银杏达莫注射液联合黛力新治疗急性缺血性脑卒中后抑郁临床疗效观察

目的:探讨银杏达莫注射液联合黛力新对急性缺血性脑卒中后抑郁的治疗效果。方法:选取符合标准的119例患者,随机分为2组,对照组60例,应用黛力新及缺血性脑卒中的常规治疗;试验组59例,在对照组治疗方案的基础上,联合应用银杏达莫注射液。2组均治疗14d,2组在治疗前后,采用HAMD-17及SDS评估患者抑郁的改变,ADL评估患者神经功能及日常生活能力的改变,并在治疗后3、6个月时随访,比较2组脑卒中的复发率。结果:治疗后,试验组HAMD-17、SDS及ADL评分改善均明显优于对照组(P0.05)。试验组治疗后3个月时脑卒中复发率及治疗后6个月累计复发率,分别低于对照组(P0.05)。结论银杏达莫注射液联合黛力新能显著改善急性缺血性脑卒中后抑郁,降低脑卒中的复发率。     

认知能力评测及训练对脑卒中早期患者疗效的影响

目的：观察本科室开发的视空间能力评测及训练软件系统（VETS）对脑卒中早期患者康复疗效的影响。方法：61例急性脑卒中患者随机分为VETS组31例和对照组30例,均接受以运动再学习疗法、针刺及神经肌肉电刺激等为主的康复治疗。VSET组在此基础上配合使用VETS。2组治疗前后均采用VETS和改良Barthel指数评定认知功能和ADL。结果：治疗1个月时,2组患者认知功能和ADL评分与治疗前比较均有提高（P〈0.01）;2组间比较,VETS组认知功能评分及治疗前后ADL差值均明显高于对照组（P〈0.01）。相关回归分析显示,认知功能的提高与ADL能力提高呈正相关关系。结论：通过VETS检测发现,急性脑卒中患者均存在不同程度认知功能障碍,进行针对性认知能力训练可有效加快患者治疗进程,促进认知功能恢复,提高ADL能力。     

集体康复模式在脑卒中二级预防及整体功能康复中的应用研究

目的观察集体康复模式对脑卒中偏瘫患者二级预防及整体功能康复的影响。 方法采用随机数字表法将100例脑卒中偏瘫患者分为观察组及对照组。2组患者均给予康复科常规护理及集体康复教育,对照组同时辅以常规康复训练,观察组则辅以集体康复训练。于干预4周时及随访时评价2组患者认知功能、日常生活活动（ADL）能力及运动功能,于干预结束6个月时复查血压（HP）、糖化血红蛋白（HbA1c）、低密度脂蛋白(LDL),随访卒中复发情况。 结果干预结束6个月随访时发现观察组血压达标率、糖化血红蛋白达标率、低密度脂蛋白达标率均明显高于对照组（P<0.05）,而卒中复发率明显低于对照组（P<0.05）;经4周干预后,观察组ADL、Fugl-Meyer运动功能评分(FMA)均明显高于干预前及对照组水平（P<0.05）;干预结束6个月随访时观察组蒙特利尔认知量表（MoCA)、ADL、FMA评分均明显高于干预前及对照组水平（P<0.05）。 结论集体康复模式干预能明显提高脑卒中偏瘫患者血压、糖化血红蛋白、低密度脂蛋白达标率,进而降低卒中复发率,有利于卒中二级预防;集体康复模式干预能明显改善卒中偏瘫患者认知功能、ADL及运动功能,且改善作用具有持续性;该康复干预模式值得进一步推广、应用。     

