目的 观察老年髋部骨折患者术后1周内给予唑来膦酸(zoledronic acid,ZOL)治疗对骨代谢标志物的影响.方法 收集2015年5～12月北京积水潭医院收治的99例老年髋部骨折患者的临床资料,分为ZOL组(n=55)和对照组(n=44).于用药前、用药后2周 ～1个月、用药后1～3个月、用药后3～6个月、用药后6～9个月、用药后≥9个月6个时间点检测患者血清总Ⅰ型胶原氨基末端前肽(total procollagen typeⅠamino terminal peptide,tPINP)、碱性磷酸酶(alkaline phosphatase,ALP)、Ⅰ型胶原羧基端肽 β特殊序列(β-isomerized C-terminal telopeptides,β-CTX)、血清骨钙素(osteocalcin,OC)、25-羟基维生素D3、甲状旁腺激素及血钙、血磷水平,比较两组骨代谢标志物特点及变化差异.结果 ZOL组在用药后2周 ～1个月 β-CTX及OC均值出现下降,且用药2周后的5个检测点两指标均数皆显著低于对照组(P均<0.05);ZOL组tPINP及ALP均数在用药后2周 ～1个月出现波峰消失(P<0.05),且用药后2周 ～6个月的3个检测点两指标均数皆显著低于对照组(P<0.05),25-羟基维生素D3、甲状旁腺激素及血钙、血磷组间比较,差异无统计学意义.结论 老年髋部骨折患者术后早期输注ZOL,可出现骨吸收及骨转换水平迅速、显著而且持久的抑制;术后骨形成高峰呈"消减"表现,但对骨形成的抑制作用于6个月后不再显著.上述骨代谢标志物变化特点未见显著的性别差异.ZOL对骨代谢的持续作用有待更长时间的随访观察.

目的 随着北京市空气质量的改善以及新冠疫情对呼吸道慢病管理与个人卫生习惯的影响,有必要对近年来医院慢性阻塞性肺疾病(COPD)入院患者的变化趋势及预后影响因素进行回顾性分析,为临床工作提供数据参考.方法 登录北京市生态环境监测中心官网,收集北京市2015～2020年度细颗粒物(PM2.5)、可吸入颗粒物(PM10.0)、二氧化硫(SO2)、二氧化氮(NO2)以及累计优良天数的公共数据信息;调取2015年1月～2020年12月北京积水潭医院诊断为COPD伴或不伴急性加重/肺部感染的所有病例(共1493例),进行回顾性研究.结果 COPD入院人数以12月至次年2月最多,之后逐步下降,7月达谷值;就年度变化趋势而言,从2017年开始COPD入院人数出现下降,2020年出现显著下降.相关性分析显示入院人数与空气质量指标PM2.5、PM10.0、SO2、NO2水平以及累计优良天数均呈显著相关(P＜0.05),COPD入院病死率从2018年呈现显著下降,入院病死率与PM2.5、PM100、NO2显著相关(P＜0.05);出院组与死亡组的年龄、日常生活能力评分(Barthel指数)、住院天数、存在慢性心功能不全、房颤、慢性肾功能不全、低蛋白血症7个变量比较,差异有统计学意义(P＜0.05).多因素logistic回归分析显示,NO2、房颤、慢性肾功能不全为COPD患者不良预后的独立危险因素(P＜0.05),入院时Barthel指数为其保护因素(P＜0.05).受试者工作特征曲线显示,入院时Barthel指数为37.5是不良预后的最佳风险预测截断值,特异度为75.5％,灵敏度为74.5％.结论 COPD疾病发展及预后与空气质量及个人卫生防护习惯相关.同时,日常生活能力评分(Barthel指数)可作为疾病风险预测特异性及敏感性均较好的指标,而合并肾功能不全及房颤的COPD患者临床应给予足够重视,避免不良预后.

