Ep. 17 – Previewing EASL: Part 2

FOCUS: More of the presentations that will make NASH/NAFLD news at the Digital International Liver Congress later this month
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Donna Cryer, President & CEO of the Global Liver Institute, and Louise Campbell, Founder of Tawazun Health, become Surfing regulars in an episode focused on the pivotal papers at EASL’s Digital ILC meeting August 27-29. The group discusses the section addressing COVID-19 and liver disease links along with presentations and posters discussing use of FibroScan, AI-aided test analysis, reducing cardiovascular risk by treating NAFLD and evaluating liver fibrosis in diabetes workups. The group also discussed cultural issues in NASH patient education and answer a letter about supporting Fatty Liver treatment in Africa. A truly multi-disciplinary look at this important meeting.

This Week’s Music: Mr. Parr is a musician and a 6th grade teacher in Franklin Lakes, NJ, who produces music to teach students different elements of science. He is a two-time teacher of the year winner whose songs have been played on the Weather Channel, YouTube and Science Curriculum networks. You can find his songs through Teachers Pay Teachers.


 

Roger Green: For everyone with an interest in NASH or more broadly fatty liver disease, surfs up because Episode 17 of Surfing the NASH Tsunami starts now.

Roger Green: We have lots of new, exciting things this week. Last week, you may remember had a lot of energy but it was mostly about chaos with a new distributor, new editor, lost lists, blah blah blah. This week, lots of energy, all positive. First, I promised this week I would announce our new permanent surfing line-up. Let me congratulate Louise Campbell on getting her own surfboard and being invited to hang out with the rest of us on a regular every week basis. Louise, thanks for joining us.

Louise Campbell: It’s a pleasure as always.

Roger Green: And a pleasure to have you with us. Now I would like to introduce, and I gave a hint on this when I said reintroduce, our new permanent surfer. Donna Cryer, the President & CEO of the Global Liver Institute who joined us for the International NASH Day episode, will be coming aboard now as a permanent surfer. Donna, good afternoon.

Donna Cryer: Good afternoon or whatever time our listeners are experiencing this.

Roger Green: It’s true, it’s afternoon here as we’re taping, but we have no knowledge where it is at the moment you’re listening – this exact moment as we tape it’s something like 2:00 in the morning in India. Donna, do us all a favor, take a couple of minutes and tell folks about yourself.

Donna Cryer: Sure. First of all, it is an honor to be included in this group. I’ve enjoyed the many… I guess this is the 16th provocative and informative conversation on the ever-evolving ecosystem in nonalcoholic steatohepatitis or NASH.

Donna Cryer: So, I am a patient, patient advocate and leader of a patient advocacy organization so the triple threat. I had my first diagnosis when I was 13 and a liver transplant by the time I was in my 20s. At this point, I have lived more of my life as a patient than not, and even more of it as a liver transplant recipient than with original parts. Being able to establish and scale the Global Liver Institute to meet the myriad needs in liver health, the myriad needs of liver patients around the world is really a humbling obligation and a privilege.

Donna Cryer: I was really thoughtful on the 20th anniversary of my liver transplant and I wasn’t all assured that other liver patients coming behind me would have the same access to innovations whether in therapy, you know, I started on a drug that was at that time called FK506, we now know as Prograf or tacrolimus, or innovations in care, you know, wonderful hospital under very skilled hands with very great minds using the latest research for me. Even at recent AASLD meetings, Willis Maddrey, whom we all know, looked over at me in prime health and he said, “We did a pretty good job on you, gal,” and I agree he did. I know the entire team that it takes to create help for someone who like me was on the brink of death and had only seven days to live.

Donna Cryer: The obligation and the honor and the opportunity to work and we’ll apply it to NASH since that’s our focus here but to apply to NASH and make sure that the research community – and that includes investors and companies and scientists, clinicians who are grappling with this, the patients and the policy makers whether they’re regulators or in state and we see today out in COVID the importance of public health officials and state and federal policy makers all together and we can’t do it without any one piece, – all together on what creates a successful patient outcome. Keeping all of those parts moving forward is what I have the opportunity to do every day at the Global Liver Institute.

Roger Green: Thanks, that’s a fantastic introduction and a good way for people to start to get to know you if they miss the one episode you’re on and aren’t otherwise engaged in the myriad things that Global Liver Institute does.

Roger Green: That’s our first news of the week, permanent surfers. We will have folks joining us from time to time, we will have guests. Suneil Hosmane coming on from time to time to talk about diagnostics and, you know, Naim Alkhouri will be back as he did a great job a couple of weeks ago but this five, this is going to be the core.

Roger Green: Number two, we will be talking a little later today about our formalized and expanded coverage of the Digital International Liver Conference or the EASL Conference on August 27, 28 and 29. I’ll talk about that as my professional highlight of the week.

