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Minimal Hepatic Encephalopathy in Cirrhosis- How Long to Treat?
Omesh Goyal
Corresponding author
goyalomesh@yahoo.co.in

Correspondence and reprint request:
, Sandeep S. Sidhu
Corresponding author
sandeepsidhu1963@gmail.com

Correspondence and reprint request:
, Harsh Kishore
* Dayanand Medical College and Hospital, Ludhiana, Punjab, India
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="s0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0035">Introduction</span><p id="p0005" class="elsevierStylePara elsevierViewall">Minimal hepatic encephalopathy &#40;MHE&#41; is the mildest form of spectrum of HE which is characterized by subtle cognitive and psychomotor deficits in the absence of recognizable clinical symptoms of HE&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Patients with MHE have increased incidence of motor-vehicle accidents&#44; poor quality of life and increased chance of developing episodes of overt hepatic encephalopathy &#40;OHE&#41;&#44; which impose a formidable burden on their families and health care sys-tem&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2-5</span></a> Overt episodes of hepatic encephalopathy can occur without warning&#44; and render the patient incapable of self-care&#44; and frequently require hospitalized care&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;7</span></a> Overall&#44; MHE is associated with poor prognosis and is probably an independent predictor of survival&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;9</span></a></p><p id="p0010" class="elsevierStylePara elsevierViewall">MHE is diagnosed by using neuro-psychometric &#40;NP&#41; tests or neurophysiological tests&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Treatment of MHE has been mainly targeted towards ammonia lowering therapies which include lactulose&#44;<span class="elsevierStyleSup">11-16</span> rifaximin&#44;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17&#44;18</span></a> probiotics&#44;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">19-22</span></a> L-ornithine-L- aspartate&#44;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">23-26</span></a> L-carnitine&#44;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> branched-chain amino acids&#44;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> etc&#46; Treatment of MHE has been shown to lead to MHE reversal&#44; improve quality of life and also decrease the frequency of occurrence of episodes of OHE&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11-26</span></a> Therefore&#44; it has been proposed the MHE should be treat-ed&#46;<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">29&#44;30</span></a> However&#44; most of the trials have focused only on short-term &#40;8-12 weeks&#41; treatment of MHE&#46; What happens after the treatment of MHE is stopped&#63; Do the patients who once become MHE negative after short-term treatment&#44; remain negative for MHE on follow up&#63; How frequently does MHE relapse on follow up&#63; Does short-term treatment of MHE decrease the incidence of future episodes of OHE and improve long-term survival&#63; These questions have not been answered by any trial till now&#46;</p><p id="p0015" class="elsevierStylePara elsevierViewall">In this study&#44; we aimed to evaluate the long-term &#40;9 months&#41; efficacy of a short-term &#40;3 month&#41; treatment of MHE with lactulose or rifaximin&#44; for maintenance of remission from MHE&#44; in out-patient cirrhotics diagnosed to have MHE&#46;</p></span><span id="s0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0040">Material and Methods</span><p id="p0020" class="elsevierStylePara elsevierViewall">This prospective study was conducted at the Gastroen-terology out-patient department of a tertiary care institute in northern India&#46; The study consisted of 2 phases&#58;<ul class="elsevierStyleList" id="l0010"><li class="elsevierStyleListItem" id="u0005"><span class="elsevierStyleLabel">&#8226;</span><p id="p0025" class="elsevierStylePara elsevierViewall">A 3-month treatment phase&#44; and</p></li><li class="elsevierStyleListItem" id="u0010"><span class="elsevierStyleLabel">&#8226;</span><p id="p0030" class="elsevierStylePara elsevierViewall">6 months follow&#8211;up phase&#46;</p></li></ul></p><p id="p0035" class="elsevierStylePara elsevierViewall">Consecutive patients with cirrhosis visiting the out-patient department were screened for the presence of MHE&#46; MHE was diagnosed if any two of the five neuro-psycho-metric tests were positive &#40;details below&#41;&#46;</p><p id="p0040" class="elsevierStylePara elsevierViewall">Inclusion criteria were- liver cirrhosis&#44; age 18-65 years and presence of MHE&#46;</p><p id="p0045" class="elsevierStylePara elsevierViewall">Exclusion criteria were- current or recent &#40;&#60; 6 weeks&#41; use of alcohol&#59; use of Lactulose&#47;Lactitol&#44; Probiotics&#44; Met-ronidazole&#44; Rifaximin within last six weeks&#59; use of inter-feron therapy&#44; psychoactive drugs&#44; anti-epileptics within last six weeks&#59; infection or gastrointestinal hemorrhage within last six weeks&#59; opium addiction&#59; presence of hepa-tocellular carcinoma &#40;HCC&#41;&#59; history of portosystemic shunt surgery and past history of OHE&#46;</p><p id="p0050" class="elsevierStylePara elsevierViewall">Laboratory assessment was carried out at baseline&#44; after 3 months of treatment and at 6 months of post-treatment follow up&#46; This included hemogram&#44; liver and renal function tests&#44; prothrombin time index&#44; and fasting blood sugar&#46; Child-Turcotte-Pugh &#40;CTP&#41; score and Model for End Stage Liver disease &#40;MELD&#41; score for stage of cirrhosis were calculated&#46;</p><p id="p0055" class="elsevierStylePara elsevierViewall">Written informed consent was taken from each patient&#46; The Institutional ethics committee approved the study protocol&#44; and it conformed to ethical guidelines of the 1975 Declaration of Helsinki&#46;</p><span id="s0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0045">Diagnosis of minimal hepatic encephalopathy</span><p id="p0060" class="elsevierStylePara elsevierViewall">Patients with a Mini Mental State Examination score &#62; 25 were considered for neuropsychometric testing using number connection test A &#40;NCT-A&#41;&#44; figure connection test-A &#40;FCT-A&#41;&#44; digit symbol test &#40;DST&#41;&#44; picture completion test &#40;PCT&#41;&#44; and block design test &#40;BDT&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;31&#44;32</span></a> Diagnosis of MHE was made if two or more neuropsy-chometric tests were impaired beyond two standard deviations of known control values&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Neuropsychometric test results were expressed as Z-scores&#44; indicating differences &#40;in standard deviation&#41; between observed and expected scores&#46; A Z-score of &#60; -2 indicated that the result was impaired beyond 2 standard deviations of the known control value&#46; The mean Z-score was calculated for each patient in order to avoid bias related to multiple comparisons&#46; Mean Z-score &#40;&#916; mZS&#41; after three months of treatment served as a quantitative measure of psychometric change&#46;</p></span><span id="s0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0050">Treatment phase &#40;3 months&#41;</span><p id="p0065" class="elsevierStylePara elsevierViewall">Patients with MHE were randomized into two groups &#40;group A and B&#41; using computer-generated randomization &#40;1&#58;1&#41; and sealed opaque envelope method&#46; Group A patients to receive Lactulose &#40;Duphalac&#59; Abbott India Limited&#44; Mumbai&#44; India&#41; per orally&#44; 30-120 mL&#47;day and group B patients to receive Rifaximin tablets &#40;Rifagut&#59; Sun Pharmaceutical Industries Ltd&#44; Mumbai&#44; India&#41; per orally&#44; 400mg three times&#47;day&#44; for three months&#46; Dosage of lactulose was adjusted to make the patient pass 2 to 3 semi-formed stools&#46; Patients were followed up at regular intervals for assessment of compliance and for the development of any new symptoms&#47;treatment related adverse events&#46; At the end of 3 months&#44; repeat neuropsychometric testing was done&#59; specific therapy for MHE &#40;Lactulose&#47; Rifaximin&#41; was stopped while standard medical therapy for cirrhosis was continued&#46;</p></span><span id="s0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0055">Follow-up phase &#40;6 months&#41;</span><p id="p0070" class="elsevierStylePara elsevierViewall">All patients were followed up after six months of stopping treatment &#40;i&#46;e&#46;&#44; 9 months post-randomization&#41;&#44; the general condition of each patient was enquired telephoni-cally&#46; Patients who could not be contacted were labeled as &#8216;lost to follow-up&#8217;&#46; Patients who had not suffered from any adverse events like OHE or death in the 6 month follow-up period were called to the hospital for repeat evaluation&#46; Routine investigations and testing for MHE was performed in these patients&#46;</p></span><span id="s0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0060">Diet and concurrent therapy</span><p id="p0075" class="elsevierStylePara elsevierViewall">During the entire study period&#44; patients were allowed to take a normal protein diet &#40;~1 g&#47;kg body weight&#44; predominantly vegetable&#47;casein based&#41;&#46; Salt restriction was advised to those who had ascites&#46; Standard treatment for cirrhosis including diuretics and &#946; -blockers were given&#44; if indicated&#46;</p></span><span id="s0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0065">Statistical analysis</span><p id="p0080" class="elsevierStylePara elsevierViewall">Data are presented as means with 95&#37; confidence intervals &#40;CI&#41; for quantitative variables and as proportions with 95&#37; CI for qualitative variables&#46; The changes in NP test results and within and between the groups were assessed by analysis of variance&#46; Multiple logistic regression analysis was performed to assess the factors associated with MHE relapse&#44; and results expressed as odds ratio &#40;OR&#41; with 95&#37; CI&#46; Fisher&#8217;s exact test was performed to assess improvement in MHE on an intention-to-treat basis&#46; A P-value of &#60; 0&#46;05 was considered statistically significant&#46; Statistical analysis was carried out with SPSS software&#44; version 11&#46;5 &#40;SPSS&#44; Chicago&#44; IL&#41;&#46;</p></span></span><span id="s0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0070">Results</span><p id="p0085" class="elsevierStylePara elsevierViewall">A total of 527 patients with liver cirrhosis were screened&#46; Out of these&#44; 176 &#40;33&#46;4&#37;&#41; patients were excluded due to various reasons &#40;127 patients had history of recent OHE and were using Lactulose&#44; L-ornithine-L-aspartate or Rifax-imin&#44; 44 had history of opium addiction&#44; 27 had history of current&#47;recent &#40;&#60; 6 weeks&#41; use of alcohol&#44; 11 had advanced cardiopulmonary disease&#44; nine had used antibiotics within last six weeks&#44; seven had hepatocellular carcinoma&#44; five were using psychoactive drugs&#47;anti-epileptics&#44; seven had history of gastrointestinal hemorrhage within last six weeks&#44; four had renal insufficiency&#44; and