血清心肌肌钙蛋白I诊断川崎病急性期心肌损伤的临床价值

为探讨血清心肌肌钙蛋白I(cTnI)诊断川崎病(KD)急性期心肌损伤的临床价值。检测KD组(n=40)及对照组(n=23)患儿血清cTnI、肌酸激酶(CK)、肌酸激酶同功酶(CK-MB)、乳酸脱氢酶(LDH)与谷草转氨酶(GOT)浓度。结果显示①KD组与对照组血清CK、LDH、GOT浓度无显著性差别(P＞0.05);而血清cTnI、CK-MB浓度明显高于对照组水平(P＜0.001)。②在诊断KD患儿急性期心肌损伤上cTnI优于CK-MB(P＜0.05),。结果表明cTnI与CK-MB对KD患儿急性期心肌损伤有诊断价值;与CK-MB比较,cTnI具有高特异性、灵敏度。     

呼吸道合胞病毒感染病程中肌酸激酶同工酶的动态变化及意义

目的 探讨心肌肌酸激酶同工酶（CK-MB）在呼吸道合胞病毒（respiratory syncytial virus,RSV）感染中的动态变化规律,并分析CK-MB/CK对于心肌损害的诊断价值.方法 2010年至2013年在本院住院RSV感染伴有CK-MB/CK＞ 5％的患儿,共577例,其中男317例,女260例,年龄2～18个月,其中心肌损害共44例,比较伴有心肌损害与未伴有心肌损害RSV感染患儿的CK-MB动态变化规律,并对采用营养心肌治疗和常规治疗的患儿CK-MB进行对比分析,采用受试者操作特征曲线分析CK-MB/CK对心肌损害的预测价值.结果 RSV感染患儿约46.5％伴有CK-MB异常,少数（3.5％）伴有心肌损害,伴有心肌损害与未伴有心肌损害RSV感染患儿CK-MB达到高峰及持续异常时间不同,未伴有心肌损害患儿是否营养心肌治疗CK-MB差异无统计学意义（P＞0.05）,CK-MB/CK预测心肌损害曲线下面积为0.663（95％ CI 0.578,0.747）.结论 CK-MB在小儿RSV感染过程中有其固有的变化规律,对于心肌损害的诊断价值低.     

危重症患儿胰岛素抵抗与心肌损害的临床相关性研究

目的：危重症患儿多伴明显的胰岛素抵抗和心肌损害。本研究探讨危重症患儿胰岛素抵抗与心肌损害的关系。方法：选取2010年3月至2011年6月住院治疗的危重症患儿63例为病例组,测定空腹血糖、血清胰岛素及心肌酶、肌钙蛋白I（CTnI）水平,同时计算胰岛素抵抗指数（HOMA-IR）。HOMA-IR>1.0 者归入胰岛素抵抗组（30例）,HOMA-IR≤1.0者归入非胰岛素抵抗组（33例）。同时选取健康儿童30例作为对照组。结果：胰岛素抵抗组患儿的HOMA-IR、乳酸脱氢酶（LDH）、天门冬氨酸氨基转移酶（AST）、肌酸激酶（CK）、肌酸激酶同工酶（CK-MB）、α-羟丁酸脱氢酶（α-HBDH）、CTnI水平均明显高于非胰岛素抵抗组及对照组,差异有统计学意义（均P<0.05）;非胰岛素抵抗组患儿的LDH、AST、CK、CK-MB、α-HBDH、CTnI水平明显高于对照组,差异有统计学意义（均P<0.05）。胰岛素抵抗组患儿的HOMA-IR与LDH、CK、CK-MB、AST、α-HBDH、CTnI水平呈正相关（分别r=0.697,0.739,0.781,0.642,0.381,0.792,均P<0.05）。结论：胰岛素抵抗可以加重心肌损害,HOMA-IR可以作为心肌损害程度的预测指标。     

