缺血性脑卒中社区康复临床路径的疗效研究:多中心、单盲、随机对照前瞻性研究

目的:从临床功能角度评估缺血性脑卒中社区康复临床路径康复方案的效果,为脑卒中社区康复临床路径的优化和推广提供数据支持。方法:采用随机、单盲、平行对照、多中心的前瞻性研究,符合纳入标准的缺血性脑卒中患者247例,随机分为临床路径组(129例)和常规康复组(118例)。临床路径组进入社区康复临床路径并执行相应康复治疗方案,常规康复组采取常规康复治疗,不进入临床路径,对康复治疗内容及时间不做要求。主要结局指标采用改良Barthel指数(MBI)及次要结局指标Fugl-Meyer运动功能评分量表(FMA)对两组患者ADL能力、综合功能水平、运动功能进行评定和分析。结果:临床路径组康复治疗前后的MBI差值、MBI改善程度均显著高于常规康复组,差异有显著性意义(P0.05)。两组患者康复治疗前后FMA差值及FMA改善程度比较,差异有显著性意义(P0.05)。结论:社区康复临床路径结合规范化的康复方案能提高缺血性脑卒中患者的ADL能力,改善患者的功能。     

苏南地区缺血性脑卒中患者三级康复临床路径的效果分析

目的:探讨苏南地区三级康复临床路径在首次缺血性脑卒中患者康复中的应用效果。方法:50例首次缺血性脑卒中患者,随机分配到三级临床路径组和常规康复组。临床路径组患者按照三级转诊的方式进入相应层次的临床路径,完成三层次康复医疗机构的统一康复治疗方案。常规康复组按所就诊康复机构中的常规康复模式和方法完成。分别于治疗前、治疗后第3周末、第9周末、第17周末,应用简化Fugl-Meyer运动功能量表(FMA)评定肢体运动功能和改良Barthel指数量表(MBI)评定日常生活活动能力,对比评价效果。结果:临床路径组和常规康复组的FMA和MBI评分在治疗后第3周末、第9周末、第17周末均较前提高,第3周末、第9周末临床路径组的FMA和MBI评分与常规康复组比较有显著性差异(P0.05),而第17周末两者的FMA和MBI评分差异无显著意义(P0.05)。临床路径组第9周末总费用高于常规康复组,但成本效益比(费用/MBI差值)更好且并发症发生率低于常规康复组(P0.05)。结论:按临床路径方法开展缺血性脑卒中的三级康复治疗,前期(一级/二级)更有利于患者肢体运动功能、日常生活活动能力的恢复,减少了并发症的发生,减轻了患者的经济负担,值得进一步研究及推广。     

康复护理对脑卒中患者运动功能及日常生活活动能力的效果

目的探讨康复护理干预对脑卒中患者运动功能及日常生活活动能力的影响。方法将140 例脑卒中患者随机分为对照组和康复组各70 例,对照组给予神经内科常规药物、康复治疗与一般护理,康复组在此基础上进行康复护理干预。治疗前和治疗5 周后,分别采用简化Fugl-Meyer 运动功能评分量表(FMA)和改良Barthel 指数(MBI)对两组运动功能和日常生活活动能力进行比较分析。结果两组患者治疗前FMA和MBI评分无显著性差异(P>0.05);治疗5 周后康复组FMA和MBI评分均显著高于对照组(P<0.001)。结论康复护理干预对脑卒中患者运动功能及日常生活活动能力的恢复具有促进作用。     

临床康复路径对亚急性期脑梗死患者功能恢复及医疗成本效益的影响

目的 探讨临床康复路径对亚急性期脑梗死患者功能恢复及医疗成本效益的影响。 方法 采用多中心单盲平行随机对照方法,搜集早期康复治疗结束后的亚急性期脑梗死患者286例,其中15例患者在试验未开始前撤回知情同意书,14例患者出院失访,10例中途退出。最终有247例脑梗死患者纳入统计分析,按随机数字表法分为临床康复路径组（129例）和常规康复组（118例）。临床路径组接受标准化的康复流程干预及药物治疗,常规康复组接受常规康复治疗及药物治疗。分别于康复治疗前（治疗前）及康复治疗3周时和康复治疗6周后,采用简化Fugl-Meyer运动功能评分（FMA）、改良Barthel指数（MBI）对2组患者的运动功能和ADL能力进行评价,比较2组患者康复治疗前后各指标的差值及改善程度;比较2组患者住院6周的费用,并进行成本-效果分析。 结果 临床路径组治疗6周后与治疗3周时的FMA和MBI评分增值以及FMA和MBI评分改善程度均显著高于常规康复组（P<0.05）,2组患者康复治疗3周时和治疗6周后的FMA评分增值和FMA评分改善程度与组内治疗前比较,其MBI评分增值和MBI评分改善程度差异均无统计学意义（P>0.05）。临床路径组平均住院总费用明显低于常规康复组（P<0.05）,常规康复组FMA和MBI评分每增加１分与临床路径组相比,均需多花费2166元和1940元,组间差异有统计学意义（P<0.05）。 结论 临床康复路径能有效改善亚急性期脑梗死患者运动功能和日常生活(ADL)能力,提高医疗成本-效益比。     

