本文選題：胸部創(chuàng)傷 + 高遷移率族蛋白-1��； 參考：《重慶醫(yī)科大學》2013年碩士論文

【摘要】：研究背景 創(chuàng)傷已成為全球性健康問題，是45歲以下人群死亡的主要原因，而胸部創(chuàng)傷是嚴重威脅生命的急癥，約占創(chuàng)傷相關入院率的30%-40%，占創(chuàng)傷相關死亡的25%。機體在遭受嚴重創(chuàng)傷后，常誘發(fā)全身炎癥反應綜合征（systemic inflammatory response syndrome, SIRS），并繼發(fā)膿毒癥（Sepsis）和多器官功能障礙綜合征（multiple organ dysfunctionsyndrome, MODS），是嚴重創(chuàng)傷患者住院死亡的主要原因。胸部創(chuàng)傷并發(fā)Sepsis和MODS時，病情復雜、變化快，救治難度大，如果不及時有效的進行處理，可造成嚴重后果。雖然目前Sepsis和MODS的治療方法眾多，但是治療水平尚未達到理想目標，其原因主要是現階段的Sepsis和MODS的治療都是在創(chuàng)傷并發(fā)癥發(fā)生以后。由于缺乏早期判別創(chuàng)傷后嚴重并發(fā)癥風險性的預警診斷方法，因而難以在包括Sepsis和MODS以內的嚴重并發(fā)癥發(fā)生前或發(fā)生即刻進行預防和早期治療。如何早期識別和干預創(chuàng)傷后并發(fā)癥，以提高救治預后是臨床一直以來期待解決的醫(yī)學課題。 機體在遭受創(chuàng)傷時，組織細胞會主動分泌或被動釋放損傷相關分子模式（damage-associated molecular patterns, DAMPs），引起炎癥反應，促進壞死組織和細胞碎片的清除及損傷修復。DAMPs主要包括高遷移率族蛋白1(High-mobility group box1, HMGB1)、S100蛋白家族、熱休克蛋白等。HMGB1是HMGB家族中唯一可分泌到細胞外并具有細胞因子活性的蛋白，多項研究已證實HMGB1是一種重要的晚期炎癥介質，可從細胞內釋放至體內調控炎癥反應，在感染和損傷引起的炎癥性疾病中具有重要的作用。 現已研究表明，基因組序列上的變異，即基因多態(tài)性（genepolymorphism）是決定人體對疾病易感性與抵抗性、疾病臨床表型多樣性以及人體對藥物治療反應差異性的重要因素。因此，，個體基因表達上的差異，很可能是部分患者易發(fā)生創(chuàng)傷后嚴重并發(fā)癥或/和預后較差的重要因素之一。基于以上事實，對于嚴重胸部鈍性傷臨床進程、創(chuàng)傷后炎癥反應程度及嚴重并發(fā)癥發(fā)生風險等創(chuàng)傷后預后的相關性研究可以從基因多態(tài)性的角度去分析。 第一部分HMGB1在嚴重胸部鈍性傷患者中的動態(tài)變化和臨床意義目的： HMGB1是一種重要的晚期炎癥介質，在創(chuàng)傷后的炎癥反應中發(fā)揮著重要的調控作用。本研究為了探討HMGB1和TNF-α在嚴重創(chuàng)傷患者血液中的動態(tài)變化及臨床意義，并評估血漿HMGB1在嚴重胸部鈍性傷患者傷后并發(fā)癥發(fā)生風險及臨床預后中的作用。 材料與方法： 1.樣本：本研究樣本來自于重慶醫(yī)科大學附屬第一醫(yī)院胸外科和重慶市急救醫(yī)療中心收集的創(chuàng)傷患者血液樣本�；颊呒{入標準為：①創(chuàng)傷后24小時內；②I SS評分≥16分；③年齡≥18歲且≤65歲，性別不限；④存活時間超過1周。 2.創(chuàng)傷后的第1、3、5、7d各取外周靜脈血，冷凍保存，標本收齊后同時應用ELISA法檢測HMGB1和TNF-α水平的測定。 3.分析HMGB1和TNF-α動態(tài)變化與創(chuàng)傷嚴重程度、傷情特點及致傷特征、近遠期預后的關系。 4.比較胸部創(chuàng)傷患者傷后不同時間點血清HMGB1和TNF-α對預后判斷的ROC曲線結果。 結果： 1.嚴重胸部鈍性傷患者血漿HMGB1水平在傷后第1天、第3天逐漸升高，第5天達高峰，第7天仍呈持續(xù)上升趨勢。而TNF-а水平在創(chuàng)傷后第1天至第7天呈逐漸降低的趨勢。 2.嚴重胸鈍性傷患者傷后第1、3、5、7天血漿HMGB1與ISS評分呈正相關，其中第3天、第5天及第7天相關性具有統(tǒng)計學差異（P均0.01）；TNF-а水平與ISS評分也呈正相關（P均0.05）。 3.嚴重胸鈍性傷患者傷后第3、5、7天血漿HMGB-1與傷后感染、Sepsis、MODS、創(chuàng)傷后應激障礙及近期生活質量（SF-36）相關（P均0.05）。 4.兩者在創(chuàng)傷后并發(fā)癥預測方面，傷后第1天，HMGB1和TNF-а水平的ROC曲線下面積差異無統(tǒng)計學意義（P0.05）；而在第3、5、7天血漿HMGB1水平對預測傷后并發(fā)癥的ROC曲線下面積均大于TNF-а的ROC曲線下面積（P均0.05）。 結論： 我們的研究發(fā)現嚴重胸部鈍性傷患者血漿HMGB1水平在傷后進行性增高，且與創(chuàng)傷的嚴重程度相關，相關性強于TNF-а，其預測并發(fā)癥發(fā)生情況，敏感性要優(yōu)于血漿中TNF-а的變化，尤其是在創(chuàng)傷后晚期；創(chuàng)傷后血漿HMGB1水平升高提示患者預后不佳，心理健康及生存質量較差。 第二部分HMGB1基因標簽單核苷酸多態(tài)性與創(chuàng)傷并發(fā)癥風險性的關聯研究 目的： 本實驗旨在探討HMGB1基因標簽單核苷酸多態(tài)性與嚴重胸部鈍性傷后并發(fā)Sepsis和MODS風險性的關聯性。 材料和方法： 一、主要信息資源及分析工具： 1.主要查詢數據庫：NCBI數據庫：www.ncbi.nlm.nih.gov；Hapmap數據庫：www.hapmap.org。 2.分析軟件：Haploview(4.0版)； 二、實驗方法： 1.