目的 探讨阿仑膦酸钠和唑来膦酸治疗原发性骨质疏松症的疗效,以及骨转换标志物(BTMs)作为骨质疏松症药物疗效观察指标的优势.方法 收集2017年1月至2019年3月在北京积水潭医院骨质疏松症门诊就诊的原发性骨质疏松患者,64例患者纳入本研究,并按照随机数字表法分为阿仑膦酸盐组(ALN组,34例)和唑来膦酸盐组(ZOL组,30例)接受治疗.所有患者在就诊期间都完成了数据采集,包括一般临床情况、BTMs和骨密度(BMD)水平等.在使用抗骨质疏松药物3～6个月时,均重新检查BTMs,1年时检查BTMs和BMD水平.结果 ALN组和ZOL组的组间年龄和性别与治疗前肝肾功能、BTMs、BMD比较,均差异无统计学意义;治疗3～6个月,两组BTMs均下降,ALN组BTMs治疗有效率高于ZOL组[Ⅰ型胶原交联C-末端肽(CTX):(0.18±0.13)μg/L比(0.20±0.16)μg/L,P=0.56;Ⅰ型原胶原N-端前肽(P1NP):(23.46±11.33)μg/L比(22.98±10.10)μg/L,P=0.86;骨钙素(OC):(12.82±4.20)μg/L比(12.65±4.90)μg/L,P=0.88].治疗1年,ALN组BTMs治疗有效率继续升高,ZOL组则下降[CTX:(0.15±0.08)μg/L比(0.21±0.17)μg/L,P=0.04;P1NP:(20.05±10.26)μg/L比(26.14±11.61)μg/L,P=0.03;OC:(10.53±3.06)μg/L比(12.62±5.40)μg/L,P=0.07].两组BMD较原始值均增加(P≤0.05),BMD治疗有效率ALD组低于ZOL组.结论 ZOL对骨密度的改善作用优于ALN.BTMs水平显示,ZOL的作用相对更快,而ALN的作用更平缓、持续时间更长.对于接受唑来膦酸治疗的患者,建议下次治疗前应及时复查BTMs,必要时适当缩短治疗间隔.

目的 探讨纤维支气管镜吸痰联合肺泡灌洗对高龄慢性阻塞性肺疾病(COPD)合并重症肺炎患者的临床疗效.方法 回顾性分析北京积水潭医院2018年6月至2020年9月收治的62例高龄COPD合并重症肺炎患者的临床资料.其中行抗感染,雾化吸入,按需吸痰管吸痰,维持水、电解质、酸碱平衡及营养支持等常规对症治疗32例(对照组),在常规对症治疗基础上接受纤维支气管镜吸痰联合肺泡灌洗治疗30例(观察组).比较2组治疗前和治疗5 d后血气分析指标[动脉血氧分压(PaO2)、氧合指数、动脉血二氧化碳分压(PaCO2)、乳酸]和炎症因子[白细胞计数(WBC)、C反应蛋白、降钙素原]水平,痰菌阳性率和临床疗效.结果 治疗前,2组动脉血气分析指标水平比较差异均无统计学意义(均P＞0.05);治疗后2组PaO2均高于治疗前、且观察组高于对照组[(74±8)mmHg(1 mmHg=0.133 kPa)比(66±8)mmHg],PaCO2和乳酸水平均低于治疗前、且观察组均低于对照组[(38±8)mmHg比(46±9)mmHg,(1.3±0.9)mmol/L比(1.9±l.l)mmol/L];治疗后观察组氧合指数高于本组治疗前和对照组[(269±82)比(196±74)、(189±90)](均P＜0.05).治疗前,2组WBC、C反应蛋白和降钙素原水平比较差异均无统计学意义(均P＞0.05);治疗后2组WBC和C反应蛋白水平均低于治疗前、且观察组均低于对照组,治疗后观察组降钙素原水平低于本组治疗前和对照组(均P＜0.05).观察组痰菌阳性率和总有效率均高于对照组[93.3％(28/30)比59.4％(19/32),93.3％(28/30)比62.5％(20/32)](均 P＜0.05).结论 纤维支气管镜吸痰联合肺泡灌洗治疗可有效改善高龄COPD合并重症肺炎患者氧合情况,减轻机体炎症反应,提高痰菌阳性率和疗效.

