Adventures in Developing an App for Covert Hepatic Encephalopathy

Blood gas levels, cardiovascular strain and cognitive performance during surgical mask and filtering face piece application

Mask induced airway resistance and carbon dioxide rebreathing is discussed to impact gas exchange and to induce discomfort and impairments in cognitive performance. N = 23 healthy humans (13 females, 10 males; 23.5 ± 2.1 years) participated in this randomized crossover trial (3 arms, 48-h washout periods). During interventions participants wore either a surgical face mask (SM), a filtering face piece (FFP2) or no mask (NM). Interventions included a 20-min siting period and 20 min steady state cycling on an ergometer at 77% of the maximal heart rate (HR). Hemodynamic data (HR, blood pressure), metabolic outcomes (pulse derived oxygen saturation, capillary carbon dioxide (pCO₂), and oxygen partial pressure (pO₂), lactate, pH, base excess), subjective response (ability to concentrate, arousal, perceived exertion) and cognitive performance (Stroop Test) were assessed. Compared to NM, both masks increased pCO₂ (NM 31.9 ± 3.3 mmHg, SM = 35.2 ± 4.0 mmHg, FFP2 = 34.5 ± 3.8 mmHg, F = 12.670, p < 0.001) and decreased pH (NM = 7.42 ± 0.03, SM = 7.39 ± 0.03, FFP2 = 7.39 ± 0.04, F = 11.4, p < 0.001) during exercise. The FFP2 increased blood pressure during exercise (NM = 158 ± 15 mmHg, SM = 159 ± 16 mmHg, FFP2 = 162 ± 17 mmHg, F = 3.21, p = 0.050), the SM increased HR during sitting (NM = 70 ± 8 bpm, SM = 74 ± 8 bpm, FFP2 = 73 ± 8 bpm, F = 4.70, p = 0.014). No mask showed any comparative effect on other hemodynamic, metabolic, subjective, or cognitive outcomes. Mask wearing leads to slightly increased cardiovascular stress and elevated carbon dioxide levels during exercise but did not affect cognitive performance or wellbeing.

Acceptance and use of a smartphone application in cirrhosis

BACKGROUND AND AIMS

The development of cirrhosis-related smartphone applications for remote monitoring is increasing. Whether patients with cirrhosis will welcome such new technology, however, is uncertain.

METHODS

We prospectively enrolled patients with cirrhosis (N = 102) to determine predictors of acceptance and utilization of a smartphone application for cirrhosis management using a 12-item Technology Acceptance Model (TAM) survey. Patients were then shown the EncephalApp© and evaluated for their willingness to download and use the application.

RESULTS

Patients had a median age of 61.3 years and 63.7% had a history of hepatic decompensation. Intention to use the hypothetical application was associated with perceived usefulness (β: 0.4, 95% CI: 0.3-0.5) and the presence of a caregiver (β: 1.1, 95% CI: 0.2-2.0). Of the eligible participants, 71% agreed to download the EncephalApp© and the decision was influenced by computer anxiety, behavioural intent, caregiver presence and disease state factors. Actual usage was 32% and not associated with baseline characteristics or the technology acceptance model.

CONCLUSIONS

Patient acceptance of smartphone applications for the management of cirrhosis is high and related to their attitudes towards technology and the presence of a caregiver. However, usage was low. Future research must employ behavioural interventions to optimize uptake and utilization of remote monitoring technology.

Attitudes towards digital health tools for outpatient cirrhosis management in patients with decompensated cirrhosis

Background

Technology represents a promising tool to improve healthcare delivery for patients with cirrhosis. We sought to assess utilisation of technology and preferred features of a digital health management tool, in patients with an early readmission for decompensated cirrhosis.

Methods

We conducted a cross-sectional study of patients readmitted within 90 days for decompensated cirrhosis. A semistructured interview obtained quantitative and qualitative data through open-ended questions.

Results

Of the 50 participants, mean age was 57.6 years and mean (range) model for end stage liver disease was 22.7 (10–46). Thirty-eight (76%) patients own a Smartphone and 62% have regular access to a computer with internet. Thirty-nine (78%) patients would consider using a Smartphone application to manage their cirrhosis. Forty-six (92%) patients report having a principal caregiver, of which 80% own a Smartphone. Patients were interested in a Smartphone application that could communicate with their physician (85%), send medication notifications to the patient (65%) and caregiver (64%), transmit diagnostic results and appointment reminders (82%), educate about liver disease (79%), regularly transmit weight data to the doctor (85% with ascites) and play a game to detect cognitive decline (67% with encephalopathy). Common themes from qualitative data include a desire to learn about liver disease and communicate with providers via digital tools.