超敏C反应蛋白、同型半胱氨酸与脑卒中严重程度及日常生活活动能力相关性分析

目的：探讨血清超敏C反应蛋白（hs-CRP）、同型半胱氨酸（Hcy）与脑卒中严重程度、转归及ADL能力的相关性。方法：129例脑卒中患者（卒中组）应用乳胶增强散色比浊法测定发病≤24 h、30 d及6个月时血清hs-CRP及Hcy水平,并与97例正常人（对照组）比较。应用美国国立卫生院神经功能缺损评分（NIH stroke scale,NIHSS）检测卒中组患者神经功能缺损程度;Barthel指数（BI）评分评定ADL能力;6个月应用改良Rankin评分评定神经功能缺损程度及转归。结果：卒中组在发病≤24 h及30 d时与对照组比较,hs-CRP及Hcy均显著升高;与NIHSS及BI呈正相关（P〈0.01）。发病6个月后卒中组hs-CRP及Hcy与Rankin评分仍呈正相关（P〈0.05）,其他指标无统计学意义。结论：测定发病时血清中hs-CRP及Hcy水平可反映脑卒中神经功能受损的严重程度,对患者ADL预后及病情转归的预测有重要的临床价值。     

星状神经节阻滞联合认知训练治疗脑卒中后认知障碍

目的：观察星状神经节阻滞（SGB）结合计算机辅助认知训练（CACR）对脑卒中后认知功能障碍的改善效果.方法：脑卒中后认知功能障碍的患者60例,按随机数字表法分为2组各30例,2组患者均给予常规对症处理及CACR,观察组在此基础上加用SGB治疗.治疗前后对2组患者采用简易精神状态检查（MMSE）、神经行为认知状态检查量表（NCSE）和改良的Barthel指数（MBI）进行功能评定,并利用经颅多普勒超声（TCD）检测其左侧椎动脉（LVA）、右侧椎动脉（RVA）和大脑中动脉（MCA）的平均流速（Vm）.结果：治疗1个月后,2组MMSE、NCSE及MB评分均较治疗前明显提高（P＜0.01）,且观察组更高于对照组（P＜0.05）;2组LVA、RVA及MCA的Vm治疗后均明显低于治疗前（P＜0.01）,且观察组更低于对照组（P＜0.05）.结论：SGB结合CACR可改善脑循环提高脑血流量,促使脑卒中患者的认知功能及ADL能力恢复,具有较好临床应用价值.     

护理干预对提高脑卒中恢复期患者生活质量的研究

目的：探讨护理干预对提高脑卒中患者恢复期生活质量的影响。方法：将150例脑卒中患者随机分为干预组和对照组各75例,采用日常生活能力量表（ADL）和生活质量量表（SF-12）对两组刚出院脑卒中恢复期患者进行测评,6个月后进行相同测评,并对比结果;另外统计出院6个月时患者的抑郁症焦虑症发生率和脑卒中的复发率,并对比结果。结果：干预组和对照组比较,出院时ADL、SF-12评分无统计学差异（P〉0.05）。进行护理干预后6个月再次比较两组评分,以及抑郁症焦虑症发生率和脑卒中的复发率,出现明显差异,具有显著统计学意义（P〈0.05）。结论：护理干预可显著提高脑卒中恢复期患者出院后生活质量,值得推广学习。     

早期强化健康教育干预对急性脑卒中患者心理和日常生活能力的影响

目的：探讨早期强化健康教育干预对急性脑卒中患者心理和日常生活能力（ADL）的影响。方法：将123例急性脑卒中患者随机分为干预组和对照组。经治疗1～6个月后,采用ADL量表、神经功能缺损（AFI）与抑郁自评两表（SDS）评分。结果：两组AFI减少,ADL明显提高,SDS降低,但干预组改善明显（P〈0．01）。结论：急性脑卒中患者进行强化健康教育干预可减轻患者心理负担,有效改善患者神经功能缺损（AFI）,提高患者日常生活能力（ADL）。     

