Method of diagnosing hepatic encephalopathy of latent stage in patients with chronic liver diseases

FIELD: medicine.

SUBSTANCE: invention relates to field of medicine, namely to neurology and hepatology. Multi-level neurodynamic analysis of cardiorhythmograms is registered and realised by means of rhythmocardiograph and hardware and software complex "Omega-C". Determined are indices, reflecting: "A" - association of all, but mainly peripheral rhythmic processes, "B1" - degree of equilibration of sympathetic and parasympathetic effects on sinus node of heart, "C1" - state of central subcortical regulation, "D1" - state of central cortical regulation. Diagnostics index (YHE-L) is calculated in patients with chronic liver diseases by formula: YHE-L= -1.5 + 0.003*A + 0.013*B1 + 0.006*C1 + 0.053*D1. If YHE-L value is from -0.47 to 0.49, hepatic encephalopathy of latent stage in patients with chronic liver diseases is determined.

EFFECT: method makes it possible to increase reliability of diagnostics of hepatic encephalopathy of latent stage.

8 tbl, 2 ex

 

The invention relates to medicine, namely neurology and Hepatology, and relates to a method of determining latent hepatic encephalopathy stage (PE-L) in patients with chronic liver disease (HSP). The method can be used in hospitals, clinics, diagnostic centers.

"Hepatic encephalopathy" (PE) is a potentially reversible disorder of the Central nervous system, caused by metabolic changes resulting from hepatic cell failure and/or portosystemic shunting of blood [1].

According to the modern classification of portosystemic (liver) encephalopathy - Herber and Schomerus (2000) [2] distinguish two stages: latent (subclinical) and clinically relevant. The importance of the selection PE-L is for two reasons:

1. encephalopathy may precede the development of clinically severe liver failure, 2. psychomotor disturbances that occur when PE-L, have a negative impact on patient's quality of life, leading to reduced efficiency. Stage clinically pronounced Peh, in turn, divided into 4 stages of development:

I - light (sleep disturbance, inability to concentrate, a slight personality change, confusion, apraxia) (PE-I).

II - moderate (lethargy, fatigue, drowsiness, apathy, inadequate for the introduction with a noticeable change in personality structure, impaired orientation in time, "flapping" tremor, monotonous speech).

III - heavy (disorientation, stupor, severe disorientation in time and space, aswatona speech, aggression, "flapping" tremor, convulsions).

IV - coma (loss of consciousness).

Currently, for the diagnosis of PE is used:

Assessment of clinical symptoms (assessment of disorders of consciousness, intelligence, character, personality changes, speech). When PE-L consciousness is not changed, when a targeted survey there is a decrease in concentration and memory.

Assessment of neuropsychiatric changes, detected by psychometric testing. This purpose can be applied [3]:

1. Tests on the speed of cognitive activity:

test connection numbers (part a and b), the test Reitan;

test number-symbol.

2. Accuracy tests fine motor skills:

test line (maze);

tests of obedeniya dotted figures.

The most widespread test connection numbers (TSC) and test line (t)whose sensitivity in the diagnosis of PE is 80% [1]. When performing TSC examined as soon as possible to connect with each other in order of the numbers from 1 to 25, within 30 seconds. The time spent on correcting errors were taken into account in the overall assessment of the results. When evaluating run-time TSC patients who terse 50 years applied a correction factor of 0.7.

For standards TCC accepted the results obtained from the survey of adult patients of the European population[3, 4, 5, 6]:

The stage of hepatic encephalopathyTSC (s)
0 absentless than 30 seconds
latent PE30-45 sec
I degree PE46-60 seconds
II degree PE61-80 sec
III degree PE81-120 sec
IV degree PE>120 sec (the patient is unable to perform the test)

The task facing the patient when performing a test, the maze, includes the need to draw existing line as quickly as possible, without touching the adjacent lines. The elapsed time and the mistakes made were considered separately [7].

However, the use of psychometric testing to evaluate neuropsychiatric changes when PE has a number of limitations: the lack of commonality, the possibility of the effect of training in the evaluation of flow dynamics PE [3].

Instrumental methods of diagnostics is PE:

A) Electroencephalography (EEG). When PE depending on the stage of encephalopathy is slowing down the activity of α-rhythm: when PE-0 and latent stage - frequency α-rhythm 8,5-12 oscillations in 1 second, when the PH of the first degree clinically expressed stage - frequency α-rhythm 7-8 oscillations in 1 second, when PE-II degree clinically expressed stage - frequency α-rhythm 5-7 oscillations in 1 second, when the PH of the III degree clinically expressed stage - frequency α-rhythm 3-5 oscillations in 1 second, when the PH of the fourth degree clinically expressed stage - the frequency of α-rhythm < 3 oscillations in 1 second, with the "detection of low-amplitude slow oscillations". Starting with the second stage, you receive the δ - and θ-activity. Relatively typical, but not specific appearance, starting with the second stage, bilateral simultaneous outbreaks of acute "phase waves", mainly in frontotemporal leads. Electroencephalography (EEG) reflects the General bioelectric brain activity (BEA) and not objectively evaluate cognitive impairment, does not provide information about the features of these disorders. According to some authors, the sensitivity of the EEG when PE is not more than 30-40%, and often changes the EEG did not correlate with the severity of the disease, they are only of secondary importance [2, 8]. However, patients with HSP and is in clear consciousness, the presence of EEG such changes - dostava the hydrated diagnostic feature [1, 9].

B) Visual evoked potentials R-300 (or test "blink rate", which is a modification of the EEG). If test "blink rate" uses high-frequency light that is perceived by the subject using a special optical glasses. The value of the critical frequency of flicker (critical flicker frequency CFF) in healthy individuals exceed a frequency of 39 Hz, patients this figure is significantly lower. The results of this test are statistically significantly correlated with indices of psychometric tests [1, 10].

