OBJECTIVE To study the clinical characteristics,prevention and treatment of nosocomial fungemia.METHODS Fifty four consecutive patients with nosocomial fungemia were studied in clinical retrospective manner.RESULTS Sixty fungal strains were isolated from blood.Candida was the predominant pathogenic organism(86.7%),6 cases had mixed infection causing by two fungal species(11.1%).Twenty two cases had concomitant bacteremia(40.7%).Overall mortality rate was 68.5%,directly related mortality rate in treatment group was significantly lower than that in nontreatment one(28.9% vs.88.9%,χ2=11.268，P＜0.01).Effective rate of amphotericin B was 68.8%,fluconazole 70.8%,combined treatment 80.0%.CONCLUSIONS Fungal infection has become prominently fatal cause of critically ill patients.Removing predisposing factors,monitoring fungal pathogen and effective antifungal therapy are important measures to reduce the incidence and mortality of fungal infection.Fluconazole and amphotericin B are effective drugs of treating deep fungal infection.

Objective To explore the effective evaluation methods of case-based learning (CBL) in critical disease teaching.Methods Totally 53 undergraduate students in department of clinical medicine of Shanghai Jiao Tong University,who practiced in our hospital from 2010 to 2012,were divided into the traditional teaching group and CBL teaching group.We used traditional teaching combining with CBL teaching in CBL group.Common cases of critical illness(severe acute pancreatitis and multiple trauma)in intensive care unit (ICU) were selected for CBL cases.The evaluation of theoretical knowledge,mini-clinical evaluation exercise(Mini-CEX)and direct observation of procedural skills (DOPS) were continued after teaching and practice.Results These was no significant difference in the theoretical knowledge examination between the two groups. In Mini-CEX,the students in CBL group were better concerning the medical interview capacity (P=0.000),humanistic care (P=0.013),clinical diagnosis(P=0.035),counseling(P=0.009) and the overall clinical competence (P=0.008) than those in traditional teaching group.The DOPS scores of endotracheal intubation (P=0.016)and central venous catheterization (P=0.001)discussed in CBL teaching were significantly higher in CBL group.Conclusion Traditional theoretical knowledge examination has little significance in the assessment of CBL teaching,but Mini-CEX and DOPS can reflect the advantages of CBL teaching better in the assessment of clinical abilities and skills.

Objective To evaluate the effect on inflammatory mediators and mechanism of dynamic factors on lung injury in a dog model of acute respiratory distress syndrome (ARDS). Method The ARDS dog model was duplicated by instillation hydrochloric acid. The dogs were randomly (random number) divided into six groups: (1) normal control group (N group); (2) ARDS group (M group); (3) low VT (6 mL/kg) at respiratory rate 30, low inspiratory flow 6 mL/(kg·s). (4) large VT (20 mL/kg) at respiratory rate 30, high inspiratory flow 20 mL/kg·s.(5) large VT (20 mL/kg) at respiratory rate 15, high inspiratory flow 17 mL/(kg·s). (6) large VT (20 mL/kg) at respiratory rate 15, low inspiratory flow 10 mL/(kg·s). All the dogs were killed after 4 h ventilation. TNF-α、IL-8, p38 MAPK and NF-κB activity in the lung were measured. Results The expression of IL-8 protein in B and C groups was much higher than that of other groups ( P < 0.01) . There was no significant difference among M, A and D groups (P > 0.05). The gray scale ratio of B group was obviously higher than that of other groups (P < 0.01), except C group (P > 0.05). There was no significant changes among M, A and D groups in TNF-α protein contents. p38 MAPK value of positive staining of B group was the strongest, significantlyhigher than that of D group ( P < 0.01) .The expression of p38 MAPK in B and C groups was much higher than other groups (P <0.01). NF-κB activity in B group (33.56±2.85%) was significantly higher than that in A (10.35±0.6%)、D(7. 11 ± 0.47%)group, but there was no difference between B and C group (30.87 ± 1.16%). Conclusions Ventilation at high tidal volume, high inspiratory flow rate, high respiratory rate could activate p38 MAPK and increase the activity of NF-κB with the result of aggravating the release of inflammatory mediators. p38 MAPK and NF-κB activation are the major mechanisms in the development of VILI.

