Disseminated intravascular coagulation ( DIC ) is a exceedingly complicated pathophysiological process,both pro and anti coagulation factors are activated and consumed,it is difficult to determine acute stage of the syndrome for physicians based on clinical presentations and laboratory tests,management strategy of DIC is not same due to different etiology,the dose and regimen of drug administration are uncertain. At present pediatricians usually treat children patients with DIC according to researches and guidelines for adults. The key strategies to DIC management is to treat underlying diseases aggressively so as to clear risk factors triggering extensive coagulation and resuscitate with ap-propriate blood products. No clinical trials have proved that heparin can improve clinical outcome,efficacies of activated protein C,antithrombin, tissue factor pathway inhibitor and thrombomodulin are needed to be verified by more high qua-lity clinical trials in DIC treatment.

Objective To analysis the clinical characteristics and the long-term effect of children with acute lymphoblastic leukemia (ALL).Methods From 2005 to 2010,80 newly diagnosed ALL children were enrolled and treated with protocol based on ALL-BFM2002.The five-years overall survival (OS)and event-free survival(EFS) were analyzed by the method of Kaplan-Meier.Results For the 80 patients,male to female ratio is 1.22∶1.The median age was 4.3 years.33 were in standard risk(41.2％),37 were in medium risk(46.3％),and 10 were in high risk(12.5％).22 had white blood cell count ≥20 x 109/L(27.5％).three patients with BCR-ABL translocation(3.8％),one patient with MLL gene rearrangement(1.3％),17 patients with TEL-AML translocation (21.3％).During induction therapy,79 patients (98.8 ％) achieved complete remission(CR).The five-years OS and EFS were (85.9 ± 4.0) ％ and (79.2 ± 4.7) ％ respectively.The five-years EFS:SR group (86.6 ± 6.4) ％,IR group (81.1 ± 6.4) ％,HR group (48.0 ± 16.4) ％.The difference among risk groups was statistically significant(x2 =7.03,P ＜0.05).12 patients relapsed(15.0％),the median time from diagnosis to relapse was 23.5 months.11 patients died (13.8 ％).Conclusion According to stratification by risk factors and risk-adapted therapy,the quality of ALL children's life had improved.

Objective To explore the expressions of growth factor receptor binding protein 2 -associated bin-ding protein -1 (Gab -1 )and glioma -associated oncogene homologue -1 (Gli -1 )in pediatric medulloblastoma,and to analyze their correlation between clinical and pathological characteristics and prognosis in pediatric medulloblastoma. Methods Elivision immunohistochemistry was used to detect the expressions of Gab -1 and Gli -1 protein in tissue microarray of 40 paraffin embedded pediatric medulloblastoma specimens.Chi -square test or Fisher exact test was used to analyze the correlation between Gab -1 and Gli -1 protein expressions with gender,age,tumor location and pathological subtypes.Follow -up data were handled by using Kaplan -Meier survival analysis and Cox regression anal-ysis.Results Positive expression ratios of Gab -1 and Gli -1 protein in 40 pediatric medulloblastoma were 35.0%and 55.0%,respectively.The positive expression rate of Gab -1 in medulloblastoma tissues had no statistical signifi-cance between different genders[male:30.4%(7 /23 cases)vs.female:41 .2%(7 /17 cases)],age[<3 years old:40.0%(6 /15 cases)vs.≥3 years old:32.0%(8 /25 cases)],tumor location[cerebellum:25.0%(5 /20 cases)vs. the fourth ventricle:45.0%(9 /20 cases)]and pathological subtype[classical type:40.7%(11 /27 cases)vs.desmo-plastic /nodular type:50.0%(5 /10 cases)vs.anaplastic /large cell type:66.7%(2 /3 cases)](χ2 =0.496,0.264, 1 .758,3.289,all P >0.05).There were statistical differences of positive expression rate of Gli -1 protein in different age groups[<3 years old:80.0%(12 /15 cases)vs.≥3 years old 40.0%(10 /25 cases)],different pathological sub-types[classical type:40.7%(11 /27 cases)vs.desmoplastic /nodular type:90.0%(9 /10 cases)vs.anaplastic /large cell type:66.7%(2 /3 cases)](χ2 =6.061 ,7.333,all P <0.05 ).There was no statistical difference in positive expression rate of Gli -1 protein between different gender[male:60.9%(14 /23 cases)vs.female:47.1 %(8 /17 cases)]and different tumor location [cerebellum:55.0% (11 /20 cases)vs.the fourth ventricle:55.0% (11 /20 cases)](χ2 =0.753,0.000,all P >0.05).Kaplan -Meier survival analysis showed that the age,the expressions of Gab -1 and Gli -1 protein were correlated with prognosis of pediatric medulloblastoma(all P <0.05).Cox regression indicated that the age,pathological subtypes and the expression of Gli -1 protein were independent prognostic indicators in pediatric medulloblastoma(all P <0.05).Conclusion Expression of Gab -1 and Gli -1 protein is significantly correlated with the prognosis of medulloblastoma,and the positive expression is a marker of unfavorable prognosis.

