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Ning L, Fu Y, Wang Y, Deng Q, Lin T, Li J. Fear of disease progression and resilience parallelly mediated the effect of post-stroke fatigue on post-stroke depression: A cross-sectional study. J Clin Nurs 2024. [PMID: 38887145 DOI: 10.1111/jocn.17323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2024] [Revised: 05/02/2024] [Accepted: 06/03/2024] [Indexed: 06/20/2024]
Abstract
AIMS To explore the effect of post-stroke fatigue (PSF) on post-stroke depression (PSD) and examine the mediating effects of fear of disease progression (FOP) and resilience between PSF and PSD. DESIGN A cross-sectional study. METHODS A total of 315 stroke patients participated in the questionnaire survey between November 2022 and June 2023. Data were collected using the General Information Questionnaire, Fatigue Severity Scale, Fear of Disease Progression Questionnaire-Short Form, Connor-Davidson Resilience Scale-10 Item and Hospital Anxiety and Depression Scale-Depression Subscale. Data were analysed by descriptive analysis, Mann-Whitney U-test, Kruskal-Wallis H-test, Pearson or Spearman correlation, hierarchical regression analysis and mediation analysis. RESULTS PSF had a significant positive total effect on PSD (β = .354, 95% CI: .251, .454). Additionally, FOP and resilience played a partial parallel-mediating role in the relationship between PSF and PSD (β = .202, 95% CI: .140, .265), and the total indirect effect accounted for 57.06% of the total effect. CONCLUSIONS FOP and resilience parallelly mediated the effect of PSF on PSD, which may provide a novel perspective for healthcare professionals in preventing PSD. Targeted interventions aiming at reducing PSF, lowering FOP levels and enhancing resilience may be possible ways to alleviate PSD. IMPLICATIONS FOR THE PROFESSION AND PATIENT CARE Interventions that tail to reducing PSF, lowering FOP levels and enhancing resilience may be considered as possible ways to alleviate PSD. IMPACT This study enriched the literature by exploring the effect of PSF on PSD and further examining the mediating effects of FOP and resilience between PSF and PSD. Findings emphasized the important effects of PSF, FOP and resilience on PSD. REPORTING METHOD The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist for cross-sectional studies was used to guide reporting. PATIENT OR PUBLIC CONTRIBUTION One tertiary hospital assisted participants recruitment.
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Affiliation(s)
- Liuqiao Ning
- School of Nursing, Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Yingjie Fu
- School of Nursing, Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Yuenv Wang
- School of Nursing, Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Qianying Deng
- School of Nursing, Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Tingting Lin
- School of Nursing, Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Jufang Li
- School of Nursing, Wenzhou Medical University, Wenzhou, Zhejiang, China
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Goodman GW, Do TH, Tan C, Ritzel RM. Drivers of Chronic Pathology Following Ischemic Stroke: A Descriptive Review. Cell Mol Neurobiol 2023; 44:7. [PMID: 38112809 DOI: 10.1007/s10571-023-01437-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 11/25/2023] [Indexed: 12/21/2023]
Abstract
Stroke is the third leading cause of death and long-term disability in the world. Considered largely a disease of aging, its global economic and healthcare burden is expected to rise as more people survive into advanced age. With recent advances in acute stroke management, including the expansion of time windows for treatment with intravenous thrombolysis and mechanical thrombectomy, we are likely to see an increase in survival rates. It is therefore critically important to understand the complete pathophysiology of ischemic stroke, both in the acute and subacute stages and during the chronic phase in the months and years following an ischemic event. One of the most clinically relevant aspects of the chronic sequelae of stroke is its extended negative effect on cognition. Cognitive impairment may be related to the deterioration and dysfunctional reorganization of white matter seen at later timepoints after stroke, as well as ongoing progressive neurodegeneration. The vasculature of the brain also undergoes significant insult and remodeling following stroke, undergoing changes which may further contribute to chronic stroke pathology. While inflammation and the immune response are well established drivers of acute stroke pathology, the chronicity and functional role of innate and adaptive immune responses in the post-ischemic brain and in the peripheral environment remain largely uncharacterized. In this review, we summarize the current literature on post-stroke injury progression, its chronic pathological features, and the putative secondary injury mechanisms underlying the development of cognitive impairment and dementia. We present findings from clinical and experimental studies and discuss the long-term effects of ischemic stroke on both brain anatomy and functional outcome. Identifying mechanisms that occur months to years after injury could lead to treatment strategies in the chronic phase of stroke to help mitigate stroke-associated cognitive decline in patients.
