急診醫學評分系統對於預測急診病患死亡率的效能：從創傷弧菌感染與細胞性肝膿瘍的證據

Performance of emergency medicine score system for predicting mortality in emergency department patients: evidences from Vibrio Vulnificus infection and pyogenic liver abscess

郭勝弘(Sheng-Hung Kuo)

指導教授 ： 陳宣志 ； 翁瑞宏

中山醫學大學/醫學院/醫學研究所/博士(2014年)

https://doi.org/10.6834/CSMU.2014.00201

摘要

急診醫學評分系統 (emergency medicine score system) 對於急診部門病患之死亡率預測是有價值的，可提供給臨床者當作對於這些病患進行危險性區分的一項及時的、可行的、且可靠的輔助工具。
首先，我們評估171名創傷弧菌 (Vibrio vulnificus) 感染患者在到院時的疾病嚴重度評分模式的效能 (平均年齡：63.1 ± 12.3歲)。每位病患的人口學和臨床特徵、到院時之疾病嚴重度、處置方法、以及結果都被收集，並被取出分析，邏輯斯迴歸 (logistic regression) 與接受者操作特徵曲線 (receiver operating characteristic curve [ROC curve])　則被執行。在到院時，病患的平均快速急診醫學分數 (Rapid Emergency Medicine Score [REMS]) 為6.5 ± 3.0分。在多變項分析中，原先具有肝臟疾病的呈現 (P = 0.002)、出血性水皰損傷 (hemorrhagic bullous lesions) 與壞死性筋膜炎 (necrotizing fasciitis) (P = 0.012)、以及到院時較高的REMS分數 (P < 0.0001) 是相關於增加的死亡危險性；在到院與手術處置之間的時間間隔不到24小時則相關於降低的死亡危險性 (P = 0.007)。此外，REMS在預測死亡危險性的ROC曲線下面積是0.895 (P < 0.0001)；最適的切點是REMS >= 8，其敏感度為81%、特異度為85%、以及26.6倍的死亡危險性 (P < 0.0001)。
接續，我們評估431名具有細菌性肝膿瘍 (pyogenic liver abscess [PLA]) 病患的死亡率預測指標。從病歷所獲得的資料，包括臨床特徵、實驗室檢驗、處置、以及結果都被分析，並且執行多變項邏輯斯廻歸 (logistic regression) 與ROC曲線分析。細菌性肝膿瘍病患到院時之急診部門敗血症死亡率 (Mortality in Emergency Department Sepsis [MEDS]) 分數平均為4.8 ± 4.1分 (範圍：0-17)。多變項分析顯示，到院時較高的MEDS分數 (P < 0.001)、以及原先具有惡性腫瘤的呈現 (P = 0.006)、多發性膿瘍 (P = 0.001)、厭氧菌感染 (P < 0.0001)、高膽紅素血症 (hyperbilirubinemia, P < 0.0001)、以及高血清肌酸酐 (serum creatinine) 濃度 (P < 0.0001) 是顯著地相關於細菌性肝膿瘍死亡率。MEDS對於預測細菌性肝膿瘍死亡率的ROC曲線下面積是0.829 (P < 0.0001)，在最適切點MEDS數值為7或以上的敏感度為76%以及特異度為81%，具有10.7倍的細菌性肝膿瘍死亡危險性 (P < 0.0001)。
我們的結論是，REMS可提供給臨床者來對於創傷弧菌感染病患作為一項有效的輔助危險分級工具，並且到院時的MEDS分數對於具有細菌性肝膿瘍之患者是顯著的預後指標。

關鍵字

創傷弧菌 ； 快速急診醫學分數 ； 細菌性肝膿瘍 ； 急診部門敗血症死亡率

並列摘要

Emergency medicine score system for predicting mortality in emergency department (ED) patients could be of great value in providing ED clinicians with an immediate, feasible, and reliable adjunct tool for risk stratification in these patients.
Initially, we evaluated the performance of the severity-of-illness scoring model on admission in 171 Vibrio vulnificus (V vulnificus)-infected patients (mean age: 63.1 ± 12.3 years). Demographic and clinical characteristics, illness severity on admission, treatment, and outcomes were collected for each patient and extracted for analysis. Logistic regression and receiver operating characteristic (ROC) curve analyses were performed. The mean Rapid Emergency Medicine Score (REMS) on admission was 6.5 ± 3.0 points. In multivariate analysis, the presence of underlying liver disease (P = 0.002), hemorrhagic bullous lesions/necrotizing fasciitis (P = 0.012), and higher REMS values on admission (P < 0.0001) were associated with increased mortality risk; a time span < 24 hours between arrival and surgical treatment was associated with a decreased mortality risk (P = 0.007). Additionally, the area under the ROC curve for the REMS in predicting mortality risk was 0.895 (P < 0.0001). An optimal cut-off REMS ≥ 8 had a sensitivity of 81% and a specificity of 85%, with a 26.6-fold mortality risk (P < 0.0001).
Subsequently, we evaluated the predictor index of mortality in 431 patients with pyogenic liver abscess (PLA). Clinical characteristics, laboratory results, treatments, and outcomes retrieved from medical records were analyzed. Multiple logistic regression and ROC curve analyses were performed. The mean Mortality in Emergency Department Sepsis (MEDS) score on admission in PLA patients was 4.8 ± 4.1 (range, 0-17). Multivariate analysis revealed that higher MEDS scores on admission (P < 0.0001) and the presence of underlying malignancy (P = 0.006), multiple abscesses (P = 0.001), anaerobic infections (P < 0.0001), hyperbilirubinemia (P < 0.0001), and higher serum creatinine levels (P < 0.0001) were significantly associated with PLA mortality. The estimated area under the receiver operating characteristic curve for MEDS in predicting PLA mortality was 0.829 (P < 0.0001). The optimal cutoff MEDS value of 7 or higher had a sensitivity of 76% sensitivity and a specificity of 81%, with a 10.7-fold PLA mortality risk (P < 0.0001).
Our conclusions are that the REMS could provide clinicians with an effective adjunct risk stratification tool for V vulnificus-infected patients; and the MEDS scores on admission represent a significant prognostic indicator for patients with PLA.

並列關鍵字

Vibrio vulnificus ； Rapid Emergency Medicine Score ； pyogenic liver abscess ； Mortality in Emergency Department Sepsis.

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