糖尿病在急性心肌梗死危险评估中地位的探讨

目的 观察血糖升高对急性心肌梗死(AMI)患者预后的影响,探讨糖尿病在AMI危险评估中的地位.方法 回顾性选择解放军第八一医院2000年1月至2010年5月收治的AMI患者.将无糖尿病史、空腹血糖(FBG)≥7.0 mmol/L,而后又恢复正常定义为非糖尿病AMI患者的应激性高血糖.根据FBG水平将糖尿病和非糖尿病患者分为<7.0、7.0～7.9、8.0～11.0及≥11.1 mmol/L 4组,观察院内病死率、并发症发生率及降糖治疗情况;并对AMI预后危险因素进行Logistic回归分析.结果 共入选AMI患者152例,糖尿病组45例,其中FBG≥8.0 mmol/L者占73.3%(33例),FBG≥11.1 mmol/L者占46.7%(21例);非糖尿病组107例,发生应激性高血糖者(47例,占43.9%)中有91.5%的患者(43例)FBG为7.0～11.0 mmol/L.糖尿病组院内病死率较非糖尿病组显著增高(35.6%比15.9%,P=0.007),且两组病死率均随FBG升高呈上升趋势.多因素Logistic回归分析显示,FBG≥8.0 mmol/L糖尿病患者死亡风险是FBG<8.0 mmol/L者的12.28倍,FBG≥7.0 mmol/L非糖尿病患者死亡风险是FBG<7.0 mmol/L者的4.81倍.FBG是AMI死亡的独立危险因素,糖尿病组相对比值比(OR)为1.03,95%可信区间(95%CI)为1.01～1.16,P=0.012;非糖尿病组OR为1.56,95%CI为1.09～2.23,P=0.015.糖尿病组充血性心力衰竭发生率较非糖尿病组显著增高(40.0H比22.4%,P=0.027);其中非糖尿病组FBG≥7.0 mmol/L者肺部感染、充血性心力衰竭、严重心律失常及急性脑血管事件发生率(分别为51.1%、34.0%、27.7%、14.9%)均较FBG<7.0 mmol/L者(分别为18.3%、13.3%、10.0%、0)显著增高(P<0.05或P<0.01),而在糖尿病组中未观察到该现象.糖尿病组中有80.0%(36例)的患者接受降糖治疗,其中23例(占63.9%)应用胰岛素;而非糖尿病组应激性高血糖者无一例进行降血糖治疗.结论 糖尿病AMI患者及伴应激性高血糖的非糖尿病AMI患者院内病死率和并发症发生率增加,糖尿病史和血糖都是影响AMI预后的危险因素,将二者结合起来对AMI进行危险分层更为合理.

Abstract：

Objective To determine the impact of elevated in-hospital glucose level on outcome of patients with acute myocardial infarction (AMI),and evaluate the role of diabetes mellitus as a risk factor of AMI.Methods The study included a retrospective analysis of AMI patients who were admitted to No.81 Hospital of PLA from January 2000 to May 2010.In patients without a history of diabetes,and those with fasting blood glucose(FBG)≥7.0 mmol/L at admission but returned to normal range soon after admission were defined as stress hyperglycemia of non-diabetic AMI patients.Both diabetic patients and non-diabetic patients were stratified into four mutually exclusive groups according to FBG levels:<7.0,7.0-7.9,8.0-11.0 and≥11.1 mmol/L.The in-hospital mortality,incidence of complications,and treatment to lower glucose level were analyzed.Logistic regression analysis was conducted on risk factors of outcome of AMI patients.Results One hundred and fifty-two AMI patients were enrolled with 45 diabetic patients and 107 patients without previous diabetes.In diabetic group patients with FBG≥8.0 mmol/L and those with FBG≥11.1 mmol/L accounted for 73.3%(33 cases)and 46.7%(21 cases),respectively.In non-diabetic group patients with stress hyperglycemia accounted for 43.9%(47 cases),among which patients with FBG levels of 7.0-11.0 mmol/L accounted for 91.5%(43 cases).Compared with the non-diabetic group,the in-hospital mortality was significantly higher in diabetic group(35.6%vs.1 5.9%,P=0.007).In both groups,the in-hospital mortality presented an elevating tendency with an increasing FBG level.Multivariate Logistic regression analysis demonstrated that in diabetic group patients with FBG≥8.0 mmol/L had 12.28-fold higher risk of death than patients with FBG<8.0 mmol/L,and that in non-diabetic group patients with FBG≥7.0 mmol/L had 4.81-fold higher risk of death than patients with FBG<7.0 mmol/L.FBG was an independent risk factor of death with relative odds ratio(OR)1.03,with 95% confidence interval(95% CI)1.01-1.16,P=0.012,and OR 1.56,95% CI 1.09-2.23,P=0.015 in diabetic group and non-diabetic group,respectively.The incidence of congestive heart failure in diabetic group was significantly higher than that in non-diabetic group (40.0% vs.22.4%,P=0.027).In non-diabetic group,the incidence of lung infection,congestive heart failure,serious arrhythmias and acute cerebrovascular events(51.1%,34.0%,27.7%,14.9%,respectively) was increased significantly in patients with FBG≥7.0 mmol/L than that in patients with FBG<7.0mmol/L(18.3%,13.3%,10.0%,0,respectively,P<0.05 or P<0.01).This association was not seen in diabetic group.80.0%of patients(36 cases)in diabetic group received anti-hyperglycemia treatments in which insulin therapy accounted for 63.9%(23 cases),while there was not even 1 patient who needed insulin therapy in non-diabetic patients with stress hyperglycemia.Conclusion In-hospital mortality and complications were significantly increased in diabetic AMI patients and in non-diabetic AMI patients with stress hyperglycemia.Both a history of diabetes mellitus and stress hyperglycemia have strong influence on AMI prognosis.It seems to be more plausible to collaborate blood glucose level with history of diabetes in considering risk factors in AMI patients.     

