Angina pectoris, myocardial infarction and sudden cardiac death with normal coronary arteries: a clinicopathologic study of 9 patients with progressive systemic sclerosis

The syndrome of angina pectoris or acute myocardial infarction without obstructive coronary artery disease has been the subject of much interest. We studied nine autopsied patients with progressive systemic sclerosis and evidence of ischemic heart disease but morphologically normal coronary arteries. Three patients had angina pectoris and three others chest pains of unknown etiology, six had ventricular arrhythmias, four had clinically suspected acute myocardial infarction, and eight had sudden cardiac death. At autopsy extensive focal myocardial necrosis was present in seven patients and myocardial scarring in all nine, but all patients had widely patent intramural and extramural coronary arteries. The finding of contraction band myocardial necrosis in seven of the eight patients who experienced sudden death suggests that the myocardial damage was a consequence of reperfusion of focally nonperfused myocardium, and thus due to a myocardial Raynaud's phenomenon. Patients with PSS may provide a model of spasm of intramyocardial vessels causing angina pectoris or myocardial infarction with morphologically normal coronary arteries.     

TLR4基因表达及TNF-α在老年大鼠多器官功能障碍综合征中作用的研究

目的探讨Toll样受体4基因（TLR4）与TNF-α在老年大鼠多器官功能障碍综合征（MODSE）发病机制中的作用.方法20月龄和3月龄SD大鼠各40只,分别设为老年组及青年组,予油酸（OA）0.25ml/kg和脂多糖（LPS）3.5mg/kg分次静脉注射（间隔4h）,建立二次打击MODSE和青年多器官功能障碍综合征（MODSY）模型.观察对照组及伤后2、6、24h肺、心、肝、肾的病理改变及功能变化,检测肺、心、肝和肾组织中TLR4 mRNA表达及TNF-α含量.结果OA/LPS二次致伤能够导致青年及老年鼠MODS,其中肺脏损害出现最早最重,在同一时相点,老年鼠脏器损害重于青年鼠（P＜0.05～0.01）.致伤后肺、心、肝和肾组织中TLR4 mRNA表达均显著升高（P＜0.05～0.01）,以肺组织中表达最高,2h达峰值,心、肝、肾组织中于6h达峰值;各组织中TNF-α含量均显著升高（P＜0.05～0.01）,以肺组织中升幅最大.在相同时相点老年鼠各组织中TLR4 mRNA表达及TNF-α含量高于青年鼠（P＜0.05～0.01）.结论OA/LPS致伤后老年鼠肺组织中TLR4 mRNA表达及TNF-α水平迅速升高,在MODS发病机制中起重要作用,有可能是MODSE过程中肺损伤出现最早最重的重要原因.     

P wave changes on exercise in patients with isolated mitral stenosis

Patients with mitral stenosis usually showed a marked increase in the P negativity following exercise. The P terminal force in Lead V₁ in 20 cases with isolated mitral stenosis was ?0.090 mm. sec. before exercise, which changed to ?0.177 mm. sec. following the single Master two-step test.Normal adults never showed such changes on exercise. The phenomenon was considered to be due to the posterior rotation of the P wave vector in the horizontal plane, which was induced by the enlargement of the left atrial wall on exercise.     

