifth, their skill in responding to questions. Next slide. At the conclusion of each debate, you'll get to vote on which team you think presented the best arguments. Polling will be open following the full set of debate presentations, including the panelist and audience Q&As. Once that has taken place, we will prompt you to go to the tab here in the Liver Meeting DX called Polling to submit your vote. The winner will be announced at the end of the entire session. Also, the Q&A portal is now open, and at any time, you may submit a question. We'll cover as many as we can during the audience Q&A. Now let's move on to the debate and the debate teams. Our first topic is liver transplantation for intrapartic cholangiocarcinoma. We'll have two arguments. Intrapartic cholangiocarcinoma should be a standard indication for liver transplantation. And second, intrapartic cholangiocarcinoma should be a contraindication to liver transplantation. The two teams debating will be the University of Michigan and Duke University. While some of us of a certain vintage will remember the last titanic clash between these two great universities. It was 30 years ago in the 1992 NCAA men's basketball final. In the final, Duke thrashed the University of Michigan Fab Five by 20 points after Duke had defeated Kentucky in the semifinal, which many people regard as the greatest NCAA basketball game of all time. It was Coach K's second NCAA championship and was back to back. The first argument pro intrapartic cholangiocarcinoma should be a standard indication for liver transplantation will be given by the University of Michigan Wolverines. I think it's about time for the U of M to avenge that defeat now 30 years ago. The Wolverines are represented tonight by Drs. Jason Pan and Avi Shanoi with support from their faculty member, Bob Fantana. Next slide. Here are their disclosures. And without any further ado, let's go blue. Thank you so much. Tonight, we will be discussing intrapathic cholangiocarcinoma, or ICCAs. These are defined by their location above the second-order bile ducts, which makes them a distinct disease entity from perihylar and distal cholangiocarcinomas. They are found in only one to two people per 100,000 persons per year, which translates into about 2,500 to 5,000 cases per year. And they almost always occur in patients over the age of 45, with a peak incidence in the seventh decade. Often, there is no underlying liver disease, and the incidence is rising in the U.S. Speaking of rising, let's take a look at the preseason rankings of the men's basketball teams. Here, you'll see that Michigan is currently number six, and while Duke... We'll take a look at the next slide now. So, current therapies for ICCAs have poor outcomes. The median survival is less than three years with the best care, and only 12% to 40% at diagnosis are even candidates for resection. The overall five-year survival after an R0 resection is less than 40%. So, therefore, we argue that ICCAs should be a standard indication for liver transplantation. Transplant has the best outcomes if risk factors for recurrence are excluded, and our experience with transplant for HCC and hyaluronic cholangiocarcinoma are proof of the feasibility. I don't want this audience to be misled by liver transplant studies prior to 2012. Although these studies suggest a two-year survival of 30%, nearly all of these studies combine results from patients who had extrapatic cholangiocarcinoma, particularly hyaluronic cholangiocarcinoma. They lack standardized patient selection criteria, and they don't use any neoadjuvant therapy. We propose that patients with ICCAs who meet these following requirements be given MELD exception points. First, they should have an unresectable ICCA up to five centimeters in maximal diameter without any microvascular invasion, poor differentiation, or a CA99 greater than 1,000. There should be no vascular invasion or extrapatic disease based on a bone scan, a CT or MRI, and also selective use of PET if there are any suspicious nodules. And importantly, there should be at least six months of observation to ensure stability and response. During this time, they would receive a neoadjuvant chemotherapy and also local regional therapy if they're a candidate. At the end of this observation period, an EUS with lymph node sampling or a mini-staging laparotomy with lymph node dissection should be done to ensure that there is no extrapatic disease. We anticipate with these criteria only 50 to 100 cases per year would meet them and not be a particular burden to the transplant system, and living donation could also be considered as an excellent option. In the first study, we will show you that liver transplant is feasible in early ICCAs. In this 2016 Retrospective International Study, 48 liver transplant recipients with only ICCAs on explant were enrolled. The early group had a single tumor less than two centimeters, while the advanced group had up to two tumors between two to five centimeters. The transplants in the early ICCAs did very well. On the left is the Kaplan-Meier recurrence curve, with the top line being advanced, the bottom line being early. The five-year recurrence was 61% in the advanced group, but only 18% in the early, and the five-year survival was 45% in the advanced group and a significant 65% in the early group. Additionally, this study showed that the predictor of recurrence was bad tumor biology. Microvascular invasion and poor tumor differentiation were significant predictors. And looking at the median wait time, the early group had a longer median wait time of 11 months compared to six months, suggesting that they had less aggressive tumors. The second study we'll look at demonstrates that liver transplant is superior to liver resection. This was a French multicenter study where 75 cirrhotic patients underwent either liver transplant or liver resection. All these patients had ICCAs or tumors that had combined HCC and cholangio up to five centimeters. There were similar rates of vascular invasion and poor tumor differentiation, and the resection group achieved an R0 margin in nearly 90%. The results are quite startling. The five-year tumor recurrence in the transplant group was only 20% compared to 50% in the resection group, and the five-year recurrence-free survival was nearly three quarters in the transplant group compared to 40% in the resection group. Additionally, this study showed that two- to five-centimeter tumors did well with transplant, with survival of 65%, recurrence of 21%, and notably compared to study one, a longer median time to transplant of 18 months. Additionally, neoadjuvant therapy prior to liver transplant can improve outcomes. These two studies used patients with locally advanced disease greater than five centimeters in size, with even multinodular disease and microvascular invasion, and they received either chemotherapy and or local regional SBRT, and they achieved a five-year survival of 83% to up to 100%, with the second study not having any tumor recurrence at five years. So we say just do it in carefully selected patients. The five-year liver transplant recurrence-free survival of carefully selected ICCAs are similar to those outcomes of hyaluronic cholangio, HCC, and even the overall liver transplant five-year survival rate. So we agree with you, Duke, in this 2021 review article by your faculty members. Patients with ICCAs may benefit from liver transplant. Did you know the first basketball game between Michigan and Duke took place in 1963? It was a real nail-biter, and Michigan won 83-67. Here's a photo of Dick Vitale and Dr. Lake broadcasting the game, and we also have a photo of the last shot in point. It was a slam dunk by Dr. Fontana while Coach K and Dr. King looked on. Thank you so much for your time. Thank you very much, Dr. Pan. The second argument on intrapathic cholangiocarcinoma should be a contraindication to liver transplantation will be given by the Duke University Blue Devils. Drs. Kara Wegerman and Jackie Henson, with support from their faculty mentor, Lindsay King. They're ready to make the Cameron Crazies proud. These are their disclosures. Take it away, Blue