OBJECTIVE To explore the relationship between the point mutations of gene CYP51 and the azole-resistance mechanism in clinical Candida albicans isolates.METHODS The paper diffusion test and NCCLS M-27 protocols were used to screen the fluconazole-resistant and itraconazole-resistant C.albicans clinical isolates.Gene CYP51 of two azole-resistant C.albicans clinical strains(2007H and 2007T strains) was amplified by three pairs of primers,respectively.The PCR products purified were sequenced,and compared with the nucleotide sequences of C.albicans(accession No.:X13296) to find out the mutation sites.RESULTS The nucleotide sequence analysis showed that there were both significant point mutations and silent mutations in gene CYP51 from two azole-resistant isolates of C.albicans.Seven mutations previously described,F105L,K128T,Y132H,T199I,R267H,G464S,and R467K,were identified in the two strains.The animo acid substitutions of Y132H and R467K,known to contribution to azole resistance,were detected in both 2007H strain and 2007T strain.Four novel mutations,including F71L,W244R,T311N and T352I,were simultanously identified.Nine silent mutations appeared in two isolates.CONCLUSIONS In this survey,the two azole-resistant C.albicans clinical isolates contained more than one mutation in gene CYP51 that is associated with azole resistance.Four novel mutations of CYP51 may be associated with the resistance of C.albicans to azoles.And the mechanisms need to be further studied in detail.

Objective To assess the safety and the curative effect of the combination of minipercutaneous nephrolithotomy (mini-PCNL) and ureteroscopic lithotripsy (URL) in the treatment of nonhydronephrotic staghorn calculi. Methods The clinical data of 53 eases with non-hydronephrotic staghom calculi treated by mini-PCNL combined with URL were retrospectively analyzed. Results Fifty-three cases (64 renal units) were performed first-stsge operation, 9 renal units were stone free in first-stage operation, 33 renal units were stone free in second-stage operation, other 13 renal units were stone free in third-stage operation. A complete stone clearance rate of 85.9%(55/64) was achieved, and after one to three sessions of mini-PCNL and extracorpereal shock wave lithotripsy afterwards that increased to 95.3% (61/64). Blood transfusion was performed in 3 cases, no major complication was noted in the patients. Conclusions The combination of mini-PCNL and URL has more advantages, less invasions, easier recovery and less complications. It provides a new minimally invasive way for non-hydronephrotic staghorn calculi.

Objective To explore emergency treatment methods for acute renal failure caused by negative imaging ureterolith. Methods There were 36 cases of acute renal failure caused by negative imaging ureterolith, which were finally diagnosed by ureteroscope examination. The negative imaging ureterolith were broken by air pressure ballistic curve shock wave,and taken out of ureter by ureteroscope. All cases were put double-J in ureter. Results Thirty-six cases were got success relieves of ureter obstruction in 24 hours. The urine volume of them were increased, symptoms of urinemia were disappeared, BUN and creatinine were normal after operations. Conclusions The treatment and diagnosis methods by ureteroscope for acute renal failure caused by negative imaging ureterolith are quick and safety, which can treat both side ureterolith at the same time and get reliable and safe effect with less trauma. It should be the first choice to treat acute renal failure caused by negative imaging ureterolith.

Objective To explore the effect of early supplemental parenteral nutrition on the outcomes of critically ill patients.Methods Totally 302 patients admitted in the intensive care unit (ICU) of Taizhou Hospital of Zhejiang Province from 2015 to March 2017 were enrolled and divided into two groups:the enteral nutrition group and the supplemental parenteral nutrition group.The clinical data of the two groups were retrospectively analyzed and the outcomes was compared between the two groups.Results The time of ICU stay,mechanical ventilation days,nosocomial infections in ICU and the rate of feeding intolerance were significantly lower in the supplemental parenteral nutrition group than in the enteral nutrition group (P＜0.05).There was no statistically significant difference in the mortality rate in 28 days between the two groups.Conclusion Supplemental parenteral nutrition has many advantages like reduce the duration of ventilation,ICU stay and the rate of feeding intolerance,and it does not affect the 28-day mortality rate of critically ill patients with NRS2002 score＞5,or increase the complication of infection.

In the ICU,nutritional status is intimately related to the prognosis of critically ill patients and cannot be neglected;nonetheless,between 38%～78%of critically ill patients are malnourished.Individualized nutritional monitoring and therapy is recommended for critically ill patients to improve prognosis.Nutritional treatment includes enteral and parenteral nutrition.Enteral nutrition can be provided by prepyloric feeding through a nasogastric tube,which is simple and generally applicable,or by retropyloric feeding through a nasojejunal tube,which can reduce the risk of reflux aspiration.Parenteral feeding can be administered by creating peripheral venous access for convenient administration or central venous access for the delivery of nutritional solutions with high osmotic pressure.In addition to the patient's condition,the choice of nutrition route should take into account the initiation time,ability to meet nutritional needs,and potential feeding related complications.Current guidelines are not united,and previ-ous research has not fully addressed existing conflicts.In this paper,problems associated with each nutrition pathway are reviewed to provide a clinical reference.

