多巴酚丁胺负荷磁共振成像检测存活心肌的临床研究

目的 评价小剂量多巴酚丁胺(10μg·kg-1·min-1)负荷磁共振成像(MRI)检测存活心肌的临床价值.方法 经彩色多普勒超声检查存在左心室壁节段运动障碍冠心病患者24例,进行MRI、小剂量多巴酚丁胺负荷MRI、冠状动脉造影(CAG)及经皮冠状动脉介入治疗(PCI),所有狭窄病变行完全血运重建.参照美国超声心动图学会16节段划分法,经MRI测得各运动异常节段小剂量多巴酚丁胺负荷前后舒张末期室壁厚度(EDWT),以应用小剂量多巴酚丁胺后室壁增厚为存活心肌标准;术后1、3、6个月时复查心脏超声,以冠状动脉血运重建后室壁节段收缩功能改善为判断存活心肌的金标准.结果 24例冠心病患者共获得符合条件的室壁运动异常节段170个,根据金标准判断其中115个为存活心肌,55个为非存活心肌;MRI检测存活心肌的敏感度、特异度、准确度分别是76.5%、90.9%、81.2%.结论 小剂量多巴酚丁胺负荷MRI检测存活心肌有较高的临床价值.     

多巴酚丁胺负荷下应变率成像预测冠状动脉成形术后存活心肌功能改善的价值

目的探讨应变率成像(SRI)结合小剂量多巴酚丁胺负荷超声心动图(LDDSE)检测冠状动脉成形术(PTCA)后存活心肌功能改善的价值。方法采用SRI结合LDDSE测量20例陈旧性心肌梗死患者PTCA术前1 d静息下和负荷下室壁运动异常节段收缩期峰值应变率(SSR)及峰值速度(Vs),并计算不同负荷下SSR增长百分数(ΔSSR%)和VS增长百分数(ΔVS%)。结果PTCA术后,48节段室壁运动改善(存活组),24节段室壁运动未改善(坏死组)。分别以5μg.kg-1.min-1负荷下ΔSSR%≥2.02%、ΔVS%≥8.5%和10μg.kg-1.min-1负荷下ΔSSR%≥24.7%、ΔVS%≥28.5%为截断值,预测PTCA术后室壁运动功能改善的敏感性依次为93.8%,89.6%和95.8%,91.7%。静息状态下存活组和坏死组平均SSR差异有统计学意义,而平均Vs差异无统计学意义。结论与LDDSE相结合,SRI比组织速度成像能更敏感地预测PTCA术后存活心肌功能改善情况。     

小剂量多巴酚丁胺- 硝酸甘油超声心动图试验检测存活心肌的研究

目的　评价小剂量多巴酚丁胺 -硝酸甘油超声心动图 (DNE)检测存活心肌的临床价值。方法　心肌梗塞后伴节段性室壁运动异常患者 36例 ,接受梗塞相关血管经皮腔内冠状动脉成形术 (PTCA)前进行DNE试验。PTCA后随访 9个月 ,将DNE识别为存活心肌的室壁节段与实际运动改善节段做对比判定DNE检测存活心肌的准确性。结果　DNE检测存活心肌的敏感性、特异性及准确性分别为 80 %、81%及 82 %。结论　DNE为一敏感、可靠的检测存活心肌的方法 ,试验安全 ,具有很高的临床应用价值     

多巴酚丁胺负荷心肌声学造影的临床研究

目的 探讨多巴酚丁胺负荷心肌声学造影的临床应用价值。方法 10例正常人、1例冠脉旁路移植术和10例陈旧性心肌梗死患者共21例受试者分别于多巴酚丁胺负荷试验（DST）前后行经静脉心肌灌注显像（MCE）检查。采用能量谐波方法显像,16节段半定量记分法目测评分。梗死室壁色泽得分＝梗死室壁各节段得分总和／总节段数。多巴酚丁胺负荷心肌声学造影后梗死节段显像较前增加1分以上为心肌具有存活性。结果 10例正常人和1例冠脉旁路移植术患者大剂量多巴酚丁胺负荷心肌声学造影前后室壁节段显像记分间差异均无显著性意义。10例陈旧性心肌梗死患者进行了小剂量多巴酚丁胺负荷心肌声学造影估测心肌存活的研究,60个室壁节段,23个异常节段（不显像11节段;稀疏显像12节段）,负荷后12节段（不显像4节段,稀疏显像8节段）得到1分以上的改善,显色缺损较不显色节段可能具有更多的存活心肌（P＜0．05）。结论 多巴酚丁胺负荷心肌声学造影增加冠脉心肌血流量,使能量谐波状态下的心肌声学造影图像质量更好,可评估冠脉储备能力和估测梗死区的存活心肌。     

