脑梗死吞咽障碍针刺治疗方案的初步优选

目的:对脑梗死吞咽障碍针刺治疗方案进行初步优选.方法:以63例脑梗死假性延髓麻痹吞咽障碍患者为研究对象,以洼田饮水试验为观察指标,采用正交设计法,研究针刺时机(A因素:A1:1～10天,A2:11～20天,A3:21～40天),选穴配伍(B因素:B1:项部穴,B2:项部穴十舌咽部穴,B3:项部穴十舌咽部穴十辨证取穴),针刺深度(C因素:C1:浅刺,C2:中刺,C3:深刺),疗程(D因素:D1:2疗程,D2:4疗程,D3:6疗程)4因素3水平的不同搭配组合方案,对脑梗死假性延髓麻痹吞咽障碍患者的影响,初步确定脑梗死吞咽障碍针刺治疗优选方案.结果:正交设计法的直观分析显示,4因素3水平的最佳水平及搭配方案为A1(或A2)、B3、C3、D3,即在病程20天内,选用项部穴、舌咽部穴位,配合辨证取穴,采用深刺法,治疗6个疗程,对洼田饮水试验起最佳改善作用.4因素的作用主次比较(方差分析)显示:因素A、C为显著因素(P＜0.05),因素B、D为不显著因素(P＞0.05),说明针刺时机与针刺深度在获得临床疗效方面作用显著.显著因素A、C不同水平间的优劣比较(多重比较)显示:A1、A2显著优于A3(P＜0.001),A1与A2比较差异无统计学意义(P＞0.05);C3显著优于C2、C1 (P＜0.001,P＜0.01),C2显著优于C1(P＜0.05).结论:对直观分析、方差分析、多重比较结论结合临床实际情况进行综合分析认为,对于所考察的4因素3水平而言,在病程1～20天内,采用项部穴为主,或结合舌咽部穴,或配合辨证取穴,行深刺法,治疗4～6个疗程,为脑梗死假性延髓麻痹吞咽障碍患者的针刺治疗优选方案.     

Racial disparities in the development of dysphagia after stroke: analysis of the California (MIRCal) and New York (SPARCS) inpatient databases

Gonzalez-Fernandez M, Kuhlemeier KV, Palmer JB. Racial disparities in the development of dysphagia after stroke: analysis of the California (MIRCal) and New York (SPARCS) inpatient databases.

Objectives

To determine whether the proportion of patients with stroke experiencing dysphagia differs among racial groups and whether this relation can be explained by stroke type or severity.

Design

Case-control study using California's Medical Information Reporting and New York's Statewide Planning and Research Cooperative System databases for 2002. Cases had primary diagnosis of cerebrovascular disease (International Classification of Disease, 9th Revision [ICD-9] codes 430-438.9, excluding transient [435-435.9] and late-effects [438-438.9]), and self-identified race was white, black, or Asian. Two comparison groups were selected: (1) Parkinson's disease (ICD-9 codes 332-332.1) and (2) oral cancer (ICD-9 codes 141-149).

Setting

Inpatient admissions in the respective states.

Participants

Cases with primary diagnosis of cerebrovascular disease whose self-identified race was white, black, or Asian.

Interventions

Not applicable.

Main Outcome Measure

Dysphagia, defined by ICD-9 codes 787.2 (dysphagia), 507.0 (aspiration pneumonia), or presence of a feeding tube in the absence of a diagnosis of coma (Current Procedural Terminology codes 432.46 or 437.50 without ICD-9 code 780.01).

Results

In the stroke group, the adjusted odds ratio (OR) with 95% confidence interval (CI) for dysphagia was significantly higher for Asians than whites in New York (OR=1.64; 95% CI, 1.50-1.79) and California (OR=1.69; 95% CI, 1.34-2.13). The adjusted OR was slightly but significantly higher for blacks than whites in New York (OR=1.15; 95% CI, 1.03-1.28), but not in California (OR=1.08; 95% CI, 0.97-1.19). No statistically significant differences among racial groups were found in patients with Parkinson's disease or oral cancer. Other factors strongly associated with dysphagia included hemiplegia (OR=2.19; 95% CI, 2.07-2.32) and aphasia (OR=1.97; 95% CI, 1.83-2.11).

Conclusions

Asians were more likely to have dysphagia after stroke. This association was statistically significant after adjusting for age, sex, stroke severity indicators, comorbidities, and stroke type.     

The association of functional oral intake and pneumonia in patients with severe traumatic brain injury

Hansen TS, Larsen K, Engberg AW. The association of functional oral intake and pneumonia in patients with severe traumatic brain injury.

Objectives

To investigate the incidence and onset time of pneumonia for patients with severe traumatic brain injury (TBI) in the early phase of rehabilitation and to identify parameters associated with the risk of pneumonia.

Design

Observational retrospective cohort study.

Setting

Subacute rehabilitation department in a university hospital in Denmark.

