本文選題：急性缺血性腦卒中 + 白細(xì)胞　； 參考：《蘇州大學(xué)》2013年碩士論文

【摘要】：研究目的 1.探討入院時白細(xì)胞計數(shù)水平與急性缺血性腦卒中病人發(fā)生殘疾或住院期間死亡的關(guān)系； 2.探討入院時纖維蛋白原水平與急性缺血性腦卒中病人發(fā)生殘疾或住院期間死亡的關(guān)系； 3.探討入院時血清膽紅素水平與急性缺血性腦卒中病人發(fā)生殘疾或住院期間死亡的關(guān)系。 對象與方法 對象：連續(xù)納入2009年6月1日到2012年5月31日期間在遼寧省阜新市中心醫(yī)院、內(nèi)蒙古興安盟人民醫(yī)院和大連大學(xué)附屬中山醫(yī)院所有入院治療的急性缺血性腦卒中病人為研究對象，納入分析樣本量為8244例。 方法：由培訓(xùn)合格的調(diào)查員采用統(tǒng)一設(shè)計的病例調(diào)查表，所有調(diào)查對象均進(jìn)行了入院時白細(xì)胞計數(shù)、纖維蛋白原和血清膽紅素水平和其他一般情況及出院結(jié)局相關(guān)資料的收集。結(jié)局定義為發(fā)生殘疾或死亡，當(dāng)有結(jié)局發(fā)生即定義為結(jié)局不良。殘疾的定義參照Modified Rankin’s scale（MRs）腦卒中量表中有關(guān)生活依賴程度的標(biāo)準(zhǔn)進(jìn)行，將評分標(biāo)準(zhǔn)記錄在調(diào)查表中，評分在3分及其以上者（MRs≥3）定義為殘疾。 統(tǒng)計分析：采用Epidata3.1建立數(shù)據(jù)庫，所有調(diào)查表均經(jīng)過雙人雙錄核查。采用SPSS18.0軟件進(jìn)行統(tǒng)計分析。急性缺血性腦卒中發(fā)病月份分布描述采用圓形分布，比較入院時生活方式、一般特征和臨床特征在急性缺血性腦卒中病人無結(jié)局和發(fā)生殘疾、死亡間的差異應(yīng)用方差分析或非參數(shù)檢驗（Kruskal-Wallis H test）。入院時白細(xì)胞、纖維蛋白原和血清膽紅素水平與殘疾、死亡的關(guān)聯(lián)分析采用無序多分類logistic回歸方法，不同亞型急性缺血性腦卒中危險因素的分析采用兩分類非條件logistic回歸方法，計算比值比（Odds ratio，OR）及95%可信區(qū)間（95%Confident interval，95%CI）。所有檢驗均為雙側(cè)檢驗，檢驗水準(zhǔn)α=0.05。 研究結(jié)果 1.3個臨床現(xiàn)場共納入分析的研究對象為8244例急性缺血性腦卒中病人，發(fā)生急性缺血性腦卒中的高峰日為4月22號，高峰期是上一年12月1號到下一年8月20號（r=0.0825，z=56.0738，P0.05）；不同亞型的急性缺血性腦卒中病人構(gòu)成比分別為腦血栓72.12%，腦栓塞3.66%，腔隙性梗死24.21%；其中，共有1169人（14.18%）發(fā)生殘疾（MRs≥3），死亡195人（2.37%）。 2.對于不同出院結(jié)局的急性缺血性腦卒中病人，以無結(jié)局組為對照，殘疾組和死亡組病人的平均年齡較大（P0.0001），發(fā)病-入院時間死亡組最短（P0.0001），急性缺血性腦卒中亞型的分布在三組間不一致（P0.0001）；吸煙、飲酒情況在三組間不一致（分別P=0.0023、P=0.001）；入院時體溫、收縮壓（Sbp）、血糖、纖維蛋白原、尿素氮水平和WBC、Tbil、Dbil、Ibil在發(fā)生殘疾或死亡時較高（P0.05），血脂異常和有糖尿病史、心臟病史、房顫史、腦卒中病史的病人更易發(fā)生殘疾或死亡（P0.05），死亡的病人甘油三脂（Tg）較低（P0.05）。 3.急性缺血性腦卒中病人按入院白細(xì)胞、纖維蛋白原和血清膽紅素水平不同分組，各水平組發(fā)生殘疾和死亡的百分比不同，均表現(xiàn)為相對于低水平組，高水平組殘疾和死亡的發(fā)生率更高（均P0.05）。 4.傳統(tǒng)影響因素分析中，急性缺血性腦卒中病人發(fā)生殘疾、死亡的單因素?zé)o序多分類logistic回歸分析結(jié)果顯示，相對無結(jié)局組，年齡、體溫、高血糖、尿素氮的升高和房顫史、腦卒中病史可能是發(fā)生殘疾、死亡的危險因素，其OR（95%CI）分別是1.26（1.20～1.34）、1.77（1.54～2.04），1.85（1.60～2.13）、2.36（1.83～3.04），1.59（1.40～1.80）、2.39（1.78～3.22），1.04（1.02～1.05）、1.06（1.04～1.08）、2.78（2.16～3.58）、5.32（3.48～8.12）和1.43（1.26～1.63）、1.63（1.22～2.18）。