探讨老年急性心肌梗死患者冠状动脉介入治疗后ST段与血糖和肌钙蛋白T的关系

目的探讨入院时血糖水平对老年急性心肌梗死(AMI)患者PCI术后ST段下降幅度(STR)和肌钙蛋白T峰值的影响。方法首次AMI的412例老年患者,根据其血糖水平分为3组:A组(血糖<7.0mmol/L)156例;B组(血糖7.0～11.1mmol/L)135例;C组(血糖>11.1mmol/L)121例;分析3组患者急诊PCI术后90minSTR与血浆肌钙蛋白T峰值的相关性。结果C组患者PCI术后90minSTR>70%较A组显著减少(17.96%vs51.49%,P<0.01),B组患者PCI术后90minSTR30%～70%与血糖水平的高低差异无统计学意义(P=0.061);PCI术后,STR>70%的患者肌钙蛋白T峰值低于STR<30%患者[(0.033±0.018)ng/Lvs(0.107±0.055)ng/L,P<0.05],差异有统计学意义;logistic回归分析显示,C组肌钙蛋白T峰值升高与血糖的相关性最为密切(r=0.399,P=0.001)。入院时血糖水平与肌钙蛋白T峰值呈显著正相关,入院时血糖水平越高,血清肌钙蛋白T峰值升高越明显。结论入院时血糖升高的老年AMI患者PCI术后,较好的控制血糖对于此类患者有效的心肌再灌注是十分重要的。     

应激性高血糖对老年急性心肌梗死急诊介入术后心肌灌注及预后的影响

目的探讨老年急性ST段抬高心肌梗死(STEMI)患者并发应激性高血糖(SHG)对直接经皮冠状动脉介入治疗(PCI)后心肌灌注水平及患者临床预后的影响。方法回顾性分析2009年6月至2011年6月在该院心内科住院初次发生STEMI并在起病12 h内成功接受直接PCI治疗的老年非糖尿病患者(年龄60岁)348例,按入院即刻血糖(SG)水平分为3组:正常血糖组(SG7.0 mmol/L);血糖升高组(7.0 mmol/L≤SG≤11.1 mmol/L);高血糖组(SG11.1 mmol/L)。比较3组患者直接PCI后心肌灌注及左心功能指标的差异,术后动态追踪观察三组患者随访12个月内心脏主要不良事件(MACE)的发生情况。结果 3组患者入院SG越高,术后2 h ST段回落(STR)良好比例及TIMI心肌灌注分级(TMPG)2~3级比例越低(71.4%vs 54.6%vs 46.3%,P0.01;75.0%vs 56.3%vs 48.2%,P0.01);术后肌酸激酶同工酶(CK-MB)峰值越高〔(186.3±86.7)mmol/L vs(222.6±79.7)mmol/L vs(265.8±77.9)mmol/L,P0.01〕;并且术后7~10 d左室射血分数(LVEF)明显降低〔(52.6±7.3)%vs(50.9±5.8)%vs(48.9±5.3)%,P0.01〕。术后随访12个月,Kaplan-Meier生存分析发现3组患者累积无MACE事件生存率差异有统计学意义(89.3%vs 85.9%vs 76.3%,Log rank 7.355,P=0.025),在校正了年龄、性别后,多因素Cox回归分析显示SHG是老年STEMI患者直接PCI术后MACE发生的独立预测因子。高血糖组患者较正常血糖组患者术后发生MACE的风险增加5.811倍(RR=5.811,P0.01)。结论老年STEMI患者并发SHG会导致直接PCI再灌注治疗后心肌灌注水平降低,术后MACE发生率升高,影响患者的临床预后。     

