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据2018年国际癌症中心数据显示[1],2012年全球新发结直肠癌约135.1万例,居恶性肿瘤第3位。肠造口术虽能有效解决排便问题[2],但其本质上破坏了机体正常结构,病人不仅需要承受形象紊乱,同时还要接受社会适应障碍的心理压力,在这种情况下,病人极易产生心理障碍。美国国立综合癌症网指出,心理障碍已成为继发疼痛之后的第六大生命体征[3]。有报道[4]称约30%完成初级治疗的癌症幸存者存在心理障碍问题,但这一比例因癌症部位和研究而异。结直肠癌造口病人因排便形态改变,所承受的精神、心理伤害较其他恶性肿瘤病人更严重。一项横断面问卷调查[5]显示,更高的焦虑、抑郁等心理问题是妇科癌症病人生活质量低的原因;一项前瞻性纵向研究[6]中证实,焦虑、抑郁等可增加癌症病人心理脆弱。在肺癌[7]、前列腺癌[8]中,年龄、癌症类型、肿瘤分期等被证实为导致心理障碍的相关因素,但上述因素是否为影响结直肠癌造口病人的相关因素研究相对较少。为此,笔者团队进行了一项问卷调查研究,确定可能影响结直肠癌造口病人心理障碍的相关因素并构建预测模型,旨在早期识别结直肠癌造口心理障碍人群,制定合理的干预措施提供理论依据,现作报道。
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本次调查发放并收回问卷290份,剔除无效问卷2份(训练、测试集各1例),最终获得有效问卷288份,有效回收率为99.31%(288/290)。
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训练集最终纳入202例,其中心理障碍组67例(33.17%),非心理障碍组135例(66.83%)。
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训练集心理障碍组和非心理障碍组年龄、受教育年限、体质量指数、婚姻状态、医疗费用支付方式、肿瘤分期、病理分型、造口类型、造口大小、PSQI评分比较差异均无统计学意义(P>0.05),性别、造口时间、SSRS评分、造口并发症、自我管理能力比较差异均有统计学意义(P < 0.05~P < 0.01)(见表 1)。
因素 心理障碍组(n=67) 非心理障碍组(n=135) t P 人口学资料 年龄/岁 46.54±8.96 45.97±9.87 0.41 >0.05 性别 女 44 66 5.09* < 0.05 男 23 69 体质量指数/(kg/m2) 22.78±1.33 22.67±1.42 0.54 >0.05 受教育年限/年 9.12±2.58 9.37±2.61 0.65 >0.05 婚姻状态 未婚 10 25 0.40* >0.05 已婚 57 101 医疗费用支付方式 医保 45 101 1.31* >0.05 自费 22 34 临床资料 肿瘤分期 Ⅰ~Ⅱ期 42 82 0.07* >0.05 Ⅲ~Ⅳ期 25 53 病理分型 息肉样型 29 52 0.53* >0.05 狭窄型 24 55 溃疡型 14 28 造口时间/年 2.82±0.83 3.26±0.88 3.48 < 0.05 造口类型 回肠造口 12 20 0.32* >0.05 结肠造口 55 115 造口大小/cm 3.21±1.01 3.17±1.02 0.26 >0.05 造口并发症 是 33 42 6.31* < 0.05 否 34 93 自我管理能力评分/分 71.57±16.66 84.68±17.71 5.16 < 0.01 SSRS评分/分 29.92±4.51 32.70±5.29 3.89 < 0.01 PSQI评分/分 15.26±3.26 16.01±3.01 1.58 >0.05 *示χ2值 表 1 影响训练集病人心理障碍发生的单因素分析(x±s)
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根据单因素分析结果,将是否出现心理障碍作为因变量(发生心理障碍=1,未发生心理障碍=0)行logistic回归分析,结果显示:性别为女性、造口时间长、自我管理能力评分高、SSRS评分高为结直肠癌造口病人心理障碍的保护因素,造口并发症为结直肠癌造口病人心理障碍发生的危险因素(P < 0.05~P < 0.01)(见表 2、3)。
相关因素 变量 赋值 性别 X1 女=1,男=0 造口时间 X2 连续变量,实测值 造口并发症 X3 发生=1,未发生=0 自我管理能力评分 X4 连续变量,实测值 SSRS评分 X5 连续变量,实测值 心理障碍 Y 发生心理障碍=1,未发生心理障碍=0 表 2 训练集结直肠癌造口病人心理障碍发生多因素logistic分析的赋值表
因素 B SE Waldχ2 P OR 95%CI 性别 -0.744 0.369 4.06 < 0.05 0.475 0.230~0.980 造口时间 -0.519 0.201 6.69 < 0.05 0.595 0.402~0.882 造口并发症 0.742 0.373 3.96 < 0.05 2.101 1.011~4.365 自我管理能力评分 -0.047 0.011 18.65 < 0.01 0.954 0.933~0.974 SSRS评分 -0.095 0.035 7.15 < 0.01 0.910 0.848~0.975 常量 7.583 1.577 23.12 < 0.01 — — 表 3 训练集结直肠癌造口病人心理障碍发生影响因素logistic回归分析
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将训练集中结直肠癌造口病人心理障碍发生的独立相关因素纳入列线图模型,预测结直肠癌造口病人心理障碍相关因素的C-index为0.804(95%CI:0.743~0.857)(见图 1)。应用Bootsrap内部验证法对模型进行验证,结果显示预测曲线和时间曲线基本一致(见图 2)。应用ROC曲线进一步验证,结果显示,结直肠癌造口病人心理障碍预测的特异度为88.50%,敏感度为81.60%(见图 3)。
