循证医学时代安慰剂的再认识

安慰剂的治疗作用早已被人们认识,但是对于其在医学上的应用却一直存在争议。在循证医学兴起的今天,我们应该如何辩证地看待安慰剂的作用及不足,以及在临床试验中应该如何应用安慰剂是一个值得探讨的问题。     

痛苦共情的功能性核磁共振成像研究述评

对他人痛苦的共情是指自动模拟受痛者的情感和运动状态,以及在自我-他人区分的基础上替代性地分享和理解他人由于受痛所引发的情绪状态.痛苦共情的fMRI研究常用图片诱导范式和线索诱导范式.痛苦共情的神经机制,包括(1)疼痛矩阵(该区域在个体自身受痛时也会激活)和(2)观点采择的相关脑区.痛苦共情的水平会受到实验范式和任务,以及共情者对于受痛者态度两方面因素的共同影响.加强应用研究和推出新型范式是痛苦共情研究的当务之急.     

临床工作中应重视“安慰剂”效应

目前我国临床工作中对“安慰剂”效应重视不够。“安慰剂”效应建立在患者对医生的信任之上。生物医学模式重视疾病的生物学意义而忽视社会、心理因素的影响,导致医生对患者态度冷漠,患者对医生缺乏信任,已成为我国医患关系恶化的重要原因,继而弱化了医疗的“安慰剂”效应。推行生物-心理-社会医学模式,提倡临床工作以人为本而非以疾病为主,建立医患共赢的医疗体制,改善医疗环境,有利于产生和加强临床工作的“安慰剂”效应,切实促进医疗和谐。     

老年慢性疼痛患者疼痛接受与疼痛程度的相关关系

了解老年慢性疼痛患者疼痛接受与疼痛程度,探讨两者的相关关系.采用简易慢性疼痛接受问卷（CPAQ-8）中文版、简化McGill疼痛问卷（SF-MPQ）与一般情况调查表对335例老年疼痛患者进行调查.结果纳入有效样本308例,SF-MPQ总体平均分为（50.24±23.35）分,中文版CPAQ-8总体平均得分（21.74±5.97）分.老年慢性疼痛患者的受教育程度、疼痛期、疼痛部位及疼痛点数目等差异有统计学意义（P＜0.05）.疼痛接受与疼痛程度呈负相关（P＜0.01）,即接受程度越高者,其疼痛程度越低.     

The Social Pain Posit

Although discussion of social pain has become popular among researchers in psychology and behavioural neuroscience, the philosophical community has yet to pay it any direct attention. Social pain is characterized as the emotional reaction to the perception of the loss or devaluation of desired relationships. These are argued to comprise a pain type and are explicitly intended to include the everyday sub-types grief, jealousy, heartbreak, rejection, and hurt feelings. Social pain is accordingly posited as a nested type of pain encompassing multiple emotional sub-types. Call this the social pain posit. This article focuses on whether we should endorse the social pain posit and, in particular, whether social pain is pain. I present the four lines of evidence for the social pain posit that are currently offered in the literature and I argue that each provides only inadequate support, taken either individually or together. I close by considering the significance of the presented argument for philosophical theorizing about the nature and the moral significance of affective experiences in particular and mental taxonomizing more generally.     

团队合作对4838例居家癌痛患者疼痛管理的效果与思考

通过对大连医科大学附属第一医院宁养院2001年3月～2013年11月收治的4838例癌痛患者进行调查,总结归纳居家癌痛患者的疼痛控制情况,探索癌痛患者的疼痛管理方法,结果提示依靠团队合作在居家条件下免费向癌痛患者及其家属提供身体、心理、社会和精神全方位的照顾和支持,即理想的疼痛管理是“整体性疼痛”与“整体性痛苦”的治疗,不仅针对临床疼痛症状,还必须处理相关因素。     

Placebo in the investigation of psychotropic drugs,especially antidepressants

The paper presents major ethical, legal and methodological problems related to the use of placebo in mental disorders, especially in depression. It is pointed out that although authoritative groups of experts and numerous publications in the field of psychopharmacology indicate advisability of the double blind design with placebo in clinical trials of antidepressants, in recent years there have been more and more voices questioning legitimacy of this method. Objections of an ethical nature are raised, and reliability of this approach is put into doubt from the methodological viewpoint. These issues are discussed in more detail in the paper. Available alternative solutions should be implemented in psychotropic drug studies. The author shares these objections and doubts of an ethical nature, and believes that the placebo procedure is not a necessity in clinical trials of antidepressants. An earlier version of this paper was presented at an international conference, “Placebo: Its Action and Place in Health Research Today,” held in Warsaw, Poland on 12–13 April, 2003.     