老年经皮冠状动脉介入患者血糖水平与心肌灌注及不良心脏事件的关系

目的探讨老年经皮冠状动脉介入手术(PCI)患者血糖水平与心肌灌注及不良心脏事件的关系。方法接受PCI再灌注治疗的急性ST段抬高型心肌梗死(STEMI)患者394例,根据患者的血糖水平分成对照组(血糖水平<7.0 mmol/L)136例及血糖上升组(血糖水平7.0~11.1 mmol/L)148例、高血糖组(血糖水平>11.1 mmol/L)110例。对比各组PCI术后的心肌灌注和心功能指标,随访6个月,记录患者的不良心脏事件发生情况,Logistic回归分析评价影响PCI术后不良心脏事件的危险因素。结果血糖上升组与高血糖组肌酸激酶同工酶(CK-MB)峰值明显高于对照组,左室射血分数(LVEF)水平、ST段回落较好及心肌灌注的血流分级(TMPG)2~3级的比例明显低于对照组,高血糖组CK-MB峰值明显高于血糖上升组,LVEF水平明显低于血糖上升组(均P<0.05)。394例患者PCI术后发生不良心脏事件者62例(15.74%)。PCI术后发生不良心脏事件者存在应激性高血糖(SHG)、TMPG 0~1级、吸烟及泵衰竭≥Ⅱ级的比例均分别明显高于未发生不良心脏事件者(均P<0.05),且Logistic回归分析显示,上述4个指标均是影响PCI术后不良心脏事件的危险因素。结论老年PCI患者的血糖水平与其心肌灌注以及不良心脏事件之间均存在紧密联系,存在SHG、TMPG 0~1级、吸烟以及泵衰竭≥Ⅱ级会增加PCI术后不良心脏事件发生风险。     

STEMI患者血糖对PCI术后冠状动脉血流的影响

目的评价入院血糖与急性ST段抬高性心肌梗死(STEMI)PCI术后冠状动脉血流的关系。方法采集2008年1月—2009年6月ST段抬高性心肌梗死并行急诊PCI(植入药物支架)的患者101例;分为入院高血糖组(血糖≥11mmol/L,30例)及入院血糖11mmol/L(71例)两组。除了糖尿病史外,其余临床基线资料无差异。结果入院血糖11mmol/L组的校正TIMI血流帧数显著高于入院血糖11mmol/L组〔(45.6±29.3)vs(33.6±16.9),P0.05〕,校正的TIMI帧数与入院血糖值有明显相关性(P=0.0025);心肌酶峰值(CK-MB)在入院血糖≥11mmol/L组明显高于入院血糖11mmol/L组〔(180.9±172.1)vs(326.3±260.7)〕。结论在急性ST段抬高性心肌梗死PCI术后,入院高血糖与冠状动脉血流受损有相关性,入院高血糖是心肌梗死面积较大的可能原因之一。     

入院血糖水平对STEMI患者行急诊PCI术后心功能的影响

目的分析入院血糖水平对急性ST段抬高型心肌梗死(STEMI)行急诊经皮冠状动脉介入术(PCI)后患者心功能的影响。方法选取180例行急诊PCI术后的STEMI患者,根据入院患者血糖水平及既往有无糖尿病病史将患者分为3组,A组(58例):血糖7.0 mmol/L(无糖尿病病史);B组(65例):血糖为7.0~11.1 mmol/L(无糖尿病病史以及应激性血糖升高);C组(57例):血糖≥11.1mmol/L(有糖尿病病史)。观察3组患者的心功能情况,主要包括B型脑钠肽(BNP)水平、左室射血分数(LVEF)和心功能Killip分级。结果血糖升高组B组及C组较A组患者BNP水平升高(P0.05),LVEF降低(P0.05),心功能Killip≥2级的比例升高(P0.05);C组较B组患者BNP水平升高(P0.05),LVEF降低(P0.05)。结论入院血糖水平升高对行急诊PCI术后STEMI患者心功能下降有预测价值。     

应激性高血糖对急诊PCI患者心肌灌注及临床预后的影响

目的探讨应激性高血糖(SHG)对接受直接经皮冠状动脉介入治疗(PCI)急性ST段抬高心肌梗死(STEMI)患者心肌灌注及临床预后的影响。方法纳入初次发生STEMI并在起病12 h内行直接PCI治疗的非糖尿病患者352例,按入院即刻血糖(SG)水平分为三组:正常血糖组(SG7.0 mmol/L)114例;血糖升高组(7.0 mmol/L≤SG≤11.1 mmol/L)128例;高血糖(SHG)组(SG11.1 mmol/L)110例。比较三组患者直接PCI后心肌灌注指标包括术后2 h ST段回落(STR),TIMI心肌灌注分级(TMPG)及心肌肌酸激酶同工酶(CK-MB)峰值、术后左室射血分数(LVEF)的差异。PCI后随访12个月,观察并记录三组患者随访期内心脏不良事件(MACEs)的发生情况。结果正常血糖组、血糖升高组、SHG组三组患者随血糖水平升高,术后2h STR良好比例(71.9%vs.53.9%vs.44.5%)及TMPG2-3级比例(70.2%vs.54.7%vs.46.4%),均逐渐降低(P均0.05),术后CK-MB峰值逐渐升高(189.2±78.9mmol/L vs.214.6±80.1mmol/L vs.246.5±79.2mmol/L,P0.01)且术后7~10天LVEF明显降低,以高血糖组降低最明显[(52.7±7.2)%vs.(50.8±6.7)%vs.(49.1±5.5)%,P0.01]。PCI后随访12个月,Kaplan-Meier生存分析发现三组患者累积无MACEs事件生存率差异有统计学意义(89.5%vs.85.9%vs.77.3%,Logrank=7.173,P=0.028),在校正了年龄后,多因素Cox回归分析显示SHG是STEMI患者直接PCI术后MACEs发生的独立预测因子。SHG组患者较正常血糖组患者术后发生MACEs的风险增加3.546倍(RR=3.546,P0.01)。结论 STEMI患者并发SHG会导致直接PCI再灌注治疗后心肌灌注水平降低,致使心脏不良事件发生率升高,影响患者的临床预后。     

