controlling nutritional status score
术前CONUT评分预测HBV相关的HCC患者术后生存率
术前CONUT评分预测HBV相关的HCC患者术后生存率周超军;陈磊;蔡斌斌;蔡秀鹏;林炜航;方冠;杨文军【摘要】目的了解控制营养状况(controlling nutritional status,CONUT)评分预测乙型肝炎病毒(HBV)相关的肝细胞性肝癌(HCC)患者术后总体生存率的能力,并将与常用分期评分标准进行比较.方法回顾性分析温州医科大学附属第一医院2007年1月至2013年6月收治的373例HBV相关的HCC患者临床资料.生成受试者工作特征曲线(ROC),并计算曲线下面积(AUC),评估不同评分系统辨别1、3、5年存活率的能力.再将患者分为高CONUT组(CONUT>2,n=15)和低CONUT组(CONUT≤2,n=216),比较两组的临床病理特征及术后总生存期(OS)的差异,通过Cox模型进行单因素、多因素分析,明确影响患者预后的独立危险因素.结果 ROC 曲线下面积比较显示,CONUT的AUC值始终较高.低CONUT组的5年OS高于高CONUT组(P<0.05).将临床病理特征以及CONUT和CLIP评分等进行OS的单因素和多因素分析,结果显示,CLIP评分(P=0.004,HR 1.400,95％CI 1.113～1.762),纤维蛋白原<1 g/L或>4 g/L(P=0.002,HR 1.976,95％CI 1.272～3.072),TNM分期(P=0.003,HR 1.767,95％CI 1.212～2.575)和CO-NUT>2(P=0.010,HR1.697,95％CI 1.132～2.544)为患者预后的独立危险因素.结论 CONUT>2分可以作为HBV相关HCC患者预后的独立危险因素;在与Okuda评分、CLIP评分、BCLC分期评分标准比较中,CONUT具有更好的预测价值.【期刊名称】《肝胆胰外科杂志》【年(卷),期】2019(031)006【总页数】6页(P329-334)【关键词】癌,肝细胞;控制营养状况评分;乙型肝炎病毒;总生存期【作者】周超军;陈磊;蔡斌斌;蔡秀鹏;林炜航;方冠;杨文军【作者单位】温州医科大学附属第一医院肝胆外科,浙江温州 325000;温州医科大学附属第一医院肝胆外科,浙江温州 325000;温州医科大学附属第一医院肝胆外科,浙江温州 325000;温州医科大学附属第一医院肝胆外科,浙江温州 325000;温州医科大学附属第一医院肝胆外科,浙江温州 325000;温州医科大学附属第一医院结直肠肛门外科,浙江温州 325000;温州医科大学附属第一医院肝胆外科,浙江温州325000【正文语种】中文【中图分类】R735.7肝细胞性肝癌（HCC）是最常见的恶性肿瘤之一，是第二大癌症死亡原因[1]。
基线控制营养状况(CONUT)评分与腹膜透析患者临床结局的相关性研究介绍演示培训课件
指导营养干预
通过定期监测患者的CONUT评 分变化，可以及时发现营养不良 并采取相应的营养干预措施，从
而改善患者的临床结局。Fra bibliotek腹膜透析患者营养状况特点
蛋白质能量营养不良
腹膜透析患者由于蛋白质丢失和能量消耗增加，容易出现 蛋白质能量营养不良。表现为血清白蛋白降低、体重下降 、肌肉萎缩等。
02
探索降低腹膜透析患者CONUT评分 的有效干预措施。虽然本研究证实了 CONUT评分与患者临床结局的相关 性，但如何有效降低患者的CONUT 评分仍需进一步探讨。未来研究可以 关注饮食调整、营养补充、运动锻炼 等方面的干预措施，为患者提供个性 化的营养管理方案。
03
开展多中心、大样本量的研究以验证 本研究的结论。虽然本研究取得了一 定的成果，但样本量相对较小，可能 存在一定的偏倚。未来可以开展多中 心、大样本量的研究，进一步验证 CONUT评分与腹膜透析患者临床结 局的相关性，提高研究的可靠性和普 适性。
THANKS
感谢观看
炎症与感染情况分析
探讨CONUT评分与患者炎症、感染等并发症发生率的关系。
生活质量评价
评估不同CONUT评分组患者的生活质量差异，如身体功能、心 理状况、社会功能等方面。
05
结果讨论与解释
结果展示与解读
基线CONUT评分与患者生存率的关系
研究发现，基线CONUT评分较高的患者生存率显著降低，提示营养不良可能是影响腹 膜透析患者预后的重要因素。
生存率分析
根据患者的CONUT评分，将其分为 不同组别，比较各组患者的生存率差 异。
影响因素分析
采用多因素分析方法，探讨CONUT 评分对患者生存率的影响程度，并考 虑其他潜在影响因素。
氨康源氨基酸固体饮料 中英文对照
1、解酒护肝型氨康源氨基酸固体饮料，以人体必需氨基酸为基础的科学配方，通过现代科技手段，充分的保证了氨基酸的多样性、必需性、高营养性，同时也解决了在饮料中的稳定性，并且可充分发挥氨基酸在溶液中易吸收性，是一种全新低热量高营养性护肝解酒饮料。
饮料中含有肝脏所需要的解救氨基酸，同时也含有人体肝脏细胞的功能性营养元素，对肝细胞是很好的保护作用，同时解决饮酒后对小脑和纹状体的损害，减少身体对酒精的依赖性，有减轻酒精中毒的作用，调节机体对酒精的刺激，促进酒后机体的恢复，减少酒后的疲乏、胃肠紊乱、记忆力下降等等的酒后症状，同时减轻因为酒精中毒引起的手震颤等等现象。
1. The solid drink of anti-inebriation and liver protective type employs the scientific formula based on the human essential amino acids, through modern scientific methods; it is fully guaranteed the variety, essentiality, and high nutrition. Meanwhile, it keeps stability of the amino acids in the solution, and fully takes the advantages of their solubility inside the solution. It is an all new low calories, high nutrition drink of anti-inebriation and liver protection.The drink contains amino acids of salvation pathway that are needed in the liver. There are also functional nutritious elements of human liver in the drink. At the same time, the drink solves the damage problems of alcohol to the cerebellum and corpus striatum. It decreases the dependence of the body to alcohol. It has the effects on alleviating the alcohol intoxication, body adjusting to the alcohol stimuli, improving the body recovery after alcohol, reducing the post-alcohol symptoms of fatigue, gastro-intestinal disorders, and memory decrease, etc. It can also ease the hand tremors caused by alcohol intoxication, etc2、氨康源氨基酸饮料，以人体必需氨基酸为基础的科学配方，通过现代科技手段，充分的保证了氨基酸的多样性、必需性、高营养性，同时也解决了在饮料中的稳定性，并且可充分发挥氨基酸在溶液中易吸收性，是一种全新低热量高营养性抗疲劳饮料。
不同术前营养评分系统在肝细胞癌切除术预后评估中的意义
doi:10.11659/jjssx.02E023029·临床研究·不同术前营养评分系统在肝细胞癌切除术预后评估中的意义陆明1,胡孔旺2,涂从银1 （1. 中国科学技术大学附属第一医院西区普外科，安徽合肥 230031；2. 安徽医科大学第一附属医院普外科，安徽合肥 230022）［摘要］ 目的 评估术前预后营养指数（PNI）、控制营养状态评分（CONUT）、那不勒斯预后评分（NPS）3种营养评分系统与肝细胞癌切除术患者临床病理特征及预后的关系。
方法 回顾性分析2016年1月至2019年12月在中国科学技术大学附属第一医院行肝细胞癌根治性切除术的122例原发性肝细胞癌患者的临床病理资料，分析术前PNI、CONUT和NPS与临床病理特征及预后之间的关系。
采用Kaplan-Meier法绘制生存曲线；Cox比例风险模型进行单因素及多因素分析肝细胞癌患者总生存期的影响因素。
受试者工作特征（ROC）曲线下面积（AUC）比较各评分系统的预测价值。
结果 术前PNI与肿瘤分化程度、微血管侵犯(MVI)、肝硬化、术前血红蛋白水平有关（P<0.05）；术前CONUT与肿瘤分化程度、肝硬化、术前血红蛋白水平有关（P<0.05）；术前NPS与肝硬化、术前血红蛋白水平有关（P<0.05）。
低PNI组、高CONUT组、高NPS组分别相较于高PNI组、低CONUT组、低NPS组的术后住院时间更长、术后并发症发生率更高，差异均具有统计学意义（P<0.05）。
Cox比例风险模型得出术前PNI、CONUT、NPS与肝细胞癌患者的预后相关（P<0.05）；但只有术前NPS是影响肝细胞癌患者预后的独立危险因素（P<0.05）。
ROC曲线结果显示，NPS的AUC高于PNI、CONUT。
结论 术前PNI、CONUT和NPS 3种营养评分系统均与行肝细胞癌切除术患者的预后有关，其中术前NPS的预测价值高于术前PNI和CONUT。
术前预后营养指数在高龄大肠癌患者预后中的临床价值
·临床论著·Clinical Article·40术前预后营养指数在高龄大肠癌患者预后中的临床价值侯伟李连谦武文龙肖博文赵丽萍盘锦市中心医院普通外科（辽宁盘锦124010）[作者简介]侯伟(1982-01~),男,辽宁大洼人,副主任医师,研究方向:胃肠道肿瘤疾病。
E-mail:*********************大肠癌是全球癌症相关死亡的主要原因之一[1-2],过往肿瘤分期和分化程度被广泛用于评估大肠癌患者预后,但它并不精确,尤其是在伴有基础疾病的老年患者人群中[1-2]。
术前炎症反应和营养不良与肿瘤的免疫抑制状态密切相关,其为肿瘤术后复发提供了一个微环境[2-5],因此有研究认为术前炎症反应和营养不良与恶性肿瘤的长期预后有关[6-13]。
预后营养指数(prognostic nutritional index,PNI)是On⁃odera等[14]首次报道的一种同时包含营养(血清白蛋白水平)和免疫成分(外周血淋巴细胞计数)的预后指标,近年来多项研究表明,低PNI是大肠癌患者预后不佳的独立危险因素[13-17]。
随着人口老龄化的进展,高龄大肠癌的发病率也在迅速增加[18-20]。
现阶段高龄患者通常合并慢性炎症、营养不良等多种基础疾病[21]。
与中青年人群相比,高龄患者术前血清白蛋白和总淋巴细胞计数较低[21]。
然而,PNI和炎症指标在高龄大肠癌手术患者中的预测价值仍不清楚。
本研究旨在明确高龄大肠癌患者术前PNI与远期预后的相关性。
1资料与方法1.1一般资料回顾性分析2010年1月—2014年10月在盘锦市中心医院普通外科择期行根治性大肠癌切除术的超过80岁的154例患者的临床资料,男85例,女69例。
全部患者或家属知晓相关治疗计划,并签署知情同意书。
1.2排除标准符合以下标准之一的患者被排除本研究:(1)术前伴有其他感染性疾病;(2)大肠癌TNM分期为Ⅳ期;(3)临床资料不完整;(4)因伴有肠梗阻行急诊手术;(5)术后随访不足3个月。
个性化营养干预对结直肠癌患者围术期营养及生活质量的效果研究
生命科学-医药卫生生命科学仪器 2023年第21卷/第6期234作者简介:谭凤娟,(1987,04),女,本科,护师,主要从事胃肠外科的临床和教学工作㊂邮箱:x gr c b 6252@163.c o m ㊂个性化营养干预对结直肠癌患者围术期营养及生活质量的效果研究谭凤娟* 何业萍 龚 艳(中山市小榄人民医院胃肠外科,广东中山528415)摘要 目的探究在结直肠癌患者的围术期中实施个性化营养干预对患者营养状况和生活质量的效果㊂方法选择中山市小榄人民医院2021年1月至2023年6月80例接受手术治疗的结直肠癌患者㊂采用随机数字表法将选取的患者分为对照组(n =40,给予常规营养干预)和研究组(n =40,给予个性化营养干预)㊂对比分析两组患者的不良反应发生率㊁营养状况评分和胃肠道生活质量指数评分㊂结果研究组不良反应总发生率(7.50%,3/40)低于对照组(25.00%,10/40),差异有统计学意义(χ2=4.501,P =0.034)㊂干预后,研究组P A ㊁A L B 和T P 高于对照组(P <0.05)㊂研究组患者干预1周和干预2周G I Q L I 评分高于对照组(P <0.05)㊂结论结直肠癌患者术后易出现营养不良,需要给予营养干预,实施个性化营养干预可改善患者营养情况,保证患者安全,提高患者日常生活质量,效果显著㊂关键词 个性化营养干预;结直肠癌;围术期;生活质量E f f e c t o f p e r s o n a l i z e d n u t r i t i o n i n t e r v e n t i o n o n p e r i o pe r a t i v e n u t r i t i o n a n d q u a l i t y of l i f e i n p a t i e n t s w i t h c o l o r e c t a l c a n c e r T A N F e ng j u a n *,H E Y e p i n g,G O N G Y a n (S t o m a c h E n t e r o c h i r u r g i a ,Z h o n g s h a n X i a o l a n P e o p l e 's H o s p i t a ,Z h o n gs h a n 528415,C h i n a )*C o r r e s p o n d i n g a u t h o r :T A N F e n g j u a n ,S e n i o r n u r s e ;E -m a i l :x gr c b 6252@163.c o m ʌA b s t r a c t ɔO b je c t i v e :T o e x p l o r e t h e ef f e c t o f p e r s o n a l i z e d n u t r i t i o n i n t e r v e n t i o n o n t h e n u t r i t i o n a l s t a t u s a n d q u a l i t y o f l i f e o f p a t i e n t s w i t h c o l o r e c t a l c a n c e r d u r i ng p e r i o pe r a t i v e p e r i o d .M e t h o d s :80p a t i e n t s w i t h c o l o r e c t a l c a n c e r w h o r e c e i v e d s u r g i c a l t r e a t m e n t i n Z h o n g s h a n X i a o l a n P e o p l e 's H o s p i t a lf r o m J a n u a r y 2021t o J u n e 2023w e r e s e l e c t e d .R a n d o m i z e d n u m b e r t a b l e m e t h o d w a s u s e d t o d i v i d e t h e s e l e c t e d p a t i e n t s i n t o c o n t r o l g r o u p (n =40,r e c e i v i n gc o n -v e n t i o n a l n u t r i t i o n i n t e r v e n t i o n )a nd s t u d y g r o u p (n =40,re c e i v i n g pe r s o n a l i z e d n u t r i t i o n i n t e r v e n t i o n ).T h e i n c i -d e n c e of a d v e r s e r e a c t i o n s ,n u t r i t i o n a l s t a t u s s c o r e a n dg a s t r o i n t e s t i n a l q u a l i t y o f l i f e i n d e x s c o r e w e r e c o m pa r e db e -t w e e n t h e t w o g r o u p s .R e s u l t s :T h e t o t a l i nc ide n c e of a d v e r s e r e a c t i o n s i n t h e s t u d yg r o u p (7.50%,3/40)w a s l o w e r t h a n t h a t i n t h e c o n t r o l g r o u p (25.00%,10/40),t h e d i f f e r e n c e w a s s t a t i s t i c a l l y s i gn i f i c a n t (χ2=4.501,P =0.034).A f t e r i n t e r v e n t i o n ,P A ,A L B a n d T P i n t h e s t u d y g r o u p w e r e h i g h e r t h a n t h o s e i n t h e c o n t r o l g r o u p (P <0.05).G I Q L I s c o r e s i n t h e s t u d y g r o u p w e r e h i g h e r t h a n t h o s e i n t h e c o n t r o l g r o u p (P <0.05)a f t e r 1a n d 2w e e k s o f i n t e r v e n t i o n .C o n c l u s i o n :P a t i e n t s w i t h c o l o r e c t a l c a n c e r a r e p r o n e t o m a l n u t r i t i o n a f t e r s u r g e r y,a n d n u t r i t i o n a l i n t e r v e n t i o n i s n e e d e d .T h e i m p l e m e n t a t i o n o f p e r s o n a l i z e d n u t r i t i o n a l i n t e r v e n t i o n c a n i m pr o v e t h e n u t r i t i o n a l s t a -t u s o f p a t i e n t s ,e n s u r e t h e s a f e t y o f p a t i e n t s ,a n d i m p r o v e t h e q u a l i t y o f d a i l y l i f e o f p a t i e n t s ,w i t h s i g n i f i c a n t e f f e c t s .