【作者】 赵幸娟；

【导师】 张苏明；

【作者基本信息】 华中科技大学 ， 神经病学， 2007， 博士

【摘要】 目的针对临床上常见的多种血管病危险因素共存在于同一个体,其复发率较高且损害较重的特点,对尚未出现血管疾病但是有血管病危险因素的个体进行前瞻性研究,了解其发病程度。并通过动物实验了解多因素存在使血管内膜的病损程度。进一步调查了洛阳市医务工作者关于代谢综合症知识的认识情况,为卫生行政部门制定预防血管病策略提供资料和依据。方法该研究分四部分组成。第一部分了解代谢综合症个体患脑卒中后的转归情况,取首次发生脑卒中的患者,给予相同的治疗和健康教育,分为合并代谢综合征组(A)和单纯脑卒中组(B),观察各自的中位生存时间和首次发病时与再发卒中时的神经功能缺损评分,两者进行统计学分析。第二部分评估中国人代谢综合症不同异常数目与血管疾病之间的关系。根据中华医学会糖尿病协会提出的代谢综合症诊断标准选定血压、血糖、甘油三脂、高密度脂蛋白及体重的异常指标作为我们的研究对象。以居住在洛阳的市民中进行了一项序列研究,选取样本334例,年龄36岁-75岁(男人183例,女人151例),根据不同的异常数目分组,共分为五组,观察两年,了解其在这两年中发生血管病的情况,并进行统计学处理。在这项研究中我们所提到的血管病包括冠心病、脑卒中和周围动脉疾病。第三部分动物实验。将相同动物进行随机分组,分别给予高脂喂养和高脂加果糖水喂养。其他生存条件相同,在实验开始时、六周和12周时禁食不禁水一夜,于次日清晨从尾静脉采血,送生化检测,取得各自的NO,ET-1,TC,HDL-C,LDL-C,FBS ,IN各项指标,并测血压,计算每个均值,进行统计学处理。试验结束时处死所有大鼠,观察两类不同大鼠的颈内动脉和椎基底动脉壁的结构和细胞结构。第四部分了解医务人员对代谢综合症的认识并做出分析。2005.10-2006.1在洛阳市医务人员4589人中发放问卷,包括代谢综合症的基本内容、危害、治疗及预防,每一项内容分若干小项,并将其量化,对结果按年龄、职业和受教育程度划分并进行X2分析。结果通过研究显示:第一部分单纯脑卒中组的中位生存时间为22个月,合并代谢综合症的脑卒中患者中为生存时间为13个月,两者相比统计量为28.9703,p<0.01有明显统计学意义。且他们的神经功能缺损评分,在首发时单纯脑卒中的患者为24.58±5.63,合并代谢综合症的患者为24.59±6.43,统计量为0.01,p值为0.9938,无明显差异。而再发卒中时,单纯脑卒中的患者为26.59±4.61,合并代谢综合症的患者为30.67±5.41,统计量为4.06,p<0.05,有明显差异。合并代谢综合征组的神经功能缺损明显高于单纯脑卒中组,有明显差异。第二部分在中国人群中代谢综合征中的异常指标数目与血管病之间有显著的相关性,且异常数目越多血管病发病率越高。所有数据采用x2检验以得到各组与血管疾病的发生在横断面上和前瞻性研究的不同,该研究使用Mantel-Haenzel断层x2检验分析得出血管疾病的发生率与血液中异常成分之间的相对危险度和各自的可信区间。所有分析采用SAS8 (version 1)统计软件处理。有一个异常成分的人群发生血管疾病的发生率定为1(即最低的患病率)各组的相对危险度:在2,3,4,5个异常成分的组中患冠心病的相对危险度依次为1.81, 2.65, 4.03, 4.10,患脑卒中的相对危险度依次为1.41, 2.23, 3.30, 3.85,患周围血管病的相对危险度依次为1.63, 1.62, 3.22, 5.34。我们可以得出患冠心病,脑卒中,周围血管病的发生率随着代谢综合症中异常成分的增多而升高。经过调整年龄,又得出单纯高血压与血管病之间的相对危险度为7.27(95% CI: 4.74 to 11.17),在正常血压和不正常血压之间该数值有显著意义统计量为92.5883,p<0.001。同理可以得出,高血糖,高密度脂蛋白降低,高甘油三脂及超重发生血管病得相对危险度依次为4.36 (95% CI: 2.92 to 6.49), 1.52 (95% CI: 1.05 to 2.21), 1.31(95% CI: 0.9 to 1.9), 2.73(95% CI: 1.86 to 4)除甘油三脂(其统计量为1.9893,p>0.05)外,在各自正常值和不正常值之间该数值有显著意义,各自的统计量及p值依次为:高血糖56.17,p<0.001高密度脂蛋白降低4.95,p<0.05,超重27.79,p<0.001。除甘油三脂不是血管病独立的危险因素外,其余各项,无论是哪项值的异常,均和血管病有直接相关性。从我们的研究中还可看出对于中国人群代谢综合症的各种异常因素中,高血压发生率最高,其次是糖尿病。第三部分在入选时NO,ET-1,TC,HDL-C,LDL-C,FBS ,IN指标均无差异,所有指标的p值均>0.05,在第6周时HDL和BP无差异p>0.05,而Tc、NO、ET、FBS、IN和LDL均有差异P<0.05,到第12周时,HDL、NO、ET和BP有差异P<0.05,Tc、LDL、FBS和IN有显著差异P<0.01。并经过重复方差分析结果显示,血压、血糖、胰岛素、甘油三脂、低密度脂蛋白这几项指标不仅存在组间的差异和时间点上的差异,并且组间和时间的交互效应也有差异,其P值均小于0.05。而高密度脂蛋白、NO、ET这三项指标时间点上有差异p小于0.05,组间和时间和组间的交互效应均无差异p大于0.05。从光镜图片可以看出MS组颈内动脉和基底动脉内膜不完整,平滑肌细胞排列紊乱,并可以看到大量脂滴浸润之平滑肌层。高血脂组颈内动脉内膜完整,平滑肌层细胞排列整齐,但是在平滑肌细胞之间可看到较少的脂滴。电镜下显示MS组大鼠的血管内皮细胞核已经完全变形,胞浆内有大量的脂滴,泡沫细胞已经形成。高脂血症组大鼠血管内皮细胞核变大、轮廓还没有完全破坏,胞浆内有脂滴。单纯高脂血症大鼠的血管结构和细胞结构损害较代谢综合症大鼠的血管结构和细胞结构损害轻,并且在有高血糖存在的情况下,血管病危险因素更加向血管病方向转化。第四部分调查得出,从年龄划分,年龄大于50岁的人群对各种知识的知道比率为36.15%,较同类比较的人群要大得多p<0.05具有统计学意义,而小于30岁的人群对各种知识的知晓率为30.73%,三十岁到五十岁的人群对各种知识的知晓率为27.00%。从学历划分,本科学历以上的人群对各种知识知道的比率为39.73%,在同分类中与其他相比有显著差异p<0.05,而高中和中专的人群对此知识知道比率为30.09%,而大专的人群对此知识知道比率为29.49%,从职业划分,医生对各种知识的认识知道比率为29.34%,护士对各种知识的认识知道比率为28.26%。而行政后勤人员对各项知识的认识程度较低,仅有14.77%。结论第一部分本研究旨在证明血管危险因素的多或少对血管病及生存质量的影响,我们的调查中单纯脑卒中患者危险因素相对减少,血管病的复发率较低,且中位生存时间也明显延长;由于危险因素的增加,对血管的影响相对增加,在代谢综合症组,脑卒中的复发率明显升高,中位生存时间也明显缩短,并且两者的神经功能评分在第一次入院时无明显差别,第二次复发时则有明显差别。由此提醒我们一定要提高对血液成分变化的认识,并加以干预。第二部分研究指出居住在城镇的中国居民患有代谢综合症不同异常因素增加了冠心病,脑卒中和周围血管病的发生率。对于中国人群代谢综合症的各种异常因素中,高血压发生率最高,其次是糖尿病。为了控制,认识并治疗代谢综合征,公共卫生事业应加大对高血压和糖尿病的防治,同时不可放松对其他异常因素的控制。这些措施将有助于减轻我国在血管病方面的社会医疗负担。第三部分该项试验选择了高血脂动物和高血脂合并高血糖动物,以观察两者血液成分和血管内皮结构的改变和不同,结果发现在高血糖存在时,高血脂的动物其血液成分更加向有害方面发展,血管内皮细胞的损害加重,因此我们推测,当多种血管病危险因素共同存在时,它们对血管的损害不仅仅是各自危害的叠加,这些因素是相互作用加速了损害。尽管我们还没有证明它们相互作用的具体数据化信息,但是其互相促进的模式已经存在。由此提醒我们,在相同条件下代谢综合症严重影响血管内皮的完整和功能,单纯的高脂血症对血管内皮的完整性和功能有影响,但是比起代谢综合症要小得多,这就提醒我们对代谢综合症要加强监护和治疗。第四部分调查分析得出医务工作者对代谢综合症认识处于较低级阶段,社会人群的认识可能更低,这就要求我们医务工作者行动起来,自己要及时更新知识,并积极对社会人员宣传教育,使代谢综合症的观念深入人心,从根本上减少心脑血管病的发生。更多还原

