#61
|
||||
|
||||
Öèòàòà:
|
#62
|
||||
|
||||
Öèòàòà:
Comparison of Myocardial Perfusion Imaging and Cardiac Troponin I in Patients Admitted to the Emergency Department With Chest Pain (Circulation. 1999;99:2073-2078.)Methods and Results... Sensitivity for predicting revascularization or significant coronary disease was significantly higher for perfusion imaging than for serial cTnI, although specificity for all end points was significantly lower. Lowering the cutoff value of cTnI to 1.0 ng/mL did not significantly change the results. Conclusions—Early perfusion imaging and serial cTnI have comparable sensitivities for identifying myocardial infarction. Perfusion imaging identified more patients who underwent revascularization or who had significant coronary disease, but it had lower specificity. The 2 tests can provide complementary information for identifying patients at risk for ACS. Radionuclide imaging in risk assessment after acute coronary syndromes J E Udelson1 and E J Flint2 Heart 2004;90:v16 Comparison with enzymatic and biomarkers of ACS … Subsequently, the maximum troponin I over the first 24 hours had sensitivity similar to that of the acute rest sestamibi imaging, but at a distinctly later time point. Thus, acute MPI has the potential to identify ACS much earlier in their evolution than enzyme markers. Moreover, SPECT perfusion imaging data have been shown to provide incremental risk stratification value for predicting unfavourable cardiac events (fig 3 ).15. Çäåñü òîëüêî âûâîäû. Îáå ðàáîòû, íàðÿäó ñ íå çíà÷èòåëüíûìè, íà èõ âçãëÿä, íåäîñòàòêàìè SPECT, ïîä÷åðêèâàþò äâà âàæíûõ åå ïðåèìóùåñòâà – âðåìÿ è çíà÷åíèå îòáîðà áîëüíûõ ñ çíà÷èìûì ïîðàæåíèåì êîðîíàðíîãî ðóñëà íà ðåâàñêóëÿðèçàöèþ. Ïîíÿòíî, ÷òî ýòè ïðåèìóùåñòâà ðàáîòàþò ëèøü òàì, ãäå, óæå â ïðåäåëàõ êðóãëîñóòî÷íîãî ïðèåìà ñêîðîïîìîùíûõ êëèíèê, ñóùåñòâóåò è âîçìîæíîñòü íåîòëîæíîé êîðîíàðíîé õèðóðãèè èëè àíãèîïëàñòèêè. Åñëè æå ó Âàñ ñïåøêè íåò, (âûíóæäåí íàìîìíèòü óæå óñòàðåâøåå – âðåìÿ – ýòî äåíüãè. Ìîæåò áûòü, åùå è áîëåå ñîõðàííûé ìèîêàðä, áåç ðåìîäåëèðîâàíèÿ è ò.ä. ) òî êîíå÷íî, äåøåâëå âîñïîëüçîâàòüñÿ òåì, ÷òî ïðåäëàãàåò óâàæàåìûé dmblok Öèòàòà:
