异丙酚复合瑞芬太尼应用于单肺通气麻醉的临床研究

目的：研究异丙酚复合瑞芬太尼联合应用单肺麻醉时对肺内分流、PaO2、清醒的影响．方法：选择胸外科行肺叶切除24例病人，随机分为两组，A组：异丙酚复合瑞芬太尼静脉全麻组12例；B组：异丙酚复合吸入异氟醚麻醉组12例。A组：静脉泵注异丙酚50μg／kg/min与瑞芬太尼0．05μg／kg/min混合液维持麻醉；B组：静脉泵注芬太尼0．05μg/kg／min与氟派利多2．5μg/kg／min混合液、复合吸人异氟醚1％～2％维持麻醉，分别在麻醉前、TLV 30min（TLV1），OLV 30min、OLV 60min．再次TLV 30min（TLV2）、手术结束等5个时点抽取动脉血和混合静脉血进行血气分析。结果：OLV开始后，Qs／Qt于TLV时高于麻醉前与TLV1时，OLV 30min、60min时Qs／Qt达最高，B组在OLV 30min、OLV 60min时，Qs／Qt高于A组（P〈0．01）。结论：异丙酚和瑞芬太尼联合麻醉能改善动脉血氧和减少肺内分流，且容易清醒。     

Risk and risk factors for epilepsy in shunt-treated children with hydrocephalus

ObjectEpilepsy is a major comorbidity in children with hydrocephalus (HC) and has a serious impact on their developmental outcomes. There are variable influencing factors, thus the individual risk for developing epilepsy remains unclear. Our aim was to analyse risk factors for developing epilepsy in children with shunted HC.MethodsA retrospective, single-centre analysis of 361 patients with the diagnosis of HC was performed. Age at HC diagnosis, shunt treatment, development of epilepsy, epilepsy course, and the aetiology of HC were considered. The influence of shunt therapy, including its revisions and complications, on the development of epilepsy was investigated.ResultsOne-hundred forty-three patients with HC (n = 361) had a diagnosis of epilepsy (39.6%). The median age at the first manifestation of epilepsy was 300 days (range:1–6791; Q1:30, Q3: 1493). The probability of developing epilepsy after HC decreases with increasing age. The most significant influence on the development of epilepsy is that of the HC itself and its underlying aetiology (HR 5.9; 95%-CI [3–10.5]; p < 0.001). Among those, brain haemorrhage is associated with the highest risk for epilepsy (HR 7.9; 95%-CI [4.2–14.7]; p < 0.01), while shunt insertion has a lower influence (HR 1.5; 95%-CI [0.99; 2.38]; p = 0.06). The probability of epilepsy increases stepwise per shunt revision (HR 2.0; p = 0.03 after 3 or more revisions). Five hundred days after the development of HC, 20% of the children had a diagnosis of epilepsy. Shunt implantation at a younger age has no significant influence on the development of epilepsy nor does sex.ConclusionChildren with HC are at high risk for developing epilepsy. The development of epilepsy is correlated mainly with HC's underlying aetiology. The highest risk factor for the development of epilepsy seems to be brain haemorrhage. The age at shunt implantation appears to be unrelated to the development of epilepsy, while structural brain damage at a young age, shunt revisions and complications are independent risk factors. The onset of epilepsy is most likely to take place within the first 500 days after the diagnosis of HC.     

Transcatheter ductus arteriosus stenting in paediatric cardiology: Indications,results and perspectives

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Occlusion of the Modified Blalock–Taussig Shunt: Unique Methods of Treatment and Review of Catheter‐based Intervention

Objective. To report unique methods of treatment and review catheter‐based intervention for occluded modified Blalock–Taussig shunts (BTS). Methods. Case reports and articles involving children undergoing catheter‐based treatment for occluded modified BTS were reviewed. Results. Literature review detailed 38 patients in whom occluded modified BTS were treated with 39 catheter‐based interventions. Thrombolytics alone were delivered by catheter in 13 cases. Balloon angioplasty was performed in 23 cases, 5 with stent implantation. Both thrombolytic delivery and angioplasty were performed in 3 cases, 2 with stent implantation. Intervention was initially successful at re‐establishing modified BTS patency in 35/39 (90%) of cases. Patency could not be established in 2 patients who then proceeded to the operating for surgical shunt revision. Two deaths occurred during the procedures. Three cases at Emory University demonstrate uncommon or unique instances of catheter‐based intervention: (1) declotting of a shunt in a patient supported by extracorporeal membrane oxygenation (ECMO); (2) declotting of a shunt via a right axillary arterial approach; and (3) declotting of a shunt using a carotid arterial (ECMO) cannula for percutaneous access. Conclusions. The use of catheter‐based techniques for the treatment of BTS occlusion is highly successful, and potentially avoids high‐risk re‐operative intervention. ECMO can provide for a stable patient during the procedure. Hopefully, with improved technology and innovative procedures, more children in the future with BTS occlusion can be served by successful percutaneous intervention.     

