希氏束不应期左心室刺激鉴别窄QRS波心动过速1例

本文报道1例隐匿性左外侧游离壁旁路参与的顺向型房室折返性心动过速(O-AVRT), 在心室起搏下消融过程中, 冠状静脉窦A波激动顺序由冠状静脉窦远端最早突然变为近端最早, 并可诱发以心房激动顺序存在的心动过速。于右心室反复行希氏束不应期心室刺激(RS2)均未提前下一A波, 似乎不支持旁路参与, 左心室RS2证实为经第2条左侧房室旁路逆传的O-AVRT;消融成功。     

三磷酸腺苷对室房传导的电生理作用

目的　探讨三磷酸腺苷 (adenosine triphosphate,ATP)对房室结双径路参与的房室交界区折返性心动过速和旁路参与的房室折返性心动过速患者的室房传导的电生理作用。　方法　 39例房室交界区折返性心动过速和 6 7例房室折返性心动过速患者在右心室起搏 (频率 140次 / m in)时 ,经股静脉快速注射 ATP 2 0 mg,连续记录体表心电图和心内电图 ,观察室房传导变化。　结果　房室交界区折返性心动过速组 33例 (84.6 % )在注射 ATP后出现室房阻滞 ,其余 6例无变化。6 7例房室旁路患者在消融前 ,6 1例 (91% )室房传导无变化 ,另 6例出现室房阻滞 ,其中 2例具递减性传导 ;而在消融后 2 4例右心室起搏频率超过 16 0次 / m in,仍为 1∶ 1逆传 ,注射 ATP后 2 3例出现室房阻滞 ,仅 1例不受影响。　结论　 ATP对房室结及旁路的电生理作用不同 ,注射 ATP后出现室房阻滞对鉴别经房室结或旁路逆传有一定价值 ,是旁路消融成功的一个判别指标 ,但并不一定完全可靠     

快频率依赖性室房逆传左侧隐匿性房室旁道参与的心动过速及射频导管消融

目的探讨快频率依赖性室房逆传特性左侧隐匿性房室旁道的电生理特点及射频消融。方法对8例心电图显示窄QRS波群心动过速的患者行电生理检查,分析房室、室房传导情况、心动过速特点、旁道定位,并行射频消融。结果8例患者均证实存在快频率依赖性室房逆传特性左侧隐匿性旁道,在较慢频率起搏右心室时旁道逆传发生阻滞,而以中等频率起搏时表现为间断旁道逆传,较快频率起搏时才表现为旁道1：1传导且均诱发了房室折返性心动过速,于快频率心室刺激下标测消融靶点,消融均获成功。结论左侧隐匿性房室旁道有时可发生快频率依赖性室房逆传现象,并伴发房室折返性心动过速,在射频消融中需注意分辨,以免漏诊。     

射频消融治疗具有快频率依赖性室房逆传特性的旁道

目的报道具有快频率依赖性室房逆传特性的房室旁道电生理检查及射频消融结果。方法4例患者,均有阵发性心悸史,且发作时心电图均显示为窄QRS波心动过速,按常规方法接受心脏电生理检查及射频消融治疗。结果4例均证实存在旁道的快频率依赖性室房逆传,且均诱发了房室折返性心动过速,室房逆传最早激动部位均为左房。于快频率心室刺激下标测消融靶点,消融均获成功。结论旁道的快频率依赖性传导为一种少见电生理现象,可伴发房室折返性心动过速。     

左侧房室慢旁路的电生理特征和射频消融靶点的定位

目的 :探讨左侧游离壁慢传导旁路的电生理特点和射频消融方法。方法 :5例患者诱发心动过速后用心室感知S2程序刺激中止心动过速确立心室为房室折返环的一部分。结果 :4例中止心动过速时无心房逆行 A波 ,1例有逆行 A波 ,旁路 1例有递减传导特点 ,均在心室侧消融成功。成功消融靶点 A波较冠状窦标测导管最早 A波提前 8～2 2 m s。结论 :心室感知 S2心室程序刺激终止心动过速是鉴别房性心动过速的可靠方法。     

