社区分级康复管理模式对脑卒中后居家患者功能恢复的效果评价

目的 探讨专科医院-社区-家庭的分级康复管理模式的使用效果,对社区规范化管理的脑卒中患者开展评价。 方法 选取2014年3月—2015年2月于上海专科医院住院经CT或磁共振确诊的脑卒中患者共计100例,随机分为康复组50例和对照组50例。康复组给予专科医院病房-社区卫生服务中心-家庭的三级脑卒中康复:(1)初级康复:急性期时在医院的治疗;(2)二级康复:社区卫生服务中心(站)对患者出院后培训3个月,至少2次/周,40 min/次,同时对脑卒中患者发放康复锻炼宣传手册;(3)三级康复:社区的康复医师到患者的家庭进行康复训练9个月,最少1次/2周,30 min/次。社区康复医师同时需教会患者家属正确的护理方法,非治疗时间要求患者在家属的帮助下完成护理和康复训练,1~2次/d。对照组继续进行一般化管理。应用康复运动功能评定测量表(Fugl-Meyer)[8]、改良Barthel指数、功能独立性评定法(FIM)、生活质量量表(SS-QOL量表)评定患者的治疗效果。 结果 康复治疗前,2组Fugl-Meyer评分、改良Barthel指数和FIM评分差异无统计学意义(P>0.05)。康复治疗后6个月和12个月,康复组Fugl-Meyer评分、改良Barthel指数和FIM评分均明显高于对照组,差异有统计学意义(P<0.01)。康复治疗后12个月,康复组SS-QOL得分高于对照组,差异有统计学意义(P<0.01)。 结论 通过规范化管理,促进脑卒中患者自理能力恢复,对提高生活质量有很好的作用,具备良好的社会经济效果。      

Influence of chronic kidney disease and haemodialysis on stroke outcome

INTRODUCTIONStroke patients with underlying chronic kidney disease (CKD) and those on haemodialysis have complex rehabilitation needs, and their survival and functional outcomes are limited. This study aimed to review post-stroke survival and functional outcomes following rehabilitation in patients with CKD and those on haemodialysis.METHODSWe conducted a retrospective analysis of consecutive stroke patients with underlying CKD (Stages G3b, G4 and G5; n = 30) and those on dialysis at the time of stroke (n = 7), who underwent in-patient rehabilitation between June 2008 and May 2017. The mean duration of follow-up was 56 months. Demographic details, associated comorbidities and laboratory parameters were reviewed. Baseline and follow-up scores of the National Institute of Health Stroke Scale (NIHSS) and Functional Independence Measure (FIM), and dates of death of the patients were analysed.RESULTSOf the 37 consecutive stroke patients (mean age 64.7 years), 34 had ischaemic stroke and three had haemorrhagic transformation. Significant improvements in NIHSS and FIM scores were observed from the time of admission to after discharge. Older age, longer duration of hospital stay, lower estimated glomerular filtration rate and low haemoglobin levels were all significantly related to mortality.CONCLUSIONDespite significant functional and neurological improvements following rehabilitation, stroke patients with underlying CKD had higher average duration of hospital stay, more recurrent hospitalisations and poorer survival outcomes than those without underlying CKD. This could be attributed to the complications associated with CKD rather than stroke. Multidisciplinary community rehabilitation may be an alternative to reduce recurrent hospitalisations and morbidity in this group of patients.     

院前GCS中运动评分与重型颅脑外伤患者预后的关系

目的： 分析Glasgow 昏迷分级（GCS）中运动评分与重型颅脑外伤（severe traumatic brain injury, sTBI）患者死亡率及愈合结果之间的关系,探讨运动评分应用于院前评估的可靠性。方法： 回顾性分析sTBI患者出院病历,统计患者到达急诊室时的GCS评分。预后指标包括ICU死亡率,存活者（生存时间超过1个月）ICU时间、出院时的Glasgow结果分级（GOS）、伤后第6个月的GOS。结果： 本组患者共140例,65例（46.4%）在ICU治疗期间死亡,入院时总GCS评分及睁眼、言语和运动评分与ICU死亡率之间均存在显著性相关,评分越低,死亡率越高,其中最为相关的是总GCS、运动评分。生存时间超过1个月的患者中,运动评分与出院时GOS和伤后第6个月GOS之间均存在显著性相关,评分越高,愈合结果越好。结论： GCS中运动评分与sTBI患者死亡率和愈合结果之间存在显著性相关,可以替代总GCS,作为院前评估指标。
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Evidence-based care and outcomes of acute stroke managed in hospital specialty units

