Objective To assess and compare the efficacy and safety of cyclosporine A in the treatment of primary nephritic syndrome in adults and children. Methods The Cochrane library, Pubmed, EMBASE, CBMdis, CNKI and VIP were searched till September 30, 2006. Three reviewers assessed the quality of included studies, extracted data and processed meta-analysis of homogenous studies using RevMan 4.2.8. Results Fifteen studies involving 796 participants were included and graded in term of randomization, allocation concealment and blinding. Three studies were graded A, ten studies were graded B and the other two were graded C. Meta-analysis based on included studies showed: ① In children, the complete remission rate (6 months) (OR=12.64, 95％CI:1.46-109.48), and the complete or partial remission rate (6 months) (OR=22.57,95％CI:4.56-111.76) were higher in treatment group with cyclosporine than with placebo or without treatment; but there were no significant differences in the complete or partial remission rate (18 months) (OR=1.96,95％CI:0.58-6.56), the incidence of hypertension (OR=0.93,95％CI:0.11-7.59) and ESRD or mortality (OR=0.63,95％CI:0.12-3.47). In adults, the complete or partial remission rate in 6 months (OR=11.48,95％CI:4.72,27.92) and in 18 months (OR=2.71,95％CI:1.10-6.67), and the incidence of hypertension (OR=2.89,95％CI:1.23-6.80) were higher in treatment group with cyclosporine than control group in high quality studies, while there were no significant differences in the complete remission rate (6 months) (OR=1.92, 95％CI:0.78-4.70) and ESRD or mortality (OR=0.61,95％CI:0.28-1.33) in low quality studies. ② In children, the complete or partial remission rate in 6 months (OR=1.79,95％CI:1.00-3.19 ) was higher in the treatment group of cyclosporine A combined with prednisone than the group treated with high dose prednisone, but there was no significant difference in 24 months. ③ Compared with other immunodepressive drugs, in children the treatment group with cyclosporine A had lower complete or partial remission rate in 24 months (OR=0.10,95％CI:0.03-0.29), and no differences were found in the complete remission rate (6 months) (OR=1.26, 95％CI:0.33-4.73), the complete or partial remission rate（6 months）(OR=1.57,95％CI:0.65-3.78) and the incidence of hypertension (OR=3.15,95％CI:0.12-82.16) between two groups. In adults, the complete or partial remission rate was higher in the group treated with cyclosporine A than in that with other immunodepressive drugs, but no differences were found in the complete remission rate (6 months) (OR=1.01, 95％CI:0.34-3.02), the complete or partial remission rate (24 months) (OR=0.95,95％CI:0.35-2.57) and the ESRD or mortality (OR=0.76,95％CI:0.26-2.24) between two groups. ④ The evidence was not strong enough to judge whether the treatment with cyclosporin is superior to ACEI due to only one quasi-RCT was enrolled. Conclusions Available evidence showed cyclosporine A could improve short term efficacy in primary nephritic syndrome, but could not improve long term and endpoint efficacy. As a whole, there was a trend that the effect of cyclosporine A on nephritic syndrome for adults was superior to children.
Objective To investigate clinical settings and status of admissions in 25 pediatric intensive care units (PICU) in China. Methods Basic clinical settings were obtained from inquiry forms. From January 1stto June 30th, 2005, all those 29 days to 14 years old children who were admitted to 25 PICU (each for 12 months) in China were prospectively surveyed by using a Chinese pediatric critical care scoring system and American guidelines for admission and discharge policies for PICU. Sepsis and organ dysfunction were identified by using criteria of Levy. Respiratory failure was defined as PaO2< 50 mmHg in room air at sea level or PaO2/FiO2< 250 mmHg under oxygen inhalation, in the absence of cyanotic congenital heart disease. Acute respiratory distress syndrome was identified by using AmericanEuropean Consensus Conference definition. Results There were (11.4±8.0) beds and (6.1±3.7) ventilators in these settings. The highest bed/ventilator ratio was 7.5∶1, and the lowest ratio was 1∶2, and the mean value was 1.9∶1. All beds were equipped with monitors for heart rates, respiratory rates, pulse oxygen saturation, etc. Central venous pressure monitoring could be executed in 44% PICU. None of PICU could execute pulmonary artery wedge pressure monitoring. Of the 12 018 patients admitted to the PICUs during the 12month period, 7 269 cases were defined as critical case, of whom 5 590(76.9%) were medical cases and 1 223(16.8%) were surgical ones and 456(6.3%) were the others. Average duration of hospital stay in the PICU for these critical cases was 63 days. Diagnoses were made as pneumonia in 3 013(41.4%), nonpulmonary sepsis in 688(9.5%), trauma in 397(5.5%), respiratory failure in 2 009, and 1 957 were mechanically ventilated, 1 300 (17.9%) received mechanical ventilation over 24 h,105(1.44%) were acute respiratory distress syndrome. The mortality rate of critical case was 6.7%(485/7 269) (95%CI, 6.10% to 7.27%). The overall mortality of children in PICU was 40%(485/12 018) (95%CI, 3.7% to 4.4%). The mortality was varied from 1.3%-61.0% in different diseases. The incidence/mortality ratios of respiratory failure, mechanical ventilation, sepsis, severe pneumonia, and ARDS were 27.6%/17.1%, 26.9%/16.9%, 9.5%/17.7%, 41.4%/5.3%, and 1.44%/61.0%, respectively. The incidence/mortality ratios of trauma, head injury and multiple injury were 5.5%/7.1%, 2.6%/9.7% and 1.3%/17.6%, respectively. There were differences in admissions and mortality among different PICUs.Admissions were from 94 to 900 among PICUs in 12 months periods. The mortalities among different PICUs were from 1.4% to 23.9% in critical case, from zero to 42.1% in respiratory failure, from zero to 42.9% in mechanical ventilation and from zero to 100% in acute respiratory distress syndrome. Conclusion The current level of clinical settings of PICUs in China is moderate. The differences in admission and care standard as well as socioeconomic factors contributed to the status of surveyed PICUs.
