Analysis on Protocol Violation in Pediatric Clinical Trials and Its Countermeasures / 中国医学伦理学

By collecting 475 protocol violation reports of pediatric clinical trials accepted by the ethics committee of a grade A tertiary hospital from January 2016 to December 2022, and conducting classification statistics of the responsible body, types of violation, and natures of violation, this paper analyzed and discussed the specific reasons and response measures for protocol violation. The results showed that the most common types of protocol violation included missed medication and incorrect medication dosage for pediatric research participants, missed laboratory inspection, over-windowed follow-up, and non-compliance with inclusion/exclusion criteria. And the responsibility bodies were pediatric research participants and/or their guardians, followed by the researchers. Besides, the sponsor, clinical trial coordinator, and other factors also contributed to protocol violation. Establishing awareness of responsible body, emphasizing subject management, building sound quality control system, and strengthening ethical supervision are the main countermeasures to prevent and reduce protocol violation in pediatric clinical trials, which helps to protect the safety and rights of pediatric research participants and promote standardized research in pediatric clinical trials.

Long-term outcomes and influencing factors of idiopathic nephrotic syndrome in children / 中华肾脏病杂志

Pediatric idiopathic nephrotic syndrome (INS) is characterized by massive albuminuria, hypoproteinemia, edema and hyperlipidemia, with a long course and high probability of relapse and prolongation. Long-term complications caused by long-term usage of hormones and immunosuppressants in children with INS seriously affect their physical and mental health and quality of life. Most children with steroid-sensitive nephrotic syndrome can be cured before adulthood, while some of them relapse in adulthood. Long-term prognosis of children with steroid-resistant nephrotic syndrome is poor. There have been few studies in China followed the long-term outcomes and its related factors of children with INS over 10 years. The paper reviewed the literatures on the long-term outcomes of children with INS, including renal survival, growth, mental health, learning and work, marriage and fertility, disease recurrence and long-term related complications, to explore the factors related to the poor long-term outcomes of children with INS and to assist in clinical decision-making and follow-up management.

Progress of C3 glomerulopathy / 国际儿科学杂志

C3 glomerulopathy is a rare disease of glomeruli mediated by abnormal activation of alternative complement pathway secondary to congenital genetic defects and acquired autoantibodies.Renal biopsy is the gold standard for diagnosing C3 glomerulopathy.C3 glomerulopathy encompasses both dense deposit disease and C3 glomerulonephritis.The main glomerular immunofluorescence staining is C3, with few or without immunoglobulins deposition, which is the obvious pathological feature.The clinical manifestations of C3 glomerulopathy are usually various, with limited detection methods and therapies and poor prognosis.This article mainly reviews the progress of C3 glomerulopathy in recent years, in order to improve clinical understanding of C3 glomerulopathy, and choose individualized therapy.

Mechanism of adrenocorticotropic hormone in the treatment of nephrotic syndrome / 中华实用儿科临床杂志

In recent years, it has been demonstrated in some studies that adrenocorticotropic hormone (ACTH) is effective in the treatment of certain steroid-resistant nephrotic syndrome, including membranous nephropathy, focal segmental glomerular sclerosis, minimal change nephropathy and so forth.ACTH can effectively relieve proteinuria and protect renal function, suggesting that there may be other mechanisms in addition to the adrenocorticotropic effect.This article mainly introduces the biological characteristics of ACTH, in combination with the clinical and basic studies on the treatment of nephrotic syndrome by ACTH, and clarifies several possible mechanisms, in an attempt to provide basis for clinical application.

