This review discussesed the application of healthcare simulation in the post-graduation education of pediatric emergency and critical care medicine in China,puting forward the necessity of its application,introducing the application scenarios from four aspects:basic skills simulation training,specialized skills simulation training,situational simulation training and screen simulation training,and analyzing the existing problems from three aspects:teaching staff,curriculum research and training equipment.Some suggestions are put forward to strengthen the system guarantee,concentrate the development of multidisciplinary forces,and integrate the strength of domestic industry,university and research.

Objective:To investigate the clinical characteristics, treatment process and prognosis of children with severe side effects after chimeric antigen receptor T cell immunotherapy(CAR-T), so as to provide evidence for timely intervention after CAR-T treatment.Methods:From June 1, 2015 to May 31, 2020, children with cytokine release syndrome(CRS)or immune cell related neurotoxicity syndrome(ICANS)who were treated with CAR-T therapy in our hospital and revealed severe effects transferred to PICU were included in the study, and their clinical course and multiple laboratory examination data were systematically analyzed.Results:Seventeen children showed CRS reaction and entered PICU after CAR-T therapy.The most common clinical symptoms were respiratory distress(13 cases) and circulatory disorder(10 cases), of which 7 cases were complicated with severe ICANS.Serum interferon -γ(IFN-γ)and interleukin-6(IL-6)levels significantly increased after CAR-T cell infusion, reaching the peak at (5.1±1.6)days.The serum levels of IFN-γ and IL-6 in children with severe CRS were significantly higher than those in children with mild CRS(all P<0.05). The level of serum IL-6 in children with high tumor load was significantly higher than that in children with low tumor load( P<0.05). The mortality rate of children with elevated level of serum TNF-α was higher(5/5 vs.3/11, P<0.05). Children with severe CRS were more likely to develop grade 4 ICANS(4/4 vs.0/3, P<0.05). The mortality rate of children with oxygenation index(P/F value)<200 mmHg(1 mmHg=0.133 kPa) was higher(5/5 vs.2/12, P<0.05). The vasoactive inotropic score[ M( Min, Max)] in the death group was significantly higher than that in survival group[29.5(14.0, 50.0) vs.1.5(0, 25.0), Z=8.000, P=0.027]. Conclusion:Serum IL-6 and IFN-γ are crucial causes of CRS.High tumor load is one of the factors causing high level of serum inflammatory factors.Respiration and circulation systems are the most frequently involved systems.Therefore, the evaluation indexes of these two systems can help us judge the prognosis of children.

Objective:To analyze the clinical characteristics and risk factors for mortality of severe pneumocystis carinii pneumonia(PCP)in pediatric liver transplant(LT)recipients.Methods:The data of severe PCP in LT recipients diagnosed at Shanghai Children′s Medical Center from November 2019 to February 2021 were collected.The clinical characteristics and risk factors for 28-day mortality were analyzed.Results:Fifteen patients were enrolled in the study.Thirteen cases survived and 2 cases were non-survived.There was no routine anti-pneumocystis prophylaxis after LT.The median age of onset of PCP was 12(7, 26)months.The median time after LT was 3.00(0.33, 4.00)months.The onset clustered in November-December and June-August.All patients were mechanically ventilated, and some patients were given prone ventilation(11 cases), neuromuscular blocking agents(13 cases)and high concentration oxygen(more than 60%, nine cases). Fourteen cases were complicated with other infections.Two cases were complicated with pneumothorax and subcutaneous/mediastinal emphysema.There were 2 cases with septic shock-like manifestation, 1 case of right heart insufficiency, 1 case of right heart failure(death), and 1 case of multiple organ failure(death). Compared with the survived group, the non-survived group had higher pediatric risk of mortality Ⅲ score[3.5(0.0, 6.0)vs.8.5(5.0, 12.0), Z=1.993, P=0.046] and lactate dehydrogenase level[1 731.5(1 012.0, 3 270.0)U/L vs.4 387.5(3 606.0, 5 169.0)U/L, Z=2.148, P=0.032]. Conclusion:PCP in pediatric LT is critical and complicated.Pediatric risk of mortality Ⅲ scores and lactate dehydrogenase increase in 28-day hospitalized deaths.

