肺脏超声联合血清单核细胞趋化蛋白-1对重症社区获得性肺炎短期预后的预测价值.pdf

第 23 卷第 3 期2023 年6月泰州职业技术学院学报Journal of Taizhou Polytechnic CollegeVol.23 No.3Jun.2023肺脏超声联合血清单核细胞趋化蛋白-1对重症社区获得性肺炎短期预后的预测价值朱泽文1，沈小飞2，尹明2（1.扬州大学附属泰州人民医院；2.南京医科大学附属泰州人民医院，江苏泰州225300）摘要：目的探究肺脏超声联合血清单核细胞趋化蛋白-1（MCP-1）对重症社区获得性肺炎（CAP）短期预后的预测价值。方法选取本院2019年3月2022年11月收治的137例重症CAP患者。根据治疗28天后患者是否死亡将其分为生存组（n=86）和死亡组（n=51）。比较不同组别中临床资料、血清指标的差异。采用Pearson分析评估LUS评分、血清MCP-1水平与其他临床指标的相关性。采用二元Logistic分析评估CAP患者死亡的影响因素。采用受试者工作特征曲线（ROC）评估LUS评分、MCP-1对CAP患者28天死亡的预测价值。结果死亡组患者的SOFA评分、LUS评分及MCP-1较生存组升高，而氧合指数较生存组降低（P0.05）。LUS评分、血清MCP-1水平与SOFA评分呈正相关，而与氧合指数呈负相关（P0.05）。二元Logistic分析显示，SOFA评分、LUS评分及MCP-1是CAP患者28天发生死亡的危险因素（P18岁。排除标准：（1）伴有肺癌、肝癌及食管癌等恶性肿瘤者。（2）伴有胸廓畸形、胸部外伤及严重气胸等严重胸部病变者。（3）入院前两周内服用过抗炎药物治疗者。（4）肝肾功能异常者。1.2研究方法1.2.1超声检查采用Mindray 7 Series便携式超声诊断仪，频率为2.55.0 MHz。嘱患者取仰卧、俯卧位，将腋前线和腋后线作为分界，全肺共分为12个区，探头与肋骨垂直，先垂直于肋骨间隙进行检查，然后将探头旋转 90进行横向检查。采用半定量标准对肺部超声征象进行评分，每个区域分值 03分，共计36分。肺部超声评分（lung ultrasound score，LUS）分值越高，代表患者肺含气量越低，病情越严重。具体评分标准为4：（1）0分：A 线平滑和或 B线2 条。（2）1分：出现肺组织通气减少区，即出现多条不规则分布的B线。（3）2分：肺组织通气减少区进一步增多，同时伴有多条融合且弥漫分布的B线。（4）3分：出现肺实变，局部见空气支气管征。1.2.2血清MCP-1检测CAP患者均于入院时采集 2 mL 静脉血置于试管中，通过KA-2000离心机离心，条件为3000 r/min（4），离心时间5min，收集上层清液。采用酶联免疫吸附法检测血清中MCP-1水平。MCP-1试剂盒购自上海研伴实业有限公司（货号：YB-E10020）。严格遵照实验流程进行操作。1.3观察指标记录CAP患者的性别、年龄、基础疾病史及体质量指数（BMI）等临床资料。同时评估序贯器官衰竭估计评分（Sequential organ failure estimation score，SOFA）、氧合指数、肺泡动脉氧压差、白细胞计数及血清 C-反应蛋白水平。1.4随访随访时间从入院开始，到第28 d或患者死亡（全因CAP死亡）为止。1.5统计方法数据均由 SPSS26.0 软件处理分析。数据均符合正态分布。计量资料以sx 表示，两组间比较采用独立样本t检验。计数资料以%表示，采用卡方检验。采用Pearson分析评估LUS评分、血清MCP-1水平与其他临床指标的相关性。采用二元Logistic分析评估重症CAP患者死亡的影响因素。采用受试者工作特征曲线（receiver operator characteristic curve，ROC）评估LUS评分、MCP-1对重症CAP患者28天死亡的预测价值。以P0.05表明数据差异具有统计学意义。2结果2.1两组重症CAP患者的MCP-1、LUS评分及临床资料比较死亡组患者的SOFA评分、LUS评分及MCP-1较生存组升高，而氧合指数较生存组降低（P0.05），见表1。2.2重症CAP患者的MCP-1、LUS评分与其他临床指标的相关性比较LUS评分、血清MCP-1水平与SOFA评分呈正相关，而与氧合指数呈负相关（P0.05），见表2。表2重症CAP患者的MCP-1、LUS评分与其他临床指标的相关性比较指标SOFA评分氧合指数LUS评分r0.502-0.568P0.0050.000MCP-1（pg/mL）r0.605-0.591P0.0000.0002.3二元Logistic分析评估重症CAP患者28天死亡的影响因素纳入表1中具有统计学意义的指标进行分析，以CAP患者28天是否发生死亡为因变量（否=0，是=1），以SOFA评分、LUS评分、MCP-1及氧合指数为自变量。