老年人中风的临床康复研究

为评价康复疗法对老年人中风的治疗效果．作者观察了60例（观察组）在中西药物与针灸的相同治疗基础上加用康复疗法的老年中风患者，并与对照组进行比较，结果观察组治疗后神经功能缺损积分和总的生活能力均较对照组有改善，康复疗法对老年人中风各型均有显著疗效。     

SOCIETAL BURDEN OF STROKE REHABILITATION: COSTS AND HEALTH OUTCOMES AFTER ADMISSION TO STROKE REHABILITATION

ObjectiveTo estimate societal costs and changes in health-related quality of life in stroke patients, up to one year after start of medical specialist rehabilitation.DesignObservational.PatientsConsecutive patients who received medical specialist rehabilitation in the Stroke Cohort Out-comes of REhabilitation (SCORE) study.MethodsParticipants completed questionnaires on health-related quality of life (EuroQol EQ-5D-3L), absenteeism, out-of-pocket costs and healthcare use at start and end of rehabilitation and 6 and 12 months after start. Clinical characteristics and rehabilitation costs were extracted from the medical and financial records, respectively.ResultsFrom 2014 to 2016 a total of 313 stroke patients completed the study. Mean age was 59 (standard deviation (SD) 12) years, 185 (59%) were male, and 244 (78%) inpatients. Mean costs for inpatient and outpatient rehabilitation were US$70,601 and US$27,473, respectively. For inpatients, utility (an expression of quality of life) increased significantly between baseline and 6 months (EQ-5D-3L 0.66–0.73, p = 0.01; visual analogue scale 0.77–0.82, p < 0.001) and between baseline and 12 months (visual analogue scale 0.77–0.81, p < 0.001).ConclusionOne-year societal costs from after the start of rehabilitation in stroke patients were considerable. Future research should also include costs prior to rehabilitation. For inpatients, health-related quality of life, expressed in terms of utility, improved significantly over time.LAY ABSTRACTThe objective of this study was to estimate societal costs and changes in health-related quality of life in stroke patients, up to one year after the start of rehabilitation. Participants were stroke patients who received inpatient or outpatient rehabilitation. They completed questionnaires on quality of life, absenteeism, out-of-pocket costs and healthcare use at start and end of rehabilitation and 6 and 12 months after the start of rehabilitation. Rehabilitation costs were obtained from the financial records. From 2014 to 2016 a total of 313 patients completed the study. Mean age was 59 years, 185 (59%) were male and 244 (78%) inpatients. Mean costs for inpatient and outpatient rehabilitation were $70,601 and $27,473, respectively. For inpatients, health-related quality of life increased significantly between baseline and 6 months, and between baseline and 12 months. In conclusion, societal costs one year after the start of rehabilitation were considerable and health-related quality of life improved for inpatients.Key words: stroke, rehabilitation, cost analysis, utility, health-related quality of life

The number of people living with stroke in Europe is expected to increase from 1.1 million per year in 2000 to 1.5 million per year in 2025 (1). Stroke survivors may experience severe functional impairments, including impairments in physical functioning (2), cognition (3), and speech/language (4), which, in turn, lead to limitations in activities and participation and to worse quality of life (QoL) (5). Specialist rehabilitation was proven to be effective in improving functional outcomes after stroke (6), such as motor function, balance, walking speed and activities of daily living (7–9). Furthermore, in stroke patients admitted for inpatient rehabilitation, QoL increased significantly between admission and discharge (10).Besides the fact that rehabilitation after stroke is effective, rehabilitation was also found to be the main contributor to the costs of post-stroke care, according to a systematic review published in 2018 including 42 publications (11). Costs of post-stroke care, but not those of acute care, were included. Rehabilitation in different care settings was evaluated, which included primary, secondary and tertiary care, and the costs often applied to part of the patients and were not described in detail. For the delivery of value-based healthcare (VBHC), it is important to consider not only the health effects and patient-reported outcome measures, but to also evaluate the costs of care, since it is important to achieve good patient outcomes per dollar spent (12, 13).The aim of the current study was therefore: (i) to estimate the 1-year societal costs from the start of the rehabilitation in stroke patients treated in a medical specialist rehabilitation facility in The Netherlands; and (ii) to evaluate health changes in terms of utility (an expression of quality of life) over that year.     

CRITICAL COMPONENTS OF A SLEEP ASSESSMENT FOR CLINICAL PRACTICE SETTINGS

Disturbed sleep affects multiple aspects of an individual's life, including daytime activity, social interactions, mood, and quality of life. Individuals with mental health issues often experience disturbed sleep, and particular attention must be given to underlying lifestyle, family issues, and health problems that may perpetuate a sleep complaint. In addition to patients' medical conditions, clinicians should ask patients about their sleep-wake patterns and medication use, since these factors contribute to disturbed sleep and adverse mental health outcomes. This article provides advanced practice nurses with a brief sleep assessment guide for use in psychiatric practice with adults or children.     