Objective:To explore the implementation of individualized lung protection ventilation strategy in pediatric acute respiratory distress syndrome(pARDS)guided by transthoracic electrical impedance tomography(EIT)and critical care ultrasound(CCU).Methods:We retrospectively analyzed the therapeutic process of protective ventilation strategy in one case of severe pARDS.EIT and CCU were used to guide the implementation of lung protective ventilation strategy.Results:EIT was used to guide lung recruitment and optimal positive end-expiratory pressure titration.CCU was used to assess hemodynamics and lung status of ARDS patient, and guide the implementation of right ventricular protective ventilation and circulatory protective ventilation.Finally, the patient eventually survived.Conclusion:The idea of ARDS protective ventilation has changed from traditional lung protective ventilation to right heart protective ventilation and circulatory protective ventilation, and finally achieved the protection of pulmonary vascular endothelium.EIT and CCU enrich the understanding of the pathophysiology and protective ventilation strategy in pARDS.

Objective:To investigate the immunity markers related to nosocomial infection in children with sepsis.Methods:A retrospective study including 155 cases diagnosed as sepsis from September 2015 to June 2020 in children′s intensive care unit (PICU) of Shanghai Children′s Medical Center was conducted. According to the presence of nosocomial infection occurred in PICU, septic children were divided into two groups: no nosocomial infection and nosocomial infection group. The differences about helper T-cells 1 and 2 cytokines, T cells subgroup absolute count, the proportion of CD14 + human leukocyte antigen DR (CD14 +HLA-DR), the proportion of regulatory T cells, pediatric risk of mortality Ⅲ (PRISM-Ⅲ), the treatment and outcome between the two groups were compared. Through propensity score matching (PSM), the disease severity and treatment of the two groups were matched to analyze the differences between the above indicators. Chi-square test or U test was used for comparison between groups. Receiver operating characteristic (ROC) curve was used to predict the occurrence of nosocomial infection. Results:There were 104 cases in no nosocomial infection group and 51 cases in nosocomial infection group. The first PICU-acquired infections occurred at (12±7) days after PICU admission. The most common PICU-acquired infections were pneumonia (26 cases, 51.0%) and bloodstream infections (15 cases, 29.4%). PRISM-Ⅲ of nosocomial infection group was significantly higher than that in no nosocomial infection group (8 (0-31) vs. 4 (0-17), Z=3 913.00, P<0.01).The proportion of using vasoactive drugs and invasive mechanical ventilation of nosocomial infection group was significantly higher (35.3% (18/51) vs. 10.6% (11/104), χ2=13.77, P<0.01; 86.3% (44/51) vs. 38.5% (40/104), χ2=31.51, P<0.01).The PICU length of stay of nosocomial infection group was significantly longer (20 (3-94) vs.7 (2-41) days, Z=4 585.50, P<0.01). The mortality of the nosocomial infection group was significantly higher than that of the group without nosocomial infection (29.4% (15/51) vs. 6.7% (7/104), χ2=14.45, P<0.01). Interleukin-6 and interleukin-10 of the nosocomial infection group were significantly higher than that in no nosocomial infection group (37.83 (2.23-7 209.99) vs. 13.45 (0.80~50 580.64) ng/L, Z=3 390.50, P=0.01; 10.42 (1.11-6 052.21) vs.4.10 (0.16-409.28) ng/L, Z=3 212.00, P=0.03). CD4 +/CD8 + and the percentage of CD14 +HLA-DR were significantly lower in the nosocomial infection group compared with the no nosocomial infection group (1.16 (0.44-4.96) vs. 1.61 (0.15-6.37), Z=1 955.00, P=0.01; 0.48 (0.08-0.99) vs. 0.67 (0.09-0.98), Z=1 915.50, P<0.01). After PSM, the percentage of CD14 +HLA-DR of nosocomial infection group was significantly lower than that in no nosocomial infection group (0.44 (0.08-0.99) vs. 0.64 (0.09-0.98), Z=758.00, P=0.02). The ROC curve analysis of the percentage of CD14 +HLA-DR in predicting nosocomial infection showed that the area under the curve was 0.642, the cut-off value was 0.39, and the 95% CI was 0.528-0.755. Conclusion:The level of the percentage of CD14 +HLA-DR maybe is related to the occurrence of nosocomial infection in children with sepsis.

