组织多普勒成像测定Tei指数及E/（Ea×Sa）评价系统性红斑狼疮活动期患者左心室功能变化

目的 探讨组织多普勒成像（TDI）测定左心室Tei指数及E/ （Ea×Sa）评价早期无明显临床心血管症状的系统性红斑狼疮（SLE）活动期患者的左心室功能价值.方法 30例SLE活动期患者（SLE组）和27例正常人（对照组）行常规超声心动图及TDI检查,测量二尖瓣口血流频谱E峰、A峰;应用定量组织速度成像（QTVI）分别测量受检者二尖瓣环水平6个室壁节段收缩期S 峰（Sa）、舒张期E 峰（Ea）、A峰（Aa）峰值速度,计算E/A、Ea /Aa、E/ Ea、E/ （Ea×Sa）值;同时测量各节段等容舒张期时间（IRT）、等容收缩期时间（ICT）、射血时间（ET）,计算Tei指数;以上参数均取6个室壁节段平均值进行两组对比分析.结果 与对照组比较,SLE组Aa 、Tei指数、IRT、E/ Ea、 E/（Ea×Sa）均明显升高（P〈0.01或P〈0.05）,Ea、Ea/ Aa、ET值均明显减小（P〈0.01）.E/ （Ea×Sa） 及E/ Ea与Tei指数呈正相关（r=0.523,P〈0.01;r=0.323,P〈0.05）,E/ （Ea×Sa）及E/ Ea与 Ea呈负相关（r=-0.605、r=-0.726,P均〈0.01）.结论 Tei指数及E/ （Ea×Sa） 有可能作为评估SLE活动期患者左心室功能减低的早期指标.     

多普勒组织成像评价高血压心脏病心功能

目的应用多普勒组织成像（DTI）脉冲速度模式测量二尖瓣环运动速度，以评价高血压心脏病心功能的改变。方法32例高血压心脏病患者作为高心组，35例健康志愿者作为正常组。取心尖四腔观、二腔观、心尖左心室长轴观，行DTl分别测量二尖瓣环各点舒张早期峰值速度（Ea）、舒张晚期峰值速度（Aa）及收缩期峰值速度（Sa）。结果高心组Ea、sa均较正常组低，两组间差异有非常显著性意义（P〈0．01）；Aa两组间相比无显著性差异。结论高血压心脏病患者左心室长轴收缩功能及主动松弛功能较正常人减低。     

多普勒组织成像评价肥厚型梗阻性心肌病心功能

目的应用多普勒组织成像(DTI)脉冲速度模式测量二尖瓣环运动速度,以评价肥厚型梗阻性心肌病(HOCM)心功能的改变.方法 26例HOCM患者作为HOCM组,50例健康志愿者作为正常组,取心尖四腔观、二腔观、心尖左心室长轴观,行DTi分别测量二尖瓣环各点舒张早期峰值速度(Ea)、舒张晚期峰值速度(Aa)及收缩期峰值速度(Sa).结果 HOCM组Ea、Sa均较正常组低,两组间差异有非常显著性意义(P＜0.01);Aa两组间相比无显著性差异.结论HOCM患者左心室长轴收缩功能及主动松弛功能较正常人减低.     

多普勒组织成像评价糖尿病及糖尿病合并高血压患者左室功能

目的应用多普勒组织成像(DTI)技术评价2型糖尿病患者左室功能;探讨高血压对糖尿病心脏结构和功能的影响.方法应用超声心动图诊断仪检测糖尿病患者、糖尿病合并高血压患者左心室DTI频谱,测量Sa、Ea、Aa与Ea/Aa,并与30例正常人做对照.结果两组糖尿病患者Aa与对照组比较有显著性差异,糖尿病合并高血压组与正常血压糖尿病组Sa、Ea比较有显著降低.结论组织多普勒技术可以早期无创评价糖尿病患者心脏的收缩和舒张功能,高血压加重糖尿病患者心脏结构和功能的损害.     

多普勒组织成像评价肺动脉高压患者右室心功能应用

目的:应用多普勒组织成像技术(Doppler tissue imaging,DTI)测定肺动脉高压(Pulmonary hypertension,PHT)患者的三尖瓣环运动频普,探讨其评价右室心功能的价值。材料与方法:常规超声心动图检查28例PHT组及32例健康对照组,并检测三尖瓣口舒张早期速度(E)、舒张晚期速度(A),DTI检测三尖瓣环的收缩期峰值速度(Sa)、舒张早期速度(Ea)、舒张晚期速度(Aa),计算E/A、Ea/Aa,并对两组参数进行比较。结果:PHT组三尖瓣环及瓣口Sa、Ea、Ea/Aa及E/A均减低(P0.05),Ea/Aa更为明显(P0.01),Aa高于对照组(P0.05)。结论:应用DTI测定三尖瓣环运动,可以敏感地反映PHT患者右室功能的变化,是评价右室整体功能的较好指标。     

组织多普勒成像对左室肥厚鉴别诊断的意义

目的探讨多普勒组织成像技术(TDI)评价肥厚型心肌病(HCM)与高血压性继发性左室肥厚(sLVH)心肌运动对左室肥厚进行鉴别诊断的意义。方法应用TDI测定HCM和sLVH患者55例及正常对照组44例心肌收缩峰值速度(Sa)、舒张早期峰值速度(Ea)、舒张晚期峰值速度(Aa)。结果 HCM和sLVH组测量位点Sa、Ea和Ea/Aa均降低(P<0.01);HCM组室间隔基底段除Aa外,与sLVH组室间隔基底段均差异有统计学意义(P<0.01)。结论 TDI技术可发现HCM患者局部心肌功能异常并与sLVH鉴别有一定临床意义。     

