血浆脑钠肽和C反应蛋白在急性冠脉综合征患者介入治疗前后的变化及意义

目的:观察脑钠肽(BNP)和C反应蛋白(CRP)在急性冠脉综合征(ACS)患者冠状动脉介入治疗(PCI)前后的变化,探讨PCI对ACS患者血浆BNP和CRP水平的影响。方法:选择ACS患者80例,其中不稳定型心绞痛29例,非ST段抬高型心肌梗死51例,分为介入组40例和药物组40例,测定治疗前后血浆BNP、CRP浓度。另设对照组40例,测定空腹血浆BNP、CRP水平。结果:介入组和药物组血浆BNP和CRP均高于对照组(P<0.001);介入组、药物组治疗前BNP、CRP水平差异无统计学意义(P>0.05),药物组治疗后1周血浆BNP和CRP水平均低于治疗前(P<0.01);介入组术后24h血浆BNP水平较术前明显升高,术后1周明显低于药物组(P<0.01)。结论:ACS患者血浆BNP、CRP水平升高,可预测疾病的严重程度;PCI术后24h血浆BNP水平升高,可作为心肌缺血的监测指标。ACS患者治疗后血浆BNP和CRP水平明显下降,介入治疗后下降更明显,可作为疗效观察的重要参数,对病情的评估具有重要意义。     

老年急性冠脉综合征冠状动脉损伤程度与血清 hs-CRP、MCP-1、TAT及IL-18的相关性研究

目的:探讨老年急性冠脉综合征(ACS)冠状动脉损伤程度与血清高敏C反应蛋白(hs-CRP)、单核细胞趋化蛋白1(MCP-1)、凝血酶抗凝血酶复合物(TAT)及白细胞介素18(IL-18)的相关性.方法:采用ELISA法检测48例老年ACS患者、加例老年稳定型心绞痛(SAP)及25例正常老年人血清hs-CRP、MCP-1及IL-18水平、血浆TAT含量.采用Gensini评分方法评价ACS、SAP患者冠脉病变损伤程度.结果:老年ACS组血清(浆)hs-CRP、MCP-1、TAT、IL-18水平显著高于SAP组及正常老年人(P<0.01);老年ACS组与SAP组Gensini评分差异无显著性(P>0.05);Pearson相关分析显示,血清(浆)hs-CRP、MCP-1、TAT、IL-18与Gensini评分之间无相关性(r值分别为0.201、0.192、0.140、0.154,均P>0.05),hs-CRP、MCP-1、IL-18与TAT之间有相关性(r值分别为0.531、0.453、0.436,均P<0.05).结论:促炎症细胞因子在老年ACS粥样斑块的易损性方面发挥了作用,易损斑块容易导致凝血系统的激活;冠脉造影Gensini评分不能作为判断老年冠心痛病情危险性的指标.     

血浆脑钠肽和C反应蛋白在急性冠脉综合征患者介入治疗前后的变化及意义

目的：观察脑钠肽（BNP）和c反应蛋白（CRP）在急性冠脉综合征（ACS）患者冠状动脉介入治疗（PCI）前后的变化，探讨PCI对ACS患者血浆BNP和CRP水平的影响。方法：选择ACS患者80例，其中不稳定型心绞痛29例，非ST段抬高型心肌梗死51例，分为介入组40例和药物组40例。测定治疗前后血浆BNP、CRP浓度。另设对照组40例，测定空腹血浆BNP、CRP水平。结果：介入组和药物组血浆BNP和CRP均高于对照组（P〈0．001）；介入组、药物组治疗前BNP、CRP水平差异无统计学意义（P〉0．05），药物组治疗后1周血浆BNP和CRP水平均低于治疗前（P〈0．01）；介入组术后24h血浆BNP水平较术前明显升高。术后1周明显低于药物组（P〈0．01）。结论：ACS患者血浆BNP、CRP水平升高，可预测疾病的严重程度；PCI术后24h血浆BNP水平升高。可作为心肌缺血的监测指标。ACS患者治疗后血浆BNP和CRP水平明显下降，介入治疗后下降更明显，可作为疗效观察的重要参数．对病情的评估具有重要意义．     

