先天性心脏病术后下腔静脉口-三尖瓣环峡部依赖性心房扑动的导管消融疗效分析

目的:报道先天性心脏病术后下腔静脉口-三尖瓣环峡部依赖性心房扑动的相对发生率及导管消融的疗效和安全性。方法:选择2002年1月-2006年4月在我院因先天性心脏病术后心房内折返性心动过速行射频消融的40例患者,应用常规电生理标测方法或三维标测方法(Carto和Ensite)指导导管消融,观察下腔静脉口-三尖瓣环峡部心房扑动相对发生率及其导管消融结果。结果:40例患者共诱发出50种房性心动过速,具有典型下腔静脉口-三尖瓣环峡部依赖性心房扑动心电图表现,且成功靶点在下腔静脉口和三尖瓣环峡部者31种(31／50,62．0％)。另外19种(19／50,38．0％)房性心动过速临床心电图表现与典型心房扑动不同,表现为P’波,其中11种(11／50,22．0％)成功靶点在右心房游离壁疤痕-下腔静脉峡部,瘢痕-上腔静脉峡部者2种,瘢痕与瘢痕之间峡部者2种;在瘢痕和三尖瓣环之间2种。房间隔补片和上腔静脉之间、房间隔补片和三尖瓣环之间各消融成功1种。40例患者射频消融成功,无并发症。随访1例患者心动过速复发,二次消融成功;1例患者出现持续性心房颤动伴RR长间歇,植入永久性起搏器。结论:先天性心脏病术后心房内折返性心动过速常常为下腔静脉口-三尖瓣环峡部心房扑动,导管消融具有较高的疗效和安全性。     

Halo电极远端电位方向逆转作为典型心房扑动消融终点标准的观察

目的探讨一种通过Halo电极远端电位方向发生逆转来判断典型心房扑动(简称房扑)三尖瓣环峡部线性消融成功的方法。方法 20例典型房扑患者接受射频消融治疗,将Halo电极经右股静脉置于三尖瓣环上,从远端电极至近段电极呈顺时针方向。于窦性心律下,行三尖瓣环至下腔静脉之间线性消融,与此同时,于冠状窦口行S1S1500ms起搏。消融过程中,Halo电极标测显示远端电极及近端电极呈双向传导。以Halo电极远端电位方向逆转作为消融成功终点。结果 20例均消融成功,无消融并发症发生。消融后,反复电刺激未诱发房扑。术后随访6个月,未见房扑复发。结论冠状窦口起搏刺激下,Halo电极远端电位方向出现逆转可作为典型房扑三尖瓣环峡部线性消融成功的可靠指标。     

典型心房扑动消融术后峡部计时间期的变化预测双向阻滞的价值

典型的心房扑动(房扑)是右心房内的大折返所致已成共识，下腔静脉、三尖瓣环峡部是折返环的一部分。因此，射频消融下腔静脉、三尖瓣环峡部并产生峡部双向阻滞，是成功消融典型房扑和减少复发的可靠标志。目前，多采用心房激动顺序或消融部位的双电位技术确定峡部双向阻滞的存在。通过比较房扑成功消融前、后右心房峡部传导时间，从而提出峡部传导时间的延长程度对峡部完全性     

慢传导带传导阻滞作为心房扑动消融终点的意义（附Halo导管应用一例报告）

应用Ｈａｌｏ导管标测技术，结合冠状静脉窦与希氏束电图识别心房扑动折返环的慢传导带，在下腔静脉口到三尖瓣环峡部作射频线性消融，并以慢传导带出现双向阻滞作为心房扑动消融成功的标志，治疗了１例Ｉ型心房扑动患者。随访１个月心动过速未发。由于Ｈａｌｏ导管能在右房内全面记录右房激动顺序，便于了解峡部的传导情况，在心房扑动消融中有助于明确其诱发与终止的机制，并为慢传导带传导阻滞作为成功消融终点提供了可靠的手段。     

下腔静脉、三尖瓣环峡部的射频消融治疗心房朴动

目的：报道以下腔静脉、三尖瓣环峡部双向传导阻滞作为终点的心房扑动射顿消融方法，观察该终点对长期疔效的作用。方法；对5例Ⅰ型心房扑动患者的下腔静脉、三尖瓣环峡部进行射频消融。根据右房下侧壁和冠状静脉窦口起搏的右房激动顺序和传导时间变化、评竹蚨部传导阻滞。术后门诊随访观察。结果：5例患者分别于心房扑动(2例)和赛性心律(3例)时接受射频消融治疗，消融后峡部均发生双向传导阻滞。右房下侧壁和冠状静脉赛口起搏的右房激动顺序分别呈顺时针和逆时针单一方向，右房传导时间分别延长82和78ms。随访4个月无一例复发。结论：峡部双向传导阻滞是射频消融心房扑动成功的可靠标志在赛性心律下，亦可对Ⅰ型心房扑动患者进行消融。     

