生理性心脏起搏的选择及应用限制的探讨

１２１例安置生理性心脏起搏器的患者，完全性及高度房室传导阻滞４２例；病窦综合征７９例，其中窦性心动过缓、窦性停搏６０例、慢─快综合征１９例。安置ＤＤＤ起搏器４０例，２８例为心房变时性反应正常的完全性房室传导阻滞。安置ＡＡＩ、ＡＡＩＲ（变时性反应不良者选用）起搏器４９例。发生并发症１４例，均为采用心房电极起搏方式者。其中电极脱位３例、低感知４例、膈刺激现象及输出阻滞各２例、起搏器介导性心动过速３例，根据笔者的经验，对不同心律失常类型提出了选择生理性起搏方式的原则，并就其应用限制进行了讨论，强调全面评估病情是作出最佳选择的前提。     

窦房结功能不良与传导阻滞患者植入双腔起搏器后动态心电图的表现及其意义

目的 探讨窦房结功能不良与传导阻滞患者植入双腔起搏器后动态心电图的表现及临床意义。 方法 分析植入DDD型双腔起搏器的160例患者的动态心电图,其中窦房结功能不良组80例,传导阻滞组80例,比较2组患者植入双腔起搏器后的动态心电图表现、主要的工作模式、心室起搏情况、自身心律失常及起搏器所致的心律失常。 结果 窦房结功能不良组与传导阻滞组起搏比例≥60%者均多于起搏比例<60%者（82%比18%、85%比15%）,组间差异无统计学意义。窦房结功能不良组心房按需起搏工作模式显著高于传导阻滞组（31%比2%,P<0.01）,而心室按需起搏/心房同步心室起搏工作模式显著低于传导阻滞组（19%比50%,P<0.01）;组间比较,双腔按需起搏工作模式检出率二者无统计学差异（50%比48%）。窦房结功能不良组心室安全起搏检出率显著高于传导阻滞组（25%比12%,P<0.05）,而心室起搏融合波的检出率则显著低于传导阻滞组（35%比51%,P<0.05）。窦房结功能不良组起搏介导性心动过速及感知房性心动过速触发快速型心室起搏的检出率显著高于传导阻滞组（12%比2%,24%比11%,P<0.05）,房性心动过速和频发房性早搏的检出率亦显著高于传导阻滞组（38%比18%,22%比4%,均P<0.05）。 结论 窦房结功能不良与传导阻滞患者植入双腔起搏器后对应的主要工作模式可以通过动态心电图的各种表现进行识别,全面了解起搏器的工作状态,为起搏器的合理程控以及自身心律失常提供可靠的依据。     

射频消融和DDD起搏器治疗典型心房扑动伴缓慢心室率五例

目的探讨典型心房扑动(简称房扑)伴缓慢心室率的介入治疗。方法5例房扑伴缓慢心室率患者,房扑频率240～260次/分,房室传导比例5:1～6:1。1例患者已置入VVI起搏器,但仍有症状。对房扑采用解剖学影像定位法消融下腔静脉与三尖瓣环的峡部。对缓慢心室率采取DDD起搏器治疗(1例VVI改换DDD)。结果消融中房扑终止,峡部达双相阻滞,房扑终止后1例为Ⅱ度Ⅱ型房室传导阻滞,4例为Ⅲ度房室传导阻滞。均成功置入DDD起搏器。随访7～37个月,房扑未见复发,起搏器工作良好,患者症状消失。结论射频消融和DDD起搏器联合治疗典型房扑伴缓慢心室率患者有效而且安全。     

不同起搏部位的心室电机械同步性分析

目的:本研究旨在评价心脏不同起搏部位对心室电及机械同步性的影响.方法:选择2019年1月-2019年10月于天津市胸科医院因房室传导阻滞或心房颤动(房颤)伴缓慢心室率行永久起搏器安置术、左室射血分数(LVEF)＞40％的患者53例.根据心室电极植入位置分为希浦系统起搏24例,其中包括希氏束起搏(HBP)组14例,左束支...     

