本文選題：早產(chǎn)兒 + 壞死性小腸結(jié)腸炎�。� 參考：《大連醫(yī)科大學(xué)》2017年碩士論文

【摘要】：第一部分實(shí)驗(yàn)室檢驗(yàn)指標(biāo)用于協(xié)助決策早產(chǎn)NEC患兒手術(shù)的價(jià)值背景NEC(necrotizing enterocolitis,壞死性小腸結(jié)腸炎)是早產(chǎn)兒急性腸道炎癥性疾病,病死率高,預(yù)后相對(duì)較差。臨床可表現(xiàn)為胃潴留、腹脹、便血等腸道癥狀,又可表現(xiàn)為呼吸暫停、反應(yīng)低下、休克等全身中毒癥狀。目前臨床醫(yī)生對(duì)此疾病的治療原則和方法已相對(duì)統(tǒng)一,包括絕對(duì)禁食、持續(xù)胃腸減壓、抗生素的應(yīng)用等內(nèi)科保守治療方法和壞死腸管切除等外科手術(shù)治療。ⅡB期至ⅢA期之間的NEC患兒,疾病發(fā)展變化快,表現(xiàn)又無(wú)明顯特殊性。此時(shí)手術(shù)的相對(duì)適應(yīng)癥難以把握,這時(shí)應(yīng)用內(nèi)科保守治療能否控制病情的發(fā)展,還是需積極手術(shù)去除腸道病灶,是否有臨床特異性的指標(biāo)來(lái)協(xié)助治療,是我們亟需思考的問(wèn)題。目的本文將討論早產(chǎn)NEC患兒發(fā)病后前三天不同實(shí)驗(yàn)室檢驗(yàn)指標(biāo)與NEC手術(shù)的相關(guān)性,選擇可信度更高的指標(biāo)評(píng)估患兒NEC手術(shù)的需要,以更好把握臨床手術(shù)時(shí)機(jī)。方法本研究收集2014年12月至2015年7月我院極早產(chǎn)NICU科室收住的30例胎齡33周、Bell分期Ⅱ期以上的NEC患兒的臨床資料。根據(jù)治療方案分為手術(shù)組16例,未行手術(shù)治療的保守組14例。將早產(chǎn)NEC手術(shù)治療組和保守組發(fā)病后連續(xù)三天內(nèi)實(shí)驗(yàn)室檢驗(yàn)指標(biāo),應(yīng)用SPSS 19.0統(tǒng)計(jì)軟件進(jìn)行分析比較。研究因素包括:發(fā)病后三天內(nèi)白細(xì)胞計(jì)數(shù)、粒細(xì)胞比值、血小板計(jì)數(shù)、C反應(yīng)蛋白數(shù)值。結(jié)果在研究因素中,早產(chǎn)NEC患兒發(fā)病第一天的白細(xì)胞計(jì)數(shù)和CRP值,第二天的血小板計(jì)數(shù)和CRP值,第三天的血小板計(jì)數(shù)和CRP值與NEC手術(shù)相關(guān)。發(fā)病后第二天的血小板計(jì)數(shù)的減低是NEC手術(shù)的獨(dú)立高危因素。針對(duì)發(fā)病后第二天血小板計(jì)數(shù)進(jìn)行ROC曲線分析計(jì)算出cut-off值為144.5*109/l,對(duì)應(yīng)的敏感性為81.3%,特異性為87.5%,陽(yáng)性預(yù)測(cè)值為89.45%,陰性預(yù)測(cè)值為91.52%。結(jié)論1.早產(chǎn)NEC患兒發(fā)病第一天的白細(xì)胞計(jì)數(shù)和CRP值,第二天的血小板計(jì)數(shù)和CRP值,第三天的血小板計(jì)數(shù)和CRP值與NEC手術(shù)治療相關(guān)。2.發(fā)病后24-48小時(shí)內(nèi)血小板計(jì)數(shù)是NEC手術(shù)的獨(dú)立高危因素。當(dāng)數(shù)值低于144.5*109/l時(shí),提示手術(shù)需要性高,我們需要結(jié)合患兒臨床進(jìn)程情況,決策更好的治療方案,把握最佳手術(shù)時(shí)機(jī)。第二部分早產(chǎn)NEC患兒血清定量蛋白組學(xué)分析背景NEC可導(dǎo)致腸道急性炎癥性病變,其發(fā)病原因錯(cuò)綜復(fù)雜,更容易侵襲腸道發(fā)育不成熟、功能低下以及免疫功能弱的早產(chǎn)新生兒。此病無(wú)特異性表現(xiàn)及檢驗(yàn)標(biāo)準(zhǔn),進(jìn)展快,疾病預(yù)后差,對(duì)新生兒生長(zhǎng)發(fā)育和生活質(zhì)量影響極大�，F(xiàn)多認(rèn)為NEC的發(fā)病機(jī)理為腸上皮屏障功能低下或損傷、腸道血供調(diào)節(jié)差及飲食的影響,大量條件致病菌滋生或菌群易位等等。從而大量炎癥介質(zhì)產(chǎn)生,引起腸上皮細(xì)胞損傷,腸壁壞死穿孔、全身炎癥反應(yīng)綜合征甚至休克、多器官衰竭。雖然近年有關(guān)NEC的研究熱度持續(xù)升高,但其相關(guān)的分子機(jī)制的組學(xué)文獻(xiàn)亦較少。差異蛋白組學(xué)是分析不同時(shí)期或不同狀態(tài)下,動(dòng)態(tài)變化的蛋白質(zhì)組之間的差異。TMT(Tandem Mass Tags,串聯(lián)質(zhì)譜標(biāo)簽)技術(shù)是應(yīng)用同位素標(biāo)簽,特異性標(biāo)記多肽氨基集團(tuán),進(jìn)行質(zhì)譜分析,并行計(jì)量了多樣品中蛋白質(zhì)的相對(duì)含量。目的通過(guò)TMT技術(shù)研究早產(chǎn)NEC患兒血清定量蛋白組學(xué),利用分子細(xì)胞學(xué)信息,獲取對(duì)疾病發(fā)生發(fā)展機(jī)制更深層的認(rèn)識(shí)。方法:收集2014年12月在我院極早產(chǎn)NICU住院治療雙胎1對(duì),其中1例為明確診斷NEC患兒,Bell分期為ⅢA,生后24小時(shí)入院,胎齡為30周,NEC發(fā)生前喂養(yǎng)量達(dá)110ml/kg.d。另1例為與NEC患兒同期住院的雙胞胎(沒(méi)有罹患NEC、病情相對(duì)穩(wěn)定、沒(méi)有嚴(yán)重感染)。將血樣收集,血清去高豐度蛋白,經(jīng)過(guò)樣品質(zhì)量檢驗(yàn)、TMT標(biāo)記全蛋白、C18色譜柱樣品分級(jí)、質(zhì)譜相對(duì)定量檢測(cè)和質(zhì)譜數(shù)據(jù)分析得出差異蛋白。將所有差異蛋白的基因ID信息導(dǎo)入KOBAS 2.0軟件,進(jìn)行信號(hào)通路、疾病和GO富集分析。結(jié)果:1.