前脑利钠肽评价柔红霉素致急性白血病患儿心脏不良反应研究

目的 通过监测急性白血病患儿柔红霉素化疗前后血浆前脑利钠肽(NT-pro-BNP)及心肌酶谱(CK、CKMB)水平变化并进行对照研究,以探讨NT-pro-BNP对柔红霉素引起患儿心肌损伤的敏感程度的评价作用.方法 选取62例确诊急性白血病并接受正规化疗的患儿,根据柔红霉素的累积剂量将其分为三组:A组累积剂量≤60 mg/m2;B组累积剂量60～120 mg/m2;C组累积剂量＞120mg/m2.15例患儿应用去甲柔红霉素或米托蒽醌作为替代柔红霉素治疗分为D组.用电化学发光免疫法测定患儿血浆NT-pro-BNP,用速率法检测心肌酶谱(CK、CKMB).结果 所有人选患儿在应用柔红霉素治疗后NT-pro-BNP水平与未接受柔红霉素化疗时相比明显升高(P=0.000),而应用柔红霉素前后心肌酶谱比较无显著差异(CK,P=0.085;CKMB,P=0.076).柔红霉素累积剂量＞60 mg/m2时NT-pro-BNP水平明显升高(P＜0.01),当累积剂量＞120 mg/m2时CKMB水平开始升高(P＜0.05).15例患儿应用去甲氧柔红霉素或米托蒽醌代替柔红霉素治疗后,NT-pro-BNP水平从(239.9±230.0)ng/L降为(137.0±131.9)ng/L(P＜0.05).结论 ①NT-pro-BNP能比心肌酶谱早期预测柔红霉素引起心脏不良反应.②选用二至三代蒽环类药物可明显减轻患儿心肌不良反应,改善心肌功能.     

二维斑点追踪成像技术评价急性白血病患儿柔红霉素化疗后左室扭转功能

目的 评价柔红霉素化疗对急性白血病患儿左心室短轴心肌扭转功能的影响.方法 应用超声二维斑点追踪成像技术(two-dimensional speckle tracking imaging,2DSI)对60例急性白血病患儿,于柔红霉素化疗前和化疗后对左室短轴基底段和心尖段的心肌节段收缩期峰值旋转运动作定量检测,计算左室心肌收缩期峰值扭转角度.60例健康儿童为正常对照组.结果 白血病组化疗后心脏功能指标EF、E/A比值与化疗前比较差异均无统计学意义(P＞0.05).正常儿童左室短轴表现为基底段心肌呈顺时针旋转、心尖段心肌呈逆时针旋转的扭转.白血病组化疗前,左室短轴扭转方向和角度与正常对照组差异均无统计学意义.化疗后左室基底段旋转减小、左室扭转减小,与对照组(11.4°±3.8°对12.3°±3.7°)和化疗前(11.4°±3.8°对12.4°±3.5°)比较差异均有统计学意义(P<0.05). 结论白血病患儿柔红霉素化疗存在心脏扭转功能损伤,二维斑点追踪成像技术可无创性定量评估患儿心脏功能的变化,对临床评价柔红霉素的心脏毒性,预防后遗症的发生有重要意义.     

肺炎并心力衰竭患儿血浆脑钠肽变化及其与心功能的关系

目的探讨肺炎并心力衰竭患儿血浆脑钠肽（BNP）变化及其与心功能的关系。方法选取4年住院肺炎并心力衰竭患儿（肺炎心衰组）40例,男26例,女14例;年龄3个月-2岁。一般肺炎患儿（一般肺炎组）40例,男25例,女15例;年龄3个月-3岁。健康对照组为本院同期体检健康儿童共40例,男25例,女15例;年龄5个月-3岁。抽取各组患儿静脉血2-3 mL,采用酶联免疫吸附法（ELISA）测定血清BNP水平;同时均行心脏超声测定其左室射血分数（LVEF）和左室短轴缩短（LVFS）。比较各组BNP水平;以及BNP与LVEF、FS的相关性。结果肺炎心衰组较健康对照组和一般肺炎组血清BNP水平显著升高,[（579.0±90.0）ng·L^-1]vs[（108.6±15.0）ng·L^-1],[（579.0±90.0）ng·L^-1]vs[（121.5±10.1）ng·L^-1];LVEF和LVFS水平降低;有统计学差（P〈0.05）。肺炎心衰组血清BNP与LVEF、LVFS均呈负相关（r=-0.89,-0.78,P〈0.05）。结论肺炎心衰患儿血浆BNP水平显著升高,与左室功能呈负相关。血浆BNP水平可作为判断肺炎并心力衰竭患儿的心衰程度的指标。     

