低频重复经颅磁刺激治疗脑卒中后非流畅性失语的疗效观察

目的观察低频重复经颅磁刺激(rTMS)治疗脑卒中后非流畅性失语的临床疗效。 方法将40例脑卒中后非流畅性失语患者按随机数字表法随机分为rTMS组(n=20)和对照组(n=20)。两组患者均给予常规言语治疗,rTMS组在右侧大脑半球Broca镜像区给予0.5Hz的rTMS治疗,每日1次,每周5次,连续治疗3周。于治疗前和治疗3周后（治疗后）采用西方失语成套测验（WAB）和日常生活交流能力检查（CADL）评定2组患者的语言功能和交流能力。 结果治疗后,对照组患者WAB评分中,仅自发言语较组内治疗前有显著改善,差异有统计学意义（P<0.05）,rTMS组患者WAB各项评分较组内治疗前均显著改善,差异均有统计学意义（P<0.05）,且听理解、复述、命名以及AQ评分分别为（153.90±31.79）分、（82.65±15.14）分、（81.28±22.12）分和（63.66±13.64）分,均明显优于对照组治疗后,差异均有统计学意义（P<0.05）。 结论0.5Hz的rTMS作用于右侧大脑半球Broca镜像区可显著改善脑卒中后恢复早期非流畅性失语患者的语言功能。     

低频重复经颅磁刺激联合高压氧治疗卒中后非流利性失语的疗效观察

目的 观察低频重复经颅磁刺激（rTMS）联合高压氧（HBO）治疗卒中后非流利性失语患者的疗效。 方法 采用随机数字表法将48例脑卒中后非流利性失语患者分为对照组、HBO组及观察组。3组患者均给予常规康复干预（包括药物治疗、语言训练及肢体康复训练等）,HBO组患者在此基础上辅以HBO治疗,观察组患者则辅以HBO及低频rTMS联合治疗,磁刺激部位为右侧大脑半球Broca镜像区,磁刺激频率为1 Hz。于治疗前、治疗4周后分别使用中文版西方失语症成套检验（WAB）评估患者语言功能情况,采用改良Barthel指数（MBI）评价患者日常生活活动能力改善情况。 结果 治疗前3组患者WAB各项指标评分及MBI评分组间差异均无统计学意义（P>0.05）;经4周治疗后,发现HBO组、观察组WAB各项指标评分及MBI评分均较治疗前明显改善;并且观察组WAB自发言语评分［（9.13±3.01）分］、听理解评分［（150.19±34.36）分］、复述评分［（83.94±18.20）分］、命名评分［（75.63±21.71）分］、AQ评分［（65.18±16.22）分］及MBI评分［（67.38±16.15）分］均显著优于HBO组及对照组（P<0.05）,HBO组上述指标评分亦显著优于对照组（P<0.05）。 结论 低频rTMS联合HBO治疗可有效改善卒中后非流利性失语患者早期语言功能,提高其日常生活活动能力及生活质量,该联合疗法值得在卒中后失语患者中推广、应用。     

