A review of fall fear in patients with visual impairment
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摘要:
视力障碍是由多种原因导致的双眼视力缺损或视野缩小。视力障碍患者常伴有跌倒恐惧，进而引发活动受限。本研究阐述跌倒恐惧的定义，总结跌倒恐惧的评估工具，并综述视力障碍患者跌倒恐惧的研究现状及护理进展，以期为临床护理实践和研究提供参考。
Abstract:Visual impairment refers to the loss of visual acuity or reduction in visual field in both eyes due to various reasons. Patients with visual impairment experience fall fear, thereby causing activity limitation. This study reviewed the definition of fall fear, summarized the assessment tools for fall fear, and discussed the current research status and nursing progress regarding fall fear in patients with visual impairment, aiming to provide references for clinical nursing practice and research.
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Keywords:
- visual impairment /
- fall fear /
- assessment tools /
- research review
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2型糖尿病(T2DM) 是临床常见慢性代谢紊乱综合征，可累及全身各重要器官引起多种并发症，包括大血管病变等。研究[1]证实, T2DM大血管病变主要由动脉粥样硬化(AS)形成。T2DM大血管病变是一种慢性炎症疾病，患者局部组织缺血缺氧，导致内皮因子产生，加速血管内皮斑块内新生血管生成[2]。慢性炎症和内皮功能障碍都加重了血管病变的发生。目前，大血管并发症诊断金标准为冠状动脉造影，费用昂贵且对髂动脉等受体壁厚度影响较大的大血管误诊率较高。近年来，研究[3]发现内皮细胞特异分子-1 (Endocan-1)和脂肪特异性丝氨酸蛋白酶抑制剂(Vaspin)均可作为内皮功能障碍的新型标志物。本研究探讨Endocan-1和Vaspin在T2DM大血管疾病中的诊断价值，现报告如下。
1. 材料与方法
1.1 一般材料
选取2019年1—12月在黑龙江省佳木斯中心医院治疗的72例T2DM患者为研究对象，均符合WHO糖尿病标准诊断。根据是否合并大血管疾病，分为T2DM组36例和T2DM大血管病变(MVC)组36例; 此外，选同期36例健康者作为对照组。MVC组男17例，女19例，年龄(57.75±5.20)岁; T2DM组男19例，女17例，年龄(44.65±4.56)岁; 对照组男16例，女20例，年龄(53.28±3.48)岁。
糖尿病患者中大血管病变诊断标准: 经物理诊断确定大血管病变患者。排除标准: ①孕妇; ②肿瘤、结核、肝损伤、自身免疫疾病、糖尿病其他急慢性并发症者; ③患有其他内分泌代谢疾病者; ④服用抗纤维化的药物及近期应用糖皮质激素者; ⑤具有急性感染、近期手术、创伤等应激情况者。
1.2 方法
收集研究对象的性别、年龄以及身高、体质量，计算体质量指数(BMI)。采用酶标仪测定标本血清Endocan-1、Vaspin数值(芬兰Labsystems Multiskan MS公司)，酶联免疫吸附测定(ELISA)试剂盒购于上海信帆生物科技有限公司，严格按照说明书操作。
1.3 观察指标
分析血清Endocan-1、Vaspin水平与糖尿病合并大血管病变相关性。
1.4 统计学分析
采用SPSS 21.0统计软件对结果进行分析，符合正态分布的数据以(x±s)表示，组间计量资料比较采用独立样本t检验，采用受试者工作特征(ROC)曲线分别判断Endocan-1、Vaspin水平对T2DM合并大血管疾病的预测诊断价值, P < 0.05为差异有统计学意义。
2. 结果
2.1 3组一般资料及血清Endocan-1、Vaspin水平比较
3组一般资料比较差异无统计学意义(P>0.05), 具有可比性。T2DM组和MVC组血清Endocan-1水平均高于对照组，且MVC组高于T2DM组，差异有统计学意义(P < 0.05)。MCV组Vaspin水平低于T2DM组和对照组, T2DM组高于对照组，差异有统计学意义(P < 0.05)。见表 1。
