电视胸腔镜与经胸骨手术治疗重症肌无力伴胸腺瘤的临床对比研究

目的比较重症肌无力(MG)伴胸腺瘤患者行胸腔镜胸腺切除和经胸骨胸腺切除术的疗效。方法回顾性分析2000至2014年276例行电视胸腔镜(电视胸腔镜组)、胸骨正中劈开(胸骨正中劈开组)和第二肋间胸骨横断小切口(胸骨横断小切口组)入路行胸腺扩大切除术的MG伴胸腺瘤患者的临床资料及其治疗效果。结果电视胸腔镜组的性别、年龄、病程、术前肺活量预计值、重症肌无力基金会分级和总有效率等数据与胸骨正中劈开组和胸骨横断小切口组比较,差异无统计学意义(P0.05);而手术切口长度、留置引流管数、术后引流时间、术后住院时间、术后出现并发症的例数均显著低于胸骨正中劈开组和胸骨横断小切口组,差异有统计学意义(P0.05)。结论虽然3种胸腺切除手术方式在治疗MG的总有效率方面差异无显著性,但胸腔镜手术患者的围手术期优势明显。     

单操作孔胸腔镜与传统胸腔镜下胸腺扩大切除治疗重症肌无力的对比研究

目的探讨单操作孔胸腔镜胸腺扩大切除治疗重症肌无力(myasthenia gravis,MG)的手术安全性和临床疗效。方法回顾性分析2017年1月至2019年3月北京医院胸外科经单操作孔胸腔镜(单操作孔组)和传统三孔法胸腔镜(三孔组)行胸腺扩大切除术治疗MG的患者,比较两组患者的临床资料、手术安全指标和疗效。结果本研究共入组MG 104例,其中单操作孔组51例,三孔组53例。两组均无中转开胸和围术期死亡,三孔组中1例术后当日因胸廓内动脉出血二次胸腔镜探查止血。单操作孔组手术时间稍长于三孔组[(142.25±42.78)min比(125.85±37.76)min,P=0.04],两组术中出血量(50 mL比50 mL,P=0.249)、胸腔引流量[(836.47±441.19)mL比(930.47±498.75) mL,P=0.312]、胸管留置时间(3 d比3 d,P=0.114)、术后住院时间(6 d比7 d,P=0.619)、围术期总体并发症(27.45%比28.30%,P=0.923)、肌无力危象(11.76%比16.98%,P=0.449)、切口并发症(7.84%比9.43%,P=0.773)的差异无统计学意义。单操作孔组术后第1、2、3天疼痛评分低于三孔组(P0.05),术后镇痛药物使用率低于三孔组(27.45%比50.94%,P0.05)。全组随访率98.08%,中位随访时间24.2个月(11.2～38.1个月),两组术后1年有效率(90.20%比88.24%,P=0.750)的差异无统计学意义。结论单操作孔胸腔镜胸腺扩大切除治疗MG的手术安全性和疗效良好,有助于降低术后疼痛。肌无力危象、肺部并发症、切口并发症和术后疼痛仍是影响MG患者围术期安全和生活质量的重要因素,围术期应注意预防以上并发症,从而提高治疗安全性和有效率。     

