Minimal hepatic encephalopathy (MHE) is the mildest form of the spectrum of neurocognitive impairment in cirrhosis. It is a frequent occurrence in patients of cirrhosis and is detectable only by specialized neurocognitive testing. MHE is a clinically significant disorder which impairs daily functioning, driving performance, work capability and learning ability. It also predisposes to the development of overt hepatic encephalopathy, increased falls and increased mortality. This results in impaired quality of life for the patient as well as significant social and economic burden for health providers and care givers. Early detection and treatment of MHE with ammonia lowering therapy can reverse MHE and improve quality of life. ( J CLIN EXP HEPATOL 2015;5:S42-S48) H epatic encephalopathy (HE) is a neurocognitive disorder in which brain function is impaired and is associated with both acute and chronic liver dysfunction. 1 It is a major complication that develops in some form and at some stage in a majority of patients with liver cirrhosis. Minimal HE (MHE) is the mildest form of spectrum of HE which is characterized by subtle cognitive and psychomotor deficits in the absence of recognizable clinical symptoms of HE. 2 It occurs in patients with liver dysfunction and/or portosystemic shunts. In MHE, neurocognitive abnormalities primarily affect attention, speed of information processing, executive control, motor ability and coordination in an individual. 3 In 1970, Zeegen et al 4 first described this condition when they discovered that 38% of patients who had undergone portal decompression surgery scored abnormal in Reitan trail making test (number connection test). Eight years later, the term subclinical HE 5 was introduced to describe these patients. Since then, this condition was described under various names like early HE, latent HE, subclinical HE and finally minimal HE. The latest classification combines MHE and grade 1 HE into covert HE while higher grades are classified as overt HE, thus simplifying the clinical schema so that HE can be uniformly diagnosed. 6 Covert HE means that the mental defect is not detectable by the clinician using conventional testing and is not noticeable to the patient. However, it is significant because these patients usually have neuropsychiatric and neurophysiological abnormalities on advanced testing which are not enough to cause disorientation or asterixis. MHE is regarded as a preclinical stage of HE and ammonia and systemic inflammation plays an important role in its pathogenesis similar to HE. Ammonia lowering therapies were used in the treatment of MHE and found to be effective.MHE is clinically significant as it impairs daily functioning, health related quality of life (HRQOL) and driving skills, predicts the development of overt HE and is associated with poor survival. 7-11 Overt HE develops in >50% of MHE patients within three years. 10 These patients pose a significant burden to their care givers depending on the severity of cognitive dysfunction. 2,12 Considering all ...

This study conclusively demonstrated learning impairment in cirrhotic patients with a previous episode of OHE despite normal mental status. Improvement in PHES on repetition may be a measure of learning.

Author's summary Intravascular lithotripsy (IVL) is a newer calcium modification therapy with limited clinical experience compared to other established techniques. Single-armed studies have shown IVL is safe and effective for heavily calcified coronary lesions. This study compares our initial IVL experience with rotational atherectomy in real-world high-risk patients. We found that in-hospital adverse outcomes were not statistically significant, although 30-day major adverse cardiovascular events was higher with IVL. Differences in baseline characteristics and the small cohort numbers preclude definitive conclusions. With better experience and case selection, these outcomes are likely to improve, allowing IVL to effectively treat complex calcified coronary lesions.

Background & ObjectivesThis longitudinal study was carried out to evaluate the prognostic significance of fragmented QRS (fQRS) in patients with acute ST elevation myocardial infarction (STEMI) undergoing revascularization.MethodsThis study included 103 STEMI patients belonging to Killip class I and II who underwent primary revascularization. All patients underwent twelve lead ECG at admission before PCI. Serial ECG were done after PCI at 3 hours, 6 hours, 24 hours, 48 hours and at discharge for detection of fQRS and echocardiography on day 3 post revascularization. Patients developing fQRS within 48 hours and with persistence of fQRS till discharge were included in “persistent fQRS” group. They were followed up after 30 days for major adverse cardiac events (MACE) and assessment of LV function by echocardiography.ResultsfQRS was present in 64 patients (61.5%) of study population with 37 patients (57.8%) having persistent fQRS. MACE rates were low (4.8%) and did not differ with respect to fQRS. fQRS significantly correlated with LV dysfunction at 30 days on univariate analysis (p-0.003) but not on multivariate analysis (p -0.10). fQRS was significantly related to impaired myocardial reperfusion as assessed by ΣSTR (percent of total ST segment resolution) (adjusted odds ratio, 95% CI [4.265 (1.034 – 17.58)], p = 0.04).ConclusionIn our study, fQRS did not predict MACE and LV dysfunction in acute STEMI patients belonging to Killip class I and II on short term follow-up of 30 days. But, fQRS independently predicted impaired microvascular myocardial reperfusion as assessed by ΣSTR.

A 14-year-old boy suffering from chronic rheumatic heart disease came to the emergency department with recurrent episodes of presyncope and syncope. He was found to have complete heart block (CHB) and required temporary pacemaker insertion. Further workup revealed that CHB was secondary to acute rheumatic carditis. His atrioventricular (AV) conduction abnormalities recovered in a stepwise fashion over 5 days while he was being treated with corticosteroids, without the need for permanent pacemaker insertion. This case illustrates that acute rheumatic carditis can rarely present with advanced AV conduction block, which may be reversible.

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