急性心肌梗死患者血浆脑钠素峰值浓度的变化与预后的关系

目的探讨血浆脑钠素(BNP)峰值浓度的变化与急性心肌梗死(AMI)预后的关系。方法用放射免疫法测定78例AMI患者入院即刻、6、12、18、24小时,第3、5、7天血浆BNP浓度,经住院期间及出院后平均12个月的随访,观察早期再灌注组与非早期再灌注组患者的血浆BNP峰值浓度的差异,以及心血管事件发生组与未发生组患者的血浆BNP峰值浓度的差异。结果AMI后血浆BNP第一峰值浓度(386.3±114.0)ng/L和第二峰值浓度(296.5±96.2)ng/L均呈显著升高,明显高于正常对照组(52.6±27.1)ng/L,两组比较差异有统计学意义(P<0.01);早期再灌注可明显降低AMI患者BNP第二峰值浓度[(301±97.7)ng/L对(176.4±105.6)ng/L(P<0.01)];发生心血管事件的患者血浆BNP第一、第二峰值浓度明显高于未发生组[(406.5±98.2)ng/L,(348.4±99.3)ng/L对(341.1±104.3)ng/L,(224.9±92.5)ng/L(P<0.01)]。结论BNP可作为AMI后评估预后的血浆标记物之一。积极的早期再灌注治疗有助于血浆脑钠素峰值浓度的降低和AMI预后的改善。     

B型利钠肽与急性心肌梗死患者预后的关系

目的探讨B型利钠肽(BNP)浓度与急性心肌梗死(AMI)患者预后的关系。方法采用酶联免疫吸附法(ELISA)测定49名健康对照者和80例AMI患者急性期的血浆BNP浓度,并对AMI患者在住院期及随后平均16个月进行随访,观察其预后状况。结果AMI患者发作期血浆BNP浓度(1784.40±1593.40ng/L)显著高于正常对照组(72.93±32.32ng/L),两者之间的差异有显著意义(P<0.01)。随访结果显示,其后心血管事件发生组在AMI期间的BNP浓度(2230.81±870.28ng/L)明显高于未发生组(1374.50±1011.42ng/L),差异有显著意义(P<0.05);并且BNP浓度越高,再发心血管事件的机率越大,BNP浓度<1 500ng/L,其心血管事件发生率为30%,BNP浓度1 500～3 000ng/L,心血管事件发生率42.86%,BNP浓度>3 000ng/L,心血管事件发生率62.5%,且各组间差异有统计学意义(P<0.05)。logistic多元回归分析显示BNP浓度是心血管事件发生的危险因子。结论BNP浓度与AMI患者的预后有着密切的关系,发生心血管事件组的BNP浓度显著高于未发生组,并且BNP浓度越高其发生心血管事件的概率越高,BNP可作为AMI后心血管事件发生的独立预测因子。     

急性心肌梗死患者预后与血清脑钠肽浓度的临床探讨

脑钠肽（BNP）作为急性心肌梗死（AMI）患者预后的标记物在AMI患者中均可升高，其与经典的心肌坏死标记物肌钙蛋白T（TnT）的相关性如何，尤其在AMI患者中的预后价值如何，需要加以深入研究。探讨血浆BNP浓度与TnT的相关性及BNP对早发AMI患者近期预后的预测价值，以期为高危人群的早期筛选、危险分层和治疗策略的制定提供理论依据。     

急性心肌梗死患者血清生长分化因子15、肌钙蛋白及脑钠肽的表达及其临床意义

目的:探讨血清生长分化因子15(GDF-15)和肌钙蛋白I(cTnI)、脑钠肽(BNP)在急性心肌梗死(AMI)患者中的关系及对其近期预后的预测价值。方法:选择因胸痛(发病时间<12h)入院诊断为AMI患者122例为研究对象,冠状动脉造影正常者40例为对照组。采用ELISA法测定GDF-15及BNP浓度,采用免疫荧光定量技术测定cTnI浓度。记录患者住院和平均随访12个月期间的心血管事件(心血管死亡、心力衰竭、再发心绞痛或再发心肌梗死)的发生情况。结果:AMI组GDF-15与BNP和cTnI浓度呈正相关;发生心血管事件组GDF-15水平高于未发生心血管事件组;多变量logistic逐步回归表明GDF-15是预测近期心血管事件的危险因素(OR=0.79,95%CI:0.67～0.84,P<0.05)。结论:GDF-15与BNP和cTnI浓度呈正相关,GDF-15水平是预测近期心血管事件的有效指标之一。     

