不同射血分数慢性心衰患者的临床特征分析

[目的]分析不同射血分数慢性心衰患者的临床特征.[方法]选择2015年11月至2016年10月湖南省人民医院收治的381例慢性心衰患者,符合纳入和排除标准348例.根据左室射血分数(LVEF)分组:LVEF<40%分为射血分数降低的心衰(HFrEF)组,LVEF在41%~49%之间为射血分数中间的心衰(HFmrEF)组,LVEF>50%为射血分数保留的心衰(HFpEF)组,对三组间患者进行临床特征分析.[结果]HFrEF组年龄、女性所占比例、合并高血压、房颤明显低于HFpEF组,合并冠心病、陈旧心梗则显著高于HFpEF组(均P<0.05);HFrEF组年龄、女性所占比例高于HFmrEF组(均P<0.05).HFmrEF组和HFpEF组的三酰甘油(TG)、白蛋白(ALB)水平显著高于HFrEF组(P<0.05),其谷丙转氨酶(ALT)、谷草转氨酶(AST)、同型半胱氨酸(Hcy)、氨基末端脑钠肽前体(NT-proBNP)水平明显低于HFrEF组(P<0.05);HFrEF组和HFmrEF组左房内径、左室舒张末期内径明显高于HFpEF组(P<0.05).[结论]HFrEF患者多合并冠心病及陈旧心梗,HFpEF则以高龄、女性、高血压和房颤患者多见,HFmrEF临床特征介于HFrEF和HFpEF之间;HFrEF组血尿酸(UA)、Hcy、NT-proBNP等心衰预后危险因子水平较HFmrEF组和HFpEF组高,提示LVEF降低可能是心衰预后不良的危险因素.     

维持性血液透析患者不同射血分数心力衰竭的危险因素分析

目的探讨维持性血液透析合并心力衰竭患者中射血分数保留型(heart failure with preserve ejection fraction,HFpEF)、中间型(heart failure with mid-range of ejection fraction,HFmrEF)以及降低型(heart failure with reduced ejection fraction,HFrEF)心力衰竭的发生率及其危险因素。方法回顾性收集152例维持性血液透析合并心力衰竭住院患者的临床资料、实验室指标及心脏彩超结果,组间比较不同类型心力衰竭的临床特征,多因素logistics回归分析探讨影响左室射血分数(left ventricular ejection fraction,LVEF)的危险因素,并通过多元线性回归分析进行验证。结果 152例患者中HFpEF为110例(72.4%)、HFmrEF为16例(10.5%)、HFrEF为26例(17.1%)。HFrEF组Ⅳ级心力衰竭高于HFpEF组(χ2=6.369,P=0.041);HFpEF组收缩压(systolic blood pressure,SBP)、尿酸(uric acid,UA)、血浆白蛋白(albumin,ALB)高于HFrEF组(t=3.144,P=0.002;t=2.131,P=0.033;t=2.933,P=0.003);HFrEF组血红蛋白(hemoglobin,HB)高于HFpEF组和HFmrEF组(t=3.211,P=0.001;t=0.789,P=0.005)。HFpEF组E/A(E峰/A峰)比值明显低于HFrEF组(t=2.971,P=0.003);HFpEF组左房内径(left atrium,LA)、左室舒张末期直径(left ventricular end-diastolic dimension,LVEDd)低于HFmrEF组(t=3.055,P=0.002;t=5.461,P=0.000)和HFrEF组(t=2.151,P=0.031;t=4.307,P=0.000)。多因素Logistic回归分析结果提示维持性血液透析合并心力衰竭患者中LVEF与SBP呈正相关性(OR0.338,95%CI 0.086~0.263,P0.001),而与HB(OR 0.188, 95%CI-0.024~-0.033,P=0.010)和LVEDd(OR 0.563,95%CI-1.421~-0.743,P0.001)呈负相关,并通过多元线性回归分析进行验证(t=7.906, P=0.004;t=-4.191,P=0.025;t=-5.582,P=0.011),提示SBP、HB、LVDd可能是LVEF的独立影响因素。结论维持性血液透析合并心力衰竭患者主要表现为射血分数保留型心力衰竭,可能与贫血、高血压导致心脏重塑有关。     

