双心室起搏治疗慢性心力衰竭患者的护理与生活质量评价

目的 观察双心室起搏对慢性心力衰竭患者生活质量的影响,定量反应该治疗的效果.方法 慢性心力衰竭伴室内传导阻滞患者9例,全部植入三腔双心室起搏器,比较双心室起搏前后患者超声心动图和生活质量的变化.结果 双心室同步起搏后,患者左室射血分数,6 min步行距离(m),生活质量评分比治疗前有显著性差异(P＜0.05).结论 双心室起搏能有效改善慢性心衰患者心肺功能,提高生活质量.     

慢性心力衰竭患者双心室起搏器植入术后的护理

目的总结慢性心力衰竭（chronic heart failure,CHF）患者双心室起搏器植入术后的护理要点,尤其是心理干预及患者教育的作用。方法对2009年3月-2010年5月收治的34例接受双心室起搏治疗的CHF患者进行观察和全面护理,主要是进行心理干预及患者教育,并在出院后进行长时间随访。结果患者在双心室起搏器植入术后的随访过程中,心力衰竭症状缓解,左心室射血分数、心输出量、左心室充盈时间增加。结论双心室起搏植入术后,辅以全面合理的护理措施,尤其是心理干预及患者教育可以进一步防止并发症的发生,有利于患者改善预后,提高生活质量。     

双心室再同步起搏对慢性心力衰竭患者短期疗效观察（附37例分析）

目的：观察心脏再同步化治疗对慢性心力衰竭（CHF）患者的短期临床疗效。方法：对37例CHF患者行双心室再同步起搏治疗前和起搏后6个月的心功能分级（NYHA）,左室射血分数（LVEF）,6min步行试验,心电图QRS波群时限,最大摄氧量（VO2MAX）,生活质量（QOL）作自身对比分析。结果：NYHA,LVEF均有明显改善;QRS时限缩短;6min步行距离由298.48±80.60m上升至375.31±82.51m,提高了25%;VO2MAX绝对值（L.min^-1）由768.18±325.24升至918.39±443.87,VO2MAX相对值（L.min^-1.kg^-1）由12.95±3.95提高至15.52±5.67,QOL评分由22.70±16.10降至8.86±9.40,均有显著差异。结论：双心室起搏能够有效地改善具有心室传导延迟、心脏收缩不同步的慢性心力衰竭患者的心功能,提高生活质量,是治疗慢性心力衰竭的有效方法。     

双心室起搏与右心室起搏对充血性心力衰竭急性心功能的影响

目的最近研究提示心脏再同步治疗有效地改善了慢性心肌病心力衰竭患者心功能。本研究旨在探讨双心室和右心室起搏对心功能的相对影响。方法 15例慢性心力衰竭患者心功能Ⅲ级,左心室射血分数〈35%,QRS〉130ms和二尖瓣反流。安装心房-双心室再同步起搏器。彩色多普勒超声心动图观察心功能变化。结果急性双心室和右心室起搏并未影响左心室内径和短轴缩短率,也不影响左心室射血速度和排血量。左心室压力上升和下降峰速率无明显变化。等容收缩时间缩短（P〈0.05）,但不影响等容舒张时间。增加Z比例（P〈0.05）。缩短二尖瓣反流时间（P〈0.05）,对二尖瓣环和三尖瓣环运动幅度和峰速率无明显影响。双心室和右心室起搏之间无明显差别。结论双心室起搏改善了慢性心肌病心功能。双心室和右心室起搏无明显差别。双心室起搏是一种有前途的心脏再同步治疗方法。     

双心室同步起搏治疗慢性充血性心力衰竭10例围术期护理

慢性充血性心力衰竭(CHF)、心功能Ⅲ～Ⅳ级的患者生活质量下降,病死率高.双心室同步起搏可纠正室内传导延迟导致的左室充盈时间缩短、收缩不同步及二尖瓣反流,从而改善患者心功能,提高生活质量,延长寿命[1].近年来,我们对10例CHF患者进行双心室同步起搏治疗,经精心围术期护理,效果满意.现报告如下.     

