比索洛尔对维持性血液透析患者高血压及心率变异性的影响

目的:观察比索洛尔对维持性血液透析患者高血压及心率变异性的疗效。方法:选取2010年6月～12月在我科行维持性血液透析患者33例,在常规高血压治疗基础上加用比索洛尔5～10mg/d,观察时间为6个月,治疗前和治疗6月后检测动态心电图和生化指标。结果:比索洛尔能明显降低维持性血液透析患者的血压(P<0.05),改善心率变异性(P<0.05),减少心律失常的发生率(P<0.05),而对血清总胆固醇、尿酸、血糖没有明显影响(P>0.05)。结论:比索洛尔能改善维持性血液透析患者的心率变异性,是安全有效的治疗措施。     

Heart Rate Variability,Left Ventricular Functions,and Cardiac Autonomic Neuropathy in Patients Undergoing Chronic Hemodialysis

Objective.?Autonomic neuropathy and impairment of left ventricular functions (LVF) have been frequently encountered in chronic renal failure (CRF). The aim of the present study was to evaluate the relationship of cardiac autonomic modulation impairments, as assessed by means of heart rate variability (HRV), with clinical characteristics, and left ventricular function in the patients with CRF undergoing hemodialysis (HD). Methods.?Twenty control subjects (Group I) and 22 comparable by age and gender patients with CRF undergoing hemodialysis (Group II) were enrolled in the study. After routine clinical and biochemical evaluations, electrocardiography, and 2 Dimensional, M Mode echocardiography were performed in all participants. Frequency domain HRV analysis was studied by using Kardiosis System. The powers (P₁ and P₂) and the central frequencies (F₁ and F₂) of low and of high frequency spectral bands were recorded. Results.?End systolic (ESV) and end diastolic volumes (EDV) were significantly higher in Group II (59.3 ± 21.1 mL vs. 34.0 ± 14.3 mL and 131.5 ± 37.3 mL vs. 96.9 ± 18.9 mL, p<0.01, p<0.05, respectively) when compared to those of Group I. Ejection fraction (EF) and fractional shortening (FS) were significantly lower in Group II than in control subjects (52.3 ± 2.4% vs. 63.7 ± 10.1% and 0.29 ± 0.01 vs. 0.34 ± 0.07, p<0.001, p<0.05, respectively). P1 and P2 were decreased in Group II than in Group I (136.2 ± 173.9 m s² vs. 911.0 ± 685.5 and 96.5 ± 149.6 vs. 499.7 ± 679.5, p<0.001, p<0.01, respectively). Significant correlations were found between high frequency spectral power and dialysis duration (DD), ESV, EDV, EF, FS (r = 0.52 p<0.01, r = 0.68 p<0.001, r = 0.65 p<0.002, r = 0.66 p<0.02, and r = 0.69 p<0.01). Conclusion.?As a result, the dependence of cardiac autonomic neuropathy on the disease duration and degree of left ventricular function impairment was shown in the patients undergoing chronic hemodialysis.     

盐酸右美托咪定对老年冠心患者全麻气管插管期心率变异性的影响

目的：研究盐酸右美托咪定（dexmedetomidine．Dex）在全麻诱导气管插管期间对老年冠心病患者自主神经系统功能的影响。方法：98例择期腹部手术老年冠心病患者．随机分成盐酸右美托咪定（D组n=49,诱导前给予负荷剂量右美托咪定0．7ug,／0g．注射泵缓慢静脉注射．输注时间超过10rain．维持剂量以0．4ug/（kg·h）持续静脉注射）和安慰剂组（P组n=49．诱导前静脉注射等容量氯化钠溶液）．分别于麻醉前（To）．麻醉诱导后（T1）及气管插管后（T2）用心率变异功率谱分析（heart rate Power spectrum analysis．HRPSA）技术观察患者的心率变异性（heart rate variability．HRV）改变。结果：麻醉诱导后．两组HRV总功率频段（TP）和其中低频段（LF）、高频段（HF）．LF／HF（低频／高频比）均显著降低（P〈O．05）．组问比较D组LF低于P组（P〈O．05）;气管插管后,两组LF、HF及TP均显著升高（P〈O．05）,而D组的LF／HF较麻醉前（T0）差异无统计意义,P组的LF／HF较麻醉前（T0）显著升高（P〈O．05）：组间比较D组LF、TP升高程度显著低于P组（P〈0．05）．HF组间差异无统计学意义。结论：盐酸右美托咪定能明显抑制插管操作引起的对植物神经功能的干扰,有利于维护老年冠心病患者围插管期心脏的自主神经调节功能。     

