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Ballester MP, Tranah TH, Balcar L, Fiorillo A, Ampuero J, Kerbert AJC, Thomsen KL, Escudero MD, Mandorfer M, Reiberger T, Shawcross DL, Romero-Gómez M, Montoliu C, Carbonell-Asins JA, Jalan R. Development and validation of the AMMON-OHE model to predict risk of overt hepatic encephalopathy occurrence in outpatients with cirrhosis. J Hepatol 2023; 79:967-976. [PMID: 37277075 DOI: 10.1016/j.jhep.2023.05.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 05/05/2023] [Accepted: 05/08/2023] [Indexed: 06/07/2023]
Abstract
BACKGROUND & AIMS Neuropsychological and psychophysical tests are recommended to assess the risk of overt hepatic encephalopathy (OHE), but their accuracy is limited. Hyperammonaemia is central in the pathogenesis of OHE, but its predictive utility is unknown. In this study, we aimed to determine the role of neuropsychological or psychophysical tests and ammonia, and to develop a model (AMMON-OHE) to stratify the risk of subsequent OHE development in outpatients with cirrhosis. METHODS This observational, prospective study included 426 outpatients without previous OHE from three liver units followed for a median of 2.5 years. Psychometric hepatic encephalopathy score (PHES) <-4 or critical flicker frequency (CFF) <39 was considered abnormal. Ammonia was normalized to upper limit of normal (AMM-ULN) at the respective reference laboratory. Multivariable frailty competing risk and random survival forest analyses were performed to predict future OHE and to develop the AMMON-OHE model. External validation was carried out using 267 and 381 patients from two independent units. RESULTS Significant differences were found in time-to-OHE (log-rank p <0.001) according to PHES or CFF and ammonia, with the highest risk in patients with abnormal PHES plus high AMM-ULN (hazard ratio 4.4; 95% CI 2.4-8.1; p <0.001 compared with normal PHES and AMM-ULN). On multivariable analysis, AMM-ULN but not PHES or CFF was an independent predictor of the development of OHE (hazard ratio 1.4; 95% CI 1.1-1.9; p = 0.015). The AMMON-OHE model (sex, diabetes, albumin, creatinine and AMM-ULN) showed a C-index of 0.844 and 0.728 for the prediction of a first episode of OHE in two external validation cohorts. CONCLUSIONS In this study, we developed and validated the AMMON-OHE model, comprising readily available clinical and biochemical variables that can be used to identify outpatients at the highest risk of developing a first episode of OHE. IMPACT AND IMPLICATIONS In this study, we aimed to develop a model to predict which patients with cirrhosis are at risk of developing overt hepatic encephalopathy (OHE). Using data from three units and including 426 outpatients with cirrhosis, we developed the AMMON-OHE model - comprising sex, diabetes, albumin, creatinine and ammonia levels - which demonstrated good predictive ability. The AMMON-OHE model performs better than PHES and CFF to predict the first episode of OHE in outpatients with cirrhosis. This model was validated in 267 and 381 patients from two independent liver units. The AMMON-OHE model is available online for clinical use.
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Affiliation(s)
- Maria Pilar Ballester
- Digestive Disease Department, Hospital Clínico Universitario de Valencia, Spain; INCLIVA Biomedical Research Institute, Valencia, Spain.
| | - Thomas H Tranah
- Institute of Liver Studies, Department of Inflammation Biology, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King´s College London, London, United Kingdom
| | - Lorenz Balcar
- Vienna Hepatic Hemodynamic Laboratory, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Austria
| | | | - Javier Ampuero
- Digestive Diseases Department, Ciberehd, Virgen del Rocío University Hospital, Instituto de Biomedicina de Sevilla (HUVR/CSIC/US), University of Seville, Sevilla, Spain
| | - Annarein J C Kerbert
- Liver Failure Group, Institute for Liver and Digestive Health, University College London, Royal Free Campus, London, United Kingdom
| | - Karen L Thomsen
- Liver Failure Group, Institute for Liver and Digestive Health, University College London, Royal Free Campus, London, United Kingdom; Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - María Desamparados Escudero
- Digestive Disease Department, Hospital Clínico Universitario de Valencia, Spain; Department of Medicine, Faculty of Medicine, University of Valencia, Spain
| | - Mattias Mandorfer
- Vienna Hepatic Hemodynamic Laboratory, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Austria
| | - Thomas Reiberger
- Vienna Hepatic Hemodynamic Laboratory, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Austria
| | - Debbie L Shawcross
- Institute of Liver Studies, Department of Inflammation Biology, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King´s College London, London, United Kingdom
| | - Manuel Romero-Gómez
- Digestive Diseases Department, Ciberehd, Virgen del Rocío University Hospital, Instituto de Biomedicina de Sevilla (HUVR/CSIC/US), University of Seville, Sevilla, Spain
| | - Carmina Montoliu
- INCLIVA Biomedical Research Institute, Valencia, Spain; Department of Pathology, Faculty of Medicine, University of Valencia, Spain
| | | | - Rajiv Jalan
- Liver Failure Group, Institute for Liver and Digestive Health, University College London, Royal Free Campus, London, United Kingdom; European Foundation for the Study of Chronic Liver Failure (EF Clif), Spain.
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Swansson WD, Anderson BM, Yeoh SW, Lewis DJ. Management of minimal and overt hepatic encephalopathy with branched-chain amino acids: a review of the evidence. Eur J Gastroenterol Hepatol 2023; 35:812-821. [PMID: 37395232 DOI: 10.1097/meg.0000000000002595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/04/2023]
Abstract
Hepatic encephalopathy (HE) is a challenging complication of liver disease that is associated with substantial morbidity and mortality. Branched-chain amino acid (BCAA) supplementation in the management of HE is a debated topic. This narrative review aims to provide an up-to-date review of the topic and includes studies featuring patients with hepatocellular carcinoma. A review of the literature was performed using the online databases MEDLINE and EMBASE for studies between 2002 and December 2022. Keywords 'branched-chain amino acids', 'liver cirrhosis' and 'hepatic encephalopathy' were used. Studies were assessed for inclusion and exclusion criteria. Of 1045 citations, 8 studies met the inclusion criteria. The main outcomes reported for HE was changed in minimal HE (MHE) (n = 4) and/or incidence of overt HE (OHE) (n = 7). Two of the 4 studies reporting on MHE had improvement in psychometric testing in the BCAA group, but there was no change in the incidence of OHE in any of the 7 papers in the BCAA group. There were few adverse effects of BCAA supplementation. This review found weak evidence for BCAA supplementation for MHE, and no evidence for BCAAs for OHE. However, given the relative paucity and methodological heterogeneity of the current research, there is scope for future studies to examine the effects of varying timing, dosage, and frequency of BCAAs on outcomes such as HE. Importantly, research is also needed to examine BCAAs in conjunction with standard therapies for HE such as rifaximin and/or lactulose.
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Affiliation(s)
| | | | - Sern Wei Yeoh
- Melbourne Medical School, The University of Melbourne
- Department of Gastroenterology, Northern Health, Melbourne, VIC, Australia
| | - Diana J Lewis
- Melbourne Medical School, The University of Melbourne
- Department of Gastroenterology, Northern Health, Melbourne, VIC, Australia
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Psychometric tests, critical flicker frequency, and inflammatory indicators in covert hepatic encephalopathy diagnosis. HEPATOLOGY FORUM 2023; 4:19-24. [PMID: 36843898 PMCID: PMC9951890 DOI: 10.14744/hf.2022.2022.0010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 08/09/2022] [Accepted: 08/29/2022] [Indexed: 01/19/2023]
Abstract
Background and Aim Hepatic encephalopathy (HE) is a frequent complication of liver diseases. Systemic inflammation is key for HE pathogenesis. The main goal of the study was to investigate the role of psychometric tests, critical flicker frequency (CFF), and comparative evaluation of inflammatory indicators for the diagnosis of covert HE (CHE). Materials and Methods The study was a prospective, nonrandomized, case-control study with a total of 76 cirrhotic patients and 30 healthy volunteers. The West Haven criteria were used to determine the occurrence of CHE in cirrhotic patients. Psychometric tests were applied to healthy and cirrhotic groups. CFF, venous ammonia, serum endotoxin, IL-6, IL-18, tumor necrosis factor alpha (TNF-α) levels, and hemogram parameters were evaluated for cirrhotic patients. Results CFF values and psychometric tests were found to accurately discriminate CHE positives from CHE negatives (p<0.05). When the control group was excluded, the digit symbol test and the number connection A test failed, unlike CFF and other psychometric tests. Using CFF, a 45 Hz cutoff value had 74% specificity and 75% sensitivity. Basal albumin levels (p=0.063), lymphocyte-to-monocyte ratio (LMR) (p=0.086), and neutrophil-to-lymphocyte ratio (p 0.052) were significant, albeit slightly, among CHE groups. Basal albumin levels had 50% sensitivity and 71% specificity when 2.8 g/dL was used as a cutoff value to determine CHE. Conclusion Both psychometric tests and CFF can be useful in diagnosing CHE. Using cytokine and endotoxin levels seems to be inadequate to diagnose CHE. Using LMR and albumin levels instead of psychometric tests for diagnosing CHE can be promising.
