***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Hepatic encephalopathy ( HE ) is an important component of hepatic decompensation , which reduces survival in patients with cirrhosis . The Model for End-Stage Liver Disease ( MELD ) score has been used to predict survival of patients with cirrhosis . The aims of this study were to determine whether HE is a predictor of survival of patients with cirrhosis and to examine the degree to which HE may add to the survival prediction of MELD . Patients with end-stage liver disease whose data were included in 2 data bases were included in the analysis : 223 patients undergoing transjugular intrahepatic portosystemic shunt ( TIPS ) insertion , and 271 patients hospitalized with hepatic decompensation . In univariate analysis , HE grade 3 or higher was associated with a 3.7-fold ( 95 % confidence interval , 1.9 - 7.3 , P<0.01 ) increase in the risk of death in the TIPS patients and HE grade 2 or higher was associated 3.9-fold increase ( 95 % confidence interval [ 95 % CI ] , 2.6 - 5.7 , P<0.01 ) in hospitalized patients . As expected , MELD and Child-Turcotte-Pugh scores ( with and without HE included ) were also markedly associated with survival . When HE ( grade 2 or higher ) and MELD were considered together , HE remained strongly statistically significant in the hospitalized patients ( hazard ratio=2.6 , 95 % CI , 1.7 - 3.8 , P<0.01 ) . The effect became smaller in the TIPS patients ( hazard ratio=1.1 ; 95 % CI , 0.7 - 1.6 , P=0.76 ) . In conclusion , this retrospective study demonstrates that HE is an important event in the natural history of cirrhosis that affects subsequent survival of patients . HE may provide additional prognostic information independent of MELD , which warrants prospect i ve validation BACKGROUND In this clinical trial , polyethylene glycol ( PEG ) solution was compared with lactulose in the treatment of hepatic encephalopathy in patients with cirrhosis . METHODS This r and omized controlled trial was performed on 40 patients in two groups . The patients in the lactulose group received either 20 - 30 grams of lactulose orally or by a nasogastric tube , or 200 grams of lactulose enema by a rectal tube . The patients in the PEG – lactulose group received the same amount of oral or rectal lactulose , plus 280 grams of PEG in 4 liters of water orally as a single dose in 30 - 120 minutes . Serial physical examinations , hepatic encephalopathy scoring algorithm ( HESA ) , blood level of ammonia , and serum biochemical studies were used to evaluate the severity of hepatic encephalopathy . RESULTS In comparison with lactulose alone , PEG-lactulose could improve HESA score in 24 hours more effectively ( p = 0.04 ) . Overall , PEG-lactulose regimen was associated with a decrease in length of hospital stay compared with lactulose treatment ( p = 0.03 ) but in subgroup analysis we found that PEG-lactulose regimen could only decrease the length of hospital stay in women significantly ( p = 0.01 ) . CONCLUSION The use of PEG along with lactulose in comparison with lactulose alone is more effective in the treatment of hepatic encephalopathy in patients with cirrhosis and results in more rapid discharge from hospital BACKGROUND & AIMS In patients with cirrhosis , hepatic encephalopathy ( HE ) has acute but reversible as well as chronic components . We investigated the extent of residual cognitive impairment following clinical resolution of overt HE ( OHE ) . METHODS Cognitive function of cirrhotic patients was evaluated using  psychometric tests ( digit symbol , block design , and number connection [ NCT-A and B ] ) and the inhibitory control test ( ICT ) . Improvement ( reduction ) in ICT lures and first minus second halves ( DeltaL(1 - 2 ) ) were used to determine learning of response inhibition . Two cross-sectional studies ( A and B ) compared data from stable cirrhotic patients with or without prior OHE . We then prospect ively assessed cognitive performance , before and after the first episode of OHE . RESULTS In study A ( 226 cirrhotic patients ) , 54 had experienced OHE , 120 had minimal HE , and 52 with no minimal HE . Despite normal mental status on lactulose after OHE , cirrhotic patients were cognitively impaired , based on results from all tests . Learning of response inhibition ( DeltaL(1 - 2 ) > or = 1 ) was evident in patients with