探索不用Halo电极射频消融治疗典型心房扑动的方法

目的探讨不用Halo电极消融典型心房扑动(AF)的方法和右心房峡部传导时间间期的意义.方法对9例AF患者进行了心脏电生理检查和射频消融.将普通标测电极分别放置高位右房(A点)、低位右房(B点)、希氏束(C点)、冠状窦(CS34为D点),标测AF发作时右房激动顺序,起搏时和消融后测量右心房峡部传导时间间期(BD、DB). 结果不用Halo电极成功消融9例AF病例.消融后于冠状窦口处起搏时起搏信号至右房下侧壁的时间间期(DB=140.7ms±66.1ms)和右房下侧壁起搏时起搏信号至冠状窦口CS34的时间间期(BD=123.2ms±42.1ms)均较消融前(DB=66.0ms±12.5ms,BD=62.5ms±13.0ms)明显延长,P＜0.01. 结论不用Halo电极能成功消融典型AF,该方法简便、费用低;右心房峡部传导时间间期的定量测定可作为判断峡部完全性双向传导阻滞的方法之一.     

典型心房扑动消融术后峡部时间间期的变化预测双向阻滞的价值

通过比较心房扑动 (简称房扑 )成功消融前后右心房峡部时间间期 ,分析峡部时间间期的延长程度对峡部完全性双向阻滞的预测价值。选择 1996～ 2 0 0 2年在我院行射频消融治疗的典型房扑患者 30例 ,男 2 3例、女 7例 ,年龄 4 7.85± 9.35岁 ,采用解剖和影像定位法 ,在冠状静脉窦口持续起搏下消融峡部。结果 :2 9例消融成功 ,达到双向传导阻滞的标准 ,成功率 96 .6 7%。消融后起搏信号至右房下侧壁的时间间期 (SAH1 2 )和起搏信号至冠状窦口CS3 4的时间间期明显延长 (14 0 .4 7± 2 0 .4 8msvs73.82± 13.0 1ms ;138.17± 15 .5 5msvs77.6 3± 8.36ms ,P <0 .0 0 0 1)。 2 9例中有 17例在完全性传导阻滞前可以记录到不完全性传导阻滞 ,峡部不完全性传导阻滞时SAH1 2 比术前增加 4 5 .4 9%± 8.7%。消融前后右心房峡部传导时间间期增加≥ 5 0 % ,预测峡部完全性双向传导阻滞的灵敏度 10 0 % ,特异度 83.3%。结论 :右心房峡部传导时间间期的定量分析是判断峡部完全性双向传导阻滞的有价值的方法。     

下腔静脉、三尖瓣环峡部的射频消融治疗心房朴动

目的：报道以下腔静脉、三尖瓣环峡部双向传导阻滞作为终点的心房扑动射顿消融方法，观察该终点对长期疔效的作用。方法；对5例Ⅰ型心房扑动患者的下腔静脉、三尖瓣环峡部进行射频消融。根据右房下侧壁和冠状静脉窦口起搏的右房激动顺序和传导时间变化、评竹蚨部传导阻滞。术后门诊随访观察。结果：5例患者分别于心房扑动(2例)和赛性心律(3例)时接受射频消融治疗，消融后峡部均发生双向传导阻滞。右房下侧壁和冠状静脉赛口起搏的右房激动顺序分别呈顺时针和逆时针单一方向，右房传导时间分别延长82和78ms。随访4个月无一例复发。结论：峡部双向传导阻滞是射频消融心房扑动成功的可靠标志在赛性心律下，亦可对Ⅰ型心房扑动患者进行消融。     

低右房电图极性改变评价典型心房扑动射频消融结果

目的　在典型心房扑动 (房扑 )射频消融中观察临近峡部的低位右房心内电图极性改变 ,来迅速判断是否形成峡部双向阻滞。方法　对 10例典型房扑患者 ,沿三尖瓣环放置Halo电极 ,Halo远端紧邻峡部消融线 ,房扑发作中消融在房扑终止后行冠状窦起搏 ,窦性心律下消融则同时行冠状窦电极起搏 ,观察紧邻消融线低右房侧的心房电极电图起始部分的主波方向 (H电位 )的极性表现 ,并与最终双向阻滞评价结果比较。结果　 8例在窦性心律下行冠状窦电极起搏时消融 ,2例在房扑发作中消融。 10例患者最终消融结果均为双向阻滞。 2例房扑发作时H电位极性均为负向 ,8例窦性心律下H电位极性均为正向 ,峡部缓慢传导时该极性仍为正向 ,形成双向阻滞后H电位极性变为负向。结论　典型心房扑动行峡部线性消融时 ,行冠状窦起搏观察到紧邻峡部消融线低右房侧H电位的极性改变可能是峡部消融成功的新指标。该指标简单、快速、可靠性高。     