校正了年龄、糖尿病史、高血压史及C-反应蛋白等混杂因素，结果表1两组重症CAP患者的MCP-1、LUS评分及临床资料比较项目年龄（岁）男例（%）BMI指数（kg/m2）高血压史例（%）糖尿病史例（%）SOFA评分氧合指数肺泡动脉氧压差（mmHg）白细胞计数（109/L）C-反应蛋白（mg/L）LUS评分MCP-1（pg/mL）生存组（n=86）55.8510.1341（47.67）21.352.0235（40.70）22（25.29）6.591.87143.0225.06310.6875.9112.263.7915.752.2416.032.72105.6533.68死亡组（n=51）56.1210.3728（54.90）21.942.5620（39.22）14（27.45）9.431.52126.7427.28326.1772.8813.013.1616.082.6820.912.03136.7730.25t或20.1490.6691.4060.0290.0589.6903.4791.1841.2460.73911.1095.579P0.8820.4130.1620.8640.8100.0000.0010.2380.2150.4610.0000.00068第 3 期朱泽文，沈小飞，尹明：肺脏超声联合血清单核细胞趋化蛋白-1对重症社区获得性肺炎短期预后的预测价值显示，SOFA评分、LUS评分及MCP-1是重症CAP患者28天发生死亡的危险因素（P0.05），见表3。表3二元Logistic分析评估CAP患者28天死亡的影响因素自变量LUS评分SOFA评分MCP-1（pg/mL）氧合指数B1.3230.9251.201-0.688SE0.6020.3690.5370.447Wald24.8306.2845.0022.369P0.0280.0120.0250.124HR（95%CI）3.755（1.15412.218）2.522（1.2245.198）3.323（1.1609.521）0.503（0.2091.207）2.4LUS评分、血清MCP-1水平对重症CAP患者28天死亡的预测价值以CAP患者28天是否发生死亡前提绘制ROC曲线。结果显示，LUS评分、MCP-1联合诊断的AUC值明显高于单一LUS评分或MCP-1的AUC值（P0.05），见表4和图1。图1LUS评分、血清MCP-1水平预测重症CAP患者28天死亡的ROC曲线表4LUS评分、血清MCP-1水平对重症CAP患者28天死亡的预测价值LUS评分MCP-1（pg/mL）LUS评分+MCP-1AUC（95%CI）0.728（0.640-0.816）0.685（0.589-0.782）0.810（0.735-0.885）最佳截断截值19.37121.13-灵敏度（%）86.2770.5980.39特异度（%）74.4273.2681.403讨论据流行病学统计，重症CAP常并发感染性休克、呼吸衰竭及多器官功能障碍等严重并发症，其发生率约为 19.2%36.3%，且死亡率高达35.8%5。肺部CT是诊断重症CAP的金标准，但由于患者自身病情较重、电离辐射等因素的限制，无法实时、反复进行肺部CT检查。而肺部超声凭借安全便捷、动态无创的优势，在诊断及评估肺部感染时具有较大价值2。趋化因子已被证实在肺炎进展中具有重要的调控作用。近年来，随着血清指标检测技术的不断成熟，通过检测血清中趋化因子水平评估肺炎严重程度及预后已成为研究热点话题。因此，LUS评分和MCP-1联合应用预测重症CAP短期预后值得深入探索研究。正常的肺部超声表现光滑的胸膜线和等距平行与胸膜线分布的高回声线（A线）。但是，在重症CAP的病理状态下，肺内气液比例剧烈变化，从而在超声声像图上显示与胸膜线垂直的束带状伪影（B 线），B 线越多表明肺通气功能越差，LUS评分随之增加6。研究显示，LUS评分能够早期辅助临床评估呼吸困难和低氧血症的潜在病因7。Mongodi等8发现，在抗生素治疗肺部感染过程中，LUS评分在评估肺通气变化情况时，比床旁胸片更准确。本研究结果显示，死亡组患者的LUS评分较生存组上升，提示LUS评分能够反映重症CAP患者的预后情况。其原因重症CAP发生时，肺泡内液体增多，肺小叶间隔增厚，肺内气液比例显著变化，从而使B线数量增多，LUS评分升高6。MCP-1主要由树突细胞、巨噬细胞及单核细胞合成分泌，参与调控炎症反应过程。研究表明，MCP-1通过趋化单核巨噬细胞，诱导白细胞黏附分子1活化，从而刺激白细胞介素（interleukin，IL）-1、IL-6合成，加剧炎症反应9。基础研究表明，MCP-1能够调节单核细胞内钙离子浓度，使其吞噬、分泌功能增强，从而参与一系列免疫应答反应10。本研究结果显示，死亡组患者血清中MCP-1水平较生存组升高，说明MCP-1可能在CAP进展过程中发挥作用。其原因可能是重症CAP通过正反馈作用，促进单核细胞表面特异性抗原受体活化，分泌合成大量MCP-1入血，从而进一步加剧炎症反应9。Pearson分析显示，LUS评分、血清MCP-1水平与SOFA评分呈正相关，而与氧合指数呈负相关，提示LUS评分、血清MCP-1水平能够侧面反映重症CAP患者的病情严重程度。二元Logistic显示，SOFA评分、LUS评分及MCP-1是CAP患者28天发生死亡的危险因素，提示较高的LUS评分、69泰州职业技术学院学报第3 期血清MCP-1水平是导致重症CAP患者短期死亡的重要因素。ROC曲线显示，LUS评分、MCP-1联合诊断的AUC值明显高于单一LUS评分或MCP-1的 AUC 值，其灵敏度和特异度分别为 80.39、81.40，提示LUS评分、MCP-1联合应用能够提高重症CAP患者短期死亡的预测效能，对临床早期筛查具有重要价值。