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Margaryan SR, Mitupov ZB, Razumovsky AY. [Hepatic encephalopathy after portosystemic bypass surgery]. Khirurgiia (Mosk) 2023:57-65. [PMID: 37379406 DOI: 10.17116/hirurgia202307157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/30/2023]
Abstract
The most effective modern treatment for gastrointestinal bleeding following portal hypertension is portosystemic bypass surgery. Hepatic encephalopathy after these procedures is still an urgent problem in modern pediatric surgery, and radical treatment is unknown. To optimize treatment outcomes in children with hepatic encephalopathy, we should choose adequate treatment considering the risk of hepatic encephalopathy in the future. In this review, the authors discuss modern data on hepatic encephalopathy regarding symptoms, advantages and disadvantages of various treatment methods. Risk of hepatic encephalopathy with and without surgical treatment, as well as methods of diagnosis and treatment are particularly analyzed. Total portosystemic bypass surgery, especially portocaval shunt, is followed by higher risk of hepatic encephalopathy compared to selective shunts and physiological mesoportal bypass. The last two approaches are advisable to improve treatment outcomes in children with hepatic encephalopathy.
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Affiliation(s)
- S R Margaryan
- Pirogov Russian National Research Medical University, Moscow, Russia
- N.F. Filatov Children's City Clinical Hospital, Moscow, Russia
| | - Z B Mitupov
- Pirogov Russian National Research Medical University, Moscow, Russia
- N.F. Filatov Children's City Clinical Hospital, Moscow, Russia
| | - A Yu Razumovsky
- Pirogov Russian National Research Medical University, Moscow, Russia
- N.F. Filatov Children's City Clinical Hospital, Moscow, Russia
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Towey J, Ngonadi C, Rajoriya N, Holt A, Greig C, Armstrong MJ. Protocol for a case-control prospective study to investigate the impact of Hepatic Encephalopathy on Nutritional Intake and Sarcopenia status in patients with end-stage LIVer disease: HENS-LIV study. BMJ Open Gastroenterol 2022; 9:bmjgast-2022-001052. [PMID: 36564096 PMCID: PMC9791380 DOI: 10.1136/bmjgast-2022-001052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Accepted: 12/13/2022] [Indexed: 12/24/2022] Open
Abstract
INTRODUCTION Hepatic encephalopathy (HE) is a debilitating symptom of end-stage liver disease (ESLD), but there remains a paucity of evidence regarding its impact on nutritional status, nutritional intake, compliance with nutritional support and resultant muscle health and function. Malnutrition and sarcopenia are associated with increased morbidity and mortality in patients with ESLD. The aim of the current case-control study is to prospectively investigate the impact of HE on nutritional intake and sarcopenia status in patients with ESLD. METHODS AND ANALYSIS Patients with ESLD, with HE (n=10) and without HE (n=10) will be recruited at the outpatient liver unit, University Hospital Birmingham, UK. All patients will undergo clinical assessment at baseline and again at 6-8 weeks (in-line with their routine clinical follow-up), to assess the impact of HE on reported nutritional intake, nutritional status and sarcopenia/physical functional status. Standard medical, dietetic and home-based exercise physiotherapy care will continue for all participants as determined by their clinical team. Two methods of assessing nutritional intake will include the 24-hour food recall and 3-day food diaries. Assessment of sarcopenia status will be undertaken using anthropometry (mid-arm muscle circumference (MAMC)) and ultrasound imaging of the quadriceps muscle group. Markers of physical function (hand grip strength; chair rise time), frailty (Liver Frailty Index (LFI)), physical activity (accelerometery) and exercise capacity (Duke Activity Status Index (DASI)) will be assessed at both clinic visits. ETHICS AND DISSEMINATION The study is approved by Wales Research Ethics Committee 2 and Health Research Authority (REC reference: 21/WA/0216). Recruitment into the study commenced November 2021. The findings will be disseminated through peer-reviewed publications and international presentations. TRIAL REGISTRATION NUMBER RRK7156.
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Affiliation(s)
- Jennifer Towey
- Department of Nutrition and Dietetics, Queen Elizabeth Hospital, Birmingham, UK,University of Birmingham, Birmingham, UK
| | | | - Neil Rajoriya
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Andrew Holt
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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Primary Norfloxacin Prophylaxis for APASL-Defined Acute-on-Chronic Liver Failure: A Placebo-Controlled Double-Blind Randomized Trial. Am J Gastroenterol 2022; 117:607-616. [PMID: 35041634 DOI: 10.14309/ajg.0000000000001611] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 12/14/2021] [Indexed: 12/11/2022]
Abstract
INTRODUCTION This study aimed to evaluate the role of prophylactic norfloxacin in preventing bacterial infections and its effect on transplant-free survival (TFS) in patients with acute-on-chronic liver failure (ACLF) identified by the Asian Pacific Association for the Study of the Liver criteria. METHODS Patients with ACLF included in the study were randomly assigned to receive oral norfloxacin 400 mg or matched placebo once daily for 30 days. The incidence of bacterial infections at days 30 and 90 was the primary outcome, whereas TFS at days 30 and 90 was the secondary outcome. RESULTS A total of 143 patients were included (72 in the norfloxacin and 71 in the placebo groups). Baseline demographics, biochemical variables, and severity scores were similar between the 2 groups. On Kaplan-Meier analysis, the incidence of bacterial infections at day 30 was 18.1% (95% confidence interval [CI], 10-28.9) and 33.8% (95% CI, 23-46) (P = 0.03); and the incidence of bacterial infections at day 90 was 46% (95% CI, 34-58) and 62% (95% CI, 49.67-73.23) in the norfloxacin and placebo groups, respectively (P = 0.02). On Kaplan-Meier analysis, TFS at day 30 was 77.8% (95% CI, 66.43-86.73) and 64.8% (95% CI, 52.54-75.75) in the norfloxacin and placebo groups, respectively (P = 0.084). Similarly, TFS at day 90 was 58.3% (95% CI, 46.11-69.84) and 43.7% (95% CI, 31.91-55.95), respectively (P = 0.058). Thirty percent of infections were caused by multidrug-resistant organisms. More patients developed concomitant candiduria in the norfloxacin group (25%) than in the placebo group (2.63%). DISCUSSION Primary norfloxacin prophylaxis effectively prevents bacterial infections in patients with ACLF.
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Cunha-Silva M, Neto FLP, de Araújo PS, Pazinato LV, Greca RD, Secundo TML, Imbrizi MR, Monici LT, Sevá-Pereira T, Mazo DF. EncephalApp Stroop Test validation for the screening of minimal hepatic encephalopathy in Brazil. Ann Hepatol 2022; 27:100543. [PMID: 34571266 DOI: 10.1016/j.aohep.2021.100543] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 04/24/2021] [Accepted: 05/04/2021] [Indexed: 02/07/2023]
Abstract
INTRODUCTION AND OBJECTIVES The EncephalApp Stroop Test was developed to more easily diagnose minimal hepatic encephalopathy (MHE). A cut-off of >274.9sec (ONtime+OFFtime) reached a 78% sensitivity and 90% specificity in the validation study, but it has been poorly studied in Brazil. We aim to analyze the usefulness of this diagnostic method and to describe a cut-off value to screen MHE in Brazil. METHODS In this cross-sectional and single-center study, three positive psychometric tests defined the diagnosis of MHE as the gold standard. We evaluated gender, age, education, familiarity with smartphones, etiology of cirrhosis, Child-Pugh/MELD scores, and previous hepatic encephalopathy (HE). Healthy controls and patients without HE were compared for the task validation. The Chi-square and Mann-Whitney tests, logistic regression analysis, and ROC curves were used for statistical evaluation. RESULTS We included 132 patients with cirrhosis (61% male) and 42 controls (62% male) around 51y. Sixty-three were diagnosed with MHE on psychometric tests and 23 had clinical HE. Viral hepatitis (38%) was the major etiology of cirrhosis. The median MELD was 10 and Child-Pugh A was more frequent (70%). There was no significant difference in test results between controls and patients without HE. There was also no influence of gender, age, education, and familiarity with smartphones in the test results. Child-Pugh A was associated with MHE (p=0.0106). A cut-off of >269.8sec (ONtime+OFFtime) had an 87% sensitivity and 77% specificity to detect MHE (p=0.002). CONCLUSION This is a valid and reliable tool for screening MHE. However, optimal cut-off values need to be validated locally.