C) Magnetic resonance spectroscopy - the main changes relate to increasing signal intensity of the T1-basal ganglia and white matter of the brain, reducing the magnitude of the ratio of myo-Inositol/creatine (by decreasing the content of myo-Inositol in astrocytes) and increase peak glutamine in grey and white matter of the brain (due to the accumulation of glutamine in astrocytes) [11, 12]. The intensity of the signal glutamine can also be used to characterize clinical stage PE [13, 14]. The sensitivity of this method in PE-L approaching 90-100% [15, 16, 17]. However, according to other authors, the above changes, detected by magnetic resonance spectroscopy, are not connected with the PE, and correlated with the concentration of bilirubin and manganese in the blood[18, 19, 20].

D) Magnetic resonance imaging (the RT) allows to quantify the severity of brain edema and atrophy of the cortex in symptomatic stages of PE [9]. These changes are due to serious disturbances of liver function and is especially pronounced in patients with long-persistent PE. When PE-L often changes not detected [20, 21].

However, the high cost of application methods: visually evoked potentials R-300, magnetic resonance spectroscopy and MRI brain allows them to use only a few research centers [21], which requires further search objective, instrumental, simple methods for the diagnosis of PE-L.

On the closest in technical essence as a prototype we have chosen a method for the diagnosis of PE-L in patients HSP when multilevel neurodynamic analysis cardiotocogram using rythmocardiography [22]. Basically, this publication focuses on the use of the correction of hepatic encephalopathy (p.24-28 and p.37). The publication also contains information on using the multi-level neurodynamic analysis cardiotocogram to assess the dynamics of chronic liver disease and hepatic encephalopathy.

The diagnostic technique of hepatic encephalopathy latent stage in this publication are not reflected. The source contains only mentioned "use multilevel neurodynamic analysis cardiotocogram for evaluation of flow dynamics is hronicheskih liver disease and hepatic encephalopathy", based on the correlation of certain indices with the stage of hepatic encephalopathy. To carry out the method for the diagnosis of hepatic encephalopathy latent stage, using only the recorded information obtained only when casting layered neurodynamic analysis cardiotocogram, without further conversion as it is not possible, because this method reflects the integral indicators of the state of the cardiovascular system and gives information about the function of the Central parts of the system of regulation of the organism as a whole. More detailed information about the implementation of this method is missing, i.e. there are no specific diagnostic values or formulas, obtained by the method of multilevel neurodynamic analysis cardiotocogram, which is diagnosed latent stage of hepatic encephalopathy, which can be attributed to the lack of method, we have chosen as a prototype.

The technical result of the invention is the development of specific diagnostic criteria, obtained by the method of multilevel neurodynamic analysis cardiotocogram to determine hepatic encephalopathy latent stage in patients with chronic liver diseases.

The technical result is achieved by the eat, that rythmocardiography and hardware-software complex "omega-" carry out multilevel neurodynamic analysis cardiotocogram evaluate the following indices - "And" - conjugation of all, but mainly peripheral rhythmic processes, "B1" - the degree of balance between sympathetic and parasympathetic influences on the sinus node of the heart, "C1" is the Central subcortical regulation, "D1" is the Central cortical regulation, with the subsequent calculation of the rate of diagnosis of PE-L in patients with chronic liver disease according to the formula: YPE-L=-1,5+0,003·A+0,013·B1+0,006·C1+0,053·D1. When the value of YPE-Lfrom - 0,49 0,47 to diagnose hepatic encephalopathy latent stage in patients with chronic liver diseases.

The method is as follows. When making use of one-stage multilevel neurodynamic analysis cardiotocogram (RF patent No. 2233616, 2004 - a method for the diagnosis of disorders of the Central neurohormonal regulation and patent RF №31943, 2003 - Device for forming rhythmogram heart). We used PAK "omega" (manufacturer LLC Mekomos-E", Moscow, Russia). For the same purpose may be used such rythmocardiography as "Valens+".

When conducting multilevel it is dinamicheskogo analysis cardiotocogram exclude the impact on patient irritating factors: physical activity, conversations, sharp sounds.

The study did not include patients with complex cardiac arrhythmias, confirmed by electrocardiography heart (ECG), and applying anti-arrhythmic therapy, due to the influence of these factors on the results.

For the diagnosis of PE-L evaluate the following indices are obtained when the behavior of one-stage multilevel neurodynamic analysis cardiotocogram [23, 24]:

"A" is a Conjugation of all, but mainly peripheral rhythmic processes (fractal analysis of the overall rhythmic pattern system-regulatory activities of the body, the evaluation of long-term adaptation).

B1 - Vegetative balance (the balance between sympathetic and parasympathetic influences on the sinus node of the heart, the assessment of the current level of adaptation).

"C1" Central subcortical regulation (neurodynamic analysis of pacemaker control codes, which are formed at the level of GGNK, short-term projected assessment of the level of adaptation).

"D1" is the Functional activity of the cortex (neurodynamic analysis of pacemaker control codes that are formed at the level of the cerebral cortex, short-term projected assessment of the level of psykopunkz).

Latent stage of hepatic encephalopathy is calculated by the formula: YPE-L=-1,5+0,003·A+0,013·B1+0006·C1+0,053·D1. When the value of YPE-Lfrom -0,47 to 0,49 determine hepatic encephalopathy latent stage in patients JSP.

Distinguishing the essential features of the proposed method are:

- when making a layered neurodynamic analysis evaluate indexes "A" conjugation of all, but mainly peripheral rhythmic processes, "B1" - the degree of balance between sympathetic and parasympathetic influences on the sinus node of the heart, "C1" is the Central subcortical regulation, "D1" is the Central cortical regulation;

in the subsequent rate of diagnosis of PE-L in patients with chronic liver disease is calculated by the formula: YPE-L=-1,5+0,003·A+0,013·B1+0,006·C1+0,053·D1;

- when value isPE-Lfrom -0,47 to 0,49 determine hepatic encephalopathy latent stage in patients with chronic liver diseases.

