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Abstract:西方恩格尔提出生物-心理-社会医学模式已33年,至今模式转变推进迟缓.一是模式与医务人员实施模式的理论与能力缺乏的矛盾;二是人群中心身疾病的的比例及其程度与现有医疗卫生资源滞后的矛盾.恩格斯[1]说:"不管自然科学家采取什么样的态度,他们还得受哲学的支配."……

Abstract:Objective To investigate the risk factors of complication of depressive symptoms in elderly patients with cardiovascular diseases(CVD).Methods A total of 482 elderly individuals who received routine physical examinations were enrolled,among whom,416 with definite CVD and 66 without CVD.The depressive symptoms in all subjects were investigated with questionaire of the Geriatric Depression Scale.The relationship between depressive symptoms and coronary heart disease(CHD),arrhythmia,and hypertension were analyzed.Results The depressive symptoms were significantly more frequently in subjects with CVD than those without CVD(P=0.01,OR=7.619,95%CI 1.826-31.785).The elderly CVD patients had a higher depressive symptoms complication proportion with the age increasing(P<0.01).The elderly CVD patients had a higher frequency of depressive symptoms in those with CHD than without CHD(P<0.01).Conclusion The elderly CVD patients have a higher frequency of depressive symptoms than the age-matched controls,and the symptoms increase in an age-dependent manner.?更多

Abstract:Objective To examine the risk factors and outcome of post-stoke depression(PSD)and to analyze the personality of the elderly PSD patients using Minnesota Multiphasic Personality Inventory.Methods A total of 160 elderly PSD patients were analyzed retrospectively.The risk factors were analyzed using logistic regression analysis.The personality of the elderly PSD patients was also assessed.Results The scores on personalities of suspicion and depression were significantly different between PSD and non-PSD cases(P<0.05),which were positively Correlated with PSD in the elderly cases.Spouse support,PSD sites,mini-mental status examination,and National Institutes of Health stroke scale were associated with PSD in the elderly.Rankin score and Bathel index between PSD and non-PSD patients were significantly different(P<0.05).Conclusion The personalities of suspicion and depression are predominant in the elderly PSD patients.No spouse support,lesion of anterior circulation,cognitive disorder,and severe stoke are risk factors for PSD in the elderly cases.PSD in the elderly cases postpones hospitalization duration and predicts worse clinical outcome.

Abstract:Objective To investigate the influence of intensive intervention on cadiovascular disease(CVD) in community-dwelling elderly with hypertension or complicated by abnormal lipid metabolism.Methods A cluster sample of 1 215 subjects from 2 different communities in Nanning city were randomly categorized into intensive intervention group and control group.The intensive intervention group received different treatment regimens according to the corresponding disorders,and the control group kept normal medical situation,including seeking medical advice and taking medicine voluntarily.After 43.5 months follow-up,CVD occurrence were recorded.Results After 43.5 months follow-up,the systolic and diastolic blood pressure decreased significantly in both intensive intervention group and control group(P<0.01).There were a total of 40 cases(4.0%) who developed CVD in both groups,among them,there were more patients with hypertension than without hypertension(6.9% vs 2.9%,(χ2=9.004,P=0.003,OR = 2.492,95%CI 1.349-4.601).There were less patients who developed CVD in intensive intervention group than in control group(χ2=4.729 and 6.822,P=0.03 and 0.009,OR=2.645 and 3.438,95%CI 1.006-6.562 and 1.296-9.118).Conclusion Hypertension is a high-risk factor in community-dwelling elderly;both the routine and intensive intervention can significantly decrease the blood pressure of the cases of hypertension or those complicated by abnormal lipid metabolism.Compared with the non-intensive intervention,the intensive intervention can more effectively reduce the occurrence of CVD in community-dwelling elderly.

