本文選題：降鈣素原 + 降鈣素原清除率��； 參考：《天津醫(yī)科大學(xué)》2017年碩士論文

【摘要】：背景與目的早期神經(jīng)功能惡化(Early neurological deterioration,END)是急性卒中患者常見的并發(fā)癥,END的發(fā)生與患者致殘率和病死率增加、住院天數(shù)延長、醫(yī)療費用增長密切相關(guān)。目前,END的發(fā)病機制尚不清楚,沒有準(zhǔn)確可靠的早期預(yù)測指標(biāo),也缺乏有效的預(yù)防和治療措施。因此,尋找可預(yù)測END發(fā)生的早期臨床指標(biāo),以期及時給予干預(yù)治療,預(yù)防END的發(fā)生迫在眉睫。目前研究發(fā)現(xiàn)并發(fā)肺炎是卒中患者發(fā)生神經(jīng)功能惡化的一項獨立預(yù)測因素。而卒中相關(guān)性肺炎(Stroke-Associated Pneumonia,SAP)是急性卒中常見并發(fā)癥,研究表明SAP發(fā)生與卒中預(yù)后不良密切相關(guān)。但卒中相關(guān)性肺炎與急性卒中后早期神經(jīng)功能惡化發(fā)生之間的關(guān)系的報導(dǎo)還較少。血降鈣素原(Procalcitonin,PCT)是一個新的炎癥指標(biāo),較目前常用的炎癥指標(biāo)如體溫、白細(xì)胞數(shù)、中性粒細(xì)胞比例、C反應(yīng)蛋白(C-Reactive Protein,CRP)、紅細(xì)胞沉降率等有更高的敏感性和特異性。因此,在本研究中,我們擬通過大量采集卒中患者臨床資料,分析SAP與END發(fā)生之間的關(guān)系,并在SAP患者中,連續(xù)監(jiān)測血降鈣素原(Procalcitonin,PCT)水平,計算降鈣素原清除率(Procalcitonin Clearance,PCTc),并分析PCT及PCTc與END發(fā)生之間的關(guān)系,從而評估利用PCT及PCTc預(yù)測END發(fā)生的能力,進(jìn)而闡明卒中相關(guān)性肺炎患者進(jìn)行感染控制的價值。資料與方法本研究為前瞻觀察性研究,選擇2010年11月至2013年10月在環(huán)湖醫(yī)院六病區(qū)連續(xù)收治的急性腦卒中患者作為研究對象。參照2010卒中相關(guān)性肺炎診治中國專家共識制定的卒中相關(guān)性肺炎的診斷標(biāo)準(zhǔn)[1],將患者分為SAP組和非SAP組。END定義為急性缺血性卒中發(fā)病7天內(nèi)NIHSS評分增加≥4分。所有患者均完善相關(guān)影像學(xué)檢查包括CT或MRI,詢問患者現(xiàn)病史、既往史,個人史,并記錄患者相關(guān)危險因素以及個人基本情況,并對患者進(jìn)行NIHSS評分。以是否出現(xiàn)SAP分為SAP組及非SAP組。SAP患者在確診后即刻,以及第24小時,第48小時,第72小時檢測血PCT,并計算第24小時,第48小時,第72小時的PCTc。分別計算END組和非END組第24小時,第48小時,第72小時的PCTc,進(jìn)而通過統(tǒng)計計算評價PCTc與END之間的關(guān)系。結(jié)果1.共收治2062名卒中患者,其中363例(17.6%)出現(xiàn)卒中相關(guān)性肺炎,為SAP組,1699例(82.4%)未出現(xiàn)卒中相關(guān)性肺炎,為非SAP組。兩組患者在性別組成,高血壓史,高脂血癥史,吸煙史等方面無統(tǒng)計學(xué)差異(p0.05,表1)。2.與非SAP組比較,SAP組年齡偏高,合并糖尿病、入院時NIHSS評分存在差異,兩組間均達(dá)到統(tǒng)計學(xué)顯著性差異(p0.05,表1)。且房顫,腫瘤,心肌梗死的比例,及存在意識障礙,吞咽困難的比例均高,兩組間達(dá)到顯著統(tǒng)計學(xué)差異(p0.05,表3)。3.363例SAP組出現(xiàn)END78例。1699例非SAP組出現(xiàn)END235例。與非SAP組的卒中患者相比,SAP組的END發(fā)生率較高,差異達(dá)到統(tǒng)計學(xué)差異(p0.05,表2)。4.SAP是急性卒中患者發(fā)生END的獨立危險因素(OR=3.143,95%CI1.314~5.209,p0.05,表4)。5.END組和非END組間一般情況比較:363例卒中相關(guān)性肺炎患者,78例(21.49%)并發(fā)END,為END組;285例(78.51%),為非END組。兩組患者在年齡、性別組成;高血壓史、高脂血癥史、吸煙史和既往卒中史及在中性粒細(xì)胞比例、APACHEⅡ、HDL及LDL水平,TG及血壓水平等方面均無統(tǒng)計學(xué)差異(p0.05,表1)。與非END組患者相比,END組患者合并糖尿病的比例及WBC、CRP、TG、Fi及Hb A1c水平,入院時NIHSS評分均高,兩組間均達(dá)到統(tǒng)計學(xué)顯著性差異(p0.05,表5)。6.END組和非END組間PCT的比較:與非END組相比,END組在入院時、24小時及48小時的PCT值無明顯差異(p0.05),72小時PCT值則高于非END組的PCT值(p0.05)。而對于PCTc,24小時和48小時兩組間無明顯差異(p0.05),72小時的PCTc,END組明顯低于非END組(p0.05)(表6)。7.相關(guān)危險因素分析:將兩組間存在明顯差異的白細(xì)胞、CRP、CHO、Fi及Hb A1c,入院時NIHSS評分,糖尿病史及72小時PCT及PCTc水平納入多元線性回歸方程分析,進(jìn)行Logistic回歸分析,結(jié)果顯示,END只與72小時的PCTc之間存在密切關(guān)系。72小時PCTc是END的獨立因素(OR=0.031,95%CI 0.008~0.128,p0.05),72小時PCT絕對值并不是END發(fā)生的獨立危險因素(表7)。8.ROC研究曲線表明72小時PCTc預(yù)測END發(fā)生的AUC為0.838(95%CI0.751~0.924),截斷值為32.2%時,敏感性為77.14%,特異性為87.5%(表8)。結(jié)論本研究收集了SAP組與非SAP組的性別、年齡、高血壓史、糖尿病史、房顫、腫瘤史、NIHSS、TG、Fi、Hb A1c等影響因素結(jié)果,以研究導(dǎo)致SAP的相關(guān)危險因素。結(jié)果表明SAP組合并房顫,腫瘤,糖尿病,心肌梗死的比例,及入院NIHSS評分,存在意識障礙,吞咽困難的比例均高,兩組間達(dá)到顯著統(tǒng)計學(xué)差異(p0.05,表1)。本研究分析了END組和非END組患者的高血壓史、糖尿病史、高脂血癥史、吸煙史、卒中史、性別、年齡、WBC、中性粒細(xì)胞比例、CRP、APACHEⅡ、NIHSS、HDL、LDL、CHO、TG、Fi、Hb A1c、收縮壓、舒張壓等影響因素結(jié)果,以研究導(dǎo)致END的相關(guān)危險因素。