Objective To investigate the changes of CD4 +CD25highFoxp3 +regulatory T (Treg) cells and their significance in immune escape of childhood B-cell acute lymphocytic leukemia ( B-ALL ) . Methods Forty-two children with B-ALL and twenty-eight age-matched healthy children were enrolled in this study.Flow cytometry analysis was performed to evaluate the proportion of CD 4 +CD25high Foxp3 +Treg cells as well as CD4 +CD25high ICOS+Foxp3 +and CD4 +CD25high ICOS-Foxp3 +subsets in peripheral blood samples.The expression of associated molecules including IL-10, TGF-β, IL-35, TGF-βRII, ICOS and CD28 at protein level were also measured by flow cytometry analysis .The transcription level of Smad3/4, TIEG1 and Itch by CD4 +T cells were determined by quantitative real-time PCR.The concentration of TGF-βin plasma was detected by enzyme-linked immunosorbent assay.Results (1)The proportion of CD4 +CD25highFoxp3 +Treg cells in children with B-ALL were significantly higher than those of health subjects (P<0.05).The proportion of both ICOS +Foxp3 +and ICOS -Foxp3 +subsets were increased in comparison with those of control group (P<0.05), while the ratio of ICOS +Foxp3 +to ICOS-Foxp3 +was decreased (0.73 ±0.21 vs 1.87 ±0.59, P<0.05).(2) The expression of Foxp3, TGF-β, IL-10 and IL-35 by ICOS+Foxp3 +Treg cells and the expression of membrane bound TGF-βby ICOS -Foxp3 +Treg cells were significantly increased in children with B-ALL (P<0.05).However, the expression of Foxp3 by ICOS -Foxp3 +Treg cells showed no significant difference between the two groups (P>0.05).(3)The concentra-tion of TGF-βin plasma from children with B-ALL were higher than those from control group [ ( 25 .83 ± 12.65) ng/ml vs (8.59 ±5.73) ng/ml, P<0.05].The expression of TGF-βRII and its associated mole-cules (Smad3/4, TIEG1 and Itch) by CD4 +T cells were significantly up-regulated.Moreover, an increased expression of ICOS and CD28 by CD4 +CD25highFoxp3 +Treg cells were also observed in children with B-ALL (P<0.05).Conclusion The hyper-activity of TGF-β, ICOS and CD28 signaling might be closely associ-ated with the increased proportion of CD4 +CD25high Foxp3 +Treg cells and the imbalance of its subsets in children with B-ALL.