危重症患者不同原因血糖升高的临床意义及预后

目的 探讨急诊危重症患者不同原因导致的血糖升高以及与预后的关系.方法 选择北京朝阳医院急诊抢救室2006年10月至2007年11月救治的危重症患者826例,就诊第1小时内进行快速随机血糖测定,有651例患者随机血糖异常升高并进一步行糖化血红蛋白(glycated hemoglobin,GHb)检测,根据GHb测试结果将651例患者分为GHb正常与GHb升高两组.651例患者均随访28 d记录患者是否诊断为糖尿病(包括就诊时已经明确糖尿病)以及生存死亡情况,GHb正常与GHb升高两组患者根据患者是否确诊为糖尿病再分为两亚组,分别计算各个亚组患者28 d病死率.结果 651例随机血糖异常升高患者确诊糖尿病患者385例,其中既往无糖尿病病史者155例,占血糖升高例数的23.81%;应激性高血糖266例,占血糖升高例数的40.86%;GHb升高组患者28 d病死率(12.23%)较GHb正常组患者28天病死率(5.82%)明显升高(P=0.001);GHb升高组内无明确糖尿病病史患者病死率(19.21%)较有明确糖尿病病史患者病死率(7.11%)明显升高(P=0.000).结论 危重症患者既往无明确糖尿病史血糖升高不能全部归因为应激性高血糖;不同原因导致的危重症患者血糖升高其预后不同.

Abstract：

Objective To clarify the clinical significance and prognoses of critical patients with hyperglycemia incurred by various causes. Method A total of 826 critical patients were enrolled during the period from October 2006 to November 2007, and blood sugar was measured by using rapid testing devices within the first hour after admission. If blood sugar measured was more than 11.1 mmol/L, the diagnosis of hyperglycemia was made, and furthermore, glycosylated hemoglobin (GHb) was detected as well. The diagnosis of hyperglycemia was made in 651 critical patients and those patients were followed up for 28 days to confirm the diagnosis. According to the levels of GHb, they were divided in two groups, namely normal GHb and high GHb groups. Each group was further divide into two subgroups, namely diabetes group and non -diabetes group in order to compare the fatality rate between the two groups. Results There were 385 patients diagnosed to have diabetes and among them, 155 patients had no clear history of diabetes, accounting for about 23.81% of the 651 hyperglycemia patients. There were 266 (40.86% ) patients were diagnosed to have stress induced hyperglycemia, The fatality rate of 28 - day in the high GHb group was higher than that in the normal GHb group (12. 23% vs 5. 82% , P = 0.001) . In the high GHb group, the fatality rate of 28-day in the patients without clear history of diabetes was higher than that in the patients with clear history of diabetes (19.21% vs7.11%, P =0. 000). Conclusions The hyperglycemia found in critical patients could not be all attributed to the stress induced hyperglycemia especially in the patients without clear history of diabetes, and the prognoses of patients with variously causal hyperglycemia were various.     

Clinical correlates of hypotension in patients with acute organophosphorus poisoning

BACKGROUND:The aim of the present study is to describe the clinical correlates of hypotension and its associated outcomes in patients with acute organophosphorus poisoning(AOPP).METHODS:In this retrospective cohort study,we analyzed data pertaining to 871 patients with AOPP who were treated at two hospitals.Data from hypotensive and non-hypotensive patients were compared to identify clinical correlates of hypotension.We also evaluated the association between clinical parameters(including hypotension)and in-hospital mortality.RESULTS:The incidence of hypotension in AOPP patients was 16.4%.Hypotensive patients showed signifi cantly higher in-hospital mortality(1.1%vs.39.9%,P<0.001).Advanced age(odds ratio[OR]1.25,95%confi dence interval[CI]1.08–1.44),history of diabetes(OR 2.65,95%CI 1.14–5.96),and increased white blood cell count(OR 1.06,95%CI 1.03–1.09),plasma cholinesterase(OR 0.91,95%CI 0.84–0.94),plasma albumin(OR 0.88,95%CI 0.85–0.92),serum amylase(OR 1.01,95%CI 1.01–1.02),and blood pH(OR 0.64,95%CI 0.54–0.75)were signifi cantly associated with hypotension.After adjusting for potential confounders,hypotension was associated with increased in-hospital mortality(hazard ratio 8.77–37.06,depending on the controlled variables).CONCLUSIONS:Hypotension is a common complication of AOPP and is associated with increased in-hospital mortality.Advanced age,history of diabetes,and changes in laboratory parameters were associated with hypotension in AOPP patients.     

