Cost-effectiveness of screening for deep vein thrombosis by ultrasound at admission to stroke rehabilitation

OBJECTIVE: This project was a cost-effectiveness analysis of the practice of routine Doppler ultrasound screening for deep vein thrombosis (DVT) in patients with ischemic stroke at the time of admission to rehabilitation. DESIGN: A decision-analysis model was created to compare 2 approaches for detecting DVT in a stroke population: (1) screening all patients with acute ischemic stroke at admission to stroke rehabilitation for DVT by Doppler ultrasound with subsequent treatment; or (2) clinical surveillance for signs of DVT and treatment after confirmation by Doppler ultrasound. The prevalence of DVT, risk of complication from DVT, and risk of complication from treatment were obtained from published reports. Costs are in 2004 dollars and the effectiveness was measured in quality-adjusted life-years (QALYs) gained. We conducted these analyses from a societal perspective. SETTING: Inpatient stroke rehabilitation unit. PARTICIPANTS: Not applicable. INTERVENTION: Screening all patients with acute ischemic stroke at admission to stroke rehabilitation for DVT by Doppler ultrasound with subsequent treatment. MAIN OUTCOME MEASURE: Cost in 2004 dollars per QALY gained by screening all patients with acute ischemic stroke at admission to stroke rehabilitation for DVT by Doppler ultrasound with subsequent treatment. RESULTS: The expected utility of screening patients with ischemic stroke for DVT by Doppler ultrasound on admission to rehabilitation is 1.875 QALYs and that of not screening is 1.872 QALYs. The expected gain is .0026 QALYs (23 h). Obtaining this increase in quality-adjusted life incurs additional cost of 168 dollars per stroke patient and a marginal cost-effectiveness of 67,200 dollars for each QALY gained. CONCLUSIONS: This study estimates that the cost-effectiveness ratio is considerably higher than that reported in other rehabilitation conditions and higher than the commonly stated level for an intervention to be considered cost-effective. The difference from previous reports primarily relates to the shorter life expectancy following stroke, the prevalence of occult DVT at admission, rate of complications of anticoagulation, and the estimates of the screening's test characteristics used in our study. Further study of these areas is likely to contribute to improving our understanding of the most appropriate care of these patients.     

Deep vein thrombosis: prophylaxis in acute spinal cord injured patients

The purpose of this prospective, randomized study was to evaluate the efficacy of low-dose heparin, alone or in combination with electric stimulation, in the prevention of deep vein thrombosis (DVT) in C2 to T11 motor complete and incomplete-preserved motor, nonfunctional spinal cord injured patients. The tibialis anterior and gastrocnemius-soleus muscle groups were stimulated bilaterally, using 50 microsecond pulses given at 10Hz with a four-second "on" and an eight-second "off" cycle for 23 hours daily over a 28-day period. Forty-eight patients, less than two weeks after injury, were randomly assigned to saline placebo (n = 17), low-dose heparin (5,000U, subcutaneous every eight hours) (n = 16), and low-dose heparin plus electric stimulation (n = 15). A normal 125-I fibrinogen scan and impedance plethysmography were required for entry into the study. Surveillance for DVT was evaluated by daily 125-I fibrinogen scanning. Venography was performed to confirm a positive impedance plethysmography and/or 125-I fibrinogen scanning tests for two consecutive days and at the completion of the study. The incidence of DVT was 8 of 17 in the placebo group, 8 of 16 in the low-dose heparin group, and 1 of 15 in the electric stimulation plus low-dose heparin group. The use of electric stimulation plus low-dose heparin significantly (p less than 0.05) decreased the incidence of DVT compared to the other treatments.     

Image-directed Doppler ultrasound: a screening technique for patients at high risk to develop deep vein thrombosis.

Hip fracture patients typify a population at high risk to develop deep vein thrombosis (DVT). Recently ultrasound has been used successfully to diagnose DVT when clinical suspicion exists. In this prospective study, 88 hip fracture patients asymptomatic for DVT were screened serially with compression ultrasound to assess the development of thrombus within the femoral or popliteal systems. Contrast venography was employed as a control. Twelve of the 76 patients (16%) completing the study were noted by ultrasound to have a clot. Venography confirmed a clot in each case and detected no additional femoral or popliteal clot. The possibility of utilizing ultrasound to screen additional high risk groups for DVT should be investigated based on the encouraging results of this series.     

