Contrast-enhanced ultrasound of a traumatic neuroma of the extrahepatic bile duct: A case report and review of literature.

BACKGROUND: Traumatic neuromas result from nerve injury after trauma or surgery but rarely occur in the bile duct. However, it is challenging to diagnose traumatic neuromas correctly preoperatively. Although some previous reports have described the imaging features of traumatic neuroma in the bile duct, no features of traumatic neuromas in the bile duct have been identified by using contrast-enhanced ultrasound (CEUS) imaging before. CASE SUMMARY: A 55-year-old male patient presented to our hospital with a 3-mo history of abdominal distension and anorexia and history of cholecystectomy 4 years ago. Grayscale ultrasound demonstrated mild to moderate intrahepatic bile duct dilatation. Meanwhile, a hyperechoic nodule was found in the upper extrahepatic bile duct. The lesion approximately 0.8 cm × 0.6 cm with a regular shape and clear margins. The nodule of the bile duct showed slight hyperenhancement in the arterial phase and isoenhancement in the venous phase on CEUS. Laboratory tests showed that alanine aminotransferase and aspartate aminotransferase were increased significantly, while the tumor marker carbohydrate antigen 19-9 was increased slightly. Then, hilar bile duct resection and end-to-end bile ductal anastomosis were performed. The histological examination revealed traumatic neuroma of the extrahepatic bile duct. The patient had an uneventful recovery after surgery. CONCLUSION: The current report will help enhance the current knowledge regarding identifying traumatic neuromas by CEUS imaging and review the related literature.

Differentiating malignant and benign focal liver lesions in children using CEUS LI-RADS combined with serum alpha-fetoprotein.

BACKGROUND: Contrast-enhanced ultrasound (CEUS) can be used to diagnose focal liver lesions (FLLs) in children. The America College of Radiology developed the CEUS liver imaging reporting and data system (LI-RADS) for standardizing CEUS diagnosis of FLLs in adult patients. Until now, no similar consensus or guidelines have existed for pediatric patients to improve imaging interpretation as adults. AIM: To evaluate the performance of CEUS LI-RADS combined with alpha-fetoprotein (AFP) in differentiating benign and malignant FLLs in pediatric patients. METHODS: Between January 2011 and January 2021, patients ≤ 18 years old who underwent CEUS for FLLs were retrospectively evaluated. The following criteria for diagnosing malignancy were proposed: Criterion I considered LR-4, LR-5, or LR-M lesions as malignancies; criterion II regarded LR-4, LR-5 or LR-M lesions with simultaneously elevated AFP (≥ 20 ng/mL) as malignancies; criterion III took LR-4 Lesions with elevated AFP or LR-5 or LR-M lesions as malignancies. The sensitivity, specificity, accuracy and area under the receiver operating characteristic curve (AUC) were calculated to determine the diagnostic value of the aforementioned criteria. RESULTS: The study included 63 nodules in 60 patients (mean age, 11.0 ± 5.2 years; 26 male). There were no statistically significant differences between the specificity, accuracy, or AUC of criterion II and criterion III (95.1% vs 80.5%, 84.1% vs 87.3%, and 0.794 vs 0.902; all P > 0.017). Notably, criterion III showed a higher diagnostic sensitivity than criterion II (100% vs 63.6%; P < 0.017). However, both the specificity and accuracy of criterion I was inferior to those of criterion II and criterion III (all P < 0.017). For pediatric patients more than 5 years old, the performance of the three criteria was overall similar when patients were subcategorized by age when compared to all patients in aggregate. CONCLUSION: CEUS LI-RADS combined with AFP may be a powerful diagnostic tool in pediatric patients. LR-4 with elevated AFP, LR-5 or LR-M lesions is highly suggestive of malignant tumors.

Cavernous hemangioma of an intrapancreatic accessory spleen mimicking a pancreatic tumor: A case report.