本文先對兩組患者的相關(guān)危險因素進(jìn)行單因素分析,結(jié)果表明END組合并糖尿病的比例及WBC、CRP、TG、Fi及Hb A1c水平,入院時NIHSS評分,72小時PCT及72小時PCTc與非END組相比差異有統(tǒng)計學(xué)意義(p0.05,表1)。進(jìn)一步進(jìn)行多元回歸分析來分析這些有統(tǒng)計學(xué)意義的影響因素,結(jié)果表明影響SAP患者發(fā)生END的獨立危險因素只有只有72小時PCTc,而CRP并不是SAP患者發(fā)生END的獨立危險因素。進(jìn)一步ROC曲線分析顯示,72小時PCTc在一定程度上可以預(yù)測早期神經(jīng)功能惡化的發(fā)生,72小時PCTc下降〈32.2%,是END的預(yù)測因素(p0.05)。本研究表明,SAP患者發(fā)生END,單因素分析顯示與入組時及24小時,48小時PCT無關(guān),與72小時PCT有關(guān),但多因素分析顯示72小時PCT并不是END的獨立危險因素,而與72小時PCTc有關(guān),表明SAP患者如果最初存在的感染并不一定會造成END出現(xiàn),但感染控制不佳可能會引起END發(fā)生。監(jiān)測PCT的絕對值,并不能對SAP患者出現(xiàn)END做出預(yù)測,而引入PCTc有助于觀察PCT的動態(tài)變化,并對END出預(yù)測。進(jìn)而我們可以依據(jù)PCTc的變化,調(diào)整抗生素的治療。這提示我們對于發(fā)生SAP的患者要及時有效的應(yīng)用抗生素,并根據(jù)PCTc的變化來指導(dǎo)抗生素治療。
[Abstract]:Background and objective early neurological deterioration (Early neurological deterioration, END) is a common complication of acute stroke patients. The occurrence of END is associated with an increase in the rate of disability and mortality, the prolonged hospitalization days, and the increase of medical costs. At present, the pathogenesis of END is not yet clear, and there is no accurate and reliable early predictor, too. There is no effective prevention and treatment. Therefore, it is urgent to find the early clinical indicators that can predict the occurrence of END in order to give intervention therapy in time and prevent the occurrence of END. The current study found that pneumonia is an independent predictor of neurological deterioration in stroke patients. And stroke associated pneumonia (Stroke-Associated Pneumon) IA, SAP) is a common complication of acute stroke. Studies have shown that the occurrence of SAP is closely related to poor prognosis. However, fewer reports have been reported on the relationship between stroke related pneumonia and the occurrence of early neurological deterioration after acute stroke. Procalcitonin (PCT) is a new index of inflammation, compared with the current commonly used inflammatory markers. Temperature, leukocyte count, neutrophils ratio, C reactive protein (C-Reactive Protein, CRP), erythrocyte sedimentation rate and so on are more sensitive and specific. Therefore, in this study, we intend to analyze the relationship between SAP and the occurrence of END by collecting a large number of clinical data of stroke patients, and continuously monitor the serum calcitonin (Procalci) in SAP patients (Procalci). Tonin, PCT) level, calculate the Procalcitonin Clearance (PCTc), and analyze the relationship between PCT and PCTc and END, so as to assess the ability to predict END occurrence using PCT and PCTc, and then to clarify the value of infection control in patients with stroke related pneumonia. Acute stroke patients who were admitted to the six disease District of the lake hospital from November to October 2013, 10 years 10 years, were used as the research object. Referring to the 2010 stroke related pneumonia, the diagnosis standard of stroke related pneumonia was established by the Chinese expert consensus. The patients were divided into SAP group and non SAP group.END defined as NIHSS score within 7 days of acute ischemic stroke. All