ApoE、CALHM1基因多态性与颞叶癫痫的关联研究中文版儿童癫痫影响量表的信度与效度分析

【作者】 吕瑞娟；

【导师】 吴立文； 金丽日；

【作者基本信息】 中国协和医科大学 ， 神经病学， 2010， 博士

【摘要】 第一部分ApoE、CALHM1基因多态性与颞叶癫痫的关联研究研究背景与目的癫痫是神经系统中仅次于脑血管疾病的第二大病种。全球大约有50000000人患有癫痫,其中发展中国家的患者占80%。癫痫给患者、家庭以及整个社会都带来了极大的疾病负担。内侧颞叶癫痫(mesial temporal lobe epilepsy, MTLE)是发病率最高的成人部分性癫痫,也是临床上最常见的难治性癫痫综合征。散发性MTLE是由遗传因素和环境因素共同作用所导致的一类多基因复杂疾病,其中遗传因素在MTLE的发生发展中扮演着重要的角色。遗传背景的差异在散发性MTLE人群中主要表现为单核苷酸多态性(single nucleotide polymorphisms, SNPs),大量的研究证据表明基因多态性在MTLE的易感性方面发挥了重要的作用。一些研究表明载脂蛋白E (apolipoprotein E, ApoE)基因可能是MTLE的一个易感基因,另有研究发现ApoEε4等位基因与一些疾病相关的特征比如创伤后癫痫发作、MTLE早的起病年龄、难治性复杂部分性发作以及MTLE发作后意识障碍有关。而其它的一些研究未能发现ApoEε4等位基因与MTLE的关联或者不能复制以前的关联研究。鉴于上述不一致的研究结果,再加上不同地域和人种的群体在遗传方面常存在差异,因此我们试图在中国汉族人群进行ApoE基因多态性与MTLE以及上述报道的一些MTLE相关临床变量的关联研究。另外,最近一研究发现人钙稳态调节蛋白1基因(calcium homeostasis regulator 1, CALHM1)能够调节钙离子稳态、提高脑内β-淀粉样蛋白(amyloid-p,Aβ)的产生。钙离子稳态和脑内Aβ的沉积均与MTLE的发生有密切的关系,据此我们推测CALHM1基因可能是MTLE的易感基因,因而探讨了CALHM1基因多态性与MTLE的关联。研究方法本研究采用病例对照研究设计,在735例癫痫患者(包括560例MTLE患者)、558例健康对照受试者中探讨了ApoEε4等位基因和-491A／T多态性与MTLE及其一些相关临床变量的相关性；在560例MTLE患者、401例健康对照受试者中探讨了CALHM1基因5个多态性位点与MTLE易感性之间的关联。采用PCR-PIRA (Primer Introduced Restriction Analysis,引物引入限制性分析)和PCR-RFLP (Restriction Fragment Length Polymorphism,限制性片段长度多态性)法进行基因分型。采用盲法和随机抽取10%的样本重测进行质量控制。结果1.ApoE基因多态性与MTLE的相关性中国汉族人群MTLE患者ApoEε4等位基因与既往较严重的头部创伤有关,既往有颅脑损伤的患者中携带ε4等位基因者发展成MTLE的风险是无ε4等位基因者的1.873倍(OR=1.873,95%CI 1.084-3.237,p=0.023). MTLE组与健康对照组比较,ApoE和-491A／T的等位基因、基因型及单倍型分布无明显差异。ApoEε4等位基因与难治性MTLE的起病年龄、难治性复杂部分性发作以及MTLE发作后意识障碍无关。2. CALHM1基因多态性与MTLE的相关性CALHM1基因rs1119692位点等位基因与MTLE有明显关联(OR=1.35,95%CI1.10-1.65,p=0.003),经多重比较校正后p值仍有统计学差异(校正后p=0.015)。MTLE组rs1119692-A等位基因的频率(32.4%)明显大于健康对照组(26.2%)。基因型分析也表明rs1119692变异与MTLE显著相关(p=0.004,校正后p=0.02)。CALHM1基因多态对于MTLE遗传易感性的影响与ApoEε4等位基因无关。四位点单倍型rs1119692-rs729211-rs2986016-rs2986017与MTLE的关联最强(x2=19.87,p=0.0005)。其中G-G-G-T单倍型能够显著增加MTLE的发生风险(OR=2.09,95%CI1.27-3.42,p=0.0029),而G-A-G-C单倍型能够明显降低MTLE的发生风险(OR=0.70,95%CI 0.53-0.92,p=0.0106)。另外,二位点、三位点和五位点单倍型分析也表明了它们与MTLE有明显的关联。与Alzheimer病不同,本研究未发现rs2986017(Pro86Leu)与MTLE的关联。MTLE组与健康对照组比较,其它的三个位点(rs729211、rs2986018、rs2986016)的等位基因与基因型均无统计学差异。结论ApoEε4等位基因可能是既往有颅脑创伤史患者发生MTLE的一个危险因素,而ApoE和-491A／T多态性与中国汉族人群MTLE的易感性、难治性MTLE的起病年龄、难治性复杂部分性发作以及MTLE发作后意识障碍无关。CALHM1基因rs1119692多态性改变可能与MTLE的发病有关,且不依赖于ApoEε4等位基因的存在。第二部分中文版儿童癫痫影响量表的信度与效度分析研究背景和目的癫痫是儿童时期最常见的慢性神经系统疾病之一,我国儿童癫痫(不含热性惊厥)每年的发病率为151／10万,患病率为3.45%o,因此癫痫是危害儿童身心发育的重要疾病之一。最近大量的研究提示癫痫治疗的终极目标已不再仅仅局限于控制癫痫发作,还要使癫痫患儿的生活质量得到全面的提高。目前,尽管已有很多用于评定儿童癫痫对癫痫患儿生活质量影响的量表问世,但仍然缺乏能够用来评价儿童癫痫对其家庭及患儿生活质量影响的癫痫特异性调查问卷。儿童癫痫影响量表(theimpact of pediatric epilepsy scale, IPES)就是针对评价儿童癫痫对其家庭及自身生活质量的影响这一目的而创建的,它是一合适、有效的测评量表。不同的经济和文化背景可能会对西方国家适用的测评工具直接在其他国家使用时的可信性和有效性产生影响。因此,本研究的目的是将英文版IPES量表恰当地翻译成中文,并检验其信度、效度以及敏感度,从而为我国心理学研究以及常规临床护理提供一个良好的测量工具。方法根据欧洲癌症研究及治疗机构生活质量小组的量表翻译过程指南,将英文版IPES量表翻译成中文。严格按照录入和排除标准纳入合适的病人。该量表的聚合效度是通过分析中文版IPES量表中的每个项目与中文版父母评价的儿童癫痫生活质量量表和儿童癫痫影响测评表的亚量表的相关性来评价；采用主成份分析,并作方差最大旋转(varimax rotation)来检验该量表的结构效度。Cronbach’s a系数用于评估每个项目与总量表的内部一致性信度；采用组内相关系数(the intraclass correlation coefficient, ICC)模型来评价该量表的重测信度。敏感度的分析是通过比较不同癫痫严重程度患儿的项目平均得分的差异是否显著来评价。结果在将英文版IPES量表翻译为中文的过程中,遇见的主要问题是能否准确理解其含义和文化背景的差异。共有110例患者纳入本研究,在研究人员的督促下所有入组患者均完成了重测测验。完成该量表的平均时间为5分钟(3-10分钟),每个项目的平均得分范围是0.30-2.82分。该量表的所有项目都对该测量工具有显著贡献。效度分析表明,IPES量表的每个项目平均得分与中文版父母评价的儿童癫痫生活质量量表和儿童癫痫影响测评表中概念相近的亚量表显著相关,主成份分析显示三个因素(外部活动的参与、社会功能、家庭生活)解释了该量表72%的方差。第一次和第二次测验的总体内部一致性系数分别为0.916和0.930；该量表的重测信度范围为0.891-0.992。另外,该量表能够区分不同严重程度的癫痫患儿,提示其具有较高的敏感度。结论中文版IPES量表的翻译过程经过反复斟酌,心理测量学特征分析结果提示该量表具有较好的效度、极好的内部一致性信度和重测信度以及较高的敏感度,因此它可以作为在中国评价儿童癫痫对其家庭及自身生活质量影响的严重程度的一个确切、可接受、简洁的生活质量测评工具。该量表在未来的心理学研究以及常规临床护理中都具有重要的应用价值。更多还原

