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意识障碍患者撤销生命维持治疗的伦理困境

医学与哲学 2022年第22期43卷 22-25页

作者：李美琦孙玲秀程丽娟李岩 steven laureys 狄海波杭州师范大学国际植物状态和意识科学研究所浙江杭州311121 比利时列日大学GIGA意识研究组昏迷科学团队比利时列日4000

意识障碍领域中广泛存在着分类定义不清晰、诊断误诊率高、治疗缺乏有效性和康复不佳的临床问题。在意识障碍患者限制治疗的过程中,患者的最佳利益始终是一个未被讨论透彻的问题,西方医疗决策模式仍然存在一些缺陷且与我国存在显著差异... 详细信息

意识障碍领域中广泛存在着分类定义不清晰、诊断误诊率高、治疗缺乏有效性和康复不佳的临床问题。在意识障碍患者限制治疗的过程中,患者的最佳利益始终是一个未被讨论透彻的问题,西方医疗决策模式仍然存在一些缺陷且与我国存在显著差异。结合我国当下意识障碍患者医疗管理现状及医疗决策特点,提出可能的解决途径,如意识障碍患者多模态评估、分类管理、共同决策、预立照护计划。以期为意识障碍临床实践提供动力,并推进撤销意识障碍患者生命维持治疗的认识。

关键词：意识障碍撤销治疗伦理困境

Detecting movement volition in patients with disorders of consciousness

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Detecting movement volition in patients with disorders of co...

作者： Lihua Ding Fuyan Wang Xiaohua Hu Dan Yu steven laureys Haibo Di International Vegetative State and Consciousness Science Institute Hangzhou Normal University Coma Science Group The Affiliated Hospital of Hangzhou Normal university Hangzhou Wujing Hospital Cyclotron Research Centre and Neurology Department University of Liege

Objectives:The accurate assessment of patients with disorders of consciousness(DOC) is still a challenge to most experienced *** a potential clinical tool,functional magnetic resonance image(fMRI) could detect signs of consciousness in patients with DOC without the need of any actual motor response on their ***,we adopt a simple and feasible active fMRI motor paradigm(hand raising) to detect residual awareness in these ***:A total of 30 patients were recruited in our study,who met the diagnosis of vegetative state/unresponsive wakefulness syndrome(VS/UWS;n=21),minimally conscious state(MCS;n=8) and emergence from the MCS(EMCS;n=1).We analyzed the command following responses for robust evidence of appropriate,consistent,and statistically reliable markers of motor execution,similar to those noted in 15 healthy ***:Of the 30 patients,5(1 EMCS,2 MCS,2 VS/UWS) were able to modulate their brain activities to "hand raising" command and they showed activation in motor-related regions(which could not be discovered in own-name task).Longitudinal behavioral assessments showed that all 2 patients in VS/UWS at the time of the fMRI examination evolved to MCS,and of 19 patients in VS/UWS who failed to show activation in motor-related regions,10 patients stayed in a VS/UWS,2 patients died and 7 patients reached at least an MCS at the end of the observation period(sensitivity22%,specificity 100%).One of 2 patients in an MCS with activation in motor-related regions evolved to MCS+.Of 6 patients in an MCS who did not show activation,3 patients stayed in an MCS and 3 patient emerged from the MCS(sensitivity 25%,specificity 75%).Conclusions:The active fMRI "hand raising" task can elicit brain activation in patients with DOC similar to those observed in healthy *** of the motor-related network may serve as an indicator of high-level cognition that cannot be discerned through conventional behavioral assessment.

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植物状态临床意识检测的一个简便方法:瞳孔近反射

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植物状态临床意识检测的一个简便方法:瞳孔近反射

中国生理学会第24届全国会员代表大会暨生理学学术大会

作者：狄海波顾一滔黄王姗成功胡晓华 Aurore Thibaut steven laureys 杭州师范大学国际植物状态和意识科学研究所武警浙江总队杭州医院康复中心比利时列日大学昏迷科学团队

随着急诊技术的提高,昏迷后严重意识障碍患者显著增多。严重意识障碍（DOC）包括昏迷、植物状态（VS,亦称无反应觉醒综合征UWS）、最小意识状态（MCS）。目前,客观方法有了一定的进步,但以CRS-R作为代表的行为检测还是金标准。临床诊断... 详细信息

随着急诊技术的提高,昏迷后严重意识障碍患者显著增多。严重意识障碍（DOC）包括昏迷、植物状态（VS,亦称无反应觉醒综合征UWS）、最小意识状态（MCS）。目前,客观方法有了一定的进步,但以CRS-R作为代表的行为检测还是金标准。临床诊断基于评估者对DOC患者行为反应的主观推测。在CRS-R中,视觉通道的行为检测是一个重要方面。但是视觉检测存在不稳定,同时,对于反射种类的选择甚至是同一反射的不同刺激都有不同意见,对于DOC患者的行为量化很困难,行为量表需要进一步改进。瞳孔近反射（也称瞳孔调节反射）是一个视觉通道的行为反应,是指瞳孔在注视一个物体由远及近的过程中发生的大小变化。这是一个常见的反射。由于通过瞳孔大小变化客观判断反射存在与否,可在一定程度上克服行为检测的主观性,尤其是瞳孔检测不需要眼球转动。该反射反射弧主要与植物神经有关,故对一些眼球运动神经受损的患者而言更具价值。因此,我们拟采用瞳孔近反射来评估DOC患者的意识状态,试图补充并改进CRS-R对VS患者的诊断。

