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Thuluvath AJ, Polineni P, Morrissey S, Belfanti K, Nizamuddin M, Siddiqui O, Daud A, Simpson DC, Levitsky J, Flores AM, Duarte-Rojo A, Ladner DP. Home-based LIver FrailTy Intervention (LIFT) in Transplant Candidates: A Feasibility Study. Transplantation 2025; 109:e202-e212. [PMID: 40131764 PMCID: PMC11950627 DOI: 10.1097/tp.0000000000005263] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/22/2025]
Abstract
BACKGROUND Frailty is prevalent in end-stage liver disease and predicts higher waitlist and posttransplant mortality. Despite association of frailty with poor clinical outcomes, evidence-based interventions to reverse frailty remain scarce. METHODS In this pilot study, we tested the feasibility of a novel home-based frailty intervention using home exercise equipment, a smartphone application, and remote frailty assessments to create a dynamic and personalized exercise program for patients with cirrhosis evaluated for liver transplantation. RESULTS Fifty-four patients (mean 57.2 [±9.9] y, 59% men) enrolled in the study, with a mean Model for End-Stage Liver Disease-Na 16.9 (±5.8; 70% decompensated). The mean baseline Liver Frailty Index (LFI) was 3.59 (±0.60). The mean follow-up time was 259 (±190) d and the mean change in LFI at the end of the intervention was -0.11 (3.59 versus 3.48, P = 0.05), representing a clinically meaningful improvement in frailty previously associated with increased survival. In comparison, the retrospective control group, which had similar demographics and clinical characteristics as the intervention group, did not show a significant change in LFI (3.97 versus 3.91, P = 0.57). Fifty-six percent of patients were adherent (fully or partially) to recommended levels of exercise, and adherence rates declined from 1 to 3 mo after enrollment, underscoring the need to maintain patient engagement in exercise. CONCLUSIONS This study shows that a home-based frailty intervention is feasible. The intervention led to significant improvement in frailty, which was not seen in the retrospective control group. Future studies, including randomized controlled trials, are necessary to further assess the efficacy of the intervention and also determine its impact on downstream clinical outcomes.
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Affiliation(s)
- Avesh J. Thuluvath
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC), Feinberg School of Medicine, Northwestern University, Chicago, Illinois
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University
| | - Praneet Polineni
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC), Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Sheila Morrissey
- Department of Physical Therapy and Human Movement Sciences, Feinberg School of Medicine, Northwestern University
| | - Kimberly Belfanti
- Department of Physical Therapy and Human Movement Sciences, Feinberg School of Medicine, Northwestern University
| | - Mohammad Nizamuddin
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC), Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Osama Siddiqui
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC), Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Amna Daud
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC), Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Dinee C. Simpson
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC), Feinberg School of Medicine, Northwestern University, Chicago, Illinois
- Division of Transplant, Department of Surgery, Feinberg School of Medicine, Northwestern University
| | - Josh Levitsky
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC), Feinberg School of Medicine, Northwestern University, Chicago, Illinois
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University
| | - Ann Marie Flores
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC), Feinberg School of Medicine, Northwestern University, Chicago, Illinois
- Department of Physical Therapy and Human Movement Sciences, Feinberg School of Medicine, Northwestern University
- The Robert H. Lurie Comprehensive Cancer Center, Feinberg School of Medicine, Northwestern University
- Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University
| | - Andrés Duarte-Rojo
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC), Feinberg School of Medicine, Northwestern University, Chicago, Illinois
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University
| | - Daniela P. Ladner
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC), Feinberg School of Medicine, Northwestern University, Chicago, Illinois
- Division of Transplant, Department of Surgery, Feinberg School of Medicine, Northwestern University
- Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University
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Li XQ, Cao W, Yin TT, Lu R, Li Y, Sha YY. A Qualitative Study on Cryptogenic Hepatic Encephalopathy Screening Cognition Among Hepatology Medical Care Personnel. J Multidiscip Healthc 2025; 18:1539-1547. [PMID: 40110531 PMCID: PMC11921800 DOI: 10.2147/jmdh.s508992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2024] [Accepted: 03/07/2025] [Indexed: 03/22/2025] Open
Abstract
Objective In this study, we focused on gaining an in-depth understanding on the attitudes and perceptions of hepatology healthcare professionals toward screening for cryptogenic hepatic encephalopathy (CHE), with the goal of providing references for the scientific and standardized implementation of CHE screening. Study Methods Based on the phenomenological research method, semi-structured in-depth interviews with nine medical professionals were conducted in March 2023 at the department of hepatology of a tertiary hospital in Taizhou city. The collected data was then integrated and analyzed using the Colaizzi seven-step method. Results Three main themes and seven sub-themes were identified: Inadequate knowledge of relevant information (inadequate knowledge of CHE, inadequate knowledge of neuropsychological test tools for CHE); positive attitudes toward screening for cirrhosis CHE; and screening factors (limited human resources, lack of stringent rules from the management, inability to properly use neuropsychological test tools, lack of cooperation from patients and their families, and lack of auxiliary means of screening). Conclusion Hepatology medical care personnel had a favorable outlook on CHE screening, however there is room for improvement in both their level of knowledge and clinical work. As a result the administrative departments of hospitals should focus on the factors affecting the clinical work of hepatology medical care personnel and formulate corresponding countermeasures. Emphasis should be placed on the screening and management of CHE for early recognition, early intervention, improvement of quality of life, and effective prevention of hepatic encephalopathy.
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Affiliation(s)
- Xiao-Qin Li
- Department of Infectious Disease, The Affiliated Taizhou People's Hospital of Nanjing Medical University, Taizhou, 225300, People's Republic of China
| | - Wen Cao
- Department of Infectious Disease, The Affiliated Taizhou People's Hospital of Nanjing Medical University, Taizhou, 225300, People's Republic of China
| | - Tian-Tian Yin
- Department of Infectious Disease, The Affiliated Taizhou People's Hospital of Nanjing Medical University, Taizhou, 225300, People's Republic of China
| | - Rui Lu
- Department of Infectious Disease, The Affiliated Taizhou People's Hospital of Nanjing Medical University, Taizhou, 225300, People's Republic of China
| | - Yang Li
- Department of Infectious Disease, The Affiliated Taizhou People's Hospital of Nanjing Medical University, Taizhou, 225300, People's Republic of China
| | - Ya-Yun Sha
- Department of Infectious Disease, The Affiliated Taizhou People's Hospital of Nanjing Medical University, Taizhou, 225300, People's Republic of China
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Pagès EG, Kontaxis S, Siddi S, Miguel MP, de la Cámara C, Bernal ML, Ribeiro TC, Laguna P, Badiella L, Bailón R, Haro JM, Aguiló J. Contribution of physiological dynamics in predicting major depressive disorder severity. Psychophysiology 2025; 62:e14729. [PMID: 39552159 PMCID: PMC11870817 DOI: 10.1111/psyp.14729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Revised: 10/01/2024] [Accepted: 11/04/2024] [Indexed: 11/19/2024]
Abstract
This study aimed to explore the physiological dynamics of cognitive stress in patients with Major Depressive Disorder (MDD) and design a multiparametric model for objectively measuring severity of depression. Physiological signal recordings from 40 MDD patients and 40 healthy controls were collected in a baseline stage, in a stress-inducing stage using two cognitive tests, and in the recovery period. Several features were extracted from electrocardiography, photoplethysmography, electrodermal activity, respiration, and temperature. Differences between values of these features under different conditions were used as indexes of autonomic reactivity and recovery. Finally, a linear model was designed to assess MDD severity, using the Beck Depression Inventory scores as the outcome variable. The performance of this model was assessed using the MDD condition as the response variable. General physiological hyporeactivity and poor recovery from stress predict depression severity across all physiological signals except for respiration. The model to predict depression severity included gender, body mass index, cognitive scores, and mean heart rate recovery, and achieved an accuracy of 78%, a sensitivity of 97% and a specificity of 59%. There is an observed correlation between the behavior of the autonomic nervous system, assessed through physiological signals analysis, and depression severity. Our findings demonstrated that decreased autonomic reactivity and recovery are linked with an increased level of depression. Quantifying the stress response together with a cognitive evaluation and personalization variables may facilitate a more precise diagnosis and monitoring of depression, enabling the tailoring of therapeutic interventions to individual patient needs.
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Affiliation(s)
- Esther García Pagès
- Department de Microelectrònica i Sistemes electrònicsUniversitat Autònoma de BarcelonaCerdanyola del VallèsSpain
- Centro de Investigación Biomédica en Red de BioingenieríaBiomateriales y NanomedicinaMadridSpain
| | | | - Sara Siddi
- Parc Sanitari Sant Joan de DéuInstitut de Recerca Sant Joan de DéuSant Boi de LlobregatSpain
- Departament de MatemàtiquesUniversitat Autònoma de BarcelonaCerdanyola del VallèsSpain
| | | | | | | | - Thais Castro Ribeiro
- Department de Microelectrònica i Sistemes electrònicsUniversitat Autònoma de BarcelonaCerdanyola del VallèsSpain
- Centro de Investigación Biomédica en Red de BioingenieríaBiomateriales y NanomedicinaMadridSpain
| | - Pablo Laguna
- Centro de Investigación Biomédica en Red de BioingenieríaBiomateriales y NanomedicinaMadridSpain
- Universidad de ZaragozaZaragozaSpain
| | - Llorenç Badiella
- Departament de MatemàtiquesUniversitat Autònoma de BarcelonaCerdanyola del VallèsSpain
| | - Raquel Bailón
- Centro de Investigación Biomédica en Red de BioingenieríaBiomateriales y NanomedicinaMadridSpain
- Universidad de ZaragozaZaragozaSpain
| | - Josep Maria Haro
- Parc Sanitari Sant Joan de DéuInstitut de Recerca Sant Joan de DéuSant Boi de LlobregatSpain
- Centro de Investigación Biomédica en Red de Salud MentalMadridSpain
- Universitat de BarcelonaBarcelonaSpain
| | - Jordi Aguiló
- Department de Microelectrònica i Sistemes electrònicsUniversitat Autònoma de BarcelonaCerdanyola del VallèsSpain
- Centro de Investigación Biomédica en Red de BioingenieríaBiomateriales y NanomedicinaMadridSpain
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Gananandan K, Kazankov K, Tapper EB, Mookerjee RP. The new digital era in decompensated cirrhosis. Lancet Digit Health 2025; 7:e54-e63. [PMID: 39572283 DOI: 10.1016/s2589-7500(24)00174-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 05/14/2024] [Accepted: 08/05/2024] [Indexed: 12/28/2024]
Abstract
There is a growing global burden of liver disease with the current management for complications of liver cirrhosis being reactive as opposed to proactive, affecting outcomes. Management can often be suboptimal in overburdened health-care systems with considerable socioeconomic and geographical disparity existing, which was exacerbated by the COVID-19 pandemic, highlighting the need for sustainable care pathways to be delivered remotely. To this end, digital health care could be the key and, in this Review, we highlight the principal studies that have explored the use of digital technology in the management of cirrhosis complications. While digital health care is a somewhat new field, considerable advances have been made in various domains, particularly in the development of remote monitoring and risk modelling. We aim to provide a balanced perspective of the opportunities for and barriers to the integration of digital technology into established liver-care pathways. Lastly, we reflect on the current acceptability of digital health care and the required future directions to ensure the digital transformation of hepatology is a success.
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Affiliation(s)
- Kohilan Gananandan
- Liver Failure Group, Institute for Liver and Digestive Health, University College London, London, UK
| | - Konstantin Kazankov
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Elliot B Tapper
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI, USA
| | - Rajeshwar P Mookerjee
- Liver Failure Group, Institute for Liver and Digestive Health, University College London, London, UK; Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark.
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Jiang TT, Liu XL, Yu H, Sun YX, Zhou JY, Yang ZY, Chen G. External validation of EncephalApp Stroop test to screen minimal hepatic encephalopathy patients with nonalcoholic cirrhosis. World J Hepatol 2024; 16:1450-1457. [DOI: 10.4254/wjh.v16.i12.1450] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2024] [Revised: 08/29/2024] [Accepted: 09/11/2024] [Indexed: 11/29/2024] Open
Abstract
BACKGROUND Neurocognitive impairment, including minimal hepatic encephalopathy (MHE) and overt hepatic encephalopathy, is one of the most common complications of all types of primary liver diseases, such as hepatitis B, biliary cholangitis, and autoimmune hepatitis. The EncephalApp Stroop test is a smartphone application-based test that is time-saving for MHE screening. However, neurocognitive impairment is different between alcoholic cirrhosis patients and nonalcoholic cirrhosis patients, so the cutoff value for MHE diagnosis might be inflated.
AIM To validate the Stroop test in nonalcoholic cirrhosis patients.
METHODS This external validation was performed at the National Center for Infectious Diseases (Beijing). Liver cirrhosis patients aged between 18 and 65 years who voluntarily enrolled in the study and provided signed informed consent were included. The Psychometric Hepatic Encephalopathy Score (PHES) test was used as the standard diagnostic criterion for MHE. The EncephalApp Stroop test was then performed on the iPad, including two sessions of tests (“off” and “on”) to measure patients’ ability to differentiate between numbers and letters. We assessed the performance of the EncephalApp Stroop test in terms of the area under the curve (AUC), sensitivity, specificity, positive predictive value, and negative predictive value, with the PHES as the standard criterion.
RESULTS A total of 160 nonalcoholic cirrhosis patients were included in this validation study, including 87 (54.4%) patients without MHE and 73 (45.6%) patients with MHE. Taking the PHES as the gold standard, the EncephalApp Stroop test performed well for nonalcoholic liver cirrhosis patients in terms of “off” time [AUC: 0.85, 95% confidence interval (CI): 0.79-0.91] and “on + off” time (AUC: 0.85, 95%CI: 0.80-0.91); however, total runs of “off” session (AUC: 0.61, 95%CI: 0.52-0.69), total runs of “on” session (AUC: 0.57, 95%CI: 0.48-0.65), and “on – off” time (AUC: 0.54, 95%CI: 0.44-0.63) were comparatively low. The optimal cutoff points were “off” time > 101.93 seconds and “on + off” time > 205.86 seconds, with sensitivities of 0.84 and 0.90, specificities of 0.77 and 0.71, positive predictive values of 0.75 and 0.72, and false-positive values of 0.85 and 0.89, respectively.
CONCLUSION Our results suggest that different cutoffs should be used for the EncephalApp Stroop tool for MHE screening between alcoholic and nonalcoholic living patients, which is a critical check before generalization to screen for neurocognitive impairment among the whole population of chronic liver diseases.
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Affiliation(s)
- Ting-Ting Jiang
- Center of Integrative Medicine, Beijing Ditan Hospital Affiliated to Capital Medical University, Beijing 100015, China
| | - Xiao-Li Liu
- Center of Integrative Medicine, Beijing Ditan Hospital Affiliated to Capital Medical University, Beijing 100015, China
| | - Hao Yu
- Center of Integrative Medicine, Beijing Ditan Hospital Affiliated to Capital Medical University, Beijing 100015, China
| | - Ya-Xuan Sun
- T.H. Chan School of Public Health, Harvard University, Boston, MA 02115, United States
| | - Jia-Yan Zhou
- School of Medicine, Stanford University, Stanford, CA 94305, United States
| | - Zhi-Yun Yang
- Center of Integrative Medicine, Beijing Ditan Hospital Affiliated to Capital Medical University, Beijing 100015, China
| | - Guang Chen
- LKS Faculty of Medicine, University of Hong Kong, Hong Kong 999077, China
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Hurtado-Díaz-de-León I, Tapper EB. Systems of care that improve outcomes for people with hepatic encephalopathy. Metab Brain Dis 2024; 40:50. [PMID: 39621162 DOI: 10.1007/s11011-024-01430-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2024] [Accepted: 10/31/2024] [Indexed: 12/11/2024]
Abstract
Hepatic encephalopathy (HE) is a critical neuropsychiatric complication of liver cirrhosis with a significant impact on patient quality of life and survival. The global prevalence of cirrhosis and associated HE necessitates a comprehensive understanding of the condition and effective systems of care to optimize outcomes. This review addresses the epidemiology, classification, diagnosis, and management of HE, with an emphasis on systems of care that improve outcomes for people with HE. Current diagnostic challenges include differentiating cognitive deficits attributable to HE from those caused by other etiologies, highlighting the need for accurate diagnostic methods. Traditional psychometric tests, while valuable for diagnosing covert HE (CHE), are limited in their ability to predict overt HE (OHE) due to various confounding factors. As a result, non-psychometric tools have been developed to provide outcome-based predictions aligned with the clinical course of HE. The management of HE includes addressing precipitating factors, pharmacologic interventions to reduce ammonia levels, and supportive care, with lactulose and rifaximin playing a central role. Preventive strategies with the use of remote monitoring in the outpatient management of HE, integrating technology for real-time tracking of therapy compliance and symptom evolution, could contribute to reducing hospital readmissions and improving patient care.
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Affiliation(s)
- Ivonne Hurtado-Díaz-de-León
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Elliot B Tapper
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI, USA.
