卒中相关性肺炎患者降钙素原清除率与早期神经功能恶化关系的临床研究

发布时间：2018-05-08 20:35

本文选题：降钙素原 + 降钙素原清除率　；参考：《天津医科大学》2017年硕士论文

【摘要】：背景与目的早期神经功能恶化(Early neurological deterioration,END)是急性卒中患者常见的并发症,END的发生与患者致残率和病死率增加、住院天数延长、医疗费用增长密切相关。目前,END的发病机制尚不清楚,没有准确可靠的早期预测指标,也缺乏有效的预防和治疗措施。因此,寻找可预测END发生的早期临床指标,以期及时给予干预治疗,预防END的发生迫在眉睫。目前研究发现并发肺炎是卒中患者发生神经功能恶化的一项独立预测因素。而卒中相关性肺炎(Stroke-Associated Pneumonia,SAP)是急性卒中常见并发症,研究表明SAP发生与卒中预后不良密切相关。但卒中相关性肺炎与急性卒中后早期神经功能恶化发生之间的关系的报导还较少。血降钙素原(Procalcitonin,PCT)是一个新的炎症指标,较目前常用的炎症指标如体温、白细胞数、中性粒细胞比例、C反应蛋白(C-Reactive Protein,CRP)、红细胞沉降率等有更高的敏感性和特异性。因此,在本研究中,我们拟通过大量采集卒中患者临床资料,分析SAP与END发生之间的关系,并在SAP患者中,连续监测血降钙素原(Procalcitonin,PCT)水平,计算降钙素原清除率(Procalcitonin Clearance,PCTc),并分析PCT及PCTc与END发生之间的关系,从而评估利用PCT及PCTc预测END发生的能力,进而阐明卒中相关性肺炎患者进行感染控制的价值。资料与方法本研究为前瞻观察性研究,选择2010年11月至2013年10月在环湖医院六病区连续收治的急性脑卒中患者作为研究对象。参照2010卒中相关性肺炎诊治中国专家共识制定的卒中相关性肺炎的诊断标准[1],将患者分为SAP组和非SAP组。END定义为急性缺血性卒中发病7天内NIHSS评分增加≥4分。所有患者均完善相关影像学检查包括CT或MRI,询问患者现病史、既往史,个人史,并记录患者相关危险因素以及个人基本情况,并对患者进行NIHSS评分。以是否出现SAP分为SAP组及非SAP组。SAP患者在确诊后即刻,以及第24小时,第48小时,第72小时检测血PCT,并计算第24小时,第48小时,第72小时的PCTc。分别计算END组和非END组第24小时,第48小时,第72小时的PCTc,进而通过统计计算评价PCTc与END之间的关系。结果1.共收治2062名卒中患者,其中363例(17.6%)出现卒中相关性肺炎,为SAP组,1699例(82.4%)未出现卒中相关性肺炎,为非SAP组。两组患者在性别组成,高血压史,高脂血症史,吸烟史等方面无统计学差异(p0.05,表1)。2.与非SAP组比较,SAP组年龄偏高,合并糖尿病、入院时NIHSS评分存在差异,两组间均达到统计学显著性差异(p0.05,表1)。且房颤,肿瘤,心肌梗死的比例,及存在意识障碍,吞咽困难的比例均高,两组间达到显著统计学差异(p0.05,表3)。3.363例SAP组出现END78例。1699例非SAP组出现END235例。与非SAP组的卒中患者相比,SAP组的END发生率较高,差异达到统计学差异(p0.05,表2)。4.SAP是急性卒中患者发生END的独立危险因素(OR=3.143,95%CI1.314~5.209,p0.05,表4)。5.END组和非END组间一般情况比较:363例卒中相关性肺炎患者,78例(21.49%)并发END,为END组;285例(78.51%),为非END组。两组患者在年龄、性别组成;高血压史、高脂血症史、吸烟史和既往卒中史及在中性粒细胞比例、APACHEⅡ、HDL及LDL水平,TG及血压水平等方面均无统计学差异(p0.05,表1)。与非END组患者相比,END组患者合并糖尿病的比例及WBC、CRP、TG、Fi及Hb A1c水平,入院时NIHSS评分均高,两组间均达到统计学显著性差异(p0.05,表5)。6.END组和非END组间PCT的比较:与非END组相比,END组在入院时、24小时及48小时的PCT值无明显差异(p0.05),72小时PCT值则高于非END组的PCT值(p0.05)。而对于PCTc,24小时和48小时两组间无明显差异(p0.05),72小时的PCTc,END组明显低于非END组(p0.05)(表6)。7.相关危险因素分析:将两组间存在明显差异的白细胞、CRP、CHO、Fi及Hb A1c,入院时NIHSS评分,糖尿病史及72小时PCT及PCTc水平纳入多元线性回归方程分析,进行Logistic回归分析,结果显示,END只与72小时的PCTc之间存在密切关系。72小时PCTc是END的独立因素(OR=0.031,95%CI 0.008~0.128,p0.05),72小时PCT绝对值并不是END发生的独立危险因素(表7)。8.ROC研究曲线表明72小时PCTc预测END发生的AUC为0.838(95%CI0.751~0.924),截断值为32.2%时,敏感性为77.14%,特异性为87.5%(表8)。结论本研究收集了SAP组与非SAP组的性别、年龄、高血压史、糖尿病史、房颤、肿瘤史、NIHSS、TG、Fi、Hb A1c等影响因素结果,以研究导致SAP的相关危险因素。结果表明SAP组合并房颤,肿瘤,糖尿病,心肌梗死的比例,及入院NIHSS评分,存在意识障碍,吞咽困难的比例均高,两组间达到显著统计学差异(p0.05,表1)。本研究分析了END组和非END组患者的高血压史、糖尿病史、高脂血症史、吸烟史、卒中史、性别、年龄、WBC、中性粒细胞比例、CRP、APACHEⅡ、NIHSS、HDL、LDL、CHO、TG、Fi、Hb A1c、收缩压、舒张压等影响因素结果,以研究导致END的相关危险因素。本文先对两组患者的相关危险因素进行单因素分析,结果表明END组合并糖尿病的比例及WBC、CRP、TG、Fi及Hb A1c水平,入院时NIHSS评分,72小时PCT及72小时PCTc与非END组相比差异有统计学意义(p0.05,表1)。进一步进行多元回归分析来分析这些有统计学意义的影响因素,结果表明影响SAP患者发生END的独立危险因素只有只有72小时PCTc,而CRP并不是SAP患者发生END的独立危险因素。进一步ROC曲线分析显示,72小时PCTc在一定程度上可以预测早期神经功能恶化的发生,72小时PCTc下降〈32.2%,是END的预测因素(p0.05)。本研究表明,SAP患者发生END,单因素分析显示与入组时及24小时,48小时PCT无关,与72小时PCT有关,但多因素分析显示72小时PCT并不是END的独立危险因素,而与72小时PCTc有关,表明SAP患者如果最初存在的感染并不一定会造成END出现,但感染控制不佳可能会引起END发生。监测PCT的绝对值,并不能对SAP患者出现END做出预测,而引入PCTc有助于观察PCT的动态变化,并对END出预测。进而我们可以依据PCTc的变化,调整抗生素的治疗。这提示我们对于发生SAP的患者要及时有效的应用抗生素,并根据PCTc的变化来指导抗生素治疗。
[Abstract]:Background and objective early neurological deterioration (Early neurological deterioration, END) is a common complication of acute stroke patients. The occurrence of END is associated with an increase in the rate of disability and mortality, the prolonged hospitalization days, and the increase of medical costs. At present, the pathogenesis of END is not yet clear, and there is no accurate and reliable early predictor, too. There is no effective prevention and treatment. Therefore, it is urgent to find the early clinical indicators that can predict the occurrence of END in order to give intervention therapy in time and prevent the occurrence of END. The current study found that pneumonia is an independent predictor of neurological deterioration in stroke patients. And stroke associated pneumonia (Stroke-Associated