Minimal Hepatic Encephalopathy among Cirrhotics; A Cross Sectional, Clinico- Epidemiological, Multi-Centre Registry in Patients of Pakistan. The PREEMPT Registry

Minimal Hepatic Encephalopathy among Cirrhotics; A Cross Sectional, Clinico- Epidemiological, Multi-Centre Registry in Patients of Pakistan. The PREEMPT Registry | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Minimal Hepatic Encephalopathy among Cirrhotics; A Cross Sectional, Clinico- Epidemiological, Multi-Centre Registry in Patients of Pakistan. The PREEMPT Registry Shahid Rasool, Raeefuddin Ahmed, Bilal Nasir, Zeeshan Ali, Karim Kammeruddin, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7378822/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Background: Minimal hepatic encephalopathy (MHE) is a common yet underrecognized complication of liver cirrhosis, associated with cognitive decline and reduced health-related quality of life (HRQoL). Early detection is essential, particularly in low-resource settings like Pakistan, where the burden of chronic liver disease is high. This study aimed to determine the prevalence and clinical features of MHE, identify associated risk factors, and assess its impact on HRQoL using the SF-36 tool. Methods: This multicenter, cross-sectional survey included adults aged 18–65 years with liver cirrhosis and no overt hepatic encephalopathy, recruited from primary care and gastroenterology clinics across Pakistan. Participants with Mini-Mental State Examination (MMSE) scores ≥24 were assessed for MHE using the Psychometric Hepatic Encephalopathy Score (PHES), with a cutoff of ≤−5. HRQoL was evaluated using the SF-36 questionnaire. Statistical analyses included chi-square tests, unpaired t-tests, and multivariable logistic regression. Results: Of 1,096 participants, 602 (54.9%) met criteria for MHE. These patients had significantly lower SF-36 scores: physical component score (41.4 ± 8.2 vs. 43.2 ± 8.1) and mental component score (41.3 ± 10.6 vs. 46.9 ± 11.0; p < 0.001). Hepatitis C was the most common etiology (71.4%), though it was inversely associated with MHE (OR 0.42, 95% CI 0.32–0.55). Independent risk factors included age (OR 1.01), NASH/NAFLD (OR 4.59), hepatitis B (OR 2.20), low sodium (OR 1.03), and tobacco chewing (OR 2.88). Commonly prescribed medications included lactulose, omeprazole, and carvedilol. Conclusion: MHE is highly prevalent among cirrhotic patients in Pakistan and significantly impairs both physical and mental well-being. Routine cognitive screening and integration of tools like MMSE and SF-36 into standard cirrhosis care may improve early detection and patient outcomes in high-burden, resource-limited settings. Minimal Hepatic Encephalopathy Health-Related Quality of Life Cirrhosis SF-36 Pakistan Figures Figure 1 Figure 2 Figure 3 Figure 4 Background/Introduction A common neuropsychiatric symptom of both acute and chronic liver disease, hepatic encephalopathy (HE) is characterized by disruptions in psychomotor, intellectual, cognitive, emotional/affective, behavioral, and fine motor functioning of differing degrees of severity ( 1 ). The mildest form of HE, known as minimal hepatic encephalopathy (MHE), is diagnosed using specialized psychometric tests and manifests without any apparent clinical impairment (normal mental and neurologic condition on clinical examination). It is typified by mild cognitive and motor impairments that lower health-related quality of life (HRQL) ( 2 ). HE may not seem obvious when diagnosing a patient exhibiting symptoms; therefore, multiple tools are used to assess a patient, which can help assess the disease's prevalence and incidence. MHE commonly remains undiagnosed or underdiagnosed as there are no clinical manifestations of the condition. The actual prevalence of MHE is still unknown ( 4 ). However, it has been estimated to be between 22% and 80%( 3, 5–9). However, studies in India suggest that the prevalence of MHE in the region can range from 53%-62% ( 10 – 11 ). MHE negatively impacts the quality of life and day-to-day functioning of the patient. MHE patients struggle with working memory, attention, and reaction inhibition, all of which are linked to impaired driving and a higher risk of motor vehicle accidents ( 12 ). The epidemiological (non-interventional), multi-center, cross-sectional study (PREEMPT) conducted in 2019 to assess the incidence of MHE among stable cirrhotic patients without overt symptoms of HE enabled the inception of this current study ( 13 ). Further, the study helped us in the design of this PREEMPT registry, which depicted the frequency of MHE among cirrhotic patients in a larger population as compared to the PREEMPT Study and develop a consensus on the clinical management of MHE in Pakistan. Thus, the Preempt registry is a continuation of the Preempt study to evaluate the incidence of MHE amongst a cirrhotic patients in a wider population. This study stretched across a larger number of cities, and a larger sample size enabled us to understand the impact of MHE on HRQoL even better. Methods and Materials The multicenter study was cross-sectional survey conducted in Pakistan, in adherence to the guidelines of ICH-Good Clinical Practice along with all the relevant national guidelines. The information produced in this study was kept confidential and was not shared with any individual who was not directly involved in the study. The protocol and relevant study documents were submitted for review and approval of Institutional Review Board. The ethics approval was obtained from respective hospitals’ IRBs which are mentioned in Appendix 1. Study procedure: As Figure 1 shows, Patients with a confirmed diagnosis of liver cirrhosis who presented to the outpatient gastroenterology or hepatology department were first approached for participation. Upon obtaining written informed consent from the patients, the demographic details, relevant medical history, previous laboratory values, radiological and endoscopic findings, current medications, potential etiological factors, and comorbidities associated with cirrhosis were documented. The eligible patients (those meeting Grade 0 criteria of the West Haven classification) were enrolled according to the study’s inclusion criteria however, patients with inability to perform neuropsychometric tests and to complete the SF-36 questionnaire as decided by the physician were excluded. The enrolled patients’ cognitive function was initially assessed using the Mini-Mental State Examination (MMSE), and those with scores MMSE≥ 24 underwent further evaluation with the Psychometric Hepatic Encephalopathy Score (PHES). Patients who achieved a normal PHES score (greater than –5) were categorized as not having MHE, whereas those with abnormal scores (≤ –5) were diagnosed with MHE. Regardless of MHE status, all participants subsequently completed the SF-36 questionnaire to evaluate HRQOL, and details of prescribed medications were recorded for analysis. Study population As the study was multicenter, total 15 medical facilities from Pakistan including, Karachi, Hyderabad, Quetta, Faisalabad, Multan, Islamabad, Rawalpindi, and Peshawar were included in the study. The patients with a diagnosis of liver cirrhosis visiting the outpatient departments of these facilities were enrolled in the study after getting an informed consent form signed. Sample size Using the prevalence of 59.7% of minimal hepatic encephalopathy among liver cirrhosis patients as indicated by Rathi et al(14) in a multicenter study of India, with margin of error of +/- 3% and confidence interval of 95%, the minimum required sample size was n=1007. Statistical analysis: . The block method was performed on variables reaching a significance of P ≤ 0.05 on univariate analysis to determine the influence on the presence of MHE. A P value of ≤0.05 was considered statistically significant. Statistical analysis was performed using STATA software for Windows, version 16. Study Results Following results were identified after the data analysis: Study Primary Variables Demographic and other baseline characteristics Of all evaluable cirrhotic patients(n=1096) (MMSE score ≥ 24), the mean age of study population was 45.5 (±11.4) years. The majority of the study patients were males (n= 668, 60.9%), with most of the patients being married (n=973, 88.8%). The mean weight was similar between the groups (71.1 ± 13.7 vs. 70.8 ± 10.7; p = 0.66). However, the MHE group exhibited a significantly higher mean BMI (31.9 ± 22.3 vs. 26.8 ± 13.0; p < 0.001). Further demographic characteristics are depicted in Table 1a. Table 1:Demographic Characteristics Parameter Total Non-MHE MHE p-value n=1,096 n=494 n=602 AGE Mean (±S.D) 45.5 (±11.4) 44.6 (±10.9) 46.3 (±11.7) 0.016 a Median (IQR) 46 (38-55) 45 (37-53) 48 (38-56) Weight Mean (±S.D) 71.0 (±12.4) 70.8 (±10.7) 71.1 (±13.7) 0.66 a Median (IQR) 70 (63-78) 70 (65-78) 70 (62-78) Height Mean (±S.D) 161.5 (±18.4) 165.7 (±13.8) 157.9 (±20.8) <0.001 a Median (IQR) 164 (156-171) 168 (160.02-172) 160 (152-169) BMI Mean (±S.D) 29.5 (±18.8) 26.8 (±13.0) 31.9 (±22.3) <0.001 a Median (IQR) 25.93 (23.5-29.5) 25.18 (22.98-27.63) 26.75 (24.0-31.24) Education Level n (%) 0.006 b High School 236 (21.5%) 96 (19.4%) 140 (23.3%) Intermediate 201 (18.3%) 85 (17.2%) 116 (19.3%) Middle (up to class 8) 253 (23.1%) 112 (22.7%) 141 (23.4%) Primary 185 (16.9%) 77 (15.6%) 108 (17.9%) Undergraduate/ Graduate 221 (20.2%) 124 (25.1%) 97 (16.1%) Gender n (%) 0.23 b Female 427 (39.0%) 181 (36.6%) 246 (40.9%) Male 668 (60.9%) 313 (63.4%) 355 (59.0%) Marital Status n (%) 0.40 b Divorced 3 (0.3%) 1 (0.2%) 2 (0.3%) Married 973 (88.8%) 435 (88.1%) 538 (89.4%) Unmarried 118 (10.8%) 56 (11.3%) 62 (10.3%) MHE, minimal hepatic encephalopathy. a: Analyzed using t-test. b: Analyzed using chi-square test. Of all the study patients, more than 19% (n=211, 19.3%) were smokers and, on average they smoked 13.0 (±6.6) cigarettes per day. The average duration of smoking was 13.9 ±7.8 years. Some (7.4%) patients had history of tobacco chew, and only 20 (1.8%) patients had history of alcohol consumption. History for habits like cigarette smoking, tobacco chewing, and alcohol consumption is depicted in Table 1b. Table 1b: History of habits like smoking Parameter Total Non-MHE MHE p-value n=1,096 n=494 n=602 Smoking Status n (%) 0.29 b Non- Smoker 885 (80.7%) 392 (79.4%) 493 (81.9%) Smoker 211 (19.3%) 102 (20.6%) 109 (18.1%) Duration of smoking (years) Mean (±S.D) 13.9 (±7.8) 13.8 (±7.0) 14.1 (±8.5) 0.79 a cigarettes per day Mean (±S.D) 13.0 (±6.6) 13.4 (±6.3) 12.7 (±6.9) 0.43 a Tobacco Chewing n (%) <0.001 b No 1,013 (92.4%) 475 (96.2%) 538 (89.4%) Yes 81 (7.4%) 19 (3.8%) 62 (10.3%) Missing 2 (0.2%) 0 (0.0%) 2 (0.3%) Duration (years) Mean (±S.D) 13.5 (±8.8) 11.1 (±9.4) 14.3 (±8.5) 0.16 a Alcohol Consumption n (%) 0.89 b No 1,072 (97.8%) 482 (97.6%) 590 (98.0%) Yes 20 (1.8%) 10 (2.0%) 10 (1.7%) Quantity of Alcohol n (%) 0.33 b 2-4 drinks per day 7 (0.6%) 2 (0.4%) 5 (0.8%) < 2 drinks per day 13 (1.2%) 8 (1.6%) 5 (0.8%) Alcohol type n (%) 0.52 b 120 mL of wine 3 (0.3%) 2 (0.4%) 1 (0.2%) 30 mL of hard liquor 13 (1.2%) 5 (1.0%) 8 (1.3%) 360 mL of beer 4 (0.4%) 3 (0.6%) 1 (0.2%) a: Analyzed using t-test. b: Analyzed using chi-square test . All enrolled patients had fibrosis-4 (FIB-4) score value >3.25. However, there was no significant differences between MHE and non-MHE groups for AST, Platelet, ALT, and Fib 4 levels, as indicated by p-values of 0.21, 0.45, 0.23, and 0.85, respectively (Table-1c). Table-1c: Laboratory measures for determining Fibrosis-4 score Parameter Total Non-MHE MHE p-value n=1,096 n=494 n=602 AST Mean (± Stdev) 113.6 (±99.8) 109.4 (±98.9) 117.1 (±100.4) 0.21 a Median (IQR) 79 (57-123.5) 78 (56-108) 80 (58-148) ALT Mean (± Stdev) 96.3 (±99.0) 92.4 (±95.0) 99.6 (±102.1) 0.23 a Median (IQR) 56 (37-106.5) 57 (38-98) 56 (37-120) Platelet Mean (± Stdev) 100.2 (±49.6) 98.9 (±53.8) 101.2 (±45.9) 0.45 a Median (IQR) 96 (73.5-115) 95 (70-114) 97 (76-118) Fib 4 Mean (±Stdev) 6.0 (±4.4) 6.0 (±4.5) 6.0 (±4.3) 0.85 a Median (IQR) 4.67 (3.66-6.76) 4.7 (3.63-6.76) 4.65 (3.69-6.76) a: Analyzed using t-test Frequency of Minimal & Non-minimal hepatic encephalopathy (MHE) among cirrhotic patients: Of the 1096 evaluable cirrhotic patients, 602 had a psychometric hepatic encephalopathy score ≤−5, indicating MHE frequency in our study population as 54.9%. Mean MMSE score in cirrhotic patients is 27.09 ±2.35 (table 2). Table 2:Physical score, mental score & MMSE scores in MHE & Non-MHE Patients Parameter Total Non-MHE MHE p-value N=1,096 N=494 N=602 PCS Mean (±S.D) 42.2 (±8.2) 43.2 (±8.1) 41.4 (±8.2) <0.001 a MCS Mean (±S.D) 43.8 (±11.1) 46.9 (±11.0) 41.3 (±10.6) <0.001 a a: Analyzed using t-test. b: Analyzed using chi-square test. Etiology and co-morbid conditions