Table of Content

20 September 2023, Volume 18 Issue 9

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Stroke Center Construction and Quality Control: A Long Way to Go 

XU Yuming

2023, 18(9):  973-977.  DOI: 10.3969/j.issn.1673-5765.2023.09.001

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Stroke is the leading cause of death in China. The establishment and quality control of stroke centers aim to create a comprehensive stroke emergency treatment system for more efficient and standardized stroke diagnosis and treatment. China has already developed a considerable scale of stroke center network. The construction of stroke centers adheres to government leadership, and the promotion by the health administrative departments provided strong support for the orderly development of various work aspects. Popularizing stroke knowledge and education is the prerequisite for stroke center construction, and it is essential to continuously and adaptively promote early stroke identification and health knowledge at all levels. Pre-hospital identification, emergency dispatch, and transportation are the key factors in reducing the delay in pre-hospital delay, reflecting the objective demand for accelerating the construction of the “stroke emergency care map”. The construction of green channels in hospital stroke is the core of the construction of stroke center, and we should actively explore and establish appropriate green channel models. Encouraging the development of mature regions to build primary stroke treatment units actively, increasing the application of remote stroke diagnosis and treatment methods, and effectively bridging “the last mile” in stroke treatment are important. Continue to promote information quality control work throughout the entire process in the construction of stroke center and quality control, comprehensively improving the efficiency and objectiveness of construction work. The situation in China determines that there is enormous potential and a long road ahead for the development of stroke centers and quality control. 

Stroke Center Construction and Quality Control

XU Yuming

2023, 18(9):  978-978. 

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Research Progress of the Construction and Quality Control of Stroke Center

GAO Yuan, LIU Kai, LI Yapeng, YANG Zongyu, LI Yusheng, SONG Bo, XU Yuming

2023, 18(9):  979-985.  DOI: 10.3969/j.issn.1673-5765.2023.09.002

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The construction of stroke centers and quality control has been a hot topic in the field of stroke treatment in recent years. China’s construction of stroke centers, through the integration of medical resources and multidisciplinary collaboration, has formed a regional organized stroke treatment network that integrates pre-hospital identification and transfer, acute phase treatment, early rehabilitation, secondary prevention, follow-up education, quality inspection and improvement. A standardized, efficient, and standardized system for stroke treatment and quality control has been established, which plays a crucial role in standardizing and enhancing the diagnosis and efficiency of stroke in medical institutions, promoting the improvement of medical service quality, and reducing the burden of disease. The construction of the emergency map focuses on how to reduce time delay in emergency response and acute phase treatment, including pre-hospital identification and emergency dispatch. China has gradually built a “national-province-prefecture-level city” three-tier stroke emergency map system, constructing a “regional stroke emergency map” centered on prefecture-level cities. The construction of China’s stroke emergency green channel has developed rapidly in the past 10 years. Medical institutions at all levels have established multidisciplinary teams for acute stroke diagnosis and treatment, changed the patient flow from serial to parallel, carried out detailed quality inspections and continuous improvements, and gradually improved efficiency using information technology, effectively reducing in-hospital delays, increasing thrombolysis rates, and improving clinical efficacy. Primary medical institutions face the vast number of stroke patients more directly. However, due to disadvantages in medical hardware, talent reserves, and institutional mechanisms, it is extremely challenging to bridge the “last mile” of stroke treatment. The proactive exploration conducted in Henan province is worth referencing and learning from. Stroke units can significantly improve the clinical outcomes of acute stroke patients. Their construction covers acute phase treatment, secondary prevention, early rehabilitation, and health education for stroke patients, requiring enhanced multidisciplinary collaboration. Mobile stroke units are an innovative model that extends stroke treatment to the pre-hospital stage. They can significantly shorten the time from onset to thrombolysis decision and have high safety. Their promotion and application are crucial for improving the treatment level of stroke patients. In terms of quality control of stroke centers, China has initially formed a three-tier quality control network of “national-province-prefecture-level city”, forming a relatively comprehensive quality control network system covering different levels nationwide. However, facing significant socio-economic development disparities, the future construction of stroke centers and quality control work remains a long journey ahead.