应用多普勒组织成像评价肥厚型心肌病心功能

目的：应用多普勒组织成像脉冲技术测量二尖瓣环舒缩速度，以评价肥厚型心肌病心功能改变。方法：按左心室流出道是否梗阻分为梗阻性与非梗阻性肥厚型心肌病，分别测量正常人、梗阻性及非梗阻性肥厚型心肌病3组二尖瓣环各点收缩期峰值速度（Sa)、舒张早期峰值速度（Ea)、舒张晚期峰值速度（Aa)。结果：梗阻性与非梗阻性肥厚型心肌病患者与正常组Ea、Sa比较差异均有显著性意义（P＜0．001），Aa差异则无显著性意义（P＞0．05）。梗阻性与非梗阻性肥厚型心肌病间Ea差异有显著性意义（P＜0．05），Sa、Aa差异无显著性意义（P＞0．05）。结论：肥厚型心肌病左心室长轴收缩功能及主动松弛功能较正常人减低。梗阻性较非梗阻性肥厚型心肌病左心室主动松弛功能减低。     

组织多普勒成像技术评价肺动脉高压患者右心室收缩及舒张功能

目的:应用多普勒组织成像(DTI)技术评价肺高压患者右心室功能的变化。方法:应用DTI技术对3组不同程度肺高压患者的三尖瓣环运动频谱进行分析, 测量三尖瓣前叶、后叶及隔叶瓣环的收缩期峰值速率(Sa)、舒张早期峰值速率(Ea)及舒张晚期峰值速率(Aa),对3组患者各参数进行比较,并与正常组对照分析。结果:肺动脉高压组较正常组诸参数有显著差异:肺高压Ⅱ组及Ⅲ组,三尖瓣环前叶、隔叶Sa较对照组减小(P<0.05)。肺高压Ⅲ组前叶Sa较Ⅰ组亦有统计学差异(P<0.05)。Ⅲ组后叶瓣环Sa较对照组减小(P<0.05)。肺高压Ⅲ组,前叶瓣环Ea较对照组减小(P<0.05),隔叶Ea值较对照组与Ⅰ组减小(P<0.05),隔叶和后叶瓣环Aa肺高压Ⅲ组均较对照组减低(P<0.05)。肺高压Ⅱ组,Ⅲ组前叶瓣环Ea/Aa均较对照组减小(P<0.05),隔叶、后叶Ea/Aa值Ⅲ组较对照组减小(P<0.05)。结论:中至重度肺动脉高压能引起右心室舒缩功能的减低,收缩功能出现损害早于舒张功能。     

Tei指数和组织多普勒联合N端B型钠尿肽前体评价右心早期放射性损伤

目的探讨Tei指数和组织多普勒成像(TDI)联合N端B型钠尿肽前体(NT-proBNP)评价胸部肿瘤患者放疗后右心早期损伤的价值。方法对21例接受胸部全程放疗的胸部肿瘤患者,于放疗前、放疗后1天和1个月行NT-proBNP和超声心动图检查,检查指标:①Tei指数;②常规指标,包括三尖瓣血流舒张早期峰值流速(E)、心房收缩期峰值流速(A)、E/A和E峰减速时间;右心室舒张末期内径和右心房收缩末期内径,右心室面积变化率及三尖瓣瓣环运动幅度;③TDI:三尖瓣环内侧和外侧处收缩期峰值速度(Sa)、舒张早期峰值速度(Ea)、舒张晚期峰值速度(Aa)及E/Ea。结果与放疗前相比,NT-proBNP在放疗后1天明显升高(P<0.05),放疗后1个月降低;放疗后Tei指数升高,Sa、Ea减低,Aa和E/Ea均升高;常规指标在放疗前后无明显变化。结论胸部肿瘤患者放疗后出现右心功能早期轻度损伤;Tei指数、DTI联合NT-proBNP可对其进行评价。     

肥厚型心肌病与高血压伴室壁增厚患者左心室Tei指数研究

目的用Tei指数评价左心室质量指数(LVMI)相近的肥厚型心肌病与高血压伴左心室壁增厚患者左心室功能。方法选取正常人35例(正常组),左心室心肌质量指数增高的高血压患者31例(高血压组),以及肥厚型心肌病患者17例(肥厚型心肌病组)。在常规超声检测基础上采用二尖瓣多普勒血流频谱(PW)、二尖瓣环组织多普勒(TVI)方法测量Tei指数。结果高血压组与肥厚型心肌病组左心室质量指数差异无统计学意义;PW和TVI所测Tei指数(TeiPW和TeiTVI)以及这两种方法测得Tei指数平均值(TeiM)均为正常组(0.38±0.015、0.46±0.07、0.45±0.11)小于高血压组(0.51±0.11、0.60±0.15、0.55±0.08)小于肥厚型心肌病组(0.61±0.10、0.71±0.23、0.63±1.73),3组之间差异有统计学意义(P0.05);3组之间的左心室射血分数(LVEF)差异无统计学意义。在本实验所有超声心动图指标中,上述Tei指数均与室间隔厚度(IVS)和二尖瓣环组织多普勒舒张早期E峰(E’)相关性较好。多元逐步回归分析显示上述Tei指数的独立预测因子一致,为E’和IVS。结论 Tei指数对LVEF正常的肥厚型心肌病与高血压伴室壁肥厚者的左心室整体心功能早期改变具有诊断价值,肥厚型心肌病患者的心功能减低较高血压伴室壁增厚患者更明显,这两种病变心功能的早期改变以舒张功能减退为主。     

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.     

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.     

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.     

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.