Placebo: Its action and place in health research today

The place for the placebo in human clinical research is addressed in this paper. The World Medical Association which is comprised of some 80 National Medical Associations uses much of its resources to address medical ethics and human rights issues. It adopted the Declaration of Helsinki in June 1964 which addressed the protection of individuals in clinical trials. The use of placebos assumes an important role in this document. Five Revisions of the Declaration of Helsinki have occurred and the most recent was adopted in October 2000. The provisions on placebo are now in Paragraph 29 which reads as follows: “The benefit, risks, burdens and effectiveness of a new method should be tested against those of the best current prophylactic, diagnostic and therapeutic methods. This does not exclude the use of placebo, or no treatment, in studies where no proven prophylactic, diagnostic or therapeutic methods exists.” The reactions to the newly revised version of the Declaration of Helsinki were numerous and rapid, not the least of which was the paragraph I quoted above. At the direction of the WMA Council, a small group of experts together with the WMA workgroup studied the Paragraph 29 to ensure that no ethically sound research was being restricted by the revision. The outcome was approved by the Council and later the WMA General Assembly in October 2000. This gives a note of clarification as to the appropriate use of placebos. Numerous papers and statements over the last several years have described positions very much in line with the Note of Clarification cited above. This paper was presented at an international conference, “Placebo: Its Action and Place in Health Research Today,” held in Warsaw, Poland on 12–13 April, 2003.     

The Pain of Dying

SUMMARY

Dying can be a painful and difficult business. Fears, hopes, losses, questions, and uncertainty result in a form of pain that lies beyond the therapeutic reach of science and pharmacology. Efforts to preserve and prolong life or to make things better can sometimes result in this pain being overlooked or remaining unheard. To search the deepest part of oneself is the journey that beckons us all as we are dying. Within this space resides the source of our own suffering but also the seeds for healing. This exploration has a momentum of its own but requires conditions not often found within the biomedical paradigm. If this model of care remains the only source of hope for those with a life-threatening illness, ‘the pain of dying’ may not be addressed.     

新生儿疼痛管理方法与培训现状

总结了目前新生儿疼痛管理方法与培训现状.疼痛管理方法包括非药物性止痛方法如口服蔗糖水、非营养性吸吮、襁褓包裹及袋鼠式护理等,药物镇痛如瑞芬太尼与丙泊酚用于小儿气管插管及其他;培训现状包括权威教科书上缺少关于新生儿疼痛管理知识、缺乏特异性调查问卷、缺乏专业师资及培训机构.认为在新生儿的治疗护理中医护人员要坚持科学的认识论,把握医学伦理学的要求,在日常的治疗护理中体现对新生儿的人文关怀,才能进一步提高医疗护理质量,达到医院与患者的双赢.     

The Future of Psychology in Pain Management

Pain treatment facilities have proliferated in recent years and psychology has enjoyed considerable success in the clinical and research arenas of pain management. However, changes in the health care environment present significant challenges to the future of psychology in pain management. This article discusses concerns in three important areas of pain treatment that psychologists must address if they are to maintain a strong presence in this field: (1) evaluating and treating patients in the pain treatment setting, (2) evaluating and enhancing the efficacy of pain treatment, and (3) applying pain treatment services to other patient populations. With appropriate attention to these issues, psychology can continue to thrive in pain treatment settings.     

The Accuracy of the DSM-IV Pain Disorder and the ICD-10 Persistent Somatoform Pain Disorder in Chronic Pain Patients

Objectives. In this investigation we studied the relationships between different psychological relevant subgroups and the presence of different psychosomatic symptoms in a sample of chronic pain patients, testing the accuracy of the DSM- and ICD classification systems.Results. We found no evidence for a “pure” pain syndrome according to the DSM- and ICD systems. On the contrary, we found highly significant evidence of a mixed psychosomatic condition.Conclusion. The results suggest a broad somatoform classification, with subgroups based on personality characteristics taking a stress—coping model into account, including interpersonal attachment behaviour. An alternative model of a diagnostic approach is presented.     

