无创检查可预测器质性心脏病房颤的发生

目的　研究无创检查对器质性心脏病房颤的预测。方法　总结我院近 5年来收治的 15 4例器质性心脏病患者的超声心动图及心电图检查资料 ,进行回顾性研究。测量 6 8例房颤组患者和 86例非房颤组患者的左房内径(LAD)、左室内径 (LVD)、左室射血分数 (LVEF)、左室舒张功能、最大P波 (Pmax)、最小P波 (Pmin)、P波离散度(pd)。 结果　两组病例 (房颤组vs非房颤组 ) :LAD(43.0 7± 6 .77)mmvs(36 .96± 5 .5 4 )mm、Pmax(12 3.0 7± 9.94 )msvs(113.0 1± 10 .86 )ms、Pd(6 3.6 5± 9.4 9)msvs(5 2 .6 1± 11.82 )ms,差异有统计学意义 (均为P <0 .0 0 1) ;年龄(6 9.5± 8.3)岁vs(6 5 .9± 11.1)岁 ,差异有统计学意义 (P <0 .0 5 ) ;左室舒张功能、P波离散度及左房内径与房颤关系密切。结论　测量窦性心律时左室舒张功能、P波离散度及左房内径可以预测器质性心脏病房颤的危险。     

P波离散度与原发性高血压病合并阵发性心房颤动关系的临床分析

目的:探讨P波离散度(Pd)与高血压病合并阵发性心房颤动(房颤)的临床关系。方法:测量57例高血压合并阵发性房颤患者(Ⅰ组)窦性心律时12导联心电图的P波离散度[Pd=最大P波时限(Pmax)-最小P波时限(Pmin)],超声心动图测定左心房内径(LAD)、左心室舒张末期内径(LVD)和左心室射血分数(LVEF),并与单纯高血压组(Ⅱ组)55例比较。检测阵发性房颤的敏感度、特异度、阳性预测值。结果:PmaxⅠ组显著高于Ⅱ组[(121.5±16.3)msvs(107.3±10.3)ms,P<0.05];PdⅠ组显著高于Ⅱ组(45.3±12.7)msvs(24.7±10.5)ms,P<0.05);两组间Pmin、LAD、LVEF差异无显著性。Pmax>100ms预测的敏感性为89.5/,特异性为80.0/;Pd≥40ms预测的敏感性为86.0/,特异性为75.9/;Pmax>100ms Pd≥40ms的敏感性为78.5/,特异性为88.9/。结论:P波离散度是高血压病患者合并阵发性房颤的敏感性和特异性较高的预测指标之一。     

P波离散度预测阵发性心房颤动射频消融术后复发的价值

【目的】探讨阵发性房颤射频消融术后复发的预测因素。【方法】145例行环肺静脉导管射频消融术的阵发性房颤患者,记录术前及术后心电图,测量最大、最小P波时限,计算P波离散度。【结果】术后平均随访（6．1±0．2）个月,根据是否复发房颤分为复发组51例和未复发组94例。复发组较未复发组的术前最大P渡时限增大[（120．2±11．0）ms比（105．6±7．8）ms,P〈0．001];P波离散度明显增大[（53．6±6．2）ms比（39．9±4．7）ms,P〈0．001];两组P波最小时限及其他临床指标均无统计学差异。多因素分析示术前P波离散度≥46ms（P=0．04）和发作频率≥5次／月（P=0．01）是房颤复发的预测因素,二者预测复发的灵敏度分别是87％和86％;特异度92％和85％。【结论】术前P波离散度及房颤发作频率一定程度上可预测阵发性房颤射频消融术后的复发。     

