血栓弹力图评价经皮冠脉介入治疗患者服用抗血小板药物效果的研究

目的评价采用血栓弹力图观察经皮冠脉介入治疗（PCI）患者服用抗血小板药物后血小板抑制效果。方法选择住院的135例冠心病患者,其中120例接受PCI治疗并联合服用阿司匹林与氯吡格雷的患者作为联合用药组,15例未接受PCI治疗的患者（单独用药组）分别单独服用阿司匹林（阿司匹林组,8例）或氯吡格雷（氯吡格雷组,7例）。采用血栓弹力图检测花生四烯酸（AA）和磷酸腺苷（ADP）途径诱导的血小板抑制率,并比较两组抗血小板治疗的效果。结果阿司匹林组AA途径诱导的血小板抑制率为（61．66±21．44）％,高于氯吡格雷组ADP途径诱导的血小板抑制率[（55．23±13．44）％],但差异无统计学意义（P〉0．05）;联合用药组AA和ADP途径诱导的血小板抑制率分别为（65．52±24．61）％和（58．67±22．75）％,高于阿司匹林组AA途径和氯吡格雷组ADP途径,但差异无统计学意义（P均〉0．05）;联合用药组抗血小板治疗的疗效（良好率）均优于单独应用阿司匹林或氯吡格雷组（40．00％郴12．50％,26．67％ vs 0,P均〈0．01）。结论阿司匹林与氯吡格雷均能起到很好的抗血小板作用,但氯吡格雷稍差,联合服用阿司匹林和氯吡格雷能起到更强的抗血小板作用。血栓弹力图是评价血小板抑制率的有效工具,可根据AA／ADP抑制率的情况发现对阿司匹林和／或氯吡格雷抵抗的患者,进而调整用药方案。     

血栓弹力图对老年患者抗血小板治疗的研究

目的：应用血栓弹力图观察老年患者服用抗血小板药物后血小板抑制率情况。方法对15例服用阿司匹林和85例服用氯吡格雷的老年患者进行血栓弹力图检测,分别测定花生四烯酸（AA）和二磷酸腺苷（ADP）途径诱导的血小板抑制率。结果服用阿司匹林的患者对血小板的抑制率平均值为67.85%±34.47%,其中有33.3%其AA诱导的血小板聚集率≤50%,提示患者对阿司匹林反应低下。服用氯吡格雷的患者对血小板的抑制率平均值为56.00%±30.04%,其中有21.2%其ADP诱导的血小板聚集率＜30%,提示患者对氯吡格雷反应低下。结论对于接受抗血小板治疗的老年患者,进行血栓弹力图检测是必要的。     

急性脑梗死患者阿司匹林抵抗危险因素分析

目的探讨急性脑梗死患者阿司匹林抵抗（AR）现象及其影响因素。方法收集330例急性脑梗死患者,根据血栓弹力图测定花生四烯酸（AA）诱导途径的血小板抑制率。血小板抑制率≤20％即判定为AR,抑制率在20％-50％之间则判定为阿司匹林半抵抗（ASR）,抑制率〉50％即为阿司匹林敏感（AS）。根据上述标准将患者进行分组,研究AR的发生率,并分析各组间各项临床特征的差异,采用Logistic回归分析影响AR与ASR的危险因素。结果330例急性脑梗死患者中AR发生率为33．9％,ASR发生率为19．7％。与As组相比,AR＋ASR组中高敏C反应蛋白（hs—CRP）水平明显升高（P〈0．05）。≥65岁患者中,高风险患者AR＋ASR发生率显著升高（P〈0．05）。Logistic回归分析表明血小板计数[OR=0．996,95％可信区间（CI）：0．991—0．999,P=0．041]和hs．CRP（OR=0．972,95％I：0．959—0．996,P=0．014）是发生AR与ASR的危险因素。结论急性脑梗死患者AR的发生率较可能与血小板数量和患者炎症状态有关。     

