急性脑卒中三级康复的功能结局和经济学评价

目的探讨三级康复方案对急性脑卒中患者功能恢复的影响，并进行相关的临床经济学分析。方法将100例急性脑卒中患者以随机方式分为康复组50例，对照组50例。2组均进行神经内科常规治疗，康复组患者在急性期至6个月末进行规范的康复治疗，包括运动疗法、作业疗法和言语治疗等（神经内科．康复医学科．社区康复组成的三级医疗方案）。每组人选病例均于人选时及3个月末、6个月末时采用功能综合评定量表（FCA）评定疗效。比较2组在6个月病程中的相关费用，并进行成本-效果分析。用多元回归分析总费用的影响因素。结果病程3个月和6个月时2组患者的功能状况均有不同程度的改善（P〈0．05），其中康复组患者功能改善程度较大，与对照组相比差异有统计学意义（P〈0．05）。3个月康复组的直接医疗费用和总费用和对照组比较相对较高，6个月康复组的直接医疗费用仍高于对照组，但总费用2组差异无统计学意义（P〉0．05）。康复组3个月和6个月FCA评分每提高1分，花费的直接医疗费用和总费用康复组均低于对照组。3个月和6个月总费用的主要影响因素包括住院时间、医药费用支付方式和人组FCA评分，其中住院时间是最强的影响因素，住院时间最主要影响人组FCA评分。结论三级康复方案对急性脑卒中患者综合功能的恢复具有良好的促进作用，并有更好的经济学效应。     

急性脑卒中康复治疗的成本-效果分析

目的探讨急性脑卒中三级康复方案的经济有效性。方法将2002年1月1日至2003年12月31日住院的符合入选条件的急性脑卒中患者80例,随机分为康复组和对照组,康复组给予规范的三级康复治疗,对照组不进行任何康复治疗,但不排除自行的传统康复(如针灸、推拿等),2组均采用常规的内科治疗;在入选时及发病后1,3,6个月末用简化Fugl-Meyer运动功能评定法(FMA)、改良Barthel指数评定法(MBI)、综合功能评定法(FCA)分别进行评定,并计算三级康复治疗的总成本,包括直接医疗成本、间接医疗成本、间接成本,进行成本-效果分析。结果入选时康复组与对照组各项测评量表的差异无统计学意义(P>0.05);康复组经过规范的三级康复治疗后,各项测评量表的评分明显高于对照组,差异有统计学意义(P<0.01),各项测评量表评分的增加值也明显高于对照组(P<0.01)。康复组患者的总费用(人民币元)为(32228.11±2723.24)元,对照组为(33593.57±6584.97)元,2组差异无统计学意义(P>0.05),但康复组各项测评量表每增加一分所需费用比对照组少,2组差异有统计学意义(P<0.05)。康复组与对照组比较,运动功能评分每增加1分,少花费33.8元;日常生活能力评分每提高5分,少花费243.19;综合功能评分每增加1分,少花费64.03元。结论急性脑卒中三级康复方案是一种既经济又有显著疗效的康复治疗方案。     

三级康复整体护理方案对脑卒中偏瘫患者运动功能康复的影响

目的：探索三级康复整体护理方案对于脑卒中偏瘫患者运动功能康复的影响。方法：将129例脑卒中患者随机分为护理组、康复组和对照组各43例,三组患者常规内科治疗,康复组在此基础上接受三级康复治疗,护理组在康复组的基础上给予三级康复整体护理。在脑卒中发病后2周内、1个月末、3个月末及6个月末采用Fugl-Meyer运动功能评定量表评价患者的肢体运动功能。结果：护理组在1个月末、3个月末及6个月末的运动功能评分明显优于对照组,3个月末与6个月末的运动功能评分优于康复组（P均〈0.05）;护理组患者各阶段运动功能评分的差值明显高于对照组,3个月末与入选时和6个月末与入选时的运动功能评分差值高于康复组（P均〈0.05）。结论：实施三级康复整体护理方案能够有效地促进脑卒中偏瘫患者运动功能恢复。     

