Objective:To investigate the effect and mechanisms of mitochondrial dynamic-related protein 1(Drp1)on the in-flammatory response after intracerebral hemorrhage(ICH)in mice.Methods:Western blot was used to detect the expressions of Drp1 and phosphorylated Drp1(p-Drp1)in brain tissues after ICH,and the optimal concentration of selective Drp1 inhibitor(Mdivi-1)were screened.The mice were randomly divided into sham group,ICH group,ICH+solvent control group(ICH+Vehicle group)and ICH+Mdivi-1 group.The neurological function was evaluated by mNSS,the content of brain water was measured by wet-dry weight method,HE and Nissl staining were used to observe the morphological changes of brain tissues,neutrophil infiltration were observed by MPO staining,and the expression of inflammatory cytokines(IL-6,TNF-α)and mitochondrial membrane marker proteins TOM20,COX4Ⅰ1 were detected by Western blot.Results:Compared with sham group,the expression of p-Drp1 was significantly increased at 12 h after ICH(P<0.01).Compared with ICH+Vehicle group,the neurological function score(P<0.01)and brain water content(P<0.05)of ICH+Mdivi-1 group were increased,the protein expressions of IL-6 and TNF-α and the number of MPO positive cells around hematoma in ICH+Mdivi-1 group were significantly increased(P<0.05),and the expressions of mitochondrial membrane proteins TOM20 and COX4Ⅰ1 in ICH+Mdivi-1 group were significantly elevated(P<0.01).Conclusion:Inhibition of Drp1 can inhibit mito-chondrial division and aggravate inflammatory injury after ICH in mice.Therefore,Drp1 may reduce the inflammation after ICH.

目的 探讨儿童帽状腱膜下血肿(SGH)合并血友病的临床特点,为临床早期识别该病提供帮助,减少临床对血友病的漏诊及其带来的不良结局.方法 回顾性分析2015年1月—2021年1月重庆医科大学附属儿童医院收治的22例SGH患儿的临床资料.按照是否合并血友病分为合并组(n=7)和未合并组(n=15),对比两组的临床特点.结果 合并组患儿中,血友病轻型3例,中间型2例,重型2例.合并组跌伤/摔伤后头部包块6例(6/7,85.7％),未合并组车祸伤/跌伤/高坠伤后发现头部包块8例(8/15,53.3％).未合并组中位年龄7.0岁(最大15.0岁,最小1.3 d),合并组中位年龄0.9岁(最大5.0年,最小2.8 d),P=0.005;未合并组中位病程时间2.0 d(最长15.0 d,最短0.2 d),合并组中位病程时间7.0 d(最长5.0年,最短0.5 d),P=0.032;未合并组中位血红蛋白107 g/L(最高145 g/L,最低82 g/L),合并组中位血红蛋白69 g/L(最高92 g/L,最低58 g/L),P=0.001;未合并组入院中位活化部分凝血活酶时间(APTT)31.8 s(最长34.0 s,最短24.9 s),合并组中位活化部分凝血酶时间62.7 s(最长124 s,最短42 s),P=0.000;未合并组外伤后合并颅骨骨折/颅内出血8例(53.3％),合并组3例(42.9％).结论 相对于单纯性SGH,合并血友病的SGH患儿发病年龄小,以婴幼儿为主,病程较长,入院查血提示血红蛋白低,APTT延长,SGH合并血友病的类型以轻、中间型为主;跌伤/摔伤为血友病患儿形成SGH的主要诱因.早期识别该病有助于尽早干预,尽可能减少因血友病漏诊带来的不良结局.

目的 探讨基于角色扮演的线上线下混合式教学法在儿外科学生临床教学中的应用价值.方法 选取2020年12月—2021年5月重庆医科大学附属儿童医院儿外轮转实习学生44名,随机分为角色扮演组(23名)和传统教学组(21名).角色扮演组结合线上线下混合式教学法,采用基于角色扮演教学法的PBL教学,传统教学组进行传统PBL教学.采用两独立样本t检验比较两组的学习成绩、学生教学反馈评分等指标,以Mann-Whitney U检验比较PBL教学评价.结果 角色扮演组学习成绩、PBL教学评价均优于传统教学组,角色扮演组在教学反馈评价各项也明显优于传统教学组,差异有统计学意义(P<0.05).结论 基于角色扮演的线上线下混合式教学法能够增强学习体验,提升学习效果,促进价值观塑造,同时优化教学资源,在临床教学中值得应用.

