上海社区脊髓损伤者康复训练情况调查分析

摘要 目的：分析上海市社区样本脊髓损伤患者康复训练情况。 方法：在上海市养志康复医院（上海市阳光康复中心）参加社区康复指导员培训的脊髓损伤患者中开展问卷调查，调查内容是个人基本情况、受伤情况、康复认知和意向情况、康复训练历史情况等，同时对全市脊髓损伤者“希望之家”康复训练的情况进行调查。 结果：调查了16个区31名脊髓损伤者和全市21个脊髓损伤者希望之家。调查对象平均受伤24年，康复认知水平总体较高，了解及以上的比例高达85.0%，但少数患者对部分康复原则不了解。上海市各区希望之家开展康复训练的比例高达90.5%，患者对社区康复训练的好处、重要性和开展的必要性有明确认同，大部分人认同每月组织1—2次集中康复训练，这与实际情况一致。调查对象认为影响社区开展康复训练的第一位影响因素是缺乏专业人员指导（85.7%），影响患者定期参加社区集中康复训练的第一位因素是交通因素（64.5%）。54.8%调查对象在受伤1年内进行过早期康复训练。患者受伤1年以后参加机构康复训练的比例是87.1%，但训练次数较少，迄今平均5年参加0.48次训练。康复训练效果方面，机构康复训练最好，其次是社区康复训练，早期和家庭康复训练的效果有待进一步提升。 结论：上海脊髓损伤患者的康复训练已经初步形成了服务体系，未来应进一步加大脊髓损伤者早期康复训练和机构康复训练服务的供给。连续系统的康复训练模式是未来的发展方向，目前通过培训社区康复训练指导员，促进社区和家庭康复训练工作是可以探索的途径。     

问题解答

北京管庄医院杨振威医生问：社区对脑卒中如何进行康复指导？ 北京市垂杨柳医院袁伟红医生答：根据患者的具体情况，制定相应的训练计划与内容，教会患者及家属在家中进行康复训练和注意事项，鼓励其持之以恒，不懈努力，以获得最大限度的功能改善。     

认知障碍的远程康复进展

在美国 ,每年有七百万脑外伤患者 ,其中 10 %属中等程度外伤 ,严重者占 5 %～ 7% ,经积极救治后 ,大多数患者要接受出院回家的现实。即使运动功能恢复良好 ,脑损伤患者也会长期存在不同程度的认知与行为障碍[1] 。面对这些问题 ,患者家属往往束手无策 ,医护人员也是处于进退两难的境地。通过互联网建立的远程康复系统很好地解决了这个问题 ,使医院与社区、家庭人员之间的面对面沟通与交流成为现实。远程康复 ,特别是远程认知康复在国外发展迅速 ,方兴未艾[2 4] 。本文就国外远程康复及有关进展予以介绍并探讨。远程认知功能评估脑部损伤后…     

新疆乌鲁木齐市肢体残疾人康复服务供需现状调查

目的：调查新疆维吾尔自治区乌鲁木齐市肢体残疾人康复服务供求现状，发现问题并提出可能行之有效的改进措施。方法：随机抽取乌鲁木齐市500名20～49岁的持证肢体残疾人，通过问卷调查形式对其生活现状及康复服务供需情况进行调查。结果：2016年3月～2018年10月间共收取有效调查问卷458份，结果显示曾接受过康复相关服务（包括医院康复、社区康复、功能训练、辅助器具发放、职业康复）的比例为42.14%，接受辅助器具发放的占多数（28.72%）。曾接受过医院康复治疗或社区康复治疗的数量少，分别为3.98%和4.40%。接受功能训练的肢体残疾人占5.04%（不属于医院或社区康复的类型），无人接受过职业康复。进行无障碍家居改造者为4.59%，均未经康复专业人员指导。被调查者的康复训练需求为36.04%，辅助器具需求则达到47.27%，在家居无障碍改造方面，入门和通道、卫生间的改造需求者居多。结论：在新疆地区，乌鲁木齐市康复资源相对集中，但残疾人康复服务供需仍有显著差距。应从政府层面着手，完善分层级、分阶段的康复服务体系建设；残联应当加强与各级医院合作，提高残疾人康复服务专业化水平，缩小残疾人康复供需差距。     