左心室刺激在射频消融左侧房室旁路中的价值

目的室房传导的不完全阻断可能会导致房室折返性心动过速复发.鉴于心脏的解剖关系和电生理特点,推测左心室内刺激对于判定经左侧旁路的室房传导是否被彻底阻断要优于传统的右心室刺激.方法213例左侧旁路参与的顺向型房室折返性心动过速患者(男性125例),平均年龄(38±19)岁.在射频消融前、后均进行右心室心尖部S1S2程序刺激及S1S1分级递增刺激;射频消融后,在右心室刺激显示经旁路的室房逆传完全被阻断后,经大头消融电极在左心室游离壁进行S1S1和S1S2刺激.结果在常规右心室刺激显示经旁路的室房传导被阻断之后,共有6例患者在经大头电极以相同的条件在左心室刺激时显示经旁路的室房传导仍然存在.其中1例术前有心室预激,消融后预激已消失而室房传导仍存在,有2例仍能诱发出房室折返性心动过速.另l例既往接受消融后复发的病例在此次消融前即见到此现象.7例患者均接受射频消融,直至右心室心尖部和左心室刺激均无经旁路的室房传导.平均随访(18±9)个月,均无预激或房室折返性心动过速复发.结论在对左侧旁路参与的顺向型房室折返性心动过速进行射频消融治疗时,左心室刺激可以作为判定经左侧旁路的室房传导是否被完全阻断的电生理检查手段,这可能有助于减少左侧旁路射频消融之后房室折返性心动过速的复发机会.     

射频消融具有Mahaim纤维特性的左侧旁道一例

报道1例具有Mahaim纤维特性左侧旁道参与的宽QRS波心动过速:V1～V6均以R波为主,电轴左偏,呈右束支阻滞型。心内电生理检查:无典型预激图形,心房刺激出现与心动过速一致的宽QRS波,见旁道前传文氏现象;室房逆传呈向心性递减,心动过速时His束电图呈V-H-A顺序,逆传A波以His束部位最早;三磷酸腺苷可阻断旁道前传。窦性心律下,在左室中后间隔消融放电阻断旁道,术前极易发作的心动过速不再诱发,术后见房室传导跳跃现象。考虑该旁道起自房室结慢径或附近的心房肌,止于左室基底部。     

疑难性的房室及房室结折返性心动过速与房性心动过速快速简捷的鉴别方法

目的探讨简便、快捷鉴别疑难的房室及房室结折返性心动过速与房性心动过速的方法.方法分别对20例间隔旁路(包括4例慢旁路),20例房室结双径路(包括不典型房室结双经路1例)以及11例房速(6例房速,5例房室结双径路慢径路消融术后S1S1心房刺激模拟房速)患者,在心动过速过程中行心室RS2刺激,所有患者心室RS2刺激均能夺获心室并且逆传心房,而且不终止心动过速,观察心室刺激时心房的反应,反应方式分别为V＇-A＇-V-A(V＇S2刺激后心室波,A＇V＇波逆传心房波,V心动过速时室波,A心动过速时房波)或V＇-A＇-A-V.结果20例间隔区房室折返性心动过速的患者,心室RS2刺激的反应方式均为V＇A＇VA,其中16例V＇A＇间期＜A＇-V间期,4例慢旁道V＇A＇间期＞A＇V间期,V-A均较远(＞60ms),V＇A＇间期与VA间期相近.20例房室结折返性心动过速病人行心室RS2刺激的反应方式呈V＇A＇-V-A14例,呈V＇-A＇-A-V6例,1例不典型房室结折返性心动过速患者VA间期130ms,余13例呈V＇-A＇-V-A反应的患者VA均较近(VA＜60ms),6例呈V＇-A＇AV的患者AV较近或者融合(AV＜60ms).6例房速以及5例模拟房速患者心室RS2刺激均呈V＇-A＇-A-V反应,AV均较远(100ms).结论心动过速过程中行RS2心室刺激,是鉴别疑难的阵发性室上性心动过速的快速、简洁而有效的方法.     

射频消融具有Mahaim纤维特性的左侧旁道一例

报道1例具有Mahaim纤维特性左侧旁道参与的宽QRS波心动过速：V1～V6均以R波为主，电轴左偏，呈右束支阻滞型。心内电生理检查：无典型预激图形，心房刺激出现与心动过速一致的宽QRS波，见旁道前传文氏现象；室房逆传呈向心性递减，心动过速时His束电图呈V-H-A顺序，逆传A波以His柬部位最早；三磷酸腺苷可阻断旁道前传。窦性心律下，在左室中后间隔消融放电阻断旁道，术前极易发作的心动过速不再诱发，术后见房室传导跳跃现象。考虑该旁道起自房室结慢径或附近的心房肌，止于左室基底部。     