A TEN TASK-BASED PROGRESSION IN REHABILITATION AFTER ACL RECONSTRUCTION: FROM POST-SURGERY TO RETURN TO PLAY – A CLINICAL COMMENTARY

There is a need to improve patient outcomes after anterior cruciate ligament reconstruction (ACLR). To do this likely involves a strong focus on optimizing rehabilitation processes and practices. Movement re-training is considered an important element of rehabilitation after ACLR, but there is a lack of knowledge on the ‘how’ and ‘what’ movement re-training should occur after ACLR. In its basic form, movement re-training after ACLR is about progressing a patient through gradually more demanding tasks from the point of being able to walk to being able to perform highly complex sports movements. However, there is a lack of guidance on when to implement certain tasks (e.g. when to begin running) and how to transition between tasks. This paper presents a 10 task progressions system which can form an important aspect of the movement-based re-training process, providing structure and patient autonomy. Monitoring knee function and movement and neuromuscular status to safely transition between these tasks is important. Although this task-based progression is designed for patients following a rehabilitation program after ACLR, it may have generalizability for all major lower limb injuries. The task-based progression was formed by combining theory, the best available evidence, and significant practice experience applied to movement re-training after ACLR. This approach supports patient autonomy, medical team communication and collaboration and can provide structure to the movement re-training process.     

AN INTRODUCTORY COURSE TO FACILITATE THE IMPLEMENTATION OF A CLINICAL PHARMACY PROGRAMME IN IRAQ

An introductory course in clinical pharmacy is discussed which is designed to implement the basic concepts of clinical pharmacy as well as assist in the stepwise transition from a pharmacy school, with primary emphasis on dispensing, to a more clinically (patient) oriented pharmacy programme. The course is composed of a 2-h didactic session and a 3-h observation session per week for 3 months followed by daily 3-h practical clerkships for 4 months in the following areas: in-patient and out-patient hospital pharmacy, clinical laboratory, internal medicine, paediatrics, surgery, and retail pharmacy. Weekly 2-hour discussion sessions at the college or site of the clerkship are scheduled to review these experiences and introduce additional topics such as patients rights, pharmacist-patient relations, and pharmacy relations with other health professionals. This course promotes the development of a clinically oriented attitude in students and staff members in the college, and decreases the trauma of direct change from a product-oriented to a more patient-oriented curriculum.     

EVIDENCE-BASED MEDICINE AND OSTEOPOROSIS: A COMPARISON OF FRACTURE RISK REDUCTION DATA FROM OSTEOPOROSIS RANDOMISED CLINICAL TRIALS

The goal of osteoporosis therapy is to prevent fractures, and many therapies are available for this disease. Regarding proven fracture benefit, however, the quality of the randomised clinical trial evidence varies substantially among therapies. The purpose of this paper is, therefore, to review the published osteoporosis randomised clinical trial literature and to assess the quality of the evidence. Although more than 35 randomised trials for different therapies were reviewed, only alendronate and vitamin D plus calcium have clearly demonstrated a fracture benefit, with alendronate providing the greatest relative risk reduction. Quality clinical trial fracture data for calcitonin, etidronate, fluoride, hormone replacement therapy, parathyroid hormone, calcitriol (and other vitamin D preparations), vitamin D and calcium monotherapy, and selective oestrogen receptor modulators are either lacking or inconclusive or published only as abstracts.     

HOSPITAL READMISSION IN STROKE SURVIVORS ONE YEAR VERSUS THREE YEARS AFTER DISCHARGE FROM INPATIENT REHABILITATION: PREVALENCE AND ASSOCIATIONS IN AN ASIAN COHORT

ObjectiveTo examine the prevalence and risk factors for readmission after inpatient rehabilitation in stroke survivors, in a developed multi-ethnic Southeast Asian country.MethodsA retrospective cohort study of 1,235 stroke survivors who completed inpatient rehabilitation in a tertiary rehabilitation centre.ResultsA total of 296 (24.0%) patients with stroke were readmitted within the first year, and 87 (7.0%) patients were readmitted 1–3 years after stroke. Significant risk factors for readmission of patients in the first year post-stroke were older age (p = 0.027), lower admission Functional Independence Measure (FIM) motor (p = 0.001) and cognition scores (p = 0.025), a Charlson Comorbidity Index (CCI) ≥1 (p < 0.001) and the presence of at least one medical complication during initial hospitalization (p < 0.001), while FIM gain was found to be protective (p < 0.001). Looking at readmission after 1 year post-stroke, a CCI ≥1 (p < 0.001) and the presence of medical complications during initial hospitalization (p < 0.001) were risk factors for readmission, while FIM gain (p = 0.001) was protective. Common causes for readmission include recurrent stroke and falls.ConclusionThere is a high readmission rate in stroke survivors, even after the first year post-stroke. Interventions, such as fall risk assessments, vaccinations, meticulous catheter care, intensified secondary risk factors interventions and continued post-discharge rehabilitation, may hold promise for reducing readmission rates.LAY ABSTRACTReadmission of stroke patients results in high morbidity and healthcare costs. Although many studies have examined readmission of stroke survivors in the first year post-stroke, there is a scarcity of studies into readmission after the first year post-stroke, and the effect of rehabilitation on these patients. This study investigated 1,235 patients 3 years post-stroke rehabilitation. Of these patients, 296 (24.0%) were readmitted within the first year, and 87 (7.0%) were readmitted 1–3 years post-stroke. Significant risk factors for readmission included older age, lower functional scores on admission, presence of chronic medical conditions and medical complications during their initial hospital stay. However, functional improvement during inpatient rehabilitation was associated with a reduced readmission rate. This study demonstrates that there is a high readmission rate even after the first year post-stroke. It also highlights the importance of rehabilitation in reducing readmission in stroke survivors.Key words: patient readmission, stroke rehabilitation, stroke, cerebral haemorrhage, risk factors, treatment outcome