目的 探讨可调压抗虹吸分流装置在颅内生殖细胞肿瘤(IGCTs)所致脑积水治疗中的意义及远期移除分流装置的可行性.方法 重庆医科大学附属儿童医院神经外科2013年1月—2017年12月间42例拟诊为IGCTs伴梗阻性脑积水患儿,均采用可调压抗虹吸分流装置行脑室腹腔分流术(VPS),术后予以行诊断性化疗;回顾性分析其中20例在肿瘤达到完全缓解后行分流装置移除术的诊疗过程.结果 行VPS术后,20例患儿的高颅压症状均获得显著缓解,无症状加重者.术后复查CT或MRI显示脑室系统正常;眼底检查未见明显损害情况,术前视力模糊者术后视力逐渐恢复正常,现视力与同龄人相仿.治疗过程中未见分流装置堵塞、感染病例,予以诊断性化疗,肿瘤获得完全缓解,6～12个月后行分流装置夹闭或移除术,随访36～92个月,20例患者均未出现颅内高压症状.至随访结束时均已入学,生活质量未见明显影响.结论 IGCTs所致梗阻性脑积水行VPS早期可以快速降低颅压,缓解颅内高压症状,降低颅内压持续升高而发生脑疝的风险.术后经诊断性化疗,在肿瘤获得完全缓解后,可行分流装置移除术,降低分流装置堵塞、感染、断裂等风险,避免患儿终生留置体内分流装置,可有效提高患儿生活质量.

Objective To study the normal reference values of intracranial pressure and cerebral perfusion pressure in children of different ages. Methods A retrospective study was conducted on the children with simple epidural hematoma who received hematoma removal and implantation for intracranial pressure monitoring in our department from January 2015 to June 2022.The intracranial pressure and arterial blood pressure of the children were monitored per hour after surgery, and the changes in intracranial pressure and cerebral perfusion pressure were analyzed based on time and age in different age groups.The intracranial pressure and cerebral perfusion pressure in stable period (72 h after surgery) were used as the relative normal reference values, and the 95% range of intracranial pressure and cerebral perfusion pressure were calculated statistically by percentile method as the reference range. Results A total of 207 children were included in this study, including 25 in the < 2-year-old group, 82 in the 2~6-year-old group and 100 in the >6-year-old group.Intracranial pressure in different age groups was increased rapidly after a short period of low level, while cerebral perfusion pressure experienced a short period of high level, and both reached a peak and a trough from 12 to 24 h after surgery, and gradually reached a stable range at 72 h after surgery.The range of intracranial pressure 72 h after surgery was 3.0~8.0 mmHg for the < 2-year-old group, 5.0~11.0 mmHg for the 2~6-year-old group, and 6.0~14.0 mmHg for the >6-year-old group.Cerebral perfusion pressure range was 50.9~68.7, 55.0~73.3, and 57.3~79.6 mmHg, respectively for the above 3 age groups. Conclusion The normal ranges of intracranial pressure and cerebral perfusion pressure are different in children of different ages, and we suggest increasing with age.

迷走神经刺激术(vagus nerve stimulation,VNS)是一种安全有效的神经调控治疗手段,在药物难治性癫痫(drug refractory epilepsy,DRE)治疗中的应用较多.VNS不仅可以降低DRE患儿的癫痫发作频率,还有利于患儿的神经发育和社会认知功能改善.近年来,VNS用于治疗儿童DRE的研究越来越多,但儿童VNS术后参数的调控尚无统一标准,VNS治疗癫痫的具体作用机制尚不明确.本文综述VNS治疗儿童DRE的临床疗效、对社会认知和生活质量的改善以及术后参数调控.

Influenced by a combination of genetic and environmental factors, neural tube defects (NTDs) are the most common congenital malformations of central nervous system.Such important genes in key signaling pathways of neural tube closure as SHH, PCP, folate metabolism and inositol metabolism correlated closely with the occurrence of NTDs.They regulate the occurrence of NTDs through gene mutations, gene interactions and epigenetic modifications.Additionally such environmental factors as nutritional deficiency and exposure during pregnancy play an important role in the occurrence of NTDs.This review focused on the latest etiological researches of NTDs to provide practical references for further researches, preventions and treatments of NTDs.