Objective: To investigate the safety, feasibility and operation key points of whole lung lavage in infants with pulmonary alveolar proteinosis. Methods: The clinical manifestations, genetic screening, therapeutic interventions and outcome of an infant with pulmonary alveolar proteinosis complicated with respiratory failure who received whole lung lavage in November 2018 in Shanghai Children′s Medical Center Affiliated to Shanghai Jiaotong University School of Medicine were reported. Websites including PubMed, Springer Link, China National Knowledge Infrastructure (CNKI), Weipu Database, and Wanfang Database were searched using the key words of "whole lung lavage" "pediatric" and "pulmonary alveolar proteinosis" for articles published from their establishments to April 2019. Relevant literature was reviewed. Results: A 3-month-old boy had experienced cough, shortness of breath and cyanosis for 1 week prior to admission to pediatric intensive care unit. Physical examination showed hepatosplenomegaly. Complete blood cell count showed mild anemia (hemoglobin 96 g/L) and normal white blood cells. The patient had normal C-reactive protein and normal blood platelet. Biochemical panel showed hypoalbuminemia (31 g/L), mildly elevated glutamic oxaloacetic transaminase (115 U/L) and blood ammonia (165 μmol/L), extremely elevated lactate dehydrogenase (>6 600 U/L) and hyperferritinemia (>4 500 μg/L). Chest computed tomography (CT) revealed decreased transmittance of both lungs, patchy high density shadow and ground glass opacity. Genetic testing revealed a mutation of c.625+1G>A in SLC7A7. Schiff reaction (PAS staining) in bronchoalveolar lavage fluid was positive. The patient was diagnosed with severe pneumonia, respiratory failure, lysinuria urinary protein intolerance, and pulmonary alveolar proteinosis. The patient received sequential unilateral whole lung lavage in 2 days and was successfully weaned from ventilator. He was discharged home breathing room air. Eleven articles (11 in English and non in Chinese) were reviewed. Twenty-one patients were included. After whole lung lavage, 76% (16/21) of the patients had improvement in respiratory function. Conclusions Whole lung lavage can effectively improve respiratory failure caused by pulmonary alveolar proteinosis in infant patients. The procedure is feasible and safe.

Objective: To explore the clinical characteristics prevalence of respiratory adenovirus infections in children, and to provide reference for diagnosis, monitoring and timely treatment. Methods: A total of 775 clinical specimens were collected from Shanghai Children′s Medical Center during November 2016 to November 2017, and 84 cases of adenovirus infections were detected by FilmArray. Results: Among 775 samples, 84 samples(10.8%) were adenovirus positive.The epidemic peak of adenovirus infection was winter, spring and summer, especially in winter(20.8%), and the highest detection rate was in January(32.2%). The age ranged from 6 months to 2 years(47.7%). The common clinical manifestations are fever(91.7%), cough(96.4%), wheezing(48.8%), and shortness of breath(14.2%). A total of 15 cases(17.9%) had underlying diseases, the most of them were congenital heart diseases(9 cases, 10.7%). A total of 53 cases(63.1%) were mixed infection, and 21 cases(25.0%) were complicated with human rhinovirus/enterovirus.There were 5 cases of upper respiratory tract infection, 3 cases of bronchitis and 76 cases of pneumonia, including 55 cases of mild pneumonia and 21 cases of severe pneumonia.The average length of hospital stay was 8.3 days.The length of hospital stay, cases of wheezing and severe cases in the mixed infection group were significantly higher than those in the single infection group(P<0.05). Hospitalization days, wheezing symptoms, extrapulmonary symptoms, basic diseases and mixed infections in severe group were significantly higher than those in mild group(P<0.05). Conclusion Adenovirus infection occurs in children aged 6 months to 2 years, with a high incidence in winter, spring and summer.The peak month is January.The main clinical manifestations are high fever, cough and wheezing.Children with underlying diseases, wheezing symptoms, extrapulmonary symptoms and mixed infections are more likely to develop severe diseases.FilmArray detection system can quickly and accurately detect pathogens, provide a good basis for early diagnosis, monitoring and treatment of clinicians.

Objective:To analyze the clinical characteristics, diagnosis and treatment strategies of cryptococcus neoformans infection in children, and to explore the application value of PCR and high-throughput gene analysis in the diagnosis and treatment of cryptococcus neoformans infection.Methods:The clinical data of children with cryptococcus neoformans infection were retrospectively analyzed, who were hospitalized in Shanghai Children′s Medical Center from July 1998 to December 2018, including epidemiological characteristics (age, gender, underlying disease, and contact history, etc.), clinical manifestations, laboratory tests, imaging studies, pathogen detection methods, and treatment and prognosis.Results:A total of ten children were enrolled in the survey, including five males and five females, and the median age was 6.28(4.08, 12.02) years; four cases had a history of poultry/soil/corrosion exposure; seven cases were diagnosed as cryptococcus neoformans meningitis, three cases were diagnosed as disseminated cryptococcal disease; five cases had underlying disease, including two cases of which were found to have primary immunodeficiency through high-throughput genetic analysis; headache with fever was the most common clinical symptom of cryptococcus neoformans meningitis.All three cases of disseminated cryptococcosis had primary or secondary immunodeficiency.All children were treated with 5-fluorocytosine + amphotericin B/amphotericin B liposome in induction therapy, and fluconazole in consolidation therapy.Notably, two cases showed hypokalemia during induction therapy, and one case showed mild renal dysfunction during consolidation treatment; five cases were cured, three cases were abandoned, one case was relapsed, and one case died.Conclusion:Children with cryptococcosis neoformans infection who are considered to have normal immune function may have primary immunodeficiency caused by gene mutation.PCR can improve the detection rate of cryptococcus neoformans and shorten the detection time.A significant increase in eosinophils may indicate the spread of infection.Hydration and regular potassium supplementation may reduce the toxicity of amphotericin B. Control of intracranial hypertension is the key to improve the success rate of treatment.

