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幼年特发性关节炎相关葡萄膜炎诊疗中国专家共识(2023)
详细信息Chinese Expert Consensus on Juvenile Idiopathic Arthritis-associated Uveitis (2023)
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摘要: 幼年特发性关节炎(juvenile idiopathic arthritis，JIA)是儿童时期常见的风湿免疫性疾病。幼年特发性关节炎相关葡萄膜炎(juvenile idiopathic arthritis-associated uveitis，JIA-U)是JIA重要的关节外并发症，主要表现为隐匿起病的虹膜和睫状体前部非肉芽肿性炎症(虹膜睫状体炎)，是造成儿童时期残疾和失明的重要原因之一。近年来，美国风湿病学会(American College of Rheumatology，ACR)及欧洲儿科风湿病学的单一枢纽和接入点(Single Hub and Access Point for Pediatric Rheumatology in Europe，SHARE)先后均发表了JIA-U的临床指南，但我国尚缺乏诊疗相关指导性文件。为进一步加强该病的临床认知和诊疗规范，中华医学会儿科学分会免疫学组、中国儿童风湿免疫病联盟、国家儿童健康与疾病临床研究中心风湿免疫联盟联合眼科专家共同制定了《幼年特发性关节炎相关葡萄膜炎诊疗中国专家共识(2023)》，在疾病筛查、诊断、治疗等方面达成初步共识，以供临床参考。Abstract: Juvenile idiopathic arthritis (JIA) is a common chronic rheumatologic disease in childhood. JIA-associated uveitis (JIA-U), an important extra-articular complication of JIA, is one of the major causes of childhood disability and blindness. It is predominantly anterior, nongranulomatous inflammation affecting the iris and ciliary body (iridocyclitis) of insidious onset. Recently, American College of Rheumatology (ACR) and the Single Hub and Access Point for Pediatric Rheumatology in Europe (SHARE) have published clinical guidelines for JIA-U. There is no guideline of diagnosis and treatment of JIA-U in China. To promote the standardization of clinical understanding and treatment, the Subspecialty Group of Immunology of the Society of Pediatrics of Chinese Medical Association, Chinese Alliance of Pediatric Rheumatic and Immunologic Diseases, and National Clinical Research Center for Child Health and Disorders organized experts and scholars in related fields to discuss the issue and finally formed this consensus for clinicians' reference.
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Keywords:
- juvenile idiopathic arthritis /
- uveitis /
- diagnosis /
- treatment /
- expert consensus
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无偿献血是一项事关广大人民群众身体健康和生命安全的社会公益事业。在党和国家的高度重视下，我国无偿献血制度、血液管理法制体系和血站采供血服务体系日趋完善[1-2]。但时有非法卖血行为发生，对我国血液管理制度造成严重破坏，对用血安全造成严重干扰[3]。非法组织卖血罪是指违反国家有关规定，非法组织出卖他人血液的行为。其严重扰乱医疗机构诊疗秩序，威胁血液质量安全，应予以严厉打击。本研究对近年来北京地区发生的非法组织卖血罪案件进行总结，旨在为针对性预防措施的出台提供参考，为首都健康公益事业保驾护航。
1. 资料与方法
1.1 资料来源
