入院白细胞、纤维蛋白原和血清胆红素水平与急性缺血性脑卒中出院结局的关系

发布时间：2018-06-23 11:34

本文选题：急性缺血性脑卒中 + 白细胞　；参考：《苏州大学》2013年硕士论文

【摘要】：研究目的 1.探讨入院时白细胞计数水平与急性缺血性脑卒中病人发生残疾或住院期间死亡的关系； 2.探讨入院时纤维蛋白原水平与急性缺血性脑卒中病人发生残疾或住院期间死亡的关系； 3.探讨入院时血清胆红素水平与急性缺血性脑卒中病人发生残疾或住院期间死亡的关系。对象与方法对象：连续纳入2009年6月1日到2012年5月31日期间在辽宁省阜新市中心医院、内蒙古兴安盟人民医院和大连大学附属中山医院所有入院治疗的急性缺血性脑卒中病人为研究对象，纳入分析样本量为8244例。方法：由培训合格的调查员采用统一设计的病例调查表，所有调查对象均进行了入院时白细胞计数、纤维蛋白原和血清胆红素水平和其他一般情况及出院结局相关资料的收集。结局定义为发生残疾或死亡，当有结局发生即定义为结局不良。残疾的定义参照Modified Rankin’s scale（MRs）脑卒中量表中有关生活依赖程度的标准进行，将评分标准记录在调查表中，评分在3分及其以上者（MRs≥3）定义为残疾。统计分析：采用Epidata3.1建立数据库，所有调查表均经过双人双录核查。采用SPSS18.0软件进行统计分析。急性缺血性脑卒中发病月份分布描述采用圆形分布，比较入院时生活方式、一般特征和临床特征在急性缺血性脑卒中病人无结局和发生残疾、死亡间的差异应用方差分析或非参数检验（Kruskal-Wallis H test）。入院时白细胞、纤维蛋白原和血清胆红素水平与残疾、死亡的关联分析采用无序多分类logistic回归方法，不同亚型急性缺血性脑卒中危险因素的分析采用两分类非条件logistic回归方法，计算比值比（Odds ratio，OR）及95%可信区间（95%Confident interval，95%CI）。所有检验均为双侧检验，检验水准α=0.05。研究结果 1.3个临床现场共纳入分析的研究对象为8244例急性缺血性脑卒中病人，发生急性缺血性脑卒中的高峰日为4月22号，高峰期是上一年12月1号到下一年8月20号（r=0.0825，z=56.0738，P0.05）；不同亚型的急性缺血性脑卒中病人构成比分别为脑血栓72.12%，脑栓塞3.66%，腔隙性梗死24.21%；其中，共有1169人（14.18%）发生残疾（MRs≥3），死亡195人（2.37%）。 2.对于不同出院结局的急性缺血性脑卒中病人，以无结局组为对照，残疾组和死亡组病人的平均年龄较大（P0.0001），发病-入院时间死亡组最短（P0.0001），急性缺血性脑卒中亚型的分布在三组间不一致（P0.0001）；吸烟、饮酒情况在三组间不一致（分别P=0.0023、P=0.001）；入院时体温、收缩压（Sbp）、血糖、纤维蛋白原、尿素氮水平和WBC、Tbil、Dbil、Ibil在发生残疾或死亡时较高（P0.05），血脂异常和有糖尿病史、心脏病史、房颤史、脑卒中病史的病人更易发生残疾或死亡（P0.05），死亡的病人甘油三脂（Tg）较低（P0.05）。 3.急性缺血性脑卒中病人按入院白细胞、纤维蛋白原和血清胆红素水平不同分组，各水平组发生残疾和死亡的百分比不同，均表现为相对于低水平组，高水平组残疾和死亡的发生率更高（均P0.05）。 4.传统影响因素分析中，急性缺血性脑卒中病人发生残疾、死亡的单因素无序多分类logistic回归分析结果显示，相对无结局组，年龄、体温、高血糖、尿素氮的升高和房颤史、脑卒中病史可能是发生残疾、死亡的危险因素，其OR（95%CI）分别是1.26（1.20～1.34）、1.77（1.54～2.04），1.85（1.60～2.13）、2.36（1.83～3.04），1.59（1.40～1.80）、2.39（1.78～3.22），1.04（1.02～1.05）、1.06（1.04～1.08）、2.78（2.16～3.58）、5.32（3.48～8.12）和1.43（1.26～1.63）、1.63（1.22～2.18）。高血压的病人发生残疾的危险性是非高血压病人的1.36（1.20～1.54）倍，或与死亡无关；血脂异常的病人发生死亡的危险性是正常病人的1.57（1.15～2.13）倍。发病-入院时间和住院时间越短，发生残疾、死亡的危险性越大，相对于最短时间，，最长时间组的OR（95%CI）分别是0.59（0.51～0.69）、0.28（0.20～0.38）和0.66（0.56～0.78）、0.15（0.10～0.19），糖尿病史的病人发生残疾的危险性是非糖尿病病人的1.41（1.23～1.62）倍，或与死亡无关。吸烟对发生残疾或死亡有保护作用（OR（95%CI）:0.83（0.71～0.96）、0.61（0.42～0.89）），饮酒对发生死亡有保护作用（OR（95%CI）:0.45（0.28～0.73））。 5.