溶栓及经皮冠脉腔内成形术治疗急性心肌梗死的疗效及费用效果分析

目的　对比直接冠状动脉内介入治疗 (PCI)及静脉尿激酶 (UK)溶栓对急性心肌梗死 (AMI)治疗的临床疗效及费用效果比。方法　采用观察性队列研究的方法 ,对 93例AMI病人采用UK溶栓 ,5 9例AMI病人采用直接PCI治疗 ,比较两组住院及随访期的超声心动图 (UCG)、临床结果及费用。结果　住院期间UCG检查室壁运动正常者在PCI组为 38 98% ,高于UK组 (2 4 73% ) (P =0 0 2 1) ,矛盾运动发生率PCI组为 0 ,而UK组为 11 83%。LVEF在PCI组为 5 6 77± 9 85高于UK组(5 2 2 3± 10 6 9) (P =0 0 2 9)。住院期心衰发生率UK组为 30 10 % ,高于PCI组 (16 90 % ) (P =0 0 6 8)。随访 (13 32± 6 86 )个月累计心衰发生率UK组为 38 70 % ,也高于PCI组 (13 6 0 % ) (P =0 0 0 1)。住院期间的病死率UK组为 10 80 % ,PCI组为3 4 0 % (P =0 0 83)。累计病死率UK组为 15 10 % ,明显高于PCI组 (3 4 0 % ) (P =0 0 14 )。 6 0岁以上年龄组累计的病死率仍然是UK组 (13 98% )高于PCI组 (3 39% ) (P =0 0 2 2 )。在随访 3、6、12及 2 4个月时PCI组的生活质量计分均高于同时期UK组的计分 (P <0 0 5 )。住院期间的费用、累计总费用及心功能获益费用均是直接PCI组高于UK治疗组。结论　直接PCI治疗AMI病人与UK治疗相比能改善     

低密度脂蛋白胆固醇联合高敏C反应蛋白对初发ST段抬高型心肌梗死患者近期及远期预后的预测作用分析

目的 研究低密度脂蛋白胆固醇(LDL-C)联合高敏C反应蛋白(hs-CRP)对初发急性ST段抬高型心肌梗死患者预后的影响.方法 选取2009年1月至2010年1月宣武医院心脏科收治的发病24 h内初发ST段抬高型急性心肌梗死(AMI)患者253例;全面收集患者住院资料,并随访主要心血管事件.根据LDL-C、hs-CRP水平分组,分析LDL-C及hs-CRP与AMI患者近期及远期预后的关系.结果 (1)AMI患者住院死亡率为6.3%(16/253);(2)平均随访(7.5±3.7)个月,心脏性死亡占2.5%(6/237),非致死性心肌梗死占0.4%(1/237),心绞痛住院占3.4%(8/237),心力衰竭住院占1.3%(3/237),冠状动脉血运重建占3.0%(7/237),总终点事件占10.5%(25/237);(3)经Cox回归分析与远期死亡相关的因素是hs-CRP水平(r=0.177,P=0.006,OR=1.219,95% CI:1.061~1.400);hs-CRP、LDL-C值均高的组随访心脏性死亡事件(9.0%)明显高于其他组(0),P=0.001.结论 hs-CRP是AMI患者远期死亡预测指标,LDL-C和hs-CRP的联合检测可为AMI患者长期预后提供依据.     