Objective:To investigate the effects of Notch1 signaling on histone acetylation of Foxp3 gene and its roles in regulating regulatory T (Treg) cells in children with acute B-cell precursor lymphoblastic leukemia (BCP-ALL).Methods:Blood samples were collected form 38 children with BCP-ALL before treatment and 15 age-matched healthy children (control group). Flow cytometry was performed to detect the proportion of peripheral blood CD4 + CD25 hiFoxp3 + Treg cells and the expression of Foxp3, cytotoxic lymphocyte antigen 4 (CTLA4), glucocorticoid-induced tumor necrosis factor receptor (GITR), CD39 and Notch1 at protein level. Histone 4 acetylation (H4Ac) at Foxp3 gene promoter and the binding abilities of Foxp3 gene promoter to NICD1 and p300 in CD4 + T cells were measured by chromatin immunoprecipitation. Quantitative real-time PCR was performed to detect the expression of Foxp3, presenilin 1 (PSEN1), mastermind-like transcriptional coactivator 1 (MAML1), SKI-interacting protein (SKIP), F-box and WD40 domain protein 7 (FBXW7), glycogen synthase kinase-3 beta (GSK3β) and IKAROS at mRNA level in CD4 + T cells. The concentrations of TGF-β and IL-10 in plasma were evaluated by ELISA. Results:(1) The proportion of peripheral blood CD4 + CD25 hiFoxp3 + Treg cells, the expression of differentiation- and function-associated molecules (Foxp3, CTLA4, GITR and CD39) and the concentrations of TGF-β and IL-10 in plasma were higher in the BCP-ALL group than in the control group ( P<0.05). (2) In children with acute BCP-ALL, H4Ac at Foxp3 promoter and the binding abilities of Foxp3 gene promoter to NICD1 and p300 were significantly increased as compared with those in control group( P<0.05). The binding abilities of Foxp3 gene promoter to NICD1 and p300 were positively correlated with the expression of Foxp3 at mRNA level ( r=0.58 and 0.46, both P<0.05). After competitive inhibition, the three aforementioned indexes in the acute BCP-ALL group were significantly lower than those in untreated group ( P<0.05); the binding ability of Foxp3 gene promoter to NICD1 in the control group was also significantly lower than that in untreated control group ( P<0.05), but no statistical differences in the other two indexes were found between the control groups with or without treatment ( P>0.05). ⑶ Compared with the control group, the expression of Notch1, PSEN1, MAML1 and SKIP in CD4 + T cells were elevated significantly ( P<0.05), while the transcription level of negative regulatory factor FBXW7 was decreased remarkably in children with acute BCP-ALL ( P<0.05). No statistical differences in the expression of GSK3β or IKAROS were found between the two groups ( P>0.05). Conclusions:Overactivation of Notch1 signaling caused by low expression of FBXW7 might be the key factor resulting in histone 4 hyperacetylation at foxp3 gene promoter and Treg cell dysfunction in children with acute BCP-ALL.

Objective:Discipline construction is the key and effective method for the high-quality development of hospitals. This study summarized the practical and valuable experience of discipline construction with the support of the ″Sanming Project of Medicine″ in Shenzhen, to provide a worthy reference for similar projects and hospital specialty development.Methods:Taking the introduction of the hematology-oncology team of the Canadian Children′s Hospital as an example, we analyzed the background, the process, and the effectiveness of discipline construction of hematology and oncology of Shenzhen Children′s Hospital under the support of the ″Sanming Project of Medicine″, and explored the common rules for rapid specialty development.Results:Through the implementation of two levels supporting policies from cities and hospitals and quantifiable and verifiable annual progressive program, the adoption of the international advanced medical management mode and concepts, and the transformation and application of cutting-edge clinical technologies, we successfully built the largest pediatric hematologic oncology diagnosis and treatment center in South China and the largest pediatric hematopoietic stem cell transplant center in China. By executing a multi-level talent developing program, the number of specialists with MD and PhD degrees increased by 6.5 times, and 23 doctors and nurses were trained abroad, leading to the development of provincial key clinical specialties and municipal key scientific research platforms.Conclusions:This project concluded the beneficial experience of introducing high-level overseas medical teams to boost discipline construction, including internationally advanced medical concepts and management modes, tiered talent cultivation schemes, the construction of clinical and basic research platforms, etc., providing references for the rapid improvement of discipline construction in terms of health care for other hospitals in Shenzhen and similar cities.

Objective:To explore the early identification, diagnosis and pathogenesis of childhood acute lymphoblastic leukemia (ALL) complicated with cytokine release syndrome(CRS).Methods:The clinical data of childhood ALL complicated with CRS admitted to Shenzhen Children's Hospital in February 2021 were retrospectively analyzed. The relevant literature was reviewed.Results:The little girl was 2 months and 11 days of age and was diagnosed with ALL with MLL rearrangement positive by bone marrow aspiration because of abdominal mass and abnormal hemogram. She had recurrent high fever with pulmonary imaging characteristic changes during the early intensive induction chemotherapy, accompanied by the elevated interlukin (IL)-2, IL-6, IL-10 and interferon (IFN)-γ. Finally, she was diagnosed with ALL complicated with CRS. Glucocorticoid therapy showed a good efficacy and her clinical symptoms improved.Conclusions:ALL complicated with CRS is essentially induced by cytarabine syndrome drugs in the chemotherapy. The main clinical manifestations include recurrent high fever accompanied by the elevated IL-2, IL-6, IL-10 and IFN-γ. The symptomatic and supportive therapy is usually based on glucocorticoids. Early identification and diagnosis can reduce adverse drug reactions and improve the life quality of children.

