小剂量多巴酚丁胺负荷超声心动图结合多普勒组织成像评价存活心肌的研究

目的：研究多普勒组织成像（DTI）结合小剂量多巴酚丁胺负荷超声心动图评价心肌活性的可行性，并研究其与^99mTc-MIBI硝酸甘油介入心肌显像在评价存活心肌方面的一致性。方法：对30例经冠状动脉造影确冠心病的患者行超声心动图及心脏核素检查，超声心动图检查使用DTI速度模式，采用两级多巴酚丁胺超声心动图试验，所有患者均行静息显像及硝酸甘油介入后显像，结果：（1）30例冠心病患者用超声心动图静息DTI检测480个室壁节段，检出166个运动常节段，运动减弱节段108个，运动消失节段58个。（2）对患者行超声心动图小剂量多巴酚丁胺负荷试验DTI检测480个室壁节段，检出166个运动异常节段中89个节段运动改善，提示为存活心肌节段（A组）；余77个节段无变化，为坏死心肌（B组）。A组静息及负荷超声心动图DTI差异有显著性意义（P＜0．05），B组静息及负荷超声心动图DTI差异无显著性意义（P＞0．05）。A组与B组静息超心动图DTI差异无显著性意义（P＞0．05）。（3）30例冠心病患者用^99mTc-MIBI硝酸甘油介入心肌显像检测480个室壁节段，检出185个病变节段，其中97个为存活心肌节段，小剂量多巴酚丁胺结合超声心动图DTI诊断存活心肌的敏感性达83％，特异性达86％，结论：DTI结合小剂量多巴酚丁胺是评心肌活性的一项超声新技术，其结果与^99mTc-MIBI硝酸甘油介入心肌显像进行对照分析显示良好的一致性，应用前景较为乐观。     

多巴酚丁胺负荷磁共振成像检测存活心肌的临床研究

目的 评价小剂量多巴酚丁胺(10μg·kg-1·min-1)负荷磁共振成像(MRI)检测存活心肌的临床价值.方法 经彩色多普勒超声检查存在左心室壁节段运动障碍冠心病患者24例,进行MRI、小剂量多巴酚丁胺负荷MRI、冠状动脉造影(CAG)及经皮冠状动脉介入治疗(PCI),所有狭窄病变行完全血运重建.参照美国超声心动图学会16节段划分法,经MRI测得各运动异常节段小剂量多巴酚丁胺负荷前后舒张末期室壁厚度(EDWT),以应用小剂量多巴酚丁胺后室壁增厚为存活心肌标准;术后1、3、6个月时复查心脏超声,以冠状动脉血运重建后室壁节段收缩功能改善为判断存活心肌的金标准.结果 24例冠心病患者共获得符合条件的室壁运动异常节段170个,根据金标准判断其中115个为存活心肌,55个为非存活心肌;MRI检测存活心肌的敏感度、特异度、准确度分别是76.5%、90.9%、81.2%.结论 小剂量多巴酚丁胺负荷MRI检测存活心肌有较高的临床价值.     

多巴酚丁胺负荷超声和实时声学造影评价介入治疗术后心肌灌注

目的应用实时心肌声学造影和多巴酚丁胺负荷超声心动图,定量评价冠状动脉(冠脉)介入治疗术后心肌血流量和血流储备。方法12例前壁和前间隔心肌梗死患者,在心肌梗死后3周至1年择期行冠脉造影和支架介入术,在介入术后1周,在基础状态下和多巴酚丁胺负荷试验时进行实时声学造影。应用Qlab软件定量分析实时声学造影再灌注曲线,得到曲线平台值(A)、曲线上升速度(β)和A·β(心肌血流量,MBF),以及各参数的储备值。结果负荷试验时的室壁运动指数明显下降(1.45±0.24对1.25±0.18,P<0.05),左室射血分数显著增加[(45.74±8.45)%对(59.80±11.92)%,P<0.05]。静息状态和负荷时,正常冠脉供血节段的A、β和MBF均显著高于病变冠脉供血区(均P<0.05)。与静息时相比,负荷时正常冠脉供血节段的A、β和MBF显著增加(均P<0.001),病变冠脉供血区的A、β和MBF也明显上升(均P<0.01),但增加幅度不及正常冠脉供血区(P<0.05)。除A值储备外(P=0.17),病变冠脉供血区的β和MBF的储备均明显低于正常冠脉供血区(P分别为1.06×10-7,7.66×10-5)。存活心肌节段β及MBF储备明显高于梗死心肌节段(均P<0.05)。结论心肌梗死患者在择期介入治疗术后仍存在心肌灌注异常和室壁运动障碍,多巴酚丁胺负荷实时声学造影能够有效地定量心肌血流量和检测存活心肌,有助于判断心肌的血流储备能力,为临床评价冠心病提供了简便、可靠、无创伤性的新方法。     