Objective To investigate the related risk factors,clinical features and prognosis of hospital-acquired acute kidney injury (AKI) in intensive care unit (ICU).Methods We retrospectively analyzed 48 patients with both acute kidney injury and multiple organ dysfunction syndrome (MODS),who received renal replacement therapy from October 2006 to February 2011 in our ICU.According to whether the occurrence time of AKI was 48 hours after admission,they were divided into hospital-acquired AKI (HA-AKI) group and community-acquired AKI (CA-AKI) group,with 13 and 35 cases respectively.We compared the differences between these two groups in gender,age,acute physiology and chronic health evaluation Ⅲ (APACHE Ⅲ),primary diseases,days of mechanical ventilation,times of renal replacement therapy,number and indicators of organ failure,prognosis,renal function recovery,length of stay in ICU and hospital.Results The mean age of HA-AKI group is ( 64.5 ± 21.4) years,which is older than that in CA-AKI group ( 50.2 ± 17.5 ) years (P=0.022).The top three primary diseases in CA-AKI group are severe infection(42.8％ ),chronic kidney disease (CKD) concurrency of AKI ( 11.4％ ) and multiple trauma without head injury ( 8.6％ ).However severe infection still occupies the first in HA-AKI group ( 30.8％ ),followed by stroke (23.1％,P=0.024),multiple trauma with head injury( 15.4％,P=0.018 ) and gastrointestinal bleeding( 15.4％ ) ;Patients in HA-AKI group with more than four organ failures account for 84.6％,significantly higher than 65.7％ in CA-AKI group (P=0.000).On the first day,the levels of serum sodium ( P =0.036 ) and bicarbonate ( P=0.001 ) in HA-AKI group are higher than that in CA-AKI group,and the urinary volume is more(P =0.046).In HA-AKI group,the level of urea nitrogen on the seven day increases so progressively that it becomes significantly higher than that on the first day(P=0.015),but in CA-AKI group,there is no significant change in the levels of serum creatinine and urea nitrogen after AKI,while the levels of seruum sodium ( P=0.023 ) and bicarbonate ( P=0.030) increase significantly;APACHE Ⅲ score in HA-AKI group after admission 24 hours is significandy lower than that in CA-AKI group(53.2 ±22.8) point vs (89.1±25.7) point,P=0.000),and the length of stay in ICU and hospital and days of mechanical ventilation in HA-AKI group are significantly longer than that in CA-AKI group,but there are no significant differences in times of RRT therapy,prognosis and recovery of renal function.Conclusion APACHE Ⅲ score after 24 hours of admission does not accurately reflect the prognosis of patients with MODS and HA-AKI.There are great differences in age,primary diseases,organ function changes and other aspects of HA-AKI when compared with CA-AKI.

Objective The feasibility and effectiveness of bilingual teaching combined with CBL (case-based learning) was evaluated in our study. Methods From 2011 to 2012, 69 students from Shanghai Jiaotong University were randomly divided into Bilingual CBL group (36 students) and Chinese CBL group(33 students). A case of salvage of multiple trauma patients was selected as a text-book case and students' acceptance to textbooks and teachers was assessed. Besides, students' self-evaluation, teachers' evaluation of students, students' achievement in procedures and the final theory test scores were evaluated as the outcome of the assessment. Results Students' acceptance of textbook in Bilingual CBL group is lower than that in the Chinese CBL group(P=0.035). Differences in students' evaluation of teacher (P=0.093), students' self-evaluation (P=0.816), and teachers' evaluation of the student(P=0.812) were not statistically significant. Final written examination scores(P=0.100), operat-ing procedures in tracheal intubations (P=0.489), and cardiopulmonary resuscitation (P=0.764) were not statistically different . Only central venous puncture showed a statistical difference ( P=0 . 011 ) . Conclusions Medical bilingual CBL teaching is feasible, without affecting the original teaching of medical knowledge. Bilingual teaching can improve students' English proficiency and enhance their interest in learning.

OBJECTIVE To investigate the site of nosocomial infection in ICU,distribution and resistance of bacteria in order to make the intervention strategy.METHODS Antimicrobial susceptibility of pathogenic bacteria isolated from nosocomial infection patients in ICU from Jul 2006 to Jul 2008 was performed by Kirby-Bauer method.RESULTS The main pathogens of nosocomial infection in ICU were Gram-negative organisms(48.09%),Gram-positives(38.93%),and fungi(12.98%).The most common pathogens were Staphylococcus aureus,Acinetobacter baumannii,Pseudomonas aeruginosa,fungi,and S.haemolyticus.All strains of S.aureus and S.haemolyticas were antimicrobial sensitive to vancomycin,teicoplanin and linezolid.All A.baumannii strains were antimicrobial sensitive to cefoperazone/sulbactam.They were resistant to other antimicrobial agents.CONCLUSIONS Gram-negative organisms are the main pathogenic bacteria of nosocomial infection in ICU,but the percentage of Gram-positives and fungi is increasing,S.aureus is the most main pathogenic bacterium of nosocomial infection in ICU.S.haemolyticus is also a main pathogenic bacterium.The pathogenic bacteria of nosocomial infection in ICU are highly resistant to the most antimicrobial agents.

Objective To evaluate the early emergency management process for severe pelvic fractures combined with multiple trauma. Methods The study involved 113 patients with severe pelvic fractures combined with multiple trauma treated from January 2007 to May 2011.The patients were divided into two groups,ie,before trauma team establishment (26 patients treated from January 2007 to May 2008) and after trauma team establishment (87 patients treated from June 2008 to May 2011 ) in accordance with the establishment period of trauma team in June 2008.The mortality was compared before and after application of trauma-team-based algorithm with damage control resuscitation,external fixation and angiographic embolization.Variables including age and gender distribution,ISS score,injury type and mechanism,transportation time,associated injury number,initial systolic pressure hemoglobin and blood transfusion were analyzed for study of their relation with mortality. Results After trauma team establishment,the mortality (23％) was significantly lower than before trauma team establishment (46％).The mortality showed significant relation to ISSN score and over two regions of associated injury,but showed no correlation with age and gender distribution,injury type and mechanism,transportation time initial systolic pressure hemoglobin,and blood transfusion. Conclusion The application of trauma team is effective in treatment of severe pelvic fractures combined with multiple trauma and can decrease the mortality.

