急性冠状动脉综合征患者头发皮质醇水平与倦怠的相关性及其对生活质量的影响研究

背景　头发皮质醇水平是一个反映慢性压力的指标,课题组前期研究结果提示倦怠可能是急性冠状动脉综合征（ACS）的独立危险因素,但目前国内尚缺乏关于头发皮质醇水平与倦怠和ACS的研究。目的　探讨ACS患者头发皮质醇水平与倦怠的相关性,以及头发皮质醇水平对患者出院1个月后生活质量的影响。方法　以2015年3月-2018年2月因首次发生ACS收住昆明医科大学第一附属医院心内科的89例患者为试验组,以同期在本院进行年度体检的42例健康者为对照组。取两组受试者少量头发进行皮质醇水平检测,采用哥本哈根倦怠量表（CBI）的一般倦怠子量表评估ACS患者的倦怠水平,采用生活质量8条简明量表（SF-8）和西雅图心绞痛量表（SAQ）评估ACS患者出院１个月后的生活质量。对头发皮质醇数据进行自然对数转换,两组头发皮质醇水平比较采用成组t检验,并采用多重线性回归排除混杂因素对结果的影响;ACS患者头发皮质醇水平和倦怠的相关性采用偏相关分析;构建多重线性回归模型分析ACS患者头发皮质醇水平与出院1个月后生活质量的关系。结果　75例ACS患者和38例健康者提供了头发样本进行皮质醇水平检测。ACS患者的头发皮质醇水平高于健康者〔（2.00±1.82）ln ng/g比（1.59±1.48）ln ng/g,t=2.42,P=0.017〕,构建多重线性回归模型排除性别、年龄、体质指数、工作状况、受教育程度、吸烟、饮酒的影响后,组别是头发皮质醇水平的影响因素〔b（95%CI）=2.038（0.198,3.878）,P=0.037〕。偏相关分析结果显示,排除性别、年龄、体质指数、工作状况、受教育程度、婚姻状况、吸烟、饮酒、Killip心功能分级、既往史、心血管病家族史的影响后,ACS患者的头发皮质醇水平与倦怠评分呈正相关（偏相关系数为0.303,P=0.011）。ACS患者头发皮质醇水平是出院1个月后SF-8生理健康评分、SAQ心绞痛稳定状态和心绞痛发作频率评分的影响因素〔b（95%CI）分别为-1.459（-1.984,-0.934）、-8.821（-15.629,-2.013）、-6.342（-12.653,-0.031）,P均<0.05〕。结论　ACS患者的头发皮质醇水平高于健康者;在ACS患者中,倦怠与头发皮质醇水平呈正相关关系;基线头发皮质醇水平高的ACS患者出院1个月后的生活质量较差。     

血清细胞黏附分子对脓毒症急性肾损伤的预测价值研究

背景　细胞黏附分子是急性重症脓毒症造成器官功能障碍（例如肾损伤）的生物标志物,但目前尚不明确血清细胞黏附分子是否对脓毒症急性肾损伤（AKI）的预测有临床价值。　目的　研究血清细胞黏附分子对脓毒症AKI的预测价值。方法　选择2016年1月—2017年12月南通大学附属医院急诊重症监护室（EICU）的84例脓毒症患者为研究对象,根据AKI的诊断标准将患者分为AKI组和非AKI组。入院后24 h内收集患者的临床资料,计算患者急性生理学和慢性健康状况（APACHE）Ⅱ评分、序贯器官衰竭评估（SOFA）评分、查尔森共病指数（CCI）评分,检测患者炎性指标〔C反应蛋白（CRP）、降钙素原（PCT）、乳酸（LAC）〕及血清细胞黏附分子〔细胞间黏附分子-1（ICAM-1）、血管细胞黏附分子-1（VCAM-1）、血小板选择素（P-selectin）、内皮选择素（E-selectin）〕表达水平。采用Pearson相关分析探讨炎性指标、血清细胞黏附分子与AKI严重程度的关系,采用受试者工作特征（ROC）曲线下面积（AUC）评价炎性指标、血清细胞黏附分子对脓毒症AKI的预测价值。结果　AKI组患者入院后24 h内出现休克、需要机械通气治疗的比例、APACHE Ⅱ评分、SOFA评分、血清肌酐（Scr）、LAC、ICAM-1、VCAM-1、E-selectin水平高于非AKI组（P<0.05）。Pearson相关分析结果显示,E-selectin与Scr呈正相关（r=0.223,P=0.041）。CRP、PCT、LAC、ICAM-1、VCAM-1和E-selectin预测脓毒症AKI的AUC分别为0.523〔95%CI（0.421,0.687）〕、0.637〔95%CI（0.435,0.618）〕、0.609〔95%CI（0.529,0.781）〕、0.702〔95%CI（0.619,0.846）〕,0.661〔95%CI（0.503,0.794）〕、0.774〔95%CI（0.623,0.871）〕,其中,E-selectin的诊断效能最高,其预测脓毒症AKI的最佳截断值为117.2 μg/L（灵敏度79.8%,特异度71.0%）。结论　脓毒症AKI的患者病死率高于脓毒症患者,而E-selectin与AKI的严重程度相关,是预测脓毒症AKI的重要临床标志物。     

