神经阻滞定位的临床进展

神经阻滞定位有解剖定位,异感定位,超声与放射学定位和神经刺激器定位,这些定位方法有各自的优缺点。近年来,随着神经刺激器的发展,越来越多的神经定阻滞在神经刺激器辅助下完成,关于其使用的优缺点及连续导管法行神经阻滞的临床应用也存在不同的意见,现就此方面的进展作一综述。

Platelets and depression in cardiovascular disease:A brief review of the current literature

Major depression is an independent risk factor for cardiovascular mortality and morbidity. The exact mechanisms linking depression and increased cardiovascular risk remain poorly understood. Several mechanisms have been proposed including increased platelet reactivity. This review focuses on the current literature that examines the platelet hypothesis of depression. To date studies show increased serotonin response, increased platelet serotonin receptor density, decreased serotonin transporter binding, and decreased platelet serotonin levels in individuals with depression. However other studies have shown no change in serotonin uptake. In addition to platelet serotonin specific pathways, other platelet pathways that have shown significant changes in depressed individuals include blunting of the platelet adenosine response, increased platelet thrombin response, increased glycoprotein Ⅰb expression, increased P-selectin, β thromboglobulin, and platelet factor four, as well as decreased platelet brain derived neurotrophic factor. However there are other studies that show conflicting evidence of increased platelet activation as measured by integrin receptor α2b β3. Other conflictingdata include α adrenergic density and platelet response to augmented serotonin. The direction of future research in platelet functional changes in depression and coronary artery disease should continue to focus on serotonin specific pathways with emphasis on potential mechanisms of specific pathway changes.

Implantable cardioverter defibrillator lead-related methicillin resistant Staphylococcus aureus endocarditis:Importance of heightened awareness

Methicillin resistant Staphylococcus aureus(MRSA) septicemia is associated with high morbidity and mortality especially in patients with immunosuppression,diabetes,renal disease and endocarditis.There has been an increase in implantation of cardiac implantable electronic devices(CIED) with more cases of devicelead associated endocarditis been seen.A high index of suspicion is required to ensure patient outcomes are optimized.The excimer laser has been very efficient in helping to ensure successful lead extractions in patients with CIED infections.We present an unusual case report and literature review of MRSA septicemia from device-lead endocarditis and the importance of early recognition and prompt treatment.

Fluoroscopy:An essential diagnostic modality in the age of highresolution cross-sectional imaging

The importance of fluoroscopy as an imaging modality has been minimized relative to other cross-sectional modalities,including high-resolution computed tomography(CT),magnetic resonance imaging(MRI)and ultrasound.Fluoroscopy examinations have decreased in clinical practice due to reduced appreciation of its usefulness,insufficient training of residents,fewer staff with adequate expertise,and poor reimbursements relative to other modalities.We revisit and build upon the prior literature and history of this decreased utilization.We then seek to prove continued value,through categorized examples and within multiple subspecialties,wherein fluoroscopy plays an integral part toward clinical diagnoses as well as optimizing patient outcomes.This is particularly true for motility and esophageal disorders,where structure and function with real-time evaluation is essential.We additionally show several post-operative cases where the synergy of fluoroscopy with CT and endoscopy is apparent.The fluoroscopic radiologist also has the unique ability to vary patient positioning,as opposed to traditional CT or MRI,where orthogonal views are employed without positional or temporal changes.We turn attention to the modern era,with synergistic and novel cases demonstrating that fluoroscopy remains instrumental toward achieving a diagnosis alongside other modalities.Our cases stress the need to maintain expertise in fluoroscopy skill,and underline its continued importance in residency training programs.We conclude that fluoroscopy is a relatively inexpensive modality that is often under-appreciated in diagnostic radiology.We suggest that competency in fluoroscopy is crucial for future generations of radiologists to both work with their peers,as well as to aid clinicians in the optimal treatment of patients.