patients had more than 4 points. All the patients had improved the relevant imaging examinations including CT or MRI, asked the patient's history, history, personal history, and recorded the patient's risk factors and individual basic conditions, and the NIHSS score was performed on the patients. SAP was divided into SAP and non SAP group.SAP patients immediately after the diagnosis, and twenty-fourth hours, forty-eighth small At seventy-second hours, blood PCT was detected, and twenty-fourth hours, forty-eighth hours, and seventy-second hours of PCTc. were calculated for twenty-fourth hours, forty-eighth hours and seventy-second hours PCTc respectively in group END and non END group, and then the relationship between PCTc and END was evaluated by statistical calculation. Results 1. were treated with 2062 stroke patients, 363 cases (17.6%) appeared stroke associated pneumonia, SAP Group, 1699 cases (82.4%) did not have stroke related pneumonia, non SAP group. There was no statistical difference in sex composition, history of hypertension, hyperlipidemia and smoking history in the two groups (P0.05, table 1).2. and non SAP group, SAP group was higher in age, with diabetes, and there was a difference in NIHSS score at the time of admission, and the difference between the two groups reached statistical significant difference. (P0.05, table 1) and the proportion of atrial fibrillation, tumor, myocardial infarction, and the existence of consciousness disorder, the proportion of dysphagia were high, the two groups reached significant statistical differences (P0.05, table 3).3.363 cases SAP group, END78 cases,.1699 cases, non SAP group appeared END235 cases. Compared with the non SAP group, END incidence in the SAP group was higher, the difference reached statistical difference. The difference (P0.05, table 2).4.SAP was an independent risk factor for END in acute stroke patients (OR=3.143,95%CI1.314~5.209, P0.05, table 4).5.END and non END groups: 363 cases of stroke associated pneumonia, 78 cases (21.49%) complicated with END, 285 cases (78.51%), non END group. Two group of patients in age, sex composition, hypertension history, high The history of lipoemia, the history of smoking and the history of stroke and the proportion of neutrophils, APACHE II, HDL and LDL levels, TG and blood pressure levels were not statistically different (P0.05, table 1). Compared with the non END group, the proportion of diabetes in the END group and the level of WBC, CRP, TG, Fi and Hb were all high, and the two groups were all reached statistics. The comparison of the significant differences (P0.05, table 5).6.END and non END group PCT: compared with the non END group, there was no significant difference in the PCT value between the 24 hours and the 48 hours (P0.05) and the 72 hour PCT value was higher than the PCT value (P0.05) in the non END group. But there was no significant difference between the two groups in the 24 and 48 hours. Lower than non END group (P0.05) (Table 6).7. related risk factors analysis: leucocytes, CRP, CHO, Fi and Hb A1c in the two groups were significantly