充血性心力衰竭患者行双心室起搏治疗围术期护理

慢性充血性心力衰竭(CHF)、心功能Ⅲ～Ⅳ级患者,药物治疗难以控制症状,患者生活质量下降,存活率低。由于双心室同步起搏纠正了因室内传导延迟导致的左室充盈时间缩短,收缩不同步,以及二尖瓣返流,从而改善了心功能,提高了患者的生活质量,延长了患者的生命。因此,双心室同步起搏技术已成为近年来药物疗效不佳的CHF患者新的主要治疗方法之一[1]。我科自2001年3月～2004年3月对30例心力衰竭患者实施双心室起搏治疗,效果良好,现将护理体会介绍如下。1临床资料本组30例患者,男24例,女6例,年龄34～77岁,平均年龄为59.86岁。其中扩张性心肌病16例…     

心室再同步化起搏除颤器安置术二例的护理

心室再同步起搏治疗（cardiac resynchronous therapy，CRT）充血性心力衰竭伴心室内阻滞患者的疗效已被多个临床试验所证实。植入型心律转复除颤器（implantable cardioverter defibrillator，ICD）作为治疗恶性室性心律失常也已广泛应用于临床。在植入ICD患者中有相当一部分患者伴有充血性心力衰竭及心室内传导阻滞，而双心室同步起搏可使这一部分患者心功能得到改善，     

1例CRT-D型永久起搏器植入术的护理

植入型三腔转复除颤器（CRT—D），独立RV和LV输出和顺序双室起搏，优化双心室起搏，左室自动阈值管理功能，确保双心室同步。它充电时间快速稳定，减少患者晕厥，减少不必要的电击治疗，确保患者安全。它能全面评估患者心力衰竭和心律失常状况，帮助医师、护士全面管理心力衰竭患者，现将我科1例CRT—D型永久起搏器植入术的护理体会报道如下。     

心室起搏、美托洛尔治疗慢室率房颤伴慢性充血性心力衰竭

目的观察美托洛尔对慢室率房颤伴慢性充血性心力衰竭在心室起搏后的疗效。方法在血管扩张剂（ACEI及硝酸脂类）、利尿剂等抗心力衰竭治疗基础上，植放心室起搏器，待病情稳定后加用美托洛尔。起始剂量6．25mg／日，如能耐受前一剂量，每隔2～4周将剂量加倍。目标剂量（血压目标）：加量后患者休息坐位收缩压90～110mmHg。最大剂量200mg／日。观察治疗前后左室内径（LVDs）、每搏量（SV）、每分输出量（CO）、心脏指数（CI）、左室射血分数（LVEF）、心胸比、6min步行距离的变化。结果治疗前及治疗6～12月后各项心功能指标明显改善。结论对慢室率房颤伴慢性充血性心力衰竭病人．应适当放宽起搏器适应症，在安装心室起搏器后，给予倍他受体阻滞剂治疗能明显改善心功能。     

充血性心力衰竭患者行双心室起搏治疗围术期护理

慢性充血性心力衰竭(CHF)、心功能Ⅲ～Ⅳ级患者,药物治疗难以控制症状,患者生活质量下降,存活率低.由于双心室同步起搏纠正了因室内传导延迟导致的左室充盈时间缩短,收缩不同步,以及二尖瓣返流,从而改善了心功能,提高了患者的生活质量,延长了患者的生命.     

