高新技术临床应用中不合理诊疗行为的思考

高新医疗技术临床应用中的不合理诊疗行为,主要包括医方趋利性医疗行为和防御性医疗行为。通过典型案例对高新医疗技术临床应用中的不合理诊疗行为的成因进行分析,剖析不合理的诊疗行为,提出了规范应用高新医疗技术的对策。     

包医合同法律效力分析

虽然医疗行为存在多种风险与不确定性,但也不是所有的医疗行为都是不确定的。生活中经常有医方向患者承诺保证治疗效果的情形,从法律的角度来说,这时在医方与患者之间就形成了包医合同关系。论述了包医合同的性质及其法律效力。     

Treatment Sensitivity of a Brief Rating Scale for Attention-Deficit Hyperactivity Disorder (ADHD) Symptoms

This study examined the treatment sensitivity of the ADHD Questionnaire (ADHD-Q), which is a brief rating scale for measuring symptoms of inattention, hyperactivity, and impulsivity in children. Parent, teacher, and child self-report data of the ADHD-Q were obtained for 17 clinically referred children with ADHD on the three occasions: (1) during the regular intake assessment, (2) just before the start of the stimulant medication (i.e., methylphenidate) intervention, and (3) four weeks after the start of the medication intervention. Results showed that ADHD-Q scores remained fairly stable in the period prior to the intervention, but then showed a substantial decline after the stimulant medication had been administered. Clearly, this finding supports the treatment sensitivity of the ADHD-Q.     

Feasibility and Acceptability of Cognitive Bias Modification for Interpretation as an Adjunctive Treatment for OCD and Related Disorders: A Pilot Randomized Controlled Trial

Cognitive models implicate interpretation bias in the development and maintenance of obsessive compulsive and related disorders (OCRDs), and research supports Cognitive Bias Modification for Interpretation (CBM-I) in targeting this mechanism. However, prior studies in OCRDs have been limited to nonclinical populations, adolescents, and adults in a laboratory setting. This study evaluated the feasibility and acceptability of CBM-I as an adjunctive intervention during intensive/residential treatment (IRT) for adults with OCRDs. We modified a lab-based CBM-I training for adults seeking IRT for OCRDs, and conducted a feasibility trial (N = 4) and subsequent pilot RCT; participants (N = 31) were randomized to receive CBM-I or psychoeducation. Benchmarks were met for feasibility, acceptability, and target engagement. From pre- to post-intervention, the CBM-I group showed a large effect for change in interpretation bias (d = .90), whereas this effect was trivial (d = .06) for psychoeducation. This was the first study to evaluate CBM-I in naturalistic treatment for adults seeking IRT for OCRDs. Findings support the feasibility and acceptability of CBM-I in this novel sample and setting. A larger scale RCT is needed to determine whether CBM-I can enhance OCRD treatment response.     

Can a Single Measure Estimate Protocol Adherence for Two Psychosocial Treatments for Youth Anxiety Delivered in Community Mental Health Settings?

Treatment adherence measurement can be time and resource-intensive in clinical trials, so the ability to measure protocol adherence for two distinct treatment programs with a single measure may benefit the field. The present study sought to determine if the Therapy Process Observational Coding System – Revised Strategies Scale (TPOCS-RS) could assess protocol adherence to two youth treatment programs. Treatment sessions (N = 796) from 55 youth (M age = 9.89 years, SD = 1.71; range 7–15 years; 55.0% White; 46.0% female) with primary anxiety problems treatment by 39 clinicians (M age = 40.54 years, SD = 9.56; 50.0% White; 80.0% female) were independently scored by coders using observational treatment adherence and alliance measures. The youth received one of three treatments: (a) Standard (i.e., cognitive-behavioral treatment program), (b) Modular (i.e., a program with cognitive-behavioral and parent training components), or (c) Usual Care. Consultants filled out a self-report measure of protocol adherence within the Standard and Modular conditions. Interrater reliability, ICC(2,2) for the various items for the full sample ranged from .17 to .92 (M ICC = .67; SD = .17). Scores from a TPOCS-RS subscale that mapped onto the specific content of the treatment protocols used in the Standard and Modular conditions evidenced convergent validity with the consultant-report adherence measure and discriminant validity with the alliance measure. The model-specific TPOCS-RS subscales also discriminated between the Standard and Modular treatments and Usual Care. This study provides initial evidence that (a) the TPOCS-RS has utility in estimating protocol adherence in different treatment programs and (b) support the score validity of the self-report consultation records.     

