Stroop Test Validation to Screen for Minimal Hepatic Encephalopathy in Pediatric Extrahepatic Portal Venous Obstruction

ABSTRACTObjectives:Minimal Hepatic encephalopathy (MHE) has been reported in children with extra hepatic portal vein obstruction (EHPVO). MHE assessment is restricted to research situations as neuropsychiatric tests are time-intensive. Computerised Stroop Test (CST) has been used in cirrhotic adults for MHE screening. The study aims to assess MHE frequency in young Indian children with EHPVO and validate CST for MHE screening in pediatric EHPVOMethods:37 children with EHPVO between 7–12 years of age and 37 age and gender matched controls were enrolled. Fasting plasma ammonia was measured. MHE was diagnosed by Revised Amsterdamse Kinder Intelligentie Test (RAKIT). The performance of a Tamil language version of CST in MHE screening was assessed.Results:MHE was diagnosed in 18.9% (7/37) of EHPVO (EHPVO-MHE). Plasma ammonia levels were higher in EHPVO-MHE compared to EHPVO without MHE (EHPVO-No-MHE) but abnormal plasma ammonia levels are unsuitable for MHE screening. CST was administered in 35 EHPVO and 37 controls. EHPVO-MHE, compared to EHPVO-No-MHE, had longer "on time", "off time", "(on+off) time" and "(on-off) time". For MHE diagnosis, specificity and sensitivity of '(on+off) time' were 100% and 89.6% for a cut-off of >180.4 s (AUROC=0.97).Conclusions:In the absence of other risk factors for neurological insult or patent surgical shunts, MHE frequency in young Indian children with EHPVO, determined by RAKIT, was lesser than in earlier studies. CST is suitable for MHE screening in clinical practice to select patients for neuropsychiatric evaluation. Objectives: Minimal Hepatic encephalopathy (MHE) has been reported in children with extra hepatic portal vein obstruction (EHPVO). MHE assessment is restricted to research situations as neuropsychiatric tests are time-intensive. Computerised Stroop Test (CST) has been used in cirrhotic adults for MHE screening. The study aims to assess MHE frequency in young Indian children with EHPVO and validate CST for MHE screening in pediatric EHPVO Methods: 37 children with EHPVO between 7–12 years of age and 37 age and gender matched controls were enrolled. Fasting plasma ammonia was measured. MHE was diagnosed by Revised Amsterdamse Kinder Intelligentie Test (RAKIT). The performance of a Tamil language version of CST in MHE screening was assessed. Results: MHE was diagnosed in 18.9% (7/37) of EHPVO (EHPVO-MHE). Plasma ammonia levels were higher in EHPVO-MHE compared to EHPVO without MHE (EHPVO-No-MHE) but abnormal plasma ammonia levels are unsuitable for MHE screening. CST was administered in 35 EHPVO and 37 controls. EHPVO-MHE, compared to EHPVO-No-MHE, had longer "on time", "off time", "(on+off) time" and "(on-off) time". For MHE diagnosis, specificity and sensitivity of '(on+off) time' were 100% and 89.6% for a cut-off of >180.4 s (AUROC=0.97). Conclusions: In the absence of other risk factors for neurological insult or patent surgical shunts, MHE frequency in young Indian children with EHPVO, determined by RAKIT, was lesser than in earlier studies. CST is suitable for MHE screening in clinical practice to select patients for neuropsychiatric evaluation. Address correspondence and reprint requests to Barath Jagadisan, Associate Professor, Pediatric gastroenterology, Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research, Dhanvantri Nagar, Pondicherry – 605006, India (e-mail: barathjag@yahoo.com). Received 15 November, 2017 Accepted 11 January, 2018 Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML text of this article on the journal's Web site (www.jpgn.org). Financial Disclosure and funding: The authors have no financial relationships relevant to this article to disclose. No conflict of interests. The study was funded by an intramural grant from the institute (JIP/Res/Intra-MD-MS/1/2015-16). Ethical clearance: The study had been approved by the institute ethic committee that complies with international standards and is registered with the government of India (JIP/IEC/2015/15/577). Trial registration: Not applicable. This article has not been published elsewhere in any language and it is not currently under consideration for publication elsewhere. © 2018 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology,

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