体表心电图对急性下壁心肌梗死患者梗死相关动脉及闭塞部位的预测价值

目的：探讨体表心电图(ECG)对 ST 段抬高性急性下壁心肌梗死(IAMI)患者梗死相关动脉及闭塞部位的预测价值。方法选择 ST 段抬高性 IAMI 患者95例,记录入院时18导联 ECG,并行急诊经皮冠状动脉介入治疗,按照冠状动脉造影(CAG)结果进行分析。结果 ST Ⅲ抬高>STⅡ预测右冠状动脉(RCA)闭塞的敏感度和特异度分别为93.4%、73.7%;ST V3/Ⅲ≤1.2、ST aVL 下移>STⅠ预测 RCA 闭塞的敏感度分别为88.2%和92.1%;而 ST V3R-V5R 抬高判断 RCA 闭塞的特异度为100%;ST V3/Ⅲ<0.5预测 RCA 近段闭塞的敏感度为86.7%;ST V4R 抬高判断 RCA 近段闭塞的特异度为93.5%,ST Ⅲ抬高≤ STⅡ判断左回旋支(LCX)闭塞的敏感度和特异度分别为73.7%和93.4%,ST V2压低>0.15 mV 预测 LCX 近段闭塞的敏感度为87.5%。结论体表心电图Ⅲ、V3、V4R、aVL 导联 ST 段改变对预测 RCA 闭塞有价值,而 ST V2压低有助于预测 LCX 闭塞。     

急性下壁心肌梗死中心电图与梗死相关动脉间的关系

目的 探讨急性下壁心肌梗死（AMI）时体表心电图对梗死相关动脉（IRA）的判断价值.方法 选择经冠状动脉造影确诊的急性下壁AMI患者98例,观察其心电图表现与冠状动脉造影的关系.结果 98例下壁AMI患者中,右冠状动脉（RCA）病变68例,左回旋支（LCX）病变30例.以RCA病变为主时,心电图表现为Ⅲ导联ST段抬高幅度〉Ⅱ导联ST段抬高幅度、aVL 导联ST段压低和aVR导联ST段抬高;以LCX病变为主时,心电图表现为Ⅲ导联ST段抬高幅度〈Ⅱ导联ST段抬高幅度、aVL 导联ST段抬高和aVR导联ST段压低.结论 临床医师可通过心电图上的ST段移位对急性下壁AMI的患者的IRA作出初步判断.     

常规心电图早期判定急性右心室梗死的探讨

目的 探讨急性右心室梗死早期心电图不同导联ST段改变的诊断意义.方法 连续选择2000～2005年首次因急性下壁心肌梗死住入我院心内科患者,回顾性分析临床诊治资料, 其中91例有冠状动脉造影结果,重点分析心电图不同导联ST段改变与下壁心肌梗死相关动脉的关系以及对急性右心室梗死诊断的意义.结果 下壁心肌梗死相关动脉分别为右冠脉(RCA)病变组73例(80%),左回旋支(LCX)病变组18例(20%).显示ST段抬高V4R≥1 mV阳性发生率、抬高程度Ⅲ＞Ⅱ导联、ST段下移程度aVL>Ⅰ导联,RCA组明显多于LCX组,差异有统计学意义(P值均为0.001).结论 利用常规心电图检测不同导联的ST段改变有助于识别梗死相关动脉,可以早期判定急性右室梗死.     

比较Ⅱ、Ⅲ导联ST段抬高幅度预测急性下壁心肌梗死罪犯血管

急性下壁心肌梗死的罪犯血管通常是右冠状动脉(RCA)，少数为左回旋支(LCX)。当RCA近段完全闭塞时。常并发高度房室传导阻滞和(或)休克等严重并发症。增加患住院期病死率。因此，早期识别急性下壁心肌梗死的罪犯血管将有助于采取合理有效的治疗措施，预防严重并发症。本研究旨在评估Ⅱ、Ⅲ导联ST段抬高幅度比较存预测下壁心肌梗死的罪犯血管中的价值。     

急性下壁心肌梗死74例侧壁导联心电图改变分析

目的：分析急性下壁心肌梗死侧壁导联（I、AVL）心电图改变对梗死相关动脉预测价值。方法：根据74例急性下壁心肌梗死侧壁导联心电图ST段改变,对比其与冠状动脉造影显示梗死相关动脉的关系。结果：本组右冠状动脉（RCA）62例（83.8%）,为左回旋支（LCX）共12例（16.2%）。结论：急性下壁心肌梗死侧壁导联（I、AVL）心电图ST段压低是判断梗死相关动脉为右冠状动脉的较敏感指标,尤以AVL导联更敏感。AVL导联无压低是判断梗死相关动脉为左回旋支的较好指标。     

