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經典生酮飲食和改良阿特金斯飲食治療兒童難治性癲癇的效果比較

研究旨在比較改良阿特金斯飲食（Modified Atkins diet，MAD）和經典生酮飲食（Ketogenic diet，KD）在治療兒童難治性癲癇的療效、安全性和耐受性。研究納入 2011 年 3 月—2014 年 3 月就診的 1～18 歲難治性癲癇患者，將其隨機分配至一種飲食治療組（ClinicalTrials.gov，編號 NCT2100501）。癇性發作記錄被用于比較飲食治療后 3、6 個月癇性發作頻率與飲食治療前基線發作頻率。研究納入 KD 組 51 例患者，MAD 組 53 例患者。KD 組平均基線癇性發作百分比在治療后 3 個月（KD 組 38.6%，MAD 組 47.9%）和 6 個月（KD 組 33.8%，MAD 組 44.6%）均低于 MAD 組，但差異無統計學意義［3 個月，95%CI （24.1，50.8），P=0.291；6 個月，95%CI（17.8，46.1），P=0.255］。然而，在<2 歲患兒中，KD 組癇性發作控制效果優于 MAD 組。這些患者飲食治療開始的 3 個月內，KD 組癲癇無發作率高于 MAD 組，差異有統計學意義（KD 組 53%，MAD 組 20%，P=0.047）。MAD 組耐受性更好并且副反應更少。MAD 可能是治療兒童難治性癲癇的首要選擇，但經典 KD 更適合<2 歲患者的一線飲食治療方案。

新改良LeFort Ⅰ型截骨線在鼻旁凹陷畸形矯治中的應用

目的 總結新改良LeFort Ⅰ型截骨線在鼻旁凹陷畸形矯治中的應用。 方法 2008 年4 月－2009 年9 月，采用新改良LeFort Ⅰ型截骨線矯治3 例面中部發育不良鼻旁凹陷畸形女性患者。年齡18 ～ 26 歲。均表現為上頜后縮伴明顯鼻旁區凹陷及下頜前凸，為Angle Ⅲ類錯頜畸形。術前經正畸治療后，修正SNA 平均為73.6°，SNB 平均為82.7°。 結果 術中出血量400 ～ 600 mL，平均350 mL。術后切口均Ⅰ期愈合，無骨塊壞死等并發癥發生。3 例均獲隨訪，隨訪時間6 ～ 23 個月，平均15 個月。畸形無復發，面型穩定無變化，咬調整為Angle Ⅰ類咬。 結論 采用新改良LeFort Ⅰ型截骨線矯治鼻旁凹陷畸形效果理想。

全肝血流阻斷無血切肝技術的臨床應用

改良克氏針鋼絲內固定治療鎖骨骨折46例

Remodeling+Ring (modified Yacoub) technique for the treatment of bicuspid aortic valve regurgitation with ascending aortic aneurysm: A case report

Patients with bicuspid aortic valve are often complicated with aortic dilatation. If the aortic valve is of good quality, aortic root replacement with aortic valve preservation is feasible. A 35-year-old male patient with bicuspid aortic regurgitation complicated with ascending aortic aneurysm underwent Remodeling+Ring (modified Yacoub) operation. Echocardiography showed that there was no aortic regurgitation on the 3rd day after operation, and the patient was discharged satisfactorily on the 6th day after operation. Remodeling+Ring surgery ensures the physiological movement of the aortic valve, solves the enlarged annulus, avoids the problems caused by valve replacement, and significantly improves the quality of life of patients, which is worth popularizing.

