末期老年住院患者多重用药及药物重整调查

目的分析末期老年住院患者临床特点及用药情况。方法采用老年人1年内死亡率预测指数评分,入选2015年1月至2017年12月北京协和医院老年医学科病房≥70岁的末期老年患者99例,收集并分析患者慢性病、老年综合征特点、入院带药种数、经药物重整后出院带药种数及患心脑血管疾病的末期老年患者用药情况。应用SPSS 21.0统计软件对数据进行分析。根据数据类型,组间比较采用t检验或McNemar配对χ~2检验。结果 99例患者1年内死亡率预测指数7～16(9.8±2.3)分。患者慢性病占比前3位依次为恶性肿瘤(76.8%)、高血压(56.6%)及冠心病(39.4%),前3位老年综合征依次为多重用药(出院带药≥5种,72.7%)、营养不良或营养风险(72. 7%)及便秘(45. 4%)。入院时患者用药数(4. 7±3. 7)种,药物重整后出院带药数显著增加,为(7. 4±3. 9)种,其中维生素、通便药、镇痛药、呼吸系统药、抑酸药、铁剂及抗抑郁药等对症药物的使用率显著增加,对因药物降压药使用率显著降低,差异均有统计学意义(P0. 05)。患有心脑血管疾病的48例患者出院时52.1%(25/48)使用抗血小板药,66. 7%(32/48)使用他汀类药物。23例因出血风险较高,或存在活动性出血未使用抗血小板药; 16例患者主要因失能、他汀类药物相关不良反应风险高、新发肌痛或新发肝功能异常未使用他汀类药物。结论末期老年患者经药物重整后对症治疗药物使用率增加,对因药物使用率下降,心血管疾病用药策略需结合患者自身情况合理制定。     

80岁以上高龄老年人主要慢性病的疾病谱调查与分析

目的为加强慢性病管理,针对高龄老年人主要慢性病的疾病谱进行调查,从而为制定相应的保健措施提供基础数据。方法于2012年5月~2014年12月,采用《老年健康综合评估量表》对北京市军队干休所5530例高龄老年人进行调查,其中男性5077例,女性453例,年龄80~104(87.1±3.9)岁。80~84岁老年人2119例(38.3%),85~89岁老年人2370例(42.9%),≥90岁老年人1041例(18.8%)。统计基本信息、慢性病种类及相关生化检查。结果调查对象中,人均慢性病数量为(4.2±2.1)种,患有5~6种慢性病女性高龄老年人的比例明显低于男性(21.0%vs 30.7%,P=0.000)。≥90岁高龄老年人患≥7种(24.9%vs 11.7%、15.0%,P=0.000)、5~6种慢性病(31.6%vs 29.4%、29.7%,P=0.034)的比例明显高于80~84岁、85~89岁人群。高血压、冠心病的患病率超过半数,分别为64.6%和56.8%,共有14种慢性病患病率≥10.0%。结论≥80岁高龄老年人合并多种慢性病情况严重,主要为心脑血管疾病和代谢相关性疾病。     

住院老年糖尿病患者运动功能与衰弱的关系

目的 探讨住院老年糖尿病患者运动功能与衰弱的关系。方法 采用方便抽样，抽取253例年龄≥60岁的住院老年糖尿病患者进行横断面调查，利用衰弱表型(FP)量表将患者分为无衰弱期组(n=70)、衰弱前期组(n=98)和衰弱期组(n=85)。结果 253例患者中无衰弱期70例(27.7%),衰弱前期98例(38.7%),衰弱期85例(33.6%)。运动功能中位得分7(1,23)分，单因素分析显示3组性别、年龄、婚姻、支付方式、吸烟史、饮酒史、体质量指数(BMI)、多重用药、糖尿病并发症、糖化血红蛋白(HbA1c)和运动功能差异有统计学意义(P<0.05);Logistic回归分析显示年龄、HbA1c、运动功能是住院老年糖尿病患者衰弱期的显著危险因素(P<0.05);危险因素的风险诊断效能分析显示年龄≥68.5岁，HbA1c≥8.15%,运动功能得分≥7.5分是住院老年糖尿病患者衰弱危险因素的最佳截断值。结论 建议对年龄≥68岁，HbA1c≥8.15%,运动功能得分≥7.5分的住院老年糖尿病患者进行入院衰弱评估，早期识别衰弱症状，为制定个体化治疗护理方案提供依据。     