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Ortiz-Treviño JF, Kuljacha-Gastélum AL, Tovar-Durán A, Wade-Isidro ME. Stroop test, Quickstroop, and the 1-min animal naming test for minimal hepatic encephalopathy diagnosis: A multicenter study in Mexico. Ann Hepatol 2024; 29:101531. [PMID: 39033930 DOI: 10.1016/j.aohep.2024.101531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2024] [Revised: 07/04/2024] [Accepted: 07/09/2024] [Indexed: 07/23/2024]
Abstract
INTRODUCTION AND OBJECTIVES Although the Psychometric Hepatic Encephalopathy Score (PHES) remains the gold standard in diagnosing minimal hepatic encephalopathy (MHE), its complexity limits its application in clinical practice. While more convenient tests, such as the Stroop test, Quickstroop, and the 1-min animal naming test (ANT-1), have emerged, they haven't been validated in our setting. Our objective was to validate these tests in our population. PATIENTS AND METHODS This multicenter, observational, descriptive, and cross-sectional study was conducted in three hospitals in northeastern Mexico. MHE was defined as a PHES <-4. We included patients with cirrhosis aged >15 years without a history of overt hepatic encephalopathy. Data regarding sex, age, education, Child-Pugh/MELD-Na scores, etiology of cirrhosis, diabetes, hypertension, obesity, ascites, and clinically significant portal hypertension was collected. Fisher's exact test, Mann-Whitney U test, and receiver operating characteristic (ROC) curves were used for statistical analysis. RESULTS Of the 121 patients included, 35.5 % were diagnosed with MHE. The presence of MHE was significantly associated with education level, years of study, and scores in the Stroop test, Quickstroop, and ANT-1. The AUROC curves were 77.9 %, 74.6 %, and 72.7 % for the Stroop test, Quickstroop, and ANT-1, respectively. The resulting cut-off points were 218.398 (sensitivity: 74 %; specificity: 74 %), 40.535 (sensitivity: 77 %; specificity: 68 %), and <16 animals (sensitivity: 58 %; specificity: 79 %), respectively. CONCLUSIONS These tests are valid diagnostic tools for detecting MHE in our population. Their simpler use and applicability could increase the early diagnosis of MHE and prompt primary prophylaxis initiation for overt hepatic encephalopathy.
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Affiliation(s)
- Juan F Ortiz-Treviño
- Gastroenterology department, high specialty medical unit (UMAE) No. 25, Northeast National Medical Center, IMSS, Monterrey, Nuevo León, P.C. 64320, Mexic
| | - Alma L Kuljacha-Gastélum
- Gastroenterology department, high specialty medical unit (UMAE) No. 25, Northeast National Medical Center, IMSS, Monterrey, Nuevo León, P.C. 64320, Mexic.
| | - Alejandro Tovar-Durán
- Gastroenterology Department, Zone General Hospital No. 33, IMSS, Monterrey, Nuevo León, P.C. 64010, Mexic
| | - Martha E Wade-Isidro
- Gastroenterology Department, Zone General Hospital No. 17, IMSS, Monterrey, Nuevo León, P.C. 64420, Mexic
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Siedlecki KL, Minahan Zucchetto J, Yazdani N. The Influence of Instructional Constraints and Cognitive Control on the Positivity Bias and the Positivity Effect in Autobiographical Memory. Int J Aging Hum Dev 2024:914150241268181. [PMID: 39105308 DOI: 10.1177/00914150241268181] [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: 08/07/2024]
Abstract
The positivity effect and the positivity bias were examined in voluntary and involuntary autobiographical memories in a sample of younger (n = 69, Mage = 23.2) and older adults (n = 57, Mage = 67.72). The positivity effect has been shown to be sensitive to instructional constraints and cognitive resources. Instructions were manipulated in the voluntary autobiographical memory condition such that participants were instructed to retrieve memories with different levels of constraints. Participants also completed two measures of cognitive control and an assessment of future time perspective. There was no evidence of the positivity effect or positivity bias once depressive symptoms were included as a covariate in the analyses, nor did cognitive control influence memory valence. Future time perspective did not mediate the relationship between age and memory valence. These results suggest that additional research should focus on potential variables that may influence the positivity effect and bias within autobiographical memories.
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Affiliation(s)
| | | | - Neshat Yazdani
- Department of Psychology, Fordham University, Bronx, NY, USA
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Li X, Liu S, Guo Y, Zu H, Xiang H, Yang S, Zhang X, Meng F, Bianba Y, Li J, Liu F, Lei C, Lv J, Yang Q, Fu W, Ye W, Chen J, Gao Y, Wu C, Wang N, Zheng Q, Wang F, Yu J, Wang J, Yang X, Wang X, Liu Y, Zhao X, Wu C, Gou W, Bajaj JS, Wang F, Fu J, Qi X. Detection of minimal hepatic encephalopathy in patients with cirrhosis based on the Stroop-CN model (NCRCID-CHESS 2106): a prospective multicenter study. MedComm (Beijing) 2024; 5:e627. [PMID: 39015557 PMCID: PMC11247336 DOI: 10.1002/mco2.627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 05/21/2024] [Accepted: 05/23/2024] [Indexed: 07/18/2024] Open
Abstract
Minimal hepatic encephalopathy (MHE) has a substantial impact on the clinical outcomes and quality of life (QOL) of patients with cirrhosis. However, timely diagnosis and intervention are challenging due to sophisticated diagnostic methods. In this study, 673 healthy controls and 905 patients with cirrhosis were screened, and 660 healthy controls and 757 patients with cirrhosis, divided into the test (292 patients) and validation (465 patients) cohort, were analyzed after screening. A diagnostic model of the Stroop test (Stroop-CN) was constructed by multivariate linear regression based on the results of healthy controls. The prevalence of MHE and the comparison results with psychometric hepatic encephalopathy score through the Stroop-CN model were stable in the test and validation cohorts. Moreover, the prevalence of MHE remained significantly higher in patients with worse disease conditions marked as high Child-Pugh grades and the Model for End-stage Liver Disease and Sodium (MELD-Na) scores in the test and validation cohort. The EuroQol 5-D questionnaire revealed that patients with MHE had a worse QOL than those without MHE both in the test and validation cohort. In conclusion, an easy and practical Stroop-CN model for MHE diagnosis based on the EncephalApp is established. It is found that a considerable number of Chinese patients with cirrhosis experience MHE, which significantly impacts their QOL.
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Affiliation(s)
- Xiaoyan Li
- Medical School of Chinese PLABeijingChina
- Senior Department of Infectious DiseasesThe Fifth Medical Center of Chinese PLA General Hospital, National Clinical Research Center for Infectious DiseasesBeijingChina
| | - Shanghao Liu
- Center of Portal HypertensionDepartment of RadiologyZhongda Hospital, Medical School, Southeast University, Nurturing Center of Jiangsu Province for State Laboratory of AI Imaging & Interventional Radiology (Southeast University)NanjingChina
- Basic Medicine Research and Innovation Center of Ministry of EducationZhongda HospitalSoutheast UniversityNanjingChina
- State Key Laboratory of Digital Medical EngineeringNanjingChina
| | - Ying Guo
- Department of HepatologyThe Third People's Hospital of TaiyuanTaiyuanChina
| | - Hongmei Zu
- Department of GastroenterologyThe Fourth People's Hospital of Qinghai ProvinceXiningChina
| | - Huiling Xiang
- Department of Gastroenterology and HepatologyTianjin Third Central Hospital, Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, Institute of Hepatobiliary DiseaseTianjinChina
| | - Shaoqi Yang
- Department of GastroenterologyThe General Hospital of Ningxia Medical UniversityYinchuanChina
| | - Xiaoning Zhang
- Senior Department of Infectious DiseasesThe Fifth Medical Center of Chinese PLA General Hospital, National Clinical Research Center for Infectious DiseasesBeijingChina
| | - Fanping Meng
- Senior Department of Infectious DiseasesThe Fifth Medical Center of Chinese PLA General Hospital, National Clinical Research Center for Infectious DiseasesBeijingChina
| | - Yangzhen Bianba
- Department of HepatologyThe Third People's Hospital of Tibet Autonomous RegionLhasaChina
| | - Jie Li
- Department of Infectious DiseasesNanjing Drum Tower Hospital, The Affiliated Hospital of Medical SchoolNanjing UniversityNanjingChina
| | - Fei Liu
- Department of Infectious DiseasesHunan Key Laboratory of Viral HepatitisXiangya HospitalCentral South UniversityChangshaChina
| | - Chuang Lei
- Department of Infectious DiseasesThe First People's Hospital of Changde CityChangdeChina
| | - Jiaojian Lv
- Department of Infectious DiseaseLishui City People's HospitalLishuiChina
| | - Qiao‐hua Yang
- Hepatology Department of Infectious Diseases CenterThe First People's Hospital of HuaihuaHuaihuaChina
| | - Wei Fu
- Department of HepatologyShenyang 739 HospitalShenyangChina
| | - Wei Ye
- Liver Cirrhosis Treatment CenterNanjing Hospital Affiliated to Nanjing University of Traditional Chinese MedicineNanjingChina
| | - Jiafang Chen
- Department of GastroenterologyDatong City Fourth People's HospitalDatongChina
| | - Yanjing Gao
- Department of GastroenterologyQilu Hospital of Shandong UniversityJinanChina
| | - Caiyun Wu
- Department of HepatologyThird People′s Hospital of Linfen CityLinfenChina
| | - Ningning Wang
- Department of GastroenterologyThe First Hospital of China Medical UniversityShenyangChina
| | - Qi Zheng
- Department of HepatologyHepatology Research InstituteThe First Affiliated HospitalFujian Medical UniversityFuzhouChina
| | - Fang Wang
- Department of HepatologyShenzhen Third People's Hospital, National Clinical Research Center for Infectious Disease, The Second Affiliated Hospital, School of Medicine, Southern University of Science and TechnologyShenzhenChina
| | - Jiali Yu
- Department of GastroenterologyThe First Affiliated Hospital of Dalian Medical UniversityDalianChina
| | - Jing Wang
- Department of GastroenterologyThe Second Affiliated Hospital of Baotou Medical CollegeBaotouChina
| | - Xiaoting Yang
- Department of GastroenterologyWuzhong People's HospitalWuzhongChina
| | - Xiangmei Wang
- Department of Severe HepatologyMengchao Hepatobiliary Hospital of Fujian Medical UniversityFuzhouChina
| | - Yayuan Liu
- Department of GastroenterologyCentral hospital of DandongDandongChina
| | - Xuelan Zhao
- Department of Gastroenterology Liver DiseasesChongqing Public Health Medical CenterChongqingChina
| | - Chenxi Wu
- Liver Disease Diagnosis and Treatment CenterYiyang Fourth People's HospitalYiyangChina
| | - Wei Gou
- Qingdao Sixth People's HospitalQingdaoChina
| | - Jasmohan S. Bajaj
- Division of Gastroenterology, Hepatology and NutritionVirginia Commonwealth University and Central Virginia Veterans Healthcare SystemRichmondVirginiaUSA
| | - Fu‐Sheng Wang
- Medical School of Chinese PLABeijingChina
- Senior Department of Infectious DiseasesThe Fifth Medical Center of Chinese PLA General Hospital, National Clinical Research Center for Infectious DiseasesBeijingChina
| | - Junliang Fu
- Medical School of Chinese PLABeijingChina
- Senior Department of Infectious DiseasesThe Fifth Medical Center of Chinese PLA General Hospital, National Clinical Research Center for Infectious DiseasesBeijingChina
| | - Xiaolong Qi
- Center of Portal HypertensionDepartment of RadiologyZhongda Hospital, Medical School, Southeast University, Nurturing Center of Jiangsu Province for State Laboratory of AI Imaging & Interventional Radiology (Southeast University)NanjingChina
- Basic Medicine Research and Innovation Center of Ministry of EducationZhongda HospitalSoutheast UniversityNanjingChina
- State Key Laboratory of Digital Medical EngineeringNanjingChina
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10
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Smith ML, Wade JB, Wolstenholme J, Bajaj JS. Gut microbiome-brain-cirrhosis axis. Hepatology 2024; 80:465-485. [PMID: 36866864 PMCID: PMC10480351 DOI: 10.1097/hep.0000000000000344] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 02/10/2023] [Indexed: 03/04/2023]
Abstract
Cirrhosis is characterized by inflammation, degeneration, and fibrosis of liver tissue. Along with being the most common cause of liver failure and liver transplant, cirrhosis is a significant risk factor for several neuropsychiatric conditions. The most common of these is HE, which is characterized by cognitive and ataxic symptoms, resulting from the buildup of metabolic toxins with liver failure. However, cirrhosis patients also show a significantly increased risk for neurodegenerative diseases such as Alzheimer and Parkinson diseases, and for mood disorders such as anxiety and depression. In recent years, more attention has been played to communication between the ways the gut and liver communicate with each other and with the central nervous system, and the way these organs influence each other's function. This bidirectional communication has come to be known as the gut-liver-brain axis. The gut microbiome has emerged as a key mechanism affecting gut-liver, gut-brain, and brain-liver communication. Clinical studies and animal models have demonstrated the significant patterns of gut dysbiosis when cirrhosis is present, both with or without concomitant alcohol use disorder, and have provided compelling evidence that this dysbiosis also influences the cognitive and mood-related behaviors. In this review, we have summarized the pathophysiological and cognitive effects associated with cirrhosis, links to cirrhosis-associated disruption of the gut microbiome, and the current evidence from clinical and preclinical studies for the modulation of the gut microbiome as a treatment for cirrhosis and associated neuropsychiatric conditions.
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Affiliation(s)
- Maren L Smith
- Department of Pharmacology and Toxicology, Virginia Commonwealth University, Richmond, Virginia, USA
- Alcohol Research Center, Virginia Commonwealth University, Richmond, Virginia, USA
| | - James B Wade
- Department of Psychiatry, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Jennifer Wolstenholme
- Department of Pharmacology and Toxicology, Virginia Commonwealth University, Richmond, Virginia, USA
- Alcohol Research Center, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Jasmohan S Bajaj
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and Central Virginia Veterans Healthcare System, Richmond, Virginia, USA
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11
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Grigoroiu M, Paul JF, Brian E, Aegerter P, Boddaert G, Mariolo A, Jorrot P, Bellahoues M, Seguin-Givelet A, Perduca V. 3D printing in anatomical lung segmentectomies: A randomized pilot trial. Heliyon 2024; 10:e31842. [PMID: 38867971 PMCID: PMC11168317 DOI: 10.1016/j.heliyon.2024.e31842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2024] [Revised: 05/04/2024] [Accepted: 05/22/2024] [Indexed: 06/14/2024] Open
Abstract
Objective This pilot study evaluated the impact of using a 3D printed model of the patient's bronchovascular lung anatomy on the mental workload and fatigue of surgeons during full thoracoscopic segmentectomy. Design We performed a feasibility pilot study of a prospective randomized controlled trial with 2 parallel arms. All included patients underwent digital 3D visual reconstruction of their bronchovascular anatomy and were randomized into the following two groups: Digital arm (only a virtual 3D model was available) and Digital + Object arm (both virtual and printed 3D models were available). The primary end-point was the surgeons' mental workload measured using the National Aeronautics and Space Administration-Task Load Index (NASA-TLX) score. Setting Between October 28, 2020 and October 05, 2021, we successively investigated all anatomic segmentectomies performed via thoracoscopy in the Thoracic Department of the Montsouris Mutualiste Institute, except for S6 segmentectomies and S4+5 left bi-segmentectomies. Participants We assessed 102 patients for anatomical segmentectomy. Among the, 40 were randomly assigned, and 34 were deemed analysable, with 17 patients included in each arm. Results Comparison of the two groups, each comprising 17 patients, revealed no statistically significant difference in primary or secondary end-points. The consultation of the visual digital model was significantly less frequent when a 3D printed model was available (6 versus 54 consultations, p = 0.001). Notably, both arms exhibited high NASA-TLX scores, particularly in terms of mental demand, temporal demand, and effort scores. Conclusion In our pilot study, 3D printed models and digital 3D reconstructions for pre-operative planning had an equivalent effect on thoracoscopic anatomic segmentectomy for experienced surgeons. The originality of this study lies in its focus on the impact of 3D printing of bronchovascular anatomy on surgeons, rather than solely on the surgical procedure.
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Affiliation(s)
- Madalina Grigoroiu
- Institut Mutualiste Montsouris, Institut Du Thorax Curie-Montsouris, 42, Boulevard Jourdan, 75014, Paris, France
| | - Jean-François Paul
- Institut Mutualiste Montsouris, Département de Radiologie, 42, Boulevard Jourdan, 75014, Paris, France
| | - Emmanuel Brian
- Institut Mutualiste Montsouris, Institut Du Thorax Curie-Montsouris, 42, Boulevard Jourdan, 75014, Paris, France
| | - Philippe Aegerter
- GIRCI-IDF, Cellule Méthodologie, 4, Av Richerand, 75010, Paris, France
- Université Paris-Saclay, UVSQ, Inserm, CESP U1018, 12, Av Paul-Couturier 94807, Villejuif, France
| | - Guillaume Boddaert
- Institut Mutualiste Montsouris, Institut Du Thorax Curie-Montsouris, 42, Boulevard Jourdan, 75014, Paris, France
| | - Alessio Mariolo
- Institut Mutualiste Montsouris, Institut Du Thorax Curie-Montsouris, 42, Boulevard Jourdan, 75014, Paris, France
| | - Pierre Jorrot
- Institut Mutualiste Montsouris, Département de Rythmologie, 42, Boulevard Jourdan, 75014. Paris, France
| | - Mouloud Bellahoues
- Institut Mutualiste Montsouris, Département de Recherche Clinique, 42, Boulevard Jourdan, 75014, Paris, France
| | - Agathe Seguin-Givelet
- Institut Mutualiste Montsouris, Institut Du Thorax Curie-Montsouris, 42, Boulevard Jourdan, 75014, Paris, France
| | - Vittorio Perduca
- Université Paris Cité, CNRS, MAP5, 44, Rue des Saint Pères, 75006, Paris, France
- Université Paris Saclay, UVSQ, INSERM, CESP U1018, « Exposome, Heredity, Cancer and Health » Team, Gustave Roussy, 12, Av Paul-Couturier, 94807, Villejuif, France
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12
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Neye RM, Kircheis G, Stratmann D, Hilger N, Lüth S. Assessment of Cirrhotic Patients by the EncephalApp Fails to Predict Low-Grade Hepatic Encephalopathy. Dig Dis 2024; 42:567-575. [PMID: 38865987 DOI: 10.1159/000538924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 04/13/2024] [Indexed: 06/14/2024]
Abstract
INTRODUCTION An early detection of low-grade hepatic encephalopathy (HE) is of high importance. The aim of the study was to compare a neuropsychological with a psychophysical test on the basis of the psychometric hepatic encephalopathy score (PHES) regarding effectiveness in diagnosing minimal HE (MHE). METHODS In our prospective controlled observational study, we examined a total of 103 patients with liver cirrhosis for HE. The PHES, CFF, and EncephalApp were performed in all patients. Graduation was based on the result of the PHES. Patients without evidence for HE 1&2 according to the mental state (West-Haven criteria) with a PHES <-4 value points and no clinical symptoms were defined as having MHE. Patients were considered as HE0 when in the PHES none of the psychometric subtest results was abnormal or with a PHES ≥-4 value points. Patients with clinical symptoms were considered HE 1&2 patients. Different cut-off values were determined, and their specificity and sensitivity were calculated. RESULTS Ninety-six of the involved patients had liver cirrhosis and 25 acted as a healthy control group. The ROC analysis for the classification resulted in an AUC of 0.806, with the highest Youden index for the cut-off time >224 s, for which the sensitivity was 82% and the specificity 75%. Cases of withdrawals were seen in 10.74% of all tested patients. CONCLUSION The EncephalApp distinguishes well between HE0 and MHE but has its limitations in grading higher forms of HE. Diagnosis using only the EncephalApp is not sufficient.
