综合性医院新冠肺炎疫情防控常态化管理难点与策略探讨

目的:探索综合性医院新冠肺炎疫情防控常态化管理策略与防控体系建设.方法:以淮安市第一人民医院在新冠肺炎疫情防控工作难点与实践为基础,进行门诊、入院、住院等重要诊疗流程的改造与工作机制上的创新,筑牢常态化疫情防控体系.结果:及时收集结果并调整防控管理策略,发现防控效果显著,工作量、线上访问量、筛查量、核酸检测量均明显增长.结论:疫情防控策略实施卓有成效,为国内综合性医院新冠肺炎及其他传染性疾病的防控提供参考,基于平急结合原则,需不断调整疫情防控方案,疫情防控体系建设仍值得深入探讨.     

卡马西平治疗新诊断部分性发作癫痫患者的预后

癫痫是神经科常见疾病,其中约2/3为部分性发作患者.多数癫痫患者预后良好,但仍有30％～40％的患者经适当抗癫痫药物(AEDs)治疗后仍有发作,成为耐药性癫痫[1-3].既往有关癫痫患者预后的研究,观察对象大多是所有发作类型癫痫患者,很少有针对部分性发作癫痫患者的研究;有研究发现部分性较全面性发作癫痫患者预后差,易发展为耐药性癫痫[4-6].卡马西平是公认治疗部分性发作癫痫的首选药物,新诊断部分性发作癫痫患者初次给予卡马西平治疗效果如何?对卡马西平初次治疗效果差的患者再次给予其他AEDs治疗,其预后如何?     

某三甲医院单病种管理的探索与实践△

目的：单病种质量管理与控制工作在公立医院高质量发展中起着重要驱动型作用。本研究对临床一线深入开展单病种管理调查研究，以期构建优质高效单病种管理体系，进一步推动医院内涵质量提升。方法：对某三甲公立医院临床科室进行抽样调查，对单病种上报结果进行统计分析和费用分析，并对上报数据进行了质控数据分析。结果：自2023年单病种管理体系规范建立以来，单病种上报工作和单病种费用控制均取得了良好的成绩。结论：医院内部需要对单病种行精细化管理，依托于科室的单病种管理体系可显著提升医院单病种管理的水平。     

即刻和延迟治疗对新诊断癫痫患者复发的影响

目的 探讨不同治疗时机(即刻和延迟治疗)对新诊断癫痫患者复发的影响.方法 前瞻性收集新诊断癫痫患者的临床资料,根据治疗前发作次数将患者分为即刻治疗组(≤2次)及延迟治疗组(＞2次),给予合理抗癫痫药物治疗,至少观察2年.采用Kaplan-Meier统计分析比较2组患者治疗后至第1、2次复发的时间,同时比较治疗后不同随访时间点(3、6、12、24个月)的累计复发率.结果 共收集162例癫痫患者,其中即刻治疗组65例,延迟治疗组97例,随访2～14年(中位数3年).即刻治疗组治疗后至第1、2次复发时间均明显长于延迟治疗组,差异均有统计学意义(x2=5.94,P=0.020;x2=7.210,P=0.007).至随访终点,即刻治疗组有58.5%患者复发,低于延迟治疗组的72.2%,但差异没有统计学意义(x2=3.289,P=0.070).即刻治疗组和延迟治疗组治疗后3、6、12、24个月累计癫痫复发率分别为16.9%vs 35.1%、26.2%vs 48.5%、41.5%vs 56.7%、50.8%vs64.9%,仅在3、6月时差异均有统计学意义(x2=6.376,P=0.012;x2=8.098,P=0.004).结论 ≤2次癫痫发作后即刻给予合理抗癫痫药治疗可降低癫痫患者早期的复发风险.