血栓弹力图在冠心病患者抗血小板治疗中的临床应用

目的在冠心病患者中,使用血栓弹力图测定血小板抑制率,评价抗血小板药物的作用效果。方法对该院联合服用阿司匹林和氯吡格雷的402例冠心病住院患者进行血栓弹力图检测,测得二磷酸腺苷(ADP)受体途径诱导的血小板抑制率和花生四烯酸(AA)通路途径诱导的血小板抑制率,按照ADP和AA抑制率参考值高低分别分为低、正常、高抑制率3组,并对各组的普通杯R、K、角度、MA值相关性进行统计分析。结果 ADP低、正常、高抑制率3组为81例(20.1%)、251例(62.4%)和70例(17.4%),AA低、正常、高抑制率3组为50例(12.4%)、174例(43.3%)、178例(44.3%)。按照ADP低、正常、高抑制率分组,3组间的R、K、角度、MA值、AA低、正常、高抑制率差异均无统计学意义(P0.05),按照AA低、正常、高抑制率分组,ADP抑制率在正常抑制率组与高抑制率组比较差异有统计学意义(P0.05)。结论普通杯参数不能反映阿司匹林和氯吡格雷抗血小板的效果,ADP抑制率与AA抑制率存在一定的正相关性,根据AA和ADP抑制率的情况发现对阿司匹林和氯吡格雷抵抗的患者,进而调整用药方案。     

三联抗血小板方案在STEMI患者PCI术后的应用效果

目的研究三联抗血小板方案在急性ST段抬高型心肌梗死(STEMI)患者经皮冠状动脉介入术(PCI)后的应用效果。方法采用随机数表法将河南医学高等专科学校附属医院2017年6月至2019年7月行PCI治疗的150例STEMI患者作为研究对象,根据治疗方法将患者分为双联组与三联组,每组75例,双联组给予双联抗血小板方案治疗,三联组给予三联抗血小板方案治疗。比较两组患者术后慢血流、出血事件和主要心血管事件发生率,并探讨血栓弹力图指标变化。结果治疗前两组患者花生四烯酸(AA)抑制率、二磷酸腺苷(ADP)抑制率以及AA诱导最大血块强度(MA-ADP)比较,差异未见统计学意义(P0.05),治疗后三联组AA抑制率、ADP抑制率明显高于双联组,MA-ADP明显低于双联组(P0.05);两组患者大出血以及小出血发生率比较,差异未见统计学意义(P0.05),但三联组患者慢血流(6.67%,5/75)以及心血管事件发生率(9.33%,7/75)明显低于双联组[17.33%(13/75),21.33%(16/75)],差异有统计学意义(P0.05)。结论与双联抗血小板方案比较,三联血小板方案可有效改善血栓弹力图指标,提高血小板抑制率,降低术后慢血流发生率。     

血栓弹力图在血液透析患者内瘘堵塞中的作用

目的研究血栓弹力图（TEG）与常规凝血检查在血液透析患者内瘘堵塞的关系。方法选择济南市中心医院血液净化中心规律血液透析患者50例,按内瘘是否堵塞分为两组,内瘘堵塞组（A组）和未堵塞组（B组）,回顾性检查血栓弹力图,凝血常规和血常规。结果①血红蛋白和凝血常规各指标在内瘘堵塞组（A组）和对照组（B组）间无显著性差异（国际标准化率INR（0．98±0．05）比（0．98±0．09）,P=0．48〉0．05;活化部分凝血时间APTT（33．78±4．85）比（32．05±4．15）,P=0．21〉0．05;凝血酶原时间PT（11．92±0．64）比（11．90±1．15）,P=0．48〉0．05,血小板数量两组间有显著差异（190．7±40．07）×10^9／L比（189．7±42．01）×10^9／L,P=0．04〈0．05）;②14例内瘘堵塞患者（A组）中经TEC提示高凝状态10例,血小板高度活化4例。36例对照组（B组）中TEC提示高凝状态30例,30例中血小板功能升高16例,血小板和凝血因子高度活化6例;③血栓弹力图（TEG）中,R,K,ANGLE,CI值在两组间均有显著差异,明显提示内瘘堵塞组（A组）的高凝状态。结论血栓弹力图与其他常规凝血检查比较更能反映血液透析患者的高凝状态,对尿毒症血液透析内瘘血栓形成倾向监测有很大的帮助。     