OBJECTIVES: To assess the use of evidence-based investigations and treatments in patients with acute stroke in selected Australian hospitals and to compare management and outcomes between stroke and other types of hospital specialty unit. DESIGN: Retrospective, multicentre audit of hospital case files. SETTING: Eight metropolitan tertiary-care hospitals from five Australian States. SUBJECTS: 300 consecutive patients from each hospital admitted between 17 September 1999 and 23 May 2001 and having a discharge diagnosis of stroke or transient ischaemic attack. MAIN OUTCOME MEASURES: Use of investigations and treatments supported by best available evidence; comparison of management and outcomes between stroke, neurology, general medical and geriatric units. RESULTS: 2383 patients were audited (median age, 72.7 years; 52% men); 72% had ischaemic events, and 28% haemorrhagic events. Use of investigations and treatments varied between hospitals and types of unit. Stroke units or teams cared directly for 23% of patients (range across hospitals, 0-100%). Although 47% of patients with ischaemic events presented within 3 hours of symptom onset (when thrombolysis might provide benefit), only nine (2%) received thrombolysis. Angiotensin-converting enzyme (ACE) inhibitors were given to 28% of survivors at discharge (range, 14%-38%). Stroke units were more likely to use diagnostic tests, while neurology units were more likely to prescribe heparin acutely for patients with ischaemic stroke (not recommended for patients in general), and geriatric units were less likely to discharge patients with atrial fibrillation on anticoagulation therapy. Outcomes also varied significantly between types of unit. In-hospital survival rates were 90% (stroke units), 91% (neurological units), 82% (general medical units) and 79% (geriatric units) (P < 0.001). Stroke units and neurological units sent more patients home than the other units. Stroke units also sent fewer patients to rehabilitation and had longer mean length of stay. CONCLUSIONS: Acute stroke care varies between Australian tertiary-care hospitals and types of specialty unit, with suboptimal use of many evidence-based interventions.     

Stroke audit

Medical audit is vital to ensure continuous quality assurance and quality improvements. We did a retrospective study to ascertain the adequacy of clinical documentation and the factors hindering early discharge after an acute stroke in a restructured hospital. The medical records of all patients with acute stroke who died or were discharged from a restructured hospital in Singapore in January and February 1999 were reviewed retrospectively. Demographic data and the presence or absence of clinical documentation were noted. Factors hindering the discharge of patients at Day 5, Day 10 of stroke and at final discharge were noted and classified into: stroke-related, complications of stroke, medical-related and social factors. There were 101 patients in the study cohort, 55 males (54.5%) and 46 females (45.5%). The mean age was 67.9 years (SD 12.3). Documentation in Barthel scores (0%), presence of depression (0%), mental scores (1.0%), visual problems (10.0%), bladder continence (39.6%), admission functional status (37.6%) and dysphagia (52.5%) were deficient. The mean length of stay (LOS) was 13.0 (SD 14.2) days. The main factor hindering discharge at Day 5 (90.4%), Day 10 (95.2%) and at final discharge (82.1%) was stroke-related problems. Poor function (60.3%) and dysphagia (15.8%) were the 2 most common stroke-related problems hindering final discharge. Complications of stroke, medical-related problems and social reasons hindered final discharge in 10.8%, 17.8% and 2.9% of patients respectively. This audit revealed inadequacy in clinical documentation in patients with acute stroke. The main hindrance to final discharge of patients was stroke-related problems. The 2 most important stroke-related problems were poor function and dysphagia.     

