新生儿先天梅毒临床分类及治疗探讨

目的探讨新生儿先天梅毒(CS)临床分类及治疗.方法回顾性分析1996年7月至2000年12月我科收治的新生儿CS 111例.结果有临床表现的新生儿CS 81例,临床表现复杂,多样化,累及多个脏器,依次为肢端掌趾脱皮、斑疹,肝脾肿大,低体重,呼吸困难,腹胀,梅毒性假麻痹、贫血、黄疸、血小板减少和水肿.梅毒血清学(RPR及TPHA)阳性.无临床表现30例,但梅毒血清学检查阳性.青霉素治疗有效,未发现不良反应.13例因不可逆的严重多脏器损害死亡.随访26例,体格发育无明显异常,血RPR 6个月时转阴15/22例(68.1%),12个月时转阴20/22例(90.9%),TPHA 12个月时转阴10/16例(62.5%).结论新生儿CS临床可分为二类,具有典型早期临床表现和无症状先天梅毒.诊断要依据临床表现、梅毒血清学检查及母梅毒病史.青霉素治疗有效.     

《中国儿童肥厚型心肌病诊断的专家共识》诊断价值国内多中心研究

目的　比较《中国儿童肥厚型心肌病诊断的专家共识》（简称国内共识）与《2020年AHA/ACC肥厚型心肌病诊断及治疗指南》（简称AHA/ACC指南）对儿童肥厚型心肌病（HCM）的诊断价值。方法　回顾性分析2015年1月至2019年12月国内32家医院收治的466例心肌肥厚患儿的临床资料,以超声心动图最终随访结果和基因检测结果为金标准,分别按国内共识及AHA/ACC指南制定的诊断流程进行诊断,其诊断结果分为确诊和排除,比较国内共识和AHA/ACC指南对儿童HCM诊断的敏感度、特异度和准确度。结果　466例心肌肥厚患儿超声心动图检查以室间隔和左室后壁肥厚者最多（57.08%）,其次为室间隔肥厚（31.33%）,第3位为左室后壁肥厚（9.23%）,心尖部肥厚患儿最少（2.36%）。93例患儿行基因检测,其中32例存在致病性变异,27例为可能致病性变异。按照金标准,全组病例中396例确诊为HCM,排除70例;按照国内共识确诊370例,排除96例;按照AHA/ACC指南确诊346例,排除120例。国内共识和AHA/ACC指南对所有病例的诊断特异度均为100%;对于全组病例、＞1岁病例和未行基因检测病例,国内共识诊断的敏感度和准确度均高于AHA/ACC指南,且国内共识的Youden指数高于AHA/ACC指南（P＜0.01）;对于≤1岁病例,AHA/ACC指南的诊断敏感度和准确度稍高于国内共识,但二者 Youden指数差异无统计学意义（P＞0.05）。结论　国内共识和AHA/ACC指南均可准确诊断儿童HCM,但国内共识更加适合于我国儿童HCM的精准诊断。     

先天性梅毒的流行病学和诊断治疗现状

梅毒（syphilis）是严重危害人类身心健康的一种性传播疾病,最早起源于美洲,后逐渐传播至全世界。新中国成立之后,梅毒一度被消灭。自1979年中国大陆再次报道梅毒病例至今,梅毒已在全国呈明显的流行趋势,在部分省市,梅毒已占各种法定报告传染疾病的首位,预防与控制梅毒已迫在眉睫。本文就先天性梅毒（congenital syphilis,CS）的流行病学、病原学、病理改变、规范化处理、诊断治疗和随访等综述如下。     

儿童系统性红斑狼疮(附24例临床分析)

系统性红斑狼疮(简称SLE)是一种多系统受累的自身免疫性疾病,大约20%的病例在儿童期发病。兹将我科1975～1986年收治的24例分析如下。临床资料一、诊断标准本组病例均按美国风湿病协会1982年6月对SLE修订之诊断标准:①蝶形红斑;②盘状红斑;③日光过敏;④口腔溃疡;⑤关节炎;⑥浆膜炎;⑦肾脏损害;⑧神经障碍;⑨血液障碍(溶血性贫血或白细胞<4×10~9/L或淋巴细胞<1.5×10~9/L或血小板<100×10~9/L);⑩免疫障碍(狼疮细胞阳性或抗脱氧核糖核酸抗体阳性,或抗SM抗体阳性,或梅毒血清反应阳性);(11)抗核抗体滴     