通过老年综合评估分析北京市社区老年人的营养状况

目的通过包括微型营养评定简表(MNA-SF)、慢病、生活方式以及其他老年问题的老年综合评估(CGA),了解北京市老年人营养状况及其影响因素。方法对北京市朝阳区4个社区941例≥65岁、同意接受调查的老年人进行面对面调查。结果 4个社区老人年龄(75.8±7.0)岁,中位年龄76岁;体质量指数(BMI)(23.8±4.2)kg/m~2。MNA-SF提示营养不良(0~7分)34例,占3.6%,营养不良风险(8~11分)407例,占43.3%,营养问题总计441例(46.9%)。营养问题的风险因素有:≥85岁(χ~2=9.65,P=0.002)、女性(χ~2=6.82,P=0.01)、单身(χ~2=5.63,P=0.02)、仍工作(χ~2=4.36,P=0.04)、合并≥3种慢病(χ~2=3.71,P=0.05)及患慢性肺病(χ~2=5.21,P=0.02)。结论营养问题是社区常见的老年问题,建议加强教育,将营养筛查与评估纳入常规健康查体,尤其应关注高龄及共病老人。     

老年综合评估在老年高血压患者综合治疗中的应用价值

目的 探讨老年综合评估(CGA)在老年高血压患者综合治疗中的应用价值。方法收集2018年3月至2019年12月永康市永康医院年龄65～85岁的老年高血压患者100例,对照组为同期住院非高血压患者100例,两组均进行老年综合评估。分析老年高血压患者经评估后联合干预治疗2周和单纯药物治疗2周的获益比较。结果 发现高血压组患者在体位性低血压、共病(患病种类≥5种)、多重用药(服用药物≥5种)、生活能力下降、简易精神状态检查≤24分、抑郁、营养不良、跌倒高风险人群、听力障碍、视力障碍方面发生率均高于对照组,差异有统计学意义(χ2=4.153、5.128、5.307、4.568、4.678、8.140、4.421、6.082、6.452、6.095,P 0.05)。在血压达标率、患者满意度、疾病诊断相关分类医疗费用控制方面,联合干预比常规干预有获益(χ2=6.546、13.131、-89.855,P 0.05)。结论 老年高血压患者通过CGA并根据结果进行有效干预,能提高血压控制达标率,提高患者治疗体验满意度、降低治疗费用。     

社区老年慢性病患者多重用药情况及对处方干预的认知分析

目的分析社区老年慢性病患者多重用药情况及对处方干预的认知情况。方法抽取我院2017年6月至2019年6月收治的260例老年慢性病患者,调查相关治疗尤其是用药情况及对处方干预的认知情况。结果260例患者疾病种类平均(7.2±3.5)种。高血压病、高脂血症、冠心病、慢性胃炎、糖尿病是最常见的5种慢性疾病。钙通道阻滞药、非胰岛素类降糖药、作用肾素-血管紧张素系统药物、血脂调节药、抗血小板药是最常用的5种药物。患者用药种类平均(10.0±5.5)种,每天服用药剂量平均(22.0±8.5)片。患者用药完全依从率仅为25.00%。多重用药患者“认为服用药品太多”“希望减少药品”“希望降低药费”“担心药品有副作用”的比率明显高于非多重用药患者(P<0.05)。结论社区老年慢性病患者普遍存在多病共存以及多重用药现象,针对患者积极实施处方干预具有重要的现实意义。     

