Registration for the 1st Kidney Meets Liver Meeting in Amsterdam on 16th March 2018 is open!

February 20, 2018 2:03 pm Published by Leave your thoughts1 Comment% Comments

EASL International Liver Foundation and European Renal Association – European Dialysis and Transplant Association are holding the first Kidney Meets Liver meeting on March 16th 2018 in Amsterdam. This one-day event will provide an innovative and interactive program addressing the latest research and developments in clinical management on two liver conditions that have significant impact on chronic kidney disease patients: viral hepatitis and non-alcoholic fatty liver disease.

The meeting is being co-organised by leading Nephrologists and Hepatologists: Professor Michel Jadoul (Cliniques Universitaires Saint-Luc, Belgium), Professor Paul Martin (University of Miami, USA), and Professor Stanislas Pol (Coachin Hospital, France).

To see the full program or to register, please go to http://www.euromeetings.it/EILFAmsterdam2018.html

Download PDF of Full Programme

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EILF NAFLD Policy Review is Launching this month

February 20, 2018 1:59 pm Published by Leave your thoughts1 Comment% Comments

With an estimated global prevalence of 25%, Non-alcoholic fatty liver disease (NAFLD) is a global public health epidemic that is not receiving enough attention. The first step to taking a comprehensive public health response to NAFLD is to review the relevant policies and guidelines in place. For this reason, EASL International Liver Foundation (EILF) will launch the EILF NAFLD policy review later this month to determine to what extent governments and key stakeholders like medical associations and patient groups are responding to NAFLD and its complications such as diabetes and HCC.

This project is being led by Professors Jeffrey Lazarus (IS Global, University of Barcelona), Professor Quentin Anstee (Newcastle University) and Professor Helena Cortez-Pinto (University Hospital Lisbon). Preliminary results are expected to be announced at the EASL International Liver Congress in April, 2018.

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New Project alert: Viral Hepatitis Elimination in Migrants

February 20, 2018 1:55 pm Published by Leave your thoughts1 Comment% Comments

The world is currently experiencing the greatest level of forced displacement that has ever been recorded, and as a result the disease burden profiles in Europe are changing. It is estimated that migrants account for 25% of all chronic HBV cases and 14% of all chronic HCV infections in Europe (European Center for Disease Control and Prevention (ECDC), 2016). Despite the heavy burden of viral hepatitis and other infections such as HIV and TB among migrant populations the delivery of prevention, screening, and treatment is greatly impeded by many social, political and structural barriers.

In efforts to reach this high-risk marginalized population and deliver much needed prevention and treatment interventions, EILF is developing programs specifically targeting migrants in Italy; the main point of arrival into Europe.

The first project will launch in Milan in March 2018 in collaboration with Fondazione ARCA and is being led by Dr. Giuseppe Colucci. This project will target migrants who have applied for refugee or residence status.

Through these two programs, EILF will develop and implement sustainable infectious disease prevention, screening and treatment models for migrants. The models will empower countries and key stakeholders to implement migrant specific elimination programs; assisting countries to achieve the WHO 2030 viral hepatitis elimination targets.

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Update from Pakistan

February 20, 2018 1:52 pm Published by Leave your thoughts1 Comment% Comments

EILF delegates, Professor Massimo Colombo (EILF Chairman of the Board), Professor Mark Thursz (EILF Board Member), and Professor Mario Mondelli have recently returned from a productive trip to Pakistan.

EILF and Aga Khan University jointly held a one-day workshop in Karachi, bringing together EILF delegation, local experts, Sindh government officials, and Sindh healthcare providers, including local non-governmental organisations with the aim of tackling the hepatitis C epidemic in the province of Sindh. This meeting generated a call to action and together and spurred the development of viral hepatitis micro-elimination programs targeting high-risk populations in the province of Sindh, which alone has a population of over 100 million people.

The EILF delegation then participated in the Pakistan Society for the Study of Liver Diseases (PSSLD) annual meeting in Islamabad on the theme of Integrating Science into Clinical Practice. This meeting provided a fantastic opportunity to share knowledge and experiences between local and international experts in the field of Hepatology. During the PSSLD meeting, the EILF delegation participated in a public policy forum on viral hepatitis elimination with the Pakistan Federal Government, industry and non-governmental organisations and provided state of the art presentations on hepatitis B, hepatitis C, HCC and NASH.

