本文選題：臨床路徑 + 垂體瘤手術(shù)�。� 參考：《浙江大學(xué)》2017年碩士論文

【摘要】：目的觀察垂體瘤圍術(shù)期患者的內(nèi)分泌功能評估及替代治療情況,分析執(zhí)行臨床路徑對其產(chǎn)生的影響,并闡明對垂體瘤圍術(shù)期患者進(jìn)行臨床路徑管理的重要性。方法:從內(nèi)分泌科的垂體瘤患者隨訪數(shù)據(jù)庫以及全院病案系統(tǒng)中,選取2009.7至2015.12期間在我院接受垂體瘤手術(shù)治療及門診隨訪的患者作為研究對象。根據(jù)是否執(zhí)行臨床路徑,將研究對象分為路徑組和非路徑組。收集術(shù)前(合并癥、臨床癥狀,影像學(xué),內(nèi)分泌評估等)、術(shù)中(術(shù)式、病理、并發(fā)癥等)、術(shù)后(內(nèi)分泌評估,藥物治療等)等相關(guān)資料。其中內(nèi)分泌評估資料包括泌乳素、性腺軸激素、甲狀腺軸激素、皮質(zhì)軸激素、生長激素、胰島素樣生長因子-1、血鈉、尿比重等指標(biāo)以及相關(guān)內(nèi)分泌動態(tài)試驗資料。按照術(shù)前1周、術(shù)后1周,術(shù)后1、3、6、12月的評估時間點,對資料進(jìn)行整理錄入。路徑組和非路徑組患者,分別以性別、年齡(+/-5歲)進(jìn)行1:2配對。觀察比較兩組在內(nèi)分泌評估以及替代治療上的差異,并對術(shù)后激素軸(性腺軸、甲狀腺軸、腎上腺軸)以及整體內(nèi)分泌功能的恢復(fù)情況(激素水平達(dá)到正�；蛞研邢嚓P(guān)替代治療)進(jìn)行單因素分析,并將單因素分析中P0.05的因素納入有序回歸分析。因變量:在術(shù)后激素軸功能恢復(fù)的因素分析中,以"靶腺激素水平達(dá)到正常的時間"作為因變量,并以術(shù)后1、3月為切點,將因變量分為"早、中、晚"三組進(jìn)行統(tǒng)計。在術(shù)后整體內(nèi)分泌功能恢復(fù)的因素分析中,自定義"整體內(nèi)分泌恢復(fù)評分"做為因變量�？傇u分為泌乳素、性腺軸、甲狀腺軸、腎上腺軸、生長激素、抗利尿激素的功能恢復(fù)評分之和,并根據(jù)評分高低,分為整體內(nèi)分泌功能恢復(fù)情況"好、中、差"三組進(jìn)行統(tǒng)計。自變量:組別、性別、年齡、學(xué)歷,術(shù)前癥狀,合并癥、煙酒史,腫瘤直徑、腫瘤分型、侵襲性,手術(shù)術(shù)式,術(shù)后并發(fā)癥以及依從性評分(門診的內(nèi)分泌隨訪次數(shù)之和)、有效評估評分(激素或激素軸功能的有效評估次數(shù)之和)等。使用SPSS 20.0進(jìn)行統(tǒng)計分析。結(jié)果:研究最終納入180例患者進(jìn)入分析統(tǒng)計,男性87人,女性93人,平均年齡(49.82±12.76)歲,其中路徑組60人,非路徑組120人,兩組腫瘤直徑無明顯差異(22.10mm VS.25.08mm,P=0.09)。相較于非路徑組,路徑組的內(nèi)鏡使用率更高(86.7%VS.18.3%,P0.01),腦脊液漏發(fā)生率更高(28.3%VS.10%,P=0.002)。術(shù)前1周,術(shù)后1周,術(shù)后1、3、6、12月,性腺軸、甲狀腺軸、腎上腺軸、生長激素、后葉功能的有效評估率,路徑組均高于非路徑組;功能低下患、者中,路徑組的藥物替代率也較非路徑組更高。術(shù)后單激素軸功能恢復(fù)的有序回歸分析顯示,相較于良好評估(有效評估得分3)的患者,不良評估(有效評估得分≤3)患者的甲狀腺軸、皮質(zhì)軸功能在術(shù)后短期內(nèi)未能達(dá)到正常的風(fēng)險更高(P0.05),OR分別為3.26,3.13。性激素軸的有序回歸分析結(jié)果顯示,相較于路徑組,非路徑組患者在術(shù)后短期內(nèi)功能未能達(dá)到正常的風(fēng)險更高(OR=2.66,P0.05)。術(shù)后整體內(nèi)分泌功能恢復(fù)的有序回歸分析顯示,相比于路徑組,非路徑組患者,其術(shù)后內(nèi)分泌功能恢復(fù)的情況更差(OR=13.46,P=0.000);有效評估得分低的患者比有效評估得分高的患者,術(shù)后內(nèi)分泌功能的恢復(fù)情況更差(OR=12.80,P=0.002)。結(jié)論:執(zhí)行臨床路徑,有助于提高垂體瘤圍術(shù)期患者的內(nèi)分泌有效評估率、藥物替代率,有助于垂體瘤手術(shù)患者的內(nèi)分泌功能在術(shù)后早期達(dá)到正常。
[Abstract]:Objective To observe the endocrine function assessment and replacement therapy in the perioperative patients with pituitary adenomas, to analyze the effect of the clinical pathway on its production, and to clarify the importance of the clinical path management for the patients in the perioperative period of pituitary adenomas. Methods: 2009.7 to the follow-up database of the pituitary tumor patients in the Department of Endocrinology and the whole hospital medical record system were selected. 2015.12 patients who received pituitary adenoma surgery and outpatient follow-up were studied in our hospital. According to whether the clinical pathway was performed, the subjects were divided into the path group and the non path group. The preoperative (complication, clinical symptoms, imaging, endocrine assessment, etc.), intraoperative (surgical, pathological, complications, etc.), postoperative (endocrine assessment, drugs) were collected. Endocrine assessment data included prolactin, gonadotropin, thyroid axis hormone, corticosteroid, growth hormone, insulin-like growth factor -1, blood sodium, urine specific gravity, and related endocrine dynamic test data. The data were measured at 1 weeks before operation, 1 weeks after operation, and the time points for 1,3,6,12 months after operation. The patients in the path group and the non path group were paired with the sex and age (+/-5 years). The differences in the endocrine assessment and the replacement therapy were observed and compared between the two groups, and the recovery of the postoperative hormone axis (gonadal axis, thyroid axis, adrenal axis) and the overall secretory