【作者】 凌家艳；

【导师】 沈霖；

【作者基本信息】 华中科技大学 ， 中西医结合临床， 2013， 博士

【摘要】 第一部分动脉粥样硬化性血栓性脑梗死患者急性期GPIba和ADAM17的表达目的：探讨动脉粥样硬化性血栓性脑梗死患者急性期GPIba和ADAM17的表达,以及GPIba脱落和AD AM17的关系。方法：306例急性期动脉粥样硬化性血栓性脑梗死病人作为观察组,230例健康人作为对照组,他们在年龄、性别、种族、高血压、糖尿病史方面统计学无明显差异。分别通过流式细胞学、蛋白质印迹、酶联免疫吸附法检测了血小板膜上GPIba、 ADAM17和血浆中的糖盏蛋白(GC)。结果：与对照组相比,动脉粥样硬化血栓性脑梗死患者急性期GPIba的表达明显下降(P=0.000, P<0.01),ADAM17的表达升高(P=0.000,P<0.01),血浆中糖盏蛋白的含量增高,但没有统计学意义(P=0.699,P>0.05)。相关分析显示动脉粥样硬化性血栓性脑梗死患者急性期GPIba与GC没有相关性(r=0.095,P>0.05), GPIba与NIHSS有负相关(r=-0.514,P<0.01)。结论：ADAM17可能是动脉粥样硬化性血栓性脑梗死的危险因素,GPIba可以作为中风严重程度的一个指标。第二部分缺血性中风中经络患者凝血指标与中医证型的关系目的：观察缺血性中风(中经络)患者不同中医证型与凝血指标的关系,为缺血性中风的预防和治疗提供客观依据。方法：306例缺血性中风中经络患者根据《中风病辨证诊断标准》分为五型：风痰瘀阻型、风火上扰型、痰热腑实型、阴虚风动型、气虚血瘀型。230例来自于社区没有中风证据的人作为对照组。抽血检测GPIbα、ADAM17、血小板计数(PLT)、平均血小板体积(MPV)、血小板分布宽度(PDW)、凝血功能和同型半胱氨酸,并比较各证型患者凝血指标的水平及其相关性。结果：(1)缺血性中风中经络病人辨证属风痰瘀阻型102人,占33.33%；风火上扰型68人,占22.22%；痰热腑实型51人,占16.67%；阴虚风动型45人,占14.71%；气虚血瘀型40人,占13.07%。(2)306例病人中,男性147例,占48%,女性159例,占52%,平均年龄为63.30士10.76岁。缺血性中风不同证型之间性别比较,经X2检验差异无显著性(X2=2.758,P>0.05)；各组间年龄经F检验差异无显著性(F=0.227,P=0.923,P>0.05)。(3)各证型之间GPIba经F检验差异有显著性(F=3.737,P=0.006,P<0.01),经LSD法两两比较：气虚血瘀型与风痰瘀阻型、风火上扰型有明显差异(P=0.011,P<0.05; P=0.001, P<0.01),阴虚风动型与风火上扰型有明显差异(P=0.009,P<0.01)。各证型之间ADAM17的表达无显著性差异(F=1.008,P=0.403,P>0.05)。(4)各证型间Hcy经F检验有显著性差异(F=4.613,P=0.001,P<0.01)。风痰瘀阻型与风火上扰型、气虚血瘀型比较有统计学意义(P=0.026,P=0.017,P均<0.05)；风痰瘀阻型与阴虚风动型比较差异有显著性(P=0.000,P<0.01),风痰瘀阻型与痰热腑实型无明显差异(P=0.051,P>0.05)。(5)各证型间MPV经F检验差异有显著性(F=2.503,P=0.042,P<0.05),风痰瘀阻型与风火上扰型、阴虚风动型比较有统计学差异(P=0.01,P=0.015,P均<0.05)。各组间PDW经F检验差异有显著性(F=2.515,P=0.042,P<0.05),风痰瘀阻型与风火上扰型、阴虚风动型比较有统计学差异(P=0.01,P=0.02,P均<0.05),风痰瘀阻型、痰热腑实型与气虚血瘀型比较无统计学意义(P=0.62,P=6.02,P均>0.05)。(6)各证型间PLT、PT、TT、APTT、INR经F检验差异无显著性(P均>0.05)。各组间Fib经F检验有显著性差异(F=14.143,P=0.000,P<0.01),风痰瘀阻型与痰热腑实型、阴虚风动型有显著性差异(P=0.000,P=0.000,P均<0.01)；气虚血瘀型与痰热腑实型、阴虚风动型有显著性差异(P=0.000,P=0.000,P均<0.01)；而风痰瘀阻型、风火上扰型和气虚血瘀型之间无明显差异(P=0.169,P=0.748,P=0.167,P均>0.05)。(7)各证型间D-二聚体经F检验差异有显著性(F=2.962,P=0.02,P<0.05),风痰瘀阻型与风火上扰型、痰热腑实型、阴虚风动型比较有统计学意义(P=0.022,P<0.05；P=0.047,P<0.05; P=0.005, P<0.01);阴虚风动型与气虚血瘀型比较有统计学意义(P=0.038,P<0.05)。(8)缺血性中风中经络患者GPIbα与纤维蛋白原呈明显负相关(r=-0.249,P=0.000,P<0.01)。缺血性中风中经络患者纤维蛋白原和D-二聚体呈正相关(r=0.151,P=0.008,P<0.01)。结论：(1)风痰瘀阻型可能是缺血性中风中经络的主要证型。(2)缺血性中风中经络的证型与年龄、性别、AD AM17, PT、TT、APTT、INR无明显关系,与GPIbα、同型半胱氨酸、D-二聚体、纤维蛋白原、MPV、PDW有关。(3)风火上扰、风痰瘀阻型GPIbα最高；风痰瘀阻型Hcy最高；风痰瘀阻型MPV、 PDW最高；风痰瘀阻型、风火上扰型、气虚血瘀型纤维蛋白原较高；风痰瘀阻型与气虚血瘀型D-二聚体变化最明显。说明风痰瘀阻、痰热腑实、气虚血瘀证与凝血指标的关系密切。(4)缺血性中风中经络患者GPIbα与纤维蛋白原呈明显负相关,纤维蛋白原和D-二聚体呈正相关。更多还原

【Abstract】 Part One:Changes in platelet GPIba and AD AM17in the acute stage of atherosclerotic ischemic strokeObjective:Glycoprotein (GP)Iba ectodomain shedding has important implications for thrombosis and hemostasis. A disintegrin and metalloproteinase17(ADAM17) was identified to play an essential role in agonist induced GPIba shedding. The relationship of GPIba shedding and ADAM17in the acute stage of atherosclerotic ischemic stroke (AIS) patients has not been thoroughly studied.Methods:306patients and230controls matched for age, sex, race, history of hypertension and diabetes mellitus were enrolled in the study. GPIba, ADAM17, glycocalicin (GC) were detected by flow cytometry, western blotting and enzyme-linked