冠心病患者血浆纤维蛋白原与脂蛋白相关磷脂酶A2水平

目的分析冠心病(CAD)患者血浆纤维蛋白原(Fbg)、脂蛋白相关磷脂酶A2(Lp-PLA2)水平。方法分别检测110例急性冠脉综合征(ACS)、80例稳定性心绞痛(SAP)患者和48例健康人对照组的血浆Lp-PLA2,Fbg水平及CAD病变程度,分析其相互关系。结果与健康人对照组相比较,CAD患者Lp-PLA2,Fbg水平均显著升高,差异有统计学意义(t=4.556,8.095;均P<0.01);与SAP组相比较,ACS组的Lp-PLA2,Fbg,Gensini积分以及cTnI水平均显著升高,差异有统计学意义(t=3.537,2.126,3.286;均P<0.05)。相关性分析显示,CAD患者血浆Lp-PLA2,Fbg均与Gensini积分(r1=0.356,r2=0.348;均P<0.01),cTnI水平(r1=0.262,r2=0.213;均P2<0.05)呈正相关,且Lp-PLA2与Fbg亦呈正相关(r=0.203,P<0.01)。多元回归分析显示,CAD患者血浆Lp-PLA2和Fbg(β=0.263,0.204,均P<0.05)水平共同决定了10.70%的Gensini积分变化;cTNI和Fbg(β=0.484,0.293;均P<0.01)共同决定了35.00%的Lp-PLA2变化,而Lp-PLA2是Fbg的唯一显著的独立预测因子(β=0.368,P<0.01)。结论CAD患者血浆Lp-PLA2,Fbg水平升高,与动脉粥样硬化(As)病变程度密切相关,且两者相互促进相互影响。     

B型钠尿肽在急性冠脉综合征中的临床意义

目的研究急性冠脉综合征(ACS)患者血浆B型钠尿肽(BNP)水平对早期临床诊断、危险分层的临床价值。方法对58例ACS患者行心电图、血浆BNP、血清酶(肌红蛋白、肌酸磷酸激酶同工酶、心肌肌钙蛋白I)、超声心动图检查。结果血浆BNP水平在ST段抬高的急性心肌梗死组明显高于非ST段抬高的ACS组(188.46±222.03 pg/mL vs.37.91±52.35pg/mL,P=0.001);左室舒张末径(LVEDD)、左室收缩末径(LVESD)、左房径(LAD)、左室射血分数(LVEF)两组无显著性差异(P>0.05)。血浆BNP浓度与LVEF呈显著负相关(r=-0.393,P<0.05),与LVEDD、LVESD有明显正相关性(r=0.415及0.421,P<0.05)。血浆BNP浓度、cTnI浓度、LVEF与ACS患者近期心脏不良事件明显相关(OR值:2.640、2.782、2.036)。结论血浆BNP浓度是ACS患者一个特异性较好的监测指标,是ACS患者早期危险分层的独立预测因子。     

血浆vaspin浓度与急性冠脉综合征的相关性

目的探讨血浆腹腔脂肪型丝氨酸蛋白酶抑制剂(Vaspin)浓度与急性冠脉综合征的相关性。方法选择稳定型心绞痛患者共87例(SAP组),急性冠脉综合征患者共51例(ACS组),另外选择50例冠状动脉正常者为对照组。检测血清vaspin水平,Gensini积分方法评估冠脉病变程度并分析。结果 ACS组血清vaspin水平显著低于SAP组和对照组,ACS组Gensini积分显著高于SAP组和对照组,差异均有显著性(P0.05)。Spearman相关分析发现,各组血清vaspin水平与Gensini积分具有显著负相关关系(r=-0.762~-0.812;P0.001)。多支病变组血清vaspin水平显著低于单支病变组和2支病变组。结论血清vaspin水平可作为反映急性冠脉综合征患者冠脉病变的新的血清标记物。     

血浆同型半胱氨酸、超敏C反应蛋白与中青年急性冠状动脉综合征的相关性

目的 探讨血浆同型半胱氨酸(Hcy)、超敏C反应蛋白(hs-CRP)与中青年急性冠状动脉综合征(ACS)的相关性。方法 收集天津市胸科医院心内科入院的中青年(29~45岁)ACS患者142例,包括急性心肌梗死(AMI)61例和不稳定型心绞痛(UAP)81例,并以冠状动脉正常的中青年患者60例为对照组,测定3组Hcy、hs-CRP水平,分析血浆Hcy、hs-CRP水平与ACS的相关性。结果 AMI组Hcy、hs-CRP水平明显高于对照组及UAP组(P＜0.05),UAP组与对照组比较,Hcy、hs-CRP水平差异无统计学意义(P＞0.05),血清Hcy、hs-CRP水平与Gensini积分呈正相关(r=0.17、0.26,P均＜0.05)。应用Logistic 回归模型分析结果示:Hcy为中青年ACS患者的独立危险因素。结论 血浆Hcy、hs-CRP水平升高与中青年ACS关系密切,亦可为评价冠状动脉病变程度提供参考价值。     

