發(fā)布時(shí)間：2018-05-17 23:07

  本文選題：腎綜合征出血熱 + 危重度評(píng)分��； 參考：《山東大學(xué)》2013年碩士論文

【摘要】：背景和目的 腎綜合征出血熱(hemorrhagic fever with renal syndrome,HFRS)是以鼠類為主要傳染源的人畜共患傳染病,主要臨床表現(xiàn)為發(fā)熱、充血出血、低血壓休克、腎功能損害,病原體為漢坦病毒屬,其病理基礎(chǔ)是由病毒直接作用以及免疫損傷導(dǎo)致的全身廣泛小血管和毛細(xì)血管的損害。HFRS起病急,病情變化快,病死率高,因此早期預(yù)測(cè)疾病的轉(zhuǎn)歸,及早采取相應(yīng)的治療措施對(duì)提高救治率具有重要意義。目前臨床上主要的評(píng)分系統(tǒng)有簡化急性生理學(xué)評(píng)分(simplified acute physiology score,SAPS Ⅱ)、感染相關(guān)器官衰竭評(píng)估(sepsis-related organ failure assessment,SOFA)、多器官功能障礙評(píng)分(]multiple organ dysfunction syndrome,MODS)等多種,這些評(píng)分系統(tǒng)從不同角度,以定量賦分的形式對(duì)一些重癥疾病的發(fā)展、預(yù)后及轉(zhuǎn)歸進(jìn)行分析,具有積極的臨床指導(dǎo)意義。但由于HFRS的病理生理及臨床過程有其本身的特殊性,現(xiàn)有的評(píng)分系統(tǒng)很難準(zhǔn)確地對(duì)患者的病情作出評(píng)估。 參照臨床分型的指標(biāo)并根據(jù)HFRS本身的的臨床特點(diǎn),本研究設(shè)計(jì)了HFRS的危重度評(píng)分,選取了全身炎癥反應(yīng)綜合征(SIRS)狀態(tài)、外滲程度、血漿膠體滲透壓、血小板計(jì)數(shù)和尿蛋白濃度等5個(gè)參數(shù),以期能更簡捷、更有針對(duì)性地對(duì)患者的病情發(fā)展、轉(zhuǎn)歸和預(yù)后作出判斷。 方法 研究對(duì)象為2000年1月至2011年4月住院治療并確診為HFRS的患者,共120例,其中男89例,女31例,年齡16-75歲,平均為(46.0±14.7)歲,按預(yù)后情況分為存活組(90例)和死亡組(30例)。HFRS的診斷均符合1987年全國流行性出血熱會(huì)議制定的診斷與分型標(biāo)準(zhǔn),血清漢坦病毒抗體(IgM)陽性。確診為HFRS后,選擇發(fā)熱期第3-5天為觀察點(diǎn),收集患者相關(guān)臨床資料,并根據(jù)患者3個(gè)月后的預(yù)后情況進(jìn)行分組。 HFRS危重度評(píng)分的設(shè)立：由SIRS狀態(tài)、外滲程度、血漿膠體滲透壓、血小板計(jì)數(shù)和尿蛋白濃度5個(gè)參數(shù)構(gòu)成。每一參數(shù)按嚴(yán)重程度不同分為5個(gè)等級(jí),從低到高依次記為0、1、2、3和4分,合計(jì)總分最高為20分。SIRS診斷標(biāo)準(zhǔn)至少具備以下4條中的2條：(1)體溫38℃或36℃；(2)心率90次／分；(3)呼吸20次／分或過度通氣,PaCO232mmHg;(4)血白細(xì)胞計(jì)數(shù)12x109個(gè)/L或4×109個(gè)/L(12000個(gè)/μL或4000個(gè)/μL或未成熟粒細(xì)胞10%)。血漿膠體滲透壓(mmHg)[6]=血漿白蛋白(g/dl)×5.54+因漿球蛋白(g/d1)×1.43。外滲程度分輕度、中度、重度和極重度,輕度：僅有球結(jié)膜水腫；中度：球結(jié)膜水腫+顏面水腫；重度：球結(jié)膜水腫+全身皮膚水腫(或三腔積液)；極重度：球結(jié)膜水腫+全身皮膚水腫+三腔積液。三腔積液是指經(jīng)彩超檢查明確有腹腔、胸腔和／或心包腔積液者。 用Paswstat18.0統(tǒng)計(jì)軟件分析,資料以x±S表示,組間差異采用t檢驗(yàn)。采用受試者工作特征(receive operating characteristic, ROC)曲線下面積(area under curve, AUC)比較各評(píng)分方法對(duì)HFRS死亡風(fēng)險(xiǎn)的預(yù)測(cè)能力。根據(jù)其ROC曲線確定最佳診斷截?cái)嘀?并確定截?cái)嘀档拿舾行?sensitivity,SN)和特異性(specificity,SP),計(jì)算Youden指數(shù)。 結(jié)果 1、在HFRS危重度評(píng)分5個(gè)參數(shù)的單項(xiàng)評(píng)分中,死亡組的記分均高于存活組。死亡組的SIRS狀態(tài)、血漿膠體滲透壓和尿蛋白濃度的評(píng)分,均高于存活組(P0.05)。死亡組的外滲程度和血小板計(jì)數(shù)評(píng)分明顯高于生存組存活組(P0.01)。 