[Analysis of risk factors of mortality in infants and toddlers with moderate to severe pediatric acute respiratory distress syndrome].

Objective: To identify the risk factors in mortality of pediatric acute respiratory distress syndrome (PARDS) in pediatric intensive care unit (PICU). Methods: Second analysis of the data collected in the "efficacy of pulmonary surfactant (PS) in the treatment of children with moderate to severe PARDS" program. Retrospective case summary of the risk factors of mortality of children with moderate to severe PARDS who admitted in 14 participating tertiary PICU between December 2016 to December 2021. Differences in general condition, underlying diseases, oxygenation index, and mechanical ventilation were compared after the group was divided by survival at PICU discharge. When comparing between groups, the Mann-Whitney U test was used for measurement data, and the chi-square test was used for counting data. Receiver Operating Characteristic (ROC) curves were used to assess the accuracy of oxygen index (OI) in predicting mortality. Multivariate Logistic regression analysis was used to identify the risk factors for mortality. Results: Among 101 children with moderate to severe PARDS, 63 (62.4%) were males, 38 (37.6%) were females, aged (12±8) months. There were 23 cases in the non-survival group and 78 cases in the survival group. The combined rates of underlying diseases (52.2% (12/23) vs. 29.5% (23/78), χ2=4.04, P=0.045) and immune deficiency (30.4% (7/23) vs. 11.5% (9/78), χ2=4.76, P=0.029) in non-survival patients were significantly higher than those in survival patients, while the use of pulmonary surfactant (PS) was significantly lower (8.7% (2/23) vs. 41.0% (32/78), χ2=8.31, P=0.004). No significant differences existed in age, sex, pediatric critical illness score, etiology of PARDS, mechanical ventilation mode and fluid balance within 72 h (all P>0.05). OI on the first day (11.9(8.3, 17.1) vs.15.5(11.7, 23.0)), the second day (10.1(7.6, 16.6) vs.14.8(9.3, 26.2)) and the third day (9.2(6.6, 16.6) vs. 16.7(11.2, 31.4)) after PARDS identified were all higher in non-survival group compared to survival group (Z=-2.70, -2.52, -3.79 respectively, all P<0.05), and the improvement of OI in non-survival group was worse (0.03(-0.32, 0.31) vs. 0.32(-0.02, 0.56), Z=-2.49, P=0.013). ROC curve analysis showed that the OI on the thind day was more appropriate in predicting in-hospital mortality (area under the curve= 0.76, standard error 0.05,95%CI 0.65-0.87,P<0.001). When OI was set at 11.1, the sensitivity was 78.3% (95%CI 58.1%-90.3%), and the specificity was 60.3% (95%CI 49.2%-70.4%). Multivariate Logistic regression analysis showed that after adjusting for age, sex, pediatric critical illness score and fluid load within 72 h, no use of PS (OR=11.26, 95%CI 2.19-57.95, P=0.004), OI value on the third day (OR=7.93, 95%CI 1.51-41.69, P=0.014), and companied with immunodeficiency (OR=4.72, 95%CI 1.17-19.02, P=0.029) were independent risk factors for mortality in children with PARDS. Conclusions: The mortality of patients with moderate to severe PARDS is high, and immunodeficiency, no use of PS and OI on the third day after PARDS identified are the independent risk factors related to mortality. The OI on the third day after PARDS identified could be used to predict mortality.

[Analysis of clinical and endoscopic characteristics of colorectal polyps in children].

To analyze the clinical and endoscopic characteristics of colorectal polyps in children, and to explore the detection rate, age and gender distribution characteristics, endoscopic treatment effect and follow-up monitoring of colorectal polyps in children, so as to provide reference for disease management of colorectal polyps in children. The clinical and endoscopic characteristics of children with colorectal polyps in Xi 'an Children's Hospital from January 2019 to December 2019 were retrospectively analyzed. The patients were divided into 5 groups according to age (y): 0

[A comparative study of four cross-sectional investigations on the status of pediatric intensive care unit in China over the past 30 years].