BACKGROUND: Intrapancreatic accessory spleen (IPAS) is an uncommon condition, with the majority of cases presenting as solid lesions. Thus, this condition is frequently misdiagnosed as pancreatic solid neoplasm. Moreover, splenic cavernous hemangioma is a rare disorder, whereas lesions with a cystic appearance arising from IPAS have not been reported. CASE SUMMARY: Herein, we present a case involving a 32-year-old male who had a complex cystic lesion in the tail of the pancreas revealed by conventional ultrasound. The lesion was misdiagnosed as a pancreatic cystadenoma because of its confusing anatomic location, as well as due to its peripheral nodular and internal septal enhancement patterns on contrast-enhanced ultrasound. After multidisciplinary discussion, the patient finally underwent laparoscopic pancreatic body and tail resections. Postoperative pathology demonstrated the lesion to be a cavernous hemangioma arising from the IPAS. CONCLUSION: Cavernous hemangioma in the intrapancreatic accessory spleen may mimic pancreatic cystadenoma, which is a condition with the potential to be malignant. Imaging follow-ups or surgical interventions may be helpful for the exclusion of malignant risks in complicated cystic lesions, especially those with parietal and septal enhancements.

Contrast-enhanced ultrasound in association with serum biomarkers for differentiating combined hepatocellular-cholangiocarcinoma from hepatocellular carcinoma and intrahepatic cholangiocarcinoma.

BACKGROUND: Combined hepatocellular-cholangiocarcinoma (CHC) is a rare type of primary liver cancer. Due to its complex histopathological characteristics, the imaging features of CHC can overlap with those of hepatocellular carcinoma (HCC) and intrahepatic cholangiocarcinoma (ICC). AIM: To investigate the possibility and efficacy of differentiating CHC from HCC and ICC by using contrast-enhanced ultrasound (CEUS) Liver Imaging Reporting and Data System (LI-RADS) and tumor biomarkers. METHODS: Between January 2016 and December 2019, patients with histologically confirmed CHC, ICC and HCC with chronic liver disease were enrolled. The diagnostic formula for CHC was as follows: (1) LR-5 or LR-M with elevated alpha-fetoprotein (AFP) and carbohydrate antigen 19-9 (CA19-9); (2) LR-M with elevated AFP and normal CA19-9; or (3) LR-5 with elevated CA19-9 and normal AFP. The sensitivity, specificity, accuracy and area under the receiver operating characteristic curve were calculated to determine the diagnostic value of the criteria. RESULTS: After propensity score matching, 134 patients (mean age of 51.4 ± 9.4 years, 108 men) were enrolled, including 35 CHC, 29 ICC and 70 HCC patients. Based on CEUS LI-RADS classification, 74.3% (26/35) and 25.7% (9/35) of CHC lesions were assessed as LR-M and LR-5, respectively. The rates of elevated AFP and CA19-9 in CHC patients were 51.4% and 11.4%, respectively, and simultaneous elevations of AFP and CA19-9 were found in 8.6% (3/35) of CHC patients. The sensitivity, specificity, positive predictive value, negative predictive value, accuracy and area under the receiver operating characteristic curve of the aforementioned diagnostic criteria for discriminating CHC from HCC and ICC were 40.0%, 89.9%, 58.3%, 80.9%, 76.9% and 0.649, respectively. When considering the reported prevalence of CHC (0.4%-14.2%), the positive predictive value and NPV were revised to 1.6%-39.6% and 90.1%-99.7%, respectively. CONCLUSION: CHCs are more likely to be classified as LR-M than LR-5 by CEUS LI-RADS. The combination of the CEUS LI-RADS classification with serum tumor markers shows high specificity but low sensitivity for the diagnosis of CHC. Moreover, CHC could be confidently excluded with high NPV.

Can contrast enhanced ultrasound differentiate intrahepatic cholangiocarcinoma from hepatocellular carcinoma?