脑钠素与急性心肌梗死患者临床表现的相关性研究

目的 观察血浆脑钠素(BNP)水平与急性心肌梗死(AMI)范围、左室功能及预后的关系.方法 63例确诊为AMI的患者,入院后进行常规检查且24 h后测血浆脑钠素浓度,其中,62例患者行PCI,1例行CABG治疗.1周后检查超声心动图测定左室射血分数(LVEF),所有患者随访3个月,观察血浆BNP浓度与AMI的范围、左室功能及预后的关系.结果 血浆BNP水平与AMI面积呈正相关(P<0.01),与LVEF呈负相关(P<0.05),且血浆BNP高的患者心血管事件发生率高(P<0.05),均有统计学意义.结论 血浆BNP浓度反映了AMI的严重程度;AMI范围越大,左室功能越差,脑钠素的水平越高,且脑钠素可作为心血管事件的预测指标.     

血浆N氨基末端脑钠肽前体水平及QRS积分对急性ST段抬高型心肌梗死患者预后的预测价值

目的:探讨血浆N氨基末端脑钠肽前体(NT-proBNP)水平及心电图QRS积分对行急诊经皮冠状动脉介入治疗(PCI)的急性ST段抬高型心肌梗死(STEMI)患者预后的预测价值。方法:采用酶联免疫吸附法检测98例行急诊PCI的STEMI患者心肌梗死1周时的血浆NT-proBNP浓度,同时评价其心电图QRS积分。按照患者在6个月内是否发生梗死后心绞痛、再梗死、心血管死亡等心血管事件。将98例患者分为心血管事件组和无心血管事件组,比较两组患者上述指标的差异。结果:心血管事件组37例,无心血管事件组61例。心血管事件组患者的NT-proBNP[(1040.8±377.2)pg/mL)]和QRS积分(6.5±0.5)与无心血管事件组[(309.9±134.2)pg/mL,4.3±0.4]相比,均显著升高(P<0.01和P<0.05)。相关性分析显示,NT-proBNP与QRS积分呈正相关(r=0.618,P<0.05)。结论:血浆NT-proBNP水平与QRS积分是反映心肌梗死后半年内患者发生心血管事件的风险的敏感指标,它可以反映STEMI患者的近期预后。     

血浆脑钠素水平测定对无ST段抬高的急性冠状动脉综合征患者预后的预测价值

目的探讨血浆脑钠素(BNP)对无ST段抬高的急性冠状动脉综合征(ACS)患者预后的预测价值。方法对192例无ST段抬高的ACS患者(ACS组),20例性别、年龄相匹配的健康体检者(正常对照组)进行血浆BNP测定,并观察6个月内心血管事件(包括不稳定型心绞痛、急性心肌梗死、心力衰竭、全因死亡)发生情况。结果ACS组血浆BNP(36.45±14.96)ng/L,明显高于正常对照组(11.45±3.95)ng/L(P<0.01);在ACS组内,心肌梗死(AM I)亚组中血浆BNP(43.19±15.26)ng/L,明显高于不稳定型心绞痛(UA)亚组(31.73±12.85)ng/L(P<0.01);正常对照组无1例发生心血管事件;ACS组中,BNP>30 ng/L亚组心血管事件发生率为29.5%,显著高于BNP正常亚组的16.3%(P=0.029),比数比(OR)2.146(95%可信区间为1.07~4.29),血浆BNP>30 ng/L判断心血管事件的阳性预测值为29.5%,阴性预测值为83.6%。结论血浆BNP检测对无ST段抬高的ACS患者预后有较好的判断价值。     