【Abstract】 Background and ObjectivesEpilepsy is the second common neurological disorder after cerebrovascular disease. It is estimated that the condition affects approximately 50 million people in the world,80%of whom live in developing countries. Epilepsy brings huge disease burden to the patient, his or her family and the whole society. Mesial temporal lobe epilepsy (MTLE) possesses the highest incidence of adult partial epilepsy and also is the most common drug-resistant epilepsy syndrome. Sporadic MTLE is accepted as a complex disorder attributed to the interaction of genetic and environmental factors. The genetic background plays an important role in induction and maintainance of MTLE. The difference of genetic background in sporadic MTLE population mainly appears as single nucleotide polymorphisms (SNPs). Considerable research has indicated that genetic polymorphism plays a vital role in the susceptibility to MTLE. Some studies indicate that apolipoprotein E (ApoE) may be a susceptibility gene to MTLE. Previous studies indicate that ApoE s4 is associated with several disease-related traits including the increased risk of late posttraumatic seizures, earlier onset of MTLE, refractory complex partial seizures, and postictal confusion. Contradictory data were also reported regarding the association between ApoE polymorphisms and MTLE. The above findings are inconsistent. Furthermore, the genetic background is often different in different geographic area and different ethnicity. Therefore, this study was designed to investigate ApoE gene polymorphisms among the Chinese Han patients with MTLE and its relationship with the clinical variables associated with MTLE. In addition, a recent study identified a SNP (Pro86Leu, rs2986017) in calcium homeostasis regulator 1 (CALHM1) gene influences Ca2+homeostasis and increases cerebral amyloid-β(Aβ) peptide production. Ca2+ homeostasis and high levels of AP in brain are intimately related to MTLE. Thus, we speculate that CALHM1 may be a susceptibility gene, and we also examine the association between CALHM1 gene polymorphisms and MTLE.MethodsThis study, a case-control association study design, was to investigate the association between ApoE and-491A/T polymorphisms and MTLE as well as the clinical variables associated with MTLE in 558 controls and 735 patients including 560 MTLE patients. We also examined the association between CALHM1 gene polymorphisms and MTLE in 401 controls and 560 MTLE patients. We genotyped the polymorphisms by polymerase chain reaction-primer introduced restriction analysis (PCR-PIRA) and polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP). In addition, genotyping was performed blindly and 10% of the samples were randomly selected for repeated assays.Results1. Association of ApoE gene polymorphisms with MTLE