走出循证医学的误区——关于证据的反思

循证医学在临床实践中起着越来越重要的作用,证据的可靠性是循证医学赖以生存的基石。循证医学遵循的证据来自随机对照试验,这些证据并非完美。临床医师在采纳这些证据时须注意以下几个方面的问题证据的适用人群,干预措施是否存在均一性,对照是否存在片面性,试验的研究终点是否与临床脱节,证据的时效性,以及随机试验提供的证据不足等。只有结合医生的专业技能和临床经验,考虑病人的价值和愿望,对证据进行正确评估和采纳,才能使证据发挥最大的效能,促进循证医学的发展。     

A survey on adverse incidents in legal psychology studies: Reflections on ethics review

Ethics committees (ECs) regulate research activities to maintain research participants' autonomy and to protect them from harm and injury. No research to date attempted to establish how much risk is involved in social‐science research. Using a survey approach, we set out to estimate the risk of being involved in an incident for research participants in legal psychology and assessed researchers' views of ECs. Fifty‐nine of 188 respondents (31%) stated that they had experienced one or more incidents with a participant. The estimated risk of being involved in an incident was one to three per 10,000 participants, which according to biomedical standards defines a rare risk. Although some researchers were satisfied with their EC, the general tenor was one of discontent due to conservative decision‐making, lacking expertise, and overstepping demands. Whether ECs succeed in protecting participants from loss of autonomy, harm and injury are unknown but are open to empirical research.     

Mand acquisition across different teaching methodologies

Many children diagnosed with an autism spectrum disorder lack functional independent communication. The current study used a combined multiple‐baseline and alternating‐treatments design to evaluate whether the presence or absence of a verbal prompt (asking a question) during teaching affected independent verbal manding. Two teaching procedures were used to teach specific responses (two per teaching condition) and evaluate if the acquired response, once trained, occurred independently (in the absence of stimuli or supplemental prompts). One student learned more rapidly under the mand training condition whereas the other learned at a similar rate under both conditions. The assessment methodology presented may be beneficial in future practice to determine if one teaching procedure is more effective than the other for a learner.     

Strategy Induction Enhances Creativity in Figural Divergent Thinking

Instructional effects in creative‐thinking tasks are important to understand in order to promote creative performance of individuals. In divergent‐thinking tasks, for example, instructional and strategic enhancement effects have been extensively studied for verbal tasks. However, while studies on instructional enhancement effects on creative drawing tasks exist, it is surprising that strategy enhancement in figural divergent thinking is still underresearched. In this study, we used a strategy manipulation approach to reassess the role of executive strategy implementation and the moderating role of an indicator of fluid intelligence, figural analogical reasoning, in two types of figural divergent‐thinking tasks (abstract vs. concrete). The sample comprised N = 75 high‐school students. Importantly, we found strategic enhancement effects by combining strategy instructions with a prompt to “be creative.” This combined instruction was contrasted with a standard instruction, and main effects were found for overall, concrete, and abstract creativity. Moreover, we found in a regression analysis a main effect for figural analogical reasoning on overall creativity and creativity for only the concrete object tasks. An expected interaction effect of instruction and figural analogical reasoning was not found. As another addition, the role of current motivation in figural divergent thinking was explored.     

The role of dark‐side of motivation and intention to continue in exercise: A self‐determination theory approach

Motivation plays an important role when it comes to regular physical exercise. Hence, low levels of intentions to continue exercising in the future may ultimately lead to higher rates of exercise dropout. The first objective of the present research was to test a theoretical model considering the dark side of motivational determinants on intentions towards exercising in the future. The second objective consisted in comparing groups with different characteristics, as a way to identify individuals with weaker intention, which is believed to be an indicator of a higher dropout risk. In total, 544 (294 female; 250 male) gym exercisers aged between 18 and 58 years (M = 35.00; SD = 11.57) partook in the present research. Participants were engaged in fitness group classes (n = 273) or in cardio/resistance workouts (n = 271), and their exercise experience ranged from 3 to 120 months (M = 47.41; SD = 7.54). Results showed that the measurement and the structural model had an excellent fit. In addition, the structural model was invariant between gender, fitness activities, and exercise experience. Each group displayed different explained variance in intention to continue exercising. Overall, male, young adults and more experienced exercisers had stronger intentions towards exercising. Fitness instructors should be aware of their own thwarting behaviors, especially when interacting with female, young and less experienced exercisers, since they have weaker intentions to exercise in the future, possibly representing an increased risk of withdrawal.     

