儿童肝未分化性胚胎性肉瘤误诊分析

对儿童肝未分化性胚胎性肉瘤(UESL)疾病增加认识,提高其诊断率及生存率。对2006年1月~2015年8月笔者所在医院的11例UESL患儿的临床资料进行回顾性分析。从诊断学角度分析其误诊原因及随访资料。11例患儿中,男性6例,女性5例,年龄最小为3.5岁,最大12.5岁。10例术前出现误诊,误诊为肝母细胞瘤7例,肝脏囊性占位2例,肝包虫病1例,主要误诊原因为:患儿临床症状、影像学及血清学检查无明显特异性,医生主观对此病认识不足等。UESL为儿童少见肝脏恶性肿瘤,术前诊断困难,容易误诊。治疗上首先考虑手术切除,有针对性的联合化疗方案可改善其预后。行早期诊断,早期治疗,对提高患儿生存率有重大意义。     

小儿输尿管息肉诊治经验探讨

探讨小儿输尿管息肉的临床及影像学特点,减少漏诊误治。回顾性分析2005年9月~2015年9月笔者所在科室收治及外院转入的36例输尿管息肉患儿临床资料,男28例,女8例,左侧29例,右侧6例,双侧1例,均有不同程度的肾盂分离,合并结石8例,因外院漏诊延期手术8例。36例患儿均行手术治疗,手术及术后病理证实均为输尿管息肉。术后6个月、12个月、24个月复查静脉肾盂造影(IVP)肾积水减轻或消失,随访6个月~10年,患儿腹痛症状消失,肾积水未再反复,未见息肉复发。小儿输尿管息肉起病较为隐匿、症状不典型、易合并泌尿系结石、肾积水不重,常误诊为肠系膜淋巴结炎、肠痉挛或单纯性泌尿系结石而误诊漏诊,需引起临床重视。     

儿童难治性肺炎支原体肺炎的治疗

儿童难治性肺炎支原体肺炎(RMPP)大环内酯类抗生素耐药率较高,但临床应用大环内酯类抗生素不一定无效,可能与其抗炎作用密不可分,故目前临床上仍是治疗儿童肺炎支原体肺炎(MPP)首选抗菌药物。RMPP出现肺大片实变、肺不张、并发支气管扩张或有肺外并发症时,使用糖皮质激素治疗已基本达成共识。MPP患者,应尽早应用孟鲁司特钠治疗,减轻气道慢性炎症,减轻咳嗽症状,改善肺功能,降低哮喘发生率。丙种球蛋白不常规推荐用于普通MPP的治疗,对伴有严重肺外并发症的RMPP患儿,静注丙种球蛋白联合糖皮质激素治疗,疗效会更佳。对RMPP疗程长,治疗后炎性指标持续升高,应注意混合感染的可能,选择敏感抗生素治疗。纤维支气管镜的应用,可减少气道炎症因子、防治气道闭塞以及解除肺不张,减轻或降低RMPP并发症及后遗症的发生。较多文献报道中西医结合治疗的有效率明显高于单纯西药治疗。     

不同剂量重组人干扰素α2b注射液对小儿病毒性肺炎的疗效研究

探讨不同剂量重组人干扰素α2b注射液治疗小儿病毒性肺炎的临床疗效。将病毒性肺炎患儿106例随机分为高剂量组、低剂量组和对照组。三组均接受病毒性肺炎常规治疗,高剂量组和低剂量组加用重组人干扰素α2b注射液20万U/kg·次、10万U/kg·次静脉滴注,疗程1周。高剂量组、低剂量组症状改善时间短于对照组,总有效率明显高于对照组(P0.05),高剂量组、低剂量组总有效率、住院时间无统计学差异,三组不良反应发生率无统计学差异(P0.05)。治疗后高剂量组患儿T细胞亚群优于低剂量组患儿,低剂量组患儿T细胞亚群优于对照组患儿(P0.05)。结果表明重组人干扰素α2b注射液可以调节患儿T细胞亚群,治疗小儿病毒性肺炎效果较好。但10万U/kg·次和20万U/kg·次临床疗效并无统计学差异。     

甲状腺功能亢进症合并烟雾病2例报道并文献复习

探讨甲状腺功能亢进症（甲亢）合并烟雾病的发病机制、临床特点、治疗方法及预后.回顾性分析报道2例甲亢合并烟雾病患者的临床表现、诊疗经过及预后,结合文献分析.甲亢合并烟雾病较为罕见,2例患者均为青年女性,主要表现为以脑梗死为主的脑缺血症状,临床症状均发生于甲状腺毒症期,控制甲亢及血管重建术等治疗可以有效改善神经系统缺损症状,预防复发.对拟诊烟雾病患者筛查甲亢,有脑血管病症状的甲亢患者行脑血管影像学检查,以利于早期发现,综合治疗,预防复发.     