Devils. Thanks so much for tuning in, everyone. I'm Kara Wegerman, and Duke will argue that intrapathic cholangiocarcinoma should be a contraindication to liver transplantation. Next slide, please. We base this argument on three main points. First, post-transplant survival is poor and inferior to other indications for liver transplant, even in highly selected patients. Second, there is a high risk of recurrence post-liver transplant. And finally, because organs are a scarce resource, we should allocate them to provide the most benefit to our patients. Next slide. First, we will discuss poor post-transplant outcomes. Next slide. Early studies of liver transplant for intrapathic cholangiocarcinoma demonstrated poor five-year survival of 30% to 40%, as our colleagues mentioned. Based on this data, intrapathic cholangiocarcinoma appropriately became a contraindication to liver transplant. Next slide. Here are studies to date on liver transplant for intrapathic cholangiocarcinoma. A meta-analysis published this fall found a pooled five-year survival rate of only 42% shown at the top. A few studies shown in the middle found five-year survival rates around 60% at best. However, these were primarily explant studies of incidental intrapathic cholangiocarcinoma or misdiagnosed HCC within Milan criteria. These biased toward favorable outcomes because incidental tumors are more likely to be small and indolent as they were not detected on routine pre-transplant imaging. Next slide. Not only are survival rates poor, they are inferior to other indications for liver transplant. The most recent SRTR annual report shows five-year post-transplant survival of 75% to 80% with some variation by indication. The 42% estimate for intrapathic cholangiocarcinoma is therefore inferior. And it is inferior to post-transplant survival for hilar cholangiocarcinoma, which is 65% to 85% based on available data. Next slide. Some have suggested that with careful patient selection, as occurs in hilar cholangiocarcinoma, outcomes would be acceptable. Unfortunately, post-transplant survival appears inferior even in highly selected patients. This explant study found 65% five-year survival in very early intrapathic cholangiocarcinoma defined as one tumor less than two centimeters, still far below other indications. Half of the very early tumors were identified incidentally. And these had five-year survival of 80% versus those known prior to liver transplant with five-year survival of 53%, not that much better than patients with advanced tumors. If intrapathic cholangiocarcinoma becomes a standard indication for liver transplant, we would be transplanting patients with non-incidental tumors that we could find. Next slide, please. Survival is inferior to other indications even after neoadjuvant therapy. Among 30 patients at UCLA, five-year survival was only 49%. More recent data from Methodist MD Anderson on 18 patients showed 62% five-year survival from listing, even though patients were highly selected. They had to demonstrate six months of stable disease, and most did not have underlying liver disease. Earlier data from the same study on six patients reported 83% five-year survival, but three of the patients at risk were followed for less than three years, and only one surviving patient was actually followed for five years, which is an important caveat. Next slide, please. We'll now discuss the high risk of recurrence. Next slide. Intrapathic cholangiocarcinoma is an aggressive and infiltrative cancer. Studies have demonstrated microvascular invasion in roughly 50% of patients, and 20% to 30% may have occult metastatic disease at diagnosis. All of these factors are associated with recurrence, and they are hard to identify prior to transplant based on imaging alone. When you combine this high risk for recurrence with immunosuppression, you would anticipate bad outcomes. Next slide, please. And in fact, studies have found high risk for recurrence after liver transplant. The recent meta-analysis of primarily explant studies found a pooled 43% recurrence rate. Alarmingly, recurrence occurred after a mean of 14.3 months. In other words, even though these patients had earlier indolent disease that was not detected pre-liver transplant, or they met HCC criteria for transplant, nearly half experienced recurrence just after a year. Next slide, please. There is a high risk for recurrence even after neoadjuvant therapy. The Methodist MD Anderson 18 patient cohort had 52% recurrence-free survival at three years after listing, not after transplant. And this was only three patients at risk at that time point shown in the curve on the left. Their earlier data had shown recurrence in 50%, and it was metastatic in all of these patients. To put this into context, the original Milan criteria study in HCC showed 92% recurrence-free survival at four years after transplant, and published recurrence rates are 15% to 20%. And the 2012 multicenter study of 287 patients with hyaluronic cholangiocarcinoma found 72% recurrence-free survival among those transplanted within standard criteria. Therefore, we cannot simply extrapolate HCC or hyaluronic cholangiocarcinoma data in this situation. Next slide, please. Now we'll talk about organ stewardship. Next slide. Organs are a scarce resource, so we have to balance the benefit to the individual with the benefit to all patients. As of late October, there were 11,694 patients on the liver transplant waiting list. Transplantation may improve survival for an individual patient with intraepatic cholangiocarcinoma compared to systemic therapy or resection. However, we are obligated to transplant patients who will survive longer, will have better post-transplant quality of life, and allocate a limited resource for maximal benefit. Next slide, please. We cannot justify transplanting patients with inferior outcomes when people who will experience better outcomes are dying on the wait list. Imagine we transplant the patient with intraepatic cholangiocarcinoma on the left. Five-year survival is poor and recurrence is likely. Because we allocated a liver to this patient, our other patient with PBC and cirrhosis will die on the wait list. Her five-year survival would have been 75% or even 85% at Duke, based on internal data, with potentially excellent quality of life after liver transplant. As much as we want to help the patient on the left, if we transplant her, both patients will have a poor outcome. Next slide, please. In summary, intraepatic cholangiocarcinoma should be a contraindication to liver transplant. Survival is poor and inferior to other indications, even in highly selected patients, and there is a high risk of recurrence post-liver transplant. Organs are a scarce resource, and we should allocate them to provide the most benefit. And although it was a good idea, like Michigan making the playoff, it just doesn't seem to pan out. Next slide, please. Thank you for your time. And now let's take a two-minute timeout to let the teams head back to the sidelines and review some X's and O's with their mentors. And we can have some fun while we bring back the panelists, I believe. So here's our five panelists. So what's your takeaway from the debate so far? Lorna, what did you think? I think I'm a Tar Heel, so I'm sort of biased, but the Duke team did very good, and it's impressive for me to say that as a Tar Heel. I think a large part of their argument was based on organ stewardship, because if they had all the organs in the world, there is no absolute cutoff for, you know, what would be good enough to say everybody doesn't have the same outcome. So, but I think both teams did a great job. So Andres, I don't think you would appreciate that. Yeah, Jack, I would agree. Both teams did a great job, but I would say I was struck by the fact that they both seemed to lump the patients with cirrhosis and small intrapartic clangio with the larger tumors treated with neoadjuvant therapy. So that's an interesting grouping of the data. I was going to say, Andres, some of the basketball humor probably went over your head, but in Spain, where you have the highest organ donation rates in the world, what do you guys think