关于结直肠患者的PCQ风险评分系统的运用进展

摘要：回顾关于结直肠患者的PCQ（patient consultation questionnaire,问卷量表一加权评分系统）风险评估体系自1999年产生以来的运用进展情况。查阅了1999年至今的相关文献,分析总结PCQ系统的评估原理、评估流程、评估效果,并作一综述。结果显示：PCQ系统对各种疾病的分辨能力较高,随着WNS（weighed numerical score,加权分数）分数的增加,各种疾病分数表现为阶梯状上升的层级分布图。癌症患者与非癌症患者的平均WNS分剐是70-80、40-55之间,有统计学意义。当以WNS分数60为界时,WNS系统的敏感度、特异度可分别达到86.5％、84.5％。以WNS50为转诊标准,仅40％的患者需紧急转诊,发现91％的癌症患者。提示PCQ系统的准确性高、特异性强,是一个很有发展前景的评估体系,可以进一步的开展多中心研究进行验证,进而推广使用并引进到中国。     

The Ideal Patient and the Realities of Clinical Work

As candidates, and later as practicing analysts, we filter the idea of what patients, analysts, and the analytic process should look like through our own ego ideal. Literature that is often stilted toward a theoretical ideal further muds the picture. Finally, we are often confused by the quest for the perfect patient who meets the criteria for analyzability outlined by our training institute, our supervisors, our teachers, and our own demanding superegos. This paper examines several cases of clinical work that falls far short of any ideal. However, these realistic snapshots of day-to-day clinical work are too important to be ignored as simply failed cases with unanalyzable patients. Often, even the briefest of clinical encounters enrich the analyst's understanding of human functioning and occasionally benefits the patient as well. If the analyst uses the analytic stance with all of his patients, a useful analytic discourse may take place with some of them. These cases are not standard or complete analytic treatments, but the results are often valuable to the practitioner and potentially helpful to the patient.     

Talking about Spirituality in the Clinical Setting: Can Being Professional Require Being Personal?

Spirituality or religion often presents as a foreign element to the clinical environment, and its language and reasoning can be a source of conflict there. As a result, the use of spirituality or religion by patients and families seems to be a solicitation that is destined to be unanswered and seems to open a distance between those who speak this language and those who do not. I argue that there are two promising approaches for engaging such language and helping patients and their families to productively engage in the decision-making process. First, patient-centered interviewing techniques can be employed to explore the patient's religious or spiritual beliefs and successfully translate them into choices. Second, and more radically, I suggest that in some more recalcitrant conflicts regarding treatment plans, resolution may require that clinicians become more involved, personally engaging in discussion and disclosure of religious and spiritual worldviews. I believe that both these approaches are supported by rich models of informed consent such as the transparency model and identify considerations and circumstances that can justify such personal disclosures. I conclude by offering some considerations for curbing potential unprofessional excesses or abuses in discussing spirituality and religion with patients.     

Encouraging patient participation in general practice consultations: Effect on consultation length and content,patient satisfaction and health

Abstract

Following the evidence from earlier research that one-to-one interventions can increase the patient's contribution to the consultation, this paper reports the results from a randomised control trial which assessed the effects of a leaflet designed to enhance patient participation in consultations. A random sample of patients (aged 16 to 74) waiting to see a general practitioner were given either an intervention leaflet, which encouraged the patient to take an active role in the consultation, or a control leaflet which gave dietary advice. The effects of the intervention were assessed by measuring length of consultation, number of questions asked by the patient, patient satisfaction score, doctor's feelings about the consultation, the change in patients' health in the 4 weeks following the consultation (measured by the SF-36 Health Survey) and the number of patient visits to a GP in the following year. The results showed that patients in the intervention group had significantly longer consultations than those in the control group and tended to ask more questions but there was no significant effect on patient satisfaction. The doctor tended to feel that he had a better understanding of patients in the intervention group. Overall there was no significant effect on SF-36 scores but, for patients under the age of 40, and for those in higher social classes the scores of patients in the intervention group improved to a significantly greater degree than did those for the control group. The intervention did not have any effect on the number of GP visits made by patients in the subsequent year. The study results show that a relatively simple leaflet can have an impact on patients' behaviour during the consultation, even though there were no effects on patient satisfaction with the consultation or in the number of GP visits in the following year.     

ICU向患者家属开放的理论研究

ICU实行的基本是封闭式管理,这不仅带来了一些伦理问题,也容易引发医疗纠纷,从伦理学的需要、预防医疗纠纷、改善医患关系等方面探讨ICU向患者家属开放的必要性,分析开放存在的问题,论证了ICU向患者家属开放的可行性。     

Effects of Different Listening-While-Reading Rates on Comprehension in Secondary Students with Reading Deficits

Abstract

Effects of instructing students to read silently as another person reads aloud (listening-while-reading) on comprehension in secondary students with learning disabilities were examined. Two separate treatment conditions were implemented. During student rate listening-while-reading, (SLWR), experimenters read aloud at rates that approximated each student's oral reading rate. During fast rate listening-while-reading, (FLWR), experimenters increased their reading rates. A silent reading (SR) control condition was also implemented. Following each intervention the students answered five literal and five inferential questions. SLWR resulted in lower inferential accuracy than FLWR and SR. Discussion focuses on future research and implications for accommodating secondary students with reading skills deficits in general education classrooms.     

