心肌淀粉样变心电学特征研究

目的 :分析总结无创性心电学检查诊断心肌淀粉样变(CA)的特点。方法 :回顾分析2008-08至2013-12我院诊断为CA的60例患者的临床及其心电学特征。结果 :60例CA患者中男性48例,女性12例。初诊率低,确诊平均年龄(54.5±14.2)岁。60例患者中:(1)合并心力衰竭32例(53.3%),胸腔或心包积液12例(20%),房性心律失常20例(33.3%),室性心律失常8例(13.3%),窦房阻滞4例(6.7%),房室阻滞15例(25%),左束支阻滞4例(6.7%),右束支阻滞5例(8.3%),室内阻滞8例(13.3%)(;2)合并肢体导联低电压32例(53.3%),胸前导联假性Q波52例(86.7%),ST-T改变48例(60%),其中30例同时合并肢体导联低电压和假性Q波(;3)合并胸腔或心包积液、胸前假性Q波患者出现肢体导联低电压比例显著升高,但仍有22例(45.8%)不存在胸腔或心包积液的患者出现肢体导联低电压(;4)QRS间期为(104±26)ms,QT间期为(404±34)ms,QTc为(462±35)ms。aV R导联最小负向R波电压均值为0.17 mV、QRS波电压均值为0.30 mV,肢体导联和V1~3导联R波电压均值均0.5 m V,V1~3的Q或S波电压均值分别为0.62 m V、1.61 m V及1.56 m V。V1~3导联R/S的比值分别为0.19、0.12和0.20。结论:CA患者胸前导联假性Q波发生率最高,同时合并肢体导联低电压、胸前导联假性Q波伴深Q或S波以及ST-T改变有助于CA的鉴别诊断。     

肥厚型心肌病体表心电图特征

目的 探讨肥厚型心肌病（HCM）患者体表心电图（ECG）特征。 方法 选取2015年5月~2017年4月期间住院治疗的HCM患者60例，同时选取本院同期查体的正常人60例，作为对照组，要求两组人员性别、年龄、体质量指数匹配。分析ECG各导联QRS波时限和R波、S波振幅，异常q波情况，QTC时限，R/S比值， ST段下移与抬高，T波低平、倒置，P波时限等指标。 结果 ①HCM组的V2、V3导联QRS波时限；Ⅱ、V4导联异常Q波比例；QTC时限；P波时限；左心室肥厚ECG诊断公式SV1+RV5/V6及（SV3+RaVL）×QRS波时限均显著高于正常对照组。②HCM组的I、aVR、aVL、aVF导联QRS波时限；aVR导联Q波所占比例； I、Ⅱ、Ⅲ、aVL、aVF、V3、V4、V5、V6导联QRS波主波与T波方向一致性； V4、V5、V6导联R/S比值均显著低于正常对照组。 结论 ECG诊断HCM首先要满足左心室肥厚的诊断标准，再结合上述ECG导联的特异性参数进行综合判断。     

碎裂QRS波与HCM室性心律失常及猝死的关系

目的探讨碎裂QRS波与肥厚型心肌病患者发生室性心律失常及心源性猝死的关系。方法选取来我院就诊的肥厚型心肌病患者70例,随访1年。20例出现室性心律失常或心源性猝死入选试验组,50例未出现室性心律失常或心源性猝死入选对照组。所有入选患者均行心电图检查,统计分析两组患者碎裂QRS波特点。结果下壁导联碎裂QRS波发生率高于其它区域。试验组前壁导联碎裂QRS波发生率大于对照组(35%vs. 10%,p=0.012);三个或以上区域碎裂QRS波发生率大于对照组(30%vs. 4%,p=0.008)。三个或以上区域碎裂QRS波对肥厚型心肌病室性心律失常及心源性猝死的敏感性30%,特异性96%。结论三个或以上区域碎裂QRS波与肥厚型心肌病室性心律失常及心源性猝死有关,在一定程度上可以预警肥厚型心肌病高危患者。     