2、在SOFA評(píng)分、SAPSⅡ評(píng)分和HFRS危重度評(píng)分中,死亡組患者的分值均顯著高于存活組(P0.01)。 3、SOFA評(píng)分、SAPSⅡ評(píng)分和HFRS危重度評(píng)分的AUC均0.7,分別為0.704,0.731和0.804。Youden指數(shù)以HFRS危重病評(píng)分為最高,SAPS Ⅱ評(píng)分次之,SOFA評(píng)分最低,分別為0.535、0.421、0.352。當(dāng)取HFRS危重度評(píng)分的截?cái)嘀禐?0分時(shí),其預(yù)測(cè)患者存在死亡風(fēng)險(xiǎn)的敏感性為78.8%,特異性為77.4%。應(yīng)用正態(tài)性z檢驗(yàn)分別比較HFRS危重度評(píng)分與SAPS Ⅱ評(píng)分和SOFA評(píng)分的AUC,差異均有統(tǒng)計(jì)學(xué)意義(z=13.16,P0.05；z=29.68,P0.01)。 結(jié)論 1、HFRS危重度評(píng)分參數(shù)的設(shè)定符合HFRS臨床的病理生理變化特點(diǎn),與傳統(tǒng)的評(píng)分相比,更具有針對(duì)性和可操作性,方法簡單、快捷。 2、HFRS危重度評(píng)分在發(fā)熱期即能對(duì)HFRS疾病的嚴(yán)重程度和預(yù)后做出判斷,能更好地提示臨床醫(yī)師及早采取防范措施。 3、當(dāng)取HFRS危重度評(píng)分的最佳截?cái)嘀?0時(shí),預(yù)測(cè)患者住院期間死亡風(fēng)險(xiǎn)的敏感性為78.8%,特異性為77.4%。 4、SOFA評(píng)分和SAPS Ⅱ評(píng)分對(duì)HFRS患者預(yù)后的評(píng)價(jià)具有一定的臨床價(jià)值,但其敏感度和特異度明顯低于血漿滲透壓綜合評(píng)分,差異具有統(tǒng)計(jì)學(xué)意義。
[Abstract]:Background and purpose
Hemorrhagic fever with renal syndrome (HFRS) is a zoonotic infectious disease with rodent as the main source of infection. The main clinical manifestations are fever, hyperemia, hypotension, and renal function damage, and the pathogen is hantavirus. The pathological basis is the direct effect of the virus and the wide range of the whole body caused by the immune injury. The damage of small blood vessels and capillaries is urgent, the condition changes quickly and the mortality rate is high. Therefore, it is of great significance to predict the prognosis of the disease and take the corresponding treatment measures early to improve the treatment rate. The main clinical scoring system is to simplify the acute physiological score (Simplified Acute physiology score, SAPS II) and infection. Related organ failure assessment (sepsis-related organ failure assessment, SOFA), multiple organ dysfunction score (]multiple organ dysfunction syndrome, MODS) and so on. These scoring systems have a positive clinical guidance for the analysis of the development, prognosis and prognosis of some severe diseases from different angles. However, because of the special nature of HFRS's pathophysiology and clinical process, it is difficult for the existing scoring system to accurately assess the patient's condition.
