Cover StoryPublication Exclusive

Collaboration in Buffalo: How Liver Care is Changing the Face of a City

When Andrew Talal, MD, MPH, received an email from a search firm in 2011 regarding opportunities in Buffalo, NY, he promptly forgot about it.

“I deleted the email,” he told HCV Next with a laugh. “But, opportunity knocks again and again when it’s meant to be.”

After a speaking engagement in the city, Thomas A. Russo, MD, professor of medicine at the University at Buffalo opened Talal’s eyes to the opportunities that lie in a city without a liver center, but with a population in great need of liver care due to a high prevalence of undiagnosed liver disease.

 

 “I was impressed by the openness and his willingness to tell me about this town and their work,” Talal said. That lasting impression pushed him to meet with other leadership within the medical school at the University at Buffalo (UB), now known as the Jacobs School of Medicine and Biomedical Sciences.

“I began to understand the vision here and the vision that could be built,” he said, speaking now as professor of medicine and director of the Center for Clinical Care and Research in Liver Disease at UB.

With a leap of faith in the city and his own aspirations, Talal made the move to Buffalo, eventually recruiting a former fellow, Anthony Martinez, MD, to help him create what is now a burgeoning liver program.

“When I first showed up, I didn’t see a patient for 6 months,” Martinez said. Instead, he explained, he went door-to-door to talk with general gastroenterologists and primary care physicians to discuss the to-be-launched liver program and to initiate the relationships with these providers, bringing doughnuts and promises of collaboration.

By introducing himself and the idea of the liver center, Martinez ensured the referrals they needed to go from three hepatology patients on the schedule to full capacity within 22 months. When HCV Next visited Talal and Martinez, there were 24 patients seen in one half-day session at Buffalo General Medical Center and a waiting list out 6 months. The number of patients seen at the Erie County Medical Center (ECMC) tripled, according to Martinez, and they cut the no-show rate in half.

 

“We had to grease the skins,” Talal said. “They had to be constantly reminded we are here.”

“There was no glossy marketing campaign,” Martinez added. “That’s outreach. ... You build your army and that’s what we did ... guerrilla style.”

About a year ago, their work paid off and the two clinics were designated as liver centers.

“Community outreach and education brings the patients in. Without that, nothing else works,” Martinez said. “This is our contribution to the revitalization of Buffalo.”

Patient Care, Trust

Going into the lowest level at ECMC, Martinez explains that the liver clinic still bears the title of Immunodeficiency Clinic, but so much has changed in the 3 years they have been present that this, too, will likely change.

“You look like a different dude,” Martinez said to a patient during his co-infection clinic.

“This has really changed my life,” the patient said in response, explaining how he has more energy and is grateful for the opportunity to be treated. “He has worked so hard behind the scenes on everything. It’s more than anyone knows,” the patient added, referring to Martinez.

“Our show rate is near 100%. They all come, every time,” Martinez said.

Similarly, the complementary liver clinic at Buffalo General is housed in the basement and many of the same physicians and fellows meet with patients.

 

“Our hep C philosophy is ‘treat everybody.’ If you can do it, you should,” Martinez said. “Everything stems from the patients — research, funding, everything.”

And the interactions between both Martinez and Talal and their patients show that priority.

“You do have cirrhosis,” Talal said to a patient, breaking the news a patient dreads, “but we’re going to treat you.”

Teaching Opportunities

Talal pointed out that UB has one more gastroenterology fellow per year than he had in his previous appointment at Weill Cornell Medical College (WCMC), and he likes to make the most of those three openings in an attempt to maximize the fellow’s clinical and research experiences.

“I’m very selective about whom I mentor, and I’m very interested in those fellows that do research and want to do research,” he said.

HCV Next had the opportunity to meet Alia Hasham, MD, a third-year fellow, and Tara Menon, MD, a first-year fellow, who explained how the collaboration among the liver centers, the Veterans’ Administration and UB expands their learning.

“It’s a very diverse training and that’s what’s been most surprising and refreshing,” Menon said. “Who we learn from is pretty incredible — nursing, other staff, not just other physicians. It’s definitely a team-based approach here. ... Everyone’s excited to teach.”

And it is not only clinical care to which they are exposed, but also to practice management, as they reach out for approval of HCV treatments.

“We’re actively involved in the whole process, seeing the denials and everything,” Hasham said. “We do need to see both ends of it.”