Objective:To explore the clinical characteristics and essentials of diagnosis and treatment in children with Apert syndrome (AS).Methods:From January 2016 to December 2020, clinical data were reviewed for 16 AS children. There were 8 boys and 8 girls with a median age of 10(4-60) months. All of them had multiple malformations at birth, including craniofacial deformities and finger/toe deformities. There were abnormal skull shape (n=16) , syndactyly of hands and feet (n=16) , premature closure of coronary sutures (n=10) , exopthalmos (n=8) , cleft palate (n=7) and cardiac malformations (n=3). Also a literature review was performed.Results:Except for one abandoning case, the remainders underwent operations. The median number of surgical years (length of time between initial surgery and the last surgery) was 18.5(4-64) months and the average number of operations was 2.8(1-5). Postoperative recovery was excellent and both morphology and function significantly improved as compared previously. Cranial deformity was corrected at 3 months to 2 years. In conjunctions with a literature review, complete skull deformity correction was recommended before 6 months and mid-facial depression deformity correction at (6-7) years.Conclusion:Frequently misdiagnosed clinically, AS should be differentiated from associated simple malformations or other syndromic types of craniosynostosis. Gene detection aids in making a definite diagnosis. The overall goal is to correct malformations and restore functions as much as possible.

目的 探讨基于马克思主义哲学基本原理的线上线下混合式教学模式在儿外科临床教学中的应用价值.方法 选取2020年9月至2021年6月该院儿外轮转的学生49人,随机分为混合教学组(24人)和传统教学组(25人).混合教学组采用基于马克思主义哲学基本原理的线上线下混合式教学模式进行教学查房+融入马克思主义哲学原理的以问题为导向的学习(PBL)教学,传统教学组采用传统教学查房和传统PBL教学.比较两组学生的测试成绩、教学查房质量评分、PBL教学评分、教学反馈评价等指标.结果 混合教学组测试成绩、教学查房质量评分、PBL教学评分均优于传统教学组[(92.75±2.31)分vs.(85.40±5.43)分、(8.80±0.54)分vs.(8.05±0.55)分、(8.45±0.55)分vs.(7.85±0.58)分],且在各项教学反馈评价方面也明显优于传统教学组,差异均有统计学意义(P<0.05).结论 基于马克思主义哲学基本原理的线上线下混合式教学模式能够优化教学资源,融入课程思政元素,提升学习效果和学生综合素质,值得推广.

Objective:To investigate the clinical features and surgical outcomes of temporal lobe tumors in children with epileptic seizures as initial symptom.Methods:The clinical data of 27 children with temporal lobe tumors and epileptic seizures as initial symptom who underwent surgery in the Neurosurgery Department of the Children′s Hospital of Chongqing Medical University from January 2013 to January 2020 were retrospectively analyzed. The children underwent clinical follow-up after operation, and the effect of seizure control was evaluated by the Engel grading standard. According to the pathological results, the patients were divided into benign tumor group[World Health Organization (WHO) grade Ⅰ] and malignant tumor group(WHO grade Ⅱ-Ⅳ). The general data and seizure outcomes of the two groups were compared.Results:Total tumor resection was achieved in all 27 children, of whom 18 patients underwent lesion resection and standard anterior temporal lobectomy, and 9 underwent extended lesion resection. The pathological results revealed 5 cases of oligodendroglioma (WHO grade Ⅱ), 5 cases of dysembryoplastic neuroepithelial tumor (WHO grade Ⅰ), 4 cases of pilocytic astrocytoma (WHO grade Ⅰ), 4 cases of desmoplastic infantile astrocytoma and ganglioglioma (WHO grade Ⅰ), 4 cases of ependymoma (WHO grade Ⅱ), 3 cases of meningioma (WHO grade Ⅰ), 1 case of ganglioglioma (WHO grade Ⅰ) and 1 case of anaplastic ependymoma (WHO grade Ⅲ). All 27 children were followed up after operation, and the median follow-up time was 36 months (12-96 months). At the last follow-up, there were 21 cases (77.8%) of Engel grade Ⅰ, 5 cases (18.5%) of Engel grade Ⅱ, and 1 case (3.7%) of Engel grade Ⅲ. Compared with the malignant tumor group, the children in the benign tumor group were younger ( P=0.040), and there were no statistical differences between the two groups in gender, epilepsy duration, tumor growth location in the temporal lobe, or postoperative outcome of seizure control (all P>0.05). The proportions of benign tumor group and malignant tumor group reaching Engel grade Ⅰ after operation were 14/17 and 7/10 respectively. Conclusions:Preliminary observation has suggested that among the children with temporal lobe tumors and epileptic seizure as initial symptom who underwent surgical treatment, oligodendrocyte tumor and dysembryoplastic neuroepithelial tumor are most common. The tumors are mostly benign and malignant tumors are mostly low-grade. After surgical resection of the tumor, the postoperative effect of seizure control seems satisfactory.

