对新冠病毒肺炎危重症患者引入缓和医疗的伦理论证

新型冠状病毒肺炎尚无治疗特效药和疫苗。在继续加强防控的同时,把有限的资源优先放在探索对重症和危重症患者的支持性治疗,积极建立和完善对重症、危重症患者及其家属的缓和医疗等方面,有利于患者群体利益最大化,经得起伦理辩护。缓和医疗有助于改善患者预后,降低住院病死率,有效缓解患者濒死痛苦;对医患双方而言,如果死亡已无可避免,帮助临终者走得平安、少些痛苦,是医学对患者最后的人文关怀。     

Cognitive Behavioral Therapy for Postamputation Chronic Pain: A Case Report

Limb amputation has a significant impact on an individual, not only physically but emotionally. Consequences of both traumatic and atraumatic amputations are vast and can result in functional disability, impaired emotional functioning, and changes in overall quality of life. These consequences may be further complicated by the development of chronic pain. Traditional management of postamputation chronic pain often involves invasive procedures and pharmacotherapy. While research notes behavioral interventions, such as cognitive-behavioral therapy (CBT) as a viable treatment alternative for chronic pain, there is no literature supporting CBT for postamputation chronic pain. In this case report, we present a 63-year-old male lower limb amputee complicated with chronic pain who experienced pain reduction and improved quality of life following manualized treatment with CBT for chronic pain. Treatment took place over 12 sessions with fidelity (93%) being measured throughout to ensure accurate utilization of the treatment manual. As part of the treatment manual, self-report measures (Pain Rating Scale, Pain Catastrophizing Scale, Pain Outcomes Questionnaire, and subjective units of distress) were used throughout to track patient progress. All measures showed improvement with the biggest gains being seen in pain ratings and pain catastrophizing.     

Does proactive cyclic usage of a footrest prevent the development of standing induced low back pain?

Various interventions, such as standing intermittently with one leg on a footrest, have been suggested to prevent low back pain (LBP) development during prolonged standing. To assess this standing intervention twelve participants stood for 80 min while cycling through three minute periods of level-ground standing divided by one minute periods with either the right or left leg elevated onto a platform. All participants had previously participated in a prolonged level standing protocol and were classified as pain (PD) or non-pain developers (NPD). Out of the six known PDs, only one PD developed LBP by the end of the standing intervention. The intervals of elevated leg standing resulted in increased lumbar spine flexion in comparison to level standing. In addition, over time there was an increase in lumbar spine flexion during the level standing intervals. This change in lumbar spine posture in standing pain developers likely contributed to the reduced LBP development during this prolonged standing intervention     

Everyday worry in adolescents with and without chronic pain: a diary study

Young people report frequent worry, but we know little about the extent, character, or consequence of worry in adolescence, or individual differences associated with worry. Adolescents with chronic pain are one population that are known to have high levels of anxiety, which is associated with higher levels of disability and depression, impairing function. In this study we report a diary study: adolescents (N = 60; aged 16–18) recorded their worry over seven days. Our first aim was to describe the characteristics of adolescent worry and its consequences in a community sample. Our second aim was to compare the experience of girls to boys, and to compare the experience of those with and without chronic pain. Adolescents reported characteristics of each worry they had throughout the week, including content, frequency, strength, interference, emotion, and the strength of emotion associated with worry content. Adolescents reported the consequence for each content and the strength of the consequence. Worry content and consequences were categorised into four categories; health, relationship, personal competence, and other. Adolescents reported 675 unique episodes of worry over the seven-day period that were predominantly about personal competence. The strength of worry content was (M = 6.61, SD = 1.27) and the strength associated with the worry consequence was (M = 5.59, SD = 1.41). Worries were not reported as highly interfering (M = 4.14, SD = 1.61). Contrary to predictions, there were no differences in worry characteristics between adolescents with and without chronic pain. To conclude, worry is a frequent occurrence in older adolescents and the characteristics of worry are discussed. Adolescents worry mostly about personal competence. Adolescents with and without chronic pain reported similar worry characteristics.     

How do I cope with pain? Let me count the ways: awareness of pain coping behaviors and relationships with depression and anxiety

Patients with chronic pain are often undertreated with medications alone and need alternative ways of coping. Identifying pain coping skills patients use may be beneficial; however, no research has investigated whether patients are aware of their coping skills. The purpose of this study was to determine whether patients are aware of their pain coping skills, whether certain patient characteristics were related to using coping strategies, and whether coping strategies were related to psychiatric symptoms. Chart reviews were conducted on seventy-eight chronic pain patients who completed a semi-structured psychological interview. Patients endorsed using more coping strategies on the measure compared to the verbal self-report. Identifying with certain patient demographics was related to higher use of some coping strategies. Symptoms of anxiety and depression were also related to the use of some coping strategies. Anxiety was negatively related to ignoring the pain and using self-talk coping statements and positively related to catastrophizing. Depression was negatively related to the use of distraction, ignoring the pain, and using self-talk coping statements. Depression and pain severity were both positively related to catastrophizing and prayer. Results suggest that clinicians may need to help patients become aware of adaptive coping strategies they already use and that the use of certain coping strategies is related to lower levels of depression and anxiety.     