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Affiliation(s)
- Rebecca Maria Neye
- Department of Gastroenterology, Hepatology and Diabetology, Center of Internal Medicine II, University Hospital Brandenburg an der Havel, Brandenburg an der Havel, Germany,
- Department of Otorhinolaryngology, Head and Neck Surgery, Hospital Ernst von Bergmann Potsdam, Potsdam, Germany,
| | - Gerald Kircheis
- Department of Gastroenterology, Hepatology and Diabetology, Center of Internal Medicine II, University Hospital Brandenburg an der Havel, Brandenburg an der Havel, Germany
| | - Daria Stratmann
- Department of Gastroenterology, Hepatology and Diabetology, Center of Internal Medicine II, University Hospital Brandenburg an der Havel, Brandenburg an der Havel, Germany
| | - Norbert Hilger
- Department of Psychology, University of Bonn, Bonn, Germany
| | - Stefan Lüth
- Department of Gastroenterology, Hepatology and Diabetology, Center of Internal Medicine II, University Hospital Brandenburg an der Havel, Brandenburg an der Havel, Germany
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13
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Sanal-Hayes NEM, Mclaughlin M, Hayes LD, Berry ECJ, Sculthorpe NF. Examining Well-Being and Cognitive Function in People with Long COVID and ME/CFS, and Age-Matched Healthy Controls: A Case-Case-Control Study. Am J Med 2024:S0002-9343(24)00273-0. [PMID: 38750713 DOI: 10.1016/j.amjmed.2024.04.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2024] [Revised: 04/25/2024] [Accepted: 04/25/2024] [Indexed: 06/17/2024]
Abstract
BACKGROUND Well-being and cognitive function had not previously been compared between people with long COVID and people with myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS). Therefore, this study examined well-being and cognitive function in people with long COVID (∼16 months illness duration; n = 17) and ME/CFS (∼16 years illness duration; n = 24), versus age-matched healthy controls (n = 16). METHODS Well-being was examined using several questionnaires, namely the Health Visual Analogue Scale (VAS), Fatigue Severity Scale (FSS), post-exertional malaise (PEM), Pittsburgh Sleep Quality Index (PSQI), European Quality of Life-5 Domains (EQ-5D), MRC Dyspnoea, Self-Efficacy (SELTC), The Edinburgh Neurosymptoms Questionnaire (ENS), General Anxiety Disorder 7 (GAD-7) and Patient Health Questionnaire 9 (PHQ-9). Cognitive function was examined using Single Digit Modalities Test (SDMT), Stroop test and Trails A and B. These were delivered via a mobile application (app) built specifically for this remote data collection. RESULTS The main findings of the present investigation were that people with ME/CFS and people with long COVID were generally comparable on all well-being and cognitive function measures, but self-reported worse values for pain, fatigue, post-exertional malaise, sleep quality, general well-being in relation to mobility, usual activities, self-care, breathlessness, neurological symptoms, self-efficacy and other well-being such as anxiety and depression, compared to controls. There was no effect of group for cognitive function measures. CONCLUSIONS These data suggest that both people with long COVID and people with ME/CFS have similar impairment on well-being measures examined herein. Therefore, interventions that target well-being of people with ME/CFS and long COVID are required.
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Affiliation(s)
- Nilihan E M Sanal-Hayes
- School of Health and Society, University of Salford, Salford, UK; Sport and Physical Activity Research Institute, School of Health and Life Sciences, University of the West of Scotland, Glasgow, UK.
| | - Marie Mclaughlin
- Sport and Physical Activity Research Institute, School of Health and Life Sciences, University of the West of Scotland, Glasgow, UK; School of Sport, Exercise & Rehabilitation Sciences, University of Hull, Hull, UK
| | - Lawrence D Hayes
- Sport and Physical Activity Research Institute, School of Health and Life Sciences, University of the West of Scotland, Glasgow, UK; Lancaster Medical School, Lancaster University, Lancaster, UK
| | - Ethan C J Berry
- Sport and Physical Activity Research Institute, School of Health and Life Sciences, University of the West of Scotland, Glasgow, UK
| | - Nicholas F Sculthorpe
- Sport and Physical Activity Research Institute, School of Health and Life Sciences, University of the West of Scotland, Glasgow, UK
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14
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Redfield R, Latt N, Munoz SJ. Minimal Hepatic Encephalopathy. Clin Liver Dis 2024; 28:237-252. [PMID: 38548436 DOI: 10.1016/j.cld.2024.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
Minimal hepatic encephalopathy (MHE) is a pervasive frequent complication of cirrhosis of any etiology. The diagnosis of MHE is difficult as the standard neurologic examination is essentially within normal limits. None of the symptoms and signs of overt HE is present in a patient with MHE, such as confusion, disorientation, or asterixis. Progress has been made in diagnostic tools for detection of attention and cognitive deficits at the point of care of MHE. The development of MHE significantly impacts quality of life and activities of daily life in affected patients including driving motor vehicles and machine operation.
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Affiliation(s)
- Rachel Redfield
- Thomas Jefferson Hospital, Division of Gastroenterology, 132 S. 10th Street, Suite 480, Philadelphia, PA 19106, USA
| | - Nyan Latt
- Virtua Health System, Center for Liver Disease and Transplant Program, 63 Kresson Road, Suite 101, Cherry Hill, NJ 08034, USA
| | - Santiago J Munoz
- The Johns Hopkins University School of Medicine and Medical Institutions, Division of Gastroenterology and Hepatology, 600 N. Wolfe Street, Blalock Building, Suite 465, Baltimore, MD 21287, USA.
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15
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Lin E, Gandhi D, Volk M. Preventing Readmissions of Hepatic Encephalopathy: Strategies in the Acute Inpatient, Immediate Postdischarge, and Longitudinal Outpatient Setting. Clin Liver Dis 2024; 28:359-367. [PMID: 38548445 DOI: 10.1016/j.cld.2024.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
Hepatic encephalopathy (HE) is a strong predictor of early hospital readmission in patients with cirrhosis. Early hospital readmission increases health care costs and is associated with worse survival. Herein we provide an overview of strategies to prevent hospital readmissions in patients with HE, divided into 3 contexts: (a) acute inpatient, (b) immediate postdischarge, and (c) longitudinal outpatient setting.
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Affiliation(s)
- Emily Lin
- Department of Gastroenterology, Loma Linda University, Loma Linda, CA, USA
| | - Devika Gandhi
- Department of Gastroenterology, Loma Linda University, Loma Linda, CA, USA.
| | - Michael Volk
- Department of Medicine, Baylor Scott and White, Central Texas Region, Temple, TX, USA
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16
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Wiest IC, Sicorello M, Yesmembetov K, Ebert MP, Teufel A. Usage Behaviour and Adoption Criteria for Mobile Health Solutions in Patients with Chronic Diseases in Gastroenterology. Visc Med 2024; 40:61-74. [PMID: 38584857 PMCID: PMC10995963 DOI: 10.1159/000534191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 09/18/2023] [Indexed: 04/09/2024] Open
Abstract
Introduction Mobile Health (mHealth) applications allow for new possibilities and opportunities in patient care. Their potential throughout the whole patient journey is undisputed. However, the eventual adoption by patients depends on their acceptance of and motivation to use mHealth applications as well as their adherence. Therefore, we investigated the motivation and drivers of acceptance for mHealth and developed an adapted model of the Unified Theory of Acceptance and Use of Technology (UTAUT2). Methods We evaluated 215 patients with chronic gastroenterological diseases who answered a questionnaire including all model constructs with 7-point Likert scale items. Our model was adapted from the Unified Theory of Acceptance and Use in Technology 2 and includes influencing factors such as facilitating conditions, performance expectancy, hedonic motivation, social influence factors, effort expectancy, as well as personal empowerment and data protection concerns. Model evaluation was performed with structural equation modelling with PLS-SEM. Bootstrapping was performed for hypothesis testing. Results and Conclusion Patients had a median age of 55.5 years, and the gender ratio was equally distributed. Forty percent received a degree from a university, college, technical academy, or engineering school. The majority of patients suffered from chronic liver disease, but patients with inflammatory bowel diseases, GI cancers, and pancreatic diseases were also included. Patients considered their general technology knowledge as medium to good or very good (78%). Actual usage of mHealth applications in general was rare, while the intention to use them was high. The leading acceptance factor for mHealth applications in our patient group was feasibility, both in terms of technical requirements and the intuitiveness and manageability of the application. Concerns about data privacy did not significantly impact the intention to use mobile devices. Neither the gamification aspect nor social influence factors played a significant role in the intention to use mHealth applications. Interpretation Most of our patients were willing to spend time on a mHealth application specific to their disease on a regular basis. Acceptance and adherence are ensured by efficient utilization that requires minimum effort and compatible technologies as well as support in case of difficulties. Social influence and hedonic motivation, which were part of UTAUT2, as well as data security concerns, were not significantly influencing our patients' intention to use mHealth applications. A literature review revealed that drivers of acceptance vary considerably among different population and patient groups. Therefore, healthcare and mHealth providers should put effort into understanding their specific target groups' drivers of acceptance. We provided those for a cohort of patients from gastroenterology in this project.
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Affiliation(s)
- Isabella C. Wiest
- Department of Medicine II, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Maurizio Sicorello
- Department of Psychosomatic Medicine and Psychotherapy, Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Kakharman Yesmembetov
- Department of Medicine III, University Medical Center Aachen, Aachen, Germany
- Department of Gastroenterology and Hepatology, National Research Oncology Center, Astana, Kazakhstan
| | - Matthias P. Ebert
- Department of Medicine II, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
- Clinical Cooperation Unit Healthy Metabolism, Center for Preventive Medicine and Digital Health Baden-Württemberg (CPDBW), Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Andreas Teufel
- Clinical Cooperation Unit Healthy Metabolism, Center for Preventive Medicine and Digital Health Baden-Württemberg (CPDBW), Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
- Division of Hepatology, Division of Bioinformatics, Department of Medicine II, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
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17
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Pun CK, Huang HC, Chang CC, Hsu SJ, Huang YH, Hou MC, Lee FY. Hepatic encephalopathy: From novel pathogenesis mechanism to emerging treatments. J Chin Med Assoc 2024; 87:245-251. [PMID: 38109364 DOI: 10.1097/jcma.0000000000001041] [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: 12/20/2023] Open
Abstract
Hepatic encephalopathy (HE) is one of the major complications of liver disease and significantly affects the quality of life (QOL) of patients. HE is common and frequently relapses in cirrhotic patients. The management of HE is supportive, and precipitating conditions should be eliminated. Most drugs used to treat HE are conventional and include nonabsorbable disaccharides such as lactulose, and antibiotics such as rifaximin. However, their therapeutic efficacy is still suboptimal, and novel therapeutic agents are urgently needed. In addition, the optimal management and diagnosis of minimal HE/covert HE are under debate. In this review, we focus on novel pathogenetic mechanisms such as central nervous system clearance, and emerging therapeutic targets of HE, such as fecal material transplantation. We also discuss different classifications and etiologies of HE.
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Affiliation(s)
- Chon Kit Pun
- Faculty of Medicine, National Yang Ming Chiao Tung University School of Medicine, Taipei, Taiwan, ROC
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Therapeutic and Research Center of Liver Cirrhosis and Portal Hypertension, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Hui-Chun Huang
- Faculty of Medicine, National Yang Ming Chiao Tung University School of Medicine, Taipei, Taiwan, ROC
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Therapeutic and Research Center of Liver Cirrhosis and Portal Hypertension, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Ching-Chih Chang
- Faculty of Medicine, National Yang Ming Chiao Tung University School of Medicine, Taipei, Taiwan, ROC
- Division of Holistic and Multidisciplinary Medicine, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Shao-Jung Hsu
- Faculty of Medicine, National Yang Ming Chiao Tung University School of Medicine, Taipei, Taiwan, ROC
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Therapeutic and Research Center of Liver Cirrhosis and Portal Hypertension, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Yi-Hsiang Huang
- Faculty of Medicine, National Yang Ming Chiao Tung University School of Medicine, Taipei, Taiwan, ROC
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Ming-Chih Hou
- Faculty of Medicine, National Yang Ming Chiao Tung University School of Medicine, Taipei, Taiwan, ROC
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Therapeutic and Research Center of Liver Cirrhosis and Portal Hypertension, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Fa-Yauh Lee
- Faculty of Medicine, National Yang Ming Chiao Tung University School of Medicine, Taipei, Taiwan, ROC
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Therapeutic and Research Center of Liver Cirrhosis and Portal Hypertension, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
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18
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Varma N, Han JK, Passman R, Rosman LA, Ghanbari H, Noseworthy P, Avari Silva JN, Deshmukh A, Sanders P, Hindricks G, Lip G, Sridhar AR. Promises and Perils of Consumer Mobile Technologies in Cardiovascular Care: JACC Scientific Statement. J Am Coll Cardiol 2024; 83:611-631. [PMID: 38296406 DOI: 10.1016/j.jacc.2023.11.024] [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: 11/01/2023] [Accepted: 11/16/2023] [Indexed: 02/08/2024]
Abstract
Direct-to-consumer (D2C) wearables are becoming increasingly popular in cardiovascular health management because of their affordability and capability to capture diverse health data. Wearables may enable continuous health care provider-patient partnerships and reduce the volume of episodic clinic-based care (thereby reducing health care costs). However, challenges arise from the unregulated use of these devices, including questionable data reliability, potential misinterpretation of information, unintended psychological impacts, and an influx of clinically nonactionable data that may overburden the health care system. Further, these technologies could exacerbate, rather than mitigate, health disparities. Experience with wearables in atrial fibrillation underscores these challenges. The prevalent use of D2C wearables necessitates a collaborative approach among stakeholders to ensure effective integration into cardiovascular care. Wearables are heralding innovative disease screening, diagnosis, and management paradigms, expanding therapeutic avenues, and anchoring personalized medicine.
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Affiliation(s)
- Niraj Varma
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA.
| | - Janet K Han
- Department of Cardiology, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA; Department of Cardiology, David Geffen School of Medicine at the University of California-Los Angeles, Los Angeles, California, USA
| | - Rod Passman
- Department of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Lindsey Anne Rosman
- Division of Cardiology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Hamid Ghanbari
- Department of Cardiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Peter Noseworthy
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Abhishek Deshmukh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Prashanthan Sanders
- Department of Cardiology, University of Adelaide, South Australia, Australia
| | | | - Gregory Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University, and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom; Department of Clinical Medicine, Danish Center for Clinical Health Services Research, Aalborg University, Aalborg, Denmark
| | - Arun R Sridhar
- Department of Cardiology, Pulse Heart Institute, Seattle, Washington, USA; Department of Clinical Medicine, Danish Center for Clinical Health Services Research, Aalborg University, Aalborg, Denmark
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19
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Bajaj JS, Fagan A, Gavis EA, Mousel T, Gallagher ML, Puri P, Fuchs M, Davis BC, Hylemon PB, Zhou H, Ahluwalia V, Cadrain R, Sikaroodi M, Gillevet PM. The RIVET RCT: Rifamycin SV MMX improves muscle mass, physical function, and ammonia in cirrhosis and minimal encephalopathy. Hepatol Commun 2024; 8:e0384. [PMID: 38315140 PMCID: PMC10843468 DOI: 10.1097/hc9.0000000000000384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 01/02/2024] [Indexed: 02/07/2024] Open
Abstract
BACKGROUND Minimal hepatic encephalopathy (MHE) negatively affects the prognosis of cirrhosis, but treatment is not standard. Rifamycin SV MMX (RiVM) is a nonabsorbable rifampin derivative with colonic action. METHODS In a phase 2 placebo-controlled, double-blind randomized clinical trial patients with MHE were randomized to RiVM or placebo for 30 days with a 7-day follow-up. The primary endpoint was a change in stool cirrhosis dysbiosis ratio. Gut-brain (cognition, stool/salivary microbiome, ammonia, brain magnetic resonance spectroscopy), inflammation (stool calprotectin/serum cytokines), patient-reported outcomes (sickness impact profile: total/physical/psychosocial, high = worse), and sarcopenia (handgrip, bioelectric impedance) were secondary. Between/within groups and delta (post-pre) comparisons were performed. RESULTS Thirty patients (15/group) were randomized and completed the study without safety concerns. While cirrhosis dysbiosis ratio was statistically similar on repeated measures ANOVA (95% CI: -0.70 to 3.5), ammonia significantly reduced (95% CI: 4.4-29.6) in RiVM with changes in stool microbial α/β-diversity. MHE status was unchanged but only serial dotting (which tests motor strength) improved in RiVM-assigned patients. Delta physical sickness impact profile (95% CI: 0.33 = 8.5), lean mass (95% CI: -3.3 to -0.9), and handgrip strength (95% CI: -8.1 to -1.0) improved in RiVM versus placebo. Stool short-chain fatty acids (propionate, acetate, and butyrate) increased post-RiVM. Serum, urine, and stool bile acid profile changed to nontoxic bile acids (higher hyocholate/ursodeoxycholate and lower deoxycholate/lithocholate) post-RiVM. Serum IL-1β and stool calprotectin decreased while brain magnetic resonance spectroscopy showed higher glutathione concentrations in RiVM. CONCLUSIONS RiVM is well tolerated in patients with MHE with changes in stool microbial composition and function, ammonia, inflammation, brain oxidative stress, and sarcopenia-related parameters without improvement in cognition. RiVM modulates the gut-brain axis and gut-muscle axis in cirrhosis.