2020年11月18日于中国裁判文书官方网站(https://wenshu.court.gov.cn)以“北京”和“非法组织卖血罪”为关键词，检索2013—2019年北京地区非法组织卖血罪的裁判文书。以全部裁判文书为研究对象进行分析。
1.2 方法
对裁判文书涉及的案件资料进行分类汇总，包括罪犯个人信息与判决结果、犯罪时间、犯罪区域与地点等。
1.3 统计学处理
采用Microsoft Excel 2007软件进行资料整理和图表绘制。计数资料以频数(百分数)的形式进行描述。
2. 结果
2.1 案件总体情况
共检索2013—2019年北京地区非法组织卖血罪的裁判文书58份，涉及58起案件和115名罪犯。58起案件涉及北京8个城区，共组织638人卖血，非法卖血13 600 mL，卖血价格为400~600元/400 mL。共5份裁判文书记述招募卖血者方式，其中散发小广告2份(40.0%)、随机打电话2份(40.0%)、利用互联网媒介发布信息2份(40.0%)、上门问询1份(20.0%)等。关于罪犯判决情况，最轻的刑罚为拘役三个月缓刑六个月，并处罚金人民币二千元，最重的判决为有期徒刑一年八个月，并处罚金人民币五千元。
2.2 罪犯个人信息及判决结果
115名罪犯，男性99人(86.1%)，女性16人(13.9%)；罪犯年龄18~61岁，平均年龄33岁。其中20~29岁年龄段人数最多(42.6%，49/115)，其次为30~39岁(24.3%，28/115)；有违法记录25人(21.7%)，无违法记录90人(78.3%)。判处拘役、缓刑并处罚金10人(8.7%)，有期徒刑、缓刑并处罚金8人(7.0%)，有期徒刑并处罚金97人(84.3%)，详情见表 1。
表 1 58起非法组织卖血犯罪案件涉及罪犯判决结果[n(%)]指标 拘役、缓刑、处罚金 有期徒刑、缓刑、处罚金 有期徒刑、处罚金 合计 性别 男性 8(8.1) 4(4.0) 87(87.9) 99(86.1) 女性 2(12.5) 4(25.0) 10(62.5) 16(13.9) 年龄(岁) ＜20 0(0) 1(16.7) 5(83.3) 6(5.2) 20~29 2(4.1) 3(6.1) 44(89.8) 49(42.6) 30~39 1(3.6) 2(7.1) 25(89.3) 28(24.3) 40~49 5(26.3) 0(0) 14(73.7) 19(16.5) 50~59 2(16.7) 2(16.7) 8(66.7) 12(10.4) ≥60 0(0) 0(0) 1(100) 1(0.9) 违法记录 有 0(0) 1(4.0) 24(96.0) 25(21.7) 无 10(11.1) 7(7.8) 73(81.1) 90(78.3) 2.3 犯罪时间分布
2013—2019年北京地区非法组织卖血犯罪案件频次总体呈波动下降趋势，其中2015年出现较大反弹，案件发生频次最高(34.5%, 20/58)，2018年案件发生频次最低(0)。组织卖血人数变化趋势与案件频次变化趋势基本一致，2015年最高(62.1%，396/638)，2018年最低(0)，见图 1。
从案件发生所处的月份上看，1月发生的案件频次最高(32.8%，19/58)，其次为6月(15.5%，9/58)，而4、5月均无非法组织卖血犯罪案件发生。关于案件涉及的卖血人数，1月占比最高(61.6%，393/638)，12月次之(13.6%，87/638)，见图 2。
2.4 犯罪区域与地点
58起非法组织卖血罪案件发生区域涉及北京8个城区，其中海淀区占比最高(62.1%，36/58)，其次为房山区(22.4%，13/58)，余6区案件频次占比均较低。发生于房山区的案件涉及的组织卖血人数最多(50.2%, 320/638)，其次为海淀区(20.2%, 129/638)，见图 3。
从犯罪地点上看，发生于医院的案件占比55.2%(32/58)，组织卖血人数占比61.2%(390/638)；发生于血液中心(包括采血站)的案件占比44.8%(26/58)，组织卖血人数占比38.8%(248/638)，见图 4。
3. 讨论与建议
3.1 讨论
无偿献血是传递爱心的公益事业，同时也是满足医疗服务需求，完善血液供应保障机制的重要组成部分，事关人民福祉和社会稳定，必须保障人民群众用血安全，维持采供血机制完善。非法组织卖血的行为干扰了血液供应机制的正常运行，社会危害极大，应严厉杜绝。本研究对2013—2019年北京地区58起非法组织卖血犯罪的特征进行了总结，探究其规律和特征，以实现精准预防。
首先从案件的年度分布上看，2013—2019年案件频次和涉及的卖血人数整体均呈下降趋势，间接反映出在各级党委、政府和相关部门的组织领导和有力推动下，北京血液管理体系和血站采供血机制逐渐完善，取得了显著成绩。积极推进无偿献血事业的进程，必须在坚持中发展。为净化供血环境，保障临床用血安全，2015年1月30日北京市公安局曾联合多部门对位于房山区某第一医院的非法组织卖血活动进行专项集中整治，打掉犯罪团伙11个，形成裁判文书11份，可能是2015年案件频次出现较大波动的原因。
对案件发生所处的月份进行分析，发现1、6月为案件高发期，而4、5月均无相关案件发生。临床用血来源主要依靠无偿献血，学生与进城务工人员等流动性人员是无偿献血的主体人群之一。受寒暑假期间流动性人口返乡以及酷热、严寒对其出行的影响，可能导致寒暑期间血液采集量大为减少。北京地区临床用血量较多，不可避免地发生季节性“血荒”[4]，为非法组织卖血人员提供了可乘之机。1月份临近春节，部分经济拮据的人可能为增加经济收入，而参与非法卖血。