心房扑动经导管消融治疗的临床分析

目的探讨典型心房扑动（AF）的电生理特性及导管消融（RFCA）疗效。方法18例AF者行心内电生理检查，标测心房激动顺序，确定折返环部位行线性消融治疗。结果18例中持续性AF8例（44．4％），诱发出AF10例（55．6％）。其中合并不纯性AF1例、房室结折返性心动过速、房室折返性心动过速及室性心动过速各1例。18例均行下腔静脉（IVC）、三尖瓣环（TA）后狭部RFCA，17例即时消融成功，成功率为94．4％，1例不成功者合并有心房纤颤（表现为不纯性AF）。结论典型AF行线性消融治疗效果可靠，成功率高；如能应用射频导管新技术如Halo电极导管等，可以更全面记录AF的激动方向和顺序，为判断消融成功提供更快捷、简便的手段。     

阻断共同通道治疗房室结折返性心动过速与心房扑动的研究

目的 探讨房室结折返性心动过速(AVNRT)与心房扑动(AFL)的共同发病机制。方法 20例AVNRT并发AFL的患者通过电生理检查明确其心动过速性质后，行冠状窦口附近的慢径消融术(RFCA)，消融能量平均25W；术后在静脉滴注异丙肾上腺素下反复各种电刺激诱发，双径现象消失或无PSVT发作，视为手术成功。结果 20例患者术后及随访期内(3月～33月)，无AVNRT与AFL发作，亦无房室传导阻滞等并发症发生。结论 部分AVNRT并发AFL患者在返环途径上可能存在共同通道，RFCA可使其同时得到治疗。     

射频导管消融典型心房扑动和手术疤痕折返性房性心动过速共存一例

典型心房扑动(房扑)的成功消融部位是右心房的先天性峡部(三尖瓣环-下腔静脉峡部)，而对于手术疤痕折返性房性心动过速(疤痕折返性房速)，消融部位则是与手术疤痕相关的后天性峡部。本文报道1例共存有上述两种心动过速患者的成功消融过程。     

非接触标测系统用于典型心房扑动的右房标测和导航消融

应用非接触标测系统实施典型心房扑动 (AFL)的右房 (RA)全心腔标测和导航射频消融。 6例典型AFL ,男 5例、女 1例 ,年龄 5 6 .2± 15 .3(35～ 76 )岁。常规放置冠状静脉窦和His束电极 ,将标测球囊置于RA中下部 ,构建RA心内膜模型 ,分别于低位RA和冠状窦口 (CSO)S1S16 0 0ms起搏观察峡部传导 ,诱发并标测AFL的激动顺序和折返路径。 1例为顺钟向AFL ,4例为逆钟向AFL ,1例未能诱发AFL。AFL周期 2 0 7± 34ms,非接触标测可显示整个折返环路、激动顺序和缓慢传导区。AFL的激动可以穿过界嵴上部并且传导相对缓慢 ,提示RA平滑部是折返环的一部分。后位峡部线性消融在导航系统指导下进行 ,无需X线透视。消融完成后重复上述起搏验证峡部双向传导阻滞。除 1例术中出现心房颤动 (AF)外 ,其余病例即刻均达到峡部双向阻滞 ,未出现其他并发症 ,随访 8.1± 6 .7(3～15 )个月未见复发。非接触标测系统可安全、有效和直观地实现典型AFL的右房全心腔标测并导航消融 ,验证峡部双向阻滞 ,减少X线曝光时间和无效放电次数。界嵴在典型AFL时具备传导功能 ,RA平滑部和粗糙部共同参与折返环的组成。     