小剂量多巴酚丁胺负荷下运用校正背向散射声学参数检测存活心肌

目的探讨在小剂量多巴酚丁胺负荷(LDDSE)下运用校正背向散射声学参数能否提高检测存活心肌的敏感性和特异性.方法心肌梗死患者46例,按照PTCA术后室壁运动改善状况将心肌节段分为存活心肌组和非存活心肌组,比较2组在PTCA前LDDSE下的心肌背向散射指标.结果 LDDSE下存活心肌的CVIB及校正CVIB值均高于静息状态,而非存活心肌的CVIB与校正CVIB值在两种状态下无明显差异.以CVIB＞5.0 dB和校正CVIB＞3.8 dB作为判断存活心肌的标准,敏感性、特异性、准确性分别为82.1%和85.7%、68.9%和72.4%、77.6%和81.2%.二维室壁运动评分法判断存活心肌的敏感性、特异性、准确性分别为76.9%、75.9%、76.5%.结论背向散射技术结合小剂量多巴酚丁胺负荷超声心动图能较好地定量评价存活心肌,相对于二维室壁运动评分法,是更为客观准确的评价室壁运动的方法.     

心肌超声造影结合多巴酚丁胺负荷试验探讨冠心病心肌灌注与心肌收缩功能的关系

目的探讨心肌实时超声造影结合小剂量多巴酚丁胺负荷试验中心肌灌注与收缩功能之间、心肌灌注储备与心肌收缩功能储备之间的关系。方法26例住院患者进行了常规超声心动图、基础状态下和小剂量多巴酚丁胺负荷状态下的心肌超声造影。造影图像采用QLab软件对微泡再充盈曲线进行定量分析,求出各节段的A、β值及其乘积A·β。然后对各节段心肌灌注参数和室壁运动评分进行统计分析。结果在基础状态和负荷状态下,心肌灌注参数(β和A·β值)均随着室壁运动评分的增加而降低(P<0.01)。在小剂量多巴酚丁胺负荷状态下室壁运动改善的节段较无改善者具有较高的心肌灌注储备值(P<0.01)。结论心肌灌注和心肌收缩功能具有很好的相关性,检测心肌灌注储备有助于识别存活心肌。     

多巴酚丁胺负荷试验中多普勒组织成像技术的应用价值

目的　静息状态与大剂量多巴酚丁胺 (Dob)负荷状态下 ,采用多普勒组织成像 (DTI)技术观察冠心病患者室壁运动 ,探讨大剂量 Dob负荷试验中 DTI检测冠心病的应用价值。方法　采用 DTI测量大剂量 Dob负荷试验中 32例冠心病患者 (至少 1支冠状动脉主支狭窄≥ 5 0 % )静息状态、峰值负荷下侧壁、后室间隔、前壁、下壁心肌基底段、中段心内膜下心肌运动频谱 ,对照组 2 5例相应节段作对照。 DTI分析指标 :收缩期峰值运动速度 (Vs)。结果　选择性冠状动脉造影结果将冠心病组患者心肌节段区分为正常节段与缺血节段。静息状态下 ,冠心病缺血节段(abnormal,A组 )与对照组相应正常节段 (normal,N组 )间 Vs无显著性差异 ;与 N组比较 ,峰值负荷下 A组各节段 Vs明显降低 (P<0 .0 5 ) ;以选择性冠状动脉造影为诊断冠心病的金标准 ,将峰值负荷下基底段心肌 Vs≤ 11.5 cm/ s,中段心肌 Vs≤ 9.5 cm/s为诊断冠状动脉狭窄的截断值 ,DTI结合大剂量多巴酚丁胺负荷试验诊断冠状动脉狭窄的敏感性、特异性、准确率分别为 85 .7%、84 .0 %、 84 .8% ;与常规多巴酚丁胺负荷超声心动图中室壁运动评分 (WMS)比较 ,DTI结合大剂量多巴酚丁胺负荷试验诊断冠状动脉狭窄的特异性与其并无显著差异 ;而敏感性、准确率显著增高 (P<0 .0 1)。结     

低剂量多巴酚丁胺超声心动图试验对急性心梗后梗死区室壁运动障碍改善的预测价值

目的 :评价低剂量多巴酚丁胺超声心动图试验 (LDDSE)对急性心梗后梗死区存活心肌的识别及对室壁运动障碍改善的预测价值。方法 :32例Q波急性心梗患者 ,其中溶栓 18例 ,平均年龄 ( 5 5 .47± 9.10 )岁 ;于发病后 4周行LDDSE。观察静态和静注多巴酚丁胺 [5 μg/(min·kg) ]后梗死区室壁运动变化 ,计算室壁运动得分指数 (WMSI)。 4个月后随访观察室壁运动改善情况。结果 :32例患者 5 12个节段 ,静态时发现室壁运动异常 89个节段 ,LDDSE发现 49个节段( 5 5 .1% )室壁运动有不同程度改善。静态时运动减弱节段的室壁运动改善比无运动节段更常见 ( 70 .9%和 35 .5 % ,P <0 .0 1)。LDDSE后WMSI低于静态 ( 1.11± 0 .13和 1.2 6± 0 .15 ,P <0 .0 1)。绍栓组LDDSE后WMSI明显低于静态 ( 1.0 8± 0 .12和 1.2 7± 0 .16 ,P <0 .0 1) ,同时低于非溶栓组 ( 1.0 8± 0 .12和 1.16± 0 .14 ,P <0 .0 5 ) ,4个月后随访 14例 38个节段异常中 ,室壁运动改善 19个节段 ( 5 0 % ) ,室壁运动减弱节段 ,随访时室壁运动改善的发生率明显高于无运动节段( 78.9%和 2 1.1% ,P <0 .0 5 )。结论 :LDDSE能识别AMI后梗死区的存活心肌 ,并能预测梗死区室壁运动障碍的改善 ,是一种简单、安全和易重复的识别心肌存活的方法。     

