Research progress in regulation of microglial polarization by RhoA/ROCK signaling pathway
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摘要:
小胶质细胞广泛参与中枢神经系统的多种病理生理过程, 其极化特性则与神经元的炎症反应和损伤修复密切相关。Ras同源基因家族蛋白A(RhoA)/Rho相关卷曲螺旋蛋白激酶(ROCK)信号通路对小胶质细胞极化具有重要的调控功能。目前，通过促进小胶质细胞M2型极化治疗神经元受损的相关研究已成为神经科学领域的热点之一，但RhoA/ROCK通路对极化的调控作用仍未明确。本文综述RhoA/ROCK信号通路对小胶质细胞极化的影响，以期为脑保护分子机制研究及临床治疗提供新思路。
Abstract:Microglia are widely involved in various pathophysiological processes of the central nervous system, and their polarization characteristics are closely related to the inflammatory response and injury repair of neurons. Ras homologous gene family protein A (RhoA)/Rho-associated coiled-coil protein kinase (ROCK) signaling pathway plays an important role in regulating microglia polarization. At present, the related research on the treatment of neuronal damage by promoting microglial M2-type polarization has become one of the hot spots in the field of neuroscience, but the effect of RhoA/ROCK pathway on polarization is still unclear. This article reviewed the effect of RhoA/ROCK signaling pathway on microglial polarization in order to provide new ideas for the study of molecular mechanism of brain protection and clinical treatment.
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Keywords:
- Rho factor /
- Rho-associated kinases /
- microglia /
- polarization /
- inflammation /
- cerebral injury
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精神疾病康复是指使用现代治疗手段和技术对精神患者进行精神上、心理上及职业上的康复，主要目的是通过各种康复措施以及康复训练使患者尽快恢复社会功能，为患者重建社会功能[1], 提高其生活质量，减少致残率，防止精神疾病复发，使患者症状缓解后能顺利回归社会，减少或延缓精神残疾的发生，也是精神科从业人员的重要任务之一[2]。有学者提出，精神康复过程包括住院康复和社会功能康复，强调注重每一环节的康复，给患者提供最有优质的精神康复服务。而病房是精神病患者康复过程的起点，精神康复工作需在医院进行，必须实行院内与社区康复训练并重[1]。为了解南通地区住院精神病患者的精神康复现状，特对南通地区9所精神病专科医院住院患者进行调查，现将调查结果报告如下。
1. 资料与方法
1.1 一般资料
本调查以南通地区9所精神病专科医院2018年9—10月200例住院精神患者为调查对象。所有参加问卷调查的患者均签署知情同意书。纳入标准: ①符合ICD-10疾病诊断标准; ②处于疾病恢复期; ③能阅读和理解问卷内容，配合调查。排除标准: ①有冲动行为; ②无家属陪同者; ③精神症状明显，不能进行正常交流者。共发放问卷200份，回收有效问卷192份，有效问卷率96.00%。192例患者中，年龄15~77岁，平均(44.10±12.29)岁; 男129例，女63例; 文化程度: 大专以上33例，高中36例，初中94例，小学26例，文盲3例; 婚姻状况: 已婚33例，丧偶9例，离异53例，未婚97例; 精神疾病类型: 精神分裂症78.10%(150/192), 心境障碍12.00%(23/192), 精神发育迟滞所致精神障碍3.10%(6/192), 其他精神障碍6.80%(13/192)。
1.2 调查方法与内容
本调查采用自行设计问卷调查表对9家精神病专科医院的200例符合纳入标准的住院患者进行现场调查。问卷经过课题小组讨论，查找文献后拟定条目，再通过预调查最终修订而成。调查内容包括住院精神患者的一般情况、对精神康复的了解及参与度、参加精神康复活动的满意度、希望参加住院精神康复的项目、不愿意参加精神康复的主要原因等条目。
