急性心肌梗死后康复运动患者的心脏功能评价

目的检测急性心肌梗死(AMI)患者进行早期指导性康复运动和无康复运动者分别在发病第3天及3个月时血清N末端B型钠尿肽前体(NT-proBNP)的水平、左室射血分数(LVEF)和左室舒张末期直径(LVDd)的变化,探讨AMI无严重并发症患者早期康复运动的血清NT-proBNP水平、心脏功能情况。方法选择54例AMI无严重并发症患者,运动组29人(运动+药物治疗),非运动组25人(仅药物治疗)。在AMI第3天做超声心动图检查及检测患者血清NT-proBNP水平,于AMI后3个月时重复上述检查。结果(1)运动组的患者心梗第3天及3个月时NT-proBNP水平从1076.00(666.50-1723.50)ng/L显著下降至211.00(141.75-374.00)ng/L(P<0.05),非运动组的患者血清NT-proB-NP水平从573.00(231.00-1059.50)ng/L降至462.10(218.30-1042.00)ng/L,无显著变化。3个月时两组间有显著性差异(P<0.01)。(2)运动组患者心梗的第3天及3个月时LVDd(50.63±4.89)mm增加到(50.78±4.10)mm没有显著变化,但非运动组的患者从(50.31±4.27)mm增加到(51.85±4.37)mm,LVDd呈显著增加。3个月时两组间LVDd比较有显著性差异(P<0.01)。(3)运动组患者心梗第3天及3个月时的LVEF从(55±9)%升高到(60±8)%,LVEF呈显著升高(P<0.05),非运动组的患者(53±9)%减少到(52±8)%,无显著性变化。3个月时两组间LVEF值有显著性差异(P<0.05)。结论AMI无严重并发症患者早期进行指导性康复运动是安全可行的,可以降低患者血清NT-proBNP水平,增加左室射血分数,可能降低左室舒张末期直径。     

AMI患者血清NT-proBNP水平在预测心脏功能中的临床意义

目的通过观察急性心肌梗死(acutemyocardialinfarction,AMI)患者在发病后第3天血清N末端B型脑钠尿肽前体(N-terminalpro-brainnatriureticpeptide,NT-proBNP)的水平与患者发病后3个月时左室舒末容积的增加率之间的关系,探讨预测AMI晚期左室重构的指标。方法选择2004年6月至2005年4月于北京大学第三医院诊断为前壁、前间壁及前侧壁AMI的患者106例,分别在患者发病后第3天和3个月时做超声心动图测定左室舒末容积,依据左室舒末容积的增加率(目前我国诊断左室重构的指标之一,cutoff值定为0.2),将患者分为左室重构组及非左室重构组;于发病后第3天采集患者空腹静脉血,采用电化学免疫发光法检测血清NT-proBNP水平。结果AMI发病后第3天,左室重构组,血清NT-proBNP平均为1819.0(1009.5～4601.5)pg/ml;无左室重构组,血清NT-proBNP平均为504.15(212.50～856.25)pg/ml,两组比较有显著性差异(P<0.05)。患者发病后3个月时左室舒末容积较基础值增加率与NT-proBNP水平的相关系数为0.702(P<0.001)。血清NT-proBNP的受试者工作特征曲线(receiveroperatingcharacteristiccurve,ROC曲线)下面积为0.892,当预测特异度为81.8%时,NT-proBNP的敏感度为83.3%;在预测敏感度为98.8%,NT-proBNP的特异度为36.4%,其cutoff值为952pg/ml。结论AMI患者血清NT-proBNP水平是评估AMI后晚期心脏功能的较理想指标。     

急性心肌梗死后血清Ⅲ型前胶原蛋白与左室功能变化关系的临床研究

目的　研究血清Ⅲ型前胶原蛋白 (PCⅢ )水平与急性心肌梗死 (AMI)后左室功能的关系。方法　应用放免法测定AMI患者血清PCⅢ水平 ,以其在AMI后第 4天的水平分为 2组 (A组PCⅢ <15 0 μg/L ;B组PCⅢ >15 0 μg/L) ,并将其与左室舒张末期直径 (LVDd)和射血分数 (EF)做相关性分析。结果　研究发现 ,AMI后血清PCⅢ水平较正常对照组升高 ,并在第 4天具有显著性差异。比较A组与B组的心室功能 ,发现A组的LVDd明显低于B组 [(5 1± 3 4 )vs(5 7 9± 5 6 ) ,P <0 0 5 ],而EF值较B组高 [(5 5 4± 4 5 )vs(46 5± 6 9) ,P <0 0 1],而且第 4天的血清PCⅢ水平与LVDd呈明显正相关关系 (r =0 5 ,P <0 0 5 ) ,而与EF值无明显相关关系 (P >0 0 5 )。结论　在AMI后血清PCⅢ水平与左室功能变化相关 ,可作为临床上判断AMI早期心室重沟的间接依据。     

