26例左心室主动固定导线应用的回顾性分析

目的评价左心室主动固定导线（Starfix^4195美国美敦力公司）在心脏再同步治疗（CRT）中的应用价值。方法分析自2010年7月至2012年8月在浙江大学医学院附属第二医院植入Starfix^4195导线的26例患者,男16例,女10例,平均年龄（68．1±7．7）岁,其中扩张型心肌病16例,缺血性心肌病5例,其他5例。观察Staffix^4195导线植入至最优起搏位点的手术成功率;术后中位随访10．5个月,观察出现左心室导线脱位、膈神经刺激及阈值升高等并发症的发生率。结果26例患者均成功植入Staffix^4195导线,手术成功率100％,24例患者（92．3％）左心室导线植入在最优起搏位点。CRT术后随访时间≥6个月的124例患者中,CRT有反应21例（87．5％）,无反应3例（12．5％）。术后中位随访10．5个月,左心室导线起搏阈值稳定,与术中比较无明显增高[（1．0±0．5）V对（1．2±0．7）V,P〉0．05],术后均未出现左心室导线脱位、膈神经刺激等并发症。结论在CRT植入术中,Starfix^4195导线能稳定固定在左心室最优起搏位点,明显提高手术成功率,并显著减少术后并发症。     

永久起搏器主动固定电极导线的长期随访观察

目的观察主动固定电极导线的长期参数变化,并探讨其应用的稳定性。方法2006年1月至2007年8月在沈阳军区总医院植入永久起搏器并置放主动固定电极导线的患者124例（共心房电极1根,心室电极124根）,其中男67例,平均年龄为（69±9）岁。植入部位：右心耳1例,室间隔93例,心尖部31例。测试手术后即刻及术后1、3、6、12个月的参数变化。结果参数变化：起搏阈值：手术即刻增高,术后1个月下降,两者有显著的统计学差异,术后3、6、12个月起搏阈值与术后1个月比较无明显改变。感知：手术即刻与术后多次随访均无明显变化。阻抗：手术即刻增高,术后随访各个月的阻抗均较手术即刻的阻抗低,与术中比较有显著统计学差异。2例患者在术后6个月时阈值升高。结论主动固定电极导线固定较牢固,脱位率低于被动固定电极导线,术后阈值升高发生率较低（1.6%）,长期观察参数均较稳定。     

心房螺旋电极导线植入术后起搏阈值的急性改变

目的:探讨心房螺旋电极导线植入术后起搏阈值的急性变化,用以评价心房螺旋电极导线植入是否有效、安全。方法:收集2015年11月至2016年6月期间在我院植入埋藏式人工心脏双腔起搏器、且心房植入螺旋电极导线的患者68例,根据患者植入术中即刻起搏阈值是否1 V分为高阈值组和低阈值组2组,记录患者在植入术中即刻,术后1、3、6、24 h的起搏参数变化及并发症等情况。结果:68例患者中术中即刻起搏阈值≤1 V的低阈值组患者35例(51%),平均起搏阈值为(0.79±0.20)V,术后1 h下降为(0.69±0.34)V、3 h(0.61±0.21)V、6 h(0.59±0.19)V、24 h(0.58±0.18)V,术后3、6、24 h的起搏阈值与术中即刻相比,差异具有统计学意义(均P0.01)。术中即刻起搏阈值1 V的高阈值组患者33例(49%),其平均起搏阈值为(1.48±0.20)V,术后1 h下降为(0.85±0.32)V、3 h(0.74±0.23)V、6 h(0.64±0.18)V、24 h(0.60±0.24)V,术后1、3、6、24 h的起搏阈值与术中即刻相比,差异均具有统计学意义(均P0.01)。术后除3 h外,其余各时间点间2组间起搏阈值差异均无统计学意义(均P0.05)。结论 :心房螺旋电极导线植入术中即刻起搏阈值较高,术后降低。植入术中即刻起搏阈值高不应作为更换电极位置的标准。     

右心耳切除术后心房主动电极导线的植入:单中心长期随访结果

目的探索伴有右心耳切除术的患者起搏器植入术中使用心房主动固定电极导线的长期适应性和稳定性。方法入选85例病窦综合征或Ⅱ度或高度房室传导阻滞的患者并且分为,切除组(n=22)行右心耳切除术且植入双腔起搏器,保留组(n=63)未行心外科手术即右心耳保留患者行双腔起搏器。分别于植入时(0天)、1天;3、6、12、24和36个月进行起搏参数测定(起搏阈值、P/R振幅和阻抗)、植入时以及每年一次X线摄片、心脏超声检查以及电极导线植入术中和术后起搏器相关并发症的随访。结果所有电极导线植入位置均保持稳定。两组患者心房、心室电极导线的初始感知灵敏度相当(P0.05)且长期保持稳定。从植入术时至1个月,电极导线阻抗轻微下降(前后比较,P0.05),且随后保持稳定。心房电极导线的起搏阈值从植入时至术后3个月随访时有降低趋势(P0.05),在随后的随访中保持稳定,心室起搏电极导线的起搏阈值在随访全程中保持稳定,且两组间不存在显著性差异(P0.05)。但两组术前术后自身比较可见左、右心房直径、左室舒张/收缩末内径有缩小,射血分数值有一定降低,但均无显著性差异(P0.05)。随访全程两组患者未发现电极导线穿孔、移位等起搏器相关并发症发生。结论心房主动固定电极导线可成功地植入到行右心耳切除术后患者的心耳基底部,在长期随访中起搏器电极导线参数满意且保持稳定。     