共鑒定和定量了1515種蛋白。選擇表達(dá)上調(diào)2倍和表達(dá)下調(diào)0.5,且配對(duì)t檢驗(yàn)p值小于0.05,作為定義差異蛋白的篩選標(biāo)準(zhǔn),共發(fā)現(xiàn)44種差異蛋白,其中表達(dá)顯著上調(diào)的有24種,下調(diào)的有20種。2.顯著富集的通路包括血小板活化、補(bǔ)體和凝血級(jí)聯(lián)反應(yīng)、蛋白降解、活性氧類物質(zhì)解毒、外源性抗原交叉呈遞、碳水化合物代謝、細(xì)胞調(diào)亡的調(diào)節(jié)。顯著富集的信號(hào)通路涉及到TGF-β受體信號(hào)傳導(dǎo)通路、P53信號(hào)通路、Hedgehog信號(hào)通路等等。結(jié)論:1.TMT定量蛋白質(zhì)組學(xué)技術(shù)可有效用于篩選NEC患兒差異表達(dá)的蛋白質(zhì);2.本研究通過(guò)對(duì)NEC患兒特異血清標(biāo)記物和發(fā)病機(jī)制進(jìn)行初步探索,篩選出可信度高的44種差異蛋白質(zhì),顯著富集的生物過(guò)程包括血小板活化、活性氧類物質(zhì)解毒、傷口愈合等,多種蛋白也與參與到血小板脫顆粒、血小板活化等生物活性中,結(jié)合第一部分內(nèi)容,揭示了在多種病理因素作用下,血小板相關(guān)生物過(guò)程與NEC的發(fā)生有直接的關(guān)系;3.本次研究在蛋白組學(xué)的基礎(chǔ)篩選出顯著富集的信號(hào)通路,提示NEC疾病的發(fā)生涉及了TGF-β受體信號(hào)傳導(dǎo)通路、P53信號(hào)通路、Hh信號(hào)通路等等,它們?cè)诓〕讨薪閷?dǎo)了上皮間質(zhì)轉(zhuǎn)化、腸道細(xì)胞調(diào)亡、腸道組織損傷和修復(fù)、維持腸道緊密連接屏障完整性等生物過(guò)程。
[Abstract]:The first part of the laboratory test index is used to assist in the operation of children with premature delivery of NEC. The value background NEC (necrotizing enterocolitis, necrotizing enterocolitis) is an acute intestinal inflammatory disease in preterm infants with high mortality and relatively poor prognosis. The treatment principles and methods of the disease have been relatively unified, including the absolute fasting, continuous gastrointestinal decompression, the application of antibiotics and the surgical treatment of necrotic bowel resection, and so on. Second, NEC children between phase II B to stage III A, rapid development of disease, table There is no obvious specificity at the moment. At this time, the relative indications of the operation are difficult to grasp. At this time, it is a problem we need to think about whether conservative treatment can control the development of the disease, whether it needs active operation to remove the intestinal focus, and whether there are clinical specific indicators to help the treatment. The purpose of this article will be to discuss the first three of the preterm NEC children. The correlation between the test indexes of different laboratory and the NEC operation, and choosing a more reliable index to evaluate the needs of NEC operation in children to better grasp the time of clinical operation. Methods this study collected the clinical data of 30 children aged 33 weeks of fetal age and more than NEC in Bell staging period from the NICU Department of our hospital from December 2014 to July 2015. According to the treatment scheme, 16 cases of the operation group and 14 cases of the conservative group were treated without operation. The laboratory test indexes of the premature NEC operation group and the conservative group within three days after the onset of the disease were analyzed and compared with the SPSS 19 statistical software. The factors included the white cell count, the granulocyte ratio, the platelet