急性心肌梗死死亡及再梗死相关因素的分析

目的 :确定尿激酶 (UK )溶栓治疗和经皮冠状动脉腔内成形术 (PTCA)治疗的急性心肌梗死 (AMI)患者住院期和随访期死亡和再发心肌梗死 (心梗 )的预测因素。方法 :采用双向性队列研究 ,观察 190例 AMI患者住院期和随访期的临床结果。将死亡和再发心梗合并为恶性事件 ,应用 Spearm an等级相关法分析及多变量L ogist回归分析方法确定住院期和随访期恶性事件的相关因素及独立预测因素。结果 :住院期恶性事件发生率UK组为 15 .4 6 % ,PTCA组为 6 .4 5 % ;随访 (13.81± 7.39)月累计的恶性事件发生率 U K组为 30 .93% ,PTCA组为 9.6 8%。与 U K组和 PTCA组住院和随访期恶性事件发生呈正相关的因素包括 :年龄、Q波导联数、Killip分级、住院期心力衰竭 (心衰 )、既往高血压病史、心梗史等 ;呈负相关的因素是 :吸烟史、收缩压、住院期射血分数值等。介入治疗是两组患者住院期和随访期恶性事件的独立预测因子 ,也是介入治疗组患者恶性事件惟一的独立预测因子 ,能降低恶性事件的发生率。 U K组住院期恶性事件发生的独立预测因子还有增龄、住院期心衰和 Q波导联数 ;随访期恶性事件的独立预测因子还有增龄、住院期心衰。梗死前心绞痛与心梗住院期恶性事件发生呈负相关 ;溶栓治疗与补救性 PTCA组患者住院期恶性事件发生     

氨基末端B型利钠肽前体和"急性呼吸困难"的诊断及预后

目的 探讨氨基末端B型利钠肽前体(NT-proBNP)对急性呼吸困难的诊断及预后评估的应用价值.方法 回顾性分析533例急性呼吸困难患者,根据临床资料及心脏超声心动图分为急性充血性心力衰竭组(心衰组)及非心衰组,测定并比较两组患者NT-proBNP水平,评价NT-proBNP对急性呼吸困难患者鉴别诊断的价值;同时对心衰组患者随访,观察心力衰竭患者心源性再住院及死亡等事件,评价NT-proBNP对预后判定的价值.结果 心衰组患者为272例,非心衰组患者为261例,两组患者NT-proBNP水平差异具有统计学意义[(3018.6±114.7)pg/mL vs.(238.6±8.7)pg/mL,P＜0.01].其中心衰组中220例患者平均随访(158±32.8)d,心源性再住院组及心源性死亡组的NT-proBNP水平显著高于无再发事件组,分别为(2683.4±86.9),(3283.4±105.7)及(1123.5±72.1)pg/mL,差异具有统计学意义(P＜0.01).COX多元回归分析显示log NT-proBNP(r=0.987;P=0.002)和心房颤动(r=0.876;P=0.005)、室性心动过速(r=0.891;P=0.005)是心源性死亡、再住院患者独立的相关因素.结论 急诊检测NT-proBNP有利于对急性呼吸困难患者做出快速诊断和鉴别诊断,NT-proBNP对急性呼吸困难中心衰患者的预后预测价值好.LogNT-proBNP、心房颤动、室性心动过速,是心源性死亡、再住院事件的独立相关因素.     

计帧法在急性心肌梗死经皮冠状动脉介入治疗中的临床意义

目的 :评价计帧法测定校正的心肌梗死溶栓治疗临床试验帧数 (CTFC)在急性心肌梗死 (AMI)经皮冠状动脉介入治疗 (PCI)中的临床意义。方法 :10 2例AMI患者直接PCI或溶栓失败后的挽救性PCI ,PCI后根据住院期间有无心脏不良事件分为有心脏不良事件组 ( 2 9例 )和无心脏不良事件组 ( 73例 ) ,用计帧法测定梗死相关动脉的CTFC ,以CTFC 2 7帧为界将患者分为梗死相关动脉血流正常者和梗死相关动脉血流缓慢者两部分 ,观察两部分患者心功能和住院期间心脏不良事件发生率的差异。结果 :所有患者CTFC平均为 ( 3 7 0 8± 15 92 )帧 ,左心室射血分数和CTFC负相关 (r =-0 .65 ,P <0 0 0 1) ,住院期间有心脏不良事件组的CTFC明显高于无心脏不良事件组( 5 2 81± 19 5 2vs 2 4 98± 8 96) ,差异有显著性 (P <0 0 0 1)。梗死相关动脉血流正常和血流缓慢患者射血分数和住院期间心脏不良事件发生率差异有显著性 (P <0 0 0 5 )。多元回归分析发现CTFC和心脏不良事件有良好的相关性 [OR =-1 81,95 %可信限 (CI) =-1 42～ -2 3 7,P <0 0 0 5 ]。ROC曲线分析表明CTFC能较好地预测住院期间是否发生心脏不良事件。结论 :计帧法测定CTFC是一种较好的评价冠状动脉血流的方法 ,其结果和心功能、临床近期预后密切相关     