Roger Green: Number three, I want to thank the dozens of our listeners who sent letters last week or notes on LinkedIn or Facebook in response to our efforts to reach out to everyone who would ever contact us about the podcast. One of the understandings that we got was that people would like to be in more dynamic touch with us. They like listening but they have questions, they have things they want to ask, they like to know how their issues play with some of their colleagues’. So we would like to make that possible.

Roger Green: Starting today, we’re going to open discussion groups on LinkedIn and on Facebook for people listening to Surfing the NASH Tsunami. Ask us questions, ask each other questions, share experiences, share views of the liver community, whatever you wish but there will be one discussion group running on each of those places. Louise and I will each check in with each discussion group at least once a day. We’re going to get a schedule out to you on the next couple of days. I haven’t talked to Peter or Donna or Stephen but we’re hoping that they’ll be able to join us as well.

Roger Green: We’re excited just to get to talk to people more often because the more we talk to this community, the more I learn about the fascinating way they live their lives and the way they adapt to the challenges of the disease and, of course, doing everything they do. Donna, you’re one of the more exceptional examples I know but there are bunches of people who do all kinds of fantastic things within the community and who have made their lives go with a liver they didn’t start out with or with whatever other adjustments they have to make in their lives. We will put that on to discussion groups and we look forward to having conversations with all of you there.

Roger Green: Next, brief reminder, we have done a really good job at recapturing links to Spotify and to Stitcher and to many of the other boards that we had and, in fact, that’s new boards that have come on this week but Apple and Google we’ve still not recaptured very well. If you have friends and coworkers who listen to this podcast particularly on Apple or Google, let them know we’ve moved. They can find the address by going to the Surfing Nash website or the old Surfing Nash page. We are looking forward to more and more folks coming in and joining us over time. People from 13 countries have already found us in one week – I think that’s a good start. We look forward to growing everybody back from there and maybe being stronger than ever.

Roger Green: Finally, music of the liver community. While we’re waiting to line-up some of the higher-end artists who we might be able to bring on to be part of this because they have a history of liver disease or because they’re professionals in the community, the always intrepid Louise Campbell went on YouTube and found an array of rather interesting, dare I say, liver music of different kinds. My favorite incorporated rap, rock, it has some rather fascinating lyrical choices. Starting this week, we’re going to be playing our liver community feature at the back end, it will be right before the outro as you leave the podcast. We hope you enjoy what we came up with this week. If you know of anybody in the community or if you personally have any musical background, we’d love to know about it. So far, we’ve got blues, we’ve got oud. This week, we’ve got weird liver, kitschy music. We’re willing to absorb anything that has a liver connection to it, please let us know what you got in mind.

Roger Green: With that, here we start. This week, we’re going to be talking about professional highlights. Brave one, go first.

Peter Traber: It’s actually challenging to come up with professional highlights every week and I like the way we alternate it between personal and professional. I’m actually going to choose as my professional highlight the fact that we’re welcoming Donna Cryer on to this podcast. I remember when I first heard her speak and met her four or five years ago, how impressed I was with her as a person and her mission for the institute. I think that what we’ve seen is that it’s grown over the years and it’s just a real privilege to welcome her on this podcast and I’m very much looking forward to all of her perspectives.

Donna Cryer: Wow, Peter, it’s quite the honor to be somebody’s professional highlight. I’m certainly the apple of my daddy’s eye and sometimes my mom’s favorite daughter although she only has one but I don’t think I’ve ever been anybody’s professional highlight before so I thank you.

Roger Green: Donna, does that mean your professional highlight is having been somebody’s professional highlight or you have something else to add?

Donna Cryer: Well, I do like that one. I think though for this purposes of this national podcast, perhaps my professional highlight is having pinned down the FDA Hepatology and Nutrition division staff to have a meeting with patient advocates this Wednesday and more to come after that happens.

Roger Green: Just so everybody listening to this podcast knows, we’re taping this on Monday August 3, so by the time you hear this that meeting would have happened already.

Donna Cryer: Yes. This is August 5th, yes. By August 5th, we have attained that meeting with the FDA staff and, hopefully, we’ll get some explanations and clarifications about the intent and meeting of their recent regulatory actions in NASH.

Stephen Harrison: And next week, it’ll be a personal and professional highlight to report on the positive outcome of that meeting.

Donna Cryer: Yes, absolutely, no doubt.

Roger Green: Well done, Stephen. Well done. Stephen, you want to go ahead since we just heard your voice?

Stephen Harrison: Sure. Professional highlight: So as many of you know, I run a clinical trial network called Summit and we hit another major milestone in the midst of an ongoing pandemic for screening fatty liver patients for the week in the month of July. We hit all-time highs for the week and we screen more people in the month of July than we ever have before. Just kudos to the team and to all the sites that are part of the Summit Network for finding a way to persevere and be consistent and persistent in their efforts to bring therapies to our patients that are suffering from fatty liver.