三尖瓣环传导时间在确定典型心房扑动消融终点中的价值

目的评价三尖瓣环的传导时间在确定心房扑动(房扑)消融终点中的价值。方法19例经体表心电图证实为典型房扑的患者,在心动过速中根据房扑激动顺序及拖带标测证明折返环沿三尖瓣环运行。测定房扑周长(tachycardial interval,TCL)及起搏后间期(post-pacing interval,PPI)。在三尖瓣环与下腔静脉之间的峡部消融,经冠状窦口及低位右心房起搏证明峡部双向阻滞。分别在冠状窦口、冠状窦远端及高位右心房刺激,用大头电极在峡部消融线上记录在3个部位起搏时的双电位间期(double potential interval,DPI),DPI=刺激信号至第二个电位间期(T2)-刺激信号至第一个电位间期(T1);三尖瓣环传导时间(tricuspid valve annulus conductiontime,TACT),TACT=(T1 T2)-(PPI-TCL);计算TACT/TCL。结果19例患者在消融术中均形成峡部双向阻滞,无并发症发生,停用任何抗心律失常药物,平均随访(27±8)个月,复发1例,经再消融后成功。TCL为210~385ms(平均267·21±36·64ms),冠状窦近端测得的PPI为235~390ms(平均291·32±42·88ms),冠状窦远端PPI为273~450ms(平均334·25±43·04ms),高位右心房的PPI为230~385ms(平均277·13±35·91ms)。提示高位右心房及冠状窦口接近折返环(与TCL相比,P>0·05),而冠状窦远端远离折返环(与TCL相比,P<0·05)。经冠状窦口及低位右心房起搏证实峡部双向阻滞后,分别于冠状窦口、冠状窦远端及高位右心房起搏测定DPI,分别为(152·56±56·66)ms,(150·08±48·35)ms及(85·6±34·47)ms。高位右心房起搏时DPI与冠状窦起搏时比较差异有统计学意义(P<0·05)。3个部位计算的TACT分别为(234·72±58·03)ms、(219·73±40·87)ms,(232·3±43·24)ms,差异无统计学意义。三个部位计算的TACT/TCL分别为(0·87±0·14),(0·82±0·12)及(0·91±0·15),差异无统计学意义。结论三尖瓣环传导时间不受起搏部位的影响,仅与环内折返运动时间长短有关。不论房扑周长的长短及双电位间期的大小,只要三尖瓣环传导时间与房扑周长之比接近于1,提示峡部完全阻滞。     

Halo电极远端电位方向逆转作为典型心房扑动消融终点标准的观察

目的探讨一种通过Halo电极远端电位方向发生逆转来判断典型心房扑动(简称房扑)三尖瓣环峡部线性消融成功的方法。方法 20例典型房扑患者接受射频消融治疗,将Halo电极经右股静脉置于三尖瓣环上,从远端电极至近段电极呈顺时针方向。于窦性心律下,行三尖瓣环至下腔静脉之间线性消融,与此同时,于冠状窦口行S1S1500ms起搏。消融过程中,Halo电极标测显示远端电极及近端电极呈双向传导。以Halo电极远端电位方向逆转作为消融成功终点。结果 20例均消融成功,无消融并发症发生。消融后,反复电刺激未诱发房扑。术后随访6个月,未见房扑复发。结论冠状窦口起搏刺激下,Halo电极远端电位方向出现逆转可作为典型房扑三尖瓣环峡部线性消融成功的可靠指标。     

心电图P波形态变化在典型心房扑动射频消融中意义的再评价

目的以峡部消融线上标测到稳定的宽间期双电位作为典型心房扑动(AFL)射频消融(RFCA)终点标准,对消融前后低侧位右房与冠状窦口刺激心电图P波形态变化进行比较,进而评价其临床应用意义。方法24例典型AFL患者,进行三尖瓣环至下腔静脉之间的线性消融。消融后于消融线标测双电位。消融前后,以及消融过程中分别进行低侧位右房与冠状窦口刺激,比较心电图P波形态的变化。结果RFCA成功后行低侧位右房及冠状窦口起搏,所有患者体表心电图Ⅱ,Ⅲ,aVF导联的P波在负向成分之后出现一正向波成分(100%),且P波时限延长,但是6例患者出现特征性心房激动顺序变化时(即低侧位右房刺激时呈顺钟向传导,逆钟向阻滞。冠状静脉窦刺激时呈逆钟向传导,顺钟向阻滞),消融线局部双电位为71.0±11.2ms,此时低侧位右房与冠状静脉窦口刺激也出现相同的P波变化,继续消融可见双电位延长至118.20±10.2ms,而再予刺激,并不出现P波形态的进一步变化(25%)。结论:对于典型AFL的射频消融治疗,峡部消融后进行峡部两侧刺激可以产生心电图P波形态的特征性变化。但是由于峡部为缓慢传导或者残存传导裂隙时也可以出现此种变化,加之影响P波形态的因素较多,所以这种判断方法临床实践应用的意义不大。     