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Affiliation(s)
- Grant W Goodman
- Department of Neurology, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Trang H Do
- Department of Neurology, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Chunfeng Tan
- Department of Neurology, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Rodney M Ritzel
- Department of Neurology, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, USA.
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Long Z, Li J, Fan J, Li B, Du Y, Qiu S, Miao J, Chen J, Yin J, Jing B. Identifying Alzheimer's disease and mild cognitive impairment with atlas-based multi-modal metrics. Front Aging Neurosci 2023; 15:1212275. [PMID: 37719872 PMCID: PMC10501142 DOI: 10.3389/fnagi.2023.1212275] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 08/21/2023] [Indexed: 09/19/2023] Open
Abstract
Introduction Multi-modal neuroimaging metrics in combination with advanced machine learning techniques have attracted more and more attention for an effective multi-class identification of Alzheimer's disease (AD), mild cognitive impairment (MCI) and health controls (HC) recently. Methods In this paper, a total of 180 subjects consisting of 44 AD, 66 MCI and 58 HC subjects were enrolled, and the multi-modalities of the resting-state functional magnetic resonance imaging (rs-fMRI) and the structural MRI (sMRI) for all participants were obtained. Then, four kinds of metrics including the Hurst exponent (HE) metric and bilateral hippocampus seed independently based connectivity metrics generated from fMRI data, and the gray matter volume (GMV) metric obtained from sMRI data, were calculated and extracted in each region of interest (ROI) based on a newly proposed automated anatomical Labeling (AAL3) atlas after data pre-processing. Next, these metrics were selected with a minimal redundancy maximal relevance (MRMR) method and a sequential feature collection (SFC) algorithm, and only a subset of optimal features were retained after this step. Finally, the support vector machine (SVM) based classification methods and artificial neural network (ANN) algorithm were utilized to identify the multi-class of AD, MCI and HC subjects in single modal and multi-modal metrics respectively, and a nested ten-fold cross-validation was utilized to estimate the final classification performance. Results The results of the SVM and ANN based methods indicated the best accuracies of 80.36 and 74.40%, respectively, by utilizing all the multi-modal metrics, and the optimal accuracies for AD, MCI and HC were 79.55, 78.79 and 82.76%, respectively, in the SVM based method. In contrast, when using single modal metric, the SVM based method obtained a best accuracy of 72.62% with the HE metric, and the accuracies for AD, MCI and HC subjects were just 56.82, 80.30 and 75.86%, respectively. Moreover, the overlapping abnormal brain regions detected by multi-modal metrics were mainly located at posterior cingulate gyrus, superior frontal gyrus and cuneus. Conclusion Taken together, the SVM based method with multi-modal metrics could provide effective diagnostic information for identifying AD, MCI and HC subjects.
