目的 探讨托伐普坦在长寿老人(≥90岁)射血分数保留心衰(HFpEF)患者中应用的疗效及安全性.方法 采用自身对照的方法,回顾性选取2017年1月～2018年12月解放军空军特色医学中心收治的12例90岁以上HFpEF患者,对比分析加用托伐普坦前后心衰症状、不良反应、以及用药后2周、1月时尿量、血钠、肝肾功能、心功能等指标的变化.结果 1例因过敏反应停药.所有患者体液潴留的症状明显改善,用药后2周及1月时尿量均较用药前显著增加,差异有统计学意义(P＜0.05);血清钠轻度升高,差异具有统计学意义(P＜0.05);其他肝肾功能、心功能指标用药前后无显著改变.2例患者在此期间死于肺部感染.结论 托伐普坦对90岁以上HFpEF患者具有良好的疗效及安全性.

军队保健工作是一项特殊的医疗服务工作,保健医师需要谙熟健康管理学、保健医学、预防医学、老年医学、全科医学、营养学、心理学等多学科的理论知识和技能[1].目前国内的保健医学尚未形成独立、完整的学科体系,从业人员多由全科医师、老年病科医师或其他专科医师经过培训后担任.我院全军老年医学研究所,从事军队高级干部医疗保健服务工作数十年来,积累了丰富的工作经验,并参考有关全科医师的培训方法和模式[2],培养了保健专业的各级医师.现将我们多年来临床带教各级医师的经验及教学培训规划总结如下,可供保健、全科及老年病科等相关学科探讨和借鉴.

目的 探讨超高龄(90岁以上)患者永久心脏起搏治疗的一般临床特性、疗效及安全性.方法 回顾性分析21例超高龄行永久心脏起搏治疗患者的临床资料,包括年龄、性别、适应证、合并疾病、认知能力评估、手术并发症及手术前后心、肾功能指标变化等,并观察术后1年的临床随访结果.结果 所有患者顺利完成手术,术后心动过缓所致症状消失;1例发生起搏器介导心动过速,经程控参数后终止;1例术后心衰加重,经药物治疗后好转出院,于术后10个月死于肺部感染;1例于术后11个月死于颅内恶性肿瘤;本组患者无其他手术相关并发症发生,术后12个月左室射血分数(LVEF)及肾功能较术前无显著变化.结论 超高龄患者行永久心脏起搏治疗有效而安全,术后1年内肾功能、LVEF等较术前无明显变化.

目的 观察主动心脏起搏电极在超高龄(≥90岁)患者中的应用特点.方法 回顾性分析13例超高龄患者右房及右室心尖部主动起搏电极的使用情况,手术相关并发症的发生,如心肌穿孔、电极脱位、囊袋血肿或感染、术后心、肾功能变化等,以及术中即刻、术后1个月起搏参数的变化特点.结果 术后1例患者心功能不全加重,其他患者无相关并发症发生;术后1个月随访起搏电极的阈值及阻抗低于术中即刻,差异有统计学意义(P<0.05).结论 主动电极在超高龄患者心脏起搏治疗中有效、安全,术中起搏阈值和阻抗明显升高,术后1个月逐渐下降.