儿童库欣综合征的诊断标准

由于儿童库欣综合征(CS)血皮质醇水平波动范围大,其病因复杂,不同病因相关激素水平往往有重叠,诊断及鉴别诊断常常十分困难.现介绍近年国际上欧洲内分泌学会及不同的多中心工作组制定的包括儿童患者在内的CS的诊断共识和指南,以加强儿科临床工作者对CS的认识.     

基于AGREEⅡ的儿童泌尿系感染临床实践指南质量现状分析

目的对全球儿童泌尿系感染(UTI)临床实践指南质量进行评价,为规范制订我国儿童UTI临床指南提供参考。方法计算机检索MEDLINE、EMbase、National Guideline Clearinghouse、Guidelines International Network、National Institute for Health and Clinical Excellence,以及万方、中国知网及中国指南协作网(从建库到2015年1月)等中英文数据库和相关网站。根据纳入、排除标准筛选公开发表的有关儿童UTI的临床指南,按照国际公认的指南评价工具(AGREE)分析纳入指南的方法学质量,使用组内相关系数(ICC)进行评价员间一致性检验。结果共纳入10篇儿童UTI指南,覆盖4个洲9个组织。指南发布时间跨度为1999—2015年,其中7篇为首版,3篇为更新版。纳入指南主题涉及诊断、管理、预防、危险因素评估和治疗等,均是基于循证证据的指南。纳入指南AGREEⅡ评分显示,6个领域的评价得分分别为88%、57%、54%、98%、26%、44%;纳入7篇指南的范围及目的、清晰性领域的评分均50%;英国国家卫生与临床优化研究所(NICE)、阿拉贡健康科学研究所(IACS)发布指南的6个领域评分均50%。结论不同国家和地区儿童UTI临床指南的质量差别较大。循证是当前临床实践指南的发展趋势,应注重指南制定方法的严谨性、报告的规范性和指南的实用性。     

先天梅毒新生儿临床特点和诊治

目的总结先天梅毒新生儿的临床特点,探讨诊断和治疗措施。方法回顾33例先天梅毒新生儿的病史资料、临床表现、诊断依据及治疗方案。将抗梅毒治疗所需天数作为疗效反应指标,并据此分组,<21 d属敏感组,≥21 d者为不敏感。比较两组性别、胎龄、出生体质量、入院年龄、重要脏器合并症及母亲妊娠期抗梅毒治疗是否存在差异。结果除3例剔除病例,余30例患儿均好转或治愈出院,无死亡病例。先天梅毒新生儿同时存在2个或2个以上重要脏器合并症者18例(54.55%)。两组胎龄、重要脏器合并症及母亲妊娠期是否接受抗梅毒治疗比较均有显著差异,P均<0.05。结论经正规抗梅毒治疗,先天梅毒可治愈,但其预后取决于病原体已造成的损害程度。     

先天性梅毒发病与否和早期干预

近几年 ,梅毒的发病率有明显增加趋势 ,母亲一旦感染梅毒其危害极大 ,梅毒螺旋体可通过胎盘直接感染胎儿致先天梅毒 ,严重者可致流产、早产、死胎和围产期死亡。本文对我院１９９９年９月～２００１年５月１４例妊娠并存梅毒孕妇分娩的新生儿临床资料进行回顾性总结如下。临床资料一、病例来源病例资料来自１９９９年９月～２００１年５月在本院分娩的１４例新生儿 ,其母被诊断为妊娠合并梅毒。诊断方法为所有来本院产前检查者 ,抽血查快速血浆反应素试验 (ＲＰＲ) ,进行梅毒血清学筛查 ,试剂盒由上海荣盛生物技术公司提供。如ＲＰＲ阳性 ,…     

