本文選題：電子病歷 + 臨床路徑　； 參考：《浙江大學(xué)》2014年博士論文

【摘要】：研究背景：信息化時(shí)代撲面而至,如何更好地利用信息化手段規(guī)范優(yōu)化臨床流程,挖掘臨床科研數(shù)據(jù)已經(jīng)成為當(dāng)今醫(yī)學(xué)發(fā)展的重要方向之一。在亞洲地區(qū),慢加急性肝衰竭是一組發(fā)病率高,病死率高,治療費(fèi)用昂貴的臨床癥候群。然而,迄今為止,鮮有在不區(qū)分病因情況下,特異性基于大樣本亞洲慢加急性肝衰竭人群,利用保守治療后的預(yù)后數(shù)據(jù),建立的慢加急性肝衰竭預(yù)后評(píng)價(jià)系統(tǒng),更缺乏針對(duì)慢加急性肝衰竭傾向人群的預(yù)后評(píng)價(jià)系統(tǒng)。因此,本研究的目的：充分利用信息化技術(shù),構(gòu)建肝衰竭臨床科研系統(tǒng),更有效率的實(shí)現(xiàn)臨床科研數(shù)據(jù)的清洗,整理和歸類(lèi)分析,解決數(shù)據(jù)一致性問(wèn)題,進(jìn)一步摸索慢加急性肝衰竭傾向患者的預(yù)后情況,并且建立一個(gè)針對(duì)保守治療后的慢加急性肝衰竭和慢加急性肝衰竭傾向患者的預(yù)后評(píng)價(jià)模型。 方法：通過(guò)對(duì)肝衰竭臨床診治流程的梳理和規(guī)劃,構(gòu)建了包括肝衰竭電子病歷和臨床路徑,肝衰竭多中心臨床試驗(yàn)電子數(shù)據(jù)采集(EDC)系統(tǒng),肝衰竭隨訪(fǎng)系統(tǒng),人工肝診治和隨訪(fǎng)系統(tǒng)在內(nèi)的肝衰竭臨床科研系統(tǒng)�；谏鲜鱿到y(tǒng),本研究對(duì)2008年12月1號(hào)至2012年2月1號(hào)收治浙江大學(xué)醫(yī)學(xué)院附屬第一醫(yī)院,予以保守治療的857例慢加急性肝衰竭和慢加急性肝衰竭傾向患者,進(jìn)行了回顧性隊(duì)列研究和分析。按照病情輕重程度,有無(wú)肝硬化等情況建立亞組,采用Kaplan-Meier生存曲線(xiàn)進(jìn)行實(shí)際生存情況分析和比較。采用雙變量分析和COX比例風(fēng)險(xiǎn)回歸模型進(jìn)一步分析了影響慢加急性肝衰竭預(yù)后的獨(dú)立危險(xiǎn)因素,并建立預(yù)后模型。采用ROC曲線(xiàn)下面積對(duì)新模型和現(xiàn)有模型進(jìn)行了比較。 結(jié)果：在研究中,我們發(fā)現(xiàn)慢加急性肝衰竭傾向組的患者12周的病死率是30.5%,24周的病死率是33.2%,而慢加急性肝衰竭早期組的患者12周的病死率是33.9%,24周的病死率是37.1%,慢加急性肝衰竭中期組的患者12周的病死率是49.5%,24周的病死率是53.8%；慢加急性肝衰竭晚期組的患者12周的病死率是77.2%,24周的病死率是78.5%。無(wú)論是12周病死率還是24周病死率,慢加急性肝衰竭傾向組的患者病死率和慢加急性肝衰竭早期組的患者病死率均沒(méi)有統(tǒng)計(jì)學(xué)差異(P0.05)。而慢加急性肝衰竭傾向組的患者病死率和慢加急性肝衰竭中期組的患者病死率均有明顯統(tǒng)計(jì)學(xué)差異(P0.0001)。慢加急性肝衰竭早期組的患者病死率和慢加急性肝衰竭中期組的患者病死率比較,慢加急性肝衰竭中期組的患者病死率和慢加急性肝衰竭晚期組的患者病死率比較,也均有明顯統(tǒng)計(jì)學(xué)差異(P0.0001)。 研究根據(jù)有無(wú)肝硬化,將全部的857例患者分為肝硬化組(n=455)和非肝硬化組(n=402)。發(fā)現(xiàn)肝硬化組的患者12周病死率是63.1%,24周病死率是65.5%,而非肝硬化組的患者12周病死率是45.5%,24周病死率是46.5%,無(wú)論是12周病死率還是24周病死率,兩組之間均有明顯的統(tǒng)計(jì)學(xué)差異(P0.0001)。 雙變量分析和COX比例風(fēng)險(xiǎn)回歸模型分析發(fā)現(xiàn)五個(gè)和慢加急性肝衰竭以及慢加急性肝衰竭傾向患者預(yù)后密切相關(guān)的獨(dú)立危險(xiǎn)因素,分別是MELD評(píng)分,年齡,肝性腦病,甘油三酯和血小板計(jì)數(shù)水平。