Yuval Patel
@yuvalpatelMD
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GI Liver doc @BorlandGroover / Alumni @DukeU and @HopkinsMedicine / Trained @OslerResidency and @Duke_GI_ / first gen to college
Joined June 2020
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Referral for ⬆️ liver tests, male ~40
Labs: iron% low, low nl ferritin, mildly low hgb. No bleeding.
Offer egd/colon (liver inflam ⬆️ ferritin)
3.5 cm bleeding sigmoid polyp, EMR neg margins, tva w/ hgd!
Don’t put blinders at the reason for referral!
#MedTwitter
#GITwitter
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@jsvalenti1
The reason to go straight to colonoscopy is bc cologuard is a coinflip at finding advanced polyps. 😳
It’s fantastic at detecting cancer.
But ask yourself… why is the goal to detect cancer? 🧐
Your goal is to PREVENT cancer!
And only a colonoscopy can do that.
#GITwitter
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@arghavan_salles
Respectfully disagree. It’s just perpetuating bad behavior from their bosses/owners.
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@Dr_Oubre
He probably lost his license … or had some distasteful clinical behavior that was flagged by HR
No one becomes a physician to be the peer-to-peer guy
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@tommytuckermd
@ndyG83
Or... the physicians there need basic training for when to consider end of life care approaches. Recognition of when someone is dying and suffering is an essential skill for all healthcare workers.
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👉Disparities in Liver Telehealth, COVID era:
🔹>6000 visit attempts
🔹Use disparities in vulnerable pop, ex. Black, older, gov ins
👉Need focus on barriers!
@DDS_Journal
@KWegermann
@Julius__Wilder
@AMuir_DukeGI
@ZiadGelladMD
@Duke_GI_
#livertwitter
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Provider-driven ETOH counseling can be powerful! Our study👉 . In pts with HCV + risky alcohol use, counseling during DAA therapy leads to sustained ⬇️ in alcohol use well after HCV cure.
@AMuir_DukeGI
@GoachPA_DukeGI
@Duke_GI_
#livertwitter
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Congrats to
@SwathiEluri
(my better half 😉) for her
@AmerGastroAssn
award! 🥳
Thanks to
#AGAResearchFoundation
for supporting research on
#barrettsesophagus
&
#esophagealcancer
👍🏽
@MayoClinic
@MayoClinicGIHep
#GITwitter
#CancerResearch
#WomeninGI
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@VipsMDMEd
A qi project that evaluates which qi projects are useless so made up metrics with no true outcome influence don’t get repeated over and over and over at every hospital system around the country.
Make it lean.
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@Duke_GI_
fellows I've worked w/, 3 posters (2🎓), check out👉
🔹
@pnabMD
1389 SLKT,
@AST_LICOP
,💡
@pummy92
🔹
@NikhilKapilaMD
1416 MDRO,
@AST_LICOP
, 💡
@rrosenblattmd
🔹
@KWegermann
633 telehealth disparities,
@ZiadGelladMD
@AMuir_DukeGI
@Julius__Wilder
@AASLDtweets
#TLMdX
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@anish_koka
Most physicians that are minorities have taken care of pts that overtly hate them (meaning openly verbally racist for ex, not microaggressions) at some point in their careers.
It’s inexcusable to ever hurt a patient on purpose, no matter how small or inconsequential it may seem.
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@ebtapper
I use a car analogy, struggling to go up hill, dark smoke out the back, need to give it better fuel(protein), take care of it(no etoh,etc),not efficient cleaning toxins (HE).For pHTN I explain complxns by highway traffic jam analogy - detour (varices) and back up (volume)
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@sgremminger
You don’t know the patients that doctor had already seen today
Some visits take 15 min, some take way more, rarely you have to arrange for direct ambo to ED
This isn’t a drive thru or a car wash
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@yeet_the_ute
This is absurd. Depending on where you work, it also can be unsafe given the hours residents typically come and go.
What’s the GME leadership doing about this?
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@umnmedschool
This person should not become a doctor. The hate he must have to act this way cannot be blamed on being drunk. Expelling him and revisiting the admissions process is needed.
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@jaumebosch9
@stevenbollipo
@enrrikke
@drkeithsiau
@KM_Pawlak
@pinoygastro
@ebtapper
@AndrewOngML
Seems like a good time to plug livertox — I use this website all the time to see if the herbal/supplement/otc/med has a record of causing liver injury
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Thanks to
@AASLDtweets
for including our study on outcomes of “hard to place” donor livers in this impressive list!