Roger Green: Kudos, what a fantastic highlight.

Donna Cryer: That’s fantastic.

Roger Green: Yes, I’d love to welcome Donna to the team. Having that patient input along with us, clinicians, and nursing side, it rounds the ball, I think. It’s fantastic. I suppose my professional highlight of the week is we’re starting to open our clinics. Our lifestyle clinics will be opening in Monument from next week so people can just book in their own scan. Particularly with all of the recent information and releases about fatty liver disease and COVID, we’re getting some interest in there. We open our Harley Street clinic back up this week which is excellent news as well. We’re getting some movement here in the UK for opening business.

Roger Green: Congratulations, that’s great. Mine, I have a bunch of them but I think the one I would focus on this week is we’re announcing officially what we will be doing to cover the Digital ILC, the EASL media on the 27th, 28th and 29th.

Roger Green: If you recall in episode 15, Stephen and Peter and Dr. Alkhouri and I each identified one paper each day that we thought will be particularly interesting. Today, Louise and Donna will identify one paper each of them finds interesting as well and we’ll talk a little bit about, at a larger level, what each of the five of us is hoping to get out of the meeting in kind of a meta-level. Every day, after the conference shuts down, we will commence a taping session and we will discuss the five papers that we describe between Episode 15 and today, share comments about what else we saw in the media that we found interesting, wrap that up, get it edited and our aim is to have it out at 10:00 Eastern Time that night so that when people wake up in Europe the next morning or get to work and have their first tea break in India, that you’ll have that tape available for you to listen to.

Roger Green: We’re hoping to have guests. We’re hoping to have all kinds of interesting things. We’ll be working on those over the next couple of weeks and announcing them as they come true. I can tell you right now, mark your calendars for the mornings of the 28th, 29th and 30th because we will have information for you so what you didn’t follow the previous day, you can catch by listening to us. Very exciting stuff, we’re thrilled to be able to get it done and to do it.

Roger Green: Letters this week. As I said, we got a couple of dozen, most of them were just saying nice things about the podcast. This one, I think, is fascinating and particularly interesting on the week that Donna happens to show up. This is from a listener in Africa who writes, “Hello. I am Dr. El-Attar, pathologist and also a co-founder of Data Pathology, a digital path startup in Morocco. How can we work together to fight NASH in Africa?” I ask a little bit about his lab, they support roughly 900 patients a month, a range of diseases, oncology is large and then fatty liver is large. He’s got a staff of five to 10 professionals mostly nurses. Donna, let me kick this to you first and Louise second and then the rest of us. What can you do, what can Global Liver Institute do to help Dr. El-Attar fight NASH in Africa?

Donna Cryer: Well, we certainly love to partner with him. One of our board members is a renowned medical oncologist, Dr. Lewis Roberts, who’s at Mayo but is originally from Ghana so it’s always been an interest of us to make sure that we’re not just trying to solve for liver cancer and NASH and now pediatric and liver diseases in the developing world but to make sure that we’ve had African interest, so to speak, in mind from the start. We’re just scaling to the point where we can really be useful in developing those models.

Donna Cryer: I think it was one of the most exciting part of International NASH Day, for me, to be able to have at least one speaker from Nigeria as part of our IND panel. As we build on that infrastructure of partners that we had in 25 countries, 80 different partners from International NASH Day, I really do think that, particularly in Africa, able to help build that infrastructure in culture, education and community outreach and connecting networks of gastroenterologists and hepatologists as Dr. Roberts has and goes back to frequently. Connecting that African network that he has built with folks who are interested and able to treat NAFLD and NASH is really such an exciting pronouncement.

Roger Green: That’s great.

Louise Campbell: It’s interesting because we’ve been asked to look at whether or not we can put FibroScan capability into a couple of countries in Africa, Nigeria being one of them. I had a conversation recently with a consultant colleague of mine from Norwich who used to work in Liberia with us. One of the interesting things that I took from that scoping conversation was they consider being overweight a positive, it’s a sign of having affluence, it’s a sign of being able to eat properly whereas we look at it from an opposite perspective in the Western world. I think that concept of how different nationalities, different cultures view fatty liver disease is something that’s going to be an interesting concept in each of the marketing models, in each of the research, designs and how we get into and develop those networks within the countries and I’m sure Donna has come across this a lot of times with the coalition.

Donna Cryer: Louise is absolutely right. That’s what I meant by being able to develop things in culture. When GLI starts to expand our programs and build our models, it’s really important to have two things in place before we even make a step forward. We need to have a physician champion in country and a patient champion in country to give us just those types of nuances. That one I knew from being African American that anytime, particularly when I was a little closer post-transplant and was a size 0 or 2 instead of the healthy COVID weight I am right now, it wasn’t perceived as, oh, you look model thin, it’s, “you look you need to eat, are you hungry, has somebody not fed you well enough.” Making sure that whatever country will you go into, that things are not only in language but in culture. It’s so important.

