本文選題：肝硬化 + 腹膜炎��； 參考：《南昌大學(xué)》2017年博士論文

【摘要】：背景與目的:癥狀性細(xì)菌性腹水(symptomatic bacterascites,SB)是一種變異的自發(fā)性細(xì)菌性腹膜炎(spontaneous bacterial peritonitis,SBP),有感染表現(xiàn),但腹水多形核細(xì)胞(polymorphonuclear,PMN)計(jì)數(shù)250個(gè)/mm3,僅能通過腹水細(xì)菌培養(yǎng)陽性確診。由于腹水培養(yǎng)常耗時(shí)數(shù)日,故臨床難以及時(shí)發(fā)現(xiàn)SB。目前,缺乏早期診斷SB的有效方法。本研究目的是通過建立肝硬化數(shù)據(jù)庫來總結(jié)SB病原學(xué)特點(diǎn)和探索SB快速篩查模型及其臨床應(yīng)用。方法:1.創(chuàng)建肝硬化數(shù)據(jù)庫參照國(guó)內(nèi)外肝硬化相關(guān)診療指南,經(jīng)專家討論確定數(shù)據(jù)庫擬收集的內(nèi)容,然后運(yùn)用Epi InfoTM 7軟件創(chuàng)建肝硬化數(shù)據(jù)庫并錄入臨床數(shù)據(jù)。2.癥狀性細(xì)菌性腹水的病原菌及耐藥特征從創(chuàng)建的數(shù)據(jù)庫中篩選腹水培養(yǎng)陽性的SBP病例,分為SB組與常規(guī)SBP組(腹水PMN計(jì)數(shù)≥250個(gè)/mm3)。比較兩組病原菌構(gòu)成、耐藥特征及預(yù)后。3.血降鈣素原與C反應(yīng)蛋白篩查癥狀性細(xì)菌性腹水從創(chuàng)建的數(shù)據(jù)庫中選取符合要求的肝硬化病例,分為SB組與非感染性腹水組。利用受試者工作特征(receiver operating characteristic,ROC)曲線的曲線下面積(area under curve,AUC)來評(píng)價(jià)PCT及CRP篩查SB的價(jià)值。4.癥狀性細(xì)菌性腹水快速篩查模型的構(gòu)建與臨床應(yīng)用從創(chuàng)建的數(shù)據(jù)庫中選取符合條件的肝硬化病例,分為SB組與非感染性腹水組,通過單因素分析及二分類Logistic回歸分析篩選自變量并構(gòu)建SB快速篩查模型。將SB快速篩查模型判為陽性的新入院肝硬化腹水患者隨機(jī)分為試驗(yàn)組(給予抗菌素治療)與對(duì)照組(不予抗菌素治療)。前瞻性比較兩組的治療應(yīng)答率、病情變化及預(yù)后。結(jié)果:1.創(chuàng)建肝硬化數(shù)據(jù)庫 建立的肝硬化數(shù)據(jù)庫包括患者基本信息界面、病史資料界面、主訴體檢界面、實(shí)驗(yàn)室檢查界面、影像學(xué)及內(nèi)鏡檢查界面、內(nèi)科治療界面、干預(yù)治療界面、病情評(píng)估及預(yù)后界面、并發(fā)癥界面及出院隨訪界面,具有數(shù)據(jù)錄入、數(shù)據(jù)自檢、自動(dòng)計(jì)算等功能,目前已錄入568例住院肝硬化患者的臨床數(shù)據(jù)。2.癥狀性細(xì)菌性腹水的病原菌及耐藥特征共收集SB組103例和常規(guī)SBP組110例。SB組病原以革蘭陽性菌為主(占55.3%,53/103),常規(guī)SBP組以革蘭陰性菌為主(占71.8%,79/110),差異有統(tǒng)計(jì)學(xué)意義(c2=16.18,P0.01)。革蘭陽性菌和革蘭陰性菌對(duì)未加酶抑制劑的第三代頭孢菌素的耐藥分級(jí),在SB組為安全和預(yù)警,在常規(guī)SBP組為安全和不宜經(jīng)驗(yàn)用藥。患者30天內(nèi)死亡率在SB組為36.9%(38/103),在常規(guī)SBP組為43.6%(48/110),差異無統(tǒng)計(jì)學(xué)意義(c2=1.005,P=0.316)。3.血降鈣素原與C反應(yīng)蛋白篩查癥狀性細(xì)菌性腹水共納入SB組30例與非感染性腹水組51例。PCT、CRP、兩者串聯(lián)、兩者并聯(lián)診斷SB的AUC依次為0.725、0.848、0.737、0.706,兩兩差異無統(tǒng)計(jì)學(xué)意義(P0.05)。診斷SB的最佳界值,PCT為≥0.43ng/m L,CRP為≥12.76mg/L。依據(jù)上述界值,PCT、CRP、兩者串聯(lián)、兩者并聯(lián)診斷SB的敏感性依次為70.0%、70.0%、53.3%、86.7%,特異性依次為76.5%、88.2%、94.10%、74.5%。4.癥狀性細(xì)菌性腹水快速篩查模型的構(gòu)建與臨床應(yīng)用回顧性納入SB組103例與非感染性腹水組204例,利用其臨床數(shù)據(jù)構(gòu)建了以體溫、腹部壓痛、血中性粒細(xì)胞百分比、血總膽紅素、凝血酶原時(shí)間及腹水有核細(xì)胞計(jì)數(shù)為參數(shù)的SB快速篩查模型。模型診斷SB的AUC為0.939,最佳診斷界值為篩查評(píng)分≥0.328,其敏感性為86.4%,特異性為92.2%。前瞻性納入試驗(yàn)組12例與對(duì)照組12例。試驗(yàn)組有6例全程使用頭孢他啶,另6例因治療反應(yīng)不佳而調(diào)整抗菌素。至研究終點(diǎn)時(shí),兩組治療應(yīng)答率分別為66.7%(8/12)與16.7%(2/12),差異有統(tǒng)計(jì)學(xué)意義(Fisher精確概率法,P=0.036)。試驗(yàn)組中腹水PMN計(jì)數(shù)≥250個(gè)/mm3、腹水有核細(xì)胞計(jì)數(shù)≥500個(gè)/mm3、腹水培養(yǎng)陽性、確診SB、發(fā)熱且腹痛、腹部壓痛或/和反跳痛以及肝性腦病的事件發(fā)生率均低于對(duì)照組,但差異無統(tǒng)計(jì)學(xué)意義(P0.05);兩組均無死亡事件。結(jié)論:1.Epi Info~(TM7)軟件構(gòu)建肝硬化數(shù)據(jù)庫切實(shí)可行,能有效協(xié)助臨床醫(yī)生進(jìn)行臨床科研。2.SB與常規(guī)SBP的病原菌構(gòu)成及耐藥特點(diǎn)不同,而預(yù)后相當(dāng)。經(jīng)驗(yàn)性初治,未加酶抑制劑的第三代頭孢菌素可用于SB,但不宜用于常規(guī)SBP。3.血PCT、CRP及兩者聯(lián)合對(duì)SB均有良好的診斷價(jià)值且各有優(yōu)勢(shì),臨床可根據(jù)實(shí)際需要合理選用。4.SB快速篩查模型可有效識(shí)別SB病例,對(duì)該模型判為陽性的患者使用抗菌素可使其獲益。