白细胞计数、纤维蛋白原和血清胆红素的无序多分类logistic回归分析中，经过年龄、发病-入院时间、体温、高血压、高血糖、血脂异常、心脏病史、房颤史和脑卒中病史等因素的调整后，多分类logistic回归分析结果显示对于WBC10×109/L组，WBC水平每增加2×109/L发生残疾、死亡的危险性都在相应增加，其OR（95%CI）值均1，WBC水平≥14×109/L组发生残疾、死亡的OR（95%CI）分别为3.40（2.51～4.60）和13.15（8.56～20.20）；纤维蛋白原水平按四分位间距分组，结果为相对于最低分位组，最高分位组（≥3.54g/L）发生残疾、死亡的OR（95%CI）分别为1.76（1.45～2.13）和1.83（1.18～2.84）。血清胆红素同样按四分位间距分组，相对于最低分位组，Tbil最高分位组（≥18.91umol/L）发生残疾、死亡的OR（95%CI）分别为1.83（1.53～2.18）和2.59（1.72～3.89）；除第二分位（2.00～3.10μmol/L）对残疾发生有保护作用（OR（95%CI）：0.82（0.68～0.99）），不同水平Dbil与残疾发生无关，但与死亡有关，最高分位组（≥4.71umol/L）发生死亡的OR（95%CI）为1.75（1.15～2.67）；Ibil最高分位组（≥14.41umol/L）发生残疾、死亡的OR（95%CI）分别为1.30（1.09～1.55）和1.79（1.18～2.72）。 6．对纳入分析的急性缺血性脑卒中3种亚型：脑血栓、脑栓塞和腔隙性梗死进行分层分析，模型选择二分类非条件logistic回归，应变量为是否发生结局不良。结果显示，（1）调整了年龄、脑卒中病史后，相对于WBC10×109/L组，脑血栓病人WBC在10～11.9×109/L、12～13.9×109/L和≥14×109/L发生结局不良的OR（95%CI）值分别为2.40（1.90～3.03）、3.02（2.18～4.18）和5.41（4.03～7.25）；脑栓塞病人WBC为12～13.9×109/L和≥14×109/L发生结局不良的OR（95%CI）值分别3.60（1.19～10.87）和10.40（2.26～47.93）；腔隙性梗死病人WBC在10～11.9×109/L、12～13.9×109/L和≥14×109/L发生结局不良的OR（95%CI）值分别为2.24（1.32～3.81）、4.14（1.94～8.86）和4.95（2.35～10.43）。（2）调整了年龄、脑卒中病史后，脑血栓病人纤维蛋白原水平在四分位最高分位（≥3.54g/L）相对于最低分位（＜2.56g/L）发生结局不良的OR（95%CI）为1.94（1.58～2.38）；腔隙性梗死病人纤维蛋白原水平在四分位最高分位（≥3.54g/L）相对于最低分位（＜2.56g/L）发生结局不良的OR（95%CI）为1.84（1.19～2.84）；不同纤维蛋白原水平对脑栓塞病人结局不良的OR值没有统计学意义。（3）调整了年龄、脑卒中病史后，脑血栓病人Tbil在四分位最高分位（≥18.91μmol/L）相对于最低分位（＜10.90μmol/L）发生结局不良的OR（95%CI）为1.94（1.58～2.38），Dbil在四分位最高分位（≥4.71μmol/L）相对于最低分位（＜2.00μmol/L）发生结局不良的OR（95%CI）为1.22（1.00～1.48），Ibil在四分位最高分位（≥14.41μmol/L）相对于最低分位（＜7.60μmol/L）发生结局不良的OR（95%CI）为1.30（1.08～1.57）；而脑栓塞和腔隙性梗死的OR值没有统计学意义。结论 1.与正常白细胞计数的病人相比，急性缺血性脑卒中病人中较高水平的白细胞计数独立的与发生残疾或住院期间死亡相关联。 2.与纤维蛋白原水平四分位最低分位组相比，急性缺血性脑卒中病人最高分位组纤维蛋白原水平独立的与发生残疾或住院期间死亡相关联。 3.与总胆红素、直接胆红素和间接胆红素水平四分位最低分位组相比，急性缺血性脑卒中病人在最高分位组总胆红素、直接胆红素和间接胆红素水平独立的与发生残疾或住院期间死亡相关联。 4.较高的白细胞计数与不同亚型急性缺血性脑卒中发生结局不良均有关联性；不同纤维蛋白原水平与不同亚型急性缺血性脑卒中发生结局不良的相关性不一致；不同血清胆红素水平与不同亚型急性缺血性脑卒中发生结局不良的相关性不一致。
[Abstract]:research objective
1. to explore the relationship between the level of white blood cell count during admission and the occurrence of disability or hospitalization in patients with acute ischemic stroke.
2. to explore the relationship between the level of fibrinogen at admission and death in patients with acute ischemic stroke.