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Affiliation(s)
- Jasmohan S. Bajaj
- Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, Virginia Commonwealth University and Richmond VA Medical Center, Richmond, Virginia, USA
| | - Andrew Fagan
- Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, Virginia Commonwealth University and Richmond VA Medical Center, Richmond, Virginia, USA
| | - Edith A. Gavis
- Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, Virginia Commonwealth University and Richmond VA Medical Center, Richmond, Virginia, USA
| | - Travis Mousel
- Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, Virginia Commonwealth University and Richmond VA Medical Center, Richmond, Virginia, USA
| | - Mary L. Gallagher
- Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, Virginia Commonwealth University and Richmond VA Medical Center, Richmond, Virginia, USA
| | - Puneet Puri
- Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, Virginia Commonwealth University and Richmond VA Medical Center, Richmond, Virginia, USA
| | - Michael Fuchs
- Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, Virginia Commonwealth University and Richmond VA Medical Center, Richmond, Virginia, USA
| | - Brian C. Davis
- Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, Virginia Commonwealth University and Richmond VA Medical Center, Richmond, Virginia, USA
| | - Phillip B. Hylemon
- Department of Microbiology and Immunology, Virginia Commonwealth University and Richmond VA Medical Center, Richmond, Virginia, USA
| | - Huiping Zhou
- Department of Microbiology and Immunology, Virginia Commonwealth University and Richmond VA Medical Center, Richmond, Virginia, USA
| | - Vishwadeep Ahluwalia
- Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, Virginia Commonwealth University and Richmond VA Medical Center, Richmond, Virginia, USA
- Center for Advanced Brain Imaging, Georgia Institute of Technology, Atlanta, Georgia, USA
| | - Robert Cadrain
- Collaborative Advanced Research Imaging Center, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Masoumeh Sikaroodi
- Microbiome Analysis Center, George Mason University, Manassas, Virginia, USA
| | - Patrick M. Gillevet
- Microbiome Analysis Center, George Mason University, Manassas, Virginia, USA
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Huang CH, Yu TY, Tseng WEJ, Huang YT, Chang SH, Hsieh SY, Chien RN, Amodio P. Animal naming test is a simple and valid tool for detecting covert hepatic encephalopathy and predicting outcomes in Chinese-speaking regions: a preliminary study. Ann Med 2023; 55:2236013. [PMID: 37494454 PMCID: PMC10373624 DOI: 10.1080/07853890.2023.2236013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 06/19/2023] [Accepted: 07/09/2023] [Indexed: 07/28/2023] Open
Abstract
BACKGROUND AND AIMS Hepatic encephalopathy (HE) implies high morbidity and mortality. The assessment of covert HE (CHE) [i.e. minimal HE (MHE) plus grade 1 HE] is often neglected in Taiwan. Therefore, the aim was to investigate the potential of the animal naming test (ANT1 and simplified ANT1 (S-ANT1)) for assessing CHE in Chinese-speaking regions, specifically Taiwan. METHODS A prospective cohort study was conducted, comprising 65 cirrhotic patients and 29 healthy controls (relatives of the patients). Patients were followed up every three months and censored after two years or until death. Hospitalization for overt HE (OHE) and mortality were considered. All subjects underwent ANT1, psychometric HE score (PHES), and mini-mental state examination (MMSE). The patients underwent an electroencephalogram (EEG) to detect slowing indicative of MHE. Cut-off values for ANT1 and S-ANT1 were assessed by ROC analysis and Youden's index, considering CHE as a reference. The prognostic values for OHE and OHE-free survival were assessed. RESULTS Preliminary analysis confirmed that PHES ≤-4 is a good discriminant point for abnormal results. CHE was found in 29 patients: 9 had MHE (PHES ≤ -4 or altered EEG) and 20 had grade 1 HE. ANT1 and S-ANT1 were found to have diagnostic values for CHE: AUC = 0.807, 0.786; cut off: 18 and 19, respectively. ANT1 and S-ANT1 were found to have prognostic value for OHE, number of hospitalization episodes for OHE, and OHE recurrence-free survival. CONCLUSIONS ANT1 shows promise as a tool for CHE detection, quantification, and follow-up in Taiwan and other Chinese-speaking regions.Key messagesThe animal naming test (ANT1) is a simple and valid semantic fluency test that can be easily performed in outpatient or bedside settings in one minute and can also be used as a tool for covert hepatic encephalopathy (CHE) detection, quantification, and follow-up in Taiwan, other Chinese-speaking regions, and many other countries.The diagnostic value of ANT1 and S-ANT1 for CHE were found to be significant, with area under the receiver operating characteristic curve (AUROC) values of 0.807 and 0.786 respectively, and cut-off scores of 18 and 19.ANT1 and S-ANT1 have prognostic value for the first breakthrough of overt hepatic encephalopathy (OHE), number of hospitalization episodes for OHE, and OHE recurrence-free survival, independent of the MELD score.
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Affiliation(s)
- Chien-Hao Huang
- Division of Hepatology, Department of Gastroenterology and Hepatology, Chang-Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan
- College of Medicine, Chang-Gung University, Taoyuan, Taiwan
| | - Tung-Yang Yu
- College of Medicine, Chang-Gung University, Taoyuan, Taiwan
- Department of Physical Medicine and Rehabilitation, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Wei-En Johnny Tseng
- College of Medicine, Chang-Gung University, Taoyuan, Taiwan
- Section of Epilepsy, Department of Neurology, Chang Gung Memorial Hospital at Linkou Medical Center and Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Yu-Tung Huang
- Center for Big Data Analytics and Statistics, Department of Medical Research and Development, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan
- Graduate Institute of Nursing, Chang Gung University of Science and Technology, Taoyuan, Taiwan
| | - Shang-Hung Chang
- College of Medicine, Chang-Gung University, Taoyuan, Taiwan
- Graduate Institute of Nursing, Chang Gung University of Science and Technology, Taoyuan, Taiwan
- Cardiovascular Division, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan City, Taiwan
| | - Sen-Yung Hsieh
- Division of Hepatology, Department of Gastroenterology and Hepatology, Chang-Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan
- College of Medicine, Chang-Gung University, Taoyuan, Taiwan
| | - Rong-Nan Chien
- Division of Hepatology, Department of Gastroenterology and Hepatology, Chang-Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan
- College of Medicine, Chang-Gung University, Taoyuan, Taiwan
| | - Piero Amodio
- Department of Medicine, University of Padova, Padova, Italy
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Hasan M, Bidargaddi N, Muller K, Ramachandran J, Narayana S, Wigg AJ. Integrating smart phone applications in the management of cirrhotic patients: A scoping review. JGH Open 2023; 7:826-831. [PMID: 38162857 PMCID: PMC10757474 DOI: 10.1002/jgh3.13021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Revised: 10/27/2023] [Accepted: 12/01/2023] [Indexed: 01/03/2024]
Abstract
Background and Aim Chronic liver disease and cirrhosis is a significant cause of healthcare utilization and patient morbidity and mortality worldwide. Smartphone applications have high uptake in most communities and therefore have great potential to provide remote support solutions to this patient population. The aim of this scoping review was therefore to provide a comprehensive overview using narrative synthesis on the use of smartphone-application-based digital interventions in cirrhotic populations. Materials and Methods PRISMA guidelines were followed, with two independent researchers identifying 10 relevant studies. Patients studied were predominantly those with decompensated cirrhosis, and hepatic encephalopathy was the most common complication studied. Results Smartphones were the most common platform used, but training periods, prior to commencement of the study, were rarely offered. Patient engagement rates with the technology were reported only in three studies, but all reported high (>50%) rates of engagement. Only one study examined the clinical effects of their digital intervention, with a 38% reduction in readmission rate reported. Conclusion Overall, the use of smartphone apps in cirrhosis is in an early phase of development and evaluation but preliminary studies suggest significant potential as an adjunct to routine medical care. Further high-quality studies of well-designed digital interventions are needed to advance this promising early experience.
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Affiliation(s)
- Mohamed Hasan
- Hepatology and Liver Transplantation Medicine UnitSouthern Adelaide Local Health NetworkBedford ParkSouth AustraliaAustralia
| | - Niranjan Bidargaddi
- College of Medicine and Public HealthFlinders University of South AustraliaBedford ParkSouth AustraliaAustralia
| | - Kate Muller
- Hepatology and Liver Transplantation Medicine UnitSouthern Adelaide Local Health NetworkBedford ParkSouth AustraliaAustralia
- College of Medicine and Public HealthFlinders University of South AustraliaBedford ParkSouth AustraliaAustralia
| | - Jeyamani Ramachandran
- Hepatology and Liver Transplantation Medicine UnitSouthern Adelaide Local Health NetworkBedford ParkSouth AustraliaAustralia
- College of Medicine and Public HealthFlinders University of South AustraliaBedford ParkSouth AustraliaAustralia
| | - Sumudu Narayana
- Hepatology and Liver Transplantation Medicine UnitSouthern Adelaide Local Health NetworkBedford ParkSouth AustraliaAustralia
| | - Alan J Wigg
- Hepatology and Liver Transplantation Medicine UnitSouthern Adelaide Local Health NetworkBedford ParkSouth AustraliaAustralia
- College of Medicine and Public HealthFlinders University of South AustraliaBedford ParkSouth AustraliaAustralia
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Ploydang T, Khovidhunkit W, Tanaka H, Suksom D. Nordic Walking in Water on Cerebrovascular Reactivity and Cognitive Function in Elderly Patients with Type 2 Diabetes. Med Sci Sports Exerc 2023; 55:1803-1811. [PMID: 37204017 DOI: 10.1249/mss.0000000000003216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
INTRODUCTION Aquatic Nordic walking (ANW) is a novel whole-body low-impact exercise that can be practiced by a variety of older adults with chronic conditions. However, its efficacy on several aspects of health is largely unknown. PURPOSE This study aimed to determine the effects of regular ANW on glycemic control and vascular function in older adults with type 2 diabetes and mild cognitive impairment. METHODS Thirty-three older adults with type 2 diabetes age 60-75 yr were randomly allocated to nonexercising control ( n = 17) or ANW ( n = 17) groups. Nordic walking was performed in a pool at water temperature of 34°C-36°C, three times per week for 12 wk. RESULTS Measures of functional physical fitness including chair stand, timed up and go, chair sit and reach, reach and back scratch, and 6-min walk test scores were all improved after ANW (all P < 0.05). Plasma glucose, glycosylated hemoglobin, and homeostasis model assessment of insulin resistance decreased (all P < 0.05) in ANW. Vascular reactivity as assessed by brachial flow-mediated dilation increased, and arterial stiffness as assessed by brachial-ankle pulse wave velocity decreased in ANW (all P < 0.05). No significant changes were observed in the control group. Middle cerebral artery pulsatility index decreased with ANW under normocapnia condition ( P < 0.05). Cerebrovascular conductance increased with ANW under hypercapnia condition. Montreal Cognitive Assessment score increased in the ANW group ( P < 0.001). Changes in Montreal Cognitive Assessment scores were positively associated with corresponding changes in brain-derived neurotrophic factor ( r = 0.540, P = 0.031). CONCLUSIONS Nordic walking in water was a safe and effective innovative exercise modality to improve glycemic control, vascular function, physical fitness, cerebrovascular reactivity, and cognitive function in older adults with type 2 diabetes.
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Affiliation(s)
| | | | - Hirofumi Tanaka
- Department of Kinesiology and Health Education, The University of Texas at Austin, Austin, TX
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23
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Calvo Córdoba A, García Cena CE, Montoliu C. Automatic Video-Oculography System for Detection of Minimal Hepatic Encephalopathy Using Machine Learning Tools. SENSORS (BASEL, SWITZERLAND) 2023; 23:8073. [PMID: 37836903 PMCID: PMC10575013 DOI: 10.3390/s23198073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 09/18/2023] [Accepted: 09/21/2023] [Indexed: 10/15/2023]
Abstract
This article presents an automatic gaze-tracker system to assist in the detection of minimal hepatic encephalopathy by analyzing eye movements with machine learning tools. To record eye movements, we used video-oculography technology and developed automatic feature-extraction software as well as a machine learning algorithm to assist clinicians in the diagnosis. In order to validate the procedure, we selected a sample (n=47) of cirrhotic patients. Approximately half of them were diagnosed with minimal hepatic encephalopathy (MHE), a common neurological impairment in patients with liver disease. By using the actual gold standard, the Psychometric Hepatic Encephalopathy Score battery, PHES, patients were classified into two groups: cirrhotic patients with MHE and those without MHE. Eye movement tests were carried out on all participants. Using classical statistical concepts, we analyzed the significance of 150 eye movement features, and the most relevant (p-values ≤ 0.05) were selected for training machine learning algorithms. To summarize, while the PHES battery is a time-consuming exploration (between 25-40 min per patient), requiring expert training and not amenable to longitudinal analysis, the automatic video oculography is a simple test that takes between 7 and 10 min per patient and has a sensitivity and a specificity of 93%.
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Affiliation(s)
- Alberto Calvo Córdoba
- Escuela Técnica Superior de Ingenieros Industriales, Center for Automation and Robotics, UPM-CSIC, Universidad Politécnica de Madrid, José Gutiérrez Abascal St., 2, 28006 Madrid, Spain
| | - Cecilia E. García Cena
- Escuela Técnica Superior de Ingeniería y Diseño Industrial, Center for Automation and Robotics, UPM-CSIC, Universidad Politécnica de Madrid, Ronda de Valencia, 3, 28012 Madrid, Spain;
| | - Carmina Montoliu
- Instituto de Investigación Sanitaria-INCLIVA, 46010 Valencia, Spain;
- Servicio de Medicina Digestiva, Hospital Clínico de Valencia, 46010 Valencia, Spain
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24
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Morais MJ, de Oliveira VN, Viana RB, Andrade MS, Vancini RL, Arida RM, Costa GDCT, Campos MH, Vieira CA, Weiss K, Knechtle B, de Lira CAB. Acute effects of moderate-intensity continuous physical exercise performed with different amounts of muscle mass on executive function in healthy young adults: a randomized trial. EXCLI JOURNAL 2023; 22:1032-1046. [PMID: 38023569 PMCID: PMC10630524 DOI: 10.17179/excli2023-6434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 09/12/2023] [Indexed: 12/01/2023]
Abstract
We examined the effect of amount of muscle mass involved in moderate-intensity continuous physical exercise on executive function. To this end, fifty-five participants completed two acute physical exercise sessions on an airbike ergometer using the upper and lower limbs simultaneously and only the upper limbs, and a resting control session in a randomized order. The physical exercise session lasted 30 min and was performed at moderate intensity (between 64 %-76 % of maximal heart rate evaluated in graded maximal exercise testing). Participants took the Stroop test (congruent and incongruent trials) before and after the sessions to assess executive performance. For the congruent trial, both physical exercise interventions improved executive function performance (pre vs. post, p-value = 0.002 and 0.003 for physical exercise with upper limbs and physical exercise with upper and lower limbs, respectively). Furthermore, executive function performance was higher after the physical exercise interventions than after the control session (p-value = 0.002 and 0.004 for physical exercise with upper limbs and physical exercise with upper and lower limbs, respectively). For the incongruent trial, both physical exercise interventions also improved executive function performance (pre vs. post, p-value < 0.001 for physical exercise with upper limbs and physical exercise with upper and lower limbs, respectively). However, there were no significant differences after both physical exercise interventions and resting control session (p-value = 0.175). Executive function (congruent trial) was positively impacted by acute aerobic physical exercise regardless of the amount of muscle mass involved (upper limbs or upper plus lower limbs). Therefore, we recommend aerobic physical exercise with less or more muscle mass involved to improve cognitive function.
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Affiliation(s)
- Marcos José Morais
- Faculdade de Educação Física e Dança, Universidade Federal de Goiás, Goiânia, Brazil
| | | | - Ricardo Borges Viana
- Instituto de Educação Física e Esportes, Universidade Federal do Ceará, Fortaleza, Brazil
| | | | - Rodrigo Luiz Vancini
- Centro de Educação Física e Desportos, Universidade Federal do Espírito Santo, Vitória, Brazil
| | - Ricardo Mario Arida
- Departamento de Fisiologia, Universidade Federal de São Paulo, São Paulo, Brazil
| | | | - Mario Hebling Campos
- Faculdade de Educação Física e Dança, Universidade Federal de Goiás, Goiânia, Brazil
| | | | - Katja Weiss
- Institute of Primary Care, University of Zurich, Zurich, Switzerland
| | - Beat Knechtle
- Institute of Primary Care, University of Zurich, Zurich, Switzerland
- Medbase St. Gallen, Switzerland
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25
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Hamzaoui L, Mahmoudi M, Mohamed G, Elloumi H, Laabidi A, Boubaker J, Boudabbous M, Tahri N, Jemni I, Safer L, Jomni T, Douggui H, Trad D, Gargouri D, Ayadi S, Debbeche R, Belhouchet S, Marouani R, Cheikh I, Abdelli MN. EncephalApp Stroop Test for covert hepatic encephalopathy screening in Tunisian cirrhotic patients. F1000Res 2023; 11:686. [PMID: 37767072 PMCID: PMC10521086 DOI: 10.12688/f1000research.121781.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/29/2023] [Indexed: 09/29/2023] Open
Abstract
Background: Covert hepatic encephalopathy (CHE) is underdiagnosed and is difficult to detect. The EncephalApp Stroop test is validated for its screening. The aim of the study was to define Tunisian norms for the test based on healthy controls norms and to estimate the prevalence of CHE in cirrhotic Tunisian patients. Methods: A prospective, multicenter, cross-sectional study was conducted. Ambulatory or hospitalized cirrhotic patients aged 40 years and over were recruited at 11 centers. Healthy subjects aged 40 years and over were recruited at 8 centers. We used a translated Arabic version of the streamlined EncephalApp Stroop test. The task has two components: "Off" and "On" state depending on the discordance or concordance of the stimuli. Results: 142 patients were included. The mean age was 57.26 years [40-86]. 40 (28.17%) of cirrhotic patients who were included were diagnosed as having a minimal hepatic encephalopathy or CHE. Among the ineligible patients, 22 had overt hepatic encephalopathy. If we consider these patients, the overall prevalence rate of CHE was around 24.39% in cirrhotic patients. It was more frequent in women (34.21% vs 25.96%), and in patients whose level of school education is between 6 and 13 years. Its prevalence does not appear to be affected by gender, MELD score, etiology of cirrhosis and age group of patients, as these variables were independent with respective p according to the chi-square test 0.413; 0.736; 0.663 and 0.1. The stroop times (On / Off and On + Off) correlated significantly with each other, are associated significantly and positively with age (respective Pearson coefficients: 0.578; 0.567 and 0.6). The more the age increases, the more the stroop response times increases (p > 10 -3). Conclusions: EncephalApp Stroop test was an efficient screening tool for CHE in Tunisian cirrhotic patients.
