Chinese guidelines for the assessment and provision of nutrition support therapy in critically ill children.

BACKGROUND: This document represents the first evidence-based guidelines to describe best practices in nutrition therapy in critically ill children (> 1 month and < 18 years), who are expected to require a length of stay more than 2 or 3 days in a Pediatric Intensive Care Unit admitting medical patients domain. METHODS: A total of 25,673 articles were scanned for relevance. After careful review, 88 studies appeared to answer the pre-identified questions for the guidelines. We used the grading of recommendations, assessment, development and evaluation criteria to adjust the evidence grade based on the quality of design and execution of each study. RESULTS: The guidelines emphasise the importance of nutritional assessment, particularly the detection of malnourished patients. Indirect calorimetry (IC) is recommended to estimate energy expenditure and there is a creative value in energy expenditure, 50 kcal/kg/day for children aged 1-8 years during acute phase if IC is unfeasible. Enteral nutrition (EN) and early enteral nutrition remain the preferred routes for nutrient delivery. A minimum protein intake of 1.5 g/kg/day is suggested for this patient population. The role of supplemental parenteral nutrition (PN) has been highlighted in patients with low nutritional risk, and a delayed approach appears to be beneficial in this group of patients. Immune-enhancing cannot be currently recommended neither in EN nor PN. CONCLUSION: Overall, the pediatric critically ill population is heterogeneous, and an individualized nutrition support with the aim of improving clinical outcomes is necessary and important.

[The establishment of digital model about sagittal split ramus osteotomy and stability analysis of 3 different fixation methods].

PURPOSE: To establish the digital model about sagittal split ramus osteotomy and discuss the stress and displacement of 3 different fixation methods. METHODS: Three-dimensional reconstruction software Mimics and Geomagic were used to establish the three-dimensional entity model of mandible, and simulated sagittal split ramus osteotomy and fixation. Three-dimensional finite element model was established by mesh generation through ANSYS. After boundary constraint the occlusal load of 132N on the bilateral lower first molars was applied. RESULTS: Three-dimensional finite element models of sagittal split ramus osteotomy and 3 different fixation methods were established, and the biomechanical character of stress and displacement after occlusal load preoperatively and after splitting mandibles were found. CONCLUSIONS: As the stress distribution tends to uniformity and the displacement at split area is the least one, the fixation by bicortical screws in inverted-L position after sagittal split ramus osteotomy is the stablest of the 3 fixation methods. Supported by Natural Science Foundation of Guangdong Province (S2011010003872) and Science and Technology Projects of Guangzhou City (7421165457455).

[Application of fenestration and suction drainage for treatment of large odontogenic mandibular cystic lesions].

OBJECTIVE: To evaluate the effect of fenestration and suction drainage in the treatment of large odontogenic mandibular cystic lesions. METHODS: From 2005 to 2009, 24 cases of large odontogenic mandibular cystic lesions were treated with fenestration and suction drainage. The clinical symptoms and radiographical findings were evaluated before the operation and at 1 month and 6 months after suction drainage. RESULTS: Follow-up for 1-3 years showed that all the cystic lesions disappeared without recurrence, and the clinical symptoms were resolved. CONCLUSION: Fenestration and suction drainage can reduce the cystic size and rapidly correct the deformity to serve as a useful modality for primary management of large odontogenic mandibular cystic lesions.

[Clinical analysis of 47 children with types 3 and 7 adenovirus pneumonia].