急性白血病患儿血浆D-D、FDP及FIB水平变化和临床意义研究

目的探讨急性白血病(AL)患儿血浆D-二聚体(D-D)、纤维蛋白原降解产物(FDP)及纤维蛋白原(FIB)水平的变化,及其在其病情状态、疗效观察及预后判断中的临床意义。方法将65例AL患儿依据小儿AL的诊疗标准分为初诊组、化疗缓解组、复发组,并与健康对照组进行比较。采用胶体金方法测定其血浆D-D,酶联免疫吸附测定(ELISA)方法测定其FDP、FIB水平,观察各组血浆D-D、FDP及FIB水平的变化。结果与健康对照组比较,AL初诊组、复发组患儿血浆D-D、FDP及FIB水平均显著升高(P0.05),而化疗缓解组与健康对照组比较,差异无统计学意义(P0.05);与初诊组比较,化疗缓解组患儿血浆D-D、FDP及FIB水平均显著降低(P0.05),而复发组上述指标则显著升高(P0.05);与化疗缓解组比较,复发组上述指标显著增高,差异有统计学意义(P0.05)。结论 AL患儿在初诊、复发时D-D、FDP及FIB水平显著升高,化疗完全缓解时则降为正常,说明AL初诊、复发时存在不同程度的凝血与纤溶系统激活,有继发纤溶亢进;而随着化疗完全缓解后,继发纤溶亢进解除,提示小儿AL血浆D-D、FDP及FIB与病情状态密切相关,可作为其病情判断、化疗效果及预后评估的指标。     

脑钠尿肽在老年人非心脏手术后的变化及意义

目的 探讨血浆脑钠尿肽(BNP)浓度在老年人非心脏手术后的变化及意义.方法 依据术前血浆BNP浓度将101例择期行非心脏手术患者分为两组,A组(n=61):BNP浓度≤100 ng/L;B组(n=40):BNP浓度>100 ng/L,对比分析手术前后BNP浓度及术后心脏事件的发生情况.结果 A组术前、术后BNP浓度分别为(58.2±28.7)ng/L、(53.7±25.9)ng/L(P>0.05);B组术前、术后BNP浓度分别为(147.3±72.1)ng/L、(341.5±92.4)ng/L(P<0.05).A组无心脏事件发生,B组中有14例发生心脏事件(P<0.05).结论 术前血浆BNP 浓度>100 ng/L的老年人非心脏手术后血浆BNP浓度变化大,可能发生心脏事件.     

高血压对房颤患者血浆脑钠肽水平的影响及临床意义

目的 探讨高血压对房颤(AF)患者血浆脑钠肽(BNP)水平的影响及其临床意义.方法 选取心功能Ⅰ ～Ⅳ级AF患者126例,采用干性免疫法测定AF患者AF发作时血浆BNP水平,按是否合并高血压病将患者分为两组,即合并高血压组和不合并高血压组,比较两组血浆BNP水平的差异.结果 合并高血压组患者AF发作时血浆BNP水平为(432.40±492.46)ng/L,不合并高血压组血浆BNP水平为(274.12±368.99)ng/L,两组比较有差异统计学意义(P<0.05).结论 高血压对AF患者血浆BNP水平有一定的影响,提示高血压可能干扰临床医生根据血浆BNP水平变化对AF和心力衰竭等情况做出评估.     