about intrapartic clangio as an indication? We have the same problems as well. I mean, we do have more organ donation. However, our donors are not as good as they used to be. We do face similar problems as other countries do. So we do have a problem with organ donation in terms of supply and we do practice organ stewardship. Well, I think they both did a great job. We here in Barcelona, we also debate what type of patients and the point about cirrhosis and non-cirrhotic patients is extremely important for us because we do see patients that present with intrapathic cholangic carcinoma. They may have underlying NASH without full-blown cirrhosis or decompensated cirrhosis. So those patients in our view are different. I think it's made a great argument. I'm gonna have to interrupt you, Andres. We're at time. So we're gonna go with rebuttals now. And now both teams should be back from their timeout, looking refreshed and focused. Let's get ready for the rebuttals. Duke has the first crack at rebuttal. Thank you. We would like to respond to several points. First, the arguments made for transplanting these patients are based almost exclusively on small explant studies, which are biased towards better outcomes as we outlined. For these reasons, data from explant studies cannot be extrapolated to the population being discussed for transplant. Yet even with these biases, the survival was still inferior to standard indications for transplant. On the basis of explant data, our opponents argued for transplanting early tumors less than two centimeters. However, among this subgroup, there was a clear difference in outcomes between incidental and non-incidental. With the non-incidental tumors with much poor survival. This means the population we would realistically be targeting with this strategy had even worse outcomes. It was also argued based on explant data that these patients should be transplanted due to less recurrence compared to resection. But the populations being compared were fundamentally different. In the highlighted study, over half had enough disease stability to wait one to four years between a diagnosis of presumed HCC in transplant, which speaks to a more favorable tumor biology. In addition, 63% received treatment pre-transplant compared to only 15 pre-resection, further biasing these results. Another argument was made for transplanting patients after neoadjuvant therapy. This was made on the basis of six patients, but updated data on 18 patients had a much lower 62% survival. Again, inferior to other indications. More concerning is that despite six months disease stability, 40% had recurrence with all of the published data being metastatic disease. The UCLA cohort had improved survival more recently after 2008, but this was only seven patients. Are we really going to change national policy on seven patients? We showed the data that was used to support transplanting HCC. The studies for hyaluronic cholangio had survival rates exceeding 75 to 80% in a cohort of over 60. We do not have evidence even approaching this level for intra-hepatic cholangio. Therefore, it is clear that it should remain a contraindication to transplant. Even with biased data and highly selected patients, there is inferior survival and a high risk of recurrence, and we have a shortage of organs for patients who will experience better outcomes. Thank you. Thank you. Okay, and now, Michigan, go ahead and present your rebuttal. Thank you to Duke University for bringing some excellent points up. We are not suggesting to transplant every single person with intra-hepatic cholangiocarcinoma. I just wanted to repeat that. We are not suggesting to transplant every person with intra-hepatic cholangiocarcinoma. We agree that ICCA is a very complex disease, but at the same time, not all ICCAs are created equally. Our strict selection criteria will be transplanting only 50 to 100 patients per year who will otherwise die fairly quickly with the current treatment options for unresectable disease. Patients with well-differentiated tumors with other surrogates of less aggressive disease who have stability on follow-up imaging at three and six months with a mini staging laparotomy or lymph node biopsy treated with neoadjuvant therapy should be eligible for transplantation, especially if we have a prolonged pre-transplant follow-up on the wait list. So here are a few points. Careful selection of unresectable ICCA candidates results in excellent survival and recurrence rates as rightly pointed out by Dr. Pan and provides hope for this otherwise lethal condition. Incidents of ICCA meeting our strict selection criteria for liver transplant will not significantly cause burden to the organ shortage given the selectivity of our criteria. And we would utilize mild exception points for ICCA and propose a UNOS certified protocol for certain transplant centers, similar to what's in place for hyaluronic glandular carcinomas with outcome tracking. Thank you so much. Thank you. Congratulations to both the University of Michigan and Duke. We're now down to the two minute warning, or it's actually a 10 minute warning here because it's actually time for the questions in the ASLD debate league. It's time for our panelists to first ask questions and they anticipate some very tough questions and provide their critiques. So why don't we begin with Louis Roberts. Louis Roberts. Thanks, great work by both teams. Those were excellent arguments and rebuttals. I have a question for the Michigan group. You mentioned microvascular invasion as the absence of microvascular invasion as one of your criteria for inclusion, but how would you determine this in patients who had not had a resection? Is this something that in the studies was found, you know, after in the explants, you know, or is this something that you are going to be able to find prior to during the evaluation for transplant? Thank you for your question. So this was proposed more as an exclusion criteria rather than an inclusion criteria. We were using multiple risk factors for high recurrence, including if microvascular invasion was found, it would be an exclusion criteria, same as if poor tumor differentiation was found or a very elevated CA-19-9. We think there would be great value in getting a biopsy to histologically confirm and determine the diagnosis of ICCA. Jim Trotter, why don't you ask the next question? Or maybe Jim can't hear me. Julie, why don't you go ahead and ask the next question? I think I'm on now, Jack. Can you hear me now? Yeah, we can hear you. Yeah, sorry about that. So those were both evidence-based questions. Yeah, we can hear you. Yeah, sorry about that. So those were both excellent presentations. I really thought that both groups really did well, and I would commend you on that because I know how difficult this is to prepare for these. And I would throw this question out to either Duke or Michigan. I took notes and Michigan reported 65% survival in one study and 75% in another. And on the other hand, Duke said it was 42% survival. And so the question is, this is a topic I don't know that much about, to be honest with you. Why the difference in survivals? You're talking about almost a two-fold difference in survival. What's the difference between those in the groups? Yeah, we can answer that. So I think the 45% or 42% we showed was from a recent meta-analysis that was summarizing essentially all of the studies to date, most of which were explant studies, as we sort of explained, and then included, I think in that meta-analysis, some of the prospective data from UCLA and then some of the prospective data from Methodist and Andy Anderson. So that's where the 45% or 42% came from. And then some of the other data, or excuse me, survival that was quoted, I think came from, I think 65% was maybe in one of the explant studies that Michigan sort of mentioned. And I forget which other number you sort of threw out, but I think that's why there's a variety. I think the prospective studies, the most recent data that we saw that was presented at ATC last year was updated data from the Methodist MD Anderson group that was updated on their six patients to now 18 patients, which