急性冠脉综合征患者生活事件与冠状动脉粥样硬化斑块稳定性的相关性研究：抑郁的中介作用

背景　急性冠脉综合征（ACS）主要由不稳定斑块形成及破裂所致。研究表明,生活事件可增加ACS的发生风险,然而生活事件是否可通过影响斑块稳定性导致ACS的发生,目前尚不清楚。同时研究证实,生活事件可引起个体抑郁的负性情绪,且抑郁与斑块稳定性密切相关,然而抑郁是否在生活事件与斑块稳定性间发挥中介作用尚未明确。目的　探究ACS患者发病前1年内生活事件与冠状动脉粥样硬化斑块稳定性的关系,以及抑郁在其中的中介作用。方法　选取2018年9月-2019年4月于哈尔滨市某三级甲等医院心血管内科行冠状动脉造影首次确诊为ACS的患者311例为研究对象。采用生活事件量表（LES）、抑郁自评量表（SDS）调查其发病前1年内生活事件及抑郁的发生情况。同时采用光学相干断层成像技术（OCT）测量患者冠状动脉粥样硬化斑块稳定性,OCT指标包括薄纤维帽粥样硬化斑块（TCFA）（TCFA以纤维帽厚度、脂质核心角度衡量）、斑块破裂、富脂质斑块、血栓、巨噬细胞及胆固醇结晶。结果　165例（53.1%）患者发病前1年内发生生活事件,67例（21.5%）患者存在抑郁。多因素Logistic 回归分析结果显示,生活事件是TCFA〔OR=1.029,95%CI（1.016,1.043）,P<0.001〕、斑块破裂〔OR=1.022,95%CI（1.010,1.034）,P<0.001〕、富脂质斑块〔OR=1.018,95%CI（1.005,1.031）,P=0.005〕、血栓〔OR=1.032,95%CI（1.014,1.050）,P=0.001〕、胆固醇结晶〔OR=1.013,95%CI（1.002,1.024）,P=0.025〕的独立影响因素。Spearman秩相关分析显示,生活事件与SDS评分（rs=0.461,P<0.01）、脂质核心角度（rs=0.385,P<0.01）呈正相关,与纤维帽厚度呈负相关（rs=-0.465,P<0.01）;SDS评分与脂质核心角度呈正相关（rs=0.406,P<0.01）,与纤维帽厚度呈负相关（rs=-0.494,P<0.01）。路径分析及Bootstrap检验中介效应显示,抑郁在生活事件与斑块纤维帽厚度〔β=-0.117,95%CI（-0.157,-0.089）,P<0.01〕及脂质核心角度〔β=0.114,95%CI（0.070,0.173）,P<0.01〕之间起中介作用。结论　发病前1年内生活事件与冠状动脉粥样硬化斑块稳定性密切相关,且抑郁在其中发挥中介作用。因此,早期筛查经历生活事件及发生抑郁的个体,有助于识别斑块不稳定的高危人群,及时实施心理干预有利于减缓不稳定斑块的发生进程,将ACS的防治关口前移。     

Difficulties in diagnosing acute kidney injury post liver transplantation using serum creatinine based diagnostic criteria

Renal function in patients with advanced cirrhosis is an important prognostic factor for survival both prior to and following liver transplantation. The importance of renal function is reflected by the introduction of the model for end stage liver disease(MELD) score, which includes serum creatinine. The MELD score has been shown to predict the short term risk of death for transplant wait listed patients and is currently used by many countries to allocate liver transplants on the basis of severity of underlying illness. Changes in serum creatinine are also used to stage acute kidney injury. However prior to liver transplantation the serum creatinine typically over estimates underlying renal function, particularly when a colorimetric Jaffe based assay is used, and paradoxically then under estimates renal function post liver transplantation, particularly when immunophyllins are started early as part of transplant immunosuppression. As acute kidney injury is defined by changes in serum creatinine, this potentially leads to over estimation of the incidence and severity of acute kidney injury in the immediate post-operative period.     

