走进云医疗 ,李勇:糖尿病患者血管内皮功能损伤及外周动脉疾病管理的新进展

2020-09-18 门诊杂志 门诊新视野

糖尿病患者的主要死亡原因是心脑血管疾病。随着对心脑血管疾病研究的不断深入,血管内皮功能与心脑血管疾病的关系引起研究者极大关注。

糖尿病患者的主要死亡原因是心脑血管疾病。随着对心脑血管疾病研究的不断深入,血管内皮功能与心脑血管疾病的关系引起研究者极大关注。血管内皮功能障碍是动脉粥样硬化的始动因素之一,因此保护血管内皮功能对于降低糖尿病患者的心脑血管疾病死亡风险具有重要意义。同时,外周动脉疾病(PAD)是糖尿病患者主要的慢性并发症之一,是重要的致残及致死病因。为进一步提升我国临床医师尤其是内分泌科医师对糖尿病的认识和治疗水平,《门诊》特邀复旦大学附属华山医院心脏科李勇教授结合当前国内外前沿进展、指南更新等,围绕血管内皮功能损伤、PAD相关新的诊断和治疗手段、技术、方法等临床医师密切关注的信息进行专访。

《门诊》:代谢相关疾病的进展与血管内皮功能损害以及PAD密切相关,但当前临床医师对这方面的认识还略有不足,能否请你简述一下二者之间的关系?近年在代谢相关疾病领域都有哪些值得关注的最新进展?相关指南又有何新的指导意见?

李勇教授:严格来讲,任何疾病的起始均为细胞代谢异常,因此,不管是血管内皮功能损害还是PAD均属于代谢疾病。在过去一段时间里,未曾把代谢异常作为一个重要问题进行认识,而是普遍采取诸如血压高降血压、心力衰竭(以下简称心衰)强心治疗的策略。随着我们对高血压、心衰的病理生理机制的更深入了解,发现这些疾病均与代谢异常密不可分;这些疾病最初均伴有局部神经代谢功能紊乱和细胞代谢异常,而细胞代谢的异常又启动或加速了神经代谢功能紊乱。

细胞代谢异常与胰岛素抵抗关系密切。后者可导致胰岛素的受体和受体后的调控机制发生异常变化,由此诱发细胞的氧化应激反应和炎症反应。这些反应本来是一个适应性的改变,但随着时间推移,极易发展为一种不良的适应或者疾病的病因,加重血管、心肌细胞的损伤,引起血管、心脏重构,动脉粥样硬化和心脏功能的衰退也将随之产生。因此,越早发现代谢异常(包括糖代谢异常),越早改善胰岛素敏感性,越有利于减轻或延缓血管、心脏、肾脏等靶器官的损伤。

过去糖尿病的治疗主要围绕“调糖”进行,血糖高了,将加速动脉粥样硬化,而血糖低了,甚至可能马上致命。但即便在胰岛素已诞生约100年、口服降糖药物也已诞生约60年的今天,临床中发现将血糖降至最佳水平并不能带来CVD风险的明显减少。因此,从降低糖尿病患者CVD风险、延长其寿命的角度上讲,调糖已变得不那么重要。

2015年后,新型降糖药物的出现给降糖治疗带来了重大突破。两类新型降糖药物,即钠-葡萄糖共转运蛋白2抑制剂(SGLT2i)和胰高血糖素样肽1受体激动剂(GLP-1RA),均显示出对糖尿病合并心血管疾病(CVD)或者高危因素患者在降低心血管事件、延长寿命等方面的获益。鉴于此,欧美最新指南也越来越强调这两类药应成为血糖代谢异常合并心血管危险患者的基础用药,不论其是否已血糖达标或是否在用其他任何降糖药物,均应加用或起始使用这两类药物作为最基本的糖代谢管理、改善心血管预后的药物。