Abstract:Objective To monitor the changes in plasma levels of brain natriuretic peptides(BNP),procalcitonin(PCT),monocyte human leukocyte antigen DR(HLA-DR) and acute physiology and chronic health evaluation(APACHE) Ⅲ score in elderly patients with septic shock,and to evaluate the clinical significance.Methods The above indices were measured before and at one week after resuscitation in 62 elderly patients with septic shock.Results At one week after resuscitation,the plasma levels of BNP,PCT,and APACHE Ⅲ score showed a significant decreasing tendency,and the expression of HLA-DR a significant increasing tendency in 8 patients(resuscitation successful group)(P<0.05).The plasma levels of BNP,PCT,and APACHE Ⅲ score showed a significant increasing tendency,and the expression of HLA-DR a significant decreasing tendency in 42 patients(resuscitation failure group).Twelve patients died(death group);among them,the level of plasma BNP reached more than 4000 ng/L in 3 patients and more than 3000 ng/L in 7 patients on the day of death.There was significant difference in plasma BNP level and APACHE Ⅲ score(P<0.05),and no difference in PCT and HLA-DR(P>0.05)among the 3 groups.Conclusion In elderly patients with septic shock,the higher plasma BNP level predicates poorer prognosis.Plasma BNP level might be an strong predicator for treatment effciency evaluation and prognosis of septic shock in the elderly patients.?更多

Abstract:Objective To explore the relationship of cytokines and glucocorticoids levels with prognosis in elderly septic patients.Methods Teh serum levels of interleukin-6(IL-6),tumor necrosis factor-α(TNF-α),IL-10,corticosteroid(Cor),and adrenocorticotrophic hormone(ACTH) were measured in 42 elderly septic patients and 30 healthy elderly controls using ELISA and radioimmunoassay before and 1 week after treatments.Results Levels of IL-6,TNF-α and ACTH increased significantly in elderly septic patients compared with controls.Cor and IL-10 levels had no significant difference between the two groups.One week after treatments,15 patients died.Levels of IL-6,TNF-α and ACTH were significantly higher,but levels of Cor and IL-10 significantly lower in dead patients than in survival patients.Conclusion Elderly septic patients with higher inflammatory cytokines and lower Cor and IL-10 levels after treatment have poor prognosis.?更多

Abstract:Objective To determine the morphological characteristics of hypertrophic obstructive cardiomyopathy(HOCM) patients by left ventriculography.Methods A total of 74 patients with hypertrophic cardiomyopathy(HCM),who got a definite diagnosis by ventriculography and ultrasonography,were enrolled.The patients with left ventricular outflow tract pressure gradient ≥ 30 mmHg was categorized as HOCM group,those ≤30 mmHg as hypertrophic nonobstructive cardiomyopathy(HNCM) group.The morphological characteristics and ventriculographic results were compared between the two groups.Results(1) In 74 patients,there were 14 cases(18.9%) of HOCM(6 cases of systolic anterior motion,3 cases of coronary heart disease) and 60 cases(81.1%) of HNCM(11 cases complicated by coronary heart disease).(2) Ultrasonography showed that left ventricular(LV) septal wall thickness was(11.4±2.5) mm,posterior wall thickness(9.8±1.7) mm,LV end-diastolic inner diameter(LVEDD)(48±5) mm,left atrial(LA) anterior posterior diameter(36±5) mm.(3) Left ventriculography demonstrated that LV end-diastolic volume(LVEDV) was(123±31) ml,LV end-systolic volume(LVESV)(27±11) ml,LV ejection fraction(LVEF)(78±6)%.(4) According to morphological characteristics revealed by left ventriculography,there were 14 cases of HOCM,including 5 cases with normal LV structure,and 60 cases of HNCM,including 27 cases with normal LV structure.Conclusion There is no significant difference between HNCM and HOCM groups in LVEDD,LVEDV,LVESV,LVEF,and number of cases with normal LV morphological characteristics.

Abstract:Objective To evaluate the therapeutic efficiency and safety of metformin in non-obese elderly patients with type 2 diabetes mellitus(T2DM).Methods A total of 228 elderly T2DM patients admitted in Chinese PLA General Hospital between January 1996 and September 2006 were analyzed retrospectively.The changes in fasting blood glucose(FBG),post blood glucose(PBG),HbA1c,blood lipid level,liver and kidney function,blood lactic acid and body mass before and after metformin administration were compared between obese and non-obese patients.Results The levels of FBG,PBG,HbA1c,total cholesterol(TC),and low density lipoprotein cholesterol(LDL-C) in both obese and non-obese patients were all significantly reduced after metformin treatment(P<0.01),but with no difference between the two groups.Body mass,body mass index(BMI),and the level of triglycerides(TG)were significantly reduced after metformin treatment in both groups,more significantly in obese group than in non-obese group(P<0.01).The liver and kidney function had no significant change after treatment.No lactic acidosis was reported.Conclusion Metformin treatment is effective and safe in both obese and non-obese elderly T2MD patients.