Objective To understand changes and characteristics of bone mineral density(BMD)and early-stage bone turnover biochemical markers in elderly hip fracture patients of different genders.Methods This was a retrospective cohort study.A total of 1 161 elderly patients with hip fractures hospitalized in Beijing Jishuitan Hospital from May 2015 to December 2017 were enrolled.Based on gender,patients were divided into the female group (n =831) and the male group (n =330).Clinical data,BMD,serum type Ⅰ procollagen amino terminal propeptide(P1NP),and 25-hydroxyvitamin D3 [25-(OH) VD3],type Ⅰ collagen cross linked carboxy terminal peptide beta degradation products (β-CTX),osteocalcin(OC)and parathyroid hormone(PTH)were measured and compared between the two groups.Results Of the 1 161 elderly patients with hip fractures,831 were female and 330 were male.The BMD of the lumbar vertebrae and the total hip in the female and male groups showed that 30.4％(353/1 161)and 6.8％(79/1 161)had T≥-1.0 SD respectively;36.6％ (425/1 161)and 44.7％(519/1 161)had-2.5 SD＜T＜-1.0 SD;and 33.0％(383/1 161)and 48.5％(563/1 161)had T≤-2.5 SD respectively.The sensitivity of the hip BMD T value was better than that of lumbar vertebrae(P＜0.05).Female BMD was significantly lower than that of male BMD(P＜0.05).The BMD T values,which were significantly related to age,were recorded at the femoral neck and the total hip(femoral neck was better than total hip)for males and at total hip(the total hip T value is the most strongly related index) for females;(2) In the early stage of elderly hip fractures,25-(OH) VD3 was significantly lower than normal,and bone resorption and bone formation indexes were not significantly increased(P＞0.05).The levels of tP1NP,β-CTX,OC and PTH in females were higher than those in males,and the level of 25-(OH)VD3 was lower than that in males(all P ＜ 0.05).As the T value decreased,β-CTX and OC increased and 25-(OH)VD3 decreased accordingly (all P ＜ 0.05).Conclusions With the increase of age,the BMD T value in elderly patients with hip fractures shows a downward trend,but its decline in women is faster and earlier.Overall,the BMD T value is not sensitive enough for osteoporosis diagnosis or hip fracture prediction in the elderly,especially in men.In the early stage of fractures,the bone turnover biochemical markers show varying degrees of change,and bone resorption and bone formation are both reduced.The significance of OC,β-CTX and VD levels in early bone metabolic abnormalities requires further study.

目的 通过对老年髋部骨折病例分析,了解老年髋部骨折患者致伤因素,为预防髋部骨折提供依据.方法 收集北京积水潭医院2015年9月1日至2016年8月31日老年髋部骨折住院病例570例,按照年龄、性别等对致伤因素进行分析.结果 老年髋部骨折病例中男性167例(29. 3%),女性403例(70. 7%),平均年龄79. 5岁(60～100岁).老年髋部骨折患者中94. 9%为低应力骨折,且随着年龄增长脆性骨折比例逐步升高;骨折地点随着年龄增高逐步由户外为主转为室内为主;患者在户外及室内客厅发生髋部骨折的时间段均以白天为主(8:00～20:00),卧室及卫生间发生髋部骨折的时间段均以晚上为主(20:00～6:00);髋部骨折地域不同,摔倒的主要原因亦有不同;570例患者中95. 1%合并基础疾病,随着年龄的增长合并多种基础疾病的比例也逐步升高;多元回归分析进一步得出,存在呼吸系统基础疾病、中重度营养不良以及患者基础疾病数量是髋部骨折后新发急性疾病严重程度的独立危险因素.结论 老年髋部骨折致伤原因包括自身因素、药物因素以及环境因素等多方面,医疗工作人员应做好预防摔倒宣教、积极控制基础疾病、纠正骨质疏松,以期降低髋部骨折风险.