高血壓的病人發(fā)生殘疾的危險性是非高血壓病人的1.36（1.20～1.54）倍，或與死亡無關(guān)；血脂異常的病人發(fā)生死亡的危險性是正常病人的1.57（1.15～2.13）倍。發(fā)病-入院時間和住院時間越短，發(fā)生殘疾、死亡的危險性越大，相對于最短時間，，最長時間組的OR（95%CI）分別是0.59（0.51～0.69）、0.28（0.20～0.38）和0.66（0.56～0.78）、0.15（0.10～0.19），糖尿病史的病人發(fā)生殘疾的危險性是非糖尿病病人的1.41（1.23～1.62）倍，或與死亡無關(guān)。吸煙對發(fā)生殘疾或死亡有保護(hù)作用（OR（95%CI）:0.83（0.71～0.96）、0.61（0.42～0.89）），飲酒對發(fā)生死亡有保護(hù)作用（OR（95%CI）:0.45（0.28～0.73））。 5.白細(xì)胞計數(shù)、纖維蛋白原和血清膽紅素的無序多分類logistic回歸分析中，經(jīng)過年齡、發(fā)病-入院時間、體溫、高血壓、高血糖、血脂異常、心臟病史、房顫史和腦卒中病史等因素的調(diào)整后，多分類logistic回歸分析結(jié)果顯示對于WBC10×109/L組，WBC水平每增加2×109/L發(fā)生殘疾、死亡的危險性都在相應(yīng)增加，其OR（95%CI）值均1，WBC水平≥14×109/L組發(fā)生殘疾、死亡的OR（95%CI）分別為3.40（2.51～4.60）和13.15（8.56～20.20）；纖維蛋白原水平按四分位間距分組，結(jié)果為相對于最低分位組，最高分位組（≥3.54g/L）發(fā)生殘疾、死亡的OR（95%CI）分別為1.76（1.45～2.13）和1.83（1.18～2.84）。血清膽紅素同樣按四分位間距分組，相對于最低分位組，Tbil最高分位組（≥18.91umol/L）發(fā)生殘疾、死亡的OR（95%CI）分別為1.83（1.53～2.18）和2.59（1.72～3.89）；除第二分位（2.00～3.10μmol/L）對殘疾發(fā)生有保護(hù)作用（OR（95%CI）：0.82（0.68～0.99）），不同水平Dbil與殘疾發(fā)生無關(guān)，但與死亡有關(guān)，最高分位組（≥4.71umol/L）發(fā)生死亡的OR（95%CI）為1.75（1.15～2.67）；Ibil最高分位組（≥14.41umol/L）發(fā)生殘疾、死亡的OR（95%CI）分別為1.30（1.09～1.55）和1.79（1.18～2.72）。 6．對納入分析的急性缺血性腦卒中3種亞型：腦血栓、腦栓塞和腔隙性梗死進(jìn)行分層分析，模型選擇二分類非條件logistic回歸，應(yīng)變量為是否發(fā)生結(jié)局不良。結(jié)果顯示，（1）調(diào)整了年齡、腦卒中病史后，相對于WBC10×109/L組，腦血栓病人WBC在10～11.9×109/L、12～13.9×109/L和≥14×109/L發(fā)生結(jié)局不良的OR（95%CI）值分別為2.40（1.90～3.03）、3.02（2.18～4.18）和5.41（4.03～7.25）；腦栓塞病人WBC為12～13.9×109/L和≥14×109/L發(fā)生結(jié)局不良的OR（95%CI）值分別3.60（1.19～10.87）和10.40（2.26～47.93）；腔隙性梗死病人WBC在10～11.9×109/L、12～13.9×109/L和≥14×109/L發(fā)生結(jié)局不良的OR（95%CI）值分別為2.24（1.32～3.81）、4.14（1.94～8.86）和4.95（2.35～10.43）。（2）調(diào)整了年齡、腦卒中病史后，腦血栓病人纖維蛋白原水平在四分位最高分位（≥3.54g/L）相對于最低分位（＜2.56g/L）發(fā)生結(jié)局不良的OR（95%CI）為1.94（1.58～2.38）；腔隙性梗死病人纖維蛋白原水平在四分位最高分位（≥3.54g/L）相對于最低分位（＜2.56g/L）發(fā)生結(jié)局不良的OR（95%CI）為1.84（1.19～2.84）；不同纖維蛋白原水平對腦栓塞病人結(jié)局不良的OR值沒有統(tǒng)計學(xué)意義。