直接经皮冠状动脉介入治疗对高龄急性心肌梗死患者心室重构与心功能的影响

目的评估直接经皮冠状动脉介入治疗(PCI)对高龄急性心肌梗死(AMI)患者心室重构及心功能的影响。方法选取2017年5月至2019年5月我科收治的高龄AMI患者100例,分为研究组和对照组,每组患者各50例,其中研究组接受直接PCI治疗+标准药物治疗,对照组给予标准的药物治疗,比较治疗前后两组的可溶性ST2(sST2)和N-末端脑钠肽前体(NT-proBNP)水平及超声心动图结果。结果治疗后两组的sST2、NT-proBNP水平均有所下降,且研究组下降幅度优于对照组(P<0.05);治疗后两组左室舒张末期容积(LVEDV)、左室收缩末期容积(LVESV)、球形指数(SI)、室间隔厚度(IVST)及左室后壁厚度(LVPWT)均下降,而左室射血分数(LVEF)均升高,且研究组效果优于对照组(P<0.05)。结论直接PCI可有效挽救高龄AMI患者的梗死心肌,能有效延缓高龄AMI患者的心室重构,改善心功能,是高龄AMI患者的有效且安全的治疗手段。     

急性心肌梗死后冠状动脉自发再通的预测因素及其临床意义

目的　探讨急性心肌梗死 (AMI)后冠状动脉自发再通 (SR)的预测因素及其临床意义。方法　行选择性冠状动脉造影和左室造影的 2 16例首次AMI患者 ,分组比较SR对肌酸激酶 (CK)峰值浓度、左室功能和临床转归的影响 ,并分析SR的预测因素。结果　①分组 :有自发再通的A组 5 7例 (2 6 4 % ) ,无自发再通的B组 15 9例 (73 6 % )。②入院时Killip心功能分级A组低于B组 (P <0 0 5 ) ,CK及CK -MB峰值浓度A组显著低于B组 (P <0 0 5 )。③左室射血分数A组明显低于B组(P <0 0 1) ,而室壁运动记分则A组明显低于B组 (P <0 0 1)。④PTCA术后TIMI血流 3级的比例A组显著高于B组 (P <0 0 5 ) ;总的院内心脏事件发生率A组显著低于B组 (P <0 0 5 )。⑤梗死前心绞痛 (P <0 0 1)、发病至治疗间期 (≤ 4h) (P <0 0 5 )和梗死相关动脉的侧支循环 (0～ 1级 ) (P <0 0 5 )是SR的独立预测因素。结论　AMI后冠状动脉自发再通的患者左室功能和临床预后较好 ,其发生可能与梗死前心绞痛和发病至治疗的间期有关。     

急性心肌梗死溶栓时间对心肌梗死面积及左心室功能的影响

目的 :探讨急性心肌梗死 (AMI)发病后不同时间溶栓治疗对心肌梗死面积及左心室功能的影响。方法 :选我市三家医院 3年来有溶栓适应证的急性心肌梗死患者 46例 ,按发病至溶栓时间随机分为A组、B组、C组 ,三组均给予组织型纤溶酶原激活剂 (rt -PA) 5 0mg配合静脉应用肝素 ,以aPTT结果调整肝素剂量 ,三组常规治疗相同。 3周后 ,据治疗前后QRS分值 ,二维超声心动图评价急性心肌梗死溶栓治疗时间对AMI梗死面积和心室容量及心功能改善方面的影响。结果 :A、B组QRS分值明显减低 ,梗死面积明显缩小 (P <0 0 5 ) ,C组与A、B组比较P <0 0 0 1,差异性显著。三组治疗前后心室容量和心功能改善情况比较 :A、B组左心室容积 (ESV、EDV)减少 ,左室射血分数 (LVEF)明显提高 ,C组ESV、EDV增大 ,射血分数明显降低 ,C组与A、B组相比有显著性差异 (P <0 0 0 1)。结论 :AMI后 6h内溶栓治疗有肯定疗效 ,及时有效再灌注可明显缩小心肌梗死面积 ,改善左心功能     