Additionally, in Buffalo, both the pharmacists and the nursing programs offer residencies in HCV for these health care professionals. The pharmacists work closely with Martinez and Talal to counsel patients on drug-drug interactions, while the nurses continue educating community physicians about how to screen and care for patients with HCV.

 

Ellen O’Brien, practice manager at ECMC, explained how their coinfection clinic incorporates a mental health professional, a drug counselor, a social worker, a PharmD and a dietician to give patients the best chance of success in treatment.

“When patients are coming into our care, they’re seeing every discipline in the clinic,” she said. “There’s never a clinic that’s not fully booked.”

Telemedicine

One of the programs that Talal and Martinez piloted while working together at Cornell University was an HCV treatment program integrated into a methadone clinic, as Martinez specializes in addiction medicine.

Upon coming to Buffalo, they transformed this program into a telemedicine clinic. Talal works with START Treatment and Recovery Centers to counsel patients who have tested positive for HCV and to guide them through the new treatment processes. Working with Phyllis Andrews, RPA-C, they have had tremendous success with medication approvals and Talal virtually visits with them at regular intervals. Talal explains, “The medical directors of many of the managed care plans we approached during the formulation of the project were very encouraging of the telemedicine-based approach to HCV care in a methadone clinic.”

“The medications are delivered to the site and they are then dispensed at the same time that the methadone is dispensed,” Talal said. “We’ve been able to do directly observed therapy.”

Talal and Andrews consult on patients’ progress and utilize a shared electronic health record to maintain the highest level of care.

“The patients are very satisfied to be receiving their treatment here, where they come for their methadone treatment. It’s very convenient for them and we’ve only had the rare missed appointment,” Andrews said. “A lot have heard about interferon and side effects and that kept a lot of them away. Now they’re hearing from patients here that it was a breeze for them and more are coming forward.”

Recently, Talal said, he saw 10 patients in 2.5 hours via the telemedicine network. HCV Next had the opportunity to interview one of the first patients who completed HCV therapy via the telemedicine-based approach, and who remains HCV RNA undetectable.

This patient was very enthusiastic about the program and speaks on its behalf to other methadone-maintained patients in need of HCV care.

 

“It’s a good thing. I can’t be in Buffalo, but for me it was wonderful and I didn’t miss anything. ... It’s the next best thing to being there,” the patient said. “It was a breeze and I’m very appreciative. ... Anyone that has [HCV] needs to know their status. These are the right people to be with. The method they use is secondary to themselves.”

Research, Biorepository

Along with improving clinical care in Buffalo, Talal wanted to improve research in hepatology and specifically HCV when he arrived.

Timothy F. Murphy, MD, director of UB’s Clinical and Translational Research Center and the senior associate dean for Clinical and Translational Research, spoke with HCV Next about how Talal’s research has worked into the overall goals at UB and the center.

“Talal’s research just fits absolutely perfectly into the mission of our building and our clinical and translational enterprise in Buffalo,” Murphy said, referring to the three year old, $118 million building that houses UB’s clinical and translational research activities as well as Talal’s office and laboratory space. “The research will, undoubtedly, and has already, resulted in improved patient care.”

Specifically, Talal and Martinez have been researching how to improve the screening of HCV within the population of Buffalo.

“It’s a mutually beneficial goal. So the funding comes through the research and the research is benefitted by all the screening, but the health of the community benefits from the screening as well,” Murphy said. “There’s been nobody driving that agenda until Talal arrived.”

Recently, UB was granted a Clinical Translational Science Award, a $16 million grant over 4 years to improve patient care through research, including a career development program to mentor up-and-coming clinician-scientists on how to conduct clinical research. This award, in Murphy’s opinion, puts UB into the league with leading medical centers in the country.

 

“His group has started two liver clinics ... that didn’t exist before,” he continued. “There are real, live, quantitative metrics in terms of what it’s doing to our clinical research, bringing in more studies, bringing in more resources, more money, connections with industry, industry partners and NIH and CDC grants. It’s impacting — in a very positive way — the research operation enterprise at the university and then also in clinical care in terms of the clinics.”

Pamela K. Anderson, RN, BSN, and Kimberly Brunton, RN, MSN, associate operating directors for the Clinical Research Office, credit Talal with being the “anchor” by which collaboration began in Buffalo.