急性下壁心肌梗死心电图的改变与相关冠脉病变的关系

[目的]探讨急性下壁心肌梗死时心电图ST段改变对判断心肌梗死相关冠状动脉病变的关系.[方法]对50例急性下壁心肌梗死ST段改变与冠状动脉造影结果对比分析.[结果]①血管闭塞发生在右冠状动脉占70.0%,回旋支占30.0% ②ST段抬高Ⅲ/Ⅱ〉1,提示右冠状动脉阻塞的敏感性91.4%,特异性86.7% Ⅲ/Ⅱ≤1提示回旋支闭塞的敏感性86.7%,特异性91.4% ③Ⅰ、aVL导联ST段压低预测右冠脉阻塞敏感性71.4%,特异性80.0%,Ⅰ、aVL导联ST段抬高预测回旋支阻塞敏感性80.0%,特异性71.4%.[结论]下壁心肌梗死时心电图对梗死相关动脉有重要的预测价值.     

急性下壁心肌梗死中梗死相关血管的心电图表现

目的：探讨心电图在判断下壁急性心肌梗死（AMI）中梗死相关血管（IRA）和预测患者住院期间心脏事件中的价值。方法：选择经冠状动脉造影确诊的下壁AMI患者163例，观察其心电图表现与冠状动脉造影、住院期间心脏事件的关系。结果：163例下壁AMI患者中，有冠状动脉（RCA）病变112例，左回旋支（LCX）病变5I例。以RCA病变为主时,心电图表现为Ⅲ导联ST段抬高幅度〉Ⅱ导联ST段抬高幅度、aVL导联ST段压低和aVR导联ST段抬高：LCX病变心电图多表现为Ⅲ导联ST段抬高幅度〈Ⅱ导联ST段抬高幅度、aVL导联ST段抬高和aVR导联ST段压低。Ⅲ导联ST段抬高幅度〉Ⅱ导联ST段抬高幅度，则提示合并有心室AMI及缓慢性心律失常的发生率高于Ⅲ导联ST段抬高幅度〈Ⅱ导联ST段抬高幅度者。结论：临床医师可通过心电图上的ST段移位对AMl患者的IRA作出初步判断,并评估其预后。     

不同的梗死相关血管急性下壁心肌梗死特点

目的分析不同梗死相关血管的急性下壁心肌梗死患者的临床特点。方法根据冠状动脉造影结果将急性下壁心肌梗死患者分2组,A组76例为右冠状动脉(RCA)闭塞,B组24例为左回旋支冠状动脉(LCX)闭塞,并进行比较分析。结果心电图ST段抬高STⅢ>STⅡA组显著高于B组(P<0.05);ST段抬高STⅢ0.1mVA组显著高于B组(P<0.05);合并左前降支冠状动脉(LAD)病变的患者数在胸前导联ST段压低的患者中显著多于无胸前导联ST段压低患者(P<0.05);左室射血分数(LVEF)A组显著低于B组[(51±14)%vs(57±10)%,P<0.05];合并右室心肌梗死A组显著高于B组(P<0.05);心源性休克,心力衰竭,Ⅱ度、Ⅲ度房室传导阻滞,室性心动过速/心室颤动,住院死亡率等两组比较差异无统计学意义(P>0.05)。结论心电图Ⅲ、Ⅱ及V4R导联ST段变化能预测急性下壁心肌梗死患者梗死相关血管,急性下壁心肌梗死患者伴胸前导联ST段压低提示LAD病变,RCA闭塞所致下壁心肌梗死LVEF低于LCX闭塞者,但临床并发症两组间差异无统计学意义。     