左侧房室慢旁路的电生理特征和射频消融靶点的定位

目的 探讨左侧游离壁慢传导旁路的电生理特点和射频消融方法。方法 5例患诱发心动过速后用心室感知S2程序刺激中止心动过速确立心室为房室折返环的一部分。结果 4例中止心动过速时无心房逆行A波，1例有逆行A波，旁路1例有递减传导特点，均在心室侧消融成功。结论 心室感知S2心室程序刺激中止心动过速是鉴别房性心动过速的可靠方法，成功消融靶点A波较冠状窦标测导管最早A波提前8～22ms。     

The immunoneuroendocrine role of melatonin

Abstract: A tight, physiological link between the pineal gland and the immune system is emerging from a series of experimental studies. This link might reflect the evolutionary connection between self-recognition and reproduction. Pinealectomy or other experimental methods which inhibit melatonin synthesis and secretion induce a state of immunodepression which is counteracted by melatonin. In general, melatonin seems to have an immunoenhancing effect that is particularly apparent in immunodepressive states. The negative effect of acute stress or immunosuppressive pharmacological treatments on various immune parameters are counteracted by melatonin. It seems important to note that one of the main targets of melatonin is the thymus, i.e., the central organ of the immune system. The clinical use of melatonin as an immunotherapeutic agent seems promising in primary and secondary immunodeficiencies as well as in cancer immunotherapy. The immunoenhancing action of melatonin seems to be mediated by T-helper cell-derived opioid peptides as well as by lymphokines and, perhaps, by pituitary hormones. Melatonin-induced-immuno-opioids (MHO) and lymphokines imply the presence of specific binding sites or melatonin receptors on cells of the immune system. On the other hand, lymphokines such as -γ-interferon and interleukin-2 as well as thymic hormones can modulate the synthesis of melatonin in the pineal gland. The pineal gland might thus be viewed as the crux of a sophisticated immunoneuroendocrine network which functions as an unconscious, diffuse sensory organ.     

Response of rat pineal melatonin to calcium, magnesium, and lithium is circadian stage dependent

Abstract: Herein we documented the response of pineal melatonin production to electrolytes known to be effective on pineal function in view of a possible circadian stage dependence. We studied the release of melatonin by perifused rat pineal glands at 2 different circadian stages corresponding to the middle of the light and dark periods, i.e., respectively, 7 and 19 HALO (Hours After Light Onset, L:D = 12:12). The initial efflux rates were, as expected, much higher in the perifusates of glands removed from rats sacrificed during the dark phase than of those removed during the light phase. After 3 hr of perifusion, melatonin release reached similar levels which were found constant up to the 8th hr of perifusion, whatever the circadian stage. Perifusion of the glands with physiological concentrations for the rat of calcium (5.2 mmol/1) and magnesium (1.34 mmol/1) resulted in a stimulatory effect on the pineal glands removed from rats sacrificed in the middle of the dark period (19 HALO), whereas no effects were observed on the pineal glands removed from rats sacrificed during the light (7 HALO). Lithium (0.28 and 0.55 mmol/1) was ineffective on melatonin release in pineal glands removed 7 and 19 HALO. Our results show differences in the initial efflux rates of melatonin and in the response of perifused pineal glands to calcium and magnesium according to the circadian stage.     

Changes in connexin43, the gap junction protein of astrocytes, during development of the rat pineal gland

Abstract: The abundance of gap junctions between rat pineal astrocytes formed by connexin43 (Cx43) was studied during development. Levels and distribution of Cx43 were measured by immunoblotting and indirect immunofluorescence, respectively. The amount of Cx43 in cells located within the gland was low until about the 7th postnatal day and increased to adult values between the 14th and 21st days postpartum. Although astrocytes, recognized by their vimentin immunoreactivity, were scarce before birth, they were abundant by the 7th postnatal day suggesting that the low levels of Cx43 found at this age corresponded to a low expression of this protein. Localization of the immunoreactivity to Cx43 and vimentin showed a close correlation, indicating that mature or immature pineal astrocytes form gap junctions made of Cx43. Since Cx43 levels attained their adult values at about the time the innervation and the functional state of the gland reached maturity (2–3 weeks after birth), it is proposed that astrocyte gap junctions are involved in the function of the adult rat pineal gland.     