老年急性缺血性脑卒中患者血浆N端-脑钠肽前体水平的变化及与预后的关系

目的 通过分析老年急性脑卒中患者N端-脑钠肽前体（NT-pro-BNP）水平的变化,探讨NT-pro-BNP与老年急性脑卒中预后的关系.方法 将80例老年急性缺血性脑卒中患者按TOAST分型标准分为心源性卒中组和非心源性卒中组,每组40例;另选择同期健康体检的老年人（对照组）30例.分别于入院48 h,治疗第14、90天进行美国国立卫生研究卒中量表（NIHSS）评分;观察各组入院48 h和第14天的血浆NT-pro-BNP水平的变化及患者入院时血浆NT-pro-BNP水平与缺血性卒中患者预后的关系.结果 缺血性脑卒中患者入院48 h及入院第14天血浆NT-pro-BNP水平均较对照组明显增高（P＜0.05）;心源性卒中组血浆NT-pro-BNP水平较非心源性卒中组明显增高（P＜0.05）;心源性卒中组及非心源性卒中组入院第14天血浆NT-pro-BNP水平较48 h的NT-pro-BNP明显降低（均P＜0.05）.心源性卒中组及非心源性卒中组入院第14、90天的NIHSS评分均较入院48 h明显下降,尤以入院第90天降低更明显（P＜0.05或P＜0.01）.NIHSS评分≤6分组入院时血浆NT-pro-BNP浓度明显低于NIHSS＞6分组（P＜0.0l）.好转组入院时血浆NT-pro-BNP浓度明显低于死亡组（P＜0.05）.结论 BNP水平越高患者病情越严重,预后越差.老年急性缺血性脑卒中患者血浆NT-pro-BNP升高可作为预测急性缺血性脑卒中预后的一个危险因子.     

手工艺制作训练对脑卒中后抑郁患者疗效的影响

目的：探讨手工艺制作训练对改善脑卒中后抑郁患者的负性情绪,提高认知功能和ADL能力的作用。方法：60例脑卒中后抑郁患者分为A、B 2组各30例,均按脑卒中常规治疗,并给予抗抑郁药物及常规康复训练等治疗。A组增加刺绣、剪纸及贴画等手工艺制作训练。治疗前后分别采用汉密尔顿抑郁量表（HAMD）、简易精神状态评定量表（MMSE）、Barthel指数（BI）对患者抑郁程度、认知功能和ADL进行评定。结果：治疗2个月时2组MMSE和BI评分均有明显提高（P〈0.05）;HAMD评分明显下降。治疗6个月后A组MMSE及BI评分继续上升;HAMD除体重、日夜变化及睡眠障碍单项分与2个月时比较变化不明显外,其余各单项分仍持续下降（均P〈0.05）。B组与治疗2个月时比较,仅BI有上升。结论：辅助手工艺制作训练有助于改善脑卒中患者抑郁症状及认知功能,增强患者康复治疗的主动性,进而整体康复疗效明显。     

认知干预对社区脑卒中患者认知障碍的影响

目的探讨认知干预在社区脑卒中患者认知障碍康复中的价值，为社区认知康复干预提供依据。方法将92例符合人组标准的脑卒中后认知功能障碍患者以随机数字表法分为认知干预组与对照组，2组均接受规范、系统的社区康复治疗与指导，认知干预组在此基础上进行专门的认知康复训练。2组患者在人组时及治疗结束后分别采用神经行为认知状态检查（NCSE）量表、综合功能量表（FCA）、改良的巴氏指数（MBI）进行认知功能、运动功能和日常生活活动（ADL）能力的评定。结果认知干预组治疗后，NCSE各领域评分和总分、FCA评分及MBI评分均明显高于治疗前和对照组（均P〈0．05）。结论社区认知干预不仅能改善脑卒中患者的认知功能障碍，而且能促进患者运动功能与ADL能力的恢复。     

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.     

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.     