Objective: To understand the history, current situation and trends of intensive care unit (ICU) of pediatrics in China over the past 30 years. Methods: The results of the cross-sectional investigation on the status of ICU of pediatrics in 2014 were compared with those in 1993, 2001 and 2009. The main measurements were the number of participated provinces and hospitals, the availability of equipment, staffing, and medical technologies, the major diseases and the source of the patients. Besides, the equipment allocation and technology implementation in 2014 were compared with the standards in the "recommendations on grading construction and management of children's intensive care unit in China" published in 2016. Results: The contents of the four surveys were slightly different, with only a few measurements not documented in one or more surveys. (1) The number of provinces and hospitals involved in the four surveys were 20 hospitals in 14 provinces in year 1993, 27 hospitals in 17 provinces in year 2001, 33 hospitals in 25 provinces in year 2009 and 108 hospitals in 25 provinces in year 2014. (2) In 1993, 2001, 2009 and 2014, the ratio of doctors/beds were 0.7∶1,0.8∶1, (0.4-0.5) ∶1 and 0.5∶1, and the ratio of nurses/beds were 1.1∶1,1.4∶1, (1.1-1.7) ∶1 and 1.3∶1, respectively. (3) Regarding the equipment availability, in 1993, 2001, 2009, and 2014, the numbers of monitors were 0.3/ICU, 0.3/bed, 1.1-1.4/bed and 1.0/bed; the numbers of invasive ventilators were 0.4/bed, 0.5/bed, 0.6/bed and 0.4/bed, respectively. In 2001, 2009 and 2014, there were 60.0%, 100.0% (33/33) and 88.0% (95/108) of the participating ICU equipped with blood gas analyzer, and 70.0%, 93.9% (31/33) and 90.7% (98/108) with bedside X-ray machines, respectively. In 2009 and 2014, 69.7% (23/33) and 92.6% (100/108) ICU were equipped with non-invasive ventilators respectively. In 2014, 10.2% (11/108) ICU were equipped with extracorporeal membrane oxygenation (ECMO) equipment and 45.4% (49/108) ICU with bedside continuous blood purification equipment. In 1993, 2001 and 2014, the numbers of infusion pump were 0.5/ICU, 1.1/bed and 1.7/bed, respectively. (4) Regarding the conducted medical technology, in 2014, invasive mechanical ventilation was used in 100% (108/108) ICU, and non-invasive ventilation in 89.8% (97/108) ICU. High frequency ventilation was used in 78.8% (26/33) and 38.0% (41/108) ICU in 2009 and 2014 respectively. Blood purification was used in 22.0%, 69.7% (23/33) and 47.2% (51/108) ICU, and the application of surfactant was in 48.0%, 97.0% (32/33) and 24.1% (26/108) ICU in 2001, 2009 and 2014, respectively. Nitric oxide inhalation (iNO) was used in 24.0% and 9.3% (10/108) in 2001 and 2014 respectively. ECMO was used in 6 and 7 hospitals in 2009 and 2014 respectively. (5) Compared with the criteria in the "recommendations on grading construction and management of children's intensive care units in China" in 2016, only the availability of monitors and conventional mechanical ventilation in 2014 met the standards.The original data in 2001 was not shown due to the lack of absolute values. Conclusions: The number of ICU of pediatrics and its beds in China increased significantly from 1993 to 2014, as well as the equipment availability and the conducted medical technology. But the status in 2014 was still far behind the recommendations in 2016, with a significant shortage of professional staff.

[Value of procalcitonin in predicting the severity and prognosis of neonates with septicemia].