We detected significant association between prior severe trauma and the ApoEε4 allele in Han Chinese MTLE patients, and the relative risk of MTLE for patients with prior trauma carryingε4 allele was 1.873 (Odds Ratio,1.873; 95%Confidence Interval, 1.084-3.237;p=0.023). There were no statistically significant differences in frequency of ApoE and-491A/T alleles, genotypes or haplotypes between MTLE and control groups. The ApoE s4 allele was not associated with the increased risk of onset of refractory MTLE, refractory complex partial seizures, and postictal confusion.2. Association of SNPs in CALHM1 gene with MTLEA significant allelic association for rs1119692 was observed (OR=1.35,95%CI 1.10-1.65, p=0.003). After a Bonferroni correction was applied, there was still a significant association between rs1119692 and MTLE (corrected p=0.015). The frequency of the rs1119692-A allele was greater in patients (32.4%) than in control subjects (26.2%). Genotype analysis also showed an association for rs1119692 (uncorrected p=0.004, corrected p=0.02). CALHM1 rs1119692 variant might play a causal role in MTLE development independent of ApoEε4. The four-SNP haplotype (rs1119692-rs729211-rs2986016-rs2986017) showed the strongest association with MTLE (x2=19.87, p=0.0005). The G-G-G-T haplotype exhibited association with the increased risk of MTLE (OR=2.09,95%CI 1.27-3.42,p=0.0029) whereas the G-A-G-C haplotype was significantly associated with the reduced risk (OR=0.70,95%CI 0.53-0.92,p=0.0106). In addition, two-, three-, and five-SNP haplotype analysis also showed strong association with MTLE. In contrast with Alzheimer disease, no evidence of an association between rs2986017 and the risk for MTLE was found in our study. The other three SNPs (rs729211, rs2986018, rs2986016) did not show allelic or genotypic association with MTLE.ConclusionsThe ApoEε4 allele probably contributes to the development of MTLE in those patients with prior trauma. However, there were no significant association of ApoE and-491A/T polymorphisms with the increased risk of MTLE, onset of refractory MTLE, refractory complex partial seizures, and postictal confusion. CALHM1 rs1119692 variant may contribute to MTLE development independent of ApoE s4. Background and objectivesEpilepsy is one of the most common neurological disorders in children. The incidence and prevalence of childhood epilepsy (excluding febrile convulsion) in China is 1.51%o and 3.45%o, respectively. Therefore, epilepsy is one of the most important diseases that do great harm to physical and mental development of children. In recent years, considerable research shows the goal of childhood epilepsy treatment has been not only the control of epileptic seizures, but also an improvement of health-related quality of life (HRQOL). At present, although many scales can be used to assess the HRQOL of children with epilepsy, there are few epilepsy-specific questionnaires to evaluate the impact on the child’s and the family’s life. The impact of pediatric epilepsy scale (IPES) was developed to evaluate the impact on the family and the child of childhood epilepsy appropriately and efficiently. Since people from