老年脑梗死患者下呼吸道医院感染直接经济损失研究

目的 研究老年急性脑梗死患者发生下呼吸道医院感染的直接经济损失,明确引起经济损失的各 项费用来源。 方法 采用回顾性调查分析的方法,调查2012年1月至2013年6月于老年病科住院的急性脑梗死患者 285例,选择下呼吸道医院感染患者和无医院感染患者,根据配对条件配成35对,包括病例组（下呼 吸道医院感染组）和对照组（未发生医院感染组）,比较两组间各项住院费用的差异。 结果 病例组医疗费用中位数14 193元,对照组11 913元,两组差异有显著（Z=－5.159,P＜0.001）; 住院费用中,支出费用最多是药品费用,病例组药品费用中位数8801元,对照组6642元（Z=－5.143,P ＜0.001）;病例组较对照组住院日延长,差异有显著性（Z=－5.179,P＜0.001）。 结论 老年脑梗死患者发生下呼吸道医院感染增加了直接经济损失。     

重型颅脑损伤患者颅内压、脑灌注压监护的探讨

目的 探讨重型颅脑损伤患者颅内压(Intracrania Press ,ICP)和脑灌注压(Cerebral Perfusion Pressure , CPP)监护的作用.方法 选择40例重型颅脑损伤患者随机分为2组,监护组患者入院或开颅手术后行ICP、CCP监护;对照组患者根据常规神经外科治疗,未行ICP、CCP 监护.结果 监护组在脱水剂应用时间、剂量及并发症方面均低于对照组,2组差异有显著性(P＜0.01),预后监护组优于对照组(P＜0.01).结论 对重型颅脑损伤患者行连续性ICP、CPP监护,可及时发现颅内继发性病变,有利于指导和及时调整治疗措施,降低并发症,提高预后.     

术中颅内压监测在治疗重型颅脑创伤中的应用

目的 探讨术中持续颅内压(ICP)监测在治疗重型颅脑创伤患者中的应用价值.方法 对我科2008年3月至2010年3月收治的58例重型颅脑创伤患者的术中ICP监测结果进行分析.根据预后情况分为较好组(GOS 4 ～5分)和较差组(GOS1 ～3分),分析并比较两组患者开颅术中ICP的波动规律及其对手术操作和预后的影响.结果 两组间手术初始、去除骨瓣后及关颅术后的ICP均值以及两组各步骤间ICP波动变化差异有统计学意义(P＜0.01).结论 术中ICP监测在治疗重型颅脑外伤患者中有助于及时发现问题,指导治疗及评估预后,具有重要的临床应用价值.     

颅内压监测对重型创伤性颅脑损伤患者临床疗效的Meta分析

目的系统评价持续颅内压(ICP)监测对重型颅脑损伤(TBI)患者疗效与安全性的影响。方法计算机检索Cochrane Library、MEDLINE、EMbase、CNKI、万方等数据库,收集符合纳入标准的研究,检索时限均为从建库至2015年3月,并追溯纳入研究的参考文献和手工检索相关会议资料。由两位研究者按照纳入与排除标准独立筛选文献、提取资料和评价质量后,采用Rev Man5.2软件进行Meta分析。结果共纳入1个随机对照研究,11个病例对照研究。Meta分析结果显示,与传统的临床和影像学监测对照组相比,ICP监测组的病死率并未显著降低,OR=0.87,95%CI(0.62,1.22),P=0.42。亚组分析结果显示,在经济发达及欠发达地区,ICP监测组与对照组的病死率相比,差异无统计学意义。2012年以后发表的文献合并OR值显示,ICP监测可显著降低病死率,OR=0.61,95%CI(0.39,0.95),P=0.03;ICP监测组与对照组ICU病死率及6个月的病死率相比,差异均无统计学意义;仅2周的病死率显著减少,OR=0.52,95%CI(0.40,0.68),P0.01。结论对于重型TBI患者,持续ICP监测的临床疗效受多方面因素的影响,统一研究对象的纳入标准及ICP的规范化应用将会得出更为可靠的临床结论。     

