“早产儿脑损伤诊断与防治专家共识”解读

近20年来,早产儿、尤其极低出生体重儿(very low birth weight infants)和超低出生体重儿(extremely low birth weight infants)的成活率有了显著提高,但其神经系统伤残如脑瘫及神经系统发育障碍等不但没有相应减少反呈增加趋势,包括那些颅脑影像学检查无异常发现者[1-2],其重要原因之一是国内外迄今尚无统一、规范的早产儿脑损伤(brain injury in premature infants,BIPI)诊断标准和防治方案供临床医师参照应用,从而使对BIPI的诊治处于无章可循的状态.     

影响早产儿20项行为神经评分的危险因素分析

目的 分析早产儿20项行为神经评分(NBNA)特点,探讨影响早产儿NBNA的危险因素.方法 应用新生儿20项行为神经评价方法对我院274例纠正胎龄40周的早产儿进行评定,按NBNA评分分为NBNA正常组(n=221)和NBNA异常组(n=53).回顾早产儿出生史、母亲孕产期情况、新生儿期原发疾病住院情况及检查结果,分析影响早产儿NBNA评分的可能危险因素.结果 两组患儿在胎龄、出生体质量、头围、身长、Apgar评分,复苏时间、住院时间、达完全胃肠营养时间方面比较差异有统计学意义(P＜0.05);多胎、肺透明膜病、出血性和缺氧性脑损伤、严重感染、低血糖、高胆红素血症、慢性肺疾病的发生率两组比较差异有统计学意义(P＜0.05);而性别、产前使用激素、贫血、低血压及听觉通路异常情况两组比较差异无统计学意义(P＞0.05).窒息、低出生体质量、肺透明膜病、出血性和缺氧性脑损伤、严重感染、高胆红素血症、反复低血糖及慢性肺疾病是影响早产儿NBNA评分的危险因素.结论 早产儿生后虽纠正胎龄足月,但在行为能力和主动肌张力方面得分仍低.低Apgar评分、低出生体质量、肺透明膜病、出血性和缺氧性脑损伤、严重感染、高胆红素血症、反复低血糖及慢性肺部疾病与早产儿NBNA评分密切相关.

Abstract：

Objective To analyze the characteristic of twenty-item premature behavioral neurological assessment,and to assess the risk factors of neonatal behavioral neurological assessment(NBNA) in premature infants. Methods Total two hundred and seventy-four premature infants hospitalized in Guangzhou Children's Hospital were assessed with the NBNA after correcting age 40 weeks,premature infants were divided into two groups:normal group (n =221 ) and abnormal group (n =53) according to NBNA. The birth history, mother pregnancy situation, the disease during neonatal period and results in hospital were reviewed,and the risk factors of NBNA in premature infants were assessed. Results There were significant differences in gestational age, birth weight, head circumference, body height, Apgar score, resuscitation time, hospitalization time and total gastrointestinal nutrition time between the two groups( P ＜ 0. 05 ). The incidences of superfoetation,hyaline membrane disease, hemorrhagic and hypoxic brain injury, severe infection, hyperbilirubinemia, hypoglycemia and chronic lung disease were different between the two groups( P ＜ 0. 05 ). There were no differences in gender, antenatal hormone use, anaemia, hypotension and evoked potential abnormality (P ＞0. 05 ). Multivariate logistic regression analysis showed that the risk factors of NBNA score in premature infants would include low Apgar score, low birth weight, hyaline membrane disease, hemorrhagic and hypoxic brain injury, severe infection, hyperbilirubinemia, hypoglycemia and chronic lung disease. Conclusion Although the premature infants corrected age 40 weeks,but the capability and initiative muscular tension are still lower than term infant. Low Apgar score, low birth weight, hyaline membrane disease, hemorrhagic and hypoxic brain injury ,severe infection ,hyperbilirubinemia,hypoglycemia and chronic lung disease are important risk factors related to premature behavioral neurological assessment.     

促红细胞生成素对早产儿脑损伤神经行为的影响

目的 探讨重组人类基因促红细胞生成素(EPO)对早产儿脑损伤保护作用及临床疗效.方法 将42例发生脑室周围白质软化(PVL)脑损伤的早产儿(男25例,女17例)随机分为EPO治疗组(22例)和常规治疗组(20例),治疗组于生后3～5 d予以EPO治疗4周.所有患儿于纠正胎龄40周进行新生儿行为神经检测(NBNA),随诊至6个月,定期行头颅影响学检查、脑电图检查,3、6个月时分别进行发育商(DQ)测定.结果 治疗组患儿NBNA评分及DQ评估均明显高于对照组,差异有显著性(P＜0.05).结论 EPO能促进神经系统损伤修复,对脑损伤的早产儿神经行为发育有促进作用,可改善预后.