immunosorbent assay (ELISA) respectively.Results:Compared with the control group, the expression of GPIba in acute ischemic stroke patients were significantly lower (P=0.000, P<0.01). The amount of plasma glycocalicin and AD AM17were higher than those in control group (P=0.699, P=0.000), and AD AM17showed significant difference. Pearson’s analysis showed glycocalicin had no correlation with GPIba in AIS patients (r=0.095, P>0.05). GPIba and NIHSS had negative correlation (r=-0.514,P<0.01).Conclusion:Our findings indicate that ADAM17may be a risk factor in AIS patients and the expression of GPIba can serve as a measure for stroke severity. Part Two:Study on the relationship between levels of coagulation markers and TCM syndrome differentiation in ischemic strokeObjective:To observe the relationship between levels of coagulation markers and TCM syndrome differentiation in ischemic stroke and provide theoretical basis for prevention and cure methods on stroke.Methods:306cases of ischemic stroke (merdian stroke) were divided into five types: wind-phlegm blocking collateral type、upward invading of wind-fire type、phlegm-heat with blocked intestines type、wind syndrome due to yin-deficiency type and blood stagnancy due to qi-deficiency type.230cases of healthy people were chosen as control. GPIbα、AD AM17、PLT、MPV、PDW、 coagulation function and homocysteine(Hcy) were detected by drawing blood and analysed according to different TCM syndrome type.Results:(1)Among306patients with ischemic stroke(merdian stroke),33.33%patients were wind-phlegm blocking collateral type,22.22%patients were upward invading of wind-fire type,16.67%patients were phlegm-heat with blocked intestines type,14.71%patients were wind syndrome due to yin-deficiency type and13.07%patients were blood stagnancy due to qi-deficiency type.(2) Among those patients,there were147males(48%) and159females(52%).The average age was63.30±10.76years. There were no significant difference among different TCM syndrome types in sex(X2=2.758, P>0.05)and age(F=0.227, P=0.923, P>0.05).(3) GPIba showed significant difference among five types (F=3.737, P=0.006, P<0.01).There were significant difference between blood stagnancy due to qi-deficiency type and wind-phlegm blocking collateral type (P=0.011, P<0.05)、upward invading of wind-fire type (P=0.001, P<0.01).GPIba of wind syndrome due to yin-deficiency type showed significant difference compared to that of upward invading of wind-fire type(P=0.009, P<0.01).ADAM17showed no significant difference among different types (F=1.008, P=0.403, P>0.05)(4) There were statistical difference in Hcy among different types(F=4.613, P=0.001, P<0.01).There were significant difference between wind-phlegm blocking collateral type and upward invading of wind-fire type、blood stagnancy due to qi-deficiency type、wind syndrome due to yin-deficiency type (P=0.026, P=0.017, P=0.000, P<0.05).Hcy of phlegm-heat with blocked intestines type showed no significant difference compared with that of wind-phlegm blocking collateral type (P=0.051, P>0.05).