急性心肌梗死冠状动脉介入术后心肌灌注程度对心室功能和收缩同步性的影响

目的 应用心肌灌注分级(MBG)的方法判断急性前壁心肌梗死患者直接经皮冠状动脉成形术(AMI-PCI)后的微循环灌注情况,并评价其对局部、整体心室收缩功能和同步性的影响.方法 首发前壁AMI患者124例,于12 h内行直接PCI,按MBG方法将患者分为心肌灌注不良组(MBG 0～1级,A组)和心肌灌注良好组(MBG 2～3级,B组).于PCI后即行左心室造影,测定心室容积、压力参数和室壁运动积分(WMS);AMI后1周时行平衡法核素心室造影,测定左室整体和局部收缩功能、舒张功能和收缩同步性参数;AMI后6个月随访时重复行心室造影和核素心室造影检查测定上述参数,并记录主要恶性心脏事件(MACE)的发生率.结果 AMI-PCI后6个月随访时,A组LVESVI、LVEDVI、WMS和LVEDP均较B组分别增高27.02%、12.02%、27.65% 和 33.61% (P均<0.05),而LVEF、PER和PFR均较B组降低14.72%、15.79%、21.08%(P均<0.05).AMI-PCI后6个月,A组LrEF2～8分别较B组降低19.43%、32.98%、34.55%、35.89%、28.78%、27.49%和21.77%(P均<0.05).相位分析显示,A组左室收缩同步性参数PS、FWHM和PSD亦均高于B组.在6个月随访期内,A组MACE发生率明显高于B组.结论 经MBG判定的直接PCI后的微循环损伤状态可导致左室局部、整体收缩和同步性的降低,减弱心室射血的力学效应,促进心室重构,直接影响AMI患者的长期预后.     

心肌梗死前心绞痛对心肌梗死后近远期心功能的影响

[目的]探讨心肌梗死前心绞痛（PIA）对心肌梗死（MI）左室功能的影响。[方法]150例首次急性心肌梗死（AMI）患者,按既往有无梗死前心绞痛分为3组：A组50例,梗死前无心绞痛史;B组55例,梗死前1个月内有心绞痛,且梗死前48h内至少有一次典型心绞痛发作;C组45例,梗死1个月前有心绞痛;监测心肌梗死后12～18个月的左室功能。[结果]①C组患者双支以上血管病变多于A组和B组（P〈0．05）;②CK—MB峰值水平B组患者低于A组患者和c组患者（P〈0．01）;③组内比较,所有患者LVDd均降低（P〈O．05）,B组患者LVEF增高（P〈0．01）,A组和B组患者E／A增高（P〈0．05）;组间比较,B组患者LVEDd低于A组（P〈0．05）,B组患者LVEF、E／A均高于A组和C组患者（P〈0．01）;④于3组患者中,梗死后主要心脏事件（除外严重心律失常）B组最少,C组最多（P〈0．05～〈0．01）。[结论]梗死前1个月内心绞痛可保护梗死后近期与远期左心室功能、降低梗死后心脏事件发生率。     

易化PCI与直接PCI对老年急性ST段抬高型心肌梗死术后心室重构与心功能的影响

目的:比较易化PCI(即溶栓后即刻PCI)与直接PCI对老年急性ST段抬高型心肌梗死(STEMI)术后心室重构与心功能影响。方法:回顾性分析2012-06-2015-03达州市中心医院收治的163例行PCI治疗的老年STEMI病历资料,其中易化PCI 85例(A组)、直接PCI 78例(B组),比较2组PCI治疗前后血管再通比例、左室射血分数(LVEF)%、峰射血率(PER)、峰充盈率(PFR)、左室收缩末期容积指数(LVESVI)、左室舒张期末容积指数(LVEDVI)、N-末端脑钠肽前体(NT-proBNP)与金属基质蛋白酶-9(MMP-9)。结果:首次冠脉造影显示A组PCI术前IRA再通比例显著高于B组(P0.05);2组支架成功植入率与支架植入后血管再通比例差异均无统计学意义。2组术后各有1例死于左心衰。2组术后14dLVEF、PER、PFR、LVESVI、LVSF等均较治疗前显著改善,A组术后LVEF显著高于B组(P0.05),其余术后14d超声心动图指标组间差异均无统计学意义。2组术后NT-proBNP、MMP-9均较治疗前显著下降(P0.05),术后差异均无统计学意义。结论:对老年STEMI行易化PCI较直接PCI可以提高支架植入前血管再通率与术后射血功能,短期内两种介入方案对AMI患者左室重构的影响相近。     

培哚普利与卡托普利对急性心肌梗死患者心功能远期恢复的影响

目的 :探讨培哚普利及卡托普利对急性心肌梗死 (AMI)心功能远期恢复的影响。方法 :选择 70例前壁AMI患者 ,随机分为两组 ,每组 35例 ,在常规治疗的基础上分别给予培哚普利 (A组 )和卡托普利 (B组 )治疗 ;两组分别在梗死后 4周和 6个月进行多普勒超声心功能测定。结果 :梗死后 4周两组心脏收缩及舒张功能相似 ;A、B两组 6个月时心功能与 4周时相比均明显好转 (P <0 .0 1或 0 .0 5 ) ;AMI后 6个月时A组心脏收缩功能明显好于B组 (P <0 .0 1)。结论 :AMI患者心功能恢复需较长的时间 ,培哚普利更有利于梗死后心功能的远期恢复     