frequency in cirrhotic patients. The most common underlying etiology of cirrhosis was viral hepatitis-C (n=783, 71.4%) followed by viral hepatitis-B (n=184, 16.8%) and Nonalcoholic Steatohepatitis/Nonalcoholic fatty liver disease NASH/ NAFLD (n=32, 2.9%). Viral Hepatitis B was more common among patients with MHE (n=129, 70.1%) than among those patients without MHE 55 (29.9%). Among associated comorbidities, hypertension is found in greater number (n=140, 12.8%) followed by diabetes (n=63, 5.7%). Details of etiology and co- morbid conditions are depicted in Table3. Table 3:Etiology and co-morbid conditions frequency in cirrhotic patients Parameter n(%) Total Non-MHE MHE N=1,096 N=494 N=602 Etiology of Cirrhosis Viral Hepatitis C 783 (71.4%) 399 (50.9%) 384 (49.1%) Viral Hepatitis B 184 (16.8%) 55 (29.9%) 129 (70.1%) NASH/ NAFLD 32 (2.9%) 5 (15.6%) 27 (84.4%) Autoimmune Hepatitis 18 (1.6%) 6 (33.3%) 12 (66.6%) Wilson's Disease 13 (1.2%) 4 (30.7%) 9 (69.2%) Budd- Chiari syndrome 17 (1.6%) 8 (47.05%) 9 (52.95%) Excessive Alcohol consumption 9 (0.8%) 5 (55.5%) 4 (45.5%) Drug-induced Liver disease 3 (0.3%) 1 (33.3%) 2 (66.6%) Chronic Right-sided Heart Failure 2 (0.2%) 0 (0.0%) 2 (100%) Hemochromatosis 2 (0.2%) 1 (50%) 1 (50%) Tricuspid regurgitation 2 (0.2%) 0 (0.0%) 2 (100%) Glycogen storage disease 1 (0.1%) 0 (0.0%) 1 (100%) Blockage of Bile ducts 1 (0.1%) 1 (100%) 0 (0.0%) Primary sclerosing cholangitis 1 (0.1%) 0 (0.0%) 1 (100%) Others 26 (2.4%) 8 (30.7%) 18 (69.3%) Associated comorbidities Hypertension 140 (12.8%) 44 (31.4%) 96 (68.6%) Diabetes 63 (5.7%) 18 (28.5%) 45 (71.5%) Dyslipidemia 27 (2.5%) 5 (18.5%) 22 (81.5%) Others 45 (4.1%) 14 (31.1%) 31 (69.9%) Study Secondary Variables Association of etiologies and co-morbid conditions with minimal hepatic encephalopathy: Associations between etiologies, comorbid conditions and minimal hepatic encephalopathy are determined through logistic regression univariate & multivariate analysis. The univariate analysis revealed that age (O.R. 1.01, C.I. 1.0-1.02), NASH/NAFLD (O.R. 4.59, C.I. 1.75-12.01), Viral Hepatitis B (O.R. 2.2, C.I. 1.54-3.06) & C (O.R. 0.42, C.I. 0.32-0.55), sodium levels (O.R. 1.03, C.I. 1.01-1.06), and tobacco chewing (O.R. 2.88, C.I. 1.7-4.89) are significantly associated with MHE. However, upon multivariate analysis only Viral Hepatitis C (O.R. 4.59, C.I. 1.75-12.01) retained the statistically significant association with the MHE. Univariate & multivariate analyses for the associations are depicted in Table 4a & 4b. Table 4a: Univariate Analyses for association of Etiologies & Comorbid Conditions with MHE Variable (univariate) Odds ratio 95% Wald confidence limits P value a Age (years) 1.01 1.0-1.02 0.016 Etiology NASH/ NAFLD 4.59 1.75- 12.01 0.002 Viral Hepatitis B 2.2 1.54- 3.06 0.000 Viral Hepatitis C 0.42 0.32-0.55 0.000 Wilson Disease 1.86 0.57- 6.07 0.305 Autoimmune Hepatitis 1.65 0.62-4.44 0.318 Budd- Chiari syndrome 0.92 0.35-2.41 0.868 Excessive Alcohol consumption 0.65 0.17-2.45 0.528 Co-morbidities Diabetes mellitus 1.06 0.57-1.97 0.861 Dyslipidemia 1.94 0.71-5.33 0.196 Hypertension 0.82 0.489 – 1.38 0.46 Other Sodium (mmol/L) 1.03 1.01-1.06 0.005 Tobacco chewing 2.88 1.7-4.89 0.000 Smoking 0.85 0.63-1.15 0.289 a: Analyzed using Logistic Regression Table 4a: Univariate Analyses for association of Association of Etiologies & Comorbid Conditions with MHE Variable (multivariate) Odds ratio 95% Wald confidence limits P value a Age (years) 1.0 0.99-1.01 0.285 NASH/ NAFLD 4.2 0.96-18.39 0.067 Viral Hepatitis B 0.98 0.53 – 1.84 0.973 Viral Hepatitis C 0.34 0.24-0.50 0.000 Sodium (mmol/L) 1.0 0.99-1.03 0.145 Tobacco chewing 1.6 0.91-2.92 0.101 a: Analyzed using logistic regression. Health Related Quality of Life (HRQoL) assessment using SF-36 Questionnaire: The Mental Component Score (MCS) and Physical Component Score (PCS), derived from SF-36 questionnaire are calculated for both MHE and Non-MHE cirrhotic patients. MHE patients had significantly lower PCS scores than non-MHE patients (41.4 ± 8.2 vs. 43.2 ±8.1). Similarly, MHE patients had significantly lower MCS scores as well (41.3 ±10.6 vs. 46.9 ±11.0). Patients’ physical and mental component scores derived from SF-36 questionnaire are depicted in Table-5 and Figure- 1a & b. Table 5: Quality of Life Assessment using SF-36 questionnaire among MHE and Non-MHE Patients: Parameter Total Non-MHE MHE p-value N=1,096 N=494 N=602 PCS Mean (±S.D) 42.2 (±8.2) 43.2 (±8.1) 41.4 (±8.2) <0.001 a MCS Mean (±S.D) 43.8 (±11.1) 46.9 (±11.0) 41.3 (±10.6) <0.001 a a- Independent t-test was used to determine the statistical significance. n 602 494 Mean (±S.D) 41.4 (±8.2) 43.2 (±8.1) Study Exploratory Variables: Multiple drugs were prescribed to the patients; pattern of drug prescriptions is depicted in figures 2 & 3. Discussion Studies reveal that efforts are being made to recommend screening within all patients with cirrhosis with neurocognitive symptoms ( 18 ), since it is now apparent that effective treatment of MHE is readily available. This study highlights the high prevalence of cognitive dysfunction in Pakistan, specifically minimal hepatic encephalopathy (MHE), in cirrhotic patients despite the absence of evident clinical manifestations of hepatic encephalopathy (HE). MHE is rarely screened in routine clinical practice due to its diagnostic complexity and the need for specialized psychometric tools. Without any overt clinical manifestation of Hepatic Encephalopathy (HE), this study emphasizes the high prevalence rates of cognitive dysfunction in the form of MHE in the cirrhotic population. MHE is seldom if ever, screened for in routine clinical practice because of its difficulty in diagnosis and the need for specialized psychometric tests for identification. The study found that 54.9% of the 1,096 evaluable cirrhotic patients had minimal hepatic encephalopathy (MHE), as indicated by a PHES score ≤ -5. This high prevalence aligns with previous studies, emphasizing the widespread occurrence of MHE among cirrhotic patients that patients with liver cirrhosis have a higher chance of developing MHE over the course of time ( 15 – 17 ). Moreover, among the etiology of the disease, viral Hepatitis C was the most common underlying cause of cirrhosis (71.4%), followed by Viral Hepatitis B (16.8%) and NASH/NAFLD (2.9%). These findings are in line with global trends where viral hepatitis remains a leading cause of cirrhosis. Notably, Viral Hepatitis B was more prevalent among MHE patients (21.4%) compared to non-MHE patients (11.1%). However, the odds ratio of the participants with viral hepatitis B suggested no impact of the disease over the incidence of MHE because, as per our data, all the patients with viral hepatitis B had developed MHE. Another study conducted in 2023 on a cohort of 736 patients with liver cirrhosis from a variety of etiologies determined the association of those etiologies with the prevalence of MHE ( 18 ). The study also found associated risk factors that the prevalence was significantly higher in patients with a history of alcohol consumption than those with etiologies such as HBV and HCV-related liver cirrhosis. To further elaborate on this finding, our study had a very insignificant representation of the population consuming alcohol; therefore, no such association was detected. However, our study identifies chewing tobacco as a significant risk factor for patients with liver cirrhosis to develop MHE. Univariate analysis identified age, NASH/NAFLD, Viral Hepatitis C, sodium levels, and tobacco chewing as significant factors associated with MHE. Multivariable logistic regression confirmed that Viral Hepatitis C had a protective effect against MHE (odds ratio < 1), while other factors did not show statistically significant associations. These results underscore the complex interplay of various risk factors in the development of MHE and suggest that specific etiologies of cirrhosis might influence the risk differently. Routine screening and management of MHE is necessary in clinical practice because of its high frequency among cirrhotic patients and its substantial influence on quality of life and concomitant diseases. The study provided important insights towards the drug prescription trends and how the patient care can benefit.In order to lessen the effects of MHE, future research should concentrate on examining the mechanisms behind these correlations and creating focused therapies. The study results support existing evidence that underscores the clinical importance of MHE. These findings highlight the value of early screening and effective management within routine care to reduce its negative effects on patients’ daily functioning and quality of life ( 19 ). The data also confers that more than 50% of the population had a Psychometric Hepatic Encephalopathy Score (PHES) of ≤ -5, indicating a high prevalence of MHE among cirrhotic patients. These findings align with global trends where viral hepatitis, particularly Hepatitis C, remains a leading cause of cirrhosis ( 20 ). Interestingly, the odds ratio for participants with viral Hepatitis B suggested that the disease will eventually lead the patients to develop MHE as all patients with hepatitis-B were found to have MHE in the said study project. It was also noted that MHE prevalence was significantly higher in patients with a history of tobacco chewing compared to those with HBV and HCV-related liver cirrhosis. These findings accentuate the importance of routine MHE screening and suggest that targeted interventions could significantly benefit cirrhotic patients, improving their quality of life and overall disease management. Study Conclusion The study revealed a prevalence of minimal hepatic encephalopathy (MHE) in 54.9% of the evaluated cirrhotic patients. Demographic insights showed that the average age of these patients was 45.5 years, with a majority being male (60.9%). Regarding comorbidities and etiologies, Viral Hepatitis C was the most common cause, affecting 71.4% of the patients, followed by Viral Hepatitis B at 16.8%. Additionally, hypertension (12.8%) and diabetes (5.7%) were notable comorbid conditions. The health-related quality of life (HRQoL) assessment indicated that patients with MHE had significantly lower Physical Component Scores (PCS) and Mental Component Scores (MCS) compared to those without MHE. In terms of drug prescription patterns, medications such as Carvedilol, Omeprazole, and Lactulose were frequently prescribed both before and after the diagnosis of MHE, highlighting the therapeutic approaches in managing this condition. Declarations Ethics Approvals The study was conducted under the ethical approval guidelines present in ICH-GCP, E6-R3 guidelines. Approval of the following IRBs were obtained for the study: NBC-R (National Bioethics Committee at National Institute of Health) IRB - BUMHS (Bolan University of Medical & Health Sciences) IRB – FMHD (Fatima Memorial Hospital, College of Medicine & Dentistry) Madina Teaching Hospital Faisalabad], approved by the Ethical Institutional Review Board (The University of Faisalabad). IRB - PKLI (Pakistan Kidney and Liver Institute and Research Centre) IRB – LRH (Lady Reading Hospital, Medical Teaching Institution) IRB – AIMS (Asian Institute of Medical Sciences) IRB – JPMC (Jinnah Postgraduate Medical Centre). Consent to participate Participants in the study were patients with confirmed diagnosis of cirrhosis who visited gastroenterology and hepatology clinics at the institutions involved in the study. Patients who met the study's inclusion criteria and those who voluntarily agreed to participate signed an informed consent form after being verbally briefed about the study's specifics. Availability of data and materials The datasets generated and analyzed in the current study are not readily available online; however, these datasets can be made available from the corresponding author upon reasonable request. Competing interests: Raeefuddin Ahmed and Tabrez Ali are salaried and full-time employees of Abbott Laboratories (Pakistan) Limited. The other authors declared no competing interests. Funding: This research was funded by Abbott Laboratories Pakistan Limited Authors and Affiliations: Zeeshan Ali 1 , Raeefuddin Ahmed 2 , Shahid Rasool 3 , Bilal Nasir 4 , Karim Kammeruddin 5 , Bushra Ali 6 , Farhana Kayani 7 , Tabrez Ali 8 Affiliations Jinnah Postgraduate Medical Centre, Karachi, Pakistan Aga Khan Medical University Hospital, Pakistan Madina Teaching Hospital Faisalabad, Pakistan Doctors Specialist Hospital Lahore / Gulab Devi Hospital, Lahore, Pakistan Zainab Medical Centre, Karachi, Pakistan Fatima Memorial Hospital, College of Medicine & Dentistry, Lahore, Pakistan Sheikh Zayed Hospital & Quetta Hospital/ Bolan Medical University, Quetta, Pakistan Abbott Laboratories Pakistan Limited, Pakistan Acknowledgement: Dimensions Research acted as the Contract Research Organization (CRO), Metrics Research did Medical Writing for the study. All authors read and approved the final version. 