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Affiliation(s)
- Lamine Hamzaoui
- Gastroenterology, Mohamed Taher Maamouri Hospital, Tunis El Manar University, Faculty of Medicine of Tunis, Nabeul, Tunisia
| | - Moufida Mahmoudi
- Gastroenterology, Mohamed Taher Maamouri Hospital, Tunis El Manar University, Faculty of Medicine of Tunis, Nabeul, Tunisia
| | - Ghanem Mohamed
- Gastroenterology, Military Hospital of Tunis, Tunis El Manar University, Faculty of Medicine of Tunis, Tunis, Tunisia
| | - Hanene Elloumi
- Gastroenterology, Habib Bougatfa Hospital, Tunis El Manar University, Faculty of Medicine of Tunis, Bizerte, Tunisia
| | - Asma Laabidi
- Gastroenterology, La Rabta Hospital A, Tunis El Manar University, Faculty of Medicine of Tunis, Tunis, Tunisia
| | - Jalel Boubaker
- Gastroenterology, La Rabta Hospital A, Tunis El Manar University, Faculty of Medicine of Tunis, Tunis, Tunisia
| | - Mona Boudabbous
- Gastroenterology, Hedi Chaker Hospital, Faculty of Medicine of Sfax, Sfax, Tunisia
| | - Nabil Tahri
- Gastroenterology, Hedi Chaker Hospital, Faculty of Medicine of Sfax, Sfax, Tunisia
| | - Imen Jemni
- Gastroenterology, Fattouma Bourguiba University Hospital, Monastir, Monastir, Tunisia
| | - Leila Safer
- Gastroenterology, Fattouma Bourguiba University Hospital, Monastir, Monastir, Tunisia
| | - Taieb Jomni
- Gastroenterology, La Marsa Internal Security Forces Hospital, Tunis El Manar University, Faculty of Medicine of Tunis, Tunis, Tunisia
| | - Hedi Douggui
- Gastroenterology, La Marsa Internal Security Forces Hospital, Tunis El Manar University, Faculty of Medicine of Tunis, Tunis, Tunisia
| | - Dorra Trad
- Gastroenterology, Habib Thameur Hospital, Tunis El Manar University, Faculty of Medicine of Tunis, Tunis, Tunisia
| | - Dalila Gargouri
- Gastroenterology, Habib Thameur Hospital, Tunis El Manar University, Faculty of Medicine of Tunis, Tunis, Tunisia
| | - Shema Ayadi
- Gastroenterology, Hospital Charles Nicolle, Tunis, Tunis El Manar University, Faculty of Medicine of Tunis, Tunis, Tunisia
| | - Radhouane Debbeche
- Gastroenterology, Hospital Charles Nicolle, Tunis, Tunis El Manar University, Faculty of Medicine of Tunis, Tunis, Tunisia
| | | | - Ridha Marouani
- Gastroenterology, Kasserine Hospital, Kasserine, Tunisia
| | - Imed Cheikh
- Gastroenterology, Habib Bougatfa Hospital, Tunis El Manar University, Faculty of Medicine of Tunis, Bizerte, Tunisia
| | - Mohamed Nabil Abdelli
- Gastroenterology, Military Hospital of Tunis, Tunis El Manar University, Faculty of Medicine of Tunis, Tunis, Tunisia
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Thornburg B. Hepatic Encephalopathy following Transjugular Intrahepatic Portosystemic Shunt Placement. Semin Intervent Radiol 2023; 40:262-268. [PMID: 37484451 PMCID: PMC10359131 DOI: 10.1055/s-0043-1769770] [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: 07/25/2023]
Abstract
Hepatic encephalopathy (HE) is a complex condition that arises as a complication of chronic liver disease and portosystemic shunting. Its pathophysiology involves several factors, including impaired ammonia metabolism, portosystemic shunting, sarcopenia, and systemic inflammation. The symptoms of HE can vary significantly, with manifestations ranging from subclinical signs to a comatose state. The West Haven classification system is most commonly used to grade the severity of HE. There is a broad differential for the presenting symptomatology of HE and other causes of altered mental status must be excluded during the workup. HE is a well-known complication of transjugular intrahepatic portosystemic shunt (TIPS) placement. Even though newer stent designs help reduce the risk of HE with smaller diameter shunts, it is essential that patients are counseled regarding this potential risk prior to the procedure. Once a diagnosis of HE has been confirmed, the mainstay of therapy is lactulose and rifaximin. In cases where a patient has received a TIPS placement and continues to experience refractory HE despite medical therapy, it may be necessary to consider shunt reduction or closure.
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Affiliation(s)
- Bartley Thornburg
- Department of Radiology, Section of Interventional Radiology, Northwestern Memorial Hospital, Chicago, Illinois
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27
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Tosun ŞD, Demirtaş CÖ. Is There a More Practical Way for Screening Minimal Hepatic Encephalopathy? THE TURKISH JOURNAL OF GASTROENTEROLOGY : THE OFFICIAL JOURNAL OF TURKISH SOCIETY OF GASTROENTEROLOGY 2023; 34:672. [PMID: 37303247 PMCID: PMC10441061 DOI: 10.5152/tjg.2023.23197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 04/26/2023] [Indexed: 06/13/2023]
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28
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Saleh ZM, Tapper EB. Predicting which patients with cirrhosis will develop overt hepatic encephalopathy: Beyond psychometric testing. Metab Brain Dis 2023; 38:1701-1706. [PMID: 36308589 PMCID: PMC11165565 DOI: 10.1007/s11011-022-01112-3] [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: 07/31/2022] [Accepted: 10/17/2022] [Indexed: 11/24/2022]
Abstract
It remains challenging to identify covert hepatic encephalopathy and predict progression to overt hepatic encephalopathy. Psychometric testing is a widely used diagnostic modality, but it is often inaccurate and difficult to implement in diverse populations, making it a less than ideal assessment. Alternatively, by using easily accessible data from the electronic health record, simple clinical assessment tools, and patient-reported outcomes, we may be better able to predict hepatic encephalopathy across multiple populations. Furthermore, incorporation of patient-reported outcomes into our diagnostic toolset not only aids detection of covert hepatic encephalopathy and prediction of overt hepatic encephalopathy, but also allows us to target therapies and track their impact. Herein, we outline a potential algorithm based on these easily integrated tools to promote patient risk-stratification and early therapeutic intervention.
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Affiliation(s)
- Zachary M Saleh
- Department of Internal Medicine, University of Michigan Health System, Ann Arbor, MI, USA
| | - Elliot B Tapper
- Division of Gastroenterology, University of Michigan Health System, 3912 Taubman, SPC 5362, 1500 E Medical Center Dr, Ann Arbor, MI, 48109, USA.
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Gairing SJ, Schleicher EM, Galle PR, Labenz C. Prediction and prevention of the first episode of overt hepatic encephalopathy in patients with cirrhosis. Hepatol Commun 2023; 7:02009842-202304010-00007. [PMID: 36930868 PMCID: PMC10027066 DOI: 10.1097/hc9.0000000000000096] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 12/13/2022] [Indexed: 03/19/2023] Open
Abstract
Hepatic encephalopathy (HE) is one of the most important complications of patients with liver cirrhosis. In addition, HE is associated with a dismal prognosis and has detrimental effects on patients' quality of life. Thus, it is of pivotal importance to identify patients at high risk for overt HE (OHE) in whom primary prophylaxis may be justified. In this narrative review, we aim to provide insight into predictors and prediction tools for a first-time episode of OHE and to scrutinize the current level of evidence of primary prophylaxis. In recent decades, several cognitive tests, composite scores, and blood-based biomarkers have been demonstrated to be predictive of a first-time episode of OHE. Among the best validated are the established tests for minimal HE, such as the Psychometric Hepatic Encephalopathy Score, determination of the critical flicker frequency, Stroop EncephalApp, or the Animal Naming Test. Individualized risk stratification using blood-based biomarkers and cross-sectional imaging (sarcopenia and spontaneous portosystemic shunts) is coming to the fore, but validation in larger multicenter cohorts is often lacking. On the basis of current evidence, a recommendation for primary prophylaxis of a first episode of OHE cannot be made in general. Only 2 studies have investigated the prevention of a first-time OHE episode as the primary endpoint. In this narrative review, we provide a concise overview of the current evidence levels on prediction tools and pharmacological prevention of a first episode of OHE. In addition, we give an outlook on future research targets to improve knowledge on this important topic.
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Affiliation(s)
- Simon J Gairing
- Department of Internal Medicine I, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
- Cirrhosis Center Mainz (CCM), University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Eva M Schleicher
- Department of Internal Medicine I, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
- Cirrhosis Center Mainz (CCM), University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Peter R Galle
- Department of Internal Medicine I, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
- Cirrhosis Center Mainz (CCM), University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Christian Labenz
- Department of Internal Medicine I, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
- Cirrhosis Center Mainz (CCM), University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
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Thabut D, Bouzbib C, Meunier L, Haas M, Weiss N, Louvet A, Imbert-Bismut F, Mochel F, Nadjar Y, Santiago A, Thevenot T, Duhalde V, Oberti F, Francoz C, Coilly A, Hilleret MN, Lebray P, Liou-Schischmanoff A, Barbier L, Duvoux C, Pageaux GP, Bismuth M, Galanaud D, Broucker TD, Cadranel JF, Leroy V, Di Martino V, Larrey D, Camus C, Scatton O, De Ledinghen V, Mallat A, Rudler M, Bureau C. Diagnosis and management of hepatic encephalopathy: The French recommendations. Liver Int 2023; 43:750-762. [PMID: 36625084 DOI: 10.1111/liv.15510] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 11/27/2022] [Accepted: 12/31/2022] [Indexed: 01/11/2023]
Abstract
Hepatic encephalopathy (HE) is a frequent and severe complication of liver disease with poor patient outcomes. However, it is a poorly understood complication, with no consensus for diagnosis. Therefore, HE is often underdiagnosed. Differential diagnosis may be cumbersome because of non-specific symptoms, such as confusion, cognitive disorders, the aetiological factors of cirrhosis and comorbidities, which are often observed in cirrhotic patients. Therefore, an overt or covert form of HE should be systematically investigated. Advice is provided to drive patient work-up. Effective treatments are available to prevent or treat HE bouts, but the issue of single or combination therapy has not been resolved. Transjugular intrahepatic portosystemic shunt (TIPS) placement largely improved the prognosis of cirrhotic patients, but HE occurrence of HE is often a fear, even when post-TIPS HE can be avoided by a careful selection of patients and preventive treatment. HE is an indication of liver transplantation. However, its reversibility post-transplantation and the consequences of transplantation in patients with other causes of neurological disorders remain controversial, which supports the performance of an extensive work-up in expert centres for this subset of patients. The present guidelines assist clinicians in the diagnosis of the overt or covert form of HE to implement curative and preventive treatments and clarify which patients require referral to expert centres for consideration for liver transplantation. These guidelines are very clinically oriented and address different frequent clinical issues to help physicians make bedside decisions.
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Affiliation(s)
- Dominique Thabut
- APHP-Sorbonne Université, Service d'hépato-gastroentérologie, Hôpital Pitié-Salpêtrière. INSERM, Centre de Recherche Saint-Antoine (CRSA), Institute of Cardiometabolism and Nutrition (ICAN). Brain-Liver Pitié-Salpêtrière Study Group (BLIPS), Paris, France
| | - Charlotte Bouzbib
- APHP-Sorbonne Université, Service d'hépato-gastroentérologie, Hôpital Pitié-Salpêtrière. INSERM, Centre de Recherche Saint-Antoine (CRSA), Institute of Cardiometabolism and Nutrition (ICAN). Brain-Liver Pitié-Salpêtrière Study Group (BLIPS), Paris, France
| | - Lucy Meunier
- Service d'hépato-gastroentérologie A et Transplantation, Hôpital Saint-Eloi, CHU de Montpellier, Montpellier, France
| | - Manon Haas
- APHP-Paris Saclay, Centre Hépato-Biliaire, Hôpital Paul Brousse, Université Paris-saclay, Villejuif, France
| | - Nicolas Weiss
- APHP-Sorbonne Université, Service de réanimation neurologique, Hôpital Pitié-Salpêtrière. INSERM, Centre de Recherche Saint-Antoine (CRSA), Institute of Cardiometabolism and Nutrition (ICAN). Brain-Liver Pitié-Salpêtrière Study Group (BLIPS), Paris, France
| | - Alexandre Louvet
- Services des maladies de l'appareil digestif, CHRU de Lille, Lille, France
| | - Francois Imbert-Bismut
- APHP-Sorbonne Université, Service de biochimie, Hôpital Pitié-Salpêtrière, Paris, France
| | - Fanny Mochel
- APHP-Sorbonne Université, Service de génétique, Hôpital Pitié-Salpêtrière, Paris, France
| | - Yann Nadjar
- APHP-Sorbonne Université, Service de neurologie, Hôpital Pitié-Salpêtrière, Paris, France
| | - Antoine Santiago
- APHP-Sorbonne Université, Service d'hépato-gastroentérologie, Hôpital Pitié-Salpêtrière. INSERM, Centre de Recherche Saint-Antoine (CRSA), Institute of Cardiometabolism and Nutrition (ICAN). Brain-Liver Pitié-Salpêtrière Study Group (BLIPS), Paris, France
| | - Thierry Thevenot
- Service d'hépatologie, Hôpital Jean Minjoz, CHU de Besançon, Besançon, France
| | - Véronique Duhalde
- Service de pharmacie, Hôpital Rangueil, CHU de Toulouse, Toulouse, France
| | - Frédéric Oberti
- Laboratoire HIFIH, UPRES-EA2170, Faculté de Médecine, Service d'hépato-gastroentérologie, CHU ANGERS, Angers, France
| | - Claire Francoz
- APHP-Hôpital Beaujon, Service d'hépatologie, Clichy, France
| | - Audrey Coilly
- APHP-Paris Saclay, Centre Hépato-Biliaire, Hôpital Paul Brousse, Université Paris-saclay, Villejuif, France
| | | | - Pascal Lebray
- APHP-Sorbonne Université, Service d'hépato-gastroentérologie, Hôpital Pitié-Salpêtrière. INSERM, Centre de Recherche Saint-Antoine (CRSA), Institute of Cardiometabolism and Nutrition (ICAN). Brain-Liver Pitié-Salpêtrière Study Group (BLIPS), Paris, France
| | | | - Louise Barbier
- Service de chirurgie hépatique et transplantation, CHU de Tours, Tours, France
| | | | - Georges-Philippe Pageaux
- Service d'hépato-gastroentérologie A et Transplantation, Hôpital Saint-Eloi, CHU de Montpellier, Montpellier, France
| | - Michael Bismuth
- Service d'hépato-gastroentérologie B, Hôpital Saint Eloi, CHU de Montpellier, Montpellier, France
| | - Damien Galanaud
- APHP-Sorbonne Université, Service de neuro-radiologie, Hôpital Pitié-Salpêtrière, Paris, France
| | - Thomas De Broucker
- Service de Neurologie Hôpital Pierre Delafontaine, Centre Hospitalier de Saint-Denis, Saint-Denis, France
| | - Jean-François Cadranel
- Service d'hépato-gastroentérologie de nutrition et d'Alcoologie-GHPSO site de Creil, Creil, France
| | - Vincent Leroy
- APHP Hôpital Henri-Mondor, Service d'hépatologie, Créteil, France
| | - Vincent Di Martino
- Service d'hépatologie, Hôpital Jean Minjoz, CHU de Besançon, Besançon, France
| | - Dominique Larrey
- Service d'hépato-gastroentérologie A et Transplantation, Hôpital Saint-Eloi, CHU de Montpellier, Montpellier, France
| | - Christophe Camus
- Service de réanimation Médicale, Hôpital Pontchaillou, CHU de Rennes, Rennes, France
| | - Olivier Scatton
- APHP-Sorbonne Université, Service de chirurgie et transplantation hépatique, Hôpital Pitié-Salpêtrière, Paris, France
| | - Victor De Ledinghen
- Service d'hépato-gastroentérologie, Hôpital du Haut-Lévêque, CHU de Bordeaux, Bordeaux, France
| | - Ariane Mallat
- APHP Hôpital Henri-Mondor, Service d'hépatologie, Créteil, France
| | - Marika Rudler
- APHP-Sorbonne Université, Service d'hépato-gastroentérologie, Hôpital Pitié-Salpêtrière. INSERM, Centre de Recherche Saint-Antoine (CRSA), Institute of Cardiometabolism and Nutrition (ICAN). Brain-Liver Pitié-Salpêtrière Study Group (BLIPS), Paris, France
| | - Christophe Bureau
- Service d'hépatologie, Hôpital Rangueil, CHU de Toulouse, Toulouse, France
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Kaplan A, Comisar L, Ufere NN, Jannat-Khah D, Rosenblatt R, Fortune B, Prigerson HG, Brown R. Understanding Prognosis: Discrepancy in Prognosis Estimates Between Patients With Cirrhosis and their Hepatologists. Clin Gastroenterol Hepatol 2023; 21:1005-1012.e4. [PMID: 35643416 PMCID: PMC9699897 DOI: 10.1016/j.cgh.2022.04.042] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 03/28/2022] [Accepted: 04/26/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Patients require a clear understanding of their prognosis to make informed decisions about their care. The aim of this study was to compare the perceptions of prognosis and transplant candidacy between patients with cirrhosis and their hepatologists. METHODS Patients with cirrhosis and their hepatologists were prospectively recruited at an urban liver transplant center. Patients and hepatologists were asked about transplant candidacy and about how many years patients would live with and without a liver transplant. Agreement between patients and hepatologists was assessed with the weighted kappa statistic. Associations between patient/hepatologists' prognostic estimates and those predicted by patients' Model for End-Stage Liver Disease-Sodium (MELD-Na) score were estimated using the Pearson correlation coefficient. RESULTS Seventy patients and 6 hepatologists were enrolled in the study. Patients were predominantly male (61.4%) and white (68.6%), with a mean MELD-Na score of 19 ± 9. There was no-slight agreement between patients and hepatologists regarding survival without and with a liver transplant (κ = 0.1 and 0.2, respectively), with patients more optimistic than their hepatologists. There was greater agreement between patients and hepatologists about transplant candidacy (κ = 0.6). There was a negligible association between MELD-Na and patient estimates (r = -0.24, P = .05) but a moderate association between MELD-Na and hepatologist estimates (r = -0.51, P < .001), with higher MELD-Na scores associated with lower predicted survival. CONCLUSIONS Patients with cirrhosis are more optimistic and less accurate in their predictions of survival compared with hepatologists, although they are more realistic about their transplant candidacy. Aligning patient and provider expectations may increase the likelihood that patients receive value-concordant care.