血浆N端B型脑钠肽水平在脓毒症合并心肌损伤患儿中的临床诊断价值

目的 本研究旨在探讨N端B型脑钠肽（N-terminal pro brain natriuretic peptide,NT-proBNP）在脓毒症合并心肌损伤患儿中的临床诊断价值.方法 将2013年1月1日至6月30日入住我院PICU的162例确诊脓毒症的患儿按照是否发生心肌损伤分为非心肌损伤组和心肌损伤组,其中心肌损伤组61例（37.65％）,非心肌损伤组101例（62.35％）,入院24 h内对162例脓毒症患儿进行NT-proBNP、乳酸脱氢酶、肌酸激酶同工酶（CK-MB）、肌钙蛋白Ⅰ（cTnⅠ）、肌红蛋白（MB）等检测,比较心肌损伤组与非心肌损伤组间NT-proBNP值,分析NT-proBNP与CK-MB、cTnⅠ、MB的相关性.结果 心肌损伤组NT-proBNP水平[M（Q）,3 632（668.5,15 453.5） pg/ml]高于非心肌损伤组[349（169,1 500） pg/ml],差异有统计学意义（Z=91.881,P=0.000）.NT-proBNP、CK-MB、cTnⅠ、MB为非正态分布资料,经对数转换后进行相关分析,logNT-proBNP与logCK-MB（r=0.367,P=0.000）、logcTnⅠ（r =0.304,P=0.001）、logMB（r=0.302,P=0.000）均呈正相关.以NT-proBNP≥1 163 pg/ml为截断点诊断心肌损伤,敏感性76％,特异性74％.结论 NT-proBNP可用来帮助诊断脓毒症合并心肌损伤.     

Myocardial Ischaemia in Aphyxia Neonatorum

ABSTRACT. Serial electrocardiograms and creatine kinase (CK) isoenzyme activities were studied prospectively in 20 asphyxiated term newborn infants and 43 normal neonates. By adapting a previously described grading system for ischaemic changes, a degree of electrocardiographic ischaemia was defined which occurred almost solely in asphyxiated infants. Infants with this degree of abnormality had signficantly higher mean CK-MB and MM activities than other asphyxiated infants at 0, 8 and 28 hours. Histological changes of peripartum myocardial necrosis were seen in 4 of the 5 infants on whom an autopsy was performed, and either electrocardiogram or CK-MB was abnormal in all four. It is concluded that myocardial injury in the newborn period is often associated with CK-MB release, but in view of the lack of cardiac-specificity of CK-MB in newborn infants, caution is urged in the interpretation of elevated isoenzyme activity in the neonate.     

Myocardial ischaemia in asphyxia neonatorum. Electrocardiographic, enzymatic and histological correlations

Serial electrocardiograms and creatine kinase (CK) isoenzyme activities were studied prospectively in 20 asphyxiated term newborn infants and 43 normal neonates. By adapting a previously described grading system for ischaemic changes, a degree of electrocardiographic ischaemia was defined which occurred almost solely in asphyxiated infants. Infants with this degree of abnormality had significantly higher mean CK-MB and MM activities than other asphyxiated infants at 0, 8 and 28 hours. Histological changes of peripartum myocardial necrosis were seen in 4 of the 5 infants on whom an autopsy was performed, and either electrocardiogram or CK-MB was abnormal in all four. It is concluded that myocardial injury in the newborn period is often associated with CK-MB release, but in view of the lack of cardiac-specificity of CK-MB in newborn infants, caution is urged in the interpretation of elevated isoenzyme activity in the neonate.     

Patterns and risks in spinal trauma.

BACKGROUND: Spinal injury in children is rare, and poses many difficulties in management. AIMS: To ascertain the prevalence of spinal injury within the paediatric trauma population, and to assess relative risks of spinal injury according to age, conscious level, injury severity score (ISS), and associated injuries. METHODS: Spine injured children were identified from the UK Trauma Audit & Research Network Database from 1989 to 2000. Relative risks of injury were calculated against the denominator paediatric trauma population. RESULTS: Of 19 538 on the database, 527 (2.7%) suffered spinal column fracture/dislocation without cord injury and 109 had cord injury (0.56% of all children; 16.5% of spine injured children). Thirty children (0.15% of all children; 4.5% of spine injured children) sustained spinal cord injury without radiological abnormality (SCIWORA). Cord injury and SCIWORA occurred more commonly in children aged < or =8. The risk of spine fracture/dislocation without cord injury was increased with an ISS >25 and with chest injuries. The risk of cord injury was increased with reduced GCS, head injury, and chest injury. CONCLUSIONS: Spinal cord injury and SCIWORA occur more frequently in young children. Multiple injuries and chest injuries increase the risk of fracture/dislocation and of cord injury. Reduced GCS and head injuries increase the risk of cord injury.     