疼痛表达与中国人表达的躯体化

西方研究者认为中国人习惯用躯体化方式表达心理不适,不能区分身体疼痛和心理痛苦。通过回顾中文文本,认为在传统中国的语境中,身心互应的哲学观念使个体能够以一种隐性但自明的方式来表达自身情感。但在社会变迁的环境中,原有的社会关联多数都已崩解,个体开始使用躯体化以及疼痛作为索引,从而提供自我的某种参照。     

Neural Bases of Human Working Memory

Working memory is the memory system that allows us to briefly keep information active, often so we can operate on it. Studies with rhesus monkeys first established that this system is partly mediated by neural mechanisms in the prefrontal cortex. Recently, there has been a substantial effort to study the neural bases of working memory in humans, using neuroimaging techniques such as positron emission tomography and functional magnetic resonance imaging. Some of the initial neuroimaging studies with humans focused on the neural mechanisms that mediate our ability to keep spatial information active. These results indicated that human spatial working memory is partly mediated by regions in parietal and prefrontal cortex. Subsequent research has shown that a different neural system is involved when people store object (rather than spatial) information, a difference similar to that found in monkeys.     

不同年龄妇科患者痛阈测试及其临床意义

采用双盲、前瞻性研究,选择90例妇科择期全麻下子宫肌瘤剔除或子宫全切手术患者,ASA分级Ⅰ或Ⅱ级,按年龄分两组,中青年组（A组）50例,年龄25岁～50岁,老年组（B组）40例,年龄60岁-80岁,术前使用电刺激测定并记录患者的痛阈和耐痛阈,观察不同年龄妇科患者痛阈和耐痛阈以及两者之间相关性。结果显示A组与B组痛阈分别为（1．86±0．51）mA和（1．89±0．66）mA差异无统计学意义;A组比B组耐痛阈低分别为（6．16±2．53）mA和（8．40士3．21）mA,差异有统计学意史;A组痛阈与耐痛阈之间有相关性（Spearman相关系数为-0．42,P〈0．05）;B组痛阈与耐痛阈之间无相关性。因此,老年患者耐痛阈升高,中青年患者术前痛阈和耐痛闽均可预测术后疼痛,老年患者术前痛阈不能预测术后疼痛。     

慢性腰背痛患者和抑郁症患者的情绪、睡眠及疼痛症状

本研究对慢性腰背痛患者、抑郁症患者和对照人群的疼痛、抑郁水平、焦虑水平和睡眠质量进行测评,发现慢性腰背痛患者的抑郁、焦虑程度增高,失眠较常见;抑郁症患者的焦虑和失眠现象严重,疼痛是其常见症状。结果提示临床上对慢性疼痛患者和抑郁症患者的疼痛、情绪和睡眠问题予以评定和治疗具有重要意义。     

The Neurobiological Underpinnings of Coping With Pain

ABSTRACT— The biopsychosocial model treats pain as resulting from a complex interaction of biological, psychological, and social factors. Individual differences in approaches to coping with pain-related symptoms are important determinants of pain-related outcomes, and are often classified under the "psychological" category within the biopsychosocial model. However, engagement in various cognitive, affective, and behavioral pain-coping strategies appears to exert biological effects, which we review here. Pain-coping activities such as catastrophizing, distracting oneself from pain sensations, or reappraisal of pain may exert effects on activity in a variety of pain-processing and pain-modulatory circuits within the brain, as well affect the functioning of neuromuscular, immune, and neuroendocrine systems. The interface between pain-related neurobiology and the use of specific pain-coping techniques represents an important avenue for future pain research.     

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。     

治疼必需知痛

疼痛是人体可感知所有伤害性刺激中最难以忍受的恶性刺激,医学范畴下的疼痛是指组织损伤的前提下产生的＂躯体的不愉快的疼感觉＂加上＂与之相匹配的痛苦情感体验＂两方面内容。长期以来我们的医疗行为＂过多关注组织损伤对疼的调控、忽视了痛苦体验的人文关怀＂制约了我们服务层次。新的生物医学模式下诊疗工作强调细化疼痛分类、躯体与心理并重,以专科诊疗思路指导临床,提高医务人员对病痛的理解、引导供需匹配式的人性医疗服务是时代发展务实之举。