×òî æå êàñàåòñÿ íàøåãî ñëó÷àÿ, òî âñïîìíèì, ãäå ÷àùå âñåãî ïðèìåíÿåòñÿ SPECT? Ïî ëèòåðàòóðíûì äàííûì – ýòî îòáîð áîëüíûõ íà èíâàçèâíûå ìåòîäû èññëåäîâíèÿ. Ìåòîäèêè, ÷àùå âñåãî âêëþ÷àþò ñðàâíåíèå èçîáðàæåíèé â ïîêîå è ïðè ôàðìàêîëîãè÷åñêèõ òåñòàõ èëè ïðîáàõ ñ ôèçè÷åñêèìè íàãðóçêàìè. Òî åñòü ñðàâíèâàþò èçîáðàæåíèÿ ïåðôóçèè, â ìîìåíò, êîãäà êëèíè÷åñêîãî ñîáûòèÿ íå áûëî, ñ èçîáðàæåíèåì, ïîëó÷åííûì â ìîìåíò ýòîãî ñîáûòèÿ. Íàëè÷èå íîâûõ íàðóøåíèé ïåðôóçèè è ÿâëÿåòñÿ ïîâîäîì äëÿ âûâîäîâ.  ñâîåì çàêëþ÷åíèè ÿ ñäåëàë òî æå ñàìîå. Ðàçíèöà çàêëþ÷àëàñü ëèøü â òîì, ÷òî ýòî ñîáûòèå áûëî íå ïðåõîäÿùàÿ èøåìèÿ, à ïîäîçðåíèå íà ïåðåíåñåííûé èíòðàîïåðàöèîííûé ÎÈÌ. Ïîäîçðåíèå, ñâÿçàííîå ñ ÝÊÃ, íî íèêàê íå ñ êëèíèêîé. Ïîíÿòíî, ÷òî èíòðàîïåðàöèîííûé ÈÌ, êîòîðûé äàë áû òàêèå èçìåíåíèÿ íà ÝÊà íå îãðàíè÷èëñÿ áû íåñêîëüêèìè ìèëëèìåòðàìè. Ìàëî òîãî, ÿ èñïîëüçîâàë íå òî èññëåäîâàíèå, êîòîðîå àíàëèçèðîâàëè â äîêóìåíòå ïðåäñòàâëåííîì óâàæàåìûì dmblok. ÍÅ ñòàòè÷åñêóþ ñöèíòèãðàôèþ, à ñöèíòèãðàôèþ êîòîðàÿ ïîçâîëÿåò â âèäå òðåõìåðíûõ ïîëÿðíûõ êàðò 1- âûäåëèòü îòäåëüíî èçîáðàæåíèÿ ïåðôóçèè â ñèñòîëó è â äèàñòîëó, ÷òî íàìíîãî ïîâûøàåò ÷óâñòâèòåëüíîñòü ñîáñòâåííî ïåðôóçèîííûõ èçîáðàæåíèé. 2 èçîáðàæåíèÿ äâèæåíèÿ ìèîêàðäà 3 èçîáðàæåíèÿ åãî ñèñòîëè÷åñêîãî óòîëùåíèÿ. Àíàëèç òàêèõ èçîáðàæåíèé â îòäåëüíûõ ñòàòüÿõ åñòü. Îí ïîêàçûâàåò î÷åíü âûñîêóþ èõ ÷óâñòâèòåëüíîñòü. Åñëè áû ìàëåéøèå ïðèçíàêè íîâûõ îñòðûõ î÷àãîâûõ áûëè, ïîïóñòèòü èõ áûëî áû íåâîçìîæíî. Ìíå óæå ïðèõîäèëîñü äèôôåðåíöèðîâàòü ïîñòðåïåðôóçèîííûå èçìåíåíèÿ íà ÝÊà è êàê âûãëÿäÿò âàðèàíòû «îãëóøåíèÿ» ìíå çíàêîìî. Íî ýòî îòäåëüíàÿ, äëèííàÿ òåìà. Ñòàòüè ïî íåé åñòü, íî öåíòðàëèçîâàííûõ ïðîãðàììíûõ äîêóìåíòîâ ïî íåé ÿ åùå íå âèäåë. Ñ óâàæåíèåì êî âñåì Âàì. |
#63
|
||||
|
||||
Öèòàòà:
×åðåç 9-12 ìåñÿöåâ ïîñëå ðåâàñêóëÿðèçàöèè. Ýòî áîëüøîé ñðîê...." Öèòàòà:
|
#64
|
||||
|
||||
