兔急性肺栓塞后左、右肺动脉流量差异变化

目的探讨兔急性肺栓塞(APE)后左、右肺动脉流量差异的变化及其意义。方法建立兔APE模型,以多普勒超声心动图检测APE模型前、后的左、右肺动脉流量差异的变化。结果成功建立兔APE模型23只,通过多普勒超声心动图所获结果显示APE后主肺动脉、左、右肺动脉血流速度、VTI、Flow均较栓塞前减低(P<0.05),△VTI/mean、△Flow/mean均较栓塞前增大(P<0.05),单侧为重肺栓塞显著。结论APE后左、右肺动脉流量的分布发生了明显的改变,左、右肺动脉流量差异变化率(△VTI/mean、△Flow/mean)增大,单侧为重肺栓塞显著。     

256层螺旋CT肺动脉成像量化评价急性肺动脉栓塞患者右心室功能和肺动脉栓塞程度

目的 应用256层螺旋CT肺动脉成像(CTPA)定量评价急性肺动脉栓塞(APE)患者右心室功能和肺动脉栓塞程度。方法 选择经256层螺旋CTPA证实的APE患者75例, 年龄25~80岁,平均(59.2±13.3)岁,其中男42例,女33例,采用CT肺动脉栓塞分数(obstruction scores,OS)评价APE程度,根据OS值将患者分为轻(n=18,OS<30%)、中(n=25,OS=30%~50%)和重度(n=32,OS<30%),通过测量CT图像上右心室短轴最大直径(RVd)、左心室短轴最大直径(LVd)、右心室短轴与左心室短轴最大直径比率(RVd/LVd)、主肺动脉(MPA)、奇静脉及上腔静脉(SVC)直径评价右心室功能。同时比较3组右心室功能CT参数。结果 CT肺动脉栓塞程度和心血管参数之间有明显相关性(P<0.01),表现为在中、重度APE患者中RVd、RVd/LVd、主肺动脉直径、奇静脉直径及上腔静脉直径均较轻度APE患者高(P<0.05),而LVd值较轻度APE患者低,同时中度和重度APE患者之间这些参数差异也有统计学意义(P<0.05)。结论 应用CTPA得到的量化CT参数对评价APE患者右心室功能和APE程度是十分有力的工具,APE患者右心室功能障碍和APE程度密切相关。     

超声心动图评估房间隔缺损患者右心室功能的价值

目的探讨超声心动图评估房间隔缺损(atrial septal defect,ASD)患者右心室功能的临床价值。方法选择2011—2015年诊断为ASD行介入封堵术患者48例,依据肺动脉收缩压水平分为肺动脉压正常组(肺动脉收缩压30 mm Hg)20例和肺动脉压升高组(肺动脉收缩压≥30 mm Hg)28例。术前采用经胸二维超声检测2组右心房前后径(RAD)、右心室前后径(RVD)、左心房前后径(LAD)、左心室前后径(LVD)、右心室射血分数(RVEF)。采用二维斑点追踪显像技术测量右心室前壁基底段、中间段、心尖部收缩期径向应变峰值(PSLS)与右心室短轴圆周应变峰值(GCS)。采用血流多普勒与组织多普勒技术比较2组三尖瓣舒张早期血流速度峰值/舒张晚期血流速度峰值比(E/A),以及三尖瓣舒张早期血流速度峰值/三尖瓣瓣环根部舒张早期运动峰值速度比(E/e)。结果肺动脉压升高组RAD大于肺动脉压正常组(P0.01);肺动脉压升高组右心室各节段及整体PSLS和各节段GCS均低于肺动脉压正常组,差异均有统计学意义(P0.01);肺动脉压升高组E/A为0.87±0.15明显低于肺动脉压正常组的1.29±0.23,差异有统计学意义(t=3.076,P0.05);肺动脉压升高组E/e为7.47±0.83明显高于肺动脉压正常组的5.38±0.61(t=2.651,P0.05)。结论伴有不同程度肺动脉高压的ASD患者右心室功能存有差异,当肺动脉压升高,右心室负荷加重,右心室功能受损程度越明显。超声心动图可以从多角度评估ASD患者右心室功能。     