Exploration and Practice of the Construction of Stroke Center in Henan Province

LI Yapeng, GAO Yuan, LIU Kai, YANG Zongyu, WANG Jingjing, ZHOU Lue, DONG Xiaokang, LI Yusheng, SONG Bo, XU Yuming

2023, 18(9):  986-992.  DOI: 10.3969/j.issn.1673-5765.2023.09.003

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In order to curb the high incidence of stroke and reduce the rate of death and disability in the acute phase of stroke, the Health Commission of Henan Province has successively established the Henan Stroke Prevention and Treatment Center and the Henan Stroke Quality Control Center to take charge of the construction of stroke centers in Henan province. We have established stroke prevention and quality control system in the provincial, municipal, and county levels, and have actively promoted the continuous input from local governments. The hospital dean forum, regional advanced stroke center visits and exchanges, and appropriate techniques training on stroke prevention and treatment are regularly carried out, which effectively promotes the service capacity of stroke centers. The Health Commission of Henan Province has included the construction of stroke centers as a necessary condition for hospital level evaluation. Through measures such as implementing rapid stroke emergency response, increasing screening and evaluation of high-risk groups for stroke, widely conducting early stroke identification and education, and establishing the management system of stroke centers, the number and quality of stroke centers have been significantly improved. Appropriate techniques such as intravenous thrombolysis, mechanical thrombolysis and carotid endarterectomy have been developed rapidly in Henan province.



Relationship between Characteristics of Ischemic Infarction Distribution and Involved Vascular Segments in Patients with Ischemic Stroke Caused by Spontaneous Carotid Artery Dissection

WU Di, JING Jing, PAN Yuesong, CHEN Xuzhu, ZHAO Xingquan

2023, 18(9):  993-1000.  DOI: 10.3969/j.issn.1673-5765.2023.09.004

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Objective  The aim of the study is to investigate the relationship between the characteristics of ischemic infarction distribution and involved artery segments in patients with ischemic stroke caused by spontaneous carotid artery dissection. Spontaneous carotid artery dissection includes spontaneous common carotid artery bifurcation dissection (sCCABD) and spontaneous internal carotid artery dissection (sICAD). 
Methods  This was a single-center retrospective study. Patients hospitalized from December 1, 2014 to November 15, 2021 were continuously recruited. They were treated for ischemic stroke caused by spontaneous carotid artery dissection (sCCABD or sICAD or both). For each patient, the clinical data, medical history, imaging characteristics, and other relevant information were collected. Then they were divided into three groups as no cerebral infarction, single infarction, and multiple infarctions and compared by radiological findings, involved vascular location, and segments of arteries. 
Results  A total of 17 patients with ischemic stroke caused by spontaneous carotid artery dissection (sCCABD or sICAD or both) were included, including two patients with no infarction, four patients with a single infarction, and 11 patients with multiple infarctions. In the no infarction group, the arterial dissection location included C1 ascending (two cases), C2, C3, and C4 segments of the internal carotid artery (one case, respectively). Dissections were mainly found in the C1 ascending segment in the single infarction group (five cases). In the multiple infarctions group, arterial dissection occurred mostly in the C1 ascending and C3 segment (five cases, respectively), followed by the C2 (four cases), C1 bulbar (three cases), and C4 segment (three cases), and least in the common carotid artery bifurcation segment and C5 segment (one case, respectively). As for infarction location, territorial infarction (two cases), localized infarction (one case), and deep larger infarction (one case) were found in the single infarction group; internal watershed infarction (four cases), territorial infarction (three cases), localized infarction (two cases), deep larger infarction (two cases), small superficial (one case), and deep lacunar infarction (one case) were revealed in the multiple infarction group.
Conclusions  In this study, multiple infarctions are more common in patients with ischemic stroke caused by spontaneous carotid artery dissection (sCCABD or sICAD or both). Dissection occurs mostly in C1 ascending and C3 segments of carotid artery, followed by the C1 bulbar, C2 and C4 segments, and rarely in the bifurcation of the common carotid artery and C5 segment of the internal carotid artery. Furthermore, the spontaneous dissection could occur in the carotid bulb and cause its occlusion. The relationship between the numbers of cerebral infarction and the involved dissected artery segments is to be explored by more cases in future.