励-协夫曼言语治疗对帕金森病患者言语功能及生活质量的影响

目的探讨励-协夫曼（Lee Silverman）言语治疗技术对帕金森病患者言语功能及生活质量的影响。 方法选取伴有不同程度言语障碍且Hoehn-Yahr临床分期1～3期的帕金森病患者98例，按随机数字表法分为干预组和对照组，每组49例。2组患者均进行言语康复训练治疗，每次治疗1h，每周4d，共训练12周，其中对照组接受常规言语康复治疗，包括舌唇运动、韵律、发声、音量、语速和呼吸控制等，干预组接受励-协夫曼言语治疗，主要针对嗓音异常问题，注重发音训练，包括训练持续元音发音最大时长、训练患者发音的最大基频范围、阶梯式的声强训练等，治疗期间，要求患者遵从以上治疗方法，在家自主进行家庭训练，治疗日每天完成1次家庭训练，治疗间歇日每天2次家庭训练以维持疗效。分别于干预前（治疗前）和干预12周末（治疗后），采用嗓音障碍指数量表（VHI）、西方失语症成套检查（WAB）、统一帕金森病综合评价量表（UPDRS-Ⅲ）运动部分的言语表达评分项和言语清晰度评分，对2组患者言语功能的治疗效果进行评估。 结果治疗前，2组患者的VHI、WAB、UPDRS-Ⅲ运动部分的言语表达评分和言语清晰度评定得分比较，差异均无统计学意义（P>0.05）；治疗后，2组患者的上述指标均较组内治疗前有明显改善，干预组患者的VHI总体评价得分［（60.39±9.84）分］、WAB各项评分［自发言语（14.64±1.98）、听语理解（112.67±19.43）、复述（65.31±7.98）和命名（39.89±9.84）分］及AQ得分［（69.19±10.78）分］、UPDRS-Ⅲ评分［（1.39±0.61）分］均较对照组治疗后上述各项指标［（71.03±11.01）、（13.67±1.06）、（111.53±29.61）、（63.75±7.41）、（37.89±9.29）、（62.14±10.21）和（1.82±0.82）分］改善更为明显,且组间差异均有统计学意义（P<0.05）。治疗后，干预组和对照组患者的言语清晰度评分分别为（77.61±11.72）和（59.67±10.04）分，均较组内治疗前［（54.36±10.71）和（53.98±9.92）分］明显提高(P<0.05)，且干预组得分提高较对照组更为明显(P<0.05)。 结论励-协夫曼言语治疗能有效改善帕金森病患者的言语功能及生活质量。     

抑制性rTMS刺激联合镜像神经元训练系统对脑卒中后完全性失语的作用研究

目的：探讨抑制性重复经颅磁刺激(rTMS)联合镜像神经元训练系统(MNS)对脑卒中后完全性失语的临床疗效及其作用机制。方法：50例脑卒中后完全性失语患者按随机数字表法随机分为对照组16例、MNS组16例和联合组18例。对照组仅给予常规的言语康复训练,MNS组在对照组的基础上给予镜像神经元系统训练,联合组在MNS组的基础上给予右侧Broca同源区1Hz的rTMS刺激,于治疗前和治疗3周后评定3组患者西方失语成套测验(WAB)以及波士顿失语症程度分级（BDAE）评分。结果：治疗3周后,3组WAB各项评分和BDAE评分均较治疗前明显提高（P<0.05）;且联合组WAB各项评分及BDAE评分显著高于MNS组和对照组（P<0.05）,MNS组WAB评分中自发语评分及AQ评分亦高于对照组（P<0.05）,BDAE评分MNS组和对照组治疗后比较差异无统计学意义。结论：抑制性rTMS刺激右侧Broca同源区联合MNS训练系统对改善脑卒中后完全性失语患者的语言功能有一定作用。     

旋律语调治疗改善脑卒中后Broca失语的疗效观察

目的 探讨旋律语调疗法（MIT）对脑卒中后Broca失语患者语言功能的影响。 方法 选取40例符合入组标准的脑卒中后Broca失语患者，按随机数字表法分为治疗组（20例）和对照组（20例）。治疗组进行改编的旋律语调治疗，对照组进行常规言语康复训练（包括口腔发音器官的训练、口语表达训练、文字表达训练、听理解训练等）；均采用一对一的治疗方式，治疗时间每日1次，每次30 min，每周5 d，20次为1个疗程，连续治疗3个疗程。分别于入组时（治疗前）和治疗3个疗程后（治疗后），对2组患者进行西方失语成套测验（WAB）评估，对自发言语、听理解、复述、命名四项评估。最后通过统计学分析，考察治疗组的临床疗效。 结果 干预后，对照组和治疗组的各项语言评分值及失语商（AQ值）较组内治疗前均有不同程度改善（P<0.05）；治疗组自发言语评分［（13.15±2.82）］、听理解评分［(8.42±1.61)分］、命名评分［(5.484±1.69)分］和失语商（AQ值）评分［（66.87±11.75）分］亦显著优于对照组［（10.55±3.61）、（7.92±2.19）、（4.32±1.89）分和（57.03±16.58）分］，差异均有统计学意义(P<0.05)。 结论 以有语调和节奏的训练词库的MIT训练可以更有效地改善患者的言语功能及日常生活语言沟通能力。     

