發(fā)布時間：2018-04-30 22:13

  本文選題：老年髖部骨折 + 肺部感染��； 參考：《西南醫(yī)科大學(xué)》2017年碩士論文

【摘要】：目的:建立川南地區(qū)老年髖部骨折術(shù)后常見并發(fā)癥發(fā)生率和死亡率的預(yù)測模型,并檢驗其預(yù)測價值。方法:1.建立4份資料收集表,包括老年髖部骨折術(shù)后肺部感染、術(shù)后認(rèn)知功能障礙(POCD)、術(shù)后下肢深靜脈血栓形成(術(shù)后LEDVT)、術(shù)后死亡;2.收集2012年1月到2016年10月于西南醫(yī)科大學(xué)附屬醫(yī)院住院手術(shù)治療的此類患者臨床數(shù)據(jù),填入相對應(yīng)的資料收集表;3.然后利用Epidata3.1軟件建立相應(yīng)4個數(shù)據(jù)庫并將相對應(yīng)的資料收集表中的臨床數(shù)據(jù)錄入數(shù)據(jù)庫;將數(shù)據(jù)導(dǎo)入spss19.0軟件進(jìn)行統(tǒng)計分析:計量資料采用t檢驗、計數(shù)資料采用χ2檢驗進(jìn)行變量的單因素分析,獲得有統(tǒng)計學(xué)意義的變量(以?=0.05為檢驗水準(zhǔn),P值(27)0.05變量有統(tǒng)計學(xué)意義);4.在生理學(xué)和手術(shù)嚴(yán)重度評分系統(tǒng)(physical and operation severity score for the enumeration of mortality and morbidity,POSSUM)的基礎(chǔ)上,將這些變量分為生理學(xué)指標(biāo)和手術(shù)嚴(yán)重性指標(biāo)兩類,建立起老年髖部骨折術(shù)后肺部感染、POCD、術(shù)后LEDVT、術(shù)后死亡的評分系統(tǒng)。通過Logistic回歸分析得出此類患者術(shù)后肺部感染、POCD、術(shù)后LEDVT、術(shù)后死亡發(fā)生率預(yù)測模型;5.最后用實際值與預(yù)測值的比值、ROC曲線、Hosmer-Lemeshow檢驗來評估其預(yù)測價值。結(jié)果:1.術(shù)后肺部感染組:1)生理學(xué)指標(biāo)中的年齡、白細(xì)胞、ASA分級、COPD、心功能分級、合并癥數(shù)量,以及手術(shù)嚴(yán)重性指標(biāo)中的術(shù)前準(zhǔn)備時間、手術(shù)時間、術(shù)中失血量、麻醉方式是術(shù)后肺部感染的危險因素。2)術(shù)后肺部感染風(fēng)險評分系統(tǒng)預(yù)測模型:Ln[R/(1-R)]=-7.187+0.226×PS+0.161×OS。3)該模型術(shù)后肺部感染率的預(yù)測值平均8.93%,實際值9.89%,實際值/預(yù)測值1.11,兩者之間差異無統(tǒng)計學(xué)意義(χ2=0.279,P=0.6730.05)。ROC曲線結(jié)果顯示靈敏度(Se)=82.7%,特異度(Sp)=72.4%,誤診率(?)=27.6%,漏診率(β)=17.3%,ROC曲線下面積為0.814。對該預(yù)測模型進(jìn)行Hosmer-Lemeshow檢驗,結(jié)果顯示,此評分系統(tǒng)預(yù)測術(shù)后肺部并發(fā)癥發(fā)生率(H2=7.707,df=8,P=0.4630.05)效果良好,數(shù)據(jù)中的信息被充分提取。2.術(shù)后LEDVT組:1)生理學(xué)指標(biāo)中的年齡、FIB、血清甘油三酯、BMI、靜脈曲張、高血壓、冠心病、糖尿病、腦卒中、感染以及手術(shù)嚴(yán)重性指標(biāo)中的麻醉、術(shù)前準(zhǔn)備時間、出血量、手術(shù)時間是術(shù)后LEDVT的危險因素。2)術(shù)后LEDVT風(fēng)險評分系統(tǒng)預(yù)測模型:Ln[R/(1-R)]=-11.493+0.347×PS+0.327×OS。3)該模型術(shù)后LEDVT發(fā)生率預(yù)測值為平均12.57%,實際值為13.38%,實際值/預(yù)測值為1.06,兩者之間差異無統(tǒng)計學(xué)意義(χ2=0.144,P=0.7760.05)。ROC曲線結(jié)果顯示Se=74.20%,Sp=86.20%,?=13.80%,β=25.80%,ROC曲線下面積為0.87。對該預(yù)測模型進(jìn)行Hosmer-Lemeshow檢驗,結(jié)果顯示,該評分系統(tǒng)預(yù)測術(shù)后LEDVT發(fā)生率(H2=3.309,df=8,P=0.9140.05)效果良好,數(shù)據(jù)中的信息被充分提取。3.POCD組:1)生理學(xué)指標(biāo)中的年齡、血壓(收縮壓)、白蛋白、氧分壓、合并癥數(shù)量,COPD、腦卒中以及手術(shù)嚴(yán)重性指標(biāo)重的手術(shù)時間、失血量、麻醉方式是POCD的危險因素。2)POCD風(fēng)險評分系統(tǒng)預(yù)測模型:Ln[R/(1-R)]=-6.88+0.191×PS+0.302×OS。3)該模型POCD發(fā)生率的預(yù)測值為平均12.38%,實際為14.28%,實際值/預(yù)測值為1.15,兩者之間差異無統(tǒng)計學(xué)意義(χ2=0.330,P=0.6670.05)。ROC曲線結(jié)果顯示Se=53.3%,Sp=90%,?=10%,β=46.7%,ROC曲線下面積為0.759。對該預(yù)測模型進(jìn)行Hosmer-Lemeshow檢驗,結(jié)果顯示,此評分系統(tǒng)預(yù)測術(shù)后POCD發(fā)生率(H2=7.707,df=8,P=0.4630.05)效果良好,數(shù)據(jù)中的信息被充分提取。4.術(shù)后死亡組:1)生理學(xué)指標(biāo)中的年齡、白細(xì)胞、白蛋白、血壓(收縮壓)、肌酐、ASA分級、心功能分級、合并癥數(shù)量、COPD、腦卒中、糖尿病以及手術(shù)嚴(yán)重性指標(biāo)中的手術(shù)方式、術(shù)前準(zhǔn)備時間、手術(shù)時間、術(shù)中失血量是術(shù)后死亡的危險因素。