showed 62%- So is there anything fundamentally different about the patient groups in those two survival groups? Because they're so different. And it was 75% and 65% that Michigan presented versus 42%. And then I'll be quiet. Yes, I'd like to answer this question. And I would like to bring up that review that was mentioned because that was one of our final slides. We had mentioned that a Duke faculty member was involved in that analysis and that at the end, their concluding remark was that transplant may be considered in ICCA patients in highly selected situations. And it's important to note that many liver transplant studies combined patients with hyaluronic cholangiocarcinoma, as well as using older studies prior to 2012, they often did not use neoadjuvant therapy, nor was there careful transplant selection criteria. And so you have to take into account when looking at a meta-analysis, whether these older studies are being included. So Michigan is saying these are non-representative patients from days gone by, and they don't represent the current practice, to be my summary. That's correct, thank you. I would also encourage the audience to submit their questions in the Q&A tab. We look forward to hearing some questions from the audience as well. We'll go back to our panelists, Julie Heimbach. Yeah, I would also like to congratulate both teams for some fantastic debate presentations. My question goes to the Michigan team. It does seem that you're advocating for transplant for a group of tumors up to five centimeters, but it seems like you're lumping the cirrhotic patients where that data was in the less than two or less than three centimeter group with the group from Texas, which was largely a non-cirrhotic patient. So can you clarify which patient population you're advocating for? Is it patients with cirrhosis and small intrapartic cholangio, or non-cirrhotic patients who you would want to include, or is it both? Thank you. So the French multicenter study that we looked at in the second study involved cirrhotic patients with up to five centimeter ICCAs, and they did quite well. So I would be okay with transplanting both non-cirrhotic and cirrhotic patients up to five centimeters, particularly based on that DeMartin et al study published in liver transplantation in 2020. And neoadjuvant therapy for those patients with cirrhosis as well? Yeah, because it appears based on those two center experiences that neoadjuvant therapy can further improve outcomes, particularly five-year outcomes. Great. Thank you very much for that clarification. Andres, do you have a question? Well, I just, I want to congratulate both teams. I think they did a fantastic job defending their points of view. And I do have a question for Michigan because it is interesting to look at the data and see that most of the data they're actually discussing is based on retrospective studies. So if you look at the slide that the Duke team presented, only two prospective studies have been published on this. So that does beg the question that how reliable do you think the data on the retrospective studies is in order for you to recommend liver transplantation even for those that have less than five centimeters? I think that's a great point. We don't have enough prospective studies out there right now, obviously, for intrapartic cholangiocarcinoma. But with the limited data we have, we feel quite comfortable transplanting patients with intrapartic cholangiocarcinoma. A lot of the data for perihylar cholangiocarcinoma was also retrospective as well. And those patients are doing quite well. So I think it's not about necessarily looking at patients of course, it's looking at patients prospectively, but I think looking at patients that have well differentiated tumors is the key. Patients that have slow tumor biology. And if you have an appropriate wait time, you can, they can declare themselves if patients get sick or recur. If I may add, right now we cannot prospectively and knowingly transplant patients with ICCAs. It's not a current indication. And our prior experience with HCC was based on retrospective studies. Lorna, before we get to you, there's three questions from the audience that are all of the same question. And that is about a biopsy and the issue of tumor seeding. And also somebody raised the issue that the biopsy of cholangiocarcinoma is contraindicated to transplantation based on the Mayo protocol. Would you either team care to comment on the risk of seeding and whether biopsies are actually contraindicated here? So the evidence for tumor seeding during a fine needle aspiration biopsy is specific for perihylar cholangiocarcinoma. And it was in a 2011 Mayo study, but this evidence has not been demonstrated in intrapathic cholangiocarcinoma. Additionally, we can also ablate the track when obtaining a biopsy to reduce the risk of tumor seeding. Yeah, I would just jump in there. There's a significant biologic difference between crossing the peritoneum in a hylar lesion and then crossing the liver parenchyma in intrapathic lesion. And I think that would be the primary reason for that difference. And then Lorna, you had the last question. That'd be a short question and a short answer. Okay, I just want to say congratulations to both teams. It was really a nail-biter, as you said. For the Duke team, I think you made great arguments about organ stewardship, and I love that slide when we thought about that NAFL patient who didn't get transplanted. That was a good point. But is there any threshold that you would feel comfortable with allowing this to go forward? Or are you advocating for a study, a prospective study, to look at that as opposed to just an absolute contraindication? I think we'd just like to see more prospective data. I think at some point we may reach, we may figure out who this population is who would benefit from transplant, but I think it needs to be, for now, under research protocols. And I just don't think we have enough data showing good outcomes that we can make this a standard indication. But certainly the hope would be this could be achieved in the future when you see more prospective data. Well, thank you, both teams. It's now time for the audience voting. We're gonna open up polling. It's now up to you, the audience at home, to vote. You've got two minutes to go to the polling tab and vote for the best argument based on the following criteria. Construction of argument, quality of their argument slides, mastery of the topic, their presentation styles, and their skill in responding to questions. I feel like we should play music or something. If I'd known it was gonna take this long, I'd have had a few jokes. I do have to say, that was a pretty intense interrogation of our two teams. I don't think I've seen an interrogation like that since the movie, A Few Good Men. So again, for the audience, please go to the polling tab and vote for the team that you thought had the best arguments in this debate. We have 20 seconds to get the vote in before we're going to close the polls. And the time is up. Thank you very much for voting. We'll announce the winner at the conclusion of our second debate, which will kick off shortly. Next slide. Our second debate. It also involves two great universities, the University of Southern California, historically has been one of the best NCAA football programs with 11 national championships, and seven Heisman Trophy winners. The University of Chicago actually generated the first Heisman Trophy winner, but their football history is not quite as legendary as the University of Southern California. Nonetheless, the University of Chicago, boasts an affiliation with 101 Nobel laureates, including 50 long term faculty members, and 34 UC alumni. Our topic for a second debate is mandatory vaccination for COVID-19. The current argument COVID-19 vaccination should be. Next slide. Should be a requirement for liver transplant listing will be given by the University of Chicago phoenixes. Let's hope they don't have to rise from the ashes. The phoenixes are represented tonight by Dr. Anuya Gampa and Matthew, Dr. Matthew Odenwald, with support from their faculty member, Anjana