ʌK e y wo r d s ɔP e r s o n a l i z e d n u t r i t i o n i n t e r v e n t i o n ;C o l o r e c t a l c a n c e r ;P e r i o p e r a t i v e p e r i o d ;Q u a l i t y o f l i f e 中图分类号:R 322.4+5 文献标识码:A D O I :10.11967/2023211258结直肠癌是临床常见疾病,发病率㊁死亡率较高;临床治疗以手术切除根治术为主,且临床效果较佳,但患者术后易伴随免疫力下降㊁营养供应不足等情况,这对患者康复产生不良影响,且明显降低了患者生活质量,严重威胁患者生命安全;故于术后给予患者针对性个性化营养干预尤为重要[1-4]㊂本研究以我院选取80例结直肠癌患者为研究对象,应用个性化营养干预法探究其具体效果㊂1 资料与方法1.1 一般资料 选择中山市小榄人民医院2021年1月至2023年6月80例接受手术治疗的结直肠癌患者为研究对象㊂采用随机法将患者分为40例的研究组(n =40)和40例对照组(n =40)㊂研究组男26例㊁女14例;年龄48~88岁,平均(65.56ʃ5.45)岁;低分化16例㊁中分化14例㊁高生命科学仪器 2023年第21卷/第6期生命科学-医药卫生235分化10例㊂对照组男25例㊁女15例;年龄50~86岁,平均(65.99ʃ5.19)岁;低分化17例㊁中分化15例㊁高分化8例㊂两组患者一般资料比较,差异无统计学意义(P >0.05),表明两组患者的资料差异可忽略不计,研究成立㊂纳入标准:(1)患者入院后病理检查和影像学检查结果符合结直肠癌诊断指标[5-7];(2)患者体征稳定,可接受手术治疗;(3)患者能够配合试验,具有相关能力,而且主观表示同意㊂排除标准:(1)患者肿瘤已经发生转移,同时伴随多处病灶;(2)患者意识不清楚,无法保证理解能力;(3)患者合并脏器(肝脏㊁肾脏等)损伤问题㊂1.2 研究方法1.2.1 对照组接受常规营养干预,术后对患者情况进行观察,严格记录各项营养指标,同时结合实际为患者输注合适剂量的混合营养液(葡萄糖㊁氨基酸)㊂1.2.2 研究组给予个性化营养干预㊂术前风险评估:于患者术后对患者进行监测,针对临床营养不良发生率较高的因素,应用风险筛查评估量表对患者展开风险评估㊂并根据风险情况为患者制定个性化的营养干预方案,计算患者每日所需要的营养和热量,以便于日后严格按照标准给予患者营养治疗㊂可以口服的患者进行日常饮食,无法口服的患者采用肠内营养方式㊂术前健康宣教:给予患者饮食宣教,制作资料卡片或发放饮食指导手册,为患者讲解饮食对自身恢复的积极意义㊂通常此过程患者会提出多种疑问,可以引导和允许患者提问,给予详细解答,提高患者对饮食问题的重视㊂术前营养液配置:营养液需要满足患者日常中对水㊁钾离子㊁钠离子㊁钙离子㊁脂肪㊁糖类等成分的需求,严格根据患者体征进行营养成分占比配置,通常情况下,其对应的剂量分别为30m l ㊁0.7~0.9g ㊁1~1.4g㊁0.11g ㊁2g ㊁2g ㊂术后营养液输注:每日辅助给予患者营养液输注,需要结合患者情况展开,一般情况下,需要对其能量供给量进行设定,控制在10~12.5k J/(k g/d ),其中所对应的主要成分分别为氮量(0.15~0.2)g /(k g/d )和非蛋白热量(120~150)㊂术后饮食原则:术后早期需要给予患者肠内营养干预,逐渐恢复经口饮食㊂此过程中需要严格遵循饮食原则,结合患者的具体情况为其制定饮食计划,以米汤等流质饮食为主,随后逐渐过渡到米粥类半流质食物㊂为了满足患者营养所需,可以将鸡肉㊁蔬菜㊁水果等打成汁状或是糊状,补充患者营养成分㊂在营养干预过程中,还需要叮嘱患者多饮水,并遵循少食多餐原则,保证患者康复㊂1.3 观察指标 观察患者的不良反应,包括电解质紊乱㊁切口感染㊁切口愈合不良㊁吻合口瘘㊂干预前㊁干预后评价患者营养状况改善情况,采集患者5m l 空腹静脉血,离心(3500r /m i n ),10m i n 后取上清液进行生化检验,主要指标包括血清前白蛋白(P r e a l b u m i n ,P A )㊁白蛋白(A l b u -m i n ,A L B )和总蛋白(T o t a l pr o t e i n ,T P )[8-9]㊂干预前㊁干预1周和干预2周采用胃肠道生活质量指数量表(G a s t r o i n t e s t i n a l q a l i l y of l i f e i n -d e x ,G I Q L I)[10]评估患者生活质量㊂此量表涉及36个条目,评价采用5级评分法,计算分数最高为144分,测量分数越高,表明患者的生活质量越好㊂1.4 统计学方法 使用统计学软件S P S S 20.0进行数据处理㊂计量资料以(x ʃs)表示,组间比较采用t 检验,计数资料以例(%)表示,组间比较采用χ2检验,以P <0.05为差异有统计学意义㊂2 结果2.1 2组不良反应发生情况比较 研究组不良反应总发生率(7.50%,3/40)低于对照组(25.00%,10/40),差异有统计学意义(χ2=4.501,P=0.034)㊂见表1㊂2.2 2组营养状况比较 干预前,2组P A ㊁A L B和T P 比较,差异无统计学意义(P>0.05);干预后,研究组P A ㊁A L B 和T P 高于对照组,差异有统计学意义(P <0.05)㊂见表2㊂表1 2组不良反应发生情况比较[例(%)]组别例数电解质紊乱切口感染切口愈合不良吻合口瘘总发生率研究组401(2.50)1(2.50)0(0.00)1(2.50)3(7.50)对照组403(7.50)2(5.00)3(7.50)2(5.00)10(25.00)2.3 2组G I Q L I 评分比较 干预前两组患者G I Q L I 评分比较,差异无统计学意义(P>0.05);研究组患者干预1周和干预2周G I Q L I 评分高于对照组,差异有统计学意义(P <0.05)㊂见表3㊂3 讨论结直肠癌已经成为全球范围内对人体健康造成严重威胁的疾病种类㊂结直肠癌治疗难度系数大,且患者的术后恢复较慢,容易出现营养不良㊂生命科学-医药卫生生命科学仪器 2023年第21卷/第6期236因此,术后加强对患者的营养管理,及时补充营养液,并指导患者正确饮食对保证治疗成功尤为重要[11-13]㊂表2 2组患者营养状况比较(x ʃs)组别例数P A (m g/L )A L B (g/L )T P (g/L )干预前干预后干预前干预后干预前干预后研究组40181.66ʃ18.77284.45ʃ22.7737.66ʃ1.8840.45ʃ2.3366.55ʃ3.1262.34ʃ1.66对照组40181.23ʃ18.56245.45ʃ22.7737.67ʃ1.8732.23ʃ2.4466.44ʃ3.1153.23ʃ1.55t 0.1037.6600.02415.4090.15825.369P0.918<0.0010.981<0.0010.875<0.001注:P A 血清前白蛋白,A L B 白蛋白,T P 总蛋白表3 2组患者G I Q L I 评分比较(x ʃs)组别例数干预前干预1周干预2周研究组4082.23ʃ6.55102.23ʃ7.66105.45ʃ5.45对照组4082.33ʃ6.18112.34ʃ8.78116.78ʃ5.34t 0.0705.4889.391P0.944<0.001<0.001 个性化营养干预主要是从患者实际情况出发,结合患者具体患病情况及症状,为患者合理规划饮食,每日补充定量的维生素㊁脂肪㊁水等人体必需成分,促进机体恢复,为患者的康复提供基础㊂实施个性化营养干预后,患者可了解和掌握饮食的重要原则,保证健康饮食㊁促进机体恢复,临床应用价值较高[14-15]㊂本研究实施个性化营养干预,结果显示:两组患者均出现了不良反应,且研究组不良反应总发生率低于对照组(P<0.05);干预后,研究组患者的P A ㊁T P 和A L B 高于对照组(P<0.05)㊂研究组患者在干预1周和干预2周的评分显著高于对照组(P <0.05)㊂这结果表明在结直肠癌患者中实施个性化营养干预,更有利于保证患者的营养指标得到恢复,为患者及时补充所需营养,减少不良情况的发生,提高患者体质,意义显著㊂邱权威等[16]研究以结直肠癌患者为研究对象给予营养干预㊂结果显示试验组患者术后的P A ㊁T P 和A L B 均高于对照组(P<0.05)㊂且试验组患者术后1d ㊁术后1周㊁术后2周G I Q L I 评分分别为(100.26ʃ8.12)分㊁(112.46ʃ8.45)分和(116.26ʃ5.12)分,均高于对照组(P<0.05)㊂本研究结果与之一致,均证明了在结直肠癌患者术后实施个性化营养干预可促进患者恢复,提高患者生活质量㊂综上所述,在结直肠癌患者术后展开营养干预尤为重要,此过程中配合实施个性化营养实施,可更好的满足患者营养所需,提高患者生活质量,将并发症发生率进行有效控制,意义价值较高,可推广宣传㊂参考文献[1]中国抗癌协会肿瘤营养专业委员会,中华医学会肠外肠内营养学分会.结直肠癌患者的营养治疗专家共识[J ].肿瘤代谢与营养电子杂志,2022,9(6):735-740.[2]吴少彬,李艳芳,万婷,等.术前营养风险筛查对结直肠癌根治患者术后康复的影响及并发症发生的危险因素分析[J ].现代医学与健康研究电子杂志,2023,7(1):46-50.[3]霍耀亮,黄河,郭云童,等.全营养配方F S M P 在结直肠癌患者术后早期应用的随机对照研究[J ].肿瘤代谢与营养电子杂志,2023,10(4):530-536.[4]赵中海,刘秀,任丽,等.老年结直肠癌术后应用口服营养支持对患者营养状态及生活质量的影响[J ].中国临床医生杂志,2023,51(7):824-826.[5]刘浩燕,徐飞.术后规范化营养干预在老年结直肠癌患者中的应用效果[J ].医学临床研究,2023,40(10):1463-1470.[6]户艳丽,王月,袁翠玲.基于营养风险筛查下的营养支持对老年结直肠癌术后患者营养状态的影响[J ].中国疗养医学,2021,30(5):494-496.[7]容洁,钟倩,李玥镝,等.运动联合营养干预对结直肠癌患者术后恢复的影响[J ].当代临床医刊,2023,36(2):3-4.[8]刘晓微,王茜茜,郑文钦.早期肠内营养联合优化护理对结直肠肿瘤切除术后营养状态及康复的影响[J ].中外医学研究,2019,17(21):166-168.[9]李明晖,武雪亮,王立坤,等.某院结直肠肿瘤患者围术期营养风险筛查与营养支持的现状分析[J ].重庆医学,2020,49(12):1919-1922.[10]陈育珊.参与式培训模式对直肠癌术后心理状况及生存质量的影响[J ].中国医学创新,2017,14(7):4.D O I :10.3969/j.i s s n .1674-4985.2017.07.027.[11]谢大伟.术前营养风险评估的老年结直肠癌患者接受营养支持对术后肠功能恢复情况及相关营养指标的影响[J ].中国医学创新,2023,20(11):141-145.[12]宋丽,叶家慧.营养状态对结直肠癌患者术后手术部位感染的影响[J ].中国肛肠病杂志,2023,43(2):44-46.[13]吴惠芳,廖柳荫,卢琳媚.结直肠癌病人术前营养风险与术后并发症的相关性[J ].护理研究,2023,37(15):2826-2830.[14]赵阳昱,朱忠华.药物治疗管理在结直肠肿瘤病人围手术期营养支持治疗中的实践[J ].安徽医药,2023,27(9):1881-1885.[15]李朋,尹磊.老年结直肠癌行回肠造口术患者术前和术后营养评估[J ].浙江临床医学,2023,025(005):718-720.[16]邱权威,杨一群,刘全丽,等.腹腔镜结直肠癌根治术后口服肠内营养对术后康复作用的临床研究[J ].包头医学院学报,2023,39(9):40-43+63.。
PYMS小儿约克希尔营养不良评分信息和用户指南说明书
PYMS Paediatric Yorkhill Malnutrition ScoreInformation and User’s Guide2009© Nutrition Tool Steering Group, Women and Children’s Directorate, NHS Greater Glasgow and Clyde, 2009.The content of this booklet is provided for general information only and should not be relied upon. Whilst we use all reasonable efforts to ensure that the information contained in the booklet is current, accurate and complete at the date of publication, no representations or warranties are made (express or implied) as to the reliability, accuracy or completeness of such information. Greater Glasgow Health Board cannot therefore be held liable for any loss arising directly or indirectly from the use of, or any action taken in reliance on, any information appearing in the booklet.The information in this booklet is designed to comply with the laws and regulations of the United Kingdom. Although accessible by users from other countries, it and its content is intended for access and use by residents of the United Kingdom only. Disclaimer:- ALL RIGHTS RESERVED. No part of this publication may be copied, modified, reproduced, stored in a retrieval system or transmitted in any material form or by any means (whether electronic, mechanical, photocopying, recording or otherwise and whether or not incidentally to some other use of this publication) without the prior written permission of the copyright owner except in accordance with the provisions of the Copyright, Designs and Patents Act 1988.ContentsPage Introduction (3)Development of the Paediatric Yorkhill Malnutrition Score (PYMS) (5)Validation of the Paediatric Yorkhill Malnutrition Score (PYMS) (5)PYMS User’s Guide (6)The PYMS Form Explained (13)PYMS Form (15)Nurse’s Quick Reference Guide (17)Quick Guides for Measuring Heights/Lengths and Weights (19)References (23)“Freedom from…malnutrition is a basic human right”(World Health Organisation, 20081).IntroductionThe Paediatric Yorkhill Malnutrition Score (PYMS) has been developed to assist nursing staff and other health professionals identify hospitalised children, between the ages of 1-16 years, who are at risk of malnutrition and offer them appropriate care. The following explanatory notes offer an overview of malnutrition and provide information on the development and use of PYMS.MalnutritionIdentification of children at risk of malnutrition is essential in treating disease-related malnutrition and optimising the health of all hospitalised patients. Malnutrition is: “the state of nutrition in which a deficiency or excess (or imbalance) of energy, protein, and other nutrients causes measurable adverse effects on tissue/body function and clinical outcome”2. The term malnutrition refers to both over-nutrition and under-nutrition but, for the purposes of this document it only refers to energy/protein under-nutrition.Malnutrition continues to be a significant health issue in developed countries, with an estimated cost in the UK of approximately £13 billion3. Despite this malnutrition continues to be largely unrecognised and under treated4. It has been estimated that up to 30%5-10 of hospitalised patients are at risk of malnutrition and this figure can be as high as 60% in some paediatric patient groups11,12.Why is Malnutrition Important?Malnutrition is undesirable, not only because it leads to weight loss, but also because it is a recognised risk factor for the development of complications of disease. These include increased morbidity and mortality, longer duration of hospitalisation and increased health care costs13. In children, there are additional concerns as malnutrition can potentially lead to long-term effects on brain development, linear growth and bone health that impact on health later in life14.Failure to consider nutritional status may also have medico-legal consequences, with an increasing number of cases of nutritional neglect being pursued within the judicial system15.In the general population approximately 2.5% of children have a body weight which is below the reference range for their age and gender. However, a much larger proportion (16%) of children attending hospital are underweight and malnutrition remains largely undiagnosed and untreated amongst hospitalised children9-10. This is mainly due to a lack of nutritional training and awareness amongst staff and can also be attributed to a lack of established protocols for screening, assessment and action15.Introduction to Nutritional ScreeningFood and water are essential elements of care and failure to detect malnutrition or the risk of becoming malnourished has the potential to cause patients considerable harm. The Nursing and Midwifery Council (NMC) Code of Conduct requires all nursing staff to ‘protect and promote the health and well being of those their care’16. This responsibility is detailed in NHS Quality Improvement Scotland Guidelines (2003) which state that because high quality nutritional care is crucial for the well being of patients, all patients should be screened using a validated tool that is appropriate to the patient population17. Such screening should be carried out on admission and regularly during a patient’s hospital stay. Nutritional screening provides a means of ensuring that patients, who following screening appear to be at high risk, will be assessed by dietetic staff and managed appropriately.Screening tools validated in adult patients18-19 areinappropriate for use in children, as malnutrition presentsdifferently within the paediatric population. Thus far,nutritional screening in paediatrics has been hindered due toa lack of a valid generic paediatric screening tool15.Development of the Paediatric Yorkhill Malnutrition Score (PYMS)A multidisciplinary healthcare team from the Royal Hospital for Sick Children, Glasgow and Royal Alexandra Hospital, Paisley, both part of the Women and Children’s Directorate NHS Greater Glasgow and Clyde, was assigned to develop a local paediatric malnutrition screening tool. The project team consisted of senior nursing, dietetic, research, academic and medical staff.The primary purpose of the project team was to develop and validate a tool that would be simple, quick to use, user and patient friendly and would detect the majority of children at risk of malnutrition. The tool would be used by nursing staff to screen patients on admission and at intervals during their hospital stay. The tool was developed for use in children aged 1-16 years. A separate tool was considered necessary to assess neonates and infants under the age of 1 year, due to their rapid growth during the first year of life and complex issues surrounding prematurity.A preliminary malnutrition screening tool was developed based on the guidelines for nutritional screening from the European Society of Clinical Nutrition and Metabolism15. The PYMS was designed to incorporate questions/measurements to address the following four principles:1. The current nutritional status2. The stability of nutritional status3. The recent changes to nutritional status4. The likelihood of the acute disease condition to affect the nutritional statusadversely.Validation of the Paediatric Yorkhill Malnutrition Score (PYMS)Following the development of the tool a 4 month validation study was undertaken, within 4 paediatric wards (3 medical, 1 surgical) of a tertiary paediatric hospital and the general paediatric ward of a district general hospital. The diagnostic accuracy and performance of PYMS was evaluated through a four stage validation study, the results of which have been presented20-22 and are expected to be published in due course.PYMS User’s GuideDescription of the PYMS FormThe PYMS form is presented as a simple structured questionnaire, consisting of four questions (steps) which are strong predictors/symptoms of malnutrition. Each of these steps bears a score from 0 to 2 and an overall nutritional risk score (step 5) is calculated based on the sum of the results of steps 1-4. An action plan follows according to the overall nutrition score. The four steps are outlined below:Step 1: Body Mass Index (BMI)•BMI is a useful measure of nutritional risk and is based on height and weight.