Abstract:Objective To evaluate the impact of the myocardial reperfusion status after percutaneous coronary intervention(PCI) on improvement of left ventricular function in acute myocardial infarction patients by intracoronary myocardial contrast echocardiography(MCE).Methods Eighteen acute myocardial infarction patients were selected and injected with SonoVue via left main or right coronary artery before and 15 minutes after PCI respectively.MCE images were visually valued with score on the perfusion situation of segmental myocardial regions.Left ventricular function in all patients was evaluated at 1 month after PCI.The perfusion score index(PSI) and wall motion score index(WMSI) were calculated by definite formulae.Results Among 30 myocardial segments with PSI as 0 before PCI,there were 20(66.7%) had the WMSI of 3-5 at 1 month after PCI.Among 11 myocardial segments with PSI as 2 before PCI,there were 8(72.7%) had the WMSI of 1-2 at 1 month after PCI.Statistical analysis showed that the level of myocardial reperfusion before PCI was related to the postoperative 1-month status of left ventricular segmental wall motion(P<0.05).Among 12 myocardial segments with PSI as 0 after PCI,there were 11(91.7%) had the WMSI of 3-5 at 1 month after PCI.Among 22 myocardial segments with PSI as 2 after PCI,there were 17(77.2%) had the WMSI of 1-2 at 1 month after PCI.Statistical analysis showed that the level of myocardial reperfusion after PCI was also related to the 1-month status of left ventricular segmental wall motion(P<0.01),and was obviously associated with left ventricular systolic function at 1 month after PCI(P<0.01).Conclusion The myocardial reperfusion status affects the improvement of left ventricular function after PCI in AMI patients.Intracoronary MCE can estimate the level of myocardial perfusion and left ventricular function.It might have the predictive value on clinical prognosis.

Abstract:Objective To evaluate the change in Th1/Th2 related cytokines in the peripheral blood of patients with acute coronary syndrome(ACS),and to determine its roles in assessing the development of the lesion.Methods Sixty-four ACS patients were selected,including 22 patients with acute myocardial infarction(AMI),and 42 patients with unstable angina pectoris(UAP).Another 34 patients with stable angina pectoris(SAP) and 22 healthy persons served as controls.Serum concentrations of Th1/Th2 cytokines,such as IFN-γ,IL-2,IL-4,and IL-10 were measured.All patients underwent coronary angiography(CAG).Results The level of Th1 cytokines,including IFN-γ and IL-2,was elevated in patients with UAP and AMI compared to that with SAP and healthy controls.The level of Th2 cytokines,including IL-4 and IL-10,was decreased in patients with UAP and AMI compared to that with SAP and healthy controls.Compared with the type Ⅰ lesion,patients with type Ⅱ lesions showed higher in-gate percentage of Th1 cytokines and lower in-gate percentage of Th1 cytokines.Conclusion The imbalance of Th1/Th2 cytokines is correlated with the development of ACS,which could be useful for monitoring the stabilization of the lesion.?更多

Abstract:Objective To compare the therapeutic effects of high volume hemofiltration(HVHF) and coupled plasma filtration absorption(CPFA) on sepsis patients with multiple organ dysfunction syndromes(MODS) or multiple organ failure in the elderly(MOFE).Methods Fourteen sepsis patients complicated with MODS were enrolled and randomly divided into HVHF and CPFA groups.The two groups respectively received 10 h of HVHF or CPFA treatment.The primary endpoints were changes in hemodynamic effects,electrolytes and acid-base balance,sepsis-related organ failure assessment(SOFA) score and acute physiology and chronic health evaluation Ⅱ(APACHEⅡ) score after pulse HVHF or CPFA.Results(1) After the therapies,blood urea nitrogen(BUN) and serum creatinine(Cr) all significantly decreased,electrolytes and acid-base balance were well maintained,and no visible influence was found in white blood cell count,platelet or hematocrit.(2) After CPFA,SOFA score and APACHEⅡscore decreased dramatically(P<0.05),mean arterial pressure(MAP) and oxygenation index(PaO2/FiO2) showed significant improvement(P<0.05).However,after HVHF,only SOFA score was markedly decreased(P<0.05),no significant differences were found in MAP,oxygenation index or APACHEⅡ score(P>0.05).(3) No therapy related adverse reactions such as hemorrhage,hypersensitiveness or embolism were noted even in the aged during the two treatments.(4) Seven days after therapies,4 patients survived in the HVHF group and 6 survived in the CPFA group.Conclusion Both HVHF and CPFA therapies improve the clinical manifestations of sepsis patients with MODS,and the effect of CPFA is superior to HVHF.

