流产儿归置中的伦理问题及其对策

近年来,关于流产儿归置问题引发广泛热议。流产儿虽未出生,但不同阶段的流产儿具有的伦理属性各有不同,应该从人的生命权和人格权角度来考虑。不同阶段的流产儿在胚胎干细胞研究和器官移植等领域体现的价值,引发了伦理审查、实验研究取材等问题,现有的法律规定不足以解决实际问题,应当针对处于不同时期的流产儿,辅以伦理道德情感的考虑来加以处置。     

Adoptability and limitation of cancer treatment guidelines: a Chinese oncologist’s perspective

In recent years,great progress has been made in the treatment of cancer;one of the significant reasons is the wide adaptation and implementation of standardized treatment based on high-level clinical evidence.Undoubtedly,the advent of guidelines that represent the achievement of the latest and highest quality clinical studies made a significant contribution to the improvement of cancer treatment and management.Aside from cancer patient care,guidelines have also been widely used as standards or primary references in the diagnosis and treatment of other diseases.Numerous guidelines are being enacted each year by a variety of guideline-makers, including national, regional and intemational academic organizations, medical associations,as well as research institutions and hospitals.     

饮酒对心血管系统影响的双向效应争论中的共识与分歧

当今世界饮用酒精饮料的人群日益增加。饮酒可诱发多种疾病，对人类健康构成严重威胁，但其对心血管系统是否存在积极影响尚有争议。传统观念认为，少到中等量饮酒（女性每日摄取纯酒精≤ 1个标准量，男性每日摄取纯酒精≤ 2个标准量，1个标准量=12~15 g纯酒精）可能有益于治疗心血管系统疾病（如动脉粥样硬化性心血管疾病），而过量饮酒（每日摄取纯酒精> 2个标准量）则会导致心血管系统损害，即"J"型曲线的双向效应。近年来，针对上述传统观念是否正确的争论愈演愈烈，并涉及饮酒方式、酒精饮料类型及所影响的不同类型心血管疾病等诸多方面。本文通过汇总、分析国内外相关研究的最新成果，讨论饮酒对心血管系统影响的双向效应争论中的共识与分歧，发现尽管目前相关研究并未形成一致观点，但多数研究结果提示，少到中等量饮酒可能有益于心血管健康，尤其是对于中老年人及已存在动脉粥样硬化性心血管疾病的患者，可为今后制订与心血管疾病防控相关的生活方式干预指南提供思路。     

乙型肝炎病毒子宫内传播的研究

应用Southern blot杂交试验对39例流产的死胎,检测其肝细胞中HBV-DNA的存在状态。并用免疫组织化学酶标记ABC方法检测肝细胞中的HBcAg的存在状态。结果:23例HBeAg阳性孕妇胎儿中有3例,8例HBsAg单项阳性孕妇胎儿中有1例,在胎肝细胞基因组中检出整合型HBV-DNA顺序。经片断探针杂交:4例中有3例出现HBV-C基因及Pre-s基因整合型杂交带,其中2例胎肝细胞核内有HBcAg存在。证明HBV能在子宫中从HBsAg阳性携带者孕妇传给其胎儿。     

《2013 ESH/ESC动脉高血压管理指南》解读

本指南对写作过程中所有该领域可利用的证据进行总结和评估,为协助医师在日常实践中对每个不同情况的患者选择最佳诊断或治疗方案。和其他学会及组织一样,欧洲心脏学会（ESC）近年来发表并定期更新了大量指南。     

Swedish guidelines for registry-based randomized clinical trials

Abstract

During the last decade Sweden has invested in a national infrastructure for collection of structured clinical data in the form of healthcare registries (in Sweden known as Kvalitetsregister). These data can be combined with other public data using the national personal identifiers that are issued to Swedish citizens. The healthcare registries have an almost complete coverage of Swedish healthcare, and a large network of clinicians is involved in the quality assurance and continuous improvement of healthcare using these registries. Uppsala Clinical Research Center (UCR) has been a technology provider of large-scale national registries and has a strong background in clinical trial management. This effort combines the areas of healthcare registries and clinical trials into a novel way of performing clinical trials to be able to: 1) run clinical trials as an integrated part of normal clinic workflow; and 2) leverage the nationwide network of outcome reporting. This strategy was shown to be successful in the TASTE (Thrombus Aspiration in Myocardial Infarction) study. When TASTE had been published, the New England Journal of Medicine wrote a perspective on the study calling it ‘The randomized registry trial—the next disruptive technology in clinical research?’ Since then several studies have been conducted in this way with great success. UCR has been appointed, by Clinical Studies Sweden and the Swedish Research Council, to develop the Swedish national guidelines for registry-based randomized clinical trials in order to ensure the possibility for more organizations to run this kind of study. This paper describes key concepts of register-based randomized clinical trials and the development of Swedish national guidelines.     