Öèòàòà:
Íàñ÷åò ñðîêîâ ÿ óæå ãîâîðèë. Íó ÷òî Âû âñå ñòàðàåòåñü çàöåïèòü ìåíÿ? Íó ïëîõîé ÿ, ïëîõîé. Âû - íó ïðîñòî óìíèöà. Íó ê ÷åìó ýòî? Êàæäûé Âàø âîïðîñ- ýòî îãðîìíàÿ òåìà äëÿ ðàçãîâîðà. Åñëè áû ÿ ìîã îòâåòèòü êðàòêî, ÿ áû ýòî ñäåëàë. Íî âîïðîñû ñòàâèòå òàê, ÷òî ÿ íà íèõ äîëæåí öåëûå ëèòîáçîðû ïèñàòü. Îäíîñëîæíî íå îòâåòèøü. À ñèäåòü íî÷àìè ó êîìïüþòåðà óæå íå ìîãó. Èçâèíèòå. ÎÅÍ. |
#65
|
||||
|
||||
Öèòàòà:
Óâàæàåìûé Åâãåíèé Íèêîëàåâè÷. "Ñ. ìóæ÷èíà 52 ëåò, ïîñòóïèë â îòäåëåíèå êîðîíàðíîé õèðóðãèè ñ æàëîáàìè íà áîëè çà ãðóäèíîé ïðè ôèçè÷åñêèõ íàãðóçêàõ...áåç ïðåäøåñòâóþùåãî êîðîíàðíîãî àíàìíåçà 28.09.2003 ïàöèåíò ïåðåíåñ îñòðûé êðóïíîî÷àãîâûé ÈÌ â îáëàñòè çàäíåé ñòåíêè". Íà ÝÊà çóáöû R â èíôàðêòñâÿçàííûõ îòâåäåíèÿõ. Óæå òîëüêî ýòîãî äîñòàòî÷íî, ÷òî áû çàïîäîçðèòü, ÷òî æèçíåñïîñîáíûé ìèîêàðä ó ïàöèåíòà, ñêîðåå âñåãî, èìååòñÿ. Èëè ýòî íå òàê? "ÝÕÎÊÃ: ...ñîêðàòèòåëüíàÿ ñïîñîáíîñòü ñíèæåíà. Íà ôîíå äèôôóçíîãî ãèïîêèíåçà îòìå÷åíà óäîâëåòâîðèòåëüíàÿ êèíåòèêà áîêîâîé ñòåíêè Ëæ". Ãèïîêèíåç îáû÷íî ñâèäåòåëüñòâóåò î íåòðàíñìóðàëüíîì ïîðàæåíèè , ÷òî è ïîäòâåðäèëà ïåðôóçèîííàÿ ñöèíòèãðàôèÿ. Ôðàçà èç Âàøåé ñòàòüè: "ïðåäîïåðàöèîííûé àíàëèç ïàðàìåòðè÷åñêèõ èçîáðàæåíèé, âûïîëíåííûõ ïðè îðòîñòàçå è ñóáëèíãâàëüíîì ïðèåìå íèòðîãëèöåðèíà, ïîçâîëÿåò ñ 85% ÷óâñòâèòåëüíîñòüþ è 95% ñïåöèôè÷íîñòüþ âûÿâèòü çîíû ìèîêàðäà, êîòîðûå âîññòàíàâëèâàþò ôóíêöèþ ñðàçó ïîñëå ðåâàñêóëÿðèçàöèè (“ñïÿùèé” ìèîêàðä)" Ôðàçà èç Âàøåãî êëèíè÷åñêîãî ïðèìåðà: "Ðàäèîíóêëèäíàÿ âåíòðèêóëîãðàôèÿ: ...ÎÔ ËÆ=38%, ÎÔ ÏÆ= 34%.  îòâåò íà íèòðîãëèöåðèí – ÎÔ ËÆ=46%, ÎÔ ÏÆ=40%,  îòâåò íà îðòîñòàç ÎÔÂËÆ= 47% ÎÔ ÏÆ=41%." ß ñ÷åë ÷òî ïðèðîñò â ÎÔ ïðîèçîøåë çà ñ÷åò æèçíåñïîñîáíîãî ìèîêàðäà... Âïðî÷åì, Âàì âèäíåå. È åùå "Ïåðôóçèîííàÿ ñöèíòèãðàôèÿ ìèîêàðäà ñèíõðîíèõèðîâàííàÿ ñ ÝÊà ... Çîí òðàíìóðàëüíîãî êàðäèîñêëåðîçà íå âûÿâëåíî". Íåòðàíñìóðàëüíîå ïîðàæåíèå, îáû÷íî ñâèäåòåëüñòâóåò î íàëè÷èè æèçíåñïîñîáíîãî ìèîêàðäà. Öèòàòà:
