2011年 · 第49卷第09期

A male, 11 d, was admitted to the hospital on July 8, 2008 due to "less milk feeding and yellow skin staining for 1 week". The child was the first child and the first child, delivered naturally at 38 weeks of pregnancy, with a birth weight of 2750 g. He was in good condition at birth and had no history of asphyxia rescue. Breastfeeding after birth, good appetite. One week before admission, there was gradually less milk feeding, accompanied by yellowing skin, no fever, no cough, no vomiting and diarrhea. The hospital diagnosed "neonatal jaundice". After phototherapy and other anti-yellowing treatment, the jaundice improved, but he still had poor appetite, so he was transferred to our hospital. The outpatient chest radiograph showed a little exudation from the two lower lungs, which was considered pneumonia. Therefore, it is proposed that "neonatal pneumonia" will be admitted to the neonatal ward of our hospital.

In 2009, the 8th issue of Chinese Journal of Pediatrics published the "Expert Consensus on Diagnosis and Treatment Principles of Children's Diarrheal Diseases" (hereinafter referred to as the "Consensus") jointly formulated by relevant experts from the Gastroenterology Group of the Pediatrics Branch of Chinese Medical Association, the Infectiology Group of the Pediatrics Branch of Chinese Medical Association and the Editorial Committee of Chinese Journal of Pediatrics. The treatment of severe dehydration in children with diarrheal disease in the "Consensus" describes: "Intravenous infusion: Use a mixed solution of sugar and salt for intravenous use (must be performed in hospital): first, a 2:1 isotonic solution of 20 ml/kg, intravenous bolus or rapid instillation within 30 to 60 minutes to rapidly increase blood volume and improve circulation and renal function; after volume expansion, according to the nature of dehydration...". In this regard, Jin Yingji and others raised questions: The recommended isotonic solution for the first stage of intravenous rehydration of children with severe dehydration of diarrhea in the "Chinese Diagnosis and Treatment Plan of Diarrhea Disease" includes 2:1 solution, normal saline and balanced saline solution^[1]； At present, it is recommended to use normal saline, Ringer's solution and other isotonic fluids for the resuscitation of pediatric shock (including septic shock and hypovolemic shock)^[2]Children with diarrhea and severe dehydration often have hypovolemic shock. I don't know why the "consensus" only recommends the use of 2:1 isotonic solution, not saline? In the fourth issue of 2010, the expert explanation column of Chinese Journal of Pediatrics explained in a question and reply to "Expert Consensus on Diagnosis and Treatment Principles of Children's Diarrhea": "During diarrhea, a large amount of water and electrolytes (sodium, chloride, potassium and carbonate) are lost through loose stool. Therefore, the above substances should be supplemented when rehydrating diarrhea and dehydration. 2:1 isotonic sodium-containing solution contains sodium, chloride and carbonate, so it is a suitable liquid. At the same time, because it is often diluted with 5% ~10% glucose solution when prepared, it also provides glucose and helps prevent hypoglycemia. Although normal saline is also isotonic solution, it does not contain alkaline solution, so it is not conducive to correcting acidosis during diarrhea and dehydration ". We think it is worthy of discussion.

Since the publication of "Expert Consensus on Diagnostic Principles of Childhood Diarrheal Diseases" in the 8th issue of this journal in 2009^[1](hereinafter referred to as "Consensus"), "Consensus Interpretation" published in 2010^[2]And "A Question and Answer to the Consensus"^[3]Later, some readers raised some different opinions or questions about the fluid rehydration scheme for severe dehydration of diarrhea in the consensus through various ways. It is summarized and discussed as follows.

