肺动脉高压对右心室收缩功能和收缩同步性的影响

目的 观察肺动脉高压(PAH)对右心室收缩功能和收缩同步性的影响.方法 选取PAH患者34例,其中轻度PAH者10例(轻度组),中重度者24例(中重度组).另选择同期相匹配的30例临床及超声心动图检测正常者作为对照组.采用四腔心切面速度成像和应变成像测量室间隔(IVS)、右心室游离壁(RVW)两点及左心室游离壁(LVW)的达峰时间(TTP)并计算相互间的差值.测量右心室收缩末期面积(RVESA)、舒张末期面积(RVEDA)并计算面积变化率(RVFAC),测量等容收缩期加速度(IVA)及三尖瓣环处的收缩期峰值速度(Sm).结果 与对照组比较,组织速度及应变成像测量右心室收缩活动在中重度组明显延迟(P＜0.01),而轻度组右心室心肌收缩活动亦出现明显延长(P＜0.01),中重度组右心室心肌收缩活动延迟更为明显(P＜0.05).与对照组比较,中重度组RVESA、RVEDA均明显增大(P＜0.01),RVFAC、IVA及Sm显著减低(P＜0.05).结论 PAH不仅导致右心室重构改变,降低右心室收缩功能,亦引起了右心室心肌收缩的不同步性,尤其是中重度PAH不同步性更为明显.     

左心室瘢痕负荷SPECT相位分析法检测及其对心脏再同步治疗疗效的影响

目的 观察慢性心力衰竭患者心脏再同步治疗(CRT)后有反应和无反应者之间左心室瘢痕负荷的差异性,评价左心室瘢痕负荷对CRT疗效的影响.方法 对30例2006年至2010年因慢性心力衰竭在南京医科大学第一附属医院接受CRT的患者进行静息核素心肌显像检查,应用相位分析技术检测左心室瘢痕负荷、收缩期相位时间标准差( phase S D)和带宽(BW)并用来评价心脏同步性.以术后6个月超声心动图的检测结果及随访6个月内是否因心力衰竭住院作为分组标准,左心室射血分数(LVEF)提高≥0.05且无因心力衰竭住院的患者入选反应组,LVEF提高＜0.05或者入院1次以上的患者入选无反应组,观察两组之间左心室瘢痕负荷和同步性指标之间的差异.结果 30例患者中反应组19例(男8例),无反应组11例(男8例).两组之间术前临床资料相似,年龄、性别均差异无统计学意义;有反应组术前QRS时限显著大于无反应组[(163.0±7.7)ms对(134.6±11.8) ms,P＜0.05];两组术前LVEF差异无统计学意义,但术后有反应组显著高于无反应组(0.49±0.02对0.33±0.15,P＜0.01).两组患者左心室瘢痕负荷和CRT术后左心室同步性差异具有统计学意义,有反应组患者的左心室瘢痕负荷明显低于无反应组(24.6％±3.6％对36.5％±3.9％,P=0.022);有反应组左心室同步性较好,收缩期相位时间标准差明显小于无反应组(28.1°±4.4°对56.1°±6.9°,P＜0.01),收缩期带宽明显小于无反应组(88.0°±13.9°对170.1°±24.4°,P＜0.01).左心室瘢痕负荷和心脏同步性对CRT疗效具有明显的影响.结论 接受CRT的慢性心力衰竭患者,左心室瘢痕负荷和CRT术后心脏同步性与CRT疗效密切相关.     