脊髓损伤患者社区康复训练指导

随着社会的发展 ,工伤、交通事故、运动损伤等日见增多 ,这些外伤和某些非外伤性脊髓病变如横贯性脊髓炎、肿瘤和血管意外 ,以及骨质增生对脊髓的压迫等 ,均可引起脊髓损伤 ,导致肢体功能障碍 (包括四肢瘫、截瘫 ) ,造成患者的重度残疾 ,并产生心理障碍 ,影响其生活自理 ,而且给家庭、社会带来负担。康复治疗的目的 ,就是最大限度地提高患者的残存功能 ,使其尽可能生活自理 ,改善心理状态 ,回归社会。1脊髓损伤及其合并症、并发症1.1临床表现　严重的脊柱外伤可发生在任一方向 ,并造成脊椎骨折或脱位 (或两者同时存在 ) ,或造成脊椎骨的错位…     

脊髓损伤患者的心理问题及康复策略

脊髓损伤患者从正常状态到突然致残 ,再通过康复训练回归家庭和社会 ,心理方面会出现一系列问题[1] 。及时处理心理问题 ,不仅有利于患者的心理康复 ,而且可以促进整体康复的进程。特别是对那些身体已经残疾 ,不可能再恢复正常的患者而言 ,心理的康复比机体的康复更为重要。因此 ,了解脊髓损伤患者的心理问题 ,探讨进行心理康复的策略和方法 ,也是我们临床心理工作者的一项重要任务。1脊髓损伤患者常见心理问题1.1心理创伤　人的心理是一个动态的过程 ,当受到外界的强烈刺激时 ,会产生心理的应激[2 ] 。如果某种刺激过于强烈 ,就会产生个体…     

Deep venous thrombosis: diagnosis in spinal cord injured patients

Because the acute spinal cord injured patient is at high risk for the development of deep venous thrombosis (DVT), accurate diagnosis is critical. Clinical evaluation is unreliable 50% of the time, however, and the two highly accurate diagnostic procedures--venography and 125I-labelled fibrinogen scanning--are invasive and present serious drawbacks. The literature concerning the effectiveness of the two most widely used noninvasive diagnostic alternatives (Doppler ultrasound and venous occlusion plethysmography [VOP]) is equivocal. In our systematic evaluation of a series of 21 patients, using clinical examination, Doppler ultrasound and VOP, all patients who developed DVT were identified by all three methods. Overall accuracy, sensitivity and specificity were 100%.     

The value of serial leg measurements for monitoring deep vein thrombosis in spinal cord injury.

Deep vein thrombosis (DVT) is a common complication of spinal cord injury (SCI). Many specialized SCI nursing units use serial leg measurements to establish clinical diagnosis of DVT, in spite of extensive studies showing that clinical signs and symptoms of DVT have a specificity and sensitivity hardly better than chance. For 30 patients who spent 920 days in an SCI intensive care unit, we collected daily serial calf and thigh measurements and the results of radiofibrinogen uptake test (RFUT) performed about every third day. Three criteria for clinical diagnosis of DVT found in the literature were used: an increase from baseline, an increase from the previous day or a right-left difference of a specific minimal size. The cut-off points for minimal size used were also those suggested by the literature: over .5 inch, over 1 cm, or 1.2 cm and over for women, 1.5 cm and over for men. We found such changes or differences correlated weakly or not at all with RFUT results, and symptomatic increases or differences occurred very frequently. Major factors presumably underlying the variability of measurements and their lack of sensitivity and specificity are: premorbid leg asymmetry; atrophy of the legs after SCI; true changes in circumference due to factors other than DVT; and lack of measurement reliability. It was concluded taking serial leg measurements is of no value in the SCI population. For those reluctant to abandon tradition, suggestions are provided for improving the quality of measurements and related decision making. Further research is needed.     

脊髓损伤病人对深静脉血栓认知评价要素的质性研究

[目的]探讨和分析脊髓损伤治疗专家及护理专家对下肢静脉血栓的理解和认知,确定评价病人对下肢血栓认知的基本要素。[方法]以质性研究的方法为指导,对10名专家进行深入访谈并收集资料。[结果]共提炼出4个基本内容,包括下肢静脉血栓的概念及机制、对下肢静脉血栓危害性认识、脊髓损伤病人患下肢静脉血栓的危险因素、脊髓损伤病人对下肢静脉血栓的预防方法(运动、饮食、治疗)。[结论]构建了脊髓损伤病人对下肢血栓认知的基本框架,为以后开展量性研究提供依据。     

Duplex ultrasound screening for carotid arteriosclerotic disease in asymptomatic patients.

