联合营养管理对重症脑卒中患者营养状况和近期并发症的影响

目的评价联合营养管理措施对重症脑卒中患者营养状况、并发症及近期预后的影响。方法 90例重症脑卒中患者按照数字随机表法分为对照组48例和观察组42例。在早期肠内营养支持基础上,观察组由护士联合医师、营养师和康复师组成团队实施联合营养管理,对照组由护士按照营养师医嘱进行,评估入院后第1天和第21天2组营养指标血红蛋白(Hb)、血清白蛋白(ALB)、前白蛋白(PA)、总胆固醇(TC)、甘油三酯(TG)水平和上臂肌围(AMC)的变化,肺部感染、应激性溃疡和泌尿系感染等并发症的发生率,NIHSS评分及Barthel指数的变化以及营养支持治疗满意度。结果住院第21天,观察组和对照组各项营养指标均有下降,且对照组营养指标减低更为显著,观察组各项营养指标明显优于对照组(P0.05)。第21天观察组低蛋白血症发生率(19.04%)显著低于对照组(39.6%)。观察组感染发生率(23.8%)显著低于对照组(62.5%)。第21天2组NIHSS评分和Barthel指数差异有统计学意义(P0.05)。观察组对联合营养管理满意率显著高于对照组(P0.05)。结论包括临床医师、护士、营养师及康复师在内的联合营养管理模式有利于重症脑卒中患者的营养供给,提高脑卒中患者的生存质量,值得临床推广使用。     

肠内营养对急性脑卒中伴吞咽障碍患者短期预后的影响

目的探讨肠内营养对急性脑卒中伴吞咽障碍患者短期预后的影响。方法将86例急性脑卒中伴吞咽障碍患者随机分为肠内营养组(实验组)43例和家庭传统喂养组(对照组)43例。比较21d后2组患者的营养状态、感染发生率、神经功能缺损评分(NIHSS)。结果住院21d时,实验组血清白蛋白、前白蛋白、血红蛋白、上臂肌围等指标均优于对照组,差异均有统计学意义(P0.05);实验组合并感染的发生率为27.9%,对照组为53.5%,2组差异有统计学意义(P0.05);实验组NIHSS评分(11.13±2.03)分低于对照组的(15.35±2.76)分,2组间比较差异有统计学意义(P0.05)。结论对于急性脑卒中伴吞咽障碍患者,早期实施肠内营养能够提升患者营养状态,减少感染发生率,降低神经功能缺损评分,从而改善患者短期预后。     

序贯肠内营养对急性脑梗死患者营养状况和预后的影响

目的 探讨序贯肠内营养对急性脑梗死(ACI)患者营养状况及预后的影响.方法 将80例ACI伴吞咽障碍患者分为序贯肠内营养组和对照组,各40例.肠内营养组患者给予短肽型肠内营养制剂(总量按每天84～126 kJ/kg)鼻饲3 d,第4 d起改用整蛋白型肠内营养制剂鼻饲;对照组给予普通流质食物鼻饲;均持续≥10 d.观察两组患者营养治疗第1 d、7 d、14 d的营养指标[三头肌皮褶厚度(TSF)、上臂三头肌肌围(MAMC)、血清白蛋白(Alb)、血清前白蛋白(PAB)、血红蛋白(Hb)含量]、感染并发症发生率及美国国立卫生研究院卒中量表(NIHSS)评分和Barthel指数(BI).结果 肠内营养组在治疗后第14 d营养指标(TSF、MAMC、血清Alb、血清PAB、Hb含量)明显高于对照组(P<0.05～0.01);感染并发症的发生率明显低于对照组( P<0.05);肠内营养组治疗后第14 d NIHSS评分明显低于对照组,BI值明显高于对照组(均 P<0.05).结论 序贯肠内营养治疗能够改善ACI患者的营养状况,降低感染性并发症的发生率,改善患者的近期预后.     

早期肠内营养对重症脑血管病患者营养状况、免疫功能及预后的影响分析

目的探讨和分析早期肠内营养支持对重症脑血管病(SCVD)患者营养状况、免疫功能及预后的影响。方法选取我院的56例重症脑血管病患者作为研究资料,依据护理方式不同,双盲法随机分为对照组(肠外营养支持)和研究组(早期肠内营养支持),各28例。分别于入院当天、营养支持后10 d对两组患者的营养状况、免疫功能以及预后进行比较。结果营养支持10 d后,研究组血清总蛋白(TP)、三酰甘油(TG)、谷丙转氨酶(ALT)、血糖(GLU)4项指标显著优于对照组,差异具有统计学意义(P0.05)。研究组与对照组相比,Ig G、Ig A、CD4/CD8水平显著升高,TLC水平显著下降,差异均具有统计学意义(P0.05)。研究组日常生活能力(ADL)评分和Fugl-Meyer运动功能(FMA)评分高于对照组,美国国立卫生研究院卒中量表(NIHSS)指数低于对照组,差异均具有统计学意义(P0.05)。结论对于重症脑血管病患者,早期的肠内营养支持能给予患者必须的营养支持,改善机体调节紊乱,增强免疫能力,改善患者预后及提升患者生存质量,临床值得推广运用。     

