急性心力衰竭患者远期死亡的预测因素分析

目的 探讨急性心力衰竭(AHF)患者远期死亡的预测因素。方法 连续入选南方医科大学顺德医院2012年6月—12月因AHF住院的患者512例,根据出院后1年内是否死亡分为存活组(n＝323)和死亡组(n＝189)。记录患者的基线资料。对出院患者进行中位随访时间20.2月的随访,记录全因死亡事件。使用Cox比例风险回归模型分析死亡的危险因素。结果 1年内全因死亡率为36.9%。单因素Cox比例风险回归模型分析提示,AHF病史(HR 1.41,95%CI 1.02～1.95,P＜0.05)、心率增快(HR 1.01,95%CI 1.00～1.02,P＜0.05)、脑钠肽升高(HR 1.78,95%CI 1.05～3.01,P＜0.05)、低白蛋白(HR 0.94,95%CI 0.92～0.97,P＜0.001)、低血钠(HR 0.97,95%CI 0.94～1.00,P＜0.05)是AHF患者远期死亡的独立预测因素。多因素Cox比例风险回归模型分析提示,AHF病史(HR 1.41,95%CI 1.06～1.88,P＝0.018)、心率增快(HR 1.01,95%CI 1.00～1.01,P＝0.024)、低白蛋白(HR 0.96,95%CI 0.94～0.99,P＝0.003)、低血钠(HR 0.97,95%CI 0.94～0.99,P＝0.010)是AHF患者远期死亡的危险因素。结论 AHF病史、心率增快、低白蛋白、低血钠是AHF患者远期死亡的预测因素。     

老年冠心病合并慢性肾脏病发病状况及其对远期预后的影响

目的 调查老年冠心病（CHD）患者合并慢性肾脏病（CKD）的发病状况及其对远期预后的影响.方法 采用回顾性队列研究的方法.纳入795例老年冠心病患者,依照基线时是否合并CKD,分为合并CKD组（n=228）与单纯CHD组（n=567）,调查两组患者的基线指标水平及相关危险因素情况.以全因死亡作为研究终点,进行10年随访,分析合并CKD对老年冠心病患者远期预后的影响及其他相关危险因素.结果 老年冠心病患者中CKD发生率为28.7%,呈现出随年龄增加递增的趋势.老年冠心病患者发生CKD的独立危险因素包括：年龄、慢性心衰病史、血红蛋白水平、血尿酸水平.随访10年,老年冠心病患者全因死亡率为32.8%,合并CKD组患者全因死亡率,显著高于单纯CHD组患者死亡率（41.7% vs.28.9%,P＜0.05）,合并CKD死亡风险是单纯CHD死亡风险的1.725倍（95%CI：25.6%～33.0%）.10年全因死亡多因素分析显示,CKD是老年冠心病全因死亡的独立危险因素.结论 住院老年冠心病患者CKD发病率高,预后不佳.CKD是老年冠心病患者全因死亡独立的危险因素.     

冠心病患者造影剂相关急性肾损伤后使用肾素-血管紧张素系统抑制剂对远期预后的影响

目的 探讨冠心病患者造影剂相关急性肾损伤(CA-AKI)后使用肾素-血管紧张素系统抑制剂(RASI)对远期预后的影响。方法 共纳入1 526例自2008年1月—2018年12月在广东省人民医院行冠状动脉造影确诊为冠心病且术后出现CA-AKI的患者,根据是否服用RASI分为RASI组(n＝984)和非RASI组(n＝542)。主要终点是远期全因死亡。比较两组患者的基线临床资料。使用Kaplan-Meier方法和COX回归分析评估RASI对远期预后的影响。结果 RASI组使用β受体阻滞剂、他汀类药物的比例高于非RASI组(P＜0.01)。在4.75(2.82,6.67)年的随访期间,有332例患者死亡,全因死亡率为21.76%。Kaplan-Meier生存分析显示,RASI组患者的死亡率低于非RASI组患者(P＝0.001)。单因素和多因素COX回归分析显示出院后接受RASI治疗与全因死亡呈显著负相关(P＝0.001,P＝0.034),RASI是远期全因死亡的独立保护因素。结论 RASI是冠心病患者CA-AKI后远期预后的独立保护因素,长期使用RASI治疗可减少冠心病合并CA-AKI患者的全因死亡。     