兔急性肺栓塞面积与血流动力学的相关性研究

[目的]制备不同梗阻面积的兔急性肺栓塞模型,探讨肺栓塞面积与血流动力学变化的相关性。[方法]通过介入方法经导管注入自体血栓选择性栓塞肺动脉,建立不同栓塞面积的兔急性肺栓塞模型;比较栓前、栓后15min,30min,1h,2h血流动力学指标变化,同时观察心脏超声影像学变化。[结果]自体血栓均按要求阻塞相应肺动脉,肺栓塞形成后心输出量下降,肺动脉压力显著增高,并在1h,2h达到峰值,各血流动力学指标随肺栓塞面积增大而变化更显著。[结论]此急性肺栓塞动物模型制作方法确切可行,具有可重复性。肺栓塞导致血流动力学及左右心室功能紊乱,栓塞面积与其损害程度呈正相关,并严重影响预后。     

超声评价肺栓塞所致肺动脉高压左室血流动力学变化

探究肺栓塞所致肺动脉高压采用超声检测评价其左室血流动力学变化的临床价值。入选符合标准的慢性肺栓塞患者90例,按照其肺动脉高压程度分为轻度组、中度组和重度组各30例;同时选取同期体检健康人30例设为对照组,观察并分析超声检测后各组左室血流动力学变化情况。经超声检测后,中度组和重度组的CI、LVSV、LVCO指标数值显著低于对照组,差异具有统计学意义(P0.05);但轻度组的各项指标数值与对照组相比较,差异无统计学意义(P0.05);三组肺栓塞患者的LVEF指标与对照组相比较,差异无统计学意义(P0.05)。肺栓塞所致的肺动脉高压可能存在明显的左室血流动力学变化,而临床检测左室射血分数(LVEF)指标的意义不大,超声心动图检测患者的心脏指数(CI)、左心输出量(LVCO)和左室每搏量(LVSV)指标则对于临床评估患者预后意义较大。     

血浆氨基末端脑钠肽前体检测对急性肺栓塞患者右心衰竭诊断的意义

目的探讨血浆氨基末端脑钠肽前体(NT-proBNP)水平对急性肺栓塞(APE)所致右心衰竭的诊断价值以及对预后判断的意义。方法 31例APE患者分为3组:大面积栓塞组(9例),次大面积栓塞组(15例),小面积栓塞组(7例)。所有患者均测量血压、血肌酐、D-二聚体及NT-proBNP水平,并行心脏及双下肢静脉血管彩色多普勒超声检查,观察患者临床表现和预后情况。结果大面积栓塞组D-二聚体、NT-proBNP水平及右心室/左心室舒张末内径比值均明显高于次大面积栓塞组,而小面积栓塞组上述指标明显低于次大面积栓塞组,差异均具有统计学意义(P均0.05)。结论 APE患者右心室功能障碍与NT-proBNP水平明显相关。检测NT-proBNP水平有助于评价APE患者危险分层。     

多普勒超声检测肺动脉分支血流对评估急性肺血栓栓塞症的意义

目的 应用多普勒超声心动图分析急性肺血栓栓塞症（APE）患者左右肺动脉分支血流频谱特点及对APE栓塞部位的评估意义。 方法 利用多普勒超声检测32例正常对照者（组Ⅰ）及42例大面积或次大面积APE患者肺动脉主干及其左右分支血流频谱。其中左侧肺动脉栓塞为主者19例（组Ⅱ），右侧肺动脉栓塞为主者11例（组Ⅲ），双侧肺动脉栓塞者12例（组Ⅳ）。 结果 各组APE患者肺动脉及左、右栓塞分支血流速度及速度时间积分（VTI）减低，加速时间缩短（P〈0．05）；组Ⅱ左、右肺动脉VTI比值及左肺动脉与主干VTI比值减低（P〈0．05）；组Ⅲ右肺动脉与主干VTI比值减低（P〈0．05）。 结论 多普勒超声检测APE患者肺动脉主干及其左、右分支血流频谱，对快速早期提示APE栓塞部位及程度具有显著的临床应用价值。     