Efficacy of adrenocorticotropic hormone in treating primary nephrotic syndrome in children with dual resistance to glucocorticoids and calcineurin inhibitors / 中华肾脏病杂志

Objective:To investigate the efficacy and safety of adrenocorticotropic hormone (ACTH) in treating primary nephrotic syndrome in children with dual resistance to glucocorticoids and calcineurin inhibitors (CNIs).Methods:Clinical data of 6 children with primary nephrotic syndrome treated with ACTH in the Children's Hospital of Zhejiang University School of Medicine from January 1, 2015 to December 31, 2019 were retrospectively collected. All the enrolled patients were children with primary nephrotic syndrome with dual resistance to glucocorticoids and CNIs. All the 6 children were given 0.4-1.0 IU·kg -1·d -1 ACTH (total ≤25 IU)+5% glucose 500 ml intravenous infusion for 8 h during the hormone reduction process, with a course of treatment for 5 days, once a month, and continuous treatment for 3-6 months. Clinical data such as 24 h urinary protein quantification, serum albumin, serum cholesterol, estimated glomerular filtration rate (eGFR) level and glucocorticoid dosage were collected at equal time points at 6 months before treatment, at the beginning of treatment, at the end of treatment and at 6 months of follow-up after treatment of ACTH to evaluate the efficacy and adverse reactions. Results:The onset age of 6 children was (4.89±1.77) years, and the age of the first treatment with ACTH was (9.49±3.06) years. All the 6 children completed 3 to 6 months of ACTH treatment, with 2 cases of complete remission, 2 cases of partial remission and 2 cases of no remission. At the end of ACTH treatment, 24 h urinary protein was significantly decreased ( P=0.026), serum albumin level was significantly increased ( P=0.003), and glucocorticoid dosage was significantly decreased ( P<0.001) than before treatment. At 6 months after the end of ACTH treatment, there was no statistical significance in 24 h urinary protein, serum albumin and hormone dosage compared with the end of ACTH treatment (all P>0.05), and the blood cholesterol level continued to decrease ( P=0.039). There was no significant change in eGFR during observation period ( P>0.05). In the process of ACTH infusion, all the 6 children showed transient decrease in urine output, rash in 2 cases, and elevated blood glucose in 1 case, which could be spontaneously relieved after drug withdrawal. There were no serious cardiovascular events, renal impairment, infection and other adverse reactions. Conclusions:ACTH has a good effect on children with primary nephrotic syndrome who are dual resistant to glucocorticoids and CNIs. ACTH can reduce proteinuria, decrease the dosage of glucocorticoids, improve the clinical remission rate, and has good security.

Progress in diagnosis and treatment of hemolytic uremic syndrome / 中华实用儿科临床杂志

Hemolytic uremic syndrome (HUS) is one of the important causes of acute and chronic renal dysfunction in children, with microvascular hemolytic anemia, thrombocytopenia, and renal injury as its characteristic triad.In recent years, with new insights into the etiology and pathogenesis of HUS, the classification of HUS has become more detailed, the diagnosis and treatment are more accurate, and the emergence of complement C 5 monoclonal antibody has greatly improved the treatment rate of HUS.In this study, the diagnosis, and treatment of HUS are introduced.

Progress of anti-tumor mechanism of arsenic / 肿瘤研究与临床

The arsenic compounds including arsenic trioxide and arsenic sulfide have played a crucial role in the clinical treatment of hematologic malignancies and solid tumors. Arsenic agents can induce tumor cells differentiation, apoptosis and autophagy, eliminate leukemia-initiating cells, and directly bind to the target proteins. This paper reviews the mechanism progress of arsenic agents in various tumors to further understand the intricate anti-tumor mechanisms of arsenic agents and to expand its therapeutic spectrum.

Concerns for immunization of children with idiopathic nephrotic syndrome in the post-epidemic era / 中华实用儿科临床杂志

Infection is one of the most familiar complications in children with idiopathic nephrotic syndrome.Although vaccination is an effectual measure in prevention of secondary infections, it still faces many problems.On the one hand, children′s own immune status (immune system dysfunction, administration with immunosuppressants, etc.) lends additional uncertainties to whether the immune system can produce sufficient protective antibodies after vaccination.On the other hand, potential risks (recurrence of nephrotic syndrome and induction of vaccine related diseases) need to be comprehensively assessed at the time of vaccination.In this paper, the safety, effectiveness and timing of va-ccination in children with nephrotic syndrome in the post-COVID-19 period were summarized, and possible problems of vaccination against severe acute respiratory syndrome Coronavirus 2(SARS-CoV-2) were discussed.