Predictors of mortality in mechanically ventilated patients

Objectives: There are scarce data from India validating scoring systems used to predict outcome in patients requiring mechanical ventilation. This study prospectively compared the organ system failure (OSF), the acute physiology and chronic health evaluation (APACHE) II, and the APACHE III, scores on patients requiring mechanical ventilation in the medical intensive care unit, to predict outcome. Methods: 200 consecutive patients requiring mechanical ventilation in a medical intensive care unit were recruited. OSF, APACHE II, and APCHE III scores were calculated at admission and daily for one week or until discharge in all patients. Other variables recorded include age, sex, diagnosis, oxygen therapy before ventilation, complications on ventilation, duration in hospital before ventilation, duration of ventilation, type of respiratory failure, alveolar arterial oxygen gradient, P/F ratio, use of tracheostomy, time on ventilator before tracheostomy, muscle relaxant used, fluid balance, inotrope support. Logistic regression analysis and area under the curve were computed to determine which variables independently predict outcome. Results: Of the 200 patients, at discharge 143 patients (71.5%) had died. The factors that independently predicted outcome among these patients on mechanical ventilation were the type of respiratory failure (type I) OR = 2.7 (p = 0.02), the use of inotropes OR 2.4 (p = 0.04), and the APACHE II score OR = 1.8 (p = 0.008) for every five point increase in APACHE II score. Conclusions: Type 1 respiratory failure, the use of inotropes, and the APACHE II score measured at admission are significant independent predictors of mortality in the patients on mechanical ventilation.     

分部分期针刺联合Bobath技术在脑卒中偏瘫患者治疗中的应用

目的 探究分部分期针刺联合神经发育疗法(Bobath技术)对脑卒中偏瘫患者的康复疗效.方法 选取2018年10月—2020年12月期间平顶山市第一人民医院收治的脑卒中偏瘫患者146例,按照随机数字表法分为对照组和观察组,每组各73例.两组患者均给予控制血压、抗凝、抗血小板聚集、营养神经等常规治疗,在此基础上,对照组予以...     

联合卒中单元治疗急性脑卒中的临床观察

目的观察在联合卒中单元模式下治疗急性脑卒中的疗效。方法选择同期住院急性脑卒中患者200例,分为A、B两组各100例,A组患者在联合卒中单元病房内治疗,B组普通病房治疗。观察治疗14、90天神经功能缺损评分(NIHSS),Barthel指数(BI)。90天改良Rankin量表(mRS)评分及临床疗效。结果治疗14天后两组NIHSS、BI比较P<0.05,90天后临床有效率A组为92%,B组为89%,P<0.01;生活能力mRS评分有明显改善,P<0.01。结论联合卒中单元病房内治疗急性脑卒中疗效好。     

重症监护病房儿童脑卒中临床特征和功能结局分析

目的 探讨儿童重症监护病房(PICU)脑卒中临床特征和分析功能结局的危险因素。方法 选取2018年7月—2022年6月复旦大学附属儿科医院PICU收住的脑卒中连续病例163例,以出院时脑功能分类量表评分(范围1～6分)≥4分为功能结局预后差。采集临床特征,通过多因素logistic回归分析,评估功能结局预后差及院内死亡的危险因素。结果 163例脑卒中患儿中男88例(54.0%),起病年龄为4.5(1.2,9.3)岁;缺血性脑卒中(IS)84例,出血性脑卒中(HS)79例,急性期总体出院病死率为16.6%,IS和HS病死率分别为8.3%(7/84)和25.3%(20/79);55例(33.7%)出院时功能结局预后差;136例出院存活患儿中,95例(69.9%)遗留残疾;收入PICU时的改良格拉斯哥昏迷评分(GCS)低(OR=0.658,95%CI:0.582～0.743,P<0.001)与出院时功能结局预后差显著相关;HS(OR=3.071,95%CI:1.121～8.417,P=0.029)和改良GCS低(OR=0.738,95%CI:0.648～0.840,P<0.001...     

The effect of socioeconomic status on outcomes for seriously ill patients: a linked data cohort study