Participants

Patients (N=173) aged 16 to 65 years with severe TBI who were admitted during a 5-year period. Patients are transferred to the brain injury unit as soon as they ventilate spontaneously.

Interventions

Not applicable.

Main Outcome Measure

Pneumonia.

Results

Twenty-seven percent of the patients admitted to the brain injury unit were in treatment for pneumonia; pneumonia developed in 12% of the patients during rehabilitation; the condition occurred within 19 days of admission in all but 1 patient. Of these patients, 81% received nothing by mouth. Three factors identified patients at highest risk of pneumonia: Glasgow Coma Scale score less than 9 (1 day after cessation of sedation); Rancho Los Amigos Scale score less than 3 (on admission); and no oral intake on admission. Having a tracheotomy tube and/or feeding tube was also associated with a higher occurrence of pneumonia.

Conclusions

Among patients with severe TBI, 27% had pneumonia at transfer from the intensive care unit. Pneumonia developed in only 12% of the participants during rehabilitation. Patients with a low level of consciousness and patients with a tracheotomy tube or feeding tube had a higher likelihood of pneumonia.     

早期吞咽训练对脑卒中后吞咽障碍的疗效观察

目的探讨脑卒中后吞咽障碍康复训练的方法和疗效。方法将36例脑卒中后吞咽障碍患者随机分为两组：训练组20例和对照组16例,训练组患者除给予内科常规治疗外进行吞咽障碍康复训练,对照组仅采用内科常规治疗,治疗4周后对比分析两组的疗效。结果训练组经过4周的康复训练,吞咽功能明显改善,吞咽障碍程度与对照组比较差异有统计学意义（P〈0．05）。训练组20例患者中显效10例,有效7例,无效3例;对照组16例患者中显效1例,有效8例,无效7例,两组患者的疗效间差异有统计学意义（P〈0．01）。结论早期康复训练能明显提高脑卒中后吞咽障碍患者的吞咽功能。     

经皮胃造瘘术联合特殊医学用途配方食品对晚期恶性肿瘤病人免疫功能及营养状况的影响

目的观察数字减影血管造影(DSA)引导下经皮胃造瘘术联合特殊医学用途配方食品对吞咽障碍的晚期恶性肿瘤病     

The Dysphagia Outcome and Severity Scale

The Dysphagia Outcome and Severity Scale (DOSS) is a simple, easy-to-use, 7-point scale developed to systematically rate the functional severity of dysphagia based on objective assessment and make recommendations for diet level, independence level, and type of nutrition. Intra- and interjudge reliabilities of the DOSS was established by four clinicians on 135 consecutive patients who underwent a modified barium swallow procedure at a large teaching hospital. Patients were assigned a severity level, independence level, and nutritional level based on three areas most associated with final recommendations: oral stage bolus transfer, pharyngeal stage retention, and airway protection. Results indicate high interrater (90%) and intrarater (93%) agreement with this scale. Implications are suggested for use of the DOSS in documenting functional outcomes of swallowing and diet status based on objective assessment.     

Scintigraphic quantification of pharyngeal retention following deglutition

A procedure is described for quantifying the amount of bolus material retained in the pharynx after completion of a swallow, using radionuclide swallow techniques. Data are derived from scintigraphic time-activity curves. The procedure takes into consideration the differential attenuation of radioactivity through various regions in the body, and expresses the result as a percentage of the total radioactivity in the ingested bolus. Illustrative examples are provided for swallows by normal individuals and patients with head and neck cancer.     

Endoscopic dilatation and surgical myectomy of symptomatic cervical esophageal webs

During a 10-year period a cervical esophageal web or stricture was diagnosed at rigid endoscopy in 57 patients. Of these patients 72% had restricted their dietary habits because of their symptoms of dysphagia. Cineradiography of the pharynx had revealed abnormalities in 90% of the patients. Dilatation of the webs was performed with semisolid bougies, the endoscope itself, or with balloon inflation. Twelve patients were treated by myectomy of the cricopharyngeal muscle because of unsatisfactory results from the dilatation treatment. Cineradiographic outcome and improvement in dietary habits as a result of the treatment are reported.     

Chewing and the dimension of the pharyngoesophageal segment

Masticatory efficiency was evaluated in 21 adults for four chewing parameters: mixing of a color-patterned chewing gum mass, shaping of a chewing gum mass, particle reduction of a silicone tablet, and number of chewing strokes before the first swallow of an almond. The results of these tests were correlated with the dimension of the pharyngoesophageal (PE) segment during swallow of liquid barium and solid meat. The transverse width of the PE segment during swallow of liquid barium correlated significantly with the chewing parameters. The sagittal width of the PE segment during swallow of liquid barium correlated only weakly with the chewing parameters. The PE segment dimension during swallow of a solid meat bolus did not correlate with the chewing parameters. The results suggest that there is feedback during chewing and swallowing between the PE segment and the oral cavity.