A causal relationship between significant distinctive features and achieve the result.

The invention is based on the following etiopathogenetic views of the pathogenesis of PE:

1. The development of PE is caused by dysfunction of the liver cells, the development of hepato-cellular failure, as well as the formation of Porto-systemic shunting of blood [1], i.e. cellular-tissue contour of the body. Therefore, this fact must find with the OE reflected in changes in autonomic regulation of cardiac activity, and overall balance of peripheral rhythms of the body.

2. The development of PE due to the action of metabolites in the liver, the formation of hyperammonia and increased levels of γ-aminobutyric acid (GABA), which changes the processes of neurotransmission in cortical and subcortical structures of the brain, forming neurotoxic effect [1, 4], i.e. disrupted observance (system-regulatory) Central contour of the body. This fact should be reflected in changes in the parameters of codes of pacemaker structures of the cortex and the cortex.

3. The method of the multilevel neurodynamic analysis cardiotocogram allows not only to estimate the statistical and variational indices of heart rate and through them the degree of tension of the autonomic regulation of cardiac activity, but also provides information on the functioning of the Central links system regulation (cerebral cortex and area HGNC) and the organism as a whole ("fractal portrait") [24, 25, 26]. The basis of this technology on the principle nonparametrical multilevel analysis of the state system of regulation by extracting stable, repetitive, invariant to noise neurodynamic codes that are contained in any ramagrama (this technology in cardiotocogram). Extraction was named narodi omicheskogo decoding. The physiological interpretation of these codes gives an idea about the type, pace and direction of the pathologic process that allows you to assess your current and prospective severity of the patient and manage clinical activity.

The method of the multilevel neurodynamic analysis cardiotocogram for analysis of HRV provides for the registration of 300 cardiocycle. Then from the original graphic recorder automatically extracted 5 rhythmogram [23, 24]:

- R-R interferogram sequence of R-R intervals

- R-P interferogram sequence R-P intervals

- R-T interferogram sequence R-T intervals

- The ratio of the amplitudes R and T splines sequence of values of the ratio of the amplitudes R and T teeth

The duty cycle of the FORMER sequence of values of the ratio of the repetition period cardiocomplex to its duration

All 5 rhythmogram converted from analog format to digital and transmitted to the computer for future software conversion.

The second stage of the software processing the source entry kardiointervalogrammy is divided into 4 stages. In the first stage used a set of statistical methods and variational estimates only standard R-R cardiotocogram (indexes "In the" programs). In the second stage used isulan neurodynamic analysis of all 5 cardiotocogram (index "C" program). The third stage is applied neurodynamic analysis of artificially synthesized pseudointegrable (index "L" program), and the fourth - estimated conjugation of all rhythmic processes in the body (index "A" program). On the first three stages is calculated from the set of intermediate parameters, which are grouped into two indices (B1, B2, C1, C2, D1, D2). All indexes with the number 1 is assigned to the indicators of the so-called "fast" regulation, and indexes with figure 2 - indicators - "slow" regulation.

We selected indexes, that is, B1, C1, D1, have the greatest sensitivity and reflect changes in the status of fast obscheorganizmenny regulation, while the index And reflects the status of all almerigogna processes (fast and slow) (Patent RF №2233616, 2004 - a method for the diagnosis of disorders of the Central neurohormonal regulation).

The meaning of this diagnostic technology is to assess the quality obscheorganizmenny (system) regulation through the evaluation of the quality control codes. Reference codes are not dependent on age and sex and always reflect the ideal degree of adaptation of the organism. Codes can be changed at any chronic disease occurs in one scenario, which reflects the degree of adjustment-maladjustment of the body in response to the action of one or ins is damaging factors. Therefore, the technology in its methodological orientation alternative most used diagnostic technologies, serving the methodology multiparameter descriptions of individual organ-functional subsystems of the organism.

A result of changes in the methodological approach is the possibility of obtaining prognostic information, because changing settings control codes occurs much earlier than changes in peripheral organs and tissues that are sent to these regulatory impact. This is in virtue of the vertical functional hierarchy of regulatory structures. In practice, this allows to predict the risk of complications in the aggregate regulatory criteria [10, 24]. This method systematically regulatory neurodynamic assessment cardiotocogram gives information about the functioning of the system of regulation of heart rhythm, including 4th level:

a) the level of vegetative homeostasis, reflecting the assessment of the balance of the peripheral autonomic effects on the sinus node of the heart,

b) the level of activity of the hypothalamic-pituitary complex neurohormonal (GTC)determining a condition of the Central subcortical regulation;

C) the level of activity of the cerebral cortex, reflecting the status of the Central cortical regulation;

g) the level of the balance, mainly peripheral rhythms of the body (the so-called "fractal portrait of the organism").

4-tier model of regulation of heart rhythm, virtual, however, the information obtained with its help, it is real, but cannot be obtained by the methods of investigating specific structural-morphological education cardio-vascular or neuro-endocrine system. This is because the coordinated functioning of all sub-levels and subsystems of an organism is carried out by operation of a single control codes, which differ in different organs and structures only its spatial-temporal dimension. In these circumstances, such information has predictive power [23, 27].

The inventive method was tested in 152 patients with chronic liver diseases.

Detection of PE consisted of 2 stages:

Stage I (Control):

Given that PE-L difficult to diagnose and may not be reliably diagnosed on the basis of one single method psychometric, clinical, or diagnostic tool, to minimize inaccuracies diagnosis of PE-L in the control phase was used labor-intensive, integrated approach to the identification PE-L, including the following methods:

1. Monitoring of manifestations of hepatic encephalopathy [4, 5]:

- psychometric t is the investing (test connection numbers the test line);

assessment of cognitive functions was performed using the method of "10 words" Arioli (memory impairment) and tables Schulte (deterioration);

- diagnosis of depression according to the method of the Dung.

