肠造口周围潮湿相关性皮肤损伤风险预测模型的构建及应用

doi:10.3761/j.issn.0254-1769.2021.11.002

摘要/Abstract

摘要：

目的构建肠造口周围潮湿相关性皮肤损伤（peristomal moisture-associated skin damage,PMASD）风险预测模型并应用于临床,验证该模型的预测效果。方法采用前瞻性研究设计,便利选取2019年11月—2020年9月在上海市4所三级甲等医院接受肠造口术的329例患者作为建模组,根据患者术后3个月内是否发生PMASD分为并发症组（141例）和非并发症组（188例）,基于单因素分析、Lasso变量筛选结果构建Logistic回归预测模型。采用Hosmer-Lemeshow检验判断模型的拟合度,受试者操作特征曲线下面积检验模型的区分度,Bootstrap重抽样法进行内部验证。于2020年10月—11月选取109例患者作为验证组对模型进行外部验证。结果建模组术后3个月内PMASD发生率为42.9%（141/329）,验证组为37.6%（41/109）。最终纳入模型的预测变量为性别（OR=0.497）、造口部位（OR=4.338）、造口开口高度（OR=0.304）、底盘区域手术切口（OR=3.479）、底盘贴合情况（OR=2.399）、软食（OR=3.155）、半流质饮食（OR=3.325）。Hosmer-Lemeshow检验P=0.274,受试者操作特征曲线下面积为0.812,约登指数为0.500,灵敏度为0.688,特异度为0.798。外部验证Hosmer-Lemeshow检验P=0.515,受试者操作特征曲线下面积为0.860,灵敏度为0.610,特异度为0.882。结论该研究构建的预测模型预测效能良好,可为临床护理人员筛选PMASD高风险患者提供参考。

关键词: 肠造口术, 造口周围潮湿相关性皮肤损伤, 皮肤保护, 模型, 统计学, 护理

Abstract:

Objective To develop a risk prediction model of peristomal moisture-associated skin damage（PMASD）,and to apply to clinical practice to validate its prediction performance. Methods The prospective study design and the convenience sampling method were adopted. A total of 329 patients from 4 hospitals in Shanghai were enrolled from November 2019 to September 2020,and predictors between the complication group（141 cases）and the non-complication group（188 cases） were compared using Logistic regression based on Lasso selection for model development. The goodness of fit of the model was verified by Hosmer-Lemeshow test. The discrimination was evaluated by the area under the ROC curve（AUC）. The Bootstrap resampling was used for internal validation. From October to November 2020,109 patients were recruited for external validation. Results The incidence of complication in the development cohort was 42.9%（141/329）,and 37.6%（41/109） in the validation cohort. The predictors that ultimately entered the prediction model were gender（OR=0.497）,type of stoma（OR=4.338）,height of stoma（OR=0.304）,surgical wound in plate area（OR=3.479）,plate attachment（OR=2.399）,soft diet（OR=3.155）,and semi-fluid diet（OR=3.325）. The H-L test P=0.274;the AUC was 0.812. The Youden index was 0.500,with the sensiti-vity of 0.688 and the specificity of 0.798. While the external validation H-L test P=0.515,the AUC was 0.860 with the sensitivity of 0.610 and the specificity of 0.882. Conclusion The prediction model developed in this study has a good performance,which can provide a reference for clinical screening of high-risk patients with PMASD.

Key words: Enterostomy, Peristomal Moisture-Associated Skin Damage, Skin Care, Models, Statistics, Nursing Care

刘莺歌, 吴燕, 曹秋君, 邱群, 吕桂芬, 徐洪莲, 高键. 肠造口周围潮湿相关性皮肤损伤风险预测模型的构建及应用[J]. 中华护理杂志, 2021, 56(11): 1612-1617.

LIU Yingge, WU Yan, CAO Qiujun, QIU Qun, LÜ Guifen, XU Honglian, GAO Jian. The development and validation of a risk prediction model for peristomal moisture-associated skin damage[J]. Chinese Journal of Nursing, 2021, 56(11): 1612-1617.

图/表 4

表1 建模组肠造口周围潮湿相关性皮肤损伤的单因素分析[例（百分比,%）]

Table 1 The univariate analysis of peristomal moisture-associated skin damage in the development cohort[cases （percentage,%）]

表2 预测变量赋值

Table 2 Assignment of predictors

表3 肠造口周围潮湿相关性皮肤损伤Logistic回归分析

Table 3 Logistic regression analysis of peristomal moisture- associated skin damage

图1 肠造口周围潮湿相关性皮肤损伤风险预测模型的受试者操作特征曲线

Figure 1 The ROC curve of the prediction model for peristomal moisture-associated skin damage

