Inhibitory Control Test for the Diagnosis of Minimal Hepatic Encephalopathy (original) (raw)
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Improving the Inhibitory Control Task to Detect Minimal Hepatic Encephalopathy
Gastroenterology, 2010
Quantification of the number of noninhibited responses (lures) in the inhibitory control task (ICT) has been proposed for the diagnosis of minimal hepatic encephalopathy (MHE). We assessed the efficacy of ICT compared with recommended diagnostic standards. METHODS: We studied patients with cirrhosis and healthy individuals (controls) who underwent the ICT at 2 centers (center A: n ϭ 51 patients and 41 controls, center B: n ϭ 24 patients and 14 controls). Subjects were evaluated for MHE by psychometric hepatic encephalopathy score (PHES). Patients from center B also were assessed for MHE by critical flicker frequency and spectral electroencephalogram analyses. RESULTS: Patients with cirrhosis had higher ICT lures (23.2 Ϯ 12.8 vs 12.9 Ϯ 5.8, respectively, P Ͻ .01) and lower ICT target accuracy (0.88 Ϯ 0.17 vs 0.96 Ϯ 0.03, respectively, P Ͻ .01) compared with controls. However, lures were comparable (25.2 Ϯ 12.5 vs 21.4 Ϯ 13.9, respectively, P ϭ .32) among patients with/without altered PHES (center A). There was a reverse, U-shaped relationship between ICT lure and target accuracy; a variable adjusting lures was devised based on target accuracy (weighted lures at center B). This variable differed between patients with and without MHE. The variable weighted lures was then validated from data collected at center A by receiver operator characteristic curve analysis; it discriminated between patients with and without PHES alterations (area under the curve ϭ 0.71 Ϯ 0.07). However, target accuracy alone was as effective as a stand-alone variable (area under the curve ϭ 0.81 Ϯ 0.06). CONCLUSIONS: The ICT is not useful for the diagnosis of MHE, unless adjusted by target accuracy. Testing inhibition (lures) does not seem to be superior to testing attention (target accuracy) for the detection of MHE.
A Simplified Psychometric Evaluation for the Diagnosis of Minimal Hepatic Encephalopathy
Clinical Gastroenterology and Hepatology, 2011
The psychometric hepatic encephalopathy score (PHES), which includes 5 psychometric tests, is a standard for the diagnosis of minimal hepatic encephalopathy (HE). We investigated whether a simplified PHES (SPHES) is as useful as the whole PHES. METHODS: The PHES was determined for 79 cirrhotic patients (the training group), who were followed up for the development of overt HE. Backward logistic regression was performed by eliminating stepwise variables-removal did not impair regression. A separate series of 65 patients was used as a validation group. RE-SULTS: The PHES was abnormal in 45 patients. The SPHES, determined from the digit symbol, serial dotting, and line tracing tests, did not differ significantly from the full PHES; 24 of the 79 patients developed overt HE. The likelihood of developing overt HE was higher among patients with an abnormal PHES (log-rank P ϭ .003) or SPHES (P ϭ .004). By using Cox regression and model for end-stage liver disease scores to analyze data from patients with previous HE and transjugular intrahepatic portosystemic shunts, PHES (relative risk, 4.16; P ϭ .003) and SPHES (relative risk, 3.70; P ϭ .004) were the only variables associated with the development of overt HE. The accuracy of the SPHES was confirmed in the validation group.
Assessment of minimal hepatic encephalopathy (with emphasis on computerized psychometric tests)
Clinics in liver disease, 2012
Minimal hepatic encephalopathy (MHE) is associated with a high risk of development of overt hepatic encephalopathy, impaired quality of life, and driving accidents. The detection of MHE requires specialized testing because it cannot, by definition, be diagnosed on standard clinical examination. Psychometric and neurophysiologic techniques are often used to test for MHE. Paper-pencil psychometric batteries and computerized tests have proved useful in diagnosing MHE and predicting its outcomes. Neurophysiologic tests also provide useful information. The diagnosis of MHE is an important issue for clinicians and patients alike. Testing strategies depend on the normative data available, patient comfort, and local expertise.
The study of psychometric test for detection and assessment in subclinical hepatic encephalopathy
International Journal of Medical Research and Review
Background: During past two decades, psychometric tests have been used extensively for detection of SHE. However, the results have been variables with different tests. In real practice we require the tests, which can be administered quickly by treating physician with simplicity and with simple instrument or only with a simple form. Objective: (1) To apply a battery of psychometric tests in cases of cirrhosis of liver. (2) To correlate findings of psychometric tests with Child`s index of severity for cirrhosis of liver. Methodology: 25 patients of cirrhosis of liver diagnosed by ultrasonography, biochemical and clinical evidence, admitted in the Medicine ward, will constitute the study group. These patients will undergo a battery of psychometric tests and EEG along with other routine hematological and radiological test. 25 control group with confounding factors as age, sex, education and socioeconomic status. Results: We observed that on WAPIS test cirrhotic performed significantly worse than controls. Mean IQ±SD non-Alcoholic cirrhotic on WAPIS was [67.78±11.29] and Mean IQ±SD of alcoholic cirrhotics was (66.45±9.71). On analysis of data the difference was not significant (p>0.005). Taken together the performance test was abnormal in 14 (56%) cases. Conclusion: We concluded that for quick assessment of mental status and screening for detecting SHE in cases of cirrhosis of liver with portal hypertension, TMT test is useful and for complete assessment of cerebral function derangement WAPIS is most sensitive and complete test.