Objective: To explore the value of procalcitonin(PCT) in predicting the severity and prognosis of neonates with septicemia. Methods: The clinical data of the hospitalized neonates over the age of 72 hours with double positive blood cultures from December 1st, 2011 to September 30, 2017 at the neonatal intensive care unit of Children's Hospital Affiliated to Capital Institute of Pediatrics was analyzed retrospectively. Results: A total of 75 neonates were included in the study. There was a significant negative correlation between PCT and neonatal critical illness score (r=-0.440, P<0.05). Among the groups of non-critical, critical and extremely critical, the levels of PCT had significant difference [0.27(0.10-2.55), 4.34(1.24-20.32), 19.49(1.92-106.49)µg/L, H=20.717, P<0.01]. At a cut-off point of 0.56 µg/L, PCT showed 88.6% sensitivity and 61.3% specificity for critical group diagnosis, with optimal area under the curve of 0.804 (P<0.05). At a cut-off point of 11.45 µg/L, PCT showed 65.2% sensitivity and 82.7% specificity for extremely critical group diagnosis, with optimal area under the curve of 0.735 (P<0.05). Among the groups of none organ dysfunction, single organ dysfunction and shock or multiple organ dysfunction, the levels of PCT had significant difference[0.10(0.43-2.56), 3.18(0.67-20.95), 18.97(1.92-82.90) µg/L, H=20.299, P<0.01]. At a cut-off point of 2.64 µg/L, PCT showed 70.0% sensitivity and 77.1% specificity for single organ dysfunction diagnosis, with optimal area under the curve of 0.793 (P<0.05). At a cut-off point of 9.06 µg/L, PCT showed 61.3% sensitivity and 86.4% specificity for shock or multiple organ dysfunction diagnosis, with optimal area under the curve of 0.782 (P<0.05). PCT levels were significantly higher in the death group than the survival group. At a cut-off point of 75.65 µg/L, PCT showed 80.0% sensitivity and 90.0% specificity for the judgment of death, with optimal area under the curve of 0.886 (P<0.05). C-reactive protein (CRP), white blood cell (WBC) and neutrophil lymphocyte ratio (NLR) had no significant difference in the severity and the degree of organ dysfunction of neonates with septicemia(all P>0.05). Conclusion: Compared to CRP, WBC and NLR, PCT has high value in predicting the severity, the degree of organ dysfunction and the prognosis of neonates with septicemia.

[Survey on the prevalence of continuous blood purification in Chinese pediatric critical care].

Objective: To investigate the current application status of continuous blood purification (CBP) technology and equipment in pediatric intensive care unit (PICU) in China. Methods: A cross-sectional survey was conducted to understand the current popularization of CBP technology and equipment, the management of CBP equipment and consumables, and the application of CBP in different diseases. A questionnaire named Application Status of Continuous Blood Purification Technology was applied. Children's hospitals and polyclinic hospitals with the pediatric qualification (pediatric emergency or critical care unit members of Chinese Medical Association and Chinese Medical Doctor Association) were selected. Results: From December 2016 to February 2017, 53 hospitals completed the questionnaire, including 7 in northeast, 6 in north China, 16 in east China, 9 in south China, 5 in central China, 4 in the northwest, and 6 in the southwest region. Continuous renal replacement therapy (CRRT), the most widely used technology, was carried out in 51 hospitals. Other technologies were peritoneal dialysis (IPD) (n=37), artificial liver support (ALSS) (n=26) and blood adsorption (PA) (n=13). There were 107 CBP machines in the 51 hospitals used CBP technology, with an average of 2.10/hospital. In 36 hospitals CBP machines were managed independently by PICU (70%). Hospitals made their own displacement liquid (n=40, 78%), or purchased displacement liquid (n=11, 22%). Hospitals prepared dialysate on their own (n=38, 75%), or purchased dialysate (n=13 hospitals, 25%). In 46 (90%) hospitals, hemodialysis catheter was placed independently by PICU doctors. The routine operation and maintenance of CBP were mainly completed by the PICU nurses in 36 hospitals (71%). There were 39 hospitals (76%) where professional nurses manage and maintain CBP. Puncture sites were femoral vein (n=26, 51%), internal jugular vein (n=21, 41%) and venae subclavia (n=4, 8%). Forty-two hospitals (82%) selected B-mode ultrasound positioning and guidance when performing internal jugular vein puncture. A total of 40 (78%) hospitals have developed post dilution and combined dilution techniques during the implementation of CBP. The most common indications of CBP technology were different in different regions. They were sepsis in northeast (24.0%, 243/1 011) and east China region (32.0%, 982/3 069), multiple organ dysfunction syndrome in south China (29.2%, 444/1 520), north China (15.8%, 126/796), and southwest region (30.1%, 460/1 526), drug poisoning in central China region (21.6%, 325/1 506), and renal failure in northwest region (53.0%, 44/83). Conclusions: CBP technology is widely used in the field of pediatric severe diseases in China. The eastern regions possess more CBP equipment than the western regions. CBP is widely used in the treatment of sepsis.