Objective To explore the epidemiological rule and correlated risk factors of premature infant with brain injury ,on the basis of MRI. Methods The Study was prospectively performed on 358 preterm infants from January 2005 to January 2007 at the neonatal intensive care unit of the Shengjing Hospital of China Medical University. Detailed clinical data of all subjects were recorded ,including:gender,gestation age,birth weight,and the following risk factors:precipitate labor,pregnancyinduced hypertension,fetal distress,twin, prenatal infection, placental abraption, placenta praevia, gestional diabetes mellitus, prenatal steroids recipitate, magnesium sulfate, resuscitation, circutatory disorder, vaginal delivery, infection, mechanical ventilation, blood gas analysis(metabolic acidosis, hyperkalemia, hyponatremia, hypocalcemia).Conventional MRI and diffusion-weighted imaging(DWI) were performed in 358 preterm infants using 3 Tesla MR scanner. The infants were sedated for imaging with chloral hydrate(50 mg·kg-1). Seriously ill intubated newborns were monitored by clinician during scanning and handventilated,and pulse oximetry and electrocardiography were monitored throughout the procedure.All MRI scans were assessed by two radiologists,blinded to neonatal clinical data.Subjects with brain injury were classified into two different groups according to MRI: hemorrhagic brain injury and ischemic brain injury.Statistical analyses were performed using SPSS for Windows(ver 11.5). All data were described as mean±standard deviation. Student＇s t test was used to evaluate the difference in numerical variables. The significance of the difference between premature infants with brain injury and control cases was tested using the Chi-square test. A logistic regression analysis was performed on factors which found to be significant in univariate analysis. A probability value of P<0.05 was considered statistically significant. Results The number of premature infants with hemorrhagic brain injury was 128 cases（70.7%）；premature infants with ischemic brain injury were 96 cases （53.0%）; premature infants with both hemorrhagic and ischemic brain injruy were 43 cases (23.7%). 21 risk factors were analyzed. Univariate analysis: precipitate labor(χ2=5.295,P=0.021),twin(χ2=4.576,P=0.003), prenatal infection(χ2=7.922,P=0.005), circutatory disorder(χ2=5.710,P=0.017), vaginal delivery(χ2=53.624,P=0.000), metabolic acidosis(χ2=13.594,P=0.001), hyponatremia(χ2=11.691,P=0.001), hypocalcemia(χ2=12.805,P=0000) for premature infants with hemorrhagic brain injury were considered statistically significant; prenatal infection(χ2=5.628,P=0.018), gestional diabetes mellitus(χ2=14.944,P=0.001), magnesium sulfate(χ2=9.248,P=0.002), resuscitation(χ2=6.362,P=0.012), circutatory disorder(χ2=6.341,P=0.012), vaginal delivery(χ2=17.029,P=0.000), metabolic acidosis(χ2=14.944,P=0.001), hyponatremia(χ2=20.242,P=0.000), hypocalcemia(χ2=32.595,P=0.000) for premature infants with ischemic brain injury were considered statistically significant. Logistic regression analysissitus: prenatal infection (OR=4.738，95%CI:1.01,18685, P<0.05),vaginal delivery (OR=9.191,95%CI:4.699,17.979, P<0.05) hyponatremia(OR=3.331,95%CI:1.506,7.366, P<0.05)and hypocalcemia (OR=3.162,95%CI:1.325,7.545, P<0.05)were risk factors for premature infants with hemorrhagic brain injury.Maternal deibetes (OR=5.211,95%CI:1.272,21.341, P<0.05) ,vaginal delivery (OR=3.078,95%CI:1.824,5.194, P<0.05), hyponatremia(OR=3.331,95%CI:1.506,7.366,P<0.05) and hypocalcemia(OR=4.713,95%CI:2.412,9.209, P<0.05)were risk factors for premature infants with ischemic brain injury.While the prenatal use of magnesium sulfate(OR=0.375,95%CI:0.183,0.766, P<0.05)was its protective factors. Conclusions Intrauterine exposure included prenatal mothers suffering from infection,diabetes and so on. Intrauterine exposure factors, process of delivery and postnata internal environment disorders were all risk factors for premature infant brain injury. Therefore premature infant brain injury is a complex outcome of mulfacorial interaction. Perinatal diagnosis and treatment should avoid these factors to redude neurological complications or alleviate its severity.
