2018年 · 第56卷第08期

Streptococcus pneumoniae disease is one of the world's serious public health problems, and domestic clinical and disease prevention and control experts also attach great importance to it. Several consensus or guidelines related to Streptococcus pneumoniae and its disease have been published successively^[1,2,3,4,5]This issue will publish the "Suggestions on the Diagnosis, Treatment, Prevention and Control of Streptococcus pneumoniae in Children" jointly formulated by the Infectious Diseases Group of the Pediatrics Branch of the Chinese Medical Association and the Editorial Committee of the Chinese Journal of Pediatrics^[6]。 The harm of Streptococcus pneumoniae has been systematically described in these consensus and recommendations, but because of the pathogenic characteristics of Streptococcus pneumoniae, the harm stated in the document is inconsistent with the personal experience of most people, and the phenomenon of slighting the harm of Streptococcus pneumoniae is still very common. Professor Yang Yonghong^[7]Has been discussed on this topic. From the perspective of the development of disease burden assessment theory, this paper attempts to analyze the clinical characteristics of Streptococcus pneumoniae pathogenesis which are easy to be ignored, improve the understanding, avoid the misleading of personal experience, understand the content of consensus or suggestion, recognize the necessity of prevention and control of Streptococcus pneumoniae disease, and can put scientific suggestions into practice.

Streptococcus pneumoniae is the most common pathogen of bacterial meningitis in children over 3 months of age, and it is also a common pathogen of bloodstream infection, community acquired pneumonia (CAP), empyema, acute otitis media, and sinusitis in children. Occasionally, it can also cause cellulitis, suppurative arthritis, osteomyelitis, endocarditis, pericarditis, peritonitis, etc. Streptococcal diseases (PD) involve various specialties of pediatrics. The prevention and diagnosis and treatment strategies of PD vary greatly among different regions, hospitals and specialties, especially for invasive PD (IPD). There are many confusions. The Infectiology Group of Pediatrics Branch of Chinese Medical Association and the Editorial Committee of Chinese Journal of Pediatrics organized domestic experts to formulate this recommendation on the basis of comprehensively analyzing the latest progress in etiology, epidemiology, main infection types, clinical characteristics, laboratory testing, treatment and specific prevention of Streptococcus pneumoniae in children at home and abroad, so as to standardize and improve the diagnosis, treatment and prevention and control level of PD in children in China.

Neonatal acute respiratory distress syndrome (ARDS) is a critical respiratory disease that seriously threatens the life of newborns. Its main clinical manifestations are different degrees of hypoxemia, diffuse decrease of light transmittance in both lungs, inflammatory exudation and decrease of lung compliance^[1]。 A previous study classified neonatal respiratory diseases into five categories: neonatal respiratory distress syndrome, transient respiratory enhancement, meconium aspiration syndrome, neonatal pneumonia, atypical respiratory diseases; Among them, the incidence of atypical respiratory diseases is about 28.8%^[2]。 According to the interim report of the International Multicenter Study of Neonatal ARDS, the mortality rate of neonatal ARDS is approximately 20%. Although the diagnostic criteria for ARDS in adults and children [Berlin criteria^[3]Consensus Conference on Pediatric Acute Lung Injury (PALICC) Criteria^[4]] has deepened clinicians' understanding of ARDS, but due to the particularity of neonatal ARDS, its onset triggers and clinical process need to be further clarified, and the diagnosis and treatment plan are still not standardized. In order to promote the clinical and basic research of neonatal ARDS and substantially reduce the incidence and mortality of neonatal ARDS. The International Multicentre Multidisciplinary Collaborative Group on Neonatal ARDS was established in January 2014 with the support of the European Association for Child and Neonatal Intensive Care (ESPNIC) and the European Association for Child Research (ESPR). The aim of this collaborative group, composed of 12 experts with extensive experience, is to: analyze the published literature related to ARDS and, on this basis, develop preliminary diagnostic criteria for neonatal ARDS; To test the applicability of newly established diagnostic criteria for neonatal ARDS in neonatal ARDS. In August 2017, the diagnostic criteria of ARDS were discussed in multiple rounds of meetings for more than 3 years, and the full text was finally adoptedLancet Respiratory MedicineOfficial release (hereinafter referred to as Montreux diagnostic criteria for ARDS)^[1]。 In order to connect with the previous diagnostic criteria for ARDS in adults and children, the Montreux diagnostic criteria for ARDS also adopt corresponding basic criteria: (1) acute onset; (2) Oxygenation disorder is accompanied by a decrease in residual air volume, and positive pressure ventilation is needed to facilitate lung recruitment; (3) Respiratory failure caused by pulmonary edema cannot be completely explained by heart failure; (4) Chest X-ray showed diffuse reduction of light transmittance in both lungs. On the basis of these basic criteria, in order to facilitate clinicians to understand and apply this criterion, the Montreux diagnostic criteria emphasize 10 problems that need attention, which are now interpreted.

