1 病例资料 患者,男,68岁,因"间断胸闷胸痛16 h"于2018年12月10日入院.患者16 h前无明显诱因出现胸闷、胸痛,为心前区压榨紧缩感,伴眩晕、大汗、恶心、呕吐,持续约30 min,经休息缓解.4 h前再次出现胸闷,伴一过性意识丧失,约半分钟后意识恢复,醒后无肢体活动障碍.急到我院就诊,测血压66/47 mmHg(1 mmHg=0.133kPa).心电图示窦性心动过速,104次/min,Ⅱ、Ⅲ、aVF可见Q波,STV4～6压低,左前分支传导阻滞以及房性期前收缩(图1).急查心肌损伤三项:肌酸激酶同工酶(CK-MB)80 ng/mL(正常值0～4.3 ng/mL),肌红蛋白(MYO)500 ng/mL(正常值＜107 ng/mL),肌钙蛋白Ⅰ(cTnⅠ)25.1 ng/mL(正常值0～0.4 ng/mL),以"急性心肌梗死"收入我科.入院查体:T 36.5℃,P 108次/min,R 20次/min,BP 92/56 mmHg;神志清,双肺呼吸音清,未闻及干湿啰音.心率112次/min,心律不齐,可闻及期前收缩,1～3次/min,心音可,各瓣膜听诊区未闻及病理性杂音;腹软,无压痛,肝脾肋下未及,双下肢无水肿.

目的 观察养心定悸胶囊治疗伴长RR间期的心房颤动合并慢性心力衰竭患者的效果.方法 将2016年5月1日—2018年6月1日就诊于河北省人民医院的104例伴长RR间期的心房颤动合并慢性心力衰竭患者随机分为试验组52例和对照组52例,2组均给予改善心功能、稳定心率在内的规范化治疗,试验组在此基础上加服养心定悸胶囊,6粒/次,2次/d.观察2组患者治疗12周后症状、心率、RR间期、心功能[左室射血分数(LVEF)、左室舒张末期内径(LVEDD)、左房内径(LAD)、N端前脑钠肽(NT-proBNP)]及心率变异性指标[窦性心率RR间期标准差(SDNN)、RR间期平均值标准差(SDANN)、相邻RR间期差值的均方根(RMSSD)、窦性相邻RR间期之差>50 ms的计数占总RR间期数的百分比(PNN50)]的变化,记录2组不良反应发生情况.结果 治疗12周后,试验组和对照组的临床症状总有效率分别为88.5％(46/52)和75.0％(39/52),试验组明显高于对照组(P<0.05);2组患者的24 h总心搏次数、心率及长RR间歇次数均显著少于治疗前,最长间歇时间均显著短于治疗前,且试验组最长间歇时间显著短于对照组,长RR间歇次数显著少于对照组,差异均有统计学意义(P均<0.05);2组患者的LVEF及均心率变异性各指标显著高于治疗前,LVEDD、LAD及NT-proB-NP水平均显著低于治疗前,且试验组的变化都更为显著,差异均有统计学意义(P均<0.05).治疗期间2组患者的不良反应发生率比较差异无统计学意义(P>0.05).结论 养心定悸胶囊辅助治疗可明显改善伴长RR间期的心房颤动合并慢性心力衰竭患者症状,有效稳定心率,缩短长间歇,改善心功能,调节心率变异性,且安全性高.