2型糖尿病患者微、大血管病变与白细胞计数的关系

目的　探讨 2型糖尿病微血管和大血管病变与外周血白细胞计数之间的关系。方法　分析了 6 4 1例 2型糖尿病住院患者和 6 5例正常对照组 (D0 )体脂参数、血压、血脂、血糖、外周白细胞计数水平 ,采用稳态模式 (HOMA)评价胰岛素抵抗和胰岛分泌功能。结果　糖尿病微血管病变组 (D2 )、糖尿病大血管病变组 (D3 )和糖尿病同时合并微血管和大血管病变组 (D4)的体重指数 (BMI)、收缩压 (SBP)、舒张压 (DBP)、空腹血糖 (FBG)、甘油三酯 (TG)和稳态模式评价的胰岛素抵抗 (HOMA IR)水平均高于正常对照组 (D0 ) (P <0 .0 1) ,高密度脂蛋白胆固醇 (HDL C)和稳态模式评价 β细胞功能 (HOMA β)低于D0 组 (P <0 .0 1)。D2 、D3 和D4组白细胞计数 (WBC)水平高于D0 组 (P <0 .0 5 )。D2 与D0 组患者Spearman相关分析显示 ,白细胞计数与SBP(r =0 .195 ,P <0 .0 5 ) ,DBP(r =0 .14 6 ,P <0 .0 5 ) ,TG(r =0 .2 0 5 ,P <0 .0 0 1) ,体重指数 (r =0 .15 8,P <0 .0 5 ) ,组别 (r =0 .195 ,P <0 .0 0 1) ,尿蛋白排泄率 (r =0 .2 38,P <0 .0 0 1)呈正相关。D3 与D0 组患者Spearman相关分析显示 ,白细胞计数与SBP(r =0 .2 11,P <0 .0 5 ) ,BMI(r =0 .2 16 ,P <0 .0 5 ) ,TG(r =0 .2 90 ,P <0 .0 0 1) ,HOMA IR(r =0 .2 4 2 ,P <0     

白细胞计数与冠状动脉狭窄及肌钙蛋白T的关系

目的 探讨急性心肌梗死(AMI)患者白细胞计数与冠状动脉病变及肌钙蛋白T之间的关系.方法 入选49例发病12 h以内的AMI患者,根据入院时的白细胞计数分为:WBC正常组31例(白细胞≤10×109/L)和WBC升高组18例(白细胞>10×109/L),分别统计并比较2组冠状动脉积分及肌钙蛋白T的定量值,并确定其与白细胞计数的相关关系.结果 2组间冠状动脉积分无明显差别[(5 2. 14±32.80)分与(50.61±36.64)分,t=0.539,P=0.604];WBC升高组的肌钙蛋白T高于WBC正常组[(3.98±1. 52)mmoL/L与(1.99±1.79)mmoL/L,t=2.448,P=0.031],且肌钙蛋白T与白细胞水平呈正相关(r=0.498,P=0.035).结论 AMI白细胞计数与冠状动脉狭窄无明显关系,而与肌钙蛋白T有明显相关性.     