“Research is really a collaborative effort. None of this would be possible if you didn’t have the capability to bring different teams together,” Anderson said. “You really require a lot of support from many different individuals.”

“You can see the rewards of that collaboration. It furthers the science because people are talking to each other,” Brunton added

Murphy and Talal credit leadership at the university for believing in the research.

“It’s remarkable what’s happening here,” Murphy said. “It’s easy to cut research because you don’t see the results immediately. The leadership has had the vision.”

Part of that vision now, for Talal, is the creation of a regional liver biobank, a vision that is presently becoming reality through an $850,000 grant to Talal from the Kaleida Health Foundation Troupe Fund to establish a biorepository in liver disease.

At Weill Cornell, Talal established a biorepository that currently holds samples from approximately 8,000 patients, with data on 35,000. He continues to hold an appointment at WCMC and works closely with their faculty on collaborative research projects. Building upon the success of the Weill Cornell liver biorepository, the first steps have been taken at UB with the purchase of a freezer to begin their own biorepository. Samples will be collected from ECMC and Buffalo General to seed the collaborations needed for research.

“We have already built strong collaborative relationships with the bariatric and general surgeons and are awaiting IRB-approval to initiate sample collection,” Talal added.

“The biobank starts with liver but, like HCV treatment ..., can expand outward,” Talal said. “Research can be blended into clinical care. One supports the other.”

Community Growth

Murphy also spoke to the growth that has happened within the city and the university in the past 5 years, specifically pointing toward the construction of a new facility to house the growing medical school and to enable it to move to a new location in downtown Buffalo.

“It’s a once in a lifetime opportunity to build a new medical school. It’s going to put the teaching, the research and the patient care all on one campus,” he said. “There’s going to be 20,000 people on this campus by 2017 and the businesses are cropping up around here. It’s been a tremendous economic boon to the city. The biomedical research and medical education enterprise as an economic growth factor has been very important.”

Michael E. Cain, MD, dean of the medical school, (top right) was behind much of this vision of growth, Talal said.

“The school of medicine for the last 70 years has been a split school. We have part of it on this campus and part of it 6 miles from here,” Cain told HCV Next, proud of “the ability to make it whole again by building a brand new, 21st century building.”

This growth will also allow the medical school to expand its class size from 144 students to 180 students.

 

“We want to be a school that increasingly is known for the creation of new knowledge, the place you want to go to get a superior medical education and if you need a physician to take care of you, then these are the physicians that you want to go to and want others to go to as well,” he added. “We’ve been able to create here a synergistic environment and progressive culture where the goal is to achieve excellence through internal collaboration and not internal competition. Once you can establish that culture, where you’re actually part of a team and that team is really working collectively, then you get greater benefit than you do out of isolated camps that are not working collaboratively together. People in Buffalo are seeing the advantage of that medical symphony as opposed to a bunch of isolated medical bands.”

Talal explained that the interdisciplinary nature of liver disease and HCV melds well with this vision.

“Liver disease is a discipline that builds synergy between specialties without being in competition with local gastroenterologists for procedures. Furthermore, as has been shown again and again, interdisciplinary collaboration leads to the best treatment outcomes in HCV.”

Talal sees the liver center and the research coming together, using HCV treatment to help integrate services and foster multidisciplinary care, education, community engagement and provider education.

“Buffalo has been like the ornate abandoned church, with broken stained glass windows,” he said gazing out the window at a similar building. “Now the renaissance in Buffalo is occurring, and we are fortuitous to have the opportunity for clinical care, education and research in liver diseases to be at the forefront of the revitalization of biomedical science in this community.” — by Katrina Altersitz

Disclosure: Martinez reports being a speaker for AbbVie, Bayer, Bristol-Myers Squibb, Gilead Sciences and Salix; a consultant for Gilead Sciences and Intercept Pharmaceuticals; and receiving research funding from AbbVie, Gilead Sciences, Merck and Tobira. Talal reports receiving research and grant support from Abbott, AbbVie, Galactin, Gilead Sciences, Intercept Pharmaceuticals, Lily, Merck, Tibotec and Tobira; serving as on committee for or as advisor for Abbott Diagnostics, AbbVie, the Chronic Liver Disease Foundation, Merck and Pfizer; and serving on the speaker’s bureau for the Chronic Liver Disease Foundation and the Empire Liver Disease Foundation.