埋藏式心脏起搏器的临床应用

为２１０例患者安置埋藏式心脏起搏器。植入途径：锁骨下静脉穿刺１６６例，头静脉切开５６例，其他２例；起搏阈值：心室０．４￣０．７（平均０．５）Ｖ，心房０．３￣０．９（平均０．６）Ｖ；起搏方式：心室起搏１８１例，房室顺序起搏４３例。安置起搏器后患者症状缓解，心功能明显改善。认为熟练的锁骨下静脉穿刺、精确的电极定位和严格的囊袋处理是手术成功的关键。     

生理性与非生理性起搏方式并发症的对比分析

目的探讨生理性与非生理性起搏并发症及对患者预后的影响。方法对两种起搏方式６７３例（非生理性起搏５２５例,生理性起搏１４８例）患者的并发症进行回顾性对比分析。随访时间最长２２年３个月,最短１个月。结果两种起搏方式并发症总发生率差异无显著性,非生理性起搏组并发症发生率为２０．１％,生理组为１９．６％（Ｐ＞０．０５）。非生理性起搏组起搏器综合征发生率为４．２％、心房颤动发生率为６．９％,高于生理组的０％（Ｐ＜０．００１）,脑梗塞发生率为２．５％;生理组无起搏器综合征、心房颤动发生,脑梗塞发生率仅为０．１％,本组并发症主要为感知过度及起搏器介入性心动过速（ＰＭＴ）,其发生率均为７．４％,高于非生理组的１．１％（Ｐ＜０．０１）,ＰＭＴ为本组所特有并发症。结论生理组并发症多因起搏器调整不当所引起,对患者预后影响不大,通过调整起搏器可得到解决［１］。非生理性起搏并发症多与血液动力学改变有关,这些并发症影响患者生活质量及预后,部分患者需更换起搏方式。     

老年心房颤动不同方式的经导管射频消融治疗

目的研究不同方式经导管射频消融治疗对老年房颤的治疗效果。方法53例房颤患者，男性38例，女性15例，年龄60-83岁。按接受不同的经导管消融方法将上述患者分为3组：消融隔离肺静脉治疗阵发性房颤组20例、消融典型房扑治疗房颤合并房扑组26例、消融房室传导加植入永久性起搏器治疗持续性房颤伴药物难以控制的快速心室率和（或）心力衰竭组7例。结果消融隔离肺静脉组中15例采用环状标测电极导管引导电隔离3～4根肺静脉成功，术后无房颤发作8例（53％），房颤发作明显减少4例（27％）；采用电解剖系统引导下环双侧肺静脉线性消融隔离肺静脉5例，无房颤发作4例（80％）。消融房扑组26例典型房扑均消融成功，随访中15例（58％）无房颤发作，8例（31％）房颤发作较前减少。经导管消融房室传导组7例全部成功，4例行右心室、3例行双心室VVI模式起搏，随访中生活质量和（或）心力衰竭症状明显改善。结论针对不同类型的老年房颤患者采用不同的经导管消融方法可以取得较好的临床效果。     

3房室传导阻滞伴心室双重逸搏点1例

３房室传导阻滞伴心室双重逸搏点１例李寿祥患者，女性，７１岁，因反复晕厥半年，查心电图示３　房室传导阻滞（３　ＡＶＢ）住院治疗，后转院安置人工心脏起搏器。图１为安置起搏器前１周的心电图Ｖ１导联记录。Ｐ－Ｐ周期相等，频率约１１５ｂｐｍ；Ｒ－Ｒ周期基本相等...     

VDD起搏治疗幼儿完全性房室阻滞(附一例报告)

一例３．５岁的女性幼儿因室间隔缺损修补术致迟发性完全性房室阻滞（ＣＡＶＢ）而安置ＶＤＤ起搏器。经锁骨下静脉途径埋置单根心房感知、心室触发起搏电极，使之于右房内塑形并贴靠房壁；起搏器埋于同侧皮下胸大肌筋膜上囊袋内。术中测得起搏阈值０．１Ｖ、脉宽０．４ｍｓ、电极阻抗５２０Ω、Ａ波振幅１．５ｍＶ、Ｖ波振幅１０．６ｍＶ，Ａ波感知设定０．２５ｍＶ。术后房室同步起搏率１００％，临床症状改善。表明ＶＤＤ起搏器不仅埋置简便，而且具有房室同步、频率应答等生理性起搏特点，是治疗幼儿ＣＡＶＢ的理想起搏方式。     

