Evaluation and Treatment of Depression in Managed Care (Part II)

Depression is under-detected, but is treatable and relapses can be prevented. Living with depression, whether acute or chronic, has consequences for quality of life, premature end of life, and productive life. Thoughtful and strategic quality improvement (QI) programs offer one avenue for improving the treatment of depression. Part I of this two-part series addresses improving the treatment of depression and employing disease management as a strategy to accomplish that aim. This article, part II, provides an overview of other QI initiatives that demonstrated treatment effectiveness for depression, including several used in managed care practice.Currently, the majority of QI programs for depression target adult patients; therefore, there are future challenges ahead as managed care attempts to address the needs of special populations, such as adolescents and older adults. Public education, professional education, and population-based interventions are also considerations as part of successful treatment. Although consumer-based interventions are typically more expensive, they may ultimately yield the best results for improving depression care for the consumer and payors based on available research. The success of a consumer-centric approach is highly reliant on the person’s engagement with QI programs, the treating clinician’s appreciation and support of such depression programs, and managed care’s response to solving quality problems using continuous monitoring, evaluation, feedback, system enhancements, and training. Models of collaboration between consumers and medical and behavioral health systems offer the most promising approaches to care improvements for patients with depression.     

岭南医药启示录(十二)

17清末民初广东伤寒学与温病学之发展（上） 清代至民国时期，广东伤寒学与温病学有长足的发展，表现为著名的医家与著作的林立，由师徒相授而举办学校，应对传染病能力的增强等等。考其原因，主要：一是病谱的变化，海外传来许多新的疫病如霍乱，烂喉痧等，老传染病如鼠疫，天花等的不断爆发流行。二是西医传人，废止中医之举屡起，中医危亡不能不起而抗争，研究理论，提高临床诊治水平、举办学校、出版著作与刊物都势在必行，实际是寻求奋发图强、发展中医之路。现就清末民初有代表性的几位伤寒学家与温病学家略加介绍，以见一般。     

新型粘结固定桥临床应用初步观察

目的 观察一种用于牙列缺损永久修复的新型粘结固定桥的临床效果。方法 选择有单个或多个牙缺失的病人，进行固定桥基牙的牙周和特定的牙体预备。然后制作固定桥并试戴，用4－META／MMA－TBB树脂粘结剂粘结固定桥。结果 267例（304个）固定桥病人经二年以上随访，发现192个前牙桥中只有1个，112个后牙桥中只有2个脱落，其余固定桥稳定、功能良好。结论 采用树脂粘接技术，结合基牙的机械预备，能较好地克服3／4冠桥、桩冠桥和嵌体桥的缺陷，使之成为良好永久的修复体。     

Inappropriate social and sexual responses to a female student by male patients with dementia and organic brain disorder

Little attention has been directed toward inappropriate social and sexual approaches by patients with dementia diagnoses and organic disorders of the brain. A female student who approached patients who had dementia and organic brain disorders was frequently approached and touched in a sexual manner that was distressing to her and led her to believe that she was behaving in a manner that elicited these responses. It is recommended that students and volunteers be prepared for experience in settings with patients with these diagnoses through individual or group discussion, training and role playing as a way of enhancing their experiences and avoiding unnecessary feelings of guilt and embarrassment.     

四肢带表浅静脉干的局部皮瓣在创伤修复中的应用

设计4种带表浅静脉干的局部皮瓣用于修复四肢创面14例,获得了满意的效果。该皮瓣所包含的一条浅静脉干,不仅有利于静脉回流,且其血流对皮瓣亦有营养作用。因此,该皮瓣容易成活,长宽比值可大于传统任意型皮瓣。并具有操作简便,不损伤主要动脉等优点。文中介绍了皮瓣的设计及手术方法,并对该皮瓣的血液循环特点、适应证及供区选择等进行了讨论。     

