静脉溶栓后与非溶栓后经皮冠状动脉内球囊成形术用于心肌梗塞…

为了比较静脉溶栓联合经皮冠状动脉内球囊成型术（ＰＴＣＡ）在心肌梗塞治疗中的作用，本文将３４例急性心肌梗塞患者分为静脉溶栓后ＰＴＣＡ（Ｕ＋ＰＴＣＡ）１４例和扩冠抗凝后ＰＴＣＡ（ＮＨ＋ＰＴＣＡ）２０例２组，２组在发病后分别静脉滴尿激酶１００万单位和连续静滴硝酸甘油肝素。２组在急性心肌梗塞后３周行冠脉造影，４周行ＰＴＣＡ。观察梗塞后出发心绞痛，冠脉狭窄程度，左室ＥＦ值，梗塞支ＰＴＣＡ时间组的梗塞支病变狭     

253例PTCA临床和造影资料分析

讨论了２５３例冠心病患者的２９４个血管段ＰＴＣＡ的临床及造影资料，成功率９０．１％。失败的主要原因是导引钢丝和球囊导管不能通过病变的血管段。ＰＴＣＡ术后再狭窄主要发生于４个月内，再次ＰＴＣＡ的成功率与首次ＰＴＣＡ相同。左前降支病变ＰＴＣＡ后再狭窄发生率明显高于其它血管段。ＰＴＣＡ术后严重并发症的发生率７．１％。尚讨论了影响ＰＴＣＡ成功率及并发症发生的因素。     

经皮腔内冠状动脉形术（PTCA）治疗复杂冠状动脉病变

对９０例冠心病病人的１７ｏ处复杂靶病变进行ＰＴＣＡ，成功率９３．５％，术中３例出现急性血管关闭，经冠脉内溶栓、置入支架或灌注球囊扩张后治疗。２例高龄、三支冠脉病变的不稳定心绞痛者出现非扩张冠脉血栓性闭塞合并心源性休克死亡。术后随访１个月～３年，６例再狭窄者５例经再ＰＴＣＡ治疗。     

静脉溶栓后与非溶栓后经皮冠状动脉内球囊成形术用于心肌梗塞的比较

为了比较静脉溶栓联合经皮冠状动脉内球囊成型术（ＰＴＣＡ）在心肌梗塞治疗中的作用，本文将３４例急性心肌梗塞患者分为静脉溶栓后ＰＴＣＡ（Ｕ＋ＰＴＣＡ）１４例和扩冠抗凝后ＰＴＣＡ（ＮＨ＋ＰＴＣＡ）２０例２组。２组在发病后分别静滴尿激酶１００方单位和连续静滴硝酸甘油肝素。２组在急性心肌梗塞后３周行冠脉造影，４周行ＰＴＣＡ。观察梗塞后再发心绞痛、冠脉狭窄程度、左室ＥＦ值、梗塞支ＰＴＣＡ时间和ＰＴＣＡ成功率。发现Ｕ＋ＰＴＣＡ组再发心绞痛５７％（８．４），ＮＨ＋ＰＴＣＡ组２０％（４／２０）；Ｕ＋ＰＴＣＡ组的梗塞支病变狭窄程度重于ＮＨ＋ＰＴＧＡ组（９０＋０．０８％：９６．９±４．２３％，ｐ＜０．０１）；Ｕ＋ＰＴＣＡ组左室ＥＦ值高于ＮＨ＋ｐＴＣＡ组（０．５０±０．０２∶０．４６±０．０４，ｐ＜０．０５）；Ｕ＋ＰＴＣＡ组梗塞支ＰＴＣＡ时间少于ＮＡ＋ＰＴＣＡ组（０．９１±０．２６小时：１．７３±０．５６小时，ｐ＜０．０１）；Ｕ＋ＰＴＣＡ组的成功率与ＮＨ＋ＰＴＣＡ组相同（９３％：９０％，ｐ＞０．０５）。     