Effect of sedation on short-term and long-term outcomes of critically ill patients with acute respiratory insufficiency

BACKGROUND: The present study aimed to determine the short-term and long-term outcomes of critically ill patients with acute respiratory insuffi ciency who had received sedation or no sedation.METHODS: The data of 91 patients who had received mechanical ventilation in the first 24 hours between November 2008 and October 2009 were retrospectively analyzed. These patients were divided into two groups: a sedation group(n=28) and a non-sedation group(n=63). The patients were also grouped in two groups: deep sedation group and daily interruption and /or light sedation group.RESULTS: Overall, the 91 patients who had received ventilation ≥48 hours were analyzed. Multivariate analysis demonstrated two independent risk factors for in-hospital death: sequential organ failure assessment score(P=0.019, RR 1.355, 95%CI 1.051–1.747, B=0.304, SE=0.130, Wald=50483) and sedation(P=0.041, RR 5.015, 95%CI 1.072–23.459, B=1.612, SE=0.787, Wald=4.195). Compared with the patients who had received no sedation, those who had received sedation had a longer duration of ventilation, a longer stay in intensive care unit and hospital, and an increased in-hospital mortality rate. The Kaplan-Meier method showed that patients who had received sedation had a lower 60-month survival rate than those who had received no sedation(76.7% vs. 88.9%, Log-rank test=3.630, P=0.057). Compared with the patients who had received deep sedation, those who had received daily interruption or light sedation showed a decreased in-hospital mortality rate(57.1% vs. 9.5%, P=0.008). The 60-month survival of the patients who had received deep sedation was signifi cantly lower than that of those who had daily interruption or light sedation(38.1% vs. 90.5%, Log-rank test=6.783, P=0.009).CONCLUSIONS: Sedation was associated with in-hospital death. The patients who had received sedation had a longer duration of ventilation, a longer stay in intensive care unit and in hospital, and an increased in-hospital mortality rate compared with the patients who did not receive sedation. Compared with daily interruption or light sedation, deep sedation increased the in-hospital mortality and decreased the 60-month survival for patients who had received sedation.     

急性冠状动脉综合征患者血浆晚期蛋白氧化产物升高的机制及意义

Objective To examine the advanced oxidation protein products (AOPP) in patients with acute coronary syndrome(ACS) and discuss the relationship between oxidative stress with the development of atherosclero-sis(AS). Methods Plasma were collected in 59 acute myocardial infarction (AMI) patients including 35 patients underwent selective PCI,24 patients underwent emergency PCI,43 unstable angina pectoris(UA) patients and 10 non-coronary artery disease (non-CAD) patients. All cases underwent coronary angiography (CAG). Plasma was collected immediately,post-24 hours and post-48 hours after admission. AOPP was determined by measurements of absorbance (A) at 340 nm under acidic conditions via spectrophotometry. Results AOPP was (236.42±30.41) ( n = 35 ), ( 207.84±29.50 ) mmol/L ( n = 35 ), ( 227.79 ± 35.18 ) mmol/L ( n = 31 ) respectively immediately, post-24 hours and post-48 hours after admission in AMI ( selective PCI ), ( 239.95 ±39.94 ) mmol/L ( n = 43 ), (175.92 ±29.46) mmol/L(n =38) ,and (156.54 ±28.29) mmol/L(n =35) in UA group and (57.41 ± 13.60) mmol/L( n = 9 ), (56.11 + 11.90) mmol/L ( n = 10 ) and ( 61.75 ± 12.28 ) mmol/L ( n = 8 ) in non-CAD group. Compared with normal group ( without CAD ) , significantly higher plasma AOPP was detected in AMI ( selective PCI) and UA patients ( P < 0.05 ). AOPP level was significantly increased in AMI selective PCI patients as compared with that of emergency PCI group immediately and post-24 hours after admission( P <0.01 ) ,and post-48 hours after admission( P < 0.05 ), but there was no statistical significance between emergency PCI and UA group( P > 0.05 ). Conclusions Oxidative stress is an important step in the development of atherosclerosis, and the higher levels of AOPP in ACS patients show that AOPP may be as good markers in these patients.     

