急性心肌梗塞患者再灌注治疗后ST段回落的影响因素

目的:分析急性心肌梗塞(AMI)患者再灌注治疗后ST段回落(STR)的影响因素。方法:收集114例溶栓和71例急诊经皮冠状动脉介入(PCI)治疗的AMI患者,按溶栓或PCI治疗后90min心电图单导联STR分别分为STR<50%和STR≥50%组,对临床资料中多个变量进行单因素分析和Logistic回归分析。结果:单因素分析显示,与STR<50%患者相比,PCI组STR≥50%患者入院时血糖(Glu)(P=0.016)和白细胞(WBC)(P=0.011)较低,单支冠脉血管病变者较多(P=0.023),溶栓组STR≥50%患者Glu(P=0.002)、WBC(P=0.036)和killip心功能分级(P=0.012)较低,发病到治疗的时间更短(P=0.016),有高血压病史者(P=0.033)和前壁梗塞者(P=0.011)较少。Logistic回归分析结果PCI组最终进入方程的变量为入院时Glu(B=-0.299,P=0.021)和WBC(B=-0.201,P=0.026),溶栓组进入方程的变量有高血压病史(B=-0.978,P=0.027)、GIu(B=-0.252,P=0.003)和治疗前时间(B=-0.004,P=0.018)。结论:入院时血糖水平为AMI患者PCI或溶栓治疗后ST段回落独立的影响因素,WBC是PCI患者ST段回落的另一影响因素,高血压病史和治疗前时间则是溶栓治疗患者ST段回落的另外两个影响因素。     

糖化血红蛋白对直接冠状动脉介入术后心肌组织灌注的影响

目的:观察糖化血红蛋白(HbA1c)水平对急性心肌梗死(AMI)患者接受直接冠状动脉介入(PCI)术后心肌组织灌注的影响。方法:选择因AMI行直接PCI的患者492例,根据HbA1c水平将所有患者分为HbA1c≥6.5%组189例和HbA1c<6.5%组(对照组)303例。通过观察TIMI心肌灌注(TMP)分级、心肌blush分级(MBG)及术后ST段回落率(STR),评价2组患者的术后心肌组织灌注及预后。结果:与对照组比较,HbA1c≥6.5%组的病变血管数、术中出现无复流/慢血流比例、住院期间病死率及梗死相关动脉开通时间显著增加,而术后达到TIMI血流3级、MBG 3级、TMP 3级和STR的比例及LVEF均明显降低(均P<0.05)。多因素分析结果显示,HbA1c≥6.5%是影响术后STR(OR=2.156,95%CI:1.057～4.328,P=0.036)及住院期间病死率(OR=1.021,95%CI:0.418～2.412,P=0.022)的独立危险因素。结论:HbA1c升高的AMI患者心肌组织灌注较差,住院期间病死率高。应重视这些高危患者,并尽早处理,从而改善患者的预后。     

糖尿病对急性ST段抬高心肌梗死急诊经皮冠状动脉介入治疗心肌灌注的影响

目的采用心电图ST段回落指数（STR）和冠状动脉造影心肌呈色分级（MBG）评价糖尿病对急性心肌梗死（AMI）直接PCI后心肌灌注以及患者预后影响的价值。方法287例AMI并行急诊PCI的患者依据病史以及入院前是否接受药物和非药物降糖治疗的情况分为糖尿病组（n=95例）和非糖尿病组（n=192例）。所有患者分析心电图STR和MBG,并进行临床随诊。结果与非糖尿病组比较,糖尿病组年龄较大[（65±12）岁比（57±11）岁,P〈0．05]。两组PCI术后TIMIⅢ级血流的患者数差异无统计学意义（P〉0．05）。糖尿病组心肌微循环灌注不良多于非糖尿病组（MBG 0／156．0％比41．1％,P=0．019）,ST段回落不全也多于非糖尿病组（43．2％比30．7％,P=0．038）。糖尿病组患者在随诊期间联合终点事件的发生率明显多于非糖尿病组（27．4％比16．1％,P=0．025）。多因素回归分析显示糖尿病是患者预后不良的独立危险因素（RR=1．83,95％CI：1．04～3．36,P=0．01）。患者接受再灌注的时间（RR=3．63,95％CI：1．27～10．42,P=0．03）、ST段回落不全（RR=11．71,95％CI：1．53～38．70,P=0．03）以及MBG0／1（RR=1．16,95％CI：1．03～1．38,P=0．01）与患者预后不良相关。结论糖尿病是AMI患者在成功接受介入治疗术后预后不良的独立危险因素,这可能与糖尿病患者出现心肌微循环灌注不良有关。     

