2009甲型H1N1流感儿童胸X线片表现

目的 总结儿童2009甲型H1N1流感的胸部X线影像特点.方法 选取2009年5月1日至2010年1月31日经首都儿科研究所病毒研究室病原学检测确诊且影像学资料完整的2009甲型H1N1流感患儿235例,按病情分为轻度组(172例)、中度组(49例)、重度组(14例),对患儿发病至首次拍片时间以及首次胸X线片影像表现进行比较.三组间性别、影像表现差异使用χ2检验.患儿年龄及发病至首次拍片时间的比较使用非参数检验.结果 各组患儿年龄、性别差异无统计学意义(P＞0.05).3组发病至拍摄胸X线片的时间分别为:轻度组(5.91±1.64)d,中度组(3.60±1.43)d,重度组(1.21±0.41)d,3组间差异有统计学意义(χ2=13.368,P＜0.01).首次胸X线片影像异常率:轻度组79.7%,中度组91.8%,重度组100.0%,在胸X线片表现上,各组出现肺纹理粗重、模糊(轻度组55.2%,中度组83.7%,重度组78.6%),肺实变(轻度组34.3%,中度组69.4%,重度组100.0%),肺过度充气(轻度组22.1%,中度组44.9%,重度组50.0%)以及磨玻璃密度影(轻度组0.6%,中度组2.0%,重度组14.3%)的比例差异均有统计学意义(P＜0.01).重度组病灶分布广、不对称,累及多个肺叶.结论 儿童2009甲型H1N1流感首次胸X线片出现异常时间、异常率、胸X线片表现严重度与临床病情严重程度成正比.

Abstract：

Objective To evaluate chest radiographic findings of children with 2009 influenza ( H1N1 ) virus infection. Method Data of 235 patients who had microbiologically confirmed H1N1 infection and available chest radiograph obtained between May 1st 2009 and Jan. 31st 2010 were retrospectively analyzed. The final study group was divided on the basis of clinical course [group 1 mild, outpatients without hospitalization ( n = 172 ); group 2 moderate, inpatients with brief hospitalization ( n = 49 ); group 3 severe, ICU admission (n = 14)]. Four pediatric radiologists reviewed all the chest radiographs of lung parenchyma, airway, pleural abnormalities and also anatomic distribution of the disease. Result No significant sex or age differences were found among the study groups ( P ＞0.05 ). The mean interval between the onset of clinical symptom and the initial chest radiography was (5.91 ± 1. 64) days (group 1 ), (3.60 ±1.43 ) days ( group 2) and ( 1.21 ± 0.41 ) days ( group 3 ), respectively. The differences among the three groups were significant statistically ( χ2 = 13.368, P ＜ 0.01 ). The ratio of abnormality presented at initial chest X-ray was 79.7% in group 1,91.8% in group 2 and 100% in group 3. Radiographically, there were prominent peribronchial markings ( group 1, 55.2%; group 2, 83.7%; and group 3, 78.6% ),consolidation ( group 1, 34.3%; group 2, 69.4%; and group 3, 100.0% ), hyperinflation ( group 1,22.1%; group 2, 44.9%; and group 3, 50.0% ) and ground glass opacity ( group 1, 0.6%; group 2,2.0%; and group 3, 14.3% ) in the chest radiographs. The differences of presenting were statistically significant (P ＜0.01 ). In the severe group, the lesions distributed diffusely and asymmetrically with multi lobe involvements. Conclusion In children with 2009 influenza A H1N1 viral infection, the interval between the onset of clinical symptom and initial chest radiography, the ratio of abnormality presented at initial chest X-ray film and the severity of chest film are parallel to their clinical situation.     

手足口病病原体流行特征分析及临床意义

Objective To investigate the epidemic characteristics of etiological agents in children with hand, foot and mouth disease (HFMD) and analyze the differences between the severe and mild cases with HFMD seen from 2008 to 2009 in the Children's Hospital Methods A total of 154 patients with HFMD were enrolled from May 2008 to September 2008 and from May 2009 to September 2009, including 28 severe HFMD patients. Data from 80 cases with suspected herpangina were collected as control. Enterovirus universal type, enterovirus type 71 (EV71) and coxsackie virus group A 16 (CA16) were detected by realtime RT-PCR respoctively. Results The positive rate of enterovirus universal type in the 154 patients with HFMD was 81.82% (126/154). EV71 positive rate in these 126 patients with enterovirus universal type infection was 57.14% (72/126). The positive rate of enterovirus universal type in the 80 cases with suspected herpangina was 68.75% (55/80). There was no EV71 infection in these 80 cases with suspected herpangina. EV71 infection was mainly popular in 2008. Both EV71 and CA16 were prevalent in 2009. The epidemic characteristics of enterovirus infection with HFMD between 2008 and 2009 had significant differences (X2 = 23.50, P = 0.000) ( P ＜ O.01 ). The epidemic characteristics of enterovirus infection between severe and mild HFMD patients also had significant differences (X2 = 29.85, P ＜ O. 01). There were 28 cases with severe HFMD, in whom the EV71 positive rate was 92.86% (26/28). EV71 positive rate in the mild HFMD was 36.51% (46/126) (X2 =29.22, P ＜0.01). There was no significant difference in the gender ( X2 = 0.135, P = 0.714) and virus load (t = 0.141, P = 0.889) between the mild and severe HFMD cases. But the age of mild and severe HFMD showed a significant difference ( t = 2.926, P =O.009). Patients who were less than 2 years of age had a proportion of 88.89% (8/9) with severe HFMD.The mean age of mild HFMD patients was 3.19 years. Conclusion HFMD showed different epidemic characteristics at different times of enterovirus infection. There was no significant difference in the gender and virus load between the mild and severe cases with HFMD. Children under 3 years of age with EV71 infection were at high risk for severe HFMD.     