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Journal of Clinical and Experimental Hepatology. 2018 Jun 1;8(2):156-61. Elgohary MN, Amer K, Bassiony MA. Prevalence and risk factors of minimal hepatic encephalopathy in patients with compensated liver cirrhosis. The Egyptian Journal of Hospital Medicine. 2020 Jul 1;80(2):871-5. Dhiman RK, Kurmi R, Thumburu KK, Venkataramarao SH, Agarwal R, Duseja A, Chawla Y. Diagnosis and prognostic significance of minimal hepatic encephalopathy in patients with cirrhosis of liver. Digestive diseases and sciences. 2010 Aug;55:2381-90. Li X, Liu S, Xiang H, Zhang Q, Guo Y, Zu H, Wang J, Lv J, Zhang X, Meng F, Li J. Prevalence and risk factors for minimal hepatic encephalopathy in cirrhotic patients with different etiologies. Portal Hypertension & Cirrhosis. 2023 Dec 30;2(04):171-80. Ridola L, Nardelli S, Gioia S, Riggio O. Quality of life in patients with minimal hepatic encephalopathy. World J Gastroenterol. 2018;24(48):5446-5453. doi:10.3748/wjg.v24.i48.5446 Alberts CJ, Clifford GM, Georges D, Negro F, Lesi OA, Hutin YJ, de Martel C. Worldwide prevalence of hepatitis B virus and hepatitis C virus among patients with cirrhosis at country, region, and global levels: a systematic review. The Lancet Gastroenterology & Hepatology. 2022 Aug 1;7(8):724-35. Additional Declarations No competing interests reported. Supplementary Files Appendix1.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 24 Sep, 2025 Reviewers agreed at journal 18 Sep, 2025 Reviewers invited by journal 27 Aug, 2025 Editor invited by journal 19 Aug, 2025 Editor assigned by journal 18 Aug, 2025 Submission checks completed at journal 18 Aug, 2025 First submitted to journal 15 Aug, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7378822","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":503553707,"identity":"d8966ef4-96de-4591-bcf7-1d4c3f42df97","order_by":0,"name":"Shahid Rasool","email":"","orcid":"","institution":"Madina Teaching Hospital","correspondingAuthor":false,"prefix":"","firstName":"Shahid","middleName":"","lastName":"Rasool","suffix":""},{"id":503553708,"identity":"16156e5d-6c45-4cfe-86d7-e6834045ddbf","order_by":1,"name":"Raeefuddin Ahmed","email":"","orcid":"","institution":"Madina Teaching Hospital","correspondingAuthor":false,"prefix":"","firstName":"Raeefuddin","middleName":"","lastName":"Ahmed","suffix":""},{"id":503553709,"identity":"93415a42-c34e-4f1b-b199-501ad761bf9b","order_by":2,"name":"Bilal Nasir","email":"","orcid":"","institution":"Madina Teaching Hospital","correspondingAuthor":false,"prefix":"","firstName":"Bilal","middleName":"","lastName":"Nasir","suffix":""},{"id":503553710,"identity":"18960379-0301-40f9-99a2-8373a5f8e7ca","order_by":3,"name":"Zeeshan Ali","email":"","orcid":"","institution":"Madina Teaching Hospital","correspondingAuthor":false,"prefix":"","firstName":"Zeeshan","middleName":"","lastName":"Ali","suffix":""},{"id":503553711,"identity":"274c0994-0353-4746-97b4-7ca92f1d723d","order_by":4,"name":"Karim Kammeruddin","email":"","orcid":"","institution":"Madina Teaching Hospital","correspondingAuthor":false,"prefix":"","firstName":"Karim","middleName":"","lastName":"Kammeruddin","suffix":""},{"id":503553712,"identity":"4bb8c076-c6bb-43dc-a7d3-248a32bef3c9","order_by":5,"name":"Bushra Ali","email":"","orcid":"","institution":"Madina Teaching Hospital","correspondingAuthor":false,"prefix":"","firstName":"Bushra","middleName":"","lastName":"Ali","suffix":""},{"id":503553713,"identity":"13340cc9-6770-4788-b7d3-fbfa5ae24936","order_by":6,"name":"Farhana Kayani","email":"","orcid":"","institution":"Madina Teaching Hospital","correspondingAuthor":false,"prefix":"","firstName":"Farhana","middleName":"","lastName":"Kayani","suffix":""},{"id":503553714,"identity":"5286cd34-b7ac-4d00-9b1c-acc7c87a3940","order_by":7,"name":"Tabrez Ali","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA1ElEQVRIiWNgGAWjYFACHgjFx8x8gJmxgSgNUC1szGwJIC0SPMRrYeAxIE6LPfvZYx8+/GGQZ2Pn+fi5cIdNnT0D88NHN/DZwpOXPHMGD4NhGzPvZumZZ9KAtrAZG+fgdViOMTOPBAMjUMsGad62w0AtPGzSeLXwvzFm/mPAYN/GzPP4N3FaJIC2MCQwJAK1sBFpy413yYw9BySS25jZzKyBfpHsOUzAL+z9uYcZfvyxse3nP/z4NjDE+Nnbmx8+xqcFCiSQ2MyElY+CUTAKRsEoIAAAIuc6mARzXm4AAAAASUVORK5CYII=","orcid":"","institution":"Madina Teaching Hospital","correspondingAuthor":true,"prefix":"","firstName":"Tabrez","middleName":"","lastName":"Ali","suffix":""}],"badges":[],"createdAt":"2025-08-15 06:23:18","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7378822/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7378822/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":89642192,"identity":"df05f90c-15bd-4c0c-b8d4-d6094a0c27eb","added_by":"auto","created_at":"2025-08-22 08:13:31","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":131694,"visible":true,"origin":"","legend":"\u003cp\u003eStudy Fow Chart Along With Categories and Subgroups of Subjects\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7378822/v1/08e2f94f68dd92dd9f3274a9.png"},{"id":89642195,"identity":"33824d13-1034-4771-a776-8bf2c773de60","added_by":"auto","created_at":"2025-08-22 08:13:31","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":45341,"visible":true,"origin":"","legend":"\u003cp\u003eFigure 1a: Physical Scores of MHE \u0026amp; Non- MHE Patients\u003c/p\u003e\n\u003cp\u003eFigure-1b: Mental component score in MHE \u0026amp; Non-MHE Patients\u003c/p\u003e","description":"","filename":"Fig1.png","url":"https://assets-eu.researchsquare.com/files/rs-7378822/v1/8e1379050c500abf0544775d.png"},{"id":89643304,"identity":"a4a516af-d16b-4703-8356-db6547e80b14","added_by":"auto","created_at":"2025-08-22 08:29:31","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":44929,"visible":true,"origin":"","legend":"\u003cp\u003eFigure 2: Pattern of drug prescription before the diagnosis of MHE in treatment naïve patients and those on therapy.\u003c/p\u003e","description":"","filename":"FIg2.png","url":"https://assets-eu.researchsquare.com/files/rs-7378822/v1/bd4279b41536784be8c5c72f.png"},{"id":89642199,"identity":"fddf7240-8d48-43f7-b26d-0977c4e6e0c0","added_by":"auto","created_at":"2025-08-22 08:13:31","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":41883,"visible":true,"origin":"","legend":"\u003cp\u003eFigure 3: Pattern of drug prescription after the diagnosis of MHE in treatment naïve patients and those on therapy.\u003c/p\u003e","description":"","filename":"Fig3.png","url":"https://assets-eu.researchsquare.com/files/rs-7378822/v1/f3e5121a28b6e75be82a8d1e.png"},{"id":89644771,"identity":"35aca8dc-6576-4089-890e-d1c80a95d23b","added_by":"auto","created_at":"2025-08-22 08:45:32","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1758668,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7378822/v1/49f22cb3-e94c-41f7-852e-0845900d067a.pdf"},{"id":89642577,"identity":"e0383699-081c-4c0a-b6f1-ceed56c543ec","added_by":"auto","created_at":"2025-08-22 08:21:31","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":15428,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix1.docx","url":"https://assets-eu.researchsquare.com/files/rs-7378822/v1/341ee3f05841d8327694b487.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Minimal Hepatic Encephalopathy among Cirrhotics; A Cross Sectional, Clinico- Epidemiological, Multi-Centre Registry in Patients of Pakistan. The PREEMPT Registry","fulltext":[{"header":"Background/Introduction","content":"\u003cp\u003eA common neuropsychiatric symptom of both acute and chronic liver disease, hepatic encephalopathy (HE) is characterized by disruptions in psychomotor, intellectual, cognitive, emotional/affective, behavioral, and fine motor functioning of differing degrees of severity (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). The mildest form of HE, known as minimal hepatic encephalopathy (MHE), is diagnosed using specialized psychometric tests and manifests without any apparent clinical impairment (normal mental and neurologic condition on clinical examination). It is typified by mild cognitive and motor impairments that lower health-related quality of life (HRQL) (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eHE may not seem obvious when diagnosing a patient exhibiting symptoms; therefore, multiple tools are used to assess a patient, which can help assess the disease's prevalence and incidence. MHE commonly remains undiagnosed or underdiagnosed as there are no clinical manifestations of the condition. The actual prevalence of MHE is still unknown (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). However, it has been estimated to be between 22% and 80%( 3, 5\u0026ndash;9). However, studies in India suggest that the prevalence of MHE in the region can range from 53%-62% (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). MHE negatively impacts the quality of life and day-to-day functioning of the patient. MHE patients struggle with working memory, attention, and reaction inhibition, all of which are linked to impaired driving and a higher risk of motor vehicle accidents (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe epidemiological (non-interventional), multi-center, cross-sectional study (PREEMPT) conducted in 2019 to assess the incidence of MHE among stable cirrhotic patients without overt symptoms of HE enabled the inception of this current study (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Further, the study helped us in the design of this PREEMPT registry, which depicted the frequency of MHE among cirrhotic patients in a larger population as compared to the PREEMPT Study and develop a consensus on the clinical management of MHE in Pakistan.\u003c/p\u003e\u003cp\u003eThus, the Preempt registry is a continuation of the Preempt study to evaluate the incidence of MHE amongst a cirrhotic patients in a wider population. This study stretched across a larger number of cities, and a larger sample size enabled us to understand the impact of MHE on HRQoL even better.\u003c/p\u003e"},{"header":"Methods and Materials","content":"\u003cp\u003eThe multicenter study was cross-sectional survey conducted in Pakistan, in adherence to the guidelines of ICH-Good Clinical Practice along with all the relevant national guidelines. The information produced in this study was kept confidential and was not shared with any individual who was not directly involved in the study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe protocol and relevant study documents were submitted for review and approval of Institutional Review Board. The ethics approval was obtained from respective hospitals\u0026rsquo; IRBs which are mentioned in Appendix 1.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy procedure:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAs Figure 1 shows, Patients with a confirmed diagnosis of liver cirrhosis who presented to the outpatient gastroenterology or hepatology department were first approached for participation. Upon obtaining written informed consent from the patients, the demographic details, relevant medical history, previous laboratory values, radiological and endoscopic findings, current medications, potential etiological factors, and comorbidities associated with cirrhosis were documented.\u003c/p\u003e\n\u003cp\u003eThe eligible patients (those meeting Grade 0 criteria of the West Haven classification) were enrolled according to the study\u0026rsquo;s inclusion criteria however, patients with inability to perform neuropsychometric tests and to complete the SF-36 questionnaire as decided by the physician were excluded. The enrolled patients\u0026rsquo; cognitive function was initially assessed using the Mini-Mental State Examination (MMSE), and those with scores MMSE\u0026ge; 24 underwent further evaluation with the Psychometric Hepatic Encephalopathy Score (PHES).\u003c/p\u003e\n\u003cp\u003ePatients who achieved a normal PHES score (greater than \u0026ndash;5) were categorized as not having MHE, whereas those with abnormal scores (\u0026le; \u0026ndash;5) were diagnosed with MHE. Regardless of MHE status, all participants subsequently completed the SF-36 questionnaire to evaluate HRQOL, and details of prescribed medications were recorded for analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy population\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAs the study was multicenter, total 15 medical facilities from Pakistan including, Karachi, Hyderabad, Quetta, Faisalabad, Multan, Islamabad, Rawalpindi, and Peshawar were included in the study. The patients with a diagnosis of liver cirrhosis visiting the outpatient departments of these facilities were enrolled in the study after getting an informed consent form signed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSample size\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eUsing the prevalence of 59.7% of minimal hepatic encephalopathy among liver cirrhosis patients as indicated by Rathi et al(14) in a multicenter study of India, with margin of error of +/- 3% and confidence interval of 95%, the minimum required sample size was n=1007.