Perceived stress,recurrent pain,and aggregate salivary cortisol measures in mid‐adolescent girls and boys

Measures of perceived stress have been criticized for theoretical inconsistency. However, the validated pressure activation stress scale has been suggested as a theoretically sound alternative. But it is unclear how pressure and activation stress relate to objective and subjective measures including commonly used aggregate cortisol measures and health complaints respectively. Specifically, this study aimed at investigating how pressure and activation stress were related to aggregate salivary cortisol measures and recurrent pain in mid‐adolescent girls and boys. Mid‐adolescents (119 girls and 56 boys) provided self‐reports in questionnaires on activation and pressure stress and recurrent pain (headache, stomach ache, neck/shoulder and back pain). Additionally, adolescents sampled saliva during an ordinary school day: (1) immediately at awakening; (2) 30 minutes after waking up; (3) 60 minutes after waking up, and (4) at 8 p.m. These samples were analyzed for cortisol. Hierarchical regressions showed no statistically significant associations between activation and pressure stress and cortisol, neither for girls nor for boys. However, activation and pressure stress were significantly associated with recurrent pain but only for girls. The findings may relate to subjective and objective measures reflecting distinct aspects of stress‐related functioning. However, the study participants included mid‐adolescents whose bodily systems are flexible and still relatively unaffected by the strain of their daily stress perceptions. To conclude, the non‐significant relationships between activation and pressure stress and commonly used aggregate measures of cortisol adds to the understanding of how perceived stress may relate to physiological functioning in the daily life of adolescents when using such aggregate measures.     

Comparison of the trunk-pelvis and lower extremities sagittal plane inter-segmental coordination and variability during walking in persons with and without chronic low back pain

Inter-segmental coordination can be influenced by chronic low back pain (CLBP). The sagittal plane lower extremities inter-segmental coordination pattern and variability, in conjunction with the pelvis and trunk, were assessed in subjects with and without non-specific CLBP during free-speed walking. Kinematic data were collected from 10 non-specific CLBP and 10 non-CLBP control volunteers while the subjects were walking at their preferred speed. Sagittal plane time-normalized segmental angles and velocities were used to calculate continuous relative phase for each data point. Mean absolute relative phase (MARP) and deviation phase (DP) were derived to quantify the trunk-pelvis and bilateral pelvis-thigh, thigh-shank and shank-foot coordination pattern and variability over the stance and swing phases of gait. Mann-Whitney U test was employed to compare the means of DP and MARP values between two groups (same side comparison). Statistical analysis revealed more in-phase/less variable trunk-pelvis coordination in the CLBP group (P < 0.05). CLBP group demonstrated less variable right or left pelvis-thigh coordination pattern (P < 0.05). Moreover, the left thigh-shank and left shank-foot MARP values in the CLBP group, were more in-phase than left MARP values in the non-CLBP control group during the swing phase (P < 0.05). In conclusion, the sagittal plane lower extremities, pelvis and trunk coordination pattern and variability could be generally affected by CLBP during walking. These changes can be possible compensatory strategies of the motor control system which can be considered in the CLBP subjects.     

Variations on the concept of traumatism: Traumatism,traumatic, trauma1

In this paper, the author outlines Freud's fundamental hypotheses concerning the concept of traumatism, then goes on to differentiate three notions (French being a particularly apposite language for such a venture): ‘traumatism’, ‘traumatic’ (in a substantive sense) and ‘trauma’. These three terms correspond to the three turning points in Freud's theory with respect to the concept of traumatism (1895‐97, 1920, 1938). The author evokes also the developments that are due to Ferenczi, particularly in his later writings (1928‐33), where he defi ned and discussed the question of ‘trauma’ in contemporary clinical practice; the author goes on to explore the different variations on this theme as regards mental functioning. He then defi nes, from a metapsychological point of view, the differences between ‘traumatisms’ that have been ‘worked over by secondary processes’, organised and governed by the pleasure‐unpleasure principle (‘traumatism’) and ‘early’ or ‘primary traumatisms’, which interfere with the process of binding the instinctual drives (‘trauma’); states of mind infl uenced by a traumatic imprint (‘traumatic’) are looked upon as belonging to both categories of the above mentioned traumatisms. The author illustrates his hypotheses with a clinical example.     

Invited Special Review: Psychological Approaches for Managing Chronic Pain

Psychologists have had an important impact on the conceptualization, assessment, and treatment of chronic pain. Their contributions have been in the areas of emotional distress, behavioral limitations, cognitive mediating events, and psychosocial disruption of chronic pain. These foci have enabled them to clarify the multidimensional nature of chronic pain and to support the biopsychosocial framework as a conceptual guide for research and clinical purposes. Clinically, along with members of an interdisciplinary team, psychologists have a key role in the assessment and treatment of patients with chronic pain. Interdisciplinary collaboration allows the team to recognize important interactions between biomedical and psychosocial dimensions and to appreciate a broader conceptualization of patients' problems. The literature documents strong empirical support for operant-behavioral and cognitive-behavioral therapies for the treatment of chronic pain. On the other hand, although widely accepted from a clinical perspective, the use of motivational interviewing and motivational enhancement therapies is more recent and less well documented for use with patients with chronic pain.