本文選題：結(jié)核性胸膜炎　切入點(diǎn)：類肺炎性胸腔積液　出處：《山東大學(xué)》2017年碩士論文　論文類型：學(xué)位論文

【摘要】：研究目的:結(jié)核性胸膜炎和類肺炎性胸腔積液是臨床上引起胸腔積液的常見病因,然而目前國(guó)內(nèi)關(guān)于二者鑒別的胸水實(shí)驗(yàn)室檢測(cè)指標(biāo)研究相對(duì)較少。故本文旨在通過檢測(cè)胸腔積液中腺苷脫氨酶(ADA)和有核細(xì)胞計(jì)數(shù)水平,研究ADA、有核細(xì)胞計(jì)數(shù)以及二者聯(lián)合檢測(cè)鑒別結(jié)核性胸膜炎和類肺炎性胸腔積液的臨床價(jià)值。方法:回顧性收集2010年12月至2017年3月在山東省立醫(yī)院東院呼吸科住院的胸腔積液患者175例,其中經(jīng)內(nèi)科胸腔鏡活檢確診或經(jīng)臨床診斷的結(jié)核性胸膜炎64例、類肺炎性胸腔積液41例、惡性胸腔積液54例、其他病因(低白蛋白血癥、肺栓塞、結(jié)締組織病相關(guān)、寄生蟲)等引起胸腔積液16例。對(duì)比分析同類型胸腔積液中ADA及有核細(xì)胞計(jì)數(shù)的水平并應(yīng)用ROC曲線評(píng)價(jià)ADA和有核細(xì)胞計(jì)數(shù)對(duì)于結(jié)核性胸膜炎和類肺炎性胸腔積液的鑒別診斷價(jià)值。結(jié)果:1.不同性質(zhì)胸腔積液中ADA含量比較及分析結(jié)核性胸膜炎患者胸腔積液ADA測(cè)定值為36.9± 10.7U/L;類肺炎性胸腔積液ADA測(cè)定值為56.7±15.85.惡性胸腔積液組患者胸腔積液胸腔積液ADA測(cè)定值為11.6±3.5U/L類肺炎性胸腔積液ADA水平顯著高于結(jié)核性胸膜炎組和惡性胸腔積液組,結(jié)核性胸膜炎組顯著高于惡性胸腔積液組,三者比較均有統(tǒng)計(jì)學(xué)差異。2.不同性質(zhì)胸腔積液有核細(xì)胞計(jì)數(shù)比較及分析結(jié)核性胸膜炎患者胸腔積液有核細(xì)胞計(jì)數(shù)測(cè)定值為2951.5±375.2*10^6個(gè)/L;類肺炎性胸腔積液有核細(xì)胞數(shù)測(cè)定值為35858.3±1679.3*10^6個(gè)/L;惡性胸腔積液組有核細(xì)胞計(jì)數(shù)測(cè)定值為2279.9±269.3*10^6個(gè)/L。類肺炎性胸腔積液患者胸水中有核細(xì)胞計(jì)數(shù)顯著高于結(jié)核性胸膜炎與惡性胸腔積液組,結(jié)核性胸膜炎組與惡性胸腔積液組無顯著差異。3.以1-特異性為x軸,敏感度為y軸繪制roc曲線,ADA聯(lián)合有核細(xì)胞計(jì)數(shù)檢測(cè)(AUC=0.826)優(yōu)于單獨(dú)檢測(cè)有核細(xì)胞計(jì)數(shù)(AUC=0.477)(P0.05),但與單獨(dú)檢測(cè)ADA(AUC=0.776)無顯著性差異(p0.05)。ADA檢測(cè)結(jié)核性胸膜炎臨界值為18.15U/L,此時(shí)檢測(cè)結(jié)核性胸膜炎的敏感度為0.891,特異性為0.695;有核細(xì)胞計(jì)數(shù)對(duì)于診斷結(jié)核性胸膜炎意義不大。4.ADA聯(lián)合有核細(xì)胞計(jì)數(shù)(AUC=0.724)檢測(cè)類肺炎性胸腔積液優(yōu)于單獨(dú)檢測(cè)ADA(AUC=0.626)(p0.05);但與單獨(dú)檢測(cè)有核細(xì)胞計(jì)數(shù)(AUC=0.703)差異不明顯(p0.05)。有核細(xì)胞計(jì)數(shù)最佳診斷臨界值為6249.5*10^6個(gè)/L,此時(shí)敏感度為0.512,特異度為0.932;ADA最佳診斷臨界值為63U/L,此時(shí)敏感度為0.317,特異度為0.975。5.根據(jù)roc曲線得出的ADA與有核細(xì)胞計(jì)數(shù)的臨界值,將兩種指標(biāo)進(jìn)行組合發(fā)現(xiàn):18.15U/LADA63U/L且有核細(xì)胞計(jì)數(shù)6250*10^6個(gè)時(shí)/L時(shí)對(duì)于診斷結(jié)核性胸膜炎的靈敏度和特異性均達(dá)96.9,陽(yáng)性預(yù)測(cè)率達(dá)95.4,陰性預(yù)測(cè)率達(dá)97.9;ADA≥63U/L且有核細(xì)胞計(jì)數(shù)≥6250*10^6個(gè)/L時(shí)對(duì)于診斷類肺炎性胸腔積液靈敏度為21.9,特異性達(dá)95.8,陽(yáng)性預(yù)測(cè)率為64.3,陰性預(yù)測(cè)率為77.9;ADA≤18.15U/L且有核細(xì)胞數(shù)6250*10^6個(gè)/L時(shí)診斷惡性胸腔積液的靈敏度達(dá)88.9,特異性達(dá)82.6,陽(yáng)性預(yù)測(cè)率為70.6,陰性預(yù)測(cè)率達(dá)94.1。結(jié)論:1.利用胸腔積液實(shí)驗(yàn)室檢查指標(biāo)對(duì)胸腔積液性質(zhì)進(jìn)行早期診斷對(duì)于當(dāng)前的臨床工作仍有很高實(shí)用價(jià)值。單一利用胸腔積液的某一指標(biāo)鑒別其不明原因胸腔積液性質(zhì)具有一定的局限性,但聯(lián)合利用有限的指標(biāo)則可以在一定程度上提高診斷效能。2.利用受試者工作特征曲線計(jì)算臨界值劃定診斷標(biāo)準(zhǔn),將ADA和有核細(xì)胞計(jì)數(shù)進(jìn)行組合,結(jié)核性胸膜炎診斷的敏感性和特異性都達(dá)到了96.9%,陽(yáng)性和陰性預(yù)測(cè)率分別達(dá)到了 95.4和97.9,值得臨床應(yīng)用推廣。3.ADA含量在結(jié)核性胸膜炎和類肺炎性胸腔積液中均有升高,二者升高程度不同,類肺炎性胸腔積液ADA含量顯著高于結(jié)核性胸膜炎。4.本研究中所檢測(cè)的ADA診斷結(jié)核性胸膜炎臨界值為18.5U/L,低于既往公認(rèn)的ADA40U/L,與國(guó)內(nèi)外相關(guān)研究結(jié)果類似。5.在診斷類肺炎性胸腔積液時(shí),有核細(xì)胞計(jì)數(shù)表現(xiàn)了很高的特異性,值得臨床重視,并進(jìn)行大樣本量分析獲得更準(zhǔn)確的診斷臨界值。