Donna Cryer: I remember doing Asian American outreach in the US for hepatitis B and working with a fabulous ad agency that would send me our copy back in seven different Asian languages and I have to just look at them and be like, “They look great, I think they’re right,” but making sure … Also, when we’re dealing with different Hispanic campaigns which would be so important to NASH, whether I will be asking, do you want Cuban Spanish or do you want Latin American Spanish or Mexican Spanish.

Donna Cryer: I think it’s really really important and I think it’s an essential patient concept, you know, nothing about us without us. This certainly goes double when we talk about translating or using models of programs in different countries, the people in those countries who know what works, what doesn’t, what’s defensive, what’s not, what gets traction, what works in the flow of people’s lives and utilizes the natural resources. Those are both resources of intellect and creativity as well as physical resources or clinical and medical resources are the ways that programs will ultimately be successful.

Donna Cryer: I’m really excited about working in Africa and working with friends of mine throughout healthcare who have done fantastic programs in HIV or other things and learning from them as we go to implement the NASH in Africa. Send them to me, Roger, happy to take them. Happy to work with you and Louise, on what we all do there but I think it’s really important, just everything in healthcare, that we don’t build something for the developed world and leave Africa and Brazil, other countries as afterthoughts. We really need to be building this entire field from scratch in a way that everyone can benefit from the innovations as they’re developed.

Louise Campbell: Absolutely

Peter Traber: Roger. I had something that I wanted to add here. I think one recommendation is to start working across regions regarding education and identifying what the issues are. Louise and Donna have mentioned a couple of them but let me just use two examples for you. For a long time, there was a widespread misconception among physicians that African Americans are protected from developing NASH and that was something that a lot of people believed. Additional studies have been done since then and as it turns out, African Americans appear to have lower triglyceride accumulation in the liver but once NAFLD develops, NASH occurs just as frequently and just as severe in other populations. I just use that as an example of the fact that there was a misconception that was dispelled by research and education.

Peter Traber: There are a number of epidemiological studies that have been initiated and done in African countries but I think that that needs to be expanded on and defining the populations, defining the disease, doing it within a cultural context but making sure the rest of the world understands that that region, just like many other underserved regions, have just as an important burden of this disease to focus on.

Roger Green: Donna, you mention differences of different cultures, how is North Africa different from Sub-Saharan Africa? Do you have enough experience or any of you to comment on that difference?

Donna Cryer: Well, some and I’m sure Louise has much more. There’s large differences in religion and exposure to Europe, historically different diets. I don’t pretend in the least that we can take the continent of Africa as a monolith. We really have to think of it, any more than you could say or even to a lesser degree that you could say all of Europe and deal with it in one way or all of United States. I would say, we have to deal with it more country by country or by sub-regions within the African continent.

Roger Green: Louise, does any of your work in the Middle East or around the Middle East give you any sense of how North Africa might be different than the rest of Africa or what might be unique in its own right?

Louise Campbell: I think one of the easiest ways I can describe … That was a very bizarre support group I have once and half the room were European, half the room were African. One group couldn’t understand why everybody felt stigmatized by liver disease because they have viral hepatitis and it was just something everybody had. The other half of the room couldn’t understand why you wouldn’t feel stigmatized by having viral hepatitis. It was the most surreal experience as they both try to explain why one didn’t and one did. I think each culture, as Donna so rightly said, is so unique. I think it is so valuable and important to learn all the time from everybody I meet, and keep learning and keep designing systems around everybody which is why it’s important that clinical trials take into account the diversity.

Louise Campbell: They are very organized in a particular way that limits some of the racial mixes, A, by the definition, there’s very few definitions on ethnicity because the trials are organized out of the US. We just spent a long time within Iraq and Middle Eastern cultures and yet the Middle Eastern Arabic culture is not represented in ethnicity in the clinical trial so it’s very difficult, they behave differently and they respond differently in hepatitis C which is vast part of my experience. I think it was always difficult to describe the culture or the ethnicity of somebody when you’re given such limitations on clinical trials, for example. It was a very bizarre group, that’s all I can say.

Donna Cryer: Louise, I absolutely agree. In talking so often with our Asian colleagues and Asian Americans and explaining to them how difficult it was particularly early on but still today to get interest and traction in liver disease and liver health in the US. There was like zero awareness and no real thinking about the liver which is so vastly different than in Japan or China or Singapore, elsewhere because different types of viral hepatitis or even pediatric liver diseases are so endemic and often dealt with as public health issues. To have it understand, first, the mindset and the ecosystem that we’re challenging here in the US and then to start with that understanding is so important. It’s a really important point that we’re making here as we’re co-creating the field, that we need to bring in multiple perspectives and test our own assumptions about everything moving forward.