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Update from Uzbekistan

February 20, 2018 1:49 pm Published by Leave your thoughts1 Comment% Comments

The government of Uzbekistan is launching a national program to fight viral hepatitis. To facilitate the implementation of this program the EASL International Liver Foundation was called to bring a group of experts to the country. The delegation comprised Chairman Prof. Massimo Colombo alongside Board members Prof. Stefan Wiktor and Prof. Jeffrey Lazarus and Prof. Francesco Negro from the EASL Governing Board. As part of their mission, the EILF delegation took part in the educational meeting “Hepatology Day in Uzbekistan” which covered many important topics including the following: epidemiology, interventions to improve linkage of care to HCV testing, care and treatment, conditions to eliminate HCV and the challenge of post SVR management.
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Liver Cancer Takes Another Life: Susan Lambert and the Heart-Breaking Story of her Fight Against Liver Cancer

February 20, 2018 1:31 pm Published by Leave your thoughts1 Comment% Comments

Garry Lambert

Susan Lambert, 28 September 1946 – 4 January 2018.

In loving memory of his dear wife Sue, Garry Lambert relates the heartbreaking story of her fight against liver cancer.

A shining light of love, laughter and generosity was brutally extinguished on 4 January 2018 when my adored wife Susan Lambert passed away at age 71, after a short but terrifying battle against cancer of the liver.
It was a tragedy with so little warning. Although Sue suffered bravely for over 30 years with autoimmune hepatitis complicated by liver cirrhosis, six-monthly monitoring by her gastroenterologist, and immuno-suppressant drugs including Imurek® and others such as Prednison Streuli®, had seemingly kept it under control for all that time. Despite unpleasant side effects she refused to allow the disease to prevent her from leading a full life.

 

Dreadful news
We had absolutely no idea that all was not right until she saw her general practitioner at the end of November, complaining of painfully swollen legs. He diagnosed an enlarged liver and an MRI scan confirmed the presence of hepatocellular carcinoma (HCC). Oncologists at the Genolier Clinic in Switzerland then gave us the dreadful news that the aggressive cancers were too advanced to treat and palliative care was really the only option.
From then on we were hit by an express train that took dear Sue from us in a little over four weeks. We were with her almost day and night at the clinic, sharing a roller coaster ride of hope, and dashed hope, as the team of doctors treated her with a cocktail of drugs, infusions and transfusions, but could do little to save her.
The progress of the disease from her admission to the clinic on 3 December 2017 to her death on 4 January was terrifying to watch and frighteningly fast.
A silent killer?
Since then myself and my son and daughter have experienced many tearful emotions from deep grief to anger — anger that more could not have been done to save her. That the oncologists were unable to apply any sort of remedial treatment prompts several questions in my mind:
“How had the tumours become so advanced before my wife noticed any sort of discomfort?” “Would closer monitoring, including ultrasound examinations, have resulted in earlier diagnosis and possible treatment?” “Is liver cancer a silent killer that can strike without warning?”

 

A call for more research
Since my wife’s passing, two other women, one only aged 45, have died of liver cancer at the clinic. Although I speak as a layman and not as a health care professional, it suggests to me that liver cancer is difficult to treat successfully, and that survival rates are lower than most other cancers. I have seen statistics showing that liver cancer is the sixth most frequent cancer, but the second leading cause of death after pancreatic cancer.
While many human diseases are now successfully cured or controlled, the same cannot be said for this leading killer. Clearly, there is an urgent need for more effective treatment of cancer of the liver to cut the tragic annual loss of life. But the intensive research necessary to achieve this goal does, of course, demand substantial funding.

Yet another life lost to liver cancer. 

 

“Sue was the loveliest personality, warm hearted and sweet natured, she lit up the room. Life will never be so much fun again without her.” 

