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Liver Transpl. 2018 May;24(5):587-594. doi: 10.1002/lt.25032.

Assessment of the spectrum of hepatic encephalopathy: A multicenter study.

Author information

1
Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, VA.
2
Division of Gastroenterology, Department of Internal Medicine, University of Washington, Seattle, WA.
3
Centre Hospitalier de l'Université Montreal, McGill University Medical Centers, Montreal, Quebec, Canada.
4
Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN.
5
Department of Gastroenterology, University of California, San Francisco, CA.
6
Division of Gastroenterology, Department of Internal Medicine, University of Alberta, Edmonton, Alberta, Canada.

Abstract

Hepatic encephalopathy (HE) is a major cause of morbidity in cirrhosis. However, its severity assessment is often subjective, which needs to be studied systematically. The aim was to determine how accurately trainee and nontrainee practitioners grade and manage HE patients throughout its severity. We performed a survey study using standardized simulated patient videos at 4 US and 3 Canadian centers. Participants were trainees (gastroenterology/hepatology fellows) and nontrainees (faculty, nurse practitioners, physician assistants). We determined the accuracy of HE severity identification and management options between grades <2 or ≥2 HE and trainees/nontrainees. In total, 108 respondents (62 trainees, 46 nontrainees) were included. For patients with grades <2 versus ≥2 HE, a higher percentage of respondents were better at correctly diagnosing grades ≥2 compared with grades <2 (91% versus 64%; P < 0.001). Specialized cognitive testing was checked significantly more often in grades <2, whereas more aggressive investigation for precipitating factors was ordered in HE grades >2. Serum ammonia levels were ordered in almost a third of grade ≥2 patients. For trainees and nontrainees, HE grades were identified similarly between groups. Trainees were less likely to order serum ammonia and low-protein diets, more likely to order rifaximin, and more likely to perform a more thorough workup for precipitating factors compared with nontrainee respondents. There was excellent concordance in the classification of grade ≥2 HE between nontrainees versus trainees, but lower grades showed discordance. Important differences were seen regarding blood ammonia, specialized testing, and nutritional management between trainees and nontrainees. These results have important implications at the patient level, interpreting multicenter clinical trials, and in the education of practitioners. Liver Transplantation 24 587-594 2018 AASLD.

PMID:
29457869
PMCID:
PMC5912984
DOI:
10.1002/lt.25032
[Indexed for MEDLINE]
Free PMC Article

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