[Nasal continuous positive airway pressure ventilation in children with community-acquired pneumonia under five years of age: a prospective, multi-center clinical study].

Objective: To analyze the clinical characteristics of community-acquired pneumonia (CAP) in children under five years of age and analyze the safety and efficiency of nasal continuous positive airway pressure (NCPAP) ventilation for CAP in this population. Method: This was a prospective multicenter study. Children who were admitted to these six centers with CAP and met the NCPAP ventilation indications, aged from 29 d to 5 years, were continuously included during November 2013 to October 2015. The baseline data were collected and NCPAP ventilation were then followed up by operation standards, and the vital signs and arterial blood gas change at special time points were observed and recorded. Any side effect associated with NCPAP were recorded. For categorical variables, comparisons were performed using Fisher test. Rank-sum test and t test were performed respectively for abnormal and normal distribution continuous variables. The variables pre-NCPAP and post-NCPAP were analyzed by repeated measures ANOVA analysis. Result: Totally 145 children were included, and 13 children were excluded due to incomplete data. One hundred and two children(77.3%)were ≤12 months; 91 children (68.9%) were from rural area. NCPAP ventilation was effective in 123 children, with a response rate of 93.2%, were all discharged with a better condition; it was ineffective in 9 children(6.8%), and they were all intubated and went on mechanical ventilation, 5 were discharged with a better condition, and 4 died after gaving up treatment. The gender, age, body weight, residence, main symptoms, main signs, imaging diagnosis, medications, partial pressure of oxygen(PaO(2)), breath and heart rate before NCPAP treatment of two groups had no significant differences(allP>0.05). The rates of combining underlying diseases, trouble with feeding and cyanosis, and the partial pressure of carbon dioxide(PaCO(2) ) before NCPAP ventilation were higher in NCPAP ineffective group ((59±11 )vs.( 49±11) mmHg, 1 mmHg=0.133 kPa, t=-2.597, P=0.028); while the PaO(2)/fraction of inspiration O(2) (FiO(2) ) before NCPAP was lower((150±37) vs. (207±63) mmHg, t=2.697, P=0.008). The breathing, heart rate and PaCO(2) of NCPAP effective group decreased significantly, while the PaO(2) and PaO(2)/FiO(2) increased significantly after 2, 8, 24 h of NCPAP ventilation(all P=0.000). PaCO(2) in children with hypercapnia before NCPAP ventilation in NCPAP effective group decreased significantly ((48±9), (47±12), (45±11)vs.(58±7)mmHg, all P=0.000). All children tolerated well to NCPAP ventilation, and there were no severe side effects or complications associated with NCPAP ventilation. Conclusion: NCPAP ventilation is safe and effectively improved the oxygenation and hypercapnia in infants with CAP. But it may not work well in children with underlying diseases, manifest as difficulty in feeding/cyanosis and extremely high PaCO(2) or low PaO(2)/FiO(2), and they may need early intubation.

[Effect of N-acetylcysteine inhalation on ventilator-associated pneumonia caused by biofilm in endotracheal tubes].