2)術(shù)后死亡風(fēng)險評分系統(tǒng)預(yù)測模型:Ln[R/(1-R)]=-11.565+0.265×PS+0.121×OS。3)該模型術(shù)后死亡率的預(yù)測值為平均3.99%,實際為5.18%,實際值/預(yù)測值為1.3,兩者之間差異無統(tǒng)計學(xué)意義(χ2=0.820,P=0.4510.05)。ROC曲線結(jié)果顯示Se=96.2%,Sp=88.8%,?=11.2%,β=3.8%,ROC曲線下面積為0.967。對該預(yù)測模型進(jìn)行Hosmer-Lemeshow檢驗,結(jié)果顯示,該評分系統(tǒng)預(yù)測術(shù)后死亡發(fā)生率(H2=10.869,df=8,P=0.2090.05)效果良好,數(shù)據(jù)中的信息被充分提取。結(jié)論:本課題初步建立起川南地區(qū)老年髖部骨折術(shù)后常見并發(fā)癥發(fā)生率和死亡率的評分系統(tǒng)及其預(yù)測模型:1)術(shù)后肺部感染風(fēng)險評分系統(tǒng)預(yù)測模型:Ln[R/(1-R)]=-7.187+0.226×PS+0.161×OS。2)術(shù)后LEDVT風(fēng)險評分系統(tǒng)預(yù)測模型:Ln[R/(1-R)]=-11.493+0.347×PS+0.327×OS。3)POCD風(fēng)險評分系統(tǒng)預(yù)測模型:Ln[R/(1-R)]=-6.88+0.191×PS+0.302×OS。4)術(shù)后死亡風(fēng)險評分系統(tǒng)預(yù)測模型:Ln[R/(1-R)]=-11.565+0.265×PS+0.121×OS。并用實際值與預(yù)測值的比值、ROC曲線、Hosmer—Lemeshow檢驗來評估其預(yù)測價值,結(jié)果顯示四個預(yù)測模型均具有良好的準(zhǔn)確度。本課題針對術(shù)后并發(fā)癥的范圍廣泛的問題將其進(jìn)行細(xì)化,對常見的不同并發(fā)癥,具體問題具體分析,得出各自的手術(shù)風(fēng)險因素,排除一些與本并發(fā)癥無關(guān)的風(fēng)險因素,針對性更強(qiáng),效率更高。但樣本樣不足,未進(jìn)行前瞻性研究,沒有將本次研究結(jié)果與PPOSSUM以及骨科POSSUM的統(tǒng)計結(jié)果相比較,故仍需要進(jìn)一步的深入研究。
[Abstract]:Objective: to establish a predictive model for the incidence and mortality of common complications after hip fracture in the south of Sichuan, and to test its predictive value. Methods: 1., 4 data collection tables were established, including postoperative pulmonary infection, postoperative cognitive dysfunction (POCD), postoperative deep venous thrombosis (postoperative LEDVT), postoperative death, and postoperative death; 2. The clinical data of these patients who were hospitalized in the Affiliated Hospital of Southwest Medical University from January 2012 to October 2016 were collected and the corresponding data collection table was filled. 3. then the corresponding 4 databases were established by using Epidata3.1 software and the clinical data in the corresponding data collection table were recorded into the database; the data were introduced into the spss19.0 software. Statistical analysis: the measurement data were tested by T, and the count data were analyzed by the x 2 test for single factor analysis. The statistical variables were statistically significant (with =0.05 as the test level and the P value (27) 0.05 variables were statistically significant); 4. was in the physiological and surgical severity score system (physical and operation severity score for the enumeration. On the basis of of mortality and morbidity, POSSUM), these variables are divided into two categories of physiological index and surgical severity index. The scoring system for postoperative lung infection, POCD, postoperative LEDVT, and postoperative death of the aged hip fractures is established. The postoperative pulmonary infection, POCD, postoperative LEDVT, and postoperative death are obtained by Logistic regression