肝硬化隱匿型肝性腦病常用診斷方法的比較研究
發(fā)布時(shí)間：2018-07-23 17:47
【摘要】：背景肝性腦病(hepatic encephalopathy,HE)是肝硬化患者一種主要的、尚未被解決的并發(fā)癥。輕微型肝性腦病(minimal hepatic encephalopathy,MHE)或隱匿型肝性腦病(covert hepatic encephalopathy,CHE)可增加患者的死亡率和住院風(fēng)險(xiǎn),健康相關(guān)生命質(zhì)量(Health Related Quality of Life,HRQo L)受損及看護(hù)者的負(fù)擔(dān)增加。檢測(cè)MHE或CHE可以指導(dǎo)治療,可能改善臨床結(jié)局和生命質(zhì)量。然而,臨床實(shí)踐中對(duì)肝硬化患者實(shí)施MHE或CHE的檢測(cè)并不常見。HE早期診斷和治療的主要障礙是缺乏一個(gè)有效的、標(biāo)準(zhǔn)化的檢測(cè)及描述HE的方法。缺乏客觀和靈敏的HE分級(jí)方法,限制了我們對(duì)于HE流行病學(xué)和發(fā)病機(jī)制的理解和評(píng)估HE靶向治療療效的困難。因此,近期的AASLD/EASL指南推薦:使用2種或更多種輔助檢測(cè)方法診斷隱匿型肝性腦病。這些方法包括紙筆測(cè)試,如肝性腦病心理學(xué)評(píng)分(psychometric hepatic encephalopathy score,PHES);神經(jīng)生理學(xué)測(cè)試,如臨界閃爍頻率(critical flicker frequency,CFF);計(jì)算機(jī)測(cè)試,如Encephal App Stroop。簡易智能量表(mini-mental state examination,MMSE)是一種最普遍使用的評(píng)估認(rèn)知精神狀況的方法,其在認(rèn)知障礙篩查中具有良好的信度和效度。過去不僅被應(yīng)用于肝病的研究,在國外一些研究中,甚至用于評(píng)估肝性腦病的嚴(yán)重性和作為肝性腦病的監(jiān)測(cè)方法之一。然而,我國研究人員尚未進(jìn)行類似方面的研究。目的本研究采用近期歐美肝病協(xié)會(huì)肝性腦病共識(shí)指南推薦的診斷標(biāo)準(zhǔn),即使用2種或以上方法診斷隱匿型肝性腦病。在此基礎(chǔ)上,初步探索簡易智能量表(MMSE)、臨界閃爍頻率(CFF)、肝性腦病心理學(xué)評(píng)分(PHES)和斯特魯普測(cè)試(Encephal App Stroop)等隱匿型肝性腦病(CHE)常用檢測(cè)方法的臨床應(yīng)用價(jià)值。方法納入110例肝硬化失代償期患者和81例無肝病的對(duì)照者,以PHES-4分作為CHE的參考閾值,分析得出CFF和Stroop測(cè)驗(yàn)的測(cè)試時(shí)間診斷CHE的閾值。以PHES、CFF、Stroop測(cè)驗(yàn)中至少2項(xiàng)陽性作為診斷CHE的“金標(biāo)準(zhǔn)”,評(píng)價(jià)這3種檢測(cè)方法診斷CHE的臨床應(yīng)用價(jià)值。同時(shí)將簡易智能量表根據(jù)測(cè)試的功能不同劃分為多個(gè)項(xiàng)目,分別分析各子項(xiàng)目對(duì)于肝性腦病的初篩及預(yù)測(cè)價(jià)值。統(tǒng)計(jì)學(xué)方法采用t檢驗(yàn)、單因素方差分析及ROC曲線分析。結(jié)果110例肝硬化患者中,肝硬化無肝性腦病(HE0)患者40例,CHE 52例,肝性腦病II級(jí)18例。(1)對(duì)照組CFF值和Stroop測(cè)驗(yàn)的總時(shí)間分別為(43.70±1.92)Hz、(201.17±20.65)s,HE0組CFF值為(41.40±1.85)Hz,高于CHE組的(38.33±2.32)Hz,差異有統(tǒng)計(jì)學(xué)意義(t=-7.116,P0.01);HE0組Stroop測(cè)驗(yàn)的總時(shí)間為(197.91±26.68)s,短于CHE組的(253.24±33.33)s,差異有統(tǒng)計(jì)學(xué)意義(t=8.936,P0.01)。(2)當(dāng)以PHES-4分作為CHE的參考閾值時(shí),CFF診斷CHE的閾值為39Hz,敏感度為94.9%,特異度為73.1%,AUC值為0.879;Stroop測(cè)驗(yàn)的總時(shí)間診斷CHE的閾值為233.80s,敏感度為83.3%,特異度為71.7%,AUC值為0.803。(3)CHE組患者PHES5項(xiàng)子測(cè)試中的NCT-A、NCT-B和DST的完成時(shí)間分別為(80.27±36.05)、(124.18±55.96)和(25.03±8.23)s,與HE0組的(56.68±18.82)、(80.00±25.58)和(34.68±8.75)s相比,差異均有統(tǒng)計(jì)學(xué)意義(t=3.691、4.108、-4.780,P值均0.01);與PHES和Stroop測(cè)驗(yàn)聯(lián)合診斷HE0、CHE和HE2的檢測(cè)結(jié)果比較,以CFF值39Hz作為檢測(cè)閾值的一致率分別達(dá)95.0%、61.5%和100.0%。(4)肝功能Chi ld-pugh評(píng)分與MMSE總分、時(shí)間定向、空間定向、注意力和計(jì)算力、回憶、寫句子、畫五角形7個(gè)項(xiàng)目的Pearson相關(guān)系數(shù)分別為-0.352,-0.417,-0.342,-0.243,-0.275,-0.303,-0.278,P值均0.01);HE0、CHE和OHE 3組患者間MMSE總分差異顯著(P值均0.001),尤其OHE患者的MMSE總分均值相比CHE患者及HE0患者明顯減低,分別為18.50±4.17分、24.93±4.23分、27.88±2.70分。HE0與CHE兩組間比較時(shí)發(fā)現(xiàn),時(shí)間定向和空間定向2個(gè)項(xiàng)目均無統(tǒng)計(jì)學(xué)差異(P0.05),而OHE組不論與HE0組或CHE組比較,時(shí)間定向和空間定向均差異顯著(P均0.001)。結(jié)論P(yáng)HES中的NCT-A、NCT-B和DST3個(gè)子測(cè)試檢測(cè)CHE的效能較高。CFF和Stroop測(cè)驗(yàn)也是較為可靠的篩選鑒別CHE的檢測(cè)方法,具有客觀和特異性強(qiáng)的檢測(cè)優(yōu)勢(shì)。MMSE總分、時(shí)間定向和空間定向3個(gè)項(xiàng)目對(duì)于OHE具有一定的預(yù)測(cè)價(jià)值,而CHE的診斷仍需結(jié)合多種診斷方法,提高篩查率。