BACKGROUND: Hepatocellular carcinoma (HCC) and intrahepatic cholangiocarcinoma (ICC) differ in treatment and prognosis, warranting an effective differential diagnosis between them. The LR-M category in the contrast-enhanced ultrasound (CEUS) liver imaging reporting and data system (LI-RADS) was set up for lesions that are malignant but not specific to HCC. However, a substantial number of HCC cases in this category elevated the diagnostic challenge. AIM: To investigate the possibility and efficacy of differentiating ICC from HCC classified in the LR-M category according to the CEUS LI-RADS. METHODS: Patients with complete CEUS records together with pathologically confirmed ICC and LR-M HCC (HCC classified in the CEUS LI-RADS LR-M category) between January 2015 and October 2018 were included in this retrospective study. Each ICC was assigned a category as per the CEUS LI-RADS. The enhancement pattern, washout timing, and washout degree between the ICC and LR-M HCC were compared using the χ 2 test. Logistic regression analysis was used for prediction of ICC. Receiver operating characteristic (ROC) curve analysis was used to investigate the possibility of LR-M criteria and serum tumor markers in differentiating ICC from LR-M HCC. RESULTS: A total of 228 nodules (99 ICCs and 129 LR-M HCCs) in 228 patients were included. The mean sizes of ICC and LR-M HCC were 6.3 ± 2.8 cm and 5.5 ± 3.5 cm, respectively (P = 0.03). Peripheral rim-like arterial phase hyperenhancement (APHE) was detected in 50.5% (50/99) of ICCs vs 16.3% (21/129) of LR-M HCCs (P < 0.001). Early washout was found in 93.4% (93/99) of ICCs vs 96.1% (124/129) of LR-M HCCs (P > 0.05). Marked washout was observed in 23.2% (23/99) of ICCs and 7.8% (10/129) of LR-M HCCs (P = 0.002), while this feature did not show up alone either in ICC or LR-M HCC. Homogeneous hyperenhancement was detected in 15.2% (15/99) of ICCs and 37.2% (48/129) of LR-M HCCs (P < 0.001). The logistic regression showed that rim APHE, carbohydrate antigen 19-9 (CA 19-9), and alpha fetoprotein (AFP) had significant correlations with ICC (r = 1.251, 3.074, and -2.767, respectively; P < 0.01). Rim APHE presented the best enhancement pattern for diagnosing ICC, with an area under the ROC curve (AUC) of 0.70, sensitivity of 70.4%, and specificity of 68.8%. When rim hyperenhancement was coupled with elevated CA 19-9 and normal AFP, the AUC and sensitivity improved to 0.82 and 100%, respectively, with specificity decreasing to 63.9%. CONCLUSION: Rim APHE is a key predictor for differentiating ICC from LR-M HCC. Rim APHE plus elevated CA 19-9 and normal AFP is a strong predictor of ICC rather than LR-M HCC. Early washout and marked washout have limited value for the differentiation between the two entities.

Diagnostic Accuracy of CEUS LI-RADS for the Characterization of Liver Nodules 20 mm or Smaller in Patients at Risk for Hepatocellular Carcinoma.

Background American College of Radiology contrast agent-enhanced US Liver Imaging Reporting and Data System (CEUS LI-RADS) was developed to improve the accuracy of hepatocellular carcinoma (HCC) diagnosis at contrast agent-enhanced US. However, to the knowledge of the authors, the diagnostic accuracy of the system in characterization of liver nodules 20 mm or smaller has not been fully evaluated. Purpose To evaluate the diagnostic accuracy of CEUS LI-RADS in diagnosing HCC in liver nodules 20 mm or smaller in patients at risk for HCC. Materials and Methods Between January 2015 and February 2018, consecutive patients at risk for HCC presenting with untreated liver nodules 20 mm or less were enrolled in this retrospective double-reader study. Each nodule was categorized according to the CEUS LI-RADS and World Federation for Ultrasound in Medicine and Biology (WFUMB)-European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) criteria. Diagnostic performance of CEUS LI-RADS and WFUMB-EFSUMB characterization was evaluated by using tissue histologic analysis, multiphase contrast-enhanced CT and MRI, and imaging follow-up as reference standard and compared by using McNemar test. Results The study included 175 nodules (mean diameter, 16.1 mm ± 3.4) in 172 patients (mean age, 51.8 years ± 10.6; 136 men). The sensitivity of CEUS LR-5 versus WFUMB-EFSUMB criteria in diagnosing HCC was 73.3% (95% confidence interval [CI]: 63.8%, 81.5%) versus 88.6% (95% CI: 80.9%, 94%), respectively (P < .001). The specificity of CEUS LR-5 versus WFUMB-EFSUMB criteria was 97.1% (95% CI: 90.1%, 99.7%) versus 87.1% (95% CI: 77%, 94%), respectively (P = .02). No malignant lesions were found in CEUS LR-1 and LR-2 categories. Only two nodules (of 41; 5%, both HCC) were malignant in CEUS LR-3 category. The incidences of HCC in CEUS LR-4, LR-5, and LR-M were 48% (11 of 23), 98% (77 of 79), and 75% (15 of 20), respectively. Two of 175 (1.1%) histologic analysis-confirmed intrahepatic cholangiocarcinomas were categorized as CEUS LR-M by CEUS LI-RADS and misdiagnosed as HCC by WFUMB-EFSUMB criteria. Conclusion The contrast-enhanced US Liver Imaging Reporting and Data System (CEUS LI-RADS) algorithm was an effective tool for characterization of small (≤20 mm) liver nodules in patients at risk for hepatocellular carcinoma (HCC). Compared with World Federation for Ultrasound in Medicine and Biology-European Federation of Societies for Ultrasound in Medicine and Biology criteria, CEUS LR-5 demonstrated higher specificity for diagnosing small HCCs with lower sensitivity. Published under a CC BY 4.0 license. See also the editorial by Crocetti in this issue.