OBJECTIVE: To investigate the association between socioeconomic status (SES) and outcomes for seriously ill patients. DESIGN AND SETTING: A retrospective cohort study based on data from an intensive care unit clinical database linked with data from the Western Australian hospital morbidity and mortality databases over a 16-year period (1987-2002). MAIN OUTCOME MEASURES: In-hospital and long-term mortality. RESULTS: Data on 15,619 seriously ill patients were analysed. The in-hospital mortality rate for all seriously ill patients was 14.8%, and the incidence of death after critical illness was 7.4 per 100 person-years (4.8 per 100 person-years after hospital discharge). Patients from the most socioeconomically disadvantaged areas were more likely to be younger, to be Indigenous, to live in a remote area, to be admitted non-electively, and to have more severe acute disease and comorbidities. SES was not significantly associated with in-hospital mortality, but long-term mortality was significantly higher in patients from the lowest SES group than in those from the highest SES group, after adjusting for age, ethnicity, comorbidities, severity of acute illness, and geographical accessibility to essential services (hazard ratio for death in lowest SES group v highest SES group was 1.21 [95% CI, 1.04-1.41]; P = 0.014). The attributable incidence of death after hospital discharge between patients from the lowest and highest SES groups was 1.0 per 100 person-years (95% CI, 0.3-1.6 per 100 person-years). CONCLUSION: Lower SES was associated with worse long-term survival after critical illness over and above the background effects of age, acuity of acute illness, comorbidities, Indigenous status and geographical access to essential services.     

早期康复训练对急性脑梗死偏瘫患者的治疗效果及机制探讨

目的 观察早期康复训练对急性脑梗死偏瘫患者的治疗效果,并探讨其可能的机制.方法 选取2013年1月至2016年6月该院收治的急性脑梗死偏瘫患者100例,将其分为康复训练组和对照组,各50例.对照组给予常规药物治疗,康复训练组在常规药物治疗的基础上给予早期康复训练,使用功能独立性测评(FIM)、Fugl-Meyer评分法(FMA)、改良Barthel指数(MBI)评估治疗效果;采用酶联免疫吸附双抗体夹心法测定血浆基质细胞衍生因子-1α(SDF-1α)水平,流式细胞术测定外周血CD34+KDR+水平.结果 治疗前两组FIM总分、FIM运动功能评分、FIM认知功能评分、FMA评分、MBI评分、SDF-1α及CD34+KDR+水平比较,差异均无统计学意义(P>0.05).治疗后,康复训练组FIM总分、FIM运动功能评分、FMA评分、MBI评分、SDF-1α及CD34+KDR+水平均高于对照组,差异均有统计学意义(P<0.05).结论 早期康复训练对急性脑梗死偏瘫患者的治疗效果显著,其机制可能与早期康复训练能够促进外周血SDF-1α和CD34+KDR+表达有关.     

脑梗死患者入院特征预测住院时间初步研究

目的探讨脑梗死患者入院特征与住院时间(LOS)之间的关系及意义。方法回顾性分析557例主要诊断为脑梗死患者的入院特征和LOS。结果脑梗死患者平均LOS为18.5d(LOS为16d)。多元回归分析发现脑梗死患者的医保种类、脑梗死严重程度[美国国立卫生院卒中量表(NIHSS)评分,格拉斯哥昏迷量表(GCS)评分]、牛津郡社区卒中计划(OCSP)分类、某些合并症[冠心病、慢性阻塞性肺疾病(COPD)和高脂血症]以及入院时白细胞升高是LOS的主要预测因子(P<0.05)。结论脑梗死严重程度、OCSP分类、某些合并症(冠心病、COPD和高脂血症)、入院时白细胞升高及医保种类是预测LOS的主要因素。     

园艺疗法结合康复治疗对脑卒中单侧空间忽略的疗效观察

目的:探讨园艺疗法结合康复治疗对脑卒中单侧空间忽略（USN）的临床疗效。方法:将46例脑卒中USN 病人随机分为观察组和对照组,各23例。对照组采用常规康复治疗,观察组在对照组的基础上进行园艺疗法结合针对性康复训练治疗。治疗前后,所有研究对象均采用汉密尔顿抑郁量表（HAMD）评定心理状态,Fugl-Meyer运动功能评定法（FMA）评估运动功能,采用改良Barthel 指数（MBI） 和功能独立性评定法（FIM）评定日常生活活动能力,并进行比较。结果:2组病人治疗前的FMA、MBI、HAMD评分及FIM各项评分差异均无统计学意义（P>0.05）,治疗后各项评分均较治疗前明显改善（P<0.01）,而观察组病人治疗后各项评分改善程度均显著优于对照组（P<0.01）。结论:在脑卒中USN康复过程中,利用园艺疗法结合针对性的康复训练治疗,不仅可以改善USN状况,提高病人生存质量,且对于脑卒中病人的康复及预后都有重要的意义。     

