超声心动图对心内膜弹力纤维增生症患儿血流动力学变化的分析研究

目的 应用二维多普勒超声心动图技术对心内膜弹力纤维增生症(EFE)患儿的血流动力学变化进行分析研究.方法 超声心动图检查EFE患者32例,平均年龄(1.5±0.6)岁,正常对照(NC)组30例.结果 EFE组与NC组比较,各指标均有显著性差异(P<0.001),超声参数的特点为舒张期左房内径(LADd)、左室内径(LVDd)、室间隔厚度(IVSTd)、左房射血力(LAF)、室壁应力指数(ws I～Ⅲ)、峰值速度A(A峰)及等容舒张时间(IRTs)增大;但射血分数(EF)、心脏指数(CI)、心室短轴缩短率(FS)、峰值速度E(E峰)、峰值速度比(E/A)、舒张早期快速充盈加速度(AC)、1/3及1/2充盈分数(1/3FF、1/2FF)及标准化充盈分数(NPFR)降低;将EFE组治疗前后比较除IVSd、A峰及IRTs无显著性差异(P>0.05)~b,其余各指标均有显著性差异(P<0.01-0.001).结论 EFE患儿可出现房室腔扩大、心脏收缩和舒张功能降低、室壁应力增大及左房射血力代偿性增加;而二维多普勒超声心动图对于EFE患儿的早期诊断、疗效评价及预后估测都有极为重要的临床价值.     

超声心动图诊断心内膜弹力纤维增生症和川崎病的应用研究

目的探讨超声心动图技术对心内膜弹力纤维增生症(EFE)和川崎病的临床诊断及鉴别诊断的作用。方法选取我院诊治的川崎病患儿1756例(川崎病组)、EFE患儿1032例(EFE组),以及体检的健康儿童1340例(对照组),应用超声心动图检查其左房内径(LA)、右室内径(RV)、左室舒张末期内径(LVDd)、左室射血分数(LVEF)、左室短轴缩短率(LVFS)、左室舒张早期快速充盈的充盈峰与舒张晚期心房收缩充盈的充盈峰比值(E/A),比较各组临床症状和上述超声心动图检测参数治疗前后的差异。结果 EFE组和川崎病组患儿症状(呼吸道感染、发热/多汗、气促/紫绀、乏力、哭闹/烦躁、不进食/体重增加缓慢、肝脏增大、心动过速/心音低钝、心力衰竭)构成比较差异均有统计学意义(均P0.05),其中EFE组和川崎病组患儿主要临床症状为呼吸道感染(发生率84.97%vs.75.58%,P0.05)。三组LA、RV、LVDd、LVEF、LVFS、E/A比较,差异均有统计学意义(均P0.05);组间两两比较上述各指标差异均有统计学意义(均P0.05)。EFE组治疗前、后LA、RV、LVDd、LVEF、LVFS、E/A比较,差异均有统计学意义(均P0.05)。具体分析各项指标差异的来源,均为组间因素、时间因素和交互作用的影响(均P0.05)。结论超声心动图对EFE和川崎病的诊断及鉴别诊断、评价转归过程均有明显指导作用,具有重要的临床意义。     

二维彩色多普勒超声心动图评定左室舒张功能

本文用彩色多普勒超声心动图检测100例(20～76岁)正常人舒张功能,按低龄(20～35岁)、中龄(36～50岁)、高龄(>51岁)分为三组。测量二尖瓣多普勒血流频谱①EA 两峰时间—速度积面(T—A);②分别测量 E、A 峰时间—速度积面(F—A)、(A—A)及舒张期前1/2时间—速度积面(50%)(T—A)。心尖四腔或左室二腔切面测量舒张末期左室容积(V)或左室长轴切面、M 型取腱索水平测舒张末期最大内径及二尖瓣短轴切面的(?)口面积。计算下列7项指标。(1)峰值充盈速率(ml/s)PFR;(2)校正峰值充盈速率(Sec~(-1))NPFR;(3)半充盈分数1/2 FF;(4)舒张早期快速充盈的减速度(cm/s~2)DEF;(5)A 峰值速度/E峰值速度 A/E;(6)A 峰时间—速度积面/E 峰时间—速度积面 A—A/E—A;(7)A 峰时间—速度积面/总积面 A—A/T—A。上述所测数据,发现正常人左室舒张功能随年龄增长而改变。舒张早期与 E 峰有关测值随年龄增长而降低(PFR、NPFR、1/2 FF、DEF);舒张晚期与 A 峰有关测值随年龄增长而升高(A/E、A—A/E—A、AA/T—A)。经统计学处理后各组值间有显著差异或非常显著差异(P<0.05或0.001)这一特征与创伤性检查相一致。说明正常人左室舒张功能和顺应性有随着年龄增长而有“衰变”的趋势,这一“衰变”在50岁以上显得明显。多普勒测量左室舒张功能比 M 型敏感。     

