7. Propuesta de mejoramiento educativo
7.6. Población objetivo
86
Table 4.7 shows the results of the components of PHES derived by applying it on the apparently normal population (controls) and on the patients (cases). The normative values of the
psychometric tests were derived by applying the formula: X + 2 SD for NCT-A, NCT-B, SDT and LTT and X – 2 SD for DST on the results obtained from normal controls.
(Where X is mean of the psychometric test, SD is standard deviation).
Based on this, the cut-off of normal for the various aspects of PHES was derived as follows:
NCT-A > 40 seconds; NCT-B > 102seconds; DST < 28 properly matched pairs; SDT > 64 seconds; LTT> 84 seconds.
Furthermore, when compared with normal subjects, patients with liver cirrhosis performed poorly in all components of PHES (p < 0.0001).
Table 4.7: PHES evaluation in the study population
87 TEST CIRRHOTICS/
CONTROL
MIN MAX MEAN ± 2SD NORMAL VALUE
t test p value NCT-A Cirrhotics 26 61 40.60 ± 18.64 39.75 9.63 < 0.001*
Normal controls 21 42 30.45 ± 9.30
NCT-B Cirrhotics 71 164 102.22 ± 41.96 101.53 8.11 < 0.001*
Normal controls 62 99 83.73 ± 17.80
DST Cirrhotics 15 51 30.30 ± 18.04 27.35 13.38 < 0.001*
Normal controls 34 75 49.45 ± 22.10
SDT Cirrhotics 41 90 58.03 ± 22.70 63.40 6.89 < 0.001*
Normal controls 33 66 48.72 ± 14.68
LTT Cirrhotics 58 115 84.11 ± 29.20 83.52 7.01 < 0.001*
Normal controls 44 82 64.98 ± 18.54
* Statistically significant
Abbreviations: NCT, Number Connection Test; DST, Digits Symbol Test; SDT, Serial Dotting Test; LTT: Line Tracing Test. Max, Maximum; Min, Minimum.
Table 4.8 shows the frequency of abnormal components of PHES in the cases. Subjects with abnormal scores in at least 2 components of the PHES were deemed to have MHE. Forty seven
88
patients (46%) with liver cirrhosis fulfilled this criterion and were classified as having Minimal Hepatic Encephalopathy.
Table 4.8: Frequency of abnormal components of PHES in the cases
TEST FREQUENCY PERCENTAGE
NCT-A 48 47.1
NCT-B 41 40.2
DST 53 52
SDT 31 30.4
LTT 35 34.3
In Table 4.9, the results of the psychometric tests of patients with MHE were compared with those of patients without MHE. This showed that of the five tests, DST, NCT-A and NCT-B exhibited statistically significant difference between the two groups while SDT and LTT did not show statistically significant difference between the two groups.
Table 4.9: PHES evaluation in patients with and without MHE
TEST MHE/NO MHE MIN MAX MEAN ± SD t test p-value
89
NCT-A MHE (N=47) 35 61 46.81 ± 6.89 10.73 0.0043*
NO MHE (N=55) 26 59 35.22 ± 7.58
NCT-B MHE (N=47) 67 164 119.06 ± 17.44 9.55 <0.005*
NO MHE (N=55) 62 99 90.95 ± 9.58
DST MHE (N=47) 24 51 23.23 ± 5.80 11.69 <0.0001*
NO MHE (N= 55) 34 75 36.44 ± 6.47
SDT MHE (N= 47) 34 90 65.13 ± 11.66 7.22 0.063
NO MHE (N=55) 40 71 51.67 ± 6.74
LTT MHE (N= 47) 74 115 96.29 ± 11.00 8.54 0.052
NO MHE (N= 55) 58 88 74.00 ± 8.43
* Statistically significant.
NCT: Number Connection Test; DST: Digits Symbol Test; SDT: Serial Dotting Test; LTT: Line Tracing Test; Min: Minimum; Max: Maximum.
