Prise en charge des symptômes médicalement inexpliqués en médecine interne : un paradigme de la relation médecin-malade en situation d’incertitude

Medically unexplained symptoms (MUS) are extremely common in general practice as in all medical specialties, but their designation is not unambiguous and the approaches to take care of the patients differ from conventional therapeutic approaches. The difficulty is not to confirm the diagnosis, which is rapidly obvious with some experience, but to establish a genuinely human therapeutic relationship, without any technical help, which pushes the doctor to the edge of his empathy and communication skills. The discomfort or even distress regularly encountered by physicians in front of a patient with MUS shows that the foundations of the doctor-patient relationship under uncertainty are poorly mastered. Patients with MUS are regularly abused by the doctors, who unwittingly participate in the maintenance of their symptoms and even freeze them, leading to disastrous psychosocial and economic consequences. Yet the doctor-patient relationship is the key to their recovery or, at least, their improvement. The means of a successful patient-centered relationship are not always intuitive but can be learned. It is therefore essential to include SMI in medical school curricula and post-graduate medical education. Finally, if the management of early MUS mainly concerns the family medicine, that of severe MUS, including some fibromyalgia and chronic fatigue syndromes, falls within the scope of the internist doctor, who should be able to deliver a comprehensive care in partnership with the general practitioner and possibly a psychiatrist.     

Vers une gestion autonome de la médication en psychiatrie ? Approche anthropologique

From the patient’s viewpoint, a good quality of compliance supposes a good relationship with his/her doctor; this relationship is directly linked to the heeding and the interest shown to the patient, and not to his/her symptoms alone. If individual motivation plays an important part at the outset, it will nevertheless be seriously influenced by the relationship between the doctor and his/her patient. It is one of the rare factors for which a positive correlation with compliance can be observed, as shown by practically all medical psychological research. These well-known classical medical notions meet with average values of non-compliance, which may vary widely. These data are proof of the wide gap existing between what is expected and what is actually achieved. This discrepancy is felt by the patient as well as by his/her therapist, and involves many other factors linked to culture, to the medical and religious background, to medical anthropology, and to the real or supposed proprieties of the Pharmakon. Our study aims at synthesizing the most recent data concerning this issue, which is still at the core of numerous debates and hardly ever tackled in French language literature. Based on the summary of these data and on the testimony of 135 persons involved in this dynamic (patients, families, doctors, nurses, members of pharmaceutical industry), we shall try to obtain a better understanding of what happens between the patient and his/her therapists from an anthropological viewpoint. Social isolation remains one of the greatest losses in mental disease. For many authors, people with schizophrenia can have no friends, no spouse, and sometimes no family. Two thirds of the patients with schizophrenia return to their parents’ house when discharged from a hospital after the first psychosis. Family members generally receive very little education as to what they can expect. They may not even know the importance of medication compliance. Family members are the primary victims of violence from psychotic individuals, usually their own son or daughter, and most families cannot believe their own son or daughter would be capable of such violence. Although families are usually the main care givers at the beginning of schizophrenia they often find their experience very frustrating for a number of reasons, and consequently relationships suffer. Family education and support have been shown to improve outcomes considerably and family education is the second strongest factor in relapse prevention. Without education and good relapse prevention families often disintegrate. Most of the homeless mentally ill in downtown city cores have lost their family relationships. It is not a reflection on their families so much as the lack of adequate treatment and support. The families tried again and again but finally lost their sick relative. These reflections show how information of and about the psychiatric patient is necessary, and underlines the importance of the relationships between the patient and his family. Our article also insists on this theme which is rarely developed in the literature.     

Administration, politics and science in alcohol prevention in Swiss cantons

Summary Public administration, politics, and science in the alcohol prevention of the Swiss member statesObjetives:The article assesses the effects that different constellations of science, administration, and the political sphere have on the policy design and the output performance in the field of alcohol prevention policy.Method:Comparative bivariate analysis of results from a written survey of the Swiss cantons.Results:A broad and adequate policy design is found in cantons with an alcohol prevention policy dominated by administrative actors. Output performance shows to be comparatively higher in cantons with a high influence either of scientific actors or of political actors.Conclusion:In an overall comparison focusing on the two dependent variables of this study, a combined model of administrative dominance with strong affiliation to the scientific community prevails against the other models considered.