Abstract:Objective To explore the association between job stress and myocardial infarction.Methods A total of 260 subjects were investigated,including 164 cases of myocardial infarction and 96 controls.In this case-control study,job stress in the past career was measured by effort-reward imbalance(ERI) model,and coronary heart disease was diagnosed by combination of clinical manifestation and angiography.The association between job stress and myocardial infarction was explored by the multivariate analysis.Results Compared with the baseline,high effort,high ERI or high overcommitment increased the risk of myocardial infarction.The odds ratio(OR) was 2.4(95%CI 1.2-5.2),2.8(95%CI 1.3-6.1),and 2.7(95%CI 1.2-5.8),respectively,after adjustment for age,gender,primary hypertension,hyperlipidemia,diabetes mellitus,family history of coronary heart disease,smoking,body mass index,education and marriage.The combination of high ERI and high overcommitment led to the highest risk of coronary heart disease with adjusted OR 4.9(95%CI 1.7-14.2).Job stress affected the risk of myocardial infarction in a dose-dependent manner.Conclusion Job stress increases the risk of myocardial infarction,and it is probably a new potential important risk factor of myocardial infarction.?更多

Abstract:Objective To investigate the clinical features of silent myocardial ischemia(SMI) in elderly patients with coronary heart disease(CHD) and the unfavorable prognostic factors for recurrent heart events,such as acute myocardial infarction(AMI) or sudden cardiac death(SCD).Methods A total of 216 elderly CHD patients with SMI were followed up for 2-7(mean 5.01) years.The clinical features,including age,gender,systemic hypertension,diabetes mellitus,hyperlipidemia,smoking,history of myocardial infarction,complex ventricular arrhythmia attack,left ventricular hypertrophy,frequency and ischemia duration of SMI,and degree of ST segment depression,as well as Holtor′s parameters,were recorded.The occurrence of AMI and SCD were also noted.Results There were 27 patients who sufferred AMI or SCD at the end of follow-up.The accumulative incidence of recurrent heart events was 14.54% during 7-year follow-up.Cox multivariable regression analysis showed that age,left ventricular hypertrophy,history of myocardial infarction,and hyperlipidemia were independent risk factors for recurrent heart events.Conclusion It would be helpful to improve the prognosis of elderly CHD patients with SMI to remove or alleviate these negative prognostic factors.

Abstract:Objective To evaluate the predictive value of the maximum(Pmax) and minimum(Pmin) P-wave durations for paroxysmal atrial fibrillation(PAF).Methods Ninety consecutive inpatients with heart diseases who underwent 12-lead Holter monitoring during the period of January 2008 to October 2008 were retrospectively collected.There were 32 patients with PAF and 58 with non-atrial fibrillation(NAF).The Pmax,Pmin and clinical characteristics were compared between the two groups.Results The Pmax and average 24-h heart rate were significantly higher in PAF group than in NAF group((114±15)vs(104±11) ms,P<0.01;(89±25) vs(74±15) beats/min,P<0.01).There was no significant difference in Pmin between PAF and NAF groups.After adjustment for other covariates,it was shown that higher Pmax and average ventricular heart rate were the independent risk factors of PAF in inpatients with heart diseases.Conclusion Higher Pmax and average ventricular heart rate in 12-lead Holter monitoring are reliable predictors for the risk of PAF in inpatients with heart disease.