minimal HE and no minimal HE but was lost after OHE . In study B ( 50 additional patients who developed > or = 1 documented OHE episode during follow-up ) , the number of OHE hospitalizations correlated with severity of residual impairment , indicated by ICT lures ( r = 0.5 , P = .0001 ) , digit symbol test ( r = -0.39 , P = .002 ) , and number connection test-B ( r = 0.33 , P = .04 ) . In the prospect i ve study ( 59 cirrhotic patients without OHE ) , 15 developed OHE ; ICT lure response worsened significantly after OHE ( 12 before vs 18 after , P = .0003 ) , and learning of response inhibition was lost . The 44 patients who did not experience OHE did not have deteriorations in cognitive function in serial testing . CONCLUSIONS In cirrhosis , episodes of OHE are associated with persistent and cumulative deficits in working memory , response inhibition , and learning The number connection test ( NCT ) , which assesses the extent of organic brain damage , has been used extensively to evaluate mental state in portasystemic encephalopathy , but has certain inherent limitations . It can not be performed by illiterates and those unfamiliar with Roman alphanumeric notations . We , therefore , devised a figure connection test ( FCT ) based on the subject 's identification of figures rather than alphabets or numerals . Four variations each of FCT-A ( A1-A4 ) and FCT-B ( B1-B4 ) employing different motifs were developed and compared with four variations each of NCT-A ( A1-A4 ) and NCT-B ( B1-B4 ) in groups of healthy volunteers with differing educational status . These volunteer groups were as follows : postgraduates 64 ; graduates 66 ; subgraduates 75 ; and illiterates 45 . Significant differences in mean scores of various tests were observed between these normal groups . Control values of the tests for these groups have been st and ardized and can serve as nomograms . The effect of educational attainments on performance of FCT and other psychometric tests was analysed and trail-making tests were vali date d for serial use . The FCT was then prospect ively vali date d on 70 patients ( classified for comparison with controls according to educational status as follows : postgraduates 7 ; graduates 21 ; subgraduates 32 ; and illiterates 10 ) with cirrhosis of liver without over encephalopathy , to detect sub clinical hepatic encephalopathy . NCT-A was abnormal in 31.7 % , NCT-B in 38.3 % , FCT-A in 42.9 % and FCT-B in 28.6 % of patients . Taken together these tests diagnosed sub clinical hepatic encephalopathy in 34 ( 48.5 % ) patients . We conclude that FCT is as useful as NCT in detecting psychomotor performance defects in cirrhotic patients without overt encephalopathy OBJECTIVES To analyze sources search ed in Cochrane review s , to determine the proportion of trials included in review s that are indexed in major data bases , and to compare the quality of these trials with those from other sources . METHODS All new systematic review s in the Cochrane Library , Issue1 2001 , that were restricted to r and omized controlled trials ( RCTs ) or quasi- RCTs were selected . The sources search ed in the review s were recorded , and the trials included were checked to see whether they were indexed in four major data bases . Trials not indexed were checked to determine how they could be identified . The quality of trials found in major data bases was compared with those found from other sources . RESULTS The range in the number of data bases search ed per review ranged between one and twenty-seven . The proportion of the trials in the four data bases were Cochrane Controlled Trials Register = 78.5 % , MEDLINE = 68.8 % , Embase = 65.0 % , and Science/Social Sciences Citation Index = 60.7 % . Search ing another twenty-six data bases after Cochrane Controlled Trials Register ( CCTR ) , MEDLINE , and Embase only found 2.4 % additional trials . There was no significant difference between trials found in the CCTR , MEDLINE , and Embase compared with other trials , with respect to adequate allocation concealment or sample size . CONCLUSIONS There was a large variation between review s in the exhaustiveness of the literature search es . CCTR was the single best source of RCTs . Additional data base search ing retrieved only a small percentage of extra trials . Contacting authors and manufacturers to find unpublished trials