【Abstract】 Objective: There are multipul risk factor of angionosis coexist in one body. It have the feature which can leads heighter relapse rate of vessel disease(VD) and more severe disadvantage then one which have only one risk factor of angionosis .Doing perspective study in some one who have one or more risk fector of VD but have not appear VD to understand the relation between them.Then studying the interaction of mutipul risk factor exist same one and the damage of endangium with animal experiment. Last we investigat to get the message about metabolic syndrome knowledge among medical worker.The aim is to provide some data to Medical Adminstrative Command for formulation preventing VD.Method : The study consists of four parts.Each part is listed as following. First To understand the tuneover condition in human who had metabolic syndrome and had not metabolic syndrome after having first stroke.We got the first stroke patients and divided into two groups, stroke addition metabolism syndrome (A )and simple stroke (B). Taking alike treatment and health education ,we get theire meso-lifetime and the score of neurologic impaiment at first stroke and relapse,and do statistic analyze. Second This study aimed to assess the number of abnormal components in the metabolic syndrome (MetS) and their association with cardiovascular diseases (CVD) in Chinese population. The information available about the abnormal components of the Metabolic Syndrome (MetS) was according to Chinese Diabetes Federation proposed the definition. We conducted a population-based succession study in an urban of Luoyang, based on the number of abnormal we divide five parts in a sampling of 334 participants who age is 36 to 75 years (183 men, 151 women) .To getting the relation between the relaps of VD and the abnormal factor , we observe this sample in two years. The CVD included in this study was diagnosed coronary heart disease (CHD), strokes, and peripheral arterial diseases (PAD).Third Getting 24 SD rats, we divide into two groups A and B randomization. Taking different feeding condition and identical life condition:height fat with water and height fat with diabetin water.Drown blood from the vena caudalis of rat who were fasted during the fore night then the blood sample were carried out biochemical analysis.The markers were total cholesterol(TC) , high-density lipoprotein cholesterol(HDL-C), low-density lipoprotein cholesterol(LDL-C),fast blood sugar(FBS),insulin(IN),nitric oxide(NO), endothelium-1(ET-1) at the begin ,6 weeks and 12 weeks. Up to the end, killing all rats observes these structure of the two groups rat’s internal carotid and basilar artery and cellular structure.Fourth In 2005.12-2006.1,we distrubuted questionnaire to Luoyang medical worker in all 4589. It includes three parts: base concept, detriment,cure and precaution .Every part was dividatured some small parts and becomes quantization.We divided this result according to aged,occupation and educations .To anasis this result with x2。