碎裂QRS波与肥厚型心肌病患者心肌纤维化/瘢痕的关系

目的 评价常规12导联心电图检出的碎裂QRS波(fragmented QRS complex,fQRS)与肥厚型心肌病患者心肌纤维化/瘢痕的关系.方法 91例肥厚型心肌病患者,通过心脏磁共振检查检出心肌纤维化/瘢痕.记录所有患者的常规12导联心电图,判读是否存在fQRS.结果 9l例患者中,58例(63.7％)经由心脏磁共振检出了延迟增强(late gadolinium enhancement,LGE),其中19例(20.9％)心电图检出fQRS.LGE阳性患者的fQRS检出率显著高于LGE阴性患者(31.0％对3.0％,P=0.002).在检出fQRS的19例患者中,18例(94.7％)检出了LGE.在检出LGE的患者中,fQRS阳性患者较fQRS阴性患者的LGE节段分布更为广泛(2.8±1.6对2.0±1.1,P=0.035).fQRS在肥厚型心肌病患者中检出心肌纤维化/瘢痕的敏感性和特异性分别为31.0％和97.0％.结论 常规12导联心电图上检出的fQRS是肥厚型心肌病患者存在心肌纤维化/瘢痕的特异性指标,但其敏感性有限.     

The analysis of 11 cases with cardiac amyloidosis misdignosised as idiopathic hypertrophic cardiomyopathy

目的 分析11例心脏淀粉样变误诊为原发性肥厚型心肌病患者的临床特征,探讨误诊原因及诊断要点.方法 11例患者均为男性,平均年龄(56.3±21.5)岁,在外院诊断为原发性肥厚型心肌病,通过分析患者心电图、超声心动图和心力衰竭的特征及伴随的肾脏、肝脏、呼吸系统及甲状腺受累的临床特点及相关实验室检查,分析心脏淀粉样变与原发性肥厚型心肌病的鉴别要点.结果 所有患者均表现为进行性充血性心力衰竭,超声心动图显示左心室肥厚伴颗粒样闪光现象,6例患者心电图肢导联QRS波低电压,5例患者V1～ V4导联呈QS型,所有患者心电图电压( SV5+ RV1)与左室横截面积比值＜1.0,5例患者伴心房静止.患者均伴有蛋白尿,7例患者表现为肾病综合征,6例患者伴有肝肿大,4例患者伴呼吸睡眠暂停低通气综合征、原发性甲状腺功能减低及皮肤紫癜.腹壁脂肪活检及刚果红染色提示淀粉样变性.结论 心脏淀粉样变有其特有的心电图及超声心动图改变,同时多伴有其他系统受累的临床表现,是其与原发性肥厚型心肌病鉴别的关键.     

aVR导联法对于鉴别诊断房颤伴室性心动过速的临床价值

目的探讨a VR导联法对于鉴别房颤伴室性心动过速的临床价值。方法选取武汉大学人民医院收治的110例心房颤动伴连发3~5个以上畸形宽QRS波患者,分析其心电图特征,采用a VR导联法确定其为室性还是室上性。同时选取研究对象动态心电图中282处单发宽QRS波进行分析,将a VR导联法诊断室性心动过速与心室内差异性传导结果与传统方法进行对比分析。结果 a VR导联法鉴别房颤合并宽大畸形QRS波群患者,诊断室性心动过速的敏感性为88.54%,特异性为85.71%,诊断准确性为88.18%。传统方法与a VR法应用于室性心动过速诊断的符合率由高至低分别为QRS波群呈非三相或多相波(95.40%);有类代偿间歇(94.56%);无长短周期(84.52%);QRS波群起始向量相同导联数≤7(52.30%)。传统方法与a VR导联法诊断的心室内差异性传导符合率由高到低顺序依次为有长短周期(93.02%);QRS波群呈三相或多相波(79.06%);QRS波群起始向量相同导联数≥10(72.09%);无类代偿间歇(25.00%)。结论 a VR导联法在对室性心动过速与心室内差异性传导的鉴别诊断中方便实用,但是其仍然有一定的临床限制,需与传统方法相结合进行联合诊断。     

扩张型心肌病的心电图分析

目的 探讨心电图对扩张型心肌病的诊断价值.方法 选择102例扩张型心肌病患者常规12导联同步心电图,分析心律失常、传导阻滞、ST-T改变、异常Q波、肢导联低电压、胸前导联R波递增不良及左胸导联高电压等指标.结果 心律失常的发生率为46.08%,以室性早搏和心房颤动最常见;传导阻滞发生率为42.16%,以一度房室阻滞和完全性左束支阻滞常见;ST-T改变发生率高达94.12%;异常Q波发生率为21.57%;肢导联低电压的发生率为13.73%;胸前导联R波递增不良的发生率为67.65%.RV5+SV1≥3.5 mV或RV6≥3.5 mV的发生率为36.27%;RV6/RV5>1的发生率为61.76%;连续三个心搏的R波和S波电压之和为QRS总电压V6>V5的发生率为36.27%;RV6/Rmax≥3的发生率为31.37%.结论 扩张型心肌病常出现多种异常心电图表现,常规12导联心电图对扩张型心肌病的诊断有一定的实用价值.     