低频重复经颅磁刺激治疗老年人失眠症的疗效观察

目的 观察低频重复经颅磁刺激（rTMS）对失眠症老年人睡眠和情绪的影响。 方法 选取34例失眠症老年患者,按照随机数字表法将其分为试验组（18例）和对照组（16例）。试验组采用低频rTMS刺激右背外侧前额叶皮质（DLPFC)治疗,对照组给予交变磁场治疗。治疗前及治疗4周后（治疗后）,使用匹兹堡睡眠质量指数(PSQI)、汉密尔顿焦虑量表(HAMA)和汉密尔顿抑郁量表(HAMD)对患者进行评估。为了消除睡眠变化对患者HAMA和HAMD评分的影响,对此两项评分去除睡眠相关项得分后的分值（标记为HAMA-A、HAMD-A）进行评估。 结果 治疗前,2组患者的PSQI、HAMA和HAMD评分比较,差异无统计学意义（P>0.05）。治疗后,试验组与对照组患者的PSQI、HAMA、HAMD评分均明显下降（P<0.05）,且试验组PSQI［(8.44±1.82)分］、HAMA［(10.66±2.59)分］、HAMD［(11.78±3.64)分］较对照组低,差异有统计学意义（P<0.05）。除去HAMA与HAMD的睡眠相关选项得分后,试验组患者治疗后HAMA-A、HAMD-A较组内治疗前低（P<0.05）,对照组患者治疗后HAMA-A、HAMD-A虽较组内治疗前低,但差异无统计学意义（P>0.05）。试验组患者治疗后HAMA-A［(11.11±2.72)分］、HAMD-A［(10.17±3.28)分］较对照组低（P<0.05）。 结论 rTMS治疗老年失眠症的疗效优于交变磁场,能显著改善患者睡眠和情绪。     

高压氧联合重复经颅磁刺激治疗血管性认知功能障碍的临床研究

目的 探讨高压氧（HBO）联合重复经颅磁刺激（rTMS）治疗血管性认知功能障碍（VCI）的临床疗效。 方法 将52例VCI患者按随机数字表法分为HBO+rTMS组(25例)和rTMS组(27例)。2组患者均给予药物、常规康复治疗和rTMS治疗,HBO+rTMS组在此基础上增加HBO治疗。治疗前和治疗4周后（治疗后）,采用简易精神状态量表(MMSE)、蒙特利尔认知评估量表(MoCA)、洛文斯顿作业疗法认知评定量表(LOTCA)及改良Barthel指数(MBI)评估2组患者的认知功能及恢复情况。 结果 治疗前,两组患者MMSE、MoCA、LOTCA、MBI评分比较,差异无统计学意义(P>0.05)。治疗后,两组患者MMSE、MBI评分均较组内治疗前改善,且HBO+rTMS组MMSE、MBI评分优于rTMS组,差异有统计学意义（P<0.05）。rTMS组除命名外,其他项目及总分均较治疗前提高（P<0.05）。HBO+rTMS组各项分值及总分均较治疗前提高（P<0.05）。rTMS组知觉、思维、视运动和总分较治疗前改善（P<0.05）;HBO+rTMS组各项评分及总分均较治疗前改善（P<0.05）。组间治疗后比较,HBO+rTMS组的视空间执行［(2.48±0.78)分］、抽象［(1.91±0.78)分］、延迟回忆［(2.67±0.90)分］、定向分值［(3.46±1.05)分］及总分［(17.52±2.53)分］均高于对照组（P<0.05）,HBO+rTMS组患者的定向［(5.20±1.26)分］、知觉［(20.02±1.65)分］、思维能力［(18.59±2.81)分］和总分［(62.33±8.13)分］均高于rTMS组（P<0.05）。 结论 HBO联合rTMS可显著提高非痴呆型VCI患者的认知功能,提高日常生活活动能力,改善患者生存质量。     