2. Consultation of the neurologist and psychiatrist to exclude other causes of encephalopathy. Evaluated neurological symptoms: tremor of the fingers, paresthesias of the extremities, increased tendon reflexes, change handwriting, gait.

3. Frequency analysis of electroencephalogram.

4. Biochemical and clinical analysis of blood.

Patients without evidence of clinically apparent PE, psychometric testing within normal limits (TSC less than 30 seconds), the absence of cognitive dysfunction, the results of the EEG frequency of the α-rhythm of 8.5-12 oscillations in 1 second, - it belonged to the group PE-0 (absent). Patients, slow performing psychometric testing (TSC 30-45 seconds) and/or detection in EEG - disritmia with deformation of α-rhythm with a frequency of 8.5-12 oscillations in 1 second, without evidence of clinically apparent PE - referred to the group PE-L. Patients with evidence of clinically apparent PE, slowing perform psychometric testing (TSC 46-60 s) and/or detection of EEG - disritmia with deformation of α-rhythm with a frequency of 7-8 oscillations in 1 sec - were classified as PE-I.

Stage II (study) was layered not the dynamic analysis of cardiotocograms (present method).

According to the results obtained under the first phase of the 49 people (32%) were diagnosed with absence of PE, these patients constituted group 1, 53 (35%) were diagnosed with PE-L (group 2) and 50 persons (33%) were diagnosed with PE-I degree clinically severe stage (group 3).

The distribution of patients according to nosological form and PE are presented in table 1. As can be seen from this table, we investigated patients with autoimmune, chronic viral and alcoholic hepatitis, non-alcoholic steatohepatitis in equal proportions.

Table 2 shows the main clinical symptoms and syndromes of patients HSP characteristic of PE. As can be seen from this table, psychomotor disorders in patients JSP there is a decrease in cognitive functions (attention, memory, perception, thinking), established in 61% of people. Changes in sleep (inversion of sleep rhythm, difficulty falling asleep and/or nocturnal awakening), which is the initial manifestations of human consciousness, was observed in 45% of patients. The lack of coordination in the performance of small movements were observed in 45% of patients. Patients with PE-L was complained of only a slight decrease of cognitive functions (memory loss, concentration, attention, thinking), the average score when PE-L=1,0±0,20, when PE-I=2,4±0,20, p<0,05. The marked change in the nature of sleep - patients with PE-L reported difficulty covered what I the day was marked drowsiness. Compared with patients PE-0, in patients PE-L more than 3 times more prevalent decrease of cognitive function, loss of coordination, however, severity, data psychomotor changes did not differ p>0,05. In 7 (13%) with PE-L - detected change of handwriting, whereas PE-I - change your handwriting revealed - 17 (34%).

The results of the psychometric testing showed that patients with PE-L easily understand their objective, carry it with interest, but the time spent on tests, exceeds the edge boundary (TSC<30 sec). Since patients with PE-L time spent executing TSC of 36.5±2.40 a sec, and t - 55,9±3,50 s, (p<0.05), and the number of errors t (COT) - 5,2±1,10, whereas patients without showing signs of PE (PE-0) TSC performed for 24,6±2,20 s, t - 37,2±2,50 s, COTis 2.2±0,70. When PE-I TSC accounted for 50.9±2.40 a sec, t is 69.5±3,50 s, COT- 8,7±1,10 (p<0,05). The accuracy of psychometric testing (TSC) for the diagnosis of PE-L was 72% (from 53 patients - 38), but, despite the high accuracy, TSC is subjective research method, depending on a number of factors: vision training.

The results of laboratory and instrumental examinations are presented in table 3 and 4, which show that patients HSP when is progressirovanii PE marked increase biochemical activity (ALT, ACT, bilirubin, alkaline phosphatase, GGT), erythrocyte sedimentation rate, low blood platelet count, total protein and albumin.

When the background EEG in patients HSP depending on the severity of PE violation of bioelectric brain activity reflected mainly on the parameters of the α-rhythm.

In the group PE-0 in 22% of patients identified deformed α-rhythm with a frequency of 8.5-12 oscillations in 1 second, when PE-L in 37% of patients on the background of polymorphic disritmia was identified deformed α-rhythm with a frequency of 8.5-12 oscillations in 1 second. When PE-I EEG changes were more diverse: a 25% slowing of the α-rhythm reached 7-8 oscillations in 1 second at 19% frequency fluctuations amounted to 5-7 oscillations in 1 second. All EEG changes were detected in 55 (36%) patients, while 34 patients (64%) with PE-L - changes in EEG were not discovered. The accuracy of EEG for the diagnosis of PE-L was 36%.

At the second stage of the survey when conducting multilevel neurodynamic analysis cardiotocogram using PAK "omega" (manufacturer LLC Mekomos-E", Moscow, Russia) were the results of the indices A, B1, C1 and D1, are presented in table 5.

Table 6 presents the correlation information index a, B1, C1 and D1 data psychometric tests, laboratory and instrumental methods of examination and EEG.

As a result, the data obtained using multilevel neuro is dinamicheskogo analysis cardiotocogram unequivocally confirm the quality of information the assessment of regulatory changes in PE, confirmed by other methods of its diagnostics (psychometric testing, EEG, clinical laboratory values). So in addition to the qualitative evaluation, the advantage of the multilevel neurodynamic analysis cardiotocogram is the ability to quantify pathological changes in the diagnosis of PE.

Using discriminant analysis, using the computer program SPSS 13.0 created discriminant function with the definition of these coefficients to the values of the discriminant functions was clearly distinguish groups: PE-0, PE-L, PE-I.