中老年急性缺血性脑卒中患者共病状态与卒中后功能恢复的相关性研究

背景　中老年急性缺血性脑卒中患者同时患有多种慢性病,并且这种共病状态对患者的预后功能恢复产生较大影响。目的　探讨中老年急性缺血性脑卒中患者共病状态与卒中后出院美国国立卫生研究院卒中量表（NIHSS）评分及出院3个月后改良Rankin量表（mRS）评分的关系。方法　收集2016年1月-2018年6月在温江区人民医院神经内科住院的≥45岁的急性缺血性脑卒中患者293例,记录其临床信息、疾病累积评分量表（CIRS）评分、共病指数、严重指数、入院及出院的NIHSS评分（以出院NIHSS评分为0~2分或较入院时减少≥4分为出院时好转）、出院3个月后mRS评分（以出院3个月后mRS评分≤2分为预后良好）等资料。分析患者共病状态与出院好转与否及出院3个月随访卒中后功能恢复的关系。结果　最终纳入的264例患者的CIRS平均得分为（9.58±5.04）分、严重指数为（0.67±0.36）、共病指数为（3.30±1.83）、入院NIHSS得分为6（4,11）分、出院NIHSS得分为3（1,8）分。不同CIRS评分分层患者的年龄、严重指数、共病指数、入院NIHSS评分、出院NIHSS评分、住院天数、出院3个月后mRS评分比较,差异有统计学意义（P<0.05）;出院时是否好转患者的CIRS评分分层比较,差异有统计学意义（P<0.05）;不同预后情况患者的CIRS评分分层、年龄、严重指数、共病指数、出院NIHSS评分、住院天数比较,差异有统计学意义（P<0.05）。出院NIHSS评分、入院NIHSS评分、严重指数、CIRS评分、心房颤动、共病指数、年龄、住院天数与患者出院3个月后mRS评分呈正相关;高血压与患者出院3个月后mRS评分呈负相关（P<0.05）。结论　中老年急性缺血性脑卒中患者共病状态与卒中后出院NIHSS评分、3个月后mRS评分有密切的关系。CIRS评分较低、年龄较小、共病指数和严重指数低的患者预后良好。     

脑卒中急性期肺功能障碍的研究进展

急性肺功能障碍是脑卒中的常见并发症之一。卒中后因呼吸中枢的神经通路中断或间接作用致肺通气、换气功能障碍,血液动力学异常,进而引起缺氧状态,将明显增加急性期患者死亡率,延长住院时间,导致心肺功能、体适能下降、自主活动时间不足,进一步影响神经功能恢复,还会增加卒中再发风险。本文拟卒中后急性期肺功能障碍的可能原因、呼吸病理机制、评估以及肺康复治疗进行综述,为卒中后的临床康复治疗提供理论依据。     

补益脾胃法结合虫类药治疗中后期脊髓损伤

目的 观察补益脾胃法结合虫类药对中后期脊髓损伤患者神经功能恢复的影响。方法 将40例脊髓损伤中后期患者随机分为治疗组和对照组,每组20例,对照组予综合康复治疗和甲钴胺片口服,治疗组予综合康复治疗和龙芪强肌饮及虫类药煎服,观察比较治疗前后两组患者美国脊髓损伤协会（American spinal injury association,ASIA）感觉功能、运动功能评分,功能独立性测量（the functional independent measure,FIM）评分以及体感诱发电位（somatosensory evoked potential,SEP）潜伏期。结果 两组治疗后ASIA感觉功能评分、运动功能评分,FIM评分均明显高于治疗前（P＜0.05）,SEP潜伏期低于治疗前（P＜0.05）。两组治疗前后ASIA感觉功能评分、运动功能评分,FIM评分,SEP潜伏期差值比较,差异均有统计学意义（P＜0.05）。结论 补益脾胃法结合虫类药能有效促进中后期脊髓损伤患者神经功能的恢复。     

Effect of power-frequency electromagnetic fields on stroke during rehabilitation]