[Abstract]:Objective: tuberculous pleurisy and pleural effusion is the most common cause of pleural effusion in clinic, but currently on the two identification of hydrothorax laboratory research is relatively small. Therefore, this paper aims at the detection of adenosine deaminase in pleural effusion (ADA) and nuclear cell counts, ADA, clinical value the number of the nucleated cells and two differential diagnosis of tuberculous pleurisy and pleural effusion. Methods: retrospectively collected from December 2010 to March 2017 in 175 pleural effusion patients hospitalized in the Department of respiration of Shangdong Province-owned Hospital of Eastern Hospital, which through medical thoracoscopy biopsy or clinical diagnosis of tuberculous pleurisy in 64 cases, 41 cases of type pleural effusion, 54 cases of malignant pleural effusion, other etiologies (hypoalbuminemia, pulmonary embolism, connective tissue disease, parasites) induced pleural effusion in 16 Cases. Compared with the type of ADA in pleural effusion and nucleated cell count level and to evaluate the application of ROC ADA curve and nucleated cell count in the differential diagnosis of tuberculous pleurisy and pleural effusion. Results: 1. different kinds of ADA in pleural effusion were compared and analysis of tuberculous pleurisy pleural effusion in patients with ADA measured value was 36.9 + 10.7U/L; pleural effusion ADA determination of the values of 11.6 + 3.5U/L for pleural effusion ADA levels were significantly higher in tuberculous pleurisy group and malignant pleural effusion group was 56.7 + 15.85. group of malignant pleural effusion in patients with pleural effusion pleural effusion ADA, tuberculous pleurisy group was significantly higher than that of malignant pleural effusion group three, there were significant differences between the.2. of pleural effusion nucleated cell count comparison and analysis of patients with tuberculous pleurisy pleural effusion nucleated cell count determination A value of 2951.5 + 375.2*10^6 /L; pleural effusion cells was 35858.3 + 1679.3*10^6 for /L; malignant pleural effusion group nucleated cell count values were 2279.9 + 269.3*10^6 /L. parapneumonic pleural effusion in patients with nucleated cell count was significantly higher than that of tuberculous pleurisy and malignant pleural effusion. Group, tuberculous pleurisy and malignant pleural effusion group.3. had no significant difference in the specificity of 1- for the X axis, Y axis sensitivity of ROC curve, ADA and nucleated cell count assay (AUC=0.826) detection is better than the single nucleated cell count (AUC=0.477) (P0.05), but with the separate detection of ADA (AUC=0.776) no significant differences (P0.05).ADA detection of tuberculous pleurisy critical value is 18.15U/L, the detection of tuberculous pleurisy sensitivity was 0.891, specificity was 0.695; nucleated cell count