王曉波　杜潘艷　趙玉萍　王寶林　高翠紅　張　雙

(唐山市婦幼保健院，唐山063000)

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手足口病重癥患兒營(yíng)養(yǎng)素水平與病情的相關(guān)性分析

王曉波杜潘艷趙玉萍王寶林高翠紅張雙

(唐山市婦幼保健院，唐山063000)

[摘要]目的：探討手足口病患兒外周血中營(yíng)養(yǎng)素前白蛋白(PA)、纖維連接蛋白(FN)、視黃醇結(jié)合蛋白(RBP)、C-反應(yīng)蛋白(CRP)、微量元素鐵、鋅及維生素D(VitD)水平與病情的相關(guān)性。方法：采用免疫比濁法檢測(cè)PA、FN、RBP和CRP水平；采用火焰原子吸收法檢測(cè)全血微量元素鐵、鋅水平；采用電化學(xué)發(fā)光法檢測(cè)VitD水平。結(jié)果：重癥組與普通組、對(duì)照組比較，PA、FN、RBP、鐵、鋅及VitD水平均低，CRP水平升高(P<0.05)；普通組與對(duì)照組比較，PA 、FN和RBP水平均降低，CRP水平升高(P<0.05)；鐵、鋅及VitD水平在普通組和對(duì)照組間無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05)。重癥恢復(fù)期PA、FN、RBP、鐵、鋅及VitD水平均高于急性期(P<0.01)，但仍低于對(duì)照組(P<0.05)；恢復(fù)期CRP水平與對(duì)照組無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05)。PA、FN和RBP水平與手足口病病情呈顯著負(fù)相關(guān)(P<0.05)；而CRP與病情呈顯著正相關(guān)(P<0.05)；鐵、鋅、VitD水平與病情呈低度負(fù)相關(guān)(P<0.05)。結(jié)論：手足口病重癥病例存在營(yíng)養(yǎng)缺乏，臨床應(yīng)對(duì)其進(jìn)行營(yíng)養(yǎng)狀態(tài)動(dòng)態(tài)評(píng)估并適量補(bǔ)充營(yíng)養(yǎng)。

[關(guān)鍵詞]手足口??；重癥；營(yíng)養(yǎng)素；相關(guān)性

手足口病(Hand，foot and mouse disease，HFMD)是一種主要由腸道病毒引發(fā)的急性傳染病。普通病例呈自限性，重癥病例可合并神經(jīng)系統(tǒng)、呼吸系統(tǒng)、循環(huán)系統(tǒng)等嚴(yán)重并發(fā)癥[1]。低齡兒童是易感人群。有研究表明兒童體內(nèi)營(yíng)養(yǎng)素缺乏可影響免疫系統(tǒng)功能，容易發(fā)生感染性疾病[2，3]。本研究對(duì)本院確診的手足口病患兒外周血中營(yíng)養(yǎng)指標(biāo)前白蛋白(Pre albumin，PA)、纖維連接蛋白(Fibronectin，F(xiàn)N)、視黃醇結(jié)合蛋白(Retinol binding protein，RBP)、C-反應(yīng)蛋白(C- reactive protein，CRP)、微量元素鐵(Iron)、鋅(Zinc)及維生素D(Vitamin D，VitD)水平等進(jìn)行總結(jié)分析，并探討其與病情相關(guān)性。

1資料與方法

1.1研究對(duì)象病例組為2013年6月～2015年8月期間于本院兒科已確診的手足口病病例381例，年齡4月～8歲，平均年齡(3.2±1.2)歲。根據(jù)《手足口病診療指南 (2010年版)》臨床分類(lèi)標(biāo)準(zhǔn)[4]表1病例組和對(duì)照組比較結(jié)果將病例分為普通組和重癥組。普通組276例，男142例，女134例，平均年齡(3.4±1.1)歲；重癥組105例，男56例，女49例，平均年齡(2.9±1.0)歲。對(duì)照組88例，為病例收集同期于兒童保健科體檢的健康兒童，男47例，女41例，年齡4月～8歲，平均年齡(3.2±1.0)歲，且近1月內(nèi)未發(fā)生過(guò)消化系統(tǒng)疾病。對(duì)照組與病例組間性別、年齡比較，均無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05)。

Tab.1Comparison between case group and control group

GroupsCasesPA(mg/L)FN(mg/L)RBP(mg/L)CRP(mg/L)Iron(mmol/L)Zn(μmol/L)VitD(nmol/L)Control88256.9±33.4236.6±38.939.4±8.21.7±0.98.4±2.289.4±8.341.6±8.4General276224.3±40.2217.3±44.734.6±10.515.5±9.28.2±2.386.8±17.938.2±16.6Severe105182.5±30.6168.6±43.926.7±9.445.4±19.76.7±2.670.4±12.831.5±12.7P1)<0.05P2)<0.05>0.05

Note：1)Comparison between the severe group and the general、control group;2)Comparison between the general group and control group.

