謝晉 藝術總監
余秋雨 文學顧問
劉曉慶 領銜主演
上海話劇藝術中心 聯合演出
前言:
根據統計,台灣地區每一千個人中約有五個人以上患有心律不整的問題,然而心律不整的臨床表現症狀有很大的差異從輕微的胸口不適、心悸,以至於暈眩、休克、猝死都是可能的臨床表現,如果不早期治療,就可能有嚴重的後果。
(一)那心臟如何運作呢 ?
心臟就像幫浦(pump), 一個心臟由四個腔組成。兩個腔室在左邊,兩個在右邊。上面的兩個腔室分別為左、右心房,收集血液。下面的兩個腔室分別為左、右心室,打出血液。左心室收縮時,將血液打出去,循環全身,藉由血液攜帶養份及氧氣到身體各部位。
(二) 心臟的電氣生理
心臟是靠電路的傳導及刺激來引發收縮與舒張,主要的傳導系統有竇房節、房室節、希氏束及蒲金氏束。
竇房結 位於右心房,是電氣脈衝的起始點,是由一群特殊的細胞所組成,竇房結就像是「自然的節律點」啟動心跳。將脈衝傳到達心房,引起心房收縮,繼而將血液擠送到心室,之後脈衝便由心房傳到位於心房及心室間的房室結(AV node),再經希氏束及蒲金氏維束(His-Purkinje fiber)迅速的把電流性脈衝傳到心室,引起心室收縮,將血液擠送到肺臟或全身
心律不整是指在正常活動之下出現了不正常速率或不規則的心律, (註:正常竇性節律(normal sinus rhythm)是心跳的速率是60 到100次/分,且節律規則)
(三)心律不整
大致可分為心搏過快 ,心搏過慢或不規則,如果醫師懷疑您有心律不整時,他可能會安排一些診斷性的檢查,如下:
1.十二導程心電圖是一個最簡單的檢查,用來記錄心臟中電流的活動。心電圖中一系列的波形是表示心臟中電流活動的情形。藉由仔細觀察心電圖中所顯示的電流活動情形,使醫師能診斷出心律不整。
2.攜帶式心電圖記錄檢查(24hrs. Holtor’s scan),它是一種記錄二十四小時的心電圖,讓病人戴在身上,以便能持續性的記錄。病人依舊可從事日常生活的活動。這項檢查能發現到十二導程心電圖測試中沒有出現的心律不整。這種持續性的記錄方式,可以持續24小時,記錄到較不易被人察覺到的不正常心律。
3.當以上的基本檢查,無法提供所需要的訊息時,電氣生理學檢查可以精確的發現問題的所在,進而找出處理問題的方法。
因此電氣生理學檢查的應用,可使用在心律不整的病人身上以了解心律不整的機轉,或是在病人一直無法改善症狀,而懷疑是心律不整所引起,而其他的檢查又無法查出原因。
(四)電氣生理學檢查
電氣生理學檢查可以用來診斷出心臟電氣傳導的問題,醫師會從腹股溝旁的靜脈植入幾根(三至四根)導管,導管會沿著血管放至心臟內去測量並記錄心臟電氣傳導訊號其作用如下:
1.電極導管可以接收到心臟放電的訊號,分析訊號可了解心臟的電衝動是如何進行的。
2.電極導管可以傳送微小的電流刺激心臟,來改變心跳速率或節律。醫師可以利用刺激來引發病患心臟不正常的節律的重現,藉以了解心律不整的原因及機轉。
(五)術前及術中注意事項
在檢查前的晚上,醫護人員會要求病患將腹股溝洗淨並剃毛,因檢查時醫師會在腹股溝處的血管插入導管。且前一晚護士會告知病患,若隔天早上檢查,則前一日晚上12點禁食,若下午檢查則於檢查當天早餐後禁食,但藥物仍舊可繼續服用(除了醫師特別囑咐的藥物之外),在吃藥時可喝少許的開水以便吞嚥,當病患不再吃任何東西時,將牙齒及嘴巴漱洗乾淨。
當病患住院後電氣生理學檢查的心臟內科醫師會來探訪您,醫師將告訴病患大致會在何時進行檢查,以及是否由股靜脈,鎖骨下或內頸靜脈植入導管,有任何問題可在此時提出來討論。請注意在檢查當天,請20歲以上、能參與病情討論協助病人做決定的家屬到場,一定要有家人陪伴在您身邊。
檢查進行前病患必須先排空膀胱,換上手術衣、取下假牙、戒指、髮夾以及貴重物品等。當病患準備萬全時將被送到心導管室,如果病患有任何需要,醫護人員均會幫著病患。
在病患被安置在心導管室檢查床上時,將被接上各種監測的儀器,同時在病患的身上,會覆蓋一層無菌巾。這時請勿亂動或亂觸摸無菌巾, 因為整個侵入性的檢查過程必須是無菌以避免感染,再來醫師會在導管要插入的地方(鼠蹊部、頸部或鎖骨下)消毒的十分乾淨。同時使用非常小的針頭來做局部麻醉,使導管插入處失去感覺。首先以針來扎血管(動脈或靜脈)再將皮膚切一小個切口便放入導管護套,接著才將電極導管置入。電極導管是個含有電極,及軟且可彎曲的導線,它可以傳送電流訊號。
如果在電氣生理學檢查時可以確定心臟不正常放電位置在何處時,便會進行電氣灼燒術。
(六) 不整脈經導管燒灼術