二维超声观察AAI与VVI起搏前后血流动力学的变化

作者对２３例安装永久性起搏器患者，采用二维超声，比较起搏器植入前后血流动力学的变化。结果显示:植入后心房按需起搏（ＡＡＩ）组和心室按需起搏（ＶＶＩ）组的心排血量均明显增加（Ｐ＜０．０５），分别增加４０．６％和２１．２％；但植入后ＶＶＩ组的左室射血分数、每搏量、左室舒张末期容积均降低（Ｐ＜０．０５），ＡＡＩ组无变化。研究表明ＡＡＩ生理性起搏对于患者血流动力学的改善优于ＶＶＩ非生理性起搏。心排血量是评价血流动力学改善的敏感指标     

胰岛素瘤的解剖分布特点分析

目的胰岛素瘤是最常见的胰腺神经内分泌肿瘤，因其临床表现多样，导致诊断困难。影像学诊断尤其是超声内镜(EUS)在胰岛素瘤的诊断中起着重要作用，拥有较高的敏感性和特异性。本研究拟通过明确胰岛素瘤的解剖分布特点，以期有助于提高影像学的诊断准确率和降低漏诊率，尤其是在教育和培训实践中对于EUS的学习者更具有指导价值。 方法回顾性分析解放军总医院第一医学中心病案资料数据库1993年1月至2019年11月经外科手术、病理确诊为胰岛素瘤的患者的临床资料，检索方法采取搜索术后病理诊断为"胰岛素瘤"的病例，通过查阅病例的方法，提取出胰岛素瘤的大小和解剖分布等数据，进一步分析其特点。 结果共检索到确诊为胰岛素瘤的患者116例，其中，男45例、女71例，年龄13～76岁，平均年龄(44.4±14.85)岁。胰岛素瘤单发110例(94.8%)、多发6例(5.2%)。位置分布：头颈部46例(39.7%)，单发45例、多发1例；体尾部68例(58.6%)，单发65例、多发3例；全胰腺多发2例(1.7%)。病变大小特点：最大径0.4～3.4 cm，平均大小(1.53±0.58)cm。≤1 cm 29例、>1 cm而≤1.5 cm41例、>1.5 cm而≤2.0 cm28例，≤3 cm 15例，>3 cm 3例。年龄与肿瘤的大小相关，≤44岁患者肿瘤平均大小为(1.36±0.51)cm、>44岁患者肿瘤平均大小为(1.70±0.60)cm，P<0.05。头颈部的肿瘤大于体尾部的肿瘤，头颈部肿瘤平均大小(1.66±0.63)cm，体尾部(1.42±0.52)cm，P<0.05。 结论胰岛素瘤在胰腺体尾部较头颈部更好发；绝大多数单发，但可以全胰腺多发；多数小于1.5 cm，肿瘤的大小与患者年龄和肿瘤的解剖分布相关。     

Pathogenesis of carcinoma of the papilla of Vater

Most adenomas and carcinomas of the small intestine and extrahepatic bile ducts arise in the region of the papilla of Vater. In familial adenomatous polyposis (FAP) it is the main location for carcinomas after proctocolectomy. In many cases symptoms due to stenosis lead to diagnosis at an early tumor stage. In about 80%, curative intended resection is possible. Operability is the most relevant prognostic factor. Most ampullary carcinomas resp. carcinomas of the papilla of Vater develop from adenomatous or flat dysplastic precursor lesions. They can be sited in the ampulloduodenal part of the papilla of Vater, which is lined by intestinal mucosa. They also can develop in deeper parts of the ampulla, which are lined by pancreaticobiliary duct mucosa. Intestinal-type adenocarcinoma and pancreaticobiliary-type adenocarcinoma represent the main histological types of ampullary carcinoma. Furthermore, there exist unusual types and undifferentiated carcinomas. Many carcinomas of intestinal type express the immunohistochemical marker profile of intestinal mucosa (keratin 7?, keratin 20+, MUC2+). Carcinomas of pancreaticobiliary type usually show the immunohistochemical profile of pancreaticobiliary duct mucosa (keratin 7+, keratin 20?, MUC2?). Even poorly differentiated carcinomas, as well as unusual histological types, may conserve the marker profile of the mucosa they developed from. These findings underline the concept of histogenetically different carcinomas of the papilla of Vater which develop either from intestinal- or from pancreaticobiliary-type mucosa of the papilla of Vater. Molecular alterations in ampullary carcinomas are similar to those of colorectal as well as pancreatic carcinomas, although they appear at different frequencies. In future studies, molecular alterations in ampullary carcinomas should be correlated closely with the different histologic tumor types. Consequently, the histologic classification should reflect the histogenesis of ampullary tumors from the two different types of papillary mucosa.     