表2重癥組急性期與恢復(fù)期比較結(jié)果

Tab.2Comparison between acute phase and convalescence of severe group

GroupsCasesPA(mg/L)FN(mgl/L)RBP(mg/L)Iron(mmol/L)Zn(umol/L)VitD(nmol/L)CRP(mg/L)Control88256.9±33.4236.6±38.939.4±8.28.4±2.289.4±8.341.6±8.41.7±0.9Acutestage105182.5±30.6168.6±43.926.7±9.46.7±2.670.4±12.831.5±12.745.4±19.7Recoveryperiod105211.4±46.6192.4±48.532.8±10.77.3±2.880.8±8.436.5±10.72.4±1.5P1)<0.01P2)<0.05>0.05

Note：1)Comparison of convalescence and acute phase;2)Comparison of convalescence and control group.

1.2實(shí)驗(yàn)方法采集研究對(duì)象入院12 h內(nèi)及重癥患兒恢復(fù)期空腹靜脈血3管，一管肝素鋰抗凝2 ml，采用火焰原子吸收法檢測(cè)全血微量元素鐵、鋅水平，試劑由北京博暉公司提供；兩管無(wú)抗凝劑3 ml，分離血清，其中1管采用免疫比濁法檢測(cè)PA、FN、RBP、CRP水平，試劑由南京波音特生物科技公司提供；另1管采用電化學(xué)發(fā)光法檢測(cè)維生素D水平，試劑為德國(guó)羅氏診斷公司提供。

2結(jié)果

2.1病例組和對(duì)照組比較結(jié)果重癥組與普通組、對(duì)照組比較，患兒PA、FN、RBP、鐵、鋅及VitD水平均低，CRP水平升高，差異均有統(tǒng)計(jì)學(xué)意義(P<0.05)；普通組與對(duì)照組比較，PA、FN和RBP水平均降低，CRP水平升高，差異均有統(tǒng)計(jì)學(xué)意義(P<0.05)；微量元素鐵、鋅及VitD水平在普通組和對(duì)照組間無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05)。見(jiàn)表1。

表3營(yíng)養(yǎng)素與HFMD病情相關(guān)性

Tab.3Correlation between nutrients and state of HFMD

StatisticavaluePAFNRBPCRPIronZnVitDr-0.784-0.717-0.7220.812-0.435-0.341-0.451P<0.05

2.2重癥組急性期與恢復(fù)期比較結(jié)果重癥組患兒恢復(fù)期與急性期比較，PA、FN、RBP、鐵、鋅及VitD水平均升高(P<0.01)；但這些指標(biāo)水平均低于對(duì)照組(P<0.05)；恢復(fù)期CRP水平降低，與對(duì)照組無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05)。見(jiàn)表2。

2.3營(yíng)養(yǎng)素與HFMD病情相關(guān)性PA、 FN、RBP水平與HFMD病情呈顯著負(fù)相關(guān)(P<0.05)；而CRP與病情呈顯著正相關(guān)(P<0.05)；鐵、鋅、VitD水平與病情呈中度負(fù)相關(guān)(P<0.05)。見(jiàn)表3。

3討論

手足口病起病急，病情發(fā)展迅猛，控制不及時(shí)容易發(fā)展成重癥病例，甚至危及生命。HFMD的發(fā)生發(fā)展與機(jī)體免疫水平密切相關(guān)[5]，而人體免疫水平的高低受多種因素影響，其中營(yíng)養(yǎng)因素起著非常重要的作用，是維持人體正常免疫功能和健康的物質(zhì)基礎(chǔ)。營(yíng)養(yǎng)失調(diào)會(huì)對(duì)人體免疫系統(tǒng)造成很大損傷。有研究顯示在發(fā)展中國(guó)家入院或重癥監(jiān)護(hù)病房存在急性或慢性營(yíng)養(yǎng)不良的患兒可達(dá)53%[6]。