four were on Interferon therapy&#41;&#46; A total of 69 patients were excluded due to multiple reasons&#46; The remaining 351 patients were found eligible and tested for MHE&#46; Out of these&#44; 112 &#40;31&#46;9&#37;&#41; patients were diagnosed to have MHE &#40;mean age 55&#46;3 years&#59; 75&#37; males&#41;&#46; They were randomized to receive Rifaximin &#40;n &#61; 57&#59; 1200 mg&#47;day&#41; or Lactulose &#40;n &#61; 55&#59; 30-120 ml&#47;day&#41; for three months&#46; Later&#44; these patients were followed up to 9 months &#40;<a class="elsevierStyleCrossRef" href="#f0005">Figure 1</a>&#41;&#46; Baseline characteristics of the 2 groups were similar &#40;<a class="elsevierStyleCrossRef" href="#t0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="f0005"></elsevierMultimedia><elsevierMultimedia ident="t0005"></elsevierMultimedia><span id="s0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0075">Treatment phase &#40;3 months&#41;</span><p id="p0090" class="elsevierStylePara elsevierViewall">The detailed results of treatment phase are available elsewhere&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a> In brief&#44; at two weeks&#44; 30&#47;57 patients &#40;52&#46;6&#37;&#41; in the Rifaximin group experienced MHE reversal compared to 22&#47;55 &#40;40&#46;0&#37;&#41; in the Lactulose group &#40;based on the intention-to-treat population&#41;&#46; The absolute difference in percentages with MHE reversal was calculated to be 12&#46;6&#37; &#40;95&#37; C&#46;I&#46; -2&#46;8&#37; to 27&#46;2&#37;&#41;&#46;</p><p id="p0095" class="elsevierStylePara elsevierViewall">At 3 months&#44; forty-two out of 57 patients &#40;73&#46;7&#37;&#41; in the Rifaximin group experienced MHE reversal compared to 38 out of 55 &#40;69&#46;1&#37;&#41; in the Lactulose group &#40;based on the intention-to-treat population&#41; &#40;p &#61; 0&#46;677&#41;&#46; The absolute difference in percentages with reversal &#40;Rifaximin-Lactu-lose&#41; was calculated to be 4&#46;6&#37; &#40;95&#37; C&#46;I&#46;-9&#46;3&#37; to 18&#46;4&#37;&#41;&#46; This corresponds to an odds ratio of 1&#46;25 &#40;95&#37; C&#46;I&#46; 0&#46;63 to 2&#46;50&#41; for Rifaximin relative to Lactulose&#46;</p><p id="p0100" class="elsevierStylePara elsevierViewall">In the Rifaximin group&#44; two patients developed OHE&#44; one patient went for liver transplant and eight were lost to follow up&#46; In the Lactulose group&#44; one patient developed OHE&#44; two patients developed hepato-cellular carcinoma&#44; two patients died&#44; and 4 were lost to follow up&#46;</p></span><span id="s0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0080">Follow-up phase &#40;6 months&#41;</span><p id="p0105" class="elsevierStylePara elsevierViewall">In the Rifaximin group&#44; at 6 months follow-up&#44; 18 &#40;42&#46;8&#37;&#41; out of 42 patients &#40;who had become MHE negative with treatment&#41; were still MHE negative&#46; Out of the rest&#44; 20 patients &#40;47&#46;6&#37;&#41; had relapse of MHE&#44; while 3 &#40;7&#46;1&#37;&#41; developed OHE and one &#40;0&#46;23&#37;&#41; expired&#46; Out of the 4 patients who had persisted to be MHE positive at 3 months despite treatment&#44; 2 expired &#40;50&#37;&#41;&#44; one &#40;25&#37;&#41; developed OHE and one was lost to follow up&#46;</p><p id="p0110" class="elsevierStylePara elsevierViewall">In the lactulose group&#44; at 6 months follow-up&#44; 19 &#40;50&#37;&#41; out of 38 patients &#40;who had become MHE negative with treatment&#41; were still MHE negative&#46; Out of the rest&#44; 16 patients &#40;42&#46;1&#37;&#41; had relapse of MHE and 3 &#40;7&#46;9&#37;&#41; developed OHE&#46; Out of the 8 patients who had persisted to be MHE positive at 3 months despite treatment&#44; 3 &#40;37&#46;5&#37;&#41; developed OHE&#44; 3 expired &#40;37&#46;5&#37;&#41; and 2 were lost to follow up&#46;</p><p id="p0115" class="elsevierStylePara elsevierViewall">Results of individual NP test scores&#44; CTP score and MELD score in the two groups are shown in <a class="elsevierStyleCrossRef" href="#t0010">table 2</a>&#46; Comparison between the 2 groups revealed that the incidence of MHE relapse at 6 months was not significantly different between the Rifaximin and lactulose groups &#40;47&#46;6&#37; <span class="elsevierStyleItalic">vs&#46;</span> 42&#46;1&#37; respectively&#44; p &#61; 0&#46;274&#41;&#46; The mean CTP score &#40;8&#46;2 &#177; 2&#46;3 <span class="elsevierStyleItalic">vs&#46;</span> 6&#46;3 &#177; 1&#46;9&#59; p &#61; 0&#46;0001&#41; and MELD scores &#40;11&#46;8 &#177; 4&#46;5 <span class="elsevierStyleItalic">vs&#46;</span> 8&#46;7 &#177; 3&#46;9&#59; p &#61; 0&#46;0016&#41; of patients who had MHE relapse were higher compared to those who didn&#8217;t have a relapse of MHE&#46;</p><elsevierMultimedia ident="t0010"></elsevierMultimedia><p id="p0120" class="elsevierStylePara elsevierViewall">The 6-month incidence of development of OHE among patients who became MHE negative at 3 months was not significantly different between the 2 groups &#40;7&#46;1&#37; <span class="elsevierStyleItalic">vs</span>&#46; 7&#46;9&#37; respectively&#59; p &#61; 0&#46;924&#41;&#46; However&#44; the incidence of OHE among those who had persisted to be MHE positive at 3 months was significantly higher &#40;25&#37; and 37&#46;5&#37; in the two groups respectively&#59; p &#61; 0&#46;011&#41;&#46;</p><p id="p0125" class="elsevierStylePara elsevierViewall">The mortality rate at 6-month follow-up among patients who became MHE negative at 3 months was not significantly different in the 2 groups &#40;0&#46;23&#37; <span class="elsevierStyleItalic">vs&#46;</span> 0&#37; respectively&#41;&#46; The 6-month mortality rate among patients who persisted to be MHE positive at 3 months was much higher &#40;50&#37; and 37&#46;5&#37; in the two groups respectively&#59; p &#61; 0&#46;014&#41;&#46;</p></span><span id="s0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0085">Factors affecting MHE relapse</span><p id="p0130" class="elsevierStylePara elsevierViewall">Various factors like age&#44; sex&#44; CTP score&#44; MELD score&#44; serum bilirubin&#44; platelet count and baseline NP test score &#40;Z-score&#41; were evaluated for association with MHE relapse &#40;<a class="elsevierStyleCrossRef" href="#t0015">Table 3</a>&#41;&#46; On univariate analysis&#44; CTP&#44; score&#44; MELD score and Z-score were associated with MHE relapse&#46; On multivariate regression analysis&#44; MELD score was an independent predictor of MHE relapse&#46;</p><elsevierMultimedia ident="t0015"></elsevierMultimedia></span></span><span id="s0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0090">Discussion</span><p id="p0135" class="elsevierStylePara elsevierViewall">The prevalence of MHE in patients with cirrhosis varies between 30&#37; and 84&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;9&#44;10&#44;34</span></a> With treatment&#44; MHE reversal has been reported to occur in about 54-75&#37; of the patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;13&#44;17&#44;33</span></a> In addition&#44; treatment has been shown to improve health related quality of life&#44; decrease road-traffic accidents&#44; improve daily performance and also decrease the occurrence of episodes of OHE&#44; during the treatment period&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;13&#44;17&#44;18&#44;23</span></a> The present study is the first study that followed up patients of MHE after short-term treatment with lactulose or Rifaximin&#44; and found that although about 65&#37; of patients had MHE reversal after treatment for 3 months&#44; almost half of these patients had relapse of MHE at 6 months follow-up&#46; The frequency of MHE relapse&#44; OHE development and mortality were similar in the lactulose or Rifaximin groups&#46; However&#44; the incidence of OHE and mortality were higher among patients who didn&#8217;t experience MHE reversal at 3 months compared to those who had initial MHE reversal&#46;</p><p id="p0140" class="elsevierStylePara elsevierViewall">MHE&#44; although common&#44; is not routinely tested in clinical practice&#44; as there are no clinical guidelines recommending the universal screening of MHE&#46;<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">35-37</span></a> However&#44; testing of MHE in cirrhotic patients has gained importance in the recent years as it can provide useful and meaningful information at the individual level and help to plan a tailored therapy&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a> Some subgroups of patients would benefit the most from testing for MHE as specific recommendations can be made if they have MHE&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;30</span></a> For example&#44; active drivers should be cautioned regarding the increased probability of road traffic accidents due to their increased reaction time&#44; and workers engaged in high risk jobs should be counseled against handling of complex&#47;dangerous machinery&#46; In addition&#44; patients who have cognitive impairment and decline in work performance perceived by themselves&#44; relatives or by colleagues should be assessed and&#44; if possible&#44; changes in daily&#47; working activities should be carried out&#46;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">30&#44;35</span></a> The importance of testing MHE has further been strengthened by a recent study by Ampuero&#44; <span class="elsevierStyleItalic">et al</span>&#46;&#44; which showed that MHE is associated with a reduced 5-year survival rate of patients with cirrhosis&#46; Evaluation of MHE could help predict survival times and outcomes of patients with specific MELD scores&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a></p><p id="p0145" class="elsevierStylePara elsevierViewall">The decision to initiate medical therapy for MHE ought to be individualized&#44; based on the estimation of the extent of patient&#8217;s daily life impairment that can ameliorate with therapy&#46;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">30&#44;35</span></a> In the recent years&#44; various medical therapies that have been found effective for treating MHE patients include lactulose&#44;<span class="elsevierStyleSup">11-16</span> rifaximin&#44;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17&#44;18</span></a> probiotics&#44;<span class="elsevierStyleSup">19-22</span> L-orni-thine-L- aspartate<span class="elsevierStyleSup">23-26</span> and improved nutritional status&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a> However&#44; none of these studies have reported the follow up data of the patients after withdrawal of specific therapy for MHE&#46; Thus&#44; the long-term benefit of these therapeutic options for MHE had remained questionable till now&#46; The present study attempted to fill this lacuna in the knowledge regarding the long-term efficacy of treatment of MHE&#46; This study differs from previous studies in that it evaluated the long-term beneficial effect of a short-term therapy with Ri-faximin and lactulose&#44; rather than their short-term benefits only&#46; In our study&#44; after treatment with lactulose or Rifax-imin for 3 months&#44; about 65&#37; of patients had MHE reversal&#46; These results are similar to the previously reported data on MHE reversal after short-term treatment with lactulose or Rifaximin&#46;<span class="elsevierStyleSup">13&#44;14&#44;17&#44;18</span> However&#44; after 