母梅毒之新生儿13例临床分析

对母确诊为梅毒的13例新生儿病例进行临床分型、影像学检查、免疫测定和定期随访,探讨母产前梅毒螺旋体治疗情况对新生儿发病的影响,新生儿期先天性梅毒(CS)的主要临床表现。新生儿期确诊为CS共5例,疑诊3例,正常5例;确诊5例中母未治疗4例,产时较治疗前RPR滴度下降<4倍1例,产时RPR滴度>1:4共4例,新生儿RPR滴度≥母4倍3例。CS临床表现以早产、肝脾肿大、皮疹为主。神经系统早期改变主要为脑脊液蛋白增高。13例中失防2例,确诊组和正常组各1例;确诊组1例给予重复治疗,3例RPR滴度不同程度下降;疑诊组RPR滴度均在4个月内阴转;正常组持续阴性。结论:新生儿期的CS症状不典型,需根据临床、X线检查以及血清学等综合分析进行诊断。母产前定期监测、有效治疗可降低CS的发病率,而新生儿科医师对该病的认识和警惕性有利于患儿得到及时治疗。     

新生儿先天性梅毒预防及早期诊断探讨

目的 探讨母亲梅毒治疗情况对新生儿先天性梅毒发病的影响.方法 回顾性分析2007年1月至2010年6月我科梅毒螺旋体明胶颗粒凝集试验(TPPA)阳性新生儿的临床资料.将TPPA阳性新生儿分成母亲正规治疗组、非正规治疗组及未治疗组,对3组新生儿先天性梅毒发病情况进行统计学分析,总结新生儿先天性梅毒的临床表现.结果 117例TPPA阳性新生儿中,确诊先天性梅毒患儿26例.母亲正规治疗组新生儿先天性梅毒发生率明显低于非正规治疗组及未治疗组（6.6％比47.1％、36.1％,P均＜0.01）.新生儿先天性梅毒可累及多个系统,表现为皮肤损害、病理性黄疸、肝脾肿大、水肿、贫血、血小板减少、C反应蛋白增高、骨损害、脑脊液异常等.结论 新生儿先天性梅毒临床表现缺乏特异性,早期诊断需结合母亲病史及梅毒血清学检查.积极防治母亲梅毒感染是预防新生儿先天性梅毒的关键.     

Policy statement—Recommendations for the prevention of perinatal group B streptococcal (GBS) disease

The Centers for Disease Control and Prevention (CDC) guidelines for the prevention of perinatal group B streptococcal (GBS) disease were initially published in 1996. The American Academy of Pediatrics (AAP) also published a policy statement on this topic in 1997. In 2002, the CDC published revised guidelines that recommended universal antenatal GBS screening; the AAP endorsed these guidelines and published recommendations based on them in the 2003 Red Book. Since then, the incidence of early-onset GBS disease in neonates has decreased by an estimated 80%. However, in 2010, GBS disease remained the leading cause of early-onset neonatal sepsis. The CDC issued revised guidelines in 2010 based on evaluation of data generated after 2002. These revised and comprehensive guidelines, which have been endorsed by the AAP, reaffirm the major prevention strategy--universal antenatal GBS screening and intrapartum antibiotic prophylaxis for culture-positive and high-risk women--and include new recommendations for laboratory methods for identification of GBS colonization during pregnancy, algorithms for screening and intrapartum prophylaxis for women with preterm labor and premature rupture of membranes, updated prophylaxis recommendations for women with a penicillin allergy, and a revised algorithm for the care of newborn infants. The purpose of this policy statement is to review and discuss the differences between the 2002 and 2010 CDC guidelines that are most relevant for the practice of pediatrics.     

Consistency of diagnostic criteria for acute otitis media: a review of the recent literature

Clinicians use various criteria to diagnose acute otitis media (AOM). Using American Academy of Pediatrics (AAP) guidelines, we reviewed the consistency of AOM diagnosis in clinical trials (1994-2005). Eighty-one percent of the studies required at least one of the three AAP criteria. Only 20% of the 88 studies met all three AAP criteria for a diagnosis. We found no association between the number of criteria met and study quality or industry sponsorship. Better agreement on the definition of AOM using AAP criteria could facilitate a more accurate clinical diagnosis and provide standardization of research and patient care practices.     