左乙拉西坦与丙戊酸钠分别治疗婴幼儿癫痫综合征的疗效观察

探讨左乙拉西坦治疗婴幼儿癫痫综合征的临床疗效和对患儿智能发育的影响。选择确诊为癫痫综合征的87例患儿,随机分为治疗组44例,对照组43例,治疗组给予左乙拉西坦、对照组给予丙戊酸钠,治疗6个月后评价癫痫控制情况。在治疗前、治疗后6个月、12个月分别采用婴幼儿智力发育量表检测智力发育指数(MDI)和运动发育指数(PDI)评估患儿智能发育情况。治疗组41例完成治疗,症状完全控制29例、好转10例、无效3例,总有效率92.86%;对照组39例完成治疗,症状完全控制28例、好转9例、无效3例,总有效率94.87%;两组总有效率无显著差异(P0.05)。治疗前、治疗后6个月时段两组患儿MDI和PDI值无统计学差异(P0.05);治疗12个月后,治疗组患儿的MDI和PDI明显高于对照组,两组有统计学差异(P0.01)。左乙拉西坦治疗婴幼儿癫痫综合征的临床疗效与丙戊酸钠相同;且左乙拉西坦治疗对婴幼儿癫痫患者的智力及运动发育有一定改善作用。     

妊娠合并结核临床诊治的决策

妊娠合并结核是一种对母婴健康危害极大的妊娠期疾病。在妊娠期结核病中,多数患者无明显症状,早期症状与妊娠期某些生理反应相似,加之妊娠与结核病的相互影响,x线、CT等重要的影像学检查受限,致使本病易被误诊或误治。某些抗结核药物对母婴的不良影响,使其治疗难以实施,由于结核病本身及治疗后可能对胎儿的影响,在临床上是否终止妊娠往往难以决策。本文就妊娠合并结核诊治过程中的相关问题进行综述,以期为临床诊治决策提供帮助。     

颈部横切口外翻式颈动脉内膜切除术治疗颈动脉狭窄

讨论采用颈部横切口,实施外翻式颈动脉内膜切除术在治疗颈动脉粥样硬化性狭窄性疾病中的疗效。总结2009年4月1日到2009年10月20日共10例患者临床资料,分析术前术后的影像学资料和临床症状的比较。手术均获成功,患者术后临床症状均改善,术后影像学资料显示狭窄部位均获得完全改善。术后3个月,切口处皮肤基本没有麻木感。外翻式颈动脉内膜切除术在治疗颈动脉狭窄中,具有手术时间短、术后再狭窄率低、增厚内膜及斑块剥离彻底等优点,应用改进的颈部横切口,切口沿皮肤自然皱纹,并采用皮内缝合方法,术后不用拆线,既达到美观效果,又可以明显缩短患者住院时间。     

超声心动图与心血管造影X线引导下先心病介入封堵治疗的比较

目前先天性心脏病介入治疗已成为介入心脏病学的新热点,而先心病介入治疗离不开影像学引导,目前临床上常用的影像学引导方式主要有超声心动图和心血管造影两种,本文针对两者优缺点,从治疗方式、疗效、费用等方面进行比较,为临床治疗思路提供借鉴。     

颈部横切口外翻式颈动脉内膜切除术治疗颈动脉狭窄

讨论采用颈部横切口,实施外翻式颈动脉内膜切除术在治疗颈动脉粥样硬化性狭窄性疾病中的疗效.总结2009年4月1日到2009年10月20日共10例患者临床资料,分析术前术后的影像学资料和临床症状的比较.手术均获成功,患者术后临床症状均改善,术后影像学资料显示狭窄部位均获得完全改善.术后3个月,切口处皮肤基本没有麻木感.外翻式颈动脉内膜切除术在治疗颈动脉狭窄中,具有手术时间短、术后再狭窄率低、增厚内膜及斑块剥离彻底等优点,应用改进的颈部横切口,切口沿皮肤自然皱纹,并采用皮内缝合方法,术后不用拆线,既达到美观效果,又可以明显缩短患者住院时间.     