[Application of Multimodal Transcranial Ultrasound in SD Rats of Cerebral Ischemic Model at Super Early Stage].

OBJECTIVE: To determine the value of applying multimodal ultrasound (mUS) in SD rats of cerebral ischemic model at super early stage (5-15 min after modeling). METHODS: Fifteen focal cerebral ischemic models were established in SD rats with thinning skulls using the suture method. Gray-scale ultrasound, contrast-enhanced ultrasound, and enhanced color Doppler (CECDUS) were performed before and immediately after the modeling to observe the location of the in-cranial suture, perfusion of the right hemisphere, and color flow signal of the middle cerebral artery and the anterior cerebral artery, respectively.A modified neurological deficit score (mNSS) and 2, 3, 5-triphenyltetrazolium chloride (TTC) stains were obtained three hours later to confirm the successful modeling as the gold standard. The positive rate detected by mUS was compared with the gold standard using McNemar tests. RESULTS: One rat died and 14 rats completed the experiment.mUS imaging detected 71% (10/14) positive signals, no significant difference compared with the gold standard (64%, 9/14) ( P>0.05). A hyperechoic double-line at the bottom of the right brain and focal hypoperfused areas in the right hemisphere were observed by gray scale ultrasound and contrast-enhanced ultrasound in the successfully modeled rats, respectively. The CECDUS found no blood flow in the anterior and middle cerebral arteries. Time intensity curve (TIC) analyses indicated significant changes in peak intensity (PI), area under the curve (AUC), wash in slope (WIS), and time to peak (TTP) after successful modeling. CONCLUSION: Multimodal ultrasound can assess modeling success quickly and accurately immediately after the establishment of ischemic model of SD rats.

A novel model for predicting posthepatectomy liver failure in patients with hepatocellular carcinoma.

Posthepatectomy liver failure (PHLF) is the most leading cause of mortality following hepatectomy in patients with hepatocellular carcinoma (HCC). Platelet count was reported to be a simple but useful indicator of liver cirrhosis and function of spleen. Spleen stiffness (SS) was used to evaluate the morphological change of spleen and was reported to be related to liver cirrhosis and portal hypertension. However, the predictive value of platelet to spleen stiffness ratio (PSR) on PHLF remains unknown. A retrospective study was performed to analyze 158 patients with HCC following hepatectomy from August 2015 to February 2016. Univariate and multivariate analyses were performed to evaluate the value of each risk factor for predicting PHLF. The predictive efficiency of the risk factors was evaluated by receiver operating characteristic (ROC) curve. PHLF occured in 23 (14.6%) patients. PSR (P<0.001, odds ratio (OR) = 0.622, 95% confidence interval (CI) 0.493~0.784), hepatic inflow occlusion (HIO) (P = 0.003, OR = 1.044, 95% CI 1.015~1.075) and major hepatectomy (P = 0.019, OR = 5.967, 95% CI 1.346~26.443) were demonstrated to be the independent predictive factors for development of PHLF in a multivariate analysis. Results of the present study suggested PSR is a novel and non-invasive model for predicting PHLF in patients with HCC.

Hepatic Venous Outflow Stenosis After Auxiliary Left Hemiliver Transplantation Diagnosed by Ultrasonic Shear Wave Elastography Combined With Doppler Ultrasonography.

Hepatic vein stenosis after liver transplantation is a relatively rare complication that could even result in graft loss. However, it is difficult to arrive at a definite diagnosis at the early stage of postoperation, and there are few researches on ultrasonic shear wave elastography in the diagnosis of hepatic vein stenosis. We report the case of an 11-year-old male patient with cirrhosis due to hepatolenticular degeneration who received an auxiliary left hemiliver graft from his uncle. Massive ascites developed in 4 days after the operation. Stenosis was suspected at the site of anastomosis by Doppler ultrasonography when elevating the velocity of the left hepatic vein. Meanwhile, increased stiffness of the graft was revealed by ultrasonic shear wave elastography. The stenosis was confirmed by subsequent digital subtraction angiography. Ascites decreased gradually after the stent implantation. Our case indicates that ultrasonic shear wave elastography combined with Doppler ultrasonography is a promising method for noninvasive diagnosis of hepatic venous outflow stenosis following liver transplantation.