手足口病病原体流行特征分析及临床意义

Objective To investigate the epidemic characteristics of etiological agents in children with hand, foot and mouth disease (HFMD) and analyze the differences between the severe and mild cases with HFMD seen from 2008 to 2009 in the Children's Hospital Methods A total of 154 patients with HFMD were enrolled from May 2008 to September 2008 and from May 2009 to September 2009, including 28 severe HFMD patients. Data from 80 cases with suspected herpangina were collected as control. Enterovirus universal type, enterovirus type 71 (EV71) and coxsackie virus group A 16 (CA16) were detected by realtime RT-PCR respoctively. Results The positive rate of enterovirus universal type in the 154 patients with HFMD was 81.82% (126/154). EV71 positive rate in these 126 patients with enterovirus universal type infection was 57.14% (72/126). The positive rate of enterovirus universal type in the 80 cases with suspected herpangina was 68.75% (55/80). There was no EV71 infection in these 80 cases with suspected herpangina. EV71 infection was mainly popular in 2008. Both EV71 and CA16 were prevalent in 2009. The epidemic characteristics of enterovirus infection with HFMD between 2008 and 2009 had significant differences (X2 = 23.50, P = 0.000) ( P ＜ O.01 ). The epidemic characteristics of enterovirus infection between severe and mild HFMD patients also had significant differences (X2 = 29.85, P ＜ O. 01). There were 28 cases with severe HFMD, in whom the EV71 positive rate was 92.86% (26/28). EV71 positive rate in the mild HFMD was 36.51% (46/126) (X2 =29.22, P ＜0.01). There was no significant difference in the gender ( X2 = 0.135, P = 0.714) and virus load (t = 0.141, P = 0.889) between the mild and severe HFMD cases. But the age of mild and severe HFMD showed a significant difference ( t = 2.926, P =O.009). Patients who were less than 2 years of age had a proportion of 88.89% (8/9) with severe HFMD.The mean age of mild HFMD patients was 3.19 years. Conclusion HFMD showed different epidemic characteristics at different times of enterovirus infection. There was no significant difference in the gender and virus load between the mild and severe cases with HFMD. Children under 3 years of age with EV71 infection were at high risk for severe HFMD.     

出生时抗氧化维生素及重金属水平对两岁幼儿智力发育影响的相关分析

Objective Epidemiologic study on the perinatal interaction of antioxidant vitamins and heavy metals on offspring's intellectual development is extremely limited.The aim of this prospective cohort study was to investigate the status of maternal and cord blood antioxidant vitamins(Vitamin A,E and C)and heavy metMs(lead, cadmium and mercury)at delivery and correlations between these antioxidant vitamins or metals and neurodevelopment of early childhood,and to explore the protective effect of antioxidant vitamins against the injure of heavy metals to intellectual development in children in Tongliang,Chongqing, China.Method A total of 150 pairs of mothers-neonates were recruited.Serum concentrations of vitamin(V)A,vitamin E, vitamin C,lead, cadmium and mercury in maternal and cord blood after delivery were determined and intellectual development was evaluated by Gesell Development Schedule (GDS)at two years of age.Result A total of 111 pairs of maternal-neonatal subjects with completed data were iticluded into statistical analysis.After aajusting for potential confounders.cord blood mercury level was found negatively associated with all the development quotients(DQs)(β=-0.486,β=-0.716,β=-0.846,β=-0.935,β=-0.702,P＜0.05).Cord VE level was positively correlated with motor,adaptation,language and average DQ(β=0.475,β=0.458,β=0.403,β=0.395,P＜0.05).When antioxidant vitamins and heavy metals levels were all included into the multiple regression model, cord vitamin E level was statistically positively related with motor,adaptation and average DQs(β=0.449,β=0.412,β=0.349,P＜0.05).While cord blood mercury level was negatively correlated with adaptation,language,social and average DQ(β=-0.397,β=-0.727,β=-0.935,β=-0.628,P＜0.05),the relationship between cord mercury level and motor DQ was not statistically significant(β=0.0890).The motor,adaptation,language and average DQs in high cord VE group were higher than those in low VE group (t=2.93,t=2.06,t=2.13,t=2.27,P＜0.05).Social DQ in high cord lead group was significantly lower than that in low lead group(x2=5.56,P=0.015).Cord VC level in high cadmium group was significantly lower than that in low cadmium group(x2=7.62,P=0.006).VA placental transport ratio in high mercury group was significantly lower than those in low mercury group(x2=8.02,P=0.005).Conclusion Our data suggested that there may be certain interaction between antioxidant vitamin A,E.C and heavy metals lead,cadmium,mercury.Antioxidant vitamins at delivery may have protective effect on the early neurodevelopment via interaction with the heavy metals.     