非接触标测系统用于典型心房扑动的右房标测和导航消融

应用非接触标测系统实施典型心房扑动 (AFL)的右房 (RA)全心腔标测和导航射频消融。 6例典型AFL ,男 5例、女 1例 ,年龄 5 6 .2± 15 .3(35～ 76 )岁。常规放置冠状静脉窦和His束电极 ,将标测球囊置于RA中下部 ,构建RA心内膜模型 ,分别于低位RA和冠状窦口 (CSO)S1S16 0 0ms起搏观察峡部传导 ,诱发并标测AFL的激动顺序和折返路径。 1例为顺钟向AFL ,4例为逆钟向AFL ,1例未能诱发AFL。AFL周期 2 0 7± 34ms,非接触标测可显示整个折返环路、激动顺序和缓慢传导区。AFL的激动可以穿过界嵴上部并且传导相对缓慢 ,提示RA平滑部是折返环的一部分。后位峡部线性消融在导航系统指导下进行 ,无需X线透视。消融完成后重复上述起搏验证峡部双向传导阻滞。除 1例术中出现心房颤动 (AF)外 ,其余病例即刻均达到峡部双向阻滞 ,未出现其他并发症 ,随访 8.1± 6 .7(3～15 )个月未见复发。非接触标测系统可安全、有效和直观地实现典型AFL的右房全心腔标测并导航消融 ,验证峡部双向阻滞 ,减少X线曝光时间和无效放电次数。界嵴在典型AFL时具备传导功能 ,RA平滑部和粗糙部共同参与折返环的组成。     

第46课射频消融后诊断下腔静脉—三尖瓣环峡部阻滞的简易起搏方法

前言下腔静脉-三尖瓣环峡部(CTI)消融已成为典型心房扑动(AFL)的治疗方法.最初,治疗的目标是中止心房扑动且不能诱发,而现在接受的终点是下腔静脉-三尖瓣环峡部双向阻滞,以防止复发.鉴别下腔静脉-三尖瓣环峡部阻滞与缓慢传导是困难的,一直提倡"鉴别起搏",该方法关注的是逐渐远离下腔静脉-三尖瓣环峡部的起搏对消融线或附近记录到的电图(EGM)时间的影响.为分析前-后(逆钟向, CCW)传导,选用多极导管于右心房前壁多个层面起搏,用同一导管远端电极对或消融电极导管于下腔静脉-三尖瓣环峡部处作记录.后-前(顺钟向, CW)传导常由冠状窦近端起搏实施,另需一根电极导管起搏右心房间隔中部作鉴别起搏.在后-前传导检测中,下腔静脉-三尖瓣环峡部电图因电压低或多个成分(指多个波,译者加注),难以解释.此外,在下腔静脉-三尖瓣环峡部阻滞的情况下,起搏冠状窦时跨过界嵴的传导酷似下腔静脉-三尖瓣环峡部传导.我们将报道一种简单的方法,无需冠状窦电极导管,根据经下腔静脉-三尖瓣环峡部消融线间隔缘起搏时右心房前壁的激动顺序,评估下腔静脉-三尖瓣环峡部后-前阻滞.这种方法使得整个手术的完成只需两根电极导管:多极参考导管和消融电极导管.     

差异性起搏法对典型心房扑动消融后峡部完全传导阻滞的预测价值

目的探讨一种简单的方法用以鉴别峡部消融线是完全阻滞还是存在缓慢传导,以降低典型心房扑动(简称房扑)消融后的复发率。方法前瞻性研究30例典型房扑患者消融后峡部的传导,放置20极Halo电极,使最远端的两对电极靠近阻滞线,分别起搏这两对电极并在消融线上标测局部双电位或多电位,我们假设局部电位的初始成分和终末成分分别代表消融线两侧的激动,当起搏部位由离消融线较近的电极对转为较远电极对起搏时,刺激信号到局部电位初始电位成分的时间将会延迟,而刺激信号到局部电位终末成分的时间变化取决于阻滞线是否完整。终末电位提前或不变提示完全阻滞,终末电位延迟提示阻滞线上有传导缝隙。结果用传统判断峡部阻滞的方法做参照标准,选取位点进行差异性起搏共54次,峡部完全阻滞前18次,峡部完全阻滞后36次。当起搏部位转为较远电极对时,初始电位均延迟,平均18±9ms,峡部不全阻滞时,终末电位延迟13±7ms,峡部完全阻滞后,终末电位提前12±8ms。差异性起搏对预测峡部完全阻滞的灵敏度达100%,特异度达88.9%。结论差异性起搏可准确鉴别峡部形成完全阻滞还是存在缓慢传导。     

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.     

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.     

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.     

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.