血栓弹力图在指导阿司匹林相关性脑出血治疗中的应用

目的评价血栓弹力图对服用阿司匹林脑出血患者治疗的临床指导作用。方法回顾性分析2015年1月至2016年12月住院的服用阿司匹林及未服用阿司匹林的脑出血患者各45例,服用阿司匹林的患者入院行血栓弹力图检测,其中AA抑制率≥50%患者给予输注血小板,再次行血栓弹力图检测,TEG-MAX(AA)、AA抑制率结果正常后,再予治疗。两组病例根据病情分别采取相应治疗。观察两组病例治疗1个月、3个月的病死率,以及采用GOS评分、巴氏指数(BI)评定量表对两组患者的神经功能缺损进行评估。结果服用阿司匹林组中38例AA抑制率≥50%,输用血小板后TEG-MAX(AA)延长,AA抑制率降低,与血小板治疗前比较差异有统计学意义(P0.05)。服用阿司匹林组治疗后1个月病死率高于未服用阿司匹林组,但差异无统计学意义(P0.05);GOS评分、BI低于未服用阿司匹林组,差异有统计学意义(P0.05)。结论服用阿司匹林的脑出血患者凝血功能差,病死率高,血栓弹力图可以对服用阿司匹林脑出血患者的治疗进行指导。     

原发性血小板增多症90例患者JAK2基因突变的分析

目的研究原发性血小板增多症（ET）患者JAK2基因突变的发生情况及其与临床指标的相关性。方法采用等位基因特异性PCR方法及直接测序,检测90例ET患者外周血单个核细胞JAK2V617F的发生情况。结果90例ET患者中检出49例（54．4％）存在JAK2V617F突变;突变型组患者平均年龄为（55±16）岁。高于野生型组的（38±15）岁（P〈0．05）,突变型组患者的外周血白细胞计数[（18．9±8．2）×10^9／L]明显高于野生型组[（9．7±6．7）×10^/L机上患者（P〈0．01）,两组患者的血红蛋白水平及血小板计数的差异无统计学差异（．P〉0．05）突变型组患者血栓事件发生率（52．9％）明显高于野生型组（15．4％）患者（P〈0．05）。结论ET患者中JAK2V617F突变的发生率较高,JAK2V617F突变与ET患者年龄、外周血白细胞计数及血栓事件具有相关性。     

丹参酮ⅡA抑制血小板与肿瘤细胞相互作用的实验研究

目的 探究丹参酮IIA(TanⅡA)抗血小板作用以及抑制人血小板与结肠癌HCT116细胞的相互作用。方法 采用不同浓度TanⅡA(10、20、40μmol/L)处理健康志愿者全血或血小板,通过血栓弹力图试验（TEG）检测二磷酸腺苷（Adenosinediphosphate,ADP）、花生四烯酸（arachidonicacid,AA）抑制率,流式细胞术检测血小板CD62P、PAC-1表达率,黏附试验检测TanⅡA处理后血小板与HCT116细胞的黏附情况,划痕试验检测TanⅡA处理后血小板对HCT116细胞的迁移能力的影响。结果 TEG结果表明,TanIIA呈浓度依赖性抑制ADP、AA诱导的血小板聚集（P <0.01）,低浓度TanⅡA处理就能获得较好的ADP抑制率,为（73.48±19.63）%,高浓度TanⅡA才能获得较好的AA抑制率,为（78.20±18.58）%。流式细胞术结果显示,TanⅡA可以呈浓度依赖抑制凝血酶或ADP诱导的血小板表面CD62P、PAC-1表达（P <0.05）。黏附试验结果证实,TanⅡA能显著抑制凝血酶或ADP激活血小板与HCT116细胞之间的...     