Ê ÷åìó ýìîöèè?... Âû îïèñàëè íåêèé êëèíè÷åñêèé ñëó÷àé. Ñ êîòîðûì âðà÷è, êîòîðûå äîñòàòî÷íî äîëãî ïðîðàáîòàëè â ñåðüåçíûõ ëå÷åáíûõ ó÷ðåæäåíèÿõ, ðàíåå íå âñòðå÷àëèñü. Ðåçîííî, ÷òî âîçíèêàþò âîïðîñû. Ïðè÷åì ðàçãîâîð âåäåòñÿ èñêëþ÷èòåëüíî ïî äåëó è ðàäè âûÿñíåíèÿ èñòèííîãî ïîëîæåíèÿ âåùåé. Áîëüøèíñòâî ññûëîê, êîòîðûå äîëæíû áûëè áû ïðîèëëþñòðèðîâàòü ýòîò ñëó÷àé, ñ ìîåé òî÷êè çðåíèÿ, íå âïîëíå ñïðàâèëèñü ñ ýòîé çàäà÷åé, íî ïðè ýòîì áûëè âåñüìà ïîçíàâàòåëüíû. Íå äóìàþ, ÷òî â ìîèõ âîïðîñàõ åñòü êàêîé-òî íàõðàï èëè ïðèçíàêè âîïèþùåé íåêîìïåòåíòíîñòè. Âíå âñÿêîãî ñîìíåíèÿ, Âû êðóïíûé ó÷åíûé è ïðîôåññèîíàë ñ áîëüøîé áóêâû, ïîýòîìó Âàøå ìíåíèå, êàê ñïåöèàëèñòà è àâòîðà êëèíè÷åñêîãî ïðèìåðà êðàéíå èíòåðåñíî. Åñëè ó Âàñ ñëîæèëîñü èíîå ìíåíèå, òî ãîòîâ ïðèíåñòè ñâîè ñîæàëåíèÿ ïî ýòîìó ïîâîäó. Õîòåë áû òàê æå çàìåòèòü, ÷òî â ìåäèöèíå è â ÷àñòíîñòè â êàðäèîëîãèè ñóùåñòâóåò âåñüìà áîëüøîé ïåðå÷åíü äèàãíîñòè÷åñêèõ ìåòîäèê. Î÷åâèäíî, ÷òî ñïåöèàëèñò, êîòîðûé ïðîôåññèîíàëüíî âëàäååò îäíîé èç íèõ, âèäèò ïðåèìóùåñòâà ýòîãî ìåòîäà è ÿâëÿåòñÿ åãî àïîëîãåòîì. Ýòî î÷åíü õîðîøî. Íî òàê æå õîðîøî, ÷òî ðåøåíèå, êàêèì ìåòîäîì âîñïîëüçîâàòüñÿ â òîé èëè èíîé ñèòóàöèè ïðèíèìàåò ëå÷àùèé âðà÷, êîòîðûé îðèåíòèðóåòñÿ â ñâîåé ðàáîòå íà íåàíãàæèðîâàííûå îôèöèàëüíûå ðåêîìåíäàöèè, ðàçðàáîòàííûå äëÿ òîé èëè èíîé ïàòîëîãèè. Ýòî êàñàåòñÿ íå òîëüêî äèàãíîñòèêè, íî è ëå÷åíèÿ. Íàïðèìåð, ðåøåíèå êàêîé ìåòîä ðåâàñêóëÿðèçàöèè ïðåäïî÷åñòü äëÿ êîíêðåòíîãî áîëüíîãî, äîëæåí ïðèíèìàòü êàðäèîëîã. Èìåííî îí îïðåäåëÿåò ïîêàçàíèÿ ê âìåøàòåëüñòâó. À õèðóðã è àíãèîãðàôèñò îïðåäåëÿþò òåõíè÷åñêóþ âîçìîæíîñòü ïðîâåäåíèÿ îïåðàöèè è ñïåöèôè÷åñêèå ïðîòèâîïîêàçàíèÿ. |
#66
|
||||
|
||||
Öèòàòà:
Êðîìå ýòîãî, â âèäå íåêîé "ïîäñêàçêè" ÿ ïðèâåäó îäíó ôðàçó " À ó áîëüíûõ õðîíè÷åñêèìè ôîðìàìè è ïîäâèæíûé ìèîêàðä ìîæåò áûòü ðóáöîâîèçìåíåííûì, " è îäíó ññûëêó. [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] Charles Nelson, MBBS, FRACP*, Jane McCrohon, MBBS, PhD, FRACP*, Frederick Khafagi, MBBS, FRACP*, Stephen Rose, PhD*, Rodel Leano, BS* and Thomas H. Marwick, MBBS, PhD, FACC*,* “Impact of scar thickness on the