@Duke_GI_
#livertwitter
❄️ Right in time for the holidays - The Best of The Liver Meeting slides are now available for download! Head over to LiverLearning to access this great content:
#TLMdX
#LiverLearning
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@AaronGoodman33
They flat out should just pay them more. A lot more. They are the core of great healthcare.
This is the problem with admins running hospitals who just look simply at what generates revenue.
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In 2016, ~4.8 million North Carolinians voted (~65% eligible voters).
So far ~1.5 million have already early voted.
There are ~7.8 million eligible voters in NC —- so remind people to vote, and tell them to remind their friends/family... chances are they haven’t voted!
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Interested in improving
#NAFLD
identification and pop health mgt?
Check out our posters on an effective NLP scheme for NAFLD (1659), and a large health system evaluation of NAFLD referrals (659)!
#LiverMtg21
#LiverTwitter
@Duke_GI_
@AASLDtweets
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Brutal. Patient with esophagitis on egd on 40 daily ppi + uncontrolled symptoms.
@Cigna
is declining any version (including generic) of 40 mg ppi bid. I call and takes 10 min+ to finally speak to a human. 10 min+ for a new phone number to call. Then another number to call.
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Great study led by stellar residents Sukrit Jain and Sriya Murali!
@IMResidencyDuke
@AimeeZaas
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@olsonplanner
It depends on the goal-
If goal is become an excellent clinician, regardless of specialty, free is way to go from a %chance of success
If goal is become amazing researcher, the “brand” and people at the med school imo may increase %chance of success
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Need for pre-tx midodrine for KT-alone pts linked with 👎🏽 post-KT outcomes. What about for SLKT? Our series suggests they do fine, and most off midodrine quickly!
@pnabMD
@lindsayykingmd
@drewbarbz
@LMcElroy23
@Duke_GI_
#livertwitter
#transplanttwitter
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Per protocol analysis does matter because in this study only 42% got screened. The evidence is quite strong if people actually get their colonoscopy- risk of colon cancer related death goes down by 50%.
@gi_sullivan
thoughts?
NEJM paper now out
FIRST EVER RCT of colonoscopy
With 10 year follow up, 42% adherence, no gain in colon cancer death nor all cause death
I break down the trial, history & interpretation in 30 mins youtube video worth your time
Here is an excerpt
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“Even as immigrants represent 17% of the overall U.S. civilian workforce, they are 28% of physicians” ... ... and often Immigrants are the only care providers in areas of rural America... used to being under-appreciated, and it’s only gotten worse sadly.
I dont like politics but she is talking about me and many many of us!! 👇🏼Lets start with the example of
#FrontLineHeroes
including doctors and nurses
#Immigrants
#EqualityForAll
#MedTwitter
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@achdDoc12
When stuff like this Happens it’s amazing to read the notes and feel the history
I remember caring for a patient with LT that had the LT done by Dr Starzl at upmc >40 years ago at this point
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@gnioannou
@RachelRamoni
@serperm
@JasmohanBajaj
@rrosenblattmd
@elizabeth_verna
@VeteransHealth
@AtoosaRabiee
@annmohare
Congrats! regarding the lack of racial/ethnic disparities here— the VA by nature is universal access for veterans. Makes u think, improve access for historically underserved that struggle with private insurance, and the disparities should improve
@Julius__Wilder
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@jaumebosch9
@AtoosaRabiee
@SultanMahmoodMD
@doctornikkid
@ibdtweets
@JuanAbraldes
@jturnesv
@ggarciatsao
@sconglymd
@docberza
Also, not sure if many do this, but If I have a compensated cirrhosis pt on metoprolol for afib/cad, I always talk to the cardiologist to switch to carvedilol. Portal hypertension drives outcomes, so if you can tweak anything while addressing other medical issues, consider it.
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Many ignore rectal bleeding… and assume it’s from an internal hemorrhoid
Rectal bleeding has the highest positive predictive value for cancer or large polyps 😳
There’s only one way to be sure 🔦
And that’s an endoscopic evaluation
#MedTwitter
#GITwitter
Rectal bleeding and anaemia are the 2 symptoms with highest adjusted PPV for cancer and large polyps, the risk from all other symptoms was similar to what would be expected within the general population.
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@stevenbollipo
@KapuriaMD
@GI_Pearls
Researchers skilled, trial conducted with good intentions
Unfortunately only 42% had the intervention in the intervention arm, which is terrible, no?
ADR below standards
Per protocol has issues, yes, but In this context ITT results also shouldnt be taken blindly IMO 🤷🏽♂️
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Favorite annual conference- wish it were in person, but kudos to
@AASLDtweets
for an excellent virtual setup.