经皮血管内冠状动脉成形术的临床应用（附25例报告）

本文报告用ＰＴＣＡ治疗２５例２６支冠状动脉狭窄的临床经验。全部病例经５６次扩张，平均每根血管扩张２．２（１－６）次，扩张的最大压力为７－１０ａｔｍ，每根血管总扩张时间平均２４１（３５－４８０）秒，术后残存血管狭窄均〈３０％，心绞痛消失，无并发症。ＰＴＣＡ成功率１００％。术后平均随访１４（８－４０）个月，７例（２８％）出现心绞痛，其中２例为冠脉痉挛，仅５例可能与再狭窄有关。     

硝酸甘油介入心肌断层显像在心肌存活评价的临床应用

目的：探讨硝酸甘油介入心肌断层显像在心肌存活评价的临床应用价值，方法：应用静息、硝酸甘油介入９９ｍＴＣ－ＭＩＢＩ心肌血流灌注断层显像，对２０例不稳定型心绞痛患者（其中８例有陈旧性心梗病史）ＰＴＣＡ术前术后进行自身对比分析。结果：２０例患者１６０个心肌节段中、静息显像异常积分为１９６（１分３３个节段、２分２０个节段、３分４１个节段）：硝酸甘油介入显像及ＰＴＣＡ术后静息显像异常积分均较术前静息显像明显减少且两者积分接近，分别为１０４和９７分。而核素分布正常节段分别增加４６和５３个心肌节段增加６７．７％，７７．９％，两者相似（Ｐ＞０．０５），两者和术前静息显像相比有显著差异（Ｐ＜０．０１）。术前患者射血分数为４４．５±１２．６％，术后为５６．４±１６．３％，增加２６．８％。结论：揭示核素心肌硝酸甘油介入心肌断层显像对存活心肌评价简便无创，客观准确，为心绞痛患者ＰＴＣＡ术前选择适应症及术后评价疗效提供了有力手段     

32例冠状动脉内球囊扩张及支架植入术后症状改善分析

冠状动脉支架植入术是在经皮冠状动脉内成形术 (简称ＰＴＣＡ)的基础上 ,在球囊扩张后的单狭窄部位植入支架 ,以解除冠状动脉狭窄 ,改善心肌供血 ,达到治疗目的。我科 1999年—2 0 0 0年 8月对 3 2例病人植入支架 3 6枚 ,其中 5例单行ＰＴＣＡ ,结果 3 2例取得满意的临床疗效 ,现就临床症状及心电图的改变分析如下。1　临床资料本组 3 2例 ,其中男 2 3例、女 9例 ,年龄 46岁～ 72岁 ,平均年龄 5 9岁 ;不稳定性心绞痛 17例 ,梗死后心绞痛 14例 ,急性心肌梗死 1例 ;合并糖尿病者 5例 ,合并高血压病者 8例。 3 2例术前均有典型的心绞痛病史 ,Ｓ…     

冠脉介入治疗的术后监护

1997年至 2 0 0 0年 8月 ,我们对5 4例冠脉介入患者术后进行了监护 ,从而提高了介入治疗的成功率 ,减少了并发症。现将其术后监护措施介绍如下。1　临床资料5 4例患者中男 43例 ,女 11例 ,30～ 83岁 ,单纯冠脉造影 (ＣＡＧ) 17例、ＣＡＧ 左室造影 11例、ＰＴＣＡ 8例、ＡＭＩ急诊ＰＴＣＡ 5例、ＰＴＣＡ ＣＳ8例 ,冠脉搭桥 (ＣＡＢＧ) 5例 ;临床诊断陈旧性心肌梗死 7例、ＡＭＩ 8例、冠心病 39例。术前均因心慌、胸闷或心绞痛反复发作而住院。结果 :急诊ＣＡＢＧ 3例、死亡 1例 ,余均成功。2　术后监护2 1　掌握操作过程、用药与术后并…     