Outcomes of critically ill cancer patients with Acinetobacter baumannii infection

AIM: To describe the intensive care unit(ICU) outcomes of critically ill cancer patients with Acinetobacter baumannii(AB) infection.METHODS: This was an observational study that included 23 consecutive cancer patients who acquired AB infections during their stay at ICU of the National Cancer Institute of Mexico(INCan), located in Mexico City. Data collection took place between January 2011, and December 2012. Patients who had AB infections before ICU admission, and infections that occurred during the first 2 d of ICU stay were excluded. Data were obtained by reviewing the electronic health record of each patient. This investigation was approved by the Scientific and Ethics Committees at INCan. Because of its observational nature, informed consent of the patients was not required.RESULTS: Throughout the study period, a total of 494 critically ill patients with cancer were admitted to the ICU of the INCan, 23(4.6%) of whom developed AB infections. Sixteen(60.9%) of these patients had hematologic malignancies. Most frequent reasons for ICU admission were severe sepsis or septic shock(56.2%) and postoperative care(21.7%). The respiratory tract was the most frequent site of AB infection(91.3%). The most common organ dysfunction observed in our group of patients were the respiratory(100%), cardiovascular(100%), hepatic(73.9%) and renal dysfunction(65.2%). The ICU mortality of patients with 3 or less organ system dysfunctions was 11.7%(2/17) compared with 66.6%(4/6) for the group of patients with 4 or more organ system dysfunctions(P = 0.021). Multivariate analysis identified blood lactate levels(BLL) as the only variable independently associated with inICU death(OR = 2.59, 95%CI: 1.04-6.43, P = 0.040). ICU and hospital mortality rates were 26.1% and 43.5%, respectively.CONCLUSION: The mortality rate in critically ill patients with both HM, and AB infections who are admitted to the ICU is high. The variable most associated with increased mortality was a BLL ≥ 2.6 mmol/L in the first day of stay in the ICU.     

非ST段抬高和ST段抬高心肌梗死患者介入结果的比较

Objective To evaluate the short-term and long-term outcomes of patients with ST-segment elevation myocardial infarction (STEMI) compared with those with non-STEMI after percutaneous coronary intervention (PCI). Method The DESIRE Ⅱ (Drug-Eluting Stent Impact on Revascularization Ⅱ) was a single-center registered retrospective study of coronary revascularization in our institution between July 2003 and September 2009.Data of demographics, clinical features and revascularization record of STEMI and non-STEMI patients from the DESIRE Ⅱ trial were analyzed. The patients were followed up in OPD or by telephone after discharge. MACCE (major adverse cardiocerebral events) including death, neo-myocardial infarction, stroke and revascularization were recorded. The clinical outcomes of patients of two types were evaluated. Results There were 6005 patients studied with a median follow-up of 566 days. A total of 1009 STEMI and non-STEMI patients were analyzed. The patients with non-STEMI ( n = 206) had higher prevalence of hypertension and history of higher frequency of myocardial infarction as well as revascularization compared with patients with STEMI ( n = 803). The patients with non-STEMI had higher ratio of treatment for multivessel disease (43.7% vs. 34.4%, P = 0.039). There were no significant differences in in-hospital mortality and long-term outcomes (one year survival rate: 96% vs. 98%)between patients with STEMI and non-STEMI. The predictors of 1-year mortality were LVEF and blood creatine.Conclusions Despite different chnical features, patients with STEMI and non-STEMI after PCI had similar both short-term and long-term outcomes.     

施行糖尿病患者康复教育的临床意义

Background:Diabetes is a kind of chronically permanent disease.Management during hospitalization was insufficient.Now,health education is the important project in diabetes study.Patients' lifestyle ,attitude to condition and previous treatment showed obvious impact on diabetes control.Some investigators indicated patients had less knowledge about diabetes-related matters,and their self-health idea was unobvious.They rarely abided by physicians' demands.So,rehabilitative education is important for diabetes patients. Objective:To observe the therapeutic effect of rehabilitative education on diabetes patients. Unit:Department of Leader Health,Laiwu People's Hospital. Subjects:80 diabetes were recruited during July 1997 to July 2001.Among these patients,46 were males,34 were females aged 12～ 72(mean age:56.5).42 had high school education and others had middle school education. Intervention:Based on education project for diabetes developed by Endocrine Institute of Hunan Medical University,health education was conducted during hospitalization.After admission,《 Elementary knowledge about diabetes prevention and treatment》 was given to patients.Extensive education ways were used for diabetes patients and their family members.Patients can seek tele-medical directions with telephone or letters according to their demands. Patients were evaluated before and after education. Main prognosis indexes:Comprehensive condition for elementary knowledge about diabetes,fasting blood glucose and accordance behavior were evaluated. Result: (1)Elementary knowledge about diabetes was mastered by 26% patients before education and 80% after education.(2)Fasting blood glucose was (8.22± 0.80)mmol/L before education and (6.10± 0.50)mmol/L after education(P< 0.05).Follow-up showed no changes in fasting blood glucose after discharge.(3) Accordance rate of drugs uptake,diet control,activity intensity,detection of blood glucose and urinary glucose was 50% before education and 85% after education. Conclusion:Rehabilitative education can enhance patients' self regulation and self detection ability,delay development of complications.     

