国家重点学科临床医师强化培训的探索与实践

医学人才的培养关系到社会的整体医疗水平.我国传统的医师培训模式已不适应当今社会对医疗服务的高质量要求,有必要探索提高我国医师培养的新路子.我们认为,建立住院医师强化培训可以从根本上提高医师的临床工作能力.国家重点学科南京大学医学院临床学院(南京军区南京总医院)全军普通外科研究对此进行了探索与实践,取得了卓越成效.     

Contingency Management in the 21st Century: Technological Innovations to Promote Smoking Cessation

Information technology represents an excellent medium to deliver contingencies of reinforcement to change behavior. Recently, we have linked the Internet with a science-based, behavioral treatment for cigarette smoking: abstinence reinforcement therapy. Under abstinence reinforcement interventions, incentives are provided for objective evidence of abstinence. Several studies suggest that the intervention is effective in initiating abstinence. The intervention addresses limitations (access, cost, sustainability, and dissemination potential) inherent in traditional abstinence reinforcement delivery models. It can also be applied to vulnerable, at-risk populations, and to other behavior to promote health. Information technologies offer unprecedented and rapidly expanding opportunities to facilitate behavior change.     

变性近视后巩膜加固术患者的个性化护理

介绍对变性近视后巩膜加固术患者实施个性化护理的经验.针对患者不同的心理状态和不同的术后表现,我们给予个性化、系统、全面的护理,有效提高了患者满意度,从而提升了护理质量.经3 ～18个月的复查,术后视力增加28眼,不变1眼,下降1眼.     

The pharmacology of impulsive behaviour in rats VI: the effects of ethanol and selective serotonergic drugs on response choice with varying delays of reinforcement

Rationale: Tolerance to delay of reinforcement has been proposed as an important facet of self-control in both animals and man. Poor self-control, leading to impulsive behaviour, can be a major problem if it reaches pathological levels. Objectives: The effects of five serotonergic drugs were compared to those of ethanol on a procedure for measuring tolerance to delay of reinforcement in rats in order to elucidate further the role of the serotonin systems in the regulation of impulsive behaviour. Methods: Rats were trained to choose between a single food pellet (small reinforcer) delivered immediately or five food pellets (large reinforcer) delivered after programmed delays. At the start of each session, there was no delay between the response and delivery of the large reinforcer, but this was increased stepwise during the session to delays of 10, 20, 40 and 60 s. Results: The rats showed consistent preference for the larger reinforcer when it was not delayed but showed a shift in preference as the session continued, so that they preferred the small reinforcer when the large was delayed by 40 or 60 s. Ethanol at a dose of 1.0 g/kg produced a significance increase in preference for the small, immediate reinforcer throughout the session, although there were marked individual differences in the size of the effect. A similar, but somewhat smaller effect was seen with the 5-HT₂ agonist, DOI, at a dose of 1.0 mg/kg. In contrast, the 5-HT_1A agonist, 8-OH-DPAT (0.3 mg/kg) reduced preference for the large reinforcer at the start of the session, and reduced preference for the small reinforcer at the end of the session, i.e. produced a regression to indifference. Lower doses of these three drugs, and treatment with the 5-HT receptor subtype selective antagonists WAY-100635 (5-HT_1A: 0.01–0.1 mg/kg), ritanserin (5-HT₂: 0.1 and 0.3 mg/kg) and MDL-72222 (5-HT₃: 1.0 and 3.0 mg/kg) had no significant effects on reinforcer choice. Conclusion: These data show that ethanol and DOI increase preference for the immediate reinforcer, which can be construed as evidence of an increase in impulsive behaviour (reduction in self control), whereas selective blockade of the 5-HT_1A, 5-HT₂ or 5-HT₃ receptors using selective antagonists does not affect self-control. Received: 24 October 1998 / Final version: 16 February 1999     

基于事件相关脑电的个体决策过程

决策过程指的是在一特定情况下，从现有的几个可选策略中挑选某一个策略的评价过程。然而，在一个复杂的环境中，个体的决策往往会受其他个体影响而随机改变策略，从而很难做出一个最佳决策。虽然博弈论提供了多种决策方案，但是并未明确决策是如何受经验影响的。最佳的决策行为需要根据近期的收益来灵活调整策略。为了探究人类决策过程的本质，文章采用零和博弈中的猜硬币正反游戏。假设这种灵活性是在强化学习的过程中产生的，并建立了一个强化学习模型。另外，全程记录了受试者在实验过程中的事件相关电位。对事件相关电位数据的分析主要集中在反馈相关负波上，一个被认为反映神经错误信号的与收益相关的脑电位。结果显示，在输给对方后事件相关电位的幅值暗示了受试者是否会在随后的出招中改变出招策略。     

Classical conditioning of amphetamine-induced lateralized and nonlateralized activity in rats