#LiverMtg21
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Great
@LiverFellow
podcast interviewing the ALTROC bandleader
@rrosenblattmd
!
With some homage of
@Julius__Wilder
and
@CindyMoylan_MD
work on transplant disparities
@Duke_GI_
Ready for the Liver Meeting?!
Get hyped w/the 1st in a special3⃣part podcast series highlighting works from junior faculty & trainees.
The 1st guest is
@rrosenblattmd
discussing the
#TLMdx
at large & his research
Spotify:
Apple:
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Going into endoscopy suite today— can’t help but feel for my patients that had to colon prep while watching the election result trickle last night!
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Patient referred for “fatty liver”
First lab I always look for while I’m waiting for the patient to be roomed—
Platelets… and they’re low 100s.
#livertwitter
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@rrosenblattmd
@AutoImmuneLiver
@CholestasisDoc
@ebtapper
@KowdleyMd
@BrettEFortuneMD
@aly_kaplanMD
@LizzieAbyMD
@PBCRobert
@PBCers
@PBCFoundation
Just want to verify you looked at costplusdrugs
16.50 for 30 pills of 300 mg
cost prohibitive still ?
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NAFLDsig with a list of all star speakers, a must listen
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@SPuro88
Depending on where you work in the US, your hospital or academic center may not provide even the basic basic stuff your mentioning in your physician lounge…
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Just finished reading this master class guidance. Congrats on important work
@ArpanPatelMD
@NnekaUfereMD
@KanwalFasiha
Access the newest practice guidance available from AASLD: Palliative care and symptom-based management in decompensated cirrhosis.
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After accepting 2 offers for LTs complicated by marked elevation in PA pressures and hypotension following induction of anesthesia, a new approach was needed.
So the team used V-A ECMO.
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@CoryRohlfsen
The family member acknowledgement is unbeatable
Take care of the patient
Then the patient’s parent comes to your clinic a month later and tells you their son/daughter told them to see you
There’s nothing better, truly. Makes your day.
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@emily_fri
When administrator types think of logistical improvement in healthcare workflows, the natural inclination is to “add more”
Majority of the time the additional “feature” is more work w/o benefit
There is no incentive to streamline processes, it’s just not as appealing
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@AdamMikMD
@ebtapper
@JasmohanBajaj
@AtoosaRabiee
@rrosenblattmd
@stevenbollipo
@ggarciatsao
@jaumebosch9
@jturnesv
@AnjanaPillaiMD
@john_ricemd
@LizzieAbyMD
It’s a little cruel to subject someone to lactulose if they don’t necessarily need it 🤷🏽♂️
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@drsaraancello
@jturnesv
Just want to mention given your mention of bblockers- GAVE wouldn’t respond to bblockers in the way other pHTN manifestations (varices) typically would, recall many pts have GAVE without cirrhosis or pHTN
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@mdlizs
I prechart, but do so in bullet form- key labs, rads, etc. I review med hx + make sure I’m aware of problems that impacts liver. I type hpi during visit (look at pt entire time). After visit, I edit the PE, type AP. Rinse/repeat, key is realizing 5 min typing now = 20+ min later
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@RNSuperHero
Time is brain
I remember a pt I met in residency who had a delayed diagnosis of hsv meningoencephalitis. Just terrible.
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5 yo let his preferences known this morning, can’t disagree with the choice
@DocWithBowtie
@jglissenbrown
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@NnekaUfereMD
@sargsyanz
For cirrhosis / all hep I talk about consuming protein shakes like it’s medicine.
Helps to revisit the goal daily and check on how many shakes consumed every day — and have a goal for how to succeed with protein as an outpt, often boost/ensures cost prohibitive.