华法林对阵发性房颤抗凝治疗的临床观察

目的探讨华法林对老年阵发性房颤抗凝治疗的有效性和安全性。方法将126例65岁以上的阵发性房颤患者,随机分成华法林组（n＝65）和阿司匹林组（n＝61）。华法林组口服华法林进行抗凝治疗,初始剂量3mg／d国际标准化比值（INR）2．0～3．0,根据INR监测情况调整剂量,随访分析患者终点事件和出血事件的发生及与抗强度的关系并与阿司匹林组（口服阿司匹林200mg／d）作对照分析。结果随访6～24个月,华法林平均剂量（3．5±0．69）mg。用药期间发生血栓栓塞华法林组为3例（4．61％）,阿司匹林组为9例（17．64％）,2组比较差异有统计学意义（P〈0．05）;2组出血发生率差异无统计学意义[华法林组4例（6．15％）,阿司匹林组4例（6．56％）（P〉0．05）;2组低危亚组发生血栓栓塞差异无统计学意义[华法林组1例（4．34％）,阿司匹林组3例（15．00％）（P〉0．05）,而2组高危亚组发生血栓栓塞差异有统计学意义[华法林组2例（4．76％）,阿司匹林组6自（14．63％）]（P〈0．05）,而各亚组出血发生率差异均无统计学意义（均P〉0．05）。结论阵发性房颤患者应用华法林抗凝INR维持在2．0～3．0是有效安全的。有必要对确诊的老年阵发性房颤患者进行危险因素分层,65岁以上具备高危因素的老年阵发性房颤患者需应用华法林抗凝治疗。     

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.     

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.     

俯卧位通气对高海拔地区肺复张治疗无效急性呼吸窘迫综合征患者氧合的影响

目的 探讨俯卧位通气对高海拔地区肺复张术(RM)治疗无效急性呼吸窘迫综合征(ARDS)患者的治疗作用.方法 从海拔2260m的地区医院筛选RM治疗无效的41例ARDS患者[平均氧合指数( PaO2/FiO2)较RM前升高＜20％视为RM无效],依不同病因分为肺内源性ARDS组(ARDSp组)和肺外源性ARDS组(ARDSexp组),每组再按信封法随机分为俯卧位组和仰卧位组,即ARDSp俯卧位组(11例)、ARDSp仰卧位组(9例)、ARDSexp俯卧位组(10例)、ARDSexp仰卧位组(11例).在通气前及通气1、2、3、4h监测动脉血氧分压( PaO2)、PaO2/FiO2、静态顺应性(Cst)、气道阻力(Raw)的变化.结果 通气lh时,ARDSexp俯卧位组PaO2/FiO2( mm Hg,l mm Hg=0.133 kPa)即较通气前显著升高(157.4±40.6比129.3±48.7,P＜0.05),并随通气时间延长呈持续增高趋势,4h达峰值(219.1 ±41.1);且ARDSexp俯卧位组通气3h内PaO2/FiO2较其他3组显著增高,另3组间则差异无统计学意义.ARDSp俯卧位组、ARDSexp俯卧位组通气4h时PaO2/FiO2均较相应仰卧位组显著增高(208.8±39.7比127.4±47.1,219.1±41.1比124.9±50.8,均P＜0.05).4组通气前后Cst无显著改变,各组间差异也无统计学意义.ARDSp俯卧位组通气4h时Raw(cmH2O·L-1·s-1)较通气前显著降低(6.8±1.7比10.7±1.8,P＜0.05),且明显低于其他3组;其他3组各时间点Raw组内及组间比较差异均无统计学意义.结论 俯卧位通气作为ARDS机械通气重要策略之一,可以改善RM无效高原ARDS患者的氧合,为抢救患者赢得宝贵的时间.     

