儿童结核病的治疗进展

我国是结核病高负担国家,儿童结核病的疫情仍未控制,了解结核病的治疗进展非常重要。现对结核病治疗观点、原则以及抗结核药物的进展进行介绍。     

The Use of Diagnostic Systems for Tuberculosis in Children

Effective management of tuberculosis (TB) in children and important data of disease burden continue to rely on a clinical approach to diagnosis, as diagnosis of childhood TB is not confirmed in the majority. Many diagnostic scoring systems have been developed to aid with diagnosis. This article reviews the use and evaluation of these approaches. The diagnostic systems are often closely related and all rely on the well-known clinical features associated with TB disease in children. The scoring systems are not well validated and validation is limited by the lack of a gold standard for comparison. When they have been validated, some systems perform reasonably well but may bias to identify the most obvious clinical cases. They perform less well in important sub-groups that pose the greatest diagnostic challenge and are at greatest risk for poor outcome, such as the young, malnourished or HIV-infected. There is marked variation in performance between these diagnostic approaches. The better validated systems may have a role as a screening tool in some settings, but this would need careful consideration as to the most useful and safest approach. More attention is being given to improving diagnosis and management of child TB, including within National TB Programmes. Research with new diagnostics should include children so that there is less reliance on clinical features alone. However, the clinical approach will continue to be relevant and so it is important to strive to improve the diagnostic approach to TB in children, and to validate the approach in different settings.     

儿童结核病的实验室诊断

儿童结核病属载菌量小的疾病,且小儿痰标本留取困难,因此痰涂片或结核菌培养阳性率低。获取合格标本和多次送检可提高阳性率。结核菌抗体检测简便易行,特别是干扰素分析试验可区分卡介苗接种和其他分枝杆菌感染,是诊断结核病的重要方法。     

MRI in Thoracic Tuberculosis of Children

Objective

To explore the utility of lung magnetic resonance imaging (MRI) in children with thoracic tuberculosis (TB).

Methods

This prospective study of forty children (age range of 5 to 15 y) with thoracic TB was approved by the institutional ethics committee. Chest radiograph, lung MRI and computed tomography (CT) scan were performed in all children. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) of MRI were calculated and kappa test of agreement was used to determine the strength of agreement between the MRI and CT findings.

Results

MRI performed equivalent to CT scan in detection of mediastinal and hilar lymphadenopathy, pleural effusion and lung cavitation (considered typical for TB) with sensitivity and specificity of 100%. MRI also yielded a sensitivity of 88.2% and specificity of 95.7% for nodules, with sensitivity of 100% and specificity of 92.9% for consolidation. Kappa agreement between CT and MRI in detection of each finding was almost perfect (k: 0.8–1).

Conclusions

Although CT scan is still superior to MRI in detection of smaller nodules, MRI demonstrates a very high degree of correlation and agreement with CT scan for detecting lung and mediastinal pathology related to TB, in children with thoracic TB and can be particularly useful in select population and follow-up of these children to avoid repeated radiation exposures.

     

USPSTF Perspective on Evidence-Based Preventive Recommendations for Children

The development and use of evidence-based recommendations for preventive care by primary care providers caring for children is an ongoing challenge. This issue is further complicated by the fact that a higher proportion of recommendations by the US Preventive Services Task Force (USPSTF) for pediatric preventive services in comparison with adult services have insufficient evidence to recommend for or against the service. One important root cause for this problem is the relative lack of high quality screening and counseling studies in pediatric primary care settings. The paucity of studies limits the development of additional evidence-based guidelines to enhance best practices for pediatric and adolescent conditions. In this article, we describe the following: (1) evidence-based primary care preventive services as a strategy for addressing important pediatric morbidities, (2) the process of making evidence-based screening recommendations by the USPSTF, (3) the current library of USPSTF recommendations for children and adolescents, and (4) factors influencing the use of USPSTF recommendations and other evidence-based guidelines by clinicians. Strategies to accelerate the implementation of evidence-based services and areas of need for future research to fill key gaps in evidence-based recommendations and guidelines are highlighted.     

The Urgent Need for New Diagnostics for Symptomatic Tuberculosis in Children

TB is a major public health problem causing 9 million cases, of which 10%–15% occur in children each year. Historically, children have received lower priority within TB control activities because they are considered less infectious than smear-positive adults. This review argues that TB is a public health problem in children and that poor awareness of the magnitude of the problem emanates from the lack of suitable pediatric diagnostic tests for TB and the characteristics of the disease in young children. New TB diagnostics, approved for use in adults have not been evaluated in children, although there is limited evidence that some of these tests hold promise and should be assessed. There are several approaches that could be used to improve the performance of tests in pediatric patients. These include improved methods for specimen collection and processing. The value of collecting specimens from multiple anatomical sites to shorten the diagnostic process and improve sensitivity was reported recently and the combination of expectorated sputum, nasopharyngeal aspirate, induce sputum and gastric aspirate may result in a similar yield than specimens collected over consecutive days. Methods for sample collection such as fine needle aspiration biopsy should be used more frequently and the Microscopic Observation Drug Sensitivity (MODS) assay has higher sensitivity than LJ culture. There is however very scanty evidence of the performance of other promising tests such as the fully automated NAAT (Xpert) and Line Probe Assays and loop mediated isothermal amplification. Although the future holds promise, increased support from international organizations and funding agencies is needed to promote the evaluation and development of new diagnostics that are suitable for TB in children.     