住院老年慢性肾脏病患者肾脏不适当用药调查及影响因素分析

目的 分析住院老年慢性肾脏病(CKD)患者肾脏不适当用药(RIM)的发生情况及相关影响因素,为临床肾脏合理用药提供依据。方法 回顾性分析2020年1月至2020年12月某大型综合三甲医院748例住院老年CKD患者的临床资料。利用国内外药品说明书、专家共识、用药手册以及Micromedex数据库等药学工具评估RIM的发生情况。采用SPSS 22.0统计软件进行数据分析。采用多因素logistic回归分析影响RIM的危险因素。结果 本研究住院老年CKD患者RIM发生率为50.27%(376/748),共发生RIM 739次。RIM发生频次排名前5的药物类别分别为抗微生物药[46.01%(340/739)]、内分泌系统药[11.77%(87/739)]、泌尿系统药[11.50%(85/739)]、心血管系统药[9.88%(73/739)]及镇痛药[7.31%(54/739)],排名前3的药物品种分别为螺内酯[9.47%(70/739)]、左氧氟沙星[9.34%(69/739)]及头孢哌酮钠舒巴坦钠[7.04%(52/739)]。主要不适当用药情况为肾功能下降时,未调整相关药物剂量。多因素logistic回归分析结果显示,年龄(75~84岁:OR=1.582,95%CI 1.101～2.272,P=0.013;≥85岁:OR=3.026,95%CI 1.532～5.978,P<0.001 ),药物品种数(11~25种:OR=2.379,95%CI 1.500～3.773,P<0.001;＞25种:OR=13.086,95%CI 6.991-24.496,P<0.001),CKD分期(3b期:OR=2.183,95%CI 1.348～3.536,P=0.002;4期:OR=4.287,95%CI 2.485～7.395,P<0.001;5期:OR=4.779,95%CI 2.984～7.654,P<0.001)及查尔森合并症指数(CCI)≥5(OR=2.455,95%CI 1.523～3.957;P<0.001)是患者发生RIM的独立危险因素。结论 老年CKD 住院患者RIM发生率较高,应重点关注年龄≥75岁、药物品种≥11种、CKD分期≥3b以及CCI≥5的老年CKD患者,以减少RIM的发生。     

4036例老年胃癌住院患者心血管代谢性疾病分布特征

目的探讨老年胃癌住院患者中心血管代谢性疾病(CMD)的分布特征。方法回顾性分析2008年5月～2018年3月解放军总医院第一医学中心所有科室收治的老年胃癌住院患者4036例,男性3124例,女性912例,65～74岁2758例、75～84岁1175例及年龄≥85岁103例,将糖尿病、高血压、缺血性心脏病、脑卒中作为主要的CMD纳入分析。结果入选的老年胃癌患者中,CMD 1183例(29.3%),CMD≥2种患者416例(10.3%)。男性已婚、全费、城镇及稳定职业比例明显高于女性(P0.05,P0.01);CMD患病率明显低于女性(28.1%vs 33.3%,P=0.002)。男性与女性CMD病种数量比较,无统计学差异(P=0.134)。65～74岁、75～84岁及≥85岁CMD病种数量比较,有统计学差异(P=0.005)。65～74岁、75～84岁、≥85岁患者CMD患病率存在线性趋势逐渐升高(27.7%vs 32.4%vs 37.9%,P_(趋势)0.01)。糖尿病、高血压、缺血性心脏病、脑卒中患病率分别为11.5%,21.0%,7.3%,1.8%。结论老年胃癌住院患者中有相当比例同时患有≥1种CMD,CMD患病率存在性别差异,且随增龄呈现线性升高的趋势。     

住院老年冠心病患者合并衰弱的患病率及影响因素研究

目的:分析住院老年冠心病患者合并衰弱的患病率及其影响因素。方法:连续入选2017年12月至2018年12月间年龄≥65岁、在北京协和医院老年医学科及心内科住院治疗的冠心病患者364例。运用老年综合评估评价患者的并存疾病及老年综合征,其中衰弱的评估采用临床衰弱评分。采用Logistic回归分析老年冠心病患者合并衰弱的影响因素。结果:364例入选老年冠心病患者中,合并衰弱者87例(23.9%)。合并衰弱患者与非衰弱患者相比,合并衰弱患者的年龄更大[(79.33±6.14)岁vs (73.11±5.79)岁,P0.001],男性比例较低(46.0%vs 64.3%,P=0.002),患急性冠状动脉综合征比例较低(18.4%vs 30.3%,P=0.030),Charlson共病指数更高(2.17±1.63 vs 1.25±1.20,P0.001),长期用药种类更多[(8.01±3.24)种vs (6.90±2.90)种,P=0.003],住院天数更长[(14.07±8.49)天vs(11.84±7.58)天,P=0.034],营养不良(8.0%vs 1.8%,P=0.012)、尿失禁(41.4%vs 16.6%,P0.001)、1年内跌倒史(39.1%vs23.1%,P=0.003)的比例更高。多因素Logistic回归分析显示,年龄(β=0.069, SE=0.030,P=0.020)、步速(β=-4.445,SE=0.953,P0.001)、不能完成全足距测试(β=1.428, SE=0.365,P0.001)、简易营养评估量表(MNA-SF)评分(β=-0.187,SE=0.086,P=0.029),以及Charlson共病指数(β=0.338,SE=0.132,P=0.010)均是老年冠心病患者合并衰弱的影响因素。结论:住院老年冠心病患者合并衰弱患病率较高。衰弱受年龄、步速、不能完成全足距测试、MNA-SF评分以及Charlson共病指数等因素影响,临床医师应重视老年冠心病患者功能状态的评估以及对合并老年综合征及共病的识别与管理。     