6 months of post-treatment follow up&#44; only about 50&#37; of these patients in our study remained negative for MHE&#44; while the rest suffered from adverse outcomes &#40;MHE&#44; OHE or mortality&#41;&#46; In a study by Das&#44; <span class="elsevierStyleItalic">et al&#46;</span><a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> describing the natural history of MHE&#44; 32 patients who were negative for MHE were followed up for a mean of 5&#46;4 months&#46; At the end of follow up&#44; 68&#46;8&#37; patients were still negative for MHE while the rest had adverse outcomes &#40;MHE in 18&#46;7&#37;&#44; OHE in 6&#46;2&#37; and mortality in 6&#46;2&#37;&#41;&#46; These data indicate that the natural history of MHE in patients who become MHE negative with short-term treatment is worse than those who are MHE negative at the baseline&#46; This is because of the high relapse rate of MHE after as short-term treatment&#46; This suggests that the therapy of MHE may need to be given for a longer period for secondary prevention of MHE&#46;</p><p id="p0150" class="elsevierStylePara elsevierViewall">The prognostic significance of MHE has been reported in another study by Dhiman&#44; <span class="elsevierStyleItalic">et al&#46;</span><a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">40</span></a> In this study&#44; the 2-year mortality rate among untreated MHE positive patients was significantly higher compared to MHE negative patients &#40;39&#46;1&#37; <span class="elsevierStyleItalic">vs</span>&#46; 22&#46;9&#37; respectively&#41;&#46; Similar results were observed in our study&#44; where the 6 month mortality among patients who persisted to be MHE positive at 3 months despite treatment was significantly higher compared to those who became MHE negative &#40;37&#46;5&#37; <span class="elsevierStyleItalic">vs</span>&#46; 0&#46;23&#37; respectively&#41;&#46; Also&#44; in concordance with the Dhiman&#44; <span class="elsevierStyleItalic">et al&#46;</span> study&#44; the incidence of OHE was significantly higher among MHE positive patients compared to MHE negative patients in our study &#40;37&#46;5&#37; <span class="elsevierStyleItalic">vs&#46;</span> 8&#37;&#41;&#46; MHE with poor psychometric hepatic encephalop-athy score was an independent predictor of survival in their study&#46; In a recent study&#44; Patidar&#44; <span class="elsevierStyleItalic">et al</span>&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">41</span></a> have shown that covert HE was associated with worsened survival&#44; increased risk of hospitalization and overt HE development after controlling for the MELD score&#46; These data highlight the need to treat MHE to reduce long-term morbidity and mortality&#46;</p><p id="p0155" class="elsevierStylePara elsevierViewall">The next question arises&#58; How long should patients be treated for secondary prevention of MHE&#63; Although the long-term data for secondary prevention of MHE is not available&#44; similar data for secondary prevention of OHE with ammonia lowering therapies for after treatment of acute episode has been addressed by various studies&#46; In a single-center&#44; open-label study of 120 patients&#44; lactulose therapy was found to be more effective than no active treatment in the prevention of overt hepatic encephalopa-thy&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">42</span></a> Later&#44; Bass&#44; <span class="elsevierStyleItalic">et al&#46;</span> showed that the addition of Rifax-imin to lactulose reduced the risk of a breakthrough episode of OHE during a 6-month period among patients in remission who had a recent history of recurrent overt hepatic encephalopathy &#40;&#8805; 2 episodes within the previous 6 months&#41; before enrollment&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">43</span></a> Recently&#44; Neff&#44; <span class="elsevierStyleItalic">et al&#46;</span> has reported that Rifaximin use for greater than 6 months proved to be effective in the management of HE&#44; especially in patients with MELD less than equal to 20&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">44</span></a> As the underlying pathophysiology of MHE and OHE are same&#44; it is understandable that both of these conditions need long term treatment for their secondary prevention&#46; As discussed earlier&#44; specific sub-groups of MHE patients are likely to benefit the most from treatment&#46; Hence&#44; the decision to treat MHE for short-term or long term needs to be individualized&#46;</p><p id="p0160" class="elsevierStylePara elsevierViewall">To conclude&#44; this is the first study to provide the follow-up data of MHE patients after short-term treatment&#46; Of the patients who became MHE negative after short-term &#40;3 months&#41; treatment with rifaximin&#47;lactulose&#44; almost 50&#37; had a relapse of MHE at 6 months follow-up&#46;</p><p id="p0165" class="elsevierStylePara elsevierViewall">Future multi-centric placebo-controlled studies must address questions regarding the efficacy&#44; safety and cost-effectiveness of long-term treatment of MHE with lactu-lose or rifaximin&#46;</p></span><span id="s0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0095">Abbreviations</span><p id="p0170" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="l0015"><li class="elsevierStyleListItem" id="u0015"><span class="elsevierStyleLabel">&#8226;</span><p id="p0175" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">BDT&#58;</span> block design test&#46;</p></li><li class="elsevierStyleListItem" id="u0020"><span class="elsevierStyleLabel">&#8226;</span><p id="p0180" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">CTP&#58;</span> Child Turcotte Pugh score&#46;</p></li><li class="elsevierStyleListItem" id="u0025"><span class="elsevierStyleLabel">&#8226;</span><p id="p0185" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">DST&#58;</span> digit symbol test&#46;</p></li><li class="elsevierStyleListItem" id="u0030"><span class="elsevierStyleLabel">&#8226;</span><p id="p0190" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">FCT-A&#58;</span> figure connection test-A&#46;</p></li><li class="elsevierStyleListItem" id="u0035"><span class="elsevierStyleLabel">&#8226;</span><p id="p0195" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">HCC&#58;</span> hepatocellular carcinoma&#46;</p></li><li class="elsevierStyleListItem" id="u0040"><span class="elsevierStyleLabel">&#8226;</span><p id="p0200" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">MELD&#58;</span> Model for End Stage Liver Disease&#46;</p></li><li class="elsevierStyleListItem" id="u0045"><span class="elsevierStyleLabel">&#8226;</span><p id="p0205" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">MHE&#58;</span> minimal hepatic encephalopathy&#46;</p></li><li class="elsevierStyleListItem" id="u0050"><span class="elsevierStyleLabel">&#8226;</span><p id="p0210" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">NCT A&#58;</span> number connection test A&#46;</p></li><li class="elsevierStyleListItem" id="u0055"><span class="elsevierStyleLabel">&#8226;</span><p id="p0215" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">NP&#58;</span> neuro-psychometric&#46;</p></li><li class="elsevierStyleListItem" id="u0060"><span class="elsevierStyleLabel">&#8226;</span><p id="p0220" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">OHE&#58;</span> overt hepatic encephalopathy&#46;</p></li><li class="elsevierStyleListItem" id="u0065"><span class="elsevierStyleLabel">&#8226;</span><p id="p0225" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">PCT&#58;</span> picture completion test&#46;</p></li></ul></p></span><span id="s0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0100">Financial Support</span><p id="p0230" class="elsevierStylePara elsevierViewall">Dayanand Medical College and Hospital&#46; Tagore Na-gar&#44; Civil lines&#46; Ludhiana&#44; Punjab&#44; India&#44; 141001&#46;</p></span></span>"
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          "titulo" => "Abstract"
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              "titulo" => "Introduction"
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              "titulo" => "Diagnosis of minimal hepatic encephalopathy"
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              "titulo" => "Treatment phase &#40;3 months&#41;"
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              "titulo" => "Follow-up phase &#40;6 months&#41;"
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    "fechaRecibido" => "2016-05-09"
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      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abs0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0010">Introduction</span><p id="sp0025" class="elsevierStyleSimplePara elsevierViewall">Minimal hepatic encephalopathy &#40;MHE&#41; can reverse after short-term treatment&#46; However&#44; relapse rate of MHE after stopping treatment has not been studied so far&#46; We aimed to evaluate long-term &#40;9 months&#41; efficacy of a short-term &#40;3 months&#41; treatment of MHE with lactulose&#47;rifaximin&#44; for maintenance of remission from MHE&#46;</p></span> <span id="abs0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0015">Material and Methods</span><p id="sp0030" class="elsevierStyleSimplePara elsevierViewall">In this prospective study&#44; consecutive patients with cirrhosis and MHE were treated with lactulose&#47;rifaximin for 3 months&#46; After treatment&#44; they were followed up for 6 months&#46; Psychometric testing for diagnosis of MHE was performed at baseline&#44; 3 months and 9 months&#46;</p></span> <span id="abs0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0020">Results</span><p id="sp0035" class="elsevierStyleSimplePara elsevierViewall">Of the 527 patients screened&#44; 351 were found eligible and tested for MHE&#46; Out of these&#44; 112 &#40;31&#46;9&#37;&#41; patients had MHE &#40;mean age 55&#46;3 years&#59; 75&#37; males&#41;&#46; They were randomized to receive Rifaximin &#40;n &#61; 57&#59; 1&#44;200 mg&#47;day&#41; or Lactulose &#40;n &#61; 55&#59; 30-120 mL&#47;day&#41; for three months&#46; At 3 months&#44; 73&#46;7&#37; &#40;42&#47;57&#41; patients in Rifaximin group experienced MHE reversal compared to 69&#46;1&#37; &#40;38&#47;55&#41; in Lac-tulose group &#40;p &#61; 0&#46;677&#41;&#46; Six months after stopping treatment&#44; 47&#46;6&#37; &#40;20&#47;42&#41; in rifaximin group and 42&#46;1&#37; &#40;16&#47;38&#41; patients in lactu-lose group experienced MHE relapse &#40;p &#61; 0&#46;274&#41;&#46; The overt hepatic encephalopathy development rate &#40;7&#46;1&#37; <span class="elsevierStyleItalic">vs&#46;</span> 7&#46;9&#37;&#41; and mortality rate &#40;0&#46;23&#37; <span class="elsevierStyleItalic">vs&#46;</span> 0&#37;&#41; were similar in both groups&#46; The Child-Turcotte-Pugh score and model for end stage liver disease &#40;MELD&#41; scores of patients who had MHE relapse were higher compared to those who didn&#8217;t&#46; On multivariate regression analysis&#44; MELD score was an independent predictor of MHE relapse&#46;</p></span> <span id="abs0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0025">Conclusion</span><p id="sp0040" class="elsevierStyleSimplePara elsevierViewall">Of the patients who became MHE negative after short-term &#40;3 months&#41; treatment with rifaximin&#47;lactulose&#44; almost 50&#37; had a relapse of MHE at 6 months follow-up&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abs0010"