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Affiliation(s)
- Zhuqing Long
- Medical Apparatus and Equipment Deployment, Hunan Children’s Hospital, Changsha, Hunan Province, China
- School of Biomedical Engineering, Capital Medical University, Beijing, China
| | - Jie Li
- Medical Apparatus and Equipment Deployment, Hunan Children’s Hospital, Changsha, Hunan Province, China
| | - Jianghua Fan
- Department of Pediatric Emergency Center, Hunan Children’s Hospital, Changsha, Hunan Province, China
| | - Bo Li
- Department of Traditional Chinese Medicine, Beijing Chest Hospital, Capital Medical University, Beijing Tuberculosis and Thoracic Tumor Research Institute, Beijing, China
| | - Yukeng Du
- Medical Apparatus and Equipment Deployment, Hunan Children’s Hospital, Changsha, Hunan Province, China
| | - Shuang Qiu
- Medical Apparatus and Equipment Deployment, Hunan Children’s Hospital, Changsha, Hunan Province, China
| | - Jichang Miao
- Department of Medical Devices, Nanfang Hospital, Guangzhou, China
| | - Jian Chen
- School of Electronic, Electrical Engineering and Physics, Fujian University of Technology, Fuzhou, Fujian, China
- Beijing Key Laboratory of Fundamental Research on Biomechanics in Clinical Application, Beijing, China
| | - Juanwu Yin
- Medical Apparatus and Equipment Deployment, Hunan Children’s Hospital, Changsha, Hunan Province, China
| | - Bin Jing
- School of Biomedical Engineering, Capital Medical University, Beijing, China
- Beijing Key Laboratory of Fundamental Research on Biomechanics in Clinical Application, Beijing, China
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Qiu X, Wang H, Lan Y, Miao J, Pan C, Sun W, Li G, Wang Y, Zhao X, Zhu Z, Zhu S. Explore the influencing factors and construct random forest models of post-stroke depression at 3 months in males and females. BMC Psychiatry 2022; 22:811. [PMID: 36539755 PMCID: PMC9764471 DOI: 10.1186/s12888-022-04467-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 12/13/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Post-stroke depression (PSD) is one of the most common neuropsychiatric complications after stroke. The occurrence, development and prognosis of PSD have long been different between males and females. The main purpose of this study was to explore the influencing factors of PSD at 3 months in males and females, and construct random forest (RF) models to rank the influencing factors. METHODS This is a prospective multicenter cohort study (Registration number: ChiCTR-ROC-17013993). Stroke patients hospitalized in the department of Neurology of three hospitals in Wuhan were enrolled from May 2018 to August 2019. Scale assessments were performed 24 hours after admission and 3 months after stroke onset. Binary logistic regression analysis was used for univariate and multivariate (stepwise backward method) analysis, when p was less than 0.05, the difference between groups was considered statistically significant. Lastly, the RF models were constructed according to the results of multivariate regression analysis. RESULTS This study found that several baseline variables were associated with PSD at 3 months in males and females. RF model ranked them as stroke severity (OR [odds ratio] =1.17, p < 0.001, 95%CI [confidence interval]:1.11-1.24), neuroticism dimension (OR = 1.06, p = 0.002, 95%CI:1.02-1.10), physical exercise (OR = 0.62, p = 0.007, 95%CI:0.44-0.88), sleeping time < 5 h (OR = 1.91, p = 0.006, 95% CI:1.20-3.04) and atrial fibrillation (OR = 4.18, p = 0.012, 95%CI:1.38-12.68) in males. In females, RF model ranked them as psychological resilience (OR = 0.98, p = 0.015, 95%CI:0.96-1.00), ability of daily living (OR = 0.98, p = 0.001, 95%CI:0.97-0.99), neuroticism dimension (OR = 1.11, p = 0.002, 95%CI:1.04-1.18) and subjective support (OR = 1.11, p < 0.001, 95%CI:1.05-1.78). CONCLUSION The study found influencing factors of PSD at 3 months were different in males and females, and construct RF models to rank them according to their importance. This suggests that clinicians should focus their interventions on sex-specific influencing factors in order to improve the prognosis of PSD patients. TRIAL REGISTRATION ChiCTR-ROC-17013993.