Objective:To evaluate the role of minimal residual disease (MRD) monitoring during early induction therapy for the treatment of childhood acute lymphoblastic leukemia (ALL).Methods:This was a multicenter retrospective cohort study. Clinical data of 1 164 ALL patients first diagnosed between October 2016 and June 2019 was collected from 16 hospitals in South China Children′s Leukemia Group. According to MRD assay on day 15 of early induction therapy, they were divided into MRD<0.10% group, MRD 0.10%-<10.00% group and MRD≥10.00% group. According to MRD assay on day 33, they were divided into MRD<0.01% group, MRD 0.01%-<1.00% group and MRD≥1.00% group. Age, onset white blood cell count, central nervous system leukemia (CNSL), molecular genetic characteristics and other data were compared between groups. Kaplan-Meier method was used for survival analysis. Cox regression model was used to analyze prognostic factors.Results:Of the 1 164 enrolled patients, there were 692 males and 472 females. The age of diagnosis was 4.7 (0.5, 17.4) years. The white blood cell count at initial diagnosis was 10.7 (0.4, 1 409.0) ×10 9/L. Among all patients, 53 cases (4.6%) had CNSL. The follow-up time was 47.6 (0.5, 68.8) months. The 5-year overall survival (OS) and 5-year relapse-free survival (RFS) rates were (93.1±0.8) % and (90.3±1.1) %. On day 15 of early induction therapy, there were 466 cases in the MRD<0.10% group, 523 cases in the MRD 0.10%-<10.00% group and 175 cases in the MRD≥10.00% group. The 5-year OS rates of the MRD<0.10% group, MRD 0.10%-<10.00% group and MRD≥10.00% group were (95.4±1.0) %, (93.3±1.1) %, (85.4±2.9) %, respectively, while the RFS rates were (93.2±1.6) %, (90.8±1.4) %, (78.9±4.3) %, respectively ( χ2=16.47, 21.06, both P<0.05). On day 33 of early induction therapy, there were 925 cases in the MRD <0.01% group, 164 cases in the MRD 0.01%-<1.00% group and 59 cases in the MRD≥1.00% group. The 5-year RFS rates in the MRD 0.01%-<1.00% group was lowest among three groups ((91.4±1.2) % vs. (84.5±3.2) % vs. (87.9±5.1) %). The difference between three groups is statistically significant ( χ2=9.11, P=0.010). Among ALL patients with MRD≥10.00% on day 15 of induction therapy, there were 80 cases in the MRD <0.01% group on day 33, 45 cases in the MRD 0.01%-<1.00% group on day 33 and 45 cases in the MRD≥1.00% group on day 33. The 5-year RFS rates of three groups were (83.9±6.0)%, (67.1±8.2)%, (83.3±6.9)% respectively ( χ2=6.90, P=0.032). Univariate analysis was performed in the MRD≥10.00% group on day 15 and the MRD 0.01%-<1.00% group on day 33.The 5-year RFS rate of children with CNSL was significantly lower than that without CNSL in the MRD≥10.00% group on day 15 ((50.0±20.4)% vs. (80.3±4.4)%, χ2=4.13, P=0.042). Patients with CNSL or MLL gene rearrangement in the MRD 0.01%-<1.00% group on day 33 had significant lower 5-year RFS rate compared to those without CNSL or MLL gene rearrangement ((50.0±25.0)% vs. (85.5±3.1)%, χ2=4.06, P=0.044;(58.3±18.6)% vs. (85.7±3.2)%, χ2=9.44, P=0.002). Multivariate analysis showed that age ( OR=0.58, 95% CI 0.35-0.97) and white blood cell count at first diagnosis ( OR=0.43, 95% CI 0.27-0.70) were independent risk factors for OS. The MRD level on day 15 ( OR=0.55,95% CI 0.31-0.97), ETV6-RUNX1 fusion gene ( OR=0.13,95% CI 0.03-0.54), MLL gene rearrangement ( OR=2.55,95% CI 1.18-5.53) and white blood cell count at initial diagnosis ( OR=0.52,95% CI 0.33-0.81) were independent prognostic factors for RFS. Conclusions:The higher the level of MRD in early induction therapy, the worse the OS. The MRD levels on day 15 is an independent prognostic factor for RFS.The MRD in early induction therapy guided accurate risk stratification and individualized treatment can improve the survival rate of pediatric ALL.