急性心肌梗死合并心原性休克 ( acute myocardial infarction with cardiogenic shock,AMICS)是由于急性心肌缺血坏死引起心输出量显著减少,导致组织低灌注的一类临床综合征. 临床表现为反复或进行性药物难以控制的缺血性症状,同时伴随血流动力学不稳定、危及生命的心律失常、心脏骤停、机械性并发症和急性心力衰竭等[1].

正常情况下眼表菌群与人体和平共生,在眼部的防御体系和机体免疫调节中起着重要作用.当机体状态改变或免疫功能异常时,这种互利共生的平衡可能被打破,眼表菌群多样性和核心组成发生改变,从而影响眼表稳态,导致眼部疾病的出现.微生物虽存在于眼表,但其对机体的免疫功能和作用路径仍值得深入研究.本文将着重阐述眼表菌群的影响因素,眼表菌群与慢性全身性疾病(如代谢性疾病、感染性疾病、退行性疾病和肿瘤等)相关研究进展,以期进一步拓宽眼表微生物组与关联疾病的研究范围,为眼表菌群研究开启新思路.

进入21世纪20年代,心力衰竭(心衰)的临床研究取得了很大的进展,从心衰概念的更新到治疗模式的转变,都发生了根本性的进步.心衰新定义为,心衰是一种临床综合征,是因心脏结构/或功能异常引起的心衰相关症状和体征,同时合并血清利钠肽水平升高及存在心源性肺循环或体循环淤血的客观证据两项中的其中一项[1].新定义强调了心衰生物标志物在诊断心衰中的地位.为更清晰地理解心衰含义和指导心衰治疗,新定义还将心衰类型和分期重新进行了划分,在既往根据左心室射血分数(LVEF)降低(HFrEF)、保留(HFpEF)或轻度降低(HFmrEF)3种心衰类型基础上,该分类提出了一种新的心衰类型 —LVEF改善的心衰(HFimpEF),即指基线 LVEF≤40％,经过治疗后 LVEF 比基线增加 ≥10％,且LVEF> 40％的心衰类型.

本课题组根据多年研究和实践经验,对医养结合的概念和医养结合机构进行了定义、分类和界定,提出对医养结合专业机构实施分级管理以及各级机构建设标准、职能设定、质量控制和等级评定的设想,建议将医养结合专业机构定名为"医养院",列入国家医疗保健体制内,作为国家正式规范的慢病防治机构.

本文对本课题组试点的不同模式的医养结合机构进行了比较研究,认为医养结合机构只有找准了目标定位,明确了服务对象,铸造了自己的品牌,才能获得可持续性发展的核心竞争力.

目的 探究居家老年共病患者多重用药现状及其影响因素.方法 自行设计问卷,抽选2020年8月 ～11月期间在北京市某三甲医院门诊参加体检年龄≥60周岁的219名患有共病的老年人作为研究对象,调查居家的老年共病患者多重用药现况.结果 调查发现,155例患者存在多重用药情况,多重用药率达到了70.8％.该调查人群,每日平均服用药物(8.6±3.2)种,服用药物的数量最少为5片(粒/丸),最多为72.5片(粒/丸),用药不良反应发生率则达到29％.年龄、疾病种类、用药依从性是居家老年共病患者多重用药的影响因素.结论 居家老年共病患者是发生多重用药的高危人群,针对影响因素管理居家老年共病患者多重用药,对患者的用药安全具有重要意义.

本文根据作者多年的医养结合研究实践,提出了建立覆盖城乡的医养结合服务体系是实现"全民健康"的基础工程和快捷路径,并为此提出了建立医养结合服务体系的思路、原则和方法.

作者根据多年医养结合健康养老的研究、实践和探索工作,提出了健康养老的五要素,认为健康养老的核心是健康维护;主要方法是依托"互联网+医养结合+健康管理"的服务体系,科学应用中医药的健康服务.因此,提出了如下健康养老的基本模式:政府主导的区域化医养结合模式,医院主导的院中院医养结合模式,企业主导的风景区医养结合模式.这三种模式分别承担大约90％的普通老人、7％的高危老人和3％的活力老人服务,即所谓新9073模式.