音乐治疗在脑出血Broca失语患者中的应用研究

目的:观察音乐治疗应用于脑出血Broca失语患者的疗效。方法:脑出血Broca失语患者62例分为观察组32例和对照组30例,2组均给予常规的言语康复训练,观察组在此基础上增加音乐治疗训练。治疗前后均采用波士顿诊断性失语症检查法(BDAE)中的失语症严重程度分级和西方失语成套测试(WAB)进行评定。结果:治疗8周后,观察组BDAE轻度患者例数明显多于对照组(P<0.05),且观察组有效率明显高于对照组(62.5%、33.3%,P<0.05);治疗后,2组患者WAB各项评分均较治疗前明显提高(P<0.05),且观察组各项评分均更高于对照组(P<0.05)。结论:音乐治疗在脑出血Broca失语患者的治疗中有积极意义。     

反应扩充疗法联合rTMS对脑卒中后非流畅性失语症患者的语言疗效分析

目的:探讨反应扩充疗法(RET)联合重复经颅磁刺激(rTMS)治疗脑卒中后非流畅性失语的临床疗效。方法:选取脑卒中后非流畅性失语患者90例随机分为2组各45例,对照组予以常规语言训练和低频rTMS治疗;联合组在对照组治疗基础上予以反应扩充疗法训练,疗程均为4周。比较2组治疗前后西方失语症成套测验(WAB)评分、汉语标准失语症检查工具(CRRCAE)中动作说明评分、画面说明评分和日常生活交流能力量表(CADL)评分及波士顿失语诊断测验(BDAE)分级。结果:治疗后,2组自发言语、听理解、复述、命名及AQ评分较治疗前增加(P<0.01),CRRCAE动作说明评分、画面说明评分和CADL评分均较治疗前增加(均P<0.01),BDAE分级显著改善(P<0.01)。治疗后联合组自发言语、听理解、复述、命名及AQ评分均高于对照组(P<0.01);CRRCAE动作说明评分、画面说明评分和CADL评分均高于对照组(P<0.01),BDAE分级优于对照组(P<0.05),结论:rTMS是非流畅性失语有效的康复治疗方法,RET联合rTMS有利于增加WAB评分、RRCAE动作说明、画面说明评分和CADL评分,改善BDAE分级,治疗脑卒中后非流畅性失语效果显著。     

重复经颅磁刺激对脑梗死患者下肢运动功能的影响

目的探讨重复经颅磁刺激（rTMS）对脑梗死患者下肢运动功能的影响。 方法纳入脑梗死后下肢功能障碍患者60例,按照随机数字表法将其分为rTMS治疗组和对照组,每组30例。2组均给予常规药物和康复治疗,rTMS治疗组在此基础上加用健侧M1区rTMS治疗,疗程4周。2组分别于治疗前、治疗4周后（治疗后）及治疗完成后2周（治疗后2周）进行下肢简式Fugl-Meyer运动功能（FMA）和10m最大步行速度（10m MWS）测定,观察并记录治疗过程中及治疗后2周内有无明显不良反应。 结果2组患者治疗前FMA、10m MWS比较,差异均无统计学意义(P>0.05)。治疗后和治疗后2周,2组患者FMA、10m MWS均较组内治疗前有所改善(P<0.05),且rTMS治疗组治疗后FMA［（28.2±2.8）分］、10m MWS［（56.78±20.15）m/min］及治疗后2周FMA［（27.8±2.9）分］、10m MWS［（55.89±21.06）m/min］均较对照组改善更明显(P<0.05)。2组均未出现明显不良反应。 结论rTMS治疗可提高脑梗死后患者的下肢运动功能,安全性较好,值得临床应用。     

Determination of creatine kinase isoenzyme MB activity in serum using immunological inhibition of creatine kinase M subunit activity. Activity kinetics and diagnostic significance in myocardial infarction.

This is a new method for the determination of creatine kinase isoenzyme MB activity in serum. The method uses direct activity measurement of creatine kinase B subunit activity after blocking of CK-M subunit activity by inhibiting antibodies. The test takes no longer than 15 min. The method yields an intra-serial C.V. of 2.0-12.9%, and a C.V. from day to day of 5.5%. The detection limit is 3.4 U/l creatine kinase MB. In the 95 cases with proven myocardial infarction several types of creatine kinase MB activity kinetics could be determined. The percentage of creatine kinase MB of peak CK-total is 6-25%, with a mean of 11.1%. The amount of creatine kinase MB with respect to total CK activity after reinfarction is higher than the amount after initial infarction.     