药师干预对老年2型糖尿病患者合理用药与血糖水平的影响

目的研究药师干预对老年2型糖尿病患者合理用药与血糖水平的影响。方法抽选2018年3月—2020年3月时间段接收的96例老年2型糖尿病患者,应用统计学奇偶数分组方式将研究对象划分为两组,组别名称为对照组与研究组,对照组应用常规方式对患者进行常规治疗和用药指导,研究组患者在常规治疗基础上应用药师干预,对两组患者合理用药、血糖水平以及血压指标方面的情况进行比较。结果干预后,研究组患者不合理用药发生率(8.3%)显著低于对照组(27.1%),数据比较差异有统计学意义(χ~2=5.790,P=0.016);研究组患者空腹血糖、餐后2 h血糖以及糖化血红蛋白数据分别为(6.21±0.91)mmol/L、(9.08±1.08)mmol/L、(6.11±0.72)%,其数据均显著低于对照组,差异有统计学意义(t=8.795、7.036、7.746,P0.001);研究组患者舒张压与收缩压指标分别为(82.34±3.18)、(124.04±5.71)mmHg,其数据均显著优于对照组,差异有统计学意义(t=7.716、5.979,P0.001)。结论老年2型糖尿病患者以临床治疗为主,借助药师干预方式可以提高临床合理用药程度,有助于维持血糖与血压水平的稳定。     

Three layer functional model and energy exchange concept of aging process

Relying on a certain degree of abstraction, we can propose that no particular distinction exists between animate or living matter and inanimate matter. While focusing attention on some specifics, the dividing line between the two can be drawn. The most apparent distinction is in the level of structural and functional organization with the dissimilar streams of ‘energy flow’ between the observed entity and the surrounding environment. In essence, living matter is created from inanimate matter which is organized to contain internal intense energy processes and maintain lower intensity energy exchange processes with the environment. Taking internal and external energy processes into account, we contend in this paper that living matter can be referred to as matter of dissipative structure, with this structure assumed to be a common quality of all living creatures and living matter in general. Interruption of internal energy conversion processes and terminating the controlled energy exchange with the environment leads to degeneration of dissipative structure and reduction of the same to inanimate matter, (gas, liquid and/or solid inanimate substances), and ultimately what can be called ‘death.’ This concept of what we call dissipative nature can be extended from living organisms to social groups of animals, to mankind. An analogy based on the organization of matter provides a basis for a functional model of living entities. The models relies on the parallels among the three central structures of any cell (nucleus, cytoplasm and outer membrane) and the human body (central organs, body fluids along with the connective tissues, and external skin integument). This three-part structural organization may be observed almost universally in nature. It can be observed from the atomic structure to the planetary and intergalactic organizations. This similarity is corroborated by the membrane theory applied to living organisms. According to the energy nature of living matter and the proposed functional model, the decreased integrity of a human body's external envelope membrane is a first cause of the structural degradation and aging of the entire organism. The aging process than progresses externally to internally, as in single cell organisms, suggesting that much of the efforts towards the restoration and maintenance of the mechanisms responsible for structural development should be focused accordingly, on the membrane, i.e., the skin. Numerous reports indicate that all parts of the human body, like: bones, blood with blood vessels, muscles, skin, and so on, have some ability for restoration. Therefore, actual revival of not only aging tissue of the human body's membrane, but the entire human body enclosed within, with all internal organs, might be expected. We assess several aging theories within the context of our model and provide suggestions on how to activate the body's own anti-aging mechanisms and increase longevity. This paper presents some analogies and some distinctions that exist between the living dissipative structure matter and inanimate matter, discusses the aging process and proposes certain aging reversal solutions.     