本文提出了数字时代人类主动健康的四个基本条件和新的健康理念.论述了支撑此健康理念的健康生态和产业链,提出了构建主动健康服务体系的思路和方法.

目的 探讨基于“互联网+”可穿戴式远程网络心电图诊断平台在院外场景的应用价值.方法 选取2017年4月～ 2019年3月在院外采集并实时传输到解放军总医院心电图网络会诊中心的67 730例远程网络心电图.分析心电图的质量以及对心律失常与心肌缺血的诊断价值.结果 无法正常判读心电图约794份(1.17％);检出标注为“危急”的心电图共311份(0.46％),标注为“急”的心电图共4 586份(6.77％).发现心律失常25 797例(38.09％),其中恶性心律失常,如心室停搏＞2.5 s145例(0.21％)、三度房室传导阻滞14例(0.02％)、室性心动过速21例(0.03％).共检出ST段改变患者7 991例(11.80％);确诊急性心肌缺血106例(0.16％);检出心肌梗死共86例(0.13％),其中陈旧性心梗53例(0.08％),急性ST段抬高型心肌梗死33例(0.05％).33例急性心肌梗死患者中,30例被及时转诊行急诊PCI,转诊率达91％;三度房室传导阻滞、心室停搏患者均转诊至对应医院,转诊率100％;其中30例患者植入永久起搏器.结论 远程网络可穿戴式心电图设备操作简便,适用于家庭及社区.心电图可诊断率高,出具报告时间短,危急患者可通过网络平台转诊,第一时间获得心电图诊断并得到及时救治.

Objective: To investigate the outcome and inlfuencing factors of graft vessels including saphenous vein graft (SVG) and left internal mammary artery graft (LIMAG) in patients after coronary artery bypass grafting (CABG). Methods: A total of 92 patients with post-CABG symptom recurrence from 2010 to 2015 were analyzed by angiography and clinical features for their native coronary vessel and graft vessel. There were 83 male and 9 female patients with the mean age of (62.6±10.8) years. The outcomes of graft vessel were assessed; correlation study was conducted between SVG, LIMAG lesions and traditional atherosclerosis risk factors like age, gender, hypertension, hyperlipidemia, diabetic mellitus, smoking, family history of coronary artery disease (CAD) with other clinical factors such as the time of angina recurrence, thetime from coronary angiography (CAG) to CABG, type of SVG (sequential graft or individual graft), the features of native target vessel lesions prior grafting. Results: The average time from CABG to symptom recurrence was (35.10±24.7) months. There were 146 grafts including 52 LIMAG and 94 SVG (60 individual and 34 sequential grafts), the patency rate of LIMAG was higher than SVG (63.5% vs 44.7%),P=0.030. SVG lesion was positively related to symptom recurrence (OR=1.119, 95% CI 1.002-1.249,P=0.046) and trended to female gender (P=0.065), while not related to other clinical factors; LIMGA lesion was not related to any clinical factors. The patency rate of sequential SVG was higher than individual SVG (58.9% vs. 36.7%,P=0.038). The native target vessel lesion (deifned by pre-operative occlusion/stenosis) was similar between individual SVG group (24/14) and no-lesion SVG group (17/5),P=0.388; while the native target vessel lesion in LIMAG group (7/12) was lower than no-lesion LIMAG group (23/10),P=0.04. Conclusion: Post-CABG lesion was not obviously related to traditional risk factors of CAD, post-SVG lesion was positively related to the time of post-CABG angina recurrence. SVG mid-and long-term patency in sequential graft vessel was higher than that in individual graft vessel. Pre-CABG native coronary blood lfow would affect the outcome of individual LIMAG but not SVG.

我国已名副其实地步入老龄社会,而且半数以上老年人患有各种慢性疾病,医疗负担重,家庭和社会压力大. 因此,构建科学的、新型的医疗和养老机构,真正实现医疗、康复、养老的结合,已成为当前医药卫生体制改革面临的重要问题. 医养结合的优势在于整合医疗、 康复和养老多方面的资源,以医疗为基础,构建医疗、康复、保健、生活照护的一体化体系,将有限的医疗资源发挥到极致,促进全民身体健康.

