心内膜下心肌梗死的常见误诊病例浅析

目的:探讨心内膜下心肌梗死的常见误诊原因及对策。方法:回顾性分析9例心内膜下心肌梗死患者的病历资料,包括病史、系统体格检查,ECG、心肌酶谱、胸片、超声心动图检查等。结果:9例心内膜下心肌梗死患者均有临床症状、ECG及心肌酶学指标的动态变化,诊断明确,以冠状动脉病变为其主要病因,在此基础上由其他因素诱导发病。结论:临床医师对心内膜下心肌梗死认识不足、对ECG和心肌酶谱的特异性动态改变未充分认识,是导致误诊的主要原因,建议详细询问病史、系统体格检查及辅助检查,综合判断明确诊断。     

Coronary artery thrombosis and evaluated urine immunoreactive thromboxane B2

Immunoreactive thromboxane B₂ (i-TXB₂) was measured by radio-immunoassay (RIA) in urine collective over eight hours on the day of admission in 25 patients who were admitted with the diagnosis of myocardial infarction. In 16 of the patients myocardial infarction was confirmed by ECG and plasma enzymes. Another patient presented with pulmonary embolism and the remaining eight patients had angina pectoris. A further eight hour urine collection was obtained 24 hours later from eleven of the sixteen patients with myocardial infarction. In these eleven patients myocardial infarction was associated with five fold higher urine i-TXB₂ (2.72 ± 0.48 ng/ml) at the day of admission when compared to patients admitted under the same diagnosis but found to have angina only (0.51 ± 0.08 ng/ml, p < 0.001). In patients with myocardial infarction the urine i-TXB₂ values were reduced 24 hours later (1.58 ± 0.27 ng/ml, p < 0.01). One patient was followed with urine i-TXB₂ from three days prior to diagnosis of myocardial infarction and to one day prior to a second infarction. In this patient i-TXB₂ was highest three days prior to infarction. We conclude that this early elevation of urine i-TXB₂ three days prior to diagnosis of infarction and the increased i-TXB₂ in patients with myocardial infarction when compared to patients with angina suggest thromboxane is probably released from activated platelets prior to infarction. We suggest that urine i-TXB₂ may be of value in the differential diagnosis between myocardial infarction and angina.     

High mean platelet volume after myocardial infarction: is it due to consumption of small platelets?

Seventy nine men surviving after sustaining a myocardial infarction in 1982, and who had at that time had raised mean platelet volumes compared with controls, were followed up after 18 months. The shape of each man''s platelet distribution curve was calculated from the mean platelet volume, platelet count, and platelet distribution width. The calculated curves were in close agreement with the curves plotted by the Coulter counter from the raw data. These curves did not differ significantly from those of a current control group, but the curves plotted from the variables measured at the time of myocardial infarction in 1982 showed a deficit of platelets in the volume range 5-12 fl amounting at maximum to 30% (p less than 0.0001); there were no significant differences above 12 fl. The deficit of small platelets became more appreciable during initial admission, was less at one month''s follow up, and had disappeared at one year. The deficit of small platelets is probably an effect rather than a cause of infarction.     

Should we abandon Kielland's forceps?

To assess the risks associated with the use of Kielland''s forceps 2708 consecutive deliveries were studied prospectively and the neonatal outcome related to the mode of delivery. Of the 1191 primigravidas, 279 (23.4%) underwent instrumental delivery, of whom 65 (5.5%) were delivered with Kielland''s forceps. There was no difference in early neonatal outcome (as judged by Apgar scores, intubations, and admission to the special care baby unit) between these babies and those delivered normally or by non-rotational forceps, but a higher proportion of the 127 (10.7%) delivered by emergency caesarean section were compromised. Of the 1517 multigravid patients, only 57 (3.8%) underwent instrumental delivery, 15 (1.0%) by Kielland''s forceps. Among these babies, also, the outcome was no worse than for those delivered normally, but the babies delivered by caesarean section showed a greatly increased incidence of low Apgar scores, intubations, and admission to the special care baby unit. There were no stillbirths or neonatal deaths among babies delivered by Kielland''s forceps, nor were there any cases of severe birth trauma or of obvious neonatal morbidity.     