北京市城区精神病医院焦虑障碍患者疾病经济负担的初步调查

目的 探讨焦虑障碍患者的疾病经济负担,为制定有效的疾病防治策略提供经济学依据.方法 采用卫生经济学方法,通过自行设计的门诊和住院焦虑障碍患者疾病经济负担调查问卷,回顾性收集北京市城区焦虑障碍患者的疾病经济负担资料,测算其直接经济负担和间接经济负担.结果 (1)焦虑障碍患者的年人均疾病经济负担为16 509元,其中直接经济负担占63.5%(10 490元),间接经济负担占36.5%(6019元);(2)患者的单次门诊费用中位数为254元,单次住院费用中位数为16 893元;(3)二级精神病医院的患者单次门诊费用中位数为145元,三级精神病医院的患者单次门诊费用中位数为546元.结论 焦虑障碍给患者及其家庭带来沉重的疾病经济负担.     

颅内压监测及脑脊液乳酸水平对重型颅脑损伤患者预后预测研究

目的探究颅内压(ICP)监测与脑脊液乳酸水平在重型颅脑损伤患者预后评估中的应用价值。方法选取2016年2月～2017年8月于我院神经外科ICU治疗的重型颅脑损伤患者80例为研究对象,根据预后情况分组,预后良好组(轻、中度残疾)21例,预后不良组(重残及植物生存)44例,死亡组15例。对比不同预后患者住院期间ICP监测情况及脑脊液乳酸水平,探究ICP、脑脊液乳酸水平与重型颅脑损伤患者预后的相关性。结果不同预后组患者ICP最高值、ICP平均值及脑脊液乳酸水平的差异均有统计学意义(P0.05),其中预后良好组ICP最高值、ICP平均值及脑脊液乳酸水平显著低于预后不良组,预后不良组ICP最高值、ICP平均值及脑脊液乳酸水平显著低于死亡组,差异有统计学意义(P0.05)。Logistical单因素回归分析显示,ICP最高值、ICP平均值及脑脊液乳酸水平均可预测重型颅脑损伤患者预后,ICP最高值、ICP平均值及脑脊液乳酸水平升高均为预后不良的独立性危险因素(OR值=2.439、7.584、3.898,P0.05)。结论持续颅内压及脑脊液乳酸水平监测对重型脑损伤患者预后具有较好的评估价值,值得临床推广。     

临床快捷护理路径在重型颅脑外伤患者中的应用价值

目的探讨临床快捷护理路径在重型颅脑外伤患者中的应用价值。方法选取我院收治的52例重型颅脑外伤患者,随机均分为对照组(常规护理)和观察组(临床快捷护理路径),比较2组患者抢救时间、抢救费用、住院时间、住院费用和并发症发生率的差异。结果观察组抢救时间、抢救费用和住院时间均显著少于对照组(P0.05);2组患者住院费用比较无显著差异(P0.05);观察组并发症发生率19.2%,显著低于对照组的53.8%(P0.05)。结论在重型颅脑外伤患者中应用临床快捷护理路径效果确切,可显著缩短抢救时间,降低并发症发生率,值得临床推广使用。     

颅内压及中心静脉压监测在脑水肿治疗中的应用

目的探讨联合监测颅内压(ICP)及中心静脉压(CVP)在重型颅脑损伤患者伤后脑水肿治疗中的临床应用价值。方法 45例重型颅脑颅脑损伤患者随机分为对照组(21例)及治疗组(24例)。对照组以常规治疗方法控制ICP;治疗组在常规治疗基础上,联合监测ICP及CVP,并根据监测结果调整治疗方案。治疗终结后随访半年,采用格拉斯哥预后评分(GOS)对患者恢复情况进行评分。结果治疗组1周内日均甘露醇用量较对照组显著减少(P0.01);治疗组GOS评分较对照组显著提高(P0.05)。结论 ICP及CVP联合监测既能保证ICP的精准调控,又能保证血容量的平衡,可改善重型颅脑损伤患者的预后。     

