射血分数中间值心力衰竭新进展

心力衰竭（心衰）是心脏疾病发展的终末阶段。既往研究通过左心室射血分数对心力衰竭进行分类,分为射血分数降低性心力衰竭与射血分数保留性心力衰竭。近年研究发现介于上述两种心衰的灰色区域,2016年欧洲心脏病学会（ESC）慢性心衰指南首次提出,并将这个灰色区域命名为射血分数中间值心衰。本文对射血分数中间值心衰近年的研究进行综述。     

射血分数保留心力衰竭患者与高尿酸血症的相关研究

目的探讨射血分数保留心力衰竭患者与高尿酸血症的相关性。方法选取射血分数保留心力衰竭患者285例,非心力衰竭组218例,观察各组血液指标及超声心动图指标。结果分别按照N-末端B型脑钠肽前体(NT-pro BNP)值及血尿酸(UA)值分组后,比较差异具有统计学意义(χ2=6.59,P0.05)。Pearson相关分析结果显示:NT-pro BNP与血尿素氮(BUN)(r=0.25,P0.01)、肌酐(Scr)(r=0.24,P0.01)、UA(r=0.11,P0.05)等指标呈正相关。二元Logistic回归检验结果显示:尿酸对射血分数保留心力衰竭的OR为1.93(95%CI:1.16~3.21,P0.05)。结论心力衰竭组患者高尿酸血症比例高于非心力衰竭组,UA水平与NT-pro BNP呈正相关,高尿酸血症是射血分数保留心力衰竭患者的独立危险因素。     

脉搏波速度与射血分数保留性心衰舒张功能的相关性分析

目的探讨脉搏波速度与射血分数保留性心衰舒张功能的相关性分析。方法选取于2014年9月~2016年1月在我院心内科接收治疗的射血分数保留性心衰患者40作为观察组,将同期进行体检的健康人群40例作为对照组。对所有研究对象进行脉搏波速度的测定以及心脏结构与功能的检测,观察比较两组患者的脉搏波速度,并对各指标进行相关性分析。结果观察组患者的CF-PWV(颈-股动脉脉搏波速度)、LAVi(左心房容积指数)、LADi(左心房内径指数)、E峰以及D峰等指标与对照组相比明显升高,差异有统计学意义(P0.05);CF-PWV与患者的年龄、收缩压、舒张压、MAP(平均动脉压)、LAVi以及LADi等指标具有相关性。结论脉搏波速度与射血分数保留性心衰舒张功能具有一定的相关性。     

老年高血压患者中心动脉压与动脉粥样硬化及左心室功能的关系

目的 探讨老年高血压患者中心动脉压与动脉硬化及左心功能的关系. 方法 155例老年高血压患者,分为60～79岁组71例.80～95岁组84例.分别应用脉搏波分析仪计算中心动脉压及反射波增强指数;用全自动动脉硬化测量仪测定动脉硬化相关指标:臂踝脉搏波传导速度、踝臂指数、趾臂指数;用多普勒超声心动仪测定左心功能相关指标:舒张末期室间隔厚度、舒张末期左心室内径、舒张末期左心室后壁厚度、左心室相对厚度、左心室质量指数、二尖瓣前叶EF斜率、左心室射血分数、短轴缩短率. 结果 80～95岁组收缩压、脉压、中心动脉压、反射波增强指数、臂踝脉搏波传导速度均高于60～79岁组(P<0.05),踝臂指数、趾臂指数均低于60～79岁组(P<0.01).80～95岁组舒张末期室间隔厚度、舒张末期左心室后壁厚度、左心室相对厚度,左心室质量指数均高于60～79岁组(P<0.05),二尖瓣前叶EF斜率显著低于60～79岁组(P<0.05),舒张末期左心室内径、左心室射血分数、短轴缩短率两组阃差异无统计学意义(均P>0.05).经年龄、性别、体质指数、血糖、血脂、血尿酸、血肌酐调整后,中心动脉压与反射波增强指数、臂踝脉搏波传导速度呈正相关(r值分别为0.505和0.284,P<0.01);与踝臂指数、趾臂指数无相关性(P>0.05).中心动脉压与左心室肥厚及心功能指标舒张末期室间隔厚度、舒张末期左心室后壁厚度、左心室相对厚度、左心室质量指数亦呈正相关(P<0.05),而与二尖瓣前叶EF斜率呈负相关(P<0.01),与左心室射血分数、短轴缩短率、舒张末期左心室内径无相关性(P>0.05). 结论 随年龄的增长,老年高血压患者中心动脉压升高,动脉硬化程度加重,并伴随左心室肥厚及舒张功能下降.中心动脉压可用于早期动脉硬化的诊断和筛查.     