Lack of correlation of degree of villous atrophy with severity of clinical presentation of coeliac disease

BACKGROUND AND AIM: Both the clinical presentation and the degree of mucosal damage in coeliac disease vary greatly. In view of conflicting information as to whether the mode of presentation correlates with the degree of villous atrophy, we reviewed a large cohort of patients with coeliac disease. PATIENTS AND METHODS: We correlated mode of presentation (classical, diarrhoea predominant or atypical/silent) with histology of duodenal biopsies and examined their trends over time. RESULTS: The cohort consisted of 499 adults, mean age 44.1 years, 68% females. The majority had silent coeliac disease (56%) and total villous atrophy (65%). There was no correlation of mode of presentation with the degree of villous atrophy (p=0.25). Sixty-eight percent of females and 58% of males had a severe villous atrophy (p=0.052). There was a significant trend over time for a greater proportion of patients presenting as atypical/silent coeliac disease and having partial villous atrophy, though the majority still had total villous atrophy. CONCLUSIONS: Among our patients the degree of villous atrophy in duodenal biopsies did not correlate with the mode of presentation, indicating that factors other than the degree of villous atrophy must account for diarrhoea in coeliac disease.     

Demonstration of the mechanism of action of biguanides

Summary Palmitic acid oxidation in rat diaphragm homogenate is depressed by biguanide concentrations that are still incapable of inhibiting oxidative phosphorylation. Glucose oxidation is not directly effected by the same biguanide concentrations: however, the inhibitory effect of palmitic acid on glucose oxidation is partly removed by biguanides. Inhibition of fatty acid oxidation, which accounts for most of the metabolic effects caused by these drugs, can be regarded as the fundamental mechanism of action of biguanides. There is some evidence suggesting that these drugs might interact with carnitine, thus preventing long-chain fatty acids from being transported across the mitochondrial membrane to the site of oxidation. Traduzione a cura degli AA.     

血吸虫童虫生长发育及其机制的研究进展

血吸虫童虫是宿主免疫系统攻击的重要靶标,包括皮肤型、肺型和肝门型童虫。宿主分子对童虫生长发育具有重要作用。童虫生长发育机制包括免疫调节、信号转导、性别发育及凋亡等。肌动蛋白、组织蛋白酶、烯醇化酶和葡萄糖基转移酶等分子为血吸虫童虫生长发育的重要分子。本文对血吸虫童虫生长发育及其机制的研究进展做一综述。     

124例耐多药结核分枝杆菌基因突变特征分析

目的对临床分离的耐多药结核分枝杆菌相关基因的突变特征进行分析。方法对124例耐多药结核分枝杆菌以及50株敏感株的耐药相关基因(包括异烟肼inh A、kat G、oxyR-ahp C间隔区以及利福平rpo B)进行序列测定,分析其基因突变情况。结果异烟肼耐药inh A基因突变率为14.5%;kat G基因突变率为70.2%(87/124),主要位于315位;oxyR-ahp C间隔区突变率为15.3%;inh A、kat G两种基因同时突变率75.0%,三种基因同时突变率为89.5%。利福平rpo B基因突变的检出率高达95.2%,突变主要发生在531、526、516位点。结论我省耐多药菌异烟肼耐药相关基因最常见突变为kat G 315、inh A C-T(-15)、axyR-ahp C间隔区(-10)C-T,利福平为rpo B531、526、516。结合MDR-TB耐药相关基因的特征分析,可以建立一种快速、准确、特异的适合于我省的检测结核菌耐多药性的新方法。     

Assessment of quality of life of parents of children with juvenile chronic arthritis