When Andrew Talal, MD, MPH, received an email from a search firm in 2011 regarding opportunities in Buffalo, NY, he promptly forgot about it.

“I deleted the email,” he told HCV Next with a laugh. “But, opportunity knocks again and again when it’s meant to be.”

After a speaking engagement in the city, Thomas A. Russo, MD, professor of medicine at the University at Buffalo opened Talal’s eyes to the opportunities that lie in a city without a liver center, but with a population in great need of liver care due to a high prevalence of undiagnosed liver disease.

 

 “I was impressed by the openness and his willingness to tell me about this town and their work,” Talal said. That lasting impression pushed him to meet with other leadership within the medical school at the University at Buffalo (UB), now known as the Jacobs School of Medicine and Biomedical Sciences.

“I began to understand the vision here and the vision that could be built,” he said, speaking now as professor of medicine and director of the Center for Clinical Care and Research in Liver Disease at UB.

With a leap of faith in the city and his own aspirations, Talal made the move to Buffalo, eventually recruiting a former fellow, Anthony Martinez, MD, to help him create what is now a burgeoning liver program.

“When I first showed up, I didn’t see a patient for 6 months,” Martinez said. Instead, he explained, he went door-to-door to talk with general gastroenterologists and primary care physicians to discuss the to-be-launched liver program and to initiate the relationships with these providers, bringing doughnuts and promises of collaboration.

By introducing himself and the idea of the liver center, Martinez ensured the referrals they needed to go from three hepatology patients on the schedule to full capacity within 22 months. When HCV Next visited Talal and Martinez, there were 24 patients seen in one half-day session at Buffalo General Medical Center and a waiting list out 6 months. The number of patients seen at the Erie County Medical Center (ECMC) tripled, according to Martinez, and they cut the no-show rate in half.

 

“We had to grease the skins,” Talal said. “They had to be constantly reminded we are here.”

“There was no glossy marketing campaign,” Martinez added. “That’s outreach. ... You build your army and that’s what we did ... guerrilla style.”

About a year ago, their work paid off and the two clinics were designated as liver centers.

“Community outreach and education brings the patients in. Without that, nothing else works,” Martinez said. “This is our contribution to the revitalization of Buffalo.”

Patient Care, Trust

Going into the lowest level at ECMC, Martinez explains that the liver clinic still bears the title of Immunodeficiency Clinic, but so much has changed in the 3 years they have been present that this, too, will likely change.

PAGE BREAK

“You look like a different dude,” Martinez said to a patient during his co-infection clinic.

“This has really changed my life,” the patient said in response, explaining how he has more energy and is grateful for the opportunity to be treated. “He has worked so hard behind the scenes on everything. It’s more than anyone knows,” the patient added, referring to Martinez.

“Our show rate is near 100%. They all come, every time,” Martinez said.

Similarly, the complementary liver clinic at Buffalo General is housed in the basement and many of the same physicians and fellows meet with patients.

 

“Our hep C philosophy is ‘treat everybody.’ If you can do it, you should,” Martinez said. “Everything stems from the patients — research, funding, everything.”

And the interactions between both Martinez and Talal and their patients show that priority.

“You do have cirrhosis,” Talal said to a patient, breaking the news a patient dreads, “but we’re going to treat you.”

Teaching Opportunities

Talal pointed out that UB has one more gastroenterology fellow per year than he had in his previous appointment at Weill Cornell Medical College (WCMC), and he likes to make the most of those three openings in an attempt to maximize the fellow’s clinical and research experiences.

“I’m very selective about whom I mentor, and I’m very interested in those fellows that do research and want to do research,” he said.

HCV Next had the opportunity to meet Alia Hasham, MD, a third-year fellow, and Tara Menon, MD, a first-year fellow, who explained how the collaboration among the liver centers, the Veterans’ Administration and UB expands their learning.

“It’s a very diverse training and that’s what’s been most surprising and refreshing,” Menon said. “Who we learn from is pretty incredible — nursing, other staff, not just other physicians. It’s definitely a team-based approach here. ... Everyone’s excited to teach.”

And it is not only clinical care to which they are exposed, but also to practice management, as they reach out for approval of HCV treatments.

“We’re actively involved in the whole process, seeing the denials and everything,” Hasham said. “We do need to see both ends of it.”