血糖在急性心肌梗死介入治疗患者的预后价值

目的:观察入院时随机血糖对急性ST段抬高性心肌梗死患者直接冠状动脉介入术(PCI)后的心肌灌注的影响及预后价值。方法:对直接PCI治疗的182例资料完整的急性ST段抬高性心肌梗死患者进行了回顾性分析,根据患者入院后即刻的随机血糖分为3组:A组血糖<7.8mmol/L,B组血糖7.8～11.0mmol/L,C组血糖≥11.0mmol/L。评估PCI后TIMI血流分级及TMPG心肌灌注分级;发病后1周内行超声心动图检查测定左心室射血分数(LVEF),评价心脏收缩功能。结果:①冠状动脉造影结果中多支血管病变:C、B组(65.8%、63.6%)多于A组∶(49.4%,P<0.05);②PCI后梗死相关血管TIMI血流分级3级:3组无明显差异(89.9%、87.3%、89.5%,P>0.05);③PCI后心肌灌注分级(TMPG)0～1级:C、B组(28.9%、27.3%)高于A组∶(14.6%,P<0.05);④PCI后1周内超声心动图左室射血分数(LVEF值):C、B组[(49.6±7.0)%,(51.4±7.0)%低于A组∶(58.5±7.2)%,P<0.05]。结论:入院随机血糖高的急性ST段抬高性心肌梗死患者在介入治疗后的心肌灌注差、心功能差。     

入院高血糖对急诊经皮冠状动脉介入后复流的影响

目的 评价入院血糖水平与ST段抬高型急性心肌梗死(AMI)患者急诊经皮冠状动脉(冠脉)介入治疗(PCI)后复流的相关性.方法 入选2007-2010年共1413例ST段抬高型AMI并在发病24 h内成功进行急诊PCI的患者,分为无复流组和复流正常组,收集所有患者的临床、冠脉造影和PCI相关的资料以评价复流现象,采用多元回归方法 评价无复流的独立预测因素.结果 1413例患者中发生无复流现象的患者为297例(21.0%),无复流患者入院血糖水平显著高于复流正常患者[(13.80±7.47)mmol/L比(9.67±5.79)mmol/L,P＜0.0001],多元回归分析发现吸烟、高脂血症、再灌注时间＞6 h、入院肌酐清除率＜90 ml/min、PCI前使用主动脉内气囊反搏和入院血糖水平＞13.0 mmol/L是ST段抬高型AMI患者急诊PCI后无复流的独立预测因素.随着入院血糖水平的逐渐增加,无复流发生率也显著增加,血糖水平为＜7.8 mmol/L和＞13.0 mmol/L时,无复流发生率分别为14.6%和36.7%(P=0.009).结论 入院血糖水平＞13.0 mmol/L是ST段抬高型AMI患者急诊PCI后无复流的独立预测因素.