•Height and weight should be obtained according to local hospital guidelines.•Weight must be repeated each time PYMS is carried out and it is recommended that for long term admissions, height/length should be recorded monthly for infants and three-monthly for older children.(N.B. please follow local hospital policy).Instructions outlining the correct procedure for obtaining weights and heights/lengths are included in this information & users guide (page 21-24) (N.B. please follow local hospital guidelines). Once measurements have been correctly obtained, they should be recorded in the appropriate boxes on the PYMS form. After that, the Body Mass Index (BMI) for the patient can be calculated using a BMI calculation wheel.The BMI calculation wheel consists of two wheels (see figure 1).To use:•Locate the weight (kilograms) of the patient on the outer wheel and the height/length (centimetres) of the patient on the inner wheel.•Rotate the inner wheel until child’s weight and height are aligned.•The BMI value is displayed in the window by the red arrow, record the value obtained in the appropriate box on the PYMS form.Figure 1: BMI Calculation Wheel(Produced with permission from Blundell Harling Ltd.)Normal BMI values vary according to age and gender and therefore a scoring guide located on the back of the PYMS form, gives the minimum acceptable BMI values. The age of the child should not be rounded up when referring to this scoring guide. A BMI below the minimum acceptable value indicates a possible risk factor for malnutrition. The following scoring should be used for step 1:i. Score 0 if BMI value is greater than that shown for age and gender according to the scoring guide.ii. Score 2 if BMI value is below that shown for the age and gender according to the scoring guide.NB : If it is NOT POSSIBLE TO OBTAIN A HEIGHT, a member of medical staff should be asked to plot the patient’s weight on a growth chart. If the weight is below the 2nd centile, a SCORE of 2 should be entered for step 1.The reason why a height could not be obtained should be documented in the comments table on the back of the form.STEP 2: Recent Weight LossUnintentional weight loss may indicate that a child is at nutritional risk. Ask parents/guardians if they have noticed any recent weight loss, or compare current weight with previously documented weights. These should be recorded in the patient’s notes or parent hand held record.If the child is under 2 years of age, parents/guardians should be asked if they have any concerns about the child’s weight gain recently. Failure to gain weight may also be an indication of nutritional risk in very young children (<2 years).i. Score 0 if:a. Weight is increasingb. Weight is static and child is more than 2 years oldc. Weight loss is intentional as the child has been or is overweight andis on a calorie restricted diet.ii. Score 1 if:a. Unintentional weight loss noticed by the child/carers or has beenidentified after comparing with previously documented weightsb. Weight static in a child less than 2 years oldc. Clothes have become more ill fitting due to noted weight lossd. Intentional weight loss because of eating disorderse.g. if the childsuffers from anorexia nervosa.STEP 3: Assess Recent Change in Diet/Nutritional Support (for at least the last week)A decreased nutritional intake may increase the risk of developing malnutrition. Ask carers/child about food intake for at least the last week. If the child is usually on any artificial feeds (enteral feeds, dietary supplements or parenteral nutrition) then ask whether there has been any change in the amount taken and/or tolerated.i. Score 0 if:a. There has been no change to normal diet or enteralnutrition, dietary supplements or parenteral nutritionii. Score 1 if:a. There has been a decrease in usual dietary intake, enteralfeeds, dietary supplements or parenteral nutrition for a minimum of thelast 7 days (unless health professional instructed decrease to restrictcalorie intake).iii. Score 2 if:a. There has been no or minimal intake over the last week, includingintake from oral feeds, enteral nutrition, dietary supplements orparenteral nutrition.N.B. If there is very minimal intake (only a few sips of feed per day) this should be counted as no intake (score 2).STEP 4: Acute Admission/Condition Effect on Nutrition (at least the next week) Some patients may be at risk of becoming undernourished during their hospital admission or soon after their discharge, because of the effect of the medical condition on their nutritional status. This may be due to decreased intake, increased gut losses and increased energy requirements.i. Score 0 if:a. The patient’s nutritional status is unlikely to be unchanged duringthis admission or soon after their discharge.ii. Score 1 if at least one or more of the following is expected over at least the next week:a. Decreased intake from oral, enteral or parenteral nutrition(e.g. orofacial disease or trauma, severe nausea)b. Increased gut losses (e.g. significant ongoing diarrhoea or vomiting,large stoma losses)c. Increased energy requirements (e.g. major trauma, burns, sepsis,pyrexia).iii. Score 2 if for the next week:a. No or minimal intake is expected from oral, enteral orparenteral nutrition (e.g. major abdominal surgery).N.B. If there is very minimal intake (only a few sips of feed per day) this should be counted as no intake (score 2).STEP 5: Total Nutrition Risk Score and Action PlanOnce all the above scores have been entered onto the PYMS form add them together to provide a total score (step 5). A total score of 2 or more reflects significant nutritional risk.i. If the score is 2 or more, a request for dietetic review should bemade according to the established hospital request system andthe medical/surgical team should also be informed. PYMSshould be repeated weekly.ii. If the score is 1, then the child should be observed for any further deterioration of intake. The quantity and type of food andfluid consumed should be recorded. PYMS should be repeatedin 3 days and medical staff informed.iii. If the score is 0, then no further action is required at this time but PYMS should be repeated weekly.N.B.If there are clinical concerns about a patient’s nutritional status, a dietetic review MUST be requested and medical staff informed even if the child has scored less than 2.Local policies and clinical judgement are not replaced by this scoring system and children should be managed following local guidelines for nutrition management. This should include plotting of height and weight on a growth chart and any additional nutritional concerns discussed with the medical/surgical team and a request made to dietetics if deemed necessary (e.g. food allergies, special diets etc).PYMS is designed to detect children at risk of energy/protein under-nutrition (malnutrition) only, and will therefore not detect children with vitamin and/or mineral deficiencies. It is not designed to detect children at risk of over-nutrition (obesity).The PYMS Form ExplainedLocal hospital policy may require that 2 peoplecheck weight and height measurementsObtain each time PYMS is calculatedRecord calculated BMI here- obtain using BMI wheel.Age required to calculate BMI and compare against cut off valueMeasure length/ height monthly in infants and 3 monthly in older childrene.g; • Major trauma• Major burns • Sepsis • Pyrexiae.g;• Persistent diarrhoea • Persistent vomitinge.g;• orofacial disease/ trauma • severe nauseaUnless a health professional hasinstructed reduction in calorie intake.Use BMIscoring guide overleafStanding Height MeasurementFeet straight together with soles touching the boardBare feet, legs togetherHeels, calves, buttocks, shoulder, head touching theback plateReference List1. World Health Organisation (WHO) (2008) Nutrition for health and development. [online] http://www.who.int/nutrition/nhd/en/index.html Accessed 28th April 2008.2. Elia M, Ljungqvist O and Dowsett J (2005) Principal of Clinical Nutrition: Contrasting the Practice of Nutrition in Health and Disease. Oxford, Blackwell Science Ltd.3. Bapen (2009) Combating Malnutrition Recommendations for Action. Executive summary. Redditch, British Association of Parenteral and Enteral Nutrition (BAPEN) [online] /pdfs/reports/advisory_group_report.pdf Accessed 15th July 2009.4. McWhirter JP and Pennington CR (1994) Incidence and recognition of malnutrition in hospital. British Medical Journal 308 945-948.5. Hendricks KM, Duggan C, Gallacher L, Carlin AC, Richardson DS, Collier SB, Simpson W and Lo C (1995) Malnutrition in hospitalized paediatric patients: current prevalence. Archives of Pediatrics and Adolescent Medicine 149 (10) 1118-1122.6. Joosten KFM, Zwart H, Hop WC and Hulst JM (2009) National malnutrition screening days in hospitalized children in the