血清NT-proBNP和CRP水平对AMI后左室重构的预测价值

目的通过观察急性心肌梗死(AM I)患者在发病第3天血清N末端B型钠尿肽前体(NT-proBNP)和C反应蛋白(CRP)的水平与AM I后3个月的左室舒张末期容积增加率之间的关系,寻找可用于预测AM I晚期左室重构的较理想指标。方法选择106例前壁、前间壁及前侧壁AM I患者,分别在发病第3天和3个月做超声心动图测定左室舒张末期容积的变化,将患者分为左室重构(LV remodeling,LVR)组及非左室重构组;采用电化学免疫发光法和免疫比浊法检测血清NT-proBNP和CRP水平。结果AM I后3个月左室舒张末期容积较基础值增加率与NT-proBNP水平的相关系数为0.706,P<0.001;与CRP的相关系数为0.596,P<0.05。血清NT-proBNP、CRP的ROC曲线下面积分别为0.892和0.825,二者曲线下面积无统计学差异。结论AM I患者血清NT-proBNP、CRP水平是预测晚期LVR的理想指标;AM I患者发病第3天的血清NT-proBNP水平与3个月时LVR呈正相关;血清NT-proBNP水平预测晚期LVR优于血清CRP水平。     

外周血PLGF水平预测老年性急性心肌梗死预后的价值

目的研究胎盘生长因子(PLGF)、超敏C-反应蛋白(Hs-CRP)、肌酸激酶同工酶(CK-MB)与心肌梗死(AMI)患者的动态变化,以及PLGF水平与心肌梗死面积大小、心室重构程度的关系。方法选取患者66例AMI患者和健康体检者30例。AMI患者采用溶栓再通或者介入再通,在AMI后的12 h、第3天、第7天、第30天采集外周静脉血测定PLGF水平,检查超声心动图测定左心室射血分数(LVEF),左心室舒张末期容积(LVEDV),并与健康患者比较。结果 AMI患者发病血清PLGF及CK-MB 12 h、第3天、第7天均明显高于健康对照组(P<0.01),而在第30天血清PLGF与正常对照组比较差异无统计学意义(P>0.05)。AMI组血清Hs-CRP水平于发病12 h、第3天、第7天,第30天均明显高于正常对照组,差异具有统计学意义(P<0.01),其中发病第3天为高峰期。AMI组第3天至第7天及第7天至第30天的血清PLGF与CK-MB呈正相关(P<0.01);AMI组第3天到第7天的血清PLGF与LVEF呈负相关(P<0.01),而与LVEDV呈正相关(P<0.01),AMI组第7天到第30天血清PLGF与LVEF呈正相关(P<0.01),而与LVEDV呈负相关(P<0.01)。结论 PLGF及CK-MB在AMI12 h开始升高,第3天达高峰,第30天开始降至正常水平,血清PLGF动态变化及其与心肌梗死面积大小、心室重构程度相关。     

急性心肌梗死患者血浆N-末端脑钠肽前体水平检测及其临床意义

目的探讨急性心肌梗死(AMI)患者住院早期血浆N-末端脑钠肽前体(NT-proBNP)水平与梗死面积、心功能及住院期心脏事件的关系。方法采用ELISA法测定41例AMI患者住院后48小时内血浆NT-proBNP水平,并与患者肌酸激酶(CK)和肌酸激酶同功酶(CK-MB)峰值浓度、左室射血分数(LVEF)、住院期主要不良心脏事件(MACE)对比分析。结果AMI患者血浆NT-proBNP水平明显高于正常对照组(699.44±386.28pg/ml vs 41.75±24.26pg/ml,P<0.001)。血浆NT-proBNP水平与CK、CK-MB峰值浓度呈正相关(r=0.817,P=0.001;r=0.772,P=0.001),与LVEF呈负相关(r=-0.661,P<0.01)。住院期发生MACE患者的血浆NT-proBNP水平明显高于未发生MACE者(971.50±367.01pg/ml vs 393.60±261.16pg/ml,P<0.001)。结论AMI患者血浆NT-proBNP水平与CK、CK-MB峰值呈正相关,与LVEF呈负相关。检测血浆NT-proBNP水平可预测AMI患者梗塞面积、心功能及住院期心血管事件。     