Abstract：

Objective To assess the association between admission plasma glucose (APG) and noreflow during primary percutaneous coronary intervention (PCI) in patients with ST-elevation acute myocardial infarction (STEMI). Methods A total of 1413 patients with STEMI successfully treated with PCI were divided into no-reflow group and normal reflow group. Results The no-reflow was found in 297 patients (21.0%) of 1413 patients; their APG level was significantly higher than that of the normal reflow group [( 13.80 ±7.47) vs (9.67 ±5.79) mmol/L, P＜0.0001]. Multivariate logistic regression analysis revealed that current smoking ( OR 1.146, 95% CI 1.026-1. 839,P = 0.031), hyperlipidemia ( OR 1. 082,95% CI 1. 007-1. 162, P = 0. 032), long reperfusion ( ＞ 6 h, OR 1. 271, 95% CI 1. 158-1. 403, P =0. 001 ) , admission creatinine clearance ( ＜ 90 ml/min, OR 1.046, 95% CI 1. 007-1.086, P = 0.020 ) ,IABP use before PCI (OR 9.346, 95%CI 1.314-67. 199, P=0.026), and APG ( ＞ 13.0 mmol/L, OR1.269, 95% CI 1.156-1.402, P = 0.027) were the independent no-reflow predictors. The no-reflow incidence was increased as APG increased ( 14. 6% in patients with APG ＜ 7. 8 mmol/L and 36. 7% in patients with APG ＞ 13.0 mmol/L, P = 0.009 ). Conclusion APG ＞ 13.0 mmol/L is an independent noreflow predictor in patients with STEMI and PPCI.     

急性心肌梗死患者行急诊经皮冠状动脉介入术后ST段回落与高血糖的关系

目的　探讨急性心肌梗死 (AMI)患者行急诊经皮冠状动脉介入术 (PCI)后ST段回落与血糖的关系。方法　入选AMI患者 80例 ,急诊入院后 90min内行冠状动脉造影示梗死相关血管前向血流TIMI 0到 1级 ,PCI后梗死相关血管前向血流TIMI恢复到 3级。术前常规心电图、生化与cTnI检查及抗栓治疗。术后 0 5h行心电图检查 ,1周后复查心电图。按血糖水平分为两组 :血糖 <8 8mmol/L(16 0mg/dl)为Ⅰ组 (41例 ) ,血糖≥ 8 8mmol/L(16 0mg/dl)为Ⅱ组 (39例 )。比较两组术前、术后及 1周时各导联ST段抬高的平均值及术前、术后ST段回落程度 ,并对其进行统计学分析。结果　Ⅱ组与Ⅰ组相比 ,术后及 1周时各导联抬高的ST段平均值及术前、术后ST段回落程度差异有显著性 ,患者既往是否有糖尿病其差异也有显著性。结论　急性心肌梗死再灌注治疗后心电图抬高的ST段回落程度受高血糖的影响。高血糖可能通过激活炎症及凝血系统 ,影响心肌的微循环灌注。     

老年急性心肌梗死患者介入治疗预后与白细胞水平的相关研究

目的探讨老年急性ST段抬高心肌梗死患者人院时白细胞计数与心脏不良事件发生及心肌组织水平灌注状态的关系。方法对2002年3月至2004年5月在我院因ST段抬高心肌梗死患者连续行直接PCI的101例老年患者于入院时立即取外周血查血常规,白细胞计数10×10~9/ L为分界点,将患者分为高WBC组和低WBC组,直接PCI术后监测心电图抬高的ST段回落≥50%的时间。观察住院及随访期间发生的重大心脏事件的情况。结果(1)高白细胞组48例,发病6个月至1年发生不良事件25例(52．1%),低白细胞组为53例,不良事件发生12例(22．6%)．两组差异有统计学意义(P＜0．01)；(2)低白细胞组45例(93．7%)PCI术后60 min内ST段回落≥50%,高白细胞组23例(43．3‰)≥50%,两组比较差异有统计学意义(P＜0．01)。结论入院时白细胞计数与老年人心肌梗死预后有关,与心肌组织水平灌注状态也有一定的相关性。     

肿瘤病人弓形虫感染分析

在肿瘤的发生和发展进程中 ,多伴有免疫功能低下或缺陷 ,从而极易遭受各种感染。弓形虫是机会感染因子 ,当患者免疫功能受损时 ,易于感染 ,还会使隐性感染激活 ,引起低热不退、淋巴结肿和脑神经系统的反应 ,此现象尚未引起临床医师的重视。近年来 ,我们对 4 0 9例肿瘤病人进行了弓形虫感染及弓形虫病的分析观察 ,报告如下 :1　材料与方法1 1　材料　 30 4例病人血清取自江西省肿瘤医院住院或门诊病人 ,随机抽样后低温保存待检 ,10 5例取自其他医院送检样品 ,有急性症状者随到随检 ,以便及时做病原学检测。1 2　弓形虫病诊断方法1 2 1　免疫…     

A patient with rectal ulcer with severe stenosis presenting with perforated peritonitis

