甲状腺激素、肌钙蛋白Ⅰ和B型钠尿肽在急性冠状动脉综合征患者中的变化及预后评价

目的观察急性冠状动脉综合征(ACS)患者住院期间甲状腺激素(TH)、心肌肌钙蛋白Ⅰ(cTnI)和B型钠尿肽(BNP)水平的变化,探讨其与主要不良心脏事件(MACE)发生的关系。方法随机选取ACS患者120例,按照病型分为ST段抬高型心肌梗死(STEMI)、非ST段抬高型心肌梗死(NSTEMI)和不稳定性心绞痛(UA)3个亚组;按照患者住院期间是否再次发生MACE分为发生组[MACE(+)]和未发生组[MACE(-)],分别观察TH、cTnI和BNP水平。结果 NSTEMI组和STEMI组总三碘甲状腺原氨酸(TT3)水平明显低于UA组(P<0.05、P<0.01);NSTEMI组游离三碘甲状腺原氨酸(FT3)水平明显低于STEMI组和UA组(P<0.05)。MACE(+)组TT3和FT3水平明显低于MACE(-)组(P<0.01)。STEMI组、NSTEMI组cTnI水平明显高于UA组(P<0.01),NSTEMI组高于STEMI组(P<0.05),但在MACE(+)和MACE(-)组之间差异无统计学意义(P>0.05)。促甲状腺激素(TSH)、总甲状腺素(TT4)、游离甲状腺素(FT4)和BNP水平在STEMI、NSTEMI和UA 3组间以及MACE(+)和MACE(-)组间差异均无统计学意义(P>0.05)。MACE(+)组cTnI、BNP阳性率与MACE(-)组比较差异无统计学意义(P>0.05)。结论 ACS患者住院期间出现低TT3和FT3水平易发生MACE;cTnI和BNP对ACS患者住院期间发生MACE无提示意义,有待于进一步研究和探讨。     

洛伐他汀治疗老年退行性心脏瓣膜病120例临床观察

目的研究洛伐他汀对老年退行性心脏瓣膜病(SDHVD)的治疗效果和安全性。方法 2005～2007年在我院住院并诊断为SDHVD的患者120例,随机分为两组,治疗组(n=62)在基础治疗上加用洛伐他汀20 mg/睡前,对照组接受基础治疗(n=58),平均随访时间24月。记录不良心血管事件(心衰,急性冠脉综合征和死亡)的发生情况。结果治疗组共发生心衰事件102人次,对照组则为97人次(P>0.05);急性冠脉事件在治疗组有7例(12.07%),低于对照组的13例(20.97%)(P<0.05)。结论 洛伐他汀对减少SDHVD的急性冠脉事件有效,但不能降低心衰发生率和总病死率。     

BNP水平与急性冠脉综合征远期预后相关性分析

【目的】探讨脑利尿钠肽（BNP）水平与急性冠脉综合征（ACS）发生主要心血管不良事件的相关性。【方法】收集2007年1月至2008年12月本院收治的不稳定型心绞痛（UA）、急性非ST段抬高心肌梗死（NSTEMI）及急性ST段抬高心肌梗死（STEMI）239例患者的临床资料,于2009年1月至12月根据调查问卷电话随访发生MACE情况,分析BNP与ACS及MACE的相关性。【结果]BNP水平为AMI组（NSTEMl及STEMI组）高于UA组（P〈o．01）;MACE累积发生率分别为uA组31例（26．50％）,NSTEMI组57例（34．75％）,STEMI组93例（38．91％）,差异无显著性（P〉O．05）;NSTEMI组BNP水平大于114．5pg／mL,STEMI组BNP水平大于155．5pg／mL,MACE发生风险增加,灵敏度分别为75％、67．4％,特异度分别为90．9％、71．7％。[结论]AMI患者BNP水平高于uA患者;BNP大于114．5pg／mL及155．5pg／mL有助于预测NSTEMI及STEMI发生MACE风险．     

网织血小板和血小板参数在急性冠脉综合征中的变化及意义

目的:探讨急性冠脉综合征(ACS)患者网织血小板(RP)和血小板参数的变化及意义。方法:随机选取ST段抬高心肌梗死(STEMI)27例为STEMI组,非ST段抬高心肌梗死(NSTEMI)25例为NSTEMI组,不稳定心绞痛(UA)31例为UA组,健康体检者30例为对照组进行检测。用CD61-PE单抗标记血小板,噻唑橙(TO)为染料,应用富含血小板血浆(PRP)法检测RP;用COULTERJT型全自动血液分析仪测定血小板参数[血小板计数(PLT)和血小板平均体积(MPV)]。结果:STEMI、NSTEMI、UA组3组RP%均显著性高于对照组(P<0.05);STEMI、NSTEMI组的RP%显著高于UA组(P<0.05);STEMI、NSTEMI组的MPV均显著高于对照组(P<0.05)。结论:RP可能成为评估ASC患者血小板活性的新指标,它和MPV的检测可能对ACS有着一定的临床意义。     