Objective:To investigate the clinical effect of flexible neuroendoscopy-assisted drilling irrigation and external drainage in the treatment of subdural effusion complicated with purulent meningitis in infants.Methods:A retrospective analysis was conducted on the clinical data of 40 infants with purulent meningitis complicated with subdural effusion who were admitted to the Department of Neurosurgery, Children′s Hospital of Chongqing Medical University from January 2016 to December 2020. According to the different treatment methods, 40 children were divided into an endoscopy group (treated by burr hole irrigation and external drainage assisted by flexible neuroendoscopy, 20 cases) and a control group (treated by skull burr hole drainage, 20 cases). The general data, clinical manifestations, treatment-related indicators and complications of the two groups were compared.Results:There was no significant difference between the endoscopy group and the control group in gender, age, course of disease, clinical manifestations, location of effusion, or preoperative cerebrospinal fluid-related indicators (all P>0.05). The improvement time of symptoms and cerebrospinal fluid indicator (the white blood cell count in the cerebrospinal fluid returning to the normal range) in the endoscopy group were earlier than those in the control group (postoperative symptom improvement time: 4.4±2.3 d vs. 8.7±3.0 d; cerebrospinal fluid indicator improvement time: 6.3±3.5 d vs. 13.2±5.2 d). Postoperative anti-infective treatment time [ M ( Q1,Q3)] in the endoscopy group was shorter than that in the control group[11.5 (8.3, 14.0) d vs. 19.0 (14.0, 27.3) d]. All the differences above were statistically significant ( P<0.001). In terms of postoperative complications, there were 5 cases (25%) of secondary subarachnoid hemorrhage and cerebral contusion in the control group, and 0 cases (0%) in the endoscopy group. Conclusion:For purulent meningitis complicated with subdural effusion, infants treated with flexible neuroendoscopy-assisted burr hole irrigation and external drainage can achieve better clinical outcomes compared with skull burr hole drainage.

目的 探讨高保真情景模拟教学在儿科住院医师规范化培训(简称住培)中的作用及意义.方法 选重庆医科大学附属儿童医院 2017 级和 2018 级共两届儿科第一年住院医师共 168 名(每届 84 名)作为研究对象,随机分配为观察组和对照组,每届每组 42 人,观察组采用高保真模拟设备教学,对照组采用普通模型教学.采用评分法和迷你临述评估(mini-clinical evaluation exercise,Mini-CEX)对两组住院医师的总体表现和临床思维能力进行评估.培训结束时对两组的指导医师和住院医师发放问卷,进行满意度调查.结果(1)两组住院医师在模拟教学之前评分无明显差异,模拟教学之后评分均有提高,但观察组评分提高程度明显高于对照组,差异有统计学意义(P<0.05).(2)观察组Mini-CEX评分提高程度高于对照组,两组比较差异有统计学意义(P<0.05).观察组住院医师在临床思维能力以及在问诊技巧、人文关怀和沟通技能上得到了显著的提升,对病患的诊疗更加有效.(3)住院医师在临床思维能力提高的满意度方面,观察组得分更高,差异有统计学意义(P<0.05).结论 高保真情景模拟教学法有利于住院医师临床思维能力的培养,人文关怀和沟通技能提升更显著.

入科教育是住院医师规范化培训过程中的第一环节,良好的入科教育能使规培医师高效快速地完成临床教学实践任务.选取神经外科2019年7—12月出院病历(1375份),按照首页质控、框架质控和终末质控的数据进行整理和分析,结果在病案首页质控中与出院诊断有关的错误20处(28.17％);框架质控中与签名有关的错误35处(53.85％);终末病案质控与签名有关的错误35处(53.85％).依据病案质控分析中暴露出的问题,对新入科规培医师进行有针对性的入科教育,有效提高了规范化培训的教学质量.

室管膜瘤起源于脑室内壁和脊髓中央管的室管膜细胞[1],可出现在神经轴任何部位,发生在各年龄阶段.儿童室管膜瘤75％发生在后颅窝,25％发生在幕上脑室系统和脑实质内[2],其中发生在幕上脑实质内室管膜瘤(supraten-torial cortical ependymoma, SCE)少见,约占 3.5％～5.7％[3].回顾性分析重庆医科大学附属儿童医院 2012 年 1 月至2020 年12 月收治的16 例SCE 临床资料,结合相关文献分析其临床表现、影像特点、治疗及预后,现报告如下.

Cerebral hemispherical damage surgery is indicated for children with drug resistant epilepsy caused by hemispheric lesions.It is intended to cut off the connection between affected hemisphere and the rest of nervous system.It offers a decent prognosis for refractory epilepsy with specific indications.Currently there are numerous clinical trials.However, systematic literature review is lacking.This review summarized the latest therapeutics of intractable epilepsy in children with cerebral hemisphere damage surgery.