Objective To provide reference and theoretical basis for the medical care in retired military cadres by analyzing the physical examination results of 3247 cases.Methods A total of 3247 cadres retired from army who took physical examination in our hospital from March 2014 to March 2016 were enrolled in this study .They were 2684 males and 563 females, and at an age of 75.0 ±13.8 (50-95) years.According to their age , they were divided into 50-59, 60-69, 70-79 and 80 -95 years groups (n=374, 1184, 1547 and 142).The results of physical examination , medical examination and laboratory test were collected and analyzed.Results Compared with other aged group , the 80-95 years group had higher ratios of females , more comorbidities of coronary heart disease, diabetes and hyperuricemia, higher proportion of medication, and lower 25-(OH)D3 level (P<0.05).Abdominal ultrasound results showed that fatty liver , hepatic cyst , gallbladder polyps , gallbladder stones and kidney stones were more common in the 80-95 years old group (P<0.05).Chest X-ray filming indicated there were more images of increased pulmonary markings , thoracic vertebra degeneration , obsolete pulmonary tuberculosis , pulmonary interstitial changes , arteriosclerosis , pulmonary emphysema , pulmonary patchy shadow and adhesion of the pleural cavity in the 80-95 years old group (P<0.05).Electrocardiogram indicated there were more images of ischemic change , bundle branch block ,sinus arrhythmia ,myocardial infarction ,left ventricular hypertrophy , premature contraction, atrial ventricular block in the 80 -95 years group ( P <0.05).At the same time, the incidence rates of mammary hyperplasia and uterine fibroids were higher in the females from the 60-69 years group , and those of prostate hypertrophy , prostatic calculus and prostatic calcification were common in the males of the 80 -95 years group ( P<0.05 ) .Conclusion The abnormality rates of medical examination results are quite high in the retired cadres .So, pertinent health guidance should be carried out and related risk factors should be monitored and controlled for the senile patients , so as to get benefits from early discovery and active intervention.More attention should be paid to the health care in those aged 80-95 years.

目的：探讨军队离退休老干部心电图的变化规律。方法按照年龄的差异将3247例军队离退休老干部分为四个年龄组，即中年组（50～59岁）374名、低龄老年组（60～69岁）1184名、中龄老年组（70～79岁）1547名和高龄老年组（80～95岁）142名，均行常规12导联心电图检查，并对心电图异常情况进行统计分析。结果3247例中正常心电图286例，异常心电图2961例，军队离退休老干部的心电图异常情况为缺血性改变76.67％（2270／2961）、束支传导阻滞58.76％（1740／2961）、窦性心律失常53.56％（1586／2961）、心肌梗死47.15％（1396／2961）、左心室肥厚30.63％（907／2961）、各种期前收缩25.13％（744／2961）和房室传导阻滞21.65％（641／2961）等，四个年龄组的心电图异常情况比较均有非常显著性差异（χ2＝75.42，P＜0.01）。结论应尽早行心电图检查，对早期发现、诊断和治疗心血管疾病具有重要意义。

病例1:1例78岁女性患者,因脑梗死、心房颤动口服达比加群酯抗凝治疗,初始剂量110 mg,bid,治疗前凝血四项均正常.服药5d后及其后多次复查凝血酶时间(TT)明显延长,最长147 s(正常上限21 s);活化部分凝血活酶时间(APTT)轻度延长或正常高限,凝血酶原时间(PT)、凝血酶原时间国际标准化比值(INR)、纤维蛋白原(FIB)正常,患者出现皮下出血.停药3d后测TT、APTT正常,恢复服药后TT、APTT再度延长.达比加群酯减至55 mg,qd,TT延长缩短至62.2 s,APTT正常.病例2:1例71岁男性患者,因阵发性房颤口服达比加群酯150 mg,bid抗凝治疗.1个月后查PT 13.3 s略延长,APTT延长47.3 s,TT＞60 s明显延长,INR、FIB正常.停用达比加群酯5d后查PT、APTT、TT均正常.该2例患者均于口服达比加群酯后出现TT、APTT延长,且停药后均恢复正常,病例1提示TT、APTT延长程度与药物剂量有关,提示TT、APTT或许可以作为监测达比加群药物作用的指标,其结论仍需大规模的研究加以验证.

Two elderly patients (one was male, 90 years-old;the other female, 63 years-old) with coronary disease and depression received citalopram 20 mg daily for 4 years and 1 year, respectively.The width of their electrocardiogram QT interval was normal.They received diltiazem 15 mg three times daily (the male) and 30 mg three times daily (the female) due to recurrent attacks of angina pectoris.QT interval prolongation was found by electrocardiographic examination on day 4 (the male) and day 83 (the female) of medication with diltiazem, the QT interval/corrected QT interval (QT/QTc) were 448/526 ms (the male) and 430/447 ms (the female), respectively.The QT/QTc in the male patient decreased to 432/510 ms 5 days after diltiazem withdrawal.The QT/QTc in the female patient decreased to 388/406 ms on 35 days after diltiazem's dosage was halved.

