实时三维超声心动图指导心脏再同步化治疗左心室起搏电极靶向植入的临床研究

目的 探讨实时三维超声心动图(RT-3DE)指导心脏再同步化治疗(CRT)左心室起搏电极靶向植入对提高CRT疗效的影响.方法 连续入选慢性心力衰竭(CHF)拟行CRT患者48例,按1∶1的比例随机分为2组:靶向治疗组和常规治疗组,两组在术前均行RT-3DE检查,筛选出左心室收缩最延迟部位,指导靶向治疗组在术中左心室起搏电极尽可能植入到左心室收缩最延迟部位,常规治疗组按照常规方法选择左心室起搏电极位置.术后6月比较左室收缩末容积(LVESV)、左室射血分数(LVEF)、左室16节段收缩末期容积达峰时间标准差(Tmsv16-SD)以及各指标的手术前后变化率(△LVESV、△LVEF、△Tmsv16-SD)等指标.结果 与常规治疗组比较,靶向治疗组左心室电极植入到最佳位置成功率显著增高(P =0.022),植入到远离部位发生率显著减低(P=0.026);靶向治疗组术后6月LVESV以及Tmsv16-SD显著减低(P均＜0.05),LVEF显著增加(P=0.042),CRT术前后△LVESV、△LVEF以及△Tmsv16-SD均显著增加(P均＜0.05).结论 RT-3DE能够指导CRT左心室起搏电极植入到左心室最延迟部位,进而显著提高CRT疗效,使行CRT患者最大化获益.     

实时三维超声心动图在酒精性心肌病患者中的应用价值

目的探讨实时三维超声心动图(RT-3DE)在酒精性心肌病(ACM)患者中的应用价值。方法 ACM患者33例,正常对照组30例。应用RT-3DE测定左心室舒张末期内径(LVEDV),左心室收缩末期内径(LVESV),左心室射血分数(LVEF),左心室心肌质量(LVM),左心室质量指数(LVMI)及左心室容积-时间曲线参数Tmsv16-SD、Tmsv16-Dif、Tmsv16-SD/R-R(%)、Tmsv16-Dif/R-R(%)。将两组各参数进行统计学比较,同时与二维超声心动图(2DE)法测值进行比较。结果与正常对照组比较,ACM组LVEDV、LVESV、LVM及LVMI均显著增高,LVEF显著减低;ACM组Tmsv16-SD、Tmsv16-Dif、Tmsv16-SD/R-R(%)、Tmsv16-Dif/R-R(%)与对照组比较显著升高,差异均具有统计学意义(P<0.05)。RT-3DE法测LVMI、LVEDV、LVESV与LVEF呈负相关(r=-0.864,-0.808,-0.862;P均<0.01),2DE法测LVMI、LVEDV、LVESV与LVEF呈负相关(r=-0.635,-0.507,-0.698;P均<0.01)。结论 RT-3DE可反映酒精性心肌病患者左心室结构及功能异常和收缩不同步,为临床诊断提供参考价值。     

实时三维超声心动图评价2型糖尿病合并心力衰竭患者左心室功能及同步性

目的采用实时三维超声心动图(RT-3DE)评价2型糖尿病合并心力衰竭患者左心室功能及同步性。方法选择18例2型糖尿病合并心力衰竭患者(观察组)和18名健康志愿者(正常组),应用RT-3DE测定左心室舒张末期容积(LVEDV)、左心室收缩末期容积(LVESV)、左心室射血分数(LVEF)、左心室心肌质量(LVM)、左心室心肌质量指数(LVMI)以及左心室容量-时间曲线各参数Tmsv16-SD、Tmsv16-Dif、Tmsv16-SD/R-R(%)、Tmsv16-Dif/R-R(%),并对两组各参数进行统计学比较。结果与正常组比较,观察组LVEDV、LVESV、LVM、LVMI、左心室容量-时间曲线参数Tmsv16-SD、Tmsv16-Dif、Tmsv16-SD/R-R(%)、Tmsv16-Dif/R-R(%)显著升高,而LVEF明显降低(P<0.05)。结论 RT-3DE可反映2型糖尿病合并心力衰竭患者左心室功能异常和收缩不同步,为临床诊断提供可靠依据。     