The Effect of Standardized Training on the Reliability of Glasgow Coma Score Evaluation by Nurses

WANG Yanxin, YUAN Yuan, XU Ming, CHAO Mingzhu, NIE Ximing

2023, 18(9):  1001-1005.  DOI: 10.3969/j.issn.1673-5765.2023.09.005

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Objective  To evaluate the effect of standardized training on the reliability of Glasgow coma score (GCS) evaluation by nurses.
Methods  The current internationally recognized GCS scoring standardized training including text explanation, test and clinical practice training, were conducted for nurses. The consecutive patients with severe neurological diseases who were admitted to Neurointensive care unit, Department of neurology, Beijing Tiantan Hospital, Capital Medical University were prospectively included. Twenty nurses with low seniority (less than 2 years of service) were selected to conduct GCS scores for 100 patients with severe neurological conditions before and after standardized GCS scoring training. The intraclass correlation coefficient (ICC) was used to compare the consistency of GCS scores evaluation before and after the standardized training. In addition, the GCS scores evaluation by neurointensive care specialists who conducted training were used as the gold standard to evaluate the validity of the nurses’ scale assessment before and after the training.
Results  The standardized training improved the reliability of the GCS evaluation among the low seniority nurses, the ICC of GCS total score increased from 0.862 to 0.956, that of verbal response assessment increased from 0.874 to 0.953, that of motor response assessment increased from 0.689 to 0.922, and that of eye movement assessment increased from 0.486 to 0.665. After the training, the validity of the nurses in assessing GCS increased from 0.85 6 to 0.942. 
Conclusions  Standardized training can improve the reliability and validity of the GCS scale among the low seniority nurses. 


LACC1 Aggravated Ischemia Reperfusion by Phosphorylate AMP-activated Protein Kinase/Nucleotide-binding Oligomerization Domain-like Receptor Protein 3 in Cerebral Infarction

JIAO Junping, BAO Junqiang, SHI Huimin, GAO Chao, TIAN Shujuan

2023, 18(9):  1006-1013.  DOI: 10.3969/j.issn.1673-5765.2023.09.006

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Objective  To investigate the effect and mechanism of laccase gene LACC1 on ischemic reperfusion after cerebral infarction.
Methods  ①Purchase 20 C57BL/6J LACC1 knockout (LACC1-/-) mice and 20 wild-type (WT) mice, and establish middle cerebral artery occlusion/reperfusion (MCAO/R) model with 15 mice each, the volume of cerebral infarction was compared between the two groups, and western blot was performed to detect phosphorylate AMP-activated protein kinase (p-AMPK) and nucleotide-binding oligomerization domain-like receptor protein 3 (NLRP3) in brain tissue. Microarray analysis of long noncoding RNA (lncRNA) expression profiles in peripheral blood and exploration of possible signal transduction pathways involved. ②Preparation of a mouse microglia oxygen glucose deprivation/reperfusion (OGD/R) model and upregulation and inhibition of LACC1 expression by siRNA transfection technique to clarify the regulatory effects of LACC1 on inflammation and oxidative stress in an in vitro model of cerebral infarction, western blot detection levels of p-AMPK and NLRP3. Serum catalase (CAT), superoxide dismutase (SOD), malondialdehyde (MDA), reactive oxygen species (ROS), IL-1β, IL-6, interferon-γ (INF-γ), TNF-α levels were measured by enzyme linked immunosorbent assay (ELISA).
Results  The proportion of cerebral infarction volume in WT mouse group of MCAO/R model was (21.38%±4.06%) and that in LACC1-/- mouse group was (19.07%±2.86%), the difference was statistically significant (P=0.041). Meanwhile, the expression level of p-AMPK protein in brain tissue of LACC1-/- mice was increased. NLRP3 protein expression was inhibited. Down-regulation of LACC1 inhibited the expression of NLRP3 protein and increased the expression of p-AMPK protein in OGD/R cell models. In OGD/R cell model, over expression of LACC1 increased the production of IL-1β, IL-6, INF-γ, TNF-α, MDA and ROS, and decreased the levels of CAT and SOD (P<0.05).
Conclusions  LACC1 may exacerbate the inflammatory response after ischemia-reperfusion via the AMPK/NLRP3 pathway, which may provide a new therapeutic option for cerebral infarction or other neurological diseases and their related complications.




