Multidrug-resistant organisms are growing worldwide public health problem and few therapeutic options remain available.The traditional antimicrobials (glycopeptides) for multidrug-resistant Grampositive infections are declining in efficacy.New antimicrobials that are presently available are linezolid,daptomicin and tigecycline,which have well-defined indications for severe multidrug-resistant organisms infections.Unfortunately,the therapies available for multidrug-resistant Gram-negatives including carbapenem-resistant Pseudomonas aeruginosa,Acinetobacter baumannii and Enterobacteriaceae are limited to colistin and tigecycline only.Distribution of multidrug-resistant organisms are changing in recent years.Strains of multidrug-resistant organisms were dominated by Gram-negative bacteria in most hospital particularly in intensive care unit.Multidrug-resistant/pandrug-resistant Pseudomonas aeruginosa,Acinetobacter baumannii are increasing rapidly in trend.Strategy that includes surveillance,infection control procedures,isolation and antimicrobial principle should be emphasized and implemented to reduce multidrug-resistant organism diffusion.

Objective To observe the effect of electronic colonoscopy on heart rate,blood pressure,arterial hemoglobin oxygen saturation and electrocardiography in elderly patients.Methods 60 patients were divided into two groups,elderly group (over 60 years old,n=30) and non-elderly group (＜ 60 years old,n =30).The changes in heart rate,blood pressure,arterial hemoglobin oxygen saturation and electrocardiography before and during colonoscopy were compared between the two groups.The increased heart rate was observed in both groups(the non-elderly group:t=10.746,P＜0.001; the elderly group:t=4.892,P＜0.001),and the increment of heart rate was higher in non-elderly group than in elderly group [(6.9±3.7) /min vs.(4.0±3.8) /min,t=2.88,P＜ 0.01].Results Systolic and diastolic pressures were increased in both groups during colonoscopy as compared with pre-colonoscopy(t=3.88,5.88,6.55 and 7.43,respectively,P＜0.01 or 0.001),but there were no significant differences in the increment between the two groups(t=0.31 and 0.32,bothP＞0.05).Arterial hemoglobin oxygen saturation was decreased in both groups during colonoscopy as compared with pre-colonoscopy(t=3.05 and 2.98,P＜0.05 or 0.01),and there was no significant difference in the decrease between the two groups(t=-0.13,P＞0.05).Abnormal ECG can be detected in both groups,but had no statistical significance between the two groups (20.0％ vs.16.7％,x2 =0.11,P＞ 0.05).Conclusions Electronic colonoscopy can be performed relatively safely in the elderly.

Objective To study the etiology, clinical features, risk factors of septic shock and multiple organ dysfunction syndrome /multiple organ failure (MODS/MOF) caused by gastroenteritis infection in the pediatric intensive care unit (PICU). Methods Case records of patients with gastroenteritis complicated by septic shock and MODS/MOF admitted to PICU in Children's hospital affiliated to Shanghai Jiaotong University from January 2000 to December 2004 were reviewed for etiology, case fatality rate, prognosis and relationship with MODS/MOF. Univariate analyses were performed to analyse the risk factors associated with septic shock and MODS/MOF. Results During the 5 years, 1 536 patients with critical illness were admitted and MODS/MOF associated with gastroenteriitis infection developed in 28 patients. The overall mortality of patients with MODS/MOF associated with gastroenteriitis was 75%. The mean age was (1.9?3.4)years and 19 cases(67.8%)were under 1 year. The patients with MODS/MOF involved (3.7?0.9)organs or systems on average. The numbers of involved organs systems were circulatory in 28 patients(100%), gastrointestinal system in 21(75%), lung in 20(71.4%), kidney in 14(50%),brain in 9(32.4%),blood in 9(32.4%) and liver in 5(17.9%). The first dysfunctional system was gastrointestinal tract in 13(46.4%),circulatory in 11(39.3%),and lung in 4(14.3%). The average volume of fluid resuscitation was (46.2?12.6)ml/kg and range from 30 ml/kg to 75 ml/kg in the first hour. The average fluid was (92.7?33.9)ml/kg and range from 70 ml/kg to 120 ml/kg in 6 hours. The cases fatality of patients with or without successful volume resuscitation were 66.7% (12 in 18 cases) and 90%(9 in 10 cases) in 6 hours respectively.Univariate analyses indicated the following risk factors: numbers of failed organ and lower pediatric critical illness score(P