Improving adherence to medication regimens for children with asthma and its effect on clinical outcome.

We examined the effects of a combined education and token system intervention to improve adherence to inhaled corticosteroids for an 8-year-old girl and a 10-year-old boy with asthma. Adherence was measured by an electronic chronolog monitor, and disease outcome was assessed by repeated pulmonary function testing. A withdrawal design demonstrated improved adherence and, for 1 child, an associated improvement in pulmonary function occurred. Methodological and clinical implications are discussed, including variables other than adherence that may affect disease outcome.     

Sliding doors: some reflections on the parent–child–therapist triangle in parent work–child psychotherapy

The parental presence as therapy agents, namely as a medium and support for the therapeutic process, is one of the paradoxical parameters of working with children. Parental presence serves as a reminder of the need to find a balance between inner and outer reality. The door that is closed in the therapy room leaves a parent on the other side but at the same time provides the child’s inner world with more latitude to reveal itself. This paper examines the fabric of relations created in the therapeutic parent–child–therapist triangle (analogous to Britton’s conceptualisation of the parent–parent–child link). How does this triangular connection affect the ability to be with the silent self (Winnicott) when the parent remains (tangibly and symbolically) on the other side of the therapy door? This paper presents two clinical examples to illustrate the complex fabric of relations created in the therapeutic parent–child–therapist triangle and the interactions between the internal and external reality of the parent–child relationship.     

Nymphet or Lolita? A Gender Analysis of Online Child Pornography Websites

ABSTRACT

Previous research on child pornography has primarily focused on the consumption and distribution of the material – the consumer side. In this study, we turn the focus on the content of child pornography websites. While some research assessed the content, there was little consideration of gender. This paper assesses whether gender is important in correlating the presence of images of child exploitation in websites. The 300 websites examined were either directly, or indirectly connected to a known child pornography website. Results suggest that, although the majority of websites in the sample were oriented toward boy-related content, 1) the presence of girl keywords, and 2) an indicator of the sexualization of young girls were both associated with websites known to contain illegal images.     

MOURNING THE LOSS BUILDS THE BOND: PRIMAL COMMUNICATION BETWEEN FOSTER,ADOPTIVE, OR STEPMOTHER AND CHILD

In this article, a particular source for the gifts and agonies of non-biological mothering bonds will be examined, namely the losses both mother and child bring to the new bond-building endeavor. As many women choose non-biological parenting because they are unable to have children of their own, the degree to which they grieve their loss is a factor in their capacity to fully attach with foster, step or adoptive children. On the other side of the connection, many agonies that mothers endure result from the use of projective identification by the child to communicate the devastating feelings due to losses experienced prior to engaging with this new caretaker. The child, too, needs to make peace with these losses, to have them acknowledged so that s/he can move on to new developmental pains and gains. On neither side of the interaction can the attachment process be taken for granted: both mother and child have to work at belonging to one another. Often the feelings which permeate the intersubjective space between mother and newly-claimed child seem like insurmountable obstacles because of their unconscious, primitive or preverbal nature.The mother may be called upon to contain and bear witness to the child's profound distress, which can undermine her confidence as a mother. Similarly the child may be subject to the mother's unconscious fantasies about the child she wished she'd had, and experience the futility of living up to such expectations.This piece is an attempt to delineate the pitfalls, due to not-yet-mourned losses, on the way to mutual recognition on the part of mother and child in non-biological bonds.     

Destruction and guilt: Splitting and reintegration in the analysis of a traumatised patient

The author traces in detail how, in the analytic relationship, she was slowly able to read aspects of the trauma as 'quotations' and gradually, through transference, transform them into a symbolic language. Split-off aggression and guilt feelings became progressively accessible to interpretation through transferential projective identifi cations. During his analysis, the patient discovered he was the child of Nazi criminals: on his mother's side they were the third generation; on his father's side, the second.     