心肌超声造影结合多巴酚丁胺负荷试验探讨冠心病心肌灌注与心肌收缩功能的关系

目的探讨心肌实时超声造影结合小剂量多巴酚丁胺负荷试验中心肌灌注与收缩功能之间、心肌灌注储备与心肌收缩功能储备之间的关系。方法26例住院患者进行了常规超声心动图、基础状态下和小剂量多巴酚丁胺负荷状态下的心肌超声造影。造影图像采用QLab软件对微泡再充盈曲线进行定量分析,求出各节段的A、β值及其乘积A·β。然后对各节段心肌灌注参数和室壁运动评分进行统计分析。结果在基础状态和负荷状态下,心肌灌注参数(β和A·β值)均随着室壁运动评分的增加而降低(P<0.01)。在小剂量多巴酚丁胺负荷状态下室壁运动改善的节段较无改善者具有较高的心肌灌注储备值(P<0.01)。结论心肌灌注和心肌收缩功能具有很好的相关性,检测心肌灌注储备有助于识别存活心肌。     

多巴酚丁胺负荷PLGA心肌造影下二维应变定量评价存活心肌研究

目的 探讨PLGA经主动脉心肌造影联合多巴酚丁胺负荷条件下,二维应变评价节段心肌存活性的准确性。方法 30只杂种犬建立急性心肌缺血再灌注模型,经主动脉根部行PLGA心肌造影,通过多巴酚丁胺负荷试验,获取心肌节段二维应变参数。结果 多巴酚丁胺负荷后,非存活节段的收缩期二维峰值应变较静息时无明显升高。存活节段的应变值随剂量增加而升高,与非存活节段比较,二者间有统计学显著性差异。结论 PLGA心肌造影联合多巴酚丁胺负荷试验可以提高超声图像质量,获取二维应变参数,提高评价心肌存活的准确性。     

小剂量多巴酚丁胺负荷超声心动图结合组织多普勒成像诊断存活心肌的量化指标评价

目的探讨小剂量多巴酚丁胺负荷超声心动图结合组织多普勒成像(TDI)检测存活心肌的组织多普勒指标变化范围。方法对明确诊断的急性心肌梗死患者20例、心绞痛患者6例,于经皮冠状动脉介入术前1～3d接受小剂量多巴酚丁胺负荷试验,分别采集患者在基础状态、低剂量、峰剂量及恢复期的标准左心室长轴、短轴乳头肌水平、心尖四腔心、心尖二腔心切面的二维图像和心尖切面的TDI频谱,根据二维图像心内膜运动和室壁收缩期增厚率进行室壁节段运动评分,同时分别测量各组二尖瓣环位置的TDI频谱等容收缩期峰值(S1)、射血期峰值(S2)、等容舒张期峰值(SIVR)和等容收缩时间(IVST)、射血时间(ET)、等容舒张时间(IVRT),计算各值在多巴酚丁胺峰剂量作用下的变化百分率。结果26例患者共104个心肌节段,在静息状态下TDI频谱测量各组S1、SIVR、IVST、ET差异无统计学意义,S2、E/A在梗死组、存活心肌组较正常组低(P<0.05),IVRT在梗死组、存活心肌组较正常组明显延长(P<0.01)。多巴酚丁胺负荷峰剂量下正常心肌组和存活心肌组S1波明显增高(P<0.01),IVST缩短(P<0.05),正常心肌组和存活心肌组多巴酚丁胺负荷前后IVRT缩短(P<0.01或P<0.05),而梗死心肌组差异无统计学意义。结论TDI可以量化评价局部心室壁运动状态,与小剂量多巴酚丁胺负荷超声试验相结合,可为检出存活心肌提供量化评定指标。     

多普勒组织成像检测冠心病室壁运动及心肌活性的应用价值

本文报道了应用多普勒组织成像（ＤＴＩ）检测冠心病室壁运动异常，并配合小剂量多巴酚丁胺负荷超声心动图判断心肌活性。结果显示：冠心病室壁运动异常节段的收缩期，舒张期速度均低于正常组（Ｐ＜０．０５）。应用小剂量多巴酚丁胺后，１００个异常节段中，３５个节段运动改善（心肌存活组，Ａ组），６５个节段无明显变化（坏死心肌组，Ｂ组）；ＤＴＩ检测Ａ组的收缩期速度Ｖｓ与速度增长率ＶＲ均明显高于Ｂ组。表明ＤＴＩ对心肌缺血及缺血心肌活性的判断有一定价值     