慢性射血分数降低心力衰竭患者出院用药调查及对预后的影响

目的了解慢性射血分数降低心力衰竭(简称心衰)患者服用指南推荐药物情况及其对预后的影响。方法这是一项单中心回顾性研究,对2007年1月1日至2009年12月31日在本院住院诊断为慢性心衰且左室射血分数(LVEF)≤0.45的患者通过查阅住院、门诊病历和电话随访进行研究。研究出院时服用药物对全因死亡,以及全因死亡或心源性再住院的影响。结果共187例患者组成研究人群,中位数随访18个月(2～41个月),92%患者出院时服用β受体阻滞剂,79%患者服用血管紧张素转换酶抑制剂/血管紧张素Ⅱ受体拮抗剂(ACEI/ARB),67%患者服用他汀类药物,62%患者服用利尿剂,40%患者服用醛固酮受体拮抗剂,34%患者服用地高辛。全因死亡率为19%,全因死亡或首次心源性再住院率为41%。LVEF≤0.35慢性心衰患者全因死亡率以及全因死亡或首次心源性再住院率分别为27%和53%。校正多重因素后全因死亡的预测因子为年龄(HR 1.34/每增加10岁,95%可信区间1.01～1.77)、NYHA心功能分级(HR 3.17/NYHA每增加1级,95%可信区间1.94～5.19)和慢性肾脏病(CKD)分期(HR 1.85/CKD每增加1期,95%可信区间1.12～3.05),以及出院时服用β受体阻滞剂(HR 0.38,95%可信区间0.15～0.93)和他汀类药物(HR 0.44,95%可信区间0.22～0.88)。结论大多数慢性射血分数降低患者出院时服用了指南推荐的药物,但这部分患者预后差,特别是LVEF≤0.35患者。β受体阻滞剂、ACEI/ARB和他汀类药物能改善预后。     

他汀类药物对急性心肌梗死患者直接冠状动脉介入治疗后对比剂肾病的预防作用

目的探讨急性心肌梗死（acute myocardial infarction,AMI）患者行直接经皮冠状动脉介入（percutaneouscoronary intervention,PCI）治疗前,应用他汀类药物对于对比剂肾病（contrast-induced nephropathy,CIN）的预防作用。方法回顾性分析186例行直接PCI治疗的急性ST段抬高AMI患者的临床资料,根据入院前是否接受他汀类药物治疗,分为他汀组（42例）和非他汀组（144例）,收集其PCI治疗前和治疗后48～72 h内的血清肌酐浓度,计算内生肌酐清除率。结果186例患者中34例发生CIN,CIN发生率为18.3%;他汀组CIN发生率显著低于非他汀组,差异有统计学意义（7.1%vs.21.5%,P〈0.05）。他汀组术后血清肌酐浓度明显低于非他汀组,差异有统计学意义[（90.3±26.0）μmol/L vs.（101.5±28.4）μmol/L,P〈0.05]。术后他汀组内生肌酐清除率明显高于非他汀组,差异有统计学意义[（72.5±21.1）mL/min vs.（63.9±18.2）mL/min,P〈0.05]。多因素回归分析显示,PCI治疗前应用他汀类药物（OR 0.48,95%CI 0.11～0.89,P〈0.05）和肾功能不全（基线内生肌酐清除率〈60 mL/min）、使用主动脉内球囊反搏治疗、心源性休克是CIN的独立预测因素。结论急性AMI行直接PCI治疗的患者,术前应用他汀类药物治疗能保护肾功能,降低CIN的发生率,提示术前他汀类药物预处理可能具有预防CIN的作用。     