Impact of tumor size and cirrhotic background for differentiating HCC and ICC with CEUS: does it matter for patients undergoing hepatectomy?

OBJECTIVES: The aim of this study was to investigate the role of contrast-enhanced ultrasound (CEUS) in differentiating hepatocellular carcinoma (HCC) vs. intrahepatic cholangiocarcinoma (ICC) and primary liver cancer vs. benign liver lesions for surgical decision making. METHODS: Data from 328 patients (296 primary liver cancer patients: 232 HCC and 64 ICC patients and 32 benign hepatic lesion patients) who underwent hepatectomy at our center were retrospectively collected from 2010 to 2015. Conventional ultrasound (US) and CEUS were performed for all patients before hepatectomy. Enhancement patterns in CEUS were classified and compared for HCC vs. ICC and for primary liver cancer vs. benign lesions. RESULTS: Primary liver cancer and hepatic benign lesions could be distinguished by CEUS in different phases. The most obvious differences were in the portal and delayed phases, in which benign lesions could still show hyperenhancement (46.9% vs. 0.0% and p < 0.001 in the portal phase; 43.7% vs. 0.0% and p < 0.001 in the delayed phase). For differentiating HCC and ICC, our results revealed that HCC and ICC displayed different enhancement patterns in the arterial phase (p < 0.001) and the portal phase (p < 0.001). In the subgroup analyses, both HCC and ICC showed a high rate of homogeneous hyperenhancement during the arterial phase when tumors were ≤5 cm (87.2% vs. 64.0% and p = 0.008) or the Ishak score was ≥5 (75.8% vs. 42.9% and p = 0.023), although there was statistical difference. However, during the portal phase, ICC > 5 cm showed significantly more frequent hypoenhancement (92.3% vs. 54.5% and p < 0.001) and less isoenhancement (7.7% vs. 45.5% and p < 0.001) than HCC; additionally, during the portal phase, there was no statistical difference in the enhancement patterns of ICC with different hepatic backgrounds. CONCLUSIONS: Tumor size and hepatic background should be taken into consideration when distinguishing HCC and ICC before surgery. However, CEUS is a helpful tool for differentiating malignant and benign hepatic lesions. For patients who require surgical treatment, CEUS may help with surgical decision making.

Simultaneous determination of seven constituents in Artemisia argyi leaves by HPLC / 中成药

AIM To establish an HPLC method for the simultaneous content determination of neochlorogenic acid,cryptochlorogenic acid,chlorogenic acid,caffeic acid,isochlorogenic acid B,isochlorogenic acid A and isochlorogenic acid C in the leaves of Artemisia argyi Levl.et Vant..METHODS The analysis of 50％ methanol extract of A.argyi leaves was performed on a 30 ℃ Prevail C1s column (4.6 mm ×250 mm,5 μmn),with the mobile phase comprising of acetonitrile-water flowing at 1.0 rnL/min in a gradient elution manner,and the detection wavelength was set at 325 nm.RESULTS Seven constituents showed good linear relationships within their own ranges (r ≥ 0.999 5),whose average recoveries were 98.28％-101.11％ with the RSDs of 1.04％-2.59％.CONCLUSION This simple,accurate and reproducible method can be used for the quality control of A.argyi leaves.

Simultaneous determination of seven constituents in Artemisia argyi leaves by HPLC / 中成药

AIM To establish an HPLC method for the simultaneous content determination of neochlorogenic acid,cryptochlorogenic acid,chlorogenic acid,caffeic acid,isochlorogenic acid B,isochlorogenic acid A and isochlorogenic acid C in the leaves of Artemisia argyi Levl.et Vant..METHODS The analysis of 50％ methanol extract of A.argyi leaves was performed on a 30 ℃ Prevail C1s column (4.6 mm ×250 mm,5 μmn),with the mobile phase comprising of acetonitrile-water flowing at 1.0 rnL/min in a gradient elution manner,and the detection wavelength was set at 325 nm.RESULTS Seven constituents showed good linear relationships within their own ranges (r ≥ 0.999 5),whose average recoveries were 98.28％-101.11％ with the RSDs of 1.04％-2.59％.CONCLUSION This simple,accurate and reproducible method can be used for the quality control of A.argyi leaves.