The aim of the study was to assess the quality of life (QOL) and the psychological status of parents of children with juvenile chronic arthritis (JCA). The QOL, anxiety and depression of the parents of 28 children with JCA were evaluated and compared to those of the parents of 28 healthy children. Mothers of JCA children and mothers of healthy children reported similar QOL. The reported anxiety and depression levels were similar for mothers and fathers in both groups. The parents of children with pauciarticular-type JCA reported lower QOL and higher levels of anxiety and depression than the parents of children with other types, namely polyarticular and systemic JCA. These findings may be explained by the fact that the pauciarticular patients had shorter disease duration and were less frequently seen in the outpatient clinic. The QOL of mothers of children with JCA was found to be slightly impaired in the group of children with pauciarticular JCA. Future larger studies are needed to confirm these results, as the number of subjects in the three groups was rather low. Received: 26 September 2001 / Accepted: 8 February 2002     

Numerical Simulation of the Effect of Rate of Change of Glucose on Measurement Error of Continuous Glucose Monitors

Background

A 5-day in-patient study designed to assess the accuracy of the FreeStyle Navigator® Continuous Glucose Monitoring System revealed that the level of accuracy of the continuous sensor measurements was dependent on the rate of glucose change. When the absolute rate of change was less than 1 mg•dl⁻¹•min⁻¹ (75% of the time), the median absolute relative difference (ARD) was 8.5%, with 85% of all points falling within the A zone of the Clarke error grid. When the absolute rate of change was greater than 2 mg•dl⁻¹•min⁻¹ (8% of the time), the median ARD was 17.5%, with 59% of all points falling within the Clarke A zone.

Method

Numerical simulations were performed to investigate effects of the rate of change of glucose on sensor measurement error. This approach enabled physiologically relevant distributions of glucose values to be reordered to explore the effect of different glucose rate-of-change distributions on apparent sensor accuracy.

Results

The physiological lag between blood and interstitial fluid glucose levels is sufficient to account for the observed difference in sensor accuracy between periods of stable glucose and periods of rapidly changing glucose.

Conclusions

The role of physiological lag on the apparent decrease in sensor accuracy at high glucose rates of change has implications for clinical study design, regulatory review of continuous glucose sensors, and development of performance standards for this new technology. This work demonstrates the difficulty in comparing accuracy measures between different clinical studies and highlights the need for studies to include both relevant glucose distributions and relevant glucose rate-of-change distributions.     

Angiographic diagnosis of the degree of serosal invasion of carcinoma of the colon

Angiography using Prostaglandin El^® was performed on 38 patients with carcinoma of the colon in order to diagnose the degree of serosal cancer invasion. The findings at angiography were classified into four groups:1) AG-S3, abnormal change (irregularity and/or encasement) up to marginal vessels; 2) AG-S2, abnormality up to vasa recta; 3) AG-S1, abnormality of penetrating branches of vasa recta within the wall of the colon; and 4) AG-S0, no distinct findings of abovementioned vessels. These angiographic findings were compared with both macroscopic and microscopic serosal cancer invasion. Angiographic diagnosis is in accord with the macroscopic findings in 84.2 percent of cases. Angiographic diagnosis is in accord with the microscopic findings in 32.4 percent of cases. Macroscopic findings confirm the angiographic diagnosis precisely but the conflict with microscopic findings should not be overlooked. This may be the result of inflammatory change, adhesion, and fibrosis around carcinoma of the colon.     

Study of constancy of hydrogen-consuming flora of human colon

The constancy of the hydrogen consuming flora of the human colon was studied in 15 healthy subjects via two measurements obtained 18 to 36 months apart. Hydrogen disappearance rate and the major products of H₂-consuming bacteria, methane and sulfide, were measured during incubation of fecal homogenates with excess hydrogen and sulfate. In 11/15, the hydrogen consumption rate and the predominant hydrogen-consuming pathway (methanogenesis, sulfate reduction, or neither) remained constant. However, major shifts in these pathways were observed in four subjects, with two losing and two gaining the ability to produce methane. Methanogenesis was associated with the highest hydrogen consumption rate. This study demonstrates that clinically unrecognizable, major alterations of the colonic flora occur in healthy subjects. Understanding of the factors responsible for these alterations might allow for therapeutic manipulation of the colonic flora.Supported in part by the Department of Veterans Affairs and NIDDKD RO1 DK 13309-25.