簡介：4800英文單詞，英文單詞，26萬英文字符，中文萬英文字符，中文7900字文獻出處文獻出處QAYUMA,GUPTAA,GUPTAA,ETALENVIRONMENTALTAXATIONBASEDINTEGRATEDMODELINGTOWARDSSUSTAINABLEENVIRONMENTALCONSERVATIONAPPROACHJENVIRONMENTALSYSTEMSRESEARCH,2016,5123ENVIRONMENTALTAXATIONBASEDINTEGRATEDMODELINGTOWARDSSUSTAINABLEENVIRONMENTALCONSERVATIONAPPROACHABDULQAYUM,ANJANAGUPTA,AKANKSHAGUPTAANDRAKESHARYAABSTRACTBACKGROUNDGLOBALIZATIONANDRAPIDINDUSTRIALIZATIONWASINEVITABLEDURINGLATENINETEENTHCENTURYCONSIDERINGTHEDEMAND–SUPPLYDEFICITANDREQUIREMENTSOFEVOLVINGSOCIETIESHOWEVER,ATLATERSTAGETHESEFACTORSWEREMAPPEDTOBEMAJORREASONSFORTHEENVIRONMENTALPOLLUTIONFURTHER,ATTHECOSTOFENVIRONMENTDEGRADATION,DEVELOPMENTANDECONOMICGROWTHCANNOTBEACHIEVEDTHEOBJECTIVEOFTHEWORKISTODESIGNAGREENTAXATIONPOLICYTOMITIGATEHAZARDOUSENVIRONMENTALIMPACTSOFVARIOUSSECTORSANDTOVISUALIZETHEBENEFITSWHICHCANBRIDGETHESOCIOECONOMICDIVIDEPREVALENT,ESPECIALLYINDEVELOPINGNATIONSTHEAPPROACHISAMALGAMATIONOFEIABASEDAPPROACHONTHEENERGYRESEARCHINSTITUTECRITERIAANDENVIRONMENTENERGY,ECONOMYRESULTSINTEGRATEDMODELISBASEDONTHEPRINCIPLETHATTHETAXRATEHASTOBECOMMENSURATEWITHTHEENVIRONMENTALDAMAGESWHICHANYPROJECTCAUSESANDITWASFOUNDTHATBOTHECONOMICGROWTHANDENVIRONMENTALPOLLUTIONARESYNCHRONOUSGROWTHANDDEVELOPMENTRELATEDPROJECTSCANNOTBECOMPROMISEDBECAUSEOFINCREASEDDEMANDSTHEREFORE,THEREHASTOBEFINEBALANCEBETWEENDEVELOPMENTANDCONSERVATIONCONCLUSIONSTHEPOLICIESMAYBEDESIGNEDONTHEMODELDISCUSSEDTOBRINGOUTOPTIMALCONTRIBUTIONOFINDUSTRYSECTORTOWARDSGENERATINGRESOURCESFORECONOMICGROWTHANDTOBRIDGESOCIOECONOMICDIVIDEGREENTAXATIONPROVESTOBEDETERRENTTOOLTOWARDSENVIRONMENTALDEGRADATIONANDOPTIMALENERGYUTILIZATIONKEYWORDSDENOVOAPPROACH,ENERGYECONOMYENVIRONMENT,ENVIRONMENTALCONSERVATION,ENVIRONMENTALIMPACTASSESSMENT,GREENTAXATION,SOCIOECONOMICGROWTHBACKGROUNDITISWIDELYARGUEDTHATTHEREISHUGEECONOMICDEVELOPMENTPRESSUREAMONGDEVELOPINGNATIONSTOADDRESSINCREASEDNEEDOFTHEPEOPLE,WHERERESOURCESARESCARCENARULAANDDUNNING2000SCARCITYCOMPOUNDSTHEPRESSUREONENVIRONMENTDUETOMAXIMALUTILIZATIONOFNATURALRESOURCESAND,INDIAISNOTANEXCEPTIONASITISSECONDMOSTPOPULOUSCOUNTRYINTHEWORLDASPERANESTIMATE,ITISVERYLIKELYTOOVERPASSCHINABY2040TOOCCUPYTHEAPEXPOSITIONINTHEPOPULATIONPYRAMIDMCDEVITT1996ITISARGUEDTHATENERGYCONSUMPTIONVARIESDIRECTLYWITHPOPULATIONINCREASEJOHNANDPAUL1974INDIAWILLBEUNDERTREMENDOUSPRESSURETOINCREASEITSENERGYDEMANDTOMEETITSOVERRIDINGSOCIALANDECONOMICOBLIGATIONSDUETOBURGEONINGPOPULATIONTHEREFORE,ENVIRONMENTALCONSERVATIONBYMITIGATINGEFFECTSOFVARIOUSEFFLUENTSANDPOLLUTANTSBECOMESINEVITABLETAXATIONPROVEDTOBEADETERRENTTOWARDSREDUCINGTHEENERGYDEMANDBYIMPROVINGENERGYINTENSITYINEUROPE,FUELDEMANDWOULDHAVEBEENTWICEIFITHADNOTFOLLOWEDTHEPOLICYOFHIGHFUELTAXATIONSTERNER2007INEUROPEANUNIONEU,ITWASFOUNDTHATINDUSTRIESTHATREDUCEPOLLUTIONINCREASEITSRESOURCEPRODUCTIVITYANDSWITCHTORENEWABLESOURCESISHIGHLYENCOURAGEDINTURKEY,ASECONDTERI,NEWDELHIQAYUMANDGUPTA2014TERIHASDEVELOPED“GREENRATINGFORINTEGRATEDHABITATASSESSMENT”SYSTEMWHICHISANEVALUATIONTOOLANDMAINTAINSARESOURCEEFFICIENTBUILTENVIRONMENTGRIHA2010ITEVALUATESENVIRONMENTALPERFORMANCEOFABUILDINGHOLISTICALLYOVERITSENTIRELIFECYCLE,THEREBYPROVIDINGDEFINITIVESTANDARDSFORWHATCONSTITUTEA‘GREENBUILDING’THESCOPEOFTHECURRENTPAPERISRESTRICTEDTOTAXINCENTIVEMODELFORTHEEFFECTIVEMITIGATIONOFTHEENVIRONMENTALDAMAGECAUSEDBYTHECONSTRUCTIONINDUSTRYCONSIDERINGTHELIMITATIONOFTERI–GRIHACRITERIATHEGLOBALPRESSUREACTINGINWARDANDINDIA’SMORALOBLIGATIONTOREDUCETHEEMISSIONLEVELMAKESTHISSTUDYMUCHMORERELEVANTANDITADOPTSINTEGRATEDMODELINGBYCONSIDERINGENERGY–ECONOMY–ENVIRONMENTDYNAMICSTOGETHEROFCOMPUTABLEGENERALEQUILIBRIUMCGEMODELMETHODSTHEPRESENTEDMODELISPRIMARILYBASEDONTRIADOFENVIRONMENTENERGYECONOMYENVEEMMODELGURKAN2003INCONJUNCTIONWITHDENOVOAPPROACHOFENVIRONMENTALTAXATIONFORMERISDYNAMICCGEMODELINGBASEDONINTERACTIONAMONGTHETRIADSFIG1WHILETHELATTERISFORMULATIONOFINTEGRATIONOFTERIGUIDELINEWITHPROPOSEDENVIRONMENTALTAXATIONPOLICYFIG2CGEISTHEPRINCIPALANALYTICALTOOLOFFEREDFORCONDUCTINGECONOMICANALYSESOFENERGY,ECONOMYANDTHEENVIRONMENTTHEREEXISTTWOSIMULTANEOUSEQUILIBRIUMSOF‘GOVERNMENTTOPRODUCERS’AND‘PRODUCERSTOCONSUMERS’WITHSURROUNDINGPARAMETERSASINFIG1INFIRSTEQUILIBRIUM,SUPPLYOFCOMMODITYANDGREENTAXIMPOSITIONWITHREVENUEISANINPUTFROMVARIOUSSECTORSSUCHASENERGY,TECHNOLOGYMATRIXINTERMEDIATEGOODSETCWHILEINSECONDEQUILIBRIUMSUPPLYOFCAPITAL,LABORANDSUPPLYOFCOMMODITIESPLAYAKEYVARIABLEROLEENVEEMMODELINVOLVESPARALLELINTERACTIONOFCONSUMERTOGOVERNMENTVIAPRODUCERS,WHILE,PRODUCERISNERVECENTEROFTHEMODELINCORPORATINGNUMEROUSINFLOWSANDBIDIRECTIONALFLOWSFROMBOTHCONSUMERANDTHEGOVERNMENTEPICENTERSINTHEMEANPROCESS,IMPOSITIONOFINDIRECTGREENTAXESCOMESINTOTHEPICTUREFROMWHICHTERIBASEDMODELEVOLVESFIG1ENVEEMMODELFORIMPOSITIONOFINDIRECTGREENTAXESTHEENERGYRESEARCHINSTITUTECRITERIAAREPOINTBASEDTOTAL106ANDMANDATORY30ANDSOMEAREOPTIONALINNATURETHEREISADDITIONALSCOREBONUSFORCOVERINGTHESEASPECTSOFENVIRONMENTALCONSERVATIONTABLE1ASCHEMATICFLOWCHARTFIG2WASDEVELOPEDFORTHE