Aim: The aim of this study is to determine the effect of exogenous phosphocreatine (PCr) with different concentration on transient outward potassium (Ito), natrium (INa) and L-type calcium (ICa,L) current in ischemic ventricular cells of rat and to explore its role in the treatment of ischemic heart disease. Methods: Ventricular cells were isolated enzymatically from left ventricular of rat. Peak Ito, INa and ICa,L current were recorded using patch clamp techniques in the whole-cell configuration in the setting of cells superfused with normal Tyrode solution, simple simulated ischemic solution (SI), ischemic solution containing PCr with concentration of 5, 10, 20, 30 mmol/L for 10 min respectively. Results: Compared with simple simulated ischemic solution, peak Ito, INa and ICa,L current and current density of ischemic solution containing PCr of 5, 10, 20, 30 mmol/L significantly improved (p 0.05). Compared with PCr of 10 mmol/L, peak INa current and density decreased in that of 20 and 30 mmol/L (p<0.05). Conclusion: PCr could partly reverse the inhibition of Ito, INa and ICa,L current of rat ventricular cells under ischemic condition, which could be the ionic basis of therapeutic role in the treatment of ischemic heart disease. 0 ~ 10 mmol/L PCr exerted significant dose-effect relationship.

目前,全球平均人寿命虽然从1990年的65.3岁增加到2013年的71.5岁 (我国2015年平均寿命75.99岁),但生育率下降和人口老龄化使平均人死亡年龄大约为60岁. 相对经济发达地区,儿童死亡人数大幅下降,而80岁以上人群死亡人数大幅增加.大多数死亡和残疾原因是与年龄相关的非传染性疾病(NCD),如心血管疾病(CVD)、癌症、糖尿病和慢性呼吸道疾病.NCD死亡占全部疾病死亡的86%(WHO统计NCD死亡3400万占全部5600万死亡人数的60%)和77%的经济负担,给人类健康、经济发展带来了越来越大的压力,尤其是65岁以上的老年人.在美国和欧洲,CVD死亡是NCD的主要死因,约占全部死亡的50%[1- 2].65岁以上的1/3及85岁以上的1/2老人临床上有明显的CVD表现,且通常多病共存. 改善饮食习惯和偏好、戒烟、促进身体运动使工业化国家总体CVD死亡率下降,但慢性CVD患者总数由于人口老年化问题而明显增加,且在未来几年将大幅增加. 尤其缺血性心脏病(IHD)死亡率受年龄影响,随着人口老龄化的综合作用将使全球的IHD死亡人数继续增加.据估算全球每年大约耗费1960亿欧元来防治CVD,包括降低血压、降低胆固醇水平及戒烟,虽使发达国家的CVD死亡率大幅下降,如欧洲心脏病死亡人数从2008年报告的430万人/年下降到现在的400万人/年,但这种下降的趋势是否会使老年人受益尚不清楚.

目的 比较主动脉球囊反搏(IABP)与IABP联合机械通气治疗急性心肌梗死合并心源性休克的临床疗效,探讨更有效的治疗方法.方法 回顾性分析2005年1月～ 2013年12月共71例心肌梗死合并心源性休克患者,药物治疗效果不佳,38例应用IABP(IABP组),33例应用IABP联合机械通气(IABP+ MV组),比较两组间基线资料、临床指标、并发症等的差异,并分析影响院内死亡的因素.结果 IABP+MV组左心室射血分数(LVEF)由治疗前的(36.4±5.2)％增加至治疗后的(43.8±5.3)％(t=5.761,P=0.000),IABP组由治疗前的(41.7±4.5)％增加至治疗后的(44.0±4.9)％(t=2.103,P=0.039),可见IABP+ MV组比IABP组增加更显著(t=3.806,P=0.000).IABP+ MV组肺部感染(x2=4.283,P=0.038)及肾功能不全(x2=3.997,P=0.046)发生率明显高于IABP组,肺部感染、肾功能不全与院内死亡的危险性呈正相关,为阳性预测因子;成功血运重建与院内死亡危险呈负相关,为阴性预测因子.结论 IABP联合机械通气,有益于心源性休克患者心功能改善,但并不能降低院内死亡率,降低院内死亡率主要依赖于成功血运重建.IABP联合机械通气可能会增加肺部感染和肾功能不全的发生率,二者也是影响心源性休克患者院内死亡的主要危险因素.