Netherlands. Archives of Diseases in Childhood[published online 3 May 2009] doi:10.1136/adc.2008.157255.7. Edington J, Boorman J, Durrant ER, Perkins A, Giffin CV, James R, Thomson JM, Oldroyd JC, Smith JC, Torrance AD, Blackshaw V, Green S, Hill CJ, Berry C, McKenzie C, Vicca N, Ward JE and Coles SJ (2000) Prevalence of malnutrition on admission to four hospitals in England. The Malnutrition Prevalence Group. Clinical Nutrition 19 191-195.8. Moy RJD, Smallman S and Booth IW (1990) Malnutrition in a UK children’s hospital. Journal of Human Nutrition and Dietetics 9 93-100.9. Pawelleck I, Dokoupil K and Koletzko B. (2008) Prevalence of malnutrition in paediatric hospital patients. Clinical Nutrition 27 72-76.10. Hendriske WH, Reilly JJ and Weaver LT (1997) Malnutrition in a children’s hospital. Clinical Nutrition 16 13-18.11. Cameron JW, Rosenthal A and Olson AD (1995) Malnutrition in hospitalised children with congenital heart disease. Archives of Pediatrics and Adolescent Medicine 149 (10) 1098-1102.12. De Staebel O (2000) Malnutrition in Belgian children with congenital heart disease on admission to hospital. Journal of Clinical Nursing 9 (5) 784-791.13. Correia MI and Waitzberg DL. (2003) The impact of malnutrition on morbidity, mortality, length of hospital stay and costs evaluated through a multivariate model analysis. Clinical Nutrition 22 235-9.14. Lucas A, Morley R and Cole TJ (1998) Randomised trial of early diet in preterm babies and later intelligence quotient. British Medical Journal 317 1481-1487.15. Kondrupt J, Allison SP, Elia M, Vellas B and Plauth M. (2003) ESPEN Guidelines for Nutrition Screening 2002. Clinical Nutrition 22 415-421.16. Nursing and Midwifery Council (NMC) (2008) The Code. Standards of Conduct, Performance and Ethics for Nurses and Midwives. London, Nursing and Midwifery Council.17. NHS Quality Improvement Scotland (QIS) (2003) Food, fluid and nutritional care in hospitals. Edinburgh, NHS QIS.18. Gerasimidis K, Drongitis P, Murray, L, Young D and McKee R (2007) A local nutritional screening tool compared to malnutrition universal screening tool. European Journal of Clinical Nutrition 61 916-921.19. Green SM and Watson R (2005) Nutritional screening and assessment tools for use by nurses: literature review. Journal of Advanced Nursing 50 (1) 69-83.20. Gerasimidis K, Macleod I, McGrogan P, Maclean A, Buchanan E, McAuley M, Stewart G, Wright C and Flynn D (2009) Development and Performance of a New Paediatric Nutritional Screening Tool in a Tertiary and District General Hospital. The PYMS Project. British Society of Paediatric Gastroenterology, Hepatology and Nutrition (BSPGHAN) winter meeting (Sheffield), oral presentation.21. Gerasimidis K, Keane O, Macleod I, Buchanan E, Maclean A, McGrogan P, Stewart G, McAuley M, Flynn D and Wright C (2009) Criterion validity and inter-rater reliability of the Paediatric Yorkhill Malnutrition Score. European Society of Paediatic Gastroenterology, Hepatology and Nutrition (ESPGHAN) annual meeting (Budapest), oral presentation, abstract in press.22. Macleod I, Gerasimidis K, Purcell O, Mohammed T, Swinbank I, Wright C, FlynnD and McAuley M (2009) Implementing a novel paediatric nutritional screening tool (Paediatirc Yorkhill Malnutrition Score) in nursing practice.Challenges and impact in paediatric nursing practice. European Society of Paediatic Gastroenterology, Hepatology and Nutrition (ESPGHAN) annual meeting (Budapest), poster presentation, abstract in press.NotesProduced by The Nutrition Tool Steering Group,Women and Children’s Directorate,NHS Greater Glasgow and Clyde.Medical Illustration, Job No. 20584727。
一例胃癌术后化疗患者的营养护理体会
一例胃癌术后化疗患者的营养护理体会发布时间：2022-12-06T06:57:35.662Z 来源：《护理前沿》2022年23期作者：李莉[导读] 目的:总结分析1例胃癌术后化疗患者的营养护理体会。
方法：对我院2022.01.20收治1例胃癌术后化疗患者的临床资料进行回顾性分析总结，对其机体营养状况进行评估筛查，并针对性的给予营养护理，最后总结分析该患者的营养护理体会，以为临床胃癌术后化疗患者的营养护理提供些许实际参考意义。
李莉江西省肿瘤医院消内二病区 330000【摘要】目的:总结分析1例胃癌术后化疗患者的营养护理体会。
方法：对我院2022.01.20收治1例胃癌术后化疗患者的临床资料进行回顾性分析总结，对其机体营养状况进行评估筛查，并针对性的给予营养护理，最后总结分析该患者的营养护理体会，以为临床胃癌术后化疗患者的营养护理提供些许实际参考意义。
【关键词】胃癌；术后化疗；营养护理；护理体会胃癌即病变于胃黏膜上皮的恶性肿瘤，属于临床消化系统最为常见的恶性肿瘤之一，患病率与病亡率均较高，其病亡率目前居于消化道肿瘤的首位[1]。
目前针对胃癌的治疗主要以手术结合化疗为主，可有效的延长患者生命周期。
但是由于疾病原因、胃部组织的切除，加之化疗引发的一系列不良反应等，会影响患者的正常进食，继而导致其机体容易出现营养不良状况[2,3]。
相关研究表明，胃癌为一种消耗性疾病，胃癌患者营养不良的占比高达60%-85%，患者一旦出现营养不良，可直接影响患者的后续的化疗以及预后生存质量[4]。
因此，对于胃癌术后化疗患者需要营养科学合理的营养护理支持，以改善患者胃肠道功能，促进其营养吸收，继而达到改善预后的目的[5]。
故该次个案以2022.01.20收治1例胃癌术后化疗患者为研究对象，就对患者进行营养评估后为其制定针对性的营养护理支持，现将营养护理的具体体会整理如下。
具体情况报告如下：1、病例摘要患者姓名常**，女，31岁。
2014住院患儿营养风险筛查和营养评估
营养评估-人体学测量
• 生长发育参考标准
– WHO生长参考标准 – CDC2000生长曲线 – 中国2005年九城市体格发育参考值 – IOTF建立的肥胖标准 – WGOC推荐的中国青少年超重肥胖筛查
前白蛋白
运铁蛋白
8-10天
铁的携带蛋白
怀孕、肝炎、 铁缺乏、脱水 、慢性出血
视黄醇结 合蛋白
在蛋白质营养不良 时反应急性变化， 正常值为2.77.6mg/dl
12小时
运输视黄醇
肾衰竭、怀孕
营养评估-实验室检验
• 氮平衡
– =摄入氮-(尿素氮+4) – 评估蛋白质营养状况
• 免疫功能
– 淋巴细胞总数 – 皮肤抗原试验
Screening Tool for the Assessment of Malnutrition in Paedetrics (STAMP)
• 评估内容
– 临床诊断 – 营养摄入 – 人体测量
• 得分
– 0-1分 低营养风险 – 2-3分 中营养风险 – ≥4分 高营养风险
• 无终点结果参数
McCarthy H, et al. J Hum Nutr Diet 2008;21:395-6
营养评估-人体学测量
J Acad Nutr Diet. 2014;114:1988-2000
营养评估-实验室检验
血清蛋白 白蛋白 临床意义 轻度28-35g/l 中度21-27g/l 重度<21g/l 轻度10-15mg/dl 中度5-10mg/dl 重度<5mg/dl 轻度150-200mg/dl 中度100-150mg/dl 重度<100mg/dl 半衰期 功能 浓度增加因素 浓度降低因素 肝肾病、感染、 术后水肿、过度 水化、吸收不良 疾病急性期、手 术后、能量/氮 平衡改变、肝病 感染、透析 慢性感染、急性 期、肾病症候群 、铁贮存增加、 肝损伤、过度水 化、营养不良 维生素A缺乏、 急性期、手术后 、肝病 14-20天 携带蛋白质、维 脱水 持血浆胶体渗透 压 2-3天 视黄醇结合蛋白 慢性肾衰竭 的携带蛋白
CONUT评分与急性心肌梗死患者死亡的相关性研究
CONUT评分与急性心肌梗死患者死亡的相关性研究杨珍珍;赵晶;彭瑜;马慧;马春香;张钲【摘要】目的:应用CONUT评分评估急性心肌梗死患者入院时的营养状态,分析营养状态与死亡事件的相关性.方法:本试验为单中心回顾性队列研究,研究对象为急性心肌梗死并完成了经皮冠状动脉介入治疗(PCI)的患者,终点事件为全因死亡,随访时间中位数为36(33,36)个月.根据CONUT评分的营养状态分为3组:正常组(CONUT=0~1, n=304例),轻度营养不良组(CONUT=2~4,n=476例)与中重度营养不良组(CONUT=5~12,n=58例).比较三组患者死亡事件的差异.结果:共入选838例急性心肌梗死行PCI术的患者,其中534例(63.7%)处于营养不良状态,死亡51例(6.1%).三组的死亡率分别为:2.6%、6.3%、22.4%,轻度营养不良组、中重度营养不良组死亡率均高于正常组(P=0.021, P<0.001).Cox比例风险回归模型分析结果表明调整了其他相关因素后,与正常组相比,轻度营养不良组(HR=3.473, 95%CI:1.507~8.003,P=0.003)和中重度营养不良组(HR=10.775,95%CI:3.958~29.334,P<0.001) 死亡风险显著增加.结论:大部分急性心肌梗死PCI术后的患者处于营养不良状态,CONUT评分的营养状态可以作为急性心肌梗死患者死亡的独立预测因子.%Objectives: To evaluate the impact of nutritional states on mortality of acute myocardial infarction (AMI) patients by the controlling nutritional (CONUT) score. Methods: We performed a monocentric retrospective cohort study among AMI patients after percutaneous coronary intervention(PCI) and the median follow-up was 36(33, 36 interquartile range) months. The endpoint was all cause of death. Information was obtained by medical records, clinical visit and telephone calls.Patients were divided into three groups:normal(CONUT=0~1,n=304),mild malnutrition (CONUT=2~4, n=476) and moderate-severe malnutrition (CONUT=5~12, n=58) groups.The differences on mortality among groups were compared by Kaplan-Meier survival analysis. Results: 51 patients out of 838 patients died during follow up, 63.7% patients were in the malnutrition state according to the CONUT score.The mortality was 2.6%, 6.3%, and 22.4% in normal, mild malnutrition and moderate-severe malnutrition groups, respectively.The mortality was significantly higher in mild and moderate-severe groups than in normal group (P=0.021, P<0.001, respectively). The Cox proportional hazard analyses revealed that the risk of all cause of death of both mild and moderate-severe groups were significantly higher than in normal group in full-adjusted model (MildHR[95%CI]:3.473[1.507-8.003] , P=0.003; moderate-severe HR[95%CI]: 10.775[3.958-29.334] , P<0.001). Conclusions: Malnutrition is a common phenomenon in AMI patients treated with PCI and relates to increased risk of all-cause mortality. CONUT score could be used to predict the risk ofall-cause mortality in AMI patients undergoing PCI.【期刊名称】《中国循环杂志》【年(卷),期】2018(033)010【总页数】6页(P978-983)【关键词】心肌梗死;经皮冠状动脉介入治疗;营养不良;CONUT评分【作者】杨珍珍;赵晶;彭瑜;马慧;马春香;张钲【作者单位】730000 甘肃省兰州市,兰州大学第一医院心血管内科甘肃省心血管疾病重点实验室;730000 甘肃省兰州市,兰州大学第一医院心血管内科甘肃省心血管疾病重点实验室;730000 甘肃省兰州市,兰州大学第一医院心血管内科甘肃省心血管疾病重点实验室;730000 甘肃省兰州市,兰州大学第一医院心血管内科甘肃省心血管疾病重点实验室;730000 甘肃省兰州市,兰州大学第一医院心血管内科甘肃省心血管疾病重点实验室;730000 甘肃省兰州市,兰州大学第一医院心血管内科甘肃省心血管疾病重点实验室【正文语种】中文【中图分类】R541心血管疾病占居民疾病死亡构成的40%以上，为我国居民的首位死因[1]。
心力衰竭患者营养评估及营养支持治疗的研究进展
㊃综述㊃心力衰竭患者营养评估及营养支持治疗的研究进展董宇娇㊀王扬懿㊀马改改710004西安交通大学第二附属医院心血管内科(董宇娇㊁马改改);310013杭州,浙江大学医学院附属浙江医院老年科(王扬懿)通信作者:马改改,电子信箱:magaigai@DOI:10.3969/j.issn.1007-5410.2023.05.019㊀㊀ʌ摘要ɔ㊀心力衰竭(心衰)是各种心脏病发展的严重和终末阶段㊂营养评估及营养支持治疗是心衰患者管理中的重要部分,然而目前尚缺乏对饮食干预和营养治疗的研究,指南对于心衰患者的营养管理也缺乏具体推荐㊂本文就心衰患者的营养评估㊁营养支持的研究现状与进展作一综述㊂ʌ关键词ɔ㊀心力衰竭;㊀营养不良;㊀营养评估;㊀营养干预Research progress of nutritional assessment and nutritional support in patients with heart failureDong Yujiao,Wang Yangyi,Ma GaigaiDepartment of Cardiology,the Second Affiliated Hospital of Xi an Jiaotong University,Xi an710004,China(Dong YJ,Ma GG);Department of Geriatrics,Affiliated Zhejiang Hospital,Zhejiang University School of Medicine,Hangzhou310013,China(Wang YY)Corresponding author:Ma Gaigai,Email:magaigai@ʌAbstractɔ㊀Heart failure(HF)is a severe and terminal stage in the development of various heart diseases.Nutritional assessment and nutritional support therapy are important parts of the management ofpatients with HF.However,there is currently a lack of research on dietary intervention and nutritional therapy,and most guidelines also lack specific recommendations for nutritional management of patients withHF.This article reviews the current research status and progress of nutritional assessment and nutritionalsupport for patients with HF.