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Determination of Turkish norms of psychometric tests for diagnosing minimal hepatic encephalopathy and proposal of a high sensitive screening test battery

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Abstract

Background

Psychometric hepatic encephalopathy score (PHES) needs local standardization.

Aims

This study aimed at standardizing PHES for Turkish patients and compare them with German norms; to determine minimal hepatic encephalopathy (mHE) prevalence with two different methods [PHES battery and Critical Flicker Frequency (CFF)] and to assess whether sub-tests of the battery can be used for screening for mHE.

Methods

Healthy volunteers (n = 816; 400 male) and cirrhotics (n = 124; 58 male) were included. For mHE diagnosis PHES score threshold was set at ≤ − 5 points and that of CFF at < 39 Hz. For comparing German and Turkish norms, datasets were combined. Multiple backward procedure was applied to assess effects of age, sex and education on single tests of the battery. Receiver operating characteristic (ROC) curves were created for assessing diagnostic capabilities of subtests of the battery.

Results

PHES norms for Turks were developed. MHE prevalence in compensated cirrhotics was 29.8% and 27.4% with PHES and CFF tests, respectively, with low compatibility (kappa coefficient 0.389); mHE prevalence decreased to 16% when both tests were combined. Turks performed worse vs Germans in the digit symbol (DS) and serial dotting (SD) subtests but performed better in other subtests. In ROC analyzes of subtests, the combination of DS + SD tests achieved an AUROC of 0.974 versus PHES.

Conclusions

Use of two methods for diagnosing mHE is important for research purposes. From a clinical perspective, sensitivity with acceptable specificity may suffice for screening instruments for mHE. Combined use of DS and SD subtests of the PHES battery appears suitable for this purpose.

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Data availability statement

The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.

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Funding

The Critical Flicker Frequency device was kindly provided by ASSOS Pharmaceuticals throughout the study. We did not receive any financial support for conducting the study.

Author information

Authors and Affiliations

  1. Department of Internal Medicine, Ankara University Medical School, Ankara, Turkey

    Burak Özbaş, Irfan Karahan & Fatih Oğuz Önder

  2. Department of Gastroenterology, Ankara University Medical School, Ankara, Turkey

    Onur Keskin, Çağdaş Kalkan, Aysun Kartal, Ramazan Idilman & Cihan Yurdaydin

  3. Department of Biometrics, Hannover Medical School, Hannover, Germany

    Hartmut Hecker

  4. Department of Public Health, Gazi University Medical School, Ankara, Turkey

    Cansu Özbaş

  5. Department of Psychiatry, Ankara University Medical School, Ankara, Turkey

    Burcu Kahveci Öncü

  6. Department of Gastroenterology and Hepatology, Koç University Medical School, Istanbul, Turkey

    Genco Gençdal , Murat Akyildiz & Cihan Yurdaydin

  7. Department of Gastroenterology, Ege University Medical School, Izmir, Turkey

    Fulya Günşar & Ömer Özütemiz

  8. Department of Neurology, Hannover Medical School, Hannover, Germany

    Karin Weissenborn

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  1. Burak Özbaş
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Contributions

CY, FG and KW contributed to the study design. BO, OK, IK, CO, CK, AC, FOO, BKÖ contributed to acquisition of data, BO, CO, HH, FG, KW and CY contributed to data analysis, interpretation of data, drafting of the manuscript, BO, OK, HH, GG, MA, FG, OO, KW, CY contributed to revising of the manuscript. All authors have seen and approved the last version of the manuscript.

Corresponding author

Correspondence to Cihan Yurdaydin.

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Conflict of interest

Burak Ozbas, Onur Keskin, Hartmut Hecker, Irfan Karahan, Cansu Ozbas, Cagdas Kalkan, Aysun Kartal, Fatih Oguz Onder, Burcu Kahveci Oncu, Genco Gencdal, Murat Akyildiz, Fulya Gunsar, Ramazan Idilman, Karin Weissenborn, Omer Ozutemiz, Cihan Yurdaydin declare no competing interests.

Ethics approval

The study was approved by the University of Ankara Medical School Ethics Committee. The experiments conformed to the ethical guidelines of the 1975 Declaration of Helsinki.

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Informed consent was obtained from patients, prior to their participation in the study.

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Supplementary file1 (DOCX 17 kb)

12072_2021_10207_MOESM2_ESM.docx

Comparison of the psychometric hepatic encephalopathy scores in German and Turkish healthy populations by applying German and Turkish norms to both populations. No significant differences were found between the populations when Turkish norms were applied, but 142 of 785 subjects classified as normal with Turkish norms would be classified as out of norm if the Hannover Scores were applied (DOCX 51 kb)

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Özbaş, B., Keskin, O., Hecker, H. et al. Determination of Turkish norms of psychometric tests for diagnosing minimal hepatic encephalopathy and proposal of a high sensitive screening test battery. Hepatol Int 15, 1442–1455 (2021). https://doi.org/10.1007/s12072-021-10207-5

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