Fibrinogen and fibrin structure and functions

Fibrinogen molecules are comprised of two sets of disulfide-bridged Aalpha-, Bbeta-, and gamma-chains. Each molecule contains two outer D domains connected to a central E domain by a coiled-coil segment. Fibrin is formed after thrombin cleavage of fibrinopeptide A (FPA) from fibrinogen Aalpha-chains, thus initiating fibrin polymerization. Double-stranded fibrils form through end-to-middle domain (D:E) associations, and concomitant lateral fibril associations and branching create a clot network. Fibrin assembly facilitates intermolecular antiparallel C-terminal alignment of gamma-chain pairs, which are then covalently 'cross-linked' by factor XIII ('plasma protransglutaminase') or XIIIa to form 'gamma-dimers'. In addition to its primary role of providing scaffolding for the intravascular thrombus and also accounting for important clot viscoelastic properties, fibrin(ogen) participates in other biologic functions involving unique binding sites, some of which become exposed as a consequence of fibrin formation. This review provides details about fibrinogen and fibrin structure, and correlates this information with biological functions that include: (i) suppression of plasma factor XIII-mediated cross-linking activity in blood by binding the factor XIII A2B2 complex. (ii) Non-substrate thrombin binding to fibrin, termed antithrombin I (AT-I), which down-regulates thrombin generation in clotting blood. (iii) Tissue-type plasminogen activator (tPA)-stimulated plasminogen activation by fibrin that results from formation of a ternary tPA-plasminogen-fibrin complex. Binding of inhibitors such as alpha2-antiplasmin, plasminogen activator inhibitor-2, lipoprotein(a), or histidine-rich glycoprotein, impairs plasminogen activation. (iv) Enhanced interactions with the extracellular matrix by binding of fibronectin to fibrin(ogen). (v) Molecular and cellular interactions of fibrin beta15-42. This sequence binds to heparin and mediates platelet and endothelial cell spreading, fibroblast proliferation, and capillary tube formation. Interactions between beta15-42 and vascular endothelial (VE)-cadherin, an endothelial cell receptor, also promote capillary tube formation and angiogenesis. These activities are enhanced by binding of growth factors like fibroblast growth factor-2 (FGF-2) and vascular endothelial growth factor (VEGF), and cytokines like interleukin (IL)-1. (vi) Fibrinogen binding to the platelet alpha(IIb)beta3 receptor, which is important for incorporating platelets into a developing thrombus. (vii) Leukocyte binding to fibrin(ogen) via integrin alpha(M)beta2 (Mac-1), which is a high affinity receptor on stimulated monocytes and neutrophils.     

Migraine and genetic and acquired vasculopathies

It is remarkable that migraine is a prominent part of the phenotype of several genetic vasculopathies, including cerebral autosomal dominant arteriopathy with subcortical infarcts and leucoencephalopathy (CADASIL), retinal vasculopathy with cerebral leukodystrophy (RVCL) and hereditary infantile hemiparessis, retinal arteriolar tortuosity and leukoencephalopahty (HIHRATL). The mechanisms by which these genetic vasculopathies give rise to migraine are still unclear. Common genetic susceptibility, increased susceptibility to cortical spreading depression (CSD) and vascular endothelial dysfunction are among the possible explanations. The relation between migraine and acquired vasculopathies such as ischaemic stroke and coronary heart disease has long been established, further supporting a role of the (cerebral) blood vessels in migraine. This review focuses on genetic and acquired vasculopathies associated with migraine. We speculate how genetic and acquired vascular mechanisms might be involved in migraine.     

创伤高血糖与感染和MODS早期诊断和干预

本文详细介绍了创伤后血糖应激适度理论,以及高血糖与感染和多器官功能不全综合征的关系;提出涉及胰岛B细胞功能不全的MODS实验诊断新方案和极化液个体化干预新措施,可早期发现创伤MODS、降低感染率及MODS发生率和病死率。     

