数字连接试验检测肝病患者亚临床肝性脑病的研究

目的 以数字连接试验(NCT)检测慢性肝病尤其是病毒性肝炎患者的亚临床肝性脑病(SHE)发病率，以了解肝功能与SHE的关系。方法 对177例慢性肝病进行NCT检测。结果 慢性肝病患者的NCT异常率31．1％(55／177)，病毒性肝炎患者的NCT异常率29．7％(47／158)；肝功损害轻度及重症肝炎时，肝硬化组与非肝硬化组的NCT异常率无差别，肝功损害中度和重度时，肝硬化组的异常率高于非肝硬化组，且有显著性差异；肝功分级间的SHE发病率无差异；男女间的NCT异常率无差别。结论肝病病人出现智力障碍与肝功损害及肝硬化的门体分流都有关，而与病因无关；肝功损害程度与SHE的发生率末显示线性关系。     

Prevalence of subclinical hepatic encephalopathy in patients with cirrhosis determined by psychometric tests

OBJECTIVE: To investigate the prevalence of subclinical hepatic encephalopathy (SHE) in patients with stable hepatic cirrhosis. METHODS: One hundred and seventy‐five consecutive cirrhotic patients (mean age 53 years, range 27?72 years) without overt clinical encephalopathy were screened for SHE using the number connection test (NCT) part A and symbol digit test (SDT). Subclinical hepatic encephalopathy was defined as the presence of at least one abnormal psychometric test. The age‐corrected normal value was defined as the mean ± 2SD obtained from 356 subjects without liver disease and in normal mental condition. Illiterate patients and patients with concurrent use of alcohol or psychotropic drugs, and those with previous portosystemic shunt and were excluded. RESULTS: In different age subgroups, the NCT scores and SDT quotients for cirrhotic patients were significantly different compared with those for controls (P < 0.05?0.001). Fifty patients (28.6%) were found to be abnormal in both the NCT and SDT, 16 (9.1%) patients were abnormal only in the SDT and 34 patients (19.4%) only in the NCT. Taken together, SHE was diagnosed in 100 patients (57.1%) by using the two tests. The prevalence of SHE increased from 46.8% and 53.0% in Child?Pugh grades A and B, to 76.6% in Child?Pugh grade C (P < 0.05). No significant correlation was found between the development of SHE and the etiology of cirrhosis, patient age and smoking habit. CONCLUSION: By using a combination of NCT and SDT, SHE was diagnosed in 57.1% of cirrhotic patients without overt clinical encephalopathy. The prevalence of SHE was significantly correlated with the severity of liver cirrhosis.     

数字连接试验对诊断亚临床肝性脑病的价值

目的：研究数字连接试验（NCT）的影响因素及其对亚临床肝性脑病（SHE）的诊断价值。方法：对450例正常人进行NCT检测,探讨影响因素并定出正常参考值范围,与智力检测（IQ）、脑诱发电位（EP）检查同时应用于40例肝硬化患者,研究其应用价值。结果：（1）NCT值受年龄及文化程度影响（P＜0.001）;（2）肝硬化患者NCT异常率为30％（12／40）,低于IQ异常率的58％（23／40）（P＜0.01）;(3)IQ检查中的木块图、图片排列、图形拼凑及NCT4种方法检查本组肝硬化患者阳性率为53％,与全套IQ的阳性率（58％）相比,其敏感性为87％,特异性为94％。（4）本组病人SHE的检出率为85％（34／40）。结论：NCT结果受年龄及文化程度影响,单独应用敏感性低。我们推荐采用IQ检查中的木块图、图片排列、图形拼凑及NCT4种方法代替全套IQ检查,用于SHE的临床诊断。     