3. to explore the relationship between serum bilirubin level and the death of patients with acute ischemic stroke during hospitalization.
Object and method
Participants: from June 1, 2009 to May 31, 2012, all the patients with acute ischemic stroke in Fuxin Central Hospital, Liaoning Province, Inner Mongolia, Inner Mongolia, and the Zhongshan Hospital Affiliated to Dalian University were studied. The samples were included in 8244 cases.
Methods: a unified design case questionnaire was used by qualified investigators. All the subjects were collected at admission, leucocyte count, fibrinogen and serum bilirubin level, other general information and discharge related data. The outcome was defined as a residual disease or death, which was defined as the outcome when the outcome occurred. The definition of disability was referred to the standard of life dependence in the Modified Rankin 's scale (MRs) stroke scale, and the scoring criteria were recorded in the questionnaire, and those with a score of 3 or more (MRs > 3) were defined as disability.
Statistical analysis: the database was established by Epidata3.1. All the questionnaires were checked by double and double records. SPSS18.0 software was used for statistical analysis. The distribution of the months of acute ischemic stroke was described by circular distribution, the life style was compared with the admission, and the general characteristics and clinical characteristics were no result and hair in the patients with acute ischemic stroke. Variance analysis or nonparametric test (Kruskal-Wallis H test) for the difference between death and disability. The association of leukocyte, fibrinogen and serum bilirubin to disability and death was analyzed by disordered multi classification logistic regression, and the analysis of risk factors for different subtypes of acute ischemic stroke was divided into two categories. Logistic regression method is used to calculate the ratio Ratio (Odds ratio, OR) and 95% confidence interval (95%Confident interval, 95%CI). All tests are both bilateral test, test level alpha =0.05.