            "titulo" => "Introduction"
          ]
          1 => array:2 [
            "identificador" => "abs0015"
            "titulo" => "Material and Methods"
          ]
          2 => array:2 [
            "identificador" => "abs0020"
            "titulo" => "Results"
          ]
          3 => array:2 [
            "identificador" => "abs0025"
            "titulo" => "Conclusion"
          ]
        ]
      ]
    ]
    "multimedia" => array:4 [
      0 => array:7 [
        "identificador" => "f0005"
        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 1209
            "Ancho" => 1534
            "Tamanyo" => 160492
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="sp0005" class="elsevierStyleSimplePara elsevierViewall">Flow of participants in the study&#46; MHE&#58; minimal hepatic encephalopathy&#46; OHE&#58; overt hepatic encephalopathy&#46; &#42; P value &#61; 0&#46;677&#46; &#42;&#42; P value &#61; 0&#46;274&#46;</p>"
        ]
      ]
      1 => array:8 [
        "identificador" => "t0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "fuente" => "Data are expressed as mean &#40;95&#37; confidence interval&#41; or number &#40;percent&#41;&#46; P value is non-significant for all comparison between both the arms&#46; CTP&#58; Child Turcotte Pugh&#46; MELD&#58; Model for End Stage Liver Disease&#46; NAFLD&#58; Non Alcoholic Fatty Liver Disease&#46;"
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Lactulose arm &#40;n &#61; 55&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Rifaximin arm &#40;n &#61; 57&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Age &#40;years&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">57&#46;5 &#40;54&#46;4 - 59&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">52&#46;9 &#40;49&#46;6 - 54&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Male&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">39 &#40;71&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">45 &#40;79&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Urban residence&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">28 &#40;51&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">26 &#40;46&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Education &#40;years&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#46;6 &#40;6&#46;3 - 9&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&#46;8 &#40;7&#46;5 - 9&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Diabetes mellitus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8 &#40;15&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12 &#40;21&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cirrhosis duration &#40;months&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">27&#46;8 &#40;18&#46;9 - 36&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">21&#46;5 &#40;15&#46;5 - 29&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Etiology of cirrhosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Alcohol&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">24 &#40;44&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">34 &#40;60&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hepatitis C virus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12 &#40;22&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5 &#40;9&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NAFLD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5 &#40;9&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8 &#40;14&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hepatitis B virus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cryptogenic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6 &#40;11&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Mixed&#47;others&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7 &#40;12&#46;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6 &#40;10&#46;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Varices present&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">26 &#40;47&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">26 &#40;46&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ascites duration&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11&#46;4 &#40;6&#46;9 - 15&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11&#46;9 &#40;5&#46;33 - 15&#46;31&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;months&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ascites present&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">32 &#40;58&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">33 &#40;58&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">CTP score&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#46;9 &#40;6&#46;6 - 7&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#46;1 &#40;6&#46;6 - 7&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">MELD score&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11&#46;1 &#40;10&#46;2 - 12&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11&#46;8 &#40;10&#46;6 - 13&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab2046029.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="sp0010" class="elsevierStyleSimplePara elsevierViewall">Baseline characteristics of patients&#46;</p>"
        ]
      ]
      2 => array:8 [
        "identificador" => "t0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "fuente" => "Data are expressed as mean &#40;95&#37; confidence interval&#41;&#46;"
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Parameter&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Baseline &#40;n &#61; 112&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">3 months &#40;n &#61; 92&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">9 months &#40;n &#61; 73&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Number Connection Test&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">-4&#46;75 &#40;-5&#46;82 to -3&#46;68&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">-2&#46;21 &#40;-2&#46;93 to -1&#46;49&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">-1&#46;64 &#40;-2&#46;28 to -1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Figure Connection Test&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">-5&#46;70 &#40;-6&#46;38 to -5&#46;02&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">-2&#46;60 &#40;-3&#46;31 to -1&#46;89&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">-2&#46;4 &#40;-3&#46;11 to -1&#46;71&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Digit Symbol Test&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">-1&#46;24 &#40;-1&#46;36 to -1&#46;12&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">-0&#46;77 &#40;-0&#46;94 to -0&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;84 &#40;0&#46;66 to 1&#46;02&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Picture Completion Test&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">-1&#46;82 &#40;-1&#46;96 to -1&#46;68&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">-1&#46;27 &#40;-1&#46;43 to -1&#46;11&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">-1&#46;08 &#40;-1&#46;27 to -0&#46;89&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Block Design Test&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">-1&#46;75 &#40;-1&#46;94 to -1&#46;56&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">-1&#46;15 &#40;-1&#46;35 to -0&#46;95&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">-1&#46;34 &#40;-1&#46;63 to -1&#46;05&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Model for End Stage Liver Disease score&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11&#46;48 &#40;10&#46;72 to 12&#46;24&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&#46;79 &#40;10&#46;05 to 11&#46;53&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9&#46;92 &#40;9&#46;12 to 10&#46;72&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Child-Pugh score&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#46;00 &#40;6&#46;72 to 7&#46;28&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#46;72 &#40;6&#46;39 to 7&#46;05&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#46;62 &#40;6&#46;29 to 6&#46;95&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab2046027.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="sp0015" class="elsevierStyleSimplePara elsevierViewall">Comparison of psychometric test performance and liver performance status of all patients at baseline&#44; 3 months and 9 months&#46;</p>"
        ]
      ]
      3 => array:7 [
        "identificador" => "t0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " rowspan="2" align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Variables</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Univariate analysis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="2" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Multivariate analysis</th></tr><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">p value&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">O&#46;R&#46; &#40;95&#37; C&#46;I&#46;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">p value&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Age &#62; 40 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;757&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Male Sex&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;631&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Past history of alcohol intake&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;439&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Child-Pugh score &#62;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;005&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;23 &#40;0&#46;61 - 3&#46;56&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;06&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Model for End Stage Liver Disease &#62; 11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#46;45 &#40;1&#46;23 - 9&#46;81&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;002&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bs0010"
          "bibliografiaReferencia" => array:44 [
            0 => array:3 [
              "identificador" => "bib0005"
              "etiqueta" => "1&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Hepatic encephalopathy definition&#44; nomenclature&#44; diagnosis&#44; and quantification&#58; final report of the working party at the 11th World Congresses of Gastroenterology&#44; Vienna&#44; 1998"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "Ferenci P&#46;"
                            1 => "Lockwood A&#46;"
                            2 => "Mullen K&#46;"
                            3 => "Tarter R&#46;"
                            4 => "Weissenborn K&#46;"
                            5 => "Blei A&#46;T&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1053/jhep.2002.31250"
                      "Revista" => array:6 [
                        "tituloSerie" => "Hepatology"
                        "fecha" => "2002"
                        "volumen" => "35"
                        "paginaInicial" => "716"
                        "paginaFinal" => "721"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11870389"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0010"