Chinese Stroke Association Guidelines for Clinical Management of Cerebrovascular Diseases (Second Edition) (Excerpt) ——Chapter Five Clinical Management of Intracerebral Hemorrhage

ZHANG Qian, JI Ruijun, ZHAO Meng, WANG Wenjuan, LU Jingjing, LI Na, LIU Yanfang, BIAN Liheng, YU Songlin, LI Hao, ZHANG Qian, WU Jianwei, WANG Dandan, WANG Jing, LI Zhaoxia, JIANG Ruixuan, KANG Kaijiang, XUE Yimeng, YA Xiaolong, HE Qiheng, MO Shaohua, ZHAO Xingquan, ZHAO Jizong, the Writing Committee of Chinese Stroke Association Guidelines for Clinical Management of Cerebrovascular Diseases ( Contributed equally)

2023, 18(9):  1014-1023.  DOI: 10.3969/j.issn.1673-5765.2023.09.007

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Spontaneous intracerebral hemorrhage represents a severe subtype of stroke, accounting for approximately 23.4% of stroke cases in China. It is characterized by its rapid onset, swift disease progression, and high rates of mortality and disability. Given the urgency and complexity in managing intracerebral hemorrhage, this guideline aims to provide systematic and comprehensive recommendations for its clinical management. This chapter covers all key aspects ranging from pre-hospital evaluation and medical intervention to secondary prevention and rehabilitation. With respect to specific recommendations, this guideline offers exhaustive guidance based on varying levels of evidence for early diagnosis, imaging assessments, acute-phase interventions, medical and ICU management, surgical interventions, and secondary prevention strategies, with the ultimate aim of enhancing the scientific rigor and systematic quality of spontaneous intracerebral hemorrhage management. 



Chinese Stroke Association Guidelines for Clinical Management of Cerebrovascular Diseases (Second Edition) (Excerpt)——Chapter Six Clinical Management of Subarachnoid Hemorrhage

CHENG Xin, ZHONG Weiyi, DONG Yi, LI Qi, NI Wei, GU Hongqiu, GU Yuxiang, DONG Qiang, the Writing Committee of Chinese Stroke Association Guidelines for Clinical Management of Cerebrovascular Diseases

2023, 18(9):  1024-1029.  DOI: 10.3969/j.issn.1673-5765.2023.09.008

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SAH is one of common hemorrhagic cerebrovascular diseases with severe complications. Many survivors are left with persistent neurological deficit and reduced quality of life. Researchers at home and abroad have been committed to exploring effective diagnosis and treatment of SAH to improve the clinical outcomes of patients. This guideline has formed evidence-based recommendations in comprehensive management of SAH, especially in diagnosis and severity assessment, multidisciplinary collaboration, measures to prevent rebleeding and complication managements, in order to provide standardized guidance for clinical practice of SAH in China. 



Chinese Stroke Association Guidelines for Clinical Management of Cerebrovascular Diseases (Second Edition) (Excerpt)——Chapter Seven Clinical Management of Cerebral Venous Thrombosis

FAN Yuhua, DANG Chao, YU Jian, CHEN Hongbing, DUAN Jiangang, MO Dapeng, ZHU Wenhao, OUYANG Fubing, WANG Bo, ZENG Jinsheng, the Writing Committee of Chinese Stroke Association Guidelines for Clinical Management of Cerebrovascular Diseases

2023, 18(9):  1030-1035.  DOI: 10.3969/j.issn.1673-5765.2023.09.009

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The incidence of CVT is low, but the rate of clinical missed diagnosis and misdiagnosis is high. Improving understanding of CVT, timely diagnosis and treatment can help improve the prognosis of patients with CVT. This chapter presents recommendations for the diagnosis and treatment of CVT, including the application of imaging diagnostic technology, the selection and treatment course of anticoagulants, the selection of intravascular treatment, and the prevention and treatment of complications.