Unusual responses of nocturnal pineal melatonin synthesis and secretion to swimming: Attempts to define mechanisms

Abstract: The effect of swimming at night on rat pineal melatonin synthesis was compared with that of light exposure at night. Rats were forced to swim at 0030 hr (lights out at 2000 hr) and sacrificed by decapitation 15 and 30 min later, immediately after swimming. Other groups of animals were exposed to white light (650μW/cm²) for 15 and 30 min at same time. Swimming caused a rapid and highly significant drop in the melatonin content in the pineal gland; however, the activity of N-acetyltransferase (NAT), the supposed rate limiting enzyme in the melatonin production, was not changed. Despite the drop in pineal melatonin levels, serum concentrations of the indole remained elevated in the rats that swam. In contrast, melatonin levels in the pineal and serum of light exposed rats fell precipitously, accompanied by a significant suppression of NAT activity. Since we anticipated that the strenuous exercise associated with swimming may induce release of artrial natriuretic peptide (ANP) from the heart, which in turn could cause the release of pineal melatonin, in a second study we injected physiological saline intravenously to stretch the cardiac muscle and release ANP. Three milliliters of normal saline was injected during the day into the jugular vein of anesthetized rats that were pretreated with isoproterenol to stimulate pineal melatonin production. Animals were killed 15 min after the saline injection, and pineal NAT activity and pineal melatonin levels were measured. The saline injections caused no alteration in the elevated levels of either NAT or melatonin. These data suggest that the disparity in pineal NAT activity (which was high) and pineal melatonin (which was low), in animals swum at night, may not be caused by ANP which is released during strenuous exercise such as swimming.     

Melatonin and photoperiodic time measurement: Seasonal breeding in the sheep

Abstract: Well-established circadian physiology supports the view that photoperiodic time measurement utilizes the coincidence between the presence of light and a photosensitive phase of a 'biological clock' to alter reproductive status—the so-called external coincidence model of seasonal breeding. In this review, we examine the mechanism whereby photoperiod interacts with presumed suprachiasmatic nuclei activity to allow endogenous melatonin to normally synchronize reproductive activity to the optimal time of year. The Romney Marsh sheep is particularly explored as an experimental model. It is suggested that the on/off activity of seasonal reproduction may be a robust mechanism able to be predictably manipulated by the judicious use of the light/dark cycle and exogenous melatonin, but firmly based on circadian principles.     

The immunoneuroendocrine role of melatonin

Abstract: A tight, physiological link between the pineal gland and the immune system is emerging from a series of experimental studies. This link might reflect the evolutionary connection between self-recognition and reproduction. Pinealectomy or other experimental methods which inhibit melatonin synthesis and secretion induce a state of immunodepression which is counteracted by melatonin. In general, melatonin seems to have an immunoenhancing effect that is particularly apparent in immunodepressive states. The negative effect of acute stress or immunosuppressive pharmacological treatments on various immune parameters are counteracted by melatonin. It seems important to note that one of the main targets of melatonin is the thymus, i.e., the central organ of the immune system. The clinical use of melatonin as an immunotherapeutic agent seems promising in primary and secondary immunodeficiencies as well as in cancer immunotherapy. The immunoenhancing action of melatonin seems to be mediated by T-helper cell-derived opioid peptides as well as by lymphokines and, perhaps, by pituitary hormones. Melatonin-induced-immuno-opioids (MHO) and lymphokines imply the presence of specific binding sites or melatonin receptors on cells of the immune system. On the other hand, lymphokines such as -γ-interferon and interleukin-2 as well as thymic hormones can modulate the synthesis of melatonin in the pineal gland. The pineal gland might thus be viewed as the crux of a sophisticated immunoneuroendocrine network which functions as an unconscious, diffuse sensory organ.     