本研究也存在一定的局限性：（1）样本量有限，需要在后续研究中进一步扩大样本量，再次验证本次试验所得到的结论。（2）由于受试者病情较危重，部分体位无法配合，可能对肺部超声的结果造成影响。综述所述，随着重症 CAP 患者病情进展，LUS评分、血清MCP-1水平升高。同时，LUS评分、血清MCP-1水平是影响重症CAP患者短期预后的重要因素，对指导临床实践具有重要价值。参考文献：1Zan YM,Zheng TP,Wang Y,et al.Combining a FrailtyIndex Based on Laboratory Data and Pneumonia Severity Assessments to Predict In-Hospital Outcomes inOlder Adults with Community-Acquired PneumoniaJ.J Nutr Health Aging,2023,27(4):270-276.2闫媛媛,娄君鸽,肖燕,等.肺超声评分联合血清降钙素原对呼吸机相关性肺炎的诊断价值J.中国超声医学杂志,2021,37(12):1353-1356.3朱晓菡,林爱琴,寇应琳,等.血清IL-8与TNF-和MCP-1对革兰阴性菌感染呼吸机相关性肺炎的诊断价值J.中华医院感染学杂志,2021,31(23):3532-3536.4Monastesse A,Girard F,Massicotte N,et al.Lung Ultrasonography for the Assessment of Perioperative Atelectasis:A Pilot Feasibility Study J.Anesth Analg,2017,124(2):494-504.5姜宁,龙秋月,郑雅莉,等.社区获得性肺炎流行病学与病原学及其治疗进展J.中华预防医学杂志,2023,57(1):91-99.6Elamry E,Alkady HM,Menaissy Y,et al.Predictorsof in-hospital mortality in isolated total anomalouspulmonary venous connection J.Heart Surg Forum,2019,22(3):191-196.7穆楠,蒋亚洲,卓烈,等.肺部超声评分联合血CRP、LDH水平对肺炎支原体肺炎患儿病变程度评估的临床意义J.中国超声医学杂志,2021,37(9):993-997.8Mongodi S,Via G,Girard M,et al.Lung Ultrasoundfor Early Diagnosis of Ventilator-Associated Pneumonia J.Chest,2016,149(4):969-980.9Hassan AI,Samir A,Youssef HF,et al.Effects of silvernanoparticles-polysaccharideonbleomycin-induced pulmonary fibrosis in rats J.J Pharm Pharmacol,2021,73(11):1503-1512.10Kang S,Tanaka T,Inoue H,et al.IL-6 trans-signaling induces plasminogen activator inhibitor-1from vascular endothelial cells in cytokine releasesyndrome J.Proc Natl Acad Sci USA,2020,117(36):22351-22356.（责任编辑刘红）The Predictive Value of Lung Ultrasound Combined with Serum Monocyte Chemoattractant Protein-The Predictive Value of Lung Ultrasound Combined with Serum Monocyte Chemoattractant Protein-1 1 for thefor theShort-term Prognosis of Severe Community-acquired PneumoniaShort-term Prognosis of Severe Community-acquired PneumoniaZHU Ze-wenZHU Ze-wen1 1,SHEN Xiao-fenSHEN Xiao-fen2 2,YIN MingYIN Ming2 2(1.Affiliated Taizhou Peoples Hospital of Yangzhou University;2.The Affiliated Taizhou Peoples Hospital of Nanjing Medical University,Taizhou Jiangsu 225300,China)AbstractAbstract:Objective To explore the predictive value of lung ultrasound combined with serum monocyte chemoattractant