早期再灌注对急性心肌梗死伴室壁瘤形成的阻抑效应和心功能改善作用的超声心动图观察

目的　超声心动图观察早期再灌注对急性心肌梗死伴室壁瘤形成的阻抑效应和心脏收缩功能改善作用。方法　发病 12h以内急性前壁心肌梗死伴室壁瘤形成患者 98例,随机分为经皮腔内冠状动脉成形术(PCI)组(36例)、溶栓组(31)例和常规药物治疗组(31例),三组患者均在治疗后 2周、12周、24周分别行超声心动图测量左室收缩末期容积(LVESV)、左室舒张末期容积 (LVEDV),并以体表面积校正为左室收缩末期容积指数(LVESVI)、左室舒张末期容积指数(LVEDVI),同时测左室射血分数 (LVEF)、局部室壁运动指数 (RWMI)、左室质量(LVM),后者与体表面积相除得到左室质量指数(LVMI),评价LVESVI、LVEDVI和心室收缩功能改善状况。结果　治疗后 2周,PCI组和溶栓组各参数优于药物治疗组,治疗后 12周,PCI组LVESVI、LVEDVI低于溶栓组(均P<0. 05),溶栓组各参数优于药物治疗组(均P<0. 05)。PCI组和溶栓组各参数自身前后比较明显改善(均P<0. 05),LVEF较 2周时显著增高(P<0. 05)。治疗后 24周,PCI组LVEDVI、LVESVI仍低于溶栓组(P<0. 05),PCI组和溶栓组各参数均优于药物治疗组 (均P<0. 05),PCI组LVESVI、LVEDVI、RWMI较 2周、12周均减小(均P<0. 05),LVEF较 2周、12周显著增高(均P<0. 05);溶栓组各时段比较与PCI组大致相同。结论　超声心动图     

急性心肌梗死后不同Killip分级患者直接冠状动脉介入治疗与溶栓治疗临床疗效的对比研究

目的对比研究直接经皮冠状动脉介入(PCI)和溶栓这两种不同的血运重建治疗方法对急性心肌梗死(AMI)后不同心功能状态患者心室功能以及远期预后的影响。方法首次AMI患者166例,KillipⅡ～Ⅲ级组79例,其中43例行直接PCI治疗,36例予溶栓治疗;KillipⅠ级组87例,其中39例行直接PCI治疗,48例予溶栓治疗。观察所有入选患者AMI后1～2周主要心血管事件发生情况,并行ERNA检查。随访24周观察主要心血管事件发生情况,并于24周时复查ERNA。结果①与溶栓组相比,KillipⅡ～Ⅲ级AMI患者直接PCI组1～2周、24周时心室功能指标均明显改善;KillipⅠ级AMI患者直接PCI组心室功能指标略优于溶栓组,但差异无统计学意义。②KillipⅡ～Ⅲ级AMI患者住院1～2周、24周时再缺血事件发生率分别为9．3% vs 25．0%、18．6% vs 41．7%,直接PCI组较溶栓组显著降低(P＜0．05);KillipⅠ级AMI患者住院1～2周、24周时再缺血事件发生率分别为7．7% vs 12．5%、12．8% vs 22．9%,直接PCI组较溶栓组显著降低(P＜0．05)。结论KillipⅡ～Ⅲ级AMI患者直接PCI较溶栓治疗能更好地改善心室功能,而KillipⅠ级AMI患者直接PCI和溶栓治疗疗效相近。直接PCI术后再缺血血管事件发生率明显低于溶栓治疗。     

NT-proBNP和MMP-9与急性心肌梗死患者早期左室重构的相关性研究

【目的】探讨氨基末端B型脑钠肽前体（N T‐proBN P ）、基质金属蛋白酶‐9（M M P‐9）对急性心肌梗死（AMI）患者经皮冠脉介入治疗（PCI）术后早期心室重构的影响及其相关性。【方法】根据PCI术后4周时92例AMI患者左心室容积增加率的不同,将其分为左室重构组,非左室重构组,并设稳定性冠心病对照组。比较患者NT‐proBNP、MMP‐9水平及其与PCI术后患者的左室收缩末期容积（ LVESV）和舒张末期容积（LVEDV）、左室射血分数（LVEF）、左室收缩末容积指数（ LVESVI）、左室舒张末容积指数（LVEDVI）等的关系。【结果】AMI患者PCI治疗前后血浆NT‐proBNP和MMP‐9水平较稳定型冠心病对照组明显升高;左室重构组血浆 NT‐proB‐NP、MMP‐9水平持续增高,与非左室重构组在PCI术后7 d比较差异有统计学意义（ P＜0．01）。血浆NT‐proB‐NP、MMP‐9水平与LVEDV均呈明显正相关（ P ＜0．01）,与LVEF均呈明显负相关（ P ＜0．05）。【结论】AMI患者血浆NT‐proBNP、MMP‐9水平与左室重构指标有相关性,可作为AMI早期左室重构的预测因子。     

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.     