原发性高血压并发阵发性心房颤动的心电学预测

目的　探讨最大P波时限 (themaximumPwaveduration ,Pmax)、P波离散度 (Pwavedispersion ,Pd)和P波变异 (varianceofPwaveduration ,Pv)在预测原发性高血压患者发生阵发性心房颤动方面的意义。方法　观察 5 0例原发性高血压并发阵发性心房颤动患者 (I组 )的Pmax、Pd和Pv ,并与 5 1例原发性高血压无阵发性心房颤动患者 (II组 )比较。结果　Pmax、Pd和PvI组显著大于II组 [Pmax :( 12 2 .0 0± 11.5 2 )ms比 ( 10 5 .2 0± 8.66)ms,t=8.2 8,P <0 .0 0 1;Pd:( 47.0 0± 14.2 9)ms比 ( 3 8.63± 10 .5 9)ms,t =3 .3 4,P <0 .0 1;Pv :( 2 44 .3 0± 180 .2 1)ms2 比 ( 167.15± 80 .5 4)ms2 ,t =2 .77,P <0 .0 1]。而左室射血分数 (leftventricularejectionfraction,LVEF)I组显著小于II组 [( 62 .0 3± 6.41) %比( 65 .76± 5 .93 ) % ,P <0 .0 1]。多因素Logistic回归分析表明 ,仅Pmax是阵发性心房颤动的独立预测因子。 结论　Pmax、Pd和Pv均可以预测原发性高血压并发阵发性心房颤动的发生 ,其中Pmax是阵发性心房颤动的独立预测因子     

QRS波时限对慢性心力衰竭患者的预测价值

目的评价慢性充血性心力衰竭患者出现QIRS波时限延长的意义。方法回顾性分析2006年1月至2007年3月北京大学人民医院心内科普通病房住院的慢性充血性心力衰竭患者共97例，收集其心电罔及超声心动罔资料。结果慢性充血性心力衰竭患者（1）QRS波时限延长与左心房内径无关[（4．55&#177;1．539）cm比（4．50&#177;0．760）cm，P=0．845]；（2）与QRS波时限〈120ms组相比，QRS波时限≥120ms组左心室舒张末内径明显增大[（5．83&#177;1．05）cm比（6．73&#177;1．478）cm，P=0．001]；（3）QRS波时限与二尖瓣反流情况无明显相关性（P=0．365）；（4）QRS波时限与左心室射血分数相关，与QRS波时限〈120ms组相比，QRS波时限≥120ms组左心室射血分数显著降低[（51．0&#177;15．7）％比（39．0&#177;15．7）％，P=0．0001]；QRS波时限与NYHA分级具有一定的相关性（P=0．04）；（5）QRS波时限与死亡率无明显相关性（P=0．251）。结论心电图作为一种简单、实用、经济的检查手段，有助于识别高危的心力衰竭患者进行进一步评价。     

经胸超声心动图对无支架生物主动脉瓣功能特点的评估

目的　应用经胸超声心动图 (TTE)评估无支架生物主动脉瓣功能特点 ,指导临床术后心功能恢复用药 ,观察其远期效果。方法　随机对无支架生物主动脉瓣及有支架生物主动脉瓣置换术患者各 8例于术前及术后 4周进行超声心动图检查。结果　无支架组和有支架组患者术前TTE各项指标测值差异无显著性意义 ,术后的各项指标测值差异有显著性意义。两组的主动瓣跨瓣压差分别为 ( 2 .33± 0 .6 7)kPa和 ( 4 .40± 1.18)kPa( P =0 .0 5 ) ;左室舒张末期内径分别为 ( 4 3.6± 3.1)mm和 ( 5 0 .9± 9.4)mm ( P =0 .0 35 ) ;左室射血分数分别为( 6 7.3± 7.3) %和 ( 5 5 .4± 12 .6 ) % ( P =0 .0 3) ;瓣环内径分别为 ( 2 1.0± 1.9)mm和 ( 17.1± 1.8)mm ( P =0 .0 1)。结论　TTE显示无支架生物主动脉瓣较有支架生物主动脉瓣更符合人体半月瓣及血流动力学。     