Objective To explore the clinical features, diagnostic approaches and management of congenital intestinal lymphangiectasia through a study of two cases and a review of the literatures. Methods The two patients studied, in addition to regular serological studies, urinalysis, echocardiogram, abdominal ultrasonogram and abdominal CT scan, underwent gastroscopy and/or double balloon enteroscopy (DBE) and small intestine mucosa biopsies were taken for pathological studies. Results Case 1: 5yearold female, presenting with recurrent edema, was diagnosed as suffering from hypoalbuminemia not due to renal, cardiac and hepatic causes after comprehensive workup including serological studies, urinalysis, echocardiogram, abdominal ultrasonogram and liver biopsy. Under gastroscopy, small white dots were seen in the duodenal mucosa. Retrograde DBE was later performed. Throughout the ileum and jejunum, diffuse, generalized whiteyellowish nodular changes resembling a cobblestone appearance were seen. Normal intestinal villous morphology was lost, and patchy areas of superficial hemorrhage were also observed. Pathological observation revealed the presence of dilated lymphatic vessels without evidence of endothelial hyperplasia in the lamina propria and muscularis mucosae, and diagnosis of intestinal lymphangiectasia was made. Case 2: 6monthold female baby presenting with edema and diarrhea and hypoalbuminemia not due to extraintestinal causes. Gastroscopy examination revealed diffuse whitish military changes in the duodenal mucosa, with patchy superficial mucosal hemorrhage and loss of normal villous appearance. Pathological observation revealed dilatation of the lymphatic vessels in the lamina propria and interstitial edema in individual villi, and intestinal lymphangiectasia was suggested. Considering the young age of the patients, the diagnosis of primary intestinal lymphangiectasia was made. In both patients, dietary treatment with mediumchain triglyceride supplementation (plain MCT or emulsion) to substitute for longchain fat was initiated. During followup, marked improvement in the symptoms was seen. Conclusions Intestinal lymphangiectasia may not be rare in children and should be aware of this diagnosis whenever we see patients with recurrent hypoalbuminemia, peripheral edema, ascites or chronic diarrhea. Early diagnosis with endoscopy, biopsy and pathological examination, together with special dietary supplementation are important in the management of these cases.
Objective To explore the role of regulatory T cells in murine cytomegalovirus (MCMV) infection of mouse embryonic fibroblasts (MEF). Methods A coculture system of T cells and MCMV infected MEF (MEFMCMV) was established. T cells were isolated from spleens of BALB/c mice infected by MCMV two months ago. CD3 T cells were purified by nylon wool column method and confirmed by flow cytometry. Treg and TdepTreg(T cells depleted of Treg) were isolated from T cells purified by MACS Treg Isolation Kit and confirmed by flow cytometry. To understand whether regulatory T cell (Treg) inhibits antiviral immune responses of T cells, Tregaddition and Tregremoval experiments were performed. In the co-culture system, the rates of effector T cell (Te) subpopulations, including Tc1 (CD3+CD8+IFN-γ+)，Tc2 (CD3+CD8+IL4+)，Th1 (CD3+CD8-IFN-γ+)，Th2 (CD3+CD8-IL-4+) were detected by flow cytometry; The levels of Treg cytokines, IL-10 and TGF-β of coculture supernatants were measured by doubleantibody sandwich ELISA; influence of cocultured T cells on MCMV replication was determined by measuring the viral load of MCMV in coculture supernatants using plaque assay. Results Tregremoval study showed, viral load of TdepTreggroup was markedly lower than that of MCMV infected MEF group, and the proportions of Th1, Tc1 and Tc2 were increased significantly compared with those of infected control. In Tregaddition study, adding Treg to coculture system in proportion could increase viral load; meanwhile, the percentages of Tc1, Tc2 and Th1 were obviously lower than that of TdepTreg-MEFMCMVgroup, and the percentage of Th2 was not significantly decreased until Treg percentage reached 20% (P<0.05); The percentage of Treg was inversely correlated with those of Th1, Tc1 and Tc2 cells (P<0.01); Moreover, the expressing levels of both IL10 and TGFβ in Tregadding groups were significantly increased compared with TdepTreg-MEFMCMV groups. Conclusions Treg appeared to downregulate the proportions of Tc1, Tc2, Th1 and Th2, and the disproportion inhibition of Treg led to the disturbance of Th1/Th2 and Tc1/Tc2 ratios, which benefited for CMV replication.