重庆地区驾驶员血液中乙醇浓度与驾驶能力的关系

目的　探讨重庆地区驾驶员血液中乙醇浓度 (BAC)和驾驶能力的关系 ,为交通安全立法提供科学依据。　方法　随机选择重庆地区 59名驾驶员志愿者 ,建立饮酒后驾车模型、科学的BAC测定以及驾驶能力评价体系 ,对不同BAC下驾驶能力进行测评。　结果　受试者出现驾驶能力损害时的BAC均数为 685.9mg/L ,最小值 190 .0mg/L ,最大值 152 0 .0mg/L ,总体均数 95%可信区间为 60 2 .4～ 70 9.5mg/L。汉族和土家族间、汉族男性和女性间、2 3～ 3 5岁和 3 6～ 56岁年龄组间差异无显著性意义 (P >0 .0 5) ,而既往饮酒量不同的三个组别间差异有显著性意义 (P <0 .0 5)。随着BAC增高 ,驾驶能力受损人数增加。在 2 0 0 .0mg/L有 3 % (2 / 59)的受试者驾驶能力降低 ,80 0 .0mg/L则达到 68% (40 / 59)。　结论　随着BAC增高 ,重庆地区驾驶员驾驶能力受损人数比例增加 ,出现驾驶能力明显损害时BAC为 60 2 .4～ 70 9.5mg/L ,既往酒量较大人群中该值较高     

食管癌切除术并发胸导管损伤的早期诊断及治疗

我院1990年至1993年共施行食管癌切除术160例，术中胸导管损伤5例，发生率为2．1％，5例中3例于术中发现并及时处理，未发生乳糜胸，另2例于术后并发乳糜胸才诊断，经早期剖胸手术治愈,本文介绍了食管癌切除术并发胸导管损伤的早期诊治体会。     

医学技术的进步与传统医学伦理的矛盾

此文全面论述了先进医学技术给传统医学伦理的医患关系模式、医生义务论、生命认识论、资源分配论等诸多方面带来的巨大冲击,并由此提出先进医学技术发展应遵循的伦理规则。     

兔动静脉短路环法诱导组织工程骨支架材料血管生成的初步研究

Objective To compare the effects of 2 vascular carriers, arteriovenous loop and arteri-ovenous bundle, on inducing angiogenesis in coral scaffold of vascularized tissue-engineered bone in animal models.Methods Thirty-six adult male New Zealand rabbits were randomized into 2 even groups.In group A, an arteriovenous loop (AVL) was formed by microsurgical anastomosis at the proximal ends between the femoral poptiteal artery and vein, and placed in the circular side groove of the coral block (6 mm × 8 mm × 10 mm) .In group B, flow-through vessels bundles of both femoral artery and vein were placed in the side grooves of the coral block.All the implants in 2 groups were wrapped by a micro-porous expand-ed-polytetrafluoroethylene (ePTFE) membrane, and fixed subcutaneously by suturing.Evaluation methods included gross morphological observations, histological examinations, India ink perfusion and vascular casting after 2, 4, 6 weeks.The density of blood vessels was analyzed by the statistical software SPSS 10.0.Results All the corals were encased by newly formed fibrovascular tissues in 2 groups.Ink-stained vessels distributed the surfaces and side grooves, and invaded the interspaces of corals.The degree of vascularization increased over the course of experiment.Blood vessel density demonstrated a significant continuous increase between 2 and 6 weeks after implantation in group A.The mean value of blood vessel density in group A (2 weeks 276.60±4.67, 4 weeks 517.20±10.66, 6 weeks 707.00 ±11.87) was significantly higher than in group B (2 weeks 153.60 ±7.16, 4 weeks 269.40±6.80, 6 weeks 279.20±6.53) (P <0.01).Vascular casting showed that in group A, significant blood vessels sprouted from all areas of the loop, espe-cially at the entrance of the arteriovenous pediele where the small tubes were densely interconnected.In group B, however, no blood vessels sprouted from the arteriovenous bundles and only some small vessels grew from the entrance and exit.Conclusions A vascularized coral model can be constructed by inserting an ar-teriovenous loop or an arteriovenous bundle, useful in vascular bone tissue engineering.The former, however, have stronger abilities to induce angiogenesis than the latter.