稳定性冠心病B型利钠肽水平与冠脉病变及介入的关系

目的:初步探讨稳定性冠心病(coronary artery disease,CAD)患者静脉血浆B型利钠肽(B-type natriuretic peptide,BNP)水平与冠脉病变的关系,以及药物洗脱支架植入前后BNP水平的变化.方法:研究入选了88例稳定性CAD,均经冠脉造影(coronary angiography,CAG)证实.收集临床、CAG和经皮冠脉介入(percutaneous coronary intervention,PCI)资料.所有入选者微粒子酶免分析法(化学发光法)测定静脉BNP浓度.其中29例在DES植入后进行了CAG复查和BNP测定.结果:BNP水平在单支病变组(123.51±18.50)pg/mL,2支病变组(148.32±34.97)pg/mL,3支病变(166.11±28.53)pg/mL,组间BNP浓度比较差异无显著性(P=0.493 3).Gensini 积分≤33组BNP水平为(118.94±16.47)pg/mL;Gensini积分＞33组为(180.59±27.35)pg/mL,P=0.046 8.DES植入8个月后BNP水平明显降低[(230.43±48.81)pg/mLvs(149.33±17.49)pg/mL,P=0.038 2].结论:冠脉痛变越重,BNP水平越高;稳定性CAD患者DES植入8个月后BNP水平明显降低.     

血清胱抑素C水平与冠心病严重程度的关系

目的:探讨血清胱抑素C水平(Cystatin C,CysC)与冠心痛严重程度的关系.方法:经选择性冠状动脉造影入选150例患者,确诊为冠心病110例(冠心病组),冠脉病变程度用病变血管支数及Gensini积分表示;非冠心病40例(为对照组).测定其血清CysC、超敏C反应蛋白(high-sensitive C-reactive protein,hs-CRP)、血脂等水平,分析血清cysc水平与冠心病、hs-CRP等之间的关系.结果:(1)冠心病组血清CysC 水平(1.26±0.43 mg/L)明显高于非冠心病组(1.01±0.23 mg/L)(P<0.05);随冠脉病变支数的增加,血清CysC、Gensini积分、hs-CRP均明显升高(P<0.05).(2)血清CysC水平与年龄、hs-CRP呈正相关,与血脂水平无明显相关性.(3)血清CysC与Gensini积分之间存在线性正相关(P<0.001).结论:血清CysC水平与冠心病严重程度密切相关,与hs-CRP呈正相关,可能成为冠心病严重程度的预测指标之一.     

血清基质金属蛋白酶-9与急性冠脉综合征的相关性

目的:分析血清基质金属蛋白酶-9(MMP-9)与急性冠脉综合征(ACS)的关系。方法:用酶联免疫吸附法检测76例ACS[其中急性心肌梗死(AMI)22例,不稳定性心绞痛(UA)54例]和20例稳定性心绞痛(SA)患者的血清MMP-9,同时行冠脉造影(CAG)和测血脂、肌酸激酶同功酶(CK-MB)、肌钙蛋白Ⅰ(TNI)、白细胞(WBC)、C反应蛋白(CRP)。结果:AMI、UA及SA患者的MMP-9浓度分别为51.34±8.26 ng·ml~(-1)、48.19±6.95 ng·ml~(-1)、27.08±4.67 ng·ml~(-1)。AMI与UA的MMP-9浓度无显著差异,而AMI及UA血清MMP-9浓度均明显高于SA(AMI vs SA,P<0.01;UA vs SA,P<0.01)。血清MMP-9浓度与WBC计数(ACS:P<0.01;SA:P<0.05)及CRP水平(ACS:P<0.01;SA:P<0.05)呈正相关,而与冠脉病变支数、病变程度、CK-MB、TNI及血脂水平无关。结论:ACS患者的血清MMP-9浓度较SA患者明显升高,提示血清MMP-9可能是一项预测不稳定斑块、发生ACS的有用指标。     

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.     