超敏C-反应蛋白、白细胞介素18与青年缺血性脑卒中后焦虑的相关性

目的探讨血清超敏C-反应蛋白(hypersensitive C-reactive protein,hs-CRP)、白细胞介素-18(interleukin-18,IL-18)水平与青年缺血性脑卒中后焦虑的关系。方法选取首次发病的确诊的青年缺血性脑卒中患者49例(脑卒中组),以健康体检者53例为健康对照(对照组),分别于入院后1d、7d、14d和21d检测hs-CRP及IL-18水平,3周后使用汉密尔顿焦虑量表对患者进行焦虑评分。根据该评分将患者分为脑卒中后焦虑组和脑卒中后非焦虑组,比较脑卒中组与对照组及脑卒中后焦虑组与非焦虑组hs-CRP及IL-18水平的差异。结果脑卒中组hs-CRP水平在入院1d〔(9.55±2.53)mg/L vs.(1.25±0.18)mg/L,t=22.89,P=0.008〕、7d〔17.31±4.83)mg/L vs.(0.78±0.23)mg/L,t=23.92,P=0.005〕、14d〔(15.56±3.67)mg/L vs.(1.34±0.30)mg/L,t=27.10,P=0.007〕、21d(13.28±2.96)mg/L vs.(0.85±0.34)mg/L,t=21.90,P=0.003〕均高于对照组。脑卒中后焦虑组hs-CRP水平在入院7d〔(19.43±2.17)mg/L vs.(14.56±1.83)mg/L,t=8.38,P=0.004〕、14d〔(17.85±2.75)mg/L vs.(13.21±2.94)mg/L,t=5.45,P=0.001〕和21d〔(14.08±1.86)mg/L vs.(9.78±2.67)mg/L,t=6.02,P=0.003〕时高于脑卒中后非焦虑组。与对照组比较,脑卒中组血清IL-18水平在入院7d〔(19.68±3.23)mg/L vs.(17.34±1.86)mg/L,t=4.32,P=0.006〕、14d〔(22.68±2.65)mg/L vs.(16.68±2.48)mg/L,t=11.53,P=0.002〕和21d〔(27.74±4.96)mg/L vs.(15.74±3.12)mg/L,t=14.03,P=0.001〕时均升高。脑卒中后焦虑组IL-18水平在入院7d〔(21.77±3.56)mg/L vs.(18.85±3.44)mg/L,t=2.82,P=0.007〕、14d〔(25.57±2.54)mg/L vs.(22.13±2.71)mg/L,t=4.15,P=0.002〕和21d〔(29.35±4.14)mg/L vs.(26.79±4.98)mg/L,t=4.15,P=0.002〕时高于非焦虑组。在7d、14d、21d时,焦虑组与非焦虑组患者炎性因子hs-CRP、IL-18水平均明显高于对照组(均P0.01)。结论脑卒中后焦虑可能与hs-CRP、IL-18高水平有关。     

神经内镜辅助与枕下开颅血肿清除术治疗高血压小脑出血疗效比较

目的探讨神经内镜在高血压小脑出血患者治疗中的临床应用价值。方法回顾性分析38例小脑出血患者的临床资料,18例经神经内镜辅助下小脑血肿清除术,20例采用枕下开颅血肿清除术,统计两组患者的围手术期指标及临床转归。结果与开颅手术组比较,神经内镜组的平均手术时间缩短[(82.9±17.0)min vs.(177.9±28.8)min,t=12.545,P0.01]、术中平均出血量减少[(45.1±15.6)mL vs.(197.9±29.5)mL,t=20.237,P0.01]、术后脑室引流管留置时间缩短[(3.5±1.5)d vs.(5.3±1.4)d,t=3.751,P=0.001]、术后ICU留置时间缩短[(2.9±1.0)d vs.(4.7±1.5)d,t=4.146,P0.01]、总住院时间缩短[(7.4±1.5)d vs.(9.9±2.8)d,t=3.348,P=0.002]。术后2周,神经内镜组死亡1例,开颅手术组死亡2例,差异没有统计学意义(P=1.000,P0.05);随访3个月,神经内镜组格拉斯哥预后扩展评分(Glasgow Outcome Score Extended,GOSE)4分14例,开颅手术组GOSE4分13例,差异没有统计学意义(χ~2=0.752,P=0.386)。结论神经内镜辅助下小脑血肿清除术在死亡率与临床转归与枕下开颅手术没有差异,但是能缩短手术时间,减少术中出血,缩短脑室引流管留置时间,缩短ICU留置时间,缩短总住院时间,是安全、有效的手术方式,具有临床推广应用价值。     

电视胸腔镜下胸腺扩大切除术治疗重症肌无力的围术期管理

重症肌无力(myasthenia gravis,MG)是一种以横纹肌神经肌肉传导障碍为特点的自身免疫性疾病,与胸腺异常关系密切.MG有多种治疗方法[1],其中电视胸腔镜手术目前已得到普及.此文作者2004-10-2008-12成功为51例MG患者进行了电视胸腔镜胸腺扩大切除术并取得较好近期效果,此文对其围术期管理进行报道.     