不仅如此,今年ESC大会上的两项重磅研究(EMPEROR-Reduced研究和DAPA-CKD研究)均提示,对于已有心衰、慢性肾病(CKD)患者,即便未合并糖尿病,也应采用SGLT2i治疗,可使心衰患者的心血管死亡和心衰住院风险减少,CKD患者的肾衰竭、肾性死亡、因心衰住院及心血管死亡几率减少。因此,新型降糖药物已经逐步扩展出降糖领域,在心衰和CKD等非糖尿病领域迅速崭露头角。

《门诊》:高血糖、脂代谢紊乱、氧化应激等诸多因素诱导的血管内皮细胞(ECs)功能障碍是糖尿病血管病变发生发展的重要因素和关键环节。您认为临床中临床医师应如何识别和诊断内皮损伤?预防和治疗血管内皮损伤的主要方法有哪些?通过加强对血管内皮损伤的监测,将对糖尿病患者带来怎样的切实获益?

李勇教授:血管内皮功能的准确测定是医学工作者持续追求的方向。

既往有研究使用超声检测仪进行内皮依赖的血管舒张(FMD)技术检测患者肱动脉施压前后血管内径的变化情况,并用来评估患者内皮功能损伤情况,但通常这种实验很难进行,且不同研究中心的检测结果差异很大;近年来,专用于血管内皮功能检测的超声仪器的出现,能够提高检测的自动化程度,重复性较高。

后来发现,小便中的尿微量白蛋白量可反映肾小球微血管的内皮功能损伤程度;曾也用微量尿蛋白反映全身的微血管内皮功能。但这些尿蛋白量更多反映的是肾脏功能,并不能很好的反应全身大血管内皮功能。因此,肾科医生认为很好,但心血管医生认为不太准确,最终并未得到广泛推广;

目前,有研究人员采用脉搏波传导速度进行检测,但是该数据更多反映的是动脉硬化情况;另一个较为简便的方法是测定踝肱指数,也可反映外周血管的功能,动脉粥样硬化与动脉硬化均可。因此,或许踝肱指数的实用性更大;

到现在为止临床中仍缺乏一些很好的指标,如能确定一个简易的物理学检测手段或生化指标,将具有很好的临床应用前景。目前欧姆龙公司已采用踝肱指数用于动脉硬化的检测,这是一个很好的趋势。

尽管目前还在追求和探索准确、客观测定血管内皮功能的方法,但至少我们已知道采用钙拮抗剂或ACEI/ARB强化降压、他汀强化降脂、SGLT2i和GLP-1RA强化控糖,就有可能使得血管内皮的损伤得到明显遏制,带来更好的血管保护作用。此外,也有研究发现抗炎药物(如白介素转化酶抑制剂)、肿瘤坏死因子抑制剂均有一定的血管内皮保护功能,有研究表明白介素-1β抑制剂卡纳单抗具有血管内皮保护作用,但这些药物的临床循证医学证据还相对较少。总体来说,按照现有理论,及早检测和控制血管内皮功能损伤将可能有利于降低PAD和CVD风险,特别在在 2 型糖尿病患者中,应重视无创性血管内皮功能检查,遵循早期发现、规范治疗的原则,预防心血管事件。

《门诊》:PAD在临床上常指下肢动脉疾病,是2型糖尿病常见慢性并发症之一,也是2型糖尿病患者致残、致死的重要原因,但PAD的临床症状不明显,不易引起糖尿病患者的注意。您认为导致PAD的常见原因有哪些?糖尿病高发或糖尿病人群应如何预防和控制PAD的发生和发展?临床上常见PAD诊断和治疗的方法有哪些?

李勇教授:现有资料显示,我国人群的PAD患病率比欧美国家更低。可能是由于中国的动脉粥样硬化患病率暂没有欧美国家高,但随着中国高血压、糖尿病及血脂异常人数的不断增加,未来我国的PAD患病率也将进一步升高;另外,从动脉粥样硬化的角度上讲,PAD和冠心病、脑缺血及脑卒中具有同样的致病机制,因此从流行病学的推论来看,中国PAD的患者病也将逐步增加。