What happens in a psychoanalysis?

A group of experienced analysts has developed scales and a coding manual illustrated with clinical examples to evaluate recorded analyses and psychodynamic therapies. The analytic process scales (APS) assesses three dimensions: (1) the contribution of the analyst: helping to develop a relationship in which the analyst can provide clarification and interpretation of transference and resistance; (2) the contribution of the patient: the communication of experience and the expression of feeling in ways which provide information about needs, wishes and conflicts, accompanied by self-reflection; and (3) interactional characteristics of the emerging relationship, explored by studying sessions divided into psychoanalytically coherent segments. A preliminary study of nine sessions has established that the variables assessed by the APS can be rated reliably. Study of the analysts' contributions illuminated their varied and complexstructure. Important differences emerged among the three patient-analyst pairs studied, and changes in scores over time tracked developments in the analytic work which would imply different treatment outcomes. The APS appears to be a reliable tool facilitating the systematic study of psychoanalyses.     

Consultant or Comrade: Comments About Analysts' Working Relationships in Schools

The articles in this issue of the Journal of Applied Psychoanalytic Studies pose a dilemma for educators. On the one hand, each article describes an important psychosocial intervention implemented in schools. On the other hand, these interventions, at least as described in the articles, are either imposed on the work of teachers and students or isolated from that work. Either circumstance ultimately limits the impact of the intervention. I claim that analysts and teachers are natural allies despite lack of evidence for alliance in these articles. To extend that alliance beyond conversations about individual children, analysts must understand that teachers' views of learning and development are different from those that influence the organization and management of schools.     

患者参与患者安全的国内外研究分析

患者是患者安全的主体和核心,保证患者安全,不仅是医护人员和医疗机构的责任,同时需要患者的参与。自1999年美国医学研究院发表了《孰能无错,构建更为安全的卫生保健体系》报告后,患者安全首次成为学术组织、公众媒体关注的焦点,其相关研究如雨后春笋般涌现,包括患者参与患者安全的研究。     

Taking Cognitive-Behavior Therapy to School: A School-Based Mental Health Approach

This paper offers an overview using cognitive-behavior therapy (CBT) within a school system. In addition to providing services to individual students, this article provides an overview of implementing CBT into a system of school-wide mental health services. Interventions are discussed at three levels—universal school-wide interventions, target interventions with at-risk students, and intensive interventions with students in need. Examples of specific programs or intervention are given for each level.     

One REBTers Model for Business Consulting

Organizational consulting offers opportunities to diversify one’s practice and increase one’s income, all the while reducing the frustrations associated with working with insurance and managed care companies. This paper describes one REBT therapist’s conception of the “personality” of any organization, a list of potential services to offer businesses, and a few practical suggestions to successfully transfer from the clinical office into the organizational world.     

Performance as annihilation or integration?1

What happens when the analyst has the impression of being annihilated by the patient? Analysts have a tendency to use more general, i.e. simplifying, constructions such as destructiveness, psychosis or death instinct as explanatory models. In the authors' view, these constructions in the end evade rather than mirror clinical reality. More recent research points to promising possibilities of differentiation, e.g. psychotic mechanisms which are‐as yet undiscussed‐based on Freud's notion of the partial ‘rent in the relation between ego and external world’. These findings emphasize the restitutive function of a symptom or disturbance, i.e. destruction of a relationship which hinders the therapeutic process and which is not understood initially, instead of solely stressing the destructive meaning in a tabooing gesture. The concept of performance attempts to replace simplifying models with a discriminant process, and will be preliminarily defined and explained in delineation to terms already in use such as acting out, enactment, and role responsiveness. The authors explore the question of how the perception of unthought certainty in the performance can either be recognized as a blueprint, i.e. organizing activity, or as the destruction of the relationship so that a new one can emerge. The evidence from a detailed clinical example shows that many treatments can fail at this point and demonstrates how an understanding of performance in this sense offers a chance for integrating processes that otherwise impede treatment.     

“向病人学习”的多重意蕴探究

“向病人学习”作为一种态度、行为取向应该为尽可能多的医者所认同和仿效。从三个维度探究其意蕴：首先,在界定“学习”的基础上阐述“向病人学习”及其客观性,从关系哲学角度揭示它对医患关系的建构意义。其次,以制度化的医患交往环境为背景,阐述“向病人学习”对医生自我定义、自我反省乃至成为好医生的意义。最后,从医学教育的现状分析突出“走向病人”即获得“亲知”的开始,与从物的角度作比较,强调“向病人学习”即从人的角度看待病人,在与每个独一无二的病人交往中获得经验的过程。

     

Training District Personnel as Peer Consultants and Inservice Leaders: Implementation and Evaluation of a Training Program

For several years, Furman University has offered training for special educators to develop skills as peer inservice providers and as peer consultants to general education personnel. By means of a personnel preparation grant, School Initiated Teacher Education (SITE) Outreach, 61 special education teachers, speech therapists, and curriculum specialists have been involved in a series of three graduate level courses designed to address development of skills in inservice content and presentation and peer consultation. Evaluation data were collected to determine the impact of the training program, perceived benefits to the participants, and the receptiveness of the participating school districts in terms of the incorporation of peer inservice and consultation activities into the ongoing instructional program.