Effect of captopril on serum TNF-α level in acute lung injury rats induced by HCL

Objective:To observe the effect of captopril on the tumor necrosis factor-α(TNF- α) level and arterial blood gases in acute lung injury(All) induced by HCL in rats,and to analyze its protective mechanism.Methods:Fifty Wistar rats were selected and randomly divided into three groups,with 20 rats in Group Ⅰ and Ⅱ,respectively and 10 animals in Group Ⅲ.ALI model was constructed by intratracheal injection of diluted hydrochloric acid(pH=1.25.1.2 mL/kg).Group Ⅰrats received not any treatment after construction of AM model.Group Ⅱ rats were treated with captopril(5 mg/kg,i.p.) 5 min after induction of ALI.Group Ⅲ served as normal control without any treatment.Ninety minutes after construction of ALI model,all the rats were sacrificed.Blood was withdrawn for detection of TNF- α level and arterial blood gases index.And lung tissue slices of the three groups were prepared for observation of pathologic histology changes.Results:TNF- α level in serum of Group Ⅰ and Ⅱ rats was significantly higher than that in Group Ⅲ(P0.05),while TNF- α level in serum of Group Ⅱ was significantly lower in Group Ⅰ(P0.05).PaCO_2 level was significantly higher(P0.05),while PaO_2 was significantly lower(P0.05) in Group Ⅰ and Ⅱ rats than those in Group Ⅲ.PaCO_2 was significantly lower(P0.05) and PaO_2 was significantly higher(P0.05) in Group Ⅱ than those in Group Ⅰ.Histological observation showed diffuse congestion and severe edema of luug tissue,obvious thickening and structure damage of alveolar walls and a large amount of neutrophil infiltration in Group Ⅰ rats.Group Ⅱ rats showed mild edema of lung tissue;only a small portion of alveolar walls showed thickening and only a few of neutrophil infiltration could be observed.The degree of injury was remarkably slighter than that of Group Ⅰ rats.Group Ⅲ rats showed clear lung tissue structure and normal morphology:alveolar walls were uniform and the margin was smooth and few neutrophil could be observed.Conclusions:Captopril can significantly reduce serum TNF- α level,elevate PaO_2 and reduce PaCO_2 in rats with ALI.It has a protective effect on ALI rats.     

急性心梗患者应用阿替普酶与尿激酶静脉溶栓对血流动力学状态的影响比较

目的研究比较急性心梗患者应用阿替普酶与尿激酶静脉溶栓对血流动力学状态的影响。方法运用随机数表法将本院2017年1月~2019年3月诊治的94例急性心梗患者分为观察组与对照组,各47例。对照组采用尿激素静脉溶栓治疗方法,观察组采用阿替普酶进行治疗。结果观察组治疗后ESR、Fb、nbl、nbh血液动力学指标均比对照组低(P<0.05);观察组患者在60min、90min、120min的血管再通率均比对照组显著高(P<0.05),观察组患者在30min的血管再通率比对照组高(P>0.05);观察组患者心率失常、心率衰竭、再梗死、休克、出血、心脏破裂不良反应发生率比对照组低(P>0.05)。结论对于急性心梗患者,阿替普酶相比尿激酶静脉溶栓可以更好改善血流动力学,增加血管再通率,减少不良反应,值得应用推广。     

通心络胶囊治疗非ST段抬高型急性心肌梗死的效果及对心肌组织灌注水平的影响

目的探讨通心络胶囊治疗非ST段抬高型急性心肌梗死(NSTEMI)的效果及对心肌组织灌注水平的影响。方法 2017年2月-2018年4月我院收治的100例NSTEMI患者,按照随机数表法分为观察组及对照组各50例,对照组给予常规抗心肌缺血治疗及抗凝治疗,观察组在对照组基础上加服通心络胶囊。比较两组临床总有效率、冠状动脉造影TIMI血流分级及并发症情况。结果观察组临床总有效率为88.00%明显高于对照组66.00%(P<0.05);观察组TIMI分级中0级、1级比例较对照组明显减少,2级、3级比例较对照组明显增加(P<0.05);观察组并发症总发生率20.00%与对照组总发生率24.00%差异不显著(P>0.05)。结论应用通心络胶囊治疗NSTEMI能够有效提高患者疗效,改善心肌组织灌注水平,并发症较少。     

Effects of different LAD-blocked sites on the development of acute myocardial infarction and malignant arrhythmia in a swine model

Objective

To explore the effects of various left anterior descending (LAD) artery-blocked sites on the development of acute myocardial infarction (AMI) and malignant arrhythmia in a swine model.