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@CarlKayMD
@BalissMichelle
@NumanLaith
@AndrewOngML
@john_damianosMD
@BlaneyMD
@md_myer
@howiethedoc
@stevenbollipo
@drkeithsiau
@ShimaghavimiMD
Good for boards and good for real life-
If you see a disproportionately low aphos when compared to Bili (ratio <2)
think Wilson’s disease
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@ebtapper
@RabieeAnahita
@DrSarahWakeman
Most fellows have their inpatient templates for cirrhosis that include HE management, gi bleeding, volume…
Don’t forget to add:
-Nutrition goals (protein goal, late night snack) and nutrition consult
-substance abuse consult / case manager consult for alcohol rehab options
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A common dilemma that comes up all the time on service! 👏🏽
#livertwitter
&
#cardiotwitter
- Finally! An answer to often-asked question: "Does transeophageal
#echocardiography
⬆️risk of variceal bleeding?" in
@HepCommJournal
💉No overt bleeding observed
💉After adjusting for confounders, no ⬆️bleeding events
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@InduPartha
@DrJoyBB
@CoryRohlfsen
@CchristmColleen
@drjenniferbest
@ShreyaTrivediMD
@LekshmiMD
@VipsMDMEd
@DevikaDasMD
@DrMamaKai
@RUBraveEnough
@TsengJennifer
@KTamirisaMD
My day to day home life priority:
1) finish my clinical work + get home
2) school drop + pick up (if I can)
What that means-
1) work efficiently, do l notes as I see pts
2) non time sensitive work - gets done when kids are asleep
3) can’t day to day leave much work for home
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@kjdelay1
Inflation is out of control but don’t worry your efforts as a physician will be financially worth less (financially worthless works too). Happening year after year without an inflection point in sight.
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BAFLD!
Just published our review by
@FcoIdalsoaga
et al. Non-alcoholic Fatty Liver Disease and Alcohol-Related Liver Disease: Two Intertwined Entities in
@FrontiersIn
@MarcoArreseMD
@Omar_Mousa85
@AnandVKulkarni2
#ALDsig
#NAFLDsig
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🔥📃 new paper on height mismatch ratio and outcomes for peds liver grafts into adults, though overall small num for peds to adults, important to optimize graft selection
@SJKesseli
@MLSamoylova
@Duke_GATORs
@LMcElroy23
@drewbarbz
#livertwitter
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I personally enjoyed call during residency much more than doing a string of nights…
One resident said their favorite thing about their program was their 24hr call and I said *nope.*
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Early voted. Waited 10 minutes. If you are thinking of holding off on voting, writing in, or third party because an ideal selection doesn’t exist for you, please reflect on the reality of the current binary choice. One of the two will be president for another 4 years.
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@LizzieAbyMD
@Tabibian_MDPhD
@OliveViewUCLA
@MayoClinicGIHep
@penngihep
@drfolamay
@ArpanPatelMD
@JBenhammouMD
@TrishaJamesMBA
@esrailian
@DasharathySonya
@AThakerMD
@jennphanmd
@DannyIssaMD
@TienDongMD
He may not remember this, but he gave me and a small group of med studs a talk on cholestatic liver dz while I was rotating on Thayer
@OslerResidency
@sanjayvdesai
, ACS was
@nljonassaint
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@InduPartha
@DrJoyBB
@CoryRohlfsen
@CchristmColleen
@drjenniferbest
@ShreyaTrivediMD
@LekshmiMD
@VipsMDMEd
@DevikaDasMD
@DrMamaKai
@RUBraveEnough
@TsengJennifer
@KTamirisaMD
Once you have your first kid…
The realization that you can’t spend 30 minutes to write the elusive perfect note comes
You time prioritize your day (no idle time wasted)
You stop taking a true break and work through lunch
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#NASH
wish list:
1. NASH mgt 💡less in isolation, and more w/n multiD metab synd/obesity effort (👏
@NPagidipati
🫀-metabolic wt-loss clinic
@DukeCardiology
@Duke_GI_
)
2. Healthy food/exercise access cheaper
3. Wt-loss agents cheaper (👀GLP-1)
@AASLDtweets
#livertwitter
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@ebtapper
Would add change in natural history for two major cirrhosis etiologies:
NAFLD- barriers to exercise/activity, worse food intake behavior
Alcohol- increase in use, harder to engage in relapse prevention / support
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@residencyreview
@acgme
It’s been studied
I personally enjoyed call much more than doing a week of nights, far more tolerable
Why not have residents try and March to a program that fits there schedule needs rather than force no more call
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@VPrasadMDMPH
No one is saying the trial is flawed.
The trial was set up well & w/ good intentions.
But unfortunately only 42% of the intervention arm got a colonoscopy.
and ADRs were well below standard of care.
Therefore the data needs to be interpreted with this context, not blindly.
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@JSinghDO
Humans are more motivated to post a negative review than a positive review for any “thing”, any “service”
Saved someone’s life recently and got a tearful hug
Stopped caring about reviews in general again for a bit
You do good work, and you will continue to do so
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24 hr early voting sites and late night voting! Cities like Houston are doing it right. Games can be played to suppress the vote but cities can strategize! All heavy population centers should consider this.