目的 探讨动态对比增强磁共振(dynamic contrast-enhanced perfusion MRI,DCE-MRI)在儿童髓母细胞瘤(medulloblastoma,MB)鉴别诊断中的初步应用价值.方法 收集2019年9月至2020年10月重庆医科大学附属儿童医院初诊后颅窝肿瘤患儿34例,进行常规MRI平扫+增强和DCE-MRI检查,生成常规及血流动力学参数图像.图像经后处理获得容量转移常数(Ktrans)、速率常数(Kep)、血管外/细胞外间隙容积分数(Ve)、血浆容积分数(Vp)值,并行统计学分析.结果 34例初诊后颅窝肿瘤患儿中,经术后病理学诊断髓母细胞瘤16例,毛细胞型星形细胞瘤(pilocytic astrocytoma,PA)10例,间变型室管膜瘤8例,其中髓母细胞瘤(0.907±0.246、0.627±0.313、0.963±0.397)与间变型室管膜瘤(0.273±0.046、0.091±0.027、0.115±0.077)在感兴趣区(region of interest,ROI)Ve最大值、ROI Vp最大值、ROI Ktrans平均值均有统计学差异(P<0.01),在ROI Ktrans第90百分位(P90)值、对照区(region of contract,ROC)Ktrans最大值、ROC Kep最大值、ROC Ve平均值均有统计学差异(P<0.05);髓母细胞瘤(2.320±0.695)与毛细胞型星形细胞瘤(0.725±0.455)在ROI Kep最大值有统计学差异(P<0.01),在ROI Kep第90百分位(P90)值有统计学差异(P<0.05).结论 DCE-MRI能够准确地显示病变血流动力学变化,从而通过多种参数准确地对髓母细胞瘤与其他后颅窝肿瘤进行鉴别诊断.

儿童创伤疾病是小儿外科住院医师规范化培训(简称住培)的重点内容之一.目前,国内儿童医院大多未创建创伤外科,对不同脏器的创伤疾病大多收治在各个专科病房,住院医师创伤疾病培训多是各个专科独立、分散性培训.医院成立儿童创伤外科是发展趋势,有利于对住院医师进行儿童创伤疾病的集中、全面培训.该文阐述了儿童创伤外科住培的相关经验.

Objective:To investigate the preoperative evaluation and treatment methods of non-firearm penetrating brain injury (PBI) in children.Methods:A retrospective analysis was performed. The clinical data of 18 children with non-firearm PBI admitted to our hospital from January 2012 to December 2020 were collected.Results:CT angiography was performed in 10 patients and MRI in 8 patients before treatment. CT angiography indicated that the intracranial large vessels were not injured by the foreign bodies. The foreign bodies of 7 patients were removed by craniotomy and the foreign bodies of 3 patients were removed directly under general anesthesia; the foreign bodies of 8 patients were removed directly outside the hospital without anesthesia. Cerebrospinal fluid leakage was noted in 4 patients and intracranial infection in 7 patients after surgery; no foreign body residue or intracranial hemorrhage after surgery was noted. After 3-69 months of follow-up, 3 patients had visual decline, one had limited eye movement, and one had olfactory decline.Conclusion:CT angiography is a safe and effective evaluation method for children with non-firearm PBI, and direct extraction of foreign body under general anesthesia is a feasible surgical method when CT angiography shows that the blood vessels are not hurted by the foreign bodies.

目的 探讨以临床实践能力为核心构建新的儿外科临床型研究生培养模式的方法和效果.方法 建立新的儿外科临床型研究生培养模式,以提高学生临床实践能力为导向,通过实施"导师负责制",设置特色教学课程,引入现代化模拟教学等方法,强化临床教学管理,提高学生综合素质.通过对比不同年级学生形成性评价成绩和OSCE考核成绩,并分析师生问卷调查结果,评价新培养模式的效能.结果 新的培养模式能有效促进儿外科临床型研究生临床实践能力的提高,在教师评价和学生评教中获得一致认可.结论 以提高临床实践能力为核心构建的临床教学新模式能切实增强儿外科临床型研究生的临床思维和工作能力,有利于为社会输送更多更好的"实用性人才",值得在同类医学院校推广应用.

新型冠状病毒肺炎疫情防控期间,医学院校面临如何安全、有效开展教学工作的难题.重庆医科大学儿科学院以网络教学平台为依托,开展混合式线上教学,顺利完成了《小儿外科学》的教学任务,并获得了满意的教学效果.该文就突发公共卫生事件期间网络教学平台和混合式线上教学的应用及其重要意义进行了初步探讨.