重症脑卒中患者急性期给予肠内营养的临床价值

目的探讨重症脑卒中患者急性期给予肠内营养的临床价值。方法选取我院120例急性重症脑卒中患者,按照1∶1随机分为肠内营养组(EN)和肠外营养组(PN)。入院后所有患者均予以常规治疗,EN组经鼻饲空肠管匀速泵入整蛋白肠内营养制剂,PN组经深静脉置管滴注全胃肠外营养。分别于入院第1天、第14天、第21天检测血红蛋白(Hb)、血清白蛋白(Alb)及甘油三酯(TG)水平,并进行NIHSS评分,在入院及出院时分别测量体质量变化情况。结果第14天、21天2组各项营养指标均有所下降,PN组下降更为明显(P0.05);2组患者感染率发生情况,EN组显著低于PN组(P0.05);2组NIHSS评分均有明显改善,EN组与PN组相比改善情况差异明显,EN组明显优于PN组,差异具有统计学意义(t=3.59,6.12,P0.05);出院时2组体质量均明显下降,但PN组下降明显高于EN组(P0.05)。结论重症脑卒中患者急性期肠内营养给予能有效改善患者营养状况,降低感染发生率,改善预后。     

重症脑卒中患者早期肠内和肠外营养支持的对比分析

目的探讨重症脑卒中患者早期肠内营养支持及肠外营养支持的效果。方法选取我院接受治疗的重症脑卒中患者105例为研究对象,根据患者入院时间先后分为2组。对照组52例给予早期肠外营养支持,观察组53例给予早期肠内营养支持,对比2组治疗前后谷丙转氨酶(ALT)、血清白蛋白(Alb)、血清葡萄糖(GLU)、尿胆素(BUN)等营养指标差异,同时比较2组并发症发生率、ICU住院时间等。结果观察组ALT、GUN及Alb等营养指标与对照组比较差异均有统计学意义(P0.05)。观察组并发症发生率26.4%,对照组56.6%,差异有统计学意义(P0.05)。观察组ICU入住时间及住院费用均低于对照组,差异有统计学意义(P0.05)。结论早期肠内营养支持能有效降低重症脑卒中患者并发症发生率,改善患者体内血清白蛋白等多项营养指标,住院费用低且时间短,值得临床推广。     

早期肠内营养支持对危重症脑卒中患者营养状况和并发症的影响

目的评价早期肠内营养支持对危重症脑卒中患者营养状况和并发症的影响。方法将117例重症脑卒中患者采用信封随机法分为试验组63例,对照组54例。试验组采用早期肠内营养支持,对照组发病10d后给予肠内营养。比较干预前后2组的营养状况(包括血清白蛋白、血清前白蛋白及维生素C含量)、并发症如肺部感染、腹泻及便秘的发生率。结果干预后试验组营养状况,如血清白蛋白、血清前白蛋白及维生素C含量高于对照组(P0.05),并发症如肺部感染、腹泻及便秘的发生率低于对照组(P0.05)。结论早期肠内营养支持可改善危重症脑卒中患者的营养状况,降低并发症发生率,值得临床推广使用。     

重症颅脑外伤患者引入以循证为基础的早期营养支持干预的效果分析

目的 探讨重症颅脑外伤患者引入以循证为基础的早期营养支持干预的效果。方法 选择2017年5月-2019年5月本院神经外科收治的重症颅脑外伤患者108例,按随机数字表法分为2组,各54例; 对照组术后行早期常规营养支持干预,观察组术后行以循证为基础的早期营养支持干预; 比较2组肠内营养耐受性、治疗依从性、干预前后NIHSS评分、FMA评分变化及术后并发症发生率。结果 观察组颅脑外伤后第7 d肠内营养最大输注量高于对照组(P<0.05); 观察组治疗依从性优于对照组(P<0.05); 观察组干预后NIHSS评分低于对照组,FMA评分高于对照组(P<0.05); 观察组术后总并发症发生率低于对照组(P<0.05)。结论 重症颅脑外伤患者引入以循证为基础的早期营养支持干预可改善肠内营养耐受性,提高治疗依从性,促进神经功能和运动功能恢复,降低术后并发症发生率。     