达利全对心力衰竭患者心功能及sFas的影响

目的　观察达利全 (卡维地洛 )对慢性充血性心力衰竭 (CHF)患者的心功能及血清可溶性Fas(sFas)水平的影响。方法　 72例CHF患者随机分成达利全组和治疗对照组 ,于治疗前、后查超声心动图 (UCG)的左室射血分数 (LVEF)、左室收缩末内径 (LVDd)、左室舒张末内径 (LVDs)、血清sFas。 10例心功能正常者为血清sFas正常对照组。结果　治疗 4个月后两组LVEF升高、LVDd和LVDs均缩小 ,血清sFas水平降低 ,但达利全组明显优于对照组 P<0 .0 1。结论　达利全能改善CHF患者心功能和心室重构。     

自体骨髓单个核细胞移植治疗扩张型心肌病的临床观察

目的:观察自体骨髓单个核细胞冠脉内移植治疗扩张型心肌病的临床疗效。方法:扩张型心肌病16例(男性5例, 女性11例),平均年龄(45．3±10．8)岁,心功能Ⅳ级,左室射血分数(LVEF)<30％。抽取骨髓,用Ficoll密度梯度离心法分离骨髓单个核细胞,经外周动脉穿刺插管,将骨髓单个核细胞分别直接注入左、右冠脉。比较移植前后心功能的变化。结果:移植3个月后,心功能(NYHA分级)得到改善,总有效率87．5％,超声心动图检查均示左室舒张末径(mm)(72．94± 4．01 vs 63．63±2．58．P<0．001)、左室收缩末径(mm)(52．00±2．80 vs 44．38±1．78．P<0．001)减小,左室射血分数(％) (22．88±5．29vs33．81±3．33,P<0．001)、短轴缩短率(％)(12．00±2．39 vs 20．94±3．70,P<0．001)明显增加;心脏ECT 检查与术前相比,术后患者缺血及坏死心肌节段减少,(3．4±0．3vs2．1±0．4,P<0．05)(2．5±0．5 vs 1．6±0.3,P< 0．01)个。结论:自体骨髓单个核细胞移植有可能通过缺血心肌血运改善,坏死心肌区有心肌细胞再生而改善扩张型心肌病的心功能。     

组织多普勒超声对急性心肌梗死患者急诊PCI后二尖瓣环舒张早期速度与心室重构关系的研究

目的 观察急性ST段抬高心肌梗死(STEMI)患者急诊经皮冠状动脉介入(PCI)后二尖瓣环舒张早期峰值速度(Em)与心室重构关系.方法 随机选取79例急诊PCI治疗的STEMI患者,应用超声心动图及组织多普勒超声测定患者入院第7天及发病6个月时左室舒张末期容积(LVEDV)、左室收缩末期容积(LVESV)、左室射血分数(LVEF)、左室舒张末期容积指数(LVEDVI)及二尖瓣环收缩期运动速度(Sm)、舒张期早期运动速度(Em)、舒张晚期运动速度(Am).按6个月时LVEDVI较第7天增加20%为标准分为重构组(18例)与未重构组(61例).结果 重构组患者发病第7天及6个月时Em均显著低于未重构组,P值<0.05.6个月LVEDVI与第7天Em呈负相关,r=-0.426,P<0.001.第7天Em ≤3 cm/s的患者6个月时LVEF显著减低,心室重构率显著增加(P<0.05).结论 急诊PCI治疗的STEMI患者发病第7天Em降低与半年后心室重构密切相关.     