OBJECTIVE: To explore the clinical features of types 3 and 7 adenovirus pneumonia in children and compare the difference between two types. METHODS: A total of 47 patients with adenovirus pneumonia at our hospital from January 2009 to June 2011 were reviewed. According to the serological types, they were divided into two groups: type 3 (n = 19) and type 7 (n = 28). Two groups were analyzed statistically with regards to age, gender, clinical presentation, critical scores, laboratory examinations, radiographic findings, lung function changes, complications and prognosis respectively. RESULTS: For types 3 and 7 adenovirus pneumonia, the median age of onset were 1.8 and 1.1 years old respectively. The male-to-female ratio were 14:5 and 20:8 respectively. As compared with type 3, type 7 had the longer fever time ((18 ± 10) vs (11 ± 7)days, P = 0.010), the higher critical proportion (13/28 (46.4%) vs 3/19 (15.8%), P = 0.031), the longer hospital stays ((28 ± 17) vs (15 ± 6) days, P = 0.003)), the higher proportion of involved lung ≥ 3 lobes (22/28 (78.6%) vs 4/19 (21.1%), P = 0.000), the lower oxygenation index ((192 ± 85) vs (256 ± 79) mm Hg,1 mm Hg = 0.133 kPa, P = 0.011), the higher proportion of mechanical ventilation (17/28 (60.7%) vs 5/19 (26.3%), P = 0.020) and the higher proportion of multiple organ dysfunction syndrome (16/28 (57.1%) vs 5/19 (26.3%), P = 0.037). In type 7, organ dysfunction was more obvious, particularly in nervous system, blood system and enzyme changes. Three cases of type 7 had pulmonary sequela with small airway disease. CONCLUSION: With more severe clinical manifestations, laboratory parameters and imaging data than type 3, type 7 adenovirus pneumonia in children is more likely to cause pulmonary sequela.

[Analysis of clinical manifestations of hospitalized children infected with seasonal influenza A virus and 2009 novel influenza A (H1N1) virus in Beijing].

OBJECTIVE: The novel influenza A (H1N1) virus firstly detected in April 2009 in Mexico rapidly spread to many countries including the United States and Canada where humans were infected with the H1N1 virus and deaths were reported. The pandemic virus strain had never been detected in specimen of human beings and swine. It was so highly contagious and widely spread that threatened life of humans globally. This study aimed to analyze clinical data of hospitalized children patients with 2009 novel H1N1 influenza A virus infection confirmed by etiologic tests, and compared with that of seasonal influenza A. METHOD: Clinical manifestations, laboratory and therapy data from the hospitalized children were collected by designed case report form and analyzed. All patients were enrolled from Capital Institute of Pediatrics from January 2003 to 2010. There were 152 cases in seasonal influenza A group, which was composed of 100 boys and 52 girls. Other 93 boys and 86 girls formed 2009 novel influenza A group. RESULT: Influenza A was dominate from 2003 to 2008 and the peak season was December and January, while the peak hospitalized time of 2009 novel H1N1 influenza was from November 2009 to January 2010. The median age of seasonal influenza group was 35 months, which was lower than that of novel influenza group (Z = -6.702, P<0.01). Besides, 80.9% of the patients in seasonal influenza group were infants, while the novel influenza A group was mainly composed of infants and pre-school children (chi2 = 40.725, P<0.01). The cases of both groups had influenza-like symptoms at onset and the most common presentations were fever and cough. The duration of fever was much longer in 2009 novel influenza group (Z = -7.173, P<0.01). Patients in two groups nearly had the same symptoms except cough was more frequently presented by novel influenza A group cases (chi2 = 4.109, P<0.05). In laboratory examination, the novel influenza group had more cases with abnormality in blood platelet, CRP, ALT, and CK-MB than that of seasonal influenza group (chi2 = 7.562, 17.245, 4.398, 6.217, P<0.01). Patients in novel influenza A group had more changes in electrocardiogram (chi2 = 24.461, P<0.01). More patients had common underlying medical condition in novel influenza groups than those in seasonal influenza group (chi2 = 12.553, P<0.01). Furthermore, the groups had different age distribution in underlying medical diseases (chi2 = 7.231, P<0.05). Children with 2009 novel H1N1 virus infection tended to catch pneumonia (chi2 = 8.661, P<0.01) and became the severe cases (chi2 = 10.595, P<0.01). They had much higher ICU admission rate (chi2 = 12.873, P<0.01) and longer hospital stay (Z = -2.764, P<0.01). CONCLUSION: As a new variant of influenza virus A, 2009 novel H1N1 influenza A had stronger pathogenicity. Children with underlying medical conditions had the high risk to be infected and developed severe manifestations.