1.3 质量控制
正式调查前严格审查问卷并制作临床研究评定表，召开会议培训调查人员，以保证调查的同质性。回收调查问卷后严格进行检查，将无效问卷剔除。所得数据应用SPSS 17.0软件进行统计分析。
2. 结果
2.1 住院精神病患者对精神康复概念的了解及认识
在对精神康复概念的了解方面，了解占8.30%(16/192), 部分了解占75.00%(144/192), 不了解占16.70%(32/192)。对精神康复的认识上, 68.20%(131/192)的患者认为精神康复对工作、生活、学习会有一定的帮助, 31.80%(61/192)的患者认为精神康复没有太大意义。
2.2 参加精神康复治疗及满意度
在参加住院精神康复治疗方面，经常参加的占31.80% (61/192), 有时参加占21.90%(42/192), 46.40%(89/192)的患者没有或偶尔参加精神康复治疗。在参加精神康复活动的103例中，满意占87.40%(90/103), 不满意占12.60%(13/103), 不满意的主要原因为对康复治疗没有兴趣。
2.3 愿意参加精神康复治疗及希望参加的项目
在是否愿意参加精神康复治疗的调查中, 95.30%(183/192)的患者愿意参加精神康复治疗, 4.69%(9/192)的患者不愿意参加。在希望参加的精神康复项目中，作业治疗占87.00%(167/192)、心理治疗占69.30%(133/192)、音乐治疗占70.80%(136/192)、职业技能训练占46.40%(89/192)、其他项目占16.70%(32/192), 有7例患者提出出院后最好能到社区康复继续治疗。
2.4 医疗保障情况及自费承担精神康复治疗费用
所调查人员中, 97.40%(187/192)的患者有社会医疗保险(包括城镇职工基本医疗保险、居民医保、新农合)或商业医疗保险, 2.60%(5/192)为全自费。在自费承担精神康复治疗费用方面, 13.50%(26/192)的患者表示全部可以承担, 40.10%(77/192)的患者可以部分承担, 46.40%(89/192)的患者表示不能承担。
3. 讨论
精神疾病是一种慢性迁延性疾病，病因不明，发病机制复杂，患者在思维、情感、意志行为等方面表现明显不协调，患者的生命质量与社会功能明显受损[3]。研究[4]表明，精神疾病及精神残疾的患病率均呈上升趋势。近年来，国内各精神病专科医院相继开展了多种康复训练模式及项目以改善患者的各项社会功能，均取得了显著的效果[5-7]。事实证明，精神康复在精神疾病的治疗及康复过程中发挥着重要作用，已成为不可忽视的精神卫生问题[1]。本调查结果显示, 91.70%患者对精神康复概念只有部分了解或完全不了解, 31.80%患者认为精神康复没有太大意义，可见精神康复对多数患者来说是一个陌生的概念，治疗效果容易被忽视。因此，各级精神病专科医院要进一步重视精神康复问题，通过多种途径宣传精神康复治疗的相关知识。在本调查发现结果表明，患者对康复理念的认知不够深入，提示今后工作中医护人员要通过适当的方法向患者及家属普及精神康复的相关知识，以提高认可度和参与积极性。
同时，因地制宜地改善精神康复条件，加强精神康复治疗的基础设施建设也尤为重要。在本调查的9所医院中，只有1家三级专科医院设有精神康复中心且设施比较齐全，其余医院部分有活动场所，部分医院是以饭厅兼活动场所，精神康复形式比较简单，内容比较单一，缺乏规范性、系统性、连续性。因此，各级精神病专科医院对精神康复场地要进行科学规划，合理布局，添加康复设施，为住院精神病患者提供良好的精神康复治疗环境。本研究调查中发现，9所医院中共有15名从事精神康复工作的医务人员，其中3名康复技师，其余均为护士，接受过精神科康复进修或培训的人员占73.33%, 康复技师和进修人员均集中在南通地区唯一的一家三级精神病专科医院。要规范做好住院精神患者的康复治疗工作，首先必须有一支专业的康复团队，精神病专科医院应加大对精神康复专业人员的引进。其次，要加大对从事康复人员的培训力度，提供培训进修学习的机会，培养优秀康复技术人才。此外，康复工作人员应使精神康复的理念先进化，内容系统化，方法科学化，形式多样化，不断提升康复工作的内涵质量和服务能力，构建精神康复工作的长效机制，提升患者对精神康复工作的满意度。
2016年3月，人力资源社会保障部等五部委联合发布了“关于新增部分医疗康复项目纳入基本医疗保障支付范围的通知”，将康复综合评定、精神障碍作业疗法训练等20项医疗康复项目纳入基本医疗保险支付范围，这对于保障精神疾病参保人员基本医疗康复需求起到了积极作用。随着医疗水平的提高，精神康复事业的发展，有更多更好的精神康复技术可用于临床，康复训练已成为精神患者治疗护理的关键[8-10]。但目前南通市职工居民医保精神病专科治疗项目中，仍有近一半的项目是全自费或部分自费的，其中包括工娱治疗、音乐治疗、心理治疗等。本调查中46.4%的患者表示无力承担精神康复的自费费用。为进一步促进精神患者的康复，希望政府继续给予政策支持，进一步加大精神卫生投入，增加精神康复项目的报销种类和比例，不断完善医疗保障体系，使患者的精神康复治疗得到有效保障。同时，精神病专科医院要不断探索精神康复模式和方法，扩大住院精神患者的康复受益面和参与度。
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