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。     

血浆脑钠素和超敏C反应蛋白联合监测对急性冠脉综合征的评估价值

目的:探讨血浆脑钠素(BNP)和超敏C反应蛋白(hs～CRP)水平联合监测对急性冠脉综合征(ACS)早期病情及预后的评估价值。方法:测定50例ACS患者发病24h及14d和15例冠脉造影无明显狭窄对照组患者的血浆BNP和hs-CRP水平,分析其与临床指标的关系。结果:ACS患者发病24h、14d血浆BNP和hs-CRP水平均明显高于对照组(P<0.01),急性心肌梗死(AMI)组的BNP和hs-CRP水平亦均高于不稳定性心绞痛(UAP)组(P<0.05)。ACS患者发病后24h的血浆BNP和hs-CRP水平与冠脉病变积分(Gensini积分)、冠心病危险因素积分(RSC)无显著相关,但第14天的血浆BNP与Gensini积分呈正相关(r=0.411.P<0.05),第14天的血浆hs-CRP水平与RSC、Gensini积分均呈正相关(r=0.375,P<0.05;r= 0.423,P<0.05)。第14天的血浆BNP明显升高组(>80 pg·ml~1组),其hs-CRP水平显著高于非高BNP组(<80pg·ml~1)。4周后的左室射血分数(LVEF)明显低于非BNP明显升高组(<80pg·ml~1组)(P<0.05)。结论:血浆BNP和hs- CRP水平的联合监测有助于ACS病情及预后的评估,对ACS的危险分层具有一定临床指导意义。     

B型利钠肽对严重感染及感染性休克患者预后的预测作用

目的 评价B型利钠肽(BNP)对严重感染及感染性休克预后的预测作用.方法 观察102例严重感染及感染性休克患者入重症监护病房(ICU)24 h血浆BNP水平、临床及预后相关资料.将患者分为28 d死亡组和存活组,比较其差异性,并用受试者工作特征曲线(ROC曲线)评价BNP水平对死亡的预测作用;进一步将存活患者分为BNP升高组和正常组,比较其差异性.结果 死亡组(39例)患者急性生理学与慢性健康状况评分系统Ⅱ(APACHEⅡ)评分显著高于存活组[63例,(28.9±5.9)分比(20.2±5.4)分,P<0.013,但两组白细胞计数、血乳酸值则差异无统计学意义.死亡组患者血浆BNP水平[(1 451.3±531.7)ng/L]明显高于存活组((394.55±81.7)ng/L,P<0.01);以血浆BNP水平>681.4 ng/L作为预测死亡的界点,敏感度为91.4%,特异性为80.3%.在存活组患者中,BNP升高组(48例)的ICU住院天数[(23.75±7.5)d]明显长于正常组(15例,(14.9±5.1)d,P<0.053;但两组APACHE 评分则差异无统计学意义.结论 血浆BNP水平可以预测严重感染及感染性休克的预后.     

充血性心力衰竭患者血浆脂联素和脑钠肽的相关性研究

目的 探讨充血性心力衰竭(CHF)患者血浆脂联素(APN)、脑钠肤(BNP)水平的变化及临床意义.方法 应用酶联免疫吸附法(ELISA)分别测定70例扩张型心肌病CHF患者治疗前、治疗后及20例正常人血浆APN和BNP水平,并进行统计学分析比较.结果 ①CHF组APN、BNP水平分别为(11.66±4.59)mg/L、(1079.78±550.76)ng/L明显高于正常对照组(1.38±0.47)mg/L、(59.63±22.43)ng/L(均P＜0.01);②心功能Ⅱ、Ⅲ、Ⅳ级组APN分别为(5.59±1.85)mg/L、(11.27±3.00)mg/L及(15.19±3.81)mg/L,BNP水平分别为(463.78±169.50)ng/L、(917.05±290.19)ng/L及(1 595.72±481.76)ng/L,随着心功能恶化二者水平显著升高(均P＜0.01).③CHF组治疗后APN(5.88±2.55)mg/L、BNP(547.25±234.88)ng/L明显低于治疗前水平,(11.66±4.59)mg/L、(1 079.78±550.76)ng/L(均P＜0.01);④CHF组血浆APN水平与BNP呈正相关(r=0.680,P＜0.01).结论 CHF患者血浆APN和BNP水平明显高于正常对照组且随着心功能恶化而显著升高.CHF患者经治疗后随心功能好转血浆APN和BNP水平可降低.CHF患者血浆APN和BNP呈正相关.     

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.     