According to the clinical classification index and according to the clinical characteristics of HFRS itself, this study designed the critical score of HFRS, selected 5 parameters, such as systemic inflammatory response syndrome (SIRS), exosmosis, plasma colloid osmotic pressure, platelet count and urine protein concentration, in order to be more concise and more targeted to the development of the patient's condition. The outcome and prognosis are judged.
Method
The subjects were 120 patients who were hospitalized from January 2000 to April 2011 and diagnosed as HFRS, including 89 males and 31 females, 16-75 years old, and the average age was (46 + 14.7) years old. The prognosis was divided into the survival group (90 cases) and the death group (30 cases) in accordance with the diagnostic and classification criteria established by the national epidemic hemorrhagic fever conference in 1987. The serum hantavirus antibody (IgM) was positive. After the diagnosis of HFRS, the 3-5 day fever period was selected as the observation point. The related clinical data were collected and the patients were grouped according to the prognosis of the patients after 3 months.
The establishment of HFRS severity score was composed of 5 parameters: SIRS status, osmotic degree, plasma colloid osmotic pressure, platelet count and urine protein concentration. Each parameter was divided into 5 grades according to the severity, from low to high to 0,1,2,3 and 4, and the total score of the total score was 20.SIRS, with at least 2 of the following 4 items: 1 ) temperature 38 or 36; (2) heart rate 90 / fraction; (3) respiration 20 / sub or hyperventilation, PaCO232mmHg; (4) blood leukocyte count 12x109 /L or 4 x 109 /L (12000 / mu L or 4000 / L or immature granulocyte 10%). Plasma colloid osmotic pressure (mmHg) [6]= blood albumin (g/dl) x 5.54+ (g/d1) * 1.43. extravasation degree is light Degree, moderate, severe and extremely severe, mild: nodular conjunctiva edema; moderate conjunctival edema + facial edema; severe conjunctiva edema + total body edema (or three cavity effusion); extremely severe: conjunctiva edema + total body edema + three cavity effusion. Three cavity effusion was defined by color Doppler examination of abdominal cavity, thoracic cavity and / or pericardial cavity. Effusions.
Using the Paswstat18.0 statistical software, the data were expressed in X + S, and the difference between groups was tested by t test. The prediction ability of the death risk was compared with the area under the receive operating characteristic (ROC) curve (area under curve, AUC). The best diagnostic truncation value was determined according to the curve and the cut was determined. The sensitivity (sensitivity, SN) and specificity (specificity, SP) of the broken values were calculated, and the Youden index was calculated.
Result
1, the score of the death group was higher than the survival group in the single score of the 5 parameters of the HFRS severity score. The SIRS status of the death group, the plasma colloid osmotic pressure and the urinary protein concentration were all higher than those in the survival group (P0.05). The degree of exosmosis and platelet count in the death group were significantly higher than those in the survival group (P0.01).
2, in the SOFA score, SAPS II score and HFRS severity score, the scores in the death group were significantly higher than those in the survival group (P0.01).
3, SOFA score, SAPS II score and HFRS critical severity score were 0.7, respectively, 0.704,0.731 and 0.804.Youden index were the highest in HFRS critical disease score, SAPS II score was the second, and SOFA score was the lowest, respectively, when 0.535,0.421,0.352. when the truncated value of HFRS critical score was 10, the sensitivity of the patient to predict the risk of death was 78.. 8%, the specificity was 77.4%. application normal Z test to compare the HFRS critical severity score and the SAPS II score and the SOFA score AUC respectively. The difference was statistically significant (z=13.16, P0.05; z=29.68, P0.01).
conclusion
1, the setting of HFRS severity scoring parameters conforms to the characteristics of the pathophysiological changes in the clinical HFRS. Compared with the traditional score, it is more pertinent and operable, and the method is simple and quick.
2, HFRS severity score can predict the severity and prognosis of HFRS disease in the febrile period. It can better prompt clinicians to take preventive measures as early as possible.
3, when the optimal cut-off value of HFRS was 10, the sensitivity of predicting the risk of death during hospitalization was 78.8%, and the specificity was 77.4%.
4, SOFA score and SAPS II score have a certain clinical value in evaluating the prognosis of HFRS patients, but their sensitivity and specificity are significantly lower than that of plasma osmotic pressure, and the difference is statistically significant.
【學(xué)位授予單位】：山東大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2013
【分類號(hào)】：R512.8

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