体重指数对择期经皮冠状动脉介入治疗术后全因死亡率的预测意义

目的探讨体重指数(BMI)对择期经皮冠状动脉介入治疗(PCI)术后全因死亡率的影响。方法入选2009年7月至2011年9月接受择期PCI的患者2964例,将患者分为体重正常组(BMI24.0 kg/m~2,810例)、超重组(24.0≤BMI28.0 kg/m~2,1454例)、肥胖组(BMI≥28 kg/m~2,700例)。比较各组患者临床特点及术后全因死亡率的差异。结果体重正常组患者年龄大于超重组[(60.1±10.2)岁比(59.2±10.3)岁]和肥胖组[(60.1±10.2)岁比(57.2±11.4)岁],超重组患者年龄大于肥胖组[(59.2±10.3)岁比(57.2±11.4)岁],差异均有统计学意义(均P0.017);体重正常组患者女性比例高于超重组(30.1%比21.9%),而肥胖组患者女性比例高于超重组(27.9%比21.9%),差异均有统计学意义(均P0.017)。体重正常组患者高血压病、白细胞计数、血红蛋白、三酰甘油、空腹血糖、前降支近端病变比例等小于超重组和肥胖组,差异均有统计学意义(均P0.017);肥胖组患者高血压病比例、收缩压、总胆固醇、低密度脂蛋白胆固醇、三酰甘油均高于超重组患者,而估算的肾小球滤过率水平、双联抗血小板治疗比例均低于超重组,差异均有统计学意义(均P0.017)。平均随访时间为(571.5±130.8)d,失访237例(8.0%),完成随访2727例(92.0%)。体重正常组患者死亡23例(2.8%),超重组死亡23例(1.6%),肥胖组死亡8例(1.1%),三组间比较差异有统计学意义(P=0.027)。单因素分析显示,年龄、BMI、糖尿病、左心室射血分数、血红蛋白、估算的肾小球滤过率、空腹血糖、冠状动脉多支血管病变、PCI处理血管支数、完全血管血运重建是死亡的危险因素(均P0.05)。将单因素分析P0.2的变量纳入Cox回归多因素分析显示,与肥胖组患者比较,体重正常组患者术后死亡风险增高(HR 2.241,95%CI 1.154～4.350,P=0.017),超重组患者术后死亡风险差异无统计学意义(HR 1.908,95%CI 0.689～5.291,P=0.213)。结论在接受择期PCI的患者中,超重和肥胖患者预后好于体重正常患者。     

老年患者直接冠状动脉介入术后心肌组织灌注的特点及预后分析

目的观察老年急性心肌梗死(AMI)患者接受PCI后的心肌组织水平的灌注特点及预后情况。方法选择因AMI行PCI的患者388例,根据患者年龄分为老年组(≥60岁)187例及中青年组(<60岁)201例。通过观察TIMI心肌灌注(TMP)分级、心肌blush分级(MBG)及术后ST段回落比例,评价2组患者的术后心肌组织灌注及预后。结果中青年组较老年组病变血管数明显降低,梗死相关血管开通时间明显缩短,术后MBG 3级、术后TMP 3级及ST段回落比例及LVEF均明显升高(P<0.05)。结论老年AMI患者冠状动脉病变程度重,PCI术后虽病死率低于中青年,但组织水平灌注和心功能较差,应给予足够的重视。     

再灌注时间对急诊冠状动脉介入治疗心肌灌注的影响

目的:分析再灌注时间对急性ST段抬高型心肌梗死(STEMI)患者急诊经皮冠状动脉介入治疗(PCI)后心肌灌注及近期预后的影响. 方法:101例首发STEMI并行急诊PCI的患者按症状发作至再灌注的时间(t)分为3组:t≤3 h为A组,37例;3 h0.05).B组及C组PCI术后MBG0/1(58.06%、57.58%)和ST段回落不全(STR<50%)的比例(51.61%、54.55%)均高于A组(32.43%和27.03%,P<0.05),B组与C组间MBG、STR无统计学差异(P>0.05).B组及C组在30 d随访期间的死亡率、Killip分级和心源性休克发生率均显著高于A组(P<0.05). 结论:在STEMI急诊PCI中,12 h内不同时间组获得TIMI 3级血流的比例相同,但再灌注时间<3 h的患者心肌组织灌注水平提高,近期预后较好.     