Debate about multiple pregnancies moves to new heights in Britain.

The controversy about multiple pregnancy and abortion has taken on a new dimension in Britain as a result of two widely publicized cases. A mother who was carrying twins wanted to give birth to only one child, so one fetus was aborted. Public outrage turned to dismay when it was revealed another mother who had been taking fertility drugs refused selective termination, a standard procedure to ensure the growth of healthy fetuses, in an ill-fated attempt to give birth to eight babies.     

针灸和东方医学在美国发展现状

Since its first mention in U.S. media in the early 1970s, the practiceof acupuncture and Oriental medicine （AOM） has grown in stature from a fringe,counter-culture movement to a valid, evidenced-based treatment option for patients.In the last 40 years, AOM schools and colleges have been accredited by the U.S.Department of Education, offering both masters and doctoral degree programs. Todate, forty-seven states and the District of Columbia license or certify acupuncturistsbased on competency proven through state examination or professional certificationby the National Certification Commission for Acupuncture and Oriental Medicine（NCCAOM）. As acceptance of AOM in the U.S. has increased through both theassurance of psychometrically sound certification and the education of the Americanpublic on this topic, many challenges have emerged. Problems such as theunderemployment of AOM clinicians, methodological hurdles for the investigation of mechanisms, and efficacyof acupuncture and other AOM treatment techniques have been observed. Investigative challenges also includegaps in research training as well as a dearth of the basic resources needed to conduct randomized controlledtrials （RCTs）. As AOM research has sought integration into the Western research model, problems have beenidentified in the design of AOMRCTs, and strategies for their resolution through methods such as translationalresearch have been examined. Incorporating these strategies as well as efficacy, effectiveness, and qualitativemeasures will strengthen the evidence base and thus provide clinical decision makers with more tools that canbe used to design patient treatment regimens.     

低剂量阿司匹林预防子痫前期的关注焦点

孕期服用低剂量阿司匹林是目前国内外专家广泛推荐的子痫前期（preeclampsia, PE）预防方法。尽管该方法在PE预防中已有较多报道，但是阿司匹林标准化预防PE的治疗方案仍未在国内的临床指南中达成共识。这是由于在现有研究中，高危人群服用阿司匹林的剂量、初始时间和筛查方法不同，尚未对阿司匹林用药方案形成统一结论。本文基于循证医学证据，总结现有指南推荐意见，对阿司匹林在预防PE时的剂量、具体用药时机、起止时间等焦点问题进行综述，为临床实践提供依据。综合目前阿司匹林预防PE的研究结果及临床实践，我们建议:PE风险筛查应在妊娠11～13+6周时进行；PE高风险孕妇预防性使用阿司匹林的推荐剂量为150 mg/d，最低有效推荐剂量为100 mg/d；PE高风险孕妇于妊娠16周前开始口服低剂量阿司匹林；妊娠36周为低剂量阿司匹林的停药时机。     

剖宫产术中寒战的研究进展

剖宫产是最常见的妇产科手术之一。现如今,剖宫产技术已经发展的比较成熟,但是术中产妇出现的不良反应仍然较多。寒战是手术中最常见的不良反应之一,具体发生机制至今没有明确阐述。而剖宫产术中发生的寒战对母体和胎儿都具有较大的负面影响。预防和治疗术中寒战的手段较多,主要分为物理和药物疗法,但至今没有权威的预防和治疗指南。该文就术中寒战的相关研究以及在剖宫产中的应用进展进行综述。     

Abortion decisions as inclusion and exclusion criteria in research involving pregnant women and fetuses

From the perspective of investigators conducting research involving pregnant women and fetuses, a woman's decision about whether to have an abortion can sometimes be relevant to the suitability of the woman and fetus as research subjects. However, prominent ethicists disagree over whether it is permissible for a woman's decision about abortion to be an inclusion or exclusion criterion for participation in research. A widely held view is that fetuses to be aborted and fetuses to be carried to term should be treated equally as research subjects. Some hold that this principle implies that a woman's decision about whether to have an abortion should not be an inclusion or exclusion criterion. This paper identifies types of research in which investigators might want to have inclusion or exclusion criteria based on decisions about abortion. It examines the arguments for and against having the woman's decision about abortion included in such criteria. It is argued that there are types of research in which such criteria are ethically permissible.     