different, and the scores of NIHSS, diabetes history and 72 hours PCT and PCTc were analyzed by multiple linear regression equation, and the Logistic return analysis was carried out. The relationship.72 hour PCTc is an independent factor of END (OR=0.031,95%CI 0.008~0.128, P0.05), 72 hours PCT absolute value is not an independent risk factor for END (Table 7).8.ROC research curve indicating 72 hours PCTc prediction END AUC is 0.838, when the truncated value is 32.2%, sensitivity is 77.14%, specificity is 87.5% (table 8). The study collected the effects of sex, age, hypertension, diabetes, atrial fibrillation, tumor history, NIHSS, TG, Fi, Hb A1c in group SAP and non SAP groups to study the risk factors associated with SAP. The results showed that the proportion of SAP combination and atrial fibrillation, the proportion of tumor, diabetes, myocardial infarction, and admission NIHSS score, consciousness disorder, dysphagia The proportion of the two groups was significantly different (P0.05, table 1). This study analyzed the history of hypertension, diabetes, hyperlipidemia, smoking, stroke, sex, age, WBC, neutrophils, CRP, APACHE II, NIHSS, HDL, LDL, CHO, TG, Fi, systolic and diastolic pressure in the END and non END groups. A single factor analysis of the related risk factors of the two groups of patients was first studied. The results showed that the proportion of END combined with diabetes and the level of WBC, CRP, TG, Fi and Hb A1c, the score of NIHSS, 72 hours PCT and 72 hours PCTc were statistically significant compared with those of the non END group (Table 1). Multivariate regression analysis was used to analyze these statistically significant factors. The results showed that the independent risk factors affecting the occurrence of END in SAP patients were only 72 hours PCTc, and CRP was not an independent risk factor for END in SAP patients. Further ROC curve analysis showed that 72 hours PCTc could predict early neurological deterioration to some extent. The 72 hour PCTc decreased (32.2%), a predictor of END (P0.05). This study showed that SAP patients had END. The single factor analysis showed that it was related to the entry group and 24 hours, 48 hours PCT, and 72 hours PCT, but the multivariate analysis showed that PCT was not an independent risk factor for END, and was associated with 72 hour PCTc, indicating SAP patients such as The initial infection does not necessarily lead to the occurrence of END, but the poor control of infection may cause the occurrence of END. Monitoring the absolute value of PCT does not predict the occurrence of END in SAP patients, and the introduction of PCTc helps to observe the dynamic changes in PCT and predicts END. In this way, we can adjust the treatment of antibiotics according to the changes in PCTc. It is suggested that we should promptly and effectively apply antibiotics to patients with SAP and guide antibiotic therapy according to the changes of PCTc.

【學(xué)位授予單位】：天津醫(yī)科大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2017
【分類號】：R743.3;R563.1

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