Gender Policing in the Clinical Setting: Discussion of Sandra Silverman’s “The Colonized Mind: Gender,Trauma, and Mentalization”

This is a discussion of Sandra Silverman’s clinical paper “The Colonized Mind: Gender, Trauma, and Mentalization.” Her patient, David née Ava, started early in life as a gender variant child. In adolescence, she became more stereotypically gender conforming. She entered treatment with Silverman as a young adult who was feeling great shame about both her past and present gender dysphoria. This discussion focuses on the clinical problem of gender policing, its external and internal manifestations as well as its appearance in the countertransference.     

Parent–Child Discrepant Effects on Positive Youth Outcomes at the Aggregate Family Functioning Context in Hong Kong

Prior investigations concerning the influence of parent–child discrepancies in family functioning on child development seldom examined different family functioning components, e.g., parenting and family processes, in a single study, or they predominantly emphasized the negative side of child outcomes, e.g., delinquencies and psychological problems. What’s more, most studies considered parent–child discrepant effects independent of aggregate nature of the family dynamics under study and also did not consider any potential factors’ role in mediating the relationship. To fill in the research gap, a sample of 223 Chinese parent-youth dyads, in which the youth were mainly in their middle and late adolescence as well as young adulthood, was surveyed to examine the effects of parent–child discrepancies in family functioning in terms of effective parenting and positive family processes on the youths’ positive outcomes, i.e., self-control and other perspective taking behavior. In the current study, youth self-concept was included as a mediator, and the aggregate nature of family functioning components was taken into account. Results affirmed the adverse effects of parent–child discrepancies on the two positive youth outcomes directly or indirectly through self-concept. However, these adverse effects are found to be contingent on the aggregate family functioning. Implications and future study directions are also discussed.     

Child Sexual Abuse

Summary

Children who are recent victims of sexual abuse may initially present to their primary care health provider. Often, the outward manifestations of sexual abuse are somatic complaints or nonspecific behavioral changes. Retrospective reports of adults suggest that about 20-30% of women were sexually abused as children, with figures for men ranging from 10-15%. Interview guidelines for children and adolescents emphasize the need for sensitivity to cognitive development and emotional issues while simultaneously being focused on eliciting specific behavioral data. The use of anatomically detailed dolls, in the context of a comprehensive assessment, is discussed. Health care providers are mandated reporters and must disclose suspected child sexual abuse to the state's child protective service department. Guidelines for reporting as well as addressing this issue with parents are discussed.     

老年肺栓塞临床诊治进展

急性肺栓塞在老年患者中属于高发疾病,并可能严重危及生命,其危险因素、临床表现常因基础疾病的掩盖而造成误诊或漏诊。当患者出现特异性较高的易患因素及晕厥表现,应高度警惕肺栓塞的发生,并根据临床具体条件确定诊查策略,选择合适的诊断手段,尽早确定或排除诊断。抗凝治疗仍是所有肺栓塞患者的基本治疗方法,当血流动力学不稳定时,可以考虑启动溶栓治疗。老年肺栓塞的治疗更强调个体化施治以最大限度地提高治疗收益,降低治疗风险。     

Münchhausen by proxy syndrome in clinical child neuropsychology: a case presenting with neuropsychological symptoms.

Münchhausen by proxy syndrome (MBPS) is a rare but dramatic variant of child abuse. In MBPS adults, mostly the mother, invent, manipulate, or produce the child's illness, and as a consequence the child has to undergo numerous diagnostic or treatment procedures. Typically, valid information about the etiology of the child's illness is withheld by the parents, and reversible symptoms vanish, when the child and the responsible adults are separated. Although valid statistical data about the epidemiology of MBPS are not available, MBPS should be considered more often than normally recognized. Neurological and neuropsychological presentations including developmental delays and learning problems appear to be common among MBPS cases so that clinical child neuropsychologists should be aware of this problem and consider MBPS at least in some of the mysterious cases that come to their attention. The present study describes a case of MBPS in which neurological and neuropsychological symptoms predominate. It presents a MBPS variant that is characterized by developmental delays and learning problems induced by unnecessary isolation at home, hospitalization, and treatment procedures. In the present case MBPS was at first suspected following neuropsychological assessment, since some of the main features of non-authenticity of symptom presentation gave cause for suspecting deceptive behavior on the mother's (and possibly also on the maternal grandmother's) side.