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Wu J, Duan C, Yang Y, Wang Z, Tan C, Han C, Hou X. Insights into the liver-eyes connections, from epidemiological, mechanical studies to clinical translation. J Transl Med 2023; 21:712. [PMID: 37817192 PMCID: PMC10566185 DOI: 10.1186/s12967-023-04543-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Accepted: 09/19/2023] [Indexed: 10/12/2023] Open
Abstract
Maintenance of internal homeostasis is a sophisticated process, during which almost all organs get involved. Liver plays a central role in metabolism and involves in endocrine, immunity, detoxification and storage, and therefore it communicates with distant organs through such mechanisms to regulate pathophysiological processes. Dysfunctional liver is often accompanied by pathological phenotypes of distant organs, including the eyes. Many reviews have focused on crosstalk between the liver and gut, the liver and brain, the liver and heart, the liver and kidney, but with no attention paid to the liver and eyes. In this review, we summarized intimate connections between the liver and the eyes from three aspects. Epidemiologically, we suggest liver-related, potential, protective and risk factors for typical eye disease as well as eye indicators connected with liver status. For molecular mechanism aspect, we elaborate their inter-organ crosstalk from metabolism (glucose, lipid, proteins, vitamin, and mineral), detoxification (ammonia and bilirubin), and immunity (complement and inflammation regulation) aspect. In clinical application part, we emphasize the latest advances in utilizing the liver-eye axis in disease diagnosis and therapy, involving artificial intelligence-deep learning-based novel diagnostic tools for detecting liver disease and adeno-associated viral vector-based gene therapy method for curing blinding eye disease. We aim to focus on and provide novel insights into liver and eyes communications and help resolve existed clinically significant issues.
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Affiliation(s)
- Junhao Wu
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan, 430022 Hubei China
| | - Caihan Duan
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan, 430022 Hubei China
| | - Yuanfan Yang
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Centre, Sun Yat-Sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangzhou, China
| | - Zhe Wang
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan, 430022 Hubei China
| | - Chen Tan
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan, 430022 Hubei China
| | - Chaoqun Han
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan, 430022 Hubei China
| | - Xiaohua Hou
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan, 430022 Hubei China
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Calvo Córdoba A, García Cena CE, Montoliu C. Automatic Video-Oculography System for Detection of Minimal Hepatic Encephalopathy Using Machine Learning Tools. SENSORS (BASEL, SWITZERLAND) 2023; 23:8073. [PMID: 37836903 PMCID: PMC10575013 DOI: 10.3390/s23198073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 09/18/2023] [Accepted: 09/21/2023] [Indexed: 10/15/2023]
Abstract
This article presents an automatic gaze-tracker system to assist in the detection of minimal hepatic encephalopathy by analyzing eye movements with machine learning tools. To record eye movements, we used video-oculography technology and developed automatic feature-extraction software as well as a machine learning algorithm to assist clinicians in the diagnosis. In order to validate the procedure, we selected a sample (n=47) of cirrhotic patients. Approximately half of them were diagnosed with minimal hepatic encephalopathy (MHE), a common neurological impairment in patients with liver disease. By using the actual gold standard, the Psychometric Hepatic Encephalopathy Score battery, PHES, patients were classified into two groups: cirrhotic patients with MHE and those without MHE. Eye movement tests were carried out on all participants. Using classical statistical concepts, we analyzed the significance of 150 eye movement features, and the most relevant (p-values ≤ 0.05) were selected for training machine learning algorithms. To summarize, while the PHES battery is a time-consuming exploration (between 25-40 min per patient), requiring expert training and not amenable to longitudinal analysis, the automatic video oculography is a simple test that takes between 7 and 10 min per patient and has a sensitivity and a specificity of 93%.