簡介：QAYUMETALENVIRONSYSTRES2016523DOI101186/S4006801600741RESEARCHENVIRONMENTALTAXATIONBASEDINTEGRATEDMODELINGTOWARDSSUSTAINABLEENVIRONMENTALCONSERVATIONAPPROACHABDULQAYUM1,ANJANAGUPTA2,AKANKSHAGUPTA3ANDRAKESHARYA4ABSTRACTBACKGROUNDGLOBALIZATIONANDRAPIDINDUSTRIALIZATIONWASINEVITABLEDURINGLATENINETEENTHCENTURYCONSIDERINGTHEDEMAND–SUPPLYDEFICITANDREQUIREMENTSOFEVOLVINGSOCIETIESHOWEVER,ATLATERSTAGETHESEFACTORSWEREMAPPEDTOBEMAJORREASONSFORTHEENVIRONMENTALPOLLUTIONFURTHER,ATTHECOSTOFENVIRONMENTDEGRADATION,DEVELOPMENTANDECONOMICGROWTHCANNOTBEACHIEVEDTHEOBJECTIVEOFTHEWORKISTODESIGNAGREENTAXATIONPOLICYTOMITIGATEHAZARDOUSENVIRONMENTALIMPACTSOFVARIOUSSECTORSANDTOVISUALIZETHEBENEFITSWHICHCANBRIDGETHESOCIOECONOMICDIVIDEPREVALENT,ESPECIALLYINDEVELOPINGNATIONSTHEAPPROACHISAMALGAMATIONOFEIABASEDAPPROACHONTHEENERGYRESEARCHINSTITUTECRITERIAANDENVIRONMENTENERGY,ECONOMYRESULTSINTEGRATEDMODELISBASEDONTHEPRINCIPLETHATTHETAXRATEHASTOBECOMMENSURATEWITHTHEENVIRONMENTALDAMAGESWHICHANYPROJECTCAUSESANDITWASFOUNDTHATBOTHECONOMICGROWTHANDENVIRONMENTALPOLLUTIONARESYNCHRONOUSGROWTHANDDEVELOPMENTRELATEDPROJECTSCANNOTBECOMPROMISEDBECAUSEOFINCREASEDDEMANDSTHEREFORE,THEREHASTOBEFINEBALANCEBETWEENDEVELOPMENTANDCONSERVATIONCONCLUSIONSTHEPOLICIESMAYBEDESIGNEDONTHEMODELDISCUSSEDTOBRINGOUTOPTIMALCONTRIBUTIONOFINDUSTRYSECTORTOWARDSGENERATINGRESOURCESFORECONOMICGROWTHANDTOBRIDGESOCIOECONOMICDIVIDEGREENTAXATIONPROVESTOBEDETERRENTTOOLTOWARDSENVIRONMENTALDEGRADATIONANDOPTIMALENERGYUTILIZATIONKEYWORDSDENOVOAPPROACH,ENERGYECONOMYENVIRONMENT,ENVIRONMENTALCONSERVATION,ENVIRONMENTALIMPACTASSESSMENT,GREENTAXATION,SOCIOECONOMICGROWTH?2016THEAUTHORSTHISARTICLEISDISTRIBUTEDUNDERTHETERMSOFTHECREATIVECOMMONSATTRIBUTION40INTERNATIONALLICENSEHTTP//CREATIVECOMMONSORG/LICENSES/BY/40/,WHICHPERMITSUNRESTRICTEDUSE,DISTRIBUTION,ANDREPRODUCTIONINANYMEDIUM,PROVIDEDYOUGIVEAPPROPRIATECREDITTOTHEORIGINALAUTHORSANDTHESOURCE,PROVIDEALINKTOTHECREATIVECOMMONSLICENSE,ANDINDICATEIFCHANGESWEREMADEBACKGROUNDITISWIDELYARGUEDTHATTHEREISHUGEECONOMICDEVELOPMENTPRESSUREAMONGDEVELOPINGNATIONSTOADDRESSINCREASEDNEEDOFTHEPEOPLE,WHERERESOURCESARESCARCENARULAANDDUNNING2000SCARCITYCOMPOUNDSTHEPRESSUREONENVIRONMENTDUETOMAXIMALUTILIZATIONOFNATURALRESOURCESAND,INDIAISNOTANEXCEPTIONASITISSECONDMOSTPOPULOUSCOUNTRYINTHEWORLDASPERANESTIMATE,ITISVERYLIKELYTOOVERPASSCHINABY2040TOOCCUPYTHEAPEXPOSITIONINTHEPOPULATIONPYRAMIDMCDEVITT1996ITISARGUEDTHATENERGYCONSUMPTIONVARIESDIRECTLYWITHPOPULATIONINCREASEJOHNANDPAUL1974INDIAWILLBEUNDERTREMENDOUSPRESSURETOINCREASEITSENERGYDEMANDTOMEETITSOVERRIDINGSOCIALANDECONOMICOBLIGATIONSDUETOBURGEONINGPOPULATIONTHEREFORE,ENVIRONMENTALCONSERVATIONBYMITIGATINGEFFECTSOFVARIOUSEFFLUENTSANDPOLLUTANTSBECOMESINEVITABLETAXATIONPROVEDTOBEADETERRENTTOWARDSREDUCINGTHEENERGYDEMANDBYIMPROVINGENERGYINTENSITYINEUROPE,FUELDEMANDWOULDHAVEBEENTWICEIFITHADNOTFOLLOWEDTHEPOLICYOFHIGHFUELTAXATIONSTERNER2007INEUROPEANUNIONEU,ITWASFOUNDTHATINDUSTRIESTHATREDUCEPOLLUTIONINCREASEITSRESOURCEPRODUCTIVITYANDSWITCHTORENEWABLESOURCESISHIGHLYENCOURAGEDINTURKEY,ASECONDDIVIDENDOFENVIRONMENTALTAXATION,THATISECONOMICBENEFITSINADDITIONTOENVIRONMENTALIMPROVEMENTS,SHOWSPOTENTIALWHENIMPORTEDFUELSAREPRIMARYSOURCEOFPOLLUTANTGURKAN2003THECONCEPTOPENACCESSCORRESPONDENCEAKANKS11_ISJJNUACIN3CENTREFORWESTASIANSTUDIES,JAWAHARLALNEHRUUNIVERSITY,NEWDELHI,INDIAFULLLISTOFAUTHORINFORMATIONISAVAILABLEATTHEENDOFTHEARTICLEPAGE3OF10QAYUMETALENVIRONSYSTRES2016523WHILE,PRODUCERISNERVECENTEROFTHEMODELINCORPORATINGNUMEROUSINFLOWSANDBIDIRECTIONALFLOWSFROMBOTHCONSUMERANDTHEGOVERNMENTEPICENTERSINTHEMEANPROCESS,IMPOSITIONOFINDIRECTGREENTAXESCOMESINTOTHEPICTUREFROMWHICHTERIBASEDMODELEVOLVESTHEENERGYRESEARCHINSTITUTECRITERIAAREPOINTBASEDTOTAL106ANDMANDATORY30ANDSOMEAREOPTIONALINNATURETHEREISADDITIONALSCOREBONUSFORCOVERINGTHESEASPECTSOFENVIRONMENTALCONSERVATIONTABLE1ASCHEMATICFLOWCHARTFIG2WASDEVELOPEDFORTHETAXATIONMETHODOLOGYANDISDERIVEDFROMENVEEMMODELFIG1WHICHTRIGGERSTHEINTRODUCTIONOFGTTOSTABILIZETHEDYNAMICEQUILIBRIUMOFPRODUCERWITHTHEGOVERNMENTWHILETERIMODELDESCRIBESTHEDETAILEDMETHODOFTAXATIONFORAPARTICULARINDUSTRYFORAPROJECT,EIAISDONEUSINGTERICRITERIAANDITISEVALUATEDAGAINSTTHEENVIRONMENTDAMAGESITHASCAUSEDORCAUSESDURINGANDPOSTCONSTRUCTIONPHASEPERCENTAGEADHERENCEOFAPROJECTTOTHELISTEDCRITERIAISALSOESTIMATEDUSINGAFACTOR‘X’WHICHWASCALCULATEDASCOMPLIANCEOFTHEPROJECTWITHTERICRITERIAOFGREENBUILDINGBASEDON‘X’TAXINCENTIVESAREGRANTEDASPERTHESCHEMATICFLOWCHARTFIG2REVENUEGENERATEDFROMADDITIONALGTPENALTYSHALLGOTOTHESOCIOECONOMICDEVELOPMENTANDREVENUEFROMGTSHALLGOTOTHE‘GREENCLIMATEFUND’FORLONGTERMGOALSTHISWILLCOLLECTIVELYLEADTOBETTERGOVERNANCE,SUSTAINABLEGROWTHTARGETS,ANDWILLCATALYZETHEENDEAVORSFORBRIDGINGTHEEXPANDINGSOCIOECONOMICDIVIDESHOWCGEMODELISAPPLICABLEFORINDIATHEENVIRONMENTANDCLIMATECHANGEISSUESARENOTRESTRICTEDTOANYGEOGRAPHICALTERRITORYRATHERIT’SAGLOBALISSUEMOREOVER,TURKISHECONOMYISNOTMUCHDIFFERENTFROMTHEINDIANCOUNTERPARTCONSIDERINGTHEISSUETOBEGLOBALANDWITHOUTANYSPECIFICTURKISHECONOMYPARAMETERSUSEDINTHECGEMODEL,ITCANBEEXTENDEDTOINDIAASWELLWITHOUTL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簡介：4250英文單詞，英文單詞，24萬英文字符，中文萬英文字符，中文6600字文獻出處文獻出處LEECC,LINTT,CHENGPCTHEDETERMINANTSOFTHETRANSPORTATIONOUTSOURCINGSTRATEGYFORTHEEXPRESSDELIVERYCOMPANYJSERVICEBUSINESS,2013,72207225THEDETERMINANTSOFTHETRANSPORTATIONOUTSOURCINGSTRATEGYFORTHEEXPRESSDELIVERYCOMPANYCHIACHILEE,TYRONETLIN,PEICHUCHENGABSTRACTTHISARTICLEEXPLORESTHEDETERMINANTSTHATAFFECTTHETRANSPORTATIONOUTSOURCINGSTRATEGYOFTHEEXPRESSDELIVERYCOMPANYINTAIWANTHERESULTSSHOWTHATTHEFOLLOWINGSITUATIONSRESULTINHIGHEROUTSOURCINGPROBABILITYCUSTOMERCOMPANIESBELONGINGTOTHEHIGHTECHINDUSTRY,CUSTOMERSBRINGINGHIGHERFREIGHTREVENUE,CUSTOMERSHAVINGABETTERRELATIONSHIPWITHTHECASESTUDYCOMPANY,ANDCUSTOMERS’COMPANYHAVINGABIGGERSCALETHEFINDINGSPROVIDEENTERPRISESWITHAREFERENCEOFDECISIONMAKINGTOFOLLOWINIMPLEMENTINGTHETRANSPORTATIONOUTSOURCINGMEASUREFORDIFFERENTCUSTOMERS’NEEDSTHEOUTSOURCINGSTRATEGYINCREASESTHEFLEXIBILITYOFOPERATINGFUNDSTOENHANCECUSTOMERSERVICEQUALITYKEYWORDSTRANSPORTATION,OUTSOURCINGSTRATEGY,EXPRESSDELIVERYCOMPANY,LOGISTICREGRESSION1INTRODUCTION11RESEARCHBACKGROUNDANDMOTIVATIONTHEMANAGEMENTPROBLEMORTHEOUTSOURCINGBUSINESSISGETTINGATTENTIONINTODAY’SBUSINESSOPERATIONSDUETOTHERISEOFTHEOUTSOURCINGDEMANDOVERTHEPASTYEARSTHEMAINREASONBEHINDTHISISBECAUSEOUTSOURCINGISNOTONLYTHEROOTOFBUSINESSOPERATIONSTRATEGIESTOREDUCECOSTS,BUTALSOONEOFTHEIMPORTANTSTRATEGICTOOLSFORCOMPANIESTOGET‘‘FLEXIBILITY’’,‘‘SPEED’’,ANDOTHERREQUIREMENTSOFTHEADVANTAGESINAHIGHLYCOMPETITIVEENVIRONMENTHOWEVER,THECOSTISAVERYIMPORTANTFACTORINDECIDINGWHETHERTOTAKEOUTSOURCINGMEASURESORNOTSOENTERPRISESSHOULDREPLACETHETRADITIONALWAYOFDISTRIBUTIONBYTHEOUTSOURCINGSTRATEGYANDLETTHEPROFESSIONALOUTSOURCINGCOMPANIESEXECUTERELATEDSTRATEGIES,PLANNING,IMPLEMENTATION,ANDOTHERSERVICESTHEREFORE,ENTERPRISESCANEFFECTIVELYREDUCETHEOPERATINGCOSTSANDTHEMANPOWERSHORTAGEPROBLEMDURINGTHENONWORKINGHOURS,WITHOUTINCREASINGOTHERCOSTSINTHEINTERNALCONSTRUCTIONOFASSETS,PERSONNELDELIVERY,DEPRECIATIONANDAMORTIZATION,ANDOTHERRELATEDMAINTENANCEDUNN1999POINTSOUTTHATAPARTFROMTHEFINANCIALPROFITSOFOUTSOURCING,THEREAREFIVEOTHERBENEFITSSUCHASSHARPENINGMANAGEMENTFOCUS,INCREASINGPROFITABILITY,IMPROVINGBUSINESSPROCESSES,ENHANCINGSERVICELEVELS,ANDSHARINGRISKSBROMAGE2000SHOWSTHATTHEREAREALOTOFFACTORSFORCOMPANIESTOBEWILLINGTOUSETHEOUTSOURCINGSTRATEGY,INCLUDINGEFFICIENCYIMPROVEMENTS,LOWERCOSTS,IMPROVEDFLEXIBILITY,ANDSOONHENCE,THEMUTUALDEPENDENCEAMONGCOMPANIESWILLCONTRIBUTETANGIBLYANDINTANGIBLYTOPARTNERSHIPANDMUTUALINTERESTSFREDRIKSSONANDJOHANSSON2009INDICATETHATUSINGTHEGENERALPROCESSINCLUDINGLOGISTICSWILLREDUCETHEPOSSIBILITYOFOVERLOOKINGIMPORTANTCONSIDERATIONSDURINGOUTSOURCINGPROJECTSANDDECREASETHEPROBLEMSDISCOVEREDAFTERIMPLEMENTATIONLINETAL2009INDICATETHATENTERPRISESOUTSOURCETHEIRNONCORECOMPETITIVELOGISTICSOPERATIONSTOTHE3RDPARTYLOGISTICS3PLSSERVICEPROVIDERSTHEORGANIZATIONALCOLLABORATIONWITH3PLSPROVIDESAPOSSIBILITYTOIMPROVETHEEFFICIENCYOFENTERPRISES’LOGISTICSOPERATIONSBYCREATINGALOWERLOGISTICSOPERATINGCOSTASWELLASAHIGHERCUSTOMERSERVICELEVELTHESTATISTICSINTHEMINISTRYOFECONOMICAFFAIRS’WEBSITESHOWTHATTHEFLUCTUATIONSINOILTHROUGHTHEREASSIGNMENTOFWORKORSTAFFTHEREFORE,OUTSOURCINGISNOTASEASYASTOACCESSDIFFERENTGOODSORSERVICECONTRACTSPERRY1997MENTIONSTHATOUTSOURCINGEXPLAINSTHATTHEORIGINALWORKOFTHESTAFFWILLBEOUTSOURCEDTOOTHERMANUFACTURERSTODEALWITHTHATIS,FROMTHEEMPLOYER’SVIEWPOINT,OTHERCONTRACTORSWORKINGINTHEFIELDOFOUTSOURCINGHAVECOMPETITIVEADVANTAGESTHESECOMPETITIVEADVANTAGESMAYINCLUDE1RELIABILITYCONSISTENCYOFPRODUCTORSERVICEQUALITY2QUALITYIMPROVEMENTOFTHEPRODUCTSORSERVICEQUALITYDESIGNATEDBYEMPLOYERS3COSTREDUCTIONOFTHECOSTSOFPRODUCTSORSERVICESPROVIDEDBYEMPLOYERSINORDERTOINCREASECORPORATEPROFITSCOOKE1997DESCRIBESTHEOUTSOURCINGOPERATIONSAREENTRUSTINGTHEENTERPRISE’SORIGINALVALUEDACTIVITIESTOEXTERNALAGENCIESTAKINGTHEMANUFACTURINGFOREXAMPLE,EACHASPECTOFTHEENTIRESUPPLYCHAIN,THATIS,FROMTHESOURCEOFRAWMATERIALSTOTHECONSUMERS,INCLUDINGRESEARCHANDDEVELOPMENT,MANUFACTURING,TRANSPORTATION,WAREHOUSING,INVENTORYMANAGEMENT,AFTERSALESSERVICE,DOCUMENTATIONFLOW,ANDBILLINGOPERATIONSCANBEVALUEDTHEACTIVITIESOFOUTSOURCINGQUINN1999DEFINESOUTSOURCINGASTHEORGANIZATION’SENTRUSTINGSOMEORALLTHEPERIPHERALFUNCTIONALACTIVITIESOUTOFTHECORECOMPETENCETOTHEEXTERNALCONTRACTORSBASEDONTHESTRATEGICOUTSOURCINGAPPROACH,THEORGANIZATIONSHOULDJUSTIMPLEMENTTHEMOSTSPECIALIZEDANDVALUABLEPARTOFTHEVALUECHAINACTIVITIESTHERESTCANBEOUTSOURCEDTOOTHERCONTRACTORSLETUSSYNTHESIZETHEABOVEARGUMENTSOFSCHOLARSTHEADVANTAGESOFOUTSOURCINGFORTHEEXPRESSDELIVERYINDUSTRYWILLBETHETRANSFEROFALLORPARTOFTHEFIXEDCOSTSOFFREIGHTEQUIPMENTLOADTOTHEPROFESSIONALFREIGHTCONTRACTORTHEEXPRESSDELIVERYCOMPANIESCANJUSTCONCENTRATEONTHEIRCOREBUSINESSTOREDUCEOPERATINGCOSTS,MAKETHEBESTUSEOFHUMANRESOURCESONIMPROVINGSERVICEQUALITY,ANDMAINTAINTHEIROWNCOMPETITIVEADVANTAGESLALONDEANDCOOPER1989SAYTHATAPARTNERSHIPSHOULDEXISTINTHEBUSINESSTOBUSINESSRELATIONSHIPSCHOEMAKER1992MENTIONSSINCEOUTSOURCINGISCONSIDEREDASONEOFTHEIMPORTANTDECISIONMAKINGTOOLSOFCORPORATEDEVELOPMENT,THECOMPANYMUSTFIRSTOFALLTAKEINTOACCOUNTTHEINTERNALANDEXTERNALENVIRONMENTALCONDITIONSTOCONSIDERHOWTOUSEOUTSOURCINGTOCREATETHEMAXIMUMBENEFITFORTHECOMPANYGORDON1994POINTSOUTTHATTHEOUTSOURCINGINDUSTRYHASBEENWELLESTABLISHEDOVERSEVERALDECADESSINCETHEINDUSTRIALREVOLUTION,MANUFACTURERSHAVEBEGUNTORELYONPROFESSIONALPEOPLETOSHARETHEWORKPREVIOUSLYUNDERTAKENBYTHEINTERNALHUMANRESOURCESINARAPIDLYCHANGINGENVIRONMENT,SEGMENTINGTHECORECOMPETITIVENESSASTHEOPERATINGENVIRONMENTISDIFFICULTTOGRASP,ENTERPRISESENTRUSTPARTORALLOFTHEORGANIZATIONFUNCTIONSOUTSIDETHECORECOMPETITIVENESSTOTHEPROFESSIONALSUPPLYINDUSTRYELLRAM1995ALSOBELIEVESTHATAPARTNERSHIPISABUSINESSAGREEMENTBETWEENTHEOUTSOURCERANDTHECONTRACTORTHEREFORE,THEESTABLISHMENTOFAGOODPARTNERSHIPISCONDUCIVETOACHIEVINGTHEOUTSOURCINGPERFORMANCEANDEFFECTIVELYSETTINGUPTHEDEVELOPMENTOFCOMPETITIVEADVANTAGEJENNINGS1997ALSOMENTIONSTHATTHEBENEFITSOFOUTSOURCINGFROMTHEVIEWPOINTOFHUMANRESOURCESWILLBETHECOMBINATIONOFTHEFOLLOWINGBENEFITSSERVICEVALUEENHANCEMENT,SERVICESPEEDIMPROVEMENT,ANDSERVICECOSTREDUCTIONVININGANDGLOBERMAN1999ANDMOMMEANDHVOLBY2002FINDTHATOUTSOURCINGHASTHREEADVANTAGES1UPGRADINGTHEIRPROFESSIONALCOMPETENCEOFTHETRANSPORTFUNCTIONSANDIMPROVINGTHEIRSERVICEFLEXIBILITYBYENTRUSTINGTHENONCOMPETITIVETRANSPORTOPERATIONSTOOUTSOURCEDMANUFACTURERS2THEREISNOEXPENDITUREOFFIXEDCOSTSANDUSERSONLYPAYFORTHESERVICEWHENITISRENDERED3THEMAINAGREEMENTPERIODISUSUALLYBASEDONTHESIGNEDCONTRACTIFTHEOPERATIONOFOUTSOURCINGVENDORSISINEFFICIENTORNOTIMPROVEDDURINGTHEIMPLEMENTATIONPERIOD,ENTERPRISESCANTERMINATETHE

簡介：EMPIRICALARTICLETHEDETERMINANTSOFTHETRANSPORTATIONOUTSOURCINGSTRATEGYFORTHEEXPRESSDELIVERYCOMPANYCHIACHILEETYRONETLINPEICHUCHENGRECEIVED28SEPTEMBER2011/ACCEPTED18JUNE2012/PUBLISHEDONLINE4JULY2012?SPRINGERVERLAG2012ABSTRACTTHISARTICLEEXPLORESTHEDETERMINANTSTHATAFFECTTHETRANSPORTATIONOUTSOURCINGSTRATEGYOFTHEEXPRESSDELIVERYCOMPANYINTAIWANTHERESULTSSHOWTHATTHEFOLLOWINGSITUATIONSRESULTINHIGHEROUTSOURCINGPROBABILITYCUSTOMERCOMPANIESBELONGINGTOTHEHIGHTECHINDUSTRY,CUSTOMERSBRINGINGHIGHERFREIGHTREVENUE,CUSTOMERSHAVINGABETTERRELATIONSHIPWITHTHECASESTUDYCOMPANY,ANDCUSTOMERS’COMPANYHAVINGABIGGERSCALETHEFINDINGSPROVIDEENTERPRISESWITHAREFERENCEOFDECISIONMAKINGTOFOLLOWINIMPLEMENTINGTHETRANSPORTATIONOUTSOURCINGMEASUREFORDIFFERENTCUSTOMERS’NEEDSTHEOUTSOURCINGSTRATEGYINCREASESTHEFLEXIBILITYOFOPERATINGFUNDSTOENHANCECUSTOMERSERVICEQUALITYKEYWORDSTRANSPORTATION?OUTSOURCINGSTRATEGY?EXPRESSDELIVERYCOMPANY?LOGISTICREGRESSION1INTRODUCTION11RESEARCHBACKGROUNDANDMOTIVATIONTHEMANAGEMENTPROBLEMORTHEOUTSOURCINGBUSINESSISGETTINGATTENTIONINTODAY’SBUSINESSOPERATIONSDUETOTHERISEOFTHEOUTSOURCINGDEMANDOVERTHEPASTYEARSCCLEETHEREFORE,OUTSOURCINGISNOTASEASYASTOACCESSDIFFERENTGOODSORSERVICECONTRACTSPERRY1997MENTIONSTHATOUTSOURCINGEXPLAINSTHATTHEORIGINALWORKOFTHESTAFFWILLBEOUTSOURCEDTOOTHERMANUFACTURERSTODEALWITHTHATIS,FROMTHEEMPLOYER’SVIEWPOINT,OTHERCONTRACTORSWORKINGINTHEFIELDOFOUTSOURCINGHAVECOMPETITIVEADVANTAGESTHESECOMPETITIVEADVANTAGESMAYINCLUDE1RELIABILITYCONSISTENCYOFPRODUCTORSERVICEQUALITY2QUALITYIMPROVEMENTOFTHEPRODUCTSORSERVICETHEDETERMINANTSOFTHETRANSPORTATIONOUTSOURCINGSTRATEGY209123

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簡介：2900英文單詞，英文單詞，17000英文單詞，中文英文單詞，中文5100字文獻出處文獻出處IOANFRANCV,RISTEAAL,POPESCUCINTEGRATEDURBANGOVERNANCEANEWPARADIGMOFURBANECONOMYJPROCEDIAECONOMICSURBANREGENERATIONINTEGRATEDURBANGOVERNANCE1INTRODUCTIONARECENTECREPORTONCITIESOFTOMORROWCHALLENGES,VISIONANDPROSPECTS?EC,2011B,P91REAFFIRMEDTHEIMPORTANCEOFPRINCIPLES,PRIORITIESANDFUNDAMENTALOBJECTIVESOFURBANANDTERRITORIALDEVELOPMENTFORMULATEDINTHELEIPZIGCHARTAONTHESUSTAINABLEEUROPEANCITYEU,2007,THETOLEDODECLARATIONONURBANDEVELOPMENTEU,2010ANDTHEEUTERRITORIALAGENDA2020EU,2011A,ASWELLASTHESIGNIFICANCEOFAGREATERTERRITORIALDIMENSIONINTHEFUTUREPOLICYOFCOHESIONPOINTINGOUTTHATEUROPEISONEOFTHEMOSTURBANIZEDCONTINENTSOVERTWOTHIRDSOFEUROPE’SPOPULATIONLIVEINURBANAREASANDTHEFIGUREISRISING,THATCITIESARETHEKEYOFTHEEU’SSUSTAINABLEDEVELOPMENT,THEECREPORT2011BPRESENTTHEMAJORCHALLENGESANDTHEDIRECTIONSOFACTIONTOMEETTHESECHALLENGESACTUALLY,THEEUROPEANMODELOFSUSTAINABLEURBANDEVELOPMENTISVERYTHREATENEDBYTENDENCIESWITHANEGATIVEIMPACTEC,2011B,PVIDEMOGRAPHICEVOLUTION,DIFFERENTFROMCITYTOCITY,CAUSESSEVERALPROBLEMSSUCHASPOPULATIONAGEING,URBANDECREASEORINTENSIFICATIONOFTHEEXPANSIONOFADMINISTRATIVETERRITORIALAREASSLOWINGDOWNOREVENDIMINISHINGECONOMICGROWTHAFFECTINGEUROPEPERIODICALLYISAMAJORTHREATOMANYCITIES,ESPECIALLYCENTRALANDEASTERNEUROPEANCITIES,ASWELLASOLDINDUSTRIALCITIESOFWESTERNEUROPE,THEECONOMYOFWHICHISSTAGNANTORONTHEDECLINELABOURMARKETISSTRONGLYINFLUENCEDBYTHEDISCREPANCYBETWEENECONOMICGROWTH,ONONEHAND,ANDDIMINISHINGNUMBEROFJOBSANDSOCIALPROGRESS,ONTHEOTHERHANDMOREANDMOREECONOMICS–ALSOCALLEDSPATIALECONOMY–THERESEARCHERS’ANDPRACTITIONERS’INTERESTINCLUDINGACTORSINVOLVEDINTERRITORIALDEVELOPMENTPROJECTSCOULDCONFINETHEMSELVESTOGIVINGANSWERSTOASETOFQUESTIONSSUCHASWHYDOTHINGSHAPPENHEREANDNOTELSEWHEREANYECONOMICACTIVITY,IRRESPECTIVEOFITSNATUR,TAKESPLACEONASITEBUTWHYTHISONEANDNOTANOTHERONEHOWCOULDWEEXPLAINTHESPATIALBEHAVIOUROFTHEECONOMICAGENTS,BOTHBUSINESSES/ORGANISATIONSANDPEOPLEWHYDOPOPULATIONSMOVEFROMONEREGIONTOANOTHERONECANWEEXPLAINTHESEPOPULATIONMOVEMENTSBYECONOMICANALYSISWHYDOINDUSTRIESFOCUSONACERTAINCITYORQUARTERPEOPLEDEALINGWITHURBANANDREGIONALECONOMICSMAYCONSIDERTHEFOLLOWINGQUESTIONSWHYARETHERECITIESWHATISTHEIRECONOMICBASISWHYDOCITIESNOTCEASETOEXPAND,INSPITEOFALLCONSTRAINTSISTHEREANYECONOMICLOGICFOREXPLAININGTHEWAYCITIESAREDISTRIBUTEDTHROUGHOUTTHETERRITORYWHYARETHEREINCOMEORJOBDISPARITIESAMONGTHECOUNTRYREGIONSWHATISTHEPROBABLEEFFECTIVENESSOFPUBLICINTERVENTIONSINREGIONALECONOMICDEVELOPMENTWHATISTHEIMPACTOFTECHNOLOGICALPROGRESSONTHELOCATIONOFBUSINESSESHOWCOULDWEEXPLAINTHECITYARRANGEMENTINDISTINCTRESIDENTIALQUARTERSWHYPLOTSARESYSTEMATICALLYMOREEXPENSIVEINSOMEQUARTERSTHATINOTHERONESAFTERTHE1980S,THESUSTAINABLEDEVELOPMENTSTRATEGYOFTHEEUROPEANUNIONHASPAIDSPECIALATTENTIONTOSUSTAINABLEDEVELOPMENTOFEUROPEANCITIESOFANYSIZEWHICHAPPEAREDTHROUGHOUTHISTORYANDREPRESENTEDECONOMIC,SOCIALANDCULTURALASSETSOFHIGHVALUEURBANDEVELOPMENTINTHEEUROPEANUNIONISBASEDONTHENEWCONCEPTMODELOFINTEGRATEDURBANPLANNING,WHICHCAUSESASHIFTINTHESTATE’SROLEFROMCONTROLLINGCITYDEVELOPMENTTOENCOURAGINGLOCALENTREPRISEINTHISWAY,WECANPROMOTETHEINTEGRATEDPROJECTOFURBANREGENERATION,WHICH–ACCORDINGTOMODERNURBANECONOMICS–ISANEWPARADIGMFOCUSEDONCITYMANAGEMENT,BASEDONACOMMONCOLLECTIVESTRATEGICALPOSITIONONDEVELOPMENTGINAVARANCAETAL,2007,PP89ALONGWITHTHEEMERGENCEOFGLOBALISATION,CITIES,INPARTICULAR,HAVEBEENCONFRONTEDWITHTWOVITALPROBLEMSTHATCANBEAPPROACHEDONLYININTERDEPENDENCEHOWTOREDUCE,EVENTOPREVENT,SOCIALANDSPATIALDISPARITIESASWELLASTHERELATEDLOCALECONOMICGROWTH,INTERNATIONALANDINTERREGIONALCOMPETITIVENESSASWELLASLABOURMARKETINSERTIONCONFRONTEDWITHTHESECHALLENGES,THETRADITIONALSECTORALAPPROACHESPROVETOBEONEROUSANDINEFFECTIVE,ANDCONSEQUENTLYNEWFORMSOFGOVERNANCEACQUIREIMPORTANCEAMONGTHEM,INTEGRATEDURBANGOVERNANCE–ASANEWCONCEPT–IMPLIESACHANGEINTHEADMINISTRATIVESITUATIONANDTHEWAYOFTHINKINGOFTHEDECISIONMAKERSINFORMULATINGANDIMPLEMENTINGTERRITORIALDEVELOPMENTPOLICIES3INTEGRATEDURBANGOVERNANCEJUSTIFICATION,APPROACH,ADVANTAGESINTHENEWCONTEXTOFECONOMICSOCIALDEVELOPMENTOFTHECOUNTRIESDETERMINEDBYTHEGLOBALIZATIONOFMARKETSANDNTIC,ESPECIALLYLARGECITIESFACENEWFORMSOFECONOMICCOMPETITIONANDPOLITICALANDADMINISTRATIVEACTIONBASEDONPRINCIPLESOFTHESTANDARDTRADITIONALURBANECONOMICSARENOLONGERABLETOPROVIDESOLUTIONSBERNINGER,COORDINATOR,SCHWEDLER,2011,P10LARGECITIESBECOMESTRONGCOMPETITORSANDTHEYSTRUGGLEWORLDWIDETOATTRACTNEWTECHNOLOGIESANDINNOVATIVESERVICES,FINANCIALINSTITUTIONSANDTOBECOMERESIDENTIALAREASFORHIGHQUALIFIEDSPECIALISTS

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簡介：中文中文2200字出處出處YILDIZA,BOSTANC,AKINF,ETALCONCURRENTPULMONARYEMBOLISMANDACUTECORONARYSYNDROMEWITHDYNAMICELECTROCARDIOGRAPHICCHANGESJAMERICANJOURNALOFEMERGENCYMEDICINE,2012,304637E1637E4肺栓塞并發(fā)急性冠脈綜合征伴動態(tài)心電圖變化肺栓塞并發(fā)急性冠脈綜合征伴動態(tài)心電圖變化YILDIZA,BOSTANC,AKINF,ETAL【摘要】肺栓塞并發(fā)急性冠脈綜合征是罕見的，急性肺栓塞（APE）發(fā)生右心室心肌缺血并發(fā)急性冠脈綜合征的早期診斷和治療是至關重要的。不可逆轉的右心室心肌功能障礙是急性肺栓塞主要死亡危險因素。我們報道了一名66歲的女病人與APE有嚴重右冠狀動脈（RCA）病變，被寄予了血管成形術及支架植入術成功治療。急性肺栓塞（APE）是一種較常見的心血管急重癥，通常出現胸痛和氣短的癥狀。據報道，APE的的整體院內死亡率為7％至11％。有休克癥狀者死亡率上升高65，發(fā)生心跳驟停者為25％。因為急性肺動脈床阻塞，危及生命的嚴重右心功能不全的可能發(fā)生。右心室發(fā)生不可逆轉的功能障礙是死亡的主要危險因素。因此，急性冠脈綜合征（ACSS），合并APE尤其是右室功能受影響的APE應早期確定和處置。在本病例中，一名被確診為APE并發(fā)ACS的患者被成功的進行RCA經皮冠狀動脈介入治療。一位66歲的女子被送往急診科，主訴呼吸急促和胸部燒灼痛4小時。她介紹了一個星期之前她進行了4小時的巴士之旅后左腿發(fā)生腫脹和疼痛。鑒別診斷胸痛的原因后，她被轉移到冠心病監(jiān)護病房。檢體發(fā)現，血壓為180/100MMHG，心率達104次/每分，律齊。呼吸頻率為30次/分，血氧飽和度為90％。心電圖（ECG）示竇性心律，不完全性右束支傳導阻滯，T波倒置，V1至V6導聯(lián)ST段壓低05MM（圖1）。床旁經胸超聲心動圖檢查發(fā)現右心室擴大，基底段中等運動和心尖段搏動亢進（MCCONELL征）。三尖瓣中度關閉不全，估計肺動脈壓力為45MMHG。由于不存在休克和低血壓癥狀，未考慮溶栓治療。對患者行多層螺旋計算機斷層掃描成像（MSCT）。初始治療采用ENOXAPARINE（01MG/KG，BID），乙酰水楊酸（300MG/天），美托洛爾（50MG/天）。生化檢驗表明，D二聚體（2500NG/ML），肌鈣蛋白I水平（12）U/L，正常肌酐激酶/肌酸激酶MB水平。在她住院的第二天，血流動力學不穩(wěn)定（收縮壓8090MMHG）和胸痛，伴發(fā)陣發(fā)性房顫（PAF）（圖2）。由于PAF發(fā)作變得頻繁，損害了血流動力學穩(wěn)定，進行冠狀動脈造影，以消除急性冠脈事件。冠狀血管造影術顯示左前降支中間段的（LAD）60％?70％管狀狹窄，RCA近中段95％?99％狹窄（圖3A）。行經皮腔內冠狀動脈成形術（PTCA）治療RCA的嚴重阻塞。RCA梗阻處通過一個2014毫米水銀氣球（雅培，雅培公園，IL）擴張，植入27516毫米（20個大氣壓，33毫米FLEXMASTERJOMED有限公司，德國RANGENDIRGEN，裸金屬支架）金屬支架（圖3B）。干預后，患者血流動力學穩(wěn)定，3天后多層螺旋CT肺動脈造影顯示雙側肺動脈主干血栓形成，直到遠端段（圖4）。多普勒超聲檢查也發(fā)現左下肢股深靜脈血栓。在第五天，PTCA在LAD病變處進行。該患者在第八天出院，出院后服用華法林，阿司匹林，氯吡格雷，阿托伐他汀，美托洛爾，和雷米普利。急性肺栓塞是臨床急重癥，會導致肺動脈主干及其分支急性梗阻。急性大面積肺栓塞（PE）會引起引起低血壓、嚴重的右心衰竭，很短的時間會發(fā)生死亡3。報道稱APE院內死亡率7％至11％，伴發(fā)休克的患者為25％和心跳呼吸驟?；颊邽?51,2。急性冠脈綜合征伴發(fā)APE是相當罕見的，因為臨床表現和癥狀很相似，診斷不易確定APE的急性冠脈事件中可根據3份文獻評估。右心室缺血或梗死先發(fā)生，繼發(fā)右心室后負荷增加。在這些情況下，在一般情況下，沒有顯著的冠狀動脈阻塞，但卻可能會導致右心室缺血4,5。然而，根據6例大塊PE伴隨著孤立的右心室心肌梗死的尸體解剖結果，冠狀動脈正常者被確定為1例，其余5例存在左或右冠狀動脈有明顯的阻塞。有研究稱，這些栓子可能解釋APE發(fā)生右心室壞死的原因6。ACS伴隨APE的患者中冠狀動脈栓塞是罕見的病因。據報道，在一些沒有被診斷出患有卵圓孔未閉（PFO）的患者可發(fā)生79心肌梗死繼發(fā)APE。因為在這些患者中觀察心電圖STT段的變化過程中的APE進行冠脈造影冠狀動脈中觀察到類似血栓栓子。卵圓孔未閉，它允許通過從右心房進入左心房血栓，此后，進入冠狀動脈系統(tǒng)，超聲心動圖檢查確定。第三個原因導致ACS繼發(fā)APE是冠狀動脈嚴重阻塞的存在。文獻有報道病人因急性胸痛和肌鈣蛋白水平升高行冠狀動脈造影，并行經皮冠狀動脈介入治療LAD嚴重阻塞10。在目前的情況下，進行經皮冠狀動脈介入治療RCA明顯梗阻，從而導致ACS。兒茶酚胺排出增加，激活凝血系統(tǒng)，由于血管痙攣的原因加重很可能已經存在的冠狀動脈動脈阻塞癥狀。已經受APE影響的右心室心肌收縮功能，由于RCA嚴重梗阻，變得更加惡化。進行經皮血運重建過程中，心律失常和低血壓消失顯示出急性冠脈事件的重要性，應該盡快作出診斷與治療。APE患者的心電圖通常是正常的，但既不敏感，也不特異。竇性心動過速和非特異性T段和T波改變是最常見的結果。胸前導聯(lián)T波倒置，包括右心室高負荷，S1QT3，暫時性右束支傳導阻滯，突發(fā)房顫，和其他房性心律失常是PE常見的心電圖改變11。在本病例中，有不完全性右束支傳導阻滯，Q波和T波倒置在D3表示右心室負荷。這些心電圖結果是APE常見的變化。T波前派生的變化可能是遇到的APE非特異性變化由于阻塞LAD或缺血性改變。此外，在這種情況下，觀察到的頻繁PAF出現可能是由于APE交感神經興奮性增高，但是，要牢記，他們也可能會發(fā)生因急性缺血性胸痛患者的冠脈事件而發(fā)生。APE患者的肌鈣蛋白水平升高與死亡率相關12。右心室壓力快速和嚴重增加導致心肌缺血和肌鈣蛋白的釋放。在這種情況下，入院時應測定肌鈣蛋白水平。肌鈣蛋白升高可能由于右心室壓力的增加或由于ACS導致的右心室缺血。應該牢記的是急性冠脈事件可能伴隨APE，進而發(fā)生右心室功能嚴重受損，難治性房性心律失常和胸痛。早期診斷和治療是必要的，尤其是有冠狀動脈受累導致右心室缺血的情況下。