自從不整脈經導管燒灼術(Transcatheter Radiofrequency Ablation for Arrhythmia)於1980年代發展以來,心律不整的治療 有相當大的改變,此治療方式不同於一般的抗心律不整藥物治療、心律調節器及心臟電擊術(Cardioversion)。除了外科手術外,不整脈經導管燒灼術是所有治療心律不整的方法中,唯一可以根治心律不整的方法。所謂的不整脈經導管燒灼術,乃是用電氣生理檢查出問題的所在,再以電流導引入放在心臟內的電極導管,用導管末端的金屬端點產生熱能,來灼燒去除異常的傳導路徑。其中又以射頻波(Radiofrequency)為最常使用的能量來源。
在進行不整脈經導管燒灼時,醫師會如前述方式將四至五根電極導管置於您的心臟,且確定導管位於心臟異常放電處。此時,讓電能源經由電極導管來灼燒心臟異常放電處。
電極導管的前端具有加熱及破壞組織的功能,它可以直接接觸於心臟不正常放電的組織,使心律不整消失。在整個檢查治療過程中,雖然會給病患服用藥物,幫助放鬆。但是病患的意識仍是清醒的。同時,醫護人員會在整個過程中,利用儀器來密切觀察病患的情況。
在整個治療過程中,通常不會有痛感,只有一開始植入導管時使用局部麻醉時,會有局部的疼痛,以及在燒灼時,胸部會有輕微不舒服。同時,病患可能會因需平躺過久而不舒服或疲倦。
在執行此項治療時,醫師會利用「微小電波刺激」來引導出病患心臟心律不整的情況出現。但不會有被電到的感覺,病患可能會有心悸或像以前心律不整發作的症狀出來。如果此時,有頭昏、眼花、心悸、胸痛、呼吸急促,記得告訴醫護人員。而這樣心律不整的情形,如果沒有自動恢復,醫師則會採用電刺激或電擊方式,來幫助恢復到正常的心跳節律。
這樣一個不整脈經導管燒灼治療,通常需耗費2~6個小時,情況通常是依病人的心律不整的情形而定,因此在台上一定要和醫護人員合作不可隨意亂動或深呼吸以免造成電燒的併發症。
(七)併發症
整體而言電氣生理學檢查及不整脈經導管燒灼術是屬於侵入性治療,因此當然也會有危險,但它的危險性相當低。一般來說是非常安全的。其併發症如下
1.心導管插入處會有瘀青、腫脹的情形:極少出現
2.心導管插入處會有動靜脈瘤:極少出現
3.死亡機率低於千分之一
4.心臟破裂及心包膜填塞症機率:千分之一
5.完全房室傳導阻斷機率:百分之二點六
6.其他如冠狀動脈阻塞、血管受損、氣胸或血胸、感染辦膜破裂 、及中風等併發症極微罕見
(八)不整脈經導管燒灼術對病患的好處
不整脈經導管燒灼術在治療心律不整的結果,可說是相當成功。對於房室結迴旋頻脈(atrioventricular nodal reentrant tachycardia)電燒慢速傳導路徑來切斷其迴路,可以達到高成功率(幾近100%),且復發率相當的低 (只有1%)。同樣地,電燒附加傳導路徑(accessory pathway)來治療房室迴旋頻脈(atrioventricular reentrant tachycardia),或沃爾夫.巴金森.懷特氏症候群(Wolff-Parkinson-White Syndrome),也有高達97%之成功率以及低復發率。近年來,隨著電氣生理學之進步,電燒灼治療心房撲動(Atrial flutter),都可以有相當好的成果。以往病患得了心房撲動,只能利用藥物控制或作開心手術,甚至心臟電擊。但由於藥物仍無法完全治療,開心手術有一定的危險性,令病人感到不安。現今不整脈經導管燒灼術的發明及應用推廣,可以有效治療85%以上的病患。總之,不整脈經導管燒灼療法是一種非常低危險性的治療,它可以治癒您心律不整方面的問題。在許多個案中,在做了不整脈經導管燒灼術後,不用持續服用藥,且擁有一個正常規律的心臟跳動。
(九) 不整脈經導管燒灼術後的護理
當不整脈經導管燒灼術程序完成,而且心導管拔除後,醫師會直接在導管插入處加壓10~20分鐘,以避免出血。之後病患會被送回病房,回病房後無嘔吐或不適感則可以喝水、進食,但必須再平躺4~6小時(有時可能會更久),讓插入處的血管癒合。此時,病患必須避免彎曲及抬起檢查側之腿,以促進血管之癒合,但仍可稍微擺動您的腳趾,舒緩一下。
在這期間,護士會監控病患的脈搏及血壓,以及導管插入處是否出血。如果發現導管插入處會痛 瘀青、與腫脹加劇,或有下列症狀時如頭昏、眼花、心悸、胸痛、呼吸急促、發燒時,請立即通知護士。 整個檢查完成後,醫師會在當天與病患討論整個檢查結果,並告知何時再度回院門診追蹤。
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Gresham’s Law from Wikipedia, the free encyclopedia
”’Gresham’s law”’ is commonly stated as: "When there is a legal tender currency, bad money drives good money out of circulation".