中性粒细胞和血小板与淋巴细胞比值在不同类型心力衰竭中的差别

目的分析在射血分数中间值心力衰竭(HFmrEF)患者的中性粒细胞与淋巴细胞比值(NLR)、血小板淋巴细胞比值(PLR)与射血分数减低心力衰竭是否存在差别。方法连续收集安徽医科大学第一附属医院心内科自2018年1月至2019年1月射血分数<50%的心力衰竭患者222例,依据左心室射血分数(LVEF),分为射血分数减低心力衰竭组(HFrEF)(LVEF<40%)121例和射血分数中间值心力衰竭(HFmrEF)(49%>LVEF>40%)101例。采用病例对照研究分析两组间NLR、PLR的差别。结果两组在年龄、性别比例、入院舒张压、合并心房颤动的发生率差异均无统计学意义(P>0.05);HFmrEF组患者入院收缩压水平及合并高血压的发生率明显高于HFrEF组(P<0.05),合并糖尿病的发生率明显偏低(P<0.05);两组NLR、PLR水平差异均无统计学意义(P>0.05);在HFmrEF组不同心功能分级之间NLR、PLR水平差异无统计学意义(P>0.05)。结论NLR和PLR水平在HFmrEF患者与HFrEF患者相似,两者可能具有相同的预后及死亡率。     

多激素缺乏综合征与慢性心力衰竭的相关性研究进展

<正>心力衰竭(心衰)~([1])是由于任何心脏结构或功能异常导致心室充盈或射血能力受损的一组复杂临床综合征,主要临床表现为呼吸困难和乏力(活动耐量受限),以及液体潴留(肺淤血和外周水肿)。根据左室射血分数(LVEF)情况,心衰分为射血分数保留型心衰(HFpEF,LVEF≥50%)、射血分数降低型心衰(HFrEF,LVEF40%)及射血分数中间型心衰(HFmrEF,40≤LVEF50%)~([2])。神经体液机制在心     

年龄对心力衰竭患者临床特征及预后的影响

目的观察年龄增长对心力衰竭（心衰）患者的临床特征及2年预后的影响。 方法回顾性分析天津医科大学总医院和天津胸科医院两所医院2014年3月至2016年2月以心衰为主要病因、纽约心脏病学会（NYHA）心功能分级Ⅱ~Ⅳ、完成2年终点事件随访且资料完整的患者1747例,按照年龄分为非老年组（<65岁）650例,普通老年组（65~79岁）718例和高龄老年组（≥80岁）379例。分析年龄增长对心衰患者临床特征和2年预后的影响。 结果非老年组、普通老年组和高龄老年组男性患者比例逐渐下降（分别为74.9%、59.2%、55.1%,χ²=53.85,P<0.001）,射血分数降低心衰（HFrEF）患者比例逐渐减少（分别为49.2%、39.8%、34.6%,χ²=23.88,P<0.001）,射血分数保留心衰（HFpEF）患者比例逐渐增加（分别为23.2%、32.3%、37.7%,χ²=26.73,P<0.001）;而射血分数中间值心衰（HFmrEF）患者比例差异无统计学意义（分别为27.5%、27.9%、27.7%,P>0.05）。非老年组、普通老年组和高龄老年组患者NYHA心功能Ⅳ患者比例逐渐增加（分别为19.5%、27.7%和53.3%,χ²=133.02,P<0.001）、病种数逐渐增加（P<0.001）、平均住院天数明显延长（P<0.05）。经2年随访,非老年组、普通老年组和高龄老年组患者全因死亡率、心衰再入院率及复合终点事件发生率逐渐升高（全因死亡率分别为19.1%、32.6%、44.1%,P<0.001;心衰再入院率分别为20.5%、27.7%、33.5%,P<0.001;复合终点事件发生率分别为32.8%、47.1%、63.1%,P<0.001）。与非老年组相比较,普通老年组、高龄老年组的全因死亡风险比（HR）分别为1.81［95%可信区间（1.45~2.25）］和1.67［95%可信区间（1.49~1.88）］,心衰再入院HR分别为1.41［95%可信区间（1.13~1.75）］和1.34［95%可信区间（1.18~1.51）］,复合终点事件HR分别为1.54［95%可信区间（1.30~1.83）］和1.53［95%可信区间（1.39~1.68）］。 结论随年龄增长心衰患者出现明显的性别差异,且HFrEF比例逐渐减少,HFpEF比例逐渐增加,病种数更多,心功能更差,心衰更严重,住院时间更长,2年全因死亡率、心衰再入院率及复合终点事件发生率及风险更高。     