Abstract：

Objective To study the clinical curative and protective effects of erythropoietin (EPO)on treating the premature infants with brain damage. Methods Forty-two premature infants with periventricular leukomalacia were divided into the EPO treatment group (n = 22) and control group (n = 20). From postnatal day 3 to 5 ,the EPO treatment group received EPO for 4 weeks. Neonatal behavioral neurological assessments (NBNA) for all infants were performed separately in 40 weeks after correcting gestational age. All infants were followed up until 6 month after birth, MRI and electroencephalogram were performed. The developmental quotient(DQ) was evaluated at the age of 3 and 6 months. Results The NBNA scores of EPO group in 40 weeks and DQ were significantly higher than those of control group (P ＜ 0.05). Conclusion EPO can rehabilitate the damaged neurological system of premature infants with brain damage. Early EPO therapy can promote development of the neurobehavioral and improve prognosis.     

High-mobility group box-1 and receptor for advanced glycation end products in preterm infants with brain injury

Background:High-mobility group box-1 (HMGB1) protein acts as an important pro-inflammatory mediator,which is capable of activating inflammation and tissue repair.HMGB1 can bind to its receptor such as advanced glycation end products (RAGE).RAGE,in turn,can promote the production of pro-inflammatory cytokines.Soluble RAGE (sRAGE) is a truncated form of the receptor comprising the extracellular domain of RAGE and can inhibit RAGE-activation.The objective of this study was to investigate whether HMGB1 and RAGE are involved in the development of brain injury in preterm infants.Methods:In total,108 infants ≤34 weeks gestation at birth were divided into 3 groups according to cranial altrasound scan:mild brain damage (n=33),severe brain damage (n=8) and no brain damage (n=67).All the placentas were submitted for pathologic evaluation.Histological chorioamnionitis (HCA) was defined as neutrophil infiltration of amniotic membranes,umbilical cord or chorionic plate.Expressions of HMGB1 and RAGE proteins were assessed by immunohistochemical analysis.The concentration of HMGB1 and sRAGE in umbilical cord blood were measured by enzyme-linked immunosorbent assay.Results:The frequency of HCA was 30.12％.HCA was associated with elevated concentrations of HMGB1 and decreased sRAGE in umbilical cord blood.The severe brain injury group demonstrated higher cord blood HMGB1 concentrations (P＜0.001) and lower sRAGE concentrations (P＜0.001) than both other groups.Brain injury in the premature infants was linked to intense staining for HMGB1/RAGE,particularly in inflammatory cells.Conclusions:Changes of cord blood HMGB1 and sRAGE of premature infants had direct relationship with the degree of inflammation and severity of brain damage.Monitoring sRAGE and HMGB1 levels may be helpful to predict intrauterine infection and brain injury in premature infants.     

早产儿脑损伤影像学及脑电图诊断的研究进展

早产儿特别是28周的超未成熟儿,由于脑血管发育不成熟,脑血流自主调节能力较差,极易出现脑血流动力学紊乱,且早产儿神经元、少突胶质细胞及其前体对缺氧缺血异常敏感,耐受性低,易损性高,导致早产儿脑损伤及神经系统后遗症发生率较足月儿高。但临床上早产儿脑损伤往往缺乏明显的神经系统症状和体征,容易漏诊而错过治疗时机。头颅超声、MRI及脑电图均是早产儿脑损伤早期诊断的特殊检查手段。在早期颅内出血诊断上头颅超声优于后两者,但脑白质软化评估则MRI特别是DWI诊断价值最高,而脑电图可在各时期辅助诊断脑损伤患儿,三者各有优劣,临床上若能合理运用三者诊断早产儿脑损伤,则有助于及时发现疾病,尽早治疗,减少早产儿神经系统后遗症的发生,降低致残率,改善远期预后。     