Optimized AAV package and experimental application of recombinant AAV8/hFⅧ for gene therapy on hemophilia A mice / 中华血液学杂志

Objective@#To evaluate the effects of adeno-associated virus (AAV) carrying hFⅧ by serotype 8 (AAV8/hFⅧ) on hemophilia A (HA) mice by gene therapy strategy.@*Methods@#pAAV-CB-EGFP, pH22 (serotype 2) and pfΔ6 (adenovirus helper) were used to package AAV into HEK-293 cells in different conditions (ratios of cells to plasmids). The efficiency of transfection and infection were evaluated using immunofluorescence microscope to seek an optimized package condition. pAAV-TTR-hFⅧ, pH 28 (serotype 8) and pfΔ6 were applied to package AAV8/hFⅧ in HEK-293 cells using the optimized package condition. The purified AAV8/hFⅧ were intravenously injected into HA mice and the effects of gene therapy were estimated.@*Results@#The efficiency of package was evaluated according to the amount and intensity of enhanced green fluorescent protein (EGFP) under immunofluorescence microscope. Four package conditions including 10 cm-dish to transfect 10 μg plasmids, 20 cm-dish to 20 μg, 30 μg and 40 μg plasmids were employed, and the condition of 20 cm-dish to transfect 20 μg plasmids reached the highest transfection efficiency at 24 h, 48 h and 72 h after transfection. The small scale AAV-EGFP was packaged using the optimized condition and an AAV crude extract was harvested by a freeze-thaw method. HEK-293 and 16095 cells were infected by the AAV crude extract, and the preferential infection efficiency was recognized in 16095 cells under immunofluorescence microscope. Then, AAV8/hFⅧ was packaged and purified based on the optimized transfection condition, and the high purity of AAV8/hFⅧ was detected by Western blot. Fractions of AAV8/hFⅧ at the dose of 8×1012 vg/kg were injected into HA mice through tail vein, an eye-bleeding was performed at every two weeks, and the activity of FⅧ was measured by aPTT assay. Results showed that the activity of FⅧ maintained at the therapeutic level and lasted up to 12 weeks after injection.@*Conclusion@#The purified AAV8/hFⅧ based on the optimized package condition could play a role in HA mice gene therapy, and the long-term therapeutic effects of AAV8/hFⅧ were observed in vivo.

Principles and suggestions on biosafety protection of biological specimen preservation during prevalence of COVID-19 / 浙江大学学报·医学版

Coronavirus disease 2019 (COVID-19) is a grade B infectious disease caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). In pace with the spreading of the disease, biosafety risk of the biological specimen preservation in biobanks has been significantly increased and biosafety protection during biological specimen preservation become increasingly important. According to the related national rules and the corresponding guidelines of Chinese Medical Association, this paper introduced the etiology about SARS-CoV-2, epidemiology about COVID-19, and the biosafety protection principles of individuals and biological specimen storage places in the process of personal protection, protection of collection, transport, handling, preservation, detection, post-detection disposal and emergencies of biological specimen. Emphasized to carry out a strict biosafety-risk assessment on biological specimen basing on virus load information, infectivity, and sample type (possible contact transmission, aerosol transmission, and fecal oral transmission).

Analysis of Alport syndrome induced by type IV collagen alpha 5 gene mutation in two families / 浙江大学学报·医学版

OBJECTIVE@#To investigate genetic characteristics of Alport syndrome.@*METHODS@#High-throughput sequencing-based whole exome sequencing was performed in two patients with recurrent unexplained abnormal urinalysis. The pathogenicity of the genetic variations, type of Mendelian genetics, and clinical phenotypes were analysed, and the disease-cause mutations were confirmed in the family members using Sanger sequencing.@*RESULTS@#Two heterozygous splice site mutations of gene c.2147-2A > T (IVS27) and c.646-2A > G (IVS11) (NM_033380) were found in patients of the two families, which showed a co-segregation association with the affected members of the families.@*CONCLUSIONS@#Alport syndrome is mainly inherited from direct female patients, and prenatal genetic screening based on amniotic fluid testing can effectively prevent birth defects in patients with a family history of this characteristic phenotype.