目的 探讨异丙酚对兔创伤失血性休克复苏胃黏膜损伤(trauma hemorrhagic shock resuscitation-gastric mucosal injury,THSR-GMI)核因子κB(nuclear factor-κB,NF-κB)表达及其炎性反应和细胞凋亡的影响,以明确异丙酚对THSR-GMI的作用及机制.方法 成年新西兰雄性大白兔75只,随机分为对照组(S组)、模型组(M组)以及失血前应用异丙酚组(P1组)、复苏前应用异丙酚组(P2组)和复苏后应用异丙酚组(P3组)各15只.建立THSR-GMI模型.P1组、P2组及P3组分别于失血前10 min、复苏前10 min及复苏20 min时静脉注射异丙酚5mg/kg后,以20 mg· kg-1·h-1速度持续静脉泵注,S组和M组给予等容量生理盐水.复苏90 min时取静脉血及胃组织标本,肉眼下观察胃黏膜损伤程度,放大镜下计算胃黏膜损伤指数(damage index,DI)及光镜下计数中性粒细胞(polymorphonuclear leukocyte,PMN),采用末端脱氧核苷酰基转移酶介导性dUTP切口末端标记(terminaldeoxynucleatidyl transferase-mediated dUTP incision end labeling,TUNEL)法和免疫组织化学技术分别测定胃黏膜细胞凋亡指数(apoptotic index,AI)和NF-κB表达,以酶联免疫吸附测定法测定血清肿瘤坏死因子α(tumornecrosis factor-α,TNF-α)和白细胞介素6(interleukin-6,IL-6)浓度.结果 与S组比,M组、P1组、P2组和Ps组胃黏膜出现不同程度损伤,其DI值、PMN计数、AI值、NF-κB表达以及血清TNF-α和IL-6浓度均升高(P＜0.05);与M组比,P1组、P2组和P3组的胃黏膜损伤不同程度减轻,其DI值、PMN计数、AI值、NF-κB表达以及血清TNF-α和IL-6浓度均降低(P＜0.05).与P3组比,P1组的胃黏膜损伤减轻,其DI值、PMN计数、AI值、NF-κB表达以及血清TNF-α和IL-6浓度均降低(P＜0.05).结论 异丙酚可通过下调NF-κB表达,抑制炎性反应和细胞凋亡,从而减轻兔THSR-GMI,以失血前应用效果较佳.

Objective To investigate the effects and mechanism of remifentanil on renal ischemia/reperfusion(IR) injury via mediating Fas apoptosis signal pathway in rats.Methods Sprague-Dawley rats were divided into 3 groups (n =20 each) by using the random number table method:sham operation group (S group),IR control group (IR group),experimental group (Rgroup).The renal IR model was prepared by clamping the bilateral renal arteries for 45 min followedby reperfusion in IR group and R group.In R group,remifentanil was infused at 1.0μg·kg-1 ·min-1 via the tail vein starting from 15 min before ischemia until 30 min of reperfusion.In S group and IR group,the same volume of physiological saline was given.At 15 min before ischemia and at 3 h,12 h,24 h of reperfusion,the renal tissue samples were obtained for detecting the apoptosis rate by flow cytometry,determining the level of Fas mRNA expression by RT-PCR,the level of caspase-8 and caspase-3 activation by Western blotting,and scoring the number of kidney tubules injury by Paller'method.Results In IR group,the renal tubular injury score,the apoptosis rate,the expression of Fas mRNA and the activation of caspase-3 in renal tissue increased at 3 h after reperfusion,and those continued to increase at 12 h after reperfusion and reached the peak at 24 h after reperfusion (P＜0.01),and the activity of caspase-8 increased at 3 b,reached the peak at 12 h after reperfusion and decreased at 24 h after reperfusion (P＜0.01).As compared with S group,the renal tubular injury score,apoptosis rate,the expression of Fas mRNA and the activation of caspase-3 at 3 h,12 h and 24 h of reperfusion and the activation of caspase-8 at 12 h,24 h of reperfusion were all increased in IR group and R group (P＜0.05 or 0.01).As compared with IR group,the renal tubular injury score,apoptosis rate,the expression of Fas mRNA and the activation of caspase-8 and caspase-3 at 3 h,12 h and 24 h of reperfusion were decreased in R group (P＜0.05 or 0.01).Conclusion Remifentanil inhibits cell apoptosis and alleviates renal IR damage by reducing the expression of Fas receptor and the activation of caspase-8 and caspase-3,and regulating the apoptotic signal pathway of Fas.

