摘要
目的探讨肾上腺髓质素（AM）对急诊社区获得性肺炎（CAP）患者的预后和危险分层价值。方法采用前瞻性观察性临床研究，选取2011年8月至2012年11月北京朝阳医院急诊科收入的符合CAP诊断标准的成年患者，检测循环AM水平并进行肺炎严重度（PSI）评分和CURB一65评分，比较入选时重症社区获得性肺炎（SCAP）患者与非重症社区获得性肺炎（NSCAP）患者、28d死亡与存活患者之间各指标的差异，并通过逻辑回归和受试者工作特征曲线（ROC曲线）评估AM、PSI评分和CURB-65评分对SCAP诊断和CAP预后的价值。结果共人选CAP患者511例，其中SCAP患者127例；28d病死率为34．2％（175／511）。SCAP患者AM水平、PSI评分和CURB-65评分显著高于NSCAP患者；28d死亡患者AM水平、PSI评分和CURB-65评分显著高于存活患者。AM和CURB-65评分为SCAP的独立预测因素[AM的优势比（OR）=1．127，95％可信区间（95％CI）为1．096-1．158，P=O．000；CURB-65评分的OR=1．421，95％CI为1．072-1．882，P=O．014]；AM联合CURB-65评分[ROC曲线下面积（AUC）为0．822，95％C／为0．781。0．863，P=O．000]可较单独应用AM（AUC为0．808，95％CI为0．766-0．850，P=O．000）、CURB-65评分（AUC为0．644，95％CI为0．590-0．698，P=O．000）提高诊断SCAP的准确性（敏感度：81．1％比75．6％、70．9％，特异度：70．1％比72．9％、523％，阳性预测值：46．6％比48．0％、33．0％，阴性预测值：91．7％比90．0％、84．5％）。AM和PSI评分为28d死亡的独立预测因素（AM的OR=1．084，95％C／为1．060-1．108，P=0．000；PSI评分的OR=1．019，95％C／为1．011-1．027，P=O．000）；AM联合PSI评分（AUC为0．803，95％C／为0．763-0．843，P=0．000）可较单独应用AM（AUG为0．724，95％C／为0．678-0．770，P=0．000）、PSl评分（AUC为0．731，95％C／为0．686-0．776，P=0．000）提高预测28d死亡的准确性（敏感度：78．3％比69．1％、77．7％，特异度：70．5％比65．5％、58．9％，阳性预测值：56．6％比51．1％、49．6％，阴性预测值：85．9％比80．3％、83．5％）。结论循环AM水平对于急诊CAP患者具有一定的危险分层和预后价值，与CURB-65评分联用可以用于诊断SCAP，与PSI评分联用可以提高对预后的预测价值。
Objective To evaluate the prognostic and stratified value of adrenomedullin （AM） in community acquired pneumonia （CAP） patients in the emergency department （ED）. Methods A prospective observational study was conducted. Adult patients who fulfilled the CAP criteria admitted to the ED of Beijing Chaoyang Hospital from August 2011 to November 2012 were enrolled. Serum AM was detected, pneumonia severity index （PSI） score and CURB-65 score were calculated at enrollment. AM level, PSI and CURB-65 scores were compared between patients with severe CAP （SCAP） and non-SCAP （NSCAP）, survivors and non-survivors. The prognostic and stratified value of AM, PSI score and CURB-65 score was assessed by logistic regression analysis and receiver operating characteristic （ROC） curve. Results 511 CAP patients, including 127 of SCAP, were enrolled. The 28-day mortality of the study was 34.2% （ 175/511 ）. AM, PSI score and CURB-65 score in SCAP patients were much higher than those in NSCAP patients, and were higher in non-survivors than those in survivors. Using logistic regression analysis, AM and CURB-65 score were independent predictors of SCAP JAM： odds ratio （OR） ~1.127, 95% confidence interval （95%CI）： 1.096-1.158, P=0.000; CURB-65 score： OR=1.421, 95%CI： 1.072-1.882, P=O.014]. Combination of AM and CURB-65 score [area under ROC curve （AUC）： 0.822, 95%CI： 0.781-0.863, P=0.O00~ improved the accuracy of both AM （AUC： 0.808, 95%CI： 0.766-0.850, P=0.O00） and CURB-65 score （AUC： 0.644, 95%CI： 0.590-0.698, P=0.000） in predicting SCAP （sensitivity： 81.1% vs. 75.6%, 70.9%; specificity： 70.1% vs. 72.9%, 52.3%; positive predictive value： 46.6% vs. 48.0%, 33.0%; negative predictive value： 91.7% vs. 90.0%, 84.5% ）. AM and PSI score were independent predictors of 28-day mortality （AM： OR = 1.084, 95% CI： 1.060-1.108, P=0.000;PSI score ： OR= 1.019, 95% C1：1.011-1.027, P-=0.000）. The accuracy of AM （AUC ： 0.724, 95%CI： 0.678-0.770, P=0.000） and PSI score （AUC： 0.731, 95%CI： 0.686-0.776, P=0.000） in predicting the risk of 28-day mortality was improved with the combination of AM and PSI score （AUC： 0.803, 95%CI： 0.763-0.843, P=0.000; sensitivity： 78.3% vs. 69.1%, 77.7%; specificity： 70.5% vs. 65.5%, 58.9%; positive predictive value： 56.6% vs. 51.1%, 49.6%; negative predictive value ： 85.9% vs. 80.3%, 83.5% ）. Conclusions AM is valuable for prognosis and stratification of CAP patients in ED. Combination of AM and CURB-65 score is useful for the diagnosis of SCAP. Combination of AM and PSI score improves the prognostic performance in oredicting 28-day mortality.
出处
《中华危重病急救医学》
CAS
CSCD
北大核心
2014年第2期115-119,共5页
Chinese Critical Care Medicine
基金
北京市优秀博士学位论文指导教师科研项目（20121002501）