关键词： DOC CRS-R PNR

意识障碍患者昏迷疼痛量表修订版的信效度分析

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中华行为医学与脑科学杂志 2018年第11期27卷 1039-1042页

作者：王静华雯程丽文夏志刚胡晓华闫怡帆 steven laureys 狄海波杭州师范大学医学院国际植物状态与意识科学研究所杭州310036 武警浙江总队杭州医院康复中心杭州310054 列日大学昏迷科学中心列日4000

目的使用昏迷疼痛量表-修订版(nociception coma scale-revised,NCS-R)评估意识障碍患者的疼痛,并分析其信效度,评价该量表在国内的临床应用价值。方法用NCS-R量表对62名意识障碍患者进行疼痛评估,分析量表的内部一致性,评估者间的一致... 详细信息

目的使用昏迷疼痛量表-修订版(nociception coma scale-revised,NCS-R)评估意识障碍患者的疼痛,并分析其信效度,评价该量表在国内的临床应用价值。方法用NCS-R量表对62名意识障碍患者进行疼痛评估,分析量表的内部一致性,评估者间的一致性,评估与再评估的一致性,同时效度。结果该量表的内部一致性Cronbach'α系数为0.611,重复评估总分Sperman相关系数为0.884,运动、言语和面部表情分量表的Cronbach'skappa系数分别为0.856,0.870,0.856,评估者之间的总分Sperman相关系数为0.662,运动、言语和面部表情分量表信度的Cronbach'skappa系数分别为0.962,0.867,0.671;与其他疼痛量表的同时效度的Sperman相关系数为0.560(均P<0.01)。结论NCS-R具有较好的信度和效度,适用于临床医生和研究人员评估意识障碍患者的疼痛情况。

关键词：昏迷疼痛量表-修订版疼痛评估意识障碍信度和效度

Pupil near response--a promising index to evaluate consciousness in patients with disorders of consciousness

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Pupil near response--a promising index to evaluate conscious...

作者： Yitao Gu Wentao Zeng Gong Cheng Lizette Heine Xiaohua Hu Shan Jing steven laureys Haibo Di Hangzhou Normal University International Vegetative State and Consciousness Science Institute University of Liege and University Hospital of LiegeCyclotron Research Center and Neurology DepartmentComa Science Group Hangzhou Wujing Hospital Department of Rehabilitation

Objective:To determine if pupil near response(PNR) can be added into Coma Recovery Scale Revised[CRS-R]as an index of consciousness to improve CRS-R’s diagnostic accuracy in patients with disorders of consciousness(DOC) by removing the influence of patients’ motor impairment and assessor’s personal ***:PNR was evaluated in 20 patients who had been diagnosed as UWS(by means of CRS-R).The outcome was assessed by CRS-R 3 months later to determine the prognosis value of the ***:4 of 20 patients showed PNR(PNR+ group) in this *** was better in these patients than in PNR-patients(4/4 versus 5/16 recovered to MCS at follow up,p=0.026).The detection of conscious visual behaviors at follow-up was more frequent among PNR+ patients than in PNR-patients(4/4 versus 2/16,p=0.003).Conclusions:The significant difference between PNR+ patients and PNR-patients’ outcome suggests that PNR could be considered as a sign of good prognosis for consciousness ***,PNR’s presence requires no motor function and the assessment of PNR by ratio of pupillary constriction(pupil diameter change/original pupil diameter before PNR test)needs no personal *** 2 features of PNR remove the influence of motor impairment and personal interpretation on the diagnostic accuracy of CRS-R in DOC patients,making it can be used as a supplementary index of CRS-R that improves its diagnostic accuracy.

关键词：

Repeated stimulation of the posterior parietal cortex in patients in minimally conscious state:a sham-controlled randomized clinical trial

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Repeated stimulation of the posterior parietal cortex in pat...