Amphetamine-induced lateralized activity (rotation) and nonlateralized activity (extra quarter turns) was classically conditioned in female rats using the test environment as the conditioned stimulus (CS) and 1.25 mg/kg d-amphetamine as the unconditioned stimulus. Conditioned lateralized activity extinguished more rapidly than nonlateralized activity. Also, d-amphetamine-induced nonlateralized activity was selectively decreased by a schedule of 50% partial reinforcement. These results indicate that the two d-amphetamine responses can be distinguished, that they are differentially affected by learning, and that a schedule of partial reinforcement can selectively attenuate one effect of a drug while leaving the other intact. In addition, haloperidol blocked conditioned lateralized activity; this suggests that the conditioned response may be, like the drug-induced response, mediated by dopamine.     

Endovascular management of endotension by graft reinforcement followed by direct sac embolization

Purpose: To assess the efficacy of graft reinforcement followed by percutaneous direct sac embolization (PDSE) for the treatment of endotension after endovascular abdominal aortic aneurysm repair (EVAR).

Materials and methods: A total of 290 patients underwent elective EVAR. All patients regularly underwent scheduled surveillance with contrast-enhanced computed tomography (CT). Two hundred thirty-five patients were followed for ≥24?months after EVAR. Aneurysmal sac expansion of ≥10?mm was observed in 20 patients. The patients with sac expansion of ≥10?mm with no evidence of endoleak were treated with graft reinforcement. Graft reinforcement consisted of graft extension and graft relining. The patients with sac expansion at 6?months after graft reinforcement received PDSE using metallic coils and n-butyl cyanoacrylate–Lipiodol mixture. The aneurysm diameter was measured by CT performed 6?months and every year after the final intervention.

Results: Seven patients (7 men, 0 women; mean age, 69.1?±?4.2?years, Zenith^®:5/Excluder^®:1/Powerlink^®:1) underwent graft reinforcement. Two patients underwent graft reinforcement alone, and five patients underwent PDSE after graft reinforcement. Mean follow-up time after the final intervention was 21.1?months. The sac diameter stabilized after the final intervention in all patients.

Conclusion: Graft reinforcement followed by complementary PDSE could be a useful treatment strategy for endotension.     

Further evaluation of latency-based brief functional analysis methods: An evaluation of treatment utility

Objective: Objectives were to evaluate latency-based brief functional analysis (BFA) model for identifying functions of aberrant behavior and treatments generated based on the results of the latency-based brief functional analysis. Methods: We conducted latency-based BFA, including contingency reversals, and function-based treatment evaluations, including non-contingent reinforcement (NCR) and differential reinforcement of alternative behavior (DRA) with three individuals with autism using single subject design methodology. Results: Socially-mediated functions (attention; tangible) were indicated for two participants and an automatic function was identified for one participant. The treatments generated based on results of the BFA were effective at reducing aberrant behavior for all participants. Conclusions: Results provide additional support that latency-based BFA model has utility in (a) the identification of functions of aberrant behavior and (b) the generation of function-based treatments. These results suggest clinicians who encounter setting and client-specific constraints (e.g. time; severity of aberrant behavior) have additional flexibility in choosing assessment tools.     

The Drinking Expectancy Questionnaire for Men who have Sex with Men (DEQ-MSM): a measure of substance-related beliefs

Introduction and Aims. Alcohol expectancies are associated with drinking behaviour and post‐drinking use thoughts, feelings and behaviours. The expectancies held by specific cultural or sub‐cultural groups have rarely been investigated. This research maps expectancies specific to gay and other men who have sex with men (MSM) and their relationship with substance use. This study describes the specific development of a measure of such beliefs for alcohol, the Drinking Expectancy Questionnaire for Men who have Sex with Men (DEQ‐MSM). Design and Methods. Items selected through a focus group and interviews were piloted on 220 self‐identified gay or other MSM via an online questionnaire. Results. Factor analysis revealed three distinct substance reinforcement domains (‘Cognitive impairment’, ‘Sexual activity’ and ‘Social and emotional facilitation’). These factors were associated with consumption patterns of alcohol, and in a crucial test of discriminant validity were not associated with the consumption of cannabis or stimulants. Similarities and differences with existing measures will also be discussed. Discussion and Conclusions. The DEQ‐MSM represents a reliable and valid measure of outcome expectancies, related to alcohol use among MSM, and represents an important advance as no known existing alcohol expectancy measure, to date, has been developed and/or normed for use among this group. Future applications of the DEQ‐MSM in health promotion, clinical settings and research may contribute to reducing harm associated with alcohol use among MSM, including the development of alcohol use among young gay men.[Mullens AB, Young R McD, Dunne MP, Norton G. The Drinking Expectancy Questionnaire for Men who have Sex with Men (DEQ‐MSM): A measure of substance‐related beliefs. Drug Alcohol Rev 2011;30:372–380]