冠状动脉旁路移植术后序贯性机械通气20例治疗效果观察与护理

目的：探讨三级康复整体护理方案对脑卒中偏瘫患者神经功能缺损程度及日常生活能力（ADL）的影响。方法：将129例脑卒中患者随机分为护理组、康复组和对照组各43例,三组均给予常规内科治疗、护理,康复组接受三级康复治疗,护理组在康复组的基础上给予三级康复整体护理;在脑卒中发病后2周内、1个月末、3个月末及6个月末采用美国国立卫生研究院脑卒中量表（NIHSS量表）、改良的Barthel指数评价患者临床神经功能缺损程度、日常生活能力恢复情况。结果：护理组患者在1个月末、3个月末及6个月末的NIHSS评分、MBI评分明显优于对照组（P〈0.05）,3个月末与6个月末的NIHSS评分、MBI评分明显优于康复组（P〈0.05）。结论：实施三级康复整体护理方案能够有效地降低脑卒中偏瘫患者神经功能缺损程度,提高ADL。     

社区康复对脑卒中患者功能和生存质量的远期疗效观察

目的：应用功能综合评定量表(FCA)和WHO生存质量测定简式量表(WHOQOL-BREF)中文版研究社区康复（CBR）对脑卒中患者功能和生存质量(QOL)的远期疗效。方法：80例脑卒中患者随机分为社区康复组(40例)和对照组(40例),社区康复组进行康复治疗和随访,对照组只进行随访。于入组时、5个月末和17个月末,采用FCA、WHOQOL-BREF中文版对两组患者进行评定。结果：入组时两组患者FCA和WHOQOL-BREF评分差异无显著意义（P＞0.05）,治疗5个月后,社区康复组和对照组的FCA和WHOQOL-BREF评分比较,康复组效果优于对照组（P＜0.05）,17个月后康复组有进一步提高（P＜0.05）,而对照组改善不明显（P＞0.05）。结论：社区康复治疗对提高脑卒中患者FCA和WHOQOL-BREF作用显著;社区康复治疗介入时间越早,脑卒中患者功能和生存质量恢复的作用越明显。     

规范三级康复治疗脑卒中偏瘫患者的临床疗效研究

目的探讨规范三级康复治疗对脑卒中偏瘫患者综合功能的临床疗效。 方法选择80例脑卒中患者，男性58例，女性22例；年龄（62.94±8.59）岁。用随机化的方法分为康复组和对照组（对照组中1例脑出血伴发重症胰腺炎患者死亡，1例脑缺血患者进食时窒息死亡），两组均用相同的内科治疗方案，康复组在此基础上增加规范的三级康复治疗技术。两组患者一般资料比较，差异无统计学意义（P&rt;0.05）。两组患者疗效标准采用简化Fugl-Meyer运动功能评定法（FMA）、改良Barthel指数评定法（MBI）和综合功能评定法（FCA）。在入选时（V0）、发病后1个月末（V1）、3个月末（V2）、6个月末（V3）分别进行评定。所有数据均用（x-±s）表示，采用SPSS 10.0软件进行统计分析，组间比较采用t检验。 结果入选时康复组与对照组各项评分差异无统计学意义（P＞0.05），康复组经过规范的三级康复治疗后，各阶段（1个月末、3个月末、6个月末）各项评分明显高于对照组，差异有统计学意义(P<0.01），各阶段各项评分的积分差值也明显高于对照组（P<0.01）。 结论规范三级康复治疗对脑卒中偏瘫患者各阶段综合功能有显著的临床疗效。     

脑卒中患者三级康复治疗6个月间的成本-效果研究

目的：对脑卒中患者三级康复治疗方案作成本-效果的经济学分析评价。方法：按分层区组随机化的方法将82例脑卒中患者随机纳入到康复组和对照组，康复组在常规内科治疗基础上给予规范的三级康复治疗，对照组仅一般的常规内科治疗．分别采集两组患者自发病到发病后6个月的直接医疗费用、直接非医疗费用和间接费用，以及各费用的详细费用构成。对于每例样本在入选时（V0）和第六个月月末（V3）分别采用功能综合评定量表进行功能评价。结果：康复组患者运动功能每提高1分，则需要消耗的住院相关费用、西药费、规范的康复费、总的康复费、直接医疗费和总的成本费用分别为：￥314．90、￥133．79、￥100．12、￥187．49、￥579．25和￥851．65，认知功能每提高1分消耗的成本费用分别为：￥1905．36、￥809．50、￥605．82、￥1134.48、￥3504．94和￥5153．17，综合功能每提高1分消耗的成本费用分别为：￥272．85、￥115．92、￥86．75、￥162．46、￥501．92和￥737．95。不管是运动功能、认知功能，还是综合功能每提高1分，康复组所耗费的成本费用明显较对照组为低，对照组约是康复组的2-3倍。结论：三级康复治疗是一种经济的、有效的脑卒中患者的康复治疗方案。     