镇静镇痛对重型颅脑损伤患者术后颅内压的影响分析

目的探讨镇静镇痛对重型、特重型颅脑损伤（TBI）患者术后颅内压（ICP）的影响。 方法选取湖州市第一人民医院神经外科自2016年1月至2018年6月收治的重型TBI患者45例,根据GCS评分将患者分为重型TBI组（GCS评分6~8分,26例）与特重型TBI组（GCS评分3~5分,19例）,观察2组镇静镇痛下及撤除镇静镇痛/唤醒下ICP值波动情况。 结果特重型TBI患者在镇静镇痛前后ICP差异无统计学意义（P>0.05）,重型TBI患者撤除镇静镇痛/唤醒后,ICP前后变化差异有统计学意义（P<0.05）。 结论镇痛镇静与重型TBI开颅术后颅内压力波动有显著相关性,使用镇静镇痛可获得安全、平稳的ICP。     

重型颅脑损伤术中持续脑灌注压监测的意义

目的 探讨重型颅脑损伤(sTBI)患者术中持续脑灌注压(CPP)监测的意义.方法 解放军第一○一医院2009年6月至2011年12月收治的63例sTBI患者根据预后情况分为较好(GOS 4～5分)及较差(GOS 1～3分)两组,对两组患者术中CPP、平均动脉压(MAP)及颅内压(ICP)的变化进行相关性分析.结果 两组间ICP、CPP总体差异有统计学意义(P＜0.05),而两组间MAP总体差异无统计学意义(P＞0.05)；各组内ICP、MAP及CPP在不同时间点变化的差异有统计学意义(P＜0.05)；两组间ICP、MAP及CPP在不同时间点变化的差异有统计学意义(P＜0.05).结论 术中持续CPP监测有助于术者及时判断和处理术中出现的病情变化,对改善sTBI患者的预后可能有着积极的临床意义.     

Hepatic Considerations in the Use of Antiepileptic Drugs

Summary: Virtually all of the major antiepileptic drugs (AEDs) can cause hepatotoxicity, although fatal hepatic reactions are rare. The mechanisms, incidences, and risk profiles for such reactions differ from drug to drug. With carbamazepine and phenytoin, hepatotoxicity may be due to drug hypersensitivity. Although the profiles of patients at risk have not been well-defined for these two antiepileptic drugs, it would appear from reports in the literature that older adolescents and adults are at higher risk than children of developing serious or fatal hepatotoxicity. Once hepatotoxicity develops, mortality rates are 10–38% with phenytoin and 25% for carbamazepine. The risk profile for valproate fatal hepatotoxicity has been more clearly defined. Those at primary risk of fatal hepatic dysfunction are children under the age of 2 years who are receiving multiple anticonvulsants and also have significant medical problems in addition to severe epilepsy. The risk is considerably lower for patients over the age of 2 years on valproate monotherapy. In contrast to the risk profile with other AEDs, adults receiving valproate as monotherapy have the lowest risk of hepatotoxicity. Fatal hepatic dysfunction coincident with valproate may be the result of aberrant drug metabolism. Concomitant use of AEDs that induce microsomal P450 enzymes (e.g., phenytoin and phenobarbital) may enhance the production of a toxic metabolite, and hence the greater risk of hepatotoxicity with polypharmacy.     

Vascular Malformations and Epilepsy: Clinical Considerations and Basic Mechanisms

Summary: Vascular malformations (VMs) are associated with epilepsy. The natural history of the various VMs, clinical presentation, and tendency to provoke epilepsy determine treatment strategies. Investigations have probed the mechanisms of epileptogenesis associated with these lesions. Electrophysiologic changes are associated with epileptogenic cortex adjacent to VMs. Putative pathophysiologic mechanisms of epileptogenesis include neuronal cell loss, glial proliferation and abnormal glial physiology, altered neurotransmitter levels, free radical formation, and aberrant second messenger physiology.     