参松养心胶囊对心功能及心脏电生理影响的实验研究

目的 观察中成药参松养心胶囊对日本大耳兔心力衰竭模型的心功能及心脏电生理特性的影响,以探讨其治疗心力衰竭及心律失常的机制.方法 将32只日本大耳兔随机分为假手术对照组、假手术参松组、心力衰竭对照组、心力衰竭参松组,以人工主动脉瓣反流术联合腹主动脉缩窄术建立心力衰竭模型,药物干预组于主动脉瓣反流术后给予0.4g·kg-1·d-1参松养心原粉灌胃.8周后,行超声心动图检查及在体电生理研究.结果 心力衰竭对照组与假手术对照组相比,心力衰竭对照组左心室收缩末期内径(LVESD)、左心室舒张末期内径(LVEDD)、左心室收缩末期容积(LVESV)、左心室舒张末期容积(LVEDV)增大(P＜0.05),左心室射血分数(LVEF)、左心室短轴缩短分数(LVFS)减小(P＜0.05);左右心房、心室动作电位时限复极90％时间(MAPD90)延长(P＜0.05);右心房、左右心室有效不应期(ERP)延长(P＜0.05);左心室内、中、外膜层心肌细胞MAPD90及跨室壁复极离散度(TDR)明显延长(P＜0.05);心室颤动(室颤)阈值(VFT)明显降低(P＜0.05).心力衰竭参松组与心力衰竭对照组比较,心力衰竭参松组LVESD减小(P＜0.05),LVFS、LVEF增大(P＜0.05);左心房MAPD90缩短(P＜0.05);右心房、右心室MAPD50、MAPD90、ERP均缩短(P＜0.05);左心室MAPD90、ERP缩短(P＜0.05);左心室内、中、外膜层心肌细胞MAPD90、TDR明显缩短(P＜0.05);VFT明显升高(P＜0.05).结论 参松养心胶囊可改善因前后负荷增加引起的心功能减退、缩短因压力负荷增加而延长的ERP及APD,通过缩短TDR、提高VFT发挥抗心力衰竭后心律失常的作用.     

心脏再同步化治疗起搏参数优化对心脏同步性及心功能的影响

目的 应用组织多普勒研究心脏再同步化治疗(CRT)术后A-V、V-V间期优化对心脏同步性能及心功能的影响,探索A-V、V-V间期优化在增强CRT临床疗效中的作用.方法 32例慢性心力衰竭患者接受CRT治疗,于术后7天、3个月、6个月进行A-V、V-V间期优化,观察心脏同步性和心功能变化.采用彩色超声诊断仪进行图像采集及下线分析.结果 经观察,术后7天、3个月、6个月的A-V间期需行优化的例数分别为28例、10例、6例,V-V间期需行优化的例数分别为29例、6例、5例.与CRT术前相比:CRT治疗术后未优化时的左室12节段组织速度达峰时间标准差明显改善[(68.8±26.4)ms与(41.6±23.1)ms,P＜0.01],左室射血分数增加[(28±4)%与(31±3)%,P＜0.05],主动脉瓣前向血流速度时间积分增加[(13.6±3.1)cm与(15.5±4.3)cm,P＜0.05],舒张早期跨二尖瓣血流峰速和舒张早期心肌组织运动峰速的比值下降(13.1±5.3与9.3±4.3,P＜0.05),左室舒张充盈时间延长[(313.2±93.6)ms与(368.6±97.1)ms,P＜0.05].与术后未优化时相比:术后7天优化心脏同步性指标进一步改善(P＜0.05),心功能指标无明显改变;术后3个月、6个月优化与术后7天优化相比,心脏同步性指标无明显改变,P＞0.05;术后6个月优化的左室射血分数增加,左室舒张充盈时间延长,P＜0.01.结论 CRT术后7天,A-V、V-V间期优化治疗改善心脏同步指标;术后6个月优化进一步改善心功能.     

实时三维超声心动图评价心脏再同步化治疗慢性心力衰竭的短期临床疗效

目的通过实时三维超声心动图评价心脏再同步化治疗(CRT)慢性心力衰竭的短期临床疗效。方法选取2014年1月—2018年5月在宝鸡市人民医院诊断为慢性心力衰竭且行CRT的病人48例,所有病人均采用实时三维超声心动图评价心脏再同步化治疗的疗效,观察术前和术后病人左心室功能指标、左室同步化情况和心功能变化。结果术后病人左室收缩末期容积(LVESV)、左室舒张末期容积(LVEDV)、左室舒张末期内径(LVEDD)、Tmvs16-sd/RR值和Tmvs16-Dif/RR值均较术前降低,左室射血分数(LVEF)较术前升高,术后病人每搏量(SV)、心排血量(CO)和6 min步行距离均高于术前,差异均有统计学意义(P0.05)。结论 CRT可有效改善心力衰竭病人的心功能,实时三维超声心动图能有效评价左室收缩功能,可对CRT治疗的短期疗效评估提供有效的定量信息。     