参考文献 20

[1]	Wound,Ostomy and Continence Nurses Society,Guideline Development Task Force. WOCN society clinical guideline:management of the adult patient with a fecal or urinary ostomy-an executive summary[J]. J Wound Ostomy Continence Nurs, 2018, 45(1):50-58. DOI URL
[2]	Colwell JC, Ratliff CR, Goldberg M, et al. MASD part 3:peristomal moisture-associated dermatitis and periwound moisture-associated dermatitis:a consensus[J]. J Wound Ostomy Continence Nurs, 2011, 38(5):541-553. DOI URL
[3]	陶艳, 陈鲁红, 胡成文, 等. 肠造口患者造口周围潮湿相关性皮肤损伤发生现状及影响因素分析[J]. 中国实用护理杂志, 2019, 35(5):321-325.
	Tao Y, Chen LH, Hu CW, et al. Analysis on the present situation and influencing factors of peristomal moisture-associated skin damage[J]. Chin J Pract Nurs, 2019, 35(5):321-325.
[4]	Taneja C, Netsch D, Rolstad BS, et al. Clinical and economic burden of peristomal skin complications in patients with recent ostomies[J]. J Wound Ostomy Continence Nurs, 2017, 44(4):350-357. DOI URL
[5]	Salvadalena GD. The incidence of stoma and peristomal complications during the first 3 months after ostomy creation[J]. J Wound Ostomy Continence Nurs, 2013, 40(4):400-406. DOI URL
[6]	Neil N, Inglese G, Manson A, et al. A cost-utility model of care for peristomal skin complications[J]. J Wound Ostomy Continence Nurs, 2016, 43(1):62-68. DOI URL
[7]	赵东芳, 陈晨, 苏春燕, 等. 呼吸科住院患者抗生素药物相关腹泻风险预测模型的构建及验证[J]. 中华护理杂志, 2021, 56(1):28-32.
	Zhao DF, Chen C, Su CY, et al. Establishment of a nomogram model for risks of antibiotic associated diarrhea in hospitalized patients with respiratory diseases[J]. Chin J Nurs, 2021, 56(1):28-32.
[8]	魏月清, 李红, 李芸, 等. ICU后认知障碍风险预测模型的构建及验证[J]. 中华护理杂志, 2021, 56(1):14-20.
	Wei YQ, Li H, Li Y, et al. Construction of a risk prediction model for post-intensive care syndrome-cognitive impairment[J]. Chin J Nurs, 2021, 56(1):14-20.
[9]	Moons KG, Altman DG, Reitsma JB, et al. Transparent reporting of a multivariable prediction model for individual prognosis or diagnosis(TRIPOD):explanation and elaboration[J]. Ann Intern Med, 2015, 162(1):1-73. DOI
[10]	Vergouwe Y, Steyerberg EW, Eijkemans MJ, et al. Substantial effective sample sizes were required for external validation studies of predictive logistic regression models[J]. J Clin Epidemiol, 2005, 58(5):475-483. PMID
[11]	李小寒, 尚少梅. 基础护理学[M]. 第6版. 北京: 人民卫生出版社, 2017:308-309.
	Li XH, Shang SM. Basic nursing[M]. 6th ed. Beijing: People’s Medical Publishing House, 2017:308-309.
[12]	黄琼梅, 黄丽明. 肠造口周围皮肤损伤的危险因素分析与对策[J]. 结直肠肛门外科, 2017, 23(6):783-787.
	Huang QM, Huang LM. Analysis on risk factors of peristomal moisture-associated skin damage and prevention[J]. J Color Anal Surg, 2017, 23(6):783-787.
[13]	Gray M, Black JM, Baharestani MM, et al. Moisture-associated skin damage:overview and pathophysiology[J]. J Wound Ostomy Continence Nurs, 2011, 38(3):233-241. DOI URL
[14]	云红, 张怡, 郑薇, 等. 预防性回肠造口术后粪水性皮炎的危险因素及护理对策[J]. 中华结直肠疾病电子杂志, 2019, 8(4):413-416.
	Yun H, Zhang Y, Zheng W, et al. Risk factors and nursing strategies of fecal dermatitis after prophylactic ileostomy[J]. Chin J Color Dis Electron Ed, 2019, 8(4):413-416.
[15]	王泠, 高志冬, 马蕊, 等. 成人肠造口护理团体标准[EB/OL].(2019-11-10)[2021-01-18]. http://www.zhhlxh.org.cn/cnaWebcn/article/2866- .
	Wang L, Gao ZD, Ma R, et al. The group standard for nursing care for adult stoma patients[EB/OL]. (2019-11-10)[2021-01-18]. http://www.zhhlxh.org.cn/cnaWebcn/article/2866- .
[16]	Mahoney MF. Basic ostomy skin care:a guide for patients and health care basic ostomy skin care[EB/OL]. (2018-11-10)[2021-01-18]. https://www.wocn.org/.
[17]	Nybaek H, Bang Knudsen D, Nørgaard Laursen T, et al. Skin problems in ostomy patients:a case-control study of risk factors[J]. Acta Derm Venereol, 2009, 89(1):64-67. DOI URL
[18]	陈劼, 赵锦. 肠造口患儿造口周围皮肤损伤现状及影响因素调查[J]. 护理学杂志, 2017, 32(20):36-39.
	Chen J, Zhao J. Peristomal skin assessment in children with colostomy and the influencing factors[J]. J Nurs Sci, 2017, 32(20):36-39.
[19]	Stelton S, Zulkowski K, Ayello EA. Practice implications for peristomal skin assessment and care from the 2014 world council of enterostomal therapists international ostomy guideline[J]. Adv Skin Wound Care, 2015, 28(6):275-286. DOI PMID
[20]	祁阳, 王璇, 刘凤, 等. 结直肠癌造口患者造口周围皮肤状况与营养的相关性分析[J]. 中西医结合护理(中英文), 2020, 6(5):1-5.
	Qi Y, Wang X, Liu F, et al. Correlation analysis of skin condition around stoma and nutritional status in colorectal cancer patients with stoma[J]. Nurs Integr Tradit Chin West Med, 2020, 6(5):1-5.