Pillai. Any other disclosures. Okay, University of Chicago, you're on the clock. Go ahead. All right, thank you, Dr. Lake. My name is Matthew Odenwald, and with Dr. Gampa, we will be representing the University of Chicago to argue that COVID-19 vaccination should be a requirement for liver transplantation. With the COVID-19 pandemic still a major health concern, and the advent of multiple highly effective vaccines, national attention is now being focused on solid organ transplant centers that are acquiring vaccine prior to transplant listing. This has garnered significant attention from coast to coast and extra noise from the media, leaving us as a community of transplant hepatologists wondering, what should we do. These three prominent liver transplant programs have publicly committed to requiring the COVID-19 vaccine prior to listing, and many others have followed suit. Today, we will present the facts that lie squarely on the side of requiring vaccination against this deadly virus before listing patients to receive a scarce resource of a life saving liver transplant. We will go through data clearly demonstrating the requirements already exist to be listed for transplants. Patients with liver disease are at extremely high risk for adverse outcomes from COVID-19, including death. A COVID-19 infection has an unacceptably high risk post transplant. And finally, vaccinations is less effective if given post transplant. The nature of pre transplant requirements is not new. There are a whole host of vaccines that the AST infectious disease guidelines strongly recommend prior to solid organ transplant to prevent known pathogens. Moreover, we should not forget that to receive a solid organ patients must demonstrate many behaviors that show a commitment to a lifelong relationship with a transplant team, and that they will be good stewards of the life saving scarce resource. Just as importantly, not adhering to medical care, severe cardiopulmonary disease, active cancers, and active polysubstance abuse are all reasons for exclusion from the list. And these rules are not punitive, but are strongly enforced due to the high risk of post transplant complications, including graft loss and death. And that same thing is not even the slightest stretch to include COVID-19 vaccine to this list. Patients with cirrhosis are at increased risk of adverse outcomes from the COVID-19 infection, including hospitalization, ICU admission, a need for invasive ventilation, and importantly death. In this international registry study of 745 patients with chronic liver disease who contracted COVID, mortality rate was an alarming 32% in those with cirrhosis, and worse in patients with more advanced child abuse scores. Child's PUC patients had an astounding 51% chance of dying of COVID-19, more than nine times the risk of patients without cirrhosis. And importantly, this study was done prior to the vaccine being available and shows the natural course of disease without any prevention. Thankfully, the COVID vaccine is highly effective in patients with cirrhosis and with a 100% efficacy in preventing both hospitalization and death from COVID-19 in a large retrospective cohort study from the VA of more than 24,000 patients. Together, this data led the CDC and IDSA to list cirrhosis as a condition with higher risk of COVID-19 complications, and both EASL and AASLD have strongly recommended vaccinating patients with liver disease. So while COVID-19 is a real threat to kill our patients prior to transplant while on the wait list, we have the tool to fight this deadly disease, we just need to use it. The data also indicate that our patients are at an unacceptably high risk of mortality from COVID-19 post-transplant. The most complete data studying the risk of COVID-19 in solid organ transplant recipients observed 28-day mortality stratified based on organ type. Liver transplant recipients fared second worst of all solid organ recipients behind lung recipients with a 12% 28-day mortality after a COVID-19 infection. Other smaller studies suggested even worse prognosis with up to a 23% mortality from COVID-19. With a disease that's readily preventable that portends such a poor prognosis in a patient population where we strive to do everything possible for them, we should not accept such a high risk. Moreover, when our programs are all highly scrutinized for one-year mortality rates and the fate of many other patients eagerly waiting for liver transplants could be at stake, should we really be taking this losing gamble as our colleagues will argue next? While post-vaccine data in liver transplant recipients is still pending, we expect that this will be promising as it has been in both the general population and in patients with chronic liver disease. And we can't afford to wait on a trial of vaccine efficacy in transplant recipients to learn the obvious, what we already know. The vaccine, like this smart pigs parachute, works and saves lives. And finally, the data indicate that the vaccine is more immunogenic pre-transplant prior to using strong immunosuppression. Compared to healthy controls in whom 100% of patients mount a measurable antibody response to the COVID-19 vaccine, fewer than half of liver transplant recipients have measurable antibodies. Additionally, those who were positive for antibodies had average titers less than half of the healthy controls, suggesting that the vaccine given after transplant may not be as effective. Multiple additional studies have shown increasing antibody response with more doses of vaccine. But even after the third dose of mRNA vaccines, antibodies are detected in only about 70% of solid organ transplant recipients. Together, this suggests that the COVID-19 vaccine should be given pre-transplant. So in conclusion, we've shown you that requirements already exist to be listed for liver transplant and COVID-19 vaccination should be no different. This is because patients with cirrhosis have an increased risk of death from COVID-19 infection. And our goal is to get our patients to a life-saving liver transplant. COVID-19 infection also has a high mortality risk post-transplant, which is preventable with vaccination and frankly, an unacceptable risk. And finally, this should be done before transplant to prevent death, but also to improve chances of vaccine efficacy. Thank you and be safe. Thank you very much, Dr. Wittenwald. The second argument, Khan, COVID vaccination should not be a requirement for liver transplant listing, will be given by the University of Southern California Trojans. The Trojans are represented tonight by Drs. Cynthia Iriana and Jasleen Singh, with support from the faculty member, Jeffrey Khan. They're ready to make the Trojan faithful proud. These are the disclosures. Take it away, Trojans. Thank you, Dr. Lake. We agree. Next slide, please. We agree that SARS-CoV-2 vaccination has demonstrated safety and efficacy in the general population, resulting in significant reduction of COVID infection in the general population. Therefore, we fully support vaccination for COVID-19. We are against a vaccine mandate in liver transplant candidates because, one, withholding life-saving liver transplant due to mandate will lead to greater harm than COVID. Number two, mandate will worsen pre-existing disparities in liver transplantation. And number three, patient-centered strategies are a better option to improve vaccine uptake. Next slide. Before COVID-19, end-stage liver disease was an already significant and growing health care problem. Delays in care during the pandemic are anticipated to have long-lasting and negative effects on this population. The majority of patients who require a listing for liver transplant face extremely high mortality rates, greater than 50% in 90 days if mailed over 30. In contrast, the daily case count of COVID continues to drop, such that the daily risk of acquiring COVID right now and putting a patient at risk for graft loss or death post-transplant from COVID has become very small. Next slide. In a U.S.