单根电极VDD起搏器的初步应用（附七例报告）

自１９９４年１～１０月共为７例（完全性房室传导阻滞６例、高度房室传导阻滞１例）病人应用了单电极ＶＤＤ起搏器。术后随诊３～１２（平均６．５±２．５）个月，动态心电图监测全部达到心房同步起搏的目的，其中１例有个别间断性Ｐ波感知差而自动转为ＶＶＩ起搏，但总的Ｐ波感知率在９８％以上。如植入病例经严格选择（窦房功能正常的房室传导阻滞），单电极ＶＤＤ起搏可代替双腔ＤＤＤ起搏。     

单根电极心室起搏双腔感知双重反应型起搏器心房感知功能的测试观察

目的：观察单根电极心室起搏双腔感知双重反应型起搏器（ＶＤＤ）心房电极感知功能的稳定性。方法：测试了１４例安装单根电极ＶＤＤ的患者在不同体位、扩胸运动及日常活动时的心房漂浮电极的最低感知阈值。并将术中测得的Ｐ波与术后测得的心房最低感知阈值做相关及线性回归分析。结果：１４例中有１２例患者不同体位的心房感知阈值不一致。其中９例在坐、立位时感知阈值最低，将心房感知阈值调至较最低感知阈值低两档的位置后做Ｈｏｌｔｅｒ检查，全部患者心房感知、房室顺序起搏功能良好。扩胸运动中无一例患者出现过度感知。术中所测Ｐ波振幅与术后测得的最低心房感知阈值相关性良好（ｒ＝０．６９，Ｐ＜０．０５）。结论：单根电极ＶＤＤ可替代双电极导管的双腔起搏双腔感知双重反应型起搏器（ＤＤＤ），用于窦房结功能正常的高度房室传导阻滞患者的起搏治疗。     

VDD起搏治疗幼儿完全性房室阻滞(附一例报告)

一例３．５岁的女性幼儿因室间隔缺损修补术致迟发性完全性房室阻滞（ＣＡＶＢ）而安置ＶＤＤ起搏器。经锁骨下静脉途径埋置单根心房感知、心室触发起搏电极，使之于右房内塑形并贴靠房壁；起搏器埋于同侧皮下胸大肌筋膜上囊袋内。术中测得起搏阈值０．１Ｖ、脉宽０．４ｍｓ、电极阻抗５２０Ω、Ａ波振幅１．５ｍＶ、Ｖ波振幅１０．６ｍＶ，Ａ波感知设定０．２５ｍＶ。术后房室同步起搏率１００％，临床症状改善。表明ＶＤＤ起搏器不仅埋置简便，而且具有房室同步、频率应答等生理性起搏特点，是治疗幼儿ＣＡＶＢ的理想起搏方式。     

儿童矫正性大动脉转位伴Ⅲ度房室阻滞的VDD生理性？…

一例１１岁矫正性大动脉转位（ＳＬＬ）的女性患儿有晕厥史１０年，超声心动图证实心内无分流，动态心电图及是生理检查均证实为Ⅲ度房室阻滞，窦房结功能正常，安置ＶＤＤ生理性起搏器，感知与起搏电极间距为１３ｃｍ，Ｐ波振幅２．２ｍＶ，心房感知０．７５ｍＶ心室起搏阈值０．４Ｖ，术后观察心房感知率９８％，给心内无分流的心脏畸形患者安置起搏器要充分考虑生理和生长发育的需要，如合理选择起搏器类型和电极长度，进行电生理     

双房同步起搏技术的临床应用

双房同步起搏是恢复双房电活动同步化的一种新的起搏技术,可防治快速房性心律紊乱。笔者对１７例房内、房间传导阻滞并快速房性心律失常患者进行双房同步起搏治疗,１４例行三腔起搏（ＤＤＤ）、３例行双房起搏（ＡＡＩ）,冠状静脉窦电极均经左锁骨下静脉途径放置。起搏器及电极导线均顺利植入,未发现脱位、穿孔等并发症。冠状静脉窦电极导线顶端电极测定的Ｐ波振幅为５．６９±２．６３（２．４～９．６）ｍＶ、起搏阻抗６５５±１９４．１１（５２０～９６０）Ω、单极起搏阈值０．９２±０．６８（０．４～２．２）Ｖ。冠状静脉窦电极位置较深,则测得起搏阈值较低。随访８．６（３～１５）个月,１例猝死、１６例健在;其预防心房扑动、颤动的显效率达６２．５％、有效率达８１．２５％。结论：双房同步起搏技术是房间传导阻滞合并房性心动过速,心房扑动、颤动的有效治疗和预防方法。     