A retrospective analysis of severe multiple trauma with secondary thrombocytosis北大核心CSCD

Objective To estimate the clinic features of severe multiple trauma with secondary thrombocytosis as a factor influencing the prognosis. Methods A retrospective single-center study was carried out in 680 patients with severe multiple trauma survived longer than 72 hours in Chongqing Emergency Medical Center from March 2010 through March 2013. The variables including age, gender, ISS (injury severity score) , APACHE II score, splenectomy and the usages of vasopressors, blood products transfusion, hematopoietic medicines and anticoagulant were analyzed. The prognosis indices including total in-hospital mortality after 72 hours, length of hospital stay and morbidity of thrombo-embolism were explored. The clinic characteristics and prognosis of severe multiple trauma with secondary thrombocytosis ( platelet count more than 450 × 109 L-1 ) were evaluated. T test or rank sum test was used for comparison between measurement data and Chi-square test or Fisher' s exact test was used for comparison between enumeration data. Results Thrombocytosis was identified in 99 (14.56% ) patients and it occurred one week after injury with median time of 27 days ( ranged from 8 days to 304 days) , and maintained for (18. 62 ±4.38) d. The median of platelet count was 584 × 109 L-1(lowest 478 × 109 L-1, highest 1 072 × 109 L-1) in severe multiple trauma patients with thrombocytosis. The proportions of splenectomy, prolonged use of vasopressors and employment of hematopoietic medicines or anticoagulant were significantly higher in patients with thrombocytosis than those in patients without thrombocytosis (14. 14% vs. 7. 06% , P =0. 03; 62. 63% is. 39.07% , P <0. 01; 28.28% vs. 6.71% , P <0. 01; 90. 91% vs. 19.45% , P < 0. 01). The highest D-Dimer level presenting in patients with thrombocytosis during the time of platelet increasing was significantly more common than that in patients of non- thrombocytosis group 7 days after trauma [ (11. 68 ± 11. 90) vs. (5. 05 ±5. 11) , P =0. 004]. However, the mortality, length of hospital stay and morbidity of thrombo-embolism were not significantly increased in patients with thrombocytosis compared with patients without thrombocytosis [8. 08% vs. 8. 78% , P =0. 82; 34 d (28. 5, 54. 5) d vs. 45d(23, 67) d, P = 0.41; 10.10% vs. 10.50%, P=0.91]. Conclusion There was a higher rate of secondary thrombocytosis in severe multiple trauma patients. The factors such as splenectomy, vasopressors, hematopoietic medicines and so on might induce the reactive thrombocytosis in trauma patients. Thrombocytosis might increase the incidence of thromboembolism in severe multiple trauma patients without appropriate prophylactic anticoagulation. For the sake of prophylaxis, employment of anti-platelet agent might be the appropriately therapeutic strategy for patients suffering from severe multiple trauma with secondary thrombocytosis accompanying risk factors of arterial thrombo-embolism.     

Risk factors for adverse cardiac events in adults with fulminant myocarditis during hospitalization

BACKGROUND Fulminant myocarditis is the critical form of myocarditis that is often associated with heart failure, malignant arrhythmia, and circulatory failure. Patients with fulminant myocarditis who end up with severe multiple organic failure and death are not rare.AIM To analyze the predictors of in-hospital major adverse cardiovascular events(MACE) in patients diagnosed with fulminant myocarditis.METHODS We included a cohort of adult patients diagnosed with fulminant myocarditis who were admitted to Beijing Anzhen Hospital from January 2007 to December2017. The primary endpoint was defined as in-hospital MACE, including death,cardiac arrest, cardiac shock, and ventricular fibrillation. Baseline demographics,clinical history, characteristics of electrocardiograph and ultrasonic cardiogram,laboratory examination, and treatment were recorded. Multivariable logistic regression was used to examine risk factors for in-hospital MACE, and the variables were subsequently assessed by the area under the receiver operating characteristic curve(AUC).RESULTS The rate of in-hospital MACE was 40%. Multivariable logistic regression analysis revealed that baseline QRS duration > 120 ms was the independent risk factor for in-hospital MACE(odds ratio = 4.57, 95%CI: 1.23-16.94, P = 0.023). The AUC of QRS duration > 120 ms for predicting in-hospital MACE was 0.683(95%CI: 0.532-0.833, P = 0.03).CONCLUSION Patients with fulminant myocarditis has a poor outcome. Baseline QRS duration is the independent risk factor for poor outcome in those patients.     

