口咽部吞咽障碍的治疗

0引言口咽部吞咽障碍的治疗包括恢复代偿功能疗法、口内矫治疗法、感觉运动协调疗法和吞咽动作演练疗法等,是治疗此项病变的主要方法,有效率可达80%以上[1,2].此类治疗方法有其特殊性.设计和指导此项工作的医师必须熟悉口咽部有关吞咽的生理解剖和口咽部动态造影检查的表现;必须在造影检查中观察吞咽失常的情况,选择和试验较为适合的治疗方法并在造影中观察其效果.但患者在实行代偿功能疗法过程中,却可在不了解生理解剖,“知其然而不知其所以然”的情况下,获得良好疗效.1动态造影是治疗的依据口咽部的吞咽动作非常迅速,约在0.75s内完成.口咽…     

肝硬化失代偿与“再代偿”

肝硬化分期评价体系从关注疾病进展规律到进一步细化急性失代偿时疾病状态分类,提出病因治疗后失代偿期肝硬化可再代偿的概念,系统补充了失代偿期肝硬化分期评价体系,其中门静脉高压、系统性炎症变化等多种因素可影响失代偿期肝硬化的临床转归。肝硬化再代偿这一新概念的提出,需要更多的临床证据去阐明包括病毒性肝炎等在内的病因治疗后获得“再代偿”患者的临床特征及其潜在的机制。     

COPD患者口咽部吞咽障碍研究进展

吞咽障碍是由于下颌、双唇、舌、软腭、咽喉、食管括约肌或食管功能受损而引起的不能通过吞咽安全有效地把食物由口腔送至胃腔中,导致未能获得足够营养和水分的进食困难。COPD 患者由于吞咽肌损害及呼吸与吞咽协调性差而容易发生吞咽障碍和误吸。误吸可能是 COPD 急性加重的诱因。因此我们应高度重视 COPD 患者误吸的发生。     

Nesiritide与失代偿心力衰竭治疗

Nesiritide是重组人脑钠肽,国外多项前瞻性临床研究证实它能较传统静脉治疗药物短期内迅速改善急性失代偿心力衰竭患者的血流动力学状况和症状,从而成为现代心力衰竭治疗的一种新药。但汇总分析调查其安全性发现,可增加短期病死率和肾功能损害的危险性,提示重组人脑钠肽的短期高效并不能代替长期安全性。是否能成为失代偿心力衰竭治疗新的一线用药,需要以病死率为终点事件的大规模前瞻性随机双盲对照研究提供循证医学依据。     

电生理疗法联合吞咽-摄食训练治疗脑卒中后吞咽障碍疗效观察

目的探讨电生理疗法联合吞咽-摄食训练治疗脑卒中后吞咽障碍的临床疗效。方法入选2016年6月至2017年12月在深圳市龙华区中心医院就诊治疗的脑卒中后吞咽障碍患者135例。依据治疗方法不同,按随机数表法将135例患者分为3组:康复训练组、电生理疗法组和联合治疗组,每组45例。康复训练组行单纯吞咽-摄食康复训练治疗,电生理疗法组行单纯电生理疗法,联合治疗组行电生理疗法联合吞咽-摄食训练进行治疗,均治疗4周。对比分析3组患者的治疗有效率、治疗前后Gugging吞咽功能评估量表(GUSS)评分、功能性经口摄食量表(FOIS)分级,并比较3组并发症发生情况。采用SPSS 19.0软件进行数据处理。依据数据类型,组间比较分别采用t检验或χ~2检验。结果联合治疗组患者的治疗显效率(53.3%vs 33.3%vs 35.6%)、总有效率(95.6%vs 73.3%vs 75.6%)均高于康复训练组和电生理疗法组,差异有统计学意义(P0.05)。治疗后,联合治疗组的GUSS评分[(14.26±2.59)vs(11.43±2.31)vs(11.98±2.40)]、FOIS评分[(4.02±1.27)vs(2.91±0.75)vs(3.52±0.74)]显著高于康复训练组及电生理疗法组(P0.05)。联合治疗组患者并发症总发生率(4.4%)较康复训练组(44.4%)和电生理疗法组(26.7%)显著降低,差异均具有统计学意义(P0.05)。结论电生理疗法联合吞咽-摄食训练治疗脑卒中后吞咽障碍疗效显著,可有效提高吞咽功能,减少并发症。     