脑卒中后社区三级康复治疗的卫生经济学评价

目的：对脑卒中后社区三级康复治疗服务模式进行成本-效果分析。方法：将49例脑卒中患者按社区随机分为康复组和对照组,康复组在常规内科治疗的基础上给予规范的社区三级康复治疗,对照组给予常规内科治疗,没有进行规范的社区康复治疗。分别在入组时、2个月末和5个月末应用临床神经功能缺损程度量表(clinical neural impairment measures scale,NIM)进行神经功能评定,并进行费用调查。结果：规范的社区三级康复治疗2个月末和5个月末,康复组患者的NIM评分分别平均降低了3.26分和4.74分,对照组平均降低了1.08分和1.84分,康复组患者改善程度均显著优于对照组（P<0.01）。在2个月末和5个月末,康复组NIM每降低1分需要的总费用、直接医疗成本、康复治疗费、西药费用分别为￥752.82,￥447.75 ,￥199.89 ,￥241.99和￥1176.76,￥647.01,￥255.52,￥382.22;对照组每提高1分需要相关费用分别为￥2760.36,￥1443.69,￥358.30 ,￥1072.06和￥3899.72,￥1988.45,￥503.91,￥1475.41。对照组约是康复组各项相关费用的2—3倍。结论：社区三级康复治疗服务模式是经济有效的脑卒中社区康复治疗方案。     

脑卒中恢复期患者个体化主动康复在社区的推广研究

探讨个体化主动康复对脑卒中恢复后期患者功能康复的影响,观察其在社区推广应用的效果。方法：脑卒中恢复后期患者75例,随机分为机构传统康复组（A组）、机构个体化主动康复组（B组）和社区个体化主动康复组（C组）,分别进行对应的干预治疗并评价其效果。结果：治疗4周后,3组患者的功能综合评定量表（FCA）评分均较治疗前明显提高（P〈0．05）,且B、C组明显高于A组（P〈0．05）,B、C组间比较差异无统计学意义。结论：个体化主动康复比传统康复训练更能有效改善脑卒中恢复后期患者的功能;对于脑卒中恢复期患者,在机构康复和在社区康复的效果相当。     

自我强化主动活动对偏瘫患者生活独立性的影响

目的：探讨自我强化主动活动对脑卒中患者日常生活独立性的影响。方法：脑卒中偏瘫患者49例随机分为传统时间康复组（A组）24例和自我强化康复组（B组）25例,2组均进行8周的个体化主动康复治疗,B组增加除传统治疗时间之外的剩余时间主动活动,2组均采用综合功能评定（FCA）和生存质量（WHOQOL-BREF）测定。结果：治疗8周后,2组FCA运动功能、认知功能、总分及WHOQOL-BREF评分均明显高于治疗前（P＜0．05,0．01）,且B组更高于A组（P＜0．01）,结论：自我强化主动康复治疗能更明显改善脑卒中恢复后期患者的 FCA总分,生存质量也有明显提高。     

创伤高血糖与感染和MODS早期诊断和干预

本文详细介绍了创伤后血糖应激适度理论,以及高血糖与感染和多器官功能不全综合征的关系;提出涉及胰岛B细胞功能不全的MODS实验诊断新方案和极化液个体化干预新措施,可早期发现创伤MODS、降低感染率及MODS发生率和病死率。     