-based case-control study comparing hospitalized patients with cirrhosis plus COVID, represented in light green, and age- and sex-matched controls represented in dark green, patients with cirrhosis plus COVID had similar rates of in-hospital mortality to patients hospitalized with cirrhosis alone. In a 90-day follow-up analysis, readmissions were statistically similar in the cirrhosis groups but higher than COVID alone. In other words, cirrhosis is the primary driver of in-hospital deaths and high health care utilization, not COVID. The only life-saving treatment for cirrhosis is liver transplant. Next slide. Furthermore, increasing availability of disease-modifying treatments for COVID means that the overall benefit of mandating vaccination as a method to prevent post-transplant COVID mortality is growing smaller. A single-centered study early in the pandemic demonstrated that an aggressive, programmatic approach including outpatient COVID monoclonal antibody therapy and the COVID-positive abdominal organ transplant recipient at the earliest signs of symptoms significantly decreased hospitalizations from 32% to 15% and eliminated mortality. While a preventative approach, vaccination is, of course, ideal for patients for whom vaccination is not an option, and with the uncertainty of long-term vaccine immunogenicity, effective COVID treatments are increasingly viable options for harm reduction. Next slide. Taken together, we argue that in the face of certain high mortality among patients awaiting liver transplant, denial of a life-saving treatment because of a vaccine mandate will result in more deaths than the uncertain potential of graft loss or death due to severe COVID infection in an unvaccinated patient after transplant. Next slide. Operational and ethnic minorities have a disproportionate burden of chronic liver disease, yet for many reasons experience disparities in liver transplantation. Several studies have highlighted these disparities among Black and Hispanic patients who have lower rates of liver transplant referral, more advanced liver disease and hepatocellular carcinoma diagnosis, and lower rates of living donor liver transplantation, just to name a few. A study combining data from the CDC Wonder and UNOS databases between 2014 and 2018 found that Black patients faced disparities in access to liver transplantation with the lowest listing rates relative to death from end-stage liver disease compared to other racial and ethnic groups. A necessary step in achieving equity in liver transplantation is a commitment to reducing ethnic and racial disparities in access to transplantation. Next slide. The same Black and Hispanic communities disadvantaged in transplant have lower rates of vaccine uptake across the nation as compared to Whites and Asians in data from the CDC and Kaiser Foundation. The reasons for this disparity are multifaceted, but are not malevolent in nature. For many communities, historical and contemporary context of systemic racism, marginalization, and neglect have led to rightful mistrust. Structural inequities, including limited access to vaccine and treatment access points, hinder vaccine accessibility. It should be emphasized that for these vulnerable patients, vaccine hesitancy does not necessarily equal refusal, which in turn does not equal noncompliance. Next slide. In addition, a mandate is not likely to be an effective strategy to overcome hesitancy. Based on the Gallup panel, a national survey examining public attitudes towards COVID vaccine mandates, fewer Black respondents were accepting of state mandates for adults, and in fact, significantly more found them to be unacceptable. Therefore, mandating vaccination will only serve to exacerbate existing racial, ethnic, and socioeconomic disparities in access to liver transplantation. Next slide. There are respectful and patient-centered strategies to increase vaccine uptake instead of a mandate. A single-centered study serving vaccine concerns among GI and liver patients demonstrated that rates of vaccine accessibility increased by at least 20% in serotics and liver transplant recipients to more than over 90%, with the simple intervention of a transplant provider recommending the vaccine. This highlights that vaccine discussions with a trusted provider can alleviate many fears that many patients have towards a new vaccine. Next slide. Additional patient-centered strategies have shown efficacy in increasing vaccine uptake. A randomized control trial demonstrated that educational handouts on the personal benefits of COVID vaccine reduced hesitancy. Multiple studies have also shown that patient reminders, recall interventions, and optimizing access points have been effective in enhancing vaccination against other preventable illnesses. All of these strategies and personally discussing the vaccine with our patients are more compassionate, evidence-based, and likely more effective options than a mandate to achieving the goal of vaccination in our society. In conclusion, an individualized rather than a one-size-fits-all approach is less likely to harm, is more equitable, and is more patient-centered. No mandate is the right choice for our patients. And this concludes our presentation. Thank you. Thank you very much. Now let's take a two-minute timeout to let the teams head back to the sidelines and strategize with their mentors. And we'll have a little bit of fun during the rebuttals. So could we bring the panels back up? So first of all, a controversy has arisen about what the nickname of the University of Chicago is. Is it the Phoenix? Or, as somebody's brought up, is it the Maroons? And here's what Dr. Google says. While Maroons is the official nickname of the University of Chicago sports teams, the Phoenix, which is featured as part of the University Shield, serves as a school's mascot. The University of Chicago Board of Trustees adopted the Shield in 1910. So you guys can make up your own mind. I wanted to ask the panelists, what's the craziest excuse you've heard from a patient as to why they didn't want to get vaccinated? I'll tell you mine. I saw a patient who was 26 years after transplantation, a terrible diabetic, minus both legs, and had a kidney transplant 15 years ago. And I said, why aren't you vaccinated? And he leaned in and he said, Doc, you know how many people have died from the vaccine? I said, none. He said, 652,000. I didn't have an answer for him. Anybody else have a crazy story? Well, I had a patient whose husband got COVID and she locked him in the basement and fed him through the dog door, but she still didn't want to get the vaccine. So, I mean, she was totally committed to the isolation part, but she just said she didn't trust the science. And I thought, well, my goodness, you trusted the science of having a liver transplant and you don't want to trust the science of the vaccination. So it was a challenging discussion, but I followed that sort of personalized discussion and walked through the data. And I will say she did get the shot after our chat. I wasn't so successful with the guy who said 652,000 people have died from the vaccine. I just can't believe she kept her husband in the basement for a week and fed him through the dog door. I thought that was awesome. Maybe she didn't like him, but I don't know. All right. Well, thank you very much. And now both teams should be back from their time out looking refreshed. And with new arguments, the Trojans from USC will have the first crack at rebuttals. Great presentation, University of Chicago. And we agree the vaccine has saved lives and we hope everyone receives it. But the incidence and mortality of COVID-19 is on the downtrend. Yet the mortality rates from decompensated cirrhosis are not decreasing. We have shown data that patients with high MELD have up to 80% mortality at three months. The rates at which our decompensated cirrhotic patients will die of their liver disease if we do not list them is much higher at this point than them dying from COVID. Furthermore, we take chances on our patients regularly. We even continue transplanting in the pre-vaccination era because we allocate organs based on urgency, not utility. In fact, data shows that patients transplanted for acute liver failure have mortality rates up to 20% and graft loss rates of close to 30% at