锌指蛋白A20在炎症性肠病患儿肠黏膜中的表达及意义

目的 探讨炎症性肠病(IBD)患儿肠道炎症反应与锌指蛋白A20(A20)表达水平之间的关系.方法 收集2008至2010年就诊于我院并行肠镜检查的患儿肠道黏膜标本共57份.将标本分为正常对照组(n=16)、IBD缓解期组(n=12)、IBD活动期组(n=13)和非IBD肠炎组(n=16).内镜下取各组患儿末端回肠黏膜标本,采用荧光定量PCR和免疫组化法检测A20、NF-κB、IL-6、IL-8的表达水平.结果 (1)NF-κB、A20在正常对照组肠黏膜中仅微量表达,IBD活动期组和非IBD肠炎组NF-κB、A20表达水平明显高于正常对照组(P均＜0.01);(2)IBD缓解期组较正常对照组NF-κB[(9.35±4.84)%vs(0.57±0.44)%,P＜0.01]、IL-6(t'=1.34,P＞0.05)、IL-8(t=1.38,P＞0.05)表达水平高,而A20在mRNA水平(t=1.03,P＞0.05)和蛋白水平[(0.36±0.18)%vs(0.87±0.29)%,P＜0.01]上表达均偏低;(3)与非IBD肠炎组相比,IBD活动期组NF-κB[(24.17±11.27)%vs(55.29±21.84)%,P＜0.01]、IL-6(t=2.22,P＜0.05)、IL-8(t=2.97,P＜0.01)表达水平明显升高,而A20在mRNA(t=2.26,P＜0.05)和蛋白水平[(29.23±11.70)%vs(16.8l±5.90)%,P＜0.01]上表达均较低;(4)IBD缓解期组与非IBD肠炎组相比,IL-6、IL-8表达水平差异无统计学意义(t'值和t值分别为0.03和0.28,P均＞0.05),而A20在mRNA水平(t=4.42,P＜0.01)和蛋白水平[(29.23±11.70)%vs(0.47±0.25)%,P＜0.01]上表达均较低.结论 IBD患儿存在肠道炎症反应过度而A20表达水平上调不足的现象;A20表达水平的异常可能参与了IBD的发生和发展.

Abstract：

Objective It is demonstrated that excessive activation of NF-κB is central to the pathogenesis of inflammatory bowel disease(IBD).Zinc finger protein A20(A20)is a key player in the negative feedback regulation of NF-κB signaling in response to multiple stimuli and has been described as central gatekeeper in inflammation and immunity.Mice genetically deficient in A20 develop severe intestinal inflammation and have increased susceptibility to dextran sodium sulfate(DSS)-induced colitis.Few studies have been done to explore the role of A20 in the pathogenesis of IBD.To clarify the relationship between intestinal inflammation and the expression level of A20 in IBD patients,the expression level of A20 and a series of inflammatory cytokines,such as NF-κB,IL-6,and IL-8,in children with IBD and controls were examined.Method Terminal ileal mucosal samples were obtained via endoscopy. Fifty-seven mucosal samples were divided into 4 groups:normal control group(n = 16),IBD remission group(n = 12),IBD active group(n = 13)and non-IBD enteritis group(n = 16).According to disease activity index scores,the IBD patients were divided into IBD remission group and IBD active group. Normal control group was consisted of patients with functional bowel disorders or intestinal polyps.Non-IBD enteritis was defined as changes in which endoscopy and histological examination showed inflammatory changes but could not be diagnosed as IBD.Real-time PCR was adopted for detecting the mRNA levels of A20,IL-6 and IL-8.Meanwhile immunohistochemistry was performed to measure the expression of A20 and NF-κB.Result (1)The expression of A20 and NF-κB were very low in normal control group,but significantly up-regulated in IBD active group and non-IBD enteritis group(P＜ 0.01 for beth);(2)Compared with normal control group,expression of NF-κB [(9.35±4.84)% vs.(0.57±0.44)%,P＜0.01],IL-6(t' = 1.34,P ＞0.05),IL-8(t = 1.38,P ＞0.05)increased in IBD remission group,while the expression of A20 in both mRNA(t = 1.03,P ＞ 0.05)and protein levels [(0.36±0.18)% vs.(0.87±0.29)%,P＜ 0.01]decreased;(3)Compared with non-IBD enteritis group,although the expression of NF-κB [(24.17±11.27)% vs.(55.29±21.84)%,P＜0.01],IL-6(t =2.22,P＜0.05),IL-8(t=2.97,P＜0.01)were highly increased in IBD active group,the expression of A20 in both mRNA(t =2.26,P＜0.05)and protein levels [(29.23±11.70)% vs.(16.81±5.90)%,P＜ 0.01] significantly decreased;(4)The expression of IL-6,IL-8 were similar in IBD remission group and non-IBD enteritis group(both P ＞0.05),but the expression of A20 was much lower in both mRNA(t =4.42,P＜0.01)and protein levels [(29.23±11.70)% vs.(0.47±0.25)%,P＜ 0.01] in IBD remission group.Conclusion The results demonstrate that there is an excessive inflammatory response but insufficient up-regulation of A20 expression in IBD patients.Low levels expression of A20 may play an important role in the pathogenesis of IBD.     

