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目的了解单次小剂量(0.4g/kg)静脉输注免疫球蛋白(IVIG)提升初发免疫性血小板减少性紫癜(ITP)患儿血小板至安全范围(≥30×109/L)的作用。方法研究对象为北京大学第一医院儿科2008-04-01—2011-04-01收治初发ITP患儿62例,其中2008-04-01—2009-10-01收治的30例为激素组,初始接受常规剂量醋酸泼尼松治疗;2009-10-02—2011-04-01就诊的32例为IVIG组,初始接受0.4g/(kg·d)IVIG治疗1～5d,每天复查血常规,血小板升至安全范围则规范停用。比较两组治疗第1、3、5天时血小板升至安全范围比例及长期随访结果。结果治疗前,激素组和IVIG组血小板中位值分别是10×109/L和6×109/L。治疗1d后两组血小板升至安全范围的比例分别是3.33%和43.75%,差异有统计学意义(P<0.01)。随访7～42个月后激素组和IVIG组分别有3.45%和3.23%血小板未升至正常(≥100×109/L)。所有患儿均无颅内出血发生及死亡。结论单次小剂量IVIG可使近半数初治ITP患儿血小板升至≥30×109/L相对安全范围,明显高于常规剂量醋酸泼尼松疗效。     

抗-D免疫球蛋白治疗儿童免疫性血小板减少症疗效的Meta分析

目的采用Meta分析方法评估抗-D免疫球蛋白(anti-D)治疗儿童新近诊断的免疫性血小板减少症(ITP)的临床疗效及安全性。方法检索PubMed、EMBASE、Cohrane Library、Ovid、中国知网及万方数据库,收集相关的随机对照试验(RCT)文献,检索时间均为建库至2017年4月,采用Review Manager 5.3软件进行Meta分析。结果有7篇RCT文献符合纳入标准。Meta分析结果显示,在治疗72 h、7 d后anti-D组血小板(PLT)20×10~9/L的患儿百分比低于静脉用免疫球蛋白(IVIG)组(P0.05);anti-D 50μg/kg组与IVIG组治疗24 h、72 h及7 d后的PLT计数比较差异无统计学意义(P0.05);anti-D 50μg/kg组与anti-D 75μg/kg组治疗24 h、7 d后的PLT计数比较差异无统计学意义(P0.05)。治疗后anti-D组比IVIG组血红蛋白含量下降更明显,但均不需要输血。anti-D组与IVIG组均未出现严重不良反应。结论静脉注射anti-D治疗儿童急性ITP在提高PLT计数方面效果可能与IVIG相同,但在治疗后PLT上升的反应速度方面效果可能略差于IVIG。使用剂量为50μg/kg和75μg/kg的anti-D疗效可能相当。使用推荐剂量的anti-D治疗ITP是安全的。     

HD-MP与IVIG代替全血或血小板输注在抢救重度ITP中的疗效评价

探讨大剂量甲基强的松龙 (HD MP)冲击与静脉注射免疫球蛋白 (IVIG)两种方法替代全血或血小板输注在重度、极重度急性型特发性血小板减少性紫癜 (ITP)抢救中的价值。方法　对 36例入院时PLT≤ 18× 10 9 L、出血倾向明显的重度、极重度急性型ITP患儿随机分两组 ,Ig组 :IVIG 4 0 0mg kg·d ,连用 5天 ,接强的松 2mg kg·d口服 ;MP组 :MP 15- 30mg kg·d ,连用 3天 ,接强的松 2mg kg·d口服。连续监测治疗效果。结果　IVIG组用药 2 .1± 1.1天出血征开始减轻 ,5 .0± 1.9天PTL升至≥ 10 0× 10 9 L ,6 .7± 1.8天PTL达到峰值 334± 10 6× 10 9 L。MP组用药 5 .3± 1.5天出血倾向开始减轻 ,7.3± 2 .4天PLT升到≥ 10 0× 10 9 L ,10 .0± 2 .5天PLT达到峰值 199± 92× 10 9 L。两组三项指标均差异显著 (P <0 .0 1)。结论　在重度、极重度急性型ITP伴严重出血倾向患儿的抢救中 ,IVIG比HD MP冲击疗法升高PLT的作用更迅速、显著 ,是重度、极重度急性型ITP防治危及生命的严重出血代替血小板输注的较理想药物     