Conservative management of perforated duodenal diverticulum： A case report and review of the literature

Duodenal diverticula are a relatively common condition. They are asymptomatic, unless they become complicated, with perforation being the rarest but most severe complication. Surgical treatment is the most frequently performed approach. We report the case of a patient with a perforated duodenal diverticulum, which was diagnosed early and treated conservatively with antibiotics and percutaneous drainage of secondary retroperitoneal abscesses. We suggest this method could be an acceptable option for the management of similar cases, provided that the patient is in good general condition and without septic signs.     

Presence of immunoreactive growth hormone and prolactin in the ovine pineal gland

Abstract: The use of antisera raised against bovine growth hormone (GH) and ovine prolactin (PRL) enabled the detection of related immunoreactive (ir) sequences of proteins in ovine pineal tissue. The isolation of PRL-like ir-material was accomplished using a 0.25 M ammonium sulphate (pH 5.5) extraction followed by ethanol precipitation, whereas the resulting 2.0 M ammonium sulphate (pH 7.0) precipitate contained a GH-like immunoreactivity. Gel chromatography of the GH-like immunoreactivity (Sephadex G-100) indicated the presence of several GH-like fragments ranging in the M_r range of 7,000 to 55,000. Analyses of the PRL-like ir-material found in pineal tissue on HPLC using a TSK 545-DEAE column led to the resolution into a single peak of immunoreactivity. A single peak of activity was also observed following chromatofocusing and hydrophobic interaction chromatography of the ir-peak from the TSK 545-DEAE column. The PRL-like ir-material inhibited the binding of [¹²⁵I]ovine PRL-S14 to anti-ovine PRL antibodies without showing an affinity for binding to anti-rat PRL or anti-bovine GH antibodies. Scatchard analysis of the binding of pineal PRL-like ir-material and pituitary ovine PRL-S14 to liver membranes from day-20 pregnant rats revealed similar affinity constants (K_a of 4.7 ± 0.2 × 10⁹ M^-1). In addition, the replication of Nb 2 Node rat lymphoma cells was stimulated by pineal PRL-like ir-material, an effect known to be specific for lactogenic hormones. The pineal PRL-like immunoreactivity appeared on sodium dodecyl sulfate polyacrylamide gels as a single major band of M_r 24,000. The functional status of PRL-and GH-like ir-material in the ovine pineal remains to be determined, but evidence is presented that the overall protein synthesis rate of the rat pineal responded to circulating concentrations of PRL.     

Microbiology of human immunodeficiency virus anorectal disease

PURPOSE: Individuals who are seropositive for the human immunodeficiency virus are at high risk for opportunistic infection and anorectal disorders. Little prospective information is available regarding anorectal pathogens in these patients. METHODS: One hundred sixty-three HIV-seropositive patients presented to the colorectal clinic between 1989 and 1992. Forty-seven (29 percent) patients were thought to have an infectious process and were prospectively studied using a standardized multiculture protocol. RESULTS: Mean age was 33 (range, 19–59) years. All were male; high-risk behavior accounted for 87 percent of HIV transmissions. Presenting complaints included anorectal pain (79 percent), pus per anum (28 percent), and blood per anum (26 percent). Examination revealed perianal tenderness (60 percent), condyloma (38 percent), perianal ulcers (38 percent), and anal fissures (34 percent). Sixty-six sets of cultures were performed; 28 patients had one set, 15 had two sets, and 4 had three sets. Thirty-two of these 47 patients (68 percent) had positive cultures including herpes (50 percent), cytomegalovirus (25 percent),Neisseria gonorrhoeae (16 percent), chlamydia (16 percent), acidfast bacilli (2 percent), and others (9 percent). Six of 32 patients with positive cultures had more than one organism cultured. Sixteen (50 percent) patients with positive cultures were treated medically, 8 (25 percent) were treated surgically and 8 (25 percent) were treated with both modalities. Sixty-one procedures were performed on 17 patients for condylomata. Eighteen patients had 20 procedures for abscesses, 50 percent of whom had positive cultures for other than common bowel flora; all improved. Fourteen patients underwent 33 procedures for perianal fistulas.Mycobacterium fortuitum was cultured from one patient who required 13 procedures for abscesses and fistulas. Forty-five (96 percent) patients were followed for an average of 12.5 months ±2.9 SEM (range, 1–94 months). Symptoms were improved or resolved in 22 of 32 (69 percent) patients with positive cultures and in 11 of 13 (84 percent) with negative cultures. CONCLUSIONS: Specific pathogens may often be identified in human immunodeficiency virus-seropositive patients with anorectal disorders if aggressively sought. Although patients without specific pathogens identified may be expected to improve with planned empiric treatment, positive identification allows more directed therapy.