different countries have different economic and cultural backgrounds, the inventories developed in western countries may not have good reliability and validity when directly used in other countries. Thus, the aim of this study was to translate and to adapt the original version of IPES into a Chinese version, and to verify its reliability, validity, and sensitivity, which can provide a good measure for future psychological research and routine clinical care in China.MethodsThe IPES was translated into Chinese according to the procedure of the European Organization for Research and Treatment of Cancer Quality of Life Group. The eligible patients were selected strictly according to the inclusion and exclusion criterion. Convergent validity was assessed by analyzing the correlations between the translation and the subscales of the Chinese version of the Parent-Proxy Health-Related Quality of Life Measure for Children with Epilepsy (PPRS-QOLCE) as well as the impact of childhood epilepsy schedule. A principal components analysis, with a varimax rotation, was conducted to examine the construct of the measure. Cronbach’s alpha coefficient was used to evaluate the internal consistency of the item and total scores. The intraclass correlation coefficient (ICC Model 2.1) was used to analyze the degree of agreement between test and retest scores at the item level. The sensitivity of the IPES was evaluated by examining the relationship between the mean score and epilepsy severity. ResultsThe main translational problems encountered in developing the Chinese version of IPES were due to the exact meaning of items and cross-cultural problems. One hundred and ten patients met the eligibility criteria. Under the supervision of the researcher, all eligible patients’parents completed the retest assessment. The subjects recruited completed all items in approximately 5 min (range:3-10 min). Mean item scores ranged from 0.30 to 2.82. All items contributed significantly to the summary measure. Considering the validity, all items were substantially correlated with the subscales with similar concept in PPRS-QOLCE and the impact of childhood epilepsy schedule. The principal components analysis indicated that three factors (outside activity participation, social well-being, home life) accounted for 72%of the variance of the scale. The internal consistency coefficients of the first and second test for the total were 0.916 and 0.930 respectively, and the test-retest reliability ranged from 0.891 to 0.992. Additionally, the IPES can detect the differences in HRQOL between the subjects according to epilepsy severity, which has good sensitivity.ConclusionsAfter a multistage translation and cultural adaptation, psychometric analysis suggests the Chinese version of IPES exhibits appropriate validity, excellent internal consistency and test-retest reliability, and good sensitivity, supporting its usefulness as an accurate, acceptable and brief measurement tool that reflects the way that childhood epilepsy affects the child’s and family’s HRQOL in China. Future psychological research and routine clinical care will undoubtedly benefit from the use of this measure.更多还原