慢性完全闭塞病变对接受急诊介入治疗的急性心肌梗死患者远期预后的影响

目的:分析慢性完全闭塞(CTO)病变对接受急诊介入治疗的急性心肌梗死(AMI)患者远期预后的影响。方法:分析自2013年1月至2014年9月间纳入中国急性心肌梗死(CAMI)注册登记研究的接受急诊介入治疗的14176例AMI患者,根据冠状动脉造影的结果,将患者分为AMI合并CTO病变组(n=1235)和AMI不合并CTO病变组(n=12941)。随访2年,比较两组的临床预后,主要研究终点为死亡率,次要研究终点为包括心原性死亡、脑卒中、心力衰竭再入院、再次血运重建等的主要不良心血管事件。结果:合并CTO病变的AMI患者占8.7%(1235/14176)。随访2年,AMI合并CTO病变组的患者全因死亡率(9.9%vs.5.4%)和心原性死亡率(5.0%vs.2.6%)明显高于AMI不合并CTO病变组患者(P均<0.01)。单因素分析显示,CTO病变增加AMI患者死亡(HR=1.44,95%CI:1.02~2.03,P=0.04)和再次血运重建(HR=2.14,95%CI:1.55~2.96,P<0.01)风险。多因素回归分析显示,高龄(HR=1.07,95%CI:1.05~1.09)和就诊时存在心力衰竭(HR=2.05,95%CI:1.36~3.09)与患者2年死亡的不良预后明显相关(P均<0.01),而CTO病变不是2年死亡的独立危险因素(HR=1.33,95%CI:0.93~1.90,P=0.11)。结论:合并CTO病变的AMI患者的远期死亡率和心原性死亡率明显高于不合并CTO病变的患者。高龄和就诊时存在心力衰竭是远期死亡的独立危险因素,而CTO病变并不是远期死亡的独立危险因素。     

急性心肌梗死患者早期他汀类药物应用的意义

目的观察急性心肌梗死(AMI)患者早期(出院前)他汀类药物应用对长期服药率及预后的影响。方法入选1998~1999年从我院出院的AMI患者,根据出院前是否应用他汀类药物分为他汀组与非他汀组,随访两组主要终点即全因死亡、因心绞痛再住院、非致死性再梗、血管重建(冠状动脉介入治疗,冠状动脉旁路移植术)及脑卒中的发生率,同时观察两组目前他汀类药物的应用情况。结果(1)符合入选标准的患者260例,完成随访227例,其中在出院前应用他汀类药物的患者(他汀组)107例,未应用他汀类药物的患者(非他汀组)120例,随访(52.5±16.1)月。(2)随访期间他汀组主要终点发生率明显降低(31.8%比50.8%;P=0.004)。(3)应用logistic多因素回归分析,仅年龄和出院前应用他汀类药物和主要终点显著相关(P均为0.038)。(4)随访期间他汀组患者比非他汀组患者服药率明显提高(62%比19.4%;P<0.001)。结论AMI早期他汀类药物应用可以减少主要终点的发生率,提高长期服药率。     

急性心肌梗死后血B型尿钠肽水平与急诊经皮冠状动脉介入及远期死亡率的相关性分析

目的探讨急性心肌梗死（AMI）急性期血B型尿钠肽水平（BNP）是否受急诊经皮冠状动脉介入（PCI）影响,及其对患者远期死亡率的预测价值。方法连续录入心脏病监护病房住院的230例AMI患者,对比急诊PCI与未行急诊PCI治疗组血BNP水平的差别;对该组患者进行随访,平均（38.1±8.5）个月,随访率86.1%;记录AMI后3年发生的心源性死亡情况;采用Kaplan-Meier曲线进行无心源性死亡生存率分析,并采用LogRank法对比不同BNP水平患者生存率的差别。结果经急诊PCI治疗患者在AMI急性期LnBNP显著低于未行急诊PCI治疗组（5.0±1.2vs5.8±1.3,P〈0.001）,3年期随访心源性死亡患者LnBNP显著高于存活组（6.6±1.1vs5.3±1.3,P〈0.001）;经急诊PCI治疗患者生存率显著高于后者（93.4%vs77.5%,P〈0.01）。通过绘制ROC曲线,BNP=316.5ng/L被确定为分界点把患者分成高BNP水平组和低BNP水平组。经Kaplan-Meier曲线分析提示,两组生存曲线显著分离。经Log Rank分析提示,低BNP水平组生存率显著高于高BNP水平组（95.1%vs66.4%,P〈0.001）。结论急诊PCI治疗可显著降低AMI急性期血BNP水平。BNP是AMI远期预后的优良血清标记物,与患者远期死亡率相关。     