实时三维超声预测心脏再同步化治疗短期疗效的研究

目的 探讨实时三维超声(RT3DE)评价左室收缩同步性,预测心脏再同步化治疗(CRT)短期疗效的价值.方法 接受CRT治疗的心力衰竭患者24例,在术前3 d及术后1个月采用RT3DE检测左室16个心肌节段达收缩末最小容积时间的差值(Tmsv 16-Dif)和标准差(Tmsv 16-SD)作为同步性参数,同时测量左室收缩末容积(LVESV)和射血分数(LVEF).将术后LVESV减小率ΔLVESV≥15%定义为CRT短期治疗有效.结果 14例患者(58.3%)为CRT短期治疗有效组(R组).术前R组Tmsv 16-Dif和Tmsv 16-SD长于无效组(NR组),其余参数无差异.术后与NR组比较,R组的LVESV减小,LVEF增高,Tmsv 16-Dif和Tmsv 16-SD缩短.Tmsv 16-SD是预测ΔLVESV≥15%的独立因素,Tmsv 16-SD＞3.9%预测CRT短期疗效的敏感性和特异性分别为82%和79%.结论 CRT短期疗效可改善左室收缩同步性和收缩功能.RT3DE能准确评价左室收缩同步性和收缩功能,预测CRT短期疗效.     

实时三维超声心动图评价右心室心尖部起搏对左心室收缩同步性的早期影响

目的 评价右心室心尖部起搏(RVAP)对左心室收缩同步性的早期影响.方法 53例起搏器植入(均为RVAP)的患者和30位正常人,在术前及术后1个月采用实时三维超声心动图(RT3DE)检测左心室16个心肌节段达收缩末最小容积时间的差值(Tmsv 16-Dif) 和标准差(Tmsv 16-SD)作为同步性参数,同时测量左心室射血分数(LVEF).结果术后Tmsv 16-Dif和Tmsv 16-SD 显著延长(P＜0.001),20.75%～22.64%患者出现左心室收缩不同步,而LVEF呈减低趋势(P＞0.05).Tmsv 16-Dif和Tmsv 16-SD与LVEF负相关(r=-0.40和r=-0.52).结论 RVAP早期即可导致左心室收缩不同步,且其可能是收缩功能减低的主要原因.RT3DE可准确评价左心室收缩同步性.     

左心室同步性指标预测冠状动脉旁路移植术后左心室逆重构的价值

目的 探讨实时三维超声心动图(RT-3DE)左心室同步性指标预测冠心病(CAD)患者冠状动脉旁路移植术(CABG)后左心室逆重构价值.方法 经选择性冠状动脉造影证实为3支冠状动脉病变的31例CAD患者,应用RT-3DE于术前及术后1个月测量左心室舒张末容积(LVEDV)及16节段同步性等指标,依据CABG术后LVEDV减少≥15%为左心室逆重构标准将病例组分为有反应组(A组,LVEDV减少≥15%)和无反应组(B组,LVEDV减少＜15%),并与20例冠状动脉正常的受检者对比分析,且对CAD患者LVEDV与左心室16节段达峰时间最大差值(Tmsv16-Dif)及标准差(Tmsv16-SD)做相关分析.结果 与对照组比较,CAD患者手术前后左心室同步性指标均显著降低(P<0.01);与术前比较,A组左心室同步性有显著提高(P<0.01),B组则无明显提高改善(P>0.05).CAD患者LVEDV与左心室Tmsv16-Dif及Tmsv16-SD均呈显著正相关(分别为r=0.751,P<0.01;r=0.655,P<0.01).结论 CABG术后发生左心室逆重构的患者其同步性提高,且LVEDV与左心室同步性指标相关良好,此表明左心室同步性指标亦可作为一种新的预测心室逆重构的方法应用于临床.     

