不同左房面积占房颤患者的比例及房颤相关疾病的回顾性研究

目的探讨不同左房面积占房颤的比例，为临床提供精确可靠的治疗依据，降低房颤患者的致残率和病死率；同时分析统计房颤患者中各种心脏病发病的先后顺序。方法对2004年7月～2005年6月39例经我院临床确认为持续性房颤超过5年的患者，接受经胸常规二维及多普勒超声显像，仔细测量心尖四腔心切面左心房和右心房的上下径与左右径，计算出面积；并将房颤相关疾病进行有序排列。结果房颤患者中，左房轻度增大17例，占43．59％；中度增大3例，占7．69％；重度增大5例，占12．82％；合计25例，占64．10％。房颤患者全中，各种心脏病所占的比例为：冠心病占30．77％；风心病占25．64％；冠心病合并高血压性心脏病占12．82％；高血压性心脏病占7．69％；肺心病占7．69％；其它心脏病占15．38％。结论房颤患者左房轻度增大时（即2000mm^2≤左房面积〈3000mm^2），尚处于良好的代偿状态，一旦突破这一期，处于中度增大的时间很短，左房急剧增大，进入重度增大期，增加了左房血栓的发生率，增加了致残率和病死率。在现有的房颤患者中，冠心病的发病率位居首位，风心病次之，改变了以往风心病房颤率最高的状况。     

老年心房颤动的临床分析

目的 分析和探讨老年人心房颤动(AF)的病因。方法 85例为经检查心电图或动态心电图证实为心房颤动的患者。根据病史、体检、心电图、24h动态心电图、超声心动图等辅检以及实验室检查资料诊断冠心病(CHD)、高血压病、糖尿病(DM)、风湿性心脏病及其他相关疾病。结果 病因分析为:CHD60例、占70.6％,其中40例均有合并疾病。高血压病43例,占50.6％,其中30例合并CHD或和DM。所有病例中,有DM共17例,风心病占5.9％,病态窦房结综合征占10.6％,特发性房颤占4.7％。41例房颤患者有2种或以上疾病,其中以同时患有CHD、高血压病和DM多见。结论 老年房颤与很多疾病存在有关,可由多种原因引起,也可与其他病种并存。冠心病和高血压人群中房颤的发生率尤为显著。老年人房颤发病与多因素共同作用有关,左室肥厚及心腔扩大是房颤的高危因素。     

200例心房颤动患者病因及抗凝治疗临床分析

【目的】探讨房颤患者的病因及抗凝治疗的特点。【方法】回顾性分析200例房颤患者的-临床资料。【结果】房颤患者病因组成前四位依次为风心病41．5％；冠心病24．5％；高血压病15．5％；特发性8．5％。治疗多以地高辛为主控制心率125例，应用阿司匹林抗血小板聚集172例，使用华法令28例。【结论】房颤患者病因以风心病、冠心病、高血压最多见。治疗上应注意控制心率并使用阿司匹林抗血小板聚集，华法令应用不足，血栓栓塞事件发生率高。     

40岁以上房颤患者冠脉造影结果及病因分析

目的:40岁以上的房颤患者,其房颤的主要原因通常被认为是冠心病。冠状动脉造影是诊断冠心病的金标准。本文通过比较冠状动脉造影结果分析房颤的原因。方法:疑诊为冠心病的76例房颤患者行冠状动脉造影、心电图(ECG)2、4 h心电监测(Hollter)、超声心动图(UCG)等检查。结果:房颤的原因及相关因素冠心病21.8%,高血压49%,风心病20.9%,特发性房颤8.4%,心肌病3.1%,病窦综合症(SSS)3.4%,糖尿病2.9%,甲亢2.3%。房颤者冠状动脉病变的情况与无房颤者相同。40岁以上房颤原因复杂,冠心病不是其主要因素。     

心房颤动患者抗凝治疗的现状调查

目的探讨心房颤动患者抗凝治疗的现状。方法就我院2006年1月至2009年12月就诊的65例房颤患者进行收集、整理,对其抗凝情况行回顾性分析。结果65例患者中,年龄为44～86岁,男女比例1：0．63,最常见的病因是风心病。全部患者中合并血栓栓塞者9例（13．8％）,其中使用华法林抗凝者1例（11．1％）。瓣膜性房颤患者中用华法林抗凝者9例（25．7％）,非瓣膜性房颤患者用华法林抗凝者5例（16．7％）。结论血栓栓塞是房颤患者重要的并发症,抗凝治疗需进一步加强。     