Objective To investigate the effects of propofol on gastric mucosal blood flow(GMBF), nitric oxide(NO) and endothelin(ET), and to confirm the role and mechanism of propofol in the gastric mucosal injury after trauma hemorrhagic shock resuscitation in rabbits.Methods Seventy-five healthy adult male rabbits were randomly divided into 5 groups of 15 rabbits: control(S group), trauma hemorrhagic shock resuscitation gastric mucosal injury(M group) and 10 min before hemorrhage(P1 group), 10 min before resuscitation(P2 group), 20 min after resuscitation(P3 group) application propofol group [5 mg/kg propofol was injected intravenously, then 20 mg/(kg·h) was infused].The S and M groups were given the same amount of saline.The GMBF was detected by laser Doppler flowmetry.The gastric tissue samples were obtained at 90 min after resuscitation.Gastric mucosal damage index(DI) was calculated by Guth method.The contents of NO and ET-1 were determined by nitrate reductase and radioimmunoassay respectively.The NO/ET-1 ratio was calculated and the correlation between GMBF and NO/ET-1 ratio and between DI value and GMBF, NO, ET-1 or NO/ET-1 ratio was observed.Results ①Compared with group S, the GMBF, NO and NO/ET-1 ratio were significantly lower, while DI and ET-1 were significantly high after resuscitation in group M and group P(P<0.05 or P<0.01).②The GMBF at 30 min and 90 min after resuscitation in group P1, P2 and that at 90 min after resuscitation in group P3 were significantly higher, and NO content and NO/ET-1 ratio in group P1, P2 or P3 were significantly higher, but DI and ET-1 content in group P1, P2 or P3 were significantly lower than those in group M(P<0.05 or P<0.01).③The GMBF at 90 min after resuscitation and NO/ET-1 ratio were significantly higher, but DI was significantly lower in group P1 than in group P3(P<0.05 or P<0.01).④At 90 min after resuscitation, there was a close correlation between GMBF and NO/ET-1, DI and GMBF, NO or NO/ET-1, DI and ET-1(r=0.913,-0.699,-0.762,-0.678 and 0.705 respectively, P<0.01).Conclusion Propofol can improve NO and ET-1 balance, raise NO/ET-1 ratio and is beneficial to maintaining GMBF.Propofol can also reduce the gastric mucosal injury after trauma hemorrhagic shock resuscitation in rabbits;it is of great effectiveness when being applied before ischemia.

Objective To investigate the effect of target intracoronary injection of nicorandil for the prevention of no-reflow phenomenon (NRP) during emergency percutaneous coronary intervention(PCI) in patients with acute ST-segment elevation myocardial infarction(STEMI).Methods The enrolled 105 cases of acute STEMI receiving emergency PCI in the Third Hospital of Hebei Medical University from January 2015 to September 2016 were randomized them into nicorandil group,sodium nitroprusside group and control group with 35 cases in each,and treated with target intracoronary injection of 2 mg nicorandil diluted in 10 ml 0.9% sodium chloride solution,200 μg sodium nitroprusside diluted in 10 ml 0.9% sodium chloride solution,and 10 ml 0.9% sodium chloride solution,respectively,into the place that was 2 mm distant from the target lesion via pre-dilated balloon and pressure pump.The TIMI flow grade of infarct-related artery,corrected TIMI frame count (cTFC),TIMI myocardial perfusion grade (TMPG) before and at the end of PCI,the incidence of NRP during PCI,the ST-segment resolution (STR) rate at 90 min after PCI were observed.N-terminal pro-brain natriuretic peptide (NT-proBNP) was measured before and at 1 week after PCI.CK-MB and cTnI were measured before and at every 4 h after PCI,and their peak levels were recorded.Color Doppler echocardiography was used to calculate the wall motion score index (WMSI) and left ventricular ejection fraction(LVEF) before and at 1 week after PCI.The incidence of hypotension during PCI and postoperative prognosis were observed.Results Before PCI,the TIMI flow grade,the proportion of patients with TMPG grade 3,NT-proBNP,values of CK-MB,cTnI,WMSI and LVEF did not differ significantly among the three groups(P>0.05).After PCI,compared with control group,the