超声心动图监测中老年女性肺动脉高压患者心功能的临床价值

目的探讨超声心动图对中老年女性肺动脉高压患者心室功能的评价。方法选择中老年女性肺动脉高压患者50例为观察组,50例健康正常女性为对照组。应用超声心动图对患者各项心功能参数指标进行检测。结果观察组患者右心室功能参数指标右心房收缩末期面积(RAESA)、右心室收缩末期面积(RVESA)、右心室舒张末期面积(RVEDA)都高于对照组(P0.01)。观察组右心室面积变化分数(RVFAC)低于对照组(P0.01)。观察组患者左心室舒张功能指标二尖瓣口舒张早期血流速度(E)峰、二尖瓣侧瓣环舒张早期运动峰值速度(E')峰、E/舒张晚期峰值流速(A)比值都低于对照组(P0.01)。观察组患者二尖瓣E/E'、E峰下降时间(DT)、左心室等容舒张时间(IRT)都高于对照组(P0.01)。与对照组相比,观察组肺动脉高压患者左心室舒张末期容积(LVEDV)、左心室收缩末期容积(LVESV)均减低,搏出量减低(P0.01)。与对照组相比,观察组肺动脉高压患者左心室射血分数(LVEF)无明显变化(P0.05),而整体收缩期径向应变(GRSS),整体收缩期纵向应变(GLSS)、整体收缩期环形反应(GCSS)绝对值均减低(P0.01)。结论超声心动图能够较好地监测中老年女性肺动脉高压患者左心功能的变化,具有较高的临床价值。     

心脏再同步治疗AV、VV间期优化对缺血性与扩张性心肌病的疗效比较

目的比较AV、VV间期优化的心脏再同步治疗(CRT)对缺血性与扩张性心肌病患者的疗效。方法 2例缺血性心肌病与24例扩张性心肌病患者因心力衰竭植入CRT的患者分别于术后1 w及6个月行超声心动图以及组织多普勒,测定左心室舒张末期直径(LVED)、射血分数(LVEF)、舒张期二尖瓣反流速度时间积分(VTImr)、主动脉瓣射血时间速度积分(VTIa)、右心室侧壁与左心室壁收缩达峰时间差及间隔对左心室后壁的运动延迟时间差(SPWMD)。植入术后1 w在超声指导下行AV、VV间期优化。结果 AV、VV间期优化后随访6个月,缺血性心肌病组与扩张性心肌病组比较:LVED(P=0.48)及LVEF(P=0.88)均无差异;VTIa(P=0.55)及VTImr(P=0.98)均无差别;右心室侧壁与左心室壁收缩达峰时间差(P=0.49)及SPWMD(P=0.15)均无差异。结论缺血性心肌病组与扩张性心肌病对AV、VV间期优化的CRT均反应良好,两者无明显差异。     

尿毒症患者右心室功能变化的超声心动图研究

目的:探讨尿毒症患者右心室功能变化及其影响因素。方法:纳入61例左心室收缩功能正常(LVEF≥50%)的尿毒症患者及性别、年龄匹配的健康受试者30例,分析比较两组常规超声心动图参数和应变参数,并分析尿毒症患者右心室功能参数与其他参数的相关性。结果:尿毒症患者与对照组比较,三尖瓣环收缩期位移(TAPSE)、三尖瓣口舒张早期与舒张晚期血流速度比(E/A)及右心室整体长轴应变(RV GLS)绝对值均减低(P0.05),三尖瓣口舒张早期血流速度与三尖瓣环舒张早期运动速度比(E/Em)、右心室等容舒张期(IRT)及Tei指数增高(P0.05)。尿毒症患者右心室Tei指数与LV GLS绝对值呈负相关(r=-0.364,P0.05),RV GLS绝对值与LV GLS绝对值呈正相关(r=0.488,P0.05),与右心室面积变化率(FAC)呈正相关(r=0.411,P0.05),与TAPSE呈正相关(r=0.546,P0.05),与左心室心肌质量指数(LVMI)呈负相关(r=-0.495,P0.05),与Tei指数呈负相关(r=-0.374,P0.05)。结论:尿毒症患者右心室收缩及舒张功能均不同程度减低,且与左心室功能及左心室心肌质量指数等相关;二维斑点追踪技术能更敏感识别尿毒症患者右心室功能的变化,对临床管理、治疗及预后判断有指导意义。     