急性情感应激与心律失常

急性情感应激可能对心脏造成明显负面影响,导致左室收缩功能障碍、心肌梗死或心律失常。尽管这些影响多为短暂的,但却可能带来严重损伤,甚至有时导致死亡。关于这种不良心血管事件有很多记载。

Stem cell-derived three-dimensional (organoid) models of Alzheimer's disease: a precision medicine approach

The major challenges of the "brain disorders" field-dementia,schizophrenia,other neuropsychiatric disorders-are that these are defined by clinical phenotypes whose underlying biology is poorly understood.There is great variability in definition,prognosis,trajectory,and treatment response indicating that the next step is defining subgroups by combining clinical and biologic information at the level of the individual.These challenges are especially relevant and urgent in the case of dementia and related disorders.

轻度高血压老年患者的运动状态氧脉与静息状态左室收缩和舒张功能相关

Background: The mechanisms responsible for impaired cardiovascular hemodynamics during exercise among persons with milder forms of hypertension are not well documented. We examined the relationship of oxygen pulse during exercise, a correlate of stroke volume, with echocardiographic indices of resting left ventricular function to determine whether abnormal contractility and relaxation are related to abnormal cardiovascular dynamics during exercise among such persons. Methods: Subjects were 44 men and 55 women ages 55 to 75 years with mild hypertension but who were otherwise healthy. Resting left ventricular systolic and diastolic functions were assessed with 2-dimensional Doppler echocardiography and tissue Doppler imaging. Oxygen pulse(millimeters per beat)at rest and during multistage treadmill testing was derived from measurements of oxygen consumption and heart rate. The slope of oxygen pulse between successive exercise stages was calculated. Results: After a steep rise in oxygen pulse from rest to stage 1 of exercise, a markedly diminished oxygen pulse slope was seen between subsequent exercise stages. In stepwise regression analysis, the increase in the slope of oxygen pulse from rest to stage 1 was explained by a greater lean body mass(57% , P< .001)and a larger left atrial size(2% , P< .001). After exercise stage 1, the increase in the slope of oxygen pulse was explained by sex(24% , P< .001), higher mitral E/A ratio(6% , P< .001), and higher mitral annular systolic velocity(6% , P< .001). Conclusions: These results suggest that a blunted oxygen pulse response to exercise among older persons with milder forms of hypertension may reflect impaired left ventricular stroke volume changes during exercise secondary to subtle abnormalities in both systolic and diastolic left ventricular functions.

轻度高血压老年患者左室功能的性别差异

Background: Epidemiologic studies suggest that women are at increased risk of developing heart failure secondary to hypertension. Other studies have documented sex differences in left ventricular systolic and diastolic function in the presence of pressure overload states such as seen in aortic stenosis and hypertension. It is less clear if sex differences are present among older persons with mild hypertension. Methods: One hundred seven healthy subjects, aged 55 to 75 years,with blood pressures ranging from 130 to 159 mmHg systolic and/or 85 to 99 mmHg diastolic, were examined by standard echocardiography and the newer modalities of tissue Doppler and color M-mode imaging. Results: Women had a lower peak mitral annular systolic velocity(Sm), 8.9(95% CI 8.4- 9.5)cm/s versus 10.2(95% CI 9.6- 11.0)cm/s,(P< .01)than men. Among women, increasing age was associated with a reduction in diastolic function. For every decade of age, peak early mitral annular diastolic velocity(Em)declined by 1.6 cm/s(P< .01), mitral inflow velocity of propagation(Vp)declined by 26% (P< .01), E/Vp ratio increased by 20% (P=.03), and E/Em ratio increased by 11% (P=.04)in women. No age-associated changes were seen in men. Conclusions: As revealed by newer echocardiographic imaging modalities, women with mild hypertension showed greater reductions in systolic and diastolic function as they aged compared with men. Our findings are consistent with the increased risk older women have of developing heart failure because of hypertension.

