应用超声定量组织速度成像(QTVI)技术评价冠心病患者PTCA支架置入术后局部心肌运动的临床研究

目的探讨超声定量组织速度成像（QTW）技术评价冠心病患者VIVA支架置入前后局部心肌运动速度的临床应用价值。方法26例接受左前降支（LAD）支架置入术的冠心病患者，在术前1天内、术后1周内以及3个月时分别行QTVI检查。结果与术前相比，术后一周内LAD对应节段（前间隔，前壁，室间隔中段和心尖段）的收缩期峰值速度（PSMV）、舒张早期峰值速度（PDMV）明显增高。结论成功的冠状动脉内支架置入术后左室局部室壁运动显着改善，超声QTVI技术能提供新的定量评价指标。     

超声定量组织速度成像评价冠状动脉腔内成形并支架置入术的近期疗效

目的探讨超声定量组织速度成像(QTVI)技术评价冠心病患者行经皮腔内冠状动脉成形并支架置入(PTCA 支架置入)治疗的近期疗效.方法16例因单纯冠状动脉左前降支狭窄而接受PTCA 支架置入治疗的冠心病患者,治疗前经小剂量多巴酚丁胺负荷超声心动图试验证实拟研究的心肌节段为存活心肌后,分别于治疗前1天、治疗后1周及1个月测量左前降支供血区(介入治疗血管供血区--PCI区)及远离PCI区局部心肌收缩期峰值速度(Sa)及舒张早期峰值速度(Ea),比较治疗前后上述参数的变化,并将治疗前1天及治疗后1个月上述参数与18名健康人相应心肌节段速度比较.结果(1)PCI区心肌:Sa、Ea于治疗前明显低于正常心肌,治疗后(1周,1周至1个月)明显增快,至治疗后1个月达到正常值水平;(2)远离PCI区心肌:与正常对照组比较,治疗前后Sa、Ea均无明显变化.结论冠心病患者PTCA 支架置入治疗后1个月内,PCI区心肌运动明显改善,且呈进行性经过.QTVI作为一种分析室壁运动的新技术,能够定量分析治疗前后局部心肌运动速度的变化情况.     

定量组织速度成像对冠心病患者PTCA支架置入后左心室功能及其同步性的评价

目的 应用定量组织速度成像(QTVI)技术探讨冠心病患者PTCA支架置入后缺血节段心肌运动的同步性变化及其对心功能的影响.方法 左前降支单支病变狭窄率≥75%患者36例,分别于支架治疗前3 d及治疗后1周、1个月应用Q TVI曲线测量左室心肌5个节段的收缩期峰值速度(Vs)、舒张早期峰值速度(Ve)、舒张晚期峰值速度(Va)、收缩期同步性指标(Ts)并计算Ts标准差(Ts-SD).结果 冠心病患者各节段Vs、Ve、Va值均较低,Ve/Va倒置;支架置入治疗1周后,各节段Vs、Ve值均较术前升高(P＜0.05),Ve/Va值恢复.治疗后1月.速度指标继续增高,Vs、Ve均较术前差异有统计学意义(P＜0.01),与治疗后1周比较(P＜0.05),Va均无明显变化.术前不同步指标Ts明显延长.治疗后1周、1月均较术前明显缩短,差异有统计学意义(分别P＜0.05.P＜0.01).结论 QTVI技术能够定量分析冠心病患者缺血心肌运动及室壁同步性,监测PTCA术后心脏功能和同步性变化.     