实时三维超声心动图和超声斑点追踪技术评价扩张型心肌病左心室收缩同步性

目的 利用实时三维超声心动图(RT-3DE)和超声斑点追踪技术(STI)评价正常人和扩张型心肌病(DCM)患者左心室收缩同步性.方法 选取27例DCM患者(DCM组)与29名正常人(对照组)的标准心尖位左室流出道切面,四腔心切面,两腔心切面及实时三维经胸超声心动图,得到左心室舒张末期容积(LVEDV)、收缩末期容积(LVESV)、左心室射血分数(LVEF)、心电图Q波起始点距离16节段和12节段最小容积点时间间隔的标准差(Tmsv16-SD、Tmsv12-SD)及其最大差(Tmsv16-Dif、Tmsv-12Dif).用STI分别测量其左心室心肌各节段心电图Q波起始点到组织速率收缩峰值(Ts-SD)、应变率收缩峰值时间的标准差(Tsr-SD).结果 DCM组左心室心肌的组织速率、应变率及RT-3DE的容积-时间曲线交错紊乱,同步性差;DCM组Tmsv16-SD、Tmsv12-SD、Tmsv16-Dif、Tmsv-12Dif、Ts-SD、Tsr-SD与对照组相比差异有统计学意义(P均<0.05).结论 RT-3DE 和 STI两种方法 均能够评价左心室心肌收缩同步性.STI是通过检测多个心动周期,而RT-3DE则是在同一心动周期检测,更加快速、简便、准确.     

斑点追踪显像、实时三维超声心动图与门控心肌灌注SPECT显像评价左心室收缩同步性的相关性研究

目的 探讨斑点追踪显像(speckle tracking imaging,STI)、实时三维超声心动图(real-time three-dimensional echocardiography,RT-3DE)与门控心肌灌注SPECT显像(gated myocardial perfusion single-photon emission computed tomography,GMPS)评价冠心病患者左室收缩同步性的相关性.方法 13例冠心病患者进行STI及RT-3DE检查,获得左室12节段径向应变及圆周应变达峰时间标准差(Trs12-SD,Tcs12-SD),左室16节段纵向应变达峰时间标准差(Tls16-SD),左室16节段和12节段达最小容积时间标准差(Tmsv16-SD,Tmsv12-SD).测量结果与GMPS评价左室收缩同步性参数进行比较.结果 STI参数Trs12-SD与GMPS参数相位标准差、相位宽度正相关(分别为r=0.800,P＜0.05;r=0.607,P＜0.05);RT-3DE参数Tmsv16-SD与GMPS参数相位标准差、相位宽度相关性更好(分别为r=0.847,P=0.001;r=0.890,P＜0.001).结论 RT-3DE参数较STI参数与GMPS参数的相关性更好,提示RT-3DE参数有望成为评价左心室收缩同步性的理想指标.     

实时三维超声心动图与二维斑点追踪成像技术共同评价冠心病患者左心室收缩功能与同步性及二者相关性初探

目的 探讨实时三维超声心动图(RT-3DE)与二维斑点追踪成像技术(2D-STI)评价冠心病患者左心室收缩功能与同步性的应用价值,并初步研究2种技术的相关性.方法 55例患者根据冠状动脉造影结果分3组,对照组25例,分别进行2D-STI和RT-3DE.分析心肌收缩期峰值纵向应变(LS)、径向应变(RS)和圆周应变(CS),并测量左心室短轴水平心肌节段收缩期达峰值径向应变的时间(TRS)及前间壁和后壁TRS的差值(TAS-POST);分析17节段时间一容积曲线,获得左室舒张末期容积(EDV)、收缩末期容积(ESV)、射血分数(EF)及左心室16节段达到最小收缩容积时间差的标准差校正值(Tmsv-16SD％),并对Tmsv16-SD％与TAS-POST行相关性分析.结果 病例组各参数与对照组对应参数比较,差异均有统计学意义(P＜0.05),病例组间比较,多支病变组EDV、ESV及TAS-POST高于LCA组与RCA组(P＜0.05),多支病变组、LCA组LS与Tmsv16-SD％与RCA组有明显差异.Tmsv16-SD％与TAS-POST呈显著正相关(r=0.794,P＜0.001).结论 RT-3DE与2D-STI均能较好地评价不同冠状动脉狭窄的冠心病患者左心室的收缩功能与同步性变化情况,并且2种技术的在评价左心室同步性上存在一定的相关性.     