Research results
1.3 clinical sites were included in 8244 cases of acute ischemic stroke. The peak day of acute ischemic stroke was in April 22nd, the peak period was from December 1st to August 20th (r=0.0825, z=56.0738, P0.05), and the ratio of acute ischemic stroke in different subtypes was 72. of cerebral thrombosis, respectively. 12%, 3.66% of cerebral embolism and 24.21% of lacunar infarction, of which 1169 (14.18%) had disability (MRs > 3) and 195 (2.37%) died.
2. for the acute ischemic stroke patients with different discharge outcomes, the average age of the patients in the disabled group and the death group was higher (P0.0001), the shortest (P0.0001) in the death group (P0.0001) and the distribution of acute ischemic stroke Central Asian type in the group of death (P0.0001); smoking and drinking in the three groups were not consistent. (P=0.0023, P=0.001); at admission temperature, systolic blood pressure (Sbp), blood sugar, fibrinogen, urea nitrogen level and WBC, Tbil, Dbil, Ibil in the occurrence of disability or death (P0.05), dyslipidemia and diabetes history, heart disease history, atrial fibrillation history, stroke patients more prone to disability or death (P0.05), the death of the patient glycerin three fat ( Tg) is lower (P0.05).
3. patients with acute ischemic stroke were divided into different groups according to the level of admission leukocyte, fibrinogen and serum bilirubin. The percentage of disability and death in each group was different, and the incidence of disability and death in the high level group was higher (all P0.05).
4. in the analysis of traditional influencing factors, acute ischemic stroke patients were disabled, and the single factor disorder multiple classification logistic regression analysis showed that the relative unending group, age, temperature, hyperglycemia, higher urea nitrogen and the history of atrial fibrillation may be the risk factors of disability and death, and the OR (95%CI) was 1.26 (1). .20 to 1.34), 1.77 (1.54 to 2.04), 1.85 (1.60 to 2.13), 2.36 (1.83 to 3.04), 1.59 (1.40 ~ 1.80), 1.59. The risk of death in patients with dyslipidemia was 1.57 (1.15 to 2.13) times that of normal patients. The shorter the hospitalization time and the hospitalization time, the greater the risk of death, the OR (95%CI) of the longest time group was 0.59 (0.51 to 0.69), 0.28 (0.20 to 0.38) and 0.66 (0.56 ~ 0.78), 0, respectively. .15 (0.10 ~ 0.19), the risk of disability in patients with diabetes is 1.41 (1.23 to 1.62) times of non diabetic patients, or not related to death. Smoking has a protective effect on the occurrence of disability or death (OR (95%CI): 0.83 (0.71 to 0.96), 0.61 (0.42 ~ 0.89)), and drinking has a protective effect on the occurrence of death (OR (95%CI): 0.45 (0.28 ~ 0.73)).
5. leucocyte count, fibrinogen and serum bilirubin in the disordered multi classification logistic regression analysis, after the adjustment of age, onset time, body temperature, hypertension, hyperglycemia, dyslipidemia, history of heart disease, history of atrial fibrillation, and stroke history, the results of multiclass logistic regression analysis showed that WBC10 x 109/L group, WBC water The risk of death was increased by 2 x 109/L, the OR (95%CI) value was 1, the WBC level was more than 14 x 109/L group, and the OR (95%CI) was 3.40 (2.51 to 4.60) and 13.15 (8.56 to 20.20), and the fibrinogen level was grouped at four subdivision intervals, and the result was the highest fraction (> 3.54). G/L) OR (95%CI) was 1.76 (1.45 to 2.13) and 1.83 (1.18 ~ 2.84). The serum bilirubin was also grouped at the four point spacing. Compared with the lowest fraction, the highest Tbil sub group (> 18.91umol/L) was disabled, and the OR (95%CI) of the death was 1.83 (1.53 to 2.18) and 2.59 (1.72 ~ 3.89), respectively. L/L) had a protective effect on the occurrence of disability (OR (95%CI):0.82 (0.68 ~ 0.99)). Different levels of Dbil were not related to the occurrence of disability, but related to death, OR (95%CI) of the highest sub group (> 4.71umol/L) was 1.75 (1.15 ~ 2.67); the highest fraction of Ibil (> 14.41umol/L) was disabled, and OR (95%CI) was 1.30 (1.09 to 1.55) and 1.79, respectively. (1.18 to 2.72).
