本文選題：發(fā)生 + 進(jìn)展　； 參考：《北京中醫(yī)藥大學(xué)》2016年博士論文

【摘要】：目的和意義：研究糖尿病視網(wǎng)膜病變發(fā)生及進(jìn)展的相關(guān)影響因素,探討糖尿病視網(wǎng)膜病變進(jìn)展的預(yù)測方法,以指導(dǎo)臨床早期診斷糖尿病視網(wǎng)膜病變,預(yù)防其進(jìn)展。研究方法：1.糖尿病視網(wǎng)膜病變發(fā)生影響因素的臨床研究：本研究以2014年3月就診295例患者為研究對象。根據(jù)眼底表現(xiàn)情況,分為糖尿病視網(wǎng)膜病變(DR)組和非DR組,對比分析兩組患者一般資料、伴隨疾病、家族史、臨床測量指標(biāo)、理化指標(biāo)、中醫(yī)癥狀及中醫(yī)證素,篩查糖尿病視網(wǎng)膜病變發(fā)生的影響因素。2.糖尿病視網(wǎng)膜病變進(jìn)展危險因素及預(yù)測模型的建立：本研究以2014年3月-2015年12月完成隨訪的58例患者為研究對象。根據(jù)眼底視網(wǎng)膜病變變化情況,分為進(jìn)展組和未進(jìn)展組,比較兩組入組時一般資料、伴隨疾病、家族史、臨床測量指標(biāo)、理化指標(biāo)、中醫(yī)癥狀及中醫(yī)證素,篩查DR進(jìn)展的危險因素。采用多因素Logistic分析,篩查DR進(jìn)展的獨立危險因素,制定DR進(jìn)展預(yù)測模型。結(jié)果：一、基于差異性分析,得出與糖尿病視網(wǎng)膜病變發(fā)生與否有關(guān)影響因素1.一般資料：基于納入及排除標(biāo)準(zhǔn),去掉不符合條件者,非DR組入組183例,其中男103例,女80例,平均年齡58.67±11.30歲；DR組入組112例,其中男61例,女51例,平均年齡59.97±10.91歲,兩組年齡及性別分布無顯著差別；與非DR組相比,DR組吸煙比例、飲酒比例明顯高于非DR組,差異具有統(tǒng)計學(xué)意義。2.伴發(fā)病癥及家族史：與非DR組相比,DR組高血壓病、腦梗死病及低血糖比例明顯高于非DR組,差異具有統(tǒng)計學(xué)意義；與非DR組相比,DR組脂肪肝比例明顯低于非DR組,差異具有統(tǒng)計學(xué)意義；兩組伴發(fā)冠心病、高血脂、高尿酸血癥、父親家族史、母親家族史、兄弟姐妹家族史無顯著差別。3.臨床測量指標(biāo)：與非DR組相比,DR組收縮壓明顯高于非DR組,差異具有統(tǒng)計學(xué)意義；兩組舒張壓、體重指數(shù)、腰臀比無顯著差別,差異不具有統(tǒng)計學(xué)意義。4.理化指標(biāo)：與非DR組相比,DR組24h尿蛋白定量、尿微量白蛋白／血肌酐比值、血肌酐、血尿素氮、血尿酸、糖化血紅蛋白、血鉀、血磷明顯高于非DR組,差異具有統(tǒng)計學(xué)意義；與非DR組相比,DR組紅細(xì)胞計數(shù)、血總蛋白、血白蛋白明顯低于非DR組,差異具有統(tǒng)計學(xué)意義；兩組內(nèi)生肌酐清除率、腎小球濾過率、空腹血糖、總膽固醇、甘油三酯、高密度脂蛋白、低密度脂蛋白、血紅蛋白、血鈣無顯著差別,差異不具有統(tǒng)計學(xué)意義。5.中醫(yī)癥狀：非DR組中醫(yī)四診信息頻次最高的十個癥狀依次分別是：倦怠乏力、咽燥口干、性欲減退、腰膝酸痛、齒松動脫發(fā)、肢體困重、口干口苦、目睛干澀、健忘、自汗；DR組中醫(yī)四診信息頻次最高的十個癥狀依次分別是：倦怠乏力、少氣懶言、性欲減退、咽燥口干、齒松動脫發(fā)、腰膝酸痛、視物昏花、肢體困重、目睛干澀、夜尿頻多；與非DR組相比,DR組少氣懶言、小便黃赤、周身浮腫癥狀頻次分布明顯升高,差異具有統(tǒng)計學(xué)意義；與非DR組相比,DR組自汗、頭暈眼花、五心煩熱、喘促氣短、健忘、口苦口干癥狀頻次分布明顯低于非DR組,差異具有統(tǒng)計學(xué)意義。6.中醫(yī)證素：非DR組中醫(yī)各證素頻次分布高低依次分別是：陰虛、氣虛、陽虛、血瘀、血虛、濕熱、痰濁、氣滯、熱盛；DR組中醫(yī)各證素頻次分布高低依次分別是：氣虛、陰虛、血虛、陽虛、血瘀、熱盛、痰濁、氣滯、濕熱；與非DR組相比,DR組陰虛、濕熱證素頻次分布明顯降低,差異具有統(tǒng)計學(xué)意義。二、基于差異性分析,得出與糖尿病視網(wǎng)膜病變進(jìn)展與否有關(guān)影響因素1.基線一般資料：未進(jìn)展組基線入組43例,其中男20例,女23例,平均年齡63.28±7.48歲；進(jìn)展組基線入組15例,其中男10例,女5例,平均年齡59.97±10.91歲：與未進(jìn)展組相比,進(jìn)展組年齡明顯低于未進(jìn)展,差異具有統(tǒng)計學(xué)意義；兩組性別分布無統(tǒng)計學(xué)差異；與未進(jìn)展組相比,進(jìn)展組吸煙、飲酒比例無顯著差別,差異不具有統(tǒng)計學(xué)意義。2.伴發(fā)病癥及家族史：與未進(jìn)展組相比,進(jìn)展組高血壓病病史比例明顯高于未進(jìn)展,差異具有統(tǒng)計學(xué)意義；與未進(jìn)展組相比,進(jìn)展組冠心病、腦梗死病、高血脂、脂肪肝、高尿酸血癥、低血糖、家族史比例無顯著差別,差異不具有統(tǒng)計學(xué)意義。3.臨床測量指標(biāo)：與未進(jìn)展組相比,進(jìn)展組收縮壓、舒張壓無顯著差別,差異不具有統(tǒng)計學(xué)意義；與未進(jìn)展組相比,進(jìn)展組體重指數(shù)、腰臀比明顯高于未進(jìn)展,差異具有統(tǒng)計學(xué)意義。4.理化指標(biāo)：與未進(jìn)展組相比,進(jìn)展組24小時尿蛋白定量、尿液微蛋白/肌酐比值、血肌酐、血尿素氮、血糖、糖化血紅蛋白、血磷明顯高于未進(jìn)展,內(nèi)生肌酐清除率、腎小球濾過率低于未進(jìn)展組,差異具有統(tǒng)計學(xué)意義；。與未進(jìn)展組相比,進(jìn)展組尿酸、總膽固醇、甘油三酯、低密度脂蛋白、高密度脂蛋白、紅細(xì)胞計數(shù)、血紅蛋白、血鉀、血鈣、血總蛋白、血白蛋白無顯著差別,差異不具有統(tǒng)計學(xué)意義。5.中醫(yī)癥狀：未進(jìn)展組基線水平中醫(yī)四診信息頻次最高的十個癥狀依次分別是：倦怠乏力、肢體困重、性欲減退、咽燥口干、腰膝酸痛、齒松動脫發(fā)、健忘、視物昏花、皮膚瘙癢、自汗；進(jìn)展組患者基線水平中醫(yī)四診信息中出現(xiàn)頻次最高的前十個癥候是：倦怠乏力、目睛干澀、肢體困重、頭暈眼花、齒松動脫發(fā)、口干口苦、皮膚瘙癢、形寒肢冷、腰膝酸痛、性欲減退；與非進(jìn)展組相比,進(jìn)展組基線水平心悸怔仲、失眠多夢、爪甲不榮癥狀頻次分布明顯低于未進(jìn)展,差異具有統(tǒng)計學(xué)意義。6.中醫(yī)證素：非進(jìn)展組基線水平中醫(yī)各證素頻次分布高低依次分別是：氣虛、陰虛、血虛、濕熱、血瘀、氣滯、痰濁、熱盛、陽虛；進(jìn)展組基線水平中醫(yī)各證素頻次分布高低依次分別是：氣虛、陰虛、陽虛、血虛、濕熱、血瘀、痰濁、熱盛、氣滯；與未進(jìn)展組相比,進(jìn)展組陽虛證素頻次分布明顯高于未進(jìn)展,差異具有統(tǒng)計學(xué)意義。