analysis. Incidence prediction model; 5. finally, using the ratio of actual value to predicted value, ROC curve, and Hosmer-Lemeshow test to evaluate its predictive value. Results: 1. postoperative pulmonary infection group: 1) age, leukocyte, ASA classification, COPD, cardiac function classification, number of complications, and preoperative preparation time in surgical severity index, operation time, operation time, operation time, operation time, operation time, operation time, operation time, operation time, operation time, operation time, operation time, operation time The amount of blood loss during the operation, the way of anesthesia was the risk factor of pulmonary infection after operation.2) the prediction model of the lung infection risk score system after operation: Ln[R/ (1-R)]=-7.187+0.226 x PS+0.161 x OS.3) the predicted value of the pulmonary infection rate of the model was 8.93%, the actual value was 9.89%, the actual value / prediction value was 1.11, there was no statistical difference between the two (x 2=0.27). 9, P=0.6730.05).ROC curve showed sensitivity (Se) =82.7%, specificity (Sp) =72.4%, misdiagnosis rate (?) =27.6%, missed diagnosis rate (beta) =17.3%, and 0.814. under ROC curve for Hosmer-Lemeshow test of the prediction model. The results showed that the rate of lung complications after the pre test of this scoring system was good, data were good, data were good, data The information in the LEDVT group was fully extracted after.2.: 1) age, FIB, serum triglycerides, serum triglycerides, BMI, varicose veins, hypertension, coronary heart disease, diabetes, stroke, infection, and surgical severity indicators, preoperative preparation time, bleeding volume, and operation time, the risk factor of LEDVT after operation,.2), LEDVT risk score after operation. System prediction model: Ln[R/ (1-R)]=-11.493+0.347 x PS+0.327 x OS.3) the prediction value of LEDVT incidence of the model after operation is 12.57%, the actual value is 13.38%, the actual value / prediction value is 1.06, there is no statistical difference between the two (P=0.7760.05).ROC curve fruit display Se=74.20%, Sp=86.20%, beta, beta area under the curve area Hosmer-Lemeshow test was performed on the 0.87. model for the prediction model. The results showed that the scoring system predicted the LEDVT incidence (H2=3.309, df=8, P=0.9140.05) after operation. The information in the data was fully extracted from the.3.POCD group: 1) age, blood pressure (systolic pressure), albumin, oxygen pressure, number of complications, COPD, stroke and hands in the physiological indexes. The operation time, the amount of blood loss and the way of anesthesia were the risk factor of POCD.2) POCD risk scoring system prediction model: Ln[R/ (1-R)]=-6.88+0.191 x PS+0.302 x