醋酸钙联合低钙透析治疗透析患者高磷血症及对冠状动脉钙化的影响

【】目的 观察应用口服醋酸钙联合低钙透析液对维持性血液透析患者高磷血症的治疗及对冠状动脉钙化的影响。方法 选择本院血液净化中心90例有高磷血症、血钙正常伴不同程度冠状动脉钙化的维持性血液透析(MHD)患者,随机分成治疗组和对照组,治疗组采用低钙透析液(钙浓度为1.25mmol/L,透析期间口服醋酸钙),对照组采用常规透析液(钙浓度为1.75mmol/L,透析期间口服醋酸钙),所有患者透析12个月。在透析初始、3个月、6个月、12个月时检测患者血钙、血磷、血清全段甲状旁腺激素(iPTH)、观察前后血压及不良反应,同时用64层MSCT检查患者冠状动脉钙化积分。结果 透析12个月后,治疗组患者血钙水平有所下降,血磷及钙磷乘积显著下降(P＜0.05),iPTH有所上升(P＞0.05);对照组血钙、钙磷乘积和血清全段甲状旁腺激素(iPTH)均不同程度上升(P＞0.05),观察低钙透析不良反应的发生率为7/90(7.8%),主要为肌痉挛、低血压。治疗组在透析3个月、6个月、12个月冠脉钙化积分(CACS)轻微增高,而对照组患者冠脉钙化积分随透析时间延长持续增高。结论 对有高磷血症合并冠状动脉钙化的MHD患者,阶段性采用低钙透析液联合口服醋酸钙的方法,可以有效降低血磷、钙磷乘积,延缓冠状动脉钙化进展速度,值得临床广泛使用。     

醋酸钙联合低钙透析液治疗透析患者高磷血症及对冠状动脉钙化的影响

目的:观察应用口服醋酸钙联合低钙透析液对维持性血液透析患者高磷血症的治疗及对冠状动脉钙化的影响。方法:选择2013年10月~2014年10月本院血液净化中心90例有高磷血症、血钙正常伴不同程度冠状动脉钙化的维持性血液透析(MHD)患者,随机分成治疗组和对照组,治疗组采用低钙透析液(钙浓度为1.25 mmol/L,透析期间口服醋酸钙),对照组采用常规透析液(钙浓度为1.75 mmol/L,透析期间口服醋酸钙),所有患者透析12个月。在透析初始、3个月、6个月、12个月时检测患者血钙、血磷、血清全段甲状旁腺激素(iPTH)、观察前后血压及不良反应,同时用64层MSCT检查患者冠状动脉钙化积分。结果:透析12个月后,治疗组患者血钙水平有所下降,血磷及钙磷乘积显著下降(P0.05),血清全段甲状旁腺激素(iPTH)有所上升(P0.05);对照组血钙、钙磷乘积和iPTH均不同程度上升(P0.05)。全部患者低钙透析不良反应的发生率为7/90(7.8%),主要为肌痉挛、低血压。治疗组在透析3个月、6个月、12个月冠脉钙化积分(CACS)轻微增高,而对照组患者冠脉钙化积分随透析时间延长持续增高。结论:对有高磷血症合并冠状动脉钙化的MHD患者,阶段性采用低钙透析液联合口服醋酸钙的方法,可以有效降低血磷、钙磷乘积,延缓冠状动脉钙化进展速度,值得临床广泛使用。     

不同钙浓度透析液对维持性血液透析患者影响的对照研究

目的观察不同钙浓度(1.25mmol/L和1.75mmol/L)透析液治疗6个月对患者血压、钙、磷和甲状旁腺素影响。方法选择中山大学附属第三医院肾内科维持性血液透析患者20例,首先接受钙离子1.75mmol/L(高钙)透析液治疗6个月,而后接受钙离子1.25mmol/L(低钙)透析液治疗6个月,其它治疗不变。检测两种治疗组入组时、后3个月和6个月患者透析前后血压、血清钙、磷、甲状旁腺素、碱性磷酸酶的水平。结果使用低钙透析液单次治疗4h后血压下降(P<0.05),血钙下降7.5%(P>0.05),甲状旁腺素升高(P<0.05);而高钙透析液治疗后血压和血钙均升高(P<0.05),甲状旁腺素有所下降(P>0.05);治疗6个月后,使用低钙透析液,患者血压下降(P>0.05),血钙下降(P>0.05),血磷和钙磷乘积显著下降(P<0.05),甲状旁腺素升高(P>0.05),碱性磷酸酶升高(P<0.05);两种钙离子浓度透析液应用后收缩压、甲状旁腺素和碱性磷酸酶的变化相比差异有显著性(P<0.05)。结论单次应用低钙透析液进行透析,透析后甲状旁腺素升高,血压下降;与使用高钙透析液相比,长期应用(6个月)低钙透析液进行透析,钙负荷减轻,血钙磷乘积和收缩压下降,血清甲状旁腺素和碱性磷酸酶升高。     