糖尿病酮症酸中毒患儿氧化应激状况及影响因素分析

Objective To investigate the oxidative stress state in children with diabetic ketoacidosis (DKA),and analyze whether any observed abnormalities were related to metabolic disturbances.Methods Four groups of subjects were studied,comprising with 22 patients with DKA(group 1),18 diabetic children with medium metabolic control,whose glycated hemoglobin(HbAlc) below 9%(group 2),22 children with poorly controlled diabetes,whose Hbal c above 9%(group 3),and 36 healthy control children(group 4).Malondialdehyde(MDA),nitrate oxidase(NO),glutathione peroxidase(GSH-Px),superoxide dismutase(SOD),and metabolic parameters such as fasting blood glucose,HbAlc,blood gas analysis,serum ion,renal function of the subjects were measured.Results Mean serum MDA value was significantly higher in group 1 than in group 2(P ＜0.01) and group 4(P ＜0.01),but was not different from that in group 3 (P ＞0.05).Serum levels of NO were significantly higher in group 1,2 and 3 compared with group 4(P＜0.01).Serum levels of GSH-Px were significantly lower in group 1,2 and 3 than in group 4(P＜0.01).There were no significant differences of serum SOD value among the four groups(P＞0.05).Both serum MDA and NO values in the diabetic patients(groups 1 +2 +3) were positively related to HbAlc(r=0.375,P ＜0.01;r=0.250,P ＜0.05),and serum SOD values in the DKA patients were negatively related to HbAlc(r= -0.507,P＜0.05),there were not any significant relationship between the other oxidative markers and metabolic parameters.Conclusion There is an increase of oxidative stress and decrease of antioxygenic ability in DKA children,and these changes tend to correlate more with markers of diabetic imbalance than with parameters of acute metabolic disturbances of DKA.     

糖尿病酮症酸中毒患儿氧化应激状况及影响因素分析

Objective To investigate the oxidative stress state in children with diabetic ketoacidosis (DKA),and analyze whether any observed abnormalities were related to metabolic disturbances.Methods Four groups of subjects were studied,comprising with 22 patients with DKA(group 1),18 diabetic children with medium metabolic control,whose glycated hemoglobin(HbAlc) below 9%(group 2),22 children with poorly controlled diabetes,whose Hbal c above 9%(group 3),and 36 healthy control children(group 4).Malondialdehyde(MDA),nitrate oxidase(NO),glutathione peroxidase(GSH-Px),superoxide dismutase(SOD),and metabolic parameters such as fasting blood glucose,HbAlc,blood gas analysis,serum ion,renal function of the subjects were measured.Results Mean serum MDA value was significantly higher in group 1 than in group 2(P ＜0.01) and group 4(P ＜0.01),but was not different from that in group 3 (P ＞0.05).Serum levels of NO were significantly higher in group 1,2 and 3 compared with group 4(P＜0.01).Serum levels of GSH-Px were significantly lower in group 1,2 and 3 than in group 4(P＜0.01).There were no significant differences of serum SOD value among the four groups(P＞0.05).Both serum MDA and NO values in the diabetic patients(groups 1 +2 +3) were positively related to HbAlc(r=0.375,P ＜0.01;r=0.250,P ＜0.05),and serum SOD values in the DKA patients were negatively related to HbAlc(r= -0.507,P＜0.05),there were not any significant relationship between the other oxidative markers and metabolic parameters.Conclusion There is an increase of oxidative stress and decrease of antioxygenic ability in DKA children,and these changes tend to correlate more with markers of diabetic imbalance than with parameters of acute metabolic disturbances of DKA.     