酶联免疫斑点技术对小儿结核病的诊断价值

目的 探讨酶联免疫斑点技术(ELISPOT)对新疆地区小儿结核病的诊断价值.方法收集2006年10月-2007年12月新疆医科大学第一附属医院儿科2个月～14岁疑似结核病的115例患儿,采集外周静脉血,利用ELISPOT结核感染T细胞诊断试剂盒进行ELISPOT检测,同期行结核菌纯蛋白衍生物(PPD)试验,并进行全面临床评估,随访3～6个月,结合疗效进行最终诊断.对ELISPOT检测结果与最终确诊结果进行比较,计算其灵敏度、特异度,并与PPD试验作对比.分析不同年龄组(≤36个月龄及＞36个月龄)、有无并营养不良、是否为重症结核病、结核部位(肺结核或肺外结核)以及不同民族(维吾尔族、汉族)间ELISPOT检测与PPD试验阳性率的差异,及不同因素对ELISPOT试验和PPD试验结果的影响.结果ELISPOT诊断小儿结核病的灵敏度80%,特异度86%.ELISPOT试验阳性率显著高于PPD试验阳性率(P＜0.01).在结核病病例中,并营养不良组及重症结核病组PPD试验阳性率明显低于未并营养不良组及非重症结核病组(Pa＜0.05),而ELISPOT阳性率在各组间均无统计学差异(Pa＞0.05);＞36个月龄组与≤36个月龄组、维吾尔族组与汉族组、肺结核组与肺外结核组比较,无论ELISPOT试验还是PPD试验的阳性率均无统计学差异(Pa＞0.05).结论ELISPOT诊断小儿结核病敏感、快速,而且受营养不良、重症结核病因素的影响较小,对儿童结核病具有较高的诊断价值,可用于新疆地区小儿结核病的早期快速诊断.     

小儿血脂紊乱的群体预防策略及个体干预措施

随着生活水平的提高与生活方式的转变,儿童血脂紊乱的发病率逐年增加。研究证实,血脂紊乱与成人疾病如糖尿病、动脉粥样硬化(AS)密切相关,且AS的早期病理改变在血脂紊乱儿童中已经出现。因此制定血脂异常儿童的群体防治策略和个体化干预方案是预防成人期疾病的重要手段。一、群     

Umbilical Signs of Peritoneal Tuberculosis in Children

Objectives  

To report the observation of involvement of the umbilicus with alteration of its morphology in association with peritoneal tuberculosis.     

介入治疗在小儿腹部恶性肿瘤的应用

目的 对巨大腹部肿瘤采用介入治疗,为肿瘤完整切除创造有利条件。方法 对１２例腹部恶性肿瘤患儿进行介入治疗,其中男７例,女５例。年龄２个月￣７岁。肝母细胞瘤６例,神经母细胞瘤３例,肾母细胞瘤２例肾上腺皮质癌１例。采用Ｓｅｌｄｉｎｇｅｒ’ｓ技术进行动脉插管造影,确定肿瘤主要供血动脉,进行肿瘤供血动脉超选择性插管,局部注入化疗药物,然后用碘油、明胶海绵或白芨微球栓塞肿瘤的供血动脉。结果 １２例中７例手术     

儿童获得性再生障碍性贫血的免疫抑制治疗

再生障碍性贫血(再障)包括获得性及先天性2种类型,是儿童常见的难治性血液病之一,尤其重型再障(SAA),病情严重,死亡率高。80年代初,HLA配型全相合的骨髓移植被认为是根治SAA的唯一方法,近20余年,随着有关免疫介导致病机制的深入研究及临床免疫抑制治疗经验的不断总结,认为儿童获得性再障大多存在免疫功能紊乱,应用免疫抑制治疗(immunosuppressive therapy,IST)使SAA的治疗缓解率已由20世纪80年代10%以下提高到60%~80%,长期存活率及生存质量与骨髓移植相当[1~3],目前在我国因造血干细胞来源困难和昂贵经费等问题限制其广泛应用情况下,…     

横纹肌肉瘤的治疗

目的：讨横纹肌肉瘤的有效治疗措施。方法：顾分析上海儿童医学中心1998年10月～2006年6月诊断治疗的29例横纹肌肉瘤。肿瘤部位包括颈背部5例、胸壁1例、腹壁2例、后腹膜盆腔12例、肢体9例。病理分类胚胎型19例（65．5％），腺泡型8例（27．6％），多型性2例（6．9％）。临床分期Ⅰ期2例，Ⅱ期6例，Ⅲ期9例，Ⅳ期12例。26例（89．4％）肿瘤5～25cm，3例（10、3％）肿瘤2～5cm。结果：29例随访中2例1个疗程后自行终止治疗并失访。19例获得完全缓解（其中4例停药3个月到3年后复发或死亡，1例自行停药3个月复发），4例部分缓解（其中3例发病6个月后复发），4例治疗无反应（其中3例均复发或进展，1例病情反复处于带瘤生存）。14例持续缓解时间为5～77个月，平均22．9个月。停药平均16．9个月。结论：横纹肌肉瘤手术的完整切除、术前、术后的化疗起重要作用。     

Latent Tuberculosis in Children: Diagnosis and Management

Control of tuberculosis in children often escapes attention because of the paucibacillary nature of the illness. However, they contribute much of the morbidity, mortality and future reservoir of the disease which reiterates the importance of risk-factor based screening for latent infection and appropriate treatment. We review the modalities and importance of diagnosis and treatment of latent tuberculosis infection in children. At this time, the role for interferon-gamma release assays in low-income, high-burden settings is rather limited but further research in the coming years might clear their role in children. An important emerging area of research is the development of an improved skin test for TB that uses specific mycobacterial antigens rather than tuberculin, thus is more feasible and useful in resource limited settings.