Conclusion

Among patients with cirrhosis with an early readmission for decompensation, most have Smartphones and would be willing to use a Smartphone to manage their disease. Future digital health management tools should be tailored to the use patterns and preferences of the patients with cirrhosis and their caregivers.

Advances in psychometric tests for screening minimal hepatic encephalopathy: From paper-and-pencil to computer-aided assessment

Minimal hepatic encephalopathy (MHE) is a major neuropsychiatric complication of liver cirrhosis and portosystemic shunting. Although MHE produces a spectrum of cognitive impairments in the domains of short-term attention, working memory, and executive function, it generally does not present with obvious clinical manifestation on conventional assessments. Paper-and-pencil psychometric tests, such as the psychometric hepatic encephalopathy score and the repeatable battery for the assessment of neuropsychological status, are recommended to diagnose MHE. However, these tests are neither rapid nor convenient to use in practice. To facilitate repeated testing in clinic and follow-up, computer-aided psychometric tests, such as the scan test, Cognitive Drug Research assessment battery, inhibitory control test, EncephalApp Stroop App, and critical flicker frequency, have been used to screen for MHE among patients with liver cirrhosis. The aim of this review was to describe the progression from the utility of paper-and-pencil to computer-aided psychometric tests for MHE screening in clinical practice.

Validation of the Korean Stroop Test in Diagnosis of Minimal Hepatic Encephalopathy

The burden of minimal hepatic encephalopathy (MHE) is significant, but no universal criteria for diagnosis have been established. We aimed to validate the Korean Stroop Test for MHE screening. Chronic hepatitis B-related liver cirrhosis patients were recruited prospectively from 13 centers. The Korean Stroop Test consisted of two Stroop-off states (color and word) and two Stroop-on states (inhibition and switching). Accuracy adjusted psychomotor speed (rate correct score) of these tests were analyzed. Sex- and age- adjusted rate correct scores of these tests were rated as the Korean Stroop Score (K-Stroop score). MHE was diagnosed when Portosystemic Encephalopathy Syndrome Test (PHES) scores were below −4. A total of 220 liver cirrhosis patients and 376 healthy controls were enrolled. Prevalence of MHE was 20.6% in cirrhosis patients. Rate correct scores and the K-Stroop score showed significant differences between healthy controls, cirrhosis patients without MHE, and cirrhosis patients with MHE. The rate correct score of the K-Stroop score was 0.74 (95% Confidence Interval: 0.66–0.83, P < 0.001). Female gender and the K-Stroop score were significant for MHE diagnosis. The Korean Stroop Test is simple and valid for screening of MHE.

Interventions to improve physical function and prevent adverse events in cirrhosis

Cirrhosis is associated with debilitating complications that significantly impact on a patient’s physical function and reduce quality of life. Owing to highly prevalent sarcopenia, malnutrition and hepatic encephalopathy, functional impairment or frailty is a common complication of cirrhosis. Frailty in turn increases the patient’s risk of hospitalization, accidental falls and fractures, and death. The management of frailty and its associated adverse effects is imperative in improving the overall prognosis of patients with advanced liver disease. The cornerstone of therapy revolves around optimizing physical function with appropriate nutrition and exercise. Nutritional therapy with protein supplementation has shown significant benefit, while studies on exercise have been controversial. However, newly emerging studies trend towards a beneficial effect of physical exercise with improvement in quality of life. The implementation of technology in liver disease management shows future promise. Fitbits and other wearable devices can be used to help monitor a patient’s personal progress in physical exercise and nutritional optimization. Additionally, the progressive development of new smartphone applications to help aid in the diagnosis and monitoring of complications of cirrhosis provides a sophisticated avenue for improving care of patients with cirrhosis.

Recent advances in hepatic encephalopathy

Hepatic encephalopathy describes the array of neurological alterations that occur during acute liver failure or chronic liver injury. While key players in the pathogenesis of hepatic encephalopathy, such as increases in brain ammonia, alterations in neurosteroid levels, and neuroinflammation, have been identified, there is still a paucity in our knowledge of the precise pathogenic mechanism. This review gives a brief overview of our understanding of the pathogenesis of hepatic encephalopathy and then summarizes the significant recent advances made in clinical and basic research contributing to our understanding, diagnosis, and possible treatment of hepatic encephalopathy. A literature search using the PubMed database was conducted in May 2017 using "hepatic encephalopathy" as a keyword, and selected manuscripts were limited to those research articles published since May 2014. While the authors acknowledge that many significant advances have been made in the understanding of hepatic encephalopathy prior to May 2014, we have limited the scope of this review to the previous three years only.