人单核细胞埃里希体病

A 56-year-old man with a history of Wegener granulomatosis presented with 6 days of sinus congestion, fever, malaise, myalgias, episcleritis, and a morbilli form rash. An exacerbation of Wegener granulomatosis was the principal concern because of the frequency of flares in that disease. The patient developed acute r enal failure, thrombocytopenia, transaminitis, and, finally, severe myocarditis that led to congestive heart failure. Additional history-taking and the evoluti on of his clinical features led to empirical treatment with doxycycline for huma n monocytic ehrlichiosis(HME). The diagnosis of HME was confirmed by both a poly merase chain reaction assay for Ehrlichia chaffeensis and by the demonstration of morulae within peripheral blood mononuclear cells. The patient improved prompt ly followinginstitution of doxycycline, and his cardiac function returned to nor mal over a period of 4 months.

运动后近昏厥状态

Syncope and near syncope are great diagnostic challenges in medicine. On the one hand, the symptom may result from a benign condition and pose little or no t hreat to health other than that related to falling. On the other hand, syncope o r near syncope can be the manifestation of a serious underlying condition that poses an imminent threat to life. Patients with a cardiac cause of syncope are a t far greater risk of dying in the first year after an episode of syncope or nea r syncope than individuals with a noncardiac cause. A cardiac cause of syncope should be considered in every patient with syncope or near syn cope, but it is particularly common in older patients or in patients with known structural hear t disease, arrhythmia, or certain electrocardiographic abnormalities. Although m any diagnostic tests may be helpful in the evaluation of syncope and near synco pe, the history, physical examination, and electrocardiogram pinpoint the cause in many circumstances. Syncope after exercise may be due to left ventricular out flow tract obstruction from aortic stenosis or hypertrophic obstructive cardiomy opathy but can also suggest the diagnosis of postexercise hypotension in which a n abnormality in autonomic regulation of vascular tone or heart rate results in vasodilation or bradycardia after moderate intensity aerobic activity. The pati ent discussed in this case highlights the importance of the clinical history in the evaluation of this condition, since the diagnosis was revealed as the patien ts story was described and eventually acted out.

卡维地洛快速滴定应用于充血性心力衰竭患者:一项比较自动化远程医疗与频繁门诊就诊的随机试验

Background: Because of potential side effects and logistical difficulty of titrating medications, outpatients with congestive heart failure rarely receive appropriate doses of carvedilol or other β-blockers. To address these obstacles, we studied if an automated telemedicine system named TeleWatch(TW) could facilitate carvedilol titration in outpatients with left ventricular systolic dysfunction. Methods: Forty-nine patients with New York Heart Association class II and III left ventricular systolic dysfunction, who were tolerating appropriate afterload-reducing therapy and not receiving β-blockers, were enrolled into a 3-month study. Patients were randomized to have clinic-only(CO)(n=24) carvedilol titration or titrations which combined clinic visits with TW monitoring(n=25). All patients were seen in clinic biweekly, and those in the TW group were remotely monitored daily. Using a predefined algorithm, patients in the CO and TW groups were eligible for carvedilol titration on a biweekly or weekly basis, respectively, by physicians blinded to group assignment. Results: There was no statistical difference in the mean final daily dose of carvedilol between the CO and TW groups(39.4 vs 36.2 mg/d, P=.52). Because remote telemedicine titrations were as successful as titrations in the clinic, the time to reach the final dose of carvedilol was significantly shorter in the TW group(33.6 vs 63.7 days, P< .0001). There were 5 serious adverse events in the study, 4 of which were in the TW group(P=.29); however, TW prospectively detected 2 adverse events. Conclusions: Remote monitoring with an automated telemedicine system can successfully facilitate titration of carvedilol in outpatients with New York Heart Association class II and III congestive heart failure.

功能性消化不良合并焦虑障碍病理机制及中医药干预研究进展

功能性消化不良（functional dyspepsia,FD）全球发病率为5%~11%[1]。脑肠互动异常为包括FD在内的功能性胃肠疾病的主要发病机制[2]。焦虑障碍（anxiety disorder,AD）与FD发病密切相关,在我国FD住院患者中54.2%合并有焦虑和（或）抑郁倾向,较普通人群（9.1%）明显升高[3]。部分病例中焦虑先于消化系统症状出现[4]。