手转胎头术失败的原因与分娩结局临床分析

目的 探讨手转胎头术失败的原因与分娩结局.方法 选择2008年1月至2010年12月于我院住院分娩的持续性枕横位、枕后位产妇198例,根据行手转胎头术后结果分为成功组126例、失败组72例.比较两组分娩结局,对比分析失败原因.结果 失败组胎儿体质量≥3500 g的发生率[76.4％(55/72)]明显高于成功组[31.7％(40/126)],差异有统计学意义(x2=30.177,P=0.001)、失败组宫缩乏力发生率[58.3％(42/72)]高于成功组[38.1％ (48/126)],差异有统计学意义(x2=7.569,P=0.006)、失败组骨盆临界或轻度狭窄发生率[38.9％ (28/72)]高于成功组[23.8％(30/126)],差异有统计学意义(x2 =5.030,P=0.002)、失败组手转胎头时机不当(宫口开大＜6 cm、胎头位于坐骨棘上及宫口开大8～10 cm、胎头位于坐骨棘下≥2 cm)发生率[61.1％(44/72)]高于成功组[38.9％(49/126)],差异有统计学意义(x2=9.084,P=0.003).失败组母儿并发症(产后出血、产褥病率、胎儿窘迫、新生儿窒息)发生率高于成功组(x2 =9.586,P=0.002、x2=9.334,P=0.002、x2=5.910,P=0.015、x2=5.240,P=0.022)、失败组剖宫产发生率[72.2％(52/72)]明显高于成功组[34.1 ％(43/126),x2=26.641,P=0.001)].结论 手转胎头术能使难产变顺产,降低剖宫产率,减少母儿并发症,但须积极预防、处理导致手转胎头术失败的原因,对矫正失败后继续矫正及试产应慎重.     

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.     

Evidence-Based Pain Management and Palliative Care in Issue Four for 2009 of The Cochrane Library

ABSTRACT

The Cochrane Library of Systematic Reviews is published quarterly. Issue 4 for 2009 contains 4027 complete reviews, 1906 protocols for reviews in production, and 11447 one-page summaries of systematic reviews published in the general medical literature. In addition, there are citations of 600,000 randomized controlled trials, and 12,200 cited papers in the Cochrane methodology register. The health technology assessment database contains over 7500 citations. This edition of the Library contains 90 new reviews, of which 19 have potential relevance for practitioners in pain and palliative medicine.     

Wie zuverlässig sind Angaben zu nichtentzündlichen ausgedehnten Schmerzen?

ZusammenfassungFragestellung Es wurde geprüft, wie sich der Differenziertheitsgrad zweier Schmerzmessmethoden auf Angaben zur Ausgedehntheit klinischer Schmerzen auswirkt. Zugleich wurde der Referenzzeitraum variiert, über den die Patienten berichten sollten.Methode Erfasst wurde der Einfluss zu Lasten der Befragungsdifferenziertheit durch den Vergleich zweier Körperschema-Bildvorlagen. Drei Referenzzeiträume (Schmerz aktuell, letzte Woche, letztes halbes Jahr) wurden vorgegeben.Ergebnisse Patienten mit ausgedehnten Schmerzen gaben bei differenzierter Befragung um so mehr Schmerzen an, je weiter die Schmerzen zurück lagen und je größer der Berichtszeitraum war. Patienten mit gelenknahen Schmerzen gaben bei hoch differenzierter Befragung weniger ausgedehnte Schmerzen in der Vergangenheit an als bei globaler Einschätzung. Patienten mit Rückenschmerzen berichteten bei differenzierter Befragung zum aktuellen Schmerz über weniger ausgedehnte Schmerzen als bei globaler Befragung.Schlussfolgerung Die Angaben zur Schmerzausdehnung variieren vor allem bei Patienten mit ausgedehnten Schmerzen in Abhängigkeit von der Differenziertheit der Befragung. In diesen Fällen ist die Wahrscheinlichkeit erhöht, dass sich die Beschwerdesymptomatik zumindest teilweise erst in der Reaktion auf die situativen Befragungsbedingungen konstituiert und daher nicht auf andere Befragungsbedingungen generalisiert werden kann.