Chinese Stroke Association Guidelines for Clinical Management of Cerebrovascular Diseases (Second Edition) (Excerpt)——Chapter Eight Cerebrovascular Disease Rehabilitation Management

ZHANG Tong, ZHAO Jun, LI Xueping, BAI Yulong, WANG Baojun, QU Yun, LI Bingjie, MEI Liping, the Writing Committee of Chinese Stroke Association Guidelines for Clinical Management of Cerebrovascular Diseases

2023, 18(9):  1036-1048.  DOI: 10.3969/j.issn.1673-5765.2023.09.010

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Stroke is characterized by high morbidity, high mortality and high disability. Rehabilitation for stroke patients can improve dysfunctions and activities of daily living (ADL), and potentially prevent stroke-related complications. Therefore, surviving patients could return to their families and fit into the world. Standardized rehabilitation procedures and programs are particularly critical. This guideline will introduce the stroke rehabilitation management model, the tertiary stroke rehabilitation network. Recommendations were formed on the assessment and rehabilitation of specific functional disorders (motor dysfunction, sensory impairment, dysphagia, dysarthria, aphasia, cognitive disorder, cardiopulmonary dysfunction, psychological disorder), rehabilitation of ADL and social participation disorders, vocational rehabilitation, assessment and rehabilitation of complications (skin breakage, contracture, deep vein thrombosis, intestinal and bladder incontinence, hemiplegic shoulder pain, shoulder-hand syndrome, central pain, osteoporosis), and rehabilitation nursing. 



Ischemic Stroke Caused by Internal Carotid Artery Dissection Associated with Styloid Process Syndrome: A Case Report

WANG Lijia, SHI Dai, LIU Huihui, CAO Yongjun, LIU Chunfeng, SHI Jijun

2023, 18(9):  1049-1053.  DOI: 10.3969/j.issn.1673-5765.2023.09.011

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Elongated styloid process is the main anatomical abnormality leading to carotid dissection, and the patient with ischemic stroke caused by carotid dissection associated with elongated styloid process was reported here. The patient had a long-standing history of frequent head down and head lift work and CTA with three-dimensional reconstruction showed bilateral elongated styloid processes. Left internal carotid artery dissection due to long-term mechanical injury was the underlying cause of this ischemic stroke, and arterial dissection was repaired well after stenting in the left internal carotid artery. Adequate attention should be paid to ischemic stroke associated with styloid process syndrome to reduce the risk of recurrent stroke. 



Heterozygous HTRA1-related Hereditary Cerebral Small Vessel Disease: A Case Report and Literature Review

ZU Yu, YU Shasha, ZHANG Yujing, LYU Jing, FENG Xuedan

2023, 18(9):  1054-1059.  DOI: 10.3969/j.issn.1673-5765.2023.09.012

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Clinical symptoms, imaging findings, and genetic testing results of a 60-year-old male patient with mild cognitive impairment and dizziness were analyzed. The patient had a history of hypertension, hyperlipidemia, hyperuricemia, and long-term smoking and alcohol consumption. His mother had dementia. Cranial magnetic resonance images revealed multiple lacunar infarctions, white matter degeneration, and multiple microbleeding lesions. Genetic testing report showed a heterozygous mutation in the HTRA1 gene (c.1174T > C). All of above results are consistent with the diagnosis of heterozygous HTRA1-related hereditary cerebral small vessel disease. 

A Case Report on the Treatment of Ischemic Stroke Caused by Moyamoya Disease with Ginaton

REN Xiaojia, LIU Guanjie, HAO Wenqiang

2023, 18(9):  1060-1064.  DOI: 10.3969/j.issn.1673-5765.2023.09.013

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Moyamoya disease is a chronic vascular disease of unknown cause, characterized by progressive intracranial vascular stenosis, occlusion and abnormal vascular network formation. It can be clinically manifested as ischemic or hemorrhagic stroke, headache, epilepsy, etc. Treatment includes surgery and drug therapy. In this paper, the clinical efficacy of a case of ischemic stroke caused by moyamoya disease was compared before and after treatment, and the occurrence of adverse reactions was observed, so as to explore the efficacy and feasibility of sequential therapy of Ginaton for clinical reference. 

