多模式镇痛在幻肢痛预防中的临床研究

为探讨多模式镇痛预防截肢后幻肢痛的临床效果。选择50例下肢截肢患者,随机分为2组,试验组（Ⅰ组）和对照组（Ⅱ组）,观察患者疼痛评分,患者自控镇痛按压次数,使用其他镇痛药物的情况,记录所有的不良反应及幻肢痛发生率。结果显示,镇痛评分,Ⅱ组高于Ⅰ组（P〈0．01）;PCA按压次数,Ⅱ组多于Ⅰ组（P〈0．01）;不良反应发生率Ⅱ组高于Ⅰ组（P〈0．01）;Ⅱ组幻肢痛发生率明显高于Ⅰ组（P〈0．01）。采取多模式镇痛预防幻肢痛是安全有效的。     

癌痛治疗中的辅助用药

辅助镇痛药物最初的用途都不是镇痛,但对癌痛患者却能起到缓解疼痛、降低麻醉药品用量、减轻大剂量麻醉药品带来的药物不良反应的作用。尤其适用于那些对阿片类药物不敏感或不仅对阿片类药物敏感的癌病病人。遗憾的是临床上通常在阿片类药物镇痛效果不理想的时候才考虑添加辅助用药,癌痛治疗还存在用药过于单一的弊端。因此,为了加强止痛治疗效果、优化治疗策略,必须充分重视癌痛治疗中的辅助用药。     

癌痛治疗中的辅助用药

辅助镇痛药物最初的用途都不是镇痛,但对癌痛患者却能起到缓解疼痛、降低麻醉药品用量、减轻大剂量麻醉药品带来的药物不良反应的作用。尤其适用于那些对阿片类药物不敏感或不仅对阿片类药物敏感的癌病病人。遗憾的是临床上通常在阿片类药物镇痛效果不理想的时候才考虑添加辅助用药,癌痛治疗还存在用药过于单一的弊端。因此,为了加强止痛治疗效果、优化治疗策略,必须充分重视癌痛治疗中的辅助用药。     

暗示感受性和针刺对痛刺激引起的大脑诱发电位影响的关系

本工作的目的为继续探讨皮肤感觉(电感受性、电痛觉)的暗示感受性和针刺镇痛的关系。被试为30例正常人。方法:针刺镇痛的效果是通过观察针刺对痛刺激引起的大脑诱发电位的抑制效应,以第一体感区的P_2次波幅变化为客观指标。暗示实验重复过去方法。主要结果:1)针刺能镇痛,针刺对多数被试(21/3D)能抑制痛刺激引起的大脑诱发电位。2)暗示后电感受性和痛阈均有提高(分别为31.26％和18.37％)3)暗示感受性高低和针刺抑制痛刺激引起的大脑诱发电位没有相关(P>0.50)。还看到被试对针刺能镇痛的信任程度与针效无关,提示暗示在针刺镇痛中不起主要作用。     

麻醉科医师在晚期癌痛治疗中的作用

1986年WHO推出的“三阶梯”癌痛镇痛用药方案目前在临床工作中存在误区。麻醉科医师必须明确在晚期癌痛治疗转变中的责任和义务:具有专业能力、保健与防病能力,消除使用阿片类药物成瘾恐惧症;团队协作能力、新技术的评估能力,实行跨学科综合姑息保健;遵循生物心理社会医学模式,对晚期癌痛患者实施人文关怀。不仅会运用药物和医疗技术手段,还需配合心理和社会方面进行全面的诊疗,更好地为患者服务。     

麻醉科医师在晚期癌痛治疗中的作用

1986年WHO推出的"三阶梯"癌痛镇痛用药方案目前在临床工作中存在误区.麻醉科医师必须明确在晚期癌痛治疗转变中的责任和义务:具有专业能力、保健与防病能力,消除使用阿片类药物成瘾恐惧症;团队协作能力、新技术的评估能力,实行跨学科综合姑息保健;遵循生物心理社会医学模式,对晚期癌痛患者实施人文关怀.不仅会运用药物和医疗技术手段,还需配合心理和社会方面进行全面的诊疗,更好地为患者服务.     