Hepatology, 2013
Minimal hepatic encephalopathy(MHE) detection is difficult due to the unavailability of short screening tools. Therefore MHE patients can remain undiagnosed and untreated. Aim-To use a Stroop smartphone application(EncephalApp_Stroop) to screen for MHE. Methods-The App and standard psychometric tests(SPT; 2/4 abnormal is MHE, gold standard), psychometric hepatic encephalopathy score(PHES) and Inhibitory control(ICT) tests were administered to cirrhotics [with/without prior-overt HE(OHE)] and age-matched controls from two centers; a subset underwent re-testing. A separate validation cohort was also recruited. Stroop has "off"state with neutral stimuli and "on"state with incongruent stimuli. Outcomes: time to complete five correct runs, number of trials needed in On(Ontime) and Off(Offtime) states. Stroop results were compared between controls and cirrhotics with/without OHE, and those with/without MHE(using SPT,ICT,PHES). ROC analysis was performed to diagnose MHE in cirrhotics with/ without prior OHE. Results-125 cirrhotics (43 prior OHE) and 134 controls were included in the original cohort. App times were correlated with MELD (Offtime:r=0.57,Ontime:r=0.61,p<0.0001) and were worst in prior-OHE patients compared to the rest and controls. Stroop performance was also significantly impaired in those with MHE compared to no-MHE according to SPT,ICT and PHES (all p<0.0001). A cutoff of>274.9 seconds(OnTime+OffTime) had an AUC=0.89 in all patients and 0.84 in patients without prior OHE for MHE diagnosis using SPT as the gold standard. The validation cohort showed 78% sensitivity and 90% specificity with the >274.9 seconds OnTime +OffTime cutoff. App result patterns were similar between the centers. Test-retest reliability in controls and those without prior OHE was good; a learning effect on Ontime in cirrhotics without prior OHE was seen. In conclusion, the Stroop smartphone app is a short, valid and reliable tool for screening of MHE.
2021
Background: Psychometric hepatic encephalopathy score (PHES) needs standardization for countries and is used for minimal hepatic encephalopathy (mHE) diagnosis. Assessing it is cumbersome.Aims: To standardize PHES for Turkish patients and compare it with German norms; to determine mHE prevalence with two different methods and to assess whether the PHES test can be simplified.Methods: Healthy volunteers (n=816; 400 male) and cirrhotics (n=124; 58 male) were included. PHES score threshold was set at ≤-5 points and that of critical flicker frequency (CFF) at <39 Hz for mHE diagnosis. For comparing German and Turkish norms, datasets were combined. Multiple backward procedure was applied. Receiver operating characteristic (ROC) curves were created for assessing diagnostic capabilities of single subtests of the PHES test. Results: Turkish norms displayed non-linear dependence on age and education. Rate of mHE in compensated cirrhotics was 29.8% and 27.4% with PHES and CFF tests, respec...
Journal of Gastroenterology and Hepatology Research, 2017
tests. On these 33 patients, ICT and CFF were applied. 35 healthy subjects served as controls for the ICT and CFF. RESULTS: Taking > 9 lures as positive ICT according to receiver operator characteristic (ROC) curve, the sensitivity, specificity, PPV and NPV were 90.9%, 37.1%, 57.6%, 81.3% respectively. Cirrhotics with MHE had significantly higher lures (22 ± 7.8 vs 11 ± 5.6, p < 0.001) or (56% vs 28%) and lower target response (90% vs 97%) compared with controls. For CFF taking < 37 Hz as cutoff , the sensitivity, specificity, PPV and NPV were 57.5%, 94.3%, 90.5% and 70.2%. We also found that CFF is less time consuming as compare to ICT. CONCLUSION: ICT and CFF are useful tools to assess MHE. CFF to be less time to consume, less sensitive but more specific than ICT.
PLOS ONE, 2017
Background Minimal hepatic encephalopathy (MHE) is clinically undetectable and the diagnosis requires psychometric tests. However, a lack of clarity exists as to whether the tests are in fact able to detect changes in cognition. Aim To examine if the continuous reaction time test (CRT) can detect changes in cognition with anti-HE intervention in patients with cirrhosis and without clinically manifest hepatic encephalopathy (HE). Methods Firstly, we conducted a reproducibility analysis and secondly measured change in CRT induced by anti-HE treatment in a randomized controlled pilot study: We stratified 44 patients with liver cirrhosis and without clinically manifest HE according to a normal (n = 22) or abnormal (n = 22) CRT. Each stratum was then block randomized to receive multimodal anti-HE intervention (lactulose+branched-chain amino acids+rifaximin) or triple placebos for 3 months in a double-blinded fashion. The CRT is a simple PC-based test and the test result, the CRT index (normal threshold > 1.9), describes the patient's stability of alertness during the 10-minute test. Our study outcome was the change in CRT index in each group at study exit. The portosystemic encephalopathy (PSE) test, a paper-and-pencil test battery (normal threshold above-5), was used as a comparator test according to international guidelines. Results The patients with an abnormal CRT index who were randomized to receive the active intervention normalized or improved their CRT index (mean change 0.92 ± 0.29, p = 0.01).