急性脑水肿重症患儿经颅多普勒超声监测的临床研究

目的 观察急性脑水肿患儿经颅多普勒(TCD)各项检测参数及频谱的变化,探讨TCD在监测与评估急性脑水肿患儿颅内压的作用.方法 对广州市儿童医院2004年6月至2007年4月收治的73例符合急性脑水肿诊断的危重症患儿应用TCD进行床边监测,分析各年龄段急性脑水肿患儿以及小儿昏迷量表评分不同分值下TCD的各项参数(Vs、Vd、Vm、PI、RI)和血流频谱特征并与同龄段的正常对照组进行比较.结果 急性脑水肿患儿的TCD显示,Vd及Vm下降,PI、RI升高,与对照组相比有着显著性差异(P＜0.01),Vs与对照组相比无显著性差异(P＞0.05).同时其血流频谱在颅内压升高的不同阶段呈现出不同的特征性改变即急性脑水肿ICP增高初期,血流频谱表现为收缩峰变尖锐,而平均血流速度无明显改变.部分病例表现为收缩期与舒张期血流速度均升高,频窗紊乱,Lindegaard指数(VmMCA/VmICA)＞3,提示脑血管痉挛;随病情发展,脑血流速度进一步下降,频谱表现为收缩峰尖锐高阻波形.当脑血管阻力进一步增加,TCD监测频谱表现为高尖的收缩期正相血流,舒张期逆向负相血流的"振荡波",当颅内压接近舒张压时,舒张期血流消失,频谱表现为"钉子波",病情进展最终血流信号减弱直至消失.结论 TCD可直接提示脑血流灌注的状态,反映脑水肿患儿颅内压力的变化,以及脑血流自动调节功能是否尚存,对于病情判断以及颅内压增高的早期干预均有重要的临床指导意义.当TCD频谱表现为收缩期血流正相而舒张期血流负相的振荡波、收缩期血流钉子波或无血流信号,患儿预后极差.     

经颅多普勒超声观察甘露醇对颅高压患儿脑血流的影响

目的 应用经颅多普勒超声(TCD)观察甘露醇对颅高压患儿脑血流动力学的影响.方法 对深圳市儿童医院重症监护室2008年1月至2009年7月收治的颅高压危重症患儿应用TCD进行床边检测,以大脑中动脉为靶血管,观察32例颅内压增高患儿应用首剂甘露醇前后脑血流的变化.结果 28例注射甘露醇后收缩期峰流速、舒张期流速、平均流速增加,脉动指数降低(P<0.05).23例TCD频谱改变呈高阻力型,表现为收缩峰尖窄伴舒张期低平.4例注射甘露醇前后均无血流信号.结论 颅高压的患儿使用甘露醇治疗可改善脑灌注,但对于脑损伤严重、TCD频谱明显异常、舒张期血流消失或反向血流甚至无血流信号的患儿,甘露醇则难以发挥治疗作用,预后不良.     

经颅超声多普勒在PICU的临床应用

经颅超声多普勒(transcranial Doppler ultrasonography,TCD)可以无创、实时监测脑血流变化,在神经系统疾病中,尤其是神经危重症的诊治中应用广泛.在创伤性脑损伤、颅内压增高、脑血管痉挛、中风、脑血管功能障碍、中枢神经系统感染、脑死亡等疾病的临床诊断和治疗中,TCD均可以发挥重要作用:一方面可以明确患儿的脑灌注情况,监测患儿对治疗的反应,指导治疗,提示预后;另一方面,通过分析脑血流的变化情况,可以分析疾病潜在的病理生理机制,提高对疾病的认识.本文就TCD对PICU神经危重症患儿的临床应用作一概述,从而加深对TCD的认识,为神经危重症患儿的监测和治疗提供更多帮助.     

经颅多普勒超声在心肺复苏患者脑循环监测中的应用

经颅多普勒超声（TCD）通过无创监测颅底大动脉血流速度,反映脑血流动力学变化,提供脑循环灌注信息。本文综述了近年来国外学者使用TCD对心肺复苏期间脑血流动力学变化以及TCD频谱改变与预后的关系等研究现状。多数结果发现TCD监测有助于发现心肺复苏早期及后期脑供血不足或脑充血,并有可能用于评估某些药物对脑灌注的影响及其它治疗方法的效果。     