脉搏波传导速度与冠心病心功能不全的相关性

目的 评价踝臂脉搏波传导速度(baPWV)与冠心病不同程度心功能不全的相关性.方法 连续入院253例明确诊断冠状动脉粥样硬化性心脏病的患者,按纽约心脏病学协会标准(NYHA)进行心功能分级,所有患者采用无创动脉硬化自动测定仪测量baPWV,同时测定脑钠肽(BNP),左室射血分数(LVEF),左室舒张末容量(LVEDV),左室收缩末容量(LVESV),并进行相关性分析.结果 baPWV与BNP(r=0.394,P<0.001)、NYHA分级(r=0.444,P<0.001)、LVEDV (r=-0.130,P<0.05)之间具有显著相关性,但与LVEF、LVESV之间无显著相关性.ROC曲线下面积表明:当baPWV>1717 cm/s时,诊断心功能不全的敏感性为72.9%,特异性为61.8%;左侧踝臂脉搏波传导速度(LbaPWV)≥1900 cm/s时,其对应的敏感性是61.5%,特异性是81.9%.结论 baPWV与冠心病患者NYHA分级之间具有显著相关性,可作为评价心功能的一个指标.     

呼出气体丙酮浓度在射血分数降低的心力衰竭患者诊断中的应用

目的：研究呼出气体丙酮(exhaled breath acetone,EBA)浓度与射血分数降低的心力衰竭的相关性,明确EBA浓度对射血分数降低的心力衰竭的诊断价值。 方法：分别收集20例健康者者及44例射血分数降低的心力衰竭患者的呼出气体约1000ml于Tedlar袋中;采用气相色谱-质谱法检测EBA浓度,采用SPSS软件统计分析;采用方差分析检验分析两样本均数差别的显著性,若差异有统计学意义,做ROC曲线评价EBA浓度在诊断射血分数降低的心力衰竭患者的灵敏度和特异度。 结果：用气相色谱-质谱法检测44例射血分数降低的心力衰竭患者与20例健康受试者的EBA浓度,发现心衰组的EBA浓度（39.19&#177;24.75 mg/m3）明显高于健康对照组（9.39&#177;4.98 mg/m3）,二者之间具有统计显著性（p&lt;0.05);ROC曲线分析得知AUC=0.947,具有较高诊断准确性,且丙酮浓度为13.95 mg/m3为该试验的最佳诊断截断值,敏感度为90.9%,特异度为85%。 结论：EBA浓度可以作为射血分数降低的心力衰竭的诊断方法,但仍需要大样本临床试验来证实。     