早期帕金森病隐喻理解研究

目的了解早期帕金森病患者是否存在隐喻理解障碍,并探讨帕金森病患者隐喻理解障碍的相关因素。方法设计隐喻理解检查软件对42例帕金森病患者(PD组)及30例健康对照(对照组)进行隐喻理解研究,比较两组间隐喻理解成绩是否存在差别,以及起病侧、疾病分型对隐喻理解成绩的影响。结果帕金森病患者隐喻理解得分低于对照组〔(71.7±10.8)分vs.(81.6±7.7)分,t=4.204,P=0.000〕。病程与隐喻理解成绩呈负相关(r=-0.355,P=0.023)。右侧起病患者隐喻理解得分与左侧起病者比较〔(72.3±13.2)分vs.(70.9±7.9)分,t=0.415,P=0.681〕,以震颤为主型患者隐喻理解得分与强直少动为主型患者比较〔(72.4±10.5)分vs.(70.5±11.4)分,t=0.541,P=0.592〕差异均无统计学意义。结论帕金森病患者可能存在隐喻理解障碍,且该障碍可能随着病程的延长逐渐加重。     

22例重症肌无力合并胸腺瘤的手术治疗体会

目的 探讨重症肌无力(myasthenia gravis,MG)合并胸腺瘤患者的围手术期处理方法及手术治疗效果.方法 对本院2006-03～2008-03接受手术治疗的22例重症肌无力合并胸腺瘤患者的临床资料进行回顾性分析.采用改良Osserman标准分为:Ⅰ型9例,Ⅱa型5例,Ⅱb型7例,Ⅲ型1例,手术切口采用胸骨正中切口.手术均行胸腺瘤、胸腺脂肪组织切除及纵隔脂肪组织清扫.结果 22例无手术死亡,3例术后早期发生MG危象,经气管切开、辅助呼吸等抢救治疗治愈.结论 完善围手术期处理措施,减少MG危象的发生,手术治疗重症肌无力合并胸腺瘤可获得良好的疗效.     

重症肌无力患者血清铁水平与AChR-Ab、IL-6的关系

目的探讨重症肌无力(MG)患者外周血清铁(serum iron,SI)的水平变化及其与乙酰胆碱受体抗体(AChR-Ab)、白细胞介素6(IL-6)的相关性。方法选取德阳市人民医院2015-07-2018-03期间收治的重症肌无力MG患者76例(MG组),另选取同期健康体检者50例名作为健康对照组。采用比色法检测所有纳入者外周血清中SI水平(以SI水平8.95μmol/L作为SI缺乏的标准);分别采用酶联免疫吸附法及放射免疫法检测所有纳入者外周血清中IL-6、AChR-Ab的阳性率及表达水平。比较MG患者与正常健康者血清中IL-6、AChR-Ab的阳性率及表达水平,观察MG患者SI水平正常者与SI水平缺乏者血清中IL-6AChAb的表达水平并进行相关分析。结果 MG组患者SI缺乏率、AChR-Ab阳性率、AChR-Ab水平、IL-6水平明显高于健康对照组[分别为73.68%vs.26.00%、81.58%vs.0.00%、(1.05±0.40)nmol/L vs.(0.21±0.09)nmol/L、(183.54±35.26)ng/mL vs.(121.43±28.45)ng/mL),均P0.01)]。MG患者中SI缺乏组患者AChR-Ab、IL-6水平明显高于SI正常组[分别为(1.15±0.34)nmol/L vs.(0.81±0.45)nmol/L、(193.12±31.70)ng/mL vs.156.74±31.19)ng/mL,均P0.01];相关性分析表明MG患者SI水平与AChR-Ab、IL-6水平呈显著负相关(分别r=-0.776,r=-0.663,均P0.01)。结论 MG患者存在着铁缺乏,且MG患者SI水平与AChR-Ab、IL-6水平呈负相关。     