20例经皮冠状动脉腔内成形术

目的：总结经皮冠状动脉腔内成形术（ＰＴＣＡ）的经验以求改善ＰＴＣＡ技术，提高临床ＰＴＣＡ的成功率。方法：ＰＴＣＡ按Ｇｒｕｎｔｚｉｇ方法进行。结果：对２０例严重冠状动脉硬化性心脏病患者进行ＰＴ－ＣＡ，共计３０支３９处血管病变中的２６支３５处病变进行了有效扩张，平均扩张次数３．５±２．６次／处，扩张时间６５±２１秒／次，扩张压力每次７．５±２．３ａｔｍ。平均狭窄程度由８７％减轻至１５％，狭窄完全消失的病变有２８处。１例术中发生急性冠状动脉闭塞，经植入支架后恢复正常，未发生其它严重并发症。总成功率１００％。术后心绞痛、心电图缺血性ＳＴＴ改变消失或减轻。结论：ＰＴＣＡ具有创伤小、疗效确切和较安全等优点；植入冠状动脉内支架是处理ＰＴＣＡ所致急性冠状动脉闭塞的有效方法；对于有指征的陈旧性心肌梗塞患者也宜积极采取ＰＴＣＡ的治疗，有助于提高生活质量，改善预后     

经皮冠状动脉腔内成形术对心绞痛和心肌梗塞QT离散度的影响及其临床意义

目的：探讨经皮冠状动脉内成形术（ＰＴＣＡ）对心绞痛和心肌梗塞病人ＱＴ离散度（ＱＴｄ）的影响及其意义。方法：分析８４例心绞痛和心肌梗塞患者ＰＴＣＡ术前、术后一天内所记录的心电图,测算ＱＴ间期、ＱＴ离散度、心率校正ＱＴ离散度（ＱＴｃｄ）。病例分为三组：心绞痛ＰＴＣＡ成功组、心肌梗塞ＰＴＣＡ成功组、心肌梗塞ＰＴＣＡ失败组。分别对三组ＱＴｄ、ＱＴｃｄ作术前、术后比较。结果：前二组术后ＱＴｄ、ＱＴｃｄ较术前显著减少（Ｐ＜０．０１）,失败组术前、术后ＱＴｄ及ＱＴｃｄ差异无显著性（Ｐ＞０．０５）。结论：成功的ＰＴＣＡ能显著减少心绞痛和心肌梗塞患者的ＱＴｄ,提示可能减少心律失常的发生率,从而减少心肌缺血患者的死亡率,可以改善患者的预后,术后心肌梗塞患者ＱＴｄ减少可能反映了顿抑或冬眠心肌的“苏醒“,并表明梗塞区内尚有存活心肌。     

Guns and Knives in New Mexico: Patterns of Penetrating Trauma, 1978–1993

Objective: To identify patterns of nonfatal and fatal penetrating trauma among children and adults in New Mexico using ED and medical examiner data.
Methods: The authors retrospectively sampled in 5-year intervals all victims of penetrating trauma who presented to either the state Level-1 trauma center or the state medical examiner from a 16-year period (1978–1993). Rates of nonfatal and fatal firearm and stabbing injury were compared for children and adults.
Results: Rates of nonfatal injury were similar (firearm, 34.3 per 100,000 person-years; stabbing, 35.1). However, rates of fatal injury were significantly different (firearm, 21.9; stabbing, 2.7; relative risk: 8.2; 95% confidence interval: 5.4, 12.5). From 1978 to 1993, nonfatal injury rates increased for children (p = 0.0043) and adults (p < 0.0001), while fatal penetrating injury remained constant. The increase in nonfatal injury in children resulted from increased firearm injury rates. In adults, both stabbing and firearm nonfatal injury rates increased.
Conclusions: Nonfatal injury data suggest that nonfatal violence has increased; fatal injury data suggest that violent death rates have remained constant. Injury patterns vary by age, mechanism of trauma, and data source. These results suggest that ED and medical examiner data differ and that both are needed to guide injury prevention programs.     

Systematic Reviews Published in the January 2011 Issue of The Cochrane Library

ABSTRACT

The Cochrane Library of Systematic Reviews is published quarterly as a DVD and monthly online. The January 2011 issue (first quarterly DVD for 2011) contains 4515 complete reviews, 1985 protocols for reviews in production, and 13,521 one-page summaries of systematic reviews published in the general medical literature. In addition, there are citations of 641,000 randomized controlled trials, and 14,018 cited papers in the Cochrane methodology register. The health technology assessment database contains over 9300 citations. One hundred and seven new reviews have been published in the last 3 months, of which five have potential relevance for practitioners in pain and palliative medicine.     