关于控制PAD患病率,欧美国家的经历值得我国借鉴。60年代后欧美国家肥胖和糖尿病患病人数明显增加,致使90年代PAD患者数明显增加,再加上欧美国家加强了对冠状动脉疾病的重视,冠心病患者人数相对减少,此时PAD现状也变得愈加突出。因此,为避免我国重走欧美国家的老路,及早预防和治疗高血压、糖尿病、高血脂,预防动脉粥样硬化,对于控制我国PAD患病率将具有重要意义。

目前,暂未发现有专门的研究关注采用药物预防和治疗PAD。这很大程度上是因为PAD最明显的临床表现是生活质量的降低,且致命风险小,而心脏和大脑相关疾病的致命风险较大,因此临床上通常优先重视对心脏和大脑相关疾病的治疗。但需指出的是,PAD与动脉粥样硬化密不可分,从这个角度上讲,采用兼具改善血糖和动脉粥样硬化的SGLT2i和GLP-1RA,也将改善PAD患者的临床预后,相信未来将很快有相关研究的发表。

当前,主要的PAD治疗策略是抗血小板治疗,也可采用扩张血管的药物治疗(诸如钙拮抗剂),但最基本的治疗策略仍然是控制血压、血糖,强化他汀治疗,抗动脉粥样硬化治疗,在这基础上,采用抗血小板药物治疗预防血栓栓塞是非常重要的。

《门诊》:相信随着临床医师对代谢相关疾病认识的不断加深,一定会更加重视血管内皮功能及PAD的预防与处理,在这方面现如今有哪些新技术、新手段值得广大临床医师的关注?

李勇教授:首要推荐的是生活方式干预,包括对高糖饮料的控制、一定量蔬菜和水果的摄入、积极参加体育锻炼等;其次,重视血压、血糖、血脂管理,在此基础上采用抗血小板药物治疗预防血栓栓塞;在上述措施无效时,可考虑外科手术疏通或修复血管;对于肥胖人群,必要时可考虑外科代谢手术,可在减肥的同时有效改善血管内皮功能。