NMES联合吞咽训练与单纯吞咽训练对脑卒中后吞咽障碍的对比研究

目的评估神经肌肉电刺激(NMES)配合吞咽训练治疗脑卒中后吞咽障碍的疗效。方法选择经过电视透视检查诊断的脑卒中后吞咽障碍病人95例,随机分成神经电刺激组与吞咽训练组,神经肌肉电刺激组45例,吞咽训练组50例。吞咽训练组仅给以单纯吞咽训练,而神经肌肉电刺激组同时给予神经肌肉电刺激和吞咽训练治疗。吞咽训练每次(30~60)min,神经肌肉电刺激每次20min,1次/日,每周连续治疗5d,休息2d,4周为一个疗程。神经肌肉电刺激组与吞咽训练组在治疗前后分别进行饮水试验和藤岛一郎吞咽障碍分级标准评估。结果两组治疗前饮水试验评分及吞咽障碍程度分级评分无统计学意义(P0.05);在治疗4周后,两组饮水试验评分均比治疗前显著降低,差异具有统计学意义(P0.01)。两组吞咽障碍程度分级评分比治疗前显著升高,差异具有统计学意义(P0.01)。电刺激组治疗后饮水试验评分较吞咽训练组低,差异具有统计学意义(P0.01);吞咽障碍程度评分较吞咽训练组高,差异具有统计学意义(P0.05)。4周治疗后,两组P物质含量均比治疗前显著升高(P0.05)。结论神经肌肉电刺激配合吞咽训练治疗脑卒中后吞咽障碍的疗效优于单纯吞咽训练;神经肌肉电刺激治疗吞咽障碍有效。     

老年吞咽障碍患者的吞咽功能康复研究

目的探讨在养老院开展老年吞咽障碍者吞咽功能康复训练的可行性。方法对宁波市8家养老院的86例老年吞咽障碍患者进行吞咽功能康复训练,主要包括基础吞咽训练、冰刺激疗法、摄食训练及针对性训练。训练2个月后采用洼田氏饮水试验进行评价。结果治疗前后的洼田氏饮水试验、吞咽能力评价分级改善均有统计学显著意义(P<0.05)。结论在养老院实施吞咽功能康复训练有助于改善老年人吞咽功能,延缓吞咽障碍的进展。     

乙型肝炎肝硬化失代偿期与酒精性肝硬化失代偿期患者血小板参数变化的临床分析

目的探讨不同HBV DNA水平乙型肝炎肝硬化失代偿期与酒精性肝硬化失代偿期血小板计数（PLT）及血小板平均体积（MPV）变化的临床意义。方法对36例健康人、38例HBV DNA〈105拷贝/ml乙型肝炎肝硬化失代偿期患者、36例HBV DNA〉105拷贝/ml乙型肝炎肝硬化失代偿期患者及31例酒精性肝硬化失代偿期患者的外周血PLT及MPV进行测定及分析。结果与健康人相比,乙型肝炎肝硬化及酒精性肝硬化患者PLT均下降,差异有统计学意义（P〈0.05）;与酒精性肝硬化失代偿期患者相比,HBV DNA〉105拷贝/ml乙型肝炎肝硬化失代偿期患者PLT下降,差异有统计学意义（P〈0.05）;不同HBV DNA水平的乙型肝炎肝硬化失代偿期患者PLT均下降,差异有统计学意义（P〈0.05）。与健康人相比,酒精性肝硬化失代偿期、HBV DNA〉105拷贝/ml乙型肝炎肝硬化失代偿期患者MPV均下降,差异有统计学意义（P〈0.05）;与酒精性肝硬化失代偿期患者相比,HBV DNA〉105拷贝/ml乙型肝炎肝硬化失偿代期患者MPV下降,差异有统计学意义（P〈0.05）;不同HBV DNA水平的乙型肝炎肝硬化失代偿期患者MPV变化,差异有统计学意义（P〈0.05）。结论乙型肝炎肝硬化失代偿期患者高载量HBV DNA对血小板参数降低有一定的影响。     