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Affiliation(s)
- Alberto Calvo Córdoba
- Escuela Técnica Superior de Ingenieros Industriales, Center for Automation and Robotics, UPM-CSIC, Universidad Politécnica de Madrid, José Gutiérrez Abascal St., 2, 28006 Madrid, Spain
| | - Cecilia E. García Cena
- Escuela Técnica Superior de Ingeniería y Diseño Industrial, Center for Automation and Robotics, UPM-CSIC, Universidad Politécnica de Madrid, Ronda de Valencia, 3, 28012 Madrid, Spain;
| | - Carmina Montoliu
- Instituto de Investigación Sanitaria-INCLIVA, 46010 Valencia, Spain;
- Servicio de Medicina Digestiva, Hospital Clínico de Valencia, 46010 Valencia, Spain
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García Cena CE, Gómez-Andrés D, Pulido-Valdeolivas I, Sánchez-Seco VG, Domingo-Santos A, Moreno-García S, Benito-León J. Toward an Automatic Assessment of Cognitive Dysfunction in Relapsing-Remitting Multiple Sclerosis Patients Using Eye Movement Analysis. SENSORS (BASEL, SWITZERLAND) 2022; 22:8220. [PMID: 36365918 PMCID: PMC9657913 DOI: 10.3390/s22218220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 10/13/2022] [Accepted: 10/22/2022] [Indexed: 06/16/2023]
Abstract
Despite the importance of cognitive function in multiple sclerosis, it is poorly represented in the Expanded Disability Status Scale (EDSS), the commonly used clinical measure to assess disability, suggesting that an analysis of eye movement, which is generated by an extensive and well-coordinated functional network that is engaged in cognitive function, could have the potential to extend and complement this more conventional measure. We aimed to measure the eye movement of a case series of MS patients with relapsing−remitting MS to assess their cognitive status using a conventional gaze tracker. A total of 41 relapsing−remitting MS patients and 43 age-matched healthy controls were recruited for this study. Overall, we could not find a clear common pattern in the eye motor abnormalities. Vertical eye movement was more impaired in MS patients than horizontal movement. Increased latencies were found in the prosaccades and reflexive saccades of antisaccade tests. The smooth pursuit was impaired with more corrections (backup and catchup movements, p<0.01). No correlation was found between eye movement variables and EDSS or disease duration. Despite significant alterations in the behavior of the eye movements in MS patients, which are compatible with altered cognitive status, there is no common pattern of these alterations. We interpret this as a consequence of the patchy, heterogeneous distribution of white matter involvement in MS that provokes multiple combinations of impairment at different points in the different networks involved in eye motor control. Further studies are therefore required.
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Affiliation(s)
- Cecilia E. García Cena
- Escuela Técnica Superior de Ingeniería y Diseño Industrial, Centre for Automation and Robotics, ETSIDI-CAR, Universidad Politécnica de Madrid, 28012 Madrid, Spain
| | - David Gómez-Andrés
- Child Neurology Unit, Hospital Universitari Vall d’Hebron, Vall d’Hebron Research Institute (VHIR), Euro-NMD and ERN-RND, 08035 Barcelona, Spain
| | - Irene Pulido-Valdeolivas
- Anatomy, Histology and Neuroscience Department, Universidad Autónoma de Madrid, 28049 Madrid, Spain
| | | | - Angela Domingo-Santos
- Department of Neurology, “La Mancha Centro” General Hospital, Alcázar de San Juan, 13600 Ciudad Real, Spain
| | - Sara Moreno-García
- Department of Neurology, University Hospital “12 de Octubre”, 28041 Madrid, Spain
| | - Julián Benito-León
- Department of Neurology, University Hospital “12 de Octubre”, 28041 Madrid, Spain
- Centro de Investigación Biomédica en Red sobre Enfermedades Neurodegenerativas (CIBERNED), 28029 Madrid, Spain
- Department of Medicine, Complutense University, 28040 Madrid, Spain
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Casanova-Ferrer F, García-Cena CE, Gallego JJ, Fiorillo A, Urios A, Calvo-Córdoba A, Ballester MP, Ríos MP, Durbán L, Hidalgo MR, García F, Felipo V, Montoliu C. Minimal hepatic encephalopathy is associated to alterations in eye movements. Sci Rep 2022; 12:16837. [PMID: 36207472 PMCID: PMC9547018 DOI: 10.1038/s41598-022-21230-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 09/23/2022] [Indexed: 11/09/2022] Open
Abstract
Minimal hepatic encephalopathy (MHE) is diagnosed using PHES battery, but other tests are more sensitive, and a simple tool for early MHE detection is required. Assessment of saccadic eye movements is useful for early detection of cognitive alterations in different pathologies. We characterized the alterations in saccadic eye movements in MHE patients, its relationship with cognitive alterations and its utility for MHE diagnosis. One-hundred and eighteen cirrhotic patients (86 without and 32 with MHE) and 35 controls performed PHES and Stroop test and an eye movements test battery by OSCANN system: visual saccades, antisaccades, memory-guided saccades, fixation test and smooth pursuit. We analyzed 177 parameters of eye movements, assessed their diagnostic capacity for MHE, and correlated with cognitive alterations. MHE patients showed alterations in 56 of the 177 variables of eye movements compared to NMHE patients. MHE patients showed longer latencies and worse performance in most eye movements tests, which correlated with mental processing speed and attention impairments. The best correlations found were for antisaccades and memory-guided saccades, and some parameters in these tests could be useful for discriminating MHE and NMHE patients. Eye movements analysis could be a new, rapid, reliable, objective, and reproducible tool for early diagnose MHE.