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Affiliation(s)
- Alyson Kaplan
- Division of Gastroenterology and Hepatology, Department of Medicine, Weill Cornell School of Medicine, New York Presbyterian, New York, New York
| | - Lauren Comisar
- Weill Cornell Medical College, Weill Cornell Medicine, New York, New York
| | - Nneka N Ufere
- Gastrointestinal Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Deanna Jannat-Khah
- Weill Cornell Medical College, Weill Cornell Medicine, New York, New York
| | - Russell Rosenblatt
- Division of Gastroenterology and Hepatology, Department of Medicine, Weill Cornell School of Medicine, New York Presbyterian, New York, New York
| | - Brett Fortune
- Division of Gastroenterology and Hepatology, Department of Medicine, Weill Cornell School of Medicine, New York Presbyterian, New York, New York
| | - Holly G Prigerson
- Weill Cornell Medical College, Weill Cornell Medicine, New York, New York
| | - Robert Brown
- Division of Gastroenterology and Hepatology, Department of Medicine, Weill Cornell School of Medicine, New York Presbyterian, New York, New York.
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Nardelli S, Gioia S, Faccioli J, Riggio O, Ridola L. Hepatic encephalopathy - recent advances in treatment and diagnosis. Expert Rev Gastroenterol Hepatol 2023; 17:225-235. [PMID: 36843291 DOI: 10.1080/17474124.2023.2183386] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/28/2023]
Abstract
INTRODUCTION Hepatic encephalopathy (HE) is a peculiar kind of brain dysfunction typical of liver cirrhosis characterized by nonspecific neurological and psychiatric manifestations. HE ranges from minimal hepatic encephalopathy (MHE) to the most severe form characterized by alteration of consciousness or coma (overt HE, OHE). Once the diagnosis of OHE is made, every effort to identify and correct the precipitating cause is essential for the resolution of symptoms. Clinical studies that assessed the prevalence and incidence of any type of HE (MHE and OHE) in patients affected by cirrhosis were included in this review. No language, publication date, or publication status restrictions were imposed. The studies were identified by searching electronic databases (PubMed and SCOPUS). AREAS COVERED The most widely empirical pharmacological approach consists of non-absorbable antibiotics (rifaximin) and non-absorbable disaccharides (lactulose, lactitol per os and per enemas). Other agents (including branched-chain amino acids, probiotics, other antibiotics, or intravenous L-ornithine L-aspartate) are available, but the evidence supporting their efficacy remains under debate. EXPERT OPINION Gray areas and future needs remain the therapeutic approach to MHE and issues in the design of therapeutic studies for HE which have been extensively discussed in this review.
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Affiliation(s)
- Silvia Nardelli
- Department of Translational and Precision Medicine, "Sapienza" University of Rome, Rome, Italy
| | - Stefania Gioia
- Department of Translational and Precision Medicine, "Sapienza" University of Rome, Rome, Italy
| | - Jessica Faccioli
- Department of Translational and Precision Medicine, "Sapienza" University of Rome, Rome, Italy
| | - Oliviero Riggio
- Department of Translational and Precision Medicine, "Sapienza" University of Rome, Rome, Italy
| | - Lorenzo Ridola
- Department of Translational and Precision Medicine, "Sapienza" University of Rome, Rome, Italy
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Lupescu IC, Iacob S, Lupescu IG, Pietrareanu C, Gheorghe L. Assessment of Minimal Hepatic Encephalopathy with Brain MRI and EncephalApp Stroop Test. MAEDICA 2023; 18:4-11. [PMID: 37266463 PMCID: PMC10231161 DOI: 10.26574/maedica.2023.18.1.4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Background: Minimal hepatic encephalopathy (MHE) consists of subtle cognitive deficits that are not apparent on a standard neurological examination. Minimal hepatic encephalopathy has been reported in up to 80% of cirrhotic patients and is associated with decreased job performance, poor driving performance, impaired quality of life, and poor survival. In parallel, brain magnetic resonance imaging (MRI) abnormalities are known to occur in liver cirrhotic patients in the form of T1 globus pallidus hyperintensities. In recent years, a new psychometric test for diagnosing MHE has been developed as an app for smartphones and tablets (EncephalApp Stroop test). A translated version of the app is available in Romanian language. Aim:To use EncephalApp Stroop test for MHE diagnosis in our cirrhotic patients; to describe the main brain MRI abnormalities encountered in these patients; and to establish if Stroop test results correlate with imaging findings, clinical neurologic findings, and liver function parameters or prognosis. Material and methods:Cross-sectional study over a one-year period, involving 30 adult patients with liver cirrhosis. Subjects were evaluated through a standard neurological examination, psychometric testing using EncephalApp Stroop test, electroencephalogram and brain MRI. In parallel, 40 adult healthy controls were also recruited and evaluated with the EncephalApp Stroop test using the same methodology. Results:Age distribution was similar between the two groups (p=0.6). The mean age of patients was 50±10 years and that of controls 51±12 years. Mean Stroop result was 171±26 seconds for the patient group and 143±20 seconds for the control group (p<0.0001). There was a direct correlation between Stroop test results and age in the control group (R=0.69, p<0.0001) but not also in the patient group (R=0.28, p=0.13). Statistically significant results were obtained by using the Fischer exact test for both cut-off values: 145 seconds in patients < 45-year-old (p<0.001) and 190 seconds in those ≥45 years-old (p=0.03). MRI T1-hyperintensities of the basal ganglia, blood ammonia levels and electroencephalographic changes were not associated with poorer results. Conclusion:Our pilot study, although small, confirmed that patients with liver cirrhosis may have subtle deficits in cognitive areas like attention, concentration or reaction time. This can be assessed easily with the EncephalApp Stroop test which is readily available for use on smartphones or tablets.
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Affiliation(s)
- I C Lupescu
- Neurology Department, Fundeni Clinical Institute, Bucharest, Romania
- "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
| | - S Iacob
- Gastroenterology and Hepatology Department, Fundeni Clinical Institute, Bucharest, Romania
- "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
| | - I G Lupescu
- Radiology and Medical Imaging Department, Fundeni Clinical Institute, Bucharest, Romania
- "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
| | - C Pietrareanu
- Gastroenterology and Hepatology Department, Fundeni Clinical Institute, Bucharest, Romania
- "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
| | - L Gheorghe
- Gastroenterology and Hepatology Department, Fundeni Clinical Institute, Bucharest, Romania
- "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
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Kovačević N, Mihanović F, Lušić Kalcina L, Hrbić K, Poklepović Peričić T, Matijaš T, Galić T. Influence of cognitive performance and swimming capacities on selection of youth water polo players to national team. J Sports Med Phys Fitness 2023; 63:34-41. [PMID: 35230069 DOI: 10.23736/s0022-4707.22.13592-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Water-polo is an official competitive olympic sport with high energy and technical-tactical demands. The aim of this study was to evaluate the influence of cognitive performance and specific swimming capacities on the selection of youth water polo players to the national water polo team. METHODS There were 83 youth water polo players (mean age 13.61±0.67 years) who attended the Croatian Water Polo Foundation training camps included in this cross-sectional study. Testing included anthropometric measurements, specific swimming capacities and cognitive performance (Stroop test). RESULTS Among 83 youth water polo players included in this study there were 13 goalkeepers, 13 center-defenders, 13 centers, 31 perimeter players and 13 wings. Selected players (N.=40) performed faster in OffTime (selected 62.99±10.21 s vs. non-selected 69.98±8.93 s, P=0.002) and OnTime (selected 75.61±15.85 s vs. non-selected 86.01±15.40 s, P=0.004) of the Stroop test than non-selected players (N.=43). Logistic regression analysis showed significant association between selection of youth water polo players to the national team and swimming results in 400 m crawl and 100 m crawl, as well as OffTime, OnTime and OnTime minus OffTime on the Stroop test. CONCLUSIONS The results of this study showed that psychomotor ability, inhibition, motor speed and cognitive flexibility were found to be the most important predictors for the selection of youth water polo players to the national water polo team. Furthermore, selected water polo players demonstrated better psychomotor abilities, inhibition, and motor speed, as well as better results in all specific swimming tests in comparison to non-selected players.
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Affiliation(s)
- Neven Kovačević
- Faculty of Kinesiology, University of Split, Split, Croatia.,Croatian Water Polo Federation, Zagreb, Croatia
| | - Frane Mihanović
- Department of Health Sciences University of Split, Split, Croatia
| | - Linda Lušić Kalcina
- Department of Neuroscience, School of Medicine, University of Split, Split, Croatia
| | | | - Tina Poklepović Peričić
- Department of Prosthodontics, School of Medicine, Study of Dental Medicine, University of Split, Split, Croatia
| | - Tatjana Matijaš
- Department of Health Sciences University of Split, Split, Croatia
| | - Tea Galić
- Department of Neuroscience, School of Medicine, University of Split, Split, Croatia - .,Department of Prosthodontics, School of Medicine, Study of Dental Medicine, University of Split, Split, Croatia
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Margaryan SR, Razumovsky AY, Mitupov ZB, Gurevich AI, Titova EA. [Reconstruction of total portosystemic shunt into selective portosystemic shunt in a child]. Khirurgiia (Mosk) 2023:140-146. [PMID: 38088852 DOI: 10.17116/hirurgia2023121140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
To date, side-to-side splenorenal shunt (SRS) and its analogues (splenosuprarenal shunts (SSRS)) are mainly used for portal hypertension. These are total portosystemic shunts characterized by total blood shunt from portal vein into inferior vena cava. The latter is fraught with a significant risk of complications such as pulmonary hypertension, decreased portal liver perfusion, liver failure and hepatic encephalopathy. Prevention of these complications is still an urgent problem in modern surgery. However, we proposed a new method of treatment, i.e. reconstruction of SRS and SSRS into selective shunt. This procedure was performed in 37 patients after 2020. We present laparoscopic reconstruction in an 11-year-old girl with portal hypertension and signs of hepatic encephalopathy identified after previous SSRS.
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Affiliation(s)
- S R Margaryan
- Pirogov Russian National Research Medical University, Moscow, Russia
- Children's City Clinical Hospital named after N.F. Filatov, Moscow, Russia
| | - A Yu Razumovsky
- Pirogov Russian National Research Medical University, Moscow, Russia
- Children's City Clinical Hospital named after N.F. Filatov, Moscow, Russia
| | - Z B Mitupov
- Pirogov Russian National Research Medical University, Moscow, Russia
- Children's City Clinical Hospital named after N.F. Filatov, Moscow, Russia
| | - A I Gurevich
- Children's City Clinical Hospital named after N.F. Filatov, Moscow, Russia
| | - E A Titova
- Children's City Clinical Hospital named after N.F. Filatov, Moscow, Russia
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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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Evaluation of CirrhoCare® - a digital health solution for home management of individuals with cirrhosis. J Hepatol 2023; 78:123-132. [PMID: 36087864 DOI: 10.1016/j.jhep.2022.08.034] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 08/10/2022] [Accepted: 08/11/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND & AIMS Individuals with cirrhosis discharged from hospital following acute decompensation are at high risk of new complications. This study aimed to assess the feasibility and potential clinical benefits of remote management of individuals with acutely decompensated cirrhosis using CirrhoCare®. METHODS Individuals with cirrhosis with acute decompensation were followed up with CirrhoCare® and compared with contemporaneous matched controls, managed with standard follow-up. Commercially available monitoring devices were linked to the smartphone CirrhoCare® app, for daily recording of heart rate, blood pressure, weight, % body water, cognitive function (CyberLiver Animal Recognition Test [CL-ART] app), self-reported well-being, and intake of food, fluid, and alcohol. The app had 2-way patient-physician communication. Independent external adjudicators assessed the appropriateness of CirrhoCare®-based decisions. RESULTS Twenty individuals with cirrhosis were recruited to CirrhoCare® (mean age 59 ± 10 years, 14 male, alcohol-related cirrhosis [80%], mean model for end-stage liver disease-sodium [MELD-Na] score 16.1 ± 4.2) and were not statistically different to 20 contemporaneous controls. Follow-up was 10.1 ± 2.4 weeks. Fifteen individuals showed good engagement (≥4 readings/week), 2 moderate (2-3/week), and 3 poor (<2/week). In a usability questionnaire, the median score was ≥9 for all questions. Five CirrhoCare®-managed individuals had 8 readmissions over a median of 5 (IQR 3.5-11) days, and none required hospitalisation for >14 days. Sixteen other CirrhoCare®-guided patient contacts were made, leading to clinical interventions that prevented further progression. Appropriateness was confirmed by adjudicators. Controls had 13 readmissions in 8 individuals, lasting a median of 7 (IQR 3-15) days with 4 admissions of >14 days. They had 6 unplanned paracenteses compared with 1 in the CirrhoCare® group. CONCLUSIONS This study demonstrates that CirrhoCare® is feasible for community management of individuals with decompensated cirrhosis with good engagement and clinically relevant alerts to new decompensating events. CirrhoCare®-managed individuals have fewer and shorter readmissions justifying larger controlled clinical trials. IMPACT AND IMPLICATIONS As the burden of cirrhosis grows worldwide, increasing demands are being placed on limited healthcare resources, necessitating the adoption of more sustainable care models that allow for at-home patient management. The CirrhoCare® management system was developed to fill this care gap, deploying a novel combination of hardware, apps, and algorithms, to monitor and intervene in individuals at risk of new decompensation. This study highlights the possibility of reducing hospital readmissions for cirrhosis by optimising specialist community care, reducing the need for interventions such as paracentesis, while providing a more sustainable care pathway that is acceptable to patients. However, given the pilot and non-randomised nature of this study, the outcomes require further validation in a larger randomised controlled trial, to assess both clinical effectiveness and cost-effectiveness. Moreover, the data generated will also facilitate data modelling and further research to refine the CirrhoCare® algorithms to increase their detection sensitivity and utility.
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Jesse MT, Haver DB. Current recommendations regarding evaluation of cognitive functioning in organ transplant candidates. Curr Opin Organ Transplant 2022; 27:523-529. [PMID: 36094545 DOI: 10.1097/mot.0000000000001021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
PURPOSE OF REVIEW Cognitive impairment is associated with negative effects on solid organ transplant candidates, recipients, and their care partners. However, because of the heterogeneity of mechanisms, presentations, and assessment measures, research suggests a wide array of impairments, patterns of impairments, and unclear trajectories posttransplant. This review provides an abbreviated synthesis of recent research on cognitive impairments observed in organ-eligible candidates and potential trajectories through posttransplant, current clinical recommendations regarding integration of assessment into routine clinical transplant practice, as well as recommendations for future research. RECENT FINDINGS Transplantation may resolve certain disease-contributing factors to cognitive impairments but also introduces new potential neurocognitive assaults. Recent studies in kidney and lung recipients document continued impairments in subsets of patients, particularly those identified as frail. For liver candidates, new assessment measures of hepatic encephalopathy have been developed and preliminarily tested with potential for translation into routine clinical care. Clinical implications, as well as ethical considerations are discussed. SUMMARY Although guidelines agree that cognitive assessment is an important part of the organ transplantation process, many questions remain of how to best assess cognition and intervene when cognitive impairment is identified in transplant populations. Further research should focus on prospective, longitudinal assessments in transplant-eligible populations through posttransplant.