目的 探讨糖化血红蛋白(HbA1c)对老年男性颈动脉硬化的预测价值.方法 共50例HbA1c≥6.0％的老年男性患者(A组)和48例HbA1c＜6.0％的老年男性患者(B组)纳入本研究,采集其空腹及餐后2h血标本测定空腹血糖、餐后2h血糖、血脂,使用动态血压检测仪和彩色多普勒测量受检者的血压和颈动脉内膜中层厚度(CIMT).结果 (1)A组空腹血耱、餐后2h血糖、糖尿病病史、三酰甘油、24h收缩压、白昼收缩压、夜间收缩压均高于B组(P＜0.05);(2)B组左侧CIMT为(0.98±0.18) mm、右侧为(0.92±0.18) mm,内膜增厚率为62.5％,斑块检出率为37.5％;A组左侧CIMT为(1.22±0.18) mm、右侧为(1.16±0.19) mm,内膜增厚率为94％,斑块检出率为64％.组间差异有统计学意义(P＜0.01).(3)多元线性回归分析结果显示,老年男性的CIMT与HbA1c、吸烟史、餐后2h血糖、24 h收缩压、糖尿病病史相关.结论 HbA1c是老年男性颈动脉硬化的重要预测因子.

一系列的研究表明骨骼肌细胞内甘油三酯(intramyocellular triacyglycerol,IMTG)和胰岛素抵抗之间有密切联系.许多因素可调控IMTG的动态变化,如甘油三酯水解酶、激素敏感性脂肪酶、甘油一酯脂肪酶和脂滴结合蛋白等.而IMTG的代谢中间产物甘油二酯、神经酰胺和脂肪酸在骨骼肌中的聚集也与胰岛素抵抗密切相关.脂滴和线粒体对于细胞内甘油三酯及其代谢产物的周转速度起关键作用,对胰岛素抵抗也起着重要的作用.

目的:冠心病的发病率越来越高,成为临床上常见的心血管疾病.冠心病的发生、发展与冠状动脉病变程度直接相关.通过手术引起冠脉狭窄,探讨冠脉狭窄与骨保护素(OPG)的相关性,从而为临床冠心病的预测提供理论依据.方法:(1)20头巴马小型猪,在胸腔镜直视下手术丝线永久性结扎左前降支近端建立轻度(狭窄程度20-49％)、中度(狭窄程度50-69％)和重度(狭窄程度≥70％)狭窄的冠状动脉狭窄模型;(2)各组小型猪分别在其手术处理前后1 min留取静脉血和分离血浆,测定骨保护素的含量.结果:(1)手术对各组小型猪血浆OPG的影响差异无统计学意义(P＞0.05),同时,各组之间冠脉狭窄模型猪手术后血浆OPG的浓度较对照组升高,但无统计学差异(P＞0.05).结论:(1)手术作为一种应激性损伤,导致OPG升高.(2)骨保护素与冠状动脉硬化和血管钙化有关,但与没有动脉硬化和钙化引起的的冠脉狭窄无关.

Objective To determine the value of mean platelet volume (MPV) and platelet large cell ratio (P-LCR) in the diagnosis of acute coronary syndrome (ACS) in patients with chest pain. Methods A total of 83 chest pain patients with identified ACS and 56 chest pain patients without cardiovascular disease in our hospital from January to June 2013 were subjected in this study. Their venous blood samples were collected within 6 h of onset for platelet parameters. Mean comparison between the 2 groups and logistic regression analysis were used to find the effective platelet parameters, and receiver operating characteristic (ROC) curve analysis was used to evaluate their diagnostic significances for ACS. Results ACS group had significantly lower platelet than the non-cardiac chest pain group [(191.28±67.07)×109 vs (236.75±64.09)×109/L)], and significantly higher MPV [(11.88±1.24) vs (10.73±1.08)fL], platelet distribution width (PDW) [(15.54±1.87) vs (13.40±2.35)fL] and P-LCR [(47.49±9.55)%vs (35.11±10.00)%] (all P<0.05). There was no statistical difference in the platelet parameters among different types of ACS patients (P>0.05). Logistic regression analysis showed that P-LCR and MPV were auxiliary diagnostic indicatos for ACS. ROC curve analysis showed that the cut-off was 0.15μg/L, 38.5%, 11.05fL, and 19.0U/L, respectively, for troponin I (TnI), P-LCR, MPV and creatine kinase-MB (CK-MB), and their areas under the curve were 0.987, 0.817, 0.754 and 0.598, respectively. Their sensitivity was 97.3%, 92.8%, 71.1%and 45.8%respectively, the specificity were 90.3%, 64.3%62.5%, and 73.2%respectively, and the diagnostic accuracy were 100%, 80%, 72.6%, and 67.2%, respectively for TnI, P-LCR, MPV and CK-MB. Conclusion MPV and P-LCR are helpful in the early diagnosis of ACS, and can be seperately used as auxiliary diagnostic indicators of ACS in patients with chest pain. Because of their high diagnostic accuracy, the 2 parameters can be served as a reference for early prediction and differential diagnosis of ACS.