定量组织速度成像技术评价冠心病心肌缺血及冠脉支架植入术疗效的研究

目的探讨定量组织速度成像(QTVI)技术在冠心病患者心肌缺血评价中的价值,同时采用QTVI技术观察冠状动脉(冠脉)支架植入术后左室局部心肌功能变化,以评价其疗效。方法 53例临床诊断冠心病或可疑冠心病行冠脉造影检查(CAG)的患者纳入本研究。在行CAG检查前作QTVI检查,根据节段室壁运动速度情况(以心底部5cm/s,中段3cm/s界定)分为无心肌缺血组(n=26)和心肌缺血组(n=27)。测定左室6个壁的基底段和中段运动的收缩期峰流速(Vs)与峰值位移(Ds),比较2组的Vs及Ds,并与CAG结果对照,以评价QTVI对冠心病的诊断价值。其中8例单纯左前降支(LAD)病变患者分别于支架植入前1天、植入后1周、4周采用QTVI技术分析室壁的运动速度指标(Vs),以评价支架植入术的疗效。结果在左室长轴切面、心尖四腔切面、心尖两腔切面心肌缺血组左室相应节段的Vs和Ds均低于无心肌缺血组(P<0.05);QTVI发现的有心肌缺血的27例患者,CAG均能发现2支或以上主要冠脉狭窄;8例LAD病变患者冠脉支架植入术前LAD供血区各节段心肌Vs均明显低于无心肌缺血组(P<0.01或P<0.05),与冠脉支架植入前相比,治疗后1周及4周,LAD供血区各节段心肌Vs明显增快(P<0.01或P<0.05)。结论 QTVI技术通过定量测定节段性室壁运动失调及局域性心功能不良,可以评价冠心病严重冠脉狭窄患者的心肌缺血,且可作为一种测定冠脉支架植入前后局部心肌速度的无创技术,用以评价冠脉支架植入术的疗效。     

超声定量组织速度成像对病变心肌节段纵向运动速度的研究

目的探讨定量组织速度成像(QTVI)技术与冠状动脉狭窄左室相关的节段心肌运动速度变化的定量关系。方法应用定量组织速度成像技术对31例冠状动脉造影证实的冠状动脉狭窄病人(病变组)和21例正常人(对照组)左室心肌的12个节段测量其QTVI曲线的收缩期峰值速度(Vs)、舒张早期峰值速度(Ve)和舒张晚期峰值速度(Va)。结果左前降支、回旋支和右冠状动脉狭窄供血区节段心肌的Vs、Ve与正常组比较均具有显著性差异(P<0.001或P<0.05),Va则无统计学意义。左前降支狭窄轻、中、重度狭窄组之间各指标相比均无显著性差异。结论定量组织速度成像的Vs和Ve能较准确地检出冠心病人静息状态下冠状动脉狭窄供血区的异常心肌节段,但对区分冠状动脉的狭窄程度似无显著作用。     

定量组织速度成像技术对冠心病心肌缺血的研究

目的运用定量组织速度成像技术(QTVI)测定冠心病患者病变血管相应节段心肌室壁运动速度,评价局部心肌收缩和舒张功能。方法选择38例冠心病住院患者,通过冠脉CT或冠脉造影检查证实冠脉狭窄≥50%,病变血管共59支。其中左前降支(LAD)病变22例,回旋支(LCX)病变19例,右冠(RCA)病变18例。健康对照组20例。所有冠心病患者行冠脉CT或冠脉造影检查前均行普通超声(包括二维、M型及解剖M型超声)检查和心肌定量组织速度成像(QTVI)检查,分别比较结果。结果与健康对照组相比,冠心病组病变血管相应心肌节段室壁的舒张晚期心肌运动速度(Va)差异无统计学意义,右室侧壁收缩期峰值运动速度(Vs)无明显降低。而左室收缩期峰值运动速度(Vs)、舒张早期心肌运动速度(Ve)及Ve/Va均显著降低(P<0.05)。普通超声心动图检测38例冠心病患者结果显示正常者11例,占29%,而以上患者经组织速度成像显示心室各节段Ve、Ve/Va及左室的Vs均有明显降低。结论QTVI能够直观、定量的显示心室局部缺血心肌收缩和舒张功能异常。     

正常成年人心肌各节段运动速度及其影响因素分析

目的 探讨正常成年人不同节段心肌运动速度的变化规律并分析其相关影响因素。方法 应用心肌组织速度成像技术观察108例正常成年人左、右心室不同室壁各节段心肌收缩期峰值速度(Vs)、舒张早期峰值速度(Ve)、心房收缩期峰值速度(Va)和Ve／Va，并分析其变化规律以及年龄、性别、体表面积和心率对其的影响。结果 ①不同室壁心肌运动速度不同，右室侧壁最高，前、后间隔最低，而左室侧壁、下壁、前壁和后壁则介于二者之间；②同一室壁不同节段心肌运动速度显著不同，由基底段、中段至心尖段运动速度逐渐减低；③各节段心肌Ve／Va值由基底段至心尖段逐渐增加，左室侧壁和前壁Ve／Va值显著高于其他室壁；④年龄是影响室壁舒张期速度的主要因素，随着年龄增长，Ve逐渐减低，Va逐渐增加，而Ve／Va值逐渐减低。结论 左、右室不同心肌节段运动速度呈规律性变化，年龄对心肌舒张速度影响显著。     