Comparision of different pacing sites of the right ventricle on right myocardial function by using tissue Doppler imaging

目的 应用组织多普勒显像技术(TDI)评价右室流出道间隔部起搏(RVOT)和心尖部起搏(RVA)对右心室功能的影响.方法 72例置人DDD型起搏器的患者根据心室电极放置的部位分为RVOT起搏组(38例)和RVA起搏组(34例),术前和术后3个月测定右心室侧壁三尖瓣环处的相关TDI参数.结果 RVOT组患者术后3个月与术前相比收缩期峰值速度(Sim)无明显变化(P＞0.05);而舒张早期峰值速度(Em)、舒张晚期峰值速度(Am)及Em/Am均较术前有明显改善(P＜0.05);等容收缩期时间(IVCT)无明显改变(P＞0.05),而等容舒张期时间(IVRT)缩短,射血时间(ET)延长,Tei指数由0.52±0.08下降至0.40±0.07(P ＜0.05).RAV组术后3个月与术前相比,Sm无明显变化(P＞0.05),Em/Am由0.76±0.10下降为0.68 +0.20(P ＜0.05),IVCT无明显改变,而IVRT延长,ET缩短,Tei指数由0.58±0.09上升至0.71 +0.06(P ＜0.05).术后3个月RVOT组与RAV组相比,Sm及IVCT无明显变化,而反映舒张功能的主要指标Em/Am、Tei指数有显著改善(P＜0.05).结论 RVOT起搏能够改善依赖心室起搏的Ⅱ度或Ⅲ度房室传导阻滞患者3个月时的右心室舒张功能,而RVA起搏则会使此类患者右心室舒张功能恶化,两种不同部位起搏对右室的收缩功能影响不显著.     

双心室同步起搏治疗难治性心力衰竭的长期临床疗效

目的探讨心脏同步化治疗(CRT)对于药物难治性慢性心力衰竭的效果。方法回顾性分析我院自1999年以来48例药物治疗无效的顽固性心力衰竭患者的临床资料,其中男性40例,女性8例,年龄48~84(70.0±18.5)岁。其心力衰竭的NYHA分级为Ⅲ~Ⅳ级,左心室射血分数(LVEF)≤35%,QRS间期≥130ms,左心室舒张末内径(LVEDd)≥60mm。在CRT治疗后平均随访时间(29.0±7.5)个月。采用心电图观察QRS时限、超声心动图计算LVEF,组织多普勒了解心室壁同步的情况;6min步行距离测量心脏的负荷能力的变化。结果(1)QRS时限起搏前(188±40)ms、右心室起搏(222±34)ms、左心室起搏(212±42)ms、双心室起搏(169±26)ms,双心室起搏和起搏前、右心室起搏、左心室起搏比较QRS时限明显缩短(P<0.05)。(2)心功能分级(NYHA)术前Ⅲ~Ⅳ级,术后1周Ⅰ~Ⅱ级,术后1个月直至随访时仍旧Ⅰ~Ⅱ级。(3)LVEF术前(28.30±3.94)%,术后1周(37.80±3.98)%,随访结束时(41.67±6.77)%,术后1周和术前比较明显提高(P<0.05),随访时和术前比较亦明显提高(P<0.05),但是随访时和手术后1周比较差异无统计学意义。(4)6min步行距离术前(398±168)m,术后1周(478±126)m,随访时增加至(506±134)m,术后1周和术前比较有明显提高(P<0.05),随访时和术前比较亦明显提高(P<0.05),随访时和手术后1周比较也明显提高(P<0.05)。1例患者在CRT治疗后1年行心脏移植。共计6例患者死亡。结论CRT短期就可以减轻药物难治性慢性心力衰竭患者的症状,增加其运动能力,改善心脏功能,可以使患者长期获益。     

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.     

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.     

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.     

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.