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical analysis:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e. The block method was performed on variables reaching a significance of P \u0026le; 0.05 on univariate analysis to determine the influence on the presence of MHE. A P value of \u0026le;0.05 was considered statistically significant. Statistical analysis was performed using STATA software for Windows, version 16.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy Results\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFollowing\u0026nbsp;results\u0026nbsp;were\u0026nbsp;identified\u0026nbsp;after\u0026nbsp;the\u0026nbsp;data analysis:\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy Primary Variables\u003c/strong\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cu\u003eDemographic\u0026nbsp;and\u0026nbsp;other\u0026nbsp;baseline\u0026nbsp;characteristics\u003c/u\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eOf all evaluable cirrhotic patients(n=1096) (MMSE score\u0026nbsp;\u0026ge; 24), the mean age of study population was 45.5 (\u0026plusmn;11.4)\u0026nbsp;years.\u0026nbsp;The majority of the study patients were males (n= 668, 60.9%), with most of the patients being married (n=973, 88.8%). The mean weight was similar between the groups (71.1 \u0026plusmn; 13.7 vs. 70.8 \u0026plusmn; 10.7; p = 0.66). However, the MHE group exhibited a significantly higher mean BMI (31.9 \u0026plusmn; 22.3 vs. 26.8 \u0026plusmn; 13.0; p \u0026lt; 0.001). Further demographic characteristics are depicted in Table 1a.\u003c/p\u003e\n\u003cp\u003eTable 1:Demographic Characteristics\u003c/p\u003e\n\u003cdiv align=\"Left\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" rowspan=\"2\" valign=\"top\" style=\"width: 256px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eParameter\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNon-MHE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMHE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003en=1,096\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e\u003cstrong\u003en=494\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003en=602\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 167px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAGE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eMean (\u0026plusmn;S.D)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e45.5 (\u0026plusmn;11.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e44.6 (\u0026plusmn;10.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e46.3 (\u0026plusmn;11.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.016\u003csup\u003ea\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eMedian (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e46 (38-55)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e45 (37-53)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e48 (38-56)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 167px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWeight\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eMean (\u0026plusmn;S.D)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e71.0 (\u0026plusmn;12.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e70.8 (\u0026plusmn;10.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e71.1 (\u0026plusmn;13.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.66\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e\u003csup\u003ea\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eMedian (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e70 (63-78)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e70 (65-78)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e70 (62-78)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 167px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHeight\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eMean (\u0026plusmn;S.D)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e161.5 (\u0026plusmn;18.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e165.7 (\u0026plusmn;13.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e157.9 (\u0026plusmn;20.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e\u003csup\u003ea\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eMedian (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e164 (156-171)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e168 (160.02-172)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e160 (152-169)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 167px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBMI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eMean (\u0026plusmn;S.D)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e29.5 (\u0026plusmn;18.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e26.8 (\u0026plusmn;13.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e31.9 (\u0026plusmn;22.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e\u003csup\u003ea\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eMedian (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e25.93 (23.5-29.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e25.18 (22.98-27.63)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e26.75 (24.0-31.24)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 167px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEducation Level\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003en (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.006 \u003csup\u003eb\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 167px;\"\u003e\n \u003cp\u003eHigh School\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e236 (21.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e96 (19.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e140 (23.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 167px;\"\u003e\n \u003cp\u003eIntermediate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e201 (18.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e85 (17.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e116 (19.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 167px;\"\u003e\n \u003cp\u003eMiddle\u0026nbsp;(up\u0026nbsp;to\u0026nbsp;class 8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e253 (23.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e112 (22.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e141 (23.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 167px;\"\u003e\n \u003cp\u003ePrimary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e185 (16.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e77 (15.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e108 (17.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 167px;\"\u003e\n \u003cp\u003eUndergraduate/ Graduate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e221 (20.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e124 (25.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e97 (16.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 167px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003en (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.23\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e\u003csup\u003eb\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 167px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e427 (39.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e181 (36.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e246 (40.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 167px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e668 (60.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e313 (63.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e355 (59.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 167px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMarital Status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003en (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.40\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e\u003csup\u003eb\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 167px;\"\u003e\n \u003cp\u003eDivorced\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e3 (0.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e1 (0.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e2 (0.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 167px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e973 (88.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e435 (88.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e538 (89.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 167px;\"\u003e\n \u003cp\u003eUnmarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e118 (10.8%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e56 (11.3%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e62 (10.3%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cem\u003eMHE,\u0026nbsp;minimal\u0026nbsp;hepatic encephalopathy. a: Analyzed\u0026nbsp;using\u0026nbsp;t-test.\u0026nbsp;b: Analyzed\u0026nbsp;using\u0026nbsp;chi-square test.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eOf\u0026nbsp;all\u0026nbsp;the\u0026nbsp;study\u0026nbsp;patients,\u0026nbsp;more\u0026nbsp;than\u0026nbsp;19%\u0026nbsp;(n=211,\u0026nbsp;19.3%)\u0026nbsp;were\u0026nbsp;smokers\u0026nbsp;and,\u0026nbsp;on\u0026nbsp;average\u0026nbsp;they smoked\u003c/p\u003e\n\u003cp\u003e13.0\u0026nbsp;(\u0026plusmn;6.6)\u0026nbsp;cigarettes\u0026nbsp;per\u0026nbsp;day.\u0026nbsp;The\u0026nbsp;average\u0026nbsp;duration\u0026nbsp;of\u0026nbsp;smoking\u0026nbsp;was\u0026nbsp;13.9\u0026nbsp;\u0026plusmn;7.8\u0026nbsp;years.\u0026nbsp;Some\u0026nbsp;(7.4%) patients had history of tobacco chew, and only 20 (1.8%) patients had history of alcohol consumption.\u0026nbsp;History\u0026nbsp;for\u0026nbsp;habits\u0026nbsp;like\u0026nbsp;cigarette\u0026nbsp;smoking,\u0026nbsp;tobacco\u0026nbsp;chewing,\u0026nbsp;and\u0026nbsp;alcohol\u0026nbsp;consumption is depicted in Table 1b.\u003c/p\u003e\n\u003cp\u003eTable 1b: History of habits like smoking\u003c/p\u003e\n\u003cdiv align=\"Left\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" rowspan=\"2\" valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eParameter\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNon-MHE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMHE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u003cstrong\u003en=1,096\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e\u003cstrong\u003en=494\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u003cstrong\u003en=602\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSmoking\u0026nbsp;Status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003en (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.29\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e\u003csup\u003eb\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003eNon- Smoker\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e885 (80.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e392 (79.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e493 (81.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003eSmoker\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e211 (19.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e102 (20.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e109 (18.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003eDuration\u0026nbsp;of smoking (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eMean (\u0026plusmn;S.D)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e13.9 (\u0026plusmn;7.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e13.8 (\u0026plusmn;7.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e14.1 (\u0026plusmn;8.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.79\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e\u003csup\u003ea\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003ecigarettes\u0026nbsp;per day\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eMean (\u0026plusmn;S.D)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e13.0 (\u0026plusmn;6.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e13.4 (\u0026plusmn;6.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e12.7 (\u0026plusmn;6.