OBJECTIVE: To observe the formation of the biofilm in endotracheal tubes, the characteristics of etiology, drug resistance and effect on the biofilm and ventilator-associated pneumonia (VAP) of inhaled N-acetylcysteine (NAC). METHOD: We selected 117 tracheally intubated and undergoing mechanical ventilation for ≥48 h in our hospital ICU from September 2010 to August 2012. All the cases were randomly divided into control group (60 cases) and study group (57 cases). The patients in the study group were treated with different doses of aerosolized NAC according to different ages, starting the first administration within 12 hours of mechanical ventilation, once every 8 hours, until stopping mechanical ventilation. Comparison was performed on the two groups in biofilm structure under the scanning electron microscopy, biofilm culture positive rate, VAP incidence, the etiology and drug resistance of the lower airway secretions and biofilms. RESULT: (1) Electron microscopy showed that biofilm had formed in the endotracheal tube inner wall in early period of mechanical ventilation. With prolonged mechanical ventilation, biofilm structure improved. At the same time of mechanical ventilation, the thickness of biofilm in the study group decreased as compared with the control group. (2) Biofilm culture positive rate and incidence of ventilator-associated pneumonia decreased in the study group compared with in the control group (65%(37/57) vs. 80%(48/60), P<0.05; 11% (6/57)vs. 32%(19/60), P<0.01). (3) A large number of pathogenic bacteria colonized in the biofilm and gram-negative bacilli dominated. With prolonged mechanical ventilation, the cultured pathogens converged from the lower airway secretions and biofilm. CONCLUSION: With prolonged mechanical ventilation, biofilm structure was improved. Inhalation of NAC can inhibit biofilm formation and reduce the incidence of VAP.

[TSLPR/STAT5 signaling modulates innate immunity in corneal fibroblasts triggered by Aspergillus fumigatus].

OBJECTIVE: To study the primary role of TSLPR/STAT5 signaling in inflammatory responses triggered by Aspergillus fumigatus(AF) in telomerase-immortalized human stromal fibroblasts (THSF). METHODS: Experimental study. Baseline expression of TSLPR in THSF was assessed by immunofluorescence analysis. Human recombinant TSLP was added. At 5, 15, 30 and 60 min after incubation, cells were harvested for Western blot to assess the protein levels of p-STAT5 and STAT5. After stimulated with AF hyphae for 1, 3, 6, 12, 24 and 48 h, cells were collected for measurement of mRNA of TSLPR and IL-7Rα. After incubated with AF hyphae for 12, 24 and 48 h, cells were harvested for Western blot to assess the protein levels of TSLPR, p-STAT5 and STAT5. Incubation with anti-TSLPR antibody was performed for 4 h, and at 24 h after AF hyphae were added, cells were harvested to assess the protein levels of p-STAT5 and STAT5. RESULTS: Immunofluorescence staining evidenced that expression of TSLPR was visualized in THSF. Western blot assay showed that p-STAT5 protein was increased and peaked at 30 min after stimulation with hTSLP (AF group: 8.87±0.75; control group: 1.00±0.14; P<0.01). RT-PCR revealed that the expression levels of TSLPR mRNA were increased after incubation with AF hyphae for 3, 6, 12 and 24 h (AF group: 0.000 50±0.000 07, 0.001 20±0.000 11, 0.002 30±0.000 25 and 0.001 70±0.000 17; control group: 0.000 20±0.000 03, 0.000 20±0.000 05, 0.000 20±0.000 03 and 0.000 20±0.000 04; t=-9.955, -17.329, -16.735 and -18.214, P<0.01), but the expression levels of IL-7Rα mRNA were not increased significantly (t=-0.684,-0.029,-0.319,-1.034, P>0.05). In comparison with the control group, after being challenged with AF hyphae for 24 h, both TSLPR and p-STAT5 protein were increased significantly (p-STAT5: 9.46±2.08 vs. 1.00±0.06; TSLPR: 1.80±0.27 vs. 1.00±0.34; t=-7.055, -3.170, P<0.01). Western blot showed that the elevated p-STAT5 expression levels observed after AF hyphae stimulation can be inhibited by TSLPR antibody (anti-TSLPR-AF: 0.55 ± 0.20; CTR Ab-AF: 1.00 ± 0.08; t=3.506, P<0.05). CONCLUSION: TSLP/TSLPR/STAT5 signaling pathway plays an important role in inflammatory responses triggered by AF in THSF.

Double contrast percutaneous transhepatic cholangiographic CT in patients with obstructive jaundice: an initial experience of seven cases.