诱发电位对肝硬化患者轻微肝性脑病的诊断价值

目的 探讨诱发电位(EP)在没有症状性肝性脑病(OHE)的肝硬化患者中检测轻微肝性脑病(MHE)的价值.方法 对114例无OHE的肝硬化患者进行盲法、自身同步对照的数字连接试验A(NCT-A)、数字符号试验(DST)并检测视觉诱发电位(VEP)、脑干听觉诱发电位(BAEP)、体表感觉诱发电位(SSEP)、P300听觉事件相关诱发电位(P300ERP).NCT-A和DST检测中1项异常即诊断为MHE,比较各EP检测的异常率,评估其诊断MHE的价值.结果 114例肝硬化患者中诊断MHE 60例(52.6%),其阳性率与Child-Pugh分级呈等级正相关(r=0.278,P=0.003).VEP、BAEP、SSEP、P300ERP异常率分别为17.5%、29.8%、38.6%、57.0%.仅P300ERP的异常率与NCT-A+DST的阳性率差异无统计学意义(X2=0.432,P=0.511).VEP、BAEP、SSEP、P300ERP的诊断敏感度分别为13.3%、41.7%、46.7%、73.3%,特异度分别为77.8%、83.3%、70.4%、61.1%.P300ERP的受试者工作特征曲线(ROC)下面积最大(0.672,95%CI 0.572～0.773).VEP、BAEP、SSEP、P300ERP与NCT-A+DST的符合率分别为43.9%、61.4%、57.9%、67.5%.各EP检测的Kappa值均<0.39.结论 以P300ERP诊断无OHE的肝硬化患者MHE敏感度和特异度均较高.P300ERP不可替代NCT-A-4+DST,但可作为补充检测手段.     

事件相关电位P300和简易智能精神状态检查在轻微型肝性脑病检测中的价值

目的:评价事件相关电位P_(300)和智能精神状态检查(MMSE)诊断轻微型肝性脑病(MHE)的价值.方法:30例肝炎后肝硬化患者进行事件相关电位P_(300)和脑诱发电位检查及MMSE检测,并观察1 a后临床肝性脑病(HE)的出现情况.结果:事件相关电位P_(300)异常21例(70.0%),体感诱发电位(SEP)异常11例(36.7%),MMSE得分<27(提示有认知功能障碍)13例(43.3%),事件相关电位P_(300)和/或MMSE异常22例(73.3%),两者均异常10例(33.3%),追踪观察1 a的23位患者中,17例事件相关电位P_(300)和/或MMSE异常患者出现临床肝性脑病12例,两者均无异常的6例患者中,出现临床肝性脑病1例,两者比较有显著性差异(70.6% vs 16.7%,P<0.05).结论:事件相关电位P_(300)和MMSE可作为判断肝硬化失代偿期是否发生轻微型肝性脑病的一种敏感又可靠的方法.     

Malnutrition and diabetes mellitus are related to hepatic encephalopathy in patients with liver cirrhosis.

BACKGROUND/AIMS: Studies on animal models of hepatic encephalopathy (HE) suggest that poor nutritional status may facilitate the development of HE. Insulin resistance and diabetes mellitus have recently been reported to affect cognition in patients with hepatitis C cirrhosis awaiting liver transplantation. Our aim was to investigate the effects of malnutrition and diabetes mellitus on HE in unselected patients with liver cirrhosis. METHODS: A total of 128 consecutive cirrhotic patients were prospectively evaluated for the presence of HE according to the West-Haven criteria as well as by means of two psychometric tests and fasting plasma ammonium ion concentrations. Nutritional status was assessed by anthropometry and estimation of recent weight change. Fasting plasma glucose was measured, and in a subgroup of 84 patients fasting serum insulin and insulin resistance were also determined. RESULTS: Fifty-one (40%) cirrhotics were malnourished, 33 (26%) had diabetes and 42 (34%) had HE. Patients with vs. without malnutrition had more frequently HE (46 vs. 27%; P=0.031) but did not differ in age, aetiology or severity of liver cirrhosis (P>0.1). Multivariate analysis showed that the time needed to perform number connection test A was independently correlated to age, the Child-Pugh score, diabetes and malnutrition (P<0.05 for all). Plasma ammonium ion levels were related to insulin resistance (r=0.42, P<0.001) and muscle mass (r=0.28, P=0.003). CONCLUSION: Malnutrition and diabetes mellitus seem to be related to HE in patients with liver cirrhosis. Nutritional status and insulin resistance might be implicated in the pathogenesis of HE.     