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.43\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e\u003csup\u003ea\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTobacco\u0026nbsp;Chewing\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003en (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e\u003csup\u003eb\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e1,013 (92.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e475 (96.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e538 (89.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e81 (7.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e19 (3.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e62 (10.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003eMissing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e2 (0.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e2 (0.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003eDuration (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eMean (\u0026plusmn;S.D)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e13.5 (\u0026plusmn;8.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e11.1 (\u0026plusmn;9.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e14.3 (\u0026plusmn;8.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.16\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e\u003csup\u003ea\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAlcohol Consumption\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003en (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.89\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e\u003csup\u003eb\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e1,072 (97.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e482 (97.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e590 (98.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e20 (1.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e10 (2.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e10 (1.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eQuantity\u0026nbsp;of Alcohol\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003en (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.33\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e\u003csup\u003eb\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003e2-4\u0026nbsp;drinks\u0026nbsp;per day\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e7 (0.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e2 (0.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e5 (0.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003e\u0026lt;\u0026nbsp;2 drinks\u0026nbsp;per day\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e13 (1.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e8 (1.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e5 (0.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAlcohol type\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003en (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.52\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e\u003csup\u003eb\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003e120\u0026nbsp;mL\u0026nbsp;of wine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e3 (0.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e2 (0.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e1 (0.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003e30\u0026nbsp;mL of\u0026nbsp;hard\u0026nbsp;liquor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e13 (1.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e5 (1.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e8 (1.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003e360\u0026nbsp;mL\u0026nbsp;of beer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e4 (0.4%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e3 (0.6%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e1 (0.2%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cem\u003ea:\u0026nbsp;\u003c/em\u003e\u003cem\u003eAnalyzed using\u0026nbsp;t-test. b: Analyzed using\u0026nbsp;chi-square test\u003c/em\u003e\u003cem\u003e.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAll enrolled patients had fibrosis-4 (FIB-4)\u0026nbsp;score value \u0026gt;3.25. However,\u0026nbsp;there\u0026nbsp;was no significant differences between MHE and non-MHE groups for AST, Platelet, ALT, and Fib 4 levels, as indicated by p-values of 0.21, 0.45, 0.23, and 0.85, respectively (Table-1c).\u003c/p\u003e\n\u003cp\u003eTable-1c: Laboratory measures for determining Fibrosis-4 score\u003c/p\u003e\n\u003cdiv align=\"Left\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" rowspan=\"2\" valign=\"top\" style=\"width: 204px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eParameter\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 120px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 120px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNon-MHE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 126px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMHE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 120px;\"\u003e\n \u003cp\u003e\u003cstrong\u003en=1,096\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 120px;\"\u003e\n \u003cp\u003e\u003cstrong\u003en=494\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 126px;\"\u003e\n \u003cp\u003e\u003cstrong\u003en=602\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAST\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eMean\u0026nbsp;(\u0026plusmn; Stdev)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e113.6 (\u0026plusmn;99.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e109.4 (\u0026plusmn;98.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e117.1 (\u0026plusmn;100.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.21\u003csup\u003ea\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eMedian (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e79 (57-123.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e78 (56-108)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e80 (58-148)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eALT\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eMean\u0026nbsp;(\u0026plusmn; Stdev)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e96.3 (\u0026plusmn;99.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e92.4 (\u0026plusmn;95.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e99.6 (\u0026plusmn;102.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.23\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e\u003csup\u003ea\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eMedian (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e56 (37-106.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e57 (38-98)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e56 (37-120)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePlatelet\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eMean\u0026nbsp;(\u0026plusmn; Stdev)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e100.2 (\u0026plusmn;49.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e98.9 (\u0026plusmn;53.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e101.2 (\u0026plusmn;45.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.45\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e\u003csup\u003ea\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eMedian (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e96 (73.5-115)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e95 (70-114)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e97 (76-118)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFib 4\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eMean (\u0026plusmn;Stdev)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e6.0 (\u0026plusmn;4.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e6.0 (\u0026plusmn;4.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e6.0 (\u0026plusmn;4.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.85\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e\u003csup\u003ea\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMedian (IQR)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e4.67 (3.66-6.76)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e4.7 (3.63-6.76)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e4.65 (3.69-6.76)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cem\u003ea: Analyzed using\u0026nbsp;t-test\u003c/em\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cu\u003eFrequency\u0026nbsp;of\u0026nbsp;Minimal\u0026nbsp;\u0026amp;\u0026nbsp;Non-minimal\u0026nbsp;hepatic\u0026nbsp;encephalopathy\u0026nbsp;(MHE) among\u0026nbsp;cirrhotic\u003c/u\u003e \u003cu\u003epatients:\u003c/u\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eOf the 1096 evaluable cirrhotic patients, 602 had a psychometric hepatic encephalopathy score\u0026nbsp;\u0026le;\u0026minus;5,\u0026nbsp;indicating\u0026nbsp;MHE\u0026nbsp;frequency\u0026nbsp;in\u0026nbsp;our\u0026nbsp;study\u0026nbsp;population\u0026nbsp;as\u0026nbsp;54.9%.\u0026nbsp;Mean\u0026nbsp;MMSE\u0026nbsp;score in cirrhotic patients is 27.09 \u0026plusmn;2.35 (table 2).\u003c/p\u003e\n\u003cp\u003eTable 2:Physical score, mental score \u0026amp; MMSE scores in MHE \u0026amp; Non-MHE Patients\u003c/p\u003e\n\u003cdiv align=\"Left\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" rowspan=\"2\" valign=\"top\" style=\"width: 224px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eParameter\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNon-MHE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMHE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eN=1,096\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eN=494\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eN=602\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 145px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePCS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003eMean (\u0026plusmn;S.D)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e42.2 (\u0026plusmn;8.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e43.2 (\u0026plusmn;8.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e41.4 (\u0026plusmn;8.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e\u003csup\u003ea\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 145px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMCS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003eMean (\u0026plusmn;S.D)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e43.8 (\u0026plusmn;11.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e46.9 (\u0026plusmn;11.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e41.3 (\u0026plusmn;10.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e\u003csup\u003ea\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cem\u003ea: Analyzed using\u0026nbsp;t-test. b: Analyzed using\u0026nbsp;chi-square\u0026nbsp;test.\u003c/em\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cu\u003eEtiology\u0026nbsp;and\u0026nbsp;co-morbid\u0026nbsp;conditions\u0026nbsp;frequency\u0026nbsp;in\u0026nbsp;cirrhotic\u0026nbsp;patients.\u003c/u\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eThe most common underlying etiology of cirrhosis was viral hepatitis-C (n=783, 71.4%) followed by viral hepatitis-B (n=184, 16.8%) and Nonalcoholic Steatohepatitis/Nonalcoholic fatty liver disease NASH/ NAFLD (n=32, 2.9%). Viral Hepatitis B was more common among patients with MHE (n=129, 70.1%) than among those patients\u0026nbsp;without\u0026nbsp;MHE\u0026nbsp;55\u0026nbsp;(29.9%).\u0026nbsp;Among\u0026nbsp;associated\u0026nbsp;comorbidities, hypertension\u0026nbsp;is\u0026nbsp;found\u0026nbsp;in greater\u0026nbsp;number\u0026nbsp;(n=140,\u0026nbsp;12.8%)\u0026nbsp;followed\u0026nbsp;by\u0026nbsp;diabetes\u0026nbsp;(n=63,\u0026nbsp;5.7%).\u0026nbsp;Details\u0026nbsp;of\u0026nbsp;etiology\u0026nbsp;and\u0026nbsp;co- morbid conditions are depicted in Table3.\u003c/p\u003e\n\u003cp\u003eTable 3:Etiology and co-morbid conditions frequency in cirrhotic patients\u003c/p\u003e\n\u003cdiv align=\"Left\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 215px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eParameter n(%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 141px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 128px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNon-MHE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMHE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 141px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eN=1,096\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 128px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eN=494\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eN=602\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 215px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEtiology\u0026nbsp;of Cirrhosis\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 141px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 128px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 215px;\"\u003e\n \u003cp\u003eViral\u0026nbsp;Hepatitis C\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 141px;\"\u003e\n \u003cp\u003e783 (71.