Feasibility and Acceptability of Group-Facilitated Prolonged Exposure Therapy for PTSD in VA Residential Rehabilitation Treatment Programs

Prolonged Exposure therapy (PE) is a first-line treatment for posttraumatic stress disorder (PTSD); however, few VA patients receive this treatment. One of the barriers to PE receipt is that it is only available in an individual (one-on-one) format, whereas many VA mental health clinics provide the majority of their psychotherapy services in group format. In particular, PTSD residential rehabilitation treatment programs (RRTPs) offer most programming in group format. Consequently, strategies are needed to improve the scalability of PE by adapting it to fit the delivery setting. The current study was designed to pilot test a group-facilitated format of PE in RRTPs. Thirty-nine Veterans who were engaged in care in the PTSD RRTP at a Midwestern VA were recruited to participate in a Group-facilitated PE protocol. Participants engaged in twelve 90-minute sessions of Group PE over the course of 6 weeks, plus six 60-minute individual sessions for imaginal exposure. Group treatment followed the PE model and consisted of psychoeducation, treatment rationale, and in vivo exposure to reduce trauma-related avoidance and thereby improve PTSD symptoms. PTSD symptoms were measured via the PTSD Checklist for DSM-5 (PCL-5) and depression symptoms were measured via the Patient Health Questionnaire (PHQ-9) at baseline, endpoint (6 weeks), and at 2-month follow-up. Thirty-nine individuals initiated Group-facilitated PE and 34 completed treatment. The average number of group sessions attended was 11 out of 12. Acceptability ratings were high. Mean change (improvement) in the intent-to-treat sample at 2-month follow-up was 20.0 points on the PCL-5 (CI 18.1, 21.9; Cohen’s d = 1.1) and 4.8 points on the PHQ-9 (CI 4.1, 5.5, d = .8). These results suggest that adapted evidence-based interventions for PTSD can improve treatment access and efficiency for the RRTP setting. A group-based approach has the potential to improve the scalability of PTSD treatment by reducing required resources. A fully powered trial is now needed to test the effectiveness of Group-facilitated PE in the RRTP setting.     

Treatment Seeking for Anxiety and Depression Among Black Adults: A Multilevel and Empirically Informed Psycho-Sociocultural Model

Black adults with anxiety and/or depressive disorders underutilize outpatient psychotherapy and pharmacological treatment compared to White adults. Notably, anxiety and depressive disorders tend to be chronic and Black individuals with these disorders experience greater functional impairment than White individuals. Documented racial disparities in mental health treatment initiation indicate a need for research that addresses culture-specific barriers to treatment. This review paper critically evaluates existing theoretical models of treatment seeking among Black adults to inform a novel integrated, culturally contextualized model. This model extends previous ones by incorporating factors relevant to treatment seeking among Black adults (e.g., racial identity, perceived discrimination, medical mistrust) and critically examines how these factors intersect with key factors at three levels of influence of the treatment seeking process: the individual level, the community level, and the societal level. We posit interactions among factors at the three levels of influence and how these may impact treatment seeking decisions among Black adults. This model informs suggestions for enhancing interventions designed to support outpatient service use among Black adults.     

从炎症在心力衰竭进展中的作用谈心力衰竭治疗策略的制订

心力衰竭是一个以免疫激活和低程度的慢性炎症为特点的疾病。一些炎症因子能通过促进心肌细胞肥厚、恶化心肌收缩功能以及诱导凋亡,在心衰的发展过程中具有重要作用。炎症因子能成为心衰治疗的重要目标。但炎症因子还有心脏代偿和保护作用。制订新的心衰治疗策略时需要进一步了解心衰中炎症反应激活的机制。     

峡部裂性腰椎滑脱病因、诊疗方法的研究

峡部裂性腰椎滑脱指腰椎上、下关节突之间的峡部失去连接而发生脊椎滑移。从疾病起源、发展、转归的角度,结合自然辨证法的理论,针对峡部裂性腰椎滑脱的病因、诊断标准、治疗方法及效果三个方面进行了阐述和展望。对哲学应用于临床实践和科研教学等方面的基本问题,如对疾病发展规律的研究、诊断理论的建构等,进行了论述。     

癫痫诊治中医患同盟建立的实践与策略

癫痫治疗目前仍以长期科学规范的药物治疗为主,为保证医生的治疗计划得到贯彻,在诊治中努力寻求医患同盟的建立尤为重要,让患者清楚地认识到医生对他的关注,认识到医生治疗的计划性、和具有应对各种情况的措施方法和能力,是寻求患方合作的基本条件。本文就医生首诊中的任务、人文关怀的重要性、如何共同进行药物选择、副反应规避、家属不良治疗心态纠正等问题进行探讨。