重症加强监护医学与临床思维

重症加强监护医学的发展史,也是其临床思维的发展史,一个由个体性呼吸衰竭救治观念转化为集群性救治启动了重症加强监护学的建立,它们的发展带动亦受益于其临床思维、动态思维的发展。重症加强监护的实施,引发了医学伦理学新的思考与选择,而新的生物技术革命,必将导致重症加强监护医学及其临床思维的巨大变革。     

With Hope and Imagination: Imaginative Moral Decision-Making in Neonatal Intensive Care Units

Although the role of imagination in moral reasoning is often neglected, recent literature, mostly of pragmatist signature, points to imagination as one of its central elements. In this article we develop some of their arguments by looking at the moral role of imagination in practice, in particular the practice of neonatal intensive care. Drawing on empirical research, we analyze a decision-making process in various stages: delivery, staff meeting, and reflection afterwards. We show how imagination aids medical practitioners demarcating moral categories, tuning their actions, and exploring long-range consequences of decisions. We argue that imagination helps to bring about at least four kinds of integration in the moral decision-making process: personal integration by creating a moral self-image in moments of reflection; social integration by aiding the conciliation of the diverging perspectives of the people involved; temporal integration by facilitating the parties to transcend the present moment and connect past, present, and future; and epistemological integration by helping to combine the various forms of knowledge and experience needed to make moral decisions. Furthermore, we argue that the role of imagination in these moral decision-processes is limited in several significant ways. Rather than being a solution itself, it is merely an aid and cannot replace the decision itself. Finally, there are also limits to the practical relevance of this theoretical reflection. In the end, it is up to care professionals as reflective practitioners to re-imagine the practice of intensive care and make the right decisions with hope and imagination.

Using a new analysis of the best interests standard to address cultural disputes: Whose data,which values?

Clinicians sometimes disagree about how much to honor surrogates’ deeply held cultural values or traditions when they differ from those of the host country. Such a controversy arose when parents requested a cultural accommodation to let their infant die by withdrawing life saving care. While both the parents and clinicians claimed to be using the Best Interests Standard to decide what to do, they were at an impasse. This standard is analyzed into three necessary and jointly sufficient conditions and used to resolve the question of how much to accommodate cultural preferences and how to treat this infant. The extreme versions of absolutism and relativism are rejected. Properly understood, the Best Interests Standard can serve as a powerful tool in settling disputes about how to make good decisions for those who cannot decide for themselves.     

ICU患者外出检查风险分析与对策

为了探讨ICU危重患者外出检查风险的原因,从而降低ICU危重患者外出检查风险,本文通过对312例ICU患者外出检查风险因素进行讨论分析,研究降低风险的对策,即在规范ICU患者外出检查流程、做好检查前准备和注意途中安全及返回后的护理,结果提示285例患者无意外发生,安全返回病房,其余27例患者存在一定风险,但在相应处理措施下均安全返回病房。     

A Latent Gaussian process model for analysing intensive longitudinal data

Intensive longitudinal studies are becoming progressively more prevalent across many social science areas, and especially in psychology. New technologies such as smart-phones, fitness trackers, and the Internet of Things make it much easier than in the past to collect data for intensive longitudinal studies, providing an opportunity to look deep into the underlying characteristics of individuals under a high temporal resolution. In this paper we introduce a new modelling framework for latent curve analysis that is more suitable for the analysis of intensive longitudinal data than existing latent curve models. Specifically, through the modelling of an individual-specific continuous-time latent process, some unique features of intensive longitudinal data are better captured, including intensive measurements in time and unequally spaced time points of observations. Technically, the continuous-time latent process is modelled by a Gaussian process model. This model can be regarded as a semi-parametric extension of the classical latent curve models and falls under the framework of structural equation modelling. Procedures for parameter estimation and statistical inference are provided under an empirical Bayes framework and evaluated by simulation studies. We illustrate the use of the proposed model though the analysis of an ecological momentary assessment data set.     

Intensive Outpatient Program Using Prolonged Exposure for Combat-Related PTSD: A Case Study

Although prolonged exposure (PE) has been identified as a first-line treatment for posttraumatic stress disorder (PTSD), research has found that military service members and veterans have smaller reductions in symptom severity compared to civilians. The nature of trauma in a deployed combat setting and the unique complexities of military culture have been proposed as explanations for greater rates of PTSD and poorer treatment response to first-line psychotherapies in military and veteran populations. This paper presents a case study to highlight how a novel, intensive outpatient program utilizing prolonged exposure therapy (IOP-PE) may benefit military personnel with combat-related PTSD. The patient is a Caucasian man in his early 40s seeking treatment for PTSD after more than 10 years of enlisted, active duty military service across two branches and three combat deployments. The IOP-PE includes the standard PE components and eight, nonstandard treatment augmentations tailored for military personnel. In contrast to standard PE, which typically is delivered weekly over several months, IOP-PE consists of 15 daily, 90-minute PE sessions conducted over 3 weeks. The patient demonstrated large reductions on the Clinician-Administered PTSD Scale (28 points) and PTSD Checklist (48 points) by the 6-month posttreatment follow-up point. Findings provide support for conducting further research that determines whether IOP-PE is effective and tolerable in military and veteran populations.     

将糖化血红蛋白控制在7．0％以下是否更安全

2008年一项针对2型糖尿痛强化血糖控制对心血管病变研究（ACCORD）发现,对于病程在10年左右,30％存在心血管疾病的2型糖尿病人群,利用现有手段努力实现血糖“正常化”,即糖化血红蛋白（A1C）〈6．0％并没有减少糖尿病全因死亡。人们开始重新思考对2型糖尿病是否还需要强调强化血糖控制、血糖控制的目标多少为宜。中华医学会糖尿病学分会也在今年重新修订了其《中国2型糖尿病防治指南》的A1C控制目标,A1C目标由原来的6．5％提高到7．0％。那么这一改变对2型糖尿病患者来讲到底有多大意义呢？ACCORD强化降糖治疗终止后的随访研究发现强化组患者在血糖控制目标与标准治疗组相似的情况下,全因死亡率并没有随之减少。因此,需要重新检视2型糖尿病防治策略。     

临终患者ICU使用的相关问题

随着危重病医学的发展,越来越多的患者接受ICU治疗,而其中许多患者在临终前接受了他们所不愿接受的积极治疗。伦理学上并没有要求我们不惜一切代价挽救生命而不顾及患者及其家属的需要。让临终患者能够选择有尊严的、无痛苦的死亡,成为当前ICU治疗与护理的出发点和目标。在美国及欧洲ICU临终患者,限制生命支持治疗是主要的治疗模式,但差异显著。为真正理解“好死”的定义和判定患者生命质量、判定积极治疗的参考因素,国外已进行了大量研究。目前各国由于经济、文化、宗教等各方面的差异,直接影响临终患者的临终决策,综述了各国近年来有关ICU临终患者研究结果。     

知情权与新生儿重症监护病房(NICU)患儿父母的信息交流技巧

在新生儿重症监护病房(neonatal intensive care unit,NICU)中接受治疗的危重新生儿约90%结果良好,而这些患儿的父母100%都在此过程中遭受不同程度的心理创伤.患儿父母及其家人应被充分告知患儿的病情、治疗方案及可能的预后,这是他们拥有的知情权.在临床工作中,怎样运用良好的信息交流技巧让患儿父母充分理解病情、配合治疗又不过分紧张这对患儿的康复比对患儿实施具体的诊疗方案更重要.从患儿父母、医护人员、人文关怀的角度探讨NICU医护人员与患儿父母之间信息交流的技巧.