横断胸骨第二肋间小切口胸腺切除治疗重症肌无力引流管位置的对比研究

目的探讨横断胸骨第二肋间小切口胸腺切除术治疗重症肌无力不同位置置引流管的优缺点。方法 195例行胸腺切除术的MG患者,其中67例在两侧纵隔胸膜完整的情况下施行横断胸骨第二肋间小切口旁置纵隔引流管,88例纵隔胸膜破裂口较大者施行单侧腋中线第七肋间置胸腔引流管及40例两侧纵隔胸膜完整者施行剑突下置纵隔引流管。结果手术时间42～100（72.5±17.6）min,术后引流30～140（89.8±30.6）mL,48h内全部拔引流管,术后摄胸片未见明显胸腔积液或纵隔积液。切口Ⅰ/甲级愈合。术后随访1～12个月,胸骨愈合均满意,无＂鸡胸＂等畸形。结论施行横断胸骨第二肋间小切口旁置纵隔引流管手术操作简便、安全、创伤小,值得临床推广。     

重症肌无力患者临床特征与褪黑素水平及受体表达相关性研究

目的研究重症肌无力(myasthenia gravis, MG)患者褪黑素水平及其受体的表达并探讨其临床意义。方法收集MG患者和健康对照各15名,采用定量MG评分系统(quantitative MG scoring system,QMGs)对MG病情的严重程度进行评估;酶联免疫吸附实验(enzyme-linked immuno sorbent assay,ELISA)检测MG患者及健康对照血清褪黑素水平;流式细胞术(flow cytometry, FCM)检测外周CD4~+辅助T细胞褪黑素核受体RORα的表达;蛋白质印迹(Western blot,WB)对外周血单个核细胞(peripheral blood mononuclear cells,PBMCs)褪黑素膜受体MT1及核受体RORα进行半定量检测;比较分析MG患者及健康对照褪黑素水平及其受体表达的差异;并将其与QMGs评分进行相关性分析。结果 MG患者血清褪黑素水平[(381.2±79. 34)pg/mL vs.(403. 8±43. 07)pg/mL;t=0. 34,P0. 05]以及外周CD4~+辅助T细胞褪黑素核受体RORα的表达[(0. 68±0. 45)%vs.(0. 92±0. 57)%;t=1. 25,P0. 05]与健康对照相比无显著差异。WB结果显示MG患者PBMCs中褪黑素膜受体MT1的表达较健康对照显著下降[(0.35±0. 16)%vs.(0.55±0.21)%;t=1.25,P0. 05];患者和健康对照PBMCs中RORa表达[(0. 57±0. 23)%vs.(0. 4 5±0. 15)%;t=1. 38,P0. 05]比较无显著差异。相关性分析结果显示:MG患者血清褪黑素水平(r=0.43,P0.05)、CD4~+辅助T细胞RORα表达(r=0. 30,P0. 05)、PBMCs中褪黑素膜表面受体MT1(r=-0. 23,P0. 05)及核受体RORα(r=0. 17,P0.05)表达与QMGs评分无相关性。结论 MG患者褪黑素水平无明显改变,然而褪黑素膜受体MT1表达减少,提示褪黑素通过MT1发挥调节功能在MG患者中可能存在缺陷。     

Epilepsy and anomalies of neuronal migration: MRI and clinical aspects

Neuronal migration disorders are the result of disturbed brain development. In such disorders, neurons are abnormally located. In diagnosing these conditions, magnetic resonance imaging is superior to any other imaging technique. This enables us to improve our knowledge of the clinical correlates of neuronal migration. With reference to migrational disorder, a retrospective study of all 303 patients with epileptic seizures referred for magnetic resonance imaging during a 3-year period was performed, 13 patients (aged 12-41, mean age 27) were identified. They represent 4.3% of the entire study group. Of the patients with known epilepsy, 6.7% and of the mentally retarded, 13.7% had migrational disorders. Four patients had schizencephaly as the dominant finding, one was classified as hemimegalencephaly, 2 had isolated heterotopias, and 6 had localized pachy- and/or poly-microgyria. The clinical pictures are complex. Ectopias of grey matter are recognised foci of epilepsy, but from an epileptological and a clinical viewpoint little attention has been given to these disorders. The present study shows that malmigration is not rare in epilepsy patients, especially not in the mentally retarded.     