腹膜后纤维化与肾积水发生关系的临床研究

目的：探讨腹膜后纤维化（RPF）导致肾积水的原因及诊治经验。方法：回顾分析2004年1月—2010年12月24例腹膜后纤维化致肾积水患者的诊治资料。结果：（1）RPF患者常见首发症状为腰背痛或腹痛（69.2%）;（2）红细胞沉降率（ESR）增快和血清IgG4升高最常见。超声检查仅提示上尿路积水。RPF的静脉肾盂造影（IVP）和CT尿路成像（CTU）表现具有特征性。IVP肾盂输尿管显影不良时,CTU能较清晰的显示上尿路影像。CT扫描发现腹膜后软组织肿块9例（37.5%）,优于超声检查;（3）输尿管松解和腹腔化手术治疗22例;行肾切除术1例;行输尿管置双J管术1例。最终确诊为继发性RPF8例,其中4例为术前诊断,3例为术中腹膜后软组织肿块冷冻活检证实,1例为术后病理证实;（4）特发性RPF手术后肾积水均获长期缓解,而继发性RPF的预后取决于原发疾病及其治疗方案。结论：影像学检查是诊断RPF的重要手段,CTU优于超声检查和IVP。输尿管松解和腹腔化手术可以使特发性RPF输尿管梗阻得到长期的缓解,术中对肿块进行冷冻活检有助于鉴别特发性和继发性RPF,及时调整治疗方案。     

Fibrinogen and fibrin structure and functions

Fibrinogen molecules are comprised of two sets of disulfide-bridged Aalpha-, Bbeta-, and gamma-chains. Each molecule contains two outer D domains connected to a central E domain by a coiled-coil segment. Fibrin is formed after thrombin cleavage of fibrinopeptide A (FPA) from fibrinogen Aalpha-chains, thus initiating fibrin polymerization. Double-stranded fibrils form through end-to-middle domain (D:E) associations, and concomitant lateral fibril associations and branching create a clot network. Fibrin assembly facilitates intermolecular antiparallel C-terminal alignment of gamma-chain pairs, which are then covalently 'cross-linked' by factor XIII ('plasma protransglutaminase') or XIIIa to form 'gamma-dimers'. In addition to its primary role of providing scaffolding for the intravascular thrombus and also accounting for important clot viscoelastic properties, fibrin(ogen) participates in other biologic functions involving unique binding sites, some of which become exposed as a consequence of fibrin formation. This review provides details about fibrinogen and fibrin structure, and correlates this information with biological functions that include: (i) suppression of plasma factor XIII-mediated cross-linking activity in blood by binding the factor XIII A2B2 complex. (ii) Non-substrate thrombin binding to fibrin, termed antithrombin I (AT-I), which down-regulates thrombin generation in clotting blood. (iii) Tissue-type plasminogen activator (tPA)-stimulated plasminogen activation by fibrin that results from formation of a ternary tPA-plasminogen-fibrin complex. Binding of inhibitors such as alpha2-antiplasmin, plasminogen activator inhibitor-2, lipoprotein(a), or histidine-rich glycoprotein, impairs plasminogen activation. (iv) Enhanced interactions with the extracellular matrix by binding of fibronectin to fibrin(ogen). (v) Molecular and cellular interactions of fibrin beta15-42. This sequence binds to heparin and mediates platelet and endothelial cell spreading, fibroblast proliferation, and capillary tube formation. Interactions between beta15-42 and vascular endothelial (VE)-cadherin, an endothelial cell receptor, also promote capillary tube formation and angiogenesis. These activities are enhanced by binding of growth factors like fibroblast growth factor-2 (FGF-2) and vascular endothelial growth factor (VEGF), and cytokines like interleukin (IL)-1. (vi) Fibrinogen binding to the platelet alpha(IIb)beta3 receptor, which is important for incorporating platelets into a developing thrombus. (vii) Leukocyte binding to fibrin(ogen) via integrin alpha(M)beta2 (Mac-1), which is a high affinity receptor on stimulated monocytes and neutrophils.     