Neostigmine poisoning in children is rarely reported in China, and one case was admitted to our hospital. The report is as follows:

The child, a 6-year-old female, was admitted to the hospital in August 2009 due to "limb pain for 1 year and 10 months and fever for 2 weeks". The child started with pain in the left lower limb and pain in the right upper arm, with local swelling and limited joint movement, no fever and no anemia. Ewing's sarcoma was diagnosed in an outside hospital, and it was assessed as complete remission after 6 courses of chemotherapy. 2 weeks ago, he developed fever with pain in both lower limbs and was admitted to hospital. Physical examination: body temperature 38.6℃, 20 breaths/min, 120 pulses/min, blood pressure 100/55 mm Hg (1 mm Hg =0.133 kPa), consciousness, poor mental state, inability to walk, anemia, scattered bleeding spots on the skin of the whole body, mainly on both lower limbs, superficial lymph nodes not enlarged, no special cardiopulmonary examination, 3 cm under the costs of the liver, 5 cm under the xiphoid process, and 2.5 cm under the costs of the spleen, the shape of both lower limbs was normal, and there was no abnormal joint activity. Auxiliary examination: 1 year and 10 months ago, the blood routine was normal. X-ray film of the lower limb showed thinning of cortical absorption of the left tibial diaphysis with periosteal reaction, X-ray film of the right upper limb showed worm erosion-like changes, bone scan showed multiple concentrated foci throughout the body, and tibial bone puncture examination showed diffuse small round cell tumors in irregular trabecular bone (Figure 1，Figure 2), immunohistochemistry: CD99 (+), Fli-1 (+), CD3 (+), CD20 (-), Vimentin (+), diagnosis of Ewing's sarcoma. Blood routine after admission: WBC 42.38×10⁹/L, neutrophils 0.02, lymphocytes 0.91, hemoglobin 7.1 g/L, platelets 20×10⁹/L; CT of thorax and abdomen showed small stripes of subpleural consolidation on the dorsal side of both lungs, enlargement of liver, spleen and kidneys, and several enlarged lymph nodes in both necks; Bone marrow examination showed that 84.5% of primary + naive lymphocytes, granulocyte, erythrocytes and megakaryocytes were arrested; Immunotyping of bone marrow leukemia showed that 85% cells in R2 region expressed CD10, CD19, CD79a, HLA-DR, CD34, and were positive for bone marrow immunoglobulin heavy chain rearrangement and T cell receptor rearrangement. Bone biopsy pathology from other hospitals was sent to our hospital and other top three hospitals for consultation, which was consistent with B-lymphoblastic lymphoma (B-LBL); Immunohistochemistry: TdT^＋(Figure 3), CD99 (+), CD79 (+ /−); The pathology of retroiliac bone marrow biopsy in our hospital showed that the medullary cavity was filled with small round cell proliferation and infiltration, with little cytoplasm, round nucleus, fine chromatin, and no nucleolus. Immunohistochemistry showed that TdT (+), CD99 (+), CD79 (+ / -), CD56 (-), CD2 (-) (Figure 4)。 Combined with the child's past medical history, bone destruction was the first symptom, and the blood routine at the beginning of the disease was normal. Considering that the tumor may have originated from the periphery, the child was finally diagnosed with B-LBL, and the recurrence had reached the leukemia stage. The child was misdiagnosed as Ewing's sarcoma 1 year and 10 months ago and the disease recurred and progressed after chemotherapy. In September 2009, the child started chemotherapy according to the regimen of Beijing Children's Hospital in our hospital, and was successively given VDLD regimen (vincristine + daunorubicin + L-asparaginase + dexamethasone), 2 courses of CAT regimen (cyclophosphamide + cytarabine +6-thiopurine), 4 courses of high-dose methotrexate (HD-MTX), and 1 course of CAT regimen chemotherapy. On the 8th day of treatment, the child had zero naive cells in peripheral blood, and the tumor was assessed as complete remission on the 33rd day of treatment. At present, he is in the maintenance chemotherapy stage and in the complete remission stage.