Cardiac troponin T in neonates after acute and long-term tocolysis

The present study was designed to determine the levels of cardiac troponin T (cTnT) in cord blood of neonates exposed in utero to tocolytic therapy by beta-sympathomimetics. cTnT in 40 neonates after acute tocolysis (0.24 +/- 0.05 microg/l) was significantly higher (p < 0.05) in comparison with the control group (0.05 +/- 0.01 microg/l). The maximal values were reached in about the 3rd day of therapy (0.39 +/- 0.11 microg/l). cTnT in 30 neonates after long-term tocolysis was 0.12 +/- 0.03 microg/l. No correlation was found between cTnT and CK and its isoenzyme CK-MB or ECG. CK, unlike cTnT, significantly correlated with gestational age (r = 0.57, p < 0.05) and birth weight (r = 0.55, p < 0.05). It is possible to conclude that acute tocolytic therapy by beta-sympathomimetics increases the cTnT levels in cord blood and cardiac troponin T is more useful for the laboratory diagnosis of neonatal myocardial injury than CK-MB.     

血浆miRNA-497在小儿脓毒症心肌损伤中的表达及其临床意义

目的 探讨血浆miRNA-497在小儿脓毒症心肌损伤中的表达及其临床意义。方法 纳入148例脓毒症患儿,依据其是否发生心肌损伤分为心肌损伤组（58例）和非心肌损伤组（90例）,比较两组血浆miRNA-497、心肌肌钙蛋白I （cTnI）、肌酸激酶同工酶（CK-MB）、N末端B型钠尿肽前体（NT-proBNP）、降钙素原（PCT）、C-反应蛋白（CRP）水平及左室射血分数（LVEF）的变化。绘制受试者工作特征曲线（ROC）,评价血浆miRNA-497、cTnI、CK-MB对心肌损伤的诊断价值。应用Pearson相关分析法分析miRNA-497与cTnI、CK-MB、NT-proBNP、PCT、CRP及LVEF的相关性。结果 心肌损伤组血浆miRNA-497、cTnI、CK-MB、NT-proBNP、PCT及CRP水平均明显高于非心肌损组（P < 0.05）。血浆miRNA-497、cTnI、CK-MB及三项联合诊断心肌损伤的曲线下面积（AUC）分别为0.918、0.931、0.775、0.940。miRNA-497的最佳阈值为2.05时,其诊断心肌损伤的敏感度和特异度较好,分别为90.4%和91.2%。相关分析显示,心肌损伤患儿血浆miRNA-497与cTnI的相关性较好（r=0.728,P < 0.01）。结论 血浆miRNA-497对小儿脓毒症心肌损伤的诊断价值与cTnI相当,有望作为早期诊断心肌损伤的潜在标志物。     

Lung injury resulting from a nonaccidental crush injury to the chest

A six-week-old infant presented with rib trauma and a lung contusion from a nonaccidental compressive chest injury. He developed an illness consistent with diffuse alveolar damage, which worsened over 26 hours. This was complicated by a pneumomediastinum, and the patient recovered with conservative management. The value of isotope bone scanning in addition to x-rays is discussed. Nonaccidental injury should be considered in the differential diagnosis of a pulmonary contusion.     

Myocardial cell injury is common in children with septic shock

Objective: To determine the prevalence of myocardial cell injury in children with septic shock by estimating the levels of biochemical markers of myocardial injury, troponin I (TnI) and creatine kinase MB (CK-MB).
Patients: Children aged 3 months to 16 years were admitted to paediatric intensive care unit (PICU) with septic shock. Children with sepsis without shock and children with hypovolaemic shock were enrolled as controls.
Measurements and Main Results: Serum TnI and CK-MB levels were measured at admission and serially at 24 h, 48 h and 96 h in children with septic shock, while baseline measurement of the same markers was taken from the controls. In total, 88% (15/18) of children with septic shock had elevated TnI levels compared with 25% (5/20) with sepsis and 6.7% (1/15) with hypovolaemic shock (p < 0.001). Serial TnI levels at admission, 24 h, 48 h and 96 h were higher in the nonsurvivors. There was a positive correlation between the baseline TnI levels and the predicted mortality using the paediatric index of mortality (PIM2) scores at admission (r = 0.51, p = 0.03).
Conclusion: A majority of children with septic shock have evidence of myocardial cell injury. The estimation of serum TnI levels may help in better prognostication of children with septic shock.     

