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Detection and Treatment for Hepatic Encephalopathy Prevents Car Accidents, Reduces Costs
Inhibitory Control Test and Lactulose saves more than $3 Million over 5 years

A late stage liver condition, known as minimal hepatic encephalopathy (MHE), is associated with impaired driving skills and greater risk of motor vehicle accidents. Cost analysis of management strategies for detection and treatment of MHE are published in the April issue of Hepatology, a journal of the American Association for the Study of Liver Diseases. Findings report that MHE diagnosis using the inhibitory control test followed by treatment with lactulose was the most cost-effective approach--preventing the most car accidents and reducing societal cost by up to $3.6 million over a 5-year period.

In cirrhosis, as the liver fails, the build-up of toxic substances normally removed by the liver can lead to MHE—a reversible condition that causes cognitive impairment and loss of consciousness. Medical evidence reports that MHE is present in 55% of cirrhotic patients tested, and is associated with higher risk of motor vehicle collisions due to attention and visuomotor coordination deficits. The Inhibitory control test measures an individual’s attention and experts suggest it could be cost-effective in diagnosing MHE and correlates with driving impairments.

Previous research estimates vehicular accidents cost more than $200 billion per year in the U.S. in terms of lost productivity, medical costs, automobile damage, and insurance expenses. “Detection and treatment of MHE has potential to reduce costs and morbidity related to car accidents,” explains lead study author Dr. Jasmohan Bajaj with McGuire VA Medical Center and Associate Professor at Virginia Commonwealth University School of Medicine. “Our study analyzes the cost-effectiveness of various strategies for diagnosing and treating MHE to reduce vehicular accidents and the societal cost burden.”

Researchers compared five strategies for managing MHE that included presumptive treatment of all cirrhotic patients; diagnosis by neuropsychological exam with therapy; psychometric diagnostic testing with treatment; diagnosis using inhibitory control test with treatment; and no MHE diagnostics or treatment. Analysis was conducted on a simulated group of 1,000 cirrhotic patients treated for MHE with lactulose or rifaximin, and followed for 5 years. Researchers estimated the societal cost of a single car accident to be $42,100.

Results show the cost per motor vehicle accident prevented by diagnosing MHE with the inhibitory control test was $24,454; standard psychometric tests was $25,470; with presumptive treatment it was $30,469; and with neuropsychological exam the cost was $33,742. “Our findings provide strong evidence that detection of MHE, particularly the inhibitory control test, and subsequent treatment with lactulose reduces societal costs by preventing motor vehicle accidents in patients with MHE,” concludes Dr. Bajaj.

The authors of a related editorial also published in this month’s issue cite previous research that reports driving errors account for 71% to 98% of all motor vehicle accidents. They suggest that the high percentage of traffic accidents involving driver error makes the assessment of driving abilities crucial for patients with MHE. The study by Bajaj et al. provides evidence which may encourage further real-life effect of MHE on accident rates, and according to the authors, raise awareness of the implications for patients with liver disease and the whole of society.

Full Citations: “Diagnosis and Treatment of Minimal Hepatic Encephalopathy to Prevent Motor Vehicle Accidents: A Cost-Effectiveness Analysis.” Jasmohan S. Bajaj, Steven D. Pinkerton, Arun J. Sanyal, Douglas M. Heuman. Hepatology; December 2, 2011 (DOI: 10.1002/hep.25507); Print Issue Date: April 2012. http://onlinelibrary.wiley.com/doi/10.1002/hep.25507/abstract.

Editorial: “Attention: Minimal Hepatic Encephalopathy and Road Accidents.” Piero Amodio, Sara Montagnese, Carlo Merkel. Hepatology; January 11, 2012 (DOI: 10.1002/hep.25583); Print Issue Date: April 2012. http://onlinelibrary.wiley.com/doi/10.1002/hep.25583/abstract.

Author Contact: To arrange an interview with Dr.Bajaj, please contact Sathya Achia Abraham with Virginia Commonwealth University/VCU Medical Center sbachia@vcu.edu or 804-827-0890.


Over 20 Million Individuals Infected with Hepatitis E in Asia and Africa
70,000 Deaths and 3,000 Stillbirths Caused by Infections

New research funded by the World Health Organization (WHO) estimates that 20.1 million individuals were infected with hepatitis E virus (HEV) genotypes 1 and 2 across 9 world regions in 2005. According to findings available in the April issue of Hepatology, a journal published by Wiley-Blackwell on behalf of the American Association for the Study of Liver Diseases, there were 3.4 million symptomatic cases, 70,000 deaths, and 3,000 stillbirths from HEV that year in countries throughout Asia and Africa.

Unlike hepatitis virus B and C strains that lead to chronic disease states, HEV causes acute illness. Previous studies show HEV genotypes 1 and 2 specifically infect humans, and are associated with large outbreaks in developing countries where sanitation conditions are poor. There is evidence that HEV increases mortality risk among pregnant women. While a safe and effective HEV vaccine has been developed, it has not been widely implemented.

“Our study represents the first attempt to estimate the annual global impact of hepatitis E,” said lead author Dr. David Rein of the social science research organization NORC at the University of Chicago. Estimates were created by modeling the disease burden of HEV genotypes 1 and 2 in the 9 regions, representing 71% of the world’s population. Based on published evidence the team—a collaboration between researchers from NORC, WHO and RTI International—also estimated annual incidence of infection to determine symptomatic, asymptomatic, and mortality cases.

The team determined that the prevalence pattern of HEV was consistent across the regions, with the largest incident increase occurring in those between the ages of 5 and 20 years. The average age of infection was 17 years with the lowest age of infection in North Africa (8 years) and highest in East Asia (21 years).

Of the more than 20 million people infected with HEV, 61% of the cases occurred in East and South Asia, two regions which also accounted for 65% of deaths from HEV. Researchers also noted that North Africa accounted for 14% of all global HEV infections, but only 8.3% of symptomatic cases and 8% of deaths, which the authors attribute to the younger average age of infection in that region.

The authors caution there are limitations to the study which only estimated incidence of HEV genotypes 1 and 2, leaving out genotype 3 that prevalently occurs in Europe and the U.S., and genotype 4. “Future HEV estimates should include genotypes 3 and 4 to provide a complete picture of the global burden of HEV,” concludes Dr. Rein.

Full Citation: “The Global Burden of Hepatitis E Virus Genotypes 1 and 2 in 2005.” David B. Rein, Gretchen Stevens, Jordan Theaker, John S. Wittenborn and Steven T. Wiersma. Hepatology; Published Online: November 26, 2011 (DOI: 10.1002/hep.25505); Print Issue Date: April 2012. http://onlinelibrary.wiley.com/doi/10.1002/hep.25505/abstract.

Author Contact: To arrange an interview with Dr. Rein, please contact Raymond Boyer at raymondcboyer@gmail.com or at 312-330-6433.


These studies are published in Hepatology. Media wishing to receive a PDF of the articles may contact healthnews@wiley.com.

About the Journal
Hepatology is the premier publication in the field of liver disease, publishing original, peer-reviewed articles concerning all aspects of liver structure, function and disease. Hepatology’s current impact factor is 10.885.Each month, the distinguished Editorial Board monitors and selects only the best articles on subjects such as immunology, chronic hepatitis, viral hepatitis, cirrhosis, genetic and metabolic liver diseases and their complications, liver cancer, and drug metabolism. Hepatology is published on behalf of the American Association for the Study of Liver Diseases (AASLD). For more information, please visit http://onlinelibrary.wiley.com/journal/10.1002/(ISSN)1527-3350 .

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