Objective To investigate the causes of severe H1N1 Flu with multiple organ dysfunction, and measures to reduce mortality. Method The data of the patient, who was diagnosed as severe H1N1 Flu and mul-tiple organ dysfunction syndrome in First People's Hospital Affiliated to Shanghai Jiaotong University in September 2009, were retrospectively analyzed. The patient was male, 35 year-old, obese, high fever, sore throat, cough, progressive dyspnea, severe hypoxemia and hypotension. Effective measures were carried out, including protective lung ventilation, recruitment maneuver, vasopressor support, limited fluid resuscitation, appropriate corticosteroid, anfiviral plasma, anticoagulafion and antiviral medicine (Oseltamivir)in early stage and full dose. Results After one-month intensive care, clinical symptoms was improved obviously, oxygen pressure reached 74 mmHg without oxygen supply, CT scan showed diffused interstitial ehange. Neuromyopathy developed at approximately 3 weeks after the onset of H1N1. Conclusions H1N1 Flu can develop in healthy adults, and obesity is one of the inde-pendent risk factors. Effective measures should be taken as soon as possible to reduce the mortality.

Objective To evaluate the prognostic effect of different ratios of fresh frozen plasma (FFP) to packed red blood cells (PRBC) in massively transfused trauma patients.Methods A retrospective cohort study was conducted for 210 trauma patients who received more than 10 units of PRBC during the initial 24 hours from January 2007 to June 2015.The patients were divided into four groups:Group A(PRBC:FFP ≤1,n=41),GroupB (1 ＜PRBC:FFP≤1.5,n=63),GroupC(1.5＜PRBC:FFP≤2,n=30) and Group D (PRBC:FFP ＞2,n =76).At 24 hours after admission,blood transfusion amount,blood transfusion ratios,post-transfusion adverse reactions (allergy,non-hemolytic febrile transfusion reaction,hemolysis,congestive heart failure,pulmonary edema,etc) and coagulation changes [hemoglobin (Hb),platelet count (PC),prothrombin time(PT),activated partial thromboplastin time(APTT),international normalized ratio (INR),etc] were compared among groups.Prognostic markers including sequential organ failure assessment(SOFA),hospital stay,ICU stay,30-day mortality and causes of death were also evaluated.Results Use of PRBC was decreased significantly in Group A than in other groups (P ＜ 0.01),and there were no differences in blood transfusion adverse reactions among all groups (P ＞ 0.05).The coagulation indices (PT,APTT and INR) in Groups A and B were significantly decreased compared to Group D after transfusion (P ＜ 0.05).There were no differences in length of hospital stay and ICU stay among all groups (P ＞ 0.05).Group D was associated with higher SOFA and higher 30-day mortality than other groups(P ＜0.01),but no differences were found in Group A,B and C (P ＞0.05).Meanwhile,ratio of patients died of massive hemorrhage in Group D was also higher than other groups (P ＜0.01).Kaplan-Meier survival analysis showed the survival interval was the shortest in Group D,while the longest in Group B and C.Conclusions Modest transfusion ratios (1.5 ＜ PRBC:FFP ≤2)within 24 hours can substantially improve outcomes in trauma patients.Aggressive ratios may improve coagulation indices and reduce use of PRBC,with no more benefit to the outcomes.

Objective To investigate the role of intestinal fatty acid binding protein (IFABP) in early diagnosis of acute traumatic intestinal rupture. Methods The patients with suspected acute traumatic intestinal rupture admitted in our emergency department from July 2010 to June 2011 were involved in the study.Their blood samples were taken on admission,1,2,3,4,6,8,12,16,24 and 48 hours after admission.All the patients were given closely medical observation and therapy,and were followed up in aspects of their clinical signs and imageology according to the present diagnosis and treatment routine.Surgical procedures would be carried out as soon as the diagnosis of intestinal rupture was confirmed and the duration between the admission and the final diagnosis was recorded.All the blood samples were determined for the IFABP concentration by means of ELISA.According to the final diagnosis results,the patients were divided into the intestinal rupture group and non-intestinal rupture group.The changes of IFABP concentration and its concentration difference between the two groups at different time points were compared. Results The study involved 33 patients,including 11 patients with confirmed intestinal rupture (intestinal rapture group) and 22 without intestinal rupture (non-intestinal rupture group).The average duration from hospitalization to the final diagnosis in the intestinal rapture group was (7.0 ±2.0) hours.At all the given time points,the IFABP concentration in the intestinal rupture group was significantly higher than that in the non-intestinal rupture group (P ＜ 0.05 ).The IFABP concentration in the intestinal rupture group was ascended on admission,reached the peak one hour later and maintained the level till the surgery,while the IFABP concentration was relatively stable in the non-intestinal rupture group within 24 hours after admission. Conclusion IFABP is the index for early diagnosis of acute traumatic intestinal rupture.