 

Many friends who knew and loved Sue have donated to the International Liver Foundation in her memory. It is sadly too late to save my wife, but I hope these and many other much needed donations will help to save lives in future.
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Managing Liver Patients During War: the Syria Catastrophe

February 20, 2018 1:20 pm Published by Leave your thoughts1 Comment% Comments

Dr Nabil Antaki

Q. Dr Antaki, please introduce yourself

I am Nabil Antaki, a gastroenterologist and hepatologist. I live in Aleppo which is the second city in Syria and its economic capital.

Q. Can you describe the situation in Aleppo during war time?

The war started in Syria in March 2011 and reached Aleppo in July 2012 when the rebels invaded the East and South neighborhoods of the city. As a consequence, within weeks, half million persons fled from the rebel’s controlled area and take refuge in the government’s controlled area and became displaced people.

Living in Aleppo was very dangerous. For 5 years, daily bombing of our neighborhoods by mortars and gas canister full of nail and explosive sent by the rebels caused multiple casualties every day.

On the medical level, many hospitals were destroyed or burned. Al Kindi Hospital, one of the 2 university hospitals, was blown up and then burned. Saint Louis hospital, the private hospital where I work, received many mortars, fortunately some didn’t explode. 70% of specialist physicians left the city or the country.

Life in Aleppo was not easy. For years, we did not have electrical power replaced by candles, flash lights and batteries then by private generators. For years, the water supply was interrupted. The local authorities drilled 300 wells. Blockades of the city from few days to many weeks each time led to shortage of essential products such as drugs, gas, fuel, vegetables, bread….

Q. What about your medical practice?

Well, I have to tell you that before considering treating patients with liver diseases, I had to deal with three priorities: I had to survive, I had to help the displaced people to survive and I had to create a project to treat the war-wounded civilians.

Q. How did the war impact your practice?

Because of the war, patients were not able to move and come to the centers created by the government in 2009 in the major cities to test and treat the patients with chronic viral hepatitis. But the most serious issue were the sanctions.

Q. The sanctions?

In 2011, few months after the beginning of the war in Syria, the European Union and Switzerland imposed sanctions against Syria which were extended in 2017. The USA had taken more severe sanctions longtime ago. These sanctions on trade and financial transactions led to the closure of the offices of major international pharmaceutical companies. The embargo prevented importation of drugs, medical equipment and spare parts. The sanctions had no positive impact on the events or to bring an end to the war. They penalize the people and the patients in increasing the prices of all products which were introduced illegally to the country and thus became unaffordable to the people and in increasing the corruption.

Because of the sanctions and other difficulties related to the war, I stopped using our Fibroscan because of our inability to calibrate the probe which had to be sent abroad.

We were not able to repair our endoscopes because of the lack of spare parts. We had to wait 16 months to have one Olympus gastroscope repaired.
Only one lab. was still performing PCR and genotype testing. It is a private Lab. And people had to pay for it. Most of patients could not afford the price.
Practicing hepatology in this context was not easy.

Q. Despite all these difficulties, how did you manage your patients with liver diseases?

In spite of all these difficulties, I was able to treat more or less adequately my patients.

I had to limit the lab tests that we usually order in normal time. Liver function tests and a viral load testing by PCR were the only required tests in order to treat chronic viral hepatitis.

The anti-viral drugs for HBV, entecavir and tenofovir, were available before the war, being manufactured in Syria with the raw material imported from China or India, two countries not concerned by the sanctions. Concerning the new HCV anti-viral drugs, some of them, manufactured in Egypt, were available recently on the black market. Sorafenib for HCC was not available.

Q. one last question, do you want to send any message to your colleague and to the hepatology community?

I would like to thank all the colleagues who manifested their friendship and solidarity with the Syrian people during this war.

And I would like to ask all hepatologists in the world as well as the national and international liver associations and societies to put the pressure on the leaders, governments and the members of parliament of the European countries and America and ask them to lift the sanctions against Syria. They have to understand that sanctions have never had a positive impact on any event or war. They penalize the people, the patients and the vulnerable persons.