Roger Green: Okay. Thank you, everybody. Dr. El-Attar, as done and noted. I will get her your information so she can reach out to you but you all can move forward on that which is great.

Roger Green: So, finally, onto our main topic which is the upcoming Digital ILC meeting or EASL meeting as you would choose to call it. A couple of weeks ago, we talked about what Peter, Stephen and I were looking to learn in the meeting broadly and then what articles we thought might be interesting to cover. Today, I’d like for Louise and Donna to share with us, first of all, globally, what perspective are you bringing to the meeting and what you’re looking to see there and then we’ll take a minute and run through some titles that you might be covering. Note to the audience, we will post by the end of this week specifically the articles that the five of us will be addressing on the podcast so that you can plan accordingly. We might not get to all of that today, we hope to. Louise, Donna, either one of you jump in first, what is it that you’re looking to get out of this meeting?

Donna Cryer: I’ll cede to Louise, I’m just a freshman here.

Louise Campbell: Thanks. Well, I think I’m looking forward to seeing how seeing how digitalization works from a conference perspective. I think EASL is, obviously, a massive conference. The last time I was in there in person, there were over 10,000 delegates. Walking from the room to the room was always a difficult logistical task when there are so many sessions going on in parallel. I’m hoping that the digitalization may make that a little bit easier, certainly, we won’t be able to click 10,000 steps. I’m looking for it from a different perspective slightly this week than I was probably when Episode 15 went out, given the announcements on obesity, allied health, delivering some of that. I think there’s a number of sessions which will have a double meaning now given the outcome of COVID and what’s going on in the UK from my perspective.

Donna Cryer: Sure. I certainly will miss all the hallway conversations and the lobbies and dinners and the connections and the relationship building part of EASL as well as, certainly, the travel that I long for. When I look at the meeting as a whole both EASL and AASLD liver meeting, I’m really looking for signals for direction of the field, and specifically having run the People-Centered Outcomes Research network for a year for PCORI, really drilling down on are we solving the problems that matter to patients.

Donna Cryer: Key issues, for me, and many of these were raised in the abstract that Peter and Stephen picked in and Naim picked in Episode 15 but why are they important. We need to understand how non-invasive diagnostics are evolving and being validated so that we can get beyond the biopsy. We need to understand the relative impact of the various factors in NASH, you know, is it the metabolic drivers, the inflammatory drivers, the fibrotic drivers and patients speak like “what’s going to get me?” We need to understand how fast this progresses and in whom. Coming from a personal experience where I progressed from a diagnosis with liver disease to a transplant in liver disease in less than two years, that issue of who’s the fast progressor is really top of mind for me.

Donna Cryer: Then the issues raised about combination therapies. I think that that’s so important because we’re not seeing huge size effects, I want to make sure it’s not called “side effects” but size effects in these drugs. From the beginning in public and private conversations, that in all likelihood, given the heterogeneity of NASH, given the diversity of concurrent diseases NASH patients have, that some combination of therapies attacking multiple mechanisms will be necessary. Seeing more research in combination therapies is really interesting for me.

Donna Cryer: Then, hopefully, at some point we’ll see more about how patients can build their lives around the medical care so issues of sarcopenia or what type of lifestyle interventions and diet modifications actually work for NASH patients. We can cut through all of the false advertising that a patient would see on the web when they start to plug in the words NAFLD or NASH or even just standard advice about lose weight but how, or get into quick weight loss things and just really give people scientifically accurate evidence-based information for how to build their lives.

Roger Green: Louise, I made the comment on Episode 15 when you were on vacation, that I suspected that you and I were going to be arm-wrestling, I don’t think it was the term I use, over who cover which part of the liver and COVID symposium on Saturday. Because that was something jumped out at me and I knew it will be something jumped out at you so if we go forward, just keep that in mind. We’ll be slightly in competition here but that’s a good thing. Now, let’s go to Thursday. Donna, it’s your starting, keep going so paper on Thursday of particular interest to you will be and why.

Donna Cryer: Okay. Don’t hold me to days of the week but I do have three for the meeting as a whole, first-timer’s indulgence for not following the rules precisely. AS098 on machine learning outperforming existing non-invasive tests. As I mentioned, the machine learning, the digital, the AI aspects of it. Roger, you had spoken about this. It Is fascinating to me particularly since it seems to be that there are only five people who might be able to read a liver biopsy correctly in the world, someone said it’s only two. We need to move beyond biopsy itself. Then in this Wild West of non-invasive tests that is developing, you’re coming to some narrowing on the use case for each type of test. To add AI to the mix on top of this, I think, is intriguing. It’s intriguing to me so something I look forward to looking.

Roger Green: Louise, you have the Thursday paper?

Louise Campbell: I was like a kid in a candy store, I have to say. Getting it down to three a day was difficult because I just-

Roger Green: One a day.