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Affiliation(s)
- Xiuli Qiu
- grid.33199.310000 0004 0368 7223Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030 Hubei China
| | - He Wang
- grid.33199.310000 0004 0368 7223Department of Medical Affair, Tongji Medical College, Tongji Hospital, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030 Hubei China
| | - Yan Lan
- grid.33199.310000 0004 0368 7223Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030 Hubei China
| | - Jinfeng Miao
- grid.33199.310000 0004 0368 7223Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030 Hubei China
| | - Chensheng Pan
- grid.33199.310000 0004 0368 7223Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030 Hubei China
| | - Wenzhe Sun
- grid.33199.310000 0004 0368 7223Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030 Hubei China
| | - Guo Li
- grid.33199.310000 0004 0368 7223Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030 Hubei China
| | - Yanyan Wang
- grid.33199.310000 0004 0368 7223Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030 Hubei China
| | - Xin Zhao
- grid.33199.310000 0004 0368 7223Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030 Hubei China
| | - Zhou Zhu
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030, Hubei, China.
| | - Suiqiang Zhu
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030, Hubei, China.
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Association between physical activity levels and depressive symptoms in patients with minor ischemic stroke. J Stroke Cerebrovasc Dis 2022; 31:106641. [PMID: 35834937 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 06/22/2022] [Accepted: 07/01/2022] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE Post-stroke depression is associated with stroke recurrence and it is necessary to identify its influencing factors. The study aims to determine whether physical activity during hospitalization, as measured by accelerometer, was associated with depression after discharge in patients with minor ischemic stroke. MATERIALS AND METHODS This prospective observational study assessed 76 patients with minor ischemic stroke (aged 71.2 years) admitted to an acute care hospital. Depressive symptoms 3 months after discharge from the hospital was assessed using a questionnaire sent by mail. Baseline was set during hospitalization, and accelerometers were used to measure sedentary behavior, light and moderate-to-vigorous physical activities during hospitalization. RESULTS Three months after hospital discharge, 14 patients (18.4%) were placed in the depressive symptom group, with significantly more sedentary behavior (p = 0.021), less light physical activity (p = 0.016) and more depressive symptoms during hospitalization (p = 0.005) than in the non-depressive symptom group. Logistic regression analysis showed that sedentary behavior (odds ratio = 1.130, 95% confidence interval = 1.013‒1.281, p = 0.028) and light-intensity physical activity (odds ratio = 0.853, 95% confidence interval = 0.746‒0.976, p = 0.021) were independent factors for depressive symptoms at three months after discharge. Moderate to vigorous physical activity was not an independent factor. CONCLUSIONS Sedentary behavior and light-intensity physical activity during hospitalization were associated with depressive symptoms in patients with minor ischemic stroke after discharge. Reducing sedentary behavior and increasing light-intensity physical activity as part of inpatient rehabilitation may help prevent post-stroke depression.
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Qiu X, Wang H, Lan Y, Miao J, Pan C, Sun W, Li G, Wang Y, Zhao X, Zhu Z, Zhu S. Blood biomarkers of post-stroke depression after minor stroke at three months in males and females. BMC Psychiatry 2022; 22:162. [PMID: 35241021 PMCID: PMC8896360 DOI: 10.1186/s12888-022-03805-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 02/22/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Post-stroke depression (PSD) is one of the most common neuropsychiatric complications after stroke. Studies on the underlying mechanisms and biological markers of sex differences in PSD are of great significance, but there are still few such studies. Therefore, the main objective of this study was to investigate the association of biomarkers with PSD at 3 months after minor stroke in men and women. METHODS This was a prospective multicenter cohort study that enrolled 530 patients with minor stroke (males, 415; females, 115). Demographic information and blood samples of patients were collected within 24 h of admission, and followed up at 3 months after stroke onset. PSD was defined as a depressive disorder due to another medical condition with depressive features, major depressive-like episode, or mixed-mood features according to the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-V). Univariate analysis was performed using the chi-square test, Mann-Whitney U test, or t-test. Partial least-squares discriminant analysis (PLS-DA) was used to distinguish between patients with and without PSD. Factors with variable importance for projection (VIP) > 1.0 were classified as the most important factors in the model segregation. RESULTS The PLS-DA model mainly included component 1 and component 2 for males and females. For males, the model could explain 13% and 16.9% of the variables, respectively, and 29.9% of the variables in total; the most meaningful predictors were exercise habit and fibrinogen level. For females, the model could explain 15.7% and 10.5% of the variables, respectively, and 26.2% of the variables in total; the most meaningful predictors in the model were brain-derived neurotrophic factor (BDNF), magnesium and free T3. Fibrinogen was positively correlated with the Hamilton Depression Scale-17 items (HAMD-17) score. BDNF, magnesium, and free T3 levels were negatively correlated with the HAMD-17 score. CONCLUSIONS This was a prospective cohort study. The most important markers found to be affecting PSD at 3 months were fibrinogen in males, and free T3, magnesium, and BDNF in females. TRIAL REGISTRATION ChiCTR-ROC-17013993 .