老年心房颤动90例临床分析

目的:探讨老年心房颤动的病因和治疗方法。方法:对我院2005年1月～2009年4月住院的90例60岁以上老年房颤患者的临床资料进行回顾分析。结果:阵发性房颤21例,持续性房颤26例,永久性房颤43例。86例老年患者存在器质性心脏病,占95.6%。有老年冠心病、高血压及高血压性心脏病、风心病、肺源性心脏病、老年退行性变风湿性心瓣膜病。心功能Ⅰ～Ⅱ级患者61例,Ⅲ～Ⅳ级者29例。结论:本组分析表明,冠心病、高血压病、风心病是老年人房颤的主要原因。对老年人房颤的治疗主要有病因治疗、控制心室率、抗凝治疗、预防脑卒中、改善心功能。     

心房纤颤并发动脉栓塞115例临床分析

我院自1980年1月至1988年12月共收住动脉栓塞病人132例。其中心脏病房颤患者115例。占87.1%。本文着重分析动脉栓塞与心房颤动波及左房内径大小的关系,并讨论动脉栓塞的预防问题。 临床资料 一般资料 115例房颤并发动脉栓塞中,男43例、女72例,年龄24～82岁。风湿性心脏瓣膜病(风心病)89例(77.3%),男78例,女11例,50岁以前发病者66例(74.1%),其中女性占48例。非风心病26例,其中冠状动脉硬化性心脏病(冠心病)21例,高血压性心脏病3例,心肌病1例,肺源性心脏病1例,男15例,女11例,50岁以后发病者23例(88.4%)其中男14例。     

125例房颤病因分析

【目的】探讨心房颤动（房颤）的病因及防治措施。【方法】对本院内科1 623例住院病人中发生房颤的125例患者的临床资料进行回顾性分析。【结果】内科住院病人房颤总发生率为7.7%（125/1 623）。房颤的病因构成比依次是冠心病、高心病、风心病、肺心病,甲亢性心脏病,特发性房颤等。60岁以上的患者占69.6%（87/125）。进行复律治疗13例,抗凝或抗血小板治疗82例。18例患者曾患脑卒中。【结论】房颤病因中冠心病和高心病占主要地位,预防房颤应重点降低冠心病、高血压的患病人数。     

252例心房颤动病因分析

目的 探讨本地区心房颤动(简称房颤)的病因构成和预防.方法 对我院心内科2005年至2006年住院的252例房颤患者进行病因分析.结果 高血压性心脏病占29.8%,冠状动脉粥样硬化性心脏病(简称冠心痛)占23.8%,风湿性心脏病占12.3%,心肌病占8.7%,肺源性心脏病占8.7%,退行性瓣膜病占5.5%,甲状腺功能亢进(或甲状腺功能减退)性心脏病占3.2%,先天性心脏病占1.2%,预激综合征占0.8%,特发性房颤占6.0%.结论 房颤病因中高血压性心脏病和冠心病占主要地位,预防房颤的重点是积极预防和治疗高血压和冠心病.     

临床拟诊冠心病冠状动脉造影阴性180例分析

目的 探讨临床拟诊冠心病冠状动脉造影阴性患者的临床特点。方法对180例冠状动脉造影阴性患者的临床资料进行回顾性分析。结果无典型胸痛者占64，44％；有家族史、吸烟史者较少(分别为19．44％和22．22％)；临床检验结果大多正常；临床合并疾病较多，前3位分别为原发性高血压、高脂血症和心律失常。心电图ST-T改变占54．44％，但缺乏特征性，冠状动脉有23．33％(42／180)不完全正常，最后诊断以原发性高血压居多，心律失常次之，诊断为冠心病者仍占一定的比例。结论心电图检查虽然简便、安全，但诊断冠心病有一定局限性，明确诊断应行冠状动脉造影。     

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.     

Guns and Knives in New Mexico: Patterns of Penetrating Trauma, 1978–1993

Objective: To identify patterns of nonfatal and fatal penetrating trauma among children and adults in New Mexico using ED and medical examiner data.
Methods: The authors retrospectively sampled in 5-year intervals all victims of penetrating trauma who presented to either the state Level-1 trauma center or the state medical examiner from a 16-year period (1978–1993). Rates of nonfatal and fatal firearm and stabbing injury were compared for children and adults.
Results: Rates of nonfatal injury were similar (firearm, 34.3 per 100,000 person-years; stabbing, 35.1). However, rates of fatal injury were significantly different (firearm, 21.9; stabbing, 2.7; relative risk: 8.2; 95% confidence interval: 5.4, 12.5). From 1978 to 1993, nonfatal injury rates increased for children (p = 0.0043) and adults (p < 0.0001), while fatal penetrating injury remained constant. The increase in nonfatal injury in children resulted from increased firearm injury rates. In adults, both stabbing and firearm nonfatal injury rates increased.
Conclusions: Nonfatal injury data suggest that nonfatal violence has increased; fatal injury data suggest that violent death rates have remained constant. Injury patterns vary by age, mechanism of trauma, and data source. These results suggest that ED and medical examiner data differ and that both are needed to guide injury prevention programs.     

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.