Pneumon) IA, SAP) is a common complication of acute stroke. Studies have shown that the occurrence of SAP is closely related to poor prognosis. However, fewer reports have been reported on the relationship between stroke related pneumonia and the occurrence of early neurological deterioration after acute stroke. Procalcitonin (PCT) is a new index of inflammation, compared with the current commonly used inflammatory markers. Temperature, leukocyte count, neutrophils ratio, C reactive protein (C-Reactive Protein, CRP), erythrocyte sedimentation rate and so on are more sensitive and specific. Therefore, in this study, we intend to analyze the relationship between SAP and the occurrence of END by collecting a large number of clinical data of stroke patients, and continuously monitor the serum calcitonin (Procalci) in SAP patients (Procalci). Tonin, PCT) level, calculate the Procalcitonin Clearance (PCTc), and analyze the relationship between PCT and PCTc and END, so as to assess the ability to predict END occurrence using PCT and PCTc, and then to clarify the value of infection control in patients with stroke related pneumonia. Acute stroke patients who were admitted to the six disease District of the lake hospital from November to October 2013, 10 years 10 years, were used as the research object. Referring to the 2010 stroke related pneumonia, the diagnosis standard of stroke related pneumonia was established by the Chinese expert consensus. The patients were divided into SAP group and non SAP group.END defined as NIHSS score within 7 days of acute ischemic stroke. All patients had more than 4 points. All the patients had improved the relevant imaging examinations including CT or MRI, asked the patient's history, history, personal history, and recorded the patient's risk factors and individual basic conditions, and the NIHSS score was performed on the patients. SAP was divided into SAP and non SAP group.SAP patients immediately after the diagnosis, and twenty-fourth hours, forty-eighth small At seventy-second hours, blood PCT was detected, and twenty-fourth hours, forty-eighth hours, and seventy-second hours of PCTc. were calculated for twenty-fourth hours, forty-eighth hours and seventy-second hours PCTc respectively in group END and non END group, and then the relationship between PCTc and END was evaluated by statistical calculation. Results 1. were treated with 2062 stroke patients, 363 cases (17.6%) appeared stroke associated pneumonia, SAP Group, 1699 cases (82.4%) did not have stroke related pneumonia, non SAP group. There was no statistical difference in sex composition, history of hypertension, hyperlipidemia and smoking history in the two groups (P0.05, table 1).2. and non SAP group, SAP group was higher in age, with diabetes, and there was a difference in NIHSS score at the time of admission, and the difference between the two groups reached statistical significant difference. (P0.05, table 1) and the proportion of atrial fibrillation, tumor, myocardial infarction, and the existence of consciousness disorder, the proportion of dysphagia were high, the two groups reached significant statistical differences (P0.05, table 3).3.363 cases SAP group, END78 cases,.1699 cases, non SAP group appeared END235 cases. Compared with the non SAP group, END incidence in the SAP group was higher, the difference reached statistical difference. The difference (P0.05, table 2).4.SAP was an independent risk factor for END in acute stroke patients (OR=3.143,95%CI1.314~5.209, P0.05, table 4).5.END and non END groups: 363 cases of stroke associated pneumonia, 78 cases (21.49%) complicated with END, 285 cases (78.51%), non END group. Two group of patients in age, sex composition, hypertension history, high The history of lipoemia, the history of smoking and the history of stroke and the proportion of neutrophils, APACHE II, HDL and LDL