作者： Wangshan Huang Aurore Thibaut Sarah Wannez Felipe Fregni Xiaohua Hu Shan Jing Geraldine Martens Minhui He Haibo Di steven laureys Hangzhou Normal University International Vegetative State and Consciousness Science Institute University of Liege and University Hospital of LiegeCyclotron Research Center and Neurology DepartmentComa Science Group Spaulding Rehabilitation Hospital/Harvard Medical School Spaulding Neuro--modulation Center Hangzhou Wujing Hospital Department of Rehabilitation

Objective:We assessed the effects of transcranial direct current stimulation(tDCS) targeted to posterior parietal cortex in patients in minimally conscious state(MCS).Methods:In a randomized double-blind sham-controlled crossover study,MCS patients at least 1 month after traumatic or nontraumatic insult received one sham and one real tDCS session(2 mAduring 20 minutes once a day for five days) in a randomized order separated by five days of washout over the posterior parietal *** Recovery Scale-Revised(CRS-R) assessments were performed directly on enrollment,before the first session and after each real and sham tDCS as well as five days ***-up outcome data were acquired 1,3,6,12 months after inclusion using the ***:33 MCS patients were enrolled(mean age:57±11 years;interval 6±5 months;20 traumatic).Atreatment effect(p=0.012;effect size:0.31) was observed after real tDCS session but did not last for 5 days after the end of the session(p=0.135).We identified 9(27%)tDCS-responders(i.e.,showing new sign(s) of consciousness that was never observed before,lasting at least 5 days after the end of the stimulation).Conclusion:Five days of tDCS over the posterior parietal cortex has a small and short-lasted beneficial effect on consciousness in MCS.

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前沿进展:以国际化视野探索中国意识障碍研究与转化道路

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健康研究 2021年第5期41卷 485-489页

作者：孙玲秀刘晓晨王安琪杨昊狄海波 steven laureys 杭州师范大学国际植物状态和意识科学研究所浙江杭州311121 比利时列日大学GIGA意识研究组昏迷科学团队比利时列日4000

近年来,严重脑损伤的死亡率随着急救技术的不断发展显著下降,而继发意识障碍(disorders of consciousness,DOC)患者数量却急剧增加。文章介绍了杭州师范大学国际植物状态和意识科学研究所主办的意识障碍精准评估及临床应用论坛关于意识... 详细信息

近年来,严重脑损伤的死亡率随着急救技术的不断发展显著下降,而继发意识障碍(disorders of consciousness,DOC)患者数量却急剧增加。文章介绍了杭州师范大学国际植物状态和意识科学研究所主办的意识障碍精准评估及临床应用论坛关于意识障碍的分类诊断、治疗干预、新技术手段与未来挑战等报告内容,探讨了国际化视角下多中心、跨学科模式为我国意识障碍领域的科学研究及临床应用带来的启示。

关键词：意识障碍分类诊断治疗干预临床转化

无反应觉醒综合征体核温度节律呈现自由运转周期

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无反应觉醒综合征体核温度节律呈现自由运转周期

作者：狄海波梁佳王静黄秦特徐晓漫黄王姗丁丽华荆山陈柳衡曾文韬胡晓华 Aurore Thibaut steven laureys 杭州师范大学医学院国际植物状态与意识科学研究所武警浙江总队杭州医院比利时列日大学昏迷科学团队

目的正常人具有>24小时的内源性节律即自由运转周期。由于接受外界因素刺激,出现接近24小时的生物节律。故而推测,由于无反应觉醒综合征患者缺乏对外界感知,其生物节律可能呈现自由运转周期。本研究拟验证无反应觉醒综合征患者的体核温...

目的正常人具有>24小时的内源性节律即自由运转周期。由于接受外界因素刺激,出现接近24小时的生物节律。故而推测,由于无反应觉醒综合征患者缺乏对外界感知,其生物节律可能呈现自由运转周期。本研究拟验证无反应觉醒综合征患者的体核温度是否呈现自由运转周期。方法在控制外界因素情况下,测量7位严重意识障碍(DOC)患者的外耳道温度,红外线温度计连续168小时,每隔两小时测量一次。使用最小二乘法拟合初步生成体核温度图像,并用单余弦法测定最适周期、均值和振幅。结果 3位最小意识状态患者体核温度24小时,即呈现出自由运转周期。结论最小意识状态患者和无反应觉醒综合征患体核温度存在差别,并且无反应觉醒综合征患者体核温度节律呈现自由运转周期。

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Measuring consciousness in coma and related states

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World Journal of Radiology 2014年第8期6卷 589-597页

作者： Carol Di Perri Aurore Thibaut Lizette Heine Andrea Soddu Athena Demertzi steven laureys Neuroradiology National Neurological Institute C Mondino 27100 Pavia Italy Cyclotron Research Center and Neu-rology Department Coma Science Group University of Liège Physics and Astrono-my Department Western University London Ontario N6A 3K7 Canada

Consciousness is a prismatic and ambiguous concept that still eludes any universal definition. Severe acquired brain injuries resulting in a disorder of con-sciousness(DOC) provide a model from which insights into consciousness can be drawn. A number of recent studies highlight the difficulty in making a diagnosis in patients with DOC based only on behavioral assessments. Here we aim to provide an overview of how neuroimaging techniques can help assess patients with DOC. Such techniques are expected to facilitate a more accurate understanding of brain function in states of unconsciousness and to improve the evaluation of thepatient's cognitive abilities by providing both diagnostic and prognostic indicators.

关键词： Disorders of consciousness Neuroimaging Magnetic resonance imaging Transcranial magnetic stimulation/electroencephalography Minimally conscious state Vegetative state/unresponsive wakefulness syndrome