臺灣博碩士論文加值系統

背景：感染性心內膜炎是一種位於心臟內部表面的微生物感染症，其疾病特徵包括由血小板、纖維蛋白（fibrin）、微生物以及發炎細胞所組成的贅生物（vegetation），其發生率在歐美為1.6-7.2人／每十萬人-年，男性與女性比例為1.7 : 1。此疾病影響的部位通常在中膈缺損處、腱索（chordae tendineae）、以及心臟內膜或瓣膜。臨床診斷標準包括1981年提出的von Reyn 準則和1994年提出的Duke準則（Duke criteria），目前國際間都是以2000年提出的改良Duke準則（Modified Duke criteria）作為感染性心內膜炎診斷的準則，其診斷條件包含了特殊臨床症狀及表徵、誘發因子、血液培養及心臟超音波結果。目前並無研究針對改良Duke準則下確定診斷和疑似診斷感染性心內膜炎患者的預後直接進行分析與討論。
研究目的：本研究主要探討以改良Duke準則得到確定診斷與疑似診斷感染性心內膜炎患者，記錄其潛在疾病、併發症、以及死亡率，藉以探討兩組間預後的差異。除了更進一步了解改良Duke準則在臨床上扮演的角色之外，更希望促使臨床醫療人員以更客觀的態度來面對與治療這些病人。
研究設計：本研究為回溯性病例對照研究，收集在1999年一月一日至2005年十二月三十一日共七年間，於中山醫學大學附設醫院出院的病患，年齡大於十八歲，出院診斷為感染性心內膜炎的事件，在改良Duke準則下比較確定診斷與疑似診斷感染性心內膜炎的病患之間其預後是否具有差異。
結果：除了與改良Duke準則定義中主要條件與次要條件相關的因子之外，確定診斷感染性心內膜炎患者比疑似診斷的患者年齡較輕（p<0.01）、院內感染比例較高、（p=0.04）、白血球分類中分節型白血球比例較高（p<0.01）、血小板數量較低（p<0.01）、血中C反應蛋白濃度較高（p<0.01）、以及併發症比例較高。雖然前者平均死亡率略高，但二者之間並無統計學顯著意義（p=0.14）。
結論：以死亡率來看，疑似診斷感染性心內膜炎患者的預後並不比疑似診斷患者要好。因此，臨床上不可輕忽疑似診斷感染性心內膜炎患者，他們同樣需要積極加以治療。

Background: Infective endocarditis is a microbial infection of the endocardial surface of the heart. The vegetation, the characteristic lesion, is composed of a collection of platelets, fibrin, microorganisms, and inflammatory cells. The incidence is 1.7 to 6.2 cases per 100,000 person-years in the United States and Europe. The ratio between male and female was 1.7 to 1. Mostly, it involves heart valves as well as the site of a septal defect, the chordae tendineae, and the mural endocardium. Clinical diagnostic criteria include von Reyn criteria (1981) and Duke criteria (1994) with the echocardiography finding. Currently, the modified Duke criteria (2000) was wildly used to diagnose the infective endocarditis which includes specific clinical symptoms and signs, predisposition, the result of blood culture, and echocardiography. There are no research studies related to the prognosis comparison and the analysis between patients with definitely diagnosed and possibly diagnosed with infective endocarditis.
Study objectives: This study analyzed the underlying disease, complication, and mortality rate between patients with definitely diagnosed and possibly diagnosed with infective endocarditis, and explored the difference of prognosis between two groups. Based on this study, we expect to practice the Duke criteria precisely and clinically, and improve the knowledge and attitudes of the healthcare providers while treat these patients.
Design and setting: This study is a retrospective case control study. The subjects were older than eighteen years old who had been discharged from Chung Shan Medical University Hospital with the final diagnosis of infective endocarditis, from January 1st, 1999 to December 31st, 2005. The comparisons of the underlying disease, severity, complication, and prognosis were used to explore the differences between the two groups.
Result: According to the research findings, patients with definite infective endocarditis were younger（p<0.01）、and had higher ratio of nosocomial infection（p=0.04）、higher Segment ratio in differential count of white blood cells（p<0.01）、lower platelets concentration（p<0.01）、higher serum C-reactive protein concertration（p<0.01）、and higher complicated rate than patients with possible infective endocarditis. Although patients with definite infective endocarditis had higher mortality rate; however, there were no significant differences between these two groups（p=0.14）.
Conclusion: Since there was no statistical significant difference of the mortality rate between these two groups, the healthcare providers should also keep paying attentions to taking care of patients who were diagnosed as possible endocarditis with serious treatment.

目 錄
誌謝...I
中文摘要...II
英文摘要...IV
目錄...V
表目錄...X
圖目錄...X
第一章 緒論...1

第一節 前言...1
第二節 研究背景與動機...3
第三節 研究目的...4
第四節 名詞解釋...5
第五節 文獻探討...11
第六節 研究架構...14

第二章 材料與方法...17

第一節 研究對象...17
第二節 感染性心內膜炎個案背景與臨床診斷...17
第三節 感染性心內膜炎患者血液檢查...18
第四節 感染性心內膜炎患者心臟超音波檢查...19
第五節 感染性心內膜炎患者細菌培養及抗生素治療...19
第六節 感染性心內膜炎併發症及死亡率...20
第七節 統計分析...21

第三章 研究分析...22

第一節 病人的診斷分類...22
第二節 確定診斷與疑似診斷感染性心內膜炎患者的潛在疾病狀況...22
第三節 確定診斷與疑似診斷感染性心內膜炎患者的血液檢查...23
第四節 確定診斷與疑似診斷感染性心內膜炎患者心臟超音波檢查...24
第五節 確定診斷與疑似診斷感染性心內膜炎患者血液培養結果...25
第六節 確定診斷與疑似診斷感染性心內膜炎患者之住院治療過程...26
第七節 確定與疑似診斷感染性心內膜炎患者之併發症與死亡率...27

第四章 討論...29

第一節 研究討論...29
第二節 研究範圍及研究限制...34

第五章 結論與建議...38

第一節 結論...38
第二節 建議...39

參考文獻...40

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