Liver Stiffness and Serum Alpha-Fetoprotein in Discriminating Small Hepatocellular Carcinoma from Cirrhotic Nodule.

AIM: This study aimed to investigate the clinical significance of liver stiffness and serum alpha-fetoprotein (AFP) in differentiating small hepatocellular carcinoma (HCC) from cirrhotic nodule. METHODS: A total of 95 chronic hepatitis B patients who were diagnosed with small HCC (n = 53) or cirrhotic nodule (n = 42) underwent ultrasound elastography point quantification (ElastPQ) examinations on lesion and background liver. Three stiffness parameters, lesion stiffness value (SV), absolute stiffness difference (ASD) of lesion and background liver, stiffness ratio (lesion/background liver) (SR), and serum AFP were retrospectively analyzed. Then, the capabilities of lesion SV, ASD, SR, AFP, and the combination of each individual stiffness parameter with AFP were evaluated in differentiating small HCC from cirrhotic nodule. RESULTS: Significantly higher lesion SV, ASD, SR, and serum AFP were observed in small HCC compared with cirrhotic nodule patients (all P ≤ 0.0001). By comparing the stiffness parameters on the patients with AFP greater than 20 ng/mL and AFP of 20 ng/mL or smaller, a higher lesion SV and comparable ASD and SR were found in the small HCC patients. The diagnostic accuracy of lesion SV, ASD, SR, and AFP in the discrimination of small HCC and cirrhotic nodule was 0.731, 0.825, 0.820, and 0.789, respectively. Moreover, the improved sensitivity was observed in the combination of liver stiffness with AFP (83%, 100%, and 92% for lesion SV/AFP, ASD/AFP, and SR/AFP, respectively). CONCLUSIONS: This study illustrated that the combination of liver stiffness and serum AFP has considerable clinical value in detecting suspicious small HCC from cirrhotic nodule.

Time-dependent heart rate variability in the head-up tilt test in children with postural orthostatic tachycardia syndrome / 中国当代儿科杂志

<p><b>OBJECTIVE</b>To study the time-dependent heart rate (HR) variability in the head-up tilt test (HUTT) in children with postural orthostatic tachycardia syndrome (POTS) and to explore the HR diagnostic criteria for POTS in children.</p><p><b>METHODS</b>A retrospective analysis was performed on the clinical data of 105 children diagnosed with POTS with HR≥120 beats per minute (bpm) within the first 10 minutes of HUTT between January 2007 and December 2014. Their HR variability within the first 10 minutes of HUTT was analyzed.</p><p><b>RESULTS</b>The HR of children with POTS increased gradually from the supine position to a 60° head-up tilt position, and the increase in HR was 24±12 bpm at the beginning of HUTT, 30±14 bpm at 3 minutes of HUTT, 32±13 bpm at 5 minutes of HUTT, and 38±12 bpm at 10 minutes of HUTT. The average maximal HR increase within the first 10 minutes of HUTT was 43±10 bpm.</p><p><b>CONCLUSIONS</b>In children with POTS, the HR variability gradually increases with time, and therefore, it is suggested that HR increase ≥40 bpm is more suitable for diagnosis of POTS in children.</p>

Evaluation of psychological fear in children undergoing head-up tilt test / 中国当代儿科杂志

<p><b>OBJECTIVE</b>To investigate the effects of different tilt angles of head-up tilt test (HUTT) and different responses to HUTT on the psychological fear in children undergoing the test.</p><p><b>METHODS</b>HUTT was performed on children with unexplained syncope or pre-syncope (107 cases: 52 males and 55 females), aged 5.5-17.8 years (mean 12.0±2.8 years). All subjects were randomly assigned to undergo HUTT at an angle of 60°, 70° or 80°; the negative cases underwent sublingual nitroglycerin-provocation HUTT at the same tilt angle. The Wong-Baker Faces Pain Rating Scale was used for self-assessment of psychological fear in subjects during HUTT at the end point of the test.</p><p><b>RESULTS</b>The positive rate, hemodynamic changes and distribution of response types showed no significant differences between children at tilt angles of 60°, 70° and 80° (P>0.05). The greater the tilt angle, the higher the degree of psychological fear in children undergoing the test, but there were no significant differences between them (P>0.05). The degree of psychological fear in children who showed a positive response to HUTT (n=76) was significantly higher than that in children who showed a negative response (n=31) (P<0.01).</p><p><b>CONCLUSIONS</b>HUTT can cause psychological fear in children undergoing the test, and the degree of psychological fear increases in children tested at tilt angles from 60° to 80°, but the differences have no statistical significance. A positive response to HUTT can significantly increase the psychological fear in children.</p>