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Affiliation(s)
- Marlone Cunha-Silva
- Division of Gastroenterology (Gastrocentro), University of Campinas (Unicamp), Campinas, Brazil.
| | - Fernando L Ponte Neto
- Division of Gastroenterology (Gastrocentro), University of Campinas (Unicamp), Campinas, Brazil
| | - Priscila S de Araújo
- Division of Gastroenterology (Gastrocentro), University of Campinas (Unicamp), Campinas, Brazil
| | - Lucas V Pazinato
- Division of Gastroenterology (Gastrocentro), University of Campinas (Unicamp), Campinas, Brazil
| | - Raquel D Greca
- Division of Gastroenterology (Gastrocentro), University of Campinas (Unicamp), Campinas, Brazil
| | - Tirzah M L Secundo
- Division of Gastroenterology (Gastrocentro), University of Campinas (Unicamp), Campinas, Brazil
| | - Marcello R Imbrizi
- Division of Gastroenterology (Gastrocentro), University of Campinas (Unicamp), Campinas, Brazil
| | - Leonardo T Monici
- Division of Gastroenterology (Gastrocentro), University of Campinas (Unicamp), Campinas, Brazil
| | - Tiago Sevá-Pereira
- Division of Gastroenterology (Gastrocentro), University of Campinas (Unicamp), Campinas, Brazil
| | - Daniel F Mazo
- Division of Gastroenterology (Gastrocentro), University of Campinas (Unicamp), Campinas, Brazil; Division of Clinical Gastroenterology and Hepatology, Department of Gastroenterology, University of São Paulo School of Medicine (FMUSP), Sao Paulo, Brazil
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Kirk FT, Munk DE, Laursen TL, Vilstrup H, Ott P, Grønbæk H, Lauridsen MM, Sandahl TD. Cognitive impairment in stable Wilson disease across phenotype. Metab Brain Dis 2021; 36:2173-2177. [PMID: 34342812 DOI: 10.1007/s11011-021-00804-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 07/22/2021] [Indexed: 10/20/2022]
Abstract
In Wilson disease (WD), mutations in the gene encoding the ATP7B copper transport protein causes accumulation of copper especially in liver and brain. WD typically presents with hepatic and/or neuropsychiatric symptoms. Impaired cognition is a well-described feature in patients with neurological WD, while the reports on cognition in hepatic WD patients are fewer and less conclusive. We examined cognition in a cohort of WD patients with both phenotypes. In this cross-sectional pilot study, we investigated cognition in 28 stable Danish WD patients by the PortoSystemic Encephalopathy (PSE) and the Continuous Reaction Time (CRT) tests. Half of the patients were female, and their median age was 35.5 years (IQR 24.5). Their phenotype was hepatic in 14 (50%), neurologic in 10 (36%) and mixed in 4 (14%). The duration of treatment was > 2 year in all patients, and their condition was stable as judged by urinary copper excretion, liver enzymes, and clinical assessment. The hepatic patients did not show signs of liver failure. In total, 16 (57%) patients performed worse than normal in the PSE and/or the CRT tests. The two tests were correlated (rho = 0.60, p = 0.0007), but neither correlated with phenotype, MELD-, Child-Pugh score, 24 h-U-Cu, or treatment type. Measurable cognitive impairment was present in more than half of the stable WD patients independent of phenotype. Thus, our data questions the existence of a purely hepatic phenotype.
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Affiliation(s)
- Frederik Teicher Kirk
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, 8200, Aarhus N, Denmark.
| | - Ditte Emilie Munk
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, 8200, Aarhus N, Denmark
| | - Tea Lund Laursen
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, 8200, Aarhus N, Denmark
| | - Hendrik Vilstrup
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, 8200, Aarhus N, Denmark
| | - Peter Ott
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, 8200, Aarhus N, Denmark
| | - Henning Grønbæk
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, 8200, Aarhus N, Denmark
| | - Mette Munk Lauridsen
- Department of Hepatology and Gastroenterology, University Hospital of South Denmark, Esbjerg, Denmark
| | - Thomas Damgaard Sandahl
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, 8200, Aarhus N, Denmark
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Ligtenstein S, Song J, Jin J, Sun H, Paixao L, Zafar S, Westover MB. Do Triphasic Waves and Nonconvulsive Status Epilepticus Arise From Similar Mechanisms? A Computational Model. J Clin Neurophysiol 2021; 38:366-375. [PMID: 34155185 PMCID: PMC8429048 DOI: 10.1097/wnp.0000000000000719] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
PURPOSE Triphasic waves arising in patients with toxic metabolic encephalopathy (TME) are often considered different from generalized periodic discharges (GPDs) in patients with generalized nonconvulsive status epilepticus (GNCSE). The primary objective of this study was to investigate whether a common mechanism can explain key aspects of both triphasic waves in TME and GPDs in GNCSE. METHOD A neural mass model was used for the simulation of EEG patterns in patients with acute hepatic encephalopathy, a common etiology of TME. Increased neuronal excitability and impaired synaptic transmission because of elevated ammonia levels in acute hepatic encephalopathy patients were used to explain how triphasic waves and GNCSE arise. The effect of gamma-aminobutyric acid-ergic drugs on epileptiform activity, simulated with a prolonged duration of the inhibitory postsynaptic potential, was also studied. RESULTS The simulations show that a model that includes increased neuronal excitability and impaired synaptic transmission can account for both the emergence of GPDs and GNCSE and their suppression by gamma-aminobutyric acid-ergic drugs. CONCLUSIONS The results of this study add to evidence from other studies calling into question the dichotomy between triphasic waves in TME and GPDs in GNCSE and support the hypothesis that all GPDs, including those arising in TME patients, occur via a common mechanism.
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Affiliation(s)
- Sophie Ligtenstein
- Department of Technical Medicine, Department of Applied Mathematics, University of Twente
| | | | - Jin Jin
- Department of Neurology, Massachusetts General Hospital, Boston MA
| | - Haoqi Sun
- Department of Neurology, Massachusetts General Hospital, Boston MA
| | - Luis Paixao
- Department of Neurology, Massachusetts General Hospital, Boston MA
| | - Sahar Zafar
- Department of Neurology, Massachusetts General Hospital, Boston MA
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Oyelade T, Canciani G, Carbone G, Alqahtani JS, Moore K, Mani AR. Heart rate variability in patients with cirrhosis: a systematic review and meta-analysis. Physiol Meas 2021; 42. [PMID: 33857926 DOI: 10.1088/1361-6579/abf888] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 04/15/2021] [Indexed: 12/22/2022]
Abstract
Background. Cirrhosis is associated with abnormal autonomic function and regulation of cardiac rhythm. Measurement of heart rate variability (HRV) provides an accurate and non-invasive measurement of autonomic function as well as liver disease severity currently calculated using the MELD, UKELD, or Child-Pugh scores. This review assesses the methods employed for the measurement of HRV, and evaluates the alteration of HRV indices in cirrhosis, as well as their value in prognosis.Method.We undertook a systematic review using Medline, Embase and Pubmed databases in July 2020. Data were extracted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The risk of bias of the included studies was assessed by a modified version of the Newcastle-Ottawa Scale. The descriptive studies were analysed and the standardized mean differences of HRV indices were pooled.Results.Of the 247 studies generated from our search, 14 studies were included. One of the 14 studies was excluded from meta-analysis because it reported only the median of HRV indices. The studies included have a low risk of bias and include 583 patients with cirrhosis and 349 healthy controls. The HRV time and frequency domains were significantly lower in cirrhotic patients. Between-studies heterogeneity was high in most of the pooled studies (P < 0.05). Further, HRV indices predict survival independent of the severity of liver disease as assessed by MELD.Conclusion.HRV is decreased in patients with cirrhosis compared with healthy matched controls. HRV correlated with severity of liver disease and independently predicted survival. There was considerable variation in the methods used for HRV analysis, and this impedes interpretation and clinical applicability. Based on the data analysed, the standard deviation of inter-beat intervals (SDNN) and SDNN corrected for basal heart rate (cSDNN) are the most suitable indices for prognosis in patients with cirrhosis.
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Affiliation(s)
- Tope Oyelade
- Institute for Liver and Digestive Health, Division of Medicine, University College London, London NW3 2PF, United Kingdom
| | | | | | - Jaber S Alqahtani
- Respiratory Medicine, Division of Medicine, University College London, London NW3 2PF, United Kingdom.,Department of Respiratory Care, Prince Sultan Military College of Health Sciences, Dammam, Saudi Arabia
| | - Kevin Moore
- Institute for Liver and Digestive Health, Division of Medicine, University College London, London NW3 2PF, United Kingdom
| | - Ali R Mani
- Institute for Liver and Digestive Health, Division of Medicine, University College London, London NW3 2PF, United Kingdom
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Glal KAM, Abd-Elsalam SM, Mostafa TM. Nitazoxanide versus rifaximin in preventing the recurrence of hepatic encephalopathy: A randomized double-blind controlled trial. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2021; 28:812-824. [PMID: 33768619 DOI: 10.1002/jhbp.947] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Revised: 02/25/2021] [Accepted: 03/04/2021] [Indexed: 12/26/2022]
Abstract
BACKGROUND/PURPOSE Hepatic encephalopathy (HE) is a neuropsychiatric complication of liver cirrhosis. HE is associated with poor survival and detrimental effects on quality of life (QOL). The drawbacks of the long-term use of rifaximin in HE necessitates searching for alternative therapies. In this context, our study aimed at evaluating the safety and efficacy of nitazoxanide (NTZ) as compared to rifaximin (RFX) in preventing the recurrence of HE and assessing its impact on QOL. PATIENTS AND METHODS This prospective, randomized, double-blind controlled study included 60 patients who were randomly assigned to receive either rifaximin 550 mg twice daily (group 1; n = 30) or nitazoxanide 500 mg twice daily (group 2; n = 30) for 24 weeks. During the study period, the patients' neurological symptoms, mental status, and performance were monitored. The serum levels of HE triggers (ammonia, TNF-α, and octopamine) were assessed. The patients' health-related quality of life was also evaluated. RESULTS Six months after treatment, patients on NTZ therapy showed a statistically significant improvement in CHESS score and mental status. NTZ provided 136 days of remission vs 67 days of remission for patients on RFX (P1 = .0001) and significant reduction in Child score (P1 = .018). Additionally, NTZ showed a statistically significant decrease in serum ammonia, TNF-α, and octopamine levels as compared to rifaximin. Regarding QOL, NTZ group showed an improvement in total Chronic Liver Disease Questionnaire (CLDQ) score. Both groups experienced minor controllable side effects. CONCLUSION Nitazoxanide may represent a suitable and safe alternative therapy to rifaximin in preventing the recurrence of hepatic encephalopathy.