ʌKey wordsɔ㊀Heart failure;㊀Malnutrition;㊀Nutritional assessment;㊀Nutritional Intervention㊀㊀心力衰竭(简称 心衰 ),是各种心脏病发展的严重和终末阶段㊂我国有超900万心衰患者,且仍呈上升的趋势,其高死亡率㊁高住院率以及高额医疗费对家庭和社会造成沉重的负担[1-3]㊂随着指南的更迭,心衰管理越来越细化,近年来报道的心衰患者营养紊乱的高发生率及与死亡相关性,为多学科合作改善心衰预后开辟了新思路㊂本文就心衰患者的营养评估及营养支持治疗的研究现状与进展作一综述㊂1㊀心衰患者的营养评估1.1㊀心衰患者的营养状况及代谢特点慢性稳定性心衰患者中营养不良的发生率为16%~ 62%,而在重度和急性失代偿心衰患者中其发生率高达75%~90%,其中恶病质约占5%~15%[4]㊂营养状况与心衰的预后密切相关,营养不良会增加心衰患者再入院率㊁死亡风险和感染等并发症,而且会导致心功能恶化,形成 营养不良-炎症反应-恶病质 的恶性循环[5-6]㊂心衰患者营养不良发生机制有以下几个方面:心衰时,胃肠道细胞缺血缺氧及继发性胃肠道淤血,导致机体营养物质摄入不足和吸收障碍;同时,心衰时机体产生大量的炎症介质,合成代谢介质减少以及肾素-血管紧张素-醛固酮系统和交感神经系统等神经内分泌激活,导致合成-代谢分解失衡和氧化应激等,加重营养不良[7];此外,心衰患者应用洋地黄㊁利尿剂及过分限制水钠等,导致电解质紊乱㊂1.2㊀心衰患者的营养风险筛查和营养评估临床上有多种可用于心衰患者的营养风险和营养评估评定工具,包括营养风险筛查2002(nutritional risk screening 2002,NRS2002)㊁微型营养评价简表(mini-nutritional assessment-short form,MNA-SF)㊁控制营养状态评分(controlling nutritional status score,CO-NUT)㊁营养风险指数(nutritional risk index,NRI)及预后营养指数(prognostic nutritional index,PNI)等[4,8],然而目前尚无研究证实哪种评估工具对心衰患者更为准确㊂NRS2002作为一种简单㊁有效的营养评估方法,被中华医学会和欧洲肠内肠外营养学分会多个指南及共识推荐,其全面评估了患者的年龄㊁疾病严重程度及营养状况指标,有助于对存在营养不良风险的心衰患者进行早期筛查[5]㊂然而,NRS2002评分只能判断是否存在营养风险,并不能判断是否存在营养不良及严重程度,且该工具的使用者需要经过一定的培训㊂MNA-SF是2001年Rubenstein等在原有的微型营养评价法基础上进一步简化而来,此表从病史㊁体质指数(body mass index,BMI)㊁进食状况㊁合并应激或急性疾病㊁活动能力和精神疾病6个方面进行评分,主要是确定患者是否存在营养不良或风险㊂此外,CO-NUT评分作为一种客观营养状态评估工具,包括血清白蛋白㊁总胆固醇㊁血液淋巴细胞计数,涉及体内蛋白储备㊁卡路里消耗及免疫防御3个方面,可以为住院患者的营养状态评估提供依据,也可用于治疗过程中连续的营养状态监测㊂2019年,美国心力衰竭学会(Heart Failure Society of America,HFSA)推荐采用的简化营养评估问卷(simplified nutritional assessment questionnaire,SNAQ),仅包括3个问题:是否有非故意的体重减轻㊁过去1个月内是否有食欲下降㊁过去1个月内是否使用营养补充制剂,SNAQ筛查可在数分钟内完成,且无须测量任何指标,其敏感度为77%~92%,特异度为84%~93%,营养师和护士重复测量一致性为91%㊂但该评估问卷依赖与患者的交流,故不适用于交流障碍的患者[9]㊂仅通过评价某一指标来判断心衰患者的营养状况时会出现严重偏差,因此建议进行多种指标的综合评估[4]㊂2019年,HFSA发布的心衰患者营养㊁肥胖和恶病质共识建议,从病史㊁体格检查㊁人体测量数据㊁实验室检查㊁膳食评估和功能评估等多个方面对心衰患者的营养不良进行筛查和评估[9]㊂了解有无提示营养不良和炎症可能的相关病史及慢性病,如胃肠手术史㊁胃肠道症状㊁误吸史㊁糖尿病㊁整体热量摄入情况㊁体重变化和饮食偏好等;体格检查包括皮下脂肪和(或)骨骼肌的消耗,特定微量营养素缺乏的体征;人体测量数据包括BMI㊁肌肉质量和身体成分等;实验室检查包括炎症标志物(如C反应蛋白㊁中性粒细胞/淋巴细胞比值)㊁预后标志物(如白蛋白和前白蛋白)和缺铁的标志(如血红蛋白㊁铁饱和度和铁蛋白);膳食评估,可采用营养风险评估工具,如NRS2002评分㊁SNAQ筛查㊁MNA-SF评分等;功能评估包括呼吸功能㊁吞咽功能和肌力等㊂对于3~5d不能经口进食或无法达到推荐目标量60%以上,6个月内体重丢失超过10%或3个月内体重下降ȡ5%,BMI<20kg/m2,已确定存在营养不良指征或表现,建议采用营养干预㊂选择有效的方法筛查和评估营养不良对指导心衰临床早期干预具有重要意义,心衰患者应使用统一的营养不良筛查量表(或组合工具),然而目前尚无公认的适用于心衰患者的营养风险筛查与营养评估工具㊂识别为营养不良(或其高危人群)㊁恶病质或肥胖者,应接受专业营养师的评估和咨询㊂1.3㊀心衰患者的肥胖和恶病质随着BMI增加,心衰风险增加,但心衰发生后,BMI较高患者的预后较好,即心衰领域的 肥胖悖论 ,其可能机制包括混杂因素㊁偏倚㊁定义肥胖的指标不合理㊁营养状态和交感神经活性等[10]㊂有关心衰患者的体重管理,国内外指南尚无明确推荐意见㊂美国心脏病学学会/美国心脏协会指南强调,目前尚无大规模试验能够证实减重对肥胖心衰患者的价值;欧洲心脏病学会指南则不推荐中等程度肥胖(BMI< 35kg/m2)的心衰患者减重,仅推荐更严重肥胖的心衰患者适度减重以改善症状及运动耐力㊂尽管存在 肥胖悖论 现象,但心衰伴中-重度肥胖者减重,可减少合并症及相关症状,降低胰岛素抵抗和全身炎症[11]㊂2019年HFSA共识建议,对BMIȡ35kg/m2者,建议减轻5%~10%的体重;BMIȡ35kg/m2且NYHA心功能分级Ⅱ~Ⅲ级伴或不伴左心室辅助装置的心衰患者,可考虑减重手术[9]㊂总体来说,肥胖心衰患者的体重管理仍需开展更多前瞻性研究,且这些研究应对射血分数降低和射血分数保留的心衰进行区分㊂恶病质是一种复杂的代谢性消耗综合征,特点为非故意㊁非水肿性体重减轻㊁厌食㊁炎症和异常生化,是心衰最严重的并发症,远期死亡率高[12-13]㊂2019年HFSA共识建议,由于恶病质与不良临床结果密切相关,因此心衰患者应至少每年筛查1次有无体重减轻,以期尽早发现恶病质㊂在心衰特定治疗标准制定前,对于有肌肉减少症㊁消瘦或生化异常证据的患者,用前6~12个月内渐进性消瘦>7.5%或BMI< 20kg/m2来定义恶病质是合理的㊂2 心衰患者的营养干预国外已有心衰营养实践指南形成,2018年美国营养与饮食学会更新了心衰患者营养实践指南[14],2019年HFSA 发布了心衰患者营养㊁肥胖和恶病质共识[9],2020年欧洲心脏病学会的心力衰竭协会(Heart Failure Association of the European Society of Cardiology,HFA/ESC)又发布了心衰患者自我管理实践建议[15],为心衰患者的营养管理提供了依据㊂我国对于心衰患者的临床营养循证研究起步较晚,‘中国心力衰竭诊断和治疗指南2018“强调多学科管理,但对于营养和饮食方面的具体推荐意见较少[1]㊂2.1㊀钠盐及液体摄入心衰时,肾素-血管紧张素-醛固酮系统激活增加,以及血管加压素升高可导致钠和液体潴留,使心衰恶化㊂因此,钠盐限制,伴或不伴液体限制,可能是心衰患者使用最广泛的临床营养疗法㊂然而,限钠/限制液体摄入对心衰患者生活质量和预后影响尚缺乏高质量证据,还有一些研究结果质疑了限制钠盐摄入的有效性[16-19],指南/共识推荐等级和强度也在变化㊂‘中国心力衰竭诊断和治疗指南2018“建议心衰急性发作伴有容量负荷过重时,限制钠摄入<2g/d,同时限钠期间应定期检测血钠水平评估低钠血症风险,轻度或稳定期心衰不主张严格限制钠摄入[1]㊂2019年HFA/ESC心衰共识[20]和2020年HFA/ESC心衰患者自我管理实践建议[15],均指出尚无有力的证据表明限制心衰患者食盐摄入量可以获益,推荐限钠饮食,但对每日钠摄入量并无具体建议㊂SODIUM-HF是一项国际性㊁开放标签㊁随机对照试验,纳入806例心衰患者(NYHA心功能分级Ⅱ~Ⅲ级),随机分配为低钠饮食组(<1.5g/d)和常规护理对照组,随访12个月,结果显示,低钠组和对照组的全因死亡率㊁心血管住院和急诊就诊均无差异,但会适度改善心衰患者生活质量和NYHA心功能分级[21]㊂SODIUM-HF是迄今为止同类试验中规模最大㊁随访时间最长的研究,与既往GOURMET-HF试验[22]相似,SODIUM-HF研究也未发现低钠饮食的不良反应,同时也进一步验证了低钠饮食在心衰患者生活质量的中度获益和总体安全性㊂关于心衰患者低钠饮食对临床结局的影响,目前仍缺乏高质量的证据㊂既往研究结果也并不一致,这可能与不同研究的持续时间㊁样本量㊁纳入人群的临床和人口学特征㊁钠限制的水平㊁评估的结果以及总体研究设计的严格性有关㊂综上所述,低钠饮食对心衰患者临床结局的长期效果目前尚不能得到明确结论,仍需进行大规模㊁长时间且高质量的研究,以优化心衰治疗策略㊂但低钠饮食对心衰患者整体健康的影响是毋庸置疑的,因此目前多数指南仍推荐低钠饮食㊂有限的证据显示,限制液体摄入量可能会降低心衰患者住院风险㊂欧美以及中国的心衰相关指南均建议重度心衰患者应将液体摄入量限制在1.5~2.0L/d,而对于轻中度心衰患者常规限制液体入量并无益处[1,3,14-15]㊂临床上应及时评估患者情况,将其与药物㊁饮食管理相结合,提供个体化的液体摄入指导建议㊂2.2㊀蛋白质摄入和能量需求2018年美国营养与饮食协会更新发布的心衰患者营养实践指南推荐,对NYHA心功能分级Ⅰ~Ⅳ级或美国心脏协会分期B~D期的心衰患者,由专业营养师计算出静息代谢率,利用静息代谢率和机体活动强度估算总能量需求,并制定个体化蛋白质摄入方案,保证每日至少摄入蛋白质1.1g/kg㊂2019年HFSA共识建议蛋白质摄入量应个体化,为预防恶病质,心衰患者的蛋白质摄入量应至少0.8g㊃kg-1㊃d-1;伴有营养不良或恶病质的患者,至少摄入1.1g㊃kg-1㊃d-1的蛋白质是合理的[14]㊂2.3㊀微量营养素补充多项研究表明,线粒体功能障碍可能导致心衰的发生和发展[23-24]㊂线粒体电子传递链需要微量营养素(包括铁㊁硒㊁锌㊁铜和辅酶Q10等)的辅助才能产生足够的三磷酸腺苷(adenosine triphosphate,ATP),心衰患者若缺乏微量营养素,可能导致线粒体功能缺陷和ATP合成能力降低㊂一些研究发现,心衰患者补充辅酶Q10,可改善心功能㊁减少心血管不良事件[25-26],但入选人群㊁临床设计㊁给药剂量㊁随访时间和研究结果的异质性使辅酶Q10在心衰中的作用还难以确定㊂2019年HFSA共识建议,除外缺铁或其他特定微量元素缺乏者,日常补充微量元素在心衰患者中的作用尚不明确[9]㊂近期,Journal of Internal Medicine发表的一篇综述指出,心衰患者补充微量营养素,尤其是联合补充辅酶Q10㊁锌㊁铜㊁硒㊁铁,能够改善线粒体功能,有可能成为改善心衰患者心肌功能的潜在策略[24]㊂总体来说,关于补充微量营养素对心衰的影响,循证依据的质量和水平都不理想,需要更多周密设计的临床试验来填补围绕营养和心衰领域的循证证据空白[27]㊂3㊀营养干预方式3.1㊀营养途径的选择营养途径的选择包括肠内营养(口服/鼻饲)和肠外(静脉)营养㊂肠外营养容易出现代谢并发症,而且长期肠外营养可使肠道屏障功能受损㊁肠道细菌异位,甚至导致肠源性败血症㊂此外,心衰时机体处于高分解代谢状态,机体器官功能和免疫力下降,一般不能为外源性营养治疗所纠正㊂因此,肠内营养较肠外营养更有优势,是营养支持治疗的首选㊂对于食物摄入量不足目标量的80%的患者,首选口服营养补充;对于昏迷㊁吞咽困难或有误吸风险,且经口摄入不足目标量的50%~60%的患者,可以采用鼻饲营养㊂当肠内营养不能满足患者总热量的60%或有肠内营养禁忌和不耐受时,应选用肠外营养㊂多数情况下肠内联合肠外营养支持治疗,做到优势互补[28-29]㊂3.2㊀多学科团队协作的个体化营养干预模式近年来Jaarsma等[30]学者倡导推行临床医师㊁营养师㊁药师㊁护士等多学科团队协作的心衰患者个体化营养干预模式,国内外有实践表明该模式在改善心衰患者营养状况,提升心功能水平㊁疾病自我管理能力及满意度,降低再住院率方面有明显效果,值得进一步临床推广㊂近期公布的EFFORT研究[31]是一项前瞻性㊁多中心㊁随机对照试验,该研究在资深营养师指导下,个体化制定了每个患者的能量㊁蛋白质和微量营养素目标,并使用了多种营养支持策略以达到营养目标,提供了个性化的营养支持㊂研究纳入NRS总分ȡ3分的645例慢性心衰患者,随机分配为营养干预组和对照组,研究主要终点是30d内的全因死亡率,结果显示营养支持显著降低了心衰患者死亡率,而且与中度营养风险患者相比,高营养风险患者(NRS>4分)获益更大㊂同样,在180d的长期随访中,营养支持降低心衰患者死亡率的长期益处依然显著㊂4㊀小结与展望营养评估与营养支持治疗是心衰患者管理中的重要组成部分,然而,目前缺乏对心衰患者饮食干预和营养治疗的研究,现有指南对于心衰患者的营养管理方面也缺乏具体推荐,仍有许多空白领域有待探索㊂近年来,多学科团队协作的心衰患者营养筛查-评估-个体化营养干预模式值得推广,然而如何将流程具体化㊁系统化应是未来需要关注的重点㊂心衰患者未来营养策略的试验应随机㊁强效,区分射血分数降低和射血分数保留的心衰类型㊁随访时间足够长,且有临床相关的心衰终点事件㊂利益冲突:无参㊀考㊀文㊀献[1]中华医学会心血管病学分会心力衰竭学组,中国医师协会心力衰竭专业委员会,中华心血管病杂志编辑委员会.中国心力衰竭诊断和治疗指南2018[J].中华心血管病杂志,2018,46(10):760-789.DOI:10.3760/cma.j.issn.0253-3758.2018.10.004.㊀Heart 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[19]Chrysohoou C,Mantzouranis E,Dimitroglou Y,et al.Fluid andSalt Balance and the Role of Nutrition in Heart Failure[J].Nutrients,2022,14(7):1386.DOI:10.3390/nu14071386.[20]Seferovic PM,Ponikowski P,Anker SD,et al.Clinical practiceupdate on heart failure2019:pharmacotherapy,procedures,devices and patient management.An expert consensus meetingreport of the Heart Failure Association of the European Society ofCardiology[J].Eur J Heart Fail,2019,21(10):1169-1186.DOI:10.1002/ejhf.1531.[21]Ezekowitz JA,Colin-Ramirez E,Ross H,et al.Reduction ofdietary sodium to less than100mmol in heart failure(SODIUM-HF):an international,open-label,randomised,controlled trial[J].Lancet,2022,399(10333):1391-1400.DOI:10.1016/S0140-6736(22)00369-5.[22]Wessler JD,Maurer MS,Hummel SL.Evaluating the safety andefficacy of sodium-restricted/Dietary Approaches to StopHypertension diet after acute decompensated heart failurehospitalization:design and rationale for the Geriatric OUt ofhospital Randomized MEal Trial in Heart Failure(GOURMET-HF)[J].Am Heart J,2015,169(3):342-348.DOI:10.1016/j.ahj.2014.11.021.[23]Mollace V,Rosano GMC,Anker SD,et al.PathophysiologicalBasis for Nutraceutical Supplementation in Heart Failure:AComprehensive Review[J].Nutrients,2021,13(1):257.DOI:10.3390/nu13010257.[24]Bomer N,Pavez-Giani MG,Grote Beverborg N,et al.Micronutrient deficiencies in heart failure:Mitochondrialdysfunction as a common pathophysiological mechanism?[J].JIntern Med,2022,291(6):713-731.DOI:10.1111/joim.13456.[25]Raizner AE,Quiñones MA.Coenzyme Q10for Patients WithCardiovascular Disease:JACC Focus Seminar[J].J Am CollCardiol,2021,77(5):609-619.DOI:10.1016/j.jacc.2020.12.009.[26]Khan MS,Khan F,Fonarow GC,et al.Dietary interventions andnutritional supplements for heart failure:a systematic appraisaland evidence map[J].Eur J Heart Fail,2021,23(9):1468-1476.DOI:10.1002/ejhf.2278.[27]方理刚.心力衰竭治疗中的补充和替代治疗[J].中国心血管杂志,2023,28(3):197-200.DOI:10.3969/j.issn.1007-5410.2023.03.002.㊀Fang plementary and alternative medicines in themanagement of heart failure[J].Chin J Cardiovasc Med,2023,28(3):197-200.DOI:10.3969/j.issn.1007-5410.2023.03.002.[28]Anker SD,Laviano A,Filippatos G,et al.ESPEN Guidelineson Parenteral Nutrition:on cardiology and pneumology[J].ClinNutr,2009,28(4):455-460.DOI:10.1016/j.clnu.2009.04.023.[29]中华医学会肠外肠内营养学分会老年营养支持学组.中国老年患者肠外肠内营养应用指南(2020)[J].中华老年医学杂志,2020,39(2):119-132.DOI:10.3760/cma.j.issn.0254-9026.2020.02.002.㊀Geriatric Nutrition Support Group,Society of Parenteral andEnteral Nutrition,Chinese Medical Association.Guidelines forthe application of parenteral and enteral nutrition in elderlyChinese patients[J].Chin J Geriatr,2020,39(2):119-132.DOI:10.3760/cma.j.issn.0254-9026.2020.02.002. 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CONUT联合CTP评分预测肝硬化合并肝性脑病患者短期预后的临床意义
DOI ： 10.3969/j.issn.1008⁃7125.2023.01.002*基金项目：江苏省“六大人才高峰”项目（YY⁃177）；江苏省青年医学重点人才项目（QNRC2016400）；南通市“十三五”科教强卫工程医学重点人才项目（重点05）；南通市“十四五”科教强卫工程青年医学重点人才项目（青年75）；南通市市级科技计划项目（JCZ20077）#本文通信作者，Email:*******************CONUT 联合CTP 评分预测肝硬化合并肝性脑病患者短期预后的临床意义*卞兆连1 邵建国1 薛 红2#南通大学附属南通第三医院/南通市第三人民医院消化科1（226006） 肝病科2背景：肝性脑病（HE ）是终末期肝病患者的主要死因之一。
早期评估肝硬化合并HE 病情是改善患者预后的关键。
目的：探讨控制营养状况（CONUT ）联合CTP 评分对肝硬化合并HE 患者短期预后的影响。
方法：回顾性分析2018年1月—2021年12月南通市第三人民医院初诊的168例肝硬化合并HE 患者的临床资料，并分为生存组和死亡组。
采用Cox 回归分析评估影响预后的危险因素。
建立新的预测模型，采用ROC 曲线评价不同评分对HE 患者短期预后的价值。
采用Kaplan⁃Meier 法评估患者生存情况。
结果：死亡组ALT 、AST 、TBIL 、INR 、白细胞计数、中性粒细胞明显高于生存组（P <0.05），ALB 、总胆固醇、血清钠、纤维蛋白原、淋巴细胞明显低于生存组（P <0.05）。
CONUT （OR =1.499，95% CI : 1.092~2.057，P =0.012）、CTP 评分（OR =1.474，95% CI : 1.178~1.844，P =0.001）是肝硬化合并HE 患者90 d 病死率的独立危险因素。
CTP 、CONUT 、CONUT⁃CTP 三种评分模型的AUC 分别为0.90、0.94、0.95。
2019版：儿童围手术期营养管理专家共识(全文)
2019版：儿童围手术期营养管理专家共识（全文）儿童正处于生长发育的关键时期，营养除了提供基础代谢和活动所需外，还需要促进机体生长发育。
一些疾病导致的营养摄入不足和(或)能量消耗增加，可能造成儿童营养不良。
围手术期的各种创伤所导致的应激和代谢改变，如内分泌激素和炎症介质的释放，糖原、脂肪和蛋白质的分解代谢以及需要额外能量来修复创伤等，都可能加重患儿的营养不良[1]。
研究已经证明，营养不良是术后并发症的危险因素，而良好的营养状态和最佳的临床结局相关[2]。
优化的围手术期代谢调理和营养管理，能减轻患儿分解状态和瘦组织的丢失，促进蛋白质合成，从而减少并发症的发生，为最佳的创伤愈合和恢复提供保障[3]。
目前，我国对儿童围手术期的营养管理越来越重视，但不同地区、医疗机构之间仍然存在着较大的差异。
为了更好地规范儿外科围手术期营养管理的临床实践，我国儿外科、儿童营养和麻醉镇痛等领域的相关专家组成了"儿童围手术期营养管理专家共识"编写组，按照共识形成的标准和流程制定了本共识，以指导儿童围手术期的营养支持治疗，使患儿能以良好的状态接受手术，减轻其围手术期的应激，减少并发症的发生，加快康复进程，提高生活质量。
一、方法通过检索Medline、Embase、PubMed、SCI、Cochrane Library 和中国生物医学文献数据库，收集1990年1月1日至2019年7月1日期间发表的相关文献。
检索的中文关键词为"围手术期"、"营养"、"肠内营养"、"肠外营养"、"新生儿"、"婴儿"和"儿童"；英文关键词为"perioperativeperiod"、"nutrition"、"enteral nutrition"、"parenteral nutrition"、"neonate"、"infant"和"child"。
PG-SGA评分对改善胃癌术后化疗者营养状况及不良反应的影响
DOI：10.19368/ki.2096-1782.2023.09.115PG-SGA评分对改善胃癌术后化疗者营养状况及不良反应的影响郭超1，杜园1，马迪2，王岚3，张慧芳4，王辉1，杨金宝51.涿州市医院普外科，河北涿州072750；2.涿州市医院妇科，河北涿州072750；3.涿州市医院营养科，河北涿州072750；4.涿州市医院内镜中心，河北涿州072750；5.涿州市医院产科，河北涿州072750[摘要]目的探讨主观整体营养状况评估量表（Patient Generated Subjective Global Assessment, PG-SGA）评分对改善胃癌术后化疗者营养状况及不良反应的影响。
方法选取2019年4月—2022年10月涿州市医院普外科收治的99例限期胃癌根治术患者为研究对象，按照随机数表法分为观察组和对照组。
对照组（49例）患者接受常规饮食指导，观察组（50例）在对照组的基础上辅以PG-SGA评分指导下进行个性化营养干预。
比较两组血清蛋白水平、热量摄入量情况及体质指数情况，分析两组人体成分及化疗不良反应发生情况。
结果干预后，观察组血红蛋白、血清白蛋白及前清蛋白值均高于对照组，差异有统计学意义（P<0.05）；观察组热量摄入量情况及体质指数高于对照组，差异有统计学意义（P<0.05）。
干预后，观察组体脂含量、体蛋白质量、体骨骼肌量及体水分量水平分别为（15.6±3.1）kg、（8.9±1.9）kg、（26.8±4.1）kg、（31.2±3.1）L，均高于对照组，差异有统计学意义（t=6.000、3.869、5.579、21.063，P<0.05），观察组化疗不良反应发生率为2.0%，显著低于对照组的28.6%，差异有统计学意义（χ2=12.972，P<0.05）。