ThePE-L=-1,5+0,003·A+0,013·B1+0,006·C1+0,053·D1, where a, B1, C1 and D1 indexes obtained using multilevel neurodynamic analysis cardiotocogram. All the coefficients of the equations are significant (p=0,000001), and considered the factors have a high contribution and explain 75% (R2=0,86) variations in the dependent variables, respectively.

Table 7 presents the test of equality of group mean values used in the formula, where F Is the F-test, p - value. Using Lambda Wilks made the test for significance of differences from each other in the average values of discriminant functions in the group: Wilks Lambda = 0,39, Chi - square - 188,033, p<0,000001.

Table 8 presents the parameters InPE-Lto determine the PECs is full encephalopathy latent stage.

Thus, distinguishing the essential features are new and improve the accuracy of diagnosis of hepatic encephalopathy latent stage in patients with chronic liver diseases.

Examples of clinical complete method.

Example 1.

Patient A., 49 years old, a/C No. 3977. 23.03.2010,

Complaints: weakness, lethargy, heaviness in the right hypochondrium.

From the anamnesis it is known that more than 8 years, the increase of transaminase activity was slightly higher than normal. Were examined as outpatients, anti-HCV positive (human immunodeficiency. room 84.083. 05.11.2003 year). In 2007: diffuse induration of the liver, pancreas. Splenomegaly. Ascites. Portal hypertension. Fibrogastroduodenoscopy: varicose veins of the esophagus, gastro. RRC: hemorrhoids. 2007: Scanning of the liver and spleen: the spleen accrue isotope 15%. Conclusion: Diffuse changes of a liver with the initial signs of portal hypertension. The condition is considered chronic hepatitis C virus (HCV), cirrhotic stage. Was observed in the infectious, antiviral therapy is not received, 1 year undergoing hepatic - Heptral, Essentiale. January 2010 - outpatient screening anti-HCV positive, HBsAg - negative, ECG: heart rate 65 sinus, incomplete blockade of the right bundle branch. In the last 2 weeks notes weakness, loss of appetite, PE is iadicicco drowsiness.

Objective: at the time of inspection - conscious, oriented in time and space, the questions are answered correctly, the character of the handwriting is not modified.

Skin and visible mucous membranes of normal color, clean. The heart rate of 68 beats per minute, rhythmic, satisfactory filling and voltage. Blood pressure is 110/75 mm Hg auscultation of the heart tones somewhat muted. In the study of lung lesions were found. The belly of the correct form, is actively involved in the acts of breathing, palpation of soft, painless. Liver +7 cm from the edge of the costal arch. Ascites is minimal. Effleurage on lower back pain.

Conclusion: On the basis of complaints, physical examination and clinical laboratory findings, the patient A., chronic viral hepatitis With minimal activity, cirrhotic stage Child Pugh Century Portal hypertension (hypersplenism, DFDS esophagus 1 degree).

Ascitic syndrome.

Chronic gastroduodenitis, without exacerbation.

Complications: hepatic cell failure, class, hepatic encephalopathy latent stage.

Clinical and laboratory tests during treatment of patient A.: the Level of hemoglobin - 124 g/l, erythrocytes - 3.7 x 1012/l, leukocytes - 5,1×109/l, erythrocyte sedimentation rate of 30 mm/hour, platelet - 70×109/l, Alat - 107 units/l, AST - 70 units/l, alkaline phosphatase - 217 the doctor/l, GGT - 63 u/l, total bilirubin - 30 units/l, total protein - 77 g/l, albumin 25 g/l

Fibrogastroduodenoscopy: DFDS esophagus 1 degree, Chronic gastroduodenitis, without exacerbation.

Abdominal ultrasound: hepatosplenomegaly, v porte 15 mm, ascites

Markers of hepatitis:

HBsAg - negative.

Anti-HCV - positive.

RW - negative.

Test connection numbers (TSC) - 37 sec.

The test Line (t) - 59 sec.

The number of errors t (COT) - 4.

On psychometric testing is determined by the latent encephalopathy.

The neurologist, Neurological history is not burdened.

In neurological status - clear consciousness, orientation of all kinds stored, the normal speech rate, in conversation initiative, the questions are answered correctly, sometimes slowly, reluctantly. The elements of emotional lability. The character of the handwriting is not modified. Field of view is not changed, easy anisocoria (pupils S=D), the expression is lively, movement of the eyeballs in full, eye - no, the facial muscles are symmetric, bulbar disorders - not, sensitive disorders on the face does not show. The exit point of the trigeminal nerve is painless. Disorders of smell, hearing is not revealed. Symptoms of oral automatism is not. The power of paralysis in the extremities, abnormal stop signs - not detected. Deep reflexes D=S, the average gives and, superficial abdominal reflexes saved, D=S. asserts hyperesthesia with giperbolicheskim shade type "socks" from the level of the ankle. Vibration sensitivity on the toes and hands are not reduced. Coordinatorsee sample performs satisfactorily. In the Romberg - resistant. Meningeal symptoms - no.

Conclusion: at the time of inspection data for acute neurological pathology no. There is a latent encephalopathy, more likely hepatic dysfunction.

When EEG: Data for the pathological activity is not obtained, the frequency of the α-rhythm frequency of 8.5-12 oscillations in 1 second. Pathology it is not revealed.

When using multilevel neurodynamic analysis cardiotocogram using PAC "omega", the following data:

Index And 25%, And The Index B1 - 31%, The Index Of C1 - 8%, The Index D1 - 26%.

The claimed formula:

ThePE-L=-1,5+0,003·A+0,013·B1+0,006·C1+0,053·D1.

ThePE-L=-1,5+0,003·25+0,013·31+0,006·8+0,053·26=0,40.