Louise Campbell: Yeah, one a day but I could do three a day, I’d seen that one that Donna and also the one that Stephen had set on the other week but I think the one I’m going to really plump for is FR1016 and I think that’s in the poster session 3:00 to 3:30. It’s entitled, “Patients for nonalcoholic fatty liver disease referred from primary care have a significant serum fibrosis marker and liver stiffness measurement discordance,” and that’s David Harmon, it’s a United Kingdom piece.

Louise Campbell: Obviously, I look at liver stiffness a lot and do a lot of FibroScan and CAP, so this one particularly interested me as we’ve discussed a lot about biomarkers and the problems in primary care and using liver stiffness as well. As you know, I champion putting FibroScan or transient elastography into primary care for many reasons. One, it can potentially rewrite most of the current pathways for referring people to specialist care. I think with the growing need for those patients to see a specialist, it’s blocking the pathway because we see a lot of patients who don’t really need specialist care, that we can manage more locally. I think this is why this one interests me.

Louise Campbell: Will it find that serum markers will effect liver stiffness, how do they differ, which one was correct and how do they differentiate between it? I’ve got some ideas of my own of what may come out with that piece so it will be interesting to see whether my personal experience is supported or challenged by what he’s going to say because, obviously, I don’t know. We’ll have to tune in to find out on the 27th.

Roger Green: First of all, I think you’ve made fascinating choices. Stephen, if I recall correctly, you chose the other liver stiffness paper, the one that Naga Chalasani is doing about “Progression of liver stiffness and development of cirrhosis in histologically characterized patients with NAFLD.” Donna, I chose the other AI paper, the neural networks paper for HD-stained biopsy. I think between the four of us… Peter, I’m trying to remember what you chose on Thursday.

Peter Traber: I chose the symposium that they’re having on non-invasive testing and clinical trials, I think that that will be interesting to see the perspectives there. Also, to plug into our discussion about the FDA and the recent CRL letter and getting an update from Donna on the discussion that they have with them so I think that’ll all fit together.

Roger Green: I think between the two papers on liver stiffness, the two papers about AI and that one, I think that’s just a fantastic afternoon, we’re going to have a lot of fun kicking it around on the 27th.

Louise Campbell: The only thing I like to call to attention on that day, following our discussion last week, there’s AS160 which is Anna Mantovani from Italy and it’s the “Multidisciplinary team approach to nonalcoholic fatty liver disease improves cardiovascular risk factors.” I think we spent some time last week stressing how important multidisciplinary team working is so that will be an interesting piece to have a look at when it comes out.

Roger Green: With that, let’s go on to the second set of papers. Donna, noting that you didn’t know whether to start Thursday, Friday, Saturday, which is the second one you want to cover?

Donna Cryer: Okay. The second one, I do believe, is on Friday. I think both of my next two are on Friday so I’ll just let that happen. AS017, “A polygenic risk score for progressive nonalcoholic fatty liver disease with stratification,” by Cristiana Bianco, I think the issue of both progression and risk stratification is so important to give meaningful information to both physicians and to patients, yes, you have this NAFLD or NASH so what, are you at high risk of having some type of event or developing some type of severe outcome, is it going to truly impact your work, your life. You have to make lifestyle changes, well, how intensive, how urgent. Unless you give people that contextual information and let that stratification of risk and progression are real, you can’t expect people to do anything actionable or meaningful with the information.

Louise Campbell: And for Friday, I’ve gone for the abstract session and I’ve picked out AS064 which is, “Incorporating assessment of liver fibrosis into routine diabetic review in primary care or pilot.” This was not a deliberate choice but, again, it’s a United Kingdom study, it’s Dina Mansour and her team. Obviously, we’ve done a lot of discussion about comorbid situations and this one interests me as to what we’re doing to assess fibrosis in the diabetics in primary care. Evident the note, the session is being chaired by Professor Mark Thursz. I’ve been honored, and it’s been a pleasure to work with Mark and the team at Imperial for many years and [see] the dedication they put into their academic research. I

Roger Green: That’s interesting. Those were a bit different. I think we all chose drug sessions on Friday, the three of us, as I recall correctly. You took the TVB-2640, right? Peter, you were talking about the fatty acid synthase inhibitor.

Peter Traber: Correct

Roger Green: Stephen, I don’t remember whether you were talking about the reanalysis of the regenerator, whether you’re talking about the PDFF and the resmideron data, phase two, one or the other, you remember, which I was talking about the GLP-1 glucagon, “GIP” paper. I think that will round up the day nicely.

Donna Cryer: I think that means that you chose the right set of diverse perspectives there, Roger.

Roger Green: Well, I didn’t chose, I’m just lucky enough to listen to people who want to be part of this and say great, love to have you. Third paper. Donna, noting that you’re on Friday twice … By the way, Naim did the same thing and then … You set your next Friday paper?