卒中后吞咽障碍荧光透视与临床吞咽功能的相关性

目的探讨吞咽障碍患者的临床表现与吞咽荧光透视检查(VFSS)所示结构和功能的相关性。方法连续收集2012年6月—2014年5月浙江中医药大学附属温州市中医院收治的56例卒中后吞咽障碍患者,选择性应用4种不同质地的食物进行测试,分别完成临床吞咽功能评估和VFSS检查,并用SPSS 20.0统计软件对该两种方法的各项观察指标进行单因素分析和多因素Logistic回归分析。结果临床表现与VFSS检查的点对应关系在口腔期有口内食物残留与口唇闭合异常(95%CI:1.430~101.468,P=0.022);软腭上抬差与口腔食物残留(95%CI:1.476~102.033,P=0.020);分次吞咽与口通过时间延长(95%CI:2.616~182.897,P=0.004);舌运动障碍及软腭上抬差与食团形成障碍(95%CI分别为1.468~50.795、1.220~13.825,P值分别为0.017、0.023);食物口角漏出、咽下困难与食团从舌根掉落会厌或气管(95%CI分别为1.146~125.459、1.657~174.400,P值分别为0.038、0.017)。在咽期主要有咽反射减弱与喉上抬程度弱(95%CI:1.150~92.815,P=0.037);咽下困难、吞咽延迟与吞咽反射启动触发时间长(95%CI分别为2.123~37.770、1.233~114.176,P值分别为0.003、0.032);分次吞咽、用力吞咽、哽噎感以及喉上抬差与咽期通过时间长(95%CI分别为1.619~223.316、1.061~31.445、2.834~132.707,P值分别为0.019、0.042、0.003);咽下困难与环咽肌开放不全(95%CI:1.037~24.115,P=0.045);喉上抬程度弱、咽部异物感、吞咽后呛咳与会厌谷或梨状窝滞留或残留(95%CI分别为1.046~13.685、1.116~87.741,P值分别为0.043、0.040);吞咽过程中咳嗽、进食呛咳与误吸(95%CI分别为0.010~0.921、0.037~0.826,P值分别为0.042、0.028)等,均存在明显相关性。结论某些临床症状表现与VFSS检查发现的吞咽功能异常密切相关,借助该规律可更简捷、安全地判断患者吞咽障碍程度及类型,为不能接受VFSS检查的卒中后吞咽障碍患者进行康复治疗作指导。     

吞咽造影在脑卒中后吞咽障碍的临床应用

吞咽困难是脑卒中后的常见症状,其发生率较高,若不及时进行评定和治疗,将严重影响患者的功能恢复,甚至威胁到患者的生存。吞咽造影检查是目前评估和诊断吞咽障碍的首选和理想方法,可以有效地评定脑卒中损伤的位置与吞咽困难的关系。     

Solid swallowing versus water swallowing: manometric study of dysphagia

The aim of the study was to investigate whether a soft solid bolus can induce abnormal manometric patterns in patients with dysphagia and normal standard manometry. The study group comprised 12 normal volunteers and 22 patients with dysphagia. Manometry was performed using 10 wet swallows followed by 10 swallows of marshmallow. The results show: (1) in normal subjects the mean contraction amplitude is significantly greater (P<0.035) and the velocity of propagation significantly slower (P<0.003) for soft solid swallows compared with wet swallows; (2) in normal subjects there are fewer abnormal contractions after soft solid swallows than after wet swallows; (3) in 15 patients, soft solid swallows induced nonperistaltic contractions and/or contractions of extreme amplitude and/or duration that were not observed after wet swallows; 94) in patients, the probability of inducing abnormal contractions after soft solid swallows is significantly greater than after wet swallows (P<0.0001). We conclude that soft solid swallowing is useful in the study of patients with dysphagia.Part of this work was presented by Dr. Argaman as a thesis, to the Technion Medical School, for his MD.     