4.9: RISK FACTORS FOR MHE (UNIVARIATE ANALYSIS)
90
Patients with MHE were compared with those without MHE based on their demographic
characteristics, clinical presentations and laboratory findings by univariate analysis. (See Tables 4.10 – Table 4.12)
It was shown that those with MHE were significantly different from those without MHE in the following variables: Significant alcohol history (p-value <0.0001) HCV aetiology (p-value = 0.046); anaemia (p = 0.04); hypoalbuminaemia (p= 0.0001); thrombocytopaenia (p= 0.0001);
hypokalaemia (p = 0.044); ascites (0.0002); splenomegaly (p = 0.0001) and prolonged INR (p = 0.0001).
Table 4.10: Socio-demographic risk factors for MHE (Univariate analysis I)
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CHARACTERISTICS MHE (%)
N= 47
NO MHE (%) N= 55
X2 p-value
Mean age (years) ± 2SD 44.17 ± 12.34 38.24 ± 9.95 0.13
Sex
Male (n=73) 32 (68.1) 31 (56.4) 0.21 0.64
Female (n=39) 15 (31.9) 24 (43.6)
Educational Status
Primary (n = 25) 15 (31.9) 10 (18.2) 2.81 0.25
Secondary (n = 58) 25 (53.2) 33 (60)
Tertiary (n = 19) 7 (14.9) 12 (21.8)
Occupation
Farmers (n = 5) 3 (6.4) 2 (3.6) 0.76 0.99
Traders (n = 26) 16 (34.1) 10 (18.2)
Civil servants (n = 15) 6 (12.8) 9 (16.4) Technicians/Artisans (n = 23) 8 (17.0) 15 (27.3)
Students ( n = 13) 5 (10.6) 8 (14.5)
Professionals (n = 11) 4 (8.5) 7 (12.7)
Unemployed (n=9) 5 (10.6) 4 (7.3)
Table 4.11: Aetiologic/putative risk factors for MHE (Univariate analysis II)
92
MHE (N=47) NO MHE (N=55) OR X2 p-value
Tobacco Yes (%) No (%)
11 (23.4) 36 (76.6)
8 (13.7) 47 (86.3)
1.80 1.34 0.25
Significant alcohol use Yes (%)
No (%)
15 (31.9) 32 (68.1)
3 (5.5) 52 (94.5)
31.06
20.73
<0.0001
Hepatitis B Yes (%) No (%)
27 (57.4) 20 (42.6)
38 (69.1) 17 (30.9)
0.46
3.4
0.06
Hepatitis C
Yes (%) 2 (4.3) 7 (12.7) 0.23 3.85 0.048
No (%) 45 (95.7) 48 (87.3)
* Statistically significant OR: Odds ratio
Table 4.12: Laboratory and clinical risk factors for MHE (Univariate analysis III)
93 VARIABLES MHE N =47
n (%)
NO MHE N=55 n (%)
OR X2 p-value
Creatinine (>133µmol/L)
18 (38.3) 15 (27.3) 2.18 3.45 0.063
Total Bilirubin (>17µmol/L)
43 (91.5) 47 (85.5) 2.13 1.1 0.28
ALT (> 15 IU/L) 37 (78.7) 45 (81.8) 0.82 0.14 0.71
AST (> 17 IU/L) 39 (82.9) 47 (85.5) 0.83 0.10 0.75
ALP (>92 IU/L) 18 (38.3) 27 (49.1) 0.64 1.19 0.28 Anaemia (Hb <10g/dl) 29 (61.7) 23 (41.8) 2.30 4.16 *0.04 Hypoalbuminaemia
(<30g/l)
30 (63.8) 8 (14.5) 10.8 26.78 *0.00002 Thrombocytopaenia
(<100 × 109 /L)
33 (70.2) 9 (16.4) 12.69 30.92 *0.00001 Hypokalaemia
(<3.5 mmol/L)
28 (59.6) 8 (14.5) 8.9 22.9 *0.0001
Hyponatraemia (<130mmol/L)
17 (36.2) 13 (23.6) 1.85 1.96 0.16
Ascites 40 (85.1) 37 (62.3) 6.6 13.60 *0.0002
Splenomegaly 40 (85.1) 16 (29.1) 11.12 27.04 *0.0001
Prolonged INR (≥1.3) 24 (51.1) 7 (12.7) 7.32 17.85 *0.00003
Statistically significant Abbreviations: ALT- Alanine aminotransferase; AST – Aspartate aminotransferase;
ALP – Alkaline phosphatise; INR – International normalised ratio; - Increase.
