临床整合医学的必要性及实施中存在的问题——以慢性阻塞性肺疾病及其合并症的诊治为例

近年来人们逐渐认识到慢性阻塞性肺疾病(COPD)是一种全身性疾病,即COPD不仅会影响到气道和肺,还会引起一系列合并症,包括心血管疾病、骨质疏松、焦虑和抑郁、癌症、感染、代谢综合征和糖尿病等。这些合并症会显著地影响COPD疾病严重程度和预后,因而必须对COPD进行整体防控,然而COPD的上述合并症的诊治分属不同学科,所以要做好COPD的整体防控就需要相关学科进行医学整合。     

跨期选择中的反常现象及其心理机制

时间折现是跨期选择研究的核心问题。指数折现效用模型（DU模型）是描述时间折现现象的基本模型。跨期选择的实验研究中发现的大量违背DU模型的反常现象表明,DU模型并不能很好地解释人们在跨期选择中的真实行为。文章从时间知觉、建构水平、参照点和价值函数、情绪激活、情绪麻木、期待效用等角度探讨了造成各种反常现象的心理机制,并提出了值得进一步研究的方向和问题。     

亚健康中抑郁程度人群分布特点的对应分析

为了分析亚健康人群抑郁的不同表现程度与不同人口学资料的关系,采用"亚健康状态的测量及诊断标准研究"课题组调查的中国人亚健康资料,利用对应分析对抑郁表现因子总分的不同等级与不同的年龄、婚姻、职业和学历的关系进行分析。结果显示,20岁～30岁、未婚、学生和大专及以上学历主要表现为中重度抑郁倾向,31岁～40岁、已婚、专业人士和高中专学历主要表现为中度抑郁倾向,41岁～60岁、工人、农民和初中以下学历的抑郁倾向较轻,结论为亚健康人群的心理不适,特别是抑郁倾向,主要集中在年龄较轻、学历较高的专业人士和白领人群当中,还包括大学生群体,我们应该针对这些群体采取相应的措施减轻他们的心身不适。     

放疗诱发恶性肿瘤的临床研究与思考

放射治疗是目前许多恶性肿瘤的重要的有效治疗手段,但放射线本身具有诱发恶性肿瘤的远期效应。随着治疗手段的提高,长期生存的患者逐渐增多,放射诱发肿瘤的病例也在逐年增加,需要引起人们的重视。本文对放射治疗诱发第二恶性肿瘤进行综述和辩证思考。     

现时代的生命伦理问题

结合现时代临床,提出医疗要回归“初心”,“初心”就是“人命贵”,这是医学伦理起点,也是医学的最高宗旨;而要贯彻“初心”,又应讲究医疗科技和医学人文及伦理之间形成合力。分析认为：现时代医学伦理可能以“生态伦理”更为合适;应区分重大疫情、急性抢救、慢性病纠治等不同情况,考虑“合力”所涉及的不同方面之轻重缓急;并针对生命伦理的有利原则,指出“有利”只是动机及出发点,还需深入思考,确立动机的基线和起点;就基线而言,要搞清楚是本然“有利”,还是科学“有利”,并做出一定区分;应在科学“有利”和本然“有利”之间保持适度的张力与平衡。

     

药物成瘾者决策缺陷的特征、机制及干预

药物成瘾者存在决策缺陷, 并表现出冲动性、风险寻求、奖赏失调、躯体内感信号缺失等特征。神经影像学研究表明药物滥用导致成瘾者背外侧前额皮层、前扣带回、眶额叶皮层、腹内侧前额皮层、杏仁核、脑岛等脑区受损, 这些损伤是引发其决策缺陷的主要原因。认知训练有利于提高个体的决策能力, 如目标管理训练和正念冥想等可以增强个体工作记忆、促进自我觉察和以目标为导向的行为; 而非侵入性脑刺激则可以直接改变与成瘾者决策相关脑区的激活状态, 从而提升与决策相关的认知功能。总体而言, 未来认知训练和非侵入性脑刺激在成瘾干预方面仍有广阔的拓展空间。     

门脉高压症治疗观点之辩

对立统一规律是辩证法的实质,在唯物辩证法的理论体系中占有核心地位。门脉高压症的外科治疗有分流术与断流术两种不同的手术方法,这两种方法从治疗机制上看是矛盾的,用对立统一观来认识这两种手术的联系并揭示门脉高压外科治疗发展的哲学依据。     

Evidence-based treatment of stuttering: II. Clinical significance of behavioral stuttering treatments

An evidence-based framework can be described as an empirically-driven, measurement-based, client-sensitive approach for selecting treatments. It is believed that using such a framework is more likely to result in a clinically significant outcome. For this paper, a clinically significant outcome was defined as a meaningful treatment change. It was suggested that there are at least three groups for whom a treatment's outcome is meaningful. These groups include clinicians/clinical researchers, the clients, and relevant others who have some interest in the outcome (e.g., parents of a child who stutters). The meaning and measurement of clinical significance was discussed for each of these three groups, based on research from the behavioral stuttering treatment literature. EDUCATIONAL OBJECTIVES: The reader will learn about and be able to (1) broadly define a clinically significant outcome and identify some of the groups who are interested in such an outcome and (2) describe how clinical significance has been evaluated in stuttering treatment within an evidence-based framework.     

Towards a functional neural systems model of developmental stuttering

This paper overviews recent developments in an ongoing program of brain imaging research on developmental stuttering that is being conducted at the University of Texas Health Science Center, San Antonio. This program has primarily used H₂¹⁵O PET imaging of different speaking tasks by right-handed adult male and female persistent stutterers, recovered stutterers and controls in order to isolate the neural regions that are functionally associated with stuttered speech. The principal findings have emerged from studies using condition contrasts and performance correlation techniques. The emerging findings from these studies are reviewed and referenced to a neural model of normal speech production recently proposed by Jürgens [Neurosci. Biobehav. Rev. 26 (2002) 235]. This paper will report (1) the reconfiguration of previous findings within the Jürgens Model; (2) preliminary findings of an investigation with late recovered stutterers; (3) an investigation of neural activations during a treatment procedure designed to produce a sustained improvement in fluency; and (4) an across-studies comparison that seeks to isolate neural regions within the Jürgens Model that are consistently associated with stuttering. Two regions appear to meet this criterion: right anterior insula (activated) and anterior middle and superior temporal gyri (deactivated) mainly in right hemisphere. The implications of these findings and the direction of future imaging investigations are discussed.

Educational objectives: The reader will learn about (1) recent uses of H₂¹⁵O PET imaging in stuttering research; (2) the use of a new neurological model of speech production in imaging research on stuttering; and (3) initial findings from PET imaging investigations of treated and recovered stutterers.     

Profiles of Counseling Pioneers: A Visit With Kathleen and Gilbert Wrenn

The authors have had the honor of knowing Gilbert and Kathleen Wrenn for 20 years; this story is about them. As Gilbert stated, “I am not a lone star, but part of a constellation… ”(Wachowiak & Aubrey, 1976, p. 76). The authors are privileged to know that for Gilbert, Kathleen (his partner of 72 years in 1996) is the center of that constellation. This article briefly captures pieces of the journey of 72+ years, on which Gilbert and Kathleen, each at 96 years of age, are continuing to travel together.