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.     

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.     

Clinical Trial Updates and Hotline Sessions presented at the European Society of Cardiology Congress 2007

This article provides information and commentaries on trials which were presented at the Hotline and Clinical Trial Update Sessions at the European Society of Cardiology Congress 2007 in Vienna. The key presentations were performed by leading experts in the field with relevant positions in the trials or registries. It is important to note that unpublished reports should be considered as preliminary data, as the analysis may change in the final publications. The comprehensive summaries have been generated from the oral presentation and the webcasts of the European Society of Cardiology and should provide the readers with the most comprehensive information of relevant publications.     

Prospects for the control of neglected tropical diseases by mass drug administration

The prospects for the control of neglected tropical diseases, including soil-transmitted helminthiasis, shistosomiasis, lymphatic filariasis, onchocerciasis and trachoma, through mass drug administration, are exemplified by the elimination of the trachoma as a public-health problem in Morocco. In spite of this and other striking successes, mass drug administration programs are faced with major challenges resulting from suboptimal coverage and lack of efficacy. At current suboptimal coverage rates, programs may need prolongation for an extended period, increasing costs and undermining sustainability. Community participation through health education and information appears to be crucial to improve coverage and to achieve sustainability. Implementation of complementary measures, such as vector control, improved hygiene and environmental sanitation, are important to further control transmission and to prevent re-emergence of the infection and, again, may only be achieved effectively through community-based initiatives. To reduce costs and to relieve pressure on the health system, combining neglected tropical disease programs in areas where diseases coexist and integration with existing control programs for malaria, tuberculosis and HIV/AIDS is advocated. The risk of developing drug resistance is of particular concern in view of the lack of alternative drugs, and reduced treatment efficacy due to emerging resistance is evident for the soil-transmitted helminths and onchocerciasis. Given the risk for the development of drug resistance and the need for a high degree of participation, close attention should be paid to the monitoring of the coverage and efficacy of the different program components.     

Balance and Boundaries in Grief Counseling: An Intervention Framework for Volunteer Training

Volunteers or paraprofessional counselors are commonly used to provide supportive care to the bereaved. These counselors generally are trained in basic listening skills, providing a generic, nonspecific approach to intervention that remains to be proven effective. The present paper outlines a framework that provides paraprofessionals with a broader model for intervention with the bereaved. Attention to boundaries as a helper and balance in the grief recovery are central to the model. Interventions are described that provide the paraprofessional counselor with more options for tailoring their counseling strategy to the individual. These include techniques that are presumed to be more specific to the enhancement of grief recovery.     

A new method for the simultaneous analysis of unmodified and modified urinary nucleosides and nucleobases by high performance liquid chromatography

Details are given of a new, rapid and simple pre-fractionation method and an isocratic high performance liquid chromatography system suitable for parallel analysis of nucleosides and nucleobases from urine and other biological fluids. The quantitative recovery and excellent reproducibility of the method is demonstrated by analysis of representative standard RNA catabolites. The advantage of this new method for application to biological samples is discussed.     

Bacterial meningitis: an update of new treatment options

The outcome of bacterial meningitis critically depends on the rapid initiation of bactericidal antibiotic therapy and adequate management of septic shock. In community-acquired meningitis, the choice of an optimum initial empirical antibiotic regimen depends on the regional resistance patterns. Pathogens resistant to antibacterials prevail in nosocomial bacterial meningitis. Dexamethasone is recommended as adjunctive therapy for community-acquired meningitis in developed countries. In comatose patients, aggressive measures to lower intracranial pressure <20 mmHg (in particular, external ventriculostomy, osmotherapy and temporary hyperventilation) were effective in a case–control study. Although many experimental approaches were protective in animal models, none of them has been proven effective in patients. Antibiotics, which are bactericidal but do not lyse bacteria, and inhibitors of matrix metalloproteinases or complement factor C5 appear the most promising therapeutic options. At present, vaccination is the most efficient method to reduce disease burden. Palmitoylethanolamide appears promising to enhance the resistance of the brain to infections.