assessment of viability using dobutamine echocardiography and thallium single-photon emission computed tomography. A comparison with contrast-enhanced magnetic resonance imaging” J Am Coll Cardiol, 2004; 43:1248-1256, OBJECTIVES: We sought to determine whether the transmural extent of scar (TES) explains discordances between dobutamine echocardiography (DbE) and thallium single-photon emission computed tomography (Tl-SPECT) in the detection of viable myocardium (VM). BACKGROUND: Discrepancies between DbE and Tl-SPECT are often attributed to differences between contractile reserve and membrane integrity, but may also reflect a disproportionate influence of nontransmural scar on thickening at DbE. METHODS: Sixty patients (age 62 ± 12 years; 10 women and 50 men) with postinfarction left ventricular dysfunction underwent standard rest-late redistribution Tl-SPECT and DbE. Viable myocardium was identified when dysfunctional segments showed Tl activity >60% on the late-redistribution image or by low-dose augmentation at DbE. Contrast-enhanced magnetic resonance imaging (ceMRI) was used to divide TES into five groups: 0%, <25%, 26% to 50%, 51% to 75%, and >75% of the wall thickness replaced by scar. RESULTS: As TES increased, both the mean Tl uptake and change in wall motion score decreased significantly (both p < 0.001). However, the presence of subendocardial scar was insufficient to prevent thickening; >50% of segments still showed contractile function with TES of 25% to 75%, although residual function was uncommon with TES >75%. The relationship of both tests to increasing TES was similar, but Tl-SPECT identified VM more frequently than DbE in all groups. Among segments without scar or with small amounts of scar (<25% TES), >50% were viable by SPECT. CONCLUSIONS: Both contractile reserve and perfusion are sensitive to the extent of scar. However, contractile reserve may be impaired in the face of no or minor scar, and thickening may still occur with extensive scar Ïîâòîðþ, ýòî íå äëÿ äèñêóññèè ìåæäó ìåòîäàìè, à äëÿ òîãî, ÷òîáû ïîíÿòü, ÷òî ìû èùåì. Æäó îòâåòà, íî çàâòðà. ß ñòàðûé, ñïàòü õî÷ó. Âñåãäà âàø ÎÅÍ. |