表 1 3组一般资料和血清Endocan-1、Vaspin水平比较(x±s)指标 对照组(n=36) T2DM组(n=36) MVC组(n=36) 年龄/岁 53.28±3.48 44.65±4.56 57.75±5.20 性别 男 16 19 17 女 20 17 19 BMI/(kg/m2) 21.45±3.08 26.14±3.81 33.87±4.22 病程/年 - 2.49±4.76 9.54±3.86 吸烟/例 12 12 25 饮酒/例 5 8 4 Endocan-1/(pg/mL) 798.45±176.59 935.77±156.39* 1 141.17±148.14*# Vaspin/(pg/mL) 996.76±86.90 1 090.91±173.24* 879.58±130.30*# Endocan-1: 内皮细胞特异分子-1; Vaspin: 脂肪特异性丝氨酸蛋白酶抑制剂。
与对照组比较, *P < 0.01; 与T2DM组比较, #P < 0.05。2.2 血清Endocan-1、Vaspin水平与糖尿病合并大血管病变相关性
在MVC组中, Endocan-1与T2DM合并大血管疾病呈正相关; Vaspin与T2DM合并大血管疾病呈负相关。
2.3 血清Endocan-1、Vaspin在T2DM合并大血管疾病中诊断价值
MVC组血清Endocan-1和Vaspin的ROC曲线下面积分别为0.910%、0.720%, 截断值分别为1 410 pg/mL、890 pg/mL, 敏感度分别为81%、85%, 特异度分别为76%、73%。见图 1、图 2。
3. 讨论
Endocan-1由内皮细胞分泌，其合成和分泌受炎性因子调控，可促进新生血管形成[4], 可作为反映血管内皮功能变化的潜在血清学指标。本研究结果表明, MVC组血清Endocan-1水平显著高于T2DM组和对照组，与相关研究[5]中Endocan-1水平随心肌梗死严重程度而升高相符，说明Endocan-1在糖尿病大血管病变中发挥了重要作用。Endocan-1与T2DM及大血管病变等内皮功能障碍疾病密切相关，随着Endocan-1的升高，炎症因子水平上升，内皮功能进一步降低，促使大血管并发症发生发展。本研究表明，血清Endocan-1水平增高是T2DM大血管病变的影响因素, ROC曲线显示检测Endocan-1水平可提高T2DM大血管病的检出率，表明Endocan-1与T2DM大血管病变有关。
血清Vaspin是一种参与糖脂代谢新型脂肪因子，具有增强胰岛素敏感性的作用[6], 且Vaspin具有抗炎作用，可能是炎症标记物[7]。本研究表明, MCV组Vaspin水平显著低于T2DM组和对照组, T2DM组显著高于对照组，可能是因为Vaspin对血管内皮具有保护机制，促使其在血清的含量增多。一项荟萃分析[8]中，单纯2型糖尿病患者血清Vaspin水平明显增高，其原因可能是Vaspin抑制了激肽释放酶7的活性，进而增加胰岛素水平，对T2DM发挥代偿作用。研究[9-11]发现，机体伴随着T2DM病程的延长、大血管病变的发生，其分泌Vaspin的代偿能力会逐渐降低，与本研究结果相似。当Vaspin水平降低时，其抑制促炎介质分泌和抗内皮细胞凋亡作用减弱，活性氧产生增多，加剧内皮功能紊乱，促炎介质分泌增加，加重内皮功能的障碍，导致T2DM大血管病变的发生发展。血清中Vaspin水平降低是T2DM大血管病变的影响因素, ROC分析显示Vaspin水平检测T2DM大血管病特异度高，表明Vaspin与T2DM大血管病变有关。
血清中Endocan-1和Vaspin水平在MCV组中呈负相关，提示在多种因素影响下, Endocan-1和Vaspin可能相互作用、相互抑制。分析原因可能为当T2DM大血管发生病变时，血管内皮细胞炎症反应较单纯T2DM重，且血管内粥样斑块的形成与破裂进一步促进血管内皮炎症反应，使Endocan-1水平升高，Vaspin水平下降。血清Endocan-1和Vaspin水平ROC分析显示曲线下面积分别为0.910%和0.720%, 截断值分别为1140 pg/mL、890 pg/mL, 敏感度分别为81%、85%, 特异度分别为76%、73%, 说明检测Endocan-1和Vaspin的水平可有效提高T2DM合并大血管疾病的确诊率，对其早期诊断、治疗和预后评估具有一定的指导意义。
T2DM大血管病变从发病机制角度可以被定义为一种由糖脂代谢紊乱引发的慢性低度炎症性疾病, T2DM通过多种因子协同促使血管内皮炎症反应，可以加速大血管并发症的发生发展[12]。因此，炎症反应也是T2DM大血管并发症持续发展的关键因素。既往研究表明，急性冠状动脉综合征患者血清Endocan-1水平显著高于对照组，升高水平与冠状动脉病变严重程度正相关，是阻塞性冠状动脉疾病的独立预测因子。低水平Vaspin是冠心病的独立危险因素，参与冠心病的发生和发展过程。Vaspin作为新型脂肪因子，全程参与了机体胰岛素和血糖水平的调节，在T2DM发生发展过程中发挥重要作用。
综上所述，血清Endocan-1和Vaspin表达与T2DM大血管病变紧密相关, Endocan-1和Vaspin有望成为早期预测T2DM大血管病变的新标志物，为预防治疗提供新的靶点。但本研究仍有不足之处，样本量较小，且未进行纵向干预和随访，采用血清为研究载体，缺乏T2DM大血管病发生发展过程中的具体作用机制及分子基因水平相关数据支持，仍需进一步进行研究。
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