count, the C reaction within three days after the onset of the disease. Results in the study, results in the study factors, the first day of the onset of NEC children's leukocyte count and CRP value, second days of platelet count and CRP, third days of platelet count and CRP value associated with NEC surgery. Second days after the onset of platelet count is an independent risk factor for NEC operation. Second days after the onset of the disease, the blood is small. The ROC curve analysis showed that the cut-off value was 144.5*109/l, the corresponding sensitivity was 81.3%, the specificity was 87.5%, the positive predictive value was 89.45%, the negative predictive value was 91.52%. conclusion 1. preterm NEC children's leukocyte count and CRP value, second day blood plate count and CRP value, third day platelet count and CRP value. Platelet count is an independent risk factor for NEC surgery within 24-48 hours after the onset of.2. associated with NEC operation. When the value is lower than 144.5*109/l, it is suggested that the operation needs to be high. We need to combine the clinical process of the children, make a better treatment plan, grasp the best operating time machine. Second part of the serum quantitative protein group of premature NEC children. Background NEC can lead to acute inflammatory bowel disease. The cause of the disease is complicated, it is more likely to attack premature infants with immature intestinal development, hypofunction and weak immune function. The disease has no specific performance and test criteria, rapid progress, poor prognosis, and great influence on the growth and quality of life of the newborn. The pathogenesis of NEC is the hypofunction and damage of the intestinal epithelial barrier, the poor regulation of the intestinal blood supply and the influence of diet, a large number of pathogenic bacteria breeding or bacterial translocation, etc., resulting in a large number of inflammatory mediators, causing intestinal epithelial cell damage, intestinal wall necrosis and perforation, systemic inflammatory reaction syndrome even shock, and multiple organ failure. Although in recent years, there are many organs failure. The research heat of NEC is rising, but the related molecular mechanism is also less. Differential proteomics is the difference of.TMT (Tandem Mass Tags, tandem mass spectrometry label) using the identity label, the specific polypeptide amino group, and the analysis of the difference between different periods or different states. The relative content of protein in multiple samples was measured by mass spectrometry. Objective to study the serum quantitative proteomics of children with premature NEC by TMT technology and use molecular cytology information to obtain a deeper understanding of the mechanism of disease development. Methods: 1 pairs of twins