Abstract:Objective To study the clinical features of obstructive sleep apnea hypopnea syndrome(OSAHS) in the elderly by comparison with the young or middle-aged OSAHS patients.Methods Randomly selected 161 OSAHS patients were divided into elderly group(n=72) and young or middle-aged control group(n=89).The clinical data and polysomnographic parameters were compared between the two groups.The therapy options for the patients,followed by phone calls,were also compared between the two groups.Results The apnea hypopnea index(AHI),the lowest oxygen saturation,and oxygen desaturation index(ODI) were significantly lower in elderly group than in body mass index-matched young or middle-aged controls(P<0.05).The systolic blood pressure was higher,but the diastolic blood pressure and heart rate were lower in elderly group than in young or middle-aged controls(P<0.05).In elderly OSAHS patients,blood pressure was positively associated with AHI,ODI,and arousal index.The acceptance of surgery and oral appliances in elderly OSAHS patients was significantly lower than that in young or middle-aged controls(P<0.01),but the acceptance of continuous positive airway pressure was not significantly different between the two groups(P>0.05).Conclusion The elderly patients suffer less severe OSAHS than young or middle-aged patients.AHI,ODI,and arousal index may be related to the increased blood pressure of elderly OSAHS.The elderly OSAHS patients have lower acceptance of surgery and oral appliances compared with young and middle-aged controls.

Abstract:Objective To investigate the molecular mechanism and characteristics of atrial electrical remodeling parameters in atrial fibrillation(AF) model using monophasic action potential(MAP).Methods Seventeen mongrel dogs were randomly divided into two groups.Eleven dogs were subjected to rapid right atrial pacing(350-430 beats/min) for 8 weeks(AF group),and another 6 sham-operated dogs served as controls.Before and after 8 weeks pacing,electrophysiological examinations were performed to calculate atrial effective refractory period(AERP).The MAP amplitude(MAPA),duration(MAPD),90% repolarization duration(MAPD90),50% repolarization(MAPD50) and MAPD90-50 were measured according to MAP recordings.The content of myocardial calcium was assayed by spectrocomparator in atrial myocardium from all dogs.The messenger ribonucleic acid(mRNA) level of sarcoplasmic reticular(SR) Ca2+-ATPase and L-type calcium channel were measured by reverse transcription-polymerase chain reaction(RT-PCR) and normalized to the mRNA level of β-actin.Results Each phase of MAP was easily discerned in control dogs.Morphology of MAP was significantly changed in AF group.Compared with control group,MAPA of AF group had a tendency to decrease.MAPD,MAPD90,MAPD50 and MAPD90-50 were shortened by 16.20%,19.65%,13.59% and 31.25%,respectively.MAPD,MAPD90 and MAPD90-50 were negatively correlated to the content of calcium in right atrial myocardium.MAPD90-50 was positively correlated to the mRNA level of L-type calcium channel.All parameters had no relation to mRNA level of SR Ca2+-ATPase.Conclusion MAP provides a reliable method to investigate atrial fibrillation electrical remodeling.Changes in L-type calcium channel and SR Ca2+-ATPase may be one of the mechanism of atrial electrical remodeling.

Abstract:Objective To explore the protective effects of L-arginine(L-Arg) on the myocardial tissue of diabetic rats.Methods The rat models of diabetes mellitus(DM)(n=28) were made by intraperitoneal injection of streptozotocin(60 mg/kg),and allocated into DM group(n=14) and L-Arg treatment group(300 mg/(kg·d))(L-Arg group)(n=14) at random.Another 12 normal rats served as normal control group(NC group).After 12 weeks,the rats were sacrificed.Morphological changes in myocardium in 3 groups were observed under transmission electromicroscope(TEM).The mRNA expression levels of endothelial nitric oxide synthase(eNOS),inducible NOS(iNOS) and endothelin(ET-1) in myocardial tissue were determined by reverse transcription polymerase chain reaction(RT-PCR).The activity of eNOS,iNOS,Na+-K+-ATPase,Ca2+-ATPase and the content of NO,ET-1 in myocardial homogenate were also determined.Results In DM rats,TEM examination showed the lysis of myofibril,dilation of sarcoplasmic reticulum and swelling of mitochondria of myocardial tissue.Compared with NC rats,the mRNA expression level of eNOS and the activity of Na+-K+-ATPase,Ca2+-ATPase,as well as the NO content decreased,but the mRNA expression and content of ET-1 increased in DM rats.The pathological changes in myocardium induced by intraperitoneal injection of streptozotocin were reversed in L-Arg group.Compared with DM rats,the mRNA expression level of eNOS,the activity of Na+-K+-ATPase,Ca2+-ATPase and the content of NO increased,but the mRNA expression and content of ET-1 decreased in L-Arg group.Conclusion L-Arg exerts protective effects on diabetic myocardium,which may be through increasing the NO content and decreasing the ET-1 content,so as to improve the blood supply of myocardial tissue.

