Distinguishing Between Clinical and Minimal Hepatic Encephalopathy on the Basis of Specific Cognitive Impairment

It is well-known that liver cirrhosis is frequently accompanied by a wide range of neuropsychiatric abnormalities, including general and specific cognitive impairment. The aim of this study was to investigate which cognitive functions are selectively compromised in Hepatic Encephalopathy (HE) and to clarify the relationship between clinically overt or nonovert HE and the different forms and degrees of decay in cognitive deficits. Twenty-two patients without overt HE and 12 patients who showed overt HE at the first level of severity, along with matched control subjects, were compared in several cognitive domains. The results showed significant differences in some measures of attention between patients with minimal HE (mHE) and patients with overt HE. There were also notable differences in verbal short-term memory between patients with mHE and healthy subjects. Thus, we can hypothesize that there is a linear diminution in short-term memory and attentional performance starting from healthy patients, moving toward patients with mHE, and finally progressing toward patients with the first grade of overt HE. There are two types of diminution that we noted: between patients with mHE and the overt form, the decline in the attentional domain was more evident, while between healthy subjects and mHE patients, short-term memory showed a more evident decline.     

Diagnosis and Prognostic Significance of Minimal Hepatic Encephalopathy in Patients with Cirrhosis of Liver

Background and Aims  

Minimal hepatic encephalopathy is the mildest form of the spectrum of hepatic encephalopathy (HE) that impairs health-related quality of life. We assessed (1) the usefulness of psychometric hepatic encephalopathy score and critical flicker frequency for the diagnosis of minimal hepatic encephalopathy, and (2) prognostic significance of minimal hepatic encephalopathy.     

The Role of Inhibitory Amino Acidergic Neurotransmission in Hepatic Encephalopathy: A Critical Overview

-Aminobutyric acid (GABA) is the main inhibitory amino acid in the central nervous system (CNS). Experiments with animal models of HE, and with brain slices or cultured CNS cells treated with ammonia, have documented changes in GABA distribution and transport, and modulation of the responses of both the GABA(A)–benzodiazepine receptor complex and GABA(B) receptors. Although many of the data point to an enhancement of GABAergic transmission probably contributing to HE, the evidence is not unequivocal. The major weaknesses of the GABA theory are (1) in a vast majority of HE models, there were no alterations of GABA content in the brain tissue and/or extracellular space, indicating that exposure of neurons to GABA may not have been altered, (2) changes in the affinity and capacity of GABA receptor binding were either absent or qualitatively different in HE models of comparable severity and duration, and (3) no sound changes in the GABAergic system parameters were noted in clinical cases of HE. Taurine (Tau) is an amino acid that is thought to mimic GABA function because of its agonistic properties towards GABA(A) receptors, and to contribute to neuroprotection and osmoregulation. These effects require Tau redistribution between the different cell compartments and the extracellular space. Acute treatment with ammonia evokes massive release of radiolabeled or endogenous Tau from CNS tissues in vivo and in vitro, and the underlying mechanism of Tau release differs from the release evoked by depolarizing conditions or hypoosmotic treatment. Subacute or chronic HE, and also long-term treatment of cultured CNS cells in vitro with ammonia, increase spontaneous Tau leakage from the tissue. This is accompanied by a decreased potassium- or hypoosmolarity-induced release of Tau and often by cell swelling, indicating impaired osmoregulation. In in vivo models of HE, Tau leakage is manifested by its increased accumulation in the extrasynaptic space, which may promote inhibitory neurotransmission and/or cell membrane protection. In chronic HE in humans, decreased Tau content in CNS is thought to be one of the causes of cerebral edema. However, understanding of the impact of the changes in Tau content and transport on the pathogenic mechanisms of HE is hampered by the lack of clear-cut evidence regarding the various roles of Tau in the normal CNS.     

心理智能测验检测肝动脉化疗栓塞对肝癌合并肝硬化患者亚临床肝性脑？…

用心理智能测验研究原发性肝癌合并肝硬化患者并发亚临床肝性脑病（ＳＨＥ）的情况,了解肝动脉化疗栓塞（ＴＡＣＥ）治疗对ＳＨＥ的影响,并探讨心理智能测验能否作为判断ＴＡＣＥ治疗后ＳＨＥ变化的指标。方法：用数字连接试验（ＮＣＴ）、数字符号试验（ＳＹｙ）与数字广度试验（ＤＳｐ）３种心理智能测验对８１例原发性肝癌合并肝硬化并接受ＴＡＣＥ治疗的患者及５０例对照进行检测,其中４８例患者在ＴＡＣＥ治疗后２周进行复查     

A double‐blind,randomized, placebo‐controlled trial of intravenous l‐ornithine–l‐aspartate on postural control in patients with cirrhosis