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最终测试集纳入86例,28例发生心理障碍,58例未发生心理障碍,其中敏感性为85.71%(24/28),特异性为87.93%(51/58)。
结直肠癌造口病人心理障碍预测模型构建分析
Construction and analysis of the prediction model of psychological disorder in colorectal cancer patients with enterostomy
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摘要:
目的探讨结直肠癌造口病人心理障碍预测模型构建。 方法选取290例结直肠癌造口病人作为调查对象,随机选取70%(203例)的病例作为训练集,30%(87例)作为测试集,根据明尼苏达多相人格测试(MMPI)分为心理障碍组(MMPI≥60分)和非心理障碍组(MMPI < 60分),比较训练集中2组一般资料情况,应用logistic回归模型分析影响结直肠癌造口病人心理障碍相关因素,采用R软件基于训练集建立列线图预测模型,并在测试集评估模型效能。 结果剔除无效问卷2份(训练集、测试集各1例),最终获得有效问卷288份,有效回收率为99.31%,其中训练集最终纳入202例,心理障碍组67例(33.17%),非心理障碍组135例(66.83%),2组性别、造口时间、自我管理能力评分、社会支持评定量表(SSRS)评分、造口并发症比较差异均有统计学意义(P < 0.05~P < 0.01);多因素logistic分析显示,性别为女性、造口时间长、自我管理能力评分高、SSRS评分高为结直肠癌造口病人心理障碍的保护因素,造口并发症为结直肠癌造口病人心理障碍发生的危险因素(P < 0.05~P < 0.01),上述因素预测结直肠癌造口病人心理障碍相关因素的一致性指数为0.804(95%CI: 0.743~0.857),ROC曲线进一步验证显示,特异度88.50%,敏感度81.60%。外部验证显示该预测模型敏感性为85.71%,特异性为87.93%。 结论结直肠癌造口病人心理障碍情况较为严峻,性别、自我管理能力、社会支持、造口并发症、造口时间是心理障碍的影响因素,由此构建的预测模型具有较高的应用价值。 Abstract:ObjectiveTo explore the construction of a prediction model of psychological disorders in colorectal cancer patients with enterostomy. MethodsA total of 290 colorectal cancer patients with enterostomy were investigated, and randomly set the training set(203 cases) and test set(87 cases). According to the Minnesota multiphasic personality inventory(MMPI), the patients were divided into the psychological disorder group(MMPI≥60 points) and non-psychological disorder group(MMPI < 60 points). The general data in the training set were compared between two groups, the related factors affecting the psychological disorders of colorectal cancer patients with enterostomy were analyzed using the logistic regression model. The R software was used to establish a nomogram prediction model based on the training set, and the effectiveness of model in the test set was evaluated. ResultsTwo invalid questionnaires(one in the training set and one in the test set) were eliminated, and 288 valid questionnaires were obtained with effective recovery rate of 99.31%. Two hundred and two cases were included in the training set, and 67 cases(33.17%) in the psychological disorder group and 135 cases(66.83%) in the non-psychological disorder group were identified. The differences of the gender, enterostomy time, self-management ability score, social support rating scale(SSRS) score and enterostomy complications