（3）調(diào)整了年齡、腦卒中病史后，腦血栓病人Tbil在四分位最高分位（≥18.91μmol/L）相對于最低分位（＜10.90μmol/L）發(fā)生結(jié)局不良的OR（95%CI）為1.94（1.58～2.38），Dbil在四分位最高分位（≥4.71μmol/L）相對于最低分位（＜2.00μmol/L）發(fā)生結(jié)局不良的OR（95%CI）為1.22（1.00～1.48），Ibil在四分位最高分位（≥14.41μmol/L）相對于最低分位（＜7.60μmol/L）發(fā)生結(jié)局不良的OR（95%CI）為1.30（1.08～1.57）；而腦栓塞和腔隙性梗死的OR值沒有統(tǒng)計學(xué)意義。 結(jié)論 1.與正常白細(xì)胞計數(shù)的病人相比，急性缺血性腦卒中病人中較高水平的白細(xì)胞計數(shù)獨立的與發(fā)生殘疾或住院期間死亡相關(guān)聯(lián)。 2.與纖維蛋白原水平四分位最低分位組相比，急性缺血性腦卒中病人最高分位組纖維蛋白原水平獨立的與發(fā)生殘疾或住院期間死亡相關(guān)聯(lián)。 3.與總膽紅素、直接膽紅素和間接膽紅素水平四分位最低分位組相比，急性缺血性腦卒中病人在最高分位組總膽紅素、直接膽紅素和間接膽紅素水平獨立的與發(fā)生殘疾或住院期間死亡相關(guān)聯(lián)。 4.較高的白細(xì)胞計數(shù)與不同亞型急性缺血性腦卒中發(fā)生結(jié)局不良均有關(guān)聯(lián)性；不同纖維蛋白原水平與不同亞型急性缺血性腦卒中發(fā)生結(jié)局不良的相關(guān)性不一致；不同血清膽紅素水平與不同亞型急性缺血性腦卒中發(fā)生結(jié)局不良的相關(guān)性不一致。
[Abstract]:research objective
1. to explore the relationship between the level of white blood cell count during admission and the occurrence of disability or hospitalization in patients with acute ischemic stroke.
2. to explore the relationship between the level of fibrinogen at admission and death in patients with acute ischemic stroke.
3. to explore the relationship between serum bilirubin level and the death of patients with acute ischemic stroke during hospitalization.
Object and method
Participants: from June 1, 2009 to May 31, 2012, all the patients with acute ischemic stroke in Fuxin Central Hospital, Liaoning Province, Inner Mongolia, Inner Mongolia, and the Zhongshan Hospital Affiliated to Dalian University were studied. The samples were included in 8244 cases.
Methods: a unified design case questionnaire was used by qualified investigators. All the subjects were collected at admission, leucocyte count, fibrinogen and serum bilirubin level, other general information and discharge related data. The outcome was defined as a residual disease or death, which was defined as the outcome when the outcome occurred. The definition of disability was referred to the standard of life dependence in the Modified Rankin 's scale (MRs) stroke scale, and the scoring criteria were recorded in the questionnaire, and those with a score of 3 or more (MRs > 3) were defined as disability.