儿童矫正性大动脉转位伴Ⅲ度房室阻滞的VDD生理性起搏(附一例报告)

一例１１岁矫正性大动脉转位（ＳＬＬ）的女性患儿有晕厥史１０年，超声心动图证实心内无分流，动态心电图及电生理检查均证实为Ⅲ度房室阻滞，窦房结功能正常。安置ＶＤＤ生理性起搏器，感知与起搏电极间距为１３ｃｍ，Ｐ波振幅２．２ｍＶ、心房感知０．７５ｍＶ、心室起搏阈值０．４Ｖ。术后观察心房感知率９８％。给心内无分流的心脏畸形患儿安置起搏器要充分考虑生理和生长发育的需要，如合理选择起搏器类型和电极长度，进行电生理检查测定心尖至高位右房的距离，同时熟悉复杂心脏畸形影像学的知识对保证安置术的成功十分必要。     

植入无导线房室同步起搏器Micra AV患者随访报告及最佳适应证分析

目的 探讨无导线房室同步起搏器M icra A V最佳适应证人群.方法 分析国内首批植入M icra A V患者(n=5)入选标准、随访数据,观察疗效和不良事件.结果 接受治疗患者心脏主导节律为三度房室传导阻滞(n=4)或高度房室传导阻滞(n=1),无窦房结功能异常.以心房机械感知为基础的房室同步起搏比例在所有患者中均...     

561例快速心律失常射频消蚀经验

对５６１例快速心律失常患者进行射频导管消蚀治疗，其中房室旁路折返性心动过速（ＡＶＲＴ）４１３例（４２９条旁路），房室结折返性心动过速（ＡＶＮＲＴ）１４２例，房性心动过速３例，心房扑动２例，心脏正常的室性心动过速１例。显性旁路消蚀成功靶点心电图特征为：ＡＶ≤４０ｍｓ，Ｖ波较体表心电图最早的ｄｅｌｔａ波提前≥２０ｍｓ，Ａ／Ｖ＜１。隐匿旁路成功的靶点心电图特征为：心室起搏时ＶＡ≤４０ｍｓ，Ａ／Ｖ＜１。对左前旁路患者、合并主动脉瓣狭窄者、动脉迂曲的老年人或需同时行二尖瓣球囊扩张术者，导管经股动脉逆行放入左室不易到位，可采用房间隔穿刺法，本组６例均获成功。房室结改良患者采用下位法较后位法消蚀的平均放电次数、时间及操作时间均少（Ｐ值＜０．０５）。本组２例（０．４％）发生三度房室传导阻滞，置入永久性心脏起搏器。平均随访６．１±４．９个月，１４例（２．６％）复发，均再次消蚀成功。     

病态窦房结综合征生理性起搏治疗

对１１例ＳＳＳ患者安置了生理性起搏器，其中７例应用彩色三维超声心动图比较了心房按需型起搏（ＡＡＩ）、房室顺序起搏（ＤＶＩ）与单心室按需起搏（ＶＶＩ）三种不同起搏方式的血液动力学改变。结果显示ＡＡＩ、ＤＶＩ起搏较ＶＶＩ起搏每搏量明显增加分别达３７％、２０％（Ｐ＜０．０１）。通过程控调测、胸壁抑制试验、ＤＣＧ等定期随访患者心律失常及房室传导阻滞变化情况，在平均２０多个月的随访中尚未发现新的快速房性心律失常和传导阻滞，原有的房性心律失常也得到较好控制。认为ＳＳＳ患者的生理性起搏与ＶｖＩ起搏比较可产生较好的血液动力学效果，新的快速性房性心律失常及房室传导阻滞的发生率较低，因此对有适应症的ＳＳＳ患者应尽量选用。     

应用三维超声心动图评价三种不同起搏方式对左心功能的影响

应用三维超声心动图（３－ＤＥ）测定８例植入双腔起搏器病人心室功能参数，观察按需型起搏（ＶＶＩ）、房室顺序型起搏（ＤＶＩ）、心房按需型起搏（ＡＡＩ）三种不同起搏方式对左心功能及左室壁活动的影响。结果发现：ＡＡＩ起搏较ＤＶＩ、ＶＶＩ起搏的每搏量分别增加１３．６％，３５．２％（Ｐ＜０．０１）。ＡＡＩ与ＶＶＩ比较左室壁节段收缩率弱的面积减少，节段收缩率强的面积增加。认为ＡＡＩ起搏既保持了房室顺序同步性又维持了心室收缩舒张顺序的同步性，是较理想的起搏方式。３－ＤＥ是研究心脏起搏血液动力学变化的一种无创伤及更为准确可靠的手段。     