梗阻性肥厚型心肌病经皮心肌内室间隔射频消融术（Liwen术式）后心电图QRS波振幅的变化

目的 超声心动图引导下经皮心肌内室间隔射频消融术（Liwen术式）是治疗梗阻性肥厚型心肌病（HOCM）的一种创新方法。HOCM最常见的心电图改变是QRS波振幅增高。我们假设采用Liwen术式导致室间隔肥厚部位的变薄从而引起心电图（ECG）QRS波振幅的降低。 方法 从2016年6月至2017年6月,连续纳入肥厚型心肌病中心20例经过Liwen术式治疗的HOCM患者。术前以及术后每次随访（1周,1、2、3、6、12个月）均行心电图和超声心动图检查。采用心电图测量12导联心电图Q波、R波、S波振幅,超声心动图测量室间隔厚度（IVS）。计算心电图每个导联的QRS波振幅之和。QRS波振幅降低作为改善指标。 结果 在Liwen术式治疗后心电图QRS波振幅改善率最高的导联为V1和V2导联,分别为90%和85%。术前V1、V2导联的QRS波振幅与前室间隔厚度呈正相关,术后V1、V2导联QRS波振幅在随访期间明显降低。心电图QRS波振幅的改善可以反映术后IVS的逐渐变薄。 结论 心电图V1、V2导联的QRS波振幅降低可作为评价Liwen术式治疗HOCM室间隔变薄的指标之一。     

联合应用心电图和超声心动图在心肌淀粉样变诊断中的价值

目的探讨心电图和超声心动图联合应用在诊断心肌淀粉样中的价值。方法入选2006年至2013年之间在北京协和医院住院期间诊断为心肌淀粉样变(CA)的患者61例,此外入选肥厚型心肌病(HCM)13例,高血压17例以及健康体检者43例。收集病历资料,进行心电图和超声心动图相关参数测定。结果 CA组肢导联低电压发生率60.7%,余3组均为0%(均为P<0.01),胸导联R波进展不良发生率CA组高于高血压和健康组(47.5%比11.8%,47.5%比11.6%,均为P<0.01),CA组左室射血分数低于其他3组[(54.31%±15.00%)比(69.55%±10.50%)、(54.31%±15.00%)比(63.82%±9.80%)、(54.31%±15.00%)比(69.07%±5.88%),均为P<0.01]。CA组室间隔的厚度小于HCM组[(13.40±2.47)mm比(18.00±5.65)mm,P<0.01],左室后壁厚度大于HCM组[(13.45±2.19)mm比(10.88±3.05)mm,P<0.01],CA组室间隔与左室后壁的厚度与高血压组相比差异无统计学意义[(13.40±2.47)mm比(14.05±3.05)mm、(13.45±2.19)mm比(14.00±2.58)mm,均为P>0.05]。CA组肢导联及胸导联最高电压均小于其他3组(均为P<0.01);与HCM或高血压组比较,CA组所有12导联的QRS波电压值、Ⅰ、a VL和V5、V6导联R波与左室后壁,或与室间隔的比值均较低(均为P<0.01)。与健康组比较,CA组QRS波电压值除a VL、V2导联外,其他导联电压均较低(均为P<0.01);CA组Ⅰ、V5、V6导联R波与左室后壁或室间隔比值均低于健康组(均为P<0.01)。应用ROC曲线得出RⅠ/LVPW曲线下面积最大,当RⅠ/LVPW<0.36时,其诊断CA的敏感度和特异度最佳,分别为96.7%和88.5%。结论心电图和超声心动图检查参数结合,对心肌淀粉样变的辅助诊断和鉴别诊断有很好的临床价值,RⅠ/LVPW具有很高的敏感度和特异度。     

心尖肥厚型心肌病的临床诊断(附13例临床报告)

目的：探讨心尖肥厚型心肌病的心电及影像学检查的特点及临床诊断价值。方法：对13例心尖肥厚型心肌病的心电图、超声心动图、放射核素心肌断层显像、冠状动脉造影及左室造影、磁共振成像等检查方法进行分析总结。结果：心电图的典型改变是胸前导联巨大倒置的T波伴ST段下降和QRS波群高血压,以V4导联最为显。超声心动图示心尖部肥厚,心尖部心室腔狭小甚至闭塞。磁共振成像清晰显示心尖部心肌肥厚。心室造影左心室舒张末期呈“黑桃”样改变,但部分呈“非黑桃”样改变。结论：心电图胸前导联巨大倒置T波TV4＞TV5伴QRS波群高血压RV4＞RV5是诊断AHCM的重要线索。超声心动图是诊断AHCM的重要手段。磁共振成像对确诊该病最有价值。心血管造影及放射性核素心肌显像是AHCM的鉴别诊断手段但不是必备检查。     

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.     