肌钙蛋白T联合血清氨基末端脑钠肽诊断儿童心衰的价值

目的：研究血浆肌钙蛋白T （cTnT）与 N 末端 B型利钠肽原（NT-proBNP）联合检测诊断儿童心力衰竭（HF）的价值。方法：选择我院73例儿童 HF患者为心衰组,另选儿童保健门诊75例健康儿童为健康对照组。检测两组的 cTnT、NT-proBNP浓度及左室射血分数（LVEF）,并比较。应用受试者工作特性曲线（ROC）分析 cT-nT和 NT-proBNP联用的诊断敏感度和特异度。结果：与健康对照组相比,心衰组 NT-proBNP [（2486.7±87.5） pmol/L比（3573.8±98.2）pmol/L]、cTnT [（0.03±0.01）ng/ml 比（0.35±0.09）ng/ml]浓度显著升高, LVEF [（70.8±5.2）％比（42.6±3.8）％]显著降低,P 均＜0.05;多元 Logistic回归分析显示,NT-proBNP为HF患童 LVEF的独立相关因素（OR＝1.006,P＝0.012）;NT-proBNP取值3200pmol/L、cTnT取值0.08ng/ml联合诊断儿童 HF的敏感性为89.5％,特异性为85.7％,ROC曲线下面积为0.795。结论：N末端 B型利钠肽原与心肌肌钙蛋白T联合检测对于儿童心力衰竭有较高的诊断价值。     

代谢综合征对脉搏波速度的影响

目的 分析某查体人群合并代谢综合征对踝臂脉搏波传导速度的影响.方法 某单位健康查体人群,常规体检及测定相关代谢指标,用动脉硬化测定仪测定双侧肢体的踝臂脉搏波传导速度.按中华医学会糖尿病学分会代谢综合征评估标准,确定有无代谢异常并分组,比较各组踝臂脉搏波传导速度的变化特点,分析代谢异常与踝臂脉搏波传导速度的相关性.结果 该人群代谢综合征的患病率是13.26%,其中四项代谢异常者占2.43%.随着代谢异常组分和年龄的增加,踝臂脉搏波传导速度逐渐增加,各组间差异有统计学意义(P<0.05),均明显高于对照组,男女各组趋势与总趋势一致.即使单一代谢成分异常,踝臂脉搏波传导速度也显著高于对照组(P<0.05),以单纯高血压组增高最显著.以年龄分为<40岁组,40～59岁组及≥60岁组,前两组均有随着代谢异常数增加,踝臂脉搏波传导速度逐渐增加趋势,≥60岁组此趋势不明显.相关分析可见代谢异常与踝臂脉搏波传导速度存在相关性(左侧r=0.42,P<0.01,右侧r=0.45,P<0.01).结论 踝臂脉搏波传导速度及代谢综合征患病率均随着年龄增加而增加.代谢综合征各组分均是踝臂脉搏波传导速度增加的危险因素,随着代谢异常数的增多,踝臂脉搏波传导速度进一步增加.     

血浆脑利钠肽水平在慢性心力衰竭患者中的临床诊断价值研究

脑利钠肽（BNP）是一种由心脏分泌的由32个氨基酸残基组成的神经类激素。本研究通过观察731例慢性心力衰竭（心衰）患者血浆BNP浓度与左室射血分数（LVEF），确定BNP诊断左室收缩功能不全的诊断界值（cutoff值），探讨BNP水平在心衰诊断中的价值。     

高血压合并肥胖患者脉搏波传导速度的变化及其相关影响因素分析

目的 探讨高血压合并肥胖患者脉搏波传导速度的变化及其相关影响因素.方法 随机入选高血压合并肥胖患者和单纯高血压患者各300例.应用日本科林VP-1000动脉硬化测定仪测定臂踝脉搏波传导速度,同时检测血糖、甘油三酯、肌酐、尿酸、高密度脂蛋白胆固醇、总胆固醇及腰围等指标,并以臂踝脉搏波传导速度为因变量,以年龄、收缩压、舒张压、脉压、体质指数、腰围、血糖、甘油三酯、总胆固醇、高密度脂蛋白胆固醇、肌酐、尿酸等为自变量,行臂踝脉搏波传导速度的多因素分析.结果 高血压合并肥胖患者臂踝脉搏波传导速度(1635±239cm/s)较单纯高血压患者(1583±288 cm/s)显著升高(P<0.05).Pearson相关分析表明,两组臂踝脉搏波传导速度均与收缩压、脉压显著正相关(P<0.05),与舒张压无相关性(P>0.05).多元逐步回归分析表明,600例高血压患者中年龄、收缩压和腰围与反映动脉僵硬度的臂踝脉搏波传导速度关系密切(P<0.05).结论 高血压合并肥胖患者与单纯高血压患者之间臂踝脉搏波传导速度存在显著性差异,年龄、收缩压及腰围与臂踝脉搏波传导速度相关.     