Objective:To explore the relationship between glycosylated hemoglobin (HbA1c)and carotid artery atheroscle-rosis in aged patients with normal glucose tolerance.Methods:A total of 100 aged patients with normal glucose tolerance were selected.Their bilateral carotid arteries were measured by color Doppler ultrasonography.They were grouped accord-ing to carotid intima-media thickness (C-IMT,normal,thicken and atherosclerosis)and plaque form (no plaque,hard plaque and soft plaque);blood pressure,blood lipids and HbA1c etc.were compared among groups.Results: (1)Along with CIMT rose,there was significant increase in HbA1c level [(4.98 ± 0.55)% vs.(5.51 ± 0.42)% vs.(5.92 ± 0.39)%],and there was significant difference between any two groups (P<0.01 all);(2)HbA1c level was (5.36±0.51)%,(5.89±0.44)% and (5.97±0.2)% in no plaque group,hard plaque group and soft plaque group respectively,and there was significant difference among hard plaque group,soft plaque group and no plaque group (P <0.01 all).Conclu-sion:Glycosylated hemoglobin may become an important index assessing carotid atherosclerosis in aged people.

Objective: To explore the effects of simulated weightlessness 30 days and high + Gx overload on myocardial ultrastructure,plasma endothelin-1 and c-reactive protein in rhesus macaque,to study simulated weightlessness and overweight on the effect of cardiovascular,this experiment can provide experimental data for the Study of anti-G suits and spacecraft orbit segment emergency return overweight medicine.Methods: Fifteen male rhesus macaque are randomly divided into five groups: simulated weightlessness group(control group,A),+13 Gx/230 s group(B),+11 Gx/270 s exposure after simulated weightlessness group(C),+13 Gx/230 s exposure after simulated weightlessness group(D),+15 Gx/200 s exposure after simulated weightlessness group(E).The animals are sacrificed to extract blood to measure plasma endothelin-1 and c-reactive protein content.The tissues are fixed by glutaraldehyde and made into electron microscopy specimens to observe the change of myocardial ultrastructure in rhesus macaque.Results: The content of group C,D and E plasma endothelin-1 and C-reactive protein increase than group A,there is statistically significant(P 0.05),there is no statistical significance between the group C,D,E.The content of group D plasma endothelin-1 and C-reactive protein increase than group B,there is statistically significant(P0.05).In the electron microscope,group A visible mitochondria bilayer structure clear and mitochondrial cristae clear;part of the mitochondrial bilayer structure disappeared and the number of mitochondrial cristae reduce in the group B,C,D.group E mitochondrial edema,vacuolar degeneration,sarcomere fracture.Conclusion:(1) +13 Gx exposure after simulated weightlessness can cause myocardial minor injuries,+15 Gx exposure after simulated weightlessness can cause myocardial serious injury,along with the increase of +Gx load level,the severity of myocardial injury increased.(2) The myocardial injury of overweight after weightlessness is serious than simply overweight.(3) This study can provide experimental support for overweight endurance studies and scientific and rational spacecraft orbit segment emergency return overweight medical.