Diagnostic Difficulties and Treatment Implications

Summary: Differentiation between types of epileptic seizures has been aided in recent years by the introduction of intensive neurodiagnostic techniques and the development of increasingly detailed classification systems. Paradoxically, these developments have not simplified the task of matching the appropriate antiepileptic drug to a particular seizure type. It is reasonable to assume that anticonvulsant drugs will have different effects on different types of seizures, but faulty, circular reasoning can enter the picture if one also assumes that responses of seizures to different drugs signify different seizure types. There are several examples of differential diagnoses that can fall prey to this problem, including the diagnosis between partial seizures with secondary generalization and generalized tonic-clonic seizures, and the diagnosis between complex partial seizures and absence seizures with automatisms, among others. Considerations of etiology in future classification systems can further complicate the problem: should one then choose an anticonvulsant drug on the basis of individual seizure type or on the basis of the type of epilepsy? Ramifications of this issue extend even to the drug approval process. Official sanction is not given for use of a drug for a seizure type not included in the original efficacy studies, even if later scientific evidence shows that seizure type to be related to a type that is included. New trials must be undertaken. These problems arise from how we choose to classify seizures.     

Cognitive Dysfunction Associated with Antiepileptic Drug Therapy

Summary: Epilepsy is frequently associated with cognitive dysfunction. However, the reasons for this correlation are unclear. Possible influential factors include patient age; duration, frequency, etiology, and type of seizures; hereditary factors; psychosocial issues; and antiepileptic drug (AED) therapy. Whereas many of these factors are beyond the physician's control, AED therapy is one element that can be addressed in treatment decisions by recognizing the potential cognitive effects of particular AEDs. For example, phenobarbital impairs memory and concentration; phenytoin affects attention, problem solving ability, and performance of visuomotor tasks. In contrast, carbamazepine may affect concentration, while valproate would appear to have minimal effects on cognition. Moreover, cognitive effects of AEDs are amplified with coadministration of multiple anticonvulsants (polytherapy). A review of studies on the cognitive effects of monotherapy with AEDs, as opposed to those of polytherapy, provides evidence that drug-related cognitive dysfunction can be reversed if patients are switched to a simpler therapeutic regimen. Future research should be directed toward developing reliable measures for assessing and monitoring cognition, and understanding the particular cognitive side effects of each AED. Physicians also need to revise their opinions about which side effects are "tolerable" for epileptic patients.     

Epilepsy and anomalies of neuronal migration: MRI and clinical aspects

Neuronal migration disorders are the result of disturbed brain development. In such disorders, neurons are abnormally located. In diagnosing these conditions, magnetic resonance imaging is superior to any other imaging technique. This enables us to improve our knowledge of the clinical correlates of neuronal migration. With reference to migrational disorder, a retrospective study of all 303 patients with epileptic seizures referred for magnetic resonance imaging during a 3-year period was performed, 13 patients (aged 12-41, mean age 27) were identified. They represent 4.3% of the entire study group. Of the patients with known epilepsy, 6.7% and of the mentally retarded, 13.7% had migrational disorders. Four patients had schizencephaly as the dominant finding, one was classified as hemimegalencephaly, 2 had isolated heterotopias, and 6 had localized pachy- and/or poly-microgyria. The clinical pictures are complex. Ectopias of grey matter are recognised foci of epilepsy, but from an epileptological and a clinical viewpoint little attention has been given to these disorders. The present study shows that malmigration is not rare in epilepsy patients, especially not in the mentally retarded.     

Carbamazepine Efficacy and Utilization in Children

Summary: Carbamazepine is effective for preventing partial and generalized tonic-clonic seizures in children. Although absence epilepsies are more common in children than adults, an estimated 80% of children with epilepsy have seizure types or epilepsies that are potentially responsive to carbamazepine. The differential diagnosis of ictal staring is an especially important issue in children because absence and atypical absence seizures are more prevalent in children than adults. Age-related pharmacokinetic differences and drug interactions are major considerations in children. On average, children have higher clearance rates of carbamazepine, shorter half-lives, and higher ratios of carbamazepine-10, 11-epoxide to carbamazepine than adults. In addition, children with severe epilepsy are more likely to require multiple-drug therapy, which can lead to complex drug interactions. When carbamazepine is administered along with valproate, drug protein binding interactions can cause intermittent side effects.     