Improving guideline adherence for the diagnosis of ADHD in an ambulatory pediatric setting.

BACKGROUND: The American Academy of Pediatrics (AAP) has published clinical practice guidelines for the diagnosis of Attention Deficit Hyperactivity Disorder (ADHD). However, implementation of guidelines has been notoriously difficult to achieve in the wider context of changing individual physicians' clinical practice. OBJECTIVE: Implement a formalized diagnostic protocol for ADHD and study whether this protocol improved adherence of pediatric residents and faculty to published guidelines for the diagnosis of ADHD. METHODS: Quasi-experimental retrospective record review of 63 pediatric patients evaluated for ADHD by pediatric residents and faculty in an outpatient pediatric clinic before (n = 25) and after (n = 38) implementation of a formal diagnostic process for ADHD. The key elements of the new diagnostic process include completion of a semistructured interview and mandatory rating scales for home and school. The published AAP guidelines include 1) documentation of Diagnostic and Statistical Manual for Mental Disorders (DSM) IV criteria; 2) evidence of core symptoms obtained directly from home and 3) from school; and 4) assessment for coexisting conditions. Adherence was assessed to each criterion individually (yes/no) and was summarized in a single score. RESULTS: Only 4% of clinicians and nurse practitioners diagnosing children in the before group adhered to all 4 AAP guidelines, compared to 82% in the after group (P < .001). Significant improvement was observed across each of the 4 criteria in the AAP guidelines. Moreover, the improvement in adherence to all 4 guidelines was noted for residents and faculty. CONCLUSION: A significant improvement in adherence to AAP guidelines was obtained for all providers through implementation of a structured diagnostic approach to ADHD.     

小于胎龄儿临床分型标准的探讨

目的 观察小于胎龄儿(small for gestational age infants,SGA)的临床分型情况,并评价我国现行的SGA分型方法与SGA定义分型的相关性。方法 采用回顾性调查方法,根据“试行草案”中重量指数(ponderal index,PI)及身长／头围比值分型标准对417例SGA进行临床分型,并以SGA的定义分型为“金标准”,评价PI及身长／头围比值的分型结果。结果 (1)按PI、身长／头围比值及定义的标准,417例SGA中匀称型分别为376例(90．17％)、376例(90．17％)和187例(44．84％)。PI与身长／头围比值的诊断符合率为80．82％,但反映诊断结果一致性的指标Kappa值为-0．093。(2)PI和身长／头围比值分型与SGA定义分型的符合率分别为49．88％和50．84％。与定义标准相比,PI及身长／头围比值的敏感性为91．84％～96．38％,特异性为9．30％～25．86％,假阳性为74．14％～90．70％,诊断指数为4．95％～17．70％,Kappa值为0．070～0．167。(3)ROC曲线分析显示,足月儿和早产儿PI值的ROC曲线下面积分别为0．635和0．698;身长／头围比值法的ROC曲线下面积为0．673。结论 我国目前“试行草案”中PI及身长／头围比值两种分型标准不够合理,有进一步探讨的必要。ROC结果亦提示此两种分型方法总体上诊断价值偏低。     

Group B streptococcal infection early onset disease controversies in prevention guidelines, and management strategies for the neonate

Group B streptococcus (GBS) has been a major pathogen that is particularly devastating to the newborn for more than two decades. Initial guidelines were promoted by the AAP in 1992 to help deal with this organism, but these recommendations were poorly accepted and not widely used. In 1996-1997 the AAP, CDC, and ACOG created new guidelines for the management of the mother and infant at risk for GBS. Though usually in agreement, these three sets of recommendations still have some differences that may be confusing to the pediatrician. This paper looks at the acquisition, intrapartum treatment, and postnatal management of GBS, along with some of the controversies associated with the management of this disease.     