负荷超声心动图检测KTP激光心肌血运重建术后心肌存活性

目的　研究KTP激光心肌血运重建术 (TMLR)对梗死局部心肌存活性的影响。方法　家犬 12只 ,随机分为TM LR组和对照组 ,每组 6只 ,结扎左前降支中段 ,造成急性心肌梗死犬模型 ,TMLR组在梗死区以KTP激光行TMLR。术后动物饲养 2～ 3个月 ,采用多巴酚丁胺负荷超声心动图 ,检测心肌的存活性。结果　负荷超声心动图检查发现 ,TMLR组给予5 μg/(kg·min)多巴酚丁胺后室壁收缩增厚率、室壁运动幅度和室壁运动速度均有不同程度的改善 ,但当多巴酚丁胺剂量增大到 10 μg/(kg·min) ,前壁的室壁收缩增厚率、室壁运动幅度和室壁运动速度反而又减低 ;而对照组给予多巴酚丁胺 5 μg/(kg·min)和 10 μg/(kg·min)后 ,室壁收缩增厚率、室壁运动幅度和室壁运动速度进行性减低。 结论　KTP激光TMLR后梗死局部部分心肌保持存活。     

多巴酚丁胺负荷下背向散射技术检测存活心肌的临床研究

目的　运用背向散射技术结合小剂量多巴酚丁胺负荷超声心动图对 3 2例慢性冠心病患者不同类型的心肌进行分析 ,探讨二者相结合检测存活心肌价值。方法　测量不同负荷阶段 ( 0、5、10、2 0 μg/kg·min注药速度 )胸骨旁左心室乳头肌水平短轴切面的 4个节段 (前壁、下壁、前室间隔及后壁 )的CVIB和CVIB % ,PTCA术后随访二维超声。结果　对照组 (A组 )及非存活心肌组 (B组 )的CVIB和CVIB %在小剂量多巴酚丁胺负荷状态下无显著变化 ,而存活心肌组 (C组 )CVIB和CVIB %均在 5～ 10 μg/kg·min时增加至 2 0 μg/kg·min。结论　慢性冠心病患者的心肌背向散射积分参数在小剂量多巴酚丁胺负荷状态下呈现出有意义的改变 ,结合两种方法可用于定量检测存活心肌     

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.     

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.     

Molecular characterization of virulence and antimicrobial resistance profile of Shigella species isolated from children with moderate to severe diarrhea in northeastern Brazil

Molecular characterization of virulence and antimicrobial resistance profiles were determined for Shigella species isolated from children with diarrhea in Fortaleza, Brazil. Fecal specimens were collected along with socioeconomic and clinical data from children with moderate to severe diarrhea requiring emergency care. Shigella spp. were isolated by standard microbiological techniques, and we developed 4 multiplex polymerase chain reaction assays to detect 16 virulence-related genes (VRGs). Antimicrobial susceptibility tests were performed using disk diffusion assays. S. flexneri and S. sonnei were the predominant serogroups. S. flexneri was associated with low monthly incomes; more severe disease; higher number of VRGs; and presence of pic, set, and sepA genes. The SepA gene was associated with more intense abdominal pain. S. flexneri was correlated with resistance to ampicillin and chloramphenicol, whereas S. sonnei was associated with resistance to azithromycin. Strains harboring higher numbers of VRGs were associated with resistance to more antimicrobials. We highlight the correlation between presence of S. flexneri and sepA, and increased virulence and suggest a link to socioeconomic change in northeastern Brazil. Additionally, antimicrobial resistance was associated with serogroup specificity in Shigella spp. and increased bacterial VRGs.     

护理干预对面部中重度寻常型痤疮的临床疗效影响分析

目的研究护理干预对面部中重度寻常型痤疮的临床疗效影响。方法选取本院在2014年4月~2016年7月诊治的136例面部中重度寻常型痤疮患者,随机分为研究组与对照组,每组68例;所有患者均依据其情况给予对应的治疗,其中对照组在治疗期间给予常规护理,研究组在对照组的基础上再给予综合性护理干预,比较两组的治疗效果及护理满意度情况等。结果患者在接受治疗和护理后,研究组中度与重度患者的治疗效果较对照组均明显提高(P0.05),研究组护理满意度较对照组明显增高(P0.05)。结论对面部中重度寻常型痤疮患者在其治疗期间给予综合性护理干预,具有良好的效果。