Objective To observe the effect of Shenmai injection combined with enteral nutrition (EN) on immune function in patients with severe cardiac insufficiency. Methods Fifty-seven patients with severe cardiac insufficiency admitted to the Department of Critical Care Medicine of Taizhou Hospital of Zhejiang Province from June 2015 to June 2018 were divided into an EN group (31 cases) and an EN group combined with Shenmai injection group (26 cases). The EN group was given EN on the basis of routine western medicine treatment, while in the EN combined with Shenmai injection group was treated additionally by intravenous drip of Shenmai injection 100 mL/d on the basis of above EN group treatment. The efficacies of the two groups were evaluated after consecutive 7-day treatment in the two groups. The changes in levels of subsets of T-lymphocytes (CD3+, CD4+, CD8+, CD4+/CD8+) and immunosuppressive cells CD14+ monocyte human leukocyte antigen DR (HLA-DR) were observed before and after treatment. Results After treatment, the levels of T-cell subsets CD3+, CD4+, CD4+/CD8+ and CD14+ monocytes HLA-DR in the peripheral blood of the two groups were significantly higher than those before treatment [CD3+: EN group was 0.539±0.126 vs. 0.379±0.093,Shenmai injection group was 0.652±0.185 vs. 0.393±0.091; CD4+: EN group was 0.402±0.121 vs. 0.275±0.066,Shenmai injection group was 0.524±0.168 vs. 0.281±0.077; CD4+/CD8+:EN group was 1.83±0.70 vs. 1.11±0.70,Shenmai injection group was 2.81±0.91 vs. 1.19±0.58; CD14+HLA-DR:EN group was (43.3±7.1)% vs. (35.4±5.7)%,Shenmai injection group was (54.9±6.2)% vs. (36.1±8.3)%]; After treatment, CD8+ in EN group decreased (0.223±0.052 vs. 0.253±0.081), while CD8+ in shenmai injection group increased (0.288±0.051 vs. 0.259±0.078), and the increase degrees of the above-mentioned indexes in EN combined with Shenmai injection group were more obvious than those in the EN group after treatment [CD3+: 0.652±0.185 vs. 0.539±0.126, CD4+: 0.524±0.168 vs. 0.402±0.121, CD8+: 0.288±0.051 vs. 0.223±0.052, CD4+/CD8+: 2.81±0.91 vs. 1.83±0.70, CD14+HLA-DR: (54.9±6.2)%, (43.3±7.1)%, all P < 0.05]. Conclusion The combined use of Shenmai injection and early EN can improve the immune function of T-lymphocytes in patients with severe cardiac insufficiency. The mechanism may be related to the enhancement of the activation of T lymphocytes and promotion of the CD14+ monocytes increase and immune function.

Objective To investigate the prevalence of feeding intolerance (FI),and to explore the FI within 7 days of ICU admission in association with clinical outcome in critically ill patients.Methods The adult patients from 14 general ICUs in Zhejiang Province with an expected admission to ICU for at least 24h were recruited from March 2014 to August 2014,and all clinical,laboratory,and survival data were prospectively collected.The AGI (acute gastrointestinal injury) grade was daily assessed based on gastrointestinal (GI) symptoms,feeding details and organ dysfunction within the first week of ICU stay.The intra-abdominal pressures (IAP) was measured using AbViser device.Results Of 550 patients enrolled,418 were assessed in GI symptoms and feeding details within 7 days of ICU stay.The mean age and SOFA score were (65.1 ± 18.3) years and (8.96 ±4.10),respectively.Of them,355 patients (84.9％) were under mechanical ventilation support,and 37 (8.85％) received renal replacement therapy.The mean length of time for enteral feeding was (30.8 ±26.2) h,and the prevalence of FI on the 3rd and 7th day of ICU stay accounted for 39.2％ and 25.4％,respectively.Compared to those with FI within 7 days of ICU stay,the patients without FI had higher rate of successively weaning from mechanical ventilation (21.3％ vs.5.7％,P =0.003) and higher rate of withdrawal of vasoactive medication (45.5％ vs.20.0％,P =0.037),as well as lower mortality rate of 28-day (24.4％ vs.38.7％,P =0.004) and 60-day (29.6％ vs.44.3％,P =0.005).In multivariate Cox regression model with adjustment for age,sex,participant center,serum creatinine and lactate,AGI grade on the first day of ICU stay,and comorbidities,the FI within 7 days of ICU stay (x2 ≥ 7.24,P ＜ 0.01) remained to be independent predictors for 60-day mortality.After further adjusted for SOFA score,the FI within 7 days of ICU stay (HR =1.71,95％ CI:1.18-2.49;P =0.006) and AGI grade on the first day of ICU stay (HR =1.33,95 ％ CI:1.07-1.65;P =0.009) could provide independent prognostic values of 60-day mortality.Conclusions There is high rate of FI occurred within 7 days of ICU stay,and is significantly associated with worse outcome.In addition,this study also provides evidence to further support that measurement of gastrointestinal dysfunction could increase value of SOFA score in outcome prediction for the risk of 60-day mortality.