离休干部237例体质量指数与全因死亡的分析研究

目的 分析第二军医大学离休干部体质量指数（BMI）与全因死亡的关系。方法 收集2000年1月至2013年10月于长海医院老年病科住院的我校离休干部共237例的临床资料,并进行随访,随访截止时间为2014年10月31日。根据BMI分为4组：低体质量组,BMI＜20kg/m2;理想体质量组,BMI 20～24.9 kg/m2;超重组,BMI 25～27.9 kg/m2;肥胖组,BMI≥28kg/m2。采用Cox回归方法分析各组的全因死亡风险。结果 中位随访时间59个月,均无失访,随访结束时发生全因死亡115例。Cox回归分析不同BMI分组的全因死亡风险,校正混杂因素后,相对于低体质量组,理想体质量组、超重组和肥胖组的全因死亡风险分别下降53.6%（HR＝0.464,95%CI：0.239～0.901,P＜0.05）、65.2%（HR＝0.348,95%CI：0.162～0.749,P＜0.05）、74.2%（HR＝0.258,95%CI：0.103～0.644,P＜0.05)。结论 随着BMI增加,离休干部全因死亡风险呈下降趋势。     

高龄男性动脉粥样硬化性心血管疾病患者他汀类药物疗效分析及不良反应探究

目的探究在高龄男性动脉粥样硬化性心血管疾病(ASCVD)患者中他汀类药物的治疗效果及不良反应。方法选择我院心血管内科住院的高龄男性ASCVD患者310例,根据数次入院随访服用他汀类药物情况分为他汀组195例和非他汀组115例,分析2组全因死亡及主要终点事件。结果他汀组和非他汀组平均生存时间分别为104.10个月(95%CI:97.46～110.75)和97.14个月(95%CI:89.61～104.67)。他汀组不稳定性心绞痛发生率明显低于非他汀组(P0.05)。校正他汀类药物、高血压等混杂因素后,肾功能不全是全因死亡、主要心血管事件、不稳定性心绞痛及非致死性心肌梗死的危险因素(HR=1.944,P=0.004;HR=2.095,P=0.004;HR=2.179,P=0.014;HR=3.172,P=0.019);而在校正混杂因素后,他汀类药物治疗与不稳定性心绞痛有关(P=0.015)。他汀组LDL-C水平明显低于非他汀组,HDL-C、LDL-C达标率、丙氨酸转氨酶轻度升高率明显高于非他汀组(P0.05,P0.01)。结论他汀类药物能显著降低高龄男性ASCVD患者LDL-C水平,减缓HDL-C下降趋势,具有良好的安全性。     

Three layer functional model and energy exchange concept of aging process

Relying on a certain degree of abstraction, we can propose that no particular distinction exists between animate or living matter and inanimate matter. While focusing attention on some specifics, the dividing line between the two can be drawn. The most apparent distinction is in the level of structural and functional organization with the dissimilar streams of ‘energy flow’ between the observed entity and the surrounding environment. In essence, living matter is created from inanimate matter which is organized to contain internal intense energy processes and maintain lower intensity energy exchange processes with the environment. Taking internal and external energy processes into account, we contend in this paper that living matter can be referred to as matter of dissipative structure, with this structure assumed to be a common quality of all living creatures and living matter in general. Interruption of internal energy conversion processes and terminating the controlled energy exchange with the environment leads to degeneration of dissipative structure and reduction of the same to inanimate matter, (gas, liquid and/or solid inanimate substances), and ultimately what can be called ‘death.’ This concept of what we call dissipative nature can be extended from living organisms to social groups of animals, to mankind. An analogy based on the organization of matter provides a basis for a functional model of living entities. The models relies on the parallels among the three central structures of any cell (nucleus, cytoplasm and outer membrane) and the human body (central organs, body fluids along with the connective tissues, and external skin integument). This three-part structural organization may be observed almost universally in nature. It can be observed from the atomic structure to the planetary and intergalactic organizations. This similarity is corroborated by the membrane theory applied to living organisms. According to the energy nature of living matter and the proposed functional model, the decreased integrity of a human body's external envelope membrane is a first cause of the structural degradation and aging of the entire organism. The aging process than progresses externally to internally, as in single cell organisms, suggesting that much of the efforts towards the restoration and maintenance of the mechanisms responsible for structural development should be focused accordingly, on the membrane, i.e., the skin. Numerous reports indicate that all parts of the human body, like: bones, blood with blood vessels, muscles, skin, and so on, have some ability for restoration. Therefore, actual revival of not only aging tissue of the human body's membrane, but the entire human body enclosed within, with all internal organs, might be expected. We assess several aging theories within the context of our model and provide suggestions on how to activate the body's own anti-aging mechanisms and increase longevity. This paper presents some analogies and some distinctions that exist between the living dissipative structure matter and inanimate matter, discusses the aging process and proposes certain aging reversal solutions.     