Statistical analysis: the database was established by Epidata3.1. All the questionnaires were checked by double and double records. SPSS18.0 software was used for statistical analysis. The distribution of the months of acute ischemic stroke was described by circular distribution, the life style was compared with the admission, and the general characteristics and clinical characteristics were no result and hair in the patients with acute ischemic stroke. Variance analysis or nonparametric test (Kruskal-Wallis H test) for the difference between death and disability. The association of leukocyte, fibrinogen and serum bilirubin to disability and death was analyzed by disordered multi classification logistic regression, and the analysis of risk factors for different subtypes of acute ischemic stroke was divided into two categories. Logistic regression method is used to calculate the ratio Ratio (Odds ratio, OR) and 95% confidence interval (95%Confident interval, 95%CI). All tests are both bilateral test, test level alpha =0.05.
Research results
1.3 clinical sites were included in 8244 cases of acute ischemic stroke. The peak day of acute ischemic stroke was in April 22nd, the peak period was from December 1st to August 20th (r=0.0825, z=56.0738, P0.05), and the ratio of acute ischemic stroke in different subtypes was 72. of cerebral thrombosis, respectively. 12%, 3.66% of cerebral embolism and 24.21% of lacunar infarction, of which 1169 (14.18%) had disability (MRs > 3) and 195 (2.37%) died.
2. for the acute ischemic stroke patients with different discharge outcomes, the average age of the patients in the disabled group and the death group was higher (P0.0001), the shortest (P0.0001) in the death group (P0.0001) and the distribution of acute ischemic stroke Central Asian type in the group of death (P0.0001); smoking and drinking in the three groups were not consistent. (P=0.0023, P=0.001); at admission temperature, systolic blood pressure (Sbp), blood sugar, fibrinogen, urea nitrogen level and WBC, Tbil, Dbil, Ibil in the occurrence of disability or death (P0.05), dyslipidemia and diabetes history, heart disease history, atrial fibrillation history, stroke patients more prone to disability or death (P0.05), the death of the patient glycerin three fat ( Tg) is lower (P0.05).
3. patients with acute ischemic stroke were divided into different groups according to the level of admission leukocyte, fibrinogen and serum bilirubin. The percentage of disability and death in each group was different, and the incidence of disability and death in the high level group was higher (all P0.05).
4. in the analysis of traditional influencing factors, acute ischemic stroke patients were disabled, and the single factor disorder multiple classification logistic regression analysis showed that the relative unending group, age, temperature, hyperglycemia, higher urea nitrogen and the history of atrial fibrillation may be the risk factors of disability and death, and the OR (95%CI) was 1.26 (1). .20 to 1.34), 1.77 (1.54 to 2.04), 1.85 (1.60 to 2.13), 2.36 (1.83 to 3.04), 1.59 (1.40 ~ 1.80), 1.59. The risk of death in patients with dyslipidemia was 1.57 (1.15 to 2.13) times that of normal patients. The shorter the hospitalization time and the hospitalization time, the greater the risk of death, the OR (95%CI) of the longest time group was 0.59 (0.51 to 0.69), 0.28 (0.20 to 0.38) and 0.66 (0.56 ~ 0.78), 0, respectively. .15 (0.10 ~ 0.19), the risk of disability in patients with diabetes is 1.41 (1.23 to 1.62) times of non diabetic patients, or not related to death. Smoking has a protective effect on the occurrence of disability or death (OR (95%CI): 0.83 (0.71 to 0.96), 0.61 (0.42 ~ 0.89)), and drinking has a protective effect on the occurrence of death (OR (95%CI): 0.45 (0.28 ~ 0.73)).