左房舒张内径变化对鉴别二尖瓣血流正常与假正常的价值

目的应用超声心动图测量左房舒张期变化鉴别二尖瓣血流正常与假正常以评价左室舒张功能.方法对66例高血压病患者和59例健康人进行了研究.舒张功能包括测量二尖瓣血流E/A比值, E峰减速时间.66例舒张功能障碍的患者中46例为损伤类型(E/A＜1,E:左室舒张早期血流峰值速度,A:舒张晚期血流峰值速度),20例假正常类型(E/A＞1).用M-型超声心动图测量左房收缩和舒张期内径,左房排空分数(LAEF)计算方法为舒张末左房内径除以收缩末内径.结果左室功能损伤组LAEF 0.77±0.02,假正常组0.86±0. 05,对照组0.67±0.03,差异有高度显著性.结论舒张期左房内径的变化是用于检测左室舒张功能鉴别二尖瓣血流正常和假正常一个简单而实用的方法.     

三维超声心动图定量评价扩张型心肌病左心室舒张功能

目的 探讨三维超声心动图(3DE)定量评价扩张型心肌病(DCM)左心室舒张功能的可行性.方法 对30例DCM患者(DCM组)和30名正常人(对照组)进行超声心动图检测,测量左心室舒张末期容积(EDV)、左心室收缩末期容积(ESV)和每搏输出量(SV)及射血分数(EF),并计算左心室舒张期前1/3充盈分数(1/3FF);分析1/3FF与E/E的相关性.结果 DCM组EDV、ESV、SV及E/E显著高于对照组(P均＜0.05);DCM组EF及1/3FF显著低于对照组(P均＜0.05);两组的1/3FF与E/E均呈显著负相关(r=-0.81、-0.81,P均＜0.05).结论 3DE能定量评价DCM左心室舒张功能,可作为临床评价左心室舒张功能的一种新方法.     

心脏再同步化治疗对慢性充血性心力衰竭患者左心室舒张功能的影响

目的应用超声心动图评价左心室舒张功能,探讨心脏再同步化治疗对左心室舒张功能的影响。方法对组织多普勒提示有左心室非同步的慢性充血性心力衰竭患者12例进行心脏再同步化治疗,起搏前和起搏后1周行超声心动图检查,测量左室射血分数、Tei指数,同时测量二尖瓣血流E、A峰,E/A,左室舒张充盈时间占心动周期的比例,E峰减速时间,肺静脉血流S波、D波,二尖瓣环Em/Am。根据以上参数将舒张功能减退分为3期,应用组织多普勒测量心室机械不同步,比较起搏前后各参数的变化。结果起搏前,11例患者E峰和A峰融合,形似单峰,无法测量E、A峰值及E峰减速时间,所有患者左室舒张充盈时间缩短。起搏后1周,所有患者E峰和A峰分离,5例患者为第2期的舒张功能降低,7例患者为第1期的舒张功能降低。左室舒张充盈时间占整个心动周期的比例由起搏前的(34.5±2.9)%提高到(46.4±5.7)%(P<0.01)。左室射血分数由起搏前的(26.8±7.6)%提高到(37.7±10.1)%。左房内径在起搏后1周明显缩小(P<0.05),左室收缩非同步指数由起搏前的179.2±48.3下降到103.4±58.2(P<0.05)。结论在充血性心力衰竭患者中,由于心脏收缩的不同步,二尖瓣血流E、A峰融合较为常见。心脏再同步化治疗后,左室舒张充盈改善,体现了左室舒张功能的改善。     