三、DR進(jìn)展預(yù)測模型的建立：1.多因素分析結(jié)果顯示：體重指數(shù)(OR=2.125, P=0.754)、ACR (OR=1.002, P=0.002)、 Scr (OR=1.018, P=0.018)、糖化血紅蛋白(OR=2.705,P=0.995)與DR進(jìn)展獨立相關(guān)。2.建立DR進(jìn)展預(yù)測方程：P= exp(-31.913+0.754BMI+0.002ACR+0.018SCR+0.995HBA)/[1+exp(-31.913+0.754BMI+0.002ACR+0.018SCR+0.995HBA)]ROC曲線下面積為0.974。結(jié)合臨床實際,以youde n指數(shù)最大為原則,確定DR進(jìn)展概率的診斷界值為0.30,此時診斷靈敏度為100%,特異度為95.3%。3.驗證結(jié)果顯示靈敏度為81.8%、特異度為97.4%和準(zhǔn)確率為94%。結(jié)論1.DR發(fā)生與否的相關(guān)影響因素包括：吸煙、飲酒、伴發(fā)高血壓病、伴發(fā)腦梗死病、低血糖病史、高24h尿蛋白定量、高尿微量白蛋白血肌酐比值、高血肌酐、高血尿素氮、高血尿酸、高糖化血紅蛋白、低紅細(xì)胞計數(shù)、高血鉀、高血磷、低血總蛋白、低血白蛋白、少氣懶言、小便黃赤、周身浮腫； DR組自汗、頭暈眼花、五心煩熱、喘促氣短、健忘、口苦口干癥狀頻次分布明顯降低。2.DR進(jìn)展與否的相關(guān)影響因素包括：低齡、伴發(fā)高血壓病、高體重指數(shù)、高腰臀比、高24小時尿蛋白定量、高尿液微蛋白肌酐比值、高血肌酐、高血尿素氮、低內(nèi)生肌酐清除率、低腎小球濾過率、高空腹血糖、高糖化血紅蛋白、高血磷、陽虛。3.(1)多因素logistic回歸結(jié)果顯示：體重指數(shù)、ACR、血肌酐、糖化血紅蛋白與DR進(jìn)展與否獨立相關(guān)。(2)建立DR進(jìn)展預(yù)測方程小樣本驗證顯示靈敏度100%,特異度為95.3%。驗證靈敏度為81.8%、特異度為97.4%和準(zhǔn)確率為94%。所建模型可靠、可取。
[Abstract]:Objective and significance: To study the related factors of the occurrence and progress of diabetic retinopathy and to explore the prediction method of diabetic retinopathy in order to guide the early diagnosis of diabetic retinopathy and prevent its progress. 1. clinical study on the influencing factors of diabetic retinopathy: This study was 2014 In March, 295 patients were enrolled in the study. According to the performance of the fundus, they were divided into diabetic retinopathy (DR) group and non DR group. The general data of the patients were compared and analyzed with the disease, family history, clinical measurement index, physical and chemical index, TCM symptoms and TCM syndrome, and the screening of diabetic retinopathy in.2. diabetes. The risk factors and prediction model of retinopathy were established: 58 patients who were followed up in December -2015 March 2014 were studied in this study. According to the changes of retinopathy of the fundus, they were divided into the progress group and the non progressing group. The general data were compared in the two groups, with the disease, family history, clinical measurement index and physical and chemical index. Traditional Chinese medicine symptoms and TCM syndromes, the risk factors for screening DR progress. Using multiple factor Logistic analysis to screen independent risk factors of DR progress and develop a DR prediction model. Results: first, based on differential analysis, the general data about the incidence of diabetic retinopathy are 1.: Based on inclusion and exclusion criteria, In the non DR group, there were 183 cases in the non group, including 103 males and 80 females, with an average age of 58.67 + 11.30 years, and 112 cases in group DR, including 61 men and 51 women, with an average age of 59.97 + 10.91 years, and there was no significant difference in age and sex distribution in group two. Compared with the non DR group, the proportion of smoking in group DR was significantly higher than that in non DR group, and the difference has unification. Study significance.2. accompanied by disease and family history: compared with the non DR group, the proportion of hypertension, cerebral infarction and hypoglycemia in