between two groups were statistically significant(P < 0.05 to P < 0.01). The results of multivariate logistic analysis showed that female, long time of enterostomy, high score of self-management ability and high score of SSRS were the protective factors of psychological disorders, and the enterostomy complication was the risk factor of psychological disorders in colorectal cancer patients with enterostomy(P < 0.05 to P < 0.01). The consistency index of the above factors in predicting psychological disorders in colorectal cancer patients with enterostomy was 0.804(95%CI: 0.743-0.857). The results of further verification by ROC curve showed that the specificity was 88.50%, and the sensitivity was 81.60%. The results of external validation showed that the sensitivity and specificity of this model were 85.71% and 87.93%, respectively. ConclusionsThe psychological disorder of colorectal cancer patients with enterostomy is more severe. The gender, self-management ability, social support, enterostomy complications and time are the influencing factors of psychological disorder. The prediction model has high application value. -
Key words:
- emterostomy care /
- colorectal cancer /
- psychological disorder /
- prediction model
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表 1 影响训练集病人心理障碍发生的单因素分析(x±s)
因素 心理障碍组(n=67) 非心理障碍组(n=135) t P 人口学资料 年龄/岁 46.54±8.96 45.97±9.87 0.41 >0.05 性别 女 44 66 5.09* < 0.05 男 23 69 体质量指数/(kg/m2) 22.78±1.33 22.67±1.42 0.54 >0.05 受教育年限/年 9.12±2.58 9.37±2.61 0.65 >0.05 婚姻状态 未婚 10 25 0.40* >0.05 已婚 57 101 医疗费用支付方式 医保 45 101 1.31* >0.05 自费 22 34 临床资料 肿瘤分期 Ⅰ~Ⅱ期 42 82 0.07* >0.05 Ⅲ~Ⅳ期 25 53 病理分型 息肉样型 29 52 0.53* >0.05 狭窄型 24 55 溃疡型 14 28 造口时间/年 2.82±0.83 3.26±0.88 3.48 < 0.05 造口类型 回肠造口 12 20 0.32* >0.05 结肠造口 55 115 造口大小/cm 3.21±1.01 3.17±1.02 0.26 >0.05 造口并发症 是 33 42 6.31* < 0.05 否 34 93 自我管理能力评分/分 71.57±16.66 84.68±17.71 5.16 < 0.01 SSRS评分/分 29.92±4.51 32.70±5.29 3.89 < 0.01 PSQI评分/分 15.26±3.26 16.01±3.01 1.58 >0.05 *示χ2值 表 2 训练集结直肠癌造口病人心理障碍发生多因素logistic分析的赋值表
相关因素 变量 赋值 性别 X1 女=1,男=0 造口时间 X2 连续变量,实测值 造口并发症 X3 发生=1,未发生=0 自我管理能力评分 X4 连续变量,实测值 SSRS评分 X5 连续变量,实测值 心理障碍 Y 发生心理障碍=1,未发生心理障碍=0 表 3 训练集结直肠癌造口病人心理障碍发生影响因素logistic回归分析
因素 B SE Waldχ2 P OR 95%CI 性别 -0.744 0.369 4.06 < 0.05 0.475 0.230~0.980 造口时间 -0.519 0.201 6.69 < 0.05 0.595 0.402~0.882 造口并发症 0.742 0.373 3.96 < 0.05 2.101 1.011~4.365 自我管理能力评分 -0.047 0.011 18.65 < 0.01 0.954 0.933~0.974 SSRS评分 -0.095 0.035 7.15 < 0.01 0.910 0.848~0.975 常量 7.583 1.577 23.12 < 0.01 — — -
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