|关键词||国家早期预警评分 肌钙蛋白 B型钠尿肽 可溶性白细胞分化抗原14 死亡率|
|其他题名||Combined use of the National Early Warning Score (NEWS) and biological markers to predict 30-day mortality in emergency patients|
入选2013年9月至2015年7月我院急诊抢救室收治的576例成人危重症患者（主要为严重脓毒症、心血管急重症及其他），记录患者一般情况、入抢救室时生命体征及意识状态，对其进行NEWS评分；并特别记录患者入抢救室2~4 h内检测的cTnI、NT-proBNP、以及12~24 h内检测的sCD-14st结果；随访30 d预后。通过ROC曲线、计算曲线下面积（AUC值）评价NEWS评分、NEWS评分联合cTnI及（或）NT-proBNP、NEWS评分联合sCD-14st对患者预后的评估价值。
本研究共纳入患者573例，其中男性322人（56.2%）、女性251人（43.8%），年龄31~97岁，平均75.8±11.4岁；其中心血管急重症患者292例（50.9%），严重脓毒症患者219例（38.2%）。30 d预后存活451例（78.7%），死亡122例（21.3%）；存活组与死亡组的年龄、NEWS评分比较，存在显著差异（P<0.05）。NEWS对评估急诊常见危重症患者30 d预后的ROC曲线下面积为0.713，临界值为7分，NEWS≥7分患者的近期病死率高于NEWS<7分患者；随着NEWS评分的增高，患者30 d病死率明显升高。
心血管急重症亚组共有222例患者进行血cTnI、NT-proBNP检测，30d预后存活186例（83.8%），死亡36例（16.2%）；死亡组与存活组的NEWS评分、cTnI、NT-proBNP比较存在显著差异（P<0.05）。NEWS评分、cTnI、NT-proBNP评估30 d不良预后的ROC曲线下面积分别为0.706、0.669、0.724，三者之间比较无明显差异（P >0.05）；三者的临界值水平分别为7分、0.03ng/ml、3197pg/ml，高于临界值水平患者30 d病死率较高；高于临界值项目越多，患者30 d病死率越高。NEWS评分联合cTnI或NT-proBNP的ROC曲线下面积明显高于单独应用NEWS评分的AUC值（0.764、0.786 vs 0.706，P<0.05），较单独应用cTnI或NT-proBNP的AUC值增高，其统计学差异不显著（0.764 vs 0.669、0.786 vs 0.724，P>0.05）。三者联合的ROC曲线下面积最大，为0.809，明显高于三者单独应用的AUC值（P<0.05）。
严重脓毒症亚组中共有129例患者进行血sCD-14st检测，随访30d预后，存活87例（67.4%），死亡42例（32.6%）；存活组与死亡组的NEWS、sCD -14st有显著差异。NEWS、sCD -14st评估患者30d预后的ROC曲线下面积分别为0.675、0.722，二者之间比较无明显统计学差异（P>0.05）。NEWS评分联合sCD-14st的ROC曲线下面积为0.748，明显高于单独应用NEWS评分的ROC曲下面积（P<0.05）；较单独应用sCD-14st的AUC值增高，其统计学差异不明显（P>0.05）。NEWS评分与sCD-14st联合升高的患者，30 d病死率明显升高。
1、NEWS评分对心血管急重症、严重脓毒症等急诊常见急危重症患者30 d不良预后具有一定的评估价值，NEWS≥7分患者30 d病死率较高。
The aim of this study was to investigate the prognostic evaluation value of the National Early Warning Scores (NEWS) in adult patients emergently with critical illness. We also compared NEWS to the combined application of NEWS and biological markers.
We designed a prospective cohort study and collected data on confirmed adult patients with critical illness who visited the emergency treatment between September 2013 and July 2015. General conditions,variables relevant to the NEWS on admission were recorded by researchers calculating the scores; the result of cTnI,NT-proBNP in four hours and sCD14-st in 24 hours were registered in the same way. The researchers followed the 30-day mortality by telephone calls. The ability to predict mortality was assessed through area under the receiver operating acteristic curve (ROC) analysis and the Youden index was used to compare different curves.
A total of 573 patients were enrolled, including 322 cases in male (56.2%) and 251 cases in female (43.8%), aged 31 to 97 years old (average 75.8±11.4). Cardiovascular disease accounted for the majority, about 50.9 percents (292 cases), followed by severe sepsis with 38.2 percents (219 cases). The inpatient mortality in 30-day was 21.3% (n=122). There were significant differences in survival group and death group compared with age and the NEWS (p<0.05). The area under the receiver operating acteristic curve (AUC) of the NEWS was 0.713(95% confidence interval [CI]:0.660-0.766), with the cut-off value 7. Mortality was significantly higher in patients with more than 7.
222 patients in subgroup of cardiovascular disease had been tested for the concentration of cTnI and NT-proBNP, with the 30-day mortality 16.2% (n=36). The difference of NEWS,cTnI and NT-proBNP between survival group and death group were distinct (p<0.05). The AUC of these three parameters were 0.706,0.669 and 0.724 respectively, without significant difference (p>0.05). The cut-off value of these three parameters above were 7,0.03ng/ml and 3197pg/ml ; mortality was higher in the high-score group. The area under the ROC of the combination of NEWS and cTnI or NT-proBNP were higher than that of the single application of NEWS (0.764,0.786 vs 0.706,P<0.05), and also higher than that of cTnI or NT-proBNP alone (0.764 vs 0.669,0.786 vs 0.724,P>0.05). Combination of these three parameters has the highest AUC: 0.809, significantly higher than any of them (P<0.05).
In the subgroup of severe sepsis, there were 129 patients tested for the concentration of sCD -14st, with the 30-day mortality 32.6% (n=42). The difference of NEWS and sCD -14st between survival group and death group were distinct (p<0.05). The AUC of them were 0.675,0.722 respectively, without significant difference (p>0.05). The area under the ROC of the combination of NEWS and sCD -14st were higher than that of the single application of NEWS (0.748 vs 0.675,P<0.05), and also higher than that of sCD -14st alone (0.748 vs 0.722 P>0.05). Patients with a rise in both parameters had higher mortality than others.
1,NEWS on admission is moderately associated with 30-day poor prognosis of patients with critical diseases in emergency room. A score of 7 or more was associated with a poor outcome.
2,The combination of NEWS and cTnI or NT-proBNP is more strongly associated with 30-day death in patients with severe cardiovascular disease compared to NEWS alone. Combination of these three parameters has the highest association with 30-day death, which is better than any of them alone.
3,The combination of NEWS and sCD -14st can improve the prognostic evaluation value of NEWS in patients with severe sepsis.
|杨鲁. 国家早期预警评分（NEWS）联合生物学标志物评估常见急危重症的初步研究[D]. 北京大学第五临床医学院. 北京大学,2016.|
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