目的 探讨丹参酮ⅡA磺酸钠注射液(ST-ⅡA-S)治疗老年急性冠状动脉综合征(Acute coronary syndrome,ACS)患者的临床疗效及作用机制.方法 选取2017年7月—2020年6月期间在北京市第一中西医结合医院就诊的118例老年ACS患者为研究对象,采用随机数字表法分为观察组和对照组,每组各59例.对照组予以常规治疗,观察组在常规治疗基础上加用ST-ⅡA-S治疗.两组患者均治疗2周后,比较两组患者治疗前后炎症因子[超敏C反应蛋白(High sensitive C-reactive protein,hs-CRP)、白细胞介素-6(Interleukin-6,IL-6)、肿瘤坏死因子-α(Tumor Necrosis Factor-α,TNF-α)],氧化应激指标[基质金属蛋白酶-9(Matrix metalloprotei-nase-9,MMP-9)、同型半胱氨酸(Homocysteine,Hcy)、脂质过氧化物(Lipid Peroxidation,LPO)、丙二醛(Malondial-dehyde,MDA)、超氧化物歧化酶(Superoxide dismutase,SOD)],免疫指标[免疫球蛋白IgA(Immunoglobin A,IgA)、IgG(Immunoglobin G,IgG)、IgM(Immunoglobin M,IgM)]及心肌损伤标志物[N末端脑钠肽前体(N-terminal pro-brain nitric peptide,NT-proBNP)、肌钙蛋白I(Troponin I,TnI)]水平变化,并评估临床疗效及安全性.结果 治疗后观察组总有效率93.22％(55/59)明显优于对照组79.66％(47/59),差异有统计学意义(P<0.05).两组患者治疗后hs-CRP、TNF-α、IL-6、MMP-9、Hcy、LPO、MDA、IgA、IgG、IgM、NT-proBNP、TnI水平均较治疗前下降,SOD水平较治疗前升高,差异有统计学意义(P<0.05);且观察组hs-CRP、TNF-α、IL-6、MMP-9、Hcy、LPO、MDA、IgA、IgG、IgM、NT-proBNP、TnI指标水平均较对照组明显下降,SOD水平较对照组明显升高,差异有统计学意义(P<0.05).治疗期间,两组患者不良反应发生率比较,差异无统计学意义(P>0.05).结论 ST-ⅡA-S能减轻老年ACS患者炎症及氧化应激反应,改善免疫功能,下调心肌损伤标志物水平,临床效果较好,安全性高.

重症新冠肺炎与一般重症肺炎在临床特征和病理生理机制方面存在明显不同,严重免疫系统损伤和多器官功能受累是其突出的临床特征,呼吸系统损伤只是其病理生理的一个侧面,因此在临床救治中应重视新型冠状病毒感染的特殊性,在强调氧气疗法和呼吸机支持治疗的同时,应突出免疫调节治疗和其他重要器官支持治疗的优先地位,尽早开始应用免疫干预方法和血液净化改善内环境等器官支持措施.这对未来重症新冠肺炎患者的救治有重要指导意义.

本文探讨了危重病治疗中肺脏的非呼吸功能,主要内容有肺还是个造血器官,有约一半以上的血小板都在肺中产生;肺是药物的代谢和转化器官,药物的作用需经过肺的转化才能入动脉血达靶器官;源自静脉血液中的有毒物质最先在肺过滤和清除,肺也是易损伤器官;肺与肠道菌群密切联系,两者的双向作用和免疫联系,以及在危重病营养治疗中的意义,应引起临床重视.认识肺的非呼吸功能对危重病的治疗有重要指导意义.

在急性主动脉综合征中,主动脉夹层(AD)一旦破裂可导致患者迅速致死,被称为人体内的"不定时炸弹".主动脉壁间血肿(IMH),同属于主动脉综合征,却较少提及[1].事实上,主动脉IMH稍有不慎便可进展为主动脉破裂,可能比AD更加凶险.IMH是指血肿位于主动脉管壁内,没有内膜撕裂口,是AD的一种特殊类型或典型AD的前期病变,其主要危险是进展为经典AD,造成主动脉瘤或破裂,乃至猝死.临床多数IMH患者胸痛表现与AD或急性心肌梗死相似,但部分可呈不典型表现,诊断困难,极易误诊误治[2],现报道3例疑难主动脉壁间血肿患者,复习相关文献,以探讨其诊断策略.

本文借鉴SARS病毒感染分型系统,建议将新型冠状病毒感染可分为隐匿型(已诊断、未诊断2个亚型)、顿挫型、轻症肺炎型、重症肺炎型、危重症肺炎型5个类型;或者隐匿型(已诊断、未诊断2个亚型)、顿挫型、肺炎型(轻症、重症、危重症3个亚型)3大类型.其中,轻症肺炎型、重症肺炎型和危重症肺炎型3个类型,分别对应目前通用分类的"普通型"、"重型"和"危重型".新型冠状病毒感染新的临床分型,强调了显性感染和隐形感染的区别,弥补了传统分型不能覆盖部分临床患者的缺陷,兼顾了临床特征中病情轻重和有无肺炎2个诊断维度,提出了未诊断感染者的隐匿亚型,对未来新型冠状病毒防控具有重要意义.