急性下壁心肌梗死心电图aVL导联QRS波群变化的临床意义

目的　探讨下壁急性心肌梗死 (AMI)时患者的心电图aVL导联QRS波群变化能否作为罪犯血管的判定标准。方法　比较 6 0例下壁AMI患者aVL导联QRS波群变化与选择性冠状动脉造影结果的相关性 ,分析aVL导联QRS波群两种模式 (Ⅰ型 :S/R≤ 1/ 3,ST段抬高≤ 1mm ;Ⅱ型 :S/R >1/ 3,ST段抬高 >1mm)对判断下壁AMI罪犯血管的临床价值。结果　aVL导联的Ⅰ型QRS波群改变在左冠状动脉回旋支 (LCX)闭塞组出现率为 89% ,右冠状动脉 (RCA)闭塞组为 2 4 % (P =0 .0 0 1)。Ⅱ型改变在LCX组出现率 11%、RCA组为 76 % (P =0 .0 0 1)。Ⅰ型心电图变化预测LCX闭塞的敏感度为 89% ,特异度为 76 %。Ⅱ型心电图改变预测RCA闭塞的敏感度为 76 % ,特异度为89%。结论　aVL导联的Ⅰ型QRS波群变化是判断LCX型AMI敏感、特异的预测指标 ,而Ⅱ型QRS波群变化是RCA型AMI有效的预测指标     

急性下壁心梗心电图特点与冠脉造影梗死相关动脉相关性分析

目的 探讨根据急性下壁心肌梗死心电图(ECG)特点来判断梗死相关动脉(IRA).方法 对照研究76例急性下壁心肌梗死患者的冠脉造影资料,分析梗死相关动脉及体表心电图变化.结果 梗死相关动脉为右冠状动脉(RCA)可能性大的有:心电图ST段抬高Ⅲ＞Ⅱ(83.6％),心电图ST段压低AVL＞Ⅰ(82.1％),V3导联ST段压低与Ⅲ导联ST段抬高比值≤1.2(83.3％),aVL S/R＞ 1/3伴ST段压低＞1 mm(90％),梗死相关动脉为左回旋支动脉(LCX)可能性大的有:ST段抬高Ⅲ≤Ⅱ(80％),ST段压低aVL≤Ⅰ(71.4％),V3导联ST段压低与Ⅲ导联ST段抬高比值＞1.2(83.4％),如S/R≤1/3伴ST段压低≤1mm(85.7％).结论 急性下壁心肌梗死时体表心电图与梗死相关动脉有明显相关性,且有较好的预测价值.     

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.     

Interprofessional approaches to creating safe,high quality health care

Three supplementary perspectives are presented arguing that interprofessional collaboration is both necessary and desirable. Nonetheless, there are often too many serious intra-professional barriers and obstacles to interprofessional collaboration to make it successful. Some of these barriers, it is argued and illustrated, are found in the multiple ways in which professional identity is tacitly acquired and embodied in the practitioners' habitual, everyday practice. The paper then explores ways in which reflection, especially Second order reflection, can help to elucidate and overcome these obstacles, as well as increasing professional adaptability and competence.     

Systematic Reviews Published in the January 2011 Issue of The Cochrane Library

ABSTRACT

The Cochrane Library of Systematic Reviews is published quarterly as a DVD and monthly online. The January 2011 issue (first quarterly DVD for 2011) contains 4515 complete reviews, 1985 protocols for reviews in production, and 13,521 one-page summaries of systematic reviews published in the general medical literature. In addition, there are citations of 641,000 randomized controlled trials, and 14,018 cited papers in the Cochrane methodology register. The health technology assessment database contains over 9300 citations. One hundred and seven new reviews have been published in the last 3 months, of which five have potential relevance for practitioners in pain and palliative medicine.     

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.     

Prise en charge des entorses externes de cheville : étude clinique préliminaire sur l’efficacité du dispositif Myolux™

Ankle sprains are the most common injury of the musculoskeletal system and are associated with significant societal and economic impacts. It has been proven that classical therapeutic strategies may not be effective in preventing recurrent injuries: the recurrence rates reported in the literature can reach 73%. In order to provide an effective rehabilitation solution, a destabilizing orthosis was developed. This device is equipped with a mechanical articulator reproducing the subtalar mechanics and placed under the heel. In this paper, we present the main results of a preliminary clinical study conducted between 2004 and 2007. All subjects included in this study were treated with the abovementioned orthosis during 10 rehabilitation sessions of 30 minutes each. Data show a relatively low recurrence rate of 12% for the overall population. Moreover, it's of primary importance to note that this satisfactory ratio is largely reduced (3% of recurrence rate) for the 29 patients who performed one training session per month after the 10th initial rehabilitation sessions. Hence, the destabilizing orthosis appears to be an effective solution to prevent recurrent ankle sprains. However, joint protection requires long-term and regular training sessions. This result has motivated the development of a similar device allowing patients to perform training sessions at home. Finally, data obtained in this study are promising awaiting the final results of the comparative, multicentric and independent clinical trials currently managed by the Hospices Civils de Lyon.