Introduction: Hepatic encephalopathy (HE) is a complication of liver disease. Several treatments have been introduced but only l ‐ornithine–l ‐aspartate (LOLA) shows proven efficacy. This double‐blind, randomized, placebo‐controlled trial evaluated the effect of LOLA on postural control in cirrhotics. Methods: Forty patients were randomized to either LOLA or a placebo. HE was evaluated by psychometric testing (PSE Syndrome Test) and critical flicker frequency (CFF). Posturography [equilibrium score (ES)] provided information regarding postural control. Peripheral blood was analysed for ammonia concentration (NH₃) and the partial pressure of ammonia (pNH₃). Results: Both groups were comparable regarding baseline variables. Posturography and PSE Syndrome Test improved in both groups; improvement was greater in the LOLA group (ES: 5.3%; PSE: 1.9) compared with the placebo (ES: 3.9%; PSE: 1.3) but did not reach significance (ES: P=0.3; PSE: P=0.5). CFF remained unchanged during treatment and between groups (P=NS). NH₃ decreased in the LOLA group (Δ: ?15 μmol/L) and slightly increased in the placebo group (Δ: 11.1 μmol/L), but the differences did not reach statistical significance (P=0.07). pNH₃ remained largely unchanged (LOLA Δ: ?1.2 × 10^?5 mmHg vs. placebo Δ: ?0.3 × 10^?5 mmHg; P=0.21). Conclusion: In the LOLA group, an improvement of posturographic control and PSE Syndrome Test was observed, but a similar improvement was also achieved by the placebo. In LOLA, ammonia levels tended to decrease while they tended to increase in the placebo group. LOLA might augment the improvement achieved by intravenous fluids alone but a larger cohort will be needed to show this effect with statistical significance.     

Role of Oral Health,Frailty, and Minimal Hepatic Encephalopathy in the Risk of Hospitalization: A Prospective Multi-Center Cohort of Outpatients With Cirrhosis

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常规检验及生化检验在糖尿病患者诊断中的特异性价值对比分析

目的 对比并分析常规检验、生化检验两种方法对糖尿病患者的重要诊断价值.方法 抽选2018年10月—2020年10月期间收治的100例2型糖尿病患者,以随机抽样法将其随机分入对照组与研究组,各50例.给予对照组患者以尿常规检验,给予研究组患者以血液生化检验.组间对比诊断准确率、漏诊率、特异度、灵敏度.结果 研究组诊断准确...     

Comparative Evaluation of Visual, Somatosensory, and Auditory Evoked Potentials in the Detection of Subclinical Hepatic Encephalopathy in Patients with Nanalcoholic Cirrhosis.

To objectively determine the incidence of subclinical hepatic encephalopathy (SHE) and the relative sensitivity of different evoked potentials for its detection, 22 nonalcoholic cirrhotics without clinically detectable neurological abnormality and an equal number of matched healthy controls were studied. Of the three evoked potentials, visual evoked potential (VEP) studied by the pattern shift reversal method was not found to be abnormal in any patient. Short latency somatosensory evoked potential (SSEP) was abnormal in one (4.5%) and brain stem auditory evoked potential (BAEP) in nine (41%) patients. There was little advantage of performing both BAEP and SSEP in a patient, since the two together were abnormal in 10 (45.5%) patients, with SSEP adding only one more patient. Interpeak latencies I-III, III-V, and I-V in BAEP test were found to be the most sensitive parameters for the detection of SHE. Our results argue in favor of BAEP as the single investigation of choice for the objective assessment of SHE in patients with cirrhosis of the liver.     

尿液检验与生化检验在糖尿病诊断中的效果分析

目的 探究尿液检验与生化检验在糖尿病诊断中的效果情况.方法 选择2017年10月—2019年10月该院所收治的疑似2型糖尿病患者90例为研究对象.对受试者开展尿液检验与生化检验,并以糖化血红蛋白检验结果为金标准,分析以上方法诊断2型糖尿病的效能情况.结果 和生化检验相比,尿常规检验糖尿病阳性率明显较低;和尿常规检验...     

Association of Asthma Education with Asthma Control Evaluated by Asthma Control Test,FEV1, and Fractional Exhaled Nitric Oxide

Background. Asthma education is an important adjunct for asthma control although the way asthma education affects asthma outcomes is poorly understood. The asthma control test (ACT), forced expiratory volume in 1 s (FEV₁), and fractional exhaled nitric oxide (FeNO) have all been used as markers of asthma control. However, the use of FeNO as a surrogate marker remains controversial. Objectives. (i) To examine whether asthma education is associated with asthma control; (ii) to compare absolute levels and changes of ACT, FEV₁, and FeNO over a year; and (iii) to evaluate whether FeNO can be used as an additional marker of asthma control. Methods. Fifty asthmatics with poor adherence (12 mild, 21 moderate, and 17 severe) received asthma education at study entry. Medications were unchanged for the first 3 months, and ACT, FEV₁, and FeNO measurements were recorded at entry, 3, 6, and 12 months. Asthma control was assessed at each visit and patients were categorized as either “stable” or “unstable” asthmatics according to the global initiative for asthma (GINA) guidelines. Results. A significant decrease in FeNO and increase in ACT score were noted in the stable asthmatic group at 3 months (p < .001), and this persisted over 12 months. Significant correlations were seen between changes (Δ) in FeNO, ACT, and FEV₁ over time. However, significant correlations between the absolute levels were not maintained over 12 months. A decrease of ≥18.6% in FeNO and a ≥3-point increase in ACT score (sensitivity: 80% and 73.3% and specificity: 83.3% and 87.5%, respectively) were associated with stable asthma control although the absolute levels were not. Conclusions. Asthma education may be useful to achieve stable control. In addition, changes rather than absolute levels of FeNO and ACT may be better markers of asthma control.     