              "etiqueta" => "2&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Minimal hepatic encephalopathy is associated with motor vehicle crashes&#58; the reality beyond the driving test"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:7 [
                            0 => "Bajaj J&#46;S&#46;"
                            1 => "Saeian K&#46;"
                            2 => "Schubert C&#46;M&#46;"
                            3 => "Muhammad H&#46;"
                            4 => "Jose F&#46;"
                            5 => "Rajiv V&#46;"
                            6 => "Gibson D&#46;P&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1002/hep.23128"
                      "Revista" => array:6 [
                        "tituloSerie" => "Hepatology"
                        "fecha" => "2009"
                        "volumen" => "50"
                        "paginaInicial" => "1175"
                        "paginaFinal" => "1183"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19670416"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0015"
              "etiqueta" => "3&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Minimal hepatic en-cephalopathy impairs quality of life"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "Agrawal S&#46;"
                            1 => "Umapathy S&#46;"
                            2 => "Dhiman R&#46;K&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jceh.2014.11.006"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Clin Exp Hepatol"
                        "fecha" => "2015"
                        "volumen" => "5"
                        "paginaInicial" => "S42"
                        "paginaFinal" => "S48"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26041957"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0020"
              "etiqueta" => "4&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Subclinical hepatic encephalopathy predicts the development of overt hepatic encephalopathy"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "Romero-Gomez M&#46;"
                            1 => "Boza F&#46;"
                            2 => "Garc&#237;a-Valdecasas M&#46;S&#46;"
                            3 => "Garcia E&#46;"
                            4 => "Aguilar-Reina J&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/j.1572-0241.2001.04130.x"
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Gastroenterol"
                        "fecha" => "2001"
                        "volumen" => "96"
                        "paginaInicial" => "2718"
                        "paginaFinal" => "2723"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11569701"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            4 => array:3 [
              "identificador" => "bib0025"
              "etiqueta" => "5&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Prevalence and natural history of subclinical hepatic encephalopa-thy in cirrhosis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "Das A&#46;"
                            1 => "Dhiman R&#46;K&#46;"
                            2 => "Saraswat V&#46;A&#46;"
                            3 => "Verma M&#46;"
                            4 => "Naik S&#46;R&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "J Gastroenterol Hepatol"
                        "fecha" => "2001"
                        "volumen" => "16"
                        "paginaInicial" => "531"
                        "paginaFinal" => "535"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11350549"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            5 => array:3 [
              "identificador" => "bib0030"
              "etiqueta" => "6&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Review article&#58; the burden of hepatic encepha-lopathy"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "Poordad F&#46;F&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/j.1746-6342.2006.03215.x"
                      "Revista" => array:6 [
                        "tituloSerie" => "Aliment Pharmacol Ther"
                        "fecha" => "2007"
                        "volumen" => "25"
                        "paginaInicial" => "3"
                        "paginaFinal" => "9"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17295846"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            6 => array:3 [
              "identificador" => "bib0035"
              "etiqueta" => "7&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Hospitalizations during the use of ri-faximin versus lactulose for the treatment of hepatic en-cephalopathy"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "Leevy C&#46;B&#46;"
                            1 => "Phillips J&#46;A&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s10620-006-9442-4"
                      "Revista" => array:6 [
                        "tituloSerie" => "Dig Dis Sci"
                        "fecha" => "2007"
                        "volumen" => "52"
                        "paginaInicial" => "737"
                        "paginaFinal" => "741"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17245628"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            7 => array:3 [
              "identificador" => "bib0040"
              "etiqueta" => "8&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Clinical features and survival of cirrhotic patients with subclinical cognitive alterations detected by the number connection test and computerized psychometric tests"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:7 [
                            0 => "Amodio P&#46;"
                            1 => "Del Piccolo F&#46;"
                            2 => "Marchetti P&#46;"
                            3 => "Angeli P&#46;"
                            4 => "Iemmolo R&#46;"
                            5 => "Caregaro L&#46;"
                            6 => "Merkel C&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1002/hep.510290619"
                      "Revista" => array:6 [
                        "tituloSerie" => "Hepatology"
                        "fecha" => "1999"
                        "volumen" => "29"
                        "paginaInicial" => "1662"
                        "paginaFinal" => "1667"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10347105"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            8 => array:3 [
              "identificador" => "bib0045"
              "etiqueta" => "9&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The prognostic significance of subclinical hepatic encephalopathy"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:7 [
                            0 => "Hartmann I&#46;J&#46;"
                            1 => "Groeneweg M&#46;"
                            2 => "Quero J&#46;C&#46;"
                            3 => "Beijeman S&#46;J&#46;"
                            4 => "de Man R&#46;A&#46;"
                            5 => "Hop W&#46;C&#46;"
                            6 => "Schalm S&#46;W&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/j.1572-0241.2000.02265.x"
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Gastroenterol"
                        "fecha" => "2000"
                        "volumen" => "95"
                        "paginaInicial" => "2029"
                        "paginaFinal" => "2034"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10950053"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            9 => array:3 [
              "identificador" => "bib0050"
              "etiqueta" => "10&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Minimal hepatic encephalopa-thy&#58; diagnosis&#44; clinical significance and recommendations"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "Ortiz M&#46;"
                            1 => "Jacas C&#46;"
                            2 => "Cordoba J&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jhep.2004.11.028"
                      "Revista" => array:6 [
                        "tituloSerie" => "&#46; J Hepatol"
                        "fecha" => "2005"
                        "volumen" => "42"
                        "paginaInicial" => "S45"
                        "paginaFinal" => "S53"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15777572"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            10 => array:3 [
              "identificador" => "bib0055"
              "etiqueta" => "11&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Serum endotoxin&#44; inflammatory mediators&#44; and magnetic resonance spectroscopy before and after treatment in patients with minimal hepatic encephalopathy"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "Jain L&#46;"
                            1 => "Sharma B&#46;C&#46;"
                            2 => "Srivastava S&#46;"
                            3 => "Puri S&#46;K&#46;"
                            4 => "Sharma P&#46;"
                            5 => "Sarin S&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "J Gastroenterol Hepa-tol"
                        "fecha" => "2013"
                        "volumen" => "28"
                        "paginaInicial" => "1187"
                        "paginaFinal" => "1193"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            11 => array:3 [
              "identificador" => "bib0060"
              "etiqueta" => "12&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "An open-label randomized controlled trial of lactulose and probiotics in the treatment of minimal hepatic encephalopathy"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "Sharma P&#46;"
                            1 => "Sharma B&#46;C&#46;"
                            2 => "Puri V&#46;"
                            3 => "Sarin S&#46;K&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Eur J Gastro-enterol Hepatol"
                        "fecha" => "2008"
                        "volumen" => "20"
                        "paginaInicial" => "506"
                        "paginaFinal" => "511"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            12 => array:3 [
              "identificador" => "bib0065"
              "etiqueta" => "13&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Lactulose improves cognitive functions and health related quality of life in patients with cirrhosis who have minimal hepatic encephalopathy"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "Prasad S&#46;"
                            1 => "Dhiman R&#46;K&#46;"
                            2 => "Duseja A&#46;"
                            3 => "Chawla Y&#46;K&#46;"
                            4 => "Sharma A&#46;"
                            5 => "Agarwal R&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1002/hep.21533"
                      "Revista" => array:6 [
                        "tituloSerie" => "Hepatology"
                        "fecha" => "2007"
                        "volumen" => "45"
                        "paginaInicial" => "549"
                        "paginaFinal" => "559"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17326150"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            13 => array:3 [
              "identificador" => "bib0070"
              "etiqueta" => "14&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Efficacy of lactulose in cirrhotic patients with sub-clinical hepatic encephalopathy"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "Dhiman R&#46;K&#46;"