A multicenter study of reference intervals for 15 laboratory parameters in Chinese children / 中华儿科杂志

Objective@#To establish comprehensive laboratory reference intervals for Chinese children.@*Methods@#This was a cross-sectional multicenter study. From June 2013 to December 2014, eligible healthy children aged from 6-month to 17-year were enrolled from 20 medical centers with informed consent. They were assessed by physical examination, questionnaire survey and abdominal ultrasound for eligibility. Fasting blood samples were collected and delivered to central laboratory. Measurements of 15 clinical laboratory parameters were performed, including estradiol (E2), testosterone(T), luteinizing hormone(LH), follicle-stimulating hormone(FSH), alanine transaminase(ALT), serum creatinine(Scr), cystatin C, immunoglobulin A(IgA), immunoglobulin G(IgG), immunoglobulin M(IgM), complement (C3, C4), alkaline phosphatase(ALP), uric acid(UA) and creatine kinase(CK). Reference intervals were established according to central 95% confidence intervals for reference population, stratified by age and sex.@*Results@#In total, 2 259 children were enrolled. Finally, 1 648 children were eligible for this study, including 830 boys and 818 girls, at a mean age of 7.4 years. Age- and sex- specific reference intervals have been established for the parameters. Reference intervals of sex hormones increased gradually with age. Concentrations of ALT, cystatin C, ALP and CK were higher in children under 2 years old. Serum levels of sex hormones, creatinine, immunoglobin, CK, ALP and urea increased rapidly in adolescence, with significant sex difference. In addition, reference intervals were variable depending on assay methods. Concentrations of ALT detected by reagents with pyridoxal 5'-phosphate(PLP) were higher than those detected by reagents without PLP. Compared with enzymatic method, Jaffe assay always got higher results of serum creatinine, especially in children younger than 9 years old.@*Conclusion@#This study established age- and sex- specific reference intervals, for 15 clinical laboratory parameters based on defined healthy children.

Etiology and pathogenesis of hereditary renal tubular acidosis / 中华实用儿科临床杂志

Renal tubular acidosis (RTA) is a hyperchloremic metabolic acidosis characterized by a normal anion gap due to reduced urinary acidification.Multiple mechanisms act in the renal tubule to maintain balance in hydrogen ion secretions and bicarbonate absorption.In recent years,more and more proteins have been found to be associated with RTA,so hereditary RTA has attracted people's attention.Mutations in the gene SLC4A1,encoding C1-/HCO3-exchanger (kAE1);in the gene ATP6V1B1,encoding B1 subunit of H+-ATP ase;in the gene ATP6V0A4,encoding a4 subunit of H +-ATP ase;in the gene SLC4A4,encoding Na+/HCO3-cotransporter(kNBCe1);in the gene CA2,encoding carbonic anhydrase Ⅱ are identified in the pathogenesis of hereditary RTA.The search for pathogenetic genes for clinically suspected hereditary RTA patients can help us to make accurate genetic diagnosis and provide targeted treatment interventions.

A rare case of B-lymphoproliferative disorder with villous lymphocytes harboring t(8;14)(q24;q32) translocation / 医学前沿

Splenic lymphoma with villous lymphocytes (SLVL) or splenic marginal zone lymphoma with circulating villous lymphocytes is rare, and prolymphocytic transformation of SLVL is rarer. At present, only one case of SLVL with t(8;14)(q24;q32) translocation has been reported. In this study, we report a case of B-lymphoproliferative disorder with villous lymphocytes harboring t(8;14)(q24;q32) chromosome translocation that we inclined to SLVL with a prolymphocytic transformation. A 73-year-old female showed marked hepatosplenomegaly and high lymphocytosis (lymphocytes > 200 × 10/L). The abnormal lymphocytes had short coarse villi and round nuclei with prominent nucleoli. The immunophenotypes showed CD19, CD20, HLA-DR, CD22, CD5, Kappa, CD25, CD71, Lambda, CD7, CD10, CD23, CD34, CD33, CD13, CD14, CD117, CD64, CD103, and CD11c. The karyotype showed complex abnormality: 46XX,+ 3,-10, t(8;14)(q24; q32)[11]/46XX[9]. The cytoplasmic projection, immunological characteristics, and trisomy 3 chromosome abnormality supported the diagnosis of SLVL. However, the presence of prominent nucleoli and high lymphocytosis suggested prolymphocytic transformation, probably as a result of t(8,14) chromosome translocation. In this report, we described an unusual case of B-lymphoproliferative disorder with villous lymphocytes harboring t(8;14)(q24;q32) translocation, which could provide help in the diagnosis and differential diagnosis of B-lymphocytic proliferative diseases.