Blood Pressure and Heart Rate Variability in Patients on Conventional or Sodium-Profiling Hemodialysis

Background. Autonomic nervous system dysfunction and dialysate sodium (Na) concentration are believed to play a role in the pathogenesis of hemodialysis-related hypertension. The present study was undertaken to determine whether increases in blood pressure in hemodialysis patients are associated with changes in heart rate variability (HRV), a measure of the autonomic nervous system function, and long-term exposure to increased dialysate Na concentration. Methods. Baseline clinical, biochemical data and HRV of patients undergoing increased Na profiling dialysis (High-Na, n?=?9) and on conventional treatment (Control, n?=?11) were compared with those obtained after one year of study. Results. After one year, the mean predialysis systolic blood pressure (SBP) increased in seven patients of the High-Na and in five of the Control group, and decreased or remained unchanged in the remaining subjects. Initial HRV was significantly higher in patients with increased SBP, and it increased further in these patients after one year. At the end of the study, post-dialysis plasma Na, osmolality, and weight gains were significantly higher in the High-Na group. No significant correlation, however, was found between individual changes in intradialytic sodium elimination and the alterations in blood pressure. Conclusion. These data suggest that the dialysate sodium concentration, a most important determinant of interdialytic weight gain and fluid balance, is only partly correlated with long-term changes in blood pressure. An increased blood pressure over time may develop in a subset of hemodialysis patients with higher HRV, suggestive of increased sympathetic activity.     

胸腰段硬膜外阻滞下异丙酚镇静的心率变异性变化

目的：通过心率变异性（ＨＲＶ）的功率谱分析,观察胸腰段硬膜外阻滞下异丙酚镇静时对ＨＲＶ的影响。方法：随机选择１５例ＡＳＡⅠ～Ⅱ级、在下胸腰段硬膜外阻滞下手术的成年病人。每隔２～３ｍｉｎ静注异丙酚２０ｍｇ直至ＯＡＡ／Ｓ评分达到１分。分别观察不同ＯＡＡ／Ｓ评分值时及ＯＡＡ／Ｓ评分达到１分后１ｍｉｎ、３ｍｉｎ、５ｍｉｎ时ＨＲＶ的功率谱及心率、血压的变化。结果：ＨＲＶ各成分随病人镇静程度加深明显降低,尤以ＨＦ降低为明显。ＬＦ的标准化值由３１１％降低至１７６％;高频成分的标准化值由１４６％降至６７％。ＬＦ／ＨＦ呈上升趋势。当病人镇静作用减退时ＨＲＶ各值均有逐渐恢复趋势。结论：异丙酚镇静程度加深对病人交感神经和副交感神经活性均有明显抑制作用,尤以副交感神经活性抑制更为显著表１ＯＡＡ／Ｓ评分表反应性语音面部表情眼睛评分对正常语调呼名反应快正常正常清澈,无眼睑下垂５（清醒）对正常语调呼名反应冷淡稍减慢或含糊稍微放松凝视或眼睑轻度下垂４仅对大声和／或反复呼名有反应不清或明显变慢明显放松凝视及眼睑明显下垂３（浅睡）仅对轻推动有反应吐字不清——２对推动无反应———１（深睡）１．３ＨＲＶ数据均行常用对数转换后进行统计学处理     

咪唑安定复合异丙酚镇静时的心率变异性变化

目的：观察心率变异性（ＨＲＶ）在咪唑安定、异丙酚及其复合镇静时的变化。方法：选择ＡＳＡⅠ－Ⅱ级,在下胸腰段硬膜外阻滞下择期手术的成同人６０例,随机分为四组,每组１５例,Ⅰ组为咪唑安定组,Ⅱ组为咪唑安定０．０２５ｍｇ／ｋｇ加异丙酚组,Ⅲ组为咪唑安定０．０５ｍｇ／ｋｇ加异丙酚组,Ⅳ组为异丙酚组Ⅰ组,Ⅳ组每间隔２－３分钟静注咪唑安定１．５ｍｇ或 丙酚２０ｍｇ;Ⅱ组,Ⅲ组先静注咪唑安定０．０２５ｍｇ／ｋｇ     