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Advancing Paediatric Hepatology: the Hepatology School in Italy

February 20, 2018 1:19 pm Published by Leave your thoughts1 Comment% Comments

Professor Valerio Nobili

Q. Professor Nobili, what was the scope of the Pediatric Hepatology School?

The hepatology landscape has changed dramatically in the past year. New regimens and ever-higher cure rates for hepatitis C (HCV), an even greater focus on fatty liver disease, and new organ allocation policies and procedures for liver transplantation are among the changes affecting clinical practice. In 2017, AISF launched the first Pediatric Hepatology School, which took place in Rome at the Bambino Gesu’ Children’s Hospital. The purpose of this school was to hear experts discuss the latest in both the management and treatment of HBV and HCV and the breadth of liver disease including: NAFLD, Primary Biliary Cholangitis, Disorders of Iron Metabolism in Patients with Liver Disease, Hepatic Encephalopathy, Complications of Cirrhosis, and Hepatocellular Carcinoma. Finally, experts and attendees focused on the debated topic of ‘transition programs’.

Q. What is a Transition Program?

Seven young researchers from Italian and French Tertiary Hepatogastroenterology Centers attended the school. It was fascinating that none of the participants were pediatricians, but all were very interested in knowing “the pediatric face” of adult hepatic disorders.

All clinics and surgical specialists generally involved in the diagnostic and therapeutic work-up of pediatric patients affected by chronic hepatopathies participated as speakers during the course, such as pathologists, hepatobiliary surgeon, pediatric hepatogastroenterologists, and radiologists.

The entire school was based on an intense interaction between “teachers” and “attendees” and reserved plenty of time for personal discussion and exchanges with distinguished faculty. There was a balanced blend of lectures addressing theoretical as well as practical issues and clinical case – based discussions.

Q. Which areas of hepatology were covered?

The participants attended the Hepatometabolic and Gastroenterology and Nutrition Department of Bambino Gesù Children’s Hospital, observing the clinical cases of patients hospitalized during the days of the school. The diagnostic and therapeutic pediatric approaches were therefore practically discussed in the ward by examining the inpatient cases. For example, cases of neonatal cholestasis, chronic hypertransmiasemia, short bowel syndrome, and children treated with liver transplantation or with end stage chronic liver diseases waiting for transplantation. Moreover, a discussion section was reserved for clinically intriguing cases, which were presented by attendants to experts of “Bambino Gesù” Children’s Hospital for a useful “face to face” debate.

Q. Did the School touch on research topics too?

Another stimulating part of the school program was the visit in small groups to the Liver Research Unit of ‘Bambino Gesù’ Children’s Hospital. During this visit, attendees received a rapid overview of basic research relevant to hepatology, with the goal to improve the knowledge of participants on more recent and useful molecular and cellular techniques in the study of liver diseases. This visit also offered the opportunity to stimulate new ideas and research projects and/or collaboration with young investigators who attended the school.

Q. Should pediatricians have a place in the multidisciplinary team treating liver disease of adults?

The actual topic of transition program was addressed with a round table that involved pediatric hepatologists and adult hepatologists. In this interesting debate, the importance of a shared multidisciplinary approach in the management of young adults with childhood liver disease was highlighted. The shared opinion was that a joint structure, including both pediatric and adult staff, would be the “ideal” introduction for young people to the adult medical world.

Q. What message stemmed from the Pediatric Hepatology School?

We have assembled experts in both adult and pediatric hepatology to digest and synthesize a wide range of extremely important approaches for clinicians to know about. Attendees were able to learn in a mere three days what would otherwise take days of going to talks and reading journal articles to figure out. Attendees could sit back and enjoy learning the newest, most exciting and most clinically relevant developments of the past year in pediatric hepatology. Moreover, they were also stimulated to present and propose new insights into the field of liver diseases.