腹膜后纤维化与肾积水发生关系的临床研究

目的：探讨腹膜后纤维化（RPF）导致肾积水的原因及诊治经验。方法：回顾分析2004年1月—2010年12月24例腹膜后纤维化致肾积水患者的诊治资料。结果：（1）RPF患者常见首发症状为腰背痛或腹痛（69.2%）;（2）红细胞沉降率（ESR）增快和血清IgG4升高最常见。超声检查仅提示上尿路积水。RPF的静脉肾盂造影（IVP）和CT尿路成像（CTU）表现具有特征性。IVP肾盂输尿管显影不良时,CTU能较清晰的显示上尿路影像。CT扫描发现腹膜后软组织肿块9例（37.5%）,优于超声检查;（3）输尿管松解和腹腔化手术治疗22例;行肾切除术1例;行输尿管置双J管术1例。最终确诊为继发性RPF8例,其中4例为术前诊断,3例为术中腹膜后软组织肿块冷冻活检证实,1例为术后病理证实;（4）特发性RPF手术后肾积水均获长期缓解,而继发性RPF的预后取决于原发疾病及其治疗方案。结论：影像学检查是诊断RPF的重要手段,CTU优于超声检查和IVP。输尿管松解和腹腔化手术可以使特发性RPF输尿管梗阻得到长期的缓解,术中对肿块进行冷冻活检有助于鉴别特发性和继发性RPF,及时调整治疗方案。     

Telemedicine and teleradiology technologies and applications

Summary. Telemedicine and teleradiology hold the key for improving future health care delivery. In this paper we first review current communication and computer technologies used in telemedicine and teleradiology. Five examples in teleradiology applications are given including hospital-integrated picture archiving and communication systems, tele-neuro-imaging, telemammography, university consortium teleradiology service, and teleradiology for second opinion. Parameters important to teleradiology applications like costs, image quality, system reliability, and turn around time are considered. Data security is discussed, including patient confidentiality and image authenticity-which will be a major issue in future teleradiology applications.     

Physician and Nurse Practitioner Teamwork and Job Satisfaction: Gender and Profession

Designing interprofessional primary care teams composed of physicians and nurse practitioners (NPs) is a national priority. We assessed how profession and gender affect teamwork and job satisfaction among primary care physicians and NPs by using survey data from 186 physicians and 398 NPs practicing in New York State. Our regression models show profession (NP vs physician) moderates the associations of gender with teamwork and job satisfaction. Among NPs, men had higher job satisfaction than women. Among physicians, women had higher job satisfaction than men. Our results can benefit interprofessional primary care teams to optimize their professional and gender mix.     

探讨儿童慢性顽固性咳嗽与支原体感染的关系及临床治疗观察

目的探讨儿童慢性顽固性咳嗽与肺炎支原体（MP）感染的关系及临床疗效观察。方法采用回顾性研究方法对于现将2005年3月至2008年3月在我院的55例确诊慢性顽固性咳嗽患儿,主要表现为肺炎支原体感染为临床特点进行分析,并进一步临床治疗研究。结果①临床特点：在55例确诊慢性咳嗽的患儿中,以慢性顽固性咳嗽为主要症状。58％（32／55）的病例无肺部体征;②外周血：85％（47／55）的病例外周血变化不大,WBC（4—10）×10 9／L之间,嗜酸性粒细胞增多;③特别检查：47．27％（26／55）肺炎支原体IgM（MP—IgM）抗体阳性,83．64％（46／55）PeR技术检测肺炎支原体特异性DNA;④X光报告为多种形式。结论肺炎支原体（MP）感染是引起儿童慢性顽固性咳嗽的病因之一,对儿童慢性咳嗽,特别是顽固性咳嗽的诊治中应更加重视。     

Acetaminophen and acetylcysteine dose and duration: Past,present and future

Abstract

Acetylcysteine has been utilized successfully in the treatment of acetaminophen overdose since the 1970s. Although prospective trials as to efficacy and safety of acetylcysteine were conducted, there were no randomized controlled trials. This commentary addresses the reasons for this, and the background to choice of dose of acetylcysteine utilized in the oral and IV dosing regimens. Nomograms to predict possible hepatotoxicity based upon time of ingestion of acetaminophen were developed from a relatively arbitrary definition of toxicity as an aspartate aminotransferase/alanine aminotransferase (ALT/AST) greater than 1000 IU/L. While these have proved generally useful, patients still continue to develop hepatic damage after acetaminophen overdose, particularly if they present late after ingestion. The optimum management of these patients remains unclear, and one area of uncertainty is the dose and duration of acetylcysteine in various circumstances. This article discusses the issues that need to be elucidated to better target changes in acetylcysteine dose. The potential for measurements of other markers to improve treatment selection is the subject of further research.