血浆脑钠肽对急性心肌梗死溶栓患者心血管事件的评价

目的 探讨血浆脑钠肽(BNP)对急性心肌梗死(AMI)溶栓患者住院期间心血管事件发生的临床预测价值.方法 以2005-01-30～2008-08-19期间就诊于广州医学院第二附属医院急诊科、确诊急性ST段抬高心肌梗死(STEMI)并溶栓的62例患者为观察对象,收集其血浆BNP浓度,记录其在住院期间心血管事件的发生情况,并通过浓度危险分层统计处理.结果 STEMI溶栓后住院期间发生心力衰竭、梗死后心绞痛患者的BNP浓度明显高于未发生组(P<0.01),而两组BNP浓度在STEMI溶栓后出现死亡事件比较差异无统计学意义(P>0.05).BNP<100 pg/mL组病死率为0,BNP 100～500 pg/mL组为3.57%,BNP>500 pg/mL组为12.5%;不同BNP浓度组死亡、心力衰竭、梗死后心绞痛发生率比较差异有统计学意义(P<0.01).通过受试者操作特征(ROC)曲线测定BNP浓度对STEMI溶栓后心血管事件(包括死亡、心力衰竭、梗死后心绞痛)的预测,ROC曲线的曲线下面积(AUC)分别为0.811、0.945、0.945.结论 血浆BNP浓度对AMI急诊静脉溶栓后患者住院期间心血管事件(包括死亡、心力衰竭、梗死后心绞痛)的发生概率具有临床预测价值,能为临床医生对AMI溶栓后患者及早进行病情危险分层及预后估计提供临床依据.     

脑钠肽对2型糖尿病患者心血管危险预测作用的临床研究

目的 探讨脑钠肽(BNP)与2型糖尿病患者的心血管危险因素的关系、BNP水平与糖尿病患者合并冠心痛的严重程度及其近期预后的关系,探寻一种评价2型糖尿病患者心血管危险的方法.方法 以154例2型糖尿病患者作为研究对象,其中合并原发性高血压65例,合并冠心痛95例.合并冠心病者按临床类型分为稳定型心绞痛组30例、不稳定型心绞痛组33例、急性心肌梗死组32例.观察入选患者的BNP水平和各种心血管危险因素的关系;对合并冠心痛者,观察BNP水平和冠心病不同类型之间的关系,随访6个月观察BNP对合并冠心痛患者死亡的预测作用.结果 入选患者的BNP平均为(397.34±217.79)ng/L,2型糖尿病患者的BNP水平与患者的年龄、CRP、高血压及冠心病正相关(Spearman等级相关指数分别为0.631、0.672、0.762、0.857,P均<0.05);2型糖尿病患者BNP水平随患者年龄升高而升高(r=0.896,P<0.01):<50岁组(57.6±12.3)ng/L,50～59岁组(146.2±53.4)ng/L,60～69岁组(388.4±67.5)ng/L,≥70岁组(423.8±132.6)ng/L(P<0.01或P<0.05);2型糖尿病患者合并原发性高血压者较无高血压合并症者BNP明显升高[(314.7±125.3)ne/L与(136.8±98.7)ng/L,P<0.01];合并冠心病的患者BNP高于无冠心病合并症的患者[(425.03±200.80)ng/L与(37.64±21.57)ng/L,P<0.01],合并冠心痛BNP水平与近期预后关系密切,BNP浓度≥485 ng/L为1个月内心源性死亡的独立预测因素.结论 糖尿病患者的BNP水平和患者的心血管危险相关,对合并冠心病者BNP可作为预测心血管危险的指标.     

急性心肌梗死患者血浆心肌营养素-1水平及对预后预测的价值

【目的】探讨急性心肌梗死（AMI）患者血浆心肌营养素-1（CT-1）水平的变化及其对预后预测的价值。【方法】检测86例AMI患者入院时血浆CT-1及心肌肌钙蛋白I（cTnI）的浓度,另选24名健康体检者为对照组,根据CT—l浓度将AMI患者分为CT-1〈300pg／mL组（n=52）和CT-1〉300pg／mL组（n=34）,记录患者1个月内发生的心血管事件（心血管意外死亡、心力衰竭、再发心绞痛或再发心肌梗死）,观察AMI后CT-1水平的变化、CT-1与cTnI的相关性及其对AMI患者的预后价值。【结果】AMI患者血浆CT-1浓度明显高于对照组（P〈0．01）;血浆CT-1水平与cTnI成正相关（r=0．761,P〈0．01）;CT-1〉300pg／mL组心血管事件发生率明显高于CT-1〈300pg／mL组（P〈0．01）;多变量回归分析,CT-1是预测AMI患者发生近期心血管事件的有效指标（RR：1．753,95％CI为1．112～3．438,P=0．012）。【结论】血浆CT-1水平能够反映AMI患者心肌坏死程度,也是预测AMI患者发生近期心血管事件的有效指标。     

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.     

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.