The immunoneuroendocrine role of melatonin

Abstract: A tight, physiological link between the pineal gland and the immune system is emerging from a series of experimental studies. This link might reflect the evolutionary connection between self-recognition and reproduction. Pinealectomy or other experimental methods which inhibit melatonin synthesis and secretion induce a state of immunodepression which is counteracted by melatonin. In general, melatonin seems to have an immunoenhancing effect that is particularly apparent in immunodepressive states. The negative effect of acute stress or immunosuppressive pharmacological treatments on various immune parameters are counteracted by melatonin. It seems important to note that one of the main targets of melatonin is the thymus, i.e., the central organ of the immune system. The clinical use of melatonin as an immunotherapeutic agent seems promising in primary and secondary immunodeficiencies as well as in cancer immunotherapy. The immunoenhancing action of melatonin seems to be mediated by T-helper cell-derived opioid peptides as well as by lymphokines and, perhaps, by pituitary hormones. Melatonin-induced-immuno-opioids (MHO) and lymphokines imply the presence of specific binding sites or melatonin receptors on cells of the immune system. On the other hand, lymphokines such as -γ-interferon and interleukin-2 as well as thymic hormones can modulate the synthesis of melatonin in the pineal gland. The pineal gland might thus be viewed as the crux of a sophisticated immunoneuroendocrine network which functions as an unconscious, diffuse sensory organ.     

Changes in connexin43, the gap junction protein of astrocytes, during development of the rat pineal gland

Abstract: The abundance of gap junctions between rat pineal astrocytes formed by connexin43 (Cx43) was studied during development. Levels and distribution of Cx43 were measured by immunoblotting and indirect immunofluorescence, respectively. The amount of Cx43 in cells located within the gland was low until about the 7th postnatal day and increased to adult values between the 14th and 21st days postpartum. Although astrocytes, recognized by their vimentin immunoreactivity, were scarce before birth, they were abundant by the 7th postnatal day suggesting that the low levels of Cx43 found at this age corresponded to a low expression of this protein. Localization of the immunoreactivity to Cx43 and vimentin showed a close correlation, indicating that mature or immature pineal astrocytes form gap junctions made of Cx43. Since Cx43 levels attained their adult values at about the time the innervation and the functional state of the gland reached maturity (2–3 weeks after birth), it is proposed that astrocyte gap junctions are involved in the function of the adult rat pineal gland.     

Response of rat pineal melatonin to calcium, magnesium, and lithium is circadian stage dependent

Abstract: Herein we documented the response of pineal melatonin production to electrolytes known to be effective on pineal function in view of a possible circadian stage dependence. We studied the release of melatonin by perifused rat pineal glands at 2 different circadian stages corresponding to the middle of the light and dark periods, i.e., respectively, 7 and 19 HALO (Hours After Light Onset, L:D = 12:12). The initial efflux rates were, as expected, much higher in the perifusates of glands removed from rats sacrificed during the dark phase than of those removed during the light phase. After 3 hr of perifusion, melatonin release reached similar levels which were found constant up to the 8th hr of perifusion, whatever the circadian stage. Perifusion of the glands with physiological concentrations for the rat of calcium (5.2 mmol/1) and magnesium (1.34 mmol/1) resulted in a stimulatory effect on the pineal glands removed from rats sacrificed in the middle of the dark period (19 HALO), whereas no effects were observed on the pineal glands removed from rats sacrificed during the light (7 HALO). Lithium (0.28 and 0.55 mmol/1) was ineffective on melatonin release in pineal glands removed 7 and 19 HALO. Our results show differences in the initial efflux rates of melatonin and in the response of perifused pineal glands to calcium and magnesium according to the circadian stage.     

Conservative management of perforated duodenal diverticulum： A case report and review of the literature

Duodenal diverticula are a relatively common condition. They are asymptomatic, unless they become complicated, with perforation being the rarest but most severe complication. Surgical treatment is the most frequently performed approach. We report the case of a patient with a perforated duodenal diverticulum, which was diagnosed early and treated conservatively with antibiotics and percutaneous drainage of secondary retroperitoneal abscesses. We suggest this method could be an acceptable option for the management of similar cases, provided that the patient is in good general condition and without septic signs.     

