title: Diagnosis of Minimal Hepatic Encephalopathy Using Stroop EncephalApp: A Multicenter US-Based, Norm-Based Study.
abstract: OBJECTIVE
  Diagnosing minimal hepatic encephalopathy (MHE) is challenging, and point-of-care tests are needed. Stroop EncephalApp has been validated for MHE diagnosis in single-center studies. The objective of the study was to validate EncephalApp for MHE diagnosis in a multicenter study.
  
  
  METHODS
  Outpatient cirrhotics (with/without prior overt hepatic encephalopathy (OHE)) and controls from three sites (Virginia (VA), Ohio (OH), and Arkansas (AR)) underwent EncephalApp and two gold standards, psychometric hepatic encephalopathy score (PHES) and inhibitory control test (ICT). Age-/gender-/education-adjusted values for EncephalApp based on direct norms, and based on ICT and PHES, were defined. Patients were followed, and EncephalApp cutoff points were used to determine OHE prediction. These cutoff points were then used in a separate VA-based validation cohort.
  
  
  RESULTS
  A total of 437 cirrhotics (230 VA, 107 OH, 100 AR, 36% OHE, model for end-stage liver disease (MELD) score 11) and 308 controls (103 VA, 100 OH, 105 AR) were included. Using adjusted variables, MHE was present using EncephalApp based on norms in 51%, EncephalApp based on PHES in 37% (sensitivity 80%), and EncephalApp based on ICT in 54% of patients (sensitivity 70%). There was modest/good agreement between sites on EncephalApp MHE diagnosis using the three methods. OHE developed in 13% of patients, which was predicted by EncephalApp independent of the MELD score. In the validation cohort of 121 VA cirrhotics, EncephalApp directly and based on gold standards remained consistent for MHE diagnosis with >70% sensitivity.
  
  
  CONCLUSIONS
  In this multicenter study, EncephalApp, using adjusted population norms or in the context of existing gold standard tests, had good sensitivity for MHE diagnosis and predictive capability for OHE development.
authors.affiliation: Internal Medicine and Gastroenterology, Cleveland Clinic, Cleveland, Ohio, USA.
authors.forename: Sanath
authors.initials: S
authors.lastname: Allampati
authors.affiliation: University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA.
authors.forename: Andres
authors.initials: A
authors.lastname: Duarte-Rojo
authors.affiliation: Family and Community Health Nursing and Biostatistics, Richmond, Virginia, USA.
authors.forename: Leroy R
authors.initials: LR
authors.lastname: Thacker
authors.affiliation: Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, Virginia, USA.
authors.forename: Kavish R
authors.initials: KR
authors.lastname: Patidar
authors.affiliation: Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, Virginia, USA.
authors.forename: Melanie B
authors.initials: MB
authors.lastname: White
authors.affiliation: University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA.
authors.forename: Jagpal S
authors.initials: JS
authors.lastname: Klair
authors.affiliation: Internal Medicine and Gastroenterology, Cleveland Clinic, Cleveland, Ohio, USA.
authors.forename: Binu
authors.initials: B
authors.lastname: John
authors.affiliation: Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, Virginia, USA.
authors.forename: Douglas M
authors.initials: DM
authors.lastname: Heuman
authors.affiliation: Psychiatry, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, Virginia, USA.
authors.forename: James B
authors.initials: JB
authors.lastname: Wade
authors.affiliation: University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA.
authors.forename: Christopher
authors.initials: C
authors.lastname: Flud
authors.affiliation: Internal Medicine and Gastroenterology, Cleveland Clinic, Cleveland, Ohio, USA.
authors.forename: Robert
authors.initials: R
authors.lastname: O'Shea
authors.affiliation: Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, Virginia, USA.
authors.forename: Edith A
authors.initials: EA
authors.lastname: Gavis
authors.affiliation: Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, Virginia, USA.
authors.forename: Ariel B
authors.initials: AB
authors.lastname: Unser
authors.affiliation: Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, Virginia, USA.
authors.forename: Jasmohan S
authors.initials: JS
authors.lastname: Bajaj
mesh_terms: D000328:Adult; D003430:Cross-Sectional Studies; D005260:Female; D006501:Hepatic Encephalopathy / Q000175:diagnosis*; D006801:Humans; D008297:Male; D008875:Middle Aged; D063731:Mobile Applications; D011446:Prospective Studies; D011594:Psychometrics; D014481:United States