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Affiliation(s)
- Khadija A M Glal
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tanta University, Tanta, Egypt
| | - Sherief M Abd-Elsalam
- Department of Tropical Medicine and Infectious Diseases, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Tarek M Mostafa
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tanta University, Tanta, Egypt
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12
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Abstract
PURPOSE OF REVIEW This article describes the neurologic sequelae of various nutritional micronutrient deficiencies, celiac disease, inflammatory bowel disease, and liver disease. Where relevant, appropriate treatments for these conditions are also discussed. The developing field of the microbiome and nervous system interaction is also outlined. RECENT FINDINGS Pathology in the gastrointestinal system can affect the nervous system when it causes micronutrient deficiency, when immune responses created by the gastrointestinal system affect the nervous system, when toxins caused by gastrointestinal organ failure harm the nervous system, and when treatments aimed at a gastrointestinal medical condition cause damage to the nervous system as a side effect. SUMMARY This article addresses familiar concepts and new developments in the treatment and understanding of diseases that affect the gut and nervous system simultaneously.
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Santana Vargas ÁD, Higuera-De la Tijera F, Perez Hernandez JL. Auditory and visual P300 event-related potentials to detect minimal hepatic encephalopathy. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2021; 114:83-88. [PMID: 33562990 DOI: 10.17235/reed.2021.7709/2020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Diagnosis of Minimal hepatic encephalopathy (MHE) requires psychometric tests, although new methods are needed since sensitivity, specificity, and accuracy are low. The P300 event-related potential (ERP) is obtained by auditory and visual stimuli, although only the auditory P300 has been used to detect MHE. We aimed to compare the diagnostic features of auditory and visual P300 to detect MHE. MATERIALS AND METHODS Sixty patients with liver cirrhosis and thirty-five healthy controls completed the Psychometric Hepatic Encephalopathy Score (PHES), the critical flicker frequency (CFF), auditory, and visual P300. MHE was diagnosed if PHES and CFF scores were abnormal. RESULTS Fifty-three cirrhotic patients (age 54.5±8.6 years) completed all tests. Abnormal scores were: PHES (49.1%), CFF (67.9%). The proportion of MHE was 21.4%. The area under the receiver operating ROC curves (AUROC) for auditory P300 was better than visual P300 for distinguishing MHE from controls (AUROC 0.792 vs 0.725; p<0.005 for both; accuracy 73.8%vs 70.2%; sensitivity 72.2% both; specificity 74.2 vs 69.7, respectively. Among cirrhotic patients, only auditory P300 was useful to detect MHE, AUROC 0.723 p<0.05; 77.4% accuracy; 61.1% sensitivity; and 81.8% specificity. CONCLUSIONS The auditory P300 sensitivity, specificity, and accuracy were similar to those of CFF. Our results showed that only auditory P300 is useful to differentiate patients with MHE. Although both modalities, auditory and visual, differentiated patients with cirrhosis from controls, we consider the visual P300 is not suitable for detecting MHE.
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Machado JÚnior PAB, Ziliotto RD, Ferreira APVN, Buson TM, Couto CMD, Pissaia Junior A. USE OF THE STROOP ENCEPHALAPP FOR COVERT HEPATIC ENCEPHALOPATHY SCREENING IN CIRRHOTIC PATIENTS IN SOUTHERN BRAZIL. ARQUIVOS DE GASTROENTEROLOGIA 2020; 57:399-403. [PMID: 33237215 DOI: 10.1590/s0004-2803.202000000-73] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 07/29/2020] [Indexed: 01/22/2023]
Abstract
BACKGROUND Covert hepatic encephalopathy (CHE) is difficult to detect due to the lack of easily applicable screening tools. The Stroop EncephalApp is a smartphone application already validated for CHE screening. However, its applicability to the Brazilian population is not known. OBJECTIVE To estimate the prevalence of CHE and evaluate the use of Stroop EncephalApp in a cirrhotic population in Brazil. METHODS In this cross-sectional study, we evaluated 99 patients previously diagnosed with liver cirrhosis in a Private Hospital in Curitiba/PR. Patients were initially submitted to the mini mental state examination (MMSE) to exclude individuals with dementia. After, the Psychometric Hepatic Encephalopathy Score (PHES) test was performed and lastly, the Stroop EncephalApp test. Results were adjusted for age, sex and education levels to evaluate the accuracy of the app on detecting the disease, comparing its results with the gold standard method (PHES). Patients with one or more of the following were excluded: dementia, inadequate MMSE score, illiteracy, color blindness, history of drugs/alcohol abuse within the past 3 months and previous or actual episodes of encephalopathy. The statistical analysis was performed by SPSS 2.0 and the significance adopted by 5%. RESULTS We included 82 individuals in the final analysis. Among these patients, 29 were diagnosed with CHE by the PHES test (35.36% prevalence) and 28 of those obtained equal diagnosis by the Stroop EncephalApp (96.6% sensitivity). A total of 53 patients obtained negative results for CHE by PHES, while the Stroop test classified 27 of them as having the disease. In the multivariate analysis, high levels of education were associated with better performance during the tests. No significant relationship was observed between age and sex with the probability of diagnosing CHE through the PHES test.
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Affiliation(s)
| | - Rafaela Deneka Ziliotto
- Pontifícia Universidade Católica do Paraná (PUCPR), Escola de Medicina, Curitiba, PR, Brasil
| | | | - Thiago Mesquita Buson
- Pontifícia Universidade Católica do Paraná (PUCPR), Escola de Medicina, Curitiba, PR, Brasil
| | | | - Alcindo Pissaia Junior
- Pontifícia Universidade Católica do Paraná (PUCPR), Escola de Medicina, Curitiba, PR, Brasil.,Hospital Nossa Senhora das Graças (HNSG), Serviço de Hepatologia, Curitiba, PR, Brasil
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15
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Reinert JP, Burnham K. Non-Lactulose Medication Therapies for the Management of Hepatic Encephalopathy: A Literature Review. J Pharm Pract 2020; 34:922-933. [PMID: 32878558 DOI: 10.1177/0897190020953024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The most appropriate medication regimen to mitigate the consequences hepatic encephalopathy remains inconclusive. This review seeks to serve as a reference for clinicians to help guide therapy decisions with regard to hepatic encephalopathy. METHODS A comprehensive literature review between August 2018 and April 2019 was accomplished with the assistance of a medical librarian. Sources of literature review include PubMed, MEDLINE, SCOPUS, ProQuest Central, CINAHL, and ProQuest Dissertations. The authors selected randomized clinical and double-blind cross-over trials evaluating probiotics, zinc, polyethylene glycol, rifaximin, and flumazenil. Sixteen clinical trials are discussed in this review. Pertinent safety, efficacy, and statistical and clinical outcomes are summarized by the authors. CONCLUSIONS The most appropriate regimen to mitigate the consequences of hepatic encephalopathy remains elusive; however, the agents discussed within this review offer alternative options for patients unresponsive to or intolerant of traditional lactulose therapy. This review seeks to serve as a repository for relevant clinical trials, and as a reference for clinicians to help guide therapy decisions.
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Affiliation(s)
- Justin P Reinert
- Ben and Maytee Fisch College of Pharmacy, 12347The University of Texas at Tyler, TX, USA
| | - Kevin Burnham
- Ben and Maytee Fisch College of Pharmacy, 12347The University of Texas at Tyler, TX, USA
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16
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Abstract
Minimal hepatic encephalopathy, previously called subclinical hepatic encephalopathy, represents the earliest and mildest form of hepatic encephalopathy. It is the most under-recognized and underdiagnosed form of hepatic encephalopathy. Although there is no diagnostic gold standard, validated testing modalities have been devised to detect this neurocognitive complication. The newest developments include medically related apps for smartphones or tablets that can be easily used to diagnose and monitor minimal hepatic encephalopathy. Although recognition of this neurocognitive impairment can be challenging, early detection is paramount with the discovery of an association with worse clinical outcomes in patients diagnosed with minimal hepatic encephalopathy.