one year. Yet we transplant them even with potentially worse outcomes because patients with ALF will die without a transplant. And for our unvaccinated patients who will also die without a transplant, it is unjust to deny them a life-saving treatment based on their vaccination status. Lastly, we cannot emphasize enough how a mandate will negatively impact our most vulnerable communities. In fact, a recent study demonstrated that U.S. counties with a high social vulnerability index and high vaccine hesitancy had lower vaccination rates. The goal is that we need to implement targeted community-level interventions, not reinforce their vulnerability and unequal access to healthcare. Ultimately, we must think about the individual patient. As long as we promote a patient-centered approach, we as providers can boost vaccine uptake in a more thoughtful and compassionate manner. And similar to the recent AASLD guideline, we strongly recommend the vaccination against COVID in our patients, but we simply cannot mandate it. Thank you. Thank you. And now, the University of Chicago will present their rebuttal. You guys bring up some very interesting points. And to this, we have a few things to say. COVID is far from over. There are new multiple variants coming up, and we are in need of vaccines and further boosters. I would like to point out a few things that our colleagues have mentioned. While in-house mortality may be the same between these patients, there is a higher ICU stay and mortality rate in liver transplant patients. The cumulative incidence of ICU stay and mortality among these patients is about 20%, and that is unacceptable and costly. The average cost of a COVID admission is greater than $20,000, which is more than 140 times the cost of a simple $40 vaccine. Our colleagues have also mentioned that the cost of a COVID vaccine is higher than our colleagues have also mentioned that vaccines are ideal, and they can mitigate this with the treatment of the COVID infection. However, we already know that prevention is better than cure, and it is extensively more cost effective. We do agree that there may be some racial disparities, but these patients who are undergoing liver transplant workup have access to vaccines, and these vaccines are at no cost to the patient. We all have to give up certain personal freedoms for our benefit to society. For example, driving intoxicated is also a form of personal freedom, but this is clearly harmful, and we do not do this as law-abiding citizens. Vaccination is analogously beneficial to the individual and the community and protects vulnerable patients, including our own transplant recipients. Overall, it is clear that there is nothing but benefit to the patient and the community in requiring COVID-19 vaccinations pre-transplant, which is much more efficacious than post. I would like to end with this one statement. As Benjamin Franklin once said, an ounce of prevention, $40 for a vaccine, is worth a pound or $20,000 of cure at no cost to personal freedom or any disparities. Thank you. Thank you to both teams. That was a fantastic debate. I thoroughly enjoyed that. Let's bring our panelists back on for the question and answer period. Our panelists will provide some tough questions and provide their critiques. So we're going to go in reverse order. Lorna, you can go first. Dr. Dove. I have two questions for the USC Trojans. The first question is they seem to be making the assumption that a mandate would exclude transplant, but don't we have data that in environments where a mandate was done, more people come get vaccinated, like in the workplace. So if you mandated it, some of those patients would agree to do the vaccine based on the mandate. And then the second question is, looking at healthcare equity, more than half of Black people in the country live in southern states. And there is a lot of vaccine hesitancy in the southern states when you look at the geographic map. Was this controlled for in that study that implied that African Americans would be disadvantaged because they would choose not to be vaccinated? Yes, those were great questions. So first, to address the topic of mandate and its efficacy in the rest of the population, we do agree in other sectors of our society, it has been efficacious and that's what's ultimately also augmented vaccination rates. But I would argue that our patients are special in the fact that they have no control over the situation that they are in. They ultimately did not choose to be sick. And at this time, we're taking any power that they may have to force them to do something. Again, we strongly recommend the vaccination and our goal would be to use a patient-centered approach and boost the patient-provider relationship to educate our patients in hopes of them choosing to receive the vaccine. In terms of the study that we showed, if you were referring to the one in which that there were higher numbers of Black patients that found a mandate to be unacceptable, they did not control for the location that they were in. So that is a great point that you brought up. If we could comment about the mandate as well. Sure, go ahead. Try to keep the answers brief. Oh, yes, of course. So to the point about mandates, thank you for bringing that up. And new data does show that the vaccine mandates in the workplace really, really do work and they have improved rates from less than 50% to over 90% adherence to the vaccine. So they do really, really work in these other populations. So that's something to keep in mind. Andres, you have one of the highest vaccinated. I want to congratulate both groups on a difficult issue where we don't have a lot of information. But to USC, and I'm sorry to pester you with these questions, but the USC, we do vaccinate our patients that are liver transplant candidates with hepatitis B, hepatitis A, influenza. And that is sort of accepted in most liver transplant centers. So why do you believe not requiring a COVID vaccine is something we should rethink? Yes, that's actually an excellent question. And there actually was a study that was done that shows that vaccination rates for things such as hepatitis A, hepatitis B, tetanus are nowhere near 100%. In fact, for tetanus, which is something that's only given every 10 years or so, vaccination rates were only as high as about 80%. So when that is the case, then clearly there is no such requirement in our transplant centers. I think ultimately we do encourage everyone to get vaccinated and we make it very accessible for patients, but we can't use those as examples since those vaccination rates are nowhere close to 100% and also carry high mortality if contracted by our transplant candidates. Louis, I'll give you the next question. Great, excellent work by both teams. I'd like to address the issue of patient autonomy. And it seems as though really this is a question to some degree about patient autonomy versus an approach that is beneficial, the ethical principle of beneficence for all individuals. And so in question to the University of Chicago team, how do you think in your arguments we balance autonomy versus beneficence in ethics? So that is a really good question. And I would like to point out in terms of autonomy or coercion, the medical definition is actually when a patient is compelled to accept a proposal such as a vaccination they may otherwise reject because of an imposed threat of an unacceptably worsened outcome. While there are rules in place to prevent coercion to receive a transplant or allow for patient autonomy, with this comes an implicit agreement between the physician and the patient that the patient will undergo any necessary testing and treatment for their liver disease, including the COVID vaccine for their transplant workup. So in fact, rather than medical coercion, this vaccine is actually preventing an unacceptably worsened outcome, but still allows for balance of the autonomy of the patient once they undergo liver transplant workup. And to piggyback on that, we do require many other things while being listed for transplant that I don't think would be debated in such a forum. For instance, if someone has a ischemic