PURPOSE: To explore the technical feasibility of double contrast percutaneous transhepatic cholangiographic CT (DC-PCT-CT) in patients with bile duct obstruction. METHODS: Seven patients with bile duct obstructive diseases were studied, including 5 males and 3 females, ranging in age from 24 yrs to 74 yrs (average: 47.7 yrs). There were 5 cases of hilar cholangiocarcinoma, 1 case of sclerosing cholangitis, and 1 case of malignant transformation of adenoma at the distal end of the common bile duct. PTC was carried out initially, involving injection of 30 ml 4.5-6.0 mgl iohexol. After the bile duct system was filled, CT scan was performed, and further followed by enhanced CT with intravenous injection of 300 mgl/ml contrast agent. Arterial phase, venous phase, and parenchymal phase acquisitions were obtained. Raw CT images were viewed and multiplanar reconstruction (MPR), maximum intensity projection (MIP), and volume rendering (VR) image post-processing were performed. RESULTS: DC-PCT-CT was performed successfully and bile duct drainage was carried out. Mild lesion enhancement was demonstrated in three cases in arterial phase, while all seven cases demonstrated enhancement of various degrees in venous phase.The lesions lead to track-like, asymmetrical or irregular bile duct obstructive narrowing, and in one case intra-luminal filling defect. Reliable diagnosis was suggested in all cases. MPR, MIP and VR images were useful in demonstrating precise lesion location and for surgical planning. CONCLUSION: In patients with bile duct obstruction, DC-PTC-CT is a feasible technique offering both important diagnostic value and drainage application.

First Report of Damping-off Caused by Alternaria japonica on Chinese Cabbage Seedlings in China.

In May 2011, samples of Chinese cabbage (Brassica campestris L. subsp. chinensis Markino) seedlings at the two-to four-leaf stage with damping-off symptoms were collected from greenhouses in the Tibet Autonomous Region of China. Infected stems of the seedlings were constricted at or near the soil surface. On diseased stems, a light to dark brown coloration was demarcated from healthy tissue. Damping-off and death of seedlings occurred as the lesions enlarged, resulting in a significant reduction of seedlings. Diseased stems were cut into 3-mm-long segments, surface-sterilized with 3.5% sodium hypochlorite for 1 min, and rinsed in sterilized water three times before being placed on water agar. A fungus frequently isolated from diseased plants was hyphal tipped under a dissecting microscope and transferred onto potato dextrose agar (PDA) to obtain a pure culture. The isolate grew slowly on PDA at 25°C with a 12-h photoperiod. The colony was white at first and gradually turned gray or grayish-green. No conidia or chlamydospores developed. However, conidia were produced on potato-carrot agar. Conidia were yellow-brown, obpyriform or obpyriform with beaks, had two to eight transverse septa, one to three vertical or oblique septa, and were produced solitarily or often in chains of two or three and measured 43.5 to 85.2 × 21.5 to 28.0 µm. A few conidia without beaks were also present and were nearly round and slightly smaller than the conidia with beaks. Several adjacent chlamydospores with thickened walls were often intercalary. The isolate was tentatively identified as Alternaria japonica based on its morphological characteristics (1,2). For molecular analyses, the internal transcribed spacer (ITS) regions of ribosomal DNA from the isolate were amplified with universal primers ITS1 and ITS4. The resulting sequence (Accession No. JN654465) submitted to GenBank had a 99% identity to that of A. japonica (Accession No. AY154703.1) isolated from leaves of Raphanus sativus. To confirm the pathogenicity of A. japonica, nine healthy 10-day-old Chinese cabbage seedlings were inoculated at the stem base with one PDA plug from a 6-day-old culture, with nine noninoculated (PDA plus only) seedlings serving as controls. Two days after inoculation, symptoms similar to those on the naturally infected plants developed on the inoculated seedlings. No symptoms developed on the controls. The pathogen was reisolated from the stems of inoculated and diseased seedlings. To our knowledge, this is the first report of A. japonica leading to damping off on Chinese cabbage seedlings in China. References: (1) M. P. Corlett and M. E. Corlett. Can. J. Plant Pathol. 21:298, 1999. (2) T. Y. Zhang. Flora Fungorum Sinicorum: Alternaria (in Chinese) Vol. 16. Science Press, Beijing, 2003.