Pleuro-pulmonary involvement in children with blunt splenic trauma

OBJECTIVE: Evaluation of the importance of pleuro-pulmonary involvement in paediatric patients with blunt splenic trauma. METHOD: A retrospective chart review of 27 patients, aged 2-16 years, treated for blunt splenic injury between 1992 and 1999 was performed. RESULTS: All patients except one were treated conservatively. In 12 patients (44.4%) left-sided pleuro-pulmonary involvement was diagnosed as primary traumatic injury or as a late complication. While Grade I and II splenic injuries were prevalent, pleuro-pulmonary involvement patients had a more severe degree of splenic injury. Chest pain, dyspnoea and diminished respiratory sounds were present on primary examination in patients with chest trauma. Body temperature during the first 5 post-trauma days was significantly higher among pleuro-pulmonary involvement patients. Specific pleuro-pulmonary involvement diagnoses on admission in six children with primary chest trauma were: lung contusion, pleural thickness, or haemo-pneumothorax. Three of them developed delayed pleural effusion. In the other six children with pleuro-pulmonary involvement, late complications appeared during 2-5 days post-trauma. CONCLUSIONS: Pleuro-pulmonary involvement was observed in almost half of patients with blunt splenic trauma. Pleuro-pulmonary involvement occurred either early as a result of direct chest trauma or was delayed. High suspicion, careful monitoring of body temperature and repeated chest X-ray studies are recommended for early diagnosis and treatment of delayed pleuro-pulmonary involvement.     

轻度窒息新生儿动态心电图及心肌酶变化的临床研究

目的 探讨轻度窒息新生儿动态心电图（AECG）、心肌酶变化特点及其临床意义.方法 选取2011年6月至2013年8月我院新生儿科收治的轻度窒息新生儿为窒息组,同期选择本院分娩的30例健康新生儿为对照组,均于生后24h内行AECG检查,于出生18 ～24 h内抽取静脉血测定血清肌酸磷酸激酶（CK）、血清肌酸磷酸激酶同工酶（CK-MB）、血清乳酸脱氢酶（LDH）、血清谷草转氨酶（AST）、心肌肌钙蛋白（cTnI）.结果 窒息组（46例）与对照组（30例）新生儿AECG窦性心律指标（最慢心率、最快心率、平均心率）差异均无统计学意义（P＞0.05）;窒息组ST段改变及心律失常等其他几项综合指标（包括房早、房速、室早、Q-T间期延长、交界性逸搏）异常发生率高于对照组（65.2％比16.7％,89.1％比13.3％,P均＜0.01）.窒息组心肌酶指标及cTnI值均高于对照组[CK（604.7±275.4）比（162.0±95.1）,CK-MB（87.9±61.0）比（28.3±27.1）,LDH（686.0±383.5）比（310.7±133.5）,AST （95.0±63.1）比（35.2±13.9）,cTnI（0.12±0.11）比（0.02±0.01）,P均＜0.01].窒息组CK、CK-MB、LDH、AST异常发生率高于对照组（63.0％比16.7％,82.6％比6.7％,95.7％比20.0％,32.6％比6.7％,P均＜0.01）.结论 轻度窒息新生儿AECG监测可发现各种心律失常、ST段改变,其心肌酶亦明显高于正常新生儿,ST段改变及CK-MB的升高是诊断轻度窒息新生儿心肌损伤的可靠依据.     

Commotio cordis. The single, most common cause of traumatic death in youth baseball

Two cases of blunt chest trauma caused by a baseball are reported, including one death. At least one of these was in consequence of cardiac concussion or commotio cordis, an entity not described in teh pediatric literature. Concussion of the heart is a functional injury, in contrast to cardiac contusion or cardiac rupture, which pertains to structural injury. However, a cardiac concussion appears more likely to have immediate, dire consequences than the structural injury of cardiac contusion. Both of the cases presented occurred in the Little League baseball setting. Blunt chest trauma is reported to cause two to three deaths in youth baseball each year. There appears to be an increased pediatric susceptibility to this type of injury. Unfortunately, these cases are quite resistant to resuscitative therapy. Devices and techniques for primary and secondary prevention exist, but have yet to be systematically verified and implemented.     

