急性冠脉综合征患者炎性因子的表达与室性心律失常的关系

[目的]探讨急性冠脉综合征(ACS)患者的炎性因子的表达与室性心律失常的关系.[方法]本院115名确诊为ACS的患者其中,ST段抬高型心肌梗死(STEMI)54例,非ST段抬高型心肌梗死(NSTEMI)22例,不稳定型心绞痛(UA)39例.分别在入院时、7 d、14 d抽静脉血测定CD40配体(CD40L)、肿瘤坏死因...     

胰岛素样生长因子-1与急性冠状动脉综合征

目的探讨胰岛素样生长因子-1(IGF-1)与急性冠状动脉综合征(ACS)的关系。方法稳定型心绞痛(SAP)24例,不稳定型心绞痛(UAP)33例,急性心肌梗死(AMI)26例,其中包括ST段抬高型急性心肌梗死(STEMI)15例,非ST段抬高型急性心肌梗死(NSTEMI)11例。另选冠状动脉造影无狭窄或狭窄小于25%的31例为对照组,用酶联免疫吸附(ELISA)法测定其外周静脉血清IGF-1水平,并将非ST段抬高的急性冠状动脉综合征(NSTE-ACS)患者血清IGF-1浓度与其相应的心肌梗死溶栓治疗(TIMI)危险积分进行直线相关性分析。结果①SAP组、UAP组、STEMI组和NSTEMI组血清IGF-1浓度较对照组、SAP组明显降低,差异有统计学意义,分别为(29.06±8.64)μg/L,(19.02±9.65)μg/L,(14.62±7.08)μg/L,(14.48±6.33)μg/L vs(34.89±7.09)μg/L(P<0.05);对照组和SAP组之间差异无统计学意义,分别为(34.89±7.09)μg/L vs(29.06±8.64)μg/L(P>0.05);UAP组、STEMI组、NSTEMI组之间差异无统计学意义(19.02±9.65)μg/L,(14.62±7.08)μg/L,(14.48±6.33)μg/L(P>0.05);②NSTE-ACS患者血清IGF-1浓度与其相应的TIMI危险积分呈明显负相关(r=-0.688,P<0.05)。结论血清IGF-1浓度可能作为预测急性冠状动脉综合征的参考指标之一。     

中性粒细胞计数及血钾水平辅助诊断急性ST段抬高型心肌梗死的价值

目的 探讨中性粒细胞计数及血钾水平辅助诊断急性ST段抬高型心肌梗死的价值。方法 100例急性心肌梗死患者,其中50例ST段抬高型心肌梗死(ST-segment elevation myocardial infarction,STEMI)患者为STEMI组,50例非ST段抬高型心肌梗死(non-ST segment elevated myocardial infarction,NSTEMI)患者为NSTEMI组,测定2组入院时中性粒细胞计数及血钾水平,与同期50例体检健康者(对照组)进行比较,分析STEMI组发病≤6h、>6~12h、>12~18h、>18~24h者中性粒细胞计数和血钾水平。结果 STEMI组中性粒细胞计数((9.65±0.43)×109)高于NSTEMI组((7.10±1.04)×109)和对照组((7.20±1.20)×109)(P均<0.05),血钾水平((3.37±1.11)mmol/L)低于NSTEMI组((4.22±1.09)mmol/L)和对照组((4.30±1.21)mmol/L)(P均<0.05);不同病程STEMI患者中性粒细胞计数比较差异均无统计学意义(P>0.05),血钾水平((3.15±1.21)、(3.45±1.32)、(3.72±1.13)、(3.96±1.34)mmol/L))比较差异均有统计学意义(P<0.05)。结论 与NSTEMI患者相比,STEMI患者中性粒细胞计数增高,血钾水平降低,且血钾在发病6h内降低明显,中性粒细胞计数与血钾水平联合检测可作为辅助STEMI诊断的临床指标。     

网织血小板和血小板参数在急性冠脉综合征中的变化及意义

目的:探讨急性冠脉综合征(ACS)患者网织血小板(RP)和血小板参数的变化及意义。方法:随机选取ST段抬高心肌梗死(STEMI)27例为STEMI组,非ST段抬高心肌梗死(NSTEMI)25例为NSTEMI组,不稳定心绞痛(UA)31例为UA组,健康体检者30例为对照组进行检测。用CD61-PE单抗标记血小板,噻唑橙(TO)为染料,应用富含血小板血浆(PRP)法检测RP;用COULTERJT型全自动血液分析仪测定血小板参数[血小板计数(PLT)和血小板平均体积(MPV)]。结果:STEMI、NSTEMI、UA组3组RP%均显著性高于对照组(P<0.05);STEMI、NSTEMI组的RP%显著高于UA组(P<0.05);STEMI、NSTEMI组的MPV均显著高于对照组(P<0.05)。结论:RP可能成为评估ASC患者血小板活性的新指标,它和MPV的检测可能对ACS有着一定的临床意义。     

急性冠脉综合征急诊快速诊疗指南

<正>急性冠脉综合征(acute coronary syndrome,ACS)是指冠状动脉内不稳定的粥样斑块破裂或糜烂引起血栓形成所导致的心脏急性缺血综合征,涵盖了ST段抬高型心肌梗死(ST-segment elevation myocardial infarction,STEMI)、非ST段抬高型心肌梗死(non-ST-segment elevation myocardial infarction,NSTEMI)和不稳定性心绞痛(unstable angina,UA),其中NSTEMI与UA合称非ST段抬高     