group DR was significantly higher than that in non DR group, and the difference was statistically significant. Compared with the non DR group, the proportion of fatty liver in group DR was significantly lower than that of non DR group, and the difference was statistically significant; the two groups were accompanied with coronary heart disease, hyperlipidemia, hyperuricemia, father. Family history, mother family history, brothers and sisters family history no significant difference in.3. clinical measurement indicators: compared with the non DR group, DR group systolic pressure was significantly higher than the non DR group, the difference was statistically significant; two groups of diastolic pressure, body mass index, waist hip ratio no significant difference, the difference was not statistically significant.4. physicochemical index: compared with the non DR group, DR group 24 H urine protein quantitative, urine microalbumin / blood creatinine ratio, blood creatinine, blood urea nitrogen, blood uric acid, glycosylated hemoglobin, blood potassium, blood phosphorus were significantly higher than non DR group, the difference was statistically significant. Compared with the non DR group, the number of red blood cells in group DR, blood total protein, blood white egg white were significantly lower than that of non DR group, and the difference was statistically significant; two groups were endogenetic. Creatinine clearance rate, glomerular filtration rate, fasting blood glucose, total cholesterol, triglyceride, high density lipoprotein, low density lipoprotein, hemoglobin, and blood calcium were not significantly different, and the difference was not statistically significant.5. symptoms: the ten symptoms of the non DR group with the highest frequency of four diagnosis were: fatigue, dry mouth, dry mouth, sexual desire. The ten symptoms of the highest frequency of the four diagnosis information of the DR group were: tired lassitude, less breath and laziness, loss of libido, dryness and dryness, loosening of the teeth, pain in the waist and knees, sight of flowers, heavy limbs, eye dry, frequent night urine frequency; Compared with the non DR group, the frequency distribution of the symptom frequency distribution in the DR group was significantly higher than that in the non DR group. Compared with the non DR group, the DR group was sweating, dizzy, five heart annoyances, short breath, forgetful and dry mouth, and the frequency of dry mouth symptoms was lower than the non DR group, and the difference was statistically significant in the non DR group: non DR group: non DR group. The frequency distribution of TCM syndromes is in the following order: Yin deficiency, Qi deficiency, Yang deficiency, blood stasis, blood deficiency, damp heat, phlegm, qi stagnation, heat Sheng in DR group, respectively: Qi deficiency, yin deficiency, blood deficiency, Yang deficiency, blood stasis, heat, phlegm, qi stagnation and damp heat. Compared with the non DR group, the DR group is Yin deficiency, and the damp heat syndrome frequently distributes obvious frequency distribution obvious The difference was statistically significant. Two, based on the difference analysis, the general data of the 1. baseline related factors related to the progression of diabetic retinopathy were obtained: 43 cases in the group of 20 men and 23 women, with an average age of 63.28 + 7.48 years, and 15 cases in the progressive group, including 10 men and 5 women, with an average age of 59.97. 