医原性神经症病因分析与探讨

医原性神经症的发病因素，不只是因为医护人员的言行，由于患者的性格及病后心理变化在他所接触的人和事物的相互关系上，几乎都存在本症的发病基础。本文将讨论的焦点限制在医患关系上，以两个典型病例为契机，进一步分析了患者及医护人员两方面的发病因素，并指出患者单纯的误解是本症发生的主要原因。而来自于医护人员方面的发病因素，则正是在今后的临床工作中，必须注意和改进的问题。     

Learned Helplessness as a Framework for Practice in Long-Term Care Environments

This paper presents an overview of learned helplessness theory and uses the iatrogenic diseases of institutional life as a framework for describing long-term care environments. On the basis of the theory and the nature of the environments that offer residents little opportunity for choice and control over events in their daily lives, the author proposes some possible remedies to increase the quality of life among older people in long-term care.     

Iatrogenic effects of psychosocial interventions for substance use disorders: prevalence, predictors, prevention

AIMS: To examine the prevalence and personal and intervention-related predictors of potential iatrogenic effects associated with psychosocial interventions for substance use disorders and provide a conceptual framework to guide further research on such effects. METHOD: A review of relevant studies focuses on the prevalence and predictors of potential iatrogenic effects of psychosocial treatment and prevention programs for substance use disorders. RESULTS: Between 7% and 15% of patients who participate in psychosocial treatment for substance use disorders may be worse off subsequent to treatment than before. In addition, several controlled trials of substance use prevention have shown some apparent iatrogenic effects, including more positive expectations about substance use and a rise in alcohol use and alcohol-related problems. Probable person-related predictors of deterioration associated with treatment include younger age and unmarried status, more serious current diagnoses and substance use problems and more psychiatric and interpersonal problems. Probable intervention-related predictors of deterioration include lack of bonding; lack of monitoring; confrontation, criticism and high emotional arousal; deviancy modeling; and stigma, low or inappropriate expectations and lack of challenge. CONCLUSION: A significant minority of individuals with substance use problems appear to deteriorate during or shortly after participation in treatment or prevention programs. Safety standards and monitoring procedures are needed to routinely identify potential adverse consequences of intervention programs; research is needed to clarify whether deterioration is due to iatrogenic effects of interventions and to identify new approaches to counteract any such effects.     

Large post-hysterectomy and post-radiation vesicovaginal fistulas: repair by ileocystoplasty

PURPOSE: We devised a technique for simultaneous closure of large post-hysterectomy and post-radiation vesicovaginal fistulas, and augmentation of the concomitant shrunken bladder by ileocystoplasty as a 1-step procedure. MATERIALS AND METHODS: Between 1989 and 2000, 4 patients with large vesicovaginal fistulas after radical hysterectomy and radiotherapy for spinocellular cancer of the uterine cervix underwent fistula repair according to the technique described. The premise of utmost importance in the proposed technique is a healthy and not radiation damaged distal ileum. RESULTS: Fistula closure was achieved in 3 patients, while in 1 a 3 mm residual fistula was repaired 5 years later by a Martius skin flap. In all patients the augmented bladder allowed good quality of life with spontaneous voiding, and daytime and nighttime continence. CONCLUSIONS: The technique described seems to have certain advantages. Wide dissection of the bladder from the vagina and pelvic walls is avoided. The bladder defect is closed with a well vascularized ileal segment. Bladder capacity is enlarged simultaneously with good functional results. The procedure can be adapted to cases with concomitant damaged distal ureters.     

Infraclavicular brachial plexus injury following axillary regional block

Infraclavicular brachial plexopathy is a potential complication of axillary regional block. We retrospectively reviewed 13 such injuries and found the median nerve most often affected, followed by combined median and ulnar neuropathies, and then by various combinations involving the median, ulnar, radial, and musculocutaneous nerves. All were axon-loss in type and most were severe in degree electrophysiologically. The clinical and electrodiagnostic features of these injuries are strikingly similar to those sustained after axillary arteriography, which has been associated with the medial brachial fascial compartment (MBFC) syndrome. This syndrome is characterized by the evolution of neurologic deficits and pain following hematoma formation within a compartment of the upper arm. Thus, we believe that this mechanism underlies most nerve injuries that result from axillary angiography or axillary regional block. This has important treatment implications, as timely surgical intervention may lead to improved outcome.     

Blind loop syndrome following iatrogenic intestinal bypass in a child

High ileocolic side in side anastomosis, leading to blind loop syndrome, is an infrequent surgical misadventure in pediatric patients. Apart from well documented metabolic, hematological and nutritional disturbances, growth retardation in childhood is an additional set back. This is a clinical report of such a child, depicting dramatic post operative setbacks and reversal of those when the original bowel continuity was restored.     

透明角膜切口白内障超声乳化折叠式人工晶状体植入术

目的：评价透明角膜切口白内障超声乳化折叠式人工晶状体植入术的手术效果。方法：经透明角膜３．２ｍｍ隧道切口对１５９只眼行白内障超声乳化折叠人工晶状体植入术。结果：手术全程时间８～２１ｍｉｎ。术后裸眼视力：术后第１天在０．５或以上者占４９．１％,术后第７天为７２．３％,术后１月≥１．０为７４．８％,平均角膜散光术后第７天（０．９１±０．５５）Ｄ比术前增加０．１９Ｄ（Ｐ＜０．００１）;术后１月（０．７７±０．５６）Ｄ比术前增加０．０５Ｄ（Ｐ＞０．０５）。结论：通过透明角膜切口行晶状体超声乳化折叠式人工晶状体植入术具有视力恢复好,几乎不引起医源性散光的优点     

A Randomized Trial of Alerting to Low Glycated Hemoglobin Level in Older Adults: Results of the Low Indexes of Metabolism Intervention Trial B (LIMIT-B)

ObjectivesThe benefit of alerting clinical staff to low plasma glycated hemoglobin (HbA1c) in patients aged 75 years and older who receive antidiabetic drugs remains uncertain.Design, Setting, and ParticipantsIn a randomized controlled trial, 1684 patients with HbA1c ≤ 6.5% who received antidiabetic drugs were assigned to have an e-mail alert sent to their physician, and 1643 were assigned to have no such alert (control group). The primary outcome of the trial was annual death. Secondary outcomes included antidiabetic drug dose reduction and HbA1c change.ResultsIn the first quarter, antidiabetic drug-defined daily doses were reduced on average by 10.4 ± 35.8 (16% ± 55%) in the intervention group and by 6.4 ± 36.1 (10% ± 56%) in the control group (difference −4.1 ± 1.2, 95% confidence interval [CI] −6.5 to −1.6; P = .001). Measured HbA1c levels were raised by a mean (± standard deviation) of 0.28 ± 0.77 in the intervention group and by 0.18 ± 0.57 in the control group (difference 0.10 ± 0.02, 95% CI –0.15 to −0.059, P < .001). One year after the alerts, 121 patients (7.2%) died in the intervention group and 107 patients (6.5%) died in the control group (relative risk 1.1, 95% CI 0.86-1.42; P = .44).Conclusions and ImplicationsIn this trial, alerting clinical staff to low HbA1c in patients aged 75 years and older treated with antidiabetic medicines was associated with mildly reduced antidiabetic doses and increased HbA1c but was not associated with a significant difference in survival rate compared with usual clinical care.