Methods

Twenty-two pigs underwent occlusion of the coronary artery with balloon angioplasty were randomly divided into three groups according to the blocked site of the balloon: middle-site-blocked LAD group, bottom-third-blocked LAD group and control group. Then, the development of AMI and malignant arrhythmia, including ventricular tachycardia and ventricular fibrillation during the process of model creation, were recorded. Changes of the hemodynamics, blood gas analysis, electrocardiography, and myocardial enzymes were analyzed in each group before and after occlusion.

Results

Middle-site-LAD blockage resulted in a larger infarction size and the corresponding incidence of ventricular fibrillation was significantly higher than that of the bottom-third-blocked group (P<0.05). After the occlusion, the QTc interval of the Middle-site-blocked LAD group was significantly longer than that in the other groups (P<0.01). Moreover, mean arterial blood pressure (MAP), left ventricular ejection fraction (LVEF), and partial pressure of oxygen (PaO₂) were significantly lower, but partial pressure of carbon dioxide (PaCO₂) increased, in the Middle-site-blocked-LAD group compared with that in the bottom-third-blocked group (P<0.01). Compared with the control group, the two LAD-blocked groups showed significantly higher levels of Mb, CK-MB, LDH, AST and cTnT (P<0.01) four hours after the artery occlusion. However, these indexes were not significantly different between the two LAD-blocked groups (P>0.05).

Conclusions

Location of LAD blockages in swine models may affect the development of AMI and malignant arrhythmia.     

Prevention of post-ERCP pancreatitis

Post-procedure pancreatitis is the most common complication of endoscopic retrograde cholangio pan-creatography(ERCP) and carries a high morbidity and mortality occurring in at least 3%-5% of all procedures. We reviewed the available literature searching for "ERCP" and "pancreatitis" and "post-ERCP pancreatitis". in PubMed and Medline. This review looks at the diag-nosis, risk factors, causes and methods of preventing post-procedure pancreatitis. These include the evidence for patient selection, endoscopic techniques and phar-macological prophylaxis of ERCP induced pancreatitis. Selecting the right patient for the procedure by a risk benefits assessment is the best way of avoiding unnec-essary ERCPs. Risk is particularly high in young women with sphincter of Oddi dysfunction(SOD). Many of the trials reviewed have rather few numbers of subjects and hence difficult to appraise. Meta-analyses have helped screen for promising modalities of prophylaxis. At present, evidence is emerging that pancreatic stent-ing of patients with SOD and rectally administered non-steroidal anti-inflammatory drugs in a large unselected trial reduce the risk of post-procedure pancreatitis. A recent meta-analysis have demonstrated that rectally administered indomethecin, just before or after ERCP isassociated with significantly lower rate of pancreatitis compared with placebo [OR = 0.49(0.34-0.71); P = 0.0002]. Number needed to treat was 20. It is likely that one of these prophylactic measures will begin to be increasingly practised in high risk groups.     

Tim-3在药物性急性肾损伤动物模型中的表达及作用机制

目的 探索T细胞免疫球蛋白黏蛋白分子3(Tim-3)在急性肾损伤(AKI)中的作用,并研究其作用机制。 方法 将6~8周C57雄性小鼠随机分为对照组(CTRL组)、顺铂组(AKI组)及顺铂+阻断Tim-3组(RMT组),每组4只,AKI组使用顺铂(20 mg/kg)腹腔注射,构建AKI动物模型,检测肾脏损伤情况与Tim-3表达情况。RMT组使用抗体RMT3-23(200 μg/只)阻断Tim-3分子,建立AKI模型,检测AKI组与RMT组肾脏损伤情况以及Tim-3、自噬相关分子的表达情况。 结果 肾脏近端小管出现损伤,Western blotting 结果显示 AKI组Tim-3表达水平较CTRL组增加(t=3.876,P=0.008 2)。与AKI组相比,RMT组的NGAL和P62表达水平均增高,但差异无统计学意义(t_NGAL=1.664,P=0.157 0;t_P62=1.991,P=0.103 1),LC3II表达下降,差异有统计学意义(t=5.901,P=0.002 0),自噬受到抑制且肾脏小管损伤加重(P=0.010 1)。 结论 Tim-3可以通过调节肾小管上皮细胞自噬活性,减轻顺铂诱导的AKI肾损伤。