射频消融治疗经右心房游离壁切口术后的双环折返性房性心动过速

目的 总结经右心房游离壁切口术后双环折返性房性心动过速（房速）的发生率及射频消融后长期随访的结果.方法 2007年1月至2012年12月共入选48例在南京医科大学第一附属医院心脏科行经右心房游离壁切口治疗先天性心脏病或获得性心脏病后发作房速的患者.双环折返性房速的定义为心房同时存在两个折返环,同时在折返的可能路径上进行多部位拖带均为隐匿性.结果 共观察到8例患者术中存在双环折返性房速,男4例,平均年龄（40.4±22.0）岁.第1次外科术后至房速发作时间为（79.0±65.2）个月,第1次房速发作至第1次消融的时间为（20.8±28.3）个月,所有患者房速均持续发作.所有患者的双环折返性房速均与三尖瓣峡部以及右心房游离壁切口相关.5例患者在消融三尖瓣峡部过程中,心动周期突然变化;1例患者消融三尖瓣峡部时,心动周期无变化,右心房游离壁多部位拖带为右心房游离壁折返性房速,间隔部位拖带证实此部位不在折返环内,可能提示右心房游离壁折返性房速为主导折返环,;1例患者消融过程中心动过速终止,同样行切口致下腔的线性消融;1例患者消融三尖瓣峡部时心动过速无明显变化,但冠状静脉窦的激动有细微变化,拖带标测提示三尖瓣峡部不在折返环内,右心房游离壁多部位拖带提示为围绕右心房切口瘢痕折返的心动过速,行外科切口下部至下腔静脉消融时,房速终止.平均随访（33.6±16.7）个月,3例复发患者均为风湿性心脏病换瓣术后,其中1例复发房速,另外2例复发房颤.结论 经右心房游离壁切口术后双环折返性房速主要与三尖瓣峡部以及切口相关,三尖瓣峡部以及切口至下腔静脉线性消融常能够治疗这类心律失常.     

The immunoneuroendocrine role of melatonin

Abstract: A tight, physiological link between the pineal gland and the immune system is emerging from a series of experimental studies. This link might reflect the evolutionary connection between self-recognition and reproduction. Pinealectomy or other experimental methods which inhibit melatonin synthesis and secretion induce a state of immunodepression which is counteracted by melatonin. In general, melatonin seems to have an immunoenhancing effect that is particularly apparent in immunodepressive states. The negative effect of acute stress or immunosuppressive pharmacological treatments on various immune parameters are counteracted by melatonin. It seems important to note that one of the main targets of melatonin is the thymus, i.e., the central organ of the immune system. The clinical use of melatonin as an immunotherapeutic agent seems promising in primary and secondary immunodeficiencies as well as in cancer immunotherapy. The immunoenhancing action of melatonin seems to be mediated by T-helper cell-derived opioid peptides as well as by lymphokines and, perhaps, by pituitary hormones. Melatonin-induced-immuno-opioids (MHO) and lymphokines imply the presence of specific binding sites or melatonin receptors on cells of the immune system. On the other hand, lymphokines such as -γ-interferon and interleukin-2 as well as thymic hormones can modulate the synthesis of melatonin in the pineal gland. The pineal gland might thus be viewed as the crux of a sophisticated immunoneuroendocrine network which functions as an unconscious, diffuse sensory organ.     

Changes in connexin43, the gap junction protein of astrocytes, during development of the rat pineal gland

Abstract: The abundance of gap junctions between rat pineal astrocytes formed by connexin43 (Cx43) was studied during development. Levels and distribution of Cx43 were measured by immunoblotting and indirect immunofluorescence, respectively. The amount of Cx43 in cells located within the gland was low until about the 7th postnatal day and increased to adult values between the 14th and 21st days postpartum. Although astrocytes, recognized by their vimentin immunoreactivity, were scarce before birth, they were abundant by the 7th postnatal day suggesting that the low levels of Cx43 found at this age corresponded to a low expression of this protein. Localization of the immunoreactivity to Cx43 and vimentin showed a close correlation, indicating that mature or immature pineal astrocytes form gap junctions made of Cx43. Since Cx43 levels attained their adult values at about the time the innervation and the functional state of the gland reached maturity (2–3 weeks after birth), it is proposed that astrocyte gap junctions are involved in the function of the adult rat pineal gland.     

Response of rat pineal melatonin to calcium, magnesium, and lithium is circadian stage dependent

Abstract: Herein we documented the response of pineal melatonin production to electrolytes known to be effective on pineal function in view of a possible circadian stage dependence. We studied the release of melatonin by perifused rat pineal glands at 2 different circadian stages corresponding to the middle of the light and dark periods, i.e., respectively, 7 and 19 HALO (Hours After Light Onset, L:D = 12:12). The initial efflux rates were, as expected, much higher in the perifusates of glands removed from rats sacrificed during the dark phase than of those removed during the light phase. After 3 hr of perifusion, melatonin release reached similar levels which were found constant up to the 8th hr of perifusion, whatever the circadian stage. Perifusion of the glands with physiological concentrations for the rat of calcium (5.2 mmol/1) and magnesium (1.34 mmol/1) resulted in a stimulatory effect on the pineal glands removed from rats sacrificed in the middle of the dark period (19 HALO), whereas no effects were observed on the pineal glands removed from rats sacrificed during the light (7 HALO). Lithium (0.28 and 0.55 mmol/1) was ineffective on melatonin release in pineal glands removed 7 and 19 HALO. Our results show differences in the initial efflux rates of melatonin and in the response of perifused pineal glands to calcium and magnesium according to the circadian stage.     

