住院精神分裂症患者临床路径管理效果评价

目的评价临床路径管理对住院精神分裂症患者疗效、费用、满意度的影响。方法选取2014年3月~2015年3月石河子绿洲医院住院治疗的204例精神分裂症患者资料进行分析,将患者根据随机数字方法分为研究组(101例)和对照组(103例),对照组患者治疗时行常规方法管理,研究组实施临床路径管理,比较两组患者护理效果、平均住院天数、住院总费用、日均费用、医患满意度。结果研究组住院总费用、日均费用、药费均显著少于对照组(P0.05);研究组患者满意度、医生满意度评分高于对照组评分(P0.05);研究组患者管理后BPRS评分高于对照组(P0.05);研究组管理疗效率高于对照组(P0.05)。结论临床路径管理有利于降低病人住院费用、提高医、患满意度,更好为精神分裂症病人服务。     

精神分裂症住院患者规范化综合治疗临床路径的研究

目的 评价临床路径应用于住院精神分裂症患者的效果.方法 将2008年8月至2009年10月在首都医科大学附属北京安定医院新住院精神分裂症患者135例,依据Rihaid Doll随机分配卡法随机分为临床路径组(研究组,65例)和传统治疗组(对照组,70名),研究组采用临床路径医疗护理方法,对照组采用传统医疗护理方法;评价指标为疗效、平均住院天数、平均住院费用和满意度.结果 研究组的平均住院天数显著低于对照组[(41 ±13)d:(47±12) d;t=-2.555,P=0.012],住院总费用显著低于对照组[(9685.70±4213.75)元:(11 192.61±4118.50)元;t=-2.101,P=0.038];研究组痊愈率、显好率、好转率分别为16.9％、47.7％、35.4％,对照组分别为11.4％、30.0％、58.4％,2组比较差异有有统计学意义(x2=7.284,P =0.026);患者满意度高于对照组( 100％:88.6％;x2=24.785,p=0.000).结论 临床路径应用于住院精神分裂症患者,可以明显缩短平均住院天数,降低住院费用,提高患者满意度.     

药物基因检测指导下采用阿立哌唑治疗精神分裂症的临床研究

目的:在药物基因检测的基础上,对服用阿立哌唑治疗的精神分裂症患者实施个性化治疗,探讨应用效果。方法:将符合诊断标准的精神分裂症患者随机分为研究组(根据药物基因检测结果优先使用,31例)与对照组(根据医师用药经验使用,40例),均予以阿立哌唑片治疗,于治疗前及治疗后1、2、4、8周对两组患者使用阳性与阴性症状量表(PANSS)评定临床疗效;治疗前后以自编问卷调查两组患者的服药依从性和家属满意度,以治疗中出现的症状量表(TESS)评定不良反应。结果:研究组PANSS在治疗后1、2、4、8周改善程度明显优于对照组(t=11.7169、15.3757、11.3608、12.6233,P均0.05);研究组患者服药依从性及家属满意度显著高于对照组(P均0.05);研究组不良反应发生率较对照组差异有统计学意义(χ~2=4.3915,P0.05)。结论:实施个性化的治疗及全病程精准管理,有利于减少药物的不良反应,促进精神分裂症患者快速有效恢复。     

电子社区管理对精神分裂症患者出院后康复的影响

目的:探讨电子社区管理对出院后恢复期精神分裂症患者康复的影响。方法:将临床"痊愈"出院的精神分裂症患者206例按出院顺序交替分为研究组102例和对照组104例;两组患者均给予抗精神病药维持治疗及常规出院指导,研究组在此基础上实施电子社区管理,观察1年。采用症状自评量表(SCL-90)、Momingside康复状态量表(MRSS)、服药依从性量表在入组时和1年后分别进行测评,评价患者的心理健康、服药依从性及复发率。结果:经电子社区管理1年后,研究组SCL-90各项评分(t=2.31~5.72)、MRSS各项评分(t=2.19~5.15)均明显低于对照组(P0.05或P0.01);服药依从性高于对照组(χ2=12.67,P0.01),复发率(28.43%)低于对照组(42.30%)(χ2=4.33,P0.05)。结论:电子社区管理能显著提高出院后精神分裂症患者的服药依从性、改善社会功能及降低疾病的复发率。     