[Abstract]:Background and purpose: symptomatic bacterascites (SB) is a variant of the spontaneous bacterial peritonitis (spontaneous bacterial peritonitis, SBP), with infection, but the ascites multiform nucleus cells (polymorphonuclear, PMN) count 250 / mm3, only through the ascites bacteria culture positive diagnosis. Because of ascites culture often It takes time for several days, so it is difficult to find SB. in time and lack an effective method for early diagnosis of SB. The purpose of this study is to summarize the characteristics of SB etiology and explore the SB rapid screening model and its clinical application by establishing the database of liver cirrhosis. 1. To determine the contents of the database to be collected, then the Epi InfoTM 7 software was used to create the liver cirrhosis database and to enter the clinical data of the pathogenic bacteria and drug resistance of.2. symptomatic bacterial ascites. The positive SBP cases were screened from the created database and divided into the SB group and the routine SBP group (the ascites PMN count > 250 /mm3). The two groups of pathogens were compared. Bacterial composition, resistance characteristics and prognosis.3. serum calcitonin and C reactive protein screening symptomatic bacterial ascites from the established database to select the cases of liver cirrhosis in accordance with the requirements, divided into SB group and non infectious ascites group. The area under the curve of receiver operating characteristic, ROC (ROC) curve (area under curve). AUC) to evaluate the value of the value of PCT and CRP screening SB for the rapid screening of symptomatic bacterial ascites, the construction and clinical application of the cirrhosis cases were selected from the created database, divided into SB group and non infectious ascites group. The independent variable and two classified Logistic regression analysis were used to screen the independent variables and establish the rapid SB screening. Model. The new hospitalized cirrhotic ascites patients with SB rapid screening model were randomly divided into experimental group (antibiotic treatment) and control group (no antibiotic treatment). The treatment response rate, disease change and prognosis in two groups were compared prospectively. 1. the liver cirrhosis database established by the database of liver cirrhosis included the basic letter of the patient Interest interface, medical history data interface, medical examination interface, laboratory examination interface, imaging and endoscopic examination interface, internal medical treatment interface, intervention therapy interface, disease assessment and prognosis interface, complication interface and discharge follow-up interface, data entry, data self-examination, automatic calculation and so on, 568 cases of hospitalized liver cirrhosis have been recorded at present. The pathogenic bacteria and drug resistance of symptomatic bacterial ascites in.2. group were collected in 103 cases and 110 cases of group.SB were mainly Gram-positive bacteria (55.3%, 53/103) and Gram-negative bacteria (71.8%, 79/110) in the routine SBP group. The difference was statistically significant (c2=16.18, P0.01). Gram-positive and Gram-negative bacteria were found in the SBP group. The drug