早期综合康复治疗对急性脑卒中患者功能重建的影响

目的:探讨早期综合康复治疗对急性脑卒中患者功能重建的影响。方法:急性脑卒中患者128例,随机分为康复组和对照组各64例,2组均给予神经内科常规及对症支持治疗,康复组同期应用Brunnstrom、Bobath疗法、本体感觉神经肌肉促通法(PNF)等治疗技术进行康复训练1个月。2组治疗前后均采用临床神经功能缺损程度(CNDS)、Brunnstrom分级、改良Barthel指数(MBI)及简式Fugl-Meyer运动功能评测法(FMA)等进行疗效评定。结果:治疗后,2组患者CNS评分均较治疗前明显下降(P<0.01或0.05),康复组低于对照组(P<0.05);2组患者MBI评分、FMA上下肢评分及Brunnstrom分级均较治疗前明显提高(P<0.01或0.05),康复组高于对照组(P<0.05)。结论:急性脑卒中患者早期进行综合康复治疗能减少神经功能损害,提高肢体运动功能,改善日常生活活动能力。     

康复护理对改善急性脑梗死患者肢体功能障碍的效果分析

目的 探讨康复护理对改善急性脑梗死患者肢体功能障碍康复效果的影响.方法 将我院2006年至2009年治疗的86例急性脑梗死患者随机分为康复组与对照组各43例.2组均给予常规治疗,康复组在常规治疗基础上给予早期康复训练护理,于治疗前及治疗3周后采用Fugl-Meyer运动功能评估(FMA)对患者肢体功能进行测评;改良Barthel指数(MBI)评定日常生活活动能力.结果 治疗3周后,2组患者治疗后FMA评分及MBI均有改善,且康复组FMA评分及MBI明显高于对照组.结论 康复护理明显改善急性脑梗死患者肢体运动功能及生括能力,降低致残率.     

早期与晚期康复对脑梗死患者功能恢复影响的对照研究

目的:探讨早期与晚期康复对脑梗死患者功能恢复的影响。方法:选择216例脑梗死患者,其中早期康复组与晚期康复组各108例。早期康复组在患者生命体征稳定,神经病学体征不再进展后48h—14天开始康复。晚期康复组在发病后15—30天开始康复。两组均采用Bobath法和运动再学习法进行训练。采用改良Barthel指数(MBI)、简式Fugl-Meyer运动评分(FMA)和临床神经功能缺陷程度评分进行康复评价。结果:临床神经功能缺陷程度评分、FMA和MBI入选时两组差异无显著性意义(P>0.05),治疗30天两组均较治疗前明显改善(P<0.01),早期康复组较晚期康复组改善程度更大(P<0.01)。结论:早期与晚期康复均可明显促进神经功能恢复,早期康复的临床疗效明显优于晚期。目的:探讨早期与晚期康复对脑梗死患者功能恢复的影响。方法:选择216例脑梗死患者,其中早期康复组与晚期康复组各108例。早期康复组在患者生命体征稳定,神经病学体征不再进展后48h—14天开始康复。晚期康复组在发病后15—30天开始康复。两组均采用Bobath法和运动再学习法进行训练。采用改良Barthel指数(MBI)、简式Fugl-Meyer运动评分(FMA)和临床神经功能缺陷程度评分进行康复评价。结果:临床神经功能缺陷程度评分、FMA和MBI入选时两组差异无显著性意义(P>0.05),治疗30天两组     

综合康复疗法治疗脑卒中后肩手综合征的疗效观察

目的观察综合康复疗法治疗脑卒中后肩手综合征（shoulder-hand syndrome after stroke,SHSAS）的临床效果。方法将我院2009年1月至2010年12月确诊为SHSAS的患者分为综合康复组和对照组。对照组采用常规康复训练;综合康复组在常规康复训练基础上加用针灸治疗。对两组治疗前后临床疗效进行比较,采用Fugl-Meyer评定法（Fugl-Meyer as-sessment,FMA）和改良Barthel指数（modified Barthel index,MBI）对运动功能及日常生活活动能力进行评分。结果综合康复组有效率、FMA积分和MBI积分的增加均明显高于对照组（P〈0.05）。结论综合性康复治疗能进一步提高SHSAS患者的治疗效果,临床上值得推广。     