Unusual responses of nocturnal pineal melatonin synthesis and secretion to swimming: Attempts to define mechanisms

Abstract: The effect of swimming at night on rat pineal melatonin synthesis was compared with that of light exposure at night. Rats were forced to swim at 0030 hr (lights out at 2000 hr) and sacrificed by decapitation 15 and 30 min later, immediately after swimming. Other groups of animals were exposed to white light (650μW/cm²) for 15 and 30 min at same time. Swimming caused a rapid and highly significant drop in the melatonin content in the pineal gland; however, the activity of N-acetyltransferase (NAT), the supposed rate limiting enzyme in the melatonin production, was not changed. Despite the drop in pineal melatonin levels, serum concentrations of the indole remained elevated in the rats that swam. In contrast, melatonin levels in the pineal and serum of light exposed rats fell precipitously, accompanied by a significant suppression of NAT activity. Since we anticipated that the strenuous exercise associated with swimming may induce release of artrial natriuretic peptide (ANP) from the heart, which in turn could cause the release of pineal melatonin, in a second study we injected physiological saline intravenously to stretch the cardiac muscle and release ANP. Three milliliters of normal saline was injected during the day into the jugular vein of anesthetized rats that were pretreated with isoproterenol to stimulate pineal melatonin production. Animals were killed 15 min after the saline injection, and pineal NAT activity and pineal melatonin levels were measured. The saline injections caused no alteration in the elevated levels of either NAT or melatonin. These data suggest that the disparity in pineal NAT activity (which was high) and pineal melatonin (which was low), in animals swum at night, may not be caused by ANP which is released during strenuous exercise such as swimming.     

Melatonin and photoperiodic time measurement: Seasonal breeding in the sheep

Abstract: Well-established circadian physiology supports the view that photoperiodic time measurement utilizes the coincidence between the presence of light and a photosensitive phase of a 'biological clock' to alter reproductive status—the so-called external coincidence model of seasonal breeding. In this review, we examine the mechanism whereby photoperiod interacts with presumed suprachiasmatic nuclei activity to allow endogenous melatonin to normally synchronize reproductive activity to the optimal time of year. The Romney Marsh sheep is particularly explored as an experimental model. It is suggested that the on/off activity of seasonal reproduction may be a robust mechanism able to be predictably manipulated by the judicious use of the light/dark cycle and exogenous melatonin, but firmly based on circadian principles.     

Serological survey of HIV and syphilis in pregnant women in Madagascar

Objectives Peripartal transmission of human immunodeficiency virus (HIV) and Treponema pallidum, the causative agent of syphilis, leads to severe consequences for newborns. Preventive measures require awareness of the maternal infection. Although HIV and syphilis testing in Madagascar could be theoretically carried out within the framework of the national pregnancy follow‐up scheme, the required test kits are rarely available at peripheral health centres. In this study, we screened blood samples of pregnant Madagascan women for HIV and syphilis seroprevalence to estimate the demand for systemic screening in pregnancy. Methods Retrospective anonymous serological analysis for HIV and syphilis was performed in plasma samples from 1232 pregnant women that were taken between May and July 2010 in Ambositra, Ifanadiana, Manakara, Mananjary, Moramanga and Tsiroanomandidy (Madagascar) during pregnancy follow‐up. Screening was based on Treponema pallidum haemagglutination tests for syphilis and rapid tests for HIV, with confirmation of positive screening results on line assays. Results Out of 1232 pregnant women, none were seropositive for HIV and 37 (3%) were seropositive for Treponema pallidum. Conclusions Our findings are in line with previous studies that describe considerable syphilis prevalence in the rural Madagascan population. The results suggest a need for screening to prevent peripartal Treponema pallidum transmission, while HIV is still rare. If they are known, Treponema pallidum infections can be easily, safely and inexpensively treated even in pregnancy to reduce the risk of transmission.     