Alternatives to Randomized Experiments

ABSTRACT— Randomized experiments are preferred for making inferences about causality when they can be implemented and their assumptions are met. Yet assumptions can fail (e.g., attrition, treatment noncompliance) or randomization may be unethical or infeasible. I describe alternative design and statistical approaches that permit testing causal hypotheses and present current empirical evidence related to alternative designs. Alternative designs permit a wider range of research questions to be answered and permit more direct generalization of causal effects; however, when using such designs, estimates of the magnitude of the causal effect may be more uncertain.     

咪达唑仑—舒芬太尼靶控输注辅助神经阻滞用于颈部手术临床观察

观察咪达唑仑复合舒芬太尼TCI及恒速输注辅助颈丛阻滞颈部手术的镇痛镇静效果及对术中知晓、血液动力学和呼吸的影响,将80例择期颈部手术患者,随机分为2组各40例：咪达唑仑复合舒芬太尼TCI组（A组）;咪达唑仑复合舒芬太尼恒速输注组（B组）。比较二组MAP,HR,RR,SpO2等及术中镇痛、镇静、术中知晓和各种不良反应发生情况。发现A组血液动力学较B组更加稳定。提示TCI辅助颈丛阻滞麻醉安全有效,镇痛良好,无术中知晓,较恒速输注血液动力学更稳定,呼吸抑制少。     

由新药临床试验中的依从性问题引发的思考

本文就如何看待新药临床试验中的依从性问题提出了自己的看法：应用整体观、认识论的方法辩证地分析、处理依从性问题,以保证临床试验的顺利进行和质量可靠;文中通过实例并结合当前的医改背景,对临床医疗工作中的医患关系提出一些启发和看法,建议医务人员从自身出发重视患者的依从性。     

Öst's (2008) methodological comparison of clinical trials of acceptance and commitment therapy versus cognitive behavior therapy: Matching Apples with Oranges?

Öst (2008) recently compared the methodological rigor of studies of acceptance and commitment therapy (ACT) and traditional cognitive behavior therapy (CBT). He concluded that the ACT studies had more methodological deficiencies, and thus the treatment did not qualify as an “empirically supported treatment.” Although Öst noted several important limitations that should be carefully considered when evaluating early ACT research, his attempt to devise an empirical matching strategy by creating a comparison sample of CBT studies to bolster his conclusions was itself problematic. The samples were clearly mismatched in terms of the populations being treated, leading to differences in study design and methodology. Furthermore, reanalysis showed clear differences in grant support favoring CBT compared with ACT studies that were not reported in the original article. Given the actual mismatch between the samples, Öst's methodological ratings are difficult to interpret and provide little useful information beyond what could already be gathered by a qualitative review of ACT study limitations. Such limitations are characteristic of the earlier randomized controlled trials of any emerging psychotherapeutic approach.     

VIDEO MODELING TO TRAIN STAFF TO IMPLEMENT DISCRETE‐TRIAL INSTRUCTION

Three new direct‐service staff participated in a program that used a video model to train target skills needed to conduct a discrete‐trial session. Percentage accuracy in completing a discrete‐trial teaching session was evaluated using a multiple baseline design across participants. During baseline, performances ranged from a mean of 12% to 63% accuracy. During video modeling, there was an immediate increase in accuracy to a mean of 98%, 85%, and 94% for each participant. Performance during maintenance and generalization probes remained at high levels. Results suggest that video modeling can be an effective technique to train staff to conduct discrete‐trial sessions.