目的 探讨高龄男性慢性阻塞性肺疾病(COPD)患者的骨密度情况及相关影响因素.方法 选择北京积水潭医院老年科2019年1月～2019年6月门诊或病房诊治的47例高龄男性COPD稳定期患者为研宄对象.采集患者基本信息、血常规、生化、C反应蛋白(CRP)、血气分析、糖化血红蛋白、VitD水平,腰椎、髋部骨密度测定及肺功能检查.结果 47例COPD患者平均年龄(84.89±5.21)岁,BMI(24.06±2.04)kg/m2,有吸烟史者63.83％,吸烟指数平均417.02±60.06,戒烟比例87.2％,正在使用吸入激素的比例为17.02％;25(OH)D3(11.723±5.60)ng/ml、CRP(6.15±3.330)mg/L;腰椎总体骨密度值为(1.393±0.256)g/cm2,T值为0.862±0.192;髋部总体骨密度值为(0.950±0.198)g/cm2,T值为-0.321±0.522;FEV1％(63.383±7.061)％,FEV1/FVC(57.021±7.078)％,DLCO％(71.511±5.247)％,FVC％(82.96±10.61)％,RV/TLC(58.787±7.014)％;血气分析PaCO2(39.264±3.792)mmHg,PaO2(76.017±9.446)mmHg;logistic回归分析以腰椎总体骨密度值为因变量分析得出BMI减低、CRP升高、VitD缺乏、FVC％减低及DLCO％减低均为高龄COPD患者骨密度下降的独立危险因素;以髋部总体骨密度值为因变量分析得出增龄、吸入激素、白蛋白减低、VitD缺乏、RV/TLC升高及DLCO％减低均为高龄COPD患者骨密度下降的独立危险因素.结论 高龄男性COPD患者存在增龄、VitD缺乏、营养状况不佳及激素使用等致骨密度减低的独立危险因素,临床上应做好早期筛查及诊治工作.与此同时稳定期C RP水平、阻塞性通气功能障碍及肺气肿严重程度、肺弥散功能均与其骨密度减低独立相关,提示COPD与骨代谢之间可能存在多途径的相互作用机制,有待进一步研究.

说到慢性阻塞性肺病(简称慢阻肺、COPD)可能一些老年人并不十分了解,可"老慢支""气管炎""肺气肿"等呼吸道疾病表述其实都是慢阻肺的常见表现.慢阻肺是以持续气流受限与高气道炎症反应为特征的、可预防和可治疗的疾病,多为慢性支气管炎、肺气肿进展致肺功能明显损减的特定阶段.

目的 探讨血清胆碱酯酶(S-ChE)、C反应蛋白( CRP)在老年肺部感染患者诊断及预后评估中的价值.方法 选取2016—2018年于北京积水潭医院干部科接受治疗的200例肺部感染患者纳入B组,选取同期体检的无肺部感染的健康老年体检者200例纳入A组.根据临床肺部感染(CPIS)评分将B组患者分为评分＞6分组(n=128)与评分≤6分组( n=72)两个亚组.根据治疗后30 d内患者病情严重程度将B组患者分为好转组( n=159)与死亡组( n=41)两个亚组.比较各组患者血清S-ChE、CRP水平.根据Pearson相关性检验分析血清S-ChE、CRP水平与老年肺部感染患者病情严重程度的相关性.分析血清S-ChE、CRP及S-ChE联合CRP在老年肺部感染患者预后评估的价值.结果 B组血清S-ChE水平明显低于A组,CRP水平明显高于A组,两组比较,差异均有统计学意义( P＜0.05).评分≤6分组血清S-ChE水平明显高于评分＞6分组,CRP水平明显低于评分＞6分组,两组比较,差异均有统计学意义(P＜0.05).好转组血清S-ChE水平明显高于死亡组,CRP水平明显低于死亡组,两组比较,差异均有统计学意义(P＜0.05).血清S-ChE水平与病情严重程度呈负相关,CRP水平与病情严重程度呈正相关(P＜0.05).结论 老年肺部感染患者血清S-ChE水平明显降低,CRP水平明显升高,其对患者诊断及预后评估均具有一定价值.