肌钙蛋白Ⅰ对STEMI及NSTEMI患者早期诊断的比较分析

目的探讨心肌肌钙蛋白Ⅰ(cTnⅠ)对ST段抬高型心肌梗死EMI(ST-segment elevation myocardial infarction,STEMI)及非ST段抬高型心肌梗死(non-ST-segment elevation myocardial infarction,NSTEMI)患者早期诊断有无差异。方法收集我院2016年3月1日至2017年3月1日于入院后急诊行冠脉血管支架的急性心肌梗死患者。将其分为两个组,其中STEMI组250例,NSTEMI组59例。使用全自动荧光免疫定量分析系统对c Tn I进行快速检测,并比较两组间cTnⅠ的差异。结果STEMI和NSTEMI中cTnⅠ的统计情况分别为(10.7±16.5)μg/L、(9.3±14.4)μg/L,经秩和检验得P=0.549(P0.05),差异无统计学意义。结论急诊胸痛就诊急性冠脉综合征的患者不能仅以cTnⅠ数值大小对STEMI和NSTEMI早期判别诊断。     

冠心病患者外周血树突状细胞前体的数量变化及意义

目的:比较各种类型冠心病患者外周循环树突状细胞(dendritic cells,DCs)前体及其亚型髓系DCs(myeloid DCs,mDCs)和淋巴系DCs(plasmacytoid DCs,pDCs)的数量,探讨DCs参与的炎性免疫反应在冠心病发生发展中的作用。方法:入选冠脉狭窄50%的胸痛患者18例(N组)、稳定型冠心病(stable coronary artery disease,SCAD)患者17例(SCAD组)、不稳定型心绞痛(unstable angina,UA)患者15例(UA组)、非ST段抬高型心肌梗死(non-ST-elevation myocardial infarction,NSTEMI)患者15例(NSTEMI组)、ST段抬高型心肌梗死(ST-elevation myocardial infarction,STEMI)患者16例(STEMI组)。以流式细胞仪四色分析法计数5组外周循环DCs前体及亚型的比例及绝对数,NSTEMI和STEMI患者入院1周后随访外周循环DCs水平。结果:相比N组,UA患者外周循环mDCs和mDC1s明显增多;NSTEMI和STEMI患者外周循环mDCs和mDC1s明显减少;STEMI患者pDCs亦明显减少;SCAD患者无明显差异。入院1周后NSTEMI和STEMI患者外周循环mDCs、mDC1s、pDCs较入院时均明显升高。结论:冠心病发展过程中DCs可能使Th1应答增强,从而参与斑块的不稳定和破裂过程。     

急性冠状动脉综合征患者血清骨保护素表达水平与Gensini评分的相关性研究

目的探讨急性冠状动脉综合征(ACS)患者血清骨保护素(OPG)表达水平及其与冠状动脉病变程度Gensini评分的相关性。方法 75例ACS患者分为不稳定型心绞痛组(UA)28例,急性非ST段抬高型心肌梗死(NSTEMI)组11例,急性ST段抬高型心肌梗死(STEMI)组36例,另取13例冠状动脉造影正常者作为对照组。采用ELISA法检测各组血清OPG表达水平并进行比较,冠状动脉病变程度评分采用Gensini评分系统,采用Pearson直线相关分析OPG表达水平与Gensini评分的关系。结果 STEMI组OPG水平高于NSTEMI组,NSTEMI组OPG水平高于UA组,UA组OPG水平高于对照组,四组间两两比较均有统计学差异(P<0.001)。相关性检验显示OPG表达水平与Gensini评分呈正相关(r=0.559,P<0.001)。结论血清OPG可能参与ACS的病理生理过程;血清OPG水平越高,冠状动脉病变程度越严重。     

急性冠脉综合征中的糖代谢异常的针对性治疗

<正>急性冠状动脉综合征(ACS)是由于不稳定斑块的破裂,引起冠状动脉内血栓形成所致心肌缺血的一组进展性疾病谱,是冠心病的一个重要组成部分。临床研究中,ACS分为ST段抬高型(STE-ACS)及非ST段抬高型(NSTE-ACS)两类,前者大部分发展为ST段抬高的急性心肌梗死(STEMI),后者包括无ST段抬高的心肌梗死(NSTEMI)和不稳定心绞痛(UA)。研究发现,大多数ACS患者伴有糖代谢异常[1-4]。糖代谢异常包括糖调节受损(IGR)和糖尿     

非ST段抬高型急性冠状动脉综合征患者胸痛时间、肌钙蛋白水平及心电图ST段下移的诊断价值

目的:探讨非ST段抬高型急性冠状动脉综合征(ACS)患者胸痛时间、肌钙蛋白水平及心电图ST段下移的临床诊断价值。方法:收集自2008-06—2008-12,在急诊科因急性胸痛拟诊不稳定性心绞痛(UA)及非ST段抬高心肌梗死(NSTEMI)收入院且记录资料完整的54例患者。仔细询问病史、体检,据胸痛持续时间分成3组(0.5h,0.5～2h,≥2h),并完成常规18导联心电图检查,将患者入院时心电图ST段下移幅度分成3组(1mV,1～2mV,≥2mV),同时抽静脉血做肌钙蛋白I(TnI)检测。据TnI水平将患者分成3组(TnI0.02μg/L,0.02μg/L～0.04μg/L,≥0.04μg/L),根据冠状动脉造影结果诊断急性心肌梗死。结果:随着胸痛发生时间延长或肌钙蛋白水平升高,心肌梗死的发病率显著升高。随着ST段下移幅度加深,心肌梗死的发病率没有升高。结论:胸痛时间及TnI水平对非ST段抬高的ACS患者的预测均有重要价值,但心电图的ST段变化对于非ST段抬高的ACS患者的预测价值有待进一步探讨。     

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.