重症急性胰腺炎患者住院死亡因素的早期评估

目的 探讨早期评估重症急性胰腺炎(severe acute pancreatitis,SAP)患者住院期间死亡的相关因素,重点讨论血清胆固醇对SAP预后的影响.方法依据2003年中华医学会消化病学分会胰腺病学组制定的"中国急性胰腺炎诊治指南",回顾性分析南开医院1999年1月-2008年12月间诊断为SAP的住院患者338例,所有患者均在发病72 h内收住院,将患者按照死亡与否分为死亡组与存活组两组,且两组资料具有可比性,所有患者入院后24 h内均抽静脉血进行血常规、血生化及CT检查,并对这些因素进行单因素及Logistic多因素同归分析.结果 经Logistic回归分析,与血总胆固醇(Total cholesterol,TC)浓度≤3.67 mmol/L相比,TC浓度3.67～4.37 mmol/L,OR=0.664,P=0.412;TCA.37～5.23 mmol/L,OR=0.144,P=0.021;TC≥5.23 mmol/L时,OR=1.013,P=0.018,血CRP浓度随着血TC浓度的上升而下降.C-反应蛋白(C-reactive protein,CRP)≥170时,OR=7.074,P=0.031;血白蛋白(albumin,ALB)≤30时OR=7.224,P=0.029.结论ClIP,ALB,TC均可早期预测SAP患者住院病死率;血TC4.37～5.23 mmol/L为降低死亡优势的保护性因素,TC≤3.67 mmol/L或TC≥5.23 mmol/L为增加死亡优势的危险因素;高CRP血症、低ALB血症为增加死亡优势的危险因素,低ALB血症的危险性高于高CRP血症;血胆固醇适量增加可以对抗炎症反应,提高住院患者存活率,进而降低住院病死率.     

Ionized calcium level predicts in-hospital mortality of severe sepsis patients: A retrospective cross-sectional study

Objective: To evaluate the effect of serum ionized calcium levels on the prognosis of severe sepsis patients. Methods: This retrospective cross-sectional study included sepsis patients who were hospitalized in an intensive care unit between January 2011 and December 2014. The demographic and baseline data of the patients who died and survived were compared. The cutoff value of ionized calcium for in-hospital mortality was determined by the receiver operating characteristics curve (ROC). In-hospital mortalities and the survival rates were compared between patients with different ionized calcium levels. Besides, the risk factor of in-hospital mortality was determined. Results: This study included 145 patients with 113 patients who died in the hospital. The patients who died had significantly lower ionized calcium levels (U=2.25, P=0.034). A cut-off value of 0.93 mmol/L of ionized calcium was determined by the ROC curve. The patients with ionized calcium>0.93 mmol/L showed a significantly lower morality (χ2=9.90, P=0.002) and higher survival rate than with ≤0.93 mmol/L (log rank=6.20, P=0.010). Multivariate Cox regression revealed that ionized calcium ≤0.93 mmol/L was a risk factor of in-hospital mortality. Conclusions: Ionized calcium level≤0.93 mmol/L was an independent predictor of in-hospital mortality of severe sepsis.     

应激性高血糖对急性心肌梗死患者心功能的影响

目的 探讨应激性高血糖对非糖尿病急性ST段抬高性心肌梗死(STEMI)患者心功能及住院期间并发症的影响.方法 对62例既往无糖尿病病史的STEMI患者分为应激性高血糖(A)组和非应激性高血糖(B)组.根据非糖尿病患者急性心肌梗死(AMI)后24 h内(空腹>8 h,静脉未应用葡萄糖注射液的患者)空腹血糖≥6.1 mmol/L作为应激性高血糖的判定标准.A组34例,B组28例.所有患者于入院第2周行心脏超声检查,测定左室舒张末期内径(LVDD)、左室收缩末期内径(LVDS)、射血分数(EF)及短轴缩短率(FS).比较两组心功能的差异,并且观察患者在住院期间内并发症的发生情况.结果 A组的EF和FS均明显低于B组,差异有统计学意义(P<0.01).多元回归分析发现:血糖与AMI患者的心功能独立相关,差异有统计学意义(P<0.05).AMI伴发应激性高血糖者住院期间并发症的发生较非应激性高血糖者有增多趋势,因病例数较少未行统计学处理.结论 AMI伴发应激性高血糖者的心功能明显低于非应激性高血糖者.血糖是AMI患者独立且与心功能有关的因素.     

急性心肌梗死患者入院血糖水平与经皮冠状动脉介入治疗后预后的关系

目的 观察急性心肌梗死 (AMI) 患者随机血糖水平对介入治疗后预后的影响.方法 选取急性心肌梗死患者354例,根据入院第一次随机血糖分为3组:A组:132例,血糖＜7.80 mmol/L;B组120例,血糖7.80～11.00 mmol/L;C组102例,血糖≥11.00 mmol/L.结果 与A组相比,C组血胆固醇、低密度脂蛋白、甘油三酯浓度较高(P<0.05).冠状动脉造影示B、C组多支病变比例高于A组,但差异无统计学意义(P>0.05).B、C组校正TIMI帧数(CTFC)值高于A组(P<0.05).B、C组主要心血管事件发生率及病死率高于A组,其中C组与A组相比差异有统计学意义(P<0.05).结论 入院随机血糖升高的急性心肌梗死患者,进行直接介入治疗后预后较差,心血管事件发生率及病死率较高.     