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Affiliation(s)
- Franc Casanova-Ferrer
- Fundación de Investigación Hospital Clínico Universitario de Valencia-INCLIVA, 46010, Valencia, Spain
| | - Cecilia E García-Cena
- Centre for Automation and Robotics, Universidad Politecnica de Madrid, Madrid, Spain
| | - Juan-Jose Gallego
- Fundación de Investigación Hospital Clínico Universitario de Valencia-INCLIVA, 46010, Valencia, Spain
| | - Alessandra Fiorillo
- Fundación de Investigación Hospital Clínico Universitario de Valencia-INCLIVA, 46010, Valencia, Spain
| | - Amparo Urios
- Fundación de Investigación Hospital Clínico Universitario de Valencia-INCLIVA, 46010, Valencia, Spain
| | - Alberto Calvo-Córdoba
- Centre for Automation and Robotics, Universidad Politecnica de Madrid, Madrid, Spain
| | - Maria-Pilar Ballester
- Fundación de Investigación Hospital Clínico Universitario de Valencia-INCLIVA, 46010, Valencia, Spain.,Servicio de Medicina Digestiva, Hospital Clínico Universitario de Valencia, 46010, Valencia, Spain
| | - María Pilar Ríos
- Servicio de Medicina Digestiva, Hospital Arnau de Vilanova, 46015, Valencia, Spain
| | - Lucía Durbán
- Servicio de Medicina Digestiva, Hospital Arnau de Vilanova, 46015, Valencia, Spain
| | - Marta R Hidalgo
- Bioinformatics and Biostatistics Unit, Centro Investigación Príncipe Felipe, 46012, Valencia, Spain
| | - Francisco García
- Bioinformatics and Biostatistics Unit, Centro Investigación Príncipe Felipe, 46012, Valencia, Spain
| | - Vicente Felipo
- Laboratory of Neurobiology, Centro Investigación Príncipe Felipe, 46012, Valencia, Spain
| | - Carmina Montoliu
- Fundación de Investigación Hospital Clínico Universitario de Valencia-INCLIVA, 46010, Valencia, Spain. .,Department of Pathology, Faculty of Medicine, University of Valencia/INCLIVA-Health Research Institute, Avda. Blasco Ibañez, 17, 46010, Valencia, Spain.