<正>外源性过敏性肺泡炎(extrinsic allergic alveolitis,EAA),也称为过敏性肺炎(Hypersensitivity pneumonitis,HP),是易感者反复吸入多种具有抗原性的有机粉尘及低分子化学物质所引起的一组临床综合征[1]。病变主要累及两肺远端的细支气管、肺泡及肺问质,临床少见,但近年来发病率有上升趋势。急性发病者短期内出现发热、咳嗽及呼吸困难,常被误诊为细菌性或病毒性肺炎;隐匿起病者表现为咳嗽、进行性呼吸困

Objective: To observe the characteristics of the changes of plasma CK-MB and interleuki-6 levels in swines with different coronary artery stenosis after +Gz exposure,so as to explore the heart of the hazards,assess the pilot's flight.Methods:(1)Of 20 Bama miniature swines,the proximal left anterior descending branch(LAD) was ligated permanently by using silk suture under direct vision of the thoracoscope to establish different coronary artery stenosis models--the mild,the moderate and the severe--with stenosis degree of the LAD 20-49%,50-69%,and ≥70% respectively.(2)+Gz exposure was performed and values of the maximum +Gz acceleration tolerance were observed in each group;(3)1 minute before and after the exposure of the maximum +Gz acceleration tolerance in each group,venous blood was collected.Then,plasma were separated and CK-MB,IL-6 were measured.Results:(1) Values of the maximum +Gz acceleration tolerance in each group are as follows: ①The normal control group: +8 Gz;②The mild stenosis group:+8 Gz;③The moderate stenosis group:+6 Gz;④The severe stenosis group: +5 Gz;(2) The effects of the exposure of the maximum +Gz acceleration tolerance on plasma CK-MB and IL-6 content were significant(P0.01).Meanwhile,compared with the normal control group after the exposure of the maximum +Gz acceleration tolerance,plasma C-reactive protein and endothelin-1 levels in the moderate and the severe groups were significantly raised,but the mild was not.Conclusions: 1.The effect of +Gz exposure on plasma CK-MB and IL-6 levels in swines with different coronary artery stenosis is different-the worse the stenosis degree,the bigger the effect;2.Changes of plasma CK-MB and IL-6 levels in the normal control group are similar with those in the mild after +Gz exposure,the mild stenosis coronary pilots can continue flying.

<正>1临床资料男,84岁,以"帕金森病"于2012年10月入院治疗。给予美多巴250 mg,3/d口服后病情控制,日常生活基本能自理。患者近1年来间断出现头晕、双眼黑蒙,伴乏力及视物不清,有时不能迈步,无法辨别家人,甚至猝倒1次。上述症状持续约20 min,卧床休息10 min

目的 探讨正常高值血压与中心动脉压及动脉硬化的关系.方法 采用脉搏波分析仪记录472例受试者(理想血压组167例,正常高值血压组129例,及高血压组176例)的桡动脉脉搏波,经计算机转换函数自动转换为相应的中心动脉脉搏波,并计算中心动脉压力及反映全身动脉硬化的增强指数( AIx).结果 与理想血压者相比,正常高值血压患者体重指数、吸烟及饮酒的比例、血尿酸及总胆固醇、甘油三酯水平显著增高；中心动脉收缩压、收缩末期压及中心动脉增强压分别增加13.39 mmHg(95％ CI,9.71～ 17.08 mmHg)、11.66 mmHg(95％ CI,8.37～14.94 mmHg)及1.95 mmHg(95％ CI,0.52～3.38 mmHg),增强指数增加3.97％ (95％ CI,0.27％ ～7.68％).虽然正常高值血压组的偶测血压显著低于高血压组,但经年龄、性别及身高、心率等调整后,两组的增强指数无显著差异.结论 与理想血压者相比,正常高值血压患者有更多的心血管危险因素,且中心动脉压力及增强指数升高,提示患者左心室负荷加重,动脉顺应性下降.这些血流动力学的改变可能有助于增加心血管病危险,对其进行评价有助于正常高值血压人群的危险分层及防治.

We applied PDCA circulation to teaching management of geriatrics department according to the clinical demands of training goal for geriatrics physicians.In their continuing education,setting teaching goal,carrying out teaching method,evaluating teaching effect and summarizing teaching experience are carried out respectively in the phase of plan,do,check and action in PDCA circulation.It plays a positive role in improving teaching quality.