新生儿缺氧缺血性脑病的脑血流速度检测

采用经颅多普勒超声(TCD),对42例新生儿缺氧缺血性脑病(HIE)患儿的颅内主要大动脉进行血流速度检测并与30名健康新生儿的TCD相比较。结果发现35例异常,占83.3%,其中28例表现不同形式的血流速度降低,7例血流速度增高,7例基本正常。对新生儿HIE的脑血流动力学变化进行了扼要的讨论。     

新生儿缺氧缺血性脑病血浆内皮素-1及脑血流动力学变化

探讨新生儿缺氧缺血性脑病（HIE）血浆内皮素-1（ET-1）及脑血流变化的规律。方法采用放射免疫法检测92例HIE血浆ET-1浓度,与对照组对较,应用经颅彩色多谱勒（TCD）对32例HIE脑血流参数及结构形态进行了检测。结果HIE急性期血浆ET－1均有增高,重度增高显著,与对照组有显著差异,恢复期降低;TCD与对照组比较显示脑内各血管血流减低,阻力及搏动指数增高。结论HIE损伤大脑血管内皮细胞,使ET-1释放增加,与HIE损伤程度呈正相关。严重HIE时脑血管痉挛、阻力增加,应用TCD检测脑血流也有助于指导治疗及评估预后。     

经颅多普勒超声在危重患儿脑功能监测中的应用

脑功能监测是危重患儿监测的重要内容之一,其目的除了解患儿脑功能状态及受损程度外,对于判断疾病治疗效果和预后也有重要作用。常用监测方法包括Glasgow评分、颅内压、脑电图、脑血流和影像学监测等。经颅多普勒超声(TCD)可以穿透颅骨较薄的区域,直接获取颅底Willis环大动脉的血流动力学参数,反映脑血管的功能状态。因TCD技术具有操作简便,对患儿无损伤、无放射性,床边可行等优点,已逐渐成为儿科监护病房脑功能监测的常用方法之一。1超声窗及所探测的血管颅骨上某些区域能通过超声束并能探及血管的部位称为“超声窗”[1]。(1)颞窗:位于…     

经颅多普勒超声在心肺复苏患者脑循环监测中的应用

经颅多普勒超声（TCD）通过无创监测颅底大动脉血流速度，反映脑血流动力学变化。提供脑循环灌注信息，本文综述了近年来国外学者使用TCD对心肺复苏期间脑血流动力学变化以及TCD频谱改变与预后的关系等研究现状，多数结果发现TCD监测有助于发现心肺复苏早期及后期脑供血不足或脑充血，并有可能用于评估某些药物对脑灌注的影响及其它治疗方法的效果。     

彩色多普勒超声测定早产儿脑血流的临床意义分析

目的　彩色多普勒超声测定早产儿脑血流在国外已广泛应用 ,并具有相关早产儿脑血流速度(CBFV)的正常参考值及生理状态下脑血流变化规律 ,而国内这一技术虽已应用于临床 ,但目前还不能提供一个能准确指导临床的CBFV指标 ,故该文运用彩色多普勒超声测定早产儿脑血流的变化并与足月儿比较 ,以探讨其特点及临床意义。方法　采用美国惠普影像之星彩色多普勒超声仪测定 12 8例早产儿及 2 0例足月儿脑血流动力学变化 ,进行动态观察。结果　早产儿脑血流频谱特征及血流参数与足月儿比较 ,其血流速度慢 ,波动范围大 ,差异有极显著性意义 (P <0 .0 1) ,而阻力指数 (RI)为年龄非依赖因素 ,差异无显著性意义 (P >0 .0 5 ) ,不同胎龄、体重早产儿进行比较 ,胎龄、体重的增加与脑血流呈同步上升关系。分组进行比较 ,其差异有极显著性意义 (P <0 .0 1) ,病理因素对早产儿脑血流有直接影响 ,窒息、先心病、颅内出血、低血糖、反复呼吸暂停、酸碱平衡紊乱均可导致脑血流减慢 ,并呈现收缩期血流速度与舒张末期血流速度的比值 (S/D)值增高 ,RI值增高或明显降低 ,其差异有极显著性意义 (P <0 .0 1)。结论　彩色多普勒超声测定早产儿脑血流并进行动态观察 ,对于预测早产儿脑神经发育和判断脑损伤程度有一定的临床意义。     