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Larrazabal A, García Cena C, Martínez C. Video-oculography eye tracking towards clinical applications: A review. Comput Biol Med 2019; 108:57-66. [DOI: 10.1016/j.compbiomed.2019.03.025] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 02/20/2019] [Accepted: 03/26/2019] [Indexed: 10/27/2022]
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Methawasin K, Chonmaitree P, Wongjitrat C, Rattanamongkolgul S, Asawavichienjinda T. Movement Disorders in Non-Wilsonian Hepatic Cirrhotic Patients: The Subgroup Analysis of Various Phenotypes and Associated Risk Factors. J Mov Disord 2016; 9:104-13. [PMID: 27020458 PMCID: PMC4886199 DOI: 10.14802/jmd.15047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Revised: 01/01/2016] [Accepted: 02/22/2016] [Indexed: 11/30/2022] Open
Abstract
Objective The aim of this subgroup analysis was to identify the risk factors associated with the development of various movement disorder phenotypes. Methods Eighty-three non-Wilsonian cirrhotic patients with abnormal movements were allocated into the following groups: intention tremor, bradykinesia, Parkinsonism, and abnormal ocular movements. These movement types were considered the primary outcomes as there was a sufficient sample size. Researchers took into consideration the gender, etiologies of cirrhosis, cirrhosis-related complications, hepatic encephalopathy, medical illness, and some neurological deficits as potential factors associated with these movement disorders. Results The male gender (p = 0.002) and alcoholic cirrhosis (p = 0.005) were significant factors for the prevalence of intention tremors. In bradykinesia, hepatic encephalopathy was highly statistically significant (p < 0.001), and females more commonly developed bradykinesia (p = 0.04). The Parkinsonism features in this study were confounded by hyperlipidemia (p = 0.04) and motor or sensory deficits (p = 0.02). Jerky pursuits and a horizontal nystagmus were detected. Jerky pursuits were significantly related to hepatic encephalopathy (p = 0.003) and bradykinesia, but there were no factors associated with the prevalence of nystagmus other than an intention tremor. Conclusions The association of alcoholic cirrhosis with the development of intention tremor indicates that the persistent cerebellar malfunction in cirrhotic patients is due to alcohol toxicity. The slowness of finger tapping and jerky pursuit eye movements are significantly associated with hepatic encephalopathy. Thus, further studies are needed to evaluate the diagnostic value of these two signs for an early detection of mild hepatic encephalopathy.
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Affiliation(s)
- Kulthida Methawasin
- Department of Medicine, Faculty of Medicine, Srinakharinwirot University, Ongkharak, Nakhon Nayok, Thailand
| | - Piyanant Chonmaitree
- Department of Medicine, Faculty of Medicine, Srinakharinwirot University, Ongkharak, Nakhon Nayok, Thailand
| | - Chatchawan Wongjitrat
- Department of Medicine, Faculty of Medicine, Srinakharinwirot University, Ongkharak, Nakhon Nayok, Thailand
| | - Suthee Rattanamongkolgul
- Department of Preventive and Community Medicine, Faculty of Medicine, Srinakharinwirot University, Ongkharak, Nakhon Nayok, Thailand
| | - Thanin Asawavichienjinda
- Epidemiology Division, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
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Cunniffe N, Munby H, Chan S, Saatci D, Edison E, Carpenter RHS, Massey D. Using saccades to diagnose covert hepatic encephalopathy. Metab Brain Dis 2015; 30:821-8. [PMID: 25586511 DOI: 10.1007/s11011-014-9647-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2014] [Accepted: 12/29/2014] [Indexed: 01/18/2023]
Abstract
Covert Hepatic Encephalopathy (CHE), previously known as Minimal Hepatic Encephalopathy, is a subtle cognitive defect found in 30-70 % of cirrhosis patients. It has been linked to poor quality of life, impaired fitness to drive, and increased mortality: treatment is possible. Despite its clinical significance, diagnosis relies on psychometric tests that have proved unsuitable for use in a clinical setting. We investigated whether measurement of saccadic latency distributions might be a viable alternative. We collected data on 35 cirrhosis patients at Addenbrooke's Hospital, Cambridge, with no evidence of clinically overt encephalopathy, and 36 age-matched healthy controls. Performance on standard psychometric tests was evaluated to determine those patients with CHE as defined by the World Congress of Gastroenterology. We then compared visually-evoked saccades between those with CHE and those without, as well as reviewing blood test results and correlating saccadic latencies with biochemical parameters and prognostic scores. Cirrhosis patients have significantly longer median saccadic latencies than healthy controls. Those with CHE had significantly prolonged saccadic latencies when compared with those without CHE. Analysis of a cirrhosis patient's saccades can diagnose CHE with a sensitivity of 75 % and a specificity of 75 %. We concluded that analysis of a cirrhosis patient's saccadic latency distributions is a fast and objective measure that can be used as a diagnostic tool for CHE. This improved early diagnosis could direct avoidance of high-risk activities such as driving, and better inform treatment strategies.