关于案件发生的区域与地点，海淀区与房山区为非法组织卖血案件高发区，发生地点主要为医院，其次为血液中心。医院为主要用血单位，故非法人员瞄准医院而开展非法卖血行为。海淀区域分布广，医院和血液中心多，以致非法组织卖血案件高发。房山区为城乡结合处，外来人员多，卫生防护意识相对差，可能为非法组织卖血人员实施犯罪提供了机会。
3.2 建议
首先，司法机关应坚决打击非法组织卖血犯罪案件，尤其集团化犯罪团伙，组织卖血人员众多、影响巨大的案件予以严厉刑罚，以形成强大威慑力，实现刑罚特殊预防和一般预防的效果。本研究58起案件共涉及115名罪犯，其中判有期徒刑并罚金97名，对于减少此类案件的发生可能具有积极作用。
其次，公安机关建立非法组织卖血资料数据库，特别是案件高发的海淀区与房山区，可利用大数据实施精准打击，实现有效预防。对于血液中心、医院等高发场所，保卫部门与当地派出所建立联动机制，利用人脸识别系统实现动态监测，营造持续高压态势，发现一起，查处一起。
再次，加强血液储备和区域间血液调动，确保血液供应及时、充足，保障公民临床急救用血的需求。
最后，加强无偿献血、血液安全健康宣教，增强人民群众的法律意识。可适当建立无偿献血激励机制，积极动员广大群众至正规场所进行无偿献血，彻底铲除犯罪的土壤。
4. 小结
血液是宝贵的医疗资源，无偿献血是一种无私奉献、救死扶伤的崇高行为，保障用血安全意义重大。受利益驱动，一些不法人员进行非法组织卖血，其行为对正常的血液安全管理体系和公共卫生秩序造成了严重干扰。本研究通过对北京地区非法组织卖血案件的特征进行了总结，为今后对此类案件的预防提供了借鉴。
志谢: 感谢重庆医科大学附属第二医院流行病与卫生统计学教研室苏舒对本专家共识提供方法学指导。作者贡献：本专家共识由中华医学会儿科学分会免疫学组、中国儿童风湿免疫病联盟、国家儿童健康与疾病临床研究中心风湿免疫联盟发起，宋红梅、唐雪梅牵头成立指南制订工作组，杨曦起草本共识初稿并负责主要撰写工作，专家组成员共同进行讨论和投票, 杨培增、张美芬参与凝练本指南推荐意见。利益冲突：所有参与本共识制订的人员均声明不存在利益冲突核心专家组 (按姓氏首字母排序)：宋红梅(中国医学科学院北京协和医院儿科)，孙利(复旦大学附属儿科医院风湿科)，唐雪梅(重庆医科大学附属儿童医院风湿免疫科)，杨军(深圳市儿童医院风湿免疫科)，杨培增(重庆医科大学附属第一医院眼科)，张美芬(中国医学科学院北京协和医院眼科)工作组 (按姓氏首字母排序)：安云飞(重庆医科大学附属儿童医院风湿免疫科)，郝胜(上海市儿童医院肾脏风湿免疫科)，蒋新辉(贵阳市妇幼保健院儿童风湿免疫科)，李建国(首都儿科研究所附属儿童医院风湿免疫科)，李小青(西安市儿童医院风湿免疫科)，李晓忠(苏州大学附属儿童医院肾脏免疫科)，刘勍(重庆医科大学附属儿童医院眼科)，刘小惠(江西省儿童医院风湿免疫科)，卢美萍(浙江大学附属儿童医院风湿免疫科)，毛华伟(首都医科大学附属儿童医院免疫科)，唐琳(重庆医科大学附属第二医院风湿免疫科)，王亚军(云南省第一人民医院儿科)，吴小川(中南大学湘雅二医院儿科)，杨思睿(吉林大学第一医院儿童风湿免疫过敏科)，俞海国(南京医科大学附属儿童医院风湿免疫科)，张秋业(青岛大学附属儿童医院儿科)，张伟(成都市妇女儿童中心医院儿童风湿免疫科)，赵冬梅[乌鲁木齐市第一人民医院(儿童医院)风湿免疫科]，曾萍(广州市妇女儿童医疗中心风湿免疫科)，郑雯洁(温州医科大学附属第二医院儿童风湿科)，周纬(上海儿童医学中心肾脏风湿科)秘书组：杨曦(重庆医科大学附属儿童医院风湿免疫科)，马明圣(中国医学科学院北京协和医院儿科)，刘大玮(重庆医科大学附属儿童医院风湿免疫科)，王玉莲(重庆医科大学附属儿童医院风湿免疫科)执笔人：杨曦，唐雪梅，马明圣，宋红梅 -
2001年国际风湿病协会联盟
JIA分型2018年国际儿童风湿病试验组织
JIA分型全身型JIA 全身型JIA 少关节炎型JIA RF阳性JIA RF阳性多关节炎型JIA 附着点炎/脊柱关节炎相关性JIA RF阴性多关节炎型JIA 早发性ANA阳性JIA 银屑病性关节炎 其他类型JIA 附着点炎相关性关节炎 未分类JIA 未分化关节炎 JIA：幼年特发性关节炎；RF：类风湿因子; ANA: 抗核抗体 
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表 2 2001年牛津循证医学中心推荐强度和证据等级分类
推荐强度 证据等级 描述 A 1a 同质随机对照试验的系统评价 1b 单项随机对照试验 1c “全或无”证据(有治疗之前所有患者死亡，有治疗之后，有患者能存活；或者有治疗之前部分患者死亡，有治疗之后无患者死亡) B 2a 同质队列研究的系统评价 2b 单项队列研究(包括低质量的随机对照试验，如＜80%随访) 2c 结果研究，生态学研究 3a 同质病例对照研究的系统评价 3b 单项病例对照研究 C 4 病例报道(低质量队列研究) D 5 基于未经验证的专家意见或评论
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