#67
|
||||
|
||||
?
Öèòàòà:
|
#68
|
||||
|
||||
Öèòàòà:
PS. Ìîæåò áûòü ÿ íå ïîíÿòíî çàäàë âîïðîñ. Ïîñòàðàþñü "ðàçâåðíóòü" åãî ÷òî íà Âàø âçãëÿä îçíà÷àåò "Êàðòèíà òèïè÷íà äëÿ ìíîæåñòâåííîãî äèôôóçíîãî ïîðàæåíèÿ êîðîíàðíîãî ðóñëà.", êàê ïðè ýòîì äîëæíî âûãëÿäåòü èçîáðàæåíèå ïåðôóçèè ìèîêàðäà ËÆ? Æäó îòâåòà. Âàø ÎÅÍ. |
#69
|
||||
|
||||
Öèòàòà:
Ñîéäåò äëÿ íåñïåöèàëèñòà? |
#70
|
||||
|
||||
Öèòàòà:
Ãëàâíûé ñìûñë èçîáðàæåíèé ïåðôóçèè ìèîêàðäà â òîì, ÷òî îíè ñ âûñîêîé òî÷íîñòüþ âîñïðîèçâîäÿò ðàñïðåäåëåíèå êðîâîòîêà â ìèîêàðäå. Òîëüêî ðàñïðåäåëåíèå! Íå îáúåì, íå ñêîðîñòü, à èìåííî ðàñïðåäåëåíèå. Êîíå÷íî, ìîæíî ïîëó÷èòü èç íèõ è äðóãóþ èíôîðìàöèþ, íî ñåãîäíÿ ìû îá ýòîì ãîâîðèòü íå áóäåì. Èòàê, â íîðìå, ïðè èíòàêòíîì ìèîêàðäå è èíòàêòíûõ êîðîíàðíûõ àðòåðèÿõ ðàñïðåäåëåíèå ïåðôóçèè íà èçîáðàæåíèÿõ ìèîêàðäà ðàâíîìåðíîå. Íî, ïðè ìíîãîñîñóäèñòîì ïîðàæåíèè, êðîâîòîê òàêæå, ÷àñòî, ñíèæàåòñÿ ðàâíîìåðíî âî âñåì ìèîêàðäå è, â ýòèõ ñëó÷àÿõ, èçîáðàæåíèÿ ïåðôóçèè áóäóò òîæå ðàâíîìåðíûå. Áåç ëîêàëüíûõ íàðóøåíèé ïåðôóçèè.  òîì ñëó÷àå, åñëè íåò çîí êàðäèîñêëåðîçà. (ýòîò ôàêò, íà ñàìîì äåëå, ñïåöèàëèñòàì ÿäåðíîé êàðäèîëîãèè äàâíî èçâåñòåí è áåç ìåíÿ) Ïîýòîìó, (åñëè Âû ñîãëàñíû - ñëåäóþùèé âîïðîñ) íàïèñàííîå ðàíåå, «ñ ñíèæåíèåì ïåðôóçèè ïåðåäíåé, çàäíåé ñòåíîê è ÌÆÏ ñ ìàêñèìóìîì íà âåðõóøêå.» î ÷åì ãîâîðèëî, íà Âàø âçãëÿä? Ñ óâàæåíèåì Âàø ÎÅÍ. PS. Ìíå ïðèÿòíî,÷òî Âû öèòèðóåòå ìîè ðàáîòû. Òîëüêî âîò èíòåðïðåòàöèÿ íàïèñàííîãî... Âèíþ òîëüêî ñåáÿ. ß ìîã áû îáúÿñíèòü ðàçíèö ìåæäó Âàøèì âàðèàíòîì è ìîèì, íî îáùàë, ÷òî äåëàòü ýòîãî íå áóäó. Åñëè çàõîòèòå - ñäåëàþ ýòî ïîçæå. Ñ óâàæåíèåì.ÎÅÍ |
#71
|
||||
|
||||
Óâàæàåìûé Åâãåíèé Íèêîëàåâè÷. Âàì íå êàæåòñÿ, ÷òî ýòà âåòêà ïðåâðàùàåòñÿ â, êàêîé-òî ñòðàííûé ìåæäóñîáîé÷èê?  ïðèíöèïå ÿ ãîòîâ ïîääåðæàòü ïåðåïèñêó, íî, íàâåðíîå, ýòî ëó÷øå äåëàòü äðóãèì ñïîñîáîì è, íàâåðíîå, â äðóãîì ôîðìàòå.
