Modified‐orientation log to assess hepatic encephalopathy

Abstract

SUMMARY Background The subjectivity of the West-Haven criteria (WHC) hinders hepatic encephalopathy (HE) evaluation. The new HE classification has emphasised assessment of orientation. The modified-orientation log (MO-log, eight questions, scores 0–24; 24 normal) is adapted from a validated brain injury measure. Aim To validate MO-log for HE assessment in cirrhosis. Methods Cirrhotics admitted with/without HE were administered MO-log. We collected cirrhosis/HE details, admission/daily MO-logs and WHC (performed by different examiners), time to reach normal mentation (MO-log ≥23) and MO-log/WHC change (Δ) over day 1. Outcomes were in-hospital mortality, duration to normal mentation and length-of-stay (LOS). Regressions were performed for each outcome. MO-log inter-rater reliability was measured. Results Ninety-six HE (55 ± 8 years, MELD 21) and 20 non-HE (54 ± 5 years, MELD 19) in-patients were included. In HE patients, median admission WHC was 3 (range 1–4). Mean MO-log was 12 ± 8 (range 0–22). Their LOS was 6 ± 5 days and 13% died. Time to reach normal mentation was 2.4 ± 1.7 days. Concurrent validity: there was a significant negative correlation between admission MO-log and WHC (r = −0.79, P < 0.0001). Discriminant validity: admission MO-logs were significantly lower in those who died (7 vs. 12, P = 0.03) and higher in those admitted without HE (23.6 vs. 12, P < 0.0001). MO-log improved in 69% on day 1 (ΔMO-log 4 ± 8) which was associated with lower duration to normal mentation (2 vs. 3.5 days, P = 0.03) and mortality (3% vs.43%, P < 0.0001), not ΔWHC. Regression models for all outcomes included admission/ΔMO-log but not WHC as a predictor. Inter-rater reliability: ICC for MO-log inter-rater observations was 0.991. Conclusions Modified-orientation log is a valid tool for assessing severity and is better than West-Haven criteria in predicting outcomes in hospitalised hepatic encephalopathy patients.

The confusion assessment method for the intensive care unit in patients with cirrhosis

“…These limitations have been improved using the HE Scoring Algorithm, which incorporates neuropsychological assessments that are objective; however, this system requires significant time and expertise and is therefore not practical for routine HE assessment (Hassanein et al 2009). HE assessment using other measures, such as the Clinical HE Staging Scale and the Modified-Orientation Log, are promising, but have not been widely validated (Ortiz et al 2007; Salam et al 2012). In contrast, CAM and CAM-ICU have been validated across healthcare settings and are already used widely (Gusmao-Flores et al 2012; Wei et al 2008).…”

Correction of hyponatraemia improves cognition, quality of life, and brain oedema in cirrhosis

“…If the Na was <130meq/L, the patient was included; procedures performed were (a) history of cirrhosis complications, fluid intake and diuretic use (b) physical examination to exclude overt HE (asterixis, modified-orientation log and MMSE)[6] (c) blood drawn for electrolytes (Na, K, Mg, P), renal function (creatinine, BUN), hepatic function (albumin and MELD score) and venous ammonia (d) cognitive tests and (e) HRQOL: Chronic Liver Disease Questionnaire (CLDQ)[7]. Cognitive tests used were number connection A and B (NCT-A/B), digit symbol (DST), block design (BDT), line tracing (errors and time, LTTe/t), serial dotting(SDT) and inhibitory control tests (ICT lures and target %)[8].…”

Improvement in survival associated with embolisation of spontaneous portosystemic shunt in patients with recurrent hepatic encephalopathy

“…Episodes of HE that had been precipitated by gastrointestinal bleeding, infection, medication use, renal failure, electrolyte imbalance or other clear precipitating factors were not counted. Because only patients with overt HE were included in this study, neuropsychological and neurophysiologic tests 19,20 were not used. Recurrent HE was defined when at least two episodes of overt HE of grade 2 or higher were identified in the preceding 6 months.…”