短期心房颤动和长期心房颤动患者P波时限和P波离散度的对比研究

心房颤动(房颤)是常见的心律失常,可并发严重的心脑血管疾病,心房内与心房间电传导延缓与向异性传导是导致房颤的主要电生理学机制。P波最大时限(Pmax)是心房内或心房间传导延缓的标志,P波离散度(Pd)是心房内存在部位依从性各向异性电活动的标志,是预测房颤发生和房颤再发的重要心电图指标。心房颤动患者房颤持续时间与P波时限、Pd的关系鲜见报道,本研究探讨不同持续时间的房颤复律后P波时限与Pd的差异。     

阵发性心房颤动与P波离散度的关系

目的 :探讨阵发性心房颤动 (房颤 )与P波离散度 (Pdisp)、P波最大时限 (Pmax)的关系。方法 :应用 12导联体表心电图测定 70例阵发性房颤患者和 6 0例年龄匹配的无房性心律失常者的Pmax和Pmax与最小P波时限(Pmin)之差 (即Pdisp)。结果 :阵发性房颤组的Pmax为 ( 12 3.9± 16 .6 )ms ,Pdisp为 ( 4 8.4± 14 .8)ms ;而对照组Pmax为( 110 .0± 13.9)ms ,Pdisp为 ( 2 7.7± 9.1)ms ,两者相比均P <0 .0 0 1。以Pdisp≥ 40ms为标准 ,预报房颤的敏感性80 0 % ,特异性 85 0 % ,准确性 82 3% ;以Pmax≥ 12 0ms为标准 ,预报房颤的敏感性 72 9% ,特异性 80 0 % ,准确性76 2 % ;而以Pdisp≥ 40ms和Pmax≥ 12 0ms联合作为标准 ,预报房颤的敏感性 70 0 % ,特异性 90 0 % ,准确性79 2 %。结论 :Pdisp和Pmax可作为预报阵发性房颤的新的心电图指标。     

扩张型心肌病患者P波最大时限及离散度与阵发性心房颤动的相关分析

目的　探讨扩张型心肌病伴阵发性心房颤动患者P波最大时限(Pmax)及离散度(Pd)与发生阵发性心房颤动的相关性。方法　30例扩张型心肌病伴阵发性心房颤动者为A组,扩张型心肌病无阵发性心房颤动者26例为B组。采用12导联体表心电图测定Pmax与最小时限(Pmin),计算Pd(Pd=Pmax-Pmin),并进行比较。结果　A组Pd为( 48. 4±13. 8 )ms,Pmax为(122. 8±13. 7)ms,Pmin为( 76. 2±12. 6 )ms,与B组Pd(30. 6±10. 2)ms、Pmax(110. 2±10. 4)ms、Pmin(80. 8±11. 5)ms相比明显延长(P<0. 01)。A组左心房内径(41. 4±5. 6)mm,B组(40. 2±6. 2 )mm,两组相比无显著性差异(P>0. 05 )。预测心房颤动,取P波时限≥120ms,Pd≥40ms以及两者相结合,灵敏度分别为86%、90%、73%;特异度分别为80%、85%、89%;阳性预测值分别为84%、87%、88%。结论　Pd增加和P波宽度延长,可预测扩张型心肌病并发阵发性心房颤动的危险性。     

普罗布考对冠心病经皮冠状动脉介入术后患者P波离散度的影响

目的观察普罗布考对冠心病患者P波时限及P波离散度(Pd)的影响,从而探讨其对房颤可能的防治作用。方法选取冠心病行经皮冠状动脉介入治疗(PCI)术患者共72例,分为普罗布考组(n=37)和对照组(n=35)。两组患者在PCI术后均予常规冠心病药物治疗,普罗布考组患者加用普罗布考片口服500mg/次,2次/d。两组患者均于治疗前及治疗3个月后描记12导联心电图,比较P波最大时限(Pmax)、P波最小时限(Pmin)及Pd。结果 PCI术后3个月普罗布考组患者Pmax及Pd较服药前缩短(P<0.01),而对照组患者Pmax及Pd较3个月前增大(P<0.05)。结论普罗布考对于冠心病患者PCI术后的Pd有降低作用,可能有助于房颤的防治。     

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.