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Affiliation(s)
- Nicholas Cunniffe
- Department of Physiology, Development and Neuroscience, University of Cambridge, Cambridge, UK
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Corrias M, Turco M, Rui MD, Gatta A, Angeli P, Merkel C, Amodio P, Schiff S, Montagnese S. Covert hepatic encephalopathy: does the mini-mental state examination help? J Clin Exp Hepatol 2014; 4:89-93. [PMID: 25755545 PMCID: PMC4116703 DOI: 10.1016/j.jceh.2013.12.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2013] [Accepted: 12/31/2013] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND/OBJECTIVES The Mini-Mental State Examination (MMSE) has been utilized for the diagnosis of hepatic encephalopathy (HE). However, its threshold of abnormality has not been formally tested in patients with cirrhosis and its diagnostic/prognostic validity remains unknown. The aim of this study was to assess it in a large group of well-characterized outpatients with cirrhosis and no overt HE. METHODS One-hundred-and-ninety-one patients underwent clinical assessment, MMSE, electroencephalography (EEG) and paper-and-pencil psychometry (PHES); 117 were followed up for 8 ± 5 months in relation to the occurrence of HE-related hospitalizations. RESULTS On the day of study, 81 patients (42%) had abnormal EEG and 67 (35%) abnormal PHES; 103 (60%) had a history of HE. Average MMSE was 26.6 ± 3.5; 22 (19%) patients had abnormal MMSE based on the standard threshold of 24. Patients with abnormal EEG/PHES/history of HE had worse MMSE performance than their counterparts with normal tests/negative history (25.7 ± 4.2 vs. 27.3 ± 2.7; P < 0.01; 25.5 ± 3.2 vs. 27.9 ± 1.8, P < 0.0001; 26.3 ± 3.7 vs. 27.4 ± 2.6, P < 0.05, respectively). Based on the above results, MMSE thresholds of 26 and 27 were tested against abnormalities in clinical/EEG/PHES indices and significant associations were observed. An MMSE threshold of 26 was also a predictor of HE-related hospitalization (Cox-Mantel: P = 0.001); patients with MMSE <26 were significantly older than those with MMSE ≥26 but comparable in terms of liver dysfunction and ammonia levels. When MMSE items were considered separately, those which correlated most significantly with standard HE indices where spatial orientation and writing. CONCLUSION In conclusion, an MMSE <26 identifies older patients with cirrhosis who are more prone to manifest HE signs.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Sara Montagnese
- Address for correspondence: Sara Montagnese, Dipartimento di Medicina, University of Padova, Via Giustiniani, 2, Padova 35128, Italy. Tel.: +39 (0) 49 8218675; fax: +39 (0) 49 7960903.
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Bajaj JS, Cordoba J, Mullen KD, Amodio P, Shawcross DL, Butterworth RF, Morgan MY. Review article: the design of clinical trials in hepatic encephalopathy--an International Society for Hepatic Encephalopathy and Nitrogen Metabolism (ISHEN) consensus statement. Aliment Pharmacol Ther 2011; 33:739-47. [PMID: 21306407 PMCID: PMC3971432 DOI: 10.1111/j.1365-2036.2011.04590.x] [Citation(s) in RCA: 246] [Impact Index Per Article: 18.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The clinical classification of hepatic encephalopathy is largely subjective, which has led to difficulties in designing trials in this field. AIMS To review the current classification of hepatic encephalopathy and to develop consensus guidelines on the design and conduct of future clinical trials. METHODS A round table was convened at the 14th International Society for Hepatic Encephalopathy and Nitrogen Metabolism (ISHEN) meeting. Key discussion points were the nomenclature of hepatic encephalopathy and the selection of patients, standards of care and end-points for assessing the treatment and secondary prevention of hepatic encephalopathy. RESULTS It was generally agreed that severity assessment of hepatic encephalopathy in patients with cirrhosis, whether made clinically or more objectively, should be continuous rather than categorical, and a system for assessing the SONIC (Spectrum of Neuro-cognitive Impairment in Cirrhosis) was proposed. Within this system, patients currently classified as having minimal hepatic encephalopathy and Grade I hepatic encephalopathy would be classified as having Covert hepatic encephalopathy, whereas those with apparent clinical abnormalities would continue to be classified as overt hepatic encephalopathy. Some aspects of the terminology require further debate. Consensus was also reached on the patient populations, standards of care and endpoints to assess clinical trial outcomes. However, some compromises had to be made as there is considerable inter- and intravariability in the availability of some of the more objective surrogate performance markers. CONCLUSIONS The objectives of the round table were met. Robust, defendable guidelines for the conduct of future studies into hepatic encephalopathy have been provided. Outstanding issues are few and will continue to be discussed.