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  2. [GetPortalCommentsPageByObjectIdResponse(id=1893845, encodeId=cfae18938456c, content=<a href='/topic/show?id=33a6e0716f1' target=_blank style='color:#2F92EE;'>#疾病管理#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=33, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=70716, encryptionId=33a6e0716f1, topicName=疾病管理)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=5fca128, createdName=licz0423, createdTime=Tue Mar 09 23:05:55 CST 2021, time=2021-03-09, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1663602, encodeId=027c166360240, content=<a href='/topic/show?id=699a89540b9' target=_blank style='color:#2F92EE;'>#血管内皮功能#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=29, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=89540, encryptionId=699a89540b9, topicName=血管内皮功能)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=51bc25628263, createdName=zywlvao, createdTime=Fri May 28 06:05:55 CST 2021, time=2021-05-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=888238, encodeId=a65a88823851, content=肥胖人群,必要时可考虑外科代谢手术,可在减肥的同时有效改善血管内皮功能。, beContent=null, objectType=article, channel=null, level=null, likeNumber=79, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=b58d5402080, createdName=咻凡, createdTime=Fri Sep 25 11:40:06 CST 2020, time=2020-09-25, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1398048, encodeId=4bd913980481e, content=<a href='/topic/show?id=8bee565436d' target=_blank style='color:#2F92EE;'>#损伤#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=27, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=56543, encryptionId=8bee565436d, topicName=损伤)], attachment=null, authenticateStatus=null, createdAvatar=https://thirdwx.qlogo.cn/mmopen/vi_32/DYAIOgq83eoNX3lUOlDKGBUEPNwZx0nibmdcFyeibnX4WMhUSCU2REpGRWtSmnT2CCs0dA5waxvJknYDxwtYnIcQ/132, createdBy=294e2500218, createdName=ms3046638856685384, createdTime=Sun Sep 20 00:05:55 CST 2020, time=2020-09-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1450058, encodeId=b7091450058cb, content=<a href='/topic/show?id=85eb304409c' target=_blank style='color:#2F92EE;'>#内皮功能#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=43, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=30440, encryptionId=85eb304409c, topicName=内皮功能)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=d41d5536295, createdName=zhangxingru, createdTime=Sun Sep 20 00:05:55 CST 2020, time=2020-09-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1474987, encodeId=57bd14e4987a2, content=<a href='/topic/show?id=935fe6718e3' target=_blank style='color:#2F92EE;'>#糖尿病患者#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=30, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=76718, encryptionId=935fe6718e3, topicName=糖尿病患者)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=a38f7243741, createdName=xue8604, createdTime=Sun Sep 20 00:05:55 CST 2020, time=2020-09-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1593338, encodeId=f091159333875, content=<a href='/topic/show?id=8d1342e95fa' target=_blank style='color:#2F92EE;'>#外周动脉#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=23, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=42795, encryptionId=8d1342e95fa, topicName=外周动脉)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=b27818121614, createdName=wujh_7312825, createdTime=Sun Sep 20 00:05:55 CST 2020, time=2020-09-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1043326, encodeId=f5b5104332683, content=谢谢MedSci提供最新的资讯, beContent=null, objectType=article, channel=null, level=null, likeNumber=51, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f0620, createdName=misszhang, createdTime=Fri Sep 18 12:05:55 CST 2020, time=2020-09-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=886349, encodeId=649188634908, content=有用, beContent=null, objectType=article, channel=null, level=null, likeNumber=0, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=63645206196, createdName=1474d539m15暂无昵称, createdTime=Fri Sep 18 11:33:03 CST 2020, time=2020-09-18, status=1, ipAttribution=)]
  3. [GetPortalCommentsPageByObjectIdResponse(id=1893845, encodeId=cfae18938456c, content=<a href='/topic/show?id=33a6e0716f1' target=_blank style='color:#2F92EE;'>#疾病管理#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=33, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=70716, encryptionId=33a6e0716f1, topicName=疾病管理)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=5fca128, createdName=licz0423, createdTime=Tue Mar 09 23:05:55 CST 2021, time=2021-03-09, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1663602, encodeId=027c166360240, content=<a href='/topic/show?id=699a89540b9' target=_blank style='color:#2F92EE;'>#血管内皮功能#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=29, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=89540, encryptionId=699a89540b9, topicName=血管内皮功能)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=51bc25628263, createdName=zywlvao, createdTime=Fri May 28 06:05:55 CST 2021, time=2021-05-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=888238, encodeId=a65a88823851, content=肥胖人群,必要时可考虑外科代谢手术,可在减肥的同时有效改善血管内皮功能。, beContent=null, objectType=article, channel=null, level=null, likeNumber=79, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=b58d5402080, createdName=咻凡, createdTime=Fri Sep 25 11:40:06 CST 2020, time=2020-09-25, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1398048, encodeId=4bd913980481e, content=<a href='/topic/show?id=8bee565436d' target=_blank style='color:#2F92EE;'>#损伤#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=27, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=56543, encryptionId=8bee565436d, topicName=损伤)], attachment=null, authenticateStatus=null, createdAvatar=https://thirdwx.qlogo.cn/mmopen/vi_32/DYAIOgq83eoNX3lUOlDKGBUEPNwZx0nibmdcFyeibnX4WMhUSCU2REpGRWtSmnT2CCs0dA5waxvJknYDxwtYnIcQ/132, createdBy=294e2500218, createdName=ms3046638856685384, createdTime=Sun Sep 20 00:05:55 CST 2020, time=2020-09-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1450058, encodeId=b7091450058cb, content=<a href='/topic/show?id=85eb304409c' target=_blank style='color:#2F92EE;'>#内皮功能#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=43, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=30440, encryptionId=85eb304409c, topicName=内皮功能)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=d41d5536295, createdName=zhangxingru, createdTime=Sun Sep 20 00:05:55 CST 2020, time=2020-09-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1474987, encodeId=57bd14e4987a2, content=<a href='/topic/show?id=935fe6718e3' target=_blank style='color:#2F92EE;'>#糖尿病患者#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=30, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=76718, encryptionId=935fe6718e3, topicName=糖尿病患者)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=a38f7243741, createdName=xue8604, createdTime=Sun Sep 20 00:05:55 CST 2020, time=2020-09-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1593338, encodeId=f091159333875, content=<a href='/topic/show?id=8d1342e95fa' target=_blank style='color:#2F92EE;'>#外周动脉#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=23, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=42795, encryptionId=8d1342e95fa, topicName=外周动脉)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=b27818121614, createdName=wujh_7312825, createdTime=Sun Sep 20 00:05:55 CST 2020, time=2020-09-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1043326, encodeId=f5b5104332683, content=谢谢MedSci提供最新的资讯, beContent=null, objectType=article, channel=null, level=null, likeNumber=51, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f0620, createdName=misszhang, createdTime=Fri Sep 18 12:05:55 CST 2020, time=2020-09-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=886349, encodeId=649188634908, content=有用, beContent=null, objectType=article, channel=null, level=null, likeNumber=0, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=63645206196, createdName=1474d539m15暂无昵称, createdTime=Fri Sep 18 11:33:03 CST 2020, time=2020-09-18, status=1, ipAttribution=)]
    2020-09-25 咻凡