急诊老年危重病2798例临床特征分析

目的分析急诊老年危重病的临床特点。方法将2000-2006年在急诊室的2798例老年危重病例分3个年龄组,比较疾病谱构成比、病死率和器官功能衰竭。结果(1)老年危重患者占同期危重病例的比例呈下降趋势(χ2=539.43,P<0.01)。(2)60~69岁组占38.6%,70~79岁年龄组患者占39.4%,≥80岁组占22.1%。神经系统疾病1054例,居各系统疾病的第一位,占37.7%,其中脑血管病变858例(脑出血467例,脑梗死391例),占81.4%;循环系统疾病和各种外伤居第二、三位。(3)各年龄组前三位的疾病,60~69岁组为神经系统、各种外伤和循环系统疾病,70~79岁和≥80岁组均为神经系统、循环系统和呼吸系统疾病。(4)急诊老年危重病患者的总病死率为3.3%,病死率居前三位的是循环系统疾病(8.1%)、各种中毒(5.0%)和各种外伤(4.4%)。(5)发生器官功能衰竭患者359例,占总数的12.8%(359/2798);在70~79岁组169例,居第一位,占47.1%(169/359)。(6)一个器官功能衰竭患者316例,占总数的88.0%(316/359),呼吸衰竭和心力衰竭分别居前二位。(7)二个器官功能衰竭33例,病死率9.1%(3/33);三个及以上器官功能衰竭10例,病死率80.0%(8/10)。结论急诊老年危重病患者的重点疾病是神经系统(主要是脑血管疾病)和循环系统疾病,器官功能衰竭的重点病变是呼吸和心力衰竭。     

Effects of a home visiting program for older people with poor health status: a randomized, clinical trial in The Netherlands

OBJECTIVES: To evaluate the effectiveness of a home visiting program on health-related measures in a population of older people with poor health status.
DESIGN: Randomized, clinical trial.
SETTING: Community-dwelling citizens in the Netherlands.
PARTICIPANTS: Three hundred thirty people aged 70 to 84 randomly assigned to an intervention group (n=160) or a control group (n=170).
INTERVENTION: Eight home visits, lasting 1 hour or more, with telephone follow-up, over an 18-month period, conducted by experienced home nurses under supervision of a public health nurse; key elements of the (systematic) visits were assessment of health problems and risks, advice, and referral to professional and community services.
MEASUREMENTS: Self-rated health, functional status, quality of life, and changes in self-reported problems.
RESULTS: No differences were found between the intervention and control group in these and other outcome measures at the end of the intervention period (18 months).
CONCLUSION: The home visiting program did not appear to have any effect on the health status of older people with poor health and are probably not beneficial for such persons.     

腹部超声在诊断老年非均匀性脂肪肝中的应用价值

目的探讨腹部超声辅以彩色多普勒检查在诊断老年非均匀性脂肪肝中的应用价值.方法收集23例最终被其他方法确诊为非均匀性脂肪肝的老年患者的肝脏超声图像,回顾性分析这些患者腹部超声以及彩色多普勒的数字和图象资料,找出其内在规律并评价其在诊断老年非均匀性脂肪肝中的应用价值.结果所有23例老年患者腹部超声图象中没有一例患者的腹部超声图象表现为占位效应,其中Ⅰ型局限浸润型2例,Ⅱ型多灶浸润型1例,Ⅲ型叶段浸润型1例,Ⅳ型弥漫非均匀浸润,残存小片正常区19例;彩色多普勒检查示有7例肝内异常强回声或弱回声区（直径均＞3.0cm）,内部或周边可见正常血管分支走行.结论非占位效应也是老年非均匀性脂肪肝的最重要特征,在诊断老年非均匀性脂肪肝中具有同样高的应用价值.     

Atrial excitability and conduction in patients with interatrial conduction defects

Prolongation of P-wave duration is an accepted indicator of an interatrial conduction disturbance and may predispose patients to atrial arrhythmias. This study was performed to monitor electrophysiologic characteristics of the atria in patients with a prolonged P-wave duration. Atrial excitability and conduction times were compared in 7 patients with a P-wave duration < 115 ms (Group I) and 13 patients with a duration ≥ 115 ms (Group II). In contrast to the Group I patients, most of the 13 patients in Group II had atrial arrhythmias, including sinus nodal dysfunction (3 patients) and a history of atrial fibrillation or ectopic atrial tachycardia (6 patients). Electrophysiologic differences between the 2 groups included a higher late diastolic threshold in Group II (0.8 ± 0.2 mA versus 1.3 ± 0.2 mA; p < 0.005), and a greater increase in intraatrial conduction time (5 ± 10 ms versus 30 ± 20 ms; p < 0.005) and interatrial conduction time (5 ± 15 ms versus 30 ± 15 ms; p < 0.05) of early premature responses. There were no differences between the 2 groups in refractory periods, shape of the strength interval curve, or conduction times of premature responses occurring late in diastole.