in the hospital of NICU in our hospital in December 2014 were collected and 1 of them were identified. The Bell stage was III A, 24 hours after birth, 24 hours after birth and 30 weeks of fetal age. 1 twins were fed before NEC, and 1 were twins hospitalized in the same period of NEC children (no NEC, relatively stable, no severe infection). Blood samples were collected, serum high abundance protein, sample quality test, TMT labelled total protein, C18 The difference protein was obtained by the chromatographic column sample classification, mass spectrometry and mass spectrometric analysis. The ID information of all the differential proteins was introduced into KOBAS 2 software to carry out the signal pathway, disease and GO enrichment analysis. Results: 1., 1515 proteins were identified and quantified. The selection expression was up 2 times and the expression was down 0.5, and the p value of paired t test was small. 0.05, as the screening criteria for defining differential proteins, there were 44 different proteins, of which 24 were significantly up-regulated, and 20 kinds of.2. significantly enriched pathways included platelet activation, complement and coagulation cascade, protein degradation, reactive oxygen species detoxification, exogenous antigen cross presentation, carbohydrate metabolism, cell modulation. TGF- beta receptor signaling pathway, P53 signaling pathway, Hedgehog signaling pathway and so on. Conclusion: 1.TMT quantitative proteomics technology can be used to screen differentially expressed proteins in children with NEC; 2. this study was conducted by preliminary exploration of specific serum markers and pathogenesis of children with NEC. 44 kinds of differential proteins with high reliability were screened out. The significant enrichment of biological processes included platelet activation, detoxification of reactive oxygen species, wound healing and so on. Many proteins also combined with the biological activity of platelet degranulation and platelet activation, combined with the first part of internal volume, and revealed the platelet correlation under the action of various pathological factors. There is a direct relationship between biological processes and the occurrence of NEC; 3. this study screened a significant signaling pathway on the basis of proteomics, suggesting that the occurrence of NEC diseases involves the TGF- beta signaling pathway, the P53 signaling pathway, the Hh signaling pathway and so on, which lead to epithelial mesenchymal transition, intestinal cell apoptosis and intestinal tissue in the course of the disease. Injury and repair, maintain the integrity of intestinal tight junctions and other biological processes.
【學(xué)位授予單位】：大連醫(yī)科大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類號(hào)】：R722.6

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