Hepatic Considerations in the Use of Antiepileptic Drugs

Summary: Virtually all of the major antiepileptic drugs (AEDs) can cause hepatotoxicity, although fatal hepatic reactions are rare. The mechanisms, incidences, and risk profiles for such reactions differ from drug to drug. With carbamazepine and phenytoin, hepatotoxicity may be due to drug hypersensitivity. Although the profiles of patients at risk have not been well-defined for these two antiepileptic drugs, it would appear from reports in the literature that older adolescents and adults are at higher risk than children of developing serious or fatal hepatotoxicity. Once hepatotoxicity develops, mortality rates are 10–38% with phenytoin and 25% for carbamazepine. The risk profile for valproate fatal hepatotoxicity has been more clearly defined. Those at primary risk of fatal hepatic dysfunction are children under the age of 2 years who are receiving multiple anticonvulsants and also have significant medical problems in addition to severe epilepsy. The risk is considerably lower for patients over the age of 2 years on valproate monotherapy. In contrast to the risk profile with other AEDs, adults receiving valproate as monotherapy have the lowest risk of hepatotoxicity. Fatal hepatic dysfunction coincident with valproate may be the result of aberrant drug metabolism. Concomitant use of AEDs that induce microsomal P450 enzymes (e.g., phenytoin and phenobarbital) may enhance the production of a toxic metabolite, and hence the greater risk of hepatotoxicity with polypharmacy.     

Vascular Malformations and Epilepsy: Clinical Considerations and Basic Mechanisms

Summary: Vascular malformations (VMs) are associated with epilepsy. The natural history of the various VMs, clinical presentation, and tendency to provoke epilepsy determine treatment strategies. Investigations have probed the mechanisms of epileptogenesis associated with these lesions. Electrophysiologic changes are associated with epileptogenic cortex adjacent to VMs. Putative pathophysiologic mechanisms of epileptogenesis include neuronal cell loss, glial proliferation and abnormal glial physiology, altered neurotransmitter levels, free radical formation, and aberrant second messenger physiology.     

Classification of methods in transcranial Electrical Stimulation (tES) and evolving strategy from historical approaches to contemporary innovations

Transcranial Electrical Stimulation (tES) encompasses all methods of non-invasive current application to the brain used in research and clinical practice. We present the first comprehensive and technical review, explaining the evolution of tES in both terminology and dosage over the past 100 years of research to present day. Current transcranial Pulsed Current Stimulation (tPCS) approaches such as Cranial Electrotherapy Stimulation (CES) descended from Electrosleep (ES) through Cranial Electro-stimulation Therapy (CET), Transcerebral Electrotherapy (TCET), and NeuroElectric Therapy (NET) while others like Transcutaneous Cranial Electrical Stimulation (TCES) descended from Electroanesthesia (EA) through Limoge, and Interferential Stimulation. Prior to a contemporary resurgence in interest, variations of transcranial Direct Current Stimulation were explored intermittently, including Polarizing current, Galvanic Vestibular Stimulation (GVS), and Transcranial Micropolarization. The development of these approaches alongside Electroconvulsive Therapy (ECT) and pharmacological developments are considered. Both the roots and unique features of contemporary approaches such as transcranial Alternating Current Stimulation (tACS) and transcranial Random Noise Stimulation (tRNS) are discussed. Trends and incremental developments in electrode montage and waveform spanning decades are presented leading to the present day. Commercial devices, seminal conferences, and regulatory decisions are noted. We conclude with six rules on how increasing medical and technological sophistication may now be leveraged for broader success and adoption of tES.     

Carbamazepine Efficacy and Utilization in Children

Summary: Carbamazepine is effective for preventing partial and generalized tonic-clonic seizures in children. Although absence epilepsies are more common in children than adults, an estimated 80% of children with epilepsy have seizure types or epilepsies that are potentially responsive to carbamazepine. The differential diagnosis of ictal staring is an especially important issue in children because absence and atypical absence seizures are more prevalent in children than adults. Age-related pharmacokinetic differences and drug interactions are major considerations in children. On average, children have higher clearance rates of carbamazepine, shorter half-lives, and higher ratios of carbamazepine-10, 11-epoxide to carbamazepine than adults. In addition, children with severe epilepsy are more likely to require multiple-drug therapy, which can lead to complex drug interactions. When carbamazepine is administered along with valproate, drug protein binding interactions can cause intermittent side effects.     