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 128px;\"\u003e\n \u003cp\u003e399 (50.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e384 (49.1%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 215px;\"\u003e\n \u003cp\u003eViral\u0026nbsp;Hepatitis B\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 141px;\"\u003e\n \u003cp\u003e184 (16.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 128px;\"\u003e\n \u003cp\u003e55 (29.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e129 (70.1%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 215px;\"\u003e\n \u003cp\u003eNASH/ NAFLD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 141px;\"\u003e\n \u003cp\u003e32 (2.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 128px;\"\u003e\n \u003cp\u003e5 (15.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e27 (84.4%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 215px;\"\u003e\n \u003cp\u003eAutoimmune\u0026nbsp;Hepatitis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 141px;\"\u003e\n \u003cp\u003e18 (1.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 128px;\"\u003e\n \u003cp\u003e6 (33.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e12 (66.6%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 215px;\"\u003e\n \u003cp\u003eWilson\u0026apos;s Disease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 141px;\"\u003e\n \u003cp\u003e13 (1.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 128px;\"\u003e\n \u003cp\u003e4 (30.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e9 (69.2%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 215px;\"\u003e\n \u003cp\u003eBudd-\u0026nbsp;Chiari\u0026nbsp;syndrome\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 141px;\"\u003e\n \u003cp\u003e17 (1.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 128px;\"\u003e\n \u003cp\u003e8 (47.05%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e9 (52.95%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 215px;\"\u003e\n \u003cp\u003eExcessive\u0026nbsp;Alcohol consumption\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 141px;\"\u003e\n \u003cp\u003e9 (0.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 128px;\"\u003e\n \u003cp\u003e5 (55.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e4 (45.5%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 215px;\"\u003e\n \u003cp\u003eDrug-induced\u0026nbsp;Liver disease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 141px;\"\u003e\n \u003cp\u003e3 (0.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 128px;\"\u003e\n \u003cp\u003e1 (33.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2 (66.6%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 215px;\"\u003e\n \u003cp\u003eChronic\u0026nbsp;Right-sided\u0026nbsp;Heart\u0026nbsp;Failure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 141px;\"\u003e\n \u003cp\u003e2 (0.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 128px;\"\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2 (100%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 215px;\"\u003e\n \u003cp\u003eHemochromatosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 141px;\"\u003e\n \u003cp\u003e2 (0.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 128px;\"\u003e\n \u003cp\u003e1 (50%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e1 (50%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 215px;\"\u003e\n \u003cp\u003eTricuspid regurgitation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 141px;\"\u003e\n \u003cp\u003e2 (0.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 128px;\"\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2 (100%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 215px;\"\u003e\n \u003cp\u003eGlycogen\u0026nbsp;storage disease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 141px;\"\u003e\n \u003cp\u003e1 (0.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 128px;\"\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e1 (100%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 215px;\"\u003e\n \u003cp\u003eBlockage\u0026nbsp;of Bile\u0026nbsp;ducts\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 141px;\"\u003e\n \u003cp\u003e1 (0.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 128px;\"\u003e\n \u003cp\u003e1 (100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0 (0.0%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 215px;\"\u003e\n \u003cp\u003ePrimary\u0026nbsp;sclerosing\u0026nbsp;cholangitis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 141px;\"\u003e\n \u003cp\u003e1 (0.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 128px;\"\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e1 (100%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 215px;\"\u003e\n \u003cp\u003eOthers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 141px;\"\u003e\n \u003cp\u003e26 (2.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 128px;\"\u003e\n \u003cp\u003e8 (30.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e18 (69.3%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 215px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAssociated\u0026nbsp;comorbidities\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 141px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 128px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 215px;\"\u003e\n \u003cp\u003eHypertension\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 141px;\"\u003e\n \u003cp\u003e140 (12.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 128px;\"\u003e\n \u003cp\u003e44 (31.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e96 (68.6%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 215px;\"\u003e\n \u003cp\u003eDiabetes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 141px;\"\u003e\n \u003cp\u003e63 (5.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 128px;\"\u003e\n \u003cp\u003e18 (28.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e45 (71.5%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 215px;\"\u003e\n \u003cp\u003eDyslipidemia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 141px;\"\u003e\n \u003cp\u003e27 (2.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 128px;\"\u003e\n \u003cp\u003e5 (18.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e22 (81.5%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 215px;\"\u003e\n \u003cp\u003eOthers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 141px;\"\u003e\n \u003cp\u003e45 (4.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 128px;\"\u003e\n \u003cp\u003e14 (31.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e31 (69.9%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eStudy Secondary Variables\u003c/strong\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cu\u003eAssociation\u0026nbsp;of\u0026nbsp;etiologies\u0026nbsp;and co-morbid\u0026nbsp;conditions\u0026nbsp;with\u0026nbsp;minimal\u0026nbsp;hepatic\u0026nbsp;encephalopathy:\u003c/u\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eAssociations between etiologies, comorbid conditions and minimal hepatic encephalopathy are determined\u0026nbsp;through\u0026nbsp;logistic\u0026nbsp;regression\u0026nbsp;univariate\u0026nbsp;\u0026amp;\u0026nbsp;multivariate\u0026nbsp;analysis.\u0026nbsp;The\u0026nbsp;univariate\u0026nbsp;analysis revealed\u0026nbsp;that\u0026nbsp;age\u0026nbsp;(O.R.\u0026nbsp;1.01,\u0026nbsp;C.I.\u0026nbsp;1.0-1.02),\u0026nbsp;NASH/NAFLD\u0026nbsp;(O.R.\u0026nbsp;4.59,\u0026nbsp;C.I.\u0026nbsp;1.75-12.01), Viral\u003c/p\u003e\n\u003cp\u003eHepatitis\u0026nbsp;B\u0026nbsp;(O.R.\u0026nbsp;2.2,\u0026nbsp;C.I.\u0026nbsp;1.54-3.06)\u0026nbsp;\u0026amp;\u0026nbsp;C\u0026nbsp;(O.R.\u0026nbsp;0.42,\u0026nbsp;C.I.\u0026nbsp;0.32-0.55),\u0026nbsp;sodium\u0026nbsp;levels\u0026nbsp;(O.R. 1.03,\u003c/p\u003e\n\u003cp\u003eC.I. 1.01-1.06), and tobacco chewing (O.R. 2.88, C.I. 1.7-4.89) are significantly associated with MHE. However, upon multivariate analysis only Viral Hepatitis C (O.R. 4.59, C.I. 1.75-12.01) retained\u0026nbsp;the\u0026nbsp;statistically\u0026nbsp;significant\u0026nbsp;association\u0026nbsp;with\u0026nbsp;the\u0026nbsp;MHE.\u0026nbsp;Univariate\u0026nbsp;\u0026amp;\u0026nbsp;multivariate\u0026nbsp;analyses for the associations are depicted in Table 4a \u0026amp; 4b.\u003c/p\u003e\n\u003cp\u003eTable 4a: Univariate Analyses for association of Etiologies \u0026amp; Comorbid Conditions with MHE\u003c/p\u003e\n\u003cdiv align=\"Left\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 229px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable (univariate)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOdds ratio\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e95%\u0026nbsp;Wald\u0026nbsp;confidence\u0026nbsp;limits\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eP\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003evalue\u003csup\u003ea\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 229px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge (years)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e1.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 170px;\"\u003e\n \u003cp\u003e1.0-1.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.016\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 229px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEtiology\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 170px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 229px;\"\u003e\n \u003cp\u003eNASH/ NAFLD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e4.59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 170px;\"\u003e\n \u003cp\u003e1.75- 12.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.002\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 229px;\"\u003e\n \u003cp\u003eViral\u0026nbsp;Hepatitis B\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e2.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 170px;\"\u003e\n \u003cp\u003e1.54- 3.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.000\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 229px;\"\u003e\n \u003cp\u003eViral\u0026nbsp;Hepatitis C\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e0.42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 170px;\"\u003e\n \u003cp\u003e0.32-0.55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.000\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 229px;\"\u003e\n \u003cp\u003eWilson Disease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e1.86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 170px;\"\u003e\n \u003cp\u003e0.57- 6.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.305\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 229px;\"\u003e\n \u003cp\u003eAutoimmune Hepatitis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e1.65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 170px;\"\u003e\n \u003cp\u003e0.62-4.44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.318\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 229px;\"\u003e\n \u003cp\u003eBudd-\u0026nbsp;Chiari syndrome\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e0.92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 170px;\"\u003e\n \u003cp\u003e0.35-2.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.868\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 229px;\"\u003e\n \u003cp\u003eExcessive\u0026nbsp;Alcohol consumption\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e0.65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 170px;\"\u003e\n \u003cp\u003e0.17-2.45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.528\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 229px;\"\u003e\n \u003cp\u003eCo-morbidities\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 170px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 229px;\"\u003e\n \u003cp\u003eDiabetes mellitus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e1.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 170px;\"\u003e\n \u003cp\u003e0.57-1.97\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.861\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 229px;\"\u003e\n \u003cp\u003eDyslipidemia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e1.94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 170px;\"\u003e\n \u003cp\u003e0.71-5.