We report a patient with rectal ulcer with severe stenosis, who underwent urgent surgical treatment for perforated peritonitis. The 54-year-old man suddenly developed cramping abdominal pain and fever while hospitalized, with signs of peritoneal irritation. An emergency laparotomy was performed, and severe stenosis of the rectum and a perforated lesion on the oral side approximately 10 cm distant from the stenosis were found, with massive abdominal purulent fluid. He was treated by rectosigmoid colon resection with transverse colon loop colostomy. Histopathologically, the stenosis was caused by ulceration extending to all muscular layers of the rectum, with inflammatory changes. Benign rectal stenosis is so rare that differential diagnosis from malignancy may be difficult when there are inflammatory changes in the surrounding tissues. However, it is necessary to keep in mind the likelihood of this disease in differentiation from rectal cancer. Received: December 21, 1998 / Accepted: May 28, 1999     

Infection with Rhodococcus equi in a patient with sarcoidosis treated with corticosteroids

A 51-year-old female farmer was diagnosed as having sarcoidosis. During 4 years of observation, slow radiological progression was observed. Cough then developed, necessitating treatment with corticosteroids. After 28 months of continuous treatment with prednisolone in low doses (5-7.5 mg daily), she suffered fever episodes, recurrent haemoptyses, general malaise and loss of weight. A chest roentgenogram showed a left upper lobe infiltrate, which progressed and finally cavitated, and rib destruction. Despite efforts, including a thoracotomy, 22 months passed before a diagnosis could be made. Blood and sputum cultures and cultures from the destroyed rib showed growth of Rhodococcus equi, a common soil organism which can cause infections in foals and other animals. Treatment with rifampicin and erythromycin was successful. R. equi has been reported to cause infection in patients with neoplastic disease and/or immunosuppression, but the disease might be more common than is suggested by the sparse case reports in the literature, owing to lack of familiarity with the organism, which will tend to be overlooked as a contaminant.     

Evaluation of atrial vulnerability with transoesophageal stimulation in patients with atrioventricular junctional: Comparison with patients with ventricular pre-excitation and with normal subjects

The aim of our work was to evaluate the inducibility of atrialfibrillation in a group of patients with atrioventricular junctionalreentrant tachycardia and to compare it with that of patientswith a Kent-type ventricular pre-excitation (Wolff-Parkinson-Whitesyndrome) and a control group. One hundred and twenty-five subjects were separated into groups.Group 1 comprised 49 Wolff-Parkinson-White patients, with amean age of 26.4, range 10.66 years; group 2, 51 patients withatrioventricular junctional reentrant tachycardia inducibleby transoesophageal atrial stimulation andlor clinically documented,with a mean age of 43.4, range 16–78 years; group 3, 25control subjects with a mean age of2.64, range 13–76 years. Each subject underwent atrial transoesophageal stimulation withthe following protocol: programmed atrial stimulation with 1and 2 stimuli during atrial pacing of 100. min^–1 and 150.min^–1; atrial stimulation for 10 s at a rate of 200–300–400–500–600.min^–1 with intervals of 10 s between stimulations, fivesuccessive ‘ramp-up’ atrial stimulations for 9 swith the rate increasing from 100 to 800. min^–1 with intervalsof 10 s between stimulations. The end point was the completionof the protocol or induction of sustained atrial fibrillation(>1 min). The chi-square test was used for statistical analysis. Our resultsshowed that in group 1 atrial fibrillation was induced in 27149patients (55.1%); this was sustained in 13149 (26.5%) and non-sustainedin 14149 (28.5%); in group 2, atrial fibrillation was inducedin 22151 patients (43.0%); it was sustained in 7151 (13.7%)and non-sustained in 15151 (29.4%); in group 3, sustained atrialfibrillation was not induced in any subject and in only onesubject was a non-sustained atrial fibrillation (4 s) induced. The chi-square test showed that group 2 vs group 1 were non-significant,while group 2 vs group 3 and group 1 vs group 3 were significant(P<0.003 and P<0.0007, respectively). Therefore group 2 patients showed a greater atrial vulnerabilityin comparison to the control subjects and a similar vulnerabilityto group 1 patients. It is possible that the greater atrialvulnerability in the patients of group 2 was due to the doublenodal pathway.     

Treating patients with lupus with B-cell depletion

A new era in the treatment of systemic lupus erythematosus has dawned with the increasing introduction of monoclonal antibodies and other approaches, that target the key molecules involved in the pathogenesis of the disease. At present the ability to block the CD20 molecule on those B cells that carry this marker has proved the most effective way to treat patients resistant to conventional immunosuppressive drugs. However, these studies have all been open label and the results of double blind controlled studies are eagerly awaited.