静注免疫球蛋白及地塞米松对特发性血小板减少性紫癜患儿免疫功能的影响

探讨大剂量地塞米松 (DEX)及静注免疫球蛋白 (IVIG)治疗 ,对特发性血小板减少性紫癜 (ITP)患儿外周血 T淋巴细胞亚群及免疫球蛋白的影响 ,在以DEX、IVIG治疗 ITP患儿 ,治疗前后各抽血一次 ;以 APAAP法测定 T淋巴细胞亚群 ,以单向琼脂免疫扩散法测定免疫球蛋白。结果表明 1.ITP患儿外周血 CD4+ 降低 ,CD8+增高 CD4+ /CD8+ ,显著降低。单纯 DEX组治疗后 ,CD4+、CD8+均显著降低 ,CD4+ /CD8+升高 ,Ig A、Ig G、Ig M降低 ;单纯 IVIG组治疗后 ,CD8+显著降低 ,CD4+ /CD8+升高 ,Ig G显著升高。2 .单纯 DEX组治疗后 ITP患儿外周血白细胞计数显著高于治疗前 ,单纯 IVIG组与 IVIG加 DEX组治疗前后无显著差异。治疗过程中院内交叉感染率单纯 DEX组为 31.43% ,单纯 IVIG治疗组为 2 5 % ,IVIG加 DEX组为2 8.5 7%。因此 ,本文认为 ITP患儿外周血 T淋巴细胞亚群表达异常 ,IVIG及 DEX治疗均干扰了 ITP患儿机体的免疫状态     

糖皮质激素与静脉注射人免疫球蛋白治疗儿童原发性免疫性血小板减少症meta分析

目的分析糖皮质激素与静脉注射用人免疫球蛋白(IVIG)治疗儿童急性原发性免疫性血小板减少症(ITP)的有效性及安全性。方法计算机检索Pub Med、the Cochrane Database of Systematic Reviews、the Cochrane Central Register of Controlled Trials、中国生物医学文献数据库(CBM)、中国期刊全文数据库(CNKI)、万方数据库,手工查阅计算机检索到的文献的参考文献目录,按照纳入与排除标准筛选文献,提取数据和评价纳入文献的质量,采用Revman 5.3软件进行meta分析。结果共检索到相关文献1 500篇,有8篇文献符合纳入标准。meta分析显示,治疗48 h后,糖皮质激素组与IVIG组血小板计数(PLT)??20×109/L的差异有统计学意义(RR=0.77,95%CI:0.67~0.89);亚组分析,甲基泼尼松龙(MP)30 mg/kg与IVIG 1 g/(kg·d)×2 d比较,泼尼松(PDN)4 mg/kg与IVIG 1 g/(kg·d)×2 d比较,差异均有统计学意义(RR=0.66,95%CI:0.47~0.91;RR=0.79,95%CI:0.66~0.95)。治疗24、72 h后,糖皮质激素组与IVIG组血小板计数??20×109/L比较,差异有统计学意义(RR=0.69,95%CI:0.53~0.91;RR=0.82,95%CI:0.74~0.90)。治疗24、48、72 h后糖皮质激素组与IVIG组血小板计数??50×109/L比较,差异有统计学意义(RR=0.38,95%CI:0.21~0.69;RR=0.53,95%CI:0.41~0.69;RR=0.80,95%CI:0.70~0.93)。糖皮质激素组与IVIG组脾切除发生率的差异无统计学意义(RR=5.41,95%CI:0.95~30.74,P=0.06)。结论接受糖皮质激素治疗的急性ITP患儿在初始治疗48 h达到血小板计数??20×109/L的概率较接受IVIG患儿低23%;以在前3天内将血小板计数提升到??50×109/L为初始治疗目标,IVIG的效果更好。     

严重脓毒症患儿血小板减少原因及处理对策

目的结合血常规、凝血功能及骨髓细胞学检查,探讨严重脓毒症患儿PLT减少的原因及临床处理措施。方法选取严重脓毒症患儿72例,根据预后分为存活组和死亡组,对2组患儿的PLT计数与预后关系进行分析;分析PLT减少患儿入院时脏器累及情况;结合凝血功能监测与骨髓细胞学检查分析PLT减少的原因及其处理对策。结果死亡组入院当天及入院后7 d PLT计数与存活组相比有统计学差异。PLT<80×109L-129例患儿入院时受累器官数目≥3个19例(65.5%),死亡8例(27.6%);而PLT<50×109L-113例中受累器官数目≥3个10例(76.9%),死亡6例(46.2%)。14例死亡患儿中因PLT重度减低/DIC致重要脏器出血死亡6例(42.9%)。29例PLT减少患儿中,20例(69.0%)伴有凝血功能异常,9例(31.0%)伴骨髓巨核系成熟障碍。13例PLT<50×109L-1患儿中给予积极处理11例(84.6%),死亡4例(36.4%);未能积极处理2例(15.4%),全部死亡。结论PLT持续进行性下降提示预后差;针对PLT减少病因积极处理可显著改善预后。     