Example 1, male, 1 year 2 months, 7 kg. Physical examination: palpable tremor in suprasternal fossa, second tone of aortic valve (A₂) weakened, the second intercostal (R₂) and the third intercostal portion of the left margin of the sternum (L₃) Smell systolic murmur (SM) 3/6. Cardiac Function Classification (NYHA) II. Electrocardiogram: I ° atrioventricular block (AVB), ST segment level of II and AVF leads moved up 0.05~0.1 mm. Chest radiograph: Cardiothoracic ratio 0.67. Echocardiography (UCG): The aortic valve showed a three-leaf valve structure, the right coronary valve was poorly developed, the leaflet opening was significantly limited, the peak-to-peak systolic pressure gradient (PG) was 85 mm Hg (1 mm Hg =0.133 kPa), the orifice diameter was 3 mm, the annulus diameter was 13 mm, aortic regurgitation (AR) is mild, with a regurgitation area of 0.5 cm²The ascending aorta was distinctly dilated, with a diameter of 26 mm, and the interventricular septum and left ventricular myocardium were significantly thickened, with the interventricular septum reaching 10 mm. Patent ductus arteriosus (shunt 2 mm), left ventricular ejection fraction (EF) 80%, short axis shortening rate (FS) 47%, combined with recurrent pulmonary infection and heart failure.

Hand, foot and mouth disease is an acute infectious disease caused by enteroviruses. Severe cases are mostly caused by enterovirus 71 (EV71) infection, which is dangerous and has a high mortality rate^{[1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37]}。 In April 2010, the Ministry of Health issued the "Guidelines for the Diagnosis and Treatment of Hand, Foot and Mouth Disease (2010 Edition)" to guide medical institutions to carry out medical treatment of hand, foot and mouth disease. At present, the clinical expert group of hand, foot and mouth disease of the Ministry of Health has formulated the Expert Consensus on Clinical Treatment of Severe Cases of Enterovirus 71 (EV71) Infection (2011 Edition), as a supplement to the Guidelines for Diagnosis and Treatment of Hand, Foot and Mouth Disease (2010 Edition), for reference by medical institutions and medical staff.

The child is a male, 6 months old, Han nationality, Zhejiang native. The main reason was "persistent skin yellowing for 6 months, fever for 2 days with aggravation of skin scleral yellowing". This case had mild skin yellowing with yellow eyes and poor appetite immediately after birth, so it was not taken seriously. At the age of 1 month, the yellowing stain of the skin was gradually obvious, accompanied by dark yellow urine and lighter stool color accompanied by steatarrhea. After more than half a month of local treatment with Chinese medicine, the jaundice improved slightly. At the age of 2 months, he was hospitalized in the local provincial children's hospital due to "skin sclera yellowing for 2 months". On physical examination, the skin and sclera were obviously yellowed, the abdomen was slightly swollen, the liver was 4 cm under the costs, and the texture was medium, and the spleen was 5 cm under the costs, and the texture was medium. The stool was pale yellow, the urine was yellow, and the rest was nothing special. Except for hyperbilirubinemia and obvious elevation of transaminases, blood Torch, hepatotropic virus A-E, HIV, Epstein-Barr virus (EBV), syphilis and other active infection indexes were all negative. Thyroid function: free thyroxine (FT4) and thyroid stimulating hormone (TSH) were within the normal range, blood routine and reticulocyte count were normal, and Coombs hemolysis test was negative; There were no obvious abnormalities in the amino acid and carnitine profiles of blood tandem mass spectrometry except that octadecyl carnitine was slightly increased. X-ray chest radiograph showed no obvious abnormalities, no butterfly vertebrae; ECG normal, hearing screening passed. B-ultrasound showed that the liver echo was enhanced, the gallbladder was small and stiff; MRI showed that the common bile duct and common hepatic duct were unclear, and the gallbladder was slender, which was considered suspicious of biliary atresia. In order to further confirm the diagnosis, percutaneous liver biopsy was performed on the child. The pathology of liver tissue showed non-specific changes, including hepatocyte swelling, watery change, balloon change, and obvious cholestasis; Hepatic multinucleated giant cells are occasionally seen; Individual hepatocyte necrosis and inflammatory cell infiltration; Interlobular bile ducts are visible, the number of bile ducts is reduced, and there is no cholestasis in the bile ducts (Figure 1)。 Pathological diagnosis of "neonatal hepatitis".

