含LFES康复治疗的气管重建患者吞咽改善的预测：一项回顾性队列研究

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中文摘要

背景： 吞咽困难是气管重建术后一种临床上重要的并发症。低频电刺激（LFES）支持术后吞咽康复，但患者的吞咽结局差异很大。我们旨在识别与观察到的吞咽改善相关的预后因素，并在接受含LFES康复治疗的气管重建患者中开发一个内部验证的临床预测模型。
方法： 这项回顾性队列研究纳入了200例接受含LFES康复治疗的术后吞咽困难患者。根据康复后吞咽改善的预设标准对患者进行分组。评估了康复前可获得的人口学、围手术期、吞咽相关和预设治疗方案变量。通过结局分层随机抽样将队列分为训练集和独立验证集。使用单变量逻辑回归、LASSO、随机森林和XGBoost检查候选预测因子，随后进行多变量逻辑回归。使用ROC分析、校准、bootstrap内部验证以及探索性决策曲线、亚组和敏感性分析评估模型性能。
结果： 在200例患者中，126例（63.0%）符合预设的吞咽改善标准。年龄较大（OR=0.96，95%CI：0.93-0.98）和误吸（OR=0.41，95%CI：0.18-0.88）与较低的改善概率独立相关，而计划LFES次数较多与较高的改善概率相关（OR=1.09，95%CI：1.04-1.16）。逻辑回归模型在训练集中的AUC为0.776，在独立验证集中的AUC为0.767，校准可接受。500次bootstrap重采样后的乐观校正AUC为0.721。探索性决策曲线分析提示在评估的阈值概率范围的部分区间内可能具有净获益。XGBoost获得了数值上最高的验证AUC（0.780），其次是逻辑回归（0.765）和随机森林（0.760），这些模型之间的绝对差异很小。主要关联在敏感性分析中总体一致。
结论： 在接受气管重建术后含LFES康复治疗的患者中，年龄较大和误吸与观察到的吞咽改善概率较低相关，而计划LFES次数较多与改善概率较高相关。该模型表现出中等区分度，可能为预后风险分层和识别需要更密切康复监测的患者提供初步框架。在常规临床使用前需要外部验证。

英文摘要

BACKGROUND: Dysphagia is a clinically important complication after tracheal reconstruction. Low-frequency electrical stimulation (LFES) supports postoperative swallowing rehabilitation, yet swallowing outcomes vary substantially among patients. We aimed to identify prognostic factors associated with observed swallowing improvement and to develop an internally validated clinical prediction model among patients receiving LFES-containing rehabilitation after tracheal reconstruction.
METHODS: This retrospective cohort study included 200 patients with postoperative dysphagia who received LFES-containing rehabilitation. Patients were grouped by prespecified criteria for swallowing improvement after rehabilitation. Demographic, perioperative, swallowing-related, and prespecified treatment-plan variables available before rehabilitation were evaluated. The cohort was divided by outcome-stratified random sampling into training and independent validation sets. Candidate predictors were examined using univariable logistic regression, LASSO, random forest, and XGBoost, followed by multivariable logistic regression. Model performance was assessed using ROC analysis, calibration, bootstrap internal validation, and exploratory decision-curve, subgroup, and sensitivity analyses.
RESULTS: Among 200 patients, 126 (63.0%) met the prespecified swallowing-improvement criteria. Older age (OR = 0.96, 95% CI: 0.93-0.98) and aspiration (OR = 0.41, 95% CI: 0.18-0.88) were independently associated with a lower probability of improvement, whereas a greater planned number of LFES sessions was associated with a higher probability of improvement (OR = 1.09, 95% CI: 1.04-1.16). The logistic regression model achieved AUCs of 0.776 in the training set and 0.767 in the independent validation set, with acceptable calibration. The optimism-corrected AUC after 500 bootstrap resamples was 0.721. Exploratory decision-curve analysis suggested potential net benefit across portions of the evaluated threshold-probability range. XGBoost achieved the numerically highest validation AUC (0.780), followed by logistic regression (0.765) and random forest (0.760), with only small absolute differences among these models. Main associations were generally consistent across sensitivity analyses.
CONCLUSION: Among patients receiving LFES-containing rehabilitation after tracheal reconstruction, older age and aspiration were associated with a lower probability of observed swallowing improvement, whereas a greater planned number of LFES sessions was associated with a higher probability of improvement. The model demonstrated moderate discrimination and may provide a preliminary framework for prognostic risk stratification and identifying patients who warrant closer rehabilitation monitoring. External validation is required before routine clinical use.