静脉注射利多卡因对老年冠心病非心脏手术围插管期心率变异性的影响

目的：研究静脉注射利多卡因在全麻诱导气管插管期间对老年冠心病自主神经系统功能的影响。方法：选择90例择期腹部手术老年冠心病患者．随机分成利多卡因组（L组n=45）和安慰剂组（P组n=45）．分别于麻醉前（T0）,麻醉诱导后（T1）及气管插管后（T2）用心率变异功率谱分析（HRPSA）技术观察患者的心率变异性（HRV）改变。结果：麻醉诱导后．两组HRV总功率频段（TP）和其中低频段（LF）,高频段（HF）．LF／HF（低频／高频比）均显著降低（P〈0．05）．组间比较L组LF低于C组（P〈0．05）;气管插管后,两组LF、HF、LF／HF及TP均显著升高（P〈0．05）．组间比较L组LF与LF／HF升高程度显著低于P组（P〈0．05）,HF组间差异无统计意义。结论：静注利多卡因能明显抑制插管操作引起植物神经功能的干扰．有利于维护老年冠心病患围插管期心脏自主神经调节功能。     

非透析慢性肾脏病患者心率变异性的特点及其影响因素分析

目的：分析非透析慢性肾脏病（CKD）患者心率变异性（HRV）的特点及相关因素。方法：对263例住院且尚未行肾脏替代治疗CKD患者进行HRV（包括SDNN、RMSSD、pNN50、LF、HF、LF/HF）检测,并分析影响CKD患者HRV的因素。结果：CKD1～5期患者HRV下降的比例为57.79%,在CKD1、2、3、4、5期的比例分别为30.77%、42.00%、52.94%、72.73%和87.27%,各组间差异具有统计学意义（P〈0.05）。CKD患者SDNN均值为（110.8±33.5）ms,除CKD1与2期J间、CKD3与4间差异无统计学意义（P〉0.05）,其他各组间比较差异具有统计学意义（P〈0.05）;RMSSD均值为（30.2±18.7）ms,CKD5期明显低于其他4组,且与其他4组间比较差异具有统计学意义（P〈0.05）,但其他4组间比较差异无统计学意义（P〉0.05）;pNN50均值为9.4±5.3,CKD1、2、3、4、5期患者的pNN50呈递减趋势,且各组间比较差异均具有统计学意义（P〈0.05）;LF均值为（1014.3±609.2）ms,CKD3、4期间比较差异无统计学意义（P〉0.05）,其他各组间比较差异均具有统计学意义（P〈0.05）;HF均值为（806.9±318.3）ms,CKD3、4期间比较差异无统计学意义（P〉0.05）,其他各组间比较差异均具有统计学意义（P〈0.05）;LF/HF均值为2.1±0.9,CKD1、2期间,CKD3、4期间比较差异无统计学意义（P〉0.05）,其他各组间比较差异均具有统计学意义（P〈0.05）。血红蛋白、性别、血钠及血钾水平与HRV显著相关。结论：非透析CKD患者HRV下降的比例较高,且随着CKD分期增加,发生HRV下降的比例增加。     

Alterations in Echinocyte Transformation and Erythrocyte Sedimentation Rate During Hemodialysis