Acute Myocardial Infarction in Doncaster. II—Delays in Admission and Survival

The speed of admission of patients with suspected acute myocardial infarction was observed over a period of 12 months during which a “no refusal” coronary care scheme was functioning, with emphasis on minimizing delay. During the same period the duration of survival of cases diagnosed as coronary thrombosis by the coroner''s pathologist was measured. Comparison of the two series shows that 75% to 80% of the coroner''s cases had died before the median time of notification of the general practitioner by those patients referred to hospital.We argue that the provision of mobile coronary care on request from general practitioners is unlikely to have an appreciable effect in preventing deaths from acute myocardial infarction outside hospital.     

Results of Early Mobilization and Discharge after Myocardial Infarction

A total of 342 patients with acute myocardial infarction who were admitted to a coronary care unit are reviewed to assess the results of early mobilization and discharge. The mean duration of admission was 8·4 days and 89% of the survivors were discharged from hospital by the tenth day. The inpatient mortality was 15·5%. An additional 6·7% died during the six weeks'' follow-up period, giving a total mortality of 22·2%. Altogether, 7·6% of patients were readmitted. Venous thromboembolic phenomena occurred in 3·5% during the inpatient period. Of patients who were eligible 62% were back at work five months after their myocardial infarction. We think the results justify a short hospital admission period for acute myocardial infarction.     

Management of septic shock.

There have been important advances in the resuscitation of patients in septic shock in recent years. Survival can be improved by earlier recognition and therefore eradication of the sepsis combined with logical supportive measures. As with any acutely ill patient consultation with intensive care unit staff may be useful. Consultation with the intensive care unit does not necessarily imply the need for admission and mechanical ventilation; helpful advice may be forthcoming. Equally, referral to the intensive care unit does not mean an admission of failure but merely a recognition that additional skills and technical facilities are necessary for the patient''s survival.     

A 24-HOUR AMBULATORY ECG MONITORING IN ASSESSMENT OF QT INTERVAL DURATION AND DISPERSION IN ROWERS WITH PHYSIOLOGICAL MYOCARDIAL HYPERTROPHY

Myocardial hypertrophy (MH) due to cardiac pathology is characterized by an increase in QT interval duration and dispersion, while the findings for exercise-induced myocardial hypertrophy are contradictory. The majority of published research findings have not explored this relationship, but there have only been a few conducted studies using 24-hour ECG monitoring. The aim of the study was to determine the QT interval duration and dispersion in short-term and 24-hour ECG in endurance athletes with myocardial hypertrophy and without it. Methods: A total of 26 well-trained rowers underwent a resting 12-lead ECG, 24-hour ECG monitoring and echocardiography. Results: Athletes with MH (n = 7) at rest did not show any increase in QTc interval duration and dispersion, or mean and maximal QTc duration in Holter monitoring compared to athletes without MH (n = 19). Left ventricular mass was not significantly correlated with any QTc characteristics. Furthermore, athletes with MH had significantly longer mean QT (P = 0.01) and maximal QT (P = 0.018) intervals in Holter monitoring and higher 24-hour heart rate variability indexes due to stronger vagal effects. Conclusions: The present study demonstrated that athlete''s heart syndrome with myocardial hypertrophy as a benign phenomenon does not lead to an increase in QT interval duration, or increases in maximal and mean duration in a 24-hour ECG. An increase in QT interval duration in athletes may have an autonomic nature.     

Coronary artery thrombosis and elevated urine immunoreactive thromboxane B2

Immunoreactive thromboxane B2 (i-TXB2) was measured by radio-immunoassay (RIA) in urines collected over eight hours on the day of admission in 25 patients who were admitted with the diagnosis of myocardial infarction. In 16 of the patients myocardial infarction was confirmed by ECG and plasma enzymes. Another patient presented with pulmonary embolism and the remaining eight patients had angina pectoris. A further eight hour urine collection was obtained 24 hours later from eleven of the sixteen patients with myocardial infarction. In these eleven patients myocardial infarction was associated with five fold higher urine i-TXB2 (2.72 +/- 0.48 ng/ml) at the day of admission when compared to patients admitted under the same diagnosis but found to have angina only (0.51 +/- 0.08 ng/ml, p less than 0.001). In patients with myocardial infarction the urine i-TXB2 values were reduced 24 hours later (1.58 +/- 0.27 ng/ml, p less than 0.01). One patient was followed with urine i-TXB2 from three days prior to diagnosis of myocardial infarction and to one day prior to a second infarction. In this patient i-TXB2 was highest three days prior to infarction. We conclude that this early elevation of urine i-TXB2 three days prior to diagnosis of infarction and the increased i-TXB2 in patients with myocardial infarction when compared to patients with angina suggest thromboxane is probably released from activated platelets prior to infarction. We suggest that urine i-TXB2 may be of value in the differential diagnosis between myocardial infarction and angina.     

