库欣病术后静脉血栓栓塞症的危险因素分析及风险评估模型的建立

Risk factors and development of a risk assessment model for postoperative venous thromboembolism in Cushing′s disease

目的探究库欣病患者术后静脉血栓栓塞症(venous thromboembolism,VTE)的发病率和促血栓形成的危险因素,并进一步开发评估模型,以识别术后血栓事件风险高的患者。方法回顾性收集82例自2019年1月至2020年1月就诊于复旦大学附属华山医院并确诊库欣病患者的临床资料,评估激素水平和凝血参数,必要时进行超声检查和肺动脉造影计算机断层扫描(CT)检查。根据是否发生术后VTE进行分组,分析术后VTE的危险因素。采用最小绝对收缩和选择算子(least absolute shrinkage and selection operator,LASSO)回归分析筛选独立危险因素,初步建立库欣病术后VTE风险评估的列线图模型,并采用Bootstrap法进行内部验证。最后,在研究队列中对预测模型进行校准度和临床适用度的评估。结果19例(23.17%)患者发生VTE,其中14例发生于经鼻蝶垂体瘤切除术后。与未发生VTE的患者相比,VTE组患者年龄较大(P<0.001),且术后卧床时间更长、现患感染率更高、HbA1C更高、糖耐量受损更严重(均P<0.05)。通过LASSO回归分析,筛选出术后VTE的2个独立危险因素,即年龄和现患感染。在VTE风险评估的列线图模型中,受试者工作特征曲线的曲线下面积为0.868(95%CI 0.787~0.949),列线图校准曲线接近于理想的对角线,临床决策曲线高于两条极端曲线。结论在库欣病的临床诊疗中,需要进行更深入的术前评估,筛查库欣病VTE风险高的患者。此外,库欣病患者围手术期需要进行被动物理活动或预防性抗凝治疗。

ObjectiveTo investigate the incidence and prothrombotic risk factors of postoperative venous thromboembolism(VTE)in Cushing′s disease and to further develop an assessment model to identify those at high risk of postoperative VTE events.MethodsA retrospective study was performed in 82 patients who were admitted to Huashan Hospital,Fudan University during January 2019 and January 2020 and diagnosed with Cushing′s disease.These patients underwent the evaluation about their clinical,hormonal,and coagulation parameters,as well as ultrasonography and pulmonary angio-CT when necessary.The least absolute shrinkage and selection operator(LASSO)regression analysis was used to screen independent risk factors,and a nomogram model for postsurgical VTE risk assessment in Cushing′s disease was initially established,and Bootstrap method was used for internal verification.Finally,the predictive model was evaluated for calibration and clinical applicability in the study cohort.ResultsNineteen patients(23.17%)developed VTE events,with 14 cases occurring after endoscopic transsphenoidal surgery.Compared to patients without VTE,those in the VTE group were older(P<0.001),had longer postoperative bed rest,higher rates of current infection,higher HbA 1C levels,and more severe glucose tolerance impairment(all P<0.05).Through LASSO regression analysis,two independent risk factors for postoperative VTE were identified:Age and current infection.Then a VTE risk assessment nomogram model was established to predict the patients at high risk of VTE.In the nomogram model for VTE risk assessment,the area under the receiver operating characteristic curve was 0.868(95%CI 0.787-0.949),with the calibration curve closely aligning with the ideal diagonal line and the clinical decision curve exceeding the two extreme curves.ConclusionsAdvanced perioperative assessment needs to be taken to screen those with high VTE risks in patients diagnosed with Cushing′s disease.Additionally,during the perioperative period,patients with Cushing′s disease should undergo mandatory physical activity or prophylactic anticoagulant therapy.