The resulting coefficient of 0.40 indicates that in this patient A. hepatic encephalopathy latent stage.

Example 2.

Patient W., 44 years. A/C No. 5891. 08.04.2010,

Complaints: weakness, lethargy, daytime sleepiness, ascites, and abdominal discomfort.

From the anamnesis it is known, that in 2006 for the first time began to notice itching, doctors did not apply In 2008 for the first time said potentiality, in the clinic when examination revealed bilirubin 40 units/l Alat 89 units/l, AST - 70 units/l, HBsAg - positive (human immunodeficiency. room 53.589 on 30.06.2008), V - negative.

Ultrasound of abdomen: hepatomegaly with diffuse changes, v.porte - 16 mm, splenomegaly, fibrogastroduodenoscopy: DFDS esophagus 3 degrees. ECG: heart rate 70 sinus, without deviating from the norms. Received hepatic and detoxication therapy. In September 2009, performed ligation of the veins of the esophagus. Over the last 1 month has been noted an increase in abdominal volume, weakness, pain in the right hypochondrium.

In the last 5 days notes the increasing weakness, loss of appetite, drowsiness in the daytime.

Objective: at the time of inspection - conscious, oriented in time and space, the questions are answered correctly, the character of the handwriting is not modified.

Skin and visible mucous membranes of normal color, clean. The pulse of 70 beats per minute, rhythmic, satisfactory filling and voltage. Blood pressure is 110/70 mm Hg auscultation of the heart tones somewhat muted. In the study of lung lesions were found. The belly of the correct form, is actively involved in the acts of breathing, palpation of soft, painless. Liver +5 cm from the edge of the costal arch. Ascites. Effleurage on lower back pain.

Conclusion: On the basis of complaints, OSMO is RA and clinical and laboratory data of the patient W. is:

Chronic viral hepatitis b cirrhotic stage Child Pugh Century

Portal hypertension (hypersplenism, DFDS esophagus 3 degrees).

Ligation of the veins of the esophagus from September 2009

Ascitic syndrome.

Complications: hepatic cell failure, class, hepatic encephalopathy latent stage.

Clinical and laboratory tests during treatment the patient Sh.:

The level of hemoglobin - 103 g/l, erythrocytes - 2,8×1012/l, leukocytes - 3,1×109/l, ESR - 33 mm/hour, platelet - 54×109/l, Alat - 57 units/l, AST - 45 units/l, alkaline phosphatase - 177 units/l, GGT - 38 u/l, total bilirubin - 41 units/l, total protein 58 g/l, albumin - 21 g/L.

Fibrogastroduodenoscopy: DFDS esophagus 3 degrees. Condition after ligation of the veins of the esophagus, bleeding is not identified. Chronic gastroduodenitis, without exacerbation.

Abdominal ultrasound: hepatosplenomegaly, v porte 17 mm

Markers of hepatitis:

HBsAg - positive.

Anti-HCV - negative.

RW - negative.

Test connection numbers (TSC) - 38 sec.

The test Line (t) - 48 sec.

The number of errors t (COT) - 5.

On psychometric testing is determined by the latent encephalopathy.

The neurologist, Neurological history is not burdened.

In neurological status - clear consciousness, orientation of all types of stored speech norms is supplemented flax tempo, in conversation initiative, the questions are answered correctly, sometimes slowly, reluctantly. The elements of emotional lability. The character of the handwriting is not modified. Field of view is not changed, easy anisocoria (pupils S=D), the expression is lively, movement of the eyeballs in full, eye - no, the facial muscles are symmetric, bulbar disorders - not, sensitive disorders on the face does not show. The exit point of the trigeminal nerve is painless. Disorders of smell, hearing is not revealed. Symptoms of oral automatism is not. The power of paralysis in the extremities, abnormal stop signs - not detected. Deep reflexes D=S, the average stuffy, superficial abdominal reflexes saved, D=S. Vibration sensitivity on the toes and hands are not reduced. Coordinatorsee sample performs satisfactorily. In the Romberg - resistant. Meningeal symptoms - no.

Conclusion: at the time of inspection data for acute neurological pathology no. There is a latent encephalopathy, more likely hepatic dysfunction.

When EEG: Data for the pathological activity is not obtained, the frequency of the α-rhythm frequency of 8.5-12 oscillations in 1 second.

When using multilevel neurodynamic analysis cardiotocogram using PAC "omega", the following data:

Index a - 51%, the Index B1 - 22%, the Index of C1 - 30%, the Index D1 -14%

ThePE-L=-1,5+0,003·A+0,013·B1+0,006·C1+0,053·D1.

ThePE-L=-1,5+0,003·51+0,013·22+0,006·30+0,053·14=-0,14.

The obtained coefficient of 0.14 indicates that the patient W. hepatic encephalopathy latent stage.

The accuracy of diagnosis of hepatic encephalopathy latent stage in patients with chronic liver diseases by the present method is 75% (from 53 patients - 40), by the method similar (EEG) - 36% (from 53 patients - 19).

Unlike the prototype method, developed specific diagnostic criteria, obtained by the method of multilevel neurodynamic analysis cardiotocogram to determine hepatic encephalopathy latent stage in patients with chronic liver diseases.