cardiomyopathy, we would require a left heart catheterization prior to listing them for transplant or receiving a transplant because that would prevent an unacceptably worse outcome. But I don't think anyone would be arguing about autonomy in that setting. Dr. Kleinbach? Yeah, thank you. Both groups did an outstanding job on this challenging topic. I first have a question for the University of Chicago, which is, I just didn't clearly hear how you would manage the really urgent patient with a high MELD score who can't wait for the 28 days in between their two shots or even a fulminant patient who can't even wait a few hours. What is the approach for that group? And then my second question is for California group, and we'll come to that if there's time. Thank you for your question. So the AST has actually released new guidelines and expert opinion, and we recommend that ideally we would try to vaccinate patients two weeks prior to their transplantation. However, for certain patients in acute liver failure who need an expedited workup and transplant, we would then recommend we would mandate the vaccination one month after their transplantation. So this would not delay their care in obtaining the transplant and lifesaving medical treatment that they need, but they would still need the vaccine. Great. I appreciate that clarification. And for the University of California group, different from, say, tetanus, and really we struggled with this at our own center, when a patient is not having the vaccine, when then they come to clinic, it's really not just the risk for themselves, but it's exposing the other patients in clinic and, of course, the staff in the clinic who could also be at risk for the unvaccinated patient. And I don't know if you have any discussions about that. Yes. So that is also an excellent point and something that we have discussed as well. So you know, in terms of vaccination rates, they are actually going up and they were going up even before mandates were in place. They were going up as of April of 2021. So as more and more people in our society are becoming vaccinated, we hope that that also poses less risk to those people who may be vaccinated. Now, in a hospital setting, we do understand that that is a difficult situation as patients may be more sick. But in those cases, we would definitely use our patient-provider relationship to educate our patients and discuss the importance of them getting vaccinated. Dr. Trotter, quick question and a quick answer. Okay. The great presentation. So this would be for Chicago. You know, I think collectively, we've casually required vaccines for other viruses, flu, hepatitis B, hepatitis A and for bacterial pneumonia. And collectively, the mortality rates for those diseases are probably higher than COVID. We've never prevented somebody from being transplanted. The University of Colorado took someone off their list because they wouldn't get a COVID vaccine. What's different about the COVID vaccine compared to all these other vaccines we've never required when the mortality rate, I think, collectively for these other illnesses is probably higher than COVID? So I think we both would like to answer. So actually, the CDC... So collectively, they may be increased, but individually, COVID-19 is far more lethal than any one of those individual conditions that you're suggesting here. I think we're out of time. Yep. And then we're going to go on to the polling now. So it's now time for you, the audience at home, to vote. You've got two minutes to go to the polling tab again and vote for the best argument based on the following criteria. Construction of argument, quality of their argument slides, mastery of the topic, their presentation styles, and their skill in responding to questions. We kept the panelists on this time. There were some interesting comments that came from the audience. One person commented that the mortality from COVID that was cited really reflects the early days of the pandemic, and it's much lower now. I don't know how much lower it is. And given how politicized this is, can we really justify mandating a vaccine when the mortality is lower? Another question, there are a couple of funny ones. One was that they can't believe the Trojans are against protection. The third one was that... And I'm sure you've heard this too, that my patient told me that he doesn't trust Bill Gates, and that's why he wasn't getting the vaccines. And the final funny comment was that the Blacks and Hispanics are no longer the major group of unvaccinated people. It's white males. And how do we handle that in terms of disparities? So... Was that a funny comment too there, Jack? Well, I think it is kind of a funny comment. I remember John O'Grady told me after Brexit passed that he told me, he says, beware of the ignorant white male. Trump will win. I want to applaud you for choosing this topic. I think it was brave. I think the team did a great job. And I'm a little bit afraid that we're all going to be on CNN and Fox News tonight. Well, no, it's actually, yeah, I agree with Lorna. I want to congratulate Oren and the other organizers for putting these topics together, which are really difficult to debate. Yeah, both sessions were amazing. So it was a great session. And Jack, you did great too. Thanks, Jack. Thank you. And the time is up now. We need just a minute to crunch the numbers here. Before we wrap up, we'd like to take a couple of minutes to thank everybody who made this debate possible. Most importantly, thanks to the teams from the University of Michigan, Duke University, the University of Chicago, and the University of Southern California for putting forward such great efforts. Thanks to our panelists for asking hard-hitting questions. And finally, thanks to the program chairs and ASLD staff who have worked so diligently to develop this event and have it all come together. Finally, I'd like to thank Nancy Rowe, editor of ASLD's journal Clinical Liver Disease, for starting and continuing the tradition of inviting all debate teams to submit their debate arguments as a special article. And now that the voting is complete and tallied, and I think it's been verified by accountants from Ernst & Young, let's announce our debate winners. I have to go down. One percent. Again, thrashing the Fab Five from the University of Michigan. Applause for the people from Duke. You wanna make, Duke, are we gonna allow them to make any comments? You have 30 seconds to make a comment. You wanna thank your mother and father? We'd like to thank our mentor, Dr. Lindsey King, for her outstanding guidance in all of this. And then we'd also like to thank Dr. Carl Berg, a former high school debate champion who gave us some debate tips. In the second debate is the University of Chicago with 66%. Congratulations, University of Chicago. Would you like to make any comments? We would like to thank our mentor, Dr. Pillai, and the rest of the University of Chicago transplant team. And we wish we were in Anaheim right now so we could go to Disneyland. So thank you so much for everybody for putting this on. We had a great time and really learned a lot doing it. Thank you. Well, congratulations to both our winning teams and thank you to our runners up for great efforts. And now let's all go on to celebrate this first day of the liver meeting at the liver meeting DX kickoff reception. ASLD president, Dr. Ray Chung will introduce us to Dr. Elvis Francois, the singing surgeon. Dr. Elvis has a unique passion for sharing his voice with uplifting music, both in and outside of the hospital. In this event, you will be able to break out into virtual tables to socialize with fellow attendees and perhaps talk about passions you have inside and outside of medicine. This event will start at 8.30 Eastern time, 7.30 Central time where I am and is accessed directly through this platform. I hope to see you all there and have a fabulous virtual meeting. Thank you.

Liver Meeting

academic debates

intrahepatic cholangiocarcinoma

liver transplantation

tumor selection criteria

survival rates

COVID-19 vaccination

transplant candidates

vaccine efficacy

patient-centered care

vaccine mandates