胰岛素瘤的解剖分布特点分析

目的胰岛素瘤是最常见的胰腺神经内分泌肿瘤，因其临床表现多样，导致诊断困难。影像学诊断尤其是超声内镜(EUS)在胰岛素瘤的诊断中起着重要作用，拥有较高的敏感性和特异性。本研究拟通过明确胰岛素瘤的解剖分布特点，以期有助于提高影像学的诊断准确率和降低漏诊率，尤其是在教育和培训实践中对于EUS的学习者更具有指导价值。 方法回顾性分析解放军总医院第一医学中心病案资料数据库1993年1月至2019年11月经外科手术、病理确诊为胰岛素瘤的患者的临床资料，检索方法采取搜索术后病理诊断为"胰岛素瘤"的病例，通过查阅病例的方法，提取出胰岛素瘤的大小和解剖分布等数据，进一步分析其特点。 结果共检索到确诊为胰岛素瘤的患者116例，其中，男45例、女71例，年龄13～76岁，平均年龄(44.4±14.85)岁。胰岛素瘤单发110例(94.8%)、多发6例(5.2%)。位置分布：头颈部46例(39.7%)，单发45例、多发1例；体尾部68例(58.6%)，单发65例、多发3例；全胰腺多发2例(1.7%)。病变大小特点：最大径0.4～3.4 cm，平均大小(1.53±0.58)cm。≤1 cm 29例、>1 cm而≤1.5 cm41例、>1.5 cm而≤2.0 cm28例，≤3 cm 15例，>3 cm 3例。年龄与肿瘤的大小相关，≤44岁患者肿瘤平均大小为(1.36±0.51)cm、>44岁患者肿瘤平均大小为(1.70±0.60)cm，P<0.05。头颈部的肿瘤大于体尾部的肿瘤，头颈部肿瘤平均大小(1.66±0.63)cm，体尾部(1.42±0.52)cm，P<0.05。 结论胰岛素瘤在胰腺体尾部较头颈部更好发；绝大多数单发，但可以全胰腺多发；多数小于1.5 cm，肿瘤的大小与患者年龄和肿瘤的解剖分布相关。     

Pathogenesis of carcinoma of the papilla of Vater

Most adenomas and carcinomas of the small intestine and extrahepatic bile ducts arise in the region of the papilla of Vater. In familial adenomatous polyposis (FAP) it is the main location for carcinomas after proctocolectomy. In many cases symptoms due to stenosis lead to diagnosis at an early tumor stage. In about 80%, curative intended resection is possible. Operability is the most relevant prognostic factor. Most ampullary carcinomas resp. carcinomas of the papilla of Vater develop from adenomatous or flat dysplastic precursor lesions. They can be sited in the ampulloduodenal part of the papilla of Vater, which is lined by intestinal mucosa. They also can develop in deeper parts of the ampulla, which are lined by pancreaticobiliary duct mucosa. Intestinal-type adenocarcinoma and pancreaticobiliary-type adenocarcinoma represent the main histological types of ampullary carcinoma. Furthermore, there exist unusual types and undifferentiated carcinomas. Many carcinomas of intestinal type express the immunohistochemical marker profile of intestinal mucosa (keratin 7?, keratin 20+, MUC2+). Carcinomas of pancreaticobiliary type usually show the immunohistochemical profile of pancreaticobiliary duct mucosa (keratin 7+, keratin 20?, MUC2?). Even poorly differentiated carcinomas, as well as unusual histological types, may conserve the marker profile of the mucosa they developed from. These findings underline the concept of histogenetically different carcinomas of the papilla of Vater which develop either from intestinal- or from pancreaticobiliary-type mucosa of the papilla of Vater. Molecular alterations in ampullary carcinomas are similar to those of colorectal as well as pancreatic carcinomas, although they appear at different frequencies. In future studies, molecular alterations in ampullary carcinomas should be correlated closely with the different histologic tumor types. Consequently, the histologic classification should reflect the histogenesis of ampullary tumors from the two different types of papillary mucosa.     