(5) There were significant difference among different types in MPV (F=2.503, P=0.042, P<0.05).Wind-phlegm blocking collateral type showed significant difference compared to upward invading of wind-fire type and wind syndrome due to yin-deficiency type (P=0.01, P=0.015, P<0.05). There were significant difference among different types in PDW (F=2.515, P=0.042, P<0.05). Wind-phlegm blocking collateral type showed significant difference compared to upward invading of wind-fire type and wind syndrome due to yin-deficiency type (P=0.01, P=0.02, P<0.05).There were no significant difference among wind-phlegm blocking collateral type、blood stagnancy due to qi-deficiency type and phlegm-heat with blocked intestines type (P>0.05)(6) There were no statistical difference among five types in PLT、PT、TT、APTT and INR (P>0.05).Fibrinogen among five types showed significant difference(F=14.143,P=0.000, P<0.01).There were significant difference between wind-phlegm blocking collateral type、 upward invading of wind-fire type、blood stagnancy due to qi-deficiency type and phlegm-heat with blocked intestines type、wind syndrome due to yin-deficiency type (P<0.01).There were no statistical difference among wind-phlegm blocking collateral type%upward invading of wind-fire type and blood stagnancy due to qi-deficiency (P=0.169, P=0.748, P=0.167,P>0.05) (7) There were significant difference in D-dimer among five types (F=2.962, P=0.02, P<0.05). Wind-phlegm blocking collateral type had significant difference compared to upward invading of wind-fire type、phlegm-heat with blocked intestines type and wind syndrome due to yin-deficiency type (P=0.022, P<0.05; P=0.047, P<0.05; P=0.005, P<0.01).Wind syndrome due to yin-deficiency type showed statistical difference compared to blood stagnancy due to qi-deficiency type (P=0.038, P<0.05)(8) In ischemic stroke(meridian stroke),there were negative correlation between GPIb∝and fibrinogen (r=-0.249, P=0.000, P<0.01). Fibrinogen bore positive correlation with D-dimer(r=0.151, P=0.008, P<0.01)Conclusions:(1) In ischemic stroke(meridian stroke), the dominant TCM syndrome type is wind-phlegm blocking collateral type.(2) TCM syndrome type of ischemic stroke(meridian stroke)shows no significant relationship with age、sex、AD AM17、PT、TT、APTT and INR,while has relationship with GPIb∝、Hcy、D-dimer、Fibrinogen、MPV and PDW.(3) The expression of GPIba in upward invading of wind-fire type and wind-phlegm blocking collateral type are higer than other types. The amount of Hcy is the highest in wind-phlegm blocking collateral type.MPV and PDW were high in wind-phlegm blocking collateral type. The amount of fibrinogen were high in wind-phlegm blocking collateral type、upward invading of wind-fire type and blood stagnancy due to qi-deficiency type.Changes of D-dimer in both wind-phlegm blocking collateral type and blood stagnancy due to qi-deficiency type were the most significant.In summary,there were close relationship between levels of coagulation markers and wind-phlegm blocking collateral type、phlegm-heat with blocked intestines type and blood stagnancy due to qi-deficiency type.(4)In ischemic stroke(meridian stroke), there is negative correlation between GPIbaand fibrinogen. Fibrinogen bears positive correlation with D-dimer.更多还原