浙江省安吉县农村3个自然村的社区康复现状

目的：采用问卷调查方式，对浙江省安吉县农村社区康复进行调查，以了解该地区社区康复的现状。方法：调查于2005—07／08进行。采用随机抽样方法，抽取浙江省安吉县3个自然村中37户有残疾者的家庭，进行入户问卷调查。问卷是按照1988年制订的《中国残疾人抽样调查残疾标准》的要求，结合当地农村卫生事业的现状设计的．主要调查的项目有：致残原因、残疾类型、自身所承担的康复治疗费用、所能享受的社区康复服务资源和患者的康复服务的需要等内容。同时以当地卫生局、民政机构和卫生院等为对象，调查当地卫生资源状况。结果：①调查结果显示，当地农村社区的残疾以肢体残疾为主（占67．6％），主要是意外事故所致（占51．4％）；所承担的康复治疗费用以自费为主（占70．3％）；18．9％的残疾者在县级以上医院进行过康复训练和治疗，有73．0％残疾者愿意选择在农村社区进行康复训练和治疗；59、5％的残疾者家庭感觉康复服务费用太高，有35．1％的家庭可以承受。②当地有医务卫生工作人员1270名，其中专业康复医生6名，经过一定康复知识培训的38名，当地具备初步从事康复条件的乡卫生院（所）及医院8座（21，1％），配备完整的社区康复医疗设施和人员的乡卫生院（所）为零。结论：安吉县农村社区康复的服务与患者的需要还存在一定的差距，服务水平低与费用高是目前当地农村社区康复的主要矛盾。     

脑外伤认知障碍的康复治疗进展

近年来，认知康复在脑外伤急性期和急性期之后的康复治疗中，越来越受到临床医生的重视。虽然脑外伤后认知障碍有一个自然恢复的过程，但适当的干预仍是至关重要的。临床上常见的脑外伤后的认知障碍主要表现在注意力和觉醒障碍、记忆障碍、感觉知觉功能障碍、智力和执行功能障碍、行为情绪和人格的变化等方面。本文就脑外伤后认知障碍的康复治疗的现状及进展综述如下：     

综合康复医疗对脑外伤患者认知的影响

目的：确认综合康复医疗对脑外伤患者认知障碍治疗的有效性。方法：将６６例符合入选标准的脑外伤患者随机分为试验组和对照组，试验组接受常规物理治疗及认知康复训练，对照组只接受物理治疗，两组治疗前均接受ＬＯＴＣＡ认知评估。治疗３个月后，两组患者再次接受ＬＯＴＣＡ评估。结果：试验组患者的认知功能较治疗前有明显提高（Ｐ〈０．０１），两组治疗后的认知功能。试验组优于对照组（Ｐ〈０．０１），结论：综合康复医疗可以     

社区康复对脑卒中恢复期患者日常生活活动能力的影响

目的:探讨社区康复对恢复期脑卒中患者日常生活活动能力的影响。方法:64例脑卒中患者随机分为社区康复组32例和对照组32例,两组均给予常规药物治疗,社区康复组采用康复医师制定的康复训练计划,由康复护士每周1次到患者家中指导患者进行家庭康复训练;对照组训练采取自行训练,两组分别于康复治疗前及康复治疗90d后做日常生活能力Barthel指数评分对比。结果:两组治疗后Barthel指数评分均较前有明显改善,社区康复组显著优于对照组(P<0.01)。结论:社区康复治疗对提高脑卒中康复期患者的日常生活活动能力具有良好的促进作用。     

康复训练改善脑卒中患者认知障碍的临床观察

目的：研究康复训练对脑卒中患者认知障碍的临床效果。方法：将48 例合并有认知障碍的脑卒中患者随机分为训练组和对照组，训练组在常规康复训练的基础上给予认知康复训练，对照组予以常规康复训练，训练时间为2个月。在训练前、训练后1个月及2个月分别用简易智能状态检查（mini-mental state examination, MMSE）量表、Fugl-Meyer量表及改良Barthel指数对患者认知、运动功能分级及日常生活活动能力进行评定。结果：两组患者训练前认知、运动功能分级及日常生活活动能力差异无显著性（P>0.05）。两组患者训练1个月时Fugl-Meyer量表评分及Barthel指数无明显差异（P>0.05），MMSE评分有显著差异（P<0.05）；2个月时，两组患者之间MMSE、Fugl-Meyer量表及Barthel指数存在明显差异（P<0.05）。结论：对于合并认知障碍的脑卒中患者，同时给予认知康复训练和常规康复训练，有利于其认知功能、运动功能和日常生活活动能力的改善。     

康复护理学

老年髋关节置换术患者的康复训练；屈指肌腱损伤修复术后康复护理的研究进展（综述）；手指操训练延缓老年轻度认知障碍；上海市部分医院骨科护士康复护理行为现状及其影响因素     

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.