[Abstract]:Background hepatic encephalopathy (hepatic encephalopathy, HE) is a major, yet not resolved complication in patients with cirrhosis. Mild hepatic encephalopathy (minimal hepatic encephalopathy, MHE) or occult hepatic encephalopathy (covert hepatic encephalopathy, CHE) can increase the mortality and risk of hospitalization, and the health related quality of life (Health) Elated Quality of Life, HRQo L) damage and the burden of caregivers increase. Detection of MHE or CHE can guide treatment, may improve clinical outcome and quality of life. However, in clinical practice, the detection of MHE or CHE for patients with cirrhosis is not a common obstacle to the early diagnosis and treatment of.HE is the lack of an effective, standardized test and The lack of an objective and sensitive method of HE classification limits our understanding of the epidemiology and pathogenesis of HE and the difficulty of assessing the efficacy of HE targeting therapy. Therefore, the recent AASLD/EASL guidelines recommend 2 or more auxiliary detection methods for the diagnosis of occult hepatic encephalopathy. These include the paper pen test, such as the liver. Psychometric hepatic encephalopathy score (PHES); neurophysiological tests, such as the critical scintillation frequency (critical flicker frequency, CFF); computer testing, such as Encephal App Stroop. simple intelligence scale, is the most commonly used party to assess cognitive mental status. It has good reliability and validity in the screening of cognitive impairment. In the past, it was not only used in the study of liver disease, but also in some foreign studies, and even used to assess the severity of hepatic encephalopathy and one of the monitoring methods of hepatic encephalopathy. However, the researchers in our country have not done a similar study. The diagnostic criteria recommended by the European and American Liver Association liver encephalopathy consensus guidelines are to use 2 or more methods to diagnose occult hepatic encephalopathy. On this basis, we preliminarily explore the simple Intelligence Scale (MMSE), critical scintillation frequency (CFF), hepatic encephalopathy psychological score (PHES) and Stroop test (Encephal App Stroop) and other occult hepatic encephalopathy (CH). E) the clinical value of common detection methods. Methods included in 110 patients with decompensated cirrhosis and 81 cases of non liver disease control, using PHES-4 score as the reference threshold of CHE, the threshold of the test time of CFF and Stroop test was analyzed. At least 2 positive of the PHES, CFF, Stroop