Clinical Significance of Basal Ganglia Alterations at Brain MRI and 1H MRS in Cirrhosis and Role in the Pathogenesis of Hepatic Encephalopathy

In hepatic encephalopathy, a progressive and diffuse impairment in brain function is associated with gradual alterations that can be detected by magnetic resonance imaging (MRI) and proton magnetic resonance spectroscopy (¹H MRS). In some patients, a variety of movement disorders suggestive of extrapyramidal impairment points toward basal ganglia (BG) alterations. Accordingly, (i) hyperintensities at MRI predominant in the pallidum, an important region of BG involved in the motor control, (ii) redistribution of cerebral blood flow from cortical areas to BG structures observed using positron emission tomography studies, and (iii) the preferential pallidal location of Alzheimer astrocytosis, all support this hypothesis. In most clinical studies, little if any correlations have been found between cerebral hyperintensities and neurological manifestations. The application of a test designed to evaluate patients with Parkinson's disease (where extrapyramidal signs are typical) showed significant clinical correlations both with pallidal hyperintensity and with choline/creatine ratio at ¹H MRS in BG structures. Because of complex neuronal connections between BG and many cortical areas, BG dysfunction may influence the neurocognitive manifestations of hepatic encephalopathy. Similarities between chronic Mn intoxication and cirrhosis suggest common pathophysiological mechanisms including altered dopaminergic neurotransmission, although information in chronic liver failure is limited. Clinical observations are presented regarding the evolution of parkinsonian signs in various situations.     

Asthma Control Test and Asthma Control Questionnaire: factorial validity,reliability and correspondence in assessing status and change in asthma control

Objective: This study examined the factor structures and reliabilities of the Asthma Control Test (ACT) and the Asthma Control Questionnaire (ACQ-7; ACQ-6) and the correspondence between them in assessing both level and change in asthma control. Methods: Lung function and questionnaire data for ACT and ACQ were assessed in 113 asthma patients at the beginning (T1) and the end (T2) of inpatient rehabilitation. Confirmatory factor analyses, composite reliability coefficients, Pearson correlations, Cohen’s Kappa and positive/negative agreements were computed. Results: Unidimensional factor structure was confirmed for ACT. For ACQ configural invariance (i.e. same factor structure) over time could not be established. Furthermore, in ACQ-7, FEV1 showed no relation to the latent factor. Reliability estimates were 0.86–0.88 (ACT), 0.88–0.92(ACQ-6) and 0.81–0.86 (ACQ-7). Pearson correlations between ACT and ACQ were between 0.75 and 0.90 and tended to be higher at T2. If the aim is to identify patients with either not well-controlled asthma or change in asthma control, concordance was at least moderate (Kappa?=?0.52–0.72). Correspondence tended to be lower in identifying patients with well-controlled asthma (Kappa?=?0.30–0.79). In some circumstances, ACQ-6 showed higher agreement with ACT than did ACQ-7. Conclusions: ACT is a unidimensional measure, but factor structure of ACQ remains unclear. Correspondence between ACT and ACQ depends on the aim of the assessment. Including FEV1 in the assessment of asthma control level even lowers reliability of ACQ and concordance with ACT. Our results support GINA (2014) in conceptualizing FEV1 as a risk factor for poor asthma outcome instead of an indicator of level of asthma control.     

Comparison of Three Bile Acid Provocation Tests: Intravenous Cholecystokinin,a Standard Test Meal,and an Oral Bile Acid Load in Healthy Subjects

Three different bile acid provocation tests—an intravenous stimulation with cholecystokinin (CCK), a test meal, and an oral bile acid load of 500 mg chenodeoxycholic acid (CDAF—were compared in 12 healthy subjects. Blood samples were drawn every 30min for 3 h, and serum bile acids (SBA) were measured by an enzymatic method (Enzabile®). The CCK stimulation gave significant SB A elevations only at 30 min. After the test meal and the CDA loading tests SB A elevations were observed from 30 min and throughout the observation period. Maximal increases were obtained at 120 min after the test meal but already at 30 min after the CDA loading test. We conclude that among these three bile acid provocation tests the oral CDA loading test is to be preferred because it gives marked and rapid elevation of SBA in all subjects and is independent of bile acid pool size and normal function of the gallbladder.