Interprofessional approaches to creating safe,high quality health care

Three supplementary perspectives are presented arguing that interprofessional collaboration is both necessary and desirable. Nonetheless, there are often too many serious intra-professional barriers and obstacles to interprofessional collaboration to make it successful. Some of these barriers, it is argued and illustrated, are found in the multiple ways in which professional identity is tacitly acquired and embodied in the practitioners' habitual, everyday practice. The paper then explores ways in which reflection, especially Second order reflection, can help to elucidate and overcome these obstacles, as well as increasing professional adaptability and competence.     

Determination of creatine kinase isoenzyme MB activity in serum using immunological inhibition of creatine kinase M subunit activity. Activity kinetics and diagnostic significance in myocardial infarction.

This is a new method for the determination of creatine kinase isoenzyme MB activity in serum. The method uses direct activity measurement of creatine kinase B subunit activity after blocking of CK-M subunit activity by inhibiting antibodies. The test takes no longer than 15 min. The method yields an intra-serial C.V. of 2.0-12.9%, and a C.V. from day to day of 5.5%. The detection limit is 3.4 U/l creatine kinase MB. In the 95 cases with proven myocardial infarction several types of creatine kinase MB activity kinetics could be determined. The percentage of creatine kinase MB of peak CK-total is 6-25%, with a mean of 11.1%. The amount of creatine kinase MB with respect to total CK activity after reinfarction is higher than the amount after initial infarction.     

Prise en charge des entorses externes de cheville : étude clinique préliminaire sur l’efficacité du dispositif Myolux™

Ankle sprains are the most common injury of the musculoskeletal system and are associated with significant societal and economic impacts. It has been proven that classical therapeutic strategies may not be effective in preventing recurrent injuries: the recurrence rates reported in the literature can reach 73%. In order to provide an effective rehabilitation solution, a destabilizing orthosis was developed. This device is equipped with a mechanical articulator reproducing the subtalar mechanics and placed under the heel. In this paper, we present the main results of a preliminary clinical study conducted between 2004 and 2007. All subjects included in this study were treated with the abovementioned orthosis during 10 rehabilitation sessions of 30 minutes each. Data show a relatively low recurrence rate of 12% for the overall population. Moreover, it's of primary importance to note that this satisfactory ratio is largely reduced (3% of recurrence rate) for the 29 patients who performed one training session per month after the 10th initial rehabilitation sessions. Hence, the destabilizing orthosis appears to be an effective solution to prevent recurrent ankle sprains. However, joint protection requires long-term and regular training sessions. This result has motivated the development of a similar device allowing patients to perform training sessions at home. Finally, data obtained in this study are promising awaiting the final results of the comparative, multicentric and independent clinical trials currently managed by the Hospices Civils de Lyon.     

俯卧位通气对高海拔地区肺复张治疗无效急性呼吸窘迫综合征患者氧合的影响

目的 探讨俯卧位通气对高海拔地区肺复张术(RM)治疗无效急性呼吸窘迫综合征(ARDS)患者的治疗作用.方法 从海拔2260m的地区医院筛选RM治疗无效的41例ARDS患者[平均氧合指数( PaO2/FiO2)较RM前升高＜20％视为RM无效],依不同病因分为肺内源性ARDS组(ARDSp组)和肺外源性ARDS组(ARDSexp组),每组再按信封法随机分为俯卧位组和仰卧位组,即ARDSp俯卧位组(11例)、ARDSp仰卧位组(9例)、ARDSexp俯卧位组(10例)、ARDSexp仰卧位组(11例).在通气前及通气1、2、3、4h监测动脉血氧分压( PaO2)、PaO2/FiO2、静态顺应性(Cst)、气道阻力(Raw)的变化.结果 通气lh时,ARDSexp俯卧位组PaO2/FiO2( mm Hg,l mm Hg=0.133 kPa)即较通气前显著升高(157.4±40.6比129.3±48.7,P＜0.05),并随通气时间延长呈持续增高趋势,4h达峰值(219.1 ±41.1);且ARDSexp俯卧位组通气3h内PaO2/FiO2较其他3组显著增高,另3组间则差异无统计学意义.ARDSp俯卧位组、ARDSexp俯卧位组通气4h时PaO2/FiO2均较相应仰卧位组显著增高(208.8±39.7比127.4±47.1,219.1±41.1比124.9±50.8,均P＜0.05).4组通气前后Cst无显著改变,各组间差异也无统计学意义.ARDSp俯卧位组通气4h时Raw(cmH2O·L-1·s-1)较通气前显著降低(6.8±1.7比10.7±1.8,P＜0.05),且明显低于其他3组;其他3组各时间点Raw组内及组间比较差异均无统计学意义.结论 俯卧位通气作为ARDS机械通气重要策略之一,可以改善RM无效高原ARDS患者的氧合,为抢救患者赢得宝贵的时间.     