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.     

N-acetyl-L-cysteine combined with mesalamine in the treatment of ulcerative colitis： Randomized,placebo-controlled pilot study

AIM： To evaluate the effectiveness and safety of oral N-acetyl-L-cysteine （NAC） co-administration with mesalamine in ulcerative colitis （UC） patients.
METHODS： Thirty seven patients with mild to moderate UC were randomized to receive a four-wk course of oral mesalamine （2.4 g/d） plus N-acetyl-L-cysteine （0.8 g/d） （group A） or mesalamine plus placebo （group B）. Patients were monitored using the Modified Truelove-Witts Severity Index （MTWSI）. The primary endpoint was clinical remission （MTWSI ≤ 2） at 4 wk. Secondary endpoints were clinical response （defined as a reduction from baseline in the MTWSI of ≥ 2 points） and drug safety. The serum TNF-α, interleukin-6, interleukin-8 and MCP-1 were evaluated at baseline and at 4 wk of treatment. RESULTS： Analysis per-protocol criteria showed clinical remission rates of 63% and 50% after 4 wk treatment with mesalamine plus N-acetyl-L-cysteine （group A） and mesalamine plus placebo （group B） respectively （OR = 1.71; 95% CI： 0.46 to 6.36; P = 0.19; NNT = 7.7）. Analysis of variance （ANOVA） of data indicated a significant reduction of MTWSI in group A （P = 0.046） with respect to basal condition without significant changes in the group B （P = 0.735） during treatment. Clinical responses were 66% （group A） vs 44% （group B） after 4 wk of treatment （OR = 2.5; 95% CI： 0.64 to 9.65; P = 0.11; NNT = 4.5）. Clinical improvement in group A correlated with a decrease of IL-8 and MCP-1. Rates of adverse events did not differ significantly between both groups.
CONCLUSION： In group A （oral NAC combined with mesalamine） contrarily to group B （mesalamine alone）, the clinical improvement correlates with a decrease of chemokines such as MCP-1 and IL-8. NAC addition not produced any side effects.     

Delorme's transrectal excision for internal rectal prolapse

Surgical therapy of functional outlet obstruction in patients with internal rectal intussusception may include abdominal, perineal, or transrectal procedures. Because abdominal procedures often result in significant physiologic impact but unrelieved constipation, the authors have elected Delorme's transrectal excision for management of these patients. Since a short-term placebo effect attends many therapies, this report describes results of transrectal excision only after a threeyear postoperative period. Delorme's transrectal excision of internal intussusception accomplished sustained symptomatic relief in over 70 percent of otherwise refractory constipated patients. The association of internal intussusception with other abnormalities underscores the importance of defining both anatomic and functional components when selecting patients whose constipation may require surgical therapy. Critical technical elements, surgical pitfalls, and potential complications of the procedure are discussed.Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, Toronto, Canada, June 11 to 16, 1989.     

The oral glucose tolerance test: A comparison of the time points on the basis of limit values,normal dispersion,and reproducibility

Summary Time points in the glucose tolerance test (GTT) are compared on the basis of limit values, dispersion within a reference population, and reproducibility. We suggest using the distance between a limit value and the median reference value as a measure of the magnitude of abnormality. The distance between 140 mg/100 ml and the median fasting plasma glucose value is chosen as a standard distance and limits for other points in the GTT are calculated to equal this standard distance of abnormality. We suggest that the probability of correctly interpreting an inividual result is directly related to the reproducibility of the test and inversely related to the percentage of the total range of values which is dispersed among the normal population. The ratio of reproducibility to percentage normal dispersion is proposed as an index of the probability of correctly interpreting an individual result. According to this index, the probability of correct interpretation varies in order: fasting plasma glucose concentration>3-h>2-h>0.5-h>1-h plasma glucose concentration.