关注老年癌症止痛

虽然肿瘤的发病率在老年人并不低,但社会对老年人的关注度并不高。几乎所有肿瘤药物临床试验都把老年人排除在外,因此,不少药品说明书特别注明“缺乏老年人资料”。老年癌痛治疗领域也存在同样的问题。老年癌痛的病理生理及心理特点很独特,加之对老年癌病重视不够及缺乏正确评价,所以老年癌痛的研究相当复杂,因而癌痛的处理犹如癌症一样也需要综合治疗。癌痛治疗药物可分成两大类：非阿片类及阿片类药物。非阿片类药物中首选对乙酰氨基酚治疗轻度癌痛,非甾体类抗炎药,特别是选择性COX2抑制剂可在对乙酰氨基酚无效时应用。阿片类药物则广泛应用于中度到重度的癌痛治疗。辅助治疗药物包括三环抗抑郁药、抗惊厥药、苯二氮蕈类药物等。可用于癌痛三阶梯治疗的任一阶段,能够治疗特殊类型疼痛,改善癌痛以外的症状,增加主要药物镇痛效果,减轻副作用,但不推荐常规使用。总而言之,对于老年癌症患者更要强调以镇痛为主的姑息治疗,特别在重症老年患者,可能成为最重要的治疗,有时甚至是唯一有效妁治疗。     

关注老年癌症止痛

虽然肿瘤的发病率在老年人并不低,但社会对老年人的关注度并不高.几乎所有肿瘤药物临床试验都把老年人排除在外,因此,不少药品说明书特别注明"缺乏老年人资料".老年癌痛治疗领域也存在同样的问题.老年癌痛的病理生理及心理特点很独特,加之对老年癌痛重视不够及缺乏正确评价,所以老年癌痛的研究相当复杂,因而癌痛的处理犹如癌症一样也需要综合治疗.癌痛治疗药物可分成两大类:非阿片类及阿片类药物.非阿片类药物中首选对乙酰氨基酚治疗轻度癌痛,非甾体类抗炎药,特别是选择性COX2抑制剂可在对乙酰氨基酚无效时应用.阿片类药物则广泛应用于中度到重度的癌痛治疗.辅助治疗药物包括三环抗抑郁药、抗惊厥药、苯二氮艹+卓类药物等.可用于癌痛三阶梯治疗的任一阶段,能够治疗特殊类型疼痛,改善癌痛以外的症状,增加主要药物镇痛效果,减轻副作用,但不推荐常规使用.总而言之,对于老年癌症患者更要强调以镇痛为主的姑息治疗,特别在重症老年患者,可能成为最重要的治疗,有时甚至是唯一有效的治疗.     

金钱镇痛理论述评

当前金钱镇痛理论主要有两派观点, 一类观点认为金钱在缓解痛中起到次要和补充作用, 另一类观点认为具体的情境信息决定金钱在缓解痛中地位的主次。作者首先回顾并总结了近年来金钱是次要镇痛缓冲器和情景变化决定金钱镇痛地位的研究证据及其理论观点, 之后着重评判了这两种理论观点的优劣, 最后从金钱镇痛的范围、地位、程度和研究手段几个方面提出了未来研究的设想。     

舒芬太尼与芬太尼复合罗哌卡因用于小儿术后镇痛效果比较研究

为了观察舒芬太尼或芬太尼复合罗哌卡因用于小儿术后镇痛的效果及其不良反应,选择ASAⅠ-Ⅱ级行择期下腹部手术的小儿50例,随机分为两组,各25例,术后分别使用0．5μg·m^-1舒芬太尼或2μg·ml^-1芬太尼复合0．1％罗哌卡因行硬膜外病人自控镇痛,观察术后24h镇痛效果及其不反应。结果显示,舒芬太尼组术后24h静态和活动时镇痛效果优于芬太尼组（P〈0．05）,恶心、呕吐发生率低,程度轻（P〈0．05）。因此,舒芬太尼复合罗哌卡因可安全用于小儿下腹部术后镇痛,效果优于芬太尼复合罗哌卡因。     