Somatosensory evoked potentials and number connection test in the detection of subclinical hepatic encephalopathy

To compare the diagnostic ability of somatosensory evoked potentials and the number connection test in the detection of subclinical hepatic encephalopathy, 44 decompensated cirrhotic patients with no overt encephalopathy were admitted to the study and followed up for 6 months. Twenty-two patients developed overt encephalopathy during follow-up, and were retrospectively considered as patients with subclinical encephalopathy at entry. Of the 15 patients with abnormal somatosensory evoked potentials, 14 (93%) experienced at least one episode of hepatic encephalopathy in the following 6 months, while 16 (70%) of the 23 patients with abnormal number connection test did so. The data suggested that somatosensory evoked potential measurement was less sensitive, but more specific than number connection test in the detection of subclinical encephalopathy, although the differences were not statistically significant. Besides, the number connection test is much simpler, convenient and cheap, and it specificity could be improved if the learning effect and age, education and visual factors were carefully considered. We therefore recommend using the number connection test routinely in patients with decompensated liver diseases for the detection of subclinical hepatic encephalopathy, and reserving somatosensory evoked potential measurement as a complementary examination, when appropriate, or for assessment of overt hepatic encephalopathy.     

Renal function and cognitive impairment in patients with liver cirrhosis

Objective. Cognitive impairment is a common problem in patients with liver cirrhosis. Its pathogenesis is multifactorial and ammonia is considered to play a central role. Renal function has been shown to be important for ammonia metabolism in cirrhosis. Although renal dysfunction is common in cirrhotic patients, its effect on cognitive function is largely unexplored. Material and methods. A total of 128 consecutive cirrhotic patients were prospectively evaluated for the presence of cognitive dysfunction according to the West-Haven criteria and by means of two psychometric tests. Serum creatinine, sodium and potassium as well as plasma ammonia concentrations were assessed. Glomerular filtration rate was also measured by ⁵¹Cr- EDTA clearance in a subgroup of patients. Results. Forty-one patients (32%) were found to have cognitive dysfunction (clinical evaluation and/or psychometric tests). Sixteen patients (13%) found with serum creatinine levels above reference values had cognitive dysfunction more frequently than patients with creatinine within the normal range (69% versus 31%; p=0.001), but did not differ in aetiology or severity of cirrhosis (p>0.1). Patients with loop diuretics versus without did not differ in creatinine values (p>0.1). Multivariate analysis showed that cognitive dysfunction was related to hospital admission at inclusion in the study, international normalized ratio and serum creatinine (p<0.05 for all), but not to potassium or sodium levels. Plasma ammonia concentration was related to serum creatinine (r=0.26, p=0.004) and the glomerular filtration rate (r=?0.44, p=0.023). Conclusions. Renal dysfunction seems to be related to cognitive impairment in patients with liver cirrhosis and might be implicated in the pathogenesis of hepatic encephalopathy.     

Role of zinc in subclinical hepatic encephalopathy: comparison with somatosensory-evoked potentials

BACKGROUND AND AIM: The purpose of the present paper was to determine the role of zinc in subclinical portosystemic encephalopathy (SPSE). METHODS: The serum zinc levels were studied for 10 cirrhotic patients who did not suffer SPSE and for 10 patients who did, and the results compared with those deriving from 10 healthy volunteers. The nutritional evaluation included serum prealbumin, albumin, and transferrin levels, body mass index (BMI), mid-arm muscle circumference (MAMC), and tricep skin-fold (TSF). The occurrence of SPSE was defined as a situation when the N20-N65 interpeak latencies of median nerve-stimulated somatosensory-evoked potentials (SEP) exceeded 2.5 SD of the control mean value. RESULTS: Cirrhotic patients suffering SPSE (57.5 +/- 10.5 microg/dL) had lower serum zinc levels than those not experiencing SPSE (69.5 +/- 16.6 microg/dL, P = 0.03) and controls (77.7 +/- 6.8 microg/dL, P < 0.001). Four of the non-SPSE and nine SPSE patients had zinc levels less than the lower normal limit. Cirrhotic patients suffering SPSE had lower levels of albumin (2.8 +/- 0.4 g/dL vs 3.8 +/- 0.4 g/dL, P < 0.001), prealbumin (9.0 +/- 4.3 mg/dL vs 14.3 +/- 6.0 mg/dL, P = 0.02), and transferrin (158 +/- 56 g/L vs 218 +/- 50 g/L, P = 0.01), but a greater total bilirubin level (1.2 +/- 1.5 mg/dL vs 0.9 +/- 0.4 mg/dL, P = 0.005) than those not suffering SPSE. The serum zinc levels correlated with N20-N65 interpeak latencies (P = 0.03), serum albumin (P = 0.006), prealbumin (P < 0.001), and total bilirubin (P = 0.02) levels. CONCLUSIONS: The data show that zinc deficiency is common in cases of non-alcoholic cirrhosis with SPSE. The early assessment of malnutrition and zinc deficiency are important.     