Evaluation of TGF-beta1 and MCP-1 expression and tubulointerstitial fibrosis in children with Henoch-Schönlein purpura nephritis and IgA nephropathy: A clinical correlation

OBJECTIVES: Henoch-Schönlein purpura nephritis and immunoglobulin A nephropathy are two diseases with similar clinical presentations but very different prognoses. Transforming growth factor β1 and monocyte chemoattractant protein-1 have been associated with the development of tissue fibrosis. We examined the development of tubulointerstitial fibrosis and its relationship with Transforming growth factor β1 and monocyte chemoattractant protein-1 expression in these patients. METHODS: Renal tissue samples were collected by renal biopsy from 50 children with Henoch-Schönlein purpura nephritis and 50 children with immunoglobulin A nephropathy. Hematoxylin and eosin and Masson's trichrome-stained tissues were examined using light microscopy. Tubulointerstitial fibrosis was graded using the method described by Bohle et al. (1). The immunohistochemical detection of Transforming growth factor β1 and monocyte chemoattractant protein-1 expression was correlated with the tubulointerstitial fibrosis grade. Clinical Trial registration number: ZJCH-2012-0105. RESULTS: Transforming growth factor β1 and monocyte chemoattractant protein-1 expression in the renal tissues was significantly greater in the patients with immunoglobulin A nephropathy than in the patients with Henoch-Schönlein purpura nephritis (both p<0.001). The immunoglobulin A nephropathy patients had a higher tubulointerstitial fibrosis grade than the Henoch-Schönlein purpura nephritis patients (p<0.001). The tubulointerstitial fibrosis grade was in accordance with the Transforming growth factor β1 and monocyte chemoattractant protein-1 expression levels in both diseases (both p<0.001). CONCLUSION: Transforming growth factor β1 and monocyte chemoattractant protein-1 expression was associated with the development of immunoglobulin A nephropathy and Henoch-Schönlein purpura nephritis. Further studies are needed to better evaluate this association.

Serum Uric Acid Level and Its Influencing Factors in Children with Primary Nephrotic Syndrome / 中国医科大学学报

Objective To explore the correlation between serum uric acid levels and uric acid excretion indexes in children with primary nephrot?ic syndrome(PNS),and to reveal the prevalence of hyperuricemia and its possible causes in PNS. Methods The clinical data in 74 cases of pe?diatric PNS were retrospectively analyzed. These patients were grouped as hyperuric acid(HUA)or non?hyperuric acid(NUA),and their clinical features and laboratory findings were compared between two groups,including age,serum uric acid,serum creatinine,urea,cystatin C,triglycer?ide,cholesterol,albumin,creatinine clearance rate,24 hours urine uric acid,serum uric acid/serum creatinine,uric acid clearance,and the frac?tional excretion of uric acid and other indicators of differences. In addition ,a correlation analysis was carried out for the excretion of uric acid index. Results Several factors were lower in HUA group than that of NUA group ,such as the serum albumin and fractional excretion of uric acid(P1=0.034,P2=0.025);while the serum cystatin C and serum uric acid/serum creatinine ratio(P1=0.038,P2=0.001)was higher in HUA group. The uric acid excretion was negatively correlated with serum uric acid levels in all 74 children with PNS(r=-0.43,P=0.016),and the serum uric acid/creatinine ratio was positively correlated with serum uric acid(r=0.486,P=0.001). Conclusion Both the increase of blood uric acid production and excretion reduction were observed in children with PNS ,and the serum uric acid levels and renal tubular function is closely related.