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Affiliation(s)
- Briette Verken Karanfilian
- Department of Internal Medicine, Rutgers- Robert Wood Johnson Medical School, 125 Paterson Street, CAB 7302, New Brunswick, NJ 08901, USA
| | - Taeyang Park
- Department of Internal Medicine, Rutgers- Robert Wood Johnson Medical School, 125 Paterson Street, CAB 7302, New Brunswick, NJ 08901, USA.
| | - Frank Senatore
- Department of Gastroenterology and Hepatology, Rutgers- Robert Wood Johnson Medical School, 125 Paterson Street, CAB 7302, New Brunswick, NJ 08901, USA
| | - Vinod K Rustgi
- Center for Liver Diseases and Masses, Robert Wood Johnson Medical School, Clinical Academic Building (CAB), 125 Paterson Street, Suite 5100B, New Brunswick, NJ 08901, USA
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Ammonia Levels Do Not Guide Clinical Management of Patients With Hepatic Encephalopathy Caused by Cirrhosis. Am J Gastroenterol 2020; 115:723-728. [PMID: 31658104 DOI: 10.14309/ajg.0000000000000343] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Ammonia appears to play a major role in the pathophysiology of hepatic encephalopathy (HE), but its role in guiding management is unclear. We aimed to understand the impact of ammonia levels on inpatient HE management, hypothesizing that patients with elevated ammonia levels would receive more aggressive lactulose therapy than patients with normal ammonia or no ammonia level drawn. METHODS We examined patients with cirrhosis older than 18 years admitted for management of HE from 2005 to 2015. We additionally used propensity matching to control for confounding by the severity of underlying disease. Patients with an ammonia level taken at time of HE diagnosis were further separated into those with normal or elevated ammonia levels. The primary endpoint was the total lactulose (mL) amount (or dose) given in the first 48 hours of HE management. RESULTS One thousand two hundred two admissions with HE were identified. Ammonia levels were drawn in 551 (46%) patients; 328 patients (60%) had an abnormal ammonia level (>72 μmol/L). There were no significant differences in the Child-Pugh score, MELD, or Charlson Comorbidity Index in those with and without ammonia levels drawn. The average total lactulose dose over 48 hours was 167 and 171 mL in the no ammonia vs ammonia groups, respectively (P = 0.42). The average lactulose dose in patients with an elevated ammonia level was 161 mL, identical to the lactulose dose in patients with a normal ammonia level. There was no correlation between lactulose dose and ammonia level (R = 0.0026). DISCUSSION Inpatient management of HE with lactulose was not influenced by either the presence or level of ammonia level, suggesting that ammonia levels do not guide therapy in clinical practice.
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18
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Rosenblatt R, Yeh J, Gaglio PJ. Long-Term Management: Modern Measures to Prevent Readmission in Patients with Hepatic Encephalopathy. Clin Liver Dis 2020; 24:277-290. [PMID: 32245533 DOI: 10.1016/j.cld.2020.01.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Hepatic encephalopathy (HE) is a frequent indication for hospitalization and represents a common manifestation of portal hypertension and decompensated liver disease that contributes to hospital readmissions. Multiple new techniques are being evaluated to assist in preventing readmissions in these high-risk patients. Techniques to improve medication adherence are paramount. The use of telemedicine and on-demand patient assessment is likely to diminish hospitalizations for HE. Wearable technology has the potential to assist in HE diagnosis and prevent HE progression, with an anticipated diminution in hospital readmissions. This article discusses current and potential future techniques to improve outcomes in these vulnerable patients.
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Affiliation(s)
- Russell Rosenblatt
- Department of Medicine, Center for Liver Disease and Transplantation, NY-Presbyterian Hospital, Columbia University Medical Center, Columbia University College of Physicians and Surgeons, PH-14 622 West 168th Street, New York, NY 10032, USA
| | - Johnathan Yeh
- Department of Medicine, Center for Liver Disease and Transplantation, NY-Presbyterian Hospital, Columbia University Medical Center, Columbia University College of Physicians and Surgeons, PH-14 622 West 168th Street, New York, NY 10032, USA
| | - Paul J Gaglio
- Department of Medicine, Center for Liver Disease and Transplantation, NY-Presbyterian Hospital, Columbia University Medical Center, Columbia University College of Physicians and Surgeons, PH-14 622 West 168th Street, New York, NY 10032, USA.
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19
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Abstract
Hepatic encephalopathy (HE) occurs in patients with acute-on-chronic liver disease. It has a wide progression of symptoms, with its initial presentation being subtle. The symptoms of HE mainly affect mental status, the musculoskeletal system, and mood/behavior. Its severity ranges from minor disturbances in sleep-wake cycle to the patient being comatose. HE is categorized based on 4 main features: the underlying disease, the severity of manifestations, the time course, and whether precipitating factors are present. The severity of the manifestations is classically identified using the West Haven Criteria. There are several other clinical tests, but they require further validation.
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20
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Coronel-Castillo C, Contreras-Carmona J, Frati-Munari A, Uribe M, Méndez-Sánchez N. Efficacy of rifaximin in the different clinical scenarios of hepatic encephalopathy. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2020. [DOI: 10.1016/j.rgmxen.2019.09.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Coronel-Castillo CE, Contreras-Carmona J, Frati-Munari AC, Uribe M, Méndez-Sánchez N. Efficacy of rifaximin in the different clinical scenarios of hepatic encephalopathy. REVISTA DE GASTROENTEROLOGIA DE MEXICO (ENGLISH) 2020; 85:56-68. [PMID: 31836274 DOI: 10.1016/j.rgmx.2019.09.001] [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: 06/24/2019] [Revised: 08/21/2019] [Accepted: 09/04/2019] [Indexed: 06/10/2023]
Abstract
Hepatic encephalopathy is a frequent complication in patients with cirrhosis of the liver and is associated with a high mortality rate. Costs attributed to the management of patients with cirrhosis are especially high due to complications, such as hepatic encephalopathy, given that they increase the number of days of hospital stay. Different drugs are currently used to treat hepatic encephalopathy, and the main ones are lactulose, L-ornithine L-aspartate (LOLA), and certain antibiotics, especially rifaximin-α (RFX). Even though many of them have been shown to be effective to greater or lesser degrees, it is important to understand the differences between them, so that every patient receives individualized treatment and the best option is chosen, in accordance with the different clinical scenarios. Thus, the aim of the present study was to analyze the evidence on the advantages and disadvantages of the individual or combined use of the 3 main treatments for hepatic encephalopathy, specifically taking into consideration their different degrees of efficacy, their impact on quality of life, prophylaxis, and cost reduction.
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Affiliation(s)
- C E Coronel-Castillo
- Unidad de Investigación en Hígado, Fundación Clínica Médica Sur, Ciudad de México, México
| | - J Contreras-Carmona
- Unidad de Investigación en Hígado, Fundación Clínica Médica Sur, Ciudad de México, México
| | - A C Frati-Munari
- Departamento de Medicina Interna, Fundación Clínica Médica Sur, Ciudad de México, México
| | - M Uribe
- Unidad de Investigación en Hígado, Fundación Clínica Médica Sur, Ciudad de México, México
| | - N Méndez-Sánchez
- Unidad de Investigación en Hígado, Fundación Clínica Médica Sur, Ciudad de México, México; Facultad de Medicina, Universidad Nacional Autónoma de México, Ciudad de México, México.
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22
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Wernberg CW, Schaffalitzky de Muckadell OB, Vilstrup H, M. Lauridsen M. Prediction of overt hepatic encephalopathy by the continuous reaction time method and the portosystemic encephalopathy syndrome test in clinically mentally unimpaired patients with cirrhosis. PLoS One 2019; 14:e0226283. [PMID: 31830113 PMCID: PMC6907801 DOI: 10.1371/journal.pone.0226283] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Accepted: 11/22/2019] [Indexed: 12/24/2022] Open
Abstract
Background and aim Predicting overt hepatic encephalopathy (OHE) is important because the condition is frequent, often requires hospitalization and is potentially preventable. The risk of OHE is related to pre-existing discrete cognitive defects, and for clinical practice it is recommended to apply two different psychometric tests to detect such deficits. We used the continuous reaction time test (CRT) and the portosystemic encephalopathy (PSE) syndrome test and examined their single and combined value for OHE prediction in cirrhosis patients. Patients and methods We studied 130 clinically mentally unimpaired cirrhosis patients by the two tests and followed them for an average of 38.5 months. The CRT measures velocity and stability of motor reaction times to 150 repeated auditory signals. The PSE is a five sub-set paper-and-pencil test battery evaluating cognitive and psychomotor processing, speed and vision-motor coordination. We collected data on episodes of OHE during follow-up. The clinical course was analysed in patient groups according to the outcome of each test and of both tests together. No anti-HE treatment was initiated except for cases with OHE. Results At baseline, the CRT test was abnormal in 74 patients and the PSE in 47. During follow-up 35 patients (27%) experienced 74 OHE events. 23 patients with abnormal CRT experienced OHE (prediction sensitivity 65%). The PSE predicted OHE in 14 patients (prediction sensitivity 40%). One or both tests were abnormal in 87/130 (67%) and this predicted OHE in 27 patients (21%) (prediction sensitivity 77%). Conclusion The CRT test was clinically useful in identifying two-thirds of clinically mentally unimpaired cirrhosis patients who later experienced OHE, and the use of both the CRT and PSE showed satisfactory prediction by identifying three-fourths of later OHE cases.