低钙透析液在无动力性骨病中的应用

目的观察低钙透析液对维持性血液透析患者无动力性骨病的临床效果。方法选择该院治疗的24例无动力性骨病血液透析患者,在血液透析过程中采用低钙透析液(钙离子浓度为1.25mmol/L),疗程为6个月,对比观察在低钙透析前后血钙、磷、钙磷乘积、全段甲状旁腺激素(iPTH)等指标的变化、达标率及不良反应发生情况。结果观察结束时,患者血钙、钙磷乘积降低,iPTH升高,差异有统计学意义(P0.05);血磷较低钙透析前有所下降,但差异无统计学意义(P0.05)。结论低钙透析液能改善无动力性骨病被过度抑制的甲状旁腺功能,降低血清高钙负荷。     

低钙透析液对维持性血液透析患者动力缺失性骨病的临床研究

目的:对患有动力缺失性骨病(ABD)的维持性血液透析患者使用低钙透析液,观察其提高全段甲状旁腺激素(i PTH)和对钙磷代谢的影响,评估其对血液透析患者ABD治疗的疗效和安全性。方法:治疗组32例患者使用含钙1.25 mmol/L透析液,对照组30例患者使用含钙1.5 mmol/L透析液,常规血液透析6个月。分析治疗前后患者血iPTH、血钙、血磷、钙磷乘积等指标变化情况,及达到NFK-K/DOQI指南推荐目标范围的患者的比例。结果:治疗组经1.25 mmol/L低钙透析液治疗6个月后,血清总钙、血磷、钙磷乘积下降,与治疗前比较差异有统计学意义(P0.05),iPTH水平较治疗前明显升高(P0.01),达到NFK-K/DOQI指南推荐目标范围的患者比例上升(P0.05),仅3例患者先后出现血iPTH水平轻度超过目标范围,最高值427.3 ng/ml,需加用罗盖全治疗。对照组治疗前后比较,差异无统计学意义(P0.05)。两组治疗中均无严重低钙抽搐、精神状态改变、低血压等情况发生。结论:对ABD血液透析患者使用低钙透析液能有效升高其iPTH水平、改善钙磷代谢,从而达到治疗ABD的目的,治疗安全性较好。     

低钙透析在血液透析继发性甲旁亢25例治疗中的应用和护理

目的探讨低钙透析在血液透析患者继发性甲状旁腺功能亢进进行骨化三醇冲击治疗中的临床应用。方法采用浓度1.25 mmol/L低钙透析液,观察25例维持性血液透析继发甲旁亢患者在骨化三醇冲击治疗中血清钙、磷、钙磷乘积,血清全段甲状旁腺素(iPTH)等指标变化。结果所有患者治疗期间的血钙与治疗前比较差异无统计学意义(P>0.05),血磷、钙磷乘积,iPTH水平均较治疗前降低(P<0.05)。结论维持性血液透析继发甲旁亢患者在骨化三醇冲击治疗中同时应用低钙透析是安全有效的,避免了高钙血症,降低了骨外软组织钙化的风险。     

骨化三醇联合低钙透析在维持性血液透析老年患者中的应用——附17例报告

目的:探讨骨化三醇联合低钙透析对老年维持性血液透析患者继发性甲状旁腺功能亢进(secondary hyperparathyroidism,SHPT)的临床疗效及安全性.方法:17例SHPT患者,根据其全段甲状旁腺素(intact parathyroid hormone,iPTH)水平分为轻度组(iPTH 300～600 ng/L)和中度组(iPTH 601～1 000 ng/L),在低钙透析(透析液钙浓度为1.25 mmol/L)的基础上,轻度组予骨化三醇1 μg,中度组患者予骨化三醇2 μg,均于透析后当日20:00～22:00口服,连续20周.治疗过程中,骨化三醇用量根据钙磷乘积进行调整.观察治疗前后患者血钙、血磷、钙磷乘积、iPTH、血清白蛋白(serum albumin,SAB)等指标及药物用量变化情况.结果:所有患者均能完成疗程.17例患者治疗期间的血钙和SAB水平与治疗前比较,差异无统计学意义(P＞0.05),钙磷乘积、iPTH水平均较治疗前降低(P＜0.05～0.01).2例出现高血压、1例出现肌痉挛,经处理后症状均消失.结论:骨化三醇联合低钙透析可有效控制老年维持性血液透析患者的SHPT,安全性良好.     