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.196\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 229px;\"\u003e\n \u003cp\u003eHypertension\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e0.82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 170px;\"\u003e\n \u003cp\u003e0.489\u0026nbsp;\u0026ndash; 1.38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.46\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 229px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOther\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 170px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 229px;\"\u003e\n \u003cp\u003eSodium\u0026nbsp;(mmol/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e1.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 170px;\"\u003e\n \u003cp\u003e1.01-1.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.005\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 229px;\"\u003e\n \u003cp\u003eTobacco chewing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e2.88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 170px;\"\u003e\n \u003cp\u003e1.7-4.89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.000\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 229px;\"\u003e\n \u003cp\u003eSmoking\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e0.85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 170px;\"\u003e\n \u003cp\u003e0.63-1.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.289\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cem\u003ea: Analyzed using Logistic Regression\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eTable 4a: Univariate Analyses for association of Association of Etiologies \u0026amp; Comorbid Conditions with MHE\u003c/p\u003e\n\u003cdiv align=\"Left\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 237px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable (multivariate)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOdds ratio\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 195px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e95%\u0026nbsp;Wald\u0026nbsp;confidence\u0026nbsp;limits\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eP\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003evalue\u003csup\u003ea\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 237px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u0026nbsp;(years)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 195px;\"\u003e\n \u003cp\u003e0.99-1.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.285\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 237px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNASH/ NAFLD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e4.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 195px;\"\u003e\n \u003cp\u003e0.96-18.39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.067\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 237px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eViral\u0026nbsp;Hepatitis B\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e0.98\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 195px;\"\u003e\n \u003cp\u003e0.53\u0026nbsp;\u0026ndash; 1.84\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.973\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 237px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eViral\u0026nbsp;Hepatitis C\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e0.34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 195px;\"\u003e\n \u003cp\u003e0.24-0.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.000\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 237px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSodium\u0026nbsp;(mmol/L)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 195px;\"\u003e\n \u003cp\u003e0.99-1.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.145\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 237px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTobacco chewing\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e1.6\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 195px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.91-2.92\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.101\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cem\u003ea: Analyzed using\u0026nbsp;logistic\u0026nbsp;regression.\u003c/em\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cu\u003eHealth\u0026nbsp;Related\u0026nbsp;Quality\u0026nbsp;of\u0026nbsp;Life\u0026nbsp;(HRQoL)\u0026nbsp;assessment\u0026nbsp;using\u0026nbsp;SF-36 Questionnaire:\u003c/u\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eThe\u0026nbsp;Mental\u0026nbsp;Component\u0026nbsp;Score\u0026nbsp;(MCS)\u0026nbsp;and\u0026nbsp;Physical\u0026nbsp;Component\u0026nbsp;Score\u0026nbsp;(PCS),\u0026nbsp;derived\u0026nbsp;from\u0026nbsp;SF-36 questionnaire are calculated for both MHE and Non-MHE cirrhotic patients. MHE patients had significantly\u0026nbsp;lower\u0026nbsp;PCS\u0026nbsp;scores\u0026nbsp;than\u0026nbsp;non-MHE\u0026nbsp;patients\u0026nbsp;(41.4\u0026nbsp;\u0026plusmn;\u0026nbsp;8.2\u0026nbsp;vs.\u0026nbsp;43.2\u0026nbsp;\u0026plusmn;8.1).\u0026nbsp;Similarly,\u0026nbsp;MHE patients\u0026nbsp;had\u0026nbsp;significantly\u0026nbsp;lower\u0026nbsp;MCS\u0026nbsp;scores\u0026nbsp;as\u0026nbsp;well\u0026nbsp;(41.3\u0026nbsp;\u0026plusmn;10.6\u0026nbsp;vs.\u0026nbsp;46.9\u0026nbsp;\u0026plusmn;11.0).\u0026nbsp;Patients\u0026rsquo;\u0026nbsp;physical and\u0026nbsp;mental\u0026nbsp;component\u0026nbsp;scores\u0026nbsp;derived\u0026nbsp;from\u0026nbsp;SF-36\u0026nbsp;questionnaire\u0026nbsp;are\u0026nbsp;depicted\u0026nbsp;in\u0026nbsp;Table-5\u0026nbsp;and\u0026nbsp;Figure- 1a \u0026amp; b.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable\u0026nbsp;5:\u0026nbsp;Quality\u0026nbsp;of\u0026nbsp;Life\u0026nbsp;Assessment\u0026nbsp;using\u0026nbsp;SF-36\u0026nbsp;questionnaire\u0026nbsp;among\u0026nbsp;MHE\u0026nbsp;and\u0026nbsp;Non-MHE Patients:\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv align=\"Left\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" class=\"fr-table-selection-hover\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" rowspan=\"2\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eParameter\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 111px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNon-MHE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 106px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMHE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 99px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eN=1,096\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 111px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eN=494\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 106px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eN=602\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 110px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePCS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 88px;\"\u003e\n \u003cp\u003eMean (\u0026plusmn;S.D)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e42.2 (\u0026plusmn;8.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 111px;\"\u003e\n \u003cp\u003e43.2 (\u0026plusmn;8.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 106px;\"\u003e\n \u003cp\u003e41.4 (\u0026plusmn;8.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e\u003csup\u003ea\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 110px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMCS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 88px;\"\u003e\n \u003cp\u003eMean (\u0026plusmn;S.D)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e43.8 (\u0026plusmn;11.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 111px;\"\u003e\n \u003cp\u003e46.9 (\u0026plusmn;11.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 106px;\"\u003e\n \u003cp\u003e41.3 (\u0026plusmn;10.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e\u003csup\u003ea\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\" style=\"width: 613px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ea- Independent t-test was used to determine the statistical significance.\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cdiv align=\"Left\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 169px;\"\u003e\n \u003cp\u003e\u003cstrong\u003en\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 144px;\"\u003e\n \u003cp\u003e602\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 194px;\"\u003e\n \u003cp\u003e494\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 169px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean (\u0026plusmn;S.D)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 144px;\"\u003e\n \u003cp\u003e41.4 (\u0026plusmn;8.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 194px;\"\u003e\n \u003cp\u003e43.2 (\u0026plusmn;8.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cul\u003e\n \u003cli\u003e\u0026nbsp; \u003cstrong\u003eStudy Exploratory Variables:\u0026nbsp;\u003c/strong\u003eMultiple drugs were prescribed to the patients; pattern of drug prescriptions is depicted in figures 2 \u0026amp; 3.\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Discussion","content":"\u003cp\u003e\u003c/p\u003e\u003cp\u003eStudies reveal that efforts are being made to recommend screening within all patients with cirrhosis with neurocognitive symptoms (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e), since it is now apparent that effective treatment of MHE is readily available. This study highlights the high prevalence of cognitive dysfunction in Pakistan, specifically minimal hepatic encephalopathy (MHE), in cirrhotic patients despite the absence of evident clinical manifestations of hepatic encephalopathy (HE). MHE is rarely screened in routine clinical practice due to its diagnostic complexity and the need for specialized psychometric tools.\u003c/p\u003e\u003cp\u003eWithout any overt clinical manifestation of Hepatic Encephalopathy (HE), this study emphasizes the high prevalence rates of cognitive dysfunction in the form of MHE in the cirrhotic population. MHE is seldom if ever, screened for in routine clinical practice because of its difficulty in diagnosis and the need for specialized psychometric tests for identification. The study found that 54.9% of the 1,096 evaluable cirrhotic patients had minimal hepatic encephalopathy (MHE), as indicated by a PHES score ≤ -5. This high prevalence aligns with previous studies, emphasizing the widespread occurrence of MHE among cirrhotic patients that patients with liver cirrhosis have a higher chance of developing MHE over the course of time (\u003cspan additionalcitationids=\"CR16\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e–\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eMoreover, among the etiology of the disease, viral Hepatitis C was the most common underlying cause of cirrhosis (71.4%), followed by Viral Hepatitis B (16.8%) and NASH/NAFLD (2.9%). These findings are in line with global trends where viral hepatitis remains a leading cause of cirrhosis. Notably, Viral Hepatitis B was more prevalent among MHE patients (21.4%) compared to non-MHE patients (11.1%). However, the odds ratio of the participants with viral hepatitis B suggested no impact of the disease over the incidence of MHE because, as per our data, all the patients with viral hepatitis B had developed MHE. Another study conducted in 2023 on a cohort of 736 patients with liver cirrhosis from a variety of etiologies determined the association of those etiologies with the prevalence of MHE (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe study also found associated risk factors that the prevalence was significantly higher in patients with a history of alcohol consumption than those with etiologies such as HBV and HCV-related liver cirrhosis. To further elaborate on this finding, our study had a very insignificant representation of the population consuming alcohol; therefore, no such association was detected. However, our study identifies chewing tobacco as a significant risk factor for patients with liver cirrhosis to develop MHE.\u003c/p\u003e\u003cp\u003eUnivariate analysis identified age, NASH/NAFLD, Viral Hepatitis C, sodium levels, and tobacco chewing as significant factors associated with MHE. Multivariable logistic regression confirmed that Viral Hepatitis C had a protective effect against MHE (odds ratio \u0026lt; 1), while other factors did not show statistically significant associations. These results underscore the complex interplay of various risk factors in the development of MHE and suggest that specific etiologies of cirrhosis might influence the risk differently.