Cardiovascular disorders in patients with congenital portosystemic shunts: 23 years of experience in a tertiary referral centre

Central illustration. Time of occurrence and outcome of cardiovascular disorders in patients (pts) with congenital portosystemic shunt (CPSS). Patients with normal anatomy and those with congenital heart disease (CHD) were distinguished. Heart failure (HF) was the main symptom in both the prenatal and neonatal periods, whereas portopulmonary hypertension (PPH) and hepatopulmonary syndrome (HPS) represented the major concerns beyond the first months of life. CV: cardiovascular; NAS: no additional symptoms; PH: pulmonary hypertension; RD: respiratory distress. ^aFetal diagnosis of CPSS. ^bNeonatal diagnosis of CPSS. ^cDiagnosis of CPSS > 1 month of age

     

特发性正常压力脑积水脑脊液标志物的变化

目的 探讨特发性正常压力脑积水（iNPH）病人脑脊液（CSF）磷酸化tau蛋白（p-tau）、总tau蛋白（t-tau）、转化生长因子-β1（TGF-β1）的变化。方法 前瞻性收集2018年6月至2020年2月经分流术临床确诊的16例iNPH为确诊组,同期行脑脊液释放试验无效的16例可疑iNPH为可疑组。采用酶联免疫吸附试验检测CSF中p-tau、t-tau、TGF-β1水平。结果 确诊组CSF中p-tau水平显著低于可疑组（P<0.01）,TGF-β1水平显著高于可疑组（P<0.01）。两组CSF中t-tau水平无统计学差异（P>0.05）。8例确诊iNPH术后7 d的CSF中p-tau、t-tau水平较术前均明显降低（P<0.05）,而TGF-β1水平与术前无统计学差异（P>0.05）。结论 本文结果提示CSF中p-tau、t-tau、TGF-β1在iNPH诊断、分流术效果评估中具有一定的作用。     

A peritoneal marker for optimal timing of ventriculo-peritoneal shunt revision in early childhood

Abstract

The ventriculo-peritoneal shunt placed in a neonate or infant needs revision to lengthen the peritoneal tube at certain times during childhood. The critical time for this revision is not exactly the same between individuals. Furthermore, the level of peritoneal insertion of the shunt tube is often unclear on x-ray films. To plan for and determine the optimal timing of revision, we applied a titanium clip on the peritoneal suture line in three infants as a marker of peritoneal insertion level. During the 31- to 37-month follow-up period, abdominal x-ray clearly demonstrated the peritoneal insertion level in all three patients, allowing accurate determination of the length of the intraperitoneal portion OP) of the shunt tube. The rate of shortening of the length of IP was 20 to 27% of the increase in body height (BH). This technique allows accurate determination of the length of IP and also optimal timing for revision. [Neural Res 1998; 20: 526-528]     

Postural function in idiopathic normal pressure hydrocephalus before and after shunt surgery: A controlled study using computerized dynamic posturography (EquiTest)

Introduction

Postural dysfunction is one of the major features of idiopathic normal pressure hydrocephalus (iNPH). With computerized dynamic posturography (CDP) balance can be assessed objectively. The primary aim of this study was to describe the postural function in iNPH patients pre- and post-operatively in comparison with healthy individuals (HI) using CDP.

Subjects and methods

Thirty-five patients (16 M, 19 F) with a mean age of 73 (range 49–81) with iNPH, and sixteen HI (7 M, 9 F) aged 73 (62–89) were included. iNPH patients were operated on with a ventriculo-peritoneal shunt. Patients and HI were tested regarding motor function, balance and cognition. CDP, EquiTest (NeuroCom International, Clackamas, OR), was performed before and three months after shunt surgery and twice in HI, with a three-month interval.

Results

Pre-operatively, the 35 patients had poorer balance measured with the Sensory Organizing Test (SOT) score in every condition (p = 0.01 in SOT 1 and p < 0.001 in SOT 2–6) compared to the HI. The greatest difference was in test conditions measuring mainly vestibular function, where loss of balance (LOB) was frequent. Twenty patients were evaluated three months after shunt surgery and 18/20 (90%) of them were considered shunt responders, with a mean improvement of motor score of 26% (range 5–67%). There was an improvement post-operatively in the weighted composite SOT score (p < 0.05) but no significant change in any of the SOT conditions. LOB was not significantly reduced in any of the test conditions.

Conclusion

CDP showed that the patients had a poorer balance than the HI. The greatest difference was in SOT 5–6, indicating that the postural disturbance is of primarily central vestibular origin. There was a slight improvement of balance post-operatively.