標簽單核苷酸多態(tài)性的篩選。HMGB1基因的轉錄起始位點上游3-10kb至其終止子下游3-10kb范圍及基因所有內含子和外顯子范圍內進行標簽單核苷酸多態(tài)性的篩選，用Haploview軟件構建基因的單倍域，利用Tagger軟件在單倍域內進行標簽單核苷酸多態(tài)性的篩選。 2.基因分型。采用焦磷酸測序法對HMGB1基因進行標簽SNPs的分型。按照儀器說明進行分型反應，根據每個堿基的峰高進行結果的自動判讀。 3.臨床關聯研究，Sepsis和MODS診斷根據診斷標準，創(chuàng)傷ISS評分采用簡明損傷定級標準（2005版）。 4.統(tǒng)計分析：各SNPs的等位基因型頻率由基因計數獲得。H-W平衡采用卡方檢驗計算；多態(tài)性與MODS評分的關系采用單因素方差方法統(tǒng)計；等位計量效應采用多元Logister回歸分析統(tǒng)計，并用年齡、性別及ISS評分校正；各基因型與Sepsis、MODS發(fā)生率之間的關系采用卡方檢驗方法統(tǒng)計。 結果： 1.人HMGB1基因位于13號染色體29930877至29938081之間，長度為7.204kb。HMGB1基因共有7個SNPs，都是常見SNP，構建了2個單倍域。HMGB1挑選了3個標簽SNPs，分別是rs1412125/rs2249825/rs1045411。 2.在HMGB1的3個標簽SNPs中，只有rs2249825的C→G突變與創(chuàng)傷后Sepsis發(fā)生和MODS評分密切相關，而另外2個標簽SNPs不影響患者創(chuàng)傷后并發(fā)癥的發(fā)生率。 結論： HMGB1基因的rs2249825在中國漢族人群中與創(chuàng)傷后膿毒癥和MODS發(fā)生密切的多態(tài)性位點。HMGB1基因rs2249825的C→G突變可能是增加創(chuàng)傷后Sepsis和MODS發(fā)生風險性的遺傳因素。
[Abstract]:Research background
Trauma has become a global health problem, the main cause of death of people under 45 years of age, and chest trauma is a serious threat to life, accounting for 30%-40% of trauma related admission rate, and the 25%. body of trauma related death often induces systemic inflammatory response syndrome (systemic inflammatory response syndrome). SIRS), secondary sepsis (Sepsis) and multiple organ dysfunction syndrome (multiple organ dysfunctionsyndrome, MODS) are the main causes of death in patients with severe trauma. When thoracic trauma is complicated with Sepsis and MODS, the disease is complicated, fast and difficult to treat. If not treated in time and effectively, it can cause serious consequences. At present, there are many methods of treatment for Sepsis and MODS, but the level of treatment has not reached the ideal goal. The main reason is that the treatment of Sepsis and MODS at the present stage is after the occurrence of traumatic complications. Due to the lack of early warning diagnosis of the risk of severe complications after the early discrimination, it is difficult to include the strictness within Sepsis and MODS. Prevention and early treatment immediately before or before the occurrence of heavy complications. How to identify and intervene early posttraumatic complications and improve the prognosis of treatment is a medical subject that has been expected to be solved in clinical.