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.     

手转胎头术失败的原因与分娩结局临床分析

目的 探讨手转胎头术失败的原因与分娩结局.方法 选择2008年1月至2010年12月于我院住院分娩的持续性枕横位、枕后位产妇198例,根据行手转胎头术后结果分为成功组126例、失败组72例.比较两组分娩结局,对比分析失败原因.结果 失败组胎儿体质量≥3500 g的发生率[76.4％(55/72)]明显高于成功组[31.7％(40/126)],差异有统计学意义(x2=30.177,P=0.001)、失败组宫缩乏力发生率[58.3％(42/72)]高于成功组[38.1％ (48/126)],差异有统计学意义(x2=7.569,P=0.006)、失败组骨盆临界或轻度狭窄发生率[38.9％ (28/72)]高于成功组[23.8％(30/126)],差异有统计学意义(x2 =5.030,P=0.002)、失败组手转胎头时机不当(宫口开大＜6 cm、胎头位于坐骨棘上及宫口开大8～10 cm、胎头位于坐骨棘下≥2 cm)发生率[61.1％(44/72)]高于成功组[38.9％(49/126)],差异有统计学意义(x2=9.084,P=0.003).失败组母儿并发症(产后出血、产褥病率、胎儿窘迫、新生儿窒息)发生率高于成功组(x2 =9.586,P=0.002、x2=9.334,P=0.002、x2=5.910,P=0.015、x2=5.240,P=0.022)、失败组剖宫产发生率[72.2％(52/72)]明显高于成功组[34.1 ％(43/126),x2=26.641,P=0.001)].结论 手转胎头术能使难产变顺产,降低剖宫产率,减少母儿并发症,但须积极预防、处理导致手转胎头术失败的原因,对矫正失败后继续矫正及试产应慎重.     

Evidence-Based Pain Management and Palliative Care in Issue Four for 2009 of The Cochrane Library

ABSTRACT

The Cochrane Library of Systematic Reviews is published quarterly. Issue 4 for 2009 contains 4027 complete reviews, 1906 protocols for reviews in production, and 11447 one-page summaries of systematic reviews published in the general medical literature. In addition, there are citations of 600,000 randomized controlled trials, and 12,200 cited papers in the Cochrane methodology register. The health technology assessment database contains over 7500 citations. This edition of the Library contains 90 new reviews, of which 19 have potential relevance for practitioners in pain and palliative medicine.     

Wie zuverlässig sind Angaben zu nichtentzündlichen ausgedehnten Schmerzen?

ZusammenfassungFragestellung Es wurde geprüft, wie sich der Differenziertheitsgrad zweier Schmerzmessmethoden auf Angaben zur Ausgedehntheit klinischer Schmerzen auswirkt. Zugleich wurde der Referenzzeitraum variiert, über den die Patienten berichten sollten.Methode Erfasst wurde der Einfluss zu Lasten der Befragungsdifferenziertheit durch den Vergleich zweier Körperschema-Bildvorlagen. Drei Referenzzeiträume (Schmerz aktuell, letzte Woche, letztes halbes Jahr) wurden vorgegeben.Ergebnisse Patienten mit ausgedehnten Schmerzen gaben bei differenzierter Befragung um so mehr Schmerzen an, je weiter die Schmerzen zurück lagen und je größer der Berichtszeitraum war. Patienten mit gelenknahen Schmerzen gaben bei hoch differenzierter Befragung weniger ausgedehnte Schmerzen in der Vergangenheit an als bei globaler Einschätzung. Patienten mit Rückenschmerzen berichteten bei differenzierter Befragung zum aktuellen Schmerz über weniger ausgedehnte Schmerzen als bei globaler Befragung.Schlussfolgerung Die Angaben zur Schmerzausdehnung variieren vor allem bei Patienten mit ausgedehnten Schmerzen in Abhängigkeit von der Differenziertheit der Befragung. In diesen Fällen ist die Wahrscheinlichkeit erhöht, dass sich die Beschwerdesymptomatik zumindest teilweise erst in der Reaktion auf die situativen Befragungsbedingungen konstituiert und daher nicht auf andere Befragungsbedingungen generalisiert werden kann.