Variabilité des concentrations plasmatiques de l’angiotensinogène et risque d’hypertension artérielle chez le rat transgénique

Aim

Genetic polymorphisms of the human angiotensinogen gene are frequent and may induce up to 30% increase of plasma angiotensinogen concentrations with a blood pressure increase of up to 5 mmHg. Their role for the pathogenesis of human arterial hypertension remains unclear. High plasma angiotensinogen levels could increase the sensitivity to other blood pressure stressors.

Methods

Male transgenic rats with a 9-fold increase of plasma angiotensinogen concentrations and male non-transgenic rats aged 10 weeks were treated or not with NG-Nitro-L-arginine-methyl ester for 3 weeks in their drinking water (n = 3/group). Systolic blood pressure and body weight were measured at baseline and at the end of the study when left ventricular weight and ventricular expression of angiotensin I-converting enzyme and procollagen Iα1 were determined (polymerase chain reaction).

Results

At baseline, transgenic rats had +18 mmHg higher bood pressure and –8% lower body weight compared to non-transgenic rats (P < 0.05) without significant changes for the vehicle groups throughout the study (P > 0.05). NG-Nitro-L-arginine-methyl ester increased blood pressure, left ventricular weight and left ventricular weight indexed for body weight by +41%, +17.6% and +18.6% (P < 0.05) in transgenic and +25%, +5.3% and +6.7% (P > 0.05) in non-transgenic rats compared to untreated animals, respectively. Cardiac gene expression showed no differences between groups (P > 0.05).

Conclusion

Increased plasma angiotensinogen levels may sensitize to additional blood pressure stressors. Our preliminary results point towards an independent role of angiotensinogen in the pathogenesis of human hypertension and associated end-organ damage.     

Morphological and immunocytochemical heterogeneity of cultured pinealocytes from one-week-and two-month-old rats: Planimetric and densitometric investigations

Abstract: In vitro preparations of rat pinealocytes are widely used for biochemical analyses of signal transduction processes. This paper deals with morphological and immunocytochemical features of such preparations. Special attention was paid to the problems of whether pinealocytes represent a heterogeneous cell population and how such heterogeneity may develop during ontogeny. The investigations were performed with cells which were obtained from the pineal organ of one-week-and two-month-old rats, attached to synthetic peptide-coated coverslips or tissue culture chamber slides, and maintained under in vitro conditions overnight. The attached cells were then fixed with paraformaldehyde. These preparations yielded monolayers of spherical cells of different sizes; most cells were isolated, but some of them were aggregated and formed small clusters. On the average, the cells from the one-week-old animals were smaller than the cells from the two-month-old animals. Immunocytochemical demonstration of S-antigen, a pinealocyte-specific marker, showed that the majority of the cells from two-month-old animals were intensely or moderately labelled. Pinealocytes from one-week-old animals were less S-antigen immunoreactive. Only very few cells (less than 1% displayed glial fibrillary acidic protein (GFAP)-immunoreactivity. Planimetric investigations of the cell size and semiquantitative densitometric investigations of the intensity of the S-antigen immunoreaction revealed that (i) pinealocytes kept in vitro form a heterogeneous cell population, and that (ii) this heterogeneity increases during postnatal development from one-week-old to two-month-old animals. Two groups of pinealocytes can be distinguished based on their developmental fate: pinealocytes of one group grow dramatically, but show only a moderate increase in S-antigen immunoreactivity, and pinealocytes of the other group retain their size, but display a distinct increment in S-antigen immunoreacti vitv.     

MUTATION FREQUENCY IN NURSES AND PHARMACISTS WORKING WITH CYTOTOXIC DRUGS

Individuals occupationally exposed to cytotoxic drugs may be at risk owing to the effects of these agents on DNA. As an index of DNA damage, in vivo mutations were measured in lymphocytes from 24 oncology nurses or pharmacists and 24 matched controls. Mutation frequency was significantly increased in exposed individuals and appeared to be related to duration of exposure. However, the overall magnitude of the increase was small and its biological significance remains to be determined.