持续性和慢性免疫性血小板减少症的临床研究

目的探讨持续性免疫性血小板减少症(persistent ITP,pITP)和慢性免疫性血小板减少症(chronic ITP,cITP)患儿临床特征和疗效。方法对2002年12月-2009年12月间于我院诊断和治疗的pITP和cITP患儿103例的临床资料进行回顾性分析。结果 (1)103例患儿中96.1%年龄分布在学龄前期及以后;男女性别比例为1.24∶1。(2)73.8%有诱因,其中上呼吸道感染占89.5%;患儿病原血清学IgM阳性率为45.0%,混合感染率为36.1%。(3)有黏膜出血者占61.2%,失血性贫血者占25.2%,以轻度贫血为主。就诊时血小板计数<25×109/L者占71.9%。黏膜出血组与非黏膜出血组的血小板计数比较差异无显著性;而血小板减少与贫血程度间比较差异亦无显著性(P>0.05)。(4)遵医嘱维持用药治疗者占59.2%,该组患儿黏膜出血的发生率(55.7%)低于维持间断治疗组(69.0%);而维持用药组患儿失血性贫血发生率(8.2%)显著低于间断治疗组(50.0%),差异有极显著性(χ2=23.034,P<0.001)。(5)单用激素组(79.7%)、激素+IVIG(静脉注射用人免疫球蛋白)组(78.6%)治疗有效率高于激素+VCR(长春新碱)组(40.0%);激素+IVIG与激素+VCR组间疗效差异有显著性(χ2=4.441,P=0.035);单用激素组与激素+VCR组间疗效差异有显著性(χ2=9.772,P=0.002)。结论 (1)pITP和cITP患儿主要见于学龄前期及学龄期儿童,性别差异不明显。(2)上呼吸道感染是儿童pITP和cITP发生的主要诱因,病毒感染在ITP病情反复中起着一定的作用。(3)pITP和cITP患儿出血程度较轻,血小板减少以重型、极重型居多;而出血表现、贫血程度与血小板减少间无相关性。(4)维持用药可减轻pITP和cITP患儿出血症状,降低失血性贫血发生率。(5)单用激素组、激素+IVIG组的治疗有效率显著高于激素+VCR组。     

小剂量静注丙种球蛋白治疗儿童免疫性血小板减少性紫癜的疗效观察

为寻求应用静脉丙种球蛋白 (IVIG)治疗免疫性血小板减少性紫癜 (ITP)的最佳方法 ,将我院自 1 996年 1 1月以来收住的 ITP患儿随机分为两组 :A组应用小剂量 IVIG,即 0 .4g/ (kg·d)连用 2天 ;B组应用大剂量 IVIG,即 0 .4g/ (kg·d)连用5天。结果显示 :小剂量 IVIG与大剂量 IVIG治疗 ITP的疗效相当。小剂量 IVIG可以替代大剂量 IVIG作为 ITP患儿的急救方法     

儿童特发性血小板减少性紫癜治疗反应对疾病急慢性预测价值探讨

特发性血小板减少性紫癜(ITP)是儿科最常见的出血性疾病,根据病程可分为急性和慢性两型,以急性最为多见。约20%~25%的急性ITP将发展成慢性难治性ITP[1]。初治ITP患儿治疗反应与疾病预后是否有关,对此我们进行了回顾性分析。资料和方法1病例选择64例病例来源于2003年6月至2006年1月在我院住院治疗及出院后随访6月以上患儿。所有病例都为初诊初治,均符合ITP诊断标准[2],除外同时合并呼吸系统或其它系统感染者。记录资料包括:诊断时年龄、性别、治疗措施、治疗反应和实验室检查。2治疗方法血小板(PLT)<15×109/L伴严重出血(如消化道出…     

凉血消斑汤佐治小儿急性特发性血小板减少性紫癜疗效观察

特发性血小板减少性紫癜(ITP)又称自身免疫性血小板减少性紫癜,是儿童常见的出血性疾病,主要的临床特点是皮肤、黏膜自发性出血和束臂试验阳性,血小板(PLT)减少、出血时间延长或血块收缩不良.重症病例可因严重出血而危及生命,治疗上多采用糖皮质激素及丙种球蛋白(IVIG)等治疗方法,但两种治疗方法各有利弊.ITP属祖国医学"血证"、"紫斑"等范畴,近年来我院儿科与中医院儿科协作采用凉血消斑汤与IVIG及泼尼松联合用药的方法对住院的ITP患儿进行治疗,获得比较显著的疗效,现总结如下.     