为深入解读实验室检查的临床意义,本文诠释了实验室检查结果临床分析的五重境界:通常情况下判断正常与异常是最基本的层面,临床怀疑检验误差时应进行复检,所遵循的数学原理是“均数回归现象”;敏感性与特异性的理解为第二重;熟练运用阳性预测值和阴性预测值指导临床为第三重,血常规、尿常规、肌钙蛋白、降钙素原、C反应蛋白、脑钠肽及D二聚体均为阴性预测值很高的指标,是临床诊断的方向性指标——“北斗七星”;用Bayes定理解释实验室检查结果为第四重境界;第五重境界则是用药代动力学等类似原理解读实验室指标的动态变化曲线,并结合患者基本病情、重要器官功能及局部组织循环情况等因素进行综合的立体分析.这提示临床医师应立体、多维地解读每份实验室检查.

本文对13种淹溺病理生理机制进行解析,主要内容有神经反射、呼吸衰竭、低渗状态、高渗状态、酸碱失衡、胃进水、毛细血管渗漏综合征、体温过低、过敏反应、氯气中毒、癫痫发作、颈髓损伤、和减压病;深入理解其病理生理,对淹溺的急救有重要的指导意义.

Objective:To observe the effect of Jiuni Decoction on left heart function and quality of life in patients with acute myocardial infarction.Methods:110 patients were randomly divided into two groups.The control group was treated with routine treatment and interventional therapy.The observation group was treated with Jiuni Decoction on the basis of the control group,and the differences of left heart function,quality of life and TCM syndrome scores were compared between the two groups before and after treatment.Results:After treatment,LVEDVI,LVESVI,LVDd,and LVDs of both groups were significantly lower than before treatment and improvement in observation group were better than control group.After treatment,IVSd,LVPWd,LVEF,and LVMI of both groups were significantly lower than before treatment and obvious improvement was observed in the observation group compared with the control group (P＜ 0.05).After treatmeut,the dimensions of quality of life were significandy improved,and in the observation group and the total scores of physiological function,body pain,general health,mental health,health changes,improved significantly compared with the control group (P ＜ 0.05).After treatment,the TCM syndrome scores were significantly lower than those before treatment,and the observation group improved significantly compared with the control group (P＜0.05).Conclusion:Jiuni Decoction can improve the left heart function and increase the quality of life in patients with heart-blood stasis type acute myocardial infarction.

Objective To investigate the therapeutic effect of cinepazide maleate on patients with acute myocardial infarction and the effect on the hs-CRP and IL-6 level.Methods Retrospective analysis of clinical data of patients with acute myocardial infarction from August 2014 to May 2016 in the hospital, according to the treatment methods, they were divided into cinepazide treatment group and conventional treatment group.The therapeutic effect of two groups were observed, and the differences of inflammatory factors,heart rate variability and cardiac function were compared between the two groups before and after treatment.Results The clinical effective rate of cinepazide treatment group was 96.9%, which was significantly higher than that of the conventional treatment group 87.1%(X2=4.528,P=0.033);Before treatment, the levels of IL-6 and hs-CRP were not significantly different between the 2 groups (t=0.738,t=-0.132,P=0.231,P=0.448);after treatment, the cinepazide treatment group was lower than the conventional treatment group (t=7.706,t=8.291,P<0.01);Two groups of patients before treatment of heart rate variability levels have no significant difference (P>0.05),after treatment, the cinepazide treatment group's SDNN, SDANN, RMSSD and PNN50 (%) were higher than the control group (t=-6.299,t=-4.657,t=-7.744,t=-6.947,P<0.01);before treatment the level of SV, NT-proBNP,CTnI,SV and LVEF levels were had no significant differences between the 2 groups (t=0.036,t=0.687,t=0.057,t=0.085,P>0.05);after treatment, the cinepazide treatment group's SV and LVEF were higher than the control group (t=-5.992,t=-5.940,P<0.01), NT-proBNP, CTnI in the cinepazide treatment were lower than the conventional treatment group (t=57.370,t=17.407,P<0.01).Two groups of patients during the treatment showed no adverse reactions such as liver and kidney damage.Conclusion Cinepazide has better therapeutic effect on patients with acute myocardial infarction, it can significantly improve cardiac function and reduce hs-CRP and IL-6 level.

Objective To investigate the relationship of pneumonia severity index (PSI) and etiology of patients with community-acquired pneumonia (CAP),in order to provide a basis for empirical antibiotic therapy in emergency.Methods The clinical data of patients with CAP admitted to the Emergency Department of Beijing First Hospital of Integrated Chinese and Western Medicine were retrospectively analyzed.The patients were divided into low risk group and high risk group according to PSI.The data including gender,age,history of disease,etiology and prognosis were compared among groups.The correlations between PSI score and etiology were analyzed.Results A total of 367 patients with CAP were enrolled with 197 low risk group and 170 high risk group,and the 30-day mortality was 21.8％ (80/367).The age and proportion of men in high-risk groups were significantly higher than those in low-risk groups.The history of diabetes,cerebrovascular history,cardiovascular disease,and the prevalence of tumors in high-risk groups were significantly higher than those in the low-risk group.The most common strain of the low-risk group was mycoplasma (P ＜ 0.0301),The high-risk groups were more likely to see KNP (P =0.039) and P.Aeruginosa,There was no significant difference between the two groups of streptococcus pneumoniae and other pathogens.Mortality of High-risk group was significantly higher than those in the low-risk group (44.7％ vs.2％,P ＜ 0.001).The most deaths occurred in patients with pneumococcus pneumoniae,pseudomonas aeruginosa,pneumoniae pneumoniae,and patients who had no positive findings.Conclusions The different risk stratification of patients with community-acquired pneumonia has different pathogen profiles.