经颅多普勒超声在昏迷危重患儿中的应用

目的应用经颅多普勒超声(TCD)观察昏迷患儿脑血流动力学的一般情况及变化趋势,以及了解脑血流动力学与颅内压之间的联系。方法以大脑中动脉(MCA)为靶血管,观察昏迷组及对照组患儿(其中56例昏迷患儿)脑血流变化;腰穿或应用甘露醇前后各指标的变化;昏迷患儿不同时期及不同昏迷程度时的各指标的变化。结果昏迷组收缩期峰流速(Vp)、平均血流速度(Vm)、脉动指数(PI)、阻力指数(RI)明显高于对照组;昏迷患儿在治疗前Vp、Vm、PI、RI均高于治疗后;患儿在腰穿前大脑中动脉Vp、Vm、PI、RI均高于腰穿后;甘露醇使用前Vp、Vm、PI、RI均高于其使用后;Glasgow评分分值低者Vp、舒张期流速(Vd)、Vm偏低,而RI、PI偏高。结论昏迷患儿的脑血流动力学异于正常,TCD可反映颅内脑血流灌注情况,脑血流动力参数可随颅内压而变;因此TCD有助于判断病情、指导临床治疗和评估预后。     

Role of nutrients in the regulation of in vivo protein metabolism in humans

Nutrients regulate protein metabolism both in an acute fashion and on a long-term basis. The ingestion of meals is associated with a dramatic switch from an overall catabolic state to a state of net protein anabolism. The acute response of protein metabolism to meal ingestion is mediated, in part, by an increase in insulin secretion, itself a consequence of glucose absorption. Whereas insulin may primarily suppress rates of proteolysis, amino acids are responsible for the stimulation of protein synthesis that follows food intake. In the long run, the effects of nutrition on protein metabolism depend on the energy supply, the source of the energy (carbohydrate versus fat) and dietary protein intake. Finally, specific amino acids, such as glutamine, may play an additional role as protein anabolic agents.     

氨磷汀在儿童肿瘤化疗中的应用

目的研究氨磷汀在儿童肿瘤化疗中的作用及不良反应。方法随机选择肿瘤32例患儿,采用自身对照,观察患儿在同一化疗方案中使用氨磷汀辅助治疗后黏膜损伤、骨髓抑制时间、发热持续时间、抗生素及刺激因子应用时间及氨磷汀的不良反应。结果氨磷汀辅助治疗组发生黏膜溃疡4例,明显低于对照组9例;中性粒细胞<0.5×109/L持续时间缩短,血小板<5×109/L持续时间缩短;发热持续时间、抗生素和刺激因子应用时间缩短。两组化疗过程中均未出现低体温、皮疹、低血压等情况,化疗后肾功能、心电图均正常;对肝功能影响程度相似;氨磷汀组低钙血症尤其是低钙性抽搐发生率高。结论氨磷汀能够有效保护正常组织细胞,不良反应较低,可在儿童肿瘤患者化疗中应用。     

Determinants of pregnancy in adolescents in Nepal

Objective : Social factors and prevalent norms in the community determine the proportion of teenage pregnancy in the community. In the light of high risk associated with teenage pregnancy, the socio-cultural determinants, which influence the conception among teenagers in Nepal, need to be understood. These determinants may be modified by suitable interventions to reduce teenage pregnancy. Aim of this study was to examine the socio-cultural determinants of teenage pregnancy in eastern Nepal.Methods : A case-control study design was selected for comparing the education, economic status, family support and freedom towards conception among teenagers as compared to higher age group women.Result : Seventy adolescent pregnant women were compared with seventy primigravida women in the 20 to 29 years age group. The teenage pregnant women were less educated, had poor economic background, more likely to have accidental pregnancies as compared to the other group and more likely to have love marriages. Husbands were more likely to decide about continuation of pregnancy. They had less psychological and social support from the family.Conclusion : Marriage at young age and pregnancy during teens are associated with less social acceptance and poor support in the family.     

Diagnosis of Chlamydia pneumoniae in community-acquired pneumonia in children in Chile

The incidence of Chlamydia pneumoniae in community-acquired pneumonia in children was studied prospectively in 112 children aged 1 mo to 14 y. Diagnosis of C. pneumoniae was performed by polymerase chain reaction (PCR) on nasopharyngeal aspirates and serology by the microimmunofluorescence test on a single serum specimen. Three (2.7%) cases of pneumonia due to this agent were diagnosed by both PCR and serology. C. pneumoniae was not found in any of 62 children below 5 y of age. In the age group 5-8 y, only 1/30 (3%) was found positive, and in the age group 9-14 y, C. pneumoniae was diagnosed in 2/20 (10%) children. Conclusion: Although the number of enrolled patients is small, and the diagnostic techniques used may have some limitations, the results of this study suggest that C. pneumoniae plays a minor role in the aetiology of pneumonia in children less than 9 y of age in our country. However, it should be considered as a potential agent in pneumonia in older children.     