levels, TG and blood pressure levels were not statistically different (P0.05, table 1). Compared with the non END group, the proportion of diabetes in the END group and the level of WBC, CRP, TG, Fi and Hb were all high, and the two groups were all reached statistics. The comparison of the significant differences (P0.05, table 5).6.END and non END group PCT: compared with the non END group, there was no significant difference in the PCT value between the 24 hours and the 48 hours (P0.05) and the 72 hour PCT value was higher than the PCT value (P0.05) in the non END group. But there was no significant difference between the two groups in the 24 and 48 hours. Lower than non END group (P0.05) (Table 6).7. related risk factors analysis: leucocytes, CRP, CHO, Fi and Hb A1c in the two groups were significantly different, and the scores of NIHSS, diabetes history and 72 hours PCT and PCTc were analyzed by multiple linear regression equation, and the Logistic return analysis was carried out. The relationship.72 hour PCTc is an independent factor of END (OR=0.031,95%CI 0.008~0.128, P0.05), 72 hours PCT absolute value is not an independent risk factor for END (Table 7).8.ROC research curve indicating 72 hours PCTc prediction END AUC is 0.838, when the truncated value is 32.2%, sensitivity is 77.14%, specificity is 87.5% (table 8). The study collected the effects of sex, age, hypertension, diabetes, atrial fibrillation, tumor history, NIHSS, TG, Fi, Hb A1c in group SAP and non SAP groups to study the risk factors associated with SAP. The results showed that the proportion of SAP combination and atrial fibrillation, the proportion of tumor, diabetes, myocardial infarction, and admission NIHSS score, consciousness disorder, dysphagia The proportion of the two groups was significantly different (P0.05, table 1). This study analyzed the history of hypertension, diabetes, hyperlipidemia, smoking, stroke, sex, age, WBC, neutrophils, CRP, APACHE II, NIHSS, HDL, LDL, CHO, TG, Fi, systolic and diastolic pressure in the END and non END groups. A single factor analysis of the related risk factors of the two groups of patients was first studied. The results showed that the proportion of END combined with diabetes and the level of WBC, CRP, TG, Fi and Hb A1c, the score of NIHSS, 72 hours PCT and 72 hours PCTc were statistically significant compared with those of the non END group (Table 1). Multivariate regression analysis was used to analyze these statistically significant factors. The results showed that the independent risk factors affecting the occurrence of END in SAP patients were only 72 hours PCTc, and CRP was not an independent risk factor for END in SAP patients. Further ROC curve analysis showed that 72 hours PCTc could predict early neurological deterioration to some extent. The 72 hour PCTc decreased (32.2%), a predictor of END (P0.05). This study showed that SAP patients had END. The single factor analysis showed that it was related to the entry group and 24 hours, 48 hours PCT, and 72 hours PCT, but the multivariate analysis showed that PCT was not an independent risk factor for END, and was associated with 72 hour PCTc, indicating SAP patients such as The initial infection does not necessarily lead to the occurrence of END, but the poor control of infection may cause the occurrence of END. Monitoring the absolute value of PCT does not predict the occurrence of END in SAP patients, and the introduction of PCTc helps to observe the dynamic changes in PCT and predicts END. In this way, we can adjust the treatment of antibiotics according to the changes in PCTc. It is suggested that we should promptly and effectively apply antibiotics to patients with SAP and guide antibiotic therapy according to the changes of PCTc.

【学位授予单位】：天津医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R743.3;R563.1

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