Results The studying show: First The meso-lifetime of merely stroke(A) is 22 months more longger then the meso-lifetime of strok with metbolic syndrom(B) is 13 months. A longger then B.Their statistics is 28.9703, p<0.01 They have obviously statistical significance.Their neurologic impairment score is A24.58±5.63 ,B24.59±6.43 at first falling ill. The score is alike .Their statistics is 0.001, p>0.05. They have not obviously statistical significance.But at second falling ill the score of A is 26.59±4.61,of B is 30.67±5.41.Their statistics is4.06, p<0.05. They have obviously statistical significance.Second There was a significant relationship between the number of abnormal components in the Metabolic Syndrome and Cardiovascular Diseases in Chinese Population. We found a significantly increased prevalence of CHD, Strokes and PAD with an increasing number of METS components. Data were managed using Chi-square test to examine differences in continuous and categorical variables respectively. Mantel-Haenzel demixing Chi-square test was used to study the relation between cardiovascular disease and abnormal component in blood calculate risk ratios (RRs) and their 95% confidence intervals (CI). All analyses were conducted using SAS8 (version 1). The incidence of CVD occurred in population with only one abnormal component was defined as one (the lowest prevalence in the group), in turn the relative risk in each group was deferred. This number could be gotten based on table 1: The RR of CHD in different group is 1.81, 2.65, 4.03, 4.10 for two or more, three or more, four or more and five or more individuals. The RR of Stroke in different group is 1.41, 2.23, 3.30, 3.85 for two or more, three or more, four or more and five or more individuals. The RR of PAD in different group is 1.63, 1.62, 3.22, 5.34 for two or more, three or more, four or more and five or more individuals. We found a significantly higher prevalence of CHD, Stroke and PAD with an increasing number of METS components. after adjusting age we can get that the RR of high blood pressure was 7.27 (95% CI: 4.74 to 11.17) and there was significant difference between the population with normal and abnormal blood pressure. So as the RRs of high fasting glucose, lower high-density lipoprotein, hypertriglyceridemia, and overweight were 4.36 (95% CI: 2.92 to 6.49), 1.52 (95% CI: 1.05 to 2.21), 1.31(95% CI: 0.9 to 1.9), and 2.73(95% CI: 1.86 to 4) respectively. Besides hypertriglyceridemia( statistics is 1.9893,p>0.05) the rest every one have significant difference between the population with normal and abnormal.Thire statistics of high fasting glouse, lower high-density lipoprotein and overweight were 56.17,p<0.001, 4.95,p<0.05,27.79,p<0.001 respectively. Exept hypertriglyceridemia is not standalone risk factore of VD, the rest every one have directly associativity with VD.Chinese population, hypertension is more prevalent than the other components of MetS. The increase in fasting blood glucose is listed on second seat. Third At simple hyperlipoidemia and high fasting glouse accompaniment with hyperlipoidemia,there have not different between two parts a begin.Thire p are up 0.05.At 6 week,HDL and BP have not different, p>0.05.But Tc、NO、ET、FBS、IN and LDL have different, P<0.05. At 12 week,every one have different, P<0.05 or P<0.01. From repeat analysis of variance we can find that high blood pressure, high fasting glouse , hypertriglyceridemia, high low-density lipoprotein and insulin have different at parts and parts (p<0.005), HDL-C, NO, ET-1 have different times(p<0.005), but they have not different at parts and times multiply parts.