多普勒超声心动图评价高血压病的左室舒张功能

目的:探讨高血压病伴左室舒张功能降低的多普勒超声心动图表现。方法:采用脉冲多普勒超声心动图(PDE)测定各组高血压病60例,正常对照组60例的左室舒张早期快速充盈血流速度峰值(E峰);左房收缩期血流速度峰值(A峰);E/A比值。结果:以这三项测定结果来评价高血压病患者的左室舒张功能,正常组E/A>1;高血压病组(轻度、重度)E/A≤1,随着血压的增高E/A比值有减小的趋势。结论:上述各项测值可以辅助高血压病的早期诊断,亦可作为高血压病程度判断的依据。     

强直性脊柱炎患者心功能变化的研究

目的研究强直性脊柱炎(AS)患者心功能变化及其影响因素。方法采用多普勒超声心动图(UCG)检测140例AS患者心功能变化,并与30例健康对照组(NC)进行比较;观察AS患者实验室指标与心功能参数的相关性。结果 (1)AS组UCG检测结果异常率为33.56%,而NC组异常率为9.99%,差异有统计学意义(P0.01)。(2)与NC组相比,AS患者左房室瓣口舒张晚期血流峰值(A峰)显著升高;舒张早期血流峰值(E峰)、射血分数(EF)、E/A比值显著降低,差异均有统计学意义(P0.01)。(3)Spearman相关分析结果显示,AS组患者E峰与IL-35,A峰与心悸均呈显著正相关(P0.05或P0.01)。E峰与病程、血小板计数、免疫球蛋白G、红细胞沉降率、C反应蛋白均呈显著正相关(P0.05或P0.01),E/A比值与病程、IL-18均呈显著正相关(P0.05或P0.01),EF与病程、心悸呈显著负相关(P0.05或P0.01)。结论AS患者超声心动图检测结果异常率为33.56%,表现为E峰、EF、E/A比值显著降低,A峰显著升高且与实验室指标相关。     

超声心动图评价高血压病患者左心功能

目的运用超声心动图技术综合评价高血压病患者左室收缩功能和舒张功能。方法高血压病组56例和对照组36例,M-型和二维(2D)超声心动图检测:左房内径(LAd),舒张期室间隔厚度(IVST)和左室后壁厚度(PWT),左室舒张末期内径(LVDd),二尖瓣EF斜率,室间隔及左室后壁运动幅度,左室射血分数(EF),左室短轴缩短率(FS),每搏量(SV);脉冲多普勒(PW)检测二尖瓣口舒张早期充盈峰速度(VE),舒张晚期充盈峰速度(VA),E/A比值,等容舒张时间(IVRT)。结果高血压病患者左室壁与室间隔收缩期运动幅度普遍增强,与对照组比较P<0.01;左室收缩功能各项参数(EF、FS、SV)高于对照组(P<0.05),高血压病组左室舒张功能各参数异常,表现为VE减低,VA升高,E/A<1,IVRT延长,MV-EF斜率减慢,与对照组比较P<0.001;左房扩大(P<0.001)。结论超声心动图技术可反映高血压病患者左心结构和功能变化,为临床诊治提供客观依据。     

蒽环类药物对肿瘤患者左心功能影响的组织多普勒评价

目的探讨组织多普勒技术(TDI)在评价蒽环类药物(ATC)对肿瘤患者左心功能早期损害的临床应用价值。方法测定并比较26例肿瘤患者ATC化疗前和化疗后6个月的常规超声心动图参数及TDI参数。结果TDI显示ATC化疗后二尖瓣环的收缩期运动速度峰值(Sm)及舒张早期运动速度峰值(Em)较化疗前明显降低(P<0.05),心房收缩期运动速度峰值(Am)较化疗前明显升高(P<0.01),Em/Am较化疗前明显降低(P<0.01),但舒张早期左室充盈峰速度(E)、心房收缩期左室充盈峰速度(A)、E/A、E峰减速时间(DT)、左室等容舒张时间(IVRT)及射血分数(EF)、短轴缩短率(FS)等常规心功能指标化疗前后差异无显著性(P>0.05)。结论TDI技术能更早、更敏感地评价ATC对肿瘤患者左室功能损害。     

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.