Carbamazepine Efficacy in Adults With Partial and Generalized Tonic-Clonic Seizures

Summary: Carbamazepine and phenytoin are drugs of choice in initial monotherapy for adult partial and secondarily generalized tonic-clonic seizures. These designations reflect the results of the Veterans Administration Epilepsy Cooperative Study Group of 1985. An earlier comparative study of carbamazepine and phenytoin by Ramsay and associates found both drugs equally effective in controlling new-onset seizures. Among the advantages of carbamazepine is that it causes relatively few cognitive and dysmorphic side effects. Its disadvantages are its unavailability in parenteral formulation and its metabolic autoinduction. The latter must be compensated for by planned dosage increases to maintain therapeutic plasma steady-state levels during the first 2 or 3 months of treatment. Carbamazepine is judged a drug of choice in the treatment of these secondarily generalized tonic-clonic seizures, and the drug of choice in children, adolescents, and women susceptible to the dysmorphic side effects associated with other anticonvulsant agents.     

Etiologic and Preventive Aspects of Epilepsy in the Child–Bridging the Gap Between Laboratory and Clinic

Summary: Four broad categories of basic phenomena are pertinent to developing ways to prevent epilepsy. These include mechanisms of epileptogenesis, ictal initiation and temporary entrainment by the seizure discharge of normally functioning brain, seizure propagation, and control mechanisms that function both to restrain the cascade of epileptic events culminating in a seizure and to arrest the epileptic event and restore the interictal state. In newborns and children, hypoxia-ischemia is a major factor leading to epileptogenesis, and several schemes are proposed to classify, quantify, and prevent hypoxic-ischemic encephalopathy. Control mechanisms must be better understood in order to develop prophylactic recommendations for epilepsy, and an experimental model of "kindling antagonism" may increase our understanding of these. Programs of prevention of seizures in children will evolve only if basic researchers and clinicians work productively together to develop an adequate understanding of factors important in epileptogenesis and antiepileptogenic control mechanisms.     

Classification of methods in transcranial Electrical Stimulation (tES) and evolving strategy from historical approaches to contemporary innovations

Transcranial Electrical Stimulation (tES) encompasses all methods of non-invasive current application to the brain used in research and clinical practice. We present the first comprehensive and technical review, explaining the evolution of tES in both terminology and dosage over the past 100 years of research to present day. Current transcranial Pulsed Current Stimulation (tPCS) approaches such as Cranial Electrotherapy Stimulation (CES) descended from Electrosleep (ES) through Cranial Electro-stimulation Therapy (CET), Transcerebral Electrotherapy (TCET), and NeuroElectric Therapy (NET) while others like Transcutaneous Cranial Electrical Stimulation (TCES) descended from Electroanesthesia (EA) through Limoge, and Interferential Stimulation. Prior to a contemporary resurgence in interest, variations of transcranial Direct Current Stimulation were explored intermittently, including Polarizing current, Galvanic Vestibular Stimulation (GVS), and Transcranial Micropolarization. The development of these approaches alongside Electroconvulsive Therapy (ECT) and pharmacological developments are considered. Both the roots and unique features of contemporary approaches such as transcranial Alternating Current Stimulation (tACS) and transcranial Random Noise Stimulation (tRNS) are discussed. Trends and incremental developments in electrode montage and waveform spanning decades are presented leading to the present day. Commercial devices, seminal conferences, and regulatory decisions are noted. We conclude with six rules on how increasing medical and technological sophistication may now be leveraged for broader success and adoption of tES.     

Treatment Considerations in Anticonvulsant Monotherapy

Summary: The long-standing practice of polypharmacy in treating epilepsy is giving way to use of monotherapy. Monotherapy can improve seizure control as well as reduce the risk of serious idiosyncratic reactions, dose-related side effects, and complex drug interactions. Monotherapy also offers improved compliance and cost-effectiveness. The basis of monotherapy is accurate diagnosis and assessment of the patient's seizure type(s), followed by selection of a single appropriate anticonvulsant drug. Many patients currently treated with multiple anticonvulsants can be successfully converted to monotherapy with a carefully monitored program in which troublesome and redundant drugs are gradually withdrawn from the therapeutic regimen.