手转胎头术失败的原因与分娩结局临床分析

目的 探讨手转胎头术失败的原因与分娩结局.方法 选择2008年1月至2010年12月于我院住院分娩的持续性枕横位、枕后位产妇198例,根据行手转胎头术后结果分为成功组126例、失败组72例.比较两组分娩结局,对比分析失败原因.结果 失败组胎儿体质量≥3500 g的发生率[76.4％(55/72)]明显高于成功组[31.7％(40/126)],差异有统计学意义(x2=30.177,P=0.001)、失败组宫缩乏力发生率[58.3％(42/72)]高于成功组[38.1％ (48/126)],差异有统计学意义(x2=7.569,P=0.006)、失败组骨盆临界或轻度狭窄发生率[38.9％ (28/72)]高于成功组[23.8％(30/126)],差异有统计学意义(x2 =5.030,P=0.002)、失败组手转胎头时机不当(宫口开大＜6 cm、胎头位于坐骨棘上及宫口开大8～10 cm、胎头位于坐骨棘下≥2 cm)发生率[61.1％(44/72)]高于成功组[38.9％(49/126)],差异有统计学意义(x2=9.084,P=0.003).失败组母儿并发症(产后出血、产褥病率、胎儿窘迫、新生儿窒息)发生率高于成功组(x2 =9.586,P=0.002、x2=9.334,P=0.002、x2=5.910,P=0.015、x2=5.240,P=0.022)、失败组剖宫产发生率[72.2％(52/72)]明显高于成功组[34.1 ％(43/126),x2=26.641,P=0.001)].结论 手转胎头术能使难产变顺产,降低剖宫产率,减少母儿并发症,但须积极预防、处理导致手转胎头术失败的原因,对矫正失败后继续矫正及试产应慎重.     

Evidence-Based Pain Management and Palliative Care in Issue Four for 2009 of The Cochrane Library

ABSTRACT

The Cochrane Library of Systematic Reviews is published quarterly. Issue 4 for 2009 contains 4027 complete reviews, 1906 protocols for reviews in production, and 11447 one-page summaries of systematic reviews published in the general medical literature. In addition, there are citations of 600,000 randomized controlled trials, and 12,200 cited papers in the Cochrane methodology register. The health technology assessment database contains over 7500 citations. This edition of the Library contains 90 new reviews, of which 19 have potential relevance for practitioners in pain and palliative medicine.     

Wie zuverlässig sind Angaben zu nichtentzündlichen ausgedehnten Schmerzen?

ZusammenfassungFragestellung Es wurde geprüft, wie sich der Differenziertheitsgrad zweier Schmerzmessmethoden auf Angaben zur Ausgedehntheit klinischer Schmerzen auswirkt. Zugleich wurde der Referenzzeitraum variiert, über den die Patienten berichten sollten.Methode Erfasst wurde der Einfluss zu Lasten der Befragungsdifferenziertheit durch den Vergleich zweier Körperschema-Bildvorlagen. Drei Referenzzeiträume (Schmerz aktuell, letzte Woche, letztes halbes Jahr) wurden vorgegeben.Ergebnisse Patienten mit ausgedehnten Schmerzen gaben bei differenzierter Befragung um so mehr Schmerzen an, je weiter die Schmerzen zurück lagen und je größer der Berichtszeitraum war. Patienten mit gelenknahen Schmerzen gaben bei hoch differenzierter Befragung weniger ausgedehnte Schmerzen in der Vergangenheit an als bei globaler Einschätzung. Patienten mit Rückenschmerzen berichteten bei differenzierter Befragung zum aktuellen Schmerz über weniger ausgedehnte Schmerzen als bei globaler Befragung.Schlussfolgerung Die Angaben zur Schmerzausdehnung variieren vor allem bei Patienten mit ausgedehnten Schmerzen in Abhängigkeit von der Differenziertheit der Befragung. In diesen Fällen ist die Wahrscheinlichkeit erhöht, dass sich die Beschwerdesymptomatik zumindest teilweise erst in der Reaktion auf die situativen Befragungsbedingungen konstituiert und daher nicht auf andere Befragungsbedingungen generalisiert werden kann.