N-acetyl-cystein-(NAC)-activated creatinkinase (CK) and isoenzyme CK-MB in the serum of children

We have examined the variation of creatinekinase levels (NAC-activated) with age in 170 children. The subjects included 40 neonates, 18 premature neonates, 40 small babies, 32 infants and 40 schoolchildren. The enzyme activity of CK-MM was very high in the first hours after delivery and remained high for a few days. The isoenzyme MB in healthy newborns also showed a higher catalytic concentration. These values (about 2-12 U/l) reached normal levels of adults within 4 months of life (0.5-5 U/l). The same rule applied to CK-MM: enzyme activities of 160 U/l and more in the first days of life declined to 16-75 U/l during the first 4 months. No correlation between birth trauma and the increase in serum-CK was found. Because of the increased CK-MM (and CK-MB) found in normal newborns screening for Duchenne-type muscular dystrophy should be postponed for a few weeks after delivery. In view of the relatively high endogenous serum CK-MB in the neonates (release of CK-MB from the skeletal muscle) the test lacks the specificity for cardiac damage. Intramuscular injections of several drugs lead to a distinct increase in CK activity. A rise of CK-MM was seen 4-24 h after catheterization of the heart.     

重症监护室脓毒症患儿心肌损伤的临床研究

目的 探讨重症监护室脓毒症患儿心肌损伤的发生率,心肌肌钙蛋白I(cTnI)及CK-MB水平升高与心肌损伤、多器官功能障碍综合征(MODS)、病死率及与急性生理和慢性健康状况Ⅱ(APACHE Ⅱ)评分的关系,分析cTnI、CK-MB、APACHE Ⅱ在评价危重脓毒症患儿预后中的作用.方法 回顾性分析459例脓毒症患儿血清cTnI、CK-MB水平与MODS、心肌损伤、机械通气时间、ICU住院时间和病死率的关系.分别测定脓毒症患儿入院时、入院第3天、第7天血清cTnI及CK-MB水平,比较不同时间点酶学升高组和酶学正常组的APACHE Ⅱ评分、ICU病死率和30 d生存率.结果 459例危重病脓毒症患儿中205例(44.7%)发生心肌损伤[cTnI和(或)CK-MB升高],cTnI、CK-MB升高患儿的病死率远远高于cTnI、CK-MB未升高患儿(26.34% vs 2.36%),机械通气发生率(46% vs 21%)和持续时间(7.5 d vs 3.2 d),以及住院时间(11.9 d vs 5.3 d)均显著增高,血清cTnI、CK-MB水平与APACHE Ⅱ评分之间存在显著正相关.患儿入院时、入院24～72 h和入院第7天,酶学升高组APACHE Ⅱ评分、ICU病死率均明显高于酶学正常组(Pa＜0.05);而30 d生存率低于正常组(P＜0.01).结论 血清cTnI、CK-MB水平升高提示危重患儿心肌损伤的发生.血清 cTnI、CK-MB 在评价危重病患儿预后中发挥重要作用.血清cTnI、CK-MB和APACHE Ⅱ评分升高的患儿其病死率、MODS发生率、机械通气发生率及住院时间均显著增加.     