Digital imaging among medical facilities

The Department of Veterans Affairs (VA) in the USA operates a network of 172 medical centres which all utilize a hospital information system (HIS) which has been developed and is currently maintained by the VA. During the past several years, an image management and communication module has been developed, installed and clinically utilized at the Washington DC and Maryland VA Medical Centres. This image management and communication system, referred to as the decentralized hospital computer program (DHCP) imaging system, is fully integrated with a commercial picture archiving and communication system (PACS). The system is utilized to capture, archive, and display all images generated within the hospital including radiology, nuclear medicine, pathology, endoscopy, bronchoscopy, and dermatology, intraoperative photographs, ECG data, and a limited number of paper documents. The ultimate goal of the project is to have all patient text and image data available at any clinical workstation to any authorized user anywhere within the network of medical centres. Clinical requirements for an imaging workstation include ease of use, rapid and reliable access to the complete set of patient information, and images which are of acceptable quality to meet the requirements of the user and the subspecialty. Patient confidentiality and data security must be safeguarded at all times. Integration of the images with the remainder of the patient's database was found to be critical to the success of the project. The experience at the Washington and Maryland facilities suggests that an imaging system that is successfully integrated with a hospital information system can provide substantial clinical and economic benefits both within and among medical centres. Clinical acceptance and utilization of the system has been excellent, particularly in diagnostic radiology where DHCP Imaging has been interfaced to a commercial PAC system. Based upon this initial experience, the VA has begun to deploy the system throughout its large network of medical centres.     

Myocardial elastography at both high temporal and spatial resolution for the detection of infarcts

Myocardial elastography is a novel method for noninvasively assessing regional myocardial function, with the advantages of high spatial and temporal resolution and high signal-to-noise ratio (SNR). In this paper, in-vivo experiments were performed in anesthetized normal and infarcted mice (one day after left anterior descending coronary artery [LAD] ligation) using a high-resolution (30 MHz) ultrasound system (Vevo 770, VisualSonics Inc., Toronto, ON, Canada). Radiofrequency (RF) signals of the left ventricle (LV) in longitudinal (long-axis) view and the associated electrocardiogram (ECG) were simultaneously acquired. Using a retrospective ECG gating technique, 2-D full field-of-view RF frames were acquired at an extremely high frame rate (8 kHz) that resulted in high-quality incremental displacement and strain estimation of the myocardium. The incremental results were further accumulated to obtain the cumulative displacements and strains. Two-dimensional and M-mode displacement images and strain images (elastograms), as well as displacement and strain profiles as a function of time, were compared between normal and infarcted mice. Incremental results clearly depicted cardiac events including LV contraction, LV relaxation and isovolumetric phases in both normal and infarcted mice, and also evidently indicated reduced motion and deformation in the infarcted myocardium. The elastograms indicated that the infarcted regions underwent thinning during systole rather than thickening, as in the normal case. The cumulative elastograms were found to have higher elastographic SNR (SNR(e)) than the incremental elastograms (e.g., 10.6 vs. 4.7 in a normal myocardium, and 6.0 vs. 2.4 in an infarcted myocardium). Finally, preliminary statistical results from nine normal (m = 9) and seven infarcted (n = 7) mice indicated the capability of the cumulative strain in differentiating infracted from normal myocardia. In conclusion, myocardial elastography could provide regional strain information at simultaneously high temporal (>/=0.125 ms) and spatial ( approximately 55 microm) resolution as well as high precision ( approximately 0.05 microm displacement). This technique was thus capable of accurately characterizing normal myocardial function throughout an entire cardiac cycle, at the same high resolution, and detecting and localizing myocardial infarction in vivo.     

Clinical Pharmacokinetics of Morphine

Morphine, the most widely used mu-opioid analgesic for acute and chronic pain, is the standard against which new analgesics are measured. A thorough understanding of the pharmacokinetics of morphine is required in order to safely and effectively use this analgesic in a wide variety of patients with different levels of organ function. A MEDLINE search was conducted to identify literature published between 1966 and January 2002 relevant to the pharmacokinetics of morphine. These publications were reviewed and the literature summarized regarding unique and clinically important elements of morphine disposition relative to its parenteral administration (including intravenous, intramuscular, subcutaneous, epidural and intrathecal administration), absorption profile (immediate release, controlled release, and sublingual/buccal, and rectal administration), distribution, and its metabolism/ excretion. Special populations, including infants, elderly, and those with renal/liver failure, have a unique morphine pharmacokinetic profile that must be taken into account in order to maximize analgesic efficacy and reduce the risk of adverse events.