Changes of serum iron and serum ferritin in children with vasovagal syncope / 中华实用儿科临床杂志

Objective To explore the changes of serum iron (SI)level and serum ferritin (SF) level in children with vasovagal syncope(VVS).Methods Twenty-one children [12 male,9 famel,8-14 years old,mean(11.71 ±2.31) years old] were enrolled in this study,who came from children syncope out-patient department or in-patient department of the Second Xiangya Hospital of Central South University from May 2011 to Apr.2012,complaining of syncope or pre-syncope symptoms and turned out to be head-up tilt testing(HUTF) positive,compared with 18 healthy children(healthy control group).All the children were taken blood in the early morning with empty stomach to measure blood SI,SF,hemoglobin(Hb),hematocrit value(Hct) and average red blood cell volume(MCV).The SPSS 16.0 software was used for statistical analysis.Results 1.Age and gender differences were found no statistical significance in syncope group and healthy control group(all P ＞ 0.05).2.SI level in syncope group was lower than that in healthy control group [(15.15 ± 4.55) μmol/L vs (18.24 ± 4.15) μmol/L,P ＜ 0.05].SF level in syncope group was lower than that in healthy control group [(59.10 ± 26.81) μg/L vs (79.83 ± 33.58) μg/L,P ＜ 0.05].Hct level in syncope group was higher than that in healthy control group [(40.19 ± 3.44) ％ vs (38.01 ± 2.68) ％,P ＜ 0.05].3.Gender compare in syncope group:there were no statistical difference in SI,SF,Hct,MCV and Hb between male and female vasovagal syncope patients(all P ＞ 0.05).4.There were no statistically significant differences in SI,SF,Hb,Hct and MCV between recurrent syncope and accidental syncope (all P ＞ 0.05).Conclusions SI,SF level reduce in VVS children,and there was no gender difference.

Relationship between unexplained sighs in children and head-up tilt test / 中华实用儿科临床杂志

Objective To explore the relationship between unexplained sighs in children and head-up tilt test (HUTT).Methods Ninety-six cases of children with the main symptom of unexplained sighs were received at Specialist Out-Patient Clinic of Children's Syncope from May 2003 to Mar.2012 in the Second Xiangya Hospital of Central South University,aged 4-14 years old(50 cases were male,46 cases were female),with a mean age of (8.55 ±2.71)years.The detailed history,physical examinations,conventional 12 lead electrocardiogram,chest x-ray,and echocardiography were all investigated,as well as the examination of myocardial enzyme,to eliminate the disorders of organic chest wall,heart,lung disease,and then HUTT inspection was given to them.Results HUTT positive rate was 31.25％ (30/96 cases),and no gender differences were found [20.00％ (10/50 cases) vs 43.48 ％ (20/46 cases),x2 =3.196,P ＞0.05].The positive cases included the basic head-up tilt table test in 2 cases(6.67％) and sublingual nitroglycerin head-up tilt test in 28 patients(93.33％).The hemodynamic changes in HUTT were found in 26 cases of vascular inhibited type(86.67％),heart inhibited type in 1 patient(3.33％) and the mixed type in 3 cases(10.00％).Conclusions Almost a third of children with unexplained sighs are related to the autonomic function disorder.HUTT may help to determine the causes of clinical unexplained sighs in children.

Investigation of 24-hour blood pressure monitoring for evaluating treatment outcome of nerve-mediated syncope in children / 中国当代儿科杂志