10.91 years old: compared with the non progress group, the age of the progressing group was significantly lower than that of the non progress group, and the difference was statistically significant. There was no statistical difference in the sex distribution in the two groups. Compared with the non progressing group, there was no significant difference in the proportion of smoking and drinking in the progress group, and the difference was not statistically significant.2. associated disease and family history: compared with the non progressing group, the progression group was higher than the progress group. The proportion of the history of blood pressure disease was significantly higher than that of the non progression, and the difference was statistically significant. Compared with the non progressing group, there was no significant difference in the proportion of coronary heart disease, cerebral infarction, hyperlipidemia, fatty liver, hyperuricemia, hypoglycemia, and family history, and the difference was not statistically significant.3. clinical measurement index: compared with the non progressing group, the systolic pressure in the progressive group was compared. There was no significant difference in diastolic pressure, and the difference was not statistically significant. The body mass index (BMI) and the waist to hip ratio of the progressive group were significantly higher than those in the non progress group. The difference was statistically significant.4. physicochemical index: compared with the non progressing group, the 24 hour urine protein quantitative, the urine microprotein / creatinine ratio, the blood creatinine, blood urea nitrogen, blood sugar and saccharification, were compared with the non progressing group. Hemoglobin, blood phosphorus was significantly higher than unprogressed, endogenous creatinine clearance rate, glomerular filtration rate lower than unprogressed group, the difference was statistically significant; compared with the unprogressed group, the progressive group uric acid, total cholesterol, triglyceride, low density lipoprotein, high density lipoprotein, red blood cell count, hemoglobin, blood potassium, blood calcium, blood total protein, white egg There was no significant difference between white and white, the difference was not statistically significant.5. symptoms of traditional Chinese medicine: the ten symptoms of the highest frequency of four diagnosis of TCM in the baseline level of the group were: burnout, limb stranded, hypoderma, dryness and dryness, pain in the waist and knees, loosening of teeth, forgetfulness, visual disturbance, pruritus, perspiration, and the baseline of the progression group The top ten symptoms of the four diagnosis information of the Chinese medicine were: fatigue, eye dry, stiff limbs, heavy limbs, dizziness, loosening of