---

Verwaltung, Politik und Wissenschaft in der kantonalen Alkoholprävention

     

代谢综合征与脂肪肝的关系

目的探讨代谢综合征(MS)与脂肪肝间的相关性。方法666例干部体检者送检血脂、血糖、肝功能，肝脏B超检查，测血压、身高、体重。通过F检验、X^2检验分析血脂、血糖、血压、体重指数等对脂肪肝的影响及MS与脂肪肝间的相关关系。结果脂肪肝者体重指数、收缩压、舒张压、总胆固醇、甘油三酯、载脂蛋白B、血糖较正常者升高，高密度脂蛋白、载脂蛋白Al较正常者降低。MS组脂肪肝患病率明显高于对照组。结论MS与脂肪肝关系密切，应早期给予干预治疗。     

糖尿病患者胫前皮肤色素沉着斑与褪黑素关系的探讨

1 资料与方法 1．1 临床资料 研究对象为2001年3月至2005年4月收入本院的符合WHO标准的糖尿病患者106例，其中男性59例，女性47例，所有患者分成两组：双下肢胫前色素沉着斑组55例（女性22例，男性33例），年龄47岁～91岁，平均73岁，胫前非色素沉着斑组51例（女性25例，男性26例），年龄53岁～87岁，平均68岁，所有入选对象入选前未使用过褪黑素或脑白金。     

血栓前体蛋白含量变化与年龄的关系

目的 :检测不同年龄人群血栓前体蛋白 (TpP)含量变化及其与血栓性疾病的关系。方法 :选择年龄在 30～ 79岁健康人群 ,共 16 8例 ,按年龄分为 5组 ,采用酶联免疫分析法检测TpP含量。结果 :随着年龄的增长 ,TpP含量有递增的趋势 ,6 0～ 6 9岁组TpP含量为 9.53± 2 .0 8μg/ml,70～ 79岁组TpP含量为 11.37± 2 .0 5μg/ml,明显高于 59岁以下各组 ,差别极为显著 (P <0 .0 1)。 结论 :TpP检测可作为老年人是否有血栓形成的一个重要指标。     

论实习医师的伦理道德

临床学习是医学生成为合格的临床医师的必要环节,理论联系实际,不断提高业务水平和道德修养,是临床实习的根本要求。实习医师在临床实践活动中,兼有医师和学生的双重身份,这一特殊的群体有着特殊的伦理道德要求。     

卒中后抑郁与急性期神经功能缺损程度的相关研究

目的 探讨脑卒中后抑郁（post stroke depression，PSD）发生率以及与急性期神经功能缺损程度的关系。方法 对289例住院诊断为脑卒中的患者，用改良的爱丁堡斯堪的那维亚神经功能缺损评分表（SSS）对卒中急性期进行评分，根据急性期神经功能缺损情况分为三组。用汉密尔顿抑郁量表进行随访调查抑郁评分。结果 PSD的发病率在随访1年期间中随着时间的延长逐渐增加；PSD的发病率和重度PSD的发病率随神经功能缺损程度的加重而增加；PSD的程度随着神经功能缺损程度增加而加重。结论 PSD是脑卒中后的常见并发症，卒中后1年中发病率逐渐增加，其严重程度与卒中急性期的神经功能缺损程度一致。     

医疗保险制度下医院经济与伦理关系所面临的课题

就镇江、九江试行医疗保险制度所引发的医院经济利益和伦理道德关系的变化等问题作了理论与实践的探索.指出经济状况对伦理观的影响与伦理观对经济行为的作用,是同一因果链的两侧面.因此,医疗保险制度是经济与伦理因素互为运动的产物,它能较好地协调好医院经济利益与伦理道德的关系,体现出医疗服务的公平、公正的经济伦理原则.