function (the hormone levels reached normal or already had been achieved. A single factor analysis was carried out and the factors of P0.05 in the single factor analysis were included in the sequential regression analysis. Variable: in the factor analysis of postoperative hormone axis function recovery, the "target adenoid level reached the normal time" as the dependent variable and the three groups were divided into "early, middle, late" by 1,3 months after the operation. In the analysis of postoperative overall endocrine function recovery factor analysis, a custom "overall endocrine recovery score" was used as a dependent variable. The total score was prolactin, gonadal axis, thyroid axis, adrenal axis, growth hormone, and the functional recovery of antidiuretic hormone, and the overall endocrine function was recovered according to the level of the score, "good, medium," Difference "three groups of statistics. Independent variables: group, sex, age, education, preoperative symptoms, complications, smoking and alcohol history, tumor diameter, tumor typing, invasive, surgical procedures, postoperative complications and compliance score (the number of endocrine follow-up times in outpatients), effective assessment score (the number of hormone or hormone axis function evaluation, and so on) and so on. SPSS 20 was statistically analyzed. Results: the study was finally included in the analysis of 180 patients, 87 men, 93 women, and average age (49.82 + 12.76) years old, including 60 in the path group, 120 in the non path group and no significant difference in the diameter of the tumor (22.10mm VS.25.08mm, P= 0.09). Compared with the non path group, the use of endoscopy in the path group was higher (86.7. %VS.18.3%, P0.01), the incidence of cerebrospinal fluid leakage was higher (28.3%VS.10%, P=0.002). 1 weeks before operation, 1 weeks after operation, 1,3,6,12 months after operation, the effective evaluation rate of gonadal axis, thyroid axis, adrenal axis, growth hormone and posterior leaf function was higher than that of non path group; the replacement rate of the path group was higher than that in the non path group. The sequential regression analysis of single hormone axis functional recovery showed that the thyroid axis of patients with poor assessment (effective assessment of score 3) was higher than that of a good assessment (effective assessment of score 3). The axial function of the cortical axis did not reach the normal risk in the short term after the operation (P0.05), and the results of the sequential regression analysis of the 3.26,3.13. sex hormone axis of OR were significant. Compared to the path group, the patients in the non path group had a higher risk of failure to achieve normal function in the short term (OR=2.66, P0.05). The sequential regression analysis of the postoperative overall endocrine function recovery showed that the postoperative endocrine function recovery was worse (OR=13.46, P=0.000) in the non path group than in the path group (OR=13.46, P=0.000); the effective assessment of the score was low. The recovery of endocrine function after operation is worse than that of patients with high score (OR=12.80, P=0.002). Conclusion: the implementation of clinical pathway helps to improve the effective rate of endocrine evaluation in patients with pituitary tumor perioperative period, and the replacement rate of drugs can help the endocrine function of the patients with pituitary tumor surgery to reach normal early after operation.

【學(xué)位授予單位】：浙江大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2017
【分類號】：R736.4

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