Late-night Twitter: you might be interested in overnight voting in Houston this week. Voting Centers open at 7 a.m. Oct. 29th and don't close until 7 p.m. Oct. 30th.
#HarrisVotes
#HouNews
#Houston
#Election2020
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.
@MLSamoylova
@LMcElroy23
@drewbarbz
@KWegermann
@SJKesseli
@sehalpern5
@Duke_GATORs
@Duke_GI_
📃New paper examining impact of 2017 allocation policy for SLKT!
The impact of the 2017 kidney allocation policy change on simultaneous liver kidney utilization and outcomes by Samoylova et al.
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Anyone with experience dose reducing cellcept (or withdrawing it) for checkpoint inhibitor hepatitis (cellcept used as steroid refractory- had to go to 1500/1000 and now normal liver tests for >2 months)
#livertwitter
@ebtapper
@rrosenblattmd
@AutoImmuneLiver
@HowardTLeeMD
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@eringpark
You need to tell whomever is in charge of the clerkship. Not acceptable you were treated like that.
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@DrDiGiorgio
Quality post as usual 👏🏽👏🏽
It’s crazy this guy you are commenting on is a health policy expert and doesn’t know this
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@olsonplanner
@TeamCaptainJohn
It’s all time constraint
As a physician you try to outsource tasks to team members that you’re not required for
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@studentdrdemon
Be empathetic, be yourself. The person who gave that feedback to you is completely wrong.
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@BlaneyMD
There’s a small RCT for this very question — does result in smaller post banding ulcers (and if trial was bigger, maybe a signal for bleeding 🤷🏽♂️)
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@CarlKayMD
@stevenbollipo
@EndoCollabcom
@RobertBechara
@shandrawes
@MMendizabalMD
@Samir_Grover
@Stentingwoman
@DushDahiya
@WilliamMinteer
@drkeithsiau
You sir have the most high yield X account for gi fellows- bravo 👏🏽, great stuff
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@scottisaacsmd
Great review, love reading about overlapping + shared psthophysiology and care
Can’t help but think of my friend
@ruben_hernaez
here…
(a rare dual trained endocrinologist and hepatologist in the wild!)
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@JahangirAsgha10
The attempt and vision was admirable.
But insurance is worse than it ever was 1) premiums increasing, 2) deductibles worse, and 3) plans, in effect, cover less for more cost.
Meanwhile insurance companies making record profits.
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@MrWBond
@DrPayItBack
@DGlaucomflecken
@TakeWeightOffMD
@Cigna
Nobody goes into medicine to be an insurance drone to deny people care
Seems like the people who choose this path shouldn’t have went into medicine in the first place
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Coming up soon!
@alextoussaint25
group ride for colon cancer awareness!
@AmCollegeGastro
#GITwitter
#MedTwitter
#CancerAwareness
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@olsonplanner
Your next question should be how many doctors don’t change their job because of their noncompetes
It’s hard to do locums for a year or two or down right move when you have young families
The inertia due to a noncompete has substantial ripple effects
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@ebtapper
cohort is also 97% male. None of these tools are perfect obvi. Historically when I’m asked to stratify risk I’ve used meld and mayo risk, include that in my note, and they typically line up. Will add this to further give a “range of risk”
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@MonicaTincopa
@HowardTLeeMD
@ebtapper
@AtoosaRabiee
@MTPapaD
@Mary_J_Thomson
RFA of GAVE > banding of EV for me, just so fun with the paddle as your paintbrush. Also probably bc I RFA less often, so more of a treat.
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60 yo NASH 3-4 fibrosis by bx ~5yrs ago, loses ~15% wt, now fibroscan 6.7 kpa, 15%iqr. HCC screen when fibrosis⬇️?
#livertwitter
@jmarrero6713
@docamitgs
@AndrewMMoon
@gnioannou
@ebtapper
@DrLoomba
Serial HCC screen
33
No more HCC screen
23
MRE to val fibrosis
14
Other
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@jason_ryanmd
Devils advocate a bit here…
Some med students do participate in research not for padding their eras app but bc they’re genuinely into it
One of the ways to distinguish them is for the interviewers to ask them details about their pubs
Why advise the eras gamers to fake it?
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I share trial every few weeks or so with a hospitalist or nephrologist for an inpt with pancreatitis… did it again just now. Great study
Our dream comes true: the
#WATERFALLtrial
has been published in
@NEJM
Aggressive fluid resuscitation in acute pancreatitis is not safe & does not improve outcomes
#GItwitter
#SomosAEG
@aegastro
What's behind this publication?
It all started 21 years ago
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