    肥胖人群,必要时可考虑外科代谢手术,可在减肥的同时有效改善血管内皮功能。

    0

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  7. [GetPortalCommentsPageByObjectIdResponse(id=1893845, encodeId=cfae18938456c, content=<a href='/topic/show?id=33a6e0716f1' target=_blank style='color:#2F92EE;'>#疾病管理#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=33, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=70716, encryptionId=33a6e0716f1, topicName=疾病管理)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=5fca128, createdName=licz0423, createdTime=Tue Mar 09 23:05:55 CST 2021, time=2021-03-09, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1663602, encodeId=027c166360240, content=<a href='/topic/show?id=699a89540b9' target=_blank style='color:#2F92EE;'>#血管内皮功能#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=29, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=89540, encryptionId=699a89540b9, topicName=血管内皮功能)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=51bc25628263, createdName=zywlvao, createdTime=Fri May 28 06:05:55 CST 2021, time=2021-05-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=888238, encodeId=a65a88823851, content=肥胖人群,必要时可考虑外科代谢手术,可在减肥的同时有效改善血管内皮功能。, beContent=null, objectType=article, channel=null, level=null, likeNumber=79, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=b58d5402080, createdName=咻凡, createdTime=Fri Sep 25 11:40:06 CST 2020, time=2020-09-25, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1398048, encodeId=4bd913980481e, content=<a href='/topic/show?id=8bee565436d' target=_blank style='color:#2F92EE;'>#损伤#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=27, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=56543, encryptionId=8bee565436d, topicName=损伤)], attachment=null, authenticateStatus=null, createdAvatar=https://thirdwx.qlogo.cn/mmopen/vi_32/DYAIOgq83eoNX3lUOlDKGBUEPNwZx0nibmdcFyeibnX4WMhUSCU2REpGRWtSmnT2CCs0dA5waxvJknYDxwtYnIcQ/132, createdBy=294e2500218, createdName=ms3046638856685384, createdTime=Sun Sep 20 00:05:55 CST 2020, time=2020-09-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1450058, encodeId=b7091450058cb, content=<a href='/topic/show?id=85eb304409c' target=_blank style='color:#2F92EE;'>#内皮功能#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=43, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=30440, encryptionId=85eb304409c, topicName=内皮功能)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=d41d5536295, createdName=zhangxingru, createdTime=Sun Sep 20 00:05:55 CST 2020, time=2020-09-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1474987, encodeId=57bd14e4987a2, content=<a href='/topic/show?id=935fe6718e3' target=_blank style='color:#2F92EE;'>#糖尿病患者#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=30, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=76718, encryptionId=935fe6718e3, topicName=糖尿病患者)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=a38f7243741, createdName=xue8604, createdTime=Sun Sep 20 00:05:55 CST 2020, time=2020-09-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1593338, encodeId=f091159333875, content=<a href='/topic/show?id=8d1342e95fa' target=_blank style='color:#2F92EE;'>#外周动脉#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=23, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=42795, encryptionId=8d1342e95fa, topicName=外周动脉)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=b27818121614, createdName=wujh_7312825, createdTime=Sun Sep 20 00:05:55 CST 2020, time=2020-09-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1043326, encodeId=f5b5104332683, content=谢谢MedSci提供最新的资讯, beContent=null, objectType=article, channel=null, level=null, likeNumber=51, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f0620, createdName=misszhang, createdTime=Fri Sep 18 12:05:55 CST 2020, time=2020-09-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=886349, encodeId=649188634908, content=有用, beContent=null, objectType=article, channel=null, level=null, likeNumber=0, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=63645206196, createdName=1474d539m15暂无昵称, createdTime=Fri Sep 18 11:33:03 CST 2020, time=2020-09-18, status=1, ipAttribution=)]