(p>0.005) From light microscope picture we can find that the endarterium of arteria carotis interna and arteria basilaris is not integrated,thire smooth muscle cells rank disorder,there are much lipid droplet infiltrate in smooth muscle at MS rat .and the endarterium of arteria carotis interna and arteria basilaris is integrated,thire smooth muscle cells rank order,there are small amounts lipid droplet in smooth muscle at hyperlipoidemia rat.From electron microscope we can find that The core of endothelial cell have had completely out of shape, there are much lipid droplet infiltrate in intracytoplasm whit MS rat, and The core of endothelial cell have had bigger but out line have had not fully ruinned, there are lipid droplet infiltrate in intracytoplasm whit hyperlipoidemia rat. The damage of the blood vessel texture and celluar structure with simple hyperlipoidemia rat is more lightly then MS rat. Hperlipoidemia accompaniment with high fasting glouse, the risk factor of VD convert more quickly to VD. Fourth From our investagation,according to age divided,>50 year,30-50 year,<30 year know every news of MS is 36.15%,27.00%,30.73% respectively; according to acadimic career divided,above bachelor’s degree , between bachelor’s degree and high school, below high school know every news of MS is 39.73%,29.49%,30.09% respectively. according to occupation divided, doctor ,nurse, administration and rear service know every news of MS is know every news of MS is 29.34%, 28.26%,14.77% respectively.Conclusion First This study is to prove the contribution of between the number of the risk factor in VD and the relapse of VD, the molar of survival.From our investigation we can find the number of VD risk factor is littler,the relapse of VD is lower and the meso-live time is longer.Becouse of MS part have more risk factor then simple stroke part,the meso-live time of MS part is shorter then simple stroke part meso-live time, and then their score of neurologic impairment is likely at first with stroke, but at relapse, score of neurologic impairment of MS part is highter then score of neurologic impairment of simple stroke part.They have significant deviation. It needs us to think highly of to the change of blood constituent and do some interfere in. Second Our data indicate that Chinese people living in urban regions with abnormal parameters of MetS have increased risks for CHD, stroke, and PAD. In Chinese population, hypertension is more prevalent than the other components of MetS. The increase in fasting blood glucose is listed on second seat. In order to prevent, recognize and treat MetS, we should develop effective public health strategies to control the hypertension and the increased fasting glucose and other abnormal parameters. Third This study selected hyperlipemia rat and hyperlipemia accompaniment whit high fasting glouse to observation thire different in blood vessle endothelium fomulative and blood consitituent. At the end ,we find that The damage of the blood vessel texture and celluar structure with simple hyperlipoidemia rat is more lightly then MS rat. Hperlipoidemia accompaniment with high fasting glouse, the risk factor of VD convert more quickly to VD.So we presume when there are many risk factor of VD to exist with one the damage of the blood vessel texture and celluar structure is not only every plus each other but they interact damage each other. In spite of we have not accurate date about they interact damage each other, but the mode of they interact damage each other have existed. It call attention to us do a lot of work in care and treat at MS. Fourth The study tells us the recognition about MS in medical worker is lesser. we suppose the recognition about MS in common crowd is least. The damage of MS is more and more severity, it need us learning new knowledge in time and education to public croed, making the concept of MS interiorize and downwards the incidence of VD from base.更多还原