[Chest radiographic findings in children with 2009 influenza A (H1N1) virus infection].

OBJECTIVE: To evaluate chest radiographic findings of children with 2009 influenza (H1N1) virus infection. METHOD: Data of 235 patients who had microbiologically confirmed H1N1 infection and available chest radiograph obtained between May 1(st) 2009 and Jan. 31(st) 2010 were retrospectively analyzed. The final study group was divided on the basis of clinical course [group 1 mild, outpatients without hospitalization (n = 172); group 2 moderate, inpatients with brief hospitalization (n = 49); group 3 severe, ICU admission (n = 14)]. Four pediatric radiologists reviewed all the chest radiographs of lung parenchyma, airway, pleural abnormalities and also anatomic distribution of the disease. RESULT: No significant sex or age differences were found among the study groups (P > 0.05). The mean interval between the onset of clinical symptom and the initial chest radiography was (5.91 ± 1.64) days (group 1), (3.60 ± 1.43) days (group 2) and (1.21 ± 0.41) days (group 3), respectively. The differences among the three groups were significant statistically (χ(2) = 13.368, P < 0.01). The ratio of abnormality presented at initial chest X-ray was 79.7% in group 1, 91.8% in group 2 and 100% in group 3. Radiographically, there were prominent peribronchial markings (group 1, 55.2%; group 2, 83.7%; and group 3, 78.6%), consolidation (group 1, 34.3%; group 2, 69.4%; and group 3, 100.0%), hyperinflation (group 1, 22.1%; group 2, 44.9%; and group 3, 50.0%) and ground glass opacity (group 1, 0.6%; group 2, 2.0%; and group 3, 14.3%) in the chest radiographs. The differences of presenting were statistically significant (P < 0.01). In the severe group, the lesions distributed diffusely and asymmetrically with multi-lobe involvements. CONCLUSION: In children with 2009 influenza A H1N1 viral infection, the interval between the onset of clinical symptom and initial chest radiography, the ratio of abnormality presented at initial chest X-ray film and the severity of chest film are parallel to their clinical situation.

[Acute kidney injury in critically ill children infected with influenza A virus (H1N1) and enterovirus 71].

OBJECTIVE: To analyze the clinical characteristics of acute kidney injury (AKI) in critically ill childhood patients with influenza A virus (H1N1) and enterovirus 71 (EV71), and to study the significance of the serum creatinine and urine output in diagnosis of AKI. METHOD: The clinical data of AKI in critically ill children admitted to intensive care units (ICUs) with confirmed influenza A (H1N1) or enterovirus 71 infection (EV71 group) from Oct. 2009 to Oct. 2010. RESULT: Twenty-eight critically ill children were involved in the study. In H1N1 group, there were 18 cases including 6 males and 12 females, and the average age was 5.4 years. In EV71 group, there were 10 cases including 8 males and 2 females, and the average age was 1.1 years. In H1N1 group: 4 cases developed AKI, whose average number of involved organ was 5.3. Two children were classified as first stage completely recovered after treatment; three children who were classified as third stage died. In 14 children without AKI, the average number of involved organ was 3.0, four of these children died. In EV71 group: 3 cases (first stage) developed AKI and 3 cases' serum creatinine increased to 45.0 to 47.6 percent from baseline. The average number of involved organ was 5.7. All the six children died. The other 4 cases whose serum creatinine was normal, and the average number of involved organ was 3.0, recovered. CONCLUSION: In critically ill virus-infected children, more organs were involved in the patients who developed AKI. As to influenza A (H1N1) infected critically ill children, the prognosis was comparatively better if the children were classified as AKI stage 1 and received early effective treatment. On the contrary, the prognosis was comparatively worse for those with AKI stage 3. As to EV71 infected critically ill children, the prognosis was worse once AKI developed. As to diagnosis of AKI, the sensitivity of serum creatinine criteria seemed to be superior to the urine output criteria. However, the significance of the serum creatinine and urine output in diagnosis of AKI still needs to be investigated in the future in large scale clinical studies.