Additionally, in Buffalo, both the pharmacists and the nursing programs offer residencies in HCV for these health care professionals. The pharmacists work closely with Martinez and Talal to counsel patients on drug-drug interactions, while the nurses continue educating community physicians about how to screen and care for patients with HCV.

 

Ellen O’Brien, practice manager at ECMC, explained how their coinfection clinic incorporates a mental health professional, a drug counselor, a social worker, a PharmD and a dietician to give patients the best chance of success in treatment.

“When patients are coming into our care, they’re seeing every discipline in the clinic,” she said. “There’s never a clinic that’s not fully booked.”

Telemedicine

One of the programs that Talal and Martinez piloted while working together at Cornell University was an HCV treatment program integrated into a methadone clinic, as Martinez specializes in addiction medicine.

Upon coming to Buffalo, they transformed this program into a telemedicine clinic. Talal works with START Treatment and Recovery Centers to counsel patients who have tested positive for HCV and to guide them through the new treatment processes. Working with Phyllis Andrews, RPA-C, they have had tremendous success with medication approvals and Talal virtually visits with them at regular intervals. Talal explains, “The medical directors of many of the managed care plans we approached during the formulation of the project were very encouraging of the telemedicine-based approach to HCV care in a methadone clinic.”

PAGE BREAK

“The medications are delivered to the site and they are then dispensed at the same time that the methadone is dispensed,” Talal said. “We’ve been able to do directly observed therapy.”

Talal and Andrews consult on patients’ progress and utilize a shared electronic health record to maintain the highest level of care.

“The patients are very satisfied to be receiving their treatment here, where they come for their methadone treatment. It’s very convenient for them and we’ve only had the rare missed appointment,” Andrews said. “A lot have heard about interferon and side effects and that kept a lot of them away. Now they’re hearing from patients here that it was a breeze for them and more are coming forward.”

Recently, Talal said, he saw 10 patients in 2.5 hours via the telemedicine network. HCV Next had the opportunity to interview one of the first patients who completed HCV therapy via the telemedicine-based approach, and who remains HCV RNA undetectable.

This patient was very enthusiastic about the program and speaks on its behalf to other methadone-maintained patients in need of HCV care.

 

“It’s a good thing. I can’t be in Buffalo, but for me it was wonderful and I didn’t miss anything. ... It’s the next best thing to being there,” the patient said. “It was a breeze and I’m very appreciative. ... Anyone that has [HCV] needs to know their status. These are the right people to be with. The method they use is secondary to themselves.”

Research, Biorepository

Along with improving clinical care in Buffalo, Talal wanted to improve research in hepatology and specifically HCV when he arrived.

Timothy F. Murphy, MD, director of UB’s Clinical and Translational Research Center and the senior associate dean for Clinical and Translational Research, spoke with HCV Next about how Talal’s research has worked into the overall goals at UB and the center.

“Talal’s research just fits absolutely perfectly into the mission of our building and our clinical and translational enterprise in Buffalo,” Murphy said, referring to the three year old, $118 million building that houses UB’s clinical and translational research activities as well as Talal’s office and laboratory space. “The research will, undoubtedly, and has already, resulted in improved patient care.”

Specifically, Talal and Martinez have been researching how to improve the screening of HCV within the population of Buffalo.

“It’s a mutually beneficial goal. So the funding comes through the research and the research is benefitted by all the screening, but the health of the community benefits from the screening as well,” Murphy said. “There’s been nobody driving that agenda until Talal arrived.”

Recently, UB was granted a Clinical Translational Science Award, a $16 million grant over 4 years to improve patient care through research, including a career development program to mentor up-and-coming clinician-scientists on how to conduct clinical research. This award, in Murphy’s opinion, puts UB into the league with leading medical centers in the country.

 

“His group has started two liver clinics ... that didn’t exist before,” he continued. “There are real, live, quantitative metrics in terms of what it’s doing to our clinical research, bringing in more studies, bringing in more resources, more money, connections with industry, industry partners and NIH and CDC grants. It’s impacting — in a very positive way — the research operation enterprise at the university and then also in clinical care in terms of the clinics.”

Pamela K. Anderson, RN, BSN, and Kimberly Brunton, RN, MSN, associate operating directors for the Clinical Research Office, credit Talal with being the “anchor” by which collaboration began in Buffalo.