MODIFIED REVERSE HOMODIGITAL ARTERY ISLAND FLAP FOR REPAIR OF FINGERTIP DEFECT

Objective To investigate the operative method and cl inical efficacy of repairing fingertip defect with modified reverse homodigital artery island flap. Methods From March 2000 to September 2006, 18 cases (24 fingers) of fingertip defect were treated, including 12 males and 6 females aged 18-53 years (mean 29 years). Defect was caused by crush injuries in 12 cases, by avulsion injury in 3 cases, by twist injury in 2 cases and by incised injury in 1 case. The time from injury tooperation was 2-8 hours (mean 4 hours). The location were index fingers (3 fingers), middle fingers (4 fingers) and ring fingers (17 fingers). The defects of soft tissue were 1.9 cm × 1.7 cm to 2.4 cm × 1.9 cm in size, the reverse homodigital artery island flaps were from 2.0 cm × 1.5 cm to 2.5 cm × 2.0 cm in size. The donor site was repaired with dumped skin grafting(3 cases) and with skin grafting from medial area of planta pedis (15 cases). Results Skin flaps and skin grafting of all the 24 fingers survived after operation. All incisions and donor sites healed by first intention. Sixteen patients (22 fingers) were followed up for 1-5 years (mean 3.2 years).The appearance and function of the flaps were all satisfactory. Two-point discriminations of flaps ranged from 4.5 mm to 6.3 mm. According to the total active movement/total passive movement assessment criteria, the results were excellent in 20 fingers and good in 2 fingers; and the excellent and good rate was 100%. The circumference of donor site was 2.0-3.5 mm shorter than that of normal side. The two-point discriminations of donor site was 7.8-10.5 mm. Conclusion Repairing defect of fingertip with modified reverse homodigital artery island flap can provide good texture and contour matching the recipient area, good function and l ittle trauma at donor site.

改良第一趾蹼皮瓣游離移植修復拇指指腹缺損

目的 總結吻合血管改良第1 趾蹼皮瓣游離移植修復拇指指腹缺損的療效。 方法 2008 年2 月－2011 年2 月，收治拇指指腹缺損12 例。男8 例，女4 例；年齡20 ～ 57 歲，平均32.9 歲。機器絞傷7 例，電刨傷3 例，壓砸傷2 例。新鮮創面10 例，受傷至入院時間為2 ～ 6 h；陳舊性創面2 例，均為拇指再植術后指腹壞死，于傷后13 d 及15 d 入院。創面范圍3.0 cm × 2.0 cm ～ 3.6 cm × 2.8 cm，采用吻合血管改良第1 趾蹼皮瓣游離移植修復，切取的改良皮瓣保留了趾蹼原有功能結構，皮瓣切取范圍3.4 cm × 2.3 cm ～ 4.4 cm × 3.0 cm；供區游離植皮或用穿支血管蒂足內側隱神經營養血管皮瓣修復。 結果 術后供、受區皮瓣和植皮均完全成活，切口Ⅰ期愈合。術后患者均獲隨訪，隨訪時間8 ～24 個月，平均10 個月。修復后拇指外形美觀，伸屈、對掌功能正常，感覺恢復至S3 4 例，S3+ 6 例，S4 2 例。 結論 吻合血管改良第1 趾蹼皮瓣游離移植修復拇指指腹缺損，外形、功能恢復好，供區損傷小，是較好的修復方法之一。

Modified Hueter direct anterior approach for treatment of Pipkin type Ⅰ and Ⅱ femoral head fractures

ObjectiveTo discuss the effectiveness of the modified Hueter direct anterior approach in treatment of Pipkin typeⅠ and Ⅱ femoral head fractures.MethodsBetween September 2014 and May 2016, 12 patients with Pipkin type Ⅰ and Ⅱ femoral head fractures were treated with the modified Hueter direct anterior approach. There were 8 males and 4 females, aged from 32 to 60 years (mean, 40.2 years). The disease causes included traffic accident injury in 9 cases and falling from height injury in 3 cases. According to Pipkin typing, 8 cases were rated as type Ⅰ and 4 cases as type Ⅱ. The interval of injury and admission was 2-28 hours (mean, 7.2 hours). Reduction was performed in all patients within 6 hours after admission, and then bone traction was given. The operation was performed in 3-7 days (mean, 4.3 days) after redution. The modified Hueter direct anterior approach was applied to expose and fix femoral head fractures by Herbert screws compressively. The operation time and intraoperative blood loss were recorded, and the effectiveness was evaluated according to the Thompson-Epstein scale at last follow-up.ResultsThe operation time was 80-130 minutes (mean, 97.5 minutes), and the intraoperative blood loss was 100-200 mL (mean, 130.2 mL). All fractures achieved anatomical reduction and successful fixation. All 12 patients were followed up 12-32 months (mean, 24.3 months). All patients achieved bone union in 15-20 weeks (mean, 16.3 weeks) and no wound infection, lateral femoral cutaneous nerve injury, osteonecrosis of the femoral head, or heterotopic ossification occurred. Traumatic arthritis occured in 3 patients. According to the Thompson-Epstein scale at last follow-up, the results were excellent in 5 cases, good in 5 cases, fair in 2 cases, and the excellent and good rate was 83.3%.ConclusionThe modified Hueter direct anterior approach has the advantages of clear anatomic structure, less trauma, and shorter operation time, and it can effectively expose and fix the Pipkin typeⅠ and Ⅱ femoral head fractures.