糖尿病酮症酸中毒患儿氧化应激状况及影响因素分析

Objective To investigate the oxidative stress state in children with diabetic ketoacidosis (DKA),and analyze whether any observed abnormalities were related to metabolic disturbances.Methods Four groups of subjects were studied,comprising with 22 patients with DKA(group 1),18 diabetic children with medium metabolic control,whose glycated hemoglobin(HbAlc) below 9%(group 2),22 children with poorly controlled diabetes,whose Hbal c above 9%(group 3),and 36 healthy control children(group 4).Malondialdehyde(MDA),nitrate oxidase(NO),glutathione peroxidase(GSH-Px),superoxide dismutase(SOD),and metabolic parameters such as fasting blood glucose,HbAlc,blood gas analysis,serum ion,renal function of the subjects were measured.Results Mean serum MDA value was significantly higher in group 1 than in group 2(P ＜0.01) and group 4(P ＜0.01),but was not different from that in group 3 (P ＞0.05).Serum levels of NO were significantly higher in group 1,2 and 3 compared with group 4(P＜0.01).Serum levels of GSH-Px were significantly lower in group 1,2 and 3 than in group 4(P＜0.01).There were no significant differences of serum SOD value among the four groups(P＞0.05).Both serum MDA and NO values in the diabetic patients(groups 1 +2 +3) were positively related to HbAlc(r=0.375,P ＜0.01;r=0.250,P ＜0.05),and serum SOD values in the DKA patients were negatively related to HbAlc(r= -0.507,P＜0.05),there were not any significant relationship between the other oxidative markers and metabolic parameters.Conclusion There is an increase of oxidative stress and decrease of antioxygenic ability in DKA children,and these changes tend to correlate more with markers of diabetic imbalance than with parameters of acute metabolic disturbances of DKA.     

糖尿病酮症酸中毒患儿氧化应激状况及影响因素分析

Objective To investigate the oxidative stress state in children with diabetic ketoacidosis (DKA),and analyze whether any observed abnormalities were related to metabolic disturbances.Methods Four groups of subjects were studied,comprising with 22 patients with DKA(group 1),18 diabetic children with medium metabolic control,whose glycated hemoglobin(HbAlc) below 9%(group 2),22 children with poorly controlled diabetes,whose Hbal c above 9%(group 3),and 36 healthy control children(group 4).Malondialdehyde(MDA),nitrate oxidase(NO),glutathione peroxidase(GSH-Px),superoxide dismutase(SOD),and metabolic parameters such as fasting blood glucose,HbAlc,blood gas analysis,serum ion,renal function of the subjects were measured.Results Mean serum MDA value was significantly higher in group 1 than in group 2(P ＜0.01) and group 4(P ＜0.01),but was not different from that in group 3 (P ＞0.05).Serum levels of NO were significantly higher in group 1,2 and 3 compared with group 4(P＜0.01).Serum levels of GSH-Px were significantly lower in group 1,2 and 3 than in group 4(P＜0.01).There were no significant differences of serum SOD value among the four groups(P＞0.05).Both serum MDA and NO values in the diabetic patients(groups 1 +2 +3) were positively related to HbAlc(r=0.375,P ＜0.01;r=0.250,P ＜0.05),and serum SOD values in the DKA patients were negatively related to HbAlc(r= -0.507,P＜0.05),there were not any significant relationship between the other oxidative markers and metabolic parameters.Conclusion There is an increase of oxidative stress and decrease of antioxygenic ability in DKA children,and these changes tend to correlate more with markers of diabetic imbalance than with parameters of acute metabolic disturbances of DKA.     

糖尿病酮症酸中毒患儿氧化应激状况及影响因素分析

Objective To investigate the oxidative stress state in children with diabetic ketoacidosis (DKA),and analyze whether any observed abnormalities were related to metabolic disturbances.Methods Four groups of subjects were studied,comprising with 22 patients with DKA(group 1),18 diabetic children with medium metabolic control,whose glycated hemoglobin(HbAlc) below 9%(group 2),22 children with poorly controlled diabetes,whose Hbal c above 9%(group 3),and 36 healthy control children(group 4).Malondialdehyde(MDA),nitrate oxidase(NO),glutathione peroxidase(GSH-Px),superoxide dismutase(SOD),and metabolic parameters such as fasting blood glucose,HbAlc,blood gas analysis,serum ion,renal function of the subjects were measured.Results Mean serum MDA value was significantly higher in group 1 than in group 2(P ＜0.01) and group 4(P ＜0.01),but was not different from that in group 3 (P ＞0.05).Serum levels of NO were significantly higher in group 1,2 and 3 compared with group 4(P＜0.01).Serum levels of GSH-Px were significantly lower in group 1,2 and 3 than in group 4(P＜0.01).There were no significant differences of serum SOD value among the four groups(P＞0.05).Both serum MDA and NO values in the diabetic patients(groups 1 +2 +3) were positively related to HbAlc(r=0.375,P ＜0.01;r=0.250,P ＜0.05),and serum SOD values in the DKA patients were negatively related to HbAlc(r= -0.507,P＜0.05),there were not any significant relationship between the other oxidative markers and metabolic parameters.Conclusion There is an increase of oxidative stress and decrease of antioxygenic ability in DKA children,and these changes tend to correlate more with markers of diabetic imbalance than with parameters of acute metabolic disturbances of DKA.     