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ECHO: the hub & spoke program connecting primary care with expert centres

February 20, 2018 1:02 pm Published by Leave your thoughts1 Comment% Comments

Dr Sanjeev Arora

Earlier this year, the World Health Organization reported that its goal of eliminating viral hepatitis as a global public health threat by 2030 has come well within reach, with 194 governments committed to hepatitis elimination; drastic price reductions in medicines through the use of generics; and effective harm reduction, screening, and treatment approaches currently available. Close to 3 million people have been able to access treatment for hepatitis C over the past 2 years, and 2.8 million people started lifelong treatment for hepatitis B in 2016 alone. Yet yearly rates of new infections continue to increase worldwide. Rapid global scale-up of screening, prevention, and treatment services – putting knowledge of those services into the hands of the frontline healthcare providers who serve communities and patients most at risk – is crucial if the dream of eliminating hepatitis is ever to be fully realized.1

Project ECHO (Extension for Community Healthcare Outcomes) is an innovative tool for the dissemination of medical knowledge to providers in medically underserved areas, which has the potential to tip the scales of worldwide efforts to halt the advance of hepatitis. It is not “telemedicine,” wherein a specialist assumes the care of a patient; rather, it enables primary care providers to care more effectively for patients in their own communities.

Project ECHO was initially developed in 2003 by Dr. Sanjeev Arora, a liver specialist in the Department of Internal Medicine at the University of New Mexico Health Sciences Center, to address disparities in access to hepatitis C treatment among New Mexico’s rural populations. At the time, while over 28,000 patients in New Mexico were diagnosed with hepatitis C, fewer than 5% had received treatment with interferon and ribavirin (best practice at that time). The waiting list at Dr. Arora’s clinic in Albuquerque was 8 months long. Many of his patients had to travel hundreds of miles to get care, resulting in lost work time and income, childcare expenses, and travel costs. Low-income patients would often delay seeking care (and develop increased complications) or not seek treatment at all. People were dying from a curable disease.

In response, Dr. Arora devised the ECHO model as a solution to the problem of inadequate access to hepatitis C care in New Mexico’s rural and underserved communities. He based the ECHO model on four principles:

· Use of technology (multipoint videoconferencing and the internet) to leverage scarce healthcare resources, in this case Dr. Arora and the expert pharmacists and psychiatrists at the University of New Mexico
· Sharing of clinical best practices and guidelines for treatment
· Case-based learning: learners receive guided practice and support from a multidisciplinary expert team and master issues of complexity
· Evaluation of outcomes

Dr. Arora and his team set up 21 hepatitis C Centers of Excellence across New Mexico (16 in community health centers, 5 in state prisons), each run by primary care providers committed to becoming experts in hepatitis C prevention and treatment. Using a simple videoconference platform, Dr. Arora’s hepatitis C ECHO program connected his team of specialists at UNM (the “hub”) with those providers (the “spokes”) for weekly two-hour teleECHO sessions in which the hub team guided the spoke participants through didactic presentations and discussion of participants’ deidentified patient cases.2 The case presentations and shared discussions highlighted another key aspect of the ECHO model: all-teach, all-learn. The primary care clinicians presenting cases and the hub specialists were all viewed as experts in their own right, helping to contribute knowledge and understanding that lead to better patient care.

A teleECHO session in progress

Within two years of the launch of Dr. Arora’s Hepatitis C ECHO program, wait times at his clinic decreased to two weeks. Participating providers’ sense of self-efficacy improved. Their knowledge of the disease and how to prevent, screen for, and treat it increased. They reported feelings of reduced isolation and increased professional satisfaction.3 A prospective cohort study, published in 2011 in the New England Journal of Medicine, demonstrated that the rural primary care providers who participated in the program could treat hepatitis C just as effectively as the specialists at UNM could.4

Since this initial success, Dr. Arora and his team – now the ECHO Institute – expanded the use of the model to other common, complex conditions for which effective treatments existed and/or were rapidly developing and changing. ECHO programs are now conducted for chronic pain, diabetes, mental health, substance use disorders, rheumatology, tuberculosis, and HIV. The ECHO Institute also holds monthly training sessions for hub partners around the world; over 163 hubs now replicate the ECHO model across 24 countries for over 50 disease areas.5,6,7,8

In addition to the initial hepatitis C program in New Mexico, 21 global partners are leveraging ECHO to combat liver diseases. The ECHO Institute works with the US Center for Disease Control and Prevention (CDC) and the government of Georgia to provide training and clinical support for providers as part of that country’s hepatitis C elimination program. The ECHO team also collaborates with the United States Department of Health and Human Services for a national program addressing perinatal transmission of hepatitis B. The University of California, San Francisco, is leveraging the ECHO model for the microelimination of hepatitis C in San Francisco, and ECHO is being deployed for the CDC’s initiative to eliminate HCV in the Cherokee Nation. The University of Utah uses the ECHO model to help providers navigate patient complications due to cirrhosis, and to triage patients for liver transplant evaluation. In India, ECHO partners including the Post Graduate Institute of Medical Education and Research and the Indian National Association for the Study of the Liver are also using the model to fight hepatitis C.