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Affiliation(s)
- J. S. Bajaj
- Virginia Commonwealth University and McGuire VA Medical Center, Richmond, VA, USA
| | - J. Cordoba
- Hospital Vall d'Hebron, Universitat Autònoma de Barcelona and CIBEREHD, Insituto de Salud Carlos III, Spain
| | - K. D. Mullen
- Case Western Reserve University, Cleveland, OH, USA
| | | | - D. L. Shawcross
- Institute of Liver Studies, King's College London School of Medicine, London, UK
| | | | - M. Y. Morgan
- Centre for Hepatology, Royal Free Campus, University College London Medical School, London, UK
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Krismer F, Roos JCP, Schranz M, Graziadei IW, Mechtcheriakov S, Vogel W, Carpenter RHS, Zoller H. Saccadic latency in hepatic encephalopathy: a pilot study. Metab Brain Dis 2010; 25:285-95. [PMID: 20852922 PMCID: PMC2972426 DOI: 10.1007/s11011-010-9210-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2010] [Accepted: 05/13/2010] [Indexed: 11/30/2022]
Abstract
Hepatic encephalopathy is a common complication of cirrhosis. The degree of neuro-psychiatric impairment is highly variable and its clinical staging subjective. We investigated whether eye movement response times-saccadic latencies-could serve as an indicator of encephalopathy. We studied the association between saccadic latency, liver function and paper- and pencil tests in 70 patients with cirrhosis and 31 patients after liver transplantation. The tests included the porto-systemic encephalopathy (PSE-) test, critical flicker frequency, MELD score and ammonia concentration. A normal range for saccades was established in 31 control subjects. Clinical and biochemical parameters of liver, blood, and kidney function were also determined. Median saccadic latencies were significantly longer in patients with liver cirrhosis when compared to patients after liver transplantation (244 ms vs. 278 ms p < 0.001). Both patient groups had prolonged saccadic latency when compared to an age matched control group (175 ms). The reciprocal of median saccadic latency (μ) correlated with PSE tests, MELD score and critical flicker frequency. A significant correlation between the saccadic latency parameter early slope (σ(E)) that represents the prevalence of early saccades and partial pressure of ammonia was also noted. Psychometric test performance, but not saccadic latency, correlated with blood urea and sodium concentrations. Saccadic latency represents an objective and quantitative parameter of hepatic encephalopathy. Unlike psychometric test performance, these ocular responses were unaffected by renal function and can be obtained clinically within a matter of minutes by non-trained personnel.
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Affiliation(s)
- Florian Krismer
- Department of Medicine II—Gastroenterology and Hepatology, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria
| | | | - Melanie Schranz
- Department of Medicine II—Gastroenterology and Hepatology, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria
| | - Ivo W. Graziadei
- Department of Medicine II—Gastroenterology and Hepatology, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria
| | | | - Wolfgang Vogel
- Department of Medicine II—Gastroenterology and Hepatology, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria
| | - R. H. S. Carpenter
- Department of Physiology, Development and Neuroscience, University of Cambridge, Cambridge, CB2 3EG UK
| | - Heinz Zoller
- Department of Medicine II—Gastroenterology and Hepatology, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria
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Amodio P, Ridola L, Schiff S, Montagnese S, Pasquale C, Nardelli S, Pentassuglio I, Trezza M, Marzano C, Flaiban C, Angeli P, Cona G, Bisiacchi P, Gatta A, Riggio O. Improving the inhibitory control task to detect minimal hepatic encephalopathy. Gastroenterology 2010; 139:510-8, 518.e1-2. [PMID: 20470775 DOI: 10.1053/j.gastro.2010.04.057] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2009] [Revised: 03/30/2010] [Accepted: 04/29/2010] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS Quantification of the number of noninhibited responses (lures) in the inhibitory control task (ICT) has been proposed for the diagnosis of minimal hepatic encephalopathy (MHE). We assessed the efficacy of ICT compared with recommended diagnostic standards. METHODS We studied patients with cirrhosis and healthy individuals (controls) who underwent the ICT at 2 centers (center A: n=51 patients and 41 controls, center B: n=24 patients and 14 