冠状动脉内注射乌拉地尔对急性心肌梗死心肌灌注和心功能的影响

目的:探讨乌拉地尔对急性心肌梗死(AMI)急诊经皮冠状动脉介入治疗(PCI)患者心肌灌注和心功能的影响。方法:对经急诊PCI治疗的AMI患者54例,随机分为乌拉地尔组、硝酸甘油组和对照组。分别于经皮腔内冠状动脉成形术前冠状动脉内注射乌拉地尔、硝酸甘油、生理盐水。观察PCI术前、术后心肌梗死溶栓试验(TIMI)血流、校正的TIMI帧计数(cTFC)、心肌充血分级(MBG)、ST段回落、心肌坏死指标、左心室射血分数(LVEF)及住院期间主要心血管不良事件(MACE)。结果:乌拉地尔组与硝酸甘油组和对照组相比,PCI后cTFC降低、MBG增加、ST段回落增加、LVEF增加、CK和TnT峰值降低(P均<0.01)。结论:乌拉地尔可改善AMI急诊PCI患者冠状动脉血流、心肌灌注和左心室收缩功能,减少梗死面积,不增加住院期间MACE。     

血栓抽吸结合血栓部位注射替罗非班在急诊PCI中的应用

目的:前瞻性随机比较急性ST段抬高型心肌梗死(STEMI)患者实施直接经皮冠脉介入(PCI)及血栓抽吸术中,经抽吸导管注射替罗非班与经静脉注射替罗非班的临床疗效。方法:入选因STEMI行直接PCI术并使用血栓抽吸患者113例,随机分为为超选组61例和静脉组52例,观察PCI后冠脉TIMI血流,心肌呈色分级,ST段回落程度,CK-MB峰值,术后血NT Pro-BNP值、术后LVEF及主要心血管事件(MACE)发生率。结果:①术后超选组较静脉组TIMI 3级血流获得率、心肌MBG 3级获得率及术后2hST段回落率高(P=0.019,0.027,0.037),超选组CK-MB峰值、术后7d及术后30dNT pro-BNP值较静脉组低(P=0.012,0.031,0.009);②术后30d超选组LVEF高于静脉组(P=0.045),LVEDd、LVESd小于静脉组(P=0.048,0.037);③超选组较静脉组总MACE发生有降低趋势,但差别无统计学意义(P=0.153)。结论:STEMI患者在行直接PCI及血栓抽吸术时经抽吸导管注射替罗非班可显著改善心肌再灌注及近期预后。     

再灌注时间对急诊冠状动脉介入治疗心肌灌注的影响

目的:分析再灌注时间对急性ST段抬高型心肌梗死(STEMI)患者急诊经皮冠状动脉介入治疗(PCI)后心肌灌注及近期预后的影响。方法:101例首发STEMI并行急诊PCI的患者按症状发作至再灌注的时间(t)分为3组:t≤3h为A组,37例;3h0.05)。B组及C组PCI术后MBG0/1(58.06%、57.58%)和ST段回落不全(STR<50%)的比例(51.61%、54.55%)均高于A组(32.43%和27.03%,P<0.05),B组与C组间MBG、STR无统计学差异(P>0.05)。B组及C组在30d随访期间的死亡率、Killip分级和心源性休克发生率均显著高于A组(P<0.05)。结论:在STEMI急诊PCI中,12h内不同时间组获得TIMI 3级血流的比例相同,但再灌注时间<3h的患者心肌组织灌注水平提高,近期预后较好。     

ST段抬高型心肌梗死患者直接经皮冠状动脉介入术后心肌组织灌注的影响因素分析

目的分析ST段抬高型心肌梗死患者直接经皮冠状动脉介入(PCI)术后心肌组织灌注的影响因素。方法回顾性分析2017年1至12月因ST段抬高型心肌梗死(STEMI)于首都医科大学附属北京安贞医院住院行直接PCI的782例患者的临床资料。根据术后ST段回落率将患者分为STR50%组(131例)与对照组(STR≥50%)(651例)。比较2组心肌组织灌注情况,分析相关影响因素。结果 STR50%组患者吸烟比例、糖尿病比例以及再灌注时间明显高于/长于对照组,差异均有统计学意义(P均0.05)。STR50%组冠状动脉内应用替罗非班比例、术中无复流/慢血流比例明显高于对照组,差异均有统计学意义(P均0.05)。STR50%组术后TIMI血流、MBG灌注以及TMP灌注达到3级比率均明显低于对照组[85.5%(112/131)vs. 95.4%(621/651)、59.8%(78/131)vs. 90.1%(587/651)、64.5%(84/131)vs. 90.4%(589/651)],差异均有统计学意义(P均0.05)。Logistic回归分析发现糖尿病(RR=2.81,95%CI:1.20～6.48,P=0.021)、再灌注时间(RR=3.84,95%CI:1.26～6.51,P=0.003)、冠状动脉内应用替罗非班(RR=1.25,95%CI:1.32～6.47,P=0.034)以及术中无复流/慢血流(RR=3.98,95%CI:1.25～9.83,P0.001)是影响心肌组织灌注的因素。结论心肌组织灌注不良是多种因素共同作用结果。与吸烟、糖尿病、再灌注时间及无复流/慢血流的发生密切相关,应积极重视这些危险因素,改善心肌组织灌注,改善预后。     

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.     