动脉瘤性蛛网膜下腔出血患者外周血白细胞计数与病情严重程度的相关性分析

目的比较动脉瘤性蛛网膜下腔出血(aSAH)患者白细胞总数(WBC)及分类计数在判断aSAH患者病情严重程度中的临床价值。方法 180例aSAH患者依病情严重程度按Hunt-Hess级分为高级别、低级别,按格拉斯哥昏迷评分(GCS)分为轻中型、重型。分析入院时WBC及分类与该两个临床分级的相关性。绘制受试者工作特征(ROC)曲线,评价WBC及分类计数鉴别病情严重的能力。结果分别与Hunt-Hess低级别和GCS轻中型相比,Hunt-Hess高级别和GCS重型的WBC、中性粒细胞绝对值、中性粒细胞百分比显著升高,淋巴细胞百分比则均降低,差异均有统计学意义(P0.05)。WBC、中性粒细胞绝对值与Hunt-Hess分级较强正相关(r=0.516,P=0.000;r=0.527,P=0.000),与GCS较强负相关(r=-0.508,P=0.000;r=-0.514,P=0.000),而中性粒细胞百分比、淋巴细胞百分比与该两个临床分级弱相关。ROC曲线分析显示判断病情严重程度的最佳指标为WBC和中性粒细胞绝对值;该二者判断Hunt-Hess高级别的截点值分别为12.21×10~9/L、10.14×10~9/L;判断GCS重型的截点值分别为15.10×10~9/L、13.55×10~9/L。结论 aSAH患者入院时WBC、中性粒细胞绝对值判断病情严重程度价值相当且最佳。临床量表联合WBC和中性粒细胞绝对值有助于更可靠地准确评估aSAH病情严重程度。     

B型脑利钠肽对于老年心衰患者的预测价值

目的评价B型脑利钠肽（BNP）对于慢性充血性心力衰竭（CHF）患者预后及危险分层的预测价值。方法对中国医科大学附属盛京医院明确诊断为CHF的142例住院患者测定入院时、入院静脉治疗一天后及住院第七天血清BNP（BNP0、BNP1、BNP7）以及入院时按纽约心脏病协会心功能分级（NYHA分级）等指标随访观察患者心脏事件的再发生。结果142例CHF患者,中位随访425．50天（21—668天）,发生心脏事件50例（35．21％）。发生终点事件组与未发生终点事件组相比,患者的年龄、NYHA分级、BNPO、BNP1、BNV7中位数水平均明显偏高;入院静脉治疗一天后BNP指标变化百分比（BNP1—0％）中位数水平均明显偏低。分别以年龄和BNP1-0％及BNV7指标对心衰患者进行危险分层。结果年龄〉76岁的心衰患者,其死亡或心血管事件再住院的风险是年龄≤76岁的心衰患者的2．55倍（95％CI：1．38—4．69,P=0．003）。BNP1-0％≤12．62％的心衰患者,其死亡或心血管事件再住院的风险是BNP1-0％〉12．62％的心衰患者的2．00倍（95％CI：1．10—3．64,P=0．023）。BNP7〉552．15pg／ml的心衰患者,其死亡或心血管事件再住院的风险是BNP7≤552．15pg／ml的心衰患者的2．60倍（95％CI：1．43—4．75,P=0．002）。结论BNP可以用于对心衰患者进行心衰后心脏事件再发生的预后分析及及危险分层评估。     

白细胞检测水平与急性心肌梗死临床并发症的关系探讨

目的 探讨白细胞(WBC)水平与急性心肌梗死(AMI)范围及并发症发生率的关系.方法 AMI患者159例,于发病后抽取外周血查心肌酶谱、血常规,根据WBC检测水平分为A组66例(WBC＜10×109/L)和B组93例(WBC≥10×109/L).比较2组肌酸磷酸激酶同工酶(CK-MB)峰值AMI并发症.分析WBC检测水平与CK-MB之间的相关性.结果 WBC与CK-MB呈正相关(r=0.76,P=0.007),同时不同WBC计数组问AMI并发症的发生率也有显著性差异(P＜0.01).结论 AMI后WBC计数与梗死范围正相关,是一项预测并发症发生率的可靠独立指标.     

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.     

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.     

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.     

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.