Objective To investigate the clinical characteristics and risk factors for pulmonary infection in elderly patients with hip fracture after the treatment through a model of orthopedic-geriatric co-care,in order to provide prevention and control strategies.Methods Clinical data and laboratory results of elderly patients with hip fractures admitted into our hospital from January 2016 to May 2016 were collected.The differences in treatment outcome and adverse reactions were retrospectively compared between the two groups of patients with versus without pulmonary infection,and univariate and multivariate analysis of lung infection were performed.Results Of 207 patients,43 were infected with pneumonia and 164 were not.The proportion of patients with the time interval＜48 h from admission to surgery was 48.6％ (86/177),and the time interval＜ 1 week from admission to surgery was 98.9％ (175/177).The average length of hospital stay was(7.9±3.5)days.There was no significant difference in the time interval from admission to surgery,the time spent on surgery,length of hospital stay,surgical procedure and inflammatory indicators between the pneumonia and non-pneumonia groups.Univariate analysis showed that advanced age,multiple primary diseases,primary lung diseases,chronic respiratory failure,cerebrovascular disease,sequelae of cerebrovascular disease,immune system disease or long-term oral hormone therapy and preoperative anemia were risk factors for pulmonary infection in elderly patients with hip fracture (P ＜ 0.05 or＜ 0.01).Multivariate regression analysis showed that advanced age(OR =1.239,95％ CI:1.016 ～ 1.595,P =0.051),preoperative anemia(OR =2.491,95％ CI:1.148～ 5.403,P =0.021),sequelae of cerebrovascular disease (OR =3.987,95％ CI:1.354 ～11.741,P=0.012),primary lung diseases(OR =4.404,95％ CI:1.800 ～ 11.078,P =0.001) and immune system diseases (OR =17.166,95 ％ CI:1.750 ～ 168.409,P =0.015) were independent risk factors for pulmonary infection in elderly patients with hip fracture.Conclusions The orthopedic-geriatric co-care model seems to be in favour of controlling the progress of pulmonary infection in elderly patients with hip fracture,and to shorten waiting time before surgery and length of hospital stay.However,advanced age and chronic diseases are unpreventable risk factors for pulmonary infection in elderly patients with hip fractures.Clinicians should pay attention to the high-risk population and take prevention and control strategies to prevent the occurrence and development of lung infections.

系统性硬化症(systemic sclerosis,SSc)是一种少见的,以机体免疫功能异常、皮肤和内脏器官纤维化及闭塞性血管病变为特点,多系统受累的自身免疫性疾病。好发于40~50岁女性。晚发型 SSc 指首次出现雷诺现象的系统性硬化年龄≥75岁,亦有研究设定其界值为≥65岁[1-2]。与早发型 SSc 相比,晚发型 SSc 临床罕见,国际鲜有报道,合并消化道出血者更是未见文献报道。我们报告1例92岁起病、以消化道出血为首诊表现的晚发型 SSc 病例,并就晚发型 SSc 的临床、实验室特点及国际研究进展进行文献回顾,以供临床医护人员鉴别参考。

目的 探讨老年长期卧床患者继发肺部感染的临床及病原学特点,以及影响预后的独立危险因素.方法 回顾性分析2013年4月1日～ 2014年4月1日因肺部感染入院的、患者年龄≥65岁、卧床时间＞3个月的患者,共58例,分为低龄老年组(≤80岁)及高龄老年组(＞ 80岁),比较组间临床及实验室等特点的差异;并对肺部感染预后的相关危险因素进行多因素回归分析.结果 58例患者男女性别比为34∶24,患者平均年龄80±8岁,卧床时间中位数为12个月,病死率13.8％ (8/58).100％的患者有新发咳嗽咳痰或原有咳嗽咳痰加重,临床起病以低热为主(30例,55.6％),入院1周内谵妄、显性呛咳比例分别为53.4％ (31/58)及58.6％ (34/58).入院后首次化验显示高龄组CRP及动脉血二氧化碳分压(PaCO2)均高于低龄组,而血肌酐水平低于正常范围及高于正常范围的比例均高于低龄组.影像学以双侧渗出为主(37例,63.8％).致病细菌中,G-杆菌感染居首位(46例,79.3％),G+球菌次之(11例,19％).真菌感染31例(53.4％),白假丝酵母菌最常见(19例,61.3％).多因素回归分析显示,有COPD病史、入院前已留置导尿、入院后血肌酐水平高于正常、首次动脉血pH＞ 7.446、首次动脉血氧分压(PaO2)＜79mmHg、入院后需肠外营养支持、合并真菌感染及双肺受累是长期卧床老年患者继发肺部感染预后不佳的独立危险因素.结论 老年长期卧床患者继发肺部感染的发生率、病死率高,加之临床特点不典型容易漏诊或延迟诊断,临床医师应尽可能做到及早发现、严密监测并有针对性地给予相应治疗.