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Affiliation(s)
- Xiuli Qiu
- grid.412793.a0000 0004 1799 5032Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030 Hubei China
| | - He Wang
- grid.412793.a0000 0004 1799 5032Department of Medical Affair, Tongji Medical College, Tongji Hospital, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030 Hubei China
| | - Yan Lan
- grid.412793.a0000 0004 1799 5032Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030 Hubei China
| | - Jinfeng Miao
- grid.412793.a0000 0004 1799 5032Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030 Hubei China
| | - Chensheng Pan
- grid.412793.a0000 0004 1799 5032Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030 Hubei China
| | - Wenzhe Sun
- grid.412793.a0000 0004 1799 5032Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030 Hubei China
| | - Guo Li
- grid.412793.a0000 0004 1799 5032Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030 Hubei China
| | - Yanyan Wang
- grid.412793.a0000 0004 1799 5032Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030 Hubei China
| | - Xin Zhao
- grid.412793.a0000 0004 1799 5032Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030 Hubei China
| | - Zhou Zhu
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030, Hubei, China.
| | - Suiqiang Zhu
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030, Hubei, China.
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Bi H, Wang M. Role of social support in poststroke depression: A meta-analysis. Front Psychiatry 2022; 13:924277. [PMID: 36213910 PMCID: PMC9539912 DOI: 10.3389/fpsyt.2022.924277] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 08/15/2022] [Indexed: 11/13/2022] Open
Abstract
Poststroke depression significantly affects health and quality of life of stroke patients. This study evaluates the role of social support in influencing poststroke depression. The literature search was conducted in electronic databases and study selection was based on precise eligibility criteria. The prevalence rates reported by individual studies were pooled. A meta-analysis of standardized mean differences (SMD) in social support between depressed and non-depressed stroke patients was performed. The odds ratios and correlation coefficients showing the relationship between social support and depression were pooled to achieve overall estimates. Twenty-five studies (9431 patients) were included. The prevalence of depression was 36% [95% confidence interval (CI): 28, 45]. Patients with poststroke depression had significantly lower social support in comparison with patients with no or lower levels of depression [SMD in social support scores -0.338 (95% CI: -0.589, -0.087); p = 0.008]. The odds of depression were lower in patients receiving higher levels of social support [OR 0.82 (95% CI: 0.69, 0.95)] but were higher in patients who were receiving weaker social support [OR 5.22 (95% CI: -0.87, 11.31)]. A meta-analysis of correlation coefficients found a significantly inverse correlation between social support and poststroke depression [r -0.336 (95% CI: -0.414, -0.254)]. Poststroke depression has a significant independent inverse association with social support.
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Affiliation(s)
- Haiyang Bi
- Department of Acupuncture, The First Affiliated Hospital of Heilongjiang University of Chinese Medicine, Harbin, China
| | - Mengjia Wang
- Integrated Traditional Chinese and Western Medicine Rehabilitation Medical Center, Heilongjia Provincial Hospital, Harbin, China
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