6个月内川崎病患儿临床特点

目的 分析6个月内川崎病(KD)患儿的临床特点,提高对该年龄组KD患儿的认识和早期诊断水平.方法 收集2005年1月-2010年12月本院收治的KD患儿487例,分为≤6个月组67例(14%),>6个月组420例(86%).≤6个月又分为冠状动脉病变组(CAL组)和冠状动脉正常组(NCAL 组),对患儿相关临床资料进行回顾性分析.结果≤6个月组和>6个月组临床表现(球结膜充血:68.7% vs 79.5%,P<0.05;颈部淋巴结大:25.4% vs 64.3%,P<0.05)及实验室检查[白细胞计数(20.31±0.83)×109 L-1 vs (16.56±0.29)×109 L-1,P <0.05;血红蛋白 (97.37±1.22) g·L-1 vs (109.01±0.64) g·L-1,P<0.05;血小板(453.34±22.99 )×109 L-1 vs (338.26±6.33)×109 L-1,P<0.05;AST (43.87±6.52) U ·L-1 vs (67.64±4.23) U·L-1,P<0.05]均存在显著差异.虽然≤6个月组不完全KD的发病率明显升高(59.7% vs 33.6%,P<0.05),但冠脉损害率无显著差异(52% vs 53%,P>0.05).≤6个月CAL组和NCAL 组血红蛋白及血小板比较,差异均有统计学意义.结论 6个月内小婴儿由于临床表现迟发,且不典型,诊断及治疗也就相应延迟,心脏超声示冠状动脉异常可作为6个月内完全KD确诊的金指标.     

丙种球蛋白强的松联合治疗急性特发性血小板减少性紫癜近期疗效观察

目的：　探讨丙种球蛋白、强的松联合治疗血小板减少性紫癜(ITP)的近期疗效。方法：　观察组采用蓉生静丙,剂量每日400mg/kg,连用5d,后续用强的松治疗4周;对照组单用强的松4～6周。 结果：　观察组血小板达高峰时间为1～2周,峰值约180×10 9/L,总有效率为86.7%;对照组上述数值分别为4周,116×10 9/L和40% (P<0.05)。结论：　丙种球蛋白、强的松联合治疗ITP明显优于单用强的松组。     

Randomized trial of high-dose methylprednisolone versus intravenous immunoglobulin for the treatment of acute idiopathic thrombocytopenic purpura in children

BACKGROUND: Idiopathic thrombocytopenic purpura (ITP) is an acquired disorder characterized by immune-mediated platelet destruction. The authors performed a prospective, randomized trial comparing intravenous immunoglobulin (IVIG) with high-dose intravenous methylprednisolone in the treatment of children with acute ITP. The primary aim of the study was to compare the rate of platelet increase produced by either intervention. A decision to treat was based on the clinical presentation and not an arbitrary platelet count. In general, enrolled patients exhibited extensive bruising and platelet counts less than 10 x 10 /L (10,000/microL). PATIENTS AND METHODS: Seventy-seven consecutive patients, for whom the attending hematologist determined acute treatment was warranted, were studied. Forty-two patients received IVIG (1 g/kg/dose x2) and 35 received methylprednisolone (30 mg/kg/dose x3). Patients who exhibited an increase in platelet count of more than 50,000/microL after the first IVIG dose or the second methylprednisolone dose did not receive the second IVIG dose or the third methylprednisolone dose, respectively. Patients' ages ranged from 6 months to 15 years. Platelet counts were evaluated at presentation, 24, 48, 72 hours, 1 week, and 2 to 4 weeks. RESULTS: Eighty percent of patients treated with IVIG and 60% of patients treated with methylprednisolone demonstrated an increase in platelet count of 50,000/microL or more within 48 hours. Both IVIG and methylprednisolone therapy increased platelet counts significantly above pretreatment values. In the methylprednisolone group, the mean baseline platelet count was 4,600/microL, which rose to 14,000/microL after 24 hours, 38,000/microL after 48 hours, and 65,000/microL after 72 hours. The IVIG group had a mean baseline platelet count of 4,200/microL, which rose to 32,000/microL after 24 hours, 69,000/microL after 48 hours, and 146,000/microL after 72 hours. When compared with methylprednisolone, IVIG therapy produced a greater rise in platelet counts at 24, 48, and 72 hours, with no difference at 1 week or later time points. No serious bleeding was noted in either treatment group. CONCLUSIONS: Both IVIG and methylprednisolone produce a significant early rise in platelet count that is somewhat greater with IVIG. However, the higher platelet counts produced by IVIG may not justify the additional cost and potential risks of this agent.     