Dissociable correlates of two classes of retrieval processing in prefrontal cortex

Although substantial evidence suggests that the prefrontal cortex (PFC) implements processes that are critical for accurate episodic memory judgments, the specific roles of different PFC subregions remain unclear. Here, we used event-related functional magnetic resonance imaging to distinguish between prefrontal activity related to operations that (1) influence processing of retrieval cues based on current task demands, or (2) are involved in monitoring the outputs of retrieval. Fourteen participants studied auditory words spoken by a male or female speaker and completed memory tests in which the stimuli were unstudied foil words and studied words spoken by either the same speaker at study, or the alternate speaker. On "general" test trials, participants were to determine whether each word was studied, regardless of the voice of the speaker, whereas on "specific" test trials, participants were to additionally distinguish between studied words that were spoken in the same voice or a different voice at study. Thus, on specific test trials, participants were explicitly required to attend to voice information in order to evaluate each test item. Anterior (right BA 10), dorsolateral prefrontal (right BA 46), and inferior frontal (bilateral BA 47/12) regions were more active during specific than during general trials. Activation in anterior and dorsolateral PFC was enhanced during specific test trials even in response to unstudied items, suggesting that activation in these regions was related to the differential processing of retrieval cues in the two tasks. In contrast, differences between specific and general test trials in inferior frontal regions (bilateral BA 47/12) were seen only for studied items, suggesting a role for these regions in post-retrieval monitoring processes. Results from this study are consistent with the idea that different PFC subregions implement distinct, but complementary processes that collectively support accurate episodic memory judgments.     

俯卧位通气对高海拔地区肺复张治疗无效急性呼吸窘迫综合征患者氧合的影响

目的 探讨俯卧位通气对高海拔地区肺复张术(RM)治疗无效急性呼吸窘迫综合征(ARDS)患者的治疗作用.方法 从海拔2260m的地区医院筛选RM治疗无效的41例ARDS患者[平均氧合指数( PaO2/FiO2)较RM前升高＜20％视为RM无效],依不同病因分为肺内源性ARDS组(ARDSp组)和肺外源性ARDS组(ARDSexp组),每组再按信封法随机分为俯卧位组和仰卧位组,即ARDSp俯卧位组(11例)、ARDSp仰卧位组(9例)、ARDSexp俯卧位组(10例)、ARDSexp仰卧位组(11例).在通气前及通气1、2、3、4h监测动脉血氧分压( PaO2)、PaO2/FiO2、静态顺应性(Cst)、气道阻力(Raw)的变化.结果 通气lh时,ARDSexp俯卧位组PaO2/FiO2( mm Hg,l mm Hg=0.133 kPa)即较通气前显著升高(157.4±40.6比129.3±48.7,P＜0.05),并随通气时间延长呈持续增高趋势,4h达峰值(219.1 ±41.1);且ARDSexp俯卧位组通气3h内PaO2/FiO2较其他3组显著增高,另3组间则差异无统计学意义.ARDSp俯卧位组、ARDSexp俯卧位组通气4h时PaO2/FiO2均较相应仰卧位组显著增高(208.8±39.7比127.4±47.1,219.1±41.1比124.9±50.8,均P＜0.05).4组通气前后Cst无显著改变,各组间差异也无统计学意义.ARDSp俯卧位组通气4h时Raw(cmH2O·L-1·s-1)较通气前显著降低(6.8±1.7比10.7±1.8,P＜0.05),且明显低于其他3组;其他3组各时间点Raw组内及组间比较差异均无统计学意义.结论 俯卧位通气作为ARDS机械通气重要策略之一,可以改善RM无效高原ARDS患者的氧合,为抢救患者赢得宝贵的时间.     