Demonstration of the mechanism of action of biguanides

Summary Palmitic acid oxidation in rat diaphragm homogenate is depressed by biguanide concentrations that are still incapable of inhibiting oxidative phosphorylation. Glucose oxidation is not directly effected by the same biguanide concentrations: however, the inhibitory effect of palmitic acid on glucose oxidation is partly removed by biguanides. Inhibition of fatty acid oxidation, which accounts for most of the metabolic effects caused by these drugs, can be regarded as the fundamental mechanism of action of biguanides. There is some evidence suggesting that these drugs might interact with carnitine, thus preventing long-chain fatty acids from being transported across the mitochondrial membrane to the site of oxidation. Traduzione a cura degli AA.     

Lack of correlation of degree of villous atrophy with severity of clinical presentation of coeliac disease

BACKGROUND AND AIM: Both the clinical presentation and the degree of mucosal damage in coeliac disease vary greatly. In view of conflicting information as to whether the mode of presentation correlates with the degree of villous atrophy, we reviewed a large cohort of patients with coeliac disease. PATIENTS AND METHODS: We correlated mode of presentation (classical, diarrhoea predominant or atypical/silent) with histology of duodenal biopsies and examined their trends over time. RESULTS: The cohort consisted of 499 adults, mean age 44.1 years, 68% females. The majority had silent coeliac disease (56%) and total villous atrophy (65%). There was no correlation of mode of presentation with the degree of villous atrophy (p=0.25). Sixty-eight percent of females and 58% of males had a severe villous atrophy (p=0.052). There was a significant trend over time for a greater proportion of patients presenting as atypical/silent coeliac disease and having partial villous atrophy, though the majority still had total villous atrophy. CONCLUSIONS: Among our patients the degree of villous atrophy in duodenal biopsies did not correlate with the mode of presentation, indicating that factors other than the degree of villous atrophy must account for diarrhoea in coeliac disease.     

血吸虫童虫生长发育及其机制的研究进展

血吸虫童虫是宿主免疫系统攻击的重要靶标,包括皮肤型、肺型和肝门型童虫。宿主分子对童虫生长发育具有重要作用。童虫生长发育机制包括免疫调节、信号转导、性别发育及凋亡等。肌动蛋白、组织蛋白酶、烯醇化酶和葡萄糖基转移酶等分子为血吸虫童虫生长发育的重要分子。本文对血吸虫童虫生长发育及其机制的研究进展做一综述。     

124例耐多药结核分枝杆菌基因突变特征分析

目的对临床分离的耐多药结核分枝杆菌相关基因的突变特征进行分析。方法对124例耐多药结核分枝杆菌以及50株敏感株的耐药相关基因(包括异烟肼inh A、kat G、oxyR-ahp C间隔区以及利福平rpo B)进行序列测定,分析其基因突变情况。结果异烟肼耐药inh A基因突变率为14.5%;kat G基因突变率为70.2%(87/124),主要位于315位;oxyR-ahp C间隔区突变率为15.3%;inh A、kat G两种基因同时突变率75.0%,三种基因同时突变率为89.5%。利福平rpo B基因突变的检出率高达95.2%,突变主要发生在531、526、516位点。结论我省耐多药菌异烟肼耐药相关基因最常见突变为kat G 315、inh A C-T(-15)、axyR-ahp C间隔区(-10)C-T,利福平为rpo B531、526、516。结合MDR-TB耐药相关基因的特征分析,可以建立一种快速、准确、特异的适合于我省的检测结核菌耐多药性的新方法。     