hemophagocytic syndrome, also known as hemophagocytic lymphohistiocytosis (HLH), is a group of rare clinical syndromes caused by excessive proliferation of lymphocytes and histiocytes, uncontrolled immune response and high inflammatory response in multiple organs. It has an acute onset, rapid progression and high mortality rate. HLH can occur in individuals with their own genetic defects or can be secondary to infections, tumors, and autoimmune diseases. In recent years, the research on molecular genetics and pathogenesis of HLH has made great progress, and the treatment level has also been greatly improved.

inflammatory bowel disease (IBD) includes ulcerative colitis (UC) and Crohn's disease (CD). The incidence of IBD in children is (2.2-6.8) /100 000^[1]。 The prolonged course of IBD, recurrent diarrhea and disorder of absorption function affect the growth and development of children and reduce the quality of life of children^[2]。 Acute inflammation and chronic intestinal mucosal lesions lead to intestinal mucosal barrier damage and are important causes of diarrhea attacks^[3]。 The gastrointestinal mucosal barrier is the first immune line of defense of the intestine, defending against the stimulation of intestinal lumen antigens, bacterial endotoxins, drugs, etc. The tight junction (TJ) between intestinal cells is an important component of the mucosal barrier and determines intestinal permeability. Zeissig et al.^[4]And Oshima et al.^[5]Studies showed that the TJ structure was damaged in patients with UC and CD, and the expression of "leaking" claudin protein fold increased, while the expression of "sealing" claudin decreased or redistributed, which was closely related to the increase of intestinal permeability. This review mainly describes the regulation of TJ by claudin protein and its association with IBD.

Compared with cardiology, gastroenterology and other subjects, the development of pediatric clinical research is slower and the level is lower. From the perspective of research methods, this phenomenon is related to the characteristics of pediatrics. Pediatric clinical research is faced with the relative lack of research resources. On the one hand, this may be due to the small number of children with a certain disease in a hospital within one year, and on the other hand, it is also related to the greater difficulty in recruiting children's cases for clinical research. The results limit the development of pediatric clinical research. In view of this problem, it has become the consensus of domestic pediatric experts to introduce multi-center research methods into pediatrics and promote the development of pediatrics. Recent practice shows that some multi-pediatric center research has done well and achieved good results, but other research has various problems in design, implementation and summary, and finally failed to achieve the expected purpose. In order to enable the multi-center research method to be better designed and implemented in pediatrics, the characteristics, scope of application and problems should be paid attention to in the use of multi-center research from the perspective of research methods are introduced for the reference of pediatric experts.

In the article "Complications and Comorbidities" in Chinese Journal of Pediatrics^[1]It is pointed out in the "Editor's Note" that the analysis of the concept and usage of complications and comorbidities is not only a problem of Chinese nouns, but also an important problem of academic and professional terminology. Because the prognosis of any pediatric disease, especially serious disease, often depends on the presence or absence of complications or comorbidities, and their severity. Pediatric clinicians should understand and apply these two terms correctly, and fully understand the etiology, pathogenesis and pathophysiological processes of different individuals and various diseases. Now, we put forward our superficial understanding on this issue.

With the rapid development of medical biotechnology, there are more and more clinical diagnosis and treatment methods, and the evaluation of their clinical value, effect and cost-benefit has become an issue that clinicians, medical units and medical administrative institutions pay great attention to. How to standardize the diagnosis and treatment of diseases more effectively, which is conducive to the scientific, institutionalized and individualized treatment of medical paths, so as to ensure that patients can get the best medical service, has become an important concept of modern medicine. As early as half a century ago, foreign clinical medical experts began to try to explore the management of diagnosis, treatment and prevention of single diseases with rich clinical experience, and published it in medical journals in the form of "suggestions", "consensus", "routine", "protocol", "recommendation", "position statement" and "guidelines" of societies or groups. This process is not only conducive to patients receiving the best medical services, providing medical insurance institutions with evidence references for medical insurance policies, reducing medical costs, but also conducive to the formulation of a unified clinical medical evaluation system, which lays the necessary conditions for multi-center, large-sample, homogeneous clinical scientific research, and effectively promotes the rapid development of clinical medicine.