智力测验调查亚临床肝性脑病的发病

目的前瞻性调查肝硬化患者的亚临床肝性脑病(SHE)的发病情况.方法356例正常对照和175例无临床肝性脑病的肝硬化连续病例行数字连接试验(NCT)和数字符号试验(SDT),以对照组相应年龄段的x±2s为标准确定有无SHE.结果肝硬化中单独NCT或SDT异常分别是34例(19.4%)和16例(9.1%),二者均异常有50例(28.6%),合计有100例(57.1%)诊断为SHE.按ChildPugh分级,SHE分别是A级46.8%、B级53.0%和C级76.6%.肝硬化病因和年龄对SHE检出率无显著影响.结论无脑病症状的肝硬化中约57.1%有SHE,发病与肝功能受损程度有关.     

糖代谢与肝性脑病关系的临床观察

目的观察肝硬化患者血糖的改变,探讨糖代谢与肝性脑病（HE）的关系。方法 2008年8月至2010年8月间在嘉定区中心医院消化内科住院的肝硬化患者60人作为肝硬化组,非肝硬化住院患者30人作为对照组。收集一般资料,观察神志,体检有无扑翼样震颤,抽血检测患者血糖,根据患者检查结果,把肝硬化患者分为无扑翼样震颤组和有扑翼样震颤组,对肝硬化组与对照组糖代谢异常发生率进行比较,根据患者血糖情况分为血糖正常组及糖代谢异常组,对两组间扑翼样震颤及HE发生率进行比较。计量资料应用t检验,率的比较应用卡方检验。结果对照组30例,肝硬化组60例中无扑翼样震颤组28例,有扑翼样震颤组32例,对照组糖代谢异常发生率13.33%,肝硬化组糖代谢异常发生率26.67%,肝硬化组患者糖代谢异常发生率高于对照组（χ2=2.058,P〈0.05）。糖代谢正常组扑翼样震颤发生率50.00%,HE发生率34.09%,糖代谢异常组扑翼样震颤发生率62.50%,HE发生率37.50%,两组间差异均无统计学意义（P〉0.05）。结论肝硬化患者存在糖代谢的紊乱,但糖代谢异常不一定易于发生HE,提示存在大脑对糖的利用障碍。     

Abstinence in patients with alcoholic liver cirrhosis: A follow-up study

Aim:  To investigate the proportion of patients with alcoholic cirrhosis who abstained from alcohol after contact with a hepatology unit, the predictors for abstinence, and the role of clinical and psychosocial factors in short-term mortality in these patients.
Methods:  Eighty-seven consecutive patients with alcoholic cirrhosis from a transplant center were included. Data on cirrhosis severity and complications, as well as on abstinence and psychosocial factors were collected. Patients were followed up for 19 (12–25) months. Data on abstinence during follow up, alcohol abuse treatment, psychiatric contact, severity of cirrhosis, mortality, and liver transplantation were analyzed.
Results:  Prior to inclusion, 53/87 (61%) patients had abstained from alcohol for 24 months (interquartile range: 18–33). Twenty percent had a history of other substance abuse, 47% had undergone alcohol abuse treatment, and 21% had a previous psychiatric diagnosis. Forty-eight percent lived with a partner, 23% worked/studied, and 53% were pensioners. During follow up, 26% died, 20% received a liver transplant, 55% abstained from alcohol, 47% received alcohol abuse treatment, and 33% had psychiatric contact. In a multivariate analysis, abstinence during follow up was found to be related to abstinence upon inclusion in the study, to the model for end-stage liver disease (MELD) score at follow up, and to no abuse treatment in a detoxification unit, whereas mortality was related to index MELD and alcohol abuse treatment during follow up. Neither abstinence nor mortality was related to psychosocial factors.
Conclusion:  More than half of patients with alcoholic cirrhosis were found to abstain from alcohol during follow up, which was related to prior documentation of abstinence and cirrhosis severity. Cirrhosis severity (expressed as the MELD) and alcohol abuse treatment during follow up were related to short-term mortality.     