OBJECTIVE: To explore the effects and mechanism of power-frequency electromagnetic fields on lipoprotein metabolism and homodynamic during stroke rehabilitation. METHODS: One hundred fifteen patients with stroke were divided into 2 groups, 55 cases of them were treated by exposure to power-frequency electromagnetic fields, 60 cases were treated as control group. Barthel index and Functional Independence Measure (FIM) were used to evaluate rehabilitation outcome. The lipoprotein and its subclasses, homodynamic parameters were compared at pre- and post-rehabilitation. RESULTS: The treatment group showed a statistically significant better prognosis compared with the control group(P<0.01). The score of Barthel index also increased after treatment(P<0.001). Total cholesterol(Tc), triglycerides(TG), low-density lipoprotein cholesterol(LDL-c) levels dropped and high-density lipoprotein cholesterol(HDL-c) increased significantly. The Tc/HDL-c, LDL-c/HDL-c ratio along with the blood and plasma viscosity decreased significantly compared with the controls (P<0.01). The ratio of stroke recurrence decreased significantly after the treatment compared with the control group (P<0.05). CONCLUSION: The power-frequency electromagnetic fields can improve lipoprotein metabolism and homodynamic parameters. It can improve the ADL and FIM of stroke patients, which may have significant implications for stroke patients.     

完善卒中单元治疗重症脑卒中的临床研究

目的：探索完善＂卒中单元＂对重症脑卒中患者的临床疗效.方法：采用随机方法,研究完善＂卒中单元＂治疗重症脑卒中患者186例,选用爱丁堡＋斯堪的那维亚评分法,在治疗前与疗程结束后分别对患者的神经系统损失状态进行评分,并用卡方检验进行了统计学检验.结果：治疗组总有效率（88.3%）显著高于对照组（68.5%）（Р〈0.05）.其中出血性脑卒中两组经χ2检验差异不显著,Ridit分析发现两组区间重叠极少; 缺血性脑卒中治疗组有效率（92.5%）与对照组（67.2%）相比差异非常显著（Р〈0.01）.结论：完善卒中单元是治疗重症脑卒中患者的有效措施,能显著改善出血性脑卒中患者的生活质量,对缺血性脑卒中患者的疗效更为显著.     

早期介入康复训练对脊髓损伤患者生活质量的影响

目的观察早期介入康复训练对脊髓损伤患者心理状况、独立生活能力及功能独立的影响。方法将63例脊髓损伤患者随机分为康复组(33例)和对照组(30例),对照组给予常规治疗;康复组在常规治疗的基础上,于生命体征稳定后即介入康复治疗。两组患者治疗前及治疗后6个月,由同一医师采用焦虑抑郁量表、Barthel指数、FIM量表进行功能评定。结果通过6个月的康复训练,康复组患者焦虑抑郁评分明显降低,ADL及FIM评分明显增高,与对照组相比差异显著(P<0.05)。结论早期介入康复训练可明显改善脊髓损伤患者的心理状态,提高其独立生活能力及功能独立能力。     

早期认知护理对PSCI老年患者生活质量的影响

目的 研究早期认知护理对脑卒中后认知障碍（PSCI）老年患者出院后自理水平及生活质量的影响.方法 将2012年1月～2013年12月收治的100名脑卒中老年患者随机分为研究组及对照组各50例,两组患者入院后均接受脑卒中常规护理,研究组在对照组的基础上增加两周认知功能护理,分别在干预前和干预后采用功能独立性评定（FIM）及SF-36简易量表评估患者的自理水平及生活质量.结果 干预前,两组患者的FIM各项指标评分和总分及SF-36评分间的差异均无统计学意义（P＞0.05）.经认知护理干预后,研究组FIM各项评分及总分均优于干预前（P＜0.05）.对照组FIM分项中除交流、社会认知和运动以外,其他分项及总分较干预前明显提高（P＜0.05）.研究组除转移、运动和交流等与对照组无统计学差异外,其他指标均显著优于对照组（P＜0.05）.护理干预后6、12个月,研究组SF-36评分分别为（78.35±12.74）分、（88.35±13.78）分,对照组分别为（72.39±11.82）分和（79.17±13.01）分,研究组均高于对照组（P＜0.05）.结论 早期认知护理能提高患者出院后自理水平,提升生活质量,从而在较大程度上阻止脑卒中后认知障碍的发展.