多激素缺乏综合征与慢性心力衰竭的研究进展

<正>心力衰竭(心衰)~([1])是由于任何心脏结构或功能异常导致心室充盈或射血能力受损的一组复杂临床综合征,主要临床表现为呼吸困难和乏力(活动耐量受限),以及液体潴留(肺淤血和外周水肿)。根据左室射血分数(LVEF)情况,心衰分为射血分数保留型心衰(HFpEF,LVEF≥50%)、射血分数降低型心衰(HFrEF,LVEF<40%)及射血分数中间型心衰(HFmrEF,40≤LVEF<50%)~([2])。神经体液机制在心     

血清sST2、apelin和CPP水平与心力衰竭患者预后的相关性分析

目的:分析血清可溶性生长刺激表达基因2蛋白(sST2)、apelin及和肽素(CPP)水平与不同射血分数心力衰竭患者预后的相关性。方法:选择2018年11月至2020年5月在福建省立金山医院诊断为心力衰竭的119例患者,根据左室射血分数,将其分为射血分数降低组(HFrEF组,n=31)、射血分数中间值组(HFmrEF组,n=21)和射血分数保留组(HFpEF组,n=67)。检测3组患者血清中N末端脑钠肽前体(NT-proBNP)、sST2、apelin和CPP的含量。所有患者入院后根据指南规范化治疗心力衰竭,随访2年,分析各心脏生物学标志物与心血管死亡之间的关系。结果:3组间患者性别、收缩压、脉压、体质量指数、尿素氮、糖化血红蛋白、左心室舒张末期内径、右心房横径、右心室舒张末期内径差异均有统计学意义(P0.05)。3组患者血清中NT-proBNP和sST2含量差异有统计学意义(P0.05),CPP和apelin含量差异无统计学意义。多元线性模型分析结果显示,血清NT-proBNP水平与左室射血分数相关(F=3.49,P=0.03),而血清sST2、apelin、CPP水平与左室射血分数无相关性。随访24个月时HFrEF组、HFmrEF组、HFpEF组患者累计心血管死亡率分别为29.0%、23.8%、10.4%,差异有统计学意义(P=0.04)。Kaplan-Meier生存分析显示,HFrEF、HFmrEF、HFpEF组心血管病累计生存率依次升高(χ~2=6.48,P=0.04)。Cox回归分析结果显示,NT-proBNP、尿素氮水平及使用盐皮质激素受体拮抗剂是心力衰竭患者心血管死亡的独立影响因素(P0.01)。结论:左室射血分数、NT-proBNP、尿素氮水平及使用盐皮质激素受体拮抗剂对心力衰竭患者心血管死亡有预测作用,而血清sST2、apelin和CPP水平预测价值有限。     