脐血白细胞介素-6对早产儿脑损伤预后判断的价值

目的：探讨母亲的绒毛膜羊膜炎、脐血IL-6水平与早产儿脑损伤以及出生后3年间的神经系统后遗症之间的相互关系，了解临床检测脐血IL-6水平的意义，为及时诊断早产儿脑损伤、早期预防神经系统发育性障碍提供理论依据。方法：研究对象为26例早产儿。用ELISA方法检测早产儿脐血中IL-6水平；将母亲的胎膜组织行病理学检查，以诊断有无绒毛膜羊膜炎；早产儿生后3 d内行头颅超声或CT检查，以协助诊断有无脑损伤；随访早产儿出生后3年间的神经系统后遗症情况。结果：①有脑损伤的早产儿脑瘫、癫痫等神经系统发育性障碍的发生高于无脑损伤组；②母亲有绒毛膜羊膜炎组神经系统发育性障碍者增高；③有神经系统发育性障碍的早产儿的脐血IL-6水平明显高于无脑损伤组。结论：母亲的绒毛膜羊膜炎与早产儿脑损伤及其后发生的神经系统后遗症密切相关，故预防和积极治疗母亲的宫内感染对预防早产儿脑损伤以及降低脑瘫等严重神经系统后遗症的发病率均具有重要意义。脐血中的IL-6水平升高可能在母亲宫内感染导致早产儿发生脑损伤的过程中起重要的介导作用。     

振幅整合脑电图在早产儿应用中的研究进展

正随着围产医学和新生儿重症监护技术的发展,超低出生体重早产儿存活率不断提高,但其脑损伤问题也愈显突出,25%~50%早产儿发生脑损伤~([1])。脑损伤已成为当前早产儿死亡和遗留神经系统后遗症的重要因素之一。如何早期识别脑损伤进而判断其严重程度,预测远期预后,对指导临床早期积极治疗,改善危重早产儿生存质量具有重要意义~([2])。目前,临床迫切需要一种操作简便、易于分析、无创、适于床旁连续监测的神经功能监     

脑白质损伤防治新标靶——神经血管单元

围生期脑白质损伤是导致早产儿神经系统发育受损甚至远期后遗症最常见的脑损伤形式.其发病机制复杂,目前尚缺乏有效的防治手段.近年来,神经血管单元作为神经系统结构和功能的整体,逐渐在神经科学领域引起关注.该文就脑白质中神经血管单元的组分及相互作用,脑白质损伤的病理生理、预防和治疗等方面的研究进展作一综述.     

Nutritional support and neurodevelopmental outcome of preterm infants

随着围产医学和新生儿医学发展,极低和超低出生体质量(VLBW/ELBW)早产儿存活率普遍提高,但这些早产儿可进一步发生神经系统发育不良.除与神经系统发育有关的疾病如脑损伤外,在大脑迅速生长和发育的时期,营养同样是影响神经系统发育及不良预后的重要因素.VLBW/ELBW早产儿发生生长发育迟缓的风险增高,主要与出生后营养摄入不足有关.目前的证据显示,VLBW/ELBW早产儿出生后生长发育迟缓与神经系统发育损害有关.此外某些特殊营养素,如长链多不饱和脂肪酸与早产儿神经发育有相关关系.     

营养与早产儿神经发育结局

随着围产医学和新生儿医学发展,极低和超低出生体质量(VLBW/ELBW)早产儿存活率普遍提高,但这些早产儿可进一步发生神经系统发育不良。除与神经系统发育有关的疾病如脑损伤外,在大脑迅速生长和发育的时期,营养同样是影响神经系统发育及不良预后的重要因素。VLBW/ELBW早产儿发生生长发育迟缓的风险增高,主要与出生后营养摄入不足有关。目前的证据显示,VLBW/ELBW早产儿出生后生长发育迟缓与神经系统发育损害有关。此外某些特殊营养素,如长链多不饱和脂肪酸与早产儿神经发育有相关关系。     

An exploratory survey on the state of training in adolescent medicine and health in 36 European countries

The development of adolescent health and medicine as a medical discipline lags behind in Europe compared with other regions of the world. This study aims to evaluate the structure and content of adolescent medicine and health training curricula for medical students, paediatricians, and other primary care physicians in the European region. A questionnaire survey was sent by e-mail to experts in the field from 36 European countries, addressing the content of adolescent health issues. Data was obtained from all 36 countries. At the undergraduate level, seven countries reported some mandatory stand-alone teaching (sessions dealing specifically with adolescents), while seven countries reported optional stand-alone teaching. In only 7 out of 36 countries were issues critical to adolescents covered as stand-alone sessions. At the postgraduate level, 15 countries delivered stand-alone mandatory training sessions to primary, secondary, or tertiary care paediatricians, covering most of the five critical areas listed in the questionnaire. In another 13 countries, such sessions were not mandatory and were inexistent in eight of them. The coverage among school physicians was similar but was much lower among general practitioners.

Conclusion: Paediatric associations and academic institutions should advocate for a better coverage of adolescent health and medicine in the training curricula of health care providers.

