DST and NCT-A are two sub-tests of PHES, and the normative data based on Chinese population are still lacking 3, 4, 11. In China, due to the different language and cultural characteristics, abnormal results of both digit symbol test (DST) and number connection test A (NCT-A) have been recommended for diagnosing MHE 13, 14, 15. In western countries, the recognition of MHE depends on Psychometric Hepatic Encephalopathy Score (PHES), Stroop EncephalApp, Animal Naming Test, Critical Flicker Frequency test, and Inhibitory Control Test, et al. Previous studies also showed that patients with MHE were more likely to develop overt hepatic encephalopathy (OHE), which caused a significant burden to health systems and society overall 8, 9, 10.Ĭurrently, there is no gold standard for the diagnosis of MHE. The occurrence of MHE is common in patients with liver cirrhosis and it may affect the quality of life and patients’ driving ability 5, 6, 7. MHE is defined as alterations in psychomotor or neuropsychiatric function without clinical evidence of neurological abnormalities, which can only be identified by neuropsychological or neurophysiological alterations 3, 4. In recent decades, minimal hepatic encephalopathy (MHE), which is the mildest phase of HE, has been added into the West Haven Criteria, attracting more and more attentions 2. Patients with HE have a spectrum of neurologic and psychiatric manifestations, which can be classified into 1–5 categories by the West Haven Criteria 1. Hepatic encephalopathy (HE) is one of serious complications of liver cirrhosis, severely affecting the lives of patients. A significant proportion of Chinese cirrhotic patients suffered from MHE, especially those with worse Child–Pugh classification. The regression-based normative data of NCT-A and DST have been developed to detect MHE in China.

The prevalence of MHE was 8.89% in cirrhotic patients, and only worse Child–Pugh classification ( P = 0.002, OR = 2.389) was demonstrated to be the risk factor for MHE.

Cirrhotic patients with concurrent abnormal NCT-A and DST results were diagnosed with MHE. The norm for NCT-A was set as Z ≤ 1.64, while the norm for DST was set as Z ≥ − 1.64. The predictive equations for expected scores of NCT-A and DST were established, and Z-scores were calculated. Age, gender, education, and age by education interaction were all predictors of DST, while age, gender, and education by gender interaction were predictors of log 10 NCT-A. The regression-based procedure was applied to develop demographically adjusted norms for NCT-A and DST based on healthy controls. NCT-A and DST were administered to 648 healthy controls and 1665 cirrhotic patients. We aimed to establish the norms based on a multi-center cross-sectional study and to detect MHE in cirrhotic patients. Number connection test A (NCT-A) and digit symbol test (DST), the preferential neuropsychological tests to detect minimal hepatic encephalopathy (MHE) in China, haven’t been standardized in Chinese population.

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