                            1 => "Sawhney M&#46;S&#46;"
                            2 => "Chawla Y&#46;K&#46;"
                            3 => "Das G&#46;"
                            4 => "Ram S&#46;"
                            5 => "Dila-wari J&#46;B&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Dig Dis Sci"
                        "fecha" => "2000"
                        "volumen" => "45"
                        "paginaInicial" => "1549"
                        "paginaFinal" => "1552"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11007104"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            14 => array:3 [
              "identificador" => "bib0075"
              "etiqueta" => "15&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Clinical efficacy of lactulose in cirrhotic patients with and without subclinical hepatic encephalopathy"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:7 [
                            0 => "Watanabe A&#46;"
                            1 => "Sakai T&#46;"
                            2 => "Sato S&#46;"
                            3 => "Imai F&#46;"
                            4 => "Ohto M&#46;"
                            5 => "Arakawa Y&#46;"
                            6 => "Toda G&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1053/jhep.1997.v26.pm0009397979"
                      "Revista" => array:6 [
                        "tituloSerie" => "Hepatology"
                        "fecha" => "1997"
                        "volumen" => "26"
                        "paginaInicial" => "1410"
                        "paginaFinal" => "1414"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9397979"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            15 => array:3 [
              "identificador" => "bib0080"
              "etiqueta" => "16&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Lactulose improves psychometric testing incirrhotic patients with subclinical encephalopathy"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "Horsmans Y&#46;"
                            1 => "Solbreux P&#46;M&#46;"
                            2 => "Daenens C&#46;"
                            3 => "Desager J&#46;P&#46;"
                            4 => "Geubel A&#46;P&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Aliment Pharmacol Ther"
                        "fecha" => "1997"
                        "volumen" => "11"
                        "paginaInicial" => "165"
                        "paginaFinal" => "170"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9042989"
                            "web" => "Medline"
                          ]
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                      ]
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                  ]
                ]
              ]
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              "identificador" => "bib0085"
              "etiqueta" => "17&#46;"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Rifaximin improves psychometric performance and health-related quality of life in patients with minimal hepatic enceph-alopathy &#40;the RIME Trial&#41;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "Sidhu S&#46;S&#46;"
                            1 => "Goyal O&#46;"
                            2 => "Mishra B&#46;P&#46;"
                            3 => "Sood A&#46;"
                            4 => "Chhina R&#46;S&#46;"
                            5 => "Soni R&#46;K&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1038/ajg.2010.455"
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Gastroenterol"
                        "fecha" => "2011"
                        "volumen" => "106"
                        "paginaInicial" => "307"
                        "paginaFinal" => "316"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21157444"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            17 => array:3 [
              "identificador" => "bib0090"
              "etiqueta" => "18&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Rifaximin improves driving simulator performance in a randomized trial of patients with minimal hepatic encephalopathy"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:7 [
                            0 => "Bajaj J&#46;S&#46;"
                            1 => "Heuman D&#46;M&#46;"
                            2 => "Wade J&#46;B&#46;"
                            3 => "Gibson D&#46;P&#46;"
                            4 => "Saeian K&#46;"
                            5 => "Wege-lin J&#46;A&#46;"
                            6 => "Hafeezullah M&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1053/j.gastro.2010.08.061"
                      "Revista" => array:7 [
                        "tituloSerie" => "Gastroenterology"
                        "fecha" => "2011"
                        "volumen" => "140"
                        "paginaInicial" => "478"
                        "paginaFinal" => "487"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20849805"
                            "web" => "Medline"
                          ]
                        ]
                        "itemHostRev" => array:3 [
                          "pii" => "S0168827811008129"
                          "estado" => "S300"
                          "issn" => "01688278"
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            18 => array:3 [
              "identificador" => "bib0095"
              "etiqueta" => "19&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Probiotic yogurt for the treatment of minimal hepatic encephalopathy"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:7 [
                            0 => "Bajaj J&#46;S&#46;"
                            1 => "Saeian K&#46;"
                            2 => "Christensen K&#46;M&#46;"
                            3 => "Hafeezullah M&#46;"
                            4 => "Varma R&#46;R&#46;"
                            5 => "Franco J&#46;"
                            6 => "Pleuss J&#46;A&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Am J Gastroenter-ol"
                        "fecha" => "2008"
                        "volumen" => "103"
                        "paginaInicial" => "1707"
                        "paginaFinal" => "1715"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            19 => array:3 [
              "identificador" => "bib0100"
              "etiqueta" => "20&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Symbiotic modulation of gut flora&#58; effect on minimal hepatic encephalopathy in patients with cirrhosis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:7 [
                            0 => "Liu Q&#46;"
                            1 => "Duan Z&#46;P&#46;"
                            2 => "Ha D&#46;K&#46;"
                            3 => "Bengmark S&#46;"
                            4 => "Kurtovic J&#46;"
                            5 => "Riordan S&#46;M&#46;"
                            6 => "Hafeezullah M&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1002/hep.20194"
                      "Revista" => array:6 [
                        "tituloSerie" => "Hepatology"
                        "fecha" => "2004"
                        "volumen" => "39"
                        "paginaInicial" => "1441"
                        "paginaFinal" => "1449"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15122774"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            20 => array:3 [
              "identificador" => "bib0105"
              "etiqueta" => "21&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Bifidobacterium longum with fruc-to-oligosaccharide &#40;fos&#41; treatment in minimal hepatic encephalopathy&#58; a randomized&#44; double-blind&#44; placebo-controlled study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "Malaguarnera M&#46;"
                            1 => "Greco F&#46;"
                            2 => "Barone G&#46;"
                            3 => "Gargante M&#46;P&#46;"
                            4 => "Mala-guarnera M&#46;"
                            5 => "Toscano M&#46;A&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s10620-006-9687-y"
                      "Revista" => array:6 [
                        "tituloSerie" => "Dig Dis Sci"
                        "fecha" => "2008"
                        "volumen" => "52"
                        "paginaInicial" => "3259"
                        "paginaFinal" => "3265"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17393330"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            21 => array:3 [
              "identificador" => "bib0110"
              "etiqueta" => "22&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Can Lactobacillus acidophilus improve minimal hepatic encephalopathy&#63; A neurometabolite study using magnetic resonance spectroscopy"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "Ziada D&#46;H&#46;"
                            1 => "Soliman H&#46;H&#46;"
                            2 => "El Yamany S&#46;A&#46;"
                            3 => "Hamisa M&#46;F&#46;"
                            4 => "Hasan A&#46;M&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.ajg.2013.08.002"
                      "Revista" => array:6 [
                        "tituloSerie" => "Arab J Gastroenterol"
                        "fecha" => "2013"
                        "volumen" => "14"
                        "paginaInicial" => "116"
                        "paginaFinal" => "122"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24206740"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            22 => array:3 [
              "identificador" => "bib0115"
              "etiqueta" => "23&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Oral L-ornithine-L-aspartate in minimal hepatic encephalopathy&#58; a randomized&#44; double-blind&#44; placebo-controlled trial"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:7 [
                            0 => "Alvares-da-Silva M&#46;R&#46;"
                            1 => "de Araujo A&#46;"
                            2 => "Vicenzi J&#46;R&#46;"
                            3 => "da Silva G&#46;V&#46;"
                            4 => "Oliveira F&#46;B&#46;"
                            5 => "Schacher F&#46;"
                            6 => "Oliboni L&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/hepr.12235"
                      "Revista" => array:6 [
                        "tituloSerie" => "Hepatol Res"
                        "fecha" => "2014"
                        "volumen" => "44"
                        "paginaInicial" => "956"
                        "paginaFinal" => "963"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24033861"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            23 => array:3 [
              "identificador" => "bib0120"
              "etiqueta" => "24&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "L-ornithine-L-aspartate for hepatic encephalopathy in patients with cirrhosis&#58; a meta-analysis of randomized controlled trials"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "Bai M&#46;"
                            1 => "Yang Z&#46;"
                            2 => "Qi X&#46;"