低钙透析液在高钙血症患者血液透析中的应用

目的:探讨低钙透析液在高钙血症患者血液透析中的应用及护理方法。方法:将40例维持性血液透析的患者随机分为观察组和对照组各20例,观察组使用低钙透析液,对照组使用正常钙透析液;比较两组患者透析前后血钙、血磷、钙磷乘积及全段甲状旁腺激素(PTH)的水平。结果:透析后对照组血钙、血磷、钙磷乘积及PTH水平均轻度升高,而观察组血钙和血磷均明显降低,钙磷乘积也显著降低,PTH水平在3个月时明显上升,6个月时趋于稳定,两组比较差异有统计学意义(P<0.05)。结论:高钙血症患者采用低钙透析液透析配合有效的护理可有效地降低血磷、钙磷乘积,值得临床推广。     

低钙透析液对钙磷代谢及甲状旁腺素的影响

目的：探讨应用低钙透析液对血液透析患者钙磷代谢及甲状旁腺功能的影响。方法：15例有高磷血症的血液透析患者，应用1．25mmol／L钙浓度透析液透析8个月，比较透析前与4个月、8个月后血清钙、磷、钙磷乘积及甲状旁腺激素的变化。结果：应用低钙透析液4个月后，患者血钙、血磷及钙磷乘积均明显下降，甲状旁腺激素下降，但差异无统计学意义。8个月后，与实验前比较，血钙及钙磷乘积明显下降，血磷下降，甲状旁腺激素升高。与透析4个月比较，血钙无明显下降，血磷升高，甲状旁腺激素明显升高。结论：短期使用低钙透析液可降低血钙和钙磷乘积水平，降低甲状旁腺激素，长期应用，可能加重继发性甲状旁腺功能亢进。     

血液透析中应用低钙透析液的临床观察

目的探讨低钙透析透液用于血液透析的有效性及安全性。方法采用稀解释后浓度为1.25 mmol/L碳酸低钙透析液,常规透析治疗20例高钙血症血液透析患者的规律。观察高钙血症血液透析患者在应用碳酸低钙透析液3个月和6个月后,血钙、钙磷乘积、甲状旁腺激素(iPTH)的指标变化及不良反应。结果发现血钙下降水平与低钙透析液使用前比较有明显差异(P<0.05)乘积也有显著性差异(P<0.05)血磷无显著性差异(P>0.05);iPTH无显著性差异(P>0.05)。结论高钙血症的血液透析患者在使用低钙透析液后,血钙下降明显,可有效降低钙磷乘积,可能有益于减轻血液透板患者骨外转移性钙化的发生。     

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.     

Guns and Knives in New Mexico: Patterns of Penetrating Trauma, 1978–1993

Objective: To identify patterns of nonfatal and fatal penetrating trauma among children and adults in New Mexico using ED and medical examiner data.
Methods: The authors retrospectively sampled in 5-year intervals all victims of penetrating trauma who presented to either the state Level-1 trauma center or the state medical examiner from a 16-year period (1978–1993). Rates of nonfatal and fatal firearm and stabbing injury were compared for children and adults.
Results: Rates of nonfatal injury were similar (firearm, 34.3 per 100,000 person-years; stabbing, 35.1). However, rates of fatal injury were significantly different (firearm, 21.9; stabbing, 2.7; relative risk: 8.2; 95% confidence interval: 5.4, 12.5). From 1978 to 1993, nonfatal injury rates increased for children (p = 0.0043) and adults (p < 0.0001), while fatal penetrating injury remained constant. The increase in nonfatal injury in children resulted from increased firearm injury rates. In adults, both stabbing and firearm nonfatal injury rates increased.
Conclusions: Nonfatal injury data suggest that nonfatal violence has increased; fatal injury data suggest that violent death rates have remained constant. Injury patterns vary by age, mechanism of trauma, and data source. These results suggest that ED and medical examiner data differ and that both are needed to guide injury prevention programs.     

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.