Classifying recommendations for clinical practice guidelines

Clinical practice guidelines are intended to improve the quality of clinical care by reducing inappropriate variations, producing optimal outcomes for patients, minimizing harm, and promoting cost-effective practices. This statement proposes an explicit classification of recommendations for clinical practice guidelines of the American Academy of Pediatrics (AAP) to promote communication among guideline developers, implementers, and other users of guideline knowledge, to improve consistency, and to facilitate user understanding. The statement describes 3 sequential activities in developing evidence-based clinical practice guidelines and related policies: 1) determination of the aggregate evidence quality in support of a proposed recommendation; 2) evaluation of the anticipated balance between benefits and harms when the recommendation is carried out; and 3) designation of recommendation strength. An individual policy can be reported as a "strong recommendation," "recommendation," "option," or "no recommendation." Use of this classification is intended to improve consistency and increase the transparency of the guideline-development process, facilitate understanding of AAP clinical practice guidelines, and enhance both the utility and credibility of AAP clinical practice guidelines.     

排尿性尿路超声造影对儿童原发性膀胱输尿管反流的诊断价值

目的 探讨排尿性尿路超声造影(contrast-enhanced voiding urosonography,CeVUS)对儿童原发性膀胱输尿管反流(vesicoureteral reflux,VUR)的诊断价值.方法 回顾性分析上海儿童医学中心2018年12月至2020年6月116例[232个肾盂-输尿管单位(pye...     

Resurgence of congenital syphilis in Trinidad

Twenty-eight cases of congenital syphilis (CS) were diagnosed shortly after birth at the Mount Hope Women's Hospital, Trinidad, during the period January 1985 to December 1988. The average annual incidence of CS was 115 per 100,000 live births, and the absolute number of cases and annual incidence doubled in the latter 2 years of the study. Diagnostic criteria used were a positive VDRL test in the 23 liveborn infants (100 per cent), signs suggestive of CS and confirmatory post-mortem findings. All mothers attended antenatal clinic at least once and 18 (64 per cent) were 25 years or younger. Only 17 (68 per cent) of the 25 gravidae with a positive VDRL test received treatment. Of 11 untreated gravidae, two did not have a VDRL test done, one had a negative VDRL test, three delivered before test results became known, one went into labour before going for treatment, and four (two of whom were substance abusers) did not comply with instructions to obtain treatment. There were five stillbirths and five neonatal deaths. There was no perinatal mortality when treatment was given earlier than 5 weeks before delivery, but mortality increased steeply if treatment was delayed or not given at all during pregnancy. Factors which contributed to this rise in the incidence of CS were an increased incidence of syphilis in females and failure to treat infected pregnant women.     

An Adapted Child Safety Seat Hassles Score Is Associated With Suboptimal Child Passenger Safety Behaviors Among Parents

ObjectiveWe modified the Child Safety Seat (CSS) Hassles Scale to characterize CSS hassles in a diverse population and test for associations between hassles and caregiver-reported child passenger safety behaviors.MethodsSecondary analysis of a 2-site survey of caregivers seeking emergency care for their ≤10-year-old child in 2015. Caregivers answered questions regarding CSS hassles, child passenger safety behaviors, and demographics. Size-appropriate restraint use was defined by the American Academy of Pediatrics (AAP) 2011 Guidelines for Child Passenger Safety. We tested for associations between the number of hassles and adherence to AAP guidelines (including the consistent use of a size-appropriate CSS, travel in a back seat, and never traveling unrestrained).ResultsThere were 238 caregivers included in analyses. Overall, caregivers endorsed a median of 5 hassles (interquartile range 2, 8). Half (50.8%) of caregivers endorsed child passenger safety behaviors that were nonadherent to AAP guidelines. Compared with caregivers reporting no hassles, there was an increased odds of not adhering to AAP child passenger safety guidelines for each additional hassle reported (adjusted odds ratio [aOR] 1.11; 95% confidence interval [CI] 1.03, 1.19). In addition, a higher number of hassles was associated with the inconsistent use of a size-appropriate CSS (aOR 1.15; 95% CI 1.06, 1.25) and as sometimes traveling unrestrained (aOR 1.13; 95% CI 1.03, 1.23).ConclusionsCaregivers who reported more CSS hassles were more likely to report behaviors that were not adherent to AAP guidelines. Addressing CSS hassles may provide solutions for nonadherence of AAP child passenger safety guidelines.