Objective:To explore the clinical characteristics of influenza A virus infection in children, and provide evidence for early identification of severe patients.Methods:A total of 114 patients with influenza like symptoms admitted to Shanghai Children′s Medical Center from October 2017 to May 2019 were enrolled in our study.All the patients were confirmed influenza A infection by Xpert-Xpress influenza/respiratory syncytial virus detection platform.The patients were divided into mild influenza A group (47 cases) and severe influenza A group (67 cases with pneumonia). The clinical data of these patients were analyzed and compared.Results:The male to female ratio of 114 cases was 1.28∶1.The age of included patients ranged from 1 month 12 days to 12 years old, and the median age was 3.00 (4.27) years old.The most common clinical manifestations were fever, cough and wheezing, accounting for 79.82%, 68.42%, and 43.00%, respectively.The rate of mixed infection was 24.56%, and adenovirus(5.26%), respiratory syncytial virus(4.39%) as well as mycoplasma(3.51%) accounted for the top three, and the rate of mixed bacterial infection was 12.28%.The median age of the patients in the severe influenza A group was 1.00 (3.58) years, and that in the mild influenza A group was 4.00 (5.00) years, with statistical difference ( Z=-3.81, P<0.001). The mixed infection rate was 38.80% (26/67) in severe influenza A group and 4.26% (2/47) in mild influenza A group, with statistical difference ( χ2= 17.8, P<0.001). The neutrophil/lymphocyte ratio in peripheral blood was 2.64 (3.37) in severe influenza A group and 1.17 (2.02) in mild influenza A group, with statistical difference ( χ2=-2.46, P=0.01). Conclusion:Children with smaller age, mixed infection and higher neutrophil/lymphocyte ratio are easy to develop into severe cases.The detection system of Xpert-Xpress influenza / respiratory syncytial virus is a simple, rapid and accurate method for influenza detection, which provides a good basis for diagnosis and treatment.

Objective:To explore the application value of FilmArray detection in children with acute lower respiratory tract infection and conduct economics analysis.Methods:From December 1, 2016 to November 30, 2017, 1 380 patients were enrolled in our study.Some children(FilmArray group) were tested for respiratory pathogens with FilmArray, while others (control group) were tested by 7-box antigen test of respiratory virus, gold colloid test of influenza and mycoplasma antibody.Those with underlying diseases were excluded.A total of 160 cases in the FilmArray group and 160 cases in the control group were obtained with tendency score matching method.The physical examination of pathogens, clinical indicators, usage of anti-infective drugs and hospitalization related costs were compared.Results:The positive rate of FilmArray test was significantly higher than that in control group (86.88% vs. 45.91%). The most common pathogens detected by FilmArray were adenovirus(39 cases), rhinovirus(34 cases), and parainfluenza virus(30 cases). In the FilmArray group, nine cases were positive for botulinum pertussis, accounting for 5.6% of the total.The hospitalization time of FilmArray group was shorter than that in control group [(8.89±6.23 days vs.(11.51±14.43)days]. In FilmArray group, the antibiotics were used for a shorter time, and 18 children did not use antibiotics during hospitalization.Compared with the control group, the hospitalization cost had no significant difference in the FilmArray group, but the antibiotic cost was less, as well as hospitalization time was shorter.The average hospitalization cost saved by using the FilmArray test was nearly 2 000 yuan per person. Conclusion:The application of FilmArray detection in children with acute lower respiratory tract infection can quickly and accurately identify a various infections of virus, bacteria and atypical pathogen, which guides using anti-infective drugs more reasonably.The application of FilmArray detection shortens the average hospitalization days of children, increases the utilization efficiency of medical resources, and reduces the medical cost and indirect economic loss of children’s families, which has certain economics significance.