  8. [GetPortalCommentsPageByObjectIdResponse(id=1893845, encodeId=cfae18938456c, content=<a href='/topic/show?id=33a6e0716f1' target=_blank style='color:#2F92EE;'>#疾病管理#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=33, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=70716, encryptionId=33a6e0716f1, topicName=疾病管理)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=5fca128, createdName=licz0423, createdTime=Tue Mar 09 23:05:55 CST 2021, time=2021-03-09, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1663602, encodeId=027c166360240, content=<a href='/topic/show?id=699a89540b9' target=_blank style='color:#2F92EE;'>#血管内皮功能#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=29, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=89540, encryptionId=699a89540b9, topicName=血管内皮功能)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=51bc25628263, createdName=zywlvao, createdTime=Fri May 28 06:05:55 CST 2021, time=2021-05-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=888238, encodeId=a65a88823851, content=肥胖人群,必要时可考虑外科代谢手术,可在减肥的同时有效改善血管内皮功能。, beContent=null, objectType=article, channel=null, level=null, likeNumber=79, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=b58d5402080, createdName=咻凡, createdTime=Fri Sep 25 11:40:06 CST 2020, time=2020-09-25, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1398048, encodeId=4bd913980481e, content=<a href='/topic/show?id=8bee565436d' target=_blank style='color:#2F92EE;'>#损伤#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=27, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=56543, encryptionId=8bee565436d, topicName=损伤)], attachment=null, authenticateStatus=null, createdAvatar=https://thirdwx.qlogo.cn/mmopen/vi_32/DYAIOgq83eoNX3lUOlDKGBUEPNwZx0nibmdcFyeibnX4WMhUSCU2REpGRWtSmnT2CCs0dA5waxvJknYDxwtYnIcQ/132, createdBy=294e2500218, createdName=ms3046638856685384, createdTime=Sun Sep 20 00:05:55 CST 2020, time=2020-09-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1450058, encodeId=b7091450058cb, content=<a href='/topic/show?id=85eb304409c' target=_blank style='color:#2F92EE;'>#内皮功能#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=43, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=30440, encryptionId=85eb304409c, topicName=内皮功能)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=d41d5536295, createdName=zhangxingru, createdTime=Sun Sep 20 00:05:55 CST 2020, time=2020-09-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1474987, encodeId=57bd14e4987a2, content=<a href='/topic/show?id=935fe6718e3' target=_blank style='color:#2F92EE;'>#糖尿病患者#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=30, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=76718, encryptionId=935fe6718e3, topicName=糖尿病患者)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=a38f7243741, createdName=xue8604, createdTime=Sun Sep 20 00:05:55 CST 2020, time=2020-09-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1593338, encodeId=f091159333875, content=<a href='/topic/show?id=8d1342e95fa' target=_blank style='color:#2F92EE;'>#外周动脉#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=23, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=42795, encryptionId=8d1342e95fa, topicName=外周动脉)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=b27818121614, createdName=wujh_7312825, createdTime=Sun Sep 20 00:05:55 CST 2020, time=2020-09-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1043326, encodeId=f5b5104332683, content=谢谢MedSci提供最新的资讯, beContent=null, objectType=article, channel=null, level=null, likeNumber=51, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f0620, createdName=misszhang, createdTime=Fri Sep 18 12:05:55 CST 2020, time=2020-09-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=886349, encodeId=649188634908, content=有用, beContent=null, objectType=article, channel=null, level=null, likeNumber=0, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=63645206196, createdName=1474d539m15暂无昵称, createdTime=Fri Sep 18 11:33:03 CST 2020, time=2020-09-18, status=1, ipAttribution=)]
    2020-09-18 misszhang