Donna Cryer: Sure. Going back, again, to my principles of what I was looking for, what I think a patient will be really interested in. I chose AS018 on “Carb restriction reverses NAFLD by altering hepatic mitochondrial fluxes in humans.” I think that everybody is trying to figure out is it reducing carbs, is it going on keto, does lowering calories, is every calorie the same. What people are walking around trying to figure out particularly if you tell them 7% to 10% weight loss, you know, what does it actually mean, what should they actually do, what will work for them and for NASH. Unless you’re one of Stephen’s patients because I’ve heard Stephen talk to his patients and he has like a foolproof, no fail, no nonsense plan for his patients that I’ve seen be successful. Everybody else is wandering around, wondering what to do and I think this paper and other papers like it can be really helpful to give some direction and build that evidence base.

Louise Campbell: My paper on Saturday, well, I’m going to have an eye on a lot of papers on Saturday because I had the pleasure of chairing with Nid Aftow the very first Nurses and Allied Health Professionals Sessions that was from EASL. I’ll be looking at those during the day because it’s gone from faint to strength and you got such strong advocates in there, Michelle Clayton, Patricia Kuenzler who I both have the privilege to work with and Kathryn Jack, for example, so they continue to be great drivers.

Louise Campbell: I’m torn for the day but what I settled on was the poster session at 3:00 to 3:30 and particularly one, “The variscreen algorithm using sucessively platelets, liver stiffness and INR improves and secures screening of esophageal varices needing treatment” and that’s Federico Ravaioli from Italy. I manage to see on Twitter today that, sadly, the Baveno VII has been delayed now by a year due to COVID, which was John Bosch, I think. That interests me because, of course, we’re using Baveno criteria to try and reduce the need for endoscopies in higher risk patients with either the modified or extended the Baveno criteria. I think it may well be important post-COVID to try and get some of these lists down if we can so it’s a shame that Baveno VII has been reduced. I’m interested in that session, obviously, with FibroScan becoming, hopefully, more available.

Roger Green: Interesting. Well, in that case, I will cover the COVID and the liver session by myself delightedly because I’m really fascinated with that session.

Donna Cryer: I’ll definitely be there in the COVID and liver session as well. That was sort of an assumption, you know, having stood up our COVID-19 response program in early March, it has been intense, fascinating. I really am so grateful for how hepatology has come together to make sure that the impact on liver patients is understood as it evolves. As a liver patient myself, but talking to other liver patients, we never had a greater influx of questions from people, some of whom are on the frontlines of care themselves with liver diseases and want to understand how do they keep themselves safe and what impact it will have when they have it. I will definitely be avidly attentive to the COVID and liver presentations with you, Roger.

Roger Green: That could be your Saturday.

Donna Cryer: That can be my Saturday.

Roger Green: There you go.

Louise Campbell: Well, I’ll be there because it’s later than the other sessions so I think we’ll all be there.

Roger Green: There was not a question of either you were going to be there or you were going to be in two places at once, I know you better than that. First of all, I think this is delightful because the episode 15 with the exception of me, I think, everything focused on drugs, not surprising given who was in the room but to be able to to round it out so that we’re focusing from all the different perspectives associated, health professionals, patients taking a look at diagnostics, taking a look at epidemiology, taking a look at medications. I’m tremendously excited about this program and what we’re going to be able to bring to the people who can’t make it to the meeting or who can’t attend all the sessions they would like to attend. With that, I think we’re done through the day on [the] topic.

Roger Green: Let me close. First of all, this is the first episode of the new gang of five. I’ve got many much mischief in mind in terms of Photoshopping pictures and interesting regalia and stuff like that but we are now official as the five of us. Thank you, everybody, for, really, a great first episode. Donna, what you brought today in terms of perspective on the world and different issues is exceptional. Louise, I expect excellence from you every time so this has been a great session. Okay.

Roger Green: I want to remind everybody that we are setting up these two discussion groups on LinkedIn and on Facebook. If there’s anything that you want to know about papers at NASH or presentations at EASL having anything to do with that meeting, Digital ILC, please come talk to us on the group event and we’ll figure out how we can cover it or share information about it. If there’s anything else you want to talk with us about things that came up today, things you just want to know, this is our conduit to hear from you and to help you get the information you need, please use it.

Roger Green: Also, if we don’t have your email address, please send it to us. We have started the program of giving early announcements when we’re coming out with episodes. It takes 8, 10, 12, 16, sometimes 24 hours to get whoever your distributor is, we’ll let you know in advance what’s coming and a new place you should get to if you want to. Also, in that address, you can share with your friends who, as I said earlier, might be listening on Apple or Google and not been able to find their way back to the podcast.