protein-1(MCP-1)for the short-term prognosis of severe community-acquired pneumonia(CAP).Methods A total of 137 patients with severe CAP admitted to our hospital from March 2019 to November 2022were selected.Patients were divided into survival group(n=86)and death group(n=51)according to whetherthey died after 28 days of treatment.The differences of clinical data and serum indexes in different groups werecompared.Pearson analysis was used to evaluate the correlation between LUS score,serum MCP-1 level andother clinical indicators.Binary Logistic analysis was used to evaluate the influencing factors of death in CAP patients.The receiver operator characteristic curve(ROC)was used to evaluate the predictive value of LUS scoreand MCP-1 for 28-day mortality in CAP patients.Results The SOFA score,LUS score and MCP-1 in thedeath group were higher than those in the survival group,（下转第74页）70泰州职业技术学院学报第3 期泌尿外科杂志,2003,24(10):66-67.7孙东瑞,顾晓,赵静燕,等.扬州地区838例泌尿系结石成分及相关因素分析J.临床泌尿外科杂志,2021,36(10):776-781,784.8魏汉平,焦志敏,刘晓武,等.江苏常州885例泌尿系结石成分特点及与患者临床特征的关系J.临床泌尿外科杂志,2020(10):791-794,799.9Miller,Nicole,L,et al.Treatment of the Infected StoneJ.The Urologic clinics of North America,2015,42(4):459-472.10Zheng J,Yu H,Batur J,et al.A multicenter studyto develop a non-invasive radiomic model to identifyurinary infection stone in vivo using machine-learningJ.Kidney International,2021(4):870-880.11周磊,阿不都沙拉木阿不都瓦克,何万鹏,等.新疆单中心成人上尿路尿酸结石与代谢综合征的相关性J.现代泌尿外科杂志,2018,23(5):352-356,359.12王起,杨波,徐涛,等.代谢综合征与尿酸结石成分的相关性研究J.中华泌尿外科杂志,2016(8):583-585.13李坤,郭丰富.代谢综合征与尿酸结石关系的研究进展J.泌尿外科杂志:电子版,2019,11(2):23-27.14张鑫,孙立江.代谢综合征与泌尿系结石患者相关指标及结石成分分析J.医药前沿,2019,9(8):142-143.15张开能,柯昌兴.尿酸结石的病理生理机制与诊疗进展J.医学新知,2022,32(3):223-228.（责任编辑刘红）Analysis of the Composition and Related Clinical Characteristics ofAnalysis of the Composition and Related Clinical Characteristics of 754754 Cases Ureteral CalculiCases Ureteral Calculiin Taizhouin Taizhou,Jiangsu ProvinceJiangsu ProvinceLIANG Su-dongLIANG Su-dong,LIU YuLIU Yu,XUE Xin-fangXUE Xin-fang,XU ZhenXU Zhen(The Affiliated Taizhou Peoples Hospital of Nanjing Medical University,Taizhou Jiangsu 225300,China)AbstractAbstract:Objective To explore the relationship between the composition and the related clinical characteristics.Methods 754 