resistance classification of third generation cephalosporins without enzyme inhibitor was safe and early warning in group SB, safe and inexperienced in routine SBP group. The mortality rate in group SB was 36.9% (38/103) in 30 days and 43.6% (48/110) in routine SBP group (c2=1.005, P=0.316),.3. blood calcitonin and C reactive protein screening symptoms The sexual bacterial ascites were included in group SB 30 cases and non infectious ascites group 51 cases.PCT, CRP, both in series, the AUC in parallel diagnosis of SB was 0.725,0.848,0.737,0.706, 22 difference was not statistically significant (P0.05). The best boundary value of SB was diagnosed, and PCT was equal to 0.43ng/m L. The sensitivity of combined diagnostic SB was 70%, 70%, 53.3%, 86.7%, and the specificity of the specificity was 76.5%, 88.2%, 94.10%. The construction and clinical application of 74.5%.4. symptomatic bacterial ascites rapid screening model were included in 103 cases of SB group and non infectious ascites group in 204 cases, and the clinical data were used to construct body temperature, abdominal tenderness, and blood neutrophil. The SB rapid screening model of the ratio, blood total bilirubin, prothrombin time and the count of nuclear cells in ascites was a rapid screening model. The AUC of the model diagnosed SB was 0.939, the best diagnostic value was that the screening score was more than 0.328, the sensitivity was 86.4%, the specificity was 12 cases in the prospective trial group and 12 cases in the control group. 6 cases in the experimental group were used ceftazidime in the test group. At the end of the study, the response rates of the two groups were 66.7% (8/12) and 16.7% (2/12) at the end of the study. The difference was statistically significant (Fisher precision probability, P=0.036). The PMN count of ascites in the experimental group was more than 250 /mm3, the ascites had a nuclear cell count more than 500 /mm3, the ascites was cultured positive, confirmed SB, fever and abdomen. The incidence of pain, abdominal pressure pain, and / and anti jump pain and hepatic encephalopathy were all lower than those in the control group, but the difference was not statistically significant (P0.05). There was no death event in the two groups. Conclusion: the 1.Epi Info~ (TM7) software for the construction of liver cirrhosis database is feasible and can help clinical medical students to carry out the clinical scientific research of.2.SB and the common SBP pathogens and tolerance. The drug characteristics are different, and the prognosis is equal. Third generation cephalosporins without enzyme inhibitors can be used for SB, but it is not suitable for routine SBP.3. blood PCT. CRP and both have good diagnostic value and each have advantages. The rapid screening model of.4.SB can be used to identify SB cases effectively according to the actual needs, and the model can be effectively identified for this model. Patients with positive type can benefit from antibiotics.
【學(xué)位授予單位】：南昌大學(xué)
【學(xué)位級(jí)別】：博士
【學(xué)位授予年份】：2017
【分類號(hào)】：R572.2;R575.2

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