针刺结合运动想象疗法对脑卒中后偏侧忽略患者疗效观察

目的:探讨针刺结合运动想象疗法在脑卒中后偏侧忽略患者治疗中的疗效。方法:对本院脑卒中后偏瘫患者进行神经心理学评测,40例纳入患者随机分为3组,对照组(常规康复疗法)13例,观察组(在常规康复基础上予运动想象疗法)13例,实验组(常规康复治疗同时予针刺结合运动想象疗法)14例。3组治疗前后分别予偏侧忽略行为学量表评定(CBS)、Fugl-Meyer运动功能评定(FMA)、改良Barthel指数(MBI)评定。结果:1观察组和实验组治疗后CBS较治疗前下降(P0.01),FMA、MBI评分明显高于治疗前(P0.001),对照组治疗前后无明显差异(P0.05)。2 3组治疗前后CBS、FMA、MBI评分差值的平均效应不全相同,经过两两比较,实验组CBS、FMA、MBI评分差值均高于观察组和对照组,观察组3项评分差值均高于对照组(P0.01)。结论:针刺结合运动想象疗法治疗脑卒中后偏侧忽略患者,能够改善忽略,提高患者的运动功能和日常生活活动能力。     

藏药药浴应用于脑卒中康复的卫生经济学评价

目的:探讨藏药药浴应用于脑卒中康复的经济学价值。方法:基于多中心随机对照试验,本研究纳入脑卒中患者403例,入组患者随机分为常规康复组202例和藏药药浴组201例(常规康复加藏药药浴)。两组患者均接受常规康复治疗标准方案,包括常规物理治疗60min/d,强化抗痉挛治疗60min/d,作业治疗30min/d,每周5天,治疗4周。藏药药浴组在常规康复治疗基础上,加用藏药药浴20min/d,每周5天,治疗4周。采用Fugl-Meyer评分(FMA)、改良Barthel评分(MBI)分别在治疗前、治疗2周后、治疗4周后评估运动功能和日常生活活动能力,记录全部医疗花费。卫生经济学指标采用成本效果比,以直接医疗费用与FMA和MBI评分变化值的比值评价。同时计算藏药药浴组的增量成本效果比(ICER),以进一步衡量其成本效果。结果:治疗4周后,常规康复组FMA值、MBI值较治疗前分别提高(6.92±8.48)分和(7.78±9.49)分;藏药药浴组FMA值、MBI值较治疗前分别提高(10.26±10.86)分和(11.05±12.00)分。FMA每提高1分,直接医疗费用常规康复组为3064.22元,藏药药浴组为2343.90元,较常规康复组节省720.32元;MBI评分每提高1分,常规康复组直接医疗费用为2725.51元,藏药药浴组为2176.33元,较常规康复组节省549.18元。ICER分析结果也提示藏药药浴组较常规康复组具有更好成本效果。结论:脑卒中常规康复结合藏药药浴的综合治疗比单纯常规康复治疗具有更好的成本效果。     

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.     

Guns and Knives in New Mexico: Patterns of Penetrating Trauma, 1978–1993

Objective: To identify patterns of nonfatal and fatal penetrating trauma among children and adults in New Mexico using ED and medical examiner data.
Methods: The authors retrospectively sampled in 5-year intervals all victims of penetrating trauma who presented to either the state Level-1 trauma center or the state medical examiner from a 16-year period (1978–1993). Rates of nonfatal and fatal firearm and stabbing injury were compared for children and adults.
Results: Rates of nonfatal injury were similar (firearm, 34.3 per 100,000 person-years; stabbing, 35.1). However, rates of fatal injury were significantly different (firearm, 21.9; stabbing, 2.7; relative risk: 8.2; 95% confidence interval: 5.4, 12.5). From 1978 to 1993, nonfatal injury rates increased for children (p = 0.0043) and adults (p < 0.0001), while fatal penetrating injury remained constant. The increase in nonfatal injury in children resulted from increased firearm injury rates. In adults, both stabbing and firearm nonfatal injury rates increased.
Conclusions: Nonfatal injury data suggest that nonfatal violence has increased; fatal injury data suggest that violent death rates have remained constant. Injury patterns vary by age, mechanism of trauma, and data source. These results suggest that ED and medical examiner data differ and that both are needed to guide injury prevention programs.     

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.