\u003c/p\u003e\u003cp\u003eRoutine screening and management of MHE is necessary in clinical practice because of its high frequency among cirrhotic patients and its substantial influence on quality of life and concomitant diseases. The study provided important insights towards the drug prescription trends and how the patient care can benefit.In order to lessen the effects of MHE, future research should concentrate on examining the mechanisms behind these correlations and creating focused therapies.\u003c/p\u003e\u003cp\u003eThe study results support existing evidence that underscores the clinical importance of MHE. These findings highlight the value of early screening and effective management within routine care to reduce its negative effects on patients’ daily functioning and quality of life (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe data also confers that more than 50% of the population had a Psychometric Hepatic Encephalopathy Score (PHES) of ≤ -5, indicating a high prevalence of MHE among cirrhotic patients. These findings align with global trends where viral hepatitis, particularly Hepatitis C, remains a leading cause of cirrhosis (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Interestingly, the odds ratio for participants with viral Hepatitis B suggested that the disease will eventually lead the patients to develop MHE as all patients with hepatitis-B were found to have MHE in the said study project.\u003c/p\u003e\u003cp\u003eIt was also noted that MHE prevalence was significantly higher in patients with a history of tobacco chewing compared to those with HBV and HCV-related liver cirrhosis. These findings accentuate the importance of routine MHE screening and suggest that targeted interventions could significantly benefit cirrhotic patients, improving their quality of life and overall disease management.\u003c/p\u003e"},{"header":"Study Conclusion","content":"\u003cp\u003eThe study revealed a prevalence of minimal hepatic encephalopathy (MHE) in 54.9% of the evaluated cirrhotic patients. Demographic insights showed that the average age of these patients was 45.5 years, with a majority being male (60.9%). Regarding comorbidities and etiologies, Viral Hepatitis C was the most common cause, affecting 71.4% of the patients, followed by Viral Hepatitis B at 16.8%. Additionally, hypertension (12.8%) and diabetes (5.7%) were notable comorbid conditions. The health-related quality of life (HRQoL) assessment indicated that patients with MHE had significantly lower Physical Component Scores (PCS) and Mental Component Scores (MCS) compared to those without MHE. In terms of drug prescription patterns, medications such as Carvedilol, Omeprazole, and Lactulose were frequently prescribed both before and after the diagnosis of MHE, highlighting the therapeutic approaches in managing this condition.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics Approvals\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was conducted under the ethical approval guidelines present in ICH-GCP, E6-R3 guidelines. Approval of the following IRBs were obtained for the study:\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eNBC-R (National Bioethics Committee at National Institute of Health)\u003c/li\u003e\n \u003cli\u003eIRB - BUMHS (Bolan University of Medical \u0026amp; Health Sciences)\u003c/li\u003e\n \u003cli\u003eIRB – FMHD (Fatima Memorial Hospital, College of Medicine \u0026amp; Dentistry)\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eMadina Teaching Hospital Faisalabad], approved by the Ethical Institutional Review Board (The University of Faisalabad).\u003c/li\u003e\n \u003cli\u003eIRB - PKLI (Pakistan Kidney and Liver Institute and Research Centre)\u003c/li\u003e\n \u003cli\u003eIRB – LRH (Lady Reading Hospital, Medical Teaching Institution)\u003c/li\u003e\n \u003cli\u003eIRB – AIMS (Asian Institute of Medical Sciences)\u003c/li\u003e\n \u003cli\u003eIRB – JPMC (Jinnah Postgraduate Medical Centre).\u0026nbsp;\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants in the study were patients with confirmed diagnosis of cirrhosis who visited gastroenterology and hepatology clinics at the institutions involved in the study. Patients who met the study's inclusion criteria and those who voluntarily agreed to participate signed an informed consent form after being verbally briefed about the study's specifics.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and analyzed in the current study are not readily available online; however, these datasets can be made available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u0026nbsp;\u003c/strong\u003eRaeefuddin Ahmed and Tabrez Ali are salaried and full-time employees of Abbott Laboratories (Pakistan) Limited. The other authors declared no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eThis research was funded by Abbott Laboratories Pakistan Limited\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors and Affiliations:\u0026nbsp;\u003c/strong\u003eZeeshan Ali\u003csup\u003e1\u003c/sup\u003e, Raeefuddin Ahmed\u003csup\u003e2\u003c/sup\u003e, Shahid Rasool\u003csup\u003e3\u003c/sup\u003e, Bilal Nasir\u003csup\u003e4\u003c/sup\u003e, Karim Kammeruddin\u003csup\u003e5\u003c/sup\u003e, Bushra Ali\u003csup\u003e6\u003c/sup\u003e, Farhana Kayani\u003csup\u003e7\u003c/sup\u003e, Tabrez Ali\u003csup\u003e8\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAffiliations\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eJinnah Postgraduate Medical Centre, Karachi, Pakistan\u003c/li\u003e\n \u003cli\u003eAga Khan Medical University Hospital, Pakistan\u003c/li\u003e\n \u003cli\u003eMadina Teaching Hospital Faisalabad, Pakistan\u003c/li\u003e\n \u003cli\u003eDoctors Specialist Hospital Lahore / Gulab Devi Hospital, Lahore, Pakistan\u003c/li\u003e\n \u003cli\u003eZainab Medical Centre, Karachi, Pakistan\u003c/li\u003e\n \u003cli\u003eFatima Memorial Hospital, College of Medicine \u0026amp; Dentistry, Lahore, Pakistan\u003c/li\u003e\n \u003cli\u003eSheikh Zayed Hospital \u0026amp; Quetta Hospital/ Bolan Medical University, Quetta, Pakistan\u003c/li\u003e\n \u003cli\u003eAbbott Laboratories Pakistan Limited, Pakistan\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgement:\u0026nbsp;\u003c/strong\u003eDimensions Research acted as the Contract Research Organization (CRO), Metrics Research did Medical Writing for the study. \u0026nbsp;All authors read and approved the final version.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eVilstrup H, Amodio P, Bajaj J, Cordoba J, Ferenci P, Mullen KD, Weissenborn K, Wong P. 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Pak J Med Sci. 2016;32(3):595-98.\u003c/li\u003e\n \u003cli\u003eRathi S et al. Prevalence of Minimal Hepatic Encephalopathy in Patients With Liver Cirrhosis: A Cross-Sectional, Clinicoepidemiological, Multicenter, Nationwide Study in India: The PREDICT Study. J Clin Exp Hepatol. Jul-Aug 2019;9(4):476-483\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eBale A, Pai CG, Shetty S, Balaraju G, Shetty A. Prevalence of and factors associated with minimal hepatic encephalopathy in patients with cirrhosis of liver. Journal of Clinical and Experimental Hepatology. 2018 Jun 1;8(2):156-61.\u003c/li\u003e\n \u003cli\u003eElgohary MN, Amer K, Bassiony MA. Prevalence and risk factors of minimal hepatic encephalopathy in patients with compensated liver cirrhosis. The Egyptian Journal of Hospital Medicine. 2020 Jul 1;80(2):871-5.\u003c/li\u003e\n \u003cli\u003eDhiman RK, Kurmi R, Thumburu KK, Venkataramarao SH, Agarwal R, Duseja A, Chawla Y. Diagnosis and prognostic significance of minimal hepatic encephalopathy in patients with cirrhosis of liver. Digestive diseases and sciences. 2010 Aug;55:2381-90.\u003c/li\u003e\n \u003cli\u003eLi X, Liu S, Xiang H, Zhang Q, Guo Y, Zu H, Wang J, Lv J, Zhang X, Meng F, Li J. Prevalence and risk factors for minimal hepatic encephalopathy in cirrhotic patients with different etiologies. Portal Hypertension \u0026amp; Cirrhosis. 2023 Dec 30;2(04):171-80.\u003c/li\u003e\n \u003cli\u003eRidola L, Nardelli S, Gioia S, Riggio O. Quality of life in patients with minimal hepatic encephalopathy. World J Gastroenterol. 2018;24(48):5446-5453. doi:10.3748/wjg.v24.i48.5446\u003c/li\u003e\n \u003cli\u003eAlberts CJ, Clifford GM, Georges D, Negro F, Lesi OA, Hutin YJ, de Martel C. Worldwide prevalence of hepatitis B virus and hepatitis C virus among patients with cirrhosis at country, region, and global levels: a systematic review. The Lancet Gastroenterology \u0026amp; Hepatology. 2022 Aug 1;7(8):724-35.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-gastroenterology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmge","sideBox":"Learn more about [BMC Gastroenterology](http://bmcgastroenterol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmge/default.aspx","title":"BMC Gastroenterology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Minimal Hepatic Encephalopathy, Health-Related Quality of Life, Cirrhosis, SF-36, Pakistan ","lastPublishedDoi":"10.21203/rs.3.rs-7378822/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7378822/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e \u003cbr\u003e\nMinimal hepatic encephalopathy (MHE) is a common yet underrecognized complication of liver cirrhosis, associated with cognitive decline and reduced health-related quality of life (HRQoL). Early detection is essential, particularly in low-resource settings like Pakistan, where the burden of chronic liver disease is high. This study aimed to determine the prevalence and clinical features of MHE, identify associated risk factors, and assess its impact on HRQoL using the SF-36 tool.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e \u003cbr\u003e\nThis multicenter, cross-sectional survey included adults aged 18–65 years with liver cirrhosis and no overt hepatic encephalopathy, recruited from primary care and gastroenterology clinics across Pakistan. Participants with Mini-Mental State Examination (MMSE) scores ≥24 were assessed for MHE using the Psychometric Hepatic Encephalopathy Score (PHES), with a cutoff of ≤−5. HRQoL was evaluated using the SF-36 questionnaire. Statistical analyses included chi-square tests, unpaired t-tests, and multivariable logistic regression.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e \u003cbr\u003e\nOf 1,096 participants, 602 (54.9%) met criteria for MHE. These patients had significantly lower SF-36 scores: physical component score (41.4 ± 8.2 vs. 43.2 ± 8.1) and mental component score (41.3 ± 10.6 vs. 46.9 ± 11.0; p \u0026lt; 0.001). Hepatitis C was the most common etiology (71.4%), though it was inversely associated with MHE (OR 0.42, 95% CI 0.32–0.55). Independent risk factors included age (OR 1.01), NASH/NAFLD (OR 4.59), hepatitis B (OR 2.20), low sodium (OR 1.03), and tobacco chewing (OR 2.88). Commonly prescribed medications included lactulose, omeprazole, and carvedilol.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e \u003cbr\u003e\nMHE is highly prevalent among cirrhotic patients in Pakistan and significantly impairs both physical and mental well-being. Routine cognitive screening and integration of tools like MMSE and SF-36 into standard cirrhosis care may improve early detection and patient outcomes in high-burden, resource-limited settings.\u003c/p\u003e","manuscriptTitle":"Minimal Hepatic Encephalopathy among Cirrhotics; A Cross Sectional, Clinico- Epidemiological, Multi-Centre Registry in Patients of Pakistan. The PREEMPT Registry","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-22 08:13:26","doi":"10.21203/rs.3.rs-7378822/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2025-09-24T09:21:53+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"70871513999457026216012817534856665636","date":"2025-09-18T17:05:56+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-27T11:23:38+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-08-19T08:51:06+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-08-19T01:36:25+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-19T01:35:36+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Gastroenterology","date":"2025-08-15T06:13:44+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-gastroenterology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmge","sideBox":"Learn more about [BMC Gastroenterology](http://bmcgastroenterol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmge/default.aspx","title":"BMC Gastroenterology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a06eba21-8119-45af-bbd6-e82d8798b04b","owner":[],"postedDate":"August 22nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-08-27T11:38:12+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-22 08:13:26","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7378822","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7378822","identity":"rs-7378822","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}