体外膜肺氧合对急性右心衰竭犬血流动力学的影响

目的 探讨体外膜肺氧合(ECMO)对急性右心衰竭犬血流动力学的影响.方法体重20～25 kg健康成年雄性犬10只,按随机数字表法分为急性右心衰竭模型组和ECMO治疗组,每组5只.犬麻醉后行胸廓切开术,于右心房、右心室、肺动脉放置相关测压导管,测量右心房压(RAP)、右心室压(RVP)及肺动脉压(PAP);于主动脉及肺动脉放置血管超声探头,测量心排血量(CO)及肺动脉流量(QPA),测得结果为基础值.ECMO组建立静脉-动脉体外膜肺氧合(VA-ECMO)转流,分别经股动脉和股静脉建立动、静脉插管,随后连接预充的ECMO装置.两组均逐渐套扎肺动脉以使QPA分别降至基础值的60％、40％和0％,每降至一个程度保持30 min,并测量上述血流动力学指标,观察其变化.结果 模型组与ECMO组血流动力学指标基础值比较无明显差异.套扎肺动脉后,模型组CO(L/min)于QPA降至60％和40％时均较基础值明显下降(1.80±0.19、1.48±0.22比3.24±0.23,均P＜0.05),且显著低于ECMO组(60％QPA:1.80±0.19比3.24±0.35;40％QPA:1.48±0.22比3.20±0.37,均P＜0.05);ECMO组CO于QPA降至60％、40％和O％时与基础值比较差异无统计学意义(3.24±0.35、3.20±0.37、3.12±0.28比3.44±0.32,均P＞0.05).模型组PAP、RAP和RVP(均mm Hg,1 mm Hg=0.133 kPa)于QPA降至60％和40％时均较基础值明显增加(PAP:36.2±5.3、39.8±5.4比17.4±2.7;RAP:11.2±2.8、12.8±2.6比4.4±1.7;RVP:25.6±4.9、27.8±4.5比11.6±1.8,均P＜0.05),且显著高于ECMO组(60％QPA:PAP 36.2±5.3比23.2±5.2,RAP 11.2±2.8比6.2±2.3,RVP 25.6±4.9比15.2±3.5;40％QPA:PAP 39.8±5.4比24.4±4.8,RAP 12.8±2.6比7.0±2.4,RVP 27.8±4.5比16.8±4.2,均P＜0.05);而平均动脉压(MAP,mm Hg)较基础值明显下降(81.2±15.8、62.2±14.4比128.6±16.4,均P＜0.05),且显著低于ECMO组(60％QPA:81.2±15.8比128.0±26.5;40％QPA:62.2±14.4比124.6±25.4,均P＜0.05).ECMO组心率(HR,次/min)、PAP、RAP和RVP于QPA降至60％、40％和0％时均较基础值略有增加(HR:161.4±14.8、160.6±13.1、157.6±11.9比152.6±14.5;PAP:23.2±5.2、24.4±4.8、25.2±6.2比18.8±3.4;RAP:6.2±2.3、7.0±2.4、7.6±4.2比4.6±1.5;RVP:15.2±3.5、16.8±4.2、16.2±3.3比12.2±2.3),MAP则略有下降(128.0±26.5、124.6 ±25.4、121.2±21.4比135.8±22.2),但差异均无统计学意义(均P＞0.05).结论 VA-ECMO可以有效改善急性右心衰竭犬的心功能,并保持血流动力学稳定.     

急性肺栓塞患者合并与不合并肺动脉高压时肌钙蛋白Ⅰ及氨基末端脑钠肽前体水平的差异

目的探讨观察急性肺栓塞患者肌钙蛋白Ⅰ(cTnⅠ)及氨基末端脑钠肽前体(NT-proBNP)与肺动脉压力之间的关系。方法选择102例肺栓塞患者,通过超声心动图测得肺动脉收缩压值(PASP)将其分为肺动脉高压组(30 mm Hg)54例,肺动脉压正常组(≤30 mm Hg)组48例。对所有入选的患者进行cTnⅠ、NT-proBNP和血气分析检测,观察cTnⅠ、NT-ProBNP在急性肺动脉栓塞患者中的临床意义及与肺动脉高压相关性。结果急性肺栓塞患者合并肺动脉高压组的cTnⅠ水平(0.0415±0.049 ng/ml)明显高于肺动脉压正常组(0.0255±0.0211 ng/ml),差异具有统计学意义(P0.05);急性肺栓塞患者合并肺动脉高压组的NT-proBNP水平(2 696.3±1 933.38 pg/ml)明显高于肺动脉压正常组(465.7±226.48 pg/ml),差异具有统计学意义(P0.05)。结论急性肺栓塞患者血清cTnⅠ和NT-proBNP的水平与是否合并肺动脉高压相关,cTnⅠ和NT-proBNP可作为急性肺动脉栓塞患者病情评估的可靠指标。     