PS Õîòåë áû äîáàâèòü, ÷òî ïîäîáíûå èçìåíåíèÿ íà ÝÊà ó áîëüíûõ â êîðîòêèå ñðîêè ïîñëå ÊØ, íàì ïðèõîäèëîñü âèäåòü, â îòëè÷èå îò ñòîëü äðàìàòè÷åñêèõ èçìåíåíèé îáúåìîâ, ñåðäå÷íîãî âûáðîñà è ìàññû ìèîêàðäà. Îäíàêî, èñêëþ÷èâ ÈÌ è ïîñòïåðèêàðäèîòîìíûé ñèíäðîì, íà îñíîâàíèè ÝÕÎ-ÊÃ, ðåíòãåíà è òä ó áîëüíûõ íàõîäèëèñü îáû÷íî áîëåå ïðîñòûå è î÷åâèäíûå ïðè÷èíû äëÿ äèíàìèêè íà ÝÊÃ, â ÷àñòíîñòè ïîñëåîïåðàöèîííàÿ ðîòàöèÿ ñåðäöà. Êîòîðàÿ, î÷åâèäíî, âïîëíå ìîãëà ñîïðîâîæäàòüñÿ ñìåùåíèåì ïåðåõîäíîé çîíû âëåâî. Ñ óâàæåíèåì. |
#72
|
||||
|
||||
Öèòàòà:
Öèòàòà:
Öèòàòà:
Óâàæàåìûé dmblok! Âåðîÿòíî(ýòî ÿ ïûòàþñü îáúÿñíèòü êàê ÿ ïîíÿë Âàñ) ïîä "ïîñëåîïåðàöèîííàÿ ðîòàöèÿ ñåðäöà." Âû ïîäðàçóìåâàëè òî, ÷òî ìåõàíè÷åñêè ðóêàìè õèðóðãà ïðîñòî íå òàê ïîâåðíóëè ñåðäöå âî âðåìÿ îïåðàöèè.  òîì-òî è äåëî, ÷òî ýòè èçìåíåíèÿ îòìåòèëè íå íà 1, à íà 2-3 äåíü ïîñëå ÀÊØ. Ìàëî òîãî, íàø ïàöèåíò ñòàë âåñòè ôèçè÷åñêè àêòèâíûé îáðàç æèçíè è íà÷àë áåãàòü ñïóñòÿ íåñêîëüêî íåäåëü ïîñëå ÀÊØ. (îí î÷åíü ñïîðòèâåí è íà÷àë åæåäíåâíî áåãàòü íå ìîãó ñêàçàòü êàêèå äèñòàíöèè). Êîãäà îí ïðèøåë ê íàì ÷åðåç íåñêîëüêî ìåñÿöåâ - ÝÊà âåðíóëàñü ê èñõîäíîé.  íàøåé Êëèíèêå ÿ ñ ýòîé ñèòóàöèåé îçíàêîìèë âñåõ. Íåêîòîðûå õèðóðãè ñòàëè ïðèñìàòðèâàòüñÿ ê íåé.  òîì îòäåëåíèè, ãäå ëåæàë ýòîò áîëüíîé ÿ ðàññêàçûâàþ ñèòóàöèþ ñ ìîèì ñîîáùåíèåì çäåñü íà ôîðóìå. Áóêâàëüíî ïîçàâ÷åðà õèðóðãè ðàññêàçàëè ìíå àíàëîãè÷íóþ ñèòóàöèþ ó ïîõîæåãî áîëüíîãî. Ïðè÷åì, ïåðâûå 2 äíÿ ïîñëå ÀÊØ - èñõîäíàÿ ÝÊÃ, çàòåì 2 äíÿ - íîâûå QS (íåñìîòðÿ íà íîðìàëüíóþ êëèíèêó), ÷åðåç äâà äíÿ - îïÿòü íîðìà, åùå ñïóñòÿ äâà äíÿ - îïÿòü íîâûå QS. Ôåðìåíòû ïðîâåðèëè. Ýõî, ýêã ïîâòîðÿëè (è ïðîâåðÿëè!) åæåäíåâíî è íå ïî îäíîìó ðàçó. Íèêàêèõ ïðèçíàêîâ îñëîæíåíèé. Íî ÿ, âñå-òàêè, õîòåë áû îáúÿñíèòü êàê ÿ ïîíèìàþ, ÷òî òàêîå "æèçíåñïîñîáíîñòü" íå ñ òî÷êè çðåíèÿ òåîðèé, à ñ òî÷êè çðåíèÿ åæåäíåâíîé ïðàêòèêè, êîòîðàÿ (åñòåñòâåííî) ñëîæèëàñü ó ìåíÿ. Ìíå ïîêàçàëîñü, ÷òî ýòî ìîæåò áûòü èíòåðåñíî Âàì è, äóìàþ, íåêîòîðûì äðóãèì âðà÷àì íà ôîðìóå. Åñëè ñîãëàñíû - ïðîäîëæèì íàø "ìåæäóñîáîé÷èê". ×òî êàñàåòñÿ "äðóãîãî ôîðìàòà", ìíå êàæåòñÿ, åñëè ìû íà÷àëè íàøè îáñóæäåíèÿ "ïóáëè÷íî", òî õîòåëîñü áû òàêæå "ïóáëè÷íî" åãî è ïðîäîëæèòü. Åñëè íåò - ÿ ìîãó ëèøü òî, ÷òî ìîãó. Èçâèíèòå, Âàø ÎÅÍ. |
#73
|
||||
|
||||
Óâàæàåìûå êîëëåãè, dmblock è Åâãåíèé Íèêîëàåâè÷!
