临床初期预测甲型H1N1流感肺炎方法的探讨

Methods of predicting influenza A（H1N1） pneumonia at early clinical stage

摘要:

目的：探讨甲型H1N1流感流行期间门诊医师在临床初期预测易患流感肺炎患者的方法。方法：将承德地区2009年9月-12月全部确诊为新型甲型H1N1流感的206例患者集中免费收治于传染病医院，确诊依据符合卫生部办公厅印发的《甲型H1N1流感诊疗方案（2009第三版）》，对以上病例就诊初期情况进行回顾性分析，依据最终的影像学表现将患者分为肺炎组（51例）和非肺炎组（155例），对2组患者的临床特征和辅助检查进行对照研究，通过单因素筛选及多因素logistic回归分析确定易患肺炎的危险因素；拟定预测甲型H1N1流感肺炎的评分系统并进行拟合优度检验。结果：将2组比较有统计学差异的因素进行多因素logistic回归分析显示，首发症状有咳痰（OR=3.537，95%CI=1.016~12.311）、发病到就诊时间＞48 h（OR=19.525，95%CI= 4.576~83.309）、乳酸脱氢酶＞250 U/L（OR=16.717，95%CI=5.484~34.417）、钾离子＜3.5 mmol/L（OR=7.332，95%CI=1.763~49.709）、谷草转氨酶＞40 U/L（OR=3.809，95%CI=1.008~12.460）、存在慢性肺部疾病（OR=61.003，95%CI=5.484~34.417）是甲型H1N1流感肺炎的独立危险因素﹙P值均＜0.05﹚；接收者工作特征曲线下面积为0.965（95%CI=0.939~0.992，P＜0.001）；根据以上危险因素制定预测评分系统并分级（低危0～2分、中危3～4分、高危5～6分、极高危7分）与实际肺炎病例吻合度良好，判定系数R2=0.916，P=0.043。结论：未来甲型流感流行期间，相关科室门诊医师可以通过患者首发症状情况、发病到就诊时间、乳酸脱氢酶数值、钾离子和谷草转氨酶数值、基础疾病情况进行综合评分从而预测易患肺炎的甲型流感患者。

Abstract:

Objective：To investigate the methods of predicting susceptibility of influenza A（H1N1） pneumonia at early clinical stage in outpatient department. Methods：Totally 206 patients diagnosed as novel influenza A（H1N1） in Chengde area between September and December of 2009 were concentrated in Chengde Hospital for Infectious Diseases for free treatment. The diagnosis was consistent with the Protocol for Diagnosis and Treatment of Influenza A（H1N1）（2009 3rd ed） issued by the General Office of Ministry of Health. A retrospective study on the 206 cases was conducted. Based on the final imaging findings，these patients were divided into pneumonia group（n=51） and non-pneumonia group（n=155）. Clinical characteristics and auxiliary examination were compared between the two groups；univariate analysis and multivariate logistic regression analysis were used to identify independent predictors of pneumonia；goodness of fit test was performed on an established clinical predicting scoring system. Results：Multivariate logistic regression analysis of the statistically significant factors demonstrated that：expectoration as initial symptom（OR=3.537，95%CI=1.016 to 12.311），onset-to-treatment interval > 48 h（OR=19.525，95%CI=4.576 to 83.309），lactic dehydrogenase > 250 U/L（OR=16.717，95%CI=5.484 to 34.417），potassium ion<3.5 mmol/L（OR=7.332，95%CI=1.763 to 49.709），aspartate aminotransferase > 40 U/L（OR=3.809，95%CI=1.008 to 12.460） and presence of underlying diseases（OR=61.003，95%CI=5.484 to 34.417） were the independent risk factors of influenza A（H1N1） pneumonia（all P<0.05）. Area under receiver operating characteristic curve was 0.965（95%CI=5.484 to 34.417，P<0.001）. Prediction scoring system of pneumonia was established according to levels of six high risk factors：low risk（score 0-2），intermediate risk（score 3-4），high risk（score 5-6） and very high risk（score 7） and were categorized for predicting the occurrence of pneumonia illness. Goodness of fit test showed good results（R2=0.916，P=0.043）. Conclusions：In the future，clinical physicians can predict the susceptibility of pneumonia in patients with influenza A（H1N1） by comprehensive scoring concerning initial symptom，onset-to-treat－ment interval time，level of serum potassium ion and aspartate aminotransferase and presence of underlying diseases.