犬急性肺动脉高压模型上腔静脉多普勒血流速度频谱变化规律研究

目的 探索犬血栓栓塞性肺动脉高压模型上腔静脉血流频谱的变化规律及意义.方法 通过股静脉注入血栓栓子建立犬血栓栓塞性肺动脉高压动物模型,通过右心导管监测肺动脉压力,将探头置于右侧锁骨上窝,对血栓注入前后上腔静脉进行超声检测,测量收缩期回心波峰值血流速度(S)、舒张期回心波峰值血流速度(D)、心房收缩期反向波峰值速度(AR)及心室收缩期反向波峰值速度(VR),分析上腔静脉血流多普勒频谱形态变化规律.造模前后参数的比较采用配对资料t检验,上腔静脉频谱指标随肺动脉收缩压的改变采用Pearson相关分析.结果 以肺动脉峰值收缩压超过30 mm Hg为模型建立成功的标准,成功建立犬肺动脉高压模型24只.上腔静脉血流速度频谱显示:在中度肺动脉高压组S、AR分别为(15.37±8.08)cm/s、(14.08±5.30)cm/s,与栓塞前S、AR[(19.92±7.27)cm/s、(10.05±2.81)cm/s]比较,S减低,AR升高,差异有统计学意义(t=2.055、-3.155,P均＜0.05);重度肺动脉高压组S、AR、VR分别为[(14.72±7.42)cm/s、(21.84±6.56)cm/s、(13.03±6.67)cm/s],与栓塞前S、AR及VR[(0.49±0.19)cm/s]比较,S减低,AR、VR升高,差异有统计学意义(t=2.265、-8.892、-2.101,P均＜0.05).相关性分析结果显示:AR/S、VR/S比值随肺动脉收缩压的升高而升高,与肺动脉收缩压呈正相关(r＝0.693、0.646,P＜均0.01).结论急性肺动脉高压犬上腔静脉血流速度频谱AR/S及VR/S比值随肺动脉压力的升高而显著升高,可对肺动脉高压早期诊断具有一定参考价值.     

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.     

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.     

Molecular characterization of virulence and antimicrobial resistance profile of Shigella species isolated from children with moderate to severe diarrhea in northeastern Brazil

Molecular characterization of virulence and antimicrobial resistance profiles were determined for Shigella species isolated from children with diarrhea in Fortaleza, Brazil. Fecal specimens were collected along with socioeconomic and clinical data from children with moderate to severe diarrhea requiring emergency care. Shigella spp. were isolated by standard microbiological techniques, and we developed 4 multiplex polymerase chain reaction assays to detect 16 virulence-related genes (VRGs). Antimicrobial susceptibility tests were performed using disk diffusion assays. S. flexneri and S. sonnei were the predominant serogroups. S. flexneri was associated with low monthly incomes; more severe disease; higher number of VRGs; and presence of pic, set, and sepA genes. The SepA gene was associated with more intense abdominal pain. S. flexneri was correlated with resistance to ampicillin and chloramphenicol, whereas S. sonnei was associated with resistance to azithromycin. Strains harboring higher numbers of VRGs were associated with resistance to more antimicrobials. We highlight the correlation between presence of S. flexneri and sepA, and increased virulence and suggest a link to socioeconomic change in northeastern Brazil. Additionally, antimicrobial resistance was associated with serogroup specificity in Shigella spp. and increased bacterial VRGs.     

护理干预对面部中重度寻常型痤疮的临床疗效影响分析

目的研究护理干预对面部中重度寻常型痤疮的临床疗效影响。方法选取本院在2014年4月~2016年7月诊治的136例面部中重度寻常型痤疮患者,随机分为研究组与对照组,每组68例;所有患者均依据其情况给予对应的治疗,其中对照组在治疗期间给予常规护理,研究组在对照组的基础上再给予综合性护理干预,比较两组的治疗效果及护理满意度情况等。结果患者在接受治疗和护理后,研究组中度与重度患者的治疗效果较对照组均明显提高(P0.05),研究组护理满意度较对照组明显增高(P0.05)。结论对面部中重度寻常型痤疮患者在其治疗期间给予综合性护理干预,具有良好的效果。