Abstract: In 18 uremic patients under regular hemodialysis (HD) with bicarbonate dialysate, the echinocytes and erythrocyte sedimentation rates (ESR) were determined in 4 blood samples collected from the arterial line at 0, 45, 120, and 240 min (end-HD) in one HD session by a bio-incompatible dialyzer and in another by a biocompatible one. In the HD session by a bioincompatible dialyzer, the mean values (±SEM) of echinocytes (%) at 0. 45, 120, and 240 min were 8.89 ± 1.15, 20.77 ± 2.35, 7.39 ± 1.1, 5.27 ± 0.66 and of ESR (mm/h) were 65.00 * 6.26, 47.05 ± 3.89, 66.72 ± 6.00, 68.44 ± 5.92, respectively. According to these findings, echinocytes show a transient significant increase at 45 min HD in comparison to those at 0 (p < 0.001), 120 (p < 0.001), and 240 (p < 0.001) min while ESR shows a transient significant decrease at 45 min HD compared with the rates at 0 (p < 0.05), 120 (p < 0.05) and 240 (p < 0.01) min. In the HD sessions with the biocompatible dialyzer, the mean values (±EM) of echinocytes at the aforementioned 4 time points were 8.55 ± 1.10, 17.05 ± 2.40, 17.05 ± 1.19, and 5.11 ± 0.75%, and the ESR values were 60.89 i 6.08, 44.33 ± 4.18, 62.94 ± 6.55, and 65.61 ± 6.13 mm/h, respectively. These values also show a transient significant increase of echinocytes at 45 min HD in comparison with those at 0 (p < 0.01), 120 (p < 0.01), and 240 (p < 0.001) min, with a parallel transient decrease of ESR at 45 min HD as compared to the ones at 0 (p < 0.05), 120 (p < 0.05), and 240 (p < 0.05) min. Although the echinocytosis at 45 min HD was more prominent in HD by the bioincompatible than by the biocompatible dialyzer, the comparison between these values indicates no significant difference in the echinocytes or the ESR. In conclusion, uremic patients receiving HD exhibit echinocytes, the percentage of which shows a transient increase at 45 min HD that returns to about baseline at 120 min HD. In parallel with the changes in echinocytes, the ESR shows an inverse change at 45 min HD which returns to baseline at 120 min HD.     

维持性血液透析患者住院率及生存率分析

目的：了解我中心维持性血液透析（MHD）患者的住院率、死亡率及其原因,为提高患者生存率提供依据。方法：回顾性分析2010年5月~2013年5月我中心MHD患者的住院率、死亡率及其原因,以及治疗前后各项指标的变化。结果：我中心年住院率为595住院次/1 000病人年,主要原因有心脑血管事件（13.0%）、血管通路问题（11.5%）、感染（9.9%）等。死亡率为13人/1 000病人年,主要死亡原因为心脑血管事件（50%）、感染（25%）等。经治疗后所有患者KT/V、Hb、血清钙水平较治疗前均有明显升高（P〈0.05）。结论：心脑血管事件、血管通路、感染是我中心MHD患者住院的主要因素,其中心脑血管事件和感染是死亡的主要原因。     

The Relation Between Variability of Intact Parathyroid Hormone,Calcium, and Cardiac Mortality in Hemodialysis Patients

Chronic kidney disease‐mineral and bone disorder (CKD‐BMD) is a condition known to be associated with cardiovascular disease and mortality in hemodialysis (HD) patients. The relation between calcium (Ca), phosphorus (P), and intact parathyroid hormone (iPTH) variability in HD patients and cardiac mortality is unknown. The purpose of this study was to assess the relation between variability in these parameters and cardiac mortality. Baseline demographic and biochemical parameters of 218 HD patients together with Ca values corrected with albumin and P values measured on a monthly basis and iPTH levels measured at 3‐monthly intervals were recorded over 2 years. Standard deviation (SD) and smoothness index (SI) for each parameter were calculated to assess Ca, P, and iPTH variability. The relations between all parameters and cardiac mortality were then analyzed. Cardiac mortality was observed in 38 patients in the 2‐year study period. Nonsurviving patients' ages, systolic and diastolic blood pressure (DBP), high sensitivity C‐reactive protein (HsCRP) levels, mean iPTH, and SD iPTH were significantly higher than those of surviving patients, while albumin levels, SI iPTH and SI Ca were significantly lower. Age, low albumin, high DBP, SI iPTH, and SI Ca were identified as independent predictors of cardiac mortality at multivariate analysis. Our study shows that Ca and iPTH variability affect cardiac mortality independently of mean and baseline values. When supported by further studies, the relation between Ca and iPTH variability and cardiac mortality in HD patients can lead to a new perspective in terms of prognosis and treatment planning.     