Gresham’s law applies specifically when there are two forms of commodity money in circulation which are forced, by the application of legal tender laws, to be respected as having the same face value in the marketplace. It is named after Sir Thomas Gresham, an English financier in Tudor times.
==Definitions of "good money" and "bad money"==
The terms "good" and "bad" money are used in a technical sense, and with regard to exchange values imposed by legal tender legislation, as follows:
==Good money==
Good money is money that has little difference between its exchange value and its commodity value. In the original discussions of Gresham’s law, money was conceived of entirely as metallic coins, so the commodity value is the market value of the coined bullion of which the coins are made.
An example is the US dollar, which, prior to the 1900s was equal to 1/20.67 ounce (1.5048 g) of gold, and carried an exchange value roughly equal to its coined gold market value.
In the absence of legal tender laws, metal coin money will freely exchange at somewhat above bullion market value. (This is not a purely theoretical result, but rather can be observed today in bullion coins such as the Krugerrand (South Africa) and the American Gold Eagle (United States)). Coined money is of a known purity, and in a convenient form to handle. People prefer trading in coins to anonymous hunks of bullion, so they attribute more value to the coins. There is also a certain demand by coin collectors. Thus, coining is frequently profitable.
==Bad money==
Bad money is money that has a substantial difference between its commodity value and its market value, where market value is lower than exchange value.
In Gresham’s day, bad money included any coin that had been "debased." Debasement was often done by members of the public, cutting or scraping off some of the metal. Coinage could also be debased by the issuing body, whereby less than the officially mandated amount of precious metal is contained in an issue of coinage, usually by alloying it with base metal. Other examples of "bad" money include counterfeit coins made from base metal. In all of these examples, the market value was the supposed value of the coin in the market.
In the case of clipped, scraped or counterfeit coins, the market value has been reduced by fraud, while the exchange value remains at the higher value. On the other hand, with coinage debased by a government issuer the market value of the coinage was often reduced quite openly, but the exchange value of the debased coins was held at the higher level by legal tender laws.
All modern money is "bad money" in this sense, since fiat money has entirely replaced the commodity money to which Gresham’s law applies. The ubiquity of fiat money could indeed be taken as evidence for the truth of Gresham’s law.
==Theory==
Gresham’s law says that any circulating currency consisting of both "good" and "bad" money (both forms required to be accepted at equal value under legal tender law) quickly becomes dominated by the "bad" money. This is because people spending money will hand over the "bad" coins rather than the "good" ones, keeping the "good" ones for themselves.
Consider a customer purchasing an item which costs five pence, who has in their possession several silver sixpence coins. Some of these coins are more debased, while others are less so — but legally, they are all mandated to be of equal value. The customer would prefer to retain the better coins, and so offers the shopkeeper the most debased one. In turn, the shopkeeper must give one penny in change — and has every reason to give the most debased penny. Thus, the coins that circulate in the transaction will tend to be of the most debased sort available to the parties.
If "good" coins have a face value below that of their metallic content, individuals may be motivated to melt them down and sell the metal for its higher bullion value, even if such defacement is illegal. For an example of this, consider the 1965 US Half-dollars which were made from only 40% silver. The previous year the half-dollar was 90% silver. With the release of the 1965 half, which was legally required to be accepted at the same value as the previous year’s 90% halves, the older 90% silver coinage of the US quickly disappeared from circulation, and the debased money was allowed to circulate in its stead. As the price of bullion silver rose above the face value of the coins, many of those old half-dollars were melted down. With the 1971 issue the government gave up on including any silver in the half dollars. A similar situation is currently (2007) occurring with the rising price of zinc and copper, and has lead to attempts by the U.S. government to ban the melting or mass exportation of one and five cent coins, respectively.
In addition to being melted down for its bullion value, money that is considered to be "good" tends to leave an economy through international trade. International traders are not bound by legal tender laws the way citizens of the country are, so they will offer higher value for good coins than bad ones, and thus higher value than can be obtained within the country. The good coins may leave their country of origin to become part of international trade. Thus, the good money is driven out of the country of issue, escaping that country’s legal tender laws and leaving the "bad" money behind. This occurred in Britain during the period of the Gold Exchange Standard.