5. leucocyte count, fibrinogen and serum bilirubin in the disordered multi classification logistic regression analysis, after the adjustment of age, onset time, body temperature, hypertension, hyperglycemia, dyslipidemia, history of heart disease, history of atrial fibrillation, and stroke history, the results of multiclass logistic regression analysis showed that WBC10 x 109/L group, WBC water The risk of death was increased by 2 x 109/L, the OR (95%CI) value was 1, the WBC level was more than 14 x 109/L group, and the OR (95%CI) was 3.40 (2.51 to 4.60) and 13.15 (8.56 to 20.20), and the fibrinogen level was grouped at four subdivision intervals, and the result was the highest fraction (> 3.54). G/L) OR (95%CI) was 1.76 (1.45 to 2.13) and 1.83 (1.18 ~ 2.84). The serum bilirubin was also grouped at the four point spacing. Compared with the lowest fraction, the highest Tbil sub group (> 18.91umol/L) was disabled, and the OR (95%CI) of the death was 1.83 (1.53 to 2.18) and 2.59 (1.72 ~ 3.89), respectively. L/L) had a protective effect on the occurrence of disability (OR (95%CI):0.82 (0.68 ~ 0.99)). Different levels of Dbil were not related to the occurrence of disability, but related to death, OR (95%CI) of the highest sub group (> 4.71umol/L) was 1.75 (1.15 ~ 2.67); the highest fraction of Ibil (> 14.41umol/L) was disabled, and OR (95%CI) was 1.30 (1.09 to 1.55) and 1.79, respectively. (1.18 to 2.72).
6. of the 3 subtypes of acute ischemic stroke, cerebral thrombosis, cerebral embolism and lacunar infarction were analyzed by stratified analysis. The model selected two categories of non conditional logistic regression, and the dependent variable was bad outcome. The results showed that (1) the age was adjusted. After the history of stroke, the WBC of cerebral thrombosis patients was 10 ~ 10. The OR (95%CI) values of 11.9 * 109/L, 12 to 13.9 * 109/L and 14 x 109/L were 2.40 (1.90 to 3.03), 3.02 (2.18 to 4.18) and 5.41 (4.03 ~ 7.25), and the OR (95%CI) values of the patients with cerebral embolism were in OR (95%CI), and the patients with lacunar infarction W BC (1.32 to 3.81), 4.14 (1.94 ~ 8.86) and 4.95 (2.35 ~ 10.43) in 10 ~ 11.9 * 109/L, 12 ~ 13.9 * 109/L and 14 x 109/L were 2.24 (1.32 to 3.81), 4.14 (1.94 ~ 8.86) and 4.95 (2.35 ~ 10.43). The highest level of fibrinogen in the cerebral thrombosis patients was compared with the lowest score (< 2.56g/L). The OR (95%CI) with poor outcome was 1.94 (1.58 to 2.38), and the fibrinogen level in the patients with lacunar infarction was 1.84 (1.19 to 2.84) at the highest score of the four division (> 3.54g/L) relative to the lowest score (< 2.56g/L). The OR value of the different fibrous egg white levels for the patients with cerebral embolism was not statistically significant. (3) adjusted the age and the history of cerebral apoplexy, the highest score of Tbil in the four division of cerebral thrombosis patients (> 18.91 mu mol/L) was 1.94 (1.58 to 2.38) relative to the lowest score (< 10.90 mol/L), and the highest fraction of Dbil in the four sub position (> 4.71 Mu mol/L) was relative to the lowest score (2 mu mol/L) with the bad OR (95%) (2 mu mol/L). CI) at 1.22 (1 to 1.48), the OR (95%CI) of the highest score (> 14.41 mu mol/L) of Ibil in the four sub position (< 7.60 mol/L) was 1.30 (1.08 to 1.57), while the OR value of cerebral embolism and lacunar infarction was not statistically significant.
conclusion
1. higher levels of leukocyte count in patients with acute ischemic stroke were associated with disability or death in patients with acute ischemic stroke than in patients with normal leukocyte counts.
2. the highest level of fibrinogen in the patients with acute ischemic stroke was associated with disability or death during the hospitalization, compared with the lowest division of the fibrinogen level Four.
3. compared with the lowest score of total bilirubin, direct bilirubin and indirect bilirubin level Four, patients with acute ischemic stroke were independent of total bilirubin, direct bilirubin and indirect bilirubin levels in the highest score group, associated with disability or death during hospitalization.
4. the higher leucocyte count was associated with poor outcome in different subtypes of acute ischemic stroke, and different fibrinogen levels were not consistent with the adverse outcome of different subtypes of acute ischemic stroke; the level of different serum bilirubin and the adverse outcome of different subtypes of acute ischemic stroke The customs are not consistent.
【學(xué)位授予單位】：蘇州大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2013
【分類號】：R743.3

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