Digital imaging among medical facilities

The Department of Veterans Affairs (VA) in the USA operates a network of 172 medical centres which all utilize a hospital information system (HIS) which has been developed and is currently maintained by the VA. During the past several years, an image management and communication module has been developed, installed and clinically utilized at the Washington DC and Maryland VA Medical Centres. This image management and communication system, referred to as the decentralized hospital computer program (DHCP) imaging system, is fully integrated with a commercial picture archiving and communication system (PACS). The system is utilized to capture, archive, and display all images generated within the hospital including radiology, nuclear medicine, pathology, endoscopy, bronchoscopy, and dermatology, intraoperative photographs, ECG data, and a limited number of paper documents. The ultimate goal of the project is to have all patient text and image data available at any clinical workstation to any authorized user anywhere within the network of medical centres. Clinical requirements for an imaging workstation include ease of use, rapid and reliable access to the complete set of patient information, and images which are of acceptable quality to meet the requirements of the user and the subspecialty. Patient confidentiality and data security must be safeguarded at all times. Integration of the images with the remainder of the patient's database was found to be critical to the success of the project. The experience at the Washington and Maryland facilities suggests that an imaging system that is successfully integrated with a hospital information system can provide substantial clinical and economic benefits both within and among medical centres. Clinical acceptance and utilization of the system has been excellent, particularly in diagnostic radiology where DHCP Imaging has been interfaced to a commercial PAC system. Based upon this initial experience, the VA has begun to deploy the system throughout its large network of medical centres.     

Myocardial elastography at both high temporal and spatial resolution for the detection of infarcts

Myocardial elastography is a novel method for noninvasively assessing regional myocardial function, with the advantages of high spatial and temporal resolution and high signal-to-noise ratio (SNR). In this paper, in-vivo experiments were performed in anesthetized normal and infarcted mice (one day after left anterior descending coronary artery [LAD] ligation) using a high-resolution (30 MHz) ultrasound system (Vevo 770, VisualSonics Inc., Toronto, ON, Canada). Radiofrequency (RF) signals of the left ventricle (LV) in longitudinal (long-axis) view and the associated electrocardiogram (ECG) were simultaneously acquired. Using a retrospective ECG gating technique, 2-D full field-of-view RF frames were acquired at an extremely high frame rate (8 kHz) that resulted in high-quality incremental displacement and strain estimation of the myocardium. The incremental results were further accumulated to obtain the cumulative displacements and strains. Two-dimensional and M-mode displacement images and strain images (elastograms), as well as displacement and strain profiles as a function of time, were compared between normal and infarcted mice. Incremental results clearly depicted cardiac events including LV contraction, LV relaxation and isovolumetric phases in both normal and infarcted mice, and also evidently indicated reduced motion and deformation in the infarcted myocardium. The elastograms indicated that the infarcted regions underwent thinning during systole rather than thickening, as in the normal case. The cumulative elastograms were found to have higher elastographic SNR (SNR(e)) than the incremental elastograms (e.g., 10.6 vs. 4.7 in a normal myocardium, and 6.0 vs. 2.4 in an infarcted myocardium). Finally, preliminary statistical results from nine normal (m = 9) and seven infarcted (n = 7) mice indicated the capability of the cumulative strain in differentiating infracted from normal myocardia. In conclusion, myocardial elastography could provide regional strain information at simultaneously high temporal (>/=0.125 ms) and spatial ( approximately 55 microm) resolution as well as high precision ( approximately 0.05 microm displacement). This technique was thus capable of accurately characterizing normal myocardial function throughout an entire cardiac cycle, at the same high resolution, and detecting and localizing myocardial infarction in vivo.