Objective To investigate the effect of vasoactive intestinal peptide (VIP) and methylprednisolone (MP) on Toll-like receptor (TLR)2/4 mRNA expression in endotoxin (lipopolysaccharide,LPS) induced shock.Methods Ninety Sprague-Dawley rats were randomly divided into LPS group (n =20),LPS + VIP group (n =20),LPS + MP group (n =20),LPS + VIP + MP group (n =20) and control group (n =10).LPS group injected intravenously LPS (E Coli O55B5) 10 mg/kg.LPS + VIP group,LPS + MP group and LPS + VIP + MP group were injected intravenously VIP 5 nmol/kg,MP 3 mg/kg and VIP 5 nmoL/kg + MP 3 mg/kg after LPS 10 mg/kg injection.The control group injected normal saline intravenously instead of LPS.The rats were sacrificed at 6 h and 24 h after injection and the intestine samples were collected.Pathological changes of the intestine were observed by microscopy.RT-PCR was used to detect the intestinal TLR2 mRNA and TLR4 mRNA expressions.Results Intestinal mucosa showed edema or necrotic change with structure of the microvilli disappeared after LPS injection.The inestinal lesions in VIP,MP and VIP + MP groups were milder than LPS group.At 6 h after LPS injection,TLR2 mRNA and TLR4 mRNA expressions were significantly up-regulated in LPS group,LPS + VIP group,LPS + MP group and LPS + VIP + MP group (TLR2 mRNA:1.14 ±0.38,1.17 ±0.42,1.16 ±0.41,0.92 ± 0.29;TLR4 mRNA 1.21 ±0.18,1.04 ± 0.38,1.11 ± 0.34,1.01 ± 0.20) compared with the control group (0.32 ± 0.20,0.24 ± 0.17) (P ＜ 0.01).But there was no significant difference between LPS group,LPS + VIP group,LPS + MP group and LPS + VIP + MP group (P ＞ 0.05).At 24 h after LPS injection,TLR2 mRNA and TLR4 mRNA expressions in LPS + VIP group,LPS + MP group and LPS + VIP + MP group (TLR2 mRNA:0.63 ± 0.12,0.59 ± 0.13,0.52 ±0.19;TLR4 mRNA 0.67 ±0.09,0.64 ±0.09,0.51 ±0.13) were significantly lower than LPS group (1.04 ± 0.38,0.82 ±0.18) (P ＜0.01) (P ＜0.05).Conclusion VIP and/or MP can mitigate intestinal injury induced by LPS shock.The gastrointestinal protection of VIP and glucocorticoids were related to downregulation signaling TLR2 mRNA and TLR4 mRNA expression.But VIP/MP and VIP + MP have no significant effect on expression of intestinal TLR2/4 mRNA until 24 h after LPS shock.

ObjectiveTo investigate the effect and outcome of critically illness with acute kidney injury (AKI) treated with continuous veno-venous hemodiafiltration (CVVHDF) in children.Methods Twenty-four cases of critically illness with AKI were treated with CVVHDF in our pediatric intensive care unit from Jan 2008 to Dec 2010.The levels of creatinine (Cr),blood urea nitrogen (BUN),K +,Na + and HCO3- were observed before CVVHDF and 6,12,24,48,72 h after CVVHDF.ResultsCatheter was successfully established for CVVHDF in 24 cases of AKI.The average duration of CVVHDF was 46 h ( 16 ～142 h).The blood levels of Cr and BUN were significantly decreased at 6 h after CVVHDF [ ( 196.3 ±112.4) μmol/L,( 13.3 ± 8.5 ) mmol/L] and 12 h after CVVHDF [ ( 106.1 ± 84.2) μ mol/L,( 10.2 ± 9.7 )mmol/L] as compared to those before treatment [ (340.6 ±298.2) μmol/L,(31.6 ± 11.3) mmol/L] (P ＜0.05,P ＜ 0.01 ).After 48 h of CVVHDF,the Cr,BUN returned to normal range.The imbalance of blood K +,Na +,and HCO3- improved at 6 h after CVVHDF and returned to nomal levels at 24 h.Total 28 d fatality rate was 29.2％ (7/24),and all death cases were complicated with multiple organ dysfunction syndrome.ConclusionCVVHDF therapy for AKI can quickly clear Cr,BUN and excess water,correct electrolyte disorders,improve kidney function in children.