Âàø ìåæäóñîáîé÷èê ïðåäñòàâëÿåò áîëüøîé èíòåðåñ. Ìû, êàê ïðàâèëî, õîòèì îò äèàãíîñòîâ áîëüøå òîãî, ÷òî îíè ìîãóò. Çäåñü ñèòóàöèÿ îáðàòíàÿ: Åâãåíèé Íèêîëàåâè÷ äàåò èíôîðìàöèè áîëüøå, ÷åì ïî íàøåìó (çäåñü ÿ ñîëèäàðåí ñ óâàæàåìûì dmblock'îì) ìîæåò äàòü ìåòîä. Íî ïðè ýòîì Öèòàòà:
Óâàæàåìûé Åâãåíèé Íèêîëàåâè÷! Âû, êàê ÷åëîâåê, íåñóùèé ñâåò çíàíèé â ìàññû, äîëæíû ïîíèìàòü, ÷òî ìàññû èíåðòíû (÷òî íå âñåãäà ïëîõî, îñîáåííî â ìåäèöèíå) è ðàç Âû ñòàâèòå ïåðåä ñîáîé çàäà÷ó ïîïóëÿðèçèðîâàòü äîðîãîé Âàì ìåòîä, Âàì ïðèäåòñÿ ýòó èíåðöèþ ïðåîäîëåâàòü. |
#74
|
||||
|
||||
Öèòàòà:
|
#75
|
||||
|
||||
Öèòàòà:
Óâàæàåìûé ïðîôåññîð. Òî åñòü, ïîëó÷àåòñÿ, ÷òî Âû îïóáëèêîâàëè íà ôîðóìå ýòîò èíòåðåñíûé êëèíè÷åñêèé ñëó÷àé, ñ åäèíñòâåííîé öåëüþ îçíàêîìèòü íåîôèòîâ ñ ïîíÿòèÿìè "æèçíåñïîñîáíîñòü - íåæèçíåñïîñîáíîñòü", â Âàøåé èíòåðïðåòàöèè?  òàêîì ñëó÷àå ìíå ïðåäñòàâëÿåòñÿ áîëåå ëîãè÷íûì âàðèàíòîì, ÷òî Âû ïðîñòî ìîãëè áû àäðåñîâàòü íàñ ê ñîîòâåòñòâóþùåìó ðóêîâîäñòâó èëè ó÷åáíèêó èëè ñòàòüå. À ïîñëå íàøåãî îçíàêîìëåíèÿ ñ îíûìè, âíåñëè ñâîþ êîððåêöèþ, ïðîâåðèâ ðàáîòó íàä îøèáêàìè. À òî êàê-òî âñå èñïîäâîëü. Õîòÿ Âàì, êàê ïðåïîäàâàòåëþ, áåçóñëîâíî, âèäíåå, êàê ïîäàâàòü ìàòåðèàë. Öèòàòà:
È ó ýòîãî áîëüíîãî îáúåìû ñåðäöà, âûáðîñ è ìàññà ìèîêàðäà äîñòîâåðíî ìåíÿëèñü ïàðàëëåëüíî ñ èçìåíåíèÿìè ÝÊÃ? Öèòàòà:
Êðàéíå èíòåðåñíî Âàøå ìíåíèå ïî ýòîìó âîïðîñó, êàê ñïåöèàëèñòà. È ïî ìîåìó ñêðîìíîìó ìíåíèþ, áûëî áû ïðîùå, åñëè áû Âû âûñêàçàëè åãî â ôîðìå îáû÷íîãî ïîâåñòâîâàíèÿ, ñ ïðèìåðàìè, áåç èãðû "×òî? Ãäå? Êîãäà?", " ß óãàäàþ ýòó ìåëîäèþ ñ òðåõ íîò" è òä. Ñ óâàæåíèåì. |