[Identification and typing of adenoviruses from pediatric patients with acute respiratory infections in Beijing from 2003 to 2008].

OBJECTIVE: Adenovirus (ADV) is one of the most common causes of acute respiratory infections in infants and children. The objective of this study was to investigate the prevalence of adenovirus infection among pediatric patients with acute respiratory infections in Beijing and the types of the adenoviruses circulating in Beijing on the molecular bases. METHOD: Clinical specimens including throat swabs from outpatients and nasopharyngeal aspirates from hospitalized patients were collected from patients with acute respiratory infections in a consecutive period of 6 years from Jan 2003 to Dec 2008. Adenoviruses were identified from the collected clinical specimens by tissue culture and/or immunofluorescence assay and typed by nested-PCR based on the sequence of the encoding gene of hexon. Primers were designed for PCR amplification using hexon gene of adenovirus as target. One primer pair was designed as universal primers for amplifying a 1278 bp gene fragment located at the hexon gene of adenovirus types 3, 7, 11 and 21. Four primer pairs with the sequences located within the region of this 1278 bp fragment were designed specifically for amplifying adenoviruses types 3, 7, 11 or 21, respectively, which were used for a multiplex nest-PCR in a single tube. The products from this multiplex nest-PCR were 502 bp (for type 3), 311 bp (for type 7), 880 bp (for type 11) and 237 bp (for type 21), respectively, and the type of the adenovirus tested can be determined after agarose electrophoresis analysis of the PCR products. For those strains which could not be typed by the multiplex nest-PCR, the gene fragment was amplified by a universal primer pair for all adenovirus types from group A to F and the PCR products were sequenced directly. RESULT: Out of 17 941 clinical specimens collected, including 4378 throat swabs from outpatients and 13 563 nasopharyngeal aspirates from hospitalized patients, 304 were adenovirus positive by tissue culture and/or immunofluorescence assay, the overall positive rate was 1.69% (304/179 41). Among these 304 adenovirus positive specimens, 184 were by virus isolation and 184 by immunofluorescence assay, among which 64 were positive by both methods. The types of the adenoviruses were tested for 285 patients including 174 viral isolates and 111 clinical specimens. By using the multiplex nest-PCR, 272 were typable, including 174 (61.1%, 174/285) for ADV3, 92 (32.3%, 92/285) for ADV7, 6 for ADV11 (2.1%, 6/285) and no adenovirus type 21 was detected. Sequence analysis for those 13 nontypable specimens by the multiplex nest-PCR showed that 9 were ADV2 (3.2%, 9/285), 2 were ADV6 (0.7%, 2/285), 1 was ADV1 (0.4%, 1/285) and 1 was ADV5 (0.4%, 1/285). Most of the patients positive for adenovirus were under 5 years of age and 64.4% were from patients with lower respiratory infections, such as bronchiolitis and pneumonia. All the 5 cases of severe pneumonia with pulmonary failure were caused by ADV7 infection. CONCLUSION: Adenovirus is still an important pathogen for acute respiratory infection in infants and young children and most of the adenoviruses associated with acute respiratory infections in children in Beijing from 2003 to 2008 were ADV3 and ADV7. ADV7 could cause severe lower respiratory infections.

[Pectoralis major myocutaneous flap for repairing large tissue defects following oral cancer surgery].

OBJECTIVE: To investigate the method for reconstruction of large tissue defects following surgical resection of advanced oral cancer using pectoralis major myocutaneous flap. METHODS: From 2005 to 2009, 40 patients with advanced oral cancer received extensive surgical resection of oral cancer, and the intraoral defects were reconstructed using pectoralis major myocutaneous flaps. RESULTS: All the flaps survived except one flap with partial necrosis. CONCLUSION: Pectoralis major myocutaneous flap is effective for reconstruction of large tissue defects after resection of advanced oral cancer.

[Evaluation of forest ecosystem services value in Liaoning Province].