Radiographic anatomy of the pharynx

The radiographic surface anatomy of the normal pharynx in infants, adolescents, and adults is reviewed with illustrations of various radiographic techniques for evaluation. Maneuvers that can be utilized to demonstrate certain portions of the anatomy are discussed. The effect of patient posture on the pharyngeal contours is illustrated and discussed.     

Mechanisms of compensation and decompensation in dilated cardiomyopathy

Left ventricular (LV) function was evaluated in 32 patients with dilated cardiomyopathy (DC) who underwent cardiac catheterization during the past 6 years (group 4), and the results were compared with the data of 30 normal subjects (group 1). The patients were divided into mildly (group 2, 12 patients) and severely symptomatic subgroups (group 3, 20 patients). DC was characterized by dilated and poorly contracting left ventricle with increased muscle mass, reduced cardiac output and elevated systemic vascular resistance. LV volume was larger, ejection fraction was lower, and end-diastolic and end-systolic stresses were higher in group 3 than in groups 1 and 2. No significant differences were seen in LV muscle mass and wall thickness between groups 2 and 3. A significant inverse correlation was seen between ejection fraction and end-systolic stress in patients with DC (Y = -0.05x + 48.7, r = 0.57, p less than 0.01). The slope of the correlation line between end-systolic stress and volume in DC (Y = 1.20x + 135, r = 0.52, p less than 0.02) was less steep than that of normal subjects (Y = 3.68x + 40, r = 0.64, p less than 0.001). These observations indicate that the primary problem of DC is depressed contractility.(ABSTRACT TRUNCATED AT 250 WORDS)     

吞咽障碍患者的咽和食管钡剂造影检查

0引言咽和食管的钡剂造影检查是诊断吞咽障碍首选的和基本的方法.此法所显示和记录的资料甚为可靠,常被认为是评价吞咽障碍具体细节失常的“黄金标准”.用于检查吞咽障碍的咽和食管钡剂造影检查与传统的上胃肠道钡剂造影检查(UGI)不同.后者通常不作咽和食管颈段的观察,因钡剂在该段通过迅速,亦较难查出异常改变的具体情况.前者通常由3种方法组成,包括:(1)传统法造影,主要指钡剂的单对比造影,特别是其充盈相;(2)双对比造影;(3)动态造影(dynamicradiography,videofluorography),即用录像方法记录其动态表现.3种方法均需在透视监视下进行,前2…     

Systolic blood pressure in cardiac decompensation and during compensation

The systolic blood pressure fell in 45.7 per cent of unselected cases of cardiac failure as compensation became established. We observed this fall in cases of aortic regurgitation, mitral regurgitation, chronic myocarditis, emphysema, and chronic nephritis.It is probable that a combination of mechanical factors and increased tonus of the vasomotor center are responsible for the initial rise in systolic blood pressure during decompensation.     

吞咽的咽喉检查和内镜检查

0引言在吞咽障碍的各种检查方法中,对咽喉部的目视检查是最直接,最简单易行的检查,而现代内镜技术的发展使内镜对此范围的诊断具有更加方便可靠的新价值[1].1口腔、咽和喉的检查(非内镜)1.1设备和患者准备进行此项检查的设备相当简单.主要有:压舌板;纱布棉球;光源(头灯或能反射外来光源的头镜);喉镜;喉镜加热器或去雾剂;手套.患者取坐位,不需特别准备.1.2检查技术检查医师应首先对患者的一般情况作一初步观察.如意识状态,病情程度,有无呼吸困难,可否配合检查等.应与患者交谈,了解其发音情况;如有无发音困难,有无鼻音、嘶哑音、喘音(breathy)…