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Affiliation(s)
- Michelle T Jesse
- Transplant Institute
- Internal Medicine, Henry Ford Health, Detroit, Michigan
| | - D Brian Haver
- Bio-behavioral Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
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Hanai T, Nishimura K, Miwa T, Maeda T, Nakahata Y, Imai K, Suetsugu A, Takai K, Shimizu M. A shortened Stroop test to identify covert hepatic encephalopathy and predict overt hepatic encephalopathy in patients with cirrhosis. J Gastroenterol 2022; 57:981-989. [PMID: 36173512 DOI: 10.1007/s00535-022-01925-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 09/13/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND Covert hepatic encephalopathy (CHE) adversely affects the clinical outcomes of patients with cirrhosis but remains largely undiagnosed and untreated. Although the Stroop test is a useful method for CHE detection, a faster, simpler, and more accurate test is required to diagnose CHE. This prospective study aimed to develop a new shortened Stroop test that can detect CHE and predict overt hepatic encephalopathy (OHE) in Japanese patients with cirrhosis. METHODS Patients who underwent neuropsychological tests (NPT) and the Stroop test between November 2018 and December 2021 were enrolled and followed until OHE occurrence or March 2022. The discriminative ability of various run combinations in the off and on states to detect CHE was evaluated using the area under the receiver-operating characteristic curve (AUC) and compared with that of the total Stroop test time. RESULTS Among the 227 eligible patients, the On1-2Time cutoff value of 44.4 s had a comparable discriminative ability with the total Stroop test time to detect CHE, with an AUC of 0.791, a sensitivity of 0.827, and a specificity of 0.685. During a median follow-up period of 16 months, 37 patients developed OHE. On1-2Time ≥ 44.4 s (hazard ratio [HR], 3.93; 95% confidence interval [CI] 1.36-11.36) and serum albumin levels (HR, 0.28; 95% CI 0.11-0.67) were independently associated with OHE occurrence. CONCLUSIONS The shortened Stroop test (On1-2Time) is equivalent to the total Stroop test not only for identifying CHE but also for estimating the risk of progression to OHE.
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Affiliation(s)
- Tatsunori Hanai
- Department of Gastroenterology/Internal Medicine, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, 501-1194, Japan.
| | - Kayoko Nishimura
- Center for Nutrition Support and Infection Control, Gifu University Hospital, Gifu, Japan
| | - Takao Miwa
- Department of Gastroenterology/Internal Medicine, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Toshihide Maeda
- Department of Gastroenterology/Internal Medicine, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Yuki Nakahata
- Department of Gastroenterology/Internal Medicine, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Kenji Imai
- Department of Gastroenterology/Internal Medicine, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Atsushi Suetsugu
- Department of Gastroenterology/Internal Medicine, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Koji Takai
- Department of Gastroenterology/Internal Medicine, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Masahito Shimizu
- Department of Gastroenterology/Internal Medicine, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, 501-1194, Japan
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Casanova-Ferrer F, García-Cena CE, Gallego JJ, Fiorillo A, Urios A, Calvo-Córdoba A, Ballester MP, Ríos MP, Durbán L, Hidalgo MR, García F, Felipo V, Montoliu C. Minimal hepatic encephalopathy is associated to alterations in eye movements. Sci Rep 2022; 12:16837. [PMID: 36207472 PMCID: PMC9547018 DOI: 10.1038/s41598-022-21230-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 09/23/2022] [Indexed: 11/09/2022] Open
Abstract
Minimal hepatic encephalopathy (MHE) is diagnosed using PHES battery, but other tests are more sensitive, and a simple tool for early MHE detection is required. Assessment of saccadic eye movements is useful for early detection of cognitive alterations in different pathologies. We characterized the alterations in saccadic eye movements in MHE patients, its relationship with cognitive alterations and its utility for MHE diagnosis. One-hundred and eighteen cirrhotic patients (86 without and 32 with MHE) and 35 controls performed PHES and Stroop test and an eye movements test battery by OSCANN system: visual saccades, antisaccades, memory-guided saccades, fixation test and smooth pursuit. We analyzed 177 parameters of eye movements, assessed their diagnostic capacity for MHE, and correlated with cognitive alterations. MHE patients showed alterations in 56 of the 177 variables of eye movements compared to NMHE patients. MHE patients showed longer latencies and worse performance in most eye movements tests, which correlated with mental processing speed and attention impairments. The best correlations found were for antisaccades and memory-guided saccades, and some parameters in these tests could be useful for discriminating MHE and NMHE patients. Eye movements analysis could be a new, rapid, reliable, objective, and reproducible tool for early diagnose MHE.
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Affiliation(s)
- Franc Casanova-Ferrer
- Fundación de Investigación Hospital Clínico Universitario de Valencia-INCLIVA, 46010, Valencia, Spain
| | - Cecilia E García-Cena
- Centre for Automation and Robotics, Universidad Politecnica de Madrid, Madrid, Spain
| | - Juan-Jose Gallego
- Fundación de Investigación Hospital Clínico Universitario de Valencia-INCLIVA, 46010, Valencia, Spain
| | - Alessandra Fiorillo
- Fundación de Investigación Hospital Clínico Universitario de Valencia-INCLIVA, 46010, Valencia, Spain
| | - Amparo Urios
- Fundación de Investigación Hospital Clínico Universitario de Valencia-INCLIVA, 46010, Valencia, Spain
| | - Alberto Calvo-Córdoba
- Centre for Automation and Robotics, Universidad Politecnica de Madrid, Madrid, Spain
| | - Maria-Pilar Ballester
- Fundación de Investigación Hospital Clínico Universitario de Valencia-INCLIVA, 46010, Valencia, Spain.,Servicio de Medicina Digestiva, Hospital Clínico Universitario de Valencia, 46010, Valencia, Spain
| | - María Pilar Ríos
- Servicio de Medicina Digestiva, Hospital Arnau de Vilanova, 46015, Valencia, Spain
| | - Lucía Durbán
- Servicio de Medicina Digestiva, Hospital Arnau de Vilanova, 46015, Valencia, Spain
| | - Marta R Hidalgo
- Bioinformatics and Biostatistics Unit, Centro Investigación Príncipe Felipe, 46012, Valencia, Spain
| | - Francisco García
- Bioinformatics and Biostatistics Unit, Centro Investigación Príncipe Felipe, 46012, Valencia, Spain
| | - Vicente Felipo
- Laboratory of Neurobiology, Centro Investigación Príncipe Felipe, 46012, Valencia, Spain
| | - Carmina Montoliu
- Fundación de Investigación Hospital Clínico Universitario de Valencia-INCLIVA, 46010, Valencia, Spain. .,Department of Pathology, Faculty of Medicine, University of Valencia/INCLIVA-Health Research Institute, Avda. Blasco Ibañez, 17, 46010, Valencia, Spain.
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Moon AM, Kim HP, Cook S, Blanchard RT, Haley KL, Jacks A, Shafer JS, Fried MW. Speech patterns and enunciation for encephalopathy determination-A prospective study of hepatic encephalopathy. Hepatol Commun 2022; 6:2876-2885. [PMID: 35861546 PMCID: PMC9512449 DOI: 10.1002/hep4.2054] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 06/01/2022] [Accepted: 06/22/2022] [Indexed: 01/05/2023] Open
Abstract
Hepatic encephalopathy (HE) is a complication of cirrhosis that benefits from early diagnosis and treatment. We aimed to characterize speech patterns of individuals with HE to investigate its potential to diagnose and monitor HE. This was a single-center prospective cohort study that included participants with cirrhosis with HE (minimal HE [MHE] and overt HE [OHE]), cirrhosis without HE, and participants without liver disease. Audio recordings of reading, sentence repetition, and picture description tasks were obtained from these groups. Two certified speech-language pathologists assessed speech rate (words per minute) and articulatory precision. An overall severity metric was derived from these measures. Cross-sectional analyses were performed using nonparametric Wilcoxon statistics to evaluate group differences. Change over time in speech measures was analyzed descriptively for individuals with HE. The study included 43 total participants. Speech results differed by task, but the overall pattern showed slower speech rate and less precise articulation in participants with OHE compared to other groups. When speech rate and precision ratings were combined into a single speech severity metric, the impairment of participants with OHE was more severe than all other groups, and MHE had greater speech impairment than non-liver disease controls. As OHE improved clinically, participants showed notable improvement in speech rate. Participants with OHE demonstrated impaired speech rate, precision, and speech severity compared with non-liver disease and non-HE cirrhosis. Participants with MHE had less pronounced impairments. Speech parameters improved as HE clinically improved. Conclusion: These data identify speech patterns that could improve HE diagnosis, grading, and remote monitoring.
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Affiliation(s)
- Andrew M. Moon
- Division of Gastroenterology and HepatologyDepartment of MedicineUniversity of North CarolinaChapel HillNorth CarolinaUSA
| | - Hannah P. Kim
- Division of Gastroenterology, Hepatology, and NutritionDepartment of MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Sarah Cook
- Division of Gastroenterology and HepatologyDepartment of MedicineUniversity of North CarolinaChapel HillNorth CarolinaUSA
| | - Renee T. Blanchard
- Division of Gastroenterology and HepatologyDepartment of MedicineUniversity of North CarolinaChapel HillNorth CarolinaUSA
| | - Katarina L. Haley
- Division of Speech and Hearing SciencesDepartment of Allied Health SciencesUniversity of North Carolina School of MedicineChapel HillNorth CarolinaUSA
| | - Adam Jacks
- Division of Speech and Hearing SciencesDepartment of Allied Health SciencesUniversity of North Carolina School of MedicineChapel HillNorth CarolinaUSA
| | - Jennifer S. Shafer
- Division of Speech and Hearing SciencesDepartment of Allied Health SciencesUniversity of North Carolina School of MedicineChapel HillNorth CarolinaUSA
| | - Michael W. Fried
- Division of Gastroenterology and HepatologyDepartment of MedicineUniversity of North CarolinaChapel HillNorth CarolinaUSA
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Luo M, Hu FR, Wang PD, Yao L, Hu SJ, Bai FH. EncephalApp stroop test versus electronic number connection test-A for screening minimal hepatic encephalopathy in patients with liver cirrhosis: a comparative study. Scand J Gastroenterol 2022; 57:1066-1069. [PMID: 35348416 DOI: 10.1080/00365521.2022.2055975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Minimal hepatic encephalopathy (MHE) is a common neuropsychiatric complication of liver cirrhosis. Both EncephalApp Stroop test (EncephalApp) and electronic number connection test-A (eNCT-A) are novel computerised psychometric tests for MHE screening. We aimed to compare the efficiency, convenience, accessibility, and acceptability of EncephalApp with that of eNCT-A for MHE screening in cirrhotic patients. METHODS Ninety-five patients with hepatitis B-induced liver cirrhosis were included and respectively tested by the psychometric hepatic encephalopathy score (PHES), EncephalApp, and eNCT-A. Using PHES as the gold standard for MHE diagnosis, the efficiency of EncephalApp and eNCT-A for MHE screening were respectively analysed by the receiver operating characteristic (ROC) curve, and the areas under the ROC curve (AUROC) were compared. The convenience, accessibility, and acceptability of PHES, EncephalApp and eNCT-A were respectively evaluated by the 5-point Likert scale. RESULTS Fifty-two (55%) of included cirrhotic patients were diagnosed with MHE. The EncephalApp had a sensitivity of 84.6%, a specificity of 74.4%, and an AUROC of 0.836. Meanwhile, the eNCT-A had a sensitivity of 78.8%, a specificity of 83.7%, and an AUROC of 0.845. No significant difference in AUROC was detected between the EncephalApp and eNCT-A (p = .453). Compared with the EncephalApp, the eNCT-A presented better convenience and higher acceptability in cirrhotic patients undergoing MHE screening (p = .019 and p < .001, respectively). CONCLUSIONS As with the EncephalApp, the eNCT-A will be a potential home monitoring and point-of-care tool for cirrhotic patients at high risk of MHE.
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Affiliation(s)
- Ming Luo
- Department of Gastroenterology, People's Hospital of Ningxia Hui Autonomous Region, Yinchuan, PR China
| | - Fang-Rui Hu
- Department of Gastroenterology, People's Hospital of Ningxia Hui Autonomous Region, Yinchuan, PR China
| | - Peng-Da Wang
- Department of Gastroenterology, People's Hospital of Ningxia Hui Autonomous Region, Yinchuan, PR China
| | - Li Yao
- Department of Gastroenterology, People's Hospital of Ningxia Hui Autonomous Region, Yinchuan, PR China
| | - Sheng-Juan Hu
- Department of Gastroenterology, People's Hospital of Ningxia Hui Autonomous Region, Yinchuan, PR China
| | - Fei-Hu Bai
- Department of Gastroenterology, People's Hospital of Ningxia Hui Autonomous Region, Yinchuan, PR China
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Bloom PP, Donlan J, Torres Soto M, Daidone M, Hohmann E, Chung RT. Fecal microbiota transplant improves cognition in hepatic encephalopathy and its effect varies by donor and recipient. Hepatol Commun 2022; 6:2079-2089. [PMID: 35384391 PMCID: PMC9315114 DOI: 10.1002/hep4.1950] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 02/23/2022] [Accepted: 03/12/2022] [Indexed: 01/25/2023] Open
Abstract
Early data suggest fecal microbiota transplant (FMT) may treat hepatic encephalopathy (HE). Optimal FMT donor and recipient characteristics are unknown. We assessed the safety and efficacy of FMT in patients with prior overt HE, comparing five FMT donors. We performed an open-label study of FMT capsules, administered 5 times over 3 weeks. Primary outcomes were change in psychometric HE score (PHES) and serious adverse events (SAEs). Serial stool samples underwent shallow shotgun metagenomic sequencing. Ten patients completed FMT administration and 6-month follow-up. Model for End-Stage Liver Disease (MELD) score did not change after FMT (14 versus 14, p = 0.51). Thirteen minor adverse events and three serious adverse events (two unrelated to FMT) were reported. One SAE was extended-spectrum beta-lactamase Escherichia coli bacteremia. The PHES improved after three doses of FMT (+2.1, p < 0.05), after five doses of FMT (+2.9, p = 0.007), and 4 weeks after the fifth dose of FMT (+3.1, p = 0.02). Mean change in the PHES ranged from -1 to +6 by donor. Two taxa were identified by random forest analysis and confirmed by linear regression to predict the PHES- Bifidobacterium adolescentis (adjusted R2 = 0.27) and B. angulatum (adjusted R2 = 0.25)-both short-chain fatty acid (SCFA) producers. Patients who responded to FMT had higher levels of Bifidobacterium as well as other known beneficial taxa at baseline and throughout the study. The FMT donor with poorest cognitive outcomes in recipients had the lowest fecal SCFA levels. Conclusion: FMT capsules improved cognition in HE, with an effect varying by donor and recipient factors (NCT03420482).
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Affiliation(s)
- Patricia P. Bloom
- Division of GastroenterologyUniversity of MichiganAnn ArborMichiganUSA
| | - John Donlan
- Harvard Medical SchoolBostonMassachusettsUSA
| | | | - Michael Daidone
- Division of GastroenterologyMassachusetts General HospitalBostonMassachusettsUSA
| | - Elizabeth Hohmann
- Division of Infectious DiseaseMassachusetts General HospitalBostonMassachusettsUSA
| | - Raymond T. Chung
- Division of GastroenterologyMassachusetts General HospitalBostonMassachusettsUSA
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Häussinger D, Dhiman RK, Felipo V, Görg B, Jalan R, Kircheis G, Merli M, Montagnese S, Romero-Gomez M, Schnitzler A, Taylor-Robinson SD, Vilstrup H. Hepatic encephalopathy. Nat Rev Dis Primers 2022; 8:43. [PMID: 35739133 DOI: 10.1038/s41572-022-00366-6] [Citation(s) in RCA: 98] [Impact Index Per Article: 32.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/12/2022] [Indexed: 01/18/2023]
Abstract
Hepatic encephalopathy (HE) is a prognostically relevant neuropsychiatric syndrome that occurs in the course of acute or chronic liver disease. Besides ascites and variceal bleeding, it is the most serious complication of decompensated liver cirrhosis. Ammonia and inflammation are major triggers for the appearance of HE, which in patients with liver cirrhosis involves pathophysiologically low-grade cerebral oedema with oxidative/nitrosative stress, inflammation and disturbances of oscillatory networks in the brain. Severity classification and diagnostic approaches regarding mild forms of HE are still a matter of debate. Current medical treatment predominantly involves lactulose and rifaximin following rigorous treatment of so-called known HE precipitating factors. New treatments based on an improved pathophysiological understanding are emerging.
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Affiliation(s)
- Dieter Häussinger
- Department of Gastroenterology, Hepatology and Infectious Diseases, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany.
| | - Radha K Dhiman
- Department of Hepatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, (Uttar Pradesh), India
| | - Vicente Felipo
- Laboratory of Neurobiology, Centro de Investigación Principe Felipe, Valencia, Spain
| | - Boris Görg
- Department of Gastroenterology, Hepatology and Infectious Diseases, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Rajiv Jalan
- Liver Failure Group ILDH, Division of Medicine, UCL Medical School, Royal Free Campus, London, UK.,European Foundation for the Study of Chronic Liver Failure, Barcelona, Spain
| | - Gerald Kircheis
- Department of Gastroenterology, Diabetology and Hepatology, University Hospital Brandenburg an der Havel, Brandenburg Medical School, Brandenburg an der Havel, Germany
| | - Manuela Merli
- Department of Translational and Precision Medicine, Universita' degli Studi di Roma - Sapienza, Roma, Italy
| | | | - Manuel Romero-Gomez
- UCM Digestive Diseases, Virgen del Rocío University Hospital, Institute of Biomedicine of Seville (HUVR/CSIC/US), University of Seville, Seville, Spain
| | - Alfons Schnitzler
- Institute of Clinical Neuroscience and Medical Psychology, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Simon D Taylor-Robinson
- Department of Surgery and Cancer, St. Mary's Hospital Campus, Imperial College London, London, UK
| | - Hendrik Vilstrup
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
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Gairing SJ, Müller L, Kloeckner R, Galle PR, Labenz C. Review article: post-TIPSS hepatic encephalopathy-current knowledge and future perspectives. Aliment Pharmacol Ther 2022; 55:1265-1276. [PMID: 35181894 DOI: 10.1111/apt.16825] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Revised: 01/23/2022] [Accepted: 02/02/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND In light of the global rise in the burden of chronic liver diseases and liver cirrhosis, the number of patients suffering from decompensation events is expected to increase. Transjugular intrahepatic portosystemic shunts (TIPSS) provide effective long-term symptom control and may prolong transplant-free survival in portal hypertension-driven recurrent ascites and variceal bleeding. New-onset or recurrent hepatic encephalopathy (HE) after TIPSS insertion (post-TIPSS HE) represents the most severe post-interventional complication. AIMS To provide insight into the epidemiology and risk factors for post-TIPSS HE and scrutinize the current state of the art in treatment and drug therapy options. METHODS We conducted a literature search on post-TIPSS HE in patients with liver cirrhosis. RESULTS Post-TIPSS HE occurs in up to 54.5% of cases and particularly early recurrent HE is associated with a dismal prognosis. In recent years, several risk factors for the development of post-TIPSS HE have been identified. These include not only parameters reflecting liver function (model for end-stage liver disease score/Child-Pugh score) as well as cognitive dysfunction caused by minimal HE but also extrahepatic factors such as sarcopenia and common medications such as proton pump inhibitors. In addition, new data on the benefit of rifaximin and of smaller stent grafts emerged and may improve the prevention of post-TIPSS HE. CONCLUSIONS Careful selection of TIPSS candidates is of utmost importance to reduce the risk of post-TIPSS HE. In this narrative review, we provide a concise overview of the current epidemiology and risk factors of the treatment options for post-TIPSS HE.