奥氮平对首次发病精神分裂症患者血清叶酸、同型半胱氨酸和脑源性神经营养因子水平的影响

目的:探讨奥氮平治疗对首次发病精神分裂症患者血清叶酸(FA)、同型半胱氨酸(Hcy)和脑源性神经营养因子(BDNF)水平的影响。方法:给予首发精神分裂症患者(研究组,48例)奥氮平单药治疗12周;治疗前后检测血清FA、Hcy和BDNF水平,并与健康对照者(对照组,45人)比较。结果:治疗前研究组血清BDNF、FA水平明显低于对照组,Hcy明显高于对照组(t=4.912,10.544,8.250;P均0.05);治疗后血清BDNF、FA明显高于治疗前,Hcy明显低于治疗前(t=3.340,10.567,7.716;P均0.05);与对照组比较差异无统计学意义(t=0.378~0.920)。结论:奥氮平治疗对精神分裂症患者血清FA、Hcy和BDNF水平均有积极影响。     

过渡期护理模式对重度颅脑损伤患者的作用

目的探讨过渡期护理模式对于重度颅脑损伤患者的临床价值。方法选择172例重度颅脑损伤患者为研究对象,均经重症监护室(ICU)治疗后转入普通病房。随机均分为过渡期护理组86例和对照组86例。1周后对比2组不良事件发生率、焦虑抑郁状况以及平均出院时间、家属满意率。结果过渡期护理组不良事件发生率低于对照组,差异统计学意义(3.5%vs 16.3%,χ~2=7.898,P0.05);焦虑与抑郁发生率低于对照组,差异有统计学意义(4.7%vs 15.1%,χ~2=5.287,P0.05);平均住院时间比对照组短,差异有统计学意义(24.1±6.3vs 32.4±5.7,t=-9.060,P0.05);患者家属满意率高于对照组,差异有统计学意义(94.2%vs 80.2%,χ~2=7.505,P0.05)。结论实施过渡期护理模式可以改善重度颅脑损伤患者的心理状态,利于疾病的恢复,值得推广应用。     

利培酮合并赛来昔布治疗精神分裂症首次发病患者的随机双盲对照研究

目的 评估利培酮合并赛来昔布对精神分裂症首次发病(以下简称首发)患者的临床疗效及安全性.方法 符合美国精神障碍诊断与统计手册第4版诊断标准的精神分裂症首发住院患者90例,随机分到利培酮+赛来昔布组(研究组,46例)或利培酮+空白剂组(对照组,44例),观察时间均为12周.以阳性和阴性症状量表(PANSS)、临床疗效总评量表(CGI)、汉密尔顿抑郁量表(HAMD)评定临床疗效,以治疗中需处理的不良反应量表(TESS)、Simpson锥体外系副反应量表(SEPS)、异常不自主运动评定量表(MMS)评定药物不良反应和锥体外系副反应.结果 两组患者治疗前后比较,PANSS总分及各分量表分均明显下降(P均<0.05);研究组PANSS总分、分量表分、HAMD评分较对照组的降低更为明显,差异均有统计学意义(P均<0.05).研究组总有效率(66%)明显高于对照组(26%);X2=16.1,P=0.001.治疗第12周末,两组TESS、SEPS、MMS评分的差异均无统计学意义(P均>0.05);研究组患者体质量的增加(4±5)kg,明显高于对照组(1±4)kg,t=2.6,P<0.05.结论 赛来昔布可以提高利培酮对首发精神分裂症的疗效.     

利培酮单用与合并乙酰半胱氨酸治疗精神分裂症首次发病患者的对照研究

目的:探讨乙酰半胱氨酸(NAC)对利培酮治疗首发精神分裂症患者的辅助疗效以及对血脂代谢的影响。方法:采用随机双盲法将121例首次发病精神分裂症患者随机分为研究组61例和对照组60例,两组在利培酮治疗的基础上分别联合NAC和安慰剂,观察8周。于治疗前及治疗4周和8周时采用阳性和阴性症状量表(PANSS)评定疗效;同时检测体质量、血清总胆固醇(TC)、三酰甘油(TG)、低密度脂蛋白(LDL)水平,并对两组治疗前后变化进行比较。结果:治疗4周和8周后两组PANSS总分及各因子分均较治疗前明显降低(t=32.16~93.19,P均0.05);两组间比较,研究组(尤其阴性症状因子分)显著低于对照组(t=8.40;P0.05)。两组体质量治疗后均较治疗前显著升高(研究组:t=-5.62,t=-6.19;对照组:t=-6.20,t=-6.32),治疗前后比较,差异有统计学意义(P均0.05);两组间比较,差异无统计学意义(P0.05)。治疗后研究组TG、LDL、TC水平显著低于对照组,差异有统计学意义(t=3.97~13.51,P均0.05)。结论:利培酮单用或辅助NAC治疗可明显改善首发精神分裂症患者的精神症状;同时降低血TG、LDL、TC水平,但对体质量增加无影响。     

长期住院精神分裂症患者的孤独感与共情缺陷

目的探讨长期住院精神分裂症患者的孤独感和共情缺陷特征。方法采用病例对照研究,67例住院时间超过2年的精神分裂症患者为研究组,66例病史大于2年的门诊精神分裂症患者为对照组。所有受试完成一般情况调查表、感情-社会孤独量表(ESLS)和人际反应指针量表(IRI-C)。结果①两组性别、年龄、文化程度差异均无统计学意义(P均0.05);②研究组感情-社会孤独量表总评分高于对照组[(29.78±5.58)分vs.(27.16±3.79)分],差异有统计学意义(t=-3.17,P=0.002),情感孤独与社会孤独因子分也均高于对照组,差异有统计学意义(P均0.05);③研究组IRI-C总评分低于对照组[(31.39±11.02)分vs.(39.69±9.61)分],差异有统计学意义(t=4.61,P0.001),反映共情缺陷的"同情关心"因子评分研究组低于对照组[(9.21±3.46)分vs.(11.18±2.93)分],差异有统计学意义(t=3.55,P=0.001)。结论长期住院精神分裂症患者共情缺陷和孤独感明显,需鼓励患者回归社区以缓解孤独感,降低共情缺陷。     

男女儿童青少年精神分裂症患者临床特征的比较

目的:比较儿童青少年精神分裂症男性与女性患者临床特征的差异。方法:对125例男性(男性组)和133例女性(女性组)儿童青少年精神分裂症患者的年龄、发病年龄、病前诱因、阳性家族史、病程特点、住院天数、简明精神病量表(BPRS)、大体评定量表(GAS)及临床疗效总评量表(CGI)评分等临床特征进行比较。结果:男性与女性患者在年龄、发病年龄、病前诱因、阳性家族史、病程特点、住院天数方面比较差异无统计学意义(P均0.05)。BPRS评分中敌对性、动作迟缓、情感淡漠、缺乏活力因子分男性组高于女性组(t=2.164,t=3.317,t=2.096,t=2.230;P0.05或P0.01);幻觉、思维障碍因子分女性组高于男性组(t=3.682,t=2.987;P0.01或P0.001)。入院时GAS、CGI-SI评分及出院时CGI-GI评分两组间差异无统计学意义(P均0.05),出院时CGI-EI评分女性组高于男性组(t=2.466)、自知力评分男性组高于女性组(t=2.403),差异有统计学意义(P均0.05)。结论:男性儿童青少年精神分裂症患者的临床特征以情感淡漠、缺乏活力等阴性症状为主,女性则以幻觉、思维障碍等阳性症状更突出;女性临床疗效优于男性。     

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.     

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.     