新生儿DiGeorge综合征1例报告

No abstract available

     

不典型起病的小儿结核病5例分析

目前,临床结核病的表现似乎日趋复杂化,给临床诊断带来一定的难度。现将我院1994年9月至1999年2月的几例不典型起病的结核病报告如下:1　临床资料　　例1,男,4岁,阵发脐周疼痛2月余,夜间较重。腹痛与饮食无关,时有腹胀、便秘,无腹泻、呕吐、无盗汗。接种过卡介苗。以腹痛待查入院。查体:Ｔ36.6℃,体重12ｋｇ,慢性病容,皮肤无黄疸。心肺正常,腹平软,脐周轻压痛,无反跳痛,肝脾未触及,肠鸣音正常。化验:三大常规正常。腹部Ｂ超:正常。腹平片正常。胃肠钡餐正常。肝、肾功能正常。治疗予雷尼替丁、颠茄合剂、氟哌酸等无效。在观察中发现患儿除了…     

体外膜肺氧合技术在4例危重新生儿中的应用

<正>体外膜肺氧合技术(extracorporeal membrane oxygenation,ECMO)是一种体外生命支持技术,能为急性严重心肺衰竭患者提供心肺支持。1971年,Hill等~([1])首次应用心肺转流术设备成功救治1例24岁患多脏器损伤合并急性呼吸窘迫综合征(ARDS)的患者,标志着ECMO技术开始应用在临床。Bartlett等~([2])在1975年为1例婴儿成功进行床边心肺支持后,ECMO技术逐渐应用到儿科领域,     

儿童过敏性紫癜消化道症状临床分析

过敏性紫癜(Henoch-Schonlein Purpura,HSP)是儿科临床常见疾病。研究报道儿童HSP年发病率为3～26.7/10万[1]。本课题组前期研究结果显示,HSP住院构成比有逐年升高的趋势[2]。HSP是一种多系统免疫性血管炎,临床以皮肤、消化道、关节及肾脏等器官受累为主要表现[3]。有报道显示,HSP患者消化道受累比例为50%～80%,表现为恶心、呕吐、腹泻、腹痛和消化道出血[4]。HSP患     

儿童暴发性1型糖尿病1例

No abstract available

     

Utilization of computed tomography imaging in the pediatric emergency department

Background

In recent years, there has been a movement toward more judicious use of computed tomography (CT) imaging in an attempt to limit exposure of pediatric patients to ionizing radiation. The Image Gently Alliance and like-minded movements began advocating for safe and high-quality pediatric imaging worldwide in the late 2000s.

Objective

In the context of these efforts, we evaluate CT utilization rates in the pediatric emergency department at a major academic medical center.

Materials and methods

We tracked utilization in several categories of CT, magnetic resonance imaging (MRI) and ultrasonography (US) between July 2008 and June 2017 and compared them with utilization rates from 2000 to 2006.

Results

A total of 4,955 pediatric patients underwent a total of 5,973 CT scans, 2,775 US studies and 293 MRI scans while in the pediatric emergency department during the 2008–2017 study period. We observed decreases in CT scans across all categories, ranging from a 19% decrease in abdominal CT to a 66% decrease in chest CT. Relatively greater decreases in CT scans were observed in patients younger than 3 years of age as compared to older children and adolescents. Abdominal and pelvic US increased. Brain MRI also increased over the final two years of the study.

Conclusion

CT utilization decreased throughout the 2008–2017 study period.

     

新生儿甲状腺危象1例报告

No abstract available

     

原发性肉碱缺乏症1例报告

No abstract available

     

红细胞生成素在新生儿应用的研究近况

红细胞生成素 (ＥＰＯ)是调节红系晚期祖细胞的存活、增殖和分化的主要生长因子 ,是决定组织氧合状态的主要决定因素之一 ,ＥＰＯ通过结合细胞表面特异的红细胞受体 (ＥＰＯ Ｒ)而发挥功能[1] 。ＥＰＯ及其受体功能异常即产生疾病 ,如红细胞增多症或早产儿贫血 ,并可导致 70 %怀孕母鼠胎仔死亡。开始认为ＥＰＯ专一在造血细胞上 ,现已发现功能性ＥＰＯ Ｒ存在于多种非造血细胞上。早产儿使用重组ＥＰＯ(ｒＥＰＯ)可减少其住院期间需要输血的次数和输血的总量。此种治疗可视为生理性的。然而在使用的剂量、间隔及治疗期限上还有争议 ,本文就…