结论应用PG-SGA评分指导下进行个性化营养，对改善胃癌术后化疗患者营养状况有重要的指导意义，可改善化疗不良反应。
基于PG-SGA_评分的个体化营养干预应用于鼻咽癌同期放化疗患者的效果分析
医学食疗与健康 2022年11月中第20卷第32期·食疗理论研究·基于PG-SGA评分的个体化营养干预应用于鼻咽癌同期放化疗患者的效果分析梁雪霞（江门市五邑中医院肿瘤科，广东 江门 529000）【摘要】目的：探讨基于主观整体营养状况评量表（PG-SGA）评分的个体化营养干预应用于鼻咽癌同期放化疗患者的效果。
方法：将我院2019年1月至2019年12月期间60例患者，按照随机数字表法分为对照组和研究组,…每组30例，对照组30例给予常规膳食搭配及营养指导,…研究组30例在PG-SGA评分的基础上，给予个体化营养干预。
观察两组临床效果、营养相关指标及不良反应情况。
结果：同期放疗30次后，研究组总有效率（93.33%）高于对照组（73.33%）（P＜0.05），放化疗前，两组Alb、PA、Hb对比无统计学差异（P＞0.05）放疗30次后，研究组营养相关指标较对照组高（P＜0.05），研究组出现营养不良及贫血情况优于对照组（P＜0.05）。
结论：PG-SGA评分的个体化营养干预应用于鼻咽癌同期放化疗，可通过个体化饮食，保证患者自身营养需要，改善患者营养不良情况，降低患者贫血发生率。
在临床上值得进一步推进。
【关键词】鼻咽癌；放化疗；主观整体营养状况量表评分；个体化营养【中图分类号】R739.6…【文献标识码】A…【文章编号】2096-5249（2022）32-0017-04Effect analysis of individualized nutritional intervention based on pg-sga score in patients with nasopharyngeal carcinoma undergoing concurrent radiotherapy and chemotherapyLiang Xue-xiaDepartment of oncology, Wuyi Hospital of traditional Chinese medicine, Jiangmen 529000, Guangdong, China 【Abstract】Objective: To explore the effect of individualized nutritional intervention based on subjective global nutritional status assessment（pg-sga）in patients with nasopharyngeal carcinoma undergoing concurrent radiotherapy and chemotherapy. Methods: 60 patients in our hospital from January 2019 to December 2019 were randomly divided into control group and study group, with 30 patients in each group. 30 patients in the control group were given routine dietary matching and nutritional guidance, and 30 patients in the study group were given individualized nutritional intervention on the basis of pg-sga score. The clinical effect, nutrition related indexes and adverse reactions of the two groups were observed. Results: After 30 times of radiotherapy in the same period, the total effective rate of the study group（93.33%）was higher than that of the control group（73.33%）（P＜0.05）. Before radiotherapy and chemotherapy, there was no significant difference in the comparison of ALB, PA and Hb between the two groups（P ＞0.05）. After 30 times of radiotherapy, the nutrition related indexes in the study group were higher than those in the control group（P＜0.05）. The malnutrition and anemia in the study group were better than those in the control group（P ＜0.05）. Conclusion: Individualized nutrition intervention with pg-sga score applied to concurrent radiotherapy and chemotherapy of nasopharyngeal carcinoma can ensure patients’ own nutritional needs, improve patients’ malnutrition and reduce the incidence of anemia through individualized diet. It is worthy of further promotion in clinic. 【Keywords】Nnasopharyngeal carcinoma; Radiotherapy and chemotherapy; Subjective overall nutritional status scale score; Individualized nutrition作者简介：梁雪霞 （1982.06—），女，本科， 主管护师，研究方向：鼻咽癌放疗后护理。
泌尿系统术后留置双J管患者并发尿路感染列线图预测模型建立及验证
泌尿系统术后留置双J管患者并发尿路感染列线图预测模型建立及验证吴利兵曹勇庒华厉波李超群日照市中心医院泌尿外科山东日照276800[摘要]目的通过建立泌尿系统术后留置双J管患者尿路感染(U T I)临床预测模型,提高临床对于此类患者的诊治能力㊂方法选择2018年1月~2022年7月本院泌尿外科接受手术留置双J管患者为研究对象,经病历筛选最终入组研究对象共137例,将尿路感染患者纳入U T I组,未发生尿路感染者纳入非U T I组㊂对性别㊁年龄㊁体质量指数(B M I)㊁双J管留置时间㊁合并糖尿病㊁尿路感染史㊁术前营养控制状态评分(C O U N T)㊁手术时间㊁双J管侧别㊁合并肾功能不全情况进行统计,采用R-s t u d i o4.0.2软件的 R M S 函数包完成多因素L o g i s t i c回归模型建立㊁列线图绘制,模型及单因素对双J管感染的诊断价值分析采用受试者工作特征曲线(R O C)进行评价㊂结果 U T I组与非U T I组性别㊁年龄㊁B M I㊁合并糖尿病㊁手术时间㊁双J管侧别㊁合并肾功能情况比较差异无统计学意义(P>0.05),U T I组双J管留置时间㊁术前C O U N T评分㊁尿路感染史比例均高于非U T I组(P<0.05);多因素L o g i s t i c回归分析结果发现双J管留置时间㊁尿路感染史㊁术前C O U N T评分均为泌尿系统术后留置双J管相关尿路感染的独立影响因素(P<0.05),B o o t s t r a p法对预测模型列线图进行内部验证,H o s m e r-L e m e s h o w检验结果显示χ2=6.753,P=0.325,说明模型具有良好的校准度;R O C分析结果显示,双J管留置时间㊁尿路感染史㊁术前C O U N T评分预测术后尿路感染的曲线下面积(A U C)分别为0.793㊁0.747㊁0.750,3个单因素联合建立的预测模型预测术后尿路感染的A U C为0.925,均具有良好的预测效能(P<0.05)㊂结论基于双J管留置时间㊁尿路感染史㊁术前C O U N T评分所建立的预测模型对泌尿系统术后留置双J管患者尿路感染的发生概率有较好的预测能力,可在早期识别尿路感染高风险人群㊂[关键词]泌尿系统手术双J管尿路感染预测模型列线图[中图分类号] R743.6[文献标识码] A [文章编号]2095-2694(2024)02-111-06[D O I]10.19539/j.c n k i.2095-2694.2024.02.005E s t a b l i s h m e n t a n d v a l i d a t i o no f n o m o g r a p h i c p r e d i c t i o nm o d e l f o r u r i n a r y t r a c t i n f e c t i o n i n p a t i e n t sw i t h d o u b l e-J t u b e i n d w e l l i n g a f t e r u r o l o g i c a l s u r g e r y W uL i b i n g,C a oY o n g,Z h u a n g H u a,e t a l(D e p a r t-m e n t o f U r o l o g y,R i z h a oC e n t r a lH o s p i t a l,R i z h a o276800,C h i n a)[A B S T R A C T]O b j e c t i v e T o e s t a b l i s ha c l i n i c a l p r e d i c t i o nm o d e l o f u r i n a r y t r a c t i n f e c t i o n(U T I)i n p a t i e n t sw i t h i n d w e l l i n g d o u b l e J s t e n t s a f t e r u r o l o g i c a l s u r g e r y t o i m p r o v e t h e d i a g n o s i s a n d t r e a t m e n t o f s u c h p a t i e n t s.M e t h o d s At o t a l o f137p a t i e n t sw h ou n d e r w e n tu r o l o g i c a l s u r g e r y a n d i n d w e l l i n g d o u b l e J s t e n t s i no u r h o s p i t a l f r o mJ a n u a r y2018t o J u l y2022w e r e s e l e c t e da s t h e r e s e a r c hs u b j e c t s.A f t e rm e d i c a l r e c o r d s c r e e n i n g,a t o t a l o f137s u b j e c t sw e r e i n c l u d e d i nt h e s t u d y,a n d p a t i e n t sw i t h U T Iw e r e i n c l u d e d i nt h eU T I g r o u p,a n dt h o s ew i t h o u tU T Iw e r e i n c l u d e d i nt h en o n-U T I g r o u p. T h e g e n d e r,a g e,b o d y m a s s i n d e x(B M I),i n d w e l l i n g t i m e o f d o u b l e J s t e n t s,d i a b e t e sm e l l i t u s,h i s-111华北理工大学学报(医学版)2024年3月第26卷第2期J o u r n a l o fN o r t hC h i n aU n i v e r s i t y o f S c i e n c e a n dT e c h n o l o g y(H e a l t hS c i e n c e sE d i t i o n),M a r.2024,V o l.26,N o.2ʌ作者简介ɔ吴利兵(1978-),男,本科㊂研究方向:泌尿外科微创技术的临床应用㊂ʌ通讯作者ɔ曹勇,E m a i l:r i z h a o w l b@163.c o mt o r y o f u r i n a r y t r a c t i n f e c t i o n,p r e o p e r a t i v e n u t r i t i o n a l s t a t u s s c o r e(C O U N T),o p e r a t i o n t i m e,s i d e o f d o u b l e J s t e n t s,a n dc o m b i n e dr e n a l d y s f u n c t i o nw e r ec o l l e c t e d.T h em u l t i-f a c t o rL o g i s t i c r e g r e s s i o n m o d e lw a s e s t a b l i s h e d u s i n g t h e"R M S"f u n c t i o n p a c k a g e o f R-s t u d i o4.0.2s o f t w a r e,a n d t h e l i n e c h a r t w a s p l o t t e d.T h e d i a g n o s t i c v a l u e o f t h em o d e l a n d s i n g l e f a c t o r s f o r d o u b l e J s t e n t i n f e c t i o nw a s e v a l u-a t e du s i n g t h e r e c e i v e r o p e r a t i n g c h a r a c t e r i s t i c c u r v e(R O C).R e s u l t s T h e r ew e r e n o s i g n i f i c a n t d i f f e r-e n c e s i n g e n d e r,a g e,B M I,d i a b e t e sm e l l i t u s,o p e r a t i o n t i m e,s i d eo f d o u b l e J s t e n t s,a n dc o m b i n e d r e n a l d y s f u n c t i o nb e t w e e n t h eU T I g r o u p a n d t h e n o n-U T I g r o u p(P>0.05).T h e i n d w e l l i n g t i m e o f d o u b l e J s t e n t s,p r e o p e r a t i v eC O U N Ts c o r e,a n d p r o p o r t i o no fu r i n a r y t r a c t i n f e c t i o nh i s t o r y i nt h e U T I g r o u p w e r eh i g h e r t h a n t h o s e i n t h e n o n-U T I g r o u p(P<0.05).M u l t i v a r i a t eL o g i s t i c r e g r e s s i o n a n a l y s i s s h o w e d t h a t t h e i n d w e l l i n g t i m e o f d o u b l e J s t e n t s,u r i n a r y t r a c t i n f e c t i o nh i s t o r y,a n d p r e o p-e r a t i v eC O U N Ts c o r ew e r e i n d e p e n d e n t r i s k f a c t o r s f o r p o s t o p e r a t i v e u r i n a r y t r a c t i n f e c t i o n a f t e r u r o-l o g i c a l s u r g e r y w i t h i n d w e l l i n g d o u b l e J s t e n t s(P<0.05).T h e i n t e r n a l v a l i d a t i o no f t h e p r e d i c t i o n m o d e l l i n e c h a r tw a s p e r f o r m e du s i n g t h eB o o t s t r a p m e t h o d.T h eH o s m e r-L e m e s h o wt e s t s h o w e d t h a t χ2=6.753a n d P=0.325,i n d i c a t i n g t h a t t h em o d e l h a d g o o dc a l i b r a t i o n.R O Ca n a l y s i s s h o w e dt h a t t h eA U C s o f d o u b l e J s t e n t i n d w e l l i n g t i m e,u r i n a r y t r a c t i n f e c t i o nh i s t o r y,a n d p r e o p e r a t i v eC O U N T s c o r e f o r p r e d i c t i n gp o s t o p e r a t i v eU T Iw e r e0.793,0.747,a n d0.750,r e s p e c t i v e l y.T h eA U Co f t h e p r e d i c t i o nm o d e l e s t a b l i s h e db y t h e s e t h r e e i n d i v i d u a l f a c t o r s f o r p r e d i c t i n gp o s t o p e r a t i v eU T Iw a s0. 925,i n d i c a t i n g g o o d p r e d i c t i v e a c c u r a c y(P<0.05).C o n c l u s i o n T h e p r e d i c t i o nm o d e l b a s e d o n d o u b-l e J s t e n t i n d w e l l i n g t i m e,u r i n a r y t r a c t i n f e c t i o nh i s t o r y,a n d p r e o p e r a t i v eC O U N Ts c o r eh a s g o o d p r e d i c t i v e a b i l i t y f o r t h eo c c u r r e n c e p r o b a b i l i t y o fu r i n a r y t r a c t i n f e c t i o ni n p a t i e n t sw i t hi n d w e l l i n g d o u b l e J s t e n t s a f t e r u r o l o g i c a l s u r g e r y,w h i c h c a nb e u s e d t o i d e n t i f y h i g h-r i s k g r o u p s o f u r i n a r y t r a c t i n f e c t i o n i n t h e e a r l y s t a g e.