簡介：中文中文3200字出處出處KOSUGEM,KIMURAK,ISHIKAWAT,ETALELECTROCARDIOGRAPHICDIFFERENTIATIONBETWEENACUTEPULMONARYEMBOLISMANDACUTECORONARYSYNDROMESONTHEBASISOFNEGATIVETWAVESJAMERICANJOURNALOFCARDIOLOGY,2007,996817821急性肺栓塞與急性肺栓塞與T波倒置的急性冠脈綜合征的心電圖鑒別診斷波倒置的急性冠脈綜合征的心電圖鑒別診斷KOSUGEM,KIMURAK,ISHIKAWAT,ETAL【摘要】胸前導聯(lián)T波倒置經常出現在急性冠狀動脈綜合征患者（ACS），但也可發(fā)生急性肺栓塞（APE）。然而，很少有人注意到這些疾病之間的差異。本研究報告測量了T波倒置的40例APE和87例ACS患者入院時心電圖，胸前導聯(lián)（V1到V4）。ACS患者中77例（89％），造影證實病變位于左冠狀動脈前降支。肺型P波，S1S2S3模式，S1Q3T3模式，低電壓，順時針旋轉為APE特異，但這些研究結果的敏感性非常低。在APE患者，倒置T波通常存在于導聯(lián)II、II、AVF、V1、V2，但在導聯(lián)I、AVL、V3，V6并不常見（P005）。只有1％的ACS患者中觀察到III和V1導聯(lián)T波倒置與APE相比（P0001），敏感性，特異性，陽性預測值和陰性預測值分別為88％、99％、97％和95％?？傊?，APE患者II和V1導聯(lián)T波倒置。胸前導聯(lián)T波倒置經常出現在急性冠脈綜合征患者（ACSS）。這種心電圖（ECG）表現表明前壁嚴重缺血，然而，急性肺栓塞（APE）患者說也同樣出現負向T波急性肺栓塞的癥狀，如胸痛或呼吸困難，都是非特異性的，往往和ACS癥狀難以區(qū)分。有病例報告記錄了一名因胸痛和呼吸困難，V1到V5導聯(lián)T波倒置，并且入院時肌鈣蛋白I水平升高的患者，最初診斷為ACS病人，隨后被發(fā)現有大面積APE，因診斷和治療延誤而死亡。很多可預防的APE患者死亡與漏診相關，而不是治療失敗。心肌細胞損傷的高度敏感和特異的標志物，心肌肌鈣蛋白水平已發(fā)現在APE高風險患者中也存在，表明其鑒別診斷價值有限。用超聲心動圖是區(qū)分高風險的APE和ACS是有用的。然而，超聲心動圖有技術上的限制，經常沒有得到充分應用。12導聯(lián)心電圖是簡單的，應用廣泛，而且價格便宜。在本研究中，我們比較胸前導聯(lián)T波倒置的APE和ACS患者的心電圖表現。方法和結果獲取我院40例APE和87ACS患者的臨床特點及心電圖結果并進行比較。入選標準（1）不能排除心電圖ST段變化（即完全性左或右支束傳導阻滯，左心室肥厚，心室起搏，電解質紊亂，代謝性疾病，或藥物與潛在條件對心電圖的影響），（2）沒有明顯的心肺疾病史，及（3）入院時心電圖2個連續(xù)導聯(lián)（V1到V4）T波≥10毫米。入院心電圖2個連續(xù)的胸前導聯(lián)ST段抬高≥20毫米或Q波心肌梗死被排除在外。所有患者知情同意。該研究方案經我們的內部審查通過。有臨床癥狀和體征提示APE的患者，如急性發(fā)作的呼吸困難，呼吸急促，胸痛，心悸，暈厥，低血壓或休克，我們進行了研究。31例（78％）患者APE的診斷由肺血管造影證實，27例（68％）經肺灌注顯像，26例（65％）經螺旋CT肺動脈造影證實。12個患者三項檢查都有陽性結果，20名患者2項檢查有陽性成果。有胸部不適，心肌缺血持續(xù)≥5分鐘，涉及的疼痛為不穩(wěn)定心絞痛（休息和新發(fā)疼痛，嚴重或頻繁的心絞痛）或加速心絞痛，我們重點進行研究。住院期間，所有患者都進行了血管相關數據評價，并接受心導管術中，事件中位數為入院第三天。冠狀動脈造影評估由一個單一的心臟科醫(yī)生，對其他的臨床數據盲。超過1支主干血管狹窄查過75％被認為具有臨床意義。病變定義為病變與血管造影結果提示局部血栓，兩者兼而有之最為嚴重。記錄入院12導聯(lián)心電圖，走紙速度為25毫米/S和電壓10毫米/毫伏。心電圖檢查由一個單一的心臟科醫(yī)生實行，對所有抬高發(fā)生時左冠狀動脈前降支環(huán)繞心尖（即所謂的“包裹左冠狀動脈前降支”）第一間隔支或第一對角支遠端閉塞。因此，III導聯(lián)T波通常不伴有V1導聯(lián)T波負。在我們的研究中，ACS患者III和V1導聯(lián)同時出現T波倒置是非常罕見的（僅1％）。APE患者血流動力學，解剖，代謝及植物神經的影響，可能會改變心臟的電通路，導致心電圖變化。在APE的心電圖異常表現中，T波倒置是最常見的長期變化，機制還不完全清楚，但可能與急性肺源性心臟病引起的右心室快速擴大，右心室壓力超負荷，最終導致右心室嚴重缺血。在本研究中，超聲心動圖檢測出APE中34例（85％）發(fā)生右心功能不全（數據未顯示）。其他病理因素，包括低氧血癥和兒茶酚胺，5羥色胺，組織胺等化學介質釋放，也可能有助于倒置T波的出現。在本研究中，APE患者III，V1，V2導聯(lián)T波倒置是非常常見的。III導聯(lián)面對著右心室下壁，V1和V2導聯(lián)面對著右心室前壁。這項研究是回顧性的，單中心進行，包括患者數量較少。為了精確評估APE和ACS患者的倒置T波的差異，我們只研究APE和ACS患者的胸前導聯(lián)的倒置T波。我們的研究結果表明，標準的12導聯(lián)心電圖可準確的鑒別APE和ACS患者。此外，有些APE患者可能已經存在嚴重的冠狀動脈狹窄，甚至ACS。然而，在所有患者的APE的診斷是基于規(guī)范化的標準。因此額外的診斷檢查，特別是冠狀動脈造影，以排除伴隨冠狀動脈疾病，不被認為是合適的。

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簡介：CASEREPORTCONCURRENTPULMONARYEMBOLISMANDACUTECORONARYSYNDROMEWITHDYNAMICELECTROCARDIOGRAPHICCHANGESABSTRACTCONCOMITANTOCCURRENCEOFPULMONARYEMBOLISMANDACUTECORONARYSYNDROMEISRARETHEEARLYDIAGNOSISANDTREATMENTOFACUTECORONARYSYNDROMEWITHRIGHTVENTRICULARMYOCARDIALISCHEMIADURINGACUTEPULMONARYEMBOLISMAPEARECRUCIALTHEIRREVERSIBLERIGHTVENTRICULARMYOCARDIALDYSFUNCTIONISAMAJORRISKFACTORFORMORTALITYFROMAPEINTHISCASEREPORT,WEPRESENTA66YEAROLDFEMALEPATIENTWITHAPEWHOHADASIGNIFICANTRIGHTCORONARYARTERYRCALESION,WHICHWASSUCCESSFULLYTREATEDWITHANGIOPLASTYANDSTENTIMPLANTATIONACUTEPULMONARYEMBOLISMAPEISARELATIVELYFREQUENTCARDIOVASCULAREMERGENCYTHATGENERALLYAPPEARSWITHCHESTPAINANDSHORTNESSOFBREATHTHEOVERALLINHOSPITALMORTALITYRATEOFAPEHASBEENREPORTEDTOBE7TO11ANDRAISESTO25AMONGTHOSEWITHSHOCKANDTO65AMONGTHOSEWITHCARDIOPULMONARYARREST1,2LIFETHREATENINGSEVERERIGHTVENTRICULARDYSFUNCTIONMAYDEVELOPBECAUSEOFACUTEOBSTRUCTIONOFPULMONARYARTERIALBEDIRREVERSIBLEFUNCTIONALIMPAIRMENTOFRIGHTVENTRICLEISAMAJORRISKFACTORFORMORTALITYTHEREFORE,ACUTECORONARYSYNDROMESACSS,WHICHACCOMPANYAPEANDAFFECTTHERIGHTVENTRICLEFUNCTIONSINPARTICULAR,SHOULDBEDETERMINEDANDTREATEDINTHEEARLYPERIODINTHEPRESENTCASE,APATIENTDIAGNOSEDWITHAPEWASSUCCESSFULLYTREATEDBYPERCUTANEOUSINTERVENTIONOFTHERCAFORTHECONCURRENTACSA66YEAROLDWOMANWASADMITTEDTOOUREMERGENCYDEPARTMENTWITHCOMPLAINTSOFSHORTNESSOFBREATHANDBURNINGCHESTPAINFOR4HOURSSHEALSODESCRIBEDSWELLINGANDPAININHERLEFTLEGTHATOCCURREDAFTERA4HOURBUSTRIPAWEEKAGOSHEWASTRANSFERREDTOTHECORONARYCAREUNITFORTHEDIFFERENTIALDIAGNOSISOFTHECHESTPAINONHERPHYSICALEXAMINATION,BLOODPRESSUREWAS180/100MMHG,ANDHEARTRATEWAS104BEATSPERMINUTEANDREGULARTHERESPIRATORYRATEWAS30PERMINUTE,ANDOXYGENSATURATIONWAS90INROOMAIRHERELECTROCARDIOGRAMECGREVEALEDASINUSRHYTHMWITHINCOMPLETERIGHTBUNDLEBRANCHBLOCK,NEGATIVETWAVES,AND05MMSTSEGMENTDEPRESSIONINLEADSV1TOV6FIG1BEDSIDETRANSTHORACICECHOCARDIOGRAPHICEXAMINATIONREVEALEDANENLARGEDRIGHTVENTRICLEWITHAKINETICMIDANDBASALSEGMENTSANDHYPERKINETICAPICALSEGMENTMCCONELLSSIGNTHEREWASMODERATETRICUSPIDINSUFFICIENCY,ANDTHEESTIMATEDPULMONARYARTERYPRESSUREWAS45MMHGBECAUSEOFTHEABSENCEOFSHOCKORRESISTANTHYPOTENSION,FIBRINOLYTICTHERAPYFORAPEWASNOTCONSIDERED,ANDSHEWASSCHEDULEDFORELECTIVEMULTISLICECOMPUTEDTOMOGRAPHYMSCTIMAGINGSHEWASTREATEDINITIALLYWITHENOXAPARINE01MG/KG,BID,ACETYLSALICYLICACID300MG/D,ANDMETOPROLOL50MG/DBIOCHEMICALANALYSISSHOWEDINCREASEDDDIMER2500NG/ML,TROPONINILEVELS12U/L,ANDNORMALCREATININEKINASE/CREATININEKINASEMBLEVELSONTHESECONDDAYOFHERHOSPITALIZATION,SHEHADBURNINGCHESTPAINTHATIMPAIREDHEMODYNAMICSTABILITYSYSTOLICBLOODPRESSURE,8090MMHGANDWASACCOMPANIEDBYPAROXYSMALATRIALFIBRILLATIONPAFFIG2BECAUSETHEPAFEPISODESBECAMEFREQUENTANDIMPAIREDTHEHEMODYNAMICSTABILITY,CORONARYANGIOGRAPHYWASPERFORMEDTOELIMINATEANACUTECORONARYEVENTCORONARYANGIOGRAPHYREVEALED60TO70TUBULARNARROWINGOFTHEMIDSEGMENTOFTHELEFTANTERIORDESCENDINGARTERYLADAND95TO99NARROWINGOFTHEMIDPROXIMALSEGMENTOFTHERCAFIG3APERCUTANEOUSTRANSLUMINALCORONARYANGIOPLASTYPTCAWASPERFORMEDFORTHESEVEREOBSTRUCTIONINRCATHEOBSTRUCTIONINTHERCAWASDILATEDVIAA2014MMMERCURYBALLOONABBOTTLABORATORIES,ABBOTTPARK,IL,ANDA27516MMBAREMETALSTENT20ATM,33MMFLEXMASTERJOMEDGMBH,RANGENDIRGEN,GERMANYWASIMPLANTEDFIG3BAFTERTHEINTERVENTION,THEPATIENTWASHEMODYNAMICALLYSTABLE,ANDTHEMSCTPULMONARYANGIOGRAPHYWASPERFORMED3DAYSAFTERTHEPROCEDUREMULTISLICECOMPUTEDTOMOGRAPHYIMAGINGSHOWEDDIFFUSETHROMBUSINBOTHOFTHEMAINPULMONARYARTERIESEXTENDINGTHROUGHTOTHEDISTALSEGMENTFIG4DOPPLERULTRASOUNDEXAMINATIONALSOSHOWEDTHROMBUSINTHEDEEPFEMORALVEINOFTHELEFTLOWEREXTREMITYONTHEFIFTHDAY,PTCAWASPERFORMEDFORTHELESIONINLADTHEPATIENTWASDISCHARGEDONTHEEIGHTHDAYWITHWARFARIN,ACETYLSALICYLICACID,CLOPIDOGREL,ATORVASTATIN,METOPROLOL,ANDRAMIPRILACUTEPULMONARYEMBOLISMISANURGENTCLINICALCONDITIONRESULTINGFROMACUTEOBSTRUCTIONOFPULMONARYARTERYANDTHEBRANCHESASWELLTHEPATIENTSWITHACUTEMASSIVEPULMONARYEMBOLISMPETHATPROGRESSESTOSHOCKANDHYPOTENSIONDUETOSEVERERIGHTHEARTFAILUREDIEINASHORTTIMEWWWELSEVIERCOM/LOCATE/AJEM07356757/–SEEFRONTMATTERCROWNCOPYRIGHT?2012PUBLISHEDBYELSEVIERINCALLRIGHTSRESERVEDAMERICANJOURNALOFEMERGENCYMEDICINE201230,637E1–637E4FIG2PAROXYSMALATRIALFIBRILLATIONTHATACCOMPANIEDCHESTPAINANDHYPOTENSIONONTHESECONDDAYOFHOSPITALIZATIONFIG3A,THEIMAGEOF95TO99TUBULARNARROWINGINTHEMIDPROXIMALSEGMENTOFTHERCAB,THEIMAGEAFTERPTCAANDSTENTIMPLANTATION637E3CASEREPORT

簡介：ELECTROCARDIOGRAPHICDIFFERENTIATIONBETWEENACUTEPULMONARYEMBOLISMANDACUTECORONARYSYNDROMESONTHEBASISOFNEGATIVETWAVESMASAMIKOSUGE,MD,KAZUOKIMURA,MD,TOSHIYUKIISHIKAWA,MD,TOSHIAKIEBINA,MD,KIYOSHIHIBI,MD,IKUYOSHIKUSAMA,MD,TATUYANAKACHI,MD,MITSUAKIENDO,MD,NAOHIROKOMURA,MD,ANDSATOSHIUMEMURA,MDNEGATIVETWAVESINPRECORDIALLEADSAREOFTENSEENINPATIENTSWITHACUTECORONARYSYNDROMEACS,BUTALSOOCCURINTHOSEWITHACUTEPULMONARYEMBOLISMAPEHOWEVER,LITTLEATTENTIONHASBEENGIVENTODIFFERENCESINNEGATIVETWAVESBETWEENPATIENTSWITHTHESE2DISEASESTHEPRESENTSTUDYEXAMINESTHEVALUEOFELECTROCARDIOGRAMSFORDISCRIMINATINGBETWEEN40PATIENTSWITHAPEAND87PATIENTSWITHACSWHOHADNEGATIVETWAVESINTHEPRECORDIALLEADSV1TOV4ONTHEADMISSIONELECTROCARDIOGRAMIN77PATIENTS89WITHACS,THECULPRITLESIONWASCONFIRMEDANGIOGRAPHICALLYTOBELOCATEDINTHELEFTANTERIORDESCENDINGCORONARYARTERYPULMONARYPWAVES,S1S2S3PATTERN,S1Q3T3PATTERN,LOWVOLTAGE,ANDCLOCKWISEROTATIONWERESPECIFICFORAPE,BUTSENSITIVITIESOFTHESEFINDINGSWEREVERYLOWINPATIENTSWITHAPE,NEGATIVETWAVESWERECOMMONLYPRESENTINLEADSII,III,AVF,V1,ANDV2,BUTWERELESSFREQUENTINLEADSI,AVL,ANDV3TOV6P005NEGATIVETWAVESINLEADSIIIANDV1WEREOBSERVEDINONLY1OFPATIENTSWITHACSCOMPAREDWITH88OFPATIENTSWITHAPEP0001THESENSITIVITY,SPECIFICITY,POSITIVEPREDICTIVEVALUE,ANDNEGATIVEPREDICTIVEVALUEOFTHISFINDINGFORTHEDIAGNOSISOFAPEWERE88,99,97,AND95,RESPECTIVELYINCONCLUSION,THEPRESENCEOFNEGATIVETWAVESINBOTHLEADSIIIANDV1ALLOWSAPETOBEDIFFERENTIATEDSIMPLYBUTACCURATELYFROMACSINPATIENTSWITHNEGATIVETWAVESINTHEPRECORDIALLEADS?2007ELSEVIERINCALLRIGHTSRESERVEDAMJCARDIOL200799817–821NEGATIVETWAVESINTHEPRECORDIALLEADSAREOFTENSEENINPATIENTSWITHACUTECORONARYSYNDROMESACSSTHISELECTROCARDIOGRAPHICECGFINDINGSUGGESTSSEVEREISCHEMIAOFTHEANTERIORWALL1,2HOWEVER,NEGATIVETWAVESALSOAPPEARFREQUENTLYINPATIENTSWITHACUTEPULMONARYEMBOLISMAPE3–5SYMPTOMSOFAPE,SUCHASCHESTPAINORDYSPNEA,ARENONSPECIFICANDAREOFTENDIFFICULTTODIFFERENTIATEFROMSYMPTOMSOFACS6,7ANISOLATEDCASEREPORTDOCUMENTEDAPATIENTINITIALLYGIVENADIAGNOSISOFACSBECAUSEOFCHESTPAINANDDYSPNEA,DEEPNEGATIVETWAVESINLEADSV1TOV5,ANDINCREASEDTROPONINILEVELSATADMISSIONTHISPATIENTSUBSEQUENTLYWASFOUNDTOHAVEMASSIVEAPEANDDIEDBECAUSEOFDELAYEDDIAGNOSISANDTREATMENT8MOSTPREVENTABLEDEATHSASSOCIATEDWITHAPEHAVEBEENASCRIBEDTOMISSEDDIAGNOSESRATHERTHANFAILURETORESPONDTOAVAILABLETHERAPIES7INCREASEDLEVELSOFCARDIACTROPONIN,AHIGHLYSENSITIVEANDSPECIFICMARKEROFMYOCARDIALCELLINJURY,HAVEBEENFOUNDINHIGHRISKPATIENTSWITHAPEASWELLASTHOSEWITHACS,9–11INDICATINGLIMITEDVALUEFORDIFFERENTIALDIAGNOSISECHOCARDIOGRAPHYISUSEFULFORDISCRIMINATINGBETWEENTHOSEWITHHIGHRISKAPEANDACS2,12HOWEVER,ECHOCARDIOGRAPHYHASSEVERALTECHNICALLIMITATIONSANDFULLYASSESSABLEECHOCARDIOGRAPHICECGIMAGESAREFREQUENTLYNOTOBTAINEDTHE12LEADELECTROCARDIOGRAMISSIMPLE,UBIQUITOUSLYAVAILABLE,ANDINEXPENSIVEINTHEPRESENTSTUDY,WECOMPAREECGFINDINGSBETWEENAPEANDACSINPATIENTSWITHNEGATIVETWAVESINPRECORDIALLEADSMETHODSANDRESULTSCLINICALFEATURESANDECGFINDINGSOBTAINEDFROM40CONSECUTIVEPATIENTSWITHAPEWERECOMPAREDWITHTHOSEFROM87CONSECUTIVEPATIENTSWITHACSATOURHOSPITALPATIENTSFULFILLEDTHECRITERIAOF1NOCONDITIONSPRECLUDINGTHEEVALUATIONOFSTSEGMENTCHANGESONTHEELECTROCARDIOGRAMIE,COMPLETELEFTORRIGHTBRANCHBUNDLEBLOCK,LEFTVENTRICULARHYPERTROPHY,VENTRICULARPACING,ELECTROLYTEABNORMALITIES,METABOLICDISEASE,ORADMINISTEREDDRUGSWITHPOTENTIALEFFECTSONTHEELECTROCARDIOGRAM2NOOBVIOUSHISTORYOFCARDIOPULMONARYDISEASEAND3FULLYASSESSABLEELECTROCARDIOGRAMONADMISSIONWITHNEGATIVETWAVESOF?10MMIN?2CONTIGUOUSPRECORDIALLEADSV1TOV4PATIENTSWITHNEWSTSEGMENTELEVATIONOF?20MMIN2CONTIGUOUSPRECORDIALLEADSONTHEADMISSIONELECTROCARDIOGRAMORAQWAVEMYOCARDIALINFARCTIONONPRESENTATIONWEREEXCLUDEDALLPATIENTSGAVEINFORMEDCONSENTTHESTUDYPROTOCOLWASAPPROVEDBYOURINTERNALREVIEWBOARDSPATIENTSWHOHADCLINICALSIGNSANDSYMPTOMSSUGGESTINGAPE,SUCHASACUTEONSETOFDYSPNEA,TACHYPNEA,CHESTPAIN,PALPITATIONS,SYNCOPE,HYPOTENSION,ORSHOCK,WERESTUDIEDTHEDIAGNOSISOFAPEWASCONFIRMEDUSINGPULMONARYANGIOGRAPHYIN31PATIENTS78,LUNGPERFUSIONSCINTIGRAPHYIN27PATIENTS68,ORSPIRALCOMPUTEDTOMOGRAPHYIN26PATIENTS65TWELVEPATIENTSHADRESULTSPOSITIVEFORAPEONALL3EXAMINATIONS,AND20HADPOSITIVERESULTSON2EXAMINATIONSPATIENTSWHOHADCHESTDISCOMFORTSUGGESTEDTOBECARDIACISCHEMIALASTING?5MINUTESANDINVOLVINGANDIVISIONOFCARDIOLOGY,YOKOHAMACITYUNIVERSITYMEDICALCENTER,YOKOHAMA,JAPANMANUSCRIPTRECEIVEDSEPTEMBER17,2006REVISEDMANUSCRIPTRECEIVEDANDACCEPTEDOCTOBER30,2006CORRESPONDINGAUTHORTEL81452615656FAX81452619162EMAILADDRESSCKIMURAURAHPYOKOHAMACUACJPKKIMURA00029149/07/–SEEFRONTMATTER?2007ELSEVIERINCALLRIGHTSRESERVEDWWWAJCONLINEORGDOI101016/JAMJCARD200610043NEGATIVETWAVESINLEADSI,AVL,ANDV3TOV6NEGATIVETWAVESINBOTHLEADSIIIANDV1WEREPRESENTINONLY1OFPATIENTSWITHACSCOMPAREDWITH88OFTHOSEWITHAPEP?0001REPRESENTATIVEELECTROCARDIOGRAMSOBTAINEDONADMISSIONINPATIENTSWITHAPEANDACSARESHOWNINFIGURE2TABLE3LISTSTHESENSITIVITY,SPECIFICITY,ANDPREDICTIVEACCURACYOFECGFINDINGSFORTHEDIAGNOSISOFAPEPULMONARYPWAVES,S1S2S3PATTERN,S1Q3T3PATTERN,LOWVOLTAGE,ANDCLOCKWISEROTATIONWERESPECIFICFORAPE,BUTSENSITIVITIESOFTHESEFINDINGSWERELOWTHEABSENCEOFNEGATIVETWAVESINLEADSIANDAVLANDTHEPRESENCEOFNEGATIVETWAVESINLEADSV1ORV2WEREVERYSENSITIVEFORAPE,ANDTHEABSENCEOFNEGATIVETWAVESINLEADSV3ANDV4ANDTHEPRESENCEOFNEGATIVETWAVESINLEADAVFWEREVERYSPECIFICFORAPETHEPRESENCEOFNEGATIVETWAVESINLEADIIIWASHIGHLYPREDICTIVEOFAPEFURTHERMORE,THEDIAGNOSTICACCURACYOFTHEPRESENCEOFNEGATIVETWAVESINBOTHLEADSIIIANDV1WASVERYHIGH,BUTTHISDIDNOTREACHSTATISTICALDIFFERENCEINCOMPARISONWITHTHATINONLYLEADIIIDISCUSSIONOURSTUDYINCLUDESONLYPATIENTSWITHACLINICALDIAGNOSISOFAPEORACSWHOHADNEGATIVETWAVESIN?2CONTIGUOUSPRECORDIALLEADSV1TOV4THEPRESENCEOFNEGATIVETWAVESINBOTHLEADSIIIANDV1STRONGLYSUGGESTSAPE,THEREBYALLOWINGAPETOBESIMPLYBUTACCURATELYDIFFERENTIATEDFROMACSNEGATIVETWAVESINPRECORDIALLEADSINPATIENTSWITHACSARECONSIDEREDTOINDICATESEVEREISCHEMIAOFTHELEFTVENTRICULARANTERIORWALL1,2SEVEREISCHEMIAMAYALTERANDREVERSETHEPATHWAYOFELECTRICALREPOLARIZATION,RESULTINGINNEGATIVETWAVES13INTHEPRESENTSTUDY,THECULPRITLESIONWASLOCATEDINTHELEFTANTERIORDESCENDINGCORONARYARTERYINMOSTPATIENTSWITHACSMOSTPATIENTSHADNEGATIVETWAVESINLEADSV2TOV4,INDICATINGISCHEMIAOFTHEANTEROSEPTALREGIONIFISCHEMIAEXTENDSTOTHEANTEROLATERALREGION,NEGATIVETWAVESARELIKELYTOBEOBSERVEDINLEADSIANDAVLSIMILARLY,IFISCHEMIAEXTENDSTOTHEINFEROLATERALREGION,NEGATIVETWAVESARELIKELYTOAPPEARINLEADSV5ANDV6NEGATIVETWAVESINLEADV1WEREOBSERVEDINHALFTHEPATIENTSWITHACSLEADV1ISCONSIDEREDTOREFLECTTHERIGHTPARASEPTALREGION,SUPPLIEDBYTHESEPTALBRANCHESOFTHELEFTANTERIORDESCENDINGCORONARYARTERYALONEORTOGETHERWITHTHECONALBRANCH14THEPRESENCEOFNEGATIVETWAVESINLEADV1MAYSUGGESTSEVEREISCHEMIAOFTHEINTERVENTRICULARSEPTUMCAUSEDBYPROXIMALLEFTANTERIORDESCENDINGCORONARYARTERYDISEASEINTHEABSENCEOFALARGECONALBRANCHCONVERSELY,FREQUENCIESOFNEGATIVETWAVESININFERIORLEADSWEREVERYLOWWESPECULATETHATTHERELATIONSBETWEENCULPRITLESIONSITESANDLEADSWITHNEGATIVETWAVESINPATIENTSWITHACSARESIMILARTOTHOSEBETWEENCULPRITLESIONSITESANDLEADSWITHSTSEGMENTELEVATIONINPATIENTSWITHACUTEMYOCARDIALINFARCTIONTHEINCIDENCEOFINFERIORSTSEGMENTELEVATIONINPATIENTSWITHANTERIORACUTEMYOCARDIALINFARCTIONWASREPORTEDTORANGEFROMONLY5TO1615–17THESEREPORTSCONCLUDEDTHATSTSEGMENTELEVATIONININFERIORLEADSOCCURSWHENTHELEFTANTERIORDESCENDINGCORONARYARTERYTHATWRAPSAROUNDTHEAPEXANDSUPPLIESTHEINFERIORWALLSOCALLED“WRAPPEDLEFTANTERIORDESCENDINGCORONARYFIGURE2REPRESENTATIVEELECTROCARDIOGRAMSONADMISSIONOFPATIENTSWITHAPEANDACSAAPEINA61YEAROLDMANNEGATIVETWAVESARESEENINLEADSIII,AVF,ANDV1TOV4ACOMPUTEDTOMOGRAPHICSCANOFTHECHESTSHOWEDMULTIPLEFILLINGDEFECTSINTHEMAINRIGHTANDLEFTPULMONARYARTERIESLUNGPERFUSIONSCINTIGRAPHYSHOWEDFILLINGDEFECTSINTHERIGHTUPPER,RIGHTMIDDLE,ANDLEFTUPPERLUNGFIELDSBACSINA54YEAROLDWOMANNEGATIVETWAVESARESEENINLEADSI,AVL,ANDV1TOV6CORONARYANGIOGRAPHYPERFORMED3DAYSAFTERADMISSIONSHOWED90STENOSISOFTHEPROXIMALLESIONOFLEFTANTERIORDESCENDINGARTERY819CORONARYARTERYDISEASE/PRECORDIALNEGATIVETWAVES