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Affiliation(s)
- Charlotte W. Wernberg
- Department of Gastroenterology, Hospital of Southwest Jutland, Esbjerg, Region of Southwest of Denmark, Denmark
- * E-mail:
| | | | - Hendrik Vilstrup
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Central Denmark Region, Denmark
| | - Mette M. Lauridsen
- Department of Gastroenterology, Hospital of Southwest Jutland, Esbjerg, Region of Southwest of Denmark, Denmark
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Vidot H, Cvejic E, Finegan LJ, Shores EA, Bowen DG, Strasser SI, McCaughan GW, Carey S, Allman-Farinelli M, Shackel NA. Supplementation with Synbiotics and/or Branched Chain Amino Acids in Hepatic Encephalopathy: A Pilot Randomised Placebo-Controlled Clinical Study. Nutrients 2019; 11:E1810. [PMID: 31390762 PMCID: PMC6723588 DOI: 10.3390/nu11081810] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 07/29/2019] [Accepted: 07/30/2019] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION Hepatic encephalopathy (HE) is common in patients with cirrhosis and is characterised by reduced hepatic ammonia clearance. This is accompanied by alterations in gut bacteria that may be ameliorated with synbiotics (pro- and prebiotics). Branched chain amino acids (BCAAs) are thought to have a role in the detoxification of ammonia. We investigated the effects of the administration of synbiotics and/or BCAAs in treating HE. METHODS Participants with overt HE were randomised in a blinded placebo-controlled study to receive synbiotics, BCAAs, or a combination of BCAAs and Synbiotics. Relevant biochemical and nutritional data and depression and anxiety scores (DASS-21) were collected at entry, 4 weeks, and on completion, at 8 weeks. The Trail Making Test (TMT) and Inhibitory Control Test (ICT) were used to assess cognitive function in patients withHE. Results were analysed using linear mixed effects regression analyses. RESULTS Sixty-one participants were enrolled and 49 who returned for at least 1 follow-up review were included in the intention to treat analysis. The mean age was 55.8 ± 6.1 years and 86% were males. Despite evidence of a placebo effect, there was significant improvement in TMT B and ICT weighted lures in participants who received combined synbiotics/BCAAs treatment compared to placebo at study completion (p ≤ 0.05). Cognitive improvement occurred without a significant change in ammonia levels. CONCLUSION To our knowledge, this is the first study reporting that combined synbiotics and BCAAs improve HE, and that may be beneficial in the management of HE. A larger study is needed to confirm these results.
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Affiliation(s)
- Helen Vidot
- Department of Nutrition and Dietetics, Royal Prince Alfred Hospital, Camperdown, NSW 2050, Australia.
- Liver Injury and Cancer Centre, Centenary Research Institute, The University of Sydney, Sydney, NSW 2006, Australia.
| | - Erin Cvejic
- School of Public Health, The University of Sydney, Sydney, NSW 2006, Australia
| | - Liam J Finegan
- School of Business, The University of Sydney, Sydney, NSW 2006, Australia
| | - E Arthur Shores
- Department of Psychology, Macquarie University, Sydney, NSW 2109, Australia
| | - David G Bowen
- Liver Injury and Cancer Centre, Centenary Research Institute, The University of Sydney, Sydney, NSW 2006, Australia
- Sydney Medical School, The University of Sydney, Sydney, NSW 2006 Australia
- A.W. Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Camperdown, NSW 2050, Australia
| | - Simone I Strasser
- Sydney Medical School, The University of Sydney, Sydney, NSW 2006 Australia
- A.W. Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Camperdown, NSW 2050, Australia
| | - Geoffrey W McCaughan
- Liver Injury and Cancer Centre, Centenary Research Institute, The University of Sydney, Sydney, NSW 2006, Australia
- Sydney Medical School, The University of Sydney, Sydney, NSW 2006 Australia
- A.W. Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Camperdown, NSW 2050, Australia
| | - Sharon Carey
- Department of Nutrition and Dietetics, Royal Prince Alfred Hospital, Camperdown, NSW 2050, Australia
| | - Margaret Allman-Farinelli
- School of Life and Environmental Sciences Charles Perkins Centre, The University of Sydney, Sydney, NSW 2006, Australia
| | - Nicholas A Shackel
- Department of Medicine, University of New South Wales, Sydney, NSW 2052, Australia
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Rathi S, Chopra M, Chouduri G, Sharma P, Madan K, Chhabra M, Rai RR, Govil A, Konar A, Goenka M, Agarwal M, Mukherjee J, Thorat V, Salunkhe S, Abraham P, Nagral A, Jhaveri A, Bhat N, Varghese J, R.S. A, Ravishankar, Reddy DC, Dhiman RK. Prevalence of Minimal Hepatic Encephalopathy in Patients With Liver Cirrhosis: A Cross-Sectional, Clinicoepidemiological, Multicenter, Nationwide Study in India: The PREDICT Study. J Clin Exp Hepatol 2019; 9:476-483. [PMID: 31516264 PMCID: PMC6728606 DOI: 10.1016/j.jceh.2018.09.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Accepted: 09/19/2018] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The study aimed at assessing the prevalence and clinical profile of minimal hepatic encephalopathy (MHE) in patients with cirrhosis using neuropsychological assessment and at understanding the management practices of MHE in the Indian clinical setting. METHODS This cross-sectional, clinicoepidemiological study conducted at 20 sites enrolled liver cirrhosis patients with Grade 0 hepatic encephalopathy according to West-Haven Criteria. Patients were subjected to mini-mental state examination and those with a score of ≥24 were assessed using psychometric hepatic encephalopathy score. Short Form-36 questionnaire was administered to assess the impact on health-related quality of life. RESULTS Of the 1260 enrolled patients, 1114 were included in the analysis. The mean age was 49.5 years and majority were males (901 [81%]). The prevalence of MHE was found to be 59.7% (665/1114) based on the psychometric hepatic encephalopathy score of ≤-5. Alcohol-related liver disease was the most common etiology (482 [43.27%]) followed by viral infection (239 [21.45%]). Past smokers as well as those currently smoking were more likely to have MHE than nonsmokers. A significant association was found between tobacco chewing, smoking, alcohol consumption, diabetes, and the presence of MHE. Multivariable analysis revealed smoking as the only parameter associated with MHE. A total of 300 (26.9%) patients were on prophylaxis with lactulose/lactitol or rifaximin. These patients were less likely to have MHE as compared to those not on prophylaxis (odds ratio, 0.67; 95% confidence interval, 0.50-0.88; P = 0.005). CONCLUSION The disease burden of MHE is quite substantial in patients with cirrhosis with no apparent cognitive defect. Smoking, whether past or current, has significant association with the presence of MHE. Although MHE has been shown to adversely affect quality of life, prophylaxis for MHE is not routinely practiced in the Indian setting.The study has been registered under clinical trials registry of India (CTRI/2014/01/004306).
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Key Words
- ALD, alcohol-related liver disease
- CI, confidence interval
- DST, Digit Symbol Test
- FCT, figure connection test
- HE, hepatic encephalopathy
- HRQL, health-related quality of life
- MCS, mental component summary
- MELD, model for end-stage liver disease
- MHE, minimal hepatic encephalopathy
- MMSE, mini-mental state examination
- NCT, number connection test
- PCS, physical component summary
- PHES
- PHES, psychometric hepatic encephalopathy score
- SF-36, Short Form-36
- cirrhosis
- covert hepatic encephalopathy
- hepatic encephalopathy
- lactulose
- minimal hepatic encephalopathy
- quality of life
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Affiliation(s)
- Sahaj Rathi
- Postgraduate Institute of Medical Research, Chandigarh, India
| | - Madhu Chopra
- Postgraduate Institute of Medical Research, Chandigarh, India
| | | | | | - Kaushal Madan
- Institute of Digestive and Hepatobiliary Sciences, Medanta – The Medicity, Gurgoan, India
| | | | | | - Anurag Govil
- Santokba Durlabhji Memorial Hospital, Jaipur, India
| | | | | | | | | | | | | | - Philip Abraham
- PD Hinduja Hospital and Medical Research Centre, Mumbai, India
| | | | | | - Naresh Bhat
- Columbia Asia Referral Hospital, Bangalore, India
| | | | - Arun R.S.
- Madras Medical Mission, Chennai, India
| | | | | | - Radha K. Dhiman
- Postgraduate Institute of Medical Research, Chandigarh, India,Address for correspondence: Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India.