test were used as the "gold standard" for diagnosing CHE. The value of these 3 methods was used to diagnose the clinical application of CHE. At the same time, the simple intelligent scale was divided into multiple items according to the function of the test. The initial screening and prediction value of each sub item for hepatic encephalopathy was analyzed. The statistical method was t test, single factor analysis of variance and ROC curve analysis. Results of 110 cases of liver cirrhosis, liver 40 cases of sclerotic hepatic encephalopathy (HE0), 52 cases of CHE and 18 cases of hepatic encephalopathy II. (1) the total time of CFF value and Stroop test in the control group was (43.70 + 1.92) Hz, (201.17 + 20.65) s, and HE0 group CFF value was (41.40 + 1.85) Hz, higher than that of CHE group (38.33 + 2.32) Hz, the difference was statistically significant (197., 197.). 91 + 26.68) s, shorter than group CHE (253.24 + 33.33) s, the difference was statistically significant (t=8.936, P0.01). (2) when PHES-4 score was used as the reference threshold for CHE, CFF diagnostic CHE threshold was 39Hz, sensitivity was 94.9%, specificity was 73.1%, AUC value was 0.879; the total time diagnostic threshold of Stroop test was 83.3%, specificity was 71.7%, The AUC value was NCT-A in the PHES5 subtest of group 0.803. (3) CHE, the completion time of NCT-B and DST was (80.27 + 36.05), (124.18 + 55.96) and (25.03 + 8.23) s, compared with the HE0 group (56.68 + 18.82), (80 + 25.03) and (34.68 + 8.75) s. Compared with the detection results of HE0, CHE and HE2, the consistent rate of CFF value 39Hz as detection threshold was 95%, 61.5% and 100.0%. (4) Chi ld-pugh score and MMSE total score, time orientation, spatial orientation, attention and computing power, memory, sentence writing, and five corners of 7 items were -0.352, -0.417, etc. 243, -0.275, -0.303, -0.278, and P were all 0.01). The total score of MMSE total score in HE0, CHE and OHE 3 groups was significantly different (P value 0.001), especially the MMSE total value of OHE patients was significantly lower than that of CHE patients and patients, respectively 18.50 + 4.17, 24.93 + 4.23, 27.88 + 2.70 and two groups. Time orientation and spatial orientation 2 items were found. There were no statistical differences (P0.05), but in group OHE, both time orientation and spatial orientation were significantly different from HE0 group or CHE group (P 0.001). Conclusion NCT-A, NCT-B and DST3 sub tests in PHES were more effective and more reliable for detection of CHE, which was more objective and specific. 3 items of.MMSE total score, time orientation and spatial orientation have a certain predictive value for OHE, and the diagnosis of CHE still needs to be combined with a variety of diagnostic methods to improve the screening rate.