目的 探讨老年重症肺炎患者血小板减少与应用利奈唑胺是否相关.方法 调查1例重症肺炎患者抢救过程中的治疗及临床资料,该患者在肺炎加重期与恢复期分别两次应用利奈唑胺,期间监测血小板计数,并观察其变化.结果 患者第1次应用利奈唑胺抗感染时是炎症反应高峰期,期间维持呼吸机辅助呼吸,血小板计数已有下降,同时合并肾功能不全、呼吸衰竭等,应用利奈唑胺6d后血小板计数进一步下降为60×109/L,停用利奈唑胺改用替考拉宁治疗,4d后血小板仍继续下降至39×109/L,经输注血小板及随病情好转血小板恢复至正常;血小板恢复正常28d后由于感染未完全控制,第2次应用利奈唑胺,治疗11d 血小板均正常.结论 重症肺炎患者应用利奈唑胺与出现血小板计数下降并不是简单的因果关系,而是与全身的感染状况密切相关,此时药物的选择及是否需要停药等应综合考虑患者各方面情况,同时密切监测血小板计数以便适时停药.

随着起搏器治疗的广泛开展及起搏器功能的日趋完善,其手术适应证不断扩大,接受人群也日益壮大,其中相当一部分为血栓事件的高风险患者,围术期继续应用抗凝抗血小板药物有可能增加起搏器植入术中及术后的出血风险,而如果停用上述药物,又可能导致严重的血栓事件.围术期能否应用这些药物、如何合理选择用药方案一直是学术界讨论的热点话题,至今尚未形成统一的临床共识.介于此,笔者介绍1例起搏器植入术后抗凝抗血小板治疗致囊袋出血的病例,并就起搏器植入围术期抗凝抗血小板药物的使用问题进行文献回顾.

Objective A systematic analysis on the clinical features,natural history,diagnosis and treatment experience of isolated persistent left superior vena cava(PLSVC) was done.Methods Collected the symptoms succession and nearly 21 years of examination and detection data of one 78-year old case with isolated PLSVC,then did a comparative analysis.Results The case was without positive symptoms until 57-year-old,which was sinus bradycardia.Dual-chamber pacemaker was implanted due to the sick sinus syndrome 11 years ago,before implantation,examinations showed leukocytes,and reduction of platelets,PLSVC was found during the surgery.Seven years ago,the performances of abdominal venous congestion were visualized,and 5 years ago,he was presented to clinics due to severe tricuspid regurgitation and right ventricular dysfunction.Three months ago,his chest enhanced CT+ 3D cardiovascular reconstruction cleared the abnormalities of isolated PLSVC.Conclusion The delayed occurrence of isolated PLSVC symptoms motivates misdiagnosis of this malformation,whose first manifestation is often kinds of arrhythmias.Tricuspid systolic murmur could be found quite early.Echocardiography is the preferred screening method,cardiac catheterization or enhanced CT+3D cardiovascular reconstruction could manifested it.The treatments of cardiac arrhythmias include pacemaker implantation and coronary sinus target ablation.Some patients required early surgical treatment,at advanced stage,heart transplantation may be considered.