Research Progress of Hemorrhagic Transformation after Endovascular Treatment in Acute Ischemic Stroke

LU Jing, LI Chuanfa, ZHANG Daqi, CHEN Rong, LI Qifu

2023, 18(9):  1065-1072.  DOI: 10.3969/j.issn.1673-5765.2023.09.014

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The keypoint to the treatment of acute ischemic stroke is to timely recanalize the occluded artery, restore blood flow in the ischemic tissue, and save the ischemic penumbra. Up to now, endovascular treatment represented by mechanical thrombectomy and stent implantation has become effective treatment for acute ischemic stroke, but hemorrhagic transformation is still a catastrophic complication of endovascular treatment, and is closely related to neurological deterioration and poor functional outcomes. Therefore, it is crucial for clinicians to deepen their understandings of hemorrhagic transformation. Based on the relevant guidelines and the latest studies, this paper aims to make a comprehensive review about hemorrhagic transformation after endovascular treatment of acute ischemic stroke, discusses the pathophysiological mechanism, risk factors, predictors and prevention and treatment strategies of hemorrhagic transformation, so as to provide reference for early prediction, prevention and treatment of hemorrhagic transformation. 

Progress on Blood Pressure Management in Patients with Acute Ischemic Stroke Undergoing Mechanical Thrombectomy

ZHOU Yumeng, CHEN Lixia

2023, 18(9):  1073-1078.  DOI: 10.3969/j.issn.1673-5765.2023.09.015

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The level of blood pressure management in acute ischemic stroke is associated with prognosis. Too high or too low blood pressure may lead to poor prognosis. Mechanical thrombectomy is widely used in clinical practice, and its preoperative, intraoperative and postoperative blood pressure management is one of the important interventions affecting clinical prognosis. However, the specific target value of blood pressure management is still inconclusive, especially the postoperative blood pressure management is controversial. Its recanalization status, reperfusion injury, and blood pressure variability all affect its blood pressure management range. Clinically, it is necessary to formulate personalized plans and explore reasonable blood pressure target plans based on the specific conditions of patients. 

Risk Factors of Hemorrhagic Transformation after Ischemic Stroke

LI Chao, JIANG Yingyu, ZHANG Xinmiao, YANG Xin, WANG Chunjuan, GU Hongqiu, DU Kejin, WANG Yongjun, LI Zixiao

2023, 18(9):  1079-1084.  DOI: 10.3969/j.issn.1673-5765.2023.09.016

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Objective  To investigate the risk factors of hemorrhagic transformation (HT) after ischemic stroke (IS).
Methods  The in-hospital IS patients from the China Stoke Center Alliance (CSCA) registry database from August 1, 2015, to July 31, 2019 were enrolled in the retrospective analysis. According to the presence of HT or not after IS during hospitalization, all the subjects were divided into IS with HT group and IS without HT group. Differences in demographics, unhealthy life behaviors, disease history, in-hospital treatments, past and in-hospital medications and disease severity score of NIHSS were collected between the groups. A multivariate Poisson regression model was used to identify risk factors of HT after IS. 
Results  A total of 828 652 IS patients were enrolled in this study, with a median age of 67 years and 518 063 (62.5%) males, and the median NIHSS score was 3 points. Multivariate analysis showed that age (RR 1.01, 95%CI 1.00-1.01), stroke severity (RR 1.06, 95%CI 1.05-1.06), atrial fibrillation (RR 2.56, 95%CI 2.35-2.78), myocardial infarction (RR 1.33, 95%CI 1.11-1.60), peripheral vascular disease (RR 1.26, 95%CI 1.06-1.51), in-hospital thrombolysis treatment (RR 2.21, 95%CI 2.05-2.37), thrombectomy (RR 2.02, 95%CI 1.79-2.28), previous use of anticoagulants (RR 0.79, 95%CI 0.70-0.90), previous use of antiplatelet drugs (RR 0.87, 95%CI 0.81-0.93), in-hospital anticoagulant therapy (RR 0.57, 95%CI 0.51-0.65) and in-hospital antiplatelet therapy (RR 0.22, 95%CI 0.20-0.23) were independent risk factors for HT after IS.
Conclusions  HT is a common complication in IS patients. Older age, stroke severity, atrial fibrillation, myocardial infarction, peripheral vascular disease, in-hospital thrombolysis treatment and thrombectomy were independent risk factors for HT after IS. Prior and in-hospital use of antithrombotic drugs were protective factors for HT.