血浆N末端脑利钠肽前体水平与左心室射血分数正常心力衰竭患者预后的相关研究

目的评估血浆氨基末端脑利钠肽前体（NT-proBNP）水平对左心室射血分数（LVEF）正常（LVEF〉50%）的心力衰竭（HFPEF）患者的价值。方法选择2008年1月至12月在福建医科大学省立临床学院心内科连续住院资料完整、有心力衰竭症状或者体征、LVEF正常、有左心室舒张功能不全证据的患者133例[男76例,女57例,年龄（71.7±11.5）岁],并且与同期LVEF下降（〈50%）的心力衰竭患者78例[男54例,女24例,年龄（65.1±16.2）岁]进行比较,以NYHA分级方法评估心脏功能,同时采用电化学发光免疫分析法检测血浆NT-proBNP水平,Simpson法测定LVEF;对所有出院患者进行中位数为240d（60～420d）的随访,观察心血管事件（心力衰竭失代偿再入院和心源性死亡）再发情况。结果（1）与LVEF下降的心力衰竭相比,HFPEF组年龄大[（71.7±11.5）岁vs.（65.1±16.2）岁]、高血压比例高（78.20%vs.53.85%）、NYHA分级轻、左心室舒张末内径不大[（4.69±0.72）cmvs.（5.68±0.80）cm]、NT-proBNP中位数升高程度轻（2016.0pg/mlvs.4787.0pg/ml）,P均〈0.01;冠心病（66.92%vs.51.28%）、2型糖尿病（24.81%vs.12.82%）比例也较高,P均〈0.05;但心血管事件再发情况无统计学意义（26/78vs.30/133,P〉0.05）。（2）Cox模型回归分析显示lg（NT-proBNP）是HFPEF患者独立的心血管事件再发生的预后因素,OR=4.865（95%CI：1.607～14.726,P=0.005）。（3）Kaplan-Meier生存曲线分析表明NT-proBNP〉2016.0pg/ml组的再发心血管事件风险是NT-proBNP≤2016.0pg/ml组的3.688倍（95%CI：1.502～9.056,P=0.003）。结论血浆NT-proBNP水平对HFPEF患者预后评估有重要价值,NT-proBNP〉2016.0pg/ml提示预后不良。     

血浆脑钠肽水平在心力衰竭诊断中的应用价值

目的 研究血浆脑钠肽（BNP）在诊断心力衰竭尤其是早期心力衰竭中的作用,观察BNP 水平与纽约心脏病学会（NYHA）心功能分级及心脏超声指标的相关性;评价血浆BNP水平对心力衰竭患者不良心血管事件发生率的预测价值.方法 选取2007年10月至2009年10月在我院住院的168例慢性心力衰竭（CHF）患者,随机选择我院健康体检人员168例作为对照组.分析BNP水平与患者心功能状态、心脏超声指标的关系.结果心衰组中各心功能分级组间的BNP浓度、左室射血分数（LVEF）比较,差异有统计学意义（P〈0.01）.LVEF与BNP呈显著负相关（r=-0.708,P〈0.01）.BNP诊断心衰的灵敏度为56.1%.按心衰分级的灵敏度,分别为Ⅰ级9.5%、Ⅱ级38.9%、Ⅲ级55.6%、Ⅳ级83.3%.结论 BNP测定是辅助诊断心功能不全的有效方法,尤其是在心力衰竭早期,BNP水平还可以反映心功能不全的严重程度,并对心力衰竭患者进行心功能分级的一个较好的实验室指标.     

左室射血分数保留心力衰竭老年患者血清胱抑素C表达及意义

目的探讨左室射血分数保留心力衰竭(heart failure with preserved ejection fraction,HFpEF)老年患者血清胱抑素C(cystatin C,CysC)的表达及其与NYHA心功能分级的关系。方法老年HFpEF患者90例为HFpEF组,同期住院心功能正常老年患者79例为对照组,测定2组血浆N末端B型脑钠肽前体(N-terminal pro-brain natriuretic peptide,NT-proBNP)水平,血清CysC肌酐、尿素氮、尿酸水平,超声心动图检测左室射血分数(left ventricular ejection faction,LVEF);采用Spearman相关法分析血清CysC与血浆NT-proBNP、LVEF的相关性;绘制ROC曲线分析血清CysC诊断HFpEF的效能。结果HFpEF组血浆NT-proBNP[2 145.00(863.75,4 493.25)ng/L],血清CysC[(1.84±0.83)mg/L]、肌酐[(107.04±56.81)μmol/L]、尿素氮[(7.96±3.94)mmol/L]、尿酸[(429.93±132.14)μmol/L]水平均高于对照组[91.00(63.00,132.00)ng/L、(1.20±0.43)mg/L、(75.50±22.76)μmol/L、(5.63±1.75)mmol/L、(343.13±99.94)μmol/L],LVEF水平[(55.31±7.89)%]低于对照组[(65.78±3.79)%](P0.05);随NYHA心功能分级增加,血清CysC、血浆NT-proBNP水平逐渐升高,LVEF逐渐降低(P0.05);校正肌酐、尿素氮、尿酸等因素后,血清CysC与血浆NT-proBNP呈正相关(r=0.336,P=0.002),与LVEF呈负相关(r=-0.214,P=0.048);血清CysC为1.345mg/L时,诊断HFpEF的AUC为0.761(95%CI:0.688~0.834,P0.001),灵敏度为75.6%,特异度为74.7%。结论老年HFpEF患者血清CysC水平高于心功能正常人群,且其水平与NYHA心功能分级密切相关,对HFpEF的诊断有一定价值。     