Patients with stroke admitted to inpatient rehabilitation often have significant neurological dysfunction, resulting in a high risk of readmission for acute care after discharge. Hospital readmissions may indicate unresolved problems, quality of immediate post-hospital care, or a high degree of morbidity, and have a significant impact on healthcare costs (1). Studies also report a relatively high readmission rate between 30 days and 1 year post-stroke. Ottenbacher et al. reported a 30-day readmission rate of 12.7% after discharge from inpatient rehabilitation, based on Centers for Medicare & Medicaid Services data (2), while Zhong et al. reported a pooled 1-year hospital readmission rate of 42.5% in a meta-analysis of patients with stroke in general (1). However, there are few studies investigating the readmission rate of patients with stroke more than one year after discharge from inpatient rehabilitation.Various risk factors linked to readmission within the first year have been identified in various studies and systemic reviews, including older age, previous history of stroke and cardiovascular disease, diabetes mellitus, length of acute hospitalization and complications during acute stay, compared with control groups who were not readmitted (1–5). Less is known about the long-term risk factors for stroke survivors who survive the first year after stroke without any readmissions, and if these risk factors are different from those previously mentioned. Although a non-white ethnicity has been suggested as a risk factor for readmission (3), this finding may not be applicable to other non-Western populations with different socioeconomic demographics. Several studies have also identified infections, cardiovascular causes, and recurrent stroke as leading causes for readmission within one year after discharge, although it is uncertain if these findings are applicable for readmissions beyond 1 year post-event (1).While pre-stroke and post-rehabilitation functional scores have also been increasingly recognized as significant predictors of readmission (6, 7), this requires further validation, as many of these studies are based on billing or administrative databases, and questions on the reliability, accuracy and completeness of these data remain (8). It is also unclear if functional gains during rehabilitation have a sustained effect on readmission rates beyond 1 year post-stroke.The aim of this study is to examine the prevalence and risk factors for readmission after inpatient rehabilitation in stroke survivors, within 1 year vs 1–3 years post-stroke, in a developed multi-ethnic Southeast Asian country.     

103例胸腔镜手术临床分析

１０３例胸腔镜手术临床分析北京医科大学第一医院心胸外科（１０００３４）刘桐林，王俊，陈鸿义，崔英杰，李曰民北京卫戌区医院外二科（１０００２６）王钵我院自１９９２年１１月～１９９５年８月，经胸腔镜行胸部手术１０３例，男性７７例，女性２６例；年龄２．５～...     

CHANGES IN PHARMACY PRACTICE DUE TO A CLINICAL PHARMACY TRAINING PROGRAMME FOR A GROUP OF COMMUNITY HOSPITALS

Education for and the practice of Clinical Pharmacy in South Africa have been neglected. This paper describes one attempt to improve matters. An initial survey of pharmacies, pharmacists and other staff in a small group of private hospitals determined the level of Clinical Pharmacy organization and services. The results were used to design a Clinical Pharmacy (training) Programme for selected pharmacists in the group. The programme consisted of six units, each of which was presented in at least a full-day session, with strong audiovisual support, small group discussion and rigorous exercises. During and after each session, implementation and application in the respective hospitals were monitored, as were participants' reactions. Clinical Pharmacy services increased markedly as a result of the programme, as did job satisfaction and motivation among most of the participating pharmacists.     

BEYOND STATISTICAL SIGNIFICANCE: CLINICAL INTERPRETATION OF REHABILITATION RESEARCH LITERATURE

Evidence‐based practice requires clinicians to stay current with the scientific literature. Unfortunately, rehabilitation professionals are often faced with research literature that is difficult to interpret clinically. Clinical research data is often analyzed with traditional statistical probability (p‐values), which may not give rehabilitation professionals enough information to make clinical decisions. Statistically significant differences or outcomes simply address whether to accept or reject a null or directional hypothesis, without providing information on the magnitude or direction of the difference (treatment effect). To improve the interpretation of clinical significance in the rehabilitation literature, researchers commonly include more clinically‐relevant information such as confidence intervals and effect sizes. It is important for clinicians to be able to interpret confidence intervals using effect sizes, minimal clinically important differences, and magnitude‐based inferences. The purpose of this commentary is to discuss the different aspects of statistical analysis and determinations of clinical relevance in the literature, including validity, significance, effect, and confidence. Understanding these aspects of research will help practitioners better utilize the evidence to improve their clinical decision‐making skills.

Level of evidence:

5