Application of Problem-based Learning Combined with Flipped Classroom Teaching Method in Stroke Clinical Education

GUO Zhenni, FU Yuli, YANG Yi, WANG Zan

2023, 18(9):  1085-1088.  DOI: 10.3969/j.issn.1673-5765.2023.09.017

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Objective   To explore the application value of problem-based learning (PBL) combined with flipped classroom teaching method in stroke clinical education. 
Methods   A total of 70 postgraduate students who participated in the standardized training of resident physicians in the Stroke Center of the First Hospital of Jilin University from September 2022 to November 2022 were included and randomly divided into the experimental group and the control group, 35 in each group. The experimental group adopted PBL combined with flipped classroom teaching method, while the control group adopted traditional teaching method. After 8 class hours of training, the two groups were evaluated respectively in theory and practice, and the assessment results were compared. The enrolled students were asked to evaluate their improvement of self-comprehensive ability by questionnaire and compared the evaluation results. 
Results   The experimental group’s practical assessment score (41.66±1.57 vs. 36.29±2.02), the total theoretical and practical assessment score (88.26±2.06 vs. 82.17±2.48) and the improvement of comprehensive abilities including learning interest [ (3.9±0.4) points vs. (3.2±0.4) points], self-learning ability (3.7±0.4 vs. 3.1±0.9), clinical consultation ability (3.7±0.6 vs. 3.2±0.4) , innovation ability (3.6±0.5 vs. 2.9±0.5), interpersonal communication and teamwork ability (3.9±0.3 vs. 3.0±0.9) were higher than the control group. The differences were statistically significant (P<0.05).
Conclusions   PBL combined with flipped classroom teaching method can improve the teaching effect of stroke clinical education. 


Application of Virtual Reality Combined with Simulation Mode in Lumbar Puncture Skill Training

SUN Chao, XUE Meng, YAN Zhenhong, YANG Qian, CHANG Ting

2023, 18(9):  1089-1093.  DOI: 10.3969/j.issn.1673-5765.2023.09.018

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Objective   To evaluate the effect of virtual reality (VR) combined with simulation mode in the teaching of lumbar puncture for undergraduates. 
Methods   A total of 30 undergraduates in the Second Affiliated Hospital, Air Force Medical University were randomly divided into VR group, simulation mode group and VR combined simulation mode group with 10 students each. Firstly, one teaching hours of theoretical conducted for three groups. Then VR group received two teaching hours of VR training on lumbar puncture training and simulation mode group received two teaching hours of practical training on lumbar puncture training. VR combined simulation mode group received one teaching hour VR training and one teaching hour simulator training. Theoretical examination and clinical skills were carried out after lumbar puncture training. The subjective evaluation of the students towards the VR lumbar puncture training were analyzed by questionnaires.
Results   After training, the theoretical scores of the VR combined simulation mode group [(80.4±5.0) points vs. (69.5±9.0) points, P=0.005] were significantly higher than simulation mode group. The operating skills scores of VR combined simulation mode group were significantly higher than simulation mode group [(86.4±4.2) points vs. (79.8±3.5) points, P=0.004] and VR group [(86.4±4.2) points vs. (81.3±4.6) points, P=0.028]. The questionnaire showed that around 90% students believed that VR lumbar puncture training could effectively improve their learning interest and practical ability. 
Conclusions   The VR simulation education could effectively improve the student’s achievements of lumbar puncture. The teaching mode of VR combined simulation is better than VR or simulation mode.