4.10 RELATIONSHIP BETWEEN CHILD-PUGH CLASS AND MHE The proportion of patients with MHE progressively increased with worsening liver disease as
94
measured by the Child–Pugh class. This is shown by a progressive increase in the frequency of MHE from 18.5% among patients in CP class A to 77.1% among those in CP class C. The difference was statistically significant with p-value <0.001. Table 4.13 illustrates the trend of MHE among the patients based on their CP class.
Table 4.13: Correlation of MHE with severity of liver disease based on Child-Pugh class CHILD-PUGH GRADE MHE (N=47)
Frequency (%)
No MHE (N=55) Frequency (%)
X2 p-value
A (n=27)
5 (18.5) 22 (81.5) 23.03 <0.001*
B (n=40) 15 (37.5) 25 (62.5)
C (n=35) 27 (77.1) 8 (22.9)
X2 = 23.03; p-value < 0.0001; df =2;
* Statistically significant
In Table 4.14, the patients were divided into two groups: those who had compensated cirrhosis (patients in Child-Pugh class A) and those who were decompensated (Patients in Child-Pugh
95
class B and C combined). There was statistically significant difference between the two groups with respect to the presence or absence of MHE. (X2 = 9.8, p-value = 0.002)
Table 4.14: Correlation of MHE with severity of liver disease based on Compensated and Decompensated disease
Cirrhotic Patients MHE (N=47) Frequency (%)
No MHE (N=55) Frequency (%)
Χ2 p-value
Compensated Cirrhosis (n=27) 5 (18.5) 22 (81.5) 9.8 0.002*
Decompensated Cirrhosis (n=75) 42 (56) 33 (44)
* Statistically significant X2 = 9.8; p value < 0.002, df =1
Table 4.15 shows a progressive decline in the performance of all components of PHES based o n the Child-Pugh class of the patients. The patients in Child-Pugh A performed better than their counterparts in Child-Pugh B, who similarly performed better than those in Child-Pugh C.
Though the p-value was significant in all the domains of PHES, it was most significant in the domains of NCT-B and DST value < 0.0001) and least significant with respect to LTT (p-value = 0.044).
Table 4.15: PHES evaluation according to Child-Pugh Class of patients
TEST CHILD-PUGH MIN MAX MEAN ± 2SD p-value
96
NCT-A A 21 59 42.80 ± 6.54 0.01*
B 32 56 38 ± 8.00
C 23 61 45 ± 9.56
NCT-B A 62 142 85.85 ± 12.47 <0.0001*
B 71 164 99.48 ± 20.44
C 64 145 110.45 ± 20.75
DST A 16 75 46.21 ± 12.52 <0.0001*
B 14 49 31.33 ± 8.51
C 15 45 26.57 ± 8.30
SDT A 33 70 55.85 ± 10.34 0.0005*
B 40 90 63.69 ± 12.56
C 39 88
LTT A 44 67 84.11 ± 29.20 0.044*
B 51 108 64.98 ± 18.30
C 58 113 90.14 ± 15.29
* Statistically significant. NCT: Number Connection Test; DST: Digits Symbol Test; SDT:
Serial Dotting Test; LTT: Line Tracing Test.