OBJECTIVESevere Epstein-Barr (EB) virus infection is potentially a devastating process that often leads to death encountered in pediatrics recently. Inappropriate control of EB virus replication may cause severe infection resulting in multiple organ dysfunction. However, little information is available on pulmonary complications associated with EB virus infection. The aim of the present study was to investigate severe EB virus (EBV) infection complicated with lung injury in pediatric intensive care unit (PICU), including clinical characteristics, laboratory or imaging feature and outcomes.

METHODA total of 45 children with severe EBV infection seen in PICU of Shanghai Children's Hospital between January 2011 and December 2014 were retrospectively reviewed. According to clinical characteristics and imaging feature, 45 children were divided into non-lung injury group (n =27), lung injury without pulmonary fibrosis group(n = 12) and pulmonary fibrosis group (n = 6).

RESULTIn totally 45 cases of severe EBV infection, 21 (46.7%) were male and 24 (53. 3%) were female, mean age was 2. 4 years; 18 cases were complicated with lung injury, including 8 male and 10 female, median age was 31. 2 months. All of 18 cases presented with fever and cough, 15 of them exhibited dyspnea,12 cases were complicated with gasping, and 6 cases with ARDS. Eight cases accepted mechanical ventilation for acute respiratory distress; 6 cases who developed pulmonary fibrosis had tachypnea, refractory hypoxemia and hypercapnia, severe pulmonary air leak. The average EBV-DNA level in peripheral blood was 4. 42 x 10(6) copies/ml (range: 3. 25 x 10(3) - 6.59 x 10(7) copies/ml). Anti-EBV antibodies were positive in 41 cases, 18 cases were positive (+) for VCA-IgM, 15 cases were VCA-IgG and EA-IgG (+), 8 cases VCA-IgM and VCA-IgG (+). The radiographic findings revealed pulmonary interstitial infiltrates in all 18 cases with lung injury, 4 cases with segmental consolidation and 2 cases showed pleural effusions. HRCT scanning found EBV associated fibrosis including multifocal patches and diffuse ground-glass attenuation in both lungs, reticular opacities and honeycombing changes were observed 4 weeks after illness onset. There were significant differences in respiratory failure, PICU stay (days), Pediatric risk of mortality III (PRISM III) and pediatric clinical illness score(PCIS), serum TNF-α, EBV-DNA levels, percentage of NK cells and CD4+/CD8+ T cell ratio among non-lung injury group, lung injury without pulmonary fibrosis group and pulmonary fibrosis group (X2 =27. 12, F = 85. 23, 78. 23, 88. 68, 323. 80, 7. 35, χ2 = 6. 71, 12. 15; all P < 0. 05). COX regression analysis revealed that EBV-DNA and serum TNF-α levels were correlated with pulmonary fibrosis significantly (OR = 3. 92, P = 0. 04; OR = 5. 95, P = 0. 01). The patients with EBV-associated hemophagocytic lymphohistiocytosis (EBV-HLH) had higher incidence of pulmonary fibrosis compared with non-EB-HLH (70% vs. 13%, χ2 = 4. 82, P = 0. 03). Of 18 cases, 8 cases died, including 3 cases with pulmonary fibrosis. The surviving cases with pulmonary fibrosis needed longer additional oxygen. Chest HRCT imaging of 3 cases with pulmonary fibrosis was improved at 6 months and oxygen therapy was discontinued at 18 months after discharge.