固定螺旋主动固定导线植入早期及后期参数变化与安全性评价

目的 评价固定螺旋主动固定导线（Fineline Ⅱ EZ,美国波科公司）植入术中及术后3个月参数变化情况,评价其安全性.方法 2012年1月至2013年9月在青岛大学附属医院156例缓慢性心律失常患者行单腔或双腔起搏治疗,心室起搏导线均选用固定螺旋主动固定导线,经左或右侧锁骨下静脉置于右心室流出道间隔部,分别于导线旋入心肌即刻、旋入后5 min、术后即刻、术后3个月测试起搏参数：起搏阈值、导线阻抗和R波幅度,并观察术后有无导线脱位、导线穿孔、与经静脉有关的血栓形成及囊袋感染等严重并发症发生.结果 导线旋入即刻起搏阈值较高,5 min后明显下降[（0.76±0.22）V对（0.39±0.13）V,P＜0.001];术后即刻阈值较旋入5 min后进一步下降[（0.35±0.10）V对（0.39±0.13）V,P＜0.001].R波幅度在导线旋入后5 min测试较术后即刻降低[（12.70±4.94）mV对（8.94±4.07） mV,P＜0.001].术后仅1例患者出现导线脱位,无导线穿孔、囊袋感染等并发症发生.结论 固定螺旋主动固定导线旋入心肌5 min后起搏阈值明显降低,故可常规于旋入5min后进行测试,确定是否需要调整导线位置.固定螺旋主动固定导线在应用过程中是安全有效的.     

双腔植入型心律转复除颤器临床应用

目的以往应用的单腔心律转复除颤器(ICD)常会发生误识别，产生误放电。此外，单腔心室起搏可使心功能降低。双腔ICD可克服单腔ICD上述弊端。本文报道12例双腔ICD的临床应用。方法12例患者，男性10例，女性2例，平均年龄52岁，均有院外晕厥史，术前证实室性心动过速7例，心室颤动5例。12例患者中4例伴有阵发性心房颤动(房颤)，3例伴有阵发性房性心动过速(房速)，5例伴有心动过缓及心功能不良。12例患者均植入了双腔ICD(美敦力公司，Gem DR)。心室导线常规植入右心室心尖部，心房导线为主动固定的螺旋电极导线，此导线顶端带有弹簧除颤电极，将心房导线固定于右心耳靠外侧处，以避免发生交叉感知。结果12例患者均顺利植入双腔ICD，除颤阈值均小于20J。平均心室起搏阈值0．9V，R波高9．8mV。心房起搏阈值1.4V，P波高2．6mV。在平均随访6．8个月中，ICD共发放抗心动过速起搏(ATP)45次，低能量转复11次，除颤4次，无误放电发生。5例伴心动过缓者，心功能无进一步恶化。结论双腔ICD由于增加了心房电极导线，可提高对房性心律失常的识别能力，从而减少误放电。对伴有房性心律失常及心动过缓者应推荐使用双腔ICD。     

新型主动固定起搏导线的临床应用

目的评估植入新型主动固定起搏导线的可用性和安全性。方法选择本中心植入永久性人工心脏起搏器患者101例,分为新型导线组（n=25）和传统导线组（n=76）,新型导线组患者植入Medtronic3830导线3根,5086MRI导线14根（包括心房、心室导线）,Boston Scientific4471导线15根;传统导线组患者植入心室主动固定导线76根,心房被动固定导线58根,测量植入后各相关起搏参数,手术时间,曝光时间及心室导线过三尖瓣的次数,并常规随访。结果两组导线的阈值[（0．62-4-0．14）V、（0．63-4-017）V]、振幅[（1129±4．28）mV、（12．74±6．08）mV]、阻抗[（76768±132．73）Q、（815．14±182．46）Q]、电流[（077±0．19）mA、（0．85±0．33）mA]、斜率（2．46±1．07、2．844-102）差异均无统计学意义（均P〉005）,两组起搏导线损伤电流[（6,83±1157）mV、（6．61±1187）mV]、植入手术时间[（44．204-4．65）min、（43．42±5．55）min]、曝光时间[（3．24±1．04）min、（3．33±1．05）min]、导线过三尖瓣次数（1．36±0．57、1．34±0．63）差异均无统计学意义（均P〉0．05）。三种新型起搏导线植入时均未发生并发症,4471导线出现1例术后完全脱位。1年时随访两组导线的阈值、振幅、阻抗异均无统计学意义（均P〉0．05o结论新型起搏导线均符合起搏器植入要求,未增加手术时间和曝光时间,植入安全。     