Classification, clinic and hereditary of renal medullary cystic diseases / 中华实用儿科临床杂志

Renal medullary cystic diseases are a large class of heterogeneous diseases,and they are common in clinic,most of them often progress to end-stage renal disease.With recent advances in genetics,increasing number of genes and genetic mutations has been identified with the etiology of renal medullary cystic diseases.Although genetic testing can provide mass data for diagnosis,clinical manifestation are even more important for clinical diagnosis,differentiation and genetic counseling for the patients.In this review,the classification,renal presentations,extra-renal presentations,and genetic analysis of renal medullary cystic diseases will be discussed.

A pilot study of postgraduates students training for master degree of clinical medicine / 医学研究生学报

At present, the teaching management department is facing a big puzzle in the education of medical professional postgraduate degree. How to strengthen the appropriate scientific research training while successfully completing the 33-months clinical rotation. With the social development and increasing demands, the original training model that training professional technical personnel and scientific academic personnel seperately has been confirmed unable to adapt to the current requirements. Combining with the practi-cal experience of the medical postgraduate degree education, we put forward some constructive suggestions of boosting the innovation of the medical postgraduate degree education from several aspects, such as optimizing the training process, strengthening the stage man-agement, improving the quality of the tutor team, smoothing the communication mechanism between teachers and students, cultivating clinical research thinking, etc.

Influence of hyperglycemia on hospitalization and follow-up prognosis in emergency PCI patients / 心血管康复医学杂志

Objective:To explore influence of hyperglycemia on hospitalization and follow‐up prognosis in patients with acute ST elevation myocardial infarction (STEMI ) undergoing direct percutaneous coronary intervention (PCI) .Methods :A total of 218 patients ,who were diagnosed as STEMI and received emergency PCI within 12h af‐ter onset from our hospital ,were enrolled .According to blood glucose level at hospitalization and OGTT results , they were divided into normal blood glucose (NBG) group (n= 108) ,hyperglycemia group (n= 60) and diabetes mellitus (DM) group (n=50) .Cardiac function indexes were evaluated ;Logistic regression analysis was used to an‐alyze influencing factors for mortality in these patients .Results:Compared with NBG group , the in‐hospital mortal‐ity was significant rise (1.9% vs .10.0% ) in DM group ;there were significant rise in percentages of ≥double‐vessel coronary disease (41.2% vs .68.8% vs .66.7% ) and ≥2 stents implanted (14.72% vs .50.0% vs .55.6% ) in women in hyperglycemia group and DM group (P<0.05 or <0.01);Multi‐factor Logistic regression analysis indi‐cated that Killip class ,NT‐proBNP ,number of diseased vessels and body mass index were independent risk factors of in‐hospital mortality of these patients (OR=1.012~5.923 ,P<0.05 all) ,and female was a strong independent risk factor for in‐hospital mortality and mortality within one‐year follow‐up (OR=20.376 ,7.227 ,P<0.01 both) .Con‐clusion:The mortality significantly rises in STEMI patients undergoing emergency PCI complicated with hyperglyce‐mia ,especially in female patients .

Analysis about the papers published by hospital library in Jiangsu province / 医学研究生学报

Objective To provide the basis for scientific research management and promote innovation of knowledge service in hospital library , understand the level of academic development of hospital library , we analyzed the papers published by hospital li-brary in Jiangsu province . Methods Using bibliometric method to analyze papers published by hospital libraries in Jiangsu from 1990-2014 . Results In the 25 years, 415 papers were published , but with only 17.1%published in the core journals and thesis influence was not high .Most authors were from tertiary hospitals .The academic influence of papers was not high .Most papers were written by librarians independently , while 2.4%of papers were co-authored with other libraries or clinical departments .Thesis topic was almost traditional , so that the research was lack of innovation . Conclusion Hospital library research level is not balanced and high.We should make further effort to strengthen the continuing education , research cooperation, development of qualified personnel , and improve paper quality in order to promote the common development of hospital library in Jiangsu province .