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Rodrigues-Filho EM, Fernandes R, Garcez A. SOFA in the first 24 hours as an outcome predictor of acute liver failure. Rev Bras Ter Intensiva 2018; 30:64-70. [PMID: 29742228 PMCID: PMC5885233 DOI: 10.5935/0103-507x.20180012] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Accepted: 12/14/2017] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVE To describe a cohort of patients with acute liver failure and to analyze the demographic and clinical factors associated with mortality. METHODS Retrospective cohort study in which all patients admitted for acute liver failure from July 28, 2012, to August 31, 2017, were included. Clinical and demographic data were collected using the Epimed System. The SAPS 3, SOFA, and MELD scores were measured. The odds ratios and 95% confidence intervals were estimated. Receiver operating characteristics curves were obtained for the prognostic scores, along with the Kaplan-Meier survival curve for the score best predicting mortality. RESULTS The majority of the 40 patients were female (77.5%), and the most frequent etiology was hepatitis B (n = 13). Only 35% of the patients underwent liver transplantation. The in-hospital mortality rate was 57.5% (95%CI: 41.5 - 73.5). Among the scores investigated, only SOFA remained associated with risk of death (OR = 1.37; 95%CI 1.11 - 1.69; p < 0.001). After SOFA stratification into < 12 and ≥ 12 points, survival was higher in patients with SOFA <12 (log-rank p < 0.001). CONCLUSION SOFA score in the first 24 hours was the best predictor of fatal outcome.
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Affiliation(s)
- Edison Moraes Rodrigues-Filho
- Unidade de Terapia Intensiva de Transplantes, Hospital Dom Vicente Scherer, Irmandade Santa Casa de Misericórdia de Porto Alegre, Porto Alegre, RS, Brazil
| | - Rogério Fernandes
- Grupo de Transplante Hepático, Hospital Dom Vicente Scherer, Irmandade Santa Casa de Misericórdia de Porto Alegre, Porto Alegre, RS, Brazil
| | - Anderson Garcez
- Programa de Pós-Graduação em Saúde Coletiva, Universidade do Vale do Rio dos Sinos, São Leopoldo, RS, Brazil
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Nguyen HH, Swain MG, Wong P, Congly SE. Canadian regulations and legal ramifications for hepatic encephalopathy: a descriptive analysis. CMAJ Open 2018; 6:E575-E579. [PMID: 30510040 PMCID: PMC6277253 DOI: 10.9778/cmajo.20180024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Hepatic encephalopathy, a form of brain dysfunction seen in the setting of liver insufficiency, negatively affects driving performance and so is both a patient and public safety issue. We aimed to review the motor vehicle codes in each Canadian province and territory relating to the reporting of patients with hepatic encephalopathy and to search a Canadian legal database for cases of motor vehicle collisions involving patients with hepatic encephalopathy. METHODS In this descriptive analysis, the transportation agencies of each Canadian province and territory were contacted via telephone and/or email between April and August 2017. Requirements of physicians to report medical conditions (including liver disease and hepatic encephalopathy) affecting a patient's fitness to drive were assessed. WestlawNext Canada was searched for any Canadian cases on hepatic encephalopathy and driving-related lawsuits from inception to Dec. 31, 2017. RESULTS Reporting of medically unfit drivers is a requirement in all Canadian provinces and territories except Alberta, Quebec and Nova Scotia. Hepatic encephalopathy, cirrhosis and advanced liver disease were not specifically identified as reportable medical conditions in any province or territory. Our search did not identify any lawsuits involving a motor vehicle collision in Canada that were made either against physicians caring for patients with hepatic encephalopathy or against such patients themselves. INTERPRETATION Although hepatic encephalopathy has a substantial impact on driving performance, it is not specifically identified as a reportable medical condition in Canada. Increasing awareness of the potential impact of hepatic encephalopathy on safe driving for health care providers and the public is critical.
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Affiliation(s)
- Henry H Nguyen
- University of Calgary Liver Unit, Department of Medicine (Nguyen, Swain, Congly), Division of Gastroenterology and Hepatology, Calgary, Alta.; McGill University Health Centre (Wong), Royal Victoria Hospital, Montréal, Que
| | - Mark G Swain
- University of Calgary Liver Unit, Department of Medicine (Nguyen, Swain, Congly), Division of Gastroenterology and Hepatology, Calgary, Alta.; McGill University Health Centre (Wong), Royal Victoria Hospital, Montréal, Que
| | - Philip Wong
- University of Calgary Liver Unit, Department of Medicine (Nguyen, Swain, Congly), Division of Gastroenterology and Hepatology, Calgary, Alta.; McGill University Health Centre (Wong), Royal Victoria Hospital, Montréal, Que
| | - Stephen E Congly
- University of Calgary Liver Unit, Department of Medicine (Nguyen, Swain, Congly), Division of Gastroenterology and Hepatology, Calgary, Alta.; McGill University Health Centre (Wong), Royal Victoria Hospital, Montréal, Que.
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Jeong JH, Kim DK, Lee NS, Jeong YG, Kim HW, Kim JS, Han SY. Neuroprotective Effect of Nortriptyline in Overt Hepatic Encephalopathy Through Attenuation of Mitochondrial Dysfunction. ASN Neuro 2018; 10:1759091418810583. [PMID: 30428281 PMCID: PMC6238202 DOI: 10.1177/1759091418810583] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Revised: 09/21/2018] [Accepted: 10/01/2018] [Indexed: 12/12/2022] Open
Abstract
Hyperammonemia associated with overt hepatic encephalopathy (OHE) causes excitotoxic neuronal death through activation of the cytochrome C (CytC)-mediated mitochondria-dependent apoptotic pathway. We tested the therapeutic effect of nortriptyline (NT), a mitochondrial permeability transition pore (mPTP) blocker that can possibly inhibit mitochondrial CytC efflux to the cytosol on in vivo and in vitro OHE models. After ensuring the generation of OHE rats, established by bile duct ligation (BDL), they were intraperitoneally administered either 20 mg/kg NT (i.e., BDL+NT) or another vehicle (i.e., BDL+VEH) for 14 days. Compared with the control, BDL+VEH showed an increment of motor deficits, cell death, synaptic loss, apoptosis, and mitochondria with aberrant morphology in substantia nigra compacta dopaminergic (DA-ergic) neurons. However, the extent was significantly reversed in BDL+NT. Subsequently, we studied the neuroprotective mechanism of NT using PC-12 cells, a DA-ergic cell line, which exposed glutamate used as an excitotoxin. Compared with the control, the cells exposed to 15 mM glutamate (i.e., GLU) showed incremental cell death, apoptosis, and demise in mitochondrial respiration. Importantly, efflux of CytC from mitochondria to cytosol and the dissipation of mitochondrial membrane potential (△Ψm), an indicator of mPTP opening, were prominent in GLU. However, compared with the GLU, the cells cotreated with 10 μM NT (i.e., GLU+NT) showed a significant reduction in the aforementioned phenomenon. Together, we concluded that NT can be used for OHE therapeutics, mitigating the excitotoxic death of substantia nigra compacta DA-ergic neurons via mPTP-associated mitochondrial dysfunction inhibition.
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Affiliation(s)
- Ji Heun Jeong
- Department of Anatomy, College of Medicine, Konyang University, Daejeon, South Korea
| | - Do Kyung Kim
- Department of Anatomy, College of Medicine, Konyang University, Daejeon, South Korea
| | - Nam-Seob Lee
- Department of Anatomy, College of Medicine, Konyang University, Daejeon, South Korea
| | - Young-Gil Jeong
- Department of Anatomy, College of Medicine, Konyang University, Daejeon, South Korea
| | - Ho Won Kim
- Myunggok Medical Research Institute, College of Medicine, Konyang University, Daejeon, South Korea
| | - Jong-Seok Kim
- Myunggok Medical Research Institute, College of Medicine, Konyang University, Daejeon, South Korea
| | - Seung-Yun Han
- Department of Anatomy, College of Medicine, Konyang University, Daejeon, South Korea
- Myunggok Medical Research Institute, College of Medicine, Konyang University, Daejeon, South Korea
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Soriano G, Bajaj JS. Grading the range of hepatic encephalopathy from overt to covert: Animals to the rescue! Hepatology 2017; 66:10-12. [PMID: 28370089 DOI: 10.1002/hep.29186] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Revised: 03/13/2017] [Accepted: 03/23/2017] [Indexed: 12/07/2022]
Affiliation(s)
- German Soriano
- Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona and, CIBERehd, Instituto de Salud Carlos III, Madrid, Spain
| | - Jasmohan S Bajaj
- Division of Gastroenterology, Hepatology and Nutrition Virginia Commonwealth University and McGuire VA Medical Center, Richmond, VA
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Badea MA, Drug VL, Dranga M, Gavrilescu O, Stefanescu G, Popa I, Mihai C, Cijevschi-Prelipcean C. Diagnosis of minimal hepatic encephalopathy in a tertiary care center from eastern Romania: validation of the psychometric hepatic encephalopathy score (PHES). Metab Brain Dis 2016; 31:1463-1471. [PMID: 27461111 DOI: 10.1007/s11011-016-9878-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Accepted: 07/19/2016] [Indexed: 12/11/2022]
Abstract
The psychometric hepatic encephalopathy score (PHES) is frequently used as a "gold standard" for the diagnosis of minimal hepatic encephalopathy (MHE). In Romania, there are currently no widely available tests for the detection of MHE. In this study we aimed to standardize the PHES in a healthy Romanian population and to estimate the prevalence of MHE in a group of Romanian patients with liver cirrhosis. A total of 260 healthy volunteers and 106 patients with liver cirrhosis were included in the study. The five neuropsychological tests comprising the PHES were administered to all enroled subjects. Blood samples for routine tests and serum ammonia were collected. In the healthy volunteer group age and education years were found to be predictors of all tests and gender only in two tests: digit symbol test and serial dotting test. The PHES of the healthy volunteer group was 0,43 ± 1,37 and the cut-off between normal and pathological values was set at -3 points. In the liver cirrhosis group the mean PHES was -2,44 ± 3,41, significantly lower than in the control group (p = 0,001). The estimated prevalence of MHE was 34,7 % (37 patients). In patients with cirrhosis there was a significant correlation between PHES and the severity of the liver disease according to Child-Pugh classification (r = 0,529, p = 0,001) and MELD score (r = -0,525, p = 0,001). According to our results, accurate Romanian PHES norms for the diagnosis of MHE have been developed. MHE was diagnosed in a significant proportion of Romanian patients with liver cirrhosis.