Using FMRI to study the neural correlates of virtual reality analgesia

Excessive pain during medical procedures, such as burn wound dressing changes, is a widespread medical problem and is especially challenging for children. This article describes the rationale behind virtual reality (VR) pain distraction, a new non-pharmacologic adjunctive analgesia, and gives a brief summary of empirical studies exploring whether VR reduces clinical procedural pain. Results indicate that patients using VR during painful medical procedures report large reductions in subjective pain. A neuroimaging study measuring the neural correlates of VR analgesia is described in detail. This functional magnetic resonance imaging pain study in healthy volunteers shows that the large drops in subjective pain ratings during VR are accompanied by large drops in pain-related brain activity. Together the clinical and laboratory studies provide converging evidence that VR distraction is a promising new non-pharmacologic pain control technique.     

Self-blame, compliance, and distress among burn patients

This study addressed self-blame and adaptation by using data collected from 49 patients hospitalized for the treatment of acute burn wounds. Nurses and physical therapists rated patients' compliance with the therapeutic activities essential for proper healing, and they rated pain behavior. After controlling for burn severity and time since admission, regression analyses showed that behavioral self-blame for the burn accident was a significant predictor of poorer compliance with nurses, more pain behavior, and greater depression. People with a prior psychiatric history were also more depressed and more likely to blame themselves for the accident. These data are contrasted with research on the adaptive features of self-blame.     

Coping with the stress of a painful medical procedure

To evaluate its effect on procedure-related distress, the focus of attention was manipulated by providing training to hospitalized acute burn patients (n=42). Participants were randomly assigned to attention focusing (i.e. attending to procedural sensations) or music distraction (i.e. attention diverting) coping interventions, or to usual care during the target dressing change. Coping behavior (i.e. distraction, focusing, and three confounding methods, ignoring, catastrophizing, reinterpreting), tension and intrusiveness were evaluated 24 h retrospectively (i.e. for the prior procedure), during the targeted procedure, and 30 min after the target procedure. When coping during the target procedure by ignoring, reinterpreting, and catastrophizing were covaried, the music distraction group experienced significantly fewer intrusions, and the attention focus group had more intrusions. Additionally, secondary analyses revealed that coping by ignoring during the prior day's procedure significantly predicted higher procedural tension during, and more intrusions following, the targeted procedure. Suppression-based forms of emotion-focused coping may be enhanced by training in the use of an explicit distractor.     

烧伤治疗--仍需走出困境

以促进创面干燥,再行切痂植皮为局部治疗特点的外科技术,仍是烧伤治疗的主流,促使创面干燥是渗出的对症处理,切痂植皮的实质是将烧伤创面变为刀伤创面,然后再修补刀伤创面。显然,烧伤外科的治疗观已撤开了烧伤的病理变化和机体的免疫力,再生力,孤立地看待烧伤创面,认识上形而上学,治疗上一刀切,没有从根本上解决创面的疼痛,进行性坏死、感染和瘢痕愈合四大难题,相反,干燥切痂植皮技术的实施又是建立在病人痛苦之上的,     

The role of the clinical psychologist on a burn unit in a general teaching hospital

This paper reviews the core skills that a clinical psychologist brings to a burn unit and suggests a model for optimal psychological management of burn patients, families, and staff. Recovery from a burn injury involves three stages that comprise (a) acute treatment of severe medical complications, (b) adjustment to hospitalization, and (c) long-term rehabilitation. Each stage contains numerous issues that the clinical psychologist should monitor and manage. Assessment of patients at risk, early intervention, and specialist management are highlighted as critical components of effective psychological management of burn injury in a multidisciplinary team context.     