teeth, dry mouth, itching, cold limbs, pain in the waist and knees, loss of sexual desire. Compared with the non progressing group, the progressing group had the baseline palpitation, insomnia and the frequent symptoms of claw armour. The distribution was significantly lower than that of no progress, the difference was statistically significant.6. TCM syndrome: the frequency distribution of TCM syndromes in the baseline level of non progressing group were Qi deficiency, yin deficiency, blood deficiency, damp heat, blood stasis, qi stagnation, phlegm, heat and yang deficiency, and the frequency distribution of TCM syndromes in the baseline level of the progressing group were, in turn, Qi deficiency and yin deficiency, respectively. Yang deficiency, blood deficiency, damp heat, blood stasis, phlegm, heat and qi stagnation; compared with the non progress group, the frequency distribution of the Yang deficiency syndrome was significantly higher than that of the non progress. Three, the establishment of the DR prediction model: the 1. factor analysis results showed that the body mass index (OR=2.125, P=0.754), ACR (OR=1.002, P=0.002), Scr (OR=1.018, P=0) .018), glycosylated hemoglobin (OR=2.705, P=0.995) and DR are independent related.2. to establish the DR progression prediction equation: P= exp (-31.913+0.754BMI+0.002ACR+0.018SCR+0.995HBA) /[1+exp (-31.913+0.754BMI+0.002ACR+0.018SCR+0.995HBA)]ROC curve area is combined with the reality of the bed. The diagnostic boundary value was 0.30, at this time the diagnostic sensitivity was 100%, the specificity of 95.3%.3. was 81.8%, the specificity was 81.8%, the specificity was 97.4% and the accuracy was 94%.. The factors associated with the occurrence of 1.DR were smoking, drinking, associated hypertension, cerebral infarction, the history of hypoglycemia, high 24h proteinuria, hyperuria. The ratio of albumin blood creatinine, high blood creatinine, high blood urea nitrogen, high blood uric acid, high glycosylated hemoglobin, low erythrocyte count, hyperkalemia, high blood phosphorus, low blood total protein, low blood albumin, low blood albumin, low urine, yellow red, swelling around the body; DR group sweating, dizziness, heart trouble, shortness of breath, forgetfulness, and dryness of mouth and mouth. The factors associated with low.2.DR progression include: low age, associated hypertension, high body mass index, high waist to hip ratio, high 24 hour urine protein quantitative, high urine microprotein creatinine ratio, high blood creatinine, high blood urea nitrogen, low endogenous creatinine clearance, low glomerular filtration rate, high glycemic hemoglobin, high glycosylated hemoglobin, high blood phosphorus, and yang deficiency.3. (1) Multiple factor Logistic regression results showed that BMI, ACR, creatinine and glycated hemoglobin were independent of the progress of DR. (2) the sensitivity of DR was 100%, the specificity was 81.8%, the specificity was 81.8%, the specificity was 97.4%, and the accuracy of the model was reliable and desirable.
【學(xué)位授予單位】：北京中醫(yī)藥大學(xué)
【學(xué)位級別】：博士
【學(xué)位授予年份】：2016
【分類號】：R259;R276.7

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