Guns and Knives in New Mexico: Patterns of Penetrating Trauma, 1978–1993

Objective: To identify patterns of nonfatal and fatal penetrating trauma among children and adults in New Mexico using ED and medical examiner data.
Methods: The authors retrospectively sampled in 5-year intervals all victims of penetrating trauma who presented to either the state Level-1 trauma center or the state medical examiner from a 16-year period (1978–1993). Rates of nonfatal and fatal firearm and stabbing injury were compared for children and adults.
Results: Rates of nonfatal injury were similar (firearm, 34.3 per 100,000 person-years; stabbing, 35.1). However, rates of fatal injury were significantly different (firearm, 21.9; stabbing, 2.7; relative risk: 8.2; 95% confidence interval: 5.4, 12.5). From 1978 to 1993, nonfatal injury rates increased for children (p = 0.0043) and adults (p < 0.0001), while fatal penetrating injury remained constant. The increase in nonfatal injury in children resulted from increased firearm injury rates. In adults, both stabbing and firearm nonfatal injury rates increased.
Conclusions: Nonfatal injury data suggest that nonfatal violence has increased; fatal injury data suggest that violent death rates have remained constant. Injury patterns vary by age, mechanism of trauma, and data source. These results suggest that ED and medical examiner data differ and that both are needed to guide injury prevention programs.     

Dissociable correlates of two classes of retrieval processing in prefrontal cortex

Although substantial evidence suggests that the prefrontal cortex (PFC) implements processes that are critical for accurate episodic memory judgments, the specific roles of different PFC subregions remain unclear. Here, we used event-related functional magnetic resonance imaging to distinguish between prefrontal activity related to operations that (1) influence processing of retrieval cues based on current task demands, or (2) are involved in monitoring the outputs of retrieval. Fourteen participants studied auditory words spoken by a male or female speaker and completed memory tests in which the stimuli were unstudied foil words and studied words spoken by either the same speaker at study, or the alternate speaker. On "general" test trials, participants were to determine whether each word was studied, regardless of the voice of the speaker, whereas on "specific" test trials, participants were to additionally distinguish between studied words that were spoken in the same voice or a different voice at study. Thus, on specific test trials, participants were explicitly required to attend to voice information in order to evaluate each test item. Anterior (right BA 10), dorsolateral prefrontal (right BA 46), and inferior frontal (bilateral BA 47/12) regions were more active during specific than during general trials. Activation in anterior and dorsolateral PFC was enhanced during specific test trials even in response to unstudied items, suggesting that activation in these regions was related to the differential processing of retrieval cues in the two tasks. In contrast, differences between specific and general test trials in inferior frontal regions (bilateral BA 47/12) were seen only for studied items, suggesting a role for these regions in post-retrieval monitoring processes. Results from this study are consistent with the idea that different PFC subregions implement distinct, but complementary processes that collectively support accurate episodic memory judgments.     