[K E Y W O R D S] U r o l o g i c a l s u r g e r y.D o u b l eJs t e n t.U r i n a r y t r a c t i n f e c t i o n.P r e d i c t i o n m o d e l.L i n e c h a r t留置双J管是泌尿系统术后常见操作,双J 管可发挥解除梗阻㊁引流尿液㊁保护肾功能和减少漏尿等作用[1],留置时长约1个月~1年[2]㊂随着双J管留置时间延长,除产生腰腹部不适㊁膀胱刺激征㊁血尿和发热等下尿路症状(l o w e r u r i n a r y t r a c ts y m p t o m s,L U T S)外[3],还可造成尿路感染(u r i n a r y t r a c t i n f e c t i o n,U T I),严重者引发尿源性脓毒症,导致患者死亡㊂预防双J管留置期间并发症对于改善患者病情及预后有重要临床意义㊂研究发现,在双J管置入时细菌生物膜即开始形成,4周内细菌定植率为24%,4~6周定植率为33%,而细菌生物膜形成可产生多层组织结构,从周围液体和组织中吸附多种分子,增加机体免疫细胞清除难度[4-6]㊂双J管定植细菌生物膜和菌落数的增加可引起双J管相关尿路感染,在不同研究中其发生率约10%~22%[7-8],虽然临床中已有部分研究通过分析患者临床资料报道了双J管相关尿路感染风险因素,但由于单因素预测效能不足,且难以量化风险度等缺陷,近年来通过风险因素分析后构建临床预测模型,以模型评分量化临床结局风险的研究受到广泛关注[9-10]㊂本研究通过分析留置双J管患者临床资料并构建尿路感染预测模型,旨在为临床中识别其尿路感染风险㊁指导抗菌药物应用提供有价值参考㊂1对象与方法1.1研究对象选择2018年1月~2022年7月本院泌尿外科接受手术留置双J管患者为研究对象㊂纳入标准:(1)均符合相关手术指征,在本院进行手术;(2)均使用同一型号㊁材质的双J管㊂(3)临床资料完整㊂(4)术前未合并尿211华北理工大学学报(医学版)2024年3月第26卷第2期J o u r n a l o fN o r t hC h i n aU n i v e r s i t y o f S c i e n c e a n dT e c h n o l o g y(H e a l t hS c i e n c e sE d i t i o n),M a r.2024,V o l.26,N o.2路感染㊂排除标准:(1)存在先天性畸形,多囊肾㊁马蹄肾患者;(2)合并恶性肿瘤㊁传染性疾病;(3)入院前2周有激素和免疫抑制剂应用;(4)除尿路感染外存在其他感染;(5)妊娠及哺乳期妇女㊂经筛选最终入组研究对象共137例,对患者均进行尿路病原菌培养,参照‘医院感染诊断标准“[11]相关规定,将尿路感染患者纳入U T I 组,未发生尿路感染者纳入非U T I组,本研究纳入对象均签署对本研究的知情同意书且研究设计符合‘赫尔辛基宣言“㊂1.2 资料收集 通过本院住院病历系统,对符合条件的137例入选患者调取并统计其临床资料,包括性别㊁年龄㊁B M I ㊁双J 管留置时间㊁合并糖尿病㊁尿路感染史㊁术前营养控制状态评分(n u t r i t i o n a l c o n t r o l s t a t u s s c o r e ,C O U N T )㊁手术时间㊁双J 管侧别㊁合并肾功能不全等㊂其中C O U N T 评分为术前最后一次实验室检查结果计算得出,参考白蛋白㊁胆固醇和淋巴细胞计数3项指标,以3项总和为C O U N T 评分得分,总分0~12分,分数越高表示营养不良越严重[12]㊂1.3 统计学分析 使用S P S S 21.0软件进行统计分析,符合正态分布的计量资料采用(x ʃs )表示,两组比较采用独立样本t 检验;计数资料以例数或率表示,两组比较采用χ2检验;将单因素分析中有统计学意义的纳入多因素分析,多因素分析采用L o gi s t i c 回归模型㊂多因素L o g i s t i c 回归模型建立㊁列线图绘制均采用R -s t u d i o 4.0.2软件的 R M S函数包完成,模型及单因素对于双J 管感染的诊断价值分析采用受试者工作特征曲线(r e c e i v e ro p e r a t i n g ch a r a c -t e r i s t i c ,R O C )进行评价,图像使用G r a p h pa d 6.0软件绘制,以P <0.05为差异具有统计学意义㊂2 结果2.1 泌尿系统术后留置双J 管相关尿路感染单因素分析 U T I 组与非U T I 组性别㊁年龄㊁B M I㊁合并糖尿病㊁手术时间㊁双J 管侧别㊁合并肾功能情况比较差异无统计学意义(P >0.05),U T I 组双J 管留置时间㊁术前C O U N T 评分㊁尿路感染史比例高于非U T I 组,差异均具有统计学意义(P <0.05),见表1㊂表1 泌尿外科留置双J 管单因素分析因素U T I 组(n =29)非U T I 组(n =108)t /χ2值P 值性别(例)男17600.0870.768女1248年龄(x ʃs ,岁)49.86ʃ6.5349.68ʃ6.440.1330.894B M I (x ʃs ,k g/m 2)23.81ʃ2.0323.86ʃ2.090.1150.909双J 管留置时间(x ʃs ,d)36.64ʃ7.1631.86ʃ6.093.612<0.001合并糖尿病(例)是5140.3500.554否2494尿路感染史(例)有8134.2590.039无2195术前C O U N T 评分(x ʃs ,分)3.68ʃ0.613.06ʃ0.545.339<0.001手术时间(x ʃs ,m i n)120.64ʃ23.60121.38ʃ24.060.1480.883双J 管侧别(例)单23850.0050.943双623合并肾功能不全(例)是6210.0220.881否23872.2 尿路感染多因素L o gi s t i c 回归分析 设置进入方程α=0.05,将单因素分析有意义的变量:双J 管留置时间㊁尿路感染史㊁术前C O U N T 评分进行赋值,其中双J 管留置时间㊁术前C O U N T 评分为连续性变量,尿路感染史赋值为:发生尿路感染=1,未发生=0㊂多因素L o gi s t i c 回归分析结果发现双J 管留置时间㊁尿路感染史㊁术前C O U N T 评分均为尿路感染的311华北理工大学学报(医学版) 2024年3月第26卷第2期J o u r n a l o fN o r t hC h i n aU n i v e r s i t y o f S c i e n c e a n dT e c h n o l o g y(H e a l t hS c i e n c e sE d i t i o n ),M a r .2024,V o l .26,N o .2独立影响因素(P <0.05),B o o t s t r a p 法对预测模型列线图进行内部验证,H o s m e r -L e m e s h o w检验结果显示χ2=6.753,P =0.325,说明模型具有良好的校准度,见表2㊁图1㊂表2 泌尿系统术后留置双J 管相关尿路感染多因素L o gi s t i c 回归分析危险因素β值S E 值W a r d 值O R 值95%C IP 值双J 管留置时间0.6280.2337.2541.8731.186~2.9570.003尿路感染史0.3020.1523.9561.3531.004~1.8230.045术前C O U N T 评分0.8550.26510.4162.3521.399~3.954<0.001图1 泌尿系统术后留置双J 管相关尿路感染列线图模型2.3 预测模型对尿路感染的诊断价值 R O C分析结果显示,双J 管留置时间㊁尿路感染史㊁术前C O U N T 评分预测泌尿系统术后留置双J 相关尿路感染的曲线下面积(a r e au n d e rt h ec u r v e ,A U C )分别为0.793㊁0.747㊁0.750,见图2㊂用3个单因素建立的联合模型预测尿路感染的A U C 为0.925,表明也具有良好的预测效能,见表3㊂表3 预测模型对泌尿系统术后留置双J 相关尿路感染的诊断价值指标A U C灵敏度(%)特异度(%)95%C IP 值双J 管留置时间0.79378.6575.880.699~0.887<0.001尿路感染史0.74774.5071.520.641~0.853<0.001术前C O U N T 评分0.75074.7571.770.646~0.854<0.001预测模型0.92594.5092.650.873~0.976<0.001图2 预测模型诊断泌尿外科留置双J 管感染的R O C 图3 讨论双J 管作为泌尿外科最常用的医用置入物,感染预防具有重要临床意义[12-13]㊂对不同病情手术患者而言,双J 管置入时间有一定差异:开放结石手术㊁肾盂输尿管成型手术患者,置入时间约为2~6周[14],对于病情严重者,双J 管留置时间可达1年;不同材质双J 管可留置时间也存在一定差异㊂在诸多双J 管并发症411华北理工大学学报(医学版) 2024年3月第26卷第2期J o u r n a l o fN o r t hC h i n aU n i v e r s i t y o f S c i e n c e a n dT e c h n o l o g y(H e a l t hS c i e n c e sE d i t i o n ),M a r .2024,V o l .26,N o .2中,感染事件由于早期症状不典型㊁病原菌培养困难等因素影响,在发生早期难以准确诊断和有效干预,进一步发展还可导致尿源性脓毒血症等疾病,对患者预后产生不良影响㊂在熟悉双J管应用指征前提下预测患者双J管相关尿路感染的发生风险[15],对于减轻其治疗痛苦和经济负担有较高临床价值㊂在正常状态下双J管壁㊁管腔均存在细菌定植,双J管作为置入物可产生吸附蛋白㊁尿液沉渣和结石晶体,这些物质在管壁的附着可吸引细菌发生黏附反应,逐渐形成细菌的生物膜结构[16-17]㊂细菌的生物膜形成使细菌菌落处于被包裹状态,为细菌的长期存活和繁殖提供了天然的保护屏障,也阻碍了抗感染免疫细菌的进入,是导致细菌产生耐药㊁细菌繁殖㊁感染复发的最主要因素[18]㊂既往研究已经证实了随着双J管留置时间增加,细菌生物膜形成水平也逐渐增加[19]㊂陈瑞廷等[20]对300例接受泌尿外科手术患者进行调查发现,年龄㊁合并糖尿病㊁术前导尿术㊁留置尿管时间>3d㊁手术时间较长㊁辅助性T细胞免疫失衡为其尿路感染的主要危险因素㊂本研究调查结果显示,U T I 组双J管留置时间㊁术前C O U N T评分㊁尿路感染史比例均高于非U T I组,其中留置时间较长所导致尿路感染可能与细菌生物膜形成水平较高有关㊂营养控制状态评分由三项参数构成,可总体反应患者术前营养风险,K a t o等[21]研究就发现C O N U T评分较低者住院期间发生医院感染率较高[O R=1.61,95%C I:(1.05, 2.44)],死亡率也较高[(O R=1.66,95%C I:(1.30,2.12)];对感染性心内膜炎患儿而言,C O N U T评分>8分者预测全因死亡率敏感性为86%,特异度为76%[22],且与患者较高的全身性炎症水平㊁心力衰竭㊁肾功能障碍㊁贫血㊁瓣膜功能障碍和短期死亡显著相关;对于泌尿外科接受手术患者而言,术前营养水平对于术后机体基础免疫水平㊁免疫细胞活性以及抗感染抗体产生能力有直接影响[23]㊂本研究结果还显示了尿路感染史为双J管置管相关尿路感染危险因素,可能与尿路感染史导致泌尿道病理损伤㊁影响泌尿道免疫水平有关㊂本研究进一步多因素L o g i s t i c回归分析结果发现双J管留置时间㊁尿路感染史㊁术前C O U N T评分的A U C均为泌尿系统术后留置双J管相关尿路感染的独立影响因素,B o o t-s t r a p法对预测模型列线图进行内部验证, H o s m e r-L e m e s h o w检验结果显示模型具有良好的校准度,同时R O C分析结果显示,双J管留置时间㊁尿路感染史㊁术前C O U N T评分的A U C分别为0.793㊁0.747㊁0.750,用3个单因素建立的预测模型的A U C为0.925,显著高于各个单指标的预测效能,说明将指3个指标联合应用可提高对感染事件的预测效能㊂综上所述,本研究结果显示基于双J管留置时间㊁尿路感染史㊁术前C O U N T评分所建立的预测模型对泌尿系统术后留置双J管患者尿路感染的发生概率有较好的预测能力,可在早期识别尿路感染高风险人群㊂由于本研究为单中心研究,存在混杂因素影响及样本量不足的缺陷,需进一步在不同队列中检验预测模型的应用价值㊂参考文献[1]X i eW,Z h a n g S,L i X,e t a l.E f f e c t o f i n d w e l l-i n g t i m eo fd o u b l eJt u b eo ni n f e c t e du r e t e r a lc a l c u l i a nd t h ed i s t r i b u t i o no f p a t h o ge n i c c h a r-a c t e r i s t i c s i nd i ab e t ic s[J].A m JT r a n s lR e s,2021,13(5):5685-5690.[2]Z h a o Y,C h e n X.T h e D o u b l e-L u m e nI r r i g a-t i o n-S u c t i o nT u b e i nT h e M a n a g e m e n t o f I n c i-s i o n a l S u r g i c a l S i t e I n f e c t i o nA f t e rE n t e r o c u t a-n e o u s F i s t u l a E x c i s i o n s:A n O b s e r v a t i o n a lS t u d y[J].J I n v e s t S u r g,2021,34(7):791-797.[3]L i uJ,C h e nC,X uT,e t a l.A p p l i c a t i o no fo-m a h a s y s t e m-b a s e dc o n t i n u i n g c a r e i n p a t i e n t sw i t h r e t a i n e dd o u b l e J t u b e a f t e r u r i n a r y c a l c u-l u s s u r g e r y[J].A mJT r a n s l R e s,2021,13(4):3214-3221.[4]P e n g X,Z h u X,W u Z,e ta l.L a p a r o s c o p i cn e e d l e c a t h e t e r j e j u n o s t o m y b y u s i n g ad o u b l es e m i p u r s es t r i n g s u t u r e m e t h o di n m i n i m a l l yi n v a s i v e I v o rL e w i se s o p h a g e c t o m y[J].JT h o-511华北理工大学学报(医学版)2024年3月第26卷第2期J o u r n a l o fN o r t hC h i n aU n i v e r s i t y o f S c i e n c e a n dT e c h n o l o g y(H e a l t hS c i e n c e sE d i t i o n),M a r.2024,V o l.26,N o.2r a cD i s,2020,12(3):240-248.[5]G u oY,G u oX,W a n g J,e t a l.A b d o m i n a l i n-f e c t i o u s c o m p l i c a t i o n sa s s o c i a t e d w i t ht h ed i s-l o c a t i o no f i n t r a p e r i t o n e a l p a r t o f d r a i n a g e t u b ea n d p o o r d r a i n a g e a f t e rm a j o r s u r g e r i e s[J].I n tW o u n d J,2020,17(5):1331-1336.[6]L a r a-I s l aA,M e d i n a-P o l oJ,A l o n s o-I s a M,e ta l.U r i n a r y i n f e c t i o n s i n p a t i e n t sw i t h c a t h e t e r si n t h e u p p e r u r i n a r y t r a c t:m i c r o b i o l o g i c a ls t u d y[J].U r o l I n t,2017,98(4):442-448. [7]C e y l a nK C,B a t i h a nG,Y a z g a nS,e t a l.P l e u-r a l c o m p l i c a t i o n si n p a t i e n t s w i t hc o r o n a v i r u sd i se a s e2019(C O V I D-19):h o wt o s af e l y a p p l ya n d f o l l o w-u p w i t h a c h e s t t ub e d u r i n g t h e p a n-d e m i c[J].E u rJC a r d i o t h o r a cS u r g,2020,58(6):1216-1221.[8]C a i C,L i uY,Z h o n g W,e t a l.T h e c l i n i c a l a p-p l i c a t i o no f n e w g e n e r a t i o n s u p e r-m i n i p e r c u t a-n e o u sn e p h r o l i t h o t o m y i nt h et r e a t m e n to fȡ20mm r e n a ls t o n e s[J].JE n d o u r o l,2019,33(8):634-638.[9]T a n g J X,W a n g L,N i a nWQ,e t a l.A s p i r a t i o np n e u m o n i ad u r i n gg e n e r a l a n e s t h e s i a i n d u c t i o na f t e r e s o p h a g e c t o m y:a c a s e r e p o r t[J].W o r l d JC l i nC a s e s,2020,8(21):5409-5414.[10]S p a p e nH D,S u y sE,D i l t o e rM,e t a l.An e w l yd e v e l o p e d t r a c h e a lt u b e o f f e r i n g'p r e s s u r i s e ds e a l i n g'o u t p e r f o r m s c u r r e n t l y a v a i l a b l e t u b e s i np r e v e n t i n g c u f f l e a k a g e:ab e n c h t o p s t u d y[J].E u r JA n a e s t h e s i o l,2017,34(7):411-416.[11]I g n a c i oD U J,G o n z a l e z-M a d r o n oA,V i l l a rN G,e t a l.C O N U T:a t o o lf o r c o n t r o l l i ng n u t r i t i o n a ls t a t u s.F i r s tv a l i d a t i o ni nah o s p i t a l p o p u l a t i o n[J].N u t r H o s p,2005,20(1):38-45.[12]P a r k e rV,G i l e sM,G r a h a m L,e t a l.A v o i d i n gi n a p p r o p r i a t e u r i n a r y c a t h e t e r u s e a n d c a t h e t e r-a s s o c i a t e du r i n a r y t r a c t i n f e c t i o n(C A U T I):ap r e-p o s tc o n t r o l i n t e r v e n t i o ns t u d y[J].B M CH e a l t hS e r vR e s,2017,17(1):314.[13]P a t e l P K,G u p t aA,V a u g h nVM,e t a l.R e v i e wo fs t r a t e g i e st or e d u c ec e n t r a ll i n e-a s s o c i a t e db l o o d s t r e a mi n f ec t i o n(C L A B S I)a n dc a t h e t e r-a s s o c i a t e du r i n a r y t r a c t i n f e c t i o n(C A U T I)i na d u l t I C U s[J].JH o s p M e d,2018,13(2):105-116.[14]F l o r e s-M i r e l e s A,H r e h a T N,H u n s t a d D A.P a t h o p h y s i o l o g y,t r e a t m e n t,a n d p r e v e n t i o no fc a t h e t e r-a s s o c i a t e du r i n a r y t r a c ti n f e c t i o n[J].T o p S p i n a lC o r d I n j R e h a b i l,2019,25(3):228-240.[15]A d v a n i S D,F a k i hMG.T h e e v o l u t i o no f c a t h e-t e r-a s s o c i a t e d u r i n a r y t r a c ti n f e c t i o n(C A U-T I):i s i t t i m e f o rm o r e i n c l u s i v em e t r i c s?[J].I n f e c tC o n t r o l H o s p E p i d e m i o l,2019,40(6):681-685.[16]D u r a n tD J.N u r s e-d r i v e n p r o t o c o l s a n d t h e p r e-v e n t i o no f c a t h e t e r-a s s o c i a t e du r i n a r y t r a c t i n-f e c t i o n s:as y s t e m a t i cr e v i e w[J].A m J I n f e c tC o n t r o l,2017,45(12):1331-1341.[17]M e n e g u e t i MG,C i o l MA,B e l l i s s i m o-R o-d r i g ue sF,e t a l.L o n g-t e r m p r e v e n t i o nof c a t h-e t e r-a s s o c i a t e d u r i n a r y t r a c ti nf e c t i o n sa m o n gc r i t i c a l l y i l l p a t i e n t st h r o u g ht h ei m p l e m e n t a-t i o n o f a n e d u c a t i o n a l p r o g r a m a n d a d a i l yc h e c k l i s t f o rm a i n t e n a n c eo f i nd we l l i n g u r i n a r yc a t h e t e r s:a q u a s i-e x p e r i m e n t a l s t ud y[J].Me d-i c i n e(B a l t i m o r e),2019,98(8):e14417.[18]C l a r k eK,H a l lC L,W i l e y Z,e t a l.C a t h e t e r-a s s o c i a t e du r i n a r y t r a c t i n f e c t i o n s i n a d u l t s:d i-a g n o s i s,t r e a t m e n t,a n d p r e v e n t i o n[J].JH o s pM e d,2020,15(9):552-556.[19]江淑芳,张丽伟,狄佳,等.重症监护病房患者导尿管相关尿路感染风险评分系统的建立与验证[J].中华医院感染学杂志,2020,30(7):1077-1081.[20]陈瑞廷,赵俊峰,董建设,等.泌尿外科术后尿道感染危险因素[J].中华医院感染学杂志,2021,31(7):1047-1050.[21]K a t oT,Y a k uH,M o r i m o t oT,e t a l.A s s o c i a-t i o n w i t hc o n t r o l l i n g n u t r i t i o n a ls t a t u s(C O-N U T)s c o r ea n di n-h o s p i t a lm o r t a l i t y a n di n-f e c t i o n i n a c u t e h e a r t f a i l u r e[J].S c i R e p,2020,10(1):3320.[22]S a i t oY,A i z a w aY,I i d aK,e t a l.C l i n i c a l s i g-n i f i c a n c eo ft h ec o n t r o l l i n g n u t r i t i o n a ls t a t u s(C O N U T)s c o r e i n p a t i e n t sw i t h i n f e c t i v ee n-d o c a r d i t i s[J].I n t He a r tJ,2020,61(3):531-538.[23]T o w n s e n d E M,M o a tJ,J a m e s o n E.C a u t i'sn e x t t o p m o d e l-m o d e l d e p e n d e n t k l e b s i e l l a b i o-f i l mi n h i b i t i o n b y b a c t e r i o p h ag e sa n da n t i m i-c r o b i a l s[J].B i o f i l m,2020,100038.611华北理工大学学报(医学版)2024年3月第26卷第2期J o u r n a l o fN o r t hC h i n aU n i v e r s i t y o f S c i e n c e a n dT e c h n o l o g y(H e a l t hS c i e n c e sE d i t i o n),M a r.2024,V o l.26,N o.2。