【學(xué)位授予單位】：安徽醫(yī)科大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類號(hào)】：R575.2;R747.9
本文編號(hào)：2140164
[Abstract]:Background hepatic encephalopathy (hepatic encephalopathy, HE) is a major, yet not resolved complication in patients with cirrhosis. Mild hepatic encephalopathy (minimal hepatic encephalopathy, MHE) or occult hepatic encephalopathy (covert hepatic encephalopathy, CHE) can increase the mortality and risk of hospitalization, and the health related quality of life (Health) Elated Quality of Life, HRQo L) damage and the burden of caregivers increase. Detection of MHE or CHE can guide treatment, may improve clinical outcome and quality of life. However, in clinical practice, the detection of MHE or CHE for patients with cirrhosis is not a common obstacle to the early diagnosis and treatment of.HE is the lack of an effective, standardized test and The lack of an objective and sensitive method of HE classification limits our understanding of the epidemiology and pathogenesis of HE and the difficulty of assessing the efficacy of HE targeting therapy. Therefore, the recent AASLD/EASL guidelines recommend 2 or more auxiliary detection methods for the diagnosis of occult hepatic encephalopathy. These include the paper pen test, such as the liver. Psychometric hepatic encephalopathy score (PHES); neurophysiological tests, such as the critical scintillation frequency (critical flicker frequency, CFF); computer testing, such as Encephal App Stroop. simple intelligence scale, is the most commonly used party to assess cognitive mental status. It has good reliability and validity in the screening of cognitive impairment. In the past, it was not only used in the study of liver disease, but also in some foreign studies, and even used to assess the severity of hepatic encephalopathy and one of the monitoring methods of hepatic encephalopathy. However, the researchers in our country have not done a similar study. The diagnostic criteria recommended by the European and American Liver Association liver encephalopathy consensus guidelines are to use 2 or more methods to diagnose occult hepatic encephalopathy. On this basis, we preliminarily explore the simple Intelligence Scale (MMSE), critical scintillation frequency (CFF), hepatic encephalopathy psychological score (PHES) and Stroop test (Encephal App Stroop) and other occult hepatic encephalopathy (CH). E) the clinical value of common detection methods. Methods included in 110 patients with decompensated cirrhosis and 81 cases of non liver disease control, using PHES-4 score as the reference threshold of CHE, the threshold of the test time of CFF and Stroop test was analyzed. At least 2 positive of the PHES, CFF, Stroop test were used as the "gold standard" for diagnosing CHE. The value of these 3 methods was used to diagnose the clinical application of CHE. At the same time, the simple intelligent scale was divided into multiple items according to the function of the test. The initial screening and prediction value of each sub item for hepatic encephalopathy was analyzed. The statistical method was t test, single factor analysis of variance and ROC curve analysis. Results of 110 cases of liver cirrhosis, liver 40 cases of sclerotic hepatic encephalopathy (HE0), 52 cases of CHE and 18 cases of hepatic encephalopathy II. (1) the total time of CFF value and Stroop test in the control group was (43.70 + 1.92) Hz, (201.17 + 20.65) s, and HE0 group CFF value was (41.40 + 1.85) Hz, higher than that of CHE group (38.33 + 2.32) Hz, the difference was statistically significant (197., 197.). 91 + 26.68) s, shorter than group CHE (253.24 + 33.33) s, the difference was statistically significant (t=8.936, P0.01). (2) when PHES-4 score was used as the reference threshold for CHE, CFF diagnostic CHE threshold was 39Hz, sensitivity was 94.9%, specificity was 73.1%, AUC value was 0.879; the total time diagnostic threshold of Stroop test was 83.3%, specificity was 71.7%, The AUC value was NCT-A in the PHES5 subtest of group 0.803. (3) CHE, the completion time of NCT-B and DST was (80.27 + 36.05), (124.18 + 55.96) and (25.03 + 8.23) s, compared with the HE0 group (56.68 + 18.82), (80 + 25.03) and (34.68 + 8.75) s. Compared with the detection results of HE0, CHE and HE2, the consistent rate of CFF value 39Hz as detection threshold was 95%, 61.5% and 100.0%. (4) Chi ld-pugh score and MMSE total score, time orientation, spatial orientation, attention and computing power, memory, sentence writing, and five corners of 7 items were -0.352, -0.417, etc. 243, -0.275, -0.303, -0.278, and P were all 0.01). The total score of MMSE total score in HE0, CHE and OHE 3 groups was significantly different (P value 0.001), especially the MMSE total value of OHE patients was significantly lower than that of CHE patients and patients, respectively 18.50 + 4.17, 24.93 + 4.23, 27.88 + 2.70 and two groups. Time orientation and spatial orientation 2 items were found. There were no statistical differences (P0.05), but in group OHE, both time orientation and spatial orientation were significantly different from HE0 group or CHE group (P 0.001). Conclusion NCT-A, NCT-B and DST3 sub tests in PHES were more effective and more reliable for detection of CHE, which was more objective and specific. 3 items of.MMSE total score, time orientation and spatial orientation have a certain predictive value for OHE, and the diagnosis of CHE still needs to be combined with a variety of diagnostic methods to improve the screening rate.
【學(xué)位授予單位】：安徽醫(yī)科大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類號(hào)】：R575.2;R747.9
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