                            3 => "Fan D&#46;"
                            4 => "Han G&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "J Gastroen-terol Hepatol"
                        "fecha" => "2013"
                        "volumen" => "28"
                        "paginaInicial" => "783"
                        "paginaFinal" => "792"
                      ]
                    ]
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              "identificador" => "bib0125"
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                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "The effect of L-ornithine L-aspartate and branch chain amino acids on encephalopa-thy and nutritional status in liver cirrhosis with malnutrition"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "Ndraha S&#46;"
                            1 => "Hasan I&#46;"
                            2 => "Simadibrata M&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Acta Med Indones"
                        "fecha" => "2011"
                        "volumen" => "43"
                        "paginaInicial" => "18"
                        "paginaFinal" => "22"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21339541"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            25 => array:3 [
              "identificador" => "bib0130"
              "etiqueta" => "26&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "A randomized controlled trial comparing lactulose&#44; probiotics&#44; and L-ornithine L- aspartate in treatment of minimal hepatic encepha-lopathy"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "Mittal V&#46;V&#46;"
                            1 => "Sharma B&#46;C&#46;"
                            2 => "Sharma P&#46;"
                            3 => "Sarin S&#46;K&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1097/MEG.0b013e32834696f5"
                      "Revista" => array:6 [
                        "tituloSerie" => "Eur J Gastroenterol Hepatol"
                        "fecha" => "2011"
                        "volumen" => "23"
                        "paginaInicial" => "725"
                        "paginaFinal" => "732"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21646910"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            26 => array:3 [
              "identificador" => "bib0135"
              "etiqueta" => "27&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Acetyl-L-carnitine treatment in minimal hepatic encephalopathy"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:7 [
                            0 => "Malaguarnera M&#46;"
                            1 => "Gargante M&#46;P&#46;"
                            2 => "Cristaldi E&#46;"
                            3 => "Vacante M&#46;"
                            4 => "Risino C&#46;"
                            5 => "Cammalleri L&#46;"
                            6 => "Pennisi G&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s10620-008-0238-6"
                      "Revista" => array:6 [
                        "tituloSerie" => "Dig Dis Sci"
                        "fecha" => "2008"
                        "volumen" => "53"
                        "paginaInicial" => "3018"
                        "paginaFinal" => "3025"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18357530"
                            "web" => "Medline"
                          ]
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                      ]
                    ]
                  ]
                ]
              ]
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              "identificador" => "bib0140"
              "etiqueta" => "28&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Branched chain ami-no acids in the treatment of latent portosystemic encepha-lopathy&#46; A double blind placebo-controlled crossover study"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "Egberts E&#46;H&#46;"
                            1 => "Schomerus H&#46;"
                            2 => "Hamster W&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Gastroenterology"
                        "fecha" => "1985"
                        "volumen" => "88"
                        "paginaInicial" => "887"
                        "paginaFinal" => "895"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/3882509"
                            "web" => "Medline"
                          ]
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              ]
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              "identificador" => "bib0145"
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                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "MHE&#46; Consensus statement of a working party of the Indian national association for study of the liver"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "Dhiman R&#46;K&#46;"
                            1 => "Saraswat V&#46;"
                            2 => "Duseja A&#46;"
                            3 => "Chawla Y&#46;K&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/j.1440-1746.2010.06318.x"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Gastroenterol Hepatol"
                        "fecha" => "2010"
                        "volumen" => "25"
                        "paginaInicial" => "1029"
                        "paginaFinal" => "1041"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20594216"
                            "web" => "Medline"
                          ]
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                ]
              ]
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            29 => array:3 [
              "identificador" => "bib0150"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Management of covert hepatic encephalopathy"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "Waghray A&#46;"
                            1 => "Waghray N&#46;"
                            2 => "Mullen K&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jceh.2014.02.007"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Clin Exp Hepatol"
                        "fecha" => "2015"
                        "volumen" => "5"
                        "paginaInicial" => "S75"
                        "paginaFinal" => "S81"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26041963"
                            "web" => "Medline"
                          ]
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                      ]
                    ]
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                ]
              ]
            ]
            30 => array:3 [
              "identificador" => "bib0155"
              "etiqueta" => "31&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:1 [
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "Ramalingaswamy P&#46;"
                          ]
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                  "host" => array:1 [
                    0 => array:1 [
                      "LibroEditado" => array:4 [
                        "titulo" => "Manual of Indian Adaptation of WAIS Performance Scale"
                        "paginaInicial" => "2"
                        "paginaFinal" => "29"
                        "serieFecha" => "1974"
                      ]
                    ]
                  ]
                ]
              ]
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            31 => array:3 [
              "identificador" => "bib0160"
              "etiqueta" => "32&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Figure connection test&#58; a universal test for assessment of mental state"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "Dhiman R&#46;K&#46;"
                            1 => "Saraswat V&#46;A&#46;"
                            2 => "Verma M&#46;"
                            3 => "Naik S&#46;R&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "J Gastroenterol Hepatol"
                        "fecha" => "1995"
                        "volumen" => "10"
                        "paginaInicial" => "14"
                        "paginaFinal" => "23"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/7620102"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
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                ]
              ]
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            32 => array:3 [
              "identificador" => "bib0165"
              "etiqueta" => "33&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Rifaximin vs&#46; lactulose in treatment of minimal hepatic encephalopathy"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "Sidhu S&#46;S&#46;"
                            1 => "Goyal O&#46;"
                            2 => "Parker R&#46;A&#46;"
                            3 => "Kishore H&#46;"
                            4 => "Sood A&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/liv.12921"
                      "Revista" => array:6 [
                        "tituloSerie" => "Liver Int"
                        "fecha" => "2016"
                        "volumen" => "36"
                        "paginaInicial" => "378"
                        "paginaFinal" => "385"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26201713"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            33 => array:3 [
              "identificador" => "bib0170"
              "etiqueta" => "34&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Management options for minimal hepatic encepha-lopathy"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "Bajaj J&#46;S&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1586/17474124.2.6.785"
                      "Revista" => array:6 [
                        "tituloSerie" => "Expert Rev Gastroenterol Hepatol"
                        "fecha" => "2008"
                        "volumen" => "2"
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                        "paginaFinal" => "790"
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                ]
              ]
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              "identificador" => "bib0175"
              "etiqueta" => "35&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Minimal Hepatic En-cephalopathy&#58; The Reality Beyond Our Eyes"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "Barbosa M&#46;"
                            1 => "Marinho C&#46;"
                            2 => "Mota P&#46;"
                            3 => "Cotter J&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:7 [
                        "tituloSerie" => "Acta Med Port"
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                        "paginaInicial" => "480"
                        "paginaFinal" => "485"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26574984"
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                          "pii" => "S0002937815006043"
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                          "issn" => "00029378"
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              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Diagnosis and treatment of hepatic encephalopathy in Spain&#58; results of a survey of hepatologists"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "Vergara Gomez M&#46;"