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Affiliation(s)
- Simon Johannes Gairing
- Department of Internal Medicine I, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany.,Cirrhosis Center Mainz (CCM), University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Lukas Müller
- Department of Radiology, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Roman Kloeckner
- Department of Radiology, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Peter R Galle
- Department of Internal Medicine I, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany.,Cirrhosis Center Mainz (CCM), University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Christian Labenz
- Department of Internal Medicine I, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany.,Cirrhosis Center Mainz (CCM), University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
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Gairing SJ, Anders J, Kaps L, Nagel M, Michel M, Kremer WM, Hilscher M, Galle PR, Schattenberg JM, Wörns MA, Labenz C. Evaluation of IL-6 for Stepwise Diagnosis of Minimal Hepatic Encephalopathy in Patients With Liver Cirrhosis. Hepatol Commun 2022; 6:1113-1122. [PMID: 35032100 PMCID: PMC9035565 DOI: 10.1002/hep4.1883] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Revised: 11/28/2021] [Accepted: 12/06/2021] [Indexed: 11/10/2022] Open
Abstract
Diagnosis of minimal hepatic encephalopathy (MHE) requires psychometric testing, which is time-consuming and often neglected in clinical practice. Elevated Interleukin-6 (IL-6) serum levels have been linked to MHE. The aim of this study was to investigate the usefulness of IL-6 as a biomarker in a stepwise diagnostic algorithm to detect MHE in patients with liver cirrhosis. A total of 197 prospectively recruited patients without clinical signs of hepatic encephalopathy (HE) served as the development cohort. Another independent cohort consisting of 52 patients served for validation purposes. Psychometric Hepatic Encephalopathy Score (PHES) was applied for the diagnosis of MHE. Fifty (25.4%) patients of the development cohort presented with MHE. Median IL-6 levels were more than twice as high in patients with MHE than in patients without HE (16 vs. 7 pg/mL; P < 0.001). On multivariable logistic regression analysis, higher IL-6 levels (odds ratio 1.036; 95% confidence interval [CI] 1.009-1.064; P = 0.008) remained independently associated with the presence of MHE. IL-6 levels ≥ 8pg/mL discriminated best between patients with and without MHE in receiver operating characteristic (ROC) analysis (area under the ROC 0.751). With a cutoff value of ≥7 pg/mL, further elaborate testing with PHES could be avoided in 38% of all patients with a sensitivity of 90% (95% CI 77%-96%) and a negative predictive value (NPV) of 93% (95% CI 84%-98%). This diagnostic accuracy was confirmed in the validation cohort (sensitivity 94%; NPV 93%). Conclusion: Using IL-6 serum levels as a biomarker in a stepwise diagnostic algorithm to detect MHE could substantially reduce the number of patients requiring testing with PHES and in turn the workload. IL-6 may have especially helped in patients who are unable to perform other screening tests.
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Affiliation(s)
- Simon Johannes Gairing
- Department of Internal Medicine IUniversity Medical Center of the Johannes Gutenberg-UniversityMainzGermany.,Cirrhosis Center MainzUniversity Medical Center of the Johannes Gutenberg UniversityMainzGermany
| | - Julian Anders
- Department of Internal Medicine IUniversity Medical Center of the Johannes Gutenberg-UniversityMainzGermany
| | - Leonard Kaps
- Department of Internal Medicine IUniversity Medical Center of the Johannes Gutenberg-UniversityMainzGermany.,Cirrhosis Center MainzUniversity Medical Center of the Johannes Gutenberg UniversityMainzGermany
| | - Michael Nagel
- Department of Internal Medicine IUniversity Medical Center of the Johannes Gutenberg-UniversityMainzGermany.,Cirrhosis Center MainzUniversity Medical Center of the Johannes Gutenberg UniversityMainzGermany
| | - Maurice Michel
- Department of Internal Medicine IUniversity Medical Center of the Johannes Gutenberg-UniversityMainzGermany.,Cirrhosis Center MainzUniversity Medical Center of the Johannes Gutenberg UniversityMainzGermany
| | - Wolfgang Maximilian Kremer
- Department of Internal Medicine IUniversity Medical Center of the Johannes Gutenberg-UniversityMainzGermany.,Cirrhosis Center MainzUniversity Medical Center of the Johannes Gutenberg UniversityMainzGermany
| | - Max Hilscher
- Department of Internal Medicine IUniversity Medical Center of the Johannes Gutenberg-UniversityMainzGermany.,Cirrhosis Center MainzUniversity Medical Center of the Johannes Gutenberg UniversityMainzGermany
| | - Peter Robert Galle
- Department of Internal Medicine IUniversity Medical Center of the Johannes Gutenberg-UniversityMainzGermany.,Cirrhosis Center MainzUniversity Medical Center of the Johannes Gutenberg UniversityMainzGermany
| | - Jörn M Schattenberg
- Department of Internal Medicine IUniversity Medical Center of the Johannes Gutenberg-UniversityMainzGermany.,Metabolic Liver Research ProgramUniversity Medical Center of the Johannes Gutenberg UniversityMainzGermany
| | - Marcus-Alexander Wörns
- Department of Internal Medicine IUniversity Medical Center of the Johannes Gutenberg-UniversityMainzGermany.,Cirrhosis Center MainzUniversity Medical Center of the Johannes Gutenberg UniversityMainzGermany.,Department of Gastroenterology, Hematology, Oncology and EndocrinologyKlinikum Dortmund GmbHDortmundGermany
| | - Christian Labenz
- Department of Internal Medicine IUniversity Medical Center of the Johannes Gutenberg-UniversityMainzGermany.,Cirrhosis Center MainzUniversity Medical Center of the Johannes Gutenberg UniversityMainzGermany
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47
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Kaps L, Hildebrand K, Nagel M, Michel M, Kremer WM, Hilscher M, Galle PR, Schattenberg JM, Wörns MA, Labenz C. Validation of EncephalApp_Stroop as screening tool for the detection of minimal hepatic encephalopathy in German patients with liver cirrhosis. Clin Res Hepatol Gastroenterol 2022; 46:101873. [PMID: 35124289 DOI: 10.1016/j.clinre.2022.101873] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 12/14/2021] [Accepted: 01/17/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND In contrast to overt hepatic encephalopathy (OHE), the diagnosis of minimal HE (MHE) is challenging in patients with cirrhosis requiring elaborate, specialized testing. The EncephalApp_Stroop is a smartphone-based application established as screening tool for the diagnosis of MHE but has not yet been validated in a German cohort and country specific cut-offs are currently missing. METHODS 93 patients with cirrhosis were enroled into this study. Psychometric hepatic encephalopathy score (PHES) was used to detect MHE, and a subset of the patients was tested with critical flicker frequency (CFF). All patients underwent testing with EncephalApp_Stroop. Cut-off thresholds for EncephalApp_Stroop were calculated according to Youden's Index and a separate cut-off was determined with focus on sensitivity. RESULTS 24 (26%) patients had MHE according to PHES. EncephalApp_Stroop had a strong correlation with PHES (r=-0.76, p<0.001), while there was only a modest correlation with CFF (r=-0.51, <0.001). On time as well as on+off time discriminated best between patients with and without MHE with AUROCS of 0.87 for both measures. According to Youden's index, a cut-off of >224.7 s (sec) (on+off time) discriminated best between patients with and without MHE with a sensitivity of 71% and a specificity of 88%. The adjusted cut-off value for on+off time with focus on sensitivity (sensitivity:specificity weighed 2:1) was 185.1 s, yielding an optimized sensitivity of 92% and a negative predictive value of 96%. By using this cut-off as a pre-screening test in a stepwise diagnosis algorithm, elaborate testing with PHES could have been avoided in 49% of all patients. CONCLUSION EncephalApp_Stroop may be useful in a stepwise diagnosis algorithm or even as a stand-alone screening tool to detect MHE in German patients with cirrhosis.
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Affiliation(s)
- Leonard Kaps
- Department of Internal Medicine I, University Medical Centre of the Johannes Gutenberg-University, Mainz, Germany; Cirrhosis Centre Mainz (CCM), University Medical Centre of the Johannes Gutenberg-University, Mainz, Germany.
| | - Katharina Hildebrand
- Department of Internal Medicine I, University Medical Centre of the Johannes Gutenberg-University, Mainz, Germany; Cirrhosis Centre Mainz (CCM), University Medical Centre of the Johannes Gutenberg-University, Mainz, Germany
| | - Michael Nagel
- Department of Internal Medicine I, University Medical Centre of the Johannes Gutenberg-University, Mainz, Germany; Cirrhosis Centre Mainz (CCM), University Medical Centre of the Johannes Gutenberg-University, Mainz, Germany
| | - Maurice Michel
- Department of Internal Medicine I, University Medical Centre of the Johannes Gutenberg-University, Mainz, Germany; Cirrhosis Centre Mainz (CCM), University Medical Centre of the Johannes Gutenberg-University, Mainz, Germany
| | - Wolfgang Maximilian Kremer
- Department of Internal Medicine I, University Medical Centre of the Johannes Gutenberg-University, Mainz, Germany; Cirrhosis Centre Mainz (CCM), University Medical Centre of the Johannes Gutenberg-University, Mainz, Germany
| | - Max Hilscher
- Department of Internal Medicine I, University Medical Centre of the Johannes Gutenberg-University, Mainz, Germany; Cirrhosis Centre Mainz (CCM), University Medical Centre of the Johannes Gutenberg-University, Mainz, Germany
| | - Peter R Galle
- Department of Internal Medicine I, University Medical Centre of the Johannes Gutenberg-University, Mainz, Germany; Cirrhosis Centre Mainz (CCM), University Medical Centre of the Johannes Gutenberg-University, Mainz, Germany
| | - Jörn M Schattenberg
- Department of Internal Medicine I, University Medical Centre of the Johannes Gutenberg-University, Mainz, Germany
| | - Marcus-Alexander Wörns
- Department of Internal Medicine I, University Medical Centre of the Johannes Gutenberg-University, Mainz, Germany; Cirrhosis Centre Mainz (CCM), University Medical Centre of the Johannes Gutenberg-University, Mainz, Germany; Department of Gastroenterology, Hematology, Oncology and Endocrinology, Klinikum Dortmund, Germany
| | - Christian Labenz
- Department of Internal Medicine I, University Medical Centre of the Johannes Gutenberg-University, Mainz, Germany; Cirrhosis Centre Mainz (CCM), University Medical Centre of the Johannes Gutenberg-University, Mainz, Germany.
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Manzhalii E, Moyseyenko V, Kondratiuk V, Molochek N, Falalyeyeva T, Kobyliak N. Effect of a specific Escherichia coli Nissle 1917 strain on minimal/mild hepatic encephalopathy treatment. World J Hepatol 2022; 14:634-646. [PMID: 35582294 PMCID: PMC9055191 DOI: 10.4254/wjh.v14.i3.634] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 08/01/2021] [Accepted: 02/22/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Hepatic encephalopathy (HE) can be considered a result of dysregulated gut-liver-brain axis function, where cognitive impairment can be reversed or prevented by the beneficial effects induced by "gut-centric" therapies, such as the administration of nonabsorbable disaccharides, nonabsorbable antibiotics, probiotics and prebiotics. AIM To assess the short-term efficacy and safety of the probiotic Escherichia coli Nissle (EcN) 1917 strain compared to lactulose and rifaximin in patients with minimal/mild HE. METHODS From January 2017 to March 2020, a total of 45 patients with HE were enrolled in this prospective, single-centre, open-label, randomized study. Participants were randomly assigned at a ratio of 1:1:1 to one of the treatment groups: The EcN group (n = 15), lactulose group (n = 15) or rifaximin group (n = 15) for a 1 mo intervention period. The main primary outcomes of the study were changes in serum ammonia and Stroop test score. The secondary outcomes were markers of a chronic systemic inflammatory response (ІL-6, ІL-8, and IFN-γ) and bacteriology of the stool flora evaluated by specialized nonculture techniques after a 1 mo intervention period. RESULTS Patients who were given rifaximin or EcN showed a more significant reduction in serum ammonia and normalization of Bifidobacteria and Lactobacilli abundance compared to the lactulose group. However, the most pronounced restoration of the symbiotic microflora was associated with EcN administration and characterized by the absence of E. coli with altered properties and pathogenic enterobacteria in patient faeces. In the primary outcome analysis, improvements in the Stroop test parameters in all intervention groups were observed. Moreover, EcN-treated patients performed 15% faster on the Stroop test than the lactulose group patients (P = 0.017). Both EcN and rifaximin produced similar significant reductions in the proinflammatory cytokines INF-γ, IL-6 and IL-8. EcN was more efficient than lactulose in reducing proinflammatory cytokine levels. CONCLUSION The use of the probiotic EcN strain was safe and quite efficient for HE treatment. The probiotic reduced the ammonia content and the level of serum proinflammatory cytokines, normalized the gut microbiota composition and improved the cognitive function of patients with HE. The application of the EcN strain was more effective than lactulose treatment.
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Affiliation(s)
- Elina Manzhalii
- Department of Propedeutics of Internal Medicine, Bogomolets National Medical University, Kyiv 01601, Ukraine.
| | - Valentyna Moyseyenko
- Department of Propedeutics of Internal Medicine, Bogomolets National Medical University, Kyiv 01601, Ukraine
| | - Vitalii Kondratiuk
- Department of Propedeutics of Internal Medicine, Bogomolets National Medical University, Kyiv 01601, Ukraine
| | - Nataliia Molochek
- Educational and Scientific Centre “Institute of Biology and Medicine”, Taras Shevchenko National University of Kyiv, Kyiv 01601, Ukraine
- Department of Pediatrics, Bogomolets National Medical University, Kyiv 01601, Ukraine
| | - Tetyana Falalyeyeva
- Educational and Scientific Centre “Institute of Biology and Medicine”, Taras Shevchenko National University of Kyiv, Kyiv 01601, Ukraine
- Department of Scientific, Medical Laboratory CSD, Kyiv 01004, Ukraine
| | - Nazarii Kobyliak
- Department of Endocrinology, Bogomolets National Medical University, Kyiv 01601, Ukraine
- Department of Scientific, Medical Laboratory CSD, Kyiv 01004, Ukraine.
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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: 1.0] [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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50
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Hansen MKG, Kjærgaard K, Eriksen LL, Grønkjær LL, Mikkelsen ACD, Sandahl TD, Vilstrup H, Thomsen KL, Lauridsen MME. Psychometric methods for diagnosing and monitoring minimal hepatic encephalopathy -current validation level and practical use. Metab Brain Dis 2022; 37:589-605. [PMID: 35102491 DOI: 10.1007/s11011-022-00913-w] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 01/14/2022] [Indexed: 02/07/2023]
Abstract
Hepatic encephalopathy (HE) is cerebral dysfunction caused by liver failure and inflicts 30-40% of patients with liver cirrhosis during their disease course. Clinically manifest HE is often preceded by minimal HE (MHE) - a clinically undetectable cognitive disturbance closely associated with loss of quality of life. Accordingly, detecting and treating MHE improve the patients' daily functioning and prevent HE-related hospital admissions. The scope of this review article is to create an overview of the validation level and usage of psychometric tests used to detect MHE: Portosystemic hepatic encephalopathy test, continuous reaction time test, Stroop EncephalApp, animal naming test, critical flicker frequency test, and inhibitory control test. Our work is aimed at the clinician or scientist who is about to decide on which psychometric test would fit best in their clinic, cohort, or study. First, we outline psychometric test validation obstacles and requirements. Then, we systematically approach the literature on each test and select well-conducted studies to answer the following questions:• Which percentage of patients with cirrhosis does the test deem as having MHE?• Is the test able to predict clinically manifest HE?• Is there a well-known test-retest variation and inter-observer variation?• Is the test able to detect a treatment response?• Is the test result affected by age, educational level, gender, or comorbidities?
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Affiliation(s)
- Mads Kingo Guldberg Hansen
- Department of Gastroenterology and Hepatology, University Hospital South Denmark, Finsensgade 35, 6700, Esbjerg, Denmark.
| | - Kristoffer Kjærgaard
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus, Denmark
| | - Lotte Lindgreen Eriksen
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus, Denmark
| | - Lea Ladegaard Grønkjær
- Department of Gastroenterology and Hepatology, University Hospital South Denmark, Finsensgade 35, 6700, Esbjerg, Denmark
| | - Anne Catrine Daugaard Mikkelsen
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus, Denmark
| | - Thomas Damgaard Sandahl
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus, Denmark
| | - Hendrik Vilstrup
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus, Denmark
| | - Karen Louise Thomsen
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus, Denmark
| | - Mette Munk Enok Lauridsen
- Department of Gastroenterology and Hepatology, University Hospital South Denmark, Finsensgade 35, 6700, Esbjerg, Denmark
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