Digital imaging among medical facilities

The Department of Veterans Affairs (VA) in the USA operates a network of 172 medical centres which all utilize a hospital information system (HIS) which has been developed and is currently maintained by the VA. During the past several years, an image management and communication module has been developed, installed and clinically utilized at the Washington DC and Maryland VA Medical Centres. This image management and communication system, referred to as the decentralized hospital computer program (DHCP) imaging system, is fully integrated with a commercial picture archiving and communication system (PACS). The system is utilized to capture, archive, and display all images generated within the hospital including radiology, nuclear medicine, pathology, endoscopy, bronchoscopy, and dermatology, intraoperative photographs, ECG data, and a limited number of paper documents. The ultimate goal of the project is to have all patient text and image data available at any clinical workstation to any authorized user anywhere within the network of medical centres. Clinical requirements for an imaging workstation include ease of use, rapid and reliable access to the complete set of patient information, and images which are of acceptable quality to meet the requirements of the user and the subspecialty. Patient confidentiality and data security must be safeguarded at all times. Integration of the images with the remainder of the patient's database was found to be critical to the success of the project. The experience at the Washington and Maryland facilities suggests that an imaging system that is successfully integrated with a hospital information system can provide substantial clinical and economic benefits both within and among medical centres. Clinical acceptance and utilization of the system has been excellent, particularly in diagnostic radiology where DHCP Imaging has been interfaced to a commercial PAC system. Based upon this initial experience, the VA has begun to deploy the system throughout its large network of medical centres.     

Myocardial elastography at both high temporal and spatial resolution for the detection of infarcts

Myocardial elastography is a novel method for noninvasively assessing regional myocardial function, with the advantages of high spatial and temporal resolution and high signal-to-noise ratio (SNR). In this paper, in-vivo experiments were performed in anesthetized normal and infarcted mice (one day after left anterior descending coronary artery [LAD] ligation) using a high-resolution (30 MHz) ultrasound system (Vevo 770, VisualSonics Inc., Toronto, ON, Canada). Radiofrequency (RF) signals of the left ventricle (LV) in longitudinal (long-axis) view and the associated electrocardiogram (ECG) were simultaneously acquired. Using a retrospective ECG gating technique, 2-D full field-of-view RF frames were acquired at an extremely high frame rate (8 kHz) that resulted in high-quality incremental displacement and strain estimation of the myocardium. The incremental results were further accumulated to obtain the cumulative displacements and strains. Two-dimensional and M-mode displacement images and strain images (elastograms), as well as displacement and strain profiles as a function of time, were compared between normal and infarcted mice. Incremental results clearly depicted cardiac events including LV contraction, LV relaxation and isovolumetric phases in both normal and infarcted mice, and also evidently indicated reduced motion and deformation in the infarcted myocardium. The elastograms indicated that the infarcted regions underwent thinning during systole rather than thickening, as in the normal case. The cumulative elastograms were found to have higher elastographic SNR (SNR(e)) than the incremental elastograms (e.g., 10.6 vs. 4.7 in a normal myocardium, and 6.0 vs. 2.4 in an infarcted myocardium). Finally, preliminary statistical results from nine normal (m = 9) and seven infarcted (n = 7) mice indicated the capability of the cumulative strain in differentiating infracted from normal myocardia. In conclusion, myocardial elastography could provide regional strain information at simultaneously high temporal (>/=0.125 ms) and spatial ( approximately 55 microm) resolution as well as high precision ( approximately 0.05 microm displacement). This technique was thus capable of accurately characterizing normal myocardial function throughout an entire cardiac cycle, at the same high resolution, and detecting and localizing myocardial infarction in vivo.     

Clinical Pharmacokinetics of Morphine

Morphine, the most widely used mu-opioid analgesic for acute and chronic pain, is the standard against which new analgesics are measured. A thorough understanding of the pharmacokinetics of morphine is required in order to safely and effectively use this analgesic in a wide variety of patients with different levels of organ function. A MEDLINE search was conducted to identify literature published between 1966 and January 2002 relevant to the pharmacokinetics of morphine. These publications were reviewed and the literature summarized regarding unique and clinically important elements of morphine disposition relative to its parenteral administration (including intravenous, intramuscular, subcutaneous, epidural and intrathecal administration), absorption profile (immediate release, controlled release, and sublingual/buccal, and rectal administration), distribution, and its metabolism/ excretion. Special populations, including infants, elderly, and those with renal/liver failure, have a unique morphine pharmacokinetic profile that must be taken into account in order to maximize analgesic efficacy and reduce the risk of adverse events.