                            1 => "Flavia-Olivella M&#46;"
                            2 => "Gil-Prades M&#46;"
                            3 => "Dalmau Obrador B&#46;"
                            4 => "Cordoba-Cardona J&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Gastroenterol Hepatol"
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                        "paginaInicial" => "1"
                        "paginaFinal" => "6"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16393622"
                            "web" => "Medline"
                          ]
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                      ]
                    ]
                  ]
                ]
              ]
            ]
            36 => array:3 [
              "identificador" => "bib0185"
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              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Testing for minimal hepatic encephalopathy in the United States&#58; an AASLD survey"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "Bajaj J&#46;S&#46;"
                            1 => "Etemadian A&#46;"
                            2 => "Hafeezullah M&#46;"
                            3 => "Saeian K&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1002/hep.21515"
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                        "tituloSerie" => "Hepatology"
                        "fecha" => "2007"
                        "volumen" => "45"
                        "paginaInicial" => "833"
                        "paginaFinal" => "834"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17326210"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            37 => array:3 [
              "identificador" => "bib0190"
              "etiqueta" => "38&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Minimal hepatic encephalopathy and critical flicker frequency are associated with survival of patients with cirrhosis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:7 [
                            0 => "Ampuero J&#46;"
                            1 => "Sim&#243;n M&#46;"
                            2 => "Montoli&#250; C&#46;"
                            3 => "Jover R&#46;"
                            4 => "Serra M&#46;A&#46;"
                            5 => "C&#243;rdo-ba J&#46;"
                            6 => "Romero-G&#243;mez M&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1053/j.gastro.2015.07.067"
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                        "tituloSerie" => "Gastroenterology"
                        "fecha" => "2015"
                        "volumen" => "149"
                        "paginaInicial" => "1483"
                        "paginaFinal" => "1489"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26299413"
                            "web" => "Medline"
                          ]
                        ]
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                          "pii" => "S0016508512011870"
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                          "issn" => "00165085"
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                  ]
                ]
              ]
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            38 => array:3 [
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                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "Nutritional management contributes to improvement in minimal hepatic encephalopathy and quality of life in patients with liver cirrhosis&#58; a preliminary&#44; prospective&#44; open-label study"
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                        0 => array:2 [
                          "etal" => true
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                            1 => "Tanaka H&#46;"
                            2 => "Kawaguchi T&#46;"
                            3 => "Kanazawa H&#46;"
                            4 => "Iwasa M&#46;"
                            5 => "Sakaida I&#46;"
                            6 => "Moriwaki H&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
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                    0 => array:2 [
                      "doi" => "10.1111/j.1872-034X.2012.01092.x"
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                        "tituloSerie" => "Hepatol Res"
                        "fecha" => "2013"
                        "volumen" => "43"
                        "paginaInicial" => "452"
                        "paginaFinal" => "458"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22994429"
                            "web" => "Medline"
                          ]
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                    ]
                  ]
                ]
              ]
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                    0 => array:2 [
                      "titulo" => "Diagnosis and prognostic significance of minimal hepatic encephalopathy in patients with cirrhosis of liver"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:7 [
                            0 => "Dhiman R&#46;K&#46;"
                            1 => "Kurmi R&#46;"
                            2 => "Thumburu K&#46;K&#46;"
                            3 => "Venkataramarao S&#46;H&#46;"
                            4 => "Agarwal R&#46;"
                            5 => "Duseja A&#46;"
                            6 => "Chawla Y&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
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                    0 => array:2 [
                      "doi" => "10.1007/s10620-010-1249-7"
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                        "tituloSerie" => "Dig Dis Sci"
                        "fecha" => "2010"
                        "volumen" => "55"
                        "paginaInicial" => "2381"
                        "paginaFinal" => "2390"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20508990"
                            "web" => "Medline"
                          ]
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                    ]
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                ]
              ]
            ]
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                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "Covert hepatic encephalopa-thy is independently associated with poor survival and increased risk of hospitalization"
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                          "etal" => true
                          "autores" => array:7 [
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                            1 => "Thacker L&#46;R&#46;"
                            2 => "Wade J&#46;B&#46;"
                            3 => "Sterling R&#46;K&#46;"
                            4 => "Sanyal A&#46;J&#46;"
                            5 => "Siddiqui M&#46;S&#46;"
                            6 => "Matherly S&#46;C&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
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                    0 => array:2 [
                      "doi" => "10.1038/ajg.2014.264"
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                        "tituloSerie" => "Am J Gastroenterol"
                        "fecha" => "2014"
                        "volumen" => "109"
                        "paginaInicial" => "1757"
                        "paginaFinal" => "1763"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25178701"
                            "web" => "Medline"
                          ]
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                    ]
                  ]
                ]
              ]
            ]
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              "etiqueta" => "42&#46;"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Secondary prophylaxis of hepatic encephalopathy&#58; an open label randomized controlled trial of lactulose versus placebo"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
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                            1 => "Sharma P&#46;"
                            2 => "Agrawal A&#46;"
                            3 => "Sarin S&#46;K&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Gastro-enterology"
                        "fecha" => "2009"
                        "volumen" => "137"
                        "paginaInicial" => "885"
                        "paginaFinal" => "891"
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                    ]
                  ]
                ]
              ]
            ]
            42 => array:3 [
              "identificador" => "bib0215"
              "etiqueta" => "43&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Rifaximin treatment in hepatic encephalop-athy"
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                        0 => array:2 [
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                          "autores" => array:7 [
                            0 => "Bass N&#46;M&#46;"
                            1 => "Mullen K&#46;D&#46;"
                            2 => "Sanyal A&#46;"
                            3 => "Poordad F&#46;"
                            4 => "Neff G&#46;"
                            5 => "Leevy C&#46;B&#46;"
                            6 => "Sigal S&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1056/NEJMoa0907893"
                      "Revista" => array:6 [
                        "tituloSerie" => "N Engl J Med"
                        "fecha" => "2010"
                        "volumen" => "362"
                        "paginaInicial" => "1071"
                        "paginaFinal" => "1081"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20335583"
                            "web" => "Medline"
                          ]
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                      ]
                    ]
                  ]
                ]
              ]
            ]
            43 => array:3 [
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Durability of rifaximin response in hepatic en-cephalopathy"
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                        0 => array:2 [
                          "etal" => true
                          "autores" => array:7 [
                            0 => "Neff G&#46;W&#46;"
                            1 => "Jones M&#46;"
                            2 => "Broda T&#46;"
                            3 => "Jonas M&#46;"
                            4 => "Ravi R&#46;"
                            5 => "Novick D&#46;"
                            6 => "Kaiser T&#46;E&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1097/MCG.0b013e318231faae"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Clin Gastroenterol"
                        "fecha" => "2012"
                        "volumen" => "46"
                        "paginaInicial" => "168"
                        "paginaFinal" => "171"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22011586"
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                ]
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es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos