脊柱外科杂志  2020, Vol.18 Issue(5): 331-334   PDF    
强直性脊柱炎患者生活质量的影响因素分析
王茂蓉, 彭娜     
华中科技大学同济医学院附属协和医院骨科, 武汉 430022
摘要: 目的 探讨影响强直性脊柱炎(AS)患者生活质量的相关因素。方法 选取2017—2019年在本院治疗的AS患者为研究对象。采集患者空腹静脉血,检测人类白细胞抗原B27(HLA-B27)、C反应蛋白(CRP)、红细胞沉降率(ESR)。采用AS疾病活动评分-CRP指标(ASDAS-CRP)评估患者疾病活动情况,改良Stoke AS脊柱评分系统(mSASSS)评估脊柱病变情况,AS生活质量问卷(ASQoL)评估患者生活质量。结果 共纳入患者206例,中位年龄37.4岁,男性患者占75.2%(155/206),HLA-B27阳性患者占59.2%(122/206)。Kendall'相关分析结果显示,与ASQoL评分相关的因素有年龄、体质量指数(BMI)、学历、工作状况、病程、婚姻状况和HLA-B27,其中年龄与ASQoL的相关系数最大(r=0.815),其次为病程(r=0.786)。多重线性回归分析显示,影响ASQoL评分的因素为年龄、HLA-B27、工作状况、学历和婚姻状况,其中影响最大的因素为年龄(β=0.654),其次为HLA-B27(β=0.335)。结论 年龄、HLA-B27、工作状况、学历和婚姻状况是AS患者ASQoL评分的影响因素。在AS的长期治疗中需要积极干预,以提高患者生活质量。
关键词: 脊柱炎, 强直性    生活质量    因素分析, 统计学    
Analysis of factors influencing quality of life in patients with ankylosing spondylitis
WANG Mao-rong, PENG Na     
Department of Orthopaedics, Union Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, Hubei, China
Abstract: Objective To explose the factors influencing quality of life in patients with ankylosing spondylitis(AS). Methods The AS patients who were treated in our hospital in 2017-2019 were selected as the research objects. The fasting venous blood samples were collected to detect human leukocyte antigen B27(HLA-B27), C-reactive protein(CRP) and erythrocyte sedimentation rate(ESR). The ankylosing spondylitis disease activity score-C-reactive protein index(ASDAS-CRP) was used to assess the patient's disease activity. The modified stoke ankylosing spondylitis spine score(mSASSS) was used for spinal lesions; the Ankylosing Spondylitis Quality of Life(ASQoL) was used to assess the patient's quality of life. Results A total of 206 patients were enrolled in the study, with the median age of 37.4 years old, 75.2%(155/206) being male, and 59.2%(122/206) being HLA-B27 positive. Kendall' correlation analysis showed that ASQoL was correlated with age, body mass index, education, work status, duration of disease, marital status and HLA-B27, among which the correlation coefficient between age and ASQoL was the largest(r=0.815), followed by disease course(r=0.786). Multiple linear regression analysis showed that age, HLA-B27, work status, education and marital status were the factors influencing ASQoL, among which the most influential factor was age(β=0.654), followed by HLA-B27(β=0.335). Conclusion Age, HLA-B27, work status, education and marital status have a greater impact on ASQoL in AS patients. Active intervention in long-term treatment of AS is needed to improve quality of life in AS patients.
Key words: Spondylitis, ankylosing    Quality of life    Factor analysis, statistical    

强直性脊柱炎(AS)是一种常见的炎性关节炎,发生率约为0.5%[1],其中遗传因素是疾病风险和严重程度的主要决定因素[2]。AS轴外表现包括急性葡萄膜炎、外周关节炎、附着点炎(肌腱插入骨骼的炎症)、主动脉根部和肠道炎症[3],引起一系列关节症状及关节外症状,严重影响患者的生活质量[4]。近年来,随着临床研究的深入和生物医学模式的转变,AS患者的生活质量引起临床广泛关注,针对生活质量进行有效干预被认为是AS治疗的重要组成部分[4-6]。本研究通过临床检查资料和问卷调查相结合的方法,分析影响AS患者生活质量的危险因素,为AS的治疗提供依据,现报告如下。

1 资料与方法 1.1 研究对象

选取2017—2019年本院收治的AS患者为研究对象。纳入标准:所有患者均经过专业的影像科医师阅片(X线、CT),符合AS诊断标准;所有患者均知情同意,并签署知情同意书。排除标准:①患有抑郁症或其他严重心理和精神疾病;②患有严重心脏病、脑部疾病、肺部疾病、肿瘤等影响生命质量的疾病;③临床资料不完整;④不能配合研究。

AS诊断参照美国风湿病学会2009年推荐的中轴型脊柱关节病(SpA)分类标准[7]。患者起病年龄 < 45岁且腰背痛≥3个月,并符合下述标准中的1项:①影像学提示骶髂关节炎(MRI提示骶髂关节活动性/急性炎症,或根据1984年修订的纽约标准[8]有明确的骶髂关节炎影像学改变),且具有至少1个SpA特征;②人类白细胞抗原B27(HLA-B27)阳性,且具有至少2个SpA特征。SpA特征:①炎性背痛;②关节炎;③起止点炎(跟腱);④眼葡萄膜炎;⑤指(趾)炎;⑥银屑病;⑦克罗恩病(溃疡性结肠炎);⑧对非甾体抗炎药反应良好;⑨SpA家族史;⑩HLA-B27阳性;C反应蛋白(CRP)升高。

1.2 资料收集

采集患者来院当天或入院后第2天清晨空腹静脉血,检测HLA-B27、CRP和红细胞沉降率(ESR)。采用AS疾病活动评分-CRP指标(ASDAS-CRP)评估患者疾病活动情况[9-10],改良Stoke AS脊柱评分系统(mSASSS)[11]评估脊柱病变情况,AS生活质量问卷(ASQoL)[12](0 ~ 18分,分数越高代表生活质量越差)评估患者生活质量。量表评估和审核由经过培训的研究者完成。

1.3 统计学处理

采用SPSS 25.0软件对数据进行统计学分析。符合正态分布的计量资料以x±s表示,不符合正态分布的计量资料以中位数(0.25百分位数,0.75百分位数)表示。相关性分析采用Pearson和Kendall分析法,多重线性回归分析采用逐步向前法;以P < 0.05为差异有统计学意义。

2 结果 2.1 一般资料

共206例患者纳入本研究。患者中位年龄为37.4(24.93,42.70)岁;男性155例(75.2%),女性51例(24.8%);体质量指数(BMI)≤18.5 kg/m2 11例(5.3%),18.5 kg/m2 < BMI < 24 kg/m2 99例(48.1%),BMI≥24 kg/m2 96例(46.6%);90例(43.7%)有吸烟史,116例(56.3%)无吸烟史;109例(52.9%)为初中及以下学历,43例(20.9%)为高中学历,52例(25.2%)为本科学历,2例(1.0%)为研究生及以上学历;132例(64.1%)有工作,74例(35.9%)无业;中位病程6.40(2.66,10.83)年;141例(68.4%)已婚,65例(31.6%)未婚;HLA-B27阳性122例(59.2%),阴性84例(40.8%);中位CRP为23.70(12.85,31.73)mg/L;中位ESR为31.00(17.00,46.00)mm/h;中位ASDAS-CRP为3.10(2.00,4.00);中位mSASSS为2.98(1.30,4.80);中位ASQoL为8.15(4.90,11.00)。

2.2 各变量与ASQoL评分的相关性

Kendall相关分析结果显示,与ASQoL相关的因素有年龄(r=0.815,P < 0.05)、BMI(r=0.672,P < 0.05)、学历(r=-0.566,P < 0.05)、工作状况(r=-0.239,P < 0.05)、病程(r=0.786,P < 0.05)、婚姻状况(r=-0.565,P < 0.05)和HLA-B27(r=0.699,P < 0.05),其中年龄与ASQoL的相关系数最大,其次为病程。性别(r=-0.037,P > 0.05)、吸烟(r=0.024,P > 0.05)、CRP(r=0.041,P > 0.05)、ESR(r=0.112,P > 0.05)、ASDAS-CRP(r=0.043,P > 0.05)、mSASSS(r=0.046,P > 0.05)与ASQoL无相关性。

2.3 ASQoL评分影响因素的多重线性回归分析

多重线性回归分析结果显示,年龄、HLA-B27、工作状况、学历及婚姻状况被纳入到回归模型中,是影响ASQoL评分的因素,其中影响最大的因素为年龄,其次为HLA-B27(表 1)。

表 1 ASQoL评分影响因素的多重线性回归分析 Tab. 1 Analysis of related factors on ASQoL score using multiple linear regression
3 讨论

AS患者除了典型的关节症状,亦常并发骨质疏松、疲劳、焦虑抑郁、睡眠障碍及生育力可能降低等关节外症状,极大地影响了患者的身心健康,降低了常规治疗效果[3-4]。这些症状与AS本身导致的炎症、疼痛及功能障碍有关,亦与性别、年龄及社会心理因素密不可分[6]。关注AS患者的关节外症状,探寻影响AS患者生活质量的相关因素并采取针对性干预措施,对于进一步提升AS的整体诊治水平具有重要意义。

ASQoL是基于需求的生活质量模型,内容源自对AS患者的访谈。根据基于需求的模型,生活质量被定义为个人能够满足其基本需求的程度。当满足这些需求时,生活质量很高,而不满足这些需求时,生活质量很差[13]。该模型已被用于包括风湿性疾病(如类风湿关节炎、骨关节炎、银屑病性关节炎和系统性红斑狼疮)在内的多种免疫系统疾病中,并已经过验证可用于AS患者[14]。此外,ASQoL已被证明符合Rasch模型,提供了其单维度和构造有效性的证据[15]。本研究选择ASQoL作为评价生活质量的工具,分析了影响AS患者生活质量的相关因素。Piekutin等[16]的研究发现,随着年龄的增加,AS患者对疾病的适应性更差、患抑郁症的风险更高。Yildirim等[17]的研究发现,AS患者存在焦虑和抑郁等负面情绪,影响其生活质量,年龄高、学历低和婚姻不幸福可能进一步加剧AS患者的负面情绪。一般认为,AS与HLA-B27有直接关系,HLA-B27阳性者AS发生率为10% ~ 20%,并且AS的严重程度及生活质量与HLA-B27有相关性[18]。还有研究发现,AS与代谢综合征密切相关,病程、高尿酸血症和高BMI是AS患者的独立危险因素[19]。在本研究中,相关分析结果表明,与ASQoL相关的因素有年龄、BMI、学历、工作状况、病程、婚姻状况和HLA-B27(P < 0.05),其中年龄与ASQoL的相关系数最大(r=0.815),其次为病程(r=0.786)。多重线性回归分析结果显示,影响ASQoL评分的因素为年龄、HLA-B27、工作状况、学历和婚姻状况,其中影响最大的因素为年龄(β=0.654),其次为HLA-B27(β=0.335)。

除了常规的药物治疗以外,针对上述影响生活质量的因素,AS患者的治疗还应当注意护理干预、运动干预等辅助治疗,以改善患者生活质量,提高总体治疗效果。研究发现,适当的运动和心理干预能明显改善AS患者的生活质量[17, 20]。还有研究表明,采取积极的护理干预(心理干预、饮食干预、睡眠干预和功能训练等)能有效地提高AS非手术治疗患者的脊柱活动度、睡眠质量及生活质量[21]。此外,Pécourneau等[22]通过荟萃分析发现,运动干预能明显改善AS患者的生活质量,促进机体功能恢复。因此,医务人员应积极与病患家属沟通,指导其给予患者更多的关心,及时采取有针对性的干预措施,提高患者生活质量。

综上所述,本研究评估了影响AS患者生活质量的非关节症状因素,发现年龄、HLA-B27、工作状况、学历和婚姻状况对AS患者生活质量影响较大,在AS的长期治疗中要积极干预以提高患者生活质量。

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