白细胞介素6与急性心肌梗死后心室重构的相关性

目的探讨白细胞介素6(IL-6)与心肌梗死后早期心室重构(LVRM)的关系,为急性心肌梗死患者病情评估与预后判断提供理论依据。方法选择发病12小时内的首次急性Q波心肌梗死患者64例,测定发病72小时的血清IL-6浓度以及第14天的超声心动图。按照IL-6浓度分为低IL-6组(IL-6<10 ng/L)、高IL-6组(IL-6≥10 ng/L),比较两组间左室射血分数(LVEF)、左室收缩末容积(LVESV)、左室舒张末容积(LVEDV)、室壁瘤及总的LVRM的发生率。结果高IL-6组较低IL-6组LVEF降低(52.29±11.45)%比(58.11±9.83)%(P<0.05),而LVEDV、LVESV、室壁瘤发生率、左室重构发生率均升高(P<0.05)。相关分析:IL-6与LVEDV、LVESV、室壁瘤及左室重构均呈显著正相关(P<0.05),与LVEF呈显著负相关(P<0.05)。结论急性心肌梗死后72小时血清IL-6浓度与梗死后心室重构发生率呈正相关,是预测心肌梗死后发生心室重构的敏感性指标。     

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.     

Dissociable correlates of two classes of retrieval processing in prefrontal cortex

Although substantial evidence suggests that the prefrontal cortex (PFC) implements processes that are critical for accurate episodic memory judgments, the specific roles of different PFC subregions remain unclear. Here, we used event-related functional magnetic resonance imaging to distinguish between prefrontal activity related to operations that (1) influence processing of retrieval cues based on current task demands, or (2) are involved in monitoring the outputs of retrieval. Fourteen participants studied auditory words spoken by a male or female speaker and completed memory tests in which the stimuli were unstudied foil words and studied words spoken by either the same speaker at study, or the alternate speaker. On "general" test trials, participants were to determine whether each word was studied, regardless of the voice of the speaker, whereas on "specific" test trials, participants were to additionally distinguish between studied words that were spoken in the same voice or a different voice at study. Thus, on specific test trials, participants were explicitly required to attend to voice information in order to evaluate each test item. Anterior (right BA 10), dorsolateral prefrontal (right BA 46), and inferior frontal (bilateral BA 47/12) regions were more active during specific than during general trials. Activation in anterior and dorsolateral PFC was enhanced during specific test trials even in response to unstudied items, suggesting that activation in these regions was related to the differential processing of retrieval cues in the two tasks. In contrast, differences between specific and general test trials in inferior frontal regions (bilateral BA 47/12) were seen only for studied items, suggesting a role for these regions in post-retrieval monitoring processes. Results from this study are consistent with the idea that different PFC subregions implement distinct, but complementary processes that collectively support accurate episodic memory judgments.     

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.     

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.     

Modified micro-superior percutaneously-assisted total hip: early experiences & case reports

Because of the extensile nature and familiarity of the standard posterior-lateral approach to the hip, a family of "micro-posterior" approaches has been developed. This family includes the Percutaneously-Assisted Total Hip (PATH) approach, the Supercapsular (SuperCap) approach and a newer hybrid approach, the Supercapsular Percutaneously-Assisted Total Hip (SuperPATH) approach. Such approaches should ideally provide a continuum for the surgeon: from a "micro" (external rotator sparing) posterior approach, to a "mini" (external rotator sacrificing) posterior approach, to a standard posterior approach. This could keep a surgeon within his comfort zone during the learning curve of the procedure, while leaving options for complicated reconstructions for the more practiced micro-posterior surgeons. This paper details one author's experiences utilizing this combined approach, as well as permutations of this entire micro-posterior family of approaches as applied to more complex hip reconstructions.     

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.     

Structure and function of "metalloantibiotics"

Although most antibiotics do not need metal ions for their biological activities, there are a number of antibiotics that require metal ions to function properly, such as bleomycin (BLM), streptonigrin (SN), and bacitracin. The coordinated metal ions in these antibiotics play an important role in maintaining proper structure and/or function of these antibiotics. Removal of the metal ions from these antibiotics can cause changes in structure and/or function of these antibiotics. Similar to the case of "metalloproteins," these antibiotics are dubbed "metalloantibiotics" which are the title subjects of this review. Metalloantibiotics can interact with several different kinds of biomolecules, including DNA, RNA, proteins, receptors, and lipids, rendering their unique and specific bioactivities. In addition to the microbial-originated metalloantibiotics, many metalloantibiotic derivatives and metal complexes of synthetic ligands also show antibacterial, antiviral, and anti-neoplastic activities which are also briefly discussed to provide a broad sense of the term "metalloantibiotics."