Objective To investigate the value of mean platelet volume(MPV)combined with red blood cell distribution width(RDW)in prognosis of severe acute pancreatitis(SAP). Methods 65 SAP patients from January 1,2013 to December 31,2016 were included in the study and were divided into pospital death group(n=7) and survival group(n = 58). The basic clinical data of two groups were compared,the risk factors for hospital death and the prognostic value of MPV and RDW were analyzed. Results Compared with the survival group,the APACHEⅡ score,RDW,PLT,MPV,PDW were statistically different(P < 0.05). Logistic regression analysis was used to show APACHEⅡ score(OR = 1.793,95% CI: 1.212 ~ 2.654),PLT(OR = 0.982,95% CI: 0.967 ~0.997),MPV(OR=2.964,95% CI: 1.341~6.549),PDW(OR=1.470,95% CI: 1.019~2.122),RDW(OR=3.274,95% CI: 1.271 ~ 8.429)(P < 0.05). ROC curve analysis showed that the area under the curve of APA-CHEII score was 0.861(95% CI: 0.743 ~ 0.979,P = 0.001),MPV was 0.828(95% CI: 0.689 ~ 0.967,P =0.003,RDW was 0.849(95% CI: 0.749 ~ 0.949,P = 0.001),MPV+RDW was 0.914(95% CI: 0.832 ~ 0.997, P = 0.000). Conclusion The APACHEⅡ score,PLT,MPV,PDW,RDW are all the independent risk factors for hospital death with SAP. MPV combined with RDW has an important reference value for the prognosis of SAP patients.

OBJECTIVE: To investigate the effect of corticosteroids therapy on the inflammatory response in a critically ill coronavirus disease 2019 (COVID-19) patient. METHODS: A 55-year old female patient with critical ill COVID-19 was admitted in Taizhou Hospital on January 19, 2020. The patient was treated with methylprednisolone 80 mg on the 2nd day after admission. Thereafter, the dose was adjusted in a timely manner and the therapy lasted for 13 days. The peripheral lymphocyte subsets (CD3T, CD4 T, CD8 T, NK cells, B cells), as well as serum levels of lymphocyte factors (IL-2, IL-4, IL-6, IL-10, TNF-α, IFN-γ) were dynamically monitored. RESULTS: On D1 of admission, the numbers of peripheral blood CD3 T, CD4 T, CD8 T, and NK cells were significantly lower than the normal range. With the improvement of the disease, the numbers of CD3 T, CD8 T and CD4 T cells gradually recovered and showed a linear growth trend (linear fitting equation: =18.59+109.4, <0.05). On D2 of admission, the patient's IL-6 and IL-10 levels were significantly higher than normal values, IFN-γ was at a normal high value, and then rapidly decreased; IL-2, IL-4, and TNF-α were all in the normal range. On the D6 and D7, the IL-6 and IL-10 decreased to the normal range for the first time. On the D18, the sputum virus nucleic acid test was negative for the first time, and the fecal virus nucleic acid test was still positive; on the D20 the sputum and fecal virus nucleic acid test were both negative. On D34, the patient recovered and was discharged. At the discharge the muscle strength score of the patient was 44 and the daily life ability evaluation was 90. CONCLUSIONS In the absence of effective antiviral drugs, early use of appropriate doses of corticosteroids in critically ill patient with COVID-19 can quickly alleviate inflammatory response and improve clinical symptoms, however, it may reduce the number of T cells, and to adjust the dose in time is necessary.
Betacoronavirus ; isolation & purification ; Cell Count ; Coronavirus Infections ; diagnosis ; drug therapy ; immunology ; physiopathology ; Critical Illness ; Cytokines ; blood ; Female ; Humans ; Methylprednisolone ; administration & dosage ; adverse effects ; Middle Aged ; Pandemics ; Pneumonia, Viral ; diagnosis ; drug therapy ; immunology ; physiopathology ; T-Lymphocyte Subsets ; drug effects ; Treatment Outcome