隨著MELD評(píng)分,年齡,肝性腦病,甘油三酯水平的升高和血小板計(jì)數(shù)水平的降低,病死率增加。建立了李氏慢加急性肝衰竭模型(Li-ACLF model),R=0.021×年齡(歲)+0.279×肝性腦病分度+0.513×MELD評(píng)分一0.210×loge血小板計(jì)數(shù)(109/L)一0.176×loge甘油三酯(mg/dL)結(jié)論：研究構(gòu)建的肝衰竭臨床科研系統(tǒng)規(guī)范優(yōu)化了臨床流程,解決了數(shù)據(jù)一致性問(wèn)題,使得臨床研究能夠更有效率的利用分析數(shù)據(jù)。在此基礎(chǔ)上開(kāi)展的進(jìn)一步研究,發(fā)現(xiàn)慢加急性肝衰竭傾向患者預(yù)后較差,類(lèi)似早期慢加急性肝衰竭患者,因此,建議可適當(dāng)放寬我國(guó)2006年頒布的慢加急性肝衰竭診斷標(biāo)準(zhǔn),有利于慢加急性肝衰竭傾向患者盡早得到更有效的診治。建立的李氏慢加急性肝衰竭預(yù)后評(píng)價(jià)模型可用于慢加急性肝衰竭患者在保守治療后的預(yù)后判斷,有利于早期評(píng)估患者保守治療的生存可能,輔助判斷是否需要肝移植治療,有利于改善患者預(yù)后。
[Abstract]:Background: the information age Pumian but how to make better use of information technology means to regulate and optimize clinical process, clinical research, data mining has become one of the important direction of medical development. In Asia, acute on chronic liver failure is a group of high incidence, high mortality, high cost of treatment of clinical syndrome. However, so far so far, few in distinguishing the cause of disease cases, specific sample of Asian acute on chronic liver failure group based on the data of prognosis after conservative treatment of acute on chronic liver failure, prognosis evaluation system, lack for the evaluation of prognosis of acute on chronic liver failure tendency of population system. Therefore, the purpose of this study is: make full use of information technology, construction of liver failure in clinical research, clinical research data for cleaning more efficient, sorting and classification analysis, to solve the data consistency problem into One step to explore the prognosis of patients with chronic acute liver failure, and establish a prognosis evaluation model for patients with chronic acute liver failure and chronic acute liver failure after conservative treatment.