value of cTFC and the incidence of NRP in nicorandil group and sodium nitroprusside group were significantly decreased,but the proportion of patients with TMPG grade 3 and the proportion of STR ≥50% at 90 min after PCI were significantly increased (P<0.05);compared with the control group,the level of NT-proBNP,peak levels of CK-MB,cTnI and WMSI in nicorandil group and sodium nitroprusside group were significantly decreased,but the LVEF was significantly increased (P<0.05);there were no significant differences in the value of cTFC,the proportion of patients with TMPG grade 3,incidence of NRP,proportion of STR ≥50% at 90 min after PCI,level of NT-proBNP,peak levels of CK-MB,cTnI,WMSI and LVEF between the nicorandil group and sodium nitroprusside group(P>0.05).The incidence of hypotension in the control group,sodium nitroprusside group and nicorandil group was 9.1%(3/33),24.2%(8/33) and 0,respectively,which differed significantly among the groups (χ2=10.236,P=0.006);the sodium nitroprusside group had higher incidence of hypotension than the nicorandil group(P<0.01);patients with hypotension in both the control group and the sodium nitroprusside group were treated by dopamine.The incidence of MACEs 3 months after PCI was 15.2%(5/33),6.1%(2/33) and 5.9%(2/34) in the control group,sodium nitroprusside group and nicorandil group respectively,which showed no significant differences among the three groups(χ2=2.276,P=0.320).Conclusion For patients with acute STEMI receiving emergency PCI,target intracoronary injection of nicorandil is safe,which can effectively prevent the incidence of NRP during PCI,as well as improve the myocardial perfusion and cardiac function.

Objective To observe the treatment effects of the targeted coronary intravascular injection of nicorandil combined with tirofiban on no-reflow phenomenon(NRP) during primary percutaneous coronary intervention(PPCI)in patients with acute ST-elevation myocardial infarction(STEMI).Methods One hundred and twenty patients with acute STEMI were randomly divided into tirofiban group(T group), nicorandil group(N group) and combined medication group(T+N group), each group had 40 cases.When the NRP occurred,T group, N group and T+N group were injected with tirofiban(25 μg/kg), nicorandil(4 mg) and tirofiban(25 μg/kg) plus nicorandil(4 mg) respectively by the micro catheter coronary target vessels.After the operation, 3 groups were injected intravenously tirofiban(0.15 μg·kg-1·min-1), nicorandil(8 mg/h), tirofiban(0.15 μg·kg-1·min-1)plus nicorandil(8 mg/h) for 24 h, respectively.The thrombolysis in myocardial infarction(TIMI) blood flow grade of infarction related artery, corrected TIMI frame count(cTFC), TIMI myocardial perfusion grade(TMPG) before and at the end of PPCI operations, the ST-segment resolution(STR) rate 90 min after operations, creatine kinase isoenzyme-MB(CK-MB) and cardiac troponin-I(cTnI) before operations and those peak volume after operations, n-terminal pro-brain natriuretic peptide(NTproBNP), wall motion score index(WMSI), left ventricular ejection fraction(LVEF), the incidence of intraoperative malignant arrhythmia, hypotension, bleeding and major adverse cardiac events(MACEs) after operations were observed and recorded.Results Compared with N group and T group, the cTFC frames and the peak volume of CK-MB and cTnI after PPCI, and NTproBNP and WMSI 1 week after operations in T+N group were significantly decreased(P<0.05), but the proportion of TIMI 3 grade and TMPG 3 grade after operations, the STR rate 90 min after operations and the LVEF 1 week after operations in T+N group were significantly higher(P<0.05).There was no significant difference in the above indice between N group and T group(P>0.05).The incidence of malignant arrhythmia rate in N group or T+N group was lower than that in T group(P<0.05).Conclusion Target coronary intravascular injection of nicorandil combined with tirofiban after NRP occurred can safely and effectively treat the occurrence of NRP during PPCI operation in acute STEMI patients, and improve the level of myocardial perfusion and heart function.