CONCLUSIONEB virus infection complicated with lung injury had higher incidence of respiratory failure, pulmonary fibrosis with a fatal outcome. EBV-DNA and serum TNF-α level were found to be statistically significant indicators of pulmonary fibrosis. Pulmonary fibrosis associated with severe EB virus infection may be reversible.

Antibodies, Viral ; blood ; CD4-CD8 Ratio ; Child, Preschool ; China ; DNA, Viral ; blood ; Epstein-Barr Virus Infections ; pathology ; Female ; Herpesvirus 4, Human ; Humans ; Intensive Care Units, Pediatric ; Killer Cells, Natural ; Lung Injury ; virology ; Lymphohistiocytosis, Hemophagocytic ; pathology ; virology ; Male ; Pulmonary Fibrosis ; pathology ; virology ; Retrospective Studies ; Tumor Necrosis Factor-alpha ; blood

Objective To investigate the clinicalmanifestation,monitoring and therapeutic measure of severe enterovirus 71 ( EV71 ) infection in children.MethodsForty-five cases of severe EV71 infectionwere admitted in our PICU from May 2010 to Sep 2011.The vital sign and arterial blood pressure,central venous pressure,mixed venous oxygen saturation,dynamic non-invasive heart function and urine volume were monitored.Forty-five cases were divided into 3 stages according to clinical manifestation:( 1 ) nervous system involvement stage; (2) respiratory system involvement stage; ( 3 ) circulatory system involvement stage ( compensation and decompensation).We adopted individualized remedy measure according to different stages.ResultsIn 45 cases,38 cases discharged from hospital,the cure rate was 84.4％.Among all the 38 cases,nervous system involvement was found in 19 cases,respiratory system involvement was found in 12 cases,circulatory system involvement was found in 7 cases.Seven cases died,who had circulation failure.ConclusionWe should identify severe EV71 infection early.Positive control of high fever,appropriate liquid treatment,control of high blood pressure,early respiratory support,preventment of circulation failure are the key measures for treatment.Individualized monitoring and treatment are effective in children with severe EV71 infection.

Objective To investigate the changes of epithelial neutrophil activating peptide-78 (ENA-78) in the serum of patients with critical illness,and to analyze the relationship between the severity and prognosis.Methods Prospective case-control study was performed,and 42 cases of critically ill patients admitted to Pediatric Intensive Care Unit,Children's Hospital Affiliated to Shanghai Jiaotong University from Sep.to Nov.2013 were selected as critically ill group,blood specimens were collected within 24 hours and 7 days after their admission.Another 42 cases of blood samples were collected during physical examinations in this hospital as control group.The severity of critically ill patients were graded by Pediatric Critical Illness Score (PICS) and Pediatric Risk of Score Mortality (PRISM) Ⅲ,and the serum ENA-78 was measured by double antibody sandwich enzyme-linked immunoassay.Results 1.The level of ENA-78 in the control group was (0.44 ± 0.28) ng/L; ENA-78 in acute phase and recovery phase of critically ill group were (2.85 ± 0.89)ng/L and (1.00 ± 0.64)ng/L,respectively,there were statistical differences between control group and critically ill group,acute phase group and recovery phase group (all P =0.000).2.The negative correlation was observed between ENA-78 concentration and PCIS score(r =-0.724,P =0.000).ENA-78 in PRISM Ⅲ ≥ 10 group was significantly higher than that in PRISM Ⅲ＜ 10 group(P =0.000).The ENA-78 between death group and the survival group was significantly different(P =0.000).3.ENA-78 in patients with severe infection was higher than that in the non-infectious cases(P =0.000).4.With the organ dysfunction expanded ENA-78 rose accordingly,and the difference was statistically significant (P =0.000).Conclusions The level of ENA-78 is different in critically ill patients in children.It can provide reference of assessing the severity of disease and predicting prognosis by determing the ENA-78 level.