PA、FN、RBP對(duì)于急性營(yíng)養(yǎng)不良具有早期診斷價(jià)值，能及時(shí)反映患者腸外營(yíng)養(yǎng)狀況及恢復(fù)[7,8]。微量元素鐵、鋅和VitD在調(diào)節(jié)和介導(dǎo)免疫反應(yīng)的過(guò)程中有著重要的作用，營(yíng)養(yǎng)素缺乏影響機(jī)體免疫功能[9-11]。本研究中HFMD病患兒，尤其是重癥病例營(yíng)養(yǎng)素水平均低，與病情嚴(yán)重程度呈負(fù)相關(guān)，提示手足口病存在營(yíng)養(yǎng)素缺乏，營(yíng)養(yǎng)素水平可能影響機(jī)體正常的免疫功能。住院期間患兒受多種因素影響，營(yíng)養(yǎng)狀況進(jìn)一步惡化，易導(dǎo)致病情加重，而病情惡化又會(huì)影響營(yíng)養(yǎng)素的攝入、合成和吸收[3]。因此重癥患兒住院期間營(yíng)養(yǎng)風(fēng)險(xiǎn)篩查和營(yíng)養(yǎng)評(píng)估至關(guān)重要。

CRP作為非特異性急性炎性反應(yīng)標(biāo)記物，在急性應(yīng)激反應(yīng)狀態(tài)下，肝臟優(yōu)先合成CRP而減少合成白蛋白、前白蛋白[12]。有研究用CRP與PA的比值作為評(píng)估消化系統(tǒng)手術(shù)成功的指標(biāo)[13]。本研究中CRP水平與HFMD病情呈顯著正相關(guān)，提示CRP不僅可以判斷疾病的嚴(yán)重程度[14]，還可以間接反映患者營(yíng)養(yǎng)狀況。

本研究中重癥患兒恢復(fù)期營(yíng)養(yǎng)素水平均高于急性期，提示臨床應(yīng)對(duì)重癥病例進(jìn)行營(yíng)養(yǎng)狀態(tài)動(dòng)態(tài)評(píng)估，有助于監(jiān)測(cè)病情。重癥患兒恢復(fù)期營(yíng)養(yǎng)素水平仍低于健康兒童，可能由于病毒對(duì)患兒機(jī)體造成炎性反應(yīng)，盡管處于恢復(fù)期，但仍會(huì)影響機(jī)體對(duì)營(yíng)養(yǎng)素的吸收和合成。

綜上所述，手足口病重癥患兒存在營(yíng)養(yǎng)素缺乏狀況，在疾病的診療過(guò)程中進(jìn)行定期、動(dòng)態(tài)評(píng)估并及時(shí)給予補(bǔ)充，可利于監(jiān)測(cè)病情及改善預(yù)后。

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[收稿2015-09-11修回2015-09-21]

(編輯倪鵬)

Correlation of nutrient levels and state of severe cases with HFMD

WANGXiao-Bo,DUPan-Yan,ZHAOYu-Ping,WANGBao-Lin,GAOCui-Hong,ZHANGShuang.

TangshanWomenandChildrenHealth-CareHospital,Tangshan063000，China

[Abstract]Objective:To detect the levels of PA,FN,RBP,CRP,Iron,Zinc,VitD in peripheral blood of children with HFMD and to explore the relationship between them and the disease.Methods: The levels of PA,FN,RBP and CRP were detected by immune turbidimetric assay;and the levels of Iron and Zinc were detected by flame atomic absorption spectrometry;while the levels of VitD were detected by electro chemilumin escence.Results: The levels of PA,FN,RBP,Iron,Zinc and VitD in the severe group were lower than those in other groups,while the levels of CRP were higher than those in other groups(P<0.05);and the levels of PA,FN and RBP in the general group were lower than that in the control group,while the levels of CRP were higher than that in the control group(P<0.05).And no significance were found of the levels of Iron,Zinc and VitD in the general group and the control group(P>0.05).The levels of PA,FN,RBP,Fe,Zn and VitD in the convalescence were higher than those in the acute phase of the severe cases(P<0.01)，and lower than those in the control group(P<0.05);And no statistical significance were found of the levels of CRP between the convalescent phase of severe cases and the control group(P>0.05).There were negative correlation between the levels of PA,FN,RBP and the state of HFMD(P<0.05),while there were positive correlation between the levels of CRP and the state of HFMD(P<0.05).And there were low negative correlation between the levels of Iron,Zinc,VitD and the state of HFMD(P<0.05),respectively.Conclusion: There were nutritional deficiency in severe cases of HFMD,and the nutritional status should be assessed dynamically,then proper amount of nutrition should be supplement.

[Key words]HFMD;Severe cases;Nutrients;Correlation

中圖分類(lèi)號(hào)R725.1

文獻(xiàn)標(biāo)志碼A

文章編號(hào)1000-484X(2016)03-0414-03

作者簡(jiǎn)介：王曉波(1976年-)，男，主管檢驗(yàn)師,主要從事臨床兒科檢驗(yàn)研究。

doi:10.3969/j.issn.1000-484X.2016.03.026