The development of healthcare services for diabetic prisoners.

The conditions experienced by people in custody in the UK have received considerable attention recently and there has been considerable debate concerning the standards of healthcare in British prisons. The Prison Health Care Service works under great pressure and difficulties and doctors have to deal with a large and ever-changing population, often with mental and physical disorders, who are frequently manipulative. This article highlights problems encountered in delivering diabetes care in prisons. Prisoners may self-induce diabetic ketoacidosis by refusing insulin injections, in order to be transferred to an outside hospital. On the other hand, prison staff may mis-interpret the symptoms of poorly controlled diabetes as ''acting up'' by prisoners and inappropriate treatment can be given. If structured diabetes care is provided in prison, however, with close liaison between the Prison Staff and the local Diabetes Care Team, the basics of modern diabetes management can be provided. Good diabetic metabolic control can be achieved in the majority of patients, probably due to the rigid dietary regime, no alcohol and compliance with treatment. Imprisonment can ensure screening for diabetic complications and reassessment of treatment regimens. The British Diabetic Association guidelines for the provision of diabetes care in British prisons are outlined in this article.     

Physicians and the pharmaceutical industry (update 1994). Canadian Medical Association.

The history of health care delivery in Canada has been marked by close collaboration between physicians and the pharmaceutical and health supply industries, this collaboration extending to research as well as to education. Since medicine is a self-governing profession physicians have a responsibility to ensure that their participation in such collaborative efforts is in keeping with their duties toward their patients and society. The following guidelines have been developed by the CMA to assist physicians in determining when a relationship with industry is appropriate. Although directed primarily to individual physicians, including residents and interns as well as medical students, the guidelines also govern the relationships between industry and medical associations. These guidelines focus on the pharmaceutical companies; however, the CMA considers that the same principles apply to the relationship between its members and manufacturers of medical devices, infant formulas and similar products, and health care products and service suppliers in general. These guidelines reflect a national consensus and are meant to serve as an educational resource for physicians throughout Canada.     

一种新的人血管内皮生长因子基因的剪切形式

目的：检测人胚胎肺组织中新的血管内皮生长因子（VEGF）基因的可变剪切形式。方法：对胎儿肺组织的总RNA进行逆转录聚合酶链反应,克隆并测定扩增片段的序列。结果：用一对引物（引物5′端－21－7,3′端554－576）可扩增出3条片段,1条长度为正常的VEGF165（619bp) ,1条为正常的VEGF121（487bp),第3条为新的VEGF mRNA“异常”剪切片段,测序结果显示,此片段扩增长度为639bp,同样为VEGF165全长核苷酸序列,但在VEGF165的第三和第四外显子之间插入了长度为20bp的片段,经序列检索发现20bp的插入序列为滞留的第Ⅲ内含子终末序列,含内含子剪切信号,上述移码突变导致VEGF基因的阅读框架发生变化,在第四外显子中游出现终止密码子,结论：在一引产胎儿的肺组织中发现了新的VEGFmRNA可变剪切形式,其生物学意义有待进一步研究。     

从中国心血管病报告看全科医生如何利用好指南

《中国心血管病报告2017》指出：我国心血管病（CVD）防治工作已取得初步成效,但仍面临严峻挑战,其发病率、病死率及医疗花费仍较高。临床指南是针对特定临床问题的最佳医疗实践的总结,推动医疗行为规范化,但指南和共识并不能取代临床技能、临床经验和临床资料。目前,我国基层医生对临床指南的了解与应用并不乐观,基层医务人员对临床指南的知晓率、重视程度和使用程度均较低,对其内容的理解、掌握和应用尚存在较大差异。为尽早实现“健康中国”的战略目标,全科医生应在CVD预防-治疗-康复整个疾病链上下功夫。在实践中,强化对临床指南的学习和培训,提高基本医疗的能力;理解临床指南实质和内涵,扩大健康教育的受众;遵循临床指南的要求和规定,重视并掌握CVD总体风险的评估;重视临床指南与实践相结合,构筑CVD防治的壁垒。创建以患者为中心的,高效率、高质量的CVD全程医疗服务模式,真正贯彻层层设防的策略,有效阻断CVD发生和进展,为我国CVD下降拐点的早日到来做出贡献。     

