急性心肌梗死后左心室附壁血栓超声表现1例

患者女 ,48岁。因重症肌无力和胸腺瘤住院治疗。住院期间突然出现胸痛伴胸闷、憋气。查体 :血压 60 /90mmHg( 1mmHg =0 .13 3kPa) ,双肺呼吸音粗 ,心率 98次 /min ,心尖区闻及Ⅱ /6级轻柔的收缩期杂音。心电图 :V1～V6导联见病理性Q波 ,ST段弓背上抬 ,Ⅱ、Ⅲ、avF导联ST段缺血性压低。心肌酶 :CK MB 3 0 .8ng/ml,肌钙蛋白T8.12ng/ml。 2h后床旁超声心动图检查 :左心室轻度扩大 ,左心室前壁、前间隔和下壁的心尖段运动消失 ,心肌厚度和回声基本正常 ,二尖瓣口见轻度收缩期反流。 4d后床旁超声心动图检查 :左心室前壁、前间隔和下壁的…     

左心室心肌梗死并室壁瘤及室间隔穿孔二例

例1 患者女,60岁.2个月前出现阵发性心前区疼痛,伴大汗,每次持续约30 min缓解,未给予正规治疗.近2周症状加重,伴明显呼吸困难入院.查体:心界向左扩大,心尖可闻及3/6级收缩期吹风样杂音向心底部传导.心电图:窦性心律,Ⅱ、Ⅲ、AVF、V1～V5病理性Q波,V2～V6 ST段抬高.     

急性冠脉综合征患者运用罗伊适应模式的护理

患者,男性,50岁,21)07年9月13日因"胸骨后疼痛4h"急诊以"急性冠脉综合症(ACS)"收入我院心内科CCU,入院后第1次肌钙蛋白T定性为阳性,心电图示窦性心律,V4～6导联的S-T段下降,V5～6导联T波倒置.肌酸激酶(CK)414 IU/L,乳酸脱氢酶(LDH)1 054 U/L,动脉血气分析示pH 7.36,PaCO240mm Hg,PaO2 56 mm Hg,BE-1 mmol/L,HCO3 23 mmol/L,SaO2 86%;当时给予阿司匹林、低分子肝素钠、硝酸异山梨酯及鼻导管吸氧(4 L/min)后疼痛缓解,CK降至239 IU/L,LDH降至774 U/L.入院次日行心脏彩超示:左心室射血分数(INEF)69%,左心室功能满意,无局部室壁活动异常.     

腹膜透析抢救急性心肌梗死合并心源性休克致急性肾小管坏死1例

患者 ,男 ,76岁。入院前 2 4h ,患者情绪激动后出现胸闷、憋气 ,于当地医院查HR 30次 /min ,BP 6 0 / 0mmHg。ECG示 :ST、Ⅱ、Ⅲ、avF ,Ⅴ7～Ⅴ9,V3R～V4R抬高 ,诊断为“冠心病、急性下壁、正后壁、右室心肌梗死 ,心源性休克 ,Ⅲ度房室传导阻滞”。在当地医院住院期间 ,以多巴胺维持BP 70 / 4 0mmHg ,HR恢复到 5 0～ 6 0次 /min ,患者胸闷、憋气未缓解 ,遂转入我院。入院时 ,患者心梗时间超过 2 4h ,不适宜做溶栓及介入手术 ,故保守治疗 :维持血压、扩冠、抗凝、血小板解聚 ,生命体征渐趋平稳。入院 8h ,患者再次出现胸闷、出冷汗 ,…     

平板试验检出无症状心肌缺血冠脉多支病变1例分析

对平板试验检出无症状心肌缺血冠脉多支病变1例分析如下. 1 病历摘要 男,56岁.因间断胸闷0.5 a来院就诊.诉劳累后胸闷,休息1 min后可缓解.行运动平板试验检查,运动前BP为133/84 mm Hg,心电图示:窦性心律,心电图正常范围.运动1 min 50 s至运动结束后5 min 50 s,Ⅱ、Ⅲ、aVF导联ST段上斜型、水平型、下斜型下降0.10～0.24 mV.运动1 min 50 s～2 min 50 s,V4～V6导联ST段上斜型、水平型下降0.10～0.14 mV.运动时间4 min 12 s,未达到次级量目标心率(73%),因ST段下降超过0.2 mV,终止试验.最大心率120 次/min,METS:6.00,最高BP 174/88 mm Hg.     

早期复极综合征合并心内膜下心肌梗死1例分析

对早期复极综合征合并心内膜下心肌梗死1例分析如下. 1 病历摘要 男,35岁.因持续性心前区疼痛1.5 h半大汗,口服硝酸甘油不缓解而来我院就诊,当时立即查心电图示:各导联均见P波,Ⅱ、Ⅲ、avF、V1～V6 ST段压低0.1～0.4 mV,6 h后急查心肌三酶,结果示:CK 1 030 U/L,LDH 397 U/L,CK-MB 113 U/L,AST 132.4 IU/L.心电图有动态变化,故结合临床症状.诊断:急性下壁及广泛前壁心内膜下心肌梗死.第3天复查心电图时发现V2～V5导联T波高耸直立,特别是V2、V3导联T波高达2.0 mV,在V3～V5导联均可见到J波.以后多次复查心电图,V2～V5导联高耸T波无动态变化,此时查心肌三酶正常,故诊断早期复极综合征(ERS).     