Systematic Reviews Published in the January 2011 Issue of The Cochrane Library

ABSTRACT

The Cochrane Library of Systematic Reviews is published quarterly as a DVD and monthly online. The January 2011 issue (first quarterly DVD for 2011) contains 4515 complete reviews, 1985 protocols for reviews in production, and 13,521 one-page summaries of systematic reviews published in the general medical literature. In addition, there are citations of 641,000 randomized controlled trials, and 14,018 cited papers in the Cochrane methodology register. The health technology assessment database contains over 9300 citations. One hundred and seven new reviews have been published in the last 3 months, of which five have potential relevance for practitioners in pain and palliative medicine.     

Interprofessional approaches to creating safe,high quality health care

Three supplementary perspectives are presented arguing that interprofessional collaboration is both necessary and desirable. Nonetheless, there are often too many serious intra-professional barriers and obstacles to interprofessional collaboration to make it successful. Some of these barriers, it is argued and illustrated, are found in the multiple ways in which professional identity is tacitly acquired and embodied in the practitioners' habitual, everyday practice. The paper then explores ways in which reflection, especially Second order reflection, can help to elucidate and overcome these obstacles, as well as increasing professional adaptability and competence.     

Prise en charge des entorses externes de cheville : étude clinique préliminaire sur l’efficacité du dispositif Myolux™

Ankle sprains are the most common injury of the musculoskeletal system and are associated with significant societal and economic impacts. It has been proven that classical therapeutic strategies may not be effective in preventing recurrent injuries: the recurrence rates reported in the literature can reach 73%. In order to provide an effective rehabilitation solution, a destabilizing orthosis was developed. This device is equipped with a mechanical articulator reproducing the subtalar mechanics and placed under the heel. In this paper, we present the main results of a preliminary clinical study conducted between 2004 and 2007. All subjects included in this study were treated with the abovementioned orthosis during 10 rehabilitation sessions of 30 minutes each. Data show a relatively low recurrence rate of 12% for the overall population. Moreover, it's of primary importance to note that this satisfactory ratio is largely reduced (3% of recurrence rate) for the 29 patients who performed one training session per month after the 10th initial rehabilitation sessions. Hence, the destabilizing orthosis appears to be an effective solution to prevent recurrent ankle sprains. However, joint protection requires long-term and regular training sessions. This result has motivated the development of a similar device allowing patients to perform training sessions at home. Finally, data obtained in this study are promising awaiting the final results of the comparative, multicentric and independent clinical trials currently managed by the Hospices Civils de Lyon.     

Determination of creatine kinase isoenzyme MB activity in serum using immunological inhibition of creatine kinase M subunit activity. Activity kinetics and diagnostic significance in myocardial infarction.

This is a new method for the determination of creatine kinase isoenzyme MB activity in serum. The method uses direct activity measurement of creatine kinase B subunit activity after blocking of CK-M subunit activity by inhibiting antibodies. The test takes no longer than 15 min. The method yields an intra-serial C.V. of 2.0-12.9%, and a C.V. from day to day of 5.5%. The detection limit is 3.4 U/l creatine kinase MB. In the 95 cases with proven myocardial infarction several types of creatine kinase MB activity kinetics could be determined. The percentage of creatine kinase MB of peak CK-total is 6-25%, with a mean of 11.1%. The amount of creatine kinase MB with respect to total CK activity after reinfarction is higher than the amount after initial infarction.     

Modified micro-superior percutaneously-assisted total hip: early experiences & case reports

Because of the extensile nature and familiarity of the standard posterior-lateral approach to the hip, a family of "micro-posterior" approaches has been developed. This family includes the Percutaneously-Assisted Total Hip (PATH) approach, the Supercapsular (SuperCap) approach and a newer hybrid approach, the Supercapsular Percutaneously-Assisted Total Hip (SuperPATH) approach. Such approaches should ideally provide a continuum for the surgeon: from a "micro" (external rotator sparing) posterior approach, to a "mini" (external rotator sacrificing) posterior approach, to a standard posterior approach. This could keep a surgeon within his comfort zone during the learning curve of the procedure, while leaving options for complicated reconstructions for the more practiced micro-posterior surgeons. This paper details one author's experiences utilizing this combined approach, as well as permutations of this entire micro-posterior family of approaches as applied to more complex hip reconstructions.