Based on the long-term located observation of forest ecosystem, and by using the 2006 forest resources inventory data of Liaoning Province and the forest industry standard of the People's Republic of China( LY/T 1721-2008, specification for assessment of forest ecosystem services in China), an evaluation was made on the material quantity and services value of main forest ecosystems in fourteen cities of Liaoning Province. In this province, the forest ecosystem services value supplied by water storage, soil conservation, C fixation, O2 release, nutrients accumulation, environment purification, biodiversity conservation, and forest recreation in 2006 was 2591.72 x 10(8) yuan, which was 8.54 times of the forestry production value and 28.02% in the GDP of the province. The services value of water storage, biodiversity conservation, C fixation, and O2 release occupied 79.09% of the total, being the main forest ecosystem services in the province. Economic forest and shrub had smaller per unit services value but larger area, and hence, their ecosystem services value should not be ignored. Abies fargesii forest, Phellodendron amurense forest, Juglans mandshurica forest, and Fraxinus mandshurica forest were the representative zonal vegetations in Liaoning Province, which had high value in biodiversity conservation. Under the effects of climate and other factors, the forest area and forest quality in west Liaoning were lower than those in east Liaoning.

[Study on the association of hand, foot and mouth disease and enterovirus 71/CA16 among children in Beijing, 2007].

OBJECTIVE: To reveal the etiological agent of hand, foot and mouth disease in children in Beijing. METHODS: Throat swabs were collected from 6 infants and young children with hand, foot and mouth disease who visited the affiliated Children's Hospital from May to June 2007. Aspirated fluid from tracheal intubatton, serum and cerebral spinal fluid (CSF) were collected from a 9 years old girl (No.4243) having central neural system complication of severe hand, foot and mouth disease and admitted to the hospital from the Emergency Department. Throat swab and aspirated fluid were inoculated into the cell lines Hep-2, MDCK and Vero for virus isolation. RNAs were extracted by Trizol from 6 throat swab specimens and aspirated fluid, serum while CSF was from that severe case (No.4243). The gene fragment from 5' UTR of enterovirus was amplified from throat swabs and aspirated fluid by reverse transcription-polymerase chain reaction (RT-PCR) with the primer pairs located at the untranslated region of all enterovirus. EV71 was identified by RT-PCR with the 2 and half primer pairs located at different parts of VP1 gene of EV71. The PCR products for VP1 encoding gene of EV71 from the specimens were sequenced and sequence analysis was performed by comparing those published VP1 genes of EV71. EV71 and CA16 specific primers were used to identify the isolates by RT-PCR and the sequences were directly determined from PCR products. RESULTS: Gene fragments with expected molecular weight were amplified from all 6 throat swabs and the aspirate by the primer pairs universal for the 5' UTR of enterovirus, suggesting that these patients with hand, foot and mouth disease were infected by entorovirus. Out of these 7 specimens, 2 throat swabs and the aspirate were also showing positive for the VP1 of the EV71 by different primer sets. Sequence analysis revealed that the sequences for the amplicons from 1 throat swab (No. F4211) and the aspirate shared highest homology with those published EV71, indicating that these specimens were truly positive for EV71. The sequences amplified from these specimens shared 100% and 98.9% homology to each other and were closer to the sequences of EV71 identified from Zhejiang province than those from Taiwan and strain BrCr. Gene fragments for 5' UTR of enterovirus were obtained by RT-PCR after CPE appeared in 6 out of 7 inoculations including that aspirate fluid in Vero cell, indicating that enteroviruses were isolated from these specimens. Virus isolates from one throat swab (No. F4211) and the aspirate (No. 4243) were positive by RT-PCR with the primer pairs for EV71, which was consistent with RT-PCR amplification directly from specimens. Virus isolates from other 4 specimens were CA16 by RT-PCR and sequence analysis. CONCLUSION: These data suggested that hand, foot and mouth disease recently appeared in children in Beijing was related with EV71 and CA16. EV71 could cause severe clinical manifestations with central nerve system complications even in the child older than 5 years.