2009甲型H1N1流感住院患儿159例分析

目的 探讨因甲型H1N1流感病毒感染住院患儿的临床特征.方法 2009年11月至2010年1月于首都儿科研究所附属儿童医院经实时逆转录-聚合酶链反应(RT-PER)方法确诊的甲型H1N1流感住院患儿159例,男83例,女76例.设计临床资料观察表,逐一记录患儿的临床表现、实验室检查、影像学资料及治疗情况,并进行总结分析.结果 (1)住院患儿5岁以下者占87.4%,54例(34.0%)有基础疾病,婴幼儿组(<3岁,78例)和年长儿组(>3岁,81例)之间重症或危重病例(x2=0.105)、患肺炎比例(x2=0.212)及基础疾病比率(x2=3.383)相近(P均>0.05).(2)患儿均以流感样症状起病,以高热(115例,72.3%)、咳嗽(154例,96.8%)为主,5例危重症患者均出现呼吸困难、紫绀,血气有低氧血症.(3)H1N1流感病毒易侵犯下呼吸道,61.0%患儿出现肺炎,合并细菌感染者21.6%,并可同时有非典型病原体(20例,27.0%)及其他呼吸道病毒(5例,3.1%)感染.单纯甲型H1N1病毒感染组与混合感染组热程相近(t=0.975,P>0.05),混合感染组比单纯感染组更容易发生肺部炎症(x2=4.082,P<0.05),其平均病程及住院天数更长(t=3.182及3.190,P均<0.01).结论 绝大多数患者呼吸道症状轻微,少数病情进展呈现危重症表现.呼吸困难和低氧血症可作为危重症甲型H1N1流感早期症状识别的主要指标,除尽早给予抗病毒治疗外,继发细菌感染者还需覆盖常见病原菌的合理经验用药.     

2009甲型H1N1流感研究进展

2009年3月在墨西哥出现了一种新型甲型H1N1流感病毒,这是一个四源重排的A型流感病毒:来源于猪流感病毒、禽流感病毒及人流感病毒.其临床特点与季节性流感相似,但重症病例可发生在无基础疾病的青壮年人,这与季节性流感不同,其高危人群为患有基础疾病者、孕妇及肥胖者.尽管已经出现了耐药毒株,但奥司他韦治疗仍然有效.该文主要对2009年流行的甲型H1N1流感病毒的基因特点、临床表现及治疗的最新进展进行综述.     

儿童甲型H1N1流感12例分析

目的 了解儿童甲型H1N1流感的特点.方法 回顾分析2009年5月1日至2009年7月15日复旦大学附属儿科医院发热门诊及病房诊治的12例甲型H1N1流感的流行特征及临床特点;采取患儿鼻咽拭子标本,冰壶保存立即送上海市疾病预防控制中心,采用实时逆转录核酸扩增聚合酶链反应(RT-PCR)进行甲型H1N1流感病毒核酸检测.结果 12例儿童甲型H1N1流感均为输入性病例,5例患儿有明确的甲型H1N1流感患者密切接触史.12例有发热症状,有咳嗽、流涕、食欲不佳症状的各为7例,1例有喘息症状,所有病例均无呕吐和腹泻.11例能准确表述自身感受的患儿中,均无肌肉酸痛,6例有咽痛,3例有腹痛.2例患儿并发肺炎,其中1例患儿病情危重.1例患儿居家隔离对症治疗,11例患儿住院治疗,均参照中国国家卫生部颁布的<甲型HINI流感诊疗方案(2009年试行版第一版)>进行治疗,其中10例息儿接受奥斯他韦抗病毒治疗,未见明显不良反应,所有患儿均痊愈.结论 儿童甲型H1N1流感的症状主要表现为典型的流感症状,大部分患儿临床过程轻微,及时隔离和治疗预后良好,奥斯他韦抗病毒治疗无明显副作用.儿童甲型H1N1流感的流行特征及临床特点尚需要多地区大样本的研究资料.     