Objective To evaluate the value of urine neutrophil gelatinase-associated lipocalin (uNGAL) to early diagnose acute kidney injury(AKI) of critically ill children in PICU.Methods Eighty critically ill children at PICU of Children's Hospital Affiliated to Shanghai Jiaotong University were enrolled in this study from April to June 2013.They were continuously observed for 72 hours.According to pediatric RIFLE criteria for diagnosis of AKI,patients were divided into AKI group (15 cases) or non-AKI group (65 cases).Additionally,according to sepsis diagnostic criteria,patients were divided into sepsis group (31 cases) or non-sepsis group (49 cases).The levels of serum creatinine and uNGAL were measured within 6th hour,24th hour,48th hour,72th hour after admitted to PICU.The differences of uNGAL levels between AKI and non-AKI groups,sepsis without AKI and non-sepsis non-AKI groups,sepsis merged AKI and sepsis without AKI groups were analysed.The sensitivity and specificity of uNGAL and serum creatinine for diagnosis of AKI at 48th hour were evaluated by ROC curve.Results Thirteen cases of eighty children developed to AKI after admitted to PICU.(1)The uNGAL levels [M(QR),ng/ml] in AKI group within 6th hour,at 24th hour,48th hour,72th hour were 863.00 (696.00),700.50 (580.00),365.50 (285.00),289.50 (319.30),respectively,which were significantly higher than those in non-AKI group [20.00 (106.00),20.00 (85.30),20.00(101.00),20.00(36.00)] (P ＜0.01).(2)The uNGAL levels in new developed group were much higher than those in non-AKI group at each time point.The comparision of serum creatinine at 48th hour was statistic difference.(3)The uNGAL levels rised at early stage in sepsis without AKI group and down to normal gradually after 48th hour.(4)The uNGAL levels continued increasing in sepsis merged AKI group,and had significant differences comparing with sepsis without AKI group(P ＜ 0.01).(5) The areas under ROC curve of uNGAL and serum creatinine at 48th hour were 0.902(95％ CI:0.801 ～ 1.004) and 0.801 (95％ CI:0.768 ～ 0.981),respectively.Conclusion The level of uNGAL has earlier increase for 24 to 48 hours than that of serum creatinine in critically ill children,and it can also reflect the severity of AKI.Therefore it can be used as an early diagnostic biomarker for AKI in PICU.

Objective To study the changes of P-selectin and E-selectin in pediatric patients with critical illness ,and analyze their relationship with the severity and prognosis of diseases.Methods Forprospective study,42 critically ill patients admitted in pediatric intensive care unit (PICU ) from September,2012 to March,2013 as critically ill group were enrolled,and blood specimens were collected with 24 hours after admission.Another 42 cases blood samples were collected from children's physical examination as control group.The severity of the critically ill patients were evaluated by Pediatric Critical illness Score (PICS)and Pediatric risk of score mortality (PRISM)-III.The levels of serum P-selectin and serum E-selectin were measured by double antibody sandwich enzyme-linked immunoassay (ABC-ELISA). Results P-selectin and E-selectin in control group children and critically ill patients group were (37.23 ± 8.99)ng/mL,(36.24 ±17.82)ng/mL,and (107.24 ±35.53)ng/mL,(114.93 ±40.17)ng/mL, respectively.There were statistical differences between two groups (P=0.000).The levels of P-selectin and E-selectin in acute phase were higher than that of levels in recovery phase in critically ill group (P =0.000).Negative correlation was observed between P-selectin concentration and the PCIS score (r =-0.673,P=0.000),as well as E-selectin (r=-0.548,P=0.000).P-selectin level and E-selectin level based upon PRISMⅢ≥10 group were significantly higher than they in PRISMⅢ <10 group (P=0.003,P=0.014).In critically ill children,the differences in P-selectin,E-selectin were significant higher in death patients (P=0.003;P =0.000).Compared with the non-sepsis illness group,the level of P-selectin and E-selectin in the severe sepsis patients were significantly higher (P =0.04,P =0.025 ). Conclusions The levels of P-selectin and E-selectin are closely related to the severity and prognosis in critically ill children.Measuring the level of P-selectin and E-selectin could be used as a judegment the severity and to understand pathological physiological process.