Severe Withdrawal (and Recovery)

The problem of how to remove information from an agent's stock of beliefs is of paramount concern in the belief change literature. An inquiring agent may remove beliefs for a variety of reasons: a belief may be called into doubt or the agent may simply wish to entertain other possibilities. In the prominent AGM framework for belief change, upon which the work here is based, one of the three central operations, contraction, addresses this concern (the other two deal with the incorporation of new information). Makinson has generalised this work by introducing the notion of a withdrawal operation. Underlying the account proffered by AGM is the idea of rational belief change. A belief change operation should be guided by certain principles or integrity constraints in order to characterise change by a rational agent. One of the most noted principles within the context of AGM is the Principle of Informational Economy. However, adoption of this principle in its purest form has been rejected by AGM leading to a more relaxed interpretation. In this paper, we argue that this weakening of the Principle of Informational Economy suggests that it is only one of a number of principles which should be taken into account. Furthermore, this weakening points toward a Principle of Indifference. This motivates the introduction of a belief removal operation that we call severe withdrawal. We provide rationality postulates for severe withdrawal and explore its relationship with AGM contraction. Moreover, we furnish possible worlds and epistemic entrenchment semantics for severe withdrawals.     

Basic Infobase Change

Generalisations of theory change involving arbitrary sets of wffs instead of belief sets have become known as base change. In one view, a base should be thought of as providing more structure to its generated belief set, and can be used to determine the theory change operation associated with a base change operation. In this paper we extend a proposal along these lines by Meyer et al. We take an infobase as a finite sequence of wffs, with each element in the sequence being seen as an independently obtained bit of information, and define appropriate infobase change operations. The associated theory change operations satisfy the AGM postulates for theory change. Since an infobase change operation produces a new infobase, it allows for iterated infobase change. We measure iterated infobase change against the postulates proposed by Darwiche et al. and Lehmann.     

Contraction: On the Decision-Theoretical Origins of Minimal Change and Entrenchment

We present a decision-theoretically motivated notion of contraction which, we claim, encodes the principles of minimal change and entrenchment. Contraction is seen as an operation whose goal is to minimize loses of informational value. The operation is also compatible with the principle that in contracting A one should preserve the sentences better entrenched than A (when the belief set contains A). Even when the principle of minimal change and the latter motivation for entrenchment figure prominently among the basic intuitions in the works of, among others, Quine and Ullian (1978), Levi (1980, 1991), Harman (1988) and Gärdenfors (1988), formal accounts of belief change (AGM, KM – see Gärdenfors (1988); Katsuno and Mendelzon (1991)) have abandoned both principles (see Rott (2000)). We argue for the principles and we show how to construct a contraction operation, which obeys both. An axiom system is proposed. We also prove that the decision-theoretic notion of contraction can be completely characterized in terms of the given axioms. Proving this type of completeness result is a well-known open problem in the field, whose solution requires employing both decision-theoretical techniques and logical methods recently used in belief change.     

Conditioned inhibition of craving in drug addiction: A pilot experiment

It seems likely that an important reason for the limited success of aversion treatment of drug addiction has been that the aversion is applied only to extrinsic stimuli associated with the drug. No attempt is ordinarily made to combat the endogenous habit.

In the present experiment a subject with a Demerol (Pethidine) addiction of 3 years' standing was instructed to give himself a severe shock from a portable apparatus whenever he felt a desire for the drug arise endogenously. On three occasions he gave himself 4, 3 and 2 shocks respectively, dispelling the craving. After this the apparatus broke down, but for a period of 12 weeks the patient remained free from any but minor cravings that he could easily control.     

创新理念与烧伤治疗发展的哲学观

创新的理念始终贯穿于烧伤治疗方法改良,随着对烧伤感染及休克期补液认识的提高,烧伤治疗方法不断改进;创新促进了烧伤基础研究的深入,从最初的解剖修复到组织工程皮肤永久性修复的认识不断提高;整体观和系统观促进了烧伤治愈、康复观点的创新及跨学科合作。因此在实践和认识哲学原理的指导下的创新理念是促进烧伤治疗水平继续发展的动力。