2009甲型H1N1流感患儿免疫功能改变初探

目的 探讨2009甲型H1N1流感(以下简称"甲流")患儿免疫功能及可能的免疫发病机制.方法 深圳市儿童医院2009年11月1日-2010年1月10日甲流住院患儿60例,轻症35例(轻症肺炎),重症25例(重症肺炎或甲流相关性脑病,死亡3例),同年龄正常对照组20例.采用real-time PCR、流式细胞术及ELISA检测外周血单个核细胞胞浆模式识别受体(PRRs)维甲酸诱导基因I/黑色素瘤分化相关基因5(RIG/MDA5)、胞膜PRRs Toll样受体(TLRs)分子及其信号途径传导分子、细胞因子/趋化因子及负性调节因子变化;T、B及NK细胞凋亡及凋亡相关基因TRAIL和CASPASE-3表达.结果 (1)甲流患儿RIG/MDA5表达、TLR2、TLR4表达明显高于正常对照组[TLR2(9.69±3.15)×10-2vs.(3.96±0.83)×10-2,t=10.16,P＜0.05;TLR4(10.23±2.85)×10-2vs.(7.46±2.18)×10-2,t=3.76,P＜0.05],以重症甲流患儿增高为著,RIG/MDA5表达增高最为明显;TLRs途径信号传导分子MyD88、TRAM等表达明显高于轻症甲流患儿.(2)甲流患儿CD3+[(1.22±0.38)×109/Lvs.(3.59±1.10)×109/L,t=9.21,P＜0.05]、CD4+、CD8+T细胞及NK细胞绝对计数明显低于正常对照组,B细胞无明显改变.(3)轻症甲流患儿TNF-α、IL-6、IL-1β等炎症细胞因子血浓度或基因高于正常对照组,重症患儿炎症细胞因子TNF-α[(6.42±1.76)×10-2vs.(9.05±2.51)×10-2,t=4.55,P＜0.05]明显低于正常对照组.IFN-α/β表达持续高于正常对照组,尤以重症甲流患儿为著;IFN-I诱导基因IP-10[(20.52±6.09)×10-2vs(1.18±0.34)×10-2,t=18.74,P＜0.05]、RANTES或iNOS轻症患儿表达高于正常对照组,重症患儿表达则趋于减少.(4)甲流患儿CD3+[(32.90±7.66)%vs.(20.21±6.58)%,t=6.21,P＜0.05]、CD4+、CD8+T细胞、NK细胞凋亡高于正常对照组,以重症患儿更为显著.凋亡相关基因TRAIL和CASPASE-3表达明显高于正常对照组.(5)重症患儿PRRs负性凋节因子SOCS1、SOCS3、IRAK-M、TRAF4及FLN29表达明显高于轻症患儿,抗炎细胞因子IL-10及IL-10/TNFα比值随病情加重增高.结论 甲流患儿机体免疫功能紊乱,轻症患儿处于全身免疫激活状态,重症患儿同时存在免疫激活/免疫抑制反应.     

儿童2009甲型H1N1流感危重症14例临床特征

目的 分析儿童2009甲型H1N1流感危重症的临床特征.方法 对2009年10月1日至12月25日,我院儿科重症监护病房(PICU)14例2009甲型H1N1流感危重症患儿的临床特征及其预后进行分析.结果 14例平均年龄(4.91±4.14)岁,男女各7例,发病到入院时间为(3.09±1.30)d,从入院到入PICU时间为(0.95±0.96)d,所有患儿均表现出明显的低氧血症,入ICU时平均PaO2/FiO2(氧合指数)为(191.27±80.58)mm Hg(1 mm Hg=0.133 kPa),11例(78.6%)出现ARDS,10例(71.4%)行机械通气,平均通气时间为(12.51±10.03)d,平均ICU住院时间为(12.58±10.65)d,平均rRT-PCR检测甲型H1N1核酸呈阳性时间(17.27±5.57)d;8例(57.1%)患儿有缺铁性贫血、脑瘫和先天性心脏病等基础疾病;CK(肌酸激酶)、CK-MB(肌酸激酶同工酶)、cTnI(肌钙蛋白)和LDH(乳酸脱氢酶)在这些患儿中都有不同程度的升高;入院时第3代死亡危险评分(PRISM Ⅲ)较高和危重病例评分(PCIS)较低的患儿机械通气时间和ICU住院时间较长(P＜0.05).结论 苏州地区儿童2009甲型H1N1流感危重症病情进展快,短时间内即出现显著的低氧血症,甚至ARDS,并伴有不同程度的心肌损害,早期发现不利因素加以干预,是治疗成功的关键.     

儿童重症和危重症2009甲型H1N1流感临床特征

目的 报道儿童2009甲型H1N1流感重症与危重症的临床特征.方法 对150例经咽拭子实时荧光定量PCR检测确诊为2009甲型H1N1流感重症与危重症患儿的临床资料进行分析.结果 150例患儿中,男103例,女47例,年龄中位数为5岁;≥5岁81例,合并基础疾病21例.常见的表现依次为发热142例(95%),咳嗽133例(89%),呕吐35例(23%),喘息29例(19%),腹痛24例(16%),嗜睡11例(7%),惊厥9例(6%),肌痛9例(6%)和腹泻9例(6%).常见的检验异常为外周血白细胞计数异常60例(40%),C反应蛋白增高49例(33%),乳酸脱氢酶增高4.4例(29%),肌酸激酶增高38例(25%)和天冬氨酸转氨酶增高29例(19%).并发症主要为肺炎97例(65%),脑病18例(12%)和心肌炎7例(5%).使用奥司他韦治疗109例(73%),使用糖皮质激素治疗35例(23%).32例(21%)入住ICU,13例接受气管插管机械通气,14例接受支气管镜检查及冲洗.145例(97%)患儿治愈出院,5例死亡,其中3例死于脑病,1例死于急性呼吸窘迫综合征,1例死于继发性真菌性脑膜炎.结论 重症和危重症2009甲型H1N1流感主要发生在没有基础疾病的年长儿,其表现及检验异常比较广泛.神经系统并发症发生率较高,严重的脑病可引起死亡.早期行支气管镜检查及冲洗有可能减少肺部并发症引起的死亡.     