脾动脉瘤破裂误诊为急性心肌梗死行静脉溶栓一例

患者,男性,65岁,主因阵发性晕厥、左胸痛1d入院.入院前1d患者敲鼓时突发左胸部胀痛,随之发生意识丧失,症状持续20 min后,意识恢复,诉左胸部胀痛,就诊于当地医院,做心电图V1-V4导联ST段抬高、T波高尖,诊为“冠心病急性前壁心肌梗死超急性期”给予静脉溶栓治疗,溶栓后左胸部疼痛症状持续不缓解且心率增快,血压降至70/50 mmHg(1 mmHg =0.133 kPa),给予多巴胺升压后,血压难以维持,而转入沧州市中心医院心内二科.查体:BP 80/60 mmHg,心率125次/min,律齐.腹平、软,左上腹压痛.入院时心电图:窦速、V1-V4导联T波高尖.入院后查胸腹部CT示:腹腔积液、积血,脾门区血块.     

超声心动图误诊心肌梗死后左心室壁夹层室壁瘤形成一例

患者男,67岁,因发作性心前区疼痛11年,加重不缓解1 h急诊收入我院.11年前患者出现典型劳力型心绞痛症状,9年前行冠状动脉旁路移植术(coronary artery bypass grafting,CABG),术后5个月反复出现胸痛症状.入院前1 h出现前胸背闷痛不缓解,伴大汗、有濒死感,含服硝酸甘油无效.入院检查:心电图(ECG):Ⅲ、AVF、V3r、V4r、V5r、V7～V9导联弓背向上抬高0.05～0.1 mv,V2～V 6 ST段斜行压低0.05～0.3 mv;血肌钙蛋白T(troponin T,TnT)(±),心肌酶正常.初步诊断:急性右心室及左心室下壁、正后壁心肌梗死.予大剂量多巴胺、硝酸甘油、a阻滞剂、阿斯匹林、氯吡格雷、低分子肝素等药物治疗,胸痛症状缓解.     

超声心动图诊断左冠状动脉起源于肺动脉一例

患儿男,2个月大。因“呼吸急促2个月”入院。查体:呼吸48次/min,呈点头状呼吸,心率130次/min,心界扩大,无杂音;12导联心电图表现为Ⅱ、Ⅲ、avF导联呈qR型,V1导联呈RS型,V3、V4导联呈rS型,Ⅰ、Ⅱ、avL导联T波倒置,avF导联T波略倒置,Ⅲ导联T波直立低平,V1～V4导联T波直立高耸,V5、V6导联T波倒置,V1～V3导联ST上抬0.2～0.3mV,V5导联ST下移0.1mV,提示前壁心肌梗死(亚急性期),心肌缺血性改变。入院后超声心动图检查:大动脉短轴切面显示右冠状动脉正常起源、内径增宽,主动脉左冠状动脉窦无冠状动脉显示(图1),可见左冠状动脉起自肺动脉…     

B型预激综合征酷似下壁心肌梗死1例

患者男性 ,50岁 ,因间歇性胸闷 1周入院 ,既往体健 ,自诉无冠心病史。心电图检查示 :窦性心律 ,P R间期规则 ,频率110次 /min ,P R间歇为 0 10s ,QRS波群起始部稍粗钝 ,QRS时限为 0 0 9s ,Ⅰ、avL呈R型 ,Ⅱ、Ⅲ、avF呈QS型 ,avR呈QR型 ,V1～V3 呈rS型 ,V4～V6 呈Rs型 ;ST :Ⅰ、avL下移 0 0 5～ 0 0 7mV ,Ⅱ、Ⅲ、avF抬高 0 0 4～ 0 11mV ,胸导联ST段无明显改变 ;T :Ⅲ、avR、avF、V1～V3 倒置 ,其余导联均直立。考虑排除急性下壁心肌梗死的可能性 ,即给予ATP 15mg静脉注射 ,于 1min后重新记录同步 12导联心电图 ,此时…     

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.     

Dissociable correlates of two classes of retrieval processing in prefrontal cortex

Although substantial evidence suggests that the prefrontal cortex (PFC) implements processes that are critical for accurate episodic memory judgments, the specific roles of different PFC subregions remain unclear. Here, we used event-related functional magnetic resonance imaging to distinguish between prefrontal activity related to operations that (1) influence processing of retrieval cues based on current task demands, or (2) are involved in monitoring the outputs of retrieval. Fourteen participants studied auditory words spoken by a male or female speaker and completed memory tests in which the stimuli were unstudied foil words and studied words spoken by either the same speaker at study, or the alternate speaker. On "general" test trials, participants were to determine whether each word was studied, regardless of the voice of the speaker, whereas on "specific" test trials, participants were to additionally distinguish between studied words that were spoken in the same voice or a different voice at study. Thus, on specific test trials, participants were explicitly required to attend to voice information in order to evaluate each test item. Anterior (right BA 10), dorsolateral prefrontal (right BA 46), and inferior frontal (bilateral BA 47/12) regions were more active during specific than during general trials. Activation in anterior and dorsolateral PFC was enhanced during specific test trials even in response to unstudied items, suggesting that activation in these regions was related to the differential processing of retrieval cues in the two tasks. In contrast, differences between specific and general test trials in inferior frontal regions (bilateral BA 47/12) were seen only for studied items, suggesting a role for these regions in post-retrieval monitoring processes. Results from this study are consistent with the idea that different PFC subregions implement distinct, but complementary processes that collectively support accurate episodic memory judgments.     

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.