controlling nutritional status score
Controlling Nutritional Status ScoreIntroductionThe Controlling Nutritional Status (CONUT) score is a useful tool for evaluating the nutritional status of individuals. It takes into account three parameters: serum albumin levels, total lymphocyte count, andtotal cholesterol levels. By assessing these factors, the CONUT score provides a comprehensive assessment of an individual’s nutritional status. This article aims to explore the significance of the CONUT score and its application in clinical practice.Importance of Nutritional Status AssessmentMaintaining proper nutritional status is crucial for overall health and well-being. Poor nutritional status can lead to a weakened immune system, delayed wound healing, muscle wasting, and an increased risk of complications in various diseases. Therefore, assessing nutritional status is essential to identify individuals at risk and implement appropriate interventions to improve their nutritional status.Parameters of the CONUT ScoreThe CONUT score combines three different parameters to provide a comprehensive evaluation of nutritional status. These parameters are as follows:1. Serum Albumin LevelsSerum albumin is a protein synthesized by the liver and plays a critical role in maintaining colloidal osmotic pressure and transporting various substances in the blood. Low serum albumin levels indicate malnutrition and are associated with increased morbidity and mortality rates. In the CONUT score, albumin levels are categorized into three groups: normal (≥3.5 g/dL), mild (3.0-3.4 g/dL), and moderate (2.5-2.9 g/dL) andsevere (<2.5 g/dL) malnutrition.2. Total Lymphocyte CountLymphocytes are a type of white blood cell involved in immune responses.A decreased number of lymphocytes, known as lymphocytopenia, isindicative of immune dysfunction and malnutrition. The CONUT score categorizes lymphocyte counts into three groups: normal (≥1,600cells/μL), mild (1,200-1,599 cells/μL), and moderate (<1,200 cells/μL) and severe (<800 cells/μL) malnutrition.3. Total Cholesterol LevelsTotal cholesterol is an essential lipid involved in variousphysiological processes. Low cholesterol levels are linked to poor nutritional status and increased mortality rates. In the CONUT score, total cholesterol levels are categorized into three groups: normal(≥180 mg/dL), mild (160-179 mg/dL), and moderate (<160 mg/dL) andsevere (<100 mg/dL) malnutrition.Calculating the CONUT ScoreAfter categorizing the aforementioned parameters, each category is assigned a score: 0, 1, 2, or 3, depending on the severity of malnutrition. The scores are then summed to obtain the CONUT score,which ranges from 0 to 12. A higher score indicates poorer nutritional status.The CONUT score can be calculated using the following formula: CONUT score = serum albumin score + total lymphocyte count score + total cholesterol score.Clinical Applications of the CONUT ScoreThe CONUT score is a valuable tool in clinical practice and has several applications. Some of the key applications are as follows:1. Identifying Malnutrition RiskBy assessing the CONUT score, healthcare professionals can identify individuals at risk of malnutrition. This early identification allowsfor timely interventions to prevent further deterioration in nutritional status.2. Predicting Surgical OutcomesThe CONUT score has been shown to predict postoperative complications and outcomes in various surgical procedures. Higher CONUT scores are associated with an increased risk of surgical site infections, prolonged hospital stays, and higher mortality rates. Preoperative assessment of nutritional status using the CONUT score can help surgeons make informed decisions and optimize patient outcomes.3. Evaluating Cancer PatientsCancer patients often experience malnutrition, which negatively impacts treatment outcomes and quality of life. The CONUT score can help assess the nutritional status of cancer patients and guide interventions to improve their nutritional status. Additionally, the CONUT score can be used to monitor nutritional changes during cancer treatment and adjust interventions accordingly.4. Assessing Elderly PatientsThe elderly population is particularly vulnerable to malnutrition due to various factors such as decreased appetite, difficulty chewing or swallowing, and chronic illnesses. The CONUT score can assist in assessing the nutritional status of elderly patients and tailoring interventions to meet their specific needs.ConclusionThe Controlling Nutritional Status (CONUT) score is a valuable tool in evaluating the nutritional status of individuals. By considering serum albumin levels, total lymphocyte count, and total cholesterol levels, it provides a comprehensive assessment and helps identify individuals at risk of malnutrition. The CONUT score has diverse clinical applications, including predicting surgical outcomes, evaluating cancer patients, and assessing the elderly population. Incorporating the CONUT score intoclinical practice can improve patient outcomes by facilitating early interventions and optimizing nutritional support.。
炎症标志物及营养指标与胰腺癌预后相关性研究进展
[文章编号]1006-2440(2023)05-0454-05[引文格式]汤杰,陆玉华.炎症标志物及营养指标与胰腺癌预后相关性研究进展[J].交通医学,2023,37(5):454-457,462.胰腺癌是预后极差的恶性肿瘤,5年生存率低于5%,位于全球第7大癌症死亡原因[1]。
目前已证实肿瘤大小、分化程度、手术切缘等指标影响患者预后,但这些评估指标的敏感度和特异度不高。
消化系统肿瘤患者营养不良、全身炎症反应较常见,并与患者预后较差相关。
有研究发现,近80%胰腺癌患者存在不同程度体质量减轻和消化不良,可以将营养指标用作评估患者预后的有效手段[2]。
全身炎症反应与患者肿瘤切除后恢复密切相关,炎症指标的变化对胰腺癌进展及预后具有重要的评估价值。
本文重点介绍炎症标志物及营养指标与胰腺癌预后相关性研究进展,为临床评估胰腺癌患者预后提供参考。
1胰腺癌及其血清标志物国家癌症中心的报告显示,我国2020年新增癌症457万例,占全球23.7%。
癌症死亡超过300万例,占世界癌症死亡总数的30%,已成为癌症死亡人数最多的国家。
其中胰腺癌新发病例超过12万,占2.7%左右[3]。
胰腺癌并不是新发癌症中最多的,但其死亡率很高,这与其恶性程度极高、预后极差密不可分。
胰腺癌发病初期无典型症状,大部分患者确诊时已处于中晚期。
手术切除是首选治疗方法,但容易复发,药物治疗效果不佳。
目前反映胰腺癌的血清标志物包括癌胚抗原(car ci no-em br yoni c ant i gen,CEA)、糖类抗原199(car bohydr at e ant i gen,CA199)、糖类抗原125(car bohydr at e ant i gen,CA125)等。
CA199属于低聚糖肿瘤相关性糖类抗原,分布于胆胰系统中,尤其在胰腺﹑胆管上皮等部位,对胰腺癌具有较高的敏感性。
CA125是N-糖链与O-糖链两种修饰的跨膜糖蛋白,主要在女性生殖系统肿瘤中表达,但在其他系统肿瘤中也有表达。
三种衰弱评估方法对老年骨科患者术后谵妄的预测作用
国际老年医学杂志 ２０２３年９月 第４４卷第５期 ＩｎｔＪＧｅｒｉａｔｒ，Ｓｅｐｔｅｍｂｅｒ２０２３，Ｖｏｌ．４４Ｎｏ．５２０２３国际老年医学杂志编辑部 ２０２３ｂｙｔｈｅＥｄｉｔｏｒｉａｌＯｆｆｉｃｅｏｆＩｎｔｅｒｎａｔｉｏｎａｌＪｏｕｒｎａｌｏｆＧｅｒｉａｔｒｉｃｓ三种衰弱评估方法对老年骨科患者术后谵妄的预测作用杨梦娇 高 梅南京医科大学第一附属医院麻醉与围术期医学科，南京 ２１００２９ ［摘 要］ 目的 比较ＦＲＡＩＬ量表（ＦＳ）、临床衰弱量表（ＣＦＳ）和自我报告的埃德蒙特衰弱量表（ＲＥＦＳ）对老年骨科患者术后谵妄（ＰＯＤ）的预测作用。
方法 选取２０２１年９月～２０２２年５月于江苏省人民医院接受骨科手术的２５２例老年患者作为研究对象，根据是否发生ＰＯＤ分为ＰＯＤ组（４３例）和非ＰＯＤ组（２０９例）。
采用单因素和多因素ｌｏｇｉｓｔｉｃ回归分析来确定衰弱与ＰＯＤ的相关性，并绘制ＲＯＣ曲线比较各衰弱量表对ＰＯＤ的预测价值。
结果 单因素ｌｏｇｉｓｔｉｃ回归分析显示，年龄、体型、文化程度、婚姻状况、脑血管疾病病史、ＡＤＬ评分、营养状况、认知水平、低蛋白血症、贫血、术中输血、ＦＳ结果、ＣＦＳ结果、ＲＥＦＳ结果是ＰＯＤ的影响因素（Ｐ＜０ ０５）。
将单因素分析结果中差异有统计学意义的指标作为自变量带入多因素ｌｏｇｉｓｔｉｃ回归分析，排除混杂因素影响后，ＲＥＦＳ评估的衰弱仍是ＰＯＤ的独立危险因素（Ｐ＜０ ０５），ＲＥＦＳ预测ＰＯＤ的ＲＯＣ曲线下面积为０ ８０４（９５％ＣＩ：０ ７２３～０ ８８５）。
结论 对于骨科老年患者，ＲＥＦＳ评估的衰弱与术后谵妄之间存在显著的相关性，且ＲＥＦＳ对ＰＯＤ的预测价值较高。
［关键词］ 骨科手术；衰弱；术后谵妄 ｄｏｉ：１０ ３９６９／ｊ ｉｓｓｎ １６７４－７５９３ ２０２３ ０５ ００７ＰｒｅｄｉｃｔｉｖｅＶａｌｕｅｏｆＴｈｒｅｅＦｒａｉｌｔｙＡｓｓｅｓｓｍｅｎｔＭｅｔｈｏｄｓｏｎＰｏｓｔｏｐｅｒａｔｉｖｅＤｅｌｉｒｉｕｍｉｎＯｌｄｅｒＰａｔｉｅｎｔｓＵｎｄｅｒｇｏｉｎｇＯｒｔｈｏｐｅｄｉｃＳｕｒｇｅｒｙＹａｎｇＭｅｎｇｊｉａｏ，ＧａｏＭｅｉＤｅｐａｒｔｍｅｎｔｏｆＡｎｅｓｔｈｅｓｉｏｌｏｇｙａｎｄＰｅｒｉｏｐｅｒａｔｉｖｅＭｅｄｉｃｉｎｅ，ｔｈｅＦｉｒｓｔＡｆｆｉｌｉａｔｅｄＨｏｓｐｉｔａｌｏｆＮａｎｊｉｎｇＭｅｄｉｃａｌＵｎｉｖｅｒｓｉｔｙ，Ｎａｎｊｉｎｇ ２１００２９ ［Ａｂｓｔｒａｃｔ］ Ｏｂｊｅｃｔｉｖｅ ＴｏｃｏｍｐａｒｅｔｈｅｐｒｅｄｉｃｔｉｖｅｖａｌｕｅｏｆｔｈｅＦｒａｉｌＳｃａｌｅ（ＦＳ），ＣｌｉｎｉｃａｌＦｒａｉｌｔｙＳｃａｌｅ（ＣＦＳ），ａｎｄＲｅ ｐｏｒｔｅｄＥｄｍｏｎｔｏｎＦｒａｉｌＳｃａｌｅ（ＲＥＦＳ）ｏｎｐｏｓｔｏｐｅｒａｔｉｖｅｄｅｌｉｒｉｕｍ（ＰＯＤ）ｉｎｏｌｄｅｒｐａｔｉｅｎｔｓｕｎｄｅｒｇｏｉｎｇｏｒｔｈｏｐｅｄｉｃｓｕｒｇｅｒｙ．Ｍｅｔｈｏｄｓ Ａｔｏｔａｌｏｆ２５２ｏｌｄｅｒｐａｔｉｅｎｔｓｕｎｄｅｒｇｏｉｎｇｏｒｔｈｏｐｅｄｉｃｓｕｒｇｅｒｙｉｎＪｉａｎｇｓｕＰｒｏｖｉｎｃｅＨｏｓｐｉｔａｌｂｅｔｗｅｅｎＳｅｐｔｅｍｂｅｒ２０２１ａｎｄＭａｙ２０２２ｗｅｒｅｅｎｒｏｌｌｅｄｉｎｔｈｉｓｓｔｕｄｙ．Ａｃｃｏｒｄｉｎｇｔｏｔｈｅｐｏｓｔｏｐｅｒａｔｉｖｅｏｕｔｃｏｍｅ，ｔｈｅｐａｔｉｅｎｔｓｗｅｒｅｄｉｖｉｄｅｄｉｎｔｏａＰＯＤｇｒｏｕｐ（４３ｃａｓｅｓ）ａｎｄｎｏｎ－ＰＯＤｇｒｏｕｐ（２０９ｃａｓｅｓ）．Ｕｎｉｖａｒｉａｔｅａｎｄｍｕｌｔｉｖａｒｉａｔｅｌｏｇｉｓｔｉｃｒｅｇｒｅｓｓｉｏｎｗｅｒｅｕｓｅｄｔｏａｎａｌｙｚｅｔｈｅｃｏｒｒｅｌａｔｉｏｎｂｅｔｗｅｅｎｐｒｅｏｐｅｒａｔｉｖｅｆｒａｉｌ ｔｙｗｉｔｈＰＯＤ．Ｔｈｅｒｅｃｅｉｖｅｒｏｐｅｒａｔｉｎｇｃｈａｒａｃｔｅｒｉｓｔｉｃ（ＲＯＣ）ｃｕｒｖｅｗａｓｕｓｅｄｔｏｃｏｍｐａｒｅｔｈｅｐｒｅｄｉｃｔｉｖｅｖａｌｕｅｏｆｅａｃｈｆｒａｉｌｔｙｓｃａｌｅｏｎＰＯＤ．Ｒｅｓｕｌｔｓ Ｕｎｉｖａｒｉａｔｅｌｏｇｉｓｔｉｃｒｅｇｒｅｓｓｉｏｎａｎａｌｙｓｉｓｓｕｇｇｅｓｔｅｄａｇｅ，ｂｏｄｙｓｈａｐｅ，ｌｉｔｅｒａｃｙ，ｍａｒｉｔａｌｓｔａｔｕｓ，ｃｅｒｅｂｒｏｖａｓｃｕｌａｒｄｉｓｅａｓｅ，ａｃｔｉｖｉｔｙｏｆｄａｉｌｙｌｉｖｉｎｇ（ＡＤＬ）ｓｃｏｒｅ，ｎｕｔｒｉｔｉｏｎａｌｓｔａｔｕｓ，ｃｏｇｎｉｔｉｖｅｌｅｖｅｌ，ｈｙｐｏａｌｂｕｍｉｎｅｍｉａ，ａｎｅｍｉａ，ｉｎｔｒａｏｐｅｒａｔｉｖｅｂｌｏｏｄｔｒａｎｓｆｕ ｓｉｏｎ，ＦＳ，ｓｃｏｒｅ，ＣＦＳｓｃｏｒｅ，ａｎｄＲＥＦＳｓｃｏｒｅｗｅｒｅｔｈｅｉｎｆｌｕｅｎｔｉａｌｆａｃｔｏｒｓｆｏｒＰＯＤ（Ｐ＜０ ０５）．Ｍｕｌｔｉｖａｒｉａｔｅｌｏｇｉｓｔｉｃｒｅｇｒｅｓｓｉｏｎａｎａｌ ｙｓｉｓｓｕｇｇｅｓｔｅｄｔｈａｔｆｒａｉｌｔｙｅｖａｌｕａｔｅｄｂｙＲＥＦＳｒｅｍａｉｎｅｄａｎｉｎｄｅｐｅｎｄｅｎｔｒｉｓｋｆａｃｔｏｒｆｏｒＰＯＤ（Ｐ＜０ ０５）．ＴｈｅａｒｅａｕｎｄｅｒｔｈｅＲＯＣｃｕｒｖｅｏｆＲＥＦＳｗａｓ０ ８０４（９５％ＣＩ：０ ７２３～０ ８８５）．Ｃｏｎｃｌｕｓｉｏｎ Ｆｏｒｏｌｄｅｒｐａｔｉｅｎｔｓｕｎｄｅｒｇｏｉｎｇｏｒｔｈｏｐｅｄｉｃｓｕｒｇｅｒｙ，ｆｒａｉｌｔｙｅｖａｌｕ ａｔｅｄｂｙＲＥＦＳｉｓｓｉｇｎｉｆｉｃａｎｔｌｙａｓｓｏｃｉａｔｅｄｗｉｔｈＰＯＤ，ａｎｄＲＥＦＳｓｃｏｒｅｓｈｏｗｓｈｉｇｈｐｒｅｄｉｃｔｉｖｅｖａｌｕｅｆｏｒＰＯＤ． ［Ｋｅｙｗｏｒｄｓ］ Ｏｒｔｈｏｐｅｄｉｃｓｕｒｇｅｒｙ；Ｆｒａｉｌｔｙ；Ｐｏｓｔｏｐｅｒａｔｉｖｅｄｅｌｉｒｉｕｍ 术后谵妄（Ｐｏｓｔｏｐｅｒａｔｉｖｅｄｅｌｉｒｉｕｍ，ＰＯＤ）是一种术后短期内的认知功能障碍，常见于髋部骨折复位术后和心脏手术后，是老年患者常见的围术期并发症［１］。
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controlling nutritional status score Controlling Nutritional Status Score (CONUT)是一种评估患者营养状态的方法，可以用于预测手术后并发症和死亡率。
下面将从CONUT 的定义、评估方法、临床应用等几个方面进行阐述。
一、CONUT的定义
CONUT是Controlling Nutritional Status Score的缩写，意为控制营养状况评分，是一种用于评估患者的营养状态的方法。
通过评估血清白蛋白、总胆固醇和淋巴细胞计数三个指标，计算出CONUT分数。
CONUT分数越高，代表患者的营养状态越差。
二、CONUT的评估方法
1. 血清白蛋白：正常值为35-50g/L，低于该范围表示营养不良。
2. 总胆固醇：正常值为
3.10-5.17mmol/L，低于该范围也表示营养不良。
3. 淋巴细胞计数：正常值为1.0-3.5×109/L，低于该范围则反映免疫功能低下，提示营养不良。
通过对以上三个指标的评估，计算出CONUT的分数，分为0-4分，分数越高，患者的营养状态越差。
一般来说，CONUT分数在0-1分代表正常营养，1-2分表示轻度营养不良，2-4分则为中度至严重营养不良。
三、CONUT在临床中的应用
CONUT可以在手术前评估患者的营养状况，并预测手术后的并发症和死
亡率。
一些研究表明，CONUT分数较高的患者在手术后的感染和器官衰竭等并发症发生率较高，并且预后差。
除此之外，在长期康复期的评估中，CONUT也可以为临床医生提供可靠的指导。
对于患有肝病、营养不良等慢性疾病的患者，CONUT也可以作为评估治疗效果的一种方法。
总之，CONUT是一种简便、可重复性好的评估患者营养状态的方法，可以在临床中用于预测手术后的并发症和死亡率，对于营养不良等慢性疾病的康复期也有良好的应用。