When the body is traumatized, tissue cells release or passively release the damage-associated molecular patterns (DAMPs), causing inflammatory reactions and promoting the removal of necrotic tissue and cell debris and the repair of.DAMPs mainly including high mobility group protein 1 (High-mobility group box1, HMGB1), S100 protein .HMGB1 is the only protein in the family, such as heat shock protein, which can be secreted into the HMGB family and has the activity of cytokines. A number of studies have confirmed that HMGB1 is an important late inflammatory mediator. It can be released from the cell to the body to regulate the inflammatory response and plays an important role in the inflammatory diseases caused by infection and injury.
It has been shown that the variation in the genome sequence, that is, gene polymorphism (genepolymorphism), is an important factor in determining the susceptibility and resistance of the human body to disease, the diversity of the clinical phenotype and the difference in the response of the human body to the drug treatment. One of the important factors for severe complications or / and poor prognosis. Based on the above facts, the correlation of post-traumatic prognosis in the clinical process of severe blunt trauma, the degree of post traumatic inflammation and the risk of severe complications can be analyzed from the perspective of genetic polymorphism.
Part one: dynamic changes and clinical significance of HMGB1 in patients with severe blunt chest trauma.
HMGB1 is an important late inflammatory mediator and plays an important role in the post traumatic inflammatory response. This study aims to explore the dynamic changes and clinical significance of HMGB1 and TNF- alpha in the blood of patients with severe trauma, and to evaluate the risk and clinical prognosis of plasma HMGB1 in patients with severe blunt chest injury. Effect.
Materials and methods:
1. sample: the samples were collected from the blood samples collected from the Department of thoracic surgery in First Affiliated Hospital of Chongqing Medical University and the Chongqing emergency medical center. The patients were included in the criteria: (1) 24 hours after the trauma; (2) I SS score was more than 16; (3) the age of 18 years old and less than 65 years, and the sex was not limited; (4) the survival time was over 1 weeks.
2. after the trauma, peripheral venous blood was collected from each 1,3,5,7d. After cryopreservation, the levels of HMGB1 and TNF- TNF- were detected by ELISA.
3. to analyze the relationship between dynamic changes of HMGB1 and TNF- alpha and severity of trauma, characteristics of injury and characteristics of injury, and prognosis.
4. to compare the ROC curves of serum HMGB1 and TNF- alpha at different time points after trauma in patients with thoracic trauma.
Result錛

本文編號：1795337