Research continues to demonstrate the effectiveness of the ECHO model against hepatitis C. A recent study of providers participating in a US Veterans Affairs ECHO program for hepatitis C treatment showed that patients of those providers received significantly higher rates of antiviral treatment compared to patients of nonparticipating providers.9 Another study, presented at the 2017 EASL international conference, assessed the impact of a multi-pronged approach to hepatitis C treatment in Punjab, involving generic drugs and ECHO programs training providers in the use of those drugs. The study demonstrated a 93% cure rate across over 30,000 patients.10

As the World Health Organization has reported, we are close to the global elimination of hepatitis C, with new approaches and treatments, and more affordable medications increasingly available to aid us in reaching this goal. These approaches, medications, and treatments are useless if they do not reach the underserved populations who need them most. Project ECHO is a powerful tool that democratizes medical knowledge and improves care for those underserved patients and populations. We invite EASL members to join the ECHO movement and explore how the ECHO model can help combat hepatitis C and liver disease in their countries and regions. For more information see the Project ECHO website (https://echo.unm.edu) or contact Dr. Sanjeev Arora (sarora@salud.unm.edu).

References

(Over 70 research publications demonstrate the effectiveness of the ECHO model across a range of diseases and conditions. For a full bibliography, see https://echo.unm.edu/wp-content/uploads/2017/09/Project-ECHO-Bibliography.pdf)

 

  1. World Health Organization, “Close to 3 million people access hepatitis C cure,” http://www.who.int/mediacentre/news/releases/2017/hepatitis-c-cure/en/
  2.  Arora S, Thornton K, Komaromy M, Kalishman S, Katzman J, and Duhigg D. (2014) Demonopolizing Medical Knowledge. Academic Medicine 89 (1): 30-2.
  3. Arora S, Kalishman S, Thornton K, Dion D, Murata G, Deming P, et al. (2010) Expanding Access to hepatitis C virus treatment – Extension for Community Healthcare Outcomes (ECHO) project: disruptive innovation in specialty care. Hepatology 52 (3):1124-33.
  4.  Arora S, Thornton K, Murata G, Deming P, Kalishman S, Dion D, et. al. (2011) Outcomes of treatment for hepatitis C virus infection by primary care providers. New England Journal of Medicine 364(23):2199-207.
  5. Arora S, Kalishman S, Dion D, Som D, Thornton K, Bankhurst A, et. al. (2011) Partnering urban academic medical centers and primary care clinicians to provide complex chronic disease care. Health Affairs 30(6):1176-84.
  6. Komaromy M, Duhigg D, Metcalf A, Carlson C, Kalishman S, Hayes L, et. al. (2016) Project ECHO (Extension for Community Healthcare Outcomes): A new model for educating primary care providers about treatment of substance use disorders. Substance Abuse 37(1):20-24.
  7. Struminger B, Arora S, Zalud-Cerrato S, Lowrance D, Ellerbrock T. (2017) Building virtual communities of practice for health. The Lancet 390 (10095): 632-34.
  8. Frank J, Carey E, Fagan K, Aron D, et. al. (2015) Evaluation of a telementoring intervention for pain management in the Veterans Health Administration. Pain Medicine 16 (6): 1090-1100.
  9. Beste L, Glorioso T, Ho P, Au D, Kirsh S, et. al. (2017) Telemedicine specialty support promotes hepatitis C treatment by primary care providers in the Department of Veterans Affairs. American Journal of Medicine 130 (4):432-438.
  10. Premkumar M, Gagandeep S, Dhiman R (2017) Chronic hepatitis C: Do generics work as well as branded drugs? Journal of Clinical and Experimental Hepatology 7(3):253-261.
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