Radiologic assessment in the pediatric intensive care unit.

The severely ill infant or child who requires admission to a pediatric intensive care unit (PICU) often presents with a complex set of problems necessitating multiple and frequent management decisions. Diagnostic imaging plays an important role, not only in the initial assessment of the patient''s condition and establishing a diagnosis, but also in monitoring the patient''s progress and the effects of interventional therapeutic measures. Bedside studies obtained using portable equipment are often limited but can provide much useful information when a careful and detailed approach is utilized in producing the radiograph and interpreting the examination. This article reviews some of the basic principles of radiographic interpretation and details some of the diagnostic points which, when promptly recognized, can lead to a better understanding of the patient''s condition and thus to improved patient care and management. While chest radiography is stressed, studies of other regions including the upper airway, abdomen, skull, and extremities are discussed. A brief consideration of the expanding role of new modality imaging (i.e., ultrasound, CT) is also included. Multiple illustrative examples of common and uncommon problems are shown.     

Admissions to a Provincial Psychiatric Hospital: The Effects of Opening a Second In-patient Facility

Until 1955, the Saskatchewan Hospital, North Battleford, was the only facility designated for in-patient psychiatric treatment of the northern half of Saskatchewan''s population. In that year the University Hospital''s 39-bed psychiatric unit was opened in Saskatoon, but the number of Saskatoon patients referred to North Battleford have continued to increase.A statistical study of changes in the annual admission rates (patients/1000 population) to the Saskatchewan Hospital shows that the opening of the University Hospital unit has reduced the rate of intake of Saskatoon residents to the Saskatchewan Hospital. This decrease is related to specific diagnostic groups. There have also been changes in methods of referral.     

'Brugada ECG' elicited by imipramine overdose

The ECG hallmark of the Brugada syndrome is ST-segment elevation in the right precordial leads. However, a ''Brugada ECG'' may also occasionally be caused by other conditions. We report a case of a Brugada ECG due to an overdose of imipramine, a tricyclic antidepressant. The patient, a 66-year-old woman, was admitted to the emergency unit in a comatose state, due to autointoxication with imipramine. In addition to other signs of massive sodium-channel blockade, the ECG showed typical ST-segment elevation in the right precordial and the inferior leads. The abnormalities resolved quickly after administration of sodium bicarbonate.     

Patients with suspected Lassa fever in London during 1984: problems in their management at St Thomas's Hospital.

During 1984, 23 patients in whom a diagnosis of viral haemorrhagic fever was considered presented to the accident and emergency department at St Thomas''s Hospital. There were no confirmed cases of viral haemorrhagic fever. Nine patients were transferred to Coppett''s Wood Hospital, the nearest specially designated high security isolation unit. Malaria was the final diagnosis in 14, and in six this diagnosis was confirmed only after examining repeated smears at Coppett''s Wood Hospital. Transferral of patients to such units is time consuming, expensive, and often unnecessary. Specially designated isolation units in district general hospitals and all teaching hospitals would simplify and improve the care not only of patients with a possible viral haemorrhagic fever but also patients with tuberculosis, multiply resistant staphylococcal infections, and viral infections that may be hazardous if transmitted to immunocompromised patients.     

心内膜下心肌梗死的常见误诊病例浅析

目的：探讨心内膜下心肌梗死的常见误诊原因及对策。方法：回顾性分析9例心内膜下心肌梗死患者的病历资料。包括病史、系统体格检查,ECG、心肌酶谱、胸片、超声心动图检查等。结果：9例心内膜下心肌梗死患者均有临床症状、ECG及心肌酶学指标的动态变化,诊断明确,以冠状动脉病变为其主要病因,在此基础上由其他因素诱导发病。结论：临床医师对心内膜下心肌梗死认识不足、对ECG和心肌酶谱的特异性动态改变耒充分认识,是导致误诊的主要原因,建议详细询问病史、系统体格检查及辅助检查,综合判断明确诊断。     

Fatal Brain Damage Associated with Cardiomyopathy of Pregnancy,with Notes on Caesarean Section in a Hyperbaric Chamber

Three weeks after admission to a maternity hospital for observation following minor antepartum haemorrhage, a primiparous patient aged 22 suffered a sudden left hemiplegia and became comatose. Congestive cardiac failure ensued and because of the subsequent severe hypoxaemia she was transferred to the hyperbaric oxygen unit at the Western Infirmary, Glasgow, where it was found possible to improve her condition by means of oxygen at increased pressure. A caesarean section was w successfully performed in the hyperbaric chamber, and a normal live female infant was delivered. Though the patient''s general condition improved she never regained consciousness and died almost three months later. Necropsy confirmed the clinical diagnosis of cardiomyopathy of pregnancy with severe ischaemic changes in the brain.     