Midterm Follow-up of Modified Blalock-Taussing Shunts in the Treatment of Children with Tetralogy of Fallot

ObjectiveTo explore the midterm therapeutic effect of modified Blalock-Taussing shunts (MBTs) in the treatment of tetralogy of Fallot. MethodsWe retrospectively analyzed the clinical data of 69 children with tetralogy of Fallot undergoing MBTs in Shanghai Xinhua Hospital between July 2006 and January 2013. There were 44 males and 25 females with mean age of 17.97±24.73 months (ranged from 2 months to 10 years). The patients weighted from 4 to 24 (9.00±4.03) kg. All the MBTs between subclavian artery and pulmonary artery were performed through right or left posterior lateral incision. ResultsThe patients were followed up for 6-36 months including 57 patients with 6 months following-up, 33 patients with 6 months and 12 months following-up, 16 patients with 12 months and 24 months following-up, and 11 patients with 24 months and 36 months following-up. There was significant growth in McGoon ratio during the first 12 months follow-up (preoperative vs. 6 months:1.09 ±0.33 vs. 1.40 ±0.40, P=0.00; 6 months vs. 12 months:1.29±0.31 vs. 1.36±0.33, P=0.00). There was no obvious growth in McGoon ratio after 12 months (12 months vs. 24 month:1.22±0.31 vs. 1.19±0.32, P=0.14; 24 months vs. 36 months:1.22±0.23 vs. 1.23±0.20, P=0.45). The left ventricular end diastolic volume index (LVEDVI) increased significantly in 6 months after MBTs (preoperative vs. 6 months:29.60±10.12 ml/m2 vs. 49.18±11.57 ml/m2, P=0.00), but there was no significant growth after 6 months. There was no significant decline in left ventricular ejection fraction (LVEF) after MBTs. ConclusionThe MBTs can significantly promote the growth of McGoon ratio in 12 months of patients with tetralogy of Fallot, but there is no obvious growth of McGoon ratio after 12 months. MBTs can significantly improve left ventricular development within 6 months, and it won't lead to excessive expansion of the left ventricle when we extend follow-up time. The MBTs affects little on cardiac function of patients with tetralogy of Fallot.

Application and evaluation of modified pericardial oblique sinus approach in total anomalous pulmonary venous connection in neonates

Objective To analyze the use of modified pericardial oblique sinus approach in surgical repair for total anomalous pulmonary venous connection in neonates. Methods Between May 2005 and December 2015, 67 consecutive neonates with supracardiac or infracardiac type total anomalous pulmonary venous connection who underwent surgical repair in our institute were included in this study. The patients are divided into three groups according to the different approaches including a sulcus approach group (6 patients), a superior approach group (14 patients), and a modified pericardial oblique sinus approach group (47 patients). There were 53 males and 14 females at median age of 12.5 (7.0, 20.5) d. Results The time of cardiopulmonary bypass [88 (80.0, 107.0) min vs. 135 (121.0, 157.0) min, P<0.05] and aortic cross clamping of the modified pericardial oblique sinus approach group was significantly shorter than that of the sulcus approach group [45 (39.0, 53.0) min vs. 80 (73.0, 85.0) min, P<0.05]. Perioperative mortality (2.1% vs. 28.6%, P<0.05) was significantly lower in the modified pericardial oblique sinus approach group than that in the superior approach group. The long-term mortality (4.3% vs. 60.0%, P<0.05) was significantly lower in the modified pericardial oblique sinus approach group than that in the sulcus approach group or the superior approach group . The rate of pulmonary venous stenosis was significantly lower in the modified pericardial oblique sinus approach group than that in the sulcus approach group (2.1% vs. 50.0%, P<0.05) or superior approach group (2.1% vs. 35.7%, P<0.05). Conclusions In surgical correction of neonatal supracardiac and infracardiac total anomalous pulmonary venous, compared with the traditional surgical approach, the modified pericardial oblique sinus pathway can provide excellent surgical space and has a good surgical prognosis.