氯硝柳胺悬浮剂的毒性评价

目的评价氯硝柳胺悬浮剂的毒性，为现场大规模应用灭螺提供依据。方法按照中华人民共和国国家标准GB 15670-1995《农药登记毒理学试验方法》和鱼类毒性试验方法进行。结果经口、经皮肤的LDso雌、雄性大鼠均>5 000 mg/kg，经呼吸道的LCso雌、雄性大鼠均>5 000mg/m3，该药经口、经皮肤、经呼吸道毒性均属微毒类药物；兔眼用药后，观察期内无不良反应，对眼无刺激性；皮肤用药后对皮肤无刺激性。与氯硝柳胺原药、氯硝柳胺乙醇胺盐原药和氯硝柳胺乙醇胺盐可湿性粉剂相比，氯硝柳胺悬浮剂对鱼急性毒性最低。结论氯硝柳胺悬浮剂属微毒类药物，对鱼的毒性低于其乙醇胺盐可湿性粉剂，适合于现场应用。     

Assessment of quality of life of parents of children with juvenile chronic arthritis

The aim of the study was to assess the quality of life (QOL) and the psychological status of parents of children with juvenile chronic arthritis (JCA). The QOL, anxiety and depression of the parents of 28 children with JCA were evaluated and compared to those of the parents of 28 healthy children. Mothers of JCA children and mothers of healthy children reported similar QOL. The reported anxiety and depression levels were similar for mothers and fathers in both groups. The parents of children with pauciarticular-type JCA reported lower QOL and higher levels of anxiety and depression than the parents of children with other types, namely polyarticular and systemic JCA. These findings may be explained by the fact that the pauciarticular patients had shorter disease duration and were less frequently seen in the outpatient clinic. The QOL of mothers of children with JCA was found to be slightly impaired in the group of children with pauciarticular JCA. Future larger studies are needed to confirm these results, as the number of subjects in the three groups was rather low. Received: 26 September 2001 / Accepted: 8 February 2002     

Numerical Simulation of the Effect of Rate of Change of Glucose on Measurement Error of Continuous Glucose Monitors

Background

A 5-day in-patient study designed to assess the accuracy of the FreeStyle Navigator® Continuous Glucose Monitoring System revealed that the level of accuracy of the continuous sensor measurements was dependent on the rate of glucose change. When the absolute rate of change was less than 1 mg•dl⁻¹•min⁻¹ (75% of the time), the median absolute relative difference (ARD) was 8.5%, with 85% of all points falling within the A zone of the Clarke error grid. When the absolute rate of change was greater than 2 mg•dl⁻¹•min⁻¹ (8% of the time), the median ARD was 17.5%, with 59% of all points falling within the Clarke A zone.

Method

Numerical simulations were performed to investigate effects of the rate of change of glucose on sensor measurement error. This approach enabled physiologically relevant distributions of glucose values to be reordered to explore the effect of different glucose rate-of-change distributions on apparent sensor accuracy.

Results

The physiological lag between blood and interstitial fluid glucose levels is sufficient to account for the observed difference in sensor accuracy between periods of stable glucose and periods of rapidly changing glucose.

Conclusions

The role of physiological lag on the apparent decrease in sensor accuracy at high glucose rates of change has implications for clinical study design, regulatory review of continuous glucose sensors, and development of performance standards for this new technology. This work demonstrates the difficulty in comparing accuracy measures between different clinical studies and highlights the need for studies to include both relevant glucose distributions and relevant glucose rate-of-change distributions.     

治疗高血压药物的经济学评价

重视高血压治疗中的经济学评价,对利用我国有限的卫生资源来遏制高血压对人民群众的危害有着重要的现实意义。药物经济学对于药物治疗的成本和治疗的结果给予同样的关注。因为治疗高血压的费用,不仅涉及药物价格,还包括患者的危险水平,降压疗效和对临床终点事件的影响,以及治疗的依从性和安全性。因此药物经济学更强调整体成本和价-效比。低危病人,若非药价低廉,治疗的价-效比不够理想。而在高危的患者,价-效比越小越经济而不是药费越便宜越好。