Objective To evaluate the effect of intra-articular injection of ropivacaine mesylate alone,or combination with dezocine,or with sufentanil,or with dezocine and sufentanil for postoperative analgesia after arthroscopic knee surgery.Methods One hundred and twenty consecutive patients underwent selective unilateral arthroscopic meniscectomy in the Third Hospital of Hebei Medical University from November 2014 to January 2016 were selected as the participants and divided into 4 groups,group L,group LD,group LF,and group LDF with 30 in each by using the random number table.For postoperative analgesia,group L,group LD,group LF,and group LDF were given intra-articular injection of ropivacaine mesylate 178.8 mg,ropivacaine mesylate 178.8 mg plus dezocine 10 mg,ropivacaine mesylate 178.8 mg plus sufentanil 10 μg,and ropivacaine mesylate 178.8 mg plus dezocine 5 mg plus sufentanil 5 μg,respectively after the surgery but 10 min before releasing the thigh tourniquet.We recorded the Visual Analogue Scale (VAS) scores measured before the surgery in steady and dynamic(bipedal standing,flexing knee at 90°) states and those measured at 2,4 h and at 6,12,and 24 h after the surgery in steady and dynamic states;Bruggrmann Comfort Scale(BCS) scores evaluated before the surgery and at 2,4,6,12 and 24 h after the surgery;Ramsay Sedation Scale (RSS) scores evaluated before the surgery and at 2,4,6,12 and 24 h after the surgery and the calculated appropriate sedation rate(RSS scores of 2-3 points are considered as the appropriate sedation);the time that the patient first required readministration of analgesics;the dosage of the readministered analgesics within 24 h after the surgery;the time required to restore unassisted ambulation;patient satisfaction with analgesia;and situation of postoperative adverse reactions(nausea score,vomiting score,incidences of dizziness,urinary retention,pruritus and respiratory depression and so on).Results Analgesia method and administration time of analgesics exerted significant interaction effects on steady and dynamic VAS scores and BCS scores(P<0.05).Analgesia method had main effects on steady and dynamic VAS scores and BCS scores(P<0.05).There were no significant differences in the appropriate sedation rates among four groups at 2,4,24 h after surgery(P>0.05).There were significant differences in the appropriate sedation rates among four groups at 6,12 h after surgery(P<0.05).The appropriate sedation rates both at 6 and 12 h after surgery were higher in group LDF than in group L (P<0.05).Four groups displayed remarkable differences in terms of the time that the patient first required readministration of analgesics,the dosage of the readministered analgesics within 24 h after the surgery,the time required to restore unassisted ambulation,patient satisfaction with analgesia,nausea score,vomiting score,incidences of dizziness,and overall incidence of adverse reactions(P<0.05).Conclusion All the 4 analgesia methods can relieve the pain after arthroscopic knee surgery,but the mixture of 3 drugs injected intra-articularly provides better analgesia effects with less side effects.

Natural killer (NK)cells are the key component of the innate immunity system,which kill target cells non-specifically and directly or activate the specific immunity by regulating the activation of other immune cells through secretion of cytokines or chemotactic factors.Under physiological condition,NK cells are tolerant to normal tissues and cells.This balance depends on the interaction of NK cells' diverse surface receptors with major histocompatibility complex(MHC) class Ⅰ molecules in the specific settings.However,not all NK cells express inhibitory receptors that recognize MHC class Ⅰ proteins on the cell surface of self-tissues.NK cell development is important in the induction of immune tolerance.The related studies are of great significance to clinical applications.