Efficacy of amphotericin B in multi-drug resistant kala-azar in children in first decade of life

Fifty children in the first decade of life, and suffering from multiple drug resistant kala-azar, confirmed by demonstration of amastigotes in aspirates of bone marrow or spleen were treated with amphotericin B in gradually increasing dosage to a total dose of 20 mg/kg. All patients had classical features of severe kala-azar, and had taken more than one course of antimony and pentamidine, and three patients had taken one additional course of ketoconazole besides many courses of antimony and pentamidine. The clinical response started just after first infusion in 8 patients, and the patients became afebrile. By 5th infusion, all looked better and 18 patients became afebrile. By 15th infusion all patients were afebrile and cheerful. Their spleens became smaller and body weights and total white cell counts increased. Forty eight patients had parasitological cure at the end of treatment, and only 2 patients required an additional 5 infusions for parasitological cure. All patients were ultimately cured. No one relapsed within six months of follow up. All patients had shivering, rigor and rise of temperature on the day of infusion, which could be minimized with prior administration of low dose of hydrocortisone, but could not be eliminated. Eighteen patients had loose motions during treatment, while 14 patients had decrease in appetite which improved quickly when the treatment was over. Fourteen patients had transient rise of blood urea, in six patients serum creatinine also increased and 16 patients had a minor fall in serum potassium. It is concluded that amphotericin B is a very effective drug for multidrug resistant kala-azar in children, and should be used without hesitation in all such cases in children, but under close medical supervision.     

皮质激素在癫痫治疗中的应用

皮质激素在癫痫中的应用已有近50a的历史，现已证明其对某些癫痫综合征如婴儿痉挛症、Landau—Kleffner综合征、Rassmussen综合征、具有睡眠中癫痫性电持续状态的癫痫综合征等具有肯定的治疗作用，其确切的作用机制尚不清楚。在皮质激素应用过程中应注意其不良反应。     

他汀类药物在儿童家族性高胆固醇血症治疗中的研究进展

家族性高胆固醇血症(FH)是一种常染色体显性遗传的脂质代谢障碍疾病,由于FH早期就可引起动脉粥样硬化病变,增加患者严重心血管疾病的患病风险和死亡风险,因此目前越来越强调患者自儿童期就使用他汀类药物进行治疗,以改善远期预后。文章综述他汀类药物治疗儿童FH的必要性、有效性和安全性,同时也提出目前存在的一些问题和思考。     

Role of nutrients in the regulation of in vivo protein metabolism in humans

Nutrients regulate protein metabolism both in an acute fashion and on a long-term basis. The ingestion of meals is associated with a dramatic switch from an overall catabolic state to a state of net protein anabolism. The acute response of protein metabolism to meal ingestion is mediated, in part, by an increase in insulin secretion, itself a consequence of glucose absorption. Whereas insulin may primarily suppress rates of proteolysis, amino acids are responsible for the stimulation of protein synthesis that follows food intake. In the long run, the effects of nutrition on protein metabolism depend on the energy supply, the source of the energy (carbohydrate versus fat) and dietary protein intake. Finally, specific amino acids, such as glutamine, may play an additional role as protein anabolic agents.     

支气管镜在儿童气管食管瘘全程手术管理中的应用研究

目的 探讨支气管镜在儿童气管食管瘘术前、术中和术后的临床应用价值.方法 对14例疑似气管食管瘘患儿(其中1例支气管食管瘘)尝试应用支气管镜进行手术全程管理.结果 术前对4例患儿应用支气管镜检查明确诊断为气管食管瘘;运用相同方法确诊1例患儿为气管窦道,排除了气管食管瘘;利用支气管镜引导下气管插管技术,成功封堵1例因误食烧碱造成左主支气管-食管瘘.在术中应用"支气管镜透射照明"法和"导丝环"法精确定位3例气管食管瘘,减少了手术创伤和探查瘘管的时间.在术后应用支气管镜发现2例气管食管瘘复发和2例存在气管软化;支气管镜还充当了一次"超细胃镜",将导丝引入食道,然后进行食管狭窄的球囊扩张.结论 支气管镜在儿童气管食管瘘诊治中有很大的临床应用价值,可应用于气管食管瘘的全程管理.