“Research is really a collaborative effort. None of this would be possible if you didn’t have the capability to bring different teams together,” Anderson said. “You really require a lot of support from many different individuals.”

“You can see the rewards of that collaboration. It furthers the science because people are talking to each other,” Brunton added

Murphy and Talal credit leadership at the university for believing in the research.

PAGE BREAK

“It’s remarkable what’s happening here,” Murphy said. “It’s easy to cut research because you don’t see the results immediately. The leadership has had the vision.”

Part of that vision now, for Talal, is the creation of a regional liver biobank, a vision that is presently becoming reality through an $850,000 grant to Talal from the Kaleida Health Foundation Troupe Fund to establish a biorepository in liver disease.

At Weill Cornell, Talal established a biorepository that currently holds samples from approximately 8,000 patients, with data on 35,000. He continues to hold an appointment at WCMC and works closely with their faculty on collaborative research projects. Building upon the success of the Weill Cornell liver biorepository, the first steps have been taken at UB with the purchase of a freezer to begin their own biorepository. Samples will be collected from ECMC and Buffalo General to seed the collaborations needed for research.

“We have already built strong collaborative relationships with the bariatric and general surgeons and are awaiting IRB-approval to initiate sample collection,” Talal added.

“The biobank starts with liver but, like HCV treatment ..., can expand outward,” Talal said. “Research can be blended into clinical care. One supports the other.”

Community Growth

Murphy also spoke to the growth that has happened within the city and the university in the past 5 years, specifically pointing toward the construction of a new facility to house the growing medical school and to enable it to move to a new location in downtown Buffalo.

“It’s a once in a lifetime opportunity to build a new medical school. It’s going to put the teaching, the research and the patient care all on one campus,” he said. “There’s going to be 20,000 people on this campus by 2017 and the businesses are cropping up around here. It’s been a tremendous economic boon to the city. The biomedical research and medical education enterprise as an economic growth factor has been very important.”

Michael E. Cain, MD, dean of the medical school, (top right) was behind much of this vision of growth, Talal said.

“The school of medicine for the last 70 years has been a split school. We have part of it on this campus and part of it 6 miles from here,” Cain told HCV Next, proud of “the ability to make it whole again by building a brand new, 21st century building.”

This growth will also allow the medical school to expand its class size from 144 students to 180 students.

 

“We want to be a school that increasingly is known for the creation of new knowledge, the place you want to go to get a superior medical education and if you need a physician to take care of you, then these are the physicians that you want to go to and want others to go to as well,” he added. “We’ve been able to create here a synergistic environment and progressive culture where the goal is to achieve excellence through internal collaboration and not internal competition. Once you can establish that culture, where you’re actually part of a team and that team is really working collectively, then you get greater benefit than you do out of isolated camps that are not working collaboratively together. People in Buffalo are seeing the advantage of that medical symphony as opposed to a bunch of isolated medical bands.”

Talal explained that the interdisciplinary nature of liver disease and HCV melds well with this vision.

“Liver disease is a discipline that builds synergy between specialties without being in competition with local gastroenterologists for procedures. Furthermore, as has been shown again and again, interdisciplinary collaboration leads to the best treatment outcomes in HCV.”

Talal sees the liver center and the research coming together, using HCV treatment to help integrate services and foster multidisciplinary care, education, community engagement and provider education.

“Buffalo has been like the ornate abandoned church, with broken stained glass windows,” he said gazing out the window at a similar building. “Now the renaissance in Buffalo is occurring, and we are fortuitous to have the opportunity for clinical care, education and research in liver diseases to be at the forefront of the revitalization of biomedical science in this community.” — by Katrina Altersitz

Disclosure: Martinez reports being a speaker for AbbVie, Bayer, Bristol-Myers Squibb, Gilead Sciences and Salix; a consultant for Gilead Sciences and Intercept Pharmaceuticals; and receiving research funding from AbbVie, Gilead Sciences, Merck and Tobira. Talal reports receiving research and grant support from Abbott, AbbVie, Galactin, Gilead Sciences, Intercept Pharmaceuticals, Lily, Merck, Tibotec and Tobira; serving as on committee for or as advisor for Abbott Diagnostics, AbbVie, the Chronic Liver Disease Foundation, Merck and Pfizer; and serving on the speaker’s bureau for the Chronic Liver Disease Foundation and the Empire Liver Disease Foundation.