目的 研究睡眠剥夺对健康青年人心理健康状况和血清皮质醇含量的影响,并进一步探索血清皮质醇含量与心理健康状况的关系.方法 随机整群抽取某部队陆军160名进行24 h完全睡眠剥夺作为睡眠剥夺组和60名给予正常睡眠(睡眠≥7h)作为对照组,试验从当天下午2:00至次日下午2:00,试验结束后立即运用《军人心理疾病预测量表》陆军常模同时评定睡眠剥夺组和对照组的心理健康状况,睡眠剥夺组分别于试验次日晨7:00和正常睡眠洗脱(睡眠≥7 h)5d后次日晨7:00抽取静脉血测定皮质醇含量,对所得数据进行统计学分析.结果 (1)睡眠剥夺组心理疾病预测总分及精神病性、抑郁、躁狂、神经症、人格偏移因子分明显高于对照组(P＜0.05);(2)睡眠剥夺组心理疾病预测总分及躁狂、人格偏移因子分明显高于陆军常模(P≤0.01);(3)睡眠剥夺组睡眠剥夺中的血清皮质醇含量高于正常睡眠洗脱后(t=2.05,P=0.04);(4)睡眠剥夺组躁狂因子得分与剥夺时血清皮质醇升高量呈正相关(r=0.37,P=0.00);(5)睡眠剥夺时血清皮质醇的ROC曲线下面积为0.95,以血清皮质醇含量500.56 nmol/L为临界值时诊断躁狂状态的相关性最高.结论 睡眠剥夺可显著降低青年军人心理健康水平和引起血清皮质醇升高,睡眠剥夺时血清皮质醇升高在导致躁狂症状的过程中起正向调节作用,睡眠剥夺时血清皮质醇含量达500.56 nmol/L与预测躁狂状态有较好的相关性.

Objective To determine the impact of post-discharge statin withdrawal on the long-term prognosis in the elderly patients after acute myocardial infarction (AMI). Methods A retrospective follow-up study was carried out on the elderly patients who received percutaneous coronary intervention (PCI) treatment due to AMI in the Department of Cardiology of our hospital from January 2010 to December 2010. A total of 739 patients were recruited in this study, and divided into 2 groups on the basis of statin withdrawal history: statin withdrawal group (n=178) and continued statin therapy group (n=561). The incidences of long-term all-cause mortality and cardiac mortality were compared between the 2 groups. Results After 4 years’ follow-up, the statin withdrawal group had significantly higher all-cause mortality (21.4% vs 13.9%, HR=1.62, 95%CI: 1.04?2.85, P=0.008), and obvious higher cardiac mortality (14.5% vs 8.1%, HR=1.98, 95%CI: 1.26?3.64, P=0.002) when compared with the continued statin therapy group. Conclusion Post-charge statin withdrawal greatly increases the long-term mortality in the elderly AMI patients after PCI treatment. So, effective education and strict supervision about statin therapy are needed for these elderly patients to improve their long-term survival situation.