脑功率谱和心率变异性联合用于麻醉深度监测的临床评价

目的：联合应用脑功率谱和心率变异性监测异丙酚、咪唑安定及其复合诱导时的麻醉浓度观察伤害刺激对脑功率谱和ＨＲＶ的影响。方法：ＡＳＡⅠ－Ⅱ级，全麻下择期手术的成年病人３０例，按诱导用药不同随机分为三组，组Ⅰ异丙分配２ｍｇ／ｋｇ，组Ⅱ咪唑安定０．０５ｍｇ／ｋｇ加异丙酚１．５ｍｇ／ｋｇ，组Ⅲ发定０．２ｍｇ／ｋｇ。按各组用经 药前后合用，１分钟后静注芬太尼，然后给予挤捏斜方肌痛刺激并静注琥珀胆碱作气管插管，     

The Study of Spectral Analysis of Heart Rate Variability in Different Blood Pressure Types in Euvolemic Peritoneal Dialysis Patients

Background: Heart rate variability (HRV) is an useful noninvasive tool to assess autonomic nervous system (ANS) function and may provide an insight into the understanding of the role of ANS in the pathogenesis of blood pressure (BP) abnormality in euvolemic continuous ambulatory peritoneal dialysis (CAPD) patients. Methods: In this cross-sectional study, 62 CAPD patients with normal hydration values (assessed by a bioimpedance spectroscopy device) were enrolled from our peritoneal dialysis (PD) unit. Patients were divided into three groups according to their BP: normotension (NT), hypertension (HT), and hypotension (HyT). Spectral analysis of HRV was measured by examination of the average heart rate using standard electrocardiogram in 5 min. Results: The HyT group had the lowest serum urea nitrogen among the three groups (all p < 0.05), and a lower serum potassium and albumin as compared with the NT group (p < 0.05). The HyT group also had the highest total power (TP) and highest frequency power (HF) among the three groups (all p < 0.05), and a lower normalized low frequency power (LF), LF/HF ratio, and a higher normalized HF as compared with the HT group (all p < 0.05). Conclusion: Our study suggested that autonomic insufficiency was present in euvolemic PD patients, and hypotensives had a relatively higher parasympathetic activity and blunted sympathetic activity.     

Endoscopic Transthoracic Sympathicotomy Affects the Autonomic Modulation of Heart Rate in Patients with Palmar Hyperhidrosis

Summary  Background. Palmar hyperhidrosis has been associated with an increased activity of the sympathetic nervous system. The objective of this study was to assess the immediate and long-term effects of endoscopic transthoracic sympathicotomy on the autonomic modulation of the heart rate in patients with palmar hyperhidrosis.  Methods. Power spectrum analysis of heart rate variability in the lying position and after passive tilt to the upright position was performed in thirteen patients the day before and after sympathicotomy. A follow-up recording was performed in ten patients approximately six months later. Recordings from 26 healthy subjects were used as a reference group.  Findings. The patients had a tendency to higher power of the low-frequency (LF; 0.04–0.15 Hz) and high-frequency (HF; above 0.15 Hz) components than controls in the upright position. After sympathicotomy LF power was reduced, but HF power was unchanged. At follow-up LF power remained at a lower level, but now HF power was reduced.  Interpretation. Patients with palmar hyperhidrosis have a sympathetic overactivity but also a compensatory high parasympathetic activity. Sympathicotomy results in an initial sympathovagal imbalance with a parasympathetic predominance, which is restored on a long-term basis.     

心率变异性复杂度分析和脑电双频谱指数在监测全身麻醉时的相关性

目的：观察全身麻醉时心率变异性分析中复杂度和脑电双频谱指数（BIS）的变化,探讨复杂度和BIS在监测麻醉深度时的相关性。方法：30例全身麻醉病人,测定麻醉前（T1）、诱导插管（T2）、术中（T3）、苏醒（T4）4个时间点各5min的心率（HR）、平均动脉压（MAP）、脑电双频谱指数（BIS）和复杂度变化。结果：HR在T2、T3和T4较T1值升高（P〈0.01或0.05）。MAP在T2时较T1值降低（P〈0.05）,T3和T4较T1值升高（P〈0.05）,而T3和T4相比变化较大（P〈0.01）。BIS值在各时点较T1值下降明显（P〈0.01）,其中T4较T1略下降（P〈0.05）,T3与T2时相比明显降低（P〈0.01）,而T4较T3明显升高（P〈0.01）。复杂度值的T1值均大于各个点（P〈0.01或0.05）,其T4较T2和T3时升高（P〈0.05）,T3较T2时升高（P〈0.05）。结论：作为心率变异性非线性指标的复杂度能描述围术期心脏自主神经功能状态的变化,但其与BIS并无相关性。     