P300作为血管性痴呆早期诊断方法的临床研究

目的　探讨P30 0可否作为血管性痴呆的早期诊断方法。方法　通过对 12 3例血管性痴呆的检测 ,依据 3组年龄段分别与非痴呆组对照 ,并与健康人比较。结果　痴呆组与非痴呆组比较差异有显著性意义 (P <0 .0 5 ) ,而非痴呆组与健康对照组比较差异有显著性意义 (P <0 .0 5 ) ,结果同时显示 ,6 0岁以上痴呆组的P30 0潜伏期延长为对照组潜伏期加年龄附加值加 1.5S以上。部分患者经过早期治疗 ,P30 0潜伏期明显缩短。结论　提示P30 0改变可先于长谷川智力量表 ,作为血管性痴呆的早期诊断方法之一 ,有利于该病的早期发现、诊断和治疗。银杏总黄酮甙 (金纳多 )有利于痴呆的早期治疗。     

年龄和受教育程度矫正的数字连接测试和数字符号测试在诊断轻肝性脑病中的应用

目的 数字连接测试(NCT)和数字符号测试(DST)是诊断轻微肝性脑病(MHE)的常用方法,但研究发现NCT和DST测试结果受年龄和受教育程度影响,我们将进行年龄和受教育程度同时矫正建立对照值,以增加诊断MHE的准确性. 方法 应用NCT-A和DST对843名健康志愿者(年龄16 ～ 65岁,教育程度＞1年)进行测试建立对照值(分年龄和受教育程度矫正和不矫正),对429例肝硬化患者(Child-Pugh分级评价肝功能)进行测试,以结果超过对照值两个标准差(x-±2s)为异常,两种检测任一项异常即判断为阳性.用统计学方法分析年龄和受教育程度矫正和不矫正所得的对照值诊断MHE的差异.率的比较采用x2检验,测试结果与年龄、受教育程度、肝功能相关性采用logistic回归分析.结果 (1) NCT-A和DST均受年龄(标准系数为0.405,P=0.000;标准系数为-0.527,P=0.000)和受教育程度(标准系数为-0.347,P=0.000;标准系数为0.405,P=0.000)影响.(2)进行年龄和受教育程度矫正建立对照值,120例肝硬化患者被诊断为MHE(占27.97％),其中NCT阳性113例(占26.34％),DST阳性54例(占12.59％),两者均阳性47例(占10.96％).Child-Pugh A级阳性21例(19.81％),Child-Pugh B级46例(23.71％),Child-Pugh C级53例(41.09％);(3) logistic分析显示,按照年龄和受教育程度矫正建立的对照值诊断的MHE只与肝功能受损严重程度有关(P=0.000),不受年龄(P=0.328)和受教育程度(P=0.563)影响;不进行矫正建立对照值,年龄(P=0.000)和受教育程度(P=0.005)均会影响MHE的诊断.结论 年龄和受教育程度会影响NCT和DST在诊断MHE时的准确性,应用年龄和受教育程度同时矫正建立对照值来诊断MHE更为准确.     