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Affiliation(s)
- Mircea Alexandru Badea
- Department of Gastroenterology, University of Medicine and Pharmacy "Grigore T. Popa" Iasi, Strada Universitatii, Nr. 16, code, 700115, Iasi, Romania.
- Institute of Gastroenterology and Hepatology, Iasi, Romania.
| | - Vasile Liviu Drug
- Department of Gastroenterology, University of Medicine and Pharmacy "Grigore T. Popa" Iasi, Strada Universitatii, Nr. 16, code, 700115, Iasi, Romania
- Institute of Gastroenterology and Hepatology, Iasi, Romania
| | - Mihaela Dranga
- Department of Gastroenterology, University of Medicine and Pharmacy "Grigore T. Popa" Iasi, Strada Universitatii, Nr. 16, code, 700115, Iasi, Romania
- Institute of Gastroenterology and Hepatology, Iasi, Romania
| | - Otilia Gavrilescu
- Department of Gastroenterology, University of Medicine and Pharmacy "Grigore T. Popa" Iasi, Strada Universitatii, Nr. 16, code, 700115, Iasi, Romania
- Institute of Gastroenterology and Hepatology, Iasi, Romania
| | - Gabriela Stefanescu
- Department of Gastroenterology, University of Medicine and Pharmacy "Grigore T. Popa" Iasi, Strada Universitatii, Nr. 16, code, 700115, Iasi, Romania
- Institute of Gastroenterology and Hepatology, Iasi, Romania
| | - Iolanda Popa
- Department of Gastroenterology, University of Medicine and Pharmacy "Grigore T. Popa" Iasi, Strada Universitatii, Nr. 16, code, 700115, Iasi, Romania
- Institute of Gastroenterology and Hepatology, Iasi, Romania
| | - Catalina Mihai
- Department of Gastroenterology, University of Medicine and Pharmacy "Grigore T. Popa" Iasi, Strada Universitatii, Nr. 16, code, 700115, Iasi, Romania
- Institute of Gastroenterology and Hepatology, Iasi, Romania
| | - Cristina Cijevschi-Prelipcean
- Department of Gastroenterology, University of Medicine and Pharmacy "Grigore T. Popa" Iasi, Strada Universitatii, Nr. 16, code, 700115, Iasi, Romania
- Institute of Gastroenterology and Hepatology, Iasi, Romania
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Osman MA, Sayed MM, Mansour KA, Saleh SA, Ibrahim WA, Abdelhakam SM, Bahaa M, Yousry WA, Elbaz HS, Mikhail RN, Hassan AM, Elsayed EH, Mahmoud DA. Reversibility of minimal hepatic encephalopathy following liver transplantation in Egyptian cirrhotic patients. World J Hepatol 2016; 8:1279-1286. [PMID: 27843538 PMCID: PMC5084057 DOI: 10.4254/wjh.v8.i30.1279] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2016] [Accepted: 09/18/2016] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate the reversibility of minimal hepatic encephalopathy (MHE) following liver transplantation (LT) in Egyptian cirrhotic patients.
METHODS This prospective study included twenty patients with biopsy-proven liver cirrhosis listed for LT and twenty age- and sex-matched healthy control subjects. All underwent neuro-psychiatric examination, laboratory investigations, radiological studies and psychometric tests including trail making test A (TMT A), TMT B, digit symbol test and serial dotting test. The psychometric hepatic encephalopathy score (PHES) was calculated for patients to diagnose MHE. Psychometric tests were repeated six months following LT in the cirrhotic patient group.
RESULTS Before LT, psychometric tests showed highly significant deficits in cirrhotic patients in comparison to controls (P < 0.001). There was a statistically significant improvement in test values in the patient group after LT; however, their values were still significantly worse than those of the controls (P < 0.001). The PHES detected MHE in 16 patients (80%) before LT with a median value of -7 ± 3.5. The median PHES value was significantly improved following LT, reaching -4.5 ± 5 (P < 0.001), and the number of patients with MHE decreased to 11 (55%). The pre-transplant model for end-stage liver disease (MELD) score ≥ 15 was significantly related to the presence of post-transplant MHE (P = 0.005). More patients in whom reversal of MHE was observed had a pre-transplant MELD score < 15.
CONCLUSION Reversal of MHE in cirrhotic patients could be achieved by LT, especially in those with a MELD score < 15.
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Allampati S, Duarte-Rojo A, Thacker LR, Patidar KR, White MB, Klair JS, John B, Heuman DM, Wade JB, Flud C, O'Shea R, Gavis EA, Unser AB, Bajaj JS. Diagnosis of Minimal Hepatic Encephalopathy Using Stroop EncephalApp: A Multicenter US-Based, Norm-Based Study. Am J Gastroenterol 2016; 111:78-86. [PMID: 26644276 DOI: 10.1038/ajg.2015.377] [Citation(s) in RCA: 127] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Accepted: 10/02/2015] [Indexed: 02/08/2023]
Abstract
OBJECTIVES Diagnosing minimal hepatic encephalopathy (MHE) is challenging, and point-of-care tests are needed. Stroop EncephalApp has been validated for MHE diagnosis in single-center studies. The objective of the study was to validate EncephalApp for MHE diagnosis in a multicenter study. METHODS Outpatient cirrhotics (with/without prior overt hepatic encephalopathy (OHE)) and controls from three sites (Virginia (VA), Ohio (OH), and Arkansas (AR)) underwent EncephalApp and two gold standards, psychometric hepatic encephalopathy score (PHES) and inhibitory control test (ICT). Age-/gender-/education-adjusted values for EncephalApp based on direct norms, and based on ICT and PHES, were defined. Patients were followed, and EncephalApp cutoff points were used to determine OHE prediction. These cutoff points were then used in a separate VA-based validation cohort. RESULTS A total of 437 cirrhotics (230 VA, 107 OH, 100 AR, 36% OHE, model for end-stage liver disease (MELD) score 11) and 308 controls (103 VA, 100 OH, 105 AR) were included. Using adjusted variables, MHE was present using EncephalApp based on norms in 51%, EncephalApp based on PHES in 37% (sensitivity 80%), and EncephalApp based on ICT in 54% of patients (sensitivity 70%). There was modest/good agreement between sites on EncephalApp MHE diagnosis using the three methods. OHE developed in 13% of patients, which was predicted by EncephalApp independent of the MELD score. In the validation cohort of 121 VA cirrhotics, EncephalApp directly and based on gold standards remained consistent for MHE diagnosis with >70% sensitivity. CONCLUSIONS In this multicenter study, EncephalApp, using adjusted population norms or in the context of existing gold standard tests, had good sensitivity for MHE diagnosis and predictive capability for OHE development.
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Affiliation(s)
- Sanath Allampati
- Internal Medicine and Gastroenterology, Cleveland Clinic, Cleveland, Ohio, USA
| | | | - Leroy R Thacker
- Family and Community Health Nursing and Biostatistics, Richmond, Virginia, USA
| | - Kavish R Patidar
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, Virginia, USA
| | - Melanie B White
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, Virginia, USA
| | - Jagpal S Klair
- University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Binu John
- Internal Medicine and Gastroenterology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Douglas M Heuman
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, Virginia, USA
| | - James B Wade
- Psychiatry, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, Virginia, USA
| | - Christopher Flud
- University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Robert O'Shea
- Internal Medicine and Gastroenterology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Edith A Gavis
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, Virginia, USA
| | - Ariel B Unser
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, Virginia, USA
| | - Jasmohan S Bajaj
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, Virginia, USA
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Abstract
Both covert hepatic encephalopathy (CHE) and overt hepatic encephalopathy (OHE) impair the ability to operate machinery. The legal responsibilities of US physicians who diagnose and treat patients with hepatic encephalopathy vary among states. It is imperative that physicians know the laws regarding reporting in their state. OHE represents a neuropsychiatric impairment that meets general reporting criteria. The medical advisory boards of the states have not identified OHE as a reportable condition. In the absence of validated diagnostic guidelines, physicians are not obligated to perform tests for CHE. There is a need for explicit guidance from professional associations regarding this issue.
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