Abstract：

Objective To explore the influences of immediate and deferred treatment with antiepileptic drugs (AEDs) on relapse of epilepsy in newly diagnosed patients. Methods The clinical data of newly diagnosed epileptic patients were collected prospectively and the patients were divided into immediate (seizures≤2) and deferred (seizures＞2) treatment groups according to times of seizures before treatment; these patients were treated with antiepileptic drugs reasonably. The patients were followed up for at least 2 years. Kaplan-Meier statistics was used to analyze the times to the first and second seizures after treatment. We also observed and compared their cumulative recurrence rate during the follow-up.Results One hundred and sixty-two patients were collected, 65 of which were in the immediate treatment group and 97 of which were in the deferred treatment group; The patients were followed up for 2-14 years(median 3 years). Times to the first and second seizures in the immediate treatment group were significantly longer than those in the deferred treatment group (x2=5.394, P=0.020; x2=7.210, P=0.007,respectively). Till the end of follow-up, 58.5% patients relapsed in the immediate treatment group, which was lower than that in the deferred treatment group (72.2%), but no statistical difference was noted (x2=3.289, P=0.07). The cumulative recurrence rates in the immediate and deferred treatment groups were 16.9% vs. 35.1% (x2=6.376, P=0.012), 26.2% vs. 48.5% (x2=8.098, P=0.004), 41.5% vs. 56.7% (x2=3.580,P=0.058) and 50.8% vs. 64.9% (x2=3.241, P=0.072) in the 3rd, 6th, 12th and 24th month of follow-up.Conclusion Immediate treatment with AEDs could reduce early recurrence rate of epilepsy in newly diagnosed epileptic patients with a few seizures (seizures ≤2).     

难治性癫痫早期预测因素的病例对照研究

目的 探索癫痫患者易演变为难治性癫痫（refractory epilepsy,RE）的早期预测因素,为临床尽早处理RE提供理论依据。方法 收集173例诊断明确、治疗合理的癫痫患者,分为药物难治性癫痫(drug non-responsive epilepsy,DNR-EP)组（106例）和药物有效性癫痫(drug-responsiveepilepsy,DR-EP)组（67例）。通过观察癫痫患者早期临床特点,采用多因素Logistic回归分析,探索癫痫患者易发展为RE的预测因素。结果 多因素Logistic回归分析显示：初次治疗前＞10次发作（OR =4.46,95％ CI 1.60～12.40,P=0.004）、早期伴智能障碍(OR=19.87,95％ CI 3.60～ 109.78,P=0.001)、治疗后脑电图仍有癫痫波样异常（OR=7.57,95％ CI 2.54～22.56,P＜0.01）是癫痫患者易发展为RE的预测因素;而初次使用抗癫痫药物(AEDs)治疗效果良好是RE的保护因素（OR=0.05,95％ CI 0.018 ～0.139,P＜0.01）。结论 初次治疗前发作次数多、早期伴智能障碍、治疗后脑电图仍有癫痫波样异常、初次AEDs治疗效果差的癫痫患者易发展为RE。     

活动性癫痫患者神经心理学特征及影响因素研究

目的 评估活动性癫痫患者神经心理学特点及影响因素.方法 60例活动性癫痫患者(过去1年内至少有≥2次的非诱发性发作),以及与之性别、年龄、文化程度、病程、发作类型相匹配的30例发作缓解癫痫患者(评估前至少达1年无发作).采用连线试验、数字符号转换试验、语言流畅性试验、数字广度试验及汉密尔顿抑郁量表(HAMD)等神经心理量表,分别检测癫痫患者心理运动速度、注意力、语言、工作记忆等认知功能及抑郁情绪.结果 活动性癫痫患者较发作缓解癫痫患者数字符号、语言流畅性、数字广度评分低[分别为(47.45±18.812)分、(25.25±8.163)分、(10.39±2.228)分和(56.40±13.631)分、(30.40 ±8.414)分、(11.80±2.074)分];连线A、B耗时长[分别为(64.35±31.710)s、(133.18±47.331)s和(45.47±16.309)s、(98.00±35.003)s];HAMD评分高[(9.12±6.219)分和(3.77±3.997)分];均差异有显著性(P<0.05).多元逐步线性回归分析显示:年龄大是数字符号(β=-0.468,P=0.000)、数字广度(β=-0.439,P=0.000)、连线A(β=0.365,P=0.003)和B(β=0.346,P=0.002)的危险因素,HAMD评分高是数字符号(β=-0.244,P=0.015)的危险因素;而文化程度高、从事脑力劳动及单药治疗对认知功能有保护作用.结论 活动性癫痫患者认知功能损害与多药治疗、抑郁情绪、年龄大、文化程度低、非脑力劳动有关;癫痫患者发作完全缓解后在一定程度上改善认知功能及抑郁情绪.