Table 1
The distribution of patients according to nosological form of the disease and the stage manifestations of hepatic encephalopathy
Nosological form HSPStage PE
PE-0PE-LPE-I
Autoimmune hepatitis, n=29 (19,0%)9 (18%)11 (21%) 9 (18%)
Chronic viral hepatitis (b or C), n=42 (28,0%) [cirrhotic stage, n=19]13 (27%) [6 (12%)]15 (28%) [7 (13%)]14 (28%) [6 (12%)]
Chronic alcoholic hepatitis, n=41 (27,0%) [cirrhotic stage, n=21]14 (28%) [7 (14%)]13 (25%) [8 (15%)]14 (28%) [6 (12%)]
Non-alcoholic steatohepatitis, (Nash), n=40 (26,0%)13 (27%)14 (26%)13 (26%)
Total: n=152 (100%)49 (32%)53 (35%)50 (33%)

Table 2
Clinical characteristics of patients with chronic liver disease, typical symptoms of liver inifilepath
The main clinical symptoms and syndromes characteristic for PETotal n=152Stage PE
PE-0, n=49PE-L, n=53 PE-I, n=50
n (%)n (%)n (%)n (%)
average scoreaverage scoreaverage score
Cognitive dysfunction924 (8%)38 (72%)50 (100%)
(61%)0,5±0,21,0±0,22,4±0,2
[1][0,l]
The lack of coordination691 (2%)27 (51%)41 (82%)
(45%)0,4±0,21,2±0,22,5±0,1
[1][0,l]
Changes in sleep692 (4%)28 (53%) 39 (78%)
(45%)0,3±0,20,9±0,22,6±0,2
[1][0,l]
Impairment of consciousness100 (0%)0 (0%)10 (20%)
(7%)000,4±0,2
Disorders of intelligence250 (0%)0 (0%)25 (50%)
(16%)000,8±0,2
[1][0,l]
Personality changes100 (0%)0 (0%)10 (20%)
(7%)00[1][0,l]
Speech disorders90 (0%)0 (0%)9 (18%)
(6%)000,3±0,2
[0,l]
Asterixis180 (0%)0 (0%)18 (36%)
(12%)000,6±0,2
[1][0,l]
0 - the differences are statistically significant (p<0.05) in comparison with the performance of the group PE-0
l - the differences are statistically significant (p<0.05) in comparison with the performance of the group PE-L
1 - the differences are statistically significant (p<0.05) in comparison with the performance of the group PE-I

Table 3
Clinical parameters of blood in patients with chronic liver disease and hepatic encephalopathy
IndicatorsStage PE (M±m)
PE-0, N=49PE-L, N=53PE-I, N=50
Hb, g/l133,2±5,2132,9±4,1of 123.2±3,2
Er, ×1012/l4,43±0,24,37±0,33,90±0,2
Tr ×109/l245,1±12,5of 209.5±10,4157,8±12,6
[1][0,l]
L, ×109/n6,2±0,36,5±0,36,7±0,3
ESR, mm/h10,2±0,3the 15.6±0,222,5±0,3
[0,1] [0,l]
0 - the differences are statistically significant (p<0.05) in comparison with the performance of the group PE-0
l - the differences are statistically significant (p<0.05) in comparison with the performance of the group PE-L
1 - the differences are statistically significant (p<0.05) in comparison with the performance of the group PE-I

Table 4
Biochemical parameters of blood in patients with chronic liver disease and hepatic encephalopathy
IndicatorsStage PE (M±M)
PE-0, N=49PE-L, N=53PE-I, N=50
Total protein g/lto 75.8±1,3to 74.7±1,268,2±0,6
[1][0,l]
Albumin g/l43,3±2,039,3±1,235,6±1,4
[0]
ACT, u/l 54,5±2,4an 80.2±2,184,5±2,2
[0][0]
ALT, u/l53,9±2,1an 80.2±2,1to 88.3±2,2
[0,1][0,l]
The total bilirubin, µmol/l24,1±2,128,0±2,239,8±2,1
[1][0,l]
Alkaline phosphatase, u/l201,2±9,7to 266.8±8,7307,4±9,2
[0,1][0,l]
PTP, u/lof 111.2±8,7173,7±9,4221,8±11,7
[0,1][0,l]
PTI, %82,5±2,182,6±2,4for 77.2±1,9
0 - the differences are statistically significant (p<,05) in comparison with the performance of the group PE-0
l - the differences are statistically significant (p<0.05) in comparison with the performance of the group PE-L
1 - the differences are statistically significant (p<0.05) in comparison with the performance of the group PE-I

Table 5
Ramacaritamanasa parameters of patients with chronic liver disease depending on the stage of hepatic encephalopathy
N=152 indexesPATIENTS HSP
PE-0PE-LPE-I
N=49N=53N=50
And56,5±3,640,0±2,226,4±2,0
[0,1][0,l]
B1of 45.7±3,929,7±1,514,8±0,8
[0,1][0,l]
C146,2±3,5 8,5±0,9
[0,1][0,l]
153,4±3,914,8±1,64,2±0,8
[0,1][0,l]
0 - p<0.05 compared with group PE-0
l - p<0.05 compared with group PE-L
1 - p<0.05 compared with group PE-I

Table 6
The communication index information with the figures of other methods of examination of patients with chronic liver diseases
OptionsINDEX
AndB1C11
PE stage-0,47**-0,61**-0,66**-0,69**
TSC-0,18**-0,26**-0,23**-0,26**
T-0,13*-0,20*-0,20*-0,23*
albumin0,21*0,21*0,24**0,19*
ACT-0,18*
bilirubin-0,24**-0,19*-0,21*
platelets0,21*0,34**0,28**
Erythrocyte sedimentation rate-0,29**-0,29**-0,25**-0,21*
EEG: frequency of α-rhythm-0,34*-0,32*

Table 7
The equality test group average value is
indexesLambda WilksFp
And0,77828,313<0,000001
B10,63257,625<0,000001
C10,52788,768<0,000001
10,434129,149<0,000001

Table 8
Indices InPE-Lto determine hepatic encephalopathy latent stage
Group PEValues InPE-L
PE-stage 0 (none)≥0,50
PE-L stage-0,47-0,49
PE-I Clinically evident stage (grade 1)≤-0,48

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Method for the diagnosis of hepatic encephalopathy latent stage (PE-L) in patients with chronic liver disease, consisting in multilevel neurodynamic analysis cardiotocogram using rythmocardiography and hardware-software complex "omega-C, characterized in that when carrying out multi-level h is urodynamics analysis cardiotocogram appreciate these indexes reflect - "A" is a conjugation of all, but mainly peripheral rhythmic processes, "B1" - the degree of balance between sympathetic and parasympathetic influences on the sinus node of the heart, "C1" is the Central subcortical regulation, "D1" is the Central cortical regulation, with the subsequent calculation of the rate of diagnosis of PE-L in patients with chronic liver disease according to the formula: YPE-L=-1,5+0,003·A+0,013·B1+0,006·C1+0,053·D1, and when the value of YPE-Lfrom - 0,49 0,47 to determine hepatic encephalopathy latent stage in patients with chronic liver disease.