OS.3) the predicted value of the POCD incidence of the model was 12.38%, the actual value was 14.28%, the actual value / prediction value was 1.15, there was no statistical difference between the two (x 2=0.330,) P=0.6670.05) the results of the.ROC curve show Se=53.3%, Sp=90%, =10%, beta =46.7%, and 0.759. under ROC curve for the Hosmer-Lemeshow test of this prediction model. The results show that this scoring system predicts the incidence of POCD after operation (H2=7.707, df=8,) is good, and the information in the data is fully extracted after the operation: 1) physiological index The age, white blood cell, albumin, blood pressure (systolic pressure), creatinine, ASA classification, cardiac function classification, complication number, COPD, stroke, diabetes and surgical severity index, preoperative preparation time, operation time, intraoperative blood loss are the risk factors for postoperative death.2) the prediction model of postoperative death risk score system: Ln[ R/ (1-R)]=-11.565+0.265 x PS+0.121 x OS.3) the predictive value of postoperative mortality of the model was 3.99%, the actual value was 5.18%, the actual value / prediction value was 1.3. There was no statistical difference between the two models (P=0.4510.05).ROC curve results showed Se=96.2%, Sp=88.8%, =11.2%, beta =3.8%. Smer-Lemeshow test, the results showed that the scoring system predicted the incidence of postoperative mortality (H2=10.869, df=8, P=0.2090.05), and the information in the data was fully extracted. Conclusion: this project initially established a scoring system for the incidence and mortality of common complications after hip fracture in the south of Sichuan Province and its prediction model: 1) lung after operation. Ln[R/ (1-R)]=-7.187+0.226 x PS+0.161 x OS.2) prediction model of LEDVT risk scoring system after operation: Ln[R/ (1-R)]=-11.493+0.347 x PS+0.327 x OS.3) POCD risk scoring system prediction model: the prediction model of postoperative mortality risk score system 565+0.265 x PS+0.121 x OS. and the ratio of the actual value to the predicted value, the ROC curve and the Hosmer Lemeshow test to evaluate their predictive value. The results show that the four prediction models have good accuracy. Analyze the risk factors of the operation and eliminate some risk factors that are not related to the complications, which are more pertinent and more efficient. However, there is no prospective study on the sample sample and no comparison between the results of this study and the statistical results of the PPOSSUM and Department of orthopedics in the Department of orthopedics, so further in-depth study is needed.

【學(xué)位授予單位】：西南醫(yī)科大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2017
【分類號】：R687.3

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