These abnormalities in conduction time and excitability found in patients with a prolonged P-wave duration may predispose to the initiation of certain atrial tachyarrhythmias.     

Calcium channel blockade as primary therapy for stable angina pectoris. A double-blind placebo-controlled comparison of verapamil and propranolol

The effectiveness and safety of the beta-adrenergic blocking agent propranolol and the calcium channel antagonist verapamil were compared in 22 patients with chronic stable angina pectoris using a double-blind randomized placebo-controlled crossover protocol. The double-blind phase was preceded by a 2 week single-blind placebo period, followed by randomization to either 4 weeks' therapy with verapamil, 360 mg/day, or propranolol, 240 mg/day, followed by crossover to the other drug. Both verapamil and propranolol increased exercise tolerance (5.5 +/- 0.4 minutes with placebo, 7.8 +/- 0.5 minutes with propranolol [p less than 0.001], and 9.1 +/- 0.5 minutes with verapamil [p less than 0.001]), but the increase with verapamil was significantly greater (p less than 0.01). Both drugs prolonged the exercise duration to 1 mm S-T depression (3.3 +/- 0.4 minutes with placebo, 5.7 +/- 0.5 minutes with propranolol [p less than 0.001] and 5.5 +/- 0.6 minutes with verapamil [p less than 0.001]); the degree of improvement was similar with both active drugs. Both drugs decreased the resting heart rate (76 +/- 3 beats/min with placebo, 56 +/- 2 beats/min with propranolol [p less than 0.001], and 71 +/- 3 beats/min with verapamil [p less than 0.01]), but the heart rate decreased more with propranolol than with verapamil (p less than 0.001). Neither drug produced significant adverse reactions. This study, along with 8 similar double-blind placebo-controlled randomized investigations which have compared verapamil with propranolol, indicate that verapamil is as effective and safe as propranolol in relieving symptoms and improving exercise tolerance in patients with chronic stable angina pectoris and may be considered a first-line therapeutic agent in patients with ischemic heart disease.     

Increased R-wave amplitude induced by acute myocardial ischemia in the dog: A predictor of malignant ventricular arrhythmias

The ability of an increase of 25 % or greater in the sum of R-wave amplitudes in leads X, Y, Z, L₂, and V₅ to predict the occurrence of malignant ventricular arrhythmias (10 or more ventricular premature beats/min, ventricular tachycardia [5 or more consecutive premature beats], and/or fibrillation) was evaluated in 17 dogs during experimental acute myocardial ischemia. Each dog underwent a 15 minute ligation of the left anterior descending coronary artery followed by reperfusion and after recovery, 2 hours later, a 15 minute ligation of the circumflex coronary artery. During ligation of the left anterior descending coronary artery, 12 of 17 dogs (71%) showed no R-wave increase and no arrhythmias (true-negative response). In 5 (29%) of 17 dogs malignant ventricular arrhythmias developed: 2 of 5 (40%) dogs with arrhythmias had a concomitant R-wave increase (true-positive response), and 3 of 5 (60%) with arrhythmias had a less than 25% increase in R-wave amplitude (false-negative results). During circumflex coronary artery ligation, 13 of 17 (76%) dogs showed both R-wave increases and arrhythmias (true-positive response). Four (24%) of 17 dogs had no arrhythmias: 3 of 4 (75%) with no arrhythmias also had a less than 25% increase in R-wave amplitude (true-negative response), whereas 1 of 4 (25%) dogs with no arrhythmias had an increase in R-wave amplitude (false-positive response). In dogs with both arrhythmias and R-wave increases, R-wave changes preceded the onset of arrhythmias by a mean (± standard deviation) of 1 minute 27 seconds (± 43 seconds). Overall, R-wave increases were highly sensitive (83%), specific (94%), and predictive (94%) for the occurrence of malignant ventricular arrhythmias during experimental acute myocardial ischemia.