女性急性心肌梗死患者入院时血糖水平与预后关系的研究

目的 探讨入院时高血糖对女性急性心肌梗死(AMI)患者住院期间预后的影响.方法 对我院心脏内科1988年1月至2007年12月接诊的171例无糖尿病史的女性急性AMI患者根据其入院时血糖水平分为3组.第Ⅰ组:69例,血糖水平<6.1 mmol/L;第Ⅱ组:49例,血糖水平6.1～7.8 mmol/L;第Ⅲ组:53例,血糖水平>7.8 mmol/L.对3组患者的一般临床情况、梗死部位、主要并发症发生率和病死率进行比较.结果 ①3组患者在一般临床情况、梗死部位方面差异无统计学意义(P均>0.05);②第Ⅲ组患者住院期间心力衰竭、心源性休克、严重心律失常发生率明显高于第Ⅰ组、第Ⅱ组患者[心力衰竭发生率:第Ⅰ组30.43%(21/69),第Ⅱ组32.65%(16/49),第Ⅲ组58.49%(31/53);心源性休克发生率:第Ⅰ组5.80%(4/69),第Ⅱ组8.16%(4/49),第Ⅲ组24.53%(13/53);严重心律失常发生率:第Ⅰ组24.64%(17/69),第Ⅱ组30.61%(15/49),第Ⅲ组54.72%(29/53)],差异均有统计学意义(P均<0.05).第Ⅲ组患者院内病死率[28.30%(15/53)]显著高于第Ⅰ组[13.04%(9/69)]患者,差异有统计学意义(P<0.05).结论 女性AMI患者入院血糖水平增高时,住院期间心力衰竭、心源性休克、严重心律失常的发生率及病死率均明显增加.     

糖尿病对急性心肌梗死患者预后的影响

目的 研究急性心肌梗死(acute myocardial infarction,AMI)合并糖尿病(diabetes mellitus,DM)患者的临床特征及住院病死率,分析影响AMI预后的危险因素.方法 收集天津医科大学第二医院2000到2004年1023例AMI患者的临床资料、治疗、并发症及预后.按是否合并DM,分为DM组与非DM组,其中DM患者164例(16.03%),回顾性比较DM组与非DM组临床特征.计数资料采用χ~2检验,偏态分布的计量资料采用两独立样本秩和(Mann-Whitney U)检验,并对影响AMI住院病死率的因素进行多因素回归分析.结果 与非DM组相比,DM组女性较多(40.2%vs.28.9%,P<0.01),高血压和心绞痛患病率高(71.7%vs.41.6%,P<0.01;57.3%vs.48.3%,P<0.05),入院时间延迟,住院期间易并发肺水肿(18.9%vs.10.5%,P<0.01),心律失常,冠状动脉三支病变率较高(48.4%vs.25.4%,P<0.05),治疗中利尿剂(43.9%vs.32%,P<0.01),洋地黄类药物(27.4%vs.16.8%,P<0.01)使用率高,住院病死率约为非DM组的两倍(17.7%vs.9.2%,P<0.01).与保守治疗相比,急诊支架术可以降低DM患者病死率(χ~2=4.536,P<0.05).Logistic回归分析显示DM是AMI患者住院病死率的独立危险因子(OR,2.109;95%CI,1.229～3.619).结论 AMI合并DM患者住院期间并发症多,住院病死率高.DM是AMI患者住院病死率的独立危险因子.     

急性Stanford A型主动脉夹层急诊手术患者预后相关生物标记物的分析研究

目的探讨生物标记物与急性Stanford A型主动脉夹层（ATAAD）急诊手术患者院内死亡的相关性。 方法选择2014年12月至2015年7月首都医科大学附属北京安贞医院心外科收住的ATAAD急诊手术住院患者310例。根据住院期间患者的生存情况,将入选患者分为生存组（279例）和死亡组（31例）。比较两组患者的年龄、性别构成比、既往史[包括是否合并高血压、糖尿病、冠状动脉粥样硬化性心脏病（CHD）家族史、高脂血症、吸烟、饮酒和主动脉病史]、入院时的生物标记物[包括肌钙蛋白I、肌酸激酶同工酶（CK-MB）、D-二聚体、白细胞计数和左心室射血分数（LVEF）]表达水平以及出院时情况（死亡或者存活）等一般资料。将可能影响ATAAD住院患者院内死亡的因素纳入多元Logistic回归,分析影响ATAAD急诊手术住院患者院内死亡的危险因素。 结果两组ATAAD急诊手术住院患者肌钙蛋白I[0.071（0.013,1.532）μg/L vs. 0.052（0.014,1.133）μg/L]、D-二聚体[1 104（454,2 576）μg/L vs. 1 827（752,3 475）μg/L]和白细胞计数水平[9（7,12）× 10⁹/L vs. 12（8,17）× 10⁹/L]比较,差异均有统计学意义（U=3 202.000、3 316.000、3 118.000,P=0.036、0.041、0.011）,其他资料比较,差异均无统计学意义（P均> 0.05）。将肌钙蛋白I、D-二聚体和白细胞计数纳入多元Logistic回归分析,结果显示,白细胞计数[OR=1.133,95%CI（1.041,1.233）,P=0.004]是ATAAD急诊手术住院患者院内死亡的独立危险因素。 结论白细胞计数是ATAAD急诊手术住院患者院内死亡的独立危险因素。     