Abstract:Objective To evaluate the effects of 17β-estradiol(E2)-eluting stents on neointimal proliferation of abdominal aortas in high fat diet fed rabbits and to investigate the possible mechanism.Methods Male high fat diet fed rabbits received implantation of 17β-E2-eluting stents,or control phosphorylcholine coated stents or bare metal stents into abdominal aortas as control groups.Histology,immunohistochemistry and Western blot analysis were used to assess the inhibitive effects of E2-eluting stents on neointimal proliferation and and the possible mechanism.Results Western blot analysis revealed marked increase in ERK phosphorylation in 30 min after deployment of phosphorylcholine-coated or bare metal stents,indicating activation of MAP kinase pathway.Immunohistochemistry showed intense staining of phospho-ERK in the medial smooth muscle cells in stent-implanted region.Extensive neointimal hyperplasia developed 12 weeks after stenting.Neointimal area decreased by 36% in E2-eluting stent-implanted animals compared to bare metal stent-implanted animals.In E2-eluting stent-implanted animals,significant inhibition of ERK phosphorylation and neointimal thickening were observed and immunohistochemistry of factor Ⅷ-related antigen demonstrated an accelerated re-endothelialization as compared to the bare metal stent or phosphorylcholine-coated stent-implanted controls.Conclusion E2-eluting stents reduce neointimal proliferation and hence prevent restenosis after angioplasty,possibly by inhibiting ERK activation in smooth muscle cells and promoting re-endothelialization.?更多

Abstract:1病历摘要患者男性,83岁,因间断心前区不适30余年,加重月余于2009年12月29日入院。患者劳力时出现心前区疼痛30余年,为闷痛或刺痛,伴大汗,休息或含服硝酸甘油明显缓解,每年发作10余次,未诊治。1个月前无诱因出现餐后或劳力时心前区压迫性疼痛,伴胸闷、恶心及双侧肩部酸痛,休息或含服硝酸甘油后数分钟缓解,每天数次发作。有高血压、高血脂症等病史。不嗜烟酒。有高血压和冠心病的家族史。查体:血压130/70 mmHg,脉搏70次/min,呼吸18次/min,心界不大,心率70次/min,心律齐,各瓣膜区未闻及杂音及附加心音,双下肢无水肿,腹部及神经系统查体未见异常。辅助检查:肝肾功能、电解质正常

Abstract:华法林作为最常用的口服抗凝药物,广泛应用于慢性心房颤动、静脉血栓、肺栓塞,及心脏瓣膜置换术后等的抗凝治疗中.然而,由于华法林有效治疗剂量的范围狭窄和在个体间差异显著.加之剂量过高会导致严重出血的危险,华法林在临床上的应用受到了极大地限制.如何安全有效地应用华法林,使之达到最佳治疗效果.一直是心血管领域研究的热点和亟待解决的难题.近年来,对华法林的药物基因组学研究发现,决定华法林代谢和作用的两个主要候选基因CYP2C9和VKORC1的遗传变异型,很大程度上决定了华法林有效抗凝治疗剂量的个体问差异.本文总结了CYP2C9和VKORC1的基因变异型对华法林剂量的影响.还对近年来通过结合基因和临床因素建立的华法林剂量计算模型对预测有效华法林剂量和副作用的意义进行了综述.

Abstract:2型糖尿病是一组以慢性血葡萄糖水平升高为特征的代谢疾病群,会导致多系统的损害,上世纪20年代,Mile和Root首先报道糖尿病影响认知功能,1965年Nielsen提出"糖尿病性脑病"的概念,进一步阐述糖尿病会影响神经系统.