心率变异性近似熵分析法与脑电双频谱指数间的相关性

目的:观察全身麻醉时心率变异性分析中近似熵分析法与脑电双频谱指数(BIS)在监测麻醉深度时的相关性。方法:对40例全身麻醉病人测定麻醉前(T1)、诱导插管(T2)、术中(T3)、苏醒(T4)4个时间点各5min的心率(HR)、平均动脉压(MAP)、脑电双频谱指数(BIS)和近似熵(ApEn)变化。结果:HR在T2、T3和T4均较T1值升高(P0.01～0.05)。MAP在T2时较T1值降低(P0.05),T3、T4较T1值升高(P0.05),而T4比T3明显升高(P0.01)。BIS值在麻醉后各时点均较T1值下降明显(P0.01),其中T4也较T1下降(P0.05),T3与T2时相比明显降低(P0.01),而T4较T3明显升高(P0.01)。近似熵值的T1值均大于其他各时点(P0.01～0.05),其T4较T3时点升高(P0.01),T3较T2时点降低(P0.05)。结论:作为心率变异性的非线性分析方法指标的近似熵分析法,能描述围术期心脏自主神经功能状态的变化,但其与BIS并无相关性。     

Effects of Neuromuscular Electrical Stimulation and Aerobic Exercise Training on Arterial Stiffness and Autonomic Functions in Patients With Chronic Heart Failure

Neuromuscular electrical stimulation (NMES) of leg muscles has been introduced in clinical practice as a rehabilitation (RHB) method in patients with chronic heart failure (CHF); however, the role of NMES on the reduction of arterial stiffness and autonomic disbalance in these patients has not yet been studied. Sixty‐one patients with stable CHF (mean age 58.9 [2.1] years; mean ejection fraction 31 [4.2]%, New York Heart Association II–III) were randomly assigned into two groups. Patients in (i) exercise training group (ET; n = 30) underwent 12 weeks of bicycle ET (3 × 40 min/week); (ii) group NMES (n = 31) performed 12 weeks of NMES of quadriceps and calf muscles (frequency 10 Hz, mode “20 s on–20 s off,” intensity 60 mA), 2 × 60 min/day. Noninvasive assessment of arterial stiffness was done using the cardio‐ankle vascular index (CAVI). CAVI and heart rate variability (HRV) and were evaluated before and after RHB program. Both types of RHB reduced significantly CAVI (ET from 9.6 [0.2] to 8.9 [0.2], P < 0.012; NMES from 9.3 [0.2] to 8.7 [0.2], P < 0.013), increased high frequency (HF) component of HRV (+65.6%; P = 0.001) and decreased ratio of low frequency (LF) component with HF component (LF/HF ratio) in group ET (?39.8%; P < 0.001). Changes of HRV parameters in group NMES were not significant; however, a marked tendency to autonomic stabilization was present. Both types of RHB led also to significant increase of (ET from 18.7 [0.7] to 20.8 [0.7] mL/kg/min, P < 0.004; NMES from 17.3 [0.7] to 19.0 [0.7] mL/kg/min, P < 0.001). ET or NMES has been shown to improve significantly arterial stiffness and to stabilize autonomic balance.     

Effect of Interpersonal and Cognitive Stressors on Habituation and the Utility of Heart Rate Variability to Measure Habituation

Habituation is a decrease in responding to a repeated stimulus. Operant responding and salivation measure habituation in eating behaviour research. Stress may increase eating by acting as a distractor, yielding spontaneous recovery and prolonging responding for food. Our research tested differences in the ability of cognitive and interpersonal stressors to recover responding for food. We also tested heart rate variability (HRV) as a measure of habituation. Twenty women worked for portions of macaroni and cheese for 15 trials on three separate laboratory visits. Between the 12th and 13th trial, one of three different stressor types (speech, stroop and subtraction) was presented during each visit. HRV was measured continuously throughout the laboratory visits. Responding for food declined across the 12 trials with no difference in rate of habituation by visit (p > 0.8) There was no difference between stressor type in the magnitude of spontaneous recovery after each stressor (p > 0.8). Rates of habituation of HRV variables correlated (p < 0.02) with the rate of operant responding habituation. Cognitive and interpersonal stressors do not differ in their ability to recover reduced responding for food. HRV variables may measure habituation to food similar to operant responding. Copyright © 2014 John Wiley & Sons, Ltd.