samples of ureteral calculi in Taizhou were selected,and the components of the calculi were detected by infrared spectrum automatic analysis technology,and then analyzed by combining with clinical factors suchas gender and age.Results A total of 754 patients with ureteral calculi were included.The average age was(51.18 13.61)years old.The average age of women was higher than that of men(P0.05).The ratio of male to female was 2.25:1.The age range of 5059 years old was the highest(29%),and the age range of 4049 years oldwas the second(21%).The analysis of stone composition showed that there were more mixed stones than simplestones(441 cases vs 313 cases).Calcium oxalate monohydrate stone(80.0%)and anhydrous uric acid stone(17.6%)were the main stones in simple stones.The most common stone composition in mixed stones was calcium oxalate monohydrate and carbonate apatite(64.2%).Calcium oxalate monohydrate and carbonate apatite arethe most common stones in both men and women.Conclusion There are significant differences in age and sexdistribution of ureteral calculi in Taizhou.According to these characteristics,more appropriate measures can beformulated for the prevention and treatment of ureteral calculi in this area.Key wordsKey words:ureteral calculus;Taizhou;stone compositionwhile the oxygenation index was lower than that in the survival group(P0.05).The LUS score and serum levelof MCP-1 were positively correlated with SOFA score,but negatively correlated with oxygenation index(P0.05).Binary Logistic analysis showed that SOFA score,LUS score and MCP-1 were risk factors for 28-daymortality in CAP patients(P0.05).ROC curve showed that the AUC value of LUS score combined withMCP-1 was significantly higher than that of single LUS score or MCP-1,and the sensitivity and specificitywere 80.39 and 81.40,respectively.Conclusion With the progression of severe CAP,the LUS score and serumlevel of MCP-1 increased.Meanwhile,the LUS score and serum level of MCP-1 are important factors affectingthe short-term prognosis of patients with severe CAP,which have important value in guiding clinical practice.Key wordsKey words:community acquired pneumonia;lung ultrasound;monocyte chemotactic protein-1;correlation;ROC curve（上接第70页）74