The immunoneuroendocrine role of melatonin

Abstract: A tight, physiological link between the pineal gland and the immune system is emerging from a series of experimental studies. This link might reflect the evolutionary connection between self-recognition and reproduction. Pinealectomy or other experimental methods which inhibit melatonin synthesis and secretion induce a state of immunodepression which is counteracted by melatonin. In general, melatonin seems to have an immunoenhancing effect that is particularly apparent in immunodepressive states. The negative effect of acute stress or immunosuppressive pharmacological treatments on various immune parameters are counteracted by melatonin. It seems important to note that one of the main targets of melatonin is the thymus, i.e., the central organ of the immune system. The clinical use of melatonin as an immunotherapeutic agent seems promising in primary and secondary immunodeficiencies as well as in cancer immunotherapy. The immunoenhancing action of melatonin seems to be mediated by T-helper cell-derived opioid peptides as well as by lymphokines and, perhaps, by pituitary hormones. Melatonin-induced-immuno-opioids (MHO) and lymphokines imply the presence of specific binding sites or melatonin receptors on cells of the immune system. On the other hand, lymphokines such as -γ-interferon and interleukin-2 as well as thymic hormones can modulate the synthesis of melatonin in the pineal gland. The pineal gland might thus be viewed as the crux of a sophisticated immunoneuroendocrine network which functions as an unconscious, diffuse sensory organ.     

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.     

Response of rat pineal melatonin to calcium, magnesium, and lithium is circadian stage dependent

Abstract: Herein we documented the response of pineal melatonin production to electrolytes known to be effective on pineal function in view of a possible circadian stage dependence. We studied the release of melatonin by perifused rat pineal glands at 2 different circadian stages corresponding to the middle of the light and dark periods, i.e., respectively, 7 and 19 HALO (Hours After Light Onset, L:D = 12:12). The initial efflux rates were, as expected, much higher in the perifusates of glands removed from rats sacrificed during the dark phase than of those removed during the light phase. After 3 hr of perifusion, melatonin release reached similar levels which were found constant up to the 8th hr of perifusion, whatever the circadian stage. Perifusion of the glands with physiological concentrations for the rat of calcium (5.2 mmol/1) and magnesium (1.34 mmol/1) resulted in a stimulatory effect on the pineal glands removed from rats sacrificed in the middle of the dark period (19 HALO), whereas no effects were observed on the pineal glands removed from rats sacrificed during the light (7 HALO). Lithium (0.28 and 0.55 mmol/1) was ineffective on melatonin release in pineal glands removed 7 and 19 HALO. Our results show differences in the initial efflux rates of melatonin and in the response of perifused pineal glands to calcium and magnesium according to the circadian stage.     

Changes in connexin43, the gap junction protein of astrocytes, during development of the rat pineal gland

Abstract: The abundance of gap junctions between rat pineal astrocytes formed by connexin43 (Cx43) was studied during development. Levels and distribution of Cx43 were measured by immunoblotting and indirect immunofluorescence, respectively. The amount of Cx43 in cells located within the gland was low until about the 7th postnatal day and increased to adult values between the 14th and 21st days postpartum. Although astrocytes, recognized by their vimentin immunoreactivity, were scarce before birth, they were abundant by the 7th postnatal day suggesting that the low levels of Cx43 found at this age corresponded to a low expression of this protein. Localization of the immunoreactivity to Cx43 and vimentin showed a close correlation, indicating that mature or immature pineal astrocytes form gap junctions made of Cx43. Since Cx43 levels attained their adult values at about the time the innervation and the functional state of the gland reached maturity (2–3 weeks after birth), it is proposed that astrocyte gap junctions are involved in the function of the adult rat pineal gland.     

Conservative management of perforated duodenal diverticulum： A case report and review of the literature

Duodenal diverticula are a relatively common condition. They are asymptomatic, unless they become complicated, with perforation being the rarest but most severe complication. Surgical treatment is the most frequently performed approach. We report the case of a patient with a perforated duodenal diverticulum, which was diagnosed early and treated conservatively with antibiotics and percutaneous drainage of secondary retroperitoneal abscesses. We suggest this method could be an acceptable option for the management of similar cases, provided that the patient is in good general condition and without septic signs.