Indications for admission to a coronary care unit in patients with unstable angina.

One hundred cases with an admission diagnosis of acute coronary insufficiency or unstable angina were reviewed to establish criteria for admission to a coronary care unit. Myocardial infarction was subsequently diagnosed in 20 of the patients. Ventricular tachycardia occurred in 16 patients and ventricular fibrillation in 1 patient. Clinical features found to predict an increased risk of myocardial infarction included chest pain for more than 30 minutes within 24 hours prior to admission, new nonspecific electrocardiographic abnormalities consistent with ischemia, and diaphoresis. All patients with ventricular tachydysrhythmias had presented with both prolonged chest pain prior to admission and new electrocardiographic changes. The sensitivity, specificity and predictive value of various clinical criteria for identifying patients likely to have a myocardial infarction were calculated, and criteria with very high (greater than 90%) sensitivity were identified. These could be used to establish which patients are at increased risk of myocardial infarction and therefore require admission to a coronary care unit.     

Can children with a psychiatric disorder be treated in a general ward?

Because admission to a regional child and adolescent psychiatric unit is often fraught with difficulties children with psychiatric disorders were admitted to a general children''s ward. Over the four years (1980-4) 24 patients accounted for 31 admissions. Of these, five had feeding disorders (anorexia, bulimia), seven neuroses, three psychoses, four elimination disorders, and five other diagnoses. All the children were later discharged to their homes, most having appreciably improved. Because of the proximity of the hospital to the child''s natural environment work with the families and schools was not interrupted by the admission. The results of this approach are encouraging and could have implications for future planning of services for this category of patients.     

Role of patients' view of their illness in predicting return to work and functioning after myocardial infarction: longitudinal study.

OBJECTIVE--To examine whether patients'' initial perceptions of their myocardial infarction predict subsequent attendance at a cardiac rehabilitation course, return to work, disability, and sexual dysfunction. DESIGN--Patients'' perceptions of their illness were measured at admission with their first myocardial infarction and at follow up three and six months later. SETTING--Two large teaching hospitals in Auckland, New Zealand. SUBJECTS--143 consecutive patients aged under 65 with their first myocardial infarction. MAIN OUTCOME MEASURES--Attendance at rehabilitation course; time before returning to work; measures of disability with sickness impact profile questionnaire for sleep and rest, social interaction, recreational activity, and home management; and sexual dysfunction. RESULTS--Attendance at the rehabilitation course was significantly related to a stronger belief during admission that the illness could be cured or controlled (t = 2.08, P = 0.04). Return to work within six weeks was significantly predicted by the perception that the illness would last a short time (t = 2.52, P = 0.01) and have less grave consequences for the patient (t = 2.87, P = 0.005). Patients'' belief that their heart disease would have serious consequences was significantly related to later disability in work around the house, recreational activities, and social interaction. A strong illness identity was significantly related to greater sexual dysfunction at both three and six months. CONCLUSIONS--Patients'' initial perceptions of illness are important determinants of different aspects of recovery after myocardial infarction. Specific illness perceptions need to be identified at an early stage as a basis for optimising outcomes from rehabilitation programmes.     

Area security unit in a psychiatric hospital.

Since 1974 a psychiatric hospital security unit, designed to serve the whole catchment area, has cared for mentally ill (mostly psychotic) patients with disturbed behaviour that cannot be managed in open wards. There are a few long-term dangerous patients but most stay only briefly. The admission of women to the unit was not followed by the expected reduction in violence. The unit has facilities for occupational therapy, physical recreation, work, and study, which are particularly important for those who are too dangerous to leave it. The unit''s calming influence depends as much on the supportive effect of the high staff ratio as on the use of tranquillisers. This type of unit is not suitable for patients with personality disturbances who "act out" or for mentally abnormal offenders; but it functions well as a crisis centre for the disturbed mentally ill, and there is an increasing demand for its services.