简化版动物命名试验对肝硬化并发轻微性肝性脑病的诊断价值及相关因素分析

目的 探讨应用简化版动物命名试验(S-ANT)诊断肝硬化并发轻微性肝性脑病(MHE)的价值。方法 2020年7月～2021年6月于蚌埠医学院第一附属医院感染病科和阜阳市第二人民医院肝病科住院治疗的142例肝硬化患者,采用数字连接试验A(NCT-A)、数字符号试验(DST)、动物命名试验(ANT)筛查肝硬化并发MHE患者。常规检测血常规、血生化常规和血氨,应用多因素Logistic回归分析肝硬化并发MHE的相关因素。绘制受试者工作特征(ROC)曲线,计算曲线下面积(AUC),评价S-ANT诊断MHE的效能。结果 在142例肝硬化患者中,发生MHE者39例(27.5%);MHE组患者年龄、受教育年限和酒精性肝病占比与无MHE组比,差异显著(P<0.05);MHE组血氨水平为61.0(36.0～94.0)μmol/L,显著高于无MHE组【(47.1(33.0～69.0)μmol/L,P<0.05】;MHE组NCT-A用时为(93.5±38.9)s,显著长于无MHE组【(61.5±23.7)s,P<0.05】,DST、ANT和S-ANT评分分别为(22.7±5.7)分、(12...     

左旋门冬氨酸鸟苷酸联用复方甘草酸苷治疗肝硬化肝性脑病的探讨

探讨左旋门冬氨酸鸟苷酸（雅博司）联合复方甘草酸苷（美能）治疗肝硬化肝性脑病的疗效。80例肝硬化肝性脑病患者随机分为雅博司＋美能治疗组（A组）和谷氨酸钠＋美能治疗组（B组）疗程皆为7天。治疗后A组中24小时清醒34例,72小时清醒36例,B组24小时清醒20例,P〈0.01,72小时清醒30例,P〉0.05;A组血氨治疗前后分别为（76.25±26.5）umol/L vs（36.28±11.51）umol/L,B组为（71.58±16.99）umol/L vs（49.8±16.46）umol/L;P〈0.05,A组血ALT治疗前后分别为（92.23±41.23）U/L vs（32.8±11.74）U/L;血清胆红素则分别为（40.05±15.12）umol/L vs（20.95±11.27）umol/L,P〈0.001;B组血ALT治疗前后分别为（87.93±40.72）U/L vs（34.32±10.64）U/L;P〈0.001,血清胆红素则分别为（38.95±14.9）umol/L vs（22.33±10.9）umol/L,P〈0.001。雅博司联合复方甘草酸苷能迅速有效降低血氨及胆红素并进而加快肝性脑病清醒。     

Alzheimer病患者的脑地形图和多项诱发电位变化

目的探讨Ａｌｚｈｅｉｍｅｒ病（ＡＤ）在自发和诱发脑电方面的特征。方法对３９例ＡＤ患者及４０例健康对照者应用ＳＥＥＧ－１６道脑地形图和诱发电位系统完成了脑电图（ＥＥＧ）、脑地形图（ＢＥＡＭ）、视觉和听觉诱发电位（ＶＥＰ和ＡＥＰ）、脑干听觉反应（ＡＢＲ）和Ｐ３００６种检测。结果ＡＤ患者ＥＥＧ异常率８７．５％。ＡＤ患者ＢＥＡＭ特征：δ和θ功率在主要记录点均增高，α功率在额、后颞、枕区降低。ＡＤ患者ＶＥＰ、ＡＥＰ主成分、Ｐ３００非靶潜伏期Ｐ２，以及ＡＥＰ、ＶＥＰ和Ｐ３００的Ｐ２、Ｐ３波幅均减低。另外，ＡＤ患者的ＡＢＲ绝对潜伏期（波Ⅰ）和绝对波幅（波Ⅰ、Ⅲ、Ⅴ和Ⅵ）也延迟或降低，与脑ＣＴ结果一致。结论短和长潜时、认知电位及地形图相结合的方法有可能作为ＡＤ辅助的电生理诊断方法。     

肝硬化失代偿期与事件相关电位P300及脑干听觉诱发电位相关性探讨

探讨事件相关电位P300及脑干听觉诱发电位（BAEP）检测对肝硬化失代偿期患者并亚临床肝性脑病（SHE）的诊断定量指标的价值。对31例肝硬化失代偿期患者进行检测,事件相关电位异常22列（71%）,主要表现为P300的潜优期（IP）延长;BAEP12例异常（39%）,主要表现为I-V波的峰间期（IPL）延长,两项检测均异常有10例（32%）。事件相关电位P300潜伏期的延长和BAEP的一项异常,可作为一项判断肝硬化失代偿期是否发生亚临床肝性脑开门见山的定量指标。