Conservative management of perforated duodenal diverticulum： A case report and review of the literature

Duodenal diverticula are a relatively common condition. They are asymptomatic, unless they become complicated, with perforation being the rarest but most severe complication. Surgical treatment is the most frequently performed approach. We report the case of a patient with a perforated duodenal diverticulum, which was diagnosed early and treated conservatively with antibiotics and percutaneous drainage of secondary retroperitoneal abscesses. We suggest this method could be an acceptable option for the management of similar cases, provided that the patient is in good general condition and without septic signs.     

Presence of immunoreactive growth hormone and prolactin in the ovine pineal gland

Abstract: The use of antisera raised against bovine growth hormone (GH) and ovine prolactin (PRL) enabled the detection of related immunoreactive (ir) sequences of proteins in ovine pineal tissue. The isolation of PRL-like ir-material was accomplished using a 0.25 M ammonium sulphate (pH 5.5) extraction followed by ethanol precipitation, whereas the resulting 2.0 M ammonium sulphate (pH 7.0) precipitate contained a GH-like immunoreactivity. Gel chromatography of the GH-like immunoreactivity (Sephadex G-100) indicated the presence of several GH-like fragments ranging in the M_r range of 7,000 to 55,000. Analyses of the PRL-like ir-material found in pineal tissue on HPLC using a TSK 545-DEAE column led to the resolution into a single peak of immunoreactivity. A single peak of activity was also observed following chromatofocusing and hydrophobic interaction chromatography of the ir-peak from the TSK 545-DEAE column. The PRL-like ir-material inhibited the binding of [¹²⁵I]ovine PRL-S14 to anti-ovine PRL antibodies without showing an affinity for binding to anti-rat PRL or anti-bovine GH antibodies. Scatchard analysis of the binding of pineal PRL-like ir-material and pituitary ovine PRL-S14 to liver membranes from day-20 pregnant rats revealed similar affinity constants (K_a of 4.7 ± 0.2 × 10⁹ M^-1). In addition, the replication of Nb 2 Node rat lymphoma cells was stimulated by pineal PRL-like ir-material, an effect known to be specific for lactogenic hormones. The pineal PRL-like immunoreactivity appeared on sodium dodecyl sulfate polyacrylamide gels as a single major band of M_r 24,000. The functional status of PRL-and GH-like ir-material in the ovine pineal remains to be determined, but evidence is presented that the overall protein synthesis rate of the rat pineal responded to circulating concentrations of PRL.     

Microbiology of human immunodeficiency virus anorectal disease

PURPOSE: Individuals who are seropositive for the human immunodeficiency virus are at high risk for opportunistic infection and anorectal disorders. Little prospective information is available regarding anorectal pathogens in these patients. METHODS: One hundred sixty-three HIV-seropositive patients presented to the colorectal clinic between 1989 and 1992. Forty-seven (29 percent) patients were thought to have an infectious process and were prospectively studied using a standardized multiculture protocol. RESULTS: Mean age was 33 (range, 19–59) years. All were male; high-risk behavior accounted for 87 percent of HIV transmissions. Presenting complaints included anorectal pain (79 percent), pus per anum (28 percent), and blood per anum (26 percent). Examination revealed perianal tenderness (60 percent), condyloma (38 percent), perianal ulcers (38 percent), and anal fissures (34 percent). Sixty-six sets of cultures were performed; 28 patients had one set, 15 had two sets, and 4 had three sets. Thirty-two of these 47 patients (68 percent) had positive cultures including herpes (50 percent), cytomegalovirus (25 percent),Neisseria gonorrhoeae (16 percent), chlamydia (16 percent), acidfast bacilli (2 percent), and others (9 percent). Six of 32 patients with positive cultures had more than one organism cultured. Sixteen (50 percent) patients with positive cultures were treated medically, 8 (25 percent) were treated surgically and 8 (25 percent) were treated with both modalities. Sixty-one procedures were performed on 17 patients for condylomata. Eighteen patients had 20 procedures for abscesses, 50 percent of whom had positive cultures for other than common bowel flora; all improved. Fourteen patients underwent 33 procedures for perianal fistulas.Mycobacterium fortuitum was cultured from one patient who required 13 procedures for abscesses and fistulas. Forty-five (96 percent) patients were followed for an average of 12.5 months ±2.9 SEM (range, 1–94 months). Symptoms were improved or resolved in 22 of 32 (69 percent) patients with positive cultures and in 11 of 13 (84 percent) with negative cultures. CONCLUSIONS: Specific pathogens may often be identified in human immunodeficiency virus-seropositive patients with anorectal disorders if aggressively sought. Although patients without specific pathogens identified may be expected to improve with planned empiric treatment, positive identification allows more directed therapy.