肠内营养混悬液对重症脑卒中预后的影响

目的观察肠内营养混悬液(TPF)对重症脑卒中预后的影响及安全性。方法对比分析105例重症脑卒中应用TPF(观察组)与102例应用家属配制营养液(对照组)鼻饲者腹泻、便秘、应激性溃疡出血(SUH)、电解质紊乱、肝功能异常等并发症发生率,并于入院及营养21 d时进行神经功能缺损评分(NDS)。以2组肠内营养21 d为统计界限。结果腹泻、肝功能异常者2组发生率比较差异无统计学意义(P>0.05)。但观察组便秘、SUH、电解质紊乱发生率较对照组明显降低(P<0.05,P<0.01)。2组入院时NDS比较差异无统计学意义(P>0.05),入院21 d 2组均较入院时显著降低(P<0.01),但观察组较对照组降低更明显(P<0.05)。结论 TPF肠内营养支持可有效降低重症脑卒中患者并发症发生率,提高其生活质量,且安全、可靠。     

免疫肠内营养对神经内科重症患者营养及免疫功能指标的影响

目的探讨免疫肠内营养支持对神经内科重症患者营养学和免疫功能的影响。方法选择74例神经内科重症患者为研究对象,随机分为观察组(38例)和对照组(36例),观察组使用免疫增强型肠内营养制剂,对照组使用常规肠内营养制剂,检测2组治疗前和治疗后10d的总蛋白(TP)、白蛋白(ALB)、前白蛋白(PA)和血红蛋白(Hb)等营养学指标,以及IgA、IgG和IgM等免疫学指标,观察2组住院时间和感染发生等情况。结果治疗后10d对照组PA、Hb、IgA、IgG和IgM水平均有所下降,差异有统计学意义(P0.05),而观察组各指标水平治疗前后均无明显差异(P0.05),观察组Hb、IgA、IgG和IgM水平均高于对照组(P0.05);观察组住院时间(41.55±10.34)和感染发生率(13.16%)低于对照组,差异均有统计学意义(P0.05)。结论免疫肠内营养支持可以有效改善神经内科重症患者营养和免疫状态,降低感染发生率和住院时间,对于治疗神经内科重症疾病治疗具有重要的支持作用。     

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.     

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.     

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.     

Un nouveau cadre conceptuel de travail pour une psychiatrie revisitée ? Introduction à deux articles de E. Kandel

In two articles which appeared in the American Journal of Psychiatry and that were subsequently translated for Évolution Psychiatrique, E. Kandel examines the bases for a reinterpreted psychiatry that is prepared to confront the major challenge of the 3rd millenium: that of insight into the mind and brain. This requires a major reorganization of the discipline, which involves a reinvestment of the scientific approach and a critical  assessment of the data provided by psychoanalytical psychiatry and cognitive neurosciences. Seven concepts have therefore been proposed for interactive re-examination: consciousness, the unconscious, memory, emotion, development, desire, impulse. The dynamic relations existing between genetics and the environment allow one to see how evolutions are possible from actions at different levels, both psychotherapeutic and pharmacological. Imaging and other techniques provide additional objective information to the process of human interaction which remains the basis of psychiatry. A common framework for psychiatry and the neurosciences, a reconsideration and renewal of the psychoanalytical approach are both possible and necessary.     

Opioids and the developing organism: A comprehensive bibliography, 1984–1988

A comprehensive bibliography of the literature concerned with opioids and the developing organism for 1984-1988 is presented. Utilized with companion papers (Neurosci. Biobehav. Rev. 6:439-479; 1982; 8:387-403; 1984), these articles cover the clinical and laboratory references beginning in 1875. For the years 1984, 1985, 1986, 1987, and 1988, a total of 877 citations were recorded. A series of indexes accompanies the citations in order to make the literature more accessible. These indexes are divided into clinical and laboratory topics, and subdivided into such topics as the type of opioid explored and the general area of biological interest (e.g., physiology).     

La biologie et le futur de la psychanalyse : un nouveau cadre conceptuel de travail pour une psychiatrie revisitée

The American Journal of Psychiatry has received a number of letters in response to my earlier “Framework” article (1). Some of these are reprinted elsewhere in this issue, and I have answered them briefly there. However, one issue raised by some letters deserves a more detailed answer, and that relates to whether biology is at all relevant to psychoanalysis. To my mind, this issue is so central to the future of psychoanalysis that it cannot be addressed with a brief comment. I therefore have written this article in an attempt to outline the importance of biology for the future of psychoanalysis.     

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.     

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.