急性心肌梗死患者应激性血糖升高的临床研究

目的研究急性心肌梗死时应激性高血糖对患者心功能、心律失常及院内死亡率的影响。方法200例急性心肌梗死患者被分成非糖尿病组及糖尿病组,前者又被分为应激性血糖增高组及血糖正常组,并详细记录三组患者的临床资料。结果非糖尿病血糖增高组心力衰竭、心律失常及院内死亡率均高于血糖正常组,而血糖>10.0 mmol/L组,则上述指标与糖尿病患者相似。结论急性心肌梗死时伴有应激性高血糖可增加患者心力衰竭、心律失常及院内死亡率。     

不同时间段血乳酸水平对脓毒症院内死亡的预测价值比较：基于重症监护医学信息数据库

目的比较不同时间段的血乳酸水平对脓毒症院内死亡的预测价值,以期为临床上合理选用血乳酸提供一定的研究证据。 方法基于重症监护医学信息数据库,纳入3 299例脓毒症患者。根据患者院内死亡情况,将3 299例脓毒症患者分为院内存活组（2 445例）和院内死亡组（854例）。比较两组患者的性别比、监护室类型、简化急性生理学评分Ⅱ（SAPSⅡ）、序贯器官衰竭估计（SOFA）评分、入院24 h内血乳酸的最大值[血乳酸（24 h,max）]及最小值[血乳酸（24 h,min）]及24 ~ 48 h血乳酸的最大值[血乳酸（48 h,max）]及最小值[血乳酸（48 h,min）]。采用Logistic回归分析及受试者工作特征（ROC）曲线分析影响脓毒症患者院内死亡的相关因素,并用Z检验比较曲线下面积（AUC）。 结果院内存活组患者的血乳酸（24 h,max）[3.0（1.8,4.8）mmol/L vs. 3.6（2.1,6.3）mmol/L]、血乳酸（24 h,min）[1.5（1.1,2.2）mmol/L vs. 1.8（1.3,2.9）mmol/L]、血乳酸（48 h,max）[1.5（1.1,2.3）mmol/L vs. 2.5（1.5,4.4）mmol/L]、血乳酸（48 h,min）[1.3（1.0,1.8）mmol/L vs. 1.9（1.3,3.2）mmol/L]、SAPSⅡ评分[44（35,54）分vs. 48（37,59）分]及SOFA评分[6（4,9）分vs. 8（5,11）分]均较院内死亡组显著降低（H = 7.350、9.535、13.473、12.720、6.734、8.033,P均< 0.001）。将上述指标纳入Logistic回归分析,结果显示,血乳酸（24 h,max）[比值比（OR）= 1.099,95%置信区间（CI）（1.069,1.130）]、血乳酸（24 h,min）[OR = 1.300,95%CI（1.220,1.385）]、血乳酸（48 h,max）[OR = 1.330,95%CI（1.271,1.391）]、血乳酸（48 h,min）[OR = 1.558,95%CI（1.451,1.673）]、SAPSⅡ评分[OR = 1.014,95%CI（1.008,1.020）]和SOFA评分[OR = 1.084,95%CI（1.059,1.110）]均为影响脓毒症患者院内死亡的危险因素（P均< 0.001）。ROC曲线分析结果显示,血乳酸（24 h,max）[AUC = 0.574,95%CI（0.551,0.597）]、血乳酸（24 h,min）[AUC = 0.614,95%CI（0.591,0.636）]、血乳酸（48 h,max）[AUC = 0.693,95%CI（0.672,0.715）]、血乳酸（48 h,min）[AUC = 0.689,95%CI（0.668,0.710）]、SAPSⅡ评分[AUC = 0.577,95%CI（0.555,0.600）]及SOFA评分[AUC = 0.592,95%CI（0.569,0.614）]对脓毒症患者院内死亡均具有预测价值（P均< 0.001）,且血乳酸（48 h,max）和血乳酸（48 h,min）的AUC均显著高于血乳酸（24 h,max）（Z = 7.310、7.064,P均< 0.001）和血乳酸（24 h,min）（Z = 5.078、4.821,P均< 0.001）、SAPSⅡ评分（Z = 7.126、6.880,P均< 0.001）和SOFA评分（Z = 6.204、5.959,P均< 0.001）。 结论入院24 ~ 48 h的血乳酸水平对脓毒症患者院内死亡可能具有更好的预测价值。