组织速度成像与应变率成像技术在多巴酚丁胺负荷试验中应用价值的对比研究

目的比较定量组织速度成像(QTVI)技术与应变率成像(SRI)技术在大剂量多巴酚丁胺负荷试验(DSE)中诊断心肌缺血的应用价值。方法49例疑诊冠心病患者,分别于静息、10、20、30、40μg.kg-1.min-1多巴酚丁胺负荷下获取心尖两腔、四腔观清晰组织速度成像图。脱机分析侧壁、室间隔、前壁、下壁心肌基底段、中段心内膜下心肌QTVI与SRI曲线,QTVI测量参数为收缩期峰值运动速度(VS)和舒张早期峰值运动速度(VE),SRI测量参数为收缩期峰值应变率(SRSYS)和最大应变(εMAX)。结果根据常规HDDSE与冠状动脉造影结果,将冠心病组患者心肌节段区分为正常节段与缺血节段(缺血组);与对照组正常节段(正常组)比较,静息状态下,缺血组与正常组节段间VS、VE、SRSYS、εMAX差异无统计学意义;峰值负荷时,与正常组各节段比较,缺血组各节段VS、VE、SRSYS、εMAX明显减低(P<0.05)。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≤9.6cm/s,中段心肌VS≤8.3cm/s,SRSYS≤-2.6s-1为诊断冠状动脉狭窄的截断值,DSE中QTVI诊断心肌缺血的敏感性、特异性分别为80.8%、80.4%;DSE中SRI诊断心肌缺血的敏感性、特异性分别为83.6%、85.7%。与QTVI比较,DSE中SRI诊断心肌缺血的敏感性与特异性显著增高(P<0.01)。结论DSE中QTVI与SRI技术均能准确、无创检测冠心病缺血心肌,SRI技术敏感性、特异性更高。     

多普勒成像检测冠脉内支架置入术后左室肌局部功能变化

目的:应用组织多普勒成像(DTI)检测冠状动脉支架置入术前后左室心肌局部收缩、舒张功能的变化。方法:采用脉冲DTI技术,对48例冠心病并行支架置入术的患者分别于术前1～3 d.术后7 d、30 d检测左室12节段的局部心肌运动速度,即收缩期峰值速度(Sm)、舒张早期峰值速度(Em)和舒张晚期峰值速度(Am),比较支架置入术前后对应节段的Sm、Em、Am以及Em/Am比值的变化。结果:术后30 d LVEF较术前明显增加(P<0.05);大多数对应节段的Sm于术后7 d已明显增高,且随时间的延长进一步增加,以LAD与LCX对应节段为显;术后30 d时,全部对应节段的Sm、Em及Am均较术前显著增高(P<0.05).而绝大多数对应节段的Em/Am比值在治疗前后无显著变化(P>0.05)。结论:冠脉内支架置入术后早期左室心肌局部收缩、舒张功能均有显著改善。通过DTI检测局部室壁运动速度可用以评价冠脉内支架置入术的疗效。     

定量组织多普勒评价冠心病患者等容收缩期心肌运动特征

目的 探讨定量组织多普勒成像技术(QTVI)评价冠心病劳累型心绞痛、急性心肌梗死(AMI)患者等容收缩期心肌运动特征的价值.方法 A组正常对照组48例,B组冠心病劳累型心绞痛患者42例,C组急性心肌梗死急诊行经皮冠状动脉介入治疗(PCI)术后1周内患者32例,梗死相关动脉为左前降支(LAD),梗死部位累及左室前壁和/或前间壁.在心尖二腔心及心尖长轴切面应用QTVI分别获得左室前间隔、前壁基底段、中段共计4个节段心肌的组织多普勒速度曲线,分别测量各节段等容收缩期正向( IVC)、等容收缩期负向(-IVC)运动速度及△IVC(△IVC=正向VIC-负向VIC).结果 A、B、C 3组间在LAD供血的室壁节段 IVC均有显著差异(P＜0.05);而-IVC均无显著差异(P＞0.05).△IVC在前间隔基底段、中段3组间均无显著差异(P＞0.05);而在左室前壁基底段、中段3组间有显著差异(P＜0.01).结论 QTVI可简便、敏感地评价冠心病患者等容收缩期的心肌运动异常.     

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.