Patients with acute-on-chronic liver failure (ACLF) represent a heterogeneous population. The aim of the study is to identify distinct groups according to the etiologies of precipitating events. A total of 405 ACLF patients were identified from 1,361 patients with cirrhosis with acute decompensation and categorized according to the types of acute insults. Clinical characteristics and prognosis between the hepatic group and extrahepatic group were compared, and the performance of prognostic models was tested in different groups. Two distinct groups (hepatic-ACLF and extrahepatic-ACLF) were identified among the ACLF population. Hepatic-ACLF was precipitated by hepatic insults and had relatively wellcompensated cirrhosis with frequent liver and coagulation failure. In contrast, extrahepatic-ACLF was exclusively precipitated by extrahepatic insults, characterized by more severe underlying cirrhosis and high occurrence of extrahepatic organ failures (kidney, cerebral, circulation, and respiratory systems). Both groups had comparably high short-term mortality (28-day transplant-free mortality: 48.3% vs. 50.7%; P 5 0.22); however, the extrahepatic-ACLF group had significantly higher 90-day and 1-year mortality (90-day: 58.9% vs. 68.3%, P 5 0.035; 1-year: 63.9% vs. 74.6%, P 5 0.019). In hepatic-ACLF group, the integrated Model for End-Stage Liver Disease (iMELD) score had the highest area under the receiver operating characteristic curve (auROC 5 0.787) among various prognostic models in predicting 28-day mortality, whereas CLIF-Consortium scores for ACLF patients (CLIF-C-ACLF) had the highest predictive value in the other group (auROC 5 0.779). Conclusions: ACLF precipitated by hepatic insults is distinct from ACLF precipitated by extrahepatic insults in clinical presentation and prognosis. The iMELD score may be a better predictor for hepatic-ACLF short-term prognosis, whereas CLIF-C-ACLF may be better for extrahepatic-ACLF patients. (HEPATOLOGY 2015;62:232-242)

Aim To translate and assess the reliability and validity of the C‐SVEST scale. Background Nurses in patient safety incidents, the second victim, may also be traumatized in Western studies, but there is a lack of relevant researches and validated scales in China. Methods A cross‐sectional study of 1,442 nurses in China was conducted with the C‐SVEST questionnaire. Raw data were randomly divided into two parts for exploratory factor analysis and confirmatory factor analysis, to evaluate the construct validity. Content validity and reliability were tested by content validity index and Cronbach's α coefficients, respectively. Results Six‐factor structure was emerged, and it explained 68.62% of the total variance. The good fit of the six‐factor model was acceptable, and standardized factor loading ranged from 0.62 to 0.89. Cronbach's α coefficient of the scale was 0.866, and each dimension ranged from 0.713 to 0.896. Content validity index at the scale level was 0.99, and content validity index at the item level was 0.89–1. Conclusions The C‐SVEST scale has excellent psychometric properties, which can be applied to measure second victims experience and support level in patient safety incidents. Implications for nursing management A reliable and valid instrument is available for leaders to identify the impact of patient safety incidents in nurses, and promote their health through effective interventions.

Systemic inflammation in HB-ACLF was characterized by an excessive innate immune response, which was associated with disease progression and mortality.