Abstract：

Objective To assess the neuropsychological characteristics in active epileptic patients and investigate itsrisk factors. Methods Ninety adult epileptic patients included 60 active epileptic patients (two or more unprovoked seizures within 12 months) and 30 age-, sex-, education-, course of disease- and seizure type-matched seizure-free subjects (without epileptic seizure for at least 1 year) . The neuropsychological tests including trail making test,digit symbol test, verbal fluency test,digit span test and hamilton depression scale( HAMD) ,were used to detect mental and motor speed, attention, language, working memory and depression symptoms respectively. The neuropsychological tests were compared between active and seizure-free epileptic patients and identified the risk factors of neuropsychological deficits in active epileptic patients. Results Compared to seizure-free subjects, active epileptic patients had significantly worse scores in digit symbol test, verbal fluency test, digit span test ((47.45 ±18. 812) vs(56.40 ±13. 631), (25. 25 ±8. 163) vs(30.40 ±8. 414), (10. 39 ±2. 228) vs( 11. 80 ± 2.074) respectively) ; more time to accomplish the trail making test A and B((64. 35 ±31.710) vs( 45. 47 ± 16. 309) , ( 133. 18 ± 47. 331 ) vs ( 98. 00 ± 35. 003 ) respectively) ; and higher scores in depressive symptoms ((9.12 ±6.219)vs(3.77 ±3.997) ,all P<0.05). Within active epileptic group,significant predictors of neuropsychological deficits were identified in a stepwise linear regression analysis: advancing age was significantly negatively correlated with digit symbol test(β = -0. 468, P = 0. 000) , digit span test (β = -0. 439, P = 0. 000), trail making test A (β =0.365, P = 0.003) and B(β = 0.346, P=0.002) ; higher scores on depressive symptoms was significantly negatively correlated with digit symbol test (β = -0.244, P = 0.015) ; mental work,high-education level and monotherapy were positively correlated with some of the cognitive function subscales. Conclusion This study suggests that active epilepsy can have a direct adverse effect on cognition and depression symptoms. Multi-drug therapy, severity of depression symptoms, advancing age, low-education level and non-mental work are the predictors of neuropsychological impairment in active epilepsy. In addition, good seizure control even after 1 year can have a beneficial impact on cognitive and depression prognosis.     

大型公立医院构建三尺质控模型的实践探索

目的 构建“三尺”质控模型,促进医疗质量全面内涵管理。方法 构建由“标尺、量尺、戒尺”组成的“三尺”质控模型,具体包括：以各项质量指标的标准化保障质量的基础管理,形成“标尺”;以“标尺”为准绳,落实全面质控和监督机制,保障质量的环节管理,形成“量尺”;运用绩效奖惩等措施落实质量的终末管理,形成“戒尺”。结果 “三尺”质控模型的构建形成了全方位医疗质量监督管理机制,强化了医疗质量全面内涵管理,夯实医院高质量发展根基。结论 “三尺”质控模型的构建与推广,有助于医疗质量持续改进和医疗服务能力有效提升,为我国各级医院医疗质量持续改进提供参考。     

癫痫患者初次用药时机的选择

药物治疗目前仍是治疗癫痫的主要手段,治疗前发作次数越多,患者预后越差,而抗癫痫药物(AEDs)可对50%～90%新诊断癫痫患者的复发起到预防作用[1],因而对于多次或频繁发作的癫痫患者一直主张积极治疗.由于AEDs的普遍应用,使我们对癫痫的自然病程并不十分了解.流行病资料显示,近30%癫痫患者可不经治疗达到自发缓解[2],考虑到AEDs可产生不同程度的不良反应,故对于初次非诱发性痫样发作、早期发作稀少或可能自发缓解的某些癫痫患者,如何处理尚无定论.目前有关癫痫患者初次用药时机的研究较少,结果也不尽相同,国内更缺乏相应的研究.