病理性黄疸对新生儿心肌的影响

目的 探讨病理性黄疸对新生儿心肌组织的影响.方法 以2005年1-11月本科住院的38例病理性黄疸新生儿为研究对象,同期32例生理性黄疸新生儿为对照组.检测二组新生儿总血清胆红素(采用钒酸盐法)、心肌酶(采用酶学速率法)、心肌肌钙蛋白(cTnI)(采用化学发光免疫分析法)、心脏超声心动图及心电图,同时观察临床表现,组间比较采用t检验,相关性分析采用Pearson分析.结果 1.二组新生儿血清AST、LDH、羟丁酸脱氢酶(HBDH)、CK水平均增高,磷酸肌酸激酶同工酶(CK-MB)水平与临床标准相符,CK-MB/CK ＜6%.二组之间血清心肌各酶、cTnI无显著差异(Pa>0.05).2.观察组恢复期血清LDH、HBDH明显降低,与急性期比较差异显著(Pa<0.05),AST、CK、CK-MB与急性期比较均无显著差异(Pa>0.05).3.急性期血清胆红素与心肌酶、cTnI均无明显相关(Pa＞0.05).4.二组新生儿心脏超声心动图及心电图均无明显异常改变,临床无明显心肌受损症状及体征.结论 新生儿病理性黄疸对心肌无明显损害.对早期新生儿诊断心肌损伤仅依据其心肌酶谱、cTnI值增高是不够的,还要根据新生儿临床表现及心脏彩超、心电图改变,并结合新生儿日龄全面分析,综合判断.     

Serious and fatal air gun injuries: more than meets the eye

OBJECTIVE: To describe the epidemiology of air gun injuries to children that required hospitalization. DESIGN: A consecutive series of children with air gun injuries. SETTING: Urban pediatric teaching hospitals in Cincinnati, OH; Kansas City, MO; and Seattle, WA. METHODS: A retrospective chart review. RESULTS: A total of 101 children were studied: 81% were male; 80% were white, 18% were black, and 2% were other races. The median age was 10.9 years (range, 0.5 to 18.8). Victims were most commonly shot by a friend (30%) or sibling (21%). A total of 34% occurred at the victim's home, and 36% occurred at the home of a friend or relative. Although 71% of shootings were unintentional, 5% were assaults, and 1% were suicides. The median hospital stay was 3 days (range, 1 to 17 days). Fifteen children (15%) required treatment in intensive care. A total of 56% required at least one surgical procedure. Forty-nine had injuries to the head, including 38 with injuries to the eye, 10 with intracranial injuries, and 1 with a skull injury. Fourteen children were shot in the neck; 15 were shot in the chest, with 2 patients sustaining lacerations of the pericardium and 1 having a right ventricular foreign body. Another child had a laceration of the innominate artery. Nineteen had abdominal injuries, including laceration of the stomach (N = 3), small bowel (N = 4), colon (N = 2), and liver (N = 3). Three of 10 children with intracranial injuries died. Two had long-term neurologic deficits. Of children with eye injuries, 25 (66%) had permanent visual loss and 15 (39%) of these were blind. CONCLUSION: Air guns are associated with serious and fatal injuries. Families should be counseled that air guns may cause serious injuries and even death. Furthermore, pediatric care givers should advocate for increased regulation of air guns and expansion of safety standards.     

Traumatic chest injury in children: A single thoracic surgeon's experience in two Nigerian tertiary hospitals

Background:

This study was to determine the extent and outcome of childhood chest injury in Nigeria, and to compare results with that of other literatures.

Patients and Methods:

A Prospective study of all children under 18 years of age with chest trauma in two tertiary hospitals in Southern Nigeria from January 2012 to December 2014 was reviewed. The aetiology, type, associated injury, mechanism, treatment and outcome were evaluated. The patients were followed up in the clinic. The data were analysed using SPSS version 20.0 with a significant P < 0.05.

Results:

Thirty-one patients (12.1%) under 18 years of age of 256 chest trauma patients were managed in the thoracic units. The mean age was 9.78 ± 6.77 years and 27 (87.1%) were male. The aetiology in 13 was from falls, 10 from automobile crashes, 3 from gunshots, 4 from stabbing and 1 from abuse. The highest peak of chest injury was on Saturday of the week and April of the year. The pleural collections are as follows: 15 (71.4%) was haemothorax, 4 (19.1%) pneumothorax, 2 (9.5%) haemopneumothorax and 18 patients had lung contusion in combination or alone with the pleural collections. Seven patients who presented >12-h versus 2 who presented <12-h and 6 of children between 0 and 9 years versus 3 at 10-18 years of age had empyema thoracis (P value not significant). One death was recorded.

Conclusion:

Chest trauma in children is still not common, and blunt chest injury from falls and automobile accidents are more common than penetrating chest injury. Treatment with tube thoracostomy is the major management modality with empyema thoracis as the most common complication.Key words: Thoracic trauma, chest injury, children, thoracic surgeon, Nigeria