实时三维超声心动图评价心肌梗死后心力衰竭患者左心室收缩功能与不同步性

目的 探讨实时三维超声心动图评价心肌梗死后心力衰竭患者左心室收缩功能与不同步性的临床价值。方法对40例心肌梗死后心力衰竭患者（心肌梗死组）及30例健康者（对照组）分别行左室实时三维超声心动图17节段时间一容积分析,获取左室整体收缩功能指标：左室舒张末期容积（LVEDV）、收缩末期容积（LVESV）、射血分数（LVEF）;左室收缩同步性指标：除心尖帽外的16节段从QRS波起点到最小收缩容积的时间的标准差和最大差值（Tmsv16-SD、Tmsv16-Dif）;二者除以心动周期分别得到SDI、Tmsv16-Dif％。分析LVEF与SDI之间的关系。结果与对照组比较,心肌梗死组左室扩大,LVEDV、LVESV增高,LVEF减低,差异均有统计学意义（P〈0．01）,LVEF与LVEDV呈负相关（r=-0．83,P〈0．01）;心肌梗死组SDI高于对照组（P〈0．01）,SDI与LVEF呈负相关（r=0．84,P〈0．01）。结论陈旧性心肌梗死患者左心室重构明显,不但心功能减低而且普遍存在收缩不同步,不同步程度与收缩功能呈负相关。实时三维超声心动图能同时提供左室收缩功能和不同步性的详细信息,是评价心功能的有效手段。     

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.     

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.     

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.     

Adsorption of Charged Non-albumin Bound Drugs by Amorphous Silica

We investigated the in vitro drug adsorption of PQ 10150 sodium silicate gel (AIS, Santa Clara, CA) with particle size of 230 um and surface area of 400 nr/g. We observed 99% to 88% adsorption of gentamicin; a mean 91 % of disopyramide; a mean 89% of quinidine at low concentration, falling to 75% at higher concentration. Insulin was 88% adsorbed at low concentrations but less so (65%) at higher concentrations. We observed a mean 83 % adsorption of procainamide, a mean 84% of N-acetyl procainamide, 74% oflidocaine, 73% of amitriptyline; and 44% of desipramine. We found an average 14% reduction of total digoxin concentration when serum containing digoxin (2 to 33 ng/mL) was exposed to sodium silicate, while the reduction in free digoxin concentration was 16%. Five percent ethosuximide was also removed. The adsorption of theophylline, phenobarbital, acetaminophen, phenytoin, ethylene glycol, methotrexate, salicylate, thiocyanate and diazepam was minimal and not significant. We conclude that significant amounts of charged, non-albumin bound drugs can be removed by PQ 10150 sodium silicate gel.     

自动化酸碱平衡图在急诊社区获得性肺炎诊治中的应用

目的 探讨自动化酸碱平衡图在急诊科社区获得性肺炎(CAP)患者诊断中的价值.方法 根据病史、肺功能测定结果、慢性阻塞性肺疾病(COPD)诊断标准,将111例CAP患者分为单纯CAP组(56例)和COPD合并CAP组[即慢性阻塞性肺疾病急性加重(AECOPD)组,55例].询问患者病史后即刻抽取动脉血测血气并进行自动化酸碱平衡图分析.结果 血气分析结果显示,AECOPD组动脉血二氧化碳分压(PaCO2,kPa)、HCO3- (mmol/L)、剩余碱(BE,mmol/L)均显著高于CAP组(PaCO2:7.714±2.414比5.896±1.308,HCO3-:30.767±7.185比25.014±3.043,BE:4.345±5.371比-0.354±3.180,均P＜0.01).自动化酸碱平衡图分析结果显示,AECOPD组患者酸碱平衡紊乱高达89.1％,CAP组为66.1％.将AECOPD组和CAP组患者中正常(10.9％、33.9％)、急性呼吸性酸中毒(急性呼酸,12.7％、14.3％)、慢性呼吸性酸中毒(慢性呼酸,49.1％、10.7％)、呼吸性碱中毒(呼碱,7.3％、14.3％)、代谢性酸中毒(代酸,12.7％、17.9％)、代谢性碱中毒(代碱,12.7％、8.9％)综合进行x2分析,差异有统计学意义(x2=24.421,P=0.001),而将正常、急性呼酸、呼碱、代酸及代碱进行x2分析,差异无统计学意义(x2=5.280,P=0.260),提示AECOPD患者慢性呼酸的发生率较单纯CAP患者显著增加.结论 自动化酸碱平衡图能帮助急诊科医师快速识别CAP患者是否存在多重酸碱平衡紊乱,并可快速识别急、慢性呼吸系统疾病.