controls). Subjects were evaluated for MHE by psychometric hepatic encephalopathy score (PHES). Patients from center B also were assessed for MHE by critical flicker frequency and spectral electroencephalogram analyses. RESULTS Patients with cirrhosis had higher ICT lures (23.2+/-12.8 vs 12.9+/-5.8, respectively, P<.01) and lower ICT target accuracy (0.88+/-0.17 vs 0.96+/-0.03, respectively, P<.01) compared with controls. However, lures were comparable (25.2+/-12.5 vs 21.4+/-13.9, respectively, P=.32) among patients with/without altered PHES (center A). There was a reverse, U-shaped relationship between ICT lure and target accuracy; a variable adjusting lures was devised based on target accuracy (weighted lures at center B). This variable differed between patients with and without MHE. The variable weighted lures was then validated from data collected at center A by receiver operator characteristic curve analysis; it discriminated between patients with and without PHES alterations (area under the curve=0.71+/-0.07). However, target accuracy alone was as effective as a stand-alone variable (area under the curve=0.81+/-0.06). CONCLUSIONS The ICT is not useful for the diagnosis of MHE, unless adjusted by target accuracy. Testing inhibition (lures) does not seem to be superior to testing attention (target accuracy) for the detection of MHE.
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Affiliation(s)
- Piero Amodio
- Department of Clinical and Experimental Medicine, University of Padua, Padua, Italy.
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Abstract
This article has arisen from presentations made at the 4th International Hannover Conference on Hepatic Encephalopathy held in Dresden, 2006. Each author as listed describes their presentation given as part of a section entitled "Therapeutic Studies in Hepatic Encephalopathy." The first section deals with the justification for placebo-controlled trials in hepatic encephalopathy. The other two sections discuss, in detail, outcome parameters for therapeutic studies in the clinical and research setting, respectively.
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Affiliation(s)
- Kevin D Mullen
- Department of Gastroenterology/Hepatology, MetroHealth Medical Center, Cleveland, OH, USA
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Spahr L, Coeytaux A, Giostra E, Hadengue A, Annoni JM. Histamine H1 blocker hydroxyzine improves sleep in patients with cirrhosis and minimal hepatic encephalopathy: a randomized controlled pilot trial. Am J Gastroenterol 2007; 102:744-53. [PMID: 17222324 DOI: 10.1111/j.1572-0241.2006.01028.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Sleep difficulty is common in minimal hepatic encephalopathy (HE) and the mechanisms are not fully elucidated. Dysregulated histamine neurotransmission is associated with an altered circadian rhythmicity that is partially restored following central histamine H1 receptor blockade in cirrhotic animals. We studied the effects of the histamine H1 blocker hydroxyzine in sleep alterations in patients with cirrhosis in a double-blind, randomized controlled fashion. METHODS A total of 35 patients (age 56 yr [36-69], Pugh's score 9 [7-12], portosystemic shunt: N = 7) with minimal HE and long-standing sleep difficulties (8 months [4-48]) and free from benzodiazepines were randomized to hydroxyzine 25 mg at bedtime (N = 17) or placebo (N = 18) for a 10-day period. Measurements of sleep behavior using visual analog scale and wrist actigraphy, neuropsychological tests, and protein s100beta serum levels were performed at baseline and at day 10. RESULTS Subjective improvement in sleep was observed in 40% of hydroxyzine-treated patients but in none receiving placebo (P < 0.04). Objectively, 65% of hydroxyzine-treated patients versus 25% of patients under placebo had a >or=30% increase in sleep efficiency as measured by wrist actigraphy (P < 0.04). Neuropsychological tests (Z scores) and protein s100beta levels remained statistically unchanged in both groups. One patient developed an acute episode of encephalopathy reversible upon cessation of hydroxyzine. CONCLUSIONS In contrast to placebo, hydroxyzine 25 mg at bedtime improved sleep behavior (subjectively and using wrist actigraphy) in patients with cirrhosis and minimal HE. The risk of precipitating overt HE warrants some caution when prescribing this drug.
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Affiliation(s)
- Laurent Spahr
- Gastroenterology and Hepatology, University Hospital, Geneva, Switzerland
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