The child was a 4-year-old male. He was admitted to Beijing Children's Hospital in February 2016 due to intermittent headache, vomiting for 20 days and swelling of his left lower limb for 1 day. The child developed posterior cranial roof headache with vomiting and somnolence 20 d ago. One fever 13 days ago, more than 10 convulsions 2 hours after medication reduced the fever, manifested as disturbance of consciousness, binocular gaze, flexion of both upper limbs, stiffness of both lower limbs, normal consciousness in interval, reduced response, and intracranial hemorrhage on head CT; Cranial magnetic resonance (MRI) scan and angiography showed thrombosis in deep cerebral vein, straight sinus, sinus sinus, left transverse sinus and left sigmoid sinus. The symptoms improved after mannitol treatment. High fever with vomiting and irritability 6 days ago, but no relief after mannitol and ceftriaxone. He went to our hospital immediately. Blood routine: white blood cells 11.79×10⁹/L, neutrophils 0.686, CRP 64 mg/L; There were no abnormalities in blood biochemistry and cerebrospinal fluid examination; A chest X-ray showed a patchy shadow on the right lower lung. Treatment such as sedation and anti-infection. 1 d ago, the left lower limb was swollen, the skin was dark and cold, and he was hospitalized with "fever, convulsions to be examined, pneumonia, and deep vein thrombosis of the left lower limb". The child was the first child of her mother, the first birth, the full-term natural birth, and there was no family history of hematological diseases and tumors.

A 1-year-old male was admitted to the respiratory department of Shenzhen Children's Hospital in October 2017 due to "repeated cough and sputum with intermittent wheezing for more than 9 months, aggravated for 1 week". The child developed cough without obvious trigger at the age of 2.5 months, showing paroxysmal continuous cough, with phlegm not easy to get out, obvious in the morning, without fever, admitted to the respiratory department of our hospital for the first time at the age of 3.5 months due to "repeated cough for 1 month", wheezing after hospitalization, bronchoscopy, more pale yellow sputum was found, alveolar lavage fluid culture: Staphylococcus aureus (methicillin-sensitive Staphylococcus aureus, MSSA); At that time, the diagnosis was "persistent bacterial bronchitis, laryngomalacia, and severe malnutrition"; He was given melocillin sodium/sulbactam + amoxicillin clavulanate potassium for 2 weeks, linezolid for 2 weeks and azithromycin for 3 days to fight infection, and was discharged after his cough and wheezing improved. In the latter half of the year, he was hospitalized in other hospitals and our hospital for many times due to lower respiratory tract infections, and sputum culture as "Staphylococcus aureus (MSSA)" was performed many times. Treatment with cephalosporin III and other antibacterial drugs could relieve it, but he had been coughing and sputum in the morning. During this period, at 9 and 10 months of age, the children developed severe hypokalemia, hyponatremia, hypochloremia, metabolic alkalosis and pseudo-Bartter syndrome due to aggravated cough accompanied by anorexia and vomiting. They were given anti-infective and supportive treatment, and the electrolytes quickly returned to normal. One week before this hospitalization, I had aggravated cough with wheezing and shortness of breath. After anti-infective treatment in another hospital, my condition was slightly relieved and transferred to our hospital. In the stable period of the child's condition, the appetite and eating are acceptable, and the frequency of stool is 2 to 3 times/d, often with oily and thin stool. The child is the first birth of the mother, with a gestational age of 38⁺⁵Weeks, born naturally, birth weight 2.55 kg, mother is healthy during pregnancy. The body weight was 3.45 kg at 1 month of age and 3.75 kg at 2 months of age. Local hospitalization at birth due to "neonatal aspiration syndrome, neonatal hyperbilirubinemia".

The 53-day-old male was admitted to Shenzhen Hospital of the University of Hong Kong in March 2017 due to "cough and expectoration for 50 days". The child developed respiratory symptoms immediately after birth. The diagnosis of "neonatal pneumonia" was given anti-infective treatment, but the effect was not good, and the symptoms of pulmonary infection progressively aggravated and transferred to our hospital. The child had a birth weight of 3.1 kg and was vaccinated with BCG vaccine after birth. There was no obvious adverse vaccine reaction. Both parents are in good health, with a sister who is in good health and a brother who also developed infectious diseases after birth and died of infection at the age of 3 months.

A 13-year-old male was seen in Guangdong Provincial People's Hospital in August 2017 because of "syncope during repeated exercise for more than 4 years". The child suddenly fainted during basketball more than 4 years ago, manifested as chest tightness, black eyes followed by unconsciousness, accompanied by upper limb twitching, pale complexion and limb weakness, which lasted for 30 s and then relieved spontaneously. Since the onset of the disease, the above symptoms have appeared 6 times, respectively, in swimming, running, playing basketball and other sports. There is no history of attack when quiet, and it is not related to the change of body position. After the attack, he visited other hospitals many times, and there was no obvious abnormality in video electroencephalogram and electrocardiogram many times, and no definite diagnosis was made. There was no history of similar symptoms or sudden death in the family.

Traditional clinical research needs to scientifically design key parameters before research implementation, such as sample size, intervention measures, primary endpoint evaluation indicators, etc. The researchers then perform data collection, cleaning and analysis according to the study protocol, and the success of the study depends largely on the accuracy of the pre-assumptions. However, actual clinical studies are often more complex than we expected, and researchers may need to modify the study design and statistical protocols during the trial, so as to more efficiently identify relatively safer and more effective diagnosis and treatment options in the study. Adaptive design is a study design method that corrects unreasonable assumptions in clinical trial protocols in time without changing the validity and integrity of the trial.