网织血小板和血小板参数在急性冠脉综合征中的研究

[摘　要] 　目的：研究急性冠脉综合征(ACS) 患者外周血中网织血小板和血小板参数的变化及意义。方法：选取ST 段抬高心肌梗死( STEMI)27例，非ST 段抬高心肌梗死(NSTEMI)25例，不稳定心绞痛(UA)31例，稳定心绞痛(SA) 33 例，健康人30例，用CD61－PE 单抗标记血小板，噻唑橙(TO)为染料，应用富含血小板血浆(PRP) 法检测网织血小板（RP）值，应用全自动血细胞分析仪测定血小板计数(PL T) 、血小板平均体积(MPV) 。结果：STEMI、NSTEMI、UA组RP值均高于SA和健康组 (P <0.05)；STEMI、NSTEMI组MPV高于SA组和健康组 (P <0.05)。结论：血小板数量减少、功能亢进在急性冠脉综合征的发生发展中起着重要作用，网织血小板和MPV检测可能在急性冠脉综合征的诊断、治疗、预后中起重要作用。     

急性ST段抬高性与急性非ST段抬高性心肌梗死患者临床基本特征和冠脉病变特点的比较

目的:对比分析急性ST段抬高性心肌梗死(STEMI)与急性非ST段抬高性心肌梗死(NSTEMI)患者的临床基本特征和冠脉病变特点。方法:对50例STEMI与52例NSTEMI患者行心脏超声、冠脉造影检查,对两组患者的临床基本特征、梗死后的心功能及冠脉造影结果进行比较。结果:(1)NSTEMI组心绞痛史多见(P<0.05);(2)STEMI组肌钙蛋白T、肌酸磷酸激酶同工酶峰值较高(P<0.05),但两组的心功能无明显差别(P>0.05);(3)NSTEMI组三支病变患者比例较高(P<0.05),冠脉造影正常患者比例较低(P<0.05)。结论:与STEMI患者相比,NSTEMI患者冠状动脉病变三支病变多见,其发病前常存在缺血预适应。     

降钙素原对心脏直视手术预后的评估价值

目的探讨降钙素原(PCT)测定在体外循环心脏直视手术预后评估中的价值。方法采用回顾性研究方法,对象选择2015年1月至9月择期行心脏直视手术的277例成人心脏病患者,测定患者术后0、1、2、3 d的PCT值,根据术后第1天PCT值将患者分为三组:A组PCT≤2.0 ng/ml,B组2.0 ng/ml相似文献   

急性冠脉综合征急诊快速诊疗指南

<正>急性冠脉综合征(acute coronary syndrome,ACS)是指冠状动脉内不稳定的粥样斑块破裂或糜烂引起血栓形成所导致的心脏急性缺血综合征,涵盖了ST段抬高型心肌梗死(ST-segment elevation myocardial infarction,STEMI)、非ST段抬高型心肌梗死(non-ST-segment elevation myocardial infarction,NSTEMI)和不稳定性心绞痛(unstable angina,UA),其中NSTEMI与UA合称非ST段抬高     

经抽栓导管注射依替巴肽或替罗非班对急性ST段抬高型心肌梗死患者急诊介入治疗疗效的对比研究

目的探讨急性ST段抬高型心肌梗死(STEMI)患者行急诊经皮冠状动脉介入治疗(PCI)时,经抽栓导管向靶病变冠脉内注射依替巴肽或替罗非班后,术中发生无复流及术后主要心脏不良事件情况及临床疗效。方法连续入选105例资料齐全行急诊PCI的STEMI患者,随机分为单纯抽栓组(A组)、抽栓+冠脉内注射替罗非班组(B组)和抽栓+冠脉内注射依替巴肽组(C组)。随访6个月,比较3组患者术中无复流或慢血流的发生情况及在随访期间发生典型心绞痛、非致死性心肌梗死、心力衰竭和心源性死亡等主要心脏不良事件(MACE)的发生率,以及左室舒张末期内径(LVDd)、左室射血分数(LVEF)等指标变化情况。结果术后心肌梗死溶栓试验血流分级(TIMI)2级、TIMI心肌灌注分级(TMP)3级的比例为C组B组A组。随访6个月,左心室射血分数为A组B组C组,总MACE发生率B组和C组均低于A组,且C组低于B组。3组均无死亡事件,3组患者术后出血的比例差异无统计学意义(P0.05)。结论对于STEMI患者行急诊PCI时,血栓抽吸联合依替巴肽可以获得更好的心肌水平再灌注,并且不增加出血及其他心脏不良事件的发生。     

急性ST抬高性与非ST抬高性心肌梗死患者的临床基本特征和冠脉病变特点的比较

目的　对比分析急性ST抬高性心肌梗死（STEMI）与急性非ST抬高性心肌梗死(NSTEMI)患者的临床基本特征和冠脉病变特点。方法　对５０例STEMI与５２例NSTEMI患者行心脏超声、冠脉造影检查，对两组患者的临床基本特征、梗死后的心功能及冠脉造影结果进行比较。结果　（１）NSTEMI组心绞痛史多见（P<0.05）；（２）STEMI组cTnt、CK-MB峰值较高（P<0.05）,但两组的心功能无明显差别（P>0.05）；（３）NSTEMI组三支病变患者比例较高（P<0.05），冠脉造影正常患者比例较低（P<0.05）。结论 与STEMI患者相比，NSTEMI患者冠状动脉病变三支病变多见，其发病前常存在缺血预适应。     

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.