<p><b>OBJECTIVE</b>To investigate the clinical significance of 24-hour blood pressure monitoring (ABPM) for evaluating the treatment outcome of nerve-mediated syncope (NMS) in children.</p><p><b>METHODS</b>Twenty-eight children with NMS confirmed by a head-up tilt table test (HUTT) (12 males and 16 females, aged 6-13 years) and with a chief complaint of unexplained syncope or pre-syncope between February 2010 and August 2012, were included in the study. These children received health education combined with therapy using oral rehydration salts solution and were then reexamined for clinical symptoms as well as HUTT and ABPM results.</p><p><b>RESULTS</b>Of 28 NMS cases, 22 were vasodepressive type, 5 were mixed type, and 1 was cardioinhibitory type. The follow-up showed that 27 (96%) of all cases had improved clinical symptoms, and 18 (64%) had improved HUTT results. The ABPM follow-up revealed no significant changes in 24-hour mean systolic pressure, 24-hour mean diastolic pressure, daytime mean systolic pressure, daytime mean diastolic pressure, nighttime mean systolic pressure, nighttime mean diastolic pressure, day-night difference of systolic pressure, and day-night difference of diastolic pressure after treatment (P>0.05). The percentage of children with a dipper blood pressure pattern increased from 29% (8/28) before treatment to 50% (14/28) after treatment; the percentage of children with a non-dipper blood pressure pattern decreased from 71% (20/28) before treatment to 50% (14/28) after treatment.</p><p><b>CONCLUSIONS</b>As an effective, objective and non-invasive monitoring means, ABPM is of some clinical significance for evaluating the treatment outcome of NMS in children.</p>

Clinical significance of changes in T wave and ST segment amplitudes on electrocardiogram from supine to standing position among children with unexplained chest tightness or pain in resting stage / 中国当代儿科杂志

<p><b>OBJECTIVE</b>To investigate the clinical significance of changes in T wave and ST segment amplitudes on electrocardiogram (ECG) from supine to standing position in children with unexplained chest tightness or pain in resting stage.</p><p><b>METHODS</b>A total of 122 6-14-year-old children with a chief complaint of unexplained chest tightness or pain (resting stage) underwent head-up tilt test (HUTT). According to HUTT results, these children were divided into HUTT-positive (n=61) and HUTT-negative groups (n=61). They underwent 12-lead ECG in the supine and standing positions, and heart rate and T wave and ST segment amplitudes in II, III, aVF and V5 leads were measured.</p><p><b>RESULTS</b>In the HUTT-negative group, heart rates were significantly higher in the standing position than in the supine position (P<0.05), T wave amplitudes in II, III, aVF, and V5 leads were significantly lower in the standing position than in the supine position (P<0.05), and ST segment amplitudes in II, aVF and V5 leads were significantly higher in the standing position than in the supine position (P<0.05). In the HUTT-positive group, heart rates were significantly higher in the standing position than in the supine position (P<0.05), T wave amplitudes in II, III, aVF and V5 leads were significantly lower in the standing position than in the supine position (P<0.05), and ST segment amplitude in V5 lead was significantly higher in the standing position than in the supine position (P<0.05). There were no significant differences between the two groups with respect to ST segment amplitude and T wave amplitude in II, III and aVF leads of the supine or standing position (P>0.05). Compared with the HUTT-negative group, the HUTT-positive group had significantly greater T wave amplitude differences in II, III, aVF and V5 leads, and heart rate difference from supine to standing position (P<0.05).</p><p><b>CONCLUSIONS</b>Among the children with unexplained chest tightness or pain in resting stage, T wave amplitude differences in II, III, aVF and V5 leads and heart rate difference from supine to standing position are greater in the HUTT-positive group than in the HUTT-negative group. This suggests that the changes in T wave amplitude on ECG from supine to standing position can indicate autonomic nervous system dysfunction.</p>

Causes of unexplained syncope in children / 中国当代儿科杂志

<p><b>OBJECTIVE</b>To investigate the common causes of unexplained syncope in children.</p><p><b>METHODS</b>A total of 434 children with unexplained syncope who were aged from 3.0 to 17.9 years (192 males and 242 females) and who saw the doctor between January 2006 and October 2011. were examined in order to explore the detailed histories and causes of syncope and to analyze variance in causes among different ages, genders, syncope frequencies and head-up tilt test (HUTT) results.</p><p><b>RESULTS</b>(1) The causes of occasional syncope included persistent standing (30%), movement (13%), change in body position(9%), sitting(7%), and playing(6%). Persistent standing was more common as a cause in females than in males (P<0.01). Micturition syncope was mainly seen in males. Sultry weather was the main cause of syncope in females. Change in body position was a more common cause in the ≥12 years group than in the <12 years group (P<0.05), while other causes showed no significant differences among different age groups. Change in body position was a more common cause of syncope in children with negative HUTT results than in those with positive HUTT results (P<0.05). (2) All causes of occasional syncope can induce repeated syncope, and most repeated syncope (56%) had the same cause.</p><p><b>CONCLUSIONS</b>The common causes of unexplained syncope include persistent standing, movement and changes of body position in children. Avoiding these causes is helpful for prevention of childhood syncope.</p>