多巴酚丁胺超声心动图负荷试验与放射性核素心肌灌注显像对心肌存活性的对比研究

目的 评价小剂量多巴酚丁胺超声心动图负荷试验(DSE)和放射性核素心肌灌注显像(SPECT)预测心肌存活性的价值。方法 以15例成功行经皮冠脉介入治疗(PCI)患者术后6个月室壁运动改善为检验标准，进行小剂量多巴酚丁胺超声心动图负荷试验及SPECT检查，比较两者检测心肌存活性的准确性。结果 小剂量多巴酚丁胺超声心动图负荷试验峰剂量期与低剂量期在预测心叽存活敏感性、阴性预测差异具有显著性意义；与DSE相比，SPECT具有较高的敏感性但其特异性较低。结论 DSE与SPECT检测心肌存活性的准确性各有优点，但DSE更具实用性。     

负荷超声心动图检测KTP激光心肌血运重建术后心肌存活性

目的　研究KTP激光心肌血运重建术 (TMLR)对梗死局部心肌存活性的影响。方法　家犬 12只 ,随机分为TM LR组和对照组 ,每组 6只 ,结扎左前降支中段 ,造成急性心肌梗死犬模型 ,TMLR组在梗死区以KTP激光行TMLR。术后动物饲养 2～ 3个月 ,采用多巴酚丁胺负荷超声心动图 ,检测心肌的存活性。结果　负荷超声心动图检查发现 ,TMLR组给予5 μg/(kg·min)多巴酚丁胺后室壁收缩增厚率、室壁运动幅度和室壁运动速度均有不同程度的改善 ,但当多巴酚丁胺剂量增大到 10 μg/(kg·min) ,前壁的室壁收缩增厚率、室壁运动幅度和室壁运动速度反而又减低 ;而对照组给予多巴酚丁胺 5 μg/(kg·min)和 10 μg/(kg·min)后 ,室壁收缩增厚率、室壁运动幅度和室壁运动速度进行性减低。 结论　KTP激光TMLR后梗死局部部分心肌保持存活。     

多巴酚丁胺负荷乳酸/羟基乙酸共聚物心肌造影下二维应变定量评价犬存活心肌的研究

目的探讨乳酸/羟基乙酸共聚物(PLGA)经主动脉心肌造影联合多巴酚丁胺负荷条件下,二维应变评价犬节段心肌存活性的准确性。方法 30只犬成功建立急性心肌缺血再灌注模型,经主动脉根部行PLGA心肌造影,通过多巴酚丁胺负荷试验,获取心肌节段二维应变参数:收缩期峰值纵向应变(LS)、径向应变(RS)及圆周应变(CS)。结果共计24只犬完成实验。多巴酚丁胺负荷实验后,非存活心肌节段的收缩期二维峰值应变较静息时无明显升高;存活心肌节段的二维应变值随多巴酚丁胺剂量增加而升高,与非存活心肌节段比较差异有统计学意义(P<0.05)。以心肌标本染色结果作为金标准,分别以收缩期峰值LS、RS及CS作为评价参数,其检测存活心肌的敏感性分别为81.03%、77.59%及72.41%,特异性分别为81.30%、84.00%及78.00%。结论 PLGA心肌造影联合多巴酚丁胺负荷实验可以提高超声图像质量,获取二维应变参数,提高评价犬心肌存活的准确性。     

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.     

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.     

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.     

Modified micro-superior percutaneously-assisted total hip: early experiences & case reports

Because of the extensile nature and familiarity of the standard posterior-lateral approach to the hip, a family of "micro-posterior" approaches has been developed. This family includes the Percutaneously-Assisted Total Hip (PATH) approach, the Supercapsular (SuperCap) approach and a newer hybrid approach, the Supercapsular Percutaneously-Assisted Total Hip (SuperPATH) approach. Such approaches should ideally provide a continuum for the surgeon: from a "micro" (external rotator sparing) posterior approach, to a "mini" (external rotator sacrificing) posterior approach, to a standard posterior approach. This could keep a surgeon within his comfort zone during the learning curve of the procedure, while leaving options for complicated reconstructions for the more practiced micro-posterior surgeons. This paper details one author's experiences utilizing this combined approach, as well as permutations of this entire micro-posterior family of approaches as applied to more complex hip reconstructions.     

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.     

Structure and function of "metalloantibiotics"

Although most antibiotics do not need metal ions for their biological activities, there are a number of antibiotics that require metal ions to function properly, such as bleomycin (BLM), streptonigrin (SN), and bacitracin. The coordinated metal ions in these antibiotics play an important role in maintaining proper structure and/or function of these antibiotics. Removal of the metal ions from these antibiotics can cause changes in structure and/or function of these antibiotics. Similar to the case of "metalloproteins," these antibiotics are dubbed "metalloantibiotics" which are the title subjects of this review. Metalloantibiotics can interact with several different kinds of biomolecules, including DNA, RNA, proteins, receptors, and lipids, rendering their unique and specific bioactivities. In addition to the microbial-originated metalloantibiotics, many metalloantibiotic derivatives and metal complexes of synthetic ligands also show antibacterial, antiviral, and anti-neoplastic activities which are also briefly discussed to provide a broad sense of the term "metalloantibiotics."