Dextromethorphan: Cellular Effects Reducing Neuronal Hyperactivity

Summary: Dextromethorphan is a dextrorotary morphinan without affinity for opioid receptors, commonly used as an antitussive medication. During the past 5 years, interest in the compound and its demethylated derivative, dextrorphan, has been revived because additional neuroprotective and an-tiepileptic properties were found in in vitro studies, animal experiments, and a few clinical cases. Both morphinans are able to inhibit N -methyl-D-aspartate (NMDA) receptor channels and voltage-operated calcium and sodium channels with different potencies. The inhibition of the NMDA receptor is believed to be the predominant mechanism of action responsible for the anticonvulsant and neuroprotective properties of the compounds.     

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.     

Pediatric Epilepsy Surgery

Summary: The use of implantable arrays of epidural electrodes has made it possible to carry out extraoperative electrocorticography (ECoG) and functional localization in the awake child. This has permitted cortical excisions that are determined by criteria similar to those obtained during surgical procedures performed under local anesthesia in adults. In addition, the method also permits simultaneous ECoG and video monitoring during the child's symptomatic seizures, providing additional important localizing information that is impractical to obtain in operations under local anesthesia. We report our experience with 75 children, ages 5 months to 15 years, whom we have managed with epidural electrode arrays. The method of extraoperative ECoG is described and illustrative cases are presented to demonstrate its feasibility and utility in children. In addition, we call attention to gliomas as a common cause of chronic focal seizures in children. Of 49 children undergoing resection and followed for from 1 to 14 years (mean of 5.8 years), 32 (65%) are either seizure free or have had a significant reduction in seizure frequency that has unambiguously improved their quality of life. The results are analyzed further by relating the surgical outcome to each of the pathologic entities that caused the seizures. This analysis reveals the variety of neurological conditions that commonly cause intractable focal seizure disorder in children and distinguishes those pathologic entities in which the seizure disorder is apt to respond to surgical intervention from those that will not.     

Predisposing and Causative Factors in Childhood Epilepsy

Summary: We review information from large studies of defined populations, examining the role of known factors and especially of prenatal and perinatal factors in contributing to nonfebrile seizure disorders of early childhood. We depend especially, but not exclusively, on the recently completed analyses from the Collaborative Perinatal Project of the National Institute of Neurological and Communicative Disorders and Stroke, the NCPP. About 4% of children in the NCPP who had at least one non-febrile nonsymptomatic seizure by the age of 7 years had a previous seizure during acute neurologic illness, such as meningitis or during the acute illness after trauma. Many such seizures should potentially be preventable. Of children with seizures, 10% had had a neonatal seizure and 13% had had a febrile seizure. Among the hundreds of prenatal and perinatal factors explored as predictors of childhood seizure disorders, the principal predictors identified were congenital malformations of the fetus, cerebral and noncerebral; family history of certain neurologic disorders; and neonatal seizures. In agreement with the British National Child Development Study, labor and delivery factors in the NCPP appeared to contribute very little to childhood seizure disorders. Maldevelopment, rather than damage at birth to an initially intact nervous system, appeared to be the more common mechanism. Most seizure disorders of early childhood remained unexplained by the large set of prenatal and perinatal characteristics examined.     

Anticonvulsant Drugs and Cognitive Function: A Review of the Literature

Summary: Alterations of cognitive function are separate from disturbances of behavior seen in association with epilepsy. The nature of the cognitive disability may to a certain extent depend on the seizure type. Partial seizures, mainly derived from a temporal lobe focus, impair memory tasks, while generalized seizures seem to have more effect on attentional abilities. A number of studies, reviewed in this paper, suggest that anticonvulsant drugs further impair cognitive function. Maximal impairments are seen in patients receiving polytherapy: rationalization of polytherapy improves cognitive abilities. Studies in children and adults have allowed differentiation of the effects of various commonly used antiepileptic agents. Maximal cognitive deficits are seen with. phenytoin, while phenobarbital and sodium valproate induce moderate disturbances, and carbamazepine seems relatively free from such toxicity. Further research is needed on the interrelationship between types of seizure disorders, types of anticonvulsant medications, and cognitive function.