Methods: the clinical diagnosis and treatment of liver failure in the process of combing and planning, including the construction of electronic medical records and clinical pathway of liver failure, liver failure, multicenter clinical trial of the electronic data acquisition system (EDC), liver failure follow-up system, system of artificial liver treatment and follow-up, liver failure clinical research system. Based on the above system, the on December 1, 2008 to February 1, 2012 from the First Affiliated Hospital of Zhejiang University School of medicine, to conservative treatment of 857 cases of acute on chronic liver failure and acute on chronic liver failure tendency patients, a retrospective cohort study was conducted and analyzed. According to the severity of the disease, there is no established cirrhosis subgroup, the Kaplan-Meier survival curves and comparative analysis the actual survival situation. By using bivariate analysis and COX proportional hazards regression model to analyze the influence of chronic prognosis of acute liver failure independent risk The risk factors and the prognosis model were established. The area under the ROC curve was used to compare the new model with the existing model.
Results: in this study, we found that acute on chronic liver failure tendency group patients with 12 week mortality rate was 30.5%, the mortality rate is 33.2% to 24 weeks, and acute on chronic liver failure patients with early 12 week mortality rate was 33.9%, the mortality rate is 37.1% to 24 weeks, acute on chronic liver failure in the group of patients 12 week period mortality rate was 49.5%, the mortality rate is 53.8% to 24 weeks; chronic late acute liver failure patients 12 week mortality rate was 77.2%, the mortality rate of 78.5%. is 24 weeks whether the mortality for 12 weeks or 24 weeks, the fatality rate of acute on chronic liver failure tendency group the mortality rate in patients with acute on chronic liver failure and mortality rate in patients with early group had no significant difference (P0.05). The difference and acute on chronic liver failure tendency group mortality rate in patients with acute on chronic liver failure and mortality rate in patients with intermediate groups there were statistically significant (P0.0001). Acute on chronic liver failure early group The mortality of patients in the mid stage group was significantly lower than that in the patients with acute or chronic liver failure, and there was a significant difference in mortality between the mid and chronic acute liver failure group and the late acute liver failure group (P0.0001).
According to the study of hepatic cirrhosis, 857 cases of all patients were divided into cirrhosis group (n=455) and non cirrhosis group (n=402). It is found that the patients with liver cirrhosis group 12 week mortality rate is 63.1%, the 24 week mortality rate is 65.5%, while the non cirrhosis patients with 12 week mortality rate was 45.5%, the mortality rate is 24 weeks 46.5%, whether the mortality for 12 weeks or 24 weeks mortality rate between the two groups had statistically significant difference (P0.0001).
Independent risk factors for bivariate analysis and COX regression analysis found five and acute on chronic liver failure and acute on chronic liver failure tendency closely related to the prognosis of patients, respectively, MELD score, age, hepatic encephalopathy, triglyceride level and platelet count. With the MELD score, age, hepatic encephalopathy, lower triglyceride levels and the increase of the level of platelet count, the mortality rate increased. Lee established acute on chronic liver failure model (Li-ACLF model), R=0.021 * +0.279 * age (years) hepatic encephalopathy +0.513 * MELD score index of 0.210 * loge platelet count (109/L) of a 0.176 x loge triglyceride (mg/dL) conclusion: the construction of the liver failure of clinical research system specification to optimize the clinical procedure, solve the problem of data consistency, makes clinical research more effectively using data analysis. On the basis of the further development Study found that acute on chronic liver failure tendency of patients with poor prognosis, similar to the early chronic patients with acute liver failure, therefore, suggestions may be appropriate to relax the acute on chronic liver failure diagnosis standard of our country promulgated in 2006, for patients with acute on chronic liver failure diagnosis and treatment as early as possible to get more effective tendency. To evaluate the prognosis of chronic Lee acute liver failure model can be used for patients with acute on chronic liver failure, in the judgment of the prognosis after conservative treatment, is conducive to the early assessment of patients with conservative treatment survival may determine the need, auxiliary liver transplantation and improve the prognosis of patients.

【學(xué)位授予單位】：浙江大學(xué)
【學(xué)位級(jí)別】：博士
【學(xué)位授予年份】：2014
【分類(lèi)號(hào)】：R575.3;R-332

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本文編號(hào)：1750035