Duplex carotid sonography was performed on 254 asymptomatic patients over the age of 55, yielding 500 adequate vessel examinations. Overall, 19.8 per cent of vessels were normal, 27 per cent had mild disease (less than 30 per cent diameter stenosis), 23 per cent had 30-49 per cent stenosis, 18.8 per cent had 50-69 per cent stenosis, 8.6 per cent had severe stenosis of 70-99 per cent, and 2.8 per cent of vessels were occluded. Many of the patients eventually underwent major surgical procedures and there were no cases of operative or perioperative morbidity or mortality. Only one of 254 patients has had a stroke in the two-year study period. Arteriosclerotic disease is common in patients over 55 years of age, but, in this series, does not seem to be of clinical significance. This supports the view that invasive tests and carotid endarterectomy should be reserved for symptomatic patients. Duplex sonography is an excellent noninvasive method of evaluation and follow-up of asymptomatic patients, and long-term studies with this modality should help to determine the natural history and clinical significance of extracranial carotid arteriosclerotic disease.     

脊髓损伤患者的步行训练

步行训练是脊髓损伤患者重要的功能训练之一。在条件允许的情况下 ,应鼓励患者经常进行站立及步行训练 ,这不仅可以防止下肢发生骨质疏松 ,减少发生骨折的危险 ,减轻肌肉痉挛 ,同时还可以预防泌尿系感染等。1步行方式分类根据患者脊髓损伤平面的不同 ,可将步行训练分为治疗性步行和功能性步行。不同损伤平面的患者步行能力大致如下 :①C6 —T5损伤 :可佩戴躯体、骨盆托矫形器在平行杠内做治疗性站立 ;②T6 —T9损伤 :可佩戴骨盆托矫形器并使用拐杖进行治疗性站立步行 ;③T10 及以下损伤 :具有功能性步行能力。1.1治疗性站立步行训练　C6 …     

小儿经皮肾穿刺带后舒适度分新及护理

经皮肾穿刺术（简称肾穿刺）是确诊肾脏疾病的重要手段之一，临床上可根据肾组织病理检查进行分型诊断及确定治疗措施。近年来，随着活检技术的不断改进及定位技术的发展，经皮肾活检在临床上得到了广泛的应用。由于它是一项具有一定损伤性的检查，术后难免发生相关并发症。为了减少术后并发症的发生，要求术后严格体位制动，腹带加压包扎，但由于患儿的合作程度差，常因此带来腰背酸痛、四肢麻木、上腹疼痛、恶心呕吐、排尿困难、紧张焦虑、失眠及周身不适症状，致使舒适度下降。我科2004年11月-2005年11月行肾穿刺术112例，对术后舒适改变原因及护理对策进行了分析讨论，现报道如下。     

脊髓损伤后下肢深静脉血栓形成的预防性护理

目的探讨脊髓损伤后下肢深静脉血栓形成的预防性护理措施。方法将78例伤前没有深静脉血栓形成的新发脊髓损伤患者随机分为常规临床治疗组38例(传统护理组)及常规治疗加早期强化康复治疗组40例(强化护理组),强化护理组对下肢深静脉血栓采取预防性治疗与护理措施。进行临床评估与随访,比较2组深静脉血栓的发生情况。结果观察8周,共计7例(9.0%)患者发生深静脉血栓,其中强化护理组仅1例(2.5%)发生深静脉血栓,传统护理组6例(15.8%)(6/38),2组比较差异有统计学意义(P=0.040)。结论早期有针对性的治疗与护理可以有效降低脊髓损伤患者深静脉血栓的发生。     

School reintegration: a rehabilitation goal for spinal cord injured adolescents

This article describes how the Education for All Handicapped Children Act of 1975, Public Law 94-142, assists in achieving the rehabilitation goal of school reintegration for spinal cord injured (SCI) adolescents. It also describes how subordinate goals are achieved during the inpatient rehabilitation phase. Comments from a survey of 13 SCI adolescents who returned to school demonstrate the need to prepare SCI adolescents for the services to which they are entitled, to acquaint them with ways of resolving possible problems they may encounter, and, when they return for follow-up care, to encourage them to continue in school.     

用于脊髓损伤患者的辅助技术

脊髓损伤属于重度残疾 ,患者对辅助技术的依赖性很强。在辅助技术领域 ,脊髓损伤方面的辅助技术内容最为全面。本文通过典型案例、体系描述和重点分析 ,试图对脊髓损伤辅助技术做一较完整的阐述。1脊髓损伤辅助技术的典型应用案例患者为一名美国中学教师 ,女 ,33岁 ,7年前受伤 ,脊髓损伤水平在C6— 7,为完全性瘫痪。该患者所利用的主要辅助技术项目如下 :1.1轮椅　日常使用电动轮椅 ,选型上充分考虑教师的职业需要 ,如加高椅面。手动轮椅作为备用 ,以供应急之用。1.2汽车　患者从实用的角度考虑 ,选用的不是轿车 ,而是微型面包车。改装项目…