Neonatal Seizures: Problems in Diagnosis and Classification

Summary: The clinical identification of neonatal seizures is critical for the recognition of brain dysfunction; however, diagnosis is often difficult because of the poorly organized and varied nature of these behaviors. Current classification systems are limited in their ability to communicate motor, autonomic, and electroencephalo-graphic features of seizures precisely and to provide a basis for uniform effective diagnosis, therapy, and determination of prognosis. Recent investigations of neonates, utilizing bedside electroencephalographic/polygraphic/ video monitoring techniques, have provided the basis for improved diagnosis and classification of seizures in the newborn. These studies have demonstrated that not all clinical phenomena currently considered to be seizures require electrocortical epileptiform activity for their initiation or elaboration. In addition, the specific clinical character of the phenomena considered to be seizures, the clinical state of the infant, and the character of the EEG indicate the probable pathophysiological mechanisms involved and suggest probable etiologies, prognosis, and therapy. Similarities between animal models that demonstrate reflex physiology and neonates with motor automatisms and tonic posturing suggest that these clinical behaviors may not be epileptic in origin but, rather, primitive movements of progression and posture mediated by brainstem mechanisms. Although not all clinical behaviors currently considered to be neonatal seizures may have similar pathophysiological mechanisms, they are clinically significant because they all indicate brain dysfunction.     

Valproate Monotherapy in the Management of Generalized and Partial Seizures

Summary: For decades, therapeutic tradition has promoted the concept of polypharmacy in the management of epilepsy. In recent years, however, studies have shown that, for most patients, monotherapy can provide comparable or better seizure control than administration of multiple anticonvulsants, while diminishing the potential for adverse reactions, drug interactions, and poor compliance. Valproate is an important monotherapeutic agent that is highly effective in the control of idiopathic primary and secondarily generalized epilepsies, and partial seizures that do not generalize. Comparative studies have found that valproate is at least as effective as phenytoin and carbamazepine in the treatment of generalized and partial seizures. Given the similar efficacy, other factors such as pharmacokinetics and side effects may therefore determine anticonvulsant selection for monotherapy.     

Un nouveau cadre conceptuel de travail pour la psychiatrie

In an attempt to place psychiatric thinking and the training of future psychiatrists more centrally into the context of modern biology, the author outlines the beginnings of a new intellectual framework for psychiatry that derives from current biological thinking about the relationship of mind to brain. The purpose of this framework is twofold. First, it is designed to emphasize that the professional requirements for future psychiatrists will demand a greater knowledge of the structure and functioning of the brain than is currently available in most training programs. Second, it is designed to illustrate that the unique domain which psychiatry occupies within academic medicine, the analysis of the interaction between social and biological determinants of behavior, can best be studied by also having a full understanding of the biological components of behavior.     

Special Pharmacokinetic Considerations in Children

Summary: Pediatric patients have greater degrees of pharmacokinetic variability and unpredictability than adults. This variability results from the effects of pharmacogenetics, age and growth, prior and current comedication, and disease. Newborns with seizures have the least predictable dosage requirements, and their needs change as drug-eliminating mechanisms mature in the neonatal period. Infants have the highest relative capacities to eliminate antiepileptics of any age group and require the largest relative doses. In addition to age-related trends, children demonstrate the same drug-specific, pharmacokinetic phenomena that adults do, including nonlinear phenytoin elimination, nonlinear valproate binding, and autoinduction of carbamazepine. Intercurrent illness and drug interactions further modify the age-related pharmacokinetic patterns in children and make dosage requirements even more unpredictable. Recent studies have shown that febrile illness can affect drug elimination, sometimes decreasing drug levels by 50% or more. Intermittent treatment with benzodiazepines administered either orally or rectally can be an important adjunct and help minimize this type of problem for children with marginally controlled epilepsy. Intermittent benzodiazepines are also helpful for children who have febrile seizures and who need only occasional antiepileptic protection.