Presence of immunoreactive growth hormone and prolactin in the ovine pineal gland

Abstract: The use of antisera raised against bovine growth hormone (GH) and ovine prolactin (PRL) enabled the detection of related immunoreactive (ir) sequences of proteins in ovine pineal tissue. The isolation of PRL-like ir-material was accomplished using a 0.25 M ammonium sulphate (pH 5.5) extraction followed by ethanol precipitation, whereas the resulting 2.0 M ammonium sulphate (pH 7.0) precipitate contained a GH-like immunoreactivity. Gel chromatography of the GH-like immunoreactivity (Sephadex G-100) indicated the presence of several GH-like fragments ranging in the M_r range of 7,000 to 55,000. Analyses of the PRL-like ir-material found in pineal tissue on HPLC using a TSK 545-DEAE column led to the resolution into a single peak of immunoreactivity. A single peak of activity was also observed following chromatofocusing and hydrophobic interaction chromatography of the ir-peak from the TSK 545-DEAE column. The PRL-like ir-material inhibited the binding of [¹²⁵I]ovine PRL-S14 to anti-ovine PRL antibodies without showing an affinity for binding to anti-rat PRL or anti-bovine GH antibodies. Scatchard analysis of the binding of pineal PRL-like ir-material and pituitary ovine PRL-S14 to liver membranes from day-20 pregnant rats revealed similar affinity constants (K_a of 4.7 ± 0.2 × 10⁹ M^-1). In addition, the replication of Nb 2 Node rat lymphoma cells was stimulated by pineal PRL-like ir-material, an effect known to be specific for lactogenic hormones. The pineal PRL-like immunoreactivity appeared on sodium dodecyl sulfate polyacrylamide gels as a single major band of M_r 24,000. The functional status of PRL-and GH-like ir-material in the ovine pineal remains to be determined, but evidence is presented that the overall protein synthesis rate of the rat pineal responded to circulating concentrations of PRL.     

Microbiology of human immunodeficiency virus anorectal disease

PURPOSE: Individuals who are seropositive for the human immunodeficiency virus are at high risk for opportunistic infection and anorectal disorders. Little prospective information is available regarding anorectal pathogens in these patients. METHODS: One hundred sixty-three HIV-seropositive patients presented to the colorectal clinic between 1989 and 1992. Forty-seven (29 percent) patients were thought to have an infectious process and were prospectively studied using a standardized multiculture protocol. RESULTS: Mean age was 33 (range, 19–59) years. All were male; high-risk behavior accounted for 87 percent of HIV transmissions. Presenting complaints included anorectal pain (79 percent), pus per anum (28 percent), and blood per anum (26 percent). Examination revealed perianal tenderness (60 percent), condyloma (38 percent), perianal ulcers (38 percent), and anal fissures (34 percent). Sixty-six sets of cultures were performed; 28 patients had one set, 15 had two sets, and 4 had three sets. Thirty-two of these 47 patients (68 percent) had positive cultures including herpes (50 percent), cytomegalovirus (25 percent),Neisseria gonorrhoeae (16 percent), chlamydia (16 percent), acidfast bacilli (2 percent), and others (9 percent). Six of 32 patients with positive cultures had more than one organism cultured. Sixteen (50 percent) patients with positive cultures were treated medically, 8 (25 percent) were treated surgically and 8 (25 percent) were treated with both modalities. Sixty-one procedures were performed on 17 patients for condylomata. Eighteen patients had 20 procedures for abscesses, 50 percent of whom had positive cultures for other than common bowel flora; all improved. Fourteen patients underwent 33 procedures for perianal fistulas.Mycobacterium fortuitum was cultured from one patient who required 13 procedures for abscesses and fistulas. Forty-five (96 percent) patients were followed for an average of 12.5 months ±2.9 SEM (range, 1–94 months). Symptoms were improved or resolved in 22 of 32 (69 percent) patients with positive cultures and in 11 of 13 (84 percent) with negative cultures. CONCLUSIONS: Specific pathogens may often be identified in human immunodeficiency virus-seropositive patients with anorectal disorders if aggressively sought. Although patients without specific pathogens identified may be expected to improve with planned empiric treatment, positive identification allows more directed therapy.