Serological survey of HIV and syphilis in pregnant women in Madagascar

Objectives Peripartal transmission of human immunodeficiency virus (HIV) and Treponema pallidum, the causative agent of syphilis, leads to severe consequences for newborns. Preventive measures require awareness of the maternal infection. Although HIV and syphilis testing in Madagascar could be theoretically carried out within the framework of the national pregnancy follow‐up scheme, the required test kits are rarely available at peripheral health centres. In this study, we screened blood samples of pregnant Madagascan women for HIV and syphilis seroprevalence to estimate the demand for systemic screening in pregnancy. Methods Retrospective anonymous serological analysis for HIV and syphilis was performed in plasma samples from 1232 pregnant women that were taken between May and July 2010 in Ambositra, Ifanadiana, Manakara, Mananjary, Moramanga and Tsiroanomandidy (Madagascar) during pregnancy follow‐up. Screening was based on Treponema pallidum haemagglutination tests for syphilis and rapid tests for HIV, with confirmation of positive screening results on line assays. Results Out of 1232 pregnant women, none were seropositive for HIV and 37 (3%) were seropositive for Treponema pallidum. Conclusions Our findings are in line with previous studies that describe considerable syphilis prevalence in the rural Madagascan population. The results suggest a need for screening to prevent peripartal Treponema pallidum transmission, while HIV is still rare. If they are known, Treponema pallidum infections can be easily, safely and inexpensively treated even in pregnancy to reduce the risk of transmission.     

Conservative management of perforated duodenal diverticulum： A case report and review of the literature

Duodenal diverticula are a relatively common condition. They are asymptomatic, unless they become complicated, with perforation being the rarest but most severe complication. Surgical treatment is the most frequently performed approach. We report the case of a patient with a perforated duodenal diverticulum, which was diagnosed early and treated conservatively with antibiotics and percutaneous drainage of secondary retroperitoneal abscesses. We suggest this method could be an acceptable option for the management of similar cases, provided that the patient is in good general condition and without septic signs.     

Changes in connexin43, the gap junction protein of astrocytes, during development of the rat pineal gland

Abstract: The abundance of gap junctions between rat pineal astrocytes formed by connexin43 (Cx43) was studied during development. Levels and distribution of Cx43 were measured by immunoblotting and indirect immunofluorescence, respectively. The amount of Cx43 in cells located within the gland was low until about the 7th postnatal day and increased to adult values between the 14th and 21st days postpartum. Although astrocytes, recognized by their vimentin immunoreactivity, were scarce before birth, they were abundant by the 7th postnatal day suggesting that the low levels of Cx43 found at this age corresponded to a low expression of this protein. Localization of the immunoreactivity to Cx43 and vimentin showed a close correlation, indicating that mature or immature pineal astrocytes form gap junctions made of Cx43. Since Cx43 levels attained their adult values at about the time the innervation and the functional state of the gland reached maturity (2–3 weeks after birth), it is proposed that astrocyte gap junctions are involved in the function of the adult rat pineal gland.     

Variabilité des concentrations plasmatiques de l’angiotensinogène et risque d’hypertension artérielle chez le rat transgénique

Aim

Genetic polymorphisms of the human angiotensinogen gene are frequent and may induce up to 30% increase of plasma angiotensinogen concentrations with a blood pressure increase of up to 5 mmHg. Their role for the pathogenesis of human arterial hypertension remains unclear. High plasma angiotensinogen levels could increase the sensitivity to other blood pressure stressors.

Methods

Male transgenic rats with a 9-fold increase of plasma angiotensinogen concentrations and male non-transgenic rats aged 10 weeks were treated or not with NG-Nitro-L-arginine-methyl ester for 3 weeks in their drinking water (n = 3/group). Systolic blood pressure and body weight were measured at baseline and at the end of the study when left ventricular weight and ventricular expression of angiotensin I-converting enzyme and procollagen Iα1 were determined (polymerase chain reaction).

Results

At baseline, transgenic rats had +18 mmHg higher bood pressure and –8% lower body weight compared to non-transgenic rats (P < 0.05) without significant changes for the vehicle groups throughout the study (P > 0.05). NG-Nitro-L-arginine-methyl ester increased blood pressure, left ventricular weight and left ventricular weight indexed for body weight by +41%, +17.6% and +18.6% (P < 0.05) in transgenic and +25%, +5.3% and +6.7% (P > 0.05) in non-transgenic rats compared to untreated animals, respectively. Cardiac gene expression showed no differences between groups (P > 0.05).

Conclusion

Increased plasma angiotensinogen levels may sensitize to additional blood pressure stressors. Our preliminary results point towards an independent role of angiotensinogen in the pathogenesis of human hypertension and associated end-organ damage.