儿童急性白血病院内感染临床观察

目的分析急性白血病(AL)患儿院内感染的临床特点及血培养阳性细菌对抗生素的敏感性,探讨其防治措施。方法回顾性分析住院AL患儿院内感染的发生率;细菌感染血培养阳性与化疗时期的关系,血培养阳性患儿与阴性患儿外周血白细胞计数、血小板计数、粒细胞计数绝对值的差异,血培养阳性细菌对抗生素的耐药性及敏感性。结果 AL患儿院内感染的发生率为45.5%(112/246),其中血培养阳性率为25.0%(28/112)。血培养阳性患儿的外周血白细胞计数为(1.05±1.17)×109/L,血小板计数为(55.57±27.57)×109/L,中性粒细胞计数绝对值为(0.13±0.33)×109/L,中性粒细胞减少持续时间为(8.46±3.40)d;血培养阴性患儿的白细胞计数为(2.72±3.00)×109/L,血小板计数为(117.80±133.60)×109/L,中性粒细胞计数绝对值为(1.02±2.34)×109/L,中性粒细胞减少持续时间为(2.48±0.62)d,各项指标在血培养阳性组与阴性组之间的差异有显著性。血培养中的葡萄球菌属、大肠埃希菌、铜绿假单胞菌对青霉素类、头孢三代抗生素、红霉素的耐药率均比较高,葡萄球菌属对替考拉宁和万古霉素相对较敏感,大肠埃希菌对亚胺培南敏感性较高,铜绿假单胞菌对亚胺培南和复方新诺明较敏感。结论本研究结果提示,AL患儿骨髓抑制易发生感染。AL患儿考虑革兰阴性菌感染可选择碳青霉烯类,考虑革兰阳性菌感染可选择替考拉宁和万古霉素,必要时进行细菌药敏物敏感试验,进一步提高治疗效果。     

Clinical course of children with immune thrombocytopenic purpura treated with intravenous immunoglobulin G or megadose methylprednisolone or observed without therapy

The authors compared the prognosis in 50 children with acute immune thrombocytopenicpurpura (ITP) who received intravenous immunoglobulin G (IVIG), megadose methylprednisolone (MDMP), or no therapy. Twenty-six children were observed with no therapy, 12 children received IVIG, and 12 children received MDMP. The percentage of the patients whose platelet counts increased at a level of > 20 x 10(9)/L and > 50 x 10(9)/L at 3 days after starting therapy was significantly higher in both IVIG and MDMP groups than in the no therapy group (p < .01), but there was no significant difference at 10 and 30 days after initiation between the 3 groups (p > .05 in each comparison). This result suggested that therapy does not increase the rate of recovery but shortens the duration of thrombocytopenia in the first days. Management derision in ITP is made on clinical condition rather than on platelet count and no treatment options is to be preferred even in the face of mucosal bleeding. If the patient has extensive bleeding and the decision is to treat, both IVIG and MDMP are equally effective in providing a safe platelet level early on.     

Intravenous immune globulin versus intravenous anti-D immune globulin for the treatment of acute immune thrombocytopenic purpura

Objective  The purpose of this study was to compare the efficacy and side effects of intravenous immunoglobulin (IVIG) with intravenous anti-D immunoglobulin for treatment of newly diagnosed acute childhood Idiopathic thrombocytopenic purpura (ITP). Methods  Children (6 months to 14 years) with newly diagnosed acute ITP and platelet count below 20,000/ μL were randomized to receive single dose intravenous 75 μg/kg anti-D or 1g/kg IVIG for two consecutive days (total dose 2 g/kg). Response rate defined as a platelet count over 20,000 / μL 72 hours after initial treatment. Results  Eighty one patients (52 male and 29 female) with mean age of 5 years and 3 months randomly divided in anti-D group (n=42) and IVIG group (n=39). Mean baseline (pretreatment) platelet counts were 15406 / μL and 15230/ μL in anti-D and IVIG group, respectively. The response rate in IVIG group (98%) was more significant than anti-D group (76%); (P = 0.017). After 7 days the platelet counts of all patients in IVIG group were more than 20,000/ μL while in anti-D group 12% had platelet counts below 20,000/ μL. Conclusion  In acute childhood ITP, initial treatment with IVIG (2g/Kg in divided dose) increased platelet count more rapidly and more significant than intravenous anti-D (single dose of 75 μg/Kg) within the first 72 hours.