    谢谢MedSci提供最新的资讯

    0

  9. [GetPortalCommentsPageByObjectIdResponse(id=1893845, encodeId=cfae18938456c, content=<a href='/topic/show?id=33a6e0716f1' target=_blank style='color:#2F92EE;'>#疾病管理#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=33, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=70716, encryptionId=33a6e0716f1, topicName=疾病管理)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=5fca128, createdName=licz0423, createdTime=Tue Mar 09 23:05:55 CST 2021, time=2021-03-09, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1663602, encodeId=027c166360240, content=<a href='/topic/show?id=699a89540b9' target=_blank style='color:#2F92EE;'>#血管内皮功能#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=29, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=89540, encryptionId=699a89540b9, topicName=血管内皮功能)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=51bc25628263, createdName=zywlvao, createdTime=Fri May 28 06:05:55 CST 2021, time=2021-05-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=888238, encodeId=a65a88823851, content=肥胖人群,必要时可考虑外科代谢手术,可在减肥的同时有效改善血管内皮功能。, beContent=null, objectType=article, channel=null, level=null, likeNumber=79, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=b58d5402080, createdName=咻凡, createdTime=Fri Sep 25 11:40:06 CST 2020, time=2020-09-25, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1398048, encodeId=4bd913980481e, content=<a href='/topic/show?id=8bee565436d' target=_blank style='color:#2F92EE;'>#损伤#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=27, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=56543, encryptionId=8bee565436d, topicName=损伤)], attachment=null, authenticateStatus=null, createdAvatar=https://thirdwx.qlogo.cn/mmopen/vi_32/DYAIOgq83eoNX3lUOlDKGBUEPNwZx0nibmdcFyeibnX4WMhUSCU2REpGRWtSmnT2CCs0dA5waxvJknYDxwtYnIcQ/132, createdBy=294e2500218, createdName=ms3046638856685384, createdTime=Sun Sep 20 00:05:55 CST 2020, time=2020-09-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1450058, encodeId=b7091450058cb, content=<a href='/topic/show?id=85eb304409c' target=_blank style='color:#2F92EE;'>#内皮功能#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=43, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=30440, encryptionId=85eb304409c, topicName=内皮功能)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=d41d5536295, createdName=zhangxingru, createdTime=Sun Sep 20 00:05:55 CST 2020, time=2020-09-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1474987, encodeId=57bd14e4987a2, content=<a href='/topic/show?id=935fe6718e3' target=_blank style='color:#2F92EE;'>#糖尿病患者#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=30, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=76718, encryptionId=935fe6718e3, topicName=糖尿病患者)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=a38f7243741, createdName=xue8604, createdTime=Sun Sep 20 00:05:55 CST 2020, time=2020-09-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1593338, encodeId=f091159333875, content=<a href='/topic/show?id=8d1342e95fa' target=_blank style='color:#2F92EE;'>#外周动脉#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=23, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=42795, encryptionId=8d1342e95fa, topicName=外周动脉)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=b27818121614, createdName=wujh_7312825, createdTime=Sun Sep 20 00:05:55 CST 2020, time=2020-09-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1043326, encodeId=f5b5104332683, content=谢谢MedSci提供最新的资讯, beContent=null, objectType=article, channel=null, level=null, likeNumber=51, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f0620, createdName=misszhang, createdTime=Fri Sep 18 12:05:55 CST 2020, time=2020-09-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=886349, encodeId=649188634908, content=有用, beContent=null, objectType=article, channel=null, level=null, likeNumber=0, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=63645206196, createdName=1474d539m15暂无昵称, createdTime=Fri Sep 18 11:33:03 CST 2020, time=2020-09-18, status=1, ipAttribution=)]
    2020-09-18 1474d539m15暂无昵称

    有用

    0

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