淋巴瘤患儿感染甲型H1N1流感病毒后所致重症肺炎四例诊治分析

目的 探讨化疗期间免疫抑制的恶性淋巴瘤患儿感染甲型H1N1病毒后所致重症肺炎的临床特点及治疗.方法 回顾性分析4例非霍奇金淋巴瘤患儿化疗期间合并甲型H1N1流感肺炎的临床表现、影像学特点、误诊原因、治疗体会及预后.结果 同期收治的54例恶性血液病患儿中,甲型H1N1流感病毒感染共4例,均为恶性淋巴瘤化疗后患儿,中性粒细胞绝对值均小于0.5×109/L.起病时体温均大于39℃,伴畏寒,血压下降,迅速出现呼吸困难和低氧血症,2例继发急性呼吸窘迫综合征.C反应蛋白均大于50 mg/L,2例大于200 mg/L;4例影像学均提示广泛间实质病变.例1早期被误诊为败血症,4例患儿17次血培养均阴性,20次痰培养中2例患儿各1次痰培养真菌阳性,考虑过真菌性肺炎.4例患儿均使用了磷酸奥司他韦,第1例于第5天加用,余3例于发热的第1天加用;4例均应用了丙种球蛋白,3例应用了甲泼尼龙治疗.治疗后2例死亡,2例好转.结论 恶性淋巴瘤患儿化疗期间合并甲型H1N1流感易致重症肺炎,进展迅速,早期症状与败血症不易鉴别,影像学与单纯真菌感染不易鉴别,易误诊,死亡率高.在H1N1流感流行季节,出现高热及时做病毒筛查,及早应用磷酸奥司他韦,并予大剂量丙种球蛋白冲击及甲泼尼龙等治疗可减少病死率.     

2009甲型H1N1流感住院患儿多中心临床研究

目的 了解2009年全国多中心2009甲型H1N1流感住院患儿的临床特征,探讨危重症的高危因素和死亡原因.方法 对2009年秋冬季全国17家医院的810例2009甲型H1N1流感住院患儿的临床表现、实验室检查结果以及治疗和转归进行回顾性总结和分析.结果 810例住院患儿中,男508例,女302例,年龄中位数为43个月,其中＜5岁550例(67.9%),合并基础疾病148例(18.5%).常见的表现及例数为:发热780例(96.3%),流涕294例(36.3%),鼻塞192例(23.7%),咽痛147例(18.1%),咳嗽759例(93.7%),咯痰347例(42.8%),喘息219例(27.0%),呼吸困难163例(20.1%),呕吐130例(16.0%),腹泻66例(8.1%),烦躁79例(9.8%),嗜睡64例(7.9%),惊厥32例(4.0%).常见的实验室异常为:外周血白细胞计数增高或降低377例(46.5%),乳酸脱氢酶增高346例(42.7%),C反应蛋白增高306例(37.8%),天冬氨酸转氨酶增高257例(31.7%),肌酸激酶增高174例(21.5%).586例(72.3%)合并肺炎,49例(6.0%)合并脑炎/脑病,30例(3.7%)合并心肌炎.危重症患儿183例,其基础疾病、外周血白细胞计数增高、中性粒细胞比率增高、淋巴细胞比率降低和C反应蛋白增高的发生率明显高于非危重症患儿.19例死亡,占危重患儿的10.4%,8例死于脑炎/脑病,10例主要死于严重肺炎和急性呼吸窘迫综合征,其中5例同时伴有脑炎/脑病,1例死于继发性真菌性脑膜炎.结论 2009甲型H1N1流感容易引起全身多脏器损害.有基础疾病、外周血白细胞计数增高、中性粒细胞比率增高、淋巴细胞比率降低和C反应蛋白增高可能是发生危重症病例的高危因素.合并严重肺炎和急性呼吸窘迫综合征,以及脑炎/脑病是导致死亡的主要因素.     

新生儿甲型流感6例临床分析

目的 探讨新生儿甲型流感的临床特点、诊断及治疗.方法 选择2009年11月至2010年2月本院新生儿内科病房收治的甲型流感患儿进行回顾性分析.结果 甲型流感患儿中新型甲型H1N1流感2例,患病前有感冒患者接触史4例,症状表现为发热、吐沫、咳嗽、呛奶、反应弱、纳差、腹泻.甲型流感病毒通用M基因阳性6例;猪H1N1流感病毒通用NP基因阳性2例;白细胞总数升高3例;分类以中性粒细胞为主4例;C反应蛋白升高3例;心肌酶升高4例;肝酶升高1例;胸部X线片示肺炎3例;心电图T波低平2例,ST段上移1例;血培养均阴性;脑脊液常规、生化均正常.6例患儿均未使用奥司他韦等抗病毒药物,以抗生素、中药以及保肝、营养心肌等对症支持治疗,预后良好.结论 新生儿甲型流感临床表现缺乏特异性,患儿可出现肺炎、心肌损害、肝功损害等并发症,但病程多具有自限性,预后较好,是否需应用奥司他韦等抗病毒药物有待探讨.