A dualist analysis of abortion: personhood and the concept of self qua experiential subject

There is no issue more central to the abortion debate than the controversial issue of whether the fetus is a moral person. Abortion-rights opponents almost universally claim that abortion is murder and should be legally prohibited because the fetus is a moral person at the moment of conception. Abortion-rights proponents almost universally deny the crucial assumption that the fetus is a person; on their view, whatever moral disvalue abortion involves does not rise to the level of murder and hence does not rise to the level of something that should be legally prohibited.In this essay, I argue that, under dualist assumptions about the nature of mind, the fetus is not a person until brain activity has begun.(i) First, I argue it is a necessary condition for a thing to be a moral person that it is (or has) a self. Second, I argue it is a necessary condition for a fetus to be (or have) a self, under dualist assumptions, that there has been some electrical activity in the brain. I conclude that a dualist can take the position that abortion ought to be legally permitted at least until the beginning of brain activity in the fetus.iI make no attempt to determine what conditions are sufficient for moral personhood; for this reason, the relevant claim about personhood is purely negative.     

2018版加拿大儿科学会《儿童青少年注意缺陷多动障碍诊疗指南》解读

注意缺陷多动障碍（ADHD）是儿童期常见的慢性神经发育障碍,已经成为全球共同的公共卫生问题,世界各学术组织先后发表了相关的诊治指南。随着近几年研究的不断深入,其临床指南也得到了不断更新。2018年10月24日,加拿大儿科学会（CPS）精神卫生和发育障碍委员会牵头制定了《儿童青少年注意缺陷多动障碍诊疗指南》,指南总结了目前ADHD所有的临床证据,并制定了ADHD治疗标准,以便更好地为临床医师提供循证医学的治疗策略。本研究旨在对该指南的重点内容进行解读,同时与《2018 NICE指南：注意缺陷多动障碍的诊断和管理（NG.87）》以及我国目前相关的指南进行比较。     

中西医结合治疗帕金森病的现状和展望

通过综述有关中西医治疗帕金森病(PD)的大量相关文献，说明了中西医对PD的病因、发病机制、外科手术治疗、基因治疗、针灸康复疗法等方面已经取得了初步的成果，体现了中西医治疗PD的独特优势。     

Parents' experiences of newborn screening for genetic susceptibility to type 1 diabetes

Advances in genomic medicine have lead to debate about the potential inclusion of genetic tests for susceptibility to common complex disorders in newborn screening programmes. Empirical evidence concerning psychosocial reactions to genetic testing is a crucial component of both ethical debate and policy development, but while there has been much speculation concerning the possible psychosocial impact of screening newborns for genetic susceptibilities, there remains a paucity of data. The aim of the study reported here is to provide some of this missing empirical evidence, using type 1 diabetes as an example of a common disorder with multiple significant genetic contributors to its aetiology. Semi-structured interviews were conducted with 11 parents of babies who had received increased risk results in a study that involved newborn screening for genetic susceptibility to type 1 diabetes. Interpretative phenomenological analysis was used to evaluate the data. The interview data suggest that the probabilistic nature of results of genetic susceptibility tests impacts upon all aspects of parents' psychosocial reactions, resulting in a complex and dynamic process quite different to that described in relation to current newborn screening programmes. While parents generally reported fairly minor levels of concern in response to news of their child's increased genetic risk, these worries frequently recurred, and perception of risk also varied and fluctuated over time. Both individual and contextual factors appeared to interact with the inherent uncertainty of the test result to contribute to the dynamic nature of parental reactions, and their behavioural responses. The implications of these findings for future research and for the debate concerning potential expansion of newborn screening are discussed.     

Choosing priorities.

Dr Gray leaves us with a question at the conclusion of his article--how should we choose priorities? He says that the debate so far has been mainly on what we should choose, but perhaps we should consider how to choose even more. Under the various subheadings of Criteria, Principles and Persons Dr Gray sets out the pros and cons of the arguments in the priority debates and tries to offer some more specific guidelines to offset the criticism that the government''s priority discussions have been too generalised. Yet this is a difficult task when everyone''s priorities are so different.