目的 探讨糖化血红蛋白(HbA1c)对合并糖尿病的急性心肌梗死(AMI)患者行经皮冠状动脉介入治疗(PCI)术后远期生存的影响作用.方法 对解放军总医院心血管内科2004年1月～2004年12月间,确诊为AMI且合并糖尿病,行PCI治疗的患者155例(男性110例,女性45例)进行随访,随访截止日期为2013年12月.采用多因素Cox回归分析影响生存的相关危险因素.根据患者住院治疗期间HbA1c水平分为正常组HbA1c 4.7％～6.4％ (n=53),轻微升高组HbA1c 6.5％～8.4％(n=72),显著升高组HbA1c 8.5％～12.4％ (n=30),比较3组患者远期生存率的差异.结果 (1)入选患者PCI术后10年生存率为62.8％,正常组生存率为73.6％,轻微升高组生存率为63.2％,显著升高组生存率为46.4％.(2)3组患者的总体生存曲线比较,差异具有统计学意义(P=0.025).(3)与合并糖尿病急性心机梗死患者PCI术后远期生存相关的因素包括年龄(每增加10年)HR 1.596,95％ CI为1.204 ～ 2.115;吸烟HR 2.101,95％ CI为1.185 ～ 3.725;LVEF(每减少10％)HR 1.463,95％CI为1.112～1.923;服用ACEI或ARB类药物HR 0.514,95％ CI为0.268～0.986;HbA1c(每增加1％)HR 1.283,95％CI为1.009～ 1.628.结论 随着HbAlc水平的升高,合并糖尿病的AMI患者PCI术后10年生存率明显下降.

Objective To study the diagnosis and treatment of hypereosinophilic syndrome complicated with thromboembolism.Methods A retrospective analysis of a patient with hypereosinophilic syndrome diagnosed and treated in the Department of Cardiology, PLA General Hospital was performed.A literature research was performed with "hypereosinophilic syndrome" as the Chinese key word in Wanfang database and China national knowledge internet and " hypereosinophilic syndrome, hypereosinophilia, eosinophilia" as the English key words in PubMed and Embase database.The time interval was from January 1975 to December 2013.Results The patient was a 31 year old male with a history of bilateral lower limb swelling and a history of chest pain accompanied with blood-stained sputum.Computed tomography pulmonary arteriography (CTPA) on admission showed multiple filling defects at lobular and segmental arteries.CT venography (CTV) and ultrasound examination of the legs demonstrated multiple venous thrombosis.Literature review found 41 articles, including 8 reviews, 29 case reports and 4 other type articles.Conclusions The clinical manifestations of hypereosinophilic syndrome were varied, and therefore the disease should be managed differently according to different subtypes with glucocorticoids as the main therapy.Effectively reducing the eosinophil count could decrease the incidence of thrombotic complications.Anticoagulant therapy should be used in patients with thrombotic complications.The effectiveness of preventative anticoagulation and duration of anticoagulation are less clear and require further clinical study.

The adipose tissue-derived stem cells (ADSCs) represent a significant area of the cell therapy. Genetic modification of ADSCs may further improve their therapeutic potential. Here, we aimed to generate a lentiviral vector expressing insulin-like growth factor-I (IGF-1) and investigate the impact of IGF-1 transduction on the properties of cultured ADSCs. Isolated rat ADSCs were assessed by flow cytometric analysis. IGF-1 was cloned and inserted into the pLenO-DCE plasmid to acquire pLenO-DCE-IGF-1 plasmid. Lentivirus was enveloped with pRsv-REV, pMDlg-pRRE and pMD2G plasmids in 293T cells. The ADSCs were transfected with the vectors. And then IGF-1-induced anti-apoptosis was evaluated by annexin V-FITC. Besides, proliferation of cells was detected by MTT assay and EdU. Moreover, Akt phosphorylation was evaluated by Western blotting analysis. Stable expression of IGF-1 in ADSCs was confirmed. ADSCs were positive for CD90 and CD29, but negative for CD31, CD34 and CD45. The transduction of IGF-1 to the ADSCs caused a dramatic increase in P-Akt expression. Over-expression of IGF-1 in ADSCs could improve the paracine of IGF-1 in a time-dependent manner, but could not promote the proliferation of ADSCs. This study indicated that lentiviral vectors offered a promising mean of delivering IGF-1 to the ADSCs. Lentiviral-mediated over-expression of therapeutic IGF-1 gene in ADSCs could prolong the anti-apoptosis effect of IGF-1, which might be induced by the activation of the PI3K/Akt pathway. And our data would improve the efficacy of ADSC-based therapies.