Assessing severity of liver injury in clinical practice: an improved Child–Turcotte–Pugh score (CTP score)

More recent articles in the QJM on liver disease has focused on prognosis in chronic liver disease and vaccination in COVID times.^1,2 We expand our published work on prognosis in Liver cirrhosis by publishing work on further refinement of the Child–Turcotte–Pugh score (CTP score) in liver injury.

The CTP score was first used to predict surgical risk in patients undergoing portosystemic shunt surgery for variceal bleeding. The CTP score is now widely used to assess the severity of liver injury in clinical practice. However, the CTP score has some challenges which would include inter-observer error in assessing and scoring for ascites and hepatic encephalopathy.

More recently, baseline plasma ammonia has been shown to be a predictor of the decompensated events in liver cirrhosis in both animal and human studies. However, to date, the external validation of the role of plasma ammonia in predicting the prognosis in the patients with decompensated cirrhosis is lacking.

We therefore wellcome the study by Dr. Wang and colleagues from the Nanjing University published in the current issue of the Journal who showed in both an observational and validation cohort of patients with liver cirrhosis that for each 1-point incremental increase in Ammonia above normal was associated with a 2-fold increase in the likelihood of mortality. In addition, they showed a significant discriminatory improvement in the CTP score if plasma ammonia was incorporated instead of subjective scoring for encephalopathy in this prognostic scoring system. We recommend this important work to our readers.

Antinuclear antibodies in neurological clinical practice

Recent neurological articles in the QJM naturally have been focused on neurological disease in the COVID era particularly related to acute infection and vaccination.^3–8 As we come out of this era we wellcome the review article in this issue of the journal relating to antinuclear antibodies (ANA) and systemic autoimmune neurological disorders.

Although many techniques exist, ANA by indirect immunofluorescence remains the gold standard for diagnosing CTDs. We wellome the review article on this clinically relevant topic by Dr. Sudheer and colleagues from the All Indian Institute of Medical Sciences. They provide a comprehensive appraisal of this assay highlighting the advantages but also the potential interpretive pitfalls associated with this assay in the context of clinical relevance in various neurological diseases.

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