损伤电流在主动电极导线植入术中的临床价值和应用

目的探讨损伤电流(COI)对主动电极导线植入的指导作用和意义。方法选取心房、心室均为主动电极导线新植入的双腔起搏器患者,记录电极旋入心肌即刻、旋入后5 min的COI,同时测试该时间点的起搏参数(COI组);选取相同条件同期植入但术中未记录COI、只测试起搏参数的患者作为常规对照(常规组)。分析COI不同时间点的变化规律及心房、心室COI的特点,比较两组参数及长期随访的结果。结果共纳入85例患者,COI组40例,常规组45例。COI组中,主动电极导线旋入后即刻,COI即达到最高峰,图形特点明显,表现为最大幅度的PR段或ST段抬高[心房(2.81±0.57)mV,心室(10.12±2.38)mV]和最长的腔内心电图时限[心房(252±29)ms,心室(322±38)ms]并持续5 min以上;心房、心室旋入后即刻阈值显著高于旋入后5min[心房(1.83±0.89)V vs (1.10±0.61)V,心室(0.91±0.37)V vs (0.59±0.23)V,P均≤0.001),COI明显但阈值高的患者延长等待时间可获得明显下降的阈值,避免反复更换电极位置。两组的近期和远期随访参数均维持在正常范围,与常规组相比,COI组长期起搏参数更趋稳定。结论主动电极导线的起搏阈值通常数分钟内稳定下降,常规起搏参数可满足多数患者术中测试的需要;显著的COI,常预示阈值会有明显的下降,在心房电极导线表现更为明显,术中选择性使用,对即刻短暂的高阈值有较好的判别和指导作用。     

低位房间隔起搏的初步临床应用

目的探索主动固定电极导线在低位右心房间隔部起搏的可行性、安全性；比较低位房间隔起搏与高位右心房游离壁起搏对，心房激动时间和起搏参数的影响。方法共入选了50例，患者平均年龄（64．8±11．2）岁，随机分配到低位房间隔起搏组（n=25）和高位右心房游离壁起搏组（n=25），通过比较植入术时间、X线曝光时间、导线固定成功率、起搏参数、植入术并发症等评价低位右心房间隔起搏的可行性；测定不同部位起搏时P波宽度，以评价起搏部位对心房激动时间的影响。结果与高位右心房游离壁起搏组结果比较，低位房间隔起搏组的植入时间、X线曝光时间略有延长；低位房间隔起搏组的导线固定成功率低于右心房游离壁起搏组（84％ VS 100％），两组间的起搏参数、植入术并发症相比差异无统计学意义。低位房间隔起搏时心房激动时问明显短于高位右心房游离壁起搏[（140．5±23．0）ms VS（89．0±14．0）ms]，差异具有统计学意义。结论采用主动固定电极导线在低位房间隔起搏是安全、可行的，它明显缩短左、有心房激动时间，使心房的除极趋于同步化。但低位房间隔起搏的主动固定电极导线植入技术具有一定的难度，需要熟练掌握主动固定导线植入技术的人员方可实施。     

右心室流出道间隔部起搏与右心室心尖部起搏随机对照研究

目的应用组织多普勒方法随机对照研究右心室流出道间隔部（right ventficular outflow tract septum,RVOTS）起搏与右心室心尖部（fight ventricul arapical,RVA）起搏心脏同步性和心功能变化,探讨右心室流出道间隔部在主理性起搏中的临床意义。方法128例缓慢心律失常患者按单双数字随机分为两组,对病态窦房结综合征房室功能正常患者,起搏器植入术后根据心电图PR间期时间将起搏器AV间期调整,暂时关闭AV搜索功能以保证心室起搏。所有患者起搏器植入术后1、3、6个月定期随访,观察起搏参数、累积心室起搏百分比,同时行超声心动图检查。结果RVOTS起搏组与RVA起搏组电极导线植入时间、X线曝光时间差异有统计学意义（P〈0．01）,主动固定电极导线植入15min与植入即刻比较起搏阈值明显下降,分别为（0．76±0．21）mV和（1．13±0．25）mV（P〈0．01）。RVOTS起搏组和RVA起搏组QRS时限分别为（0．14±0．04）S、（0．16±0．03）S（P〈0．01）。随访6个月起搏参数两组之间差异无统计学意义。全部患者未出现植入并发症,随访6个月无电极导线移位、阈值增高。6个月RVOTS起搏组左心室同步指标明显优于RVA起搏组（P〈0．01）。左心室收缩末内径及舒张末内径两组比较无显著变化,左心室射血分数在RVA起搏组有所降低（P〈0．05）,心脏做功指数（Tei）、RVOTS起搏组与RVA起搏组比较差异有统计学意义（P〈0．05）,在RVA起搏组随访6个月与1个月比较差异有统计学意义（P〈0．01）。结论RVA起搏导致心脏收缩不同步,损害左心室功能。RVOTS起搏保持良好心脏收缩同步性、保护左心室功能,是较好的右心室起搏部位。     

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.     

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.     

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.