Migraine and genetic and acquired vasculopathies

It is remarkable that migraine is a prominent part of the phenotype of several genetic vasculopathies, including cerebral autosomal dominant arteriopathy with subcortical infarcts and leucoencephalopathy (CADASIL), retinal vasculopathy with cerebral leukodystrophy (RVCL) and hereditary infantile hemiparessis, retinal arteriolar tortuosity and leukoencephalopahty (HIHRATL). The mechanisms by which these genetic vasculopathies give rise to migraine are still unclear. Common genetic susceptibility, increased susceptibility to cortical spreading depression (CSD) and vascular endothelial dysfunction are among the possible explanations. The relation between migraine and acquired vasculopathies such as ischaemic stroke and coronary heart disease has long been established, further supporting a role of the (cerebral) blood vessels in migraine. This review focuses on genetic and acquired vasculopathies associated with migraine. We speculate how genetic and acquired vascular mechanisms might be involved in migraine.     

Telemedicine and teleradiology technologies and applications

Summary. Telemedicine and teleradiology hold the key for improving future health care delivery. In this paper we first review current communication and computer technologies used in telemedicine and teleradiology. Five examples in teleradiology applications are given including hospital-integrated picture archiving and communication systems, tele-neuro-imaging, telemammography, university consortium teleradiology service, and teleradiology for second opinion. Parameters important to teleradiology applications like costs, image quality, system reliability, and turn around time are considered. Data security is discussed, including patient confidentiality and image authenticity-which will be a major issue in future teleradiology applications.     

Physician and Nurse Practitioner Teamwork and Job Satisfaction: Gender and Profession

Designing interprofessional primary care teams composed of physicians and nurse practitioners (NPs) is a national priority. We assessed how profession and gender affect teamwork and job satisfaction among primary care physicians and NPs by using survey data from 186 physicians and 398 NPs practicing in New York State. Our regression models show profession (NP vs physician) moderates the associations of gender with teamwork and job satisfaction. Among NPs, men had higher job satisfaction than women. Among physicians, women had higher job satisfaction than men. Our results can benefit interprofessional primary care teams to optimize their professional and gender mix.     

Acetaminophen and acetylcysteine dose and duration: Past,present and future

Abstract

Acetylcysteine has been utilized successfully in the treatment of acetaminophen overdose since the 1970s. Although prospective trials as to efficacy and safety of acetylcysteine were conducted, there were no randomized controlled trials. This commentary addresses the reasons for this, and the background to choice of dose of acetylcysteine utilized in the oral and IV dosing regimens. Nomograms to predict possible hepatotoxicity based upon time of ingestion of acetaminophen were developed from a relatively arbitrary definition of toxicity as an aspartate aminotransferase/alanine aminotransferase (ALT/AST) greater than 1000 IU/L. While these have proved generally useful, patients still continue to develop hepatic damage after acetaminophen overdose, particularly if they present late after ingestion. The optimum management of these patients remains unclear, and one area of uncertainty is the dose and duration of acetylcysteine in various circumstances. This article discusses the issues that need to be elucidated to better target changes in acetylcysteine dose. The potential for measurements of other markers to improve treatment selection is the subject of further research.     

Trust and distrust between patient and doctor

To trust someone is to have expectations of their behaviour; distrust often involves disappointed expectations. But healthy trust and distrust require a good understanding of which expectations are reasonable, and which are not. In this paper, I discuss the limits of trustworthiness by drawing on recent studies of trust in the context of defensive medicine, biobanking and cardiopulmonary resuscitation decisions.     

妊娠合并血小板减少症与心、肝、肾脏器损伤

目的探讨妊娠合并血小板减少症伴随重要脏器的损伤情况。方法前瞻性研究我院及北华大学附属医院2004年10月至2005年5月妊娠合并血小板减少症的临床资料，对41例妊娠合并血小板减少症者尿素氮（BUN）、肌酐（CREA）、谷丙转氨酶（ALT）、乳酸脱氢酶（LDH）的测定及妊娠期高血压疾病与血小板计数（PLT），血小板平均体积（MPV）和血小板体积分布宽度（PDW）参数的测定进行对比分析。结果妊娠合并血小板减少症患者心、肝、肾等重要脏器均有不同程度的改变，且随着血小板计数降低，损害程度加剧，差异具有显著性（P〈0．01）。妊娠期高血压疾病，随着疾病程度的加重，血小板计数较正常孕妇明显减少，MPV、PDW明显升高，有显著性差异（P〈0．01）。结论血小板参数是判断疾病的重要参考指标，肝、肾、心脏器损伤程度与血小板计数具有相关性。