 

Same patents:

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FIELD: medicine.

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2 dwg, 1 ex, 2 tbl

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3 dwg, 6 ex

FIELD: medicine; cardiology.

SUBSTANCE: electrocardiogram of patients with arterial hypertension is subject to twenty-four-hours monitoring. Spectral analysis of variability of heart beating is conducted and low-frequency, very low frequency and high frequency wave components of heart beating are selected. Strength of wave components of heart beating is determined as general, day and night ones. Generalized factor W is calculated by original relation. Value of W is used for diagnosing absence or presence of hormone-active hyper-plastic process of adrenal glands.

EFFECT: screening testing at out-patient conditions.

2 ex, 2 tbl

FIELD: medicine; cardiology.

SUBSTANCE: electrocardiogram of patients suffering from arterial hypertension is subject to twenty-four-hours monitoring. Spectral analysis of variability of heart beating is carried out. Very low frequency, low frequency and high frequency wave components are selected. General, day and night strength of wave components of heart beating is determined. Any factor is estimated according to the data taken from the spreadsheet. Generalized factor Z is calculated by original mathematical relation. Value of Z is used for judging on level of influence of hormones of adrenal gland onto pace-maker activity of sinus node.

EFFECT: comfort at usage; higher efficiency at non-invasive application.

2 ex, 2 tbl

FIELD: medicine; functional medicine.

SUBSTANCE: method in based upon remote irradiation of human body with set of super wide-band electromagnet pulses with duration of 0,2-1,0 ns, repetition rate of 0,05-30,0 MHZ and average density of flow of energy at irradiated part of human body being equal or less than 0,2 mcW/cm2. Modulation component of pulse repetition rate is selected from received reflected signal which pulse repetition rate is determined by heart activity, which is used for forming heart beat rate signal. The latter is used additionally for estimating index of stress which value of index of stress is included into transmitted communication message of mobile phone.

EFFECT: prolonged monitoring of functional condition of human.

3 cl, 2 dwg

FIELD: medicine, cardiology.

SUBSTANCE: one should register a rhythmocardiogram, detect spectral values for variability of cardiac rhythm, calculate the value of autonomic index, calculate the value of autonomic tonicity by the following formula: AI/lnTp m sq. sec., where AI - autonomic index, lnTp - total power for the spectrum of variability of cardiac rhythm. At values above 3.1 one should diagnose severe flow of autonomic dystonia syndrome, at values being 3.1-2.2 - moderate flow of the mentioned disease, at values ranged 2.1-1.5 - light flow. The method enables to predict the development of hemodynamic disorders.

EFFECT: higher efficiency and accuracy of diagnostics.

3 ex

FIELD: medicine; cardiology.

SUBSTANCE: device for processing intervals of electrocardiogram has plate with Q-T (J-T) and R-R scales applied onto the plate. Plate is additionally provided with legs, rod and scale pointer at the end, arrows, and catches disposed at ends of Q-T (J-T) scale, Q-Tc (J-Tc) correlated values curves and Q-Tc (J-Tc) scale related to them. Rod is divided by axis to parts to relate as 1:5 in such a way that shorter part of rod has to be movable leg and longer part has to be the pointer of Q-T (J-T) scale. Pointer takes "0" position of Q-T (J-) scale to rest against left catch when legs close up. Motionless arrow is disposed onto longer part of rod under pointer of Q-T and/or J-T scale at level of "0" position of R-R scale. Slider with lock is mounted onto pointer to move along pointer. Slider is provided with two arrows. Formulas for building curves of Q-Tc (J-Tc) corrected values are given.

EFFECT: higher speed and comfort at processing of electrocardiograms.

3 cl, 8 dwg, 1 tbl

FIELD: medicine, electrocardiography.

SUBSTANCE: the present innovation deals with measuring parameters of electrocardiosignal (ECS) ST-segment and their analysis to detect deviations against the norm. At every step of quantization one should form the readings of first-order differences and modules of first-order differences. One should memorize N of readings for the modules of first-order differences coming after ECS readings that correspond to the onset of cardiocycle. Then it is necessary to sum up memorized values of modules and at every step of quantization one should compare the obtained current sum value with previous one. It is necessary to memorize the greater of them and according to maximal value one should form threshold level to compare current value of modules sum. Time moments when sum value is at first greater and then lower against threshold level one should consider to be, correspondingly the onset and the end of ST-segment. Time segment between the onset and the end of ST-segment should be considered as duration of ECS ST-signal. Device to isolate ECS ST-signal on-line contains a block for forming ECS, a block for primary ECS processing, a quantization block, a block for isolating the point of cardiocycle onset and measurement of its duration, a block to form first-order differences, a block to form modules of first-order differences, a block to memorize readings for the modules of first-order differences, a block to detect the number of summarized readings for the modules of first-order differences, a summarizing block, a block to form a threshold level, a block for comparison and a key device. The innovation enables to isolate ST-segment more reliably for wider class of electrocardiograms at different modifications of QRS-complex form.

EFFECT: higher efficiency.

2 cl, 12 dwg

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