6. of the 3 subtypes of acute ischemic stroke, cerebral thrombosis, cerebral embolism and lacunar infarction were analyzed by stratified analysis. The model selected two categories of non conditional logistic regression, and the dependent variable was bad outcome. The results showed that (1) the age was adjusted. After the history of stroke, the WBC of cerebral thrombosis patients was 10 ~ 10. The OR (95%CI) values of 11.9 * 109/L, 12 to 13.9 * 109/L and 14 x 109/L were 2.40 (1.90 to 3.03), 3.02 (2.18 to 4.18) and 5.41 (4.03 ~ 7.25), and the OR (95%CI) values of the patients with cerebral embolism were in OR (95%CI), and the patients with lacunar infarction W BC (1.32 to 3.81), 4.14 (1.94 ~ 8.86) and 4.95 (2.35 ~ 10.43) in 10 ~ 11.9 * 109/L, 12 ~ 13.9 * 109/L and 14 x 109/L were 2.24 (1.32 to 3.81), 4.14 (1.94 ~ 8.86) and 4.95 (2.35 ~ 10.43). The highest level of fibrinogen in the cerebral thrombosis patients was compared with the lowest score (< 2.56g/L). The OR (95%CI) with poor outcome was 1.94 (1.58 to 2.38), and the fibrinogen level in the patients with lacunar infarction was 1.84 (1.19 to 2.84) at the highest score of the four division (> 3.54g/L) relative to the lowest score (< 2.56g/L). The OR value of the different fibrous egg white levels for the patients with cerebral embolism was not statistically significant. (3) adjusted the age and the history of cerebral apoplexy, the highest score of Tbil in the four division of cerebral thrombosis patients (> 18.91 mu mol/L) was 1.94 (1.58 to 2.38) relative to the lowest score (< 10.90 mol/L), and the highest fraction of Dbil in the four sub position (> 4.71 Mu mol/L) was relative to the lowest score (2 mu mol/L) with the bad OR (95%) (2 mu mol/L). CI) at 1.22 (1 to 1.48), the OR (95%CI) of the highest score (> 14.41 mu mol/L) of Ibil in the four sub position (< 7.60 mol/L) was 1.30 (1.08 to 1.57), while the OR value of cerebral embolism and lacunar infarction was not statistically significant.
conclusion
1. higher levels of leukocyte count in patients with acute ischemic stroke were associated with disability or death in patients with acute ischemic stroke than in patients with normal leukocyte counts.
2. the highest level of fibrinogen in the patients with acute ischemic stroke was associated with disability or death during the hospitalization, compared with the lowest division of the fibrinogen level Four.
3. compared with the lowest score of total bilirubin, direct bilirubin and indirect bilirubin level Four, patients with acute ischemic stroke were independent of total bilirubin, direct bilirubin and indirect bilirubin levels in the highest score group, associated with disability or death during hospitalization.
4. the higher leucocyte count was associated with poor outcome in different subtypes of acute ischemic stroke, and different fibrinogen levels were not consistent with the adverse outcome of different subtypes of acute ischemic stroke; the level of different serum bilirubin and the adverse outcome of different subtypes of acute ischemic stroke The customs are not consistent.
【学位授予单位】：苏州大学
【学位级别】：硕士
【学位授予年份】：2013
【分类号】：R743.3

【参考文献】