appeared to be a more effective method of obtaining the additional better quality trials A r and omized double blind clinical comparison of neomycin and lactulose was performed in 33 cirrhotic patients with chronic portal-systemic encephalopathy ( PSE ) at seven cooperating hospitals . In order to maintain double blindness , sorbitol syrup was used as a control solution along with neomycin and was compared with lactulose syrup and placebo tablets in a double drug protocol . Twenty-nine patients were studied in a crossover investigation in which each received both therapeutic regimens preceded and followed by control periods . Four additional patients received one or the other agent , but did not receive both . Serial , semiquantitative assessment s were made in all patients of mental status , asterixis , and the trailmaking test ( TMT ) and electroencephalograms ( EEG ) and arterial ammonia levels . Both neomycin-sorbitol and lactulose were effective in the majority of patients ( 83 and 90 % , respectively ) . Each of these parameters ( mental state , asterixis , TMT , EEG , and NH3 ) was improved significantly by neomycin-sorbitol and lactulose . The post-treatment levels for each of these measures were similar in the neomycin and lactulose-treated groups . Mean stool pH was reduced by neomycinsorbitol to 6.1 and by lactulose to 5.5 . This difference was highly significant statistically . Bowel activity was similar in the two groups . Both drugs were free of toxicity . These investigations demonstrate that both lactulose and neomycin-sorbitol are effective in the treatment of chronic portal-systemic encephalopathy Glycerol phenylbutyrate ( GPB ) lowers ammonia by providing an alternate pathway to urea for waste nitrogen excretion in the form of phenylacetyl glutamine , which is excreted in urine . This r and omized , double-blind , placebo-controlled phase II trial enrolled 178 patients with cirrhosis , including 59 already taking rifaximin , who had experienced two or more hepatic encephalopathy ( HE ) events in the previous 6 months . The primary endpoint was the proportion of patients with HE events . Other endpoints included the time to first event , total number of events , HE hospitalizations , symptomatic days , and safety .  GPB , at 6 mL orally twice-daily , significantly reduced the proportion of patients who experienced an HE event ( 21 % versus 36 % ; P = 0.02 ) , time to first event ( hazard ratio [ HR ] = 0.56 ; P < 0.05 ) , as well as total events ( 35 versus 57 ; P = 0.04 ) , and was associated with fewer HE hospitalizations ( 13 versus 25 ; P = 0.06 ) . Among patients not on rifaximin at enrollment , GPB reduced the proportion of patients with an HE event ( 10 % versus 32 % ; P < 0.01 ) , time to first event ( HR = 0.29 ; P < 0.01 ) , and total events ( 7 versus 31 ; P < 0.01 ) . Plasma ammonia was significantly lower in patients on GPB and correlated with HE events when measured either at baseline or during the study . A similar proportion of patients in the GPB ( 79 % ) and placebo groups ( 76 % ) experienced adverse events . Conclusion : GPB reduced HE events as well as ammonia in patients with cirrhosis and HE and its safety profile was similar to placebo . The findings implicate ammonia in the pathogenesis of HE and suggest that GPB has therapeutic potential in this population . ( Clinical trials.gov , NCT00999167 ) . ( Hepatology 2014;59:1073 - 1083 Background : Ornithine phenylacetate ( OP ) has been proven effective in lowering ammonia plasma levels in animals , and to be well tolerated in cirrhotic patients . A trial to assess OP efficacy in lowering plasma ammonia levels versus placebo in cirrhotic patients after an upper gastrointestinal bleeding was performed . The primary outcome was a decrease in venous plasma ammonia at 24 hours . Methods : A total of 38 consecutive cirrhotic patients were enrolled within 24 hours of an upper gastrointestinal bleed . Patients were r and omized (  
    Output:
    
There is insufficient evidence to determine the effects of these pharmacotherapies on the prevention and treatment of hepatic encephalopathy in adults with cirrhosis .
They have the potential to reduce blood ammonia concentrations when compared to placebo , but their overall effects on clinical outcomes of interest and the potential harms associated with their use remain uncertain .