Roger Green: All right, that’s everything I got. Special thanks to our engineer, Mike Wilson, who’s come on board so neatly and seamlessly, the distribution folks at Buzzsprout who made all this really easy for us, Eric Rounds who’s overseeing this transition. Eric had a moment, the entire back room distribution went right, Eric was done getting the week’s podcasts ready Wednesday at 6:00 and he sent what could only be described as a schoolchild giggly email about how excited he was that it all went right. Eric, you put that together, thanks for doing such a great job and it’ll be easier for all of us going on out. Politea Le, our assistant; Ellyn Charap, our editor, and an extra-special thanks to all of you who’ve helped us continue to build the leading fatty liver podcast in the world.

Roger Green: Final question to everybody, the one you heard today that surprise you the most. Stephen, why don’t I start with you?

Stephen Harrison: I just remember the quote that Donna said at the beginning when we were talking about the question that came up about involvement of a physician in Africa and how can we align with him and really grow our knowledge of NASH in that environment. I think her quote, “Nothing about us without us,” I love that. Donna, I’m adding that to my repertoire of quotes, that’s amazing.

Stephen Harrison: The surprise is that we actually received a question from that part of the world, it just speaks to the outreach that this podcast has and the need for a conduit to synthesize and chew on and think about and ruminate over all these issues and begin to put some clarity a thought around them. We don’t have all the answers, that’s why we need people writing in and asking questions and really challenging us on our thought process because that’s where new information and new pathways get forged. I think it speaks to what this podcast could be, but applying that same method, that same comment that Donna made to our podcast, “Nothing about us without us,” that’s the field of NASH and we need to be all in collective, unified, working towards a common goal. That’s my thoughts for the day.

Roger Green: Amen. Peter, why don’t you go next?

Peter Traber: Yeah. I also am going to choose something that Donna said and it really was her perspective on the meeting, what are we going to get out of the meeting and taking the perspective of what does this all mean for patients and patient care. I’ve been going to liver meetings since 1984 or ’85 and I’m one of those guys that loves the science, loves to go to all the different symposia as well as scientific papers and I think that perspective of attending meetings and thinking about scientific presentations from the perspective of what it means for patient care is a very important aspect. I’m not surprised that Donna said it but I’m glad that she did.

Donna Cryer: I’m certainly surprised by all the love and respect on this podcast. If I had known that this is where I needed to come to get this type of affirmation, I would have joined earlier. I’m very very humbled and honored, I also want to give due attributions to e-patient Dave, who I believe first came up with that patient engagement statement. Not so much what’s surprised me but what I was, am so excited to have seen come to fruition, that with this diversity of perspectives represented by clinicians, CEO, nursing, patient, consultant, that, together, we approach this problem from different angles, thought of different nuances. This is what is going to take to solve all of the myriad problems there are in NASH. Just to have it come together in this way that I had hoped for and am so excited about and one of the reasons why I added this in my plate where my team is like, “Please no, please don’t add anything more,” but this was so important for me to do and has proved so worthwhile even in just this one conversation. Not surprising but that’s my takeaway from today.

Louise Campbell: The one that surprise me today was we all manage to pick totally different aspects between us all for the meeting and I think that was really nice. It’s lovely to have Donna with us and adding that additional force of patients which is what we need so I’ve enjoyed, again, the whole day as I enjoy doing most of the sessions. Yeah, just that we managed to cover quite a bit of the meeting without duplicating anybody else’s picks which was a relief when Donna started, I thought, “We’re going to pick the same ones.”

Roger Green: That’s funny. Louise, I was surprised and delighted. It was like Stephen saying saying my biggest surprise is Peter had disagreed on something because we never disagree, my biggest surprise is she [Louise] didn’t pick COVID.

Roger Green: My biggest delight though was listening to you and Donna, both of whom are passionately committed to patient care, come at it from two different angles, one, the angle of being the patient and, second, the angle of being the allied health professional care for the patient and where that drove your interest in the meeting. It speaks to me to the diversity of the group.

Roger Green: It also speaks to the idea that patient care is, in and of itself, a science. We talked about that a little bit last week in the context of wellness versus illness and how that leads you to think about communicating with patients differently. Today, I think we saw a different way which is patient care to the patient, patient care to the person who provides the most hands on care for the patient versus patient care for the passionate provider, the term Stephen uses. Three very very different perspectives, all pivotal. And If we blend them all together and we do it properly, I think that’s best for the patient and I think it will be best for this podcast as we help inform and question and help all of us think through this stuff more carefully and more thoughtfully.

Roger Green: I am delighted that this podcast has gone as well as it has. Donna, welcome aboard, fantastic stuff. We’ll be back next week with Episode 18, posting on August 13th. We’re not sure what we’re going to do yet, what we do know is that it makes us old enough to vote in the US and we will not talk about politics, not our dedication. What we will do is this, okay? On the way out, we have the piece of liver music that Louise identified that I described earlier. We will be back next week. Until then, everybody stay safe, surf on, this program is over. Bye-bye.

Peter Traber: Hey, that’s great, Roger.

 

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