for the diagnosis of tuberculous pleurisy is.4.A DA combined with the number of the nucleated cell (AUC=0.724) detection of pleural effusion is better than the single detection of ADA (AUC=0.626) (P0.05); but the number of the nucleated cell and single detection (AUC=0.703) was not significantly different (P0.05). The number of the nucleated cell of the optimal diagnostic critical value was 6249.5*10^6 /L, with a sensitivity of 0.512,. The specificity is 0.932 ADA; the optimal diagnostic critical value was 63U/L, with a sensitivity of 0.317, specificity of the critical value of 0.975.5. according to the ROC curve of ADA and nucleated cell count, two indicators were found: 18.15U/LADA63U/L combination and nucleated cell counts 6250*10^6 /L when the sensitivity and specificity of the diagnosis of tuberculous pleurisy was 96.9, the positive predictive rate was 95.4, the negative predictive rate was 97.9; ADA = 63U/L and nucleated cell count is greater than or equal to 6250*10^6 /L for the diagnosis of pleural effusion sensitivity was 21.9, specificity was 95.8, positive pre Detection rate was 64.3, the negative predictive rate was 77.9; the sensitivity of diagnosis of malignant pleural effusion ADA less than 18.15U/L and the number of nucleated cells 6250*10^6 /L was 88.9, the specificity was 82.6, the positive predictive value was 70.6, negative predictive rate was 94.1. conclusion: 1. by pleural effusion index of laboratory examination for early diagnosis of pleural effusion there is still a high practical value in clinical work. The use of a single index in differential diagnosis of pleural effusion of the unexplained pleural effusion has certain limitations, but the combined use of limited targets in a certain extent, improve the diagnostic efficiency.2. using receiver operating characteristic curve calculation of critical value of diagnostic criteria can be delineated. ADA and the number of the nucleated cells were combined, the diagnosis of tuberculous pleurisy. The sensitivity and specificity was 96.9%, positive and negative predictive rate reached 95.4 and 97.9, which is worthy of The bed application content of.3.ADA in tuberculous pleurisy and pleural effusion increased in two, increased to different degrees, pleural effusion ADA levels were significantly higher than that of tuberculous pleurisy.4. detected in this study of ADA diagnosis of tuberculous pleurisy is lower than the critical value is 18.5U/ L, previously recognized ADA40U/L, at home and abroad the related research results similar to.5. in the diagnosis of pleural effusion, nucleated cell count showed high specificity, it is worthy of attention, and analyze the large amount of critical value more accurate diagnosis.

【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】：2017
【分類號(hào)】：R521.7;R561.3

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